User login
Limitations of Best Practice Alerts on Curbing Blood Transfusions
Clinical question: Why do providers continue to transfuse blood products outside of recommended guidelines, despite best practice alerts (BPAs)?
Background: There is evidence that a restrictive approach to blood transfusion versus a liberal approach is beneficial in reducing cost, morbidity, and mortality. It is unclear why providers continue to order transfusions outside of recommended guidelines in spite of interruptive prompts.
Study design: Retrospective cohort.
Setting: Academic, tertiary care medical care center in California.
Synopsis: Researchers reviewed 10,642 blood transfusion-triggered BPAs. The BPA led to abortion of only 2% of the transfusions in this study. From the predefined institutional accepted transfusion indication list, acute bleeding was the most common (34%), followed by protocol-driven behaviors in specialty services, i.e., stem cell transplant service.
“Other” accounted for 56% of the responses; of these, only 37% entered a free text comment elaborating on the reason to override. Symptomatic anemia was the most common indication cited for these blood transfusions, followed by peri-operative transfusion and anticipation of imminent discharge. The vast majority of providers who interacted with the BPA were resident physicians (55%).
The major limitation of this study is the substantial portion (>60%) of nonspecific “other” overrides.
Bottom line: Protocol-driven behaviors and subjective indications for transfusion, such as symptomatic anemia, are unlikely to be influenced by BPAs.
Clinical question: Why do providers continue to transfuse blood products outside of recommended guidelines, despite best practice alerts (BPAs)?
Background: There is evidence that a restrictive approach to blood transfusion versus a liberal approach is beneficial in reducing cost, morbidity, and mortality. It is unclear why providers continue to order transfusions outside of recommended guidelines in spite of interruptive prompts.
Study design: Retrospective cohort.
Setting: Academic, tertiary care medical care center in California.
Synopsis: Researchers reviewed 10,642 blood transfusion-triggered BPAs. The BPA led to abortion of only 2% of the transfusions in this study. From the predefined institutional accepted transfusion indication list, acute bleeding was the most common (34%), followed by protocol-driven behaviors in specialty services, i.e., stem cell transplant service.
“Other” accounted for 56% of the responses; of these, only 37% entered a free text comment elaborating on the reason to override. Symptomatic anemia was the most common indication cited for these blood transfusions, followed by peri-operative transfusion and anticipation of imminent discharge. The vast majority of providers who interacted with the BPA were resident physicians (55%).
The major limitation of this study is the substantial portion (>60%) of nonspecific “other” overrides.
Bottom line: Protocol-driven behaviors and subjective indications for transfusion, such as symptomatic anemia, are unlikely to be influenced by BPAs.
Clinical question: Why do providers continue to transfuse blood products outside of recommended guidelines, despite best practice alerts (BPAs)?
Background: There is evidence that a restrictive approach to blood transfusion versus a liberal approach is beneficial in reducing cost, morbidity, and mortality. It is unclear why providers continue to order transfusions outside of recommended guidelines in spite of interruptive prompts.
Study design: Retrospective cohort.
Setting: Academic, tertiary care medical care center in California.
Synopsis: Researchers reviewed 10,642 blood transfusion-triggered BPAs. The BPA led to abortion of only 2% of the transfusions in this study. From the predefined institutional accepted transfusion indication list, acute bleeding was the most common (34%), followed by protocol-driven behaviors in specialty services, i.e., stem cell transplant service.
“Other” accounted for 56% of the responses; of these, only 37% entered a free text comment elaborating on the reason to override. Symptomatic anemia was the most common indication cited for these blood transfusions, followed by peri-operative transfusion and anticipation of imminent discharge. The vast majority of providers who interacted with the BPA were resident physicians (55%).
The major limitation of this study is the substantial portion (>60%) of nonspecific “other” overrides.
Bottom line: Protocol-driven behaviors and subjective indications for transfusion, such as symptomatic anemia, are unlikely to be influenced by BPAs.
Peri-Operative Atrial Fibrillation, Long-Term Risk of Ischemic Stroke
Clinical question: Is there an association between peri-operative AF and long-term risk of ischemic stroke in patients undergoing any type of surgery?
Background: Peri-operative AF is usually viewed as a transient response to physiological stress, and the long-term risk of stroke after peri-operative AF is unclear. The incidence of peri-operative AF ranges widely, from 1% to 40%. Data are scarce regarding the long-term risk of stroke from peri-operative AF in patients undergoing various types of surgery.
Study design: Retrospective cohort.
Setting: Nonfederal California acute care hospitals.
Synopsis: The goal of this study was to evaluate the relationship between peri-operative AF and long-term post-operative ischemic stroke by measuring newly diagnosed AF during the index hospitalization among 1,729,360 adult patients who underwent inpatient cardiac and noncardiac surgeries between 2007 and 2010. The main outcome variable was ischemic stroke in any hospital discharge diagnosis, which was adjusted for age, sex, race, insurance status, and cardiovascular comorbidities (hypertension, diabetes mellitus, coronary heart disease, congestive heart failure, peripheral vascular disease, chronic kidney disease, and chronic obstructive pulmonary disease). Kaplan-Meier survival statistics were used to calculate cumulative rates of stroke after surgery; cumulative stroke rates were stratified by the CHA2DS2VASc score.
Of 1.73 million eligible patients with diagnoses of ischemic strokes after discharge from the index hospitalization for surgery, 24,711 had new-onset peri-operative AF during the index hospitalization, and 13,952 experienced a stroke after discharge.
At one year after hospitalization for cardiac surgery, cumulative rates of stroke were 0.99% in those with peri-operative AF and 0.83% in those without AF. At one year after noncardiac surgery, cumulative rates of stroke were 1.47% in those with peri-operative AF and 0.36% in those without AF.
In a Cox proportional hazards analysis accounting for potential confounders, peri-operative AF was associated with subsequent stroke after both cardiac and noncardiac surgery.
Bottom line: Among patients hospitalized for surgery, peri-operative AF was associated with an increased long-term risk of ischemic stroke, especially following noncardiac surgery.
Clinical question: Is there an association between peri-operative AF and long-term risk of ischemic stroke in patients undergoing any type of surgery?
Background: Peri-operative AF is usually viewed as a transient response to physiological stress, and the long-term risk of stroke after peri-operative AF is unclear. The incidence of peri-operative AF ranges widely, from 1% to 40%. Data are scarce regarding the long-term risk of stroke from peri-operative AF in patients undergoing various types of surgery.
Study design: Retrospective cohort.
Setting: Nonfederal California acute care hospitals.
Synopsis: The goal of this study was to evaluate the relationship between peri-operative AF and long-term post-operative ischemic stroke by measuring newly diagnosed AF during the index hospitalization among 1,729,360 adult patients who underwent inpatient cardiac and noncardiac surgeries between 2007 and 2010. The main outcome variable was ischemic stroke in any hospital discharge diagnosis, which was adjusted for age, sex, race, insurance status, and cardiovascular comorbidities (hypertension, diabetes mellitus, coronary heart disease, congestive heart failure, peripheral vascular disease, chronic kidney disease, and chronic obstructive pulmonary disease). Kaplan-Meier survival statistics were used to calculate cumulative rates of stroke after surgery; cumulative stroke rates were stratified by the CHA2DS2VASc score.
Of 1.73 million eligible patients with diagnoses of ischemic strokes after discharge from the index hospitalization for surgery, 24,711 had new-onset peri-operative AF during the index hospitalization, and 13,952 experienced a stroke after discharge.
At one year after hospitalization for cardiac surgery, cumulative rates of stroke were 0.99% in those with peri-operative AF and 0.83% in those without AF. At one year after noncardiac surgery, cumulative rates of stroke were 1.47% in those with peri-operative AF and 0.36% in those without AF.
In a Cox proportional hazards analysis accounting for potential confounders, peri-operative AF was associated with subsequent stroke after both cardiac and noncardiac surgery.
Bottom line: Among patients hospitalized for surgery, peri-operative AF was associated with an increased long-term risk of ischemic stroke, especially following noncardiac surgery.
Clinical question: Is there an association between peri-operative AF and long-term risk of ischemic stroke in patients undergoing any type of surgery?
Background: Peri-operative AF is usually viewed as a transient response to physiological stress, and the long-term risk of stroke after peri-operative AF is unclear. The incidence of peri-operative AF ranges widely, from 1% to 40%. Data are scarce regarding the long-term risk of stroke from peri-operative AF in patients undergoing various types of surgery.
Study design: Retrospective cohort.
Setting: Nonfederal California acute care hospitals.
Synopsis: The goal of this study was to evaluate the relationship between peri-operative AF and long-term post-operative ischemic stroke by measuring newly diagnosed AF during the index hospitalization among 1,729,360 adult patients who underwent inpatient cardiac and noncardiac surgeries between 2007 and 2010. The main outcome variable was ischemic stroke in any hospital discharge diagnosis, which was adjusted for age, sex, race, insurance status, and cardiovascular comorbidities (hypertension, diabetes mellitus, coronary heart disease, congestive heart failure, peripheral vascular disease, chronic kidney disease, and chronic obstructive pulmonary disease). Kaplan-Meier survival statistics were used to calculate cumulative rates of stroke after surgery; cumulative stroke rates were stratified by the CHA2DS2VASc score.
