User login
Lancet joins movement to reject ‘manels’
The Lancet Group’s 18 medical journals have committed to ensuring that their editorial advisory boards include at least 50% female members by the end of 2019 as just one component of the diversity and gender parity initiative unveiled Aug. 8.
“The case for gender equity and diversity is clear: Teams that are diverse in terms of gender, ethnicity, and social background produce better health science, are more highly cited, generate a broader range of ideas and innovations, and better represent society,” group editors wrote in their comment (Lancet. 2019 Aug 10;394:452-3). They emphasized the importance of increasing inclusion in science “across gender, ethnicity, geography, and other social categories.”
The Diversity Pledge states the group’s commitment “to increasing diversity and inclusion in research and publishing, and in particular to increasing the representation of women and colleagues from low-income and middle-income countries among our editorial advisers, peer reviewers, and authors.”
The No All-Male Panel Policy echoes a call from the National Institutes of Health for ending the “Manel Tradition,” as NIH Director Francis S. Collins, MD, PhD, wrote in early June. Recognizing the need “to combat cultural forces that tolerate gender harassment and limit the advancement of women,” Dr. Collins pledged to decline speaking invitations if “attention to inclusiveness” is not clear in the event’s agenda.
Discussion of “manels” – all-male panels – and the decision to boycott them has been picking up speed in scientific, medical and even business circles over the past several years. The BBC highlighted a popular blog that shamed events with all-male panels in 2015, and a 2018 study more formally concluded that male scientists had considerably more opportunities to speak and present at the world’s largest geophysical conference.
One business and development leader even included space on his website to allow other leaders to pledge not to “serve on a panel of two people or more unless there is at least one woman on the panel, not including the chair.” More than 2,000 leaders from across the globe already have signed.
Six months ago, the Lancet published a special theme issue on women in science, medicine, and global health. The editors noted in the issue that women comprise fewer than a third of authors and reviewers in high-impact medical journals – just one example of the underrepresentation of women and people in color in medical publishing. The group is now revamping their systems to address the disparities.
“An upcoming update of our online submission system will have a field for self-selected gender, so we can better track representation across genders among authors, reviewers, editors, and editorial advisers, along with country of origin,” the editors wrote.
But they acknowledged that their efforts are just one piece of the academic ecosystem and called on others’ participation. “We encourage other publishers, journals, and members of the science community to contribute to these pledges.”
SOURCE: Lancet. 2019 Aug 10;394:452-3.
The Lancet Group’s 18 medical journals have committed to ensuring that their editorial advisory boards include at least 50% female members by the end of 2019 as just one component of the diversity and gender parity initiative unveiled Aug. 8.
“The case for gender equity and diversity is clear: Teams that are diverse in terms of gender, ethnicity, and social background produce better health science, are more highly cited, generate a broader range of ideas and innovations, and better represent society,” group editors wrote in their comment (Lancet. 2019 Aug 10;394:452-3). They emphasized the importance of increasing inclusion in science “across gender, ethnicity, geography, and other social categories.”
The Diversity Pledge states the group’s commitment “to increasing diversity and inclusion in research and publishing, and in particular to increasing the representation of women and colleagues from low-income and middle-income countries among our editorial advisers, peer reviewers, and authors.”
The No All-Male Panel Policy echoes a call from the National Institutes of Health for ending the “Manel Tradition,” as NIH Director Francis S. Collins, MD, PhD, wrote in early June. Recognizing the need “to combat cultural forces that tolerate gender harassment and limit the advancement of women,” Dr. Collins pledged to decline speaking invitations if “attention to inclusiveness” is not clear in the event’s agenda.
Discussion of “manels” – all-male panels – and the decision to boycott them has been picking up speed in scientific, medical and even business circles over the past several years. The BBC highlighted a popular blog that shamed events with all-male panels in 2015, and a 2018 study more formally concluded that male scientists had considerably more opportunities to speak and present at the world’s largest geophysical conference.
One business and development leader even included space on his website to allow other leaders to pledge not to “serve on a panel of two people or more unless there is at least one woman on the panel, not including the chair.” More than 2,000 leaders from across the globe already have signed.
Six months ago, the Lancet published a special theme issue on women in science, medicine, and global health. The editors noted in the issue that women comprise fewer than a third of authors and reviewers in high-impact medical journals – just one example of the underrepresentation of women and people in color in medical publishing. The group is now revamping their systems to address the disparities.
“An upcoming update of our online submission system will have a field for self-selected gender, so we can better track representation across genders among authors, reviewers, editors, and editorial advisers, along with country of origin,” the editors wrote.
But they acknowledged that their efforts are just one piece of the academic ecosystem and called on others’ participation. “We encourage other publishers, journals, and members of the science community to contribute to these pledges.”
SOURCE: Lancet. 2019 Aug 10;394:452-3.
The Lancet Group’s 18 medical journals have committed to ensuring that their editorial advisory boards include at least 50% female members by the end of 2019 as just one component of the diversity and gender parity initiative unveiled Aug. 8.
“The case for gender equity and diversity is clear: Teams that are diverse in terms of gender, ethnicity, and social background produce better health science, are more highly cited, generate a broader range of ideas and innovations, and better represent society,” group editors wrote in their comment (Lancet. 2019 Aug 10;394:452-3). They emphasized the importance of increasing inclusion in science “across gender, ethnicity, geography, and other social categories.”
The Diversity Pledge states the group’s commitment “to increasing diversity and inclusion in research and publishing, and in particular to increasing the representation of women and colleagues from low-income and middle-income countries among our editorial advisers, peer reviewers, and authors.”
The No All-Male Panel Policy echoes a call from the National Institutes of Health for ending the “Manel Tradition,” as NIH Director Francis S. Collins, MD, PhD, wrote in early June. Recognizing the need “to combat cultural forces that tolerate gender harassment and limit the advancement of women,” Dr. Collins pledged to decline speaking invitations if “attention to inclusiveness” is not clear in the event’s agenda.
Discussion of “manels” – all-male panels – and the decision to boycott them has been picking up speed in scientific, medical and even business circles over the past several years. The BBC highlighted a popular blog that shamed events with all-male panels in 2015, and a 2018 study more formally concluded that male scientists had considerably more opportunities to speak and present at the world’s largest geophysical conference.
One business and development leader even included space on his website to allow other leaders to pledge not to “serve on a panel of two people or more unless there is at least one woman on the panel, not including the chair.” More than 2,000 leaders from across the globe already have signed.
Six months ago, the Lancet published a special theme issue on women in science, medicine, and global health. The editors noted in the issue that women comprise fewer than a third of authors and reviewers in high-impact medical journals – just one example of the underrepresentation of women and people in color in medical publishing. The group is now revamping their systems to address the disparities.
“An upcoming update of our online submission system will have a field for self-selected gender, so we can better track representation across genders among authors, reviewers, editors, and editorial advisers, along with country of origin,” the editors wrote.
But they acknowledged that their efforts are just one piece of the academic ecosystem and called on others’ participation. “We encourage other publishers, journals, and members of the science community to contribute to these pledges.”
SOURCE: Lancet. 2019 Aug 10;394:452-3.
FROM THE LANCET
Dr. Carl Bell’s research broke new ground
Psychiatrist educated the field with his work on gun violence, prenatal alcohol exposure
With the heart of a child and the spirit of a warrior, Carl Bell always spoke his truth. And, he did so in his own inimitable way. Sporting his signature dark brown wide-brim leather cowboy hat or NMA (National Medical Association) baseball cap, aviator sunglasses, and accompanying Superman belt buckle, Carl Compton Bell, MD, – psychiatrist, researcher, mental health advocate, father, grandfather, friend, colleague, pioneer, and servant – was driven by a deep commitment to serve others.
As those who truly knew him can attest, it is not hyperbole to say that Carl Compton Bell was one of the most genuine, brilliant, and humble physicians of our professional community and time.
My collaboration and friendship began with Dr. Bell began during the summer of 2016 as I was preparing for the 2017 Washington Psychiatric Society’s (WPS) Presidential Symposium at Saint Elizabeths Hospital. As president of WPS, I had chosen gun violence as my topic and sought out Dr. Bell because of his work on the South Side of Chicago, where he had devoted himself, becoming an internationally known clinician, researcher, and mental health advocate for those personally affected by violence and trauma. He immediately accepted.
In his presentation, “Gun Violence, Urban Youth and Mental Illness,” he reviewed his research on the neurocognitive behavioral effects of prenatal exposure to alcohol and its relation to the neurodevelopmental dynamics of youth violence, intimate partner violence, and mass shootings. Dr. Bell suggested that the relationship between prenatal exposure to alcohol and the diagnosis of numerous psychiatric conditions had been underestimated in the medical community. He eventually summarized his work in Fetal Alcohol Exposure in the African-American Community, published by Third World Press (2018). This vital resource not only summarizes in plain language the scope of the problem of prenatal alcohol exposure but is a narrative of Carl Bell’s life journey.
After the symposium, he would send articles, while warning, “I can bombard you with stuff.” Sometimes we would not speak for weeks at a time while I digested the resources he had shared. However, whenever I picked up the phone to call and respond to what he had provided, he would answer the phone, “Yessssss?” – as if he were anticipating my call and was ready to address any queries or comments I might have. Even when he were about to board a plane or charting – after making rounds on his patients while listening to the music of James Brown – he would answer the phone, even if only to coordinate a more mutually convenient time to connect.
During the process of digesting the plethora of articles and resources he provided on prenatal fetal alcohol exposure, including the 1996 Institute of Medicine’s report and the American Medical Association’s 2017 resolution supporting the addition of adequate amounts of choline to prenatal vitamins, I found myself immersed in neuroscience topics, such as the role of neuronal acetylcholine receptor subunit alpha-7 in the formation of neurotransmitters, the strengthening of cell membranes, and the promotion of proper brain and spinal cord development. Dr. Bell spoke authoritatively about the neuroscience and the public health implications. One of his mantras was “Where is the data? You’ve got to have data.”
The information that he shared became the foundation of the action paper calling for the American Psychiatric Association (APA) to endorse the AMA’s resolution supporting the addition of adequate amounts (450 mg/d for pregnant women) of phosphatidylcholine to prenatal vitamins. The APA Assembly passed this action paper in May 2018.
He was also responsible for a second action paper, “Psychiatric Management of the Impact of Racism on Social and Clinical Events,” which passed at the same May 2018 assembly. Dr. Bell agreed to coauthor this paper, which was only fitting since the paper was a further elaboration of his efforts with the APA Caucus of Black Psychiatrists to implore the APA to acknowledge the deleterious effects of racism on both the victim and perpetrator.
While researching this topic, I had come across his 1980 article, Racism: A Symptom of the Narcissistic Personality Disorder (J Nat Med Assoc. 1980 Jul;72[7]:661-5), in which Dr. Bell applied psychoanalytic theory to posit that racism is one psychic derivative through which narcissism may manifest itself.
Although he was not formally trained as a psychoanalyst, he had benefited from strong psychoanalytic supervision at the Illinois State Psychiatric Institute, a training program of the University of Illinois at Chicago. He wrote confidently and clearly, applying self-psychology principles. He had the gravitas to write and speak about a range of topics, from neuroscience, psychotherapy, medical management of illness, and mental health advocacy. His 387-page curriculum vitae of 500+ articles, chapters, and books on mental health issues is a catalog of evidence that he had given thought to just about any topic along the spectrum of psychiatry and beyond.
In July 2018, after leaving a performance of “Hamilton” at the Kennedy Center, a lyric from the song “Non-Stop” stayed with me:
Why do you write like you’re running out of time?
(Why do you write like you’re running out of time?)
Write day and night like you’re running out of time?
The pace at which he read, wrote, lectured, researched, collaborated, and served on committees reminded me of the prodigious work of the former Secretary of the Treasury. When I shared this with Dr. Bell, he volunteered that he wrote to clear his mind. I suggested that, like other true writers, it seemed that he had to write. He did not disagree.
But, what was most meaningful about his productivity was his generosity of spirit. Any conversation was an opportunity for him to thoughtfully and respectfully share his knowledge. For example, once, we were discussing a clinical case that included the differential diagnosis of a patient, who happened to be African American, who was having auditory hallucinations. Dr. Bell might have been the first psychiatrist to alert the medical community about the misdiagnosis of schizophrenia among African Americans with bipolar disorder (J Nat Med Assoc. 1980 Feb 72[2]:141-5).
Contrary to my expectation that he was going to remind me of the tendency to misdiagnose, he instead offered, “You know, there are 40 reasons for auditory hallucinations.” Not what I had expected, yet, a response that reflected his continually giving nature and sharing of his abundance of gems. He was always teaching.
I later learned that his workday at Jackson Park Hospital usually ended at 2 p.m. He had treated patients, and supervised medical students and residents there for more than 40 years. The afternoons afforded him time to read, write, listen to music (Ella Fitzgerald), watch movies, and spend time with his adult children, to whom he was quite devoted. Dr. Bell was an avid martial artist and enjoyed sharing this practice with his son, William.
