Jumat, 30 Maret 2018

Individual Docs Underestimate Their Opioid Prescribing Habits

Individual Docs Underestimate Their Opioid Prescribing Habits


Most emergency department (ED) physicians underestimated the number of opioid prescriptions they wrote, but began prescribing fewer upon learning of their behavior, according to results of a study published in Academic Emergency Medicine.

Most ED physicians lack data on their opioid prescribing habits, and there are few benchmarks that would allow them to compare their habits with an accepted norm. In fact, only 17 states have published guidelines for opioid prescribing in the ED, and most that do rely on a physician’s knowledge of the opioid crisis and common sense to minimize prescribing rather than assess the behavior of individual clinicians.

In this prospective, multicenter, randomized trial, Sean S. Michael, MD, MBA, from the department of emergency medicine, University of Colorado School of Medicine, in Aurora, and colleagues investigated how providers perceive their opioid prescribing habits and assessed clinicians’ response to learning how their actual prescribing practices compared with group tendencies. The participants were then monitored for self-correction over the course of a year.

The goal of the strategy, which the researchers term “query-reveal intervention,” was to personalize how practitioners view the opioid crisis in their own workplaces. The researchers surveyed attending physicians, residents, and advanced practice providers (APPs) at four hospital EDs: an urban tertiary academic center, an urban acute care hospital/nonprimary teaching site, a small suburban community hospital, and a small rural community hospital.

The investigators randomly assigned 51 clinicians (34 attendings, 15 residents, and 2 APPs) to the intervention arm and 58 (31 attendings, 21 residents, and 6 APPs) to the control arm.

To estimate degree of opioid prescribing, a member of the study team showed each participant in the intervention group bar graphs representing all providers at their ED and asking “Each of these bars represents one provider in the group, including you. Which do you think is you?” Immediately after that, each clinician was provided with his/her true prescribing profile in absolute and relative to peers. Physicians in the control arm did not receive information on individual or group prescribing habits.

The primary outcome was change in percentage of patients discharged with an opioid prescription at 6 and 12 months.

During the year of the study, the 109 practitioners altogether discharged 119,428 patients and wrote 75,203 total prescriptions, including 15,124 (20.1%) for opioids.

Of the participants receiving the intervention, 73% of the attending physicians and advanced practice providers and 27% of the residents underestimated their prescribing rank compared with their peers by more than one decile in one metric or more. Just five providers (three residents and two attendings) overestimated their opioid prescribing rank.

Clinicians in the intervention group who had underestimated their prescribing showed larger declines in the number of patients discharged with an opioid prescription compared with clinicians in the control group. Specifically, compared with the control group, they had a median of 2.1 (95% confidence interval [CI], 0.5 – 3.9; P = .007) fewer opioid prescriptions per 100 patients at 6 months and 2.2 (95% CI, 0.01 – 4.8; P = .05) fewer prescriptions per 100 patients at 12 months.

Meanwhile, those in the intervention group who had not underestimated their prescribing at baseline prescribed 1.3 more prescriptions per 100 patients at 6 months compared with controls, and 1.2 more per 100 patients at 12 months.

“In the multivariable mixed-effects model, intervention allocation with underestimation of one’s prescribing relative to peers, physician level of training (compared to APP), and fewer years of experience were significant predictors of larger-magnitude six and twelve-month decreases in the proportion of patients discharged with an opioid prescription,” the authors write.

Providers with accurate self-perception or who overestimated their opioid prescribing practices didn’t decrease opioid prescribing compared with controls.

The four EDs served different communities but were part of the same healthcare system. Prescribing behavior did not significantly differ among them.

The researchers compare the lack of self-awareness about opioid prescribing to the observation that a majority of drivers think they are above average. They suggest that the disconnect between perceived behavior and being confronted with a different reality creates cognitive dissonance that drives behavior change.

“This randomized trial exposes important gaps in providers’ self-perceptions of opioid prescribing and demonstrates that a simple, data-driven intervention using query-reveal methodology may decrease future prescribing, particularly among providers who underestimate their own prescribing practices,” the researchers conclude.

Limitations of the study include the fact that only 5% to 10% of opioid prescriptions come from EDs, lack of information on the indications for which opioids were prescribed or whether alternative treatments were suggested, and implementation of a state law limiting opioid prescription during the eighth month of the investigation.

The researchers have disclosed no relevant financial relationships.

Acad Emerg Med. Published online March 2, 2018 Abstract

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Functional Testing Best for Detecting Coronary Artery Disease

Functional Testing Best for Detecting Coronary Artery Disease


NEW YORK (Reuters Health) – Functional testing outperforms anatomical testing for detecting coronary artery disease (CAD) in low-risk patients, according to a new network meta-analysis.

“Currently available evidence indicates that both anatomical- and functional-based diagnostic strategies have no differential effect on the subsequent risk of myocardial infarction, but considerable differences exist in the need for further investigations and revascularizations,” said Dr. George C. M. Siontis from Bern University Hospital in Switzerland.

“Physicians should make their decision following appropriate risk stratification of their patients, based on local constraints for each diagnostic strategy and patients’ preferences,” he told Reuters Health by email.

Both functional and anatomical noninvasive tests are widely available and used according to locally available resources and expertise, Dr. Siontis and his colleagues write in The BMJ, online February 20. Randomized controlled trials have not provided conclusive evidence as to which strategy gives the best results for subsequent downstream testing or clinical outcomes.

To investigate, Dr. Siontis and colleagues used a network meta-analysis of 30 diagnostic randomized controlled trials, including more than 33,000 patients and six different imaging modalities.

Among patients with low-risk acute coronary syndrome, evaluation by stress echocardiography, cardiovascular magnetic resonance, or exercise electrocardiogram was significantly less likely to trigger referral to invasive coronary angiography than was coronary CT angiography.

Similarly, patients evaluated by cardiovascular magnetic resonance and stress echocardiography less frequently underwent subsequent revascularization than did those evaluated by coronary CT angiography.

Overall, a functional-testing strategy and cardiovascular magnetic resonance were significantly less likely than an anatomical-testing strategy to lead to referrals for invasive coronary angiography.

None of the strategies affected the rate of subsequent myocardial infarction.

For patients with suspected stable CAD, there was no clear discrimination between diagnostic strategies regarding the subsequent need for invasive coronary angiography, but differences between the strategies in the risk of myocardial infarction could not be ruled out.

“Appropriate risk stratification of each patient before the application of any diagnostic strategy is the key element for a successful diagnostic approach,” Dr. Siontis said. “Hybrid strategies (which have not been tested in clinical trials so far) may be useful in selected cases, whereas ongoing trials of other emerging technologies that noninvasively evaluate anatomical and functional lesion hemodynamics or myocardial perfusion may be proven useful.”

“Nevertheless,” he said, “any additional diagnostic test should be carefully evaluated in the context of its risk. Finally, it is of high importance for the physicians to identify those patients who require directly invasive assessment (high pre-test probability).”

SOURCE: http://bit.ly/2tozc4G

BMJ 2018.



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Pfizer's Rare Heart Disease Drug Succeeds in Late-stage Study

Pfizer's Rare Heart Disease Drug Succeeds in Late-stage Study


(Reuters) – Pfizer Inc said on Thursday its drug tafamidis, for a rare and fatal disease associated with progressive heart failure, met the main goal in a late-stage study.

The company’s clinical study investigated the efficacy, safety and tolerability of an oral dose of tafamidis capsules compared with a placebo in 441 patients.

Pfizer said tafamidis showed statistically significant reduction in deaths and frequency of cardiovascular-related hospitalizations compared with a placebo at 30 months. The data also showed that tafamidis was generally well tolerated by the enrolled patients.

Tafamidis was being tested for the treatment of transthyretin cardiomyopathy, a condition that results from deposits of transthyretin protein in the heart, which leads to eventual heart failure.

The U.S. Food and Drug Administration granted tafamidis a ‘fast track’ designation in June last year. The designation aims to facilitate the development and expedite the review process for certain drugs and vaccines for serious conditions.

Currently, there are no approved medications in the United States for the treatment of transthyretin cardiomyopathy.



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FDA Expands Use of Amgen Leukemia Drug Blincyto to Patients With Relapse Risk

FDA Expands Use of Amgen Leukemia Drug Blincyto to Patients With Relapse Risk


(Reuters) – The U.S. Food and Drug Administration on Thursday expanded the use of Amgen Inc’s leukemia drug Blincyto (blinatumomab) to include patients who are in remission but still have residual signs of the disease.

The drug, part of a class known as bispecific antibodies, is already approved for patients with acute lymphoblastic leukemia (ALL) whose cancer has returned after treatment or did not respond to previous treatment, such as chemotherapy.

The expanded approval is for patients with “minimal residual disease,” meaning the presence of cancer cells below a level that can be seen under a microscope. Such patients, who can now be identified with new molecular testing, still have an increased risk of relapse.

The FDA approval marks the first time molecular tests are being used to identify patients for early intervention in order to prevent cancer from reappearing, said Gregory Friberg, head of oncology global development at Amgen.

In studies, four out of five patients with residual ALL showed no signs of the disease after a single cycle of Blincyto, he said. The drug can cause serious side effects including a potentially life-threatening inflammatory condition called cytokine release syndrome.

An estimated 5,960 Americans will be diagnosed with ALL this year, and around 1,470 will die from the disease, according to the National Cancer Institute.

Amgen’s sales of Blincyto, which has an average wholesale price near $173,000, totaled $175 million last year.



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'Treated Like Criminals': Britain's Frontline Services Fail Slavery Survivors

'Treated Like Criminals': Britain's Frontline Services Fail Slavery Survivors


NOTTINGHAM (Thomson Reuters Foundation) – As Britain clamps down on human trafficking and slavery, frontline medics and police officers often lack awareness and even the empathy required to support survivors, experts said.

At least 13,000 people across Britain are estimated by the government to be victims of forced labor, sexual exploitation and domestic servitude – but police say the true figure could be in the tens of thousands with slavery operations on the rise.

