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Air pollution tied to stroke risk, subsequent CV events, and death
Results of a UK biobank study show high levels of air pollution were associated with an increased risk of transition from health to a first stroke and subsequent progression to cardiovascular (CV) events and death.
“These results indicate that understanding and reducing the effects of air pollutants on different transition stages in stroke will be beneficial in managing people’s health and preventing the occurrence and progression of stroke,” study investigator Hualiang Lin, PhD, of Sun Yat-sen University School of Public Health, Guangzhou, China, said in a news release.
The study was published online in the journal Neurology.
A way to stop stroke progression?
The researchers assessed air pollution exposure in 318,752 people (mean age, 56) from the UK biobank database. None had a history of stroke or heart disease at the start of the study. Annual concentrations of air pollution near where people lived were estimated through land-use regressions.
During an average follow-up of 12 years, 5,967 people had a stroke, 2,985 developed post-stroke CVD, and 1,020 died.
After adjusting for confounding factors, every 5 µg/m3 increase in exposure to fine particulate matter (PM2.5) was associated with a 24% increase in transition from healthy to first stroke (hazard ratio, 1.24; 95% confidence interval, 1.10-1.40) and a 30% increase in transition from being healthy to dying (HR, 1.30; 95% CI, 1.21-1.40).
PM2.5 is less than 2.5 microns in diameter and includes fly ash from coal combustion. The World Health Organization recommends that annual PM2.5 exposure should not exceed 5 µg/m3.
Those who had a stroke during the study had an average exposure of 10.03 µg/m3 of PM2.5, compared with 9.97 µg/m3 for those who did not have a stroke.
The air pollutants nitrogen oxide and nitrogen dioxide were also associated with an increased risk of stroke and death, but the associations were weaker.
“More research is needed, but it’s possible that decreasing exposure to heavy levels of air pollution could play a role in reducing the progression of stroke,” Dr. Lin said.
“People can reduce their exposure by staying indoors on heavy pollution days, reducing their outdoor exercise, wearing masks to filter out particulate matter, and using air purifiers,” Dr. Lin added.
Public policy implications
Reached for comment, Steffen E. Petersen, MD, MPH, professor of cardiovascular medicine, Barts Health NHS Trust, London, said the study “elegantly confirms the increased risk of stroke due to air pollution in the UK Biobank population study but interestingly suggests that the impact of air pollution may continue to adversely impact cardiovascular health even after the stroke occurred.”
“This is further evidence to inform policymakers to tackle air pollution and get levels below the recommended levels,” Dr. Petersen said.
“On a personal level, everyone, including stroke patients, may wish to consider personal measures to reduce exposure to air pollution, such as avoiding walking along polluted streets and rather take a less polluted route away from the main roads,” Dr. Petersen added.
The study had no targeted funding. Dr. Lin and Dr. Petersen report no relevant financial relationships.
A version of this article first appeared on Medscape.com.
Results of a UK biobank study show high levels of air pollution were associated with an increased risk of transition from health to a first stroke and subsequent progression to cardiovascular (CV) events and death.
“These results indicate that understanding and reducing the effects of air pollutants on different transition stages in stroke will be beneficial in managing people’s health and preventing the occurrence and progression of stroke,” study investigator Hualiang Lin, PhD, of Sun Yat-sen University School of Public Health, Guangzhou, China, said in a news release.
The study was published online in the journal Neurology.
A way to stop stroke progression?
The researchers assessed air pollution exposure in 318,752 people (mean age, 56) from the UK biobank database. None had a history of stroke or heart disease at the start of the study. Annual concentrations of air pollution near where people lived were estimated through land-use regressions.
During an average follow-up of 12 years, 5,967 people had a stroke, 2,985 developed post-stroke CVD, and 1,020 died.
After adjusting for confounding factors, every 5 µg/m3 increase in exposure to fine particulate matter (PM2.5) was associated with a 24% increase in transition from healthy to first stroke (hazard ratio, 1.24; 95% confidence interval, 1.10-1.40) and a 30% increase in transition from being healthy to dying (HR, 1.30; 95% CI, 1.21-1.40).
PM2.5 is less than 2.5 microns in diameter and includes fly ash from coal combustion. The World Health Organization recommends that annual PM2.5 exposure should not exceed 5 µg/m3.
Those who had a stroke during the study had an average exposure of 10.03 µg/m3 of PM2.5, compared with 9.97 µg/m3 for those who did not have a stroke.
The air pollutants nitrogen oxide and nitrogen dioxide were also associated with an increased risk of stroke and death, but the associations were weaker.
“More research is needed, but it’s possible that decreasing exposure to heavy levels of air pollution could play a role in reducing the progression of stroke,” Dr. Lin said.
“People can reduce their exposure by staying indoors on heavy pollution days, reducing their outdoor exercise, wearing masks to filter out particulate matter, and using air purifiers,” Dr. Lin added.
Public policy implications
Reached for comment, Steffen E. Petersen, MD, MPH, professor of cardiovascular medicine, Barts Health NHS Trust, London, said the study “elegantly confirms the increased risk of stroke due to air pollution in the UK Biobank population study but interestingly suggests that the impact of air pollution may continue to adversely impact cardiovascular health even after the stroke occurred.”
“This is further evidence to inform policymakers to tackle air pollution and get levels below the recommended levels,” Dr. Petersen said.
“On a personal level, everyone, including stroke patients, may wish to consider personal measures to reduce exposure to air pollution, such as avoiding walking along polluted streets and rather take a less polluted route away from the main roads,” Dr. Petersen added.
The study had no targeted funding. Dr. Lin and Dr. Petersen report no relevant financial relationships.
A version of this article first appeared on Medscape.com.
Results of a UK biobank study show high levels of air pollution were associated with an increased risk of transition from health to a first stroke and subsequent progression to cardiovascular (CV) events and death.
“These results indicate that understanding and reducing the effects of air pollutants on different transition stages in stroke will be beneficial in managing people’s health and preventing the occurrence and progression of stroke,” study investigator Hualiang Lin, PhD, of Sun Yat-sen University School of Public Health, Guangzhou, China, said in a news release.
The study was published online in the journal Neurology.
A way to stop stroke progression?
The researchers assessed air pollution exposure in 318,752 people (mean age, 56) from the UK biobank database. None had a history of stroke or heart disease at the start of the study. Annual concentrations of air pollution near where people lived were estimated through land-use regressions.
During an average follow-up of 12 years, 5,967 people had a stroke, 2,985 developed post-stroke CVD, and 1,020 died.
After adjusting for confounding factors, every 5 µg/m3 increase in exposure to fine particulate matter (PM2.5) was associated with a 24% increase in transition from healthy to first stroke (hazard ratio, 1.24; 95% confidence interval, 1.10-1.40) and a 30% increase in transition from being healthy to dying (HR, 1.30; 95% CI, 1.21-1.40).
PM2.5 is less than 2.5 microns in diameter and includes fly ash from coal combustion. The World Health Organization recommends that annual PM2.5 exposure should not exceed 5 µg/m3.
Those who had a stroke during the study had an average exposure of 10.03 µg/m3 of PM2.5, compared with 9.97 µg/m3 for those who did not have a stroke.
The air pollutants nitrogen oxide and nitrogen dioxide were also associated with an increased risk of stroke and death, but the associations were weaker.
“More research is needed, but it’s possible that decreasing exposure to heavy levels of air pollution could play a role in reducing the progression of stroke,” Dr. Lin said.
“People can reduce their exposure by staying indoors on heavy pollution days, reducing their outdoor exercise, wearing masks to filter out particulate matter, and using air purifiers,” Dr. Lin added.
Public policy implications
Reached for comment, Steffen E. Petersen, MD, MPH, professor of cardiovascular medicine, Barts Health NHS Trust, London, said the study “elegantly confirms the increased risk of stroke due to air pollution in the UK Biobank population study but interestingly suggests that the impact of air pollution may continue to adversely impact cardiovascular health even after the stroke occurred.”
“This is further evidence to inform policymakers to tackle air pollution and get levels below the recommended levels,” Dr. Petersen said.
“On a personal level, everyone, including stroke patients, may wish to consider personal measures to reduce exposure to air pollution, such as avoiding walking along polluted streets and rather take a less polluted route away from the main roads,” Dr. Petersen added.
The study had no targeted funding. Dr. Lin and Dr. Petersen report no relevant financial relationships.
A version of this article first appeared on Medscape.com.
New ICD-10-CM codes a ‘big switch-over’ for neurocognitive disorders
Revised ICD-10-CM codes for neurocognitive disorders are now in effect, the American Psychiatric Association has announced
The coding changes for major and mild neurocognitive disorders represent “the most consequential” coding changes for DSM-5 disorders since the Oct. 1, 2015, changeover from ICD-9-CM to ICD-10-CM,” Michael First, MD, professor of clinical psychiatry at Columbia University, in New York, wrote in a statement published in Psychiatric News.
The updated codes for neurocognitive disorders are “much more specific and indicate all the different types of behavioral problems that could occur with dementia,” First, who served as editor of the DSM-5-TR, added in an interview.
This year, coding changes that affect psychiatry are largely confined to major and mild neurocognitive disorders, but they represent “a big switch-over,” Dr. First said.
What’s new
The first three characters that make up the ICD-10-CM code for major neurocognitive disorder depend on the type of etiologic medical condition and are unchanged:
- F01 for major neurocognitive disorder caused by vascular disease
- F02 for major neurocognitive disorder caused by other medical conditions in which the specific etiologic medical condition is indicated by also listing the ICD-10-CM code for the medical condition
- F03 for major neurocognitive disorder when the medical etiology is unknown
However, DSM-5-TR diagnostic criteria for major neurocognitive disorder include severity specifiers (mild, moderate, severe), but there is no provision for indicating this “clinically important” information in the current ICD-10-CM code for major neurocognitive disorder, Dr. First explained.
The 2022 coding changes for major neurocognitive disorder include the provision of a fourth character code to indicate the severity of the major neurocognitive disorder – “A” indicates mild (difficulties with instrumental activities of daily living, such as housework and managing money); “B,” moderate (difficulties with basic activities of daily living, such as feeding and dressing); and “C,” severe (fully dependent) impairment.
The coding changes for major neurocognitive disorder also now include fifth and sixth characters to indicate the presence of an accompanying behavioral or psychological disturbance, such as agitation, psychotic disturbance, mood symptoms, and anxiety.
The update, which went into effect Oct. 1, also adds to ICD-10-CM two new mental disorder codes, F06.71 and F06.70 for mild neurocognitive disorder caused by a medical condition with or without a behavioral disturbance, respectively.
The coding changes affecting psychiatry are outlined in the APA’s 2022 DSM-5-TR Update: Supplement to the Diagnostic and Statistical Manual of Mental Disorders and DSM-5-TR Neurocognitive Disorders Supplement.
Annual event
Every Oct. 1, ICD-10-CM codes for all of medicine are updated, with new codes being added and others revised or deleted. Only a small fraction of the 68,000 codes is affected. Last year, 159 new codes were added, 25 codes were deleted, and 27 existing codes were revised.
All HIPAA-compliant health care entities are required to use the most up-to-date ICD-10-CM codes.
“I think there’s a grace period where you can still use the old codes, but there will be a point where if you use the old code, it’ll get rejected because it won’t be considered a valid code,” said Dr. First.
A version of this article first appeared on Medscape.com.
Revised ICD-10-CM codes for neurocognitive disorders are now in effect, the American Psychiatric Association has announced
The coding changes for major and mild neurocognitive disorders represent “the most consequential” coding changes for DSM-5 disorders since the Oct. 1, 2015, changeover from ICD-9-CM to ICD-10-CM,” Michael First, MD, professor of clinical psychiatry at Columbia University, in New York, wrote in a statement published in Psychiatric News.
The updated codes for neurocognitive disorders are “much more specific and indicate all the different types of behavioral problems that could occur with dementia,” First, who served as editor of the DSM-5-TR, added in an interview.
This year, coding changes that affect psychiatry are largely confined to major and mild neurocognitive disorders, but they represent “a big switch-over,” Dr. First said.
What’s new
The first three characters that make up the ICD-10-CM code for major neurocognitive disorder depend on the type of etiologic medical condition and are unchanged:
- F01 for major neurocognitive disorder caused by vascular disease
- F02 for major neurocognitive disorder caused by other medical conditions in which the specific etiologic medical condition is indicated by also listing the ICD-10-CM code for the medical condition
- F03 for major neurocognitive disorder when the medical etiology is unknown
However, DSM-5-TR diagnostic criteria for major neurocognitive disorder include severity specifiers (mild, moderate, severe), but there is no provision for indicating this “clinically important” information in the current ICD-10-CM code for major neurocognitive disorder, Dr. First explained.
