LONDON—In patients with multiple sclerosis (MS), telerehabilitation is a convenient and practical method of performing physical therapy with efficacy comparable to that of conventional in-person physical therapy, as measured by objective outcomes of gait and balance. Telerehabilitation should be investigated further and used more extensively as a means of improving function and quality of life in MS, according to researchers who spoke at the 32nd Congress of the European Committee for Treatment and Research in MS (ECTRIMS).

MS often results in physical and cognitive disability. Rehabilitation methods that include physical therapy can achieve functional improvement of established physical deficits. Factors such as availability, geographical distance, mobility, transportation, and cost, however, limit access to specialized rehabilitation services. Telecommunication technology opens the possibility of supervising and directing a physical therapy program remotely through audio and visual communication in real time.

Gabriel Pardo, MD, Director of the Oklahoma Medical Research Foundation MS Center of Excellence in Oklahoma City, and colleagues sought to demonstrate the feasibility of a tele-health rehabilitation program in individuals with ambulatory deficits secondary to MS. The researchers also intended to evaluate the efficacy of the tele-health rehabilitation program and compare it with that of conventional physical therapy.

Dr. Pardo and colleagues included 30 individuals in a single-center, prospective, randomized, three-arm, evaluator-blinded study that lasted for eight weeks. About 69% of participants were female, and the population’s mean age was 54.7. Approximately 60% of participants had relapsing-remitting MS, 23% had secondary progressive MS, and 17% had primary progressive MS. The population’s mean Expanded Disability Status Scale (EDSS) score was 4.3.

All participants performed a home-based exercise program (HEP) unsupervised on five days per week for eight weeks. Participants were randomized to three intervention groups. Group 1 underwent HEP alone. Group 2 underwent HEP plus remote physical therapy supervised via audio and visual real-time telecommunication two to three times per week. Group 3 underwent HEP plus in-person physical therapy at the medical facility two to three times per week. The study outcomes were multiple measurements of gait and balance, as well as patient-reported outcomes. Selected outcomes were performed with a computerized system (ie, Neurocom SmartBalance).

Functional gait assessment improved from baseline in all groups. Improvements were no different between the telerehabilitation and the conventional PT groups, but this finding was not statistically significant. Other outcomes that were similar for Groups 2 and 3 were the Timed 25-Foot Walk, stride length, the Berg balance scale, step width, tandem sway, tandem width, limits of stability, and the sensory organization test. One participant dropped out of the study because of an MS relapse.

The researchers observed no problems with adherence in any of the groups. “If we are to demonstrate a more significant intergroup difference, we need [larger] cohorts, and consequently, further research is needed,” Dr. Pardo concluded.

LONDON—In patients with multiple sclerosis (MS), telerehabilitation is a convenient and practical method of performing physical therapy with efficacy comparable to that of conventional in-person physical therapy, as measured by objective outcomes of gait and balance. Telerehabilitation should be investigated further and used more extensively as a means of improving function and quality of life in MS, according to researchers who spoke at the 32nd Congress of the European Committee for Treatment and Research in MS (ECTRIMS).

MS often results in physical and cognitive disability. Rehabilitation methods that include physical therapy can achieve functional improvement of established physical deficits. Factors such as availability, geographical distance, mobility, transportation, and cost, however, limit access to specialized rehabilitation services. Telecommunication technology opens the possibility of supervising and directing a physical therapy program remotely through audio and visual communication in real time.

Gabriel Pardo, MD, Director of the Oklahoma Medical Research Foundation MS Center of Excellence in Oklahoma City, and colleagues sought to demonstrate the feasibility of a tele-health rehabilitation program in individuals with ambulatory deficits secondary to MS. The researchers also intended to evaluate the efficacy of the tele-health rehabilitation program and compare it with that of conventional physical therapy.

Dr. Pardo and colleagues included 30 individuals in a single-center, prospective, randomized, three-arm, evaluator-blinded study that lasted for eight weeks. About 69% of participants were female, and the population’s mean age was 54.7. Approximately 60% of participants had relapsing-remitting MS, 23% had secondary progressive MS, and 17% had primary progressive MS. The population’s mean Expanded Disability Status Scale (EDSS) score was 4.3.

All participants performed a home-based exercise program (HEP) unsupervised on five days per week for eight weeks. Participants were randomized to three intervention groups. Group 1 underwent HEP alone. Group 2 underwent HEP plus remote physical therapy supervised via audio and visual real-time telecommunication two to three times per week. Group 3 underwent HEP plus in-person physical therapy at the medical facility two to three times per week. The study outcomes were multiple measurements of gait and balance, as well as patient-reported outcomes. Selected outcomes were performed with a computerized system (ie, Neurocom SmartBalance).

Functional gait assessment improved from baseline in all groups. Improvements were no different between the telerehabilitation and the conventional PT groups, but this finding was not statistically significant. Other outcomes that were similar for Groups 2 and 3 were the Timed 25-Foot Walk, stride length, the Berg balance scale, step width, tandem sway, tandem width, limits of stability, and the sensory organization test. One participant dropped out of the study because of an MS relapse.

The researchers observed no problems with adherence in any of the groups. “If we are to demonstrate a more significant intergroup difference, we need [larger] cohorts, and consequently, further research is needed,” Dr. Pardo concluded.

LONDON—In patients with multiple sclerosis (MS), telerehabilitation is a convenient and practical method of performing physical therapy with efficacy comparable to that of conventional in-person physical therapy, as measured by objective outcomes of gait and balance. Telerehabilitation should be investigated further and used more extensively as a means of improving function and quality of life in MS, according to researchers who spoke at the 32nd Congress of the European Committee for Treatment and Research in MS (ECTRIMS).

MS often results in physical and cognitive disability. Rehabilitation methods that include physical therapy can achieve functional improvement of established physical deficits. Factors such as availability, geographical distance, mobility, transportation, and cost, however, limit access to specialized rehabilitation services. Telecommunication technology opens the possibility of supervising and directing a physical therapy program remotely through audio and visual communication in real time.

Gabriel Pardo, MD, Director of the Oklahoma Medical Research Foundation MS Center of Excellence in Oklahoma City, and colleagues sought to demonstrate the feasibility of a tele-health rehabilitation program in individuals with ambulatory deficits secondary to MS. The researchers also intended to evaluate the efficacy of the tele-health rehabilitation program and compare it with that of conventional physical therapy.

Dr. Pardo and colleagues included 30 individuals in a single-center, prospective, randomized, three-arm, evaluator-blinded study that lasted for eight weeks. About 69% of participants were female, and the population’s mean age was 54.7. Approximately 60% of participants had relapsing-remitting MS, 23% had secondary progressive MS, and 17% had primary progressive MS. The population’s mean Expanded Disability Status Scale (EDSS) score was 4.3.

All participants performed a home-based exercise program (HEP) unsupervised on five days per week for eight weeks. Participants were randomized to three intervention groups. Group 1 underwent HEP alone. Group 2 underwent HEP plus remote physical therapy supervised via audio and visual real-time telecommunication two to three times per week. Group 3 underwent HEP plus in-person physical therapy at the medical facility two to three times per week. The study outcomes were multiple measurements of gait and balance, as well as patient-reported outcomes. Selected outcomes were performed with a computerized system (ie, Neurocom SmartBalance).

Functional gait assessment improved from baseline in all groups. Improvements were no different between the telerehabilitation and the conventional PT groups, but this finding was not statistically significant. Other outcomes that were similar for Groups 2 and 3 were the Timed 25-Foot Walk, stride length, the Berg balance scale, step width, tandem sway, tandem width, limits of stability, and the sensory organization test. One participant dropped out of the study because of an MS relapse.

The researchers observed no problems with adherence in any of the groups. “If we are to demonstrate a more significant intergroup difference, we need [larger] cohorts, and consequently, further research is needed,” Dr. Pardo concluded.

LONDON—As has been previously shown with brain atrophy and lesion volume, retinal measures can have predictive value for medium-term disability in multiple sclerosis (MS), according to research presented at the 32nd Congress of the European Committee for Treatment and Research in Multiple Sclerosis (ECTRIMS). “Our preliminary findings support the utility of optical coherence tomography (OCT) as a tool to predict neurodegeneration and disease progression over time in patients with MS,” said Alissa M. Rothman, MD, a post-doctoral research coordinator at the Johns Hopkins MS Center in Baltimore.

Measures of retinal layer thicknesses obtained with OCT have been shown to correlate with visual function, grey matter volume, and Expanded Disability Status Scale (EDSS) scores in MS. However, the prognostic value of retinal measurements for predicting long-term disability in patients with MS is still being evaluated. In the present study, Dr. Rothman and colleagues sought to determine whether retinal thicknesses as assessed by OCT predicts disability in MS 10 years later.

