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What causes ‘weight fate,’ and is it really inevitable?
WASHINGTON – Young children who are overweight are four times more likely to become obese as they age. Is this a sign that we are fated from youth to be a burden on the health care system, or are their optimal points for intervention to change that fate?
In this audio interview, Solveig Cunningham, Ph.D., of Emory University, Atlanta, discusses the role of epigenetics, behavioral intervention, and maternal weight during gestation, along with other factors affecting pediatric obesity.
WASHINGTON – Young children who are overweight are four times more likely to become obese as they age. Is this a sign that we are fated from youth to be a burden on the health care system, or are their optimal points for intervention to change that fate?
In this audio interview, Solveig Cunningham, Ph.D., of Emory University, Atlanta, discusses the role of epigenetics, behavioral intervention, and maternal weight during gestation, along with other factors affecting pediatric obesity.
WASHINGTON – Young children who are overweight are four times more likely to become obese as they age. Is this a sign that we are fated from youth to be a burden on the health care system, or are their optimal points for intervention to change that fate?
In this audio interview, Solveig Cunningham, Ph.D., of Emory University, Atlanta, discusses the role of epigenetics, behavioral intervention, and maternal weight during gestation, along with other factors affecting pediatric obesity.
EXPERT ANALYSIS FROM THE AACE/ACE CONSENSUS CONFERENCE ON OBESITY
TNFR1 shown as marker for mortality risk in type 2 diabetes with kidney disease
Tumor necrosis factor receptor 1 is an effective marker for all-cause mortality in type 2 diabetes with kidney disease, according to results of a French study.
Additionally, TNFR1 was found to add clinical utility to the U.K. Prospective Diabetes Study (UKPDS) outcome equation for mortality.
"Our data showed a clear and graded relationship between concentrations of serum TNFR1 and risk of all-cause mortality," Pierre Jean Saulnier, Ph.D., of the University of Poitiers (France) and his colleagues wrote.
In a follow-up analysis of the SURDIAGENE study, designed to identify genetic and environmental causes of micro- and macrovascular complications in type 2 diabetes, investigators followed 522 patients with baseline urinary albumin to creatinine ratios (uACR) greater than 30 mg/mmol, an estimated glomerular filtration rate (eGFR) greater than 60 mL/min per 1.73 m2, or both. Patients with a history of myocardial infarction and/or stroke were considered to have cardiovascular disease at baseline (Diabetes Care 2014 March 12 [doi:10.2337/dc13-2580]).
The primary endpoint was all-cause mortality. The secondary endpoint was the occurrence of a composite renal outcome in patients who did not have end-stage renal disease at baseline. The median duration of the study was 48 months. In that time, 196 deaths occurred.
The increased rate of death correlated with increased levels of TNFR1 across quartiles: 4.7% patient years in the first quartile, 7.7% in the second, 9.3% in the third, and 15.9% in the fourth.
Of note, when the investigators ran a multivariate analysis using age, diabetes duration, hemoglobin A1c, uACR, and eGFR, they found that the risk of death tripled in patients in the fourth quartile (adjusted hazard ratio, 2.98), compared with patients in the first quartile.
When TNFR1 was combined with the UKDPS equation, which uses age, diabetes duration, sex, ethnicity, current smoking status, systolic blood pressure, HbA1c, body mass index, eGFR, heart rate, atrial fibrillation, albuminuria, and peripheral vascular disease, the predictive value for mortality improved significantly (P = .03).
TNFR1 is a proinflammatory marker that a growing body of literature indicates has prognostic value for cardiovascular disease in patients with diabetes. "Our current findings add to this literature," the researchers wrote, adding that while it was not the focus of their study, the data may contribute to understanding the role of TNFR1 in vasculopathy and diabetes-related events such as amputation.
None of the authors of this study reported any relevant disclosures. Funding was provided by the French Ministry of Health, among others.
Tumor necrosis factor receptor 1 is an effective marker for all-cause mortality in type 2 diabetes with kidney disease, according to results of a French study.
Additionally, TNFR1 was found to add clinical utility to the U.K. Prospective Diabetes Study (UKPDS) outcome equation for mortality.
"Our data showed a clear and graded relationship between concentrations of serum TNFR1 and risk of all-cause mortality," Pierre Jean Saulnier, Ph.D., of the University of Poitiers (France) and his colleagues wrote.
In a follow-up analysis of the SURDIAGENE study, designed to identify genetic and environmental causes of micro- and macrovascular complications in type 2 diabetes, investigators followed 522 patients with baseline urinary albumin to creatinine ratios (uACR) greater than 30 mg/mmol, an estimated glomerular filtration rate (eGFR) greater than 60 mL/min per 1.73 m2, or both. Patients with a history of myocardial infarction and/or stroke were considered to have cardiovascular disease at baseline (Diabetes Care 2014 March 12 [doi:10.2337/dc13-2580]).
The primary endpoint was all-cause mortality. The secondary endpoint was the occurrence of a composite renal outcome in patients who did not have end-stage renal disease at baseline. The median duration of the study was 48 months. In that time, 196 deaths occurred.
The increased rate of death correlated with increased levels of TNFR1 across quartiles: 4.7% patient years in the first quartile, 7.7% in the second, 9.3% in the third, and 15.9% in the fourth.
Of note, when the investigators ran a multivariate analysis using age, diabetes duration, hemoglobin A1c, uACR, and eGFR, they found that the risk of death tripled in patients in the fourth quartile (adjusted hazard ratio, 2.98), compared with patients in the first quartile.
When TNFR1 was combined with the UKDPS equation, which uses age, diabetes duration, sex, ethnicity, current smoking status, systolic blood pressure, HbA1c, body mass index, eGFR, heart rate, atrial fibrillation, albuminuria, and peripheral vascular disease, the predictive value for mortality improved significantly (P = .03).
TNFR1 is a proinflammatory marker that a growing body of literature indicates has prognostic value for cardiovascular disease in patients with diabetes. "Our current findings add to this literature," the researchers wrote, adding that while it was not the focus of their study, the data may contribute to understanding the role of TNFR1 in vasculopathy and diabetes-related events such as amputation.
None of the authors of this study reported any relevant disclosures. Funding was provided by the French Ministry of Health, among others.
Tumor necrosis factor receptor 1 is an effective marker for all-cause mortality in type 2 diabetes with kidney disease, according to results of a French study.
Additionally, TNFR1 was found to add clinical utility to the U.K. Prospective Diabetes Study (UKPDS) outcome equation for mortality.
"Our data showed a clear and graded relationship between concentrations of serum TNFR1 and risk of all-cause mortality," Pierre Jean Saulnier, Ph.D., of the University of Poitiers (France) and his colleagues wrote.
In a follow-up analysis of the SURDIAGENE study, designed to identify genetic and environmental causes of micro- and macrovascular complications in type 2 diabetes, investigators followed 522 patients with baseline urinary albumin to creatinine ratios (uACR) greater than 30 mg/mmol, an estimated glomerular filtration rate (eGFR) greater than 60 mL/min per 1.73 m2, or both. Patients with a history of myocardial infarction and/or stroke were considered to have cardiovascular disease at baseline (Diabetes Care 2014 March 12 [doi:10.2337/dc13-2580]).
The primary endpoint was all-cause mortality. The secondary endpoint was the occurrence of a composite renal outcome in patients who did not have end-stage renal disease at baseline. The median duration of the study was 48 months. In that time, 196 deaths occurred.
The increased rate of death correlated with increased levels of TNFR1 across quartiles: 4.7% patient years in the first quartile, 7.7% in the second, 9.3% in the third, and 15.9% in the fourth.
Of note, when the investigators ran a multivariate analysis using age, diabetes duration, hemoglobin A1c, uACR, and eGFR, they found that the risk of death tripled in patients in the fourth quartile (adjusted hazard ratio, 2.98), compared with patients in the first quartile.
When TNFR1 was combined with the UKDPS equation, which uses age, diabetes duration, sex, ethnicity, current smoking status, systolic blood pressure, HbA1c, body mass index, eGFR, heart rate, atrial fibrillation, albuminuria, and peripheral vascular disease, the predictive value for mortality improved significantly (P = .03).
TNFR1 is a proinflammatory marker that a growing body of literature indicates has prognostic value for cardiovascular disease in patients with diabetes. "Our current findings add to this literature," the researchers wrote, adding that while it was not the focus of their study, the data may contribute to understanding the role of TNFR1 in vasculopathy and diabetes-related events such as amputation.
None of the authors of this study reported any relevant disclosures. Funding was provided by the French Ministry of Health, among others.
FROM DIABETES CARE
Major finding: Increased rate of death correlated with increased rates of TNFR1 across quartiles: 4.7% patient years; 7.7%; 9.3%; 15.9%.
Data source: A prospective, single-center study of 522 patients.
Disclosures: None of the authors of this study reported any relevant disclosures. Funding was provided by the French Ministry of Health, among others.
New tanning bed technology no safer than the old
Tanning bed technology circa the year 2000, when the industry began using lamps that emit larger doses of long-wave ultraviolet A (between 335 and 400 nm), is no safer than tanning beds pre-2000, a meta-analysis of the association between melanoma and tanning beds has shown.
Globally, people who had been exposed to tanning beds were 16% more likely to have melanoma; in the United States, where tanning bed intensity is unrestricted, the risk from exposure is 23% higher than in the general population. In Europe and in Australia and New Zealand, where the intensity is limited to an ultraviolet index of 12 and 36 respectively, the increased risk was not significant, reported investigators in the March issue of the Journal of the American Academy of Dermatology (doi:10.1016/j.jaad.2013.11.050).
Further, tanning bed use before the age of 25 years additionally increased a person’s melanoma odds to 35% compared with 11% in those who had indoor tanning exposure after the age of 25 years. Sophia Colantonia of the University of Ottawa and her coauthors also found a threshold effect of 10 or more tanning bed sessions being associated with the highest risk of melanoma.
"Assessing and communicating health risk to patients in an easily understood metric based on number of tanning bed sessions could be helpful to clinical practice," wrote the investigators.
For the meta-analysis, the investigators searched Scopus, MEDLINE, and the Cumulative Index to Nursing and Allied Health Literature for studies published before Aug. 14, 2013. In all, 31 studies that included 14,956 cases of melanoma and 233,106 controls were analyzed. In those who had ever used a tanning bed, the odds ratio (OR) for melanoma was 1.16 (95% CI, 1.05-1.28). Tanning bed use after 2000 had an OR of 1.22 (95% CI, 1.03-1.45). For individuals who had used 10 or more tanning bed sessions, the OR was 1.34 (95% CI, 1.05-1.71). North Americans were found to have higher rates of melanoma (OR, 1.23; 95% CI, 1.03-1.47) vs. Europeans and Oceanianians for whom the OR was not significant. Ten or more tanning sessions in a lifetime was associated with the highest risk of melanoma (OR, 1.34; 95% CI, 1.05-1.71).
