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Study finds link between intrahepatic cholestasis of pregnancy and risk of NAFLD
Patients with intrahepatic cholestasis of pregnancy (ICP) were nearly six times more likely to have a diagnosis of nonalcoholic fatty liver disease (NAFLD) than were controls, results from a retrospective, single-center study demonstrated.
“If this connection is confirmed with future studies, intrahepatic cholestasis of pregnancy may prove a novel model through which to investigate bile acid metabolism in patients with fatty liver disease,” one of the study authors, Tatyana Kushner, MD, MSCE, said during a media briefing in advance of the annual Digestive Disease Week. “This could have implications for future management of fatty liver disease. Additionally, these findings suggest that ICP patients should be seen by a liver specialist because they may go on to develop chronic liver disease or may already have already existing underlying liver disease.”
ICP is characterized by a build-up of bile acids during pregnancy and is associated with an increased risk of negative fetal outcomes and fetal death if left untreated, said Dr. Kushner, of the division of liver diseases at the Icahn School of Medicine at Mount Sinai, New York. The most notable symptom during pregnancy is severe pruritus. In what is believed to be the first study of its kind, Dr. Kushner and colleagues set out to evaluate the association between ICP and NAFLD and associated metabolic risk factors, including obesity, dyslipidemia, hypertension, and diabetes. Between January and December of 2017, they drew from the electronic medical records of a New York City health system to identify 149 pregnancies complicated by ICP and compared them to a control group of 200 pregnancies without an ICP diagnosis. The researchers used Pearson’s chi-square or Fisher’s exact test and Wilcoxon rank-sum tests to evaluate association of ICP with categorical variables and continuous variables, respectively, and unadjusted odds ratios to compare the ICP and control groups for clinically significant outcomes.
The median age of the study population was 30 years, their mean body mass index was 27.5 kg/m2, and there was a higher proportion of Hispanic women in the ICP group, compared with the control group (75% vs. 62%, respectively). Dr. Kushner and colleagues found that Hispanic women were nearly twice as likely to be diagnosed with ICP than non-Hispanic women (OR, 1.90; 95% confidence interval, 1.87-3.03). However, patients in both the ICP and control groups were similar for median age (OR, 1.02; 95% CI, 0.99-1.06), nulliparity (OR, 0.79; 95% CI, 0.48-1.30), and prevalence of hepatitis C (OR, 1.35; 95% CI, 0.08-21.67). The two groups were also similar for certain metabolic risk factors, including prevalence of obesity (OR, 1.01; 95% CI, 0.62-1.61), hypertension (OR, 0.69; 95% CI, 0.31-1.52), hemoglobin A1c greater than 5.5% (OR, 0.80; 95% CI, 0.34-1.9), and total cholesterol above 200 mg/dL (OR, 4.15; 95% CI, 0.83-20.84). Median bile acid levels were 30.6 micromoles (interquartile range, 11.6, 32.7) in the ICP group.
Compared with patients in the control group, those in the ICP group had higher median levels of alanine aminotransferase (ALT) (32 vs. 16 U/L; P less than .0001), alkaline phosphatase (181 vs. 128 U/L; P less than .0001), and total bilirubin (0.5 vs. 0.35 mg/dL; P less than .0001). ICP patients were also more likely than their counterparts to have ALT levels above 50 U/L (two times the upper limit of normal; OR, 3.22; 95% CI, 1.48-7.03), a history of biliary disease (OR, 3.29; 95% CI, 1.39-7.80), and to have evidence of steatosis on liver imaging (OR, 4.69; 95% CI, 1.68-13.12). When the researchers evaluated a diagnosis of NAFLD based on ICD-10 codes or evidence of steatosis on liver imaging, ICP patients were significantly more likely to have a diagnosis of NAFLD than controls (OR, 5.7; 95% CI, 2.08-15.65).
“We recommend additional research to look at differences in NAFLD progression in women who had NAFLD and were later diagnosed with ICP, compared to women with NAFLD who did not go on to develop ICP, because that may be a reflection of the role that bile acid metabolism plays in these particular patients,” Dr. Kushner said.
Digestive Disease Week is jointly sponsored by the American Association for the Study of Liver Diseases (AASLD), the American Gastroenterological Association (AGA) Institute, the American Society for Gastrointestinal Endoscopy (ASGE), and the Society for Surgery of the Alimentary Tract (SSAT).
The study’s primary author was Erica Monrose, MD. The researchers reported having no financial disclosures.
SOURCE: Monrose E et al. DDW 2019, Abstract Sa1562.
Patients with intrahepatic cholestasis of pregnancy (ICP) were nearly six times more likely to have a diagnosis of nonalcoholic fatty liver disease (NAFLD) than were controls, results from a retrospective, single-center study demonstrated.
“If this connection is confirmed with future studies, intrahepatic cholestasis of pregnancy may prove a novel model through which to investigate bile acid metabolism in patients with fatty liver disease,” one of the study authors, Tatyana Kushner, MD, MSCE, said during a media briefing in advance of the annual Digestive Disease Week. “This could have implications for future management of fatty liver disease. Additionally, these findings suggest that ICP patients should be seen by a liver specialist because they may go on to develop chronic liver disease or may already have already existing underlying liver disease.”
ICP is characterized by a build-up of bile acids during pregnancy and is associated with an increased risk of negative fetal outcomes and fetal death if left untreated, said Dr. Kushner, of the division of liver diseases at the Icahn School of Medicine at Mount Sinai, New York. The most notable symptom during pregnancy is severe pruritus. In what is believed to be the first study of its kind, Dr. Kushner and colleagues set out to evaluate the association between ICP and NAFLD and associated metabolic risk factors, including obesity, dyslipidemia, hypertension, and diabetes. Between January and December of 2017, they drew from the electronic medical records of a New York City health system to identify 149 pregnancies complicated by ICP and compared them to a control group of 200 pregnancies without an ICP diagnosis. The researchers used Pearson’s chi-square or Fisher’s exact test and Wilcoxon rank-sum tests to evaluate association of ICP with categorical variables and continuous variables, respectively, and unadjusted odds ratios to compare the ICP and control groups for clinically significant outcomes.
The median age of the study population was 30 years, their mean body mass index was 27.5 kg/m2, and there was a higher proportion of Hispanic women in the ICP group, compared with the control group (75% vs. 62%, respectively). Dr. Kushner and colleagues found that Hispanic women were nearly twice as likely to be diagnosed with ICP than non-Hispanic women (OR, 1.90; 95% confidence interval, 1.87-3.03). However, patients in both the ICP and control groups were similar for median age (OR, 1.02; 95% CI, 0.99-1.06), nulliparity (OR, 0.79; 95% CI, 0.48-1.30), and prevalence of hepatitis C (OR, 1.35; 95% CI, 0.08-21.67). The two groups were also similar for certain metabolic risk factors, including prevalence of obesity (OR, 1.01; 95% CI, 0.62-1.61), hypertension (OR, 0.69; 95% CI, 0.31-1.52), hemoglobin A1c greater than 5.5% (OR, 0.80; 95% CI, 0.34-1.9), and total cholesterol above 200 mg/dL (OR, 4.15; 95% CI, 0.83-20.84). Median bile acid levels were 30.6 micromoles (interquartile range, 11.6, 32.7) in the ICP group.
Compared with patients in the control group, those in the ICP group had higher median levels of alanine aminotransferase (ALT) (32 vs. 16 U/L; P less than .0001), alkaline phosphatase (181 vs. 128 U/L; P less than .0001), and total bilirubin (0.5 vs. 0.35 mg/dL; P less than .0001). ICP patients were also more likely than their counterparts to have ALT levels above 50 U/L (two times the upper limit of normal; OR, 3.22; 95% CI, 1.48-7.03), a history of biliary disease (OR, 3.29; 95% CI, 1.39-7.80), and to have evidence of steatosis on liver imaging (OR, 4.69; 95% CI, 1.68-13.12). When the researchers evaluated a diagnosis of NAFLD based on ICD-10 codes or evidence of steatosis on liver imaging, ICP patients were significantly more likely to have a diagnosis of NAFLD than controls (OR, 5.7; 95% CI, 2.08-15.65).
“We recommend additional research to look at differences in NAFLD progression in women who had NAFLD and were later diagnosed with ICP, compared to women with NAFLD who did not go on to develop ICP, because that may be a reflection of the role that bile acid metabolism plays in these particular patients,” Dr. Kushner said.
Digestive Disease Week is jointly sponsored by the American Association for the Study of Liver Diseases (AASLD), the American Gastroenterological Association (AGA) Institute, the American Society for Gastrointestinal Endoscopy (ASGE), and the Society for Surgery of the Alimentary Tract (SSAT).
The study’s primary author was Erica Monrose, MD. The researchers reported having no financial disclosures.
SOURCE: Monrose E et al. DDW 2019, Abstract Sa1562.
Patients with intrahepatic cholestasis of pregnancy (ICP) were nearly six times more likely to have a diagnosis of nonalcoholic fatty liver disease (NAFLD) than were controls, results from a retrospective, single-center study demonstrated.
“If this connection is confirmed with future studies, intrahepatic cholestasis of pregnancy may prove a novel model through which to investigate bile acid metabolism in patients with fatty liver disease,” one of the study authors, Tatyana Kushner, MD, MSCE, said during a media briefing in advance of the annual Digestive Disease Week. “This could have implications for future management of fatty liver disease. Additionally, these findings suggest that ICP patients should be seen by a liver specialist because they may go on to develop chronic liver disease or may already have already existing underlying liver disease.”
ICP is characterized by a build-up of bile acids during pregnancy and is associated with an increased risk of negative fetal outcomes and fetal death if left untreated, said Dr. Kushner, of the division of liver diseases at the Icahn School of Medicine at Mount Sinai, New York. The most notable symptom during pregnancy is severe pruritus. In what is believed to be the first study of its kind, Dr. Kushner and colleagues set out to evaluate the association between ICP and NAFLD and associated metabolic risk factors, including obesity, dyslipidemia, hypertension, and diabetes. Between January and December of 2017, they drew from the electronic medical records of a New York City health system to identify 149 pregnancies complicated by ICP and compared them to a control group of 200 pregnancies without an ICP diagnosis. The researchers used Pearson’s chi-square or Fisher’s exact test and Wilcoxon rank-sum tests to evaluate association of ICP with categorical variables and continuous variables, respectively, and unadjusted odds ratios to compare the ICP and control groups for clinically significant outcomes.
The median age of the study population was 30 years, their mean body mass index was 27.5 kg/m2, and there was a higher proportion of Hispanic women in the ICP group, compared with the control group (75% vs. 62%, respectively). Dr. Kushner and colleagues found that Hispanic women were nearly twice as likely to be diagnosed with ICP than non-Hispanic women (OR, 1.90; 95% confidence interval, 1.87-3.03). However, patients in both the ICP and control groups were similar for median age (OR, 1.02; 95% CI, 0.99-1.06), nulliparity (OR, 0.79; 95% CI, 0.48-1.30), and prevalence of hepatitis C (OR, 1.35; 95% CI, 0.08-21.67). The two groups were also similar for certain metabolic risk factors, including prevalence of obesity (OR, 1.01; 95% CI, 0.62-1.61), hypertension (OR, 0.69; 95% CI, 0.31-1.52), hemoglobin A1c greater than 5.5% (OR, 0.80; 95% CI, 0.34-1.9), and total cholesterol above 200 mg/dL (OR, 4.15; 95% CI, 0.83-20.84). Median bile acid levels were 30.6 micromoles (interquartile range, 11.6, 32.7) in the ICP group.
Compared with patients in the control group, those in the ICP group had higher median levels of alanine aminotransferase (ALT) (32 vs. 16 U/L; P less than .0001), alkaline phosphatase (181 vs. 128 U/L; P less than .0001), and total bilirubin (0.5 vs. 0.35 mg/dL; P less than .0001). ICP patients were also more likely than their counterparts to have ALT levels above 50 U/L (two times the upper limit of normal; OR, 3.22; 95% CI, 1.48-7.03), a history of biliary disease (OR, 3.29; 95% CI, 1.39-7.80), and to have evidence of steatosis on liver imaging (OR, 4.69; 95% CI, 1.68-13.12). When the researchers evaluated a diagnosis of NAFLD based on ICD-10 codes or evidence of steatosis on liver imaging, ICP patients were significantly more likely to have a diagnosis of NAFLD than controls (OR, 5.7; 95% CI, 2.08-15.65).
“We recommend additional research to look at differences in NAFLD progression in women who had NAFLD and were later diagnosed with ICP, compared to women with NAFLD who did not go on to develop ICP, because that may be a reflection of the role that bile acid metabolism plays in these particular patients,” Dr. Kushner said.
Digestive Disease Week is jointly sponsored by the American Association for the Study of Liver Diseases (AASLD), the American Gastroenterological Association (AGA) Institute, the American Society for Gastrointestinal Endoscopy (ASGE), and the Society for Surgery of the Alimentary Tract (SSAT).
The study’s primary author was Erica Monrose, MD. The researchers reported having no financial disclosures.
SOURCE: Monrose E et al. DDW 2019, Abstract Sa1562.
