Video

VANCOUVER – Sometimes in endometriosis, pain persists despite optimal treatment. Women have multiple lesion excisions, but the pain just doesn’t go away.

Evidence is building that in those cases, central sensitization – an amplified central nervous system pain response common in chronic pain syndromes – is playing a role.

In a video interview at the World Congress on Endometriosis, Katy Vincent, DPhil, MBBS, a senior pain fellow and consultant gynecologist at the University of Oxford, England, explained the latest thinking, as well as how to recognize and treat central sensitization in endometriosis. For some women, focusing on lesions isn’t enough.

aotto@frontlinemedcom.com

VANCOUVER – Sometimes in endometriosis, pain persists despite optimal treatment. Women have multiple lesion excisions, but the pain just doesn’t go away.

Evidence is building that in those cases, central sensitization – an amplified central nervous system pain response common in chronic pain syndromes – is playing a role.

In a video interview at the World Congress on Endometriosis, Katy Vincent, DPhil, MBBS, a senior pain fellow and consultant gynecologist at the University of Oxford, England, explained the latest thinking, as well as how to recognize and treat central sensitization in endometriosis. For some women, focusing on lesions isn’t enough.

aotto@frontlinemedcom.com

VANCOUVER – Sometimes in endometriosis, pain persists despite optimal treatment. Women have multiple lesion excisions, but the pain just doesn’t go away.

Evidence is building that in those cases, central sensitization – an amplified central nervous system pain response common in chronic pain syndromes – is playing a role.

In a video interview at the World Congress on Endometriosis, Katy Vincent, DPhil, MBBS, a senior pain fellow and consultant gynecologist at the University of Oxford, England, explained the latest thinking, as well as how to recognize and treat central sensitization in endometriosis. For some women, focusing on lesions isn’t enough.

aotto@frontlinemedcom.com

VANCOUVER – Although hysterectomy will never again be the go-to treatment for endometriosis that it once was, it has become clear in recent years that it still has a role to play.

In a video interview at the World Congress on Endometriosis, Ray Garry, MD, a recently retired professor of obstetrics and gynecology at the University of Western Australia, Perth, explained why – in a limited way – the pendulum is swinging back toward hysterectomy for a select group of women.

aotto@frontlinemedcom.com

VANCOUVER – Although hysterectomy will never again be the go-to treatment for endometriosis that it once was, it has become clear in recent years that it still has a role to play.

In a video interview at the World Congress on Endometriosis, Ray Garry, MD, a recently retired professor of obstetrics and gynecology at the University of Western Australia, Perth, explained why – in a limited way – the pendulum is swinging back toward hysterectomy for a select group of women.

aotto@frontlinemedcom.com

VANCOUVER – Although hysterectomy will never again be the go-to treatment for endometriosis that it once was, it has become clear in recent years that it still has a role to play.

In a video interview at the World Congress on Endometriosis, Ray Garry, MD, a recently retired professor of obstetrics and gynecology at the University of Western Australia, Perth, explained why – in a limited way – the pendulum is swinging back toward hysterectomy for a select group of women.

aotto@frontlinemedcom.com

BOSTON – High quality wedge resection results in higher survival for patients with early stage non–small cell lung cancer when compared with stereotactic body radiation therapy, according to new research.

The analysis, reported at the annual meeting of the American Association for Thoracic Surgery, evaluated the treatment of 7,337 patients in the National Cancer Database with clinical T1-T2, N0, M0 non–small cell lung cancer who were treated with either wedge resection or stereotactic body radiation therapy from 2005 to 2012.

In this video, Varun Puri, MD, of Washington University, St. Louis, discusses the study and the significance of the findings.

agallegos@frontlinemedcom.com

On Twitter @legal_med

BOSTON – High quality wedge resection results in higher survival for patients with early stage non–small cell lung cancer when compared with stereotactic body radiation therapy, according to new research.

The analysis, reported at the annual meeting of the American Association for Thoracic Surgery, evaluated the treatment of 7,337 patients in the National Cancer Database with clinical T1-T2, N0, M0 non–small cell lung cancer who were treated with either wedge resection or stereotactic body radiation therapy from 2005 to 2012.

In this video, Varun Puri, MD, of Washington University, St. Louis, discusses the study and the significance of the findings.

agallegos@frontlinemedcom.com

On Twitter @legal_med

BOSTON – High quality wedge resection results in higher survival for patients with early stage non–small cell lung cancer when compared with stereotactic body radiation therapy, according to new research.

