Pam Harrison

The presence of gallstone disease may be a harbinger of pancreatic ductal adenocarcinoma (PDAC), researchers suggest after showing an association between the two in a SEER-Medicare database analysis. Patients with PDAC were six times more likely to have had gallstone disease in the year prior to diagnosis than noncancer patients, they found.

“We can’t be certain at this time as to whether gallstone disease is a precursor to PDAC or whether it is the end result of PDAC, but we do know there is an association, and we plan to explore it further,” commented study author Teviah Sachs, MD, MPH, Boston Medical Center.

“We don’t want anyone with gallstone disease to think that they have pancreatic cancer because, certainly, the overwhelming majority of patients with gallstone disease do not have pancreatic cancer,” he emphasized.

“But I would say to physicians that if you have a patient who presents with gallstone disease and they have other symptoms, you should not necessarily attribute those symptoms just to their gallstone disease,” Dr. Sachs commented.

“The diagnosis of pancreatic cancer should be on the differential in patients who present with symptoms that might not otherwise correlate with typical gallstones,” he added. 

Dr. Sachs was speaking at a press briefing ahead of the annual Digestive Disease Week® (DDW), where the study will be presented.

“PDAC is often fatal because it’s frequently not diagnosed until it is late-stage disease,” Dr. Sachs noted.  

Complicating earlier diagnosis is the fact that symptoms of PDAC often mirror those associated with gallstone disease and gallbladder infection, “both of which have been demonstrated to be risk factors for PDAC,” Dr. Sachs added.
 

Annual incidence

The purpose of the present study was to compare the incidence of cholelithiasis or cholecystitis in the year before a diagnosis of PDAC with the annual incidence in the general population.

A total of 18,700 patients with PDAC, median age 76 years, were identified in the SEER-Medicare database between 2008 and 2015. The incidence of hospital visits for gallstone disease in the year prior to PDAC diagnosis as well as the annual incidence of gallstone disease in the SEER-Medicare noncancer cohort were assessed.

An average of 99,287 patients per year were available from the noncancer cohort, 0.8% of whom had gallstone disease and 0.3% of whom had their gallbladders removed. In contrast, in the year before their diagnosis, 4.7% of PDAC patients had a diagnosis of gallstone disease and 1.6% had their gallbladders removed.

“Gallstone disease does not cause pancreatic cancer,” lead author, Marianna Papageorge, MD, research fellow, also of Boston Medical Center, said in a statement.

“But understanding its association with PDAC can help combat the high mortality rate with pancreatic cancer by providing the opportunity for earlier diagnosis and treatment,” she added.

A version of this article first appeared on Medscape.com.

The presence of gallstone disease may be a harbinger of pancreatic ductal adenocarcinoma (PDAC), researchers suggest after showing an association between the two in a SEER-Medicare database analysis. Patients with PDAC were six times more likely to have had gallstone disease in the year prior to diagnosis than noncancer patients, they found.

“We can’t be certain at this time as to whether gallstone disease is a precursor to PDAC or whether it is the end result of PDAC, but we do know there is an association, and we plan to explore it further,” commented study author Teviah Sachs, MD, MPH, Boston Medical Center.

“We don’t want anyone with gallstone disease to think that they have pancreatic cancer because, certainly, the overwhelming majority of patients with gallstone disease do not have pancreatic cancer,” he emphasized.

“But I would say to physicians that if you have a patient who presents with gallstone disease and they have other symptoms, you should not necessarily attribute those symptoms just to their gallstone disease,” Dr. Sachs commented.

“The diagnosis of pancreatic cancer should be on the differential in patients who present with symptoms that might not otherwise correlate with typical gallstones,” he added. 

Dr. Sachs was speaking at a press briefing ahead of the annual Digestive Disease Week® (DDW), where the study will be presented.

“PDAC is often fatal because it’s frequently not diagnosed until it is late-stage disease,” Dr. Sachs noted.  

Complicating earlier diagnosis is the fact that symptoms of PDAC often mirror those associated with gallstone disease and gallbladder infection, “both of which have been demonstrated to be risk factors for PDAC,” Dr. Sachs added.
 

Annual incidence

The purpose of the present study was to compare the incidence of cholelithiasis or cholecystitis in the year before a diagnosis of PDAC with the annual incidence in the general population.

A total of 18,700 patients with PDAC, median age 76 years, were identified in the SEER-Medicare database between 2008 and 2015. The incidence of hospital visits for gallstone disease in the year prior to PDAC diagnosis as well as the annual incidence of gallstone disease in the SEER-Medicare noncancer cohort were assessed.

An average of 99,287 patients per year were available from the noncancer cohort, 0.8% of whom had gallstone disease and 0.3% of whom had their gallbladders removed. In contrast, in the year before their diagnosis, 4.7% of PDAC patients had a diagnosis of gallstone disease and 1.6% had their gallbladders removed.

“Gallstone disease does not cause pancreatic cancer,” lead author, Marianna Papageorge, MD, research fellow, also of Boston Medical Center, said in a statement.

“But understanding its association with PDAC can help combat the high mortality rate with pancreatic cancer by providing the opportunity for earlier diagnosis and treatment,” she added.

A version of this article first appeared on Medscape.com.

The presence of gallstone disease may be a harbinger of pancreatic ductal adenocarcinoma (PDAC), researchers suggest after showing an association between the two in a SEER-Medicare database analysis. Patients with PDAC were six times more likely to have had gallstone disease in the year prior to diagnosis than noncancer patients, they found.

“We can’t be certain at this time as to whether gallstone disease is a precursor to PDAC or whether it is the end result of PDAC, but we do know there is an association, and we plan to explore it further,” commented study author Teviah Sachs, MD, MPH, Boston Medical Center.

“We don’t want anyone with gallstone disease to think that they have pancreatic cancer because, certainly, the overwhelming majority of patients with gallstone disease do not have pancreatic cancer,” he emphasized.

“But I would say to physicians that if you have a patient who presents with gallstone disease and they have other symptoms, you should not necessarily attribute those symptoms just to their gallstone disease,” Dr. Sachs commented.

“The diagnosis of pancreatic cancer should be on the differential in patients who present with symptoms that might not otherwise correlate with typical gallstones,” he added. 

Dr. Sachs was speaking at a press briefing ahead of the annual Digestive Disease Week® (DDW), where the study will be presented.

“PDAC is often fatal because it’s frequently not diagnosed until it is late-stage disease,” Dr. Sachs noted.  

Complicating earlier diagnosis is the fact that symptoms of PDAC often mirror those associated with gallstone disease and gallbladder infection, “both of which have been demonstrated to be risk factors for PDAC,” Dr. Sachs added.
 

Annual incidence

The purpose of the present study was to compare the incidence of cholelithiasis or cholecystitis in the year before a diagnosis of PDAC with the annual incidence in the general population.

A total of 18,700 patients with PDAC, median age 76 years, were identified in the SEER-Medicare database between 2008 and 2015. The incidence of hospital visits for gallstone disease in the year prior to PDAC diagnosis as well as the annual incidence of gallstone disease in the SEER-Medicare noncancer cohort were assessed.

An average of 99,287 patients per year were available from the noncancer cohort, 0.8% of whom had gallstone disease and 0.3% of whom had their gallbladders removed. In contrast, in the year before their diagnosis, 4.7% of PDAC patients had a diagnosis of gallstone disease and 1.6% had their gallbladders removed.

“Gallstone disease does not cause pancreatic cancer,” lead author, Marianna Papageorge, MD, research fellow, also of Boston Medical Center, said in a statement.

“But understanding its association with PDAC can help combat the high mortality rate with pancreatic cancer by providing the opportunity for earlier diagnosis and treatment,” she added.

A version of this article first appeared on Medscape.com.

The observation that women with lung cancer seem to live longer than men can be explained by known prognostic factors, a new study suggests.

“In this first Australian prospective study of lung cancer survival comparing men and women, we found that men had a 43% greater risk of dying from their lung cancer than women,” comments lead author Xue Qin Yu, PhD, the Daffodil Centre, the University of Sydney, and colleagues.

“[However], when all prognostic factors were considered together, most of the survival differential disappeared,” they add.

“These results suggest that sex differences in lung cancer survival can be largely explained by known prognostic factors,” Dr. Yu and colleagues emphasize.

The study was published in the May issue of the Journal of Thoracic Oncology.
 

The ‘45 and up’ study

The findings come from the Sax Institute’s 45 and Up Study, an ongoing trial involving over 267,000 participants aged 45 years and older living in New South Wales, Australia. Patients were recruited to the study between 2006 and 2009. At the time of recruitment, patients were cancer free.

A total of 1,130 participants were diagnosed with having lung cancer during follow-up – 488 women and 642 men. Compared with men, women were, on average, younger at the time of diagnosis, had fewer comorbidities, and were more likely to be never-smokers or to have been exposed to passive smoke.

Women were also more likely to be diagnosed with adenocarcinoma than men and to receive surgery within 6 months of their diagnosis.

“Lung cancer survival was significantly higher for women,” the authors report, at a median of 1.28 years versus 0.77 years for men (P < .0001).

Within each subgroup of major prognostic factors – histologic subtype, cancer stage, cancer treatment, and smoking status – women again survived significantly longer than men.

Interestingly, the authors note that “women with adenocarcinoma had significantly better survival than men with adenocarcinoma independent of smoking status,” (P = .0009). This suggests that sex differences in tumor biology may play a role in explaining the sex survival differential between men and women, they commented. That said, never-smokers had a 16% lower risk for lung cancer death than ever-smokers after adjusting for age, the authors point out.

The authors also note that approximately half of the disparity in survival between the sexes could be explained by differences in the receipt of anticancer therapy within 6 months of the diagnosis. “This could partly be due to a lower proportion of men having surgery within 6 months than women,” investigators speculate, at 17% versus 25%, respectively.

Men were also older than women at the time of diagnosis, were less likely to be never-smokers, and had more comorbidities, all of which might also have prevented them from having surgery. Women with lung cancer may also respond better to chemotherapy than men, although the sex disparity in survival persisted even among patients who did not receive any treatment for their cancer within 6 months of their diagnosis, investigators point out.

Furthermore, “smoking history at baseline was identified as a significant contributing factor to the sex survival disparity, explaining approximately 28% of the overall disparity,” Dr. Yu and colleagues observe.

Only 8% of men diagnosed with lung cancer were never-smokers, compared with 23% of women. The authors note that never-smokers are more likely to receive aggressive or complete treatment and respond well to treatment.

Similarly, tumor-related factors together explained about one-quarter of the overall sex disparity in survival.
 

Screening guidelines

Commenting on the findings in an accompanying editorial, Claudia Poleri, MD, Hospital María Ferrer, Buenos Aires, says that this Australian study provides “valuable information.”

“The risk of dying from lung cancer was significantly higher for men than for women,” she writes. “Differences in treatment-related factors explained 50% of the sex survival differential, followed by lifestyle and tumor-related factors (28% and 26%, respectively).

“Nevertheless, these differences alone do not explain the higher survival in women,” she comments.

“Does it matter to analyze the differences by sex in lung cancer?” Dr. Poleri asks in the editorial, and then answers herself: “It matters.”

“It is necessary to implement screening programs and build artificial intelligence diagnostic algorithms considering the role of sex and gender equity to ensure that innovative technologies do not induce disparities in clinical care,” she writes.

“It is crucial to conduct education and health public programs that consider these differences, optimizing the use of available resources, [and] it is essential to improve the accuracy of research design and clinical trials,” she adds.

Dr. Yu and Dr. Poleri declared no relevant financial interests.

A version of this article first appeared on Medscape.com.

The observation that women with lung cancer seem to live longer than men can be explained by known prognostic factors, a new study suggests.

“In this first Australian prospective study of lung cancer survival comparing men and women, we found that men had a 43% greater risk of dying from their lung cancer than women,” comments lead author Xue Qin Yu, PhD, the Daffodil Centre, the University of Sydney, and colleagues.

“[However], when all prognostic factors were considered together, most of the survival differential disappeared,” they add.

“These results suggest that sex differences in lung cancer survival can be largely explained by known prognostic factors,” Dr. Yu and colleagues emphasize.

The study was published in the May issue of the Journal of Thoracic Oncology.
 

The ‘45 and up’ study

The findings come from the Sax Institute’s 45 and Up Study, an ongoing trial involving over 267,000 participants aged 45 years and older living in New South Wales, Australia. Patients were recruited to the study between 2006 and 2009. At the time of recruitment, patients were cancer free.

A total of 1,130 participants were diagnosed with having lung cancer during follow-up – 488 women and 642 men. Compared with men, women were, on average, younger at the time of diagnosis, had fewer comorbidities, and were more likely to be never-smokers or to have been exposed to passive smoke.

Women were also more likely to be diagnosed with adenocarcinoma than men and to receive surgery within 6 months of their diagnosis.

“Lung cancer survival was significantly higher for women,” the authors report, at a median of 1.28 years versus 0.77 years for men (P < .0001).

Within each subgroup of major prognostic factors – histologic subtype, cancer stage, cancer treatment, and smoking status – women again survived significantly longer than men.

Interestingly, the authors note that “women with adenocarcinoma had significantly better survival than men with adenocarcinoma independent of smoking status,” (P = .0009). This suggests that sex differences in tumor biology may play a role in explaining the sex survival differential between men and women, they commented. That said, never-smokers had a 16% lower risk for lung cancer death than ever-smokers after adjusting for age, the authors point out.

The authors also note that approximately half of the disparity in survival between the sexes could be explained by differences in the receipt of anticancer therapy within 6 months of the diagnosis. “This could partly be due to a lower proportion of men having surgery within 6 months than women,” investigators speculate, at 17% versus 25%, respectively.

Men were also older than women at the time of diagnosis, were less likely to be never-smokers, and had more comorbidities, all of which might also have prevented them from having surgery. Women with lung cancer may also respond better to chemotherapy than men, although the sex disparity in survival persisted even among patients who did not receive any treatment for their cancer within 6 months of their diagnosis, investigators point out.

Furthermore, “smoking history at baseline was identified as a significant contributing factor to the sex survival disparity, explaining approximately 28% of the overall disparity,” Dr. Yu and colleagues observe.

Only 8% of men diagnosed with lung cancer were never-smokers, compared with 23% of women. The authors note that never-smokers are more likely to receive aggressive or complete treatment and respond well to treatment.

Similarly, tumor-related factors together explained about one-quarter of the overall sex disparity in survival.
 

Screening guidelines

Commenting on the findings in an accompanying editorial, Claudia Poleri, MD, Hospital María Ferrer, Buenos Aires, says that this Australian study provides “valuable information.”

“The risk of dying from lung cancer was significantly higher for men than for women,” she writes. “Differences in treatment-related factors explained 50% of the sex survival differential, followed by lifestyle and tumor-related factors (28% and 26%, respectively).

“Nevertheless, these differences alone do not explain the higher survival in women,” she comments.

“Does it matter to analyze the differences by sex in lung cancer?” Dr. Poleri asks in the editorial, and then answers herself: “It matters.”

“It is necessary to implement screening programs and build artificial intelligence diagnostic algorithms considering the role of sex and gender equity to ensure that innovative technologies do not induce disparities in clinical care,” she writes.

“It is crucial to conduct education and health public programs that consider these differences, optimizing the use of available resources, [and] it is essential to improve the accuracy of research design and clinical trials,” she adds.

Dr. Yu and Dr. Poleri declared no relevant financial interests.

A version of this article first appeared on Medscape.com.

The observation that women with lung cancer seem to live longer than men can be explained by known prognostic factors, a new study suggests.

“In this first Australian prospective study of lung cancer survival comparing men and women, we found that men had a 43% greater risk of dying from their lung cancer than women,” comments lead author Xue Qin Yu, PhD, the Daffodil Centre, the University of Sydney, and colleagues.

“[However], when all prognostic factors were considered together, most of the survival differential disappeared,” they add.

“These results suggest that sex differences in lung cancer survival can be largely explained by known prognostic factors,” Dr. Yu and colleagues emphasize.

The study was published in the May issue of the Journal of Thoracic Oncology.
 

The ‘45 and up’ study

The findings come from the Sax Institute’s 45 and Up Study, an ongoing trial involving over 267,000 participants aged 45 years and older living in New South Wales, Australia. Patients were recruited to the study between 2006 and 2009. At the time of recruitment, patients were cancer free.

A total of 1,130 participants were diagnosed with having lung cancer during follow-up – 488 women and 642 men. Compared with men, women were, on average, younger at the time of diagnosis, had fewer comorbidities, and were more likely to be never-smokers or to have been exposed to passive smoke.

Women were also more likely to be diagnosed with adenocarcinoma than men and to receive surgery within 6 months of their diagnosis.

“Lung cancer survival was significantly higher for women,” the authors report, at a median of 1.28 years versus 0.77 years for men (P < .0001).

Within each subgroup of major prognostic factors – histologic subtype, cancer stage, cancer treatment, and smoking status – women again survived significantly longer than men.

