Showbox For iPhone/iPad Download – Show Box For iOS

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  • ShowBox application Movies.

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CV Risk Very High in Gout

Action Points

  • Most patients who present with gout to rheumatology clinics are at very high risk of cardiovascular (CV) disease, and almost half of the patients who underwent carotid ultrasound in the study had atheroma plaques.
  • Note that the findings support optimizing preventive strategies in this patient population, including intensive statin therapy or stricter lipid level targets.

Most patients who present with gout to rheumatology clinics are at very high risk of cardiovascular (CV) disease, Spanish researchers found.

In a cross-sectional study assessing the CV risk profile of gout patients at presentation, “two out of every three patients with gout were classified at a very high CV risk at presentation, comparable to having already suffered from a myocardial infarction,” Mariano Andrés, MD, of the Hospital General Universitario de Alicante, and colleagues wrote online in Annals of the Rheumatic Diseases.

In addition, almost half of the patients who underwent carotid ultrasound had atheroma plaques.

The findings support optimizing preventive strategies in this patient population, “such as intensive statin therapy or stricter lipid level targets,” the team said.

Initial consultation and risk factor scoring determined that 40.1% of gout patients recruited for the study had a very high CV risk, which increased to 67.9% among patients who had carotid ultrasound performed.

For the study, the investigators enrolled 237 patients with gout, more than half of whom were referred from the emergency department to a rheumatology clinic. They underwent a structured CV consultation, and 92.3% had at least one CV risk factor. The researchers then applied the Systematic Coronary Evaluation (SCORE) and the Framingham Heart Study (FHS) risk score to all patients. Patients with a very high risk at enrollment because of prior CV disease, diabetes mellitus with complications, or severe renal failure did not have a score calculated.

CV risk was stratified according to 2011 European guidelines:

  • A SCORE <1% is considered low risk
  • A SCORE of 1% to 4% is considered moderate risk
  • Having uncomplicated diabetes, an estimated glomerular filtration rate (eGFR) of 30 to 59 mL/min, intima media thickness (IMT) on carotid ultrasound >0.9 mm, or a SCORE of 5% to 9% is considered high risk
  • Patients with prior CV disease, carotid atheroma plaques, diabetes with complications, eGFR <30 mL/mi, or a SCORE >9% were considered to be very high risk.

Eighty-eight patients were considered to be at very high risk at presentation; the risk prediction tools were applied to the remaining 149 (62.9%).

The average risk scores were 3.8% with SCORE and 6.3% with FHS, both equivalent to a moderate risk. Seven patients had a SCORE above 9% (very high risk). CV risk classification after risk prediction tools were applied showed that 95 patients (40.1%) were classified as being at very high risk and 55 patients (30.4%) were classified as moderate risk.

Carotid ultrasound was performed in 142 patients (59.9%) not initially classified as being at very high CV risk. Carotid ultrasound revealed increased IMT in 64 patients (45.1%, 95% CI 36.8%-53.3%) and the presence of carotid atheroma plaques in 66 (46.5%, 95% CI 37.8%- 54.2%), which were bilateral in 27 patients (19%, 95% CI 12.5%-25.5%). Forty-four patients (31%) showed both increased IMT and atheroma plaques on carotid ultrasound.

After carotid ultrasound assessment, the risk of 80 patients was upgraded to very high (one from low risk, 42 from moderate risk, and 37 from high risk). Final CV risk stratification differed significantly from the initial stratification (P<0.001), such that 67.9% (161/237) of the patients were finally considered to be at very high CV risk, up from 40.1% of those classified as very high risk before carotid ultrasound.

From this study and others, “the prevalence of carotid plaques in patients with gout appears greater than the general population and similar to other chronic inflammatory diseases such as rheumatoid arthritis or systemic lupus erythematosus,” Andrés and coauthors said.

The estimated area under the curve for discriminating risk was 0.711 for SCORE and 0.683 for FHS scoring, indicating a moderate discriminative capacity of risk tools for predicting carotid atheroma plaques. Although risk assessment tools are recommended for identifying patients at risk, “considering their low accuracy to detect carotid plaques, they merit cautious use in gout,” the authors wrote. “In the present study, tool-based risk level was later upgraded in 56.1% of patients after carotid ultrasound.”

Study limitations noted by the researchers included the cross-sectional design and the potential limited generalizability outside the hospital-based rheumatology setting, requiring replication of results in the primary care setting. In addition, there was no control group and the ultrasound sonographer was not blinded to the clinical data.

