Doug Brunk

SAN DIEGO – Among patients undergoing elective surgical spine procedures, the Short Form–6D derived from the Neck Disability Index was more valid and a better responsive measure of general health and quality of life, compared with the Short Form–6D derived from the Short Form–12 or the EuroQol-5D, results from a single-center study showed.

For such quality of life measures to be useful and meaningful, they “should be reproducible, responsive, economical, easy to use, and sensitive to responder burden,” Dr. John A. Sielatycki said at the annual meeting of the Cervical Spine Research Society.

“The EQ-5D is well established and commonly used in many of these studies, as is SF-6D, which in some cases has been shown to be more sensitive in certain disease states,” explained Dr. Sielatycki, a resident in the department of orthopedics at Vanderbilt University, Nashville, Tenn. “The differences between SF-6D and EQ-5D have been studied in a wide variety of disease conditions, but to our knowledge few have looked at this specifically in the setting of cervical spine operations.”

To analyze the validity and responsiveness of the SF-6D (derived from both the SF-12 and the NDI) and the EQ-5D in determining overall health and quality of life following elective cervical spine procedures, Dr. Sielatycki and his associates compared the three tools in 420 consecutive patients who presented over the course of 2 years. Trauma and workers’ compensation cases were excluded from the study, as were patients who had a tumor or an infection.

The researchers collected outcome measures at baseline, 3 months, 6 months, 12 months, and yearly thereafter, and defined meaningful improvement as having a North American Spine Society patient satisfaction score of 1, indicating the procedure “met the patient’s expectations.” Next, they generated receiver operating characteristic curves to discriminate between meaningful and nonmeaningful improvement.

The SF-6D (NDI) was a more valid discriminator of meaningful improvement, compared with the SF-6D (SF-12) or the EQ-5D (area under the curve of .69, .65, and .62, respectively). It was also a more responsive measure, compared with the SF-6D (SF-12) and the EQ-5D (standardized response means difference of .66, .48, and .44, respectively).

“Surgeons, outcomes researchers, and payers should use health metrics that are most responsive to changes in the particular disease in question,” Dr. Sielatycki said. “Based on this analysis, SF-6D derived from NDI may be a more valid and responsive measure of improvement in patients undergoing cervical procedures. We suggest that this metric be used in cost-effectiveness analysis and in calculating quality-adjusted life years for cervical spine patients.”

Dr. Sielatycki acknowledged certain limitations of the study, including the fact that it “should have some external validation done to further corroborate our findings. Our gold standard of meaningful improvement has not been established.”

Dr. Sielatycki reported having no financial disclosures.

dbrunk@frontlinemedcom.com

SAN DIEGO – Among patients undergoing elective surgical spine procedures, the Short Form–6D derived from the Neck Disability Index was more valid and a better responsive measure of general health and quality of life, compared with the Short Form–6D derived from the Short Form–12 or the EuroQol-5D, results from a single-center study showed.

For such quality of life measures to be useful and meaningful, they “should be reproducible, responsive, economical, easy to use, and sensitive to responder burden,” Dr. John A. Sielatycki said at the annual meeting of the Cervical Spine Research Society.

“The EQ-5D is well established and commonly used in many of these studies, as is SF-6D, which in some cases has been shown to be more sensitive in certain disease states,” explained Dr. Sielatycki, a resident in the department of orthopedics at Vanderbilt University, Nashville, Tenn. “The differences between SF-6D and EQ-5D have been studied in a wide variety of disease conditions, but to our knowledge few have looked at this specifically in the setting of cervical spine operations.”

To analyze the validity and responsiveness of the SF-6D (derived from both the SF-12 and the NDI) and the EQ-5D in determining overall health and quality of life following elective cervical spine procedures, Dr. Sielatycki and his associates compared the three tools in 420 consecutive patients who presented over the course of 2 years. Trauma and workers’ compensation cases were excluded from the study, as were patients who had a tumor or an infection.

The researchers collected outcome measures at baseline, 3 months, 6 months, 12 months, and yearly thereafter, and defined meaningful improvement as having a North American Spine Society patient satisfaction score of 1, indicating the procedure “met the patient’s expectations.” Next, they generated receiver operating characteristic curves to discriminate between meaningful and nonmeaningful improvement.

The SF-6D (NDI) was a more valid discriminator of meaningful improvement, compared with the SF-6D (SF-12) or the EQ-5D (area under the curve of .69, .65, and .62, respectively). It was also a more responsive measure, compared with the SF-6D (SF-12) and the EQ-5D (standardized response means difference of .66, .48, and .44, respectively).

“Surgeons, outcomes researchers, and payers should use health metrics that are most responsive to changes in the particular disease in question,” Dr. Sielatycki said. “Based on this analysis, SF-6D derived from NDI may be a more valid and responsive measure of improvement in patients undergoing cervical procedures. We suggest that this metric be used in cost-effectiveness analysis and in calculating quality-adjusted life years for cervical spine patients.”

Dr. Sielatycki acknowledged certain limitations of the study, including the fact that it “should have some external validation done to further corroborate our findings. Our gold standard of meaningful improvement has not been established.”

Dr. Sielatycki reported having no financial disclosures.

dbrunk@frontlinemedcom.com

SAN DIEGO – Among patients undergoing elective surgical spine procedures, the Short Form–6D derived from the Neck Disability Index was more valid and a better responsive measure of general health and quality of life, compared with the Short Form–6D derived from the Short Form–12 or the EuroQol-5D, results from a single-center study showed.

For such quality of life measures to be useful and meaningful, they “should be reproducible, responsive, economical, easy to use, and sensitive to responder burden,” Dr. John A. Sielatycki said at the annual meeting of the Cervical Spine Research Society.

“The EQ-5D is well established and commonly used in many of these studies, as is SF-6D, which in some cases has been shown to be more sensitive in certain disease states,” explained Dr. Sielatycki, a resident in the department of orthopedics at Vanderbilt University, Nashville, Tenn. “The differences between SF-6D and EQ-5D have been studied in a wide variety of disease conditions, but to our knowledge few have looked at this specifically in the setting of cervical spine operations.”

To analyze the validity and responsiveness of the SF-6D (derived from both the SF-12 and the NDI) and the EQ-5D in determining overall health and quality of life following elective cervical spine procedures, Dr. Sielatycki and his associates compared the three tools in 420 consecutive patients who presented over the course of 2 years. Trauma and workers’ compensation cases were excluded from the study, as were patients who had a tumor or an infection.

The researchers collected outcome measures at baseline, 3 months, 6 months, 12 months, and yearly thereafter, and defined meaningful improvement as having a North American Spine Society patient satisfaction score of 1, indicating the procedure “met the patient’s expectations.” Next, they generated receiver operating characteristic curves to discriminate between meaningful and nonmeaningful improvement.

The SF-6D (NDI) was a more valid discriminator of meaningful improvement, compared with the SF-6D (SF-12) or the EQ-5D (area under the curve of .69, .65, and .62, respectively). It was also a more responsive measure, compared with the SF-6D (SF-12) and the EQ-5D (standardized response means difference of .66, .48, and .44, respectively).

“Surgeons, outcomes researchers, and payers should use health metrics that are most responsive to changes in the particular disease in question,” Dr. Sielatycki said. “Based on this analysis, SF-6D derived from NDI may be a more valid and responsive measure of improvement in patients undergoing cervical procedures. We suggest that this metric be used in cost-effectiveness analysis and in calculating quality-adjusted life years for cervical spine patients.”

Dr. Sielatycki acknowledged certain limitations of the study, including the fact that it “should have some external validation done to further corroborate our findings. Our gold standard of meaningful improvement has not been established.”

Dr. Sielatycki reported having no financial disclosures.

dbrunk@frontlinemedcom.com

SAN DIEGO – Among incident hemodialysis patients, high-density lipoprotein cholesterol levels remained stable over time in men but mildly decreased over time in women, regardless of age.

