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When a Public Health Alert Goes Wrong
At 8:07 am on January 13, 2018, people in Hawaii received an emergency alert advising them to seek shelter from an incoming ballistic missile.
A very long 38 minutes later, the message was retracted via the same systems that had sent it—the Wireless Emergency Alert system, which sends location-based warnings to wireless carrier systems, and the Emergency Alert System, which sends television and radio alerts.
The Federal Communications Commission report that covered the debacle noted that, among other errors, the employee responsible for triggering the false alert believed the missile threat was real. Moreover, the exercise plans did not document a process for disseminating an all-clear message. And on top of that, the established ballistic missile alert checklist did not include a step to notify the Hawaii Emergency Management Agency’s public information officer responsible for communicating with the public, media, other agencies, and other stakeholders during an incident.
Researchers from the CDC and Hawaii Department of Health analyzed tweets sent during 2 periods: early (8:07-8:45 am), the 38 minutes during which the alert circulated; and the late period (8:46-9:24 am), the same amount of elapsed time after the correction had been issued.
They found 4 themes dominated the early period: information processing, information sharing, authentication, and emotional reaction (shock, fear, panic, terror). Information processing was defined as any indication of initial mental processing of the alert. Many of the tweets dealt with coming to terms with the threat.
During the late period, information sharing and emotional reaction persisted, but they were joined by new themes that, according to the researchers, were “fundamentally different” from the early-period themes and reflected reactions to misinformation: denunciation, insufficient knowledge to act, and mistrust of authority. “Insufficient knowledge to act” involved reacting to the lack of a response plan, particularly not knowing how to properly take shelter. Denunciations blamed the emergency warning and response, especially the time it took to correct the mistake. Mistrust of authority involved doubting the emergency alert system or governmental response.
How can a situation like this be better handled? The researchers say public health messaging during an emergency is complicated. For instance, it is influenced by how messages are perceived and interpreted by different people, and by the fact that messages need to be sent over multiple platforms to ensure that the information is disseminated accurately and quickly.
Which is why social media is both a handicap and a boon in public health emergencies. Tweets spread misinformation as fast as information (if not faster), so the first messages are critical. In addition to conveying timely messages, the researchers advise, public health authorities need to address the reactions during each phase of a crisis. They also need to establish credibility to prevent the public from mistrusting the public health message and its issuers.
Most important, perhaps: Alerts should carry clear instructions for persons in the affected area to carry out during an emergency.
At 8:07 am on January 13, 2018, people in Hawaii received an emergency alert advising them to seek shelter from an incoming ballistic missile.
A very long 38 minutes later, the message was retracted via the same systems that had sent it—the Wireless Emergency Alert system, which sends location-based warnings to wireless carrier systems, and the Emergency Alert System, which sends television and radio alerts.
The Federal Communications Commission report that covered the debacle noted that, among other errors, the employee responsible for triggering the false alert believed the missile threat was real. Moreover, the exercise plans did not document a process for disseminating an all-clear message. And on top of that, the established ballistic missile alert checklist did not include a step to notify the Hawaii Emergency Management Agency’s public information officer responsible for communicating with the public, media, other agencies, and other stakeholders during an incident.
Researchers from the CDC and Hawaii Department of Health analyzed tweets sent during 2 periods: early (8:07-8:45 am), the 38 minutes during which the alert circulated; and the late period (8:46-9:24 am), the same amount of elapsed time after the correction had been issued.
They found 4 themes dominated the early period: information processing, information sharing, authentication, and emotional reaction (shock, fear, panic, terror). Information processing was defined as any indication of initial mental processing of the alert. Many of the tweets dealt with coming to terms with the threat.
During the late period, information sharing and emotional reaction persisted, but they were joined by new themes that, according to the researchers, were “fundamentally different” from the early-period themes and reflected reactions to misinformation: denunciation, insufficient knowledge to act, and mistrust of authority. “Insufficient knowledge to act” involved reacting to the lack of a response plan, particularly not knowing how to properly take shelter. Denunciations blamed the emergency warning and response, especially the time it took to correct the mistake. Mistrust of authority involved doubting the emergency alert system or governmental response.
How can a situation like this be better handled? The researchers say public health messaging during an emergency is complicated. For instance, it is influenced by how messages are perceived and interpreted by different people, and by the fact that messages need to be sent over multiple platforms to ensure that the information is disseminated accurately and quickly.
Which is why social media is both a handicap and a boon in public health emergencies. Tweets spread misinformation as fast as information (if not faster), so the first messages are critical. In addition to conveying timely messages, the researchers advise, public health authorities need to address the reactions during each phase of a crisis. They also need to establish credibility to prevent the public from mistrusting the public health message and its issuers.
Most important, perhaps: Alerts should carry clear instructions for persons in the affected area to carry out during an emergency.
At 8:07 am on January 13, 2018, people in Hawaii received an emergency alert advising them to seek shelter from an incoming ballistic missile.
A very long 38 minutes later, the message was retracted via the same systems that had sent it—the Wireless Emergency Alert system, which sends location-based warnings to wireless carrier systems, and the Emergency Alert System, which sends television and radio alerts.
The Federal Communications Commission report that covered the debacle noted that, among other errors, the employee responsible for triggering the false alert believed the missile threat was real. Moreover, the exercise plans did not document a process for disseminating an all-clear message. And on top of that, the established ballistic missile alert checklist did not include a step to notify the Hawaii Emergency Management Agency’s public information officer responsible for communicating with the public, media, other agencies, and other stakeholders during an incident.
Researchers from the CDC and Hawaii Department of Health analyzed tweets sent during 2 periods: early (8:07-8:45 am), the 38 minutes during which the alert circulated; and the late period (8:46-9:24 am), the same amount of elapsed time after the correction had been issued.
They found 4 themes dominated the early period: information processing, information sharing, authentication, and emotional reaction (shock, fear, panic, terror). Information processing was defined as any indication of initial mental processing of the alert. Many of the tweets dealt with coming to terms with the threat.
During the late period, information sharing and emotional reaction persisted, but they were joined by new themes that, according to the researchers, were “fundamentally different” from the early-period themes and reflected reactions to misinformation: denunciation, insufficient knowledge to act, and mistrust of authority. “Insufficient knowledge to act” involved reacting to the lack of a response plan, particularly not knowing how to properly take shelter. Denunciations blamed the emergency warning and response, especially the time it took to correct the mistake. Mistrust of authority involved doubting the emergency alert system or governmental response.
How can a situation like this be better handled? The researchers say public health messaging during an emergency is complicated. For instance, it is influenced by how messages are perceived and interpreted by different people, and by the fact that messages need to be sent over multiple platforms to ensure that the information is disseminated accurately and quickly.
Which is why social media is both a handicap and a boon in public health emergencies. Tweets spread misinformation as fast as information (if not faster), so the first messages are critical. In addition to conveying timely messages, the researchers advise, public health authorities need to address the reactions during each phase of a crisis. They also need to establish credibility to prevent the public from mistrusting the public health message and its issuers.
Most important, perhaps: Alerts should carry clear instructions for persons in the affected area to carry out during an emergency.
HCC with no cirrhosis is more common in HIV patients
SEATTLE – Hepatocellular carcinoma (HCC) is on the rise in HIV-positive individuals, its incidence having quadrupled since 1996, and HIV-positive individuals have about a 300% increase risk of HCC, compared with the general population. However, more than 40% of patients with HIV who develop HCC have a Fibrosis-4 score (FIB-4) suggesting a lack of cirrhosis, according to a new retrospective analysis. By contrast, only about 13% of typical HCC patients have no cirrhosis.
The study also revealed some of the risk factors associated with HCC in this population, including longer duration of HIV viremia and lower CD4 cell counts, as well as markers of metabolic syndrome. “There was some signal that perhaps other markers of metabolic syndrome, obesity and diabetes, were more prevalent in those [who developed HCC] without advanced fibrosis or cirrhosis, suggesting that there may be other underlying etiologies of liver disease that we should be wary of when evaluating somebody for their risk of HCC,” Jessie Torgersen, MD, said in an interview.
Dr. Torgersen is an instructor of medicine at the University of Pennsylvania, Philadelphia. She presented the study at the Conference on Retroviruses & Opportunistic Infections.
The results of the study are tantalizing, but not yet practice changing. “I don’t think we have enough information from this study to recommend a dramatic overhaul of the current HCC screening guidelines, but with the anticipated elimination of hepatitis C, I think the emergence of [metabolic factors and their] contributions to our HIV-positive population’s risk of HCC needs to be better understood. Hopefully this will serve as a first step in further understanding those risks,” Dr. Torgersen said.
She also hopes to get a better handle on the biological mechanisms that might drive HCC in the absence of cirrhosis. “While the mechanisms are unclear as to why HCC would develop in HIV-positive patients without cirrhosis, there are a lot of biologically plausible mechanisms that seem to make [sense],” said Dr. Torgersen. The team hopes to get a better understanding of those mechanisms in order to information evaluation and screening for HCC.
The researchers analyzed data from the Veterans Affairs Cancer Registry as well as EMRs for HIV-positive veterans across the United States. The study included 2,497 participants with a FIB-4 score greater than 3.25, and 29,836 with an FIB-4 score less than or equal to 3.25. At baseline, subjects with FIB-4 greater than 3.25 were more likely to have an alcohol-related diagnosis (47% vs. 29%), be positive for hepatitis C virus RNA (59% vs. 30%), be positive for the hepatitis B surface antigen (10% versus 5%), have HIV RNA greater than or equal to 500 copies/mL (63% vs. 56%), and to have a CD4+ cell count less than 200 cells/m3 (39% vs. 26%).