REPORTING FROM DDW 2019
Evaluation, treatment of anxiety in children and adolescents with autism spectrum disorder
1 As ASD by definition involves deficits in communication and interaction, as well as restricted, repetitive patterns of behavior, interests, or activities, diagnosis and treatment of anxiety disorders in this population can present a significant challenge.
martinedoucet/E+/Getty Images
Clinical vignette
Sean is a 9-year-old boy in the fourth grade diagnosed with ASD. He is in a regular education classroom setting. Until this year, his grades have been above average. This year his mother has been getting calls from the teachers reporting that he is disruptive in class, and is having difficulty paying attention unless the subject relates to a specific interest of his. At home, his mother has been struggling to get him to do chores and homework, and even sitting at the dinner table is now a battle. He is significantly more irritable than usual. While he always preferred routines and familiar activities, deviations from them now trigger strong reactions and sometimes tantrums. He has started to insist on staying up late, and refuses to go to bed without his mother present. Notably his mother reports that she and Sean’s father recently separated, and that she believes he is very upset by this, although he refuses to talk about it.
Discussion
This case highlights the diagnostic complexity with which children with ASD may present. With the overlap between some of the core symptoms of ASD and anxiety, as well as the potential for other co-occurring disorders, a number of factors need to be explored before arriving at a treatment plan.
In evaluating behavior changes in children with ASD, I find it most helpful to start by looking for any medical or environmental factors. Medical problems such as illness or gastrointestinal difficulties may contribute to behavioral challenges and anxiety. Also, be sure to inquire if there are any precipitating events or change in the environment which might correlate with the change in behavior. In this case, we do have a situation – namely Sean’s parents separating – that may be contributing. While addressing Sean’s thoughts and feelings about this remains challenging, awareness of this factor certainly is important.
Understanding the educational setting and supports of a child with ASD is of significant importance. Academic challenges may result from learning or language difficulties, which can result in significant stress. While the vignette mentions that Sean’s grades had previously been above average, it is possible that increased complexity of material is contributing to his school struggles.
Next, it is worth looking at the question of whether Sean meets criteria for ADHD, which is estimated to occur in 30%-61% of people with ASD. In the case vignette, the mention of disruptions and attentional difficulties in the classroom warrant further investigation.
Finally, the question of whether insistence on routine, strong reactions to unfamiliar circumstances, disruptive behavior, and irritability meet criteria for an anxiety disorder is a complex one. Children with ASD may have difficulty communicating that they are anxious, making the behavioral observations of those around them especially important. An advantage pediatric primary care providers have in this circumstance is longitudinal experience with the child and family, which can help confirm whether the problem perceived as anxiety is a manifestation of core autism symptoms, or newer-onset phenomena. Assessing the severity and settings of the behavior also is necessary to guide treatment decisions. In the vignette, Sean’s irritability, acting out, and bedtime difficulties all are of relatively new onset, and occurring across multiple settings with significant functional consequences, making a diagnosis of an anxiety disorder the likely explanation.
As for treatment, cognitive behavioral therapy has been shown to be effective for anxiety in children with high functioning ASD.2 If a clinician with experience with this population is available, that certainly is preferred. If medication is being considered, there are no randomized controlled trials that have demonstrated efficacy of medication for anxiety specifically in children with co-occurring ASD. Treatment recommendations are taken from studies in typically developing children,3 where the SSRIs fluoxetine and sertraline have demonstrated efficacy in treatment of anxiety. When opting for pharmacotherapy in children with ASD, starting low, going slow, and carefully monitoring for side effects is recommended. Regardless of the method of treatment, a clear definition of the target symptoms ahead of time is critical for monitoring response and evaluating treatment effect.
Dr. Hoffnung is a pediatric psychiatrist at the University of Vermont Children’s Hospital and an assistant professor of psychiatry at the Robert Larner, M.D. College of Medicine at the University of Vermont, both in Burlington. He said he had no relevant financial disclosures. Email him at pdnews@mdedge.com.
References
1. Clin Child Fam Psychol Rev. 2011 Sep;14(3):302-17.
2. Child Psychiatry Hum Dev. 2015 Aug;46(4):533-47.
3. Pediatrics. 2016 Feb;137 Suppl 2:S115-23.
1 As ASD by definition involves deficits in communication and interaction, as well as restricted, repetitive patterns of behavior, interests, or activities, diagnosis and treatment of anxiety disorders in this population can present a significant challenge.
martinedoucet/E+/Getty Images
Clinical vignette
Sean is a 9-year-old boy in the fourth grade diagnosed with ASD. He is in a regular education classroom setting. Until this year, his grades have been above average. This year his mother has been getting calls from the teachers reporting that he is disruptive in class, and is having difficulty paying attention unless the subject relates to a specific interest of his. At home, his mother has been struggling to get him to do chores and homework, and even sitting at the dinner table is now a battle. He is significantly more irritable than usual. While he always preferred routines and familiar activities, deviations from them now trigger strong reactions and sometimes tantrums. He has started to insist on staying up late, and refuses to go to bed without his mother present. Notably his mother reports that she and Sean’s father recently separated, and that she believes he is very upset by this, although he refuses to talk about it.
Discussion
This case highlights the diagnostic complexity with which children with ASD may present. With the overlap between some of the core symptoms of ASD and anxiety, as well as the potential for other co-occurring disorders, a number of factors need to be explored before arriving at a treatment plan.
In evaluating behavior changes in children with ASD, I find it most helpful to start by looking for any medical or environmental factors. Medical problems such as illness or gastrointestinal difficulties may contribute to behavioral challenges and anxiety. Also, be sure to inquire if there are any precipitating events or change in the environment which might correlate with the change in behavior. In this case, we do have a situation – namely Sean’s parents separating – that may be contributing. While addressing Sean’s thoughts and feelings about this remains challenging, awareness of this factor certainly is important.
Understanding the educational setting and supports of a child with ASD is of significant importance. Academic challenges may result from learning or language difficulties, which can result in significant stress. While the vignette mentions that Sean’s grades had previously been above average, it is possible that increased complexity of material is contributing to his school struggles.
Next, it is worth looking at the question of whether Sean meets criteria for ADHD, which is estimated to occur in 30%-61% of people with ASD. In the case vignette, the mention of disruptions and attentional difficulties in the classroom warrant further investigation.
Finally, the question of whether insistence on routine, strong reactions to unfamiliar circumstances, disruptive behavior, and irritability meet criteria for an anxiety disorder is a complex one. Children with ASD may have difficulty communicating that they are anxious, making the behavioral observations of those around them especially important. An advantage pediatric primary care providers have in this circumstance is longitudinal experience with the child and family, which can help confirm whether the problem perceived as anxiety is a manifestation of core autism symptoms, or newer-onset phenomena. Assessing the severity and settings of the behavior also is necessary to guide treatment decisions. In the vignette, Sean’s irritability, acting out, and bedtime difficulties all are of relatively new onset, and occurring across multiple settings with significant functional consequences, making a diagnosis of an anxiety disorder the likely explanation.
As for treatment, cognitive behavioral therapy has been shown to be effective for anxiety in children with high functioning ASD.2 If a clinician with experience with this population is available, that certainly is preferred. If medication is being considered, there are no randomized controlled trials that have demonstrated efficacy of medication for anxiety specifically in children with co-occurring ASD. Treatment recommendations are taken from studies in typically developing children,3 where the SSRIs fluoxetine and sertraline have demonstrated efficacy in treatment of anxiety. When opting for pharmacotherapy in children with ASD, starting low, going slow, and carefully monitoring for side effects is recommended. Regardless of the method of treatment, a clear definition of the target symptoms ahead of time is critical for monitoring response and evaluating treatment effect.
Dr. Hoffnung is a pediatric psychiatrist at the University of Vermont Children’s Hospital and an assistant professor of psychiatry at the Robert Larner, M.D. College of Medicine at the University of Vermont, both in Burlington. He said he had no relevant financial disclosures. Email him at pdnews@mdedge.com.
References
1. Clin Child Fam Psychol Rev. 2011 Sep;14(3):302-17.
2. Child Psychiatry Hum Dev. 2015 Aug;46(4):533-47.
3. Pediatrics. 2016 Feb;137 Suppl 2:S115-23.
1 As ASD by definition involves deficits in communication and interaction, as well as restricted, repetitive patterns of behavior, interests, or activities, diagnosis and treatment of anxiety disorders in this population can present a significant challenge.
martinedoucet/E+/Getty Images
Clinical vignette
Sean is a 9-year-old boy in the fourth grade diagnosed with ASD. He is in a regular education classroom setting. Until this year, his grades have been above average. This year his mother has been getting calls from the teachers reporting that he is disruptive in class, and is having difficulty paying attention unless the subject relates to a specific interest of his. At home, his mother has been struggling to get him to do chores and homework, and even sitting at the dinner table is now a battle. He is significantly more irritable than usual. While he always preferred routines and familiar activities, deviations from them now trigger strong reactions and sometimes tantrums. He has started to insist on staying up late, and refuses to go to bed without his mother present. Notably his mother reports that she and Sean’s father recently separated, and that she believes he is very upset by this, although he refuses to talk about it.
Discussion
This case highlights the diagnostic complexity with which children with ASD may present. With the overlap between some of the core symptoms of ASD and anxiety, as well as the potential for other co-occurring disorders, a number of factors need to be explored before arriving at a treatment plan.
In evaluating behavior changes in children with ASD, I find it most helpful to start by looking for any medical or environmental factors. Medical problems such as illness or gastrointestinal difficulties may contribute to behavioral challenges and anxiety. Also, be sure to inquire if there are any precipitating events or change in the environment which might correlate with the change in behavior. In this case, we do have a situation – namely Sean’s parents separating – that may be contributing. While addressing Sean’s thoughts and feelings about this remains challenging, awareness of this factor certainly is important.
Understanding the educational setting and supports of a child with ASD is of significant importance. Academic challenges may result from learning or language difficulties, which can result in significant stress. While the vignette mentions that Sean’s grades had previously been above average, it is possible that increased complexity of material is contributing to his school struggles.
Next, it is worth looking at the question of whether Sean meets criteria for ADHD, which is estimated to occur in 30%-61% of people with ASD. In the case vignette, the mention of disruptions and attentional difficulties in the classroom warrant further investigation.
Finally, the question of whether insistence on routine, strong reactions to unfamiliar circumstances, disruptive behavior, and irritability meet criteria for an anxiety disorder is a complex one. Children with ASD may have difficulty communicating that they are anxious, making the behavioral observations of those around them especially important. An advantage pediatric primary care providers have in this circumstance is longitudinal experience with the child and family, which can help confirm whether the problem perceived as anxiety is a manifestation of core autism symptoms, or newer-onset phenomena. Assessing the severity and settings of the behavior also is necessary to guide treatment decisions. In the vignette, Sean’s irritability, acting out, and bedtime difficulties all are of relatively new onset, and occurring across multiple settings with significant functional consequences, making a diagnosis of an anxiety disorder the likely explanation.
As for treatment, cognitive behavioral therapy has been shown to be effective for anxiety in children with high functioning ASD.2 If a clinician with experience with this population is available, that certainly is preferred. If medication is being considered, there are no randomized controlled trials that have demonstrated efficacy of medication for anxiety specifically in children with co-occurring ASD. Treatment recommendations are taken from studies in typically developing children,3 where the SSRIs fluoxetine and sertraline have demonstrated efficacy in treatment of anxiety. When opting for pharmacotherapy in children with ASD, starting low, going slow, and carefully monitoring for side effects is recommended. Regardless of the method of treatment, a clear definition of the target symptoms ahead of time is critical for monitoring response and evaluating treatment effect.
Dr. Hoffnung is a pediatric psychiatrist at the University of Vermont Children’s Hospital and an assistant professor of psychiatry at the Robert Larner, M.D. College of Medicine at the University of Vermont, both in Burlington. He said he had no relevant financial disclosures. Email him at pdnews@mdedge.com.
References
1. Clin Child Fam Psychol Rev. 2011 Sep;14(3):302-17.
2. Child Psychiatry Hum Dev. 2015 Aug;46(4):533-47.
3. Pediatrics. 2016 Feb;137 Suppl 2:S115-23.
HM19: Interprofessional rounds
Better process, outcomes
Session presenters
Surekha Bhamidipati, MD, FACP; Preetham Talari, MD, FACP, SFHM; Mark V. Williams, MD, FACP, MHM
Session title
Interprofessional rounds: What’s the right way?
Session summary
Interprofessional or multidisciplinary rounds involve all members of the care delivery team, including physicians, nurses, case managers, social workers, pharmacists, nurse facilitators, and of course, patients. The primary goal for these rounds is patient-centered care, and to improve communication among the health care team members, as well as with patients and their families.
At HM19, Dr. Preetham Talari and Dr. Mark Williams of the University of Kentucky, and Dr. Surekha Bhamidipati of Christiana Care Health System in Newark, Del., discussed their system-based efforts to try to implement interprofessional rounds, and the role of these rounds in improving patient outcome measures.
