Literature Review

Among patients of European descent, higher latitude regions are associated with an earlier age at onset of multiple sclerosis (MS), according to data published online ahead of print November 3 in the Journal of Neurology, Neurosurgery and Psychiatry. Age at MS onset also is lower among people with less exposure to ultraviolet radiation.

Bruce V. Taylor, MBBS, Professorial Research Fellow at the University of Tasmania, Australia, and his collaborators examined data for 22,162 eligible patients participating in the international MSBase Registry. Eligible participants had MS, were age 16 or older, and came from centers of largely European descent. The investigators defined age at onset as the year of the first symptom suggestive of inflammatory CNS demyelination. They evaluated predictors of age at onset using linear regression.

Most patients in the sample were women (70.4%) and had relapsing-remitting MS (91.5%). In addition, most participants were from the northern hemisphere (81.4%), particularly Europe (67.2%), and a large proportion (15.7%) were from Australia. The sample’s mean age at MS onset was 32.3.

In the univariable analysis, latitude as a continuous linear factor was significantly negatively associated with age at onset. Every 10° increment of latitude was associated with a 0.3-year earlier onset. After adjustment for relevant covariates, patients of the highest latitude stratum had MS onset nearly 1.9 years earlier than patients of the lowest latitude stratum. In an evaluation of latitude as a continuous variable in the multivariable analysis, a 10° increase in latitude was associated with a 0.82-year earlier onset.

A similar pattern emerged for exposure to ultraviolet light. After adjustment for confounders, the investigators found a dose-dependent association between ultraviolet B and age at MS onset. In the multivariable analysis, people with the lowest ultraviolet B exposure had MS onset nearly two years earlier than people with the highest ultraviolet B exposure.

After adjustment for variables, age at MS onset was 0.43 years lower among women than among men. The latitudinal gradient of age at onset was not significantly different between men and women. Birth dates were evenly distributed in all four seasons, and the researchers found no association between season of birth and age at onset.

—Erik Greb

Suggested Reading

Tao C, Simpson S Jr, van der Mei I, et al. Higher latitude is significantly associated with an earlier age of disease onset in multiple sclerosis. J Neurol Neurosurg Psychiatry. 2016 Nov 3 [Epub ahead of print].

Among patients of European descent, higher latitude regions are associated with an earlier age at onset of multiple sclerosis (MS), according to data published online ahead of print November 3 in the Journal of Neurology, Neurosurgery and Psychiatry. Age at MS onset also is lower among people with less exposure to ultraviolet radiation.

Bruce V. Taylor, MBBS, Professorial Research Fellow at the University of Tasmania, Australia, and his collaborators examined data for 22,162 eligible patients participating in the international MSBase Registry. Eligible participants had MS, were age 16 or older, and came from centers of largely European descent. The investigators defined age at onset as the year of the first symptom suggestive of inflammatory CNS demyelination. They evaluated predictors of age at onset using linear regression.

Most patients in the sample were women (70.4%) and had relapsing-remitting MS (91.5%). In addition, most participants were from the northern hemisphere (81.4%), particularly Europe (67.2%), and a large proportion (15.7%) were from Australia. The sample’s mean age at MS onset was 32.3.

In the univariable analysis, latitude as a continuous linear factor was significantly negatively associated with age at onset. Every 10° increment of latitude was associated with a 0.3-year earlier onset. After adjustment for relevant covariates, patients of the highest latitude stratum had MS onset nearly 1.9 years earlier than patients of the lowest latitude stratum. In an evaluation of latitude as a continuous variable in the multivariable analysis, a 10° increase in latitude was associated with a 0.82-year earlier onset.

A similar pattern emerged for exposure to ultraviolet light. After adjustment for confounders, the investigators found a dose-dependent association between ultraviolet B and age at MS onset. In the multivariable analysis, people with the lowest ultraviolet B exposure had MS onset nearly two years earlier than people with the highest ultraviolet B exposure.

After adjustment for variables, age at MS onset was 0.43 years lower among women than among men. The latitudinal gradient of age at onset was not significantly different between men and women. Birth dates were evenly distributed in all four seasons, and the researchers found no association between season of birth and age at onset.

—Erik Greb

Suggested Reading

Tao C, Simpson S Jr, van der Mei I, et al. Higher latitude is significantly associated with an earlier age of disease onset in multiple sclerosis. J Neurol Neurosurg Psychiatry. 2016 Nov 3 [Epub ahead of print].

Among patients of European descent, higher latitude regions are associated with an earlier age at onset of multiple sclerosis (MS), according to data published online ahead of print November 3 in the Journal of Neurology, Neurosurgery and Psychiatry. Age at MS onset also is lower among people with less exposure to ultraviolet radiation.

Bruce V. Taylor, MBBS, Professorial Research Fellow at the University of Tasmania, Australia, and his collaborators examined data for 22,162 eligible patients participating in the international MSBase Registry. Eligible participants had MS, were age 16 or older, and came from centers of largely European descent. The investigators defined age at onset as the year of the first symptom suggestive of inflammatory CNS demyelination. They evaluated predictors of age at onset using linear regression.

Most patients in the sample were women (70.4%) and had relapsing-remitting MS (91.5%). In addition, most participants were from the northern hemisphere (81.4%), particularly Europe (67.2%), and a large proportion (15.7%) were from Australia. The sample’s mean age at MS onset was 32.3.

In the univariable analysis, latitude as a continuous linear factor was significantly negatively associated with age at onset. Every 10° increment of latitude was associated with a 0.3-year earlier onset. After adjustment for relevant covariates, patients of the highest latitude stratum had MS onset nearly 1.9 years earlier than patients of the lowest latitude stratum. In an evaluation of latitude as a continuous variable in the multivariable analysis, a 10° increase in latitude was associated with a 0.82-year earlier onset.

A similar pattern emerged for exposure to ultraviolet light. After adjustment for confounders, the investigators found a dose-dependent association between ultraviolet B and age at MS onset. In the multivariable analysis, people with the lowest ultraviolet B exposure had MS onset nearly two years earlier than people with the highest ultraviolet B exposure.

After adjustment for variables, age at MS onset was 0.43 years lower among women than among men. The latitudinal gradient of age at onset was not significantly different between men and women. Birth dates were evenly distributed in all four seasons, and the researchers found no association between season of birth and age at onset.

—Erik Greb

Suggested Reading

Tao C, Simpson S Jr, van der Mei I, et al. Higher latitude is significantly associated with an earlier age of disease onset in multiple sclerosis. J Neurol Neurosurg Psychiatry. 2016 Nov 3 [Epub ahead of print].

Investigators have developed prognostic models that discriminate between patients with and without posttraumatic seizures (PTS) at year 1 and year 2 after traumatic brain injury (TBI), but perform little better than chance at predicting PTS, according to research published in the September issue of Epilepsia. The models do, however, identify potentially important predictors that may help to identify populations at risk for PTS.

“Individuals with characteristics identified in prognostic models as predictors of PTS represent subpopulations that may benefit from tailored seizure prophylaxis guidelines addressing unique premorbid characteristics, pathologies, and procedures,” said Anne Ritter, MPH, PhD, of Uniformed Services University of the Health Sciences in Bethesda, Maryland.

PTS is commonly recognized as a complication of TBI that may be acute or chronic. Although risk factors for PTS have been identified, predicting who will develop PTS remains difficult. Current PTS prognostic models are not widely accepted for clinical use and do not reflect current trends in injury, diagnosis, or care.

“Accurate PTS risk prediction could help define high-risk populations in support of clinical intervention trials. Predictive models could also inform clinical algorithms to identify individuals likely to benefit from tailored seizure prophylaxis or treatment,” said Dr. Ritter.

Dr. Ritter and colleagues conducted a study to develop and internally validate preliminary prognostic regression models that predict PTS during acute care hospitalization and at year 1 and year 2 post injury.

Study Population

Eligible participants had moderate or severe TBI, were admitted to a participating hospital emergency department within 72 hours of injury, were age 16 or older, and received acute care and inpatient rehabilitation within a TBI Model System (TBIMS) designated hospital system. Moderate or severe TBI was defined as posttraumatic amnesia lasting longer than 24 h, loss of consciousness lasting longer than 30 minutes, an emergency department Glasgow Coma Scale score less than 13, or positive neuroimaging findings.