The 2022 coding changes for major neurocognitive disorder include the provision of a fourth character code to indicate the severity of the major neurocognitive disorder – “A” indicates mild (difficulties with instrumental activities of daily living, such as housework and managing money); “B,” moderate (difficulties with basic activities of daily living, such as feeding and dressing); and “C,” severe (fully dependent) impairment.
The coding changes for major neurocognitive disorder also now include fifth and sixth characters to indicate the presence of an accompanying behavioral or psychological disturbance, such as agitation, psychotic disturbance, mood symptoms, and anxiety.
The update, which went into effect Oct. 1, also adds to ICD-10-CM two new mental disorder codes, F06.71 and F06.70 for mild neurocognitive disorder caused by a medical condition with or without a behavioral disturbance, respectively.
The coding changes affecting psychiatry are outlined in the APA’s 2022 DSM-5-TR Update: Supplement to the Diagnostic and Statistical Manual of Mental Disorders and DSM-5-TR Neurocognitive Disorders Supplement.
Annual event
Every Oct. 1, ICD-10-CM codes for all of medicine are updated, with new codes being added and others revised or deleted. Only a small fraction of the 68,000 codes is affected. Last year, 159 new codes were added, 25 codes were deleted, and 27 existing codes were revised.
All HIPAA-compliant health care entities are required to use the most up-to-date ICD-10-CM codes.
“I think there’s a grace period where you can still use the old codes, but there will be a point where if you use the old code, it’ll get rejected because it won’t be considered a valid code,” said Dr. First.
A version of this article first appeared on Medscape.com.
Revised ICD-10-CM codes for neurocognitive disorders are now in effect, the American Psychiatric Association has announced
The coding changes for major and mild neurocognitive disorders represent “the most consequential” coding changes for DSM-5 disorders since the Oct. 1, 2015, changeover from ICD-9-CM to ICD-10-CM,” Michael First, MD, professor of clinical psychiatry at Columbia University, in New York, wrote in a statement published in Psychiatric News.
The updated codes for neurocognitive disorders are “much more specific and indicate all the different types of behavioral problems that could occur with dementia,” First, who served as editor of the DSM-5-TR, added in an interview.
This year, coding changes that affect psychiatry are largely confined to major and mild neurocognitive disorders, but they represent “a big switch-over,” Dr. First said.
What’s new
The first three characters that make up the ICD-10-CM code for major neurocognitive disorder depend on the type of etiologic medical condition and are unchanged:
- F01 for major neurocognitive disorder caused by vascular disease
- F02 for major neurocognitive disorder caused by other medical conditions in which the specific etiologic medical condition is indicated by also listing the ICD-10-CM code for the medical condition
- F03 for major neurocognitive disorder when the medical etiology is unknown
However, DSM-5-TR diagnostic criteria for major neurocognitive disorder include severity specifiers (mild, moderate, severe), but there is no provision for indicating this “clinically important” information in the current ICD-10-CM code for major neurocognitive disorder, Dr. First explained.
The 2022 coding changes for major neurocognitive disorder include the provision of a fourth character code to indicate the severity of the major neurocognitive disorder – “A” indicates mild (difficulties with instrumental activities of daily living, such as housework and managing money); “B,” moderate (difficulties with basic activities of daily living, such as feeding and dressing); and “C,” severe (fully dependent) impairment.
The coding changes for major neurocognitive disorder also now include fifth and sixth characters to indicate the presence of an accompanying behavioral or psychological disturbance, such as agitation, psychotic disturbance, mood symptoms, and anxiety.
The update, which went into effect Oct. 1, also adds to ICD-10-CM two new mental disorder codes, F06.71 and F06.70 for mild neurocognitive disorder caused by a medical condition with or without a behavioral disturbance, respectively.
The coding changes affecting psychiatry are outlined in the APA’s 2022 DSM-5-TR Update: Supplement to the Diagnostic and Statistical Manual of Mental Disorders and DSM-5-TR Neurocognitive Disorders Supplement.
Annual event
Every Oct. 1, ICD-10-CM codes for all of medicine are updated, with new codes being added and others revised or deleted. Only a small fraction of the 68,000 codes is affected. Last year, 159 new codes were added, 25 codes were deleted, and 27 existing codes were revised.
All HIPAA-compliant health care entities are required to use the most up-to-date ICD-10-CM codes.
“I think there’s a grace period where you can still use the old codes, but there will be a point where if you use the old code, it’ll get rejected because it won’t be considered a valid code,” said Dr. First.
A version of this article first appeared on Medscape.com.
Colonoscopy in FIT-based screening demands higher ADR
Adenoma detection rate (ADR) targets for endoscopists performing colonoscopy after a positive fecal immunochemical test (FIT) should be markedly higher compared with ADR targets used in primary colonoscopy, researchers report.
Data from the Netherlands FIT-based screening program show that the ADR is “linearly and inversely” associated with interim colorectal cancer (CRC) occurrence, first author Pieter H.A. Wisse, MD, with Erasmus University Medical Center, Rotterdam, the Netherlands, told this news organization.
“Endoscopists should strive to obtain ADRs as high as possible” in FIT-positive screenees, Wisse said.
The study was published online in Annals of Internal Medicine.
Small differences, huge consequences
The ADR is a key quality indicator for endoscopists performing colonoscopies for CRC because it reflects their ability to detect lesions and is inversely associated with the risk of interval postcolonoscopy CRC (PCCRC).
Adults with a positive FIT result have a high prevalence of adenomas, leading to high ADRs for endoscopists performing colonoscopies in this setting. However, data on optimal ADRs of endoscopists performing colonoscopies in FIT-based screening are scarce.
To investigate, Dr. Wisse and colleagues evaluated the association between the ADR and interval PCCRC in patients undergoing colonoscopy after a positive FIT result. The analysis included 362 accredited and audited endoscopists who performed 116,360 colonoscopies.
During a median follow-up of 52 months, 209 interval PCCRCs were identified.
The quality of the colonoscopic examinations in FIT-positive screenees was high; endoscopists’ ADRs ranged between 40% and 82%, with a median ADR of 67%.
A higher ADR was strongly associated with lower incidence of interval PCCRC, with an adjusted hazard ratio of 0.95 (95% confidence interval, 0.92-0.97) per 1% increase in ADR.
For endoscopists with an ADR of 60%, the cumulative incidence of interval PCCRC was nearly two times as high as that of endoscopists with an ADR of 70%. The risk was even higher for endoscopists with ADRs less than 60%.
For every 1,000 FIT-positive colonoscopies, the expected number of patients diagnosed with interval PCCRC in 5 years was roughly 2 for endoscopists with an ADR of 70%, compared with almost 3.5 for ADRs of 60% and more than 4.5 for ADRs of 55%.
The authors note that the relatively short duration of follow-up (median, 52 months) could be considered a study limitation.
Quality metrics needed
“These seemingly small ADR differences are deceptive – if an endoscopist increases their ADR by just 10%, their patients’ associated decrease in relative interval cancer risk is a remarkable 40% to 50%,” Douglas Corley, MD, PhD, MPH, from Kaiser Permanente, Oakland, Calif., points out in an accompanying editorial.
Dr. Wisse and colleagues add that FIT-based colonoscopy has now surpassed primary colonoscopy as the most commonly used primary CRC-screening method.
They say there is a need to determine specific ADR targets for FIT-positive screenees to assure quality of colonoscopies and optimize the effect of screening programs by reducing interval PCCRC risk.
For primary colonoscopy, most professional societies recommend an ADR of at least 25% as an indicator of adequate performance. The new study suggests that FIT-positive colonoscopy “demands a markedly higher ADR target than primary colonoscopy,” the authors write.
Dr. Corley said this study provides “an excellent framework for evaluating nine concepts regarding effective quality metrics and how these can illustrate pathways for meaningful metrics for the care of other cancers and disorders.”
Quality metrics must be trustworthy, important, strategic, relevant, actionable, simple, gaming-resistant, time-stamped, and owned, he explained.
Questions concerning goals, plans for implementation of interventions, and the application of goals while maintaining simplicity must be considered in metric development, Dr. Corley said.
The study had no funding.
A version of this article first appeared on Medscape.com.
Adenoma detection rate (ADR) targets for endoscopists performing colonoscopy after a positive fecal immunochemical test (FIT) should be markedly higher compared with ADR targets used in primary colonoscopy, researchers report.
Data from the Netherlands FIT-based screening program show that the ADR is “linearly and inversely” associated with interim colorectal cancer (CRC) occurrence, first author Pieter H.A. Wisse, MD, with Erasmus University Medical Center, Rotterdam, the Netherlands, told this news organization.
“Endoscopists should strive to obtain ADRs as high as possible” in FIT-positive screenees, Wisse said.
The study was published online in Annals of Internal Medicine.
Small differences, huge consequences
The ADR is a key quality indicator for endoscopists performing colonoscopies for CRC because it reflects their ability to detect lesions and is inversely associated with the risk of interval postcolonoscopy CRC (PCCRC).
Adults with a positive FIT result have a high prevalence of adenomas, leading to high ADRs for endoscopists performing colonoscopies in this setting. However, data on optimal ADRs of endoscopists performing colonoscopies in FIT-based screening are scarce.
To investigate, Dr. Wisse and colleagues evaluated the association between the ADR and interval PCCRC in patients undergoing colonoscopy after a positive FIT result. The analysis included 362 accredited and audited endoscopists who performed 116,360 colonoscopies.
During a median follow-up of 52 months, 209 interval PCCRCs were identified.
The quality of the colonoscopic examinations in FIT-positive screenees was high; endoscopists’ ADRs ranged between 40% and 82%, with a median ADR of 67%.
A higher ADR was strongly associated with lower incidence of interval PCCRC, with an adjusted hazard ratio of 0.95 (95% confidence interval, 0.92-0.97) per 1% increase in ADR.
For endoscopists with an ADR of 60%, the cumulative incidence of interval PCCRC was nearly two times as high as that of endoscopists with an ADR of 70%. The risk was even higher for endoscopists with ADRs less than 60%.
For every 1,000 FIT-positive colonoscopies, the expected number of patients diagnosed with interval PCCRC in 5 years was roughly 2 for endoscopists with an ADR of 70%, compared with almost 3.5 for ADRs of 60% and more than 4.5 for ADRs of 55%.
The authors note that the relatively short duration of follow-up (median, 52 months) could be considered a study limitation.
Quality metrics needed
“These seemingly small ADR differences are deceptive – if an endoscopist increases their ADR by just 10%, their patients’ associated decrease in relative interval cancer risk is a remarkable 40% to 50%,” Douglas Corley, MD, PhD, MPH, from Kaiser Permanente, Oakland, Calif., points out in an accompanying editorial.
Dr. Wisse and colleagues add that FIT-based colonoscopy has now surpassed primary colonoscopy as the most commonly used primary CRC-screening method.
They say there is a need to determine specific ADR targets for FIT-positive screenees to assure quality of colonoscopies and optimize the effect of screening programs by reducing interval PCCRC risk.
For primary colonoscopy, most professional societies recommend an ADR of at least 25% as an indicator of adequate performance. The new study suggests that FIT-positive colonoscopy “demands a markedly higher ADR target than primary colonoscopy,” the authors write.
Dr. Corley said this study provides “an excellent framework for evaluating nine concepts regarding effective quality metrics and how these can illustrate pathways for meaningful metrics for the care of other cancers and disorders.”
Quality metrics must be trustworthy, important, strategic, relevant, actionable, simple, gaming-resistant, time-stamped, and owned, he explained.
Questions concerning goals, plans for implementation of interventions, and the application of goals while maintaining simplicity must be considered in metric development, Dr. Corley said.
The study had no funding.
A version of this article first appeared on Medscape.com.
Adenoma detection rate (ADR) targets for endoscopists performing colonoscopy after a positive fecal immunochemical test (FIT) should be markedly higher compared with ADR targets used in primary colonoscopy, researchers report.
Data from the Netherlands FIT-based screening program show that the ADR is “linearly and inversely” associated with interim colorectal cancer (CRC) occurrence, first author Pieter H.A. Wisse, MD, with Erasmus University Medical Center, Rotterdam, the Netherlands, told this news organization.
“Endoscopists should strive to obtain ADRs as high as possible” in FIT-positive screenees, Wisse said.
The study was published online in Annals of Internal Medicine.
Small differences, huge consequences
The ADR is a key quality indicator for endoscopists performing colonoscopies for CRC because it reflects their ability to detect lesions and is inversely associated with the risk of interval postcolonoscopy CRC (PCCRC).