Interestingly, the authors note that “women with adenocarcinoma had significantly better survival than men with adenocarcinoma independent of smoking status,” (P = .0009). This suggests that sex differences in tumor biology may play a role in explaining the sex survival differential between men and women, they commented. That said, never-smokers had a 16% lower risk for lung cancer death than ever-smokers after adjusting for age, the authors point out.

The authors also note that approximately half of the disparity in survival between the sexes could be explained by differences in the receipt of anticancer therapy within 6 months of the diagnosis. “This could partly be due to a lower proportion of men having surgery within 6 months than women,” investigators speculate, at 17% versus 25%, respectively.

Men were also older than women at the time of diagnosis, were less likely to be never-smokers, and had more comorbidities, all of which might also have prevented them from having surgery. Women with lung cancer may also respond better to chemotherapy than men, although the sex disparity in survival persisted even among patients who did not receive any treatment for their cancer within 6 months of their diagnosis, investigators point out.

Furthermore, “smoking history at baseline was identified as a significant contributing factor to the sex survival disparity, explaining approximately 28% of the overall disparity,” Dr. Yu and colleagues observe.

Only 8% of men diagnosed with lung cancer were never-smokers, compared with 23% of women. The authors note that never-smokers are more likely to receive aggressive or complete treatment and respond well to treatment.

Similarly, tumor-related factors together explained about one-quarter of the overall sex disparity in survival.
 

Screening guidelines

Commenting on the findings in an accompanying editorial, Claudia Poleri, MD, Hospital María Ferrer, Buenos Aires, says that this Australian study provides “valuable information.”

“The risk of dying from lung cancer was significantly higher for men than for women,” she writes. “Differences in treatment-related factors explained 50% of the sex survival differential, followed by lifestyle and tumor-related factors (28% and 26%, respectively).

“Nevertheless, these differences alone do not explain the higher survival in women,” she comments.

“Does it matter to analyze the differences by sex in lung cancer?” Dr. Poleri asks in the editorial, and then answers herself: “It matters.”

“It is necessary to implement screening programs and build artificial intelligence diagnostic algorithms considering the role of sex and gender equity to ensure that innovative technologies do not induce disparities in clinical care,” she writes.

“It is crucial to conduct education and health public programs that consider these differences, optimizing the use of available resources, [and] it is essential to improve the accuracy of research design and clinical trials,” she adds.

Dr. Yu and Dr. Poleri declared no relevant financial interests.

A version of this article first appeared on Medscape.com.

Rates of premature return to play (RTP) among student athletes following a sport-related concussion (SRC) have dropped substantially since 2011, according to a recent chart review. Rates of premature return to learn (RTL) are essentially unchanged, however.

“Delay in recovery is the major reason why it’s important not to RTL or RTP prematurely,” said James Carson, MD, associate professor of family and community medicine, University of Toronto.

“That delay in recovery only sets students further back in terms of the stress they get from being delayed with their schoolwork – they could lose their year in school, lose all their social contacts. So, there are a number of psychosocial issues that come into play if recovery is delayed, and that is what premature RTL and premature RTP will do – they delay the student’s recovery,” he emphasized.

The study was published in Canadian Family Physician.
 

Differences by sex

The study involved 241 students who had 258 distinct cases of SRC. The researchers defined premature RTP and RTL as chart records documenting the relapse, recurrence, or worsening of concussion symptoms that accompanied the patient’s RTP or RTL. Between 2011 and 2016, 26.7% of students had evidence of premature RTP, while 42.6% of them had evidence of premature RTL, the authors noted.

Compared with findings from an earlier survey of data from 2006 to 2011, the incidence of premature RTP dropped by 38.6% (P = .0003). In contrast, symptoms associated with premature RTL dropped by only 4.7% from the previous survey. This change was not statistically significant.

There was also a significant difference between males and females in the proportion of SRC cases with relapse of symptoms. Relapse occurred in 43.4% of female athletes with SRC versus 29.7% of male athletes with SRC (P = .023).

Female athletes also had significantly longer times before being cleared for RTP. The mean time was 74.5 days for females, compared with a mean of 42.3 days for male athletes (P < .001). “The median time to RTP clearance was nearly double [for female athletes] at 49 days versus 25 days [for male athletes],” wrote the authors.

The rate of premature RTL was also higher among secondary school students (48.8%), compared with 28% among elementary students and 42% among postsecondary students.
 

More concussions coming?

Before the first consensus conference, organized by the Concussion in Sport Group in 2001, management of concussion was based on rating and grading scales that had no medical evidence to support them, said Dr. Carson. After the consensus conference, it was recommended that physicians manage each concussion individually and, when it came to RTP, recommendations were based upon symptom resolution.

In contrast, there was nothing in the literature regarding how student athletes who sustain a concussion should RTL. Some schools made generous accommodations, and others none. This situation changed around 2011, when experts started publishing data about how better to accommodate student athletes who have a temporary disability for which schools need to introduce temporary accommodations to help them recover.

“Recommendations for RTP essentially had a 12-year head-start,” Dr. Carson emphasized, “and RTL had a much slower start.” Unfortunately, Dr. Carson foresees more athletes sustaining concussions as pandemic restrictions ease over the next few months. “As athletes RTP after the pandemic, they just will not be in game shape,” he said.

“In other words, athletes may not have the neuromuscular control to avoid these injuries as easily,” he added. Worse, athletes may not realize they are not quite ready to return to the expected level of participation so quickly. “I believe this scenario will lead to more concussions that will be difficult to manage in the context of an already strained health care system,” said Dr. Carson.

A limitation of the study was that it was difficult to assess whether all patients followed medical advice consistently.
 

“Very positive shifts”

Commenting on the findings, Nick Reed, PhD, Canada research chair in pediatric concussion and associate professor of occupational science and occupational therapy, University of Toronto, said that sports medicine physicians are seeing “very positive shifts” in concussion awareness and related behaviors such as providing education, support, and accommodations to students within the school environment. “More and more teachers are seeking education to learn what a concussion is and what to do to best support their students with concussion,” he said. Dr. Reed was not involved in the current study.

Indeed, this increasing awareness led to the development of a concussion education tool for teachers – SCHOOLFirst – although Dr. Reed did acknowledge that not all teachers have either the knowledge or the resources they need to optimally support their students with concussion. In the meantime, to reduce the risk of injury, Dr. Reed stressed that it is important for students to wear equipment appropriate for the game being played and to play by the rules.

“It is key to play sports in a way that is fair and respectful and not [engage] in behaviors with the intent of injuring an opponent,” he stressed. It is also important for athletes themselves to know the signs and symptoms of concussion and, if they think they have a concussion, to immediately stop playing, report how they are feeling to a coach, teacher, or parent, and to seek medical assessment to determine if they have a concussion or not.

“The key here is to focus on what the athlete can do after a concussion rather than what they can’t do,” Dr. Reed said. After even a few days of complete rest, students with a concussion can gradually introduce low levels of physical and cognitive activity that won’t make their symptoms worse. This activity can include going back to school with temporary accommodations in place, such as shorter school days and increased rest breaks. “When returning to school and to sport after a concussion, it is important to follow a stepwise and gradual return to activities so that you aren’t doing too much too fast,” Dr. Reed emphasized.

The study was conducted without external funding. Dr. Carson and Dr. Reed reported no conflicts of interest. 

A version of this article first appeared on Medscape.com.

Rates of premature return to play (RTP) among student athletes following a sport-related concussion (SRC) have dropped substantially since 2011, according to a recent chart review. Rates of premature return to learn (RTL) are essentially unchanged, however.

“Delay in recovery is the major reason why it’s important not to RTL or RTP prematurely,” said James Carson, MD, associate professor of family and community medicine, University of Toronto.

“That delay in recovery only sets students further back in terms of the stress they get from being delayed with their schoolwork – they could lose their year in school, lose all their social contacts. So, there are a number of psychosocial issues that come into play if recovery is delayed, and that is what premature RTL and premature RTP will do – they delay the student’s recovery,” he emphasized.

The study was published in Canadian Family Physician.
 

Differences by sex

The study involved 241 students who had 258 distinct cases of SRC. The researchers defined premature RTP and RTL as chart records documenting the relapse, recurrence, or worsening of concussion symptoms that accompanied the patient’s RTP or RTL. Between 2011 and 2016, 26.7% of students had evidence of premature RTP, while 42.6% of them had evidence of premature RTL, the authors noted.

Compared with findings from an earlier survey of data from 2006 to 2011, the incidence of premature RTP dropped by 38.6% (P = .0003). In contrast, symptoms associated with premature RTL dropped by only 4.7% from the previous survey. This change was not statistically significant.

There was also a significant difference between males and females in the proportion of SRC cases with relapse of symptoms. Relapse occurred in 43.4% of female athletes with SRC versus 29.7% of male athletes with SRC (P = .023).

Female athletes also had significantly longer times before being cleared for RTP. The mean time was 74.5 days for females, compared with a mean of 42.3 days for male athletes (P < .001). “The median time to RTP clearance was nearly double [for female athletes] at 49 days versus 25 days [for male athletes],” wrote the authors.

The rate of premature RTL was also higher among secondary school students (48.8%), compared with 28% among elementary students and 42% among postsecondary students.
 

More concussions coming?

Before the first consensus conference, organized by the Concussion in Sport Group in 2001, management of concussion was based on rating and grading scales that had no medical evidence to support them, said Dr. Carson. After the consensus conference, it was recommended that physicians manage each concussion individually and, when it came to RTP, recommendations were based upon symptom resolution.

In contrast, there was nothing in the literature regarding how student athletes who sustain a concussion should RTL. Some schools made generous accommodations, and others none. This situation changed around 2011, when experts started publishing data about how better to accommodate student athletes who have a temporary disability for which schools need to introduce temporary accommodations to help them recover.

“Recommendations for RTP essentially had a 12-year head-start,” Dr. Carson emphasized, “and RTL had a much slower start.” Unfortunately, Dr. Carson foresees more athletes sustaining concussions as pandemic restrictions ease over the next few months. “As athletes RTP after the pandemic, they just will not be in game shape,” he said.

“In other words, athletes may not have the neuromuscular control to avoid these injuries as easily,” he added. Worse, athletes may not realize they are not quite ready to return to the expected level of participation so quickly. “I believe this scenario will lead to more concussions that will be difficult to manage in the context of an already strained health care system,” said Dr. Carson.

A limitation of the study was that it was difficult to assess whether all patients followed medical advice consistently.
 

“Very positive shifts”

Commenting on the findings, Nick Reed, PhD, Canada research chair in pediatric concussion and associate professor of occupational science and occupational therapy, University of Toronto, said that sports medicine physicians are seeing “very positive shifts” in concussion awareness and related behaviors such as providing education, support, and accommodations to students within the school environment. “More and more teachers are seeking education to learn what a concussion is and what to do to best support their students with concussion,” he said. Dr. Reed was not involved in the current study.

Indeed, this increasing awareness led to the development of a concussion education tool for teachers – SCHOOLFirst – although Dr. Reed did acknowledge that not all teachers have either the knowledge or the resources they need to optimally support their students with concussion. In the meantime, to reduce the risk of injury, Dr. Reed stressed that it is important for students to wear equipment appropriate for the game being played and to play by the rules.

“It is key to play sports in a way that is fair and respectful and not [engage] in behaviors with the intent of injuring an opponent,” he stressed. It is also important for athletes themselves to know the signs and symptoms of concussion and, if they think they have a concussion, to immediately stop playing, report how they are feeling to a coach, teacher, or parent, and to seek medical assessment to determine if they have a concussion or not.

“The key here is to focus on what the athlete can do after a concussion rather than what they can’t do,” Dr. Reed said. After even a few days of complete rest, students with a concussion can gradually introduce low levels of physical and cognitive activity that won’t make their symptoms worse. This activity can include going back to school with temporary accommodations in place, such as shorter school days and increased rest breaks. “When returning to school and to sport after a concussion, it is important to follow a stepwise and gradual return to activities so that you aren’t doing too much too fast,” Dr. Reed emphasized.

The study was conducted without external funding. Dr. Carson and Dr. Reed reported no conflicts of interest. 

A version of this article first appeared on Medscape.com.

Rates of premature return to play (RTP) among student athletes following a sport-related concussion (SRC) have dropped substantially since 2011, according to a recent chart review. Rates of premature return to learn (RTL) are essentially unchanged, however.

“Delay in recovery is the major reason why it’s important not to RTL or RTP prematurely,” said James Carson, MD, associate professor of family and community medicine, University of Toronto.

“That delay in recovery only sets students further back in terms of the stress they get from being delayed with their schoolwork – they could lose their year in school, lose all their social contacts. So, there are a number of psychosocial issues that come into play if recovery is delayed, and that is what premature RTL and premature RTP will do – they delay the student’s recovery,” he emphasized.

The study was published in Canadian Family Physician.
 

Differences by sex

The study involved 241 students who had 258 distinct cases of SRC. The researchers defined premature RTP and RTL as chart records documenting the relapse, recurrence, or worsening of concussion symptoms that accompanied the patient’s RTP or RTL. Between 2011 and 2016, 26.7% of students had evidence of premature RTP, while 42.6% of them had evidence of premature RTL, the authors noted.

Compared with findings from an earlier survey of data from 2006 to 2011, the incidence of premature RTP dropped by 38.6% (P = .0003). In contrast, symptoms associated with premature RTL dropped by only 4.7% from the previous survey. This change was not statistically significant.

There was also a significant difference between males and females in the proportion of SRC cases with relapse of symptoms. Relapse occurred in 43.4% of female athletes with SRC versus 29.7% of male athletes with SRC (P = .023).

Female athletes also had significantly longer times before being cleared for RTP. The mean time was 74.5 days for females, compared with a mean of 42.3 days for male athletes (P < .001). “The median time to RTP clearance was nearly double [for female athletes] at 49 days versus 25 days [for male athletes],” wrote the authors.

The rate of premature RTL was also higher among secondary school students (48.8%), compared with 28% among elementary students and 42% among postsecondary students.
 

More concussions coming?

Before the first consensus conference, organized by the Concussion in Sport Group in 2001, management of concussion was based on rating and grading scales that had no medical evidence to support them, said Dr. Carson. After the consensus conference, it was recommended that physicians manage each concussion individually and, when it came to RTP, recommendations were based upon symptom resolution.

In contrast, there was nothing in the literature regarding how student athletes who sustain a concussion should RTL. Some schools made generous accommodations, and others none. This situation changed around 2011, when experts started publishing data about how better to accommodate student athletes who have a temporary disability for which schools need to introduce temporary accommodations to help them recover.

“Recommendations for RTP essentially had a 12-year head-start,” Dr. Carson emphasized, “and RTL had a much slower start.” Unfortunately, Dr. Carson foresees more athletes sustaining concussions as pandemic restrictions ease over the next few months. “As athletes RTP after the pandemic, they just will not be in game shape,” he said.

“In other words, athletes may not have the neuromuscular control to avoid these injuries as easily,” he added. Worse, athletes may not realize they are not quite ready to return to the expected level of participation so quickly. “I believe this scenario will lead to more concussions that will be difficult to manage in the context of an already strained health care system,” said Dr. Carson.

A limitation of the study was that it was difficult to assess whether all patients followed medical advice consistently.
 

“Very positive shifts”

Commenting on the findings, Nick Reed, PhD, Canada research chair in pediatric concussion and associate professor of occupational science and occupational therapy, University of Toronto, said that sports medicine physicians are seeing “very positive shifts” in concussion awareness and related behaviors such as providing education, support, and accommodations to students within the school environment. “More and more teachers are seeking education to learn what a concussion is and what to do to best support their students with concussion,” he said. Dr. Reed was not involved in the current study.

Indeed, this increasing awareness led to the development of a concussion education tool for teachers – SCHOOLFirst – although Dr. Reed did acknowledge that not all teachers have either the knowledge or the resources they need to optimally support their students with concussion. In the meantime, to reduce the risk of injury, Dr. Reed stressed that it is important for students to wear equipment appropriate for the game being played and to play by the rules.

“It is key to play sports in a way that is fair and respectful and not [engage] in behaviors with the intent of injuring an opponent,” he stressed. It is also important for athletes themselves to know the signs and symptoms of concussion and, if they think they have a concussion, to immediately stop playing, report how they are feeling to a coach, teacher, or parent, and to seek medical assessment to determine if they have a concussion or not.

“The key here is to focus on what the athlete can do after a concussion rather than what they can’t do,” Dr. Reed said. After even a few days of complete rest, students with a concussion can gradually introduce low levels of physical and cognitive activity that won’t make their symptoms worse. This activity can include going back to school with temporary accommodations in place, such as shorter school days and increased rest breaks. “When returning to school and to sport after a concussion, it is important to follow a stepwise and gradual return to activities so that you aren’t doing too much too fast,” Dr. Reed emphasized.

The study was conducted without external funding. Dr. Carson and Dr. Reed reported no conflicts of interest. 