He was a longtime active member of the National Medical Association, recently receiving its prestigious Distinguished Service Award in Hawaii for his “exceptional work in medical service, medical research, and academic medicine.” It would be his last professional talk, though his delivery would belie his numbered days.
He was a former vice president of the Black Psychiatrists of America (BPA) and for 10 years had been the editor of the BPA Newsletter. Conversations were often peppered with anecdotes from time spent with other pioneering ancestors, such as Chester “Chet” Pierce, MD, Jeanne Spurlock, MD, Robert Phillips, MD, PhD, Charles Prudhomme, MD, Frances Cress Welsing, MD, and others. Dr. Bell was at the tail end of a generation of African American psychiatrists who had experienced firsthand the transition from segregation to federally mandated integration of our society.
Dr. Bell and his peers applied their education and training to improve clinical care for all, to decrease health inequities, and to eliminate disparities. It is evident that he loved his people and committed his life to addressing the needs of marginalized communities, those without the benefit of abundant resources, and those disproportionately affected by violence and trauma. As he stated in his last book, Fetal Alcohol Exposure in the African-American Community:
“I should add, my main concern is African American people living within the United States of America where in one community the rate of Fetal Alcohol Exposure is 388/1,000 people. ... However, this problem extends much further. Fetal Alcohol Exposure (FAE) is increasingly being found to (be) problematic in people of color around the world: Native Americans in Canada ... Aboriginal people in Australia ... and various tribes of people on the continent of Africa. ... Lastly, while the problem of Fetal Alcohol Exposure seems to be disproportionately affecting people of color, it also affects people who lack pigment in their skin. For example, FAE is a problem in Russia. From a public health perspective, so often people of color are like the proverbial “canary in a coal mine,” i.e., if there is poisonous gas in the coal mine, the canary will die first, warning the miners that they need to do something about it.”
However, Dr. Bell was a Distinguished Lifetime Fellow of the American Psychiatric Association and a Lifetime Fellow of the American College of Psychiatrists. He was a founding member of the board of directors of the National Commission on Correctional Health, and a member of prominent work groups of the National Institutes of Mental Health and the National Academy of Medicine (formerly the Institute of Medicine). And Dr. Bell’s mentees and students transcend generations, race, religions, professional disciplines, and national boundaries.
Because Dr. Bell was grounded and never forgot his roots, it was in these professional society circles that he ensured that clinicians with more privilege and limited or no exposure to communities of color were educated about the needs of those he treated. Without exposure to Carl Bell, it is likely that many of our psychiatric colleagues would remain unaware of both the brilliant dynamic resources and enormous challenges that are found in the black community and communities of color. By sharing his work with the house of medicine, he obviated the excuse of doing nothing because of ignorance.
I last saw Dr. Bell in San Francisco toward the end of the 2019 annual APA meeting. He had received the APA’s Adolf* Meyer Award for lifetime achievement. Afterward, I joined him for a dim sum lunch in Chinatown with two of his colleagues and Joseph Calhoun, his mentee in the APA’s Black Men in Psychiatry Early Pipeline Program. As we walked back to our respective hotels, we paused at what is now the Chinese Affirmative Action Center. We learned that this site had been the home of one of Dr. Bell’s former martial arts instructors. As Dr. Bell recounted his martial arts training, the reverence for his sensei was evident in his eyes.
When I reflect on how much I learned from and about Carl Bell in such a short period of time, I realize that he was one of those people who was so present and so astute that he allowed you to know him while he was giving.
So, how do we honor someone who gave so much of himself? When I now think of the lyric from “Hamilton” – “Why do you write like you’re running out of time?” – I realize that we get it twisted when we associate running out of time with our elders and their phase of life. It was not Carl Bell who was running out of time. He had been extraordinarily respectful of the space, time, and energy allotted to him in his lifetime. He would say, “People squander their personal resources.” He certainly had not squandered his.
As we reflect and mourn his passing, we will hear about his candor, authenticity, integrity, discipline, reliability, dedication, and serving spirit. This is called character.
Dr. Bell was beyond generous with his life, and it is going to take decades, if not more, for us to digest the compendium of knowledge that he left behind. I ask you: How will you use that knowledge to advance the causes he so diligently devoted his life to solving?
To Carl Compton Bell, I say, Well done. Thank you. And, rest now my dear brother.
Dr. Dunlap, a psychiatrist and psychoanalyst who practices in Washington, is a Washington Psychiatric Society representative to the APA Assembly, a past president of the Washington Psychiatric Society, and clinical professor of psychiatry and behavioral sciences at George Washington University, Washington. She is interested in the role “difference” – race, culture, and ethnicity – plays in interpersonal relationships and group dynamics.
*This column was updated 9/3/2019.
Psychiatrist educated the field with his work on gun violence, prenatal alcohol exposure
Psychiatrist educated the field with his work on gun violence, prenatal alcohol exposure
With the heart of a child and the spirit of a warrior, Carl Bell always spoke his truth. And, he did so in his own inimitable way. Sporting his signature dark brown wide-brim leather cowboy hat or NMA (National Medical Association) baseball cap, aviator sunglasses, and accompanying Superman belt buckle, Carl Compton Bell, MD, – psychiatrist, researcher, mental health advocate, father, grandfather, friend, colleague, pioneer, and servant – was driven by a deep commitment to serve others.
As those who truly knew him can attest, it is not hyperbole to say that Carl Compton Bell was one of the most genuine, brilliant, and humble physicians of our professional community and time.
My collaboration and friendship began with Dr. Bell began during the summer of 2016 as I was preparing for the 2017 Washington Psychiatric Society’s (WPS) Presidential Symposium at Saint Elizabeths Hospital. As president of WPS, I had chosen gun violence as my topic and sought out Dr. Bell because of his work on the South Side of Chicago, where he had devoted himself, becoming an internationally known clinician, researcher, and mental health advocate for those personally affected by violence and trauma. He immediately accepted.
In his presentation, “Gun Violence, Urban Youth and Mental Illness,” he reviewed his research on the neurocognitive behavioral effects of prenatal exposure to alcohol and its relation to the neurodevelopmental dynamics of youth violence, intimate partner violence, and mass shootings. Dr. Bell suggested that the relationship between prenatal exposure to alcohol and the diagnosis of numerous psychiatric conditions had been underestimated in the medical community. He eventually summarized his work in Fetal Alcohol Exposure in the African-American Community, published by Third World Press (2018). This vital resource not only summarizes in plain language the scope of the problem of prenatal alcohol exposure but is a narrative of Carl Bell’s life journey.
After the symposium, he would send articles, while warning, “I can bombard you with stuff.” Sometimes we would not speak for weeks at a time while I digested the resources he had shared. However, whenever I picked up the phone to call and respond to what he had provided, he would answer the phone, “Yessssss?” – as if he were anticipating my call and was ready to address any queries or comments I might have. Even when he were about to board a plane or charting – after making rounds on his patients while listening to the music of James Brown – he would answer the phone, even if only to coordinate a more mutually convenient time to connect.
During the process of digesting the plethora of articles and resources he provided on prenatal fetal alcohol exposure, including the 1996 Institute of Medicine’s report and the American Medical Association’s 2017 resolution supporting the addition of adequate amounts of choline to prenatal vitamins, I found myself immersed in neuroscience topics, such as the role of neuronal acetylcholine receptor subunit alpha-7 in the formation of neurotransmitters, the strengthening of cell membranes, and the promotion of proper brain and spinal cord development. Dr. Bell spoke authoritatively about the neuroscience and the public health implications. One of his mantras was “Where is the data? You’ve got to have data.”
The information that he shared became the foundation of the action paper calling for the American Psychiatric Association (APA) to endorse the AMA’s resolution supporting the addition of adequate amounts (450 mg/d for pregnant women) of phosphatidylcholine to prenatal vitamins. The APA Assembly passed this action paper in May 2018.
He was also responsible for a second action paper, “Psychiatric Management of the Impact of Racism on Social and Clinical Events,” which passed at the same May 2018 assembly. Dr. Bell agreed to coauthor this paper, which was only fitting since the paper was a further elaboration of his efforts with the APA Caucus of Black Psychiatrists to implore the APA to acknowledge the deleterious effects of racism on both the victim and perpetrator.
While researching this topic, I had come across his 1980 article, Racism: A Symptom of the Narcissistic Personality Disorder (J Nat Med Assoc. 1980 Jul;72[7]:661-5), in which Dr. Bell applied psychoanalytic theory to posit that racism is one psychic derivative through which narcissism may manifest itself.
Although he was not formally trained as a psychoanalyst, he had benefited from strong psychoanalytic supervision at the Illinois State Psychiatric Institute, a training program of the University of Illinois at Chicago. He wrote confidently and clearly, applying self-psychology principles. He had the gravitas to write and speak about a range of topics, from neuroscience, psychotherapy, medical management of illness, and mental health advocacy. His 387-page curriculum vitae of 500+ articles, chapters, and books on mental health issues is a catalog of evidence that he had given thought to just about any topic along the spectrum of psychiatry and beyond.
In July 2018, after leaving a performance of “Hamilton” at the Kennedy Center, a lyric from the song “Non-Stop” stayed with me:
Why do you write like you’re running out of time?
(Why do you write like you’re running out of time?)
Write day and night like you’re running out of time?
The pace at which he read, wrote, lectured, researched, collaborated, and served on committees reminded me of the prodigious work of the former Secretary of the Treasury. When I shared this with Dr. Bell, he volunteered that he wrote to clear his mind. I suggested that, like other true writers, it seemed that he had to write. He did not disagree.
But, what was most meaningful about his productivity was his generosity of spirit. Any conversation was an opportunity for him to thoughtfully and respectfully share his knowledge. For example, once, we were discussing a clinical case that included the differential diagnosis of a patient, who happened to be African American, who was having auditory hallucinations. Dr. Bell might have been the first psychiatrist to alert the medical community about the misdiagnosis of schizophrenia among African Americans with bipolar disorder (J Nat Med Assoc. 1980 Feb 72[2]:141-5).
Contrary to my expectation that he was going to remind me of the tendency to misdiagnose, he instead offered, “You know, there are 40 reasons for auditory hallucinations.” Not what I had expected, yet, a response that reflected his continually giving nature and sharing of his abundance of gems. He was always teaching.
I later learned that his workday at Jackson Park Hospital usually ended at 2 p.m. He had treated patients, and supervised medical students and residents there for more than 40 years. The afternoons afforded him time to read, write, listen to music (Ella Fitzgerald), watch movies, and spend time with his adult children, to whom he was quite devoted. Dr. Bell was an avid martial artist and enjoyed sharing this practice with his son, William.
He was a longtime active member of the National Medical Association, recently receiving its prestigious Distinguished Service Award in Hawaii for his “exceptional work in medical service, medical research, and academic medicine.” It would be his last professional talk, though his delivery would belie his numbered days.
He was a former vice president of the Black Psychiatrists of America (BPA) and for 10 years had been the editor of the BPA Newsletter. Conversations were often peppered with anecdotes from time spent with other pioneering ancestors, such as Chester “Chet” Pierce, MD, Jeanne Spurlock, MD, Robert Phillips, MD, PhD, Charles Prudhomme, MD, Frances Cress Welsing, MD, and others. Dr. Bell was at the tail end of a generation of African American psychiatrists who had experienced firsthand the transition from segregation to federally mandated integration of our society.
Dr. Bell and his peers applied their education and training to improve clinical care for all, to decrease health inequities, and to eliminate disparities. It is evident that he loved his people and committed his life to addressing the needs of marginalized communities, those without the benefit of abundant resources, and those disproportionately affected by violence and trauma. As he stated in his last book, Fetal Alcohol Exposure in the African-American Community:
“I should add, my main concern is African American people living within the United States of America where in one community the rate of Fetal Alcohol Exposure is 388/1,000 people. ... However, this problem extends much further. Fetal Alcohol Exposure (FAE) is increasingly being found to (be) problematic in people of color around the world: Native Americans in Canada ... Aboriginal people in Australia ... and various tribes of people on the continent of Africa. ... Lastly, while the problem of Fetal Alcohol Exposure seems to be disproportionately affecting people of color, it also affects people who lack pigment in their skin. For example, FAE is a problem in Russia. From a public health perspective, so often people of color are like the proverbial “canary in a coal mine,” i.e., if there is poisonous gas in the coal mine, the canary will die first, warning the miners that they need to do something about it.”
However, Dr. Bell was a Distinguished Lifetime Fellow of the American Psychiatric Association and a Lifetime Fellow of the American College of Psychiatrists. He was a founding member of the board of directors of the National Commission on Correctional Health, and a member of prominent work groups of the National Institutes of Mental Health and the National Academy of Medicine (formerly the Institute of Medicine). And Dr. Bell’s mentees and students transcend generations, race, religions, professional disciplines, and national boundaries.