Limitations to the meta-analysis included that not all of the studies used the same age range for their study groups, and evidence quality ranged from mediocre to poor, the investigators noted.
The investigators reported that there were no funding sources, and no conflicts of interest were declared.
Tanning bed technology circa the year 2000, when the industry began using lamps that emit larger doses of long-wave ultraviolet A (between 335 and 400 nm), is no safer than tanning beds pre-2000, a meta-analysis of the association between melanoma and tanning beds has shown.
Globally, people who had been exposed to tanning beds were 16% more likely to have melanoma; in the United States, where tanning bed intensity is unrestricted, the risk from exposure is 23% higher than in the general population. In Europe and in Australia and New Zealand, where the intensity is limited to an ultraviolet index of 12 and 36 respectively, the increased risk was not significant, reported investigators in the March issue of the Journal of the American Academy of Dermatology (doi:10.1016/j.jaad.2013.11.050).
Further, tanning bed use before the age of 25 years additionally increased a person’s melanoma odds to 35% compared with 11% in those who had indoor tanning exposure after the age of 25 years. Sophia Colantonia of the University of Ottawa and her coauthors also found a threshold effect of 10 or more tanning bed sessions being associated with the highest risk of melanoma.
"Assessing and communicating health risk to patients in an easily understood metric based on number of tanning bed sessions could be helpful to clinical practice," wrote the investigators.
For the meta-analysis, the investigators searched Scopus, MEDLINE, and the Cumulative Index to Nursing and Allied Health Literature for studies published before Aug. 14, 2013. In all, 31 studies that included 14,956 cases of melanoma and 233,106 controls were analyzed. In those who had ever used a tanning bed, the odds ratio (OR) for melanoma was 1.16 (95% CI, 1.05-1.28). Tanning bed use after 2000 had an OR of 1.22 (95% CI, 1.03-1.45). For individuals who had used 10 or more tanning bed sessions, the OR was 1.34 (95% CI, 1.05-1.71). North Americans were found to have higher rates of melanoma (OR, 1.23; 95% CI, 1.03-1.47) vs. Europeans and Oceanianians for whom the OR was not significant. Ten or more tanning sessions in a lifetime was associated with the highest risk of melanoma (OR, 1.34; 95% CI, 1.05-1.71).
Limitations to the meta-analysis included that not all of the studies used the same age range for their study groups, and evidence quality ranged from mediocre to poor, the investigators noted.
The investigators reported that there were no funding sources, and no conflicts of interest were declared.
Tanning bed technology circa the year 2000, when the industry began using lamps that emit larger doses of long-wave ultraviolet A (between 335 and 400 nm), is no safer than tanning beds pre-2000, a meta-analysis of the association between melanoma and tanning beds has shown.
Globally, people who had been exposed to tanning beds were 16% more likely to have melanoma; in the United States, where tanning bed intensity is unrestricted, the risk from exposure is 23% higher than in the general population. In Europe and in Australia and New Zealand, where the intensity is limited to an ultraviolet index of 12 and 36 respectively, the increased risk was not significant, reported investigators in the March issue of the Journal of the American Academy of Dermatology (doi:10.1016/j.jaad.2013.11.050).
Further, tanning bed use before the age of 25 years additionally increased a person’s melanoma odds to 35% compared with 11% in those who had indoor tanning exposure after the age of 25 years. Sophia Colantonia of the University of Ottawa and her coauthors also found a threshold effect of 10 or more tanning bed sessions being associated with the highest risk of melanoma.
"Assessing and communicating health risk to patients in an easily understood metric based on number of tanning bed sessions could be helpful to clinical practice," wrote the investigators.
For the meta-analysis, the investigators searched Scopus, MEDLINE, and the Cumulative Index to Nursing and Allied Health Literature for studies published before Aug. 14, 2013. In all, 31 studies that included 14,956 cases of melanoma and 233,106 controls were analyzed. In those who had ever used a tanning bed, the odds ratio (OR) for melanoma was 1.16 (95% CI, 1.05-1.28). Tanning bed use after 2000 had an OR of 1.22 (95% CI, 1.03-1.45). For individuals who had used 10 or more tanning bed sessions, the OR was 1.34 (95% CI, 1.05-1.71). North Americans were found to have higher rates of melanoma (OR, 1.23; 95% CI, 1.03-1.47) vs. Europeans and Oceanianians for whom the OR was not significant. Ten or more tanning sessions in a lifetime was associated with the highest risk of melanoma (OR, 1.34; 95% CI, 1.05-1.71).
Limitations to the meta-analysis included that not all of the studies used the same age range for their study groups, and evidence quality ranged from mediocre to poor, the investigators noted.
The investigators reported that there were no funding sources, and no conflicts of interest were declared.
FROM JOURNAL OF THE AMERICAN ACADEMY OF DERMATOLOGY
Major finding: Exposure to tanning bed technology, new or old, led to a 16% increased risk of melanoma worldwide.
Data source: A meta-analysis of 31 studies with 14,956 melanoma cases and 233,106 controls.
Disclosures: The investigators reported that there were no funding sources, and no conflicts of interest were declared.
Genomic testing refined accuracy of melanoma risk prediction
ARLINGTON, VA. – Combining test data for melanocortin-1 receptor gene variants and common genomic variants with nongenetic screening resulted in better melanoma risk prediction, Ann Cust, Ph.D., reported at the annual meeting of the American Society of Preventive Oncology.
"We’ve shown in this study that measuring genetic factors to determine who’s at high risk for melanoma can play an important role in prediction," said Dr. Cust of the University of Sydney, Australia, in an interview. "This gives us a good model for looking at whether genetic factors can improve the way we target preventive behaviors."
In the United States, melanoma accounts for only about 2% of all skin cancers, but the most skin cancer–related deaths. Fair skin, light hair, freckling, and a family history of melanoma are known risk factors for the disease. Australia, where the study was conducted, has the highest incidence of melanoma in the world.
To date, skin cancer prevention efforts in both countries have largely relied upon mass media sun protection campaigns and identifying people at high risk based on their skin and hair pigmentation, Dr. Cust said. "But some people don’t know they are at high risk, and so they aren’t taking precautions," she said.
"Some of the genetic factors for melanoma are linked to pigmentation, but there are variations in genes involved in DNA repair and other biological pathways that occur in people whose pigmentation wouldn’t suggest they are at high risk, but they are."
For the study, Dr. Cust and her colleagues genotyped common variants in 18 different genes in a study group of 552 Australians, aged 18-39 years, all of whom had confirmed cases of invasive cutaneous melanoma, and also in a control group of 405 Australians of European ancestry without melanoma. The study was a population-based, case-control family study that assessed traditional melanoma risk factors such as hair color, moles, family history of melanoma, use of indoor tanning, and tendency to sunburn. They then performed genomewide association studies to identify the 18 specific gene regions that have common genomic variants that influence melanoma risk.
The investigators found that the area under the curve (AUC) of the predicted risk in the controls went from 0.76 (95% confidence interval, 0.73-0.79) using demographic and nongenetic factors, to 0.81 (95% CI, 0.78 -0.84) when MC1R genotype and novel common genomic variant data were added. They also found that the combined contribution to the AUC of the novel common variants was similar to that of the established common variants of MC1R and CDKN2A.
By combining the genetic and nongenetic data, the quartile classification of predicted risk improved a net 17% (95% CI, 9-242), compared with the nongenetic predictive model alone.
"This is just the first step," said Dr. Cust. "The next thing we have to work out is how this knowledge of melanoma risk translates into behavior change." To that end, Dr. Cust is currently seeking a grant to study a range of implications inherent in this study.
"We need to address the ethical implications such as to do with informed consent, and the psychosocial implications, as well as the economic ones," she said. Other concerns she noted include whether it will interfere with one’s life insurance coverage.
As for the findings’ effect on practice, Dr. Cust believes that general practitioners are already caught up in the tide of genomic testing that has become part of a consumer-driven market in the last decade. "Some patients already obtain direct-to-consumer genetic tests and bring their results in to their doctors," said Dr. Cust.
Whether primary care physicians will need to learn how to administer the test and at what cost also remains to be settled.
Although she said her next study will evaluate the cost of genomics for prevention compared with the cost of intervention, there is no turning back, according to Dr. Cust. "We are part of a genomic revolution. We already use genomics for individualized treatment of cancer, so I think it’s inevitable that one day it will become part of preventive care. It’s just been slower to get into that realm."
Dr. Cust is funded by fellowships from the Australian National Health and Medical Research Council and the Cancer Institute New South Wales, Australia.
ARLINGTON, VA. – Combining test data for melanocortin-1 receptor gene variants and common genomic variants with nongenetic screening resulted in better melanoma risk prediction, Ann Cust, Ph.D., reported at the annual meeting of the American Society of Preventive Oncology.
"We’ve shown in this study that measuring genetic factors to determine who’s at high risk for melanoma can play an important role in prediction," said Dr. Cust of the University of Sydney, Australia, in an interview. "This gives us a good model for looking at whether genetic factors can improve the way we target preventive behaviors."
In the United States, melanoma accounts for only about 2% of all skin cancers, but the most skin cancer–related deaths. Fair skin, light hair, freckling, and a family history of melanoma are known risk factors for the disease. Australia, where the study was conducted, has the highest incidence of melanoma in the world.
To date, skin cancer prevention efforts in both countries have largely relied upon mass media sun protection campaigns and identifying people at high risk based on their skin and hair pigmentation, Dr. Cust said. "But some people don’t know they are at high risk, and so they aren’t taking precautions," she said.
"Some of the genetic factors for melanoma are linked to pigmentation, but there are variations in genes involved in DNA repair and other biological pathways that occur in people whose pigmentation wouldn’t suggest they are at high risk, but they are."
For the study, Dr. Cust and her colleagues genotyped common variants in 18 different genes in a study group of 552 Australians, aged 18-39 years, all of whom had confirmed cases of invasive cutaneous melanoma, and also in a control group of 405 Australians of European ancestry without melanoma. The study was a population-based, case-control family study that assessed traditional melanoma risk factors such as hair color, moles, family history of melanoma, use of indoor tanning, and tendency to sunburn. They then performed genomewide association studies to identify the 18 specific gene regions that have common genomic variants that influence melanoma risk.