Adults with a positive FIT result have a high prevalence of adenomas, leading to high ADRs for endoscopists performing colonoscopies in this setting. However, data on optimal ADRs of endoscopists performing colonoscopies in FIT-based screening are scarce.
To investigate, Dr. Wisse and colleagues evaluated the association between the ADR and interval PCCRC in patients undergoing colonoscopy after a positive FIT result. The analysis included 362 accredited and audited endoscopists who performed 116,360 colonoscopies.
During a median follow-up of 52 months, 209 interval PCCRCs were identified.
The quality of the colonoscopic examinations in FIT-positive screenees was high; endoscopists’ ADRs ranged between 40% and 82%, with a median ADR of 67%.
A higher ADR was strongly associated with lower incidence of interval PCCRC, with an adjusted hazard ratio of 0.95 (95% confidence interval, 0.92-0.97) per 1% increase in ADR.
For endoscopists with an ADR of 60%, the cumulative incidence of interval PCCRC was nearly two times as high as that of endoscopists with an ADR of 70%. The risk was even higher for endoscopists with ADRs less than 60%.
For every 1,000 FIT-positive colonoscopies, the expected number of patients diagnosed with interval PCCRC in 5 years was roughly 2 for endoscopists with an ADR of 70%, compared with almost 3.5 for ADRs of 60% and more than 4.5 for ADRs of 55%.
The authors note that the relatively short duration of follow-up (median, 52 months) could be considered a study limitation.
Quality metrics needed
“These seemingly small ADR differences are deceptive – if an endoscopist increases their ADR by just 10%, their patients’ associated decrease in relative interval cancer risk is a remarkable 40% to 50%,” Douglas Corley, MD, PhD, MPH, from Kaiser Permanente, Oakland, Calif., points out in an accompanying editorial.
Dr. Wisse and colleagues add that FIT-based colonoscopy has now surpassed primary colonoscopy as the most commonly used primary CRC-screening method.
They say there is a need to determine specific ADR targets for FIT-positive screenees to assure quality of colonoscopies and optimize the effect of screening programs by reducing interval PCCRC risk.
For primary colonoscopy, most professional societies recommend an ADR of at least 25% as an indicator of adequate performance. The new study suggests that FIT-positive colonoscopy “demands a markedly higher ADR target than primary colonoscopy,” the authors write.
Dr. Corley said this study provides “an excellent framework for evaluating nine concepts regarding effective quality metrics and how these can illustrate pathways for meaningful metrics for the care of other cancers and disorders.”
Quality metrics must be trustworthy, important, strategic, relevant, actionable, simple, gaming-resistant, time-stamped, and owned, he explained.
Questions concerning goals, plans for implementation of interventions, and the application of goals while maintaining simplicity must be considered in metric development, Dr. Corley said.
The study had no funding.
A version of this article first appeared on Medscape.com.
FROM ANNALS OF INTERNAL MEDICINE
Will AI affect the burden of patient surveillance after polyp removal?
While the use of artificial intelligence (AI) during colonoscopy may contribute to improved cancer prevention, it may also add to patient burden in terms of increased colonoscopy frequency and, in turn, health care costs, a new study suggests.
The study, published online in Clinical Gastroenterology and Hepatology, found that colonoscopy plus AI (vs. colonoscopy alone) increased the proportion of patients requiring intensive postpolypectomy colonoscopy surveillance by roughly 35% in the United States and Japan and by about 20% in Europe.
“It’s certainly possible that AI will lead to more frequent surveillance for some patients, but it may balance itself out given that recent surveillance guidelines have pushed off the surveillance interval depending on the size of the polyp,” senior author Seth A. Gross, MD, professor of medicine and clinical chief of the division of gastroenterology and hepatology at New York University Langone Health, said in an interview.
Impact on intensive colonoscopy surveillance
AI tools have been shown to increase the adenoma detection rate (ADR) during colonoscopy, but what impact this has on the frequency of surveillance colonoscopy is unknown.
To investigate, Dr. Gross and an international team conducted a pooled analysis of nine randomized, controlled trials comparing colonoscopy with or without AI detection aids. Five trials were done in China, two in Italy, one in Japan, and one in the United States.
The primary outcome was the proportion of patients recommended to undergo intensive surveillance (that is, 3-year interval).
Among a total of 5,796 patients (mean age, 53 years; 51% male), 2,894 underwent AI-assisted colonoscopy and 2,902 underwent standard colonoscopy without AI assistance.
Higher ADRs in the AI-assisted colonoscopy groups were observed in all of the trials.
When following the U.S. and Japanese guidelines, the proportion of patients recommended for intensive surveillance increased from 8.4% (95% confidence interval, 7.4%-9.5%) in the non-AI group to 11.3% (95% CI, 10.2%-12.6%) in the AI group, which is an absolute difference of 2.9% (95% CI, 1.4%-4.4%) and a risk ratio of 1.35 (95% CI, 1.16-1.57). When following the European guidelines, the increase was from 6.1% (95% CI, 5.3%-7.0%) to 7.4% (95% CI, 6.5%-8.4%), which is an absolute difference of 1.3% (95% CI, 0.01%-2.6%) and a RR of 1.22 (95% CI, 1.01-1.47).
The increases are primarily the result of reallocation of patients from low-risk to intermediate- or high-risk categories, the investigators said. That shift is likely caused by the AI-related increase in adenomas per colonoscopy, which may lead to more effective cancer prevention.
“AI does show us that there’s always an opportunity for improvement when we do screening and surveillance colonoscopy,” Dr. Gross said. “The goal is the same, which is to offer the highest quality colonoscopy exam and the best possible outcome for our patients, and I think that’s what we’re starting to see.”
Cost analysis needed
Dr. Gross noted that he sees a cost-effectiveness analysis of AI in colonoscopy in the future.
“As this becomes more and more part of regular clinical practice, if it’s not being done already, someone will look at the cost-effectiveness of incorporating AI, just like they would for other technologies that come into the area of endoscopy,” Dr. Gross said.
Commenting on the study, Atsushi Sakuraba, MD, PhD, a gastroenterologist with University of Chicago Medicine, said he believes that the “benefit of improved adenoma detection and resulting reduction in colon cancer would outweigh the downsides of increased colonoscopy frequency and cost.”
“However, an economic impact study would need to be performed to answer this question,” added Dr. Sakuraba, who wasn’t involved with this study.
The study had no specific funding. Dr. Gross has served as a consultant for Olympus, Cook, Pentax, Ambu, and Iterative Scopes, and served on the advisory board for Docbot. Dr. Sakuraba reported no relevant financial relationships.
A version of this article first appeared on Medscape.com.
While the use of artificial intelligence (AI) during colonoscopy may contribute to improved cancer prevention, it may also add to patient burden in terms of increased colonoscopy frequency and, in turn, health care costs, a new study suggests.
The study, published online in Clinical Gastroenterology and Hepatology, found that colonoscopy plus AI (vs. colonoscopy alone) increased the proportion of patients requiring intensive postpolypectomy colonoscopy surveillance by roughly 35% in the United States and Japan and by about 20% in Europe.
“It’s certainly possible that AI will lead to more frequent surveillance for some patients, but it may balance itself out given that recent surveillance guidelines have pushed off the surveillance interval depending on the size of the polyp,” senior author Seth A. Gross, MD, professor of medicine and clinical chief of the division of gastroenterology and hepatology at New York University Langone Health, said in an interview.
Impact on intensive colonoscopy surveillance
AI tools have been shown to increase the adenoma detection rate (ADR) during colonoscopy, but what impact this has on the frequency of surveillance colonoscopy is unknown.
To investigate, Dr. Gross and an international team conducted a pooled analysis of nine randomized, controlled trials comparing colonoscopy with or without AI detection aids. Five trials were done in China, two in Italy, one in Japan, and one in the United States.
The primary outcome was the proportion of patients recommended to undergo intensive surveillance (that is, 3-year interval).
Among a total of 5,796 patients (mean age, 53 years; 51% male), 2,894 underwent AI-assisted colonoscopy and 2,902 underwent standard colonoscopy without AI assistance.
Higher ADRs in the AI-assisted colonoscopy groups were observed in all of the trials.
When following the U.S. and Japanese guidelines, the proportion of patients recommended for intensive surveillance increased from 8.4% (95% confidence interval, 7.4%-9.5%) in the non-AI group to 11.3% (95% CI, 10.2%-12.6%) in the AI group, which is an absolute difference of 2.9% (95% CI, 1.4%-4.4%) and a risk ratio of 1.35 (95% CI, 1.16-1.57). When following the European guidelines, the increase was from 6.1% (95% CI, 5.3%-7.0%) to 7.4% (95% CI, 6.5%-8.4%), which is an absolute difference of 1.3% (95% CI, 0.01%-2.6%) and a RR of 1.22 (95% CI, 1.01-1.47).
The increases are primarily the result of reallocation of patients from low-risk to intermediate- or high-risk categories, the investigators said. That shift is likely caused by the AI-related increase in adenomas per colonoscopy, which may lead to more effective cancer prevention.
“AI does show us that there’s always an opportunity for improvement when we do screening and surveillance colonoscopy,” Dr. Gross said. “The goal is the same, which is to offer the highest quality colonoscopy exam and the best possible outcome for our patients, and I think that’s what we’re starting to see.”
Cost analysis needed
Dr. Gross noted that he sees a cost-effectiveness analysis of AI in colonoscopy in the future.
“As this becomes more and more part of regular clinical practice, if it’s not being done already, someone will look at the cost-effectiveness of incorporating AI, just like they would for other technologies that come into the area of endoscopy,” Dr. Gross said.
Commenting on the study, Atsushi Sakuraba, MD, PhD, a gastroenterologist with University of Chicago Medicine, said he believes that the “benefit of improved adenoma detection and resulting reduction in colon cancer would outweigh the downsides of increased colonoscopy frequency and cost.”
“However, an economic impact study would need to be performed to answer this question,” added Dr. Sakuraba, who wasn’t involved with this study.
The study had no specific funding. Dr. Gross has served as a consultant for Olympus, Cook, Pentax, Ambu, and Iterative Scopes, and served on the advisory board for Docbot. Dr. Sakuraba reported no relevant financial relationships.
A version of this article first appeared on Medscape.com.
While the use of artificial intelligence (AI) during colonoscopy may contribute to improved cancer prevention, it may also add to patient burden in terms of increased colonoscopy frequency and, in turn, health care costs, a new study suggests.
The study, published online in Clinical Gastroenterology and Hepatology, found that colonoscopy plus AI (vs. colonoscopy alone) increased the proportion of patients requiring intensive postpolypectomy colonoscopy surveillance by roughly 35% in the United States and Japan and by about 20% in Europe.
“It’s certainly possible that AI will lead to more frequent surveillance for some patients, but it may balance itself out given that recent surveillance guidelines have pushed off the surveillance interval depending on the size of the polyp,” senior author Seth A. Gross, MD, professor of medicine and clinical chief of the division of gastroenterology and hepatology at New York University Langone Health, said in an interview.
Impact on intensive colonoscopy surveillance
AI tools have been shown to increase the adenoma detection rate (ADR) during colonoscopy, but what impact this has on the frequency of surveillance colonoscopy is unknown.
To investigate, Dr. Gross and an international team conducted a pooled analysis of nine randomized, controlled trials comparing colonoscopy with or without AI detection aids. Five trials were done in China, two in Italy, one in Japan, and one in the United States.
The primary outcome was the proportion of patients recommended to undergo intensive surveillance (that is, 3-year interval).
Among a total of 5,796 patients (mean age, 53 years; 51% male), 2,894 underwent AI-assisted colonoscopy and 2,902 underwent standard colonoscopy without AI assistance.
Higher ADRs in the AI-assisted colonoscopy groups were observed in all of the trials.
When following the U.S. and Japanese guidelines, the proportion of patients recommended for intensive surveillance increased from 8.4% (95% confidence interval, 7.4%-9.5%) in the non-AI group to 11.3% (95% CI, 10.2%-12.6%) in the AI group, which is an absolute difference of 2.9% (95% CI, 1.4%-4.4%) and a risk ratio of 1.35 (95% CI, 1.16-1.57). When following the European guidelines, the increase was from 6.1% (95% CI, 5.3%-7.0%) to 7.4% (95% CI, 6.5%-8.4%), which is an absolute difference of 1.3% (95% CI, 0.01%-2.6%) and a RR of 1.22 (95% CI, 1.01-1.47).
The increases are primarily the result of reallocation of patients from low-risk to intermediate- or high-risk categories, the investigators said. That shift is likely caused by the AI-related increase in adenomas per colonoscopy, which may lead to more effective cancer prevention.