In addition, larger deviations in HDL cholesterol in the first 6 months of incident hemodialysis were associated with a higher risk of 5-year all-cause mortality.

Those are key findings from a large analysis of patients who received hemodialysis care over a 4-year period, which was presented at the meeting sponsored by the American Society of Nephrology.

“Elevated high-density lipoprotein cholesterol levels, although protective in the general population, can be associated with higher mortality in hemodialysis patients,” Dr. Kamyar Kalantar-Zadeh and his colleagues wrote in an abstract of the study. “Association of HDL change over time with mortality has yet to be examined.”

Dr. Kalantar-Zadeh of the division of nephrology and hypertension at the University of California, Irvine, and his associates examined changes in HDL cholesterol levels over time in 24,400 incident hemodialysis patients who received care from facilities affiliated with DaVita HealthCare Partners between 2007 and 2011.

They examined the association of delta HDL (HDL cholesterol change between the first and second 91-day interval from dialysis start) and HDL cholesterol trajectory with all-cause mortality, using mixed effect and Cox regression models and adjusted for demographics, comorbidities, and baseline HDL cholesterol. Delta HDL was treated both as a continuous variable using restricted cubic splines and in five categories ranging from less than –6 mg/dL to 6 mg/dL or greater.

The mean age of patients was 65 years, 44% were female, 31% were black, and 66% had diabetes.

Mean baseline HDL cholesterol was 40.5 mg/dL, with an HDL cholesterol change of 1.7 mg/dL. The researchers found that while male patients had no significant change in HDL cholesterol over time, females had a significant decrease in HDL cholesterol (a mean of –0.6mg/dL per year). At the same time, a 6 mg/dL or greater increase or decrease in delta HDL was associated with a 7% and 37% increase in all-cause mortality, respectively, compared with the reference group. Delta HDL mortality associations did not differ across gender.

“Patients who have a greater than 6 mg/dL change in HDL between the first and second patient [tests] have a higher risk of 5-year all-cause mortality,” the researchers concluded. “Change in HDL exhibits a reverse J-shaped association with mortality in hemodialysis patients. Further studies are needed to examine the underlying causes of these HDL changes and pathophysiology leading to higher risk of all-cause mortality.”

The study was supported by funding from the National Institute of Diabetes and Digestive and Kidney Diseases. The researchers reported having no financial disclosures.

dbrunk@frontlinemedcom.com

SAN DIEGO – Among incident hemodialysis patients, high-density lipoprotein cholesterol levels remained stable over time in men but mildly decreased over time in women, regardless of age.

In addition, larger deviations in HDL cholesterol in the first 6 months of incident hemodialysis were associated with a higher risk of 5-year all-cause mortality.

Those are key findings from a large analysis of patients who received hemodialysis care over a 4-year period, which was presented at the meeting sponsored by the American Society of Nephrology.

“Elevated high-density lipoprotein cholesterol levels, although protective in the general population, can be associated with higher mortality in hemodialysis patients,” Dr. Kamyar Kalantar-Zadeh and his colleagues wrote in an abstract of the study. “Association of HDL change over time with mortality has yet to be examined.”

Dr. Kalantar-Zadeh of the division of nephrology and hypertension at the University of California, Irvine, and his associates examined changes in HDL cholesterol levels over time in 24,400 incident hemodialysis patients who received care from facilities affiliated with DaVita HealthCare Partners between 2007 and 2011.

They examined the association of delta HDL (HDL cholesterol change between the first and second 91-day interval from dialysis start) and HDL cholesterol trajectory with all-cause mortality, using mixed effect and Cox regression models and adjusted for demographics, comorbidities, and baseline HDL cholesterol. Delta HDL was treated both as a continuous variable using restricted cubic splines and in five categories ranging from less than –6 mg/dL to 6 mg/dL or greater.

The mean age of patients was 65 years, 44% were female, 31% were black, and 66% had diabetes.

Mean baseline HDL cholesterol was 40.5 mg/dL, with an HDL cholesterol change of 1.7 mg/dL. The researchers found that while male patients had no significant change in HDL cholesterol over time, females had a significant decrease in HDL cholesterol (a mean of –0.6mg/dL per year). At the same time, a 6 mg/dL or greater increase or decrease in delta HDL was associated with a 7% and 37% increase in all-cause mortality, respectively, compared with the reference group. Delta HDL mortality associations did not differ across gender.

“Patients who have a greater than 6 mg/dL change in HDL between the first and second patient [tests] have a higher risk of 5-year all-cause mortality,” the researchers concluded. “Change in HDL exhibits a reverse J-shaped association with mortality in hemodialysis patients. Further studies are needed to examine the underlying causes of these HDL changes and pathophysiology leading to higher risk of all-cause mortality.”

The study was supported by funding from the National Institute of Diabetes and Digestive and Kidney Diseases. The researchers reported having no financial disclosures.

dbrunk@frontlinemedcom.com

SAN DIEGO – Among incident hemodialysis patients, high-density lipoprotein cholesterol levels remained stable over time in men but mildly decreased over time in women, regardless of age.

In addition, larger deviations in HDL cholesterol in the first 6 months of incident hemodialysis were associated with a higher risk of 5-year all-cause mortality.

Those are key findings from a large analysis of patients who received hemodialysis care over a 4-year period, which was presented at the meeting sponsored by the American Society of Nephrology.

“Elevated high-density lipoprotein cholesterol levels, although protective in the general population, can be associated with higher mortality in hemodialysis patients,” Dr. Kamyar Kalantar-Zadeh and his colleagues wrote in an abstract of the study. “Association of HDL change over time with mortality has yet to be examined.”

Dr. Kalantar-Zadeh of the division of nephrology and hypertension at the University of California, Irvine, and his associates examined changes in HDL cholesterol levels over time in 24,400 incident hemodialysis patients who received care from facilities affiliated with DaVita HealthCare Partners between 2007 and 2011.

They examined the association of delta HDL (HDL cholesterol change between the first and second 91-day interval from dialysis start) and HDL cholesterol trajectory with all-cause mortality, using mixed effect and Cox regression models and adjusted for demographics, comorbidities, and baseline HDL cholesterol. Delta HDL was treated both as a continuous variable using restricted cubic splines and in five categories ranging from less than –6 mg/dL to 6 mg/dL or greater.

The mean age of patients was 65 years, 44% were female, 31% were black, and 66% had diabetes.

Mean baseline HDL cholesterol was 40.5 mg/dL, with an HDL cholesterol change of 1.7 mg/dL. The researchers found that while male patients had no significant change in HDL cholesterol over time, females had a significant decrease in HDL cholesterol (a mean of –0.6mg/dL per year). At the same time, a 6 mg/dL or greater increase or decrease in delta HDL was associated with a 7% and 37% increase in all-cause mortality, respectively, compared with the reference group. Delta HDL mortality associations did not differ across gender.

“Patients who have a greater than 6 mg/dL change in HDL between the first and second patient [tests] have a higher risk of 5-year all-cause mortality,” the researchers concluded. “Change in HDL exhibits a reverse J-shaped association with mortality in hemodialysis patients. Further studies are needed to examine the underlying causes of these HDL changes and pathophysiology leading to higher risk of all-cause mortality.”

The study was supported by funding from the National Institute of Diabetes and Digestive and Kidney Diseases. The researchers reported having no financial disclosures.

dbrunk@frontlinemedcom.com

SAN DIEGO – Among patients with chronic kidney disease, LDL cholesterol level was positively associated with risk of atherosclerotic vascular events, regardless of baseline inflammation, according to a large, randomized study.

In addition, lowering LDL cholesterol with ezetimibe/simvastatin was similarly effective in the presence or absence of inflammation.

