Neurology

Tremors and memory symptoms were identified among individuals in a primary care setting as early as 10 years before a Parkinson’s disease diagnosis in a new study.

Most research on the causes and early signs of Parkinson’s disease (PD) have involved patients of Northern European ancestry, Cristina Simonet, MD, of Queen Mary University of London, and colleagues wrote in their paper, published in JAMA Neurology.

Additionally, data on how PD might manifest in different ethnic groups are limited, they said.

In their nested case-control, the researchers examined data from electronic health records of an ethnically diverse population of 1,016,277 adults seen in primary care practices between 1990 and Feb. 6, 2018. They compared individuals with PD with those without PD or other neurologic conditions.

The researchers identified 10 age and sex-matched controls for each PD case, and also conducted an unmatched analysis after adjusting for age and sex. The final study population included 1,055 patients with PD and 1,009,523 controls. The population of PD cases was 15.7% Black, 19.7% South Asian, 50.9% White, and 8.3% other; the population of controls was 13.3% Black, 21.5% South Asian, 43.7% White, and 11.3% other.

“We observed a constellation of symptoms noted by general practitioners up to a decade before diagnosis of PD,” the researchers said. Symptoms were identified across three time intervals (less than 2 years, 2-5 years, and 5-10 years before diagnosis) to better evaluate exposure outcome associations.

In the matched analysis of midlife risk factors, epilepsy showed the strongest association with PD diagnosis across all time periods, and type 2 diabetes or hypertension 5-10 years before diagnosis was associated with later PD.

Prediagnostic signs of PD included both motor and nonmotor manifestations.

The matched analysis revealed a significant increased association between tremor and memory symptoms less than 2 years before diagnosis (adjusted odds ratios of 151.24 and 8.73, respectively) as well as up to 10 years before diagnosis for tremors and up to 5 years for memory symptoms (aOR, 11.4 and 3.09, respectively) in PD patients, compared with controls.

Other strong associations between PD and early nonmotor features in cases, compared with controls, included hypotension (aOR, 6.81), constipation (aOR, 3.29), and depression (aOR, 4.61).

In addition, the researchers found associations for epilepsy that had not been identified in previous studies, and these associations persisted in a replication analysis.

The study findings were limited by several factors, mainly the use of routine primary care data with underascertained factors of interest, and potential mislabeling of PD, the researchers noted. Other limitations included the lack of data on prescription medication for PD, and the recording of memory problems in primary care without supportive testing to confirm cognitive impairment.

The results support a range of comorbidities and symptoms that may present in primary care, and clinicians should consider PD as a possible cause, the researchers wrote.
 

Make early referral a priority

The study is important because of the lack of diversity in Parkinson’s disease research, lead author Dr. Simonet said in an interview.

“Over the last decade, the global population suffering from Parkinson’s disease has more than doubled,” she said. Causes may include the increasing numbers of older people with longer life expectancy. “However, it seems there are other factors, including environmental, genetic, and lifestyle, that might play a role in increasing the prevalence of Parkinson’s disease.”

“More representative studies, including minority ethnic groups and those living in areas of high social and economic deprivation, are needed,” Dr. Simonet emphasized.

She said that there is little research on the association with epilepsy and hearing loss in early PD, and “for that reason, our results should encourage further studies to confirm a possible link between these manifestations and Parkinson’s disease.”
 

Early detection may drive better diagnoses

The current study is important for understanding the prediagnostic features and risk factors that may allow for earlier detection of Parkinson’s disease, William Hung, MD, a geriatrics and palliative care specialist of the Icahn School of Medicine at Mount Sinai, New York, said in an interview. “Prior to this study, there was limited understanding of these features.

“One surprise [in the findings] was that ethnicity and socioeconomic deprivation do not appear to be associated with the risk of PD, in contrast to other illnesses such as dementia,” said Dr. Hung. “The array of prediagnostic features associated with PD is not surprising, but nonetheless important for clinicians to know to consider whether PD could be the underlying cause.”

The take-home message for primary care is that “there are features, such as hearing loss, history of epilepsy, autonomic symptoms, motor symptoms, among others, for which clinicians should consider PD as part of the differential diagnosis as underlying cause and consider referral to specialists for diagnostic clarification,” said Dr. Hung.

“Additional research is needed to translate these findings to care, perhaps developing decision aids, interventions that may help with diagnosis and evaluation,” as is work on understanding the link between PD and symptoms such as hearing loss and epilepsy, he said.
 

Primary care offers opportunity to identify risk factors

The current study represents an important step in early recognition of PD, with implications for helping patients access treatments promptly and improve their quality of life, Bhavana Patel, DO, Shannon Chiu, MD, and Melissa J. Armstrong, MD, of the University of Florida, Gainesville, wrote in an accompanying editorial.

“The primary care setting is commonly where symptoms heralding the onset of PD are first discussed. However, little is known regarding the prediagnostic manifestations of PD that are seen in primary care clinics, particularly in underserved populations,” they wrote.

The study included many risk factors and prodromal markers associated with research criteria for prodromal PD, but did not include several risk and prodromal markers in the Movement Disorders Society research criteria, “such as symptoms suggestive of REM sleep behavior disorder, excessive daytime sleepiness (which overlaps with, but is distinct from, fatigue), urinary dysfunction, pesticide and solvent exposure, caffeine use, level of physical activity, and family history,” they said.

Even in individuals with diagnosed PD, certain symptoms, particularly nonmotor symptoms, are commonly underreported,” and primary care clinicians may not recognize these symptoms as PD risk factors, the authors noted.

However, “in addition to contributing to possible models of modifiable risk factors for PD, study results may also further inform algorithms designed to predict PD diagnoses in primary care,” they said. The study also highlights the need for more multivariable models to better identify PD risk factors and strategies for early identification of PD in primary care.

Several study coauthors received funding related to the study from Barts Charity, Health Data Research UK, the Department of Health and Social Care (England) and the devolved administrations, and leading medical research charities, as well as the National Institute for Health Research UCLH Biomedical Research Centre. Lead author Dr. Simonet and Dr. Hung had no financial conflicts to disclose. Dr. Patel disclosed support from the National Institute on Aging, the Mangurian-Fixel-McKnight Collaboration for Pilot Studies in Lewy Body Dementia, and the American Brain Foundation and the Mary E. Groff Charitable Trust. Dr. Chiu reported receiving grants from Mangurian-Fixel-McKnight Collaboration for Pilot Studies in Lewy Body Dementia and the Smallwood Foundation. Dr. Armstrong disclosed funding from the National Institute on Aging, the Florida Department of Health, the Lewy Body Dementia Association, the Alzheimer’s Therapeutic Research Institute/Alzheimer’s Clinical Trial Consortium, the Alzheimer’s Disease Cooperative Study as Data Safety Monitoring Board the Parkinson’s Foundation, and the American Academy of Neurology.

Tremors and memory symptoms were identified among individuals in a primary care setting as early as 10 years before a Parkinson’s disease diagnosis in a new study.

Most research on the causes and early signs of Parkinson’s disease (PD) have involved patients of Northern European ancestry, Cristina Simonet, MD, of Queen Mary University of London, and colleagues wrote in their paper, published in JAMA Neurology.

Additionally, data on how PD might manifest in different ethnic groups are limited, they said.

In their nested case-control, the researchers examined data from electronic health records of an ethnically diverse population of 1,016,277 adults seen in primary care practices between 1990 and Feb. 6, 2018. They compared individuals with PD with those without PD or other neurologic conditions.

The researchers identified 10 age and sex-matched controls for each PD case, and also conducted an unmatched analysis after adjusting for age and sex. The final study population included 1,055 patients with PD and 1,009,523 controls. The population of PD cases was 15.7% Black, 19.7% South Asian, 50.9% White, and 8.3% other; the population of controls was 13.3% Black, 21.5% South Asian, 43.7% White, and 11.3% other.

“We observed a constellation of symptoms noted by general practitioners up to a decade before diagnosis of PD,” the researchers said. Symptoms were identified across three time intervals (less than 2 years, 2-5 years, and 5-10 years before diagnosis) to better evaluate exposure outcome associations.

In the matched analysis of midlife risk factors, epilepsy showed the strongest association with PD diagnosis across all time periods, and type 2 diabetes or hypertension 5-10 years before diagnosis was associated with later PD.

Prediagnostic signs of PD included both motor and nonmotor manifestations.

The matched analysis revealed a significant increased association between tremor and memory symptoms less than 2 years before diagnosis (adjusted odds ratios of 151.24 and 8.73, respectively) as well as up to 10 years before diagnosis for tremors and up to 5 years for memory symptoms (aOR, 11.4 and 3.09, respectively) in PD patients, compared with controls.

Other strong associations between PD and early nonmotor features in cases, compared with controls, included hypotension (aOR, 6.81), constipation (aOR, 3.29), and depression (aOR, 4.61).

In addition, the researchers found associations for epilepsy that had not been identified in previous studies, and these associations persisted in a replication analysis.

The study findings were limited by several factors, mainly the use of routine primary care data with underascertained factors of interest, and potential mislabeling of PD, the researchers noted. Other limitations included the lack of data on prescription medication for PD, and the recording of memory problems in primary care without supportive testing to confirm cognitive impairment.

The results support a range of comorbidities and symptoms that may present in primary care, and clinicians should consider PD as a possible cause, the researchers wrote.
 

Make early referral a priority

The study is important because of the lack of diversity in Parkinson’s disease research, lead author Dr. Simonet said in an interview.

“Over the last decade, the global population suffering from Parkinson’s disease has more than doubled,” she said. Causes may include the increasing numbers of older people with longer life expectancy. “However, it seems there are other factors, including environmental, genetic, and lifestyle, that might play a role in increasing the prevalence of Parkinson’s disease.”

“More representative studies, including minority ethnic groups and those living in areas of high social and economic deprivation, are needed,” Dr. Simonet emphasized.

She said that there is little research on the association with epilepsy and hearing loss in early PD, and “for that reason, our results should encourage further studies to confirm a possible link between these manifestations and Parkinson’s disease.”
 

Early detection may drive better diagnoses

The current study is important for understanding the prediagnostic features and risk factors that may allow for earlier detection of Parkinson’s disease, William Hung, MD, a geriatrics and palliative care specialist of the Icahn School of Medicine at Mount Sinai, New York, said in an interview. “Prior to this study, there was limited understanding of these features.

“One surprise [in the findings] was that ethnicity and socioeconomic deprivation do not appear to be associated with the risk of PD, in contrast to other illnesses such as dementia,” said Dr. Hung. “The array of prediagnostic features associated with PD is not surprising, but nonetheless important for clinicians to know to consider whether PD could be the underlying cause.”

The take-home message for primary care is that “there are features, such as hearing loss, history of epilepsy, autonomic symptoms, motor symptoms, among others, for which clinicians should consider PD as part of the differential diagnosis as underlying cause and consider referral to specialists for diagnostic clarification,” said Dr. Hung.

“Additional research is needed to translate these findings to care, perhaps developing decision aids, interventions that may help with diagnosis and evaluation,” as is work on understanding the link between PD and symptoms such as hearing loss and epilepsy, he said.
 

Primary care offers opportunity to identify risk factors

The current study represents an important step in early recognition of PD, with implications for helping patients access treatments promptly and improve their quality of life, Bhavana Patel, DO, Shannon Chiu, MD, and Melissa J. Armstrong, MD, of the University of Florida, Gainesville, wrote in an accompanying editorial.

“The primary care setting is commonly where symptoms heralding the onset of PD are first discussed. However, little is known regarding the prediagnostic manifestations of PD that are seen in primary care clinics, particularly in underserved populations,” they wrote.

The study included many risk factors and prodromal markers associated with research criteria for prodromal PD, but did not include several risk and prodromal markers in the Movement Disorders Society research criteria, “such as symptoms suggestive of REM sleep behavior disorder, excessive daytime sleepiness (which overlaps with, but is distinct from, fatigue), urinary dysfunction, pesticide and solvent exposure, caffeine use, level of physical activity, and family history,” they said.

Even in individuals with diagnosed PD, certain symptoms, particularly nonmotor symptoms, are commonly underreported,” and primary care clinicians may not recognize these symptoms as PD risk factors, the authors noted.

However, “in addition to contributing to possible models of modifiable risk factors for PD, study results may also further inform algorithms designed to predict PD diagnoses in primary care,” they said. The study also highlights the need for more multivariable models to better identify PD risk factors and strategies for early identification of PD in primary care.

Several study coauthors received funding related to the study from Barts Charity, Health Data Research UK, the Department of Health and Social Care (England) and the devolved administrations, and leading medical research charities, as well as the National Institute for Health Research UCLH Biomedical Research Centre. Lead author Dr. Simonet and Dr. Hung had no financial conflicts to disclose. Dr. Patel disclosed support from the National Institute on Aging, the Mangurian-Fixel-McKnight Collaboration for Pilot Studies in Lewy Body Dementia, and the American Brain Foundation and the Mary E. Groff Charitable Trust. Dr. Chiu reported receiving grants from Mangurian-Fixel-McKnight Collaboration for Pilot Studies in Lewy Body Dementia and the Smallwood Foundation. Dr. Armstrong disclosed funding from the National Institute on Aging, the Florida Department of Health, the Lewy Body Dementia Association, the Alzheimer’s Therapeutic Research Institute/Alzheimer’s Clinical Trial Consortium, the Alzheimer’s Disease Cooperative Study as Data Safety Monitoring Board the Parkinson’s Foundation, and the American Academy of Neurology.

Tremors and memory symptoms were identified among individuals in a primary care setting as early as 10 years before a Parkinson’s disease diagnosis in a new study.

Most research on the causes and early signs of Parkinson’s disease (PD) have involved patients of Northern European ancestry, Cristina Simonet, MD, of Queen Mary University of London, and colleagues wrote in their paper, published in JAMA Neurology.

Additionally, data on how PD might manifest in different ethnic groups are limited, they said.

In their nested case-control, the researchers examined data from electronic health records of an ethnically diverse population of 1,016,277 adults seen in primary care practices between 1990 and Feb. 6, 2018. They compared individuals with PD with those without PD or other neurologic conditions.

The researchers identified 10 age and sex-matched controls for each PD case, and also conducted an unmatched analysis after adjusting for age and sex. The final study population included 1,055 patients with PD and 1,009,523 controls. The population of PD cases was 15.7% Black, 19.7% South Asian, 50.9% White, and 8.3% other; the population of controls was 13.3% Black, 21.5% South Asian, 43.7% White, and 11.3% other.

“We observed a constellation of symptoms noted by general practitioners up to a decade before diagnosis of PD,” the researchers said. Symptoms were identified across three time intervals (less than 2 years, 2-5 years, and 5-10 years before diagnosis) to better evaluate exposure outcome associations.

In the matched analysis of midlife risk factors, epilepsy showed the strongest association with PD diagnosis across all time periods, and type 2 diabetes or hypertension 5-10 years before diagnosis was associated with later PD.

Prediagnostic signs of PD included both motor and nonmotor manifestations.

The matched analysis revealed a significant increased association between tremor and memory symptoms less than 2 years before diagnosis (adjusted odds ratios of 151.24 and 8.73, respectively) as well as up to 10 years before diagnosis for tremors and up to 5 years for memory symptoms (aOR, 11.4 and 3.09, respectively) in PD patients, compared with controls.

Other strong associations between PD and early nonmotor features in cases, compared with controls, included hypotension (aOR, 6.81), constipation (aOR, 3.29), and depression (aOR, 4.61).

In addition, the researchers found associations for epilepsy that had not been identified in previous studies, and these associations persisted in a replication analysis.

The study findings were limited by several factors, mainly the use of routine primary care data with underascertained factors of interest, and potential mislabeling of PD, the researchers noted. Other limitations included the lack of data on prescription medication for PD, and the recording of memory problems in primary care without supportive testing to confirm cognitive impairment.

The results support a range of comorbidities and symptoms that may present in primary care, and clinicians should consider PD as a possible cause, the researchers wrote.
 

Make early referral a priority

The study is important because of the lack of diversity in Parkinson’s disease research, lead author Dr. Simonet said in an interview.

“Over the last decade, the global population suffering from Parkinson’s disease has more than doubled,” she said. Causes may include the increasing numbers of older people with longer life expectancy. “However, it seems there are other factors, including environmental, genetic, and lifestyle, that might play a role in increasing the prevalence of Parkinson’s disease.”

“More representative studies, including minority ethnic groups and those living in areas of high social and economic deprivation, are needed,” Dr. Simonet emphasized.

She said that there is little research on the association with epilepsy and hearing loss in early PD, and “for that reason, our results should encourage further studies to confirm a possible link between these manifestations and Parkinson’s disease.”
 

Early detection may drive better diagnoses

The current study is important for understanding the prediagnostic features and risk factors that may allow for earlier detection of Parkinson’s disease, William Hung, MD, a geriatrics and palliative care specialist of the Icahn School of Medicine at Mount Sinai, New York, said in an interview. “Prior to this study, there was limited understanding of these features.

“One surprise [in the findings] was that ethnicity and socioeconomic deprivation do not appear to be associated with the risk of PD, in contrast to other illnesses such as dementia,” said Dr. Hung. “The array of prediagnostic features associated with PD is not surprising, but nonetheless important for clinicians to know to consider whether PD could be the underlying cause.”

The take-home message for primary care is that “there are features, such as hearing loss, history of epilepsy, autonomic symptoms, motor symptoms, among others, for which clinicians should consider PD as part of the differential diagnosis as underlying cause and consider referral to specialists for diagnostic clarification,” said Dr. Hung.

“Additional research is needed to translate these findings to care, perhaps developing decision aids, interventions that may help with diagnosis and evaluation,” as is work on understanding the link between PD and symptoms such as hearing loss and epilepsy, he said.
 

Primary care offers opportunity to identify risk factors

The current study represents an important step in early recognition of PD, with implications for helping patients access treatments promptly and improve their quality of life, Bhavana Patel, DO, Shannon Chiu, MD, and Melissa J. Armstrong, MD, of the University of Florida, Gainesville, wrote in an accompanying editorial.

“The primary care setting is commonly where symptoms heralding the onset of PD are first discussed. However, little is known regarding the prediagnostic manifestations of PD that are seen in primary care clinics, particularly in underserved populations,” they wrote.

The study included many risk factors and prodromal markers associated with research criteria for prodromal PD, but did not include several risk and prodromal markers in the Movement Disorders Society research criteria, “such as symptoms suggestive of REM sleep behavior disorder, excessive daytime sleepiness (which overlaps with, but is distinct from, fatigue), urinary dysfunction, pesticide and solvent exposure, caffeine use, level of physical activity, and family history,” they said.

Even in individuals with diagnosed PD, certain symptoms, particularly nonmotor symptoms, are commonly underreported,” and primary care clinicians may not recognize these symptoms as PD risk factors, the authors noted.