People injured between October 1, 2011, and August 31, 2014, were included in the study. Patients injured during this time period, but not eligible for year 1 follow-up were excluded, however. Data for all participants were selected from the TBIMS National Database.

Researchers limited data to those collected at enrollment, year 1, or year 2 post injury. Enrollment data were collected using chart review and interview and included demographic, social, and injury characteristics, as well as preinjury personal and medical history and acute hospitalization outcome. PTS status, defined as the presence or absence of seizure activity, was the main outcome. It was determined during acute hospitalization, at year 1, and at year 2. In addition, investigators used multivariable logistic regression to generate prognostic models for PTS during acute hospitalization, at year 1, and at year 2. They internally validated models with resampling.

PTS Predictors of Interest

Of 2,136 participants, 2,042 had data available on all predictors identified in simple logistic regression for seizure during acute hospitalization. The sample’s demographic and clinical variables were similar in this investigation to those in previous TBI studies.

The final year 1 prognostic model identified injury severity, subdural hematoma, contusion load, craniotomy, craniectomy, seizure during acute hospitalization, preinjury condition limiting physical activity, preinjury mental health treatment or psychiatric hospitalization, and incarceration as risk factors for PTS. Craniectomy was the most statistically significant predictor in the final model.

At year 2, following validation, predictor variables included subdural hematoma, intraparenchymal fragment, craniotomy, craniectomy, seizure during acute hospitalization, and preinjury incarceration. Acute hospitalization seizure and craniectomy were the most statistically significant predictors of PTS at year 2.

Overall, the models displayed poor discrimination ability for PTS; however, these models may have added benefit, compared with prior models that were not being used clinically, said Dr. Ritter.

“These models must be examined in independent study populations to determine discriminability and validity outside the TBIMS population,” she added.

—Erica Tricarico

Suggested Reading

Ritter AC, Wagner AK, Szaflarski, et al. Prognostic models for predicting posttraumatic seizures during acute hospitalization, and 1 and 2 years following traumatic brain injury. Epilepsia. 2016;57(9):1503-1514.

Investigators have developed prognostic models that discriminate between patients with and without posttraumatic seizures (PTS) at year 1 and year 2 after traumatic brain injury (TBI), but perform little better than chance at predicting PTS, according to research published in the September issue of Epilepsia. The models do, however, identify potentially important predictors that may help to identify populations at risk for PTS.

“Individuals with characteristics identified in prognostic models as predictors of PTS represent subpopulations that may benefit from tailored seizure prophylaxis guidelines addressing unique premorbid characteristics, pathologies, and procedures,” said Anne Ritter, MPH, PhD, of Uniformed Services University of the Health Sciences in Bethesda, Maryland.

PTS is commonly recognized as a complication of TBI that may be acute or chronic. Although risk factors for PTS have been identified, predicting who will develop PTS remains difficult. Current PTS prognostic models are not widely accepted for clinical use and do not reflect current trends in injury, diagnosis, or care.

“Accurate PTS risk prediction could help define high-risk populations in support of clinical intervention trials. Predictive models could also inform clinical algorithms to identify individuals likely to benefit from tailored seizure prophylaxis or treatment,” said Dr. Ritter.

Dr. Ritter and colleagues conducted a study to develop and internally validate preliminary prognostic regression models that predict PTS during acute care hospitalization and at year 1 and year 2 post injury.

Study Population

Eligible participants had moderate or severe TBI, were admitted to a participating hospital emergency department within 72 hours of injury, were age 16 or older, and received acute care and inpatient rehabilitation within a TBI Model System (TBIMS) designated hospital system. Moderate or severe TBI was defined as posttraumatic amnesia lasting longer than 24 h, loss of consciousness lasting longer than 30 minutes, an emergency department Glasgow Coma Scale score less than 13, or positive neuroimaging findings.

People injured between October 1, 2011, and August 31, 2014, were included in the study. Patients injured during this time period, but not eligible for year 1 follow-up were excluded, however. Data for all participants were selected from the TBIMS National Database.

Researchers limited data to those collected at enrollment, year 1, or year 2 post injury. Enrollment data were collected using chart review and interview and included demographic, social, and injury characteristics, as well as preinjury personal and medical history and acute hospitalization outcome. PTS status, defined as the presence or absence of seizure activity, was the main outcome. It was determined during acute hospitalization, at year 1, and at year 2. In addition, investigators used multivariable logistic regression to generate prognostic models for PTS during acute hospitalization, at year 1, and at year 2. They internally validated models with resampling.

PTS Predictors of Interest

Of 2,136 participants, 2,042 had data available on all predictors identified in simple logistic regression for seizure during acute hospitalization. The sample’s demographic and clinical variables were similar in this investigation to those in previous TBI studies.

The final year 1 prognostic model identified injury severity, subdural hematoma, contusion load, craniotomy, craniectomy, seizure during acute hospitalization, preinjury condition limiting physical activity, preinjury mental health treatment or psychiatric hospitalization, and incarceration as risk factors for PTS. Craniectomy was the most statistically significant predictor in the final model.

At year 2, following validation, predictor variables included subdural hematoma, intraparenchymal fragment, craniotomy, craniectomy, seizure during acute hospitalization, and preinjury incarceration. Acute hospitalization seizure and craniectomy were the most statistically significant predictors of PTS at year 2.

Overall, the models displayed poor discrimination ability for PTS; however, these models may have added benefit, compared with prior models that were not being used clinically, said Dr. Ritter.

“These models must be examined in independent study populations to determine discriminability and validity outside the TBIMS population,” she added.

—Erica Tricarico

Suggested Reading

Ritter AC, Wagner AK, Szaflarski, et al. Prognostic models for predicting posttraumatic seizures during acute hospitalization, and 1 and 2 years following traumatic brain injury. Epilepsia. 2016;57(9):1503-1514.

Investigators have developed prognostic models that discriminate between patients with and without posttraumatic seizures (PTS) at year 1 and year 2 after traumatic brain injury (TBI), but perform little better than chance at predicting PTS, according to research published in the September issue of Epilepsia. The models do, however, identify potentially important predictors that may help to identify populations at risk for PTS.

“Individuals with characteristics identified in prognostic models as predictors of PTS represent subpopulations that may benefit from tailored seizure prophylaxis guidelines addressing unique premorbid characteristics, pathologies, and procedures,” said Anne Ritter, MPH, PhD, of Uniformed Services University of the Health Sciences in Bethesda, Maryland.

PTS is commonly recognized as a complication of TBI that may be acute or chronic. Although risk factors for PTS have been identified, predicting who will develop PTS remains difficult. Current PTS prognostic models are not widely accepted for clinical use and do not reflect current trends in injury, diagnosis, or care.

“Accurate PTS risk prediction could help define high-risk populations in support of clinical intervention trials. Predictive models could also inform clinical algorithms to identify individuals likely to benefit from tailored seizure prophylaxis or treatment,” said Dr. Ritter.

Dr. Ritter and colleagues conducted a study to develop and internally validate preliminary prognostic regression models that predict PTS during acute care hospitalization and at year 1 and year 2 post injury.

Study Population

Eligible participants had moderate or severe TBI, were admitted to a participating hospital emergency department within 72 hours of injury, were age 16 or older, and received acute care and inpatient rehabilitation within a TBI Model System (TBIMS) designated hospital system. Moderate or severe TBI was defined as posttraumatic amnesia lasting longer than 24 h, loss of consciousness lasting longer than 30 minutes, an emergency department Glasgow Coma Scale score less than 13, or positive neuroimaging findings.

People injured between October 1, 2011, and August 31, 2014, were included in the study. Patients injured during this time period, but not eligible for year 1 follow-up were excluded, however. Data for all participants were selected from the TBIMS National Database.

Researchers limited data to those collected at enrollment, year 1, or year 2 post injury. Enrollment data were collected using chart review and interview and included demographic, social, and injury characteristics, as well as preinjury personal and medical history and acute hospitalization outcome. PTS status, defined as the presence or absence of seizure activity, was the main outcome. It was determined during acute hospitalization, at year 1, and at year 2. In addition, investigators used multivariable logistic regression to generate prognostic models for PTS during acute hospitalization, at year 1, and at year 2. They internally validated models with resampling.

