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Different OSA subtypes respond differently to therapy
Patients with obstructive sleep apnea can be grouped into distinct clinical subtypes that differ in response to positive airway pressure treatment, according to two studies published in the March issue of the journal Sleep.
In the first study, investigators evaluated whether patients in different clinical clusters responded differently to positive airway pressure (PAP) treatment. Authors identified 706 patients with moderate to severe obstructive sleep apnea (OSA) from the Icelandic Sleep Apnea Cohort. All patients completed a sleep study prior to starting PAP treatment, and completed questionnaires to assess symptoms. Patients were grouped into one of three clusters based on symptomatology: disturbed sleep, minimally symptomatic, or sleepy, wrote Grace W. Pien, MD, of the division of pulmonary and critical care medicine at Johns Hopkins University, Baltimore, and her coauthors.
Patients in the minimally symptomatic cluster reported symptoms at lower rates than patients in the other clusters at baseline, and they remained relatively asymptomatic at follow-up, the authors noted. By comparison, patients in the sleepy group reported the highest Epworth Sleepiness Scale scores at baseline (16.0 plus or minus 3.4), which fell by five points at follow-up (mean change, −5.3; 95% confidence interval, −5.8 to −4.8). Also, patients in the sleepy group reported higher rates of drowsy driving (37.8%) at baseline, which dropped to 8.1% at follow-up (odds ratio, 0.06; 95% CI, 0.03-0.14).
At baseline, the disturbed-sleep group reported mainly insomnia-related symptoms, including difficulty falling asleep (43.2%), waking often at night (90.8%), restless sleep (74.2%), and waking up early (62.3%). At follow-up, improvements in the frequency of insomnia-related symptoms ranged from 0.28 to 1.25 points, and Epworth Sleepiness Scale scores fell significantly (−2.06; 95% CI, −2.64 to −1.48). Reductions in the proportion of patients with insomnia symptoms ranged from 13.1% (OR, 0.35; 95% CI, 0.20-0.59) for difficulty falling asleep to 39.0% (OR, 0.08; 95% CI, 0.04-0.14) for restless sleep, Dr. Pien and her colleagues reported.
The results “demonstrate that although symptoms improved overall among each of the three clinical phenotypes of moderate to severe OSA, patterns of treatment response … varied based on initial clinical presentation,” the authors wrote. “Our findings underscore the need to consider initial OSA phenotype when designing future trials.”
In the second study, also published in Sleep, investigators confirmed the three clinical OSA subtypes previously identified in the Icelandic Sleep Apnea Cohort. In analysis of an international sample, they also expanded these clusters to include two additional disease subtypes. One of these subtypes consisted of patients with symptoms dominated by indications of upper airway obstruction. The other new subtype, sleepiness dominant OSA, included patients who had excessive sleepiness but no symptoms of upper airway obstruction.
The study authors performed a cluster analysis using data from 972 patients from the Sleep Apnea Global Interdisciplinary Consortium with moderate to severe OSA, with 215 of these patients being from Iceland.
In total, 688 (70.8%) patients were diagnosed using laboratory-based polysomnography and 284 (29.2%) with home-based sleep studies. Patients completed questionnaires related to symptoms including sleepiness, insomnia, sleep disturbance, abnormal behaviors during sleep, upper airway symptoms, and other symptoms such as headaches and excessive sweating, wrote Brendan T. Keenan, of the University of Pennsylvania, Philadelphia, and his coauthors.
In the Icelandic group, results identified 72 (33.5%) patients in the disturbed-sleep cluster, 62 (28.8%) in the minimally symptomatic cluster, and 81 (37.7%) in the excessively sleepy cluster, similar to prior research. The three subtypes were found in the international sample of patients as well, with 150 (19.8%) in the disturbed-sleep cluster, 306 (40.4%) in the minimally symptomatic cluster, and 301 (39.8%) in the excessively sleepy cluster.
“Overall, this study provides a novel approach to better characterize patients with OSA presenting at sleep clinics worldwide,” wrote the authors of the second study. “This information can help inform personalized medicine approaches to OSA treatment by allowing clinicians to focus interventions on the most relevant OSA symptoms and consequences within an individual patient.”
Both studies were funded by the National Institutes of Health.
SOURCES: Pien GW et al. Sleep. 2018 Mar. doi: 10.1093/sleep/zsx201; Keenan BT et al. Sleep. 2018 Mar. doi: 10.1093/sleep/zsx214.
The results of these studies “advance the personalization of sleep apnea care by validating distinct symptom-based groups that generalize across nations and assessing how members of these clinical phenotypes respond to therapy,” wrote Vishesh K. Kapur, MD, of the division of pulmonary, critical care and sleep medicine at the University of Washington, Seattle, in an editorial published in the March issue of Sleep (2018 Mar. doi: 10.1093/sleep/zsy042).
“Patients with OSA differ in their presenting symptoms,” he said, and future studies should aim to “elucidate whether the proposed phenotypes will enable a more personalized paradigm of sleep apnea care that results in better tailored and more effective care.”
Dr. Kapur did not report any relevant disclosures.
The results of these studies “advance the personalization of sleep apnea care by validating distinct symptom-based groups that generalize across nations and assessing how members of these clinical phenotypes respond to therapy,” wrote Vishesh K. Kapur, MD, of the division of pulmonary, critical care and sleep medicine at the University of Washington, Seattle, in an editorial published in the March issue of Sleep (2018 Mar. doi: 10.1093/sleep/zsy042).
“Patients with OSA differ in their presenting symptoms,” he said, and future studies should aim to “elucidate whether the proposed phenotypes will enable a more personalized paradigm of sleep apnea care that results in better tailored and more effective care.”
Dr. Kapur did not report any relevant disclosures.
The results of these studies “advance the personalization of sleep apnea care by validating distinct symptom-based groups that generalize across nations and assessing how members of these clinical phenotypes respond to therapy,” wrote Vishesh K. Kapur, MD, of the division of pulmonary, critical care and sleep medicine at the University of Washington, Seattle, in an editorial published in the March issue of Sleep (2018 Mar. doi: 10.1093/sleep/zsy042).
“Patients with OSA differ in their presenting symptoms,” he said, and future studies should aim to “elucidate whether the proposed phenotypes will enable a more personalized paradigm of sleep apnea care that results in better tailored and more effective care.”
Dr. Kapur did not report any relevant disclosures.
Patients with obstructive sleep apnea can be grouped into distinct clinical subtypes that differ in response to positive airway pressure treatment, according to two studies published in the March issue of the journal Sleep.
In the first study, investigators evaluated whether patients in different clinical clusters responded differently to positive airway pressure (PAP) treatment. Authors identified 706 patients with moderate to severe obstructive sleep apnea (OSA) from the Icelandic Sleep Apnea Cohort. All patients completed a sleep study prior to starting PAP treatment, and completed questionnaires to assess symptoms. Patients were grouped into one of three clusters based on symptomatology: disturbed sleep, minimally symptomatic, or sleepy, wrote Grace W. Pien, MD, of the division of pulmonary and critical care medicine at Johns Hopkins University, Baltimore, and her coauthors.
Patients in the minimally symptomatic cluster reported symptoms at lower rates than patients in the other clusters at baseline, and they remained relatively asymptomatic at follow-up, the authors noted. By comparison, patients in the sleepy group reported the highest Epworth Sleepiness Scale scores at baseline (16.0 plus or minus 3.4), which fell by five points at follow-up (mean change, −5.3; 95% confidence interval, −5.8 to −4.8). Also, patients in the sleepy group reported higher rates of drowsy driving (37.8%) at baseline, which dropped to 8.1% at follow-up (odds ratio, 0.06; 95% CI, 0.03-0.14).
At baseline, the disturbed-sleep group reported mainly insomnia-related symptoms, including difficulty falling asleep (43.2%), waking often at night (90.8%), restless sleep (74.2%), and waking up early (62.3%). At follow-up, improvements in the frequency of insomnia-related symptoms ranged from 0.28 to 1.25 points, and Epworth Sleepiness Scale scores fell significantly (−2.06; 95% CI, −2.64 to −1.48). Reductions in the proportion of patients with insomnia symptoms ranged from 13.1% (OR, 0.35; 95% CI, 0.20-0.59) for difficulty falling asleep to 39.0% (OR, 0.08; 95% CI, 0.04-0.14) for restless sleep, Dr. Pien and her colleagues reported.
The results “demonstrate that although symptoms improved overall among each of the three clinical phenotypes of moderate to severe OSA, patterns of treatment response … varied based on initial clinical presentation,” the authors wrote. “Our findings underscore the need to consider initial OSA phenotype when designing future trials.”
In the second study, also published in Sleep, investigators confirmed the three clinical OSA subtypes previously identified in the Icelandic Sleep Apnea Cohort. In analysis of an international sample, they also expanded these clusters to include two additional disease subtypes. One of these subtypes consisted of patients with symptoms dominated by indications of upper airway obstruction. The other new subtype, sleepiness dominant OSA, included patients who had excessive sleepiness but no symptoms of upper airway obstruction.
The study authors performed a cluster analysis using data from 972 patients from the Sleep Apnea Global Interdisciplinary Consortium with moderate to severe OSA, with 215 of these patients being from Iceland.
In total, 688 (70.8%) patients were diagnosed using laboratory-based polysomnography and 284 (29.2%) with home-based sleep studies. Patients completed questionnaires related to symptoms including sleepiness, insomnia, sleep disturbance, abnormal behaviors during sleep, upper airway symptoms, and other symptoms such as headaches and excessive sweating, wrote Brendan T. Keenan, of the University of Pennsylvania, Philadelphia, and his coauthors.
In the Icelandic group, results identified 72 (33.5%) patients in the disturbed-sleep cluster, 62 (28.8%) in the minimally symptomatic cluster, and 81 (37.7%) in the excessively sleepy cluster, similar to prior research. The three subtypes were found in the international sample of patients as well, with 150 (19.8%) in the disturbed-sleep cluster, 306 (40.4%) in the minimally symptomatic cluster, and 301 (39.8%) in the excessively sleepy cluster.
“Overall, this study provides a novel approach to better characterize patients with OSA presenting at sleep clinics worldwide,” wrote the authors of the second study. “This information can help inform personalized medicine approaches to OSA treatment by allowing clinicians to focus interventions on the most relevant OSA symptoms and consequences within an individual patient.”
Both studies were funded by the National Institutes of Health.
SOURCES: Pien GW et al. Sleep. 2018 Mar. doi: 10.1093/sleep/zsx201; Keenan BT et al. Sleep. 2018 Mar. doi: 10.1093/sleep/zsx214.
Patients with obstructive sleep apnea can be grouped into distinct clinical subtypes that differ in response to positive airway pressure treatment, according to two studies published in the March issue of the journal Sleep.
In the first study, investigators evaluated whether patients in different clinical clusters responded differently to positive airway pressure (PAP) treatment. Authors identified 706 patients with moderate to severe obstructive sleep apnea (OSA) from the Icelandic Sleep Apnea Cohort. All patients completed a sleep study prior to starting PAP treatment, and completed questionnaires to assess symptoms. Patients were grouped into one of three clusters based on symptomatology: disturbed sleep, minimally symptomatic, or sleepy, wrote Grace W. Pien, MD, of the division of pulmonary and critical care medicine at Johns Hopkins University, Baltimore, and her coauthors.
Patients in the minimally symptomatic cluster reported symptoms at lower rates than patients in the other clusters at baseline, and they remained relatively asymptomatic at follow-up, the authors noted. By comparison, patients in the sleepy group reported the highest Epworth Sleepiness Scale scores at baseline (16.0 plus or minus 3.4), which fell by five points at follow-up (mean change, −5.3; 95% confidence interval, −5.8 to −4.8). Also, patients in the sleepy group reported higher rates of drowsy driving (37.8%) at baseline, which dropped to 8.1% at follow-up (odds ratio, 0.06; 95% CI, 0.03-0.14).
At baseline, the disturbed-sleep group reported mainly insomnia-related symptoms, including difficulty falling asleep (43.2%), waking often at night (90.8%), restless sleep (74.2%), and waking up early (62.3%). At follow-up, improvements in the frequency of insomnia-related symptoms ranged from 0.28 to 1.25 points, and Epworth Sleepiness Scale scores fell significantly (−2.06; 95% CI, −2.64 to −1.48). Reductions in the proportion of patients with insomnia symptoms ranged from 13.1% (OR, 0.35; 95% CI, 0.20-0.59) for difficulty falling asleep to 39.0% (OR, 0.08; 95% CI, 0.04-0.14) for restless sleep, Dr. Pien and her colleagues reported.
The results “demonstrate that although symptoms improved overall among each of the three clinical phenotypes of moderate to severe OSA, patterns of treatment response … varied based on initial clinical presentation,” the authors wrote. “Our findings underscore the need to consider initial OSA phenotype when designing future trials.”
In the second study, also published in Sleep, investigators confirmed the three clinical OSA subtypes previously identified in the Icelandic Sleep Apnea Cohort. In analysis of an international sample, they also expanded these clusters to include two additional disease subtypes. One of these subtypes consisted of patients with symptoms dominated by indications of upper airway obstruction. The other new subtype, sleepiness dominant OSA, included patients who had excessive sleepiness but no symptoms of upper airway obstruction.
The study authors performed a cluster analysis using data from 972 patients from the Sleep Apnea Global Interdisciplinary Consortium with moderate to severe OSA, with 215 of these patients being from Iceland.
In total, 688 (70.8%) patients were diagnosed using laboratory-based polysomnography and 284 (29.2%) with home-based sleep studies. Patients completed questionnaires related to symptoms including sleepiness, insomnia, sleep disturbance, abnormal behaviors during sleep, upper airway symptoms, and other symptoms such as headaches and excessive sweating, wrote Brendan T. Keenan, of the University of Pennsylvania, Philadelphia, and his coauthors.
In the Icelandic group, results identified 72 (33.5%) patients in the disturbed-sleep cluster, 62 (28.8%) in the minimally symptomatic cluster, and 81 (37.7%) in the excessively sleepy cluster, similar to prior research. The three subtypes were found in the international sample of patients as well, with 150 (19.8%) in the disturbed-sleep cluster, 306 (40.4%) in the minimally symptomatic cluster, and 301 (39.8%) in the excessively sleepy cluster.
“Overall, this study provides a novel approach to better characterize patients with OSA presenting at sleep clinics worldwide,” wrote the authors of the second study. “This information can help inform personalized medicine approaches to OSA treatment by allowing clinicians to focus interventions on the most relevant OSA symptoms and consequences within an individual patient.”
Both studies were funded by the National Institutes of Health.
SOURCES: Pien GW et al. Sleep. 2018 Mar. doi: 10.1093/sleep/zsx201; Keenan BT et al. Sleep. 2018 Mar. doi: 10.1093/sleep/zsx214.
FROM SLEEP
Key clinical point: Obstructive sleep apnea patients can be grouped into distinct subtypes depending on disease presentation, and these clusters differ in their responses to positive air pressure treatment.