The authors reported financial relationships with Menarini, AstraZeneca, Savient, Procaps, and Novartis.

  • Reviewed by
    Robert Jasmer, MD Associate Clinical Professor of Medicine, University of California, San Francisco and Dorothy Caputo, MA, BSN, RN, Nurse Planner


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Lack of Exercise Might Invite Dementia

News Picture: Lack of Exercise Might Invite DementiaBy Steven Reinberg
HealthDay Reporter

Latest Alzheimers News

THURSDAY, Jan. 27, 2017 (HealthDay News) — Parking yourself in front of the TV may make you as likely to develop dementia as people genetically predisposed to the condition, a Canadian study suggests.

In a study of more than 1,600 adults aged 65 and older, those who led a sedentary life seemed to have the same risk of developing dementia as those who carried the apolipoprotein E (APOE) gene mutation, which increases the chances of developing dementia.

Conversely, people who exercised appeared to have lower odds of developing dementia than those who didn’t, the five-year study found.

“Being inactive may completely negate the protective effects of a healthy set of genes,” said lead researcher Jennifer Heisz, an assistant professor in the department of kinesiology at McMaster University in Hamilton, Ontario.

However, the study didn’t prove that lack of exercise caused dementia risk to increase. It only found an association between the two.

The APOE mutation is the strongest genetic risk factor for vascular dementia, Lewy body dementia, Parkinson’s disease and, especially, Alzheimer’s disease, the researchers said.

People with a single APOE “allele” may have a three to four times increased risk of dementia than non-carriers, the study authors said.

How exercise may reduce the risk for dementia isn’t known, Heisz said.

These study results, however, suggest that your physical activity level can influence your dementia risk as much as your genetics, Heisz said. “You can’t change your genes, but you can change your lifestyle,” she added.

The kind of exercise that’s best isn’t known, although the people who were physically active in the study reported walking three times a week, Heisz said.

“Which means you don’t have to train like an Olympian to get the brain health benefits of being physically active,” she said.

The report was published Jan. 10 in the Journal of Alzheimer’s Disease.

Dr. Sam Gandy directs the Center for Cognitive Health at Mount Sinai Hospital in New York City. He said the study findings aren’t “really a surprise, but it is good to see it proven.”

Other scientists showed some years ago that people with the APOE mutation could virtually erase the risk of developing amyloid plaques in the brain if they became regular runners, Gandy said. Amyloid plaques are one of the hallmark signs of Alzheimer’s.

“That was an amazing report that, I believe, has been underpublicized,” Gandy said.

However, this new study suggests that if you are blessed with genes that lower your risk for Alzheimer’s, you could lose that benefit if you don’t exercise, he said.

“I cannot understand why the fear of dementia is not sufficient to induce everyone to adopt a regular exercise program,” Gandy said.

“I tell all my patients that if they leave with one, and only one, piece of advice, that the one thing that they can do to reduce their risk of dementia or slow the progression of dementia is to exercise,” he said.

About 47.5 million people around the world are living with dementia, the researchers said, and that number is expected to surge to 115 million by 2050. With no known cure, there’s an urgent need to explore, identify and change lifestyle factors that can reduce dementia risk, the study authors said.

Copyright © 2017 HealthDay. All rights reserved.

SOURCES: Jennifer Heisz, Ph.D., assistant professor, department of kinesiology, McMaster University, Hamilton, Ontario, Canada; Sam Gandy, M.D., Ph.D., director, Center for Cognitive Health, Mount Sinai Hospital, New York City; Jan. 10, 2017, Journal of Alzheimer’s Disease

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Mark Your Calendars: January 31st is quickly approaching

January 27
by CMS

If you still need health coverage for 2017, you have until January 31st to sign up for coverage through Through the website you can review your choices and see if you qualify for financial help. Issuers have confirmed that consumers who select a plan and pay their first premium will have coverage for 2017. And, insurers have signed contracts to provide coverage through 2017.

Consumers who want coverage – whether you are new to the Health Insurance Marketplace or have previously enrolled in health coverage – can visit, update your information, or add it for the first time, and select a plan. You may also compare plans online or on your mobile device. You can review the core plan features like cost-sharing and provider networks.

When you log onto, you need three pieces of information – your zip code, family size, and household income – to see what plans are available to you and to get an estimate of how much the plans cost. If you had coverage through for 2016, you can come back to update your information and compare your options for 2017. If you have questions or want to talk through your options with a trained professional, enrollment specialists are available all day, every day, at 1-800-318-2596. Free, confidential, in-person assistance is also available at enrollment sites and events in your state. Visit to find assistance in your community.