Because Dr. Bell was grounded and never forgot his roots, it was in these professional society circles that he ensured that clinicians with more privilege and limited or no exposure to communities of color were educated about the needs of those he treated. Without exposure to Carl Bell, it is likely that many of our psychiatric colleagues would remain unaware of both the brilliant dynamic resources and enormous challenges that are found in the black community and communities of color. By sharing his work with the house of medicine, he obviated the excuse of doing nothing because of ignorance.
I last saw Dr. Bell in San Francisco toward the end of the 2019 annual APA meeting. He had received the APA’s Adolf* Meyer Award for lifetime achievement. Afterward, I joined him for a dim sum lunch in Chinatown with two of his colleagues and Joseph Calhoun, his mentee in the APA’s Black Men in Psychiatry Early Pipeline Program. As we walked back to our respective hotels, we paused at what is now the Chinese Affirmative Action Center. We learned that this site had been the home of one of Dr. Bell’s former martial arts instructors. As Dr. Bell recounted his martial arts training, the reverence for his sensei was evident in his eyes.
When I reflect on how much I learned from and about Carl Bell in such a short period of time, I realize that he was one of those people who was so present and so astute that he allowed you to know him while he was giving.
So, how do we honor someone who gave so much of himself? When I now think of the lyric from “Hamilton” – “Why do you write like you’re running out of time?” – I realize that we get it twisted when we associate running out of time with our elders and their phase of life. It was not Carl Bell who was running out of time. He had been extraordinarily respectful of the space, time, and energy allotted to him in his lifetime. He would say, “People squander their personal resources.” He certainly had not squandered his.
As we reflect and mourn his passing, we will hear about his candor, authenticity, integrity, discipline, reliability, dedication, and serving spirit. This is called character.
Dr. Bell was beyond generous with his life, and it is going to take decades, if not more, for us to digest the compendium of knowledge that he left behind. I ask you: How will you use that knowledge to advance the causes he so diligently devoted his life to solving?
To Carl Compton Bell, I say, Well done. Thank you. And, rest now my dear brother.
Dr. Dunlap, a psychiatrist and psychoanalyst who practices in Washington, is a Washington Psychiatric Society representative to the APA Assembly, a past president of the Washington Psychiatric Society, and clinical professor of psychiatry and behavioral sciences at George Washington University, Washington. She is interested in the role “difference” – race, culture, and ethnicity – plays in interpersonal relationships and group dynamics.
*This column was updated 9/3/2019.
With the heart of a child and the spirit of a warrior, Carl Bell always spoke his truth. And, he did so in his own inimitable way. Sporting his signature dark brown wide-brim leather cowboy hat or NMA (National Medical Association) baseball cap, aviator sunglasses, and accompanying Superman belt buckle, Carl Compton Bell, MD, – psychiatrist, researcher, mental health advocate, father, grandfather, friend, colleague, pioneer, and servant – was driven by a deep commitment to serve others.
As those who truly knew him can attest, it is not hyperbole to say that Carl Compton Bell was one of the most genuine, brilliant, and humble physicians of our professional community and time.
My collaboration and friendship began with Dr. Bell began during the summer of 2016 as I was preparing for the 2017 Washington Psychiatric Society’s (WPS) Presidential Symposium at Saint Elizabeths Hospital. As president of WPS, I had chosen gun violence as my topic and sought out Dr. Bell because of his work on the South Side of Chicago, where he had devoted himself, becoming an internationally known clinician, researcher, and mental health advocate for those personally affected by violence and trauma. He immediately accepted.
In his presentation, “Gun Violence, Urban Youth and Mental Illness,” he reviewed his research on the neurocognitive behavioral effects of prenatal exposure to alcohol and its relation to the neurodevelopmental dynamics of youth violence, intimate partner violence, and mass shootings. Dr. Bell suggested that the relationship between prenatal exposure to alcohol and the diagnosis of numerous psychiatric conditions had been underestimated in the medical community. He eventually summarized his work in Fetal Alcohol Exposure in the African-American Community, published by Third World Press (2018). This vital resource not only summarizes in plain language the scope of the problem of prenatal alcohol exposure but is a narrative of Carl Bell’s life journey.
After the symposium, he would send articles, while warning, “I can bombard you with stuff.” Sometimes we would not speak for weeks at a time while I digested the resources he had shared. However, whenever I picked up the phone to call and respond to what he had provided, he would answer the phone, “Yessssss?” – as if he were anticipating my call and was ready to address any queries or comments I might have. Even when he were about to board a plane or charting – after making rounds on his patients while listening to the music of James Brown – he would answer the phone, even if only to coordinate a more mutually convenient time to connect.
During the process of digesting the plethora of articles and resources he provided on prenatal fetal alcohol exposure, including the 1996 Institute of Medicine’s report and the American Medical Association’s 2017 resolution supporting the addition of adequate amounts of choline to prenatal vitamins, I found myself immersed in neuroscience topics, such as the role of neuronal acetylcholine receptor subunit alpha-7 in the formation of neurotransmitters, the strengthening of cell membranes, and the promotion of proper brain and spinal cord development. Dr. Bell spoke authoritatively about the neuroscience and the public health implications. One of his mantras was “Where is the data? You’ve got to have data.”
The information that he shared became the foundation of the action paper calling for the American Psychiatric Association (APA) to endorse the AMA’s resolution supporting the addition of adequate amounts (450 mg/d for pregnant women) of phosphatidylcholine to prenatal vitamins. The APA Assembly passed this action paper in May 2018.
He was also responsible for a second action paper, “Psychiatric Management of the Impact of Racism on Social and Clinical Events,” which passed at the same May 2018 assembly. Dr. Bell agreed to coauthor this paper, which was only fitting since the paper was a further elaboration of his efforts with the APA Caucus of Black Psychiatrists to implore the APA to acknowledge the deleterious effects of racism on both the victim and perpetrator.
While researching this topic, I had come across his 1980 article, Racism: A Symptom of the Narcissistic Personality Disorder (J Nat Med Assoc. 1980 Jul;72[7]:661-5), in which Dr. Bell applied psychoanalytic theory to posit that racism is one psychic derivative through which narcissism may manifest itself.
Although he was not formally trained as a psychoanalyst, he had benefited from strong psychoanalytic supervision at the Illinois State Psychiatric Institute, a training program of the University of Illinois at Chicago. He wrote confidently and clearly, applying self-psychology principles. He had the gravitas to write and speak about a range of topics, from neuroscience, psychotherapy, medical management of illness, and mental health advocacy. His 387-page curriculum vitae of 500+ articles, chapters, and books on mental health issues is a catalog of evidence that he had given thought to just about any topic along the spectrum of psychiatry and beyond.
In July 2018, after leaving a performance of “Hamilton” at the Kennedy Center, a lyric from the song “Non-Stop” stayed with me:
Why do you write like you’re running out of time?
(Why do you write like you’re running out of time?)
Write day and night like you’re running out of time?
The pace at which he read, wrote, lectured, researched, collaborated, and served on committees reminded me of the prodigious work of the former Secretary of the Treasury. When I shared this with Dr. Bell, he volunteered that he wrote to clear his mind. I suggested that, like other true writers, it seemed that he had to write. He did not disagree.
But, what was most meaningful about his productivity was his generosity of spirit. Any conversation was an opportunity for him to thoughtfully and respectfully share his knowledge. For example, once, we were discussing a clinical case that included the differential diagnosis of a patient, who happened to be African American, who was having auditory hallucinations. Dr. Bell might have been the first psychiatrist to alert the medical community about the misdiagnosis of schizophrenia among African Americans with bipolar disorder (J Nat Med Assoc. 1980 Feb 72[2]:141-5).
Contrary to my expectation that he was going to remind me of the tendency to misdiagnose, he instead offered, “You know, there are 40 reasons for auditory hallucinations.” Not what I had expected, yet, a response that reflected his continually giving nature and sharing of his abundance of gems. He was always teaching.
I later learned that his workday at Jackson Park Hospital usually ended at 2 p.m. He had treated patients, and supervised medical students and residents there for more than 40 years. The afternoons afforded him time to read, write, listen to music (Ella Fitzgerald), watch movies, and spend time with his adult children, to whom he was quite devoted. Dr. Bell was an avid martial artist and enjoyed sharing this practice with his son, William.
He was a longtime active member of the National Medical Association, recently receiving its prestigious Distinguished Service Award in Hawaii for his “exceptional work in medical service, medical research, and academic medicine.” It would be his last professional talk, though his delivery would belie his numbered days.
He was a former vice president of the Black Psychiatrists of America (BPA) and for 10 years had been the editor of the BPA Newsletter. Conversations were often peppered with anecdotes from time spent with other pioneering ancestors, such as Chester “Chet” Pierce, MD, Jeanne Spurlock, MD, Robert Phillips, MD, PhD, Charles Prudhomme, MD, Frances Cress Welsing, MD, and others. Dr. Bell was at the tail end of a generation of African American psychiatrists who had experienced firsthand the transition from segregation to federally mandated integration of our society.
Dr. Bell and his peers applied their education and training to improve clinical care for all, to decrease health inequities, and to eliminate disparities. It is evident that he loved his people and committed his life to addressing the needs of marginalized communities, those without the benefit of abundant resources, and those disproportionately affected by violence and trauma. As he stated in his last book, Fetal Alcohol Exposure in the African-American Community:
“I should add, my main concern is African American people living within the United States of America where in one community the rate of Fetal Alcohol Exposure is 388/1,000 people. ... However, this problem extends much further. Fetal Alcohol Exposure (FAE) is increasingly being found to (be) problematic in people of color around the world: Native Americans in Canada ... Aboriginal people in Australia ... and various tribes of people on the continent of Africa. ... Lastly, while the problem of Fetal Alcohol Exposure seems to be disproportionately affecting people of color, it also affects people who lack pigment in their skin. For example, FAE is a problem in Russia. From a public health perspective, so often people of color are like the proverbial “canary in a coal mine,” i.e., if there is poisonous gas in the coal mine, the canary will die first, warning the miners that they need to do something about it.”
However, Dr. Bell was a Distinguished Lifetime Fellow of the American Psychiatric Association and a Lifetime Fellow of the American College of Psychiatrists. He was a founding member of the board of directors of the National Commission on Correctional Health, and a member of prominent work groups of the National Institutes of Mental Health and the National Academy of Medicine (formerly the Institute of Medicine). And Dr. Bell’s mentees and students transcend generations, race, religions, professional disciplines, and national boundaries.
Because Dr. Bell was grounded and never forgot his roots, it was in these professional society circles that he ensured that clinicians with more privilege and limited or no exposure to communities of color were educated about the needs of those he treated. Without exposure to Carl Bell, it is likely that many of our psychiatric colleagues would remain unaware of both the brilliant dynamic resources and enormous challenges that are found in the black community and communities of color. By sharing his work with the house of medicine, he obviated the excuse of doing nothing because of ignorance.
I last saw Dr. Bell in San Francisco toward the end of the 2019 annual APA meeting. He had received the APA’s Adolf* Meyer Award for lifetime achievement. Afterward, I joined him for a dim sum lunch in Chinatown with two of his colleagues and Joseph Calhoun, his mentee in the APA’s Black Men in Psychiatry Early Pipeline Program. As we walked back to our respective hotels, we paused at what is now the Chinese Affirmative Action Center. We learned that this site had been the home of one of Dr. Bell’s former martial arts instructors. As Dr. Bell recounted his martial arts training, the reverence for his sensei was evident in his eyes.
When I reflect on how much I learned from and about Carl Bell in such a short period of time, I realize that he was one of those people who was so present and so astute that he allowed you to know him while he was giving.
So, how do we honor someone who gave so much of himself? When I now think of the lyric from “Hamilton” – “Why do you write like you’re running out of time?” – I realize that we get it twisted when we associate running out of time with our elders and their phase of life. It was not Carl Bell who was running out of time. He had been extraordinarily respectful of the space, time, and energy allotted to him in his lifetime. He would say, “People squander their personal resources.” He certainly had not squandered his.
As we reflect and mourn his passing, we will hear about his candor, authenticity, integrity, discipline, reliability, dedication, and serving spirit. This is called character.
Dr. Bell was beyond generous with his life, and it is going to take decades, if not more, for us to digest the compendium of knowledge that he left behind. I ask you: How will you use that knowledge to advance the causes he so diligently devoted his life to solving?
To Carl Compton Bell, I say, Well done. Thank you. And, rest now my dear brother.
Dr. Dunlap, a psychiatrist and psychoanalyst who practices in Washington, is a Washington Psychiatric Society representative to the APA Assembly, a past president of the Washington Psychiatric Society, and clinical professor of psychiatry and behavioral sciences at George Washington University, Washington. She is interested in the role “difference” – race, culture, and ethnicity – plays in interpersonal relationships and group dynamics.
*This column was updated 9/3/2019.
Sleep disorder treatment tied to lower suicide attempt risk in veterans
in a large case-control matched study of patients in the Veterans Health Administration database.
