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Cerebral Aneurysm Size and Location Predict Rupture in Elderly Patients
Among elderly patients with unruptured cerebral aneurysms, the size and location of aneurysms, as well as patient age, are significant risk factors for aneurysm rupture, according to research published November 24, 2015, in Neurology.
Stratifying the risk of rupture in elderly patients is important “to effectively perform preventive surgical treatment for the patients who are at a high risk of rupture,” said Tomohito Hishikawa, MD, of the Department of Neurological Surgery at Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences in Japan, and colleagues.
The risk associated with surgical treatment of unruptured aneurysms in elderly patients, however, makes the management of these patients more difficult, the researchers said.
To identify risk factors for the rupture of unruptured cerebral aneurysms in elderly Japanese patients, Dr. Hishikawa and colleagues analyzed pooled data from three prospective studies that evaluated the natural course of unruptured cerebral aneurysms in Japanese patients. The researchers included 1,896 patients age 70 or older with 2,227 unruptured cerebral aneurysms. Patients had a mean age of 74.3, 10.9% were age 80 or older, and 72.9% were female. The mean aneurysm size was 6.2 mm.
During an average follow-up period of 802.7 days, 68 patients had subarachnoid hemorrhages, resulting in an overall annual rupture risk of 1.6%. The cumulative rate of subarachnoid hemorrhage for all patients was 3.8% at two years after diagnosis, and 6.3% at five years after diagnosis.
Multivariable analysis per patient revealed that patient age of 80 or older and internal carotid-posterior communicating artery aneurysms independently predicted aneurysm rupture, with hazard ratios of 2.02 and 2.45, respectively.
Aneurysm size of 7 mm or larger also predicted aneurysm rupture. The hazard ratios for aneurysms of 7–9 mm, 10–24 mm, and 25 mm or greater were 3.08, 7.82, and 43.31, respectively.
Female sex, multiple aneurysms, and basilar artery aneurysm were significant risk factors for rupture by univariable analysis, but they did not reach statistical significance by the multivariable analysis.
“When deciding [on a] therapeutic strategy for elderly patients with unruptured cerebral aneurysms, we have to consider various factors, such as the difference between chronological age and physiologic age, the difference in life expectancy between patients age 70 to 79 years and those older than 80 years, and one’s view of life and death,” the researchers said.
Unlike in prior research, there was no significant difference between men and women in the prevalence of aneurysms larger than 7 mm. “This [lack of difference] is probably one of the reasons why female sex disappeared as a risk factor for aneurysm rupture in elderly patients with unruptured cerebral aneurysms in our pooled analysis,” said the researchers. Prior studies have found that geographic region is related to the risk of aneurysm rupture, so the findings of this study “should be applied with caution” to patient populations in other countries, the investigators said.
—Jake Remaly
Suggested Reading
Hishikawa T, Date I, Tokunaga K, et al. Risk of rupture of unruptured cerebral aneurysms in elderly patients. Neurology. 2015;85(21):1879-1885.
Among elderly patients with unruptured cerebral aneurysms, the size and location of aneurysms, as well as patient age, are significant risk factors for aneurysm rupture, according to research published November 24, 2015, in Neurology.
Stratifying the risk of rupture in elderly patients is important “to effectively perform preventive surgical treatment for the patients who are at a high risk of rupture,” said Tomohito Hishikawa, MD, of the Department of Neurological Surgery at Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences in Japan, and colleagues.
The risk associated with surgical treatment of unruptured aneurysms in elderly patients, however, makes the management of these patients more difficult, the researchers said.
To identify risk factors for the rupture of unruptured cerebral aneurysms in elderly Japanese patients, Dr. Hishikawa and colleagues analyzed pooled data from three prospective studies that evaluated the natural course of unruptured cerebral aneurysms in Japanese patients. The researchers included 1,896 patients age 70 or older with 2,227 unruptured cerebral aneurysms. Patients had a mean age of 74.3, 10.9% were age 80 or older, and 72.9% were female. The mean aneurysm size was 6.2 mm.
During an average follow-up period of 802.7 days, 68 patients had subarachnoid hemorrhages, resulting in an overall annual rupture risk of 1.6%. The cumulative rate of subarachnoid hemorrhage for all patients was 3.8% at two years after diagnosis, and 6.3% at five years after diagnosis.
Multivariable analysis per patient revealed that patient age of 80 or older and internal carotid-posterior communicating artery aneurysms independently predicted aneurysm rupture, with hazard ratios of 2.02 and 2.45, respectively.
Aneurysm size of 7 mm or larger also predicted aneurysm rupture. The hazard ratios for aneurysms of 7–9 mm, 10–24 mm, and 25 mm or greater were 3.08, 7.82, and 43.31, respectively.
Female sex, multiple aneurysms, and basilar artery aneurysm were significant risk factors for rupture by univariable analysis, but they did not reach statistical significance by the multivariable analysis.
“When deciding [on a] therapeutic strategy for elderly patients with unruptured cerebral aneurysms, we have to consider various factors, such as the difference between chronological age and physiologic age, the difference in life expectancy between patients age 70 to 79 years and those older than 80 years, and one’s view of life and death,” the researchers said.
Unlike in prior research, there was no significant difference between men and women in the prevalence of aneurysms larger than 7 mm. “This [lack of difference] is probably one of the reasons why female sex disappeared as a risk factor for aneurysm rupture in elderly patients with unruptured cerebral aneurysms in our pooled analysis,” said the researchers. Prior studies have found that geographic region is related to the risk of aneurysm rupture, so the findings of this study “should be applied with caution” to patient populations in other countries, the investigators said.
—Jake Remaly
Among elderly patients with unruptured cerebral aneurysms, the size and location of aneurysms, as well as patient age, are significant risk factors for aneurysm rupture, according to research published November 24, 2015, in Neurology.
Stratifying the risk of rupture in elderly patients is important “to effectively perform preventive surgical treatment for the patients who are at a high risk of rupture,” said Tomohito Hishikawa, MD, of the Department of Neurological Surgery at Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences in Japan, and colleagues.
The risk associated with surgical treatment of unruptured aneurysms in elderly patients, however, makes the management of these patients more difficult, the researchers said.
To identify risk factors for the rupture of unruptured cerebral aneurysms in elderly Japanese patients, Dr. Hishikawa and colleagues analyzed pooled data from three prospective studies that evaluated the natural course of unruptured cerebral aneurysms in Japanese patients. The researchers included 1,896 patients age 70 or older with 2,227 unruptured cerebral aneurysms. Patients had a mean age of 74.3, 10.9% were age 80 or older, and 72.9% were female. The mean aneurysm size was 6.2 mm.
During an average follow-up period of 802.7 days, 68 patients had subarachnoid hemorrhages, resulting in an overall annual rupture risk of 1.6%. The cumulative rate of subarachnoid hemorrhage for all patients was 3.8% at two years after diagnosis, and 6.3% at five years after diagnosis.
Multivariable analysis per patient revealed that patient age of 80 or older and internal carotid-posterior communicating artery aneurysms independently predicted aneurysm rupture, with hazard ratios of 2.02 and 2.45, respectively.
Aneurysm size of 7 mm or larger also predicted aneurysm rupture. The hazard ratios for aneurysms of 7–9 mm, 10–24 mm, and 25 mm or greater were 3.08, 7.82, and 43.31, respectively.
Female sex, multiple aneurysms, and basilar artery aneurysm were significant risk factors for rupture by univariable analysis, but they did not reach statistical significance by the multivariable analysis.
“When deciding [on a] therapeutic strategy for elderly patients with unruptured cerebral aneurysms, we have to consider various factors, such as the difference between chronological age and physiologic age, the difference in life expectancy between patients age 70 to 79 years and those older than 80 years, and one’s view of life and death,” the researchers said.
Unlike in prior research, there was no significant difference between men and women in the prevalence of aneurysms larger than 7 mm. “This [lack of difference] is probably one of the reasons why female sex disappeared as a risk factor for aneurysm rupture in elderly patients with unruptured cerebral aneurysms in our pooled analysis,” said the researchers. Prior studies have found that geographic region is related to the risk of aneurysm rupture, so the findings of this study “should be applied with caution” to patient populations in other countries, the investigators said.
—Jake Remaly
Suggested Reading
Hishikawa T, Date I, Tokunaga K, et al. Risk of rupture of unruptured cerebral aneurysms in elderly patients. Neurology. 2015;85(21):1879-1885.
Suggested Reading
Hishikawa T, Date I, Tokunaga K, et al. Risk of rupture of unruptured cerebral aneurysms in elderly patients. Neurology. 2015;85(21):1879-1885.
Modifiable Risk Factors for Alzheimer’s Disease Point to Preventive Strategies
Interventions that target modifiable risk factors for Alzheimer’s disease hold promise for reducing the incidence of Alzheimer’s disease in the general population, according to a meta-analysis published in the December 2015 issue of Journal of Neurology, Neurosurgery and Psychiatry.
“Effective interventions in diet, medications, biochemical exposures, psychological condition, pre-existing disease, and lifestyle may decrease new incidence of Alzheimer’s disease,” said Jin-Tai Yu, MD, PhD, of the University of California San Francisco, and colleagues.
The causes of Alzheimer’s disease remain poorly understood, but genetic and environmental factors are believed to play a role. A 2011 study by Barnes and Yaffe indicated that nearly half of worldwide Alzheimer’s disease cases might be associated with seven common, potentially modifiable risk factors. To evaluate the association between Alzheimer’s disease and modifiable risk factors, Dr. Yu and colleagues conducted a meta-analysis of studies published in English between 1968 and July 2014. They identified 16,906 studies of potential risk factors for Alzheimer’s disease. Of those articles, they found 323 articles examining 93 separate factors that had associations with Alzheimer’s disease that met inclusion criteria for their meta-analysis. They assessed the quality of the evidence for each risk factor based on the heterogeneity of the pooled analyses and whether the pooled analyses included more than 5,000 people.
Seven general categories of modifiable risk factors emerged from their literature search, which were consistent with those identified in prior studies: pre-existing disease status, biochemical exposure, dietary factors, medical exposure to drugs or therapy, lifestyle, psychological conditions, and occupational exposures.