The analysis, reported at the annual meeting of the American Association for Thoracic Surgery, evaluated the treatment of 7,337 patients in the National Cancer Database with clinical T1-T2, N0, M0 non–small cell lung cancer who were treated with either wedge resection or stereotactic body radiation therapy from 2005 to 2012.

In this video, Varun Puri, MD, of Washington University, St. Louis, discusses the study and the significance of the findings.

agallegos@frontlinemedcom.com

On Twitter @legal_med

BOSTON – Data show a marked bias in referral patterns for coronary revascularization in stand-alone interventional cardiology units lacking a heart team.

More patients underwent percutaneous coronary intervention (PCI) in hospitals without on-site cardiac surgery than patients at hospitals with on-site cardiac surgery, according to the analysis presented at the annual meeting of the American Association for Thoracic Surgery. The multivariate logistic regression analysis showed that the absence of on-site cardiac surgery and a heart team was an independent predictor for PCI.

In this video, Ehud Raanani, MD, of Tel Aviv University in Israel discusses referral patterns for coronary revascularization in stand-alone interventional cardiology units lacking a heart team and how this phenomenon could affect patients.

agallegos@frontlinemedcom.com

On Twitter @legal_med

BOSTON – Data show a marked bias in referral patterns for coronary revascularization in stand-alone interventional cardiology units lacking a heart team.

More patients underwent percutaneous coronary intervention (PCI) in hospitals without on-site cardiac surgery than patients at hospitals with on-site cardiac surgery, according to the analysis presented at the annual meeting of the American Association for Thoracic Surgery. The multivariate logistic regression analysis showed that the absence of on-site cardiac surgery and a heart team was an independent predictor for PCI.

In this video, Ehud Raanani, MD, of Tel Aviv University in Israel discusses referral patterns for coronary revascularization in stand-alone interventional cardiology units lacking a heart team and how this phenomenon could affect patients.

agallegos@frontlinemedcom.com

On Twitter @legal_med

BOSTON – Data show a marked bias in referral patterns for coronary revascularization in stand-alone interventional cardiology units lacking a heart team.

More patients underwent percutaneous coronary intervention (PCI) in hospitals without on-site cardiac surgery than patients at hospitals with on-site cardiac surgery, according to the analysis presented at the annual meeting of the American Association for Thoracic Surgery. The multivariate logistic regression analysis showed that the absence of on-site cardiac surgery and a heart team was an independent predictor for PCI.

In this video, Ehud Raanani, MD, of Tel Aviv University in Israel discusses referral patterns for coronary revascularization in stand-alone interventional cardiology units lacking a heart team and how this phenomenon could affect patients.

agallegos@frontlinemedcom.com

On Twitter @legal_med

BOSTON – Individual surgeon case volume is a significant factor in degenerative mitral valve repair rates and overall patient survival, according to a study presented at the annual meeting of the American Association for Thoracic Surgery.

The analysis, which reviewed the outcomes of 38,128 adult patients, found that higher surgeon volume of mitral cases is associated with better degenerative mitral repair rates and higher survival. In this video, Ralph Damiano Jr., MD, of Washington University, St. Louis, discusses the threshold of mitral cases that led to better repair rates and how further cardiac surgical subspecialization could improve outcomes in patients with degenerative mitral disease.

allegros@frontlinemedcom.com

On Twitter @legal_med

BOSTON – Individual surgeon case volume is a significant factor in degenerative mitral valve repair rates and overall patient survival, according to a study presented at the annual meeting of the American Association for Thoracic Surgery.

The analysis, which reviewed the outcomes of 38,128 adult patients, found that higher surgeon volume of mitral cases is associated with better degenerative mitral repair rates and higher survival. In this video, Ralph Damiano Jr., MD, of Washington University, St. Louis, discusses the threshold of mitral cases that led to better repair rates and how further cardiac surgical subspecialization could improve outcomes in patients with degenerative mitral disease.

allegros@frontlinemedcom.com

On Twitter @legal_med

BOSTON – Individual surgeon case volume is a significant factor in degenerative mitral valve repair rates and overall patient survival, according to a study presented at the annual meeting of the American Association for Thoracic Surgery.