A total of 89 patients with MS were scanned on Stratus OCT between 2006 and 2007.  During 2015 and 2016, these patients underwent formal, blinded EDSS determination. Average peripapillary retinal nerve fiber layer (RNFL) thickness and total macular volume (TMV) were assessed by calculating the mean value of these measures for both eyes in each subject. Patients were categorized by baseline diagnosis as relapsing remitting (RRMS), secondary progressive (SPMS), or primary progressive MS (PPMS). Mixed effects linear regression models were used to investigate whether average TMV and RNFL thicknesses at baseline predict EDSS scores after 10 years.

The final analysis included 75 patients with RRMS, nine patients with SPMS, and five patients with PPMS. Fourteen of the 75 patients with a baseline diagnosis of RRMS transitioned to SPMS during the follow-up period. Baseline analyses revealed that the RRMS cohort was significantly younger than the SPMS and PPMS cohorts (mean differences = 21.5 years and 11.7 years, respectively) and that patients with SPMS patients had a longer disease duration than patients with RRMS and PPMS (mean differences = 14.2 years and 13.2 years, respectively). A history of optic neuritis (ON) was observed in the RRMS and SPMS cohorts (41% and 44%, respectively), but not in the PPMS cohorts (0%). Adjusting for age, sex, and a history of ON, the mean TMV values at baseline predicted EDSS scores after a median follow-up of 9.3 years. On average, a 1 mm³ lower TMV value at baseline predicted a mean decrease of 2 in EDSS at follow-up. Mean baseline RNFL values did not significantly predict EDSS scores.

—Glenn S. Williams

LONDON—As has been previously shown with brain atrophy and lesion volume, retinal measures can have predictive value for medium-term disability in multiple sclerosis (MS), according to research presented at the 32nd Congress of the European Committee for Treatment and Research in Multiple Sclerosis (ECTRIMS). “Our preliminary findings support the utility of optical coherence tomography (OCT) as a tool to predict neurodegeneration and disease progression over time in patients with MS,” said Alissa M. Rothman, MD, a post-doctoral research coordinator at the Johns Hopkins MS Center in Baltimore.

Measures of retinal layer thicknesses obtained with OCT have been shown to correlate with visual function, grey matter volume, and Expanded Disability Status Scale (EDSS) scores in MS. However, the prognostic value of retinal measurements for predicting long-term disability in patients with MS is still being evaluated. In the present study, Dr. Rothman and colleagues sought to determine whether retinal thicknesses as assessed by OCT predicts disability in MS 10 years later.

A total of 89 patients with MS were scanned on Stratus OCT between 2006 and 2007.  During 2015 and 2016, these patients underwent formal, blinded EDSS determination. Average peripapillary retinal nerve fiber layer (RNFL) thickness and total macular volume (TMV) were assessed by calculating the mean value of these measures for both eyes in each subject. Patients were categorized by baseline diagnosis as relapsing remitting (RRMS), secondary progressive (SPMS), or primary progressive MS (PPMS). Mixed effects linear regression models were used to investigate whether average TMV and RNFL thicknesses at baseline predict EDSS scores after 10 years.

The final analysis included 75 patients with RRMS, nine patients with SPMS, and five patients with PPMS. Fourteen of the 75 patients with a baseline diagnosis of RRMS transitioned to SPMS during the follow-up period. Baseline analyses revealed that the RRMS cohort was significantly younger than the SPMS and PPMS cohorts (mean differences = 21.5 years and 11.7 years, respectively) and that patients with SPMS patients had a longer disease duration than patients with RRMS and PPMS (mean differences = 14.2 years and 13.2 years, respectively). A history of optic neuritis (ON) was observed in the RRMS and SPMS cohorts (41% and 44%, respectively), but not in the PPMS cohorts (0%). Adjusting for age, sex, and a history of ON, the mean TMV values at baseline predicted EDSS scores after a median follow-up of 9.3 years. On average, a 1 mm³ lower TMV value at baseline predicted a mean decrease of 2 in EDSS at follow-up. Mean baseline RNFL values did not significantly predict EDSS scores.

—Glenn S. Williams

LONDON—As has been previously shown with brain atrophy and lesion volume, retinal measures can have predictive value for medium-term disability in multiple sclerosis (MS), according to research presented at the 32nd Congress of the European Committee for Treatment and Research in Multiple Sclerosis (ECTRIMS). “Our preliminary findings support the utility of optical coherence tomography (OCT) as a tool to predict neurodegeneration and disease progression over time in patients with MS,” said Alissa M. Rothman, MD, a post-doctoral research coordinator at the Johns Hopkins MS Center in Baltimore.

Measures of retinal layer thicknesses obtained with OCT have been shown to correlate with visual function, grey matter volume, and Expanded Disability Status Scale (EDSS) scores in MS. However, the prognostic value of retinal measurements for predicting long-term disability in patients with MS is still being evaluated. In the present study, Dr. Rothman and colleagues sought to determine whether retinal thicknesses as assessed by OCT predicts disability in MS 10 years later.

A total of 89 patients with MS were scanned on Stratus OCT between 2006 and 2007.  During 2015 and 2016, these patients underwent formal, blinded EDSS determination. Average peripapillary retinal nerve fiber layer (RNFL) thickness and total macular volume (TMV) were assessed by calculating the mean value of these measures for both eyes in each subject. Patients were categorized by baseline diagnosis as relapsing remitting (RRMS), secondary progressive (SPMS), or primary progressive MS (PPMS). Mixed effects linear regression models were used to investigate whether average TMV and RNFL thicknesses at baseline predict EDSS scores after 10 years.

The final analysis included 75 patients with RRMS, nine patients with SPMS, and five patients with PPMS. Fourteen of the 75 patients with a baseline diagnosis of RRMS transitioned to SPMS during the follow-up period. Baseline analyses revealed that the RRMS cohort was significantly younger than the SPMS and PPMS cohorts (mean differences = 21.5 years and 11.7 years, respectively) and that patients with SPMS patients had a longer disease duration than patients with RRMS and PPMS (mean differences = 14.2 years and 13.2 years, respectively). A history of optic neuritis (ON) was observed in the RRMS and SPMS cohorts (41% and 44%, respectively), but not in the PPMS cohorts (0%). Adjusting for age, sex, and a history of ON, the mean TMV values at baseline predicted EDSS scores after a median follow-up of 9.3 years. On average, a 1 mm³ lower TMV value at baseline predicted a mean decrease of 2 in EDSS at follow-up. Mean baseline RNFL values did not significantly predict EDSS scores.

—Glenn S. Williams

Along with a strong focus on peripheral arterial disease, VIVA late-breaking clinical trial reports will also address other critical areas of the vascular domain, from the aorta to the carotids.

On Tuesday morning, the results of two trials will be presented, which are investigating endovascular aortic repair. Ali Azizzadeh, MD, Memorial Hermann Heart and Vascular Institute, Houston, will discuss the 3-year results from the Valiant IDE Study, examining endovascular repair in acute, complicated type B aortic dissection.

Then, Zvonimir Krajcer, MD, Texas Heart Institute, Houston, will present the final results from the Prospective LIFE Registry, looking at fast-track endovascular aortic repair.

Also on Tuesday morning, the issue of interventions after the creation of an arteriovenous fistula (AVF) will be addressed by Charmaine Lok, MD, Toronto General Hospital, comparing traditional surgical AVF creation with a new endovascular approach.

Wednesday morning, Ido Weinberg, MD, Massachusetts General Hospital, Boston, will address the issue of carotid stent fractures, demonstrating that they are not associated with restenosis, stroke, myocardial infarction, or death based on the results from the ACT 1 Multicenter Randomized Trial.

Along with a strong focus on peripheral arterial disease, VIVA late-breaking clinical trial reports will also address other critical areas of the vascular domain, from the aorta to the carotids.

On Tuesday morning, the results of two trials will be presented, which are investigating endovascular aortic repair. Ali Azizzadeh, MD, Memorial Hermann Heart and Vascular Institute, Houston, will discuss the 3-year results from the Valiant IDE Study, examining endovascular repair in acute, complicated type B aortic dissection.

Then, Zvonimir Krajcer, MD, Texas Heart Institute, Houston, will present the final results from the Prospective LIFE Registry, looking at fast-track endovascular aortic repair.

Also on Tuesday morning, the issue of interventions after the creation of an arteriovenous fistula (AVF) will be addressed by Charmaine Lok, MD, Toronto General Hospital, comparing traditional surgical AVF creation with a new endovascular approach.

Wednesday morning, Ido Weinberg, MD, Massachusetts General Hospital, Boston, will address the issue of carotid stent fractures, demonstrating that they are not associated with restenosis, stroke, myocardial infarction, or death based on the results from the ACT 1 Multicenter Randomized Trial.

Along with a strong focus on peripheral arterial disease, VIVA late-breaking clinical trial reports will also address other critical areas of the vascular domain, from the aorta to the carotids.