In their primary meta-analysis, Dr. Yu and colleagues identified 13 risk factors, 28 protective factors, and 52 factors that showed no association with Alzheimer’s disease. Subsequent subgroup analysis reclassified seven factors from the neutral group as being positively associated with Alzheimer’s disease and four as negatively associated.
The investigators found grade I evidence that one environmental factor (ie, biochemical exposure to hyperhomocysteine) and one psychological factor (ie, depression) increased the risk of Alzheimer’s disease. Four medical exposures (ie, estrogen, statin, antihypertensive medication, and nonsteroidal anti-inflammatory therapy) and four dietary exposures (ie, folate, vitamin E, vitamin C, and coffee) were protective factors.
The meta-analysis also found grade I evidence that various medical conditions are associated with the risk of Alzheimer’s disease. Pre-existing conditions, including frailty, carotid atherosclerosis, hypertension, low diastolic blood pressure, and type II diabetes among Asians, increased risk, while previous history of arthritis, heart disease, metabolic syndrome, and cancer conferred protection.
Among lifestyle factors, low education, which has long been associated with a higher risk of Alzheimer’s disease, was identified as a risk factor. Other lifestyle factors such as smoking, alcohol consumption, and BMI influenced the risk of Alzheimer’s disease in contradictory ways at different ages. Those with high BMI at midlife only, and low BMI otherwise, had an increased risk of Alzheimer’s disease, while those with high BMI late in life had decreased risk. Current smoking, cognitive activity, stress, and light-to-moderate drinking were also associated with a decreased risk of Alzheimer’s disease. Interestingly, occupational exposures had little or no association with Alzheimer’s disease, the researchers noted.
—Linda Peckel
Suggested Reading
Xu W, Tan L, Wang HF, et al. Meta-analysis of modifiable risk factors for Alzheimer’s disease. J Neurol Neurosurg Psychiatry. 2015;86:1299-1306.
Interventions that target modifiable risk factors for Alzheimer’s disease hold promise for reducing the incidence of Alzheimer’s disease in the general population, according to a meta-analysis published in the December 2015 issue of Journal of Neurology, Neurosurgery and Psychiatry.
“Effective interventions in diet, medications, biochemical exposures, psychological condition, pre-existing disease, and lifestyle may decrease new incidence of Alzheimer’s disease,” said Jin-Tai Yu, MD, PhD, of the University of California San Francisco, and colleagues.
The causes of Alzheimer’s disease remain poorly understood, but genetic and environmental factors are believed to play a role. A 2011 study by Barnes and Yaffe indicated that nearly half of worldwide Alzheimer’s disease cases might be associated with seven common, potentially modifiable risk factors. To evaluate the association between Alzheimer’s disease and modifiable risk factors, Dr. Yu and colleagues conducted a meta-analysis of studies published in English between 1968 and July 2014. They identified 16,906 studies of potential risk factors for Alzheimer’s disease. Of those articles, they found 323 articles examining 93 separate factors that had associations with Alzheimer’s disease that met inclusion criteria for their meta-analysis. They assessed the quality of the evidence for each risk factor based on the heterogeneity of the pooled analyses and whether the pooled analyses included more than 5,000 people.
Seven general categories of modifiable risk factors emerged from their literature search, which were consistent with those identified in prior studies: pre-existing disease status, biochemical exposure, dietary factors, medical exposure to drugs or therapy, lifestyle, psychological conditions, and occupational exposures.
In their primary meta-analysis, Dr. Yu and colleagues identified 13 risk factors, 28 protective factors, and 52 factors that showed no association with Alzheimer’s disease. Subsequent subgroup analysis reclassified seven factors from the neutral group as being positively associated with Alzheimer’s disease and four as negatively associated.
The investigators found grade I evidence that one environmental factor (ie, biochemical exposure to hyperhomocysteine) and one psychological factor (ie, depression) increased the risk of Alzheimer’s disease. Four medical exposures (ie, estrogen, statin, antihypertensive medication, and nonsteroidal anti-inflammatory therapy) and four dietary exposures (ie, folate, vitamin E, vitamin C, and coffee) were protective factors.
The meta-analysis also found grade I evidence that various medical conditions are associated with the risk of Alzheimer’s disease. Pre-existing conditions, including frailty, carotid atherosclerosis, hypertension, low diastolic blood pressure, and type II diabetes among Asians, increased risk, while previous history of arthritis, heart disease, metabolic syndrome, and cancer conferred protection.
Among lifestyle factors, low education, which has long been associated with a higher risk of Alzheimer’s disease, was identified as a risk factor. Other lifestyle factors such as smoking, alcohol consumption, and BMI influenced the risk of Alzheimer’s disease in contradictory ways at different ages. Those with high BMI at midlife only, and low BMI otherwise, had an increased risk of Alzheimer’s disease, while those with high BMI late in life had decreased risk. Current smoking, cognitive activity, stress, and light-to-moderate drinking were also associated with a decreased risk of Alzheimer’s disease. Interestingly, occupational exposures had little or no association with Alzheimer’s disease, the researchers noted.
—Linda Peckel
Interventions that target modifiable risk factors for Alzheimer’s disease hold promise for reducing the incidence of Alzheimer’s disease in the general population, according to a meta-analysis published in the December 2015 issue of Journal of Neurology, Neurosurgery and Psychiatry.
“Effective interventions in diet, medications, biochemical exposures, psychological condition, pre-existing disease, and lifestyle may decrease new incidence of Alzheimer’s disease,” said Jin-Tai Yu, MD, PhD, of the University of California San Francisco, and colleagues.
The causes of Alzheimer’s disease remain poorly understood, but genetic and environmental factors are believed to play a role. A 2011 study by Barnes and Yaffe indicated that nearly half of worldwide Alzheimer’s disease cases might be associated with seven common, potentially modifiable risk factors. To evaluate the association between Alzheimer’s disease and modifiable risk factors, Dr. Yu and colleagues conducted a meta-analysis of studies published in English between 1968 and July 2014. They identified 16,906 studies of potential risk factors for Alzheimer’s disease. Of those articles, they found 323 articles examining 93 separate factors that had associations with Alzheimer’s disease that met inclusion criteria for their meta-analysis. They assessed the quality of the evidence for each risk factor based on the heterogeneity of the pooled analyses and whether the pooled analyses included more than 5,000 people.
Seven general categories of modifiable risk factors emerged from their literature search, which were consistent with those identified in prior studies: pre-existing disease status, biochemical exposure, dietary factors, medical exposure to drugs or therapy, lifestyle, psychological conditions, and occupational exposures.
In their primary meta-analysis, Dr. Yu and colleagues identified 13 risk factors, 28 protective factors, and 52 factors that showed no association with Alzheimer’s disease. Subsequent subgroup analysis reclassified seven factors from the neutral group as being positively associated with Alzheimer’s disease and four as negatively associated.
The investigators found grade I evidence that one environmental factor (ie, biochemical exposure to hyperhomocysteine) and one psychological factor (ie, depression) increased the risk of Alzheimer’s disease. Four medical exposures (ie, estrogen, statin, antihypertensive medication, and nonsteroidal anti-inflammatory therapy) and four dietary exposures (ie, folate, vitamin E, vitamin C, and coffee) were protective factors.
The meta-analysis also found grade I evidence that various medical conditions are associated with the risk of Alzheimer’s disease. Pre-existing conditions, including frailty, carotid atherosclerosis, hypertension, low diastolic blood pressure, and type II diabetes among Asians, increased risk, while previous history of arthritis, heart disease, metabolic syndrome, and cancer conferred protection.
Among lifestyle factors, low education, which has long been associated with a higher risk of Alzheimer’s disease, was identified as a risk factor. Other lifestyle factors such as smoking, alcohol consumption, and BMI influenced the risk of Alzheimer’s disease in contradictory ways at different ages. Those with high BMI at midlife only, and low BMI otherwise, had an increased risk of Alzheimer’s disease, while those with high BMI late in life had decreased risk. Current smoking, cognitive activity, stress, and light-to-moderate drinking were also associated with a decreased risk of Alzheimer’s disease. Interestingly, occupational exposures had little or no association with Alzheimer’s disease, the researchers noted.
—Linda Peckel
Suggested Reading
Xu W, Tan L, Wang HF, et al. Meta-analysis of modifiable risk factors for Alzheimer’s disease. J Neurol Neurosurg Psychiatry. 2015;86:1299-1306.
Suggested Reading
Xu W, Tan L, Wang HF, et al. Meta-analysis of modifiable risk factors for Alzheimer’s disease. J Neurol Neurosurg Psychiatry. 2015;86:1299-1306.
High Headache Frequency Is More Likely During Perimenopause
Women in perimenopause are at increased risk of high-frequency headache, compared with premenopausal women, according to data published online ahead of print January 21 in Headache. Women in menopause also are at increased risk of high-frequency headache, but the effect of menopause on headache frequency may be mediated or confounded by medication overuse or depression.
“Our results confirm the commonly held belief that the perimenopause worsens headache, but challenge the idea that migraine ‘always’ improves during the menopause,” said Vincent T. Martin, MD, Professor of Internal Medicine in the University of Cincinnati’s (UC) Division of General Internal Medicine and codirector of the Headache and Facial Pain Program at the UC Neuroscience Institute. “Recognition of the increased risk of high-frequency headache during the menopausal transition suggests a need for optimized preventive treatment of migraine during this time of women’s life.”
Research has suggested a lower prevalence of headache or migraine during menopause, compared with premenopause. No previous studies have analyzed whether frequency of headache attacks changes during the menopausal transition among women with migraine, however. Dr. Martin and colleagues sought to determine whether the percentage of female migraineurs with high-frequency headache, defined as 10 or more days/month, is greater during the perimenopausal and menopausal time periods, compared with the premenopausal period. The researchers also set out to examine whether any increase in high-frequency headache during a particular reproductive phase was restricted to the early or late stages of the phase.