The National Crime Agency on Monday said it received 5,145 reports of suspected slavery victims in 2017 across Britain, an increase of more than a third from 3,804 in 2016.

But police often treat victims with suspicion if they have been involved in criminal activities like cannabis farming or drug trafficking, said detective inspector Henry Dick from central England’s Leicestershire police force.

“They’re being exploited but being treated like criminals. There’s a lack of understanding and perhaps a lack of empathy,” said Dick, who is part of the police’s modern slavery unit.

He said trafficking victims often lie about how they entered the country because they fear deportation, which can compound police or immigration officers’ suspicions.

“Freedom for them might be like dipping them in ice cold water, so we need to help them ease out of that through help and support,” Dick said.

TRAUMATIC

Former nurse Nicola Wright said dealing with frontline services can be daunting for victims who often fear or distrust authorities.

“Sometimes our processes can be quite traumatic for people,” said Wright, as she helped to launch a network linking the National Health Service (NHS), charities, police, researchers and survivors to better support victims’ mental health.

“How do we build a supportive system which is based on good quality evidence that puts the survivor at the center?” said Wright, an assistant professor in mental health at the University of Nottingham.

While healthcare workers may come across slavery victims, there is no channel for them to report their suspicions or provide help, said Caroline Brookes, the NHS’s head of emergency preparedness.

“Do our staff have the skills to recognize somebody who could potentially be a modern slave?” she asked the Thomson Reuters Foundation on the sidelines of the launch event in Nottingham this week.

“If you have that professional gut feeling that something is not quite right, who do you talk to? There is such a big gap. There’s nothing at the moment,” said Brookes, who aims to roll out training for NHS staff to spot signs of trafficking.

The British government said last year it would overhaul the way it handles potential victims, with a raft of changes including drop-in services and extra shelter.

But rights groups said a government decision last month to halve financial aid for slavery survivors to 38 pounds ($53) per week could make them even more vulnerable.

For Minh Dang, it has taken years to process her experience of being enslaved by her parents and sold for sex throughout her childhood in the United States.

While rescuing victims is crucial, providing long-term care for survivors, including mental health support and employment, must also be a priority, she said.

“If we’re going to help identify victims and create space for people to exit, we need to be thinking about post-exit,” said Dang, who is researching post-slavery support for survivors at the University of Nottingham.

“Because what’s the point of being free if you’re just going to be struggling?”



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New US Diabetes Prevalence Data Distinguish by Disease Type

New US Diabetes Prevalence Data Distinguish by Disease Type


Approximately 23 million adults in the United States are living with diabetes, and of these, nearly 6% have type 1 disease, according to new surveillance data from the Centers for Disease Control and Prevention (CDC).

Unlike previous estimates that did not distinguish between types of diabetes, the new estimates are based on data collected in the 2016 National Health Interview Survey, which included supplemental questions to help classify diabetes by disease type, report Kai McKeever Bullard, PhD, from the CDC’s Division of Diabetes Translation, National Center for Chronic Disease Prevention and Health Promotion, Atlanta, Georgia, and colleagues. The study, published March 30 in the Morbidity and Mortality Weekly Report, is the first to estimate the prevalence of diagnosed type 1 and type 2 diabetes according to self-report and current insulin use among US adults.

The ability to estimate diabetes prevalence by disease type is important, the authors stress, because it allows for more accurate monitoring of trends and targeted planning and prioritization of public health responses.

The nationally representative 2016 National Health Interview Survey sample consisted of 33,028 adults aged 18 years or older, with a final response rate of 54.3%. Of these, 3519 respondents self-reported diabetes, including 2897 with type 2 diabetes and 211 with type 1 diabetes. An additional 98 cases were classified as “other” type, such as maturity-onset diabetes of the young or latent autoimmune diabetes in adults, and 1 was classified as unknown, the authors report.

The respective prevalence rates for type 1 diabetes, type 2 diabetes, and other forms of the disease were 0.55%, 8.58%, and 0.31%.

“Based on the weighted [National Health Interview Survey] population, the estimated numbers of adults with type 1, type 2, and other diabetes types were 1.3 million, 21.0 million, and 0.8 million, respectively,” the authors write. They note, however, that prevalence rates varied by age, sex, and race/ethnicity, depending on the disease type.

For type 1 diabetes, the prevalence was significantly higher among men (0.64%) than among women (0.46%; P < .05). It was also higher among non-Hispanic whites (0.67%) than among Hispanics (0.22%; P < .01). Significant differences were observed in the prevalence of type 2 diabetes among non-Hispanic blacks (11.52%), non-Hispanic Asians (6.89%), non-Hispanic whites (7.99%), and Hispanics (9.07%; P < .001).

Further, type 2 disease was most prevalent in adults 65 years and older and least prevalent in those aged from 18 to 29 years (P < .001). Prevalence decreased with higher levels of education (P < .001).

The observed variations in prevalence of type 1 and type 2 diabetes are notable from a surveillance perspective, according to the authors.

“Because the prevalence of type 2 diabetes is so much higher than that of type 1, current diabetes surveillance data that do not distinguish diabetes type are more reflective of persons with type 2 diabetes,” they state. The etiology, treatment, and outcomes of the disease vary by type, however, so action planning tied to nondifferentiated surveillance data does not meet the needs of the smaller type 1 diabetes population.

Although limited by the reliance on self-reported diagnoses and insulin use, underestimation of total diabetes prevalence, and potential misclassification of diabetes type, the study provides important information for monitoring trends by disease type and creating targeted education and prevention programs, the authors explain. “Knowledge about national prevalences of type 1 and type 2 diabetes might facilitate assessment of the long-term cost-effectiveness of public health interventions and policies aimed at improving diabetes management and help to prioritize national plans for future type-specific health services,” they write.

The authors have disclosed no relevant financial relationships.

Morb Mortal Wkly Rep. 2018;67:359-361. Full text

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Impax Reaches $20 Mln Deal to End Trial Over Generic Drug's Delay

Impax Reaches $20 Mln Deal to End Trial Over Generic Drug's Delay


BOSTON (Reuters) – Impax Laboratories Inc has agreed to pay $20 million to consumers and insurers to resolve claims that the drugmaker entered an anticompetitive deal to delay launching a generic, cheaper version of acne medication Solodyn.

The accord, disclosed in papers filed in federal court in Boston, brought to an end a rare trial in a class action lawsuit involving an alleged “pay-for-delay” patent litigation settlement between a brand-name drugmaker and a generic company.

Such settlements occur when a brand-name drugmaker pays a generic rival to delay releasing a cheaper version of its product in exchange for resolving court challenges to patents covering the treatment.

According to the plaintiffs, Impax in 2008 settled a lawsuit it filed challenging a weak patent Medicis Pharmaceutical Corp held for Solodyn by agreeing to delay releasing its generic version until 2011.

In exchange, Impax received $40 million, allowing Medicis to maintain its Solodyn monopoly longer, the plaintiffs allege. But for that settlement, Impax would have launched its generic version “at-risk” while the litigation continued, they say.

Hayward, California-based Impax denied that there was any such arrangement to delay competition.

Thursday’s settlement came in the third week of the trial and after the plaintiffs finished presenting their evidence against Impax, which in October agreed to combine with Amneal Pharmaceuticals LLC.

“It’s a fair result,” Douglas Baldridge, a lawyer for Impax, said outside of court.

The deal marked the final settlement in the litigation. Impax previously agreed to pay $35 million to resolve class action claims brought on behalf of direct purchasers of Solodyn such as retailers.

Mid-trial, Impax on Sunday settled lawsuits by retail pharmacy operators including CVS Health Corp, Rite Aid Corp, Walgreens Boots Alliance Inc, Kroger Co, Albertsons Companies Inc and HEB Grocery Company LP. Terms were not disclosed.

Valeant Pharmaceuticals International Inc, which acquired Medicis in 2012, said in February it would pay $58 million to resolve related claims.

Jurors had been asked only to determine liability because damages would have been determined at a later trial.

Lawyers for the consumers and insurers had alleged that because of the “pay-for-delay” settlement, they were overcharged by up to $790.3 million, according to an October court ruling.

“The fact that the case was presented to you had a lot to do with this case settling,” U.S. District Judge Denise Casper told jurors before excusing them on Thursday morning.

The case is In re Solodyn (Minocycline Hydrochloride) Antitrust Litigation, U.S. District Court, District of Massachusetts, No. 14-md-02503.



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U.S. Ends Presumed Freedom for Pregnant Immigrants

U.S. Ends Presumed Freedom for Pregnant Immigrants


SAN FRANCISCO (Reuters) – U.S. President Donald Trump’s administration said on Thursday it would no longer presume that many pregnant women detained by immigration authorities should be released from custody, reversing an Obama-era directive.

U.S. Immigration and Customs Enforcement officers will make a case by case determination under the new policy. Women in their third trimester will still be released as before, said Philip Miller, an ICE deputy executive associate director.

“Just like there are men who commit heinous acts violent acts, so too have we had women in custody that commit heinous acts,” Miller told reporters on Thursday.

The Republican president has vowed to crack down on illegal immigration, including policies on which deportees can remain free during pending cases. Democrats and advocacy groups have criticized the administration for separating migrants from their children when detained.

During President Barack Obama’s administration, ICE in 2016 announced that pregnant women not subject to mandatory detention should be presumptively released.

Miller said on Thursday the new directive was meant to align with a Trump executive order mandating tougher ICE enforcement. Thirty-five pregnant women are in ICE custody, all subject to mandatory detention, he said.

Since the policy was implemented in December, Miller said, 506 pregnant women have been detained by ICE. He could not say what happened to each of them, but noted that some likely had been deported while others might have been released in the United States.

Michelle Brane, director of the Migrant Rights and Justice Program with the Women’s Refugee Commission, criticized the move and said many women entering the United States are pregnant due to rape.

“Detention is especially traumatic for pregnant women and even more so for victims of rape and gender-based violence,” she said in a statement.