“There has been substantial interest in the relationship between LDL cholesterol and outcomes in the general population, and in particular among people with kidney disease,” study author Dr. Richard Haynes of the Nuffield Department of Population Health at the University of Oxford (England) said in an interview in advance of the meeting.

“Previous studies have found a paradoxical increased risk of death at low cholesterol levels, which may be due to another disease process – such as inflammation – both lowering cholesterol and increasing the risk of death, thereby creating a false association,” he explained.

Dr. Haynes and his associates set out to determine the relevance of LDL cholesterol and C-reactive protein (CRP) to cardiovascular risk among 9,270 patients with chronic kidney disease who were enrolled in the Study of Heart and Renal Protection (SHARP), in which they received either ezetimibe/simvastatin or placebo.

The researchers used Cox regression to analyze the hazard ratio for all atherosclerotic vascular events over a period of 4.9 years. The effect of ezetimibe/simvastatin on major atherosclerotic events was estimated in the presence and absence of inflammation, which was defined as a CRP of 3 mg/L. The mean age of SHARP participants was 62 years, and 63% were men.

Dr. Ben Storey, a colleague of Dr. Haynes at Oxford, reported the study results at the meeting sponsored by the American Society of Nephrology.

Among all patients, usual LDL was positively associated with the risk of atherosclerotic vascular events (hazard ratio, 1.34). Compared with patients who had low CRP, those with high CRP were at higher risk, but the relationship between LDL-C and atherosclerotic vascular event risk was similar in both groups (HR, 1.32 and 1.41, respectively).

Ezetimibe/simvastatin was similarly effective at reducing major atherosclerotic events in patients with low and high CRP (risk ratio, 0.84 and 0.83, respectively). Sensitivity analyses yielded similar results.

“The observational data from SHARP show that LDL cholesterol is positively associated with the risk of atherosclerotic vascular events, irrespective of baseline inflammation,” Dr. Storey concluded. “The randomized evidence showed that lowering LDL cholesterol was similarly effective in the presence or absence of inflammation, but CRP is associated with vascular risk in [chronic kidney disease].”

The findings’ clinical implications are that inflammation, “while it is relevant to patients’ outcomes, does not modify the beneficial effects of lowering LDL cholesterol,” according to Dr. Haynes, “So, clinicians should not be put off from prescribing statin-based, cholesterol-lowering therapy by the presence – or absence – of inflammation.”

Merck funded SHARP, but the University of Oxford conducted and analyzed the study independently. The Australian National Health and Medical Research Council, the British Heart Foundation, Cancer Research UK, and the UK Medical Research Council provided additional support.

dbrunk@frontlinemedcom.com

SAN DIEGO – Among patients with chronic kidney disease, LDL cholesterol level was positively associated with risk of atherosclerotic vascular events, regardless of baseline inflammation, according to a large, randomized study.

In addition, lowering LDL cholesterol with ezetimibe/simvastatin was similarly effective in the presence or absence of inflammation.

“There has been substantial interest in the relationship between LDL cholesterol and outcomes in the general population, and in particular among people with kidney disease,” study author Dr. Richard Haynes of the Nuffield Department of Population Health at the University of Oxford (England) said in an interview in advance of the meeting.

“Previous studies have found a paradoxical increased risk of death at low cholesterol levels, which may be due to another disease process – such as inflammation – both lowering cholesterol and increasing the risk of death, thereby creating a false association,” he explained.

Dr. Haynes and his associates set out to determine the relevance of LDL cholesterol and C-reactive protein (CRP) to cardiovascular risk among 9,270 patients with chronic kidney disease who were enrolled in the Study of Heart and Renal Protection (SHARP), in which they received either ezetimibe/simvastatin or placebo.

The researchers used Cox regression to analyze the hazard ratio for all atherosclerotic vascular events over a period of 4.9 years. The effect of ezetimibe/simvastatin on major atherosclerotic events was estimated in the presence and absence of inflammation, which was defined as a CRP of 3 mg/L. The mean age of SHARP participants was 62 years, and 63% were men.

Dr. Ben Storey, a colleague of Dr. Haynes at Oxford, reported the study results at the meeting sponsored by the American Society of Nephrology.

Among all patients, usual LDL was positively associated with the risk of atherosclerotic vascular events (hazard ratio, 1.34). Compared with patients who had low CRP, those with high CRP were at higher risk, but the relationship between LDL-C and atherosclerotic vascular event risk was similar in both groups (HR, 1.32 and 1.41, respectively).

Ezetimibe/simvastatin was similarly effective at reducing major atherosclerotic events in patients with low and high CRP (risk ratio, 0.84 and 0.83, respectively). Sensitivity analyses yielded similar results.

“The observational data from SHARP show that LDL cholesterol is positively associated with the risk of atherosclerotic vascular events, irrespective of baseline inflammation,” Dr. Storey concluded. “The randomized evidence showed that lowering LDL cholesterol was similarly effective in the presence or absence of inflammation, but CRP is associated with vascular risk in [chronic kidney disease].”

The findings’ clinical implications are that inflammation, “while it is relevant to patients’ outcomes, does not modify the beneficial effects of lowering LDL cholesterol,” according to Dr. Haynes, “So, clinicians should not be put off from prescribing statin-based, cholesterol-lowering therapy by the presence – or absence – of inflammation.”

Merck funded SHARP, but the University of Oxford conducted and analyzed the study independently. The Australian National Health and Medical Research Council, the British Heart Foundation, Cancer Research UK, and the UK Medical Research Council provided additional support.

dbrunk@frontlinemedcom.com

SAN DIEGO – Among patients with chronic kidney disease, LDL cholesterol level was positively associated with risk of atherosclerotic vascular events, regardless of baseline inflammation, according to a large, randomized study.

In addition, lowering LDL cholesterol with ezetimibe/simvastatin was similarly effective in the presence or absence of inflammation.

“There has been substantial interest in the relationship between LDL cholesterol and outcomes in the general population, and in particular among people with kidney disease,” study author Dr. Richard Haynes of the Nuffield Department of Population Health at the University of Oxford (England) said in an interview in advance of the meeting.

“Previous studies have found a paradoxical increased risk of death at low cholesterol levels, which may be due to another disease process – such as inflammation – both lowering cholesterol and increasing the risk of death, thereby creating a false association,” he explained.

Dr. Haynes and his associates set out to determine the relevance of LDL cholesterol and C-reactive protein (CRP) to cardiovascular risk among 9,270 patients with chronic kidney disease who were enrolled in the Study of Heart and Renal Protection (SHARP), in which they received either ezetimibe/simvastatin or placebo.

The researchers used Cox regression to analyze the hazard ratio for all atherosclerotic vascular events over a period of 4.9 years. The effect of ezetimibe/simvastatin on major atherosclerotic events was estimated in the presence and absence of inflammation, which was defined as a CRP of 3 mg/L. The mean age of SHARP participants was 62 years, and 63% were men.

Dr. Ben Storey, a colleague of Dr. Haynes at Oxford, reported the study results at the meeting sponsored by the American Society of Nephrology.

Among all patients, usual LDL was positively associated with the risk of atherosclerotic vascular events (hazard ratio, 1.34). Compared with patients who had low CRP, those with high CRP were at higher risk, but the relationship between LDL-C and atherosclerotic vascular event risk was similar in both groups (HR, 1.32 and 1.41, respectively).

Ezetimibe/simvastatin was similarly effective at reducing major atherosclerotic events in patients with low and high CRP (risk ratio, 0.84 and 0.83, respectively). Sensitivity analyses yielded similar results.

“The observational data from SHARP show that LDL cholesterol is positively associated with the risk of atherosclerotic vascular events, irrespective of baseline inflammation,” Dr. Storey concluded. “The randomized evidence showed that lowering LDL cholesterol was similarly effective in the presence or absence of inflammation, but CRP is associated with vascular risk in [chronic kidney disease].”

