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Dopamine synthesis capacity appears linked to psychosis in bipolar disorder
Increased dopamine synthesis – a feature classically associated with schizophrenia – might underlie bipolar psychosis, a new study suggests.
To conduct the cross-sectional case-control study, Sameer Jauhar, MRCPsych, and his associates recruited 60 people from first-episode psychosis services in London – 22 with bipolar psychosis, 16 with schizophrenia, and 22 matched controls. Of the 22 with bipolar psychosis, 18 were antipsychotic-naïve or free, and of the 16 patients with schizophrenia, 14 were antipsychotic-naïve (JAMA Psychiatry. 2017 Oct 11. doi: 10.1001/jamapsychiatry.2017.2943). The researchers used fluorodihydroxyphenyl-L-alanine ([18F]-DOPA) positron emission tomography to study dopamine synthesis capacity in the participants.
The study showed that mean dopamine synthesis capacity in the striatum was significantly higher both in the bipolar group and the schizophrenia group, compared with controls – even after excluding individuals taking antipsychotic medication.
“These results extend previous findings that dopamine synthesis capacity is elevated in schizophrenia and psychosis associated with temporal lobe epilepsy and increases with the onset of psychosis, suggesting that presynaptic dopamine dysfunction is associated with psychosis across diagnostic categories,” wrote Dr. Jauhar, who is affiliated with the Institute of Psychiatry, Psychology & Neuroscience at King’s College, London, and his coauthors.
In addition, Dr. Jauhar and his coauthors found a significant relationship between mean whole striatal dopamine synthesis capacity and Positive and Negative Syndrome Scale (PANSS) scores in the group of patients who was experiencing a psychotic episode at the time of the study, which overall explained 27% of the variance.
In the bipolar disorder group, there was a nonsignificant relationship between whole striatal dopamine synthesis capacity and the PANSS positive subscale symptom severity score. However, this became significant when the analysis was restricted to patients who were experiencing a current psychotic episode and accounted for 36% of the variance in psychotic symptoms.
But this effect was not seen in patients with schizophrenia – all of whom were experiencing a psychotic episode at the time.
“Our finding of a relationship between positive psychotic symptoms and dopamine synthesis capacity in the combined bipolar and schizophrenia sample but not in the schizophrenia group could be due to a lack of power or inclusion of more patients with longer illness durations in the schizophrenia group,” the researchers reported.
Overall, no significant difference was found in mean dopamine synthesis capacity between patients with bipolar disorder and those with schizophrenia.
The authors also controlled for duration of illness, given that those in the schizophrenia group had a longer duration of illness than those in the bipolar group, with no effect on mean dopamine synthesis capacity differences between the two. The effect was seen in the whole striatum, the associative striatum, the limbic striatum, and the sensorimotor striatum.
“Relative to controls, the subregional analyses showed significant elevations in all three functional striatal subdivisions in the bipolar group but only a suggestion in the associative striatum in the schizophrenia group, with no differences in the substantia nigra for either group,” the authors wrote.
The authors acknowledged one concern with using patients experiencing a first episode of psychosis was that their diagnoses may change over time. But even after a minimum of 18 months’ follow-up, none of the original diagnoses had changed, and they had even been strengthened by the difference in negative but not positive symptoms.
The outcome measure used – KiCER – was an index for the uptake of [18F]-DOPA into dopamine neurons, and its conversion into [18F]-dopamine and storage in terminals. “Therefore, the increased KiCER we report likely reflects an increase in one or more of these processes, as well as a net increase in dopamine synthesis capacity,” they wrote.
“This finding provides a potential neurobiological explanation for why antipsychotic drugs, which are all dopamine D2/D3 receptor blockers, are effective in bipolar psychosis and schizophrenia and identifies the regulation of dopamine synthesis as a potential novel drug target for bipolar disorder and schizophrenia.” Furthermore, they said, the findings suggest that dopamine synthesis capacity might be a drug target for bipolar disorder and schizophrenia.
The study was supported by several entities, including the Medical Research Council, the U.S. Brain & Behavior Research Foundation, the Wellcome Trust, and the National Institute for Health Research Biomedical Research Centre at South London. Three authors declared research funding, advisory or speaker engagements, or lecture payments from a variety of pharmaceutical companies. No other conflicts of interest were declared.
Some empirical evidence suggests that “schizophrenia and bipolar disorder exist along a psychosis continuum, with some patients having more affective features and others having more psychotic features,” Dost Öngür, MD, PhD, wrote in an accompanying editorial (JAMA Psychiatry. 2017 Oct 11. doi: 10.1001/jamapsychiatry.2017.2330). However, the study by Dr. Jauhar and his associates show that both illnesses are similar when it comes to dopaminergic dysfunction.
“Clinical experience is perhaps more consistent with a model including not one but two dimensions, namely, affective and psychotic,” Dr. Öngür wrote. “This is because more severe psychosis does not always indicate less severe affective illness; affective syndromes of variable intensity are seen among patients with severe psychosis and vice versa.”
Future studies could seek to quantify the psychosis dimension with the ultimate goal of “developing a more valid classification system for psychotic disorders,” he wrote.
Dr. Öngür is affiliated with the department of psychiatry at McLean Hospital and Harvard Medical School, both in Boston. He reported serving on a scientific advisory board for Neurocrine Biosciences.
Some empirical evidence suggests that “schizophrenia and bipolar disorder exist along a psychosis continuum, with some patients having more affective features and others having more psychotic features,” Dost Öngür, MD, PhD, wrote in an accompanying editorial (JAMA Psychiatry. 2017 Oct 11. doi: 10.1001/jamapsychiatry.2017.2330). However, the study by Dr. Jauhar and his associates show that both illnesses are similar when it comes to dopaminergic dysfunction.
“Clinical experience is perhaps more consistent with a model including not one but two dimensions, namely, affective and psychotic,” Dr. Öngür wrote. “This is because more severe psychosis does not always indicate less severe affective illness; affective syndromes of variable intensity are seen among patients with severe psychosis and vice versa.”
Future studies could seek to quantify the psychosis dimension with the ultimate goal of “developing a more valid classification system for psychotic disorders,” he wrote.
Dr. Öngür is affiliated with the department of psychiatry at McLean Hospital and Harvard Medical School, both in Boston. He reported serving on a scientific advisory board for Neurocrine Biosciences.
Some empirical evidence suggests that “schizophrenia and bipolar disorder exist along a psychosis continuum, with some patients having more affective features and others having more psychotic features,” Dost Öngür, MD, PhD, wrote in an accompanying editorial (JAMA Psychiatry. 2017 Oct 11. doi: 10.1001/jamapsychiatry.2017.2330). However, the study by Dr. Jauhar and his associates show that both illnesses are similar when it comes to dopaminergic dysfunction.
“Clinical experience is perhaps more consistent with a model including not one but two dimensions, namely, affective and psychotic,” Dr. Öngür wrote. “This is because more severe psychosis does not always indicate less severe affective illness; affective syndromes of variable intensity are seen among patients with severe psychosis and vice versa.”
Future studies could seek to quantify the psychosis dimension with the ultimate goal of “developing a more valid classification system for psychotic disorders,” he wrote.
Dr. Öngür is affiliated with the department of psychiatry at McLean Hospital and Harvard Medical School, both in Boston. He reported serving on a scientific advisory board for Neurocrine Biosciences.