Of 1.73 million eligible patients with diagnoses of ischemic strokes after discharge from the index hospitalization for surgery, 24,711 had new-onset peri-operative AF during the index hospitalization, and 13,952 experienced a stroke after discharge.
At one year after hospitalization for cardiac surgery, cumulative rates of stroke were 0.99% in those with peri-operative AF and 0.83% in those without AF. At one year after noncardiac surgery, cumulative rates of stroke were 1.47% in those with peri-operative AF and 0.36% in those without AF.
In a Cox proportional hazards analysis accounting for potential confounders, peri-operative AF was associated with subsequent stroke after both cardiac and noncardiac surgery.
Bottom line: Among patients hospitalized for surgery, peri-operative AF was associated with an increased long-term risk of ischemic stroke, especially following noncardiac surgery.
Lower Health Literacy Contributes to Post-Discharge Medication Errors
Clinical question: What patient characteristics contribute to post-discharge medication errors?
Background: Post-discharge medication errors are common, but the characteristics of patients associated with those errors are not well understood.
Study design: Prospective study with patient data collected via baseline interview while hospitalized and then follow-up telephone calls at three, 30, and 90 days post discharge.
Setting: Vanderbilt Hospital, Nashville, Tenn.
Synopsis: Baseline information (race, ethnicity, education, marital status, income, social support, functional health literacy, cognition, self-rated health status, depression, preadmission medication adherence, and numeracy) was collected on adult hospitalized patients with acute coronary syndrome or acute decompensated heart failure. Post-discharge telephone interviews collected data on what medications (prescription and over the counter) patients were actually taking. Binomial logistic regression was used to determine patient characteristics that predicted discordance between the discharge medication list and the patient-reported list during the post-discharge medication review.
Of the 471 patients in the study (with a mean age of 59 years and mean total number of medications of 12), over half (51.4%) of patients were taking one or more discordant medications; 27.4% did not report a medication that was on their discharge list (omission); and 35.7% reported a medication that was not on their discharge list (commission). Further, over half (59.2%) of patients misunderstood an indication (i.e., clopidogrel is “for my stomach”), a dose, or a frequency.
Bottom line: Post-discharge medication errors are common. Lower health numeracy (the ability to use and understand numbers in daily life) and lower health literacy contributes to post-discharge medication errors.
Clinical question: What patient characteristics contribute to post-discharge medication errors?
Background: Post-discharge medication errors are common, but the characteristics of patients associated with those errors are not well understood.
Study design: Prospective study with patient data collected via baseline interview while hospitalized and then follow-up telephone calls at three, 30, and 90 days post discharge.
Setting: Vanderbilt Hospital, Nashville, Tenn.
Synopsis: Baseline information (race, ethnicity, education, marital status, income, social support, functional health literacy, cognition, self-rated health status, depression, preadmission medication adherence, and numeracy) was collected on adult hospitalized patients with acute coronary syndrome or acute decompensated heart failure. Post-discharge telephone interviews collected data on what medications (prescription and over the counter) patients were actually taking. Binomial logistic regression was used to determine patient characteristics that predicted discordance between the discharge medication list and the patient-reported list during the post-discharge medication review.
Of the 471 patients in the study (with a mean age of 59 years and mean total number of medications of 12), over half (51.4%) of patients were taking one or more discordant medications; 27.4% did not report a medication that was on their discharge list (omission); and 35.7% reported a medication that was not on their discharge list (commission). Further, over half (59.2%) of patients misunderstood an indication (i.e., clopidogrel is “for my stomach”), a dose, or a frequency.
Bottom line: Post-discharge medication errors are common. Lower health numeracy (the ability to use and understand numbers in daily life) and lower health literacy contributes to post-discharge medication errors.
Clinical question: What patient characteristics contribute to post-discharge medication errors?
Background: Post-discharge medication errors are common, but the characteristics of patients associated with those errors are not well understood.
Study design: Prospective study with patient data collected via baseline interview while hospitalized and then follow-up telephone calls at three, 30, and 90 days post discharge.
Setting: Vanderbilt Hospital, Nashville, Tenn.
Synopsis: Baseline information (race, ethnicity, education, marital status, income, social support, functional health literacy, cognition, self-rated health status, depression, preadmission medication adherence, and numeracy) was collected on adult hospitalized patients with acute coronary syndrome or acute decompensated heart failure. Post-discharge telephone interviews collected data on what medications (prescription and over the counter) patients were actually taking. Binomial logistic regression was used to determine patient characteristics that predicted discordance between the discharge medication list and the patient-reported list during the post-discharge medication review.
Of the 471 patients in the study (with a mean age of 59 years and mean total number of medications of 12), over half (51.4%) of patients were taking one or more discordant medications; 27.4% did not report a medication that was on their discharge list (omission); and 35.7% reported a medication that was not on their discharge list (commission). Further, over half (59.2%) of patients misunderstood an indication (i.e., clopidogrel is “for my stomach”), a dose, or a frequency.
Bottom line: Post-discharge medication errors are common. Lower health numeracy (the ability to use and understand numbers in daily life) and lower health literacy contributes to post-discharge medication errors.
Use, Interpretation of SpO2 Treatment for Pediatric Bronchiolitis Is Questioned
Clinical question: Does artificial elevation of pulse oximetry measurement in bronchiolitis patients during ED evaluations affect hospitalization rates?
Background: Bronchiolitis is the leading cause of hospitalization for infants younger than one year, leading to direct medical costs in the U.S. of $543 million in 2002. Compromised oxyhemoglobin saturation in bronchiolitis often leads to hospitalization and is assessed by pulse oximetry (SpO2) more commonly than by arterial blood gas (SaO2) due to ease, cost, and comfort considerations.
SpO2 can vary due to fever, acidosis, hemoglobinopathies, underperfusion, and poor probe placement. An American Academy of Pediatrics clinical practice guideline published in 2006 recommended supplemental oxygen if SpO2 drops below 90% in previously healthy infants, but the data supporting this cutoff are sparse.
Recommendations for supplemental oxygen, and thus hospitalization, are variable, with recommended minimum SpO2 ranging from 90 to 95%.
Study design: Single-center randomized, double-blind, parallel-group trial.
Setting: ED at 370-bed, urban, tertiary care children’s hospital.
Synopsis: Over a 50-month period, previously healthy infants aged four weeks to 12 months who were diagnosed with bronchiolitis in the ED and had initial triage SpO2 above 88% were enrolled by investigators. Subjects were excluded if severe respiratory distress, as measured by the Respiratory Distress Assessment Instrument (RDAI), or impending respiratory failure was present. Subjects were randomized to two groups: The control group had their true SpO2 displayed during their ED stay, and the intervention group had an SpO2 that was three points higher displayed. ED physicians were not aware of the primary hypothesis being tested. All subjects underwent concealed continuous oximetry for safety reasons, with monitors alarming if SpO2 dropped below 92%. Study nurses telephoned participants discharged home 72 hours after enrollment.
The primary outcome of hospitalization was defined as admission to an inpatient ward, hospital care provided for more than six hours in the ED if no hospital beds were available, or hospitalization after discharge if within 72 hours of enrollment. Secondary outcomes included supplemental oxygen administration, length of stay in the ED, and unscheduled return visits for bronchiolitis within 72 hours. Exploratory outcomes included delayed hospitalizations within 72 hours, active hospital treatment for more than six hours (with inhaled bronchodilators, oxygen, or intravenous fluids), and hospitalization at the index visit.
Of 1,812 patients assessed, 213 were randomized after exclusion criteria and consent. The “true” group and the “altered” group were similar in initial RDAI (8.0 vs. 8.3 respectively); 41% of children in the “true” oximetry group were hospitalized within 72 hours, compared with 25% in the “high” oximetry group (P 0.005). There were no significant differences in the secondary outcomes. The only exploratory outcome to show a significant difference was treatment for longer than six hours, with 37% of the “true group” receiving treatment for longer than six hours, compared to 20% of the “altered” group (P 0.01).
Bottom line: Perception of improved oxygenation based on falsely elevated SpO2 alone can reduce the inclination of a clinician to admit children with bronchiolitis. This brings into question the use and interpretation of SpO2 in treating children with bronchiolitis.
Citation: Schuh S, Freedman S, Coates A, et al. Effect of oximetry on hospitalization in bronchiolitis: a randomized clinical trial. JAMA. 2014;312(7):712-728.
Clinical question: Does artificial elevation of pulse oximetry measurement in bronchiolitis patients during ED evaluations affect hospitalization rates?
Background: Bronchiolitis is the leading cause of hospitalization for infants younger than one year, leading to direct medical costs in the U.S. of $543 million in 2002. Compromised oxyhemoglobin saturation in bronchiolitis often leads to hospitalization and is assessed by pulse oximetry (SpO2) more commonly than by arterial blood gas (SaO2) due to ease, cost, and comfort considerations.
SpO2 can vary due to fever, acidosis, hemoglobinopathies, underperfusion, and poor probe placement. An American Academy of Pediatrics clinical practice guideline published in 2006 recommended supplemental oxygen if SpO2 drops below 90% in previously healthy infants, but the data supporting this cutoff are sparse.
Recommendations for supplemental oxygen, and thus hospitalization, are variable, with recommended minimum SpO2 ranging from 90 to 95%.
Study design: Single-center randomized, double-blind, parallel-group trial.
Setting: ED at 370-bed, urban, tertiary care children’s hospital.