The analysis, which reviewed the outcomes of 38,128 adult patients, found that higher surgeon volume of mitral cases is associated with better degenerative mitral repair rates and higher survival. In this video, Ralph Damiano Jr., MD, of Washington University, St. Louis, discusses the threshold of mitral cases that led to better repair rates and how further cardiac surgical subspecialization could improve outcomes in patients with degenerative mitral disease.

allegros@frontlinemedcom.com

On Twitter @legal_med

VANCOUVER – Ongoing pregnancies and live births were substantially higher when oil-based contrast, instead of water-based contrast, was used for hysterosalpingography (HSG) in a randomized trial at 27 hospitals in the Netherlands.

It’s long been known that HSG, commonly used to assess reproductive tract patency, also improves fertility, perhaps by immunologic effects or simply by flushing debris and mucus out of the fallopian tubes. Until now, however, it’s been unclear if oil or water contrast boosts fertility the most.

To find out, investigators randomized 554 infertile women scheduled for HSG to poppy seed oil contrast (Lipiodol Ultra-Fluid, Guerbet) and 554 others to water contrast (Telebrix Hystero, Guerbet).

A total of 220 women in the oil group (39.7%), but 161 in the water group (29.1%), achieved ongoing pregnancies (rate ratio in favor of oil, 1.37; 95% CI, 1.16-1.61; P less than 0.001). Of 552 women in each of the groups, 214 in the oil group (38.8%) and 155 in the water group (28.1%) had live births (RR, 1.38; 95% CI, 1.17-1.64; P less than 0.001). Rates of adverse events were low and similar in the two groups. About three-quarters of the pregnancies were naturally conceived, and most of the rest resulted from intrauterine insemination. Only a few women in each group used in vitro fertilization (N Engl J Med. 2017 May 18. doi: 10.1056/NEJMoa1612337).

Three women in the oil group, but none in the water group, delivered a child with a congenital anomaly. “This finding is probably due to chance. The frequency of congenital anomalies with oil contrast was not greater than rates reported in the general population, and we are unaware of other data suggesting an increased risk of congenital anomalies with oil contrast,” the researchers said.

In an interview at the World Congress on Endometriosis, senior investigator Ben Mol, MD, PhD, a professor of obstetrics and gynecology at the University of Adelaide (Australia), shared his thoughts on how the new findings should be used in routine practice when women with endometriosis and other conditions experience difficulty conceiving.

There was no industry funding for the work. Dr. Mol reported personal fees from Guerbet unrelated to the study.

aotto@frontlinemedcom.com

VANCOUVER – Ongoing pregnancies and live births were substantially higher when oil-based contrast, instead of water-based contrast, was used for hysterosalpingography (HSG) in a randomized trial at 27 hospitals in the Netherlands.

It’s long been known that HSG, commonly used to assess reproductive tract patency, also improves fertility, perhaps by immunologic effects or simply by flushing debris and mucus out of the fallopian tubes. Until now, however, it’s been unclear if oil or water contrast boosts fertility the most.

To find out, investigators randomized 554 infertile women scheduled for HSG to poppy seed oil contrast (Lipiodol Ultra-Fluid, Guerbet) and 554 others to water contrast (Telebrix Hystero, Guerbet).

A total of 220 women in the oil group (39.7%), but 161 in the water group (29.1%), achieved ongoing pregnancies (rate ratio in favor of oil, 1.37; 95% CI, 1.16-1.61; P less than 0.001). Of 552 women in each of the groups, 214 in the oil group (38.8%) and 155 in the water group (28.1%) had live births (RR, 1.38; 95% CI, 1.17-1.64; P less than 0.001). Rates of adverse events were low and similar in the two groups. About three-quarters of the pregnancies were naturally conceived, and most of the rest resulted from intrauterine insemination. Only a few women in each group used in vitro fertilization (N Engl J Med. 2017 May 18. doi: 10.1056/NEJMoa1612337).

Three women in the oil group, but none in the water group, delivered a child with a congenital anomaly. “This finding is probably due to chance. The frequency of congenital anomalies with oil contrast was not greater than rates reported in the general population, and we are unaware of other data suggesting an increased risk of congenital anomalies with oil contrast,” the researchers said.

In an interview at the World Congress on Endometriosis, senior investigator Ben Mol, MD, PhD, a professor of obstetrics and gynecology at the University of Adelaide (Australia), shared his thoughts on how the new findings should be used in routine practice when women with endometriosis and other conditions experience difficulty conceiving.

There was no industry funding for the work. Dr. Mol reported personal fees from Guerbet unrelated to the study.

aotto@frontlinemedcom.com

VANCOUVER – Ongoing pregnancies and live births were substantially higher when oil-based contrast, instead of water-based contrast, was used for hysterosalpingography (HSG) in a randomized trial at 27 hospitals in the Netherlands.