The presenters noted that the purpose of these rounds is effective communication and efficient patient care. As shown by multiple studies, there is significant impact in team member satisfaction, decrease in length of stay,1 reduction in adverse events2 and improvement in patient experience.3 They emphasized the importance of implementing these rounds at the bedside, so that patients and families can be engaged in the patient’s care, thereby improving closed communication among the team and the patient. These rounds always offer an opportunity for the patient to ask questions of multiple health care team members as they are gathered together at the same time.
The University of Kentucky named these rounds the “Interprofessional Teamwork Innovation Model (ITIM),” to promote communication and patient-centered coordinated care. Their model showed a significant reduction in readmission rates, and no increase in costs despite adding pharmacy and case managers to the rounds.
Dr. Bhamidipati described how Christiana Care Health System designed multidisciplinary rounds based on the application of Team STEPPS 2.0, a teamwork system developed by the Department of Defense and the Agency for Healthcare Research and Quality to improve the institutional collaboration and communication relating to patient safety.
The Christiana Care model is based on a few principles of team structure, communication, leadership, situation monitoring, and mutual support. The interprofessional team was trained and observed, and a short video recording was made. This video was used as an educational tool in coaching the rest of the team. Dr. Bhamidipati described the importance of interprofessional leaders as coaches to train other team members, and highlighted the engagement of unit leaders in successfully implementing these rounds. The Christiana Care team used its informational technology system to collect real-time data, which was then used for team review.
In summary, the presenters from both the University of Kentucky and Christiana Care highlighted the importance of interprofessional rounds, as well as the need for continued measurement of process and outcome metrics.
Dr. Jonnalagadda is a physician advisor, and Dr. Medarametla is medical director, Hospital Medicine, at Baystate Medical Center, Springfield, Mass.
References
1. Yoo JW et al. Effects of an internal medicine floor interdisciplinary team on hospital and clinical outcomes of seniors with acute medical illness. Geriatr Gerontol Int. 2013 Oct;13(4):942-8. doi: 10.1111/ggi.12035. Epub 2013 Feb 26.
2. O’Leary KJ et al. Structured interdisciplinary rounds in a medical teaching unit: improving patient safety. Arch Intern Med. 2011 Apr 11;171(7):678-84. doi: 10.1001/archinternmed.2011.128.
3. Ratelle JT et al. Implementing bedside rounds to improve patient-centred outcomes: a systematic review. BMJ Qual Saf. 2019;28:317-326.
Better process, outcomes
Better process, outcomes
Session presenters
Surekha Bhamidipati, MD, FACP; Preetham Talari, MD, FACP, SFHM; Mark V. Williams, MD, FACP, MHM
Session title
Interprofessional rounds: What’s the right way?
Session summary
Interprofessional or multidisciplinary rounds involve all members of the care delivery team, including physicians, nurses, case managers, social workers, pharmacists, nurse facilitators, and of course, patients. The primary goal for these rounds is patient-centered care, and to improve communication among the health care team members, as well as with patients and their families.
At HM19, Dr. Preetham Talari and Dr. Mark Williams of the University of Kentucky, and Dr. Surekha Bhamidipati of Christiana Care Health System in Newark, Del., discussed their system-based efforts to try to implement interprofessional rounds, and the role of these rounds in improving patient outcome measures.
The presenters noted that the purpose of these rounds is effective communication and efficient patient care. As shown by multiple studies, there is significant impact in team member satisfaction, decrease in length of stay,1 reduction in adverse events2 and improvement in patient experience.3 They emphasized the importance of implementing these rounds at the bedside, so that patients and families can be engaged in the patient’s care, thereby improving closed communication among the team and the patient. These rounds always offer an opportunity for the patient to ask questions of multiple health care team members as they are gathered together at the same time.
The University of Kentucky named these rounds the “Interprofessional Teamwork Innovation Model (ITIM),” to promote communication and patient-centered coordinated care. Their model showed a significant reduction in readmission rates, and no increase in costs despite adding pharmacy and case managers to the rounds.
Dr. Bhamidipati described how Christiana Care Health System designed multidisciplinary rounds based on the application of Team STEPPS 2.0, a teamwork system developed by the Department of Defense and the Agency for Healthcare Research and Quality to improve the institutional collaboration and communication relating to patient safety.
The Christiana Care model is based on a few principles of team structure, communication, leadership, situation monitoring, and mutual support. The interprofessional team was trained and observed, and a short video recording was made. This video was used as an educational tool in coaching the rest of the team. Dr. Bhamidipati described the importance of interprofessional leaders as coaches to train other team members, and highlighted the engagement of unit leaders in successfully implementing these rounds. The Christiana Care team used its informational technology system to collect real-time data, which was then used for team review.
In summary, the presenters from both the University of Kentucky and Christiana Care highlighted the importance of interprofessional rounds, as well as the need for continued measurement of process and outcome metrics.
Dr. Jonnalagadda is a physician advisor, and Dr. Medarametla is medical director, Hospital Medicine, at Baystate Medical Center, Springfield, Mass.
References
1. Yoo JW et al. Effects of an internal medicine floor interdisciplinary team on hospital and clinical outcomes of seniors with acute medical illness. Geriatr Gerontol Int. 2013 Oct;13(4):942-8. doi: 10.1111/ggi.12035. Epub 2013 Feb 26.
2. O’Leary KJ et al. Structured interdisciplinary rounds in a medical teaching unit: improving patient safety. Arch Intern Med. 2011 Apr 11;171(7):678-84. doi: 10.1001/archinternmed.2011.128.
3. Ratelle JT et al. Implementing bedside rounds to improve patient-centred outcomes: a systematic review. BMJ Qual Saf. 2019;28:317-326.
Session presenters
Surekha Bhamidipati, MD, FACP; Preetham Talari, MD, FACP, SFHM; Mark V. Williams, MD, FACP, MHM
Session title
Interprofessional rounds: What’s the right way?
Session summary
Interprofessional or multidisciplinary rounds involve all members of the care delivery team, including physicians, nurses, case managers, social workers, pharmacists, nurse facilitators, and of course, patients. The primary goal for these rounds is patient-centered care, and to improve communication among the health care team members, as well as with patients and their families.
At HM19, Dr. Preetham Talari and Dr. Mark Williams of the University of Kentucky, and Dr. Surekha Bhamidipati of Christiana Care Health System in Newark, Del., discussed their system-based efforts to try to implement interprofessional rounds, and the role of these rounds in improving patient outcome measures.
The presenters noted that the purpose of these rounds is effective communication and efficient patient care. As shown by multiple studies, there is significant impact in team member satisfaction, decrease in length of stay,1 reduction in adverse events2 and improvement in patient experience.3 They emphasized the importance of implementing these rounds at the bedside, so that patients and families can be engaged in the patient’s care, thereby improving closed communication among the team and the patient. These rounds always offer an opportunity for the patient to ask questions of multiple health care team members as they are gathered together at the same time.
The University of Kentucky named these rounds the “Interprofessional Teamwork Innovation Model (ITIM),” to promote communication and patient-centered coordinated care. Their model showed a significant reduction in readmission rates, and no increase in costs despite adding pharmacy and case managers to the rounds.
Dr. Bhamidipati described how Christiana Care Health System designed multidisciplinary rounds based on the application of Team STEPPS 2.0, a teamwork system developed by the Department of Defense and the Agency for Healthcare Research and Quality to improve the institutional collaboration and communication relating to patient safety.
The Christiana Care model is based on a few principles of team structure, communication, leadership, situation monitoring, and mutual support. The interprofessional team was trained and observed, and a short video recording was made. This video was used as an educational tool in coaching the rest of the team. Dr. Bhamidipati described the importance of interprofessional leaders as coaches to train other team members, and highlighted the engagement of unit leaders in successfully implementing these rounds. The Christiana Care team used its informational technology system to collect real-time data, which was then used for team review.
In summary, the presenters from both the University of Kentucky and Christiana Care highlighted the importance of interprofessional rounds, as well as the need for continued measurement of process and outcome metrics.
Dr. Jonnalagadda is a physician advisor, and Dr. Medarametla is medical director, Hospital Medicine, at Baystate Medical Center, Springfield, Mass.
References
1. Yoo JW et al. Effects of an internal medicine floor interdisciplinary team on hospital and clinical outcomes of seniors with acute medical illness. Geriatr Gerontol Int. 2013 Oct;13(4):942-8. doi: 10.1111/ggi.12035. Epub 2013 Feb 26.
2. O’Leary KJ et al. Structured interdisciplinary rounds in a medical teaching unit: improving patient safety. Arch Intern Med. 2011 Apr 11;171(7):678-84. doi: 10.1001/archinternmed.2011.128.
3. Ratelle JT et al. Implementing bedside rounds to improve patient-centred outcomes: a systematic review. BMJ Qual Saf. 2019;28:317-326.
Is there an epidemic of anxiety and depression among today’s adolescents?
It seems that every week there are fresh headlines about a mental health crisis in children and adolescents, reporting exploding rates of severe anxiety and depression in youth. These reports raise the question of whether or not there has been a significant change in their incidence: Are more children developing depressive and anxiety disorders? Are they having greater difficulty accessing care? Are the disorders more severe than they were in the past? Or are young people failing to develop appropriate skills to manage anxiety, sadness, and other forms of distress that are a normal (if unpleasant) part of life? These are important questions, as they will help us to advocate for the proper services to address the public health challenge that underlies this “epidemic.”
What do the data show?
It is important to start by noting that epidemiologic data on child psychiatry in the United States are not as robust as we might like. It was only in 1999 that the Surgeon General’s Report on Mental Health articulated that there was a need for a more systematic approach to collecting epidemiologic data on psychiatric illness in children and adolescents. At that time, the consensus was that approximately one in five children would develop a psychiatric illness by the age of 18 and that approximately 5% of all children would experience a severe or persistent mental illness.1 In the 2 decades since then there have been expanded efforts to collect data, including the addition of an adolescent supplement to the National Comorbidity Survey sponsored by the National Institute of Mental Health, although our current estimates still are based on representative surveys of thousands of U.S. children and teenagers, often with questionnaires filled out by their parents. Thus, we may have overestimates of some behavioral disorders that are obvious and of concern to parents or underestimates of certain internalizing disorders such as depression that can remain unstated and contained in the mind of the adolescent. And even with accurate current estimates, our ability to make statements about trends or changes in rates of disease is limited by the very short period of time in which we have been studying these disease rates in U.S. youth, some changes in definitions, and the unknown impact of increasing recognition rather than true change in incidence.
What is unequivocally clear is that psychiatric illnesses usually present in youth and that these illnesses are among the most common illnesses of youth. Current estimates are that nearly one in four young people will have a psychiatric illness (by The Diagnostic and Statistical Manual of Mental Disorders [DSM], Fifth Edition criteria) by the time they turn 18,2 although only 10% of youth will experience an illness that meets the Substance Abuse and Mental Health Services Administration criteria for a serious emotional disturbance, or one that has a substantial impact on a child’s ability to function socially, emotionally, and academically.3
While it once was believed that children did not experience psychiatric illness, we now know that the majority of psychiatric illnesses present during childhood, adolescence, and young adulthood. The Centers for Disease Control and Prevention estimates that 50% of lifetime psychiatric illness has presented by the age of 15 years and 75% by the age of 24. Only one-quarter of all lifetime psychiatric illnesses emerge in full adulthood, or after the age of 24. Early diagnosis and treatment can make a significant difference in the overall impact of serious illnesses such as schizophrenia and bipolar disorder. We also can state with confidence that anxiety disorders are the most common psychiatric illnesses of youth, making up over 30% of all diagnoses, followed by disorders of behavior (19%), mood (14%), and then substance use (11%).4 Even compared with asthma (with a prevalence of approximately 11%), widely considered to be among the most common disease of childhood, psychiatric illnesses are the most common in youth.
The question then is whether these numbers are changing. The National Comorbidity Survey conducted in 2014 found that the incidence of major depressive episodes in adolescents had increased significantly between 2005 and 2014, from 9% to 11%.5 This is a survey of nearly 200,000 youth across the United States, interviewed by phone with a structured questionnaire assessing their (self-reported) DSM criteria for a major depressive episode, along with other illnesses. During this time frame, access to specialty mental health providers increased among adolescents, alongside their rate of use of psychiatric medications and inpatient hospitalization.
In Europe, where they have more robust epidemiological data, there also has been a public perception of an increase in depression in adolescents. Studies there have suggested that prevalence rates have not changed significantly, and that the problem actually may be a function of a growing population, greater public awareness, and higher rates of psychological distress.6
In the United States, it is difficult to place the prevalence rates in a meaningful context, given the shorter time frame during which we have been following these rates in young people. It is worth highlighting that although the rates at which young people are gaining access to mental health clinicians, being prescribed medications, and being admitted to psychiatric hospitals all have increased, there has not been an associated decrease in the rate of illness or in the severity of symptoms. It certainly is possible that the increase in use of services by youth is being driven by the increased prevalence of this diagnosis, or it may be that other factors, such as those detailed in international studies, are driving this increase in the incidence of depression.
What about the suicide rate?