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Arizona Children Could Lose Big Under Obamacare Repeal

Like any college student, Vanessa Ramirez never expected chemotherapy would be part of her busy school schedule.

“I don’t have any history of cancer in my family, so it wasn’t something I was on the lookout for,” Ramirez said, sitting outside the library of her alma mater Arizona State University.

Ramirez was diagnosed with ovarian cancer when she was 23. Now more than a decade later, she’s healthy and so are her children.

“But there’s also emergencies that happen. I have two young kids who are running around. They are rambunctious. I have a daughter who likes to climb trees,” Ramirez said, explaining the priority she places on health insurance.

Overcoming her illness at such a young age, Ramirez doesn’t take health care for granted. And the Affordable Care Act has given her that security. She bought insurance through, even with her preexisting condition, and her children got covered, too.

This story is part of a partnership that includes KJZZ, NPR and Kaiser Health News. It can be republished for free. (details)logo npr

“I want them to be able to have health insurance and doctors to monitor them, in case something unfortunate comes up,” Ramirez said.

Ramirez’s kids are covered through the federal Children’s Health Insurance Program, which is for working families who don’t quite qualify for Medicaid. Arizona’s version is called KidsCare.

Arizona lawmakers froze enrollment back in 2010. And until last year, Arizona was the only state without an active program. But Obamacare helped revive it by covering the entire cost in Arizona and a handful of other states, at least through 2017.

“A lot of people don’t realize that a repeal of the Affordable Care Act could wipe out KidsCare that we just got back,” said Dana Wolfe Naimark with advocacy group the Children’s Action Alliance.

Since Gov. Doug Ducey and the legislature reopened KidsCare last year, enrollment has already surpassed 13,000. But now Naimark worries about the fallout if the ACA is repealed.

“It would be up to the state legislature whether they could invest state dollars to keep it going, or whether the coverage would go away,” Naimark said.

In recent years, Arizona has had one of the highest rates of uninsured children in the country. But Obamacare has begun to change that, bringing coverage to thousands of kids. It was also one of the Republican-led states that expanded Medicaid under the ACA but only after fierce in-fighting about growing federal influence; the same was true for reinstating KidsCare. State law halts or shuts down Medicaid expansion and KidsCare if federal funding dips too low.

“Whenever you take a look at some of these top-down Washington approaches, you really do lard up these insurance policies with a lot of benefits that individuals and families would not go out and buy on their own,” said Naomi Lopez Bauman of the conservative Goldwater Institute. Her organization sued to stop the state’s Medicaid expansion.

One of the proposals favored by Republican leadership is giving states a fixed amount of money, called a block grant, and letting them have more say in who and what they cover. Bauman said with enough flexibility, she believes the state could save money.

“How do you make it easier and better for individuals and families to get the coverage and care that best meets their own needs and preferences?” Bauman said.

But other conservatives say changing how these programs are funded could backfire. Heather Carter is a Republican state representative who voted for Medicaid expansion and for restarting KidsCare.

“What I hope does not happen is that decisions are made nationally that actually penalize us for being efficient and effective,” she said.

Carter says Arizona already has one of the lowest-cost Medicaid programs in the country. And Medicaid officials here caution that block grants could actually shortchange the state because it has a fast growing population and a large share of people living around the poverty line. Less federal funding would most likely force lawmakers to cut back services.

“We will have to make very difficult decisions in Arizona on who will and will not receive coverage,” Carter said.

It would cost Arizona hundreds of millions of dollars to keep everyone on Medicaid covered like they are now. And even Democrats like state Senate Minority Leader Katie Hobbs concede that’s not realistic.

“I don’t see anyone in the state coming forward and saying we will cover this, because don’t have the money to do it,” Hobbs said.

Arizona has more children enrolled in the federal marketplace than almost any other state. Add in Medicaid and KidsCare, and 130,000 kids or more could be at risk of losing their coverage if Congress doesn’t come up with a replacement that includes similar coverage.

This story is part of a partnership that includes KJZZ, NPR and Kaiser Health News.

Categories: Public Radio Partnership, Repeal And Replace Watch, Syndicate, The Health Law

Tags: Arizona, Children’s Health

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Repeal Ripples: Five Obamacare Exchange Chiefs Contemplate An Uncertain Future

The health insurance marketplaces created by the Affordable Care Act are in their third year of selling health insurance plans to people who don’t get insurance through work. Most states use to sell their plans, but 11 states and D.C. run their own marketplaces, also called exchanges. Under the vision of the law, the exchanges are supposed to become self-sustaining businesses within a few years, supported by the fees insurers pay to offer plans on the sites.

