LONDON – A EULAR task force issued the first update to recommendations for managing Behçet’s disease since 2008, with revised recommendations that reflect expanded use of biologic agents, and increased evidence to guide management of gastrointestinal involvement, use of anticoagulants in patients with venous involvement, and use of surgical and interventional treatments, Dr. Gülen Hatemi said while presenting the update at the European Congress of Rheumatology.

The task force, which included more than 20 members, identified 304 articles to apply to the update, and produced five overarching principal and 18 specific recommendations divided among six categories of clinical manifestations of Behçet’s disease, said Dr. Hatemi, convenor of the task force and a rheumatologist at Istanbul University.

Mitchel L. Zoler/Frontline Medical News

For mucocutaneous involvement, the update included five items that all received a “strong” recommendation from the task force: For an oral or genital ulcer, use a topical agent, such as a local steroid. Try colchicine first to prevent recurrent mucocutaneous lesions, especially when the dominant lesion is erythema nodosum or a genital ulcer. Treat papulopustular or acnelike lesions with topical or systemic agents, as when treating acne vulgaris. Coordinate treatment of leg ulcers, which can be caused by venous stasis or obliterative vasculitis, with a dermatologist and vascular surgeon. And azathioprine, thalidomide, interferon-alpha, a tumor necrosis factor (TNF)–alpha antagonist, or apremilast (Otezla) may be necessary for selected patients.

The task force issued two strong recommendations for managing eye involvement along with one conditional recommendation. The first strong recommendation was that managing uveitis requires close collaboration with an ophthalmologist, with the goal of inducing and maintaining remission. Patients with an inflammatory eye disease affecting the posterior segment should receive treatment with azathioprine, cyclosporine, interferon-alpha, or a monoclonal TNF-alpha antagonist. Treatment with a systemic corticosteroid should occur only when combined with azathioprine or another systemic immunosuppressant.

The second strong recommendation was that patients who present with an initial or recurrent acute episode of sight-threatening uveitis should receive treatment with a high-dose glucocorticoid, infliximab, or interferon-alpha. Intravitreal injection with a glucocorticoid as an adjunct to systemic therapy is an option for patients with a unilateral exacerbation. The conditional recommendation was for patients with isolated anterior uveitis. When these patients have markers of a poor prognosis – such as young age, male sex, or early disease onset – systemic treatment with an immunosuppressant is a possible option.

The panel issued three strong recommendations along with one conditional recommendation for managing vascular involvement. One of the strong recommendations called for treating acute deep vein thrombosis with a glucocorticoid as well as an immunosuppresant such as azathioprine, cyclophosphamide, or cyclosporine. A conditional recommendation said patients with refractory venous thrombosis could be considered for treatment with a monoclonal TNF-alpha antagonist, along with an anticoagulant if the patient’s risk for bleeding was generally low and a coexistent pulmonary artery aneurysm was ruled out.

Management of arterial aneurysms received the other two strong recommendations. The panel recommended high-dose glucocorticoid plus cyclophosphamide for a pulmonary artery aneurysm, followed by a monoclonal TNF-alpha antagonist for refractory cases. Patients with these aneurysms who are at high risk for major bleeding should undergo embolization in preference to open surgery. When patients have aortic or peripheral artery aneurysms, treatment should start with cyclophosphamide and a corticosteroid before an aneurysm repair is attempted. But surgery or stenting of the aneurysm should not be delayed when patients are symptomatic.

Gastrointestinal involvement received one strong and two conditional recommendations. The panel strongly recommended confirming gastrointestinal involvement using endoscopy, imaging, or both, while also ruling out treatment with a nonsteroidal anti-inflammatory drug, inflammatory bowel disease, or an infection such as tuberculosis as the cause of gastrointestinal symptoms. One of the conditional recommendations called for an urgent surgical consult when patients have perforation, major bleeding, or obstruction. The second conditional recommendation called for considering glucocorticoid treatment to treat an acute exacerbation of gastrointestinal involvement. Additional treatment options to pair with a glucocorticoid include a disease-modifying drug such as 5-aminosalicylic acid or azathioprine. For patients with severe or refractory gastrointestinal symptoms or both, a monoclonal TNF-alpha antagonist or thalidomide is another potential option.

The panel issued two strong recommendations for managing nervous system involvement. The top treatment option for parenchymal involvement is a high-dose glucocorticoid followed by slow tapering while also treating with an immunosuppressant such as azathioprine. Treatment with cyclosporine should be avoided, the panel said. Treatment with a monoclonal TNF-alpha antagonist is an option to consider as first-line treatment for patients with severe nervous system involvement or for those with refractory disease. The second strong recommendation was to treat a cerebral venous thrombus with a high-dose glucocorticoid followed by tapering, with short-term anticoagulant treatment as an option. Patients also need screening for the presence of vascular disease at an extracranial location.

The panel’s final recommendation was a strong endorsement of colchicine as first-line treatment for arthritis in Behçet’s patients, although patients with acute monoarticular disease can be managed with an intra-articular injection of a glucocorticoid. For patients with recurrent or chronic arthritis, treatment options include azathioprine, interferon-alpha, or a TNF-alpha antagonist.

Dr. Hatemi has received research support from, received honoraria from, or has been a speaker for AbbVie, Celgene, Merck Sharp & Dohme, and Pfizer.

[email protected]

On Twitter @mitchelzoler

LONDON – A EULAR task force issued the first update to recommendations for managing Behçet’s disease since 2008, with revised recommendations that reflect expanded use of biologic agents, and increased evidence to guide management of gastrointestinal involvement, use of anticoagulants in patients with venous involvement, and use of surgical and interventional treatments, Dr. Gülen Hatemi said while presenting the update at the European Congress of Rheumatology.

The task force, which included more than 20 members, identified 304 articles to apply to the update, and produced five overarching principal and 18 specific recommendations divided among six categories of clinical manifestations of Behçet’s disease, said Dr. Hatemi, convenor of the task force and a rheumatologist at Istanbul University.

Mitchel L. Zoler/Frontline Medical News

For mucocutaneous involvement, the update included five items that all received a “strong” recommendation from the task force: For an oral or genital ulcer, use a topical agent, such as a local steroid. Try colchicine first to prevent recurrent mucocutaneous lesions, especially when the dominant lesion is erythema nodosum or a genital ulcer. Treat papulopustular or acnelike lesions with topical or systemic agents, as when treating acne vulgaris. Coordinate treatment of leg ulcers, which can be caused by venous stasis or obliterative vasculitis, with a dermatologist and vascular surgeon. And azathioprine, thalidomide, interferon-alpha, a tumor necrosis factor (TNF)–alpha antagonist, or apremilast (Otezla) may be necessary for selected patients.

The task force issued two strong recommendations for managing eye involvement along with one conditional recommendation. The first strong recommendation was that managing uveitis requires close collaboration with an ophthalmologist, with the goal of inducing and maintaining remission. Patients with an inflammatory eye disease affecting the posterior segment should receive treatment with azathioprine, cyclosporine, interferon-alpha, or a monoclonal TNF-alpha antagonist. Treatment with a systemic corticosteroid should occur only when combined with azathioprine or another systemic immunosuppressant.

