AMSTERDAM – For patients with metastatic colorectal cancer, S-1 was comparable in efficacy to capecitabine (Xeloda), and was associated with a lower incidence of all grades of hand-foot syndrome, reported investigators.

Among 161 patients with untreated metastatic colorectal cancer, the investigator-assessed incidence of all grades of hand-foot syndrome was 73% for patients randomly assigned to capecitabine, compared with 45% for patients randomized to S-1 (P = .0005).

Patient-assessed symptoms also were lower with S-1 than with capecitabine, reported Robert Jan Kwakman, MD, of the Academic Medical Center in Amsterdam.

Neil Osterweil/Frontline Medical News

• Grade 1: 21% for the capecitabine arm vs. 28% for the S-1 arm (not significant).

• Grade 2: 30% vs. 14% (P = .02).

• Grade 3: 21% vs. 4% (P = .003).

The incidence of patient-assessed hand-foot syndrome of all grades was 84% in the capecitabine arm and 58% in the S-1 arm (P = .004). Patient-reported grade 3 hand-foot syndrome occurred in 18% vs. 5%, respectively (P = .05).

The only other toxicity occurring more frequently among patients on S-1 was anorexia, which occurred in 29% of patients on capecitabine compared with 41% with S-1. Grade 3 or greater anorexia occurred in 3% vs. 13%, respectively (P = .03).

Significantly more dose reductions were required for patients on capecitabine (69% vs. 41%, P = .0008). The median relative dose intensity was higher for patients on S-1 (89% vs. 95%, P = .035).

Among all patients, median progression-free survival was 8.18 months with capecitabine vs. 8.39 months with S-1, a difference that was not significant. There was a trend toward better progression-free survival for patients in each arm who received bevacizumab (8.74 vs. 6.37 months without bevacizumab), but this difference was also not significant.

Overall survival rates at 12 months were 67% with capecitabine and 62% with S-1 (not significantly different), and respective rates at 18 months were 50% vs. 39%. The hazard ratio for mortality with S-1 was 1.28 (not significant).

The study was sponsored by the Dutch Colorectal Cancer Group, with research funds supplied by Nordic Pharma BV. Dr. Kwakman disclosed receiving an honorarium from the company.

AMSTERDAM – For patients with metastatic colorectal cancer, S-1 was comparable in efficacy to capecitabine (Xeloda), and was associated with a lower incidence of all grades of hand-foot syndrome, reported investigators.

Among 161 patients with untreated metastatic colorectal cancer, the investigator-assessed incidence of all grades of hand-foot syndrome was 73% for patients randomly assigned to capecitabine, compared with 45% for patients randomized to S-1 (P = .0005).

Patient-assessed symptoms also were lower with S-1 than with capecitabine, reported Robert Jan Kwakman, MD, of the Academic Medical Center in Amsterdam.

Neil Osterweil/Frontline Medical News

• Grade 1: 21% for the capecitabine arm vs. 28% for the S-1 arm (not significant).

• Grade 2: 30% vs. 14% (P = .02).

• Grade 3: 21% vs. 4% (P = .003).

The incidence of patient-assessed hand-foot syndrome of all grades was 84% in the capecitabine arm and 58% in the S-1 arm (P = .004). Patient-reported grade 3 hand-foot syndrome occurred in 18% vs. 5%, respectively (P = .05).

The only other toxicity occurring more frequently among patients on S-1 was anorexia, which occurred in 29% of patients on capecitabine compared with 41% with S-1. Grade 3 or greater anorexia occurred in 3% vs. 13%, respectively (P = .03).

Significantly more dose reductions were required for patients on capecitabine (69% vs. 41%, P = .0008). The median relative dose intensity was higher for patients on S-1 (89% vs. 95%, P = .035).

Among all patients, median progression-free survival was 8.18 months with capecitabine vs. 8.39 months with S-1, a difference that was not significant. There was a trend toward better progression-free survival for patients in each arm who received bevacizumab (8.74 vs. 6.37 months without bevacizumab), but this difference was also not significant.

Overall survival rates at 12 months were 67% with capecitabine and 62% with S-1 (not significantly different), and respective rates at 18 months were 50% vs. 39%. The hazard ratio for mortality with S-1 was 1.28 (not significant).

The study was sponsored by the Dutch Colorectal Cancer Group, with research funds supplied by Nordic Pharma BV. Dr. Kwakman disclosed receiving an honorarium from the company.

AMSTERDAM – For patients with metastatic colorectal cancer, S-1 was comparable in efficacy to capecitabine (Xeloda), and was associated with a lower incidence of all grades of hand-foot syndrome, reported investigators.

Among 161 patients with untreated metastatic colorectal cancer, the investigator-assessed incidence of all grades of hand-foot syndrome was 73% for patients randomly assigned to capecitabine, compared with 45% for patients randomized to S-1 (P = .0005).

Patient-assessed symptoms also were lower with S-1 than with capecitabine, reported Robert Jan Kwakman, MD, of the Academic Medical Center in Amsterdam.

Neil Osterweil/Frontline Medical News

• Grade 1: 21% for the capecitabine arm vs. 28% for the S-1 arm (not significant).

• Grade 2: 30% vs. 14% (P = .02).

• Grade 3: 21% vs. 4% (P = .003).

The incidence of patient-assessed hand-foot syndrome of all grades was 84% in the capecitabine arm and 58% in the S-1 arm (P = .004). Patient-reported grade 3 hand-foot syndrome occurred in 18% vs. 5%, respectively (P = .05).

The only other toxicity occurring more frequently among patients on S-1 was anorexia, which occurred in 29% of patients on capecitabine compared with 41% with S-1. Grade 3 or greater anorexia occurred in 3% vs. 13%, respectively (P = .03).

Significantly more dose reductions were required for patients on capecitabine (69% vs. 41%, P = .0008). The median relative dose intensity was higher for patients on S-1 (89% vs. 95%, P = .035).

Among all patients, median progression-free survival was 8.18 months with capecitabine vs. 8.39 months with S-1, a difference that was not significant. There was a trend toward better progression-free survival for patients in each arm who received bevacizumab (8.74 vs. 6.37 months without bevacizumab), but this difference was also not significant.

Overall survival rates at 12 months were 67% with capecitabine and 62% with S-1 (not significantly different), and respective rates at 18 months were 50% vs. 39%. The hazard ratio for mortality with S-1 was 1.28 (not significant).

The study was sponsored by the Dutch Colorectal Cancer Group, with research funds supplied by Nordic Pharma BV. Dr. Kwakman disclosed receiving an honorarium from the company.

From the Department of Obstetrics and Gynecology, Kasturba Medical College, Manipal, Karnataka, India.

Abstracts

• Objective: To examine the association of the patient’s obstetric profile and time to normalization of blood pressure in the postnatal period among women with hypertensive disorders in pregnancy.
• Methods: We conducted a prospective cohort study at a tertiary level hospital between November 2014 and May 2015. Women with pregnancy hypertension who required antihypertensive treatment were recruited after delivery. The normalization trends in blood pressure were tested for associations with patient demographic data and details of pregnancy hypertension.
• Results: Among 109 women included in the study, earlier gestational age at onset of hypertension and earlier gestational age at delivery was correlated with slower resolution of hypertension. Time to resolution also was correlated with age, BMI, severity of hypertension, associated complications, and the number of antihypertensive medications received. There was no correlation with highest recorded systolic or diastolic blood pressures. Only 15% of women with gestational hypertension had persistent hypertension beyond 6 weeks. In the groups with nonsevere preeclampsia, severe preeclampsia, and eclampsia, blood pressure remained high after 6 weeks in 26%, 14%, and 50% of women, respectively.
• Conclusion: Women with advanced age, higher body mass index, early gestational age at the onset of hypertension, severe hypertension and who had complications of hypertension require prolonged monitoring and treatment when indicated for hypertension in postnatal period.

Key words: intensive care unit; communication; family meeting; critical illness; decision making; end of life care.

Hypertension is the most common medical problem encountered during pregnancy, complicating up to 10% of pregnancies worldwide [1]. The disorders of hypertension in pregnancy are generally classified as chronic hypertension, preeclampsia–eclampsia, preeclampsia superimposed on chronic hypertension, and gestational hypertension. The hypertensive disorders of pregnancy are a leading cause of mortality and morbidity in the perinatal period.

Women with hypertensive disorders in pregnancy show varying trends of blood pressure normalization, with the recovery period ranging from a few hours to several months after delivery. In one study, nearly one-fourth of women with preeclampsia/eclampsia had persistent high blood pressure after puerperium [2]. Identifying the obstetric risk factors for persistent hypertension will help in focusing care and research in this group of patients.

We undertook a prospective study to assess possible correlations of obstetric profile with time to normalization of blood pressure in the postnatal period among women with hypertensive disorders in pregnancy.

Methods

Setting

This prospective cohort study was conducted in the department of obstetrics and gynecology at Kasturba Hospital, Manipal, between November 2014 and May 2015. Permission for the study was obtained from the Institution Ethical Committee (IEC264/2015).

Patients

Women who had hypertension in pregnancy and required antihypertensive treatment were approached on the first postnatal day and invited to participate in the study. Women with chronic hypertension (women with known pre-pregnancy hypertension and with hypertension diagnosed before 20 weeks gestation) or secondary hypertension were excluded. After granting informed consent, enrolled women were followed until the time they no longer required antihypertensive medication (“reversion of hypertension”) or until 10 weeks postpartum, whichever came first.

During the hospital stay in the postnatal period, women had their blood pressure monitored and antihypertensives were adjusted as needed. After discharge from the hospital, blood pressure was monitored by the family physician who also made decisions regarding antihypertensive management. All women had a follow-up visit in the hospital in the 6th postnatal week as per the postnatal clinic protocol.

Definitions

Hypertension was defined as BP ≥ 140/90 mm Hg. The hypertension disorders of pregnancy were defined as follows:

• Gestational hypertension: hypertension after 20 weeks gestation on two occasions 4 hours apart without meeting criteria for preeclampsia.
• Preeclampsia: hypertension after 20 weeks gestation on two occasions 4 hours apart with proteinuria (≥ 300 mg/24 hour) or, in the absence of proteinuria, new onset of any of the following: thrombocytopenia, renal insufficiency, impaired liver function, pulmonary edema, or cerebral or visual symptoms [1]. Severe preeclampsia was defined as preeclampsia with any of the following: systolic blood pressure > 160 mm Hg diastolic BP > 110 mm Hg or more on 2 occasions 4 hours apart, thrombocytopenia (platelet count < 100,00/mL), renal insufficiency, impaired liver function, pulmonary edema, or cerebral or visual symptoms. Preeclampsia without any of these features was considered nonsevere preeclampsia.
• Eclampsia: Women with hypertension with epigastric pain, headache, vomiting, and blurring of vision were diagnosed with imminent eclampsia and those with hypertension-related convulsions were diagnosed with eclampsia.
• Complications of preeclampsia included eclampsia, placental abruption, pulmonary edema, thrombocytopenia, HELLP syndrome, disseminated intravascular coagulation, multiorgan failure, severe intrauterine growth restriction, and fetal demise.