The findings’ clinical implications are that inflammation, “while it is relevant to patients’ outcomes, does not modify the beneficial effects of lowering LDL cholesterol,” according to Dr. Haynes, “So, clinicians should not be put off from prescribing statin-based, cholesterol-lowering therapy by the presence – or absence – of inflammation.”

Merck funded SHARP, but the University of Oxford conducted and analyzed the study independently. The Australian National Health and Medical Research Council, the British Heart Foundation, Cancer Research UK, and the UK Medical Research Council provided additional support.

dbrunk@frontlinemedcom.com

SAN DIEGO – The prevalence of kidney stone disease appears to be rising in the United States.

According to an analysis of responses from the 2007-2012 National Health and Nutrition Examination Survey (NHANES), 8.8% of people in the United States have kidney stone disease (Eur Urol. 2012 Jul;62[1]:160-5), up from a prevalence of 5.2% observed in the 1988-1994 NHANES.

“There’s also been a marked increase in emergency room visits for kidney stones: 91% between 1994 and 2006,” Dr. Anna L. Zisman said at the meeting sponsored by the American Society of Nephrology.

“Unfortunately, it doesn’t only affect adults. There has been an increased incidence in ER visits for kids as well.” Though good national data on the incidence of kidney stone disease in children are lacking, one study conducted in South Carolina found that the incidence of ER visits in children rose from 8 per 100,000 in 1996 to more than 18 per 100,000 in 2007 (J Pediatr. 2010 Jul;157[1]:132-7).

What’s driving these increases? Dr. Zisman, a nephrologist at the University of Chicago, discussed a “recipe” for how to create a kidney stone, with heredity as the first step.

“Pick your parents well,” she said. “The familial clustering index is higher for nephrolithiasis than for diabetes and hypertension. A family history of stone disease is present in 16%-37% of stone formers, compared with 4%-12% of healthy controls. And the heritability estimates – how much of a given disease or trait can be attributable to genetic predisposition – is somewhere between 46% and 63%.”

According to Mayo Clinic researchers, heritable traits for kidney stone disease based on 24-hour urine measurements, adjusted for diet, include calcium, magnesium, pH, and citrate (Clin J Am Soc Nephrol. 2014 May;9[5]:943-50).

“Hypercalciuria is the most well-established risk factor for stone disease,” Dr. Zisman said. “Up to 50% of subjects with stones have a history of hypercalciuria, and 43% of first-degree relatives of hypercalciuric patients have hypercalciuria.”

Race and gender are two factors people can’t control in their risk for kidney stone disease. NHANES data suggest that non-Hispanic whites are at highest risk for stone formation, compared with Hispanics and non-Hispanic blacks. However, among whites and all of the racial categories, males have a higher risk than females.

Step two in the recipe for stone formation is timing: Age matters.

According to an analysis of 49,976 men who participated in the Health Professionals Follow-Up Study, the highest risk of stone formation was in male patients in their 40s (J Am Soc Nephrol. 2004 Dec;15[12]:3225-32). By the time white males reach their 70s, the prevalence is almost 19%, while the prevalence for white women in their 70s is 9.4% (Eur Urol. 2012 Jul;62[1]:160-5).

Step three in the recipe is location. According to Dr. Zisman, the prevalence of kidney stone disease across the world is quite varied. “That likely has to do with both genetic predispositions as well as environmental factors,” she noted. “For example, Iran, which has a pretty warm climate, has a prevalence of 5.7%, Greece 15.2%, whereas Argentina only 4%. In the United States, data suggest that the highest incidence of stone disease is in the south. It is suspected that this is due to more men working outside in manual labor in the heat, but that’s just a hypothesis.”

Step four in the recipe involves the role of certain nutrients. For example, a higher daily calcium intake is associated with a lower risk of kidney stone formation. “The theory is that with higher dietary calcium, your urine oxalate tends to drop,” she said. Increased intake of magnesium, protein, potassium, and fluid are also associated with decreased stone formation.

On the other hand, a higher daily vitamin C intake is associated with an increased risk of stone formation. Specifically, a daily intake of more than 1,000 mg confers a 41% increased risk, compared with a lower intake. “The theory there is that vitamin C intake, once absorbed, results in a higher urine oxalate,” Dr. Zisman said.

Current epidemiology literature draws no clear association between a high-sodium diet and the development of kidney stones. From a clinical standpoint, however, “I think everyone would recommend a low-sodium diet because of the physiologic mechanisms leading to higher urine calcium,” she said.

Higher body mass index and increased waist circumference also impact the risk of developing kidney stones, especially among women. “The higher [they are], the greater the risk,” Dr. Zisman said. “We know that as weight goes up, urinary pH drops. Another potential reason is that as body weight goes up, urinary oxalate goes up as well.”

Step five in the recipe for stone formation is occupation. A study from Israel found that lifeguards in that country faced about a 20-fold increased risk of kidney stones, compared with that of the general population (Adv Exp Med Biol. 1980;128:467-72). Meanwhile, a study of glass factory workers in Italy found that the prevalence of kidney stones was 8.5% among those exposed to blast furnace sites, compared with 2.4% among those who worked in ambient temperatures (P = .03) (J Urol 1993 Dec;150[6]:1757-60). A similar finding was observed in a more recent study of steel factory workers in Brazil (Urology 2005;65[5]:858-61).

Variations to the “recipe” for kidney stones include certain genetic diseases such as primary hyperoxaluria and Dent disease; anatomic variations such as horseshoe kidney and ileal conduits; coexisting disease such as inflammatory bowel disease and primary hyperparathyroidism; and effects from medication such as acetazolamide/topiramate and prednisone.

“Mix up genetic predisposition, environmental factors, and dietary/lifestyle factors and add the magic ingredient,” Dr. Zisman concluded. “There is something that is affecting some people and not others. We don’t know what that is, and we clearly need more research.”

Dr. Zisman reported having no financial disclosures.

dbrunk@frontlinemedcom.com

SAN DIEGO – The prevalence of kidney stone disease appears to be rising in the United States.

According to an analysis of responses from the 2007-2012 National Health and Nutrition Examination Survey (NHANES), 8.8% of people in the United States have kidney stone disease (Eur Urol. 2012 Jul;62[1]:160-5), up from a prevalence of 5.2% observed in the 1988-1994 NHANES.

“There’s also been a marked increase in emergency room visits for kidney stones: 91% between 1994 and 2006,” Dr. Anna L. Zisman said at the meeting sponsored by the American Society of Nephrology.

“Unfortunately, it doesn’t only affect adults. There has been an increased incidence in ER visits for kids as well.” Though good national data on the incidence of kidney stone disease in children are lacking, one study conducted in South Carolina found that the incidence of ER visits in children rose from 8 per 100,000 in 1996 to more than 18 per 100,000 in 2007 (J Pediatr. 2010 Jul;157[1]:132-7).

What’s driving these increases? Dr. Zisman, a nephrologist at the University of Chicago, discussed a “recipe” for how to create a kidney stone, with heredity as the first step.

“Pick your parents well,” she said. “The familial clustering index is higher for nephrolithiasis than for diabetes and hypertension. A family history of stone disease is present in 16%-37% of stone formers, compared with 4%-12% of healthy controls. And the heritability estimates – how much of a given disease or trait can be attributable to genetic predisposition – is somewhere between 46% and 63%.”

According to Mayo Clinic researchers, heritable traits for kidney stone disease based on 24-hour urine measurements, adjusted for diet, include calcium, magnesium, pH, and citrate (Clin J Am Soc Nephrol. 2014 May;9[5]:943-50).

