Mary Ann Moon

Measles-containing vaccines are less likely to be associated with seizures when given at 12-15 months of age as recommended than when delayed until 16-23 months of age, according to results from a study published online Oct. 14 in JAMA Pediatrics.

In the retrospective cohort study examining the effect of age at immunization on 840,348 U.S. children given the MMR or MMRV vaccines during the second year of life in 2001-2011, "we found that the magnitude of increased risk of seizures following immunization with measles-containing vaccines during the second year of life depends on age.

"While measles-containing vaccines administered at 12-15 months of age are associated with an increased risk of seizures 7-10 days following immunization, their delayed administration at 16-23 months of age may result in an even greater increased risk of that adverse event following immunization," said Dr. Ali Rowhani-Rahbar of the department of epidemiology at the University of Washington, Seattle, and his associates.

The reason for this age-related difference in seizure risk is not yet known. It may simply be attributable to the fact that the background risk of seizures is higher in the older age group. Or a better-functioning immune system at the older age may allow children to mount a more rigorous immunologic response to the vaccine, raising the risk of febrile seizures.

It also is possible that vaccination is delayed among children thought to be susceptible to seizures for medical reasons, and that these children are more likely to develop seizures when they finally are vaccinated at the later age.

Regardless of the reasons for this age association, the increase in risk of seizures was very small for all age groups.

"Our findings are of direct relevance to the recommended childhood immunization schedule; they support the timely immunization of children with the first dose of measles-containing vaccine in accordance with current recommendations," the researchers noted.

Dr. Rowhani-Rahbar and his colleagues used data from the Centers for Disease Control and Prevention’s Vaccine Safety Datalink to examine this issue. The incidence of seizures was analyzed for each child during the 7- to 10-day "exposure period" following immunization and compared with the "control period" of the 42 days after that interval.

Then the rates of seizures were compared between children who were vaccinated at 12-15 months of age and those who were vaccinated at 16-23 months of age.

Overall, there were 1,810 seizure events during the 42 days following immunization, including 519 events (28.7%) that occurred during the 7- to 10-day exposure period.

The incidence of seizures during the control intervals was consistent with background rates reported in the general population. It also peaked at age 16-18 months, which is consistent with the peak that occurs in the general population.

The overall incidence of seizures was significantly higher during the exposure periods than the control intervals at all ages.

The most important finding was that the relative risk of seizures during the exposure interval was significantly greater among children vaccinated at 16-23 months of age (RR, 6.5) than among those vaccinated at 12-15 months of age (RR, 3.4) , the investigators reported (JAMA Pediatr. 2013 Oct. 14 [doi: 10.1001/jamapediatrics.2013.2745]).

The attributable risk was 9.5 excess cases of seizure per 10,000 doses given at 16-23 months of age, compared with 4.0 excess cases of seizure per 10,000 doses given at 12-15 months of age. These results remained robust in a sensitivity analysis of the data.

"These findings collectively suggest that the administration of measles-containing vaccines at the age of highest vulnerability to febrile seizures may result in an even greater increased risk of those adverse events following immunization," Dr. Rowhani-Rahbar and his associates said.

This study was supported by the CDC-sponsored Vaccine Safety Database through a subcontract with America’s Health Insurance Plans. Dr. Rowhani-Rahbar reported no financial conflicts of interest; his associates reported ties to GlaxoSmithKline, Merck, and other companies.

Measles-containing vaccines are less likely to be associated with seizures when given at 12-15 months of age as recommended than when delayed until 16-23 months of age, according to results from a study published online Oct. 14 in JAMA Pediatrics.

In the retrospective cohort study examining the effect of age at immunization on 840,348 U.S. children given the MMR or MMRV vaccines during the second year of life in 2001-2011, "we found that the magnitude of increased risk of seizures following immunization with measles-containing vaccines during the second year of life depends on age.

"While measles-containing vaccines administered at 12-15 months of age are associated with an increased risk of seizures 7-10 days following immunization, their delayed administration at 16-23 months of age may result in an even greater increased risk of that adverse event following immunization," said Dr. Ali Rowhani-Rahbar of the department of epidemiology at the University of Washington, Seattle, and his associates.

The reason for this age-related difference in seizure risk is not yet known. It may simply be attributable to the fact that the background risk of seizures is higher in the older age group. Or a better-functioning immune system at the older age may allow children to mount a more rigorous immunologic response to the vaccine, raising the risk of febrile seizures.

It also is possible that vaccination is delayed among children thought to be susceptible to seizures for medical reasons, and that these children are more likely to develop seizures when they finally are vaccinated at the later age.

Regardless of the reasons for this age association, the increase in risk of seizures was very small for all age groups.

"Our findings are of direct relevance to the recommended childhood immunization schedule; they support the timely immunization of children with the first dose of measles-containing vaccine in accordance with current recommendations," the researchers noted.

Dr. Rowhani-Rahbar and his colleagues used data from the Centers for Disease Control and Prevention’s Vaccine Safety Datalink to examine this issue. The incidence of seizures was analyzed for each child during the 7- to 10-day "exposure period" following immunization and compared with the "control period" of the 42 days after that interval.

Then the rates of seizures were compared between children who were vaccinated at 12-15 months of age and those who were vaccinated at 16-23 months of age.

Overall, there were 1,810 seizure events during the 42 days following immunization, including 519 events (28.7%) that occurred during the 7- to 10-day exposure period.

The incidence of seizures during the control intervals was consistent with background rates reported in the general population. It also peaked at age 16-18 months, which is consistent with the peak that occurs in the general population.

The overall incidence of seizures was significantly higher during the exposure periods than the control intervals at all ages.

The most important finding was that the relative risk of seizures during the exposure interval was significantly greater among children vaccinated at 16-23 months of age (RR, 6.5) than among those vaccinated at 12-15 months of age (RR, 3.4) , the investigators reported (JAMA Pediatr. 2013 Oct. 14 [doi: 10.1001/jamapediatrics.2013.2745]).

The attributable risk was 9.5 excess cases of seizure per 10,000 doses given at 16-23 months of age, compared with 4.0 excess cases of seizure per 10,000 doses given at 12-15 months of age. These results remained robust in a sensitivity analysis of the data.

"These findings collectively suggest that the administration of measles-containing vaccines at the age of highest vulnerability to febrile seizures may result in an even greater increased risk of those adverse events following immunization," Dr. Rowhani-Rahbar and his associates said.

This study was supported by the CDC-sponsored Vaccine Safety Database through a subcontract with America’s Health Insurance Plans. Dr. Rowhani-Rahbar reported no financial conflicts of interest; his associates reported ties to GlaxoSmithKline, Merck, and other companies.

Measles-containing vaccines are less likely to be associated with seizures when given at 12-15 months of age as recommended than when delayed until 16-23 months of age, according to results from a study published online Oct. 14 in JAMA Pediatrics.

In the retrospective cohort study examining the effect of age at immunization on 840,348 U.S. children given the MMR or MMRV vaccines during the second year of life in 2001-2011, "we found that the magnitude of increased risk of seizures following immunization with measles-containing vaccines during the second year of life depends on age.

"While measles-containing vaccines administered at 12-15 months of age are associated with an increased risk of seizures 7-10 days following immunization, their delayed administration at 16-23 months of age may result in an even greater increased risk of that adverse event following immunization," said Dr. Ali Rowhani-Rahbar of the department of epidemiology at the University of Washington, Seattle, and his associates.

The reason for this age-related difference in seizure risk is not yet known. It may simply be attributable to the fact that the background risk of seizures is higher in the older age group. Or a better-functioning immune system at the older age may allow children to mount a more rigorous immunologic response to the vaccine, raising the risk of febrile seizures.

It also is possible that vaccination is delayed among children thought to be susceptible to seizures for medical reasons, and that these children are more likely to develop seizures when they finally are vaccinated at the later age.

Regardless of the reasons for this age association, the increase in risk of seizures was very small for all age groups.

"Our findings are of direct relevance to the recommended childhood immunization schedule; they support the timely immunization of children with the first dose of measles-containing vaccine in accordance with current recommendations," the researchers noted.

Dr. Rowhani-Rahbar and his colleagues used data from the Centers for Disease Control and Prevention’s Vaccine Safety Datalink to examine this issue. The incidence of seizures was analyzed for each child during the 7- to 10-day "exposure period" following immunization and compared with the "control period" of the 42 days after that interval.

Then the rates of seizures were compared between children who were vaccinated at 12-15 months of age and those who were vaccinated at 16-23 months of age.

Overall, there were 1,810 seizure events during the 42 days following immunization, including 519 events (28.7%) that occurred during the 7- to 10-day exposure period.

The incidence of seizures during the control intervals was consistent with background rates reported in the general population. It also peaked at age 16-18 months, which is consistent with the peak that occurs in the general population.

The overall incidence of seizures was significantly higher during the exposure periods than the control intervals at all ages.

The most important finding was that the relative risk of seizures during the exposure interval was significantly greater among children vaccinated at 16-23 months of age (RR, 6.5) than among those vaccinated at 12-15 months of age (RR, 3.4) , the investigators reported (JAMA Pediatr. 2013 Oct. 14 [doi: 10.1001/jamapediatrics.2013.2745]).

The attributable risk was 9.5 excess cases of seizure per 10,000 doses given at 16-23 months of age, compared with 4.0 excess cases of seizure per 10,000 doses given at 12-15 months of age. These results remained robust in a sensitivity analysis of the data.

"These findings collectively suggest that the administration of measles-containing vaccines at the age of highest vulnerability to febrile seizures may result in an even greater increased risk of those adverse events following immunization," Dr. Rowhani-Rahbar and his associates said.

This study was supported by the CDC-sponsored Vaccine Safety Database through a subcontract with America’s Health Insurance Plans. Dr. Rowhani-Rahbar reported no financial conflicts of interest; his associates reported ties to GlaxoSmithKline, Merck, and other companies.

A panel of six readily available biomarkers and clinical traits proved to be very good at predicting which women with systemic lupus erythematosus are at increased risk for cardiovascular events based on serial carotid artery ultrasound exams in a prospective case-control study.

Women with SLE who scored as "high risk" on the PREDICTS scale had a 28-fold increased odds of having or acquiring carotid plaque on serial ultrasound exams performed during a 2-year period than did SLE patients with lower scores. They also were at much higher risk of showing plaque progression (odds ratio, 15.5), reported Dr. Maureen McMahon of the rheumatology division at the University of California, Los Angeles (UCLA), Medical Center and her associates.

The PREDICTS (Predictors of Risk for Elevated Flares, Damage Progression, and Increased Cardiovascular Disease in Patients with SLE) score was more accurate at predicting the incidence or progression of carotid plaque than were any individual biomarkers or any panel of traditional cardiovascular risk factors in SLE patients, the investigators noted.

Longer follow-up is needed to definitively establish that carotid plaque deposition in these patients corresponds to later CVD events, and thus that the PREDICTS score predicts actual CVD events. Further study also will determine whether identifying these high-risk patients can guide preventive treatment and avert CVD events, the authors added.

Accelerated atherosclerosis is known to be more common in SLE patients than in the general population and to occur at a younger age. It causes significant morbidity and mortality and is thought to be related to the chronic inflammation underlying SLE.

Dr. McMahon and her colleagues assessed combinations of several biomarkers and risk factors, both traditional and novel, to develop a screen for identifying which SLE patients are at high CVD risk. They enrolled 210 women (mean age, 41 years) attending rheumatology practices at UCLA and Cedars Sinai medical centers who underwent a baseline ultrasound examination of the carotid artery and at least one follow-up ultrasound within a mean of 30 months, as well as 100 age-matched healthy control women who did not have SLE. Participants who had active renal disease or were taking statins were excluded from the study so as to avoid enrollment of women with known inflammation and hyperlipidemia.

The study subjects provided fasting blood samples that were tested for lipids, homocysteine, and high-sensitivity C-reactive protein. They also completed questionnaires that assessed SLE activity, organ damage, medications, and nonlaboratory CVD risk factors.

Univariate analysis showed that the presence, development, and progression of carotid plaque all were strongly associated with two traditional clinical factors – older age (48 years or older) and a history of diabetes – as well as four biomarkers of inflammation: high-density lipoprotein function (not HDL level), leptin level, homocysteine level, and soluble tumor necrosis factor–like weak inducer of apoptosis (sTWEAK) level.

HDL particles are anti-inflammatory in the basal state but become proinflammatory during an acute phase response. The chronic inflammation of SLE thus may inhibit HDL’s cardioprotective action and even promote cardiovascular damage, according to the investigators

Hyperleptinemia is associated with hypertension, oxidative stress, and endothelial dysfunction, and is known to be more common in SLE patients than in the general population. Homocysteine is a known indicator of inflammation and a predictor of cardiovascular disease. A high sTWEAK level has been linked to atherosclerosis, inflammation, angiogenesis, and apoptosis in laboratory studies, as well as to increased CVD mortality in other patient populations, Dr. McMahon and her associates said.

These six most significant independent predictors of incident or progressive carotid plaque were fashioned into the PREDICTS score, which proved to have the best overall predictive profile of any of the variables tested alone and in combination (Arthritis Rheum. 2013 Sept. 24 [doi: 10.1002/art.38204]).