Synopsis: Over a 50-month period, previously healthy infants aged four weeks to 12 months who were diagnosed with bronchiolitis in the ED and had initial triage SpO2 above 88% were enrolled by investigators. Subjects were excluded if severe respiratory distress, as measured by the Respiratory Distress Assessment Instrument (RDAI), or impending respiratory failure was present. Subjects were randomized to two groups: The control group had their true SpO2 displayed during their ED stay, and the intervention group had an SpO2 that was three points higher displayed. ED physicians were not aware of the primary hypothesis being tested. All subjects underwent concealed continuous oximetry for safety reasons, with monitors alarming if SpO2 dropped below 92%. Study nurses telephoned participants discharged home 72 hours after enrollment.
The primary outcome of hospitalization was defined as admission to an inpatient ward, hospital care provided for more than six hours in the ED if no hospital beds were available, or hospitalization after discharge if within 72 hours of enrollment. Secondary outcomes included supplemental oxygen administration, length of stay in the ED, and unscheduled return visits for bronchiolitis within 72 hours. Exploratory outcomes included delayed hospitalizations within 72 hours, active hospital treatment for more than six hours (with inhaled bronchodilators, oxygen, or intravenous fluids), and hospitalization at the index visit.
Of 1,812 patients assessed, 213 were randomized after exclusion criteria and consent. The “true” group and the “altered” group were similar in initial RDAI (8.0 vs. 8.3 respectively); 41% of children in the “true” oximetry group were hospitalized within 72 hours, compared with 25% in the “high” oximetry group (P 0.005). There were no significant differences in the secondary outcomes. The only exploratory outcome to show a significant difference was treatment for longer than six hours, with 37% of the “true group” receiving treatment for longer than six hours, compared to 20% of the “altered” group (P 0.01).
Bottom line: Perception of improved oxygenation based on falsely elevated SpO2 alone can reduce the inclination of a clinician to admit children with bronchiolitis. This brings into question the use and interpretation of SpO2 in treating children with bronchiolitis.
Citation: Schuh S, Freedman S, Coates A, et al. Effect of oximetry on hospitalization in bronchiolitis: a randomized clinical trial. JAMA. 2014;312(7):712-728.
Clinical question: Does artificial elevation of pulse oximetry measurement in bronchiolitis patients during ED evaluations affect hospitalization rates?
Background: Bronchiolitis is the leading cause of hospitalization for infants younger than one year, leading to direct medical costs in the U.S. of $543 million in 2002. Compromised oxyhemoglobin saturation in bronchiolitis often leads to hospitalization and is assessed by pulse oximetry (SpO2) more commonly than by arterial blood gas (SaO2) due to ease, cost, and comfort considerations.
SpO2 can vary due to fever, acidosis, hemoglobinopathies, underperfusion, and poor probe placement. An American Academy of Pediatrics clinical practice guideline published in 2006 recommended supplemental oxygen if SpO2 drops below 90% in previously healthy infants, but the data supporting this cutoff are sparse.
Recommendations for supplemental oxygen, and thus hospitalization, are variable, with recommended minimum SpO2 ranging from 90 to 95%.
Study design: Single-center randomized, double-blind, parallel-group trial.
Setting: ED at 370-bed, urban, tertiary care children’s hospital.
Synopsis: Over a 50-month period, previously healthy infants aged four weeks to 12 months who were diagnosed with bronchiolitis in the ED and had initial triage SpO2 above 88% were enrolled by investigators. Subjects were excluded if severe respiratory distress, as measured by the Respiratory Distress Assessment Instrument (RDAI), or impending respiratory failure was present. Subjects were randomized to two groups: The control group had their true SpO2 displayed during their ED stay, and the intervention group had an SpO2 that was three points higher displayed. ED physicians were not aware of the primary hypothesis being tested. All subjects underwent concealed continuous oximetry for safety reasons, with monitors alarming if SpO2 dropped below 92%. Study nurses telephoned participants discharged home 72 hours after enrollment.
The primary outcome of hospitalization was defined as admission to an inpatient ward, hospital care provided for more than six hours in the ED if no hospital beds were available, or hospitalization after discharge if within 72 hours of enrollment. Secondary outcomes included supplemental oxygen administration, length of stay in the ED, and unscheduled return visits for bronchiolitis within 72 hours. Exploratory outcomes included delayed hospitalizations within 72 hours, active hospital treatment for more than six hours (with inhaled bronchodilators, oxygen, or intravenous fluids), and hospitalization at the index visit.
Of 1,812 patients assessed, 213 were randomized after exclusion criteria and consent. The “true” group and the “altered” group were similar in initial RDAI (8.0 vs. 8.3 respectively); 41% of children in the “true” oximetry group were hospitalized within 72 hours, compared with 25% in the “high” oximetry group (P 0.005). There were no significant differences in the secondary outcomes. The only exploratory outcome to show a significant difference was treatment for longer than six hours, with 37% of the “true group” receiving treatment for longer than six hours, compared to 20% of the “altered” group (P 0.01).
Bottom line: Perception of improved oxygenation based on falsely elevated SpO2 alone can reduce the inclination of a clinician to admit children with bronchiolitis. This brings into question the use and interpretation of SpO2 in treating children with bronchiolitis.
Citation: Schuh S, Freedman S, Coates A, et al. Effect of oximetry on hospitalization in bronchiolitis: a randomized clinical trial. JAMA. 2014;312(7):712-728.
Does Intra-Arterial Treatment Benefit Patients With Ischemic Stroke?
Intra-arterial treatment is effective and safe when administered within six hours of acute ischemic stroke resulting from a proximal intracranial occlusion of the anterior circulation, according to research published online ahead of print December 17, 2014, in the New England Journal of Medicine. The treatment aids functional recovery and increases functional independence by three months, researchers said. This study follows several similar investigations that yielded mixed or negative results regarding the benefits of this therapy.
Examining Intra-Arterial Treatment and Standard Therapy
Olvert A. Berkhemer, MD, of the Department of Neurology at Erasmus University Medical Center in Rotterdam, the Netherlands, and colleagues initiated the Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands (MR CLEAN) to compare intra-arterial treatment plus standard care with standard care alone. Eligible patients were 18 or older and had an acute ischemic stroke. The investigators enrolled patients with an occlusion of the distal intracranial carotid artery, middle cerebral artery, or anterior cerebral artery that had been established with CT angiography, magnetic resonance angiography, or digital-subtraction angiography. Eligible patients also had a score of 2 or higher on the NIH Stroke Scale (NIHSS). According to the study protocol, initiation of intra-arterial treatment had to be possible within six hours of stroke onset.
The researchers randomized patients using a Web-based tool. Local interventionists chose the method of intra-arterial treatment, which consisted of arterial catheterization with a microcatheter to the level of occlusion and delivery of a thrombolytic agent, mechanical thrombectomy, or both. The investigators permitted a maximum dose of 90 mg of alteplase or 1,200,000 IU of urokinase to be administered for intra-arterial thrombolysis. The dose was restricted to 30 mg of alteplase or 400,000 IU of urokinase if IV alteplase was given. Methods of mechanical treatment included thrombus retraction, aspiration, wire disruption, and the use of a retrievable stent.
The study’s primary outcome was modified Rankin scale score at 90 days. Secondary outcomes included NIHSS score at 24 hours and at five to seven days or discharge (if earlier), activities of daily living measured with the Barthel index, and the health-related quality of life measured with the EuroQol Group 5-Dimension Self-Report Questionnaire (EQ-5D) at 90 days. Safety variables included hemorrhagic complications, progression of ischemic stroke, new ischemic stroke into a different vascular territory, and death.
Intervention Improved Modified Rankin Scale Score
Dr. Berkhemer and colleagues randomized 502 patients at 16 medical centers. Two patients withdrew consent and were not included in the intention-to-treat analysis. The study population’s mean age was 65, and 58.4% of participants were men. In all, 233 patients were assigned to the intervention group and 267 patients were assigned to the control group. Risk factors for a poor outcome, clinical risk factors for stroke, and aspects of rerandomization treatment were evenly distributed between the two treatment groups.
The median modified Rankin scale score at 90 days was 3 for patients who received intra-arterial treatment plus standard care, compared with 4 for patients who received standard care alone. Approximately 33% of patients in the intervention group had a modified Rankin score of 0 to 2 at 90 days, compared with 19% of the control group.
Median NIHSS score at five to seven days or discharge was 8 for the intervention group and 14 for the control group. Approximately 46% of patients who received intra-arterial therapy plus standard care had a Barthel index of 19 or 20 at 90 days, compared with 30% of patients who received standard care alone. Median EQ-5D score at 90 days was 0.69 for the intervention group and 0.66 for the control group.
An absence of residual occlusion at the target site was more common in the intervention group (75.4%) than in the control group (32.9%). Infarct volume was 19 mL smaller in the intervention group than in the control group, and good reperfusion was achieved in 58.7% of patients in the intervention group.
The rate of serious adverse events during follow-up did not differ significantly between the two groups. Thirteen of the 233 patients (5.6%) in the intervention group, however, had clinical signs of a new ischemic stroke in a different vascular territory within 90 days, compared with one of the 267 patients (0.4%) in the control group.
