I recently saw a 73-year-old Hispanic woman in the emergency department who said (through her daughter, who was translating) that she was experiencing mild headache, shortness of breath, and throat swelling. She had previously sought care for these complaints, but her condition had not improved. Her past medical and surgical history was otherwise unremarkable.

On examination, her voice was hoarse and she had bilateral 1+ pitting edema of her lower extremities. Her vital signs were stable, her lungs were clear, her throat appeared normal, and she didn’t have any skin rashes. However, her lab results included a white blood cell count of 2100/mcL, platelet count of 73,000/mcL, and an absolute neutrophil count of 1000/mm³. Her b-type natriuretic peptide, cardiac marker, and thyroid-stimulating hormone levels were normal.

The diagnosis was clear—neutropenia and agranulocytosis—although the cause was not. That is, until we learned about a drug the patient had obtained in Mexico.

The diagnosis was clear—neutropenia and agranulocytosis—although the cause was not.

I gathered a more detailed history and learned that the patient had been living in the United States for years, but she occasionally returned to Mexico for visits and routine medical care. During one of these trips, she’d obtained metamizole—a drug banned in the United States—and was taking it for her headaches.

A Web search revealed rare adverse effects of agranulocytosis, neutropenia, and anaphylaxis from metamizole. It is highly probable that the metamizole caused my patient’s symptoms and abnormal labs findings. I advised her of my suspicions and recommended that she stop taking the medication. A hospitalist then took over her care.

The key takeaway from this case is to account for all medications when gathering a patient’s history, including those that may be obtained outside of the United States.

Nick Ly, DO
Lillington, NC

I recently saw a 73-year-old Hispanic woman in the emergency department who said (through her daughter, who was translating) that she was experiencing mild headache, shortness of breath, and throat swelling. She had previously sought care for these complaints, but her condition had not improved. Her past medical and surgical history was otherwise unremarkable.

On examination, her voice was hoarse and she had bilateral 1+ pitting edema of her lower extremities. Her vital signs were stable, her lungs were clear, her throat appeared normal, and she didn’t have any skin rashes. However, her lab results included a white blood cell count of 2100/mcL, platelet count of 73,000/mcL, and an absolute neutrophil count of 1000/mm³. Her b-type natriuretic peptide, cardiac marker, and thyroid-stimulating hormone levels were normal.

The diagnosis was clear—neutropenia and agranulocytosis—although the cause was not. That is, until we learned about a drug the patient had obtained in Mexico.

The diagnosis was clear—neutropenia and agranulocytosis—although the cause was not.

I gathered a more detailed history and learned that the patient had been living in the United States for years, but she occasionally returned to Mexico for visits and routine medical care. During one of these trips, she’d obtained metamizole—a drug banned in the United States—and was taking it for her headaches.

A Web search revealed rare adverse effects of agranulocytosis, neutropenia, and anaphylaxis from metamizole. It is highly probable that the metamizole caused my patient’s symptoms and abnormal labs findings. I advised her of my suspicions and recommended that she stop taking the medication. A hospitalist then took over her care.

The key takeaway from this case is to account for all medications when gathering a patient’s history, including those that may be obtained outside of the United States.

Nick Ly, DO
Lillington, NC

I recently saw a 73-year-old Hispanic woman in the emergency department who said (through her daughter, who was translating) that she was experiencing mild headache, shortness of breath, and throat swelling. She had previously sought care for these complaints, but her condition had not improved. Her past medical and surgical history was otherwise unremarkable.

On examination, her voice was hoarse and she had bilateral 1+ pitting edema of her lower extremities. Her vital signs were stable, her lungs were clear, her throat appeared normal, and she didn’t have any skin rashes. However, her lab results included a white blood cell count of 2100/mcL, platelet count of 73,000/mcL, and an absolute neutrophil count of 1000/mm³. Her b-type natriuretic peptide, cardiac marker, and thyroid-stimulating hormone levels were normal.

The diagnosis was clear—neutropenia and agranulocytosis—although the cause was not. That is, until we learned about a drug the patient had obtained in Mexico.

The diagnosis was clear—neutropenia and agranulocytosis—although the cause was not.

I gathered a more detailed history and learned that the patient had been living in the United States for years, but she occasionally returned to Mexico for visits and routine medical care. During one of these trips, she’d obtained metamizole—a drug banned in the United States—and was taking it for her headaches.

A Web search revealed rare adverse effects of agranulocytosis, neutropenia, and anaphylaxis from metamizole. It is highly probable that the metamizole caused my patient’s symptoms and abnormal labs findings. I advised her of my suspicions and recommended that she stop taking the medication. A hospitalist then took over her care.

The key takeaway from this case is to account for all medications when gathering a patient’s history, including those that may be obtained outside of the United States.

Nick Ly, DO
Lillington, NC

As a scribe and accepted future medical student, I was quite interested in the article, “Medical scribes: How do their notes stack up?” by Misra-Hebert, et al (J Fam Pract. 2016;65:155-159) and the editorial, “Working with scribes—the good, the surprising” (J Fam Pract. 2016;65:154,176) in the March issue. I was struck, however, that both pieces implied that only medical assistants (MAs) are scribes.

I am familiar with practices where MAs assume a “documentation support” function in addition to their traditional role, and I currently work in a practice with professional scribes. Professional scribes are often recent college graduates who are working before beginning their studies to become a physician or physician assistant.

In my experience, MAs want to do the work they were hired and trained to do and are not enthusiastic about extensive charting. However, professional scribes apply to the position expecting to do this very task, with the goals of learning from the doctor-patient interaction, deepening their medical knowledge, and becoming comfortable in a clinical setting.

Although I am glad to see that MAs improve documentation quality per the original research mentioned above, it would be beneficial to compare the outcomes of professional scribes to those of cross-trained MAs or to traditional providers who do their own note-writing.

D. Brendan Johnson, BA
Minneapolis, Minn

As a scribe and accepted future medical student, I was quite interested in the article, “Medical scribes: How do their notes stack up?” by Misra-Hebert, et al (J Fam Pract. 2016;65:155-159) and the editorial, “Working with scribes—the good, the surprising” (J Fam Pract. 2016;65:154,176) in the March issue. I was struck, however, that both pieces implied that only medical assistants (MAs) are scribes.

I am familiar with practices where MAs assume a “documentation support” function in addition to their traditional role, and I currently work in a practice with professional scribes. Professional scribes are often recent college graduates who are working before beginning their studies to become a physician or physician assistant.

In my experience, MAs want to do the work they were hired and trained to do and are not enthusiastic about extensive charting. However, professional scribes apply to the position expecting to do this very task, with the goals of learning from the doctor-patient interaction, deepening their medical knowledge, and becoming comfortable in a clinical setting.

Although I am glad to see that MAs improve documentation quality per the original research mentioned above, it would be beneficial to compare the outcomes of professional scribes to those of cross-trained MAs or to traditional providers who do their own note-writing.

D. Brendan Johnson, BA
Minneapolis, Minn

As a scribe and accepted future medical student, I was quite interested in the article, “Medical scribes: How do their notes stack up?” by Misra-Hebert, et al (J Fam Pract. 2016;65:155-159) and the editorial, “Working with scribes—the good, the surprising” (J Fam Pract. 2016;65:154,176) in the March issue. I was struck, however, that both pieces implied that only medical assistants (MAs) are scribes.

I am familiar with practices where MAs assume a “documentation support” function in addition to their traditional role, and I currently work in a practice with professional scribes. Professional scribes are often recent college graduates who are working before beginning their studies to become a physician or physician assistant.

In my experience, MAs want to do the work they were hired and trained to do and are not enthusiastic about extensive charting. However, professional scribes apply to the position expecting to do this very task, with the goals of learning from the doctor-patient interaction, deepening their medical knowledge, and becoming comfortable in a clinical setting.

Although I am glad to see that MAs improve documentation quality per the original research mentioned above, it would be beneficial to compare the outcomes of professional scribes to those of cross-trained MAs or to traditional providers who do their own note-writing.

D. Brendan Johnson, BA
Minneapolis, Minn

Women with BRCA1 mutations who undergo risk-reducing ovary and fallopian tube removal without concomitant hysterectomy appear to be at increased risk for serous or serous-like endometrial carcinoma, results of a long-term prospective study suggest.