A total of 278 subjects were diagnosed with HCC; 43% had an FIB-4 less than or equal to 3.25. Among those 43%, more patients had a body mass index of 30 or higher (16% vs. 12%), had diabetes (31% vs. 25%), and tested positive for the hepatitis B surface antigen (26% vs. 17%).
Among subjects with FIB-4 less than or equal to 3.25, factors associated with greater HCC risk included higher HIV RNA level (hazard ratio, 1.24 per 1.0 log10 copies/mL), CD4+ cell count less than 200 cells/m3 (HR, 1.78), hepatitis C virus infection (HR, 6.32), and positive hepatitis B surface antigen (HR, 4.93).
Among subjects with FIB-4 greater than 3.25, increased HCC risk was associated with HCV infection (HR, 6.18) and positive hepatitis B surface antigen (HR, 2.12).
The study was funded by the National Institutes of Health. Dr. Torgersen reported no financial disclosures.
SOURCE: Torgersen J et al. CROI 2019, Abstract 90.
SEATTLE – Hepatocellular carcinoma (HCC) is on the rise in HIV-positive individuals, its incidence having quadrupled since 1996, and HIV-positive individuals have about a 300% increase risk of HCC, compared with the general population. However, more than 40% of patients with HIV who develop HCC have a Fibrosis-4 score (FIB-4) suggesting a lack of cirrhosis, according to a new retrospective analysis. By contrast, only about 13% of typical HCC patients have no cirrhosis.
The study also revealed some of the risk factors associated with HCC in this population, including longer duration of HIV viremia and lower CD4 cell counts, as well as markers of metabolic syndrome. “There was some signal that perhaps other markers of metabolic syndrome, obesity and diabetes, were more prevalent in those [who developed HCC] without advanced fibrosis or cirrhosis, suggesting that there may be other underlying etiologies of liver disease that we should be wary of when evaluating somebody for their risk of HCC,” Jessie Torgersen, MD, said in an interview.
Dr. Torgersen is an instructor of medicine at the University of Pennsylvania, Philadelphia. She presented the study at the Conference on Retroviruses & Opportunistic Infections.
The results of the study are tantalizing, but not yet practice changing. “I don’t think we have enough information from this study to recommend a dramatic overhaul of the current HCC screening guidelines, but with the anticipated elimination of hepatitis C, I think the emergence of [metabolic factors and their] contributions to our HIV-positive population’s risk of HCC needs to be better understood. Hopefully this will serve as a first step in further understanding those risks,” Dr. Torgersen said.
She also hopes to get a better handle on the biological mechanisms that might drive HCC in the absence of cirrhosis. “While the mechanisms are unclear as to why HCC would develop in HIV-positive patients without cirrhosis, there are a lot of biologically plausible mechanisms that seem to make [sense],” said Dr. Torgersen. The team hopes to get a better understanding of those mechanisms in order to information evaluation and screening for HCC.
The researchers analyzed data from the Veterans Affairs Cancer Registry as well as EMRs for HIV-positive veterans across the United States. The study included 2,497 participants with a FIB-4 score greater than 3.25, and 29,836 with an FIB-4 score less than or equal to 3.25. At baseline, subjects with FIB-4 greater than 3.25 were more likely to have an alcohol-related diagnosis (47% vs. 29%), be positive for hepatitis C virus RNA (59% vs. 30%), be positive for the hepatitis B surface antigen (10% versus 5%), have HIV RNA greater than or equal to 500 copies/mL (63% vs. 56%), and to have a CD4+ cell count less than 200 cells/m3 (39% vs. 26%).
A total of 278 subjects were diagnosed with HCC; 43% had an FIB-4 less than or equal to 3.25. Among those 43%, more patients had a body mass index of 30 or higher (16% vs. 12%), had diabetes (31% vs. 25%), and tested positive for the hepatitis B surface antigen (26% vs. 17%).
Among subjects with FIB-4 less than or equal to 3.25, factors associated with greater HCC risk included higher HIV RNA level (hazard ratio, 1.24 per 1.0 log10 copies/mL), CD4+ cell count less than 200 cells/m3 (HR, 1.78), hepatitis C virus infection (HR, 6.32), and positive hepatitis B surface antigen (HR, 4.93).
Among subjects with FIB-4 greater than 3.25, increased HCC risk was associated with HCV infection (HR, 6.18) and positive hepatitis B surface antigen (HR, 2.12).
The study was funded by the National Institutes of Health. Dr. Torgersen reported no financial disclosures.
SOURCE: Torgersen J et al. CROI 2019, Abstract 90.
SEATTLE – Hepatocellular carcinoma (HCC) is on the rise in HIV-positive individuals, its incidence having quadrupled since 1996, and HIV-positive individuals have about a 300% increase risk of HCC, compared with the general population. However, more than 40% of patients with HIV who develop HCC have a Fibrosis-4 score (FIB-4) suggesting a lack of cirrhosis, according to a new retrospective analysis. By contrast, only about 13% of typical HCC patients have no cirrhosis.
The study also revealed some of the risk factors associated with HCC in this population, including longer duration of HIV viremia and lower CD4 cell counts, as well as markers of metabolic syndrome. “There was some signal that perhaps other markers of metabolic syndrome, obesity and diabetes, were more prevalent in those [who developed HCC] without advanced fibrosis or cirrhosis, suggesting that there may be other underlying etiologies of liver disease that we should be wary of when evaluating somebody for their risk of HCC,” Jessie Torgersen, MD, said in an interview.
Dr. Torgersen is an instructor of medicine at the University of Pennsylvania, Philadelphia. She presented the study at the Conference on Retroviruses & Opportunistic Infections.
The results of the study are tantalizing, but not yet practice changing. “I don’t think we have enough information from this study to recommend a dramatic overhaul of the current HCC screening guidelines, but with the anticipated elimination of hepatitis C, I think the emergence of [metabolic factors and their] contributions to our HIV-positive population’s risk of HCC needs to be better understood. Hopefully this will serve as a first step in further understanding those risks,” Dr. Torgersen said.
She also hopes to get a better handle on the biological mechanisms that might drive HCC in the absence of cirrhosis. “While the mechanisms are unclear as to why HCC would develop in HIV-positive patients without cirrhosis, there are a lot of biologically plausible mechanisms that seem to make [sense],” said Dr. Torgersen. The team hopes to get a better understanding of those mechanisms in order to information evaluation and screening for HCC.
The researchers analyzed data from the Veterans Affairs Cancer Registry as well as EMRs for HIV-positive veterans across the United States. The study included 2,497 participants with a FIB-4 score greater than 3.25, and 29,836 with an FIB-4 score less than or equal to 3.25. At baseline, subjects with FIB-4 greater than 3.25 were more likely to have an alcohol-related diagnosis (47% vs. 29%), be positive for hepatitis C virus RNA (59% vs. 30%), be positive for the hepatitis B surface antigen (10% versus 5%), have HIV RNA greater than or equal to 500 copies/mL (63% vs. 56%), and to have a CD4+ cell count less than 200 cells/m3 (39% vs. 26%).
A total of 278 subjects were diagnosed with HCC; 43% had an FIB-4 less than or equal to 3.25. Among those 43%, more patients had a body mass index of 30 or higher (16% vs. 12%), had diabetes (31% vs. 25%), and tested positive for the hepatitis B surface antigen (26% vs. 17%).
Among subjects with FIB-4 less than or equal to 3.25, factors associated with greater HCC risk included higher HIV RNA level (hazard ratio, 1.24 per 1.0 log10 copies/mL), CD4+ cell count less than 200 cells/m3 (HR, 1.78), hepatitis C virus infection (HR, 6.32), and positive hepatitis B surface antigen (HR, 4.93).
Among subjects with FIB-4 greater than 3.25, increased HCC risk was associated with HCV infection (HR, 6.18) and positive hepatitis B surface antigen (HR, 2.12).
The study was funded by the National Institutes of Health. Dr. Torgersen reported no financial disclosures.
SOURCE: Torgersen J et al. CROI 2019, Abstract 90.
REPORTING FROM CROI 2019
New LDL-lowering drug under FDA review
This week in MDedge Cardiocast: A novel drug lowers LDL in on top of maximums statins, invasive cardiology is a top money maker for hospitals, a meta-analysis parses the heart and kidney benefits of new diabetes drugs, and the AHA warns that heart-harming toxins may hurt hookah smokers.
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This week in MDedge Cardiocast: A novel drug lowers LDL in on top of maximums statins, invasive cardiology is a top money maker for hospitals, a meta-analysis parses the heart and kidney benefits of new diabetes drugs, and the AHA warns that heart-harming toxins may hurt hookah smokers.
Amazon Alexa
Apple Podcasts
Google Podcasts
TuneIn
This week in MDedge Cardiocast: A novel drug lowers LDL in on top of maximums statins, invasive cardiology is a top money maker for hospitals, a meta-analysis parses the heart and kidney benefits of new diabetes drugs, and the AHA warns that heart-harming toxins may hurt hookah smokers.