The investigators found that the area under the curve (AUC) of the predicted risk in the controls went from 0.76 (95% confidence interval, 0.73-0.79) using demographic and nongenetic factors, to 0.81 (95% CI, 0.78 -0.84) when MC1R genotype and novel common genomic variant data were added. They also found that the combined contribution to the AUC of the novel common variants was similar to that of the established common variants of MC1R and CDKN2A.
By combining the genetic and nongenetic data, the quartile classification of predicted risk improved a net 17% (95% CI, 9-242), compared with the nongenetic predictive model alone.
"This is just the first step," said Dr. Cust. "The next thing we have to work out is how this knowledge of melanoma risk translates into behavior change." To that end, Dr. Cust is currently seeking a grant to study a range of implications inherent in this study.
"We need to address the ethical implications such as to do with informed consent, and the psychosocial implications, as well as the economic ones," she said. Other concerns she noted include whether it will interfere with one’s life insurance coverage.
As for the findings’ effect on practice, Dr. Cust believes that general practitioners are already caught up in the tide of genomic testing that has become part of a consumer-driven market in the last decade. "Some patients already obtain direct-to-consumer genetic tests and bring their results in to their doctors," said Dr. Cust.
Whether primary care physicians will need to learn how to administer the test and at what cost also remains to be settled.
Although she said her next study will evaluate the cost of genomics for prevention compared with the cost of intervention, there is no turning back, according to Dr. Cust. "We are part of a genomic revolution. We already use genomics for individualized treatment of cancer, so I think it’s inevitable that one day it will become part of preventive care. It’s just been slower to get into that realm."
Dr. Cust is funded by fellowships from the Australian National Health and Medical Research Council and the Cancer Institute New South Wales, Australia.
ARLINGTON, VA. – Combining test data for melanocortin-1 receptor gene variants and common genomic variants with nongenetic screening resulted in better melanoma risk prediction, Ann Cust, Ph.D., reported at the annual meeting of the American Society of Preventive Oncology.
"We’ve shown in this study that measuring genetic factors to determine who’s at high risk for melanoma can play an important role in prediction," said Dr. Cust of the University of Sydney, Australia, in an interview. "This gives us a good model for looking at whether genetic factors can improve the way we target preventive behaviors."
In the United States, melanoma accounts for only about 2% of all skin cancers, but the most skin cancer–related deaths. Fair skin, light hair, freckling, and a family history of melanoma are known risk factors for the disease. Australia, where the study was conducted, has the highest incidence of melanoma in the world.
To date, skin cancer prevention efforts in both countries have largely relied upon mass media sun protection campaigns and identifying people at high risk based on their skin and hair pigmentation, Dr. Cust said. "But some people don’t know they are at high risk, and so they aren’t taking precautions," she said.
"Some of the genetic factors for melanoma are linked to pigmentation, but there are variations in genes involved in DNA repair and other biological pathways that occur in people whose pigmentation wouldn’t suggest they are at high risk, but they are."
For the study, Dr. Cust and her colleagues genotyped common variants in 18 different genes in a study group of 552 Australians, aged 18-39 years, all of whom had confirmed cases of invasive cutaneous melanoma, and also in a control group of 405 Australians of European ancestry without melanoma. The study was a population-based, case-control family study that assessed traditional melanoma risk factors such as hair color, moles, family history of melanoma, use of indoor tanning, and tendency to sunburn. They then performed genomewide association studies to identify the 18 specific gene regions that have common genomic variants that influence melanoma risk.
The investigators found that the area under the curve (AUC) of the predicted risk in the controls went from 0.76 (95% confidence interval, 0.73-0.79) using demographic and nongenetic factors, to 0.81 (95% CI, 0.78 -0.84) when MC1R genotype and novel common genomic variant data were added. They also found that the combined contribution to the AUC of the novel common variants was similar to that of the established common variants of MC1R and CDKN2A.
By combining the genetic and nongenetic data, the quartile classification of predicted risk improved a net 17% (95% CI, 9-242), compared with the nongenetic predictive model alone.
"This is just the first step," said Dr. Cust. "The next thing we have to work out is how this knowledge of melanoma risk translates into behavior change." To that end, Dr. Cust is currently seeking a grant to study a range of implications inherent in this study.
"We need to address the ethical implications such as to do with informed consent, and the psychosocial implications, as well as the economic ones," she said. Other concerns she noted include whether it will interfere with one’s life insurance coverage.
As for the findings’ effect on practice, Dr. Cust believes that general practitioners are already caught up in the tide of genomic testing that has become part of a consumer-driven market in the last decade. "Some patients already obtain direct-to-consumer genetic tests and bring their results in to their doctors," said Dr. Cust.
Whether primary care physicians will need to learn how to administer the test and at what cost also remains to be settled.
Although she said her next study will evaluate the cost of genomics for prevention compared with the cost of intervention, there is no turning back, according to Dr. Cust. "We are part of a genomic revolution. We already use genomics for individualized treatment of cancer, so I think it’s inevitable that one day it will become part of preventive care. It’s just been slower to get into that realm."
Dr. Cust is funded by fellowships from the Australian National Health and Medical Research Council and the Cancer Institute New South Wales, Australia.
AT THE ASPO ANNUAL MEETING
Major finding: Adding genetic testing for MC1R and other novel, common genomic variants, to nongenetic screening methods improved melanoma risk prediction by 17% (95% CI, 9-24).
Data source: Combined genetic and nongenetic melanoma risk analysis of 552 Australians aged 18-39 years with confirmed invasive cutaneous melanoma, compared with that in 405 controls from an Australian, population-based, case-control family study.
Disclosures: Dr. Cust is funded by fellowships from the Australian National Health and Medical Research Council and the Cancer Institute New South Wales, Australia.
Obesity-hunger paradox prevalent in low-income cancer survivors
ARLINGTON, VA. – Low-income minority women recovering from cancer are also likely to face the paradoxical burden of obesity and hunger, a study has shown.
"It’s counterintuitive, this relationship that exists in this country where you can report having issues around hunger, food insecurity – where you don’t know where your next meal is going to come from, and whether it will be nutritious – and at the same time be obese or overweight," the poster’s presenter, Errol Philip, Ph.D., said in an interview at the annual meeting of the American Society of Preventive Oncology, where he presented the findings.
Add to that the strain of undergoing chemotherapy or other cancer interventions, and one’s quality of life is dramatically affected. Study participants whose body mass index (BMI) was near 30 kg/m2, and who self-reported skipping meals or going an entire day without food because it was not available, also tended to have the lowest scores on the Functional Assessment of Cancer Therapy scale, which measures quality of life in cancer patients, reported Dr. Philip of Memorial Sloan Kettering Cancer Center, New York.
"This obesity-hunger paradox is thought to exist because of the change in our food environment over the past 50 years," he said, noting that images of hunger in days past were of underweight individuals. "Now, those who exist on aid, who have very little access to money, are purchasing cheap calories that are highly processed, malnutritious."
For this prospective, longitudinal assessment, Dr. Philip and his colleagues, including Dr. Francesca Gany, director of the Immigrant Health and Cancer Disparities Service at Memorial Sloan Kettering Cancer Center, analyzed the self-reported food insecurity and quality-of-life scores of 426 minority cancer patients (median age, 56 years), who had either been treated for cancer of any type or were at that time undergoing cancer treatment at one of 5 urban cancer centers. Food insecurity was measured according to the U.S. Department of Agriculture’s Core Food Security Module.
The majority of participants were women (70%), half of all participants were black, and just over a third were Hispanic. The most common diagnoses were breast cancer (44%) and gastrointestinal cancer (16%). More than three-quarters of the respondents reported income below the national poverty level.
The investigators found that two-thirds of all respondents were either overweight or obese (34% and 29% respectively), with nearly three-quarters (71%) reporting food insecurity, ranging from not knowing where the next nutritious meal would be found to not eating for an entire day.
Although the BMI of men in the study did not vary significantly according to whether they experienced food insecurity, the BMI of the women in the group did. Women who reported food insecurity along with moderate hunger had the highest BMI, while those who reported food insecurity and severe hunger had the lowest (27 vs. 26.6). Women who reported their food supply was secure had, on average, a BMI of 27.2.
The women with both food insecurity and obesity had the greatest measure of impaired quality of life. As for why women should be more affected than men, Dr. Philip said several hypotheses exist, including biomechanical ones such as women’s natural propensity to gain more weight than men, and women as caretakers forsaking their own meals in order to nourish others, but that no one knows for certain.
Overall, the implications are "troubling," said Dr. Philip. "In the general population, about 15% will endorse some kind of food insecurity. For individuals living below the poverty line, that number rises to about 40%. Among those individuals who also have cancer, the number rises to 70%."
Because many cancers have been associated with excess weight and low-quality nutrition, Dr. Philip said it was important for primary care providers to be aware that while these patients are vulnerable to begin with, dealing with cancer while also juggling the effects of both obesity and a lack of nutritious food means they are even more strained.
"Primary care providers can’t make the assumption that a patient who is overweight or obese is representative of that person having sufficient food," Dr. Philip said.
Dr. Philip did not report any relevant disclosures. Support for this research was provided by grants from the National Cancer Institute, the New York Community Trust, Susan G. Komen for the Cure (Greater New York City affiliate), and the Laurie M. Tisch Illumination Fund.
This article was updated March 19, 2014.
ARLINGTON, VA. – Low-income minority women recovering from cancer are also likely to face the paradoxical burden of obesity and hunger, a study has shown.
"It’s counterintuitive, this relationship that exists in this country where you can report having issues around hunger, food insecurity – where you don’t know where your next meal is going to come from, and whether it will be nutritious – and at the same time be obese or overweight," the poster’s presenter, Errol Philip, Ph.D., said in an interview at the annual meeting of the American Society of Preventive Oncology, where he presented the findings.
Add to that the strain of undergoing chemotherapy or other cancer interventions, and one’s quality of life is dramatically affected. Study participants whose body mass index (BMI) was near 30 kg/m2, and who self-reported skipping meals or going an entire day without food because it was not available, also tended to have the lowest scores on the Functional Assessment of Cancer Therapy scale, which measures quality of life in cancer patients, reported Dr. Philip of Memorial Sloan Kettering Cancer Center, New York.
"This obesity-hunger paradox is thought to exist because of the change in our food environment over the past 50 years," he said, noting that images of hunger in days past were of underweight individuals. "Now, those who exist on aid, who have very little access to money, are purchasing cheap calories that are highly processed, malnutritious."
