Adults with migraine have an increased risk for ischemic silent brain infarction relative to their migraine-free peers, a new study confirms.

“Migraine is a neurovascular condition of the brain, with a small increased risk of silent brain infarctions, a risk factor for clinical stroke,” lead author Teshamae Monteith, MD, assistant professor of clinical neurology and chief of the Headache Division at the University of Miami Miller School of Medicine, Florida said.

“While the risk may be small, migraine patients with vascular risk factors should be treated for stroke risk factor reduction, including healthy lifestyle behaviors that include regular exercise and plenty of fruits and vegetables according the AHA/ASA [American Heart Association/American Stroke Association] guidelines,” she added.

The new findings, published online May 15 in Stroke, are from the ongoing Northern Manhattan Study (NOMAS), a collaborative effort of researchers at the University of Miami and Columbia University in New York.

Subclinical Infarction

For this report, the NOMAS investigators quantified subclinical brain infarctions and white matter hyperintensity volumes (WMHVs) in 546 men and women. Their mean age was 71 years, and 65% were Hispanic.

Compared with people without migraine, those with migraine (confirmed by International Classification of Headache Disorders-2 criteria) had a 2-fold increased odds of subclinical brain infarction (adjusted odds ratio [OR], 2.1; 95% confidence interval [CI], 1.0 – 4.2).

The association between migraine and silent brain infarction was independent of sociodemographic and cardiovascular factors, and was stronger in the subgroup of patients with migraine without aura (OR, 2.6; 95% CI, 1.3 – 5.5), the researchers note. “The presence of aura, visual changes that occur with migraine, was not important for the association as was seen in some other studies,” Dr. Monteith noted.

Hypertension, a risk factor for stroke, was more common in patients with migraine, but the association between migraine and silent brain infarction was also seen in normotensive participants, the researchers say.

“Unexpectedly,” there was no association between migraine status and WMHV. It’s possible that group differences in WMHV were not detected because of the high burden of other cardiovascular risk factors in this racially diverse older cohort, the researchers write.

This study confirms the association between migraine and silent brain infarctions in an older, diverse, predominately Hispanic population, Dr. Monteith said. “Previous studies of silent brain infarctions and migraine were conducted in predominately white populations,” she noted. “While these lesions have an ischemic stroke appearance, the exact etiology of lesions is unknown in patients with migraine.”

“Ultimately,” Dr. Monteith said, “a large migraine cohort study is in order to determine if treatment of migraine may reduce stroke risks.”

Small Numbers

Alexander Mauskop, MD, neurologist and director and founder of the New York Headache Center, New York, reviewed the study.

He noted that the study population included 64 white, 72 black, and 392 Hispanic participants. “While this is diverse, there are not enough whites or blacks to make any statistical conclusions, so the study is focused on Hispanics,” he said.

Dr. Mauskop also noted that of the 546 participants, 56 had a silent brain infarct and of these 56, 15 had a history of migraines. “These are very small numbers to make any definitive conclusions,” he said.

“We agree the numbers are small but significant,” Dr. Monteith said.

Dr. Monteith and colleagues say larger prospective multiethnic studies are needed to “elucidate the potential for silent brain infarction accumulation as a biomarker for subclinical cerebrovascular disease in individuals with migraine.”

Authors: Bertrand OF et al., J Am Coll Cardiol 2014 May 13; 63:1842

No, according to a prospective study in which postprocedural concentration of thumb capillary lactate was used as the primary endpoint.

To address ongoing controversy about whether Allen test results predict ischemic complications of transradial artery (TRA) catheterization, investigators conducted a prospective study in 203 patients with normal (83), intermediate (60), or abnormal (60) Allen test results before TRA procedures. All patients also underwent preprocedure plethysmography and pulse oximetry (Barbeau test); ulnar contrast angiography frame count for collateral assessment during catheterization; and thumb capillary lactate assessment and handgrip-strength testing immediately after catheterization, at 30 days, and at 1 year.

The primary endpoint — postprocedural concentration of thumb capillary lactate — did not differ among the groups either immediately after the procedure or at follow-up assessments, despite an increase in all three groups immediately before catheter removal. Patient discomfort peaked and handgrip strength reached a nadir during radial occlusion, but each of these endpoints was similar among all three groups during and after catheterization. Asymptomatic absence of radial pulse at day 1 was observed in five participants, only one of whom had had an abnormal Allen test; spontaneous recanalization occurred in two of the five patients at 30 days. In both groups with non-normal Allan tests, collateral circulation (as measured by the Barbeau test) improved after TRA catheterization.