The second strong recommendation was that patients who present with an initial or recurrent acute episode of sight-threatening uveitis should receive treatment with a high-dose glucocorticoid, infliximab, or interferon-alpha. Intravitreal injection with a glucocorticoid as an adjunct to systemic therapy is an option for patients with a unilateral exacerbation. The conditional recommendation was for patients with isolated anterior uveitis. When these patients have markers of a poor prognosis – such as young age, male sex, or early disease onset – systemic treatment with an immunosuppressant is a possible option.

The panel issued three strong recommendations along with one conditional recommendation for managing vascular involvement. One of the strong recommendations called for treating acute deep vein thrombosis with a glucocorticoid as well as an immunosuppresant such as azathioprine, cyclophosphamide, or cyclosporine. A conditional recommendation said patients with refractory venous thrombosis could be considered for treatment with a monoclonal TNF-alpha antagonist, along with an anticoagulant if the patient’s risk for bleeding was generally low and a coexistent pulmonary artery aneurysm was ruled out.

Management of arterial aneurysms received the other two strong recommendations. The panel recommended high-dose glucocorticoid plus cyclophosphamide for a pulmonary artery aneurysm, followed by a monoclonal TNF-alpha antagonist for refractory cases. Patients with these aneurysms who are at high risk for major bleeding should undergo embolization in preference to open surgery. When patients have aortic or peripheral artery aneurysms, treatment should start with cyclophosphamide and a corticosteroid before an aneurysm repair is attempted. But surgery or stenting of the aneurysm should not be delayed when patients are symptomatic.

Gastrointestinal involvement received one strong and two conditional recommendations. The panel strongly recommended confirming gastrointestinal involvement using endoscopy, imaging, or both, while also ruling out treatment with a nonsteroidal anti-inflammatory drug, inflammatory bowel disease, or an infection such as tuberculosis as the cause of gastrointestinal symptoms. One of the conditional recommendations called for an urgent surgical consult when patients have perforation, major bleeding, or obstruction. The second conditional recommendation called for considering glucocorticoid treatment to treat an acute exacerbation of gastrointestinal involvement. Additional treatment options to pair with a glucocorticoid include a disease-modifying drug such as 5-aminosalicylic acid or azathioprine. For patients with severe or refractory gastrointestinal symptoms or both, a monoclonal TNF-alpha antagonist or thalidomide is another potential option.

The panel issued two strong recommendations for managing nervous system involvement. The top treatment option for parenchymal involvement is a high-dose glucocorticoid followed by slow tapering while also treating with an immunosuppressant such as azathioprine. Treatment with cyclosporine should be avoided, the panel said. Treatment with a monoclonal TNF-alpha antagonist is an option to consider as first-line treatment for patients with severe nervous system involvement or for those with refractory disease. The second strong recommendation was to treat a cerebral venous thrombus with a high-dose glucocorticoid followed by tapering, with short-term anticoagulant treatment as an option. Patients also need screening for the presence of vascular disease at an extracranial location.

The panel’s final recommendation was a strong endorsement of colchicine as first-line treatment for arthritis in Behçet’s patients, although patients with acute monoarticular disease can be managed with an intra-articular injection of a glucocorticoid. For patients with recurrent or chronic arthritis, treatment options include azathioprine, interferon-alpha, or a TNF-alpha antagonist.

Dr. Hatemi has received research support from, received honoraria from, or has been a speaker for AbbVie, Celgene, Merck Sharp & Dohme, and Pfizer.

[email protected]

On Twitter @mitchelzoler

LONDON – A EULAR task force issued the first update to recommendations for managing Behçet’s disease since 2008, with revised recommendations that reflect expanded use of biologic agents, and increased evidence to guide management of gastrointestinal involvement, use of anticoagulants in patients with venous involvement, and use of surgical and interventional treatments, Dr. Gülen Hatemi said while presenting the update at the European Congress of Rheumatology.

The task force, which included more than 20 members, identified 304 articles to apply to the update, and produced five overarching principal and 18 specific recommendations divided among six categories of clinical manifestations of Behçet’s disease, said Dr. Hatemi, convenor of the task force and a rheumatologist at Istanbul University.

Mitchel L. Zoler/Frontline Medical News

For mucocutaneous involvement, the update included five items that all received a “strong” recommendation from the task force: For an oral or genital ulcer, use a topical agent, such as a local steroid. Try colchicine first to prevent recurrent mucocutaneous lesions, especially when the dominant lesion is erythema nodosum or a genital ulcer. Treat papulopustular or acnelike lesions with topical or systemic agents, as when treating acne vulgaris. Coordinate treatment of leg ulcers, which can be caused by venous stasis or obliterative vasculitis, with a dermatologist and vascular surgeon. And azathioprine, thalidomide, interferon-alpha, a tumor necrosis factor (TNF)–alpha antagonist, or apremilast (Otezla) may be necessary for selected patients.

The task force issued two strong recommendations for managing eye involvement along with one conditional recommendation. The first strong recommendation was that managing uveitis requires close collaboration with an ophthalmologist, with the goal of inducing and maintaining remission. Patients with an inflammatory eye disease affecting the posterior segment should receive treatment with azathioprine, cyclosporine, interferon-alpha, or a monoclonal TNF-alpha antagonist. Treatment with a systemic corticosteroid should occur only when combined with azathioprine or another systemic immunosuppressant.

The second strong recommendation was that patients who present with an initial or recurrent acute episode of sight-threatening uveitis should receive treatment with a high-dose glucocorticoid, infliximab, or interferon-alpha. Intravitreal injection with a glucocorticoid as an adjunct to systemic therapy is an option for patients with a unilateral exacerbation. The conditional recommendation was for patients with isolated anterior uveitis. When these patients have markers of a poor prognosis – such as young age, male sex, or early disease onset – systemic treatment with an immunosuppressant is a possible option.

The panel issued three strong recommendations along with one conditional recommendation for managing vascular involvement. One of the strong recommendations called for treating acute deep vein thrombosis with a glucocorticoid as well as an immunosuppresant such as azathioprine, cyclophosphamide, or cyclosporine. A conditional recommendation said patients with refractory venous thrombosis could be considered for treatment with a monoclonal TNF-alpha antagonist, along with an anticoagulant if the patient’s risk for bleeding was generally low and a coexistent pulmonary artery aneurysm was ruled out.

Management of arterial aneurysms received the other two strong recommendations. The panel recommended high-dose glucocorticoid plus cyclophosphamide for a pulmonary artery aneurysm, followed by a monoclonal TNF-alpha antagonist for refractory cases. Patients with these aneurysms who are at high risk for major bleeding should undergo embolization in preference to open surgery. When patients have aortic or peripheral artery aneurysms, treatment should start with cyclophosphamide and a corticosteroid before an aneurysm repair is attempted. But surgery or stenting of the aneurysm should not be delayed when patients are symptomatic.