Miller said pregnant women with asylum claims determined to be based on a “credible fear” of persecution in their home country would still likely be released.

The policy change was first reported by The Hill on Thursday, citing internal ICE documents.



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Impaired LV Response to Exercise Seen in Adults Born Preterm

Impaired LV Response to Exercise Seen in Adults Born Preterm


Adults born preterm showed blunted left ventricular (LV) functional responses to moderate-intensity exercise stress, despite normal LV function at rest, in a prospective observational study.

As a result, their LV ejection fractions and cardiac output were significantly lower at both 60% and 80% of peak exercise capacity compared with responses in comparable adults who had been born at term.

Also, the lower the gestational age at birth in the preterm group, the greater was their LV-functional impairment at exercise.

The findings were independent of birth weight, maternal health history, and adult health status and suggest that “preterm-born young adults have a reduced myocardial functional reserve that might help explain their increased risk of early heart failure,” Adam Lewandowski, DPhil, University of Oxford and John Radcliffe Hospital, United Kingdom, told theheart.org | Medscape Cardiology.

They also complement earlier research from his group and others suggesting that adults born preterm have increased LV mass and reduced LV volumes, adjusted for body size, he said in an emailed comment.

Altogether, the structural and functional abnormalities seen in preterm-born adults constitute a “unique phenotype” compared to other types of cardiomyopathy, according to Lewandowski.

“There’s no immediate cause for alarm, as most preterm-born individuals will not go on to develop heart failure as adults,” he said. “However, the more we start to understand how the heart works differently in people born preterm, the better we can start to implement primary prevention steps, including reducing cardiovascular risk scores and developing a healthy lifestyle.”

The findings, based on 101 normotensive adults in the Young Adult Cardiovascular Health Study (YACHT), were published March 19 in the Journal of the American College of Cardiology, with Odaro J Huckstep, MSc, University of Oxford and John Radcliffe Hospital as lead author and Lewandowski as senior author.

Although the study is observational and only hypothesis-generating, an accompanying editorial notes that “this type of mechanistic study is key to being able to direct preventive measures to those at risk.”

Also, conclusions based on case-control studies with small samples may be especially subject to confounding, but “There are factors speaking against a substantial selection bias in this study,” write Anna-Karin Edstedt Bonamy, MD, PhD, and Hanna Carr, BSc, from Karolinska Institutet, Stockholm, Sweden.

For example, differences in blood pressure between the preterm-born and full-term-born participants “are very similar to those previously reported in larger samples,” they say.

“Moreover, the gestational age distribution is close to that seen in real life, which strengthens the assumption that the results may be generalizable to other populations of preterm-born subjects.”

The mean gestational age at birth for the 47 participants born preterm was 32.8 weeks, with a range of 23 to 36 weeks; 81% had been born at 32 weeks or later.

Compared to the 54 adults born at term, the preterm-born participants had greater LV mass adjusted for body surface area (P = .015) and for end-diastolic volume (P < .001), but similar resting LV ejection fraction, all by two-dimensional echocardiography.

Nor was LV function significantly different between the two groups when they exercised to 40% of peak exercise capacity. But at that exercise level, the submaximal cardiac output reserve was 56% lower in the preterm-born adults than in the term-born control group (P = .021).

But progressing from rest to 60% of peak exercise capacity, LV ejection fraction rose 8.1 absolute percentage points in the preterm-born group and 15.2 points in the term-born control group (P = .039), to averages of 71.9% and 78.6%, respectively (P = .004). The preterm group also showed lower peak longitudinal strain (P = .004), the group reported.

Lewandowski said the magnitude of difference in LV functional reserve between the two groups was a bit surprising, given that the overwhelming majority of the preterm-born group was born only moderately preterm. 

Any interventions to potentially lessen the later cardiac structural and functional impact of preterm birth would likely be most effective in the early postnatal period, he proposed.

“The neonatal and infant developmental periods are very dynamic and important for growth. Some of our recently published data from this age group would suggest that this is an important window for the development of these cardiac changes,” Lewandowski said.

His group is engaged in a randomized trial of an exercise intervention in such young adults, “including a group of individuals born preterm, to determine whether lifestyle change in young adulthood can reduce blood pressure and preferentially modify cardiac phenotype.”

Huckstep, Lewandowski, and their coauthors as well as Bonamy and Carr report that they have no relevant conflicts.

J Am Coll Cardiol. 2018;71:1347-1356, 1357-1359. Abstract, Editorial

Follow Steve Stiles on Twitter: @SteveStiles2. For more from theheart.org | Medscape Cardiology, follow us on Twitter and Facebook.



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US News Ranks Top Medical School Programs by Specialty

US News Ranks Top Medical School Programs by Specialty


The top medical school for research is Harvard University in Boston, Massachusetts, according to US News & World Report‘s latest rankings of best medical schools for research.

Taking the number 2 spot for research is Johns Hopkins University in Baltimore, Maryland, and tied for third are New York University (Langone) in New York City and Stanford University in California.

Rounding out the top 10 best medical schools for research (in order) are University of California San Francisco (UCSF); Mayo Clinic School of Medicine, Rochester, Minnesota; University of Pennsylvania Perelman School of Medicine, Philadelphia; David Geffen School of Medicine at University of California Los Angeles (UCLA); Washington University, St Louis, Missouri; and Duke University, Durham, North Carolina.

The best medical school for primary care, according to US News, is the University of North Carolina Chapel Hill, followed by UCSF (number 2), University of Washington, Seattle (number 3), UCLA (number 4), and, tied for fifth, Baylor College of Medicine, Houston, Texas, and Oregon Health & Science University in Portland.

Harvard University and Johns Hopkins University have the best internal medicine programs in the country (tied for number 1), followed (in order) by UCSF, University of Pennsylvania (Perelman), Duke University, and Columbia University in New York City.

For pediatrics, Harvard again comes out on top, according to the magazine, followed by University of Pennsylvania at 2, University of Cincinnati in Ohio at 3, University of Colorado in Aurora at 4, and John Hopkins University at 5.

Thinking of a career in psychiatry? Harvard University has the best program, according to the magazine, followed by Columbia University (number 2), University of Pennsylvania (number 3), Yale University, New Haven, Connecticut (number 4), andJohns Hopkins University and UCSF (tied for 5).

If surgery is the path for you, Harvard University has the best program, according to the magazine, followed (in order) by Johns Hopkins University, University of Pennsylvania, UCSF, and Duke University.

Harvard University also has the best program for obstetrics & gynecology, followed (in order) by UCSF, Johns Hopkins, University of Michigan Ann Arbor, and University of Pennsylvania.

To produce the 2019 best medical school rankings, US News collected data on student selectivity, faculty resources, and a variety of other factors from both allopathic and osteopathic medical schools. The complete rankings and methods used are available online.



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Excellent IDEA: Shorter Adjuvant Chemo in Colon Cancer

Excellent IDEA: Shorter Adjuvant Chemo in Colon Cancer


Less may be more for many patients with colon cancer.

Most patients with stage III colon cancer can be treated with a shorter schedule of adjuvant chemotherapy, according to the findings of a large phase 3 trial. Specifically, for patients with low-risk stage III disease, treatment with 3 months of therapy was as effective as treatment for 6 months.

Low-risk disease accounts for about 60% of stage III colon cancers.

The findings were initially presented at the American Society of Clinical Oncology (ASCO) 2017 Annual Meeting and were reported by Medscape Medical News at that time. The study has now been published in the the New England Journal of Medicine.

The results are practice changing, commented Richard Schilsky, MD, chief medical officer at ASCO, when the results were presented at the meeting. “I would predict that beginning next week in clinic, patients are going to be prescribed shorter courses of adjuvant chemotherapy if they have a low-risk colon cancer.”

ASCO expert Nancy Baxter, MD, from St. Michael’s Hospital in Toronto, Ontario, Canada, also commented at that time that “less is more.”

“This is a great day for patients throughout the world,” she said. “Now, today, up to 60% of my patients with stage III colon cancer will be able to stop after 3 months of therapy and be able to get on with their lives and have a lower risk of permanent problems, such as numbness of their hands and feet.”

On the basis of this study, the National Comprehensive Cancer Network’s colon cancer guidelines were recently changed to indicate that patients with low-risk stage III colon cancers can be treated with a shorter schedule of adjuvant chemotherapy.

IDEA in Practice

Since 2004, the standard treatment for stage III colon cancer had been 6 months of adjuvant therapy with oxaliplatin plus a fluoropyrimidine. But because oxaliplatin is associated with cumulative neurotoxicity, a shorter duration of therapy would reduce the risk for adverse events and would also lower healthcare expenditures.

Led by Axel Grothey, MD, from the Mayo Clinic Cancer Center in Rochester, Minnesota, the IDEA (International Duration Evaluation of Adjuvant Therapy) collaboration pooled results from six prospective studies that involved 12,834 patients with stage III colon cancer.

The phase 3 trials, which were conducted concurrently, evaluated the noninferiority of adjuvant therapy with either FOLFOX (fluorouracil, leucovorin, and oxaliplatin) or CAPOX (capecitabine and oxaliplatin) given for 3 months as opposed to 6 months.

The primary end point was disease-free survival at 3 years. Noninferiority of 3 months of therapy in comparison with 6 months was achieved if the upper limit of the two-sided 95% confidence interval (CI) of the hazard ratio (HR) did not exceed 1.12.

However, after 3263 cases involving either disease recurrence or death were reported in the cohort, noninferiority of 3 months of treatment vs 6 months could not be confirmed in the overall study population (HR, 1.07; 95% CI, 1.00 – 1.15). The 3-year rates of disease-free survival were 74.6% for the 3-month regimen and 75.5% for 6-month regimen.

Noninferiority in Subgroups Only

Noninferiority of a 3-month regimen was observed in the subset of patients treated with the CAPOX regimen (HR, 0.95; 95% CI, 0.85 – 1.06). The 3-year rates of disease-free survival were 75.9% for the 3-month regimen and 74.8% for the 6-month regimen.