It’s long been known that HSG, commonly used to assess reproductive tract patency, also improves fertility, perhaps by immunologic effects or simply by flushing debris and mucus out of the fallopian tubes. Until now, however, it’s been unclear if oil or water contrast boosts fertility the most.

To find out, investigators randomized 554 infertile women scheduled for HSG to poppy seed oil contrast (Lipiodol Ultra-Fluid, Guerbet) and 554 others to water contrast (Telebrix Hystero, Guerbet).

A total of 220 women in the oil group (39.7%), but 161 in the water group (29.1%), achieved ongoing pregnancies (rate ratio in favor of oil, 1.37; 95% CI, 1.16-1.61; P less than 0.001). Of 552 women in each of the groups, 214 in the oil group (38.8%) and 155 in the water group (28.1%) had live births (RR, 1.38; 95% CI, 1.17-1.64; P less than 0.001). Rates of adverse events were low and similar in the two groups. About three-quarters of the pregnancies were naturally conceived, and most of the rest resulted from intrauterine insemination. Only a few women in each group used in vitro fertilization (N Engl J Med. 2017 May 18. doi: 10.1056/NEJMoa1612337).

Three women in the oil group, but none in the water group, delivered a child with a congenital anomaly. “This finding is probably due to chance. The frequency of congenital anomalies with oil contrast was not greater than rates reported in the general population, and we are unaware of other data suggesting an increased risk of congenital anomalies with oil contrast,” the researchers said.

In an interview at the World Congress on Endometriosis, senior investigator Ben Mol, MD, PhD, a professor of obstetrics and gynecology at the University of Adelaide (Australia), shared his thoughts on how the new findings should be used in routine practice when women with endometriosis and other conditions experience difficulty conceiving.

There was no industry funding for the work. Dr. Mol reported personal fees from Guerbet unrelated to the study.

aotto@frontlinemedcom.com

WASHINGTON – A new oral drug that blocks a nerve ion channel was generally tolerable and effective at reducing chronic, refractory cough in a placebo-controlled, dose-ranging, phase II study with 252 patients.

A 50 mg b.i.d dosage of MK-7264 cut cough frequency by at least 30% in 80% of patients, compared with 44% of patients on placebo, Jaclyn A. Smith, MD, said at an international conference of the American Thoracic Society.

At that dosage, 48% of patients reported some change in their taste sensations, an expected drug effect, with about 40% characterizing it as very bothersome or extremely bothersome. An additional 9% reported a complete loss of taste. However, only 6 patients out of 63 randomized to this dosage stopped taking their medication, suggesting that the drug was tolerable for most patients. The results also suggested that lower dosages with less potent taste adverse effects produced significant cough reductions in some patients.

“Patients with chronic, refractory cough are often “willing to accept some taste change to reduce their cough count. Patients are willing to put up with the taste side effects,” Dr. Smith said in a video interview.

The study enrolled patients with chronic, refractory cough at U.S. and UK centers and randomized 63 to each of three active treatment arms receiving 7.5 mg, 20 mg, or 50 mg b.i.d. of MK-7264 or to placebo for 12 weeks. The patients averaged 60 years of age and about three-quarters were women. On average, they had their cough for more than 10 years, and these patients coughed roughly 30 times an hour when awake.

The study’s primary endpoint was reduction in awake cough frequency, and, after 12 weeks on treatment with 50 mg b.i.d., this had fallen an average of 37%, compared with placebo, said Dr. Smith, a professor of respiratory medicine at the University of Manchester, England.

The 7.5-mg and 20-mg b.i.d. dosages each led to cough frequency reductions of about 22% over placebo that were not statistically significant. This was likely a result of the unexpectedly strong placebo effect in the study, Dr. Smith said. Most of the cough effect was evident after the first 4 weeks on treatment.

Dr. Smith noted that she and her associates “most definitely” plan to progress to a phase III trial. “We really lack effective treatments for cough,” she said.

The study was sponsored by Merck, the company developing MK-7264. Dr. Smith is a consultant to Merck and has a licensing agreement with Vitalograph.

mzoler@frontlinemedcom.com

On Twitter @mitchelzoler

WASHINGTON – A new oral drug that blocks a nerve ion channel was generally tolerable and effective at reducing chronic, refractory cough in a placebo-controlled, dose-ranging, phase II study with 252 patients.