Gastrointestinal involvement received one strong and two conditional recommendations. The panel strongly recommended confirming gastrointestinal involvement using endoscopy, imaging, or both, while also ruling out treatment with a nonsteroidal anti-inflammatory drug, inflammatory bowel disease, or an infection such as tuberculosis as the cause of gastrointestinal symptoms. One of the conditional recommendations called for an urgent surgical consult when patients have perforation, major bleeding, or obstruction. The second conditional recommendation called for considering glucocorticoid treatment to treat an acute exacerbation of gastrointestinal involvement. Additional treatment options to pair with a glucocorticoid include a disease-modifying drug such as 5-aminosalicylic acid or azathioprine. For patients with severe or refractory gastrointestinal symptoms or both, a monoclonal TNF-alpha antagonist or thalidomide is another potential option.

The panel issued two strong recommendations for managing nervous system involvement. The top treatment option for parenchymal involvement is a high-dose glucocorticoid followed by slow tapering while also treating with an immunosuppressant such as azathioprine. Treatment with cyclosporine should be avoided, the panel said. Treatment with a monoclonal TNF-alpha antagonist is an option to consider as first-line treatment for patients with severe nervous system involvement or for those with refractory disease. The second strong recommendation was to treat a cerebral venous thrombus with a high-dose glucocorticoid followed by tapering, with short-term anticoagulant treatment as an option. Patients also need screening for the presence of vascular disease at an extracranial location.

The panel’s final recommendation was a strong endorsement of colchicine as first-line treatment for arthritis in Behçet’s patients, although patients with acute monoarticular disease can be managed with an intra-articular injection of a glucocorticoid. For patients with recurrent or chronic arthritis, treatment options include azathioprine, interferon-alpha, or a TNF-alpha antagonist.

Dr. Hatemi has received research support from, received honoraria from, or has been a speaker for AbbVie, Celgene, Merck Sharp & Dohme, and Pfizer.

[email protected]

On Twitter @mitchelzoler

Doctors who accepted a single, industry-sponsored meal worth less than $20 were significantly more likely to prescribe the featured drug to Medicare patients, based on data from a cross-sectional study of 279,669 physicians. The findings were published online June 20 in JAMA Internal Medicine (JAMA Intern. Med. 2016 Jun. doi: 10.1001/jamainternmed.2016.2765).

In a multivariate analysis, physicians who received a single meal related to the promoted drug were 1.8 times more likely to prescribe rosuvastatin than other statins, 1.7 times more likely to prescribe nebivolol than other beta-blockers, 1.5 times more likely to prescribe olmesartan than other ACE inhibitors or ARBs, and more than twice as likely to prescribe desvenlafaxine than other SSRIs and serotonin norepinephrine reuptake inhibitors (odds ratio, 2.18).

gerenme/ThinkStock

These differences remained significant after controlling for factors including prescribing volume, physician specialty, practice setting, and demographics. Prescribing rates increased with additional meals and more expensive meals.

Previous studies have identified associations between increased prescribing and industry payments to physicians, wrote Colette DeJong, a research fellow at the University of California, San Francisco, Center for Healthcare Value, and her colleagues. However, “It is not known whether much smaller payments, such as sponsored meals, are associated with increased prescribing of the promoted brand-name drug over therapeutic alternatives,” they noted.

The researchers reviewed data from the federal Open Payments program from Aug. 1 through Dec. 31, 2013, as well as Medicare Part D prescribing data for 2013.

The results were limited by the cross-sectional nature of the study and the limitations of data from the Open Payments program, and the data reflect an association, not a cause-and-effect relationship, the researchers noted. However, “Our results are consistent with recent analyses that linked federal or state-level physician payment records with Medicare Part D prescribing data,” and with smaller studies, they said. “Future research could compare industry-sponsored meals and other methods for disseminating drug information, such as academic detailing and independent drug bulletins, with respect to the cost and quality of prescribing,” they added. The researchers had no financial conflicts to disclose.

Read the full study here: http://archinte.jamanetwork.com/article.aspx?doi=10.1001/jamainternmed.2016.2765.

Doctors who accepted a single, industry-sponsored meal worth less than $20 were significantly more likely to prescribe the featured drug to Medicare patients, based on data from a cross-sectional study of 279,669 physicians. The findings were published online June 20 in JAMA Internal Medicine (JAMA Intern. Med. 2016 Jun. doi: 10.1001/jamainternmed.2016.2765).

In a multivariate analysis, physicians who received a single meal related to the promoted drug were 1.8 times more likely to prescribe rosuvastatin than other statins, 1.7 times more likely to prescribe nebivolol than other beta-blockers, 1.5 times more likely to prescribe olmesartan than other ACE inhibitors or ARBs, and more than twice as likely to prescribe desvenlafaxine than other SSRIs and serotonin norepinephrine reuptake inhibitors (odds ratio, 2.18).

gerenme/ThinkStock

These differences remained significant after controlling for factors including prescribing volume, physician specialty, practice setting, and demographics. Prescribing rates increased with additional meals and more expensive meals.

Previous studies have identified associations between increased prescribing and industry payments to physicians, wrote Colette DeJong, a research fellow at the University of California, San Francisco, Center for Healthcare Value, and her colleagues. However, “It is not known whether much smaller payments, such as sponsored meals, are associated with increased prescribing of the promoted brand-name drug over therapeutic alternatives,” they noted.

The researchers reviewed data from the federal Open Payments program from Aug. 1 through Dec. 31, 2013, as well as Medicare Part D prescribing data for 2013.

The results were limited by the cross-sectional nature of the study and the limitations of data from the Open Payments program, and the data reflect an association, not a cause-and-effect relationship, the researchers noted. However, “Our results are consistent with recent analyses that linked federal or state-level physician payment records with Medicare Part D prescribing data,” and with smaller studies, they said. “Future research could compare industry-sponsored meals and other methods for disseminating drug information, such as academic detailing and independent drug bulletins, with respect to the cost and quality of prescribing,” they added. The researchers had no financial conflicts to disclose.

Read the full study here: http://archinte.jamanetwork.com/article.aspx?doi=10.1001/jamainternmed.2016.2765.

Doctors who accepted a single, industry-sponsored meal worth less than $20 were significantly more likely to prescribe the featured drug to Medicare patients, based on data from a cross-sectional study of 279,669 physicians. The findings were published online June 20 in JAMA Internal Medicine (JAMA Intern. Med. 2016 Jun. doi: 10.1001/jamainternmed.2016.2765).

In a multivariate analysis, physicians who received a single meal related to the promoted drug were 1.8 times more likely to prescribe rosuvastatin than other statins, 1.7 times more likely to prescribe nebivolol than other beta-blockers, 1.5 times more likely to prescribe olmesartan than other ACE inhibitors or ARBs, and more than twice as likely to prescribe desvenlafaxine than other SSRIs and serotonin norepinephrine reuptake inhibitors (odds ratio, 2.18).

gerenme/ThinkStock

These differences remained significant after controlling for factors including prescribing volume, physician specialty, practice setting, and demographics. Prescribing rates increased with additional meals and more expensive meals.

Previous studies have identified associations between increased prescribing and industry payments to physicians, wrote Colette DeJong, a research fellow at the University of California, San Francisco, Center for Healthcare Value, and her colleagues. However, “It is not known whether much smaller payments, such as sponsored meals, are associated with increased prescribing of the promoted brand-name drug over therapeutic alternatives,” they noted.

The researchers reviewed data from the federal Open Payments program from Aug. 1 through Dec. 31, 2013, as well as Medicare Part D prescribing data for 2013.