Increased dopamine synthesis – a feature classically associated with schizophrenia – might underlie bipolar psychosis, a new study suggests.
To conduct the cross-sectional case-control study, Sameer Jauhar, MRCPsych, and his associates recruited 60 people from first-episode psychosis services in London – 22 with bipolar psychosis, 16 with schizophrenia, and 22 matched controls. Of the 22 with bipolar psychosis, 18 were antipsychotic-naïve or free, and of the 16 patients with schizophrenia, 14 were antipsychotic-naïve (JAMA Psychiatry. 2017 Oct 11. doi: 10.1001/jamapsychiatry.2017.2943). The researchers used fluorodihydroxyphenyl-L-alanine ([18F]-DOPA) positron emission tomography to study dopamine synthesis capacity in the participants.
The study showed that mean dopamine synthesis capacity in the striatum was significantly higher both in the bipolar group and the schizophrenia group, compared with controls – even after excluding individuals taking antipsychotic medication.
“These results extend previous findings that dopamine synthesis capacity is elevated in schizophrenia and psychosis associated with temporal lobe epilepsy and increases with the onset of psychosis, suggesting that presynaptic dopamine dysfunction is associated with psychosis across diagnostic categories,” wrote Dr. Jauhar, who is affiliated with the Institute of Psychiatry, Psychology & Neuroscience at King’s College, London, and his coauthors.
In addition, Dr. Jauhar and his coauthors found a significant relationship between mean whole striatal dopamine synthesis capacity and Positive and Negative Syndrome Scale (PANSS) scores in the group of patients who was experiencing a psychotic episode at the time of the study, which overall explained 27% of the variance.
In the bipolar disorder group, there was a nonsignificant relationship between whole striatal dopamine synthesis capacity and the PANSS positive subscale symptom severity score. However, this became significant when the analysis was restricted to patients who were experiencing a current psychotic episode and accounted for 36% of the variance in psychotic symptoms.
But this effect was not seen in patients with schizophrenia – all of whom were experiencing a psychotic episode at the time.
“Our finding of a relationship between positive psychotic symptoms and dopamine synthesis capacity in the combined bipolar and schizophrenia sample but not in the schizophrenia group could be due to a lack of power or inclusion of more patients with longer illness durations in the schizophrenia group,” the researchers reported.
Overall, no significant difference was found in mean dopamine synthesis capacity between patients with bipolar disorder and those with schizophrenia.
The authors also controlled for duration of illness, given that those in the schizophrenia group had a longer duration of illness than those in the bipolar group, with no effect on mean dopamine synthesis capacity differences between the two. The effect was seen in the whole striatum, the associative striatum, the limbic striatum, and the sensorimotor striatum.
“Relative to controls, the subregional analyses showed significant elevations in all three functional striatal subdivisions in the bipolar group but only a suggestion in the associative striatum in the schizophrenia group, with no differences in the substantia nigra for either group,” the authors wrote.
The authors acknowledged one concern with using patients experiencing a first episode of psychosis was that their diagnoses may change over time. But even after a minimum of 18 months’ follow-up, none of the original diagnoses had changed, and they had even been strengthened by the difference in negative but not positive symptoms.
The outcome measure used – KiCER – was an index for the uptake of [18F]-DOPA into dopamine neurons, and its conversion into [18F]-dopamine and storage in terminals. “Therefore, the increased KiCER we report likely reflects an increase in one or more of these processes, as well as a net increase in dopamine synthesis capacity,” they wrote.
“This finding provides a potential neurobiological explanation for why antipsychotic drugs, which are all dopamine D2/D3 receptor blockers, are effective in bipolar psychosis and schizophrenia and identifies the regulation of dopamine synthesis as a potential novel drug target for bipolar disorder and schizophrenia.” Furthermore, they said, the findings suggest that dopamine synthesis capacity might be a drug target for bipolar disorder and schizophrenia.
The study was supported by several entities, including the Medical Research Council, the U.S. Brain & Behavior Research Foundation, the Wellcome Trust, and the National Institute for Health Research Biomedical Research Centre at South London. Three authors declared research funding, advisory or speaker engagements, or lecture payments from a variety of pharmaceutical companies. No other conflicts of interest were declared.
Increased dopamine synthesis – a feature classically associated with schizophrenia – might underlie bipolar psychosis, a new study suggests.
To conduct the cross-sectional case-control study, Sameer Jauhar, MRCPsych, and his associates recruited 60 people from first-episode psychosis services in London – 22 with bipolar psychosis, 16 with schizophrenia, and 22 matched controls. Of the 22 with bipolar psychosis, 18 were antipsychotic-naïve or free, and of the 16 patients with schizophrenia, 14 were antipsychotic-naïve (JAMA Psychiatry. 2017 Oct 11. doi: 10.1001/jamapsychiatry.2017.2943). The researchers used fluorodihydroxyphenyl-L-alanine ([18F]-DOPA) positron emission tomography to study dopamine synthesis capacity in the participants.
The study showed that mean dopamine synthesis capacity in the striatum was significantly higher both in the bipolar group and the schizophrenia group, compared with controls – even after excluding individuals taking antipsychotic medication.
“These results extend previous findings that dopamine synthesis capacity is elevated in schizophrenia and psychosis associated with temporal lobe epilepsy and increases with the onset of psychosis, suggesting that presynaptic dopamine dysfunction is associated with psychosis across diagnostic categories,” wrote Dr. Jauhar, who is affiliated with the Institute of Psychiatry, Psychology & Neuroscience at King’s College, London, and his coauthors.
In addition, Dr. Jauhar and his coauthors found a significant relationship between mean whole striatal dopamine synthesis capacity and Positive and Negative Syndrome Scale (PANSS) scores in the group of patients who was experiencing a psychotic episode at the time of the study, which overall explained 27% of the variance.
In the bipolar disorder group, there was a nonsignificant relationship between whole striatal dopamine synthesis capacity and the PANSS positive subscale symptom severity score. However, this became significant when the analysis was restricted to patients who were experiencing a current psychotic episode and accounted for 36% of the variance in psychotic symptoms.
But this effect was not seen in patients with schizophrenia – all of whom were experiencing a psychotic episode at the time.
“Our finding of a relationship between positive psychotic symptoms and dopamine synthesis capacity in the combined bipolar and schizophrenia sample but not in the schizophrenia group could be due to a lack of power or inclusion of more patients with longer illness durations in the schizophrenia group,” the researchers reported.
Overall, no significant difference was found in mean dopamine synthesis capacity between patients with bipolar disorder and those with schizophrenia.
The authors also controlled for duration of illness, given that those in the schizophrenia group had a longer duration of illness than those in the bipolar group, with no effect on mean dopamine synthesis capacity differences between the two. The effect was seen in the whole striatum, the associative striatum, the limbic striatum, and the sensorimotor striatum.
“Relative to controls, the subregional analyses showed significant elevations in all three functional striatal subdivisions in the bipolar group but only a suggestion in the associative striatum in the schizophrenia group, with no differences in the substantia nigra for either group,” the authors wrote.
The authors acknowledged one concern with using patients experiencing a first episode of psychosis was that their diagnoses may change over time. But even after a minimum of 18 months’ follow-up, none of the original diagnoses had changed, and they had even been strengthened by the difference in negative but not positive symptoms.