Major finding: Though improvements were seen in all groups, presentation and changes in symptoms varied widely across clusters; for instance, patients in the sleepy group reported the highest Epworth Sleepiness Scale scores at baseline (16.0 plus or minus 3.4), which fell by five points at follow-up (mean change, −5.3; 95% CI, −5.8 to −4.8); whereas the disturbed-sleep group reported mainly insomnia-related symptoms including difficulty falling asleep (43.2%), waking often at night (90.8%), restless sleep (74.2%), and waking up early (62.3%).
Study details: A study of 706 patients with moderate to severe OSA from the Icelandic Sleep Apnea Cohort, and a study of 972 patients from the Sleep Apnea Global Interdisciplinary Consortium with moderate to severe OSA.
Disclosures: Both studies were funded by the National Institutes of Health.
Sources: Pien GW et al. Sleep. 2018 Mar. doi: 10.1093/sleep/zsx201; Keenan B et al. Sleep. 2018 Mar. doi: 10.1093/sleep/zsx214.
Cost, coverage concerns cited as barriers to acne medication adherence
Patients with acne who did not follow through with treatment cited high prices and insurance barriers as their main reasons for medication nonadherence, in a study published in JAMA Dermatology.
In the study, more than half of the 26 participants interviewed reported that they intended to fill the acne prescriptions but were not able to do so because of cost- or insurance-related concerns, reported Kira L. Ryskina, MD, of the Leonard Davis Institute of Health Economics at the University of Pennsylvania, Philadelphia, and her coauthors.
Of the initial 385 patients, 26 agreed to participate and met inclusion criteria. Most (58%) were aged 26-40 years, 19% were over aged 40, and 23% were younger than aged 26; 73% were female. Almost 40% had Medicaid coverage, 54% had commercial insurance, and the rest had “other.” Structured interviews were conducted via telephone between November 30, 2016, and January 31, 2017. Based on recorded interviews, five major themes were identified by investigator consensus: medication costs, poor understanding of prior authorization, physician-patient communication about costs, solutions and back-up plans offered by physicians, and reservations about treatment.
Lack of insurance coverage was a concern for 10 patients (38%), and high out-of-pocket costs were a concern for 11 patients (42%), the authors reported. Additionally, 5 participants (19%) said they had received inconsistent information from physicians, physician’s office staff, and pharmacy staff about the prior authorization process.
Participants reported having discussions with providers about treatment side effects and instructions for use – but not about price concerns. In addition, patients “did not expect physicians to know medication cost or insurance coverage,” the authors said. The patients also described various approaches recommended by providers to address problems obtaining medication, including asking patients to call the office back (7%), shopping around for medication (7%), suggesting alternatives to first-line treatment (7%), and offering coupons (4%). Backup plans (offered when the medication was not available) were received positively by 23% of the patients, as was a candid conversation about cost (19%), whereas shopping around and calling the office back were not, the authors said.
Overall, 10 patients (38%) reported reservations about treatment, which included concerns about possible adverse effects (15%), unwillingness to start a “strong” medication (8%), desire to try homeopathic treatment (3%), and belief that their acne was not serious enough to require medication (12%).
The results suggest that “physician-level interventions to improve primary adherence should incorporate discussion of medication costs and provide specific alternative plans in case the patient is unable to fill the prescription, rather than asking patients to call back,” the authors wrote. “Physicians who discuss medication costs and provide a concrete alternative plan may be able to improve primary adherence among their patients,” they concluded.
Limitations of the study include its qualitative nature and its limited generalizability because all participants were part of the same Philadelphia health system.
The study was funded by a Pfizer grant from the American Academy of Dermatology and was cosponsored by the Pennsylvania Academy of Dermatology and Dermatologic Surgery.
SOURCE: Ryskina K et al. JAMA Dermatol. 2018 Feb 28. doi: 10.1001/jamadermatol.2017.6144.
Patients with acne who did not follow through with treatment cited high prices and insurance barriers as their main reasons for medication nonadherence, in a study published in JAMA Dermatology.
In the study, more than half of the 26 participants interviewed reported that they intended to fill the acne prescriptions but were not able to do so because of cost- or insurance-related concerns, reported Kira L. Ryskina, MD, of the Leonard Davis Institute of Health Economics at the University of Pennsylvania, Philadelphia, and her coauthors.
Of the initial 385 patients, 26 agreed to participate and met inclusion criteria. Most (58%) were aged 26-40 years, 19% were over aged 40, and 23% were younger than aged 26; 73% were female. Almost 40% had Medicaid coverage, 54% had commercial insurance, and the rest had “other.” Structured interviews were conducted via telephone between November 30, 2016, and January 31, 2017. Based on recorded interviews, five major themes were identified by investigator consensus: medication costs, poor understanding of prior authorization, physician-patient communication about costs, solutions and back-up plans offered by physicians, and reservations about treatment.
Lack of insurance coverage was a concern for 10 patients (38%), and high out-of-pocket costs were a concern for 11 patients (42%), the authors reported. Additionally, 5 participants (19%) said they had received inconsistent information from physicians, physician’s office staff, and pharmacy staff about the prior authorization process.
Participants reported having discussions with providers about treatment side effects and instructions for use – but not about price concerns. In addition, patients “did not expect physicians to know medication cost or insurance coverage,” the authors said. The patients also described various approaches recommended by providers to address problems obtaining medication, including asking patients to call the office back (7%), shopping around for medication (7%), suggesting alternatives to first-line treatment (7%), and offering coupons (4%). Backup plans (offered when the medication was not available) were received positively by 23% of the patients, as was a candid conversation about cost (19%), whereas shopping around and calling the office back were not, the authors said.
Overall, 10 patients (38%) reported reservations about treatment, which included concerns about possible adverse effects (15%), unwillingness to start a “strong” medication (8%), desire to try homeopathic treatment (3%), and belief that their acne was not serious enough to require medication (12%).
The results suggest that “physician-level interventions to improve primary adherence should incorporate discussion of medication costs and provide specific alternative plans in case the patient is unable to fill the prescription, rather than asking patients to call back,” the authors wrote. “Physicians who discuss medication costs and provide a concrete alternative plan may be able to improve primary adherence among their patients,” they concluded.
Limitations of the study include its qualitative nature and its limited generalizability because all participants were part of the same Philadelphia health system.
The study was funded by a Pfizer grant from the American Academy of Dermatology and was cosponsored by the Pennsylvania Academy of Dermatology and Dermatologic Surgery.
SOURCE: Ryskina K et al. JAMA Dermatol. 2018 Feb 28. doi: 10.1001/jamadermatol.2017.6144.
Patients with acne who did not follow through with treatment cited high prices and insurance barriers as their main reasons for medication nonadherence, in a study published in JAMA Dermatology.
In the study, more than half of the 26 participants interviewed reported that they intended to fill the acne prescriptions but were not able to do so because of cost- or insurance-related concerns, reported Kira L. Ryskina, MD, of the Leonard Davis Institute of Health Economics at the University of Pennsylvania, Philadelphia, and her coauthors.
Of the initial 385 patients, 26 agreed to participate and met inclusion criteria. Most (58%) were aged 26-40 years, 19% were over aged 40, and 23% were younger than aged 26; 73% were female. Almost 40% had Medicaid coverage, 54% had commercial insurance, and the rest had “other.” Structured interviews were conducted via telephone between November 30, 2016, and January 31, 2017. Based on recorded interviews, five major themes were identified by investigator consensus: medication costs, poor understanding of prior authorization, physician-patient communication about costs, solutions and back-up plans offered by physicians, and reservations about treatment.
Lack of insurance coverage was a concern for 10 patients (38%), and high out-of-pocket costs were a concern for 11 patients (42%), the authors reported. Additionally, 5 participants (19%) said they had received inconsistent information from physicians, physician’s office staff, and pharmacy staff about the prior authorization process.
Participants reported having discussions with providers about treatment side effects and instructions for use – but not about price concerns. In addition, patients “did not expect physicians to know medication cost or insurance coverage,” the authors said. The patients also described various approaches recommended by providers to address problems obtaining medication, including asking patients to call the office back (7%), shopping around for medication (7%), suggesting alternatives to first-line treatment (7%), and offering coupons (4%). Backup plans (offered when the medication was not available) were received positively by 23% of the patients, as was a candid conversation about cost (19%), whereas shopping around and calling the office back were not, the authors said.
Overall, 10 patients (38%) reported reservations about treatment, which included concerns about possible adverse effects (15%), unwillingness to start a “strong” medication (8%), desire to try homeopathic treatment (3%), and belief that their acne was not serious enough to require medication (12%).
The results suggest that “physician-level interventions to improve primary adherence should incorporate discussion of medication costs and provide specific alternative plans in case the patient is unable to fill the prescription, rather than asking patients to call back,” the authors wrote. “Physicians who discuss medication costs and provide a concrete alternative plan may be able to improve primary adherence among their patients,” they concluded.
Limitations of the study include its qualitative nature and its limited generalizability because all participants were part of the same Philadelphia health system.
The study was funded by a Pfizer grant from the American Academy of Dermatology and was cosponsored by the Pennsylvania Academy of Dermatology and Dermatologic Surgery.
SOURCE: Ryskina K et al. JAMA Dermatol. 2018 Feb 28. doi: 10.1001/jamadermatol.2017.6144.
FROM JAMA DERMATOLOGY
Key clinical point: Most patients cited high prescription costs and insurance coverage concerns as reasons for medication nonadherence.
Major finding: Of the patients in the study, 65% reported being unable to fill prescriptions because of price or insurance coverage concerns.
Data source: A qualitative analysis of structured interviews with 26 acne patients in Philadelphia.
Disclosures: The study was funded by a Pfizer grant from the American Academy of Dermatology and was cosponsored by the Pennsylvania Academy of Dermatology and Dermatologic Surgery.
Source: Ryskina K et al. JAMA Dermatol. 2018 Feb 28. doi: 10.1001/jamadermatol.2017.6144.
Effectiveness, adherence similar for nasal pillows and standard masks
according to results of a study.
In a retrospective observational study of 144 patients with obstructive sleep apnea, respiratory measures including apnea-hypopnea index (AHI), oxygen desaturation index, mean oxygen saturation, and Epworth Sleepiness scale scores did not differ between the two treatment groups at baseline and during a 12-month follow-up appointment. Treatment adherence was also similar between the two groups, reported Andrea Lanza of the Sleep Medicine Center at Niguarda Hospital in Milan, Italy, and coauthors in Sleep Medicine.
Patients received continuous positive airway pressure (CPAP) treatment between May 2012 and September 2014, and were assigned to one of two groups based on their choice of treatment. Initially, 102 opted for nasal pillows (Group P), and 42 chose the standard nasal mask (Group N). Patients who either changed masks or added a new one during titration or follow-up were assigned to a third group, Group C.
AHI did not differ significantly between groups at baseline or follow-up. In Group P, mean AHI at titration was 1.2 events per hour, compared with 1.8 in Group N and 1.9 in Group C (P = .109). At follow-up, AHI was 0.7 in Group P, 1.1 in Group N, and 0.9 in Group C (P = .172). Oxygen desaturation index and oxygen saturation also remained similar between the groups at baseline and follow-up, the investigators reported.
Additionally, long-term adherence did not differ significantly between the groups, with mean daily CPAP usage of 5.5 hours per night in Group P, 5.3 in Group N, and 5.6 in Group C. Mean usage was less than 4 hours per night for 11.6% in group P, 18.5% in group N, and 13.9% in group C, the authors added.
The frequency of side effects occurring in patients in two of the groups were similar (49% in Group P, vs. 61% in Group N; P = .212), though the nature of the side effects differed. Nostril pain or burning was reported only by patients in the nasal pillows group, and skin breakdown was reported only in the nasal mask group.
Though nasal pillows have typically been reserved for patients who do not tolerate the standard mask, the results of this study suggest that “nasal pillows could be safely prescribed as first-line interfaces,” the authors wrote. “They seem to be efficacious for CPAP titration and long-term treatment, ensuring a good rate of adherence.”
All of the authors reported having no disclosures.
SOURCE: Lanza A et al. Sleep Med. 2018 Jan;41:94-9
These results add to the body of evidence about the efficacy of nasal pillows and nasal masks. Future research should address the need for retitration when changing mask type, said Matthew R. Ebben, PhD, associate clinical professor at Cornell University, New York, in an editorial published with the study in Sleep Medicine.
“Many working in the field of sleep medicine continue to be unaware that differences in efficacy exist between mask styles, particularly in cases of moderate to severe obstructive sleep apnea,” he wrote.
“New clinical practice guidelines are needed to promote the necessity for PAP [positive airway pressure] retitration when changes in mask style are required,” he added. “Ensuring that PAP therapy is as effective as possible will reduce the need for patients and clinicians to investigate other treatment options for obstructive sleep apnea, which may be both less effective and have an inferior side effect profile compared to PAP treatment.”
These results add to the body of evidence about the efficacy of nasal pillows and nasal masks. Future research should address the need for retitration when changing mask type, said Matthew R. Ebben, PhD, associate clinical professor at Cornell University, New York, in an editorial published with the study in Sleep Medicine.
“Many working in the field of sleep medicine continue to be unaware that differences in efficacy exist between mask styles, particularly in cases of moderate to severe obstructive sleep apnea,” he wrote.
“New clinical practice guidelines are needed to promote the necessity for PAP [positive airway pressure] retitration when changes in mask style are required,” he added. “Ensuring that PAP therapy is as effective as possible will reduce the need for patients and clinicians to investigate other treatment options for obstructive sleep apnea, which may be both less effective and have an inferior side effect profile compared to PAP treatment.”
These results add to the body of evidence about the efficacy of nasal pillows and nasal masks. Future research should address the need for retitration when changing mask type, said Matthew R. Ebben, PhD, associate clinical professor at Cornell University, New York, in an editorial published with the study in Sleep Medicine.
“Many working in the field of sleep medicine continue to be unaware that differences in efficacy exist between mask styles, particularly in cases of moderate to severe obstructive sleep apnea,” he wrote.
“New clinical practice guidelines are needed to promote the necessity for PAP [positive airway pressure] retitration when changes in mask style are required,” he added. “Ensuring that PAP therapy is as effective as possible will reduce the need for patients and clinicians to investigate other treatment options for obstructive sleep apnea, which may be both less effective and have an inferior side effect profile compared to PAP treatment.”
according to results of a study.
In a retrospective observational study of 144 patients with obstructive sleep apnea, respiratory measures including apnea-hypopnea index (AHI), oxygen desaturation index, mean oxygen saturation, and Epworth Sleepiness scale scores did not differ between the two treatment groups at baseline and during a 12-month follow-up appointment. Treatment adherence was also similar between the two groups, reported Andrea Lanza of the Sleep Medicine Center at Niguarda Hospital in Milan, Italy, and coauthors in Sleep Medicine.
Patients received continuous positive airway pressure (CPAP) treatment between May 2012 and September 2014, and were assigned to one of two groups based on their choice of treatment. Initially, 102 opted for nasal pillows (Group P), and 42 chose the standard nasal mask (Group N). Patients who either changed masks or added a new one during titration or follow-up were assigned to a third group, Group C.