An Analysis of AMPP Data
To answer their questions, the investigators conducted a cross-sectional study using data from the American Migraine Prevalence and Prevention (AMPP) study. The AMPP researchers elicited data about headache from 162,756 respondents age 12 or older in 2004 and invited a random subset of 24,000 people age 18 or older with self-reported severe headache to participate in annual follow-up surveys for the subsequent five years. Follow-up surveys included questions about sociodemographics (eg, BMI, smoking, and household income) and headache types and characteristics, in addition to the Migraine Disability Assessment Score. Dr. Martin and colleagues examined data from the 2006 follow-up survey because it contained questions on the menstrual cycle.
Eligible participants in the cross-sectional study were women with a diagnosis of migraine between ages 35 and 65. Women who were pregnant, breastfeeding, had a history of hysterectomy or oophorectomy, or used hormonal therapies were excluded from the analysis. The investigators classified respondents as premenopause, perimenopause, and menopause according to Stages of Reproductive Aging Workshop criteria.
Late Perimenopause and Headache Frequency
The analysis included 3,664 women, of whom 3,454 had episodic migraine and 210 had chronic migraine. In all, 1,263 women were classified as premenopausal, 1,283 as perimenopausal, and 1,118 as menopausal. Compared with women in premenopause, women in perimenopause and menopause used more migraine preventives and were more likely to overuse medication.
Approximately 8% of premenopausal women had high-frequency headache, compared with 12.2% of perimenopausal women and 12.0% of postmenopausal women. After adjustments for sociodemographics alone, the odds ratios (ORs) of high-frequency headache were 1.62 for perimenopausal women and 1.76 for menopausal women, compared with premenopausal women. After adjustment for BMI, current migraine preventive use, medication overuse, and depression, the OR decreased, but remained significant in the perimenopausal group (OR, 1.42) and lost significance for the menopausal group (OR, 1.27). Depression and medication overuse significantly increased the likelihood of high-frequency headache.
When the researchers examined participants in the early and late stages of perimenopause and adjusted data for all covariates, women in late perimenopause had an increased likelihood of high-frequency headache (OR, 1.72), but women in early perimenopause had a statistically insignificant increased risk of this outcome (OR, 1.22), compared with premenopausal women. When the researchers examined the early and late stages of menopause, compared with premenopause, they found no significant difference in risk of high-frequency headache after controlling for all covariates.
Results Contradict Common Belief
“These results suggest that the hormonal milieu of the late perimenopause is particularly provocative for high-frequency headache among migraineurs,” said Dr. Martin. Because the researchers did not collect data on premenstrual syndrome (PMS) disorder, they could not determine whether the increased risk for high-frequency headache during perimenopause only occurred in female migraineurs with PMS or in the entire population.
Epidemiologic studies have contributed to an impression that migraine prevalence declines in menopausal women, but the current study’s results contradict this impression. “Our study used high-frequency headache as its primary outcome measure, rather than migraine prevalence. It is plausible that during menopause, migraine prevalence decreases and migraine attacks occur more frequently in subgroups of women,” said Dr. Martin. “Women, as they get older, develop lots of aches and pains, joint [pain], and back pain, and it is possible [that] their overuse of pain medications for headache and other conditions might actually drive an increase in headaches for the menopause group,” he added.
Estrogen withdrawal in the late luteal phase, low serum levels of estrogen or progesterone, and increased uterine prostaglandin release could precipitate headache during the menopausal transition, said the researchers. These hormonal changes also may change the characteristics of the menstrual cycle, which could in turn affect headache frequency.
An advantage of the cross-sectional analysis is that it was a large population-based study of persons with migraine “that should have wide generalizability to the general population,” said Dr. Martin. The outcome measure of high-frequency headache, however, was not limited to migraine, but included all headaches. In addition, headache frequency was self-reported, and investigators did not confirm it with daily headache diaries. Finally, the researchers did not account or control for aura. “Our results should be considered preliminary until confirmed in future studies,” Dr. Martin concluded.
—Erik Greb
Suggested Reading
Martin VT, Pavlovic J, Fanning KM, et al. Perimenopause and menopause are associated with high frequency headache in women with migraine: results of the American Migraine Prevalence and Prevention Study. Headache. 2016 Jan 21 [Epub ahead of print].
Women in perimenopause are at increased risk of high-frequency headache, compared with premenopausal women, according to data published online ahead of print January 21 in Headache. Women in menopause also are at increased risk of high-frequency headache, but the effect of menopause on headache frequency may be mediated or confounded by medication overuse or depression.
“Our results confirm the commonly held belief that the perimenopause worsens headache, but challenge the idea that migraine ‘always’ improves during the menopause,” said Vincent T. Martin, MD, Professor of Internal Medicine in the University of Cincinnati’s (UC) Division of General Internal Medicine and codirector of the Headache and Facial Pain Program at the UC Neuroscience Institute. “Recognition of the increased risk of high-frequency headache during the menopausal transition suggests a need for optimized preventive treatment of migraine during this time of women’s life.”
Research has suggested a lower prevalence of headache or migraine during menopause, compared with premenopause. No previous studies have analyzed whether frequency of headache attacks changes during the menopausal transition among women with migraine, however. Dr. Martin and colleagues sought to determine whether the percentage of female migraineurs with high-frequency headache, defined as 10 or more days/month, is greater during the perimenopausal and menopausal time periods, compared with the premenopausal period. The researchers also set out to examine whether any increase in high-frequency headache during a particular reproductive phase was restricted to the early or late stages of the phase.
An Analysis of AMPP Data
To answer their questions, the investigators conducted a cross-sectional study using data from the American Migraine Prevalence and Prevention (AMPP) study. The AMPP researchers elicited data about headache from 162,756 respondents age 12 or older in 2004 and invited a random subset of 24,000 people age 18 or older with self-reported severe headache to participate in annual follow-up surveys for the subsequent five years. Follow-up surveys included questions about sociodemographics (eg, BMI, smoking, and household income) and headache types and characteristics, in addition to the Migraine Disability Assessment Score. Dr. Martin and colleagues examined data from the 2006 follow-up survey because it contained questions on the menstrual cycle.
Eligible participants in the cross-sectional study were women with a diagnosis of migraine between ages 35 and 65. Women who were pregnant, breastfeeding, had a history of hysterectomy or oophorectomy, or used hormonal therapies were excluded from the analysis. The investigators classified respondents as premenopause, perimenopause, and menopause according to Stages of Reproductive Aging Workshop criteria.
Late Perimenopause and Headache Frequency
The analysis included 3,664 women, of whom 3,454 had episodic migraine and 210 had chronic migraine. In all, 1,263 women were classified as premenopausal, 1,283 as perimenopausal, and 1,118 as menopausal. Compared with women in premenopause, women in perimenopause and menopause used more migraine preventives and were more likely to overuse medication.
Approximately 8% of premenopausal women had high-frequency headache, compared with 12.2% of perimenopausal women and 12.0% of postmenopausal women. After adjustments for sociodemographics alone, the odds ratios (ORs) of high-frequency headache were 1.62 for perimenopausal women and 1.76 for menopausal women, compared with premenopausal women. After adjustment for BMI, current migraine preventive use, medication overuse, and depression, the OR decreased, but remained significant in the perimenopausal group (OR, 1.42) and lost significance for the menopausal group (OR, 1.27). Depression and medication overuse significantly increased the likelihood of high-frequency headache.
When the researchers examined participants in the early and late stages of perimenopause and adjusted data for all covariates, women in late perimenopause had an increased likelihood of high-frequency headache (OR, 1.72), but women in early perimenopause had a statistically insignificant increased risk of this outcome (OR, 1.22), compared with premenopausal women. When the researchers examined the early and late stages of menopause, compared with premenopause, they found no significant difference in risk of high-frequency headache after controlling for all covariates.
Results Contradict Common Belief
“These results suggest that the hormonal milieu of the late perimenopause is particularly provocative for high-frequency headache among migraineurs,” said Dr. Martin. Because the researchers did not collect data on premenstrual syndrome (PMS) disorder, they could not determine whether the increased risk for high-frequency headache during perimenopause only occurred in female migraineurs with PMS or in the entire population.
Epidemiologic studies have contributed to an impression that migraine prevalence declines in menopausal women, but the current study’s results contradict this impression. “Our study used high-frequency headache as its primary outcome measure, rather than migraine prevalence. It is plausible that during menopause, migraine prevalence decreases and migraine attacks occur more frequently in subgroups of women,” said Dr. Martin. “Women, as they get older, develop lots of aches and pains, joint [pain], and back pain, and it is possible [that] their overuse of pain medications for headache and other conditions might actually drive an increase in headaches for the menopause group,” he added.
Estrogen withdrawal in the late luteal phase, low serum levels of estrogen or progesterone, and increased uterine prostaglandin release could precipitate headache during the menopausal transition, said the researchers. These hormonal changes also may change the characteristics of the menstrual cycle, which could in turn affect headache frequency.
An advantage of the cross-sectional analysis is that it was a large population-based study of persons with migraine “that should have wide generalizability to the general population,” said Dr. Martin. The outcome measure of high-frequency headache, however, was not limited to migraine, but included all headaches. In addition, headache frequency was self-reported, and investigators did not confirm it with daily headache diaries. Finally, the researchers did not account or control for aura. “Our results should be considered preliminary until confirmed in future studies,” Dr. Martin concluded.
—Erik Greb
Women in perimenopause are at increased risk of high-frequency headache, compared with premenopausal women, according to data published online ahead of print January 21 in Headache. Women in menopause also are at increased risk of high-frequency headache, but the effect of menopause on headache frequency may be mediated or confounded by medication overuse or depression.
“Our results confirm the commonly held belief that the perimenopause worsens headache, but challenge the idea that migraine ‘always’ improves during the menopause,” said Vincent T. Martin, MD, Professor of Internal Medicine in the University of Cincinnati’s (UC) Division of General Internal Medicine and codirector of the Headache and Facial Pain Program at the UC Neuroscience Institute. “Recognition of the increased risk of high-frequency headache during the menopausal transition suggests a need for optimized preventive treatment of migraine during this time of women’s life.”