“AI does show us that there’s always an opportunity for improvement when we do screening and surveillance colonoscopy,” Dr. Gross said. “The goal is the same, which is to offer the highest quality colonoscopy exam and the best possible outcome for our patients, and I think that’s what we’re starting to see.”
Cost analysis needed
Dr. Gross noted that he sees a cost-effectiveness analysis of AI in colonoscopy in the future.
“As this becomes more and more part of regular clinical practice, if it’s not being done already, someone will look at the cost-effectiveness of incorporating AI, just like they would for other technologies that come into the area of endoscopy,” Dr. Gross said.
Commenting on the study, Atsushi Sakuraba, MD, PhD, a gastroenterologist with University of Chicago Medicine, said he believes that the “benefit of improved adenoma detection and resulting reduction in colon cancer would outweigh the downsides of increased colonoscopy frequency and cost.”
“However, an economic impact study would need to be performed to answer this question,” added Dr. Sakuraba, who wasn’t involved with this study.
The study had no specific funding. Dr. Gross has served as a consultant for Olympus, Cook, Pentax, Ambu, and Iterative Scopes, and served on the advisory board for Docbot. Dr. Sakuraba reported no relevant financial relationships.
A version of this article first appeared on Medscape.com.
FROM CLINICAL GASTROENTEROLOGY AND HEPATOLOGY
AI tool may improve prediction of colorectal cancer recurrence
Using artificial intelligence, researchers have developed an algorithm that can help improve the prediction of colorectal cancer (CRC) recurrence.
The QuantCRC algorithm can identify patients with CRC who might be able to skip chemotherapy, given a low probability of recurrence, and identify those patients at high risk for recurrence who may benefit from more intensive treatment or follow-up, the researchers say.
“For patients with colon cancer, the algorithm gives oncologists another tool to help guide therapy and follow-up,” Rish Pai, MD, PhD, a pathologist at Mayo Clinic, Phoenix, who developed the tool, said in a news release.
The study was published online in the journal Gastroenterology.
The tool is a deep-learning segmentation algorithm developed using 6,468 digitized CRC images. It quantifies 15 features from a CRC image and uses them to improve prediction of recurrence.
“QuantCRC can identify different regions within the tumor and extract quantitative data from these regions,” Dr. Pai explained.
“The algorithm converts an image into a set of numbers that is unique to that tumor. The large number of tumors that we analyzed allowed us to learn which features were most predictive of tumor behavior. We can now apply what we have learned to new colon cancers to predict how the tumor will behave,” Dr. Pai said.
The researchers developed a prognostic model incorporating stage, mismatch repair, and QuantCRC that resulted in a concordance (c)-index of 0.714 in the internal test and 0.744 in the external cohort. Removing QuantCRC from the model reduced the c-index to 0.679 in the external cohort.
Using QuantCRC, they identified prognostic risk groups for recurrence, which provided a hazard ratio of 2.24 for low- versus high-risk stage III CRC and 2.36 for low- versus high-risk stage II CRC, in the external cohort after adjusting for established risk factors.
The predicted median 36-month recurrence rate for high-risk stage III CRC was 32.7% versus 13.4% for low-risk stage III CRC and 15.8% for high-risk stage II CRC versus 5.4% for low-risk stage II CRC, the researchers report.
QuantCRC provides a “powerful adjunct” to routine pathologic reporting of CRC, and a prognostic model using QuantCRC can improve prediction of recurrence-free survival, they write.
Looking ahead, Dr. Pai plans to use QuantCRC to better understand mechanisms of tumor recurrence and see if it can predict the response to certain treatments, like immunotherapy, he said.
Funding for this study was provided in part by the Colon Cancer Family Registry, which is supported in part by funding from the National Cancer Institute and National Institutes of Health. Dr. Pai reports consulting income from Alimentiv, Eli Lilly, AbbVie, Allergan, Genentech, and PathAI outside of the submitted work.
A version of this article first appeared on Medscape.com.
Using artificial intelligence, researchers have developed an algorithm that can help improve the prediction of colorectal cancer (CRC) recurrence.
The QuantCRC algorithm can identify patients with CRC who might be able to skip chemotherapy, given a low probability of recurrence, and identify those patients at high risk for recurrence who may benefit from more intensive treatment or follow-up, the researchers say.
“For patients with colon cancer, the algorithm gives oncologists another tool to help guide therapy and follow-up,” Rish Pai, MD, PhD, a pathologist at Mayo Clinic, Phoenix, who developed the tool, said in a news release.
The study was published online in the journal Gastroenterology.
The tool is a deep-learning segmentation algorithm developed using 6,468 digitized CRC images. It quantifies 15 features from a CRC image and uses them to improve prediction of recurrence.
“QuantCRC can identify different regions within the tumor and extract quantitative data from these regions,” Dr. Pai explained.
“The algorithm converts an image into a set of numbers that is unique to that tumor. The large number of tumors that we analyzed allowed us to learn which features were most predictive of tumor behavior. We can now apply what we have learned to new colon cancers to predict how the tumor will behave,” Dr. Pai said.
The researchers developed a prognostic model incorporating stage, mismatch repair, and QuantCRC that resulted in a concordance (c)-index of 0.714 in the internal test and 0.744 in the external cohort. Removing QuantCRC from the model reduced the c-index to 0.679 in the external cohort.
Using QuantCRC, they identified prognostic risk groups for recurrence, which provided a hazard ratio of 2.24 for low- versus high-risk stage III CRC and 2.36 for low- versus high-risk stage II CRC, in the external cohort after adjusting for established risk factors.
The predicted median 36-month recurrence rate for high-risk stage III CRC was 32.7% versus 13.4% for low-risk stage III CRC and 15.8% for high-risk stage II CRC versus 5.4% for low-risk stage II CRC, the researchers report.
QuantCRC provides a “powerful adjunct” to routine pathologic reporting of CRC, and a prognostic model using QuantCRC can improve prediction of recurrence-free survival, they write.
Looking ahead, Dr. Pai plans to use QuantCRC to better understand mechanisms of tumor recurrence and see if it can predict the response to certain treatments, like immunotherapy, he said.
Funding for this study was provided in part by the Colon Cancer Family Registry, which is supported in part by funding from the National Cancer Institute and National Institutes of Health. Dr. Pai reports consulting income from Alimentiv, Eli Lilly, AbbVie, Allergan, Genentech, and PathAI outside of the submitted work.
A version of this article first appeared on Medscape.com.
Using artificial intelligence, researchers have developed an algorithm that can help improve the prediction of colorectal cancer (CRC) recurrence.
The QuantCRC algorithm can identify patients with CRC who might be able to skip chemotherapy, given a low probability of recurrence, and identify those patients at high risk for recurrence who may benefit from more intensive treatment or follow-up, the researchers say.
“For patients with colon cancer, the algorithm gives oncologists another tool to help guide therapy and follow-up,” Rish Pai, MD, PhD, a pathologist at Mayo Clinic, Phoenix, who developed the tool, said in a news release.
The study was published online in the journal Gastroenterology.
The tool is a deep-learning segmentation algorithm developed using 6,468 digitized CRC images. It quantifies 15 features from a CRC image and uses them to improve prediction of recurrence.
“QuantCRC can identify different regions within the tumor and extract quantitative data from these regions,” Dr. Pai explained.
“The algorithm converts an image into a set of numbers that is unique to that tumor. The large number of tumors that we analyzed allowed us to learn which features were most predictive of tumor behavior. We can now apply what we have learned to new colon cancers to predict how the tumor will behave,” Dr. Pai said.
The researchers developed a prognostic model incorporating stage, mismatch repair, and QuantCRC that resulted in a concordance (c)-index of 0.714 in the internal test and 0.744 in the external cohort. Removing QuantCRC from the model reduced the c-index to 0.679 in the external cohort.
Using QuantCRC, they identified prognostic risk groups for recurrence, which provided a hazard ratio of 2.24 for low- versus high-risk stage III CRC and 2.36 for low- versus high-risk stage II CRC, in the external cohort after adjusting for established risk factors.
The predicted median 36-month recurrence rate for high-risk stage III CRC was 32.7% versus 13.4% for low-risk stage III CRC and 15.8% for high-risk stage II CRC versus 5.4% for low-risk stage II CRC, the researchers report.
QuantCRC provides a “powerful adjunct” to routine pathologic reporting of CRC, and a prognostic model using QuantCRC can improve prediction of recurrence-free survival, they write.
Looking ahead, Dr. Pai plans to use QuantCRC to better understand mechanisms of tumor recurrence and see if it can predict the response to certain treatments, like immunotherapy, he said.
Funding for this study was provided in part by the Colon Cancer Family Registry, which is supported in part by funding from the National Cancer Institute and National Institutes of Health. Dr. Pai reports consulting income from Alimentiv, Eli Lilly, AbbVie, Allergan, Genentech, and PathAI outside of the submitted work.
A version of this article first appeared on Medscape.com.
FROM GASTROENTEROLOGY
Nifedipine during labor controls BP in severe preeclampsia
Women with preeclampsia with severe features benefit from treatment with oral nifedipine during labor and delivery, results of a randomized controlled trial suggest.
The study showed that intrapartum administration of extended-release oral nifedipine was safe and reduced the need for acute intravenous or immediate-release oral hypertensive therapy. There was a trend toward fewer cesarean deliveries and less need for neonatal intensive care.
The results suggest that providers “consider initiating long-acting nifedipine every 24 hours for individuals with preeclampsia with severe features who are undergoing induction of labor,” Erin M. Cleary, MD, with the Ohio State University, Columbus, told this news organization.
“There is no need to wait until patients require one or more doses of acute [antihypertensive] therapy before starting long-acting nifedipine, as long as they otherwise meet criteria for preeclampsia with severe features,” Dr. Cleary said.
The study was published online in Hypertension.
Clear benefits for mom and baby
Preeclampsia complicates up to 8% of pregnancies and often leads to significant maternal and perinatal morbidity.
“We know that bringing down very high blood pressure to a safer range will help prevent maternal and fetal complications. However, besides rapid-acting, intravenous medicines for severe hypertension during pregnancy, optimal management for hypertension during the labor and delivery process has not been studied,” Dr. Cleary explains in a news release.
In a randomized, triple-blind, placebo-controlled study, the researchers assessed whether treatment with long-acting nifedipine could prevent severe hypertension in women with a singleton or twin gestation and preeclampsia with severe features, as defined according to American College of Obstetrics and Gynecology criteria.
During induction of labor between 22 and 41 weeks’ gestation, 55 women were assigned to 30-mg oral extended-release nifedipine, and 55 received matching placebo, administered every 24 hours until delivery.
The primary outcome was receipt of one or more doses of acute hypertension therapy for blood pressure of at least 160/110 mm Hg that was sustained for 10 minutes or longer.
The primary outcome occurred in significantly fewer women in the nifedipine group than in the placebo group (34% vs. 55%; relative risk, 0.62; 95% CI, 0.39-0.97; number needed to treat, 4.7).
Fewer women in the nifedipine group than in the placebo group required cesarean delivery, although this difference did not meet statistical significance (21% vs. 35%; RR, 0.60; 95% CI, 0.31-1.15).
There was no between-group difference in the rate of hypotensive episodes, including symptomatic hypotension requiring phenylephrine for pressure support following neuraxial anesthesia (9.4% vs. 8.2%; RR, 1.15; 95% CI, 0.33-4.06).
After delivery, there was no difference in the rate of persistently severe blood pressure that required acute therapy and maintenance therapy at time of discharge home.
Birth weight and rates of births of neonates who were small for gestational age were similar in the two groups. There was a trend for decreased rates of neonatal intensive care unit admission among infants born to mothers who received nifedipine (29% vs. 47%; RR, 0.62; 95% CI, 0.37-1.02).
The neonatal composite outcome was also similar between the nifedipine group and the placebo group (36% vs. 41%; RR, 0.83; 95% CI, 0.51-1.37). The composite outcome included Apgar score of less than 7 at 5 minutes, hyperbilirubinemia requiring phototherapy, hypoglycemia requiring intravenous therapy, or supplemental oxygen therapy beyond the first 24 hours of life.
“Our findings support the growing trend in more active management of hypertension in pregnancy with daily maintenance medications,” Dr. Cleary and colleagues note in their article.
“Even in the absence of preeclampsia, emerging research suggests pregnant individuals may benefit from initiating and titrating antihypertensive therapy at goals similar to the nonobstetric population,” they add.
Potentially practice changing
Reached for comment, Vesna Garovic, MD, PhD, with Mayo Clinic, Rochester, Minn., said that this is an “important initial paper to start a very important conversation about blood pressure treatment goals in preeclampsia.”