Main Outcome Measure

Time to reversion of hypertension was the main outcome measure. We defined the reversion date as the day that hypertension medications were stopped. This information was obtained via in-person questioning on the 2nd postpartum day and at the 6-week postnatal visit and via telephonic survey on the 10th postnatal day and at 10 weeks postdelivery. Women who missed the 6-week postnatal visit were also followed up by telephone.

Data Collection

Demographic details (age, parity, BMI) as well as information regarding gestational age at onset of hypertension, severity, highest systolic and diastolic blood pressure recordings, treatment received, complications related to hypertension, pregnancy termination and delivery was obtained from the medical charts and/or via telephonic follow-up.

Analysis

We used Pearson’s chi-square test to assess the association between recovery trends in blood pressure and the patient’s demographic profile and details of pregnancy hypertension. Statistical analysis was done using SPSS16.

Results

In our study, earlier the gestational age at onset of hypertension and earlier gestation at delivery was associated with slower recovery from hypertension (Table 2). Time taken for recovery also was associated with age, BMI, severity of hypertension, associated complications, and the number of antihypertensive medications received (Table 2). Among women who received more than 3 antiphypertensives in pregnancy, nearly 50% continued to have hypertension beyond 6 weeks (Table 2). 

On testing for strength of correlation, it was found that body mass index and time to blood pressure normalization had a strong positive correlation (r = 0.8). The remaining parameters (ie, gestational age at onset, gestational age at delivery, severity and complications of hypertension and number of antihypertensive medications) and time to recovery were weakly correlated (r = 0.3 to 0.5 [+/–]).

Women with gestational hypertension and mild preeclampsia had faster normalization of blood pressure compared to those with severe preeclampsia and eclampsia (Figure 2). Only 15% of women with gestational hypertension had persistent hypertension beyond 6 weeks, whereas in the groups with nonsevere preeclampsia, severe preeclampsia, and eclampsia, blood pressure 

Eighteen women had additional medical problems: gestational diabetes (n = 5), anemia (n = 3), hypothyroidism (n = 4), rheumatic heart disease (n = 2), antiphospholipid antibody syndrome (n = 1) chronic kidney disease (n = 1), post atrial septal defect closure (n = 1), and tricuspid valve prolapse (TVP) with regurgitation and pulmonary arterial hypertension (n = 1). With the exception of the woman with chronic kidney disease, all reverted to normal blood pressure by 6 weeks; the woman with TVP reverted after corrective cardiac surgery in puerperium.

Discussion

In the present study we assessed possible correlations of obstetric profile with time to postpartum recovery of blood pressure in women with pregnancy hypertension. Women with advanced age, higher body mass index, early gestational age at the onset of hypertension, early gestational age at delivery, severe hypertension, and those with complications of hypertension took longer time in the postnatal period for normalization of blood pressure.

The strength of this study was its prospective design and high rate of follow-up. Those who missed a visit were followed up over telephone. However, 19 women were not available even by phone. A limitation of this study is that the information regarding when the antihypertensive was stopped was obtained by patient recall, raising the possibility of recall bias. However, as the range of recovery times was wide, an error of few days may not be significant.

In the study we noted that women with preeclampsia took a longer time to recovery compared with women with gestational hypertension. Earlier and more severe disease was associated with delay to recovery or persistence of hypertension beyond 10 weeks postpartum.

Similar to our observation, other authors have observed a consistent association of time to reversion of hypertension and early-onset hypertension in pregnancy [3–5]. Ferrazzani explained the longer time to normalization of blood pressure in preeclampsia compared to gestational hypertension as the recovery time of the endothelial damage in preeclampsia [4].

Berks et al [6] found a correlation of maximum diastolic blood pressure, maximum proteinuria in pregnancy, and diagnosis-to-delivery interval with time taken for resolution of hypertension; however, they did not find that time to resolution was correlated with gestational age at onset of preeclampsia. They opined that their observations reflected endothelial recovery after preeclampsia. They also suggested further research in the area of temporizing management of preeclampsia to determine if a conservative approach increases remote cardiovascular risk [6]. We did not study the diagnosis-to-delivery interval, but those with early delivery in our group had late postpartum recovery, indicating that they had severe/complicated preeclampsia that demanded early termination.

In conclusion, women with advanced age, higher body mass index, early gestational age at the onset of hypertension, severe and with complications of hypertension require prolonged monitoring and treatment when indicated for hypertension in the postnatal period. Women with a history of pregnancy hypertension have increased risk of stroke, cardiac ischemia, venous thrombosis within 10 to 20 years after pregnancy and higher risk of hypertension and type 2 diabetes mellitus [7–9]. Extended postnatal follow-up and regular monitoring is recommended to address the needs of these high-risk women.

Corresponding author: Dr. Shyamala Guruvare, 1-167 (C4), Lahari, Eshakripa Road, Parkala, Udupi District, Karnataka, India 576107, [email protected].

Financial disclosures: None reported.

From the Department of Obstetrics and Gynecology, Kasturba Medical College, Manipal, Karnataka, India.

Abstracts

• Objective: To examine the association of the patient’s obstetric profile and time to normalization of blood pressure in the postnatal period among women with hypertensive disorders in pregnancy.
• Methods: We conducted a prospective cohort study at a tertiary level hospital between November 2014 and May 2015. Women with pregnancy hypertension who required antihypertensive treatment were recruited after delivery. The normalization trends in blood pressure were tested for associations with patient demographic data and details of pregnancy hypertension.
• Results: Among 109 women included in the study, earlier gestational age at onset of hypertension and earlier gestational age at delivery was correlated with slower resolution of hypertension. Time to resolution also was correlated with age, BMI, severity of hypertension, associated complications, and the number of antihypertensive medications received. There was no correlation with highest recorded systolic or diastolic blood pressures. Only 15% of women with gestational hypertension had persistent hypertension beyond 6 weeks. In the groups with nonsevere preeclampsia, severe preeclampsia, and eclampsia, blood pressure remained high after 6 weeks in 26%, 14%, and 50% of women, respectively.
• Conclusion: Women with advanced age, higher body mass index, early gestational age at the onset of hypertension, severe hypertension and who had complications of hypertension require prolonged monitoring and treatment when indicated for hypertension in postnatal period.

Key words: intensive care unit; communication; family meeting; critical illness; decision making; end of life care.

Hypertension is the most common medical problem encountered during pregnancy, complicating up to 10% of pregnancies worldwide [1]. The disorders of hypertension in pregnancy are generally classified as chronic hypertension, preeclampsia–eclampsia, preeclampsia superimposed on chronic hypertension, and gestational hypertension. The hypertensive disorders of pregnancy are a leading cause of mortality and morbidity in the perinatal period.

Women with hypertensive disorders in pregnancy show varying trends of blood pressure normalization, with the recovery period ranging from a few hours to several months after delivery. In one study, nearly one-fourth of women with preeclampsia/eclampsia had persistent high blood pressure after puerperium [2]. Identifying the obstetric risk factors for persistent hypertension will help in focusing care and research in this group of patients.

We undertook a prospective study to assess possible correlations of obstetric profile with time to normalization of blood pressure in the postnatal period among women with hypertensive disorders in pregnancy.

Methods

Setting

This prospective cohort study was conducted in the department of obstetrics and gynecology at Kasturba Hospital, Manipal, between November 2014 and May 2015. Permission for the study was obtained from the Institution Ethical Committee (IEC264/2015).

Patients

Women who had hypertension in pregnancy and required antihypertensive treatment were approached on the first postnatal day and invited to participate in the study. Women with chronic hypertension (women with known pre-pregnancy hypertension and with hypertension diagnosed before 20 weeks gestation) or secondary hypertension were excluded. After granting informed consent, enrolled women were followed until the time they no longer required antihypertensive medication (“reversion of hypertension”) or until 10 weeks postpartum, whichever came first.

During the hospital stay in the postnatal period, women had their blood pressure monitored and antihypertensives were adjusted as needed. After discharge from the hospital, blood pressure was monitored by the family physician who also made decisions regarding antihypertensive management. All women had a follow-up visit in the hospital in the 6th postnatal week as per the postnatal clinic protocol.

Definitions

Hypertension was defined as BP ≥ 140/90 mm Hg. The hypertension disorders of pregnancy were defined as follows:

• Gestational hypertension: hypertension after 20 weeks gestation on two occasions 4 hours apart without meeting criteria for preeclampsia.
• Preeclampsia: hypertension after 20 weeks gestation on two occasions 4 hours apart with proteinuria (≥ 300 mg/24 hour) or, in the absence of proteinuria, new onset of any of the following: thrombocytopenia, renal insufficiency, impaired liver function, pulmonary edema, or cerebral or visual symptoms [1]. Severe preeclampsia was defined as preeclampsia with any of the following: systolic blood pressure > 160 mm Hg diastolic BP > 110 mm Hg or more on 2 occasions 4 hours apart, thrombocytopenia (platelet count < 100,00/mL), renal insufficiency, impaired liver function, pulmonary edema, or cerebral or visual symptoms. Preeclampsia without any of these features was considered nonsevere preeclampsia.
• Eclampsia: Women with hypertension with epigastric pain, headache, vomiting, and blurring of vision were diagnosed with imminent eclampsia and those with hypertension-related convulsions were diagnosed with eclampsia.
• Complications of preeclampsia included eclampsia, placental abruption, pulmonary edema, thrombocytopenia, HELLP syndrome, disseminated intravascular coagulation, multiorgan failure, severe intrauterine growth restriction, and fetal demise.

Main Outcome Measure

Time to reversion of hypertension was the main outcome measure. We defined the reversion date as the day that hypertension medications were stopped. This information was obtained via in-person questioning on the 2nd postpartum day and at the 6-week postnatal visit and via telephonic survey on the 10th postnatal day and at 10 weeks postdelivery. Women who missed the 6-week postnatal visit were also followed up by telephone.

Data Collection

Demographic details (age, parity, BMI) as well as information regarding gestational age at onset of hypertension, severity, highest systolic and diastolic blood pressure recordings, treatment received, complications related to hypertension, pregnancy termination and delivery was obtained from the medical charts and/or via telephonic follow-up.

Analysis

We used Pearson’s chi-square test to assess the association between recovery trends in blood pressure and the patient’s demographic profile and details of pregnancy hypertension. Statistical analysis was done using SPSS16.

Results

In our study, earlier the gestational age at onset of hypertension and earlier gestation at delivery was associated with slower recovery from hypertension (Table 2). Time taken for recovery also was associated with age, BMI, severity of hypertension, associated complications, and the number of antihypertensive medications received (Table 2). Among women who received more than 3 antiphypertensives in pregnancy, nearly 50% continued to have hypertension beyond 6 weeks (Table 2). 

On testing for strength of correlation, it was found that body mass index and time to blood pressure normalization had a strong positive correlation (r = 0.8). The remaining parameters (ie, gestational age at onset, gestational age at delivery, severity and complications of hypertension and number of antihypertensive medications) and time to recovery were weakly correlated (r = 0.3 to 0.5 [+/–]).