Comment

These findings suggest that an abnormal Allen test does not predict worse vascular outcomes for patients undergoing TRA catheterization. The authors propose that preexisting collateral vessels may be recruited during radial artery occlusion. Unlike previous investigations, this one showed no evidence of a greater increase in thumb capillary lactate concentration among patients with an abnormal Allen test. As noted in an accompanying editorial, the data from this careful mechanistic study suggest that results of both the Allen and Barbeau tests are unreliable predictors of distal ischemia after TRA catheterization, and that abnormal findings on these tests should not justify denial of radial access.

Authors: de Jong W-JJ et al., J Trauma Acute Care Surg 2014 May 76:1282

A Blunt Abdominal Trauma in Children score of greater than 6 had a sensitivity of 100% and specificity of 87% for intra-abdominal injury.

Investigators retrospectively validated the Blunt Abdominal Trauma in Children (BATiC) score in children less than 18 years of age presenting to a hospital in the Netherlands with blunt abdominal trauma between 2006 and 2011 (NEJM JW Emerg Med Jul 17 2009). Patients were included in the analysis if at least 6 of the 10 BATiC variables were available.

Points for the BATiC score were assigned as follows:

·4 points for abnormal abdominal ultrasound findings (free fluid, or injury to hollow or visceral organs)

·2 points each for abdominal pain, peritoneal irritation on physical exam, hemodynamic instability, aspartate aminotransferase greater than 60 IU/L, and alanine aminotransferase greater than 25 IU/L

·1 point each for white blood cell count >10 × 109/L, lactate dehydrogenase greater than 330 IU/L, amylase greater than 10 IU/L, and creatinine greater than 110 µmol/L

Of 216 patients (median age, 12 years), 18 (8%) had intra-abdominal injuries and 7 required surgical intervention. A BATiC score cut-off of greater than 6 (out of a possible score of 18) resulted in a sensitivity of 100% and specificity of 87% for intra-abdominal injury. A cut-off of 7 resulted in a sensitivity of 89% and a specificity of 94%. Using cut-offs of 6 and 7 could have avoided 47% and 56%, respectively, of the 34 computed tomography scans performed.

Comment

Although these results are promising, data for many BATiC variables were missing in the analysis. It is reasonable to use this score to help guide clinical decision making, but clinician judgment should override the score when there are concerning findings. Prospective validation is needed before the score is widely adopted.

Authors: Joseph B et al., JAMA Surg 2014 Jun 11;

Older trauma patients who were frail were more likely to have in-hospital complications and adverse discharge dispositions than those who were not frail.

Although advancing age is associated with worse outcomes in trauma patients (NEJM JW Emerg Med Oct 27 2004 and NEJM JW Emerg Med Nov 12 2010), some studies indicate that patient health status also greatly influences outcome (NEJM JW Emerg Med Jun 1 1998). To determine whether frailty is associated with in-hospital complications and adverse discharge dispositions (mortality or discharge to a skilled nursing facility) in trauma patients aged 65 years or older, researchers used the 50-item Canadian Frailty Index, which assesses demographics, social activity, activities of daily living, nutrition, and mood.

Of 250 patients (mean age, 78), 110 (44%) were frail. Frail patients were more likely to have in-hospital complications (37% vs. 21%; most commonly urinary tract infections) and adverse discharge dispositions (37% vs. 13%). Five patients died, all of whom were frail. While other factors (including older age, male sex, higher systolic blood pressure, lower Glasgow Coma Scale score, and higher Injury Severity Score) were also associated with worse outcomes, only frailty was significantly predictive in multivariate analysis.

Comment

These results make sense, and the authors are to be commended for bringing frailty into the spotlight. However, we cannot use a 50-item scale during the acute management of trauma patients. Instead, these findings should remind us to consider frailty rather than age alone when determining best treatment plans for patients with trauma and to discuss the potential implications of frailty with our less-active older patients and their families.

All healthcare stakeholders are on the same page when it comes to using value-based payments, two leaders fromCigna said yesterday at the National Bundled Payment Summit in the District of Columbia. But insurers can’t have only one type of value-based program.