Research has suggested a lower prevalence of headache or migraine during menopause, compared with premenopause. No previous studies have analyzed whether frequency of headache attacks changes during the menopausal transition among women with migraine, however. Dr. Martin and colleagues sought to determine whether the percentage of female migraineurs with high-frequency headache, defined as 10 or more days/month, is greater during the perimenopausal and menopausal time periods, compared with the premenopausal period. The researchers also set out to examine whether any increase in high-frequency headache during a particular reproductive phase was restricted to the early or late stages of the phase.
An Analysis of AMPP Data
To answer their questions, the investigators conducted a cross-sectional study using data from the American Migraine Prevalence and Prevention (AMPP) study. The AMPP researchers elicited data about headache from 162,756 respondents age 12 or older in 2004 and invited a random subset of 24,000 people age 18 or older with self-reported severe headache to participate in annual follow-up surveys for the subsequent five years. Follow-up surveys included questions about sociodemographics (eg, BMI, smoking, and household income) and headache types and characteristics, in addition to the Migraine Disability Assessment Score. Dr. Martin and colleagues examined data from the 2006 follow-up survey because it contained questions on the menstrual cycle.
Eligible participants in the cross-sectional study were women with a diagnosis of migraine between ages 35 and 65. Women who were pregnant, breastfeeding, had a history of hysterectomy or oophorectomy, or used hormonal therapies were excluded from the analysis. The investigators classified respondents as premenopause, perimenopause, and menopause according to Stages of Reproductive Aging Workshop criteria.
Late Perimenopause and Headache Frequency
The analysis included 3,664 women, of whom 3,454 had episodic migraine and 210 had chronic migraine. In all, 1,263 women were classified as premenopausal, 1,283 as perimenopausal, and 1,118 as menopausal. Compared with women in premenopause, women in perimenopause and menopause used more migraine preventives and were more likely to overuse medication.
Approximately 8% of premenopausal women had high-frequency headache, compared with 12.2% of perimenopausal women and 12.0% of postmenopausal women. After adjustments for sociodemographics alone, the odds ratios (ORs) of high-frequency headache were 1.62 for perimenopausal women and 1.76 for menopausal women, compared with premenopausal women. After adjustment for BMI, current migraine preventive use, medication overuse, and depression, the OR decreased, but remained significant in the perimenopausal group (OR, 1.42) and lost significance for the menopausal group (OR, 1.27). Depression and medication overuse significantly increased the likelihood of high-frequency headache.
When the researchers examined participants in the early and late stages of perimenopause and adjusted data for all covariates, women in late perimenopause had an increased likelihood of high-frequency headache (OR, 1.72), but women in early perimenopause had a statistically insignificant increased risk of this outcome (OR, 1.22), compared with premenopausal women. When the researchers examined the early and late stages of menopause, compared with premenopause, they found no significant difference in risk of high-frequency headache after controlling for all covariates.
Results Contradict Common Belief
“These results suggest that the hormonal milieu of the late perimenopause is particularly provocative for high-frequency headache among migraineurs,” said Dr. Martin. Because the researchers did not collect data on premenstrual syndrome (PMS) disorder, they could not determine whether the increased risk for high-frequency headache during perimenopause only occurred in female migraineurs with PMS or in the entire population.
Epidemiologic studies have contributed to an impression that migraine prevalence declines in menopausal women, but the current study’s results contradict this impression. “Our study used high-frequency headache as its primary outcome measure, rather than migraine prevalence. It is plausible that during menopause, migraine prevalence decreases and migraine attacks occur more frequently in subgroups of women,” said Dr. Martin. “Women, as they get older, develop lots of aches and pains, joint [pain], and back pain, and it is possible [that] their overuse of pain medications for headache and other conditions might actually drive an increase in headaches for the menopause group,” he added.
Estrogen withdrawal in the late luteal phase, low serum levels of estrogen or progesterone, and increased uterine prostaglandin release could precipitate headache during the menopausal transition, said the researchers. These hormonal changes also may change the characteristics of the menstrual cycle, which could in turn affect headache frequency.
An advantage of the cross-sectional analysis is that it was a large population-based study of persons with migraine “that should have wide generalizability to the general population,” said Dr. Martin. The outcome measure of high-frequency headache, however, was not limited to migraine, but included all headaches. In addition, headache frequency was self-reported, and investigators did not confirm it with daily headache diaries. Finally, the researchers did not account or control for aura. “Our results should be considered preliminary until confirmed in future studies,” Dr. Martin concluded.
—Erik Greb
Suggested Reading
Martin VT, Pavlovic J, Fanning KM, et al. Perimenopause and menopause are associated with high frequency headache in women with migraine: results of the American Migraine Prevalence and Prevention Study. Headache. 2016 Jan 21 [Epub ahead of print].
Suggested Reading
Martin VT, Pavlovic J, Fanning KM, et al. Perimenopause and menopause are associated with high frequency headache in women with migraine: results of the American Migraine Prevalence and Prevention Study. Headache. 2016 Jan 21 [Epub ahead of print].
Atrial Fibrillation Is Associated With an Increased Risk of Dementia
Atrial fibrillation entails an increased risk of dementia, even among people who never have a stroke, according to a prospective population-based cohort study published November 1, 2015, in JAMA Neurology. After adjusting for confounders such as age, sex, and cardiovascular risk factors, the investigators found that the 34% increased risk of dementia in individuals who develop atrial fibrillation, relative to those who do not, was essentially unchanged in people with or without a history of stroke.
The association between atrial fibrillation and risk of dementia in this study, which included more than 81,000 person-years of follow-up, was stronger in participants whose rhythm disturbance had an onset before age 67, compared with onset at a later age. Moreover, a longer duration of atrial fibrillation in younger individuals was associated with an increasing risk of dementia, implying a dose response, according to the study authors, who were led by M. Arfan Ikram, MD, PhD, of the Departments of Epidemiology and Radiology at Erasmus Medical Center in Rotterdam, the Netherlands.
This association is consistent with other risk factors linked with dementia, such as hypertension, hypercholesterolemia, and obesity, for which the association strengthens with earlier onset and longer duration, according to the authors. The clinical implication is that control of any or all of these risk factors might reduce the risk of subsequent dementia, even though the authors acknowledged that no protective effect from the control of atrial fibrillation could be derived from this study.
An Analysis of the Rotterdam Study
This dementia analysis was embedded in the Rotterdam Study, which investigates chronic diseases in the elderly and began enrolling individuals age 55 or older in 1989. Participants were screened for rhythm abnormalities and dementia at baseline. Follow-up examinations have been conducted every three to four years. Participants with atrial flutter were grouped with those who had atrial fibrillation because, according to the authors, the risk factors and consequences of these arrhythmias are similar.
Of the 6,514 participants evaluated, 318 had atrial fibrillation at baseline, which was classified as prevalent atrial fibrillation, and 6,196 did not. Of those without atrial fibrillation, 723 (11.7%) developed atrial fibrillation during follow-up, which was classified as incident atrial fibrillation. The relative rates of dementia were assessed for prevalent and incident atrial fibrillation, relative to the absence of atrial fibrillation.
A history of stroke at baseline was an exclusion factor, but the analysis included participants who had a stroke during the course of follow-up. Stroke occurred in approximately 3% of the study population. The relative risk of dementia was then calculated for participants with and without a history of stroke. This study also analyzed the association between atrial fibrillation and risk of Alzheimer’s disease as a specific subset of dementia.
Association With Alzheimer’s Disease Was Not Significant
Among cases of prevalent atrial fibrillation, the association of atrial fibrillation with dementia reached significance for the study population overall (hazard ratio [HR], 1.34) and for participation censored for stroke (HR, 1.35). Among cases of incident atrial fibrillation, the same patterns were observed, but fell short of statistical significance (HR, 1.13 including stroke and HR, 1.14 censored for stroke).
For the risk of Alzheimer’s disease in participants with prevalent atrial fibrillation, the trend for an association, although not significant, was strong and similar with or without the inclusion of stroke cases (HR, 1.29 including stroke and HR, 1.28 censored for stroke). Among patients with incident atrial fibrillation, the same nonsignificant trends were seen.
When the analysis was stratified by age, strong but nonsignificant trends were observed for participants age 67 or older, particularly for those with prevalent atrial fibrillation (HR, 1.28). For people younger than 67, the risk of dementia also fell short of significance for people with prevalent (HR, 1.91) and incident atrial fibrillation (HR, 1.81), but the risk of dementia climbed incrementally with longer duration of follow-up. The strongest association between atrial fibrillation and risk of dementia was in the younger group with incident atrial fibrillation followed more than 12 years. In these participants, the dementia risk was more than threefold higher, relative to those without atrial fibrillation (HR, 3.30). The correlation between duration of atrial fibrillation and dementia risk was highly significant.
Previous Findings Were Inconsistent
Previous studies have looked for an association between atrial fibrillation and dementia, but findings have been inconsistent. Methodologic problems, such as small samples sizes, may be the reason for this inconsistency, according to the authors of this most recent study. Although this study has the advantages of a prospective design, a larger sample size, and adjustment for potential confounders, the authors acknowledged potential weaknesses. In particular, they expressed concern about their inability to control for the impact of treatment of atrial fibrillation on dementia risk.
Particularly strong support for a link between atrial fibrillation and dementia can be drawn from the increasing strength of this association and longer duration of atrial fibrillation, according to the authors. Of potential mechanisms to explain this association, the authors cited the hypothesis that atrial fibrillation produces impaired blood flow and cerebral hypoperfusion. They cited experimental work linking this hypoperfusion to neuronal damage, but suggested that more data are needed to confirm clinically relevant effects.
As for prevention of dementia, one published study has linked catheter ablation for atrial fibrillation with a reduced risk of dementia, relative to no treatment, according to the authors. Randomized studies are needed, however, to test whether patients with atrial fibrillation who are successfully restored to sinus rhythm have a reduced risk of dementia, the authors suggested. Based on this study, a trial would be particularly appropriate in patients who develop atrial fibrillation before age 67.