“Hypercalciuria is the most well-established risk factor for stone disease,” Dr. Zisman said. “Up to 50% of subjects with stones have a history of hypercalciuria, and 43% of first-degree relatives of hypercalciuric patients have hypercalciuria.”

Race and gender are two factors people can’t control in their risk for kidney stone disease. NHANES data suggest that non-Hispanic whites are at highest risk for stone formation, compared with Hispanics and non-Hispanic blacks. However, among whites and all of the racial categories, males have a higher risk than females.

Step two in the recipe for stone formation is timing: Age matters.

According to an analysis of 49,976 men who participated in the Health Professionals Follow-Up Study, the highest risk of stone formation was in male patients in their 40s (J Am Soc Nephrol. 2004 Dec;15[12]:3225-32). By the time white males reach their 70s, the prevalence is almost 19%, while the prevalence for white women in their 70s is 9.4% (Eur Urol. 2012 Jul;62[1]:160-5).

Step three in the recipe is location. According to Dr. Zisman, the prevalence of kidney stone disease across the world is quite varied. “That likely has to do with both genetic predispositions as well as environmental factors,” she noted. “For example, Iran, which has a pretty warm climate, has a prevalence of 5.7%, Greece 15.2%, whereas Argentina only 4%. In the United States, data suggest that the highest incidence of stone disease is in the south. It is suspected that this is due to more men working outside in manual labor in the heat, but that’s just a hypothesis.”

Step four in the recipe involves the role of certain nutrients. For example, a higher daily calcium intake is associated with a lower risk of kidney stone formation. “The theory is that with higher dietary calcium, your urine oxalate tends to drop,” she said. Increased intake of magnesium, protein, potassium, and fluid are also associated with decreased stone formation.

On the other hand, a higher daily vitamin C intake is associated with an increased risk of stone formation. Specifically, a daily intake of more than 1,000 mg confers a 41% increased risk, compared with a lower intake. “The theory there is that vitamin C intake, once absorbed, results in a higher urine oxalate,” Dr. Zisman said.

Current epidemiology literature draws no clear association between a high-sodium diet and the development of kidney stones. From a clinical standpoint, however, “I think everyone would recommend a low-sodium diet because of the physiologic mechanisms leading to higher urine calcium,” she said.

Higher body mass index and increased waist circumference also impact the risk of developing kidney stones, especially among women. “The higher [they are], the greater the risk,” Dr. Zisman said. “We know that as weight goes up, urinary pH drops. Another potential reason is that as body weight goes up, urinary oxalate goes up as well.”

Step five in the recipe for stone formation is occupation. A study from Israel found that lifeguards in that country faced about a 20-fold increased risk of kidney stones, compared with that of the general population (Adv Exp Med Biol. 1980;128:467-72). Meanwhile, a study of glass factory workers in Italy found that the prevalence of kidney stones was 8.5% among those exposed to blast furnace sites, compared with 2.4% among those who worked in ambient temperatures (P = .03) (J Urol 1993 Dec;150[6]:1757-60). A similar finding was observed in a more recent study of steel factory workers in Brazil (Urology 2005;65[5]:858-61).

Variations to the “recipe” for kidney stones include certain genetic diseases such as primary hyperoxaluria and Dent disease; anatomic variations such as horseshoe kidney and ileal conduits; coexisting disease such as inflammatory bowel disease and primary hyperparathyroidism; and effects from medication such as acetazolamide/topiramate and prednisone.

“Mix up genetic predisposition, environmental factors, and dietary/lifestyle factors and add the magic ingredient,” Dr. Zisman concluded. “There is something that is affecting some people and not others. We don’t know what that is, and we clearly need more research.”

Dr. Zisman reported having no financial disclosures.

dbrunk@frontlinemedcom.com

SAN DIEGO – The prevalence of kidney stone disease appears to be rising in the United States.

According to an analysis of responses from the 2007-2012 National Health and Nutrition Examination Survey (NHANES), 8.8% of people in the United States have kidney stone disease (Eur Urol. 2012 Jul;62[1]:160-5), up from a prevalence of 5.2% observed in the 1988-1994 NHANES.

“There’s also been a marked increase in emergency room visits for kidney stones: 91% between 1994 and 2006,” Dr. Anna L. Zisman said at the meeting sponsored by the American Society of Nephrology.

“Unfortunately, it doesn’t only affect adults. There has been an increased incidence in ER visits for kids as well.” Though good national data on the incidence of kidney stone disease in children are lacking, one study conducted in South Carolina found that the incidence of ER visits in children rose from 8 per 100,000 in 1996 to more than 18 per 100,000 in 2007 (J Pediatr. 2010 Jul;157[1]:132-7).

What’s driving these increases? Dr. Zisman, a nephrologist at the University of Chicago, discussed a “recipe” for how to create a kidney stone, with heredity as the first step.

“Pick your parents well,” she said. “The familial clustering index is higher for nephrolithiasis than for diabetes and hypertension. A family history of stone disease is present in 16%-37% of stone formers, compared with 4%-12% of healthy controls. And the heritability estimates – how much of a given disease or trait can be attributable to genetic predisposition – is somewhere between 46% and 63%.”

According to Mayo Clinic researchers, heritable traits for kidney stone disease based on 24-hour urine measurements, adjusted for diet, include calcium, magnesium, pH, and citrate (Clin J Am Soc Nephrol. 2014 May;9[5]:943-50).

“Hypercalciuria is the most well-established risk factor for stone disease,” Dr. Zisman said. “Up to 50% of subjects with stones have a history of hypercalciuria, and 43% of first-degree relatives of hypercalciuric patients have hypercalciuria.”

Race and gender are two factors people can’t control in their risk for kidney stone disease. NHANES data suggest that non-Hispanic whites are at highest risk for stone formation, compared with Hispanics and non-Hispanic blacks. However, among whites and all of the racial categories, males have a higher risk than females.

Step two in the recipe for stone formation is timing: Age matters.

According to an analysis of 49,976 men who participated in the Health Professionals Follow-Up Study, the highest risk of stone formation was in male patients in their 40s (J Am Soc Nephrol. 2004 Dec;15[12]:3225-32). By the time white males reach their 70s, the prevalence is almost 19%, while the prevalence for white women in their 70s is 9.4% (Eur Urol. 2012 Jul;62[1]:160-5).

Step three in the recipe is location. According to Dr. Zisman, the prevalence of kidney stone disease across the world is quite varied. “That likely has to do with both genetic predispositions as well as environmental factors,” she noted. “For example, Iran, which has a pretty warm climate, has a prevalence of 5.7%, Greece 15.2%, whereas Argentina only 4%. In the United States, data suggest that the highest incidence of stone disease is in the south. It is suspected that this is due to more men working outside in manual labor in the heat, but that’s just a hypothesis.”

Step four in the recipe involves the role of certain nutrients. For example, a higher daily calcium intake is associated with a lower risk of kidney stone formation. “The theory is that with higher dietary calcium, your urine oxalate tends to drop,” she said. Increased intake of magnesium, protein, potassium, and fluid are also associated with decreased stone formation.

On the other hand, a higher daily vitamin C intake is associated with an increased risk of stone formation. Specifically, a daily intake of more than 1,000 mg confers a 41% increased risk, compared with a lower intake. “The theory there is that vitamin C intake, once absorbed, results in a higher urine oxalate,” Dr. Zisman said.

Current epidemiology literature draws no clear association between a high-sodium diet and the development of kidney stones. From a clinical standpoint, however, “I think everyone would recommend a low-sodium diet because of the physiologic mechanisms leading to higher urine calcium,” she said.

Higher body mass index and increased waist circumference also impact the risk of developing kidney stones, especially among women. “The higher [they are], the greater the risk,” Dr. Zisman said. “We know that as weight goes up, urinary pH drops. Another potential reason is that as body weight goes up, urinary oxalate goes up as well.”