However, treatment for sleep disorders was correlated to a reduced risk for suicide attempts.
Todd M. Bishop, PhD, of the Center of Excellence for Suicide Prevention, Canandaigua (N.Y.) VA Medical Center, and the department of psychiatry, University of Rochester (N.Y.) Medical Center, and his colleagues wrote that suicide is the 10th most frequent cause of death in the United States, and “nowhere is the suicide rate more alarming than among military veterans, who after adjusting for age and gender, have an approximately 1.5 times greater risk for suicide as compared to the civilian population.”
Previous research has explored the link between sleep disturbances and suicide attempts. But less has been done to look at specific sleep problems, and little research has examined the role of sleep medicine interventions and suicide attempt risk.
The investigators conducted a study to establish the association between suicide attempts and specific sleep disorders, and to examine the correlation between sleep medicine treatment and suicide attempts. Their sample consisted of 60,102 veterans who had received care within the VHA between Oct. 1, 2012, and Sept. 20, 2014. Half of the sample had a documented suicide attempt in the medical record (n = 30,051) and half did not (n = 30,051). The overall sample was predominately male (87.1%) with a mean age of 48.6 years. More than half the sample identified as white (67.4%).
Suicide attempts, sleep disturbance, and medical and mental health comorbidities were identified via ICD codes and prescription records. The predominant sleep disorders studied were insomnia, sleep-related breathing disorder (SRBD), and nightmares. The first suicide attempt in the study period was determined to be the index date for the case-control matching.
Overall, sleep disturbances were much more prevalent among cases than controls (insomnia, 46.2% vs. 12.6%), sleep-related breathing disorder (8.6% vs. 4.8%), and nightmares (7.1% vs. 1.6%). A logistic regression analysis was undertaken to examine the relationship between specific sleep disorders and suicide attempts. Insomnia, nightmares, and SRBD were each associated with increased odds of a suicide attempt with the following odds ratios: insomnia (odds ratio, 5.62; 95% confidence interval, 5.39-5.86), nightmares (OR, 2.49; 95% CI, 2.23-2.77), and sleep-related breathing disorder (OR, 1.37; 95% CI, 1.27-1.48).
A second model included known drivers of suicide attempts (PTSD, depression, anxiety disorders, schizophrenia, bipolar disorder, substance use disorder, medical comorbidity, and obesity). But after controlling for these factors, neither nightmares (OR, 0.96; 95% CI, 0.85-1.09) nor sleep-related breathing disorders (OR, 0.87, 95% CI, 0.79-0.94) remained positively associated with suicide attempt, but the association of insomnia with suicide attempt was maintained (OR, 1.51; 95% CI, 1.43-1.59).
The question of the impact of sleep medicine interventions on suicide attempts was studied with a third regression model adding the number of sleep medicine clinic visits in the 180 days prior to the suicide attempt index date as an independent variable. The variables in this model were limited to insomnia, SRBD, and nightmares. The investigators found that “for each sleep medicine clinic visit within the 6 months prior to index date the likelihood of suicide attempt is 11% less (OR, 0.89; 95% CI, 0.82-0.97).”
The limitations of the study include the lack of information on sleep treatment modalities or medications provided during the clinic visits, and the overlapping of sleep disturbance with other mental health conditions, such as alcohol dependence and PTSD. In addition, “some insomnia medications are labeled for risk of suicidal ideation and behavior, so there is some chance that the medications rather than insomnia itself were associated with the increased suicidal behavior,” the investigators wrote.
In addition to an analysis of specific types of sleep disorders associated with suicide attempts, the study showed that treatment of sleep disorders may have an important role in suicide prevention. The investigators concluded: “Identifying populations at risk for suicide prior to a first attempt is an important, but difficult task of suicide prevention. Prevention efforts can be aimed at modifiable risk factors that arise early on a patient’s trajectory toward a suicide attempt.”
The study was supported by the VISN 2 Center of Excellence for Suicide Prevention, Canandaigua VAMC. The authors had no disclosures.
SOURCE: Bishop TM et al. Sleep Med. 2019 Jul 25. doi: 10.1016/j.sleep.2019.07.016.
in a large case-control matched study of patients in the Veterans Health Administration database.
However, treatment for sleep disorders was correlated to a reduced risk for suicide attempts.
Todd M. Bishop, PhD, of the Center of Excellence for Suicide Prevention, Canandaigua (N.Y.) VA Medical Center, and the department of psychiatry, University of Rochester (N.Y.) Medical Center, and his colleagues wrote that suicide is the 10th most frequent cause of death in the United States, and “nowhere is the suicide rate more alarming than among military veterans, who after adjusting for age and gender, have an approximately 1.5 times greater risk for suicide as compared to the civilian population.”
Previous research has explored the link between sleep disturbances and suicide attempts. But less has been done to look at specific sleep problems, and little research has examined the role of sleep medicine interventions and suicide attempt risk.
The investigators conducted a study to establish the association between suicide attempts and specific sleep disorders, and to examine the correlation between sleep medicine treatment and suicide attempts. Their sample consisted of 60,102 veterans who had received care within the VHA between Oct. 1, 2012, and Sept. 20, 2014. Half of the sample had a documented suicide attempt in the medical record (n = 30,051) and half did not (n = 30,051). The overall sample was predominately male (87.1%) with a mean age of 48.6 years. More than half the sample identified as white (67.4%).
Suicide attempts, sleep disturbance, and medical and mental health comorbidities were identified via ICD codes and prescription records. The predominant sleep disorders studied were insomnia, sleep-related breathing disorder (SRBD), and nightmares. The first suicide attempt in the study period was determined to be the index date for the case-control matching.
Overall, sleep disturbances were much more prevalent among cases than controls (insomnia, 46.2% vs. 12.6%), sleep-related breathing disorder (8.6% vs. 4.8%), and nightmares (7.1% vs. 1.6%). A logistic regression analysis was undertaken to examine the relationship between specific sleep disorders and suicide attempts. Insomnia, nightmares, and SRBD were each associated with increased odds of a suicide attempt with the following odds ratios: insomnia (odds ratio, 5.62; 95% confidence interval, 5.39-5.86), nightmares (OR, 2.49; 95% CI, 2.23-2.77), and sleep-related breathing disorder (OR, 1.37; 95% CI, 1.27-1.48).
A second model included known drivers of suicide attempts (PTSD, depression, anxiety disorders, schizophrenia, bipolar disorder, substance use disorder, medical comorbidity, and obesity). But after controlling for these factors, neither nightmares (OR, 0.96; 95% CI, 0.85-1.09) nor sleep-related breathing disorders (OR, 0.87, 95% CI, 0.79-0.94) remained positively associated with suicide attempt, but the association of insomnia with suicide attempt was maintained (OR, 1.51; 95% CI, 1.43-1.59).
The question of the impact of sleep medicine interventions on suicide attempts was studied with a third regression model adding the number of sleep medicine clinic visits in the 180 days prior to the suicide attempt index date as an independent variable. The variables in this model were limited to insomnia, SRBD, and nightmares. The investigators found that “for each sleep medicine clinic visit within the 6 months prior to index date the likelihood of suicide attempt is 11% less (OR, 0.89; 95% CI, 0.82-0.97).”
The limitations of the study include the lack of information on sleep treatment modalities or medications provided during the clinic visits, and the overlapping of sleep disturbance with other mental health conditions, such as alcohol dependence and PTSD. In addition, “some insomnia medications are labeled for risk of suicidal ideation and behavior, so there is some chance that the medications rather than insomnia itself were associated with the increased suicidal behavior,” the investigators wrote.
In addition to an analysis of specific types of sleep disorders associated with suicide attempts, the study showed that treatment of sleep disorders may have an important role in suicide prevention. The investigators concluded: “Identifying populations at risk for suicide prior to a first attempt is an important, but difficult task of suicide prevention. Prevention efforts can be aimed at modifiable risk factors that arise early on a patient’s trajectory toward a suicide attempt.”
The study was supported by the VISN 2 Center of Excellence for Suicide Prevention, Canandaigua VAMC. The authors had no disclosures.
SOURCE: Bishop TM et al. Sleep Med. 2019 Jul 25. doi: 10.1016/j.sleep.2019.07.016.
in a large case-control matched study of patients in the Veterans Health Administration database.
However, treatment for sleep disorders was correlated to a reduced risk for suicide attempts.
Todd M. Bishop, PhD, of the Center of Excellence for Suicide Prevention, Canandaigua (N.Y.) VA Medical Center, and the department of psychiatry, University of Rochester (N.Y.) Medical Center, and his colleagues wrote that suicide is the 10th most frequent cause of death in the United States, and “nowhere is the suicide rate more alarming than among military veterans, who after adjusting for age and gender, have an approximately 1.5 times greater risk for suicide as compared to the civilian population.”
Previous research has explored the link between sleep disturbances and suicide attempts. But less has been done to look at specific sleep problems, and little research has examined the role of sleep medicine interventions and suicide attempt risk.
The investigators conducted a study to establish the association between suicide attempts and specific sleep disorders, and to examine the correlation between sleep medicine treatment and suicide attempts. Their sample consisted of 60,102 veterans who had received care within the VHA between Oct. 1, 2012, and Sept. 20, 2014. Half of the sample had a documented suicide attempt in the medical record (n = 30,051) and half did not (n = 30,051). The overall sample was predominately male (87.1%) with a mean age of 48.6 years. More than half the sample identified as white (67.4%).
Suicide attempts, sleep disturbance, and medical and mental health comorbidities were identified via ICD codes and prescription records. The predominant sleep disorders studied were insomnia, sleep-related breathing disorder (SRBD), and nightmares. The first suicide attempt in the study period was determined to be the index date for the case-control matching.
Overall, sleep disturbances were much more prevalent among cases than controls (insomnia, 46.2% vs. 12.6%), sleep-related breathing disorder (8.6% vs. 4.8%), and nightmares (7.1% vs. 1.6%). A logistic regression analysis was undertaken to examine the relationship between specific sleep disorders and suicide attempts. Insomnia, nightmares, and SRBD were each associated with increased odds of a suicide attempt with the following odds ratios: insomnia (odds ratio, 5.62; 95% confidence interval, 5.39-5.86), nightmares (OR, 2.49; 95% CI, 2.23-2.77), and sleep-related breathing disorder (OR, 1.37; 95% CI, 1.27-1.48).
A second model included known drivers of suicide attempts (PTSD, depression, anxiety disorders, schizophrenia, bipolar disorder, substance use disorder, medical comorbidity, and obesity). But after controlling for these factors, neither nightmares (OR, 0.96; 95% CI, 0.85-1.09) nor sleep-related breathing disorders (OR, 0.87, 95% CI, 0.79-0.94) remained positively associated with suicide attempt, but the association of insomnia with suicide attempt was maintained (OR, 1.51; 95% CI, 1.43-1.59).
The question of the impact of sleep medicine interventions on suicide attempts was studied with a third regression model adding the number of sleep medicine clinic visits in the 180 days prior to the suicide attempt index date as an independent variable. The variables in this model were limited to insomnia, SRBD, and nightmares. The investigators found that “for each sleep medicine clinic visit within the 6 months prior to index date the likelihood of suicide attempt is 11% less (OR, 0.89; 95% CI, 0.82-0.97).”
The limitations of the study include the lack of information on sleep treatment modalities or medications provided during the clinic visits, and the overlapping of sleep disturbance with other mental health conditions, such as alcohol dependence and PTSD. In addition, “some insomnia medications are labeled for risk of suicidal ideation and behavior, so there is some chance that the medications rather than insomnia itself were associated with the increased suicidal behavior,” the investigators wrote.
In addition to an analysis of specific types of sleep disorders associated with suicide attempts, the study showed that treatment of sleep disorders may have an important role in suicide prevention. The investigators concluded: “Identifying populations at risk for suicide prior to a first attempt is an important, but difficult task of suicide prevention. Prevention efforts can be aimed at modifiable risk factors that arise early on a patient’s trajectory toward a suicide attempt.”
The study was supported by the VISN 2 Center of Excellence for Suicide Prevention, Canandaigua VAMC. The authors had no disclosures.
SOURCE: Bishop TM et al. Sleep Med. 2019 Jul 25. doi: 10.1016/j.sleep.2019.07.016.
REPORTING FROM SLEEP MEDICINE
Transient opioid use linked to COPD exacerbation
according to a study of Medicaid claims data.
The data showed that opioid exposure in the prior 7 days was significantly associated with acute respiratory exacerbation. The odds of exacerbation increased as the morphine-equivalent daily dose increased and as the exposure window decreased.
These results “underline the immediacy of the risk of opioid use,” according to Yiran Rong of the department of pharmacy administration at the University of Mississippi in University and colleagues. Ms. Rong and colleagues reported their findings in the American Journal of Epidemiology.
The researchers analyzed Mississippi Medicaid administrative claims data from 2013-2017, which included 1,354 beneficiaries with 1,972 exacerbation events. The beneficiaries had a mean age of 53.11 years, 69.9% were female, and 59.7% were white. The patients had an average of 1.46 exacerbation events, and 62.27% of these events occurred in patients who had an opioid prescription filled in the previous 7 days.