But with Donald Trump installed as president and Republican majorities controlling both houses of Congress that vision, like the rest of the health law, is in question.

This story is part of a partnership that includes NPR member stations, NPR and Kaiser Health News. It can be republished for free. (details)logo npr

Here, as the ACA’s third open enrollment draws to a close at the end of the month, five exchange leaders – who all report a brisk business despite the political peril — discuss their strategies to stay in business beyond 2017.

‘Make The Individual Market Work.’ – Peter Lee, Covered California Executive Director 

More than five million Californians — about a quarter of all Americans now covered under Obamacare — gained insurance through the ACA, either through Medicaid expansion, or on the exchange, called Covered California. With the health law now on the political chopping block, California has a lot to lose.

But the executive director of Covered California, Peter Lee, said he’s planning on a different scenario—one that he hopes will position California as a leader in the push to find a new model for health care coverage nationwide.


Peter Lee (Courtesy of Covered California)

“I do think we have a number of the ingredients of [how to] make the individual market work,” said Lee. “And we want to take those lessons to members of Congress and to policy leaders.”

Lee said he plans to do that starting next week as a participant on a panel about the ACA repeal convened by two non-partisan research organizations in Washington, D.C.

In particular, Lee believes California’s market-based approach is one that would be “in sync, philosophically, with many of the things I hear from Republican and Democratic members of Congress and the Trump administration.”

“We have about 1.4 million Californians shopping in our marketplace picking private plans with the leg up of federal tax credits that make health care affordable to 90 percent of them,” Lee said.

California’s marketplace has had its share of problems. A reliance on inaccurate provider directories left some consumers exposed to higher-than-expected medical bills. Consumers also complained about narrow networks that left them unable choose the doctors they wanted.

But overall, the state is considered an ACA bellwether, thanks in part to innovative approaches, including state discretion to choose which insurers could operate in its market and then to negotiate premium prices and benefits with insurers.

“It’s a consumer-centric market solution,” Lee said. “Whether you’re a Republican or Democrat or Independent, it’s a market-based solution that has a lesson for the country.”

Still, Lee’s hopefulness is tempered by the knowledge that California faces a loss of $20 billion in federal funds if the promised Obamacare repeal happens without a replacement that preserves the Medicaid expansion and premium subsidies.

Under that scenario, Lee said, “People would have their health insurance pulled out from under them in droves.”

“The whole issue of repeal without replace is cataclysmic not just for California or Californians,” said Lee, “but for any of the 20 million Americans that have coverage because of the Affordable Care Act.”

Yet, Lee says, even in the face of a “very fuzzy” future, he’s focusing on the present, which includes shepherding more than 300,000 Californians newly enrolled in health care into 2017 coverage and on what parts of California’s plan can be adopted nationwide.

“There have been some things that have not worked great with the Affordable Care Act; there are things that have worked pretty darn well.” Lee said. “Let’s make sure the laboratory of the states is a laboratory [for] sharing the lessons of success and failure with one another.” ~Stephanie O’Neill

Donna Frescatore

Donna Frescatore

Fearing A Return To ‘$1,000 A Month For An Individual Policy’ – Donna Frescatore, NY State of Health Executive Director

The New York state health exchange is fielding its busiest enrollment period yet, even in the uncertainty of the health law’s future.

A repeal of the ACA, without significant replacement, could cost 2.7 million New Yorkers their health insurance, and the state $3.7 billion, according to Gov. Andrew Cuomo’s office.

“We believe that the stakes here in New York are dramatic — for consumers, for our health care delivery system and for our state budget as well,” said Donna Frescatore, executive director of NY State of Health, New York’s marketplace.

Losing “momentum,” is one of Frescatore’s main concerns. Between 2013 and 2015, the uninsured rate in New York folded in half, from 10 to 5 percent, according to the state’s health department.

“We talk to moms who are concerned because their children have pre-existing conditions and they’re afraid coverage might no longer be available. We talk to self-employed New Yorkers who fear that the premiums could increase to the 2013 levels — over $1,000 a month for an individual policy,” Frescatore said.

Without financial support from the federal government, premiums may increase. Options may become reminiscent of health insurance plans as they were in pre-health-law New York.