On Tuesday morning, the results of two trials will be presented, which are investigating endovascular aortic repair. Ali Azizzadeh, MD, Memorial Hermann Heart and Vascular Institute, Houston, will discuss the 3-year results from the Valiant IDE Study, examining endovascular repair in acute, complicated type B aortic dissection.

Then, Zvonimir Krajcer, MD, Texas Heart Institute, Houston, will present the final results from the Prospective LIFE Registry, looking at fast-track endovascular aortic repair.

Also on Tuesday morning, the issue of interventions after the creation of an arteriovenous fistula (AVF) will be addressed by Charmaine Lok, MD, Toronto General Hospital, comparing traditional surgical AVF creation with a new endovascular approach.

Wednesday morning, Ido Weinberg, MD, Massachusetts General Hospital, Boston, will address the issue of carotid stent fractures, demonstrating that they are not associated with restenosis, stroke, myocardial infarction, or death based on the results from the ACT 1 Multicenter Randomized Trial.

Knee and hip replacement surgeries were more expensive in the United States than in a group of six other industrialized countries in 2014, according to a report from the International Federation of Health Plans.

The U.S. average for total hospital and physician costs was $28,184 for knee replacement and $29,067 for hip replacement. Switzerland was the next most expensive country for knee replacements at $20,132, and Australia was second for hip replacements at $19,484. Spain had the lowest average cost for both surgeries: $6,687 for knee replacement and $6,757 for hip replacement, the IFHP reported.

“We look at these numbers every year and it’s always a shocking demonstration of how much procedures and prescription drugs actually cost,” IFHP Chief Executive Tom Sackville said in a written statement. “There is no reason why identical procedures and products should vary in price so much across countries: it illustrates the damaging effects of an inadequately regulated health care market.”

The IFHP consists of 80 member companies in 25 countries. For the survey, costs for each country were submitted by participating member plans. Costs for the United States are derived from over 370 million employer-sponsored medical claims incurred from Jan. 1, 2014, to Dec. 31, 2014, and paid by multiple health plans. Cost data for the other six countries were provided by one private plan in each country.

[email protected]

Knee and hip replacement surgeries were more expensive in the United States than in a group of six other industrialized countries in 2014, according to a report from the International Federation of Health Plans.

The U.S. average for total hospital and physician costs was $28,184 for knee replacement and $29,067 for hip replacement. Switzerland was the next most expensive country for knee replacements at $20,132, and Australia was second for hip replacements at $19,484. Spain had the lowest average cost for both surgeries: $6,687 for knee replacement and $6,757 for hip replacement, the IFHP reported.

“We look at these numbers every year and it’s always a shocking demonstration of how much procedures and prescription drugs actually cost,” IFHP Chief Executive Tom Sackville said in a written statement. “There is no reason why identical procedures and products should vary in price so much across countries: it illustrates the damaging effects of an inadequately regulated health care market.”

The IFHP consists of 80 member companies in 25 countries. For the survey, costs for each country were submitted by participating member plans. Costs for the United States are derived from over 370 million employer-sponsored medical claims incurred from Jan. 1, 2014, to Dec. 31, 2014, and paid by multiple health plans. Cost data for the other six countries were provided by one private plan in each country.

[email protected]

Knee and hip replacement surgeries were more expensive in the United States than in a group of six other industrialized countries in 2014, according to a report from the International Federation of Health Plans.

The U.S. average for total hospital and physician costs was $28,184 for knee replacement and $29,067 for hip replacement. Switzerland was the next most expensive country for knee replacements at $20,132, and Australia was second for hip replacements at $19,484. Spain had the lowest average cost for both surgeries: $6,687 for knee replacement and $6,757 for hip replacement, the IFHP reported.

“We look at these numbers every year and it’s always a shocking demonstration of how much procedures and prescription drugs actually cost,” IFHP Chief Executive Tom Sackville said in a written statement. “There is no reason why identical procedures and products should vary in price so much across countries: it illustrates the damaging effects of an inadequately regulated health care market.”

The IFHP consists of 80 member companies in 25 countries. For the survey, costs for each country were submitted by participating member plans. Costs for the United States are derived from over 370 million employer-sponsored medical claims incurred from Jan. 1, 2014, to Dec. 31, 2014, and paid by multiple health plans. Cost data for the other six countries were provided by one private plan in each country.

[email protected]

Amputation in diabetes is less likely when critical limb ischemia is approached in a multidisciplinary way, according to the coauthor of clinical recommendations issued earlier this year. But to ensure optimal patient outcomes, just who should be on the interdisciplinary care team, how should it be coordinated, and what algorithms are best?

To help navigate these concerns, Joseph L. Mills, MD, professor and chief of vascular surgery and endovascular therapy at Baylor College of Medicine in Houston, will discuss “the toe and flow” model of care on Sunday morning, Sept. 18, as part of the presymposium Addressing Core Questions in Critical Limb Ischemia session.

“This model of care combines podiatrists and orthopedists with vascular specialists who provide advanced open surgery and endovascular therapy, to provide best treatment for patients,” said Dr. Mills, who coauthored the Society for Vascular Surgery Threatened Limb Classification (Wound, Ischemia, and foot Infection), or “WIfI,” as well as a clinical guideline on management of the diabetic foot, released earlier this year by the SVS in collaboration with the American Podiatric Medical Association, and the Society for Vascular Medicine.

Every 20 seconds, somewhere in the world a person with diabetes undergoes leg amputation as a result of the disease, according to Dr. Mills. Not only are the resulting costs of care unmanageable, fragmented diabetic foot care compromises a patient’s quality and longevity of life, he said.

The unfortunate path to amputation in diabetes most commonly begins with a simple neuropathic foot ulcer, often made worse by peripheral artery disease. The wound eventually moves through acute and chronic stages of neuropathy, vasculopathy, and infection, until amputation is necessary. Offering appropriate intervention at any point in this trajectory, or avoiding it altogether, means the ideal care team should include specialists with expertise in these disciplines. Beyond the core team members of a vascular surgeon, podiatrist, and orthopedic specialist, Dr. Mills said that other interdisciplinary team configurations might include a diabetologist, orthopedist, plastic surgeon, infectious disease specialist, general surgeon, and pedorthist/prosthetist.

“Learning how to build ‘toe and flow’ teams into your local environment can help improve outcomes in this challenging patient population,” Dr. Mills said. “Methods and flow diagrams concerning how this can be done will be a major focus of the talk.”

Dr. Mills will cover how patient responsibilities should be divided between team members across varying levels of clinical care, ranging from basic clinics to centers of excellence. The talk will also address aftercare, as well as how to facilitate effective communication between team members and patients.

“Enthusiasm for this model is the key ingredient to helping reduce the number of amputations in your patients,” he said.

[email protected]

On Twitter @whitneymcknight

Amputation in diabetes is less likely when critical limb ischemia is approached in a multidisciplinary way, according to the coauthor of clinical recommendations issued earlier this year. But to ensure optimal patient outcomes, just who should be on the interdisciplinary care team, how should it be coordinated, and what algorithms are best?

To help navigate these concerns, Joseph L. Mills, MD, professor and chief of vascular surgery and endovascular therapy at Baylor College of Medicine in Houston, will discuss “the toe and flow” model of care on Sunday morning, Sept. 18, as part of the presymposium Addressing Core Questions in Critical Limb Ischemia session.

“This model of care combines podiatrists and orthopedists with vascular specialists who provide advanced open surgery and endovascular therapy, to provide best treatment for patients,” said Dr. Mills, who coauthored the Society for Vascular Surgery Threatened Limb Classification (Wound, Ischemia, and foot Infection), or “WIfI,” as well as a clinical guideline on management of the diabetic foot, released earlier this year by the SVS in collaboration with the American Podiatric Medical Association, and the Society for Vascular Medicine.

Every 20 seconds, somewhere in the world a person with diabetes undergoes leg amputation as a result of the disease, according to Dr. Mills. Not only are the resulting costs of care unmanageable, fragmented diabetic foot care compromises a patient’s quality and longevity of life, he said.

The unfortunate path to amputation in diabetes most commonly begins with a simple neuropathic foot ulcer, often made worse by peripheral artery disease. The wound eventually moves through acute and chronic stages of neuropathy, vasculopathy, and infection, until amputation is necessary. Offering appropriate intervention at any point in this trajectory, or avoiding it altogether, means the ideal care team should include specialists with expertise in these disciplines. Beyond the core team members of a vascular surgeon, podiatrist, and orthopedic specialist, Dr. Mills said that other interdisciplinary team configurations might include a diabetologist, orthopedist, plastic surgeon, infectious disease specialist, general surgeon, and pedorthist/prosthetist.

“Learning how to build ‘toe and flow’ teams into your local environment can help improve outcomes in this challenging patient population,” Dr. Mills said. “Methods and flow diagrams concerning how this can be done will be a major focus of the talk.”

Dr. Mills will cover how patient responsibilities should be divided between team members across varying levels of clinical care, ranging from basic clinics to centers of excellence. The talk will also address aftercare, as well as how to facilitate effective communication between team members and patients.