However, “in addition to contributing to possible models of modifiable risk factors for PD, study results may also further inform algorithms designed to predict PD diagnoses in primary care,” they said. The study also highlights the need for more multivariable models to better identify PD risk factors and strategies for early identification of PD in primary care.

Several study coauthors received funding related to the study from Barts Charity, Health Data Research UK, the Department of Health and Social Care (England) and the devolved administrations, and leading medical research charities, as well as the National Institute for Health Research UCLH Biomedical Research Centre. Lead author Dr. Simonet and Dr. Hung had no financial conflicts to disclose. Dr. Patel disclosed support from the National Institute on Aging, the Mangurian-Fixel-McKnight Collaboration for Pilot Studies in Lewy Body Dementia, and the American Brain Foundation and the Mary E. Groff Charitable Trust. Dr. Chiu reported receiving grants from Mangurian-Fixel-McKnight Collaboration for Pilot Studies in Lewy Body Dementia and the Smallwood Foundation. Dr. Armstrong disclosed funding from the National Institute on Aging, the Florida Department of Health, the Lewy Body Dementia Association, the Alzheimer’s Therapeutic Research Institute/Alzheimer’s Clinical Trial Consortium, the Alzheimer’s Disease Cooperative Study as Data Safety Monitoring Board the Parkinson’s Foundation, and the American Academy of Neurology.

Among children and adolescents aged 5-18 years, concussion was associated with a higher risk of mental health problems, compared with age- and sex-matched children and adolescents with an orthopedic injury, according to a cohort study published in JAMA Network Open.

While concussions are one of the most common head injuries in the pediatric population, the extent to which they increase the risk of new onset psychiatric disorders or subsequent psychopathology is unclear, lead author Andrée-Anne Ledoux, PhD, of the Children’s Hospital of Eastern Ontario Research Institute, Ottawa, and colleagues explained.

The researchers conducted a population-based retrospective cohort study to evaluate associations between concussion and risk of subsequent mental health issues, psychiatric hospitalizations, self-harm, or suicides in children and adolescents, with follow-up ranging from 1 month to 10 years.

The data were obtained from province-wide health administrative databases. Participants with concussion were included in an exposed group, while those with an orthopedic injury were included in a 1:2 age- and sex-matched comparison group.
 

Results

The study cohort comprised 448,803 participants, including 152,321 and 296,482 children and adolescents with concussion and orthopedic injury, respectively.

The incidence rates of any mental health problem were 11,141 per 100,000 person-years in the exposed group and 7,960 per 100,000 person-years in the unexposed group (difference, 3,181; 95% confidence interval, 3,073-3,291 per 100,000 person-years).

After concussion, the exposed group had a greater risk of developing a mental health issue (adjusted hazard ratio, 1.39; 95% CI, 1.37-1.40), psychiatric hospitalization (aHR, 1.47; 95% CI, 1.41-1.53), and self-harm (aHR, 1.49; 95% CI, 1.42-1.56). In addition, there was no significant difference in death by suicide between the exposed and unexposed groups (HR, 1.54; 95% CI, 0.90-2.61).

“Our results suggest that clinicians should assess for preexisting and new mental health symptoms throughout concussion recovery and treat mental health conditions or symptoms or refer the patient to a specialist in pediatric mental health,” wrote Dr. Ledoux and colleagues. “[Clinicians should also] assess suicidal ideation and self-harm behaviors during evaluation and follow-up visits for concussion.”

The researchers acknowledged that a key limitation of the study was the retrospective observational design. In addition, the identification of exposures using diagnostic billing codes could have introduced exposure or outcome misclassification.
 

Expert-recommended resources

“For more information, I’d recommend ‘Pedsconcussion,’ which are evidence-based living guidelines for pediatric concussion care,” Dr. Ledoux said in an interview. “Within domain 8, there are specific guidelines related to the management of mental health issues post concussion.”

Neuropsychology expert Talin Babikian, PhD, of the University of California, Los Angeles, commented: “Studies have shown that even a single psychoeducational session early after a concussion can minimize prolonged recoveries. Ensuring all stakeholders (family, clinicians, school, coach, peers) are on the same page and providing the same information is important to build trust and a sense of safety and agency.

“We want to provide psychoeducation early in the process to avoid unnecessary fear and avoidance. We also want to curtail misattribution of everyday symptoms or symptoms related to an unrelated condition to a brain injury, which are easier to do when caught early,” Dr. Babikian added.

This study was supported by the Institute for Clinical Evaluative Sciences, which is funded by an annual grant from the Ontario Ministry of Health and the Ministry of Long-term Care. One author reported financial relationships with the University of Ottawa, the National Football League, Parachute Canada, and 360 Concussion Care, an interdisciplinary concussion clinic; no other conflicts of interest were reported.

Among children and adolescents aged 5-18 years, concussion was associated with a higher risk of mental health problems, compared with age- and sex-matched children and adolescents with an orthopedic injury, according to a cohort study published in JAMA Network Open.

While concussions are one of the most common head injuries in the pediatric population, the extent to which they increase the risk of new onset psychiatric disorders or subsequent psychopathology is unclear, lead author Andrée-Anne Ledoux, PhD, of the Children’s Hospital of Eastern Ontario Research Institute, Ottawa, and colleagues explained.

The researchers conducted a population-based retrospective cohort study to evaluate associations between concussion and risk of subsequent mental health issues, psychiatric hospitalizations, self-harm, or suicides in children and adolescents, with follow-up ranging from 1 month to 10 years.

The data were obtained from province-wide health administrative databases. Participants with concussion were included in an exposed group, while those with an orthopedic injury were included in a 1:2 age- and sex-matched comparison group.
 

Results

The study cohort comprised 448,803 participants, including 152,321 and 296,482 children and adolescents with concussion and orthopedic injury, respectively.

The incidence rates of any mental health problem were 11,141 per 100,000 person-years in the exposed group and 7,960 per 100,000 person-years in the unexposed group (difference, 3,181; 95% confidence interval, 3,073-3,291 per 100,000 person-years).

After concussion, the exposed group had a greater risk of developing a mental health issue (adjusted hazard ratio, 1.39; 95% CI, 1.37-1.40), psychiatric hospitalization (aHR, 1.47; 95% CI, 1.41-1.53), and self-harm (aHR, 1.49; 95% CI, 1.42-1.56). In addition, there was no significant difference in death by suicide between the exposed and unexposed groups (HR, 1.54; 95% CI, 0.90-2.61).

“Our results suggest that clinicians should assess for preexisting and new mental health symptoms throughout concussion recovery and treat mental health conditions or symptoms or refer the patient to a specialist in pediatric mental health,” wrote Dr. Ledoux and colleagues. “[Clinicians should also] assess suicidal ideation and self-harm behaviors during evaluation and follow-up visits for concussion.”

The researchers acknowledged that a key limitation of the study was the retrospective observational design. In addition, the identification of exposures using diagnostic billing codes could have introduced exposure or outcome misclassification.
 

Expert-recommended resources

“For more information, I’d recommend ‘Pedsconcussion,’ which are evidence-based living guidelines for pediatric concussion care,” Dr. Ledoux said in an interview. “Within domain 8, there are specific guidelines related to the management of mental health issues post concussion.”

Neuropsychology expert Talin Babikian, PhD, of the University of California, Los Angeles, commented: “Studies have shown that even a single psychoeducational session early after a concussion can minimize prolonged recoveries. Ensuring all stakeholders (family, clinicians, school, coach, peers) are on the same page and providing the same information is important to build trust and a sense of safety and agency.

“We want to provide psychoeducation early in the process to avoid unnecessary fear and avoidance. We also want to curtail misattribution of everyday symptoms or symptoms related to an unrelated condition to a brain injury, which are easier to do when caught early,” Dr. Babikian added.

This study was supported by the Institute for Clinical Evaluative Sciences, which is funded by an annual grant from the Ontario Ministry of Health and the Ministry of Long-term Care. One author reported financial relationships with the University of Ottawa, the National Football League, Parachute Canada, and 360 Concussion Care, an interdisciplinary concussion clinic; no other conflicts of interest were reported.

Among children and adolescents aged 5-18 years, concussion was associated with a higher risk of mental health problems, compared with age- and sex-matched children and adolescents with an orthopedic injury, according to a cohort study published in JAMA Network Open.

While concussions are one of the most common head injuries in the pediatric population, the extent to which they increase the risk of new onset psychiatric disorders or subsequent psychopathology is unclear, lead author Andrée-Anne Ledoux, PhD, of the Children’s Hospital of Eastern Ontario Research Institute, Ottawa, and colleagues explained.

The researchers conducted a population-based retrospective cohort study to evaluate associations between concussion and risk of subsequent mental health issues, psychiatric hospitalizations, self-harm, or suicides in children and adolescents, with follow-up ranging from 1 month to 10 years.

The data were obtained from province-wide health administrative databases. Participants with concussion were included in an exposed group, while those with an orthopedic injury were included in a 1:2 age- and sex-matched comparison group.
 

Results

The study cohort comprised 448,803 participants, including 152,321 and 296,482 children and adolescents with concussion and orthopedic injury, respectively.

The incidence rates of any mental health problem were 11,141 per 100,000 person-years in the exposed group and 7,960 per 100,000 person-years in the unexposed group (difference, 3,181; 95% confidence interval, 3,073-3,291 per 100,000 person-years).

After concussion, the exposed group had a greater risk of developing a mental health issue (adjusted hazard ratio, 1.39; 95% CI, 1.37-1.40), psychiatric hospitalization (aHR, 1.47; 95% CI, 1.41-1.53), and self-harm (aHR, 1.49; 95% CI, 1.42-1.56). In addition, there was no significant difference in death by suicide between the exposed and unexposed groups (HR, 1.54; 95% CI, 0.90-2.61).

“Our results suggest that clinicians should assess for preexisting and new mental health symptoms throughout concussion recovery and treat mental health conditions or symptoms or refer the patient to a specialist in pediatric mental health,” wrote Dr. Ledoux and colleagues. “[Clinicians should also] assess suicidal ideation and self-harm behaviors during evaluation and follow-up visits for concussion.”

The researchers acknowledged that a key limitation of the study was the retrospective observational design. In addition, the identification of exposures using diagnostic billing codes could have introduced exposure or outcome misclassification.
 

Expert-recommended resources

“For more information, I’d recommend ‘Pedsconcussion,’ which are evidence-based living guidelines for pediatric concussion care,” Dr. Ledoux said in an interview. “Within domain 8, there are specific guidelines related to the management of mental health issues post concussion.”

Neuropsychology expert Talin Babikian, PhD, of the University of California, Los Angeles, commented: “Studies have shown that even a single psychoeducational session early after a concussion can minimize prolonged recoveries. Ensuring all stakeholders (family, clinicians, school, coach, peers) are on the same page and providing the same information is important to build trust and a sense of safety and agency.

“We want to provide psychoeducation early in the process to avoid unnecessary fear and avoidance. We also want to curtail misattribution of everyday symptoms or symptoms related to an unrelated condition to a brain injury, which are easier to do when caught early,” Dr. Babikian added.

This study was supported by the Institute for Clinical Evaluative Sciences, which is funded by an annual grant from the Ontario Ministry of Health and the Ministry of Long-term Care. One author reported financial relationships with the University of Ottawa, the National Football League, Parachute Canada, and 360 Concussion Care, an interdisciplinary concussion clinic; no other conflicts of interest were reported.

Many emergency departments are currently unable to provide care for geriatric patients that meets best practices and guidelines recommended by several major medical organizations, but a panel discussion in 2021 at the American Academy of Emergency Medicine’s Scientific Assembly identified three areas in which realistic improvements might be achieved.

In an article published online in the Journal of Emergency Medicine, Richard D. Shih, MD, of Florida Atlantic University, Boca Raton, and colleagues synthesized the presentation and discussion of an expert panel on the topic of the GED guidelines and the current realities of patient care.

The Geriatric Emergency Department (GED) Guidelines, published in 2014 in Annals of Emergency Medicine, were endorsed by the American College of Emergency Physicians, American Geriatrics Society, Emergency Nurses Association, and Society for Academic Emergency Medicine.

“With the substantial challenges in providing guideline-recommended care in EDs, this article will explore three high-impact GED clinical conditions to highlight guideline recommendations, challenges, and opportunities, and discuss realistically achievable expectations for non–GED-accredited institutions,” the authors wrote. The article addressed the ED patient with delirium, the ED fall patient, and the ED patient with polypharmacy.
 

Geriatric patients and delirium

When delirium in older adults is not identified in the ED, the patient’s 6-month mortality rate significantly increases, but few EDs have delirium screening protocols, the authors said. Challenges included the time and money needed to educate staff, on top of multiple mandatory training requirements on other topics. Delirium screening in the clinical setting also requires personnel to conduct assessments, and time to document symptoms and screening results in medical records.

“Perhaps the highest priority challenge for delirium experts is to evaluate and publish effective delirium intervention strategies because current evidence is completely lacking for ED-based delirium prevention or treatment,” they said. In the meantime, developing outcome measures for quality improvement of delirium care will require institutional support as well as education.
 

Geriatric patients and falls

Approximately one third of community-dwelling adults older than 65 years suffer falls, but data suggest that fewer than half of these individuals report falls to their doctors. “Older adults who present to an ED after a fall have an approximately 30% greater risk of functional decline and depression at 6 months after the event,” the authors noted.

The GED guidelines call for a comprehensive approach to evaluating and managing falls in older adults, but many of these “are untested in the ED,” the authors said. The recommended protocol includes an initial assessment of fall risk, followed by, for those at low risk, tailored recommendations for education and the use of community resources. Additional recommendations for those at high risk of falls include multifactorial assessment of modifiable risk factors, including peripheral neuropathy, balance/gait assessment, and medication review.

However, this best practice workflow is beyond the resource capacity of most EDs, the authors noted. “When ED resources are insufficient to support best practices, the care should focus on educating patients and caregivers about the significance of a fall event, providing educational materials (e.g., [the Centers for Disease Control and Prevention’s] STEADI materials), and assessing safety with respect to mobility for immediate return to the home environment and follow-up with a PCP.”
 

Geriatric patients and polypharmacy

Polypharmacy is common among older adults by virtue of their greater number of illnesses and comorbid conditions, and polypharmacy also has been associated with more adverse drug reactions, the authors said. The AGS Beers Criteria identifies medications associated with adverse drug reactions, but it is not practical for use in a busy ED setting. Instead, the authors suggested a more practical approach of focusing on a smaller list of common medications that tend to cause the adverse events that may result in ED visits.

“Perhaps targeting patients on multiple (three or more) psychoactive medications, drugs that can cause hypotension, or hypoglycemics could not only be done quickly, but identify patients in whom deprescribing should be considered in the ED,” the authors wrote. Deprescribing is a complicated process, however, and may be more effective when done via the patient’s primary care provider or in a geriatric consultation.

The GED Guidelines highlighted the specific needs of the geriatric population in the ED, the authors said. Widespread implementation remains a challenge, but many organizations provide resources to help improve care of geriatric patients in the ED and beyond.

In particular, the Geriatric Emergency Care Applied Research Network and Geriatric Emergency Department Collaborative provide funding opportunities, updated and focused published reviews, and webinars (some including free continuing medical education) for the entire health care team, including hospital administrators, the authors said.
 

Article brings attention to clinical realities

“The reality is that the overwhelming majority of emergency departments in the United States, if not globally, are simply not equipped – operationally or financially – to meet the rigorous standards that are required to fulfill the goals of operating an accredited geriatric ED,” Robert D. Glatter, MD, an emergency medicine physician at Lenox Hill Hospital, New York, said in an interview.

“Drawing attention to this important gap in accreditation is critical to not only inform hospitals, health care providers and stakeholders, but the public, patients, and their families about the important work that needs to be done to better equip all EDs with the proper tools and educational approaches to more effectively care for the geriatric community,” Dr. Glatter emphasized.

“There are currently three tiers of accreditation, with level 1 being the highest,” he explained, but there are only 100 geriatric ED accreditation-certified hospitals across the United States.

“I am not surprised at all by the challenges of implementing current GED guidelines,” said Dr. Glatter. “It comes down to operational and budget considerations, which ultimately compete with many other departments and regulatory constraints in any given hospital.”

However, “the bottom line is that such guidelines are designed with patient safety in mind, making them important issues in the eyes of any hospital administrator looking to improve outcomes and reduce medicolegal risk or exposure impacting geriatric patients in the emergency department,” he noted. 

Ultimately, guideline adherence “comes down to budget decisions, and where hospitals must invest their money to meet the bottom line,” said Dr. Glatter. “Making modifications to hospital infrastructure and architecture to accommodate geriatric patients may not be the top priority of hospital administrators when confronted with multiple competing interests. But, if it impacts patient safety, the decision to invest in structural and operational improvements may certainly have additional and important considerations.

“Until Medicare, or even the Joint Commission on Accreditation of Hospitals, adopts geriatric guidelines in emergency departments as a requirement for accreditation, there may not be adequate incentives in place currently to satisfy the intent of having a rigorous set of guidelines in the first place,” Dr. Glatter added. 

Despite the limitations of applying the current guidelines, there are some steps hospitals can take, said Dr. Glatter. “They can institute new measures in a graded fashion, with the goal of taking the important steps to satisfy at least some components of the guidelines. Attention to details can go a long way, such as rails in bathrooms, better lighting, and treads on floors that may reduce the risk of falls in the ED itself.

“Attention to fall prevention by assessing contributors including polypharmacy, gait instability, and quality of footwear can impact risk of future ED visits. Having incentives in place by Medicare or JACO may force the hand of hospital administrators to comply with geriatric guidelines and place emphasis on compliance,” noted Dr. Glatter.

More research is needed that “looks at costs of implementing geriatric guidelines in typical community and academic EDs and how this impacts key metrics such as length of stay, effect on reimbursement per ICD-10 code, and savings, if any, realized in reduced malpractice claims related to missed diagnoses (such as delirium), injuries, (patient falls), or medical misadventures due to polypharmacy,” he said.

The article received no outside funding. The authors disclosed no relevant financial relationships. Dr. Glatter disclosed no relevant financial relationships, and serves on the advisory board of Medscape Emergency Medicine.

A version of this article first appeared on Medscape.com.

Many emergency departments are currently unable to provide care for geriatric patients that meets best practices and guidelines recommended by several major medical organizations, but a panel discussion in 2021 at the American Academy of Emergency Medicine’s Scientific Assembly identified three areas in which realistic improvements might be achieved.

In an article published online in the Journal of Emergency Medicine, Richard D. Shih, MD, of Florida Atlantic University, Boca Raton, and colleagues synthesized the presentation and discussion of an expert panel on the topic of the GED guidelines and the current realities of patient care.

The Geriatric Emergency Department (GED) Guidelines, published in 2014 in Annals of Emergency Medicine, were endorsed by the American College of Emergency Physicians, American Geriatrics Society, Emergency Nurses Association, and Society for Academic Emergency Medicine.