Amazon Alexa
Apple Podcasts
Google Podcasts
TuneIn
Endarterectomy and stenting have similar efficacy in carotid stenosis
HONOLULU – , according to a pooled analysis presented at the International Stroke Conference sponsored by the American Heart Association. The treatments have similar rates of procedural complications and 4-year ipsilateral stroke, said Jon S. Matsumura, MD, chairman of the division of vascular surgery at the University of Wisconsin in Madison.
Asymptomatic severe carotid stenosis is the most common indication for carotid operations in the United States. Data support carotid endarterectomy in selected asymptomatic patients. Carotid artery stenting with embolic protection is a newer treatment option. Two of the five most recent large, randomized trials – CREST and ACT I – compared carotid stenting with endarterectomy in asymptomatic patients. Dr. Matsumura and his colleagues conducted a pooled analysis of these two trials to help inform the choice of treatment.
The investigators analyzed data from the CREST and ACT I studies, which had many similarities. The researchers in these trials carefully selected the surgeons and the interventionalists who participated in them. Each trial used single carotid stent systems, and both trials used routine, distally placed embolic protection. The trials had independent neurologic assessment, routine cardiac enzyme screening, and central clinical and adjudication committees.
Dr. Matsumura and his colleagues decided to conduct a patient-level pooled analysis and defined the primary endpoint as a composite of death, stroke, and myocardial infarction in the periprocedural period and any ipsilateral stroke within 4 years of randomization. They included in their analysis all randomized, asymptomatic patients who were younger than 80 years.
The analysis comprised 2,544 patients, 1,637 of whom were randomized to stenting, and 907 of whom were randomized to endarterectomy. The population included more than 1,000 patients with 3-year follow-up and more than 500 with 4-year follow-up. Patients randomized to stenting were slightly younger, but the percentage of patients older than age 65 was similar between groups. Current cigarette smoking was slightly more common among patients randomized to stenting. The groups were well balanced by sex, race, and risk factors such as hypertension, hyperlipidemia, and diabetes.
The rate of primary endpoint events was 5.3% in the stenting arm and 5.1% in the endarterectomy arm (hazard ratio with stenting, 1.02; 95% confidence interval, 0.7-1.5; P = .91). The rate of periprocedural stroke was 2.7% in the stenting arm and 1.5% in the endarterectomy arm (P = .07). The rate of periprocedural myocardial infarction was 0.6% in the stenting arm and 1.7% in the endarterectomy arm (P = .01). The rate of periprocedural stroke and death was 2.7% in the stenting arm and 1.6% in the endarterectomy arm (P = .07). The rate of 4-year ipsilateral stroke was 2.3% in the stenting arm and 2.2% in the endarterectomy arm (P = .97).
A secondary analysis indicated that the cumulative, 4-year rate of stroke-free survival was 93.2% in the stenting arm and 95.1% in the endarterectomy arm (P = .10). “Almost all this difference is the initial periprocedural hazard difference,” said Dr. Matsumura. The rate of cumulative 4-year survival was 91% in the stenting arm and 90.2% in the endarterectomy arm.
The results of the pooled analysis do not support the perception that stenting entails an increased risk of periprocedural stroke. “The majority of trials have been in symptomatic patients,” said Dr. Matsumura. “We’re studying asymptomatic patients. We’re also studying them in the context of second-generation devices.” The results may reflect the amount of device-related training that the researchers undertook, as well as the decision to use single-stent dedicated carotid systems, he added.
Sponsors of the analysis included the University of Wisconsin, Massachusetts General Hospital, the Medical University of South Carolina, the University of Alabama at Birmingham, Cardiovascular Associates, and Mayo Clinic Jacksonville.
HONOLULU – , according to a pooled analysis presented at the International Stroke Conference sponsored by the American Heart Association. The treatments have similar rates of procedural complications and 4-year ipsilateral stroke, said Jon S. Matsumura, MD, chairman of the division of vascular surgery at the University of Wisconsin in Madison.
Asymptomatic severe carotid stenosis is the most common indication for carotid operations in the United States. Data support carotid endarterectomy in selected asymptomatic patients. Carotid artery stenting with embolic protection is a newer treatment option. Two of the five most recent large, randomized trials – CREST and ACT I – compared carotid stenting with endarterectomy in asymptomatic patients. Dr. Matsumura and his colleagues conducted a pooled analysis of these two trials to help inform the choice of treatment.
The investigators analyzed data from the CREST and ACT I studies, which had many similarities. The researchers in these trials carefully selected the surgeons and the interventionalists who participated in them. Each trial used single carotid stent systems, and both trials used routine, distally placed embolic protection. The trials had independent neurologic assessment, routine cardiac enzyme screening, and central clinical and adjudication committees.
Dr. Matsumura and his colleagues decided to conduct a patient-level pooled analysis and defined the primary endpoint as a composite of death, stroke, and myocardial infarction in the periprocedural period and any ipsilateral stroke within 4 years of randomization. They included in their analysis all randomized, asymptomatic patients who were younger than 80 years.
The analysis comprised 2,544 patients, 1,637 of whom were randomized to stenting, and 907 of whom were randomized to endarterectomy. The population included more than 1,000 patients with 3-year follow-up and more than 500 with 4-year follow-up. Patients randomized to stenting were slightly younger, but the percentage of patients older than age 65 was similar between groups. Current cigarette smoking was slightly more common among patients randomized to stenting. The groups were well balanced by sex, race, and risk factors such as hypertension, hyperlipidemia, and diabetes.
The rate of primary endpoint events was 5.3% in the stenting arm and 5.1% in the endarterectomy arm (hazard ratio with stenting, 1.02; 95% confidence interval, 0.7-1.5; P = .91). The rate of periprocedural stroke was 2.7% in the stenting arm and 1.5% in the endarterectomy arm (P = .07). The rate of periprocedural myocardial infarction was 0.6% in the stenting arm and 1.7% in the endarterectomy arm (P = .01). The rate of periprocedural stroke and death was 2.7% in the stenting arm and 1.6% in the endarterectomy arm (P = .07). The rate of 4-year ipsilateral stroke was 2.3% in the stenting arm and 2.2% in the endarterectomy arm (P = .97).
A secondary analysis indicated that the cumulative, 4-year rate of stroke-free survival was 93.2% in the stenting arm and 95.1% in the endarterectomy arm (P = .10). “Almost all this difference is the initial periprocedural hazard difference,” said Dr. Matsumura. The rate of cumulative 4-year survival was 91% in the stenting arm and 90.2% in the endarterectomy arm.
The results of the pooled analysis do not support the perception that stenting entails an increased risk of periprocedural stroke. “The majority of trials have been in symptomatic patients,” said Dr. Matsumura. “We’re studying asymptomatic patients. We’re also studying them in the context of second-generation devices.” The results may reflect the amount of device-related training that the researchers undertook, as well as the decision to use single-stent dedicated carotid systems, he added.
Sponsors of the analysis included the University of Wisconsin, Massachusetts General Hospital, the Medical University of South Carolina, the University of Alabama at Birmingham, Cardiovascular Associates, and Mayo Clinic Jacksonville.
HONOLULU – , according to a pooled analysis presented at the International Stroke Conference sponsored by the American Heart Association. The treatments have similar rates of procedural complications and 4-year ipsilateral stroke, said Jon S. Matsumura, MD, chairman of the division of vascular surgery at the University of Wisconsin in Madison.
Asymptomatic severe carotid stenosis is the most common indication for carotid operations in the United States. Data support carotid endarterectomy in selected asymptomatic patients. Carotid artery stenting with embolic protection is a newer treatment option. Two of the five most recent large, randomized trials – CREST and ACT I – compared carotid stenting with endarterectomy in asymptomatic patients. Dr. Matsumura and his colleagues conducted a pooled analysis of these two trials to help inform the choice of treatment.
The investigators analyzed data from the CREST and ACT I studies, which had many similarities. The researchers in these trials carefully selected the surgeons and the interventionalists who participated in them. Each trial used single carotid stent systems, and both trials used routine, distally placed embolic protection. The trials had independent neurologic assessment, routine cardiac enzyme screening, and central clinical and adjudication committees.
Dr. Matsumura and his colleagues decided to conduct a patient-level pooled analysis and defined the primary endpoint as a composite of death, stroke, and myocardial infarction in the periprocedural period and any ipsilateral stroke within 4 years of randomization. They included in their analysis all randomized, asymptomatic patients who were younger than 80 years.
The analysis comprised 2,544 patients, 1,637 of whom were randomized to stenting, and 907 of whom were randomized to endarterectomy. The population included more than 1,000 patients with 3-year follow-up and more than 500 with 4-year follow-up. Patients randomized to stenting were slightly younger, but the percentage of patients older than age 65 was similar between groups. Current cigarette smoking was slightly more common among patients randomized to stenting. The groups were well balanced by sex, race, and risk factors such as hypertension, hyperlipidemia, and diabetes.
The rate of primary endpoint events was 5.3% in the stenting arm and 5.1% in the endarterectomy arm (hazard ratio with stenting, 1.02; 95% confidence interval, 0.7-1.5; P = .91). The rate of periprocedural stroke was 2.7% in the stenting arm and 1.5% in the endarterectomy arm (P = .07). The rate of periprocedural myocardial infarction was 0.6% in the stenting arm and 1.7% in the endarterectomy arm (P = .01). The rate of periprocedural stroke and death was 2.7% in the stenting arm and 1.6% in the endarterectomy arm (P = .07). The rate of 4-year ipsilateral stroke was 2.3% in the stenting arm and 2.2% in the endarterectomy arm (P = .97).