A version of this article first appeared on Medscape.com.

Globally, diagnoses and deaths from colorectal cancer (CRC) more than doubled over the past 30 years, according to a new analysis of 204 countries.

However, trends in CRC incidence and deaths varied by age, region, and sex. Investigators expressed particular concern over the rising incidence rates among people younger than 50 and those living in low and middle sociodemographic index countries in Asia and Africa.

“These results provide comprehensive and comparable estimates that can inform efforts for equitable colorectal cancer control worldwide,” the authors write. However, “further research is required to understand the causes of the colorectal cancer burden in younger adults (aged less than 50 years) and the main risk factors, including obesity, physical inactivity, alcohol consumption, smoking, and an altered gut microbiome, that might have led to the rise in the colorectal cancer burden.”

The study was published online in the Lancet Gastroenterology and Hepatology.

CRC is the third leading cause of cancer deaths worldwide, but data on incidence and mortality by location, age, and sex remain less clear.

In the current Global Burden of Diseases, Injuries and Risk Factors Study, researchers evaluated age, sex, and geography-level estimates of CRC incidence, deaths, and disability-adjusted life-years (DALYs) from 204 countries between 1990 and 2019.

The authors found that cases of CRC increased by almost 2.6-fold over the 30-year study period, from 842,098 to 2.17 million. Deaths from CRC increased at a similar but slightly lower rate – rising 2.1-fold over the same period, from 518,126 to 1.09 million. DALYs also nearly doubled, going from 12.4 million in 1990 to 24.3 million in 2019.

In addition, the global age-standardized incidence rate increased from 22.2 to 26.7 per 100,000.

Overall, the age-standardized mortality rate decreased slightly, from 14.3 to 13.7 per 100,000; however, only high-middle and high sociodemographic index regions experienced a decrease; low and middle sociodemographic index regions experienced an increase. The age-standardized DALY rate also declined overall, from 308.5 per 100,000 in 1900 to 295.5 per 100,000 in 2019.

The authors further broke down CRC incidence and deaths by age, region, and sex.

Over the study period, males demonstrated greater increases in CRC incidence, deaths, and DALYs, compared with females. In 2019, the age-standardized CRC incidence rate was 1.5 times higher in males (33.1 vs 21.2 per 100,000), as was the age-standardized mortality rate (16.6 vs. 11.2 per 100,000). The age-standardized DALY rate showed a similar trend by sex – 360 versus 238 per 100,000 in males versus females.

Trends varied by age as well. CRC incidence rates increased the most in people aged 85 and older, followed by those between 20 and 49 years, while rates decreased for those between 50 and 80 years in high sociodemographic index countries.

Geography mattered too. China, the United States, and Japan demonstrated the highest number of new CRC cases across all ages and for both sexes in 2019 – 607,900 in China, 227,242 in the United States, and 160,211 in Japan.

In terms of mortality, China, the United States, and India had the highest CRC death counts: 261,777 in China, 84,026 in the United States, and 79,098 in India.

When it comes to age-standardized incidence rates, Taiwan, Monaco, and Andorra were at the top: Taiwan with 62 per 100,000 cases, Monaco with 60.7 per 100,000, and Andorra with 56.6 per 100,000.

On the other hand, Somalia, Niger, and Bangladesh had the lowest age-standardized incidence rates, 5 per 100,000 in Somalia and 5.6 per 100,000 in Niger and Bangladesh.

The highest age-standardized mortality rates occurred in Greenland, Brunei, and Hungary: 31.4 per 100,000 in Greenland, 30.3 per 100,000 in Brunei, and 28.6 per 100,000 in Hungary.

The relative contribution of different risk factors also varied by region. For example, in sub-Saharan Africa and lower-income countries in Asia, diets low in calcium and milk were the main CRC risk factors. In contrast, smoking and alcohol consumption were the main risk factors driving CRC in high-income regions.

Still, the reasons underlying some of these trends – such as the increasing incidence of CRC in patients under the age of 50 – remain uncertain. One possible explanation for this trend, the researchers point out, is the birth cohort effect, which suggests that those born in the second half of the 20th century are increasingly exposed to potentially modifiable risk factors, such as an unhealthy diet, obesity, and sedentary lifestyles.

Overall, the authors note that the data generated in this study provide an important resource for both patients and oncologists about current trends in incidence and mortality and where gaps in preventive measures may exist.

In particular, the authors conclude that “public health interventions for colorectal cancer awareness, screening, and prevention through containment of modifiable risk factors such as alcohol, smoking, unhealthy diet ... and obesity are key to stemming the tide of colorectal cancer worldwide.”

The study was funded by the Bill & Melinda Gates Foundation. The authors have disclosed no relevant financial relationships.

A version of this article first appeared on Medscape.com.

Globally, diagnoses and deaths from colorectal cancer (CRC) more than doubled over the past 30 years, according to a new analysis of 204 countries.

However, trends in CRC incidence and deaths varied by age, region, and sex. Investigators expressed particular concern over the rising incidence rates among people younger than 50 and those living in low and middle sociodemographic index countries in Asia and Africa.

“These results provide comprehensive and comparable estimates that can inform efforts for equitable colorectal cancer control worldwide,” the authors write. However, “further research is required to understand the causes of the colorectal cancer burden in younger adults (aged less than 50 years) and the main risk factors, including obesity, physical inactivity, alcohol consumption, smoking, and an altered gut microbiome, that might have led to the rise in the colorectal cancer burden.”

The study was published online in the Lancet Gastroenterology and Hepatology.

CRC is the third leading cause of cancer deaths worldwide, but data on incidence and mortality by location, age, and sex remain less clear.

In the current Global Burden of Diseases, Injuries and Risk Factors Study, researchers evaluated age, sex, and geography-level estimates of CRC incidence, deaths, and disability-adjusted life-years (DALYs) from 204 countries between 1990 and 2019.

The authors found that cases of CRC increased by almost 2.6-fold over the 30-year study period, from 842,098 to 2.17 million. Deaths from CRC increased at a similar but slightly lower rate – rising 2.1-fold over the same period, from 518,126 to 1.09 million. DALYs also nearly doubled, going from 12.4 million in 1990 to 24.3 million in 2019.

In addition, the global age-standardized incidence rate increased from 22.2 to 26.7 per 100,000.

Overall, the age-standardized mortality rate decreased slightly, from 14.3 to 13.7 per 100,000; however, only high-middle and high sociodemographic index regions experienced a decrease; low and middle sociodemographic index regions experienced an increase. The age-standardized DALY rate also declined overall, from 308.5 per 100,000 in 1900 to 295.5 per 100,000 in 2019.

The authors further broke down CRC incidence and deaths by age, region, and sex.

Over the study period, males demonstrated greater increases in CRC incidence, deaths, and DALYs, compared with females. In 2019, the age-standardized CRC incidence rate was 1.5 times higher in males (33.1 vs 21.2 per 100,000), as was the age-standardized mortality rate (16.6 vs. 11.2 per 100,000). The age-standardized DALY rate showed a similar trend by sex – 360 versus 238 per 100,000 in males versus females.

Trends varied by age as well. CRC incidence rates increased the most in people aged 85 and older, followed by those between 20 and 49 years, while rates decreased for those between 50 and 80 years in high sociodemographic index countries.

Geography mattered too. China, the United States, and Japan demonstrated the highest number of new CRC cases across all ages and for both sexes in 2019 – 607,900 in China, 227,242 in the United States, and 160,211 in Japan.

In terms of mortality, China, the United States, and India had the highest CRC death counts: 261,777 in China, 84,026 in the United States, and 79,098 in India.

When it comes to age-standardized incidence rates, Taiwan, Monaco, and Andorra were at the top: Taiwan with 62 per 100,000 cases, Monaco with 60.7 per 100,000, and Andorra with 56.6 per 100,000.

On the other hand, Somalia, Niger, and Bangladesh had the lowest age-standardized incidence rates, 5 per 100,000 in Somalia and 5.6 per 100,000 in Niger and Bangladesh.

The highest age-standardized mortality rates occurred in Greenland, Brunei, and Hungary: 31.4 per 100,000 in Greenland, 30.3 per 100,000 in Brunei, and 28.6 per 100,000 in Hungary.

The relative contribution of different risk factors also varied by region. For example, in sub-Saharan Africa and lower-income countries in Asia, diets low in calcium and milk were the main CRC risk factors. In contrast, smoking and alcohol consumption were the main risk factors driving CRC in high-income regions.

Still, the reasons underlying some of these trends – such as the increasing incidence of CRC in patients under the age of 50 – remain uncertain. One possible explanation for this trend, the researchers point out, is the birth cohort effect, which suggests that those born in the second half of the 20th century are increasingly exposed to potentially modifiable risk factors, such as an unhealthy diet, obesity, and sedentary lifestyles.

Overall, the authors note that the data generated in this study provide an important resource for both patients and oncologists about current trends in incidence and mortality and where gaps in preventive measures may exist.

In particular, the authors conclude that “public health interventions for colorectal cancer awareness, screening, and prevention through containment of modifiable risk factors such as alcohol, smoking, unhealthy diet ... and obesity are key to stemming the tide of colorectal cancer worldwide.”

The study was funded by the Bill & Melinda Gates Foundation. The authors have disclosed no relevant financial relationships.

A version of this article first appeared on Medscape.com.

Globally, diagnoses and deaths from colorectal cancer (CRC) more than doubled over the past 30 years, according to a new analysis of 204 countries.

However, trends in CRC incidence and deaths varied by age, region, and sex. Investigators expressed particular concern over the rising incidence rates among people younger than 50 and those living in low and middle sociodemographic index countries in Asia and Africa.

“These results provide comprehensive and comparable estimates that can inform efforts for equitable colorectal cancer control worldwide,” the authors write. However, “further research is required to understand the causes of the colorectal cancer burden in younger adults (aged less than 50 years) and the main risk factors, including obesity, physical inactivity, alcohol consumption, smoking, and an altered gut microbiome, that might have led to the rise in the colorectal cancer burden.”

The study was published online in the Lancet Gastroenterology and Hepatology.

CRC is the third leading cause of cancer deaths worldwide, but data on incidence and mortality by location, age, and sex remain less clear.

In the current Global Burden of Diseases, Injuries and Risk Factors Study, researchers evaluated age, sex, and geography-level estimates of CRC incidence, deaths, and disability-adjusted life-years (DALYs) from 204 countries between 1990 and 2019.

The authors found that cases of CRC increased by almost 2.6-fold over the 30-year study period, from 842,098 to 2.17 million. Deaths from CRC increased at a similar but slightly lower rate – rising 2.1-fold over the same period, from 518,126 to 1.09 million. DALYs also nearly doubled, going from 12.4 million in 1990 to 24.3 million in 2019.

In addition, the global age-standardized incidence rate increased from 22.2 to 26.7 per 100,000.

Overall, the age-standardized mortality rate decreased slightly, from 14.3 to 13.7 per 100,000; however, only high-middle and high sociodemographic index regions experienced a decrease; low and middle sociodemographic index regions experienced an increase. The age-standardized DALY rate also declined overall, from 308.5 per 100,000 in 1900 to 295.5 per 100,000 in 2019.

The authors further broke down CRC incidence and deaths by age, region, and sex.

Over the study period, males demonstrated greater increases in CRC incidence, deaths, and DALYs, compared with females. In 2019, the age-standardized CRC incidence rate was 1.5 times higher in males (33.1 vs 21.2 per 100,000), as was the age-standardized mortality rate (16.6 vs. 11.2 per 100,000). The age-standardized DALY rate showed a similar trend by sex – 360 versus 238 per 100,000 in males versus females.

Trends varied by age as well. CRC incidence rates increased the most in people aged 85 and older, followed by those between 20 and 49 years, while rates decreased for those between 50 and 80 years in high sociodemographic index countries.

Geography mattered too. China, the United States, and Japan demonstrated the highest number of new CRC cases across all ages and for both sexes in 2019 – 607,900 in China, 227,242 in the United States, and 160,211 in Japan.

In terms of mortality, China, the United States, and India had the highest CRC death counts: 261,777 in China, 84,026 in the United States, and 79,098 in India.

When it comes to age-standardized incidence rates, Taiwan, Monaco, and Andorra were at the top: Taiwan with 62 per 100,000 cases, Monaco with 60.7 per 100,000, and Andorra with 56.6 per 100,000.

On the other hand, Somalia, Niger, and Bangladesh had the lowest age-standardized incidence rates, 5 per 100,000 in Somalia and 5.6 per 100,000 in Niger and Bangladesh.

The highest age-standardized mortality rates occurred in Greenland, Brunei, and Hungary: 31.4 per 100,000 in Greenland, 30.3 per 100,000 in Brunei, and 28.6 per 100,000 in Hungary.

The relative contribution of different risk factors also varied by region. For example, in sub-Saharan Africa and lower-income countries in Asia, diets low in calcium and milk were the main CRC risk factors. In contrast, smoking and alcohol consumption were the main risk factors driving CRC in high-income regions.

Still, the reasons underlying some of these trends – such as the increasing incidence of CRC in patients under the age of 50 – remain uncertain. One possible explanation for this trend, the researchers point out, is the birth cohort effect, which suggests that those born in the second half of the 20th century are increasingly exposed to potentially modifiable risk factors, such as an unhealthy diet, obesity, and sedentary lifestyles.

Overall, the authors note that the data generated in this study provide an important resource for both patients and oncologists about current trends in incidence and mortality and where gaps in preventive measures may exist.

In particular, the authors conclude that “public health interventions for colorectal cancer awareness, screening, and prevention through containment of modifiable risk factors such as alcohol, smoking, unhealthy diet ... and obesity are key to stemming the tide of colorectal cancer worldwide.”

The study was funded by the Bill & Melinda Gates Foundation. The authors have disclosed no relevant financial relationships.

A version of this article first appeared on Medscape.com.

There has been a flattening of sleep apnea–related mortality rates in the United States over the past 10 years. The exception is among Black men, for whom mortality from sleep apnea has continuously increased over the past 21 years, new research shows.

“OSA (obstructive sleep apnea) has been recognized as an important cause of medical morbidity and mortality and contributes to the development of systemic hypertension, cardiovascular disease, and abnormalities in glucose metabolism,” noted Yu-Che Lee, MD, University at Buffalo–Catholic Health System, Buffalo, N.Y., and colleagues.

“This study provides the first systematic assessment and demonstrates remarkable demographic disparities of age-adjusted sleep apnea–related mortality in the U.S., with higher rates in males than females and Blacks than Whites,” they concluded.

The study was published online in Sleep Medicine.
 

Twenty-one year interval

Data on sleep apnea–related mortality were obtained from the National Center for Health Statistics and were provided by the Centers for Disease Control and Prevention for the years 1999-2019. Over that 21-year interval, sleep apnea was documented as the underlying cause of death in 17,053 decedents, including 2,593 Black patients and 14,127 White patients.

The age-adjusted mortality rate attributed to sleep apnea was 2.5 per 1,000,000 population. The mortality rate was higher for men, at 3.1 per 1,000,000, than among women, 1.9 per 1,000,000 (P < .001). For both sexes, “unadjusted mortality rates were higher in groups aged ≥ 35 years, and the highest mortality rates were observed in groups aged 75-84,” the authors noted. The rate was 11.3 per 1,000,000 for those aged 75-84 and 13.3 per 1,000,000 for those older than 85.

This was also true among Black and White patients, the authors added, although the age-adjusted mortality rate was higher among Black patients than among other racial groups, at 3.5 per 1,000,000 (P < .001). “Over the 21-year study period, the overall age-adjusted mortality rate rose from 1.2 per 1,000,000 population in 1999 to 2.8 per 1,000,000 in 2019,” Dr. Lee and colleagues noted. While the annual percentage change in sleep apnea–related mortality rose by 10.2% (95% confidence interval [CI], 8.4%-12.0%) between 1999 and 2018, no significant change was observed between 2008 and 2019.

On the other hand, when examined by race and sex, age-adjusted mortality rates increased significantly by an annual percentage change of 7.5% (95% CI, 3.3%-11.9%) among Black women and by 8.2% (95% CI, 6.8%-9.6%) between 1999 and 2009 in White men and by 11.5% (95% CI, 8.9%-14.1%) in White women. “Again, these uptrends were no longer observed after that time interval,” the authors stressed.

Only among Black men was there no turning point in age-adjusted mortality rates; they experienced a steady, significant, 2.7% (95% CI, 1.2%-4.2%) annual percent increase in age-adjusted mortality rate between 1999 and 2019. The highest age-adjusted mortality rate for Black persons was recorded in Indiana, at 6.5 per 1,000,000 population; Utah recorded the highest mortality rate for White persons, at 5.7 per 1,000,000.

For both Black persons and White persons, the lowest mortality rates were in New York, at 1.2 per 1,000,000 and 1.5 per 1,000,000, respectively. Among four geographic regions analyzed, the highest age-adjusted mortality rates were in the Midwest for both sexes; Black men in the West and those in three other regional groups in the Northwest had the lowest mortality rates.
 