Noninferiority was not observed in patients treated with FOLFOX. In this subset, 6 months of adjuvant therapy was superior to 3 months (HR, 1.16; 95% CI, 1.06 – 1.26; P = .001 for superiority of the 6-month therapy). The difference in 3-year disease-free survival for the two groups was 2.4 percentage points for all stages combined (73.6% vs 76.0%).

An exploratory analysis of the combined regimens for patients with low-risk disease (T1, T2, or T3 and N1 tumors) also found that 3-month regimens were noninferior to regimens of 6 months. The 3-year disease-free survival rates were 83.1% and 83.3%, respectively (HR, 1.01; 95% CI, 0.90 – 1.12).

For patients with higher-risk T4 tumors, N2 tumors, or both, the disease-free survival rate seen with 6 months therapy was superior to that of 3 months (64.4% vs 62.7%) for the combined treatments (HR, 1.12; 95% CI, 1.03 – 1.23; P = .01 for superiority).

The 3-month regimen was associated with significantly lower rates of adverse events, regardless of the chemotherapy regimen. This was particularly true for neurotoxicity of grade 2 or higher. Rates were substantially lower in the 3-month therapy group (16.6% with FOLFOX and 14.2% with CAPOX) than in the 6-month therapy group (47.7% with FOLFOX and 44.9% with CAPOX). Rates of occurrence of other events, including diarrhea, neutropenia, thrombocytopenia, nausea, mucositis, fatigue, and the hand-foot syndrome, were also substantially lower with the 3-month regimen.

Better Markers, Less Toxic Treatments

In an accompanying editorial, Schilsky notes that the “conundrum of adjuvant chemotherapy for cancer is that for any individual patient the oncologist cannot readily determine the presence or absence of cancer or its response to treatment.”

He points out that if the tumor never recurs, it remains unclear whether the treatment was effective or unnecessary. “Thus, the most effective use of adjuvant chemotherapy depends primarily on a multidimensional assessment of risk in each patient,” he says.

The results of the current study will help to guide discussions between oncologists and their patients about the complex issues associated with adjuvant therapy. To truly optimize the use of this treatment, Schilsky emphasizes that “we need two things: better markers to assess the risk of recurrence and the likelihood of benefit and more effective, less toxic treatments.

“Until we see improvements in these two important areas, the findings of the IDEA collaboration provide useful information in helping oncologists discuss the duration of adjuvant therapy that best suits the goals, preferences, and tolerances of their patients,” he concludes.

The IDEA study was funded by grants from the Medical Research Council, the National Institute for Health Research, the National Cancer Institute, the Italian Agency for Drugs, the Japanese Foundation for Multidisciplinary Treatment of Cancer, the French Ministry of Health, and the French National Cancer Institute. Dr Grothey and several coauthors have disclosed relationships with industry, which are listed in original article. Dr Baxter has disclosed no relevant financial relationships. Dr Schilsky has received grant support and nonfinancial support from AstraZeneca, Bayer, Bristol-Myers Squibb, Eli Lilly, Genentech, Merck, and Pfizer outside the submitted work.

N Engl J Med. Published online March 29, 2018. Abstract, Editorial

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Studies Support Long-term Benefits of His-Bundle Pacing for BBB

Studies Support Long-term Benefits of His-Bundle Pacing for BBB


BARCELONA, Spain  — Permanent His-bundle pacing (HBP) corrected bundle-branch block (BBB) in more than three fourths of all-comers referred for pacemaker implantation and provided stable results in most, even during long-term follow-up.

“The main message is that we can overcome the classical indication and go directly to a new philosophy for how we pace,” study author Francesco Zanon, MD, from Santa Maria della Misericordia General Hospital, Rovigo, Italy, said at the European Heart Rhythm Association (EHRA) 2018 congress.

An early adopter of HBP, Zanon said they initially restricted the procedure to patients with sinus node dysfunction but now use it in all patients referred for pacemaker implantation.

The first study involved 147 consecutive patients referred for pacemaker implantation with varying types of BBB (left BBB in 37%; right BBB in 36%; right BBB plus left anterior or posterior hemiblock in 24%; and sinus rhythm with intraventricular conduction delay in 3%). Atrioventricular block was present in 63%, sinus node disease in 15%, and atrial fibrillation with slow ventricular rate in 22%. A backup lead was added in 45% of patients.

Their mean age was 76 years, 58% were male, and 27% had chronic atrial fibrillation.  All patients were followed yearly from implantation in a single center.

HBP resulted in narrowing of the QRS with disappearance of BBB in 117 patients (80%), while 30 patients (20%) had selective His pacing with a wide QRS identical to the native one, Zanon said.

Baseline QRS duration improved from a mean of 153 milliseconds to 137 milliseconds and left ventricular (LV) ejection fraction from 53% to 55%.

After a mean of 5.2 years, 1 patient was lost to follow-up and hisian capture terminated in 12 patients because of infections in 3, an upgrade to cardiac resynchronization therapy (CRT) in 2, and high thresholds in 7, including 1 case of syncope. Among the remaining 134 patients, “Persistence of effective His-bundle pacing was very high at 91%,” Zanon said.

The average device life was 4.3 years and a backup lead was added in 3 patients during follow-up. The pacing threshold was 2.1 V at 0.5 ms vs 1.6 V at 0.5 ms at implant.

During follow-up, 81% of patients underwent ventricular pacing (83% greater than 40% pacing); 12 patients were hospitalized with heart failure and 5 with acute coronary disease. The final QRS duration was 138 ms.

The large percentage of patients with QRS narrowing confirms reports from the United States; however, results from the single-center, noncontrolled study should be interpreted with caution, chief cardiology correspondent for theheart.org | Medscape Cardiology, John Mandrola, MD, clinical electrophysiologist, Baptist Medical Associates, Louisville, Kentucky, said in an interview.

“Clearly this group has a vast experience with HBP and the results may not be generalizable to less experienced centers,” he said. “But taken together, the cumulative data on His-bundle pacing are encouraging —  both from an efficacy and safety standpoint. At a minimum, the accumulated experience with HBP provides reassurance that it is an ideal way to pace the ventricle without inducing dyssynchrony and possible left ventricular dysfunction.”

These data, along with other reports on reversing BBB, make the case for a randomized controlled trial comparing HBP vs CRT in patients with heart failure with preserved ejection fraction and a left BBB, Mandrola said.  

“Finally, the other disruptive aspect of His-bundle pacing is that it requires knowledge and experience with cardiac electrophysiology. In many centers, non-EP cardiologists implant pacemakers. The question is whether they are up to the challenge of learning this innovative and decidedly EP-centric technique?” Mandrola said. 

During a session highlighting key studies presented at the meeting, discussant Haran Burri, MD, from the University Hospital of Geneva, Switzerland, said HBP “is very hot now” but that many physicians, including himself, have mistakenly thought that left and right BBB are relatively peripheral when in fact many of these patients have longitudinal dissociation within the His bundle itself.

“It seems that in 80% of patients the level of the block is actually very proximal and amenable to His-bundle pacing correction,” he said, noting that the paced QRS complex was roughly identical to the native QRS complex.

However, “The thresholds were relatively high, which remains one of the challenges of His-bundle pacing, and the sensing value is also quite low,” Burri said. He also highlighted the need for back-up lead placement, another critical question in HBP.

Back-up Pacing

During the formal presentation, Zanon provided additional data from a second study, in which the investigators enabled a three-chamber pacemaker to provide apical back-up sensing for patients undergoing HBP.

He noted that implanting a dual-chamber device in patients with chronic atrial fibrillation provides back-up stimulation on demand, but for those also needing an atrial lead, implanting a CRT pacemaker provides back-up stimulation at every beat. This comes at the cost of battery longevity due to higher thresholds characteristic of LV leads and may negatively affect LV function over time.

To get around this, the investigators connected the atrial lead on a three-chamber pacemaker (Hera, Medico) to the atrial port, the hisian lead to the LV port, and the apical lead to the right ventricular port. Pacing was enabled in both ventricular channels and sensing enabled only in the apical lead to detect intrinsic activity or in response to hisian pacing. A blanking period of 56 ms was set in the apical lead to prevent spike oversensing and a VV-delay programmed at 120 ms.

When HBP was effective, apical sensing occurred within the VV delay and prevented apical back-up pacing. If HBP failed, a back-up pulse was delivered at the end of the VV delay, Zanon explained.

Among 22 patients, HBP with on-demand apical sensing was achieved in 100%, he said.

The His-paced R-wave was sensed in the apical lead after a mean of 96 ms. The detection upper limit of 120 ms was exceeded in “a few cases” of nonselective HBP and corrected with higher output, narrowing the QRS and sensed within the 120-millisecond interval.

At last follow-up at 19 months, device diagnostics showed that back-up pacing was less than 1% in all but one patient and V1-V2 pacing applied in 10% of cycles.

“Avoiding the back-up pacing in each lead could prolong battery longevity and have a fantastic impact for our patients,” Zanon said.

During the discussion of the results, he observed that none of the devices are designed specifically for HBP. “So our main message to the companies is please, study, study, study and design devices for our patients.”

Zanon reported receiving modest speaker fees from Boston Scientific, Medtronic, Livanova, and St Jude Medical. Mandrola is chief cardiology correspondent for theheart.org | Medscape Cardiology.

European Heart Rhythm Association (EHRA) 2018. Presentations 42 and 43. Presented March 18, 2018.

 Follow Patrice Wendling on Twitter: @pwendl. For more from theheart.org | Medscape Cardiology, follow us on Twitter and Facebook.



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Drummer Turned Doc Defibrillates Potential Juror in His Trial

Drummer Turned Doc Defibrillates Potential Juror in His Trial


James Lilja, MD, a San Jose, California, obstetrician/gynecologist and former drummer for the famed punk band The Offspring, performed cardiopulmonary resuscitation (CPR) Tuesday on a prospective juror in the malpractice case against him.