For this prospective, longitudinal assessment, Dr. Philip and his colleagues, including Dr. Francesca Gany, director of the Immigrant Health and Cancer Disparities Service at Memorial Sloan Kettering Cancer Center, analyzed the self-reported food insecurity and quality-of-life scores of 426 minority cancer patients (median age, 56 years), who had either been treated for cancer of any type or were at that time undergoing cancer treatment at one of 5 urban cancer centers. Food insecurity was measured according to the U.S. Department of Agriculture’s Core Food Security Module.
The majority of participants were women (70%), half of all participants were black, and just over a third were Hispanic. The most common diagnoses were breast cancer (44%) and gastrointestinal cancer (16%). More than three-quarters of the respondents reported income below the national poverty level.
The investigators found that two-thirds of all respondents were either overweight or obese (34% and 29% respectively), with nearly three-quarters (71%) reporting food insecurity, ranging from not knowing where the next nutritious meal would be found to not eating for an entire day.
Although the BMI of men in the study did not vary significantly according to whether they experienced food insecurity, the BMI of the women in the group did. Women who reported food insecurity along with moderate hunger had the highest BMI, while those who reported food insecurity and severe hunger had the lowest (27 vs. 26.6). Women who reported their food supply was secure had, on average, a BMI of 27.2.
The women with both food insecurity and obesity had the greatest measure of impaired quality of life. As for why women should be more affected than men, Dr. Philip said several hypotheses exist, including biomechanical ones such as women’s natural propensity to gain more weight than men, and women as caretakers forsaking their own meals in order to nourish others, but that no one knows for certain.
Overall, the implications are "troubling," said Dr. Philip. "In the general population, about 15% will endorse some kind of food insecurity. For individuals living below the poverty line, that number rises to about 40%. Among those individuals who also have cancer, the number rises to 70%."
Because many cancers have been associated with excess weight and low-quality nutrition, Dr. Philip said it was important for primary care providers to be aware that while these patients are vulnerable to begin with, dealing with cancer while also juggling the effects of both obesity and a lack of nutritious food means they are even more strained.
"Primary care providers can’t make the assumption that a patient who is overweight or obese is representative of that person having sufficient food," Dr. Philip said.
Dr. Philip did not report any relevant disclosures. Support for this research was provided by grants from the National Cancer Institute, the New York Community Trust, Susan G. Komen for the Cure (Greater New York City affiliate), and the Laurie M. Tisch Illumination Fund.
This article was updated March 19, 2014.
ARLINGTON, VA. – Low-income minority women recovering from cancer are also likely to face the paradoxical burden of obesity and hunger, a study has shown.
"It’s counterintuitive, this relationship that exists in this country where you can report having issues around hunger, food insecurity – where you don’t know where your next meal is going to come from, and whether it will be nutritious – and at the same time be obese or overweight," the poster’s presenter, Errol Philip, Ph.D., said in an interview at the annual meeting of the American Society of Preventive Oncology, where he presented the findings.
Add to that the strain of undergoing chemotherapy or other cancer interventions, and one’s quality of life is dramatically affected. Study participants whose body mass index (BMI) was near 30 kg/m2, and who self-reported skipping meals or going an entire day without food because it was not available, also tended to have the lowest scores on the Functional Assessment of Cancer Therapy scale, which measures quality of life in cancer patients, reported Dr. Philip of Memorial Sloan Kettering Cancer Center, New York.
"This obesity-hunger paradox is thought to exist because of the change in our food environment over the past 50 years," he said, noting that images of hunger in days past were of underweight individuals. "Now, those who exist on aid, who have very little access to money, are purchasing cheap calories that are highly processed, malnutritious."
For this prospective, longitudinal assessment, Dr. Philip and his colleagues, including Dr. Francesca Gany, director of the Immigrant Health and Cancer Disparities Service at Memorial Sloan Kettering Cancer Center, analyzed the self-reported food insecurity and quality-of-life scores of 426 minority cancer patients (median age, 56 years), who had either been treated for cancer of any type or were at that time undergoing cancer treatment at one of 5 urban cancer centers. Food insecurity was measured according to the U.S. Department of Agriculture’s Core Food Security Module.
The majority of participants were women (70%), half of all participants were black, and just over a third were Hispanic. The most common diagnoses were breast cancer (44%) and gastrointestinal cancer (16%). More than three-quarters of the respondents reported income below the national poverty level.
The investigators found that two-thirds of all respondents were either overweight or obese (34% and 29% respectively), with nearly three-quarters (71%) reporting food insecurity, ranging from not knowing where the next nutritious meal would be found to not eating for an entire day.
Although the BMI of men in the study did not vary significantly according to whether they experienced food insecurity, the BMI of the women in the group did. Women who reported food insecurity along with moderate hunger had the highest BMI, while those who reported food insecurity and severe hunger had the lowest (27 vs. 26.6). Women who reported their food supply was secure had, on average, a BMI of 27.2.
The women with both food insecurity and obesity had the greatest measure of impaired quality of life. As for why women should be more affected than men, Dr. Philip said several hypotheses exist, including biomechanical ones such as women’s natural propensity to gain more weight than men, and women as caretakers forsaking their own meals in order to nourish others, but that no one knows for certain.
Overall, the implications are "troubling," said Dr. Philip. "In the general population, about 15% will endorse some kind of food insecurity. For individuals living below the poverty line, that number rises to about 40%. Among those individuals who also have cancer, the number rises to 70%."
Because many cancers have been associated with excess weight and low-quality nutrition, Dr. Philip said it was important for primary care providers to be aware that while these patients are vulnerable to begin with, dealing with cancer while also juggling the effects of both obesity and a lack of nutritious food means they are even more strained.
"Primary care providers can’t make the assumption that a patient who is overweight or obese is representative of that person having sufficient food," Dr. Philip said.
Dr. Philip did not report any relevant disclosures. Support for this research was provided by grants from the National Cancer Institute, the New York Community Trust, Susan G. Komen for the Cure (Greater New York City affiliate), and the Laurie M. Tisch Illumination Fund.
This article was updated March 19, 2014.
AT THE ASPO ANNUAL MEETING
Major finding: Three-quarters of low-income, minority women cancer survivors who were either overweight or obese reported food insecurity.
Data source: Prospective, longitudinal study of 426 cancer patients (median age, 56 years) treated for any type of cancer in 1 of 12 urban cancer centers.
Disclosures: Dr. Philip did not report any relevant disclosures. Support for this research was provided by grants from the National Cancer Institute, the New York Community Trust, Susan G. Komen for the Cure (Greater New York City affiliate), and the Laurie M. Tisch Illumination Fund.
First guidelines on pulmonary hypertension in sickle cell disease released
The first treatment guidelines for pulmonary hypertension in sickle cell disease are now available from the American Thoracic Society.
Because more effective treatments has extended the lives of patients with the disease, their risk of mortality from pulmonary hypertension and elevated tricuspid regurgitant jet velocity has increased. Until now, however, there has been no standardized approach for identifying and managing these conditions.
The guidelines are published in the March 15 issue of the American Journal of Respiratory Critical Care Medicine.
The multidisciplinary committee that wrote the guidelines defined mortality risk as a tricuspid regurgitant velocity (TRV) of at least 2.5 m/second; an N-terminal pro-brain natriuretic peptide (NT-pro-BNP) level of at least 160 pg/mL; or pulmonary hypertension (PH) confirmed by a right heart catheterization (RHC).
Patients with elevated mortality risk should be treated with hydroxyurea as first-line therapy. Chronic transfusion therapy for patients who are not candidates for or responsive to hydroxyurea is noted as a "weak recommendation."
For those with RHC-confirmed pulmonary hypertension, venous thromboembolism, and no additional risk factors for hemorrhage, indefinite – not limited – anticoagulant therapy is recommended.
For patients with either an elevated TRV or an elevated NT-pro-BNP level, the guidelines strongly recommend against pulmonary hypertensive–specific therapies such as prostanoid, endothelin-receptor antagonist, and phosphodiesterase-5 inhibitor therapy. The same guidance was given for patients who have RHC-confirmed PH.
While the guidelines recommend against targeted therapies for RHC-confirmed PH, a trial of either a prostanoid or an endothelin-receptor antagonist is recommended for patients with confirmed PH and elevated pulmonary vascular resistance, normal pulmonary capillary wedge pressure, and related symptoms. These patients should not be given phosphodiesterase-5 inhibitor therapy as first-line treatment.
The lack of both large-scale clinical trials in this population and integrated standards of care limit the guidelines’ effect, Dr. Elizabeth S. Klings, who chaired the guidelines committee, noted in a written statement. "Management of [these patients] will ultimately be a collaborative effort including adult and pediatric pulmonologists, cardiologists, and hematologists," added Dr. Klings of the department of medicine at Boston University.
Dr. Klings receives support from NIH grant R21HL107993.
"I think the guidelines are a breath of fresh air. I feel they are very well thought out. More research needs to be done on the therapies for pulmonary hypertension, but the authors of these guidelines admit that there is a paucity of data in this area.
|
|
In addition, more collaboration is needed between our pulmonary, hematology, oncology, and cardiology specialties. Pulmonologists do not perform right heart catheterizations, but when we ask cardiologists about pulmonary hypertension concerns, we regularly get shot down by the ones who feel that echocardiograms are sufficient to look for this problem. Yet when we want help managing these patients, they don’t want to do that either because it is pulmonary hypertension. You need a dedicated group of people locally to work-up these patients.
There are not many experienced pulmonary hypertension centers easily accessible for both adult and pediatric patient referrals. It is difficult, for example, to refer patients out of state and get it approved by insurance companies.
Dr. Susan Millard, pediatric pulmonologist, Helen DeVos Children’s Hospital, Grand Rapids, Mich.; and CHEST board member.
"I think the guidelines are a breath of fresh air. I feel they are very well thought out. More research needs to be done on the therapies for pulmonary hypertension, but the authors of these guidelines admit that there is a paucity of data in this area.
|
|
|
In addition, more collaboration is needed between our pulmonary, hematology, oncology, and cardiology specialties. Pulmonologists do not perform right heart catheterizations, but when we ask cardiologists about pulmonary hypertension concerns, we regularly get shot down by the ones who feel that echocardiograms are sufficient to look for this problem. Yet when we want help managing these patients, they don’t want to do that either because it is pulmonary hypertension. You need a dedicated group of people locally to work-up these patients.
There are not many experienced pulmonary hypertension centers easily accessible for both adult and pediatric patient referrals. It is difficult, for example, to refer patients out of state and get it approved by insurance companies.
Dr. Susan Millard, pediatric pulmonologist, Helen DeVos Children’s Hospital, Grand Rapids, Mich.; and CHEST board member.