The outcome measure used – KiCER – was an index for the uptake of [18F]-DOPA into dopamine neurons, and its conversion into [18F]-dopamine and storage in terminals. “Therefore, the increased KiCER we report likely reflects an increase in one or more of these processes, as well as a net increase in dopamine synthesis capacity,” they wrote.
“This finding provides a potential neurobiological explanation for why antipsychotic drugs, which are all dopamine D2/D3 receptor blockers, are effective in bipolar psychosis and schizophrenia and identifies the regulation of dopamine synthesis as a potential novel drug target for bipolar disorder and schizophrenia.” Furthermore, they said, the findings suggest that dopamine synthesis capacity might be a drug target for bipolar disorder and schizophrenia.
The study was supported by several entities, including the Medical Research Council, the U.S. Brain & Behavior Research Foundation, the Wellcome Trust, and the National Institute for Health Research Biomedical Research Centre at South London. Three authors declared research funding, advisory or speaker engagements, or lecture payments from a variety of pharmaceutical companies. No other conflicts of interest were declared.
FROM JAMA PSYCHIATRY
Key clinical point: Dopamine synthesis capacity is elevated in individuals with bipolar disorder, particularly those experiencing a psychotic episode.
Major finding: Individuals with bipolar disorder have a similarly elevated dopamine synthesis capacity as individuals with schizophrenia.
Data source: Positron emission tomography study in 22 individuals with bipolar disorder, 16 with schizophrenia, and 22 controls.
Disclosures: The study was supported by several entities, including the Medical Research Council, the U.S. Brain & Behavior Research Foundation, the Wellcome Trust, and the National Institute for Health Research Biomedical Research Centre at South London. Three authors declared research funding, advisory or speaker engagements, or lecture payments from a variety of pharmaceutical companies. No other conflicts of interest were declared.
VIDEO: New herpes zoster vaccine may boost vaccination rate
LAS VEGAS – One of the benefits of the recently approved inactivated herpes zoster is its efficacy in older adults, Kenneth J. Tomecki, MD, said in a video interview at Skin Disease Education Foundation’s annual Las Vegas Dermatology Seminar.
In addition, the vaccine will be recommended not only for healthy adults, but for ill adults aged 50 years and older, said Dr. Tomecki of the department of dermatology at the Cleveland Clinic. “Efficacy is greater than 90% for zoster and postherpetic neuralgia” with the new vaccine, he added.
Vaccination rates among eligible adults with the current vaccine, which is highly effective, are low, but ideally, the advent of the new vaccine will boost vaccination rates, especially in older adults, he noted.
for preventing herpes zoster in adults aged 50 years and older. The currently available herpes zoster vaccine, Zostavax, a live attenuated virus vaccine, was approved by the FDA in 2006.
Dr. Tomecki had no financial conflicts to disclose.
SDEF and this news organization are owned by the same parent company.
LAS VEGAS – One of the benefits of the recently approved inactivated herpes zoster is its efficacy in older adults, Kenneth J. Tomecki, MD, said in a video interview at Skin Disease Education Foundation’s annual Las Vegas Dermatology Seminar.
In addition, the vaccine will be recommended not only for healthy adults, but for ill adults aged 50 years and older, said Dr. Tomecki of the department of dermatology at the Cleveland Clinic. “Efficacy is greater than 90% for zoster and postherpetic neuralgia” with the new vaccine, he added.
Vaccination rates among eligible adults with the current vaccine, which is highly effective, are low, but ideally, the advent of the new vaccine will boost vaccination rates, especially in older adults, he noted.
for preventing herpes zoster in adults aged 50 years and older. The currently available herpes zoster vaccine, Zostavax, a live attenuated virus vaccine, was approved by the FDA in 2006.
Dr. Tomecki had no financial conflicts to disclose.
SDEF and this news organization are owned by the same parent company.
LAS VEGAS – One of the benefits of the recently approved inactivated herpes zoster is its efficacy in older adults, Kenneth J. Tomecki, MD, said in a video interview at Skin Disease Education Foundation’s annual Las Vegas Dermatology Seminar.
In addition, the vaccine will be recommended not only for healthy adults, but for ill adults aged 50 years and older, said Dr. Tomecki of the department of dermatology at the Cleveland Clinic. “Efficacy is greater than 90% for zoster and postherpetic neuralgia” with the new vaccine, he added.
Vaccination rates among eligible adults with the current vaccine, which is highly effective, are low, but ideally, the advent of the new vaccine will boost vaccination rates, especially in older adults, he noted.
for preventing herpes zoster in adults aged 50 years and older. The currently available herpes zoster vaccine, Zostavax, a live attenuated virus vaccine, was approved by the FDA in 2006.
Dr. Tomecki had no financial conflicts to disclose.
SDEF and this news organization are owned by the same parent company.
AT SDEF LAS VEGAS DERMATOLOGY SEMINAR
VIDEO: Consider a multifaceted acne treatment approach to achieve clear skin
LAS VEGAS – Patients with acne don’t want to be better, they want to be clear, Julie Harper, MD, said at Skin Disease Education Foundation’s annual Las Vegas Dermatology Seminar.
Even one lesion on the face can ruin someone’s day, said Dr. Harper, a dermatologist in private practice in Birmingham, Ala., and an author of the 2016 American Academy of Dermatology’s acne management treatment guidelines. Clinicians need to think outside the box and consider a combination of treatments, and they should not underestimate the potential role of oral contraceptives as part of an acne treatment plan, she added.
“As a specialty, we need to learn how to really clear acne,” she said in a video interview. “People don’t want to be 50% better, they want to be clear.”
Dr. Harper disclosed relationships with multiple companies including Allergan, Bayer, Galderma, La Roche-Posay, Promius, and Valeant.
SDEF and this news organization are owned by the same parent company.
LAS VEGAS – Patients with acne don’t want to be better, they want to be clear, Julie Harper, MD, said at Skin Disease Education Foundation’s annual Las Vegas Dermatology Seminar.
Even one lesion on the face can ruin someone’s day, said Dr. Harper, a dermatologist in private practice in Birmingham, Ala., and an author of the 2016 American Academy of Dermatology’s acne management treatment guidelines. Clinicians need to think outside the box and consider a combination of treatments, and they should not underestimate the potential role of oral contraceptives as part of an acne treatment plan, she added.
“As a specialty, we need to learn how to really clear acne,” she said in a video interview. “People don’t want to be 50% better, they want to be clear.”
Dr. Harper disclosed relationships with multiple companies including Allergan, Bayer, Galderma, La Roche-Posay, Promius, and Valeant.
SDEF and this news organization are owned by the same parent company.
LAS VEGAS – Patients with acne don’t want to be better, they want to be clear, Julie Harper, MD, said at Skin Disease Education Foundation’s annual Las Vegas Dermatology Seminar.
Even one lesion on the face can ruin someone’s day, said Dr. Harper, a dermatologist in private practice in Birmingham, Ala., and an author of the 2016 American Academy of Dermatology’s acne management treatment guidelines. Clinicians need to think outside the box and consider a combination of treatments, and they should not underestimate the potential role of oral contraceptives as part of an acne treatment plan, she added.
“As a specialty, we need to learn how to really clear acne,” she said in a video interview. “People don’t want to be 50% better, they want to be clear.”
Dr. Harper disclosed relationships with multiple companies including Allergan, Bayer, Galderma, La Roche-Posay, Promius, and Valeant.
SDEF and this news organization are owned by the same parent company.