Multiple causes of death

Black women were more likely to have multiple causes of death, including cardiac arrest, heart failure, and hypertension. White women were more likely to die of arrhythmia, respiratory failure, pneumonia, and depression. Black men were also more likely to die of cardiac arrest, hypertension, and obesity; arrhythmias, ischemic heart disease, and chronic obstructive pulmonary disease were more common in White men.

The authors pointed out that continuous positive airway pressure (CPAP) is the mainstay of therapy for adults with OSA, but many studies have demonstrated decreased CPAP adherence among Black persons. For example, one report indicated that Black persons use CPAP on average 92 minutes less a day after 1 month of therapy than do White persons, for reasons that are not well understood. Asked by this news organization why Black men are so adversely affected by sleep apnea, Dr. Lee pointed out that studies have shown that sleep apnea is more severe in Black men when first diagnosed.

“We know that the severity of sleep apnea is a risk factor for mortality and cardiovascular outcomes,” he said, “so maybe delayed diagnosis, delayed treatment, and noncompliance with CPAP among Black men may help explain why mortality from sleep apnea among Black men has continued to increase.” Why nonadherence to CPAP is higher among Black men is also not clear. Even when access to CPAP is equal for Black patients and White patients, studies have found that rates of noncompliance to CPAP are higher among Black persons than among White patients.

“This is again a hypothesis,” Dr. Lee emphasized, “but perhaps health literacy among Blacks is lower than it is among White patients, and they may not realize that CPAP can improve health outcomes from sleep apnea,” he suggested. The use of CPAP requires a high level of self-advocacy, which might explain part of their noncompliance.

Other health behaviors and environmental factors may contribute to the tendency among Black patients to be noncompliant with CPAP. “I think this is the first study to show that there is a significant racial disparity in mortality from sleep apnea among Black males, and it should give physicians some insight into the problem; they can develop strategies or interventions to try and reduce racial disparities in outcomes from sleep apnea,” Dr. Lee said.

“So, this study is only the beginning, and we need to have more insight and strategies to improve outcomes among Black males,” he affirmed.

Asked to comment on the findings, Diego Mazzotti, PhD, said the study helps bring attention to existing health disparities related to sleep disorders. “Some of the trends observed by the authors seem to explain the increased recognition that sleep apnea may be a risk factor for cardiovascular morbidity and mortality,” said Dr. Mazzotti, assistant professor in the division of medical informatics at the University of Kansas Medical Center in Kansas City.

“Trends in certain minority groups and certain regions in the U.S. suggest that physicians need to recognize the impact of untreated sleep apnea on the cardiovascular health of these patients,” he said.

Dr. Lee and Dr. Mazzotti have disclosed no relevant financial relationships.

A version of this article first appeared on Medscape.com.

There has been a flattening of sleep apnea–related mortality rates in the United States over the past 10 years. The exception is among Black men, for whom mortality from sleep apnea has continuously increased over the past 21 years, new research shows.

“OSA (obstructive sleep apnea) has been recognized as an important cause of medical morbidity and mortality and contributes to the development of systemic hypertension, cardiovascular disease, and abnormalities in glucose metabolism,” noted Yu-Che Lee, MD, University at Buffalo–Catholic Health System, Buffalo, N.Y., and colleagues.

“This study provides the first systematic assessment and demonstrates remarkable demographic disparities of age-adjusted sleep apnea–related mortality in the U.S., with higher rates in males than females and Blacks than Whites,” they concluded.

The study was published online in Sleep Medicine.
 

Twenty-one year interval

Data on sleep apnea–related mortality were obtained from the National Center for Health Statistics and were provided by the Centers for Disease Control and Prevention for the years 1999-2019. Over that 21-year interval, sleep apnea was documented as the underlying cause of death in 17,053 decedents, including 2,593 Black patients and 14,127 White patients.

The age-adjusted mortality rate attributed to sleep apnea was 2.5 per 1,000,000 population. The mortality rate was higher for men, at 3.1 per 1,000,000, than among women, 1.9 per 1,000,000 (P < .001). For both sexes, “unadjusted mortality rates were higher in groups aged ≥ 35 years, and the highest mortality rates were observed in groups aged 75-84,” the authors noted. The rate was 11.3 per 1,000,000 for those aged 75-84 and 13.3 per 1,000,000 for those older than 85.

This was also true among Black and White patients, the authors added, although the age-adjusted mortality rate was higher among Black patients than among other racial groups, at 3.5 per 1,000,000 (P < .001). “Over the 21-year study period, the overall age-adjusted mortality rate rose from 1.2 per 1,000,000 population in 1999 to 2.8 per 1,000,000 in 2019,” Dr. Lee and colleagues noted. While the annual percentage change in sleep apnea–related mortality rose by 10.2% (95% confidence interval [CI], 8.4%-12.0%) between 1999 and 2018, no significant change was observed between 2008 and 2019.

On the other hand, when examined by race and sex, age-adjusted mortality rates increased significantly by an annual percentage change of 7.5% (95% CI, 3.3%-11.9%) among Black women and by 8.2% (95% CI, 6.8%-9.6%) between 1999 and 2009 in White men and by 11.5% (95% CI, 8.9%-14.1%) in White women. “Again, these uptrends were no longer observed after that time interval,” the authors stressed.

Only among Black men was there no turning point in age-adjusted mortality rates; they experienced a steady, significant, 2.7% (95% CI, 1.2%-4.2%) annual percent increase in age-adjusted mortality rate between 1999 and 2019. The highest age-adjusted mortality rate for Black persons was recorded in Indiana, at 6.5 per 1,000,000 population; Utah recorded the highest mortality rate for White persons, at 5.7 per 1,000,000.

For both Black persons and White persons, the lowest mortality rates were in New York, at 1.2 per 1,000,000 and 1.5 per 1,000,000, respectively. Among four geographic regions analyzed, the highest age-adjusted mortality rates were in the Midwest for both sexes; Black men in the West and those in three other regional groups in the Northwest had the lowest mortality rates.
 

Multiple causes of death

Black women were more likely to have multiple causes of death, including cardiac arrest, heart failure, and hypertension. White women were more likely to die of arrhythmia, respiratory failure, pneumonia, and depression. Black men were also more likely to die of cardiac arrest, hypertension, and obesity; arrhythmias, ischemic heart disease, and chronic obstructive pulmonary disease were more common in White men.

The authors pointed out that continuous positive airway pressure (CPAP) is the mainstay of therapy for adults with OSA, but many studies have demonstrated decreased CPAP adherence among Black persons. For example, one report indicated that Black persons use CPAP on average 92 minutes less a day after 1 month of therapy than do White persons, for reasons that are not well understood. Asked by this news organization why Black men are so adversely affected by sleep apnea, Dr. Lee pointed out that studies have shown that sleep apnea is more severe in Black men when first diagnosed.

“We know that the severity of sleep apnea is a risk factor for mortality and cardiovascular outcomes,” he said, “so maybe delayed diagnosis, delayed treatment, and noncompliance with CPAP among Black men may help explain why mortality from sleep apnea among Black men has continued to increase.” Why nonadherence to CPAP is higher among Black men is also not clear. Even when access to CPAP is equal for Black patients and White patients, studies have found that rates of noncompliance to CPAP are higher among Black persons than among White patients.

“This is again a hypothesis,” Dr. Lee emphasized, “but perhaps health literacy among Blacks is lower than it is among White patients, and they may not realize that CPAP can improve health outcomes from sleep apnea,” he suggested. The use of CPAP requires a high level of self-advocacy, which might explain part of their noncompliance.

Other health behaviors and environmental factors may contribute to the tendency among Black patients to be noncompliant with CPAP. “I think this is the first study to show that there is a significant racial disparity in mortality from sleep apnea among Black males, and it should give physicians some insight into the problem; they can develop strategies or interventions to try and reduce racial disparities in outcomes from sleep apnea,” Dr. Lee said.

“So, this study is only the beginning, and we need to have more insight and strategies to improve outcomes among Black males,” he affirmed.

Asked to comment on the findings, Diego Mazzotti, PhD, said the study helps bring attention to existing health disparities related to sleep disorders. “Some of the trends observed by the authors seem to explain the increased recognition that sleep apnea may be a risk factor for cardiovascular morbidity and mortality,” said Dr. Mazzotti, assistant professor in the division of medical informatics at the University of Kansas Medical Center in Kansas City.

“Trends in certain minority groups and certain regions in the U.S. suggest that physicians need to recognize the impact of untreated sleep apnea on the cardiovascular health of these patients,” he said.

Dr. Lee and Dr. Mazzotti have disclosed no relevant financial relationships.

A version of this article first appeared on Medscape.com.

There has been a flattening of sleep apnea–related mortality rates in the United States over the past 10 years. The exception is among Black men, for whom mortality from sleep apnea has continuously increased over the past 21 years, new research shows.

“OSA (obstructive sleep apnea) has been recognized as an important cause of medical morbidity and mortality and contributes to the development of systemic hypertension, cardiovascular disease, and abnormalities in glucose metabolism,” noted Yu-Che Lee, MD, University at Buffalo–Catholic Health System, Buffalo, N.Y., and colleagues.

“This study provides the first systematic assessment and demonstrates remarkable demographic disparities of age-adjusted sleep apnea–related mortality in the U.S., with higher rates in males than females and Blacks than Whites,” they concluded.

The study was published online in Sleep Medicine.
 

Twenty-one year interval

Data on sleep apnea–related mortality were obtained from the National Center for Health Statistics and were provided by the Centers for Disease Control and Prevention for the years 1999-2019. Over that 21-year interval, sleep apnea was documented as the underlying cause of death in 17,053 decedents, including 2,593 Black patients and 14,127 White patients.

The age-adjusted mortality rate attributed to sleep apnea was 2.5 per 1,000,000 population. The mortality rate was higher for men, at 3.1 per 1,000,000, than among women, 1.9 per 1,000,000 (P < .001). For both sexes, “unadjusted mortality rates were higher in groups aged ≥ 35 years, and the highest mortality rates were observed in groups aged 75-84,” the authors noted. The rate was 11.3 per 1,000,000 for those aged 75-84 and 13.3 per 1,000,000 for those older than 85.

This was also true among Black and White patients, the authors added, although the age-adjusted mortality rate was higher among Black patients than among other racial groups, at 3.5 per 1,000,000 (P < .001). “Over the 21-year study period, the overall age-adjusted mortality rate rose from 1.2 per 1,000,000 population in 1999 to 2.8 per 1,000,000 in 2019,” Dr. Lee and colleagues noted. While the annual percentage change in sleep apnea–related mortality rose by 10.2% (95% confidence interval [CI], 8.4%-12.0%) between 1999 and 2018, no significant change was observed between 2008 and 2019.

On the other hand, when examined by race and sex, age-adjusted mortality rates increased significantly by an annual percentage change of 7.5% (95% CI, 3.3%-11.9%) among Black women and by 8.2% (95% CI, 6.8%-9.6%) between 1999 and 2009 in White men and by 11.5% (95% CI, 8.9%-14.1%) in White women. “Again, these uptrends were no longer observed after that time interval,” the authors stressed.

Only among Black men was there no turning point in age-adjusted mortality rates; they experienced a steady, significant, 2.7% (95% CI, 1.2%-4.2%) annual percent increase in age-adjusted mortality rate between 1999 and 2019. The highest age-adjusted mortality rate for Black persons was recorded in Indiana, at 6.5 per 1,000,000 population; Utah recorded the highest mortality rate for White persons, at 5.7 per 1,000,000.

For both Black persons and White persons, the lowest mortality rates were in New York, at 1.2 per 1,000,000 and 1.5 per 1,000,000, respectively. Among four geographic regions analyzed, the highest age-adjusted mortality rates were in the Midwest for both sexes; Black men in the West and those in three other regional groups in the Northwest had the lowest mortality rates.
 

Multiple causes of death

Black women were more likely to have multiple causes of death, including cardiac arrest, heart failure, and hypertension. White women were more likely to die of arrhythmia, respiratory failure, pneumonia, and depression. Black men were also more likely to die of cardiac arrest, hypertension, and obesity; arrhythmias, ischemic heart disease, and chronic obstructive pulmonary disease were more common in White men.

The authors pointed out that continuous positive airway pressure (CPAP) is the mainstay of therapy for adults with OSA, but many studies have demonstrated decreased CPAP adherence among Black persons. For example, one report indicated that Black persons use CPAP on average 92 minutes less a day after 1 month of therapy than do White persons, for reasons that are not well understood. Asked by this news organization why Black men are so adversely affected by sleep apnea, Dr. Lee pointed out that studies have shown that sleep apnea is more severe in Black men when first diagnosed.

“We know that the severity of sleep apnea is a risk factor for mortality and cardiovascular outcomes,” he said, “so maybe delayed diagnosis, delayed treatment, and noncompliance with CPAP among Black men may help explain why mortality from sleep apnea among Black men has continued to increase.” Why nonadherence to CPAP is higher among Black men is also not clear. Even when access to CPAP is equal for Black patients and White patients, studies have found that rates of noncompliance to CPAP are higher among Black persons than among White patients.

“This is again a hypothesis,” Dr. Lee emphasized, “but perhaps health literacy among Blacks is lower than it is among White patients, and they may not realize that CPAP can improve health outcomes from sleep apnea,” he suggested. The use of CPAP requires a high level of self-advocacy, which might explain part of their noncompliance.

Other health behaviors and environmental factors may contribute to the tendency among Black patients to be noncompliant with CPAP. “I think this is the first study to show that there is a significant racial disparity in mortality from sleep apnea among Black males, and it should give physicians some insight into the problem; they can develop strategies or interventions to try and reduce racial disparities in outcomes from sleep apnea,” Dr. Lee said.

“So, this study is only the beginning, and we need to have more insight and strategies to improve outcomes among Black males,” he affirmed.

Asked to comment on the findings, Diego Mazzotti, PhD, said the study helps bring attention to existing health disparities related to sleep disorders. “Some of the trends observed by the authors seem to explain the increased recognition that sleep apnea may be a risk factor for cardiovascular morbidity and mortality,” said Dr. Mazzotti, assistant professor in the division of medical informatics at the University of Kansas Medical Center in Kansas City.

“Trends in certain minority groups and certain regions in the U.S. suggest that physicians need to recognize the impact of untreated sleep apnea on the cardiovascular health of these patients,” he said.

Dr. Lee and Dr. Mazzotti have disclosed no relevant financial relationships.

A version of this article first appeared on Medscape.com.

The use of an electronic clinical decision support tool called “ePNa” reduced severity-adjusted, 30-day, all-cause mortality by 38% across 16 community hospitals in Utah, compared with predeployment levels, a 3-year, pragmatic, cluster-controlled study shows.

“We designed the ePNa specifically to require minimal input from the clinician so everything it does is already in the electronic medical record,” Nathan Dean, MD, University of Utah, Salt Lake City, told this news organization.

“So it’s actually putting the guideline recommendations into effect for physicians so that they can make better decisions by having all this information – it’s a comprehensive best practice kind of tool where best practices are likely to make the biggest difference for patients with a high severity of illness,” he added.

The study was published online in the American Journal of Respiratory and Critical Care Medicine.


 

Guideline-based tool

The ePNa makes use of pneumonia guidelines of 2007 and 2019 from the American Thoracic Society/Infectious Disease Society of America. The system was deployed into six geographic clusters of 16 Intermountain hospital EDs at 2-month intervals between December 2017 and November 2018. Simultaneous deployment was impractical, as implementation of the tool takes education, monitoring, and feedback that can be facilitated by focusing on only a few hospitals at a time.

The decision support tool gathers key patient indicators including age, fever, oxygen saturation, vital signs, and laboratory and chest imaging results to offer recommendations on care, including appropriate antibiotic therapy, microbiology studies, and whether a given patient should be sent to the intensive care unit, admitted to hospital, or may safely be discharged home.

Investigators analyzed a total of 6,848 patients, of whom 4,536 were managed for pneumonia before the ePNa was deployed and 2,312 after deployment.

The median age of patients was 67 years (interquartile range, 50-79 years). Roughly half were female and almost all were White. “Observed 30-day all-cause mortality including both outpatients and inpatients was 8.6% before deployment versus 4.8% after deployment of ePNa,” Dr. Dean and colleagues reported.

Adjusted for severity of illness, the odds ratio for lower mortality post-ePNa launch was 0.62 (95% confidence interval, 0.49-0.79; P < .0010) “and lower morality was consistent across hospital clusters.”

Compared with patients who were discharged home, reductions in mortality were greatest in patients who were directly admitted to ICUs from the ED (OR, 0.32; 95% CI, 0.14-0.77; P = .01). The OR for patients admitted to the medical floor was 0.53 (95% CI, 0.25-1.1; P = .09), which did not reach statistical significance.