“Enthusiasm for this model is the key ingredient to helping reduce the number of amputations in your patients,” he said.

[email protected]

On Twitter @whitneymcknight

Amputation in diabetes is less likely when critical limb ischemia is approached in a multidisciplinary way, according to the coauthor of clinical recommendations issued earlier this year. But to ensure optimal patient outcomes, just who should be on the interdisciplinary care team, how should it be coordinated, and what algorithms are best?

To help navigate these concerns, Joseph L. Mills, MD, professor and chief of vascular surgery and endovascular therapy at Baylor College of Medicine in Houston, will discuss “the toe and flow” model of care on Sunday morning, Sept. 18, as part of the presymposium Addressing Core Questions in Critical Limb Ischemia session.

“This model of care combines podiatrists and orthopedists with vascular specialists who provide advanced open surgery and endovascular therapy, to provide best treatment for patients,” said Dr. Mills, who coauthored the Society for Vascular Surgery Threatened Limb Classification (Wound, Ischemia, and foot Infection), or “WIfI,” as well as a clinical guideline on management of the diabetic foot, released earlier this year by the SVS in collaboration with the American Podiatric Medical Association, and the Society for Vascular Medicine.

Every 20 seconds, somewhere in the world a person with diabetes undergoes leg amputation as a result of the disease, according to Dr. Mills. Not only are the resulting costs of care unmanageable, fragmented diabetic foot care compromises a patient’s quality and longevity of life, he said.

The unfortunate path to amputation in diabetes most commonly begins with a simple neuropathic foot ulcer, often made worse by peripheral artery disease. The wound eventually moves through acute and chronic stages of neuropathy, vasculopathy, and infection, until amputation is necessary. Offering appropriate intervention at any point in this trajectory, or avoiding it altogether, means the ideal care team should include specialists with expertise in these disciplines. Beyond the core team members of a vascular surgeon, podiatrist, and orthopedic specialist, Dr. Mills said that other interdisciplinary team configurations might include a diabetologist, orthopedist, plastic surgeon, infectious disease specialist, general surgeon, and pedorthist/prosthetist.

“Learning how to build ‘toe and flow’ teams into your local environment can help improve outcomes in this challenging patient population,” Dr. Mills said. “Methods and flow diagrams concerning how this can be done will be a major focus of the talk.”

Dr. Mills will cover how patient responsibilities should be divided between team members across varying levels of clinical care, ranging from basic clinics to centers of excellence. The talk will also address aftercare, as well as how to facilitate effective communication between team members and patients.

“Enthusiasm for this model is the key ingredient to helping reduce the number of amputations in your patients,” he said.

[email protected]

On Twitter @whitneymcknight

SAN FRANCISCO – Frontal cortical thinning was common in late-life depression but generally did not predict executive dysfunction, according to magnetic resonance imaging studies of 157 adults.

The only exception was the left middle fronto-orbital gyrus. Thinning there predicted significantly worse performance on tests of executive function and processing speed, said Krista Farley of the late-life depression program at the University of California, San Francisco. Based on this limited finding, “further investigation of the etiology of executive dysfunction in late-life depression is warranted,” Ms. Farley said in a poster presented at the 2016 congress of the International Psychogeriatric Association.

©Jana Bla?ková/Thinkstock

About 5%-10% of community-dwelling older adults meet criteria for major depressive disorder, which is even more common in acute care and long-term care settings, and is often refractory to pharmacotherapy. Although late-life depression has been linked to cortical atrophy and executive dysfunction, it was unknown whether those two aspects of the disorder were related, Ms. Farley said.

The study by Ms. Farley and her associates of adults aged 65 years and older included 65 normal controls and 92 patients who met DSM-IV criteria for major depressive disorder, scored at least 19 on the Hamilton Depression Rating Scale, and had no evidence of dementia, having scored at least 25 on the Mini–Mental State Examination. Using T1– and T2–weighted structural MRI scans, the researchers measured the cortical thickness of six individual regions of the frontal lobe as well as the anterior cingulate gyrus. The patient and control groups resembled one another in terms of education, IQ, and age, but 71% of patients with late-life depression were female, compared with only 50% of controls.

Patients with late-life depression had significantly more thinning of the middle frontal gyrus, the inferior frontal gyrus, and the middle fronto-orbital gyrus, compared with controls, even after the investigators adjusted for age and sex (P less than .05 for all comparisons). Analyzing the left and right brain hemispheres separately localized the differences to the left hemisphere and additionally implicated the left lateral frontal orbital gyrus (mean thickness in patients, 3.2 mm; standard deviation, 0.2; versus 3.4 mm [SD = 0.31] in controls; P = .03).

Patients with late-life depression also scored significantly lower than controls on the Symbol Digit Modalities Test for information processing speed (P = .001) and the Stroop test of executive function (P = .002). The thickness of the left middle fronto-orbital gyrus was significantly inversely correlated with performance on both tests, with P values of .01 and .03, respectively. “The negative association with focal frontal regions was unexpected and deserves further investigation,” Ms. Farley said. But because cortical thinning in other locations did not predict cognitive performance, “cortical abnormalities may have a limited role in the manifestation of cognitive dysfunction in this vulnerable patient population,” Ms. Farley concluded.

The National Institutes of Health and the Leon J. Epstein Psychiatry Fund at the University of California, San Francisco, supported the work. Ms. Farley had no relevant financial disclosures.

SAN FRANCISCO – Frontal cortical thinning was common in late-life depression but generally did not predict executive dysfunction, according to magnetic resonance imaging studies of 157 adults.

The only exception was the left middle fronto-orbital gyrus. Thinning there predicted significantly worse performance on tests of executive function and processing speed, said Krista Farley of the late-life depression program at the University of California, San Francisco. Based on this limited finding, “further investigation of the etiology of executive dysfunction in late-life depression is warranted,” Ms. Farley said in a poster presented at the 2016 congress of the International Psychogeriatric Association.

©Jana Bla?ková/Thinkstock

About 5%-10% of community-dwelling older adults meet criteria for major depressive disorder, which is even more common in acute care and long-term care settings, and is often refractory to pharmacotherapy. Although late-life depression has been linked to cortical atrophy and executive dysfunction, it was unknown whether those two aspects of the disorder were related, Ms. Farley said.

The study by Ms. Farley and her associates of adults aged 65 years and older included 65 normal controls and 92 patients who met DSM-IV criteria for major depressive disorder, scored at least 19 on the Hamilton Depression Rating Scale, and had no evidence of dementia, having scored at least 25 on the Mini–Mental State Examination. Using T1– and T2–weighted structural MRI scans, the researchers measured the cortical thickness of six individual regions of the frontal lobe as well as the anterior cingulate gyrus. The patient and control groups resembled one another in terms of education, IQ, and age, but 71% of patients with late-life depression were female, compared with only 50% of controls.

Patients with late-life depression had significantly more thinning of the middle frontal gyrus, the inferior frontal gyrus, and the middle fronto-orbital gyrus, compared with controls, even after the investigators adjusted for age and sex (P less than .05 for all comparisons). Analyzing the left and right brain hemispheres separately localized the differences to the left hemisphere and additionally implicated the left lateral frontal orbital gyrus (mean thickness in patients, 3.2 mm; standard deviation, 0.2; versus 3.4 mm [SD = 0.31] in controls; P = .03).

Patients with late-life depression also scored significantly lower than controls on the Symbol Digit Modalities Test for information processing speed (P = .001) and the Stroop test of executive function (P = .002). The thickness of the left middle fronto-orbital gyrus was significantly inversely correlated with performance on both tests, with P values of .01 and .03, respectively. “The negative association with focal frontal regions was unexpected and deserves further investigation,” Ms. Farley said. But because cortical thinning in other locations did not predict cognitive performance, “cortical abnormalities may have a limited role in the manifestation of cognitive dysfunction in this vulnerable patient population,” Ms. Farley concluded.

The National Institutes of Health and the Leon J. Epstein Psychiatry Fund at the University of California, San Francisco, supported the work. Ms. Farley had no relevant financial disclosures.

SAN FRANCISCO – Frontal cortical thinning was common in late-life depression but generally did not predict executive dysfunction, according to magnetic resonance imaging studies of 157 adults.

The only exception was the left middle fronto-orbital gyrus. Thinning there predicted significantly worse performance on tests of executive function and processing speed, said Krista Farley of the late-life depression program at the University of California, San Francisco. Based on this limited finding, “further investigation of the etiology of executive dysfunction in late-life depression is warranted,” Ms. Farley said in a poster presented at the 2016 congress of the International Psychogeriatric Association.

©Jana Bla?ková/Thinkstock

About 5%-10% of community-dwelling older adults meet criteria for major depressive disorder, which is even more common in acute care and long-term care settings, and is often refractory to pharmacotherapy. Although late-life depression has been linked to cortical atrophy and executive dysfunction, it was unknown whether those two aspects of the disorder were related, Ms. Farley said.