Among 1,083 women with deleterious mutations in BRCA1, BRCA2, or both who underwent risk-reducing salpingo-oophorectomy (RRSO) without hysterectomy, there was no overall increase in the incidence of uterine corpus cancers, compared with the background population. But among women with BRCA1 mutations, however, there was increased risk for serous/serous-like endometrial carcinomas, which comprise only 10% of endometrial cancers, but account for about 40% of endometrial cancer deaths, reported Catherine A. Shu, MD, of Columbia University, New York, and her colleagues (JAMA Oncol. 2016 Jun 30. doi: 10.1001/jamaoncol.2016.1820).

©ktsimage/Thinkstock.com

“Our results suggest that BRCA1+ women are at increased risk for serous/serous-like endometrial carcinoma. Although instability in the estimated magnitude of this risk remains, we believe that the possibility of this cancer should be considered when discussing the advantages and risks of hysterectomy at the time of RRSO in BRCA1+ women,” they wrote.

Salpingo-oophorectomy to reduce risk for breast, ovarian, and fallopian-tube cancers is a standard option for women with BRCA mutations, but it’s unclear whether concomitant hysterectomy offers additional benefit, or adds only morbidity.

To help clarify the issue, investigators at nine comprehensive cancer centers enrolled 627 women with BRCA1 mutations, 453 with BRCA2 mutations, and 3 with mutations in both genes who underwent RRSO without either prior or concomitant hysterectomy. They then followed the patients for a median of 5.1 years after the date of ascertainment, receipt of BRCA testing results, or RRSO.

There were a total of 8 incident uterine cancers over the course of follow-up, compared with 4.3 that would be expected based on Surveillance, Epidemiology, and End Results (SEER) data. The observed-to-expected incidence ratio was 1.9, and was not statistically significant.

In addition, when the investigators stratified by subtype, there was no increased risk for endometrioid endometrial carcinoma or sarcoma.

However, there were five cases of serous/serous-like endometrial carcinomas occurring from 7.2 to 12, 9 years after surgery. The patients included four women positive for BRCA1 mutations, and one positive for BRCA2.

In the SEER population, 0.18 incident cases would be expected, translating into an observed-to-expected ratio for women with BRCA1 of 22.2 (P less than .001). For BRCA2, however, the ratio was 6.4, and was not statistically significant.

In the three serous/serous-like tumors from women positive for BRCA1, tumor analysis showed loss of the wild-type BRCA1 gene and/or loss of protein expression.

Finally to see whether the results could have been confounded by a history of breast cancer or exposure to tamoxifen, which is associated with a small but significant increase in risk for endometrial cancer, the investigators looked at the serous/serous-like subtype tumors, 4 of which occurred among 727 women with history of breast cancer, compared with 0.26 expected (observed-to-expected ratio 15.5, P less than .001). Among 356 women with no history of breast cancer, the expected incidence was 0.08, and the observed-to-expected ratio was 12.6 (not significant).

There were 3 serous/serous-like carcinomas among 273 women with tamoxifen exposure (expected rate 0.12, observed-to-expected ratio, 24.4, P less than .001) and two occurring in 655 women without tamoxifen exposure (expected 0.18, observed-to-expected ratio 11.3, P = .01).

The authors noted that with minimally invasive approaches, the additional surgical risks, mortality rates, and costs of adding concomitant hysterectomy to RRSO are relatively modest and may be an acceptable trade-off for some high-risk patients.

“[I]f the present results are confirmed by future studies, hysterectomy with bilateral salpingo-oophorectomy may become the preferred risk-reducing surgical approach for BRCA1+ women. However, even if these results are confirmed, RRSO alone may still have a role for BRCA1+ women if strong reasons exist for uterine retention, such as dense pelvic adhesions or desire for future pregnancy using assisted reproductive approaches,” they wrote.

Women with BRCA1 mutations who undergo risk-reducing ovary and fallopian tube removal without concomitant hysterectomy appear to be at increased risk for serous or serous-like endometrial carcinoma, results of a long-term prospective study suggest.

Among 1,083 women with deleterious mutations in BRCA1, BRCA2, or both who underwent risk-reducing salpingo-oophorectomy (RRSO) without hysterectomy, there was no overall increase in the incidence of uterine corpus cancers, compared with the background population. But among women with BRCA1 mutations, however, there was increased risk for serous/serous-like endometrial carcinomas, which comprise only 10% of endometrial cancers, but account for about 40% of endometrial cancer deaths, reported Catherine A. Shu, MD, of Columbia University, New York, and her colleagues (JAMA Oncol. 2016 Jun 30. doi: 10.1001/jamaoncol.2016.1820).

©ktsimage/Thinkstock.com

“Our results suggest that BRCA1+ women are at increased risk for serous/serous-like endometrial carcinoma. Although instability in the estimated magnitude of this risk remains, we believe that the possibility of this cancer should be considered when discussing the advantages and risks of hysterectomy at the time of RRSO in BRCA1+ women,” they wrote.

Salpingo-oophorectomy to reduce risk for breast, ovarian, and fallopian-tube cancers is a standard option for women with BRCA mutations, but it’s unclear whether concomitant hysterectomy offers additional benefit, or adds only morbidity.

To help clarify the issue, investigators at nine comprehensive cancer centers enrolled 627 women with BRCA1 mutations, 453 with BRCA2 mutations, and 3 with mutations in both genes who underwent RRSO without either prior or concomitant hysterectomy. They then followed the patients for a median of 5.1 years after the date of ascertainment, receipt of BRCA testing results, or RRSO.

There were a total of 8 incident uterine cancers over the course of follow-up, compared with 4.3 that would be expected based on Surveillance, Epidemiology, and End Results (SEER) data. The observed-to-expected incidence ratio was 1.9, and was not statistically significant.

In addition, when the investigators stratified by subtype, there was no increased risk for endometrioid endometrial carcinoma or sarcoma.

However, there were five cases of serous/serous-like endometrial carcinomas occurring from 7.2 to 12, 9 years after surgery. The patients included four women positive for BRCA1 mutations, and one positive for BRCA2.

In the SEER population, 0.18 incident cases would be expected, translating into an observed-to-expected ratio for women with BRCA1 of 22.2 (P less than .001). For BRCA2, however, the ratio was 6.4, and was not statistically significant.

In the three serous/serous-like tumors from women positive for BRCA1, tumor analysis showed loss of the wild-type BRCA1 gene and/or loss of protein expression.

Finally to see whether the results could have been confounded by a history of breast cancer or exposure to tamoxifen, which is associated with a small but significant increase in risk for endometrial cancer, the investigators looked at the serous/serous-like subtype tumors, 4 of which occurred among 727 women with history of breast cancer, compared with 0.26 expected (observed-to-expected ratio 15.5, P less than .001). Among 356 women with no history of breast cancer, the expected incidence was 0.08, and the observed-to-expected ratio was 12.6 (not significant).

There were 3 serous/serous-like carcinomas among 273 women with tamoxifen exposure (expected rate 0.12, observed-to-expected ratio, 24.4, P less than .001) and two occurring in 655 women without tamoxifen exposure (expected 0.18, observed-to-expected ratio 11.3, P = .01).

The authors noted that with minimally invasive approaches, the additional surgical risks, mortality rates, and costs of adding concomitant hysterectomy to RRSO are relatively modest and may be an acceptable trade-off for some high-risk patients.

“[I]f the present results are confirmed by future studies, hysterectomy with bilateral salpingo-oophorectomy may become the preferred risk-reducing surgical approach for BRCA1+ women. However, even if these results are confirmed, RRSO alone may still have a role for BRCA1+ women if strong reasons exist for uterine retention, such as dense pelvic adhesions or desire for future pregnancy using assisted reproductive approaches,” they wrote.

Women with BRCA1 mutations who undergo risk-reducing ovary and fallopian tube removal without concomitant hysterectomy appear to be at increased risk for serous or serous-like endometrial carcinoma, results of a long-term prospective study suggest.

Among 1,083 women with deleterious mutations in BRCA1, BRCA2, or both who underwent risk-reducing salpingo-oophorectomy (RRSO) without hysterectomy, there was no overall increase in the incidence of uterine corpus cancers, compared with the background population. But among women with BRCA1 mutations, however, there was increased risk for serous/serous-like endometrial carcinomas, which comprise only 10% of endometrial cancers, but account for about 40% of endometrial cancer deaths, reported Catherine A. Shu, MD, of Columbia University, New York, and her colleagues (JAMA Oncol. 2016 Jun 30. doi: 10.1001/jamaoncol.2016.1820).

©ktsimage/Thinkstock.com

“Our results suggest that BRCA1+ women are at increased risk for serous/serous-like endometrial carcinoma. Although instability in the estimated magnitude of this risk remains, we believe that the possibility of this cancer should be considered when discussing the advantages and risks of hysterectomy at the time of RRSO in BRCA1+ women,” they wrote.