"I think the guidelines are a breath of fresh air. I feel they are very well thought out. More research needs to be done on the therapies for pulmonary hypertension, but the authors of these guidelines admit that there is a paucity of data in this area.
|
|
|
In addition, more collaboration is needed between our pulmonary, hematology, oncology, and cardiology specialties. Pulmonologists do not perform right heart catheterizations, but when we ask cardiologists about pulmonary hypertension concerns, we regularly get shot down by the ones who feel that echocardiograms are sufficient to look for this problem. Yet when we want help managing these patients, they don’t want to do that either because it is pulmonary hypertension. You need a dedicated group of people locally to work-up these patients.
There are not many experienced pulmonary hypertension centers easily accessible for both adult and pediatric patient referrals. It is difficult, for example, to refer patients out of state and get it approved by insurance companies.
Dr. Susan Millard, pediatric pulmonologist, Helen DeVos Children’s Hospital, Grand Rapids, Mich.; and CHEST board member.
The first treatment guidelines for pulmonary hypertension in sickle cell disease are now available from the American Thoracic Society.
Because more effective treatments has extended the lives of patients with the disease, their risk of mortality from pulmonary hypertension and elevated tricuspid regurgitant jet velocity has increased. Until now, however, there has been no standardized approach for identifying and managing these conditions.
The guidelines are published in the March 15 issue of the American Journal of Respiratory Critical Care Medicine.
The multidisciplinary committee that wrote the guidelines defined mortality risk as a tricuspid regurgitant velocity (TRV) of at least 2.5 m/second; an N-terminal pro-brain natriuretic peptide (NT-pro-BNP) level of at least 160 pg/mL; or pulmonary hypertension (PH) confirmed by a right heart catheterization (RHC).
Patients with elevated mortality risk should be treated with hydroxyurea as first-line therapy. Chronic transfusion therapy for patients who are not candidates for or responsive to hydroxyurea is noted as a "weak recommendation."
For those with RHC-confirmed pulmonary hypertension, venous thromboembolism, and no additional risk factors for hemorrhage, indefinite – not limited – anticoagulant therapy is recommended.
For patients with either an elevated TRV or an elevated NT-pro-BNP level, the guidelines strongly recommend against pulmonary hypertensive–specific therapies such as prostanoid, endothelin-receptor antagonist, and phosphodiesterase-5 inhibitor therapy. The same guidance was given for patients who have RHC-confirmed PH.
While the guidelines recommend against targeted therapies for RHC-confirmed PH, a trial of either a prostanoid or an endothelin-receptor antagonist is recommended for patients with confirmed PH and elevated pulmonary vascular resistance, normal pulmonary capillary wedge pressure, and related symptoms. These patients should not be given phosphodiesterase-5 inhibitor therapy as first-line treatment.
The lack of both large-scale clinical trials in this population and integrated standards of care limit the guidelines’ effect, Dr. Elizabeth S. Klings, who chaired the guidelines committee, noted in a written statement. "Management of [these patients] will ultimately be a collaborative effort including adult and pediatric pulmonologists, cardiologists, and hematologists," added Dr. Klings of the department of medicine at Boston University.
Dr. Klings receives support from NIH grant R21HL107993.
The first treatment guidelines for pulmonary hypertension in sickle cell disease are now available from the American Thoracic Society.
Because more effective treatments has extended the lives of patients with the disease, their risk of mortality from pulmonary hypertension and elevated tricuspid regurgitant jet velocity has increased. Until now, however, there has been no standardized approach for identifying and managing these conditions.
The guidelines are published in the March 15 issue of the American Journal of Respiratory Critical Care Medicine.
The multidisciplinary committee that wrote the guidelines defined mortality risk as a tricuspid regurgitant velocity (TRV) of at least 2.5 m/second; an N-terminal pro-brain natriuretic peptide (NT-pro-BNP) level of at least 160 pg/mL; or pulmonary hypertension (PH) confirmed by a right heart catheterization (RHC).
Patients with elevated mortality risk should be treated with hydroxyurea as first-line therapy. Chronic transfusion therapy for patients who are not candidates for or responsive to hydroxyurea is noted as a "weak recommendation."
For those with RHC-confirmed pulmonary hypertension, venous thromboembolism, and no additional risk factors for hemorrhage, indefinite – not limited – anticoagulant therapy is recommended.
For patients with either an elevated TRV or an elevated NT-pro-BNP level, the guidelines strongly recommend against pulmonary hypertensive–specific therapies such as prostanoid, endothelin-receptor antagonist, and phosphodiesterase-5 inhibitor therapy. The same guidance was given for patients who have RHC-confirmed PH.
While the guidelines recommend against targeted therapies for RHC-confirmed PH, a trial of either a prostanoid or an endothelin-receptor antagonist is recommended for patients with confirmed PH and elevated pulmonary vascular resistance, normal pulmonary capillary wedge pressure, and related symptoms. These patients should not be given phosphodiesterase-5 inhibitor therapy as first-line treatment.
The lack of both large-scale clinical trials in this population and integrated standards of care limit the guidelines’ effect, Dr. Elizabeth S. Klings, who chaired the guidelines committee, noted in a written statement. "Management of [these patients] will ultimately be a collaborative effort including adult and pediatric pulmonologists, cardiologists, and hematologists," added Dr. Klings of the department of medicine at Boston University.
Dr. Klings receives support from NIH grant R21HL107993.
FROM AMERICAN JOURNAL OF RESPIRATORY CRITICAL CARE MEDICINE
First guidelines on pulmonary hypertension in sickle cell disease released
UPDATED 3/17/14*
The first treatment guidelines for pulmonary hypertension in sickle cell disease are now available from the American Thoracic Society.
Because more effective treatments has extended the lives of patients with the disease, their risk of mortality from pulmonary hypertension and elevated tricuspid regurgitant jet velocity has increased. Until now, however, there has been no standardized approach for identifying and managing these conditions.
The guidelines are published in the March 15 issue of the American Journal of Respiratory Critical Care Medicine.
The multidisciplinary committee that wrote the guidelines defined mortality risk as a tricuspid regurgitant velocity (TRV) of at least 2.5 m/second; an N-terminal pro-brain natriuretic peptide (NT-pro-BNP) level of at least 160 pg/mL; or pulmonary hypertension (PH) confirmed by a right heart catheterization (RHC).
Patients with elevated mortality risk should be treated with hydroxyurea as first-line therapy. Chronic transfusion therapy for patients who are not candidates for or responsive to hydroxyurea is noted as a "weak recommendation."
For those with RHC-confirmed pulmonary hypertension, venous thromboembolism, and no additional risk factors for hemorrhage, indefinite – not limited – anticoagulant therapy is recommended.
For patients with either an elevated TRV or an elevated NT-pro-BNP level, the guidelines strongly recommend against pulmonary hypertensive–specific therapies such as prostanoid, endothelin-receptor antagonist, and phosphodiesterase-5 inhibitor therapy. The same guidance was given for patients who have RHC-confirmed PH.
While the guidelines recommend against targeted therapies for RHC-confirmed PH, a trial of either a prostanoid or an endothelin-receptor antagonist is recommended for patients with confirmed PH and elevated pulmonary vascular resistance, normal pulmonary capillary wedge pressure, and related symptoms. These patients should not be given phosphodiesterase-5 inhibitor therapy as first-line treatment.
The lack of both large-scale clinical trials in this population and integrated standards of care limit the guidelines’ effect, Dr. Elizabeth S. Klings, who chaired the guidelines committee, noted in a written statement. "Management of [these patients] will ultimately be a collaborative effort including adult and pediatric pulmonologists, cardiologists, and hematologists," added Dr. Klings of the department of medicine at Boston University.
Dr. Klings receives support from NIH grant R21HL107993.
Commentary – ‘Guidelines are a breath of fresh air’
Dr. Susan Millard comments: "I think the guidelines are a breath of fresh air. I feel they are very well thought out. More research needs to be done on the therapies for pulmonary hypertension, but the authors of these guidelines admit that there is a paucity of data in this area.
In addition, more collaboration is needed between our pulmonary, hematology, oncology, and cardiology specialties. Pulmonologists do not perform right heart catheterizations, but when we ask cardiologists about pulmonary hypertension concerns, we regularly get shot down by the ones who feel that echocardiograms are sufficient to look for this problem. Yet when we want help managing these patients, they don’t want to do that either because it is pulmonary hypertension. You need a dedicated group of people locally to work-up these patients.
There are not many experienced pulmonary hypertension centers easily accessible for both adult and pediatric patient referrals. It is difficult, for example, to refer patients out of state and get it approved by insurance companies.
Dr. Millard is a pediatric pulmonologist at Helen DeVos Children’s Hospital, Grand Rapids, Mich., and a CHEST board member.
*Dr. David Langleben responds: Cardiology input is essential [for patients with sickle cell disease being evaluated for pulmonary hypertension]. A multidisciplinary approach always benefits the patient. The patients may have high output cardiac failure, diastolic dysfunction, cardiomyopathies and myocardial ischemia. Heart catheterization is indispensable, as is echocardiography. They are complementary.
Dr. Langleben is professor of medicine at McGill University and director of cardiology and of the Centre for Pulmonary Vascular Disease at Jewish General Hospital, both in Montreal.
UPDATED 3/17/14*
The first treatment guidelines for pulmonary hypertension in sickle cell disease are now available from the American Thoracic Society.
Because more effective treatments has extended the lives of patients with the disease, their risk of mortality from pulmonary hypertension and elevated tricuspid regurgitant jet velocity has increased. Until now, however, there has been no standardized approach for identifying and managing these conditions.
The guidelines are published in the March 15 issue of the American Journal of Respiratory Critical Care Medicine.
The multidisciplinary committee that wrote the guidelines defined mortality risk as a tricuspid regurgitant velocity (TRV) of at least 2.5 m/second; an N-terminal pro-brain natriuretic peptide (NT-pro-BNP) level of at least 160 pg/mL; or pulmonary hypertension (PH) confirmed by a right heart catheterization (RHC).
Patients with elevated mortality risk should be treated with hydroxyurea as first-line therapy. Chronic transfusion therapy for patients who are not candidates for or responsive to hydroxyurea is noted as a "weak recommendation."
For those with RHC-confirmed pulmonary hypertension, venous thromboembolism, and no additional risk factors for hemorrhage, indefinite – not limited – anticoagulant therapy is recommended.
For patients with either an elevated TRV or an elevated NT-pro-BNP level, the guidelines strongly recommend against pulmonary hypertensive–specific therapies such as prostanoid, endothelin-receptor antagonist, and phosphodiesterase-5 inhibitor therapy. The same guidance was given for patients who have RHC-confirmed PH.