Another statistic that addressed the question of whether there may be an epidemic of anxiety and depression in adolescents is the recent increase in the suicide rate. While the rate of completed suicide in 15- to 24-year-olds has been trending upward over the last decade, it is worth noting that this phenomenon appears to be occurring across age groups and is not isolated to adolescents. While adolescents may have a unique underlying set of issues driving the increase, it also may be that factors affecting the entire population (access to firearms, the epidemic of opioid addiction) may be at the core of this worrisome trend.
What about the role of stress?
It is worth noting that there is evidence of an increased rate of psychological distress in adolescents and young adults separate from any increase in the rate of psychiatric illness. Surveys of adolescents in high school and entering college demonstrate higher self-reported rates of severe stress and anxiety. One survey from the American Psychological Association from August 2018 found teenagers reporting higher levels of stress and related sadness and anxiety than the levels among the adults who were surveyed. So more young people are struggling with feelings of anxiety and sadness, without necessarily meeting criteria for a psychiatric illness. This suggests that levels of external stressors may have increased, or that the establishment of healthy coping skills has somehow been compromised in young people, or both.
What can you do as a clinician?
While the broader question of whether actual incidence rates of depression are on the rise will not be settled any time soon, when a patient of yours complains of high levels of stress, anxiety, or feelings of depression, it is very possible that the individual has a psychiatric diagnosis. A quick screening evaluation, using a questionnaire such as the Pediatric Symptom Checklist and/or a brief interview, can indicate if the patient may benefit from a referral.
In addition, all children, including those who have a psychiatric diagnosis, will benefit from a calm, patient, supportive adult who is interested in their distress. It would be very helpful if you are ready to talk about healthy coping skills, and how they are developed over time and only in the setting of actually struggling with some adversity. Help them frame their source of stress as a challenge rather than a threat. Help them identify their meaningful supports, particularly adults who know them well, and offer concrete and practical advice and motivation. And remind them about how self-care is essential to managing the normal stress of adolescence. Have handouts (or virtual ones) ready on good sleep hygiene, the value of exercise, and fact-based nutritional guidance. Offer strategies to manage screen time so that it is a recharging break and not a time sink. Support their identification of other strategies to decompress and manage stress: Are they recharged by time with friends? Exercise? Playing music? Listening to music? Playing video games? They should be building their personalized list, and it should include more active as well as passive strategies. Educate them about the risks of using drugs and alcohol “to relax,” or only having one way of unwinding. Educate your patients and parents about the special value of a mindfulness practice, whether meditation, yoga, or any activity in which they practice a nonjudgmental observation and acceptance of strong emotions.
Accurate prevalence rates can help us consider the statistical probability of a psychiatric diagnosis. By talking with your patients about stressful feelings, you can consider the individual need for a fuller psychiatric evaluation while also helping them reframe their approach to stress to one that is more empowering, adaptive, and healthy.
Dr. Swick is physician in chief at Ohana, Center for Child and Adolescent Behavioral Health, Community Hospital of the Monterey (Calif.) Peninsula. Dr. Jellinek is professor emeritus of psychiatry and pediatrics, Harvard Medical School, Boston. Email them at pdnews@mdedge.com.
References
1. Mental Health: A Report of the Surgeon General, National Institutes of Mental Health (1999).
2. Prevalence of psychiatric disorders in childhood and adolescence, in “Mental Health Services: A Public Health Perspective,” 2nd ed. (Oxford, UK: Oxford University Press; 2004, pp. 111-28).
3. Public Health Rep. 2006 May-Jun;121(3):303-10.
4. J Am Acad Child Adolesc Psychiatry. 2010 Oct;49(10):980-9.
5. Pediatrics. 2016 Dec;138(6):e20161878.
6. Depress Anxiety. 2014 Jun;31(6):506-16.
It seems that every week there are fresh headlines about a mental health crisis in children and adolescents, reporting exploding rates of severe anxiety and depression in youth. These reports raise the question of whether or not there has been a significant change in their incidence: Are more children developing depressive and anxiety disorders? Are they having greater difficulty accessing care? Are the disorders more severe than they were in the past? Or are young people failing to develop appropriate skills to manage anxiety, sadness, and other forms of distress that are a normal (if unpleasant) part of life? These are important questions, as they will help us to advocate for the proper services to address the public health challenge that underlies this “epidemic.”
What do the data show?
It is important to start by noting that epidemiologic data on child psychiatry in the United States are not as robust as we might like. It was only in 1999 that the Surgeon General’s Report on Mental Health articulated that there was a need for a more systematic approach to collecting epidemiologic data on psychiatric illness in children and adolescents. At that time, the consensus was that approximately one in five children would develop a psychiatric illness by the age of 18 and that approximately 5% of all children would experience a severe or persistent mental illness.1 In the 2 decades since then there have been expanded efforts to collect data, including the addition of an adolescent supplement to the National Comorbidity Survey sponsored by the National Institute of Mental Health, although our current estimates still are based on representative surveys of thousands of U.S. children and teenagers, often with questionnaires filled out by their parents. Thus, we may have overestimates of some behavioral disorders that are obvious and of concern to parents or underestimates of certain internalizing disorders such as depression that can remain unstated and contained in the mind of the adolescent. And even with accurate current estimates, our ability to make statements about trends or changes in rates of disease is limited by the very short period of time in which we have been studying these disease rates in U.S. youth, some changes in definitions, and the unknown impact of increasing recognition rather than true change in incidence.
What is unequivocally clear is that psychiatric illnesses usually present in youth and that these illnesses are among the most common illnesses of youth. Current estimates are that nearly one in four young people will have a psychiatric illness (by The Diagnostic and Statistical Manual of Mental Disorders [DSM], Fifth Edition criteria) by the time they turn 18,2 although only 10% of youth will experience an illness that meets the Substance Abuse and Mental Health Services Administration criteria for a serious emotional disturbance, or one that has a substantial impact on a child’s ability to function socially, emotionally, and academically.3
While it once was believed that children did not experience psychiatric illness, we now know that the majority of psychiatric illnesses present during childhood, adolescence, and young adulthood. The Centers for Disease Control and Prevention estimates that 50% of lifetime psychiatric illness has presented by the age of 15 years and 75% by the age of 24. Only one-quarter of all lifetime psychiatric illnesses emerge in full adulthood, or after the age of 24. Early diagnosis and treatment can make a significant difference in the overall impact of serious illnesses such as schizophrenia and bipolar disorder. We also can state with confidence that anxiety disorders are the most common psychiatric illnesses of youth, making up over 30% of all diagnoses, followed by disorders of behavior (19%), mood (14%), and then substance use (11%).4 Even compared with asthma (with a prevalence of approximately 11%), widely considered to be among the most common disease of childhood, psychiatric illnesses are the most common in youth.
The question then is whether these numbers are changing. The National Comorbidity Survey conducted in 2014 found that the incidence of major depressive episodes in adolescents had increased significantly between 2005 and 2014, from 9% to 11%.5 This is a survey of nearly 200,000 youth across the United States, interviewed by phone with a structured questionnaire assessing their (self-reported) DSM criteria for a major depressive episode, along with other illnesses. During this time frame, access to specialty mental health providers increased among adolescents, alongside their rate of use of psychiatric medications and inpatient hospitalization.
In Europe, where they have more robust epidemiological data, there also has been a public perception of an increase in depression in adolescents. Studies there have suggested that prevalence rates have not changed significantly, and that the problem actually may be a function of a growing population, greater public awareness, and higher rates of psychological distress.6
In the United States, it is difficult to place the prevalence rates in a meaningful context, given the shorter time frame during which we have been following these rates in young people. It is worth highlighting that although the rates at which young people are gaining access to mental health clinicians, being prescribed medications, and being admitted to psychiatric hospitals all have increased, there has not been an associated decrease in the rate of illness or in the severity of symptoms. It certainly is possible that the increase in use of services by youth is being driven by the increased prevalence of this diagnosis, or it may be that other factors, such as those detailed in international studies, are driving this increase in the incidence of depression.
What about the suicide rate?
Another statistic that addressed the question of whether there may be an epidemic of anxiety and depression in adolescents is the recent increase in the suicide rate. While the rate of completed suicide in 15- to 24-year-olds has been trending upward over the last decade, it is worth noting that this phenomenon appears to be occurring across age groups and is not isolated to adolescents. While adolescents may have a unique underlying set of issues driving the increase, it also may be that factors affecting the entire population (access to firearms, the epidemic of opioid addiction) may be at the core of this worrisome trend.
What about the role of stress?
It is worth noting that there is evidence of an increased rate of psychological distress in adolescents and young adults separate from any increase in the rate of psychiatric illness. Surveys of adolescents in high school and entering college demonstrate higher self-reported rates of severe stress and anxiety. One survey from the American Psychological Association from August 2018 found teenagers reporting higher levels of stress and related sadness and anxiety than the levels among the adults who were surveyed. So more young people are struggling with feelings of anxiety and sadness, without necessarily meeting criteria for a psychiatric illness. This suggests that levels of external stressors may have increased, or that the establishment of healthy coping skills has somehow been compromised in young people, or both.
What can you do as a clinician?
While the broader question of whether actual incidence rates of depression are on the rise will not be settled any time soon, when a patient of yours complains of high levels of stress, anxiety, or feelings of depression, it is very possible that the individual has a psychiatric diagnosis. A quick screening evaluation, using a questionnaire such as the Pediatric Symptom Checklist and/or a brief interview, can indicate if the patient may benefit from a referral.
In addition, all children, including those who have a psychiatric diagnosis, will benefit from a calm, patient, supportive adult who is interested in their distress. It would be very helpful if you are ready to talk about healthy coping skills, and how they are developed over time and only in the setting of actually struggling with some adversity. Help them frame their source of stress as a challenge rather than a threat. Help them identify their meaningful supports, particularly adults who know them well, and offer concrete and practical advice and motivation. And remind them about how self-care is essential to managing the normal stress of adolescence. Have handouts (or virtual ones) ready on good sleep hygiene, the value of exercise, and fact-based nutritional guidance. Offer strategies to manage screen time so that it is a recharging break and not a time sink. Support their identification of other strategies to decompress and manage stress: Are they recharged by time with friends? Exercise? Playing music? Listening to music? Playing video games? They should be building their personalized list, and it should include more active as well as passive strategies. Educate them about the risks of using drugs and alcohol “to relax,” or only having one way of unwinding. Educate your patients and parents about the special value of a mindfulness practice, whether meditation, yoga, or any activity in which they practice a nonjudgmental observation and acceptance of strong emotions.
Accurate prevalence rates can help us consider the statistical probability of a psychiatric diagnosis. By talking with your patients about stressful feelings, you can consider the individual need for a fuller psychiatric evaluation while also helping them reframe their approach to stress to one that is more empowering, adaptive, and healthy.
Dr. Swick is physician in chief at Ohana, Center for Child and Adolescent Behavioral Health, Community Hospital of the Monterey (Calif.) Peninsula. Dr. Jellinek is professor emeritus of psychiatry and pediatrics, Harvard Medical School, Boston. Email them at pdnews@mdedge.com.
References
1. Mental Health: A Report of the Surgeon General, National Institutes of Mental Health (1999).
2. Prevalence of psychiatric disorders in childhood and adolescence, in “Mental Health Services: A Public Health Perspective,” 2nd ed. (Oxford, UK: Oxford University Press; 2004, pp. 111-28).
3. Public Health Rep. 2006 May-Jun;121(3):303-10.
4. J Am Acad Child Adolesc Psychiatry. 2010 Oct;49(10):980-9.
5. Pediatrics. 2016 Dec;138(6):e20161878.
6. Depress Anxiety. 2014 Jun;31(6):506-16.
It seems that every week there are fresh headlines about a mental health crisis in children and adolescents, reporting exploding rates of severe anxiety and depression in youth. These reports raise the question of whether or not there has been a significant change in their incidence: Are more children developing depressive and anxiety disorders? Are they having greater difficulty accessing care? Are the disorders more severe than they were in the past? Or are young people failing to develop appropriate skills to manage anxiety, sadness, and other forms of distress that are a normal (if unpleasant) part of life? These are important questions, as they will help us to advocate for the proper services to address the public health challenge that underlies this “epidemic.”
What do the data show?
It is important to start by noting that epidemiologic data on child psychiatry in the United States are not as robust as we might like. It was only in 1999 that the Surgeon General’s Report on Mental Health articulated that there was a need for a more systematic approach to collecting epidemiologic data on psychiatric illness in children and adolescents. At that time, the consensus was that approximately one in five children would develop a psychiatric illness by the age of 18 and that approximately 5% of all children would experience a severe or persistent mental illness.1 In the 2 decades since then there have been expanded efforts to collect data, including the addition of an adolescent supplement to the National Comorbidity Survey sponsored by the National Institute of Mental Health, although our current estimates still are based on representative surveys of thousands of U.S. children and teenagers, often with questionnaires filled out by their parents. Thus, we may have overestimates of some behavioral disorders that are obvious and of concern to parents or underestimates of certain internalizing disorders such as depression that can remain unstated and contained in the mind of the adolescent. And even with accurate current estimates, our ability to make statements about trends or changes in rates of disease is limited by the very short period of time in which we have been studying these disease rates in U.S. youth, some changes in definitions, and the unknown impact of increasing recognition rather than true change in incidence.