“With the substantial challenges in providing guideline-recommended care in EDs, this article will explore three high-impact GED clinical conditions to highlight guideline recommendations, challenges, and opportunities, and discuss realistically achievable expectations for non–GED-accredited institutions,” the authors wrote. The article addressed the ED patient with delirium, the ED fall patient, and the ED patient with polypharmacy.
 

Geriatric patients and delirium

When delirium in older adults is not identified in the ED, the patient’s 6-month mortality rate significantly increases, but few EDs have delirium screening protocols, the authors said. Challenges included the time and money needed to educate staff, on top of multiple mandatory training requirements on other topics. Delirium screening in the clinical setting also requires personnel to conduct assessments, and time to document symptoms and screening results in medical records.

“Perhaps the highest priority challenge for delirium experts is to evaluate and publish effective delirium intervention strategies because current evidence is completely lacking for ED-based delirium prevention or treatment,” they said. In the meantime, developing outcome measures for quality improvement of delirium care will require institutional support as well as education.
 

Geriatric patients and falls

Approximately one third of community-dwelling adults older than 65 years suffer falls, but data suggest that fewer than half of these individuals report falls to their doctors. “Older adults who present to an ED after a fall have an approximately 30% greater risk of functional decline and depression at 6 months after the event,” the authors noted.

The GED guidelines call for a comprehensive approach to evaluating and managing falls in older adults, but many of these “are untested in the ED,” the authors said. The recommended protocol includes an initial assessment of fall risk, followed by, for those at low risk, tailored recommendations for education and the use of community resources. Additional recommendations for those at high risk of falls include multifactorial assessment of modifiable risk factors, including peripheral neuropathy, balance/gait assessment, and medication review.

However, this best practice workflow is beyond the resource capacity of most EDs, the authors noted. “When ED resources are insufficient to support best practices, the care should focus on educating patients and caregivers about the significance of a fall event, providing educational materials (e.g., [the Centers for Disease Control and Prevention’s] STEADI materials), and assessing safety with respect to mobility for immediate return to the home environment and follow-up with a PCP.”
 

Geriatric patients and polypharmacy

Polypharmacy is common among older adults by virtue of their greater number of illnesses and comorbid conditions, and polypharmacy also has been associated with more adverse drug reactions, the authors said. The AGS Beers Criteria identifies medications associated with adverse drug reactions, but it is not practical for use in a busy ED setting. Instead, the authors suggested a more practical approach of focusing on a smaller list of common medications that tend to cause the adverse events that may result in ED visits.

“Perhaps targeting patients on multiple (three or more) psychoactive medications, drugs that can cause hypotension, or hypoglycemics could not only be done quickly, but identify patients in whom deprescribing should be considered in the ED,” the authors wrote. Deprescribing is a complicated process, however, and may be more effective when done via the patient’s primary care provider or in a geriatric consultation.

The GED Guidelines highlighted the specific needs of the geriatric population in the ED, the authors said. Widespread implementation remains a challenge, but many organizations provide resources to help improve care of geriatric patients in the ED and beyond.

In particular, the Geriatric Emergency Care Applied Research Network and Geriatric Emergency Department Collaborative provide funding opportunities, updated and focused published reviews, and webinars (some including free continuing medical education) for the entire health care team, including hospital administrators, the authors said.
 

Article brings attention to clinical realities

“The reality is that the overwhelming majority of emergency departments in the United States, if not globally, are simply not equipped – operationally or financially – to meet the rigorous standards that are required to fulfill the goals of operating an accredited geriatric ED,” Robert D. Glatter, MD, an emergency medicine physician at Lenox Hill Hospital, New York, said in an interview.

“Drawing attention to this important gap in accreditation is critical to not only inform hospitals, health care providers and stakeholders, but the public, patients, and their families about the important work that needs to be done to better equip all EDs with the proper tools and educational approaches to more effectively care for the geriatric community,” Dr. Glatter emphasized.

“There are currently three tiers of accreditation, with level 1 being the highest,” he explained, but there are only 100 geriatric ED accreditation-certified hospitals across the United States.

“I am not surprised at all by the challenges of implementing current GED guidelines,” said Dr. Glatter. “It comes down to operational and budget considerations, which ultimately compete with many other departments and regulatory constraints in any given hospital.”

However, “the bottom line is that such guidelines are designed with patient safety in mind, making them important issues in the eyes of any hospital administrator looking to improve outcomes and reduce medicolegal risk or exposure impacting geriatric patients in the emergency department,” he noted. 

Ultimately, guideline adherence “comes down to budget decisions, and where hospitals must invest their money to meet the bottom line,” said Dr. Glatter. “Making modifications to hospital infrastructure and architecture to accommodate geriatric patients may not be the top priority of hospital administrators when confronted with multiple competing interests. But, if it impacts patient safety, the decision to invest in structural and operational improvements may certainly have additional and important considerations.

“Until Medicare, or even the Joint Commission on Accreditation of Hospitals, adopts geriatric guidelines in emergency departments as a requirement for accreditation, there may not be adequate incentives in place currently to satisfy the intent of having a rigorous set of guidelines in the first place,” Dr. Glatter added. 

Despite the limitations of applying the current guidelines, there are some steps hospitals can take, said Dr. Glatter. “They can institute new measures in a graded fashion, with the goal of taking the important steps to satisfy at least some components of the guidelines. Attention to details can go a long way, such as rails in bathrooms, better lighting, and treads on floors that may reduce the risk of falls in the ED itself.

“Attention to fall prevention by assessing contributors including polypharmacy, gait instability, and quality of footwear can impact risk of future ED visits. Having incentives in place by Medicare or JACO may force the hand of hospital administrators to comply with geriatric guidelines and place emphasis on compliance,” noted Dr. Glatter.

More research is needed that “looks at costs of implementing geriatric guidelines in typical community and academic EDs and how this impacts key metrics such as length of stay, effect on reimbursement per ICD-10 code, and savings, if any, realized in reduced malpractice claims related to missed diagnoses (such as delirium), injuries, (patient falls), or medical misadventures due to polypharmacy,” he said.

The article received no outside funding. The authors disclosed no relevant financial relationships. Dr. Glatter disclosed no relevant financial relationships, and serves on the advisory board of Medscape Emergency Medicine.

A version of this article first appeared on Medscape.com.

Many emergency departments are currently unable to provide care for geriatric patients that meets best practices and guidelines recommended by several major medical organizations, but a panel discussion in 2021 at the American Academy of Emergency Medicine’s Scientific Assembly identified three areas in which realistic improvements might be achieved.

In an article published online in the Journal of Emergency Medicine, Richard D. Shih, MD, of Florida Atlantic University, Boca Raton, and colleagues synthesized the presentation and discussion of an expert panel on the topic of the GED guidelines and the current realities of patient care.

The Geriatric Emergency Department (GED) Guidelines, published in 2014 in Annals of Emergency Medicine, were endorsed by the American College of Emergency Physicians, American Geriatrics Society, Emergency Nurses Association, and Society for Academic Emergency Medicine.

“With the substantial challenges in providing guideline-recommended care in EDs, this article will explore three high-impact GED clinical conditions to highlight guideline recommendations, challenges, and opportunities, and discuss realistically achievable expectations for non–GED-accredited institutions,” the authors wrote. The article addressed the ED patient with delirium, the ED fall patient, and the ED patient with polypharmacy.
 

Geriatric patients and delirium

When delirium in older adults is not identified in the ED, the patient’s 6-month mortality rate significantly increases, but few EDs have delirium screening protocols, the authors said. Challenges included the time and money needed to educate staff, on top of multiple mandatory training requirements on other topics. Delirium screening in the clinical setting also requires personnel to conduct assessments, and time to document symptoms and screening results in medical records.

“Perhaps the highest priority challenge for delirium experts is to evaluate and publish effective delirium intervention strategies because current evidence is completely lacking for ED-based delirium prevention or treatment,” they said. In the meantime, developing outcome measures for quality improvement of delirium care will require institutional support as well as education.
 

Geriatric patients and falls

Approximately one third of community-dwelling adults older than 65 years suffer falls, but data suggest that fewer than half of these individuals report falls to their doctors. “Older adults who present to an ED after a fall have an approximately 30% greater risk of functional decline and depression at 6 months after the event,” the authors noted.

The GED guidelines call for a comprehensive approach to evaluating and managing falls in older adults, but many of these “are untested in the ED,” the authors said. The recommended protocol includes an initial assessment of fall risk, followed by, for those at low risk, tailored recommendations for education and the use of community resources. Additional recommendations for those at high risk of falls include multifactorial assessment of modifiable risk factors, including peripheral neuropathy, balance/gait assessment, and medication review.

However, this best practice workflow is beyond the resource capacity of most EDs, the authors noted. “When ED resources are insufficient to support best practices, the care should focus on educating patients and caregivers about the significance of a fall event, providing educational materials (e.g., [the Centers for Disease Control and Prevention’s] STEADI materials), and assessing safety with respect to mobility for immediate return to the home environment and follow-up with a PCP.”
 

Geriatric patients and polypharmacy

Polypharmacy is common among older adults by virtue of their greater number of illnesses and comorbid conditions, and polypharmacy also has been associated with more adverse drug reactions, the authors said. The AGS Beers Criteria identifies medications associated with adverse drug reactions, but it is not practical for use in a busy ED setting. Instead, the authors suggested a more practical approach of focusing on a smaller list of common medications that tend to cause the adverse events that may result in ED visits.

“Perhaps targeting patients on multiple (three or more) psychoactive medications, drugs that can cause hypotension, or hypoglycemics could not only be done quickly, but identify patients in whom deprescribing should be considered in the ED,” the authors wrote. Deprescribing is a complicated process, however, and may be more effective when done via the patient’s primary care provider or in a geriatric consultation.

The GED Guidelines highlighted the specific needs of the geriatric population in the ED, the authors said. Widespread implementation remains a challenge, but many organizations provide resources to help improve care of geriatric patients in the ED and beyond.

In particular, the Geriatric Emergency Care Applied Research Network and Geriatric Emergency Department Collaborative provide funding opportunities, updated and focused published reviews, and webinars (some including free continuing medical education) for the entire health care team, including hospital administrators, the authors said.
 

Article brings attention to clinical realities

“The reality is that the overwhelming majority of emergency departments in the United States, if not globally, are simply not equipped – operationally or financially – to meet the rigorous standards that are required to fulfill the goals of operating an accredited geriatric ED,” Robert D. Glatter, MD, an emergency medicine physician at Lenox Hill Hospital, New York, said in an interview.

“Drawing attention to this important gap in accreditation is critical to not only inform hospitals, health care providers and stakeholders, but the public, patients, and their families about the important work that needs to be done to better equip all EDs with the proper tools and educational approaches to more effectively care for the geriatric community,” Dr. Glatter emphasized.

“There are currently three tiers of accreditation, with level 1 being the highest,” he explained, but there are only 100 geriatric ED accreditation-certified hospitals across the United States.

“I am not surprised at all by the challenges of implementing current GED guidelines,” said Dr. Glatter. “It comes down to operational and budget considerations, which ultimately compete with many other departments and regulatory constraints in any given hospital.”

However, “the bottom line is that such guidelines are designed with patient safety in mind, making them important issues in the eyes of any hospital administrator looking to improve outcomes and reduce medicolegal risk or exposure impacting geriatric patients in the emergency department,” he noted. 

Ultimately, guideline adherence “comes down to budget decisions, and where hospitals must invest their money to meet the bottom line,” said Dr. Glatter. “Making modifications to hospital infrastructure and architecture to accommodate geriatric patients may not be the top priority of hospital administrators when confronted with multiple competing interests. But, if it impacts patient safety, the decision to invest in structural and operational improvements may certainly have additional and important considerations.

“Until Medicare, or even the Joint Commission on Accreditation of Hospitals, adopts geriatric guidelines in emergency departments as a requirement for accreditation, there may not be adequate incentives in place currently to satisfy the intent of having a rigorous set of guidelines in the first place,” Dr. Glatter added. 

Despite the limitations of applying the current guidelines, there are some steps hospitals can take, said Dr. Glatter. “They can institute new measures in a graded fashion, with the goal of taking the important steps to satisfy at least some components of the guidelines. Attention to details can go a long way, such as rails in bathrooms, better lighting, and treads on floors that may reduce the risk of falls in the ED itself.

“Attention to fall prevention by assessing contributors including polypharmacy, gait instability, and quality of footwear can impact risk of future ED visits. Having incentives in place by Medicare or JACO may force the hand of hospital administrators to comply with geriatric guidelines and place emphasis on compliance,” noted Dr. Glatter.

More research is needed that “looks at costs of implementing geriatric guidelines in typical community and academic EDs and how this impacts key metrics such as length of stay, effect on reimbursement per ICD-10 code, and savings, if any, realized in reduced malpractice claims related to missed diagnoses (such as delirium), injuries, (patient falls), or medical misadventures due to polypharmacy,” he said.

The article received no outside funding. The authors disclosed no relevant financial relationships. Dr. Glatter disclosed no relevant financial relationships, and serves on the advisory board of Medscape Emergency Medicine.

A version of this article first appeared on Medscape.com.

Early results from a new study show a significant correlation between tic severity and social media use during the COVID pandemic in adolescents with a preexisting tic disorder.

The findings should help answer questions surrounding a recent increase in tic disorders, lead author Jessica Frey, MD, a movement disorders fellow at the University of Florida, Gainesville, told this news organization.

University of Florida

“We’re trying to learn why there are new-onset explosive tic disorders [or] functional tic disorders, and to find ways to educate patients, parents, and the general public about what Tourette syndrome looks like – and how we can help patients have a better quality of life,” Dr. Frey said.

The findings will be presented at the American Academy of Neurology 2022 annual meeting in April.
 

‘Robust’ increase

A neurologic disorder that causes sudden repetitive involuntary muscle movements and sounds, Tourette syndrome typically develops in childhood, worsens in adolescence, and improves or completely disappears in adulthood, Dr. Frey noted.

The condition is often negatively portrayed in films, showing people using obscene gestures or vulgar language, she said. Although social media can be an “empowering tool” for tic sufferers, it is unregulated and can be a vehicle for “false information,” she added.

Dr. Frey noted that during the pandemic there has been a “robust” increase in use by teens of social media, particularly TikTok. At the same time, there have been reports of teen girls experiencing “explosive tic onset” that mimics videos from TikTok influencers.

The new analysis included 20 teens with a tic disorder, ranging in age from 11 to 21 years (average age, 16 years). About 45% of participants identified as male, 45% as female, and 10% as nonbinary.

The nature of the tic disorder varied widely among participants. Some had experienced tics for many years, while others only developed tics during the pandemic.

Participants completed a detailed survey, part of which inquired about where they received information about tics, such as from a doctor, media, parents, or teachers.

They were also asked to rank various social media platforms, including Tik Tok, Facebook, and YouTube on a five-point Likert scale as an information source about tics.

In addition, the survey inquired about tic severity and frequency, quality of life, and whether the pandemic or social media affected respondents’ tics.
 

Worsens quality of life

Results showed 65% of respondents used social media at least four to five times per day for an average of 5.6 hours per day. Approximately 90% reported increased use of social media during COVID.

Only 5% of participants reported using social media to provide information about tics.

About half of respondents indicated social media adversely affected their tics, and 85% said their tic frequency worsened during COVID.

Dr. Frey noted that because teens had to attend school virtually, that may have led to increased hours spent online.

There was no significant correlation between social media use and self-reported frequency of tics since the onset of COVID (Pearson correlation coefficient [R], –0.0055, P = .982).

However, there was a statistically significant correlation between social media use and tic severity (R, –0.496, P = .026) and quality of life (R, –0.447, P = .048).

These results suggest teenagers did not develop more tics, but rather the tics they already had worsened and affected their quality of life, Dr. Frey noted. She added that teens sometimes injure themselves while experiencing tics.

The full study has now enrolled 50 participants, and investigators anticipate that number to go up to 80. “We’re hoping to see more patterns emerge when we have a larger cohort of data available,” said Dr. Frey.

Asking parents to weigh in on the impact of social media on their child’s tic condition would be “a great idea for a follow-up study,” she added.
 

Symptoms exacerbated

Commenting on the findings, Tamara Pringsheim, MD, professor in the department of clinical neurosciences, psychiatry, pediatrics, and community health sciences at the University of Calgary (Alta.), said she also has noticed the impact of increased social media use on young patients with tics during the pandemic.

“Many young people report that seeing other people with tics, or ticlike behaviors, can exacerbate their own symptoms,” said Dr. Pringsheim, who is the university’s program lead on Tourette and pediatric movement disorders.

She noted a principle of the Comprehensive Behavioral Intervention for Tics, which is a nonpharmacologic technique demonstrated to reduce tic severity, is to identify antecedents or triggers for tics, and to learn to manage them. It might be a good idea to remind young patients of this principle, said Dr. Pringsheim, who was not associated with the current research.

“I suggest to young people who report specific social media content as a trigger for symptoms to recognize the effect of the exposure on their symptoms and make an informed choice about what they view and how much time they spend on social media,” she added.

The study did not receive any outside funding support. Dr. Frey has disclosed no relevant financial relationships.

A version of this article first appeared on Medscape.com.

Early results from a new study show a significant correlation between tic severity and social media use during the COVID pandemic in adolescents with a preexisting tic disorder.

The findings should help answer questions surrounding a recent increase in tic disorders, lead author Jessica Frey, MD, a movement disorders fellow at the University of Florida, Gainesville, told this news organization.

University of Florida

“We’re trying to learn why there are new-onset explosive tic disorders [or] functional tic disorders, and to find ways to educate patients, parents, and the general public about what Tourette syndrome looks like – and how we can help patients have a better quality of life,” Dr. Frey said.

The findings will be presented at the American Academy of Neurology 2022 annual meeting in April.
 

‘Robust’ increase

A neurologic disorder that causes sudden repetitive involuntary muscle movements and sounds, Tourette syndrome typically develops in childhood, worsens in adolescence, and improves or completely disappears in adulthood, Dr. Frey noted.

The condition is often negatively portrayed in films, showing people using obscene gestures or vulgar language, she said. Although social media can be an “empowering tool” for tic sufferers, it is unregulated and can be a vehicle for “false information,” she added.

Dr. Frey noted that during the pandemic there has been a “robust” increase in use by teens of social media, particularly TikTok. At the same time, there have been reports of teen girls experiencing “explosive tic onset” that mimics videos from TikTok influencers.

The new analysis included 20 teens with a tic disorder, ranging in age from 11 to 21 years (average age, 16 years). About 45% of participants identified as male, 45% as female, and 10% as nonbinary.

The nature of the tic disorder varied widely among participants. Some had experienced tics for many years, while others only developed tics during the pandemic.

Participants completed a detailed survey, part of which inquired about where they received information about tics, such as from a doctor, media, parents, or teachers.

They were also asked to rank various social media platforms, including Tik Tok, Facebook, and YouTube on a five-point Likert scale as an information source about tics.

In addition, the survey inquired about tic severity and frequency, quality of life, and whether the pandemic or social media affected respondents’ tics.
 