Results Diverged From Those of Previous Studies
“Our findings stand in clear distinction to those of recent randomized, controlled trials that failed to show a benefit of intra-arterial treatment,” said Dr. Berkhemer. Unlike some of those studies, MR CLEAN required participants to have a radiologically proven intracranial occlusion. “It is likely that intra-arterial treatment will not alter the natural history of acute ischemic stroke in the absence of a proximal arterial occlusion,” added Dr. Berkhemer.
“Our study benefited from the widespread availability of retrievable stents, which were used in 82% of the patients in the intervention group. These devices were recently shown to be superior to the first-generation Merci device for both revascularization and clinical outcomes.” Yet the study was limited by slightly unbalanced randomization, a relatively low reperfusion rate, and patients’ awareness of their treatment group assignments, Dr. Berkhemer said.
One Small Step?
“MR CLEAN is the first step in the right direction,” said Werner Hacke, MD, PhD, Professor and Chairman of the Department of Neurology at the University of Heidelberg in Germany, in an accompanying editorial. Other investigators are conducting similar trials, and “it is premature to conclude that there is no longer equipoise regarding thrombectomy,” he added. “We need and will get results from other well-designed trials, not only to confirm or refute the results of MR CLEAN, but also to look at effects in subgroups (according to stroke severity, occlusion site, or time to treatment initiation), for which most single trials are underpowered.”
—Erik Greb
Suggested Reading
Berkhemer OA, Fransen PS, Beumer D, et al. A randomized trial of intraarterial treatment for acute ischemic stroke. N Engl J Med. 2014 Dec 17 [Epub ahead of print].
Hacke W. Interventional thrombectomy for major stroke - a step in the right direction. N Engl J Med. 2014 Dec 17 [Epub ahead of print].
Intra-arterial treatment is effective and safe when administered within six hours of acute ischemic stroke resulting from a proximal intracranial occlusion of the anterior circulation, according to research published online ahead of print December 17, 2014, in the New England Journal of Medicine. The treatment aids functional recovery and increases functional independence by three months, researchers said. This study follows several similar investigations that yielded mixed or negative results regarding the benefits of this therapy.
Examining Intra-Arterial Treatment and Standard Therapy
Olvert A. Berkhemer, MD, of the Department of Neurology at Erasmus University Medical Center in Rotterdam, the Netherlands, and colleagues initiated the Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands (MR CLEAN) to compare intra-arterial treatment plus standard care with standard care alone. Eligible patients were 18 or older and had an acute ischemic stroke. The investigators enrolled patients with an occlusion of the distal intracranial carotid artery, middle cerebral artery, or anterior cerebral artery that had been established with CT angiography, magnetic resonance angiography, or digital-subtraction angiography. Eligible patients also had a score of 2 or higher on the NIH Stroke Scale (NIHSS). According to the study protocol, initiation of intra-arterial treatment had to be possible within six hours of stroke onset.
The researchers randomized patients using a Web-based tool. Local interventionists chose the method of intra-arterial treatment, which consisted of arterial catheterization with a microcatheter to the level of occlusion and delivery of a thrombolytic agent, mechanical thrombectomy, or both. The investigators permitted a maximum dose of 90 mg of alteplase or 1,200,000 IU of urokinase to be administered for intra-arterial thrombolysis. The dose was restricted to 30 mg of alteplase or 400,000 IU of urokinase if IV alteplase was given. Methods of mechanical treatment included thrombus retraction, aspiration, wire disruption, and the use of a retrievable stent.
The study’s primary outcome was modified Rankin scale score at 90 days. Secondary outcomes included NIHSS score at 24 hours and at five to seven days or discharge (if earlier), activities of daily living measured with the Barthel index, and the health-related quality of life measured with the EuroQol Group 5-Dimension Self-Report Questionnaire (EQ-5D) at 90 days. Safety variables included hemorrhagic complications, progression of ischemic stroke, new ischemic stroke into a different vascular territory, and death.
Intervention Improved Modified Rankin Scale Score
Dr. Berkhemer and colleagues randomized 502 patients at 16 medical centers. Two patients withdrew consent and were not included in the intention-to-treat analysis. The study population’s mean age was 65, and 58.4% of participants were men. In all, 233 patients were assigned to the intervention group and 267 patients were assigned to the control group. Risk factors for a poor outcome, clinical risk factors for stroke, and aspects of rerandomization treatment were evenly distributed between the two treatment groups.
The median modified Rankin scale score at 90 days was 3 for patients who received intra-arterial treatment plus standard care, compared with 4 for patients who received standard care alone. Approximately 33% of patients in the intervention group had a modified Rankin score of 0 to 2 at 90 days, compared with 19% of the control group.
Median NIHSS score at five to seven days or discharge was 8 for the intervention group and 14 for the control group. Approximately 46% of patients who received intra-arterial therapy plus standard care had a Barthel index of 19 or 20 at 90 days, compared with 30% of patients who received standard care alone. Median EQ-5D score at 90 days was 0.69 for the intervention group and 0.66 for the control group.
An absence of residual occlusion at the target site was more common in the intervention group (75.4%) than in the control group (32.9%). Infarct volume was 19 mL smaller in the intervention group than in the control group, and good reperfusion was achieved in 58.7% of patients in the intervention group.
The rate of serious adverse events during follow-up did not differ significantly between the two groups. Thirteen of the 233 patients (5.6%) in the intervention group, however, had clinical signs of a new ischemic stroke in a different vascular territory within 90 days, compared with one of the 267 patients (0.4%) in the control group.
Results Diverged From Those of Previous Studies
“Our findings stand in clear distinction to those of recent randomized, controlled trials that failed to show a benefit of intra-arterial treatment,” said Dr. Berkhemer. Unlike some of those studies, MR CLEAN required participants to have a radiologically proven intracranial occlusion. “It is likely that intra-arterial treatment will not alter the natural history of acute ischemic stroke in the absence of a proximal arterial occlusion,” added Dr. Berkhemer.
“Our study benefited from the widespread availability of retrievable stents, which were used in 82% of the patients in the intervention group. These devices were recently shown to be superior to the first-generation Merci device for both revascularization and clinical outcomes.” Yet the study was limited by slightly unbalanced randomization, a relatively low reperfusion rate, and patients’ awareness of their treatment group assignments, Dr. Berkhemer said.
One Small Step?
“MR CLEAN is the first step in the right direction,” said Werner Hacke, MD, PhD, Professor and Chairman of the Department of Neurology at the University of Heidelberg in Germany, in an accompanying editorial. Other investigators are conducting similar trials, and “it is premature to conclude that there is no longer equipoise regarding thrombectomy,” he added. “We need and will get results from other well-designed trials, not only to confirm or refute the results of MR CLEAN, but also to look at effects in subgroups (according to stroke severity, occlusion site, or time to treatment initiation), for which most single trials are underpowered.”
—Erik Greb
Intra-arterial treatment is effective and safe when administered within six hours of acute ischemic stroke resulting from a proximal intracranial occlusion of the anterior circulation, according to research published online ahead of print December 17, 2014, in the New England Journal of Medicine. The treatment aids functional recovery and increases functional independence by three months, researchers said. This study follows several similar investigations that yielded mixed or negative results regarding the benefits of this therapy.
Examining Intra-Arterial Treatment and Standard Therapy
Olvert A. Berkhemer, MD, of the Department of Neurology at Erasmus University Medical Center in Rotterdam, the Netherlands, and colleagues initiated the Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands (MR CLEAN) to compare intra-arterial treatment plus standard care with standard care alone. Eligible patients were 18 or older and had an acute ischemic stroke. The investigators enrolled patients with an occlusion of the distal intracranial carotid artery, middle cerebral artery, or anterior cerebral artery that had been established with CT angiography, magnetic resonance angiography, or digital-subtraction angiography. Eligible patients also had a score of 2 or higher on the NIH Stroke Scale (NIHSS). According to the study protocol, initiation of intra-arterial treatment had to be possible within six hours of stroke onset.
The researchers randomized patients using a Web-based tool. Local interventionists chose the method of intra-arterial treatment, which consisted of arterial catheterization with a microcatheter to the level of occlusion and delivery of a thrombolytic agent, mechanical thrombectomy, or both. The investigators permitted a maximum dose of 90 mg of alteplase or 1,200,000 IU of urokinase to be administered for intra-arterial thrombolysis. The dose was restricted to 30 mg of alteplase or 400,000 IU of urokinase if IV alteplase was given. Methods of mechanical treatment included thrombus retraction, aspiration, wire disruption, and the use of a retrievable stent.
The study’s primary outcome was modified Rankin scale score at 90 days. Secondary outcomes included NIHSS score at 24 hours and at five to seven days or discharge (if earlier), activities of daily living measured with the Barthel index, and the health-related quality of life measured with the EuroQol Group 5-Dimension Self-Report Questionnaire (EQ-5D) at 90 days. Safety variables included hemorrhagic complications, progression of ischemic stroke, new ischemic stroke into a different vascular territory, and death.
Intervention Improved Modified Rankin Scale Score
Dr. Berkhemer and colleagues randomized 502 patients at 16 medical centers. Two patients withdrew consent and were not included in the intention-to-treat analysis. The study population’s mean age was 65, and 58.4% of participants were men. In all, 233 patients were assigned to the intervention group and 267 patients were assigned to the control group. Risk factors for a poor outcome, clinical risk factors for stroke, and aspects of rerandomization treatment were evenly distributed between the two treatment groups.