The results were limited by the cross-sectional nature of the study and the limitations of data from the Open Payments program, and the data reflect an association, not a cause-and-effect relationship, the researchers noted. However, “Our results are consistent with recent analyses that linked federal or state-level physician payment records with Medicare Part D prescribing data,” and with smaller studies, they said. “Future research could compare industry-sponsored meals and other methods for disseminating drug information, such as academic detailing and independent drug bulletins, with respect to the cost and quality of prescribing,” they added. The researchers had no financial conflicts to disclose.

Read the full study here: http://archinte.jamanetwork.com/article.aspx?doi=10.1001/jamainternmed.2016.2765.

Researchers have identified a “sweet spot” target for reducing low-density lipoprotein cholesterol levels with statin therapy that is associated with the lowest risk of adverse cardiac outcomes.

A study published online June 20 in JAMA Internal Medicine analyzed data from an Israeli health care organization between 2009-2013 and identified 31,619 patients with ischemic heart disease, aged 30-84 years, who were being treated with statins and were at least 80% adherent to the medication regime.

Louise Koenig/Frontline Medical News

The analysis showed individuals who achieved a “moderate” LDL-C level – between 70.1-100.0 mg/dL – after 1 year of statin treatment had an 11% lower incidence of major adverse cardiac events, compared with those with a “high” LDL-C level – between 100.1-130.0 mg/dL (95% confidence interval, 0.84-0.94; P less than .001).

However researchers observed no significant difference in the risk of adverse cardiac events between the moderate group and those who achieved a “low” LDL-C equal to or less than 70.0mg/dL (hazard ratio, 1.02; 95% CI, 0.97-1.07; P = .54).

In a further analysis that included 54,884 individuals who were at least 50% adherent to their statin therapy, there was a slightly increased risk of major cardiac events in patients who achieved a low LDL-C, compared with those in the moderate LDL-C group, and a significant 13% reduction in risk in the moderate LDL-C group, compared with the high LDL-C group.

“Whereas this may reflect clinical risk of low levels of LDL-C, these results further support the main findings of this study that achieving a level below 70 mg/dL is not beneficial for all patients,” wrote Dr. Morton Leibowitz, from the Clalit Research Institute, Tel Aviv, and his coauthors.

Adjustment for age did not significantly alter the interaction between LDL-C levels and the risk of adverse cardiac events (JAMA Intern Med. 2016 Jun 20. doi: 10.1001/jamainternmed.2016.2751).

“The question of the association between achieved LDL-C levels and major adverse cardiac events for secondary prevention has become highly relevant, particularly in the real-world context of patients excluded from [randomized, controlled trials],” the authors wrote, suggesting that their data only partially support recent claims that lower LDL-C is better for cardiac outcomes.

“Our findings of significantly lower risk of MACEs associated with achieved LDL-C level of less than 100.0 mg/dL but not with achieved LDL-C of less than 70.0 mg/dL suggest a target for long-term statin treatment.”

The study was funded by the Clalit Research Institute. No conflicts of interest were reported.

Researchers have identified a “sweet spot” target for reducing low-density lipoprotein cholesterol levels with statin therapy that is associated with the lowest risk of adverse cardiac outcomes.

A study published online June 20 in JAMA Internal Medicine analyzed data from an Israeli health care organization between 2009-2013 and identified 31,619 patients with ischemic heart disease, aged 30-84 years, who were being treated with statins and were at least 80% adherent to the medication regime.

Louise Koenig/Frontline Medical News

The analysis showed individuals who achieved a “moderate” LDL-C level – between 70.1-100.0 mg/dL – after 1 year of statin treatment had an 11% lower incidence of major adverse cardiac events, compared with those with a “high” LDL-C level – between 100.1-130.0 mg/dL (95% confidence interval, 0.84-0.94; P less than .001).

However researchers observed no significant difference in the risk of adverse cardiac events between the moderate group and those who achieved a “low” LDL-C equal to or less than 70.0mg/dL (hazard ratio, 1.02; 95% CI, 0.97-1.07; P = .54).

In a further analysis that included 54,884 individuals who were at least 50% adherent to their statin therapy, there was a slightly increased risk of major cardiac events in patients who achieved a low LDL-C, compared with those in the moderate LDL-C group, and a significant 13% reduction in risk in the moderate LDL-C group, compared with the high LDL-C group.

“Whereas this may reflect clinical risk of low levels of LDL-C, these results further support the main findings of this study that achieving a level below 70 mg/dL is not beneficial for all patients,” wrote Dr. Morton Leibowitz, from the Clalit Research Institute, Tel Aviv, and his coauthors.

Adjustment for age did not significantly alter the interaction between LDL-C levels and the risk of adverse cardiac events (JAMA Intern Med. 2016 Jun 20. doi: 10.1001/jamainternmed.2016.2751).

“The question of the association between achieved LDL-C levels and major adverse cardiac events for secondary prevention has become highly relevant, particularly in the real-world context of patients excluded from [randomized, controlled trials],” the authors wrote, suggesting that their data only partially support recent claims that lower LDL-C is better for cardiac outcomes.

“Our findings of significantly lower risk of MACEs associated with achieved LDL-C level of less than 100.0 mg/dL but not with achieved LDL-C of less than 70.0 mg/dL suggest a target for long-term statin treatment.”

The study was funded by the Clalit Research Institute. No conflicts of interest were reported.

Researchers have identified a “sweet spot” target for reducing low-density lipoprotein cholesterol levels with statin therapy that is associated with the lowest risk of adverse cardiac outcomes.

A study published online June 20 in JAMA Internal Medicine analyzed data from an Israeli health care organization between 2009-2013 and identified 31,619 patients with ischemic heart disease, aged 30-84 years, who were being treated with statins and were at least 80% adherent to the medication regime.

Louise Koenig/Frontline Medical News

The analysis showed individuals who achieved a “moderate” LDL-C level – between 70.1-100.0 mg/dL – after 1 year of statin treatment had an 11% lower incidence of major adverse cardiac events, compared with those with a “high” LDL-C level – between 100.1-130.0 mg/dL (95% confidence interval, 0.84-0.94; P less than .001).

However researchers observed no significant difference in the risk of adverse cardiac events between the moderate group and those who achieved a “low” LDL-C equal to or less than 70.0mg/dL (hazard ratio, 1.02; 95% CI, 0.97-1.07; P = .54).

In a further analysis that included 54,884 individuals who were at least 50% adherent to their statin therapy, there was a slightly increased risk of major cardiac events in patients who achieved a low LDL-C, compared with those in the moderate LDL-C group, and a significant 13% reduction in risk in the moderate LDL-C group, compared with the high LDL-C group.

“Whereas this may reflect clinical risk of low levels of LDL-C, these results further support the main findings of this study that achieving a level below 70 mg/dL is not beneficial for all patients,” wrote Dr. Morton Leibowitz, from the Clalit Research Institute, Tel Aviv, and his coauthors.

Adjustment for age did not significantly alter the interaction between LDL-C levels and the risk of adverse cardiac events (JAMA Intern Med. 2016 Jun 20. doi: 10.1001/jamainternmed.2016.2751).