Worsens quality of life

Results showed 65% of respondents used social media at least four to five times per day for an average of 5.6 hours per day. Approximately 90% reported increased use of social media during COVID.

Only 5% of participants reported using social media to provide information about tics.

About half of respondents indicated social media adversely affected their tics, and 85% said their tic frequency worsened during COVID.

Dr. Frey noted that because teens had to attend school virtually, that may have led to increased hours spent online.

There was no significant correlation between social media use and self-reported frequency of tics since the onset of COVID (Pearson correlation coefficient [R], –0.0055, P = .982).

However, there was a statistically significant correlation between social media use and tic severity (R, –0.496, P = .026) and quality of life (R, –0.447, P = .048).

These results suggest teenagers did not develop more tics, but rather the tics they already had worsened and affected their quality of life, Dr. Frey noted. She added that teens sometimes injure themselves while experiencing tics.

The full study has now enrolled 50 participants, and investigators anticipate that number to go up to 80. “We’re hoping to see more patterns emerge when we have a larger cohort of data available,” said Dr. Frey.

Asking parents to weigh in on the impact of social media on their child’s tic condition would be “a great idea for a follow-up study,” she added.
 

Symptoms exacerbated

Commenting on the findings, Tamara Pringsheim, MD, professor in the department of clinical neurosciences, psychiatry, pediatrics, and community health sciences at the University of Calgary (Alta.), said she also has noticed the impact of increased social media use on young patients with tics during the pandemic.

“Many young people report that seeing other people with tics, or ticlike behaviors, can exacerbate their own symptoms,” said Dr. Pringsheim, who is the university’s program lead on Tourette and pediatric movement disorders.

She noted a principle of the Comprehensive Behavioral Intervention for Tics, which is a nonpharmacologic technique demonstrated to reduce tic severity, is to identify antecedents or triggers for tics, and to learn to manage them. It might be a good idea to remind young patients of this principle, said Dr. Pringsheim, who was not associated with the current research.

“I suggest to young people who report specific social media content as a trigger for symptoms to recognize the effect of the exposure on their symptoms and make an informed choice about what they view and how much time they spend on social media,” she added.

The study did not receive any outside funding support. Dr. Frey has disclosed no relevant financial relationships.

A version of this article first appeared on Medscape.com.

Early results from a new study show a significant correlation between tic severity and social media use during the COVID pandemic in adolescents with a preexisting tic disorder.

The findings should help answer questions surrounding a recent increase in tic disorders, lead author Jessica Frey, MD, a movement disorders fellow at the University of Florida, Gainesville, told this news organization.

University of Florida

“We’re trying to learn why there are new-onset explosive tic disorders [or] functional tic disorders, and to find ways to educate patients, parents, and the general public about what Tourette syndrome looks like – and how we can help patients have a better quality of life,” Dr. Frey said.

The findings will be presented at the American Academy of Neurology 2022 annual meeting in April.
 

‘Robust’ increase

A neurologic disorder that causes sudden repetitive involuntary muscle movements and sounds, Tourette syndrome typically develops in childhood, worsens in adolescence, and improves or completely disappears in adulthood, Dr. Frey noted.

The condition is often negatively portrayed in films, showing people using obscene gestures or vulgar language, she said. Although social media can be an “empowering tool” for tic sufferers, it is unregulated and can be a vehicle for “false information,” she added.

Dr. Frey noted that during the pandemic there has been a “robust” increase in use by teens of social media, particularly TikTok. At the same time, there have been reports of teen girls experiencing “explosive tic onset” that mimics videos from TikTok influencers.

The new analysis included 20 teens with a tic disorder, ranging in age from 11 to 21 years (average age, 16 years). About 45% of participants identified as male, 45% as female, and 10% as nonbinary.

The nature of the tic disorder varied widely among participants. Some had experienced tics for many years, while others only developed tics during the pandemic.

Participants completed a detailed survey, part of which inquired about where they received information about tics, such as from a doctor, media, parents, or teachers.

They were also asked to rank various social media platforms, including Tik Tok, Facebook, and YouTube on a five-point Likert scale as an information source about tics.

In addition, the survey inquired about tic severity and frequency, quality of life, and whether the pandemic or social media affected respondents’ tics.
 

Worsens quality of life

Results showed 65% of respondents used social media at least four to five times per day for an average of 5.6 hours per day. Approximately 90% reported increased use of social media during COVID.

Only 5% of participants reported using social media to provide information about tics.

About half of respondents indicated social media adversely affected their tics, and 85% said their tic frequency worsened during COVID.

Dr. Frey noted that because teens had to attend school virtually, that may have led to increased hours spent online.

There was no significant correlation between social media use and self-reported frequency of tics since the onset of COVID (Pearson correlation coefficient [R], –0.0055, P = .982).

However, there was a statistically significant correlation between social media use and tic severity (R, –0.496, P = .026) and quality of life (R, –0.447, P = .048).

These results suggest teenagers did not develop more tics, but rather the tics they already had worsened and affected their quality of life, Dr. Frey noted. She added that teens sometimes injure themselves while experiencing tics.

The full study has now enrolled 50 participants, and investigators anticipate that number to go up to 80. “We’re hoping to see more patterns emerge when we have a larger cohort of data available,” said Dr. Frey.

Asking parents to weigh in on the impact of social media on their child’s tic condition would be “a great idea for a follow-up study,” she added.
 

Symptoms exacerbated

Commenting on the findings, Tamara Pringsheim, MD, professor in the department of clinical neurosciences, psychiatry, pediatrics, and community health sciences at the University of Calgary (Alta.), said she also has noticed the impact of increased social media use on young patients with tics during the pandemic.

“Many young people report that seeing other people with tics, or ticlike behaviors, can exacerbate their own symptoms,” said Dr. Pringsheim, who is the university’s program lead on Tourette and pediatric movement disorders.

She noted a principle of the Comprehensive Behavioral Intervention for Tics, which is a nonpharmacologic technique demonstrated to reduce tic severity, is to identify antecedents or triggers for tics, and to learn to manage them. It might be a good idea to remind young patients of this principle, said Dr. Pringsheim, who was not associated with the current research.

“I suggest to young people who report specific social media content as a trigger for symptoms to recognize the effect of the exposure on their symptoms and make an informed choice about what they view and how much time they spend on social media,” she added.

The study did not receive any outside funding support. Dr. Frey has disclosed no relevant financial relationships.

A version of this article first appeared on Medscape.com.

Among individuals with multiple sclerosis (MS), disease modifying therapies (DMTs) are associated with a reduced humoral response to SARS-CoV-2 vaccines, according to a new retrospective analysis. The link is particularly strong among B-cell depleting drugs.

“A lot of patients ask us if having MS by itself affects the vaccine response. We did not find that, but it’s about the disease-modifying therapy that a patient is being treated with,” Tirisham Gyang, MD, said in an interview. Dr. Gyang presented the study at a poster session during the annual meeting held by the Americas Committee for Treatment and Research in Multiple Sclerosis (ACTRIMS).

“These patients (on DMTs) had decreased neutralizing antibody levels to the vaccine after they received it. We also saw a similar marker in drugs that modulate the sphingosine S-1 receptor. These patients also had a lower titer. It wasn’t statistically significant, but we think it’s positive. It was underpowered because there was a small number of patients in that subgroup,” said Dr. Gyang, assistant professor of neurology at The Ohio State University.

The results can inform vaccine strategies among people with MS, but the issue remains complex. “I don’t know that we could do a blanket statement and say, if you wait this amount of time, everybody will be okay. It’s a very individualized approach, and patients need to discuss timing of vaccines with their providers, because we know that waiting is better. It’s preferable to wait until towards the end of the dosing cycle. The other factor is making sure that the MS is well treated,” said Dr. Gyang.

The researchers prospectively followed 83 MS patients at the The Ohio State University Wexner Medical Center. Among the cohort, 71% were female. Fifty-one subjects had serum samples analyzed following mRNA COVID-19 vaccination, and they were compared with 38 health care worker controls.

After vaccination, people with MS had about 2.4-fold lower levels of half-maximal neutralization titer (NT50) values compared with health care worker controls. This appeared to be driven primarily by DMTs. There was a more than ninefold reduction in the neutralizing antibody (nAb) response among 13 patients on B-cell depleting agents, compared with no therapy or other therapies (P < .001). Among of individuals on these agents, 61.5% had no detectable nAb.

The researchers also found an association between postvaccine NT50 values and when the vaccine was received compared with the last infusion of B-cell depleting agents. Every additional day since the previous infusion was associated with a 3.7% increase in NT50 value (P = .0032).

The average length of exposure to B-cell depleting agents was 24 months and the median was 25 months. There was no association between length of time on a B-cell depleting agent and NT50 values after vaccination (Spearman correlation 0.35, P = .24).

Subanalyses by sex and vaccine type revealed no differences in nAb levels.

The study did not look at T-cell responses after vaccination or the effect of T-cell depleting agents, and T cells likely still provide some protection, according to Dr. Gyang. “Even though the vaccine response may not be as robust as it would have been if they were not on the drug, there is still some degree of protection,” she said.
 

Some answers, more questions

The study is important, even though it was presented at the time that the COVID-19 Omicron variant surge was waning. “COVID still remains a major concern. Even though it seems to be on the wane at the moment, that doesn’t mean it will be on the wane next week,” said Mark Gudesblatt, MD, medical director at South Shore Neurologic Associates (Patchogue, N.Y.), who was asked to comment on the study.

He noted that about 21% of patients in the study who received a vaccination had no detectable antibodies. “That’s a problem. You need to pick a medication that works, but not if the medication puts you at risk for other problems, especially in the world of now, where we know there are viral pandemics that occur. And that calls into question: What if you’re immunocompromised and you get a flu vaccine or a tetanus vaccine? How much do we know about the vaccination response to most of these? No one really considers [vaccine response] when choosing a medication,” said Dr. Gudesblatt.

The results broadly confirm what has been seen in other studies, though its focus on the humoral response is a limitation, according to Patricia Coyle, MD, professor of neurology and director of Stony Brook (N.Y.) MS Comprehensive Care Center. “For example, there have been independent studies with the (anti-CD-20 therapies) that indicate that they have a normal cell-mediated vaccine response to the COVID vaccine, even though the antibody response may be impaired in a significant number of individuals, though as you continue to vaccinate the antibody response seems to get better,” Dr. Coyle said in an interview.

Dr. Gyang has served as consultant for Genentech, Horizon Therapeutics, Greenwich Biosciences and EMD Serono. Dr. Gudesblatt has no relevant financial disclosures. Dr. Coyle has consulted or received speaker fees from Accordant, Alexion, Biogen, Bristol Myers Squibb, Celgene, GlaxoSmithKline, Horizon Therapeutics, Janssen, Mylan, Novartis, Sanofi Genzyme, TG Therapeutics, and Viela Bio. Dr. Coyle has received research funding from Actelion, Alkermes, Celgene, CorEvitas LLC, Genentech/Roche, MedDay, Novartis, and Sanofi Genzyme.

Among individuals with multiple sclerosis (MS), disease modifying therapies (DMTs) are associated with a reduced humoral response to SARS-CoV-2 vaccines, according to a new retrospective analysis. The link is particularly strong among B-cell depleting drugs.

“A lot of patients ask us if having MS by itself affects the vaccine response. We did not find that, but it’s about the disease-modifying therapy that a patient is being treated with,” Tirisham Gyang, MD, said in an interview. Dr. Gyang presented the study at a poster session during the annual meeting held by the Americas Committee for Treatment and Research in Multiple Sclerosis (ACTRIMS).

“These patients (on DMTs) had decreased neutralizing antibody levels to the vaccine after they received it. We also saw a similar marker in drugs that modulate the sphingosine S-1 receptor. These patients also had a lower titer. It wasn’t statistically significant, but we think it’s positive. It was underpowered because there was a small number of patients in that subgroup,” said Dr. Gyang, assistant professor of neurology at The Ohio State University.

The results can inform vaccine strategies among people with MS, but the issue remains complex. “I don’t know that we could do a blanket statement and say, if you wait this amount of time, everybody will be okay. It’s a very individualized approach, and patients need to discuss timing of vaccines with their providers, because we know that waiting is better. It’s preferable to wait until towards the end of the dosing cycle. The other factor is making sure that the MS is well treated,” said Dr. Gyang.

The researchers prospectively followed 83 MS patients at the The Ohio State University Wexner Medical Center. Among the cohort, 71% were female. Fifty-one subjects had serum samples analyzed following mRNA COVID-19 vaccination, and they were compared with 38 health care worker controls.

After vaccination, people with MS had about 2.4-fold lower levels of half-maximal neutralization titer (NT50) values compared with health care worker controls. This appeared to be driven primarily by DMTs. There was a more than ninefold reduction in the neutralizing antibody (nAb) response among 13 patients on B-cell depleting agents, compared with no therapy or other therapies (P < .001). Among of individuals on these agents, 61.5% had no detectable nAb.

The researchers also found an association between postvaccine NT50 values and when the vaccine was received compared with the last infusion of B-cell depleting agents. Every additional day since the previous infusion was associated with a 3.7% increase in NT50 value (P = .0032).

The average length of exposure to B-cell depleting agents was 24 months and the median was 25 months. There was no association between length of time on a B-cell depleting agent and NT50 values after vaccination (Spearman correlation 0.35, P = .24).

Subanalyses by sex and vaccine type revealed no differences in nAb levels.

The study did not look at T-cell responses after vaccination or the effect of T-cell depleting agents, and T cells likely still provide some protection, according to Dr. Gyang. “Even though the vaccine response may not be as robust as it would have been if they were not on the drug, there is still some degree of protection,” she said.
 

Some answers, more questions

The study is important, even though it was presented at the time that the COVID-19 Omicron variant surge was waning. “COVID still remains a major concern. Even though it seems to be on the wane at the moment, that doesn’t mean it will be on the wane next week,” said Mark Gudesblatt, MD, medical director at South Shore Neurologic Associates (Patchogue, N.Y.), who was asked to comment on the study.

He noted that about 21% of patients in the study who received a vaccination had no detectable antibodies. “That’s a problem. You need to pick a medication that works, but not if the medication puts you at risk for other problems, especially in the world of now, where we know there are viral pandemics that occur. And that calls into question: What if you’re immunocompromised and you get a flu vaccine or a tetanus vaccine? How much do we know about the vaccination response to most of these? No one really considers [vaccine response] when choosing a medication,” said Dr. Gudesblatt.

The results broadly confirm what has been seen in other studies, though its focus on the humoral response is a limitation, according to Patricia Coyle, MD, professor of neurology and director of Stony Brook (N.Y.) MS Comprehensive Care Center. “For example, there have been independent studies with the (anti-CD-20 therapies) that indicate that they have a normal cell-mediated vaccine response to the COVID vaccine, even though the antibody response may be impaired in a significant number of individuals, though as you continue to vaccinate the antibody response seems to get better,” Dr. Coyle said in an interview.

Dr. Gyang has served as consultant for Genentech, Horizon Therapeutics, Greenwich Biosciences and EMD Serono. Dr. Gudesblatt has no relevant financial disclosures. Dr. Coyle has consulted or received speaker fees from Accordant, Alexion, Biogen, Bristol Myers Squibb, Celgene, GlaxoSmithKline, Horizon Therapeutics, Janssen, Mylan, Novartis, Sanofi Genzyme, TG Therapeutics, and Viela Bio. Dr. Coyle has received research funding from Actelion, Alkermes, Celgene, CorEvitas LLC, Genentech/Roche, MedDay, Novartis, and Sanofi Genzyme.

Among individuals with multiple sclerosis (MS), disease modifying therapies (DMTs) are associated with a reduced humoral response to SARS-CoV-2 vaccines, according to a new retrospective analysis. The link is particularly strong among B-cell depleting drugs.

“A lot of patients ask us if having MS by itself affects the vaccine response. We did not find that, but it’s about the disease-modifying therapy that a patient is being treated with,” Tirisham Gyang, MD, said in an interview. Dr. Gyang presented the study at a poster session during the annual meeting held by the Americas Committee for Treatment and Research in Multiple Sclerosis (ACTRIMS).

“These patients (on DMTs) had decreased neutralizing antibody levels to the vaccine after they received it. We also saw a similar marker in drugs that modulate the sphingosine S-1 receptor. These patients also had a lower titer. It wasn’t statistically significant, but we think it’s positive. It was underpowered because there was a small number of patients in that subgroup,” said Dr. Gyang, assistant professor of neurology at The Ohio State University.

The results can inform vaccine strategies among people with MS, but the issue remains complex. “I don’t know that we could do a blanket statement and say, if you wait this amount of time, everybody will be okay. It’s a very individualized approach, and patients need to discuss timing of vaccines with their providers, because we know that waiting is better. It’s preferable to wait until towards the end of the dosing cycle. The other factor is making sure that the MS is well treated,” said Dr. Gyang.

The researchers prospectively followed 83 MS patients at the The Ohio State University Wexner Medical Center. Among the cohort, 71% were female. Fifty-one subjects had serum samples analyzed following mRNA COVID-19 vaccination, and they were compared with 38 health care worker controls.

After vaccination, people with MS had about 2.4-fold lower levels of half-maximal neutralization titer (NT50) values compared with health care worker controls. This appeared to be driven primarily by DMTs. There was a more than ninefold reduction in the neutralizing antibody (nAb) response among 13 patients on B-cell depleting agents, compared with no therapy or other therapies (P < .001). Among of individuals on these agents, 61.5% had no detectable nAb.

The researchers also found an association between postvaccine NT50 values and when the vaccine was received compared with the last infusion of B-cell depleting agents. Every additional day since the previous infusion was associated with a 3.7% increase in NT50 value (P = .0032).

The average length of exposure to B-cell depleting agents was 24 months and the median was 25 months. There was no association between length of time on a B-cell depleting agent and NT50 values after vaccination (Spearman correlation 0.35, P = .24).

Subanalyses by sex and vaccine type revealed no differences in nAb levels.

The study did not look at T-cell responses after vaccination or the effect of T-cell depleting agents, and T cells likely still provide some protection, according to Dr. Gyang. “Even though the vaccine response may not be as robust as it would have been if they were not on the drug, there is still some degree of protection,” she said.
 

Some answers, more questions

The study is important, even though it was presented at the time that the COVID-19 Omicron variant surge was waning. “COVID still remains a major concern. Even though it seems to be on the wane at the moment, that doesn’t mean it will be on the wane next week,” said Mark Gudesblatt, MD, medical director at South Shore Neurologic Associates (Patchogue, N.Y.), who was asked to comment on the study.

He noted that about 21% of patients in the study who received a vaccination had no detectable antibodies. “That’s a problem. You need to pick a medication that works, but not if the medication puts you at risk for other problems, especially in the world of now, where we know there are viral pandemics that occur. And that calls into question: What if you’re immunocompromised and you get a flu vaccine or a tetanus vaccine? How much do we know about the vaccination response to most of these? No one really considers [vaccine response] when choosing a medication,” said Dr. Gudesblatt.