Dr. Dean explained that the reductions in mortality were seen among those with the most severe illness, in whom best practices would benefit the most. In contrast, patients who are sent home on an antibiotic are at low risk for mortality while patients admitted to the medical floor may well have another, more lethal illness from which they end up dying, rather than simple pneumonia.

“For me, this was a clear demonstration that these best practices made the biggest difference in patients who were sick and who did not have any underlying disease that was going to kill them anyway,” he emphasized. On the other hand, both 30-day mortality and 7-day secondary hospital admission were higher among patients the tool recommended for hospital ward admission but who were discharged home from the ED.

“This was an unexpected finding,” Dr. Dean observed. However, as he explained, the authors reviewed 25% of randomly selected patients who fell into this subgroup and discovered that the ePNa tool was used in only about 20% of patients – “so doctors did not use the tool in the majority of this group.”

In addition, some of these patients declined hospital admission, so the doctors may have recommended that they be admitted but the patients said no. “The hypothesis here is that if they had been admitted to the hospital, they may have had a lower mortality risk,” Dr. Dean said.
 

Noticeable changes

Another noticeable change following the introduction of the ePNa tool was that guideline-concordant antibiotic prescribing increased in the 8 hours after patients presented to the ED, from 79.5% prior to the tool’s launch to 87.9%, again after adjusting for pneumonia severity (P < .001). Use of broad-spectrum antibiotics was not significantly different between the two treatment intervals, but administration of antibiotics active against methicillin-resistant Staphylococcus aureus dropped significantly between the two treatment intervals (P < .001). And the mean time from admission to the ED to the first antibiotic taken was slightly faster, improving from 159.4 minutes (95% CI, 156.9-161.9 minutes) prior to the ePNa launch to 150.9 minutes (95% CI, 144.1-157.8) post deployment (P < .001).

“Overall outpatient disposition for treatment of pneumonia from the emergency department increased from 29.2% before ePNa to 46.9% [post ePNA],” the authors noted, while a similar increase was observed in patients for whom ePNA recommended outpatient care – from 49.2% pre-ePNA to 66.6% after ePNA.

Both hospital ward admission and admission to the ICU decreased after ePNa had been introduced. Despite a significant increase in the percentage of patients being discharged home, neither 7-day secondary hospital admission nor severity-adjusted, 30-day mortality were significantly different before versus after the introduction of ePNa, the authors stressed.

A limitation of the study was that the trial was confined to a single health care system in one region of the United States with a patient population that may differ from that in other regions.
 

Reason for its success

Asked to comment on the findings, Adam Balls, MD, emergency department chair, Intermountain Medical Center, Murray, Utah, suggested that the reason the ePNa tool has been so successful at improving care for pneumonia patients is that it puts the guidelines directly into the hands of individual providers and tells them what’s going on. (Dr. Balls was not involved in the study.) “The tool allows us to take into consideration various clinical features – a patient’s oxygen requirements and whether or not they had prior complicated pneumonias that required additional antibiotics, for example – and then it makes the best determination for not only the disposition for that patient but antibiotic treatment as well,” he said in an interview.

This then allows physicians to either appropriately discharge less severely ill patients and admit those who are more ill – “and in general, just do a better job of treating pneumonia with this tool,” Dr. Balls said. He himself uses the decision support tool when attending to his own patients with pneumonia, as he feels that the tool really does make his care of these patients better. “There is a disparity around how we treat pneumonia in the U.S.

“Clinicians sometimes have a bias or a preference for certain antibiotics and we may not be appropriately treating these patients with broad-spectrum antibiotics or are perhaps using antibiotics that are not as effective based on an individual patient scenario so this is definitely a user-friendly tool that hopefully can be deployed throughout other health care systems to improve the treatment of pneumonia overall,” Dr. Balls emphasized.

A version of this article first appeared on Medscape.com.

The use of an electronic clinical decision support tool called “ePNa” reduced severity-adjusted, 30-day, all-cause mortality by 38% across 16 community hospitals in Utah, compared with predeployment levels, a 3-year, pragmatic, cluster-controlled study shows.

“We designed the ePNa specifically to require minimal input from the clinician so everything it does is already in the electronic medical record,” Nathan Dean, MD, University of Utah, Salt Lake City, told this news organization.

“So it’s actually putting the guideline recommendations into effect for physicians so that they can make better decisions by having all this information – it’s a comprehensive best practice kind of tool where best practices are likely to make the biggest difference for patients with a high severity of illness,” he added.

The study was published online in the American Journal of Respiratory and Critical Care Medicine.


 

Guideline-based tool

The ePNa makes use of pneumonia guidelines of 2007 and 2019 from the American Thoracic Society/Infectious Disease Society of America. The system was deployed into six geographic clusters of 16 Intermountain hospital EDs at 2-month intervals between December 2017 and November 2018. Simultaneous deployment was impractical, as implementation of the tool takes education, monitoring, and feedback that can be facilitated by focusing on only a few hospitals at a time.

The decision support tool gathers key patient indicators including age, fever, oxygen saturation, vital signs, and laboratory and chest imaging results to offer recommendations on care, including appropriate antibiotic therapy, microbiology studies, and whether a given patient should be sent to the intensive care unit, admitted to hospital, or may safely be discharged home.

Investigators analyzed a total of 6,848 patients, of whom 4,536 were managed for pneumonia before the ePNa was deployed and 2,312 after deployment.

The median age of patients was 67 years (interquartile range, 50-79 years). Roughly half were female and almost all were White. “Observed 30-day all-cause mortality including both outpatients and inpatients was 8.6% before deployment versus 4.8% after deployment of ePNa,” Dr. Dean and colleagues reported.

Adjusted for severity of illness, the odds ratio for lower mortality post-ePNa launch was 0.62 (95% confidence interval, 0.49-0.79; P < .0010) “and lower morality was consistent across hospital clusters.”

Compared with patients who were discharged home, reductions in mortality were greatest in patients who were directly admitted to ICUs from the ED (OR, 0.32; 95% CI, 0.14-0.77; P = .01). The OR for patients admitted to the medical floor was 0.53 (95% CI, 0.25-1.1; P = .09), which did not reach statistical significance.

Dr. Dean explained that the reductions in mortality were seen among those with the most severe illness, in whom best practices would benefit the most. In contrast, patients who are sent home on an antibiotic are at low risk for mortality while patients admitted to the medical floor may well have another, more lethal illness from which they end up dying, rather than simple pneumonia.

“For me, this was a clear demonstration that these best practices made the biggest difference in patients who were sick and who did not have any underlying disease that was going to kill them anyway,” he emphasized. On the other hand, both 30-day mortality and 7-day secondary hospital admission were higher among patients the tool recommended for hospital ward admission but who were discharged home from the ED.

“This was an unexpected finding,” Dr. Dean observed. However, as he explained, the authors reviewed 25% of randomly selected patients who fell into this subgroup and discovered that the ePNa tool was used in only about 20% of patients – “so doctors did not use the tool in the majority of this group.”

In addition, some of these patients declined hospital admission, so the doctors may have recommended that they be admitted but the patients said no. “The hypothesis here is that if they had been admitted to the hospital, they may have had a lower mortality risk,” Dr. Dean said.
 

Noticeable changes

Another noticeable change following the introduction of the ePNa tool was that guideline-concordant antibiotic prescribing increased in the 8 hours after patients presented to the ED, from 79.5% prior to the tool’s launch to 87.9%, again after adjusting for pneumonia severity (P < .001). Use of broad-spectrum antibiotics was not significantly different between the two treatment intervals, but administration of antibiotics active against methicillin-resistant Staphylococcus aureus dropped significantly between the two treatment intervals (P < .001). And the mean time from admission to the ED to the first antibiotic taken was slightly faster, improving from 159.4 minutes (95% CI, 156.9-161.9 minutes) prior to the ePNa launch to 150.9 minutes (95% CI, 144.1-157.8) post deployment (P < .001).

“Overall outpatient disposition for treatment of pneumonia from the emergency department increased from 29.2% before ePNa to 46.9% [post ePNA],” the authors noted, while a similar increase was observed in patients for whom ePNA recommended outpatient care – from 49.2% pre-ePNA to 66.6% after ePNA.

Both hospital ward admission and admission to the ICU decreased after ePNa had been introduced. Despite a significant increase in the percentage of patients being discharged home, neither 7-day secondary hospital admission nor severity-adjusted, 30-day mortality were significantly different before versus after the introduction of ePNa, the authors stressed.

A limitation of the study was that the trial was confined to a single health care system in one region of the United States with a patient population that may differ from that in other regions.
 

Reason for its success

Asked to comment on the findings, Adam Balls, MD, emergency department chair, Intermountain Medical Center, Murray, Utah, suggested that the reason the ePNa tool has been so successful at improving care for pneumonia patients is that it puts the guidelines directly into the hands of individual providers and tells them what’s going on. (Dr. Balls was not involved in the study.) “The tool allows us to take into consideration various clinical features – a patient’s oxygen requirements and whether or not they had prior complicated pneumonias that required additional antibiotics, for example – and then it makes the best determination for not only the disposition for that patient but antibiotic treatment as well,” he said in an interview.

This then allows physicians to either appropriately discharge less severely ill patients and admit those who are more ill – “and in general, just do a better job of treating pneumonia with this tool,” Dr. Balls said. He himself uses the decision support tool when attending to his own patients with pneumonia, as he feels that the tool really does make his care of these patients better. “There is a disparity around how we treat pneumonia in the U.S.

“Clinicians sometimes have a bias or a preference for certain antibiotics and we may not be appropriately treating these patients with broad-spectrum antibiotics or are perhaps using antibiotics that are not as effective based on an individual patient scenario so this is definitely a user-friendly tool that hopefully can be deployed throughout other health care systems to improve the treatment of pneumonia overall,” Dr. Balls emphasized.

A version of this article first appeared on Medscape.com.

The use of an electronic clinical decision support tool called “ePNa” reduced severity-adjusted, 30-day, all-cause mortality by 38% across 16 community hospitals in Utah, compared with predeployment levels, a 3-year, pragmatic, cluster-controlled study shows.

“We designed the ePNa specifically to require minimal input from the clinician so everything it does is already in the electronic medical record,” Nathan Dean, MD, University of Utah, Salt Lake City, told this news organization.

“So it’s actually putting the guideline recommendations into effect for physicians so that they can make better decisions by having all this information – it’s a comprehensive best practice kind of tool where best practices are likely to make the biggest difference for patients with a high severity of illness,” he added.

The study was published online in the American Journal of Respiratory and Critical Care Medicine.


 

Guideline-based tool

The ePNa makes use of pneumonia guidelines of 2007 and 2019 from the American Thoracic Society/Infectious Disease Society of America. The system was deployed into six geographic clusters of 16 Intermountain hospital EDs at 2-month intervals between December 2017 and November 2018. Simultaneous deployment was impractical, as implementation of the tool takes education, monitoring, and feedback that can be facilitated by focusing on only a few hospitals at a time.

The decision support tool gathers key patient indicators including age, fever, oxygen saturation, vital signs, and laboratory and chest imaging results to offer recommendations on care, including appropriate antibiotic therapy, microbiology studies, and whether a given patient should be sent to the intensive care unit, admitted to hospital, or may safely be discharged home.

Investigators analyzed a total of 6,848 patients, of whom 4,536 were managed for pneumonia before the ePNa was deployed and 2,312 after deployment.

The median age of patients was 67 years (interquartile range, 50-79 years). Roughly half were female and almost all were White. “Observed 30-day all-cause mortality including both outpatients and inpatients was 8.6% before deployment versus 4.8% after deployment of ePNa,” Dr. Dean and colleagues reported.

Adjusted for severity of illness, the odds ratio for lower mortality post-ePNa launch was 0.62 (95% confidence interval, 0.49-0.79; P < .0010) “and lower morality was consistent across hospital clusters.”

Compared with patients who were discharged home, reductions in mortality were greatest in patients who were directly admitted to ICUs from the ED (OR, 0.32; 95% CI, 0.14-0.77; P = .01). The OR for patients admitted to the medical floor was 0.53 (95% CI, 0.25-1.1; P = .09), which did not reach statistical significance.

Dr. Dean explained that the reductions in mortality were seen among those with the most severe illness, in whom best practices would benefit the most. In contrast, patients who are sent home on an antibiotic are at low risk for mortality while patients admitted to the medical floor may well have another, more lethal illness from which they end up dying, rather than simple pneumonia.

“For me, this was a clear demonstration that these best practices made the biggest difference in patients who were sick and who did not have any underlying disease that was going to kill them anyway,” he emphasized. On the other hand, both 30-day mortality and 7-day secondary hospital admission were higher among patients the tool recommended for hospital ward admission but who were discharged home from the ED.

“This was an unexpected finding,” Dr. Dean observed. However, as he explained, the authors reviewed 25% of randomly selected patients who fell into this subgroup and discovered that the ePNa tool was used in only about 20% of patients – “so doctors did not use the tool in the majority of this group.”

In addition, some of these patients declined hospital admission, so the doctors may have recommended that they be admitted but the patients said no. “The hypothesis here is that if they had been admitted to the hospital, they may have had a lower mortality risk,” Dr. Dean said.
 

Noticeable changes

Another noticeable change following the introduction of the ePNa tool was that guideline-concordant antibiotic prescribing increased in the 8 hours after patients presented to the ED, from 79.5% prior to the tool’s launch to 87.9%, again after adjusting for pneumonia severity (P < .001). Use of broad-spectrum antibiotics was not significantly different between the two treatment intervals, but administration of antibiotics active against methicillin-resistant Staphylococcus aureus dropped significantly between the two treatment intervals (P < .001). And the mean time from admission to the ED to the first antibiotic taken was slightly faster, improving from 159.4 minutes (95% CI, 156.9-161.9 minutes) prior to the ePNa launch to 150.9 minutes (95% CI, 144.1-157.8) post deployment (P < .001).

“Overall outpatient disposition for treatment of pneumonia from the emergency department increased from 29.2% before ePNa to 46.9% [post ePNA],” the authors noted, while a similar increase was observed in patients for whom ePNA recommended outpatient care – from 49.2% pre-ePNA to 66.6% after ePNA.

Both hospital ward admission and admission to the ICU decreased after ePNa had been introduced. Despite a significant increase in the percentage of patients being discharged home, neither 7-day secondary hospital admission nor severity-adjusted, 30-day mortality were significantly different before versus after the introduction of ePNa, the authors stressed.

A limitation of the study was that the trial was confined to a single health care system in one region of the United States with a patient population that may differ from that in other regions.
 

Reason for its success

Asked to comment on the findings, Adam Balls, MD, emergency department chair, Intermountain Medical Center, Murray, Utah, suggested that the reason the ePNa tool has been so successful at improving care for pneumonia patients is that it puts the guidelines directly into the hands of individual providers and tells them what’s going on. (Dr. Balls was not involved in the study.) “The tool allows us to take into consideration various clinical features – a patient’s oxygen requirements and whether or not they had prior complicated pneumonias that required additional antibiotics, for example – and then it makes the best determination for not only the disposition for that patient but antibiotic treatment as well,” he said in an interview.

This then allows physicians to either appropriately discharge less severely ill patients and admit those who are more ill – “and in general, just do a better job of treating pneumonia with this tool,” Dr. Balls said. He himself uses the decision support tool when attending to his own patients with pneumonia, as he feels that the tool really does make his care of these patients better. “There is a disparity around how we treat pneumonia in the U.S.

“Clinicians sometimes have a bias or a preference for certain antibiotics and we may not be appropriately treating these patients with broad-spectrum antibiotics or are perhaps using antibiotics that are not as effective based on an individual patient scenario so this is definitely a user-friendly tool that hopefully can be deployed throughout other health care systems to improve the treatment of pneumonia overall,” Dr. Balls emphasized.

A version of this article first appeared on Medscape.com.

In assessing and managing patients presenting with acute, life-threatening asthma, if the exacerbation does not resolve relatively quickly, clinicians need to start looking for other causes of the patient’s respiratory distress, a review of the literature suggests.

“I think one of the most important points of this review is that asthma is a self-limiting disease, and it’s important to understand that with appropriate treatment and immediate response to it, exacerbations will get better with time,” Orlando Garner, MD, Baylor College of Medicine, Houston, said in an interview.

“So I think one of the key points is, if these exacerbations do not resolve within 24-48 hours, clinicians need to start thinking: ‘This could be something else,’ and not get stuck in the diagnosis that this is an asthmatic patient who is having an exacerbation. If the distress doesn’t resolve within 48 hours, it’s time to look for other clues,” he stressed.

The study was published online in the journal CHEST^®.

Appropriate triage

Appropriate triage is key in the management of acute asthma, Dr. Garner and colleagues pointed out. A simplified severity score for the evaluation of asthma in the ED can help in this regard. Depending on the presence or absence of a number of key signs and symptoms, patients can be readily categorized as having mild, moderate, or severe asthma. “Static assessments and dynamic assessments of acute asthma exacerbation in the ED can also help triage patients,” the authors added.