Step five in the recipe for stone formation is occupation. A study from Israel found that lifeguards in that country faced about a 20-fold increased risk of kidney stones, compared with that of the general population (Adv Exp Med Biol. 1980;128:467-72). Meanwhile, a study of glass factory workers in Italy found that the prevalence of kidney stones was 8.5% among those exposed to blast furnace sites, compared with 2.4% among those who worked in ambient temperatures (P = .03) (J Urol 1993 Dec;150[6]:1757-60). A similar finding was observed in a more recent study of steel factory workers in Brazil (Urology 2005;65[5]:858-61).

Variations to the “recipe” for kidney stones include certain genetic diseases such as primary hyperoxaluria and Dent disease; anatomic variations such as horseshoe kidney and ileal conduits; coexisting disease such as inflammatory bowel disease and primary hyperparathyroidism; and effects from medication such as acetazolamide/topiramate and prednisone.

“Mix up genetic predisposition, environmental factors, and dietary/lifestyle factors and add the magic ingredient,” Dr. Zisman concluded. “There is something that is affecting some people and not others. We don’t know what that is, and we clearly need more research.”

Dr. Zisman reported having no financial disclosures.

dbrunk@frontlinemedcom.com

SAN DIEGO – Functional dependence following elective cervical spine procedures was associated with a significantly increased risk of almost all 30-day complications analyzed, including mortality, a large retrospective analysis of national data demonstrated.

The findings suggest that physicians should “include the patient’s level of functional independence, in addition to more traditional medical comorbidities, in the risk-benefit analysis of surgical decision making,” Dr. Alpesh A. Patel said in an interview in advance of the annual meeting of the Cervical Spine Research Society. “Those individuals with dependence need to be counseled appropriately about their increased risk of complications including mortality.”

Dr. Patel, professor and director of orthopedic spine surgery at Northwestern University Feinberg School of Medicine, Chicago, and his associates retrospectively reviewed the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) data files from 2006 to 2013 and limited their analysis to patients undergoing elective anterior cervical fusions, posterior cervical fusions, cervical laminectomy, cervical laminotomy, cervical discectomy, or corpectomy. They divided patients into one of three groups based on the following preoperative functional status parameters: independent, comprising those not requiring assistance or any equipment for activities of daily living (ADLs); partially dependent, including those with equipment such as prosthetics, equipment, or devices and requiring some assistance from another person for ADLs; and totally dependent, in which patients require total assistance for all ADLs. The researchers used univariate analysis to compare patient demographics, comorbidities, and 30-day postoperative complications among the three groups, followed by multivariate logistic regression to analyze the independent association of functional dependence on 30-day complications when controlling for procedure and comorbidity variances.

Dr. Patel reported findings from 24,357 patients: 23,620 (97.0%) functionally independent, 664 (2.7%) partially dependent, and 73 (0.3%) totally dependent. Dependent patients were significantly older and had higher rates of all comorbidities (P less than .001), with the exception of obesity (P = .214). In addition, 30-day complication rates were higher for all complications (P less than .001) other than neurological (P =.060) and surgical site complications (P =.668). When the researchers controlled for type of procedure and for disparities in patient preoperative variables, multivariate analyses demonstrated that functional dependence was independently associated with sepsis (odds ratio 6.40; P less than .001), pulmonary (OR 4.13; P less than .001), venous thromboembolism (OR 4.27, P less than .001), renal (OR 3.32; P less than .001), and cardiac complications (OR 4.68; P =.001), along with mortality (OR 8.31; P less than .001).

“The very strong association between functional dependence and mortality was quite surprising,” Dr. Patel said. “It was, to the contrary, also surprising to see that, despite wide variance in medical comorbidities and functional status, surgical complications such as infection and neurological injury were similar in all groups.” He characterized the study as “the first large-scale assessment of functional status as a predictor of patient outcomes after cervical spine surgery. It fits in line with other studies utilizing large databases. Big data analysis of outcomes can be used to identify risk factors for complications including death after surgery. Identifying these factors is important if we are going to improve the care we provide. Accurately quantifying the impact of these risk factors is also critical when we risk stratify and compare hospitals and physicians.”

He acknowledged certain limitations of the study, including the fact that it is a retrospective study “with a heterogeneous population of patients, surgeons, hospitals, and procedures. This adds uncertainty to the analysis at the level of the individual patient but does provide generalizability to a broader patient population.”

Dr. Patel reported having no conflicts of interest.

dbrunk@frontlinemedcom.com

SAN DIEGO – Functional dependence following elective cervical spine procedures was associated with a significantly increased risk of almost all 30-day complications analyzed, including mortality, a large retrospective analysis of national data demonstrated.

The findings suggest that physicians should “include the patient’s level of functional independence, in addition to more traditional medical comorbidities, in the risk-benefit analysis of surgical decision making,” Dr. Alpesh A. Patel said in an interview in advance of the annual meeting of the Cervical Spine Research Society. “Those individuals with dependence need to be counseled appropriately about their increased risk of complications including mortality.”

Dr. Patel, professor and director of orthopedic spine surgery at Northwestern University Feinberg School of Medicine, Chicago, and his associates retrospectively reviewed the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) data files from 2006 to 2013 and limited their analysis to patients undergoing elective anterior cervical fusions, posterior cervical fusions, cervical laminectomy, cervical laminotomy, cervical discectomy, or corpectomy. They divided patients into one of three groups based on the following preoperative functional status parameters: independent, comprising those not requiring assistance or any equipment for activities of daily living (ADLs); partially dependent, including those with equipment such as prosthetics, equipment, or devices and requiring some assistance from another person for ADLs; and totally dependent, in which patients require total assistance for all ADLs. The researchers used univariate analysis to compare patient demographics, comorbidities, and 30-day postoperative complications among the three groups, followed by multivariate logistic regression to analyze the independent association of functional dependence on 30-day complications when controlling for procedure and comorbidity variances.

Dr. Patel reported findings from 24,357 patients: 23,620 (97.0%) functionally independent, 664 (2.7%) partially dependent, and 73 (0.3%) totally dependent. Dependent patients were significantly older and had higher rates of all comorbidities (P less than .001), with the exception of obesity (P = .214). In addition, 30-day complication rates were higher for all complications (P less than .001) other than neurological (P =.060) and surgical site complications (P =.668). When the researchers controlled for type of procedure and for disparities in patient preoperative variables, multivariate analyses demonstrated that functional dependence was independently associated with sepsis (odds ratio 6.40; P less than .001), pulmonary (OR 4.13; P less than .001), venous thromboembolism (OR 4.27, P less than .001), renal (OR 3.32; P less than .001), and cardiac complications (OR 4.68; P =.001), along with mortality (OR 8.31; P less than .001).

“The very strong association between functional dependence and mortality was quite surprising,” Dr. Patel said. “It was, to the contrary, also surprising to see that, despite wide variance in medical comorbidities and functional status, surgical complications such as infection and neurological injury were similar in all groups.” He characterized the study as “the first large-scale assessment of functional status as a predictor of patient outcomes after cervical spine surgery. It fits in line with other studies utilizing large databases. Big data analysis of outcomes can be used to identify risk factors for complications including death after surgery. Identifying these factors is important if we are going to improve the care we provide. Accurately quantifying the impact of these risk factors is also critical when we risk stratify and compare hospitals and physicians.”

He acknowledged certain limitations of the study, including the fact that it is a retrospective study “with a heterogeneous population of patients, surgeons, hospitals, and procedures. This adds uncertainty to the analysis at the level of the individual patient but does provide generalizability to a broader patient population.”

Dr. Patel reported having no conflicts of interest.

dbrunk@frontlinemedcom.com

SAN DIEGO – Functional dependence following elective cervical spine procedures was associated with a significantly increased risk of almost all 30-day complications analyzed, including mortality, a large retrospective analysis of national data demonstrated.