What is unequivocally clear is that psychiatric illnesses usually present in youth and that these illnesses are among the most common illnesses of youth. Current estimates are that nearly one in four young people will have a psychiatric illness (by The Diagnostic and Statistical Manual of Mental Disorders [DSM], Fifth Edition criteria) by the time they turn 18,2 although only 10% of youth will experience an illness that meets the Substance Abuse and Mental Health Services Administration criteria for a serious emotional disturbance, or one that has a substantial impact on a child’s ability to function socially, emotionally, and academically.3
While it once was believed that children did not experience psychiatric illness, we now know that the majority of psychiatric illnesses present during childhood, adolescence, and young adulthood. The Centers for Disease Control and Prevention estimates that 50% of lifetime psychiatric illness has presented by the age of 15 years and 75% by the age of 24. Only one-quarter of all lifetime psychiatric illnesses emerge in full adulthood, or after the age of 24. Early diagnosis and treatment can make a significant difference in the overall impact of serious illnesses such as schizophrenia and bipolar disorder. We also can state with confidence that anxiety disorders are the most common psychiatric illnesses of youth, making up over 30% of all diagnoses, followed by disorders of behavior (19%), mood (14%), and then substance use (11%).4 Even compared with asthma (with a prevalence of approximately 11%), widely considered to be among the most common disease of childhood, psychiatric illnesses are the most common in youth.
The question then is whether these numbers are changing. The National Comorbidity Survey conducted in 2014 found that the incidence of major depressive episodes in adolescents had increased significantly between 2005 and 2014, from 9% to 11%.5 This is a survey of nearly 200,000 youth across the United States, interviewed by phone with a structured questionnaire assessing their (self-reported) DSM criteria for a major depressive episode, along with other illnesses. During this time frame, access to specialty mental health providers increased among adolescents, alongside their rate of use of psychiatric medications and inpatient hospitalization.
In Europe, where they have more robust epidemiological data, there also has been a public perception of an increase in depression in adolescents. Studies there have suggested that prevalence rates have not changed significantly, and that the problem actually may be a function of a growing population, greater public awareness, and higher rates of psychological distress.6
In the United States, it is difficult to place the prevalence rates in a meaningful context, given the shorter time frame during which we have been following these rates in young people. It is worth highlighting that although the rates at which young people are gaining access to mental health clinicians, being prescribed medications, and being admitted to psychiatric hospitals all have increased, there has not been an associated decrease in the rate of illness or in the severity of symptoms. It certainly is possible that the increase in use of services by youth is being driven by the increased prevalence of this diagnosis, or it may be that other factors, such as those detailed in international studies, are driving this increase in the incidence of depression.
What about the suicide rate?
Another statistic that addressed the question of whether there may be an epidemic of anxiety and depression in adolescents is the recent increase in the suicide rate. While the rate of completed suicide in 15- to 24-year-olds has been trending upward over the last decade, it is worth noting that this phenomenon appears to be occurring across age groups and is not isolated to adolescents. While adolescents may have a unique underlying set of issues driving the increase, it also may be that factors affecting the entire population (access to firearms, the epidemic of opioid addiction) may be at the core of this worrisome trend.
What about the role of stress?
It is worth noting that there is evidence of an increased rate of psychological distress in adolescents and young adults separate from any increase in the rate of psychiatric illness. Surveys of adolescents in high school and entering college demonstrate higher self-reported rates of severe stress and anxiety. One survey from the American Psychological Association from August 2018 found teenagers reporting higher levels of stress and related sadness and anxiety than the levels among the adults who were surveyed. So more young people are struggling with feelings of anxiety and sadness, without necessarily meeting criteria for a psychiatric illness. This suggests that levels of external stressors may have increased, or that the establishment of healthy coping skills has somehow been compromised in young people, or both.
What can you do as a clinician?
While the broader question of whether actual incidence rates of depression are on the rise will not be settled any time soon, when a patient of yours complains of high levels of stress, anxiety, or feelings of depression, it is very possible that the individual has a psychiatric diagnosis. A quick screening evaluation, using a questionnaire such as the Pediatric Symptom Checklist and/or a brief interview, can indicate if the patient may benefit from a referral.
In addition, all children, including those who have a psychiatric diagnosis, will benefit from a calm, patient, supportive adult who is interested in their distress. It would be very helpful if you are ready to talk about healthy coping skills, and how they are developed over time and only in the setting of actually struggling with some adversity. Help them frame their source of stress as a challenge rather than a threat. Help them identify their meaningful supports, particularly adults who know them well, and offer concrete and practical advice and motivation. And remind them about how self-care is essential to managing the normal stress of adolescence. Have handouts (or virtual ones) ready on good sleep hygiene, the value of exercise, and fact-based nutritional guidance. Offer strategies to manage screen time so that it is a recharging break and not a time sink. Support their identification of other strategies to decompress and manage stress: Are they recharged by time with friends? Exercise? Playing music? Listening to music? Playing video games? They should be building their personalized list, and it should include more active as well as passive strategies. Educate them about the risks of using drugs and alcohol “to relax,” or only having one way of unwinding. Educate your patients and parents about the special value of a mindfulness practice, whether meditation, yoga, or any activity in which they practice a nonjudgmental observation and acceptance of strong emotions.
Accurate prevalence rates can help us consider the statistical probability of a psychiatric diagnosis. By talking with your patients about stressful feelings, you can consider the individual need for a fuller psychiatric evaluation while also helping them reframe their approach to stress to one that is more empowering, adaptive, and healthy.
Dr. Swick is physician in chief at Ohana, Center for Child and Adolescent Behavioral Health, Community Hospital of the Monterey (Calif.) Peninsula. Dr. Jellinek is professor emeritus of psychiatry and pediatrics, Harvard Medical School, Boston. Email them at pdnews@mdedge.com.
References
1. Mental Health: A Report of the Surgeon General, National Institutes of Mental Health (1999).
2. Prevalence of psychiatric disorders in childhood and adolescence, in “Mental Health Services: A Public Health Perspective,” 2nd ed. (Oxford, UK: Oxford University Press; 2004, pp. 111-28).
3. Public Health Rep. 2006 May-Jun;121(3):303-10.
4. J Am Acad Child Adolesc Psychiatry. 2010 Oct;49(10):980-9.
5. Pediatrics. 2016 Dec;138(6):e20161878.
6. Depress Anxiety. 2014 Jun;31(6):506-16.
Human trafficking: We must be vigilant
My medical office in Cincinnati isn’t in the best part of town. It’s next to a busy bus stop, a block from the medical center, behind a McDonald’s, and next to a convenience store. Ohio is the epicenter for the opioid crisis, and there are three drug treatment centers within a mile of my office. Hungry “ghosts” drift through my office parking lot. (See “In the Realm of Hungry Ghosts – Introduction,” Gabor Maté, MD).
I tell you these things because it helps me to rationalize how I missed something one day that should have been obvious to me at the time. I’ve been grappling for some time with my belated realization of what I may have seen that day, and what I wished I had done in response.
I mentioned that my office is next to a convenience store, and I’ve been a regular customer there over the years. One day when I was in there, paying for something, a swaggering guy in his 50s – reddish comb-over, glasses, muscular – came in with a young blond girl. I guessed her to be his 14- or 15-year-old daughter. I paid for my purchase, and glanced over to see them standing at the ice cream counter. That’s nice, I thought, he is buying his daughter an ice cream cone. I used to buy my kids ice cream here. But then I noticed that the girl was trembling, quaking really, and crying softly. I stopped, and noticed that the man had his arm around her. His grip was way too tight and his arm was draped too low. I stepped back, and I swear I saw blood running down from her scalp and behind her ear.
Good grief, this isn’t right! I was paralyzed. Maybe she wasn’t his daughter. Maybe she was some sort of a captive, a victim? Maybe he had just beaten her and was now rewarding her? I knew something was wrong, and I did not know what to do. The store was busy, and I looked around at the other people there but no one else seemed to notice her unhappiness or the blood.
I did not say ‘unhand that girl.’ I did not say ‘I am a doctor, can I help you?’ I did not even ask her if she was OK. Instead, I walked back next door to my office and started making phone calls. I called the police and got a recording. Eventually I spoke to someone, but I had no proof. I was angry with myself for not taking a picture – my phone was in my pocket. Did I observe a crime being committed? Were there other witnesses? The sorry truth is that I had walked away, the man and girl were gone, and any others who may have seen what I saw also had left. This could have been a case of human trafficking, I said, and recommended that they follow up with the store and any evidence that they could pick up from its video cameras. It’s been nearly a year, and I have heard nothing.
My failure to act at the time has tormented me for months. I have sought out more information about human trafficking, and the event I witnessed is what human trafficking looks like.
Maybe that girl was his daughter. Maybe she fell and cut her head. Maybe I was jumping to conclusions. But I am never again going to walk away from a girl who is clearly injured and potentially in trouble. I am going ask that girl if she’s OK, I am going to take a picture, and I am going to dial 911 immediately.
Don’t be a failure like me. Call 911. Take a picture. Take the risk, embarrass yourself or you will be tormented by your conscience as I am. , and stop allowing our young people to be fed to monsters.
The Centers for Disease Control and Prevention offers information and resources on human trafficking at www.cdc.gov/violenceprevention/sexualviolence/trafficking.html.
Dr. Coldiron is in private practice but maintains a clinical assistant professorship at the University of Cincinnati. He cares for patients, teaches medical students and residents, and has several active clinical research projects. Dr. Coldiron is the author of more than 80 scientific letters, papers, and several book chapters, and he speaks frequently on a variety of topics. He is a past president of the American Academy of Dermatology. Write to him at dermnews@mdedge.com.
My medical office in Cincinnati isn’t in the best part of town. It’s next to a busy bus stop, a block from the medical center, behind a McDonald’s, and next to a convenience store. Ohio is the epicenter for the opioid crisis, and there are three drug treatment centers within a mile of my office. Hungry “ghosts” drift through my office parking lot. (See “In the Realm of Hungry Ghosts – Introduction,” Gabor Maté, MD).
I tell you these things because it helps me to rationalize how I missed something one day that should have been obvious to me at the time. I’ve been grappling for some time with my belated realization of what I may have seen that day, and what I wished I had done in response.
I mentioned that my office is next to a convenience store, and I’ve been a regular customer there over the years. One day when I was in there, paying for something, a swaggering guy in his 50s – reddish comb-over, glasses, muscular – came in with a young blond girl. I guessed her to be his 14- or 15-year-old daughter. I paid for my purchase, and glanced over to see them standing at the ice cream counter. That’s nice, I thought, he is buying his daughter an ice cream cone. I used to buy my kids ice cream here. But then I noticed that the girl was trembling, quaking really, and crying softly. I stopped, and noticed that the man had his arm around her. His grip was way too tight and his arm was draped too low. I stepped back, and I swear I saw blood running down from her scalp and behind her ear.
Good grief, this isn’t right! I was paralyzed. Maybe she wasn’t his daughter. Maybe she was some sort of a captive, a victim? Maybe he had just beaten her and was now rewarding her? I knew something was wrong, and I did not know what to do. The store was busy, and I looked around at the other people there but no one else seemed to notice her unhappiness or the blood.
I did not say ‘unhand that girl.’ I did not say ‘I am a doctor, can I help you?’ I did not even ask her if she was OK. Instead, I walked back next door to my office and started making phone calls. I called the police and got a recording. Eventually I spoke to someone, but I had no proof. I was angry with myself for not taking a picture – my phone was in my pocket. Did I observe a crime being committed? Were there other witnesses? The sorry truth is that I had walked away, the man and girl were gone, and any others who may have seen what I saw also had left. This could have been a case of human trafficking, I said, and recommended that they follow up with the store and any evidence that they could pick up from its video cameras. It’s been nearly a year, and I have heard nothing.
My failure to act at the time has tormented me for months. I have sought out more information about human trafficking, and the event I witnessed is what human trafficking looks like.
Maybe that girl was his daughter. Maybe she fell and cut her head. Maybe I was jumping to conclusions. But I am never again going to walk away from a girl who is clearly injured and potentially in trouble. I am going ask that girl if she’s OK, I am going to take a picture, and I am going to dial 911 immediately.
Don’t be a failure like me. Call 911. Take a picture. Take the risk, embarrass yourself or you will be tormented by your conscience as I am. , and stop allowing our young people to be fed to monsters.
The Centers for Disease Control and Prevention offers information and resources on human trafficking at www.cdc.gov/violenceprevention/sexualviolence/trafficking.html.
Dr. Coldiron is in private practice but maintains a clinical assistant professorship at the University of Cincinnati. He cares for patients, teaches medical students and residents, and has several active clinical research projects. Dr. Coldiron is the author of more than 80 scientific letters, papers, and several book chapters, and he speaks frequently on a variety of topics. He is a past president of the American Academy of Dermatology. Write to him at dermnews@mdedge.com.