Dr. Garovic noted that for chronic hypertension in pregnancy, the blood pressure treatment goal is now less than or equal to 140/90 mm Hg.
“However, this does not apply to preeclampsia, where quite high blood pressures, such 160/110 mm Hg or higher, are still allowed before treatment is considered,” Dr. Garovic said.
“This study shows that as soon as you reach that level, treatment with oral nifedipine should be initiated and that timely initiation of oral nifedipine may optimize blood pressure control and decrease the need for intravenous therapy subsequently, and that has good effects on the mother without adversely affecting the baby,” Dr. Garovic said.
“This is potentially practice changing,” Dr. Garovic added. “But the elephant in the room is the question of why we are waiting for blood pressure to reach such dangerous levels before initiating treatment, and whether initiating treatment at a blood pressure of 140/90 or higher may prevent blood pressure reaching these high levels and women developing complications that are the consequence of severe hypertension.”
The study was funded by the Ohio State University’s Department of Obstetrics and Gynecology. Dr. Cleary and Dr. Garovic have disclosed no relevant financial relationships.
A version of this article first appeared on Medscape.com.
Women with preeclampsia with severe features benefit from treatment with oral nifedipine during labor and delivery, results of a randomized controlled trial suggest.
The study showed that intrapartum administration of extended-release oral nifedipine was safe and reduced the need for acute intravenous or immediate-release oral hypertensive therapy. There was a trend toward fewer cesarean deliveries and less need for neonatal intensive care.
The results suggest that providers “consider initiating long-acting nifedipine every 24 hours for individuals with preeclampsia with severe features who are undergoing induction of labor,” Erin M. Cleary, MD, with the Ohio State University, Columbus, told this news organization.
“There is no need to wait until patients require one or more doses of acute [antihypertensive] therapy before starting long-acting nifedipine, as long as they otherwise meet criteria for preeclampsia with severe features,” Dr. Cleary said.
The study was published online in Hypertension.
Clear benefits for mom and baby
Preeclampsia complicates up to 8% of pregnancies and often leads to significant maternal and perinatal morbidity.
“We know that bringing down very high blood pressure to a safer range will help prevent maternal and fetal complications. However, besides rapid-acting, intravenous medicines for severe hypertension during pregnancy, optimal management for hypertension during the labor and delivery process has not been studied,” Dr. Cleary explains in a news release.
In a randomized, triple-blind, placebo-controlled study, the researchers assessed whether treatment with long-acting nifedipine could prevent severe hypertension in women with a singleton or twin gestation and preeclampsia with severe features, as defined according to American College of Obstetrics and Gynecology criteria.
During induction of labor between 22 and 41 weeks’ gestation, 55 women were assigned to 30-mg oral extended-release nifedipine, and 55 received matching placebo, administered every 24 hours until delivery.
The primary outcome was receipt of one or more doses of acute hypertension therapy for blood pressure of at least 160/110 mm Hg that was sustained for 10 minutes or longer.
The primary outcome occurred in significantly fewer women in the nifedipine group than in the placebo group (34% vs. 55%; relative risk, 0.62; 95% CI, 0.39-0.97; number needed to treat, 4.7).
Fewer women in the nifedipine group than in the placebo group required cesarean delivery, although this difference did not meet statistical significance (21% vs. 35%; RR, 0.60; 95% CI, 0.31-1.15).
There was no between-group difference in the rate of hypotensive episodes, including symptomatic hypotension requiring phenylephrine for pressure support following neuraxial anesthesia (9.4% vs. 8.2%; RR, 1.15; 95% CI, 0.33-4.06).
After delivery, there was no difference in the rate of persistently severe blood pressure that required acute therapy and maintenance therapy at time of discharge home.
Birth weight and rates of births of neonates who were small for gestational age were similar in the two groups. There was a trend for decreased rates of neonatal intensive care unit admission among infants born to mothers who received nifedipine (29% vs. 47%; RR, 0.62; 95% CI, 0.37-1.02).
The neonatal composite outcome was also similar between the nifedipine group and the placebo group (36% vs. 41%; RR, 0.83; 95% CI, 0.51-1.37). The composite outcome included Apgar score of less than 7 at 5 minutes, hyperbilirubinemia requiring phototherapy, hypoglycemia requiring intravenous therapy, or supplemental oxygen therapy beyond the first 24 hours of life.
“Our findings support the growing trend in more active management of hypertension in pregnancy with daily maintenance medications,” Dr. Cleary and colleagues note in their article.
“Even in the absence of preeclampsia, emerging research suggests pregnant individuals may benefit from initiating and titrating antihypertensive therapy at goals similar to the nonobstetric population,” they add.
Potentially practice changing
Reached for comment, Vesna Garovic, MD, PhD, with Mayo Clinic, Rochester, Minn., said that this is an “important initial paper to start a very important conversation about blood pressure treatment goals in preeclampsia.”
Dr. Garovic noted that for chronic hypertension in pregnancy, the blood pressure treatment goal is now less than or equal to 140/90 mm Hg.
“However, this does not apply to preeclampsia, where quite high blood pressures, such 160/110 mm Hg or higher, are still allowed before treatment is considered,” Dr. Garovic said.
“This study shows that as soon as you reach that level, treatment with oral nifedipine should be initiated and that timely initiation of oral nifedipine may optimize blood pressure control and decrease the need for intravenous therapy subsequently, and that has good effects on the mother without adversely affecting the baby,” Dr. Garovic said.
“This is potentially practice changing,” Dr. Garovic added. “But the elephant in the room is the question of why we are waiting for blood pressure to reach such dangerous levels before initiating treatment, and whether initiating treatment at a blood pressure of 140/90 or higher may prevent blood pressure reaching these high levels and women developing complications that are the consequence of severe hypertension.”
The study was funded by the Ohio State University’s Department of Obstetrics and Gynecology. Dr. Cleary and Dr. Garovic have disclosed no relevant financial relationships.
A version of this article first appeared on Medscape.com.
Women with preeclampsia with severe features benefit from treatment with oral nifedipine during labor and delivery, results of a randomized controlled trial suggest.
The study showed that intrapartum administration of extended-release oral nifedipine was safe and reduced the need for acute intravenous or immediate-release oral hypertensive therapy. There was a trend toward fewer cesarean deliveries and less need for neonatal intensive care.
The results suggest that providers “consider initiating long-acting nifedipine every 24 hours for individuals with preeclampsia with severe features who are undergoing induction of labor,” Erin M. Cleary, MD, with the Ohio State University, Columbus, told this news organization.
“There is no need to wait until patients require one or more doses of acute [antihypertensive] therapy before starting long-acting nifedipine, as long as they otherwise meet criteria for preeclampsia with severe features,” Dr. Cleary said.
The study was published online in Hypertension.
Clear benefits for mom and baby
Preeclampsia complicates up to 8% of pregnancies and often leads to significant maternal and perinatal morbidity.
“We know that bringing down very high blood pressure to a safer range will help prevent maternal and fetal complications. However, besides rapid-acting, intravenous medicines for severe hypertension during pregnancy, optimal management for hypertension during the labor and delivery process has not been studied,” Dr. Cleary explains in a news release.
In a randomized, triple-blind, placebo-controlled study, the researchers assessed whether treatment with long-acting nifedipine could prevent severe hypertension in women with a singleton or twin gestation and preeclampsia with severe features, as defined according to American College of Obstetrics and Gynecology criteria.
During induction of labor between 22 and 41 weeks’ gestation, 55 women were assigned to 30-mg oral extended-release nifedipine, and 55 received matching placebo, administered every 24 hours until delivery.
The primary outcome was receipt of one or more doses of acute hypertension therapy for blood pressure of at least 160/110 mm Hg that was sustained for 10 minutes or longer.
The primary outcome occurred in significantly fewer women in the nifedipine group than in the placebo group (34% vs. 55%; relative risk, 0.62; 95% CI, 0.39-0.97; number needed to treat, 4.7).
Fewer women in the nifedipine group than in the placebo group required cesarean delivery, although this difference did not meet statistical significance (21% vs. 35%; RR, 0.60; 95% CI, 0.31-1.15).
There was no between-group difference in the rate of hypotensive episodes, including symptomatic hypotension requiring phenylephrine for pressure support following neuraxial anesthesia (9.4% vs. 8.2%; RR, 1.15; 95% CI, 0.33-4.06).
After delivery, there was no difference in the rate of persistently severe blood pressure that required acute therapy and maintenance therapy at time of discharge home.
Birth weight and rates of births of neonates who were small for gestational age were similar in the two groups. There was a trend for decreased rates of neonatal intensive care unit admission among infants born to mothers who received nifedipine (29% vs. 47%; RR, 0.62; 95% CI, 0.37-1.02).
The neonatal composite outcome was also similar between the nifedipine group and the placebo group (36% vs. 41%; RR, 0.83; 95% CI, 0.51-1.37). The composite outcome included Apgar score of less than 7 at 5 minutes, hyperbilirubinemia requiring phototherapy, hypoglycemia requiring intravenous therapy, or supplemental oxygen therapy beyond the first 24 hours of life.
“Our findings support the growing trend in more active management of hypertension in pregnancy with daily maintenance medications,” Dr. Cleary and colleagues note in their article.
“Even in the absence of preeclampsia, emerging research suggests pregnant individuals may benefit from initiating and titrating antihypertensive therapy at goals similar to the nonobstetric population,” they add.
Potentially practice changing
Reached for comment, Vesna Garovic, MD, PhD, with Mayo Clinic, Rochester, Minn., said that this is an “important initial paper to start a very important conversation about blood pressure treatment goals in preeclampsia.”
Dr. Garovic noted that for chronic hypertension in pregnancy, the blood pressure treatment goal is now less than or equal to 140/90 mm Hg.
“However, this does not apply to preeclampsia, where quite high blood pressures, such 160/110 mm Hg or higher, are still allowed before treatment is considered,” Dr. Garovic said.
“This study shows that as soon as you reach that level, treatment with oral nifedipine should be initiated and that timely initiation of oral nifedipine may optimize blood pressure control and decrease the need for intravenous therapy subsequently, and that has good effects on the mother without adversely affecting the baby,” Dr. Garovic said.
“This is potentially practice changing,” Dr. Garovic added. “But the elephant in the room is the question of why we are waiting for blood pressure to reach such dangerous levels before initiating treatment, and whether initiating treatment at a blood pressure of 140/90 or higher may prevent blood pressure reaching these high levels and women developing complications that are the consequence of severe hypertension.”
The study was funded by the Ohio State University’s Department of Obstetrics and Gynecology. Dr. Cleary and Dr. Garovic have disclosed no relevant financial relationships.
A version of this article first appeared on Medscape.com.
FROM HYPERTENSION
Is early-onset cancer an emerging global epidemic?
, according to a recent review.
While the rising incidence of early-onset colorectal cancer (CRC) is a well-documented problem, the trend appears to extend far beyond CRC. The authors traced patterns of early-onset cancer diagnoses across 14 different cancer types, including breast, prostate, and thyroid, over the past 3 decades and found increases in many countries.
Among the 14 cancers explored, eight relate to the digestive system, which highlights the potential role diet and the oral and gut microbiome may play in cancer risk, the authors noted.
And many of the factors that appear to influence cancer risk – such as diet, exercise, sleep, and vaccination against HPV and other cancer-causing microorganisms – are modifiable.
“[Our] immediate goals should be to raise awareness of the early-onset cancer epidemic and reduce exposure to [these] risk factors,” authors Tomotaka Ugai, MD, PhD, and Shuji Ogino, MD, PhD, with Harvard School of Public Health, Boston, noted in a joint email.
The paper was published in Nature Reviews Clinical Oncology.
While the rise in cancer screenings has contributed to earlier detection of cancers, a genuine increase in the incidence of some early-onset cancers also appears to be happening.
In the current review, Dr. Ugai, Dr. Ogino, and colleagues reviewed the literature and mapped trends in the incidence of 14 cancer types among 20- to 49-year-old adults in 44 countries between 2002 and 2012.
The authors found that, since the 1990s, the incidence of early-onset cancers in the breast, colorectum, endometrium, esophagus, extrahepatic bile duct, gallbladder, head/neck, kidney, liver, bone marrow, pancreas, prostate, stomach, and thyroid, has increased around the world. Looking at the United States, for instance, the average annual percent changes for kidney cancer was 3.6% in women and 4.1% in men and for multiple myeloma was 2% in women and 3% in men for 2002 to 2012.
This overall trend could reflect increased exposures to risk factors in early life and young adulthood, although “specific effects of individual exposures remain largely unknown,” the authors acknowledged.