The study by Ms. Farley and her associates of adults aged 65 years and older included 65 normal controls and 92 patients who met DSM-IV criteria for major depressive disorder, scored at least 19 on the Hamilton Depression Rating Scale, and had no evidence of dementia, having scored at least 25 on the Mini–Mental State Examination. Using T1– and T2–weighted structural MRI scans, the researchers measured the cortical thickness of six individual regions of the frontal lobe as well as the anterior cingulate gyrus. The patient and control groups resembled one another in terms of education, IQ, and age, but 71% of patients with late-life depression were female, compared with only 50% of controls.

Patients with late-life depression had significantly more thinning of the middle frontal gyrus, the inferior frontal gyrus, and the middle fronto-orbital gyrus, compared with controls, even after the investigators adjusted for age and sex (P less than .05 for all comparisons). Analyzing the left and right brain hemispheres separately localized the differences to the left hemisphere and additionally implicated the left lateral frontal orbital gyrus (mean thickness in patients, 3.2 mm; standard deviation, 0.2; versus 3.4 mm [SD = 0.31] in controls; P = .03).

Patients with late-life depression also scored significantly lower than controls on the Symbol Digit Modalities Test for information processing speed (P = .001) and the Stroop test of executive function (P = .002). The thickness of the left middle fronto-orbital gyrus was significantly inversely correlated with performance on both tests, with P values of .01 and .03, respectively. “The negative association with focal frontal regions was unexpected and deserves further investigation,” Ms. Farley said. But because cortical thinning in other locations did not predict cognitive performance, “cortical abnormalities may have a limited role in the manifestation of cognitive dysfunction in this vulnerable patient population,” Ms. Farley concluded.

The National Institutes of Health and the Leon J. Epstein Psychiatry Fund at the University of California, San Francisco, supported the work. Ms. Farley had no relevant financial disclosures.

MUNICH – Once-weekly dulaglutide paired with insulin glargine plus metformin allowed 69% of patients with poorly controlled type 2 diabetes to achieve a hemoglobin A_1c of 7% or lower.

Over the 28-week study, 51% of the group reached an HbA_1c of 6.5% or lower – significantly better than the 17% who achieved this goal on insulin glargine with or without metformin, Paolo Pozzilli, MD, reported at the annual meeting of the European Association for the Study of Diabetes.

Michele G. Sullivan/Frontline Medical News

The combination was safe, with just one incident of severe hypoglycemia, and well tolerated, said Dr. Pozzilli of the University Campus Bio-Medico, Rome. Nausea – the most troublesome side effect of any glucagonlike peptide receptor agonist occurred in 12% of those taking the drug. Diarrhea occurred in 11% and vomiting in 6%. All of the gastrointestinal side effects were significantly more common than they were in the placebo group.

“I would say that the combination treatment of dulaglutide and insulin glargine – with or without metformin – is a reasonable, well-tolerated, and effective option for patients with type 2 diabetes who are not hitting their treatment goals,” he said.

Dr. Pozzilli reported results of Lily’s AWARD-9 trial. The placebo-controlled trial comprised 300 patients with poorly controlled type 2 diabetes (HbA_1c, 7%-10.5%), despite being on insulin glargine and metformin. They were randomized to weekly subcutaneous placebo or 1.5 mg dulaglutide injections, in addition to their usual medications. There was no up titration on the study drug – patients started out with the full dose immediately. The study’s completion rate was high, with 92% of the investigational group and 87% of the control group finishing the 28-week treatment.

The group was typical for poorly controlled type 2 patients. Their mean age was 60 years; about 60% were men; and almost all were white. The mean body mass index was 32 kg/m². The mean disease duration was 13 years, and the mean HbA_1c was 8.4%. Their mean fasting plasma glucose was 8.7 mmol/L.

The effect of dual therapy was quickly evident, with HbA_1c levels beginning to drop within 2 weeks. By 12 weeks, the separation between groups was statistically significant (dulaglutide HbA_1c about 7%, placebo about 8%). By 28 weeks, the combination group had reached a mean HbA_1c of 6.92%, compared with 7.69% in the placebo group. The response curve of the combination group appeared to be on a continuing decline when the study ended. The final measure represented an HbA_1c decrease of 1.44% for the combination group and 0.67% for the placebo group.

By 28 weeks, 69% of the dulaglutide group and 35% of the placebo group had achieved an HbA_1c of 7% or lower – a significant difference. Half of the dulaglutide group (51%) achieved a measure of 6.5% or lower, compared with 17% of the placebo group – also a significant difference.

The addition of dulaglutide moderated the need to increase the insulin that occurred over the study period. By 28 weeks, those taking dulaglutide had increased their insulin by a mean of 0.14 U/kg, compared with an increase of 0.27 U/kg in the placebo group. This difference was also statistically significant.

Patients in the combination group lost significantly more weight as well (mean 1.91 kg vs. a gain of 0.5 kg in the placebo group). Weight loss was quickly evident; by 4 weeks, patients had lost more than 1 kg. This “encouraging sign might help boost patient compliance,” Dr. Pozzilli said.

The side-effect profile was acceptable, compared with placebo. Hypoglycemia occurred in about 55% of those taking dulaglutide and 51% of those taking the placebo; it was symptomatic in 35% and 30%, respectively. Nocturnal hypoglycemia occurred in 28% and 29%, respectively. There was one case of severe hypoglycemia, which occurred in the dulaglutide group.

In addition to the GI side effects, there was one injection site reaction in the dulaglutide group. There were no cases of pancreatitis or pancreatic cancer.

The study was sponsored by Eli Lilly. Dr. Pozzilli is on the company’s speakers’ bureau and receives research grant money from it.

[email protected]

MUNICH – Once-weekly dulaglutide paired with insulin glargine plus metformin allowed 69% of patients with poorly controlled type 2 diabetes to achieve a hemoglobin A_1c of 7% or lower.

Over the 28-week study, 51% of the group reached an HbA_1c of 6.5% or lower – significantly better than the 17% who achieved this goal on insulin glargine with or without metformin, Paolo Pozzilli, MD, reported at the annual meeting of the European Association for the Study of Diabetes.

Michele G. Sullivan/Frontline Medical News

The combination was safe, with just one incident of severe hypoglycemia, and well tolerated, said Dr. Pozzilli of the University Campus Bio-Medico, Rome. Nausea – the most troublesome side effect of any glucagonlike peptide receptor agonist occurred in 12% of those taking the drug. Diarrhea occurred in 11% and vomiting in 6%. All of the gastrointestinal side effects were significantly more common than they were in the placebo group.

“I would say that the combination treatment of dulaglutide and insulin glargine – with or without metformin – is a reasonable, well-tolerated, and effective option for patients with type 2 diabetes who are not hitting their treatment goals,” he said.

Dr. Pozzilli reported results of Lily’s AWARD-9 trial. The placebo-controlled trial comprised 300 patients with poorly controlled type 2 diabetes (HbA_1c, 7%-10.5%), despite being on insulin glargine and metformin. They were randomized to weekly subcutaneous placebo or 1.5 mg dulaglutide injections, in addition to their usual medications. There was no up titration on the study drug – patients started out with the full dose immediately. The study’s completion rate was high, with 92% of the investigational group and 87% of the control group finishing the 28-week treatment.

The group was typical for poorly controlled type 2 patients. Their mean age was 60 years; about 60% were men; and almost all were white. The mean body mass index was 32 kg/m². The mean disease duration was 13 years, and the mean HbA_1c was 8.4%. Their mean fasting plasma glucose was 8.7 mmol/L.

The effect of dual therapy was quickly evident, with HbA_1c levels beginning to drop within 2 weeks. By 12 weeks, the separation between groups was statistically significant (dulaglutide HbA_1c about 7%, placebo about 8%). By 28 weeks, the combination group had reached a mean HbA_1c of 6.92%, compared with 7.69% in the placebo group. The response curve of the combination group appeared to be on a continuing decline when the study ended. The final measure represented an HbA_1c decrease of 1.44% for the combination group and 0.67% for the placebo group.

By 28 weeks, 69% of the dulaglutide group and 35% of the placebo group had achieved an HbA_1c of 7% or lower – a significant difference. Half of the dulaglutide group (51%) achieved a measure of 6.5% or lower, compared with 17% of the placebo group – also a significant difference.

The addition of dulaglutide moderated the need to increase the insulin that occurred over the study period. By 28 weeks, those taking dulaglutide had increased their insulin by a mean of 0.14 U/kg, compared with an increase of 0.27 U/kg in the placebo group. This difference was also statistically significant.

Patients in the combination group lost significantly more weight as well (mean 1.91 kg vs. a gain of 0.5 kg in the placebo group). Weight loss was quickly evident; by 4 weeks, patients had lost more than 1 kg. This “encouraging sign might help boost patient compliance,” Dr. Pozzilli said.