The researchers compared the frequency and dose of opioid exposure in the 7 days before an exacerbation to the opioid exposure in 10 control periods, each 7 days long.
Opioid exposure in the prior 7 days was associated with an 80.8% increase in the odds of exacerbation. The odds ratio, adjusted for exposure to bronchodilators, corticosteroids, benzodiazepines, and beta-blockers, was 1.81 (95% confidence interval, 1.60-2.05).
Opioid exposure was associated with exacerbation in patients with a single exacerbation event (OR, 1.91; 95% CI, 1.61, 2.27), multiple events (OR, 1.71; 95% CI, 1.45-2.01), events recorded in the emergency department (OR, 2.01; 95% CI, 1.71-2.35), and events recorded in the hospital (OR, 1.47; 95% CI, 1.21-1.79).
The odds of exacerbation increased as the morphine-equivalent daily dose increased. Each 25-mg increase in morphine-equivalent daily dose was associated with an 11.2% increase in the odds of exacerbation (OR, 1.11; 95% CI, 1.04-1.20).
“This dose-response relationship is consistent with previously established evidence … and is indicative of the need for caution in prescribing high doses of opioids to COPD patients,” the researchers wrote.
They also found the odds of exacerbation increased as the exposure window decreased. The OR was 1.74 (95% CI, 1.54-1.97) for opioid exposure in an 8-day window before exacerbation and 2.00 (95% CI, 1.73-2.30) for opioid exposure in a 5-day window before exacerbation.
This suggests that “opioid-induced respiratory depression has a very short-term onset,” according to the researchers.
The team noted that this study has limitations, including its retrospective, observational nature, but the results suggest transient opioid use is associated with acute respiratory exacerbation of COPD.
There was no funding for this study, and none of the researchers declared conflicts of interest.
SOURCE: Rong Y et al. Am J Epidemiol. 2019 Jul 30. doi: 10.1093/aje/kwz169.
according to a study of Medicaid claims data.
The data showed that opioid exposure in the prior 7 days was significantly associated with acute respiratory exacerbation. The odds of exacerbation increased as the morphine-equivalent daily dose increased and as the exposure window decreased.
These results “underline the immediacy of the risk of opioid use,” according to Yiran Rong of the department of pharmacy administration at the University of Mississippi in University and colleagues. Ms. Rong and colleagues reported their findings in the American Journal of Epidemiology.
The researchers analyzed Mississippi Medicaid administrative claims data from 2013-2017, which included 1,354 beneficiaries with 1,972 exacerbation events. The beneficiaries had a mean age of 53.11 years, 69.9% were female, and 59.7% were white. The patients had an average of 1.46 exacerbation events, and 62.27% of these events occurred in patients who had an opioid prescription filled in the previous 7 days.
The researchers compared the frequency and dose of opioid exposure in the 7 days before an exacerbation to the opioid exposure in 10 control periods, each 7 days long.
Opioid exposure in the prior 7 days was associated with an 80.8% increase in the odds of exacerbation. The odds ratio, adjusted for exposure to bronchodilators, corticosteroids, benzodiazepines, and beta-blockers, was 1.81 (95% confidence interval, 1.60-2.05).
Opioid exposure was associated with exacerbation in patients with a single exacerbation event (OR, 1.91; 95% CI, 1.61, 2.27), multiple events (OR, 1.71; 95% CI, 1.45-2.01), events recorded in the emergency department (OR, 2.01; 95% CI, 1.71-2.35), and events recorded in the hospital (OR, 1.47; 95% CI, 1.21-1.79).
The odds of exacerbation increased as the morphine-equivalent daily dose increased. Each 25-mg increase in morphine-equivalent daily dose was associated with an 11.2% increase in the odds of exacerbation (OR, 1.11; 95% CI, 1.04-1.20).
“This dose-response relationship is consistent with previously established evidence … and is indicative of the need for caution in prescribing high doses of opioids to COPD patients,” the researchers wrote.
They also found the odds of exacerbation increased as the exposure window decreased. The OR was 1.74 (95% CI, 1.54-1.97) for opioid exposure in an 8-day window before exacerbation and 2.00 (95% CI, 1.73-2.30) for opioid exposure in a 5-day window before exacerbation.
This suggests that “opioid-induced respiratory depression has a very short-term onset,” according to the researchers.
The team noted that this study has limitations, including its retrospective, observational nature, but the results suggest transient opioid use is associated with acute respiratory exacerbation of COPD.
There was no funding for this study, and none of the researchers declared conflicts of interest.
SOURCE: Rong Y et al. Am J Epidemiol. 2019 Jul 30. doi: 10.1093/aje/kwz169.
according to a study of Medicaid claims data.
The data showed that opioid exposure in the prior 7 days was significantly associated with acute respiratory exacerbation. The odds of exacerbation increased as the morphine-equivalent daily dose increased and as the exposure window decreased.
These results “underline the immediacy of the risk of opioid use,” according to Yiran Rong of the department of pharmacy administration at the University of Mississippi in University and colleagues. Ms. Rong and colleagues reported their findings in the American Journal of Epidemiology.
The researchers analyzed Mississippi Medicaid administrative claims data from 2013-2017, which included 1,354 beneficiaries with 1,972 exacerbation events. The beneficiaries had a mean age of 53.11 years, 69.9% were female, and 59.7% were white. The patients had an average of 1.46 exacerbation events, and 62.27% of these events occurred in patients who had an opioid prescription filled in the previous 7 days.
The researchers compared the frequency and dose of opioid exposure in the 7 days before an exacerbation to the opioid exposure in 10 control periods, each 7 days long.
Opioid exposure in the prior 7 days was associated with an 80.8% increase in the odds of exacerbation. The odds ratio, adjusted for exposure to bronchodilators, corticosteroids, benzodiazepines, and beta-blockers, was 1.81 (95% confidence interval, 1.60-2.05).
Opioid exposure was associated with exacerbation in patients with a single exacerbation event (OR, 1.91; 95% CI, 1.61, 2.27), multiple events (OR, 1.71; 95% CI, 1.45-2.01), events recorded in the emergency department (OR, 2.01; 95% CI, 1.71-2.35), and events recorded in the hospital (OR, 1.47; 95% CI, 1.21-1.79).
The odds of exacerbation increased as the morphine-equivalent daily dose increased. Each 25-mg increase in morphine-equivalent daily dose was associated with an 11.2% increase in the odds of exacerbation (OR, 1.11; 95% CI, 1.04-1.20).
“This dose-response relationship is consistent with previously established evidence … and is indicative of the need for caution in prescribing high doses of opioids to COPD patients,” the researchers wrote.
They also found the odds of exacerbation increased as the exposure window decreased. The OR was 1.74 (95% CI, 1.54-1.97) for opioid exposure in an 8-day window before exacerbation and 2.00 (95% CI, 1.73-2.30) for opioid exposure in a 5-day window before exacerbation.
This suggests that “opioid-induced respiratory depression has a very short-term onset,” according to the researchers.
The team noted that this study has limitations, including its retrospective, observational nature, but the results suggest transient opioid use is associated with acute respiratory exacerbation of COPD.
There was no funding for this study, and none of the researchers declared conflicts of interest.
SOURCE: Rong Y et al. Am J Epidemiol. 2019 Jul 30. doi: 10.1093/aje/kwz169.
FROM THE AMERICAN JOURNAL OF EPIDEMIOLOGY
The postgraduate course on liver, pancreas, and biliary tract
The course was framed with the theme, “The Practice of Gastroenterology: The Literature and the Art,” with each speaker highlighting not only the relevant updates in the literature, but also sharing the insights into the art of medical practice. The course incorporated an audience response system to fully utilize the available educational technology and increase participant engagement.
Manal Abdelmalek, MD, provided an update on the hot topic of nonalcoholic fatty liver disease, including new developments in pharmacotherapy. The AGA President-elect, Hashem El-Serag, MD, MPH, AGAF, delivered a state-of-the-art presentation on the burgeoning burden of hepatocellular carcinoma and cutting-edge multidisciplinary management. Vijay Shah, MD, then reminded us of the persistent presence of alcoholic liver disease in the United States and the controversies surrounding liver transplantation in this setting. Steven Flamm, MD, completed the liver session by sharing the secrets of managing the complications of cirrhosis.
The second session, on the pancreas and biliary tract, was headed by Timothy Gardner, MD, who shared the pearls of the management of pancreatitis. Michelle Kim, MD, provided fresh and up-to-date insights on the management of pancreatic and biliary cancer, including updated technological options. Finally, Marcia Canto, MD, discussed the hot topic of pancreatic cancer and whether screening should be instituted. Both of these sessions had designated time set aside for panel discussions with questions from the audience.
This is a summary provided by the moderator of one of the AGA Postgraduate Course sessions held at DDW 2019. Dr. Ahn, MD, MS, MBA, is professor of medicine and director of clinical hepatology at Oregon Health & Science University, Portland. He has no relevant conflicts of interest.
The course was framed with the theme, “The Practice of Gastroenterology: The Literature and the Art,” with each speaker highlighting not only the relevant updates in the literature, but also sharing the insights into the art of medical practice. The course incorporated an audience response system to fully utilize the available educational technology and increase participant engagement.
Manal Abdelmalek, MD, provided an update on the hot topic of nonalcoholic fatty liver disease, including new developments in pharmacotherapy. The AGA President-elect, Hashem El-Serag, MD, MPH, AGAF, delivered a state-of-the-art presentation on the burgeoning burden of hepatocellular carcinoma and cutting-edge multidisciplinary management. Vijay Shah, MD, then reminded us of the persistent presence of alcoholic liver disease in the United States and the controversies surrounding liver transplantation in this setting. Steven Flamm, MD, completed the liver session by sharing the secrets of managing the complications of cirrhosis.
The second session, on the pancreas and biliary tract, was headed by Timothy Gardner, MD, who shared the pearls of the management of pancreatitis. Michelle Kim, MD, provided fresh and up-to-date insights on the management of pancreatic and biliary cancer, including updated technological options. Finally, Marcia Canto, MD, discussed the hot topic of pancreatic cancer and whether screening should be instituted. Both of these sessions had designated time set aside for panel discussions with questions from the audience.
This is a summary provided by the moderator of one of the AGA Postgraduate Course sessions held at DDW 2019. Dr. Ahn, MD, MS, MBA, is professor of medicine and director of clinical hepatology at Oregon Health & Science University, Portland. He has no relevant conflicts of interest.
The course was framed with the theme, “The Practice of Gastroenterology: The Literature and the Art,” with each speaker highlighting not only the relevant updates in the literature, but also sharing the insights into the art of medical practice. The course incorporated an audience response system to fully utilize the available educational technology and increase participant engagement.
Manal Abdelmalek, MD, provided an update on the hot topic of nonalcoholic fatty liver disease, including new developments in pharmacotherapy. The AGA President-elect, Hashem El-Serag, MD, MPH, AGAF, delivered a state-of-the-art presentation on the burgeoning burden of hepatocellular carcinoma and cutting-edge multidisciplinary management. Vijay Shah, MD, then reminded us of the persistent presence of alcoholic liver disease in the United States and the controversies surrounding liver transplantation in this setting. Steven Flamm, MD, completed the liver session by sharing the secrets of managing the complications of cirrhosis.
The second session, on the pancreas and biliary tract, was headed by Timothy Gardner, MD, who shared the pearls of the management of pancreatitis. Michelle Kim, MD, provided fresh and up-to-date insights on the management of pancreatic and biliary cancer, including updated technological options. Finally, Marcia Canto, MD, discussed the hot topic of pancreatic cancer and whether screening should be instituted. Both of these sessions had designated time set aside for panel discussions with questions from the audience.
This is a summary provided by the moderator of one of the AGA Postgraduate Course sessions held at DDW 2019. Dr. Ahn, MD, MS, MBA, is professor of medicine and director of clinical hepatology at Oregon Health & Science University, Portland. He has no relevant conflicts of interest.
In newborns, concentrated urine helps rule out UTI
SEATTLE – according to investigators at the University of Texas Health Science Center, Houston.
The researchers found that urine testing negative for nitrites with a specific gravity above 1.015 in children up to 2 months old had a sensitivity of 53% for ruling out UTIs, but that urine with a specific gravity below that mark had a sensitivity of just 14%. The finding “should be taken into account when interpreting nitrite results ... in this high-risk population,” they concluded.
Bacteria in the bladder convert nitrates to nitrites, so positive results are pretty much pathognomonic for UTIs, with a specificity of nearly 100%, according to the researchers.
Negative results, however, don’t reliably rule out infection, and are even less reliable in infants because they urinate frequently, which means they usually flush out bacteria before they have enough time to make the conversion, which takes several hours, they said.