Since the mid-20th century, substantial changes have occurred in diet, sleep, smoking, obesity, type 2 diabetes, and environmental exposures – all of which may influence the gut microbiome or interact with our genes to increase the incidence of early-onset cancers, the authors explained. For instance, obesity, smoking, and alcohol are all established risk factors for pancreatic cancer and have been linked with early-onset disease risk as well.
“Cancer is a multifactorial disease, and we are aware of the importance of genetics as a risk factor and screening for early detection, but this paper importantly brings to light the importance of correctable lifestyle habits that may slow the rise of early onset cancers,” oncologist Marleen Meyers, MD, director of the survivorship program at NYU Langone Perlmutter Cancer Center, who wasn’t involved in the review, said in an interview.
Although modifiable factors such as diet and exercise may ease the burden of these cancers, such changes are often difficult to implement, Dr. Meyers added. In addition, understanding the impact that certain factors, such as alcohol, obesity, physical activity, and delayed reproduction play in cancer risk requires more research to tease out, but “there is enough reason at this point to address these risk factors for both personal and public health benefits,” Dr. Meyers said.
Support for this research was provided in part by the U.S. National Institutes of Health, Cancer Research UK, Prevent Cancer Foundation, Japan Society for the Promotion of Science, and the Mishima Kaiun Memorial Foundation. Dr. Ugai, Dr. Ogino, and Dr. Meyers have disclosed no relevant financial relationships.
A version of this article first appeared on Medscape.com.
, according to a recent review.
While the rising incidence of early-onset colorectal cancer (CRC) is a well-documented problem, the trend appears to extend far beyond CRC. The authors traced patterns of early-onset cancer diagnoses across 14 different cancer types, including breast, prostate, and thyroid, over the past 3 decades and found increases in many countries.
Among the 14 cancers explored, eight relate to the digestive system, which highlights the potential role diet and the oral and gut microbiome may play in cancer risk, the authors noted.
And many of the factors that appear to influence cancer risk – such as diet, exercise, sleep, and vaccination against HPV and other cancer-causing microorganisms – are modifiable.
“[Our] immediate goals should be to raise awareness of the early-onset cancer epidemic and reduce exposure to [these] risk factors,” authors Tomotaka Ugai, MD, PhD, and Shuji Ogino, MD, PhD, with Harvard School of Public Health, Boston, noted in a joint email.
The paper was published in Nature Reviews Clinical Oncology.
While the rise in cancer screenings has contributed to earlier detection of cancers, a genuine increase in the incidence of some early-onset cancers also appears to be happening.
In the current review, Dr. Ugai, Dr. Ogino, and colleagues reviewed the literature and mapped trends in the incidence of 14 cancer types among 20- to 49-year-old adults in 44 countries between 2002 and 2012.
The authors found that, since the 1990s, the incidence of early-onset cancers in the breast, colorectum, endometrium, esophagus, extrahepatic bile duct, gallbladder, head/neck, kidney, liver, bone marrow, pancreas, prostate, stomach, and thyroid, has increased around the world. Looking at the United States, for instance, the average annual percent changes for kidney cancer was 3.6% in women and 4.1% in men and for multiple myeloma was 2% in women and 3% in men for 2002 to 2012.
This overall trend could reflect increased exposures to risk factors in early life and young adulthood, although “specific effects of individual exposures remain largely unknown,” the authors acknowledged.
Since the mid-20th century, substantial changes have occurred in diet, sleep, smoking, obesity, type 2 diabetes, and environmental exposures – all of which may influence the gut microbiome or interact with our genes to increase the incidence of early-onset cancers, the authors explained. For instance, obesity, smoking, and alcohol are all established risk factors for pancreatic cancer and have been linked with early-onset disease risk as well.
“Cancer is a multifactorial disease, and we are aware of the importance of genetics as a risk factor and screening for early detection, but this paper importantly brings to light the importance of correctable lifestyle habits that may slow the rise of early onset cancers,” oncologist Marleen Meyers, MD, director of the survivorship program at NYU Langone Perlmutter Cancer Center, who wasn’t involved in the review, said in an interview.
Although modifiable factors such as diet and exercise may ease the burden of these cancers, such changes are often difficult to implement, Dr. Meyers added. In addition, understanding the impact that certain factors, such as alcohol, obesity, physical activity, and delayed reproduction play in cancer risk requires more research to tease out, but “there is enough reason at this point to address these risk factors for both personal and public health benefits,” Dr. Meyers said.
Support for this research was provided in part by the U.S. National Institutes of Health, Cancer Research UK, Prevent Cancer Foundation, Japan Society for the Promotion of Science, and the Mishima Kaiun Memorial Foundation. Dr. Ugai, Dr. Ogino, and Dr. Meyers have disclosed no relevant financial relationships.
A version of this article first appeared on Medscape.com.
, according to a recent review.
While the rising incidence of early-onset colorectal cancer (CRC) is a well-documented problem, the trend appears to extend far beyond CRC. The authors traced patterns of early-onset cancer diagnoses across 14 different cancer types, including breast, prostate, and thyroid, over the past 3 decades and found increases in many countries.
Among the 14 cancers explored, eight relate to the digestive system, which highlights the potential role diet and the oral and gut microbiome may play in cancer risk, the authors noted.
And many of the factors that appear to influence cancer risk – such as diet, exercise, sleep, and vaccination against HPV and other cancer-causing microorganisms – are modifiable.
“[Our] immediate goals should be to raise awareness of the early-onset cancer epidemic and reduce exposure to [these] risk factors,” authors Tomotaka Ugai, MD, PhD, and Shuji Ogino, MD, PhD, with Harvard School of Public Health, Boston, noted in a joint email.
The paper was published in Nature Reviews Clinical Oncology.
While the rise in cancer screenings has contributed to earlier detection of cancers, a genuine increase in the incidence of some early-onset cancers also appears to be happening.
In the current review, Dr. Ugai, Dr. Ogino, and colleagues reviewed the literature and mapped trends in the incidence of 14 cancer types among 20- to 49-year-old adults in 44 countries between 2002 and 2012.
The authors found that, since the 1990s, the incidence of early-onset cancers in the breast, colorectum, endometrium, esophagus, extrahepatic bile duct, gallbladder, head/neck, kidney, liver, bone marrow, pancreas, prostate, stomach, and thyroid, has increased around the world. Looking at the United States, for instance, the average annual percent changes for kidney cancer was 3.6% in women and 4.1% in men and for multiple myeloma was 2% in women and 3% in men for 2002 to 2012.
This overall trend could reflect increased exposures to risk factors in early life and young adulthood, although “specific effects of individual exposures remain largely unknown,” the authors acknowledged.
Since the mid-20th century, substantial changes have occurred in diet, sleep, smoking, obesity, type 2 diabetes, and environmental exposures – all of which may influence the gut microbiome or interact with our genes to increase the incidence of early-onset cancers, the authors explained. For instance, obesity, smoking, and alcohol are all established risk factors for pancreatic cancer and have been linked with early-onset disease risk as well.
“Cancer is a multifactorial disease, and we are aware of the importance of genetics as a risk factor and screening for early detection, but this paper importantly brings to light the importance of correctable lifestyle habits that may slow the rise of early onset cancers,” oncologist Marleen Meyers, MD, director of the survivorship program at NYU Langone Perlmutter Cancer Center, who wasn’t involved in the review, said in an interview.
Although modifiable factors such as diet and exercise may ease the burden of these cancers, such changes are often difficult to implement, Dr. Meyers added. In addition, understanding the impact that certain factors, such as alcohol, obesity, physical activity, and delayed reproduction play in cancer risk requires more research to tease out, but “there is enough reason at this point to address these risk factors for both personal and public health benefits,” Dr. Meyers said.
Support for this research was provided in part by the U.S. National Institutes of Health, Cancer Research UK, Prevent Cancer Foundation, Japan Society for the Promotion of Science, and the Mishima Kaiun Memorial Foundation. Dr. Ugai, Dr. Ogino, and Dr. Meyers have disclosed no relevant financial relationships.
A version of this article first appeared on Medscape.com.
Deep brain stimulation effective for OCD, but barriers persist
“DBS is a viable option for treatment-resistant OCD that can be expected to produce significant clinical benefit in about two out of three cases,” study investigator Wayne Goodman, MD, chair, department of psychiatry and behavioral sciences, Baylor College of Medicine, Houston, said in a statement.
However, “challenges in access still prevent many eligible individuals from getting this life-improving therapy,” co-investigator Sameer Sheth, MD, PhD, vice chair of research, department of neurosurgery at Baylor, told this news organization.
The study was published online in the Journal of Neurology, Neurosurgery and Psychiatry.
50% reduction in symptoms
The analysis included 34 studies conducted from 2005 to 2021, including 9 randomized controlled trials (RCTs) and 25 non-RCTs, involving 352 patients with treatment-resistant OCD.
Both RCTs and non-RCTs had a predominantly low risk of bias.
The results show an average 14.3-point, or 47%, reduction (P < .01) in Yale-Brown Obsessive-Compulsive Scale scores with DBS at last follow-up, with no significant difference between RCTs and non-RCTs.
Two-thirds (66%) of patients fully responded to the DBS at last follow-up, the authors found.
DBS for treatment-resistant OCD also had a “strong” effect on comorbid depression, with 47% of patients considered “full responders” relative to their preoperative (baseline) depression status and an additional 16% considered partial responders (with a 30%-49% reduction in pre/post-treatment depressive symptoms).
“The demonstrated effects of DBS in this report are even more impressive when one considers that these patients have failed numerous behavioral and pharmacological therapies,” said study investigator Eric Storch, PhD, professor and vice chair for the department of psychiatry and behavioral sciences at Baylor.
The rate of hardware-related complications was roughly 8% and infection rate was about 4% – in line with other data.
This study “offers hope for patients with severe symptoms of OCD whose disorder did not respond to a range of conventional therapies,” Dr. Goodman said.
The bigger story
Dr. Sheth said the challenges in getting appropriate OCD patients access to DBS are multifactorial.
“Psychiatrists and general practitioners and even patients are not aware of it, and insurance company policies are often out of date and ignorant of recent data such as those in this study,” Dr. Sheth explained.
“Hopefully, improved awareness in the future will reverse these trends and lead to increased access for patients in need of this therapy,” Dr. Sheth said.
Access to DBS for OCD is clearly the “bigger story” here, Brian Kopell, MD, who was not involved in the study, told this news organization.
This meta-analysis “confirms what all of us that do this with some regularity know – that DBS for OCD can be extremely helpful in patients who are refractory to standard OCD therapies,” said Dr. Kopell, department of neurosurgery and director, Center for Neuromodulation, Mount Sinai Health System, New York.
Yet, there is a dramatic difference in getting reimbursement for DBS in a case of dystonia vs. OCD.
In the United States, DBS has humanitarian device exemption for use in both dystonia and OCD, Dr. Kopell noted.
“Yet because dystonia is a movement disorder, I can get DBS for dystonia paid for by most private insurance – no big deal,” Dr. Kopell said.
“But OCD, because it’s deemed a psychiatric disorder, is treated like the redheaded stepchild and it’s monumentally hard to get insurance to pay for it – and if you can’t pay for it, you can’t do it. Simple as that,” he added.
The study was supported by the McNair Foundation and the Dana Foundation. Dr. Storch is a consultant for Biohaven and owns stock in nView. Dr. Sheth is a consultant for Boston Scientific, NeuroPace, Abbott, and Zimmer Biomet. Dr. Kopell reports no relevant financial relationships.
A version of this article first appeared on Medscape.com.
“DBS is a viable option for treatment-resistant OCD that can be expected to produce significant clinical benefit in about two out of three cases,” study investigator Wayne Goodman, MD, chair, department of psychiatry and behavioral sciences, Baylor College of Medicine, Houston, said in a statement.
However, “challenges in access still prevent many eligible individuals from getting this life-improving therapy,” co-investigator Sameer Sheth, MD, PhD, vice chair of research, department of neurosurgery at Baylor, told this news organization.
The study was published online in the Journal of Neurology, Neurosurgery and Psychiatry.
50% reduction in symptoms
The analysis included 34 studies conducted from 2005 to 2021, including 9 randomized controlled trials (RCTs) and 25 non-RCTs, involving 352 patients with treatment-resistant OCD.
Both RCTs and non-RCTs had a predominantly low risk of bias.
The results show an average 14.3-point, or 47%, reduction (P < .01) in Yale-Brown Obsessive-Compulsive Scale scores with DBS at last follow-up, with no significant difference between RCTs and non-RCTs.
Two-thirds (66%) of patients fully responded to the DBS at last follow-up, the authors found.