According to the publication Law360, the potential juror went into cardiac arrest as he was waiting to be called back into the Oakland, California, courtroom, fell, then hit his head and collapsed during a morning break in the proceedings. Lilja and his nurse assistant rushed to help him and administered shocks with a defibrillator.

The man was unconscious but had a pulse when paramedics arrived.  The man’s current condition is unknown.

The incident, however, forced a mistrial in light of concerns the physician’s heroics could bias other jurors. Current jurors were dismissed, and the case will be retried April 2.

Lilja faces medical malpractice charges filed by John and Stephenie Sargiotto in Alameda County Superior Court. The couple reportedly allege that Lilja was negligent in treating Stephenie Sargiotto, but no further details were immediately available.

Before medical school, Lilja was a drummer from 1984 to 1987 for the Orange County–based The Offspring and played on the band’s 1986 debut single, “I’ll Be Waiting.” He left before the band realized mainstream success in the 1990s with hits including “Come Out and Play,” “Self Esteem,” and “Pretty Fly (for a White Guy),” according to news reports.

According to his employer’s website, Bay Area Gynecology and Oncology, Lilja received his medical degree from the University of Pittsburgh and went on to the University of Texas at Houston-MD Anderson Cancer Center for his internship and residency.  Following his residency, he completed his fellowship in gynecologic oncology at the University of Michigan.

He is chief medical officer and cofounder of Verthermia Inc, a medical device company investigating new treatments for metastatic cancer.

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Sexual Risk Assessment Lax in Many Sexually Active Youths

Sexual Risk Assessment Lax in Many Sexually Active Youths


Multiple organizations advise healthcare providers to periodically ask sexually active adolescents and adults about sexual behaviors that may increase their risk for HIV or other sexually transmitted infections (STIs), but many don’t, according to new research.

Data from the National Survey of Family Growth for 2011-2015 show that only 47% of females and just 23% of males aged 15 to 44 years who had recently engaged in sexual activity received a sexual risk assessment from a physician or other healthcare provider in the past year.

Factors affecting the rates at which patients received a sexual risk assessment included age, being of Hispanic origin and race, sexual orientation, income, and health insurance status, according to the report published online March 29 in National Health Statistics Reports.

Roughly 65% of females aged 15 to 19 years who had recently engaged in sexual activity received a sexual risk assessment in the past year, as did 63% of women aged 20 to 24. The percentage was lower (41%) for women aged 25 to 44 years, notes author Casey Copen, MPH, PhD, with the Centers for Disease Control and Prevention’s (CDC’s) National Center for Health Statistics, .

Sexual risk assessment was more common among Hispanic and non-Hispanic black females (59% and 55%) compared with non-Hispanic white females (43%). There were no marked differences by sexual orientation in the percentages of female patients who received a sexual risk assessment.

Women aged 20 to 44 whose incomes were lower than 300% of the federal poverty level were more apt to receive a sexual risk assessment than women with incomes at or above this level (49% vs 39%). More women aged 20 to 44 who had public health insurance received a sexual risk assessment (53%) compared with their peers with private health insurance (42%) or no health insurance (46%).

Among Males

Results show that roughly 44% of males aged 15 to 19 who had recently engaged in sexual activity received a sexual risk assessment in the past year, compared with 31% of men aged 20 to 24 years and just 18% of men aged 25 to 44 years.

Forty percent of non-Hispanic black males aged 15 to 44 received a sexual risk assessment in the past year, which was higher than the percentages for Hispanic (26%) and non-Hispanic white (18%) males.

A higher percentage of males in the 15 to 44 age bracket who identified as homosexual or gay (47%) or as bisexual (39%) received a sexual risk assessment compared with those who identified as heterosexual or straight (22%). More men aged 20 to 44 whose incomes were lower than 300% of the federal poverty level (23%) received a sexual risk assessment in the past year than their peers at or above this level (18%).

Roughly 30% of men aged 20 to 44 with public health insurance received a sexual risk assessment in the past year compared with 19% of those with private health insurance and 18% of those with no health insurance.

For males and females, sexual risk assessment was more common for those with two or more opposite-sex partners and for males who had a male sex partner or had engaged in any HIV risk–related sexual behaviors in the past year. Roughly 46% of males and 56% of females reported HIV risk–related sexual behaviors in the prior year. Among both males and females, HIV/STI testing within the past year was more common in those who had undergone a sexual risk assessment in the past year.

“A sexual risk assessment is a primary prevention tool that can help identify persons at risk of HIV/STI. Findings in this report may help inform HIV/STI prevention efforts within the health care setting,” writes Copen.

The CDC estimates that 20 million new STIs occur in the United States each year. Nearly half occur among those aged 15 to 24 years.

Natl Health Stat Report. Published online March 29, 2018. Full text

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Kamis, 29 Maret 2018

Animal-Based Monounsaturated Fats Linked to Total, CVD Mortality

Animal-Based Monounsaturated Fats Linked to Total, CVD Mortality


Diets rich in plant- vs animal-based monounsaturated fatty acids show significantly lower rates of total and cardiovascular disease (CVD) mortality, particularly when the plant-based fatty acids replace other notoriously unhealthy fats, including saturated or trans fats, as well as refined carbohydrates.

“Our study is the first large prospective cohort study with more than 20 years of follow-up, and more than 90,000 participants, and more than 20,000 deaths, looking at monounsaturated fatty acids from plant and animal sources,” coauthor Marta Guasch-Ferré, PhD, from the Harvard School T.H. Chan of Public Health in Boston, Massachusetts, told theheart.org | Medscape Cardiology.

In the study of more than 63,000 women in the Nurses’ Health Study and nearly 30,000 men in the Health Professionals Follow-Up, an average of 22 years of follow-up showed that a higher intake of monounsaturated fatty acids from plants was associated with a 16% lower risk for death from any cause.

A higher intake of monounsaturated fatty acids from animals was meanwhile associated with a 21% higher risk for death from any cause.

The findings were presented this week at the American Heart Association EPI | Lifestyle Scientific Sessions 2018 in New Orleans, Louisiana.

While monounsaturated fatty acids in general are linked to improved lipid profiles and reductions of cardiovascular disease risk factors, including hypertension and obesity, particularly compared with saturated or trans fats, prospective evidence on the association has been limited and inconclusive, Guasch-Ferré said.

“One possible reason is that dietary monounsaturated fatty acids can come from both plant and animal sources, with divergent nutrient components that may potentially obscure the associations for total monounsaturated fatty acids,” she said.

To take a closer look at the differences between plant- and animal-based monounsaturated fats, Guasch-Ferré and colleagues turned to the Nurses’ Health Study, including 63,412 women evaluated between 1990 and 2012, and the Health Professionals Follow-up Study, including 29,966 men from 1990 to 2010.

Intake of types of monounsaturated fatty acids were calculated according to validated food-frequency questionnaires that were collected every 4 years, in addition to food composition databases reflecting changes in food choices over time.

The study showed leading food sources of plant-based monounsaturated fats included olive oil, Italian salad dressing, peanuts, peanut butter, and other nuts.

Top food sources of animal-based monounsaturated fatty acids were beef, cheddar cheese, butter, bologna and other processed meats, and pork.

In evaluation of the 20,672 deaths that occurred during the study, including 4599 cardiovascular deaths, the authors adjusted for a wide range of demographic, lifestyle, and dietary factors, including age, ethnicity, smoking status, alcohol intake, family history of disease, menopausal status, physical activity, aspirin use, multivitamin use, baseline hypertension, baseline hypercholesterolemia, body mass index, total energy intake, and intake of fruits and vegetables.

They found that after the adjustments, higher intake of plant-based monounsaturated fatty acids was associated with reductions in total mortality (hazard ratio [HR], 0.84 [95% CI, 0.79 – 0.89]; P < .01), while higher consumption of animal-based monounsaturated fatty acids was associated with higher risk for mortality (HR, 1.21 [95% CI, 1.07 – 1.37]; P < .01).

In addition, mortality significantly improved when plant-based monounsaturated fatty acids replaced saturated fatty acids (15% lower risk for mortality), refined carbohydrates (14% lower risk), or trans fat (10% lower risk for mortality), in an equivalent number of calories the diet.

Furthermore, a model suggesting replacement of animal-based with plant-based monounsaturated fatty acids showed a total mortality risk reduction of 24%, while the replacement of a combination of animal-based monounsaturated fatty acids and saturated fatty acids with plant-based monounsaturated fatty acids showed a reduced total mortality risk of 20%.

Reductions specifically of cardiovascular mortality were similar with the same substitutions (HR, 0.74 and 0.83, respectively).

“In general, our findings support a beneficial role of monounsaturated fatty acids for the prevention of cardiovascular and total mortality, when plant-based foods such as vegetable oils, nuts, and related products are the primary sources,” Guasch-Ferré said.

Important limitations of the study include the study’s reliance on self-reporting of dietary details and the assumption that a higher consumption of plant-based foods would suggest a generally healthier lifestyle.

The findings are nevertheless consistent with the recommendations of the US Department of Health and Human Services’ 2015–2020 Dietary Guidelines for Americans, which have underscored the importance of dietary fat quality instead of quantity, Guasch-Ferré added.

“Specifically, the intake of vegetable fats, oils and other fats from plant sources has been encouraged while the intake of animal fats, and particularly red and processed meat, has been discouraged,” she said. “Our results are in accordance with these recommendations.”

Previous research has shown the Mediterranean diet, which notably emphasizes plant-based food sources and recommends low intake of red meat, to indeed be associated with a reduced cardiovascular risk, in addition to a wide array of other health benefits.  

That study, which was published in BMC Medicine and included about 23,000 UK residents, showed lower cardiovascular disease and mortality rates among those who adhered to the Mediterranean diet.