The lead investigator Raymond Parlar-Chun, MD, an assistant professor of pediatrics at the University of Texas McGovern Medical School in Houston, said he had a hunch that negative results might be more reliable when newborns urinate less frequently and have more concentrated urine.
He and his team reviewed data collected on 413 infants up to 2 months old who were admitted for fever workup and treated for UTIs both in the hospital and after discharge. Nitrite results were stratified by urine concentration. A specific gravity of 1.015 was used as the cutoff between concentrated and dilute urine, which was “midway between the parameters reported” in every urinalysis, Dr. Parlar-Chun said.
Although the sensitivity of concentrated urine was only 53%, “it’s a stark difference from” the 14% in dilute urine, he said.“You should take a look at specific gravity to interpret nitrites. If urine is concentrated, you have [more confidence] that you don’t have a UTI if you’re negative. It’s better than taking [nitrites] at face value.”
The subjects were 31 days old, on average, and 62% were boys; 112 had a specific gravity above 1.015, and 301 below.
There was no external funding, and Dr. Parlar-Chun didn’t have any disclosures.
SEATTLE – according to investigators at the University of Texas Health Science Center, Houston.
The researchers found that urine testing negative for nitrites with a specific gravity above 1.015 in children up to 2 months old had a sensitivity of 53% for ruling out UTIs, but that urine with a specific gravity below that mark had a sensitivity of just 14%. The finding “should be taken into account when interpreting nitrite results ... in this high-risk population,” they concluded.
Bacteria in the bladder convert nitrates to nitrites, so positive results are pretty much pathognomonic for UTIs, with a specificity of nearly 100%, according to the researchers.
Negative results, however, don’t reliably rule out infection, and are even less reliable in infants because they urinate frequently, which means they usually flush out bacteria before they have enough time to make the conversion, which takes several hours, they said.
The lead investigator Raymond Parlar-Chun, MD, an assistant professor of pediatrics at the University of Texas McGovern Medical School in Houston, said he had a hunch that negative results might be more reliable when newborns urinate less frequently and have more concentrated urine.
He and his team reviewed data collected on 413 infants up to 2 months old who were admitted for fever workup and treated for UTIs both in the hospital and after discharge. Nitrite results were stratified by urine concentration. A specific gravity of 1.015 was used as the cutoff between concentrated and dilute urine, which was “midway between the parameters reported” in every urinalysis, Dr. Parlar-Chun said.
Although the sensitivity of concentrated urine was only 53%, “it’s a stark difference from” the 14% in dilute urine, he said.“You should take a look at specific gravity to interpret nitrites. If urine is concentrated, you have [more confidence] that you don’t have a UTI if you’re negative. It’s better than taking [nitrites] at face value.”
The subjects were 31 days old, on average, and 62% were boys; 112 had a specific gravity above 1.015, and 301 below.
There was no external funding, and Dr. Parlar-Chun didn’t have any disclosures.
SEATTLE – according to investigators at the University of Texas Health Science Center, Houston.
The researchers found that urine testing negative for nitrites with a specific gravity above 1.015 in children up to 2 months old had a sensitivity of 53% for ruling out UTIs, but that urine with a specific gravity below that mark had a sensitivity of just 14%. The finding “should be taken into account when interpreting nitrite results ... in this high-risk population,” they concluded.
Bacteria in the bladder convert nitrates to nitrites, so positive results are pretty much pathognomonic for UTIs, with a specificity of nearly 100%, according to the researchers.
Negative results, however, don’t reliably rule out infection, and are even less reliable in infants because they urinate frequently, which means they usually flush out bacteria before they have enough time to make the conversion, which takes several hours, they said.
The lead investigator Raymond Parlar-Chun, MD, an assistant professor of pediatrics at the University of Texas McGovern Medical School in Houston, said he had a hunch that negative results might be more reliable when newborns urinate less frequently and have more concentrated urine.
He and his team reviewed data collected on 413 infants up to 2 months old who were admitted for fever workup and treated for UTIs both in the hospital and after discharge. Nitrite results were stratified by urine concentration. A specific gravity of 1.015 was used as the cutoff between concentrated and dilute urine, which was “midway between the parameters reported” in every urinalysis, Dr. Parlar-Chun said.
Although the sensitivity of concentrated urine was only 53%, “it’s a stark difference from” the 14% in dilute urine, he said.“You should take a look at specific gravity to interpret nitrites. If urine is concentrated, you have [more confidence] that you don’t have a UTI if you’re negative. It’s better than taking [nitrites] at face value.”
The subjects were 31 days old, on average, and 62% were boys; 112 had a specific gravity above 1.015, and 301 below.
There was no external funding, and Dr. Parlar-Chun didn’t have any disclosures.
REPORTING FROM PHM 2019
White and black patients have similar rates of giant cell arteritis
To determine the incidence of biopsy-proven GCA (BP-GCA) in a racially diverse cohort, Anna M. Gruener of Nottingham (England) University Hospitals NHS Trust and coauthors analyzed the medical records of more than 10 years of patients who underwent temporal artery biopsy at Johns Hopkins Wilmer Eye Institute in Baltimore. Of the 586 patients in the study, 167 (28.5%) were black, 382 (65.2%) were white, and 37 (6.3%) were other or unknown. The mean age was 70.5 years.
Of the 573 patients who were aged 50 years and older, 92 (16.1%) had a positive biopsy for BP-GCA; 14 were black (8.4% of all black patients), 75 were white (19.6% of all white patients), and 3 were other or unknown. The population-adjusted, age- and sex-standardized incidence rates per 100,000 were 3.1 (95% confidence interval, 1.0-5.2) for black patients and 3.6 (95% CI, 2.5-4.7) for white patients.
Overall, BP-GCA occurred more frequently in women than in men (incidence rate ratio, 1.9; 95% CI, 1.1-3.4; P = .03) but at similar levels in white and black patients (IRR, 1.2; 95% CI, 0.6-2.4; P = .66).
In an accompanying editorial, Michael K. Yoon, MD, and Joseph F. Rizzo III, MD, of Harvard Medical School, Boston, praised the researchers for conducting their study in a population with a large percentage of black patients, a noted weakness of earlier studies in this area (JAMA Ophthalmol. 2019 Aug 8. doi: 10.1001/jamaophthalmol.2019.2933). That said, the two doctors also recognized the limitations of the work done by Gruener et al., including relying on U.S. Census data to calculate adjusted incidence rates instead of local racial distribution and also the potentially problematic choice to count patients with healed arteritis as having BP-GCA.
Still, Dr. Yoon and Dr. Rizzo commended Gruener et al. for questioning previous findings on GCA rates. “Although the authors’ methods are imperfect,” they wrote, “the studies that had previously established a low incidence of GCA in black patients were also flawed in design.”
The study had no outside funding source, and no conflicts of interest were reported.
SOURCE: Gruener AM et al. JAMA Ophthalmol. 2019 Aug 8. doi: 10.1001/jamaophthalmol.2019.2919.
To determine the incidence of biopsy-proven GCA (BP-GCA) in a racially diverse cohort, Anna M. Gruener of Nottingham (England) University Hospitals NHS Trust and coauthors analyzed the medical records of more than 10 years of patients who underwent temporal artery biopsy at Johns Hopkins Wilmer Eye Institute in Baltimore. Of the 586 patients in the study, 167 (28.5%) were black, 382 (65.2%) were white, and 37 (6.3%) were other or unknown. The mean age was 70.5 years.
Of the 573 patients who were aged 50 years and older, 92 (16.1%) had a positive biopsy for BP-GCA; 14 were black (8.4% of all black patients), 75 were white (19.6% of all white patients), and 3 were other or unknown. The population-adjusted, age- and sex-standardized incidence rates per 100,000 were 3.1 (95% confidence interval, 1.0-5.2) for black patients and 3.6 (95% CI, 2.5-4.7) for white patients.
Overall, BP-GCA occurred more frequently in women than in men (incidence rate ratio, 1.9; 95% CI, 1.1-3.4; P = .03) but at similar levels in white and black patients (IRR, 1.2; 95% CI, 0.6-2.4; P = .66).
In an accompanying editorial, Michael K. Yoon, MD, and Joseph F. Rizzo III, MD, of Harvard Medical School, Boston, praised the researchers for conducting their study in a population with a large percentage of black patients, a noted weakness of earlier studies in this area (JAMA Ophthalmol. 2019 Aug 8. doi: 10.1001/jamaophthalmol.2019.2933). That said, the two doctors also recognized the limitations of the work done by Gruener et al., including relying on U.S. Census data to calculate adjusted incidence rates instead of local racial distribution and also the potentially problematic choice to count patients with healed arteritis as having BP-GCA.
Still, Dr. Yoon and Dr. Rizzo commended Gruener et al. for questioning previous findings on GCA rates. “Although the authors’ methods are imperfect,” they wrote, “the studies that had previously established a low incidence of GCA in black patients were also flawed in design.”
The study had no outside funding source, and no conflicts of interest were reported.
SOURCE: Gruener AM et al. JAMA Ophthalmol. 2019 Aug 8. doi: 10.1001/jamaophthalmol.2019.2919.
To determine the incidence of biopsy-proven GCA (BP-GCA) in a racially diverse cohort, Anna M. Gruener of Nottingham (England) University Hospitals NHS Trust and coauthors analyzed the medical records of more than 10 years of patients who underwent temporal artery biopsy at Johns Hopkins Wilmer Eye Institute in Baltimore. Of the 586 patients in the study, 167 (28.5%) were black, 382 (65.2%) were white, and 37 (6.3%) were other or unknown. The mean age was 70.5 years.
Of the 573 patients who were aged 50 years and older, 92 (16.1%) had a positive biopsy for BP-GCA; 14 were black (8.4% of all black patients), 75 were white (19.6% of all white patients), and 3 were other or unknown. The population-adjusted, age- and sex-standardized incidence rates per 100,000 were 3.1 (95% confidence interval, 1.0-5.2) for black patients and 3.6 (95% CI, 2.5-4.7) for white patients.
Overall, BP-GCA occurred more frequently in women than in men (incidence rate ratio, 1.9; 95% CI, 1.1-3.4; P = .03) but at similar levels in white and black patients (IRR, 1.2; 95% CI, 0.6-2.4; P = .66).
In an accompanying editorial, Michael K. Yoon, MD, and Joseph F. Rizzo III, MD, of Harvard Medical School, Boston, praised the researchers for conducting their study in a population with a large percentage of black patients, a noted weakness of earlier studies in this area (JAMA Ophthalmol. 2019 Aug 8. doi: 10.1001/jamaophthalmol.2019.2933). That said, the two doctors also recognized the limitations of the work done by Gruener et al., including relying on U.S. Census data to calculate adjusted incidence rates instead of local racial distribution and also the potentially problematic choice to count patients with healed arteritis as having BP-GCA.
Still, Dr. Yoon and Dr. Rizzo commended Gruener et al. for questioning previous findings on GCA rates. “Although the authors’ methods are imperfect,” they wrote, “the studies that had previously established a low incidence of GCA in black patients were also flawed in design.”
The study had no outside funding source, and no conflicts of interest were reported.
SOURCE: Gruener AM et al. JAMA Ophthalmol. 2019 Aug 8. doi: 10.1001/jamaophthalmol.2019.2919.
FROM JAMA OPHTHALMOLOGY
PCOS incidence is on the rise, but it remains underdiagnosed and undermanaged
SAN DIEGO – The incidence of polycystic ovary syndrome (PCOS) is on the rise, and a nurse practitioner urged her colleagues to give it full attention because of the danger it poses to patients.
“Underdiagnosed and undermanaged, it’s complex and a more serious condition than ever before because of the complications that can occur,” said R. Mimi Secor, DNP, FNP-BC, FAANP, FAAN, who spoke at the Metabolic & Endocrine Disease Summit by Global Academy for Medical Education.
PCOS is the most common reproductive endocrine disorder in the United States, affecting more than 5 million women, or an estimated 6%-10% of the population. Obesity is a risk factor, although lean women account for 10% of cases for reasons that are not understood, according to Dr. Secor, a senior lecturer at Advanced Practice Education Associates in Onset, Mass. In addition, the condition is linked to many sequelae, including multiple sclerosis, diabetes, cardiovascular disease, infertility, mental health problems, and cancer, she said.
Dr. Secor offered these pearls about PCOS:
- Understand the predictive value of oligomenorrhea (infrequent menstrual periods) as a sign of PCOS. “If you’re working in a low-income clinic, you can do well to make a diagnosis without a lot of expensive tests,” she said.
- Urge women with PCOS to get pregnant early if they want to have children. “Infertility is a big problem [among these women],” she said. “They shouldn’t wait until they’re 35 to have babies. They should have them in their 20s.”
- Use insulin control as a tool. “Insulin stimulates ovarian production of testosterone. If we can manage patients around insulin, that can be very helpful.” Losing just 5% of body weight can make a difference in insulin control, Dr. Secor said. “Go for a small change, and help [the patient] maintain that.”