For incident carotid plaque, the PREDICTS score had a sensitivity of 81%, a specificity of 79%, a positive predictive value of 40%, and a negative predictive value of 95%. SLE patients who earned a "high-risk" PREDICTS score had 28-fold higher odds of showing plaque at baseline or at follow-up ultrasound exam, compared with SLE patients whose scores didn’t indicate high risk.

In addition, SLE patients who had high-risk PREDICTS scores were significantly more likely than those who did not to show carotid plaque progression, a higher mean intima-media thickness, a higher rate of increase of intima-media thickness, and a higher mean number of new plaques per year.

In a multivariate analysis, the only variable significantly associated with carotid plaque progression over time was the PREDICTS score, with an odds ratio of 15.5.

Five participants, all of whom were SLE patients, had a documented incident cardiovascular event during follow-up, and all of them had a high PREDICTS score at baseline. In addition, 17 participants had a cerebrovascular event during follow-up, and 9 of them had high PREDICTS scores at baseline.

If these findings are verified in future research, the PREDICTS score could help clinicians identify which SLE patients are at high risk for atherosclerosis and, by implication, cardiovascular events, Dr. McMahon and her associates said.

"Although we have examined multiple biomarkers for atherosclerosis and SLE in this study and previously, our study was not exhaustive. It is likely that other, additional biomarkers have been or will be identified as promising candidates" to include in the PREDICTS scale, they added.

This study was supported by the Lupus Research Institute, the Alliance for Lupus Research, the American College of Rheumatology Research and Education Foundation, the National Institutes of Health, the Arthritis Foundation, the Iris Cantor Women’s Health Foundation, the Arthritis National Research Foundation, and a Kirkland Award.

A panel of six readily available biomarkers and clinical traits proved to be very good at predicting which women with systemic lupus erythematosus are at increased risk for cardiovascular events based on serial carotid artery ultrasound exams in a prospective case-control study.

Women with SLE who scored as "high risk" on the PREDICTS scale had a 28-fold increased odds of having or acquiring carotid plaque on serial ultrasound exams performed during a 2-year period than did SLE patients with lower scores. They also were at much higher risk of showing plaque progression (odds ratio, 15.5), reported Dr. Maureen McMahon of the rheumatology division at the University of California, Los Angeles (UCLA), Medical Center and her associates.

The PREDICTS (Predictors of Risk for Elevated Flares, Damage Progression, and Increased Cardiovascular Disease in Patients with SLE) score was more accurate at predicting the incidence or progression of carotid plaque than were any individual biomarkers or any panel of traditional cardiovascular risk factors in SLE patients, the investigators noted.

Longer follow-up is needed to definitively establish that carotid plaque deposition in these patients corresponds to later CVD events, and thus that the PREDICTS score predicts actual CVD events. Further study also will determine whether identifying these high-risk patients can guide preventive treatment and avert CVD events, the authors added.

Accelerated atherosclerosis is known to be more common in SLE patients than in the general population and to occur at a younger age. It causes significant morbidity and mortality and is thought to be related to the chronic inflammation underlying SLE.

Dr. McMahon and her colleagues assessed combinations of several biomarkers and risk factors, both traditional and novel, to develop a screen for identifying which SLE patients are at high CVD risk. They enrolled 210 women (mean age, 41 years) attending rheumatology practices at UCLA and Cedars Sinai medical centers who underwent a baseline ultrasound examination of the carotid artery and at least one follow-up ultrasound within a mean of 30 months, as well as 100 age-matched healthy control women who did not have SLE. Participants who had active renal disease or were taking statins were excluded from the study so as to avoid enrollment of women with known inflammation and hyperlipidemia.

The study subjects provided fasting blood samples that were tested for lipids, homocysteine, and high-sensitivity C-reactive protein. They also completed questionnaires that assessed SLE activity, organ damage, medications, and nonlaboratory CVD risk factors.

Univariate analysis showed that the presence, development, and progression of carotid plaque all were strongly associated with two traditional clinical factors – older age (48 years or older) and a history of diabetes – as well as four biomarkers of inflammation: high-density lipoprotein function (not HDL level), leptin level, homocysteine level, and soluble tumor necrosis factor–like weak inducer of apoptosis (sTWEAK) level.

HDL particles are anti-inflammatory in the basal state but become proinflammatory during an acute phase response. The chronic inflammation of SLE thus may inhibit HDL’s cardioprotective action and even promote cardiovascular damage, according to the investigators

Hyperleptinemia is associated with hypertension, oxidative stress, and endothelial dysfunction, and is known to be more common in SLE patients than in the general population. Homocysteine is a known indicator of inflammation and a predictor of cardiovascular disease. A high sTWEAK level has been linked to atherosclerosis, inflammation, angiogenesis, and apoptosis in laboratory studies, as well as to increased CVD mortality in other patient populations, Dr. McMahon and her associates said.

These six most significant independent predictors of incident or progressive carotid plaque were fashioned into the PREDICTS score, which proved to have the best overall predictive profile of any of the variables tested alone and in combination (Arthritis Rheum. 2013 Sept. 24 [doi: 10.1002/art.38204]).

For incident carotid plaque, the PREDICTS score had a sensitivity of 81%, a specificity of 79%, a positive predictive value of 40%, and a negative predictive value of 95%. SLE patients who earned a "high-risk" PREDICTS score had 28-fold higher odds of showing plaque at baseline or at follow-up ultrasound exam, compared with SLE patients whose scores didn’t indicate high risk.

In addition, SLE patients who had high-risk PREDICTS scores were significantly more likely than those who did not to show carotid plaque progression, a higher mean intima-media thickness, a higher rate of increase of intima-media thickness, and a higher mean number of new plaques per year.

In a multivariate analysis, the only variable significantly associated with carotid plaque progression over time was the PREDICTS score, with an odds ratio of 15.5.

Five participants, all of whom were SLE patients, had a documented incident cardiovascular event during follow-up, and all of them had a high PREDICTS score at baseline. In addition, 17 participants had a cerebrovascular event during follow-up, and 9 of them had high PREDICTS scores at baseline.

If these findings are verified in future research, the PREDICTS score could help clinicians identify which SLE patients are at high risk for atherosclerosis and, by implication, cardiovascular events, Dr. McMahon and her associates said.

"Although we have examined multiple biomarkers for atherosclerosis and SLE in this study and previously, our study was not exhaustive. It is likely that other, additional biomarkers have been or will be identified as promising candidates" to include in the PREDICTS scale, they added.

This study was supported by the Lupus Research Institute, the Alliance for Lupus Research, the American College of Rheumatology Research and Education Foundation, the National Institutes of Health, the Arthritis Foundation, the Iris Cantor Women’s Health Foundation, the Arthritis National Research Foundation, and a Kirkland Award.

A panel of six readily available biomarkers and clinical traits proved to be very good at predicting which women with systemic lupus erythematosus are at increased risk for cardiovascular events based on serial carotid artery ultrasound exams in a prospective case-control study.

Women with SLE who scored as "high risk" on the PREDICTS scale had a 28-fold increased odds of having or acquiring carotid plaque on serial ultrasound exams performed during a 2-year period than did SLE patients with lower scores. They also were at much higher risk of showing plaque progression (odds ratio, 15.5), reported Dr. Maureen McMahon of the rheumatology division at the University of California, Los Angeles (UCLA), Medical Center and her associates.

The PREDICTS (Predictors of Risk for Elevated Flares, Damage Progression, and Increased Cardiovascular Disease in Patients with SLE) score was more accurate at predicting the incidence or progression of carotid plaque than were any individual biomarkers or any panel of traditional cardiovascular risk factors in SLE patients, the investigators noted.

Longer follow-up is needed to definitively establish that carotid plaque deposition in these patients corresponds to later CVD events, and thus that the PREDICTS score predicts actual CVD events. Further study also will determine whether identifying these high-risk patients can guide preventive treatment and avert CVD events, the authors added.

Accelerated atherosclerosis is known to be more common in SLE patients than in the general population and to occur at a younger age. It causes significant morbidity and mortality and is thought to be related to the chronic inflammation underlying SLE.

Dr. McMahon and her colleagues assessed combinations of several biomarkers and risk factors, both traditional and novel, to develop a screen for identifying which SLE patients are at high CVD risk. They enrolled 210 women (mean age, 41 years) attending rheumatology practices at UCLA and Cedars Sinai medical centers who underwent a baseline ultrasound examination of the carotid artery and at least one follow-up ultrasound within a mean of 30 months, as well as 100 age-matched healthy control women who did not have SLE. Participants who had active renal disease or were taking statins were excluded from the study so as to avoid enrollment of women with known inflammation and hyperlipidemia.

The study subjects provided fasting blood samples that were tested for lipids, homocysteine, and high-sensitivity C-reactive protein. They also completed questionnaires that assessed SLE activity, organ damage, medications, and nonlaboratory CVD risk factors.

Univariate analysis showed that the presence, development, and progression of carotid plaque all were strongly associated with two traditional clinical factors – older age (48 years or older) and a history of diabetes – as well as four biomarkers of inflammation: high-density lipoprotein function (not HDL level), leptin level, homocysteine level, and soluble tumor necrosis factor–like weak inducer of apoptosis (sTWEAK) level.

HDL particles are anti-inflammatory in the basal state but become proinflammatory during an acute phase response. The chronic inflammation of SLE thus may inhibit HDL’s cardioprotective action and even promote cardiovascular damage, according to the investigators

Hyperleptinemia is associated with hypertension, oxidative stress, and endothelial dysfunction, and is known to be more common in SLE patients than in the general population. Homocysteine is a known indicator of inflammation and a predictor of cardiovascular disease. A high sTWEAK level has been linked to atherosclerosis, inflammation, angiogenesis, and apoptosis in laboratory studies, as well as to increased CVD mortality in other patient populations, Dr. McMahon and her associates said.

These six most significant independent predictors of incident or progressive carotid plaque were fashioned into the PREDICTS score, which proved to have the best overall predictive profile of any of the variables tested alone and in combination (Arthritis Rheum. 2013 Sept. 24 [doi: 10.1002/art.38204]).

For incident carotid plaque, the PREDICTS score had a sensitivity of 81%, a specificity of 79%, a positive predictive value of 40%, and a negative predictive value of 95%. SLE patients who earned a "high-risk" PREDICTS score had 28-fold higher odds of showing plaque at baseline or at follow-up ultrasound exam, compared with SLE patients whose scores didn’t indicate high risk.

In addition, SLE patients who had high-risk PREDICTS scores were significantly more likely than those who did not to show carotid plaque progression, a higher mean intima-media thickness, a higher rate of increase of intima-media thickness, and a higher mean number of new plaques per year.

In a multivariate analysis, the only variable significantly associated with carotid plaque progression over time was the PREDICTS score, with an odds ratio of 15.5.

Five participants, all of whom were SLE patients, had a documented incident cardiovascular event during follow-up, and all of them had a high PREDICTS score at baseline. In addition, 17 participants had a cerebrovascular event during follow-up, and 9 of them had high PREDICTS scores at baseline.

If these findings are verified in future research, the PREDICTS score could help clinicians identify which SLE patients are at high risk for atherosclerosis and, by implication, cardiovascular events, Dr. McMahon and her associates said.

"Although we have examined multiple biomarkers for atherosclerosis and SLE in this study and previously, our study was not exhaustive. It is likely that other, additional biomarkers have been or will be identified as promising candidates" to include in the PREDICTS scale, they added.

This study was supported by the Lupus Research Institute, the Alliance for Lupus Research, the American College of Rheumatology Research and Education Foundation, the National Institutes of Health, the Arthritis Foundation, the Iris Cantor Women’s Health Foundation, the Arthritis National Research Foundation, and a Kirkland Award.

Physicians have not adopted single-fraction radiotherapy into routine practice for uncomplicated bone metastases of prostate cancer, as has been recommended, according to a report in the Oct. 9 issue of JAMA.

In a Research Letter to the editor, investigators reported that 3% of a series of 3,050 patients eligible for single-fraction palliative radiotherapy received it, even though this approach yields pain relief for bone metastases that is comparable to that of multiple-fraction radiotherapy.

Palliative radiotherapy, with either one or multiple fractions given daily, is the mainstay of treatment for painful bone metastases. Several trials have demonstrated that single-fraction and multiple-fraction approaches deliver the same pain relief, and single-fraction radiotherapy is significantly less expensive, said Dr. Justin E. Bekelman of the department of radiation oncology, University of Pennsylvania, Philadelphia, and his associates.

In addition, single-fraction radiotherapy has other patient-centric benefits, including improved quality of life, greater convenience, and reduced travel time. It is advocated over multiple-fraction radiotherapy by the Choosing Wisely campaign, they noted.

Dr. Bekelman and his colleagues analyzed information from the Surveillance, Epidemiology, and End Results database to assess whether single-fraction radiotherapy has been incorporated into routine clinical practice as recommended. They reviewed reimbursement records for Medicare beneficiaries with prostate cancer who were treated during a 3-year period.

The median patient age was 78 years, and 82% had two or more comorbid illnesses.