“We estimate that 3.9% of all new cardiovascular disease cases or 12.5% of cardiovascular deaths in our UK-based study population could potentially be avoided if this population increased their adherence to the Mediterranean diet,” the study’s senior author, Nita Forouhi, MRCP, PhD, from the Medical Research Council Epidemiology Unit at the University of Cambridge, United Kingdom, said in a journal news release.

The new study offers important further insights underscoring the potentially different health effects within the class of monounsaturated fatty acids, Penny Kris-Etherton, PhD, RD, a distinguished professor of nutrition at the Pennsylvania State University, University Park, told theheart.org | Medscape Cardiology.

“It is very interesting to see adverse associations between animal sources of monounsaturated fatty acids and cardiovascular disease risk,” said Kris-Etherton, who is a spokesperson for the American Heart Association.

“We have always thought that monounsaturated fatty acids were a neutral fatty acid class,” she said. “The new research is now showing that plant monounsaturated fatty acids are beneficial, whereas animal monounsaturated fatty acids are not — and in fact, they are adversely associated with cardiovascular disease risk.”

With existing challenges in conveying the risks and benefits of the various types of fats, additional efforts to underscore the differences between plant- and animal-based monounsaturated fatty acids may not help matters, Kris-Etherton added.

“This could be very confusing to consumers,” she said. “A simple message is that consumers should follow current dietary guidelines and substitute saturated fats with unsaturated fats, both monounsaturated fatty acids and polyunsaturated fatty acids.”

“Major sources of saturated fat are animal foods and major food sources of monounsaturated fatty acids and polyunsaturated fatty acids are plant foods,” she added. “So, in substituting unsaturated fatty acids for saturated fatty acids, people will be eating more plant-based and less animal monounsaturated fatty acids.”

The study was supported by a research grant from Unilever R&D.  The study was also funded by research grants from the National Institutes of Health. Geng Zong and Qi Sun, from the Harvard School of Public Health, also contributed to the study. Coauthors Anne Wanders and Peter L. Zock are employees of Unilever Research and Development. Unilever is a producer of food consumer products. No other authors have disclosed conflict of interest. Kris-Etherton has been involved in research involving plant monounsaturated fatty acids (canola oil, almonds, peanuts, and avocados) as well as animal monounsaturated fatty acids (lean beef).

American Heart Association EPI | Lifestyle Scientific Sessions: Epidemiology and Prevention | Lifestyle and Cardiometabolic Health 2018.

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Warm Weather Exercise and Hot Baths May Be Okay During Pregnancy

Warm Weather Exercise and Hot Baths May Be Okay During Pregnancy


(Reuters Health) – Pregnant women who exercise outside on warm days or spend a little time in a hot bath or sauna may not necessarily raise their body temperature enough to cause problems, a research review suggests.

While most women without health problems can safely exercise during pregnancy, doctors discourage workouts in hot weather because it can lead to heat stress and dehydration. Physicians also advise women to avoid saunas and hot tubs because these activities can raise the body temperature and increase the risk of birth defects.

The risks of heat exposure from warm weather exercise, saunas and hot tubs are thought to develop when the internal body temperature reaches at least 39 degrees Celsius (102.2 degrees Fahrenheit), researchers note in the British Journal of Sports Medicine, online March 1.

For the current study, researchers examined body temperature data from 12 previously published studies of 347 pregnant women who exercised outside during hot weather, took hot baths or used saunas or hot tubs. They found no evidence that any of these activities raised the body temperature to 39 degrees Celsius.

“Presumably people have been told to avoid exercise in hot weather and sauna and hot bath exposures because of concerns about reaching this critical threshold,” said senior study author Ollie Jay of the University of Sydney in Australia.

“It is very difficult to get that hot – most people do not realize that,” Jay said in an email.

Across all of the smaller studies in the analysis, the highest temperature reported for any woman was 38.9 degrees Celsius, and that was immediately after exercise. Warm weather workouts were also associated with the highest average temperature across all of the studies, at 38.3 degrees Celsius.

By comparison, the highest average temperature after a hot bath was 36.9 degrees Celsius, while the highest average temperature after time in a sauna was 37.6 degrees Celsius.

Based on these results, the researchers conclude that pregnant women can safely engage in up to 35 minutes of high intensity aerobic exercise at outdoor temperatures of up to 25 degrees Celsius (77 degrees Fahrenheit).

These results also suggest that pregnant women may spend up to 20 minutes in a bath heated up to 40 degrees Celsius (104 Fahrenheit) or a sauna heated to 70 degrees Celsius (158 Fahrenheit), the authors write.

Beyond its small size, other limitations of the analysis include the varied designs and goals of the smaller studies it examined, which made it difficult to rule out the possibility that some factors that were not measured might have impacted the results, the authors note.

The study also wasn’t a controlled experiment designed to prove whether saunas, hot baths or warm weather workouts are safe for mothers or babies, or what duration or intensity of activity might be safest.

It’s too soon to change current recommendations against these activities for pregnant women, said Dr. Juma Rahman, a researcher at the University of Auckland in New Zealand who wasn’t involved in the study.

Beyond heat stress, the risks can include less oxygen reaching the uterus and baby, Rahman said by email. Women with certain medical conditions like anemia, carrying twins or other obstetric complications may also have an increased risk of heat-related health problems during pregnancy.

Still, pregnant women shouldn’t avoid exercise. Among other things, it can help lower the risk of elevated blood pressure or diabetes during pregnancy, help women avoid gaining too much weight and strengthen abdominal and pelvic muscles.

“There are heaps of benefits,” Rahman said.

SOURCE: https://bit.ly/2IbK2Oz

Br J Sports Med 2018.



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Chronic Fatigue Syndrome Linked to Low T3 Syndrome

Chronic Fatigue Syndrome Linked to Low T3 Syndrome


Some people with the condition known as chronic fatigue syndrome (CFS) have low circulating levels of the thyroid hormone triiodothyronine (T3) and normal levels of thyroid-stimulating hormone (TSH), new research shows. The results suggest these patients may be in a hypometabolic state, but one expert thinks the low levels are more likely a consequence, rather than a cause, of CFS.

The findings, based on 98 patients with CFS and 99 age- and sex-matched controls, were published online March 20 in Frontiers in Endocrinology by Begoña Ruiz-Núñez, a PhD student at the University of Groningen, the Netherlands, and colleagues.

Several CFS symptoms resemble those of hypothyroidism but without the marked increase in TSH. This is also the case, the authors point out, in the so-called low T3 syndrome. Low T3 syndrome, also known as euthyroid sick syndrome, is characterized by decreased serum T3 and/or thyroxin (T4) levels, increased reverse T3 (rT3), and no significant increase in TSH.

This low T3 syndrome might be in line with recent metabolomic studies that point to a hypometabolic state (Proc Natl Acad Sci U S A. 2016;113:E5472-E5480), and if confirmed, T3 and iodide supplements may be indicated as treatments, say Núñez and colleagues.

But endocrinologist Willard H Dere, MD, professor of internal medicine at the University of Utah, Salt Lake City, isn’t convinced.

“The limited data are consistent with what is seen in other inflammatory and chronic disease states. There is no current evidence that thyroxine or tri-iodothyronine replacement in those with low T3 syndrome is beneficial. Furthermore, in hypothyroid patients on thyroxine replacement, the use of tri-iodothyronine, along with L-thyroxine, is thought by some experts to be beneficial, but this view is not a consensus,” he told Medscape Medical News.

Differences Seen in Thyroid Hormones, Inflammatory Markers

The patients were recruited from a single clinic in Amsterdam, and all had been diagnosed with CFS based on 1994 criteria. However, those criteria differ in several ways from more recent definitions of what is now termed myalgic encephalomyelitis (ME)/CFS, including those published by the US Institute of Medicine (IOM) in 2015.

Both definitions include disabling fatigue that lasts more than 6 months and does not improve with rest, and cognitive impairment. However, the IOM criteria place post-exertional malaise as central to the diagnosis, whereas it’s not required in older definitions. Moreover, the IOM criteria don’t require that other potentially fatiguing illnesses be ruled out before making the diagnosis, whereas the older definition does.

In the current study, the 21 men and 77 women with CFS had a mean age of 43 years and body mass index (BMI) of 22 kg/m2. The 23 men and 76 women who were control participants had a mean age of 39 years and BMI of 23 kg/m2, which were not significantly different from the CFS group.

Compared with controls, the CFS group had lower levels of free triiodothyronine (FT3), total T4 (TT4), total T3 (TT3), percent TT3, sum activity of peripheral deiodinases (SPINA-GD), and secretory capacity of the thyroid gland (SPINA-GT), as well as lower ratios of TT3/TT4, FT3/FT4, TT3/FT3, and TT4/FT4, and higher percent rT3 and rT3/TT3 ratio.

There were no differences between groups in other thyroid hormone parameters, notably TSH, FT4, rT3, and percent TT4.

FT3 levels below the reference range were more frequent in the CFS group (16/98) compared with controls (7/99; P = .035), with an odds ratio of 2.56 (95% CI, 1.00 – 6.54).

However, Dere commented, “The subset of patients with the low T3 syndrome is relatively small, and their laboratory values don’t vary substantively from that of the control group. Overall, I think the probability of a low T3 syndrome causing ME/CFS is low.”

In measures of metabolic inflammation, no significant differences were found in white blood count, high-sensitivity C-reactive protein (hsCRP), tryptophan/kynurenine ratio, or urinary isoprostanes, but the CFS group did have lower kynurenine and tryptophan levels than controls.

Ferritin was higher and HDL-cholesterol was lower in patients with CFS. Zonulin, a parameter of intestinal permeability, was also lower in patients with CFS compared with controls.

Measures of nutritional factors influencing thyroid function and inflammation that differed between the groups included 24-hour urinary iodine output, a proxy of iodine status, which was lower in patients with CFS. Plasma selenium was similar, but intracellular selenium was higher in patients with CFS. Vitamin D [25(OH)D] status of patients with CFS was higher, but 59% of patients with CFS and 83% of controls presented with 25(OH)D levels below the optimal cutoff of 80 nmol/L, Ruiz-Núñez and colleagues report.