My medical office in Cincinnati isn’t in the best part of town. It’s next to a busy bus stop, a block from the medical center, behind a McDonald’s, and next to a convenience store. Ohio is the epicenter for the opioid crisis, and there are three drug treatment centers within a mile of my office. Hungry “ghosts” drift through my office parking lot. (See “In the Realm of Hungry Ghosts – Introduction,” Gabor Maté, MD).
I tell you these things because it helps me to rationalize how I missed something one day that should have been obvious to me at the time. I’ve been grappling for some time with my belated realization of what I may have seen that day, and what I wished I had done in response.
I mentioned that my office is next to a convenience store, and I’ve been a regular customer there over the years. One day when I was in there, paying for something, a swaggering guy in his 50s – reddish comb-over, glasses, muscular – came in with a young blond girl. I guessed her to be his 14- or 15-year-old daughter. I paid for my purchase, and glanced over to see them standing at the ice cream counter. That’s nice, I thought, he is buying his daughter an ice cream cone. I used to buy my kids ice cream here. But then I noticed that the girl was trembling, quaking really, and crying softly. I stopped, and noticed that the man had his arm around her. His grip was way too tight and his arm was draped too low. I stepped back, and I swear I saw blood running down from her scalp and behind her ear.
Good grief, this isn’t right! I was paralyzed. Maybe she wasn’t his daughter. Maybe she was some sort of a captive, a victim? Maybe he had just beaten her and was now rewarding her? I knew something was wrong, and I did not know what to do. The store was busy, and I looked around at the other people there but no one else seemed to notice her unhappiness or the blood.
I did not say ‘unhand that girl.’ I did not say ‘I am a doctor, can I help you?’ I did not even ask her if she was OK. Instead, I walked back next door to my office and started making phone calls. I called the police and got a recording. Eventually I spoke to someone, but I had no proof. I was angry with myself for not taking a picture – my phone was in my pocket. Did I observe a crime being committed? Were there other witnesses? The sorry truth is that I had walked away, the man and girl were gone, and any others who may have seen what I saw also had left. This could have been a case of human trafficking, I said, and recommended that they follow up with the store and any evidence that they could pick up from its video cameras. It’s been nearly a year, and I have heard nothing.
My failure to act at the time has tormented me for months. I have sought out more information about human trafficking, and the event I witnessed is what human trafficking looks like.
Maybe that girl was his daughter. Maybe she fell and cut her head. Maybe I was jumping to conclusions. But I am never again going to walk away from a girl who is clearly injured and potentially in trouble. I am going ask that girl if she’s OK, I am going to take a picture, and I am going to dial 911 immediately.
Don’t be a failure like me. Call 911. Take a picture. Take the risk, embarrass yourself or you will be tormented by your conscience as I am. , and stop allowing our young people to be fed to monsters.
The Centers for Disease Control and Prevention offers information and resources on human trafficking at www.cdc.gov/violenceprevention/sexualviolence/trafficking.html.
Dr. Coldiron is in private practice but maintains a clinical assistant professorship at the University of Cincinnati. He cares for patients, teaches medical students and residents, and has several active clinical research projects. Dr. Coldiron is the author of more than 80 scientific letters, papers, and several book chapters, and he speaks frequently on a variety of topics. He is a past president of the American Academy of Dermatology. Write to him at dermnews@mdedge.com.
Meeting Highlights: Cardiovascular Research Technologies 2019
A supplement to Cardiology News. This supplement was sponsored by Chiesi USA, Inc.
News included in the supplement:
- Ultrathin stent loses advantage at 3 years
- Adjunctive devices for TAVR boost outcomes
- MI alert device shows predictive value
- Readmissions high post STEMI with cardiogenic shock
- Endovascular device sustains BP reductions
- Alcohol renal denervation safe for BP reduction
A supplement to Cardiology News. This supplement was sponsored by Chiesi USA, Inc.
News included in the supplement:
- Ultrathin stent loses advantage at 3 years
- Adjunctive devices for TAVR boost outcomes
- MI alert device shows predictive value
- Readmissions high post STEMI with cardiogenic shock
- Endovascular device sustains BP reductions
- Alcohol renal denervation safe for BP reduction
A supplement to Cardiology News. This supplement was sponsored by Chiesi USA, Inc.
News included in the supplement:
- Ultrathin stent loses advantage at 3 years
- Adjunctive devices for TAVR boost outcomes
- MI alert device shows predictive value
- Readmissions high post STEMI with cardiogenic shock
- Endovascular device sustains BP reductions
- Alcohol renal denervation safe for BP reduction
Living into your legacy
What I learned from women of impact
The word legacy has been synonymous with death to me. When so and so dies, we discuss their legacy. I had a powerful experience that changed my mind on this word that is befitting for this Legacies column.
Seven years ago, I was sitting in a room of powerful women and I was the youngest one there. I wasn’t sure how I got there, but I was glad I did because it changed my life. At the time, I was panicked. The exercise was called “Craft your legacy statement.”
But, this exercise was different. The ask was to “live into your legacy.” Craft a legacy statement in THREE minutes that summarizes what you want your legacy to be … and then decide the three things you need to do now to get there. So, here is my exact legacy 3-minute statement: I am an innovator pushing teaching hospitals to optimize training and patient care delivery through novel technologies and systems science. Clearly, I did not aim high enough. One of the other attendees stated her legacy simply as “Unleash the impossible!” So clearly, I was not able to think big at that moment, but I trudged on.
Next, I had to write the three things I was going to do to enact my legacy today. Things went from bad to worse quickly since I knew this was not going to be easy. The #1 thing had to be something I was going to stop doing because it did not fit with my legacy; #2 was what I was going to start doing to enact this legacy now; and, #3 was something I was going to do to get me closer to what I wanted to be doing. So, my #1, resign my current leadership role that I had had for 8 years; #2, start joining national committees that bridge education and quality; and #3, meet with senior leadership to pitch this new role as a bridging leader, aligning education and quality.
Like all conferences, I went home and forgot what I had done and learned. I settled back into my old life and routines. A few weeks later, a plain looking envelope with awful penmanship showed up at my doorstep addressed to me. It wasn’t until after I opened it and read what was inside that I realized I was the one with horrible penmanship! I completely forgot that I wrote this letter to myself even though they told me it would come and I would forget I wrote it! So, how did I do? Let’s just say if the letter did not arrive, I am not sure where I would be. Fortunately, it did come, and I followed my own orders. Fast forward to present day and I recently stepped into a new role – associate chief medical officer: clinical learning environment – a bridging leader who aligns education and clinical care missions for our health system. Let’s just say again, had that letter not arrived, I am not sure where I would be now.
I have been fortunate to do many things in hospital medicine – clinician, researcher, educator, and my latest role as a leader. Through it all, I would say that there are some lessons that I have picked up along the way that helped me advance, in ways I did not realize:
- Be bold. Years ago, when I was asked by my chair who they should pick to be chief resident, I thought “This must be a trick question – I should definitely tell him why I should be chosen – and then pick the next best person who I want to work with.” Apparently, I was the only person who did that, and that is why my chair chose me. Everyone else picked two other people. So the take-home point here is do not sell yourself short … ever.
- Look for the hidden gateways. A few years ago, I was asked if I wanted to be an institutional leader by the person who currently had that role. I was kind of thrown for a loop, since of course I would not want to appear like I wanted to take his job. I said everything was fine and I felt pretty good about my current positions. It was only a few weeks later that I realized that he was ascertaining my interest in his job since he was leaving. They gave the job to someone else and the word on the street was I was not interested. I totally missed the gate! While it wasn’t necessarily the job I missed out on, it was the opportunity to consider the job because I was afraid. So, don’t miss the gate. It’s the wormhole to a different life that may be the right one for you, but you need to “see it” to seize it.
- Work hard for the money and for the fun. There are many things Gwyneth Paltrow does that I do not agree with, but I will give her credit for one important lesson: she divides her movie roles into those she does for love (for example, The Royal Tenenbaums) and those she does for money (for example, Shallow Hal). It made me realize that even a Hollywood starlet has to do the stuff she may not want to do for the money. So, as a young person, you have to work hard for the money, but ideally it will help you take on a project you love, whatever it is. You’ve won the game when you’re mostly paid to work for the fun ... but that may take some time.
- Always optimize what is best for you personally AND professionally. While I was on maternity leave, the job of my dreams presented itself – or so I thought it did. It was at the intersection of policy, quality, and education, with a national stage, and I would not need to move. But, I knew I could not accept the travel commitment with a young child. While I wondered if I would have regrets, it turns out the right decision professionally also has to work personally. Likewise, there are professional obligations that I take on because it works personally.
- Figure out who your tea house pals are. A few years ago, I was in San Francisco with two close friends having an epic moment about what to do with our lives as adults. We were all on the cusp of changing our directions. Not surprisingly, we could see what the other needed to do, but we could not see it for ourselves. We still text each other sometimes about the need to go back to the Tea House. Sometimes your “tea house pals” are not necessarily those around you every day. They know you, but not everyone in your work place. This “arm’s length” or distance gives them the rational, unbiased perspective to advise you, that you or your colleagues will never have.
- Look for ways to enjoy the journey. Medicine is a very long road. I routinely think about this working with all the trainees and junior faculty I encounter. You can’t be in this solely for the end of the journey. The key is to find the joy in the journey. For me, that has always come from seeking out like-minded fellow travelers to share my highs and lows. While I tweet for many reasons, a big reason is that I take pleasure in watching others on the journey and also sharing my own journey.
Here’s to your journey and living your legacy!
Dr. Arora is associate chief medical officer, clinical learning environment, at University of Chicago Medicine, and assistant dean for scholarship and discovery at the University of Chicago Pritzker School of Medicine. You can follow her journey on Twitter.
What I learned from women of impact
What I learned from women of impact
The word legacy has been synonymous with death to me. When so and so dies, we discuss their legacy. I had a powerful experience that changed my mind on this word that is befitting for this Legacies column.
Seven years ago, I was sitting in a room of powerful women and I was the youngest one there. I wasn’t sure how I got there, but I was glad I did because it changed my life. At the time, I was panicked. The exercise was called “Craft your legacy statement.”
But, this exercise was different. The ask was to “live into your legacy.” Craft a legacy statement in THREE minutes that summarizes what you want your legacy to be … and then decide the three things you need to do now to get there. So, here is my exact legacy 3-minute statement: I am an innovator pushing teaching hospitals to optimize training and patient care delivery through novel technologies and systems science. Clearly, I did not aim high enough. One of the other attendees stated her legacy simply as “Unleash the impossible!” So clearly, I was not able to think big at that moment, but I trudged on.
Next, I had to write the three things I was going to do to enact my legacy today. Things went from bad to worse quickly since I knew this was not going to be easy. The #1 thing had to be something I was going to stop doing because it did not fit with my legacy; #2 was what I was going to start doing to enact this legacy now; and, #3 was something I was going to do to get me closer to what I wanted to be doing. So, my #1, resign my current leadership role that I had had for 8 years; #2, start joining national committees that bridge education and quality; and #3, meet with senior leadership to pitch this new role as a bridging leader, aligning education and quality.
Like all conferences, I went home and forgot what I had done and learned. I settled back into my old life and routines. A few weeks later, a plain looking envelope with awful penmanship showed up at my doorstep addressed to me. It wasn’t until after I opened it and read what was inside that I realized I was the one with horrible penmanship! I completely forgot that I wrote this letter to myself even though they told me it would come and I would forget I wrote it! So, how did I do? Let’s just say if the letter did not arrive, I am not sure where I would be. Fortunately, it did come, and I followed my own orders. Fast forward to present day and I recently stepped into a new role – associate chief medical officer: clinical learning environment – a bridging leader who aligns education and clinical care missions for our health system. Let’s just say again, had that letter not arrived, I am not sure where I would be now.
I have been fortunate to do many things in hospital medicine – clinician, researcher, educator, and my latest role as a leader. Through it all, I would say that there are some lessons that I have picked up along the way that helped me advance, in ways I did not realize:
- Be bold. Years ago, when I was asked by my chair who they should pick to be chief resident, I thought “This must be a trick question – I should definitely tell him why I should be chosen – and then pick the next best person who I want to work with.” Apparently, I was the only person who did that, and that is why my chair chose me. Everyone else picked two other people. So the take-home point here is do not sell yourself short … ever.
- Look for the hidden gateways. A few years ago, I was asked if I wanted to be an institutional leader by the person who currently had that role. I was kind of thrown for a loop, since of course I would not want to appear like I wanted to take his job. I said everything was fine and I felt pretty good about my current positions. It was only a few weeks later that I realized that he was ascertaining my interest in his job since he was leaving. They gave the job to someone else and the word on the street was I was not interested. I totally missed the gate! While it wasn’t necessarily the job I missed out on, it was the opportunity to consider the job because I was afraid. So, don’t miss the gate. It’s the wormhole to a different life that may be the right one for you, but you need to “see it” to seize it.