Women with gestational hypertension and mild preeclampsia had faster normalization of blood pressure compared to those with severe preeclampsia and eclampsia (Figure 2). Only 15% of women with gestational hypertension had persistent hypertension beyond 6 weeks, whereas in the groups with nonsevere preeclampsia, severe preeclampsia, and eclampsia, blood pressure 

Eighteen women had additional medical problems: gestational diabetes (n = 5), anemia (n = 3), hypothyroidism (n = 4), rheumatic heart disease (n = 2), antiphospholipid antibody syndrome (n = 1) chronic kidney disease (n = 1), post atrial septal defect closure (n = 1), and tricuspid valve prolapse (TVP) with regurgitation and pulmonary arterial hypertension (n = 1). With the exception of the woman with chronic kidney disease, all reverted to normal blood pressure by 6 weeks; the woman with TVP reverted after corrective cardiac surgery in puerperium.

Discussion

In the present study we assessed possible correlations of obstetric profile with time to postpartum recovery of blood pressure in women with pregnancy hypertension. Women with advanced age, higher body mass index, early gestational age at the onset of hypertension, early gestational age at delivery, severe hypertension, and those with complications of hypertension took longer time in the postnatal period for normalization of blood pressure.

The strength of this study was its prospective design and high rate of follow-up. Those who missed a visit were followed up over telephone. However, 19 women were not available even by phone. A limitation of this study is that the information regarding when the antihypertensive was stopped was obtained by patient recall, raising the possibility of recall bias. However, as the range of recovery times was wide, an error of few days may not be significant.

In the study we noted that women with preeclampsia took a longer time to recovery compared with women with gestational hypertension. Earlier and more severe disease was associated with delay to recovery or persistence of hypertension beyond 10 weeks postpartum.

Similar to our observation, other authors have observed a consistent association of time to reversion of hypertension and early-onset hypertension in pregnancy [3–5]. Ferrazzani explained the longer time to normalization of blood pressure in preeclampsia compared to gestational hypertension as the recovery time of the endothelial damage in preeclampsia [4].

Berks et al [6] found a correlation of maximum diastolic blood pressure, maximum proteinuria in pregnancy, and diagnosis-to-delivery interval with time taken for resolution of hypertension; however, they did not find that time to resolution was correlated with gestational age at onset of preeclampsia. They opined that their observations reflected endothelial recovery after preeclampsia. They also suggested further research in the area of temporizing management of preeclampsia to determine if a conservative approach increases remote cardiovascular risk [6]. We did not study the diagnosis-to-delivery interval, but those with early delivery in our group had late postpartum recovery, indicating that they had severe/complicated preeclampsia that demanded early termination.

In conclusion, women with advanced age, higher body mass index, early gestational age at the onset of hypertension, severe and with complications of hypertension require prolonged monitoring and treatment when indicated for hypertension in the postnatal period. Women with a history of pregnancy hypertension have increased risk of stroke, cardiac ischemia, venous thrombosis within 10 to 20 years after pregnancy and higher risk of hypertension and type 2 diabetes mellitus [7–9]. Extended postnatal follow-up and regular monitoring is recommended to address the needs of these high-risk women.

Corresponding author: Dr. Shyamala Guruvare, 1-167 (C4), Lahari, Eshakripa Road, Parkala, Udupi District, Karnataka, India 576107, [email protected].

Financial disclosures: None reported.

From the Department of Obstetrics and Gynecology, Kasturba Medical College, Manipal, Karnataka, India.

Abstracts

• Objective: To examine the association of the patient’s obstetric profile and time to normalization of blood pressure in the postnatal period among women with hypertensive disorders in pregnancy.
• Methods: We conducted a prospective cohort study at a tertiary level hospital between November 2014 and May 2015. Women with pregnancy hypertension who required antihypertensive treatment were recruited after delivery. The normalization trends in blood pressure were tested for associations with patient demographic data and details of pregnancy hypertension.
• Results: Among 109 women included in the study, earlier gestational age at onset of hypertension and earlier gestational age at delivery was correlated with slower resolution of hypertension. Time to resolution also was correlated with age, BMI, severity of hypertension, associated complications, and the number of antihypertensive medications received. There was no correlation with highest recorded systolic or diastolic blood pressures. Only 15% of women with gestational hypertension had persistent hypertension beyond 6 weeks. In the groups with nonsevere preeclampsia, severe preeclampsia, and eclampsia, blood pressure remained high after 6 weeks in 26%, 14%, and 50% of women, respectively.
• Conclusion: Women with advanced age, higher body mass index, early gestational age at the onset of hypertension, severe hypertension and who had complications of hypertension require prolonged monitoring and treatment when indicated for hypertension in postnatal period.

Key words: intensive care unit; communication; family meeting; critical illness; decision making; end of life care.

Hypertension is the most common medical problem encountered during pregnancy, complicating up to 10% of pregnancies worldwide [1]. The disorders of hypertension in pregnancy are generally classified as chronic hypertension, preeclampsia–eclampsia, preeclampsia superimposed on chronic hypertension, and gestational hypertension. The hypertensive disorders of pregnancy are a leading cause of mortality and morbidity in the perinatal period.

Women with hypertensive disorders in pregnancy show varying trends of blood pressure normalization, with the recovery period ranging from a few hours to several months after delivery. In one study, nearly one-fourth of women with preeclampsia/eclampsia had persistent high blood pressure after puerperium [2]. Identifying the obstetric risk factors for persistent hypertension will help in focusing care and research in this group of patients.

We undertook a prospective study to assess possible correlations of obstetric profile with time to normalization of blood pressure in the postnatal period among women with hypertensive disorders in pregnancy.

Methods

Setting

This prospective cohort study was conducted in the department of obstetrics and gynecology at Kasturba Hospital, Manipal, between November 2014 and May 2015. Permission for the study was obtained from the Institution Ethical Committee (IEC264/2015).

Patients

Women who had hypertension in pregnancy and required antihypertensive treatment were approached on the first postnatal day and invited to participate in the study. Women with chronic hypertension (women with known pre-pregnancy hypertension and with hypertension diagnosed before 20 weeks gestation) or secondary hypertension were excluded. After granting informed consent, enrolled women were followed until the time they no longer required antihypertensive medication (“reversion of hypertension”) or until 10 weeks postpartum, whichever came first.

During the hospital stay in the postnatal period, women had their blood pressure monitored and antihypertensives were adjusted as needed. After discharge from the hospital, blood pressure was monitored by the family physician who also made decisions regarding antihypertensive management. All women had a follow-up visit in the hospital in the 6th postnatal week as per the postnatal clinic protocol.

Definitions

Hypertension was defined as BP ≥ 140/90 mm Hg. The hypertension disorders of pregnancy were defined as follows:

• Gestational hypertension: hypertension after 20 weeks gestation on two occasions 4 hours apart without meeting criteria for preeclampsia.
• Preeclampsia: hypertension after 20 weeks gestation on two occasions 4 hours apart with proteinuria (≥ 300 mg/24 hour) or, in the absence of proteinuria, new onset of any of the following: thrombocytopenia, renal insufficiency, impaired liver function, pulmonary edema, or cerebral or visual symptoms [1]. Severe preeclampsia was defined as preeclampsia with any of the following: systolic blood pressure > 160 mm Hg diastolic BP > 110 mm Hg or more on 2 occasions 4 hours apart, thrombocytopenia (platelet count < 100,00/mL), renal insufficiency, impaired liver function, pulmonary edema, or cerebral or visual symptoms. Preeclampsia without any of these features was considered nonsevere preeclampsia.
• Eclampsia: Women with hypertension with epigastric pain, headache, vomiting, and blurring of vision were diagnosed with imminent eclampsia and those with hypertension-related convulsions were diagnosed with eclampsia.
• Complications of preeclampsia included eclampsia, placental abruption, pulmonary edema, thrombocytopenia, HELLP syndrome, disseminated intravascular coagulation, multiorgan failure, severe intrauterine growth restriction, and fetal demise.

Main Outcome Measure

Time to reversion of hypertension was the main outcome measure. We defined the reversion date as the day that hypertension medications were stopped. This information was obtained via in-person questioning on the 2nd postpartum day and at the 6-week postnatal visit and via telephonic survey on the 10th postnatal day and at 10 weeks postdelivery. Women who missed the 6-week postnatal visit were also followed up by telephone.

Data Collection

Demographic details (age, parity, BMI) as well as information regarding gestational age at onset of hypertension, severity, highest systolic and diastolic blood pressure recordings, treatment received, complications related to hypertension, pregnancy termination and delivery was obtained from the medical charts and/or via telephonic follow-up.

Analysis

We used Pearson’s chi-square test to assess the association between recovery trends in blood pressure and the patient’s demographic profile and details of pregnancy hypertension. Statistical analysis was done using SPSS16.

Results

In our study, earlier the gestational age at onset of hypertension and earlier gestation at delivery was associated with slower recovery from hypertension (Table 2). Time taken for recovery also was associated with age, BMI, severity of hypertension, associated complications, and the number of antihypertensive medications received (Table 2). Among women who received more than 3 antiphypertensives in pregnancy, nearly 50% continued to have hypertension beyond 6 weeks (Table 2). 

On testing for strength of correlation, it was found that body mass index and time to blood pressure normalization had a strong positive correlation (r = 0.8). The remaining parameters (ie, gestational age at onset, gestational age at delivery, severity and complications of hypertension and number of antihypertensive medications) and time to recovery were weakly correlated (r = 0.3 to 0.5 [+/–]).

Women with gestational hypertension and mild preeclampsia had faster normalization of blood pressure compared to those with severe preeclampsia and eclampsia (Figure 2). Only 15% of women with gestational hypertension had persistent hypertension beyond 6 weeks, whereas in the groups with nonsevere preeclampsia, severe preeclampsia, and eclampsia, blood pressure 

Eighteen women had additional medical problems: gestational diabetes (n = 5), anemia (n = 3), hypothyroidism (n = 4), rheumatic heart disease (n = 2), antiphospholipid antibody syndrome (n = 1) chronic kidney disease (n = 1), post atrial septal defect closure (n = 1), and tricuspid valve prolapse (TVP) with regurgitation and pulmonary arterial hypertension (n = 1). With the exception of the woman with chronic kidney disease, all reverted to normal blood pressure by 6 weeks; the woman with TVP reverted after corrective cardiac surgery in puerperium.

Discussion

In the present study we assessed possible correlations of obstetric profile with time to postpartum recovery of blood pressure in women with pregnancy hypertension. Women with advanced age, higher body mass index, early gestational age at the onset of hypertension, early gestational age at delivery, severe hypertension, and those with complications of hypertension took longer time in the postnatal period for normalization of blood pressure.

The strength of this study was its prospective design and high rate of follow-up. Those who missed a visit were followed up over telephone. However, 19 women were not available even by phone. A limitation of this study is that the information regarding when the antihypertensive was stopped was obtained by patient recall, raising the possibility of recall bias. However, as the range of recovery times was wide, an error of few days may not be significant.

In the study we noted that women with preeclampsia took a longer time to recovery compared with women with gestational hypertension. Earlier and more severe disease was associated with delay to recovery or persistence of hypertension beyond 10 weeks postpartum.

Similar to our observation, other authors have observed a consistent association of time to reversion of hypertension and early-onset hypertension in pregnancy [3–5]. Ferrazzani explained the longer time to normalization of blood pressure in preeclampsia compared to gestational hypertension as the recovery time of the endothelial damage in preeclampsia [4].