Salpingo-oophorectomy to reduce risk for breast, ovarian, and fallopian-tube cancers is a standard option for women with BRCA mutations, but it’s unclear whether concomitant hysterectomy offers additional benefit, or adds only morbidity.

To help clarify the issue, investigators at nine comprehensive cancer centers enrolled 627 women with BRCA1 mutations, 453 with BRCA2 mutations, and 3 with mutations in both genes who underwent RRSO without either prior or concomitant hysterectomy. They then followed the patients for a median of 5.1 years after the date of ascertainment, receipt of BRCA testing results, or RRSO.

There were a total of 8 incident uterine cancers over the course of follow-up, compared with 4.3 that would be expected based on Surveillance, Epidemiology, and End Results (SEER) data. The observed-to-expected incidence ratio was 1.9, and was not statistically significant.

In addition, when the investigators stratified by subtype, there was no increased risk for endometrioid endometrial carcinoma or sarcoma.

However, there were five cases of serous/serous-like endometrial carcinomas occurring from 7.2 to 12, 9 years after surgery. The patients included four women positive for BRCA1 mutations, and one positive for BRCA2.

In the SEER population, 0.18 incident cases would be expected, translating into an observed-to-expected ratio for women with BRCA1 of 22.2 (P less than .001). For BRCA2, however, the ratio was 6.4, and was not statistically significant.

In the three serous/serous-like tumors from women positive for BRCA1, tumor analysis showed loss of the wild-type BRCA1 gene and/or loss of protein expression.

Finally to see whether the results could have been confounded by a history of breast cancer or exposure to tamoxifen, which is associated with a small but significant increase in risk for endometrial cancer, the investigators looked at the serous/serous-like subtype tumors, 4 of which occurred among 727 women with history of breast cancer, compared with 0.26 expected (observed-to-expected ratio 15.5, P less than .001). Among 356 women with no history of breast cancer, the expected incidence was 0.08, and the observed-to-expected ratio was 12.6 (not significant).

There were 3 serous/serous-like carcinomas among 273 women with tamoxifen exposure (expected rate 0.12, observed-to-expected ratio, 24.4, P less than .001) and two occurring in 655 women without tamoxifen exposure (expected 0.18, observed-to-expected ratio 11.3, P = .01).

The authors noted that with minimally invasive approaches, the additional surgical risks, mortality rates, and costs of adding concomitant hysterectomy to RRSO are relatively modest and may be an acceptable trade-off for some high-risk patients.

“[I]f the present results are confirmed by future studies, hysterectomy with bilateral salpingo-oophorectomy may become the preferred risk-reducing surgical approach for BRCA1+ women. However, even if these results are confirmed, RRSO alone may still have a role for BRCA1+ women if strong reasons exist for uterine retention, such as dense pelvic adhesions or desire for future pregnancy using assisted reproductive approaches,” they wrote.

BERLIN—A common medication used for the symptomatic treatment of dystonia has been shown to target brain abnormalities in the cerebral cortex in patients with cervical dystonia, according to a study presented at the 20th International Congress of Parkinson’s Disease and Movement Disorders.

Roxana G. Burciu, PhD, a postdoctoral fellow, and a team of researchers at the University of Florida, Gainesville, aimed to assess with fMRI task-related brain activity in patients with cervical dystonia with and without a single-dose administration of trihexyphenidyl, an anticholinergic medication. For decades, anticholinergic medications have been commonly prescribed for patients with varying types of dystonia, but their mechanism of action has not been determined. Although it was previously thought that anticholinergic medications primarily affect the basal ganglia, the results of this study are evidence that they are effective in other areas of the brain, particularly in the cerebral cortex.

Roxana G. Burciu, PhD

Sixteen patients with idiopathic cervical dystonia were compared using a 3T MRI scanner with 16 age- and gender-matched healthy individuals. Patients with cervical dystonia were scanned twice, both off-medication and on average two hours after a single dose of trihexyphenidyl. Control subjects did not receive the medication and were only scanned once. While off medication, the patients had reduced motor activity compared with the healthy subjects. After administration of trihexyphenidyl, there was an increase in motor-related activity in middle frontal gyrus and primary somatosensory cortex. The results suggest that somatosensory processing in cervical dystonia can be acutely changed through trihexyphenidyl administration.

Hyder A. Jinnah, MD, PhD, Professor of Neurosurgery, Human Genetics, and Pediatrics at Emory University School of Medicine in Atlanta, said, “The study by Burciu and colleagues is the first attempt to determine what part of the brain is influenced by anticholinergic drugs in dystonia. Before treatment, the patients with cervical dystonia showed abnormal activity in multiple brain regions. After treatment, the abnormal brain activity was at least partly corrected in two regions. Both of these regions were in the cerebral cortex, not the basal ganglia. This study provides clues towards which regions of the brain might be abnormal, and how trihexyphenidyl might correct these abnormalities.”

Dr. Jinnah added, “Like any good study, the findings from this study lead to many more questions than answers. Do the brain abnormalities found reflect a cause for dystonia, or a consequence of it? Does the result mean that these medications work in the cortex, not the basal ganglia, as previously believed? Why do patients with cervical dystonia have brain abnormalities that show up when they use their hands, which are not affected? Does the drug affect the brains of normal people who do not have dystonia in the same way? How can we exploit this new information to improve the value of anticholinergics for patients with dystonia?”

BERLIN—A common medication used for the symptomatic treatment of dystonia has been shown to target brain abnormalities in the cerebral cortex in patients with cervical dystonia, according to a study presented at the 20th International Congress of Parkinson’s Disease and Movement Disorders.

Roxana G. Burciu, PhD, a postdoctoral fellow, and a team of researchers at the University of Florida, Gainesville, aimed to assess with fMRI task-related brain activity in patients with cervical dystonia with and without a single-dose administration of trihexyphenidyl, an anticholinergic medication. For decades, anticholinergic medications have been commonly prescribed for patients with varying types of dystonia, but their mechanism of action has not been determined. Although it was previously thought that anticholinergic medications primarily affect the basal ganglia, the results of this study are evidence that they are effective in other areas of the brain, particularly in the cerebral cortex.

Roxana G. Burciu, PhD

Sixteen patients with idiopathic cervical dystonia were compared using a 3T MRI scanner with 16 age- and gender-matched healthy individuals. Patients with cervical dystonia were scanned twice, both off-medication and on average two hours after a single dose of trihexyphenidyl. Control subjects did not receive the medication and were only scanned once. While off medication, the patients had reduced motor activity compared with the healthy subjects. After administration of trihexyphenidyl, there was an increase in motor-related activity in middle frontal gyrus and primary somatosensory cortex. The results suggest that somatosensory processing in cervical dystonia can be acutely changed through trihexyphenidyl administration.

Hyder A. Jinnah, MD, PhD, Professor of Neurosurgery, Human Genetics, and Pediatrics at Emory University School of Medicine in Atlanta, said, “The study by Burciu and colleagues is the first attempt to determine what part of the brain is influenced by anticholinergic drugs in dystonia. Before treatment, the patients with cervical dystonia showed abnormal activity in multiple brain regions. After treatment, the abnormal brain activity was at least partly corrected in two regions. Both of these regions were in the cerebral cortex, not the basal ganglia. This study provides clues towards which regions of the brain might be abnormal, and how trihexyphenidyl might correct these abnormalities.”

Dr. Jinnah added, “Like any good study, the findings from this study lead to many more questions than answers. Do the brain abnormalities found reflect a cause for dystonia, or a consequence of it? Does the result mean that these medications work in the cortex, not the basal ganglia, as previously believed? Why do patients with cervical dystonia have brain abnormalities that show up when they use their hands, which are not affected? Does the drug affect the brains of normal people who do not have dystonia in the same way? How can we exploit this new information to improve the value of anticholinergics for patients with dystonia?”

BERLIN—A common medication used for the symptomatic treatment of dystonia has been shown to target brain abnormalities in the cerebral cortex in patients with cervical dystonia, according to a study presented at the 20th International Congress of Parkinson’s Disease and Movement Disorders.

Roxana G. Burciu, PhD, a postdoctoral fellow, and a team of researchers at the University of Florida, Gainesville, aimed to assess with fMRI task-related brain activity in patients with cervical dystonia with and without a single-dose administration of trihexyphenidyl, an anticholinergic medication. For decades, anticholinergic medications have been commonly prescribed for patients with varying types of dystonia, but their mechanism of action has not been determined. Although it was previously thought that anticholinergic medications primarily affect the basal ganglia, the results of this study are evidence that they are effective in other areas of the brain, particularly in the cerebral cortex.