AHI did not differ significantly between groups at baseline or follow-up. In Group P, mean AHI at titration was 1.2 events per hour, compared with 1.8 in Group N and 1.9 in Group C (P = .109). At follow-up, AHI was 0.7 in Group P, 1.1 in Group N, and 0.9 in Group C (P = .172). Oxygen desaturation index and oxygen saturation also remained similar between the groups at baseline and follow-up, the investigators reported.
Additionally, long-term adherence did not differ significantly between the groups, with mean daily CPAP usage of 5.5 hours per night in Group P, 5.3 in Group N, and 5.6 in Group C. Mean usage was less than 4 hours per night for 11.6% in group P, 18.5% in group N, and 13.9% in group C, the authors added.
The frequency of side effects occurring in patients in two of the groups were similar (49% in Group P, vs. 61% in Group N; P = .212), though the nature of the side effects differed. Nostril pain or burning was reported only by patients in the nasal pillows group, and skin breakdown was reported only in the nasal mask group.
Though nasal pillows have typically been reserved for patients who do not tolerate the standard mask, the results of this study suggest that “nasal pillows could be safely prescribed as first-line interfaces,” the authors wrote. “They seem to be efficacious for CPAP titration and long-term treatment, ensuring a good rate of adherence.”
All of the authors reported having no disclosures.
SOURCE: Lanza A et al. Sleep Med. 2018 Jan;41:94-9
according to results of a study.
In a retrospective observational study of 144 patients with obstructive sleep apnea, respiratory measures including apnea-hypopnea index (AHI), oxygen desaturation index, mean oxygen saturation, and Epworth Sleepiness scale scores did not differ between the two treatment groups at baseline and during a 12-month follow-up appointment. Treatment adherence was also similar between the two groups, reported Andrea Lanza of the Sleep Medicine Center at Niguarda Hospital in Milan, Italy, and coauthors in Sleep Medicine.
Patients received continuous positive airway pressure (CPAP) treatment between May 2012 and September 2014, and were assigned to one of two groups based on their choice of treatment. Initially, 102 opted for nasal pillows (Group P), and 42 chose the standard nasal mask (Group N). Patients who either changed masks or added a new one during titration or follow-up were assigned to a third group, Group C.
AHI did not differ significantly between groups at baseline or follow-up. In Group P, mean AHI at titration was 1.2 events per hour, compared with 1.8 in Group N and 1.9 in Group C (P = .109). At follow-up, AHI was 0.7 in Group P, 1.1 in Group N, and 0.9 in Group C (P = .172). Oxygen desaturation index and oxygen saturation also remained similar between the groups at baseline and follow-up, the investigators reported.
Additionally, long-term adherence did not differ significantly between the groups, with mean daily CPAP usage of 5.5 hours per night in Group P, 5.3 in Group N, and 5.6 in Group C. Mean usage was less than 4 hours per night for 11.6% in group P, 18.5% in group N, and 13.9% in group C, the authors added.
The frequency of side effects occurring in patients in two of the groups were similar (49% in Group P, vs. 61% in Group N; P = .212), though the nature of the side effects differed. Nostril pain or burning was reported only by patients in the nasal pillows group, and skin breakdown was reported only in the nasal mask group.
Though nasal pillows have typically been reserved for patients who do not tolerate the standard mask, the results of this study suggest that “nasal pillows could be safely prescribed as first-line interfaces,” the authors wrote. “They seem to be efficacious for CPAP titration and long-term treatment, ensuring a good rate of adherence.”
All of the authors reported having no disclosures.
SOURCE: Lanza A et al. Sleep Med. 2018 Jan;41:94-9
FROM SLEEP MEDICINE
Key clinical point: Nasal pillows showed equal long-term efficacy as standard nasal masks in obstructive sleep apnea patients treated with continuous positive airway pressure.
Major finding: Long-term adherence did not differ significantly between the groups, with mean daily CPAP usage of 5.5 hours per night with nasal pillows and 5.3 hours per night with standard nasal masks; respiratory measures including AHI, oxygen desaturation index, and oxygen saturation also remained similar between the groups at baseline and follow-up.
Data source: A retrospective observational study of 144 OSA patients treated with nasal pillows or standard nasal masks.
Disclosures: All of the authors reported having no disclosures.
Source: Lanza A et al. Sleep Med. 2018 Jan. doi: 10.1016/j.sleep.2017/.08.024.
cSCC staging systems poorly determine metastasis risk
Current staging systems for cutaneous squamous cell carcinoma (cSCC) poorly discerned between patients with and without metastases, according to researchers.
In a population-based case-control study of 6,721 cSCC patients, the American Joint Committee on Cancer, 7th edition (AJCC 7) staging system had the lowest rate of correctly classified cases (61.8%), followed by the AJCC 8 (68.2%), the Brigham and Women’s Hospital (BWH) system (72.3%), and the Breuninger system (76.2%). The Breuninger system performed best, with sensitivity of 77.3%, specificity of 75%, correctly classified tumor rate of 76.2%, and concordance index (C-index) of 0.81, reported Ingrid Roscher, MD, of the department of dermatology at Oslo University Hospital, and her coauthors. The report was published in JAMA Dermatology.
Investigators used data from the Cancer Registry of Norway to identify 6,721 patients with a first cSCC diagnosis between Jan. 1, 2000, and Dec. 31, 2004. Metastasis status was split into one of two categories: no metastases (local disease only) and metastasis (regional lymph node or distant metastasis).
Within 5 years follow-up, 112 patients had developed metastasis, and 112 patients without metastasis were selected at random as controls. Tumor tissue was collected for all 224 patients and checked by a pathologist. Tumors were classified under all four staging systems, and a chi-squared test was performed to compare patients with and without metastasis. Relative risk of metastasis was calculated via logistic regression analyses.
Sensitivity, specificity, and correctly identified cases were used to evaluate performance of the staging systems, and C-index was used to measure discriminatory ability, wrote Dr. Roscher and her colleagues.
AJCC 7 had a sensitivity of 85.6%, specificity of 33.3%, and C-index value of 0.59; compared with AJCC scores of 67.1%, 69.6%, and 0.70 for sensitivity, specificity, and C-index, respectively. BWH had a sensitivity of 68.9%, specificity of 76.5%, and C-index of 0.75.
Within the AJCC 7 system, 85.6% of patients with metastasis and 66.7% without metastasis fell into the T2 category, and no patients were grouped into T3 or T4 (P = .003). Under the BWH system, patients without metastasis fell mostly into the T1 category, while those with metastasis were about equally distributed among T1, T2a, and T2b (P less than .001). With the Breuninger system, more patients with metastasis than without metastasis fell into the high-risk categories for tumor diameter and depth (P less than .001). Lastly, under AJCC 8, 10% of all patients fell into the T2 category, while less than 20% of patients without metastasis and more than 50% of patients with metastasis fell into the T3 category (P less than .001).
Risk of metastasis for T2 patients was greater than for T1 patients under the AJCC 7 system (odds ratio = 2.96; 95% confidence interval, 1.43-6.15). Under BWH, OR for metastasis were 4.6 (95% CI, 2.23-9.49) for T2a patients and 21.31 (95% CI, 6.07-74.88) for T2b patients. Under the Breuninger system, tumor diameter greater than 2 cm (OR = 5.92; 95% CI, 2.18-16.07) and depth of invasion greater than 6 mm (OR = 9.00; 95% CI, 3.51-32.31) increased risk of metastasis. The AJCC 8 system showed increased metastasis risk for T2 (OR = 2.00; 95% CI, 0.62-6.44) and T3 (OR = 6.14; 95% CI, 0.41-1.09) patients, the authors reported.
The results suggest that the current staging systems “distinguished poorly to moderately between patients who developed metastases and those who did not,” Dr. Roscher and her coauthors wrote. Moreover, “the poorest results were found for the AJCC 7 system, which is most widely used,” they added.
“Our findings indicate a need for a more reliable, easy-to-perform, and clinically useful staging system than those presently available,” they concluded.
Oslo University Hospital and the Cancer Registry of Norway funded the study. No other disclosures were reported.
SOURCE: Roscher et al. JAMA Dermatol. 2018 March 7 doi: 10.1001/jamadermatol.2017.6428.
Current staging systems for cutaneous squamous cell carcinoma (cSCC) poorly discerned between patients with and without metastases, according to researchers.
In a population-based case-control study of 6,721 cSCC patients, the American Joint Committee on Cancer, 7th edition (AJCC 7) staging system had the lowest rate of correctly classified cases (61.8%), followed by the AJCC 8 (68.2%), the Brigham and Women’s Hospital (BWH) system (72.3%), and the Breuninger system (76.2%). The Breuninger system performed best, with sensitivity of 77.3%, specificity of 75%, correctly classified tumor rate of 76.2%, and concordance index (C-index) of 0.81, reported Ingrid Roscher, MD, of the department of dermatology at Oslo University Hospital, and her coauthors. The report was published in JAMA Dermatology.
Investigators used data from the Cancer Registry of Norway to identify 6,721 patients with a first cSCC diagnosis between Jan. 1, 2000, and Dec. 31, 2004. Metastasis status was split into one of two categories: no metastases (local disease only) and metastasis (regional lymph node or distant metastasis).
Within 5 years follow-up, 112 patients had developed metastasis, and 112 patients without metastasis were selected at random as controls. Tumor tissue was collected for all 224 patients and checked by a pathologist. Tumors were classified under all four staging systems, and a chi-squared test was performed to compare patients with and without metastasis. Relative risk of metastasis was calculated via logistic regression analyses.
Sensitivity, specificity, and correctly identified cases were used to evaluate performance of the staging systems, and C-index was used to measure discriminatory ability, wrote Dr. Roscher and her colleagues.
AJCC 7 had a sensitivity of 85.6%, specificity of 33.3%, and C-index value of 0.59; compared with AJCC scores of 67.1%, 69.6%, and 0.70 for sensitivity, specificity, and C-index, respectively. BWH had a sensitivity of 68.9%, specificity of 76.5%, and C-index of 0.75.
Within the AJCC 7 system, 85.6% of patients with metastasis and 66.7% without metastasis fell into the T2 category, and no patients were grouped into T3 or T4 (P = .003). Under the BWH system, patients without metastasis fell mostly into the T1 category, while those with metastasis were about equally distributed among T1, T2a, and T2b (P less than .001). With the Breuninger system, more patients with metastasis than without metastasis fell into the high-risk categories for tumor diameter and depth (P less than .001). Lastly, under AJCC 8, 10% of all patients fell into the T2 category, while less than 20% of patients without metastasis and more than 50% of patients with metastasis fell into the T3 category (P less than .001).
Risk of metastasis for T2 patients was greater than for T1 patients under the AJCC 7 system (odds ratio = 2.96; 95% confidence interval, 1.43-6.15). Under BWH, OR for metastasis were 4.6 (95% CI, 2.23-9.49) for T2a patients and 21.31 (95% CI, 6.07-74.88) for T2b patients. Under the Breuninger system, tumor diameter greater than 2 cm (OR = 5.92; 95% CI, 2.18-16.07) and depth of invasion greater than 6 mm (OR = 9.00; 95% CI, 3.51-32.31) increased risk of metastasis. The AJCC 8 system showed increased metastasis risk for T2 (OR = 2.00; 95% CI, 0.62-6.44) and T3 (OR = 6.14; 95% CI, 0.41-1.09) patients, the authors reported.
The results suggest that the current staging systems “distinguished poorly to moderately between patients who developed metastases and those who did not,” Dr. Roscher and her coauthors wrote. Moreover, “the poorest results were found for the AJCC 7 system, which is most widely used,” they added.
“Our findings indicate a need for a more reliable, easy-to-perform, and clinically useful staging system than those presently available,” they concluded.
Oslo University Hospital and the Cancer Registry of Norway funded the study. No other disclosures were reported.
SOURCE: Roscher et al. JAMA Dermatol. 2018 March 7 doi: 10.1001/jamadermatol.2017.6428.
Current staging systems for cutaneous squamous cell carcinoma (cSCC) poorly discerned between patients with and without metastases, according to researchers.
In a population-based case-control study of 6,721 cSCC patients, the American Joint Committee on Cancer, 7th edition (AJCC 7) staging system had the lowest rate of correctly classified cases (61.8%), followed by the AJCC 8 (68.2%), the Brigham and Women’s Hospital (BWH) system (72.3%), and the Breuninger system (76.2%). The Breuninger system performed best, with sensitivity of 77.3%, specificity of 75%, correctly classified tumor rate of 76.2%, and concordance index (C-index) of 0.81, reported Ingrid Roscher, MD, of the department of dermatology at Oslo University Hospital, and her coauthors. The report was published in JAMA Dermatology.
Investigators used data from the Cancer Registry of Norway to identify 6,721 patients with a first cSCC diagnosis between Jan. 1, 2000, and Dec. 31, 2004. Metastasis status was split into one of two categories: no metastases (local disease only) and metastasis (regional lymph node or distant metastasis).
Within 5 years follow-up, 112 patients had developed metastasis, and 112 patients without metastasis were selected at random as controls. Tumor tissue was collected for all 224 patients and checked by a pathologist. Tumors were classified under all four staging systems, and a chi-squared test was performed to compare patients with and without metastasis. Relative risk of metastasis was calculated via logistic regression analyses.
Sensitivity, specificity, and correctly identified cases were used to evaluate performance of the staging systems, and C-index was used to measure discriminatory ability, wrote Dr. Roscher and her colleagues.
AJCC 7 had a sensitivity of 85.6%, specificity of 33.3%, and C-index value of 0.59; compared with AJCC scores of 67.1%, 69.6%, and 0.70 for sensitivity, specificity, and C-index, respectively. BWH had a sensitivity of 68.9%, specificity of 76.5%, and C-index of 0.75.
Within the AJCC 7 system, 85.6% of patients with metastasis and 66.7% without metastasis fell into the T2 category, and no patients were grouped into T3 or T4 (P = .003). Under the BWH system, patients without metastasis fell mostly into the T1 category, while those with metastasis were about equally distributed among T1, T2a, and T2b (P less than .001). With the Breuninger system, more patients with metastasis than without metastasis fell into the high-risk categories for tumor diameter and depth (P less than .001). Lastly, under AJCC 8, 10% of all patients fell into the T2 category, while less than 20% of patients without metastasis and more than 50% of patients with metastasis fell into the T3 category (P less than .001).
Risk of metastasis for T2 patients was greater than for T1 patients under the AJCC 7 system (odds ratio = 2.96; 95% confidence interval, 1.43-6.15). Under BWH, OR for metastasis were 4.6 (95% CI, 2.23-9.49) for T2a patients and 21.31 (95% CI, 6.07-74.88) for T2b patients. Under the Breuninger system, tumor diameter greater than 2 cm (OR = 5.92; 95% CI, 2.18-16.07) and depth of invasion greater than 6 mm (OR = 9.00; 95% CI, 3.51-32.31) increased risk of metastasis. The AJCC 8 system showed increased metastasis risk for T2 (OR = 2.00; 95% CI, 0.62-6.44) and T3 (OR = 6.14; 95% CI, 0.41-1.09) patients, the authors reported.