The median modified Rankin scale score at 90 days was 3 for patients who received intra-arterial treatment plus standard care, compared with 4 for patients who received standard care alone. Approximately 33% of patients in the intervention group had a modified Rankin score of 0 to 2 at 90 days, compared with 19% of the control group.
Median NIHSS score at five to seven days or discharge was 8 for the intervention group and 14 for the control group. Approximately 46% of patients who received intra-arterial therapy plus standard care had a Barthel index of 19 or 20 at 90 days, compared with 30% of patients who received standard care alone. Median EQ-5D score at 90 days was 0.69 for the intervention group and 0.66 for the control group.
An absence of residual occlusion at the target site was more common in the intervention group (75.4%) than in the control group (32.9%). Infarct volume was 19 mL smaller in the intervention group than in the control group, and good reperfusion was achieved in 58.7% of patients in the intervention group.
The rate of serious adverse events during follow-up did not differ significantly between the two groups. Thirteen of the 233 patients (5.6%) in the intervention group, however, had clinical signs of a new ischemic stroke in a different vascular territory within 90 days, compared with one of the 267 patients (0.4%) in the control group.
Results Diverged From Those of Previous Studies
“Our findings stand in clear distinction to those of recent randomized, controlled trials that failed to show a benefit of intra-arterial treatment,” said Dr. Berkhemer. Unlike some of those studies, MR CLEAN required participants to have a radiologically proven intracranial occlusion. “It is likely that intra-arterial treatment will not alter the natural history of acute ischemic stroke in the absence of a proximal arterial occlusion,” added Dr. Berkhemer.
“Our study benefited from the widespread availability of retrievable stents, which were used in 82% of the patients in the intervention group. These devices were recently shown to be superior to the first-generation Merci device for both revascularization and clinical outcomes.” Yet the study was limited by slightly unbalanced randomization, a relatively low reperfusion rate, and patients’ awareness of their treatment group assignments, Dr. Berkhemer said.
One Small Step?
“MR CLEAN is the first step in the right direction,” said Werner Hacke, MD, PhD, Professor and Chairman of the Department of Neurology at the University of Heidelberg in Germany, in an accompanying editorial. Other investigators are conducting similar trials, and “it is premature to conclude that there is no longer equipoise regarding thrombectomy,” he added. “We need and will get results from other well-designed trials, not only to confirm or refute the results of MR CLEAN, but also to look at effects in subgroups (according to stroke severity, occlusion site, or time to treatment initiation), for which most single trials are underpowered.”
—Erik Greb
Suggested Reading
Berkhemer OA, Fransen PS, Beumer D, et al. A randomized trial of intraarterial treatment for acute ischemic stroke. N Engl J Med. 2014 Dec 17 [Epub ahead of print].
Hacke W. Interventional thrombectomy for major stroke - a step in the right direction. N Engl J Med. 2014 Dec 17 [Epub ahead of print].
Suggested Reading
Berkhemer OA, Fransen PS, Beumer D, et al. A randomized trial of intraarterial treatment for acute ischemic stroke. N Engl J Med. 2014 Dec 17 [Epub ahead of print].
Hacke W. Interventional thrombectomy for major stroke - a step in the right direction. N Engl J Med. 2014 Dec 17 [Epub ahead of print].
Marijuana’s Long-Term Effects on the Brain
The effects of chronic marijuana use on the brain may depend on age of first use and duration of use, according to a study published online ahead of print November 10 in Proceedings of the National Academy of Sciences.
Researchers have described abnormalities in brain function and structure among long-term marijuana users with multiple MRI techniques. Findings show that chronic marijuana users have smaller brain volume in the orbitofrontal cortex (OFC), a part of the brain commonly associated with addiction, but also increased brain connectivity.
“We have seen a steady increase in the incidence of marijuana use since 2007,” said Dr. Francesca Filbey, PhD, Director of the Cognitive Neuroscience Research in Addictive Disorders at the Center for Brain Health and Associate Professor of the Neurogenetics of Addictive Behavior in the School of Behavioral and Brain Sciences, University of Texas at Dallas. “However, research on its long-term effects remains scarce despite the changes in legislation surrounding marijuana and the continuing conversation surrounding this relevant public health topic.”
Chronic Users Had Lower IQ
The research team studied 48 adult marijuana users and 62 gender- and age-matched nonusers, accounting for potential biases such as gender, age, and ethnicity. The authors also controlled for tobacco and alcohol use. On average, the marijuana users who participated in the study consumed the drug three times per day. Cognitive tests showed that chronic marijuana users had lower IQ, compared with age-and gender-matched controls, but the differences did not seem to be related to the brain abnormalities, because no direct correlation could be drawn between IQ deficits and OFC volume decrease.
“What’s unique about this work is that it combines three different MRI techniques to evaluate different brain characteristics,” said Sina Aslan, PhD, Founder and President of Advance MRI and Adjunct Assistant Professor at the University of Texas at Dallas. “The results suggest increases in connectivity, both structural and functional, that may be compensating for gray matter losses. Eventually, however, the structural connectivity or ‘wiring’ of the brain starts degrading with prolonged marijuana use.”
Tests revealed that earlier onset of regular marijuana use induced greater structural and functional connectivity. The greatest increases in connectivity appear as an individual begins using marijuana. Findings showed that frequency of use was directly correlated with greater connectivity.
Although increased structural wiring declines after six to eight years of continued chronic use, marijuana users continue to display more intense connectivity than healthy nonusers, and this result may explain why chronic, long-term users “seem to be doing just fine” despite smaller OFC brain volumes, explained Dr. Filbey.
Gray Matter May Be Vulnerable to THC
“To date, existing studies on the long-term effects of marijuana on brain structures have been largely inconclusive due to limitations in methodologies,” said Dr. Filbey. “While our study does not conclusively address whether any or all of the brain changes are a direct consequence of marijuana use, these effects do suggest that these changes are related to age of onset and duration of use.”
The study offers a preliminary indication that gray matter in the OFC may be more vulnerable than white matter to the effects of delta-9-tetrahydrocannabinol (THC), the main psychoactive ingredient in the cannabis plant. The study provides evidence that chronic marijuana use initiates a complex process that allows neurons to adapt and compensate for smaller gray matter volume, according to the authors. Nevertheless, further studies are needed to determine whether these changes revert to normal with discontinued marijuana use, whether similar effects are present in occasional marijuana users versus chronic users, and whether these effects are indeed a direct result of marijuana use or a predisposing factor.
Suggested Reading
Filbey FM, Aslan S, Calhoun VD, et al. Long-term effects of marijuana use on the brain. Proc Natl Acad Sci U S A. 2014 Nov 10 [Epub ahead of print].
The effects of chronic marijuana use on the brain may depend on age of first use and duration of use, according to a study published online ahead of print November 10 in Proceedings of the National Academy of Sciences.
Researchers have described abnormalities in brain function and structure among long-term marijuana users with multiple MRI techniques. Findings show that chronic marijuana users have smaller brain volume in the orbitofrontal cortex (OFC), a part of the brain commonly associated with addiction, but also increased brain connectivity.
“We have seen a steady increase in the incidence of marijuana use since 2007,” said Dr. Francesca Filbey, PhD, Director of the Cognitive Neuroscience Research in Addictive Disorders at the Center for Brain Health and Associate Professor of the Neurogenetics of Addictive Behavior in the School of Behavioral and Brain Sciences, University of Texas at Dallas. “However, research on its long-term effects remains scarce despite the changes in legislation surrounding marijuana and the continuing conversation surrounding this relevant public health topic.”
Chronic Users Had Lower IQ
The research team studied 48 adult marijuana users and 62 gender- and age-matched nonusers, accounting for potential biases such as gender, age, and ethnicity. The authors also controlled for tobacco and alcohol use. On average, the marijuana users who participated in the study consumed the drug three times per day. Cognitive tests showed that chronic marijuana users had lower IQ, compared with age-and gender-matched controls, but the differences did not seem to be related to the brain abnormalities, because no direct correlation could be drawn between IQ deficits and OFC volume decrease.
“What’s unique about this work is that it combines three different MRI techniques to evaluate different brain characteristics,” said Sina Aslan, PhD, Founder and President of Advance MRI and Adjunct Assistant Professor at the University of Texas at Dallas. “The results suggest increases in connectivity, both structural and functional, that may be compensating for gray matter losses. Eventually, however, the structural connectivity or ‘wiring’ of the brain starts degrading with prolonged marijuana use.”
Tests revealed that earlier onset of regular marijuana use induced greater structural and functional connectivity. The greatest increases in connectivity appear as an individual begins using marijuana. Findings showed that frequency of use was directly correlated with greater connectivity.
Although increased structural wiring declines after six to eight years of continued chronic use, marijuana users continue to display more intense connectivity than healthy nonusers, and this result may explain why chronic, long-term users “seem to be doing just fine” despite smaller OFC brain volumes, explained Dr. Filbey.
Gray Matter May Be Vulnerable to THC
“To date, existing studies on the long-term effects of marijuana on brain structures have been largely inconclusive due to limitations in methodologies,” said Dr. Filbey. “While our study does not conclusively address whether any or all of the brain changes are a direct consequence of marijuana use, these effects do suggest that these changes are related to age of onset and duration of use.”