Berks et al [6] found a correlation of maximum diastolic blood pressure, maximum proteinuria in pregnancy, and diagnosis-to-delivery interval with time taken for resolution of hypertension; however, they did not find that time to resolution was correlated with gestational age at onset of preeclampsia. They opined that their observations reflected endothelial recovery after preeclampsia. They also suggested further research in the area of temporizing management of preeclampsia to determine if a conservative approach increases remote cardiovascular risk [6]. We did not study the diagnosis-to-delivery interval, but those with early delivery in our group had late postpartum recovery, indicating that they had severe/complicated preeclampsia that demanded early termination.

In conclusion, women with advanced age, higher body mass index, early gestational age at the onset of hypertension, severe and with complications of hypertension require prolonged monitoring and treatment when indicated for hypertension in the postnatal period. Women with a history of pregnancy hypertension have increased risk of stroke, cardiac ischemia, venous thrombosis within 10 to 20 years after pregnancy and higher risk of hypertension and type 2 diabetes mellitus [7–9]. Extended postnatal follow-up and regular monitoring is recommended to address the needs of these high-risk women.

Corresponding author: Dr. Shyamala Guruvare, 1-167 (C4), Lahari, Eshakripa Road, Parkala, Udupi District, Karnataka, India 576107, [email protected].

Financial disclosures: None reported.

Study Overview

Objective. To compare patients’ health care experiences related to their weight across racial and ethnic groups.

Design. Cross-sectional survey-based study.

Setting and participants. Between March and July 2015, 5400 individuals were randomly sampled from the Patient Outcomes to Advance Learning (PORTAL) obesity cohort, which includes over 5 million adults. The PORTAL network is a clinical data research network funded by the Patient Centered Outcomes Research Institute to promote collaboration across several large health systems with electronic medical records (EMRs), including all the Kaiser Permanente regions, Group Health Cooperative, Health Partners, and Denver Health. The selected 5400 cohort members were equally distributed across 3 geographically diverse Kaiser Permanente regions (Southwest, Northern and Southern California, Hawaii, Colorado, and Northwest) and Denver sites. Selected individuals were non-pregnant English or Spanish speakers with a body mass index (BMI) ≥ 25 kg/m² (per their EMR) who were members of a participating health plan and had at least 1 outpatient visit in the last 12 months. Patients with BMI ≥ 40 kg/m² were oversampled. Individuals were mailed a written 10-minute survey (offered in English or Spanish based on a patient’s written language preference noted in their EMR), consisting of 36 multiple-choice and fill-in-the-blank items. Telephone contact for verbal administration was attempted if a mailed response was not received within 4 weeks.

Main measures and analysis. The primary independent variable was a respondent’s racial/ethnic group, categorized as (1) non-Hispanic white (White), 2) non-Hispanic black (Black), 3) Hispanic, 4) Asian, or 5) Native Hawaiian/Other Pacific Islanders/American Indian/Native Alaskan (NA/PI).

Dependent variables focused on patients’ perceptions of the health care experience (based on services received at their usual place of care from their primary care providers) related to being overweight or obese using items based on the Rudd Center’s Patient Survey of Weight-Sensitive Healthcare Practices. Respondents described (1) whether and how often they avoid coming to their provider because they do not want to be weighed or have a discussion about their weight; (2) how often does their provider ask their permission before discussion their weight; (3) how often has their provider been supportive of their weight concerns and efforts to be healthy; (4) whether they think that their provider understands the physical and emotional challenges faced by individuals who are overweight or obese; (5) how often has their provider brought up their weight during a clinic visit; (6) whether their provider has ever given or discussed resources on healthy eating and weight loss; and (7) what types of weight loss resources were discussed with their provider and which types did they want more information about (ie, dietary changes, physical activity, classes, medications, meal replacements, and bariatric surgery). Covariate variables derived from EMR data included sex, age category, diabetes, hypertension, Charlson Index score (overall measures of morbidity), Medicaid enrollment, language preferences, site, and BMI. Survey-derived covariate variables included emotional well-being, perceived weight status, and educational attainment.

Descriptive statistics were generated and compared across racial/ethnic groups using Kruskal-Wallis and chi-square testing, as appropriate. To evaluate the association between a patient’s race/ethnicity and their perceived weight management experience, multinomial logistic regression adjusted for covariates was used to estimate odds ratios (OR).

Main results. From the original sample (n = 5400), 1569 individuals (29%) did not respond, 925 (17%) refused, and 114 (2%) were ineligible, leaving an eligible sample pool of 5286 individuals. The overall response rate was 53% (2197 written; 614 phone, n = 2811). Those with missing data were excluded (6 with missing race/ethnicity; 80 missing other covariates), leaving a final group of 2725 respondents for analysis. Mean age was 52.7 years (SD 15), almost 62% of participants were female, 51.7% identified as White, 21.1% identified as Black, 14.6% identified as Hispanic, 5.8% identified as Asian, and 6.7% identified as NA/PI. About a quarter (24.4%) had diabetes, less than half (43.5%) had hypertension, and most (86.2%) perceived themselves to be overweight. There were significant differences in measured baseline covariates by racial/ethnic groups including mean BMI, diabetes, and being a Medicaid beneficiary.

In response to the 7 key areas assessed regarding patients’ perceptions of the health care experience related to being overweight or obese:

• Black respondents were less likely than Whites to report that they frequently avoided care from their provider because they did not want to be weighed or discuss their weight (OR 0.49 [95% confidence interval, 0.26–0.90]), with a trend toward all groups being less likely to report frequent avoidance compared to Whites.
• While just over half of respondents (59.3%) indicated that their providers never asked for their permission before discussing their weight, Asians and NA/PI were more likely to report that their providers either frequently (Asians: OR 2.7 [1.3–5.6]; NA/PI: OR 2.3 [1.1–5.0]) or sometimes (Asians: OR 2.3 [1.2–4.3]; NA/PI: OR 2.1 [1.1–4.1]) asked their permission before discussing their weight compared to Whites.
• Over half (61.9%) indicated that their providers were sometimes or frequently supportive of their weight concerns, with no significant differences among racial/ethnic groups.
• Just over half (52.0%) indicated they felt their providers understood the physical and emotional challenges faced by people who are overweight/obese, with Blacks more likely to feel this way (OR 1.8 [1.2–2.8]) compared to Whites.
• Black patients were more likely than Whites (OR 2.0 [1.4–2.8]) to report that their providers discussed their weight with them at a clinic visit.
• While over half (59.7%) indicated that their providers had given or discussed resources with them on healthy eating and weight loss, Black and Asian respondents were more likely than Whites to recall these discussions (Black: OR 1.6 [1.2–2.1]; Asians: OR 1.8 [1.1–2.9]).
• Most weight loss resources or recommendations received were related to lifestyle changes, with very few resources given related to weight loss medications, meal replacement products, or bariatric surgery—few differences across racial/ethnic groups were identified. However, respondents from racial/ethnic minority groups were more likely than Whites to say that they wanted more information about lifestyle changes, classes, and meal replacements. Other than Blacks, all other racial/ethnic groups were also more likely than Whites to indicate that they wanted more information about bariatric surgery.

Conclusions. Most patients across racial/ethnic groups are having positive experiences with weight-related care. However, race/ethnicity correlates with patients’ perception of weight-related care and discussions in clinic encounters.

Commentary

The obesity epidemic in the United States is well-established [1], and recent data from 2014 show that over 37% of adults in the US are obese (defined as having a body mass index greater than 30 kg/m²) [2]. However, while obesity prevalence rates have increased over the past several decades across all genders, ethnicities, income levels, and education levels, important racial/ethnic disparities exist [2,3]. Primary care physicians (PCPs) are ideally situated to promote weight loss via effective obesity counseling since multiple clinic visits over time have the potential to enable rapport building and behavioral change management [4]. In fact, the US Preventive Services Task Force (USPTF) recommends that all patients be screened for obesity and offered intensive lifestyle counseling, as modest weight loss can have significant health benefits [5]. However, some studies have found racial/ethnic differences and disparities in weight-related diagnoses, counseling, and treatment by providers, but also patient perceptions of care and preferred interventions [6–10]. Other studies have described racial/ethnic differences in weight-related concerns and behaviors, body satisfaction, and body image [11–13]. Thus, research is needed to examine these differences.

This cross-sectional study contributes to the limited literature examining the potential for heterogeneity of care according to patient characteristics like race and ethnicity. Key strengths of the design include a large and both geographically and racially/ethnically diverse sample of patients (increased generalizability), the use of mailed brief surveys (reduces non-response rate and reporting bias) and telephone follow-up for verbal administration (reduces non-response rate, though it increases interviewer bias), oversampling of respondents with BMI ≥ 40 kg/m², and the controlling of key covariates including sex, age, Medicaid enrollment, site, and BMI.

However, there are several important limitations, many of which are acknowledged by the authors. While respondents were overall representative of the targeted sample population, the final respondent population was comprised of mostly older females who received managed care, which may have contributed to selection bias and impacted generalizability of findings. Further, Whites were overrepresented, Hispanics were underrepresented, and the small combined sample of NA/PI may have masked important distinctions between these subpopulations. Importantly, this study only provided the survey in English and Spanish and did not include other language translations (eg, Chinese, Japanese, Tagalog), which likely contributed to underrepresented perspectives of immigrants and ESL patients who may struggle with receiving/discussing weight management counseling and resources. The use of a surveys collected subjective and self-reported data on patient encounters as opposed to objective observations. Lastly, the study did not adjust for individual provider factors or assess the potential impact of provider-level differences on care, such as provider-patient concordance on race, ethnicity, language, and/or weight. The incorporation of qualitative interviewers or focus groups with a subsample of each racial/ethnic may have also provided relevant context to understand differences in weight-related care experiences.

Applications for Clinical Practice

As the authors suggest, this study highlights several opportunities to continue improving weight-related care and weight management counseling. PCPs should engage all overweight/obese patients in weight management discussions, and in particular, high-risk minority patients who may desire these conversations and more weight loss advice and resources. However, these discussions require sensitivity and can benefit from the simple practice of asking permission of the patient to talk about their weight in order to reduce care avoidance and improve perceptions of care. Providers should also be mindful of patient priorities and assess patient preferences for all the different weight loss strategies, including lifestyle changes, meal replacements, medications, and surgery.

—Katrina F. Mateo, MPH

Study Overview

Objective. To compare patients’ health care experiences related to their weight across racial and ethnic groups.

Design. Cross-sectional survey-based study.

Setting and participants. Between March and July 2015, 5400 individuals were randomly sampled from the Patient Outcomes to Advance Learning (PORTAL) obesity cohort, which includes over 5 million adults. The PORTAL network is a clinical data research network funded by the Patient Centered Outcomes Research Institute to promote collaboration across several large health systems with electronic medical records (EMRs), including all the Kaiser Permanente regions, Group Health Cooperative, Health Partners, and Denver Health. The selected 5400 cohort members were equally distributed across 3 geographically diverse Kaiser Permanente regions (Southwest, Northern and Southern California, Hawaii, Colorado, and Northwest) and Denver sites. Selected individuals were non-pregnant English or Spanish speakers with a body mass index (BMI) ≥ 25 kg/m² (per their EMR) who were members of a participating health plan and had at least 1 outpatient visit in the last 12 months. Patients with BMI ≥ 40 kg/m² were oversampled. Individuals were mailed a written 10-minute survey (offered in English or Spanish based on a patient’s written language preference noted in their EMR), consisting of 36 multiple-choice and fill-in-the-blank items. Telephone contact for verbal administration was attempted if a mailed response was not received within 4 weeks.