—Ted Bosworth
Suggested Reading
de Bruijn RF, Heeringa J, Wolters FJ, et al. Association between atrial fibrillation and dementia in the general population. JAMA Neurol. 2015;72(11):1288-1294.
Atrial fibrillation entails an increased risk of dementia, even among people who never have a stroke, according to a prospective population-based cohort study published November 1, 2015, in JAMA Neurology. After adjusting for confounders such as age, sex, and cardiovascular risk factors, the investigators found that the 34% increased risk of dementia in individuals who develop atrial fibrillation, relative to those who do not, was essentially unchanged in people with or without a history of stroke.
The association between atrial fibrillation and risk of dementia in this study, which included more than 81,000 person-years of follow-up, was stronger in participants whose rhythm disturbance had an onset before age 67, compared with onset at a later age. Moreover, a longer duration of atrial fibrillation in younger individuals was associated with an increasing risk of dementia, implying a dose response, according to the study authors, who were led by M. Arfan Ikram, MD, PhD, of the Departments of Epidemiology and Radiology at Erasmus Medical Center in Rotterdam, the Netherlands.
This association is consistent with other risk factors linked with dementia, such as hypertension, hypercholesterolemia, and obesity, for which the association strengthens with earlier onset and longer duration, according to the authors. The clinical implication is that control of any or all of these risk factors might reduce the risk of subsequent dementia, even though the authors acknowledged that no protective effect from the control of atrial fibrillation could be derived from this study.
An Analysis of the Rotterdam Study
This dementia analysis was embedded in the Rotterdam Study, which investigates chronic diseases in the elderly and began enrolling individuals age 55 or older in 1989. Participants were screened for rhythm abnormalities and dementia at baseline. Follow-up examinations have been conducted every three to four years. Participants with atrial flutter were grouped with those who had atrial fibrillation because, according to the authors, the risk factors and consequences of these arrhythmias are similar.
Of the 6,514 participants evaluated, 318 had atrial fibrillation at baseline, which was classified as prevalent atrial fibrillation, and 6,196 did not. Of those without atrial fibrillation, 723 (11.7%) developed atrial fibrillation during follow-up, which was classified as incident atrial fibrillation. The relative rates of dementia were assessed for prevalent and incident atrial fibrillation, relative to the absence of atrial fibrillation.
A history of stroke at baseline was an exclusion factor, but the analysis included participants who had a stroke during the course of follow-up. Stroke occurred in approximately 3% of the study population. The relative risk of dementia was then calculated for participants with and without a history of stroke. This study also analyzed the association between atrial fibrillation and risk of Alzheimer’s disease as a specific subset of dementia.
Association With Alzheimer’s Disease Was Not Significant
Among cases of prevalent atrial fibrillation, the association of atrial fibrillation with dementia reached significance for the study population overall (hazard ratio [HR], 1.34) and for participation censored for stroke (HR, 1.35). Among cases of incident atrial fibrillation, the same patterns were observed, but fell short of statistical significance (HR, 1.13 including stroke and HR, 1.14 censored for stroke).
For the risk of Alzheimer’s disease in participants with prevalent atrial fibrillation, the trend for an association, although not significant, was strong and similar with or without the inclusion of stroke cases (HR, 1.29 including stroke and HR, 1.28 censored for stroke). Among patients with incident atrial fibrillation, the same nonsignificant trends were seen.
When the analysis was stratified by age, strong but nonsignificant trends were observed for participants age 67 or older, particularly for those with prevalent atrial fibrillation (HR, 1.28). For people younger than 67, the risk of dementia also fell short of significance for people with prevalent (HR, 1.91) and incident atrial fibrillation (HR, 1.81), but the risk of dementia climbed incrementally with longer duration of follow-up. The strongest association between atrial fibrillation and risk of dementia was in the younger group with incident atrial fibrillation followed more than 12 years. In these participants, the dementia risk was more than threefold higher, relative to those without atrial fibrillation (HR, 3.30). The correlation between duration of atrial fibrillation and dementia risk was highly significant.
Previous Findings Were Inconsistent
Previous studies have looked for an association between atrial fibrillation and dementia, but findings have been inconsistent. Methodologic problems, such as small samples sizes, may be the reason for this inconsistency, according to the authors of this most recent study. Although this study has the advantages of a prospective design, a larger sample size, and adjustment for potential confounders, the authors acknowledged potential weaknesses. In particular, they expressed concern about their inability to control for the impact of treatment of atrial fibrillation on dementia risk.
Particularly strong support for a link between atrial fibrillation and dementia can be drawn from the increasing strength of this association and longer duration of atrial fibrillation, according to the authors. Of potential mechanisms to explain this association, the authors cited the hypothesis that atrial fibrillation produces impaired blood flow and cerebral hypoperfusion. They cited experimental work linking this hypoperfusion to neuronal damage, but suggested that more data are needed to confirm clinically relevant effects.
As for prevention of dementia, one published study has linked catheter ablation for atrial fibrillation with a reduced risk of dementia, relative to no treatment, according to the authors. Randomized studies are needed, however, to test whether patients with atrial fibrillation who are successfully restored to sinus rhythm have a reduced risk of dementia, the authors suggested. Based on this study, a trial would be particularly appropriate in patients who develop atrial fibrillation before age 67.
—Ted Bosworth
Atrial fibrillation entails an increased risk of dementia, even among people who never have a stroke, according to a prospective population-based cohort study published November 1, 2015, in JAMA Neurology. After adjusting for confounders such as age, sex, and cardiovascular risk factors, the investigators found that the 34% increased risk of dementia in individuals who develop atrial fibrillation, relative to those who do not, was essentially unchanged in people with or without a history of stroke.
The association between atrial fibrillation and risk of dementia in this study, which included more than 81,000 person-years of follow-up, was stronger in participants whose rhythm disturbance had an onset before age 67, compared with onset at a later age. Moreover, a longer duration of atrial fibrillation in younger individuals was associated with an increasing risk of dementia, implying a dose response, according to the study authors, who were led by M. Arfan Ikram, MD, PhD, of the Departments of Epidemiology and Radiology at Erasmus Medical Center in Rotterdam, the Netherlands.
This association is consistent with other risk factors linked with dementia, such as hypertension, hypercholesterolemia, and obesity, for which the association strengthens with earlier onset and longer duration, according to the authors. The clinical implication is that control of any or all of these risk factors might reduce the risk of subsequent dementia, even though the authors acknowledged that no protective effect from the control of atrial fibrillation could be derived from this study.
An Analysis of the Rotterdam Study
This dementia analysis was embedded in the Rotterdam Study, which investigates chronic diseases in the elderly and began enrolling individuals age 55 or older in 1989. Participants were screened for rhythm abnormalities and dementia at baseline. Follow-up examinations have been conducted every three to four years. Participants with atrial flutter were grouped with those who had atrial fibrillation because, according to the authors, the risk factors and consequences of these arrhythmias are similar.
Of the 6,514 participants evaluated, 318 had atrial fibrillation at baseline, which was classified as prevalent atrial fibrillation, and 6,196 did not. Of those without atrial fibrillation, 723 (11.7%) developed atrial fibrillation during follow-up, which was classified as incident atrial fibrillation. The relative rates of dementia were assessed for prevalent and incident atrial fibrillation, relative to the absence of atrial fibrillation.
A history of stroke at baseline was an exclusion factor, but the analysis included participants who had a stroke during the course of follow-up. Stroke occurred in approximately 3% of the study population. The relative risk of dementia was then calculated for participants with and without a history of stroke. This study also analyzed the association between atrial fibrillation and risk of Alzheimer’s disease as a specific subset of dementia.
Association With Alzheimer’s Disease Was Not Significant
Among cases of prevalent atrial fibrillation, the association of atrial fibrillation with dementia reached significance for the study population overall (hazard ratio [HR], 1.34) and for participation censored for stroke (HR, 1.35). Among cases of incident atrial fibrillation, the same patterns were observed, but fell short of statistical significance (HR, 1.13 including stroke and HR, 1.14 censored for stroke).
For the risk of Alzheimer’s disease in participants with prevalent atrial fibrillation, the trend for an association, although not significant, was strong and similar with or without the inclusion of stroke cases (HR, 1.29 including stroke and HR, 1.28 censored for stroke). Among patients with incident atrial fibrillation, the same nonsignificant trends were seen.
When the analysis was stratified by age, strong but nonsignificant trends were observed for participants age 67 or older, particularly for those with prevalent atrial fibrillation (HR, 1.28). For people younger than 67, the risk of dementia also fell short of significance for people with prevalent (HR, 1.91) and incident atrial fibrillation (HR, 1.81), but the risk of dementia climbed incrementally with longer duration of follow-up. The strongest association between atrial fibrillation and risk of dementia was in the younger group with incident atrial fibrillation followed more than 12 years. In these participants, the dementia risk was more than threefold higher, relative to those without atrial fibrillation (HR, 3.30). The correlation between duration of atrial fibrillation and dementia risk was highly significant.
Previous Findings Were Inconsistent
Previous studies have looked for an association between atrial fibrillation and dementia, but findings have been inconsistent. Methodologic problems, such as small samples sizes, may be the reason for this inconsistency, according to the authors of this most recent study. Although this study has the advantages of a prospective design, a larger sample size, and adjustment for potential confounders, the authors acknowledged potential weaknesses. In particular, they expressed concern about their inability to control for the impact of treatment of atrial fibrillation on dementia risk.
Particularly strong support for a link between atrial fibrillation and dementia can be drawn from the increasing strength of this association and longer duration of atrial fibrillation, according to the authors. Of potential mechanisms to explain this association, the authors cited the hypothesis that atrial fibrillation produces impaired blood flow and cerebral hypoperfusion. They cited experimental work linking this hypoperfusion to neuronal damage, but suggested that more data are needed to confirm clinically relevant effects.
As for prevention of dementia, one published study has linked catheter ablation for atrial fibrillation with a reduced risk of dementia, relative to no treatment, according to the authors. Randomized studies are needed, however, to test whether patients with atrial fibrillation who are successfully restored to sinus rhythm have a reduced risk of dementia, the authors suggested. Based on this study, a trial would be particularly appropriate in patients who develop atrial fibrillation before age 67.