In two sensitivity analyses that excluded patients with the highest levels of inflammatory markers, all the prior findings remained significant except FT3, which was no longer significantly lower in the CFS group.

Markers of Inflammation: Cause or Consequence?

Overall in both groups, FT3, TT3, TT4, and rT3 were positively related with hsCRP.

“The limited data from this study correlates other markers of inflammation with the presence of low T3 and high reverse T3, and are consistent with what is seen with other inflammatory and chronic disease states,” Dere noted.

He added that the low T3 state “seems to be the result, not the cause, of a systemic or localized inflammatory or chronic disease state. During caloric deprivation, the fall in T3 is believed to be an adaptive response directed to saving energy and protein for enduring this acute stress. Thus one can speculate that with some chronic disorders, the diminished plasma T3 helps to preserve caloric expenditure.”

Overall, Dere said he wouldn’t change clinical practice based on these findings. “A serum TSH is a good screening test to rule out primary thyroidal disorders.”

The authors have reported no relevant financial relationships. Dere serves on the board of directors for Radius Health, BioMarin, Seres Therapeutics, Mersana Therapeutics, and has received grants from the Working Group of California Institute of Regenerative Medicine.

Front Endocrinol. Published March 20, 2018. Full article

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Brand-Name Prescription Drug Prices Skyrocketing for Seniors

Brand-Name Prescription Drug Prices Skyrocketing for Seniors


Over the past 5 years, the cost of many of the most popular brand-name prescription drugs used by older Americans increased at nearly 10 times the rate of inflation, according to a new report from US Senator Claire McCaskill (D-MO).

“Can you imagine if you went to an auto dealership and last year’s exact model was being sold at a 20 percent mark-up, and then you went back the next year and it had happened again?” McCaskill said in a news release. “That’s exactly what’s happening in the prescription drug industry, where the cost of identical drugs skyrockets year after year. This report demonstrates that the pricing decisions made by these drug companies are outrageous.”  

At the request of McCaskill, minority staff of the Committee on Homeland Security and Governmental Affairs reviewed price increases for the 5-year-period, 2012 to 2017, across the top 20 most-prescribed brand-name drugs for seniors in the Medicare Part D program. 

Drugs making the list in 2015 included Advair Diskus (fluticasone/salmeterol), Crestor (rosuvastatin), Januvia (sitagliptin), Lantus/Lantus Solostar (insulin glargine), Lyrica (pregabalin), Nexium (esomeprazole), Nitrostat (nitroglycerin), Novolog (insulin aspart), Premarin (conjugated estrogens), Proair HFA (albuterol), Restasis (cyclosporine), Spiriva Handihaler (tiotropium), Symbicort (budesonide/formoterol), Synthroid (levothyroxine), Tamiflu (oseltamivir), Ventolin HFA (albuterol sulfate), Voltaren Gel (diclofenac), Xarelto (rivaroxaban), Zetia (ezetimibe), and Zostavax (zoster vaccine).

Among the report’s key findings are the following:

  • Prices increased for every drug on the list between 2012 and 2017. On average, prices for these drugs increased 12% every year for the last 5 years — roughly 10 times higher than the average annual rate of inflation.

  • Twelve of the 20 most commonly prescribed brand-name drugs for seniors had price increases of over 50% during the 5-year period. Six of the 20 had price increases of over 100%. In one case, the weighted average wholesale acquisition cost for a single drug increased by 477% over 5 years.

  • Although 48 million fewer prescriptions were written for the top 20 most commonly prescribed brand-name drugs for seniors between 2012 and 2017, total sales revenue resulting from these prescriptions increased by almost $8.5 billion during the same period.

Out-of-Pocket Spending Rising

Soaring drug prices are driving up healthcare costs each year, the report notes. In 2016 alone, spending on prescription drugs topped $328 billion. According to the most recent National Heath Expenditure data published by the Centers for Medicare & Medicaid Services, retail prescription drug spending grew at an average pace of 4.8% between 2006 and 2015, with two of the highest-growth years occurring in 2014 and 2015 at 12.4% and 9.0%, respectively.

Even with Medicare coverage, many older individuals also face substantial out-of-pocket costs, particularly for specialty and brand-name drugs. According to one independent study, Medicare beneficiaries’ out-of-pocket spending on prescription drugs is expected to increase from 41% of per capita Social Security income in 2013 to 50% in 2030, the report notes.

In his first State of the Union address, President Donald J Trump pledged to work to reduce prescription drug prices. As reported by Medscape Medical News, the president said that drug prices are too high and said that one of his “greatest priorities” would be to find a way to bring them down, calling them “very, very unfair.”

Trump added, “That is why I have directed my administration to make fixing the injustice of high drug prices one of my top priorities for the year. And prices will come down substantially.  Watch.”

McCaskill has made tackling rising healthcare and prescription drug costs a top priority in the Senate. She joined Senator Susan Collins (R-ME) to launch an in-depth investigation into prescription drug price increases and recently introduced legislation to end taxpayer subsidies to end taxpayer subsidies drug companies receive for the billions of dollars they spend on prescription drug advertising each year, which currently is fully tax-deductible.

In addition, McCaskill’s bipartisan legislation to boost competition for generic drugs and help lower prescription costs was signed into law by Trump. McCaskill has also introduced legislation with Collins to prohibit pharmacy gag laws that lead to consumers overpaying for prescription drugs.

The full report, “Manufactured Crisis: How Devastating Drug Price Increases Are Harming America’s Seniors,” is available online.

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New Standard of Care in Advanced Renal Cell Carcinoma?

New Standard of Care in Advanced Renal Cell Carcinoma?


Combination immunotherapy could be a new standard of care for some patients with advanced renal cell carcinoma (RCC), suggest the results of a large randomized phase 3 trial

In the trial, both overall survival and objective response rates were significantly higher with nivolumab (Opdivo, Bristol-Myers Squibb) plus ipilimumab (Yervoy, Bristol-Myers Squibb) as compared to sunitinib (Sutent, Pfizer) in patients with intermediate- and poor-risk advanced RCC.

The 18-month overall survival rate was 75% with nivolumab plus ipilimumab vs 60% with sunitinib; the objective response rate was 42% vs 27%.

The findings were initially presented at the European Society of Medical Oncology 2017 Congress and were reported by Medscape Medical News at that time. They have now been published online in the New England Journal of Medicine.

“The study showed improvement in response and overall survival compared to sunitinib for patients with intermediate or poor features, comprising about 80% of patients with metastatic RCC,” said lead author Robert Motzer, MD, a medical oncologist at Memorial Sloan Kettering Cancer Center in New York City.

“In this group, nivolumab plus ipilimumab should be a new treatment option — pending regulatory approval — and a new standard of care,” he told Medscape Medical News. “The benefit was seen in the entire kidney cancer population as well, but in the small subset of patients with favorable-risk disease, the sunitinib group had higher response rates. So sunitinib will be regarded by most as the option of choice for favorable-risk patients.”

The combination of nivolumab plus ipilimumab has already been investigated in several tumor types, and response rates tend to be better than those of either agent used alone. The combination has been approved for the treatment of advanced melanoma.

The combination has also demonstrated antitumor activity in untreated and previously treated patients with advanced RCC, the authors note.

Significant Improvement in Survival and Response

The cohort included 1082 patients with previously untreated clear-cell advanced RCC who were randomly assigned to receive treatment with nivolumab plus ipilimumab (n = 547) or with sunitinib (n = 535). In the intent-to-treat population, 423 patients had intermediate-risk disease, and 416 patients had poor-risk disease.

The coprimary end points were overall survival, objective response rate, and progression-free survival in the group at intermediate or poor risk.

In the intermediate- and poor-risk group, the 12-month overall survival rate was significantly better in the nivolumab plus ipilimumab arm compared with that in the sunitinib arm: 80% vs 72% (hazard ratio for death, 0.63; 99.8% confidence interval, 0.44 – 0.89; P < .001).

The median overall survival was not reached with nivolumab plus ipilimumab. It was 26.0 months with sunitinib.

A complete response was observed in 40 patients (9%) in the nivolumab plus ipilimumab arm and in 5 patients (1%) in the sunitinib arm. Among the intermediate- and poor-risk patients, 81% in the nivolumab plus ipilimumab arm demonstrated a duration of response of at least 1 year; 70% of patients in the sunitinib arm demonstrated a duration of response of at least 1 year. The median duration of response not reached in the nivolumab plus ipilimumab arm; it was 18.2 months in the sunitinib arm.

For progression-free survival, the median was 11.6 months with nivolumab plus ipilimumab and 8.4 months with sunitinib, but the difference between groups did not meet the prespecified threshold (P = .009) for statistical significance (hazard ratio for disease progression or death, 0.82; P = .03).

The authors assessed outcomes for the entire intent-to-treat population (patients with favorable, intermediate, or poor risk). The 12-month overall survival rate was 83% for immunotherapy vs 77% with sunitinib; the 18-month overall survival rate was 78% vs 68%.

The median overall survival was not reached for the nivolumab plus ipilimumab arm; it was 32.9 months for the sunitinib arm. The rate of independently assessed objective response was 39% with nivolumab plus ipilimumab and 32% with sunitinib (P = .02; not significant per the prespecified 0.001 threshold).

Median progression-free survival rates were similar for both groups: 12.4 with nivolumab plus ipilimumab and 12.3 months with sunitinib (hazard ratio for disease progression or death, 0.98; P = .85).

Favorable Risk Favors Sunitinib

The subgroup of patients who were considered to be at favorable risk did worse with immunotherapy than with sunitinib. An exploratory analysis found that in this small subgroup (n = 249), response rates were higher and progression-free survival was longer with sunitinib than with the combination of nivolumab and ipilimumab.