Providers have different capabilities, ownership and risk tolerance, so payers must meet doctors where they are organizationally, according to Jeannie Hubbell, director of payment innovation for Cigna Healthcare in Franklin, Tennessee.

Cigna has been using Tennessee as a Petri dish to develop payment models that reward value, said Jim Humphrey, Cigna’s operations director in Nashville, Tennessee. One approach was bundled payments for episodes of care for deliveries, hip replacements and knee replacements.

That model involved collaboration with other payers and providers. For instance, technical advisory groups (TAG), comprised of providers, other stakeholders and constituents across the state, helped develop episode definitions and metrics. Thanks to the provider input, the metrics are universally accepted by provider groups in Tennessee, Humphrey said.

Humphrey and Hubbell also emphasized that cost is very important to the bundled payment model. Cigna has to show the value of the episodes back to the client, so it looks at episodes that will have the biggest impact for the client as well as the most operational scale.

To demonstrate value, Cigna focuses on actionable reporting. It gives information to physician practices that can lead to changes in practice patterns. “If you can be transparent and show the practice where they need to go with that information, the results will come with that particular episode program,” Humphrey said.

Cigna also aims to measure bundled payment success with claim-based metrics. However, Hubbell and Humphrey said quality metrics need to expand beyond claims to include patient satisfaction, potentially avoidable complication rates and functional status.

“As we implement different reimbursement structures, performance measurements need to evolve,” Hubbell said. The industry needs to get away from discount comparisons and look at improvements in quality.

This is for our followers who practice in the ICU.

Authors: Jabre P et al., Intensive Care Med 2014 May 23;

Grief, post-traumatic stress, and depression at 1 year were reduced when family members were permitted to witness resuscitation of loved ones.

Despite data that suggest benefit to family members from allowing them to observe resuscitations (NEJM JW Emerg Med Mar 15 2013), emergency physicians may be reluctant to do so. In a prospective, cluster-randomized, controlled study involving 15 emergency medical services units in France, researchers compared psychological symptoms at 1 year between family members who were offered the chance to witness an adult resuscitation and those who were not offered the option.

Of 570 family members, 72% were evaluated at 1 year by telephone. Family members in the control group were more likely to experience major depression (31% vs. 23%), complicated grief (36% vs. 21%), and post-traumatic stress disorder-related symptoms (adjusted odds ratio, 1.8).

Comment

Many of us recall the days when fathers were not allowed in delivery rooms for the birth of their child. Death, like birth, is a transformative event for a family. Thoughtful, supportive inclusion of close family members during a resuscitation may not help the patient, but at that moment, isn’t each family member also a patient? Most providers, myself included, who have had family members present during an arrest consider it to have been a positive experience.

There’s new evidence of the “weekend effect and it’s worth examining a phenomenon of why patients don’t want to get sick on a Saturday: The increased chance they’ll face complications.

New research published this week from a Johns Hopkins Children’s Center team found simple emergency surgeries can be deadlier for kids on the weekends, raising questions about after-hours safety lapses and clinical glitches. The study further bolsters research from Johns Hopkins finding an increased risk for adult patients treated for heart attacks, strokes, an aneurism or head trauma during the weekend.

“These are provocative findings and, we hope, a conversation starter,” Dr. Seth Goldstein, a pediatric surgery resident at Johns Hopkins and lead author of the study published in the Journal of Pediatric Surgery, said in a statement. “Our next step is to understand the what, how and why behind this alarming disparity.”

We’re not talking huge numbers here. In looking at 22 years worth of surgery data from 440,000 pediatric admissions, the researchers attributed 30 deaths to the weekend effect, calling them extremely rare. Still, it was a statistically marked increase from weekdays. The data showed kids who underwent emergency procedures on weekends were 63 percent more likely to die than those treated during the week and 40 percent more likely to suffer complications.

Possible reasons? Researchers wonder whether decreased weekend staffing, slower response times and less availability of certain imaging and lab tests may be factors.

At George Washington University Hospital, Dr. Robert Shesser is skeptical. GW typically sees about 15 percent fewer patients during the weekends and has core specialty areas staffed the same way, no matter what day it is.

“It’s the same. It’s the same doctors, the same nurses. Everyone’s there,” said Shesser, the chairman of the emergency department.