DBS for treatment-resistant OCD also had a “strong” effect on comorbid depression, with 47% of patients considered “full responders” relative to their preoperative (baseline) depression status and an additional 16% considered partial responders (with a 30%-49% reduction in pre/post-treatment depressive symptoms).
“The demonstrated effects of DBS in this report are even more impressive when one considers that these patients have failed numerous behavioral and pharmacological therapies,” said study investigator Eric Storch, PhD, professor and vice chair for the department of psychiatry and behavioral sciences at Baylor.
The rate of hardware-related complications was roughly 8% and infection rate was about 4% – in line with other data.
This study “offers hope for patients with severe symptoms of OCD whose disorder did not respond to a range of conventional therapies,” Dr. Goodman said.
The bigger story
Dr. Sheth said the challenges in getting appropriate OCD patients access to DBS are multifactorial.
“Psychiatrists and general practitioners and even patients are not aware of it, and insurance company policies are often out of date and ignorant of recent data such as those in this study,” Dr. Sheth explained.
“Hopefully, improved awareness in the future will reverse these trends and lead to increased access for patients in need of this therapy,” Dr. Sheth said.
Access to DBS for OCD is clearly the “bigger story” here, Brian Kopell, MD, who was not involved in the study, told this news organization.
This meta-analysis “confirms what all of us that do this with some regularity know – that DBS for OCD can be extremely helpful in patients who are refractory to standard OCD therapies,” said Dr. Kopell, department of neurosurgery and director, Center for Neuromodulation, Mount Sinai Health System, New York.
Yet, there is a dramatic difference in getting reimbursement for DBS in a case of dystonia vs. OCD.
In the United States, DBS has humanitarian device exemption for use in both dystonia and OCD, Dr. Kopell noted.
“Yet because dystonia is a movement disorder, I can get DBS for dystonia paid for by most private insurance – no big deal,” Dr. Kopell said.
“But OCD, because it’s deemed a psychiatric disorder, is treated like the redheaded stepchild and it’s monumentally hard to get insurance to pay for it – and if you can’t pay for it, you can’t do it. Simple as that,” he added.
The study was supported by the McNair Foundation and the Dana Foundation. Dr. Storch is a consultant for Biohaven and owns stock in nView. Dr. Sheth is a consultant for Boston Scientific, NeuroPace, Abbott, and Zimmer Biomet. Dr. Kopell reports no relevant financial relationships.
A version of this article first appeared on Medscape.com.
“DBS is a viable option for treatment-resistant OCD that can be expected to produce significant clinical benefit in about two out of three cases,” study investigator Wayne Goodman, MD, chair, department of psychiatry and behavioral sciences, Baylor College of Medicine, Houston, said in a statement.
However, “challenges in access still prevent many eligible individuals from getting this life-improving therapy,” co-investigator Sameer Sheth, MD, PhD, vice chair of research, department of neurosurgery at Baylor, told this news organization.
The study was published online in the Journal of Neurology, Neurosurgery and Psychiatry.
50% reduction in symptoms
The analysis included 34 studies conducted from 2005 to 2021, including 9 randomized controlled trials (RCTs) and 25 non-RCTs, involving 352 patients with treatment-resistant OCD.
Both RCTs and non-RCTs had a predominantly low risk of bias.
The results show an average 14.3-point, or 47%, reduction (P < .01) in Yale-Brown Obsessive-Compulsive Scale scores with DBS at last follow-up, with no significant difference between RCTs and non-RCTs.
Two-thirds (66%) of patients fully responded to the DBS at last follow-up, the authors found.
DBS for treatment-resistant OCD also had a “strong” effect on comorbid depression, with 47% of patients considered “full responders” relative to their preoperative (baseline) depression status and an additional 16% considered partial responders (with a 30%-49% reduction in pre/post-treatment depressive symptoms).
“The demonstrated effects of DBS in this report are even more impressive when one considers that these patients have failed numerous behavioral and pharmacological therapies,” said study investigator Eric Storch, PhD, professor and vice chair for the department of psychiatry and behavioral sciences at Baylor.
The rate of hardware-related complications was roughly 8% and infection rate was about 4% – in line with other data.
This study “offers hope for patients with severe symptoms of OCD whose disorder did not respond to a range of conventional therapies,” Dr. Goodman said.
The bigger story
Dr. Sheth said the challenges in getting appropriate OCD patients access to DBS are multifactorial.
“Psychiatrists and general practitioners and even patients are not aware of it, and insurance company policies are often out of date and ignorant of recent data such as those in this study,” Dr. Sheth explained.
“Hopefully, improved awareness in the future will reverse these trends and lead to increased access for patients in need of this therapy,” Dr. Sheth said.
Access to DBS for OCD is clearly the “bigger story” here, Brian Kopell, MD, who was not involved in the study, told this news organization.
This meta-analysis “confirms what all of us that do this with some regularity know – that DBS for OCD can be extremely helpful in patients who are refractory to standard OCD therapies,” said Dr. Kopell, department of neurosurgery and director, Center for Neuromodulation, Mount Sinai Health System, New York.
Yet, there is a dramatic difference in getting reimbursement for DBS in a case of dystonia vs. OCD.
In the United States, DBS has humanitarian device exemption for use in both dystonia and OCD, Dr. Kopell noted.
“Yet because dystonia is a movement disorder, I can get DBS for dystonia paid for by most private insurance – no big deal,” Dr. Kopell said.
“But OCD, because it’s deemed a psychiatric disorder, is treated like the redheaded stepchild and it’s monumentally hard to get insurance to pay for it – and if you can’t pay for it, you can’t do it. Simple as that,” he added.
The study was supported by the McNair Foundation and the Dana Foundation. Dr. Storch is a consultant for Biohaven and owns stock in nView. Dr. Sheth is a consultant for Boston Scientific, NeuroPace, Abbott, and Zimmer Biomet. Dr. Kopell reports no relevant financial relationships.
A version of this article first appeared on Medscape.com.
FROM JOURNAL OF NEUROLOGY, NEUROSURGERY AND PSYCHIATRY
High-dose folic acid during pregnancy tied to cancer risk in children
new data from a Scandinavian registry of more than 3 million pregnancies suggests.
The increased risk for cancer did not change after considering other factors that could explain the risk, such as use of antiseizure medication (ASM).
There was no increased risk for cancer in children of mothers without epilepsy who used high-dose folic acid.
The results of this study “should be considered when the risks and benefits of folic acid supplements for women with epilepsy are discussed and before decisions about optimal dose recommendations are made,” the authors write.
“Although we believe that the association between prescription fills for high-dose folic acid and cancer in children born to mothers with epilepsy is robust, it is important to underline that these are the findings of one study only,” first author Håkon Magne Vegrim, MD, with University of Bergen (Norway) told this news organization.
The study was published online in JAMA Neurology.
Risks and benefits
Women with epilepsy are advised to take high doses of folic acid before and during pregnancy owing to the risk for congenital malformations associated with ASM. Whether high-dose folic acid is associated with increases in the risk for childhood cancer is unknown.
To investigate, the researchers analyzed registry data from Denmark, Norway, and Sweden for 3.3 million children followed to a median age of 7.3 years.
Among the 27,784 children born to mothers with epilepsy, 5,934 (21.4%) were exposed to high-dose folic acid (mean dose, 4.3 mg), with a cancer incidence rate of 42.5 per 100,000 person-years in 18 exposed cancer cases compared with 18.4 per 100,000 person-years in 29 unexposed cancer cases – yielding an adjusted hazard ratio of 2.7 (95% confidence interval, 1.2-6.3).
The absolute risk with exposure was 1.5% (95% CI, 0.5%-3.5%) in children of mothers with epilepsy compared with 0.6% (95% CI, 0.3%-1.1%) in children of mothers with epilepsy who were not exposed high-dose folic acid.
Prenatal exposure to high-dose folic acid was not associated with an increased risk for cancer in children of mothers without epilepsy.
In children of mothers without epilepsy, 46,646 (1.4%) were exposed to high-dose folic acid (mean dose, 2.9 mg). There were 69 exposed and 4,927 unexposed cancer cases and an aHR for cancer of 1.1 (95% CI, 0.9-1.4) and absolute risk for cancer of 0.4% (95% CI, 0.3%-0.5%).
There was no association between any specific ASM and childhood cancer.
“Removing mothers with any prescription fills for carbamazepine and valproate was not associated with the point estimate. Hence, these two ASMs were not important effect modifiers for the cancer association,” the investigators note in their study.
They also note that the most common childhood cancer types in children among mothers with epilepsy who took high-dose folic acid did not differ from the distribution in the general population.
“We need to get more knowledge about the potential mechanisms behind high-dose folic acid and childhood cancer, and it is important to identify the optimal dose to balance risks and benefits – and whether folic acid supplementation should be more individualized, based on factors like the serum level of folate and what type of antiseizure medication that is being used,” said Dr. Vegrim.
Practice changing?
Weighing in on the study, Elizabeth E. Gerard, MD, director of the Women with Epilepsy Program and associate professor of neurology at Northwestern University in Chicago, said, “There are known benefits of folic acid supplementation during pregnancy including a decreased risk of neural tube defects in the general population and improved neurodevelopmental outcomes in children born to mothers with and without epilepsy.”
“However, despite some expert guidelines recommending high-dose folic acid supplementation, there is a lack of certainty surrounding the ‘just right’ dose for patients with epilepsy who may become pregnant,” said Dr. Gerard, who wasn’t involved in the study.
Dr. Gerard, a member of the American Epilepsy Society, noted that other epidemiologic studies of folic acid supplementation and cancer have had “contradictory results, thus further research on this association will be needed. Additionally, differences in maternal/fetal folate metabolism and blood levels may be an important factor to study in the future.
“That said, this study definitely should cause us to pause and reevaluate the common practice of high-dose folic acid supplementation for patients with epilepsy who are considering pregnancy,” said Dr. Gerard.
The study was supported by the NordForsk Nordic Program on Health and Welfare. Dr. Vegrim and Dr. Gerard report no relevant financial relationships.
A version of this article first appeared on Medscape.com.
new data from a Scandinavian registry of more than 3 million pregnancies suggests.
The increased risk for cancer did not change after considering other factors that could explain the risk, such as use of antiseizure medication (ASM).
There was no increased risk for cancer in children of mothers without epilepsy who used high-dose folic acid.
The results of this study “should be considered when the risks and benefits of folic acid supplements for women with epilepsy are discussed and before decisions about optimal dose recommendations are made,” the authors write.
“Although we believe that the association between prescription fills for high-dose folic acid and cancer in children born to mothers with epilepsy is robust, it is important to underline that these are the findings of one study only,” first author Håkon Magne Vegrim, MD, with University of Bergen (Norway) told this news organization.
The study was published online in JAMA Neurology.
Risks and benefits
Women with epilepsy are advised to take high doses of folic acid before and during pregnancy owing to the risk for congenital malformations associated with ASM. Whether high-dose folic acid is associated with increases in the risk for childhood cancer is unknown.
To investigate, the researchers analyzed registry data from Denmark, Norway, and Sweden for 3.3 million children followed to a median age of 7.3 years.
Among the 27,784 children born to mothers with epilepsy, 5,934 (21.4%) were exposed to high-dose folic acid (mean dose, 4.3 mg), with a cancer incidence rate of 42.5 per 100,000 person-years in 18 exposed cancer cases compared with 18.4 per 100,000 person-years in 29 unexposed cancer cases – yielding an adjusted hazard ratio of 2.7 (95% confidence interval, 1.2-6.3).
The absolute risk with exposure was 1.5% (95% CI, 0.5%-3.5%) in children of mothers with epilepsy compared with 0.6% (95% CI, 0.3%-1.1%) in children of mothers with epilepsy who were not exposed high-dose folic acid.
Prenatal exposure to high-dose folic acid was not associated with an increased risk for cancer in children of mothers without epilepsy.
In children of mothers without epilepsy, 46,646 (1.4%) were exposed to high-dose folic acid (mean dose, 2.9 mg). There were 69 exposed and 4,927 unexposed cancer cases and an aHR for cancer of 1.1 (95% CI, 0.9-1.4) and absolute risk for cancer of 0.4% (95% CI, 0.3%-0.5%).
There was no association between any specific ASM and childhood cancer.
“Removing mothers with any prescription fills for carbamazepine and valproate was not associated with the point estimate. Hence, these two ASMs were not important effect modifiers for the cancer association,” the investigators note in their study.
They also note that the most common childhood cancer types in children among mothers with epilepsy who took high-dose folic acid did not differ from the distribution in the general population.
“We need to get more knowledge about the potential mechanisms behind high-dose folic acid and childhood cancer, and it is important to identify the optimal dose to balance risks and benefits – and whether folic acid supplementation should be more individualized, based on factors like the serum level of folate and what type of antiseizure medication that is being used,” said Dr. Vegrim.