While the guidelines recommend against targeted therapies for RHC-confirmed PH, a trial of either a prostanoid or an endothelin-receptor antagonist is recommended for patients with confirmed PH and elevated pulmonary vascular resistance, normal pulmonary capillary wedge pressure, and related symptoms. These patients should not be given phosphodiesterase-5 inhibitor therapy as first-line treatment.
The lack of both large-scale clinical trials in this population and integrated standards of care limit the guidelines’ effect, Dr. Elizabeth S. Klings, who chaired the guidelines committee, noted in a written statement. "Management of [these patients] will ultimately be a collaborative effort including adult and pediatric pulmonologists, cardiologists, and hematologists," added Dr. Klings of the department of medicine at Boston University.
Dr. Klings receives support from NIH grant R21HL107993.
Commentary – ‘Guidelines are a breath of fresh air’
Dr. Susan Millard comments: "I think the guidelines are a breath of fresh air. I feel they are very well thought out. More research needs to be done on the therapies for pulmonary hypertension, but the authors of these guidelines admit that there is a paucity of data in this area.
In addition, more collaboration is needed between our pulmonary, hematology, oncology, and cardiology specialties. Pulmonologists do not perform right heart catheterizations, but when we ask cardiologists about pulmonary hypertension concerns, we regularly get shot down by the ones who feel that echocardiograms are sufficient to look for this problem. Yet when we want help managing these patients, they don’t want to do that either because it is pulmonary hypertension. You need a dedicated group of people locally to work-up these patients.
There are not many experienced pulmonary hypertension centers easily accessible for both adult and pediatric patient referrals. It is difficult, for example, to refer patients out of state and get it approved by insurance companies.
Dr. Millard is a pediatric pulmonologist at Helen DeVos Children’s Hospital, Grand Rapids, Mich., and a CHEST board member.
*Dr. David Langleben responds: Cardiology input is essential [for patients with sickle cell disease being evaluated for pulmonary hypertension]. A multidisciplinary approach always benefits the patient. The patients may have high output cardiac failure, diastolic dysfunction, cardiomyopathies and myocardial ischemia. Heart catheterization is indispensable, as is echocardiography. They are complementary.
Dr. Langleben is professor of medicine at McGill University and director of cardiology and of the Centre for Pulmonary Vascular Disease at Jewish General Hospital, both in Montreal.
UPDATED 3/17/14*
The first treatment guidelines for pulmonary hypertension in sickle cell disease are now available from the American Thoracic Society.
Because more effective treatments has extended the lives of patients with the disease, their risk of mortality from pulmonary hypertension and elevated tricuspid regurgitant jet velocity has increased. Until now, however, there has been no standardized approach for identifying and managing these conditions.
The guidelines are published in the March 15 issue of the American Journal of Respiratory Critical Care Medicine.
The multidisciplinary committee that wrote the guidelines defined mortality risk as a tricuspid regurgitant velocity (TRV) of at least 2.5 m/second; an N-terminal pro-brain natriuretic peptide (NT-pro-BNP) level of at least 160 pg/mL; or pulmonary hypertension (PH) confirmed by a right heart catheterization (RHC).
Patients with elevated mortality risk should be treated with hydroxyurea as first-line therapy. Chronic transfusion therapy for patients who are not candidates for or responsive to hydroxyurea is noted as a "weak recommendation."
For those with RHC-confirmed pulmonary hypertension, venous thromboembolism, and no additional risk factors for hemorrhage, indefinite – not limited – anticoagulant therapy is recommended.
For patients with either an elevated TRV or an elevated NT-pro-BNP level, the guidelines strongly recommend against pulmonary hypertensive–specific therapies such as prostanoid, endothelin-receptor antagonist, and phosphodiesterase-5 inhibitor therapy. The same guidance was given for patients who have RHC-confirmed PH.
While the guidelines recommend against targeted therapies for RHC-confirmed PH, a trial of either a prostanoid or an endothelin-receptor antagonist is recommended for patients with confirmed PH and elevated pulmonary vascular resistance, normal pulmonary capillary wedge pressure, and related symptoms. These patients should not be given phosphodiesterase-5 inhibitor therapy as first-line treatment.
The lack of both large-scale clinical trials in this population and integrated standards of care limit the guidelines’ effect, Dr. Elizabeth S. Klings, who chaired the guidelines committee, noted in a written statement. "Management of [these patients] will ultimately be a collaborative effort including adult and pediatric pulmonologists, cardiologists, and hematologists," added Dr. Klings of the department of medicine at Boston University.
Dr. Klings receives support from NIH grant R21HL107993.
Commentary – ‘Guidelines are a breath of fresh air’
Dr. Susan Millard comments: "I think the guidelines are a breath of fresh air. I feel they are very well thought out. More research needs to be done on the therapies for pulmonary hypertension, but the authors of these guidelines admit that there is a paucity of data in this area.
In addition, more collaboration is needed between our pulmonary, hematology, oncology, and cardiology specialties. Pulmonologists do not perform right heart catheterizations, but when we ask cardiologists about pulmonary hypertension concerns, we regularly get shot down by the ones who feel that echocardiograms are sufficient to look for this problem. Yet when we want help managing these patients, they don’t want to do that either because it is pulmonary hypertension. You need a dedicated group of people locally to work-up these patients.
There are not many experienced pulmonary hypertension centers easily accessible for both adult and pediatric patient referrals. It is difficult, for example, to refer patients out of state and get it approved by insurance companies.
Dr. Millard is a pediatric pulmonologist at Helen DeVos Children’s Hospital, Grand Rapids, Mich., and a CHEST board member.
*Dr. David Langleben responds: Cardiology input is essential [for patients with sickle cell disease being evaluated for pulmonary hypertension]. A multidisciplinary approach always benefits the patient. The patients may have high output cardiac failure, diastolic dysfunction, cardiomyopathies and myocardial ischemia. Heart catheterization is indispensable, as is echocardiography. They are complementary.
Dr. Langleben is professor of medicine at McGill University and director of cardiology and of the Centre for Pulmonary Vascular Disease at Jewish General Hospital, both in Montreal.
FROM AMERICAN JOURNAL OF RESPIRATORY CRITICAL CARE MEDICINE
Hospital crossover high in people with epilepsy
At least a fifth of people with epilepsy, primarily children, engaged in hospital crossover over a 2-year period, a cross-sectional study of epilepsy patient data sets showed.
Health exchange information (HIE) technology has the potential to bridge the data gaps among the unaffiliated physicians who serve these patients, helping to "lower health care costs, reduce adverse events and medical errors, and improve population health," wrote Dr. Zachary M. Grinspan of Cornell University, New York, and New York Presbyterian Hospital and his coauthors. But the technology’s full value has yet to be studied.
To determine who among the epileptic community are most likely to use two or more hospitals (crossover), and why, Dr. Grinspan and his colleagues conducted a cross-sectional analysis of HIE patient-level data sets for 8,704 patients seen by seven New York City tertiary-care teaching hospitals. They examined demographics, encounter dates, and ICD-9 codes for outpatient, emergency department, inpatient, and radiology encounters for visits that occurred April 2009 through March 2012. All data were taken from the New York state–sponsored NYCLIX (New York Clinical Information Exchange), an "honest broker" of such information, and were deidentified prior to the analysis (Epilepsia 2014 March 5 [doi:10.1111/epi.12552]).
In all, 1,770 (22%) patients were found to engage in crossover during the study period. Compared with adults (median age, 36 years), children (between age 0 and 10 years) were more likely to be associated with crossover (adjusted odds ratio, 1.4; 95% confidence interval, 1.2-1.7), as were those who lived near the hospitals in the study (the borough of Manhattan vs. other New York boroughs (adjusted OR, 1.6; 95% CI, 1.4-1.8).
Crossover was also associated with significantly greater odds of more visits to emergency, radiology, inpatient, and outpatient settings (P less than .001 for each), and of having 6 or more days with a head CT scan (P less than .05 for 6-10 days and P less than .01 for 11 or more days). Both bivariate and multivariate analyses consistently associated an encephalopathy diagnosis with crossover (adjusted OR, 2.66; 95% CI, 2.14-3.29); any relationship between crossover and other comorbidities was uncertain.
Dr. Grinspan and his associates noted the possibility that their findings may actually reflect lower crossover than actually occurs, since there are 14 other hospitals in Manhattan that were not included in the data pool. Reasons for patients seeking care in multiple settings may include a desire for a second opinion or the need for emergency services in patients with uncontrolled epilepsy, wrote the authors. "Further research should investigate why hospital crossover occurs, how it affects care, and how HIE can most effectively mitigate the resultant fragmentation of medical records."
At least a fifth of people with epilepsy, primarily children, engaged in hospital crossover over a 2-year period, a cross-sectional study of epilepsy patient data sets showed.
Health exchange information (HIE) technology has the potential to bridge the data gaps among the unaffiliated physicians who serve these patients, helping to "lower health care costs, reduce adverse events and medical errors, and improve population health," wrote Dr. Zachary M. Grinspan of Cornell University, New York, and New York Presbyterian Hospital and his coauthors. But the technology’s full value has yet to be studied.
To determine who among the epileptic community are most likely to use two or more hospitals (crossover), and why, Dr. Grinspan and his colleagues conducted a cross-sectional analysis of HIE patient-level data sets for 8,704 patients seen by seven New York City tertiary-care teaching hospitals. They examined demographics, encounter dates, and ICD-9 codes for outpatient, emergency department, inpatient, and radiology encounters for visits that occurred April 2009 through March 2012. All data were taken from the New York state–sponsored NYCLIX (New York Clinical Information Exchange), an "honest broker" of such information, and were deidentified prior to the analysis (Epilepsia 2014 March 5 [doi:10.1111/epi.12552]).
In all, 1,770 (22%) patients were found to engage in crossover during the study period. Compared with adults (median age, 36 years), children (between age 0 and 10 years) were more likely to be associated with crossover (adjusted odds ratio, 1.4; 95% confidence interval, 1.2-1.7), as were those who lived near the hospitals in the study (the borough of Manhattan vs. other New York boroughs (adjusted OR, 1.6; 95% CI, 1.4-1.8).
Crossover was also associated with significantly greater odds of more visits to emergency, radiology, inpatient, and outpatient settings (P less than .001 for each), and of having 6 or more days with a head CT scan (P less than .05 for 6-10 days and P less than .01 for 11 or more days). Both bivariate and multivariate analyses consistently associated an encephalopathy diagnosis with crossover (adjusted OR, 2.66; 95% CI, 2.14-3.29); any relationship between crossover and other comorbidities was uncertain.