- Monitor patients carefully for cancer. Women who don’t ovulate regularly on a monthly basis face a higher risk of uterine cancer, compared with women who ovulate monthly, she said, and tumors can develop with few symptoms. “If [there is] one drop of bleeding more than a year after menopause,” you need to get a mandatory workup to make sure the patient doesn’t have uterine cancer. Biopsy remains the “gold standard” as a diagnostic tool, she reminded attendees.
- Watch for mental health conditions, especially anxiety, in patients with PCOS. “They seem to be wired for anxiety, and they need a lot of emotional support,” Dr. Secor said.
- Hormonal contraceptives can be safe and effective as a treatment for PCOS in women who don’t wish to become pregnant, she said. But be aware that combination contraceptive drugs can affect women emotionally.
Global Academy and this news organization are owned by the same parent company. Dr. Secor disclosed speaker relationships with Duchesnay and Osphena.
SAN DIEGO – The incidence of polycystic ovary syndrome (PCOS) is on the rise, and a nurse practitioner urged her colleagues to give it full attention because of the danger it poses to patients.
“Underdiagnosed and undermanaged, it’s complex and a more serious condition than ever before because of the complications that can occur,” said R. Mimi Secor, DNP, FNP-BC, FAANP, FAAN, who spoke at the Metabolic & Endocrine Disease Summit by Global Academy for Medical Education.
PCOS is the most common reproductive endocrine disorder in the United States, affecting more than 5 million women, or an estimated 6%-10% of the population. Obesity is a risk factor, although lean women account for 10% of cases for reasons that are not understood, according to Dr. Secor, a senior lecturer at Advanced Practice Education Associates in Onset, Mass. In addition, the condition is linked to many sequelae, including multiple sclerosis, diabetes, cardiovascular disease, infertility, mental health problems, and cancer, she said.
Dr. Secor offered these pearls about PCOS:
- Understand the predictive value of oligomenorrhea (infrequent menstrual periods) as a sign of PCOS. “If you’re working in a low-income clinic, you can do well to make a diagnosis without a lot of expensive tests,” she said.
- Urge women with PCOS to get pregnant early if they want to have children. “Infertility is a big problem [among these women],” she said. “They shouldn’t wait until they’re 35 to have babies. They should have them in their 20s.”
- Use insulin control as a tool. “Insulin stimulates ovarian production of testosterone. If we can manage patients around insulin, that can be very helpful.” Losing just 5% of body weight can make a difference in insulin control, Dr. Secor said. “Go for a small change, and help [the patient] maintain that.”
- Monitor patients carefully for cancer. Women who don’t ovulate regularly on a monthly basis face a higher risk of uterine cancer, compared with women who ovulate monthly, she said, and tumors can develop with few symptoms. “If [there is] one drop of bleeding more than a year after menopause,” you need to get a mandatory workup to make sure the patient doesn’t have uterine cancer. Biopsy remains the “gold standard” as a diagnostic tool, she reminded attendees.
- Watch for mental health conditions, especially anxiety, in patients with PCOS. “They seem to be wired for anxiety, and they need a lot of emotional support,” Dr. Secor said.
- Hormonal contraceptives can be safe and effective as a treatment for PCOS in women who don’t wish to become pregnant, she said. But be aware that combination contraceptive drugs can affect women emotionally.
Global Academy and this news organization are owned by the same parent company. Dr. Secor disclosed speaker relationships with Duchesnay and Osphena.
SAN DIEGO – The incidence of polycystic ovary syndrome (PCOS) is on the rise, and a nurse practitioner urged her colleagues to give it full attention because of the danger it poses to patients.
“Underdiagnosed and undermanaged, it’s complex and a more serious condition than ever before because of the complications that can occur,” said R. Mimi Secor, DNP, FNP-BC, FAANP, FAAN, who spoke at the Metabolic & Endocrine Disease Summit by Global Academy for Medical Education.
PCOS is the most common reproductive endocrine disorder in the United States, affecting more than 5 million women, or an estimated 6%-10% of the population. Obesity is a risk factor, although lean women account for 10% of cases for reasons that are not understood, according to Dr. Secor, a senior lecturer at Advanced Practice Education Associates in Onset, Mass. In addition, the condition is linked to many sequelae, including multiple sclerosis, diabetes, cardiovascular disease, infertility, mental health problems, and cancer, she said.
Dr. Secor offered these pearls about PCOS:
- Understand the predictive value of oligomenorrhea (infrequent menstrual periods) as a sign of PCOS. “If you’re working in a low-income clinic, you can do well to make a diagnosis without a lot of expensive tests,” she said.
- Urge women with PCOS to get pregnant early if they want to have children. “Infertility is a big problem [among these women],” she said. “They shouldn’t wait until they’re 35 to have babies. They should have them in their 20s.”
- Use insulin control as a tool. “Insulin stimulates ovarian production of testosterone. If we can manage patients around insulin, that can be very helpful.” Losing just 5% of body weight can make a difference in insulin control, Dr. Secor said. “Go for a small change, and help [the patient] maintain that.”
- Monitor patients carefully for cancer. Women who don’t ovulate regularly on a monthly basis face a higher risk of uterine cancer, compared with women who ovulate monthly, she said, and tumors can develop with few symptoms. “If [there is] one drop of bleeding more than a year after menopause,” you need to get a mandatory workup to make sure the patient doesn’t have uterine cancer. Biopsy remains the “gold standard” as a diagnostic tool, she reminded attendees.
- Watch for mental health conditions, especially anxiety, in patients with PCOS. “They seem to be wired for anxiety, and they need a lot of emotional support,” Dr. Secor said.
- Hormonal contraceptives can be safe and effective as a treatment for PCOS in women who don’t wish to become pregnant, she said. But be aware that combination contraceptive drugs can affect women emotionally.
Global Academy and this news organization are owned by the same parent company. Dr. Secor disclosed speaker relationships with Duchesnay and Osphena.
REPORTING FROM MEDS 2019
Perils of ‘type’-casting: When adult-onset diabetes isn’t what you think it is
SAN DIEGO – We all know about type 1 and type 2 diabetes. But when an adult patient comes in with symptoms suggestive of diabetes, it is never a good idea to assume it’s either one or the other. In fact, said physician assistant Ji Hyun “CJ” Chun, PA-C, MPAS, BC-ADM, there are plenty of other possibilities from cancer, to monogenetic diabetes, to a condition informally known as type 1.5.
“In most cases, it will be type 1 or type 2, but don’t default everything,” Mr. Chun said at the Metabolic & Endocrine Disease Summit by Global Academy for Medical Education.
He offered the following advice on the diagnosis of adult-onset diabetes:
- Don’t forget the 5% ... and the other 5%. In adults, an estimated 90% of cases of diabetes are type 2, but 5% are type 1 and another 5% are secondary to other conditions, said Mr. Chun, who is based at OptumCare Medical Group, Laguna Niguel, Calif., and has served as president of the American Society of Endocrine PAs. In the past, age seemed to be an important tool for diagnosis, because younger patients typically had type 1 diabetes and older patients typically had type 2, he said. But age alone is no longer useful for diagnosis. Cases of type 2 diabetes are much more common in children these days because of the prevalence of obesity in that population, and an estimated 60% of cases of type 1 disease are diagnosed after the age of 20. In fact, patients may develop type 1 into their 30s, 40s, or 50s, he said, depending on the severity of their autoimmunity.
- Keep ‘type 1.5’ in mind. Latent autoimmune diabetes in adults (LADA), also known as type 1.5, is a slowly developing subtype of type 1 diabetes, Mr. Chun said. There is reason to suspect LADA in lean patients, those younger than 50, and those with personal or family histories of autoimmunity, Mr. Chun said.
- Consider monogenetic diabetes. Many conditions can cause secondary diabetes, among them, monogenetic diabetes, which is caused by a single genetic mutation, whereas type 1 and type 2 diabetes are caused by multiple mutations. Monogenetic diabetes causes an estimated 1%-2% of diabetes cases, said Mr. Chun. Research findings have suggested that it is most likely to be misdiagnosed in younger adults, and that patients may go many years without receiving a correct diagnosis. Maturity-onset diabetes of the young (MODY) is a kind of monogenetic diabetes and typically occurs before the age of 25. There are many subtypes, of which one – MODY 2 – requires no treatment at all. In those patients, said Mr. Chun, “you do nothing. You leave them alone.” It is important to keep in mind that the genetic testing for MODY is expensive, Mr Chun cautioned. Some labs charge between $5,000 and $7,000 for panels, so “look for labs that perform cheaper tests,” he advised, adding that he has found a lab that charges just $250.
- Watch out for cancer. There is a long list of other possible causes of secondary diabetes, including Cushing’s syndrome, hyperthyroidism, hemochromatosis (iron overload), and pancreatic cancer. Mr. Chun said he has lost three patients to pancreatic cancer, while two other patients did well. “Keep in mind that these cases aren’t that common, but they’re there.” He suggested that pancreatic cancer should be considered in patients with rapid onset or worsening of diabetes without known cause, abnormal weight loss, abnormal liver/biliary studies, and jaundice.
Global Academy and this news organization are owned by the same parent company. Mr. Chun disclosed that he is on the AstraZeneca speakers bureau and the Sanofi advisory board.
SAN DIEGO – We all know about type 1 and type 2 diabetes. But when an adult patient comes in with symptoms suggestive of diabetes, it is never a good idea to assume it’s either one or the other. In fact, said physician assistant Ji Hyun “CJ” Chun, PA-C, MPAS, BC-ADM, there are plenty of other possibilities from cancer, to monogenetic diabetes, to a condition informally known as type 1.5.
“In most cases, it will be type 1 or type 2, but don’t default everything,” Mr. Chun said at the Metabolic & Endocrine Disease Summit by Global Academy for Medical Education.
He offered the following advice on the diagnosis of adult-onset diabetes:
- Don’t forget the 5% ... and the other 5%. In adults, an estimated 90% of cases of diabetes are type 2, but 5% are type 1 and another 5% are secondary to other conditions, said Mr. Chun, who is based at OptumCare Medical Group, Laguna Niguel, Calif., and has served as president of the American Society of Endocrine PAs. In the past, age seemed to be an important tool for diagnosis, because younger patients typically had type 1 diabetes and older patients typically had type 2, he said. But age alone is no longer useful for diagnosis. Cases of type 2 diabetes are much more common in children these days because of the prevalence of obesity in that population, and an estimated 60% of cases of type 1 disease are diagnosed after the age of 20. In fact, patients may develop type 1 into their 30s, 40s, or 50s, he said, depending on the severity of their autoimmunity.
- Keep ‘type 1.5’ in mind. Latent autoimmune diabetes in adults (LADA), also known as type 1.5, is a slowly developing subtype of type 1 diabetes, Mr. Chun said. There is reason to suspect LADA in lean patients, those younger than 50, and those with personal or family histories of autoimmunity, Mr. Chun said.
- Consider monogenetic diabetes. Many conditions can cause secondary diabetes, among them, monogenetic diabetes, which is caused by a single genetic mutation, whereas type 1 and type 2 diabetes are caused by multiple mutations. Monogenetic diabetes causes an estimated 1%-2% of diabetes cases, said Mr. Chun. Research findings have suggested that it is most likely to be misdiagnosed in younger adults, and that patients may go many years without receiving a correct diagnosis. Maturity-onset diabetes of the young (MODY) is a kind of monogenetic diabetes and typically occurs before the age of 25. There are many subtypes, of which one – MODY 2 – requires no treatment at all. In those patients, said Mr. Chun, “you do nothing. You leave them alone.” It is important to keep in mind that the genetic testing for MODY is expensive, Mr Chun cautioned. Some labs charge between $5,000 and $7,000 for panels, so “look for labs that perform cheaper tests,” he advised, adding that he has found a lab that charges just $250.
- Watch out for cancer. There is a long list of other possible causes of secondary diabetes, including Cushing’s syndrome, hyperthyroidism, hemochromatosis (iron overload), and pancreatic cancer. Mr. Chun said he has lost three patients to pancreatic cancer, while two other patients did well. “Keep in mind that these cases aren’t that common, but they’re there.” He suggested that pancreatic cancer should be considered in patients with rapid onset or worsening of diabetes without known cause, abnormal weight loss, abnormal liver/biliary studies, and jaundice.
Global Academy and this news organization are owned by the same parent company. Mr. Chun disclosed that he is on the AstraZeneca speakers bureau and the Sanofi advisory board.
SAN DIEGO – We all know about type 1 and type 2 diabetes. But when an adult patient comes in with symptoms suggestive of diabetes, it is never a good idea to assume it’s either one or the other. In fact, said physician assistant Ji Hyun “CJ” Chun, PA-C, MPAS, BC-ADM, there are plenty of other possibilities from cancer, to monogenetic diabetes, to a condition informally known as type 1.5.
“In most cases, it will be type 1 or type 2, but don’t default everything,” Mr. Chun said at the Metabolic & Endocrine Disease Summit by Global Academy for Medical Education.