The results broadly confirm what has been seen in other studies, though its focus on the humoral response is a limitation, according to Patricia Coyle, MD, professor of neurology and director of Stony Brook (N.Y.) MS Comprehensive Care Center. “For example, there have been independent studies with the (anti-CD-20 therapies) that indicate that they have a normal cell-mediated vaccine response to the COVID vaccine, even though the antibody response may be impaired in a significant number of individuals, though as you continue to vaccinate the antibody response seems to get better,” Dr. Coyle said in an interview.

Dr. Gyang has served as consultant for Genentech, Horizon Therapeutics, Greenwich Biosciences and EMD Serono. Dr. Gudesblatt has no relevant financial disclosures. Dr. Coyle has consulted or received speaker fees from Accordant, Alexion, Biogen, Bristol Myers Squibb, Celgene, GlaxoSmithKline, Horizon Therapeutics, Janssen, Mylan, Novartis, Sanofi Genzyme, TG Therapeutics, and Viela Bio. Dr. Coyle has received research funding from Actelion, Alkermes, Celgene, CorEvitas LLC, Genentech/Roche, MedDay, Novartis, and Sanofi Genzyme.

Mental disorders in early life are associated with a significantly increased risk of dementia in later years.

Results of a large, longitudinal, population-based study show that individuals hospitalized for a mental health disorder had a fourfold increased relative risk (RR) for developing dementia, compared with those who were not hospitalized with a mental illness.

In addition, those with dementia plus a mental disorder developed dementia almost 6 years earlier than those without a mental illness.

The findings were consistent among men and women, in patients with early- and late-onset dementia, in those with Alzheimer’s and non-Alzheimer’s dementia, and across all mental health disorders – and remained so after accounting for pre-existing physical illness and socioeconomic factors.

“Dementia is not typically treated until later in life, but our study suggests that we need to be thinking about dementia prevention much earlier in the life course,” study investigator Leah Richmond-Rakerd, PhD, assistant professor, department of psychology, University of Michigan, said in an interview.

“Supporting young people’s mental health could be a window of opportunity to help reduce the burden of dementia in older adults,” she said.

The findings were published online Feb. 16.
 

Underappreciated risk factor

“Recognition of the outsized influence of dementia on later-life functioning has fueled research into modifiable risk factors and prevention targets,” the investigators write.

Previous research suggests mental disorders may “comprise an underappreciated category of modifiable risk factors.” However, those studies focused primarily on midlife and older individuals, not on capturing mental disorders during young adulthood, which is the time of “peak prevalence,” they add. In addition, most studies have not explored the full range of mental disorders.

Dr. Richmond-Rakerd noted that it is well known that mental health disorders peak in adolescence and young adulthood – and are treatable.

“If the same people who have mental disorders when they are young tend to develop dementia when they are older, that would mean that preventing mental health problems in younger people might reduce or delay the burden of dementia in older people,” she said.

The investigators assessed records from the New Zealand Integrated Data Infrastructure, which is a de-identified register that includes the entire New Zealand population. They also examined information about hospitalizations and diagnoses from records kept by the New Zealand Ministry of Health.

The researchers followed 1,711,386 individuals born between 1928 and 1967 (50.6% men, aged 21 to 60 years at baseline) for 30 years. The population was subdivided into age groups based on birth years: 1928-1937 (14.8%), 1938-1947 (20.85%), 1948-1957 (29.35%), and 1958-1967 (35.1%).
 

Earlier onset

During the study period, 3.8% of individuals were identified as having a mental disorder, and 2% were identified as having dementia. Similar percentages of men and women had a mental disorder, and similar percentages had dementia.

Dementia was “over-represented” among participants with versus without a mental disorder (6.1% vs. 1.8%). This finding held across all age groups.

Those diagnosed with a mental disorder were also more likely to develop dementia, compared with their peers without a mental disorder (RR, 3.51; 95% confidence interval, 3.39-3.64), which is a larger association than that between physical diseases and dementia (RR, 1.19; 95% CI, 1.16-1.21).

These associations were present in both sexes and in all age groups, although the associations were stronger in more recently born cohorts.

A sixfold higher risk for dementia remained even after adjusting for pre-existing physical illnesses (HR, 6.49; 95% CI, 6.25-6.73); and the elevated risk was evident across different lengths of follow-up from the index mental disorder.

When the researchers focused specifically on individuals diagnosed with dementia, they found that those diagnosed with a mental disorder developed dementia a mean of 5.60 years earlier than those without a mental disorder diagnosis – an association observed across both sexes and all age groups.

“Individuals diagnosed with psychotic, substance use, mood, neurotic, and all other mental disorders and who engaged in self-harm were all more likely than those without a mental disorder to be diagnosed with subsequent dementia, even after accounting for their physical disease histories,” the investigators write.

Although there was a link between mental disorders in both Alzheimer’s and non-Alzheimer’s dementias, the association was larger in non-Alzheimer’s.

The researchers note that the study has several limitations, including the fact that it was conducted in New Zealand and therefore the results may not be generalizable to other regions. In addition, inpatient hospital records do not capture less severe mental disorder cases treated in the outpatient setting.

Dr. Richmond-Rakerd suggested several potential mechanisms that could account for the link between mental illness and dementia, including poor lifestyle choices and metabolic side effects associated with some psychiatric medications.

“There could also be shared risk factors for both mental disorders and dementia, such as shared genetics, or individuals may experience a lifelong brain vulnerability that shows up as mental health problems earlier in life and shows up as dementia later in life,” she said.
 

An important risk factor

Commenting for this article, Ken Duckworth, MD, chief medical officer of the National Alliance on Mental Illness, said a major strength of the study was its longitudinal scope and large population size.

He described the study as allowing clinicians to “watch the movie,” as opposed to looking at a “snapshot” of data.

“Although you can learn things from snapshots, a large, comprehensive public health system looking at 30 years of claims – something not possible in the U.S. because of our more fragmented health care system – offers more insight,” said Dr. Duckworth, who was not involved with the research.

The investigators are “painting a picture of a correlation of risk, and to me, that’s the beginning of further inquiry,” he added. “Would preventive efforts targeting dementia, such as exercise and socialization, be helpful? It’s a great study that raises these interesting questions.”

Also commenting in an interview, Claire Sexton, DPhil, director of scientific programs and outreach at the Alzheimer’s Association, said the study “adds a wealth of data to our understanding” of mental disorders as a dementia risk factor.

However, the study was observational, so “the findings cannot imply causation, [and just] because someone has depression, that does not mean they will go on to develop Alzheimer’s,” said Dr. Sexton, who also was not involved with the research.

Still, “these data support the idea that taking care of one’s mental health is incredibly important for overall wellbeing. For providers, it’s important to have mental health evaluation be a part of your patient’s regular checkups,” she added.

Dr. Richmond-Rakerd noted that even if mental health conditions are not a causal risk factor for dementia, “the presence of a mental health problem is still an important indicator of risk. Mental health providers may wish to target other risk factors for dementia that are more common in individuals with mental health conditions, such as social disconnection.”

The study was funded by grants from the National Institute on Aging, the U.K. Medical Research Council, the National Institute of Child Health and Development through the Duke Population Research Center, and the National Institute on Aging through the Center for Advancing Sociodemographic and Economic Study of Alzheimer’s Disease and Related Dementias. Dr. Richmond-Rakerd reports no relevant financial relationships. The other investigators’ disclosures are listed in the original article. Dr. Sexton and Dr. Duckworth report no relevant financial relationships.

A version of this article first appeared on Medscape.com.

Mental disorders in early life are associated with a significantly increased risk of dementia in later years.

Results of a large, longitudinal, population-based study show that individuals hospitalized for a mental health disorder had a fourfold increased relative risk (RR) for developing dementia, compared with those who were not hospitalized with a mental illness.

In addition, those with dementia plus a mental disorder developed dementia almost 6 years earlier than those without a mental illness.

The findings were consistent among men and women, in patients with early- and late-onset dementia, in those with Alzheimer’s and non-Alzheimer’s dementia, and across all mental health disorders – and remained so after accounting for pre-existing physical illness and socioeconomic factors.

“Dementia is not typically treated until later in life, but our study suggests that we need to be thinking about dementia prevention much earlier in the life course,” study investigator Leah Richmond-Rakerd, PhD, assistant professor, department of psychology, University of Michigan, said in an interview.

“Supporting young people’s mental health could be a window of opportunity to help reduce the burden of dementia in older adults,” she said.

The findings were published online Feb. 16.
 

Underappreciated risk factor

“Recognition of the outsized influence of dementia on later-life functioning has fueled research into modifiable risk factors and prevention targets,” the investigators write.

Previous research suggests mental disorders may “comprise an underappreciated category of modifiable risk factors.” However, those studies focused primarily on midlife and older individuals, not on capturing mental disorders during young adulthood, which is the time of “peak prevalence,” they add. In addition, most studies have not explored the full range of mental disorders.

Dr. Richmond-Rakerd noted that it is well known that mental health disorders peak in adolescence and young adulthood – and are treatable.

“If the same people who have mental disorders when they are young tend to develop dementia when they are older, that would mean that preventing mental health problems in younger people might reduce or delay the burden of dementia in older people,” she said.

The investigators assessed records from the New Zealand Integrated Data Infrastructure, which is a de-identified register that includes the entire New Zealand population. They also examined information about hospitalizations and diagnoses from records kept by the New Zealand Ministry of Health.

The researchers followed 1,711,386 individuals born between 1928 and 1967 (50.6% men, aged 21 to 60 years at baseline) for 30 years. The population was subdivided into age groups based on birth years: 1928-1937 (14.8%), 1938-1947 (20.85%), 1948-1957 (29.35%), and 1958-1967 (35.1%).
 

Earlier onset

During the study period, 3.8% of individuals were identified as having a mental disorder, and 2% were identified as having dementia. Similar percentages of men and women had a mental disorder, and similar percentages had dementia.

Dementia was “over-represented” among participants with versus without a mental disorder (6.1% vs. 1.8%). This finding held across all age groups.

Those diagnosed with a mental disorder were also more likely to develop dementia, compared with their peers without a mental disorder (RR, 3.51; 95% confidence interval, 3.39-3.64), which is a larger association than that between physical diseases and dementia (RR, 1.19; 95% CI, 1.16-1.21).

These associations were present in both sexes and in all age groups, although the associations were stronger in more recently born cohorts.

A sixfold higher risk for dementia remained even after adjusting for pre-existing physical illnesses (HR, 6.49; 95% CI, 6.25-6.73); and the elevated risk was evident across different lengths of follow-up from the index mental disorder.

When the researchers focused specifically on individuals diagnosed with dementia, they found that those diagnosed with a mental disorder developed dementia a mean of 5.60 years earlier than those without a mental disorder diagnosis – an association observed across both sexes and all age groups.

“Individuals diagnosed with psychotic, substance use, mood, neurotic, and all other mental disorders and who engaged in self-harm were all more likely than those without a mental disorder to be diagnosed with subsequent dementia, even after accounting for their physical disease histories,” the investigators write.

Although there was a link between mental disorders in both Alzheimer’s and non-Alzheimer’s dementias, the association was larger in non-Alzheimer’s.

The researchers note that the study has several limitations, including the fact that it was conducted in New Zealand and therefore the results may not be generalizable to other regions. In addition, inpatient hospital records do not capture less severe mental disorder cases treated in the outpatient setting.

Dr. Richmond-Rakerd suggested several potential mechanisms that could account for the link between mental illness and dementia, including poor lifestyle choices and metabolic side effects associated with some psychiatric medications.

“There could also be shared risk factors for both mental disorders and dementia, such as shared genetics, or individuals may experience a lifelong brain vulnerability that shows up as mental health problems earlier in life and shows up as dementia later in life,” she said.
 

An important risk factor

Commenting for this article, Ken Duckworth, MD, chief medical officer of the National Alliance on Mental Illness, said a major strength of the study was its longitudinal scope and large population size.

He described the study as allowing clinicians to “watch the movie,” as opposed to looking at a “snapshot” of data.

“Although you can learn things from snapshots, a large, comprehensive public health system looking at 30 years of claims – something not possible in the U.S. because of our more fragmented health care system – offers more insight,” said Dr. Duckworth, who was not involved with the research.

The investigators are “painting a picture of a correlation of risk, and to me, that’s the beginning of further inquiry,” he added. “Would preventive efforts targeting dementia, such as exercise and socialization, be helpful? It’s a great study that raises these interesting questions.”

Also commenting in an interview, Claire Sexton, DPhil, director of scientific programs and outreach at the Alzheimer’s Association, said the study “adds a wealth of data to our understanding” of mental disorders as a dementia risk factor.

However, the study was observational, so “the findings cannot imply causation, [and just] because someone has depression, that does not mean they will go on to develop Alzheimer’s,” said Dr. Sexton, who also was not involved with the research.

Still, “these data support the idea that taking care of one’s mental health is incredibly important for overall wellbeing. For providers, it’s important to have mental health evaluation be a part of your patient’s regular checkups,” she added.

Dr. Richmond-Rakerd noted that even if mental health conditions are not a causal risk factor for dementia, “the presence of a mental health problem is still an important indicator of risk. Mental health providers may wish to target other risk factors for dementia that are more common in individuals with mental health conditions, such as social disconnection.”

The study was funded by grants from the National Institute on Aging, the U.K. Medical Research Council, the National Institute of Child Health and Development through the Duke Population Research Center, and the National Institute on Aging through the Center for Advancing Sociodemographic and Economic Study of Alzheimer’s Disease and Related Dementias. Dr. Richmond-Rakerd reports no relevant financial relationships. The other investigators’ disclosures are listed in the original article. Dr. Sexton and Dr. Duckworth report no relevant financial relationships.

A version of this article first appeared on Medscape.com.

Mental disorders in early life are associated with a significantly increased risk of dementia in later years.

Results of a large, longitudinal, population-based study show that individuals hospitalized for a mental health disorder had a fourfold increased relative risk (RR) for developing dementia, compared with those who were not hospitalized with a mental illness.

In addition, those with dementia plus a mental disorder developed dementia almost 6 years earlier than those without a mental illness.

The findings were consistent among men and women, in patients with early- and late-onset dementia, in those with Alzheimer’s and non-Alzheimer’s dementia, and across all mental health disorders – and remained so after accounting for pre-existing physical illness and socioeconomic factors.

“Dementia is not typically treated until later in life, but our study suggests that we need to be thinking about dementia prevention much earlier in the life course,” study investigator Leah Richmond-Rakerd, PhD, assistant professor, department of psychology, University of Michigan, said in an interview.

“Supporting young people’s mental health could be a window of opportunity to help reduce the burden of dementia in older adults,” she said.

The findings were published online Feb. 16.
 

Underappreciated risk factor

“Recognition of the outsized influence of dementia on later-life functioning has fueled research into modifiable risk factors and prevention targets,” the investigators write.

Previous research suggests mental disorders may “comprise an underappreciated category of modifiable risk factors.” However, those studies focused primarily on midlife and older individuals, not on capturing mental disorders during young adulthood, which is the time of “peak prevalence,” they add. In addition, most studies have not explored the full range of mental disorders.

Dr. Richmond-Rakerd noted that it is well known that mental health disorders peak in adolescence and young adulthood – and are treatable.

“If the same people who have mental disorders when they are young tend to develop dementia when they are older, that would mean that preventing mental health problems in younger people might reduce or delay the burden of dementia in older people,” she said.

The investigators assessed records from the New Zealand Integrated Data Infrastructure, which is a de-identified register that includes the entire New Zealand population. They also examined information about hospitalizations and diagnoses from records kept by the New Zealand Ministry of Health.

The researchers followed 1,711,386 individuals born between 1928 and 1967 (50.6% men, aged 21 to 60 years at baseline) for 30 years. The population was subdivided into age groups based on birth years: 1928-1937 (14.8%), 1938-1947 (20.85%), 1948-1957 (29.35%), and 1958-1967 (35.1%).
 

Earlier onset

During the study period, 3.8% of individuals were identified as having a mental disorder, and 2% were identified as having dementia. Similar percentages of men and women had a mental disorder, and similar percentages had dementia.

Dementia was “over-represented” among participants with versus without a mental disorder (6.1% vs. 1.8%). This finding held across all age groups.

Those diagnosed with a mental disorder were also more likely to develop dementia, compared with their peers without a mental disorder (RR, 3.51; 95% confidence interval, 3.39-3.64), which is a larger association than that between physical diseases and dementia (RR, 1.19; 95% CI, 1.16-1.21).

These associations were present in both sexes and in all age groups, although the associations were stronger in more recently born cohorts.

A sixfold higher risk for dementia remained even after adjusting for pre-existing physical illnesses (HR, 6.49; 95% CI, 6.25-6.73); and the elevated risk was evident across different lengths of follow-up from the index mental disorder.

When the researchers focused specifically on individuals diagnosed with dementia, they found that those diagnosed with a mental disorder developed dementia a mean of 5.60 years earlier than those without a mental disorder diagnosis – an association observed across both sexes and all age groups.

“Individuals diagnosed with psychotic, substance use, mood, neurotic, and all other mental disorders and who engaged in self-harm were all more likely than those without a mental disorder to be diagnosed with subsequent dementia, even after accounting for their physical disease histories,” the investigators write.

Although there was a link between mental disorders in both Alzheimer’s and non-Alzheimer’s dementias, the association was larger in non-Alzheimer’s.

The researchers note that the study has several limitations, including the fact that it was conducted in New Zealand and therefore the results may not be generalizable to other regions. In addition, inpatient hospital records do not capture less severe mental disorder cases treated in the outpatient setting.

Dr. Richmond-Rakerd suggested several potential mechanisms that could account for the link between mental illness and dementia, including poor lifestyle choices and metabolic side effects associated with some psychiatric medications.

“There could also be shared risk factors for both mental disorders and dementia, such as shared genetics, or individuals may experience a lifelong brain vulnerability that shows up as mental health problems earlier in life and shows up as dementia later in life,” she said.
 

An important risk factor

Commenting for this article, Ken Duckworth, MD, chief medical officer of the National Alliance on Mental Illness, said a major strength of the study was its longitudinal scope and large population size.

He described the study as allowing clinicians to “watch the movie,” as opposed to looking at a “snapshot” of data.

“Although you can learn things from snapshots, a large, comprehensive public health system looking at 30 years of claims – something not possible in the U.S. because of our more fragmented health care system – offers more insight,” said Dr. Duckworth, who was not involved with the research.

The investigators are “painting a picture of a correlation of risk, and to me, that’s the beginning of further inquiry,” he added. “Would preventive efforts targeting dementia, such as exercise and socialization, be helpful? It’s a great study that raises these interesting questions.”

Also commenting in an interview, Claire Sexton, DPhil, director of scientific programs and outreach at the Alzheimer’s Association, said the study “adds a wealth of data to our understanding” of mental disorders as a dementia risk factor.