PTS Predictors of Interest

Of 2,136 participants, 2,042 had data available on all predictors identified in simple logistic regression for seizure during acute hospitalization. The sample’s demographic and clinical variables were similar in this investigation to those in previous TBI studies.

The final year 1 prognostic model identified injury severity, subdural hematoma, contusion load, craniotomy, craniectomy, seizure during acute hospitalization, preinjury condition limiting physical activity, preinjury mental health treatment or psychiatric hospitalization, and incarceration as risk factors for PTS. Craniectomy was the most statistically significant predictor in the final model.

At year 2, following validation, predictor variables included subdural hematoma, intraparenchymal fragment, craniotomy, craniectomy, seizure during acute hospitalization, and preinjury incarceration. Acute hospitalization seizure and craniectomy were the most statistically significant predictors of PTS at year 2.

Overall, the models displayed poor discrimination ability for PTS; however, these models may have added benefit, compared with prior models that were not being used clinically, said Dr. Ritter.

“These models must be examined in independent study populations to determine discriminability and validity outside the TBIMS population,” she added.

—Erica Tricarico

Suggested Reading

Ritter AC, Wagner AK, Szaflarski, et al. Prognostic models for predicting posttraumatic seizures during acute hospitalization, and 1 and 2 years following traumatic brain injury. Epilepsia. 2016;57(9):1503-1514.

Amitriptyline and topiramate, the most commonly used medications for preventing pediatric migraine, are no more effective than placebo, according to trial results published online ahead of print October 27 in the New England Journal of Medicine. The drugs are, however, associated with higher rates of adverse events.

While the researchers were conducting this study, the FDA approved topiramate for the treatment of episodic migraine in adolescents between ages 12 and 17. “Although our trial included patients outside this age range and included those with either episodic or chronic migraine, the trial results suggest that prevention medication for pediatric migraine might be reexamined,” said Scott W. Powers, PhD, Codirector of the Headache Center at Cincinnati Children’s, and colleagues.

The FDA has not approved any migraine-prevention medication for children younger than 12, and clinical practice guidelines for this indication are based on consensus, rather than evidence. Dr. Powers and colleagues conducted the Childhood and Adolescent Migraine Prevention (CHAMP) trial to compare the efficacy of common medications in children and adolescents between ages 8 and 17 with migraine. They randomized 361 patients to amitriptyline (1 mg/kg/day), topiramate (2 mg/kg/day), or placebo in a 2:2:1 ratio.

The trial included a 28-day baseline period, an eight-week dose-escalation period, and a 16-week maintenance phase. The primary outcome was a reduction of 50% or more in the number of headache days during the last 28 days of the trial, compared with baseline. Secondary outcomes included headache-related disability, headache days, number of trial completers, and serious adverse events.

The baseline characteristics of the three treatment groups were similar. The population’s mean age was 14. About 68% of the population was female, and 70% was white.

After a planned interim analysis, the investigators ended the trial early for futility. They found no significant between-group differences in the primary outcome. Approximately 52% of patients receiving amitriptyline, 55% of those receiving topiramate, and 61% of controls had a reduction in headache days of at least 50%. Headache-related disability, headache days, and the rate of trial completion also did not differ between groups.

Patients who received amitriptyline or topiramate had higher rates of several adverse events than those receiving placebo, including fatigue (30% vs 14%) and dry mouth (25% vs 12%) in the amitriptyline group and paresthesia (31% vs 8%) and weight loss (8% vs 0%) in the topiramate group. Three patients receiving amitriptyline had serious adverse events of altered mood, and one patient receiving topiramate attempted suicide.

“We see this [study] as an important opportunity for health care providers, scientists, children, and families because our findings suggest a paradigm shift,” said Dr. Powers. “First-line prevention treatment will involve a multidisciplinary team approach and focus on nonpharmacologic aspects of care. The good news is we can help children with migraines get better.”

—Erik Greb

Suggested Reading

Powers SW, Coffey CS, Chamberlin LA, et al. Trial of amitriptyline, topiramate, and placebo for pediatric migraine. N Engl J Med. 2016 Oct 27 [Epub ahead of print].

Amitriptyline and topiramate, the most commonly used medications for preventing pediatric migraine, are no more effective than placebo, according to trial results published online ahead of print October 27 in the New England Journal of Medicine. The drugs are, however, associated with higher rates of adverse events.

While the researchers were conducting this study, the FDA approved topiramate for the treatment of episodic migraine in adolescents between ages 12 and 17. “Although our trial included patients outside this age range and included those with either episodic or chronic migraine, the trial results suggest that prevention medication for pediatric migraine might be reexamined,” said Scott W. Powers, PhD, Codirector of the Headache Center at Cincinnati Children’s, and colleagues.

The FDA has not approved any migraine-prevention medication for children younger than 12, and clinical practice guidelines for this indication are based on consensus, rather than evidence. Dr. Powers and colleagues conducted the Childhood and Adolescent Migraine Prevention (CHAMP) trial to compare the efficacy of common medications in children and adolescents between ages 8 and 17 with migraine. They randomized 361 patients to amitriptyline (1 mg/kg/day), topiramate (2 mg/kg/day), or placebo in a 2:2:1 ratio.

The trial included a 28-day baseline period, an eight-week dose-escalation period, and a 16-week maintenance phase. The primary outcome was a reduction of 50% or more in the number of headache days during the last 28 days of the trial, compared with baseline. Secondary outcomes included headache-related disability, headache days, number of trial completers, and serious adverse events.

The baseline characteristics of the three treatment groups were similar. The population’s mean age was 14. About 68% of the population was female, and 70% was white.

After a planned interim analysis, the investigators ended the trial early for futility. They found no significant between-group differences in the primary outcome. Approximately 52% of patients receiving amitriptyline, 55% of those receiving topiramate, and 61% of controls had a reduction in headache days of at least 50%. Headache-related disability, headache days, and the rate of trial completion also did not differ between groups.

Patients who received amitriptyline or topiramate had higher rates of several adverse events than those receiving placebo, including fatigue (30% vs 14%) and dry mouth (25% vs 12%) in the amitriptyline group and paresthesia (31% vs 8%) and weight loss (8% vs 0%) in the topiramate group. Three patients receiving amitriptyline had serious adverse events of altered mood, and one patient receiving topiramate attempted suicide.

“We see this [study] as an important opportunity for health care providers, scientists, children, and families because our findings suggest a paradigm shift,” said Dr. Powers. “First-line prevention treatment will involve a multidisciplinary team approach and focus on nonpharmacologic aspects of care. The good news is we can help children with migraines get better.”

—Erik Greb

Suggested Reading

Powers SW, Coffey CS, Chamberlin LA, et al. Trial of amitriptyline, topiramate, and placebo for pediatric migraine. N Engl J Med. 2016 Oct 27 [Epub ahead of print].

Amitriptyline and topiramate, the most commonly used medications for preventing pediatric migraine, are no more effective than placebo, according to trial results published online ahead of print October 27 in the New England Journal of Medicine. The drugs are, however, associated with higher rates of adverse events.

While the researchers were conducting this study, the FDA approved topiramate for the treatment of episodic migraine in adolescents between ages 12 and 17. “Although our trial included patients outside this age range and included those with either episodic or chronic migraine, the trial results suggest that prevention medication for pediatric migraine might be reexamined,” said Scott W. Powers, PhD, Codirector of the Headache Center at Cincinnati Children’s, and colleagues.

The FDA has not approved any migraine-prevention medication for children younger than 12, and clinical practice guidelines for this indication are based on consensus, rather than evidence. Dr. Powers and colleagues conducted the Childhood and Adolescent Migraine Prevention (CHAMP) trial to compare the efficacy of common medications in children and adolescents between ages 8 and 17 with migraine. They randomized 361 patients to amitriptyline (1 mg/kg/day), topiramate (2 mg/kg/day), or placebo in a 2:2:1 ratio.

The trial included a 28-day baseline period, an eight-week dose-escalation period, and a 16-week maintenance phase. The primary outcome was a reduction of 50% or more in the number of headache days during the last 28 days of the trial, compared with baseline. Secondary outcomes included headache-related disability, headache days, number of trial completers, and serious adverse events.

The baseline characteristics of the three treatment groups were similar. The population’s mean age was 14. About 68% of the population was female, and 70% was white.