The side-effect profile was acceptable, compared with placebo. Hypoglycemia occurred in about 55% of those taking dulaglutide and 51% of those taking the placebo; it was symptomatic in 35% and 30%, respectively. Nocturnal hypoglycemia occurred in 28% and 29%, respectively. There was one case of severe hypoglycemia, which occurred in the dulaglutide group.

In addition to the GI side effects, there was one injection site reaction in the dulaglutide group. There were no cases of pancreatitis or pancreatic cancer.

The study was sponsored by Eli Lilly. Dr. Pozzilli is on the company’s speakers’ bureau and receives research grant money from it.

[email protected]

MUNICH – Once-weekly dulaglutide paired with insulin glargine plus metformin allowed 69% of patients with poorly controlled type 2 diabetes to achieve a hemoglobin A_1c of 7% or lower.

Over the 28-week study, 51% of the group reached an HbA_1c of 6.5% or lower – significantly better than the 17% who achieved this goal on insulin glargine with or without metformin, Paolo Pozzilli, MD, reported at the annual meeting of the European Association for the Study of Diabetes.

Michele G. Sullivan/Frontline Medical News

The combination was safe, with just one incident of severe hypoglycemia, and well tolerated, said Dr. Pozzilli of the University Campus Bio-Medico, Rome. Nausea – the most troublesome side effect of any glucagonlike peptide receptor agonist occurred in 12% of those taking the drug. Diarrhea occurred in 11% and vomiting in 6%. All of the gastrointestinal side effects were significantly more common than they were in the placebo group.

“I would say that the combination treatment of dulaglutide and insulin glargine – with or without metformin – is a reasonable, well-tolerated, and effective option for patients with type 2 diabetes who are not hitting their treatment goals,” he said.

Dr. Pozzilli reported results of Lily’s AWARD-9 trial. The placebo-controlled trial comprised 300 patients with poorly controlled type 2 diabetes (HbA_1c, 7%-10.5%), despite being on insulin glargine and metformin. They were randomized to weekly subcutaneous placebo or 1.5 mg dulaglutide injections, in addition to their usual medications. There was no up titration on the study drug – patients started out with the full dose immediately. The study’s completion rate was high, with 92% of the investigational group and 87% of the control group finishing the 28-week treatment.

The group was typical for poorly controlled type 2 patients. Their mean age was 60 years; about 60% were men; and almost all were white. The mean body mass index was 32 kg/m². The mean disease duration was 13 years, and the mean HbA_1c was 8.4%. Their mean fasting plasma glucose was 8.7 mmol/L.

The effect of dual therapy was quickly evident, with HbA_1c levels beginning to drop within 2 weeks. By 12 weeks, the separation between groups was statistically significant (dulaglutide HbA_1c about 7%, placebo about 8%). By 28 weeks, the combination group had reached a mean HbA_1c of 6.92%, compared with 7.69% in the placebo group. The response curve of the combination group appeared to be on a continuing decline when the study ended. The final measure represented an HbA_1c decrease of 1.44% for the combination group and 0.67% for the placebo group.

By 28 weeks, 69% of the dulaglutide group and 35% of the placebo group had achieved an HbA_1c of 7% or lower – a significant difference. Half of the dulaglutide group (51%) achieved a measure of 6.5% or lower, compared with 17% of the placebo group – also a significant difference.

The addition of dulaglutide moderated the need to increase the insulin that occurred over the study period. By 28 weeks, those taking dulaglutide had increased their insulin by a mean of 0.14 U/kg, compared with an increase of 0.27 U/kg in the placebo group. This difference was also statistically significant.

Patients in the combination group lost significantly more weight as well (mean 1.91 kg vs. a gain of 0.5 kg in the placebo group). Weight loss was quickly evident; by 4 weeks, patients had lost more than 1 kg. This “encouraging sign might help boost patient compliance,” Dr. Pozzilli said.

The side-effect profile was acceptable, compared with placebo. Hypoglycemia occurred in about 55% of those taking dulaglutide and 51% of those taking the placebo; it was symptomatic in 35% and 30%, respectively. Nocturnal hypoglycemia occurred in 28% and 29%, respectively. There was one case of severe hypoglycemia, which occurred in the dulaglutide group.

In addition to the GI side effects, there was one injection site reaction in the dulaglutide group. There were no cases of pancreatitis or pancreatic cancer.

The study was sponsored by Eli Lilly. Dr. Pozzilli is on the company’s speakers’ bureau and receives research grant money from it.

[email protected]

Primary care practitioners’ use of a seven-item checklist may reduce the number of pediatric patients with respiratory tract infections who are prescribed unnecessary antibiotics, a prognostic cohort study suggests.

The study revealed short illness (a duration of illness of 3 days or less), temperature (a body temperature of 37.8°C or greater at presentation), age (being under 2 years), intercostal or subcostal recession, wheeze on auscultation, asthma, and vomiting (moderate or severe in the previous 24 hours) were each independently associated with hospital admission (P less than .01 for all associations).

©Devonyu/thinkstockphotos.com

The checklist includes these seven characteristics or risk variables (short illness, temperature, age, recession, wheeze, asthma, and vomiting [mnemonic STARWAVe]). To use the checklist, a primary care practitioner would assign one point for the presence of each item in a patient then add up all of the points to determine that patient’s risk level for future hospital admission for respiratory tract infection. A score of 1 point or less, observed in 5,593 (67%) cases would be considered indicative of a very low rate of risk for hospitalization (0.3%, 0.2%-0.4%). A score of 2 or 3 points, found for 2,520 (30%) children, would be considered as a normal level of risk (1.5%, 1.0%-1.9%), and a score of 4 or more points, seen in 204 (3%) children, would signify a high risk level (11.8%, 7.3%-16.2%).

Of the 8,394 children assessed, 78 (0.9%; 95% confidence interval, 0.7%-1.2%) were admitted to a hospital. Most were admitted on days 2-7 (33, 42%) and on days 8-30 (30, 39%) following recruitment. Only 15 (19%) were admitted on the day of recruitment (day 1).

“Many clinicians report that they prescribe antibiotics just in case, to mitigate perceived risk of future hospital admission and complications, and that failing to provide a prescription for a child who subsequently becomes seriously unwell is professionally unacceptable. If primary care clinicians could identify children at low (or very low) risk of such future complications, the reduced clinical uncertainty could lead to a reduced use of antibiotics in these groups of patients,” wrote first author Alastair Hay, MD, from the Centre for Academic Primary Care in the School of Social and Community Medicine at the University of Bristol (England), and his colleagues.

These researchers conducted the study based on a structured, blinded review of the medical records from children aged between 3 months and 16 years presenting with acute cough (less than or equal to 28 days) and respiratory tract infection treated by 519 general practitioners in 247 practices in England between July 2011 and June 2013. The primary study outcome was hospital admission for respiratory tract infection within 30 days.

Additionally, a multivariable model was employed to detect factors associated with increased risk of hospital admission. As measured by receiver operating characteristic curve analysis, the accuracy of the STARWAVe score checklist in predicting risk groups and associated risk of hospitalization was found to be high (0.81; 95% CI, 0.77-0.86). The suggested probability of hospital admission for children who did not have any of the seven characteristics included in the checklist was found to be exceptionally low (0.14%).

Significantly associated parent-reported variables included both moderate or severe vomiting and severe fever, each in the previous 24 hours. Significant clinician-reported variables included intercostal or subcostal recession and wheeze on auscultation.

“The main value of our results is to reduce clinical uncertainty and antibiotic use in children least likely to benefit from them, namely those at very low risk of future hospital admission,” Dr. Hay and his associates noted in The Lancet Respiratory Medicine (Lancet Respir Med. 2016 Sep 1. doi: 10.1016/S2213-2600(16)30223-5).

Funding for this study was provided by the National Institute for Health Research and sponsored by the University of Bristol. Only one of the study’s authors, Dr. Peter Muir, reported ties to industry sources.

Primary care practitioners’ use of a seven-item checklist may reduce the number of pediatric patients with respiratory tract infections who are prescribed unnecessary antibiotics, a prognostic cohort study suggests.

The study revealed short illness (a duration of illness of 3 days or less), temperature (a body temperature of 37.8°C or greater at presentation), age (being under 2 years), intercostal or subcostal recession, wheeze on auscultation, asthma, and vomiting (moderate or severe in the previous 24 hours) were each independently associated with hospital admission (P less than .01 for all associations).

©Devonyu/thinkstockphotos.com

The checklist includes these seven characteristics or risk variables (short illness, temperature, age, recession, wheeze, asthma, and vomiting [mnemonic STARWAVe]). To use the checklist, a primary care practitioner would assign one point for the presence of each item in a patient then add up all of the points to determine that patient’s risk level for future hospital admission for respiratory tract infection. A score of 1 point or less, observed in 5,593 (67%) cases would be considered indicative of a very low rate of risk for hospitalization (0.3%, 0.2%-0.4%). A score of 2 or 3 points, found for 2,520 (30%) children, would be considered as a normal level of risk (1.5%, 1.0%-1.9%), and a score of 4 or more points, seen in 204 (3%) children, would signify a high risk level (11.8%, 7.3%-16.2%).