A secondary analysis indicated that the cumulative, 4-year rate of stroke-free survival was 93.2% in the stenting arm and 95.1% in the endarterectomy arm (P = .10). “Almost all this difference is the initial periprocedural hazard difference,” said Dr. Matsumura. The rate of cumulative 4-year survival was 91% in the stenting arm and 90.2% in the endarterectomy arm.
The results of the pooled analysis do not support the perception that stenting entails an increased risk of periprocedural stroke. “The majority of trials have been in symptomatic patients,” said Dr. Matsumura. “We’re studying asymptomatic patients. We’re also studying them in the context of second-generation devices.” The results may reflect the amount of device-related training that the researchers undertook, as well as the decision to use single-stent dedicated carotid systems, he added.
Sponsors of the analysis included the University of Wisconsin, Massachusetts General Hospital, the Medical University of South Carolina, the University of Alabama at Birmingham, Cardiovascular Associates, and Mayo Clinic Jacksonville.
REPORTING FROM ISC 2019
Cognition Concern in MS and Changes in the Brain
Subjective cognitive concern in multiple sclerosis (MS) is associated with reduced thalamic and cortical gray matter volumes, areas of the brain that have been implicated in objective cognitive impairment, according to a recent study. These findings may lend neuroanatomical significance to subjective cognitive concerns and patient-reported outcomes as measured by the Quality of Life in Neurologic Disorders Measures (Neuro-QoL). A total of 158 patients with MS completed the Neuro-QoL short forms to assess subjective cognitive concerns and underwent brain magnetic resonance imaging. Regional brain volumes from regions of interest implicated in cognitive dysfunction were measured using NeuroQuant automated volumetric quantitation. Linear regression was used to analyze the relationship between subjective cognitive concerns and brain volume. Researchers found:
- Controlling for age, disease duration, gender, depression and fatigue, increased subjective cognitive concerns were associated with reduced thalamic volume (standardized β = 0.223, t150 =2.406) and reduced cortical gray matter volume (standardized β = 0.240, t150 = 2.777).
- Increased subjective cognitive concerns were not associated with any other regions of interest that were analyzed.
Kletenik I, Alvarez E, Honce JM, Valdez B, Vollmer TL. Subjective cognitive concern in multiple sclerosis is associated with reduced thalamic and cortical gray matter volumes. Mult Scler J Exp Transl Clin. 2019;5(1); doi:10.1177/2055217319827618.
Subjective cognitive concern in multiple sclerosis (MS) is associated with reduced thalamic and cortical gray matter volumes, areas of the brain that have been implicated in objective cognitive impairment, according to a recent study. These findings may lend neuroanatomical significance to subjective cognitive concerns and patient-reported outcomes as measured by the Quality of Life in Neurologic Disorders Measures (Neuro-QoL). A total of 158 patients with MS completed the Neuro-QoL short forms to assess subjective cognitive concerns and underwent brain magnetic resonance imaging. Regional brain volumes from regions of interest implicated in cognitive dysfunction were measured using NeuroQuant automated volumetric quantitation. Linear regression was used to analyze the relationship between subjective cognitive concerns and brain volume. Researchers found:
- Controlling for age, disease duration, gender, depression and fatigue, increased subjective cognitive concerns were associated with reduced thalamic volume (standardized β = 0.223, t150 =2.406) and reduced cortical gray matter volume (standardized β = 0.240, t150 = 2.777).
- Increased subjective cognitive concerns were not associated with any other regions of interest that were analyzed.
Kletenik I, Alvarez E, Honce JM, Valdez B, Vollmer TL. Subjective cognitive concern in multiple sclerosis is associated with reduced thalamic and cortical gray matter volumes. Mult Scler J Exp Transl Clin. 2019;5(1); doi:10.1177/2055217319827618.
Subjective cognitive concern in multiple sclerosis (MS) is associated with reduced thalamic and cortical gray matter volumes, areas of the brain that have been implicated in objective cognitive impairment, according to a recent study. These findings may lend neuroanatomical significance to subjective cognitive concerns and patient-reported outcomes as measured by the Quality of Life in Neurologic Disorders Measures (Neuro-QoL). A total of 158 patients with MS completed the Neuro-QoL short forms to assess subjective cognitive concerns and underwent brain magnetic resonance imaging. Regional brain volumes from regions of interest implicated in cognitive dysfunction were measured using NeuroQuant automated volumetric quantitation. Linear regression was used to analyze the relationship between subjective cognitive concerns and brain volume. Researchers found:
- Controlling for age, disease duration, gender, depression and fatigue, increased subjective cognitive concerns were associated with reduced thalamic volume (standardized β = 0.223, t150 =2.406) and reduced cortical gray matter volume (standardized β = 0.240, t150 = 2.777).
- Increased subjective cognitive concerns were not associated with any other regions of interest that were analyzed.
Kletenik I, Alvarez E, Honce JM, Valdez B, Vollmer TL. Subjective cognitive concern in multiple sclerosis is associated with reduced thalamic and cortical gray matter volumes. Mult Scler J Exp Transl Clin. 2019;5(1); doi:10.1177/2055217319827618.
Advance care planning codes not being used
Starting in 2016, the Centers for Medicare & Medicaid Services began paying physicians for advance care planning discussions with the approval of two new codes: 99497 and 99498. The codes pay about $86 for the first 30 minutes of a face-to-face conversation with a patient, family member, and/or surrogate and about $75 for additional sessions. Services can be furnished in both inpatient and ambulatory settings, and payment is not limited to particular physician specialties.
In 2016, health care professionals in New England (Connecticut, Maine, Massachusetts, New Hampshire, Rhode Island, and Vermont) billed Medicare 26,522 times for the advance care planning (ACP) codes for a total of 24,536 patients, which represented less than 1% of Medicare beneficiaries in New England at the time, according to Kimberly Pelland, MPH, of Healthcentric Advisors, Providence, R.I., and her colleagues. Most claims were billed in the office, followed by in nursing homes, and in hospitals; 40% of conversations occurred during an annual wellness visit (JAMA Intern Med. 2019 March 11. doi:10.1001/jamainternmed.2018.8107).
Internists billed Medicare the most for ACP claims (65%), followed by family physicians (22%) gerontologists (5%), and oncologist/hematologists (0.3%), according to the analysis based on 2016 Medicare claims data and Census Bureau data. A greater proportion of patients with ACP claims were female, aged 85 years or older, enrolled in hospice, and died in the study year. Patients had higher odds of having an ACP claim if they were older and had lower income, and if they had cancer, heart failure, stroke, chronic kidney disease, or dementia. Male patients who were Asian, black, and Hispanic had lower chances of having an ACP claim.
In a related study, Emmanuelle Belanger, PhD, of Brown University, Providence, R.I., and her colleagues examined national Medicare data from 2016 to the third quarter of 2017. Across the United States, 2% of Medicare patients aged 65 years and older received advance care planning services that were billed under the ACP codes (JAMA Intern Med. 2019 March 11. doi: 10.1001/jamainternmed.2018.8615). Visits billed under the ACP codes increased from 538,275 to 633,214 during the same time period. Claim rates were higher among patients who died within the study period, reaching 3% in 2016 and 6% in 2017. The percentage of decedents with an ACP billed visit varied strongly across states, with states such as North Dakota, South Dakota, and Wyoming having the fewest ACP visits billed and states such as California and Nevada having the most. ACP billed visits increased in all settings in 2017, but primarily in hospitals and nursing homes. Nationally, internists billed the codes most (48%), followed by family physicians (28%).
While the two studies indicate low usage of the ACP codes, many physicians are discussing advance care planning with their patients, said Mary M. Newman, MD, an internist based in Lutherville, Md., and former American College of Physicians adviser to the American Medical Association Relative Scale Value Update Committee (RUC).
“What cannot be captured by tracking under Medicare claims data are those shorter conversations that we have frequently,” Dr. Newman said in an interview. “If we have a short conversation about advance care planning, it gets folded into our evaluation and management visit. It’s not going to be separately billed.”
At the same time, some patients are not ready to discuss end-of-life options and decline the discussions when asked, Dr. Newman said. Particularly for healthier patients, end of life care is not a primary focus, she noted.
“Not everybody’s ready to have an advance care planning [discussion] that lasts 16-45 minutes,” she said. “Many people over age 65 are not ready to deal with advance care planning in their day-to-day lives, and it may not be what they wish to discuss. I offer the option to patients and some say, ‘Yes, I’d love to,’ and others decline or postpone.”
Low usage of the ACP codes may be associated with lack of awareness, uncertainty about appropriate code use, or associated billing that is not part of the standard workflow, Ankita Mehta, MD, of Mount Sinai in New York wrote an editorial accompanying the studies (JAMA Intern Med. 2019 March 11. doi:10.1001/jamainternmed.2018.8105).
“Regardless, the low rates of utilization of ACP codes is alarming and highlights the need to create strategies to integrate ACP discussions into standard practice and build ACP documentation and billing in clinical workflow,” Dr. Mehta said.
Dr. Newman agreed that more education among physicians is needed.