Roxana G. Burciu, PhD

Sixteen patients with idiopathic cervical dystonia were compared using a 3T MRI scanner with 16 age- and gender-matched healthy individuals. Patients with cervical dystonia were scanned twice, both off-medication and on average two hours after a single dose of trihexyphenidyl. Control subjects did not receive the medication and were only scanned once. While off medication, the patients had reduced motor activity compared with the healthy subjects. After administration of trihexyphenidyl, there was an increase in motor-related activity in middle frontal gyrus and primary somatosensory cortex. The results suggest that somatosensory processing in cervical dystonia can be acutely changed through trihexyphenidyl administration.

Hyder A. Jinnah, MD, PhD, Professor of Neurosurgery, Human Genetics, and Pediatrics at Emory University School of Medicine in Atlanta, said, “The study by Burciu and colleagues is the first attempt to determine what part of the brain is influenced by anticholinergic drugs in dystonia. Before treatment, the patients with cervical dystonia showed abnormal activity in multiple brain regions. After treatment, the abnormal brain activity was at least partly corrected in two regions. Both of these regions were in the cerebral cortex, not the basal ganglia. This study provides clues towards which regions of the brain might be abnormal, and how trihexyphenidyl might correct these abnormalities.”

Dr. Jinnah added, “Like any good study, the findings from this study lead to many more questions than answers. Do the brain abnormalities found reflect a cause for dystonia, or a consequence of it? Does the result mean that these medications work in the cortex, not the basal ganglia, as previously believed? Why do patients with cervical dystonia have brain abnormalities that show up when they use their hands, which are not affected? Does the drug affect the brains of normal people who do not have dystonia in the same way? How can we exploit this new information to improve the value of anticholinergics for patients with dystonia?”

BERLIN—A new link has been established between superoxide dismutase 1 (SOD1) protein aggregation and neuronal loss in the Parkinson’s disease brain, according to a study released at the 20th International Congress of Parkinson’s Disease and Movement Disorders.

A trademark of many neurodegenerative diseases is abnormal accumulation of proteins in the form of deposits or aggregates. It is already known that SOD1 protein aggregation in the brain is primarily associated with neuronal loss in amyotrophic lateral sclerosis (ALS). To date, abnormal aggregation of alpha-synuclein protein into Lewy bodies is considered the primary cause of neuronal loss in Parkinson’s disease.

Benjamin G. Trist and colleagues at the University of Sydney in Australia and researchers in France sought to characterize a novel connection between SOD1 aggregation and neuronal loss in Parkinson’s disease. The researchers tested postmortem tissues from deceased patients with Parkinson’s disease and age-matched control brains and found that protein aggregates that tested positive for SOD1 were significantly more abundant in degenerating regions of the Parkinson’s disease brain ( > 5-fold increase in the substantia nigra and > 2.5-fold increase in the locus coeruleus). These findings establish a new role of SOD1 pathology in neuronal vulnerability in Parkinson’s disease.

Jeffrey H. Kordower, PhD, Professor of Neurosurgery at Rush University Medical Center and Director of the Research Center for Brain Repair in Chicago, commented, “This is a very noteworthy abstract documenting SOD1 aggregates in Parkinson’s disease. What makes this work important is the abundance of these aggregates in selectively vulnerable regions in the Parkinson’s disease brain, such as the substantia nigra and locus coeruleus, with less abundance in regions that are selectively resistant in the disease. This appears independent of alpha-synuclein pathology. What remains to be determined is whether SOD1 aggregation is a primary pathologic event or is secondary to another pathologic pathway. Still, this work suggests that multiple aggregation pathways are part of the Parkinson’s disease pathologic process.”

BERLIN—A new link has been established between superoxide dismutase 1 (SOD1) protein aggregation and neuronal loss in the Parkinson’s disease brain, according to a study released at the 20th International Congress of Parkinson’s Disease and Movement Disorders.

A trademark of many neurodegenerative diseases is abnormal accumulation of proteins in the form of deposits or aggregates. It is already known that SOD1 protein aggregation in the brain is primarily associated with neuronal loss in amyotrophic lateral sclerosis (ALS). To date, abnormal aggregation of alpha-synuclein protein into Lewy bodies is considered the primary cause of neuronal loss in Parkinson’s disease.

Benjamin G. Trist and colleagues at the University of Sydney in Australia and researchers in France sought to characterize a novel connection between SOD1 aggregation and neuronal loss in Parkinson’s disease. The researchers tested postmortem tissues from deceased patients with Parkinson’s disease and age-matched control brains and found that protein aggregates that tested positive for SOD1 were significantly more abundant in degenerating regions of the Parkinson’s disease brain ( > 5-fold increase in the substantia nigra and > 2.5-fold increase in the locus coeruleus). These findings establish a new role of SOD1 pathology in neuronal vulnerability in Parkinson’s disease.

Jeffrey H. Kordower, PhD, Professor of Neurosurgery at Rush University Medical Center and Director of the Research Center for Brain Repair in Chicago, commented, “This is a very noteworthy abstract documenting SOD1 aggregates in Parkinson’s disease. What makes this work important is the abundance of these aggregates in selectively vulnerable regions in the Parkinson’s disease brain, such as the substantia nigra and locus coeruleus, with less abundance in regions that are selectively resistant in the disease. This appears independent of alpha-synuclein pathology. What remains to be determined is whether SOD1 aggregation is a primary pathologic event or is secondary to another pathologic pathway. Still, this work suggests that multiple aggregation pathways are part of the Parkinson’s disease pathologic process.”

BERLIN—A new link has been established between superoxide dismutase 1 (SOD1) protein aggregation and neuronal loss in the Parkinson’s disease brain, according to a study released at the 20th International Congress of Parkinson’s Disease and Movement Disorders.

A trademark of many neurodegenerative diseases is abnormal accumulation of proteins in the form of deposits or aggregates. It is already known that SOD1 protein aggregation in the brain is primarily associated with neuronal loss in amyotrophic lateral sclerosis (ALS). To date, abnormal aggregation of alpha-synuclein protein into Lewy bodies is considered the primary cause of neuronal loss in Parkinson’s disease.

Benjamin G. Trist and colleagues at the University of Sydney in Australia and researchers in France sought to characterize a novel connection between SOD1 aggregation and neuronal loss in Parkinson’s disease. The researchers tested postmortem tissues from deceased patients with Parkinson’s disease and age-matched control brains and found that protein aggregates that tested positive for SOD1 were significantly more abundant in degenerating regions of the Parkinson’s disease brain ( > 5-fold increase in the substantia nigra and > 2.5-fold increase in the locus coeruleus). These findings establish a new role of SOD1 pathology in neuronal vulnerability in Parkinson’s disease.

Jeffrey H. Kordower, PhD, Professor of Neurosurgery at Rush University Medical Center and Director of the Research Center for Brain Repair in Chicago, commented, “This is a very noteworthy abstract documenting SOD1 aggregates in Parkinson’s disease. What makes this work important is the abundance of these aggregates in selectively vulnerable regions in the Parkinson’s disease brain, such as the substantia nigra and locus coeruleus, with less abundance in regions that are selectively resistant in the disease. This appears independent of alpha-synuclein pathology. What remains to be determined is whether SOD1 aggregation is a primary pathologic event or is secondary to another pathologic pathway. Still, this work suggests that multiple aggregation pathways are part of the Parkinson’s disease pathologic process.”

BERLIN—Populations living in French rural regions that require higher levels of pesticide may be at a greater risk of Parkinson’s disease, according to a study presented at the 20th International Congress of Parkinson’s Disease and Movement Disorders.

Evidence of a link between pesticides and incidence of Parkinson’s disease through occupational exposure already exists. This study, led by Sofiane Kab, a PhD student in epidemiology at the French National Institute of Health and Medical Research in Villejuif, France, and a team of French researchers investigated whether those living in rural French regions with more crops would be at a higher risk of developing Parkinson’s disease through non-occupational exposure.

The study identified cases of Parkinson’s disease from French National Health Insurance databases from 2010 to 2012 and examined the association between rates of Parkinson’s disease and types of farming. The researchers found higher rates of Parkinson’s disease in rural areas of France, particularly in areas with many vineyards, which require the most intense use of insecticides and fungicides. Ultimately, the data collected suggest that those who live in farming regions requiring high levels of pesticide are at a greater risk of Parkinson’s disease.