A 50 mg b.i.d dosage of MK-7264 cut cough frequency by at least 30% in 80% of patients, compared with 44% of patients on placebo, Jaclyn A. Smith, MD, said at an international conference of the American Thoracic Society.

At that dosage, 48% of patients reported some change in their taste sensations, an expected drug effect, with about 40% characterizing it as very bothersome or extremely bothersome. An additional 9% reported a complete loss of taste. However, only 6 patients out of 63 randomized to this dosage stopped taking their medication, suggesting that the drug was tolerable for most patients. The results also suggested that lower dosages with less potent taste adverse effects produced significant cough reductions in some patients.

“Patients with chronic, refractory cough are often “willing to accept some taste change to reduce their cough count. Patients are willing to put up with the taste side effects,” Dr. Smith said in a video interview.

The study enrolled patients with chronic, refractory cough at U.S. and UK centers and randomized 63 to each of three active treatment arms receiving 7.5 mg, 20 mg, or 50 mg b.i.d. of MK-7264 or to placebo for 12 weeks. The patients averaged 60 years of age and about three-quarters were women. On average, they had their cough for more than 10 years, and these patients coughed roughly 30 times an hour when awake.

The study’s primary endpoint was reduction in awake cough frequency, and, after 12 weeks on treatment with 50 mg b.i.d., this had fallen an average of 37%, compared with placebo, said Dr. Smith, a professor of respiratory medicine at the University of Manchester, England.

The 7.5-mg and 20-mg b.i.d. dosages each led to cough frequency reductions of about 22% over placebo that were not statistically significant. This was likely a result of the unexpectedly strong placebo effect in the study, Dr. Smith said. Most of the cough effect was evident after the first 4 weeks on treatment.

Dr. Smith noted that she and her associates “most definitely” plan to progress to a phase III trial. “We really lack effective treatments for cough,” she said.

The study was sponsored by Merck, the company developing MK-7264. Dr. Smith is a consultant to Merck and has a licensing agreement with Vitalograph.

mzoler@frontlinemedcom.com

On Twitter @mitchelzoler

WASHINGTON – A new oral drug that blocks a nerve ion channel was generally tolerable and effective at reducing chronic, refractory cough in a placebo-controlled, dose-ranging, phase II study with 252 patients.

A 50 mg b.i.d dosage of MK-7264 cut cough frequency by at least 30% in 80% of patients, compared with 44% of patients on placebo, Jaclyn A. Smith, MD, said at an international conference of the American Thoracic Society.

At that dosage, 48% of patients reported some change in their taste sensations, an expected drug effect, with about 40% characterizing it as very bothersome or extremely bothersome. An additional 9% reported a complete loss of taste. However, only 6 patients out of 63 randomized to this dosage stopped taking their medication, suggesting that the drug was tolerable for most patients. The results also suggested that lower dosages with less potent taste adverse effects produced significant cough reductions in some patients.

“Patients with chronic, refractory cough are often “willing to accept some taste change to reduce their cough count. Patients are willing to put up with the taste side effects,” Dr. Smith said in a video interview.

The study enrolled patients with chronic, refractory cough at U.S. and UK centers and randomized 63 to each of three active treatment arms receiving 7.5 mg, 20 mg, or 50 mg b.i.d. of MK-7264 or to placebo for 12 weeks. The patients averaged 60 years of age and about three-quarters were women. On average, they had their cough for more than 10 years, and these patients coughed roughly 30 times an hour when awake.

The study’s primary endpoint was reduction in awake cough frequency, and, after 12 weeks on treatment with 50 mg b.i.d., this had fallen an average of 37%, compared with placebo, said Dr. Smith, a professor of respiratory medicine at the University of Manchester, England.

The 7.5-mg and 20-mg b.i.d. dosages each led to cough frequency reductions of about 22% over placebo that were not statistically significant. This was likely a result of the unexpectedly strong placebo effect in the study, Dr. Smith said. Most of the cough effect was evident after the first 4 weeks on treatment.

Dr. Smith noted that she and her associates “most definitely” plan to progress to a phase III trial. “We really lack effective treatments for cough,” she said.

The study was sponsored by Merck, the company developing MK-7264. Dr. Smith is a consultant to Merck and has a licensing agreement with Vitalograph.

mzoler@frontlinemedcom.com

On Twitter @mitchelzoler

BOSTON – A new study highlights the success, safety, and effectiveness of a new sutureless aortic valve device in patients with severe symptomatic aortic valve stenosis (AS).