Static assessment involves assessing the severity at presentation, which in turn determines the aggressiveness of initial treatment. Objective static assessments include the measurement of peak expiratory flow (PEF) or forced expiratory volume in 1 second (FEV₁). A severe exacerbation is usually defined as a PEF or an FEV₁ of less than 50%-60% of predicted normal values, the authors noted.

Dynamic assessment is more helpful than static assessment because it gauges response to treatment. “A lack of improvement in expiratory flow rates after initial bronchodilator therapy with continuous or worsening symptoms suggests need for hospitalization,” Dr. Garner and colleagues observed. The main treatment goals for patients with acute asthma are reversal of bronchospasm and correction of hypoxemia.

These are achieved at least initially with conventional agents, such as repeated doses of inhaled short-acting beta₂-agonists, inhaled short-acting anticholinergics, systemic corticosteroids, and occasionally intravenous magnesium sulfate. If there is concomitant hypoxemia, oxygen therapy should be initiated as well. Patients who have evidence of hypercapnic respiratory failure or diaphragmatic fatigue need to be admitted to the intensive care unit, the authors indicated.

For these patients, clinicians need to remember that there are therapies other than inhalers, such as epinephrine and systemic terbutaline. During a life-threatening asthma episode, airflow in the medium and small airways often becomes turbulent, increasing the work of breathing, the researchers pointed out.

Heliox, a combination of helium and oxygen, reduces turbulent flow, they noted, although FiO₂ requirements need to be less than 30% in order for it to work. “Heliox can be used in patients with severe bronchospasm who do not respond to the conventional therapies,” the authors noted, “[but] therapy should be abandoned if there is no clinical improvement after 15 minutes of use.”

Although none of the biologics such as dupilumab (Dupixent) has yet been approved for the treatment of acute exacerbations, Dr. Garner predicts they will become the “future of medicine” for patients with severe asthma as well.
 

Ventilation in life-threatening asthma

Rapid sequence intubation is generally recommended for patients who require mechanical ventilation, but as an alternative, “we are advocating a slower approach, where we get patients to slow down their breathing and relax them with something like ketamine infusions and wait before we given them a paralytic to see if the work of breathing improves,” Dr. Garner said. Bag-mask ventilation should be avoided because it can worsen dynamic hyperinflation or cause barotrauma.

Salvage therapies such as the use of bronchoscopy with N-acetylcysteine instilled directly into the airway is another option in cases in which mucus plugging is considered to be the main driver of airflow limitation.

Asked to comment, Brit Long, MD, an emergency medicine physician at the Brooke Army Medical Center in San Antonio, Tex., felt the review was extremely useful and well done.

“We see these patients very frequently, and being able to assess them right away and get an accurate picture of what’s going on is very important,” he said in an interview. The one thing that is often more difficult, at least in the ED, is obtaining a PEF or the FEV₁ – “both very helpful if the patient can do them, but if the patient is critically ill, it’s more likely you will not be able to get those assessments, and if patients are speaking in one-word sentences and are working really hard to breathe, that’s a severe exacerbation, and they need immediate intervention.” Dr. Long also liked all the essential treatments the authors recommended that patients be given immediately, although he noted that Heliox is not going to be available in most EDs.

On the other hand, he agreed with the authors’ recommendation to take a slower approach to mechanical ventilation, if it is needed at all. “I try my best to absolutely avoid intubating these patients – you are not fixing the issue with mechanical ventilation, you are just creating further problems.

“And while I see the entire spectrum of asthma patients from very mild to severe patients, these authors did a good job in explaining what the goals of treatment are and what to do with the severe ones,” he said.

Dr. Garner and Dr. Long disclosed no relevant financial relationships.

A version of this article first appeared on Medscape.com.

In assessing and managing patients presenting with acute, life-threatening asthma, if the exacerbation does not resolve relatively quickly, clinicians need to start looking for other causes of the patient’s respiratory distress, a review of the literature suggests.

“I think one of the most important points of this review is that asthma is a self-limiting disease, and it’s important to understand that with appropriate treatment and immediate response to it, exacerbations will get better with time,” Orlando Garner, MD, Baylor College of Medicine, Houston, said in an interview.

“So I think one of the key points is, if these exacerbations do not resolve within 24-48 hours, clinicians need to start thinking: ‘This could be something else,’ and not get stuck in the diagnosis that this is an asthmatic patient who is having an exacerbation. If the distress doesn’t resolve within 48 hours, it’s time to look for other clues,” he stressed.

The study was published online in the journal CHEST^®.

Appropriate triage

Appropriate triage is key in the management of acute asthma, Dr. Garner and colleagues pointed out. A simplified severity score for the evaluation of asthma in the ED can help in this regard. Depending on the presence or absence of a number of key signs and symptoms, patients can be readily categorized as having mild, moderate, or severe asthma. “Static assessments and dynamic assessments of acute asthma exacerbation in the ED can also help triage patients,” the authors added.

Static assessment involves assessing the severity at presentation, which in turn determines the aggressiveness of initial treatment. Objective static assessments include the measurement of peak expiratory flow (PEF) or forced expiratory volume in 1 second (FEV₁). A severe exacerbation is usually defined as a PEF or an FEV₁ of less than 50%-60% of predicted normal values, the authors noted.

Dynamic assessment is more helpful than static assessment because it gauges response to treatment. “A lack of improvement in expiratory flow rates after initial bronchodilator therapy with continuous or worsening symptoms suggests need for hospitalization,” Dr. Garner and colleagues observed. The main treatment goals for patients with acute asthma are reversal of bronchospasm and correction of hypoxemia.

These are achieved at least initially with conventional agents, such as repeated doses of inhaled short-acting beta₂-agonists, inhaled short-acting anticholinergics, systemic corticosteroids, and occasionally intravenous magnesium sulfate. If there is concomitant hypoxemia, oxygen therapy should be initiated as well. Patients who have evidence of hypercapnic respiratory failure or diaphragmatic fatigue need to be admitted to the intensive care unit, the authors indicated.

For these patients, clinicians need to remember that there are therapies other than inhalers, such as epinephrine and systemic terbutaline. During a life-threatening asthma episode, airflow in the medium and small airways often becomes turbulent, increasing the work of breathing, the researchers pointed out.

Heliox, a combination of helium and oxygen, reduces turbulent flow, they noted, although FiO₂ requirements need to be less than 30% in order for it to work. “Heliox can be used in patients with severe bronchospasm who do not respond to the conventional therapies,” the authors noted, “[but] therapy should be abandoned if there is no clinical improvement after 15 minutes of use.”

Although none of the biologics such as dupilumab (Dupixent) has yet been approved for the treatment of acute exacerbations, Dr. Garner predicts they will become the “future of medicine” for patients with severe asthma as well.
 

Ventilation in life-threatening asthma

Rapid sequence intubation is generally recommended for patients who require mechanical ventilation, but as an alternative, “we are advocating a slower approach, where we get patients to slow down their breathing and relax them with something like ketamine infusions and wait before we given them a paralytic to see if the work of breathing improves,” Dr. Garner said. Bag-mask ventilation should be avoided because it can worsen dynamic hyperinflation or cause barotrauma.

Salvage therapies such as the use of bronchoscopy with N-acetylcysteine instilled directly into the airway is another option in cases in which mucus plugging is considered to be the main driver of airflow limitation.

Asked to comment, Brit Long, MD, an emergency medicine physician at the Brooke Army Medical Center in San Antonio, Tex., felt the review was extremely useful and well done.

“We see these patients very frequently, and being able to assess them right away and get an accurate picture of what’s going on is very important,” he said in an interview. The one thing that is often more difficult, at least in the ED, is obtaining a PEF or the FEV₁ – “both very helpful if the patient can do them, but if the patient is critically ill, it’s more likely you will not be able to get those assessments, and if patients are speaking in one-word sentences and are working really hard to breathe, that’s a severe exacerbation, and they need immediate intervention.” Dr. Long also liked all the essential treatments the authors recommended that patients be given immediately, although he noted that Heliox is not going to be available in most EDs.

On the other hand, he agreed with the authors’ recommendation to take a slower approach to mechanical ventilation, if it is needed at all. “I try my best to absolutely avoid intubating these patients – you are not fixing the issue with mechanical ventilation, you are just creating further problems.

“And while I see the entire spectrum of asthma patients from very mild to severe patients, these authors did a good job in explaining what the goals of treatment are and what to do with the severe ones,” he said.

Dr. Garner and Dr. Long disclosed no relevant financial relationships.

A version of this article first appeared on Medscape.com.

In assessing and managing patients presenting with acute, life-threatening asthma, if the exacerbation does not resolve relatively quickly, clinicians need to start looking for other causes of the patient’s respiratory distress, a review of the literature suggests.

“I think one of the most important points of this review is that asthma is a self-limiting disease, and it’s important to understand that with appropriate treatment and immediate response to it, exacerbations will get better with time,” Orlando Garner, MD, Baylor College of Medicine, Houston, said in an interview.

“So I think one of the key points is, if these exacerbations do not resolve within 24-48 hours, clinicians need to start thinking: ‘This could be something else,’ and not get stuck in the diagnosis that this is an asthmatic patient who is having an exacerbation. If the distress doesn’t resolve within 48 hours, it’s time to look for other clues,” he stressed.

The study was published online in the journal CHEST^®.

Appropriate triage

Appropriate triage is key in the management of acute asthma, Dr. Garner and colleagues pointed out. A simplified severity score for the evaluation of asthma in the ED can help in this regard. Depending on the presence or absence of a number of key signs and symptoms, patients can be readily categorized as having mild, moderate, or severe asthma. “Static assessments and dynamic assessments of acute asthma exacerbation in the ED can also help triage patients,” the authors added.

Static assessment involves assessing the severity at presentation, which in turn determines the aggressiveness of initial treatment. Objective static assessments include the measurement of peak expiratory flow (PEF) or forced expiratory volume in 1 second (FEV₁). A severe exacerbation is usually defined as a PEF or an FEV₁ of less than 50%-60% of predicted normal values, the authors noted.

Dynamic assessment is more helpful than static assessment because it gauges response to treatment. “A lack of improvement in expiratory flow rates after initial bronchodilator therapy with continuous or worsening symptoms suggests need for hospitalization,” Dr. Garner and colleagues observed. The main treatment goals for patients with acute asthma are reversal of bronchospasm and correction of hypoxemia.

These are achieved at least initially with conventional agents, such as repeated doses of inhaled short-acting beta₂-agonists, inhaled short-acting anticholinergics, systemic corticosteroids, and occasionally intravenous magnesium sulfate. If there is concomitant hypoxemia, oxygen therapy should be initiated as well. Patients who have evidence of hypercapnic respiratory failure or diaphragmatic fatigue need to be admitted to the intensive care unit, the authors indicated.

For these patients, clinicians need to remember that there are therapies other than inhalers, such as epinephrine and systemic terbutaline. During a life-threatening asthma episode, airflow in the medium and small airways often becomes turbulent, increasing the work of breathing, the researchers pointed out.

Heliox, a combination of helium and oxygen, reduces turbulent flow, they noted, although FiO₂ requirements need to be less than 30% in order for it to work. “Heliox can be used in patients with severe bronchospasm who do not respond to the conventional therapies,” the authors noted, “[but] therapy should be abandoned if there is no clinical improvement after 15 minutes of use.”

Although none of the biologics such as dupilumab (Dupixent) has yet been approved for the treatment of acute exacerbations, Dr. Garner predicts they will become the “future of medicine” for patients with severe asthma as well.
 

Ventilation in life-threatening asthma

Rapid sequence intubation is generally recommended for patients who require mechanical ventilation, but as an alternative, “we are advocating a slower approach, where we get patients to slow down their breathing and relax them with something like ketamine infusions and wait before we given them a paralytic to see if the work of breathing improves,” Dr. Garner said. Bag-mask ventilation should be avoided because it can worsen dynamic hyperinflation or cause barotrauma.

Salvage therapies such as the use of bronchoscopy with N-acetylcysteine instilled directly into the airway is another option in cases in which mucus plugging is considered to be the main driver of airflow limitation.

Asked to comment, Brit Long, MD, an emergency medicine physician at the Brooke Army Medical Center in San Antonio, Tex., felt the review was extremely useful and well done.

“We see these patients very frequently, and being able to assess them right away and get an accurate picture of what’s going on is very important,” he said in an interview. The one thing that is often more difficult, at least in the ED, is obtaining a PEF or the FEV₁ – “both very helpful if the patient can do them, but if the patient is critically ill, it’s more likely you will not be able to get those assessments, and if patients are speaking in one-word sentences and are working really hard to breathe, that’s a severe exacerbation, and they need immediate intervention.” Dr. Long also liked all the essential treatments the authors recommended that patients be given immediately, although he noted that Heliox is not going to be available in most EDs.

On the other hand, he agreed with the authors’ recommendation to take a slower approach to mechanical ventilation, if it is needed at all. “I try my best to absolutely avoid intubating these patients – you are not fixing the issue with mechanical ventilation, you are just creating further problems.

“And while I see the entire spectrum of asthma patients from very mild to severe patients, these authors did a good job in explaining what the goals of treatment are and what to do with the severe ones,” he said.

Dr. Garner and Dr. Long disclosed no relevant financial relationships.

A version of this article first appeared on Medscape.com.

The global burden of thyroid cancer is substantial, and incidence rates are increasing in many developed countries, including the Unites States, concluded a new analysis based on 30 years of observational data.

“We report overall increases in the burden of thyroid cancer across the majority of EU15+ countries between 1990 and 2019, evidenced by plateaus in incidence rates and reductions in mortality and DALY [disability-adjusted life-years] rates,” the authors reported.

“However, in a number of countries, including the U.S., there are unfavorable increasing mortality and DALY trends over this time period ... [and] a better understanding of the trends in the disease burden of thyroid cancer may help to inform future health system planning,” they added.

The study was published online March 10, 2022, in JAMA Otolaryngology–Head & Neck Surgery.
 

Trends in thyroid cancer

For the analysis, James Schuster-Bruce, MBChB, from St. George’s University Hospital NHS Foundation Trust, London, and colleagues compared trends in thyroid cancer across 30 years of follow-up among 15 countries of the (pre-2004) European Union as well as those in the United States, Australia, Canada, and Norway (EU15+).

Data from the Global Burden of Disease study database were used to track these trends. “We extracted age-standardized incidence rates (ASIRs), age-standardized mortality rates (ASMRs), and DALYs for thyroid cancer from EU15+ countries between 1990 and 2019 using the dedicated GBD study results tool,” the investigators explained.

In 2019, ASIRs were highest in Italy at 6.36 per 100,000 population, followed by the United States at a rate of 5.59 per 100,000 population – although incidence rates of thyroid cancer have actually recently decreased in U.S. women, they noted.

“Thirteen of 19 countries showed an average annual percentage increase in ASIR across the study period,” the investigators added. Out of all the EU15+ countries, the average annual percentage change (AAPC) was the highest in Australia at 2.5 per 100,000 population and the United States at 1.2 per 100,000.

On the other hand, a largely plateauing trend in incidence rates across the majority of EU15+ nations has been observed since 1990, as reflected by incidence rates ranging from –0.8 to 0.8 per 100,000 in the most recent period, the researchers added. ASMRs ranged from a 0.40 per 100,000 in Greece to 0.57 per 100,000 in Luxembourg.

In the United States, the ASMR in 2019 was 0.43 per 100,000 population while the ASMR was the lowest in the United Kingdom in the same year at 0.38 per 100,000 population.

Australia, Denmark, and the United States were the only countries showing positive AAPC changes, the team observed. For example, in the most recent period to 2019, Denmark and Australia had reductions in ASMR trends, whereas in the United States, the trend was toward increasing ASMRs 

In 2019, the DALYs of the EU15+ nations ranged from 9.63 per 100,000 in the United Kingdom to 14.46 per 100,000 in Luxembourg. In the most recent period, a downward trend in DALYs was observed in Australia and Denmark while it plateaued in the United States.

“Overall, we identified improvements in thyroid cancer mortality and DALYs, but overall increases in thyroid cancer incidence in EU15+ countries over the past 3 decades,” the investigators commented.

It has been widely suggested that improvements in diagnostic techniques have contributed significantly to increasing incidence rates of thyroid cancer, but there is concern about overdiagnosis.  Newer diagnostic techniques detect significant numbers of slow-growing, subclinical papillary thyroid cancers that make up at least one quarter of all thyroid cancer subtypes, the authors pointed out.

“It has therefore been suggested that an increase in subclinical disease has inflated the data to look more substantial than the clinical reality,” the authors wrote. However, they insisted that overdiagnosis alone is unlikely to account entirely for increasing incidence trends in the current analysis.

Rather, their concern for countries with high incidence rates of thyroid cancer is the surveillance burden of disease that does not affect mortality. “Close observation of future time trends in thyroid cancer disease burden should be performed in the context of recent changes in international clinical practice guidelines, which have suggested more conservative diagnostic and management strategies,” the authors suggested.