AT SDEF LAS VEGAS DERMATOLOGY SEMINAR
Mortality risks associated with emergency admission during weekends and public holidays
Clinical question: What factors contribute to increased mortality in weekend hospital admissions?
Background: The “weekend effect” is a commonly known phenomenon, where patients admitted to the hospital on weekends have higher mortality risk than those admitted on weekdays. However, little is known about the factors contributing to the excess mortality associated with weekend admissions.
Setting: Four Oxford University National Health Service hospitals in the United Kingdom (a district general hospital, a large teaching hospital, a specialist orthopedic hospital, and a major cancer center).
Synopsis: Data from the Infections in Oxfordshire Research Database of 503,938 admissions between Jan. 1, 2006, and Dec. 31, 2014 were analyzed. Thirty-day mortality was 4.7%, 5.1%, and 5.8% for patients admitted during weekdays, weekends, and public holidays, respectively (P less than .0001). Fifteen routine hematology and biochemistry test results were determined to be prognostic of high mortality risk. Adjustment for these routine test results reduced excess mortality associated with emergency admissions on weekends and public holidays. Excess mortality was notable for patients admitted on Saturdays and Sundays between 11:00 a.m. and 3:00 p.m. Hospital staffing and workload were not associated with excess mortality. The study is limited by a lack of additional patient factors such as vital signs and blood gas results that may further explain excess mortality on weekends and public holidays.
Bottom line: Patient factors, including laboratory abnormalities, rather than hospital workload and staffing may be the major contributing factors for the excess mortality seen for emergency admissions on weekends and public holidays.
Citation: Walker AS, Mason A, Quan TP, et al. Mortality risks associated with emergency admissions during weekends and public holidays: An analysis of electronic health records. The Lancet. 2017;390(10089):62-72.
Dr. Xu is assistant professor and hospitalist, Icahn School of Medicine of the Mount Sinai Health System, New York.
Clinical question: What factors contribute to increased mortality in weekend hospital admissions?
Background: The “weekend effect” is a commonly known phenomenon, where patients admitted to the hospital on weekends have higher mortality risk than those admitted on weekdays. However, little is known about the factors contributing to the excess mortality associated with weekend admissions.
Setting: Four Oxford University National Health Service hospitals in the United Kingdom (a district general hospital, a large teaching hospital, a specialist orthopedic hospital, and a major cancer center).
Synopsis: Data from the Infections in Oxfordshire Research Database of 503,938 admissions between Jan. 1, 2006, and Dec. 31, 2014 were analyzed. Thirty-day mortality was 4.7%, 5.1%, and 5.8% for patients admitted during weekdays, weekends, and public holidays, respectively (P less than .0001). Fifteen routine hematology and biochemistry test results were determined to be prognostic of high mortality risk. Adjustment for these routine test results reduced excess mortality associated with emergency admissions on weekends and public holidays. Excess mortality was notable for patients admitted on Saturdays and Sundays between 11:00 a.m. and 3:00 p.m. Hospital staffing and workload were not associated with excess mortality. The study is limited by a lack of additional patient factors such as vital signs and blood gas results that may further explain excess mortality on weekends and public holidays.
Bottom line: Patient factors, including laboratory abnormalities, rather than hospital workload and staffing may be the major contributing factors for the excess mortality seen for emergency admissions on weekends and public holidays.
Citation: Walker AS, Mason A, Quan TP, et al. Mortality risks associated with emergency admissions during weekends and public holidays: An analysis of electronic health records. The Lancet. 2017;390(10089):62-72.
Dr. Xu is assistant professor and hospitalist, Icahn School of Medicine of the Mount Sinai Health System, New York.
Clinical question: What factors contribute to increased mortality in weekend hospital admissions?
Background: The “weekend effect” is a commonly known phenomenon, where patients admitted to the hospital on weekends have higher mortality risk than those admitted on weekdays. However, little is known about the factors contributing to the excess mortality associated with weekend admissions.
Setting: Four Oxford University National Health Service hospitals in the United Kingdom (a district general hospital, a large teaching hospital, a specialist orthopedic hospital, and a major cancer center).
Synopsis: Data from the Infections in Oxfordshire Research Database of 503,938 admissions between Jan. 1, 2006, and Dec. 31, 2014 were analyzed. Thirty-day mortality was 4.7%, 5.1%, and 5.8% for patients admitted during weekdays, weekends, and public holidays, respectively (P less than .0001). Fifteen routine hematology and biochemistry test results were determined to be prognostic of high mortality risk. Adjustment for these routine test results reduced excess mortality associated with emergency admissions on weekends and public holidays. Excess mortality was notable for patients admitted on Saturdays and Sundays between 11:00 a.m. and 3:00 p.m. Hospital staffing and workload were not associated with excess mortality. The study is limited by a lack of additional patient factors such as vital signs and blood gas results that may further explain excess mortality on weekends and public holidays.
Bottom line: Patient factors, including laboratory abnormalities, rather than hospital workload and staffing may be the major contributing factors for the excess mortality seen for emergency admissions on weekends and public holidays.
Citation: Walker AS, Mason A, Quan TP, et al. Mortality risks associated with emergency admissions during weekends and public holidays: An analysis of electronic health records. The Lancet. 2017;390(10089):62-72.
Dr. Xu is assistant professor and hospitalist, Icahn School of Medicine of the Mount Sinai Health System, New York.
Adequately nourished AML patients have survival advantage
Good nutritional status can extend the lives of patients with acute myeloid leukemia going into induction chemotherapy, according to a retrospective study of 95 adult AML patients.
Those with good nutritional status had significantly shorter hospital stays than did undernourished patients. Furthermore, they had greater 12-month survival, compared with undernourished patients.
“Assessment of nutritional status is essential because undernutrition in this population is common,” Elise Deluche, MD, and her coinvestigators wrote (Nutrition. 2017 Sep;41:120-5). They assessed the nutritional status of 95 consecutive adult AML patients admitted to Limoges (France) University Hospital during 2009-2014 and followed their nutritional status for 12 months.Patients were considered undernourished if they had lost more than 5% of their weight, and had a body mass index (BMI) of under 18.5 kg/m2 if less than 70 years of age, or under 21 kg/m2 if aged at least 70 years.
Fourteen patients (15%) were undernourished at admission. That proportion grew after chemotherapy induction to 17 patients (18%), but there were no significant differences from admission in BMI, weight, or albumin.
The adequately nourished patients had significantly worse nutritional status at discharge than admission, with a significantly lower median weight (P =.02), BMI (P = .04), and albumin levels (P = .0002), compared with their admission values.
Importantly, the well nourished patients had shorter hospital stays than their undernourished counterparts, at 31 days, compared with 39 days (P = .03). Furthermore, their 12-month survival was greater, at 89.9%, than that of the undernourished patient, at 58.3% (P = .002).
After chemotherapy induction, 64 patients (67%) were in complete remission: 57 (70%) in the adequately nourished and 7 (50%) in the undernourished group, a nonsignificant difference.
This is the first study to look solely at patients with AML, Dr. DeLuche and her coinvestigators said, as previous nutritional studies have also included patients with acute lymphoblastic leukemia, and it “confirmed that the length of hospitalization was shorter for patients without undernutrition.” They added that their study included a more accurate representation of AML patients with a median patient age of 58 years, much older than the range of 28-41 found in other studies. A quarter of the patients in Dr. DeLuche’s study were over age 65.