“The question of the association between achieved LDL-C levels and major adverse cardiac events for secondary prevention has become highly relevant, particularly in the real-world context of patients excluded from [randomized, controlled trials],” the authors wrote, suggesting that their data only partially support recent claims that lower LDL-C is better for cardiac outcomes.

“Our findings of significantly lower risk of MACEs associated with achieved LDL-C level of less than 100.0 mg/dL but not with achieved LDL-C of less than 70.0 mg/dL suggest a target for long-term statin treatment.”

The study was funded by the Clalit Research Institute. No conflicts of interest were reported.

Check out the June issue of Vascular Specialist now online in our enhanced digital edition and standard PDF. This month includes stories on vascular trainee case loads, the difficulties surgeons have at estimating blood loss, and an editorial by Dr. Russell Samson asking “Why be a vascular surgeon?”

Our Point/Counterpoint features a debate on the importance of the angiosome concept in revascularization for limb salvage between Dr. Richard Neville and Dr. Bauer Sumpio, and our Medicolegal Issues column examines the liability issues raised by the new move to value-based care.

Check out the June issue of Vascular Specialist now online in our enhanced digital edition and standard PDF. This month includes stories on vascular trainee case loads, the difficulties surgeons have at estimating blood loss, and an editorial by Dr. Russell Samson asking “Why be a vascular surgeon?”

Our Point/Counterpoint features a debate on the importance of the angiosome concept in revascularization for limb salvage between Dr. Richard Neville and Dr. Bauer Sumpio, and our Medicolegal Issues column examines the liability issues raised by the new move to value-based care.

Check out the June issue of Vascular Specialist now online in our enhanced digital edition and standard PDF. This month includes stories on vascular trainee case loads, the difficulties surgeons have at estimating blood loss, and an editorial by Dr. Russell Samson asking “Why be a vascular surgeon?”

Our Point/Counterpoint features a debate on the importance of the angiosome concept in revascularization for limb salvage between Dr. Richard Neville and Dr. Bauer Sumpio, and our Medicolegal Issues column examines the liability issues raised by the new move to value-based care.

Le Gal et al (Sci Transl Med. 2015;7:308re8) discovered that antioxidant administration in mice not only increased lymph node metastases but also increased the migration and invasive properties of human melanoma cells. However, the antioxidant N-acetylcysteine (NAC) had no impact on the number and size of the primary tumors (in mice), and neither NAC nor Trolox (6-hydroxy-2,5,7,8-tetramethylchroman-2-carboxylic acid), a structurally unrelated antioxidant and soluble vitamin E analogue, affected the proliferation of human melanoma cells. Hence, the progression of malignant melanoma (MM), a cancer that is sensitive to changes in reduction-oxidation status, may be influenced by exposure to antioxidants and vitamin E.

What’s the issue?

Healthy individuals and oncology patients commonly use supplements containing antioxidants to prevent cancer and fight malignancy, respectively. However, animal studies and human clinical trials have shown that antioxidants increase cancer risk and accelerate the progression of primary lung tumors. Le Gal et al’s study regarding progression of melanoma metastases following exposure to antioxidants extends the observations demonstrated for lung neoplasms. N-acetylcysteine was added to the drinking water of mice, whereas NAC and Trolox were added to a panel of human MM cell lines. N-acetylcysteine increased lymph node metastases in the endogenous mouse model of MM, and both NAC and Trolox markedly increased the migrations and invasive properties of human MM cells.

Cancers may be caused or exacerbated by free radicals. It has been assumed that antioxidants may protect against malignancy by destroying free radicals. Although prior studies have concluded that antioxidants prevent healthy cells from transforming into cancer after exposure to free radicals, Le Gal et al’s research suggests that antioxidants may not only protect but also enhance tumor progression once a cancer has developed.

If one extends the results of animal and tissue culture studies to humans, exposure to antioxidants may potentially influence the course of metastatic disease in patients who have already developed melanoma. In addition to systemic exposure after receiving oral antioxidants, melanoma patients also can be topically exposed to antioxidants. For example, nonprescription skin care products such as cutaneous rejuvenation treatments, emollients, and sunscreens can contain β-carotene, vitamin E, and other antioxidants. It remains to be determined whether topical exposure to antioxidants can cause the same observations that have occurred following systemic absorption in mice or tissue culture studies in human cell lines. Should we caution our melanoma patients with regards to what they apply to their skin?

We want to know your views! Tell us what you think.

Le Gal et al (Sci Transl Med. 2015;7:308re8) discovered that antioxidant administration in mice not only increased lymph node metastases but also increased the migration and invasive properties of human melanoma cells. However, the antioxidant N-acetylcysteine (NAC) had no impact on the number and size of the primary tumors (in mice), and neither NAC nor Trolox (6-hydroxy-2,5,7,8-tetramethylchroman-2-carboxylic acid), a structurally unrelated antioxidant and soluble vitamin E analogue, affected the proliferation of human melanoma cells. Hence, the progression of malignant melanoma (MM), a cancer that is sensitive to changes in reduction-oxidation status, may be influenced by exposure to antioxidants and vitamin E.

What’s the issue?

Healthy individuals and oncology patients commonly use supplements containing antioxidants to prevent cancer and fight malignancy, respectively. However, animal studies and human clinical trials have shown that antioxidants increase cancer risk and accelerate the progression of primary lung tumors. Le Gal et al’s study regarding progression of melanoma metastases following exposure to antioxidants extends the observations demonstrated for lung neoplasms. N-acetylcysteine was added to the drinking water of mice, whereas NAC and Trolox were added to a panel of human MM cell lines. N-acetylcysteine increased lymph node metastases in the endogenous mouse model of MM, and both NAC and Trolox markedly increased the migrations and invasive properties of human MM cells.

Cancers may be caused or exacerbated by free radicals. It has been assumed that antioxidants may protect against malignancy by destroying free radicals. Although prior studies have concluded that antioxidants prevent healthy cells from transforming into cancer after exposure to free radicals, Le Gal et al’s research suggests that antioxidants may not only protect but also enhance tumor progression once a cancer has developed.

If one extends the results of animal and tissue culture studies to humans, exposure to antioxidants may potentially influence the course of metastatic disease in patients who have already developed melanoma. In addition to systemic exposure after receiving oral antioxidants, melanoma patients also can be topically exposed to antioxidants. For example, nonprescription skin care products such as cutaneous rejuvenation treatments, emollients, and sunscreens can contain β-carotene, vitamin E, and other antioxidants. It remains to be determined whether topical exposure to antioxidants can cause the same observations that have occurred following systemic absorption in mice or tissue culture studies in human cell lines. Should we caution our melanoma patients with regards to what they apply to their skin?

We want to know your views! Tell us what you think.

Le Gal et al (Sci Transl Med. 2015;7:308re8) discovered that antioxidant administration in mice not only increased lymph node metastases but also increased the migration and invasive properties of human melanoma cells. However, the antioxidant N-acetylcysteine (NAC) had no impact on the number and size of the primary tumors (in mice), and neither NAC nor Trolox (6-hydroxy-2,5,7,8-tetramethylchroman-2-carboxylic acid), a structurally unrelated antioxidant and soluble vitamin E analogue, affected the proliferation of human melanoma cells. Hence, the progression of malignant melanoma (MM), a cancer that is sensitive to changes in reduction-oxidation status, may be influenced by exposure to antioxidants and vitamin E.