Sofiane Kab

Caroline Tanner, MD, PhD, Professor of Neurology at the University of California San Francisco and Director of the Parkinson’s Disease Research Education and Clinical Center at the San Francisco Veteran’s Affairs Medical Center, said, “This current report is the largest study assessing newly diagnosed Parkinson’s disease and inferred pesticide exposures. Because the study is derived from the national health insurance records of France, and investigates newly diagnosed (incident) cases, bias is minimized, providing an accurate picture for the entire population. Rural residence alone increases the risk of Parkinson’s disease, suggesting that ambient pesticide exposure is a risk factor. Information on smoking, a recognized risk modifier, was also included, adding to the strength of the study design.” Dr. Tanner added, “The current report strengthens the evidence associating Parkinson’s disease and rural residence, and, by inference, pesticide exposure. More detailed investigation in this large population will be critical, and would be expected to identify specific causative pesticides, and, in turn, underlying pathophysiologic mechanisms. Ultimately, this work may identify ways to reduce Parkinson’s disease incidence.”

BERLIN—Populations living in French rural regions that require higher levels of pesticide may be at a greater risk of Parkinson’s disease, according to a study presented at the 20th International Congress of Parkinson’s Disease and Movement Disorders.

Evidence of a link between pesticides and incidence of Parkinson’s disease through occupational exposure already exists. This study, led by Sofiane Kab, a PhD student in epidemiology at the French National Institute of Health and Medical Research in Villejuif, France, and a team of French researchers investigated whether those living in rural French regions with more crops would be at a higher risk of developing Parkinson’s disease through non-occupational exposure.

The study identified cases of Parkinson’s disease from French National Health Insurance databases from 2010 to 2012 and examined the association between rates of Parkinson’s disease and types of farming. The researchers found higher rates of Parkinson’s disease in rural areas of France, particularly in areas with many vineyards, which require the most intense use of insecticides and fungicides. Ultimately, the data collected suggest that those who live in farming regions requiring high levels of pesticide are at a greater risk of Parkinson’s disease.

Sofiane Kab

Caroline Tanner, MD, PhD, Professor of Neurology at the University of California San Francisco and Director of the Parkinson’s Disease Research Education and Clinical Center at the San Francisco Veteran’s Affairs Medical Center, said, “This current report is the largest study assessing newly diagnosed Parkinson’s disease and inferred pesticide exposures. Because the study is derived from the national health insurance records of France, and investigates newly diagnosed (incident) cases, bias is minimized, providing an accurate picture for the entire population. Rural residence alone increases the risk of Parkinson’s disease, suggesting that ambient pesticide exposure is a risk factor. Information on smoking, a recognized risk modifier, was also included, adding to the strength of the study design.” Dr. Tanner added, “The current report strengthens the evidence associating Parkinson’s disease and rural residence, and, by inference, pesticide exposure. More detailed investigation in this large population will be critical, and would be expected to identify specific causative pesticides, and, in turn, underlying pathophysiologic mechanisms. Ultimately, this work may identify ways to reduce Parkinson’s disease incidence.”

BERLIN—Populations living in French rural regions that require higher levels of pesticide may be at a greater risk of Parkinson’s disease, according to a study presented at the 20th International Congress of Parkinson’s Disease and Movement Disorders.

Evidence of a link between pesticides and incidence of Parkinson’s disease through occupational exposure already exists. This study, led by Sofiane Kab, a PhD student in epidemiology at the French National Institute of Health and Medical Research in Villejuif, France, and a team of French researchers investigated whether those living in rural French regions with more crops would be at a higher risk of developing Parkinson’s disease through non-occupational exposure.

The study identified cases of Parkinson’s disease from French National Health Insurance databases from 2010 to 2012 and examined the association between rates of Parkinson’s disease and types of farming. The researchers found higher rates of Parkinson’s disease in rural areas of France, particularly in areas with many vineyards, which require the most intense use of insecticides and fungicides. Ultimately, the data collected suggest that those who live in farming regions requiring high levels of pesticide are at a greater risk of Parkinson’s disease.

Sofiane Kab

Caroline Tanner, MD, PhD, Professor of Neurology at the University of California San Francisco and Director of the Parkinson’s Disease Research Education and Clinical Center at the San Francisco Veteran’s Affairs Medical Center, said, “This current report is the largest study assessing newly diagnosed Parkinson’s disease and inferred pesticide exposures. Because the study is derived from the national health insurance records of France, and investigates newly diagnosed (incident) cases, bias is minimized, providing an accurate picture for the entire population. Rural residence alone increases the risk of Parkinson’s disease, suggesting that ambient pesticide exposure is a risk factor. Information on smoking, a recognized risk modifier, was also included, adding to the strength of the study design.” Dr. Tanner added, “The current report strengthens the evidence associating Parkinson’s disease and rural residence, and, by inference, pesticide exposure. More detailed investigation in this large population will be critical, and would be expected to identify specific causative pesticides, and, in turn, underlying pathophysiologic mechanisms. Ultimately, this work may identify ways to reduce Parkinson’s disease incidence.”

PARIS – The buzzword in transcatheter aortic valve replacement today is “minimalist.” The search is on for ways in which to safely simplify the procedure to reduce the current unsustainably high cost and improve the patient experience.

Among the elements typically involved in minimalist TAVR are performance of the procedure in the cardiac catheterization laboratory via transfemoral access rather than in the costlier operating room, use of conscious sedation rather than general anesthesia, transthoracic echocardiographic guidance, no Swan-Ganz catheter, and no ICU stay for most patients. But these are tepid measures compared with what’s under study in Germany.

The German health care system is engaged in a study of what has to be the ultimate in minimalist TAVR: doing it in hospitals without on-site cardiac surgery. And the short-term results in more than 1,300 German patients treated in such a setting look every bit as good as in patients whose procedure took place in hospitals more conventionally equipped with both cardiology and cardiothoracic surgery departments, Holger Eggebrecht, MD, reported at the annual congress of the European Association of Percutaneous Cardiovascular Interventions.

“Lack of a cardiac surgery department on site should not be regarded as a contraindication for TAVR,” concluded Dr. Eggebrecht of Agaplesion Bethanien Hospital in Frankfurt, Germany.

Of course, it is deemed an absolute contraindication to TAVR both in the current European Society of Cardiology and U.S. guidelines. But that position was developed in an earlier era when procedural safety had not yet been established. It was based on the expert consensus opinion of physicians drawn mostly from large tertiary centers with both cardiology and cardiac surgery on site. And this absolute contraindication was never supported by any data, he said.

In the United States, arguably the most litigious nation in the world, it’s virtually unthinkable – at least for now – to perform TAVR without a cardiothoracic surgeon on site in the event bailout emergency cardiac surgery should become necessary. But Germany, which boasts universal health care coverage at an affordable cost, operates differently. Indeed, in Dr. Eggebrecht’s study of all 17,919 transfemoral TAVR procedures performed in Germany during 2013 and 2014, fully 22 of the 77 hospitals where the procedures took place had no on-site cardiac surgery department.

He presented a comparison of in-hospital outcomes in the 1,332 German patients (7.4%) whose TAVR took place in hospitals without a cardiac surgery department and the 16,587 patients treated in hospitals with both cardiology and cardiac surgery departments. The data came from the prospective German Quality Assurance Registry on Aortic Valve Replacement, which records in extensive detail all TAVR and surgical replacements in the country. Participation in the registry is mandatory.

The main study finding: Even though patients at no–cardiac surgery hospitals were older, had more comorbid conditions, and were at higher predicted perioperative risk of mortality, the rates of intraprocedural complications, in-hospital strokes, and mortality were similar in the two groups.

Moreover, when Dr. Eggebrecht and coinvestigators performed a case-control substudy involving 555 patient pairs extensively matched on more than a dozen variables, including a requirement for identical scores on validated risk prediction tools for estimating in-hospital mortality, the results were the same as in the full study population.

The key to the high-quality TAVR outcomes documented at hospitals without a cardiac surgery department, Dr. Eggebrecht emphasized, is that in Germany TAVR can be performed only at hospitals where a contractually obligated heart team has signed off on the procedure. At hospitals without a cardiac surgery department, this heart team is composed of in-house cardiologists and visiting cardiac surgeons from collaborating hospitals. In TAVRs at some of these hospitals, a collaborating cardiac surgeon is present for the procedure and brings along a heart-lung machine which is primed and ready to go, if needed, as was the case in just 0.4% of the 1,332 TAVRs. At others, the surgeon is off site.