“New York had a number of very strong consumer protections in place before the Affordable Care Act, including guaranteed issue. People could get insurance regardless of whether or not they had a medical condition or illness, as well as other consumer protections. We’ll maintain those protections,” said Frescatore.

But no insurance requirements or financial assistance, she adds, made plans “just out of reach.”

For now, the health exchange continues outreach to enroll consumers and reassures that, at least as far as they know, policies won’t be disrupted in 2017.

“At this point, without knowing more details about repeal or replacement, what we’re really focused on is getting people coverage that they deserve,” Frescatore said. ~Karen Shakerdge, WXXI and Side Effects Public Media


Jim Wadleigh

‘Do A Better Job Enforcing Special Enrollment’ – Jim Wadleigh, Access Health CT CEO

Connecticut was an early adopter of the ACA. After it passed, the state expanded Medicaid ahead of schedule to cover roughly 200,000 more people a year. This year, more than 100,000 people enrolled in coverage they found on the state-based exchange, with nearly 80 percent getting subsidies.

But while it may have been attractive to some consumers, it was less so to insurers. Two of the four original insurance companies in the marketplace are no longer in it. Now, with an uncertain future ahead, Access Health CT CEO Jim Wadleigh said he’s got one hard goal in mind as he thinks beyond 2017.

“What can we do to help make the business environment that our carriers are in easier for them to be more successful?”

Here’s one quick fix. Insurers have told Wadleigh that they lose money on customers who miss open enrollment periods and go through special enrollment — the process reserved for people with big life events or job changes that merits new insurance.

“What the carriers are telling us is, these customers are coming in… finding a reason that they have a life event because they’re sick, get services and then drop out.”

That’s an expensive pattern. This week, Wadleigh is asking his board to approve a plan to ramp up enforcement.

“If we can do a better job enforcing the special enrollment, we think we can reduce the premiums by potentially 6 to 10 percent.”

Another way to reduce costs? Shrink provider networks. So, let’s say you live in Hartford. Do you really need to pay for a plan that covers a doctor’s visit in Danbury?

“Customers are telling us they would go with a network choice option, or a narrow network, if it was cheaper and/or had a lower deductible.”

That, he said, could save another few percentage points in premium dollars.

Third, Wadleigh said he’s considering reforms that would push more of the cost of emergency room visits to consumers, hoping to deter frequent ER fliers.

The question is whether all of this will work. Wadleigh said he thinks it will. He’s already had discussions with existing carriers who are curious whether other insurers are looking to get into the marketplace.

“So what that is telling me is that the carriers think that we’re making changes in the positive direction, and expect that other carriers would be interested in joining our exchange with that.”

Whether they do — and whether the exchange will even be around for them to join — is still very much unclear. ~Jeff Cohen, WNPR


Louis Gutierrez

No Guarantees, But ‘Every Day Is a Good Day of Coverage.’ – Louis Gutierrez, Massachusetts Health Connector Executive Director

A near record number of Massachusetts residents are signing up for coverage through the state’s online insurance market, the Health Connector. Enrollment is up 32 percent over last year as the deadline of Jan. 31 approaches. Around 47,000 people who did not have insurance through the Connector last year have purchased insurance for 2017.

So many members, physicians and others in the health care world were stunned when Louis Gutierrez, who runs the Connector, said he could not guarantee coverage through the end of 2017 for the nearly 240,000 enrollees so far.

“I don’t want to be in the business of speculating or making commitments about things I can’t personally control,” Gutierrez said, adding “I don’t think any of us really know” what’s going to happen with the repeal of the ACA.

Gutierrez said he is not predicting precipitous changes but, “can’t speak to the future. Every day is a good day of coverage.”

Health insurers, who are threatening to pull out of exchanges in some states, are not the main concern in Massachusetts. Gutierrez said he’s hearing very little from the state’s “mature and stable market.” Most plans that sell insurance through the Connector are nonprofits based in the state. And they may have less reason to worry that healthy members will flee, leaving insurers to cover the high costs of ill members because Massachusetts residents would still be required to buy insurance by state law if the ACA mandate is repealed.

But if federal funds shrink or disappear, coverage would likely become very expensive for the 178,000 men and women who expect to receive subsidies or tax credits for insurance purchased through the Connector.

“We’re interested in maintaining broad and affordable access to coverage,” Gutierrez said, but “that will depend on the shape of any subsidies that change or happen in the new scheme.”