The results suggest that the current staging systems “distinguished poorly to moderately between patients who developed metastases and those who did not,” Dr. Roscher and her coauthors wrote. Moreover, “the poorest results were found for the AJCC 7 system, which is most widely used,” they added.
“Our findings indicate a need for a more reliable, easy-to-perform, and clinically useful staging system than those presently available,” they concluded.
Oslo University Hospital and the Cancer Registry of Norway funded the study. No other disclosures were reported.
SOURCE: Roscher et al. JAMA Dermatol. 2018 March 7 doi: 10.1001/jamadermatol.2017.6428.
FROM JAMA DERMATOLOGY
Key clinical point: The four cSCC staging systems, especially the AJCC 7, poorly identified metastasis risk.
Major finding: The AJCC 7 staging system had the lowest rate of correctly classified cases (61.8%), followed by the AJCC 8 (68.2%), the Brigham and Women’s Hospital (BWH) system (72.3%), and the Breuninger system (76.2%).
Data source: A population-based case-control study of 6,721 patients with cSCC.
Disclosures: Oslo University Hospital and the Cancer Registry of Norway funded the study.
Source: Roscher et al. JAMA Dermatol. 2018 Mar 7. doi: 10.1001/jamadermatol.2017.6428.
OSA may provide cardioprotection
, according to researchers.
In a study of 127 patients presenting with acute coronary syndromes (ACS), median peak cardiac troponin-I (cTn-I) values were significantly higher in patients without obstructive sleep apnea, compared with OSA patients (10.7; interquartile range: 1.78-40.1, vs. 3.79; IQR: 0.37-24.3, respectively; P = .04 ). The findings were published Feb. 5 in the journal CHEST®.
The study comprised 89 OSA patients and 38 non-OSA patients who were admitted to a hospital for acute coronary syndromes. The OSA group had a median apnea-hypopnea index (AHI) of 32, while the non-OSA group had a median AHI of 4.8. There was no significant difference between the two groups in gender, age, or cardiovascular risk factors such as hypertension, diabetes mellitus, body mass index, dyslipidemia, and smoking.
The cohort was part of the Continuous Positive Airway Pressure (CPAP) in Patients With Acute Coronary Syndrome and Obstructive Sleep Apnea (ISAACC) study, a prior randomized, controlled trial that evaluated the effect of CPAP treatment on new cardiovascular events in patients with an episode of ACS and OSA, reported Alicia Sánchez-de-la-Torre, PhD, of the respiratory department at Hospital Universitari Arnau de Vilanova and Santa Maria in Catalonia, Spain, and her coauthors.
Respiratory polygraphy was performed in the first 24-72 hours after hospital admission, and patients with an AHI of at least 15 events per hour were considered to have OSA. Those with an AHI less than 15 events per hour were included in the non-OSA group.
The OSA patients were randomized to conservative or CPAP treatment. An obstructive apnea “episode” was defined as a complete cessation of airflow for 10 seconds or longer, and an episode of hypopnea was defined as a reduction in airflow for at least 10 seconds associated with a greater than 4% decrease in arterial oxygen saturation.
Blood samples were collected from patients every 6 hours until two consecutive cTn-I measurements showed a decrease, with the highest measurement considered the peak cTn-I value.
Peak cTn-I value was significantly higher in non-OSA patients than in OSA patients. Median infarct size, measured by calculating the area under the cTn-I curve, was significantly different between the two groups (451 for non-OSA patients vs. 143 in OSA patients; P = .049), wrote Dr. Sánchez-de-la-Torre and her colleagues.
As cTn-I levels decreased, there was a trend toward increased OSA severity (P = .058). In the multivariable linear regression model used to assess OSA severity, patients with severe OSA had 61% lower cTn-I levels than non-OSA patients, the authors noted.
“The effects of chronic hypoxia in individual organ systems are not well understood. While chronic sustained hypoxia as seen with COPD may lead to pulmonary hypertension, chronic intermittent hypoxia (CIH) as seen predominantly in sleep apnea has been attributed to causing widespread effects ranging from systemic hypertension to metabolic dysfunction and systemic inflammation,” noted Krishna Sundar, MD, FCCP. “Despite these associations, an increased risk of major cardiovascular events from untreated OSA is yet to be definitively established.”
In this article, a protective effect from OSA on myocardial ischemic events is demonstrated in a group of 127 consecutively admitted patients with acute coronary syndrome (ACS). While it is interesting that a high proportion of those admitted for ACS had OSA, there were no significant differences in the age, sex, BMI, usage of antihypertensive or antiplatelet agents, presence of hypertension, DM, dyslipidemia or smoking status between those with and without OSA. “OSA appeared to confer a protective effect on the size of myocardial injury with those having higher AHI values demonstrating lower peak cardiac troponin values,” said Dr. Sundar, who is an associate clinical professor of pulmonary, critical care and sleep medicine at the University of Utah.“An effect of age (mean age in this study being 64 years) and BMI (mean being 27) on the occurrence of preconditioning effects of OSA is not excluded given deleterious effects of untreated OSA on infarct size in other studies on obese or younger patients with ACS. Further understanding of molecular effects of chronic hypoxia exposure (high altitude, chronic lung disease, OSA) is required before the complex and often contradictory effects of chronic hypoxia can be affirmed as being protective or deleterious,” added Dr. Sundar, who is also medical director of the Sleep-Wake Center at the University of Utah and a member of CHEST Physician’s editorial advisory board.
According to the study’s authors, their findings “suggest that patients with higher AHI are significantly more likely to have low cTn-I levels than patients without evidence of OSA, which could imply that patients with elevated AHI, particularly those with severe OSA, may experience less severe myocardial injury.”Limitations of the study include exclusion of patients with severe ACS, exclusion of sleepy subjects, and assessment of myocardial injury using cTn-I as a biomarker, without further data to determine infarct size.
“The possible role of OSA in cardioprotection should be explored in future studies,” the authors concluded.
The authors disclosed relationships with ResMed, Spanish Ministry of Health, Spanish Respiratory Society, Catalonian Cardiology Society, and ALLER. No other disclosures were reported.
chestphysiciannews@chestnet.org
SOURCE: Chest. 2018 Feb 5;153[2]:329-38. doi: 10.1016/j.chest.2017.06.046.
Although this study cannot definitively establish a clinically meaningful protective effect, it does provide important “preliminary evidence supporting the concept of OSA-induced cardioprotection” and challenges existing research, according to an editorial by Doron Aronson, MD, of the department of cardiology at Rambam Medical Center, Haifa, Israel, and coauthors (CHEST. 2018 Feb 153[2]:295-7. doi: 10.1016/j.chest.2017.07.036).
The results should be interpreted with caution, especially since accurate assessment of infarct size poses a challenge, they wrote.
“Myocardial infarct size is highly variable and is influenced by the duration of coronary occlusion, ST-segment elevation or non–ST elevation myocardial infarction, infarct location, residual antegrade infarct-related artery flow, collateral flow, the presence of non–culprit vessel coronary artery disease and myocardial metabolic demand,” they wrote. “Without accounting for these variables in a small study, results may be affected by variation in the characteristics of the patients.”
Though further study is needed, the findings may have “profound clinical implications regarding our therapeutic approach to patients with sleep apnea” if confirmed, the authors concluded.
Although this study cannot definitively establish a clinically meaningful protective effect, it does provide important “preliminary evidence supporting the concept of OSA-induced cardioprotection” and challenges existing research, according to an editorial by Doron Aronson, MD, of the department of cardiology at Rambam Medical Center, Haifa, Israel, and coauthors (CHEST. 2018 Feb 153[2]:295-7. doi: 10.1016/j.chest.2017.07.036).
The results should be interpreted with caution, especially since accurate assessment of infarct size poses a challenge, they wrote.
“Myocardial infarct size is highly variable and is influenced by the duration of coronary occlusion, ST-segment elevation or non–ST elevation myocardial infarction, infarct location, residual antegrade infarct-related artery flow, collateral flow, the presence of non–culprit vessel coronary artery disease and myocardial metabolic demand,” they wrote. “Without accounting for these variables in a small study, results may be affected by variation in the characteristics of the patients.”
Though further study is needed, the findings may have “profound clinical implications regarding our therapeutic approach to patients with sleep apnea” if confirmed, the authors concluded.
Although this study cannot definitively establish a clinically meaningful protective effect, it does provide important “preliminary evidence supporting the concept of OSA-induced cardioprotection” and challenges existing research, according to an editorial by Doron Aronson, MD, of the department of cardiology at Rambam Medical Center, Haifa, Israel, and coauthors (CHEST. 2018 Feb 153[2]:295-7. doi: 10.1016/j.chest.2017.07.036).
The results should be interpreted with caution, especially since accurate assessment of infarct size poses a challenge, they wrote.
“Myocardial infarct size is highly variable and is influenced by the duration of coronary occlusion, ST-segment elevation or non–ST elevation myocardial infarction, infarct location, residual antegrade infarct-related artery flow, collateral flow, the presence of non–culprit vessel coronary artery disease and myocardial metabolic demand,” they wrote. “Without accounting for these variables in a small study, results may be affected by variation in the characteristics of the patients.”
Though further study is needed, the findings may have “profound clinical implications regarding our therapeutic approach to patients with sleep apnea” if confirmed, the authors concluded.
, according to researchers.
In a study of 127 patients presenting with acute coronary syndromes (ACS), median peak cardiac troponin-I (cTn-I) values were significantly higher in patients without obstructive sleep apnea, compared with OSA patients (10.7; interquartile range: 1.78-40.1, vs. 3.79; IQR: 0.37-24.3, respectively; P = .04 ). The findings were published Feb. 5 in the journal CHEST®.
The study comprised 89 OSA patients and 38 non-OSA patients who were admitted to a hospital for acute coronary syndromes. The OSA group had a median apnea-hypopnea index (AHI) of 32, while the non-OSA group had a median AHI of 4.8. There was no significant difference between the two groups in gender, age, or cardiovascular risk factors such as hypertension, diabetes mellitus, body mass index, dyslipidemia, and smoking.
The cohort was part of the Continuous Positive Airway Pressure (CPAP) in Patients With Acute Coronary Syndrome and Obstructive Sleep Apnea (ISAACC) study, a prior randomized, controlled trial that evaluated the effect of CPAP treatment on new cardiovascular events in patients with an episode of ACS and OSA, reported Alicia Sánchez-de-la-Torre, PhD, of the respiratory department at Hospital Universitari Arnau de Vilanova and Santa Maria in Catalonia, Spain, and her coauthors.
Respiratory polygraphy was performed in the first 24-72 hours after hospital admission, and patients with an AHI of at least 15 events per hour were considered to have OSA. Those with an AHI less than 15 events per hour were included in the non-OSA group.
The OSA patients were randomized to conservative or CPAP treatment. An obstructive apnea “episode” was defined as a complete cessation of airflow for 10 seconds or longer, and an episode of hypopnea was defined as a reduction in airflow for at least 10 seconds associated with a greater than 4% decrease in arterial oxygen saturation.
Blood samples were collected from patients every 6 hours until two consecutive cTn-I measurements showed a decrease, with the highest measurement considered the peak cTn-I value.
Peak cTn-I value was significantly higher in non-OSA patients than in OSA patients. Median infarct size, measured by calculating the area under the cTn-I curve, was significantly different between the two groups (451 for non-OSA patients vs. 143 in OSA patients; P = .049), wrote Dr. Sánchez-de-la-Torre and her colleagues.
As cTn-I levels decreased, there was a trend toward increased OSA severity (P = .058). In the multivariable linear regression model used to assess OSA severity, patients with severe OSA had 61% lower cTn-I levels than non-OSA patients, the authors noted.
“The effects of chronic hypoxia in individual organ systems are not well understood. While chronic sustained hypoxia as seen with COPD may lead to pulmonary hypertension, chronic intermittent hypoxia (CIH) as seen predominantly in sleep apnea has been attributed to causing widespread effects ranging from systemic hypertension to metabolic dysfunction and systemic inflammation,” noted Krishna Sundar, MD, FCCP. “Despite these associations, an increased risk of major cardiovascular events from untreated OSA is yet to be definitively established.”
In this article, a protective effect from OSA on myocardial ischemic events is demonstrated in a group of 127 consecutively admitted patients with acute coronary syndrome (ACS). While it is interesting that a high proportion of those admitted for ACS had OSA, there were no significant differences in the age, sex, BMI, usage of antihypertensive or antiplatelet agents, presence of hypertension, DM, dyslipidemia or smoking status between those with and without OSA. “OSA appeared to confer a protective effect on the size of myocardial injury with those having higher AHI values demonstrating lower peak cardiac troponin values,” said Dr. Sundar, who is an associate clinical professor of pulmonary, critical care and sleep medicine at the University of Utah.“An effect of age (mean age in this study being 64 years) and BMI (mean being 27) on the occurrence of preconditioning effects of OSA is not excluded given deleterious effects of untreated OSA on infarct size in other studies on obese or younger patients with ACS. Further understanding of molecular effects of chronic hypoxia exposure (high altitude, chronic lung disease, OSA) is required before the complex and often contradictory effects of chronic hypoxia can be affirmed as being protective or deleterious,” added Dr. Sundar, who is also medical director of the Sleep-Wake Center at the University of Utah and a member of CHEST Physician’s editorial advisory board.
According to the study’s authors, their findings “suggest that patients with higher AHI are significantly more likely to have low cTn-I levels than patients without evidence of OSA, which could imply that patients with elevated AHI, particularly those with severe OSA, may experience less severe myocardial injury.”Limitations of the study include exclusion of patients with severe ACS, exclusion of sleepy subjects, and assessment of myocardial injury using cTn-I as a biomarker, without further data to determine infarct size.
“The possible role of OSA in cardioprotection should be explored in future studies,” the authors concluded.
The authors disclosed relationships with ResMed, Spanish Ministry of Health, Spanish Respiratory Society, Catalonian Cardiology Society, and ALLER. No other disclosures were reported.
chestphysiciannews@chestnet.org
SOURCE: Chest. 2018 Feb 5;153[2]:329-38. doi: 10.1016/j.chest.2017.06.046.
, according to researchers.
In a study of 127 patients presenting with acute coronary syndromes (ACS), median peak cardiac troponin-I (cTn-I) values were significantly higher in patients without obstructive sleep apnea, compared with OSA patients (10.7; interquartile range: 1.78-40.1, vs. 3.79; IQR: 0.37-24.3, respectively; P = .04 ). The findings were published Feb. 5 in the journal CHEST®.
The study comprised 89 OSA patients and 38 non-OSA patients who were admitted to a hospital for acute coronary syndromes. The OSA group had a median apnea-hypopnea index (AHI) of 32, while the non-OSA group had a median AHI of 4.8. There was no significant difference between the two groups in gender, age, or cardiovascular risk factors such as hypertension, diabetes mellitus, body mass index, dyslipidemia, and smoking.