If anything, said Dr. Anthony Sandler, operating rooms are less chaotic and more controlled on weekends because of fewer scheduled surgeries.

“Particularly at teaching hospitals, you have some depth from the bench,” said Sandler, senior vice president of Children’s National Medical Center’s surgical care center.

The study mentions the phenomenon isn’t as likely at academic institutions. “All hospitals do have reduced staffing on weekend, but if we’re talking purely from a surgical sense, we can’t even start surgery until a faculty surgeon is there.”

That’s not to say there might not be some important lessons for hospitals to consider, Sandler added.

He wondered if there is a delay in transferring some patients to a hospital that performs the surgery they need. Or perhaps some non-teaching hospitals aren’t able to maintain enough staffing for peripheral services which support surgery. Also, a high number of patients in the study were uninsured. Perhaps they were waiting and getting in worse shape before seeking care, he said.

“Where there’s smoke, there could be fire. In any profession when there are off hours, services may be less intensive,” Sandler said. “But I hate to believe that is true because that frustrates all the the systems we have in place.”

Authors: Donnino MW et al., BMJ 2014 May 20; 348:g3028

Inpatients who experience nonshockable cardiac arrest are more likely to survive when epinephrine is administered early.

A large and increasing percentage of patients with cardiac arrests exhibit initial nonshockable rhythms (asystole or pulseless electrical activity [PEA]; 82% in 2009 vs. 69% in 2000; NEJM JW Hosp Med Nov 14 2012). Cardiac arrest guidelines recommend early use of epinephrine to manage patients with nonshockable rhythms (Circulation 2010; 122:S729), but this recommendation lacks strong evidence to support efficacy.

Investigators retrospectively evaluated more than 25,000 patients (at 570 U.S. hospitals) with in-hospital cardiac arrests who were not in intensive care units or emergency departments and who exhibited initial rhythms of asystole or PEA. Half of patients received their first dose of epinephrine greater than 3 minutes following the start of resuscitation. Delayed administration of epinephrine was associated significantly with lower chance for survival to hospital discharge, in stepwise fashion (12%, 10%, 8%, and 7% survival, respectively, for patients receiving their first epinephrine dose less than 3 minutes, 4–6 minutes, 7–9 minutes, and greater than 9 minutes after arrest). Neurologically intact survival to hospital discharge was significantly more likely after earlier epinephrine administration.

Comment

Most cardiac arrests have initial nonshockable rhythms. A focus on time to epinephrine administration — in addition to high-quality chest compressions — might be the best early intervention and, possibly, the next (or only) quality metric in PEA and asystole arrests.

Published in Anesth Analg. 2014 May;118(5):981-6

Authors: Short TG et al.,

BACKGROUND:

Deep general anesthesia has been associated with increased mortality in 5 observational studies. The association may be causal or an epiphenomenon due to increased anesthetic sensitivity in high-risk patients. We conducted a pilot study to assess the feasibility of performing a definitive randomized controlled trial. The aims of the study were to determine whether anesthetic depth targeting in a high-risk group was feasible and to document anesthetic doses and arterial blood pressures associated with “deep” and “light” general anesthesia.

METHODS:

ASA physical status III and IV patients, aged ≥60 years, having surgery lasting greater than 2 hours, with expected hospital stay greater than 2 days, and receiving general anesthesia were randomly allocated to a Bispectral Index (BIS) or spectral entropy (SE) target of 35 (“low” group) or 50 (“high” group). The primary end point was mean BIS or SE. Secondary end points were postanesthesia care unit length of stay and pain scores, quality of recovery score, hospital length of stay, postoperative complications, and death. A composite end point of postoperative complications (pneumonia, myocardial infarction, stroke, pulmonary embolism, heart failure, and death) was determined at 1 year.