Many Massachusetts residents are wondering if the state could revert to “Romneycare,” the health reform law passed in 2006 when Mitt Romney was governor, which became a model for Obamacare. The individual mandate is still on the books, but the employer mandate and other elements were replaced with provisions in the federal law.

So what would it take to reconstruct Romneycare? Aides on Beacon Hill are going through state law to see which pieces are still in place and what would have to be restored. A number of provisions in the 2006 law, like the employer mandate, were removed because they were in conflict with Obamacare. It’s not clear right now what it would it take to make Romneycare workable again. ~Martha Bebinger, WBUR

Kevin Patterson

Kevin Patterson

Lessons For ‘Whatever Post-ACA Is’ – Kevin Patterson, Chief Executive Officer Connect for Health Colorado

The view from Kevin Patterson, the CEO of Connect for Health Colorado, might be summarized as sunny with storm clouds on the horizon.

Patterson said enrollment numbers for 2017 are running 15 percent ahead of last year. “I think we’re feeling like things are going really well,” he said

But two things are clouding its future – first, the new Trump administration and Congressional Republicans vowing to undo Obamacare.

And in Colorado, the exchange is facing headwinds closer to home from state legislators. The legislative session got underway this month and as one of the first orders of business, Republicans unveiled a bill to repeal the exchange altogether. They are expected to zero in on a recent federal audit that found the exchange improperly spent millions in federal funds and called for that money to be returned. Patterson said the exchange has made many changes and disagrees with the recommendation to refund the money.

But if the exchange survives legislative turmoil, it still faces the possibility of federal subsidies disappearing. But Patterson believes the exchange could carry on. “I don’t know what our footprint might be,” he concedes. But he thinks it has a role in helping consumers with the eligibility process. “I do think there are things that we’ve learned that could be applied in a new era or whatever post-ACA is,” he said.

But he worries an Obamacare repeal without a timely, adequate replacement could cause some insurers to pull out of the exchange or charge higher rates. Already consumers saw premiums go up and choice go down this year. And this is pressing — insures have to file rate requests in Colorado in May. “So the clock is ticking,” Patterson said. “Somebody has to give us a little more guidance I think to the industry around what the new world is going to look like. And I think the sooner we do that the better it is for every consumer.”

But, he said beyond 2017, the exchange could look to expand its other lines of business beyond the individual marketplace, including helping large and small employers figure our insurance packages and benefits. “I think that’s somewhere where we can show some more value,” he said.

Colorado’s exchange is also flirting with the possibility of working with neighboring states, particularly those in the mountain time zone. “We’re kind of used to working together as western states on problems that are really unique to us,” Patterson said. “That’s where I would start.” ~John Daley, Colorado Public Radio

This story is part of a reporting partnership with NPR, local member stations and Kaiser Health News.

Categories: Insurance, Repeal And Replace Watch, Reporting Consortium, Syndicate, The Health Law

Tags: Obamacare Plans, State Exchanges

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Sleep Apnea Device Improves Breathing, But Maybe Not Heart Risk

Action Points

  • Jaw repositioning with mandibular advancement therapy significantly improved sleep scores and symptoms, but the treatment did not improve key measures of heart disease risk among CPAP-intolerant patients with severe sleep apnea.
  • Note that these findings from a sham-controlled, randomized trial thus cast doubt on the belief that successful treatment of sleep apnea will reduce the cardiovascular risk associated with the condition.

Jaw repositioning with mandibular advancement therapy significantly improved sleep scores and symptoms, but the treatment did not improve key measures of heart disease risk among CPAP-intolerant patients with severe sleep apnea in a newly reported study.

Use of a mandibular advancement device (MAD) was associated with improvements in apnea-hypopnea index (AHI) scores, micro-arousal index scores and snoring, daytime fatigue and sleepiness in the study, but the treatment did not appear to improve endothelial function or lower blood pressure.

These findings from a sham-controlled, randomized trial thus cast doubt on the belief that successful treatment of sleep apnea will reduce the cardiovascular risk associated with the condition.

The multicenter study is among the first to examine the impact of MAD therapy on cardiovascular risk factors in patients with obstructive sleep apnea (OSA), wrote study leader Frederic Gagnadoux, MD, of the University Hospital of Angers in France, and colleagues.

Their research was published online Friday in the American Journal of Respiratory and Critical Care Medicine.

Endothelial dysfunction, which is a major predictor of atherosclerosis, as well as myocardial infarction (MI) and stroke risk, can be caused or exacerbated by OSA. Untreated sleep apnea is an independent risk factor for MI and stroke, and evidence has suggested that successful treatment of OSA could lower this risk.