Dr. Grinspan and his associates noted the possibility that their findings may actually reflect lower crossover than actually occurs, since there are 14 other hospitals in Manhattan that were not included in the data pool. Reasons for patients seeking care in multiple settings may include a desire for a second opinion or the need for emergency services in patients with uncontrolled epilepsy, wrote the authors. "Further research should investigate why hospital crossover occurs, how it affects care, and how HIE can most effectively mitigate the resultant fragmentation of medical records."
At least a fifth of people with epilepsy, primarily children, engaged in hospital crossover over a 2-year period, a cross-sectional study of epilepsy patient data sets showed.
Health exchange information (HIE) technology has the potential to bridge the data gaps among the unaffiliated physicians who serve these patients, helping to "lower health care costs, reduce adverse events and medical errors, and improve population health," wrote Dr. Zachary M. Grinspan of Cornell University, New York, and New York Presbyterian Hospital and his coauthors. But the technology’s full value has yet to be studied.
To determine who among the epileptic community are most likely to use two or more hospitals (crossover), and why, Dr. Grinspan and his colleagues conducted a cross-sectional analysis of HIE patient-level data sets for 8,704 patients seen by seven New York City tertiary-care teaching hospitals. They examined demographics, encounter dates, and ICD-9 codes for outpatient, emergency department, inpatient, and radiology encounters for visits that occurred April 2009 through March 2012. All data were taken from the New York state–sponsored NYCLIX (New York Clinical Information Exchange), an "honest broker" of such information, and were deidentified prior to the analysis (Epilepsia 2014 March 5 [doi:10.1111/epi.12552]).
In all, 1,770 (22%) patients were found to engage in crossover during the study period. Compared with adults (median age, 36 years), children (between age 0 and 10 years) were more likely to be associated with crossover (adjusted odds ratio, 1.4; 95% confidence interval, 1.2-1.7), as were those who lived near the hospitals in the study (the borough of Manhattan vs. other New York boroughs (adjusted OR, 1.6; 95% CI, 1.4-1.8).
Crossover was also associated with significantly greater odds of more visits to emergency, radiology, inpatient, and outpatient settings (P less than .001 for each), and of having 6 or more days with a head CT scan (P less than .05 for 6-10 days and P less than .01 for 11 or more days). Both bivariate and multivariate analyses consistently associated an encephalopathy diagnosis with crossover (adjusted OR, 2.66; 95% CI, 2.14-3.29); any relationship between crossover and other comorbidities was uncertain.
Dr. Grinspan and his associates noted the possibility that their findings may actually reflect lower crossover than actually occurs, since there are 14 other hospitals in Manhattan that were not included in the data pool. Reasons for patients seeking care in multiple settings may include a desire for a second opinion or the need for emergency services in patients with uncontrolled epilepsy, wrote the authors. "Further research should investigate why hospital crossover occurs, how it affects care, and how HIE can most effectively mitigate the resultant fragmentation of medical records."
FROM EPILEPSIA
Major finding: More than 20% of people with epilepsy engaged in hospital crossover.
Data source: A cross-sectional study of data gathered through health information exchange technology for 8,074 people with epilepsy who visited one of seven N.Y.C. hospitals over a 2-year period.
Disclosures: This study was funded in part by the National Institutes of Health. No relevant disclosures were reported.
Laboring women preferred epidural to patient-controlled remifentanil analgesia
NEW ORLEANS – Laboring women had better overall pain relief satisfaction from epidurals than from remifentanil patient-controlled analgesia, according to results presented at the annual Pregnancy Meeting sponsored by the Society for Maternal-Fetal Medicine.
Although Dr. Liv Freeman, of Leiden (the Netherlands) University Medical Center, and her colleagues expected to find that the two pain relief methods would be equivalent, the results of their multisite, randomized controlled study instead showed a significantly higher pain appreciation (pain relief satisfaction) score in women who received epidural analgesia during delivery.
"This should be taken into account when pain relief is offered to women in labor," said Dr. Freeman, who noted that the study’s intention was to provide more definitive data about the two pain relief methods because previous studies were underpowered – with some data showing the two methods were comparable.
An advantage to using remifentanil, an opioid similar to pethidine, is that it is fast-acting, typically cycling within 3 minutes. This attribute allows the drug to be self-administered and lowers costs, said Dr. Freeman. There are maternal side effects, however, including respiratory depression, nausea and vomiting, and sedation.
Placental transfer also occurs with remifentanil, although "the drug is so short acting, it is cleared once the baby is born when discontinued in the second stage of labor," Dr. Freeman said.
As for the potential risks of using an epidural, Dr. Freeman said that although rare, epidural hematomas can occur, and that "about 1 in 100 women experience postspinal headache, and between 10% and 20% of mothers develop a fever during labor."
Before active labor began, 709 women were randomly assigned to the remifentanil patient-controlled analgesia (PCA) group, and 705 were assigned to the epidural group. The maternal age was about 31 years in each group, and other demographic baseline data also were similar. Nearly one-third more of the remifentanil PCA group, 402 women in all, opted to use the pain medication during labor, and 296 assigned to the epidural group chose to use it.
All women across the cohorts were asked hourly to rate their pain relief on a visual analog scale.
The total time-weighted pain appreciation score for the remifentanil PCA group was 25.7, versus 36.8 in the epidural group (P = .001).
Although the analysis was based on intention to treat, Dr. Freeman noted that 53 of the women in the self-administered pain relief group requested epidurals while in labor. Three women converted from an epidural to the self-administered pain medication.
The epidurals were performed according to local procedures across the 15 Dutch sites where the trial was conducted. Remifentanil PCA was 30 mcg administered intravenously with a 3-minute lockout time. The women had the option of increasing their dose to 40 mcg or decreasing it to 20 mcg.
The duration of analgesia was notably shorter in the remifentanil PCA group than in the epidural group: 236 minutes (interquartile range, 128-376 minutes) vs. 309 minutes (IQR, 181-454 minutes).
There were 22 elective cesarean deliveries in the remifentanil group and 29 in the epidural group. Three women in the epidural cohort were lost to follow-up, and two withdrew their consent.
There were no significant differences in important maternal and fetal outcomes, said Dr. Freeman. Because the safety profiles of remifentanil and epidural analgesia are essentially the same, physicians should counsel women about the pros and cons of each, she said.
This study was funded by ZonMw, the Netherlands Organisation for Health Research and Development. Dr. Freeman did not report any relevant financial disclosures.
NEW ORLEANS – Laboring women had better overall pain relief satisfaction from epidurals than from remifentanil patient-controlled analgesia, according to results presented at the annual Pregnancy Meeting sponsored by the Society for Maternal-Fetal Medicine.
Although Dr. Liv Freeman, of Leiden (the Netherlands) University Medical Center, and her colleagues expected to find that the two pain relief methods would be equivalent, the results of their multisite, randomized controlled study instead showed a significantly higher pain appreciation (pain relief satisfaction) score in women who received epidural analgesia during delivery.
"This should be taken into account when pain relief is offered to women in labor," said Dr. Freeman, who noted that the study’s intention was to provide more definitive data about the two pain relief methods because previous studies were underpowered – with some data showing the two methods were comparable.
An advantage to using remifentanil, an opioid similar to pethidine, is that it is fast-acting, typically cycling within 3 minutes. This attribute allows the drug to be self-administered and lowers costs, said Dr. Freeman. There are maternal side effects, however, including respiratory depression, nausea and vomiting, and sedation.
Placental transfer also occurs with remifentanil, although "the drug is so short acting, it is cleared once the baby is born when discontinued in the second stage of labor," Dr. Freeman said.
As for the potential risks of using an epidural, Dr. Freeman said that although rare, epidural hematomas can occur, and that "about 1 in 100 women experience postspinal headache, and between 10% and 20% of mothers develop a fever during labor."
Before active labor began, 709 women were randomly assigned to the remifentanil patient-controlled analgesia (PCA) group, and 705 were assigned to the epidural group. The maternal age was about 31 years in each group, and other demographic baseline data also were similar. Nearly one-third more of the remifentanil PCA group, 402 women in all, opted to use the pain medication during labor, and 296 assigned to the epidural group chose to use it.
All women across the cohorts were asked hourly to rate their pain relief on a visual analog scale.
The total time-weighted pain appreciation score for the remifentanil PCA group was 25.7, versus 36.8 in the epidural group (P = .001).
Although the analysis was based on intention to treat, Dr. Freeman noted that 53 of the women in the self-administered pain relief group requested epidurals while in labor. Three women converted from an epidural to the self-administered pain medication.
The epidurals were performed according to local procedures across the 15 Dutch sites where the trial was conducted. Remifentanil PCA was 30 mcg administered intravenously with a 3-minute lockout time. The women had the option of increasing their dose to 40 mcg or decreasing it to 20 mcg.
The duration of analgesia was notably shorter in the remifentanil PCA group than in the epidural group: 236 minutes (interquartile range, 128-376 minutes) vs. 309 minutes (IQR, 181-454 minutes).
There were 22 elective cesarean deliveries in the remifentanil group and 29 in the epidural group. Three women in the epidural cohort were lost to follow-up, and two withdrew their consent.
There were no significant differences in important maternal and fetal outcomes, said Dr. Freeman. Because the safety profiles of remifentanil and epidural analgesia are essentially the same, physicians should counsel women about the pros and cons of each, she said.
This study was funded by ZonMw, the Netherlands Organisation for Health Research and Development. Dr. Freeman did not report any relevant financial disclosures.
NEW ORLEANS – Laboring women had better overall pain relief satisfaction from epidurals than from remifentanil patient-controlled analgesia, according to results presented at the annual Pregnancy Meeting sponsored by the Society for Maternal-Fetal Medicine.
Although Dr. Liv Freeman, of Leiden (the Netherlands) University Medical Center, and her colleagues expected to find that the two pain relief methods would be equivalent, the results of their multisite, randomized controlled study instead showed a significantly higher pain appreciation (pain relief satisfaction) score in women who received epidural analgesia during delivery.
"This should be taken into account when pain relief is offered to women in labor," said Dr. Freeman, who noted that the study’s intention was to provide more definitive data about the two pain relief methods because previous studies were underpowered – with some data showing the two methods were comparable.
An advantage to using remifentanil, an opioid similar to pethidine, is that it is fast-acting, typically cycling within 3 minutes. This attribute allows the drug to be self-administered and lowers costs, said Dr. Freeman. There are maternal side effects, however, including respiratory depression, nausea and vomiting, and sedation.