“I would think our data show that close cooperation within the heart team is the key to successful outcomes, not having a cardiac surgeon on site,” he concluded.

Audience member Volkmar Falk, MD, strode briskly to a microphone and made no effort to hide his incredulity at this project.

“What is the real advantage in not having a surgeon present? I don’t get it,” declared Dr. Falk, professor and director of the department of cardiovascular and vascular surgery at Charité University Hospital in Berlin.

“For a surgeon, this is all quite difficult to understand,” he continued. “If a surgeon has to come to a TAVR rescue from 10 km away, I don’t know how well that works. And if surgeons have to travel with all their equipment in order to be on site, I think this is a logistical nightmare and shouldn’t be done at all.

“All of the studies, all the clinical trials we always discuss, have been done in the setting of hospitals where the procedure was done together with a surgeon on site. That’s why we have these excellent results,” Dr. Falk added.

Dr. Eggebrecht replied, “We’re having a scientific discussion here, and I think our data clearly show that you can construct a successful heart team even though you don’t have a cardiac surgery department on site.”

An Israeli cardiologist in the audience said a similar effort is underway in his country to open up TAVR to hospitals without an on-site cardiac surgeon. His objection is that, at least in Israel, a hospital with no on-site cardiac surgery is a marker for a TAVR center that is low volume, is late to embrace TAVR, and has cardiologists who are probably still early on the procedural learning curve.

Dr. Eggebrecht said that this is not the case in Germany, where some of the most experienced TAVR operators work at sites without a cardiac surgery department.

He reported that his study was partially funded by the German Cardiac Society, and he had no financial conflicts.

Simultaneously with his presentation, the study was published online (Eur Heart J. 2016 May 17. pii: ehw190).

[email protected]

PARIS – The buzzword in transcatheter aortic valve replacement today is “minimalist.” The search is on for ways in which to safely simplify the procedure to reduce the current unsustainably high cost and improve the patient experience.

Among the elements typically involved in minimalist TAVR are performance of the procedure in the cardiac catheterization laboratory via transfemoral access rather than in the costlier operating room, use of conscious sedation rather than general anesthesia, transthoracic echocardiographic guidance, no Swan-Ganz catheter, and no ICU stay for most patients. But these are tepid measures compared with what’s under study in Germany.

The German health care system is engaged in a study of what has to be the ultimate in minimalist TAVR: doing it in hospitals without on-site cardiac surgery. And the short-term results in more than 1,300 German patients treated in such a setting look every bit as good as in patients whose procedure took place in hospitals more conventionally equipped with both cardiology and cardiothoracic surgery departments, Holger Eggebrecht, MD, reported at the annual congress of the European Association of Percutaneous Cardiovascular Interventions.

“Lack of a cardiac surgery department on site should not be regarded as a contraindication for TAVR,” concluded Dr. Eggebrecht of Agaplesion Bethanien Hospital in Frankfurt, Germany.

Of course, it is deemed an absolute contraindication to TAVR both in the current European Society of Cardiology and U.S. guidelines. But that position was developed in an earlier era when procedural safety had not yet been established. It was based on the expert consensus opinion of physicians drawn mostly from large tertiary centers with both cardiology and cardiac surgery on site. And this absolute contraindication was never supported by any data, he said.

In the United States, arguably the most litigious nation in the world, it’s virtually unthinkable – at least for now – to perform TAVR without a cardiothoracic surgeon on site in the event bailout emergency cardiac surgery should become necessary. But Germany, which boasts universal health care coverage at an affordable cost, operates differently. Indeed, in Dr. Eggebrecht’s study of all 17,919 transfemoral TAVR procedures performed in Germany during 2013 and 2014, fully 22 of the 77 hospitals where the procedures took place had no on-site cardiac surgery department.

He presented a comparison of in-hospital outcomes in the 1,332 German patients (7.4%) whose TAVR took place in hospitals without a cardiac surgery department and the 16,587 patients treated in hospitals with both cardiology and cardiac surgery departments. The data came from the prospective German Quality Assurance Registry on Aortic Valve Replacement, which records in extensive detail all TAVR and surgical replacements in the country. Participation in the registry is mandatory.

The main study finding: Even though patients at no–cardiac surgery hospitals were older, had more comorbid conditions, and were at higher predicted perioperative risk of mortality, the rates of intraprocedural complications, in-hospital strokes, and mortality were similar in the two groups.

Moreover, when Dr. Eggebrecht and coinvestigators performed a case-control substudy involving 555 patient pairs extensively matched on more than a dozen variables, including a requirement for identical scores on validated risk prediction tools for estimating in-hospital mortality, the results were the same as in the full study population.

The key to the high-quality TAVR outcomes documented at hospitals without a cardiac surgery department, Dr. Eggebrecht emphasized, is that in Germany TAVR can be performed only at hospitals where a contractually obligated heart team has signed off on the procedure. At hospitals without a cardiac surgery department, this heart team is composed of in-house cardiologists and visiting cardiac surgeons from collaborating hospitals. In TAVRs at some of these hospitals, a collaborating cardiac surgeon is present for the procedure and brings along a heart-lung machine which is primed and ready to go, if needed, as was the case in just 0.4% of the 1,332 TAVRs. At others, the surgeon is off site.

“I would think our data show that close cooperation within the heart team is the key to successful outcomes, not having a cardiac surgeon on site,” he concluded.

Audience member Volkmar Falk, MD, strode briskly to a microphone and made no effort to hide his incredulity at this project.

“What is the real advantage in not having a surgeon present? I don’t get it,” declared Dr. Falk, professor and director of the department of cardiovascular and vascular surgery at Charité University Hospital in Berlin.

“For a surgeon, this is all quite difficult to understand,” he continued. “If a surgeon has to come to a TAVR rescue from 10 km away, I don’t know how well that works. And if surgeons have to travel with all their equipment in order to be on site, I think this is a logistical nightmare and shouldn’t be done at all.

“All of the studies, all the clinical trials we always discuss, have been done in the setting of hospitals where the procedure was done together with a surgeon on site. That’s why we have these excellent results,” Dr. Falk added.

Dr. Eggebrecht replied, “We’re having a scientific discussion here, and I think our data clearly show that you can construct a successful heart team even though you don’t have a cardiac surgery department on site.”

An Israeli cardiologist in the audience said a similar effort is underway in his country to open up TAVR to hospitals without an on-site cardiac surgeon. His objection is that, at least in Israel, a hospital with no on-site cardiac surgery is a marker for a TAVR center that is low volume, is late to embrace TAVR, and has cardiologists who are probably still early on the procedural learning curve.

Dr. Eggebrecht said that this is not the case in Germany, where some of the most experienced TAVR operators work at sites without a cardiac surgery department.

He reported that his study was partially funded by the German Cardiac Society, and he had no financial conflicts.

Simultaneously with his presentation, the study was published online (Eur Heart J. 2016 May 17. pii: ehw190).

[email protected]

PARIS – The buzzword in transcatheter aortic valve replacement today is “minimalist.” The search is on for ways in which to safely simplify the procedure to reduce the current unsustainably high cost and improve the patient experience.

Among the elements typically involved in minimalist TAVR are performance of the procedure in the cardiac catheterization laboratory via transfemoral access rather than in the costlier operating room, use of conscious sedation rather than general anesthesia, transthoracic echocardiographic guidance, no Swan-Ganz catheter, and no ICU stay for most patients. But these are tepid measures compared with what’s under study in Germany.

The German health care system is engaged in a study of what has to be the ultimate in minimalist TAVR: doing it in hospitals without on-site cardiac surgery. And the short-term results in more than 1,300 German patients treated in such a setting look every bit as good as in patients whose procedure took place in hospitals more conventionally equipped with both cardiology and cardiothoracic surgery departments, Holger Eggebrecht, MD, reported at the annual congress of the European Association of Percutaneous Cardiovascular Interventions.

“Lack of a cardiac surgery department on site should not be regarded as a contraindication for TAVR,” concluded Dr. Eggebrecht of Agaplesion Bethanien Hospital in Frankfurt, Germany.

Of course, it is deemed an absolute contraindication to TAVR both in the current European Society of Cardiology and U.S. guidelines. But that position was developed in an earlier era when procedural safety had not yet been established. It was based on the expert consensus opinion of physicians drawn mostly from large tertiary centers with both cardiology and cardiac surgery on site. And this absolute contraindication was never supported by any data, he said.