Of these patients, 3.3% received single-fraction radiotherapy, while the rest received multiple-fraction radiotherapy. Half of the patients received 10 or more fractions per day, the investigators said (JAMA 2013;310:1501-2).

In a sensitivity analysis restricted to the 2,028 patients who had no previous complicating events, 3.8% received single-fraction radiotherapy, confirming the results of the primary analysis.

The mean radiotherapy-related expenditures were 62% lower for patients who received single-fraction radiotherapy ($1,873), compared with those for patients who received multiple-fraction radiotherapy ($4,967).

This study was supported by the National Cancer Institute, the American Cancer Society, and the Leonard Davis Institute for Health Economics. No relevant financial conflicts of interest were reported.

TOR@frontlinemedcom.com

Physicians have not adopted single-fraction radiotherapy into routine practice for uncomplicated bone metastases of prostate cancer, as has been recommended, according to a report in the Oct. 9 issue of JAMA.

In a Research Letter to the editor, investigators reported that 3% of a series of 3,050 patients eligible for single-fraction palliative radiotherapy received it, even though this approach yields pain relief for bone metastases that is comparable to that of multiple-fraction radiotherapy.

Palliative radiotherapy, with either one or multiple fractions given daily, is the mainstay of treatment for painful bone metastases. Several trials have demonstrated that single-fraction and multiple-fraction approaches deliver the same pain relief, and single-fraction radiotherapy is significantly less expensive, said Dr. Justin E. Bekelman of the department of radiation oncology, University of Pennsylvania, Philadelphia, and his associates.

In addition, single-fraction radiotherapy has other patient-centric benefits, including improved quality of life, greater convenience, and reduced travel time. It is advocated over multiple-fraction radiotherapy by the Choosing Wisely campaign, they noted.

Dr. Bekelman and his colleagues analyzed information from the Surveillance, Epidemiology, and End Results database to assess whether single-fraction radiotherapy has been incorporated into routine clinical practice as recommended. They reviewed reimbursement records for Medicare beneficiaries with prostate cancer who were treated during a 3-year period.

The median patient age was 78 years, and 82% had two or more comorbid illnesses.

Of these patients, 3.3% received single-fraction radiotherapy, while the rest received multiple-fraction radiotherapy. Half of the patients received 10 or more fractions per day, the investigators said (JAMA 2013;310:1501-2).

In a sensitivity analysis restricted to the 2,028 patients who had no previous complicating events, 3.8% received single-fraction radiotherapy, confirming the results of the primary analysis.

The mean radiotherapy-related expenditures were 62% lower for patients who received single-fraction radiotherapy ($1,873), compared with those for patients who received multiple-fraction radiotherapy ($4,967).

This study was supported by the National Cancer Institute, the American Cancer Society, and the Leonard Davis Institute for Health Economics. No relevant financial conflicts of interest were reported.

TOR@frontlinemedcom.com

Physicians have not adopted single-fraction radiotherapy into routine practice for uncomplicated bone metastases of prostate cancer, as has been recommended, according to a report in the Oct. 9 issue of JAMA.

In a Research Letter to the editor, investigators reported that 3% of a series of 3,050 patients eligible for single-fraction palliative radiotherapy received it, even though this approach yields pain relief for bone metastases that is comparable to that of multiple-fraction radiotherapy.

Palliative radiotherapy, with either one or multiple fractions given daily, is the mainstay of treatment for painful bone metastases. Several trials have demonstrated that single-fraction and multiple-fraction approaches deliver the same pain relief, and single-fraction radiotherapy is significantly less expensive, said Dr. Justin E. Bekelman of the department of radiation oncology, University of Pennsylvania, Philadelphia, and his associates.

In addition, single-fraction radiotherapy has other patient-centric benefits, including improved quality of life, greater convenience, and reduced travel time. It is advocated over multiple-fraction radiotherapy by the Choosing Wisely campaign, they noted.

Dr. Bekelman and his colleagues analyzed information from the Surveillance, Epidemiology, and End Results database to assess whether single-fraction radiotherapy has been incorporated into routine clinical practice as recommended. They reviewed reimbursement records for Medicare beneficiaries with prostate cancer who were treated during a 3-year period.

The median patient age was 78 years, and 82% had two or more comorbid illnesses.

Of these patients, 3.3% received single-fraction radiotherapy, while the rest received multiple-fraction radiotherapy. Half of the patients received 10 or more fractions per day, the investigators said (JAMA 2013;310:1501-2).

In a sensitivity analysis restricted to the 2,028 patients who had no previous complicating events, 3.8% received single-fraction radiotherapy, confirming the results of the primary analysis.

The mean radiotherapy-related expenditures were 62% lower for patients who received single-fraction radiotherapy ($1,873), compared with those for patients who received multiple-fraction radiotherapy ($4,967).

This study was supported by the National Cancer Institute, the American Cancer Society, and the Leonard Davis Institute for Health Economics. No relevant financial conflicts of interest were reported.

TOR@frontlinemedcom.com

Six months of gemcitabine therapy increased both overall and disease-free survival in patients who had macroscopically complete removal of pancreatic cancer, according to results from a randomized phase III trial reported online Oct. 8 in JAMA.

The study findings support the use of gemcitabine in clinical practice and as the backbone for future studies of adjuvant therapy following resection of pancreatic cancer, said Dr. Helmut Oettle, of the department of medical oncology and hematology, Charité Medical University Berlin, and his associates.

The open-label study involved 368 adults who had undergone complete, curative-intent resection of pancreatic cancer at 88 medical centers in Germany and Austria over a 6-year period. The intention-to-treat analyses included 354 eligible patients, of whom 179 were randomly assigned to receive six cycles of gemcitabine every 4 weeks as outpatients (three weekly infusions followed by a 1-week break), and 175 were assigned to observation-only following a similar schedule of visits.

Disease progression was monitored using abdominal CT, MRI, or ultrasound every 8 weeks. Patients also were assessed for adverse events, performance status, and quality of life every 8 weeks for up to 5 years or until death.

During a median follow-up of 11 years, there were 308 recurrences of pancreatic cancer in 354 patients (87% of the entire study population).

The primary endpoint, disease-free survival, was significantly greater for patients who received gemcitabine (13.4 months) than for the control group (6.7 months), Dr. Oettle and his associates reported (JAMA 2013;310:1473-81).

Rates of disease-free survival also were significantly greater with gemcitabine, compared with controls, at specific time points: 5-year rates were 16.6% vs. 7.0%, respectively, and 10-year rates were 14.3% vs. 5.8%, respectively.

Adjuvant gemcitabine therapy also significantly improved overall survival. At the end of follow-up, 316 patients (89.3%) had died. Median overall survival was 22.8 months with gemcitabine, compared with 20.2 months with observation alone.

This significant difference also persisted at specific time points. Overall survival at 5 years was 20.7% in the gemcitabine group vs. 10.4% in the control group, and at 10 years was 12.2% vs. 7.7%, respectively.

These treatment benefits occurred across all subgroups of patients and regardless of tumor stage or nodal status at the time of resection.

The study findings are likely to be applicable to patients in general clinical practice in many countries, since this was a community-based trial that involved community-based oncology practices as well as academic centers, and there were no uniform standards for surgery, Dr. Oettle and his associates said.

Their research group is now testing gemcitabine monotherapy against gemcitabine combination therapy in similar patients, they added.

The trial was supported by Eli Lilly, the German Cancer Society, and Charité Medical University Berlin. Dr. Oettle reported ties to Roche Pharma, Cellgene, and Fresenius, and his associates reported ties to Bayer, Bristol-Myers Squibb, and other companies.

Six months of gemcitabine therapy increased both overall and disease-free survival in patients who had macroscopically complete removal of pancreatic cancer, according to results from a randomized phase III trial reported online Oct. 8 in JAMA.

The study findings support the use of gemcitabine in clinical practice and as the backbone for future studies of adjuvant therapy following resection of pancreatic cancer, said Dr. Helmut Oettle, of the department of medical oncology and hematology, Charité Medical University Berlin, and his associates.

The open-label study involved 368 adults who had undergone complete, curative-intent resection of pancreatic cancer at 88 medical centers in Germany and Austria over a 6-year period. The intention-to-treat analyses included 354 eligible patients, of whom 179 were randomly assigned to receive six cycles of gemcitabine every 4 weeks as outpatients (three weekly infusions followed by a 1-week break), and 175 were assigned to observation-only following a similar schedule of visits.

Disease progression was monitored using abdominal CT, MRI, or ultrasound every 8 weeks. Patients also were assessed for adverse events, performance status, and quality of life every 8 weeks for up to 5 years or until death.

During a median follow-up of 11 years, there were 308 recurrences of pancreatic cancer in 354 patients (87% of the entire study population).

The primary endpoint, disease-free survival, was significantly greater for patients who received gemcitabine (13.4 months) than for the control group (6.7 months), Dr. Oettle and his associates reported (JAMA 2013;310:1473-81).

Rates of disease-free survival also were significantly greater with gemcitabine, compared with controls, at specific time points: 5-year rates were 16.6% vs. 7.0%, respectively, and 10-year rates were 14.3% vs. 5.8%, respectively.

Adjuvant gemcitabine therapy also significantly improved overall survival. At the end of follow-up, 316 patients (89.3%) had died. Median overall survival was 22.8 months with gemcitabine, compared with 20.2 months with observation alone.

This significant difference also persisted at specific time points. Overall survival at 5 years was 20.7% in the gemcitabine group vs. 10.4% in the control group, and at 10 years was 12.2% vs. 7.7%, respectively.

These treatment benefits occurred across all subgroups of patients and regardless of tumor stage or nodal status at the time of resection.

The study findings are likely to be applicable to patients in general clinical practice in many countries, since this was a community-based trial that involved community-based oncology practices as well as academic centers, and there were no uniform standards for surgery, Dr. Oettle and his associates said.

Their research group is now testing gemcitabine monotherapy against gemcitabine combination therapy in similar patients, they added.

The trial was supported by Eli Lilly, the German Cancer Society, and Charité Medical University Berlin. Dr. Oettle reported ties to Roche Pharma, Cellgene, and Fresenius, and his associates reported ties to Bayer, Bristol-Myers Squibb, and other companies.

Six months of gemcitabine therapy increased both overall and disease-free survival in patients who had macroscopically complete removal of pancreatic cancer, according to results from a randomized phase III trial reported online Oct. 8 in JAMA.

The study findings support the use of gemcitabine in clinical practice and as the backbone for future studies of adjuvant therapy following resection of pancreatic cancer, said Dr. Helmut Oettle, of the department of medical oncology and hematology, Charité Medical University Berlin, and his associates.

The open-label study involved 368 adults who had undergone complete, curative-intent resection of pancreatic cancer at 88 medical centers in Germany and Austria over a 6-year period. The intention-to-treat analyses included 354 eligible patients, of whom 179 were randomly assigned to receive six cycles of gemcitabine every 4 weeks as outpatients (three weekly infusions followed by a 1-week break), and 175 were assigned to observation-only following a similar schedule of visits.

Disease progression was monitored using abdominal CT, MRI, or ultrasound every 8 weeks. Patients also were assessed for adverse events, performance status, and quality of life every 8 weeks for up to 5 years or until death.

During a median follow-up of 11 years, there were 308 recurrences of pancreatic cancer in 354 patients (87% of the entire study population).

The primary endpoint, disease-free survival, was significantly greater for patients who received gemcitabine (13.4 months) than for the control group (6.7 months), Dr. Oettle and his associates reported (JAMA 2013;310:1473-81).

Rates of disease-free survival also were significantly greater with gemcitabine, compared with controls, at specific time points: 5-year rates were 16.6% vs. 7.0%, respectively, and 10-year rates were 14.3% vs. 5.8%, respectively.

Adjuvant gemcitabine therapy also significantly improved overall survival. At the end of follow-up, 316 patients (89.3%) had died. Median overall survival was 22.8 months with gemcitabine, compared with 20.2 months with observation alone.

This significant difference also persisted at specific time points. Overall survival at 5 years was 20.7% in the gemcitabine group vs. 10.4% in the control group, and at 10 years was 12.2% vs. 7.7%, respectively.

These treatment benefits occurred across all subgroups of patients and regardless of tumor stage or nodal status at the time of resection.

The study findings are likely to be applicable to patients in general clinical practice in many countries, since this was a community-based trial that involved community-based oncology practices as well as academic centers, and there were no uniform standards for surgery, Dr. Oettle and his associates said.

Their research group is now testing gemcitabine monotherapy against gemcitabine combination therapy in similar patients, they added.

The trial was supported by Eli Lilly, the German Cancer Society, and Charité Medical University Berlin. Dr. Oettle reported ties to Roche Pharma, Cellgene, and Fresenius, and his associates reported ties to Bayer, Bristol-Myers Squibb, and other companies.

Primary care providers must intervene more assertively to get patients to adopt healthier lifestyles, directly targeting smoking, obesity, poor diet, and physical inactivity, according to an American Heart Association science advisory published online Oct. 7 in Circulation.

Alexander Raths/Fotolia.com

The investigators termed this science advisory "a call to action" for clinicians, citing their vital role in fostering healthier behaviors. They added that system-wide changes also are necessary "to shift the majority of the public toward the next level of improved cardiovascular health," and so also called on "the health care system, insurance companies, employers, and educational institutions" to do so.