After a planned interim analysis, the investigators ended the trial early for futility. They found no significant between-group differences in the primary outcome. Approximately 52% of patients receiving amitriptyline, 55% of those receiving topiramate, and 61% of controls had a reduction in headache days of at least 50%. Headache-related disability, headache days, and the rate of trial completion also did not differ between groups.

Patients who received amitriptyline or topiramate had higher rates of several adverse events than those receiving placebo, including fatigue (30% vs 14%) and dry mouth (25% vs 12%) in the amitriptyline group and paresthesia (31% vs 8%) and weight loss (8% vs 0%) in the topiramate group. Three patients receiving amitriptyline had serious adverse events of altered mood, and one patient receiving topiramate attempted suicide.

“We see this [study] as an important opportunity for health care providers, scientists, children, and families because our findings suggest a paradigm shift,” said Dr. Powers. “First-line prevention treatment will involve a multidisciplinary team approach and focus on nonpharmacologic aspects of care. The good news is we can help children with migraines get better.”

—Erik Greb

Suggested Reading

Powers SW, Coffey CS, Chamberlin LA, et al. Trial of amitriptyline, topiramate, and placebo for pediatric migraine. N Engl J Med. 2016 Oct 27 [Epub ahead of print].

Clinical Question: What is the validity of commonly held beliefs regarding serotonin syndrome (SS)?

Background: SS is a potentially life-threatening condition caused by serotonin excess in the central nervous system. The authors tested the validity of four widely accepted tenets about SS: that the Hunter criteria are superior, that the onset of SS is rapid compared to neuroleptic malignant syndrome (NMS), that hyperthermia is common with SS, and that SS can be distinguished from NMS based on medication history.

Study Design: Systematic review and meta-analysis.

Setting: PubMed and Web of Science.

Synopsis: Researchers identified 299 case reports from 2004 to 2014 in which SS was the most likely diagnosis based on one of three available diagnostic systems. Rhabdomyolysis with creatine kinase >1,500 and ICU treatment were used as proxies for SS severity. The Hunter criteria (the current gold standard) identified fewer overdoses, episodes of rhabdomyolysis, and ICU cases than the Sternbach or Radomski criteria. Combinations of antidepressants with methylene blue, opiates, or linezolid were the most common reasons for ICU admission. Symptom onset was within six hours in only 27.5% of cases. Hyperthermia was present in only 9.2% of patients with SS.

Hospitalists cannot rely on any one set of criteria to diagnose SS. The typical combinations of opiates or linezolid with antidepressants should raise the level of suspicion for SS. Rigidity and rhabdomyolysis occur commonly in both NMS and SS. Hyperthermia and timing of onset are not good indicators to the diagnosis of SS.

Bottom line: A high index of suspicion rather than reliance on classification systems or anecdotal key symptoms is necessary when considering SS.

Citation: Werneke U, Jamshidi F, Taylor DM, Ott M. Conundrums in neurology: diagnosing serotonin syndrome – a meta-analysis of cases. BMC Neurol. 2016;16:97.

Clinical Question: What is the validity of commonly held beliefs regarding serotonin syndrome (SS)?

Background: SS is a potentially life-threatening condition caused by serotonin excess in the central nervous system. The authors tested the validity of four widely accepted tenets about SS: that the Hunter criteria are superior, that the onset of SS is rapid compared to neuroleptic malignant syndrome (NMS), that hyperthermia is common with SS, and that SS can be distinguished from NMS based on medication history.

Study Design: Systematic review and meta-analysis.

Setting: PubMed and Web of Science.

Synopsis: Researchers identified 299 case reports from 2004 to 2014 in which SS was the most likely diagnosis based on one of three available diagnostic systems. Rhabdomyolysis with creatine kinase >1,500 and ICU treatment were used as proxies for SS severity. The Hunter criteria (the current gold standard) identified fewer overdoses, episodes of rhabdomyolysis, and ICU cases than the Sternbach or Radomski criteria. Combinations of antidepressants with methylene blue, opiates, or linezolid were the most common reasons for ICU admission. Symptom onset was within six hours in only 27.5% of cases. Hyperthermia was present in only 9.2% of patients with SS.

Hospitalists cannot rely on any one set of criteria to diagnose SS. The typical combinations of opiates or linezolid with antidepressants should raise the level of suspicion for SS. Rigidity and rhabdomyolysis occur commonly in both NMS and SS. Hyperthermia and timing of onset are not good indicators to the diagnosis of SS.

Bottom line: A high index of suspicion rather than reliance on classification systems or anecdotal key symptoms is necessary when considering SS.

Citation: Werneke U, Jamshidi F, Taylor DM, Ott M. Conundrums in neurology: diagnosing serotonin syndrome – a meta-analysis of cases. BMC Neurol. 2016;16:97.

Clinical Question: What is the validity of commonly held beliefs regarding serotonin syndrome (SS)?

Background: SS is a potentially life-threatening condition caused by serotonin excess in the central nervous system. The authors tested the validity of four widely accepted tenets about SS: that the Hunter criteria are superior, that the onset of SS is rapid compared to neuroleptic malignant syndrome (NMS), that hyperthermia is common with SS, and that SS can be distinguished from NMS based on medication history.

Study Design: Systematic review and meta-analysis.

Setting: PubMed and Web of Science.

Synopsis: Researchers identified 299 case reports from 2004 to 2014 in which SS was the most likely diagnosis based on one of three available diagnostic systems. Rhabdomyolysis with creatine kinase >1,500 and ICU treatment were used as proxies for SS severity. The Hunter criteria (the current gold standard) identified fewer overdoses, episodes of rhabdomyolysis, and ICU cases than the Sternbach or Radomski criteria. Combinations of antidepressants with methylene blue, opiates, or linezolid were the most common reasons for ICU admission. Symptom onset was within six hours in only 27.5% of cases. Hyperthermia was present in only 9.2% of patients with SS.

Hospitalists cannot rely on any one set of criteria to diagnose SS. The typical combinations of opiates or linezolid with antidepressants should raise the level of suspicion for SS. Rigidity and rhabdomyolysis occur commonly in both NMS and SS. Hyperthermia and timing of onset are not good indicators to the diagnosis of SS.

Bottom line: A high index of suspicion rather than reliance on classification systems or anecdotal key symptoms is necessary when considering SS.

Citation: Werneke U, Jamshidi F, Taylor DM, Ott M. Conundrums in neurology: diagnosing serotonin syndrome – a meta-analysis of cases. BMC Neurol. 2016;16:97.

Clinical Question: Are there particular groups of patients in which lower transfusion thresholds (transfusion only at lower hemoglobin levels) may be harmful?

Background: Previously published meta-analyses have examined transfusion thresholds for critically ill, surgical, and medical patients. By combining these patients, previous meta-analyses are limited in the identification of intervention effects. A more refined understanding of how transfusion thresholds impact outcomes for a variety of patients in different clinical settings is needed.

Study Design: Context-specific systematic review and meta-analysis of randomized clinical trials.

Setting: Adult patients in perioperative, emergency, or intensive-care settings.

Synopsis: Patient information was extracted from 31 randomized clinical trials. The authors found that among 3,465 elderly patients undergoing orthopedic surgery, those given restrictive transfusion strategies had significantly more events reflecting inadequate oxygen supply (relative risk, 1.41; 95% CI, 1.03–1.92). No statistically significant effect from restrictive transfusions was seen in 3,322 patients with cardiovascular disease undergoing cardiac or vascular procedures; 3,590 mixed medical-surgical patients in emergency and intensive-care settings; and 823 patients in a combined group of postpartum women, hematologic malignancy patients, and younger patients with neurologic injury.

The authors argue that even statistically nonsignificant differences in morbidity and mortality should encourage more liberal transfusion; apart from orthopedic surgery patients, this argument is not well-supported by the available data.

Bottom Line: It remains unclear whether restrictive transfusion strategies have a negative impact on certain types of patients, although the authors argue that there may be a trend in that direction. Further study is needed for specific patient populations.

Citation: Hovaguimian F, Myles PS. Restrictive versus liberal transfusion strategy in the perioperative and acute care settings: a context-specific systematic review and meta-analysis of randomized clinical trials. Anesthesiology. 2016;125(1):46-61.

Clinical Question: Are there particular groups of patients in which lower transfusion thresholds (transfusion only at lower hemoglobin levels) may be harmful?