“[Existing] screening tools should be improved and adapted to the specific situation of induction chemotherapy for monitoring nutritional status during hospitalization,” they concluded.
The study received no outside funding, and the investigators had no conflicts of interest.
Good nutritional status can extend the lives of patients with acute myeloid leukemia going into induction chemotherapy, according to a retrospective study of 95 adult AML patients.
Those with good nutritional status had significantly shorter hospital stays than did undernourished patients. Furthermore, they had greater 12-month survival, compared with undernourished patients.
“Assessment of nutritional status is essential because undernutrition in this population is common,” Elise Deluche, MD, and her coinvestigators wrote (Nutrition. 2017 Sep;41:120-5). They assessed the nutritional status of 95 consecutive adult AML patients admitted to Limoges (France) University Hospital during 2009-2014 and followed their nutritional status for 12 months.Patients were considered undernourished if they had lost more than 5% of their weight, and had a body mass index (BMI) of under 18.5 kg/m2 if less than 70 years of age, or under 21 kg/m2 if aged at least 70 years.
Fourteen patients (15%) were undernourished at admission. That proportion grew after chemotherapy induction to 17 patients (18%), but there were no significant differences from admission in BMI, weight, or albumin.
The adequately nourished patients had significantly worse nutritional status at discharge than admission, with a significantly lower median weight (P =.02), BMI (P = .04), and albumin levels (P = .0002), compared with their admission values.
Importantly, the well nourished patients had shorter hospital stays than their undernourished counterparts, at 31 days, compared with 39 days (P = .03). Furthermore, their 12-month survival was greater, at 89.9%, than that of the undernourished patient, at 58.3% (P = .002).
After chemotherapy induction, 64 patients (67%) were in complete remission: 57 (70%) in the adequately nourished and 7 (50%) in the undernourished group, a nonsignificant difference.
This is the first study to look solely at patients with AML, Dr. DeLuche and her coinvestigators said, as previous nutritional studies have also included patients with acute lymphoblastic leukemia, and it “confirmed that the length of hospitalization was shorter for patients without undernutrition.” They added that their study included a more accurate representation of AML patients with a median patient age of 58 years, much older than the range of 28-41 found in other studies. A quarter of the patients in Dr. DeLuche’s study were over age 65.
“[Existing] screening tools should be improved and adapted to the specific situation of induction chemotherapy for monitoring nutritional status during hospitalization,” they concluded.
The study received no outside funding, and the investigators had no conflicts of interest.
Good nutritional status can extend the lives of patients with acute myeloid leukemia going into induction chemotherapy, according to a retrospective study of 95 adult AML patients.
Those with good nutritional status had significantly shorter hospital stays than did undernourished patients. Furthermore, they had greater 12-month survival, compared with undernourished patients.
“Assessment of nutritional status is essential because undernutrition in this population is common,” Elise Deluche, MD, and her coinvestigators wrote (Nutrition. 2017 Sep;41:120-5). They assessed the nutritional status of 95 consecutive adult AML patients admitted to Limoges (France) University Hospital during 2009-2014 and followed their nutritional status for 12 months.Patients were considered undernourished if they had lost more than 5% of their weight, and had a body mass index (BMI) of under 18.5 kg/m2 if less than 70 years of age, or under 21 kg/m2 if aged at least 70 years.
Fourteen patients (15%) were undernourished at admission. That proportion grew after chemotherapy induction to 17 patients (18%), but there were no significant differences from admission in BMI, weight, or albumin.
The adequately nourished patients had significantly worse nutritional status at discharge than admission, with a significantly lower median weight (P =.02), BMI (P = .04), and albumin levels (P = .0002), compared with their admission values.
Importantly, the well nourished patients had shorter hospital stays than their undernourished counterparts, at 31 days, compared with 39 days (P = .03). Furthermore, their 12-month survival was greater, at 89.9%, than that of the undernourished patient, at 58.3% (P = .002).
After chemotherapy induction, 64 patients (67%) were in complete remission: 57 (70%) in the adequately nourished and 7 (50%) in the undernourished group, a nonsignificant difference.
This is the first study to look solely at patients with AML, Dr. DeLuche and her coinvestigators said, as previous nutritional studies have also included patients with acute lymphoblastic leukemia, and it “confirmed that the length of hospitalization was shorter for patients without undernutrition.” They added that their study included a more accurate representation of AML patients with a median patient age of 58 years, much older than the range of 28-41 found in other studies. A quarter of the patients in Dr. DeLuche’s study were over age 65.
“[Existing] screening tools should be improved and adapted to the specific situation of induction chemotherapy for monitoring nutritional status during hospitalization,” they concluded.
The study received no outside funding, and the investigators had no conflicts of interest.
FROM NUTRITION
Key clinical point:
Major finding: AML patients who were adequately nourished going into induction chemotherapy had significantly shorter hospital stays (31 days versus 39 days) and greater 12-month survival than did those who were undernourished (89.9% versus 58.3%).
Data source: A study of 95 consecutive AML patients admitted to a single center and assessed for nutritional status before and after induction chemotherapy.
Disclosures: The study received no outside funding, and the investigators had no conflicts of interest.
Multipart collaboration brings data-driven care management tools to patients
One Drop announced on Oct. 31 a multipart collaboration with Fitbit to bring enhanced data-driven care management tools to the diabetes community.
One Drop users will now be able to sync Fitbit intraday data to their One Drop accounts. The first initiative will be to help users better understand the impact of physical activity on blood glucose management. The app software also will analyze user-generated health data points with the goal of gaining deeper insights and improving health outcomes for all people with diabetes worldwide. It can potentially allow users to see how their physical activity impacts blood glucose levels. Users can review these data with their very own Certified Diabetes Educator as they work together to meet personalized health goals.
In a study published in JMIR Diabetes in August 2017, results showed a 1.1%-1.3% absolute reduction in hemoglobin A1C in just 4 months in patients using One Drop. It is noted that this was a more significant reduction than other published research suggested was possible using a mobile care management app.
“By integrating Fitbit data and creating an app for Fitbit Ionic, we will be able to provide our users and their health care providers with more data and deeper insights to better manage their diabetes,” said Jeff Dachis, CEO and founder of One Drop, in a press release.
Read the full press release here.
One Drop announced on Oct. 31 a multipart collaboration with Fitbit to bring enhanced data-driven care management tools to the diabetes community.
One Drop users will now be able to sync Fitbit intraday data to their One Drop accounts. The first initiative will be to help users better understand the impact of physical activity on blood glucose management. The app software also will analyze user-generated health data points with the goal of gaining deeper insights and improving health outcomes for all people with diabetes worldwide. It can potentially allow users to see how their physical activity impacts blood glucose levels. Users can review these data with their very own Certified Diabetes Educator as they work together to meet personalized health goals.
In a study published in JMIR Diabetes in August 2017, results showed a 1.1%-1.3% absolute reduction in hemoglobin A1C in just 4 months in patients using One Drop. It is noted that this was a more significant reduction than other published research suggested was possible using a mobile care management app.
“By integrating Fitbit data and creating an app for Fitbit Ionic, we will be able to provide our users and their health care providers with more data and deeper insights to better manage their diabetes,” said Jeff Dachis, CEO and founder of One Drop, in a press release.
Read the full press release here.