Of the 8,394 children assessed, 78 (0.9%; 95% confidence interval, 0.7%-1.2%) were admitted to a hospital. Most were admitted on days 2-7 (33, 42%) and on days 8-30 (30, 39%) following recruitment. Only 15 (19%) were admitted on the day of recruitment (day 1).

“Many clinicians report that they prescribe antibiotics just in case, to mitigate perceived risk of future hospital admission and complications, and that failing to provide a prescription for a child who subsequently becomes seriously unwell is professionally unacceptable. If primary care clinicians could identify children at low (or very low) risk of such future complications, the reduced clinical uncertainty could lead to a reduced use of antibiotics in these groups of patients,” wrote first author Alastair Hay, MD, from the Centre for Academic Primary Care in the School of Social and Community Medicine at the University of Bristol (England), and his colleagues.

These researchers conducted the study based on a structured, blinded review of the medical records from children aged between 3 months and 16 years presenting with acute cough (less than or equal to 28 days) and respiratory tract infection treated by 519 general practitioners in 247 practices in England between July 2011 and June 2013. The primary study outcome was hospital admission for respiratory tract infection within 30 days.

Additionally, a multivariable model was employed to detect factors associated with increased risk of hospital admission. As measured by receiver operating characteristic curve analysis, the accuracy of the STARWAVe score checklist in predicting risk groups and associated risk of hospitalization was found to be high (0.81; 95% CI, 0.77-0.86). The suggested probability of hospital admission for children who did not have any of the seven characteristics included in the checklist was found to be exceptionally low (0.14%).

Significantly associated parent-reported variables included both moderate or severe vomiting and severe fever, each in the previous 24 hours. Significant clinician-reported variables included intercostal or subcostal recession and wheeze on auscultation.

“The main value of our results is to reduce clinical uncertainty and antibiotic use in children least likely to benefit from them, namely those at very low risk of future hospital admission,” Dr. Hay and his associates noted in The Lancet Respiratory Medicine (Lancet Respir Med. 2016 Sep 1. doi: 10.1016/S2213-2600(16)30223-5).

Funding for this study was provided by the National Institute for Health Research and sponsored by the University of Bristol. Only one of the study’s authors, Dr. Peter Muir, reported ties to industry sources.

Primary care practitioners’ use of a seven-item checklist may reduce the number of pediatric patients with respiratory tract infections who are prescribed unnecessary antibiotics, a prognostic cohort study suggests.

The study revealed short illness (a duration of illness of 3 days or less), temperature (a body temperature of 37.8°C or greater at presentation), age (being under 2 years), intercostal or subcostal recession, wheeze on auscultation, asthma, and vomiting (moderate or severe in the previous 24 hours) were each independently associated with hospital admission (P less than .01 for all associations).

©Devonyu/thinkstockphotos.com

The checklist includes these seven characteristics or risk variables (short illness, temperature, age, recession, wheeze, asthma, and vomiting [mnemonic STARWAVe]). To use the checklist, a primary care practitioner would assign one point for the presence of each item in a patient then add up all of the points to determine that patient’s risk level for future hospital admission for respiratory tract infection. A score of 1 point or less, observed in 5,593 (67%) cases would be considered indicative of a very low rate of risk for hospitalization (0.3%, 0.2%-0.4%). A score of 2 or 3 points, found for 2,520 (30%) children, would be considered as a normal level of risk (1.5%, 1.0%-1.9%), and a score of 4 or more points, seen in 204 (3%) children, would signify a high risk level (11.8%, 7.3%-16.2%).

Of the 8,394 children assessed, 78 (0.9%; 95% confidence interval, 0.7%-1.2%) were admitted to a hospital. Most were admitted on days 2-7 (33, 42%) and on days 8-30 (30, 39%) following recruitment. Only 15 (19%) were admitted on the day of recruitment (day 1).

“Many clinicians report that they prescribe antibiotics just in case, to mitigate perceived risk of future hospital admission and complications, and that failing to provide a prescription for a child who subsequently becomes seriously unwell is professionally unacceptable. If primary care clinicians could identify children at low (or very low) risk of such future complications, the reduced clinical uncertainty could lead to a reduced use of antibiotics in these groups of patients,” wrote first author Alastair Hay, MD, from the Centre for Academic Primary Care in the School of Social and Community Medicine at the University of Bristol (England), and his colleagues.

These researchers conducted the study based on a structured, blinded review of the medical records from children aged between 3 months and 16 years presenting with acute cough (less than or equal to 28 days) and respiratory tract infection treated by 519 general practitioners in 247 practices in England between July 2011 and June 2013. The primary study outcome was hospital admission for respiratory tract infection within 30 days.

Additionally, a multivariable model was employed to detect factors associated with increased risk of hospital admission. As measured by receiver operating characteristic curve analysis, the accuracy of the STARWAVe score checklist in predicting risk groups and associated risk of hospitalization was found to be high (0.81; 95% CI, 0.77-0.86). The suggested probability of hospital admission for children who did not have any of the seven characteristics included in the checklist was found to be exceptionally low (0.14%).

Significantly associated parent-reported variables included both moderate or severe vomiting and severe fever, each in the previous 24 hours. Significant clinician-reported variables included intercostal or subcostal recession and wheeze on auscultation.

“The main value of our results is to reduce clinical uncertainty and antibiotic use in children least likely to benefit from them, namely those at very low risk of future hospital admission,” Dr. Hay and his associates noted in The Lancet Respiratory Medicine (Lancet Respir Med. 2016 Sep 1. doi: 10.1016/S2213-2600(16)30223-5).

Funding for this study was provided by the National Institute for Health Research and sponsored by the University of Bristol. Only one of the study’s authors, Dr. Peter Muir, reported ties to industry sources.

After years of relative neglect, compared with the attention given to aortic disease, studies and devices designed to expand and improve treatment of peripheral arterial disease are moving to the forefront.

At this year’s VIVA Vascular meeting, the majority of late-breaking clinical trials have a focus on peripheral arterial disease (PAD) and critical limb ischemia (CLI), emphasizing the tremendous growth of research in this area. The following are some of the latest trials for which results will be presented:

On Monday morning, Michael P. Murphy, MD, will present results from the MOBILE clinical trial, which examines the use of the MarrowStim™ PAD Kit for the treatment of CLI in subjects with severe PAD. The treatment involves removing bone marrow from the hips, which is then processed in the MarrowStim device to separate stem cells for delivery by injection to multiple sites in the affected leg.

A report on the 6-month results from the two-phase DISRUPT PAD study to assess the safety and performance of the Shockwave Lithoplasty® System in treating calcified peripheral vascular lesions will then be presented by Thomas Zeller, MD, principal investigator for the study. “Lithoplasty is a novel technology utilizing integrated lithotripsy emitters that generate mechanical pulse waves to disrupt both superficial and deep calcium normalizing vessel wall compliance prior to low-pressure balloon dilatation,” according to a company report.

In addition, results from the IN.PACT SFA randomized trial will be presented by Prakash Krishnan, MD, and data from the VIRTUS US Iliofemoral Stenting IDE Trial will be addressed by Stephen Black, MD, and Michael R. Jaff, DO, will present insights on the use of drug-coated balloon treatment for patients with intermittent claudication based on results from the IN.PACT Global full clinical cohort.

On Tuesday morning, Stefan Müller-Hülsbeck, MD, will present the 2-year results plus subgroup analysis of the Majestic Trial, which examined the efficacy benefit of using the Eluvia drug-eluting stent for treating lesions in the femoropopliteal arteries.

This will be followed by Antonio Micari, MD, PhD, who will present the 2-year results of from the SFA-Long Study, which examines the use of paclitaxel coated balloons for long femoropopliteal artery disease.

On Wednesday morning, the 3-Year Results of the Evaluation of the ESPRIT Bioresorbable Vascular Scaffold (ESPRIT BVS) in The Treatment of Patients with Occlusive Vascular Disease of the Superficial Femoral (SFA) or Common or External Iliac Arteries (ESPRIT I Trial) will be presented by Michael R. Jaff, DO.

This will be followed by a presentation of the 12-month results from the DANCE Trial Atherectomy Cohort by Chris D. Owens, MD, and John Laird, MD, discussing the 9-month results of the Prospective, Multicenter BOLSTER Trial, which examined the use of an expanded polytetrafluoroethylene balloon-expandable covered stent for obstructive lesions in the iliac artery.

In further research addressing the peripheral vascular system, Dr. Laird will also address the 24-month results from the TIGRIS randomized trial, assessing the use of a novel nitinol stent for long lesions in the SFA and the proximal popliteal artery.