The findings, reported at the annual meeting of the American Association for Thoracic Surgery, were based on a prospective, single-arm clinical trial approved under a Food and Drug Administration Investigational Device Exemption (IDE) that aimed to assess the safety and efficacy of a new bovine pericardial sutureless aortic valve in patients with severe AS undergoing aortic valve replacement with or without concomitant procedures. In this video interview, Michael Borger, MD, explains how the study was conducted and what the findings mean for future use of the sutureless aortic valve device.

agallegos@frontlinemedcom.com

On Twitter @legal_med

BOSTON – A new study highlights the success, safety, and effectiveness of a new sutureless aortic valve device in patients with severe symptomatic aortic valve stenosis (AS).

The findings, reported at the annual meeting of the American Association for Thoracic Surgery, were based on a prospective, single-arm clinical trial approved under a Food and Drug Administration Investigational Device Exemption (IDE) that aimed to assess the safety and efficacy of a new bovine pericardial sutureless aortic valve in patients with severe AS undergoing aortic valve replacement with or without concomitant procedures. In this video interview, Michael Borger, MD, explains how the study was conducted and what the findings mean for future use of the sutureless aortic valve device.

agallegos@frontlinemedcom.com

On Twitter @legal_med

BOSTON – A new study highlights the success, safety, and effectiveness of a new sutureless aortic valve device in patients with severe symptomatic aortic valve stenosis (AS).

The findings, reported at the annual meeting of the American Association for Thoracic Surgery, were based on a prospective, single-arm clinical trial approved under a Food and Drug Administration Investigational Device Exemption (IDE) that aimed to assess the safety and efficacy of a new bovine pericardial sutureless aortic valve in patients with severe AS undergoing aortic valve replacement with or without concomitant procedures. In this video interview, Michael Borger, MD, explains how the study was conducted and what the findings mean for future use of the sutureless aortic valve device.

agallegos@frontlinemedcom.com

On Twitter @legal_med

BOSTON – U.S. physicians chose to withdraw life-sustaining care from critically ill ischemic stroke patients at much higher rates in 2011 than in 2006, according to results of a new study, although overall percentages remain low.

The trend was bolstered by big jumps in “withdrawal of care” among patients who underwent thrombolysis or both thrombolysis and endovascular treatment: Over the 5-year period, their likelihood of having care withdrawn increased fivefold.

The study authors don’t know whether the trends have continued over the past 6 years, and it’s not clear why the rates rose so much from 2006 to 2011. The researchers speculate that the increase could be linked to disease severity and the preferences of patients and their families.

Whatever the case, study lead author Malik Muhammad Adil, MD, a neurology resident at the Ochsner Clinic Foundation in New Orleans, cautioned that prematurely withdrawing care can throw off stroke prognostication estimates that are already fuzzy. In an interview, he said this can then lead to “significant consequences, including suboptimal outcomes and higher risk of short-term mortality.”

Dr. Adil defines withdrawal of care as “discontinuation of life-sustaining interventions from a patient who is expected to die without this support.” These interventions include such treatments as intubation, mechanical ventilation, feeding tubes, antibiotics, and brain surgery, he said.

For the new study, researchers examined the Nationwide Inpatient Survey database for the years 2006-2011. They reported their findings at the annual meeting of the American Academy of Neurology.

The study reports the following regarding withdrawal of care among ischemic stroke patients:

• The rate grew in those who received neither thrombolysis nor endovascular treatment from 0.8% in 2006 to 3.0% in 2011 (P less than or equal to .0001).
• In those who received thrombolysis alone, the rate rose from 0.9% to 5.5% (P less than or equal to .0001).
• In those who received endovascular treatment alone, the rate increased from 2.8% to 9.0% (P = .0006).
• In patients who received both thrombolysis and endovascular treatment, the rate grew from 2.0% to 10.3% (P = .0009).

Dr. Adil said several factors can affect rates of withdrawal of care in ischemic stroke patients, such as the level of illness (patients receiving aggressive treatment are sicker), advance directives, and the decisions of family members. Some institutions may be more likely to push for withdrawal of care, too, he said. “At my institution, we are not aggressive with withdrawal of care, and I have seen a few better outcomes than expected,” he said.

Also, the lack of useful data regarding prognosis for these patients may lead to premature decisions regarding withdrawal of care, he said.

“We have few prognostic models/scores that predict mortality, and these models are not very sensitive and specific,” Dr. Adil said. “Often, physicians make these decisions based on their previous experiences. All of this leads to premature withdrawal of care. On the other hand, because of premature withdrawal of care, we do not have the data on long-term outcomes on these patients, leading to errors in prognostication.”