“In the context of the more conservative treatment guidelines and reported increase in true disease, it is important to closely observe mortality and DALYs over the coming years to ensure optimum thyroid cancer management in these nations,” they added.

The study had no specific funding. Dr. Schuster-Bruce disclosed no relevant financial relationships.

A version of this article first appeared on Medscape.com.

The global burden of thyroid cancer is substantial, and incidence rates are increasing in many developed countries, including the Unites States, concluded a new analysis based on 30 years of observational data.

“We report overall increases in the burden of thyroid cancer across the majority of EU15+ countries between 1990 and 2019, evidenced by plateaus in incidence rates and reductions in mortality and DALY [disability-adjusted life-years] rates,” the authors reported.

“However, in a number of countries, including the U.S., there are unfavorable increasing mortality and DALY trends over this time period ... [and] a better understanding of the trends in the disease burden of thyroid cancer may help to inform future health system planning,” they added.

The study was published online March 10, 2022, in JAMA Otolaryngology–Head & Neck Surgery.
 

Trends in thyroid cancer

For the analysis, James Schuster-Bruce, MBChB, from St. George’s University Hospital NHS Foundation Trust, London, and colleagues compared trends in thyroid cancer across 30 years of follow-up among 15 countries of the (pre-2004) European Union as well as those in the United States, Australia, Canada, and Norway (EU15+).

Data from the Global Burden of Disease study database were used to track these trends. “We extracted age-standardized incidence rates (ASIRs), age-standardized mortality rates (ASMRs), and DALYs for thyroid cancer from EU15+ countries between 1990 and 2019 using the dedicated GBD study results tool,” the investigators explained.

In 2019, ASIRs were highest in Italy at 6.36 per 100,000 population, followed by the United States at a rate of 5.59 per 100,000 population – although incidence rates of thyroid cancer have actually recently decreased in U.S. women, they noted.

“Thirteen of 19 countries showed an average annual percentage increase in ASIR across the study period,” the investigators added. Out of all the EU15+ countries, the average annual percentage change (AAPC) was the highest in Australia at 2.5 per 100,000 population and the United States at 1.2 per 100,000.

On the other hand, a largely plateauing trend in incidence rates across the majority of EU15+ nations has been observed since 1990, as reflected by incidence rates ranging from –0.8 to 0.8 per 100,000 in the most recent period, the researchers added. ASMRs ranged from a 0.40 per 100,000 in Greece to 0.57 per 100,000 in Luxembourg.

In the United States, the ASMR in 2019 was 0.43 per 100,000 population while the ASMR was the lowest in the United Kingdom in the same year at 0.38 per 100,000 population.

Australia, Denmark, and the United States were the only countries showing positive AAPC changes, the team observed. For example, in the most recent period to 2019, Denmark and Australia had reductions in ASMR trends, whereas in the United States, the trend was toward increasing ASMRs 

In 2019, the DALYs of the EU15+ nations ranged from 9.63 per 100,000 in the United Kingdom to 14.46 per 100,000 in Luxembourg. In the most recent period, a downward trend in DALYs was observed in Australia and Denmark while it plateaued in the United States.

“Overall, we identified improvements in thyroid cancer mortality and DALYs, but overall increases in thyroid cancer incidence in EU15+ countries over the past 3 decades,” the investigators commented.

It has been widely suggested that improvements in diagnostic techniques have contributed significantly to increasing incidence rates of thyroid cancer, but there is concern about overdiagnosis.  Newer diagnostic techniques detect significant numbers of slow-growing, subclinical papillary thyroid cancers that make up at least one quarter of all thyroid cancer subtypes, the authors pointed out.

“It has therefore been suggested that an increase in subclinical disease has inflated the data to look more substantial than the clinical reality,” the authors wrote. However, they insisted that overdiagnosis alone is unlikely to account entirely for increasing incidence trends in the current analysis.

Rather, their concern for countries with high incidence rates of thyroid cancer is the surveillance burden of disease that does not affect mortality. “Close observation of future time trends in thyroid cancer disease burden should be performed in the context of recent changes in international clinical practice guidelines, which have suggested more conservative diagnostic and management strategies,” the authors suggested.

“In the context of the more conservative treatment guidelines and reported increase in true disease, it is important to closely observe mortality and DALYs over the coming years to ensure optimum thyroid cancer management in these nations,” they added.

The study had no specific funding. Dr. Schuster-Bruce disclosed no relevant financial relationships.

A version of this article first appeared on Medscape.com.

The global burden of thyroid cancer is substantial, and incidence rates are increasing in many developed countries, including the Unites States, concluded a new analysis based on 30 years of observational data.

“We report overall increases in the burden of thyroid cancer across the majority of EU15+ countries between 1990 and 2019, evidenced by plateaus in incidence rates and reductions in mortality and DALY [disability-adjusted life-years] rates,” the authors reported.

“However, in a number of countries, including the U.S., there are unfavorable increasing mortality and DALY trends over this time period ... [and] a better understanding of the trends in the disease burden of thyroid cancer may help to inform future health system planning,” they added.

The study was published online March 10, 2022, in JAMA Otolaryngology–Head & Neck Surgery.
 

Trends in thyroid cancer

For the analysis, James Schuster-Bruce, MBChB, from St. George’s University Hospital NHS Foundation Trust, London, and colleagues compared trends in thyroid cancer across 30 years of follow-up among 15 countries of the (pre-2004) European Union as well as those in the United States, Australia, Canada, and Norway (EU15+).

Data from the Global Burden of Disease study database were used to track these trends. “We extracted age-standardized incidence rates (ASIRs), age-standardized mortality rates (ASMRs), and DALYs for thyroid cancer from EU15+ countries between 1990 and 2019 using the dedicated GBD study results tool,” the investigators explained.

In 2019, ASIRs were highest in Italy at 6.36 per 100,000 population, followed by the United States at a rate of 5.59 per 100,000 population – although incidence rates of thyroid cancer have actually recently decreased in U.S. women, they noted.

“Thirteen of 19 countries showed an average annual percentage increase in ASIR across the study period,” the investigators added. Out of all the EU15+ countries, the average annual percentage change (AAPC) was the highest in Australia at 2.5 per 100,000 population and the United States at 1.2 per 100,000.

On the other hand, a largely plateauing trend in incidence rates across the majority of EU15+ nations has been observed since 1990, as reflected by incidence rates ranging from –0.8 to 0.8 per 100,000 in the most recent period, the researchers added. ASMRs ranged from a 0.40 per 100,000 in Greece to 0.57 per 100,000 in Luxembourg.

In the United States, the ASMR in 2019 was 0.43 per 100,000 population while the ASMR was the lowest in the United Kingdom in the same year at 0.38 per 100,000 population.

Australia, Denmark, and the United States were the only countries showing positive AAPC changes, the team observed. For example, in the most recent period to 2019, Denmark and Australia had reductions in ASMR trends, whereas in the United States, the trend was toward increasing ASMRs 

In 2019, the DALYs of the EU15+ nations ranged from 9.63 per 100,000 in the United Kingdom to 14.46 per 100,000 in Luxembourg. In the most recent period, a downward trend in DALYs was observed in Australia and Denmark while it plateaued in the United States.

“Overall, we identified improvements in thyroid cancer mortality and DALYs, but overall increases in thyroid cancer incidence in EU15+ countries over the past 3 decades,” the investigators commented.

It has been widely suggested that improvements in diagnostic techniques have contributed significantly to increasing incidence rates of thyroid cancer, but there is concern about overdiagnosis.  Newer diagnostic techniques detect significant numbers of slow-growing, subclinical papillary thyroid cancers that make up at least one quarter of all thyroid cancer subtypes, the authors pointed out.

“It has therefore been suggested that an increase in subclinical disease has inflated the data to look more substantial than the clinical reality,” the authors wrote. However, they insisted that overdiagnosis alone is unlikely to account entirely for increasing incidence trends in the current analysis.

Rather, their concern for countries with high incidence rates of thyroid cancer is the surveillance burden of disease that does not affect mortality. “Close observation of future time trends in thyroid cancer disease burden should be performed in the context of recent changes in international clinical practice guidelines, which have suggested more conservative diagnostic and management strategies,” the authors suggested.

“In the context of the more conservative treatment guidelines and reported increase in true disease, it is important to closely observe mortality and DALYs over the coming years to ensure optimum thyroid cancer management in these nations,” they added.

The study had no specific funding. Dr. Schuster-Bruce disclosed no relevant financial relationships.

A version of this article first appeared on Medscape.com.

Many older patients with advanced kidney disease who decide to forgo dialysis still survive for several years after making their decision and have a good quality of life until their final days, a new systematic review of cohort studies suggests.

“Our findings challenge the common misconception that the only alternative to dialysis for many patients with advanced chronic kidney disease is no care or death,” say Susan Wong, MD, of the Renal Dialysis Unit, Seattle, and colleagues in their review, published online March 14 in JAMA Network Open.

In an accompanying commentary, Christine Liu, MD, and Kurella Tamura, MD, MPH, note: “The decision to initiate dialysis or focus on active alleviation of symptoms, known as conservative care … is likely one of the consequential decisions [patients] will face.”

“[But] in reality, dialysis is viewed as the default treatment for kidney failure, and the option to forgo dialysis treatment is often not explicitly discussed,” they add.

“We believe it is time to broaden the scope of kidney replacement therapy registries to include persons who receive conservative treatment of kidney failure … and we need to address the conservative care information gap so that lack of awareness is no longer a barrier to informed decision-making,” Dr. Liu and Dr. Tamura, both from Stanford (Calif.) University, note.

The work by Dr. Wong and colleagues “dispels the notion that conservative care for kidney failure means a grim and near-immediate death. The study advances the idea that a conservative care approach can provide time and sustain quality of life to support patients’ life goals,” they emphasize.
 

Conservative care assessed in 41 studies

The review included 41 studies involving 5,102 patients with a mean age ranging from 60 to 87 years conducted in the United Kingdom, Europe, and Asia.

Median survival of cohorts ranged from 1 to 41 months as measured from a baseline mean estimated glomerular filtration rate (eGFR) ranging from 7 to 19 mL/min/1.73m².

Younger patients between 70 and 79 years of age had a median survival of 7 to 41 months, the authors note, while cohorts consisting of patients 80 years of age and older had a median survival of 1 to 37 months despite overlapping ranges of baseline mean eGFRs.

During an observation period of 8-24 months, mental well-being improved, and physical well-being and overall quality of life were largely stable until late in the course of illness.

“Ten studies … provided information on the use of health care resources during follow-up,” the researchers say. Patients generally experienced one to two hospital admissions, 6-16 in-hospital days, seven to eight clinic visits, and two emergency department visits per person-year. Use of acute care services was “therefore common,” they note.

Not all studies provided information about end-of-life care, but those that did reported rates of hospice enrollment that ranged from 20% to 76%; hospitalization rates during the final month of life from 57% to 76%; in-hospital death rates of 27%-68%, and in-home death rates ranging from 12% to 71%.

This indicates substantial disparity in access to supportive care near the end of life across cohorts, the authors observe.

Nevertheless, “Most patients survived several years after the decision to forgo dialysis was made,” they stress.

“These findings not only suggest that conservative kidney management may be a viable and positive therapeutic alternative to dialysis, they also highlight the strengths of its multidisciplinary approach to care and aggressive symptom management.”

“Collectively, our findings demonstrate the need to implement systematic and unified research methods for conservative kidney management and to develop models of care and the care infrastructure to advance practice and outcomes of conservative kidney management,” they conclude.

Dr. Wong has no financial ties to industry. Dr. Tamura has reported receiving personal fees from the American Federation for Aging Research.

A version of this article first appeared on Medscape.com.

Many older patients with advanced kidney disease who decide to forgo dialysis still survive for several years after making their decision and have a good quality of life until their final days, a new systematic review of cohort studies suggests.

“Our findings challenge the common misconception that the only alternative to dialysis for many patients with advanced chronic kidney disease is no care or death,” say Susan Wong, MD, of the Renal Dialysis Unit, Seattle, and colleagues in their review, published online March 14 in JAMA Network Open.

In an accompanying commentary, Christine Liu, MD, and Kurella Tamura, MD, MPH, note: “The decision to initiate dialysis or focus on active alleviation of symptoms, known as conservative care … is likely one of the consequential decisions [patients] will face.”

“[But] in reality, dialysis is viewed as the default treatment for kidney failure, and the option to forgo dialysis treatment is often not explicitly discussed,” they add.

“We believe it is time to broaden the scope of kidney replacement therapy registries to include persons who receive conservative treatment of kidney failure … and we need to address the conservative care information gap so that lack of awareness is no longer a barrier to informed decision-making,” Dr. Liu and Dr. Tamura, both from Stanford (Calif.) University, note.

The work by Dr. Wong and colleagues “dispels the notion that conservative care for kidney failure means a grim and near-immediate death. The study advances the idea that a conservative care approach can provide time and sustain quality of life to support patients’ life goals,” they emphasize.
 

Conservative care assessed in 41 studies

The review included 41 studies involving 5,102 patients with a mean age ranging from 60 to 87 years conducted in the United Kingdom, Europe, and Asia.

Median survival of cohorts ranged from 1 to 41 months as measured from a baseline mean estimated glomerular filtration rate (eGFR) ranging from 7 to 19 mL/min/1.73m².

Younger patients between 70 and 79 years of age had a median survival of 7 to 41 months, the authors note, while cohorts consisting of patients 80 years of age and older had a median survival of 1 to 37 months despite overlapping ranges of baseline mean eGFRs.

During an observation period of 8-24 months, mental well-being improved, and physical well-being and overall quality of life were largely stable until late in the course of illness.

“Ten studies … provided information on the use of health care resources during follow-up,” the researchers say. Patients generally experienced one to two hospital admissions, 6-16 in-hospital days, seven to eight clinic visits, and two emergency department visits per person-year. Use of acute care services was “therefore common,” they note.

Not all studies provided information about end-of-life care, but those that did reported rates of hospice enrollment that ranged from 20% to 76%; hospitalization rates during the final month of life from 57% to 76%; in-hospital death rates of 27%-68%, and in-home death rates ranging from 12% to 71%.

This indicates substantial disparity in access to supportive care near the end of life across cohorts, the authors observe.

Nevertheless, “Most patients survived several years after the decision to forgo dialysis was made,” they stress.

“These findings not only suggest that conservative kidney management may be a viable and positive therapeutic alternative to dialysis, they also highlight the strengths of its multidisciplinary approach to care and aggressive symptom management.”

“Collectively, our findings demonstrate the need to implement systematic and unified research methods for conservative kidney management and to develop models of care and the care infrastructure to advance practice and outcomes of conservative kidney management,” they conclude.

Dr. Wong has no financial ties to industry. Dr. Tamura has reported receiving personal fees from the American Federation for Aging Research.

A version of this article first appeared on Medscape.com.

Many older patients with advanced kidney disease who decide to forgo dialysis still survive for several years after making their decision and have a good quality of life until their final days, a new systematic review of cohort studies suggests.

“Our findings challenge the common misconception that the only alternative to dialysis for many patients with advanced chronic kidney disease is no care or death,” say Susan Wong, MD, of the Renal Dialysis Unit, Seattle, and colleagues in their review, published online March 14 in JAMA Network Open.

In an accompanying commentary, Christine Liu, MD, and Kurella Tamura, MD, MPH, note: “The decision to initiate dialysis or focus on active alleviation of symptoms, known as conservative care … is likely one of the consequential decisions [patients] will face.”

“[But] in reality, dialysis is viewed as the default treatment for kidney failure, and the option to forgo dialysis treatment is often not explicitly discussed,” they add.

“We believe it is time to broaden the scope of kidney replacement therapy registries to include persons who receive conservative treatment of kidney failure … and we need to address the conservative care information gap so that lack of awareness is no longer a barrier to informed decision-making,” Dr. Liu and Dr. Tamura, both from Stanford (Calif.) University, note.

The work by Dr. Wong and colleagues “dispels the notion that conservative care for kidney failure means a grim and near-immediate death. The study advances the idea that a conservative care approach can provide time and sustain quality of life to support patients’ life goals,” they emphasize.
 

Conservative care assessed in 41 studies

The review included 41 studies involving 5,102 patients with a mean age ranging from 60 to 87 years conducted in the United Kingdom, Europe, and Asia.

Median survival of cohorts ranged from 1 to 41 months as measured from a baseline mean estimated glomerular filtration rate (eGFR) ranging from 7 to 19 mL/min/1.73m².

Younger patients between 70 and 79 years of age had a median survival of 7 to 41 months, the authors note, while cohorts consisting of patients 80 years of age and older had a median survival of 1 to 37 months despite overlapping ranges of baseline mean eGFRs.

During an observation period of 8-24 months, mental well-being improved, and physical well-being and overall quality of life were largely stable until late in the course of illness.