The science advisory urged physicians to follow "the 5 As" – a comprehensive, validated treatment algorithm of counseling steps to facilitate patient behavior change that can be completed within the constraints of the typical medical visit. These include Assessing the risk behavior; Advising change, Agreeing on goals and an action plan; Assisting with treatment; and Arranging follow-up.

Most clinicians easily follow the first A, assessing and tracking health behaviors such as smoking habits, weight gain, diet, and exercise over time.

However, "many providers say they omit the last three As because they perceive them as time consuming," and they also feel they lack the necessary counseling skills.

But even taking a single step toward that goal can be extremely helpful to patients. Simple use of patient-centered communication is key: that is, avoiding the use of "commanding language" and instead asking open-ended questions and expressing empathy signals that the physician takes an active interest in the patient’s perspective. It also reveals what actions a patient is willing to take, helping him or her to develop a behavior change plan.

Physicians also can enlist the help of many allied health professionals to take this step, including clinical psychologists, dieticians, health educators, and kinesiologists. They also should be prepared to connect patients to community resources such as park or community-center programs, biking trials, and farmers’ markets.

Direct physician intervention "will undoubtedly also take the form of answering patients’ questions about which of an armory of computer programs, applications, sensors, and online communities they should use to support healthy lifestyle changes," said Bonnie Spring, Ph.D., and Judith K. Ockene, Ph.D., cochairs of the AHA committee that issued the report. (Circulation 2013 Oct. 7 [doi:10.1161/01.cir.0000435173.25936.e1]).

On the population level, physicians should advocate for policies and strategies that support a large-scale shift toward healthier behaviors. Chief among these is the reimbursement for the intensive behavioral counseling and the multidisciplinary provider teams that are required for patients whose poor health habits put them at cardiovascular risk, Dr. Spring and Dr. Ockene said.

Copies of "Better Population Health Through Behavior Change in Adults: A Call to Action" are available at my.americanheart.org/statements.

This science advisory was issued on behalf of the AHA’s behavior change committee of the Council on Epidemiology and Prevention, the Council on Lifestyle and Cardiometabolic Health, the Council for High Blood Pressure Research, and the Council on Cardiovascular and Stroke Nursing. The writing panel’s disclosure questionnaires are available from the AHA.

Primary care providers must intervene more assertively to get patients to adopt healthier lifestyles, directly targeting smoking, obesity, poor diet, and physical inactivity, according to an American Heart Association science advisory published online Oct. 7 in Circulation.

Alexander Raths/Fotolia.com

The investigators termed this science advisory "a call to action" for clinicians, citing their vital role in fostering healthier behaviors. They added that system-wide changes also are necessary "to shift the majority of the public toward the next level of improved cardiovascular health," and so also called on "the health care system, insurance companies, employers, and educational institutions" to do so.

The science advisory urged physicians to follow "the 5 As" – a comprehensive, validated treatment algorithm of counseling steps to facilitate patient behavior change that can be completed within the constraints of the typical medical visit. These include Assessing the risk behavior; Advising change, Agreeing on goals and an action plan; Assisting with treatment; and Arranging follow-up.

Most clinicians easily follow the first A, assessing and tracking health behaviors such as smoking habits, weight gain, diet, and exercise over time.

However, "many providers say they omit the last three As because they perceive them as time consuming," and they also feel they lack the necessary counseling skills.

But even taking a single step toward that goal can be extremely helpful to patients. Simple use of patient-centered communication is key: that is, avoiding the use of "commanding language" and instead asking open-ended questions and expressing empathy signals that the physician takes an active interest in the patient’s perspective. It also reveals what actions a patient is willing to take, helping him or her to develop a behavior change plan.

Physicians also can enlist the help of many allied health professionals to take this step, including clinical psychologists, dieticians, health educators, and kinesiologists. They also should be prepared to connect patients to community resources such as park or community-center programs, biking trials, and farmers’ markets.

Direct physician intervention "will undoubtedly also take the form of answering patients’ questions about which of an armory of computer programs, applications, sensors, and online communities they should use to support healthy lifestyle changes," said Bonnie Spring, Ph.D., and Judith K. Ockene, Ph.D., cochairs of the AHA committee that issued the report. (Circulation 2013 Oct. 7 [doi:10.1161/01.cir.0000435173.25936.e1]).

On the population level, physicians should advocate for policies and strategies that support a large-scale shift toward healthier behaviors. Chief among these is the reimbursement for the intensive behavioral counseling and the multidisciplinary provider teams that are required for patients whose poor health habits put them at cardiovascular risk, Dr. Spring and Dr. Ockene said.

Copies of "Better Population Health Through Behavior Change in Adults: A Call to Action" are available at my.americanheart.org/statements.

This science advisory was issued on behalf of the AHA’s behavior change committee of the Council on Epidemiology and Prevention, the Council on Lifestyle and Cardiometabolic Health, the Council for High Blood Pressure Research, and the Council on Cardiovascular and Stroke Nursing. The writing panel’s disclosure questionnaires are available from the AHA.

Primary care providers must intervene more assertively to get patients to adopt healthier lifestyles, directly targeting smoking, obesity, poor diet, and physical inactivity, according to an American Heart Association science advisory published online Oct. 7 in Circulation.

Alexander Raths/Fotolia.com

The investigators termed this science advisory "a call to action" for clinicians, citing their vital role in fostering healthier behaviors. They added that system-wide changes also are necessary "to shift the majority of the public toward the next level of improved cardiovascular health," and so also called on "the health care system, insurance companies, employers, and educational institutions" to do so.

The science advisory urged physicians to follow "the 5 As" – a comprehensive, validated treatment algorithm of counseling steps to facilitate patient behavior change that can be completed within the constraints of the typical medical visit. These include Assessing the risk behavior; Advising change, Agreeing on goals and an action plan; Assisting with treatment; and Arranging follow-up.

Most clinicians easily follow the first A, assessing and tracking health behaviors such as smoking habits, weight gain, diet, and exercise over time.

However, "many providers say they omit the last three As because they perceive them as time consuming," and they also feel they lack the necessary counseling skills.

But even taking a single step toward that goal can be extremely helpful to patients. Simple use of patient-centered communication is key: that is, avoiding the use of "commanding language" and instead asking open-ended questions and expressing empathy signals that the physician takes an active interest in the patient’s perspective. It also reveals what actions a patient is willing to take, helping him or her to develop a behavior change plan.

Physicians also can enlist the help of many allied health professionals to take this step, including clinical psychologists, dieticians, health educators, and kinesiologists. They also should be prepared to connect patients to community resources such as park or community-center programs, biking trials, and farmers’ markets.

Direct physician intervention "will undoubtedly also take the form of answering patients’ questions about which of an armory of computer programs, applications, sensors, and online communities they should use to support healthy lifestyle changes," said Bonnie Spring, Ph.D., and Judith K. Ockene, Ph.D., cochairs of the AHA committee that issued the report. (Circulation 2013 Oct. 7 [doi:10.1161/01.cir.0000435173.25936.e1]).

On the population level, physicians should advocate for policies and strategies that support a large-scale shift toward healthier behaviors. Chief among these is the reimbursement for the intensive behavioral counseling and the multidisciplinary provider teams that are required for patients whose poor health habits put them at cardiovascular risk, Dr. Spring and Dr. Ockene said.

Copies of "Better Population Health Through Behavior Change in Adults: A Call to Action" are available at my.americanheart.org/statements.

This science advisory was issued on behalf of the AHA’s behavior change committee of the Council on Epidemiology and Prevention, the Council on Lifestyle and Cardiometabolic Health, the Council for High Blood Pressure Research, and the Council on Cardiovascular and Stroke Nursing. The writing panel’s disclosure questionnaires are available from the AHA.

Physicians must intervene more assertively to get patients to adopt healthier lifestyles, directly targeting smoking, obesity, poor diet, and physical inactivity, according to an American Heart Association science advisory published online Oct. 7 in Circulation.

"Providers’ efforts to champion a healthy lifestyle as the norm and healthy behaviors as the default in people’s lives are critical," said Bonnie Spring, Ph.D., and Judith K. Ockene, Ph.D., cochairs of the AHA’s Behavior Change Committee of the Council on Epidemiology and Prevention, the Council on Lifestyle and Cardiometabolic Health, the Council for High Blood Pressure Research, and the Council on Cardiovascular and Stroke Nursing, and their associates.

Alexander Raths/Fotolia.com

The investigators termed this science advisory "a call to action" for clinicians, citing their vital role in fostering healthier behaviors. They added that system-wide changes also are necessary "to shift the majority of the public toward the next level of improved cardiovascular health," and so also called on "the health care system, insurance companies, employers, and educational institutions" to do so.

The science advisory urged physicians to follow "the 5 As" – a comprehensive, validated treatment algorithm of counseling steps to facilitate patient behavior change that can be completed within the constraints of the typical medical visit. These include Assessing the risk behavior; Advising change, Agreeing on goals and an action plan; Assisting with treatment; and Arranging follow-up.

Most clinicians easily follow the first A, assessing and tracking health behaviors such as smoking habits, weight gain, diet, and exercise over time.

However, "many providers say they omit the last three As because they perceive them as time consuming," and they also feel they lack the necessary counseling skills.

But even taking a single step toward that goal can be extremely helpful to patients. Simple use of patient-centered communication is key: that is, avoiding the use of "commanding language" and instead asking open-ended questions and expressing empathy signals that the physician takes an active interest in the patient’s perspective. It also reveals what actions a patient is willing to take, helping him or her to develop a behavior change plan.

Physicians also can enlist the help of many allied health professionals to take this step, including clinical psychologists, dieticians, health educators, and kinesiologists. They also should be prepared to connect patients to community resources such as park or community-center programs, biking trials, and farmers’ markets.

Direct physician intervention "will undoubtedly also take the form of answering patients’ questions about which of an armory of computer programs, applications, sensors, and online communities they should use to support healthy lifestyle changes," said Dr. Spring of Northwestern University in Chicago and Dr. Ockene of the University of Massachusetts in Worcester (Circulation 2013 Oct. 7 [doi:10.1161/01.cir.0000435173.25936.e1]).

On the population level, physicians should advocate for policies and strategies that support a large-scale shift toward healthier behaviors. Chief among these is the reimbursement for the intensive behavioral counseling and the multidisciplinary provider teams that are required for patients whose poor health habits put them at cardiovascular risk, Dr. Spring and Dr. Ockene said.

Copies of "Better Population Health Through Behavior Change in Adults: A Call to Action" are available at my.americanheart.org/statements.

This science advisory was issued on behalf of the AHA’s behavior change committee of the Council on Epidemiology and Prevention, the Council on Lifestyle and Cardiometabolic Health, the Council for High Blood Pressure Research, and the Council on Cardiovascular and Stroke Nursing. The writing panel’s disclosure questionnaires are available from the AHA.

Physicians must intervene more assertively to get patients to adopt healthier lifestyles, directly targeting smoking, obesity, poor diet, and physical inactivity, according to an American Heart Association science advisory published online Oct. 7 in Circulation.

"Providers’ efforts to champion a healthy lifestyle as the norm and healthy behaviors as the default in people’s lives are critical," said Bonnie Spring, Ph.D., and Judith K. Ockene, Ph.D., cochairs of the AHA’s Behavior Change Committee of the Council on Epidemiology and Prevention, the Council on Lifestyle and Cardiometabolic Health, the Council for High Blood Pressure Research, and the Council on Cardiovascular and Stroke Nursing, and their associates.

Alexander Raths/Fotolia.com

The investigators termed this science advisory "a call to action" for clinicians, citing their vital role in fostering healthier behaviors. They added that system-wide changes also are necessary "to shift the majority of the public toward the next level of improved cardiovascular health," and so also called on "the health care system, insurance companies, employers, and educational institutions" to do so.

The science advisory urged physicians to follow "the 5 As" – a comprehensive, validated treatment algorithm of counseling steps to facilitate patient behavior change that can be completed within the constraints of the typical medical visit. These include Assessing the risk behavior; Advising change, Agreeing on goals and an action plan; Assisting with treatment; and Arranging follow-up.

Most clinicians easily follow the first A, assessing and tracking health behaviors such as smoking habits, weight gain, diet, and exercise over time.

However, "many providers say they omit the last three As because they perceive them as time consuming," and they also feel they lack the necessary counseling skills.

But even taking a single step toward that goal can be extremely helpful to patients. Simple use of patient-centered communication is key: that is, avoiding the use of "commanding language" and instead asking open-ended questions and expressing empathy signals that the physician takes an active interest in the patient’s perspective. It also reveals what actions a patient is willing to take, helping him or her to develop a behavior change plan.

Physicians also can enlist the help of many allied health professionals to take this step, including clinical psychologists, dieticians, health educators, and kinesiologists. They also should be prepared to connect patients to community resources such as park or community-center programs, biking trials, and farmers’ markets.

Direct physician intervention "will undoubtedly also take the form of answering patients’ questions about which of an armory of computer programs, applications, sensors, and online communities they should use to support healthy lifestyle changes," said Dr. Spring of Northwestern University in Chicago and Dr. Ockene of the University of Massachusetts in Worcester (Circulation 2013 Oct. 7 [doi:10.1161/01.cir.0000435173.25936.e1]).