In an interview, Adam G. Kelly, MD, a neurologist at the University of Rochester (N.Y.) and chief of neurology at Highland Hospital in Rochester, said the study is important but lacks crucial information such as the circumstances surrounding the care decisions. He hasn’t noticed trends in withdrawal of care among his patients.

“It’s possible that providers have become better at documenting discussions with patients and families which allowed this information to be better captured,” he said. “As the authors mention, it’s also possible that providers are consciously or unconsciously delivering prognoses that are biased towards negative outcomes, leading patients and families to be more apt to choose a palliative approach.”

Dr. Kelly added that neurologists need to objectively offer prognoses in stroke cases. “When the outcome is in doubt, I recommend time-limited trials of interventions of mechanical ventilation, artificial feeding, and other high-intensity interventions to allow patients and families to make the decision they feel is best,” he said.

What about trends in the years since 2011? Dr. Adil said information regarding the years since 2011 wasn’t available to him, but he hopes to analyze the period from 2012 to 2016.

Dr. Adil discussed his study and its implications in a video interview.

No funding is reported. Dr. Adil reports no relevant disclosures.

cnnews@frontlinemedcom.com

BOSTON – U.S. physicians chose to withdraw life-sustaining care from critically ill ischemic stroke patients at much higher rates in 2011 than in 2006, according to results of a new study, although overall percentages remain low.

The trend was bolstered by big jumps in “withdrawal of care” among patients who underwent thrombolysis or both thrombolysis and endovascular treatment: Over the 5-year period, their likelihood of having care withdrawn increased fivefold.

The study authors don’t know whether the trends have continued over the past 6 years, and it’s not clear why the rates rose so much from 2006 to 2011. The researchers speculate that the increase could be linked to disease severity and the preferences of patients and their families.

Whatever the case, study lead author Malik Muhammad Adil, MD, a neurology resident at the Ochsner Clinic Foundation in New Orleans, cautioned that prematurely withdrawing care can throw off stroke prognostication estimates that are already fuzzy. In an interview, he said this can then lead to “significant consequences, including suboptimal outcomes and higher risk of short-term mortality.”

Dr. Adil defines withdrawal of care as “discontinuation of life-sustaining interventions from a patient who is expected to die without this support.” These interventions include such treatments as intubation, mechanical ventilation, feeding tubes, antibiotics, and brain surgery, he said.

For the new study, researchers examined the Nationwide Inpatient Survey database for the years 2006-2011. They reported their findings at the annual meeting of the American Academy of Neurology.

The study reports the following regarding withdrawal of care among ischemic stroke patients:

• The rate grew in those who received neither thrombolysis nor endovascular treatment from 0.8% in 2006 to 3.0% in 2011 (P less than or equal to .0001).
• In those who received thrombolysis alone, the rate rose from 0.9% to 5.5% (P less than or equal to .0001).
• In those who received endovascular treatment alone, the rate increased from 2.8% to 9.0% (P = .0006).
• In patients who received both thrombolysis and endovascular treatment, the rate grew from 2.0% to 10.3% (P = .0009).

Dr. Adil said several factors can affect rates of withdrawal of care in ischemic stroke patients, such as the level of illness (patients receiving aggressive treatment are sicker), advance directives, and the decisions of family members. Some institutions may be more likely to push for withdrawal of care, too, he said. “At my institution, we are not aggressive with withdrawal of care, and I have seen a few better outcomes than expected,” he said.

Also, the lack of useful data regarding prognosis for these patients may lead to premature decisions regarding withdrawal of care, he said.

“We have few prognostic models/scores that predict mortality, and these models are not very sensitive and specific,” Dr. Adil said. “Often, physicians make these decisions based on their previous experiences. All of this leads to premature withdrawal of care. On the other hand, because of premature withdrawal of care, we do not have the data on long-term outcomes on these patients, leading to errors in prognostication.”

In an interview, Adam G. Kelly, MD, a neurologist at the University of Rochester (N.Y.) and chief of neurology at Highland Hospital in Rochester, said the study is important but lacks crucial information such as the circumstances surrounding the care decisions. He hasn’t noticed trends in withdrawal of care among his patients.

“It’s possible that providers have become better at documenting discussions with patients and families which allowed this information to be better captured,” he said. “As the authors mention, it’s also possible that providers are consciously or unconsciously delivering prognoses that are biased towards negative outcomes, leading patients and families to be more apt to choose a palliative approach.”