The 12-month overall survival rate was 94% with nivolumab plus ipilimumab and 96% with sunitinib. The 18-month overall survival rates were 88% and 93%, respectively (the hazard ratio for death favored sunitinib: 1.45; 99.8% CI, 0.51 – 4.12; P = .27). The objective response rate was 29% with nivolumab plus ipilimumab vs 52% with sunitinib (P < .001). The median progression-free survival was 15.3 months vs 25.1 months (hazard ratio for disease progression or death, 2.18; 99.1% CI, 1.29 – 3.68; P < .001), favoring sunitinib.

The rate of complete response, however, was 11% with nivolumab plus ipilimumab and 6% with sunitinib.

“It is important to evaluate and better understand the underlying tumor biology of each of these groups to better define what is driving response to nivolumab plus ipilimumab and to sunitinib,” said Motzer. “We have not compared the combination to nivolumab alone, although cross-study comparisons favor the nivolumab/ipilimumab combination in producing tumor responses.”

Patients who received the immunotherapy combination had fewer grade 3-4 adverse events than those who received sunitinib (46% vs 63%), but there were more discontinuations (22% with immunotherapy vs 12% with sunitinib) and more treatment-related deaths (8 patients vs 4 patients). Overall, treatment-related adverse events of any grade occurred in 93% of patients in the immunotherapy group vs 97% of those treated with sunitinib.

Curative Treatments Needed

In an accompanying editorial, Brendan Curti, MD, from the Earle A. Chiles Research Institute, Providence Cancer Institute, Portland, Oregon, writes that it is “notable that tumors with a greater number of mutations appear more likely to have a response to checkpoint immunotherapy.”

This may account for the better response with immunotherapy seen in some patients but not others. There may be a “higher tumor mutational load and a broad, though ineffective, extant adaptive immune response in patients with intermediate- and poor-risk renal-cell carcinoma as compared with patients with favorable-risk disease,” says Curti.

But importantly, the combination of ipilimumab and nivolumab is a step in the right direction when it comes to improving treatment in RCC. He notes that for the past quarter century, treatment has evolved from “infrequently effective cytokine-based immunotherapy to active but rarely curative TKI [tyrosine kinase inhibitor] treatment, and now to more effective immunotherapy that in some clinical settings is superior to TKIs.”

However, with current therapies, there is still only a small probability of complete response or cure. “The goal of future immunotherapy development should be not just transient response or tumor control, but rather cure in a higher proportion of patients,” Curti emphasizes.

The study was funded by Bristol-Myers Squibb and Ono Pharmaceutical. Patients treated at the Memorial Sloan Kettering Cancer Center were supported in part by a Memorial Sloan Kettering Cancer Center support grant/core grant. Dr Motzer received grant support from Bristol-Myers Squibb during the conduct of the study; has received grant support and personal fees from Pfizer, Novartis, Eisai, and Exelixis and grant support from Genentech/Roche outside the submitted work. Several coauthors have disclosed relationships with industry, as noted in the original article. Dr Curti has received grants, personal fees, and nonfinancial support from BMS and Prometheus, grants from MedImmune and Viralytics, and personal fees from Eisai outside the submitted work.

N Engl J Med. Published on March 21, 2018. Full text, Editorial

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Nonphysical Problems Common After Stroke

Nonphysical Problems Common After Stroke


A new study highlights some of the more common nonphysical problems experienced by patients after they have an ischemic stroke, with some surprising findings.

The study, which examined patient-reported information collected systematically at the Cleveland Clinic cerebrovascular clinic from 2015 to 2017, found that after physical function, the domains most affected in patients with ischemic stroke were satisfaction with social roles (eg, the ability to do domestic tasks, go out and socialize, and go to work) and executive function.

“While we would all expect physical function to be impacted by stroke, satisfaction with social roles and executive function are not as well appreciated as being common problems after stroke. We actually found that these were much more common than anxiety and depression, which was quite surprising,” lead author, Irene L. Katzan, MD, Cleveland Clinic, Ohio, told Medscape Medical News.

“Even if patients don’t have an obvious physical disability after a stroke — so on the surface they appear normal — they often suffer from these less obvious issues which can have a large effect on quality of life. While they may be able to get to the grocery store, they may have problems organizing a list or paying for their goods or they may feel too fatigued to go out at all,” she said.    

“While many centers will systematically screen for depression after stroke, I don’t think we routinely think about satisfaction with social roles and executive function as common problems for stroke patients,” Katzan added. “Our results suggest that we should.  While there is no quick fix for these problems, we can provide suggestions on how to cope better maybe, in programs aimed at integrating people back into society again.”

The study was published online in Neurology on March 28.

Katzan explained that while it is well known that stroke affects lives in many different ways, usually patients are assessed by using limited scores that don’t take account of multiple factors occurring together and how they interact with each other.

“The main scale used to assess stroke patients — the modified Rankin Scale (mRS) — is quite a crude scale with only seven different categories and is heavily weighted towards mobility. It doesn’t differentiate the impact of things like sleep, cognition, anxiety, and depression on day-to-day life.”   

For the current study, the researchers analyzed information from 1195 stroke patients by using the Patient-Reported Outcomes Measurement Information System (PROMIS), which captures patient responses for physical function, satisfaction with social roles, fatigue, anxiety, depression, pain interference, and sleep disturbance. Scores are calibrated to the US general population, which aids in the clinical interpretation of results.

Additional information on executive function was derived from response to the Neuro-QoL executive function scale.

The most affected domains were physical function (T score, 58.8), satisfaction with social roles (T score, 55.4), and executive function (T score, 53.4).

PROMIS scores for all domains except depression and sleep disturbance were worse than in the general population. However, patients with an mRS score of 0 (no symptoms) were not worse than the general population on any of the eight domains measured.

Disability, lower income, and female sex were associated with worse scores in multiple domains. Age was associated with worse physical function but lower anxiety, depression, and sleep disturbance.

Patient-reported health worsened with increasing levels of disability in all domains, although to varying degrees.

A graded response of worsening physical function, worsening executive function, and worsening satisfaction with social roles was correlated with the mRS and the National Institutes of Health Stroke Scale. While fatigue, depression, pain, and anxiety had modest correlations and sleep disturbance had only a slight correlation with disability, scores remained relatively stable in patients with disability levels ranging from mild to severe (mRS score, 2 to 5).

“Our findings that domains of health are differentially affected with increasing levels of disability support the value of assessing individual domains of health in stroke patients, regardless of stroke severity,” the researchers say. 

“The results of this study, which represents one of the largest analyses of patient-reported outcomes after stroke collected as part of routine care, improve our understanding of the well-being of patients with ischemic stroke compared to the general population and bring attention to the importance of social roles and executive function for stroke survivors,” they conclude.

In an accompanying editorial, Mary G George, MD, Centers for Disease Control and Prevention, Atlanta, Georgia, and Xingquan Zhao, MD, Beijing Institute for Brain Disorders, China, say the study “sheds light on understanding how survivors of ischemic stroke differ from the general population across multiple health domains that can be useful in improving the clinician’s understanding of patients’ challenges and needs, as well as addressing outcomes that matter most to patients.”

The study had no targeted funding. Katzan, George, and Zhao have disclosed no relevant financial relationships. Disclosures for coauthors appear in the paper.

Neurology. Published online March 28, 2018. Abstract, Editorial

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Doctors, Nurses Give Lifestyle Advice, Are Skeptical It's Heeded

Doctors, Nurses Give Lifestyle Advice, Are Skeptical It's Heeded


All nurses and physicians who responded to a Medscape Medical News poll said they advise at least some of their patients to change lifestyle practices to reduce risk for disease, but only 61% of physicians and 53% of nurses said they always offer such advice.

About a third of physicians (32%) and 36% of nurses/advanced practice nurses said they “often” offered lifestyle advice and 6% of physicians and 8% of nurses said they “sometimes” offer it.

The poll question was asked in November last year in light of mounting evidence that making positive lifestyle changes is a powerful strategy to maintain health and prevent disease.  Total responses numbered 515: 358 physicians and 157 nurses.

The poll showed a large disparity in the numbers of providers offering the advice and the numbers of patients they believe are heeding it.

Table. How Often Do Your Patients Follow Your Recommendations?

Frequency Physicians’ Estimates (%)a Nurses’/Advanced Practice Nurses’ Estimates (%)
Always 3 1
Often 21 12
Sometimes 56 60
Rarely 16 15
Never 1 1
I don’t know 4 11
aNumbers may not add up to 100 because of rounding.

 

Some comments on the poll show frustrations providers have regarding giving lifestyle advice.

A registered nurse wrote, “Diabetes, Hypertension and Kidney Failure is so high in the community I live in. Every effort is made to educate our patients, [but] too often [patients] don’t make the effort to make changes. Not too sure how much more can be done if people don’t make the effort to make healthy lifestyle modifications.”

Another registered nurse cited lack of an industry-wide focus on making changes proactively.

She wrote: “Unfortunately the health care industry mostly considers healthy lifestyles to be a personal issue rather than a healthcare system issue.  While the healthcare system is very good at treating the effects of an unhealthy lifestyle, it has shown itself to be disinterested in creating healthy lifestyles.”

Most Common Advice Given

Increased physical activity (90%), improving nutrition/diet (80%), and quitting smoking (82%) were among the lifestyle changes physicians were most likely to suggest.  Nurses answered similarly in their likelihood to make those recommendations.

However, physicians were much more likely than nurses to advise losing weight: 76% of physicians vs 61% of nurses recommended that lifestyle change.

Among advice less likely to be given, recommendations to increase socializing were made by 23% of physicians and 24% of nurses. Twelve percent of physicians and 8% of nurses said they advised patients to make a change in sexual behavior.

Some commenters brought up “motivational interviewing” and the need to help patients discover their own motivation for change.

A psychiatrist who commented wrote, “Recommending alone doesn’t do anything. You have to actively work together on this. Most people will resist such efforts. If you think about yourself, you’ll notice how hard it is to change habits. It’s even hard to do things you like to do. You have to work with the individual and figure out what works for them. Dictates or a tossed off suggestion or handouts won’t work.”

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