However, the study was observational, so “the findings cannot imply causation, [and just] because someone has depression, that does not mean they will go on to develop Alzheimer’s,” said Dr. Sexton, who also was not involved with the research.

Still, “these data support the idea that taking care of one’s mental health is incredibly important for overall wellbeing. For providers, it’s important to have mental health evaluation be a part of your patient’s regular checkups,” she added.

Dr. Richmond-Rakerd noted that even if mental health conditions are not a causal risk factor for dementia, “the presence of a mental health problem is still an important indicator of risk. Mental health providers may wish to target other risk factors for dementia that are more common in individuals with mental health conditions, such as social disconnection.”

The study was funded by grants from the National Institute on Aging, the U.K. Medical Research Council, the National Institute of Child Health and Development through the Duke Population Research Center, and the National Institute on Aging through the Center for Advancing Sociodemographic and Economic Study of Alzheimer’s Disease and Related Dementias. Dr. Richmond-Rakerd reports no relevant financial relationships. The other investigators’ disclosures are listed in the original article. Dr. Sexton and Dr. Duckworth report no relevant financial relationships.

A version of this article first appeared on Medscape.com.

The study covered in this summary was published in Research Square as a preprint and has not yet been peer reviewed.

Key takeaways

• Focal cognitive deficits are more prevalent in hospitalized patients than ambulatory patients.
• Cognitive performance is related to neuropsychiatric symptoms in ambulatory but not hospitalized patients.
• Objective neurocognitive measures can supply crucial information to guide clinical decisions regarding the need for further imaging or neurologic workup and should be included as endpoints in clinical trials.

Why this matters

• Cognitive complaints commonly occur in patients convalescing from COVID-19, although their cause is frequently unclear.
• The researchers evaluated factors that play a role in cognitive impairment in ambulatory versus hospitalized patients during the subacute stage of recovery.
• These results underscore the significance of assessing both subjective and objective complaints in ascertaining the prevalence of cognitive impairment in recovering patients and research participants.
• The drivers of cognitive complaints are likely different in hospitalized COVID-19 patients in comparison with ambulatory COVID-19 patients, so it’s important to understand these factors in making treatment decisions.
• Biopsychosocial factors appear to be a powerful driver of cognitive complaints in recovering ambulatory patients. They can be treated with interventions targeting anxiety, depression, sleep disturbances, and pain, which may prove to be the most efficient and cost-effective approach to prevent disability in individuals with mild manifestations of COVID-19.
• Objective neurocognitive deficits were more prevalent in hospitalized patients – a marker of greater disease severity – with mainly deficits in memory and psychomotor speed. Factors that contribute to focal cognitive deficits in these individuals are emerging and represent a noteworthy realm for future investigation.

Study design

• The trial prospectively recruited patients from a hospital-wide registry at the Mayo Clinic in Jacksonville, Fla.
• All patients tested positive for SARS-CoV-2 infection on a real-time reverse transcriptase polymerase chain-reaction assay between June 2020 and March 2021.
• Patients were 18 years of age or older.
• The researchers excluded those with a pre-existing major neurocognitive disorder.
• To participate, patients needed access to a desktop or laptop computer to complete a test and survey.
• They responded to a comprehensive neuropsychological questionnaire and a computerized cognitive screen using a remote telemedicine platform.
• The researchers compared rates of subjective and objective neuropsychological impairment between the ambulatory and hospitalized groups. Factors linked to impairment were analyzed separately within each group.

Key results

• After laboratory confirmation of SARS-CoV-2 infection, a total of 102 patients (76 ambulatory, 26 hospitalized) completed the symptom inventory and neurocognitive tests in 24 ± 22 days.
• Hospitalized and ambulatory patients self-reported high rates of cognitive impairment (27%-40%). There were no variations between the groups.
• However, hospitalized patients had more significant rates of objective impairment in visual memory (30% vs. 4%; P = .001) and psychomotor speed (41% vs. 15%; P = .008).
• Objective cognitive test performance was linked to anxiety, depression, fatigue, and pain in the ambulatory but not the hospitalized group.

Limitations

• The sample size of hospitalized patients was small.
• A larger fraction of hospitalized patients in the sample completed outcome assessments, compared with ambulatory patients, indicating that remote computerized testing did not present a disproportionate access barrier for patients with more severe illness.
• Owing to limited instances of delirium, seizures, and stroke, it was not possible to directly consider the contributions of these events to post–COVID-19 subjective complaints and objective impairment.
• The researchers depended on a 45-minute computerized test battery, which eliminates exposure risk and is available to patients in remote locations, but it necessitates computer literacy and access to a home desktop computer. While this requirement may have skewed the sample toward a more socioeconomically advantaged and younger population, there were no differences in age, race, or ethnicity between those who completed the computerized outcome assessments and those who did not. For patients who are able to give consent electronically, computerized testing does not pose an additional barrier.
• As a result of this study’s cross-sectional nature, the researchers could not comment on the natural history and long-term risk of COVID-19 cognitive impairment. It will be crucial to monitor cognitive progression at future time points to assess the rate and predictors of cognitive normalization versus decline.

Study disclosures

• Gregory S. Day, a coauthor, owns stock (greater than $10,000) in ANI Pharmaceuticals, a generic pharmaceutical company. He serves as a topic editor for DynaMed (EBSCO), overseeing development of evidence-based educational content, a consultant for Parabon Nanolabs (advice relevant to National Institutes of Health small business grant submission), and as the clinical director of the Anti-NMDA Receptor Encephalitis Foundation, Canada (uncompensated). The other authors have disclosed no relevant financial relationships.

This is a summary of a preprint research study, “Neurocognitive Screening in Patients Following SARS-CoV-2 Infection: Tools for Triage,” written by Karen Blackmon from Mayo Clinic in Florida, on medRxiv. This study has not yet been peer reviewed. The full text of the study can be found on medRxiv.org. A version of this article first appeared on Medscape.com.

The study covered in this summary was published in Research Square as a preprint and has not yet been peer reviewed.

Key takeaways

• Focal cognitive deficits are more prevalent in hospitalized patients than ambulatory patients.
• Cognitive performance is related to neuropsychiatric symptoms in ambulatory but not hospitalized patients.
• Objective neurocognitive measures can supply crucial information to guide clinical decisions regarding the need for further imaging or neurologic workup and should be included as endpoints in clinical trials.

Why this matters

• Cognitive complaints commonly occur in patients convalescing from COVID-19, although their cause is frequently unclear.
• The researchers evaluated factors that play a role in cognitive impairment in ambulatory versus hospitalized patients during the subacute stage of recovery.
• These results underscore the significance of assessing both subjective and objective complaints in ascertaining the prevalence of cognitive impairment in recovering patients and research participants.
• The drivers of cognitive complaints are likely different in hospitalized COVID-19 patients in comparison with ambulatory COVID-19 patients, so it’s important to understand these factors in making treatment decisions.
• Biopsychosocial factors appear to be a powerful driver of cognitive complaints in recovering ambulatory patients. They can be treated with interventions targeting anxiety, depression, sleep disturbances, and pain, which may prove to be the most efficient and cost-effective approach to prevent disability in individuals with mild manifestations of COVID-19.
• Objective neurocognitive deficits were more prevalent in hospitalized patients – a marker of greater disease severity – with mainly deficits in memory and psychomotor speed. Factors that contribute to focal cognitive deficits in these individuals are emerging and represent a noteworthy realm for future investigation.

Study design

• The trial prospectively recruited patients from a hospital-wide registry at the Mayo Clinic in Jacksonville, Fla.
• All patients tested positive for SARS-CoV-2 infection on a real-time reverse transcriptase polymerase chain-reaction assay between June 2020 and March 2021.
• Patients were 18 years of age or older.
• The researchers excluded those with a pre-existing major neurocognitive disorder.
• To participate, patients needed access to a desktop or laptop computer to complete a test and survey.
• They responded to a comprehensive neuropsychological questionnaire and a computerized cognitive screen using a remote telemedicine platform.
• The researchers compared rates of subjective and objective neuropsychological impairment between the ambulatory and hospitalized groups. Factors linked to impairment were analyzed separately within each group.

Key results

• After laboratory confirmation of SARS-CoV-2 infection, a total of 102 patients (76 ambulatory, 26 hospitalized) completed the symptom inventory and neurocognitive tests in 24 ± 22 days.
• Hospitalized and ambulatory patients self-reported high rates of cognitive impairment (27%-40%). There were no variations between the groups.
• However, hospitalized patients had more significant rates of objective impairment in visual memory (30% vs. 4%; P = .001) and psychomotor speed (41% vs. 15%; P = .008).
• Objective cognitive test performance was linked to anxiety, depression, fatigue, and pain in the ambulatory but not the hospitalized group.

Limitations

• The sample size of hospitalized patients was small.
• A larger fraction of hospitalized patients in the sample completed outcome assessments, compared with ambulatory patients, indicating that remote computerized testing did not present a disproportionate access barrier for patients with more severe illness.
• Owing to limited instances of delirium, seizures, and stroke, it was not possible to directly consider the contributions of these events to post–COVID-19 subjective complaints and objective impairment.
• The researchers depended on a 45-minute computerized test battery, which eliminates exposure risk and is available to patients in remote locations, but it necessitates computer literacy and access to a home desktop computer. While this requirement may have skewed the sample toward a more socioeconomically advantaged and younger population, there were no differences in age, race, or ethnicity between those who completed the computerized outcome assessments and those who did not. For patients who are able to give consent electronically, computerized testing does not pose an additional barrier.
• As a result of this study’s cross-sectional nature, the researchers could not comment on the natural history and long-term risk of COVID-19 cognitive impairment. It will be crucial to monitor cognitive progression at future time points to assess the rate and predictors of cognitive normalization versus decline.

Study disclosures

• Gregory S. Day, a coauthor, owns stock (greater than $10,000) in ANI Pharmaceuticals, a generic pharmaceutical company. He serves as a topic editor for DynaMed (EBSCO), overseeing development of evidence-based educational content, a consultant for Parabon Nanolabs (advice relevant to National Institutes of Health small business grant submission), and as the clinical director of the Anti-NMDA Receptor Encephalitis Foundation, Canada (uncompensated). The other authors have disclosed no relevant financial relationships.

This is a summary of a preprint research study, “Neurocognitive Screening in Patients Following SARS-CoV-2 Infection: Tools for Triage,” written by Karen Blackmon from Mayo Clinic in Florida, on medRxiv. This study has not yet been peer reviewed. The full text of the study can be found on medRxiv.org. A version of this article first appeared on Medscape.com.

The study covered in this summary was published in Research Square as a preprint and has not yet been peer reviewed.

Key takeaways

• Focal cognitive deficits are more prevalent in hospitalized patients than ambulatory patients.
• Cognitive performance is related to neuropsychiatric symptoms in ambulatory but not hospitalized patients.
• Objective neurocognitive measures can supply crucial information to guide clinical decisions regarding the need for further imaging or neurologic workup and should be included as endpoints in clinical trials.

Why this matters

• Cognitive complaints commonly occur in patients convalescing from COVID-19, although their cause is frequently unclear.
• The researchers evaluated factors that play a role in cognitive impairment in ambulatory versus hospitalized patients during the subacute stage of recovery.
• These results underscore the significance of assessing both subjective and objective complaints in ascertaining the prevalence of cognitive impairment in recovering patients and research participants.
• The drivers of cognitive complaints are likely different in hospitalized COVID-19 patients in comparison with ambulatory COVID-19 patients, so it’s important to understand these factors in making treatment decisions.
• Biopsychosocial factors appear to be a powerful driver of cognitive complaints in recovering ambulatory patients. They can be treated with interventions targeting anxiety, depression, sleep disturbances, and pain, which may prove to be the most efficient and cost-effective approach to prevent disability in individuals with mild manifestations of COVID-19.
• Objective neurocognitive deficits were more prevalent in hospitalized patients – a marker of greater disease severity – with mainly deficits in memory and psychomotor speed. Factors that contribute to focal cognitive deficits in these individuals are emerging and represent a noteworthy realm for future investigation.

Study design

• The trial prospectively recruited patients from a hospital-wide registry at the Mayo Clinic in Jacksonville, Fla.
• All patients tested positive for SARS-CoV-2 infection on a real-time reverse transcriptase polymerase chain-reaction assay between June 2020 and March 2021.
• Patients were 18 years of age or older.
• The researchers excluded those with a pre-existing major neurocognitive disorder.
• To participate, patients needed access to a desktop or laptop computer to complete a test and survey.
• They responded to a comprehensive neuropsychological questionnaire and a computerized cognitive screen using a remote telemedicine platform.
• The researchers compared rates of subjective and objective neuropsychological impairment between the ambulatory and hospitalized groups. Factors linked to impairment were analyzed separately within each group.

Key results

• After laboratory confirmation of SARS-CoV-2 infection, a total of 102 patients (76 ambulatory, 26 hospitalized) completed the symptom inventory and neurocognitive tests in 24 ± 22 days.
• Hospitalized and ambulatory patients self-reported high rates of cognitive impairment (27%-40%). There were no variations between the groups.
• However, hospitalized patients had more significant rates of objective impairment in visual memory (30% vs. 4%; P = .001) and psychomotor speed (41% vs. 15%; P = .008).
• Objective cognitive test performance was linked to anxiety, depression, fatigue, and pain in the ambulatory but not the hospitalized group.

Limitations

• The sample size of hospitalized patients was small.
• A larger fraction of hospitalized patients in the sample completed outcome assessments, compared with ambulatory patients, indicating that remote computerized testing did not present a disproportionate access barrier for patients with more severe illness.
• Owing to limited instances of delirium, seizures, and stroke, it was not possible to directly consider the contributions of these events to post–COVID-19 subjective complaints and objective impairment.
• The researchers depended on a 45-minute computerized test battery, which eliminates exposure risk and is available to patients in remote locations, but it necessitates computer literacy and access to a home desktop computer. While this requirement may have skewed the sample toward a more socioeconomically advantaged and younger population, there were no differences in age, race, or ethnicity between those who completed the computerized outcome assessments and those who did not. For patients who are able to give consent electronically, computerized testing does not pose an additional barrier.
• As a result of this study’s cross-sectional nature, the researchers could not comment on the natural history and long-term risk of COVID-19 cognitive impairment. It will be crucial to monitor cognitive progression at future time points to assess the rate and predictors of cognitive normalization versus decline.

Study disclosures

• Gregory S. Day, a coauthor, owns stock (greater than $10,000) in ANI Pharmaceuticals, a generic pharmaceutical company. He serves as a topic editor for DynaMed (EBSCO), overseeing development of evidence-based educational content, a consultant for Parabon Nanolabs (advice relevant to National Institutes of Health small business grant submission), and as the clinical director of the Anti-NMDA Receptor Encephalitis Foundation, Canada (uncompensated). The other authors have disclosed no relevant financial relationships.

This is a summary of a preprint research study, “Neurocognitive Screening in Patients Following SARS-CoV-2 Infection: Tools for Triage,” written by Karen Blackmon from Mayo Clinic in Florida, on medRxiv. This study has not yet been peer reviewed. The full text of the study can be found on medRxiv.org. A version of this article first appeared on Medscape.com.

For the first time, neuroscientists have recorded the brain activity of a dying person, revealing a brain wave pattern similar to that seen when memories are recalled. Although only a single case study, researchers say the recording raises the possibility that as we die, our lives really do flash before our eyes.

“The same neurophysiological activity patterns that occur in our brains when we dream, remember, meditate, concentrate – these same patterns also appear just before we die,” study investigator Ajmal Zemmar, MD, PhD, assistant professor of neurosurgery at the University of Louisville (Ky.), said in an interview.

The research was published online Feb. 22, 2022, in the Frontiers in Aging Neuroscience.
 

Accidental finding

The recording of brain activity was captured inadvertently in 2016 when neuroscientists used continuous EEG to detect and treat seizures in an 87-year-old man who had developed epilepsy after a traumatic brain injury, While undergoing the EEG, the patient had a cardiac arrest and died.

In the 30 seconds before and after blood flow to the brain stopped, the EEG showed an increase in gamma oscillations. These are brain waves known to be involved in high cognitive functions, including conscious perception and memory flashbacks.

Researchers also noted changes in alpha, theta, delta, and beta wave activity just before and just after cardiac arrest, and that changes in one type modulated changes in others. That suggests a coordinated rhythm, which further suggests the activity is more than just the firing of neurons as they die.

“When you observe this and you observe the rhythmic oscillation, you are inclined to think this may be a coordinated activity pattern of the brain rather than a mere discharge when the brain dies,” Dr. Zemmar said.

Although they’ve had the data since 2016, Dr. Zemmar and colleagues held off on publishing in the hopes of finding similar recordings in other individuals. That their 5-year search yielded no results illustrates just how difficult a study like this is to conduct, Dr. Zemmar noted. “We’re trying to figure out how to do this in a predictable way, but obtaining datasets like this is going to be challenging,” he said.

Although Dr. Zemmar was unable to find recordings of activity in the dying brains of other humans, he did find a similar study conducted with rats in 2013. In that research, investigators reported a surge of brain activity in rats just prior to and immediately after experimental cardiac arrest. Changes in high- and low-frequency brain waves mirrored those documented in the current case study.
 

Bringing a picture together

Commenting on the new study, George Mashour, MD, PhD, professor and chair of anesthesiology and professor of neurosurgery and pharmacology at the University of Michigan, Ann Arbor, said the results are eerily similar to a 2013 study that he coauthored.

Although the current research is just a single case study, Dr. Mashour said when taken with his team’s findings in rats and other work, the new findings are “starting to put a picture together of what might be going on in the dying brain.”

“They were able to record throughout the process of cardiac arrest and death and what they found was strikingly similar to what we found in our highly controlled animal study,” said Dr. Mashour, who is also the founding director of the Center for Consciousness Science at the University of Michigan.

“There was a surge of higher-frequency activity and there was coherence across different parts of the brain,” he added. “That suggests that what we found in the rigorous controlled setting of a laboratory actually translates to humans who are undergoing the clinical process of dying.”

What remains unclear is whether this brain activity explains the near-death experiences described in the literature, which include “life recall” of memories, Dr. Mashour said. “This higher-frequency surge that’s happening around the time of death, is that correlated with experiencing something like this near-death experience? Or is it just a neural feature that can just as easily happen in an unconscious brain?”

The study was funded by the Heidi Demetriades Foundation, the ETH Zürich Foundation, and the Henan Provincial People’s Hospital Outstanding Talents Founding Grant Project. Dr. Zemmar and Dr. Mashour disclosed no relevant financial relationships.

A version of this article first appeared on Medscape.com.

For the first time, neuroscientists have recorded the brain activity of a dying person, revealing a brain wave pattern similar to that seen when memories are recalled. Although only a single case study, researchers say the recording raises the possibility that as we die, our lives really do flash before our eyes.