One Drop announced on Oct. 31 a multipart collaboration with Fitbit to bring enhanced data-driven care management tools to the diabetes community.
One Drop users will now be able to sync Fitbit intraday data to their One Drop accounts. The first initiative will be to help users better understand the impact of physical activity on blood glucose management. The app software also will analyze user-generated health data points with the goal of gaining deeper insights and improving health outcomes for all people with diabetes worldwide. It can potentially allow users to see how their physical activity impacts blood glucose levels. Users can review these data with their very own Certified Diabetes Educator as they work together to meet personalized health goals.
In a study published in JMIR Diabetes in August 2017, results showed a 1.1%-1.3% absolute reduction in hemoglobin A1C in just 4 months in patients using One Drop. It is noted that this was a more significant reduction than other published research suggested was possible using a mobile care management app.
“By integrating Fitbit data and creating an app for Fitbit Ionic, we will be able to provide our users and their health care providers with more data and deeper insights to better manage their diabetes,” said Jeff Dachis, CEO and founder of One Drop, in a press release.
Read the full press release here.
VIDEO: Rosacea patients no longer considered in ‘buckets’
LAS VEGAS – Clinicians are starting to see and treat rosacea differently, Julie Harper, MD, said in a video interview at Skin Disease Education Foundation’s annual Las Vegas Dermatology Seminar.
“For a long time, we thought about putting rosacea patients into buckets,” based on the predominant type of rosacea they had, such as papulopustular, ocular, or erythematotelangiectatic rosacea, but “what we find is that people have pieces and parts of all of those,” she commented.
In the interview, Dr. Harper, a dermatologist in private practice in Birmingham, Ala., emphasized the importance of directing treatment to all aspects of an individual patient’s rosacea, using combinations of treatments that are approved by the Food and Drug Administration, “or at least proven to be effective for these different parts” of the disease. “That’s something that’s really new in our thinking,” she said.
Dr. Harper disclosed relationships with multiple companies including Allergan, Bayer, Galderma, La Roche-Posay, Promius, and Valeant.
SDEF and this news organization are owned by the same parent company.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
LAS VEGAS – Clinicians are starting to see and treat rosacea differently, Julie Harper, MD, said in a video interview at Skin Disease Education Foundation’s annual Las Vegas Dermatology Seminar.
“For a long time, we thought about putting rosacea patients into buckets,” based on the predominant type of rosacea they had, such as papulopustular, ocular, or erythematotelangiectatic rosacea, but “what we find is that people have pieces and parts of all of those,” she commented.
In the interview, Dr. Harper, a dermatologist in private practice in Birmingham, Ala., emphasized the importance of directing treatment to all aspects of an individual patient’s rosacea, using combinations of treatments that are approved by the Food and Drug Administration, “or at least proven to be effective for these different parts” of the disease. “That’s something that’s really new in our thinking,” she said.
Dr. Harper disclosed relationships with multiple companies including Allergan, Bayer, Galderma, La Roche-Posay, Promius, and Valeant.
SDEF and this news organization are owned by the same parent company.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
LAS VEGAS – Clinicians are starting to see and treat rosacea differently, Julie Harper, MD, said in a video interview at Skin Disease Education Foundation’s annual Las Vegas Dermatology Seminar.
“For a long time, we thought about putting rosacea patients into buckets,” based on the predominant type of rosacea they had, such as papulopustular, ocular, or erythematotelangiectatic rosacea, but “what we find is that people have pieces and parts of all of those,” she commented.
In the interview, Dr. Harper, a dermatologist in private practice in Birmingham, Ala., emphasized the importance of directing treatment to all aspects of an individual patient’s rosacea, using combinations of treatments that are approved by the Food and Drug Administration, “or at least proven to be effective for these different parts” of the disease. “That’s something that’s really new in our thinking,” she said.
Dr. Harper disclosed relationships with multiple companies including Allergan, Bayer, Galderma, La Roche-Posay, Promius, and Valeant.
SDEF and this news organization are owned by the same parent company.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
AT SDEF LAS VEGAS DERMATOLOGY SEMINAR
Use of MenACWY-CRM vaccine in 2- to 10-year-olds raised no safety concerns
, reported Sara Yee Tartof, PhD, of Kaiser Permanente Southern California, Pasadena, and her associates.
The study was undertaken to evaluate the safety of the MenACWY-CRM vaccine in the care of children aged 2-10 years in the real world. The other quadrivalent meningococcal conjugate vaccine, MenACWY-D (Menactra), was not used in this study.
In a retrospective, observational study of 327 children aged 2-10 years when they received the MenACWY-CRM vaccine as part of routine clinical care, there was only one event of interest, which was a child who developed asthma during the 1-year observation period, and that occurred 237 days after vaccination with both the MenACWY-CRM and a typhoid vaccine. “A causal link between the two events is unlikely,” Dr. Tartof and her associates wrote.
Most of the serious medically attended events were considered to be unrelated to MenACWY-CRM vaccination, or symptom onset occurred a long time after vaccination. “The remaining events were pneumonia, bronchitis, cough, febrile convulsion, and vomiting identified within 30 days of vaccination among four children,” the investigators reported. “Pneumonia, bronchitis, and cough were diagnosed in the same child; cough, febrile convulsion, and vomiting were diagnosed separately in the other 3 children.
“It appears that many MenACWY-CRM recipients in our study population received the vaccine because of travel to high-risk areas, possible exposure to meningitis, or as routine vaccinations received early as part of the ACIP-recommended routine vaccination for those 11-12 years old,” Dr. Tartof and her associates wrote.
Read more in the Pediatric Infectious Diseases Journal (2017 Nov 1. doi: 10.1097/INF.0000000000001696).
, reported Sara Yee Tartof, PhD, of Kaiser Permanente Southern California, Pasadena, and her associates.
The study was undertaken to evaluate the safety of the MenACWY-CRM vaccine in the care of children aged 2-10 years in the real world. The other quadrivalent meningococcal conjugate vaccine, MenACWY-D (Menactra), was not used in this study.
In a retrospective, observational study of 327 children aged 2-10 years when they received the MenACWY-CRM vaccine as part of routine clinical care, there was only one event of interest, which was a child who developed asthma during the 1-year observation period, and that occurred 237 days after vaccination with both the MenACWY-CRM and a typhoid vaccine. “A causal link between the two events is unlikely,” Dr. Tartof and her associates wrote.
Most of the serious medically attended events were considered to be unrelated to MenACWY-CRM vaccination, or symptom onset occurred a long time after vaccination. “The remaining events were pneumonia, bronchitis, cough, febrile convulsion, and vomiting identified within 30 days of vaccination among four children,” the investigators reported. “Pneumonia, bronchitis, and cough were diagnosed in the same child; cough, febrile convulsion, and vomiting were diagnosed separately in the other 3 children.
“It appears that many MenACWY-CRM recipients in our study population received the vaccine because of travel to high-risk areas, possible exposure to meningitis, or as routine vaccinations received early as part of the ACIP-recommended routine vaccination for those 11-12 years old,” Dr. Tartof and her associates wrote.
Read more in the Pediatric Infectious Diseases Journal (2017 Nov 1. doi: 10.1097/INF.0000000000001696).
, reported Sara Yee Tartof, PhD, of Kaiser Permanente Southern California, Pasadena, and her associates.
The study was undertaken to evaluate the safety of the MenACWY-CRM vaccine in the care of children aged 2-10 years in the real world. The other quadrivalent meningococcal conjugate vaccine, MenACWY-D (Menactra), was not used in this study.