On the population level, physicians should advocate for policies and strategies that support a large-scale shift toward healthier behaviors. Chief among these is the reimbursement for the intensive behavioral counseling and the multidisciplinary provider teams that are required for patients whose poor health habits put them at cardiovascular risk, Dr. Spring and Dr. Ockene said.

Copies of "Better Population Health Through Behavior Change in Adults: A Call to Action" are available at my.americanheart.org/statements.

This science advisory was issued on behalf of the AHA’s behavior change committee of the Council on Epidemiology and Prevention, the Council on Lifestyle and Cardiometabolic Health, the Council for High Blood Pressure Research, and the Council on Cardiovascular and Stroke Nursing. The writing panel’s disclosure questionnaires are available from the AHA.

Physicians must intervene more assertively to get patients to adopt healthier lifestyles, directly targeting smoking, obesity, poor diet, and physical inactivity, according to an American Heart Association science advisory published online Oct. 7 in Circulation.

"Providers’ efforts to champion a healthy lifestyle as the norm and healthy behaviors as the default in people’s lives are critical," said Bonnie Spring, Ph.D., and Judith K. Ockene, Ph.D., cochairs of the AHA’s Behavior Change Committee of the Council on Epidemiology and Prevention, the Council on Lifestyle and Cardiometabolic Health, the Council for High Blood Pressure Research, and the Council on Cardiovascular and Stroke Nursing, and their associates.

Alexander Raths/Fotolia.com

The investigators termed this science advisory "a call to action" for clinicians, citing their vital role in fostering healthier behaviors. They added that system-wide changes also are necessary "to shift the majority of the public toward the next level of improved cardiovascular health," and so also called on "the health care system, insurance companies, employers, and educational institutions" to do so.

The science advisory urged physicians to follow "the 5 As" – a comprehensive, validated treatment algorithm of counseling steps to facilitate patient behavior change that can be completed within the constraints of the typical medical visit. These include Assessing the risk behavior; Advising change, Agreeing on goals and an action plan; Assisting with treatment; and Arranging follow-up.

Most clinicians easily follow the first A, assessing and tracking health behaviors such as smoking habits, weight gain, diet, and exercise over time.

However, "many providers say they omit the last three As because they perceive them as time consuming," and they also feel they lack the necessary counseling skills.

But even taking a single step toward that goal can be extremely helpful to patients. Simple use of patient-centered communication is key: that is, avoiding the use of "commanding language" and instead asking open-ended questions and expressing empathy signals that the physician takes an active interest in the patient’s perspective. It also reveals what actions a patient is willing to take, helping him or her to develop a behavior change plan.

Physicians also can enlist the help of many allied health professionals to take this step, including clinical psychologists, dieticians, health educators, and kinesiologists. They also should be prepared to connect patients to community resources such as park or community-center programs, biking trials, and farmers’ markets.

Direct physician intervention "will undoubtedly also take the form of answering patients’ questions about which of an armory of computer programs, applications, sensors, and online communities they should use to support healthy lifestyle changes," said Dr. Spring of Northwestern University in Chicago and Dr. Ockene of the University of Massachusetts in Worcester (Circulation 2013 Oct. 7 [doi:10.1161/01.cir.0000435173.25936.e1]).

On the population level, physicians should advocate for policies and strategies that support a large-scale shift toward healthier behaviors. Chief among these is the reimbursement for the intensive behavioral counseling and the multidisciplinary provider teams that are required for patients whose poor health habits put them at cardiovascular risk, Dr. Spring and Dr. Ockene said.

Copies of "Better Population Health Through Behavior Change in Adults: A Call to Action" are available at my.americanheart.org/statements.

This science advisory was issued on behalf of the AHA’s behavior change committee of the Council on Epidemiology and Prevention, the Council on Lifestyle and Cardiometabolic Health, the Council for High Blood Pressure Research, and the Council on Cardiovascular and Stroke Nursing. The writing panel’s disclosure questionnaires are available from the AHA.

Nine percent of adolescents participating in a longitudinal survey assessing exposure to violence in the media reported that they had perpetrated some type of sexual violence in their lifetimes, with the incidence of initial sexually violent acts peaking at the age of 16 years, according to a report published online Oct. 7 in JAMA Pediatrics.

A total of 108 of the 1,058 14- to 21-year-old males and females participating in the national Growing Up With Media study admitted to perpetrating sexual violence. Eighty-four said that they had kissed, touched, or made someone do something sexual knowing that the other person did not want to (defined as forced sexual contact); 33 had gotten someone to give in to sex knowing that he or she did not want to (defined as coercive sex); 43 attempted but were unable to force someone to have sex (defined as attempted rape); and 18 forced someone to have sex (defined as completed rape). There was some overlap among these categories.

Perpetrators of any type of sexual violence were significantly more likely than were nonperpetrators to consume X-rated material via television, music, video games, and the Internet. In particular, they were significantly more likely to view depictions of one person physically hurting another while doing something sexual, said Michele L. Ybarra, Ph.D., of the Center for Innovative Public Health Research, San Clemente, Calif., and Kimberly J. Mitchell, Ph.D., of the Crimes Against Children Research Center, University of New Hampshire, Durham.

"Although the data do not denote causality, it seems appropriate to suggest that frequent consumption of sexual and violent material, and especially sexually violent material, should be a marker for concern for adolescent health care professionals," they noted.

The investigators added that since this is one of the first reports of national rates of sexual violence among adolescents, the findings must be replicated in future research and until then should be interpreted cautiously.

Dr. Ybarra and Dr. Mitchell undertook this study because of the paucity of data regarding sexual violence in this age group. The longitudinal Growing Up With Media survey began in 2006 when the initial 1,586 participants were aged 10-15 years, and it focused on violent media and violent behavior. But the researchers began collecting data on sexual perpetration as well in the 2010-2011 and 2011-2012 questionnaires, when participants were aged 14-21 years.

A total of 49 adolescents – 39 males and 10 females – reported that they attempted or completed rape. In 60% of these episodes, vaginal sex was attempted or completed, and in 48%, oral sex was attempted or completed.

Males were significantly more likely than were females to report such sexual violence up until the age of 18 years. For example, 98% of those who reported perpetrating at age 15 years or younger were male, as were 90% of those who reported perpetrating at age 16 or 17 years. But the number of male and female perpetrators was nearly even among those who started committing sexual violence at age 18 or 19 years.

This suggests "different developmental trajectories" between male and female perpetrators and indicates that prevention programs must be tailored and timed for these gender and age differences.

Females also were more likely to report perpetrating sexual violence as part of a team or group; 2 of the 10 female perpetrators (20%) did so, compared with only 1 of 39 male perpetrators (2.5%).

Age 16 was "by far the most common age at perpetration," with 40% of participants who admitted committing sexual violence citing 16 as the age at which they started. "It is critical that adolescent health care professionals, parents, and others interacting with youths model and educate young people about how to develop and maintain healthy sexual relationships well before this pivotal age," Dr. Ybarra and Dr. Mitchell said (JAMA Pediatr. 2013 [doi:10.1001/jamapediatrics.2013.2629]).

The study subjects were asked to provide details about their most recent coercive actions. Most (63%) said they got angry at or tried to make the victim feel guilty to obtain sex, and 32% said they argued with or put pressure on the victim. Threats and physical force were used by 5% and 8%, respectively.

Alcohol was used to coerce sex in "a notable minority of situations (15%)," the investigators wrote.

Approximately three-fourths of the victims were "romantic partners" of the perpetrator, and the remaining one-fourth of victims had some form of a relationship with the perpetrator. This finding is consistent with the literature, which demonstrates that adolescent victims are overwhelmingly more likely to be abused by someone they know than by a stranger.

It reinforces that "prevention programs need to provide youths with safety skills that can be used in both dating and nondating scenarios," Dr. Ybarra and Dr. Mitchell said.

Unfortunately, very few of the perpetrators in this study experienced any negative consequences for their actions. Fully 66% said that no one ever found out about their sexual violence. Only 1% was arrested and only an additional 1% was contacted by police. Clearly, most sexual violence committed by adolescents does not come to the attention of law enforcement, which highlights the severe limitations of data obtained from the juvenile justice system, the researchers noted.

Half of the perpetrators said their victims were completely responsible for the episodes of sexual violence, and four out of five stated that the victims were at least partly responsible. Only 35% of the perpetrators said they themselves were completely responsible for these incidents.

This finding illustrates that efforts to educate the public should emphasize taking responsibility for one’s actions and eliminating blame for the victims. There also is an urgent need for high school and middle school programs that teach bystander intervention, the investigators said.

"Adolescent health care professionals, including those providing counseling for birth control and sexually transmitted diseases, are ideally situated to educate youths about sexual violence," Dr. Ybarra and Dr. Mitchell said.

However, such professionals must first educate themselves. They should pay particular attention to challenging their own biases regarding sexual violence.

For example, it is a common belief that males cannot be raped by females. But an erection in a male who is being coerced does not necessarily reflect sexual arousal and instead can be reflexogenic. Clinicians should familiarize themselves with such information "so that they can be more effective in identifying and treating female perpetrators and male victims when they present," the researchers said.

Similarly, many people assume that sexual violence is consigned mostly to underprivileged populations. But, in this study, few differences were found between perpetrators and nonperpetrators in household income, race, or ethnicity, they added.

This study was supported by the Centers for Disease Control and Prevention. No financial conflicts of interest were reported.

Nine percent of adolescents participating in a longitudinal survey assessing exposure to violence in the media reported that they had perpetrated some type of sexual violence in their lifetimes, with the incidence of initial sexually violent acts peaking at the age of 16 years, according to a report published online Oct. 7 in JAMA Pediatrics.

A total of 108 of the 1,058 14- to 21-year-old males and females participating in the national Growing Up With Media study admitted to perpetrating sexual violence. Eighty-four said that they had kissed, touched, or made someone do something sexual knowing that the other person did not want to (defined as forced sexual contact); 33 had gotten someone to give in to sex knowing that he or she did not want to (defined as coercive sex); 43 attempted but were unable to force someone to have sex (defined as attempted rape); and 18 forced someone to have sex (defined as completed rape). There was some overlap among these categories.

Perpetrators of any type of sexual violence were significantly more likely than were nonperpetrators to consume X-rated material via television, music, video games, and the Internet. In particular, they were significantly more likely to view depictions of one person physically hurting another while doing something sexual, said Michele L. Ybarra, Ph.D., of the Center for Innovative Public Health Research, San Clemente, Calif., and Kimberly J. Mitchell, Ph.D., of the Crimes Against Children Research Center, University of New Hampshire, Durham.

"Although the data do not denote causality, it seems appropriate to suggest that frequent consumption of sexual and violent material, and especially sexually violent material, should be a marker for concern for adolescent health care professionals," they noted.

The investigators added that since this is one of the first reports of national rates of sexual violence among adolescents, the findings must be replicated in future research and until then should be interpreted cautiously.

Dr. Ybarra and Dr. Mitchell undertook this study because of the paucity of data regarding sexual violence in this age group. The longitudinal Growing Up With Media survey began in 2006 when the initial 1,586 participants were aged 10-15 years, and it focused on violent media and violent behavior. But the researchers began collecting data on sexual perpetration as well in the 2010-2011 and 2011-2012 questionnaires, when participants were aged 14-21 years.

A total of 49 adolescents – 39 males and 10 females – reported that they attempted or completed rape. In 60% of these episodes, vaginal sex was attempted or completed, and in 48%, oral sex was attempted or completed.

Males were significantly more likely than were females to report such sexual violence up until the age of 18 years. For example, 98% of those who reported perpetrating at age 15 years or younger were male, as were 90% of those who reported perpetrating at age 16 or 17 years. But the number of male and female perpetrators was nearly even among those who started committing sexual violence at age 18 or 19 years.

This suggests "different developmental trajectories" between male and female perpetrators and indicates that prevention programs must be tailored and timed for these gender and age differences.

Females also were more likely to report perpetrating sexual violence as part of a team or group; 2 of the 10 female perpetrators (20%) did so, compared with only 1 of 39 male perpetrators (2.5%).

Age 16 was "by far the most common age at perpetration," with 40% of participants who admitted committing sexual violence citing 16 as the age at which they started. "It is critical that adolescent health care professionals, parents, and others interacting with youths model and educate young people about how to develop and maintain healthy sexual relationships well before this pivotal age," Dr. Ybarra and Dr. Mitchell said (JAMA Pediatr. 2013 [doi:10.1001/jamapediatrics.2013.2629]).

The study subjects were asked to provide details about their most recent coercive actions. Most (63%) said they got angry at or tried to make the victim feel guilty to obtain sex, and 32% said they argued with or put pressure on the victim. Threats and physical force were used by 5% and 8%, respectively.

Alcohol was used to coerce sex in "a notable minority of situations (15%)," the investigators wrote.

Approximately three-fourths of the victims were "romantic partners" of the perpetrator, and the remaining one-fourth of victims had some form of a relationship with the perpetrator. This finding is consistent with the literature, which demonstrates that adolescent victims are overwhelmingly more likely to be abused by someone they know than by a stranger.