“The same neurophysiological activity patterns that occur in our brains when we dream, remember, meditate, concentrate – these same patterns also appear just before we die,” study investigator Ajmal Zemmar, MD, PhD, assistant professor of neurosurgery at the University of Louisville (Ky.), said in an interview.

The research was published online Feb. 22, 2022, in the Frontiers in Aging Neuroscience.
 

Accidental finding

The recording of brain activity was captured inadvertently in 2016 when neuroscientists used continuous EEG to detect and treat seizures in an 87-year-old man who had developed epilepsy after a traumatic brain injury, While undergoing the EEG, the patient had a cardiac arrest and died.

In the 30 seconds before and after blood flow to the brain stopped, the EEG showed an increase in gamma oscillations. These are brain waves known to be involved in high cognitive functions, including conscious perception and memory flashbacks.

Researchers also noted changes in alpha, theta, delta, and beta wave activity just before and just after cardiac arrest, and that changes in one type modulated changes in others. That suggests a coordinated rhythm, which further suggests the activity is more than just the firing of neurons as they die.

“When you observe this and you observe the rhythmic oscillation, you are inclined to think this may be a coordinated activity pattern of the brain rather than a mere discharge when the brain dies,” Dr. Zemmar said.

Although they’ve had the data since 2016, Dr. Zemmar and colleagues held off on publishing in the hopes of finding similar recordings in other individuals. That their 5-year search yielded no results illustrates just how difficult a study like this is to conduct, Dr. Zemmar noted. “We’re trying to figure out how to do this in a predictable way, but obtaining datasets like this is going to be challenging,” he said.

Although Dr. Zemmar was unable to find recordings of activity in the dying brains of other humans, he did find a similar study conducted with rats in 2013. In that research, investigators reported a surge of brain activity in rats just prior to and immediately after experimental cardiac arrest. Changes in high- and low-frequency brain waves mirrored those documented in the current case study.
 

Bringing a picture together

Commenting on the new study, George Mashour, MD, PhD, professor and chair of anesthesiology and professor of neurosurgery and pharmacology at the University of Michigan, Ann Arbor, said the results are eerily similar to a 2013 study that he coauthored.

Although the current research is just a single case study, Dr. Mashour said when taken with his team’s findings in rats and other work, the new findings are “starting to put a picture together of what might be going on in the dying brain.”

“They were able to record throughout the process of cardiac arrest and death and what they found was strikingly similar to what we found in our highly controlled animal study,” said Dr. Mashour, who is also the founding director of the Center for Consciousness Science at the University of Michigan.

“There was a surge of higher-frequency activity and there was coherence across different parts of the brain,” he added. “That suggests that what we found in the rigorous controlled setting of a laboratory actually translates to humans who are undergoing the clinical process of dying.”

What remains unclear is whether this brain activity explains the near-death experiences described in the literature, which include “life recall” of memories, Dr. Mashour said. “This higher-frequency surge that’s happening around the time of death, is that correlated with experiencing something like this near-death experience? Or is it just a neural feature that can just as easily happen in an unconscious brain?”

The study was funded by the Heidi Demetriades Foundation, the ETH Zürich Foundation, and the Henan Provincial People’s Hospital Outstanding Talents Founding Grant Project. Dr. Zemmar and Dr. Mashour disclosed no relevant financial relationships.

A version of this article first appeared on Medscape.com.

For the first time, neuroscientists have recorded the brain activity of a dying person, revealing a brain wave pattern similar to that seen when memories are recalled. Although only a single case study, researchers say the recording raises the possibility that as we die, our lives really do flash before our eyes.

“The same neurophysiological activity patterns that occur in our brains when we dream, remember, meditate, concentrate – these same patterns also appear just before we die,” study investigator Ajmal Zemmar, MD, PhD, assistant professor of neurosurgery at the University of Louisville (Ky.), said in an interview.

The research was published online Feb. 22, 2022, in the Frontiers in Aging Neuroscience.
 

Accidental finding

The recording of brain activity was captured inadvertently in 2016 when neuroscientists used continuous EEG to detect and treat seizures in an 87-year-old man who had developed epilepsy after a traumatic brain injury, While undergoing the EEG, the patient had a cardiac arrest and died.

In the 30 seconds before and after blood flow to the brain stopped, the EEG showed an increase in gamma oscillations. These are brain waves known to be involved in high cognitive functions, including conscious perception and memory flashbacks.

Researchers also noted changes in alpha, theta, delta, and beta wave activity just before and just after cardiac arrest, and that changes in one type modulated changes in others. That suggests a coordinated rhythm, which further suggests the activity is more than just the firing of neurons as they die.

“When you observe this and you observe the rhythmic oscillation, you are inclined to think this may be a coordinated activity pattern of the brain rather than a mere discharge when the brain dies,” Dr. Zemmar said.

Although they’ve had the data since 2016, Dr. Zemmar and colleagues held off on publishing in the hopes of finding similar recordings in other individuals. That their 5-year search yielded no results illustrates just how difficult a study like this is to conduct, Dr. Zemmar noted. “We’re trying to figure out how to do this in a predictable way, but obtaining datasets like this is going to be challenging,” he said.

Although Dr. Zemmar was unable to find recordings of activity in the dying brains of other humans, he did find a similar study conducted with rats in 2013. In that research, investigators reported a surge of brain activity in rats just prior to and immediately after experimental cardiac arrest. Changes in high- and low-frequency brain waves mirrored those documented in the current case study.
 

Bringing a picture together

Commenting on the new study, George Mashour, MD, PhD, professor and chair of anesthesiology and professor of neurosurgery and pharmacology at the University of Michigan, Ann Arbor, said the results are eerily similar to a 2013 study that he coauthored.

Although the current research is just a single case study, Dr. Mashour said when taken with his team’s findings in rats and other work, the new findings are “starting to put a picture together of what might be going on in the dying brain.”

“They were able to record throughout the process of cardiac arrest and death and what they found was strikingly similar to what we found in our highly controlled animal study,” said Dr. Mashour, who is also the founding director of the Center for Consciousness Science at the University of Michigan.

“There was a surge of higher-frequency activity and there was coherence across different parts of the brain,” he added. “That suggests that what we found in the rigorous controlled setting of a laboratory actually translates to humans who are undergoing the clinical process of dying.”

What remains unclear is whether this brain activity explains the near-death experiences described in the literature, which include “life recall” of memories, Dr. Mashour said. “This higher-frequency surge that’s happening around the time of death, is that correlated with experiencing something like this near-death experience? Or is it just a neural feature that can just as easily happen in an unconscious brain?”

The study was funded by the Heidi Demetriades Foundation, the ETH Zürich Foundation, and the Henan Provincial People’s Hospital Outstanding Talents Founding Grant Project. Dr. Zemmar and Dr. Mashour disclosed no relevant financial relationships.

A version of this article first appeared on Medscape.com.

Anti–calcitonin gene-related peptide (anti-CGRP) monoclonal antibodies are effective for patients with chronic migraine and medication overuse headache regardless of detoxification strategy, according to investigators.

Abruptly discontinuing overused analgesics with health care provider oversight – a frequently resource-intensive and challenging process – is no more effective for controlling medication overuse headache than simply advising patients to stop, reported lead author Umberto Pensato, MD, of the University of Bologna, Italy, and colleagues.

“[C]urrently, the abrupt discontinuation of the overused painkiller(s), accompanied by the start of a pharmacological preventive therapy, is the most recommended strategy [for medication overuse headache],” the investigators wrote in Cephalalgia. “While painkiller(s) withdrawal could be accomplished on an outpatient basis in most cases, an in-hospital setting may be required to achieve successful discontinuation in a subgroup of patients with medication overuse headache, further weighing on individual and hospital costs. Additionally hampering this approach, the abrupt discontinuation of the overused painkiller(s) invariably results in disabling withdrawal symptoms for up to 2 weeks, including a transitory worsening of headache, the so-called ‘rebound headache.’ ”
 

Inpatient or outpatient: Does it matter?

According to Dr. Pensato and colleagues, early evidence suggests that previous painkiller withdrawal does not impact the efficacy of anti-CGRPs for medication overuse headache, yet relevant data remain scarce. To address this knowledge gap, they conducted a prospective, real-world study exploring the relationship between detoxification and outcomes after starting anti-CGRP therapy.

Out of 401 patients enrolled based on initiation of erenumab or galcanezumab, 111 satisfied inclusion criteria, including diagnosis of chronic migraine and medication overuse headache, at least 28 days of analgesic usage and headache days per month in the preceding 3 months, and other factors. Of these 111 patients, 83 underwent in-hospital detox, while the remaining 28 patients, who declined detox based on personal reasons or COVID-19–related bed shortage, were advised to discontinue overused medication on an outpatient basis (without oversight).

The primary endpoint was medication overuse headache responder rate after 3 months, as defined by ICHD-3 diagnostic criteria. Secondary endpoints included 6-item headache impact test (HIT-6), monthly headache days (MHD), migraine disability assessment score (MIDAS), mean pain intensity (MPI), monthly pain medication intake (MPMI), baseline predictors of response/refractoriness, and safety.

Three months after starting anti-CGRP therapy, 59% of patients had resolution of medication overuse headache, including 57% in the inpatient detox group and 64% in the outpatient group, a difference that was not statistically significant (P = .4788). Approximately half of the patients (51%) had at least 50% reduction in monthly headache days; although the rate was numerically lower in the inpatient group compared with the outpatient group, the difference was again not significant (51% vs. 54%; P = .8393).

“Our results support the emerging evidence that anti-CGRP drugs may be effective in these patients irrespective of the detoxification program,” the investigators concluded. “Further studies are needed to definitively confirm these results, potentially leading to a paradigm shift in the management of medication overuse headache.”
 

Abrupt or gradual detox?

According to Alan M. Rapoport, MD, clinical professor of neurology at the University of California, Los Angeles, and editor-in-chief of Neurology Reviews, the study was hampered by two major design limitations.

“The biggest problem I see is that the two groups were treated very differently for their detoxification,” Dr. Rapoport said. “One group was detoxified abruptly in the hospital, so the authors were sure that the patients were off acute-care medication before they started their preventives. The other group was advised to stop their medication on an outpatient basis. The issue is that we have no follow-up as to whether the outpatients did or did not abruptly detoxify. A bigger issue was that the two groups were not randomized so there are many other variables that may have come into consideration.”

Still, Dr. Rapoport, a past president of the International Headache Society (IHS), noted that the findings strengthen a growing body of evidence supporting the efficacy of monoclonal antibodies for medication overuse headache regardless of detoxification strategy. He cited a 2020 study by Carlsen and colleagues conducted at the Danish Headache Center in Copenhagen, which reported similar medication overuse headache outcomes across three randomized cohorts whether they received preventive therapy with detoxification, preventive therapy without detoxification, or detoxification followed 2 months later by preventive therapy.

“What I have noticed since we have had monoclonal antibodies in our armamentarium is that these drugs work very well even when the patient has not fully detoxified,” Dr. Rapoport said. “What I do with my patients is not teach them how to detoxify now, but simply educate them to take fewer acute care medications as their headaches get better from the monoclonal antibodies; they should try to take fewer acute care medications for milder, shorter headaches, and just let them go away on their own. Previous research suggests that even when a patient is not educated at all about medication overuse headache and the reason for detoxification, monoclonal antibodies still work in the presence of medication overuse headache, and improve it.”

The investigators disclosed relationships with Allergan, Novartis, Teva, and others. Dr. Rapoport is on the speakers bureau for AbbVie.

Anti–calcitonin gene-related peptide (anti-CGRP) monoclonal antibodies are effective for patients with chronic migraine and medication overuse headache regardless of detoxification strategy, according to investigators.

Abruptly discontinuing overused analgesics with health care provider oversight – a frequently resource-intensive and challenging process – is no more effective for controlling medication overuse headache than simply advising patients to stop, reported lead author Umberto Pensato, MD, of the University of Bologna, Italy, and colleagues.

“[C]urrently, the abrupt discontinuation of the overused painkiller(s), accompanied by the start of a pharmacological preventive therapy, is the most recommended strategy [for medication overuse headache],” the investigators wrote in Cephalalgia. “While painkiller(s) withdrawal could be accomplished on an outpatient basis in most cases, an in-hospital setting may be required to achieve successful discontinuation in a subgroup of patients with medication overuse headache, further weighing on individual and hospital costs. Additionally hampering this approach, the abrupt discontinuation of the overused painkiller(s) invariably results in disabling withdrawal symptoms for up to 2 weeks, including a transitory worsening of headache, the so-called ‘rebound headache.’ ”
 

Inpatient or outpatient: Does it matter?

According to Dr. Pensato and colleagues, early evidence suggests that previous painkiller withdrawal does not impact the efficacy of anti-CGRPs for medication overuse headache, yet relevant data remain scarce. To address this knowledge gap, they conducted a prospective, real-world study exploring the relationship between detoxification and outcomes after starting anti-CGRP therapy.

Out of 401 patients enrolled based on initiation of erenumab or galcanezumab, 111 satisfied inclusion criteria, including diagnosis of chronic migraine and medication overuse headache, at least 28 days of analgesic usage and headache days per month in the preceding 3 months, and other factors. Of these 111 patients, 83 underwent in-hospital detox, while the remaining 28 patients, who declined detox based on personal reasons or COVID-19–related bed shortage, were advised to discontinue overused medication on an outpatient basis (without oversight).

The primary endpoint was medication overuse headache responder rate after 3 months, as defined by ICHD-3 diagnostic criteria. Secondary endpoints included 6-item headache impact test (HIT-6), monthly headache days (MHD), migraine disability assessment score (MIDAS), mean pain intensity (MPI), monthly pain medication intake (MPMI), baseline predictors of response/refractoriness, and safety.

Three months after starting anti-CGRP therapy, 59% of patients had resolution of medication overuse headache, including 57% in the inpatient detox group and 64% in the outpatient group, a difference that was not statistically significant (P = .4788). Approximately half of the patients (51%) had at least 50% reduction in monthly headache days; although the rate was numerically lower in the inpatient group compared with the outpatient group, the difference was again not significant (51% vs. 54%; P = .8393).

“Our results support the emerging evidence that anti-CGRP drugs may be effective in these patients irrespective of the detoxification program,” the investigators concluded. “Further studies are needed to definitively confirm these results, potentially leading to a paradigm shift in the management of medication overuse headache.”
 

Abrupt or gradual detox?

According to Alan M. Rapoport, MD, clinical professor of neurology at the University of California, Los Angeles, and editor-in-chief of Neurology Reviews, the study was hampered by two major design limitations.

“The biggest problem I see is that the two groups were treated very differently for their detoxification,” Dr. Rapoport said. “One group was detoxified abruptly in the hospital, so the authors were sure that the patients were off acute-care medication before they started their preventives. The other group was advised to stop their medication on an outpatient basis. The issue is that we have no follow-up as to whether the outpatients did or did not abruptly detoxify. A bigger issue was that the two groups were not randomized so there are many other variables that may have come into consideration.”

Still, Dr. Rapoport, a past president of the International Headache Society (IHS), noted that the findings strengthen a growing body of evidence supporting the efficacy of monoclonal antibodies for medication overuse headache regardless of detoxification strategy. He cited a 2020 study by Carlsen and colleagues conducted at the Danish Headache Center in Copenhagen, which reported similar medication overuse headache outcomes across three randomized cohorts whether they received preventive therapy with detoxification, preventive therapy without detoxification, or detoxification followed 2 months later by preventive therapy.

“What I have noticed since we have had monoclonal antibodies in our armamentarium is that these drugs work very well even when the patient has not fully detoxified,” Dr. Rapoport said. “What I do with my patients is not teach them how to detoxify now, but simply educate them to take fewer acute care medications as their headaches get better from the monoclonal antibodies; they should try to take fewer acute care medications for milder, shorter headaches, and just let them go away on their own. Previous research suggests that even when a patient is not educated at all about medication overuse headache and the reason for detoxification, monoclonal antibodies still work in the presence of medication overuse headache, and improve it.”

The investigators disclosed relationships with Allergan, Novartis, Teva, and others. Dr. Rapoport is on the speakers bureau for AbbVie.

Anti–calcitonin gene-related peptide (anti-CGRP) monoclonal antibodies are effective for patients with chronic migraine and medication overuse headache regardless of detoxification strategy, according to investigators.

Abruptly discontinuing overused analgesics with health care provider oversight – a frequently resource-intensive and challenging process – is no more effective for controlling medication overuse headache than simply advising patients to stop, reported lead author Umberto Pensato, MD, of the University of Bologna, Italy, and colleagues.

“[C]urrently, the abrupt discontinuation of the overused painkiller(s), accompanied by the start of a pharmacological preventive therapy, is the most recommended strategy [for medication overuse headache],” the investigators wrote in Cephalalgia. “While painkiller(s) withdrawal could be accomplished on an outpatient basis in most cases, an in-hospital setting may be required to achieve successful discontinuation in a subgroup of patients with medication overuse headache, further weighing on individual and hospital costs. Additionally hampering this approach, the abrupt discontinuation of the overused painkiller(s) invariably results in disabling withdrawal symptoms for up to 2 weeks, including a transitory worsening of headache, the so-called ‘rebound headache.’ ”
 

Inpatient or outpatient: Does it matter?

According to Dr. Pensato and colleagues, early evidence suggests that previous painkiller withdrawal does not impact the efficacy of anti-CGRPs for medication overuse headache, yet relevant data remain scarce. To address this knowledge gap, they conducted a prospective, real-world study exploring the relationship between detoxification and outcomes after starting anti-CGRP therapy.

Out of 401 patients enrolled based on initiation of erenumab or galcanezumab, 111 satisfied inclusion criteria, including diagnosis of chronic migraine and medication overuse headache, at least 28 days of analgesic usage and headache days per month in the preceding 3 months, and other factors. Of these 111 patients, 83 underwent in-hospital detox, while the remaining 28 patients, who declined detox based on personal reasons or COVID-19–related bed shortage, were advised to discontinue overused medication on an outpatient basis (without oversight).

The primary endpoint was medication overuse headache responder rate after 3 months, as defined by ICHD-3 diagnostic criteria. Secondary endpoints included 6-item headache impact test (HIT-6), monthly headache days (MHD), migraine disability assessment score (MIDAS), mean pain intensity (MPI), monthly pain medication intake (MPMI), baseline predictors of response/refractoriness, and safety.

Three months after starting anti-CGRP therapy, 59% of patients had resolution of medication overuse headache, including 57% in the inpatient detox group and 64% in the outpatient group, a difference that was not statistically significant (P = .4788). Approximately half of the patients (51%) had at least 50% reduction in monthly headache days; although the rate was numerically lower in the inpatient group compared with the outpatient group, the difference was again not significant (51% vs. 54%; P = .8393).

“Our results support the emerging evidence that anti-CGRP drugs may be effective in these patients irrespective of the detoxification program,” the investigators concluded. “Further studies are needed to definitively confirm these results, potentially leading to a paradigm shift in the management of medication overuse headache.”
 

Abrupt or gradual detox?