In a retrospective, observational study of 327 children aged 2-10 years when they received the MenACWY-CRM vaccine as part of routine clinical care, there was only one event of interest, which was a child who developed asthma during the 1-year observation period, and that occurred 237 days after vaccination with both the MenACWY-CRM and a typhoid vaccine. “A causal link between the two events is unlikely,” Dr. Tartof and her associates wrote.
Most of the serious medically attended events were considered to be unrelated to MenACWY-CRM vaccination, or symptom onset occurred a long time after vaccination. “The remaining events were pneumonia, bronchitis, cough, febrile convulsion, and vomiting identified within 30 days of vaccination among four children,” the investigators reported. “Pneumonia, bronchitis, and cough were diagnosed in the same child; cough, febrile convulsion, and vomiting were diagnosed separately in the other 3 children.
“It appears that many MenACWY-CRM recipients in our study population received the vaccine because of travel to high-risk areas, possible exposure to meningitis, or as routine vaccinations received early as part of the ACIP-recommended routine vaccination for those 11-12 years old,” Dr. Tartof and her associates wrote.
Read more in the Pediatric Infectious Diseases Journal (2017 Nov 1. doi: 10.1097/INF.0000000000001696).
FROM PEDIATRIC INFECTIOUS DISEASE JOURNAL
Early diagnosis of tuberous sclerosis may be possible in infants
with an echocardiogram for cardiac rhabdomyomas and a skin examination for hypomelanotic macules, noninvasive tests that do not require sedation, said Peter E. Davis, MD, of Boston Children’s Hospital, and his associates on behalf of the Tuberous Sclerosis Complex Autism Center of Excellence Research Network.
“Early TSC diagnosis in infants opens a window of opportunity to treat before the onset of epilepsy or other neurodevelopmental disorders and allows for close surveillance for sequelae of TSC,” the researchers said. “However, this window may be as small as a few months.”
In two concurrent, prospective, longitudinal, observational studies at five medical centers of 130 infants meeting a genetic or clinical diagnosis of TSC, cardiac rhabdomyomas, and hypomelanotic macules were the most common initial presenting features, occurring in 59% and 39% of infants, respectively; 85% of infants had either or both. In terms of prevalence, hypomelanotic macules and tubers or other cortical dysplasias were the most prevalent TSC features both occurring at 94%, followed by subependymal nodules (SENs) at 90%, and cardiac rhabdomyomas at 82%. Every infant had at least one of these diagnostic criteria, and 61% had all four of them, the investigators reported.
Neuroimaging results were available in 115 infants, of whom 94% had tubers or cortical dysplasias, 90% had SENs, and 89% had both; 6% had subependymal giant cell astrocytomas. Seizure onset occurred in 15% of infants before or when other TSC criteria were recorded, “suggesting that seizure was an initial presenting symptom.” Seizure onset occurred within 3 months after initial presentation in 17% of infants, within 6 months in 39%, and within 12 months in 57%. Ultimately, 57% of the infants had infantile spasms, 55% had focal seizures, and 12% had another seizure type, Dr. Davis and his associates said.
“Early, prospective use of EEGs may enable risk stratification in studies of epilepsy prevention in infants with TSC. The antiepileptic medication vigabatrin is particularly effective in treating infantile spasms in TSC and has mTOR [mechanistic target of the rapamycin]–inhibiting effects. Vigabatrin is currently in clinical trials to determine its efficacy at preventing epilepsy in patients with TSC,” they said, although the drug is not currently recommended for infants. “mTOR inhibitors have been successfully used to treat multiple TSC manifestations and have shown some efficacy as adjunctive treatment of refractory epilepsy,” they wrote, adding that studies are needed “to determine the safety and efficacy of mTOR inhibitors in this age group.”
Read more at Pediatrics. 2017;140(6):e20164040 (doi: 10.1542/peds.2016-4040).
with an echocardiogram for cardiac rhabdomyomas and a skin examination for hypomelanotic macules, noninvasive tests that do not require sedation, said Peter E. Davis, MD, of Boston Children’s Hospital, and his associates on behalf of the Tuberous Sclerosis Complex Autism Center of Excellence Research Network.
“Early TSC diagnosis in infants opens a window of opportunity to treat before the onset of epilepsy or other neurodevelopmental disorders and allows for close surveillance for sequelae of TSC,” the researchers said. “However, this window may be as small as a few months.”
In two concurrent, prospective, longitudinal, observational studies at five medical centers of 130 infants meeting a genetic or clinical diagnosis of TSC, cardiac rhabdomyomas, and hypomelanotic macules were the most common initial presenting features, occurring in 59% and 39% of infants, respectively; 85% of infants had either or both. In terms of prevalence, hypomelanotic macules and tubers or other cortical dysplasias were the most prevalent TSC features both occurring at 94%, followed by subependymal nodules (SENs) at 90%, and cardiac rhabdomyomas at 82%. Every infant had at least one of these diagnostic criteria, and 61% had all four of them, the investigators reported.
Neuroimaging results were available in 115 infants, of whom 94% had tubers or cortical dysplasias, 90% had SENs, and 89% had both; 6% had subependymal giant cell astrocytomas. Seizure onset occurred in 15% of infants before or when other TSC criteria were recorded, “suggesting that seizure was an initial presenting symptom.” Seizure onset occurred within 3 months after initial presentation in 17% of infants, within 6 months in 39%, and within 12 months in 57%. Ultimately, 57% of the infants had infantile spasms, 55% had focal seizures, and 12% had another seizure type, Dr. Davis and his associates said.
“Early, prospective use of EEGs may enable risk stratification in studies of epilepsy prevention in infants with TSC. The antiepileptic medication vigabatrin is particularly effective in treating infantile spasms in TSC and has mTOR [mechanistic target of the rapamycin]–inhibiting effects. Vigabatrin is currently in clinical trials to determine its efficacy at preventing epilepsy in patients with TSC,” they said, although the drug is not currently recommended for infants. “mTOR inhibitors have been successfully used to treat multiple TSC manifestations and have shown some efficacy as adjunctive treatment of refractory epilepsy,” they wrote, adding that studies are needed “to determine the safety and efficacy of mTOR inhibitors in this age group.”
Read more at Pediatrics. 2017;140(6):e20164040 (doi: 10.1542/peds.2016-4040).
with an echocardiogram for cardiac rhabdomyomas and a skin examination for hypomelanotic macules, noninvasive tests that do not require sedation, said Peter E. Davis, MD, of Boston Children’s Hospital, and his associates on behalf of the Tuberous Sclerosis Complex Autism Center of Excellence Research Network.
“Early TSC diagnosis in infants opens a window of opportunity to treat before the onset of epilepsy or other neurodevelopmental disorders and allows for close surveillance for sequelae of TSC,” the researchers said. “However, this window may be as small as a few months.”
In two concurrent, prospective, longitudinal, observational studies at five medical centers of 130 infants meeting a genetic or clinical diagnosis of TSC, cardiac rhabdomyomas, and hypomelanotic macules were the most common initial presenting features, occurring in 59% and 39% of infants, respectively; 85% of infants had either or both. In terms of prevalence, hypomelanotic macules and tubers or other cortical dysplasias were the most prevalent TSC features both occurring at 94%, followed by subependymal nodules (SENs) at 90%, and cardiac rhabdomyomas at 82%. Every infant had at least one of these diagnostic criteria, and 61% had all four of them, the investigators reported.