Continuous positive airway pressure (CPAP) is considered the front-line treatment for OSA, but patient compliance remains a challenge. Studies suggest that 29% to 84% of patients on CPAP are nonadherent, meaning they use their CPAP device for 4 hours or less each night.

Mandibular advancement therapy has emerged as the main alternative to CPAP. The oral devices open the airways by moving the lower jaw forward.

In the newly reported study, Gagnadoux and colleagues assessed the impact of MAD therapy on key measures of sleep and cardiovascular risk in patients with severe sleep apnea and no known cardiovascular disease.

A total of 150 patients with severe sleep apnea (mean apnea-hypopnea index [AHI] score of 41), but only moderate daytime sleepiness, were randomized to either MAD therapy (n=75) or sham device therapy (n=75) for 2 months.

In the effective MAD group, mean mandibular advancement was 7.9 (1.5) mm, corresponding to an average of 106% of maximum voluntary advancement. Eleven effective MAD patients and 10 sham treatment patients dropped out of the study.

The primary study outcome was change in the reactive hyperemia index (RHI), which is a validated measurement of endothelial function.

Among the main findings:

  • In the intention-to-treat analysis, RHI decreased by 0.03 points in the effective MAD group (P=0.95) and by 0.13 points (P=0.13) in the sham device group.

  • After adjustment for baseline values, age, gender, BMI, AHI, and smoking habits, the difference in RHI outcome between effective MAD and sham device groups was not statistically significant (adjusted intergroup difference 0.15, 95% CI -0.08 to 0.38; P=0.20).

  • In the overall population, change in RHI from baseline to follow-up was not correlated with either change in AHI (r=-0.08; P=0.41) or change in 3% oxygen desaturation index.

  • In a post-hoc analysis in which the median value of baseline RHI was used to classify patients into low and high RHI groups, a significant improvement in RHI was observed in the low RHI group with both effective MAD and sham device, with no significant adjusted intergroup difference between the two treatments.

The mean objective compliance with effective MAD was 6.7 hours per night, which corresponded to approximately 90% of reported sleep duration.

“Interestingly, we found that reported and objective compliance were highly correlated in the effective MAD group but not in the sham device group, which emphasizes the importance of objective compliance measurement in sham-controlled trials of MAD therapy,” the researchers wrote.

They further noted that several recent studies have shown little or no improvement in cardiovascular outcomes associated with treatment for OSA. Research published last year in the New England Journal of Medicine showed no evidence of a reduction in such outcomes among patients with moderate to severe OSA treated with CPAP.

The researchers added that the exclusion of patients with cardiovascular disease may have been a limitation of their study.

“Although our post hoc analysis showed no intergroup differences in RHI outcome in patients with low baseline RHI, further studies are required to determine whether MAD therapy for OSA can improve endothelial function in patients with overt cardiovascular disease and metabolic disorders who exhibit more severe endothelial dysfunction at baseline,” they wrote.

Funding for this research was provided by the French Ministry of Health.

  • Reviewed by
    Robert Jasmer, MD Associate Clinical Professor of Medicine, University of California, San Francisco and Dorothy Caputo, MA, BSN, RN, Nurse Planner


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Q&A: Rep. Eddie Bernice Johnson, RN

WASHINGTON — Rep. Eddie Bernice Johnson, RN, (D- Tex.), the first nurse elected to the U.S. Congress, gave MedPage Today an insider’s view of the swiftly changing healthcare system in an exclusive interview with MedPage Today.

Johnson, once chief psychiatric nurse at a VA hospital in Dallas, is now in her 12th term representing the 30th District of Texas. She told MedPage Today why she supports the Affordable Care Act and opposes privatizing healthcare for veterans, and explained why the U.S. needs a “National Nurse for Public Health.”

A press representative was present during the interview, which has been edited for brevity and clarity.

MPT: You chose to attend Pres. Donald Trump’s inauguration while many of your Democratic colleagues did not. Why?

Johnson: I don’t agree with much of what [he] has said, however, the majority of people in this country, by the method of which we choose the president, has elected him.

I have known Hillary Clinton since 1972, and I was set on doing whatever I could to help her become president. It didn’t happen, but I can’t fold my tent and go home, because I ran for office to represent District 30, and I will be here to do that.

MPT: What questions do you have for Pres. Trump?

Johnson: I need to know for sure if he’s serious about making sure insurance is available to all human beings. If he’s serious about that, then there are some components that we must put in place to make that possible.