It reinforces that "prevention programs need to provide youths with safety skills that can be used in both dating and nondating scenarios," Dr. Ybarra and Dr. Mitchell said.

Unfortunately, very few of the perpetrators in this study experienced any negative consequences for their actions. Fully 66% said that no one ever found out about their sexual violence. Only 1% was arrested and only an additional 1% was contacted by police. Clearly, most sexual violence committed by adolescents does not come to the attention of law enforcement, which highlights the severe limitations of data obtained from the juvenile justice system, the researchers noted.

Half of the perpetrators said their victims were completely responsible for the episodes of sexual violence, and four out of five stated that the victims were at least partly responsible. Only 35% of the perpetrators said they themselves were completely responsible for these incidents.

This finding illustrates that efforts to educate the public should emphasize taking responsibility for one’s actions and eliminating blame for the victims. There also is an urgent need for high school and middle school programs that teach bystander intervention, the investigators said.

"Adolescent health care professionals, including those providing counseling for birth control and sexually transmitted diseases, are ideally situated to educate youths about sexual violence," Dr. Ybarra and Dr. Mitchell said.

However, such professionals must first educate themselves. They should pay particular attention to challenging their own biases regarding sexual violence.

For example, it is a common belief that males cannot be raped by females. But an erection in a male who is being coerced does not necessarily reflect sexual arousal and instead can be reflexogenic. Clinicians should familiarize themselves with such information "so that they can be more effective in identifying and treating female perpetrators and male victims when they present," the researchers said.

Similarly, many people assume that sexual violence is consigned mostly to underprivileged populations. But, in this study, few differences were found between perpetrators and nonperpetrators in household income, race, or ethnicity, they added.

This study was supported by the Centers for Disease Control and Prevention. No financial conflicts of interest were reported.

Nine percent of adolescents participating in a longitudinal survey assessing exposure to violence in the media reported that they had perpetrated some type of sexual violence in their lifetimes, with the incidence of initial sexually violent acts peaking at the age of 16 years, according to a report published online Oct. 7 in JAMA Pediatrics.

A total of 108 of the 1,058 14- to 21-year-old males and females participating in the national Growing Up With Media study admitted to perpetrating sexual violence. Eighty-four said that they had kissed, touched, or made someone do something sexual knowing that the other person did not want to (defined as forced sexual contact); 33 had gotten someone to give in to sex knowing that he or she did not want to (defined as coercive sex); 43 attempted but were unable to force someone to have sex (defined as attempted rape); and 18 forced someone to have sex (defined as completed rape). There was some overlap among these categories.

Perpetrators of any type of sexual violence were significantly more likely than were nonperpetrators to consume X-rated material via television, music, video games, and the Internet. In particular, they were significantly more likely to view depictions of one person physically hurting another while doing something sexual, said Michele L. Ybarra, Ph.D., of the Center for Innovative Public Health Research, San Clemente, Calif., and Kimberly J. Mitchell, Ph.D., of the Crimes Against Children Research Center, University of New Hampshire, Durham.

"Although the data do not denote causality, it seems appropriate to suggest that frequent consumption of sexual and violent material, and especially sexually violent material, should be a marker for concern for adolescent health care professionals," they noted.

The investigators added that since this is one of the first reports of national rates of sexual violence among adolescents, the findings must be replicated in future research and until then should be interpreted cautiously.

Dr. Ybarra and Dr. Mitchell undertook this study because of the paucity of data regarding sexual violence in this age group. The longitudinal Growing Up With Media survey began in 2006 when the initial 1,586 participants were aged 10-15 years, and it focused on violent media and violent behavior. But the researchers began collecting data on sexual perpetration as well in the 2010-2011 and 2011-2012 questionnaires, when participants were aged 14-21 years.

A total of 49 adolescents – 39 males and 10 females – reported that they attempted or completed rape. In 60% of these episodes, vaginal sex was attempted or completed, and in 48%, oral sex was attempted or completed.

Males were significantly more likely than were females to report such sexual violence up until the age of 18 years. For example, 98% of those who reported perpetrating at age 15 years or younger were male, as were 90% of those who reported perpetrating at age 16 or 17 years. But the number of male and female perpetrators was nearly even among those who started committing sexual violence at age 18 or 19 years.

This suggests "different developmental trajectories" between male and female perpetrators and indicates that prevention programs must be tailored and timed for these gender and age differences.

Females also were more likely to report perpetrating sexual violence as part of a team or group; 2 of the 10 female perpetrators (20%) did so, compared with only 1 of 39 male perpetrators (2.5%).

Age 16 was "by far the most common age at perpetration," with 40% of participants who admitted committing sexual violence citing 16 as the age at which they started. "It is critical that adolescent health care professionals, parents, and others interacting with youths model and educate young people about how to develop and maintain healthy sexual relationships well before this pivotal age," Dr. Ybarra and Dr. Mitchell said (JAMA Pediatr. 2013 [doi:10.1001/jamapediatrics.2013.2629]).

The study subjects were asked to provide details about their most recent coercive actions. Most (63%) said they got angry at or tried to make the victim feel guilty to obtain sex, and 32% said they argued with or put pressure on the victim. Threats and physical force were used by 5% and 8%, respectively.

Alcohol was used to coerce sex in "a notable minority of situations (15%)," the investigators wrote.

Approximately three-fourths of the victims were "romantic partners" of the perpetrator, and the remaining one-fourth of victims had some form of a relationship with the perpetrator. This finding is consistent with the literature, which demonstrates that adolescent victims are overwhelmingly more likely to be abused by someone they know than by a stranger.

It reinforces that "prevention programs need to provide youths with safety skills that can be used in both dating and nondating scenarios," Dr. Ybarra and Dr. Mitchell said.

Unfortunately, very few of the perpetrators in this study experienced any negative consequences for their actions. Fully 66% said that no one ever found out about their sexual violence. Only 1% was arrested and only an additional 1% was contacted by police. Clearly, most sexual violence committed by adolescents does not come to the attention of law enforcement, which highlights the severe limitations of data obtained from the juvenile justice system, the researchers noted.

Half of the perpetrators said their victims were completely responsible for the episodes of sexual violence, and four out of five stated that the victims were at least partly responsible. Only 35% of the perpetrators said they themselves were completely responsible for these incidents.

This finding illustrates that efforts to educate the public should emphasize taking responsibility for one’s actions and eliminating blame for the victims. There also is an urgent need for high school and middle school programs that teach bystander intervention, the investigators said.

"Adolescent health care professionals, including those providing counseling for birth control and sexually transmitted diseases, are ideally situated to educate youths about sexual violence," Dr. Ybarra and Dr. Mitchell said.

However, such professionals must first educate themselves. They should pay particular attention to challenging their own biases regarding sexual violence.

For example, it is a common belief that males cannot be raped by females. But an erection in a male who is being coerced does not necessarily reflect sexual arousal and instead can be reflexogenic. Clinicians should familiarize themselves with such information "so that they can be more effective in identifying and treating female perpetrators and male victims when they present," the researchers said.

Similarly, many people assume that sexual violence is consigned mostly to underprivileged populations. But, in this study, few differences were found between perpetrators and nonperpetrators in household income, race, or ethnicity, they added.

This study was supported by the Centers for Disease Control and Prevention. No financial conflicts of interest were reported.

Of 1,250 cases of Clostridium difficile infection that occurred during a 3.6-year period in one British community, fully 45% were genetically unrelated to all other cases and must have been acquired from sources other than symptomatic patients, according to a report published online Sept. 25 in the New England Journal of Medicine.

Only 35% of these C. difficile cases were genetically related to previous cases and involved patient contact with a hospital ward where other patients were being treated, and only 19% were genetically related and involved "some sort of hospital contact," said Dr. David W. Eyre of the National Institute for Health Research Oxford (U.K.) Biomedical Research Centre and his associates.

This indicates that hospitals and medical contacts are not the major source of transmission of this organism, and that other reservoirs – possibly asymptomatic carriers of C. difficile, colonized infants, farm animals or pets, food, and water – must be targeted to minimize exposure, they noted.

Until now, most episodes of C. difficile infection were believed to be acquired in health care settings, so prevention efforts have focused on symptomatic patients and their immediate environment. "The contribution of cases acquired from [other] sources to the overall burden of disease [has been] unclear," the researchers said.

Dr. Eyre and his colleagues quantified how much transmission is caused by symptomatic patients and how much by other environmental sources when they examined whole-genome sequences in isolates taken from all patients who had C. difficile infection in a defined geographic area. This region had a typical incidence of the infection and standard infection-control practices in place.

During the 3.6-year study period, 40,924 fecal samples were submitted for C. difficile–testing from symptomatic inpatients at four university hospitals, outpatients at these hospitals, outpatients at general medical practices, and outpatients at other hospitals in Oxfordshire.

A total of 2,377 of these samples tested positive for the organism on immunoassay, and 1,714 of these were culture positive. Of these, 957 were successfully sequenced.

The median age of these patients was 78 years (range, 66-86 years).

A total of 428 of the sequenced isolates (45%) were found to be genetically unrelated to all previous cases, indicating that the organisms were acquired from numerous diverse sources rather than by a few health-care-related transmissions, the investigators said (N. Engl. J. Med. 2013 Sept. 25;369:1195-205 [doi:10.1056/NEJMoa1216064]).

"It is striking that we observed diverse subtypes in patients with C. difficile infection, each representing a separate transmission event from a reservoir or asymptomatic carrier. Typically, one or very few cases arose from each exposure, reflecting both limited secondary transmission and the absence of widespread transmission from a few point sources," they noted.

A total of 333 sequenced isolates (35%) were found to be genetically related to at least one other isolate obtained from a previous case, closely enough to indicate transmission had occurred. Of these, 126 (38%) patients were treated on the same medical ward in which the related case was being treated, 5 (2%) were treated on the same medical ward after the discharge or recovery of the patient with the related case, 29 (9%) were in the same hospital but never on the same ward as the related case, and 21 (6%) had both ward contact and hospital-wide contact with the related case.

No hospital-based contact could be established for the remaining 152 of these 333 patients (46%). However, 15 of these patients attended the same general medical practice as a patient with a related case, and 17 lived in the same postal-code district.

"Overall, 120 patients (36%) had no record of any hospital or community contact with a previous genetically related case," which "may represent exposure to at least one intermediate host or source rather than direct contact," Dr. Eyre and his associates noted.

Some genetically related cases were clustered in time, but many others were separated by periods as long as 1 year. "Distinct subtypes were identified consistently throughout the study, suggesting that the cases arose from a considerable reservoir," the investigators said.

They added that further, detailed study of these patients will shed light on the location and nature of such sources, which have yet to be identified.

This study was supported by the U.K. National Institute for Health Research, United Kingdom Clinical Research Collaboration, Medical Research Council, Biotechnology and Biological Sciences Research Council, Department of Health, and Wellcome Trust. Dr. Eyre reported no financial conflicts of interest; his associates reported ties to numerous industry sources.

Of 1,250 cases of Clostridium difficile infection that occurred during a 3.6-year period in one British community, fully 45% were genetically unrelated to all other cases and must have been acquired from sources other than symptomatic patients, according to a report published online Sept. 25 in the New England Journal of Medicine.

Only 35% of these C. difficile cases were genetically related to previous cases and involved patient contact with a hospital ward where other patients were being treated, and only 19% were genetically related and involved "some sort of hospital contact," said Dr. David W. Eyre of the National Institute for Health Research Oxford (U.K.) Biomedical Research Centre and his associates.

This indicates that hospitals and medical contacts are not the major source of transmission of this organism, and that other reservoirs – possibly asymptomatic carriers of C. difficile, colonized infants, farm animals or pets, food, and water – must be targeted to minimize exposure, they noted.

Until now, most episodes of C. difficile infection were believed to be acquired in health care settings, so prevention efforts have focused on symptomatic patients and their immediate environment. "The contribution of cases acquired from [other] sources to the overall burden of disease [has been] unclear," the researchers said.

Dr. Eyre and his colleagues quantified how much transmission is caused by symptomatic patients and how much by other environmental sources when they examined whole-genome sequences in isolates taken from all patients who had C. difficile infection in a defined geographic area. This region had a typical incidence of the infection and standard infection-control practices in place.

During the 3.6-year study period, 40,924 fecal samples were submitted for C. difficile–testing from symptomatic inpatients at four university hospitals, outpatients at these hospitals, outpatients at general medical practices, and outpatients at other hospitals in Oxfordshire.

A total of 2,377 of these samples tested positive for the organism on immunoassay, and 1,714 of these were culture positive. Of these, 957 were successfully sequenced.

The median age of these patients was 78 years (range, 66-86 years).

A total of 428 of the sequenced isolates (45%) were found to be genetically unrelated to all previous cases, indicating that the organisms were acquired from numerous diverse sources rather than by a few health-care-related transmissions, the investigators said (N. Engl. J. Med. 2013 Sept. 25;369:1195-205 [doi:10.1056/NEJMoa1216064]).

"It is striking that we observed diverse subtypes in patients with C. difficile infection, each representing a separate transmission event from a reservoir or asymptomatic carrier. Typically, one or very few cases arose from each exposure, reflecting both limited secondary transmission and the absence of widespread transmission from a few point sources," they noted.