Neuroimaging results were available in 115 infants, of whom 94% had tubers or cortical dysplasias, 90% had SENs, and 89% had both; 6% had subependymal giant cell astrocytomas. Seizure onset occurred in 15% of infants before or when other TSC criteria were recorded, “suggesting that seizure was an initial presenting symptom.” Seizure onset occurred within 3 months after initial presentation in 17% of infants, within 6 months in 39%, and within 12 months in 57%. Ultimately, 57% of the infants had infantile spasms, 55% had focal seizures, and 12% had another seizure type, Dr. Davis and his associates said.
“Early, prospective use of EEGs may enable risk stratification in studies of epilepsy prevention in infants with TSC. The antiepileptic medication vigabatrin is particularly effective in treating infantile spasms in TSC and has mTOR [mechanistic target of the rapamycin]–inhibiting effects. Vigabatrin is currently in clinical trials to determine its efficacy at preventing epilepsy in patients with TSC,” they said, although the drug is not currently recommended for infants. “mTOR inhibitors have been successfully used to treat multiple TSC manifestations and have shown some efficacy as adjunctive treatment of refractory epilepsy,” they wrote, adding that studies are needed “to determine the safety and efficacy of mTOR inhibitors in this age group.”
Read more at Pediatrics. 2017;140(6):e20164040 (doi: 10.1542/peds.2016-4040).
FROM PEDIATRICS
Applying Choosing Wisely principles to telemetry and catheter use
The Choosing Wisely recommendations for hospitalists have launched numerous research projects. One dealing with telemetry and catheter use was published in September’s American Journal of Medicine.
After reviewing the literature on how people were implementing these recommendations, the researchers noticed most projects “1) narrowly focused on only one of the recommendations; 2) often used intrusive interventions that appeared to be burdensome and not adaptable to physician workflow; and 3) were expensive to implement,” said lead author Charlie M. Wray, DO, MS, of the Division of Hospital Medicine, San Francisco Veterans Affairs Medical Center, and the University of California, San Francisco. “We set out to design a project that could minimize these aspects while hopefully decreasing the use of telemetry and Foley catheters.”
The researchers created a “silent” reminder that was posted on a widely used screen within their EHR and was only activated when the user clicked on it. “Additionally, we wanted to make sure that this intervention made its way to teaching rounds and the patients’ bedsides,” Dr. Wray said. “So, when the attendings and residents would print out their daily census, it would contain the reminders, which allowed the team to quickly review which patients were actively using telemetry or had a Foley and discuss, at a team-level, whose telemetry or Foley could be stopped.”
The project demonstrated a trend toward less telemetry use, less time spent on telemetry, fewer catheters ordered, and more selective utilization of catheters in sicker patients.
“We believe that our project shows that the bundling of interventions has the potential to impart an effect on a greater proportion of the population than those that focus on a single issue,” Dr. Wray said. “Second, future interventions that look to utilize EHR-based clinical reminders should consider utilizing a ‘silent’ design that is prominent but doesn’t intrude upon practitioners workflow.”
You don’t need to be at a large academic institution to implement this idea, he added. “A few hours with your IT expert and a champion who is willing to take the lead could easily implement this project and hopefully see similar outcomes.”
Reference
Wray, Charlie M. et al. Improving value by reducing unnecessary telemetry and urinary catheter utilization in hospitalized patients. Am J Med. 2017 Sep;130(9):1037-41.
The Choosing Wisely recommendations for hospitalists have launched numerous research projects. One dealing with telemetry and catheter use was published in September’s American Journal of Medicine.
After reviewing the literature on how people were implementing these recommendations, the researchers noticed most projects “1) narrowly focused on only one of the recommendations; 2) often used intrusive interventions that appeared to be burdensome and not adaptable to physician workflow; and 3) were expensive to implement,” said lead author Charlie M. Wray, DO, MS, of the Division of Hospital Medicine, San Francisco Veterans Affairs Medical Center, and the University of California, San Francisco. “We set out to design a project that could minimize these aspects while hopefully decreasing the use of telemetry and Foley catheters.”
The researchers created a “silent” reminder that was posted on a widely used screen within their EHR and was only activated when the user clicked on it. “Additionally, we wanted to make sure that this intervention made its way to teaching rounds and the patients’ bedsides,” Dr. Wray said. “So, when the attendings and residents would print out their daily census, it would contain the reminders, which allowed the team to quickly review which patients were actively using telemetry or had a Foley and discuss, at a team-level, whose telemetry or Foley could be stopped.”
The project demonstrated a trend toward less telemetry use, less time spent on telemetry, fewer catheters ordered, and more selective utilization of catheters in sicker patients.
“We believe that our project shows that the bundling of interventions has the potential to impart an effect on a greater proportion of the population than those that focus on a single issue,” Dr. Wray said. “Second, future interventions that look to utilize EHR-based clinical reminders should consider utilizing a ‘silent’ design that is prominent but doesn’t intrude upon practitioners workflow.”
You don’t need to be at a large academic institution to implement this idea, he added. “A few hours with your IT expert and a champion who is willing to take the lead could easily implement this project and hopefully see similar outcomes.”
Reference
Wray, Charlie M. et al. Improving value by reducing unnecessary telemetry and urinary catheter utilization in hospitalized patients. Am J Med. 2017 Sep;130(9):1037-41.
The Choosing Wisely recommendations for hospitalists have launched numerous research projects. One dealing with telemetry and catheter use was published in September’s American Journal of Medicine.
After reviewing the literature on how people were implementing these recommendations, the researchers noticed most projects “1) narrowly focused on only one of the recommendations; 2) often used intrusive interventions that appeared to be burdensome and not adaptable to physician workflow; and 3) were expensive to implement,” said lead author Charlie M. Wray, DO, MS, of the Division of Hospital Medicine, San Francisco Veterans Affairs Medical Center, and the University of California, San Francisco. “We set out to design a project that could minimize these aspects while hopefully decreasing the use of telemetry and Foley catheters.”
The researchers created a “silent” reminder that was posted on a widely used screen within their EHR and was only activated when the user clicked on it. “Additionally, we wanted to make sure that this intervention made its way to teaching rounds and the patients’ bedsides,” Dr. Wray said. “So, when the attendings and residents would print out their daily census, it would contain the reminders, which allowed the team to quickly review which patients were actively using telemetry or had a Foley and discuss, at a team-level, whose telemetry or Foley could be stopped.”
The project demonstrated a trend toward less telemetry use, less time spent on telemetry, fewer catheters ordered, and more selective utilization of catheters in sicker patients.
“We believe that our project shows that the bundling of interventions has the potential to impart an effect on a greater proportion of the population than those that focus on a single issue,” Dr. Wray said. “Second, future interventions that look to utilize EHR-based clinical reminders should consider utilizing a ‘silent’ design that is prominent but doesn’t intrude upon practitioners workflow.”
You don’t need to be at a large academic institution to implement this idea, he added. “A few hours with your IT expert and a champion who is willing to take the lead could easily implement this project and hopefully see similar outcomes.”
Reference
Wray, Charlie M. et al. Improving value by reducing unnecessary telemetry and urinary catheter utilization in hospitalized patients. Am J Med. 2017 Sep;130(9):1037-41.