I’m willing to try to see whether or not my ideas can work with some of his ideas.

MPT: If there is a repeal-and-replace of the Affordable Care Act, what key provisions would you hope to see in a replacement?

Johnson: I want to see it the same as it is now: no lifetime caps, no additional cost to women, children covered on their families’ plans until they’re 26, and no ending insurance when a person gets a certain diagnosis.

I think that the attitude of the Affordable Care Act put the responsibility where it’s supposed to be. If you paid for the insurance, you were to get the coverage, and that’ s what I’m for.

MPT: Were there other changes you would have liked to see in the ACA?

Johnson: In my state, the people who have been the sickest have been the immigrant population. If people have permission to be in this country, have been here 4 or 5 years, and have children that need coverage, I think they ought to be able to buy health insurance.

We cannot as a rich nation think that we are going to be great, when we don’t think about making sure that the people we expect to work and do the job have access to healthcare, so they can stay healthy.

MPT: Pres. Trump spoke about allowing Medicare to negotiate drug prices when he was campaigning — do you think that’s a good idea?

Johnson: We charge more for medication in this country than anywhere in the world. People in my state go across the border to buy the same medications for about 80% less. And the government invests probably more in medication than any other segment. I think it’s only appropriate to be able to negotiate that.

MPT: Do you still see tensions between nurses and physicians around scope of practice issues?

Johnson: I don’t think that physicians ought to be threatened by nurses that get more preparation. I feel that we have enough people in this country with enough needs that these two professions can work together. And there are many, many nurses that I would trust more than some doctors out there.

MPT: The Department of Veterans Affairs recently issued a rule allowing most advanced practice nurses to work independently. Do you support the idea?

Johnson: I would like for nurses to be able to work to the extent of their preparation. So, I certainly support it. And the country certainly needs it, especially in our rural areas, where we have a very big shortage of physicians.

MPT: You worked at a VA hospital before becoming a legislator. Do you think privatizing healthcare for veterans makes sense?

Johnson: The profile of the veteran has changed tremendously. Veterans now are very poor and most are looking for an avenue to get an education. Then, they find themselves in war scenes over and over again, because there’s no draft.

You’re dealing with a younger, less-prepared-for-trauma veteran. Some 90% now have posttraumatic stress disorder (PTSD). You’re talking about people who need a consortium of support; they need psychiatrists, psychologists, social workers, job counselors, and healthcare. You’re not going to get that if you go to a private hospital.

MPT: How has being a nurse shaped who you are and your role in Congress?

Johnson: I think nursing is probably one of the best professions that gives you a good foundation for coming into public office, because you’re not afraid to make quick, definitive, informed decisions and when you make them and believe in them, you’ll fight for them. And that’s what I try to do.

MPT: You re-introduced the National Nurses Act in 2015. What is the primary goal of the bill?

Johnson: What we want to do is make sure that nurses have the proper labeling, so that they can influence at that level. The more we can upgrade nurses in decision-making capacities, the more they’ll be respected for what they really are and the more utilization we can make of their talents.

MPT: Elements of another bill you co-sponsored, the Helping Families in Mental Health Crisis Act, were included in the 21st Century Cures Act, which passed with strong bipartisan support. Why is mental health reform so important?

Johnson: I was a psychiatric nurse. I know that there is hardly any family in the United States that does not have someone in need of mental health care.

In mental illness it takes a long time to get someone back in a normal sphere of operation. Most of the time, unless they’re rich, their money can run out if there’s not healthcare coverage for mental health. Often a person in crisis has no more than 48 hours in a facility, but they need longer term care. And that still is not achieved in this mental health portion of that [Cures] bill, but it does open the door for more access to care.

MPT: How do you feel about Rep. Tom Price (R-Ga.) being chosen to run the Department of Health and Human Services (HHS) ?

Johnson: He’s friendly to work with, but some of the rhetoric I’ve heard him say on the floor I don’t agree with at all.

I hope he’ll be reasonable and approachable, and realize that there are opinions perhaps outside of his personal ones. And I hope he doesn’t get rid of all the body of knowledge that is in the department.

MPT: What are you hopeful about in this next administration?

Johnson: I’m from a state that has never shown the compassion that I have wanted them to show towards people who are not rich. I’ve been working on that for 45 years. I will continue no matter who is in the White House. I have been in the majority 6 years out of 24 but I have something to show for every year that I have been here. I intend to have something to show for this coming time and this coming Congress.


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