What’s the issue?

Healthy individuals and oncology patients commonly use supplements containing antioxidants to prevent cancer and fight malignancy, respectively. However, animal studies and human clinical trials have shown that antioxidants increase cancer risk and accelerate the progression of primary lung tumors. Le Gal et al’s study regarding progression of melanoma metastases following exposure to antioxidants extends the observations demonstrated for lung neoplasms. N-acetylcysteine was added to the drinking water of mice, whereas NAC and Trolox were added to a panel of human MM cell lines. N-acetylcysteine increased lymph node metastases in the endogenous mouse model of MM, and both NAC and Trolox markedly increased the migrations and invasive properties of human MM cells.

Cancers may be caused or exacerbated by free radicals. It has been assumed that antioxidants may protect against malignancy by destroying free radicals. Although prior studies have concluded that antioxidants prevent healthy cells from transforming into cancer after exposure to free radicals, Le Gal et al’s research suggests that antioxidants may not only protect but also enhance tumor progression once a cancer has developed.

If one extends the results of animal and tissue culture studies to humans, exposure to antioxidants may potentially influence the course of metastatic disease in patients who have already developed melanoma. In addition to systemic exposure after receiving oral antioxidants, melanoma patients also can be topically exposed to antioxidants. For example, nonprescription skin care products such as cutaneous rejuvenation treatments, emollients, and sunscreens can contain β-carotene, vitamin E, and other antioxidants. It remains to be determined whether topical exposure to antioxidants can cause the same observations that have occurred following systemic absorption in mice or tissue culture studies in human cell lines. Should we caution our melanoma patients with regards to what they apply to their skin?

We want to know your views! Tell us what you think.

We understand membership applicants are anxious for a decision!

Check your mailbox. All those who submitted applications to be members of SVS will receive a letter about the membership decision around July 1.

We understand membership applicants are anxious for a decision!

Check your mailbox. All those who submitted applications to be members of SVS will receive a letter about the membership decision around July 1.

We understand membership applicants are anxious for a decision!

Check your mailbox. All those who submitted applications to be members of SVS will receive a letter about the membership decision around July 1.

At the Vascular Annual Meeting last week, members voted on new officers and approved selection of new members of the Board of Directors.

Officers elected are:

• Vice president, Dr. Michel Makaroun

• Secretary, Dr. Ali AbuRahma

• Treasurer, Dr. Kim Hodgson

New members of the Board of Directors are:

Dr. Frank Pomposelli, Clinical Practice Council chair
Dr. Michael Golden, Eastern Vascular Society
Dr. Thomas Forbes, Canadian Society for Vascular Surgery
Dr. Donald Jacobs, Midwestern Vascular Surgical Society
Dr. William Marston, Southern Association for Vascular Surgery
Dr. Thomas Bower, Society for Clinical Vascular Surgery
Dr. Darrin Clouse, Vascular and Endovascular Surgery Society
Dr. William Jordan, Association of Program Directors in Vascular Surgery.

At the Vascular Annual Meeting last week, members voted on new officers and approved selection of new members of the Board of Directors.

Officers elected are:

• Vice president, Dr. Michel Makaroun

• Secretary, Dr. Ali AbuRahma

• Treasurer, Dr. Kim Hodgson

New members of the Board of Directors are:

Dr. Frank Pomposelli, Clinical Practice Council chair
Dr. Michael Golden, Eastern Vascular Society
Dr. Thomas Forbes, Canadian Society for Vascular Surgery
Dr. Donald Jacobs, Midwestern Vascular Surgical Society
Dr. William Marston, Southern Association for Vascular Surgery
Dr. Thomas Bower, Society for Clinical Vascular Surgery
Dr. Darrin Clouse, Vascular and Endovascular Surgery Society
Dr. William Jordan, Association of Program Directors in Vascular Surgery.

At the Vascular Annual Meeting last week, members voted on new officers and approved selection of new members of the Board of Directors.

Officers elected are:

• Vice president, Dr. Michel Makaroun

• Secretary, Dr. Ali AbuRahma

• Treasurer, Dr. Kim Hodgson

New members of the Board of Directors are:

Dr. Frank Pomposelli, Clinical Practice Council chair
Dr. Michael Golden, Eastern Vascular Society
Dr. Thomas Forbes, Canadian Society for Vascular Surgery
Dr. Donald Jacobs, Midwestern Vascular Surgical Society
Dr. William Marston, Southern Association for Vascular Surgery
Dr. Thomas Bower, Society for Clinical Vascular Surgery
Dr. Darrin Clouse, Vascular and Endovascular Surgery Society
Dr. William Jordan, Association of Program Directors in Vascular Surgery.

Clinical question: What is the contribution of hospital-based medical errors to national mortality in the U.S. compared to other causes listed by the Centers for Disease Control and Prevention (CDC)?

Background: Medical error can contribute to patient mortality. Currently, the annual list of the most common causes of death in the U.S. is compiled by the CDC using the International Classification of Diseases (ICD) codes on death certificates. Deaths caused by errors are unmeasured because medical errors are not included in the death certificate.

Study design: Analysis of existing literature on medical errors.

Setting: U.S. hospitals.

Synopsis: Findings of four studies on U.S. death rates from medical errors published between 2000 and 2008 were synthesized and extrapolated to the total number of U.S. hospital admissions in 2013. This resulted in a mean rate of death from medical errors of 251,454 per year, which is much higher than the annual incidence of 44,000–98,000 deaths published in the 1999 Institute of Medicine report. Comparing these data to the CDC ranking makes medical errors the third-leading cause of death in the U.S.

Although the accuracy of this result is limited to inpatient deaths and as the authors extrapolated the data from other studies, the number is still staggering and highlights the need for systematic measurement of the problem. One simple solution for this could be to have an extra field on the death certificate asking whether a preventable complication stemming from the patient’s medical care contributed to the death.

Bottom line: Medical error as the estimated third-leading cause of the death in the U.S. remains under-recognized, underappreciated, and highly unmeasured.

Citation: Makary MA, Daniel M. Medical error-the third leading cause of death in the US. BMJ. 2016;353:i2139.

Short Take

Isolating C. Difficile Carriers Decreases Hospital-Acquired C. Difficile Infections

In a nonblinded time-series analysis, screening all patients for asymptomatic C. diff carrier status and isolating carriers reduced rates of hospital-acquired C. diff, preventing 62.4% of expected cases.

Citation: Longtin Y, Paquet-Bolduc B, Gilca R, et al. Effect of detecting and isolating Clostridium difficile carriers at hospital admission on the incidence of C difficile infections: a quasi-experimental controlled study. JAMA Inter Med. 2016;176(6):796¬-804.

Clinical question: What is the contribution of hospital-based medical errors to national mortality in the U.S. compared to other causes listed by the Centers for Disease Control and Prevention (CDC)?

Background: Medical error can contribute to patient mortality. Currently, the annual list of the most common causes of death in the U.S. is compiled by the CDC using the International Classification of Diseases (ICD) codes on death certificates. Deaths caused by errors are unmeasured because medical errors are not included in the death certificate.