—Ted Bosworth
Suggested Reading
de Bruijn RF, Heeringa J, Wolters FJ, et al. Association between atrial fibrillation and dementia in the general population. JAMA Neurol. 2015;72(11):1288-1294.
Suggested Reading
de Bruijn RF, Heeringa J, Wolters FJ, et al. Association between atrial fibrillation and dementia in the general population. JAMA Neurol. 2015;72(11):1288-1294.
Adoption of Choosing Wisely Recommendations Slow to Catch On
Clinical question: Have the Choosing Wisely campaign recommendations led to changes in practice?
Background: The Choosing Wisely campaign aims to reduce the incidence of low-value care by providing evidence-based recommendations for common clinical situations. The rate of adoption of these recommendations is unknown.
Study design: Retrospective review.
Setting: Anthem insurance members.
Synopsis: The study examined the claims data from 25 million Anthem insurance members to compare the rate of services that were targeted by seven Choosing Wisely campaign recommendations before and after the recommendations were published in 2012.
Investigators found the incidence of two of the services declined after the Choosing Wisely recommendations were published; the other five services remained stable or increased slightly. Furthermore, the declines were statistically significant but not a marked absolute difference, with the incidence of head imaging in patients with uncomplicated headaches going down to 13.4% from 14.9% and the use of cardiac imaging in the absence of cardiac disease declining to 9.7% from 10.8%.
The main limitations are the narrow population of Anthem insurance members and the lack of specific data that could help answer why clinical practice has not changed, but that could be the aim of future studies.
Bottom line: Choosing Wisely recommendations have not been adopted on a population level; widespread implementation likely will require financial incentives, provider-level data feedback, and systems interventions.
Citation: Rosenberg A, Agiro A, Gottlieb M, et al. Early trends among seven recommendations from the Choosing Wisely campaign. JAMA Intern Med. 2015;175(12):1913-1920. doi:10.1001/jamainternmed.2015.5441.
Clinical question: Have the Choosing Wisely campaign recommendations led to changes in practice?
Background: The Choosing Wisely campaign aims to reduce the incidence of low-value care by providing evidence-based recommendations for common clinical situations. The rate of adoption of these recommendations is unknown.
Study design: Retrospective review.
Setting: Anthem insurance members.
Synopsis: The study examined the claims data from 25 million Anthem insurance members to compare the rate of services that were targeted by seven Choosing Wisely campaign recommendations before and after the recommendations were published in 2012.
Investigators found the incidence of two of the services declined after the Choosing Wisely recommendations were published; the other five services remained stable or increased slightly. Furthermore, the declines were statistically significant but not a marked absolute difference, with the incidence of head imaging in patients with uncomplicated headaches going down to 13.4% from 14.9% and the use of cardiac imaging in the absence of cardiac disease declining to 9.7% from 10.8%.
The main limitations are the narrow population of Anthem insurance members and the lack of specific data that could help answer why clinical practice has not changed, but that could be the aim of future studies.
Bottom line: Choosing Wisely recommendations have not been adopted on a population level; widespread implementation likely will require financial incentives, provider-level data feedback, and systems interventions.
Citation: Rosenberg A, Agiro A, Gottlieb M, et al. Early trends among seven recommendations from the Choosing Wisely campaign. JAMA Intern Med. 2015;175(12):1913-1920. doi:10.1001/jamainternmed.2015.5441.
Clinical question: Have the Choosing Wisely campaign recommendations led to changes in practice?
Background: The Choosing Wisely campaign aims to reduce the incidence of low-value care by providing evidence-based recommendations for common clinical situations. The rate of adoption of these recommendations is unknown.
Study design: Retrospective review.
Setting: Anthem insurance members.
Synopsis: The study examined the claims data from 25 million Anthem insurance members to compare the rate of services that were targeted by seven Choosing Wisely campaign recommendations before and after the recommendations were published in 2012.
Investigators found the incidence of two of the services declined after the Choosing Wisely recommendations were published; the other five services remained stable or increased slightly. Furthermore, the declines were statistically significant but not a marked absolute difference, with the incidence of head imaging in patients with uncomplicated headaches going down to 13.4% from 14.9% and the use of cardiac imaging in the absence of cardiac disease declining to 9.7% from 10.8%.
The main limitations are the narrow population of Anthem insurance members and the lack of specific data that could help answer why clinical practice has not changed, but that could be the aim of future studies.
Bottom line: Choosing Wisely recommendations have not been adopted on a population level; widespread implementation likely will require financial incentives, provider-level data feedback, and systems interventions.
Citation: Rosenberg A, Agiro A, Gottlieb M, et al. Early trends among seven recommendations from the Choosing Wisely campaign. JAMA Intern Med. 2015;175(12):1913-1920. doi:10.1001/jamainternmed.2015.5441.
Overall Patient Satisfaction Better on Hospitalist Teams Compared with Teaching Teams
Clinical question: Is there a difference in patient experience on hospitalist teams compared with teaching teams?
Background: Hospitalist-intensive hospitals tend to perform better on patient-satisfaction measures on HCAHPS survey; however, little is known about the difference in patient experience between patients cared for by hospitalist and trainee teams.
Study design: Retrospective cohort analysis.
Setting: University of Chicago Medical Center.
Synopsis: A 30-day post-discharge survey was sent to 14,855 patients cared for by hospitalist and teaching teams, with 57% of teaching and 31% of hospitalist team patients returning fully completed surveys. A higher percentage of hospitalist team patients reported satisfaction with their overall care (73% vs. 67%; P<0.001; regression model odds ratio = 1.33; 95% CI, 1.15–1.47). There was no statistically significant difference in patient satisfaction with the teamwork of their providers, confidence in identifying their provider, or ability to understand the role of their provider.
Other than the inability to mitigate response-selection bias, the main limitation of this study is the single-center setting, which impacts the generalizability of the findings. Hospital-specific factors like different services and structures (hospitalists at their institution care for renal and lung transplant and oncology patients) could influence patients’ perception of their care. More research needs to be done to determine the specific factors that lead to a better patient experience.
Bottom line: At a single academic center, overall patient satisfaction was higher on a hospitalist service compared with teaching teams.
Citation: Wray CM, Flores A, Padula WV, Prochaska MT, Meltzer DO, Arora VM. Measuring patient experiences on hospitalist and teaching services: patient responses to a 30-day postdischarge questionnaire [published online ahead of print September 18, 2015]. J Hosp Med. doi:10.1002/jhm.2485.
Clinical question: Is there a difference in patient experience on hospitalist teams compared with teaching teams?
Background: Hospitalist-intensive hospitals tend to perform better on patient-satisfaction measures on HCAHPS survey; however, little is known about the difference in patient experience between patients cared for by hospitalist and trainee teams.
Study design: Retrospective cohort analysis.
Setting: University of Chicago Medical Center.
Synopsis: A 30-day post-discharge survey was sent to 14,855 patients cared for by hospitalist and teaching teams, with 57% of teaching and 31% of hospitalist team patients returning fully completed surveys. A higher percentage of hospitalist team patients reported satisfaction with their overall care (73% vs. 67%; P<0.001; regression model odds ratio = 1.33; 95% CI, 1.15–1.47). There was no statistically significant difference in patient satisfaction with the teamwork of their providers, confidence in identifying their provider, or ability to understand the role of their provider.
Other than the inability to mitigate response-selection bias, the main limitation of this study is the single-center setting, which impacts the generalizability of the findings. Hospital-specific factors like different services and structures (hospitalists at their institution care for renal and lung transplant and oncology patients) could influence patients’ perception of their care. More research needs to be done to determine the specific factors that lead to a better patient experience.
Bottom line: At a single academic center, overall patient satisfaction was higher on a hospitalist service compared with teaching teams.
Citation: Wray CM, Flores A, Padula WV, Prochaska MT, Meltzer DO, Arora VM. Measuring patient experiences on hospitalist and teaching services: patient responses to a 30-day postdischarge questionnaire [published online ahead of print September 18, 2015]. J Hosp Med. doi:10.1002/jhm.2485.
Clinical question: Is there a difference in patient experience on hospitalist teams compared with teaching teams?
Background: Hospitalist-intensive hospitals tend to perform better on patient-satisfaction measures on HCAHPS survey; however, little is known about the difference in patient experience between patients cared for by hospitalist and trainee teams.
Study design: Retrospective cohort analysis.
Setting: University of Chicago Medical Center.
Synopsis: A 30-day post-discharge survey was sent to 14,855 patients cared for by hospitalist and teaching teams, with 57% of teaching and 31% of hospitalist team patients returning fully completed surveys. A higher percentage of hospitalist team patients reported satisfaction with their overall care (73% vs. 67%; P<0.001; regression model odds ratio = 1.33; 95% CI, 1.15–1.47). There was no statistically significant difference in patient satisfaction with the teamwork of their providers, confidence in identifying their provider, or ability to understand the role of their provider.
Other than the inability to mitigate response-selection bias, the main limitation of this study is the single-center setting, which impacts the generalizability of the findings. Hospital-specific factors like different services and structures (hospitalists at their institution care for renal and lung transplant and oncology patients) could influence patients’ perception of their care. More research needs to be done to determine the specific factors that lead to a better patient experience.
Bottom line: At a single academic center, overall patient satisfaction was higher on a hospitalist service compared with teaching teams.
Citation: Wray CM, Flores A, Padula WV, Prochaska MT, Meltzer DO, Arora VM. Measuring patient experiences on hospitalist and teaching services: patient responses to a 30-day postdischarge questionnaire [published online ahead of print September 18, 2015]. J Hosp Med. doi:10.1002/jhm.2485.
Caprini Score Accurately Predicts Risk of Venous Thromboembolism in Critically Ill Surgical Patients
Clinical question: Is the Caprini risk assessment model (RAM) a valid tool to predict venous thromboembolism (VTE) risk in critically ill surgical patients?
Background: VTE is a major source of morbidity and mortality among hospitalized patients; prevention is critical to reduce morbidity and cut healthcare costs. Risk assessment is important to determine thromboprophylaxis, yet data are lacking regarding an appropriate tool for risk stratification in the critically ill.