Main measures and analysis. The primary independent variable was a respondent’s racial/ethnic group, categorized as (1) non-Hispanic white (White), 2) non-Hispanic black (Black), 3) Hispanic, 4) Asian, or 5) Native Hawaiian/Other Pacific Islanders/American Indian/Native Alaskan (NA/PI).

Dependent variables focused on patients’ perceptions of the health care experience (based on services received at their usual place of care from their primary care providers) related to being overweight or obese using items based on the Rudd Center’s Patient Survey of Weight-Sensitive Healthcare Practices. Respondents described (1) whether and how often they avoid coming to their provider because they do not want to be weighed or have a discussion about their weight; (2) how often does their provider ask their permission before discussion their weight; (3) how often has their provider been supportive of their weight concerns and efforts to be healthy; (4) whether they think that their provider understands the physical and emotional challenges faced by individuals who are overweight or obese; (5) how often has their provider brought up their weight during a clinic visit; (6) whether their provider has ever given or discussed resources on healthy eating and weight loss; and (7) what types of weight loss resources were discussed with their provider and which types did they want more information about (ie, dietary changes, physical activity, classes, medications, meal replacements, and bariatric surgery). Covariate variables derived from EMR data included sex, age category, diabetes, hypertension, Charlson Index score (overall measures of morbidity), Medicaid enrollment, language preferences, site, and BMI. Survey-derived covariate variables included emotional well-being, perceived weight status, and educational attainment.

Descriptive statistics were generated and compared across racial/ethnic groups using Kruskal-Wallis and chi-square testing, as appropriate. To evaluate the association between a patient’s race/ethnicity and their perceived weight management experience, multinomial logistic regression adjusted for covariates was used to estimate odds ratios (OR).

Main results. From the original sample (n = 5400), 1569 individuals (29%) did not respond, 925 (17%) refused, and 114 (2%) were ineligible, leaving an eligible sample pool of 5286 individuals. The overall response rate was 53% (2197 written; 614 phone, n = 2811). Those with missing data were excluded (6 with missing race/ethnicity; 80 missing other covariates), leaving a final group of 2725 respondents for analysis. Mean age was 52.7 years (SD 15), almost 62% of participants were female, 51.7% identified as White, 21.1% identified as Black, 14.6% identified as Hispanic, 5.8% identified as Asian, and 6.7% identified as NA/PI. About a quarter (24.4%) had diabetes, less than half (43.5%) had hypertension, and most (86.2%) perceived themselves to be overweight. There were significant differences in measured baseline covariates by racial/ethnic groups including mean BMI, diabetes, and being a Medicaid beneficiary.

In response to the 7 key areas assessed regarding patients’ perceptions of the health care experience related to being overweight or obese:

• Black respondents were less likely than Whites to report that they frequently avoided care from their provider because they did not want to be weighed or discuss their weight (OR 0.49 [95% confidence interval, 0.26–0.90]), with a trend toward all groups being less likely to report frequent avoidance compared to Whites.
• While just over half of respondents (59.3%) indicated that their providers never asked for their permission before discussing their weight, Asians and NA/PI were more likely to report that their providers either frequently (Asians: OR 2.7 [1.3–5.6]; NA/PI: OR 2.3 [1.1–5.0]) or sometimes (Asians: OR 2.3 [1.2–4.3]; NA/PI: OR 2.1 [1.1–4.1]) asked their permission before discussing their weight compared to Whites.
• Over half (61.9%) indicated that their providers were sometimes or frequently supportive of their weight concerns, with no significant differences among racial/ethnic groups.
• Just over half (52.0%) indicated they felt their providers understood the physical and emotional challenges faced by people who are overweight/obese, with Blacks more likely to feel this way (OR 1.8 [1.2–2.8]) compared to Whites.
• Black patients were more likely than Whites (OR 2.0 [1.4–2.8]) to report that their providers discussed their weight with them at a clinic visit.
• While over half (59.7%) indicated that their providers had given or discussed resources with them on healthy eating and weight loss, Black and Asian respondents were more likely than Whites to recall these discussions (Black: OR 1.6 [1.2–2.1]; Asians: OR 1.8 [1.1–2.9]).
• Most weight loss resources or recommendations received were related to lifestyle changes, with very few resources given related to weight loss medications, meal replacement products, or bariatric surgery—few differences across racial/ethnic groups were identified. However, respondents from racial/ethnic minority groups were more likely than Whites to say that they wanted more information about lifestyle changes, classes, and meal replacements. Other than Blacks, all other racial/ethnic groups were also more likely than Whites to indicate that they wanted more information about bariatric surgery.

Conclusions. Most patients across racial/ethnic groups are having positive experiences with weight-related care. However, race/ethnicity correlates with patients’ perception of weight-related care and discussions in clinic encounters.

Commentary

The obesity epidemic in the United States is well-established [1], and recent data from 2014 show that over 37% of adults in the US are obese (defined as having a body mass index greater than 30 kg/m²) [2]. However, while obesity prevalence rates have increased over the past several decades across all genders, ethnicities, income levels, and education levels, important racial/ethnic disparities exist [2,3]. Primary care physicians (PCPs) are ideally situated to promote weight loss via effective obesity counseling since multiple clinic visits over time have the potential to enable rapport building and behavioral change management [4]. In fact, the US Preventive Services Task Force (USPTF) recommends that all patients be screened for obesity and offered intensive lifestyle counseling, as modest weight loss can have significant health benefits [5]. However, some studies have found racial/ethnic differences and disparities in weight-related diagnoses, counseling, and treatment by providers, but also patient perceptions of care and preferred interventions [6–10]. Other studies have described racial/ethnic differences in weight-related concerns and behaviors, body satisfaction, and body image [11–13]. Thus, research is needed to examine these differences.

This cross-sectional study contributes to the limited literature examining the potential for heterogeneity of care according to patient characteristics like race and ethnicity. Key strengths of the design include a large and both geographically and racially/ethnically diverse sample of patients (increased generalizability), the use of mailed brief surveys (reduces non-response rate and reporting bias) and telephone follow-up for verbal administration (reduces non-response rate, though it increases interviewer bias), oversampling of respondents with BMI ≥ 40 kg/m², and the controlling of key covariates including sex, age, Medicaid enrollment, site, and BMI.

However, there are several important limitations, many of which are acknowledged by the authors. While respondents were overall representative of the targeted sample population, the final respondent population was comprised of mostly older females who received managed care, which may have contributed to selection bias and impacted generalizability of findings. Further, Whites were overrepresented, Hispanics were underrepresented, and the small combined sample of NA/PI may have masked important distinctions between these subpopulations. Importantly, this study only provided the survey in English and Spanish and did not include other language translations (eg, Chinese, Japanese, Tagalog), which likely contributed to underrepresented perspectives of immigrants and ESL patients who may struggle with receiving/discussing weight management counseling and resources. The use of a surveys collected subjective and self-reported data on patient encounters as opposed to objective observations. Lastly, the study did not adjust for individual provider factors or assess the potential impact of provider-level differences on care, such as provider-patient concordance on race, ethnicity, language, and/or weight. The incorporation of qualitative interviewers or focus groups with a subsample of each racial/ethnic may have also provided relevant context to understand differences in weight-related care experiences.

Applications for Clinical Practice

As the authors suggest, this study highlights several opportunities to continue improving weight-related care and weight management counseling. PCPs should engage all overweight/obese patients in weight management discussions, and in particular, high-risk minority patients who may desire these conversations and more weight loss advice and resources. However, these discussions require sensitivity and can benefit from the simple practice of asking permission of the patient to talk about their weight in order to reduce care avoidance and improve perceptions of care. Providers should also be mindful of patient priorities and assess patient preferences for all the different weight loss strategies, including lifestyle changes, meal replacements, medications, and surgery.

—Katrina F. Mateo, MPH

Study Overview

Objective. To compare patients’ health care experiences related to their weight across racial and ethnic groups.

Design. Cross-sectional survey-based study.

Setting and participants. Between March and July 2015, 5400 individuals were randomly sampled from the Patient Outcomes to Advance Learning (PORTAL) obesity cohort, which includes over 5 million adults. The PORTAL network is a clinical data research network funded by the Patient Centered Outcomes Research Institute to promote collaboration across several large health systems with electronic medical records (EMRs), including all the Kaiser Permanente regions, Group Health Cooperative, Health Partners, and Denver Health. The selected 5400 cohort members were equally distributed across 3 geographically diverse Kaiser Permanente regions (Southwest, Northern and Southern California, Hawaii, Colorado, and Northwest) and Denver sites. Selected individuals were non-pregnant English or Spanish speakers with a body mass index (BMI) ≥ 25 kg/m² (per their EMR) who were members of a participating health plan and had at least 1 outpatient visit in the last 12 months. Patients with BMI ≥ 40 kg/m² were oversampled. Individuals were mailed a written 10-minute survey (offered in English or Spanish based on a patient’s written language preference noted in their EMR), consisting of 36 multiple-choice and fill-in-the-blank items. Telephone contact for verbal administration was attempted if a mailed response was not received within 4 weeks.

Main measures and analysis. The primary independent variable was a respondent’s racial/ethnic group, categorized as (1) non-Hispanic white (White), 2) non-Hispanic black (Black), 3) Hispanic, 4) Asian, or 5) Native Hawaiian/Other Pacific Islanders/American Indian/Native Alaskan (NA/PI).

Dependent variables focused on patients’ perceptions of the health care experience (based on services received at their usual place of care from their primary care providers) related to being overweight or obese using items based on the Rudd Center’s Patient Survey of Weight-Sensitive Healthcare Practices. Respondents described (1) whether and how often they avoid coming to their provider because they do not want to be weighed or have a discussion about their weight; (2) how often does their provider ask their permission before discussion their weight; (3) how often has their provider been supportive of their weight concerns and efforts to be healthy; (4) whether they think that their provider understands the physical and emotional challenges faced by individuals who are overweight or obese; (5) how often has their provider brought up their weight during a clinic visit; (6) whether their provider has ever given or discussed resources on healthy eating and weight loss; and (7) what types of weight loss resources were discussed with their provider and which types did they want more information about (ie, dietary changes, physical activity, classes, medications, meal replacements, and bariatric surgery). Covariate variables derived from EMR data included sex, age category, diabetes, hypertension, Charlson Index score (overall measures of morbidity), Medicaid enrollment, language preferences, site, and BMI. Survey-derived covariate variables included emotional well-being, perceived weight status, and educational attainment.

Descriptive statistics were generated and compared across racial/ethnic groups using Kruskal-Wallis and chi-square testing, as appropriate. To evaluate the association between a patient’s race/ethnicity and their perceived weight management experience, multinomial logistic regression adjusted for covariates was used to estimate odds ratios (OR).