“The amount of education clinicians have received varies tremendously across the geography of the country,” she said. “I think the codes are going to be slowly adopted. The challenge to us is to make sure we’re all better educated on palliative care as people age and get sick and that we are sensitive to our patients explicit and implicit needs for these discussions.”
Starting in 2016, the Centers for Medicare & Medicaid Services began paying physicians for advance care planning discussions with the approval of two new codes: 99497 and 99498. The codes pay about $86 for the first 30 minutes of a face-to-face conversation with a patient, family member, and/or surrogate and about $75 for additional sessions. Services can be furnished in both inpatient and ambulatory settings, and payment is not limited to particular physician specialties.
In 2016, health care professionals in New England (Connecticut, Maine, Massachusetts, New Hampshire, Rhode Island, and Vermont) billed Medicare 26,522 times for the advance care planning (ACP) codes for a total of 24,536 patients, which represented less than 1% of Medicare beneficiaries in New England at the time, according to Kimberly Pelland, MPH, of Healthcentric Advisors, Providence, R.I., and her colleagues. Most claims were billed in the office, followed by in nursing homes, and in hospitals; 40% of conversations occurred during an annual wellness visit (JAMA Intern Med. 2019 March 11. doi:10.1001/jamainternmed.2018.8107).
Internists billed Medicare the most for ACP claims (65%), followed by family physicians (22%) gerontologists (5%), and oncologist/hematologists (0.3%), according to the analysis based on 2016 Medicare claims data and Census Bureau data. A greater proportion of patients with ACP claims were female, aged 85 years or older, enrolled in hospice, and died in the study year. Patients had higher odds of having an ACP claim if they were older and had lower income, and if they had cancer, heart failure, stroke, chronic kidney disease, or dementia. Male patients who were Asian, black, and Hispanic had lower chances of having an ACP claim.
In a related study, Emmanuelle Belanger, PhD, of Brown University, Providence, R.I., and her colleagues examined national Medicare data from 2016 to the third quarter of 2017. Across the United States, 2% of Medicare patients aged 65 years and older received advance care planning services that were billed under the ACP codes (JAMA Intern Med. 2019 March 11. doi: 10.1001/jamainternmed.2018.8615). Visits billed under the ACP codes increased from 538,275 to 633,214 during the same time period. Claim rates were higher among patients who died within the study period, reaching 3% in 2016 and 6% in 2017. The percentage of decedents with an ACP billed visit varied strongly across states, with states such as North Dakota, South Dakota, and Wyoming having the fewest ACP visits billed and states such as California and Nevada having the most. ACP billed visits increased in all settings in 2017, but primarily in hospitals and nursing homes. Nationally, internists billed the codes most (48%), followed by family physicians (28%).
While the two studies indicate low usage of the ACP codes, many physicians are discussing advance care planning with their patients, said Mary M. Newman, MD, an internist based in Lutherville, Md., and former American College of Physicians adviser to the American Medical Association Relative Scale Value Update Committee (RUC).
“What cannot be captured by tracking under Medicare claims data are those shorter conversations that we have frequently,” Dr. Newman said in an interview. “If we have a short conversation about advance care planning, it gets folded into our evaluation and management visit. It’s not going to be separately billed.”
At the same time, some patients are not ready to discuss end-of-life options and decline the discussions when asked, Dr. Newman said. Particularly for healthier patients, end of life care is not a primary focus, she noted.
“Not everybody’s ready to have an advance care planning [discussion] that lasts 16-45 minutes,” she said. “Many people over age 65 are not ready to deal with advance care planning in their day-to-day lives, and it may not be what they wish to discuss. I offer the option to patients and some say, ‘Yes, I’d love to,’ and others decline or postpone.”
Low usage of the ACP codes may be associated with lack of awareness, uncertainty about appropriate code use, or associated billing that is not part of the standard workflow, Ankita Mehta, MD, of Mount Sinai in New York wrote an editorial accompanying the studies (JAMA Intern Med. 2019 March 11. doi:10.1001/jamainternmed.2018.8105).
“Regardless, the low rates of utilization of ACP codes is alarming and highlights the need to create strategies to integrate ACP discussions into standard practice and build ACP documentation and billing in clinical workflow,” Dr. Mehta said.
Dr. Newman agreed that more education among physicians is needed.
“The amount of education clinicians have received varies tremendously across the geography of the country,” she said. “I think the codes are going to be slowly adopted. The challenge to us is to make sure we’re all better educated on palliative care as people age and get sick and that we are sensitive to our patients explicit and implicit needs for these discussions.”
Starting in 2016, the Centers for Medicare & Medicaid Services began paying physicians for advance care planning discussions with the approval of two new codes: 99497 and 99498. The codes pay about $86 for the first 30 minutes of a face-to-face conversation with a patient, family member, and/or surrogate and about $75 for additional sessions. Services can be furnished in both inpatient and ambulatory settings, and payment is not limited to particular physician specialties.
In 2016, health care professionals in New England (Connecticut, Maine, Massachusetts, New Hampshire, Rhode Island, and Vermont) billed Medicare 26,522 times for the advance care planning (ACP) codes for a total of 24,536 patients, which represented less than 1% of Medicare beneficiaries in New England at the time, according to Kimberly Pelland, MPH, of Healthcentric Advisors, Providence, R.I., and her colleagues. Most claims were billed in the office, followed by in nursing homes, and in hospitals; 40% of conversations occurred during an annual wellness visit (JAMA Intern Med. 2019 March 11. doi:10.1001/jamainternmed.2018.8107).
Internists billed Medicare the most for ACP claims (65%), followed by family physicians (22%) gerontologists (5%), and oncologist/hematologists (0.3%), according to the analysis based on 2016 Medicare claims data and Census Bureau data. A greater proportion of patients with ACP claims were female, aged 85 years or older, enrolled in hospice, and died in the study year. Patients had higher odds of having an ACP claim if they were older and had lower income, and if they had cancer, heart failure, stroke, chronic kidney disease, or dementia. Male patients who were Asian, black, and Hispanic had lower chances of having an ACP claim.
In a related study, Emmanuelle Belanger, PhD, of Brown University, Providence, R.I., and her colleagues examined national Medicare data from 2016 to the third quarter of 2017. Across the United States, 2% of Medicare patients aged 65 years and older received advance care planning services that were billed under the ACP codes (JAMA Intern Med. 2019 March 11. doi: 10.1001/jamainternmed.2018.8615). Visits billed under the ACP codes increased from 538,275 to 633,214 during the same time period. Claim rates were higher among patients who died within the study period, reaching 3% in 2016 and 6% in 2017. The percentage of decedents with an ACP billed visit varied strongly across states, with states such as North Dakota, South Dakota, and Wyoming having the fewest ACP visits billed and states such as California and Nevada having the most. ACP billed visits increased in all settings in 2017, but primarily in hospitals and nursing homes. Nationally, internists billed the codes most (48%), followed by family physicians (28%).
While the two studies indicate low usage of the ACP codes, many physicians are discussing advance care planning with their patients, said Mary M. Newman, MD, an internist based in Lutherville, Md., and former American College of Physicians adviser to the American Medical Association Relative Scale Value Update Committee (RUC).
“What cannot be captured by tracking under Medicare claims data are those shorter conversations that we have frequently,” Dr. Newman said in an interview. “If we have a short conversation about advance care planning, it gets folded into our evaluation and management visit. It’s not going to be separately billed.”
At the same time, some patients are not ready to discuss end-of-life options and decline the discussions when asked, Dr. Newman said. Particularly for healthier patients, end of life care is not a primary focus, she noted.
“Not everybody’s ready to have an advance care planning [discussion] that lasts 16-45 minutes,” she said. “Many people over age 65 are not ready to deal with advance care planning in their day-to-day lives, and it may not be what they wish to discuss. I offer the option to patients and some say, ‘Yes, I’d love to,’ and others decline or postpone.”
Low usage of the ACP codes may be associated with lack of awareness, uncertainty about appropriate code use, or associated billing that is not part of the standard workflow, Ankita Mehta, MD, of Mount Sinai in New York wrote an editorial accompanying the studies (JAMA Intern Med. 2019 March 11. doi:10.1001/jamainternmed.2018.8105).
“Regardless, the low rates of utilization of ACP codes is alarming and highlights the need to create strategies to integrate ACP discussions into standard practice and build ACP documentation and billing in clinical workflow,” Dr. Mehta said.
Dr. Newman agreed that more education among physicians is needed.
“The amount of education clinicians have received varies tremendously across the geography of the country,” she said. “I think the codes are going to be slowly adopted. The challenge to us is to make sure we’re all better educated on palliative care as people age and get sick and that we are sensitive to our patients explicit and implicit needs for these discussions.”
Friendly gut bugs, MCI-battling mushrooms, and remembering to forget
Friend or foe, how do we know?
That’s the question immune cells ask all the time, especially about gut bacteria. A study published March 7 seeks to explain how immune systems can distinguish between happy-go-lucky gut microbes and deadly pathogens. Turns out, the friendly microbes simply high five!
Well, not really. But they do have a hook-like arm, called a holdfast, which latches onto the gut lining. The holdfast is lined with vesicles that carry antigens into the gut. While antigens normally cause immune cells to attack, something about these antigens are telling T cells to hold their fire.
The authors of the study hypothesized that the packaging of the antigens – the vesicles – might be the reason for the friendliness between microbes and T cells. It’s like the immune system expects a cannonball, but is pleasantly surprised by an Amazon Prime package full of goodies showing up on their doorstep instead. Yay for presents!