Practice changing?
Weighing in on the study, Elizabeth E. Gerard, MD, director of the Women with Epilepsy Program and associate professor of neurology at Northwestern University in Chicago, said, “There are known benefits of folic acid supplementation during pregnancy including a decreased risk of neural tube defects in the general population and improved neurodevelopmental outcomes in children born to mothers with and without epilepsy.”
“However, despite some expert guidelines recommending high-dose folic acid supplementation, there is a lack of certainty surrounding the ‘just right’ dose for patients with epilepsy who may become pregnant,” said Dr. Gerard, who wasn’t involved in the study.
Dr. Gerard, a member of the American Epilepsy Society, noted that other epidemiologic studies of folic acid supplementation and cancer have had “contradictory results, thus further research on this association will be needed. Additionally, differences in maternal/fetal folate metabolism and blood levels may be an important factor to study in the future.
“That said, this study definitely should cause us to pause and reevaluate the common practice of high-dose folic acid supplementation for patients with epilepsy who are considering pregnancy,” said Dr. Gerard.
The study was supported by the NordForsk Nordic Program on Health and Welfare. Dr. Vegrim and Dr. Gerard report no relevant financial relationships.
A version of this article first appeared on Medscape.com.
new data from a Scandinavian registry of more than 3 million pregnancies suggests.
The increased risk for cancer did not change after considering other factors that could explain the risk, such as use of antiseizure medication (ASM).
There was no increased risk for cancer in children of mothers without epilepsy who used high-dose folic acid.
The results of this study “should be considered when the risks and benefits of folic acid supplements for women with epilepsy are discussed and before decisions about optimal dose recommendations are made,” the authors write.
“Although we believe that the association between prescription fills for high-dose folic acid and cancer in children born to mothers with epilepsy is robust, it is important to underline that these are the findings of one study only,” first author Håkon Magne Vegrim, MD, with University of Bergen (Norway) told this news organization.
The study was published online in JAMA Neurology.
Risks and benefits
Women with epilepsy are advised to take high doses of folic acid before and during pregnancy owing to the risk for congenital malformations associated with ASM. Whether high-dose folic acid is associated with increases in the risk for childhood cancer is unknown.
To investigate, the researchers analyzed registry data from Denmark, Norway, and Sweden for 3.3 million children followed to a median age of 7.3 years.
Among the 27,784 children born to mothers with epilepsy, 5,934 (21.4%) were exposed to high-dose folic acid (mean dose, 4.3 mg), with a cancer incidence rate of 42.5 per 100,000 person-years in 18 exposed cancer cases compared with 18.4 per 100,000 person-years in 29 unexposed cancer cases – yielding an adjusted hazard ratio of 2.7 (95% confidence interval, 1.2-6.3).
The absolute risk with exposure was 1.5% (95% CI, 0.5%-3.5%) in children of mothers with epilepsy compared with 0.6% (95% CI, 0.3%-1.1%) in children of mothers with epilepsy who were not exposed high-dose folic acid.
Prenatal exposure to high-dose folic acid was not associated with an increased risk for cancer in children of mothers without epilepsy.
In children of mothers without epilepsy, 46,646 (1.4%) were exposed to high-dose folic acid (mean dose, 2.9 mg). There were 69 exposed and 4,927 unexposed cancer cases and an aHR for cancer of 1.1 (95% CI, 0.9-1.4) and absolute risk for cancer of 0.4% (95% CI, 0.3%-0.5%).
There was no association between any specific ASM and childhood cancer.
“Removing mothers with any prescription fills for carbamazepine and valproate was not associated with the point estimate. Hence, these two ASMs were not important effect modifiers for the cancer association,” the investigators note in their study.
They also note that the most common childhood cancer types in children among mothers with epilepsy who took high-dose folic acid did not differ from the distribution in the general population.
“We need to get more knowledge about the potential mechanisms behind high-dose folic acid and childhood cancer, and it is important to identify the optimal dose to balance risks and benefits – and whether folic acid supplementation should be more individualized, based on factors like the serum level of folate and what type of antiseizure medication that is being used,” said Dr. Vegrim.
Practice changing?
Weighing in on the study, Elizabeth E. Gerard, MD, director of the Women with Epilepsy Program and associate professor of neurology at Northwestern University in Chicago, said, “There are known benefits of folic acid supplementation during pregnancy including a decreased risk of neural tube defects in the general population and improved neurodevelopmental outcomes in children born to mothers with and without epilepsy.”
“However, despite some expert guidelines recommending high-dose folic acid supplementation, there is a lack of certainty surrounding the ‘just right’ dose for patients with epilepsy who may become pregnant,” said Dr. Gerard, who wasn’t involved in the study.
Dr. Gerard, a member of the American Epilepsy Society, noted that other epidemiologic studies of folic acid supplementation and cancer have had “contradictory results, thus further research on this association will be needed. Additionally, differences in maternal/fetal folate metabolism and blood levels may be an important factor to study in the future.
“That said, this study definitely should cause us to pause and reevaluate the common practice of high-dose folic acid supplementation for patients with epilepsy who are considering pregnancy,” said Dr. Gerard.
The study was supported by the NordForsk Nordic Program on Health and Welfare. Dr. Vegrim and Dr. Gerard report no relevant financial relationships.
A version of this article first appeared on Medscape.com.
FROM JAMA NEUROLOGY
AHA targets physician burnout in academic CV medicine
In a new scientific statement, the American Heart Association highlights the unique drivers of burnout in academic cardiovascular medicine physicians and proposes system-level and personal interventions to support individual wellness in this setting.
“The future cardiovascular health of Americans relies on a well-trained and experienced physician workforce created by rigorous academic medical training,” the writing group says in Circulation.
“Cardiovascular physicians pursuing careers in academic medicine are critical to continuing this mission, which includes providing clinical care for common and increasingly complex disease, educating and training the next generation of physicians/health care workers, and pursuing scientific discovery and innovation to treat and cure disease,” write Elisa Bradley, Penn State Health Heart and Vascular Institute, Hershey, Pa., and coauthors.
Given the multitasking nature of academic medicine, exhaustion and burnout uniquely threaten future and early career academic physicians, they say.
Drivers of burnout in this setting include productivity-driven compensation models that force competition for time between clinical care and academics; the requirement for promotion in systems that have not evolved to consider combined clinical and academic expectations; and distinct expectations based on faculty pathway, such as grant funding and publications.
In addition, at the early career and fellow-in-training level, drivers of burnout also include significant changes in personal and family life, coupled with long hours and high clinical and research demands, as well as financial strain and educational debt.
Many of the drivers of burnout in academic medicine are external and beyond the control of a single individual. Therefore, proposed solutions must be largely at the level of organizations, institutions, and government, the writing group says.
These solutions include appropriate mentorship, goal planning, efficiency in the workplace, time management and time “protection,” and manageable schedules.
Professional satisfaction “should be a shared responsibility between the clinician and the institution. Each must adapt their values to find a middle ground that meets the needs of both, recognizing that health care is both personal and a business,” the writing group says.
“Interventions to support efficiency of practice and a culture of wellness span normalizing and supporting flexible work environments to enhancing clinical support,” they add.
To enhance flexible clinical environments, organizations should consider “float teams” to provide care to bridge gaps when a physician is not available, job sharing and flexible hours, and telemedicine, the writing group says.
At the individual level, academic cardiovascular professionals should build individualized strategies to combat fatigue and to promote wellness, focusing on self-care and healthy habits (adequate sleep, healthy nutrition, exercise, outside interests, meaningful social relationships), they advise.
With help, “young academicians can look forward to a fulfilling and long career in academic cardiovascular medicine,” they conclude.
This research had no commercial funding. Members of the writing group reported no relevant financial relationships.
A version of this article first appeared on Medscape.com.
In a new scientific statement, the American Heart Association highlights the unique drivers of burnout in academic cardiovascular medicine physicians and proposes system-level and personal interventions to support individual wellness in this setting.
“The future cardiovascular health of Americans relies on a well-trained and experienced physician workforce created by rigorous academic medical training,” the writing group says in Circulation.
“Cardiovascular physicians pursuing careers in academic medicine are critical to continuing this mission, which includes providing clinical care for common and increasingly complex disease, educating and training the next generation of physicians/health care workers, and pursuing scientific discovery and innovation to treat and cure disease,” write Elisa Bradley, Penn State Health Heart and Vascular Institute, Hershey, Pa., and coauthors.
Given the multitasking nature of academic medicine, exhaustion and burnout uniquely threaten future and early career academic physicians, they say.
Drivers of burnout in this setting include productivity-driven compensation models that force competition for time between clinical care and academics; the requirement for promotion in systems that have not evolved to consider combined clinical and academic expectations; and distinct expectations based on faculty pathway, such as grant funding and publications.
In addition, at the early career and fellow-in-training level, drivers of burnout also include significant changes in personal and family life, coupled with long hours and high clinical and research demands, as well as financial strain and educational debt.
Many of the drivers of burnout in academic medicine are external and beyond the control of a single individual. Therefore, proposed solutions must be largely at the level of organizations, institutions, and government, the writing group says.
These solutions include appropriate mentorship, goal planning, efficiency in the workplace, time management and time “protection,” and manageable schedules.
Professional satisfaction “should be a shared responsibility between the clinician and the institution. Each must adapt their values to find a middle ground that meets the needs of both, recognizing that health care is both personal and a business,” the writing group says.
“Interventions to support efficiency of practice and a culture of wellness span normalizing and supporting flexible work environments to enhancing clinical support,” they add.
To enhance flexible clinical environments, organizations should consider “float teams” to provide care to bridge gaps when a physician is not available, job sharing and flexible hours, and telemedicine, the writing group says.
At the individual level, academic cardiovascular professionals should build individualized strategies to combat fatigue and to promote wellness, focusing on self-care and healthy habits (adequate sleep, healthy nutrition, exercise, outside interests, meaningful social relationships), they advise.
With help, “young academicians can look forward to a fulfilling and long career in academic cardiovascular medicine,” they conclude.
This research had no commercial funding. Members of the writing group reported no relevant financial relationships.
A version of this article first appeared on Medscape.com.
In a new scientific statement, the American Heart Association highlights the unique drivers of burnout in academic cardiovascular medicine physicians and proposes system-level and personal interventions to support individual wellness in this setting.
“The future cardiovascular health of Americans relies on a well-trained and experienced physician workforce created by rigorous academic medical training,” the writing group says in Circulation.
“Cardiovascular physicians pursuing careers in academic medicine are critical to continuing this mission, which includes providing clinical care for common and increasingly complex disease, educating and training the next generation of physicians/health care workers, and pursuing scientific discovery and innovation to treat and cure disease,” write Elisa Bradley, Penn State Health Heart and Vascular Institute, Hershey, Pa., and coauthors.
Given the multitasking nature of academic medicine, exhaustion and burnout uniquely threaten future and early career academic physicians, they say.
Drivers of burnout in this setting include productivity-driven compensation models that force competition for time between clinical care and academics; the requirement for promotion in systems that have not evolved to consider combined clinical and academic expectations; and distinct expectations based on faculty pathway, such as grant funding and publications.
In addition, at the early career and fellow-in-training level, drivers of burnout also include significant changes in personal and family life, coupled with long hours and high clinical and research demands, as well as financial strain and educational debt.
Many of the drivers of burnout in academic medicine are external and beyond the control of a single individual. Therefore, proposed solutions must be largely at the level of organizations, institutions, and government, the writing group says.
These solutions include appropriate mentorship, goal planning, efficiency in the workplace, time management and time “protection,” and manageable schedules.
Professional satisfaction “should be a shared responsibility between the clinician and the institution. Each must adapt their values to find a middle ground that meets the needs of both, recognizing that health care is both personal and a business,” the writing group says.
“Interventions to support efficiency of practice and a culture of wellness span normalizing and supporting flexible work environments to enhancing clinical support,” they add.
To enhance flexible clinical environments, organizations should consider “float teams” to provide care to bridge gaps when a physician is not available, job sharing and flexible hours, and telemedicine, the writing group says.
At the individual level, academic cardiovascular professionals should build individualized strategies to combat fatigue and to promote wellness, focusing on self-care and healthy habits (adequate sleep, healthy nutrition, exercise, outside interests, meaningful social relationships), they advise.
With help, “young academicians can look forward to a fulfilling and long career in academic cardiovascular medicine,” they conclude.
This research had no commercial funding. Members of the writing group reported no relevant financial relationships.
A version of this article first appeared on Medscape.com.
FROM CIRCULATION