A total of 333 sequenced isolates (35%) were found to be genetically related to at least one other isolate obtained from a previous case, closely enough to indicate transmission had occurred. Of these, 126 (38%) patients were treated on the same medical ward in which the related case was being treated, 5 (2%) were treated on the same medical ward after the discharge or recovery of the patient with the related case, 29 (9%) were in the same hospital but never on the same ward as the related case, and 21 (6%) had both ward contact and hospital-wide contact with the related case.

No hospital-based contact could be established for the remaining 152 of these 333 patients (46%). However, 15 of these patients attended the same general medical practice as a patient with a related case, and 17 lived in the same postal-code district.

"Overall, 120 patients (36%) had no record of any hospital or community contact with a previous genetically related case," which "may represent exposure to at least one intermediate host or source rather than direct contact," Dr. Eyre and his associates noted.

Some genetically related cases were clustered in time, but many others were separated by periods as long as 1 year. "Distinct subtypes were identified consistently throughout the study, suggesting that the cases arose from a considerable reservoir," the investigators said.

They added that further, detailed study of these patients will shed light on the location and nature of such sources, which have yet to be identified.

This study was supported by the U.K. National Institute for Health Research, United Kingdom Clinical Research Collaboration, Medical Research Council, Biotechnology and Biological Sciences Research Council, Department of Health, and Wellcome Trust. Dr. Eyre reported no financial conflicts of interest; his associates reported ties to numerous industry sources.

Of 1,250 cases of Clostridium difficile infection that occurred during a 3.6-year period in one British community, fully 45% were genetically unrelated to all other cases and must have been acquired from sources other than symptomatic patients, according to a report published online Sept. 25 in the New England Journal of Medicine.

Only 35% of these C. difficile cases were genetically related to previous cases and involved patient contact with a hospital ward where other patients were being treated, and only 19% were genetically related and involved "some sort of hospital contact," said Dr. David W. Eyre of the National Institute for Health Research Oxford (U.K.) Biomedical Research Centre and his associates.

This indicates that hospitals and medical contacts are not the major source of transmission of this organism, and that other reservoirs – possibly asymptomatic carriers of C. difficile, colonized infants, farm animals or pets, food, and water – must be targeted to minimize exposure, they noted.

Until now, most episodes of C. difficile infection were believed to be acquired in health care settings, so prevention efforts have focused on symptomatic patients and their immediate environment. "The contribution of cases acquired from [other] sources to the overall burden of disease [has been] unclear," the researchers said.

Dr. Eyre and his colleagues quantified how much transmission is caused by symptomatic patients and how much by other environmental sources when they examined whole-genome sequences in isolates taken from all patients who had C. difficile infection in a defined geographic area. This region had a typical incidence of the infection and standard infection-control practices in place.

During the 3.6-year study period, 40,924 fecal samples were submitted for C. difficile–testing from symptomatic inpatients at four university hospitals, outpatients at these hospitals, outpatients at general medical practices, and outpatients at other hospitals in Oxfordshire.

A total of 2,377 of these samples tested positive for the organism on immunoassay, and 1,714 of these were culture positive. Of these, 957 were successfully sequenced.

The median age of these patients was 78 years (range, 66-86 years).

A total of 428 of the sequenced isolates (45%) were found to be genetically unrelated to all previous cases, indicating that the organisms were acquired from numerous diverse sources rather than by a few health-care-related transmissions, the investigators said (N. Engl. J. Med. 2013 Sept. 25;369:1195-205 [doi:10.1056/NEJMoa1216064]).

"It is striking that we observed diverse subtypes in patients with C. difficile infection, each representing a separate transmission event from a reservoir or asymptomatic carrier. Typically, one or very few cases arose from each exposure, reflecting both limited secondary transmission and the absence of widespread transmission from a few point sources," they noted.

A total of 333 sequenced isolates (35%) were found to be genetically related to at least one other isolate obtained from a previous case, closely enough to indicate transmission had occurred. Of these, 126 (38%) patients were treated on the same medical ward in which the related case was being treated, 5 (2%) were treated on the same medical ward after the discharge or recovery of the patient with the related case, 29 (9%) were in the same hospital but never on the same ward as the related case, and 21 (6%) had both ward contact and hospital-wide contact with the related case.

No hospital-based contact could be established for the remaining 152 of these 333 patients (46%). However, 15 of these patients attended the same general medical practice as a patient with a related case, and 17 lived in the same postal-code district.

"Overall, 120 patients (36%) had no record of any hospital or community contact with a previous genetically related case," which "may represent exposure to at least one intermediate host or source rather than direct contact," Dr. Eyre and his associates noted.

Some genetically related cases were clustered in time, but many others were separated by periods as long as 1 year. "Distinct subtypes were identified consistently throughout the study, suggesting that the cases arose from a considerable reservoir," the investigators said.

They added that further, detailed study of these patients will shed light on the location and nature of such sources, which have yet to be identified.

This study was supported by the U.K. National Institute for Health Research, United Kingdom Clinical Research Collaboration, Medical Research Council, Biotechnology and Biological Sciences Research Council, Department of Health, and Wellcome Trust. Dr. Eyre reported no financial conflicts of interest; his associates reported ties to numerous industry sources.

Performing a second bone mineral density measurement 4 years after an initial measurement was "of little value" in refining the estimation of fracture risk in osteoporosis, according to a report published online Sept. 24 in JAMA.

The finding calls into question the current practice of performing serial bone mineral density (BMD) tests at even shorter 2-year intervals to enhance fracture risk assessment, the study investigators noted.

In a secondary analysis of data from the Framingham Osteoporosis Study, BMD change during a 4-year interval "provided little additional information beyond baseline BMD for the clinical management of osteoporosis," said Dr. Sarah D. Berry of the Institute for Aging Research, Hebrew SeniorLife, Boston, and her associates (JAMA 2013;310:1256-62).

The appropriate interval between BMD assessments remains controversial, and studies of the issue have yielded mixed results.

Studies that reported a strong association between BMD loss during a short interval and subsequent fractures typically focused on the small subgroup of patients who had accelerated bone deterioration. Other studies primarily involving patients with low or normal bone loss have reported only a weak association between BMD loss and later fractures, the investigators said.

To determine whether repeat BMD testing is useful, Dr. Berry and her colleagues examined the rate of hip and major osteoporotic fracture among 310 men and 492 women in the prospective, population-based Framingham cohort.

The study patients underwent an initial BMD test of the femoral neck in 1987-1999, at a mean age of 74.8 years. None was receiving treatment for osteoporosis at that time. The patients then had at least one repeat BMD test a mean of 3.7 years later (range, 2.4-6.0 years later). The study participants then were followed for approximately 12 years or until they died.

During follow-up, 113 study patients (14.1%) had one or more major osteoporotic fractures. There were 88 hip, 24 spine, 5 shoulder, and 33 forearm fractures.

BMD loss during the interval between the first and second BMD assessments was associated with subsequent fracture. However, assessment of such loss provided little clinical value beyond that of the initial BMD test.

"The second BMD measure resulted in a small proportion of individuals [being] reclassified as [at] high risk of hip or major osteoporotic fracture," Dr. Berry and her associates said. But it remains unclear whether such a small number of reclassifications justifies the current practice of performing repeat BMD tests every 2 years, they added.

"We conclude that repeating a BMD test after 4 years would rarely change the clinical management of osteoporosis based on risk scores of hip fracture," the researchers explained. "Individuals with the greatest changes in risk scores were those who would have already been classified at high risk based on [the initial] BMD and [their] clinical characteristics."

Although some experts suggest that short rescreening intervals are warranted in high-risk patients, "we found no difference in the association between BMD change and fracture when stratified by sex, age, BMI, weight loss, T score, or fracture risk score," the study authors noted.

"Despite our findings, we recognize that detecting BMD loss would have been paramount for the small numbers of individuals reclassified by a second BMD test who went on to experience a fracture," Dr. Berry and her colleagues said. For those patients, a repeat screening test would allow physicians to give osteoporosis medications and reduce fracture risk, even among patients 75 years or older.

However, for the clear majority of patients who show normal or only mild bone loss at an initial screening, further study is needed to predict which patients are likely to transition to high risk of fracture and would therefore benefit from repeat BMD testing.

The study was limited in that almost all the patients were white. The usefulness of repeated BMD screening might be different in other racial and ethnic populations, the investigators said.

The National Institutes of Health, the National Heart, Lung, and Blood Institute, and the Friends of Hebrew SeniorLife supported the study. Dr. Berry reported no relevant financial conflicts of interest; one of her associates reported ties to Amgen, Ammonett Pharma, Eli Lilly, Hologic, Merck Sharpe & Dohme, Novartis, and Roche.

Performing a second bone mineral density measurement 4 years after an initial measurement was "of little value" in refining the estimation of fracture risk in osteoporosis, according to a report published online Sept. 24 in JAMA.

The finding calls into question the current practice of performing serial bone mineral density (BMD) tests at even shorter 2-year intervals to enhance fracture risk assessment, the study investigators noted.

In a secondary analysis of data from the Framingham Osteoporosis Study, BMD change during a 4-year interval "provided little additional information beyond baseline BMD for the clinical management of osteoporosis," said Dr. Sarah D. Berry of the Institute for Aging Research, Hebrew SeniorLife, Boston, and her associates (JAMA 2013;310:1256-62).

The appropriate interval between BMD assessments remains controversial, and studies of the issue have yielded mixed results.

Studies that reported a strong association between BMD loss during a short interval and subsequent fractures typically focused on the small subgroup of patients who had accelerated bone deterioration. Other studies primarily involving patients with low or normal bone loss have reported only a weak association between BMD loss and later fractures, the investigators said.

To determine whether repeat BMD testing is useful, Dr. Berry and her colleagues examined the rate of hip and major osteoporotic fracture among 310 men and 492 women in the prospective, population-based Framingham cohort.

The study patients underwent an initial BMD test of the femoral neck in 1987-1999, at a mean age of 74.8 years. None was receiving treatment for osteoporosis at that time. The patients then had at least one repeat BMD test a mean of 3.7 years later (range, 2.4-6.0 years later). The study participants then were followed for approximately 12 years or until they died.

During follow-up, 113 study patients (14.1%) had one or more major osteoporotic fractures. There were 88 hip, 24 spine, 5 shoulder, and 33 forearm fractures.

BMD loss during the interval between the first and second BMD assessments was associated with subsequent fracture. However, assessment of such loss provided little clinical value beyond that of the initial BMD test.

"The second BMD measure resulted in a small proportion of individuals [being] reclassified as [at] high risk of hip or major osteoporotic fracture," Dr. Berry and her associates said. But it remains unclear whether such a small number of reclassifications justifies the current practice of performing repeat BMD tests every 2 years, they added.

"We conclude that repeating a BMD test after 4 years would rarely change the clinical management of osteoporosis based on risk scores of hip fracture," the researchers explained. "Individuals with the greatest changes in risk scores were those who would have already been classified at high risk based on [the initial] BMD and [their] clinical characteristics."

Although some experts suggest that short rescreening intervals are warranted in high-risk patients, "we found no difference in the association between BMD change and fracture when stratified by sex, age, BMI, weight loss, T score, or fracture risk score," the study authors noted.

"Despite our findings, we recognize that detecting BMD loss would have been paramount for the small numbers of individuals reclassified by a second BMD test who went on to experience a fracture," Dr. Berry and her colleagues said. For those patients, a repeat screening test would allow physicians to give osteoporosis medications and reduce fracture risk, even among patients 75 years or older.

However, for the clear majority of patients who show normal or only mild bone loss at an initial screening, further study is needed to predict which patients are likely to transition to high risk of fracture and would therefore benefit from repeat BMD testing.

The study was limited in that almost all the patients were white. The usefulness of repeated BMD screening might be different in other racial and ethnic populations, the investigators said.

The National Institutes of Health, the National Heart, Lung, and Blood Institute, and the Friends of Hebrew SeniorLife supported the study. Dr. Berry reported no relevant financial conflicts of interest; one of her associates reported ties to Amgen, Ammonett Pharma, Eli Lilly, Hologic, Merck Sharpe & Dohme, Novartis, and Roche.

Performing a second bone mineral density measurement 4 years after an initial measurement was "of little value" in refining the estimation of fracture risk in osteoporosis, according to a report published online Sept. 24 in JAMA.

The finding calls into question the current practice of performing serial bone mineral density (BMD) tests at even shorter 2-year intervals to enhance fracture risk assessment, the study investigators noted.

In a secondary analysis of data from the Framingham Osteoporosis Study, BMD change during a 4-year interval "provided little additional information beyond baseline BMD for the clinical management of osteoporosis," said Dr. Sarah D. Berry of the Institute for Aging Research, Hebrew SeniorLife, Boston, and her associates (JAMA 2013;310:1256-62).

The appropriate interval between BMD assessments remains controversial, and studies of the issue have yielded mixed results.

Studies that reported a strong association between BMD loss during a short interval and subsequent fractures typically focused on the small subgroup of patients who had accelerated bone deterioration. Other studies primarily involving patients with low or normal bone loss have reported only a weak association between BMD loss and later fractures, the investigators said.