The findings suggest that physicians should “include the patient’s level of functional independence, in addition to more traditional medical comorbidities, in the risk-benefit analysis of surgical decision making,” Dr. Alpesh A. Patel said in an interview in advance of the annual meeting of the Cervical Spine Research Society. “Those individuals with dependence need to be counseled appropriately about their increased risk of complications including mortality.”

Dr. Patel, professor and director of orthopedic spine surgery at Northwestern University Feinberg School of Medicine, Chicago, and his associates retrospectively reviewed the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) data files from 2006 to 2013 and limited their analysis to patients undergoing elective anterior cervical fusions, posterior cervical fusions, cervical laminectomy, cervical laminotomy, cervical discectomy, or corpectomy. They divided patients into one of three groups based on the following preoperative functional status parameters: independent, comprising those not requiring assistance or any equipment for activities of daily living (ADLs); partially dependent, including those with equipment such as prosthetics, equipment, or devices and requiring some assistance from another person for ADLs; and totally dependent, in which patients require total assistance for all ADLs. The researchers used univariate analysis to compare patient demographics, comorbidities, and 30-day postoperative complications among the three groups, followed by multivariate logistic regression to analyze the independent association of functional dependence on 30-day complications when controlling for procedure and comorbidity variances.

Dr. Patel reported findings from 24,357 patients: 23,620 (97.0%) functionally independent, 664 (2.7%) partially dependent, and 73 (0.3%) totally dependent. Dependent patients were significantly older and had higher rates of all comorbidities (P less than .001), with the exception of obesity (P = .214). In addition, 30-day complication rates were higher for all complications (P less than .001) other than neurological (P =.060) and surgical site complications (P =.668). When the researchers controlled for type of procedure and for disparities in patient preoperative variables, multivariate analyses demonstrated that functional dependence was independently associated with sepsis (odds ratio 6.40; P less than .001), pulmonary (OR 4.13; P less than .001), venous thromboembolism (OR 4.27, P less than .001), renal (OR 3.32; P less than .001), and cardiac complications (OR 4.68; P =.001), along with mortality (OR 8.31; P less than .001).

“The very strong association between functional dependence and mortality was quite surprising,” Dr. Patel said. “It was, to the contrary, also surprising to see that, despite wide variance in medical comorbidities and functional status, surgical complications such as infection and neurological injury were similar in all groups.” He characterized the study as “the first large-scale assessment of functional status as a predictor of patient outcomes after cervical spine surgery. It fits in line with other studies utilizing large databases. Big data analysis of outcomes can be used to identify risk factors for complications including death after surgery. Identifying these factors is important if we are going to improve the care we provide. Accurately quantifying the impact of these risk factors is also critical when we risk stratify and compare hospitals and physicians.”

He acknowledged certain limitations of the study, including the fact that it is a retrospective study “with a heterogeneous population of patients, surgeons, hospitals, and procedures. This adds uncertainty to the analysis at the level of the individual patient but does provide generalizability to a broader patient population.”

Dr. Patel reported having no conflicts of interest.

dbrunk@frontlinemedcom.com

SAN DIEGO – Compared with age-matched controls, patients with cervical spondylotic myelopathy had a significantly increased incidence of falls, hip fractures, and other injuries, preliminary results from a study of Medicare data suggest.

“Cervical myelopathy is the most common cause of spinal cord dysfunction in patients over age 55,” Dr. Daniel J. Blizzard said at the annual meeting of the Cervical Spine Research Society. “In general, it’s cord compression secondary to their ossification of posterior latitudinal ligament, congenital stenosis, and/or degenerative changes to vertebral bodies, discs, and facet joints. These create an upper motor neuron lesion, which causes gait disturbances, imbalance, loss of manual dexterity and coordination, and sensory changes and weakness.”

Dr. Blizzard, an orthopedic surgery resident at Duke University, Durham, N.C., noted that myelopathy gait is the most common presenting symptom in cervical spondylotic myelopathy (CSM), affecting almost 30% of patients. “It’s present in three-quarters of CSM patients undergoing decompression,” he said. “Cord compression can lead to impaired proprioception, spasticity, and stiffness. We know that this gait dysfunction is multifactorial. Imbalance and unsteadiness lead to compensatory broad-based arrhythmic shuffling and clumsy-appearing gait to maintain balance.”

An estimated one-third of people over age 65 fall at least once per year and this may lead to significant morbidity, including institutionalization, loss of independence, and mortality, Dr. Blizzard continued. “We know that gait dysfunction is a significant risk factor for falls,” he said. “This can be CSM, lower extremity osteoarthritis, deconditioning, or poor vision. The primary cause of a gait disturbance may not be accurately identified, especially if a more obvious cause is already known.”

The researchers set out to determine the fall and injury risk of patients with CSM, “with the goal of guiding attention to what we thought might be a potentially underestimated disease with regard to morbidity, and to provide data to consider when determining the type and timing of CSM treatment,” Dr. Blizzard said. They used the PearlDiver database to search the Medicare sample during 2005-2012, and used ICD-9 codes to identify patients with CSM. They also identified a subpopulation of CSM patients that underwent decompression, “not for the purpose of comparing the effect of decompression, but to identify a population with more severe disease,” he explained. They included a control population with no CSM, vestibular disease, or Parkinson’s disease.

Dr. Blizzard reported preliminary results from a total of 601,390 patients with CSM, 77,346 patients with CSM plus decompression, and 49,550,651 controls. They looked at the incidence of falls, head injuries, skull fractures, subdural hematomas, and other orthopedic injuries including fractures of the hip, femur, leg, ankle, pelvis, and lower extremity sprains. The researchers found that when compared with controls, patients with CSM had a statistically significant increased incidence of all injuries, including hip fracture (risk ratio, 2.62), head injury (RR, 7.34), and fall (RR, 8.08). The incidence of hip fracture, head injury, and fall was also increased among the subset of CSM patients who had undergone decompression (RR of 2.25, 8.34, and 9.62, respectively).

Dr. Blizzard acknowledged certain limitations of the study, including its retrospective design. “Statistical and clinical significance are two very different things,” he emphasized. “When we get numbers this big, everything will become statistically significant, but whether things are clinically significant is up to interpretation. The presence of disease and complications is contingent upon proper coding and recognition by providers. We have no measures of severity, extent, or chronicity of disease.”

Despite such limitations, he concluded that the findings suggest that impact of CSM on morbidity “is probably underestimated by many. Symptoms of CSM can be insidious or masked. Patients can often attribute these to normal effects of aging, and often primary care physicians will not recognize these initial symptoms, especially if there is another confounding presenting complaint.”

Conservative interventions for CSM patients, he said, include gait training/physical therapy, assistive aids, hip pads, exercise programs with balance training, and an assessment of hazards in the home environment. From a surgical standpoint, the findings raise the possibility that surgeons may want to “be more aggressive” in their decision to operate on patients with CSM. “This dataset is in no way able to address this question, but I think it provides interesting information regarding the true morbidity of the disease,” Dr. Blizzard said. “There is clear risk and morbidity with cervical compression. Studies show improvement in patients regardless of age, severity, and chronicity.”

Dr. Blizzard reported having no financial disclosures.

dbrunk@frontlinemedcom.com

SAN DIEGO – Compared with age-matched controls, patients with cervical spondylotic myelopathy had a significantly increased incidence of falls, hip fractures, and other injuries, preliminary results from a study of Medicare data suggest.

“Cervical myelopathy is the most common cause of spinal cord dysfunction in patients over age 55,” Dr. Daniel J. Blizzard said at the annual meeting of the Cervical Spine Research Society. “In general, it’s cord compression secondary to their ossification of posterior latitudinal ligament, congenital stenosis, and/or degenerative changes to vertebral bodies, discs, and facet joints. These create an upper motor neuron lesion, which causes gait disturbances, imbalance, loss of manual dexterity and coordination, and sensory changes and weakness.”