“Ten studies … provided information on the use of health care resources during follow-up,” the researchers say. Patients generally experienced one to two hospital admissions, 6-16 in-hospital days, seven to eight clinic visits, and two emergency department visits per person-year. Use of acute care services was “therefore common,” they note.

Not all studies provided information about end-of-life care, but those that did reported rates of hospice enrollment that ranged from 20% to 76%; hospitalization rates during the final month of life from 57% to 76%; in-hospital death rates of 27%-68%, and in-home death rates ranging from 12% to 71%.

This indicates substantial disparity in access to supportive care near the end of life across cohorts, the authors observe.

Nevertheless, “Most patients survived several years after the decision to forgo dialysis was made,” they stress.

“These findings not only suggest that conservative kidney management may be a viable and positive therapeutic alternative to dialysis, they also highlight the strengths of its multidisciplinary approach to care and aggressive symptom management.”

“Collectively, our findings demonstrate the need to implement systematic and unified research methods for conservative kidney management and to develop models of care and the care infrastructure to advance practice and outcomes of conservative kidney management,” they conclude.

Dr. Wong has no financial ties to industry. Dr. Tamura has reported receiving personal fees from the American Federation for Aging Research.

A version of this article first appeared on Medscape.com.

Airflow obstruction caused by a malignant tracheal tumor may be managed with a uniquely designed, 3-dimensional (3D) drug-eluting tracheal stent that, at least in animal models so far, works well and may soon be ready for human trials, Chinese investigators are reporting.

The research was published online Jan. 29 in Materials Today Chemistry.

The problems with currently available stents used to treat airflow obstruction are considerable, corresponding author Shengrong Guo, PhD, professor of pharmaceutics, Shanghai Jiao Tong University, China, and colleagues observe. “Tracheal stents physically open up stenosis, recover airway patency, and promptly relieve symptoms, but [they] cannot treat the tumor,” they explain.

“Thus, tracheal restenosis always occurs soon [after], due to progressive tumor growth after stent placement,” they add. Moreover, implanted stents cover the entire tracheal mucosa, thus preventing mucus and sputum discharge, causing airway blockage, the investigators also note. Compounding these flaws is the unalterable fact that delivery of chemotherapy to a malignant tracheal tumor is inefficient, and systemic chemotherapy is always associated with systemic side effects.

All of these issues make it very challenging to treat these tumors, Dr. Guo noted. On the other hand, if there were a means to deliver a chemotherapeutic agent more directly to the disease site – as is done with drug-eluting beads, for example, in other tumor types – then at least drug delivery would be much more efficient. “In this study, a novel tracheal stent was designed with features of a C-shaped and trilayered wall,” the researchers explain.

The gap angle of the newly developed stent is 72°; the inner diameter is 0.5 cm, and it is 2.0 cm in length. The trilayered wall consists of an inner layer of poly (ε-caprolactone) (PCL), which is a biodegradable and implantable material used alone or compounded with other ingredients to print implants. The middle layer consists of magnetic nanoparticle (MNP)–loaded PCL. The authors explain that MNPs have been approved in the U.S. as contrast agents in MRI.

Combined with temperature-responsive materials, MNPs can serve as a source of magnetic thermotherapy as well, which can be used to control drug release and facilitate drug penetration into deeper tissues. The outer layer of the stent contains a paclitaxel-loaded ethylene-vinyl acetate copolymer layer.

“The C-shaped tracheal stents are easily fabricated on a roller by using a self-made specific three-dimensional printer,” the authors explain. They point out that the C-shaped tracheal stents do not cover the entire tracheal wall, and the uncovered gap in that wall allows for normal mucus and sputum discharge.
 

In vivo evaluation

Once the stents were printed, the researchers evaluated the biosafety and applicability of their C-shaped tracheal stents. Small rabbits weighing 2.5 to 3.0 kg were used as experimental models and were prepared for surgery. The stent was implanted in the rabbits’ tracheas through the use of a simple stent delivery device. During follow-up, the rabbits recovered well without any sign of infection or respiratory complications.

The animals were also eating well within about 5 days of the surgery, and their weight gradually increased, suggesting that the implantation of a stent with intermittent magnetic heating did not lead to any prominent systemic toxicities. “All rabbits were [euthanized] 30 days after the placement of the tracheal stents” and the stent was removed from the rabbits’ trachea, the researchers report.

Close observation of the trachea indicated that the gap left by the C-shaped stent could keep the airway patent without blocking either mucus or sputum discharge. “The stents have good biosafety in rabbits and keep airway patency for 1 month without the occurrence of mucus/sputum blockage after implantation in rabbit trachea,” Dr. Guo and colleagues conclude.

“These results provide a scientific basis for the development of novel self-expandable C-shaped tracheal stents with combinatorial tracheal support and local chemotherapy,” they affirm.
 

Pediatric airway obstruction

Thus far, the role of 3D printing seems to be most prominent in the treatment of pediatric airway obstruction, where it is used in the surgical planning stages and to create the implant itself. In a systematic review of its use for this, Joshua Stramiello, MD, University of California, San Diego, and colleagues identified 37 original articles, 11 of which discussed 3D printing for surgical planning, and 26 of which discussed 3D printing implants for interventions.

“3D printing for surgical planning not only improves preoperative assessment of surgical approach and stent customization but also helps facilitate patient/family education,” the authors observe. Most of the research so far has been focused on bioresorbable external airway splints and biological grafts, they add – “with both animal studies and human case reports showing good results in improving symptoms.” One clinical series focused on the use of a 3D-printed, patient-specific, bioresorbable airway splint in a cohort of critically ill children with severe tracheobronchomalacia. (Tracheobronchomalacia is the abnormal collapse of the windpipe).

When reported, 29 splints had been implanted in 15 children with intrathoracic tracheobronchomalacia. At a median follow-up of 8.5 months, 12 children were long-term survivors, and all but one lived at home. As recently discussed by George Cheng, MD, cofounder of restor3D, a Duke University startup that created the first 3D-printed airway stent using a compressible biocompatible material with properties similar to that of silicone, personalized airway stents have the potential for advance customization, minimize pressure points, and improve airflow dynamics to increase mucus clearance.

In fact, the U.S. Food and Drug Administration has already cleared patient-specific airway stents developed by Thomas Gildea, MD, of the Cleveland Clinic. Both the Duke University and Cleveland Clinic stents have been used in patients, with promising outcomes, Dr. Cheng noted.

The authors and Dr. Stramiello and colleagues have disclosed no relevant financial relationships. Dr. Cheng is the cofounder of restor3D.

A version of this article first appeared on Medscape.com.

Airflow obstruction caused by a malignant tracheal tumor may be managed with a uniquely designed, 3-dimensional (3D) drug-eluting tracheal stent that, at least in animal models so far, works well and may soon be ready for human trials, Chinese investigators are reporting.

The research was published online Jan. 29 in Materials Today Chemistry.

The problems with currently available stents used to treat airflow obstruction are considerable, corresponding author Shengrong Guo, PhD, professor of pharmaceutics, Shanghai Jiao Tong University, China, and colleagues observe. “Tracheal stents physically open up stenosis, recover airway patency, and promptly relieve symptoms, but [they] cannot treat the tumor,” they explain.

“Thus, tracheal restenosis always occurs soon [after], due to progressive tumor growth after stent placement,” they add. Moreover, implanted stents cover the entire tracheal mucosa, thus preventing mucus and sputum discharge, causing airway blockage, the investigators also note. Compounding these flaws is the unalterable fact that delivery of chemotherapy to a malignant tracheal tumor is inefficient, and systemic chemotherapy is always associated with systemic side effects.

All of these issues make it very challenging to treat these tumors, Dr. Guo noted. On the other hand, if there were a means to deliver a chemotherapeutic agent more directly to the disease site – as is done with drug-eluting beads, for example, in other tumor types – then at least drug delivery would be much more efficient. “In this study, a novel tracheal stent was designed with features of a C-shaped and trilayered wall,” the researchers explain.

The gap angle of the newly developed stent is 72°; the inner diameter is 0.5 cm, and it is 2.0 cm in length. The trilayered wall consists of an inner layer of poly (ε-caprolactone) (PCL), which is a biodegradable and implantable material used alone or compounded with other ingredients to print implants. The middle layer consists of magnetic nanoparticle (MNP)–loaded PCL. The authors explain that MNPs have been approved in the U.S. as contrast agents in MRI.

Combined with temperature-responsive materials, MNPs can serve as a source of magnetic thermotherapy as well, which can be used to control drug release and facilitate drug penetration into deeper tissues. The outer layer of the stent contains a paclitaxel-loaded ethylene-vinyl acetate copolymer layer.

“The C-shaped tracheal stents are easily fabricated on a roller by using a self-made specific three-dimensional printer,” the authors explain. They point out that the C-shaped tracheal stents do not cover the entire tracheal wall, and the uncovered gap in that wall allows for normal mucus and sputum discharge.
 

In vivo evaluation

Once the stents were printed, the researchers evaluated the biosafety and applicability of their C-shaped tracheal stents. Small rabbits weighing 2.5 to 3.0 kg were used as experimental models and were prepared for surgery. The stent was implanted in the rabbits’ tracheas through the use of a simple stent delivery device. During follow-up, the rabbits recovered well without any sign of infection or respiratory complications.

The animals were also eating well within about 5 days of the surgery, and their weight gradually increased, suggesting that the implantation of a stent with intermittent magnetic heating did not lead to any prominent systemic toxicities. “All rabbits were [euthanized] 30 days after the placement of the tracheal stents” and the stent was removed from the rabbits’ trachea, the researchers report.

Close observation of the trachea indicated that the gap left by the C-shaped stent could keep the airway patent without blocking either mucus or sputum discharge. “The stents have good biosafety in rabbits and keep airway patency for 1 month without the occurrence of mucus/sputum blockage after implantation in rabbit trachea,” Dr. Guo and colleagues conclude.

“These results provide a scientific basis for the development of novel self-expandable C-shaped tracheal stents with combinatorial tracheal support and local chemotherapy,” they affirm.
 

Pediatric airway obstruction

Thus far, the role of 3D printing seems to be most prominent in the treatment of pediatric airway obstruction, where it is used in the surgical planning stages and to create the implant itself. In a systematic review of its use for this, Joshua Stramiello, MD, University of California, San Diego, and colleagues identified 37 original articles, 11 of which discussed 3D printing for surgical planning, and 26 of which discussed 3D printing implants for interventions.

“3D printing for surgical planning not only improves preoperative assessment of surgical approach and stent customization but also helps facilitate patient/family education,” the authors observe. Most of the research so far has been focused on bioresorbable external airway splints and biological grafts, they add – “with both animal studies and human case reports showing good results in improving symptoms.” One clinical series focused on the use of a 3D-printed, patient-specific, bioresorbable airway splint in a cohort of critically ill children with severe tracheobronchomalacia. (Tracheobronchomalacia is the abnormal collapse of the windpipe).

When reported, 29 splints had been implanted in 15 children with intrathoracic tracheobronchomalacia. At a median follow-up of 8.5 months, 12 children were long-term survivors, and all but one lived at home. As recently discussed by George Cheng, MD, cofounder of restor3D, a Duke University startup that created the first 3D-printed airway stent using a compressible biocompatible material with properties similar to that of silicone, personalized airway stents have the potential for advance customization, minimize pressure points, and improve airflow dynamics to increase mucus clearance.

In fact, the U.S. Food and Drug Administration has already cleared patient-specific airway stents developed by Thomas Gildea, MD, of the Cleveland Clinic. Both the Duke University and Cleveland Clinic stents have been used in patients, with promising outcomes, Dr. Cheng noted.

The authors and Dr. Stramiello and colleagues have disclosed no relevant financial relationships. Dr. Cheng is the cofounder of restor3D.

A version of this article first appeared on Medscape.com.

Airflow obstruction caused by a malignant tracheal tumor may be managed with a uniquely designed, 3-dimensional (3D) drug-eluting tracheal stent that, at least in animal models so far, works well and may soon be ready for human trials, Chinese investigators are reporting.

The research was published online Jan. 29 in Materials Today Chemistry.

The problems with currently available stents used to treat airflow obstruction are considerable, corresponding author Shengrong Guo, PhD, professor of pharmaceutics, Shanghai Jiao Tong University, China, and colleagues observe. “Tracheal stents physically open up stenosis, recover airway patency, and promptly relieve symptoms, but [they] cannot treat the tumor,” they explain.

“Thus, tracheal restenosis always occurs soon [after], due to progressive tumor growth after stent placement,” they add. Moreover, implanted stents cover the entire tracheal mucosa, thus preventing mucus and sputum discharge, causing airway blockage, the investigators also note. Compounding these flaws is the unalterable fact that delivery of chemotherapy to a malignant tracheal tumor is inefficient, and systemic chemotherapy is always associated with systemic side effects.

All of these issues make it very challenging to treat these tumors, Dr. Guo noted. On the other hand, if there were a means to deliver a chemotherapeutic agent more directly to the disease site – as is done with drug-eluting beads, for example, in other tumor types – then at least drug delivery would be much more efficient. “In this study, a novel tracheal stent was designed with features of a C-shaped and trilayered wall,” the researchers explain.

The gap angle of the newly developed stent is 72°; the inner diameter is 0.5 cm, and it is 2.0 cm in length. The trilayered wall consists of an inner layer of poly (ε-caprolactone) (PCL), which is a biodegradable and implantable material used alone or compounded with other ingredients to print implants. The middle layer consists of magnetic nanoparticle (MNP)–loaded PCL. The authors explain that MNPs have been approved in the U.S. as contrast agents in MRI.

Combined with temperature-responsive materials, MNPs can serve as a source of magnetic thermotherapy as well, which can be used to control drug release and facilitate drug penetration into deeper tissues. The outer layer of the stent contains a paclitaxel-loaded ethylene-vinyl acetate copolymer layer.

“The C-shaped tracheal stents are easily fabricated on a roller by using a self-made specific three-dimensional printer,” the authors explain. They point out that the C-shaped tracheal stents do not cover the entire tracheal wall, and the uncovered gap in that wall allows for normal mucus and sputum discharge.
 

In vivo evaluation

Once the stents were printed, the researchers evaluated the biosafety and applicability of their C-shaped tracheal stents. Small rabbits weighing 2.5 to 3.0 kg were used as experimental models and were prepared for surgery. The stent was implanted in the rabbits’ tracheas through the use of a simple stent delivery device. During follow-up, the rabbits recovered well without any sign of infection or respiratory complications.

The animals were also eating well within about 5 days of the surgery, and their weight gradually increased, suggesting that the implantation of a stent with intermittent magnetic heating did not lead to any prominent systemic toxicities. “All rabbits were [euthanized] 30 days after the placement of the tracheal stents” and the stent was removed from the rabbits’ trachea, the researchers report.

Close observation of the trachea indicated that the gap left by the C-shaped stent could keep the airway patent without blocking either mucus or sputum discharge. “The stents have good biosafety in rabbits and keep airway patency for 1 month without the occurrence of mucus/sputum blockage after implantation in rabbit trachea,” Dr. Guo and colleagues conclude.

“These results provide a scientific basis for the development of novel self-expandable C-shaped tracheal stents with combinatorial tracheal support and local chemotherapy,” they affirm.
 

Pediatric airway obstruction

Thus far, the role of 3D printing seems to be most prominent in the treatment of pediatric airway obstruction, where it is used in the surgical planning stages and to create the implant itself. In a systematic review of its use for this, Joshua Stramiello, MD, University of California, San Diego, and colleagues identified 37 original articles, 11 of which discussed 3D printing for surgical planning, and 26 of which discussed 3D printing implants for interventions.

“3D printing for surgical planning not only improves preoperative assessment of surgical approach and stent customization but also helps facilitate patient/family education,” the authors observe. Most of the research so far has been focused on bioresorbable external airway splints and biological grafts, they add – “with both animal studies and human case reports showing good results in improving symptoms.” One clinical series focused on the use of a 3D-printed, patient-specific, bioresorbable airway splint in a cohort of critically ill children with severe tracheobronchomalacia. (Tracheobronchomalacia is the abnormal collapse of the windpipe).

When reported, 29 splints had been implanted in 15 children with intrathoracic tracheobronchomalacia. At a median follow-up of 8.5 months, 12 children were long-term survivors, and all but one lived at home. As recently discussed by George Cheng, MD, cofounder of restor3D, a Duke University startup that created the first 3D-printed airway stent using a compressible biocompatible material with properties similar to that of silicone, personalized airway stents have the potential for advance customization, minimize pressure points, and improve airflow dynamics to increase mucus clearance.

In fact, the U.S. Food and Drug Administration has already cleared patient-specific airway stents developed by Thomas Gildea, MD, of the Cleveland Clinic. Both the Duke University and Cleveland Clinic stents have been used in patients, with promising outcomes, Dr. Cheng noted.

The authors and Dr. Stramiello and colleagues have disclosed no relevant financial relationships. Dr. Cheng is the cofounder of restor3D.

A version of this article first appeared on Medscape.com.