The cohort was part of the Continuous Positive Airway Pressure (CPAP) in Patients With Acute Coronary Syndrome and Obstructive Sleep Apnea (ISAACC) study, a prior randomized, controlled trial that evaluated the effect of CPAP treatment on new cardiovascular events in patients with an episode of ACS and OSA, reported Alicia Sánchez-de-la-Torre, PhD, of the respiratory department at Hospital Universitari Arnau de Vilanova and Santa Maria in Catalonia, Spain, and her coauthors.
Respiratory polygraphy was performed in the first 24-72 hours after hospital admission, and patients with an AHI of at least 15 events per hour were considered to have OSA. Those with an AHI less than 15 events per hour were included in the non-OSA group.
The OSA patients were randomized to conservative or CPAP treatment. An obstructive apnea “episode” was defined as a complete cessation of airflow for 10 seconds or longer, and an episode of hypopnea was defined as a reduction in airflow for at least 10 seconds associated with a greater than 4% decrease in arterial oxygen saturation.
Blood samples were collected from patients every 6 hours until two consecutive cTn-I measurements showed a decrease, with the highest measurement considered the peak cTn-I value.
Peak cTn-I value was significantly higher in non-OSA patients than in OSA patients. Median infarct size, measured by calculating the area under the cTn-I curve, was significantly different between the two groups (451 for non-OSA patients vs. 143 in OSA patients; P = .049), wrote Dr. Sánchez-de-la-Torre and her colleagues.
As cTn-I levels decreased, there was a trend toward increased OSA severity (P = .058). In the multivariable linear regression model used to assess OSA severity, patients with severe OSA had 61% lower cTn-I levels than non-OSA patients, the authors noted.
“The effects of chronic hypoxia in individual organ systems are not well understood. While chronic sustained hypoxia as seen with COPD may lead to pulmonary hypertension, chronic intermittent hypoxia (CIH) as seen predominantly in sleep apnea has been attributed to causing widespread effects ranging from systemic hypertension to metabolic dysfunction and systemic inflammation,” noted Krishna Sundar, MD, FCCP. “Despite these associations, an increased risk of major cardiovascular events from untreated OSA is yet to be definitively established.”
In this article, a protective effect from OSA on myocardial ischemic events is demonstrated in a group of 127 consecutively admitted patients with acute coronary syndrome (ACS). While it is interesting that a high proportion of those admitted for ACS had OSA, there were no significant differences in the age, sex, BMI, usage of antihypertensive or antiplatelet agents, presence of hypertension, DM, dyslipidemia or smoking status between those with and without OSA. “OSA appeared to confer a protective effect on the size of myocardial injury with those having higher AHI values demonstrating lower peak cardiac troponin values,” said Dr. Sundar, who is an associate clinical professor of pulmonary, critical care and sleep medicine at the University of Utah.“An effect of age (mean age in this study being 64 years) and BMI (mean being 27) on the occurrence of preconditioning effects of OSA is not excluded given deleterious effects of untreated OSA on infarct size in other studies on obese or younger patients with ACS. Further understanding of molecular effects of chronic hypoxia exposure (high altitude, chronic lung disease, OSA) is required before the complex and often contradictory effects of chronic hypoxia can be affirmed as being protective or deleterious,” added Dr. Sundar, who is also medical director of the Sleep-Wake Center at the University of Utah and a member of CHEST Physician’s editorial advisory board.
According to the study’s authors, their findings “suggest that patients with higher AHI are significantly more likely to have low cTn-I levels than patients without evidence of OSA, which could imply that patients with elevated AHI, particularly those with severe OSA, may experience less severe myocardial injury.”Limitations of the study include exclusion of patients with severe ACS, exclusion of sleepy subjects, and assessment of myocardial injury using cTn-I as a biomarker, without further data to determine infarct size.
“The possible role of OSA in cardioprotection should be explored in future studies,” the authors concluded.
The authors disclosed relationships with ResMed, Spanish Ministry of Health, Spanish Respiratory Society, Catalonian Cardiology Society, and ALLER. No other disclosures were reported.
chestphysiciannews@chestnet.org
SOURCE: Chest. 2018 Feb 5;153[2]:329-38. doi: 10.1016/j.chest.2017.06.046.
New study establishes IBD severity index
Experts have established a severity index for inflammatory bowel disease (IBD), according to results of an analysis published in the journal Gut (doi: 10.1136/gutjnl-2016-312648). The index, conceived by a panel of IBD specialists from the International Organization for the Study of Inflammatory Bowel Diseases, is a step toward the standardization of disease severity definitions in ulcerative colitis and Crohn’s disease.
The panel determined 16 severity attributes for Crohn’s disease and 13 for ulcerative colitis. The analysis found that, in Crohn’s disease, mucosal lesions, fistulas, and abscesses were the greatest contributors to disease severity at 15.8%, 10.9%, and 9.7%, respectively. In ulcerative colitis, 18.1% of disease severity was attributed to mucosal lesions, 14% to impact on daily activities, and 11.2% to C-reactive protein, wrote Corey A. Siegel, MD, MS, of the Dartmouth-Hitchcock Medical Center in Lebanon, N.H., and his coauthors.
A type of conjoint analysis called adaptive choice-based conjoint was then performed to ascertain how different clinical factors influenced specialists’ decision making and impressions of disease severity. A series of questions was asked, with each response determining subsequent questions, until “ample consistency” was found in their choices.
The exercise first had participants decide which hypothetical patient profiles met their evaluation criteria; it then showed them two final profiles and asked which was the more severe case. Survey length depended on the consistency of participants’ responses, with those lacking consistency being given more tasks to complete, Dr. Siegel and his colleagues reported.
Respondents completed the exercise three times: first independently without discussion, then after discussion in a group setting with an automated response system, and finally, independently following group discussion. Disease severity indexes were created on a 100-point scale, and average part-worth utility scores were used to determine minimum and maximum scores for each attribute, with zero representing the absence of a symptom.
This analysis “helps redefine overall disease severity for IBD,” the authors wrote. Once validated, the indexes will offer “both further research opportunities and a practical tool by which to classify overall disease severity of patients and offer appropriate treatment without relying on present symptoms alone,” they added.
Dr. Siegel and colleagues noted that future studies should focus on prospective validation of the disease indexes in different patient populations, as well as conducting a conjoint analysis with patients.
“We expect this work to begin to address a change in how we think about patients with IBD and how to identify those at the higher end of the risk spectrum so that appropriate intensive treatment can be initiated and optimized in an efficient, precise, and cost effective manner,” they concluded.
The study was funded by AbbVie and Tillotts Pharma. The authors disclosed financial relationships with numerous additional pharmaceutical companies.
SOURCE: Siegel CA et al. Gut. 2018 Feb;67(2):244-54.
Experts have established a severity index for inflammatory bowel disease (IBD), according to results of an analysis published in the journal Gut (doi: 10.1136/gutjnl-2016-312648). The index, conceived by a panel of IBD specialists from the International Organization for the Study of Inflammatory Bowel Diseases, is a step toward the standardization of disease severity definitions in ulcerative colitis and Crohn’s disease.
The panel determined 16 severity attributes for Crohn’s disease and 13 for ulcerative colitis. The analysis found that, in Crohn’s disease, mucosal lesions, fistulas, and abscesses were the greatest contributors to disease severity at 15.8%, 10.9%, and 9.7%, respectively. In ulcerative colitis, 18.1% of disease severity was attributed to mucosal lesions, 14% to impact on daily activities, and 11.2% to C-reactive protein, wrote Corey A. Siegel, MD, MS, of the Dartmouth-Hitchcock Medical Center in Lebanon, N.H., and his coauthors.
A type of conjoint analysis called adaptive choice-based conjoint was then performed to ascertain how different clinical factors influenced specialists’ decision making and impressions of disease severity. A series of questions was asked, with each response determining subsequent questions, until “ample consistency” was found in their choices.
The exercise first had participants decide which hypothetical patient profiles met their evaluation criteria; it then showed them two final profiles and asked which was the more severe case. Survey length depended on the consistency of participants’ responses, with those lacking consistency being given more tasks to complete, Dr. Siegel and his colleagues reported.
Respondents completed the exercise three times: first independently without discussion, then after discussion in a group setting with an automated response system, and finally, independently following group discussion. Disease severity indexes were created on a 100-point scale, and average part-worth utility scores were used to determine minimum and maximum scores for each attribute, with zero representing the absence of a symptom.
This analysis “helps redefine overall disease severity for IBD,” the authors wrote. Once validated, the indexes will offer “both further research opportunities and a practical tool by which to classify overall disease severity of patients and offer appropriate treatment without relying on present symptoms alone,” they added.
Dr. Siegel and colleagues noted that future studies should focus on prospective validation of the disease indexes in different patient populations, as well as conducting a conjoint analysis with patients.
“We expect this work to begin to address a change in how we think about patients with IBD and how to identify those at the higher end of the risk spectrum so that appropriate intensive treatment can be initiated and optimized in an efficient, precise, and cost effective manner,” they concluded.
The study was funded by AbbVie and Tillotts Pharma. The authors disclosed financial relationships with numerous additional pharmaceutical companies.
SOURCE: Siegel CA et al. Gut. 2018 Feb;67(2):244-54.
Experts have established a severity index for inflammatory bowel disease (IBD), according to results of an analysis published in the journal Gut (doi: 10.1136/gutjnl-2016-312648). The index, conceived by a panel of IBD specialists from the International Organization for the Study of Inflammatory Bowel Diseases, is a step toward the standardization of disease severity definitions in ulcerative colitis and Crohn’s disease.
The panel determined 16 severity attributes for Crohn’s disease and 13 for ulcerative colitis. The analysis found that, in Crohn’s disease, mucosal lesions, fistulas, and abscesses were the greatest contributors to disease severity at 15.8%, 10.9%, and 9.7%, respectively. In ulcerative colitis, 18.1% of disease severity was attributed to mucosal lesions, 14% to impact on daily activities, and 11.2% to C-reactive protein, wrote Corey A. Siegel, MD, MS, of the Dartmouth-Hitchcock Medical Center in Lebanon, N.H., and his coauthors.
A type of conjoint analysis called adaptive choice-based conjoint was then performed to ascertain how different clinical factors influenced specialists’ decision making and impressions of disease severity. A series of questions was asked, with each response determining subsequent questions, until “ample consistency” was found in their choices.
The exercise first had participants decide which hypothetical patient profiles met their evaluation criteria; it then showed them two final profiles and asked which was the more severe case. Survey length depended on the consistency of participants’ responses, with those lacking consistency being given more tasks to complete, Dr. Siegel and his colleagues reported.
Respondents completed the exercise three times: first independently without discussion, then after discussion in a group setting with an automated response system, and finally, independently following group discussion. Disease severity indexes were created on a 100-point scale, and average part-worth utility scores were used to determine minimum and maximum scores for each attribute, with zero representing the absence of a symptom.
This analysis “helps redefine overall disease severity for IBD,” the authors wrote. Once validated, the indexes will offer “both further research opportunities and a practical tool by which to classify overall disease severity of patients and offer appropriate treatment without relying on present symptoms alone,” they added.
Dr. Siegel and colleagues noted that future studies should focus on prospective validation of the disease indexes in different patient populations, as well as conducting a conjoint analysis with patients.
“We expect this work to begin to address a change in how we think about patients with IBD and how to identify those at the higher end of the risk spectrum so that appropriate intensive treatment can be initiated and optimized in an efficient, precise, and cost effective manner,” they concluded.
The study was funded by AbbVie and Tillotts Pharma. The authors disclosed financial relationships with numerous additional pharmaceutical companies.
SOURCE: Siegel CA et al. Gut. 2018 Feb;67(2):244-54.
FROM GUT
Key clinical point: Crohn’s disease severity was dependent on intestinal damage, whereas ulcerative colitis disease severity was associated with symptoms and effects on daily life.
Major finding: Sixteen severity attributes were determined for Crohn’s disease, and 13 for ulcerative colitis; in Crohn’s disease, mucosal lesions, fistula, and abscess were the greatest contributors to disease severity at 15.8%, 10.9%, and 9.7%, respectively. In ulcerative colitis, 18.1% of disease severity was attributed to mucosal lesions, 14% to impact on daily activities, and 11.2% to C-reactive protein.
Data source: A conjoint analysis of disease attributes performed by 18 members of the International Organization for the Study of Inflammatory Bowel Diseases.
Disclosures: The study was funded by AbbVie and Tillotts Pharma. The authors disclosed financial relationships with numerous additional pharmaceutical companies.
Source: Siegel CA et al. Gut. 2018 Feb;67(2):244-54.
Early childhood vaccines not associated with increased infection risk
There was no significant difference in vaccine antigen exposure through the first 23 months of life between children with non–vaccine-targeted infections and controls between 24 and 47 months of age, according to results published March 6 in JAMA.
This was determined in a nested, matched case-control study of 193 infection cases and 751 controls, in whom estimated mean cumulative vaccine antigen exposure was 240.6 for cases of non–vaccine-targeted infections, and 242.9 for controls, reported Jason M. Glanz, PhD, of Kaiser Permanente Colorado, Denver, and his coauthors. The between-group difference was –2.3 (P = .55), a nonsignificant difference.
Using data from the Centers for Disease Control and Prevention-funded Vaccine Safety Datalink (VSD), the investigators identified children born between Jan. 1, 2003, and Sep. 31, 2013. Exclusion criteria were not having at least two well-child visits before the first birthday, medical contraindications to vaccination, or receiving vaccines not recommended by the Advisory Committee on Immunization Practices. Eligible children were followed through age 47 months or until disenrollment from their health care organization, the authors said.
ICD-9 and ICD-10 codes were used to identify non–vaccine-targeted infections, including upper and lower respiratory infections, gastrointestinal infections, and other viral and bacterial infections from ages 24to 47 months. A medical record review was performed to confirm case status. Cases were included only if it was confirmed that the infection occurred, that it was an incident outcome, that the outcome was the primary reason for the medical visit, that the outcome occurred in the inpatient or emergency department setting, and that there was no evidence that the child was diagnosed as having a vaccine preventable disease (VPD) on the same day as the infection. Controls did not have a VPD or record of a non–vaccine-targeted infection prior to the index date, Dr. Glanz and his colleagues said.
Antigen exposure was measured as the number of immunogenic proteins and polysaccharides in each vaccine, and was estimated from birth through age 23 months in both groups. Cumulative antigen exposure was estimated by adding the number of antigens in each non–vaccine-targeted infection and controls.
Estimated mean cumulative vaccine antigen exposure was 240.6 for cases of non–vaccine-targeted infections, and 242.9 for controls, the authors reported. The matched odds ratio (mOR) for estimated cumulative antigen exposure through age 23 months was not significant in children with infections, compared with controls (mOR = 0.94; 95% confidence interval, 0.84-1.07). The estimated maximum single-day antigen exposure was not significantly associated with non–vaccine-targeted infection (mOR = 1.07; 95% CI, 0.81-1.41).