Don’t skimp on the ’shrooms
While you’re piling onions onto your plate to reduce cancer and cheese for your heart, make sure you add mushrooms for extra brain power. Researchers conducting a 6-year study in Singapore observed cognitive decline in 600 Chinese people aged at least 60 years, and they found that those who eat more than two portions of cooked mushrooms per week have up to 50% reduced odds of mild cognitive impairment.
Researchers here at the LOTME Lab have harnessed the power of these food studies to determine that a Philly cheesesteak with mushrooms and onions is the healthiest meal out there. Chow down!
As far as we know, all the mushrooms were standard edible fungi, and none were magic mushrooms (although, that might help, too; try that on your own time). Researchers believe that the compound ergothioneine, an antioxidant and anti-inflammatory that cannot be synthesized by humans, might be reason for the reduced risk of mild cognitive impairment Maybe it’s time to add a cup of cooked shiitake mushrooms to your morning routine.
Fuggedaboutit!
We all have unwanted memories that we’d rather forget about. An embarrassing incident, a painful experience – everyone has moments they’d rather not think about. So, the question is: How do you get rid of these bad memories?
The obvious solution is to stop thinking about it. But if you’re a regular reader of Livin’ on the MDedge, you can probably guess that the answer isn’t that simple.
And, in fact, it isn’t! A group of researchers at the University of Texas at Austin, has performed a study on intentional forgetting, and they found that the best way to forget something is ... to think about it. Study subjects were shown a series of images and told to either remember or forget those images while their ventral temporal cortex was monitored for activity. Not only were participants successfully able to forget images by thinking about it, but activity in the brain was higher when forgetting than while remembering.
Obviously, this research would be helpful for anyone dealing with trauma, and we hope doctors who have to treat such patients keep it in mind. Just don’t think about it too much, or you’ll forget about it.
The Golden Lobbyist
If you need health care in your neighborhood
Who you gonna call? Jack Nicklaus!
You need 20 mill to make it good
Who you gonna call? Jack Nicklaus!
Health care in general didn’t do very well in President Trump’s 2020 budget proposal; Medicare, Medicaid, and the National Cancer Institute were all targeted for cuts. But it did include one particular $20-million initiative for a mobile children’s hospital.
Politico reports that the nation’s golfer in chief “personally directed the Department of Health and Human Services to earmark the funds” after playing a couple of rounds with the Golden Bear himself, Jack Nicklaus. The mobile unit would be part of the Nicklaus Children’s Hospital in Miami. The golf legend turned lobbyist also had meetings off the course with HHS Secretary Alex Azar and then-OMB Director Mick Mulvaney.
Are health care ideas running through your head?
Who you gonna call? Jack Nicklaus!
He’ll golf with the prez, and get your bread
Who you gonna call? Jack Nicklaus!
He ain’t afraid of no tweets
Friend or foe, how do we know?
That’s the question immune cells ask all the time, especially about gut bacteria. A study published March 7 seeks to explain how immune systems can distinguish between happy-go-lucky gut microbes and deadly pathogens. Turns out, the friendly microbes simply high five!
Well, not really. But they do have a hook-like arm, called a holdfast, which latches onto the gut lining. The holdfast is lined with vesicles that carry antigens into the gut. While antigens normally cause immune cells to attack, something about these antigens are telling T cells to hold their fire.
The authors of the study hypothesized that the packaging of the antigens – the vesicles – might be the reason for the friendliness between microbes and T cells. It’s like the immune system expects a cannonball, but is pleasantly surprised by an Amazon Prime package full of goodies showing up on their doorstep instead. Yay for presents!
Don’t skimp on the ’shrooms
While you’re piling onions onto your plate to reduce cancer and cheese for your heart, make sure you add mushrooms for extra brain power. Researchers conducting a 6-year study in Singapore observed cognitive decline in 600 Chinese people aged at least 60 years, and they found that those who eat more than two portions of cooked mushrooms per week have up to 50% reduced odds of mild cognitive impairment.
Researchers here at the LOTME Lab have harnessed the power of these food studies to determine that a Philly cheesesteak with mushrooms and onions is the healthiest meal out there. Chow down!
As far as we know, all the mushrooms were standard edible fungi, and none were magic mushrooms (although, that might help, too; try that on your own time). Researchers believe that the compound ergothioneine, an antioxidant and anti-inflammatory that cannot be synthesized by humans, might be reason for the reduced risk of mild cognitive impairment Maybe it’s time to add a cup of cooked shiitake mushrooms to your morning routine.
Fuggedaboutit!
We all have unwanted memories that we’d rather forget about. An embarrassing incident, a painful experience – everyone has moments they’d rather not think about. So, the question is: How do you get rid of these bad memories?
The obvious solution is to stop thinking about it. But if you’re a regular reader of Livin’ on the MDedge, you can probably guess that the answer isn’t that simple.
And, in fact, it isn’t! A group of researchers at the University of Texas at Austin, has performed a study on intentional forgetting, and they found that the best way to forget something is ... to think about it. Study subjects were shown a series of images and told to either remember or forget those images while their ventral temporal cortex was monitored for activity. Not only were participants successfully able to forget images by thinking about it, but activity in the brain was higher when forgetting than while remembering.
Obviously, this research would be helpful for anyone dealing with trauma, and we hope doctors who have to treat such patients keep it in mind. Just don’t think about it too much, or you’ll forget about it.
The Golden Lobbyist
If you need health care in your neighborhood
Who you gonna call? Jack Nicklaus!
You need 20 mill to make it good
Who you gonna call? Jack Nicklaus!
Health care in general didn’t do very well in President Trump’s 2020 budget proposal; Medicare, Medicaid, and the National Cancer Institute were all targeted for cuts. But it did include one particular $20-million initiative for a mobile children’s hospital.
Politico reports that the nation’s golfer in chief “personally directed the Department of Health and Human Services to earmark the funds” after playing a couple of rounds with the Golden Bear himself, Jack Nicklaus. The mobile unit would be part of the Nicklaus Children’s Hospital in Miami. The golf legend turned lobbyist also had meetings off the course with HHS Secretary Alex Azar and then-OMB Director Mick Mulvaney.
Are health care ideas running through your head?
Who you gonna call? Jack Nicklaus!
He’ll golf with the prez, and get your bread
Who you gonna call? Jack Nicklaus!
He ain’t afraid of no tweets
Friend or foe, how do we know?
That’s the question immune cells ask all the time, especially about gut bacteria. A study published March 7 seeks to explain how immune systems can distinguish between happy-go-lucky gut microbes and deadly pathogens. Turns out, the friendly microbes simply high five!
Well, not really. But they do have a hook-like arm, called a holdfast, which latches onto the gut lining. The holdfast is lined with vesicles that carry antigens into the gut. While antigens normally cause immune cells to attack, something about these antigens are telling T cells to hold their fire.
The authors of the study hypothesized that the packaging of the antigens – the vesicles – might be the reason for the friendliness between microbes and T cells. It’s like the immune system expects a cannonball, but is pleasantly surprised by an Amazon Prime package full of goodies showing up on their doorstep instead. Yay for presents!
Don’t skimp on the ’shrooms
While you’re piling onions onto your plate to reduce cancer and cheese for your heart, make sure you add mushrooms for extra brain power. Researchers conducting a 6-year study in Singapore observed cognitive decline in 600 Chinese people aged at least 60 years, and they found that those who eat more than two portions of cooked mushrooms per week have up to 50% reduced odds of mild cognitive impairment.
Researchers here at the LOTME Lab have harnessed the power of these food studies to determine that a Philly cheesesteak with mushrooms and onions is the healthiest meal out there. Chow down!
As far as we know, all the mushrooms were standard edible fungi, and none were magic mushrooms (although, that might help, too; try that on your own time). Researchers believe that the compound ergothioneine, an antioxidant and anti-inflammatory that cannot be synthesized by humans, might be reason for the reduced risk of mild cognitive impairment Maybe it’s time to add a cup of cooked shiitake mushrooms to your morning routine.
Fuggedaboutit!
We all have unwanted memories that we’d rather forget about. An embarrassing incident, a painful experience – everyone has moments they’d rather not think about. So, the question is: How do you get rid of these bad memories?
The obvious solution is to stop thinking about it. But if you’re a regular reader of Livin’ on the MDedge, you can probably guess that the answer isn’t that simple.
And, in fact, it isn’t! A group of researchers at the University of Texas at Austin, has performed a study on intentional forgetting, and they found that the best way to forget something is ... to think about it. Study subjects were shown a series of images and told to either remember or forget those images while their ventral temporal cortex was monitored for activity. Not only were participants successfully able to forget images by thinking about it, but activity in the brain was higher when forgetting than while remembering.
Obviously, this research would be helpful for anyone dealing with trauma, and we hope doctors who have to treat such patients keep it in mind. Just don’t think about it too much, or you’ll forget about it.
The Golden Lobbyist
If you need health care in your neighborhood
Who you gonna call? Jack Nicklaus!
You need 20 mill to make it good
Who you gonna call? Jack Nicklaus!
Health care in general didn’t do very well in President Trump’s 2020 budget proposal; Medicare, Medicaid, and the National Cancer Institute were all targeted for cuts. But it did include one particular $20-million initiative for a mobile children’s hospital.