He offered the following advice on the diagnosis of adult-onset diabetes:
- Don’t forget the 5% ... and the other 5%. In adults, an estimated 90% of cases of diabetes are type 2, but 5% are type 1 and another 5% are secondary to other conditions, said Mr. Chun, who is based at OptumCare Medical Group, Laguna Niguel, Calif., and has served as president of the American Society of Endocrine PAs. In the past, age seemed to be an important tool for diagnosis, because younger patients typically had type 1 diabetes and older patients typically had type 2, he said. But age alone is no longer useful for diagnosis. Cases of type 2 diabetes are much more common in children these days because of the prevalence of obesity in that population, and an estimated 60% of cases of type 1 disease are diagnosed after the age of 20. In fact, patients may develop type 1 into their 30s, 40s, or 50s, he said, depending on the severity of their autoimmunity.
- Keep ‘type 1.5’ in mind. Latent autoimmune diabetes in adults (LADA), also known as type 1.5, is a slowly developing subtype of type 1 diabetes, Mr. Chun said. There is reason to suspect LADA in lean patients, those younger than 50, and those with personal or family histories of autoimmunity, Mr. Chun said.
- Consider monogenetic diabetes. Many conditions can cause secondary diabetes, among them, monogenetic diabetes, which is caused by a single genetic mutation, whereas type 1 and type 2 diabetes are caused by multiple mutations. Monogenetic diabetes causes an estimated 1%-2% of diabetes cases, said Mr. Chun. Research findings have suggested that it is most likely to be misdiagnosed in younger adults, and that patients may go many years without receiving a correct diagnosis. Maturity-onset diabetes of the young (MODY) is a kind of monogenetic diabetes and typically occurs before the age of 25. There are many subtypes, of which one – MODY 2 – requires no treatment at all. In those patients, said Mr. Chun, “you do nothing. You leave them alone.” It is important to keep in mind that the genetic testing for MODY is expensive, Mr Chun cautioned. Some labs charge between $5,000 and $7,000 for panels, so “look for labs that perform cheaper tests,” he advised, adding that he has found a lab that charges just $250.
- Watch out for cancer. There is a long list of other possible causes of secondary diabetes, including Cushing’s syndrome, hyperthyroidism, hemochromatosis (iron overload), and pancreatic cancer. Mr. Chun said he has lost three patients to pancreatic cancer, while two other patients did well. “Keep in mind that these cases aren’t that common, but they’re there.” He suggested that pancreatic cancer should be considered in patients with rapid onset or worsening of diabetes without known cause, abnormal weight loss, abnormal liver/biliary studies, and jaundice.
Global Academy and this news organization are owned by the same parent company. Mr. Chun disclosed that he is on the AstraZeneca speakers bureau and the Sanofi advisory board.
REPORTING FROM MEDS 2019
Go easy on the testosterone when treating hypogonadism
SAN DIEGO – A physician assistant urged colleagues to cast a skeptical eye on male patients who try to jump on board the testosterone therapy train.
“I see many patients getting onto testosterone without having had an adequate evaluation. And I see many patients who might not need testosterone replacement,” Ji Hyun “CJ” Chun, PA-C, MPAS, BC-ADM, said at the Metabolic & Endocrine Disease Summit by Global Academy for Medical Education.
Mr. Chun, who is based at OptumCare Medical Group, Laguna Niguel, Calif., and has served as president of the American Society of Endocrine PAs, offered this advice on evaluating male patients for testosterone therapy:
- Pinpoint the type of hypogonadism. After hypogonadism has been confirmed with lab tests, additional testing should be done to distinguish primary from secondary hypogonadism. Primary hypogonadism refers to the failure of the testes to properly produce testosterone and sperm and is indicated by elevated levels of LH and FSH. Secondary hypogonadism is caused by failures of the hypothalamus, the pituitary, or both, to stimulate the testes to produce testosterone and sperm. It is indicated by low or low-normal levels of LH and FSH.
- Determine the cause of hypogonadism. Cases of hypogonadism are either organic or functional. Diagnostic guidelines provided by the Endocrine Society are helpful in determining the proper category, Mr. Chun said (J Clin Endocrinol Metab. 2018;103[5]:1715-44). Functional hypogonadism is caused by some medications; opioids; abuse of steroids, alcohol, or marijuana; and obesity, which also greatly increases the risk of secondary hypogonadism. These factors – and functional hypogonadism itself – can conceivably be stopped and/or reversed. This form of hypogonadism tends to be mild, compared with organic or “classic” hypogonadism, which is permanent and caused by factors such as advanced age, some types of chemotherapy, and testicle removal. “Organic male hypogonadism mimics female menopause,” Mr. Chun said, in areas such as rate of hormonal decline, which is typically rapid, and hormone deficiency, which is profound. When it comes to treatment, “the benefits far outweigh the risks in organic hypogonadism. But if [a patient has] late-onset [functional] hypogonadism, it gets more complicated.”
- Late-onset hypogonadism treatment. What should be done for patients who have late-onset, organic hypogonadism? According to Mr. Chun, the data regarding testosterone therapy in this population are mixed. The Food and Drug Administration has approved testosterone therapy only for men with organic hypogonadism, he said, noting that “none of the FDA-approved testosterone products are approved for use in men with low testosterone levels who lack an associated medical condition.” However, the Endocrine Society guidelines are less restrictive. In its 2018 guidelines, the society frowned on testosterone therapy for men younger than 65 years with age-related hypogonadism. As for older men, it said that for those “who have symptoms or conditions suggestive of testosterone deficiency (such as low libido or unexplained anemia) and consistently and unequivocally low morning testosterone concentrations, we suggest that clinicians offer testosterone therapy on an individualized basis after explicit discussion of the potential risks and benefits.”
- Don’t push for high testosterone levels. When treating patients, “you want to restore the testosterone to an adequate level,” Mr. Chun said. “What’s an adequate level? We don’t know.” He urged colleagues to not overdo it and to consider aiming for a testosterone level ranging between 350 ng/dL and 700 ng/dL. “I get [the levels] to the lowest level at which the patient is symptomatically fine.”
Global Academy and this news organization are owned by the same parent company. Mr. Chun disclosed that he is on the AstraZeneca speakers bureau and the Sanofi advisory board.
SAN DIEGO – A physician assistant urged colleagues to cast a skeptical eye on male patients who try to jump on board the testosterone therapy train.
“I see many patients getting onto testosterone without having had an adequate evaluation. And I see many patients who might not need testosterone replacement,” Ji Hyun “CJ” Chun, PA-C, MPAS, BC-ADM, said at the Metabolic & Endocrine Disease Summit by Global Academy for Medical Education.
Mr. Chun, who is based at OptumCare Medical Group, Laguna Niguel, Calif., and has served as president of the American Society of Endocrine PAs, offered this advice on evaluating male patients for testosterone therapy:
- Pinpoint the type of hypogonadism. After hypogonadism has been confirmed with lab tests, additional testing should be done to distinguish primary from secondary hypogonadism. Primary hypogonadism refers to the failure of the testes to properly produce testosterone and sperm and is indicated by elevated levels of LH and FSH. Secondary hypogonadism is caused by failures of the hypothalamus, the pituitary, or both, to stimulate the testes to produce testosterone and sperm. It is indicated by low or low-normal levels of LH and FSH.
- Determine the cause of hypogonadism. Cases of hypogonadism are either organic or functional. Diagnostic guidelines provided by the Endocrine Society are helpful in determining the proper category, Mr. Chun said (J Clin Endocrinol Metab. 2018;103[5]:1715-44). Functional hypogonadism is caused by some medications; opioids; abuse of steroids, alcohol, or marijuana; and obesity, which also greatly increases the risk of secondary hypogonadism. These factors – and functional hypogonadism itself – can conceivably be stopped and/or reversed. This form of hypogonadism tends to be mild, compared with organic or “classic” hypogonadism, which is permanent and caused by factors such as advanced age, some types of chemotherapy, and testicle removal. “Organic male hypogonadism mimics female menopause,” Mr. Chun said, in areas such as rate of hormonal decline, which is typically rapid, and hormone deficiency, which is profound. When it comes to treatment, “the benefits far outweigh the risks in organic hypogonadism. But if [a patient has] late-onset [functional] hypogonadism, it gets more complicated.”
- Late-onset hypogonadism treatment. What should be done for patients who have late-onset, organic hypogonadism? According to Mr. Chun, the data regarding testosterone therapy in this population are mixed. The Food and Drug Administration has approved testosterone therapy only for men with organic hypogonadism, he said, noting that “none of the FDA-approved testosterone products are approved for use in men with low testosterone levels who lack an associated medical condition.” However, the Endocrine Society guidelines are less restrictive. In its 2018 guidelines, the society frowned on testosterone therapy for men younger than 65 years with age-related hypogonadism. As for older men, it said that for those “who have symptoms or conditions suggestive of testosterone deficiency (such as low libido or unexplained anemia) and consistently and unequivocally low morning testosterone concentrations, we suggest that clinicians offer testosterone therapy on an individualized basis after explicit discussion of the potential risks and benefits.”
- Don’t push for high testosterone levels. When treating patients, “you want to restore the testosterone to an adequate level,” Mr. Chun said. “What’s an adequate level? We don’t know.” He urged colleagues to not overdo it and to consider aiming for a testosterone level ranging between 350 ng/dL and 700 ng/dL. “I get [the levels] to the lowest level at which the patient is symptomatically fine.”
Global Academy and this news organization are owned by the same parent company. Mr. Chun disclosed that he is on the AstraZeneca speakers bureau and the Sanofi advisory board.
SAN DIEGO – A physician assistant urged colleagues to cast a skeptical eye on male patients who try to jump on board the testosterone therapy train.
“I see many patients getting onto testosterone without having had an adequate evaluation. And I see many patients who might not need testosterone replacement,” Ji Hyun “CJ” Chun, PA-C, MPAS, BC-ADM, said at the Metabolic & Endocrine Disease Summit by Global Academy for Medical Education.
Mr. Chun, who is based at OptumCare Medical Group, Laguna Niguel, Calif., and has served as president of the American Society of Endocrine PAs, offered this advice on evaluating male patients for testosterone therapy:
- Pinpoint the type of hypogonadism. After hypogonadism has been confirmed with lab tests, additional testing should be done to distinguish primary from secondary hypogonadism. Primary hypogonadism refers to the failure of the testes to properly produce testosterone and sperm and is indicated by elevated levels of LH and FSH. Secondary hypogonadism is caused by failures of the hypothalamus, the pituitary, or both, to stimulate the testes to produce testosterone and sperm. It is indicated by low or low-normal levels of LH and FSH.
- Determine the cause of hypogonadism. Cases of hypogonadism are either organic or functional. Diagnostic guidelines provided by the Endocrine Society are helpful in determining the proper category, Mr. Chun said (J Clin Endocrinol Metab. 2018;103[5]:1715-44). Functional hypogonadism is caused by some medications; opioids; abuse of steroids, alcohol, or marijuana; and obesity, which also greatly increases the risk of secondary hypogonadism. These factors – and functional hypogonadism itself – can conceivably be stopped and/or reversed. This form of hypogonadism tends to be mild, compared with organic or “classic” hypogonadism, which is permanent and caused by factors such as advanced age, some types of chemotherapy, and testicle removal. “Organic male hypogonadism mimics female menopause,” Mr. Chun said, in areas such as rate of hormonal decline, which is typically rapid, and hormone deficiency, which is profound. When it comes to treatment, “the benefits far outweigh the risks in organic hypogonadism. But if [a patient has] late-onset [functional] hypogonadism, it gets more complicated.”
- Late-onset hypogonadism treatment. What should be done for patients who have late-onset, organic hypogonadism? According to Mr. Chun, the data regarding testosterone therapy in this population are mixed. The Food and Drug Administration has approved testosterone therapy only for men with organic hypogonadism, he said, noting that “none of the FDA-approved testosterone products are approved for use in men with low testosterone levels who lack an associated medical condition.” However, the Endocrine Society guidelines are less restrictive. In its 2018 guidelines, the society frowned on testosterone therapy for men younger than 65 years with age-related hypogonadism. As for older men, it said that for those “who have symptoms or conditions suggestive of testosterone deficiency (such as low libido or unexplained anemia) and consistently and unequivocally low morning testosterone concentrations, we suggest that clinicians offer testosterone therapy on an individualized basis after explicit discussion of the potential risks and benefits.”
- Don’t push for high testosterone levels. When treating patients, “you want to restore the testosterone to an adequate level,” Mr. Chun said. “What’s an adequate level? We don’t know.” He urged colleagues to not overdo it and to consider aiming for a testosterone level ranging between 350 ng/dL and 700 ng/dL. “I get [the levels] to the lowest level at which the patient is symptomatically fine.”
Global Academy and this news organization are owned by the same parent company. Mr. Chun disclosed that he is on the AstraZeneca speakers bureau and the Sanofi advisory board.
REPORTING FROM MEDS 2019