RESULTS:

One hundred twenty-five patients were recruited. The mean of the median BIS/SE values for each patient during the maintenance phase of anesthesia in the low and high groups was significantly different: 39 vs 48 (mean difference 8 [95% confidence interval {CI95}, 6 to 10], P less than 0.001). There was also a significant difference in mean volatile anesthetic administration (minimum alveolar concentration): 0.98 vs 0.64 (mean difference -0.35 [CI95, -0.44 to -0.26], P less than 0.001) and target propofol concentrations: 4.0 vs 3.1 μg/mL (mean difference -0.8 [CI95, -1.2 to -0.3], P = 0.004). Intraoperative mean arterial blood pressures were similar (85 vs 87 mm Hg; mean difference 2 [CI95, -2 to 6], P = 0.86), and there were no differences in short-term recovery characteristics or hospital length of stay. There was a significant difference in the incidence of wound infection at 30 days (13% vs 3%; risk difference -10% [CI95, -21 to -0.1], P = 0.04). At 1 year, the composite rates of complications in the low and high groups were 28% and 17% (risk difference -11 [CI95, -25 to 4], P = 0.15) and mortality rates were 12% and 9%, respectively (risk difference -2 [CI95, -14 to 9], P = 0.70).

CONCLUSIONS:

This pilot study demonstrated that depth of anesthesia targeting with BIS or SE was achievable in a high-risk population with adequate separation of processed electroencephalogram monitor targets. The expected incidence of postoperative complications and mortality occurred. We conclude that a large, multicenter, randomized controlled trial is feasible.

 

Adults with migraine have an increased risk for ischemic silent brain infarction relative to their migraine-free peers, a new study confirms.

“Migraine is a neurovascular condition of the brain, with a small increased risk of silent brain infarctions, a risk factor for clinical stroke,” lead author Teshamae Monteith, MD, assistant professor of clinical neurology and chief of the Headache Division at the University of Miami Miller School of Medicine, Florida said.

“While the risk may be small, migraine patients with vascular risk factors should be treated for stroke risk factor reduction, including healthy lifestyle behaviors that include regular exercise and plenty of fruits and vegetables according the AHA/ASA [American Heart Association/American Stroke Association] guidelines,” she added.

The new findings, published online May 15 in Stroke, are from the ongoing Northern Manhattan Study (NOMAS), a collaborative effort of researchers at the University of Miami and Columbia University in New York.

Subclinical Infarction

For this report, the NOMAS investigators quantified subclinical brain infarctions and white matter hyperintensity volumes (WMHVs) in 546 men and women. Their mean age was 71 years, and 65% were Hispanic.

Compared with people without migraine, those with migraine (confirmed by International Classification of Headache Disorders-2 criteria) had a 2-fold increased odds of subclinical brain infarction (adjusted odds ratio [OR], 2.1; 95% confidence interval [CI], 1.0 – 4.2).

The association between migraine and silent brain infarction was independent of sociodemographic and cardiovascular factors, and was stronger in the subgroup of patients with migraine without aura (OR, 2.6; 95% CI, 1.3 – 5.5), the researchers note. “The presence of aura, visual changes that occur with migraine, was not important for the association as was seen in some other studies,” Dr. Monteith noted.

Hypertension, a risk factor for stroke, was more common in patients with migraine, but the association between migraine and silent brain infarction was also seen in normotensive participants, the researchers say.

“Unexpectedly,” there was no association between migraine status and WMHV. It’s possible that group differences in WMHV were not detected because of the high burden of other cardiovascular risk factors in this racially diverse older cohort, the researchers write.

This study confirms the association between migraine and silent brain infarctions in an older, diverse, predominately Hispanic population, Dr. Monteith said. “Previous studies of silent brain infarctions and migraine were conducted in predominately white populations,” she noted. “While these lesions have an ischemic stroke appearance, the exact etiology of lesions is unknown in patients with migraine.”

“Ultimately,” Dr. Monteith said, “a large migraine cohort study is in order to determine if treatment of migraine may reduce stroke risks.”

Small Numbers

Alexander Mauskop, MD, neurologist and director and founder of the New York Headache Center, New York, reviewed the study.

He noted that the study population included 64 white, 72 black, and 392 Hispanic participants. “While this is diverse, there are not enough whites or blacks to make any statistical conclusions, so the study is focused on Hispanics,” he said.

Dr. Mauskop also noted that of the 546 participants, 56 had a silent brain infarct and of these 56, 15 had a history of migraines. “These are very small numbers to make any definitive conclusions,” he said.

“We agree the numbers are small but significant,” Dr. Monteith said.

Dr. Monteith and colleagues say larger prospective multiethnic studies are needed to “elucidate the potential for silent brain infarction accumulation as a biomarker for subclinical cerebrovascular disease in individuals with migraine.”