The study offers a preliminary indication that gray matter in the OFC may be more vulnerable than white matter to the effects of delta-9-tetrahydrocannabinol (THC), the main psychoactive ingredient in the cannabis plant. The study provides evidence that chronic marijuana use initiates a complex process that allows neurons to adapt and compensate for smaller gray matter volume, according to the authors. Nevertheless, further studies are needed to determine whether these changes revert to normal with discontinued marijuana use, whether similar effects are present in occasional marijuana users versus chronic users, and whether these effects are indeed a direct result of marijuana use or a predisposing factor.
The effects of chronic marijuana use on the brain may depend on age of first use and duration of use, according to a study published online ahead of print November 10 in Proceedings of the National Academy of Sciences.
Researchers have described abnormalities in brain function and structure among long-term marijuana users with multiple MRI techniques. Findings show that chronic marijuana users have smaller brain volume in the orbitofrontal cortex (OFC), a part of the brain commonly associated with addiction, but also increased brain connectivity.
“We have seen a steady increase in the incidence of marijuana use since 2007,” said Dr. Francesca Filbey, PhD, Director of the Cognitive Neuroscience Research in Addictive Disorders at the Center for Brain Health and Associate Professor of the Neurogenetics of Addictive Behavior in the School of Behavioral and Brain Sciences, University of Texas at Dallas. “However, research on its long-term effects remains scarce despite the changes in legislation surrounding marijuana and the continuing conversation surrounding this relevant public health topic.”
Chronic Users Had Lower IQ
The research team studied 48 adult marijuana users and 62 gender- and age-matched nonusers, accounting for potential biases such as gender, age, and ethnicity. The authors also controlled for tobacco and alcohol use. On average, the marijuana users who participated in the study consumed the drug three times per day. Cognitive tests showed that chronic marijuana users had lower IQ, compared with age-and gender-matched controls, but the differences did not seem to be related to the brain abnormalities, because no direct correlation could be drawn between IQ deficits and OFC volume decrease.
“What’s unique about this work is that it combines three different MRI techniques to evaluate different brain characteristics,” said Sina Aslan, PhD, Founder and President of Advance MRI and Adjunct Assistant Professor at the University of Texas at Dallas. “The results suggest increases in connectivity, both structural and functional, that may be compensating for gray matter losses. Eventually, however, the structural connectivity or ‘wiring’ of the brain starts degrading with prolonged marijuana use.”
Tests revealed that earlier onset of regular marijuana use induced greater structural and functional connectivity. The greatest increases in connectivity appear as an individual begins using marijuana. Findings showed that frequency of use was directly correlated with greater connectivity.
Although increased structural wiring declines after six to eight years of continued chronic use, marijuana users continue to display more intense connectivity than healthy nonusers, and this result may explain why chronic, long-term users “seem to be doing just fine” despite smaller OFC brain volumes, explained Dr. Filbey.
Gray Matter May Be Vulnerable to THC
“To date, existing studies on the long-term effects of marijuana on brain structures have been largely inconclusive due to limitations in methodologies,” said Dr. Filbey. “While our study does not conclusively address whether any or all of the brain changes are a direct consequence of marijuana use, these effects do suggest that these changes are related to age of onset and duration of use.”
The study offers a preliminary indication that gray matter in the OFC may be more vulnerable than white matter to the effects of delta-9-tetrahydrocannabinol (THC), the main psychoactive ingredient in the cannabis plant. The study provides evidence that chronic marijuana use initiates a complex process that allows neurons to adapt and compensate for smaller gray matter volume, according to the authors. Nevertheless, further studies are needed to determine whether these changes revert to normal with discontinued marijuana use, whether similar effects are present in occasional marijuana users versus chronic users, and whether these effects are indeed a direct result of marijuana use or a predisposing factor.
Suggested Reading
Filbey FM, Aslan S, Calhoun VD, et al. Long-term effects of marijuana use on the brain. Proc Natl Acad Sci U S A. 2014 Nov 10 [Epub ahead of print].
Suggested Reading
Filbey FM, Aslan S, Calhoun VD, et al. Long-term effects of marijuana use on the brain. Proc Natl Acad Sci U S A. 2014 Nov 10 [Epub ahead of print].
Updated Guidelines for Primary Stroke Prevention
For people who have not had a stroke or a transient ischemic attack, a diet rich in fruits and vegetables and high in potassium may lower the risk of stroke, according to updated guidelines from the American Heart Association and the American Stroke Association. A Mediterranean diet supplemented with nuts may be considered as a means of lowering the risk of stroke, although the evidence for this recommendation is less strong, according to the guidelines, which were published online ahead of print October 28 in Stroke.
“We have a huge opportunity to improve how we prevent new strokes, because risk factors that can be changed or controlled—especially high blood pressure—account for 90% of strokes,” said James Meschia, MD, Professor and Chair of Neurology at the Mayo Clinic in Jacksonville, Florida, and lead author of the guidelines, which were affirmed by the American Academy of Neurology.
Dr. Meschia and colleagues reviewed the evidence on established and emerging risk factors for stroke, as well as for various interventions to lower stroke risk. Among the guidelines’ updated recommendations is that healthy adults should perform at least moderate- to vigorous-intensity aerobic physical activity for 40 minutes per day, three to four days per week. Class I evidence indicates that physical activity is associated with a reduction in the risk of stroke.
In addition, the guidelines recommend weight reduction for overweight and obese individuals to lower blood pressure and reduce the risk of stroke. Patients with type 1 or type 2 diabetes should control their blood pressure to a target of less than 140/90 mm Hg, said the authors. For patients with diabetes but low 10-year risk of cardiovascular disease, the usefulness of aspirin for primary stroke prevention is unclear, they added.
Many new recommendations focus on persons with hypertension. These recommendations include regular blood pressure screening and appropriate treatment of hypertension, including lifestyle modification and pharmacologic therapy. The guidelines also recommend annual screening for high blood pressure and health-promoting lifestyle modification for patients with prehypertension.
Other new recommendations are intended for migraineurs. For example, the authors recommend smoking cessation for women with migraine headaches with aura. These women also might consider alternatives to oral contraceptives, especially those containing estrogen. Closure of patent foramen ovale is not indicated for preventing stroke in patients with migraine, however.
New evidence has strengthened the recommendation that active smokers undergo counseling in combination with drug therapy using nicotine replacement, bupropion, or varenicline to assist in quitting smoking. The authors also stated that community-wide or statewide bans on smoking in public spaces are reasonable for reducing the risk of stroke and myocardial infarction.
“Talking about stroke prevention is worthwhile,” said Dr. Meschia. “In many instances, stroke isn’t fatal, but it leads to years of physical, emotional, and mental impairment that could be avoided.”
—Erik Greb
Suggested Reading
Meschia JF, Bushnell C, Boden-Albala B, et al. Guidelines for the primary prevention of stroke: a statement for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2014 Oct 28 [Epub ahead of print].
For people who have not had a stroke or a transient ischemic attack, a diet rich in fruits and vegetables and high in potassium may lower the risk of stroke, according to updated guidelines from the American Heart Association and the American Stroke Association. A Mediterranean diet supplemented with nuts may be considered as a means of lowering the risk of stroke, although the evidence for this recommendation is less strong, according to the guidelines, which were published online ahead of print October 28 in Stroke.
“We have a huge opportunity to improve how we prevent new strokes, because risk factors that can be changed or controlled—especially high blood pressure—account for 90% of strokes,” said James Meschia, MD, Professor and Chair of Neurology at the Mayo Clinic in Jacksonville, Florida, and lead author of the guidelines, which were affirmed by the American Academy of Neurology.
Dr. Meschia and colleagues reviewed the evidence on established and emerging risk factors for stroke, as well as for various interventions to lower stroke risk. Among the guidelines’ updated recommendations is that healthy adults should perform at least moderate- to vigorous-intensity aerobic physical activity for 40 minutes per day, three to four days per week. Class I evidence indicates that physical activity is associated with a reduction in the risk of stroke.
In addition, the guidelines recommend weight reduction for overweight and obese individuals to lower blood pressure and reduce the risk of stroke. Patients with type 1 or type 2 diabetes should control their blood pressure to a target of less than 140/90 mm Hg, said the authors. For patients with diabetes but low 10-year risk of cardiovascular disease, the usefulness of aspirin for primary stroke prevention is unclear, they added.
Many new recommendations focus on persons with hypertension. These recommendations include regular blood pressure screening and appropriate treatment of hypertension, including lifestyle modification and pharmacologic therapy. The guidelines also recommend annual screening for high blood pressure and health-promoting lifestyle modification for patients with prehypertension.
Other new recommendations are intended for migraineurs. For example, the authors recommend smoking cessation for women with migraine headaches with aura. These women also might consider alternatives to oral contraceptives, especially those containing estrogen. Closure of patent foramen ovale is not indicated for preventing stroke in patients with migraine, however.
New evidence has strengthened the recommendation that active smokers undergo counseling in combination with drug therapy using nicotine replacement, bupropion, or varenicline to assist in quitting smoking. The authors also stated that community-wide or statewide bans on smoking in public spaces are reasonable for reducing the risk of stroke and myocardial infarction.
“Talking about stroke prevention is worthwhile,” said Dr. Meschia. “In many instances, stroke isn’t fatal, but it leads to years of physical, emotional, and mental impairment that could be avoided.”