In the United States, arguably the most litigious nation in the world, it’s virtually unthinkable – at least for now – to perform TAVR without a cardiothoracic surgeon on site in the event bailout emergency cardiac surgery should become necessary. But Germany, which boasts universal health care coverage at an affordable cost, operates differently. Indeed, in Dr. Eggebrecht’s study of all 17,919 transfemoral TAVR procedures performed in Germany during 2013 and 2014, fully 22 of the 77 hospitals where the procedures took place had no on-site cardiac surgery department.

He presented a comparison of in-hospital outcomes in the 1,332 German patients (7.4%) whose TAVR took place in hospitals without a cardiac surgery department and the 16,587 patients treated in hospitals with both cardiology and cardiac surgery departments. The data came from the prospective German Quality Assurance Registry on Aortic Valve Replacement, which records in extensive detail all TAVR and surgical replacements in the country. Participation in the registry is mandatory.

The main study finding: Even though patients at no–cardiac surgery hospitals were older, had more comorbid conditions, and were at higher predicted perioperative risk of mortality, the rates of intraprocedural complications, in-hospital strokes, and mortality were similar in the two groups.

Moreover, when Dr. Eggebrecht and coinvestigators performed a case-control substudy involving 555 patient pairs extensively matched on more than a dozen variables, including a requirement for identical scores on validated risk prediction tools for estimating in-hospital mortality, the results were the same as in the full study population.

The key to the high-quality TAVR outcomes documented at hospitals without a cardiac surgery department, Dr. Eggebrecht emphasized, is that in Germany TAVR can be performed only at hospitals where a contractually obligated heart team has signed off on the procedure. At hospitals without a cardiac surgery department, this heart team is composed of in-house cardiologists and visiting cardiac surgeons from collaborating hospitals. In TAVRs at some of these hospitals, a collaborating cardiac surgeon is present for the procedure and brings along a heart-lung machine which is primed and ready to go, if needed, as was the case in just 0.4% of the 1,332 TAVRs. At others, the surgeon is off site.

“I would think our data show that close cooperation within the heart team is the key to successful outcomes, not having a cardiac surgeon on site,” he concluded.

Audience member Volkmar Falk, MD, strode briskly to a microphone and made no effort to hide his incredulity at this project.

“What is the real advantage in not having a surgeon present? I don’t get it,” declared Dr. Falk, professor and director of the department of cardiovascular and vascular surgery at Charité University Hospital in Berlin.

“For a surgeon, this is all quite difficult to understand,” he continued. “If a surgeon has to come to a TAVR rescue from 10 km away, I don’t know how well that works. And if surgeons have to travel with all their equipment in order to be on site, I think this is a logistical nightmare and shouldn’t be done at all.

“All of the studies, all the clinical trials we always discuss, have been done in the setting of hospitals where the procedure was done together with a surgeon on site. That’s why we have these excellent results,” Dr. Falk added.

Dr. Eggebrecht replied, “We’re having a scientific discussion here, and I think our data clearly show that you can construct a successful heart team even though you don’t have a cardiac surgery department on site.”

An Israeli cardiologist in the audience said a similar effort is underway in his country to open up TAVR to hospitals without an on-site cardiac surgeon. His objection is that, at least in Israel, a hospital with no on-site cardiac surgery is a marker for a TAVR center that is low volume, is late to embrace TAVR, and has cardiologists who are probably still early on the procedural learning curve.

Dr. Eggebrecht said that this is not the case in Germany, where some of the most experienced TAVR operators work at sites without a cardiac surgery department.

He reported that his study was partially funded by the German Cardiac Society, and he had no financial conflicts.

Simultaneously with his presentation, the study was published online (Eur Heart J. 2016 May 17. pii: ehw190).

[email protected]

Gun violence, the LGBT community, and terrorism. Who would have imagined these 3 entities tragically colliding in Orlando last month, in the shadow of “the happiest place on earth”? The tragedy was all too real for the victims—mostly gay young Hispanic men—their families and friends, and all those who responded with urgent help. Our hearts go out to the victims and their loved ones, and our hats go off to those who rushed in to help—especially the dedicated law enforcement and medical personnel who saved many lives.

We respond as a nation and as individuals with great sadness and anger to an event like this. But are there lessons embedded in the sorrow for us as family physicians and primary care clinicians? I believe there are.

1. Ask yourself: Am I doing all I can to provide compassionate care? Although I think of myself as a caring, compassionate family physician who treats all patients equally, I realize that I must continue to educate myself about the culture and health needs of specific segments of my patient population to ensure that I provide truly excellent care. Traditionally, cultural sensitivity training has focused on knowledge of races, ethnicities, and cultures, but it must also include training about sexual orientation. Asking patients about their sexual orientation must be a routine part of the medical history.

Violence and discrimination, like chronic disease, seem to be permanent fixtures on the human landscape. What can we do to prevent and mitigate these evils?

One of the minority groups we know least about is transgender individuals, who have unique medical and psychological issues. It is tragically ironic that we had planned an article about caring for transgender patients—a group that experiences disproportionate discrimination and violence¹—for this issue of JFP long before the Orlando shooting. We still have much to learn about the most appropriate way of caring for transgender individuals because there has been so little research.

2. Treat gun violence like an infectious disease. Another lesson from the Orlando tragedy is to approach the issue of gun violence—which is always highly politicized and charged in this country—as a public health problem. One of the best examples of this approach in action is an organization called Cure Violence (cureviolence.org) led by Gary Slutkin, MD, a former Centers for Disease Control and Prevention infectious disease specialist and epidemiologist. The organization proposes that the best way to stop violence is by using the methods and strategies associated with disease control. The group claims to have made great strides in reducing violence in the communities in which it works by treating violence as an epidemic.

Violence and discrimination, like chronic disease, seem to be permanent fixtures on the human landscape. We all must do our small, but important, part as health professionals to prevent and mitigate these evils.

Gun violence, the LGBT community, and terrorism. Who would have imagined these 3 entities tragically colliding in Orlando last month, in the shadow of “the happiest place on earth”? The tragedy was all too real for the victims—mostly gay young Hispanic men—their families and friends, and all those who responded with urgent help. Our hearts go out to the victims and their loved ones, and our hats go off to those who rushed in to help—especially the dedicated law enforcement and medical personnel who saved many lives.

We respond as a nation and as individuals with great sadness and anger to an event like this. But are there lessons embedded in the sorrow for us as family physicians and primary care clinicians? I believe there are.

1. Ask yourself: Am I doing all I can to provide compassionate care? Although I think of myself as a caring, compassionate family physician who treats all patients equally, I realize that I must continue to educate myself about the culture and health needs of specific segments of my patient population to ensure that I provide truly excellent care. Traditionally, cultural sensitivity training has focused on knowledge of races, ethnicities, and cultures, but it must also include training about sexual orientation. Asking patients about their sexual orientation must be a routine part of the medical history.

Violence and discrimination, like chronic disease, seem to be permanent fixtures on the human landscape. What can we do to prevent and mitigate these evils?

One of the minority groups we know least about is transgender individuals, who have unique medical and psychological issues. It is tragically ironic that we had planned an article about caring for transgender patients—a group that experiences disproportionate discrimination and violence¹—for this issue of JFP long before the Orlando shooting. We still have much to learn about the most appropriate way of caring for transgender individuals because there has been so little research.

2. Treat gun violence like an infectious disease. Another lesson from the Orlando tragedy is to approach the issue of gun violence—which is always highly politicized and charged in this country—as a public health problem. One of the best examples of this approach in action is an organization called Cure Violence (cureviolence.org) led by Gary Slutkin, MD, a former Centers for Disease Control and Prevention infectious disease specialist and epidemiologist. The organization proposes that the best way to stop violence is by using the methods and strategies associated with disease control. The group claims to have made great strides in reducing violence in the communities in which it works by treating violence as an epidemic.

Violence and discrimination, like chronic disease, seem to be permanent fixtures on the human landscape. We all must do our small, but important, part as health professionals to prevent and mitigate these evils.

Gun violence, the LGBT community, and terrorism. Who would have imagined these 3 entities tragically colliding in Orlando last month, in the shadow of “the happiest place on earth”? The tragedy was all too real for the victims—mostly gay young Hispanic men—their families and friends, and all those who responded with urgent help. Our hearts go out to the victims and their loved ones, and our hats go off to those who rushed in to help—especially the dedicated law enforcement and medical personnel who saved many lives.

We respond as a nation and as individuals with great sadness and anger to an event like this. But are there lessons embedded in the sorrow for us as family physicians and primary care clinicians? I believe there are.