Background: Previously published meta-analyses have examined transfusion thresholds for critically ill, surgical, and medical patients. By combining these patients, previous meta-analyses are limited in the identification of intervention effects. A more refined understanding of how transfusion thresholds impact outcomes for a variety of patients in different clinical settings is needed.

Study Design: Context-specific systematic review and meta-analysis of randomized clinical trials.

Setting: Adult patients in perioperative, emergency, or intensive-care settings.

Synopsis: Patient information was extracted from 31 randomized clinical trials. The authors found that among 3,465 elderly patients undergoing orthopedic surgery, those given restrictive transfusion strategies had significantly more events reflecting inadequate oxygen supply (relative risk, 1.41; 95% CI, 1.03–1.92). No statistically significant effect from restrictive transfusions was seen in 3,322 patients with cardiovascular disease undergoing cardiac or vascular procedures; 3,590 mixed medical-surgical patients in emergency and intensive-care settings; and 823 patients in a combined group of postpartum women, hematologic malignancy patients, and younger patients with neurologic injury.

The authors argue that even statistically nonsignificant differences in morbidity and mortality should encourage more liberal transfusion; apart from orthopedic surgery patients, this argument is not well-supported by the available data.

Bottom Line: It remains unclear whether restrictive transfusion strategies have a negative impact on certain types of patients, although the authors argue that there may be a trend in that direction. Further study is needed for specific patient populations.

Citation: Hovaguimian F, Myles PS. Restrictive versus liberal transfusion strategy in the perioperative and acute care settings: a context-specific systematic review and meta-analysis of randomized clinical trials. Anesthesiology. 2016;125(1):46-61.

Clinical Question: Are there particular groups of patients in which lower transfusion thresholds (transfusion only at lower hemoglobin levels) may be harmful?

Background: Previously published meta-analyses have examined transfusion thresholds for critically ill, surgical, and medical patients. By combining these patients, previous meta-analyses are limited in the identification of intervention effects. A more refined understanding of how transfusion thresholds impact outcomes for a variety of patients in different clinical settings is needed.

Study Design: Context-specific systematic review and meta-analysis of randomized clinical trials.

Setting: Adult patients in perioperative, emergency, or intensive-care settings.

Synopsis: Patient information was extracted from 31 randomized clinical trials. The authors found that among 3,465 elderly patients undergoing orthopedic surgery, those given restrictive transfusion strategies had significantly more events reflecting inadequate oxygen supply (relative risk, 1.41; 95% CI, 1.03–1.92). No statistically significant effect from restrictive transfusions was seen in 3,322 patients with cardiovascular disease undergoing cardiac or vascular procedures; 3,590 mixed medical-surgical patients in emergency and intensive-care settings; and 823 patients in a combined group of postpartum women, hematologic malignancy patients, and younger patients with neurologic injury.

The authors argue that even statistically nonsignificant differences in morbidity and mortality should encourage more liberal transfusion; apart from orthopedic surgery patients, this argument is not well-supported by the available data.

Bottom Line: It remains unclear whether restrictive transfusion strategies have a negative impact on certain types of patients, although the authors argue that there may be a trend in that direction. Further study is needed for specific patient populations.

Citation: Hovaguimian F, Myles PS. Restrictive versus liberal transfusion strategy in the perioperative and acute care settings: a context-specific systematic review and meta-analysis of randomized clinical trials. Anesthesiology. 2016;125(1):46-61.

Clinical Question: What is the incidence of loss of independence (LOI) for older adults after surgery, and is there an association between LOI and readmission or death?

Background: LOI is being increasingly recognized as an important measure of patient-centered care and a potential opportunity for intervention to prevent disablement. This study is the first to examine links between LOI and rates of readmission or death following surgery.

Study Design: Retrospective cohort.

Setting: 26 U.S. hospitals participating in a national quality improvement project.

Synopsis: The authors examined data from 5,077 patients age 65 or older undergoing an inpatient surgical procedure. They examined ability to perform activities of daily living (ADLs), mobility, and living situation before and after surgery, and they defined LOI as a change in one or more of these factors at the time of discharge.

They found that LOI increased with age, with 49.9% of patients ages 65–74, 67.3% of patients ages 75–84, and 83.9% of patients age 85 or older experiencing LOI. The study also showed an association between LOI and negative outcomes, including readmission (odds ratio, 1.7) and death after discharge (odds ratio, 6.7).

Although this study was retrospective, the findings indicate that LOI is strongly correlated with negative short-term outcomes, especially in older populations. LOI related to surgery is a measure that deserves closer attention and greater future study as a potential target for clinical initiatives and intervention.

Bottom Line: LOI (functional ability, mobility, and living situation) after surgery increases with age and is associated with negative short-term outcomes including readmission and death.

Citation: Berian JR, Mohanty S, Ko CY, Rosenthal RA, Robinson TN. Association of loss of independence with readmission and death after discharge in older patients after surgical procedures. JAMA Surg. 2016;151(9):e161689.

Short Take

Transition to New Electronic Health Records Systems Does Not Increase Adverse Outcomes

An observational study comparing 17 hospitals implementing new electronic health records systems with 399 control hospitals showed no difference in the rate of adverse safety events or readmissions following implementation.

Citation: Barnett ML, Mehrotra A, Jena AB. Adverse inpatient outcomes during the transition to a new electronic health record system: observational study. BMJ. 2016;354:i3835.

Clinical Question: What is the incidence of loss of independence (LOI) for older adults after surgery, and is there an association between LOI and readmission or death?

Background: LOI is being increasingly recognized as an important measure of patient-centered care and a potential opportunity for intervention to prevent disablement. This study is the first to examine links between LOI and rates of readmission or death following surgery.

Study Design: Retrospective cohort.

Setting: 26 U.S. hospitals participating in a national quality improvement project.

Synopsis: The authors examined data from 5,077 patients age 65 or older undergoing an inpatient surgical procedure. They examined ability to perform activities of daily living (ADLs), mobility, and living situation before and after surgery, and they defined LOI as a change in one or more of these factors at the time of discharge.

They found that LOI increased with age, with 49.9% of patients ages 65–74, 67.3% of patients ages 75–84, and 83.9% of patients age 85 or older experiencing LOI. The study also showed an association between LOI and negative outcomes, including readmission (odds ratio, 1.7) and death after discharge (odds ratio, 6.7).

Although this study was retrospective, the findings indicate that LOI is strongly correlated with negative short-term outcomes, especially in older populations. LOI related to surgery is a measure that deserves closer attention and greater future study as a potential target for clinical initiatives and intervention.

Bottom Line: LOI (functional ability, mobility, and living situation) after surgery increases with age and is associated with negative short-term outcomes including readmission and death.

Citation: Berian JR, Mohanty S, Ko CY, Rosenthal RA, Robinson TN. Association of loss of independence with readmission and death after discharge in older patients after surgical procedures. JAMA Surg. 2016;151(9):e161689.

Short Take

Transition to New Electronic Health Records Systems Does Not Increase Adverse Outcomes

An observational study comparing 17 hospitals implementing new electronic health records systems with 399 control hospitals showed no difference in the rate of adverse safety events or readmissions following implementation.

Citation: Barnett ML, Mehrotra A, Jena AB. Adverse inpatient outcomes during the transition to a new electronic health record system: observational study. BMJ. 2016;354:i3835.

Clinical Question: What is the incidence of loss of independence (LOI) for older adults after surgery, and is there an association between LOI and readmission or death?

Background: LOI is being increasingly recognized as an important measure of patient-centered care and a potential opportunity for intervention to prevent disablement. This study is the first to examine links between LOI and rates of readmission or death following surgery.

Study Design: Retrospective cohort.

Setting: 26 U.S. hospitals participating in a national quality improvement project.

Synopsis: The authors examined data from 5,077 patients age 65 or older undergoing an inpatient surgical procedure. They examined ability to perform activities of daily living (ADLs), mobility, and living situation before and after surgery, and they defined LOI as a change in one or more of these factors at the time of discharge.

They found that LOI increased with age, with 49.9% of patients ages 65–74, 67.3% of patients ages 75–84, and 83.9% of patients age 85 or older experiencing LOI. The study also showed an association between LOI and negative outcomes, including readmission (odds ratio, 1.7) and death after discharge (odds ratio, 6.7).