—Erik Greb
For people who have not had a stroke or a transient ischemic attack, a diet rich in fruits and vegetables and high in potassium may lower the risk of stroke, according to updated guidelines from the American Heart Association and the American Stroke Association. A Mediterranean diet supplemented with nuts may be considered as a means of lowering the risk of stroke, although the evidence for this recommendation is less strong, according to the guidelines, which were published online ahead of print October 28 in Stroke.
“We have a huge opportunity to improve how we prevent new strokes, because risk factors that can be changed or controlled—especially high blood pressure—account for 90% of strokes,” said James Meschia, MD, Professor and Chair of Neurology at the Mayo Clinic in Jacksonville, Florida, and lead author of the guidelines, which were affirmed by the American Academy of Neurology.
Dr. Meschia and colleagues reviewed the evidence on established and emerging risk factors for stroke, as well as for various interventions to lower stroke risk. Among the guidelines’ updated recommendations is that healthy adults should perform at least moderate- to vigorous-intensity aerobic physical activity for 40 minutes per day, three to four days per week. Class I evidence indicates that physical activity is associated with a reduction in the risk of stroke.
In addition, the guidelines recommend weight reduction for overweight and obese individuals to lower blood pressure and reduce the risk of stroke. Patients with type 1 or type 2 diabetes should control their blood pressure to a target of less than 140/90 mm Hg, said the authors. For patients with diabetes but low 10-year risk of cardiovascular disease, the usefulness of aspirin for primary stroke prevention is unclear, they added.
Many new recommendations focus on persons with hypertension. These recommendations include regular blood pressure screening and appropriate treatment of hypertension, including lifestyle modification and pharmacologic therapy. The guidelines also recommend annual screening for high blood pressure and health-promoting lifestyle modification for patients with prehypertension.
Other new recommendations are intended for migraineurs. For example, the authors recommend smoking cessation for women with migraine headaches with aura. These women also might consider alternatives to oral contraceptives, especially those containing estrogen. Closure of patent foramen ovale is not indicated for preventing stroke in patients with migraine, however.
New evidence has strengthened the recommendation that active smokers undergo counseling in combination with drug therapy using nicotine replacement, bupropion, or varenicline to assist in quitting smoking. The authors also stated that community-wide or statewide bans on smoking in public spaces are reasonable for reducing the risk of stroke and myocardial infarction.
“Talking about stroke prevention is worthwhile,” said Dr. Meschia. “In many instances, stroke isn’t fatal, but it leads to years of physical, emotional, and mental impairment that could be avoided.”
—Erik Greb
Suggested Reading
Meschia JF, Bushnell C, Boden-Albala B, et al. Guidelines for the primary prevention of stroke: a statement for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2014 Oct 28 [Epub ahead of print].
Suggested Reading
Meschia JF, Bushnell C, Boden-Albala B, et al. Guidelines for the primary prevention of stroke: a statement for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2014 Oct 28 [Epub ahead of print].
Transition From Pediatric to Adult Epilepsy Care Remains Difficult
Adult tertiary epilepsy centers often lack the resources to manage young adult patients who are making the transition from pediatric centers, according to a study published in the October issue of Epilepsia.
“These transitioned patients require more resources and services than other young patients with epilepsy” who are receiving care in the community, said Felippe Borlot, MD, and colleagues. In addition, adult neurologists, “even those specialized in epilepsy, may not feel that they are adequately prepared to diagnose and treat part of this complex population.”
For the retrospective study, Dr. Borlot, an epilepsy fellow at the University of Toronto, and his colleagues reviewed the records of all young adults, ages 18 through 25, with childhood-onset epilepsy seen during a six-year period at a single adult tertiary epilepsy care site. The researchers reviewed patient demographic data, etiologies, and treatment regimens before sorting patients into two groups.
The first group of 170 patients had been referred from a pediatric epilepsy tertiary care center. The second group of 132 patients was age-matched with that group and consisted of people referred by community physicians, including pediatric neurologists, to the adult tertiary center. The mean age for the first group was 21.9, and the mean age for the second group was 23.2.
The first group had earlier seizure onset, longer epilepsy duration, more symptomatic etiologies, epileptic encephalopathy, and cognitive delay. The first group also required more care from other specialists, as well as polytherapy, epilepsy surgery, a ketogenic diet, and a vagus nerve stimulator. Patients from tertiary centers present more complex health care needs and require more resources than age-matched patients from the community, said Dr. Borlot and his coinvestigators.
The researchers also surveyed 86 adult neurologists and 29 pediatric neurologists. On a scale of 1 (not comfortable at all) to 5 (very comfortable), the neurologists were asked to rate their comfort level in dealing with several types of epilepsy. The survey also asked how the neurologists felt about treating attendant issues such as intellectual disabilities and autistic features.
The survey results, although not validated, showed that adult neurologists had less confidence diagnosing and treating more severe forms of childhood-onset epilepsies, as well as epilepsy associated with cognitive delay.
The study lacked data validating a successful transition from pediatric to adult care. Also, it did not include patients who were not assessed in the 12 months before the study, meaning that it was not possible to determine the percentage of patients lost to follow-up. Nevertheless, the investigators concluded that the data were useful because no previous evaluation of transition of care in the epileptic setting was available.
Dr. Borlot and his coauthors concluded that transition of care for patients with epilepsy may be enhanced by efforts to “make childhood-onset epilepsies part of adult neurologists’ training and certification requirements.”
—Whitney McKnight
Suggested Reading
Borlot F, Tellez-Zenteno JF, Allen A, et al. Epilepsy transition: Challenges of caring for adults with childhood-onset seizures. Epilepsia. 2014;55(10):1659-1666.
Adult tertiary epilepsy centers often lack the resources to manage young adult patients who are making the transition from pediatric centers, according to a study published in the October issue of Epilepsia.
“These transitioned patients require more resources and services than other young patients with epilepsy” who are receiving care in the community, said Felippe Borlot, MD, and colleagues. In addition, adult neurologists, “even those specialized in epilepsy, may not feel that they are adequately prepared to diagnose and treat part of this complex population.”
For the retrospective study, Dr. Borlot, an epilepsy fellow at the University of Toronto, and his colleagues reviewed the records of all young adults, ages 18 through 25, with childhood-onset epilepsy seen during a six-year period at a single adult tertiary epilepsy care site. The researchers reviewed patient demographic data, etiologies, and treatment regimens before sorting patients into two groups.
The first group of 170 patients had been referred from a pediatric epilepsy tertiary care center. The second group of 132 patients was age-matched with that group and consisted of people referred by community physicians, including pediatric neurologists, to the adult tertiary center. The mean age for the first group was 21.9, and the mean age for the second group was 23.2.
The first group had earlier seizure onset, longer epilepsy duration, more symptomatic etiologies, epileptic encephalopathy, and cognitive delay. The first group also required more care from other specialists, as well as polytherapy, epilepsy surgery, a ketogenic diet, and a vagus nerve stimulator. Patients from tertiary centers present more complex health care needs and require more resources than age-matched patients from the community, said Dr. Borlot and his coinvestigators.
The researchers also surveyed 86 adult neurologists and 29 pediatric neurologists. On a scale of 1 (not comfortable at all) to 5 (very comfortable), the neurologists were asked to rate their comfort level in dealing with several types of epilepsy. The survey also asked how the neurologists felt about treating attendant issues such as intellectual disabilities and autistic features.
The survey results, although not validated, showed that adult neurologists had less confidence diagnosing and treating more severe forms of childhood-onset epilepsies, as well as epilepsy associated with cognitive delay.
The study lacked data validating a successful transition from pediatric to adult care. Also, it did not include patients who were not assessed in the 12 months before the study, meaning that it was not possible to determine the percentage of patients lost to follow-up. Nevertheless, the investigators concluded that the data were useful because no previous evaluation of transition of care in the epileptic setting was available.
Dr. Borlot and his coauthors concluded that transition of care for patients with epilepsy may be enhanced by efforts to “make childhood-onset epilepsies part of adult neurologists’ training and certification requirements.”
—Whitney McKnight
Adult tertiary epilepsy centers often lack the resources to manage young adult patients who are making the transition from pediatric centers, according to a study published in the October issue of Epilepsia.
“These transitioned patients require more resources and services than other young patients with epilepsy” who are receiving care in the community, said Felippe Borlot, MD, and colleagues. In addition, adult neurologists, “even those specialized in epilepsy, may not feel that they are adequately prepared to diagnose and treat part of this complex population.”
For the retrospective study, Dr. Borlot, an epilepsy fellow at the University of Toronto, and his colleagues reviewed the records of all young adults, ages 18 through 25, with childhood-onset epilepsy seen during a six-year period at a single adult tertiary epilepsy care site. The researchers reviewed patient demographic data, etiologies, and treatment regimens before sorting patients into two groups.
The first group of 170 patients had been referred from a pediatric epilepsy tertiary care center. The second group of 132 patients was age-matched with that group and consisted of people referred by community physicians, including pediatric neurologists, to the adult tertiary center. The mean age for the first group was 21.9, and the mean age for the second group was 23.2.
The first group had earlier seizure onset, longer epilepsy duration, more symptomatic etiologies, epileptic encephalopathy, and cognitive delay. The first group also required more care from other specialists, as well as polytherapy, epilepsy surgery, a ketogenic diet, and a vagus nerve stimulator. Patients from tertiary centers present more complex health care needs and require more resources than age-matched patients from the community, said Dr. Borlot and his coinvestigators.