Study design: Analysis of existing literature on medical errors.

Setting: U.S. hospitals.

Synopsis: Findings of four studies on U.S. death rates from medical errors published between 2000 and 2008 were synthesized and extrapolated to the total number of U.S. hospital admissions in 2013. This resulted in a mean rate of death from medical errors of 251,454 per year, which is much higher than the annual incidence of 44,000–98,000 deaths published in the 1999 Institute of Medicine report. Comparing these data to the CDC ranking makes medical errors the third-leading cause of death in the U.S.

Although the accuracy of this result is limited to inpatient deaths and as the authors extrapolated the data from other studies, the number is still staggering and highlights the need for systematic measurement of the problem. One simple solution for this could be to have an extra field on the death certificate asking whether a preventable complication stemming from the patient’s medical care contributed to the death.

Bottom line: Medical error as the estimated third-leading cause of the death in the U.S. remains under-recognized, underappreciated, and highly unmeasured.

Citation: Makary MA, Daniel M. Medical error-the third leading cause of death in the US. BMJ. 2016;353:i2139.

Short Take

Isolating C. Difficile Carriers Decreases Hospital-Acquired C. Difficile Infections

In a nonblinded time-series analysis, screening all patients for asymptomatic C. diff carrier status and isolating carriers reduced rates of hospital-acquired C. diff, preventing 62.4% of expected cases.

Citation: Longtin Y, Paquet-Bolduc B, Gilca R, et al. Effect of detecting and isolating Clostridium difficile carriers at hospital admission on the incidence of C difficile infections: a quasi-experimental controlled study. JAMA Inter Med. 2016;176(6):796¬-804.

Clinical question: What is the contribution of hospital-based medical errors to national mortality in the U.S. compared to other causes listed by the Centers for Disease Control and Prevention (CDC)?

Background: Medical error can contribute to patient mortality. Currently, the annual list of the most common causes of death in the U.S. is compiled by the CDC using the International Classification of Diseases (ICD) codes on death certificates. Deaths caused by errors are unmeasured because medical errors are not included in the death certificate.

Study design: Analysis of existing literature on medical errors.

Setting: U.S. hospitals.

Synopsis: Findings of four studies on U.S. death rates from medical errors published between 2000 and 2008 were synthesized and extrapolated to the total number of U.S. hospital admissions in 2013. This resulted in a mean rate of death from medical errors of 251,454 per year, which is much higher than the annual incidence of 44,000–98,000 deaths published in the 1999 Institute of Medicine report. Comparing these data to the CDC ranking makes medical errors the third-leading cause of death in the U.S.

Although the accuracy of this result is limited to inpatient deaths and as the authors extrapolated the data from other studies, the number is still staggering and highlights the need for systematic measurement of the problem. One simple solution for this could be to have an extra field on the death certificate asking whether a preventable complication stemming from the patient’s medical care contributed to the death.

Bottom line: Medical error as the estimated third-leading cause of the death in the U.S. remains under-recognized, underappreciated, and highly unmeasured.

Citation: Makary MA, Daniel M. Medical error-the third leading cause of death in the US. BMJ. 2016;353:i2139.

Short Take

Isolating C. Difficile Carriers Decreases Hospital-Acquired C. Difficile Infections

In a nonblinded time-series analysis, screening all patients for asymptomatic C. diff carrier status and isolating carriers reduced rates of hospital-acquired C. diff, preventing 62.4% of expected cases.

Citation: Longtin Y, Paquet-Bolduc B, Gilca R, et al. Effect of detecting and isolating Clostridium difficile carriers at hospital admission on the incidence of C difficile infections: a quasi-experimental controlled study. JAMA Inter Med. 2016;176(6):796¬-804.

Several prominent hospitalist leaders have been named to Modern Healthcare magazine’s “50 Most Influential Physician Executives and Leaders” for 2016. Among them are Patrick Conway, MD, MSc, MHM, a pediatric hospitalist as well as CMO and deputy administrator for innovation and quality at the Centers for Medicare & Medicaid Services (CMS); Vivek Murthy, MD, MBA, a hospitalist and the current U.S. Surgeon General; Lynn Massingale, MD, co-founder and executive chairman of the hospitalist staffing firm TeamHealth; and Robert M. Wachter, MD, MHM, a national hospitalist leader, professor, and interim chairman of the Department of Medicine at the University of California, San Francisco (UCSF), and a founder of the hospitalist movement.

Susan George, MD, SFHM, recently received the Katharine F. Erskine Award from the YWCA in Worcester, Mass. Dr. George served as an internal medicine physician at Saint Vincent Hospital in Worcester for a total of 20 years and as hospitalist medical director there from 2007 until this year, when she left to go into private practice. Dr. George still teaches at the University of Massachusetts Medical School as an associate professor of medicine. The award is named for Katharine F. Erskine, a former YWCA president and women’s advocate since before the turn of the 20th century.

Alanna Small, MD, was recently named deputy chief of staff for Physician Services at Samuel Simmonds Memorial Hospital in Barrow, Alaska. Prior to this role, Dr. Small served as a hospitalist at the Alaska Native Medical Center in Anchorage.

Business Moves

Envision also announced its planned acquisition of Emergency Physicians Medical Group (EPMG), based in Ann Arbor, Mich., a private emergency and hospital medicine staffing firm serving the Midwestern United States since 1976.

Michael O’Neal is a freelance writer in New York City.

Several prominent hospitalist leaders have been named to Modern Healthcare magazine’s “50 Most Influential Physician Executives and Leaders” for 2016. Among them are Patrick Conway, MD, MSc, MHM, a pediatric hospitalist as well as CMO and deputy administrator for innovation and quality at the Centers for Medicare & Medicaid Services (CMS); Vivek Murthy, MD, MBA, a hospitalist and the current U.S. Surgeon General; Lynn Massingale, MD, co-founder and executive chairman of the hospitalist staffing firm TeamHealth; and Robert M. Wachter, MD, MHM, a national hospitalist leader, professor, and interim chairman of the Department of Medicine at the University of California, San Francisco (UCSF), and a founder of the hospitalist movement.

Susan George, MD, SFHM, recently received the Katharine F. Erskine Award from the YWCA in Worcester, Mass. Dr. George served as an internal medicine physician at Saint Vincent Hospital in Worcester for a total of 20 years and as hospitalist medical director there from 2007 until this year, when she left to go into private practice. Dr. George still teaches at the University of Massachusetts Medical School as an associate professor of medicine. The award is named for Katharine F. Erskine, a former YWCA president and women’s advocate since before the turn of the 20th century.

Alanna Small, MD, was recently named deputy chief of staff for Physician Services at Samuel Simmonds Memorial Hospital in Barrow, Alaska. Prior to this role, Dr. Small served as a hospitalist at the Alaska Native Medical Center in Anchorage.

Business Moves

Envision also announced its planned acquisition of Emergency Physicians Medical Group (EPMG), based in Ann Arbor, Mich., a private emergency and hospital medicine staffing firm serving the Midwestern United States since 1976.

Michael O’Neal is a freelance writer in New York City.