Although this study was retrospective, the findings indicate that LOI is strongly correlated with negative short-term outcomes, especially in older populations. LOI related to surgery is a measure that deserves closer attention and greater future study as a potential target for clinical initiatives and intervention.

Bottom Line: LOI (functional ability, mobility, and living situation) after surgery increases with age and is associated with negative short-term outcomes including readmission and death.

Citation: Berian JR, Mohanty S, Ko CY, Rosenthal RA, Robinson TN. Association of loss of independence with readmission and death after discharge in older patients after surgical procedures. JAMA Surg. 2016;151(9):e161689.

Short Take

Transition to New Electronic Health Records Systems Does Not Increase Adverse Outcomes

An observational study comparing 17 hospitals implementing new electronic health records systems with 399 control hospitals showed no difference in the rate of adverse safety events or readmissions following implementation.

Citation: Barnett ML, Mehrotra A, Jena AB. Adverse inpatient outcomes during the transition to a new electronic health record system: observational study. BMJ. 2016;354:i3835.

Clinical Question: What data are available regarding the attitudes toward and the practice of euthanasia and physician-assisted suicide (PAS)?

Background: Although controversial, euthanasia and PAS are currently legal in the Netherlands, Belgium, Luxembourg, Colombia, and Canada, while PAS (but not euthanasia) is legal in Switzerland and five states (Oregon, Washington, Montana, Vermont, and California). Knowledge about current practices is limited as only a portion of these jurisdictions have reporting requirements.

Study Design: Literature review with a focus on original data.

Setting: Data from United States, Canada, and Europe.

Synopsis: Published data from 1947 to 2016 were reviewed. U.S. public opinion surveys show a recent decline in support of PAS, from a peak of 75% in 2005 to 64% in 2012. With the exception of the Netherlands and Belgium, physicians in the U.S., Europe, and Australia are less supportive than the general public.

In the U.S., <20% of physicians reported receiving a request for euthanasia or PAS, and <5% complied. Oncologists are most likely to receive a patient request. The typical patient is older, white, insured, well-educated, and enrolled in hospice. Seventy-five percent have cancer, while 15% have neurodegenerative conditions. Loss of autonomy and dignity are common motivators, while <33% of patients cite uncontrolled pain. PAS remains rare, accounting for <0.4% of all deaths. Existing data do not indicate abuse of these practices.

The authors emphasize that existing data are limited and recommend that all countries, not just those where euthanasia and/or PAS are legal, should formally collect information on end-of-life practices.

Bottom Line: Euthanasia and PAS remain relatively rare and primarily involve oncology patients despite increasing legalization.

Citation: Emanuel EJ, Onwuteaka-Philipsen BD, Urwin JW, Cohen J. Attitudes and practices of euthanasia and physician-assisted suicide in the United States, Canada, and Europe. JAMA. 2016;316(1):79-90.

Short Take

Peer Support for Physicians May Curb Burnout

This perspective piece outlines a program of one-to-one peer outreach for physicians as a way to mitigate stress especially when dealing with adverse events or litigation, but no data are provided.

Citation: Shapiro J, Galowitz P. Peer support for clinicians: a programmatic approach. Acad Med. 2016;91(9):1200-1204.

Clinical Question: What data are available regarding the attitudes toward and the practice of euthanasia and physician-assisted suicide (PAS)?

Background: Although controversial, euthanasia and PAS are currently legal in the Netherlands, Belgium, Luxembourg, Colombia, and Canada, while PAS (but not euthanasia) is legal in Switzerland and five states (Oregon, Washington, Montana, Vermont, and California). Knowledge about current practices is limited as only a portion of these jurisdictions have reporting requirements.

Study Design: Literature review with a focus on original data.

Setting: Data from United States, Canada, and Europe.

Synopsis: Published data from 1947 to 2016 were reviewed. U.S. public opinion surveys show a recent decline in support of PAS, from a peak of 75% in 2005 to 64% in 2012. With the exception of the Netherlands and Belgium, physicians in the U.S., Europe, and Australia are less supportive than the general public.

In the U.S., <20% of physicians reported receiving a request for euthanasia or PAS, and <5% complied. Oncologists are most likely to receive a patient request. The typical patient is older, white, insured, well-educated, and enrolled in hospice. Seventy-five percent have cancer, while 15% have neurodegenerative conditions. Loss of autonomy and dignity are common motivators, while <33% of patients cite uncontrolled pain. PAS remains rare, accounting for <0.4% of all deaths. Existing data do not indicate abuse of these practices.

The authors emphasize that existing data are limited and recommend that all countries, not just those where euthanasia and/or PAS are legal, should formally collect information on end-of-life practices.

Bottom Line: Euthanasia and PAS remain relatively rare and primarily involve oncology patients despite increasing legalization.

Citation: Emanuel EJ, Onwuteaka-Philipsen BD, Urwin JW, Cohen J. Attitudes and practices of euthanasia and physician-assisted suicide in the United States, Canada, and Europe. JAMA. 2016;316(1):79-90.

Short Take

Peer Support for Physicians May Curb Burnout

This perspective piece outlines a program of one-to-one peer outreach for physicians as a way to mitigate stress especially when dealing with adverse events or litigation, but no data are provided.

Citation: Shapiro J, Galowitz P. Peer support for clinicians: a programmatic approach. Acad Med. 2016;91(9):1200-1204.

Clinical Question: What data are available regarding the attitudes toward and the practice of euthanasia and physician-assisted suicide (PAS)?

Background: Although controversial, euthanasia and PAS are currently legal in the Netherlands, Belgium, Luxembourg, Colombia, and Canada, while PAS (but not euthanasia) is legal in Switzerland and five states (Oregon, Washington, Montana, Vermont, and California). Knowledge about current practices is limited as only a portion of these jurisdictions have reporting requirements.

Study Design: Literature review with a focus on original data.

Setting: Data from United States, Canada, and Europe.

Synopsis: Published data from 1947 to 2016 were reviewed. U.S. public opinion surveys show a recent decline in support of PAS, from a peak of 75% in 2005 to 64% in 2012. With the exception of the Netherlands and Belgium, physicians in the U.S., Europe, and Australia are less supportive than the general public.

In the U.S., <20% of physicians reported receiving a request for euthanasia or PAS, and <5% complied. Oncologists are most likely to receive a patient request. The typical patient is older, white, insured, well-educated, and enrolled in hospice. Seventy-five percent have cancer, while 15% have neurodegenerative conditions. Loss of autonomy and dignity are common motivators, while <33% of patients cite uncontrolled pain. PAS remains rare, accounting for <0.4% of all deaths. Existing data do not indicate abuse of these practices.

The authors emphasize that existing data are limited and recommend that all countries, not just those where euthanasia and/or PAS are legal, should formally collect information on end-of-life practices.

Bottom Line: Euthanasia and PAS remain relatively rare and primarily involve oncology patients despite increasing legalization.

Citation: Emanuel EJ, Onwuteaka-Philipsen BD, Urwin JW, Cohen J. Attitudes and practices of euthanasia and physician-assisted suicide in the United States, Canada, and Europe. JAMA. 2016;316(1):79-90.

Short Take

Peer Support for Physicians May Curb Burnout

This perspective piece outlines a program of one-to-one peer outreach for physicians as a way to mitigate stress especially when dealing with adverse events or litigation, but no data are provided.

Citation: Shapiro J, Galowitz P. Peer support for clinicians: a programmatic approach. Acad Med. 2016;91(9):1200-1204.

Clinical Question: How often are goals of care (GOC) discussed during hospitalization of long-term care residents, and what patient characteristics make this more likely to occur?

Background: GOC discussions during hospitalization have the potential to better align patient wishes with care received and to reduce unwanted care. Previous studies have examined barriers to GOC discussions, but less is known about factors associated with GOC discussions occurring and the outcomes of these discussions.

Study Design: Retrospective chart review.

Setting: Two academic hospitals in Toronto.

Synopsis: In the review, 665 hospitalized patients during a one-year period were identified as being >65 years old and from a long-term care facility. Of the 665 patients, a random sampling of 200 unique patients was reviewed. Of these, 37.5% had a documented GOC discussion. Lower Glasgow Coma Scale scores and higher respiratory rates were correlated with a higher incidence of GOC discussions. Patients with GOC discussions had higher rates of no resuscitation and comfort care orders; these patients also had higher odds of in-hospital death and one-year mortality. Of patients that had a change in their GOC, 74% did not have this change reflected in the discharge summary.