To determine whether repeat BMD testing is useful, Dr. Berry and her colleagues examined the rate of hip and major osteoporotic fracture among 310 men and 492 women in the prospective, population-based Framingham cohort.

The study patients underwent an initial BMD test of the femoral neck in 1987-1999, at a mean age of 74.8 years. None was receiving treatment for osteoporosis at that time. The patients then had at least one repeat BMD test a mean of 3.7 years later (range, 2.4-6.0 years later). The study participants then were followed for approximately 12 years or until they died.

During follow-up, 113 study patients (14.1%) had one or more major osteoporotic fractures. There were 88 hip, 24 spine, 5 shoulder, and 33 forearm fractures.

BMD loss during the interval between the first and second BMD assessments was associated with subsequent fracture. However, assessment of such loss provided little clinical value beyond that of the initial BMD test.

"The second BMD measure resulted in a small proportion of individuals [being] reclassified as [at] high risk of hip or major osteoporotic fracture," Dr. Berry and her associates said. But it remains unclear whether such a small number of reclassifications justifies the current practice of performing repeat BMD tests every 2 years, they added.

"We conclude that repeating a BMD test after 4 years would rarely change the clinical management of osteoporosis based on risk scores of hip fracture," the researchers explained. "Individuals with the greatest changes in risk scores were those who would have already been classified at high risk based on [the initial] BMD and [their] clinical characteristics."

Although some experts suggest that short rescreening intervals are warranted in high-risk patients, "we found no difference in the association between BMD change and fracture when stratified by sex, age, BMI, weight loss, T score, or fracture risk score," the study authors noted.

"Despite our findings, we recognize that detecting BMD loss would have been paramount for the small numbers of individuals reclassified by a second BMD test who went on to experience a fracture," Dr. Berry and her colleagues said. For those patients, a repeat screening test would allow physicians to give osteoporosis medications and reduce fracture risk, even among patients 75 years or older.

However, for the clear majority of patients who show normal or only mild bone loss at an initial screening, further study is needed to predict which patients are likely to transition to high risk of fracture and would therefore benefit from repeat BMD testing.

The study was limited in that almost all the patients were white. The usefulness of repeated BMD screening might be different in other racial and ethnic populations, the investigators said.

The National Institutes of Health, the National Heart, Lung, and Blood Institute, and the Friends of Hebrew SeniorLife supported the study. Dr. Berry reported no relevant financial conflicts of interest; one of her associates reported ties to Amgen, Ammonett Pharma, Eli Lilly, Hologic, Merck Sharpe & Dohme, Novartis, and Roche.

A new clinical decision rule had a sensitivity and a specificity approaching 100% in ruling out subarachnoid hemorrhage among patients who presented to an emergency department with acute headache, in a validation study reported Sept. 25 in JAMA.

Using this new tool, which requires only that the clinician answer six simple questions regarding the patient’s presentation, has the potential to reduce the number of costly and sometimes invasive procedures that are currently relied on to distinguish subarachnoid hemorrhage (SAH) from other pathologies in such patients, said Dr. Jeffrey J. Perry of the department of emergency medicine at the University of Ottawa (Ont.) and the clinical epidemiology program at the Ottawa Hospital Research Institute and his associates.

At present it can be very difficult to determine which patients require further investigation among those who present to the emergency department with acute severe headache but who are neurologically intact. Yet this is exactly the presentation of half of all patients who have SAH. It is estimated that approximately 6% of patients with confirmed SAHs were misdiagnosed during an initial ED evaluation.

Standard practice with such patients is to perform an unenhanced head CT, and to proceed to a lumbar puncture if the results of the CT are negative. But lumbar puncture carries some risk and can itself produce a headache that muddies the diagnostic picture.

Dr. Perry and his colleagues first devised three clinical decision rules to assist clinicians in ruling out SAH, then assessed the three rules for their accuracy, reliability, and acceptability to clinicians in a validation cohort of consecutive patients aged 16 years and older who presented to an ED with a nontraumatic headache that reached maximal intensity within 1 hour.

There were 2,131 study subjects with a mean age of 44 years. Approximately 61% were women, and 26% arrived at the ED by ambulance.

All of these participants were treated by attending physicians certified in emergency medicine or by supervised residents at 10 university-affiliated urban, Canadian tertiary care teaching hospitals during a 4-year period. All were alert and oriented, with no neurologic deficits.

A total of 132 patients (6.2%) were found to have SAH.

After comparing the performances of the three candidate decision rules, the investigators refined the decision tool to combine the six factors that were most predictive of SAH: age of 40 years or older, neck pain or stiffness, witnessed loss of consciousness, onset of headache during exertion, "thunderclap headache" (defined as instantly peaking pain), and limited neck flexion (defined as the inability to touch chin to chest when upright or to raise the head 8 cm off the bed when supine).

The presence of any one of these six factors indicates that SAH is possible and further investigation is required using CT and perhaps lumbar puncture, Dr. Perry and his associates said.

This refined clinical decision rule, which they termed the Ottawa SAH rule, had an overall sensitivity of 99.2% and a specificity of 99.6% in identifying SAHs when the derivation cohort and the validation cohort were combined. Of 232 patients with SAH in the cohorts altogether, this rule identified 260, Dr. Perry and his associates reported (JAMA 2013;310:1248-55)

This level of sensitivity and specificity is expected to be deemed clinically acceptable by emergency physicians.

"Following this rule would decrease the investigation rate" – the rate of further assessment using CT and lumbar puncture – "to 74.0% from the current investigation rate of 84.1%," they added.

The Ottawa SAH rule must be evaluated further before it can be adopted into clinical practice. "An implementation study is the next step required to determine how the Ottawa SAH rule performs in clinical practice, assess the actual effects on patient care and patient outcomes, and conduct a formal health economic analysis," the researchers noted.

After that, the rule "may help to standardize which patients with acute headache require investigations, and may provide evidence for physicians to use in deciding which patients require imaging to decrease the relatively high rate of missed SAH."

This study was supported by the Canadian Institutes for Health Research, the University of Ottawa, and the Vancouver Coastal Health Research Institute. No financial conflicts of interest were reported.

A new clinical decision rule had a sensitivity and a specificity approaching 100% in ruling out subarachnoid hemorrhage among patients who presented to an emergency department with acute headache, in a validation study reported Sept. 25 in JAMA.

Using this new tool, which requires only that the clinician answer six simple questions regarding the patient’s presentation, has the potential to reduce the number of costly and sometimes invasive procedures that are currently relied on to distinguish subarachnoid hemorrhage (SAH) from other pathologies in such patients, said Dr. Jeffrey J. Perry of the department of emergency medicine at the University of Ottawa (Ont.) and the clinical epidemiology program at the Ottawa Hospital Research Institute and his associates.

At present it can be very difficult to determine which patients require further investigation among those who present to the emergency department with acute severe headache but who are neurologically intact. Yet this is exactly the presentation of half of all patients who have SAH. It is estimated that approximately 6% of patients with confirmed SAHs were misdiagnosed during an initial ED evaluation.

Standard practice with such patients is to perform an unenhanced head CT, and to proceed to a lumbar puncture if the results of the CT are negative. But lumbar puncture carries some risk and can itself produce a headache that muddies the diagnostic picture.

Dr. Perry and his colleagues first devised three clinical decision rules to assist clinicians in ruling out SAH, then assessed the three rules for their accuracy, reliability, and acceptability to clinicians in a validation cohort of consecutive patients aged 16 years and older who presented to an ED with a nontraumatic headache that reached maximal intensity within 1 hour.

There were 2,131 study subjects with a mean age of 44 years. Approximately 61% were women, and 26% arrived at the ED by ambulance.

All of these participants were treated by attending physicians certified in emergency medicine or by supervised residents at 10 university-affiliated urban, Canadian tertiary care teaching hospitals during a 4-year period. All were alert and oriented, with no neurologic deficits.

A total of 132 patients (6.2%) were found to have SAH.

After comparing the performances of the three candidate decision rules, the investigators refined the decision tool to combine the six factors that were most predictive of SAH: age of 40 years or older, neck pain or stiffness, witnessed loss of consciousness, onset of headache during exertion, "thunderclap headache" (defined as instantly peaking pain), and limited neck flexion (defined as the inability to touch chin to chest when upright or to raise the head 8 cm off the bed when supine).

The presence of any one of these six factors indicates that SAH is possible and further investigation is required using CT and perhaps lumbar puncture, Dr. Perry and his associates said.

This refined clinical decision rule, which they termed the Ottawa SAH rule, had an overall sensitivity of 99.2% and a specificity of 99.6% in identifying SAHs when the derivation cohort and the validation cohort were combined. Of 232 patients with SAH in the cohorts altogether, this rule identified 260, Dr. Perry and his associates reported (JAMA 2013;310:1248-55)

This level of sensitivity and specificity is expected to be deemed clinically acceptable by emergency physicians.

"Following this rule would decrease the investigation rate" – the rate of further assessment using CT and lumbar puncture – "to 74.0% from the current investigation rate of 84.1%," they added.

The Ottawa SAH rule must be evaluated further before it can be adopted into clinical practice. "An implementation study is the next step required to determine how the Ottawa SAH rule performs in clinical practice, assess the actual effects on patient care and patient outcomes, and conduct a formal health economic analysis," the researchers noted.

After that, the rule "may help to standardize which patients with acute headache require investigations, and may provide evidence for physicians to use in deciding which patients require imaging to decrease the relatively high rate of missed SAH."

This study was supported by the Canadian Institutes for Health Research, the University of Ottawa, and the Vancouver Coastal Health Research Institute. No financial conflicts of interest were reported.

A new clinical decision rule had a sensitivity and a specificity approaching 100% in ruling out subarachnoid hemorrhage among patients who presented to an emergency department with acute headache, in a validation study reported Sept. 25 in JAMA.

Using this new tool, which requires only that the clinician answer six simple questions regarding the patient’s presentation, has the potential to reduce the number of costly and sometimes invasive procedures that are currently relied on to distinguish subarachnoid hemorrhage (SAH) from other pathologies in such patients, said Dr. Jeffrey J. Perry of the department of emergency medicine at the University of Ottawa (Ont.) and the clinical epidemiology program at the Ottawa Hospital Research Institute and his associates.

At present it can be very difficult to determine which patients require further investigation among those who present to the emergency department with acute severe headache but who are neurologically intact. Yet this is exactly the presentation of half of all patients who have SAH. It is estimated that approximately 6% of patients with confirmed SAHs were misdiagnosed during an initial ED evaluation.

Standard practice with such patients is to perform an unenhanced head CT, and to proceed to a lumbar puncture if the results of the CT are negative. But lumbar puncture carries some risk and can itself produce a headache that muddies the diagnostic picture.

Dr. Perry and his colleagues first devised three clinical decision rules to assist clinicians in ruling out SAH, then assessed the three rules for their accuracy, reliability, and acceptability to clinicians in a validation cohort of consecutive patients aged 16 years and older who presented to an ED with a nontraumatic headache that reached maximal intensity within 1 hour.

There were 2,131 study subjects with a mean age of 44 years. Approximately 61% were women, and 26% arrived at the ED by ambulance.

All of these participants were treated by attending physicians certified in emergency medicine or by supervised residents at 10 university-affiliated urban, Canadian tertiary care teaching hospitals during a 4-year period. All were alert and oriented, with no neurologic deficits.

A total of 132 patients (6.2%) were found to have SAH.

After comparing the performances of the three candidate decision rules, the investigators refined the decision tool to combine the six factors that were most predictive of SAH: age of 40 years or older, neck pain or stiffness, witnessed loss of consciousness, onset of headache during exertion, "thunderclap headache" (defined as instantly peaking pain), and limited neck flexion (defined as the inability to touch chin to chest when upright or to raise the head 8 cm off the bed when supine).

The presence of any one of these six factors indicates that SAH is possible and further investigation is required using CT and perhaps lumbar puncture, Dr. Perry and his associates said.

This refined clinical decision rule, which they termed the Ottawa SAH rule, had an overall sensitivity of 99.2% and a specificity of 99.6% in identifying SAHs when the derivation cohort and the validation cohort were combined. Of 232 patients with SAH in the cohorts altogether, this rule identified 260, Dr. Perry and his associates reported (JAMA 2013;310:1248-55)

This level of sensitivity and specificity is expected to be deemed clinically acceptable by emergency physicians.

"Following this rule would decrease the investigation rate" – the rate of further assessment using CT and lumbar puncture – "to 74.0% from the current investigation rate of 84.1%," they added.

The Ottawa SAH rule must be evaluated further before it can be adopted into clinical practice. "An implementation study is the next step required to determine how the Ottawa SAH rule performs in clinical practice, assess the actual effects on patient care and patient outcomes, and conduct a formal health economic analysis," the researchers noted.

After that, the rule "may help to standardize which patients with acute headache require investigations, and may provide evidence for physicians to use in deciding which patients require imaging to decrease the relatively high rate of missed SAH."

This study was supported by the Canadian Institutes for Health Research, the University of Ottawa, and the Vancouver Coastal Health Research Institute. No financial conflicts of interest were reported.