The findings of this study “did not reveal any beneficial or detrimental associations with estimated cumulative vaccine antigen exposure in young children with non–vaccine-targeted infections in ED and inpatient settings,” wrote Dr. Glanz and coauthors. In addition, the study “did not find evidence that multiple vaccine exposure was associated with the risk for non-targeted infectious diseases.”
The CDC funded the study. The authors reported receiving contracts, grants, and other funding from the CDC.
SOURCE: Glanz JM et al. JAMA. 2018;319(9):906-13.
These results provide “further reassurance about the safety of the U.S. child vaccination schedule,” said Sean T. O’Leary, MD, and Yvonne A. Maldonado, MD.
However, they added, more work must be done to strengthen the public’s trust and confidence in vaccines. Parents long have voiced concerns that vaccines might weaken their children’s immune systems.
“The small but vocal minority of anti-vaccine groups may not be satisfied by the evidence provided through VSD and other vaccine safety surveillance,” they wrote. “Simply providing scientific information and assuming parents will make the decision to vaccinate is not enough.
“Delivering evidence-based information to parents and clinicians in ways that inspire confidence in the robust and safe childhood immunization schedule is critical for maintaining the health of children,” they concluded.
Dr. O’Leary and Dr. Maldonado, both of the University of Colorado, Aurora, commented in an editorial accompanying the article by Glanz et al. (JAMA. 2018 Mar 6;319(9):870-1). Dr. Maldonado reported receiving personal fees for serving on a data and safety monitoring board for Pfizer. Dr. O’Leary reported no relevant financial disclosures.
These results provide “further reassurance about the safety of the U.S. child vaccination schedule,” said Sean T. O’Leary, MD, and Yvonne A. Maldonado, MD.
However, they added, more work must be done to strengthen the public’s trust and confidence in vaccines. Parents long have voiced concerns that vaccines might weaken their children’s immune systems.
“The small but vocal minority of anti-vaccine groups may not be satisfied by the evidence provided through VSD and other vaccine safety surveillance,” they wrote. “Simply providing scientific information and assuming parents will make the decision to vaccinate is not enough.
“Delivering evidence-based information to parents and clinicians in ways that inspire confidence in the robust and safe childhood immunization schedule is critical for maintaining the health of children,” they concluded.
Dr. O’Leary and Dr. Maldonado, both of the University of Colorado, Aurora, commented in an editorial accompanying the article by Glanz et al. (JAMA. 2018 Mar 6;319(9):870-1). Dr. Maldonado reported receiving personal fees for serving on a data and safety monitoring board for Pfizer. Dr. O’Leary reported no relevant financial disclosures.
These results provide “further reassurance about the safety of the U.S. child vaccination schedule,” said Sean T. O’Leary, MD, and Yvonne A. Maldonado, MD.
However, they added, more work must be done to strengthen the public’s trust and confidence in vaccines. Parents long have voiced concerns that vaccines might weaken their children’s immune systems.
“The small but vocal minority of anti-vaccine groups may not be satisfied by the evidence provided through VSD and other vaccine safety surveillance,” they wrote. “Simply providing scientific information and assuming parents will make the decision to vaccinate is not enough.
“Delivering evidence-based information to parents and clinicians in ways that inspire confidence in the robust and safe childhood immunization schedule is critical for maintaining the health of children,” they concluded.
Dr. O’Leary and Dr. Maldonado, both of the University of Colorado, Aurora, commented in an editorial accompanying the article by Glanz et al. (JAMA. 2018 Mar 6;319(9):870-1). Dr. Maldonado reported receiving personal fees for serving on a data and safety monitoring board for Pfizer. Dr. O’Leary reported no relevant financial disclosures.
There was no significant difference in vaccine antigen exposure through the first 23 months of life between children with non–vaccine-targeted infections and controls between 24 and 47 months of age, according to results published March 6 in JAMA.
This was determined in a nested, matched case-control study of 193 infection cases and 751 controls, in whom estimated mean cumulative vaccine antigen exposure was 240.6 for cases of non–vaccine-targeted infections, and 242.9 for controls, reported Jason M. Glanz, PhD, of Kaiser Permanente Colorado, Denver, and his coauthors. The between-group difference was –2.3 (P = .55), a nonsignificant difference.
Using data from the Centers for Disease Control and Prevention-funded Vaccine Safety Datalink (VSD), the investigators identified children born between Jan. 1, 2003, and Sep. 31, 2013. Exclusion criteria were not having at least two well-child visits before the first birthday, medical contraindications to vaccination, or receiving vaccines not recommended by the Advisory Committee on Immunization Practices. Eligible children were followed through age 47 months or until disenrollment from their health care organization, the authors said.
ICD-9 and ICD-10 codes were used to identify non–vaccine-targeted infections, including upper and lower respiratory infections, gastrointestinal infections, and other viral and bacterial infections from ages 24to 47 months. A medical record review was performed to confirm case status. Cases were included only if it was confirmed that the infection occurred, that it was an incident outcome, that the outcome was the primary reason for the medical visit, that the outcome occurred in the inpatient or emergency department setting, and that there was no evidence that the child was diagnosed as having a vaccine preventable disease (VPD) on the same day as the infection. Controls did not have a VPD or record of a non–vaccine-targeted infection prior to the index date, Dr. Glanz and his colleagues said.
Antigen exposure was measured as the number of immunogenic proteins and polysaccharides in each vaccine, and was estimated from birth through age 23 months in both groups. Cumulative antigen exposure was estimated by adding the number of antigens in each non–vaccine-targeted infection and controls.
Estimated mean cumulative vaccine antigen exposure was 240.6 for cases of non–vaccine-targeted infections, and 242.9 for controls, the authors reported. The matched odds ratio (mOR) for estimated cumulative antigen exposure through age 23 months was not significant in children with infections, compared with controls (mOR = 0.94; 95% confidence interval, 0.84-1.07). The estimated maximum single-day antigen exposure was not significantly associated with non–vaccine-targeted infection (mOR = 1.07; 95% CI, 0.81-1.41).
The findings of this study “did not reveal any beneficial or detrimental associations with estimated cumulative vaccine antigen exposure in young children with non–vaccine-targeted infections in ED and inpatient settings,” wrote Dr. Glanz and coauthors. In addition, the study “did not find evidence that multiple vaccine exposure was associated with the risk for non-targeted infectious diseases.”
The CDC funded the study. The authors reported receiving contracts, grants, and other funding from the CDC.
SOURCE: Glanz JM et al. JAMA. 2018;319(9):906-13.
There was no significant difference in vaccine antigen exposure through the first 23 months of life between children with non–vaccine-targeted infections and controls between 24 and 47 months of age, according to results published March 6 in JAMA.
This was determined in a nested, matched case-control study of 193 infection cases and 751 controls, in whom estimated mean cumulative vaccine antigen exposure was 240.6 for cases of non–vaccine-targeted infections, and 242.9 for controls, reported Jason M. Glanz, PhD, of Kaiser Permanente Colorado, Denver, and his coauthors. The between-group difference was –2.3 (P = .55), a nonsignificant difference.
Using data from the Centers for Disease Control and Prevention-funded Vaccine Safety Datalink (VSD), the investigators identified children born between Jan. 1, 2003, and Sep. 31, 2013. Exclusion criteria were not having at least two well-child visits before the first birthday, medical contraindications to vaccination, or receiving vaccines not recommended by the Advisory Committee on Immunization Practices. Eligible children were followed through age 47 months or until disenrollment from their health care organization, the authors said.
ICD-9 and ICD-10 codes were used to identify non–vaccine-targeted infections, including upper and lower respiratory infections, gastrointestinal infections, and other viral and bacterial infections from ages 24to 47 months. A medical record review was performed to confirm case status. Cases were included only if it was confirmed that the infection occurred, that it was an incident outcome, that the outcome was the primary reason for the medical visit, that the outcome occurred in the inpatient or emergency department setting, and that there was no evidence that the child was diagnosed as having a vaccine preventable disease (VPD) on the same day as the infection. Controls did not have a VPD or record of a non–vaccine-targeted infection prior to the index date, Dr. Glanz and his colleagues said.
Antigen exposure was measured as the number of immunogenic proteins and polysaccharides in each vaccine, and was estimated from birth through age 23 months in both groups. Cumulative antigen exposure was estimated by adding the number of antigens in each non–vaccine-targeted infection and controls.
Estimated mean cumulative vaccine antigen exposure was 240.6 for cases of non–vaccine-targeted infections, and 242.9 for controls, the authors reported. The matched odds ratio (mOR) for estimated cumulative antigen exposure through age 23 months was not significant in children with infections, compared with controls (mOR = 0.94; 95% confidence interval, 0.84-1.07). The estimated maximum single-day antigen exposure was not significantly associated with non–vaccine-targeted infection (mOR = 1.07; 95% CI, 0.81-1.41).
The findings of this study “did not reveal any beneficial or detrimental associations with estimated cumulative vaccine antigen exposure in young children with non–vaccine-targeted infections in ED and inpatient settings,” wrote Dr. Glanz and coauthors. In addition, the study “did not find evidence that multiple vaccine exposure was associated with the risk for non-targeted infectious diseases.”
The CDC funded the study. The authors reported receiving contracts, grants, and other funding from the CDC.
SOURCE: Glanz JM et al. JAMA. 2018;319(9):906-13.
FROM JAMA
Key clinical point: No significant difference was found in vaccine antigen exposure between controls and children with infectious diseases not targeted by vaccines.
Major finding: Estimated mean cumulative vaccine antigen exposure was 240.6 for cases and 242.9 for controls.
Study details: A matched case-control study of 944 patients enrolled in six integrated health care organizations as part of the Vaccine Safety Datalink (VSD).
Disclosures: The Centers for Disease Control and Prevention funded the study. The authors reported receiving contracts, grants, and other funding from the CDC.
Source: Glanz JM et al. JAMA. 2018;319(9):906-13.
Treatment priorities often differ between RA patients, clinicians
Patients with RA and their clinicians approach treatment goals differently based on knowledge, illness experience, and competing priorities, according to findings from a qualitative study.
The results of this study underscore “the tension between having an explicit shared goal between clinicians and patients, and experiencing inherently different – and at times opposing – conceptualization of how one formulates or achieves said goal,” wrote Jennifer L. Barton, MD, of the Department of Veteran Affairs Portland Health Care System and Oregon Health & Science University, Portland, and her coauthors.
Two domains – disease knowledge and psychosocial dynamics – emerged across all focus groups, Dr. Barton and her colleagues reported in Arthritis Care & Research.
Disease knowledge and education
In the knowledge domain, themes that emerged were informed choice, medication adherence and safety, and clinician assumption of patients’ inability to interpret information. Patients disclosed, for instance, a desire for more information on disease progression and medication side effects to inform future clinician visits, and often sought such information on the Internet.
“Patients highlighted the importance of RA knowledge to understanding what was happening to them physically and the impact of medication on their bodies, and their need to seek information outside of the clinical visit,” the authors noted.
Whereas patients discussed medications in the context of informed decision making, “many clinicians connected RA education to risk of nonadherence and medication safety,” the authors reported. Additionally, “patients did not discuss their adherence to clinician treatment recommendations, though patients expressed dissatisfaction with clinicians who they believed dismissed their medication concerns.”
Some clinicians expressed frustration with patients’ self-education efforts and attitudes toward alternative medicine, and patients reported feeling as though doctors had “diminished the importance of information” they shared.
“Several clinicians voiced perceived paradoxes in current expectations of their professional role as an expert who also defers to patient preferences,” the authors said. “Many clinicians voiced frustration with patients seeking knowledge from what they considered unreliable sources, which prompted varying levels of comfort among clinicians with some adopting a more paternalistic stance.”
Psychosocial dynamics of RA illness
The psychosocial dynamics domain focused on stress and found that patients’ experiences with RA informed their treatment preferences and affected patient-provider communication. For instance, patients who experienced inability to participate in activities because of pain or fatigue prioritized treatment goals aimed at pain reduction and increased energy, with minimal side effects.
“In contrast, clinicians talked about using objective clinical markers” to inform treatment strategy, the authors said. Although they acknowledged the psychosocial stress experienced by patients, clinicians cited limited time and resources as a main reason for their inability to adequately address these concerns.
Both patients and clinicians acknowledged the role of fear in the disease experience, with providers asserting that patients’ fear “disrupted effective communication and complicated patient willingness to follow treatment recommendations,” the authors said.
Lastly, both patients and clinicians described treatment decisions as a “negotiation” in which patients’ priorities of quality of life improvements, such as pain reduction, often were at odds with objective clinical goals of the provider, such as addressing underlying damage.
“Patients indicated that clinician goals focused on objective clinical markers and helping patients achieve remission; however, patients expressed a desire for clinicians to look beyond clinical markers and consider patients’ quality of life goals as well as being open to multiple treatment possibilities,” the authors said.
Areas for improvement
The results of the study highlight potential areas for improvement in patient-clinician communication, namely by balancing the imparting of clinician knowledge with sincere consideration of patient preferences and priorities. “The mismatch in attitudes towards the goal of knowledge between patients and clinicians may lead to suboptimal communication and lack of trust,” the authors wrote. “Patients’ desire for information on a range of RA topics is important, but the value attached to that knowledge is where patients and clinicians diverge.”
Resources aimed at facilitating a conversation around goals may lead to greater goal concordance, which could potentially result in more high value treatment, the authors concluded. “With tools and training to support patient goal-directed care in rheumatology, improved outcomes and reduced disparities may be achieved.”
The study was funded by a grant to Dr. Barton from the National Institutes of Health.
SOURCE: Barton JL et al. Arthritis Care Res. 2018 Feb 13. doi: 10.1002/acr.23541.
Patients with RA and their clinicians approach treatment goals differently based on knowledge, illness experience, and competing priorities, according to findings from a qualitative study.
The results of this study underscore “the tension between having an explicit shared goal between clinicians and patients, and experiencing inherently different – and at times opposing – conceptualization of how one formulates or achieves said goal,” wrote Jennifer L. Barton, MD, of the Department of Veteran Affairs Portland Health Care System and Oregon Health & Science University, Portland, and her coauthors.
Two domains – disease knowledge and psychosocial dynamics – emerged across all focus groups, Dr. Barton and her colleagues reported in Arthritis Care & Research.
Disease knowledge and education
In the knowledge domain, themes that emerged were informed choice, medication adherence and safety, and clinician assumption of patients’ inability to interpret information. Patients disclosed, for instance, a desire for more information on disease progression and medication side effects to inform future clinician visits, and often sought such information on the Internet.
“Patients highlighted the importance of RA knowledge to understanding what was happening to them physically and the impact of medication on their bodies, and their need to seek information outside of the clinical visit,” the authors noted.
Whereas patients discussed medications in the context of informed decision making, “many clinicians connected RA education to risk of nonadherence and medication safety,” the authors reported. Additionally, “patients did not discuss their adherence to clinician treatment recommendations, though patients expressed dissatisfaction with clinicians who they believed dismissed their medication concerns.”