Politico reports that the nation’s golfer in chief “personally directed the Department of Health and Human Services to earmark the funds” after playing a couple of rounds with the Golden Bear himself, Jack Nicklaus. The mobile unit would be part of the Nicklaus Children’s Hospital in Miami. The golf legend turned lobbyist also had meetings off the course with HHS Secretary Alex Azar and then-OMB Director Mick Mulvaney.
Are health care ideas running through your head?
Who you gonna call? Jack Nicklaus!
He’ll golf with the prez, and get your bread
Who you gonna call? Jack Nicklaus!
He ain’t afraid of no tweets
What is your diagnosis?
A skin biopsy of one of the lesions on the right toe showed dermal edema with an associated lymphohistiocytic infiltrate. There are scattered areas of perieccrine involvement and areas of vasculitis. Laboratory work up showed a normal complete blood count, a negative antinuclear antibodies (ANA) titer, a negative double-stranded DNA, normal levels of inflammatory markers, and negative cryoglobulins and cold agglutinins. The patient was diagnosed with pernio. The lesions improved within several weeks. She now wears thicker socks when she is ice skating.
Children, women, and the elderly are at a higher risk.1 This condition is frequently described in Northwestern Europe and the United Kingdom, especially in those living in houses without central heating.2
Clinically, the lesions appear a few hours or days after cold exposure on the toes, fingers, and in some unusual cases on the nose and the ears. The lesions present as erythematous to violaceous macules, papules, or nodules that in severe cases may blister and ulcerate. The lesions may be asymptomatic, pruritic, or tender. In children, pernio can be associated with the presence of cryoglobulins, cold agglutinins, anorexia nervosa, and genetic interferonopathy; it may precede the diagnosis of chronic myelomonocytic leukemia and may occur as a presenting sign of a blast crisis in acute lymphoblastic leukemia.3,4 The skin lesions usually resolve within days to a few weeks. Histopathologic analysis shows dermal edema with associated superficial and deep lymphohistiocytic infiltrate and perieccrine involvement.
The differential diagnosis of pernio includes other cold-induced syndromes such as Raynaud’s syndrome, cold panniculitis, cold urticaria, livedo reticularis, acrocyanosis, and chilblain lupus. In chilblain lupus (a form of chronic cutaneous lupus), the lesions may be very similar to pernio but the histopathology is consistent with changes of discoid lupus. Lesions of idiopathic palmoplantar hidradenitis present as erythematous tender nodules on the palms and the soles.5 The lesions can be triggered by vigorous physical activity, exposure to moisture, and excessive sweating. White, blue, and red discoloration of the fingers is seen in Raynaud’s phenomenon rather than the fixed erythematous to violaceous macules, papules, or nodules seen in pernio. Patients with erythromelalgia present with red painful palms and soles triggered by heat and, in contrast to pernio, relieved by cooling. Sweet syndrome, a febrile neutrophilic dermatoses, is characterized by tender erythematous papules and plaques with associated systemic symptoms. These patients may have an associated internal malignancy or infection, or the disorder may be triggered by medications or pregnancy.
Our patient had no systemic symptoms, and the pathology didn’t show any neutrophils. When the diagnosis is in doubt, a skin biopsy may help elucidate the diagnosis.
Once the diagnosis of pernio is made, it is recommended to order a complete blood count to rule out blood malignancies and cryoproteins.
Treatment of this condition consists of rewarming the extremity. If rewarming does not improve the patient’s symptoms, systemic treatment with nifedipine may be warranted.
Dr. Matiz is a pediatric dermatologist at Southern California Permanente Medical Group, San Diego. Dr. Matiz said she had no relevant financial disclosures. Email her at pdnews@mdedge.com.
References
1. Pediatrics. 2005 Sep;116(3):e472-5.
2. Mayo Clin Proc. 2014 Feb;89(2):207-15.
3. Pediatr Dermatol. 2018 Jan;35(1):e74-5.
4. Pediatr Dermatol. 2000 Mar-Apr;17(2):97-9.
5. Eur J Pediatr. 2001 Mar;160(3):189-91.
A skin biopsy of one of the lesions on the right toe showed dermal edema with an associated lymphohistiocytic infiltrate. There are scattered areas of perieccrine involvement and areas of vasculitis. Laboratory work up showed a normal complete blood count, a negative antinuclear antibodies (ANA) titer, a negative double-stranded DNA, normal levels of inflammatory markers, and negative cryoglobulins and cold agglutinins. The patient was diagnosed with pernio. The lesions improved within several weeks. She now wears thicker socks when she is ice skating.
Children, women, and the elderly are at a higher risk.1 This condition is frequently described in Northwestern Europe and the United Kingdom, especially in those living in houses without central heating.2
Clinically, the lesions appear a few hours or days after cold exposure on the toes, fingers, and in some unusual cases on the nose and the ears. The lesions present as erythematous to violaceous macules, papules, or nodules that in severe cases may blister and ulcerate. The lesions may be asymptomatic, pruritic, or tender. In children, pernio can be associated with the presence of cryoglobulins, cold agglutinins, anorexia nervosa, and genetic interferonopathy; it may precede the diagnosis of chronic myelomonocytic leukemia and may occur as a presenting sign of a blast crisis in acute lymphoblastic leukemia.3,4 The skin lesions usually resolve within days to a few weeks. Histopathologic analysis shows dermal edema with associated superficial and deep lymphohistiocytic infiltrate and perieccrine involvement.
The differential diagnosis of pernio includes other cold-induced syndromes such as Raynaud’s syndrome, cold panniculitis, cold urticaria, livedo reticularis, acrocyanosis, and chilblain lupus. In chilblain lupus (a form of chronic cutaneous lupus), the lesions may be very similar to pernio but the histopathology is consistent with changes of discoid lupus. Lesions of idiopathic palmoplantar hidradenitis present as erythematous tender nodules on the palms and the soles.5 The lesions can be triggered by vigorous physical activity, exposure to moisture, and excessive sweating. White, blue, and red discoloration of the fingers is seen in Raynaud’s phenomenon rather than the fixed erythematous to violaceous macules, papules, or nodules seen in pernio. Patients with erythromelalgia present with red painful palms and soles triggered by heat and, in contrast to pernio, relieved by cooling. Sweet syndrome, a febrile neutrophilic dermatoses, is characterized by tender erythematous papules and plaques with associated systemic symptoms. These patients may have an associated internal malignancy or infection, or the disorder may be triggered by medications or pregnancy.
Our patient had no systemic symptoms, and the pathology didn’t show any neutrophils. When the diagnosis is in doubt, a skin biopsy may help elucidate the diagnosis.
Once the diagnosis of pernio is made, it is recommended to order a complete blood count to rule out blood malignancies and cryoproteins.
Treatment of this condition consists of rewarming the extremity. If rewarming does not improve the patient’s symptoms, systemic treatment with nifedipine may be warranted.
Dr. Matiz is a pediatric dermatologist at Southern California Permanente Medical Group, San Diego. Dr. Matiz said she had no relevant financial disclosures. Email her at pdnews@mdedge.com.
References
1. Pediatrics. 2005 Sep;116(3):e472-5.
2. Mayo Clin Proc. 2014 Feb;89(2):207-15.
3. Pediatr Dermatol. 2018 Jan;35(1):e74-5.
4. Pediatr Dermatol. 2000 Mar-Apr;17(2):97-9.
5. Eur J Pediatr. 2001 Mar;160(3):189-91.
A skin biopsy of one of the lesions on the right toe showed dermal edema with an associated lymphohistiocytic infiltrate. There are scattered areas of perieccrine involvement and areas of vasculitis. Laboratory work up showed a normal complete blood count, a negative antinuclear antibodies (ANA) titer, a negative double-stranded DNA, normal levels of inflammatory markers, and negative cryoglobulins and cold agglutinins. The patient was diagnosed with pernio. The lesions improved within several weeks. She now wears thicker socks when she is ice skating.
Children, women, and the elderly are at a higher risk.1 This condition is frequently described in Northwestern Europe and the United Kingdom, especially in those living in houses without central heating.2
Clinically, the lesions appear a few hours or days after cold exposure on the toes, fingers, and in some unusual cases on the nose and the ears. The lesions present as erythematous to violaceous macules, papules, or nodules that in severe cases may blister and ulcerate. The lesions may be asymptomatic, pruritic, or tender. In children, pernio can be associated with the presence of cryoglobulins, cold agglutinins, anorexia nervosa, and genetic interferonopathy; it may precede the diagnosis of chronic myelomonocytic leukemia and may occur as a presenting sign of a blast crisis in acute lymphoblastic leukemia.3,4 The skin lesions usually resolve within days to a few weeks. Histopathologic analysis shows dermal edema with associated superficial and deep lymphohistiocytic infiltrate and perieccrine involvement.
The differential diagnosis of pernio includes other cold-induced syndromes such as Raynaud’s syndrome, cold panniculitis, cold urticaria, livedo reticularis, acrocyanosis, and chilblain lupus. In chilblain lupus (a form of chronic cutaneous lupus), the lesions may be very similar to pernio but the histopathology is consistent with changes of discoid lupus. Lesions of idiopathic palmoplantar hidradenitis present as erythematous tender nodules on the palms and the soles.5 The lesions can be triggered by vigorous physical activity, exposure to moisture, and excessive sweating. White, blue, and red discoloration of the fingers is seen in Raynaud’s phenomenon rather than the fixed erythematous to violaceous macules, papules, or nodules seen in pernio. Patients with erythromelalgia present with red painful palms and soles triggered by heat and, in contrast to pernio, relieved by cooling. Sweet syndrome, a febrile neutrophilic dermatoses, is characterized by tender erythematous papules and plaques with associated systemic symptoms. These patients may have an associated internal malignancy or infection, or the disorder may be triggered by medications or pregnancy.