Several prominent hospitalist leaders have been named to Modern Healthcare magazine’s “50 Most Influential Physician Executives and Leaders” for 2016. Among them are Patrick Conway, MD, MSc, MHM, a pediatric hospitalist as well as CMO and deputy administrator for innovation and quality at the Centers for Medicare & Medicaid Services (CMS); Vivek Murthy, MD, MBA, a hospitalist and the current U.S. Surgeon General; Lynn Massingale, MD, co-founder and executive chairman of the hospitalist staffing firm TeamHealth; and Robert M. Wachter, MD, MHM, a national hospitalist leader, professor, and interim chairman of the Department of Medicine at the University of California, San Francisco (UCSF), and a founder of the hospitalist movement.

Susan George, MD, SFHM, recently received the Katharine F. Erskine Award from the YWCA in Worcester, Mass. Dr. George served as an internal medicine physician at Saint Vincent Hospital in Worcester for a total of 20 years and as hospitalist medical director there from 2007 until this year, when she left to go into private practice. Dr. George still teaches at the University of Massachusetts Medical School as an associate professor of medicine. The award is named for Katharine F. Erskine, a former YWCA president and women’s advocate since before the turn of the 20th century.

Alanna Small, MD, was recently named deputy chief of staff for Physician Services at Samuel Simmonds Memorial Hospital in Barrow, Alaska. Prior to this role, Dr. Small served as a hospitalist at the Alaska Native Medical Center in Anchorage.

Business Moves

Envision also announced its planned acquisition of Emergency Physicians Medical Group (EPMG), based in Ann Arbor, Mich., a private emergency and hospital medicine staffing firm serving the Midwestern United States since 1976.

Michael O’Neal is a freelance writer in New York City.

Clinical question: How do guideline-based care and outcomes of patients with transient ischemic attack (TIA) and minor ischemic stroke differ among patients admitted to the hospital and discharged from the ED, as well as in those referred versus not referred to stroke prevention clinics following discharge?

Background: Previous research demonstrated that urgent outpatient management strategies for patients with TIA and minor ischemic stroke are superior to standard outpatient care. However, there is less known about how outpatient stroke care compares to inpatient care in terms of outcomes, rapid risk factor identification/modification, and initiation of antithrombotic therapy.

Study design: Retrospective cohort study.

Setting: EDs of acute-care hospitals in Ontario, Canada.

Synopsis: Using the Ontario Stroke Registry, 8,540 patients seen in the ED with TIA or minor ischemic stroke were identified. The use of guideline-based interventions was highest in admitted patients, followed by patients discharged from the ED with stroke clinic follow-up, followed by patients discharged without follow-up. There was no significant difference in one-year mortality between admitted and discharged patients when adjusted for age, sex, and comorbid conditions (adjusted hazard ratio, 1.11; 95% CI, 0.92–1.34). However, stroke clinic referral was associated with a lower risk of one-year mortality compared with those discharged without follow-up (adjusted hazard ratio, 0.49; 95% CI, 0.38–0.64).

Limitations of this study include that it was carried out only in Ontario, where there is a universal healthcare system, which may limit the generalizability of the findings. Additionally, patient information was limited to what was available through the registry, which may mean there were other unmeasurable differences among groups.

Bottom line: Admitted patients with TIA or minor ischemic stroke are more likely to receive guideline-based therapy, and among patients discharged from the ED, referral to stroke clinic improves outcomes, including one-year mortality.

Citation: Kapral MK, Hall R, Fang J, et al. Association between hospitalization and care after transient ischemic attack or minor stroke. Neurology. 2016;86(17):1582-1589.

Clinical question: How do guideline-based care and outcomes of patients with transient ischemic attack (TIA) and minor ischemic stroke differ among patients admitted to the hospital and discharged from the ED, as well as in those referred versus not referred to stroke prevention clinics following discharge?

Background: Previous research demonstrated that urgent outpatient management strategies for patients with TIA and minor ischemic stroke are superior to standard outpatient care. However, there is less known about how outpatient stroke care compares to inpatient care in terms of outcomes, rapid risk factor identification/modification, and initiation of antithrombotic therapy.

Study design: Retrospective cohort study.

Setting: EDs of acute-care hospitals in Ontario, Canada.

Synopsis: Using the Ontario Stroke Registry, 8,540 patients seen in the ED with TIA or minor ischemic stroke were identified. The use of guideline-based interventions was highest in admitted patients, followed by patients discharged from the ED with stroke clinic follow-up, followed by patients discharged without follow-up. There was no significant difference in one-year mortality between admitted and discharged patients when adjusted for age, sex, and comorbid conditions (adjusted hazard ratio, 1.11; 95% CI, 0.92–1.34). However, stroke clinic referral was associated with a lower risk of one-year mortality compared with those discharged without follow-up (adjusted hazard ratio, 0.49; 95% CI, 0.38–0.64).

Limitations of this study include that it was carried out only in Ontario, where there is a universal healthcare system, which may limit the generalizability of the findings. Additionally, patient information was limited to what was available through the registry, which may mean there were other unmeasurable differences among groups.

Bottom line: Admitted patients with TIA or minor ischemic stroke are more likely to receive guideline-based therapy, and among patients discharged from the ED, referral to stroke clinic improves outcomes, including one-year mortality.

Citation: Kapral MK, Hall R, Fang J, et al. Association between hospitalization and care after transient ischemic attack or minor stroke. Neurology. 2016;86(17):1582-1589.

Clinical question: How do guideline-based care and outcomes of patients with transient ischemic attack (TIA) and minor ischemic stroke differ among patients admitted to the hospital and discharged from the ED, as well as in those referred versus not referred to stroke prevention clinics following discharge?

Background: Previous research demonstrated that urgent outpatient management strategies for patients with TIA and minor ischemic stroke are superior to standard outpatient care. However, there is less known about how outpatient stroke care compares to inpatient care in terms of outcomes, rapid risk factor identification/modification, and initiation of antithrombotic therapy.

Study design: Retrospective cohort study.

Setting: EDs of acute-care hospitals in Ontario, Canada.

Synopsis: Using the Ontario Stroke Registry, 8,540 patients seen in the ED with TIA or minor ischemic stroke were identified. The use of guideline-based interventions was highest in admitted patients, followed by patients discharged from the ED with stroke clinic follow-up, followed by patients discharged without follow-up. There was no significant difference in one-year mortality between admitted and discharged patients when adjusted for age, sex, and comorbid conditions (adjusted hazard ratio, 1.11; 95% CI, 0.92–1.34). However, stroke clinic referral was associated with a lower risk of one-year mortality compared with those discharged without follow-up (adjusted hazard ratio, 0.49; 95% CI, 0.38–0.64).

Limitations of this study include that it was carried out only in Ontario, where there is a universal healthcare system, which may limit the generalizability of the findings. Additionally, patient information was limited to what was available through the registry, which may mean there were other unmeasurable differences among groups.

Bottom line: Admitted patients with TIA or minor ischemic stroke are more likely to receive guideline-based therapy, and among patients discharged from the ED, referral to stroke clinic improves outcomes, including one-year mortality.

Citation: Kapral MK, Hall R, Fang J, et al. Association between hospitalization and care after transient ischemic attack or minor stroke. Neurology. 2016;86(17):1582-1589.