Although this study is a retrospective review and limited to two Canadian teaching hospitals, there is likely an opportunity for hospitalists to more frequently discuss and document GOC in hospitalized long-term care patients.

Bottom Line: In hospitalized long-term care patients, GOC are infrequently discussed and documented. Frequency of discussions is correlated with illness severity.

Citation: Wong HJ, Wang J, Grinman M, Wu RC. Goals of care discussions among hospitalized long-term care residents: predictors and associated outcomes of care [published online ahead of print July 21, 2016]. J Hosp Med.

Short Take

Sleep-Promoting Interventions Improve Sleep in Hospitalized Patients

A non-blinded, quasi-randomized pilot study of 112 patients demonstrated that sleep-promoting interventions, including education and environmental control to minimize sleep disruption, improved total nighttime sleep time as well as qualitative measures of sleep.

Citation: Gathecha E, Rios R, Buenaver LF, Landis R, Howell E, Wright S. Pilot study aiming to support sleep quality and duration during hospitalizations. J Hosp Med. 2016;11(7):467-472.

Clinical Question: How often are goals of care (GOC) discussed during hospitalization of long-term care residents, and what patient characteristics make this more likely to occur?

Background: GOC discussions during hospitalization have the potential to better align patient wishes with care received and to reduce unwanted care. Previous studies have examined barriers to GOC discussions, but less is known about factors associated with GOC discussions occurring and the outcomes of these discussions.

Study Design: Retrospective chart review.

Setting: Two academic hospitals in Toronto.

Synopsis: In the review, 665 hospitalized patients during a one-year period were identified as being >65 years old and from a long-term care facility. Of the 665 patients, a random sampling of 200 unique patients was reviewed. Of these, 37.5% had a documented GOC discussion. Lower Glasgow Coma Scale scores and higher respiratory rates were correlated with a higher incidence of GOC discussions. Patients with GOC discussions had higher rates of no resuscitation and comfort care orders; these patients also had higher odds of in-hospital death and one-year mortality. Of patients that had a change in their GOC, 74% did not have this change reflected in the discharge summary.

Although this study is a retrospective review and limited to two Canadian teaching hospitals, there is likely an opportunity for hospitalists to more frequently discuss and document GOC in hospitalized long-term care patients.

Bottom Line: In hospitalized long-term care patients, GOC are infrequently discussed and documented. Frequency of discussions is correlated with illness severity.

Citation: Wong HJ, Wang J, Grinman M, Wu RC. Goals of care discussions among hospitalized long-term care residents: predictors and associated outcomes of care [published online ahead of print July 21, 2016]. J Hosp Med.

Short Take

Sleep-Promoting Interventions Improve Sleep in Hospitalized Patients

A non-blinded, quasi-randomized pilot study of 112 patients demonstrated that sleep-promoting interventions, including education and environmental control to minimize sleep disruption, improved total nighttime sleep time as well as qualitative measures of sleep.

Citation: Gathecha E, Rios R, Buenaver LF, Landis R, Howell E, Wright S. Pilot study aiming to support sleep quality and duration during hospitalizations. J Hosp Med. 2016;11(7):467-472.

Clinical Question: How often are goals of care (GOC) discussed during hospitalization of long-term care residents, and what patient characteristics make this more likely to occur?

Background: GOC discussions during hospitalization have the potential to better align patient wishes with care received and to reduce unwanted care. Previous studies have examined barriers to GOC discussions, but less is known about factors associated with GOC discussions occurring and the outcomes of these discussions.

Study Design: Retrospective chart review.

Setting: Two academic hospitals in Toronto.

Synopsis: In the review, 665 hospitalized patients during a one-year period were identified as being >65 years old and from a long-term care facility. Of the 665 patients, a random sampling of 200 unique patients was reviewed. Of these, 37.5% had a documented GOC discussion. Lower Glasgow Coma Scale scores and higher respiratory rates were correlated with a higher incidence of GOC discussions. Patients with GOC discussions had higher rates of no resuscitation and comfort care orders; these patients also had higher odds of in-hospital death and one-year mortality. Of patients that had a change in their GOC, 74% did not have this change reflected in the discharge summary.

Although this study is a retrospective review and limited to two Canadian teaching hospitals, there is likely an opportunity for hospitalists to more frequently discuss and document GOC in hospitalized long-term care patients.

Bottom Line: In hospitalized long-term care patients, GOC are infrequently discussed and documented. Frequency of discussions is correlated with illness severity.

Citation: Wong HJ, Wang J, Grinman M, Wu RC. Goals of care discussions among hospitalized long-term care residents: predictors and associated outcomes of care [published online ahead of print July 21, 2016]. J Hosp Med.

Short Take

Sleep-Promoting Interventions Improve Sleep in Hospitalized Patients

A non-blinded, quasi-randomized pilot study of 112 patients demonstrated that sleep-promoting interventions, including education and environmental control to minimize sleep disruption, improved total nighttime sleep time as well as qualitative measures of sleep.

Citation: Gathecha E, Rios R, Buenaver LF, Landis R, Howell E, Wright S. Pilot study aiming to support sleep quality and duration during hospitalizations. J Hosp Med. 2016;11(7):467-472.

Clinical Question: How do patterns of end-of-life care compare for patients with different diseases?

Background: Studies regarding quality of care at the end of life have focused primarily on patients dying from cancer. Few studies to date have looked at patients dying from other illnesses, and few have taken into account perspectives of family members.

Study Design: Retrospective cross-sectional.

Setting: 146 inpatient facilities in the Veterans Affairs (VA) health system.

Synopsis: The authors identified 57,753 patients who died while hospitalized at VA facilities during the study period, and 34,015 next of kin completed the Bereaved Family Survey. Overall, approximately half (43.7%–50.4%) of patients with end-stage renal disease (ESRD), frailty, or cardiopulmonary disease received palliative-care consultations compared with 73.5% and 61.4% of patients with cancer and dementia, respectively. Patients with cancer or dementia were less likely to die in the ICU compared to patients with other diagnoses (8.9%–13.4% compared to 32.3%–35.2%). Quality of care as perceived by the bereaved families was higher for patients with cancer or dementia (59.2%–59.3% compared to 53.7%–54.8%).

While large, this study was limited in applicability to different populations due to being conducted within the VA system. Overall, it showed significant differences in end-of-life care between patients who died from different diseases. This study suggests several practical steps that may improve disparities in end-of-life care, in particular, increasing discussion of goals of care and improving access to inpatient palliative-care consults for patients with ESRD, frailty, or cardiopulmonary disease.

Bottom Line: Quality and satisfaction indicators for end-of-life care for patients with ESRD, frailty, or cardiopulmonary disease were lower than for patients with dementia or cancer.

Citation: Wachterman MW, Pilver C, Smith D, Ersek M, Lipsitz SR, Keating NL. Quality of end-of-life care provided to patients with different serious illnesses. JAMA Intern Med. 2016;176(8):1095-1102.

Clinical Question: How do patterns of end-of-life care compare for patients with different diseases?

Background: Studies regarding quality of care at the end of life have focused primarily on patients dying from cancer. Few studies to date have looked at patients dying from other illnesses, and few have taken into account perspectives of family members.

Study Design: Retrospective cross-sectional.

Setting: 146 inpatient facilities in the Veterans Affairs (VA) health system.

Synopsis: The authors identified 57,753 patients who died while hospitalized at VA facilities during the study period, and 34,015 next of kin completed the Bereaved Family Survey. Overall, approximately half (43.7%–50.4%) of patients with end-stage renal disease (ESRD), frailty, or cardiopulmonary disease received palliative-care consultations compared with 73.5% and 61.4% of patients with cancer and dementia, respectively. Patients with cancer or dementia were less likely to die in the ICU compared to patients with other diagnoses (8.9%–13.4% compared to 32.3%–35.2%). Quality of care as perceived by the bereaved families was higher for patients with cancer or dementia (59.2%–59.3% compared to 53.7%–54.8%).

While large, this study was limited in applicability to different populations due to being conducted within the VA system. Overall, it showed significant differences in end-of-life care between patients who died from different diseases. This study suggests several practical steps that may improve disparities in end-of-life care, in particular, increasing discussion of goals of care and improving access to inpatient palliative-care consults for patients with ESRD, frailty, or cardiopulmonary disease.