1. Ask yourself: Am I doing all I can to provide compassionate care? Although I think of myself as a caring, compassionate family physician who treats all patients equally, I realize that I must continue to educate myself about the culture and health needs of specific segments of my patient population to ensure that I provide truly excellent care. Traditionally, cultural sensitivity training has focused on knowledge of races, ethnicities, and cultures, but it must also include training about sexual orientation. Asking patients about their sexual orientation must be a routine part of the medical history.

Violence and discrimination, like chronic disease, seem to be permanent fixtures on the human landscape. What can we do to prevent and mitigate these evils?

One of the minority groups we know least about is transgender individuals, who have unique medical and psychological issues. It is tragically ironic that we had planned an article about caring for transgender patients—a group that experiences disproportionate discrimination and violence¹—for this issue of JFP long before the Orlando shooting. We still have much to learn about the most appropriate way of caring for transgender individuals because there has been so little research.

2. Treat gun violence like an infectious disease. Another lesson from the Orlando tragedy is to approach the issue of gun violence—which is always highly politicized and charged in this country—as a public health problem. One of the best examples of this approach in action is an organization called Cure Violence (cureviolence.org) led by Gary Slutkin, MD, a former Centers for Disease Control and Prevention infectious disease specialist and epidemiologist. The organization proposes that the best way to stop violence is by using the methods and strategies associated with disease control. The group claims to have made great strides in reducing violence in the communities in which it works by treating violence as an epidemic.

Violence and discrimination, like chronic disease, seem to be permanent fixtures on the human landscape. We all must do our small, but important, part as health professionals to prevent and mitigate these evils.

The Society for Vascular Surgery and the Division of Vascular and Endovascular Surgery at University of California Los Angeles have merged their board review programs, resulting in the First Annual UCLA/SVS Symposium: A Comprehensive Review and Update of What’s New in Vascular and Endovascular Surgery.”

The three-day course will be Aug. 27 to 29 at the Beverly Hilton in Beverly Hills, Calif.

This program will offer an in-depth review for those preparing to take the vascular board examinations as well as providing the basic didactic education for vascular residents and fellows in training.

For more information, visit vsweb.org/JointSymposium.

The Society for Vascular Surgery and the Division of Vascular and Endovascular Surgery at University of California Los Angeles have merged their board review programs, resulting in the First Annual UCLA/SVS Symposium: A Comprehensive Review and Update of What’s New in Vascular and Endovascular Surgery.”

The three-day course will be Aug. 27 to 29 at the Beverly Hilton in Beverly Hills, Calif.

This program will offer an in-depth review for those preparing to take the vascular board examinations as well as providing the basic didactic education for vascular residents and fellows in training.

For more information, visit vsweb.org/JointSymposium.

The Society for Vascular Surgery and the Division of Vascular and Endovascular Surgery at University of California Los Angeles have merged their board review programs, resulting in the First Annual UCLA/SVS Symposium: A Comprehensive Review and Update of What’s New in Vascular and Endovascular Surgery.”

The three-day course will be Aug. 27 to 29 at the Beverly Hilton in Beverly Hills, Calif.

This program will offer an in-depth review for those preparing to take the vascular board examinations as well as providing the basic didactic education for vascular residents and fellows in training.

For more information, visit vsweb.org/JointSymposium.

WASHINGTON – In 2015, the Florida Agency for Health Care Administration published clinical guidelines for numerous psychiatric conditions, including bipolar disorder, demoting several first-line therapies, and promoting others.

Because the authors of the Florida Best Practice Psychotherapeutic Medication Guidelines for Adults agreed that inflammation is a mechanism of action in bipolar disorder, they adopted an approach to care that seeks to avoid inflammation at all costs.

“Some medications create metabolic disturbances, which can be disruptive to the inflammatory milieu,” said Roger McIntyre, MD, a professor of psychiatry and pharmacology at the University of Toronto, and head of the Mood Disorders Psychopharmacology Unit at the University Health Network, Toronto. Dr. McIntyre, one of the coauthors of the guidelines, discussed why the combination of olanzapine and fluoxetine has been deferred in the algorithm, why other medications have moved further up, why antidepressants also are lower in the order of priority, and why psychoeducation, social rhythm therapy, and lifestyle changes have been emphasized more than ever before.

“There is no way our bipolar patients are going to achieve their goals with medication alone,” Dr. McIntyre said at the meeting, held by the Global Academy for Medical Education. In addition, Dr. McIntyre outlined why adding bipolar screening in the primary care setting is critical in 2016, and called the new recommendations “the most up-to-date guidelines for treating bipolar disorder, and the new nosology of major depression disorder with mixed features.”

To access the Florida Best Practice Psychotherapeutic Medication Guidelines for Adults online, visit the Florida Medicaid Drug Therapy Management Program for Behavioral Health website.

Dr. McIntyre has numerous industry relationships, including research funding from Eli Lilly, Janssen-Ortho, Astra-Zeneca; Pfizer, and Lundbeck. Global Academy and this news organization are owned by the same company.

[email protected]

On Twitter @whitneymcknight

WASHINGTON – In 2015, the Florida Agency for Health Care Administration published clinical guidelines for numerous psychiatric conditions, including bipolar disorder, demoting several first-line therapies, and promoting others.

Because the authors of the Florida Best Practice Psychotherapeutic Medication Guidelines for Adults agreed that inflammation is a mechanism of action in bipolar disorder, they adopted an approach to care that seeks to avoid inflammation at all costs.

“Some medications create metabolic disturbances, which can be disruptive to the inflammatory milieu,” said Roger McIntyre, MD, a professor of psychiatry and pharmacology at the University of Toronto, and head of the Mood Disorders Psychopharmacology Unit at the University Health Network, Toronto. Dr. McIntyre, one of the coauthors of the guidelines, discussed why the combination of olanzapine and fluoxetine has been deferred in the algorithm, why other medications have moved further up, why antidepressants also are lower in the order of priority, and why psychoeducation, social rhythm therapy, and lifestyle changes have been emphasized more than ever before.

“There is no way our bipolar patients are going to achieve their goals with medication alone,” Dr. McIntyre said at the meeting, held by the Global Academy for Medical Education. In addition, Dr. McIntyre outlined why adding bipolar screening in the primary care setting is critical in 2016, and called the new recommendations “the most up-to-date guidelines for treating bipolar disorder, and the new nosology of major depression disorder with mixed features.”

To access the Florida Best Practice Psychotherapeutic Medication Guidelines for Adults online, visit the Florida Medicaid Drug Therapy Management Program for Behavioral Health website.

Dr. McIntyre has numerous industry relationships, including research funding from Eli Lilly, Janssen-Ortho, Astra-Zeneca; Pfizer, and Lundbeck. Global Academy and this news organization are owned by the same company.

[email protected]

On Twitter @whitneymcknight

WASHINGTON – In 2015, the Florida Agency for Health Care Administration published clinical guidelines for numerous psychiatric conditions, including bipolar disorder, demoting several first-line therapies, and promoting others.

Because the authors of the Florida Best Practice Psychotherapeutic Medication Guidelines for Adults agreed that inflammation is a mechanism of action in bipolar disorder, they adopted an approach to care that seeks to avoid inflammation at all costs.

“Some medications create metabolic disturbances, which can be disruptive to the inflammatory milieu,” said Roger McIntyre, MD, a professor of psychiatry and pharmacology at the University of Toronto, and head of the Mood Disorders Psychopharmacology Unit at the University Health Network, Toronto. Dr. McIntyre, one of the coauthors of the guidelines, discussed why the combination of olanzapine and fluoxetine has been deferred in the algorithm, why other medications have moved further up, why antidepressants also are lower in the order of priority, and why psychoeducation, social rhythm therapy, and lifestyle changes have been emphasized more than ever before.

“There is no way our bipolar patients are going to achieve their goals with medication alone,” Dr. McIntyre said at the meeting, held by the Global Academy for Medical Education. In addition, Dr. McIntyre outlined why adding bipolar screening in the primary care setting is critical in 2016, and called the new recommendations “the most up-to-date guidelines for treating bipolar disorder, and the new nosology of major depression disorder with mixed features.”

To access the Florida Best Practice Psychotherapeutic Medication Guidelines for Adults online, visit the Florida Medicaid Drug Therapy Management Program for Behavioral Health website.

Dr. McIntyre has numerous industry relationships, including research funding from Eli Lilly, Janssen-Ortho, Astra-Zeneca; Pfizer, and Lundbeck. Global Academy and this news organization are owned by the same company.

[email protected]

On Twitter @whitneymcknight