- Work hard for the money and for the fun. There are many things Gwyneth Paltrow does that I do not agree with, but I will give her credit for one important lesson: she divides her movie roles into those she does for love (for example, The Royal Tenenbaums) and those she does for money (for example, Shallow Hal). It made me realize that even a Hollywood starlet has to do the stuff she may not want to do for the money. So, as a young person, you have to work hard for the money, but ideally it will help you take on a project you love, whatever it is. You’ve won the game when you’re mostly paid to work for the fun ... but that may take some time.
- Always optimize what is best for you personally AND professionally. While I was on maternity leave, the job of my dreams presented itself – or so I thought it did. It was at the intersection of policy, quality, and education, with a national stage, and I would not need to move. But, I knew I could not accept the travel commitment with a young child. While I wondered if I would have regrets, it turns out the right decision professionally also has to work personally. Likewise, there are professional obligations that I take on because it works personally.
- Figure out who your tea house pals are. A few years ago, I was in San Francisco with two close friends having an epic moment about what to do with our lives as adults. We were all on the cusp of changing our directions. Not surprisingly, we could see what the other needed to do, but we could not see it for ourselves. We still text each other sometimes about the need to go back to the Tea House. Sometimes your “tea house pals” are not necessarily those around you every day. They know you, but not everyone in your work place. This “arm’s length” or distance gives them the rational, unbiased perspective to advise you, that you or your colleagues will never have.
- Look for ways to enjoy the journey. Medicine is a very long road. I routinely think about this working with all the trainees and junior faculty I encounter. You can’t be in this solely for the end of the journey. The key is to find the joy in the journey. For me, that has always come from seeking out like-minded fellow travelers to share my highs and lows. While I tweet for many reasons, a big reason is that I take pleasure in watching others on the journey and also sharing my own journey.
Here’s to your journey and living your legacy!
Dr. Arora is associate chief medical officer, clinical learning environment, at University of Chicago Medicine, and assistant dean for scholarship and discovery at the University of Chicago Pritzker School of Medicine. You can follow her journey on Twitter.
The word legacy has been synonymous with death to me. When so and so dies, we discuss their legacy. I had a powerful experience that changed my mind on this word that is befitting for this Legacies column.
Seven years ago, I was sitting in a room of powerful women and I was the youngest one there. I wasn’t sure how I got there, but I was glad I did because it changed my life. At the time, I was panicked. The exercise was called “Craft your legacy statement.”
But, this exercise was different. The ask was to “live into your legacy.” Craft a legacy statement in THREE minutes that summarizes what you want your legacy to be … and then decide the three things you need to do now to get there. So, here is my exact legacy 3-minute statement: I am an innovator pushing teaching hospitals to optimize training and patient care delivery through novel technologies and systems science. Clearly, I did not aim high enough. One of the other attendees stated her legacy simply as “Unleash the impossible!” So clearly, I was not able to think big at that moment, but I trudged on.
Next, I had to write the three things I was going to do to enact my legacy today. Things went from bad to worse quickly since I knew this was not going to be easy. The #1 thing had to be something I was going to stop doing because it did not fit with my legacy; #2 was what I was going to start doing to enact this legacy now; and, #3 was something I was going to do to get me closer to what I wanted to be doing. So, my #1, resign my current leadership role that I had had for 8 years; #2, start joining national committees that bridge education and quality; and #3, meet with senior leadership to pitch this new role as a bridging leader, aligning education and quality.
Like all conferences, I went home and forgot what I had done and learned. I settled back into my old life and routines. A few weeks later, a plain looking envelope with awful penmanship showed up at my doorstep addressed to me. It wasn’t until after I opened it and read what was inside that I realized I was the one with horrible penmanship! I completely forgot that I wrote this letter to myself even though they told me it would come and I would forget I wrote it! So, how did I do? Let’s just say if the letter did not arrive, I am not sure where I would be. Fortunately, it did come, and I followed my own orders. Fast forward to present day and I recently stepped into a new role – associate chief medical officer: clinical learning environment – a bridging leader who aligns education and clinical care missions for our health system. Let’s just say again, had that letter not arrived, I am not sure where I would be now.
I have been fortunate to do many things in hospital medicine – clinician, researcher, educator, and my latest role as a leader. Through it all, I would say that there are some lessons that I have picked up along the way that helped me advance, in ways I did not realize:
- Be bold. Years ago, when I was asked by my chair who they should pick to be chief resident, I thought “This must be a trick question – I should definitely tell him why I should be chosen – and then pick the next best person who I want to work with.” Apparently, I was the only person who did that, and that is why my chair chose me. Everyone else picked two other people. So the take-home point here is do not sell yourself short … ever.
- Look for the hidden gateways. A few years ago, I was asked if I wanted to be an institutional leader by the person who currently had that role. I was kind of thrown for a loop, since of course I would not want to appear like I wanted to take his job. I said everything was fine and I felt pretty good about my current positions. It was only a few weeks later that I realized that he was ascertaining my interest in his job since he was leaving. They gave the job to someone else and the word on the street was I was not interested. I totally missed the gate! While it wasn’t necessarily the job I missed out on, it was the opportunity to consider the job because I was afraid. So, don’t miss the gate. It’s the wormhole to a different life that may be the right one for you, but you need to “see it” to seize it.
- Work hard for the money and for the fun. There are many things Gwyneth Paltrow does that I do not agree with, but I will give her credit for one important lesson: she divides her movie roles into those she does for love (for example, The Royal Tenenbaums) and those she does for money (for example, Shallow Hal). It made me realize that even a Hollywood starlet has to do the stuff she may not want to do for the money. So, as a young person, you have to work hard for the money, but ideally it will help you take on a project you love, whatever it is. You’ve won the game when you’re mostly paid to work for the fun ... but that may take some time.
- Always optimize what is best for you personally AND professionally. While I was on maternity leave, the job of my dreams presented itself – or so I thought it did. It was at the intersection of policy, quality, and education, with a national stage, and I would not need to move. But, I knew I could not accept the travel commitment with a young child. While I wondered if I would have regrets, it turns out the right decision professionally also has to work personally. Likewise, there are professional obligations that I take on because it works personally.
- Figure out who your tea house pals are. A few years ago, I was in San Francisco with two close friends having an epic moment about what to do with our lives as adults. We were all on the cusp of changing our directions. Not surprisingly, we could see what the other needed to do, but we could not see it for ourselves. We still text each other sometimes about the need to go back to the Tea House. Sometimes your “tea house pals” are not necessarily those around you every day. They know you, but not everyone in your work place. This “arm’s length” or distance gives them the rational, unbiased perspective to advise you, that you or your colleagues will never have.
- Look for ways to enjoy the journey. Medicine is a very long road. I routinely think about this working with all the trainees and junior faculty I encounter. You can’t be in this solely for the end of the journey. The key is to find the joy in the journey. For me, that has always come from seeking out like-minded fellow travelers to share my highs and lows. While I tweet for many reasons, a big reason is that I take pleasure in watching others on the journey and also sharing my own journey.
Here’s to your journey and living your legacy!
Dr. Arora is associate chief medical officer, clinical learning environment, at University of Chicago Medicine, and assistant dean for scholarship and discovery at the University of Chicago Pritzker School of Medicine. You can follow her journey on Twitter.
Linking Metabolic Health, Psychiatric Disease, and Oxytocin Levels
African American men with diabetes may be at risk for significantly low levels of oxytocin (OT), according to a study of 92 veterans by researchers from the Jesse Brown Veterans Administration Medical Center in Chicago, Illinois. Research has recently been revealing oxytocin’s role in energy homeostasis; OT derangements have also been implicated in a variety of diseases, including schizophrenia, autism, dysthymia, and attention-deficit/hyperactivity disorder.
The researchers note that their study participants represent a “unique population” of African American male veterans for whom no data on OT levels exist in the literature. The population has a disproportionately high rate of obesity and dysglycemia, as well as high rates of comorbid psychiatric disease.
In the study, urinary oxytocin was higher in men with lower weight, body mass index (BMI), and hemoglobin A1c and better renal function. Men with the highest levels of oxytocin were about 80% less likely to have type 2 diabetes. The researchers say several studies have appeared to show that intranasal OT may reduce reward-driven food intake, and that OT administration may result in weight reduction.
Men with high oxytocin levels were 4 times more likely to be using psychiatric medications. Although there was no difference in psychiatric conditions based on OT levels, the use of psychiatric medications remained significant after adjustment for BMI. The influence of psychiatric medications on oxytocinergic systems is not well understood, the researchers say. However, they add that medication-related improved psychological health outcome might result in OT changes.
Men with high oxytocin levels were also 4 times more likely to be smokers. The researchers note that chronic administration of nicotine seems to upregulate OT receptor binding in regions of the brain involved in stress and emotion regulation, and these neuro-adaptations likely influence nicotine-seeking behavior. Intranasal OT is being investigated for smoking cessation.
African American men with diabetes may be at risk for significantly low levels of oxytocin (OT), according to a study of 92 veterans by researchers from the Jesse Brown Veterans Administration Medical Center in Chicago, Illinois. Research has recently been revealing oxytocin’s role in energy homeostasis; OT derangements have also been implicated in a variety of diseases, including schizophrenia, autism, dysthymia, and attention-deficit/hyperactivity disorder.
The researchers note that their study participants represent a “unique population” of African American male veterans for whom no data on OT levels exist in the literature. The population has a disproportionately high rate of obesity and dysglycemia, as well as high rates of comorbid psychiatric disease.
In the study, urinary oxytocin was higher in men with lower weight, body mass index (BMI), and hemoglobin A1c and better renal function. Men with the highest levels of oxytocin were about 80% less likely to have type 2 diabetes. The researchers say several studies have appeared to show that intranasal OT may reduce reward-driven food intake, and that OT administration may result in weight reduction.
Men with high oxytocin levels were 4 times more likely to be using psychiatric medications. Although there was no difference in psychiatric conditions based on OT levels, the use of psychiatric medications remained significant after adjustment for BMI. The influence of psychiatric medications on oxytocinergic systems is not well understood, the researchers say. However, they add that medication-related improved psychological health outcome might result in OT changes.
Men with high oxytocin levels were also 4 times more likely to be smokers. The researchers note that chronic administration of nicotine seems to upregulate OT receptor binding in regions of the brain involved in stress and emotion regulation, and these neuro-adaptations likely influence nicotine-seeking behavior. Intranasal OT is being investigated for smoking cessation.
African American men with diabetes may be at risk for significantly low levels of oxytocin (OT), according to a study of 92 veterans by researchers from the Jesse Brown Veterans Administration Medical Center in Chicago, Illinois. Research has recently been revealing oxytocin’s role in energy homeostasis; OT derangements have also been implicated in a variety of diseases, including schizophrenia, autism, dysthymia, and attention-deficit/hyperactivity disorder.
The researchers note that their study participants represent a “unique population” of African American male veterans for whom no data on OT levels exist in the literature. The population has a disproportionately high rate of obesity and dysglycemia, as well as high rates of comorbid psychiatric disease.
In the study, urinary oxytocin was higher in men with lower weight, body mass index (BMI), and hemoglobin A1c and better renal function. Men with the highest levels of oxytocin were about 80% less likely to have type 2 diabetes. The researchers say several studies have appeared to show that intranasal OT may reduce reward-driven food intake, and that OT administration may result in weight reduction.
Men with high oxytocin levels were 4 times more likely to be using psychiatric medications. Although there was no difference in psychiatric conditions based on OT levels, the use of psychiatric medications remained significant after adjustment for BMI. The influence of psychiatric medications on oxytocinergic systems is not well understood, the researchers say. However, they add that medication-related improved psychological health outcome might result in OT changes.
Men with high oxytocin levels were also 4 times more likely to be smokers. The researchers note that chronic administration of nicotine seems to upregulate OT receptor binding in regions of the brain involved in stress and emotion regulation, and these neuro-adaptations likely influence nicotine-seeking behavior. Intranasal OT is being investigated for smoking cessation.
What We Don’t Know About Osteoporosis Treatment
A 5-member panel of experts in primary care, geriatrics, and behavioral sciences, among others, convened by the National Institutes of Health (NIH), sought to answer that question. In the Pathways to Prevention (P2P) Workshop: Appropriate Use of Drug Therapies for Osteoporotic Fracture Prevention, the panel discussed the available evidence on long-term drug therapies, in hopes of identifying research gaps and ways to “advance the field.” Then they published a report that summarizes their findings, along with recommendations for “new strengthened research.”
Trials have found 3 to 5 years of ODT is safe and effective, the panel notes, and that some ODTs reduce the incidence of nonvertebral fractures. But those studies have been done mainly in white postmenopausal women. Men, people of other race and ethnicity, residents in facilities, people with advanced and multiple comorbid conditions, and other populations are absent or underrepresented. Thus, estimates on benefits and harms may differ in practice. Moreover, the trial results presented no data on nonfracture patient outcomes or sequelae, such as mobility, hospitalizations, and nursing home placement. The studies also offered limited or no evidence on whether patient characteristics would result in different fracture outcomes.
The panel also noted that few trials extended beyond 5 years, although some observational studies provided “limited evidence” on potential benefits and harms from longer term use. Gaps exist in how to use information on bone biomarkers and other patient characteristics, such as concurrent medication use, that might modify the effects of ODT, the panel concluded.