Main results. From the original sample (n = 5400), 1569 individuals (29%) did not respond, 925 (17%) refused, and 114 (2%) were ineligible, leaving an eligible sample pool of 5286 individuals. The overall response rate was 53% (2197 written; 614 phone, n = 2811). Those with missing data were excluded (6 with missing race/ethnicity; 80 missing other covariates), leaving a final group of 2725 respondents for analysis. Mean age was 52.7 years (SD 15), almost 62% of participants were female, 51.7% identified as White, 21.1% identified as Black, 14.6% identified as Hispanic, 5.8% identified as Asian, and 6.7% identified as NA/PI. About a quarter (24.4%) had diabetes, less than half (43.5%) had hypertension, and most (86.2%) perceived themselves to be overweight. There were significant differences in measured baseline covariates by racial/ethnic groups including mean BMI, diabetes, and being a Medicaid beneficiary.

In response to the 7 key areas assessed regarding patients’ perceptions of the health care experience related to being overweight or obese:

• Black respondents were less likely than Whites to report that they frequently avoided care from their provider because they did not want to be weighed or discuss their weight (OR 0.49 [95% confidence interval, 0.26–0.90]), with a trend toward all groups being less likely to report frequent avoidance compared to Whites.
• While just over half of respondents (59.3%) indicated that their providers never asked for their permission before discussing their weight, Asians and NA/PI were more likely to report that their providers either frequently (Asians: OR 2.7 [1.3–5.6]; NA/PI: OR 2.3 [1.1–5.0]) or sometimes (Asians: OR 2.3 [1.2–4.3]; NA/PI: OR 2.1 [1.1–4.1]) asked their permission before discussing their weight compared to Whites.
• Over half (61.9%) indicated that their providers were sometimes or frequently supportive of their weight concerns, with no significant differences among racial/ethnic groups.
• Just over half (52.0%) indicated they felt their providers understood the physical and emotional challenges faced by people who are overweight/obese, with Blacks more likely to feel this way (OR 1.8 [1.2–2.8]) compared to Whites.
• Black patients were more likely than Whites (OR 2.0 [1.4–2.8]) to report that their providers discussed their weight with them at a clinic visit.
• While over half (59.7%) indicated that their providers had given or discussed resources with them on healthy eating and weight loss, Black and Asian respondents were more likely than Whites to recall these discussions (Black: OR 1.6 [1.2–2.1]; Asians: OR 1.8 [1.1–2.9]).
• Most weight loss resources or recommendations received were related to lifestyle changes, with very few resources given related to weight loss medications, meal replacement products, or bariatric surgery—few differences across racial/ethnic groups were identified. However, respondents from racial/ethnic minority groups were more likely than Whites to say that they wanted more information about lifestyle changes, classes, and meal replacements. Other than Blacks, all other racial/ethnic groups were also more likely than Whites to indicate that they wanted more information about bariatric surgery.

Conclusions. Most patients across racial/ethnic groups are having positive experiences with weight-related care. However, race/ethnicity correlates with patients’ perception of weight-related care and discussions in clinic encounters.

Commentary

The obesity epidemic in the United States is well-established [1], and recent data from 2014 show that over 37% of adults in the US are obese (defined as having a body mass index greater than 30 kg/m²) [2]. However, while obesity prevalence rates have increased over the past several decades across all genders, ethnicities, income levels, and education levels, important racial/ethnic disparities exist [2,3]. Primary care physicians (PCPs) are ideally situated to promote weight loss via effective obesity counseling since multiple clinic visits over time have the potential to enable rapport building and behavioral change management [4]. In fact, the US Preventive Services Task Force (USPTF) recommends that all patients be screened for obesity and offered intensive lifestyle counseling, as modest weight loss can have significant health benefits [5]. However, some studies have found racial/ethnic differences and disparities in weight-related diagnoses, counseling, and treatment by providers, but also patient perceptions of care and preferred interventions [6–10]. Other studies have described racial/ethnic differences in weight-related concerns and behaviors, body satisfaction, and body image [11–13]. Thus, research is needed to examine these differences.

This cross-sectional study contributes to the limited literature examining the potential for heterogeneity of care according to patient characteristics like race and ethnicity. Key strengths of the design include a large and both geographically and racially/ethnically diverse sample of patients (increased generalizability), the use of mailed brief surveys (reduces non-response rate and reporting bias) and telephone follow-up for verbal administration (reduces non-response rate, though it increases interviewer bias), oversampling of respondents with BMI ≥ 40 kg/m², and the controlling of key covariates including sex, age, Medicaid enrollment, site, and BMI.

However, there are several important limitations, many of which are acknowledged by the authors. While respondents were overall representative of the targeted sample population, the final respondent population was comprised of mostly older females who received managed care, which may have contributed to selection bias and impacted generalizability of findings. Further, Whites were overrepresented, Hispanics were underrepresented, and the small combined sample of NA/PI may have masked important distinctions between these subpopulations. Importantly, this study only provided the survey in English and Spanish and did not include other language translations (eg, Chinese, Japanese, Tagalog), which likely contributed to underrepresented perspectives of immigrants and ESL patients who may struggle with receiving/discussing weight management counseling and resources. The use of a surveys collected subjective and self-reported data on patient encounters as opposed to objective observations. Lastly, the study did not adjust for individual provider factors or assess the potential impact of provider-level differences on care, such as provider-patient concordance on race, ethnicity, language, and/or weight. The incorporation of qualitative interviewers or focus groups with a subsample of each racial/ethnic may have also provided relevant context to understand differences in weight-related care experiences.

Applications for Clinical Practice

As the authors suggest, this study highlights several opportunities to continue improving weight-related care and weight management counseling. PCPs should engage all overweight/obese patients in weight management discussions, and in particular, high-risk minority patients who may desire these conversations and more weight loss advice and resources. However, these discussions require sensitivity and can benefit from the simple practice of asking permission of the patient to talk about their weight in order to reduce care avoidance and improve perceptions of care. Providers should also be mindful of patient priorities and assess patient preferences for all the different weight loss strategies, including lifestyle changes, meal replacements, medications, and surgery.

—Katrina F. Mateo, MPH

Pediatricians take heart.

Yes, I know it is discouraging when families occasionally ignore our advice and refuse vaccines for their children. It is even worse when political leaders who ought to know better question the safety and value of vaccines.

But let’s not lose perspective. Let me share a quick reminder of why vaccines are (almost) universally considered one of the greatest public health achievements of the 20th century.

Not long ago, I reviewed a clinical case with students as part of a medical microbiology course. A 6-year-old girl presented with fever, headache, and flaccid paralysis of the right arm with areflexia. With little prompting, the students generated a short differential diagnosis. Enterovirus. West Nile virus. “I guess we should include polio,” one student offered. “But who gets that anymore?”

A mere 120 years changes everything. At the dawn of the 20th century, we didn’t even know with certainty what caused polio, although infection was suspected.

Courtesy Wikimedia Commons/Shobhit Gosain/Creative Commons License

designer491/Thinkstock

Dr. Bryant is a pediatrician specializing in infectious diseases at the University of Louisville (Ky.) and Kosair Children’s Hospital, also in Louisville. She said she had no relevant financial disclosures. Email her at [email protected].

Pediatricians take heart.

Yes, I know it is discouraging when families occasionally ignore our advice and refuse vaccines for their children. It is even worse when political leaders who ought to know better question the safety and value of vaccines.

But let’s not lose perspective. Let me share a quick reminder of why vaccines are (almost) universally considered one of the greatest public health achievements of the 20th century.

Not long ago, I reviewed a clinical case with students as part of a medical microbiology course. A 6-year-old girl presented with fever, headache, and flaccid paralysis of the right arm with areflexia. With little prompting, the students generated a short differential diagnosis. Enterovirus. West Nile virus. “I guess we should include polio,” one student offered. “But who gets that anymore?”

A mere 120 years changes everything. At the dawn of the 20th century, we didn’t even know with certainty what caused polio, although infection was suspected.

Courtesy Wikimedia Commons/Shobhit Gosain/Creative Commons License

designer491/Thinkstock

Dr. Bryant is a pediatrician specializing in infectious diseases at the University of Louisville (Ky.) and Kosair Children’s Hospital, also in Louisville. She said she had no relevant financial disclosures. Email her at [email protected].

Pediatricians take heart.

Yes, I know it is discouraging when families occasionally ignore our advice and refuse vaccines for their children. It is even worse when political leaders who ought to know better question the safety and value of vaccines.

But let’s not lose perspective. Let me share a quick reminder of why vaccines are (almost) universally considered one of the greatest public health achievements of the 20th century.

Not long ago, I reviewed a clinical case with students as part of a medical microbiology course. A 6-year-old girl presented with fever, headache, and flaccid paralysis of the right arm with areflexia. With little prompting, the students generated a short differential diagnosis. Enterovirus. West Nile virus. “I guess we should include polio,” one student offered. “But who gets that anymore?”

A mere 120 years changes everything. At the dawn of the 20th century, we didn’t even know with certainty what caused polio, although infection was suspected.

Courtesy Wikimedia Commons/Shobhit Gosain/Creative Commons License

designer491/Thinkstock

Dr. Bryant is a pediatrician specializing in infectious diseases at the University of Louisville (Ky.) and Kosair Children’s Hospital, also in Louisville. She said she had no relevant financial disclosures. Email her at [email protected].

Intermittent breaks from sunitinib therapy are feasible and don’t appear to compromise the agent’s clinical efficacy against metastatic renal cell carcinoma, according to investigators.

One of the greatest challenges in treating this cancer is balancing treatment-related toxicity against efficacy “in a setting ... in which patients are largely incurable and thus subjected to chronic therapy,” said Moshe C. Ornstein, MD, and his associates at the Cleveland Clinic Taussig Cancer Institute.

They performed a single-center phase II study that they described as the first prospective trial to assess treatment interruptions whenever tumor burden was reduced by 10% or more, followed by resumption of treatment if tumors then progressed 10% or more. This approach “may result in reduced toxicities, improved quality of life, cost savings, and potentially improved clinical outcomes.”

The study involved 37 adults (median age, 63 years) who were given 50 mg sunitinib once daily for the first 28 days of a 42-day cycle, with dose adjustments allowed to minimize toxicities. Twenty patients (54%) who showed a 10% or greater reduction in tumor burden after four cycles suspended treatment until scans showed a 10% or greater progression, at which point treatment was resumed. These 20 patients were able to take up to 11 treatment breaks (median, 3 breaks per patient), with each break having a median duration of more than 8 weeks (range, 4.7-192.1 weeks).

Seven patients were able to have extended drug holidays lasting 3-43 months, and three have never had to resume sunitinib therapy after their first break. “The overall sum of all the breaks was 1,296.6 weeks, which corresponds to 216 6-week cycles with a median of 9 saved cycles per patient,” Dr. Ornstein and his associates said (J Clin Oncol. 2017 Jan 23. doi: 10.1200/JCO.2016.71.1184).

Given that the average wholesale price of sunitinib is $17,811.83 per 28-day cycle, “the 9 cycles saved per patient translates into a median cost saving of $160,302 per patient and $3.85 million overall, not including the cost of toxicity management that may have been incurred without breaks,” they noted.