Dr. Blizzard, an orthopedic surgery resident at Duke University, Durham, N.C., noted that myelopathy gait is the most common presenting symptom in cervical spondylotic myelopathy (CSM), affecting almost 30% of patients. “It’s present in three-quarters of CSM patients undergoing decompression,” he said. “Cord compression can lead to impaired proprioception, spasticity, and stiffness. We know that this gait dysfunction is multifactorial. Imbalance and unsteadiness lead to compensatory broad-based arrhythmic shuffling and clumsy-appearing gait to maintain balance.”

An estimated one-third of people over age 65 fall at least once per year and this may lead to significant morbidity, including institutionalization, loss of independence, and mortality, Dr. Blizzard continued. “We know that gait dysfunction is a significant risk factor for falls,” he said. “This can be CSM, lower extremity osteoarthritis, deconditioning, or poor vision. The primary cause of a gait disturbance may not be accurately identified, especially if a more obvious cause is already known.”

The researchers set out to determine the fall and injury risk of patients with CSM, “with the goal of guiding attention to what we thought might be a potentially underestimated disease with regard to morbidity, and to provide data to consider when determining the type and timing of CSM treatment,” Dr. Blizzard said. They used the PearlDiver database to search the Medicare sample during 2005-2012, and used ICD-9 codes to identify patients with CSM. They also identified a subpopulation of CSM patients that underwent decompression, “not for the purpose of comparing the effect of decompression, but to identify a population with more severe disease,” he explained. They included a control population with no CSM, vestibular disease, or Parkinson’s disease.

Dr. Blizzard reported preliminary results from a total of 601,390 patients with CSM, 77,346 patients with CSM plus decompression, and 49,550,651 controls. They looked at the incidence of falls, head injuries, skull fractures, subdural hematomas, and other orthopedic injuries including fractures of the hip, femur, leg, ankle, pelvis, and lower extremity sprains. The researchers found that when compared with controls, patients with CSM had a statistically significant increased incidence of all injuries, including hip fracture (risk ratio, 2.62), head injury (RR, 7.34), and fall (RR, 8.08). The incidence of hip fracture, head injury, and fall was also increased among the subset of CSM patients who had undergone decompression (RR of 2.25, 8.34, and 9.62, respectively).

Dr. Blizzard acknowledged certain limitations of the study, including its retrospective design. “Statistical and clinical significance are two very different things,” he emphasized. “When we get numbers this big, everything will become statistically significant, but whether things are clinically significant is up to interpretation. The presence of disease and complications is contingent upon proper coding and recognition by providers. We have no measures of severity, extent, or chronicity of disease.”

Despite such limitations, he concluded that the findings suggest that impact of CSM on morbidity “is probably underestimated by many. Symptoms of CSM can be insidious or masked. Patients can often attribute these to normal effects of aging, and often primary care physicians will not recognize these initial symptoms, especially if there is another confounding presenting complaint.”

Conservative interventions for CSM patients, he said, include gait training/physical therapy, assistive aids, hip pads, exercise programs with balance training, and an assessment of hazards in the home environment. From a surgical standpoint, the findings raise the possibility that surgeons may want to “be more aggressive” in their decision to operate on patients with CSM. “This dataset is in no way able to address this question, but I think it provides interesting information regarding the true morbidity of the disease,” Dr. Blizzard said. “There is clear risk and morbidity with cervical compression. Studies show improvement in patients regardless of age, severity, and chronicity.”

Dr. Blizzard reported having no financial disclosures.

dbrunk@frontlinemedcom.com

SAN DIEGO – Compared with age-matched controls, patients with cervical spondylotic myelopathy had a significantly increased incidence of falls, hip fractures, and other injuries, preliminary results from a study of Medicare data suggest.

“Cervical myelopathy is the most common cause of spinal cord dysfunction in patients over age 55,” Dr. Daniel J. Blizzard said at the annual meeting of the Cervical Spine Research Society. “In general, it’s cord compression secondary to their ossification of posterior latitudinal ligament, congenital stenosis, and/or degenerative changes to vertebral bodies, discs, and facet joints. These create an upper motor neuron lesion, which causes gait disturbances, imbalance, loss of manual dexterity and coordination, and sensory changes and weakness.”

Dr. Blizzard, an orthopedic surgery resident at Duke University, Durham, N.C., noted that myelopathy gait is the most common presenting symptom in cervical spondylotic myelopathy (CSM), affecting almost 30% of patients. “It’s present in three-quarters of CSM patients undergoing decompression,” he said. “Cord compression can lead to impaired proprioception, spasticity, and stiffness. We know that this gait dysfunction is multifactorial. Imbalance and unsteadiness lead to compensatory broad-based arrhythmic shuffling and clumsy-appearing gait to maintain balance.”

An estimated one-third of people over age 65 fall at least once per year and this may lead to significant morbidity, including institutionalization, loss of independence, and mortality, Dr. Blizzard continued. “We know that gait dysfunction is a significant risk factor for falls,” he said. “This can be CSM, lower extremity osteoarthritis, deconditioning, or poor vision. The primary cause of a gait disturbance may not be accurately identified, especially if a more obvious cause is already known.”

The researchers set out to determine the fall and injury risk of patients with CSM, “with the goal of guiding attention to what we thought might be a potentially underestimated disease with regard to morbidity, and to provide data to consider when determining the type and timing of CSM treatment,” Dr. Blizzard said. They used the PearlDiver database to search the Medicare sample during 2005-2012, and used ICD-9 codes to identify patients with CSM. They also identified a subpopulation of CSM patients that underwent decompression, “not for the purpose of comparing the effect of decompression, but to identify a population with more severe disease,” he explained. They included a control population with no CSM, vestibular disease, or Parkinson’s disease.

Dr. Blizzard reported preliminary results from a total of 601,390 patients with CSM, 77,346 patients with CSM plus decompression, and 49,550,651 controls. They looked at the incidence of falls, head injuries, skull fractures, subdural hematomas, and other orthopedic injuries including fractures of the hip, femur, leg, ankle, pelvis, and lower extremity sprains. The researchers found that when compared with controls, patients with CSM had a statistically significant increased incidence of all injuries, including hip fracture (risk ratio, 2.62), head injury (RR, 7.34), and fall (RR, 8.08). The incidence of hip fracture, head injury, and fall was also increased among the subset of CSM patients who had undergone decompression (RR of 2.25, 8.34, and 9.62, respectively).

Dr. Blizzard acknowledged certain limitations of the study, including its retrospective design. “Statistical and clinical significance are two very different things,” he emphasized. “When we get numbers this big, everything will become statistically significant, but whether things are clinically significant is up to interpretation. The presence of disease and complications is contingent upon proper coding and recognition by providers. We have no measures of severity, extent, or chronicity of disease.”

Despite such limitations, he concluded that the findings suggest that impact of CSM on morbidity “is probably underestimated by many. Symptoms of CSM can be insidious or masked. Patients can often attribute these to normal effects of aging, and often primary care physicians will not recognize these initial symptoms, especially if there is another confounding presenting complaint.”

Conservative interventions for CSM patients, he said, include gait training/physical therapy, assistive aids, hip pads, exercise programs with balance training, and an assessment of hazards in the home environment. From a surgical standpoint, the findings raise the possibility that surgeons may want to “be more aggressive” in their decision to operate on patients with CSM. “This dataset is in no way able to address this question, but I think it provides interesting information regarding the true morbidity of the disease,” Dr. Blizzard said. “There is clear risk and morbidity with cervical compression. Studies show improvement in patients regardless of age, severity, and chronicity.”

Dr. Blizzard reported having no financial disclosures.

dbrunk@frontlinemedcom.com