Some clinicians expressed frustration with patients’ self-education efforts and attitudes toward alternative medicine, and patients reported feeling as though doctors had “diminished the importance of information” they shared.
“Several clinicians voiced perceived paradoxes in current expectations of their professional role as an expert who also defers to patient preferences,” the authors said. “Many clinicians voiced frustration with patients seeking knowledge from what they considered unreliable sources, which prompted varying levels of comfort among clinicians with some adopting a more paternalistic stance.”
Psychosocial dynamics of RA illness
The psychosocial dynamics domain focused on stress and found that patients’ experiences with RA informed their treatment preferences and affected patient-provider communication. For instance, patients who experienced inability to participate in activities because of pain or fatigue prioritized treatment goals aimed at pain reduction and increased energy, with minimal side effects.
“In contrast, clinicians talked about using objective clinical markers” to inform treatment strategy, the authors said. Although they acknowledged the psychosocial stress experienced by patients, clinicians cited limited time and resources as a main reason for their inability to adequately address these concerns.
Both patients and clinicians acknowledged the role of fear in the disease experience, with providers asserting that patients’ fear “disrupted effective communication and complicated patient willingness to follow treatment recommendations,” the authors said.
Lastly, both patients and clinicians described treatment decisions as a “negotiation” in which patients’ priorities of quality of life improvements, such as pain reduction, often were at odds with objective clinical goals of the provider, such as addressing underlying damage.
“Patients indicated that clinician goals focused on objective clinical markers and helping patients achieve remission; however, patients expressed a desire for clinicians to look beyond clinical markers and consider patients’ quality of life goals as well as being open to multiple treatment possibilities,” the authors said.
Areas for improvement
The results of the study highlight potential areas for improvement in patient-clinician communication, namely by balancing the imparting of clinician knowledge with sincere consideration of patient preferences and priorities. “The mismatch in attitudes towards the goal of knowledge between patients and clinicians may lead to suboptimal communication and lack of trust,” the authors wrote. “Patients’ desire for information on a range of RA topics is important, but the value attached to that knowledge is where patients and clinicians diverge.”
Resources aimed at facilitating a conversation around goals may lead to greater goal concordance, which could potentially result in more high value treatment, the authors concluded. “With tools and training to support patient goal-directed care in rheumatology, improved outcomes and reduced disparities may be achieved.”
The study was funded by a grant to Dr. Barton from the National Institutes of Health.
SOURCE: Barton JL et al. Arthritis Care Res. 2018 Feb 13. doi: 10.1002/acr.23541.
Patients with RA and their clinicians approach treatment goals differently based on knowledge, illness experience, and competing priorities, according to findings from a qualitative study.
The results of this study underscore “the tension between having an explicit shared goal between clinicians and patients, and experiencing inherently different – and at times opposing – conceptualization of how one formulates or achieves said goal,” wrote Jennifer L. Barton, MD, of the Department of Veteran Affairs Portland Health Care System and Oregon Health & Science University, Portland, and her coauthors.
Two domains – disease knowledge and psychosocial dynamics – emerged across all focus groups, Dr. Barton and her colleagues reported in Arthritis Care & Research.
Disease knowledge and education
In the knowledge domain, themes that emerged were informed choice, medication adherence and safety, and clinician assumption of patients’ inability to interpret information. Patients disclosed, for instance, a desire for more information on disease progression and medication side effects to inform future clinician visits, and often sought such information on the Internet.
“Patients highlighted the importance of RA knowledge to understanding what was happening to them physically and the impact of medication on their bodies, and their need to seek information outside of the clinical visit,” the authors noted.
Whereas patients discussed medications in the context of informed decision making, “many clinicians connected RA education to risk of nonadherence and medication safety,” the authors reported. Additionally, “patients did not discuss their adherence to clinician treatment recommendations, though patients expressed dissatisfaction with clinicians who they believed dismissed their medication concerns.”
Some clinicians expressed frustration with patients’ self-education efforts and attitudes toward alternative medicine, and patients reported feeling as though doctors had “diminished the importance of information” they shared.
“Several clinicians voiced perceived paradoxes in current expectations of their professional role as an expert who also defers to patient preferences,” the authors said. “Many clinicians voiced frustration with patients seeking knowledge from what they considered unreliable sources, which prompted varying levels of comfort among clinicians with some adopting a more paternalistic stance.”
Psychosocial dynamics of RA illness
The psychosocial dynamics domain focused on stress and found that patients’ experiences with RA informed their treatment preferences and affected patient-provider communication. For instance, patients who experienced inability to participate in activities because of pain or fatigue prioritized treatment goals aimed at pain reduction and increased energy, with minimal side effects.
“In contrast, clinicians talked about using objective clinical markers” to inform treatment strategy, the authors said. Although they acknowledged the psychosocial stress experienced by patients, clinicians cited limited time and resources as a main reason for their inability to adequately address these concerns.
Both patients and clinicians acknowledged the role of fear in the disease experience, with providers asserting that patients’ fear “disrupted effective communication and complicated patient willingness to follow treatment recommendations,” the authors said.
Lastly, both patients and clinicians described treatment decisions as a “negotiation” in which patients’ priorities of quality of life improvements, such as pain reduction, often were at odds with objective clinical goals of the provider, such as addressing underlying damage.
“Patients indicated that clinician goals focused on objective clinical markers and helping patients achieve remission; however, patients expressed a desire for clinicians to look beyond clinical markers and consider patients’ quality of life goals as well as being open to multiple treatment possibilities,” the authors said.
Areas for improvement
The results of the study highlight potential areas for improvement in patient-clinician communication, namely by balancing the imparting of clinician knowledge with sincere consideration of patient preferences and priorities. “The mismatch in attitudes towards the goal of knowledge between patients and clinicians may lead to suboptimal communication and lack of trust,” the authors wrote. “Patients’ desire for information on a range of RA topics is important, but the value attached to that knowledge is where patients and clinicians diverge.”
Resources aimed at facilitating a conversation around goals may lead to greater goal concordance, which could potentially result in more high value treatment, the authors concluded. “With tools and training to support patient goal-directed care in rheumatology, improved outcomes and reduced disparities may be achieved.”
The study was funded by a grant to Dr. Barton from the National Institutes of Health.
SOURCE: Barton JL et al. Arthritis Care Res. 2018 Feb 13. doi: 10.1002/acr.23541.
FROM ARTHRITIS CARE & RESEARCH
Key clinical point:
Major finding: In the knowledge domain, recurrent issues were informed choice, medication adherence, and clinician assumption of patient inability to interpret information; the psychosocial dynamics domain found that patient illness experience affected treatment decisions and patient-provider communication.
Data source: A qualitative focus group study of 19 RA patients and 18 clinicians.
Disclosures: The study was funded by a grant to Dr. Barton from the National Institutes of Health.
Source: Barton JL et al. Arthritis Care Res. 2018 Feb 13. doi: 10.1002/acr.23541.
RA associated with higher risk of psychiatric disorders
The incidence and prevalence of anxiety disorder, depression, and bipolar disorder are higher among patients with rheumatoid arthritis than individuals from the general population, according to findings from a Canadian retrospective matched cohort study.
In the study of 10,206 rheumatoid arthritis (RA) patients and 50,960 individuals matched from the general population of Manitoba between 1989 and 2012, depression incidence was higher in the RA group, compared with the matched group, when adjusted for factors including age, sex, year, region of residence, and socioeconomic status (incidence rate ratio = 1.46; 95% confidence interval, 1.35-1.58). Incidence of anxiety disorder (IRR = 1.24; 95% CI, 1.15-1.34) and bipolar disorder (IRR = 1.21; 95% CI, 1.00-1.47) were also higher in the RA group. The incidence of schizophrenia did not differ between groups (IRR = 0.96; 95% CI, 0.61-1.50), Ruth Ann Marrie, MD, PhD, of the University of Manitoba, Winnipeg, and her coauthors reported in Arthritis Care & Research.
To estimate psychiatric disorder incidence after RA diagnosis (or the index date in the matched population), the first claim had to occur after the index date, and had to be preceded by a 5-year period with no claims for that psychiatric disorder. To estimate lifetime prevalence, once a patient met the case definition for a disorder, he or she was considered affected in all subsequent years if alive and a Manitoba resident. To account for varying periods of remission, however, annual period prevalence was defined as a patient having one or more hospital claims or two or more physician claims for the disorder in that year, Dr. Marrie and her colleagues wrote.
The adjusted lifetime prevalence was also higher in the RA group for both depression (PR = 1.35; 95% CI, 1.26-1.45) and anxiety disorder (PR = 1.20; 95% CI, 1.13-1.27), as was the annual period prevalence of depression (PR = 1.36; 95% CI, 1.26-1.47) and anxiety disorder (PR = 1.30; 95% CI, 1.19-1.41). Neither lifetime prevalence of bipolar disorder (PR = 1.13; 95% CI, 0.95-1.36) and schizophrenia (PR = 1.02; 95% CI, 0.72-1.43) nor annual period prevalence of bipolar disorder (PR = 1.06; 95% CI, 0.86-1.31) and schizophrenia (PR = 0.68; 95% CI, 0.40-1.15) differed between the RA and matched cohorts, the authors reported.
Female sex was associated with risk of psychiatric disease, as was lower socioeconomic status and living in an urban area, the authors reported.
Although the study had strengths including a large study population and use of population-based data, it did not evaluate psychiatric multimorbidity, a “common and clinically relevant issue which may affect outcomes,” Dr. Marrie and her coauthors said in the report. Additionally, the use of administrative data makes it difficult to account for care provided by nonphysician providers, such as psychologists, and for conditions that cause symptoms but do not meet diagnostic criteria, the authors noted.
“Future studies should explore these issues in population-based clinical cohorts which comprehensively evaluate multiple psychiatric disorders,” they concluded.
The study was funded by the Canadian Institutes of Health Research and the Waugh Family Chair in Multiple Sclerosis. Dr. Marrie has conducted clinical trials for Sanofi Aventis. Two other authors disclosed financial ties to pharmaceutical companies.
SOURCE: Marrie R et al. Arthritis Care Res. 2018 Feb 13. doi: 10.1002/acr.23539.
The incidence and prevalence of anxiety disorder, depression, and bipolar disorder are higher among patients with rheumatoid arthritis than individuals from the general population, according to findings from a Canadian retrospective matched cohort study.
In the study of 10,206 rheumatoid arthritis (RA) patients and 50,960 individuals matched from the general population of Manitoba between 1989 and 2012, depression incidence was higher in the RA group, compared with the matched group, when adjusted for factors including age, sex, year, region of residence, and socioeconomic status (incidence rate ratio = 1.46; 95% confidence interval, 1.35-1.58). Incidence of anxiety disorder (IRR = 1.24; 95% CI, 1.15-1.34) and bipolar disorder (IRR = 1.21; 95% CI, 1.00-1.47) were also higher in the RA group. The incidence of schizophrenia did not differ between groups (IRR = 0.96; 95% CI, 0.61-1.50), Ruth Ann Marrie, MD, PhD, of the University of Manitoba, Winnipeg, and her coauthors reported in Arthritis Care & Research.
To estimate psychiatric disorder incidence after RA diagnosis (or the index date in the matched population), the first claim had to occur after the index date, and had to be preceded by a 5-year period with no claims for that psychiatric disorder. To estimate lifetime prevalence, once a patient met the case definition for a disorder, he or she was considered affected in all subsequent years if alive and a Manitoba resident. To account for varying periods of remission, however, annual period prevalence was defined as a patient having one or more hospital claims or two or more physician claims for the disorder in that year, Dr. Marrie and her colleagues wrote.
The adjusted lifetime prevalence was also higher in the RA group for both depression (PR = 1.35; 95% CI, 1.26-1.45) and anxiety disorder (PR = 1.20; 95% CI, 1.13-1.27), as was the annual period prevalence of depression (PR = 1.36; 95% CI, 1.26-1.47) and anxiety disorder (PR = 1.30; 95% CI, 1.19-1.41). Neither lifetime prevalence of bipolar disorder (PR = 1.13; 95% CI, 0.95-1.36) and schizophrenia (PR = 1.02; 95% CI, 0.72-1.43) nor annual period prevalence of bipolar disorder (PR = 1.06; 95% CI, 0.86-1.31) and schizophrenia (PR = 0.68; 95% CI, 0.40-1.15) differed between the RA and matched cohorts, the authors reported.
Female sex was associated with risk of psychiatric disease, as was lower socioeconomic status and living in an urban area, the authors reported.
Although the study had strengths including a large study population and use of population-based data, it did not evaluate psychiatric multimorbidity, a “common and clinically relevant issue which may affect outcomes,” Dr. Marrie and her coauthors said in the report. Additionally, the use of administrative data makes it difficult to account for care provided by nonphysician providers, such as psychologists, and for conditions that cause symptoms but do not meet diagnostic criteria, the authors noted.
“Future studies should explore these issues in population-based clinical cohorts which comprehensively evaluate multiple psychiatric disorders,” they concluded.
The study was funded by the Canadian Institutes of Health Research and the Waugh Family Chair in Multiple Sclerosis. Dr. Marrie has conducted clinical trials for Sanofi Aventis. Two other authors disclosed financial ties to pharmaceutical companies.
SOURCE: Marrie R et al. Arthritis Care Res. 2018 Feb 13. doi: 10.1002/acr.23539.
The incidence and prevalence of anxiety disorder, depression, and bipolar disorder are higher among patients with rheumatoid arthritis than individuals from the general population, according to findings from a Canadian retrospective matched cohort study.
In the study of 10,206 rheumatoid arthritis (RA) patients and 50,960 individuals matched from the general population of Manitoba between 1989 and 2012, depression incidence was higher in the RA group, compared with the matched group, when adjusted for factors including age, sex, year, region of residence, and socioeconomic status (incidence rate ratio = 1.46; 95% confidence interval, 1.35-1.58). Incidence of anxiety disorder (IRR = 1.24; 95% CI, 1.15-1.34) and bipolar disorder (IRR = 1.21; 95% CI, 1.00-1.47) were also higher in the RA group. The incidence of schizophrenia did not differ between groups (IRR = 0.96; 95% CI, 0.61-1.50), Ruth Ann Marrie, MD, PhD, of the University of Manitoba, Winnipeg, and her coauthors reported in Arthritis Care & Research.
To estimate psychiatric disorder incidence after RA diagnosis (or the index date in the matched population), the first claim had to occur after the index date, and had to be preceded by a 5-year period with no claims for that psychiatric disorder. To estimate lifetime prevalence, once a patient met the case definition for a disorder, he or she was considered affected in all subsequent years if alive and a Manitoba resident. To account for varying periods of remission, however, annual period prevalence was defined as a patient having one or more hospital claims or two or more physician claims for the disorder in that year, Dr. Marrie and her colleagues wrote.