Placental transfer also occurs with remifentanil, although "the drug is so short acting, it is cleared once the baby is born when discontinued in the second stage of labor," Dr. Freeman said.
As for the potential risks of using an epidural, Dr. Freeman said that although rare, epidural hematomas can occur, and that "about 1 in 100 women experience postspinal headache, and between 10% and 20% of mothers develop a fever during labor."
Before active labor began, 709 women were randomly assigned to the remifentanil patient-controlled analgesia (PCA) group, and 705 were assigned to the epidural group. The maternal age was about 31 years in each group, and other demographic baseline data also were similar. Nearly one-third more of the remifentanil PCA group, 402 women in all, opted to use the pain medication during labor, and 296 assigned to the epidural group chose to use it.
All women across the cohorts were asked hourly to rate their pain relief on a visual analog scale.
The total time-weighted pain appreciation score for the remifentanil PCA group was 25.7, versus 36.8 in the epidural group (P = .001).
Although the analysis was based on intention to treat, Dr. Freeman noted that 53 of the women in the self-administered pain relief group requested epidurals while in labor. Three women converted from an epidural to the self-administered pain medication.
The epidurals were performed according to local procedures across the 15 Dutch sites where the trial was conducted. Remifentanil PCA was 30 mcg administered intravenously with a 3-minute lockout time. The women had the option of increasing their dose to 40 mcg or decreasing it to 20 mcg.
The duration of analgesia was notably shorter in the remifentanil PCA group than in the epidural group: 236 minutes (interquartile range, 128-376 minutes) vs. 309 minutes (IQR, 181-454 minutes).
There were 22 elective cesarean deliveries in the remifentanil group and 29 in the epidural group. Three women in the epidural cohort were lost to follow-up, and two withdrew their consent.
There were no significant differences in important maternal and fetal outcomes, said Dr. Freeman. Because the safety profiles of remifentanil and epidural analgesia are essentially the same, physicians should counsel women about the pros and cons of each, she said.
This study was funded by ZonMw, the Netherlands Organisation for Health Research and Development. Dr. Freeman did not report any relevant financial disclosures.
AT THE PREGNANCY MEETING
Major finding: Time-weighted, overall satisfaction scores for women who received an epidural were 36.8, compared with 25.7 for women using remifentanil, a significant difference.
Data source: Multisite, randomized controlled equivalence trial of 705 women who were administered an epidural vs. 709 women using patient-controlled remifentanil.
Disclosures: This study was funded by ZonMw, the Netherlands Organisation for Health Research and Development. Dr. Freeman did not report any relevant financial disclosures.
Obesity does not interfere with accuracy of noninvasive preterm birth monitoring
NEW ORLEANS – Maternal obesity does not lessen the predictive value of noninvasive uterine electromyography monitoring, according to a poster presentation at the annual Pregnancy Meeting sponsored by the Society for Maternal-Fetal Medicine.
"We wanted to see if in this subset of pregnant women, the noninvasive method was as effective as in other pregnant women," said Dr. Miha Lucovnik, a perinatologist at the University Medical Center, Ljubljana, Slovenia.
"Uterine contractions, at term or preterm, are one of the most common reasons for visits to obstetrical triage, but determining which patient with contractions is in true labor and needs to be admitted is, however, difficult," said Dr. Lucovnik. "The inability to accurately diagnose preterm labor leads to missed opportunities to improve outcomes of premature neonates, and also to unnecessary costs and side effects of treatments in women who would not deliver preterm regardless of intervention."
One of the more common monitoring methods – tocodynamometry – measures length and frequency of contractions but is often ineffective at detecting these signals in women with a BMI of 30 kg/m2 and above, he said.
Electromyography (EMG) is more effective at monitoring the progression of true labor, because it can detect "the changes in cell excitability and coupling necessary for effective contractions," said Dr. Lucovnik.
To detect uterine activity, electrodes are placed on the patient’s abdomen with vertical and horizontal axes parallel to the patient’s vertical and horizontal axes, respectively, and with center-to-center distances between adjacent electrodes set about 5.0-5.5 cm apart. The uterine EMG is then measured for 30 minutes.
For the study, Dr. Lucovnik and his colleagues reviewed the predictive values of uterine EMG for preterm delivery in 88 women divided into three cohorts: 20 with a BMI of 30 or greater; 64 with a BMI of 25-29.9; and 4 with a BMI of 18.5-24.9.
The investigators did not find any significant difference between the cohorts in the area under the curve prediction of preterm delivery within 7 days (AUC was 0.95 in the normal and overweight cohorts, and 1 in the obese group; P = .08).
Six patients with low uterine EMG scores delivered prematurely within 7 days from the EMG measurement. No significant differences in BMI were reported between this false negative group (range, 26.13 plus or minus 1.03) and the combined true positive and true negative preterm labor groups (range, 28.04 plus or minus 3.77; P = .32).
"We know that predictive values of currently used methods to diagnose preterm labor are even lower in women with high BMI," said Dr. Lucovnik. "Our study showed that the accuracy of uterine EMG monitoring and its predictive value for preterm delivery are not affected by obesity in pregnant patients."
Dr. Lucovnik reported that he did not have any relevant disclosures.
NEW ORLEANS – Maternal obesity does not lessen the predictive value of noninvasive uterine electromyography monitoring, according to a poster presentation at the annual Pregnancy Meeting sponsored by the Society for Maternal-Fetal Medicine.
"We wanted to see if in this subset of pregnant women, the noninvasive method was as effective as in other pregnant women," said Dr. Miha Lucovnik, a perinatologist at the University Medical Center, Ljubljana, Slovenia.
"Uterine contractions, at term or preterm, are one of the most common reasons for visits to obstetrical triage, but determining which patient with contractions is in true labor and needs to be admitted is, however, difficult," said Dr. Lucovnik. "The inability to accurately diagnose preterm labor leads to missed opportunities to improve outcomes of premature neonates, and also to unnecessary costs and side effects of treatments in women who would not deliver preterm regardless of intervention."
One of the more common monitoring methods – tocodynamometry – measures length and frequency of contractions but is often ineffective at detecting these signals in women with a BMI of 30 kg/m2 and above, he said.
Electromyography (EMG) is more effective at monitoring the progression of true labor, because it can detect "the changes in cell excitability and coupling necessary for effective contractions," said Dr. Lucovnik.
To detect uterine activity, electrodes are placed on the patient’s abdomen with vertical and horizontal axes parallel to the patient’s vertical and horizontal axes, respectively, and with center-to-center distances between adjacent electrodes set about 5.0-5.5 cm apart. The uterine EMG is then measured for 30 minutes.
For the study, Dr. Lucovnik and his colleagues reviewed the predictive values of uterine EMG for preterm delivery in 88 women divided into three cohorts: 20 with a BMI of 30 or greater; 64 with a BMI of 25-29.9; and 4 with a BMI of 18.5-24.9.
The investigators did not find any significant difference between the cohorts in the area under the curve prediction of preterm delivery within 7 days (AUC was 0.95 in the normal and overweight cohorts, and 1 in the obese group; P = .08).
Six patients with low uterine EMG scores delivered prematurely within 7 days from the EMG measurement. No significant differences in BMI were reported between this false negative group (range, 26.13 plus or minus 1.03) and the combined true positive and true negative preterm labor groups (range, 28.04 plus or minus 3.77; P = .32).
"We know that predictive values of currently used methods to diagnose preterm labor are even lower in women with high BMI," said Dr. Lucovnik. "Our study showed that the accuracy of uterine EMG monitoring and its predictive value for preterm delivery are not affected by obesity in pregnant patients."
Dr. Lucovnik reported that he did not have any relevant disclosures.
NEW ORLEANS – Maternal obesity does not lessen the predictive value of noninvasive uterine electromyography monitoring, according to a poster presentation at the annual Pregnancy Meeting sponsored by the Society for Maternal-Fetal Medicine.
"We wanted to see if in this subset of pregnant women, the noninvasive method was as effective as in other pregnant women," said Dr. Miha Lucovnik, a perinatologist at the University Medical Center, Ljubljana, Slovenia.
"Uterine contractions, at term or preterm, are one of the most common reasons for visits to obstetrical triage, but determining which patient with contractions is in true labor and needs to be admitted is, however, difficult," said Dr. Lucovnik. "The inability to accurately diagnose preterm labor leads to missed opportunities to improve outcomes of premature neonates, and also to unnecessary costs and side effects of treatments in women who would not deliver preterm regardless of intervention."
One of the more common monitoring methods – tocodynamometry – measures length and frequency of contractions but is often ineffective at detecting these signals in women with a BMI of 30 kg/m2 and above, he said.
Electromyography (EMG) is more effective at monitoring the progression of true labor, because it can detect "the changes in cell excitability and coupling necessary for effective contractions," said Dr. Lucovnik.
To detect uterine activity, electrodes are placed on the patient’s abdomen with vertical and horizontal axes parallel to the patient’s vertical and horizontal axes, respectively, and with center-to-center distances between adjacent electrodes set about 5.0-5.5 cm apart. The uterine EMG is then measured for 30 minutes.
For the study, Dr. Lucovnik and his colleagues reviewed the predictive values of uterine EMG for preterm delivery in 88 women divided into three cohorts: 20 with a BMI of 30 or greater; 64 with a BMI of 25-29.9; and 4 with a BMI of 18.5-24.9.
The investigators did not find any significant difference between the cohorts in the area under the curve prediction of preterm delivery within 7 days (AUC was 0.95 in the normal and overweight cohorts, and 1 in the obese group; P = .08).
Six patients with low uterine EMG scores delivered prematurely within 7 days from the EMG measurement. No significant differences in BMI were reported between this false negative group (range, 26.13 plus or minus 1.03) and the combined true positive and true negative preterm labor groups (range, 28.04 plus or minus 3.77; P = .32).
"We know that predictive values of currently used methods to diagnose preterm labor are even lower in women with high BMI," said Dr. Lucovnik. "Our study showed that the accuracy of uterine EMG monitoring and its predictive value for preterm delivery are not affected by obesity in pregnant patients."
Dr. Lucovnik reported that he did not have any relevant disclosures.
AT THE PREGNANCY MEETING 2014
Major finding: No significant differences in BMI were found in the false negative group (range, 26.13 plus or minus 1.03) and the combined true positive and true negative preterm labor groups combined (range, 28.04 plus or minus 3.77) (P = .32).
Data source: Retrospective analysis of 88 women, including 20 women with BMI greater than 30 kg/m2, noninvasively monitored for preterm birth.
Disclosures: Dr. Lucovnik reported that he did not have any relevant disclosures.