Study design: Retrospective cohort.
Setting: University of Michigan Health System; 20-bed surgical ICU at an academic hospital.
Synopsis: This study included 4,844 surgical ICU patients. Primary outcome was VTE during the patient’s hospital admission. A retrospective risk scoring method based on the 2005 Caprini RAM was used to calculate the risk for all patients at the time of ICU admission. Patients were divided into low (Caprini score 0–2), moderate, high, highest, and super-high (Caprini score > 8) risk levels. The incidence of VTE increased in linear fashion with increasing Caprini score.
This study was limited to one academic medical center. The retrospective scoring model limits the ability to identify all patient risk factors. VTE outcomes were reported only for the length of hospitalization and did not include post-discharge follow-up. Replicating this study across a larger patient population and performing a prospective study with follow-up after discharge would address these limitations.
Bottom line: The Caprini risk assessment model is a valid instrument to assess VTE risk in critically ill surgical patients.
Citation: Obi AT, Pannucci CJ, Nackashi A, et al. Validation of the Caprini venous thromboembolism risk assessment model in critically ill surgical patients. JAMA Surg. 2015;150(10):941-948.
Clinical question: Is the Caprini risk assessment model (RAM) a valid tool to predict venous thromboembolism (VTE) risk in critically ill surgical patients?
Background: VTE is a major source of morbidity and mortality among hospitalized patients; prevention is critical to reduce morbidity and cut healthcare costs. Risk assessment is important to determine thromboprophylaxis, yet data are lacking regarding an appropriate tool for risk stratification in the critically ill.
Study design: Retrospective cohort.
Setting: University of Michigan Health System; 20-bed surgical ICU at an academic hospital.
Synopsis: This study included 4,844 surgical ICU patients. Primary outcome was VTE during the patient’s hospital admission. A retrospective risk scoring method based on the 2005 Caprini RAM was used to calculate the risk for all patients at the time of ICU admission. Patients were divided into low (Caprini score 0–2), moderate, high, highest, and super-high (Caprini score > 8) risk levels. The incidence of VTE increased in linear fashion with increasing Caprini score.
This study was limited to one academic medical center. The retrospective scoring model limits the ability to identify all patient risk factors. VTE outcomes were reported only for the length of hospitalization and did not include post-discharge follow-up. Replicating this study across a larger patient population and performing a prospective study with follow-up after discharge would address these limitations.
Bottom line: The Caprini risk assessment model is a valid instrument to assess VTE risk in critically ill surgical patients.
Citation: Obi AT, Pannucci CJ, Nackashi A, et al. Validation of the Caprini venous thromboembolism risk assessment model in critically ill surgical patients. JAMA Surg. 2015;150(10):941-948.
Clinical question: Is the Caprini risk assessment model (RAM) a valid tool to predict venous thromboembolism (VTE) risk in critically ill surgical patients?
Background: VTE is a major source of morbidity and mortality among hospitalized patients; prevention is critical to reduce morbidity and cut healthcare costs. Risk assessment is important to determine thromboprophylaxis, yet data are lacking regarding an appropriate tool for risk stratification in the critically ill.
Study design: Retrospective cohort.
Setting: University of Michigan Health System; 20-bed surgical ICU at an academic hospital.
Synopsis: This study included 4,844 surgical ICU patients. Primary outcome was VTE during the patient’s hospital admission. A retrospective risk scoring method based on the 2005 Caprini RAM was used to calculate the risk for all patients at the time of ICU admission. Patients were divided into low (Caprini score 0–2), moderate, high, highest, and super-high (Caprini score > 8) risk levels. The incidence of VTE increased in linear fashion with increasing Caprini score.
This study was limited to one academic medical center. The retrospective scoring model limits the ability to identify all patient risk factors. VTE outcomes were reported only for the length of hospitalization and did not include post-discharge follow-up. Replicating this study across a larger patient population and performing a prospective study with follow-up after discharge would address these limitations.
Bottom line: The Caprini risk assessment model is a valid instrument to assess VTE risk in critically ill surgical patients.
Citation: Obi AT, Pannucci CJ, Nackashi A, et al. Validation of the Caprini venous thromboembolism risk assessment model in critically ill surgical patients. JAMA Surg. 2015;150(10):941-948.
Total Knee Replacement Superior to Non-Surgical Intervention
Clinical question: Does total knee replacement followed by a 12-week non-surgical treatment program provide greater pain relief and improvement in function and quality of life than non-surgical treatment alone?
Background: The number of total knee replacements in the U.S. has increased dramatically since the 1970s and is expected to continue to rise. To date, evidence to support the effectiveness of surgical intervention compared to non-surgical intervention is lacking.
Study design: Randomized, controlled trial.
Setting: Aalborg University Hospital Outpatient Clinics, Denmark.
Synopsis: One hundred patients with osteoarthritis were randomly assigned to undergo total knee replacement followed by 12 weeks of non-surgical treatment or to receive only 12 weeks of non-surgical treatment. The non-surgical treatment program consisted of exercise, education, dietary advice, insoles, and pain medication. Change from baseline to 12 months was assessed using the Knee Injury and Osteoarthritis Outcome Score (KOOS).
The total knee replacement group had a significantly greater improvement in the KOOS score than did the non-surgical group. Serious adverse events were more common in the total knee replacement group.
The study did not include a sham-surgery control group. It is unknown whether the KOOS pain subscale is generalizable to patients with severe pain. Additionally, the intensity of non-surgical treatment may have differed between groups.
Bottom line: Total knee replacement followed by non-surgical treatment is more efficacious than non-surgical treatment alone in providing pain relief and improving function and quality of life, but it is associated with higher number of adverse events.
Citation: Skou ST, Roos EM, Laursen MB, et al. A randomized, controlled trial of total knee replacement. N Engl J Med. 2015;373(17):1597-1606.
Clinical question: Does total knee replacement followed by a 12-week non-surgical treatment program provide greater pain relief and improvement in function and quality of life than non-surgical treatment alone?
Background: The number of total knee replacements in the U.S. has increased dramatically since the 1970s and is expected to continue to rise. To date, evidence to support the effectiveness of surgical intervention compared to non-surgical intervention is lacking.
Study design: Randomized, controlled trial.
Setting: Aalborg University Hospital Outpatient Clinics, Denmark.
Synopsis: One hundred patients with osteoarthritis were randomly assigned to undergo total knee replacement followed by 12 weeks of non-surgical treatment or to receive only 12 weeks of non-surgical treatment. The non-surgical treatment program consisted of exercise, education, dietary advice, insoles, and pain medication. Change from baseline to 12 months was assessed using the Knee Injury and Osteoarthritis Outcome Score (KOOS).
The total knee replacement group had a significantly greater improvement in the KOOS score than did the non-surgical group. Serious adverse events were more common in the total knee replacement group.
The study did not include a sham-surgery control group. It is unknown whether the KOOS pain subscale is generalizable to patients with severe pain. Additionally, the intensity of non-surgical treatment may have differed between groups.
Bottom line: Total knee replacement followed by non-surgical treatment is more efficacious than non-surgical treatment alone in providing pain relief and improving function and quality of life, but it is associated with higher number of adverse events.
Citation: Skou ST, Roos EM, Laursen MB, et al. A randomized, controlled trial of total knee replacement. N Engl J Med. 2015;373(17):1597-1606.
Clinical question: Does total knee replacement followed by a 12-week non-surgical treatment program provide greater pain relief and improvement in function and quality of life than non-surgical treatment alone?
Background: The number of total knee replacements in the U.S. has increased dramatically since the 1970s and is expected to continue to rise. To date, evidence to support the effectiveness of surgical intervention compared to non-surgical intervention is lacking.
Study design: Randomized, controlled trial.
Setting: Aalborg University Hospital Outpatient Clinics, Denmark.
Synopsis: One hundred patients with osteoarthritis were randomly assigned to undergo total knee replacement followed by 12 weeks of non-surgical treatment or to receive only 12 weeks of non-surgical treatment. The non-surgical treatment program consisted of exercise, education, dietary advice, insoles, and pain medication. Change from baseline to 12 months was assessed using the Knee Injury and Osteoarthritis Outcome Score (KOOS).
The total knee replacement group had a significantly greater improvement in the KOOS score than did the non-surgical group. Serious adverse events were more common in the total knee replacement group.
The study did not include a sham-surgery control group. It is unknown whether the KOOS pain subscale is generalizable to patients with severe pain. Additionally, the intensity of non-surgical treatment may have differed between groups.
Bottom line: Total knee replacement followed by non-surgical treatment is more efficacious than non-surgical treatment alone in providing pain relief and improving function and quality of life, but it is associated with higher number of adverse events.
Citation: Skou ST, Roos EM, Laursen MB, et al. A randomized, controlled trial of total knee replacement. N Engl J Med. 2015;373(17):1597-1606.
Patients with Postoperative Myocardial Infarction May Benefit from Higher Transfusion Threshold
Clinical question: Is there an improved 30-day mortality rate if patients receive blood transfusion at higher hematocrit values after postoperative myocardial infarction (MI)?
Background: Prior studies evaluating patients with a history of coronary artery disease (CAD) who undergo non-cardiac surgery have shown similar mortality outcomes with liberal and restrictive transfusion strategies. Data are lacking for transfusion strategies in patients with CAD who experience postoperative MI after non-cardiac surgeries.
Study design: Retrospective cohort.
Setting: Veterans Affairs health system.
Synopsis: The study included 7,361 patients with a history of CAD who underwent non-cardiac surgery whose postoperative hematocrit was between 20% and 30%. Patients were stratified by postoperative hematocrit nadir and presence of postoperative MI. In patients with postoperative MI, transfusion was associated with lower mortality with hematocrit nadir of 20%–24% but not with hematocrit of 24%–27% or 27%–30%. In patients without postoperative MI, transfusion was associated with higher mortality in patients with hematocrit of 27%–30%.
This retrospective study was limited to the VA population of mostly male patients. The sample size was limited. The study was unable to determine if postoperative blood transfusion is a risk for developing MI.