The adjusted lifetime prevalence was also higher in the RA group for both depression (PR = 1.35; 95% CI, 1.26-1.45) and anxiety disorder (PR = 1.20; 95% CI, 1.13-1.27), as was the annual period prevalence of depression (PR = 1.36; 95% CI, 1.26-1.47) and anxiety disorder (PR = 1.30; 95% CI, 1.19-1.41). Neither lifetime prevalence of bipolar disorder (PR = 1.13; 95% CI, 0.95-1.36) and schizophrenia (PR = 1.02; 95% CI, 0.72-1.43) nor annual period prevalence of bipolar disorder (PR = 1.06; 95% CI, 0.86-1.31) and schizophrenia (PR = 0.68; 95% CI, 0.40-1.15) differed between the RA and matched cohorts, the authors reported.
Female sex was associated with risk of psychiatric disease, as was lower socioeconomic status and living in an urban area, the authors reported.
Although the study had strengths including a large study population and use of population-based data, it did not evaluate psychiatric multimorbidity, a “common and clinically relevant issue which may affect outcomes,” Dr. Marrie and her coauthors said in the report. Additionally, the use of administrative data makes it difficult to account for care provided by nonphysician providers, such as psychologists, and for conditions that cause symptoms but do not meet diagnostic criteria, the authors noted.
“Future studies should explore these issues in population-based clinical cohorts which comprehensively evaluate multiple psychiatric disorders,” they concluded.
The study was funded by the Canadian Institutes of Health Research and the Waugh Family Chair in Multiple Sclerosis. Dr. Marrie has conducted clinical trials for Sanofi Aventis. Two other authors disclosed financial ties to pharmaceutical companies.
SOURCE: Marrie R et al. Arthritis Care Res. 2018 Feb 13. doi: 10.1002/acr.23539.
FROM ARTHRITIS CARE & RESEARCH
Key clinical point:
Major finding: Incidence of depression (IRR = 1.46; 95% CI, 1.35-1.58), anxiety disorder (IRR = 1.24; 95% CI, 1.15-1.34), and bipolar disorder (IRR = 1.21; 95% CI, 1.00-1.47) were higher in the RA group than in the matched group.
Data source: A retrospective matched cohort study of 10,206 RA patients and 50,960 matched individuals from the general population between 1989 and 2012.
Disclosures: The study was funded by the Canadian Institutes of Health Research and the Waugh Family Chair in Multiple Sclerosis. Dr. Marrie has conducted clinical trials for Sanofi Aventis. Two other authors disclosed financial ties to pharmaceutical companies.
Source: Marrie R et al. Arthritis Care Res. 2018 Feb 13. doi: 10.1002/acr.23539
OSA may provide cardioprotection
, according to researchers.
In a study of 127 patients presenting with acute coronary syndromes (ACS), median peak cardiac troponin-I (cTn-I) values were significantly higher in patients without obstructive sleep apnea, compared with OSA patients (10.7; interquartile range: 1.78-40.1, vs. 3.79; IQR: 0.37-24.3, respectively; P = .04 ). The findings were published Feb. 5 in CHEST.
The study comprised 89 OSA patients and 38 non-OSA patients who were admitted to a hospital for acute coronary syndromes. The OSA group had a median apnea-hypopnea index (AHI) of 32, while the non-OSA group had a median AHI of 4.8. There was no significant difference between the two groups in gender, age, or cardiovascular risk factors such as hypertension, diabetes mellitus, body mass index, dyslipidemia, and smoking.
The cohort was part of the Continuous Positive Airway Pressure (CPAP) in Patients With Acute Coronary Syndrome and Obstructive Sleep Apnea (ISAACC) study, a prior randomized, controlled trial that evaluated the effect of CPAP treatment on new cardiovascular events in patients with an episode of ACS and OSA, reported Alicia Sánchez-de-la-Torre, PhD, of the respiratory department at Hospital Universitari Arnau de Vilanova and Santa Maria in Catalonia, Spain, and her coauthors.
Respiratory polygraphy was performed in the first 24-72 hours after hospital admission, and patients with an AHI of at least 15 events per hour were considered to have OSA. Those with an AHI less than 15 events per hour were included in the non-OSA group.
Blood samples were collected from patients every 6 hours until two consecutive cTn-I measurements showed a decrease, with the highest measurement considered the peak cTn-I value.
Peak cTn-I value was significantly higher in non-OSA patients than in OSA patients. Median infarct size, measured by calculating the area under the cTn-I curve, was significantly different between the two groups (451 for non-OSA patients vs. 143 in OSA patients; P = .049), wrote Dr. Sánchez-de-la-Torre and her colleagues.
As cTn-I levels decreased, there was a trend toward increased OSA severity (P = .058). In the multivariable linear regression model used to assess OSA severity, patients with severe OSA had 61% lower cTn-I levels than non-OSA patients, the authors noted.
“These results suggest that patients with higher AHI are significantly more likely to have low cTn-I levels than patients without evidence of OSA, which could imply that patients with elevated AHI, particularly those with severe OSA, may experience less severe myocardial injury,” the authors said in the report. The findings “suggest that OSA has a protective effect in the context of MI,” they added.
Limitations of the study include exclusion of patients with severe ACS, exclusion of sleepy subjects, and assessment of myocardial injury using cTn-I as a biomarker, without further data to determine infarct size.
“The possible role of OSA in cardioprotection should be explored in future studies,” the authors concluded.
The authors disclosed relationships with ResMed Inc., Spanish Ministry of Health, Spanish Respiratory Society, Catalonian Cardiology Society, and ALLER. No other disclosures were reported.
SOURCE: Chest. 2018 Feb 5;153[2]:329-38. doi: 10.1016/j.chest.2017.06.046
Although this study cannot definitively establish a clinically meaningful protective effect, it does provide important “preliminary evidence supporting the concept of OSA-induced cardioprotection” and challenges existing research, according to an editorial by Doron Aronson, MD, of the department of cardiology at Rambam Medical Center, Haifa, Israel, and coauthors (CHEST. 2018 Feb 153[2]:295-7. doi: 10.1016/j.chest.2017.07.036).
The results should be interpreted with caution, especially since accurate assessment of infarct size poses a challenge, they wrote.
“Myocardial infarct size is highly variable and is influenced by the duration of coronary occlusion, ST-segment elevation or non–ST elevation myocardial infarction, infarct location, residual antegrade infarct-related artery flow, collateral flow, the presence of non–culprit vessel coronary artery disease and myocardial metabolic demand,” they wrote. “Without accounting for these variables in a small study, results may be affected by variation in the characteristics of the patients.”
Though further study is needed, the findings may have “profound clinical implications regarding our therapeutic approach to patients with sleep apnea” if confirmed, the authors concluded.
Although this study cannot definitively establish a clinically meaningful protective effect, it does provide important “preliminary evidence supporting the concept of OSA-induced cardioprotection” and challenges existing research, according to an editorial by Doron Aronson, MD, of the department of cardiology at Rambam Medical Center, Haifa, Israel, and coauthors (CHEST. 2018 Feb 153[2]:295-7. doi: 10.1016/j.chest.2017.07.036).
The results should be interpreted with caution, especially since accurate assessment of infarct size poses a challenge, they wrote.
“Myocardial infarct size is highly variable and is influenced by the duration of coronary occlusion, ST-segment elevation or non–ST elevation myocardial infarction, infarct location, residual antegrade infarct-related artery flow, collateral flow, the presence of non–culprit vessel coronary artery disease and myocardial metabolic demand,” they wrote. “Without accounting for these variables in a small study, results may be affected by variation in the characteristics of the patients.”
Though further study is needed, the findings may have “profound clinical implications regarding our therapeutic approach to patients with sleep apnea” if confirmed, the authors concluded.
Although this study cannot definitively establish a clinically meaningful protective effect, it does provide important “preliminary evidence supporting the concept of OSA-induced cardioprotection” and challenges existing research, according to an editorial by Doron Aronson, MD, of the department of cardiology at Rambam Medical Center, Haifa, Israel, and coauthors (CHEST. 2018 Feb 153[2]:295-7. doi: 10.1016/j.chest.2017.07.036).
The results should be interpreted with caution, especially since accurate assessment of infarct size poses a challenge, they wrote.
“Myocardial infarct size is highly variable and is influenced by the duration of coronary occlusion, ST-segment elevation or non–ST elevation myocardial infarction, infarct location, residual antegrade infarct-related artery flow, collateral flow, the presence of non–culprit vessel coronary artery disease and myocardial metabolic demand,” they wrote. “Without accounting for these variables in a small study, results may be affected by variation in the characteristics of the patients.”
Though further study is needed, the findings may have “profound clinical implications regarding our therapeutic approach to patients with sleep apnea” if confirmed, the authors concluded.
, according to researchers.
In a study of 127 patients presenting with acute coronary syndromes (ACS), median peak cardiac troponin-I (cTn-I) values were significantly higher in patients without obstructive sleep apnea, compared with OSA patients (10.7; interquartile range: 1.78-40.1, vs. 3.79; IQR: 0.37-24.3, respectively; P = .04 ). The findings were published Feb. 5 in CHEST.
The study comprised 89 OSA patients and 38 non-OSA patients who were admitted to a hospital for acute coronary syndromes. The OSA group had a median apnea-hypopnea index (AHI) of 32, while the non-OSA group had a median AHI of 4.8. There was no significant difference between the two groups in gender, age, or cardiovascular risk factors such as hypertension, diabetes mellitus, body mass index, dyslipidemia, and smoking.
The cohort was part of the Continuous Positive Airway Pressure (CPAP) in Patients With Acute Coronary Syndrome and Obstructive Sleep Apnea (ISAACC) study, a prior randomized, controlled trial that evaluated the effect of CPAP treatment on new cardiovascular events in patients with an episode of ACS and OSA, reported Alicia Sánchez-de-la-Torre, PhD, of the respiratory department at Hospital Universitari Arnau de Vilanova and Santa Maria in Catalonia, Spain, and her coauthors.
Respiratory polygraphy was performed in the first 24-72 hours after hospital admission, and patients with an AHI of at least 15 events per hour were considered to have OSA. Those with an AHI less than 15 events per hour were included in the non-OSA group.
Blood samples were collected from patients every 6 hours until two consecutive cTn-I measurements showed a decrease, with the highest measurement considered the peak cTn-I value.
Peak cTn-I value was significantly higher in non-OSA patients than in OSA patients. Median infarct size, measured by calculating the area under the cTn-I curve, was significantly different between the two groups (451 for non-OSA patients vs. 143 in OSA patients; P = .049), wrote Dr. Sánchez-de-la-Torre and her colleagues.
As cTn-I levels decreased, there was a trend toward increased OSA severity (P = .058). In the multivariable linear regression model used to assess OSA severity, patients with severe OSA had 61% lower cTn-I levels than non-OSA patients, the authors noted.
“These results suggest that patients with higher AHI are significantly more likely to have low cTn-I levels than patients without evidence of OSA, which could imply that patients with elevated AHI, particularly those with severe OSA, may experience less severe myocardial injury,” the authors said in the report. The findings “suggest that OSA has a protective effect in the context of MI,” they added.
Limitations of the study include exclusion of patients with severe ACS, exclusion of sleepy subjects, and assessment of myocardial injury using cTn-I as a biomarker, without further data to determine infarct size.
“The possible role of OSA in cardioprotection should be explored in future studies,” the authors concluded.
The authors disclosed relationships with ResMed Inc., Spanish Ministry of Health, Spanish Respiratory Society, Catalonian Cardiology Society, and ALLER. No other disclosures were reported.
SOURCE: Chest. 2018 Feb 5;153[2]:329-38. doi: 10.1016/j.chest.2017.06.046
, according to researchers.
In a study of 127 patients presenting with acute coronary syndromes (ACS), median peak cardiac troponin-I (cTn-I) values were significantly higher in patients without obstructive sleep apnea, compared with OSA patients (10.7; interquartile range: 1.78-40.1, vs. 3.79; IQR: 0.37-24.3, respectively; P = .04 ). The findings were published Feb. 5 in CHEST.
The study comprised 89 OSA patients and 38 non-OSA patients who were admitted to a hospital for acute coronary syndromes. The OSA group had a median apnea-hypopnea index (AHI) of 32, while the non-OSA group had a median AHI of 4.8. There was no significant difference between the two groups in gender, age, or cardiovascular risk factors such as hypertension, diabetes mellitus, body mass index, dyslipidemia, and smoking.
The cohort was part of the Continuous Positive Airway Pressure (CPAP) in Patients With Acute Coronary Syndrome and Obstructive Sleep Apnea (ISAACC) study, a prior randomized, controlled trial that evaluated the effect of CPAP treatment on new cardiovascular events in patients with an episode of ACS and OSA, reported Alicia Sánchez-de-la-Torre, PhD, of the respiratory department at Hospital Universitari Arnau de Vilanova and Santa Maria in Catalonia, Spain, and her coauthors.
Respiratory polygraphy was performed in the first 24-72 hours after hospital admission, and patients with an AHI of at least 15 events per hour were considered to have OSA. Those with an AHI less than 15 events per hour were included in the non-OSA group.
Blood samples were collected from patients every 6 hours until two consecutive cTn-I measurements showed a decrease, with the highest measurement considered the peak cTn-I value.
Peak cTn-I value was significantly higher in non-OSA patients than in OSA patients. Median infarct size, measured by calculating the area under the cTn-I curve, was significantly different between the two groups (451 for non-OSA patients vs. 143 in OSA patients; P = .049), wrote Dr. Sánchez-de-la-Torre and her colleagues.
As cTn-I levels decreased, there was a trend toward increased OSA severity (P = .058). In the multivariable linear regression model used to assess OSA severity, patients with severe OSA had 61% lower cTn-I levels than non-OSA patients, the authors noted.
“These results suggest that patients with higher AHI are significantly more likely to have low cTn-I levels than patients without evidence of OSA, which could imply that patients with elevated AHI, particularly those with severe OSA, may experience less severe myocardial injury,” the authors said in the report. The findings “suggest that OSA has a protective effect in the context of MI,” they added.
Limitations of the study include exclusion of patients with severe ACS, exclusion of sleepy subjects, and assessment of myocardial injury using cTn-I as a biomarker, without further data to determine infarct size.
“The possible role of OSA in cardioprotection should be explored in future studies,” the authors concluded.
The authors disclosed relationships with ResMed Inc., Spanish Ministry of Health, Spanish Respiratory Society, Catalonian Cardiology Society, and ALLER. No other disclosures were reported.
SOURCE: Chest. 2018 Feb 5;153[2]:329-38. doi: 10.1016/j.chest.2017.06.046
FROM CHEST
Key clinical point: Obstructive sleep apnea may have a protective effect in acute coronary syndromes.
Major finding: Median peak cTn-I value was significantly higher in patients without obstructive sleep apnea than in OSA patients (10.7, interquartile range: 1.78-40.1 vs. 3.79; IQR: 0.37-24.3 respectively; P = .04).
Data source: An observational study of 89 OSA and 38 non-OSA patients admitted for acute coronary syndromes.
Disclosures: The authors disclosed relationships with ResMed Inc., Spanish Ministry of Health, Spanish Respiratory Society, Catalonian Cardiology Society, and ALLER.
Source: Sánchez-de-la-Torre, A et al. CHEST. 2018 Feb 5;153[2]:329-38.