Our patient had no systemic symptoms, and the pathology didn’t show any neutrophils. When the diagnosis is in doubt, a skin biopsy may help elucidate the diagnosis.
Once the diagnosis of pernio is made, it is recommended to order a complete blood count to rule out blood malignancies and cryoproteins.
Treatment of this condition consists of rewarming the extremity. If rewarming does not improve the patient’s symptoms, systemic treatment with nifedipine may be warranted.
Dr. Matiz is a pediatric dermatologist at Southern California Permanente Medical Group, San Diego. Dr. Matiz said she had no relevant financial disclosures. Email her at pdnews@mdedge.com.
References
1. Pediatrics. 2005 Sep;116(3):e472-5.
2. Mayo Clin Proc. 2014 Feb;89(2):207-15.
3. Pediatr Dermatol. 2018 Jan;35(1):e74-5.
4. Pediatr Dermatol. 2000 Mar-Apr;17(2):97-9.
5. Eur J Pediatr. 2001 Mar;160(3):189-91.
An 8-year-old girl comes to our pediatric dermatology clinic in the company of her mother for evaluation of painless purple spots on her toes. The lesions have been present for about 2 weeks. She has not been treated with any medications or creams. She denies any fevers, weight loss, mouth ulcers, sun sensitivity, joint pain, or any other symptoms. The patient has been a very healthy girl with occasional colds and no recent illnesses. The girl has never been admitted to the hospital. All her vaccinations are up to date. She takes no chronic medications. She lives in San Diego with her parents and two siblings. The girl recently started practicing ice-skating several times a week. There is no family history of any chronic medical conditions. She has no pets.
Continuers vs Discontinuers of DMT in MS Aged >60
Most patients with multiple sclerosis (MS) aged >60 who discontinued disease modifying therapy (DMT) remained off treatment, a recent study found. Among the outcomes, only the European Quality of Life 5 Dimensions (EQ-5D) index demonstrated significant differences over time, with continuers having lower quality of life scores compared to discontinuers before discontinuation (DBD). Researchers conducted a retrospective, observational study in which they identified patients from MS clinics aged ≥60 years who had been on DMT ≥2 years. They compared outcome evolution over time among treatment groups (continuers, DBD), and discontinuers after discontinuation [DAD]), by creating separate mixed-effects linear regression models that included an interaction term between time from age 60 and treatment group to study outcome trajectories. They found:
- 178 of 600 patients discontinued DMT, and 89.3% (n=159) of those who discontinued remained off DMT.
- Only the EQ-5D mixed-effects linear regression model with the interaction term was statistically significant.
- The slope relating time to EQ-5D was significantly different when comparing continuers to DBD.
- The slopes were not significantly different when comparing continuers to DAD, or when comparing the before and after discontinuation slopes among the discontinuers.
Hua LH, Harris H, Conway D, Thompson NR. Changes in patient-reported outcomes between continuers and discontinuers of disease modifying therapy in patients with multiple sclerosis over age 60. [Published online ahead of print March 1, 2019]. Mult Scler Relat Disord. doi:10.1016/j.msard.2019.02.028.
Most patients with multiple sclerosis (MS) aged >60 who discontinued disease modifying therapy (DMT) remained off treatment, a recent study found. Among the outcomes, only the European Quality of Life 5 Dimensions (EQ-5D) index demonstrated significant differences over time, with continuers having lower quality of life scores compared to discontinuers before discontinuation (DBD). Researchers conducted a retrospective, observational study in which they identified patients from MS clinics aged ≥60 years who had been on DMT ≥2 years. They compared outcome evolution over time among treatment groups (continuers, DBD), and discontinuers after discontinuation [DAD]), by creating separate mixed-effects linear regression models that included an interaction term between time from age 60 and treatment group to study outcome trajectories. They found:
- 178 of 600 patients discontinued DMT, and 89.3% (n=159) of those who discontinued remained off DMT.
- Only the EQ-5D mixed-effects linear regression model with the interaction term was statistically significant.
- The slope relating time to EQ-5D was significantly different when comparing continuers to DBD.
- The slopes were not significantly different when comparing continuers to DAD, or when comparing the before and after discontinuation slopes among the discontinuers.
Hua LH, Harris H, Conway D, Thompson NR. Changes in patient-reported outcomes between continuers and discontinuers of disease modifying therapy in patients with multiple sclerosis over age 60. [Published online ahead of print March 1, 2019]. Mult Scler Relat Disord. doi:10.1016/j.msard.2019.02.028.
Most patients with multiple sclerosis (MS) aged >60 who discontinued disease modifying therapy (DMT) remained off treatment, a recent study found. Among the outcomes, only the European Quality of Life 5 Dimensions (EQ-5D) index demonstrated significant differences over time, with continuers having lower quality of life scores compared to discontinuers before discontinuation (DBD). Researchers conducted a retrospective, observational study in which they identified patients from MS clinics aged ≥60 years who had been on DMT ≥2 years. They compared outcome evolution over time among treatment groups (continuers, DBD), and discontinuers after discontinuation [DAD]), by creating separate mixed-effects linear regression models that included an interaction term between time from age 60 and treatment group to study outcome trajectories. They found:
- 178 of 600 patients discontinued DMT, and 89.3% (n=159) of those who discontinued remained off DMT.
- Only the EQ-5D mixed-effects linear regression model with the interaction term was statistically significant.
- The slope relating time to EQ-5D was significantly different when comparing continuers to DBD.
- The slopes were not significantly different when comparing continuers to DAD, or when comparing the before and after discontinuation slopes among the discontinuers.
Hua LH, Harris H, Conway D, Thompson NR. Changes in patient-reported outcomes between continuers and discontinuers of disease modifying therapy in patients with multiple sclerosis over age 60. [Published online ahead of print March 1, 2019]. Mult Scler Relat Disord. doi:10.1016/j.msard.2019.02.028.
Aerobic Fitness and Activities of Daily Living in MS
Recent findings support previous studies on the activities of daily living in people with multiple sclerosis (MS) and the effect of aerobic exercise on independence regarding instrumental activities of daily living (IADLs) in this population. 62 adults with MS completed an incremental exercise test as a measure of aerobic fitness (peak oxygen consumption), a demographic questionnaire, and an IADL scale and underwent a neurologic examination for characterization of disability level (ie, Expanded Disability Status Scale) in a single session. Researchers found:
- The analysis revealed a weak but significant association between aerobic fitness and total IADL score (r=0.28).
- Those reporting dependence in different IADL categories (eg, shopping, food preparation, housekeeping, laundry, and responsibility for own medication) presented with lower aerobic fitness compared with those reporting independence, although the difference was not statistically significant.
Sebastião E, Pilutti LA, Motl RW. Aerobic fitness and instrumental activities of daily living in people with multiple sclerosis. A cross-sectional study. Int J MS Care. 2019;21(1):23-28. doi:10.7224/1537-2073.2017-078.
Recent findings support previous studies on the activities of daily living in people with multiple sclerosis (MS) and the effect of aerobic exercise on independence regarding instrumental activities of daily living (IADLs) in this population. 62 adults with MS completed an incremental exercise test as a measure of aerobic fitness (peak oxygen consumption), a demographic questionnaire, and an IADL scale and underwent a neurologic examination for characterization of disability level (ie, Expanded Disability Status Scale) in a single session. Researchers found:
- The analysis revealed a weak but significant association between aerobic fitness and total IADL score (r=0.28).
- Those reporting dependence in different IADL categories (eg, shopping, food preparation, housekeeping, laundry, and responsibility for own medication) presented with lower aerobic fitness compared with those reporting independence, although the difference was not statistically significant.
Sebastião E, Pilutti LA, Motl RW. Aerobic fitness and instrumental activities of daily living in people with multiple sclerosis. A cross-sectional study. Int J MS Care. 2019;21(1):23-28. doi:10.7224/1537-2073.2017-078.
Recent findings support previous studies on the activities of daily living in people with multiple sclerosis (MS) and the effect of aerobic exercise on independence regarding instrumental activities of daily living (IADLs) in this population. 62 adults with MS completed an incremental exercise test as a measure of aerobic fitness (peak oxygen consumption), a demographic questionnaire, and an IADL scale and underwent a neurologic examination for characterization of disability level (ie, Expanded Disability Status Scale) in a single session. Researchers found:
- The analysis revealed a weak but significant association between aerobic fitness and total IADL score (r=0.28).
- Those reporting dependence in different IADL categories (eg, shopping, food preparation, housekeeping, laundry, and responsibility for own medication) presented with lower aerobic fitness compared with those reporting independence, although the difference was not statistically significant.
Sebastião E, Pilutti LA, Motl RW. Aerobic fitness and instrumental activities of daily living in people with multiple sclerosis. A cross-sectional study. Int J MS Care. 2019;21(1):23-28. doi:10.7224/1537-2073.2017-078.