The researchers also surveyed 86 adult neurologists and 29 pediatric neurologists. On a scale of 1 (not comfortable at all) to 5 (very comfortable), the neurologists were asked to rate their comfort level in dealing with several types of epilepsy. The survey also asked how the neurologists felt about treating attendant issues such as intellectual disabilities and autistic features.
The survey results, although not validated, showed that adult neurologists had less confidence diagnosing and treating more severe forms of childhood-onset epilepsies, as well as epilepsy associated with cognitive delay.
The study lacked data validating a successful transition from pediatric to adult care. Also, it did not include patients who were not assessed in the 12 months before the study, meaning that it was not possible to determine the percentage of patients lost to follow-up. Nevertheless, the investigators concluded that the data were useful because no previous evaluation of transition of care in the epileptic setting was available.
Dr. Borlot and his coauthors concluded that transition of care for patients with epilepsy may be enhanced by efforts to “make childhood-onset epilepsies part of adult neurologists’ training and certification requirements.”
—Whitney McKnight
Suggested Reading
Borlot F, Tellez-Zenteno JF, Allen A, et al. Epilepsy transition: Challenges of caring for adults with childhood-onset seizures. Epilepsia. 2014;55(10):1659-1666.
Suggested Reading
Borlot F, Tellez-Zenteno JF, Allen A, et al. Epilepsy transition: Challenges of caring for adults with childhood-onset seizures. Epilepsia. 2014;55(10):1659-1666.
Adjunctive VNS Therapy May Help Children With Drug-Resistant Epilepsy
Adjunctive vagus nerve stimulation (VNS) therapy may significantly reduce seizure activity for more than one-third of children with drug-resistant epilepsy, according to a large, retrospective, multicenter study, which was published in the October issue of Epilepsia.
Iren Orosz, MD, a pediatrician at the Medical University of Lübeck, Germany, and her colleagues at 11 medical centers across Europe found that 130 (37.6%) of 346 patients with drug-resistant epilepsy had at least a 50% reduction in seizures 12 months after being implanted with a VNS device. This group of patients included 19 (5.5%) who became seizure free and 111 (32.1%) who achieved a 50% to 99% reduction in seizure frequency. A total of 59 patients (17.1%) had a 25% to 49% reduction in seizures, and 136 patients (39.3%) had a seizure reduction of 25% or less.
The authors reviewed medical records for children who were implanted with a VNS therapy device between April 1995 and April 2010. The children were ages 6 months to 17.9 years at implantation. All patients had taken a mean of 6.9 antiepileptic drugs (AEDs) before implantation, and 45% of patients had predominantly generalized seizures. The investigators assessed the change in frequency of the children’s predominant seizure type from baseline, defined as the three months before device implantation, to 12 months after implantation. They defined treatment response as a reduction in baseline seizure frequency of at least 50%. The study authors also examined the incidence of adverse events and noted clinicians’ assessments of the patients’ health outcomes, quality of life, and seizures.
The rate of reduction in baseline seizure frequency of at least 50% increased over time from 32.5% at six months to 37.6% at 12 months and to 43.8% at 24 months. The rate of this outcome “was higher in a subgroup of patients who had no change in AEDs during the study,” said Dr. Orosz, who is a Visiting Assistant Professor in the Department of Radiologic Sciences at the University of California, Los Angeles. Responder rates were “comparable to rates from randomized controlled trials of new AEDs in adult and pediatric patients with drug-resistant epilepsy,” she concluded.
—Amy Karon
Suggested Reading
Orosz I, McCormick D, Zamponi N, et al. Vagus nerve stimulation for drug-resistant epilepsy: A European long-term study up to 24 months in 347 children. Epilepsia. 2014;55(10):1576-1584.
Adjunctive vagus nerve stimulation (VNS) therapy may significantly reduce seizure activity for more than one-third of children with drug-resistant epilepsy, according to a large, retrospective, multicenter study, which was published in the October issue of Epilepsia.
Iren Orosz, MD, a pediatrician at the Medical University of Lübeck, Germany, and her colleagues at 11 medical centers across Europe found that 130 (37.6%) of 346 patients with drug-resistant epilepsy had at least a 50% reduction in seizures 12 months after being implanted with a VNS device. This group of patients included 19 (5.5%) who became seizure free and 111 (32.1%) who achieved a 50% to 99% reduction in seizure frequency. A total of 59 patients (17.1%) had a 25% to 49% reduction in seizures, and 136 patients (39.3%) had a seizure reduction of 25% or less.
The authors reviewed medical records for children who were implanted with a VNS therapy device between April 1995 and April 2010. The children were ages 6 months to 17.9 years at implantation. All patients had taken a mean of 6.9 antiepileptic drugs (AEDs) before implantation, and 45% of patients had predominantly generalized seizures. The investigators assessed the change in frequency of the children’s predominant seizure type from baseline, defined as the three months before device implantation, to 12 months after implantation. They defined treatment response as a reduction in baseline seizure frequency of at least 50%. The study authors also examined the incidence of adverse events and noted clinicians’ assessments of the patients’ health outcomes, quality of life, and seizures.
The rate of reduction in baseline seizure frequency of at least 50% increased over time from 32.5% at six months to 37.6% at 12 months and to 43.8% at 24 months. The rate of this outcome “was higher in a subgroup of patients who had no change in AEDs during the study,” said Dr. Orosz, who is a Visiting Assistant Professor in the Department of Radiologic Sciences at the University of California, Los Angeles. Responder rates were “comparable to rates from randomized controlled trials of new AEDs in adult and pediatric patients with drug-resistant epilepsy,” she concluded.
—Amy Karon
Adjunctive vagus nerve stimulation (VNS) therapy may significantly reduce seizure activity for more than one-third of children with drug-resistant epilepsy, according to a large, retrospective, multicenter study, which was published in the October issue of Epilepsia.
Iren Orosz, MD, a pediatrician at the Medical University of Lübeck, Germany, and her colleagues at 11 medical centers across Europe found that 130 (37.6%) of 346 patients with drug-resistant epilepsy had at least a 50% reduction in seizures 12 months after being implanted with a VNS device. This group of patients included 19 (5.5%) who became seizure free and 111 (32.1%) who achieved a 50% to 99% reduction in seizure frequency. A total of 59 patients (17.1%) had a 25% to 49% reduction in seizures, and 136 patients (39.3%) had a seizure reduction of 25% or less.
The authors reviewed medical records for children who were implanted with a VNS therapy device between April 1995 and April 2010. The children were ages 6 months to 17.9 years at implantation. All patients had taken a mean of 6.9 antiepileptic drugs (AEDs) before implantation, and 45% of patients had predominantly generalized seizures. The investigators assessed the change in frequency of the children’s predominant seizure type from baseline, defined as the three months before device implantation, to 12 months after implantation. They defined treatment response as a reduction in baseline seizure frequency of at least 50%. The study authors also examined the incidence of adverse events and noted clinicians’ assessments of the patients’ health outcomes, quality of life, and seizures.
The rate of reduction in baseline seizure frequency of at least 50% increased over time from 32.5% at six months to 37.6% at 12 months and to 43.8% at 24 months. The rate of this outcome “was higher in a subgroup of patients who had no change in AEDs during the study,” said Dr. Orosz, who is a Visiting Assistant Professor in the Department of Radiologic Sciences at the University of California, Los Angeles. Responder rates were “comparable to rates from randomized controlled trials of new AEDs in adult and pediatric patients with drug-resistant epilepsy,” she concluded.
—Amy Karon
Suggested Reading
Orosz I, McCormick D, Zamponi N, et al. Vagus nerve stimulation for drug-resistant epilepsy: A European long-term study up to 24 months in 347 children. Epilepsia. 2014;55(10):1576-1584.
Suggested Reading
Orosz I, McCormick D, Zamponi N, et al. Vagus nerve stimulation for drug-resistant epilepsy: A European long-term study up to 24 months in 347 children. Epilepsia. 2014;55(10):1576-1584.
LISTEN NOW: Emergency Medicine and Hospitalist Collaboration
This
The focus for emergency physicians, says Dr. Heinrich, is triage and disposition. Differing incentives for hospitalists and emergency physicians can cause stress between the groups, and dialogue is needed to defray the tension, he notes. Dr. Epstein says he thinks that collaboration can be an effective tactic against becoming a “30 day readmission rule” statistic. Shared metrics, developed in partnership, can also improve patient care, he adds.
For more features, visit The Hospitalist's podcast archive.
This
The focus for emergency physicians, says Dr. Heinrich, is triage and disposition. Differing incentives for hospitalists and emergency physicians can cause stress between the groups, and dialogue is needed to defray the tension, he notes. Dr. Epstein says he thinks that collaboration can be an effective tactic against becoming a “30 day readmission rule” statistic. Shared metrics, developed in partnership, can also improve patient care, he adds.
For more features, visit The Hospitalist's podcast archive.
This
The focus for emergency physicians, says Dr. Heinrich, is triage and disposition. Differing incentives for hospitalists and emergency physicians can cause stress between the groups, and dialogue is needed to defray the tension, he notes. Dr. Epstein says he thinks that collaboration can be an effective tactic against becoming a “30 day readmission rule” statistic. Shared metrics, developed in partnership, can also improve patient care, he adds.
For more features, visit The Hospitalist's podcast archive.