Bottom line: Patients with a history of CAD and MI who have a postoperative MI following non-cardiac surgery may benefit from higher blood transfusion thresholds; however, further controlled studies are needed.
Citation: Hollis RH, Singeltary BA, McMurtrie JT, et al. Blood transfusion and 30-day mortality in patients with coronary artery disease and anemia following noncardiac surgery [published online ahead of print October 7, 2015]. JAMA Surg. doi:10.1001/jamasurg.2015.3420.
Clinical question: Is there an improved 30-day mortality rate if patients receive blood transfusion at higher hematocrit values after postoperative myocardial infarction (MI)?
Background: Prior studies evaluating patients with a history of coronary artery disease (CAD) who undergo non-cardiac surgery have shown similar mortality outcomes with liberal and restrictive transfusion strategies. Data are lacking for transfusion strategies in patients with CAD who experience postoperative MI after non-cardiac surgeries.
Study design: Retrospective cohort.
Setting: Veterans Affairs health system.
Synopsis: The study included 7,361 patients with a history of CAD who underwent non-cardiac surgery whose postoperative hematocrit was between 20% and 30%. Patients were stratified by postoperative hematocrit nadir and presence of postoperative MI. In patients with postoperative MI, transfusion was associated with lower mortality with hematocrit nadir of 20%–24% but not with hematocrit of 24%–27% or 27%–30%. In patients without postoperative MI, transfusion was associated with higher mortality in patients with hematocrit of 27%–30%.
This retrospective study was limited to the VA population of mostly male patients. The sample size was limited. The study was unable to determine if postoperative blood transfusion is a risk for developing MI.
Bottom line: Patients with a history of CAD and MI who have a postoperative MI following non-cardiac surgery may benefit from higher blood transfusion thresholds; however, further controlled studies are needed.
Citation: Hollis RH, Singeltary BA, McMurtrie JT, et al. Blood transfusion and 30-day mortality in patients with coronary artery disease and anemia following noncardiac surgery [published online ahead of print October 7, 2015]. JAMA Surg. doi:10.1001/jamasurg.2015.3420.
Clinical question: Is there an improved 30-day mortality rate if patients receive blood transfusion at higher hematocrit values after postoperative myocardial infarction (MI)?
Background: Prior studies evaluating patients with a history of coronary artery disease (CAD) who undergo non-cardiac surgery have shown similar mortality outcomes with liberal and restrictive transfusion strategies. Data are lacking for transfusion strategies in patients with CAD who experience postoperative MI after non-cardiac surgeries.
Study design: Retrospective cohort.
Setting: Veterans Affairs health system.
Synopsis: The study included 7,361 patients with a history of CAD who underwent non-cardiac surgery whose postoperative hematocrit was between 20% and 30%. Patients were stratified by postoperative hematocrit nadir and presence of postoperative MI. In patients with postoperative MI, transfusion was associated with lower mortality with hematocrit nadir of 20%–24% but not with hematocrit of 24%–27% or 27%–30%. In patients without postoperative MI, transfusion was associated with higher mortality in patients with hematocrit of 27%–30%.
This retrospective study was limited to the VA population of mostly male patients. The sample size was limited. The study was unable to determine if postoperative blood transfusion is a risk for developing MI.
Bottom line: Patients with a history of CAD and MI who have a postoperative MI following non-cardiac surgery may benefit from higher blood transfusion thresholds; however, further controlled studies are needed.
Citation: Hollis RH, Singeltary BA, McMurtrie JT, et al. Blood transfusion and 30-day mortality in patients with coronary artery disease and anemia following noncardiac surgery [published online ahead of print October 7, 2015]. JAMA Surg. doi:10.1001/jamasurg.2015.3420.
Nebulized Hypertonic Saline Does Not Improve Outcomes for Non-ICU Infants with Acute Bronchiolitis
Clinical question: Does the use of nebulized 3% hypertonic saline shorten length of stay (LOS) in infants hospitalized with acute bronchiolitis?
Background: Acute bronchiolitis is a disease primarily of infants and young children, triggered by a viral infection that leads to variable inflammation, edema, and inspissated mucus in the lower airways. Although bronchiolitis is the most common cause of hospitalization in children under the age of two, few interventions have been shown to improve patient-level outcomes.
Hypertonic saline (generally 3%) has been one of the few interventions that has improved outcomes in some studies, leading the most recent American Academy of Pediatrics (AAP) clinical practice guideline (CPG) to state that nebulized hypertonic saline may be considered for infants and children hospitalized for bronchiolitis. The studies cited in this CPG statement were heterogeneous, with many of them performed in Europe, where the LOS for bronchiolitis is generally longer than in the U.S. In addition, most of the studies administered hypertonic saline (HS) with a bronchodilator, confounding the outcomes with an intervention not recommended in the most recent bronchiolitis CPG.
Study design: Prospective, randomized controlled, double-blinded, parallel-group study.
Setting: Urban, tertiary-care, 136-bed children’s hospital.
Synopsis: Infants 4 points received a bronchodilator and were withdrawn from the study.
Of the 227 patients enrolled after application of inclusion and exclusion criteria, 113 were randomized to receive HS and 114 to NS. Twenty patients in the HS group and 17 in the NS group discontinued intervention due to ICU transfer, provider choice to use albuterol, parental request, or protocol deviation, but patients were analyzed by intention-to-treat (ITT) assignments. No significant difference in LOS between the HS and NS groups was found, either by the traditional definition or the treatment-to-discharge order definition. No significant differences were found in secondary outcomes between the two groups, including readmission rates or clinical worsening. In addition, pre- to post-treatment RDAI score changes were not significantly different for HS versus NS.
Bottom line: Treating infants
Citation: Silver AH, Esteban-Cruciani N, Azzarone G, et al. 3% hypertonic saline versus normal saline in inpatient bronchiolitis: a randomized controlled trial. Pediatrics. 2015;136(6):1036-1043. TH
Clinical question: Does the use of nebulized 3% hypertonic saline shorten length of stay (LOS) in infants hospitalized with acute bronchiolitis?
Background: Acute bronchiolitis is a disease primarily of infants and young children, triggered by a viral infection that leads to variable inflammation, edema, and inspissated mucus in the lower airways. Although bronchiolitis is the most common cause of hospitalization in children under the age of two, few interventions have been shown to improve patient-level outcomes.
Hypertonic saline (generally 3%) has been one of the few interventions that has improved outcomes in some studies, leading the most recent American Academy of Pediatrics (AAP) clinical practice guideline (CPG) to state that nebulized hypertonic saline may be considered for infants and children hospitalized for bronchiolitis. The studies cited in this CPG statement were heterogeneous, with many of them performed in Europe, where the LOS for bronchiolitis is generally longer than in the U.S. In addition, most of the studies administered hypertonic saline (HS) with a bronchodilator, confounding the outcomes with an intervention not recommended in the most recent bronchiolitis CPG.
Study design: Prospective, randomized controlled, double-blinded, parallel-group study.
Setting: Urban, tertiary-care, 136-bed children’s hospital.
Synopsis: Infants 4 points received a bronchodilator and were withdrawn from the study.
Of the 227 patients enrolled after application of inclusion and exclusion criteria, 113 were randomized to receive HS and 114 to NS. Twenty patients in the HS group and 17 in the NS group discontinued intervention due to ICU transfer, provider choice to use albuterol, parental request, or protocol deviation, but patients were analyzed by intention-to-treat (ITT) assignments. No significant difference in LOS between the HS and NS groups was found, either by the traditional definition or the treatment-to-discharge order definition. No significant differences were found in secondary outcomes between the two groups, including readmission rates or clinical worsening. In addition, pre- to post-treatment RDAI score changes were not significantly different for HS versus NS.
Bottom line: Treating infants
Citation: Silver AH, Esteban-Cruciani N, Azzarone G, et al. 3% hypertonic saline versus normal saline in inpatient bronchiolitis: a randomized controlled trial. Pediatrics. 2015;136(6):1036-1043. TH
Clinical question: Does the use of nebulized 3% hypertonic saline shorten length of stay (LOS) in infants hospitalized with acute bronchiolitis?
Background: Acute bronchiolitis is a disease primarily of infants and young children, triggered by a viral infection that leads to variable inflammation, edema, and inspissated mucus in the lower airways. Although bronchiolitis is the most common cause of hospitalization in children under the age of two, few interventions have been shown to improve patient-level outcomes.
Hypertonic saline (generally 3%) has been one of the few interventions that has improved outcomes in some studies, leading the most recent American Academy of Pediatrics (AAP) clinical practice guideline (CPG) to state that nebulized hypertonic saline may be considered for infants and children hospitalized for bronchiolitis. The studies cited in this CPG statement were heterogeneous, with many of them performed in Europe, where the LOS for bronchiolitis is generally longer than in the U.S. In addition, most of the studies administered hypertonic saline (HS) with a bronchodilator, confounding the outcomes with an intervention not recommended in the most recent bronchiolitis CPG.
Study design: Prospective, randomized controlled, double-blinded, parallel-group study.
Setting: Urban, tertiary-care, 136-bed children’s hospital.
Synopsis: Infants 4 points received a bronchodilator and were withdrawn from the study.
Of the 227 patients enrolled after application of inclusion and exclusion criteria, 113 were randomized to receive HS and 114 to NS. Twenty patients in the HS group and 17 in the NS group discontinued intervention due to ICU transfer, provider choice to use albuterol, parental request, or protocol deviation, but patients were analyzed by intention-to-treat (ITT) assignments. No significant difference in LOS between the HS and NS groups was found, either by the traditional definition or the treatment-to-discharge order definition. No significant differences were found in secondary outcomes between the two groups, including readmission rates or clinical worsening. In addition, pre- to post-treatment RDAI score changes were not significantly different for HS versus NS.
Bottom line: Treating infants
Citation: Silver AH, Esteban-Cruciani N, Azzarone G, et al. 3% hypertonic saline versus normal saline in inpatient bronchiolitis: a randomized controlled trial. Pediatrics. 2015;136(6):1036-1043. TH