The median progression-free survival was 22.4 months for the entire study cohort and 37.6 months for the 20 patients who had intermittent therapy.

Patients who showed tumor progression during a treatment break were transitioned back to standard dosing without showing any adverse clinical effects. This suggests that “with close clinical and radiographic monitoring, patients can safely take a therapy break for extended periods of time,” the investigators said.

Intermittent breaks from sunitinib therapy are feasible and don’t appear to compromise the agent’s clinical efficacy against metastatic renal cell carcinoma, according to investigators.

One of the greatest challenges in treating this cancer is balancing treatment-related toxicity against efficacy “in a setting ... in which patients are largely incurable and thus subjected to chronic therapy,” said Moshe C. Ornstein, MD, and his associates at the Cleveland Clinic Taussig Cancer Institute.

They performed a single-center phase II study that they described as the first prospective trial to assess treatment interruptions whenever tumor burden was reduced by 10% or more, followed by resumption of treatment if tumors then progressed 10% or more. This approach “may result in reduced toxicities, improved quality of life, cost savings, and potentially improved clinical outcomes.”

The study involved 37 adults (median age, 63 years) who were given 50 mg sunitinib once daily for the first 28 days of a 42-day cycle, with dose adjustments allowed to minimize toxicities. Twenty patients (54%) who showed a 10% or greater reduction in tumor burden after four cycles suspended treatment until scans showed a 10% or greater progression, at which point treatment was resumed. These 20 patients were able to take up to 11 treatment breaks (median, 3 breaks per patient), with each break having a median duration of more than 8 weeks (range, 4.7-192.1 weeks).

Seven patients were able to have extended drug holidays lasting 3-43 months, and three have never had to resume sunitinib therapy after their first break. “The overall sum of all the breaks was 1,296.6 weeks, which corresponds to 216 6-week cycles with a median of 9 saved cycles per patient,” Dr. Ornstein and his associates said (J Clin Oncol. 2017 Jan 23. doi: 10.1200/JCO.2016.71.1184).

Given that the average wholesale price of sunitinib is $17,811.83 per 28-day cycle, “the 9 cycles saved per patient translates into a median cost saving of $160,302 per patient and $3.85 million overall, not including the cost of toxicity management that may have been incurred without breaks,” they noted.

The median progression-free survival was 22.4 months for the entire study cohort and 37.6 months for the 20 patients who had intermittent therapy.

Patients who showed tumor progression during a treatment break were transitioned back to standard dosing without showing any adverse clinical effects. This suggests that “with close clinical and radiographic monitoring, patients can safely take a therapy break for extended periods of time,” the investigators said.

Intermittent breaks from sunitinib therapy are feasible and don’t appear to compromise the agent’s clinical efficacy against metastatic renal cell carcinoma, according to investigators.

One of the greatest challenges in treating this cancer is balancing treatment-related toxicity against efficacy “in a setting ... in which patients are largely incurable and thus subjected to chronic therapy,” said Moshe C. Ornstein, MD, and his associates at the Cleveland Clinic Taussig Cancer Institute.

They performed a single-center phase II study that they described as the first prospective trial to assess treatment interruptions whenever tumor burden was reduced by 10% or more, followed by resumption of treatment if tumors then progressed 10% or more. This approach “may result in reduced toxicities, improved quality of life, cost savings, and potentially improved clinical outcomes.”

The study involved 37 adults (median age, 63 years) who were given 50 mg sunitinib once daily for the first 28 days of a 42-day cycle, with dose adjustments allowed to minimize toxicities. Twenty patients (54%) who showed a 10% or greater reduction in tumor burden after four cycles suspended treatment until scans showed a 10% or greater progression, at which point treatment was resumed. These 20 patients were able to take up to 11 treatment breaks (median, 3 breaks per patient), with each break having a median duration of more than 8 weeks (range, 4.7-192.1 weeks).

Seven patients were able to have extended drug holidays lasting 3-43 months, and three have never had to resume sunitinib therapy after their first break. “The overall sum of all the breaks was 1,296.6 weeks, which corresponds to 216 6-week cycles with a median of 9 saved cycles per patient,” Dr. Ornstein and his associates said (J Clin Oncol. 2017 Jan 23. doi: 10.1200/JCO.2016.71.1184).

Given that the average wholesale price of sunitinib is $17,811.83 per 28-day cycle, “the 9 cycles saved per patient translates into a median cost saving of $160,302 per patient and $3.85 million overall, not including the cost of toxicity management that may have been incurred without breaks,” they noted.

The median progression-free survival was 22.4 months for the entire study cohort and 37.6 months for the 20 patients who had intermittent therapy.

Patients who showed tumor progression during a treatment break were transitioned back to standard dosing without showing any adverse clinical effects. This suggests that “with close clinical and radiographic monitoring, patients can safely take a therapy break for extended periods of time,” the investigators said.

VANCOUVER—Initial pediatric concussion evaluations provide an opportunity to recognize premorbid conditions that may be exacerbated by the injury; address problems with prior management, such as excessive rest or NSAID overuse; and identify treatment approaches, according to a seminar delivered at the 45th Annual Meeting of the Child Neurology Society.

Neurologists also may decide whether imaging is warranted and note risk factors for prolonged recovery, said Sharief Taraman, MD, Director of the Children’s Concussion Program at Children’s Hospital of Orange County in Orange, California, and Assistant Clinical Professor of Pediatrics at the University of California, Irvine.

Imaging Likely Not Needed

In most cases, a CT scan is not necessary, Dr. Taraman said. He encouraged neurologists to work with their emergency department colleagues to ensure that patients only undergo CT scans when appropriate. His department uses Pediatric Emergency Care Applied Research Network (PECARN) criteria to determine when a CT scan is warranted. Many patients do not have signs of altered mental status in the emergency department, and “there is really no good reason to scan many of these kids,” he said. Patients also typically do not undergo MRI unless “a significant neurologic finding … suggests that there might have been a stronger mechanism of action.”

History taking is a vital component of initial management, and identifying premorbid conditions is a key factor, Dr. Taraman said. “What we have seen is that concussion symptoms act as a magnifying glass. If I have migraine and I get a concussion, my migraine will likely become exacerbated,” he said. Patients may also present for evaluation of concussion but have an alternate diagnosis that better explains their symptoms. For example, Dr. Taraman described a patient who had persistent symptoms following a concussion. “Listening to the story, it was clearly sleep apnea,” he said. The child underwent polysomnography and received continuous positive airway pressure treatment because he had 40 apneas in an hour.

During the evaluation, neurologists can recognize poor initial management of the injury, such as excessive bed rest or removal from activities. NSAID overuse also is a big problem. Emergency departments may tell patients to take ibuprofen every eight hours for five weeks, which can lead to rebound headaches, Dr. Taraman said.

Facilitate Recovery

Recognition of certain symptoms can inform the patient’s prognosis and suggest ways to speed recovery. For example, neurologists should look for vestibular dysfunction or balance problems and decide whether to address these symptoms. Neurologists also should check for and address cervical strain and ocular dysfunction. Treating severe convergence insufficiency or excess may help patients recover faster.

Anxiety and mood disorders suggest a prolonged recovery. Some patients develop adjustment disorder after concussion. “Interestingly, we see that patients who have more severe traumatic brain injury … are unaware of their deficits,” whereas high-functioning patients who feel slightly off perceive their deficits, which “causes a lot of discomfort for them,” he said.

Symptoms from concussions that involve assaults and litigation tend to take longer to resolve. Some patients’ symptoms persist until litigation ends, although typically not due to malingering but rather due to increased psychological stress.

Poor headache control, sleep disturbances, prior concussions, and a history of prolonged concussion recovery are other risk factors for prolonged recovery.

The Sport Concussion Assessment Tool 3 (SCAT3) is a free, standardized way of assessing symptoms. Developed as a sideline assessment tool, the SCAT3 also works well as a symptoms form, Dr. Taraman said. The tool includes a quick cognitive assessment and balance exam, and online video tutorials explain how to perform the assessment. After assessing a patient’s symptoms, including cognition, concentration, balance, and convergence insufficiency, “then you can decide, how … to triage the patient and start managing them.”

—Jake Remaly

Suggested Reading

Bressan S, Romanato S, Mion T, et al. Implementation of adapted PECARN decision rule for children with minor head injury in the pediatric emergency department. Acad Emerg Med. 2012;19(7):801-807.

Kuppermann N, Holmes JF, Dayan PS, et al. Identification of children at very low risk of clinically-important brain injuries after head trauma: a prospective cohort study. Lancet. 2009;374(9696):1160-1170.

Yengo-Kahn AM, Hale AT, Zalneraitis BH, et al. The Sport Concussion Assessment Tool: a systematic review. Neurosurg Focus. 2016;40(4):E6.

VANCOUVER—Initial pediatric concussion evaluations provide an opportunity to recognize premorbid conditions that may be exacerbated by the injury; address problems with prior management, such as excessive rest or NSAID overuse; and identify treatment approaches, according to a seminar delivered at the 45th Annual Meeting of the Child Neurology Society.

Neurologists also may decide whether imaging is warranted and note risk factors for prolonged recovery, said Sharief Taraman, MD, Director of the Children’s Concussion Program at Children’s Hospital of Orange County in Orange, California, and Assistant Clinical Professor of Pediatrics at the University of California, Irvine.

Imaging Likely Not Needed

In most cases, a CT scan is not necessary, Dr. Taraman said. He encouraged neurologists to work with their emergency department colleagues to ensure that patients only undergo CT scans when appropriate. His department uses Pediatric Emergency Care Applied Research Network (PECARN) criteria to determine when a CT scan is warranted. Many patients do not have signs of altered mental status in the emergency department, and “there is really no good reason to scan many of these kids,” he said. Patients also typically do not undergo MRI unless “a significant neurologic finding … suggests that there might have been a stronger mechanism of action.”

History taking is a vital component of initial management, and identifying premorbid conditions is a key factor, Dr. Taraman said. “What we have seen is that concussion symptoms act as a magnifying glass. If I have migraine and I get a concussion, my migraine will likely become exacerbated,” he said. Patients may also present for evaluation of concussion but have an alternate diagnosis that better explains their symptoms. For example, Dr. Taraman described a patient who had persistent symptoms following a concussion. “Listening to the story, it was clearly sleep apnea,” he said. The child underwent polysomnography and received continuous positive airway pressure treatment because he had 40 apneas in an hour.

During the evaluation, neurologists can recognize poor initial management of the injury, such as excessive bed rest or removal from activities. NSAID overuse also is a big problem. Emergency departments may tell patients to take ibuprofen every eight hours for five weeks, which can lead to rebound headaches, Dr. Taraman said.

Facilitate Recovery

Recognition of certain symptoms can inform the patient’s prognosis and suggest ways to speed recovery. For example, neurologists should look for vestibular dysfunction or balance problems and decide whether to address these symptoms. Neurologists also should check for and address cervical strain and ocular dysfunction. Treating severe convergence insufficiency or excess may help patients recover faster.