Afterwards, Richard Saxon, MD, will discuss the PRISM Indigo Aspiration System as a potential frontline tool for vacuum-assisted aspiration thrombectomy in the periphery.

After years of relative neglect, compared with the attention given to aortic disease, studies and devices designed to expand and improve treatment of peripheral arterial disease are moving to the forefront.

At this year’s VIVA Vascular meeting, the majority of late-breaking clinical trials have a focus on peripheral arterial disease (PAD) and critical limb ischemia (CLI), emphasizing the tremendous growth of research in this area. The following are some of the latest trials for which results will be presented:

On Monday morning, Michael P. Murphy, MD, will present results from the MOBILE clinical trial, which examines the use of the MarrowStim™ PAD Kit for the treatment of CLI in subjects with severe PAD. The treatment involves removing bone marrow from the hips, which is then processed in the MarrowStim device to separate stem cells for delivery by injection to multiple sites in the affected leg.

A report on the 6-month results from the two-phase DISRUPT PAD study to assess the safety and performance of the Shockwave Lithoplasty® System in treating calcified peripheral vascular lesions will then be presented by Thomas Zeller, MD, principal investigator for the study. “Lithoplasty is a novel technology utilizing integrated lithotripsy emitters that generate mechanical pulse waves to disrupt both superficial and deep calcium normalizing vessel wall compliance prior to low-pressure balloon dilatation,” according to a company report.

In addition, results from the IN.PACT SFA randomized trial will be presented by Prakash Krishnan, MD, and data from the VIRTUS US Iliofemoral Stenting IDE Trial will be addressed by Stephen Black, MD, and Michael R. Jaff, DO, will present insights on the use of drug-coated balloon treatment for patients with intermittent claudication based on results from the IN.PACT Global full clinical cohort.

On Tuesday morning, Stefan Müller-Hülsbeck, MD, will present the 2-year results plus subgroup analysis of the Majestic Trial, which examined the efficacy benefit of using the Eluvia drug-eluting stent for treating lesions in the femoropopliteal arteries.

This will be followed by Antonio Micari, MD, PhD, who will present the 2-year results of from the SFA-Long Study, which examines the use of paclitaxel coated balloons for long femoropopliteal artery disease.

On Wednesday morning, the 3-Year Results of the Evaluation of the ESPRIT Bioresorbable Vascular Scaffold (ESPRIT BVS) in The Treatment of Patients with Occlusive Vascular Disease of the Superficial Femoral (SFA) or Common or External Iliac Arteries (ESPRIT I Trial) will be presented by Michael R. Jaff, DO.

This will be followed by a presentation of the 12-month results from the DANCE Trial Atherectomy Cohort by Chris D. Owens, MD, and John Laird, MD, discussing the 9-month results of the Prospective, Multicenter BOLSTER Trial, which examined the use of an expanded polytetrafluoroethylene balloon-expandable covered stent for obstructive lesions in the iliac artery.

In further research addressing the peripheral vascular system, Dr. Laird will also address the 24-month results from the TIGRIS randomized trial, assessing the use of a novel nitinol stent for long lesions in the SFA and the proximal popliteal artery.

Afterwards, Richard Saxon, MD, will discuss the PRISM Indigo Aspiration System as a potential frontline tool for vacuum-assisted aspiration thrombectomy in the periphery.

After years of relative neglect, compared with the attention given to aortic disease, studies and devices designed to expand and improve treatment of peripheral arterial disease are moving to the forefront.

At this year’s VIVA Vascular meeting, the majority of late-breaking clinical trials have a focus on peripheral arterial disease (PAD) and critical limb ischemia (CLI), emphasizing the tremendous growth of research in this area. The following are some of the latest trials for which results will be presented:

On Monday morning, Michael P. Murphy, MD, will present results from the MOBILE clinical trial, which examines the use of the MarrowStim™ PAD Kit for the treatment of CLI in subjects with severe PAD. The treatment involves removing bone marrow from the hips, which is then processed in the MarrowStim device to separate stem cells for delivery by injection to multiple sites in the affected leg.

A report on the 6-month results from the two-phase DISRUPT PAD study to assess the safety and performance of the Shockwave Lithoplasty® System in treating calcified peripheral vascular lesions will then be presented by Thomas Zeller, MD, principal investigator for the study. “Lithoplasty is a novel technology utilizing integrated lithotripsy emitters that generate mechanical pulse waves to disrupt both superficial and deep calcium normalizing vessel wall compliance prior to low-pressure balloon dilatation,” according to a company report.

In addition, results from the IN.PACT SFA randomized trial will be presented by Prakash Krishnan, MD, and data from the VIRTUS US Iliofemoral Stenting IDE Trial will be addressed by Stephen Black, MD, and Michael R. Jaff, DO, will present insights on the use of drug-coated balloon treatment for patients with intermittent claudication based on results from the IN.PACT Global full clinical cohort.

On Tuesday morning, Stefan Müller-Hülsbeck, MD, will present the 2-year results plus subgroup analysis of the Majestic Trial, which examined the efficacy benefit of using the Eluvia drug-eluting stent for treating lesions in the femoropopliteal arteries.

This will be followed by Antonio Micari, MD, PhD, who will present the 2-year results of from the SFA-Long Study, which examines the use of paclitaxel coated balloons for long femoropopliteal artery disease.

On Wednesday morning, the 3-Year Results of the Evaluation of the ESPRIT Bioresorbable Vascular Scaffold (ESPRIT BVS) in The Treatment of Patients with Occlusive Vascular Disease of the Superficial Femoral (SFA) or Common or External Iliac Arteries (ESPRIT I Trial) will be presented by Michael R. Jaff, DO.

This will be followed by a presentation of the 12-month results from the DANCE Trial Atherectomy Cohort by Chris D. Owens, MD, and John Laird, MD, discussing the 9-month results of the Prospective, Multicenter BOLSTER Trial, which examined the use of an expanded polytetrafluoroethylene balloon-expandable covered stent for obstructive lesions in the iliac artery.

In further research addressing the peripheral vascular system, Dr. Laird will also address the 24-month results from the TIGRIS randomized trial, assessing the use of a novel nitinol stent for long lesions in the SFA and the proximal popliteal artery.

Afterwards, Richard Saxon, MD, will discuss the PRISM Indigo Aspiration System as a potential frontline tool for vacuum-assisted aspiration thrombectomy in the periphery.

BOSTON – Smartphones coupled with the rapidly growing number of medical applications are the latest disruptive technologies reshaping the way physicians conduct business and interact with patients, according to Paul Alan Wetter, MD, founder and chairman of the Society of Laparoendoscopic Surgeons.

“The message really is to the physicians out there: We need to be prepared and understand as much about this as we can,” said Dr. Wetter, clinical professor emeritus at the University of Miami. “We don’t want to be, 5 years from now ... wondering what’s going, what is this change?”

In a video interview, Dr. Wetter explained how mobile devices and apps could potentially improve technology-based tools that doctors already use, such as electronic health records, by allowing patients to carry accurate and up-to-date medical information with them.

Dr. Wetter spoke at the annual Minimally Invasive Surgery Week, held by the Society of Laparoendoscopic Surgeons. He did not report any relevant financial disclosures.

[email protected]

BOSTON – Smartphones coupled with the rapidly growing number of medical applications are the latest disruptive technologies reshaping the way physicians conduct business and interact with patients, according to Paul Alan Wetter, MD, founder and chairman of the Society of Laparoendoscopic Surgeons.

“The message really is to the physicians out there: We need to be prepared and understand as much about this as we can,” said Dr. Wetter, clinical professor emeritus at the University of Miami. “We don’t want to be, 5 years from now ... wondering what’s going, what is this change?”

In a video interview, Dr. Wetter explained how mobile devices and apps could potentially improve technology-based tools that doctors already use, such as electronic health records, by allowing patients to carry accurate and up-to-date medical information with them.

Dr. Wetter spoke at the annual Minimally Invasive Surgery Week, held by the Society of Laparoendoscopic Surgeons. He did not report any relevant financial disclosures.

[email protected]

BOSTON – Smartphones coupled with the rapidly growing number of medical applications are the latest disruptive technologies reshaping the way physicians conduct business and interact with patients, according to Paul Alan Wetter, MD, founder and chairman of the Society of Laparoendoscopic Surgeons.

“The message really is to the physicians out there: We need to be prepared and understand as much about this as we can,” said Dr. Wetter, clinical professor emeritus at the University of Miami. “We don’t want to be, 5 years from now ... wondering what’s going, what is this change?”

In a video interview, Dr. Wetter explained how mobile devices and apps could potentially improve technology-based tools that doctors already use, such as electronic health records, by allowing patients to carry accurate and up-to-date medical information with them.

Dr. Wetter spoke at the annual Minimally Invasive Surgery Week, held by the Society of Laparoendoscopic Surgeons. He did not report any relevant financial disclosures.

[email protected]