According to Alan M. Rapoport, MD, clinical professor of neurology at the University of California, Los Angeles, and editor-in-chief of Neurology Reviews, the study was hampered by two major design limitations.

“The biggest problem I see is that the two groups were treated very differently for their detoxification,” Dr. Rapoport said. “One group was detoxified abruptly in the hospital, so the authors were sure that the patients were off acute-care medication before they started their preventives. The other group was advised to stop their medication on an outpatient basis. The issue is that we have no follow-up as to whether the outpatients did or did not abruptly detoxify. A bigger issue was that the two groups were not randomized so there are many other variables that may have come into consideration.”

Still, Dr. Rapoport, a past president of the International Headache Society (IHS), noted that the findings strengthen a growing body of evidence supporting the efficacy of monoclonal antibodies for medication overuse headache regardless of detoxification strategy. He cited a 2020 study by Carlsen and colleagues conducted at the Danish Headache Center in Copenhagen, which reported similar medication overuse headache outcomes across three randomized cohorts whether they received preventive therapy with detoxification, preventive therapy without detoxification, or detoxification followed 2 months later by preventive therapy.

“What I have noticed since we have had monoclonal antibodies in our armamentarium is that these drugs work very well even when the patient has not fully detoxified,” Dr. Rapoport said. “What I do with my patients is not teach them how to detoxify now, but simply educate them to take fewer acute care medications as their headaches get better from the monoclonal antibodies; they should try to take fewer acute care medications for milder, shorter headaches, and just let them go away on their own. Previous research suggests that even when a patient is not educated at all about medication overuse headache and the reason for detoxification, monoclonal antibodies still work in the presence of medication overuse headache, and improve it.”

The investigators disclosed relationships with Allergan, Novartis, Teva, and others. Dr. Rapoport is on the speakers bureau for AbbVie.

The use of a robotic-assisted device to perform transcranial Doppler ultrasound greatly improved the detection of right-to-left cardiac shunts in patients with presumed embolic strokes compared with the current standard of care – transthoracic echocardiography – in a new study.

Being far easier to perform than regular transcranial Doppler ultrasound, it’s hoped that use of the robotic device will enable many more patients to undergo the more sensitive transcranial screening modality and increase the number of shunts identified.

“I believe robot-assisted transcranial Doppler ultrasound can fill the gap between the gold standard transcranial Doppler and transthoracic echocardiography, which is the current standard of care,” said lead author Mark Rubin, MD.  

Dr. Rubin, who is assistant professor of neurology at University of Tennessee Health Science Center, Memphis, presented results of the BUBL study at the International Stroke Conference (ISC) 2022, where they were greeted with applause from the floor.
 

An improvement in the current standard of care

Dr. Rubin explained that patients with suspected embolic stroke are routinely screened for shunts in the heart, such as patent foramen ovale (PFO), that allow blood to flow from the right chamber to the left chamber and can lead to clots from the venous system, accessing the arterial system, then traveling to the brain and causing a stroke.

The current standard of care in screening for such shunts is the use of transthoracic echocardiography (TTE), a widely available and easy to perform, non-invasive procedure. “But we have known for decades that TTE does not pick up these shunts very well. With a sensitivity of only around 45%, it identifies less than half of the patients affected,” Dr. Rubin noted.  

The more sensitive transesophageal echocardiography (TEE) gives much better results, but it is an invasive and unpleasant procedure with the ultrasound probe being passed down the throat, and the patient needing to be sedated, so it’s not appropriate for everyone, he noted.

“Transcranial Doppler ultrasound (TCD) also gives excellent results, with a sensitivity of about 96% for detecting PFO, but this procedure is difficult to perform and requires a great deal of skill in placing the probes in the right position and interpreting the signal,” Dr. Rubin said. “TCD has been around for decades, but it hasn’t caught on, as it is too difficult to do. It takes a lot of time to learn the technique.”

“With the robotic-assisted transcranial Doppler device, we can achieve the sensitivity of TCD without needing expert operators. This should vastly improve accessibility to this technology,” he said. “With such technology we can make significant strides into more accurate diagnoses on the cause of stroke, which should lead to better preventive treatments in those found to have right-to-left shunts.”  
 

Robotic detection of shunts

For the BUBL study, the robotic TCD technique was compared with the standard TTE in 129 patients who had a diagnosis of presumed embolic stroke or transient ischemic attack (TIA), with all patients undergoing both procedures.  

The robotic TCD device resembles a giant pair of headphones containing the ultrasound probes, which are attached to a frame. In the study, it was operated by a health care professional without TCD skills. Each ultrasound probe independently scans the temporal area autonomously – with angling and positive pressure against the scalp akin to a sonographer – to find and optimize bilateral middle cerebral artery signals, Dr. Rubin explained.

The primary endpoint was the detection of a right-to-left shunt. This occurred in 82 of the 129 patients (63.6%) with the robotic TCD device but in only 27 patients (20.9%) when TTE was used. This gives an absolute difference of 42.6% (95% confidence interval, 28.6%-56.7%; P < .001), which Dr. Rubin described as “astounding.”

However, he said he was not surprised by these results.

“In my experience with transcranial Doppler, I find shunts in patients every day that have not been seen with transthoracic echo,” he commented.

He noted that a previous meta-analysis has suggested a similar difference between TCD and transthoracic echo, but the current study provides prospectively collected data produced in a clinical trial setting and is therefore more reliable. 

“What I hope comes from this is that more patients will be able to undergo transcranial Doppler, which is a far superior screening technique for identifying right-to-left shunts. There is so much evidence to support the use of transcranial Doppler, but with this new artificial-intelligence robotic device, we don’t need an expert to use it,” Dr. Rubin said.   

He explained that finding a right-to-left shunt in stroke patients is particularly important, as it can direct treatment strategies to reduce future risk of recurrent strokes.

“If a patient has a large shunt, then they have a high risk of having another stroke, and the PFO should be closed.”

In this study, the robotic-assisted TCD detected three times as many large shunts that were considered “intervenable,” compared with transthoracic echo, identifying these shunts in 35 patients (27%) compared to just 13 (10%) with TTE.

“Of the 35 patients with intervenable shunts detected with robotic transcranial Doppler, TTE was completely negative in 18 of them and only suggested a small shunt in the others. So, the standard of care (TTE) missed half the patients with intervenable PFOs,” Dr. Rubin reported.
 

Study should ‘dramatically change’ practice

Commenting on the study, Patrick Lyden, MD, professor of physiology and neuroscience and of neurology, University of Southern California, Los Angeles, said: “Most clinicians hesitate to use transcranial Doppler given the need for specialized technical expertise to obtain a reliable result. This study showed that a robotic transcranial Doppler device – which can be applied by any cardiac non-invasive lab technician – provides reliable and rigorous data.”

He added: “This result will dramatically change the typical evaluation of patients with suspected PFO: In place of an invasive transesophageal echo that requires anesthesia and a cardiologist, most patients can have a non-invasive, robotic-guided transcranial Doppler and get the same diagnostic benefit.”

Dr. Lyden also pointed out that the cost of TCD is typically one-tenth that of TEE, although he said the cost of the robotic guided TCD “is not clear.”

A representative of the company that makes the robotic assisted device, NovaSignal, says the cost of the equipment is approximately $250,000, but “understanding the importance of the technology, we work with each hospital to meet their unique needs.”

The company adds that it currently has “over 45 commercial solutions deployed across 25 centers with 3-4 times growth expected year over year.”

The study was supported by NovaSignal, the company which makes the robotic device. Dr. Rubin reports acting as a consultant for the NovaSignal.

A version of this article first appeared on Medscape.com.

The use of a robotic-assisted device to perform transcranial Doppler ultrasound greatly improved the detection of right-to-left cardiac shunts in patients with presumed embolic strokes compared with the current standard of care – transthoracic echocardiography – in a new study.

Being far easier to perform than regular transcranial Doppler ultrasound, it’s hoped that use of the robotic device will enable many more patients to undergo the more sensitive transcranial screening modality and increase the number of shunts identified.

“I believe robot-assisted transcranial Doppler ultrasound can fill the gap between the gold standard transcranial Doppler and transthoracic echocardiography, which is the current standard of care,” said lead author Mark Rubin, MD.  

Dr. Rubin, who is assistant professor of neurology at University of Tennessee Health Science Center, Memphis, presented results of the BUBL study at the International Stroke Conference (ISC) 2022, where they were greeted with applause from the floor.
 

An improvement in the current standard of care

Dr. Rubin explained that patients with suspected embolic stroke are routinely screened for shunts in the heart, such as patent foramen ovale (PFO), that allow blood to flow from the right chamber to the left chamber and can lead to clots from the venous system, accessing the arterial system, then traveling to the brain and causing a stroke.

The current standard of care in screening for such shunts is the use of transthoracic echocardiography (TTE), a widely available and easy to perform, non-invasive procedure. “But we have known for decades that TTE does not pick up these shunts very well. With a sensitivity of only around 45%, it identifies less than half of the patients affected,” Dr. Rubin noted.  

The more sensitive transesophageal echocardiography (TEE) gives much better results, but it is an invasive and unpleasant procedure with the ultrasound probe being passed down the throat, and the patient needing to be sedated, so it’s not appropriate for everyone, he noted.

“Transcranial Doppler ultrasound (TCD) also gives excellent results, with a sensitivity of about 96% for detecting PFO, but this procedure is difficult to perform and requires a great deal of skill in placing the probes in the right position and interpreting the signal,” Dr. Rubin said. “TCD has been around for decades, but it hasn’t caught on, as it is too difficult to do. It takes a lot of time to learn the technique.”

“With the robotic-assisted transcranial Doppler device, we can achieve the sensitivity of TCD without needing expert operators. This should vastly improve accessibility to this technology,” he said. “With such technology we can make significant strides into more accurate diagnoses on the cause of stroke, which should lead to better preventive treatments in those found to have right-to-left shunts.”  
 

Robotic detection of shunts

For the BUBL study, the robotic TCD technique was compared with the standard TTE in 129 patients who had a diagnosis of presumed embolic stroke or transient ischemic attack (TIA), with all patients undergoing both procedures.  

The robotic TCD device resembles a giant pair of headphones containing the ultrasound probes, which are attached to a frame. In the study, it was operated by a health care professional without TCD skills. Each ultrasound probe independently scans the temporal area autonomously – with angling and positive pressure against the scalp akin to a sonographer – to find and optimize bilateral middle cerebral artery signals, Dr. Rubin explained.

The primary endpoint was the detection of a right-to-left shunt. This occurred in 82 of the 129 patients (63.6%) with the robotic TCD device but in only 27 patients (20.9%) when TTE was used. This gives an absolute difference of 42.6% (95% confidence interval, 28.6%-56.7%; P < .001), which Dr. Rubin described as “astounding.”

However, he said he was not surprised by these results.

“In my experience with transcranial Doppler, I find shunts in patients every day that have not been seen with transthoracic echo,” he commented.

He noted that a previous meta-analysis has suggested a similar difference between TCD and transthoracic echo, but the current study provides prospectively collected data produced in a clinical trial setting and is therefore more reliable. 

“What I hope comes from this is that more patients will be able to undergo transcranial Doppler, which is a far superior screening technique for identifying right-to-left shunts. There is so much evidence to support the use of transcranial Doppler, but with this new artificial-intelligence robotic device, we don’t need an expert to use it,” Dr. Rubin said.   

He explained that finding a right-to-left shunt in stroke patients is particularly important, as it can direct treatment strategies to reduce future risk of recurrent strokes.

“If a patient has a large shunt, then they have a high risk of having another stroke, and the PFO should be closed.”

In this study, the robotic-assisted TCD detected three times as many large shunts that were considered “intervenable,” compared with transthoracic echo, identifying these shunts in 35 patients (27%) compared to just 13 (10%) with TTE.

“Of the 35 patients with intervenable shunts detected with robotic transcranial Doppler, TTE was completely negative in 18 of them and only suggested a small shunt in the others. So, the standard of care (TTE) missed half the patients with intervenable PFOs,” Dr. Rubin reported.
 

Study should ‘dramatically change’ practice

Commenting on the study, Patrick Lyden, MD, professor of physiology and neuroscience and of neurology, University of Southern California, Los Angeles, said: “Most clinicians hesitate to use transcranial Doppler given the need for specialized technical expertise to obtain a reliable result. This study showed that a robotic transcranial Doppler device – which can be applied by any cardiac non-invasive lab technician – provides reliable and rigorous data.”

He added: “This result will dramatically change the typical evaluation of patients with suspected PFO: In place of an invasive transesophageal echo that requires anesthesia and a cardiologist, most patients can have a non-invasive, robotic-guided transcranial Doppler and get the same diagnostic benefit.”

Dr. Lyden also pointed out that the cost of TCD is typically one-tenth that of TEE, although he said the cost of the robotic guided TCD “is not clear.”

A representative of the company that makes the robotic assisted device, NovaSignal, says the cost of the equipment is approximately $250,000, but “understanding the importance of the technology, we work with each hospital to meet their unique needs.”

The company adds that it currently has “over 45 commercial solutions deployed across 25 centers with 3-4 times growth expected year over year.”

The study was supported by NovaSignal, the company which makes the robotic device. Dr. Rubin reports acting as a consultant for the NovaSignal.

A version of this article first appeared on Medscape.com.

The use of a robotic-assisted device to perform transcranial Doppler ultrasound greatly improved the detection of right-to-left cardiac shunts in patients with presumed embolic strokes compared with the current standard of care – transthoracic echocardiography – in a new study.

Being far easier to perform than regular transcranial Doppler ultrasound, it’s hoped that use of the robotic device will enable many more patients to undergo the more sensitive transcranial screening modality and increase the number of shunts identified.

“I believe robot-assisted transcranial Doppler ultrasound can fill the gap between the gold standard transcranial Doppler and transthoracic echocardiography, which is the current standard of care,” said lead author Mark Rubin, MD.  

Dr. Rubin, who is assistant professor of neurology at University of Tennessee Health Science Center, Memphis, presented results of the BUBL study at the International Stroke Conference (ISC) 2022, where they were greeted with applause from the floor.
 

An improvement in the current standard of care

Dr. Rubin explained that patients with suspected embolic stroke are routinely screened for shunts in the heart, such as patent foramen ovale (PFO), that allow blood to flow from the right chamber to the left chamber and can lead to clots from the venous system, accessing the arterial system, then traveling to the brain and causing a stroke.

The current standard of care in screening for such shunts is the use of transthoracic echocardiography (TTE), a widely available and easy to perform, non-invasive procedure. “But we have known for decades that TTE does not pick up these shunts very well. With a sensitivity of only around 45%, it identifies less than half of the patients affected,” Dr. Rubin noted.  

The more sensitive transesophageal echocardiography (TEE) gives much better results, but it is an invasive and unpleasant procedure with the ultrasound probe being passed down the throat, and the patient needing to be sedated, so it’s not appropriate for everyone, he noted.

“Transcranial Doppler ultrasound (TCD) also gives excellent results, with a sensitivity of about 96% for detecting PFO, but this procedure is difficult to perform and requires a great deal of skill in placing the probes in the right position and interpreting the signal,” Dr. Rubin said. “TCD has been around for decades, but it hasn’t caught on, as it is too difficult to do. It takes a lot of time to learn the technique.”

“With the robotic-assisted transcranial Doppler device, we can achieve the sensitivity of TCD without needing expert operators. This should vastly improve accessibility to this technology,” he said. “With such technology we can make significant strides into more accurate diagnoses on the cause of stroke, which should lead to better preventive treatments in those found to have right-to-left shunts.”  
 

Robotic detection of shunts

For the BUBL study, the robotic TCD technique was compared with the standard TTE in 129 patients who had a diagnosis of presumed embolic stroke or transient ischemic attack (TIA), with all patients undergoing both procedures.  

The robotic TCD device resembles a giant pair of headphones containing the ultrasound probes, which are attached to a frame. In the study, it was operated by a health care professional without TCD skills. Each ultrasound probe independently scans the temporal area autonomously – with angling and positive pressure against the scalp akin to a sonographer – to find and optimize bilateral middle cerebral artery signals, Dr. Rubin explained.

The primary endpoint was the detection of a right-to-left shunt. This occurred in 82 of the 129 patients (63.6%) with the robotic TCD device but in only 27 patients (20.9%) when TTE was used. This gives an absolute difference of 42.6% (95% confidence interval, 28.6%-56.7%; P < .001), which Dr. Rubin described as “astounding.”

However, he said he was not surprised by these results.

“In my experience with transcranial Doppler, I find shunts in patients every day that have not been seen with transthoracic echo,” he commented.

He noted that a previous meta-analysis has suggested a similar difference between TCD and transthoracic echo, but the current study provides prospectively collected data produced in a clinical trial setting and is therefore more reliable. 

“What I hope comes from this is that more patients will be able to undergo transcranial Doppler, which is a far superior screening technique for identifying right-to-left shunts. There is so much evidence to support the use of transcranial Doppler, but with this new artificial-intelligence robotic device, we don’t need an expert to use it,” Dr. Rubin said.   

He explained that finding a right-to-left shunt in stroke patients is particularly important, as it can direct treatment strategies to reduce future risk of recurrent strokes.

“If a patient has a large shunt, then they have a high risk of having another stroke, and the PFO should be closed.”

In this study, the robotic-assisted TCD detected three times as many large shunts that were considered “intervenable,” compared with transthoracic echo, identifying these shunts in 35 patients (27%) compared to just 13 (10%) with TTE.

“Of the 35 patients with intervenable shunts detected with robotic transcranial Doppler, TTE was completely negative in 18 of them and only suggested a small shunt in the others. So, the standard of care (TTE) missed half the patients with intervenable PFOs,” Dr. Rubin reported.
 

Study should ‘dramatically change’ practice

Commenting on the study, Patrick Lyden, MD, professor of physiology and neuroscience and of neurology, University of Southern California, Los Angeles, said: “Most clinicians hesitate to use transcranial Doppler given the need for specialized technical expertise to obtain a reliable result. This study showed that a robotic transcranial Doppler device – which can be applied by any cardiac non-invasive lab technician – provides reliable and rigorous data.”

He added: “This result will dramatically change the typical evaluation of patients with suspected PFO: In place of an invasive transesophageal echo that requires anesthesia and a cardiologist, most patients can have a non-invasive, robotic-guided transcranial Doppler and get the same diagnostic benefit.”

Dr. Lyden also pointed out that the cost of TCD is typically one-tenth that of TEE, although he said the cost of the robotic guided TCD “is not clear.”

A representative of the company that makes the robotic assisted device, NovaSignal, says the cost of the equipment is approximately $250,000, but “understanding the importance of the technology, we work with each hospital to meet their unique needs.”

The company adds that it currently has “over 45 commercial solutions deployed across 25 centers with 3-4 times growth expected year over year.”

The study was supported by NovaSignal, the company which makes the robotic device. Dr. Rubin reports acting as a consultant for the NovaSignal.

A version of this article first appeared on Medscape.com.