Dr. Kelly added that neurologists need to objectively offer prognoses in stroke cases. “When the outcome is in doubt, I recommend time-limited trials of interventions of mechanical ventilation, artificial feeding, and other high-intensity interventions to allow patients and families to make the decision they feel is best,” he said.

What about trends in the years since 2011? Dr. Adil said information regarding the years since 2011 wasn’t available to him, but he hopes to analyze the period from 2012 to 2016.

Dr. Adil discussed his study and its implications in a video interview.

No funding is reported. Dr. Adil reports no relevant disclosures.

cnnews@frontlinemedcom.com

BOSTON – U.S. physicians chose to withdraw life-sustaining care from critically ill ischemic stroke patients at much higher rates in 2011 than in 2006, according to results of a new study, although overall percentages remain low.

The trend was bolstered by big jumps in “withdrawal of care” among patients who underwent thrombolysis or both thrombolysis and endovascular treatment: Over the 5-year period, their likelihood of having care withdrawn increased fivefold.

The study authors don’t know whether the trends have continued over the past 6 years, and it’s not clear why the rates rose so much from 2006 to 2011. The researchers speculate that the increase could be linked to disease severity and the preferences of patients and their families.

Whatever the case, study lead author Malik Muhammad Adil, MD, a neurology resident at the Ochsner Clinic Foundation in New Orleans, cautioned that prematurely withdrawing care can throw off stroke prognostication estimates that are already fuzzy. In an interview, he said this can then lead to “significant consequences, including suboptimal outcomes and higher risk of short-term mortality.”

Dr. Adil defines withdrawal of care as “discontinuation of life-sustaining interventions from a patient who is expected to die without this support.” These interventions include such treatments as intubation, mechanical ventilation, feeding tubes, antibiotics, and brain surgery, he said.

For the new study, researchers examined the Nationwide Inpatient Survey database for the years 2006-2011. They reported their findings at the annual meeting of the American Academy of Neurology.

The study reports the following regarding withdrawal of care among ischemic stroke patients:

• The rate grew in those who received neither thrombolysis nor endovascular treatment from 0.8% in 2006 to 3.0% in 2011 (P less than or equal to .0001).
• In those who received thrombolysis alone, the rate rose from 0.9% to 5.5% (P less than or equal to .0001).
• In those who received endovascular treatment alone, the rate increased from 2.8% to 9.0% (P = .0006).
• In patients who received both thrombolysis and endovascular treatment, the rate grew from 2.0% to 10.3% (P = .0009).

Dr. Adil said several factors can affect rates of withdrawal of care in ischemic stroke patients, such as the level of illness (patients receiving aggressive treatment are sicker), advance directives, and the decisions of family members. Some institutions may be more likely to push for withdrawal of care, too, he said. “At my institution, we are not aggressive with withdrawal of care, and I have seen a few better outcomes than expected,” he said.

Also, the lack of useful data regarding prognosis for these patients may lead to premature decisions regarding withdrawal of care, he said.

“We have few prognostic models/scores that predict mortality, and these models are not very sensitive and specific,” Dr. Adil said. “Often, physicians make these decisions based on their previous experiences. All of this leads to premature withdrawal of care. On the other hand, because of premature withdrawal of care, we do not have the data on long-term outcomes on these patients, leading to errors in prognostication.”

In an interview, Adam G. Kelly, MD, a neurologist at the University of Rochester (N.Y.) and chief of neurology at Highland Hospital in Rochester, said the study is important but lacks crucial information such as the circumstances surrounding the care decisions. He hasn’t noticed trends in withdrawal of care among his patients.

“It’s possible that providers have become better at documenting discussions with patients and families which allowed this information to be better captured,” he said. “As the authors mention, it’s also possible that providers are consciously or unconsciously delivering prognoses that are biased towards negative outcomes, leading patients and families to be more apt to choose a palliative approach.”

Dr. Kelly added that neurologists need to objectively offer prognoses in stroke cases. “When the outcome is in doubt, I recommend time-limited trials of interventions of mechanical ventilation, artificial feeding, and other high-intensity interventions to allow patients and families to make the decision they feel is best,” he said.

What about trends in the years since 2011? Dr. Adil said information regarding the years since 2011 wasn’t available to him, but he hopes to analyze the period from 2012 to 2016.

Dr. Adil discussed his study and its implications in a video interview.

No funding is reported. Dr. Adil reports no relevant disclosures.

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