Anxiety and mood disorders suggest a prolonged recovery. Some patients develop adjustment disorder after concussion. “Interestingly, we see that patients who have more severe traumatic brain injury … are unaware of their deficits,” whereas high-functioning patients who feel slightly off perceive their deficits, which “causes a lot of discomfort for them,” he said.

Symptoms from concussions that involve assaults and litigation tend to take longer to resolve. Some patients’ symptoms persist until litigation ends, although typically not due to malingering but rather due to increased psychological stress.

Poor headache control, sleep disturbances, prior concussions, and a history of prolonged concussion recovery are other risk factors for prolonged recovery.

The Sport Concussion Assessment Tool 3 (SCAT3) is a free, standardized way of assessing symptoms. Developed as a sideline assessment tool, the SCAT3 also works well as a symptoms form, Dr. Taraman said. The tool includes a quick cognitive assessment and balance exam, and online video tutorials explain how to perform the assessment. After assessing a patient’s symptoms, including cognition, concentration, balance, and convergence insufficiency, “then you can decide, how … to triage the patient and start managing them.”

—Jake Remaly

Suggested Reading

Bressan S, Romanato S, Mion T, et al. Implementation of adapted PECARN decision rule for children with minor head injury in the pediatric emergency department. Acad Emerg Med. 2012;19(7):801-807.

Kuppermann N, Holmes JF, Dayan PS, et al. Identification of children at very low risk of clinically-important brain injuries after head trauma: a prospective cohort study. Lancet. 2009;374(9696):1160-1170.

Yengo-Kahn AM, Hale AT, Zalneraitis BH, et al. The Sport Concussion Assessment Tool: a systematic review. Neurosurg Focus. 2016;40(4):E6.

VANCOUVER—Initial pediatric concussion evaluations provide an opportunity to recognize premorbid conditions that may be exacerbated by the injury; address problems with prior management, such as excessive rest or NSAID overuse; and identify treatment approaches, according to a seminar delivered at the 45th Annual Meeting of the Child Neurology Society.

Neurologists also may decide whether imaging is warranted and note risk factors for prolonged recovery, said Sharief Taraman, MD, Director of the Children’s Concussion Program at Children’s Hospital of Orange County in Orange, California, and Assistant Clinical Professor of Pediatrics at the University of California, Irvine.

Imaging Likely Not Needed

In most cases, a CT scan is not necessary, Dr. Taraman said. He encouraged neurologists to work with their emergency department colleagues to ensure that patients only undergo CT scans when appropriate. His department uses Pediatric Emergency Care Applied Research Network (PECARN) criteria to determine when a CT scan is warranted. Many patients do not have signs of altered mental status in the emergency department, and “there is really no good reason to scan many of these kids,” he said. Patients also typically do not undergo MRI unless “a significant neurologic finding … suggests that there might have been a stronger mechanism of action.”

History taking is a vital component of initial management, and identifying premorbid conditions is a key factor, Dr. Taraman said. “What we have seen is that concussion symptoms act as a magnifying glass. If I have migraine and I get a concussion, my migraine will likely become exacerbated,” he said. Patients may also present for evaluation of concussion but have an alternate diagnosis that better explains their symptoms. For example, Dr. Taraman described a patient who had persistent symptoms following a concussion. “Listening to the story, it was clearly sleep apnea,” he said. The child underwent polysomnography and received continuous positive airway pressure treatment because he had 40 apneas in an hour.

During the evaluation, neurologists can recognize poor initial management of the injury, such as excessive bed rest or removal from activities. NSAID overuse also is a big problem. Emergency departments may tell patients to take ibuprofen every eight hours for five weeks, which can lead to rebound headaches, Dr. Taraman said.

Facilitate Recovery

Recognition of certain symptoms can inform the patient’s prognosis and suggest ways to speed recovery. For example, neurologists should look for vestibular dysfunction or balance problems and decide whether to address these symptoms. Neurologists also should check for and address cervical strain and ocular dysfunction. Treating severe convergence insufficiency or excess may help patients recover faster.

Anxiety and mood disorders suggest a prolonged recovery. Some patients develop adjustment disorder after concussion. “Interestingly, we see that patients who have more severe traumatic brain injury … are unaware of their deficits,” whereas high-functioning patients who feel slightly off perceive their deficits, which “causes a lot of discomfort for them,” he said.

Symptoms from concussions that involve assaults and litigation tend to take longer to resolve. Some patients’ symptoms persist until litigation ends, although typically not due to malingering but rather due to increased psychological stress.

Poor headache control, sleep disturbances, prior concussions, and a history of prolonged concussion recovery are other risk factors for prolonged recovery.

The Sport Concussion Assessment Tool 3 (SCAT3) is a free, standardized way of assessing symptoms. Developed as a sideline assessment tool, the SCAT3 also works well as a symptoms form, Dr. Taraman said. The tool includes a quick cognitive assessment and balance exam, and online video tutorials explain how to perform the assessment. After assessing a patient’s symptoms, including cognition, concentration, balance, and convergence insufficiency, “then you can decide, how … to triage the patient and start managing them.”

—Jake Remaly

Suggested Reading

Bressan S, Romanato S, Mion T, et al. Implementation of adapted PECARN decision rule for children with minor head injury in the pediatric emergency department. Acad Emerg Med. 2012;19(7):801-807.

Kuppermann N, Holmes JF, Dayan PS, et al. Identification of children at very low risk of clinically-important brain injuries after head trauma: a prospective cohort study. Lancet. 2009;374(9696):1160-1170.

Yengo-Kahn AM, Hale AT, Zalneraitis BH, et al. The Sport Concussion Assessment Tool: a systematic review. Neurosurg Focus. 2016;40(4):E6.

Do you charge for medical records?

You probably do, and so do I, at times.

Generally, I’m willing to give a patient one copy of their records or transfer them to another doctor for continuation of care, at no charge. People move away. They change insurance or doctors. They have urgent hospital admissions. To me, charging to forward records in these cases is like withholding care.

That’s not to say I don’t lose money on them. It takes a few minutes (or more) of staff time to print them up and fax them. If they need to be mailed, postage costs money. And then there’s paper, printer ink, and so on. I’m sure it adds up to something over the course of the year, although I have no idea how much.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.
 

Do you charge for medical records?

You probably do, and so do I, at times.

Generally, I’m willing to give a patient one copy of their records or transfer them to another doctor for continuation of care, at no charge. People move away. They change insurance or doctors. They have urgent hospital admissions. To me, charging to forward records in these cases is like withholding care.

That’s not to say I don’t lose money on them. It takes a few minutes (or more) of staff time to print them up and fax them. If they need to be mailed, postage costs money. And then there’s paper, printer ink, and so on. I’m sure it adds up to something over the course of the year, although I have no idea how much.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.
 

Do you charge for medical records?

You probably do, and so do I, at times.

Generally, I’m willing to give a patient one copy of their records or transfer them to another doctor for continuation of care, at no charge. People move away. They change insurance or doctors. They have urgent hospital admissions. To me, charging to forward records in these cases is like withholding care.

That’s not to say I don’t lose money on them. It takes a few minutes (or more) of staff time to print them up and fax them. If they need to be mailed, postage costs money. And then there’s paper, printer ink, and so on. I’m sure it adds up to something over the course of the year, although I have no idea how much.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.
 

The 5-year survival rate for multiple myeloma increased eightfold over an approximately 60-year span starting in the early 1950s, said Ali H. Mokdad, PhD, and his associates.

Patients with multiple myeloma had a 5-year relative survival rate of 6% in 1950-1954, compared with 49.8% in 2008-2013, according to data from the Surveillance, Epidemiology, and End Results Program (JAMA 2017;317[4]:388-406).

[email protected]

The 5-year survival rate for multiple myeloma increased eightfold over an approximately 60-year span starting in the early 1950s, said Ali H. Mokdad, PhD, and his associates.

Patients with multiple myeloma had a 5-year relative survival rate of 6% in 1950-1954, compared with 49.8% in 2008-2013, according to data from the Surveillance, Epidemiology, and End Results Program (JAMA 2017;317[4]:388-406).

[email protected]

The 5-year survival rate for multiple myeloma increased eightfold over an approximately 60-year span starting in the early 1950s, said Ali H. Mokdad, PhD, and his associates.

Patients with multiple myeloma had a 5-year relative survival rate of 6% in 1950-1954, compared with 49.8% in 2008-2013, according to data from the Surveillance, Epidemiology, and End Results Program (JAMA 2017;317[4]:388-406).

[email protected]

Over the 60-year span from the early 1950s to 2013, the 5-year survival rate for all leukemias increased by 500%, according to data from the Surveillance, Epidemiology, and End Results Program.

For 2008-2013, the 5-year relative survival rate for all leukemias was 60.1%, compared with 10% during 1950-1954, said Ali H. Mokdad, PhD, and his associates at the Institute for Health Metrics and Evaluation at the University of Washington, Seattle (JAMA 2017;317[4]:388-406).

[email protected]

Over the 60-year span from the early 1950s to 2013, the 5-year survival rate for all leukemias increased by 500%, according to data from the Surveillance, Epidemiology, and End Results Program.

For 2008-2013, the 5-year relative survival rate for all leukemias was 60.1%, compared with 10% during 1950-1954, said Ali H. Mokdad, PhD, and his associates at the Institute for Health Metrics and Evaluation at the University of Washington, Seattle (JAMA 2017;317[4]:388-406).

[email protected]

Over the 60-year span from the early 1950s to 2013, the 5-year survival rate for all leukemias increased by 500%, according to data from the Surveillance, Epidemiology, and End Results Program.

For 2008-2013, the 5-year relative survival rate for all leukemias was 60.1%, compared with 10% during 1950-1954, said Ali H. Mokdad, PhD, and his associates at the Institute for Health Metrics and Evaluation at the University of Washington, Seattle (JAMA 2017;317[4]:388-406).

[email protected]

Five-year survival for patients with non-Hodgkin lymphoma has more than doubled since the early 1950s, according to Ali H. Mokdad, PhD, and his associates.

Data from the Surveillance, Epidemiology, and End Results Program show that the 5-year relative survival rate for non-Hodgkin lymphoma in the United States went from 33% in 1950-1954 to 71.2% in 2008-2013, an increase of 116%, Dr. Mokdad and his associates reported (JAMA 2017;317[4]:388-406).

[email protected]

Five-year survival for patients with non-Hodgkin lymphoma has more than doubled since the early 1950s, according to Ali H. Mokdad, PhD, and his associates.

Data from the Surveillance, Epidemiology, and End Results Program show that the 5-year relative survival rate for non-Hodgkin lymphoma in the United States went from 33% in 1950-1954 to 71.2% in 2008-2013, an increase of 116%, Dr. Mokdad and his associates reported (JAMA 2017;317[4]:388-406).

[email protected]

Five-year survival for patients with non-Hodgkin lymphoma has more than doubled since the early 1950s, according to Ali H. Mokdad, PhD, and his associates.

Data from the Surveillance, Epidemiology, and End Results Program show that the 5-year relative survival rate for non-Hodgkin lymphoma in the United States went from 33% in 1950-1954 to 71.2% in 2008-2013, an increase of 116%, Dr. Mokdad and his associates reported (JAMA 2017;317[4]:388-406).

[email protected]