Bottom Line: Quality and satisfaction indicators for end-of-life care for patients with ESRD, frailty, or cardiopulmonary disease were lower than for patients with dementia or cancer.

Citation: Wachterman MW, Pilver C, Smith D, Ersek M, Lipsitz SR, Keating NL. Quality of end-of-life care provided to patients with different serious illnesses. JAMA Intern Med. 2016;176(8):1095-1102.

Clinical Question: How do patterns of end-of-life care compare for patients with different diseases?

Background: Studies regarding quality of care at the end of life have focused primarily on patients dying from cancer. Few studies to date have looked at patients dying from other illnesses, and few have taken into account perspectives of family members.

Study Design: Retrospective cross-sectional.

Setting: 146 inpatient facilities in the Veterans Affairs (VA) health system.

Synopsis: The authors identified 57,753 patients who died while hospitalized at VA facilities during the study period, and 34,015 next of kin completed the Bereaved Family Survey. Overall, approximately half (43.7%–50.4%) of patients with end-stage renal disease (ESRD), frailty, or cardiopulmonary disease received palliative-care consultations compared with 73.5% and 61.4% of patients with cancer and dementia, respectively. Patients with cancer or dementia were less likely to die in the ICU compared to patients with other diagnoses (8.9%–13.4% compared to 32.3%–35.2%). Quality of care as perceived by the bereaved families was higher for patients with cancer or dementia (59.2%–59.3% compared to 53.7%–54.8%).

While large, this study was limited in applicability to different populations due to being conducted within the VA system. Overall, it showed significant differences in end-of-life care between patients who died from different diseases. This study suggests several practical steps that may improve disparities in end-of-life care, in particular, increasing discussion of goals of care and improving access to inpatient palliative-care consults for patients with ESRD, frailty, or cardiopulmonary disease.

Bottom Line: Quality and satisfaction indicators for end-of-life care for patients with ESRD, frailty, or cardiopulmonary disease were lower than for patients with dementia or cancer.

Citation: Wachterman MW, Pilver C, Smith D, Ersek M, Lipsitz SR, Keating NL. Quality of end-of-life care provided to patients with different serious illnesses. JAMA Intern Med. 2016;176(8):1095-1102.

Clinical Question: Does improving hand hygiene compliance from a high level (>80%) to a very high level (>95%) reduce healthcare-associated infections?

Background: Hand hygiene compliance remains an elusive infection prevention parameter to master. Studies show a correlation in reduction of healthcare-associated infections with improved hand hygiene compliance from a low to medium level, but little data exist on very high rates of hand hygiene compliance.

Study Design: Prospective observational.

Setting: University of North Carolina Hospitals.

Synopsis: Researchers recruited all hospital staff to be hand hygiene monitors, thereby using the Hawthorne effect to drive hand hygiene compliance rates. Over a 17-month period, >4,000 unique observers made >140,000 observations. Data showed a significant increase in hand hygiene compliance rates of about 10% (P<0.001) and a significant decrease in overall healthcare-associated infection rates of about 6% (P=0.0066). A reduction in healthcare-associated Clostridium difficile infection of 14% was observed in association with the improved hand hygiene compliance. No association with multidrug-resistant organisms was found.

Bottom Line: There is continued correlation between improved hand hygiene compliance and reduced healthcare-associated infection rates even at very high levels (>95%) of hand hygiene compliance.

Citation: Sickbert-Bennett EE, DiBiase LM, Willis TM, Wolak ES, Weber DJ, Rutala WA. Reduction of healthcare-associated infections by exceeding high compliance with hand hygiene practices. Emerg Infect Dis. 2016;22(9):1628-1630.

Short Take

Avoid Fluoroquinolones in Acute Sinusitis, Acute Exacerbations of Bronchitis, and Uncomplicated Urinary Tract Infections If Other Treatment Options Exist

Because fluoroquinolones have been associated with potentially permanent side effects involving tendons, muscles, joints, and nerves, the FDA recently updated the boxed warning to state that the risk of use likely outweighs the benefit for uncomplicated infections.

Citation: Fluoroquinolone Antibacterial Drugs for Systemic Use: Drug Safety Communication - Warnings Updated Due to Disabling Side Effects. FDA website. Accessed September 9, 2016.

Clinical Question: Does improving hand hygiene compliance from a high level (>80%) to a very high level (>95%) reduce healthcare-associated infections?

Background: Hand hygiene compliance remains an elusive infection prevention parameter to master. Studies show a correlation in reduction of healthcare-associated infections with improved hand hygiene compliance from a low to medium level, but little data exist on very high rates of hand hygiene compliance.

Study Design: Prospective observational.

Setting: University of North Carolina Hospitals.

Synopsis: Researchers recruited all hospital staff to be hand hygiene monitors, thereby using the Hawthorne effect to drive hand hygiene compliance rates. Over a 17-month period, >4,000 unique observers made >140,000 observations. Data showed a significant increase in hand hygiene compliance rates of about 10% (P<0.001) and a significant decrease in overall healthcare-associated infection rates of about 6% (P=0.0066). A reduction in healthcare-associated Clostridium difficile infection of 14% was observed in association with the improved hand hygiene compliance. No association with multidrug-resistant organisms was found.

Bottom Line: There is continued correlation between improved hand hygiene compliance and reduced healthcare-associated infection rates even at very high levels (>95%) of hand hygiene compliance.

Citation: Sickbert-Bennett EE, DiBiase LM, Willis TM, Wolak ES, Weber DJ, Rutala WA. Reduction of healthcare-associated infections by exceeding high compliance with hand hygiene practices. Emerg Infect Dis. 2016;22(9):1628-1630.

Short Take

Avoid Fluoroquinolones in Acute Sinusitis, Acute Exacerbations of Bronchitis, and Uncomplicated Urinary Tract Infections If Other Treatment Options Exist

Because fluoroquinolones have been associated with potentially permanent side effects involving tendons, muscles, joints, and nerves, the FDA recently updated the boxed warning to state that the risk of use likely outweighs the benefit for uncomplicated infections.

Citation: Fluoroquinolone Antibacterial Drugs for Systemic Use: Drug Safety Communication - Warnings Updated Due to Disabling Side Effects. FDA website. Accessed September 9, 2016.

Clinical Question: Does improving hand hygiene compliance from a high level (>80%) to a very high level (>95%) reduce healthcare-associated infections?

Background: Hand hygiene compliance remains an elusive infection prevention parameter to master. Studies show a correlation in reduction of healthcare-associated infections with improved hand hygiene compliance from a low to medium level, but little data exist on very high rates of hand hygiene compliance.

Study Design: Prospective observational.

Setting: University of North Carolina Hospitals.

Synopsis: Researchers recruited all hospital staff to be hand hygiene monitors, thereby using the Hawthorne effect to drive hand hygiene compliance rates. Over a 17-month period, >4,000 unique observers made >140,000 observations. Data showed a significant increase in hand hygiene compliance rates of about 10% (P<0.001) and a significant decrease in overall healthcare-associated infection rates of about 6% (P=0.0066). A reduction in healthcare-associated Clostridium difficile infection of 14% was observed in association with the improved hand hygiene compliance. No association with multidrug-resistant organisms was found.

Bottom Line: There is continued correlation between improved hand hygiene compliance and reduced healthcare-associated infection rates even at very high levels (>95%) of hand hygiene compliance.

Citation: Sickbert-Bennett EE, DiBiase LM, Willis TM, Wolak ES, Weber DJ, Rutala WA. Reduction of healthcare-associated infections by exceeding high compliance with hand hygiene practices. Emerg Infect Dis. 2016;22(9):1628-1630.

Short Take

Avoid Fluoroquinolones in Acute Sinusitis, Acute Exacerbations of Bronchitis, and Uncomplicated Urinary Tract Infections If Other Treatment Options Exist

Because fluoroquinolones have been associated with potentially permanent side effects involving tendons, muscles, joints, and nerves, the FDA recently updated the boxed warning to state that the risk of use likely outweighs the benefit for uncomplicated infections.

Citation: Fluoroquinolone Antibacterial Drugs for Systemic Use: Drug Safety Communication - Warnings Updated Due to Disabling Side Effects. FDA website. Accessed September 9, 2016.