One of the main issues the panel investigated was how to make sure that the people at highest risk of fracture get the medicine they need. Only about one-third of women at high risk have reported treatment with osteoporosis medication. And among older adults with a hip fracture, only 11% to 13% filled any prescription for osteoporosis medication within 3 months of the fracture.
Information about ODT use and adherence was not included in the systematic evidence review, so the report relies on material provided by the workshop speakers, who say low rates of diagnosis and treatment probably stem from multiple clinician and patient factors. For instance, they said, with regard to clinicians, the problems may be lack of time, knowledge gaps, and lack of appropriate systems in primary care.
The panelists also cited another gap: in communication between clinicians about treatment as patients transition from one setting to another. One solution could be a hospital-based fracture liaison service to coordinate care, they suggest.
Patient factors include perceptions that osteoporosis is a normal part of aging, or that drugs do not work or that they are harmful and risky. Studies about decision making have found that people often overestimate their risk for rare adverse effects (AEs) and underestimate the likelihood of having a fracture.
In their assessment of studies, the workshop panelists found education-based interventions sometimes increase rates of filled prescriptions but not adherence 6 or 10 months down the road. They also found coaching and counseling have been “largely ineffective.”
“We need to identify the reasons why,” the panelists concluded, and made a number of recommendations about how to do the research. For instance, they suggest using a broader array of trial designs, such as innovative platform trials as used in cancer research, where the target of the investigation is the disease and not the drug. Studies also should focus on fracture sequelae, and include diverse populations that “more closely match” the characteristics of people who actually have fractures.
Gaps in knowledge about the uncommon AEs reported with bisphosphonates and other questions mean questions to be answered include which class of drugs should be used first, when treatment should start and how long it should last, and which doses are preferable.
Knowing how to treat can help clinicians and their patients decide whom to treat, the report suggests. Addressing the research gaps will improve the shared decision making needed for answering those questions.
The report was published in Annals of Internal Medicine on April 23, 2019.
A 5-member panel of experts in primary care, geriatrics, and behavioral sciences, among others, convened by the National Institutes of Health (NIH), sought to answer that question. In the Pathways to Prevention (P2P) Workshop: Appropriate Use of Drug Therapies for Osteoporotic Fracture Prevention, the panel discussed the available evidence on long-term drug therapies, in hopes of identifying research gaps and ways to “advance the field.” Then they published a report that summarizes their findings, along with recommendations for “new strengthened research.”
Trials have found 3 to 5 years of ODT is safe and effective, the panel notes, and that some ODTs reduce the incidence of nonvertebral fractures. But those studies have been done mainly in white postmenopausal women. Men, people of other race and ethnicity, residents in facilities, people with advanced and multiple comorbid conditions, and other populations are absent or underrepresented. Thus, estimates on benefits and harms may differ in practice. Moreover, the trial results presented no data on nonfracture patient outcomes or sequelae, such as mobility, hospitalizations, and nursing home placement. The studies also offered limited or no evidence on whether patient characteristics would result in different fracture outcomes.
The panel also noted that few trials extended beyond 5 years, although some observational studies provided “limited evidence” on potential benefits and harms from longer term use. Gaps exist in how to use information on bone biomarkers and other patient characteristics, such as concurrent medication use, that might modify the effects of ODT, the panel concluded.
One of the main issues the panel investigated was how to make sure that the people at highest risk of fracture get the medicine they need. Only about one-third of women at high risk have reported treatment with osteoporosis medication. And among older adults with a hip fracture, only 11% to 13% filled any prescription for osteoporosis medication within 3 months of the fracture.
Information about ODT use and adherence was not included in the systematic evidence review, so the report relies on material provided by the workshop speakers, who say low rates of diagnosis and treatment probably stem from multiple clinician and patient factors. For instance, they said, with regard to clinicians, the problems may be lack of time, knowledge gaps, and lack of appropriate systems in primary care.
The panelists also cited another gap: in communication between clinicians about treatment as patients transition from one setting to another. One solution could be a hospital-based fracture liaison service to coordinate care, they suggest.
Patient factors include perceptions that osteoporosis is a normal part of aging, or that drugs do not work or that they are harmful and risky. Studies about decision making have found that people often overestimate their risk for rare adverse effects (AEs) and underestimate the likelihood of having a fracture.
In their assessment of studies, the workshop panelists found education-based interventions sometimes increase rates of filled prescriptions but not adherence 6 or 10 months down the road. They also found coaching and counseling have been “largely ineffective.”
“We need to identify the reasons why,” the panelists concluded, and made a number of recommendations about how to do the research. For instance, they suggest using a broader array of trial designs, such as innovative platform trials as used in cancer research, where the target of the investigation is the disease and not the drug. Studies also should focus on fracture sequelae, and include diverse populations that “more closely match” the characteristics of people who actually have fractures.
Gaps in knowledge about the uncommon AEs reported with bisphosphonates and other questions mean questions to be answered include which class of drugs should be used first, when treatment should start and how long it should last, and which doses are preferable.
Knowing how to treat can help clinicians and their patients decide whom to treat, the report suggests. Addressing the research gaps will improve the shared decision making needed for answering those questions.
The report was published in Annals of Internal Medicine on April 23, 2019.
A 5-member panel of experts in primary care, geriatrics, and behavioral sciences, among others, convened by the National Institutes of Health (NIH), sought to answer that question. In the Pathways to Prevention (P2P) Workshop: Appropriate Use of Drug Therapies for Osteoporotic Fracture Prevention, the panel discussed the available evidence on long-term drug therapies, in hopes of identifying research gaps and ways to “advance the field.” Then they published a report that summarizes their findings, along with recommendations for “new strengthened research.”
Trials have found 3 to 5 years of ODT is safe and effective, the panel notes, and that some ODTs reduce the incidence of nonvertebral fractures. But those studies have been done mainly in white postmenopausal women. Men, people of other race and ethnicity, residents in facilities, people with advanced and multiple comorbid conditions, and other populations are absent or underrepresented. Thus, estimates on benefits and harms may differ in practice. Moreover, the trial results presented no data on nonfracture patient outcomes or sequelae, such as mobility, hospitalizations, and nursing home placement. The studies also offered limited or no evidence on whether patient characteristics would result in different fracture outcomes.
The panel also noted that few trials extended beyond 5 years, although some observational studies provided “limited evidence” on potential benefits and harms from longer term use. Gaps exist in how to use information on bone biomarkers and other patient characteristics, such as concurrent medication use, that might modify the effects of ODT, the panel concluded.
One of the main issues the panel investigated was how to make sure that the people at highest risk of fracture get the medicine they need. Only about one-third of women at high risk have reported treatment with osteoporosis medication. And among older adults with a hip fracture, only 11% to 13% filled any prescription for osteoporosis medication within 3 months of the fracture.
Information about ODT use and adherence was not included in the systematic evidence review, so the report relies on material provided by the workshop speakers, who say low rates of diagnosis and treatment probably stem from multiple clinician and patient factors. For instance, they said, with regard to clinicians, the problems may be lack of time, knowledge gaps, and lack of appropriate systems in primary care.
The panelists also cited another gap: in communication between clinicians about treatment as patients transition from one setting to another. One solution could be a hospital-based fracture liaison service to coordinate care, they suggest.
Patient factors include perceptions that osteoporosis is a normal part of aging, or that drugs do not work or that they are harmful and risky. Studies about decision making have found that people often overestimate their risk for rare adverse effects (AEs) and underestimate the likelihood of having a fracture.
In their assessment of studies, the workshop panelists found education-based interventions sometimes increase rates of filled prescriptions but not adherence 6 or 10 months down the road. They also found coaching and counseling have been “largely ineffective.”
“We need to identify the reasons why,” the panelists concluded, and made a number of recommendations about how to do the research. For instance, they suggest using a broader array of trial designs, such as innovative platform trials as used in cancer research, where the target of the investigation is the disease and not the drug. Studies also should focus on fracture sequelae, and include diverse populations that “more closely match” the characteristics of people who actually have fractures.
Gaps in knowledge about the uncommon AEs reported with bisphosphonates and other questions mean questions to be answered include which class of drugs should be used first, when treatment should start and how long it should last, and which doses are preferable.
Knowing how to treat can help clinicians and their patients decide whom to treat, the report suggests. Addressing the research gaps will improve the shared decision making needed for answering those questions.
The report was published in Annals of Internal Medicine on April 23, 2019.
Severe OSA increases cardiovascular risk after surgery
Unrecognized severe obstructive sleep apnea is a risk factor for cardiovascular complications after major noncardiac surgery, according to a study published in JAMA.
The researchers state that perioperative mismanagement of obstructive sleep apnea can lead to serious medical consequences. “General anesthetics, sedatives, and postoperative analgesics are potent respiratory depressants that relax the upper airway dilator muscles and impair ventilatory response to hypoxemia and hypercapnia. Each of these events exacerbates [obstructive sleep apnea] and may predispose patients to postoperative cardiovascular complications,” said researchers who conducted the The Postoperative vascular complications in unrecognised Obstructive Sleep apnoea (POSA) study (NCT01494181).
They undertook a prospective observational cohort study involving 1,218 patients undergoing major noncardiac surgery, who were already considered at high risk of postoperative cardiovascular events – having, for example, a history of coronary artery disease, stroke, diabetes, or renal impairment. However, none had a prior diagnosis of obstructive sleep apnea.
Preoperative sleep monitoring revealed that two-thirds of the cohort had unrecognized and untreated obstructive sleep apnea, including 11.2% with severe obstructive sleep apnea.
At 30 days after surgery, patients with obstructive sleep apnea had a 49% higher risk of the primary outcome of myocardial injury, cardiac death, heart failure, thromboembolism, atrial fibrillation, or stroke, compared with those without obstructive sleep apnea.
However, this association was largely due to a significant 2.23-fold higher risk among patients with severe obstructive sleep apnea, while those with only moderate or mild sleep apnea did not show a significant increased risk of cardiovascular complications.
Patients in this study with severe obstructive sleep apnea had a 13-fold higher risk of cardiac death, 80% higher risk of myocardial injury, more than sixfold higher risk of heart failure, and nearly fourfold higher risk of atrial fibrillation.
Researchers also saw an association between obstructive sleep apnea and increased risk of infective outcomes, unplanned tracheal intubation, postoperative lung ventilation, and readmission to the ICU.
The majority of patients received nocturnal oximetry monitoring during their first 3 nights after surgery. This revealed that patients without obstructive sleep apnea had significant increases in oxygen desaturation index during their first night after surgery, while those with sleep apnea did not return to their baseline oxygen desaturation index until the third night after surgery.
“Despite a substantial decrease in ODI [oxygen desaturation index] with oxygen therapy in patients with OSA during the first 3 postoperative nights, supplemental oxygen did not modify the association between OSA and postoperative cardiovascular event,” wrote Matthew T.V. Chan, MD, of Chinese University of Hong Kong, Prince of Wales Hospital, and coauthors.
Given that the events were associated with longer durations of severe oxyhemoglobin desaturation, more aggressive interventions such as positive airway pressure or oral appliances may be required, they noted.
“However, high-level evidence demonstrating the effect of these measures on perioperative outcomes is lacking [and] further clinical trials are now required to test if additional monitoring or alternative interventions would reduce the risk,” they wrote.
The study was supported by the Health and Medical Research Fund (Hong Kong), National Healthcare Group–Khoo Teck Puat Hospital, University Health Network Foundation, University of Malaya, Malaysian Society of Anaesthesiologists, Auckland Medical Research Foundation, and ResMed. One author declared grants from private industry and a patent pending on an obstructive sleep apnea risk questionnaire used in the study.
SOURCE: Chan M et al. JAMA 2019;321[18]:1788-98. doi: 10.1001/jama.2019.4783.
This study is large, prospective, and rigorous and adds important new information to the puzzle of the impact of sleep apnea on postoperative risk, Dennis Auckley, MD, and Stavros Memtsoudis, MD, wrote in an editorial accompanying this study. The study focused on predetermined clinically significant and measurable events, used standardized and objective sleep apnea testing, and attempted to control for many of the confounders that might have influenced outcomes.
The results suggest that obstructive sleep apnea should be recognized as a major perioperative risk factor, and it should receive the same attention and optimization efforts as comorbidities such as diabetes.
Dr. Auckley is from the division of pulmonary, critical care and sleep medicine at MetroHealth Medical Center, Case Western Reserve University, Cleveland, and Dr. Memtsoudis is clinical professor of anesthesiology at Cornell University, New York. These comments are adapted from an editorial (JAMA 2019;231[18]:1775-6). Both declared board and executive positions with the Society of Anesthesia and Sleep Medicine. Dr. Auckley declared research funding from Medtronic, and Dr. Memtsoudis declared personal fees from Teikoku and Sandoz.
This study is large, prospective, and rigorous and adds important new information to the puzzle of the impact of sleep apnea on postoperative risk, Dennis Auckley, MD, and Stavros Memtsoudis, MD, wrote in an editorial accompanying this study. The study focused on predetermined clinically significant and measurable events, used standardized and objective sleep apnea testing, and attempted to control for many of the confounders that might have influenced outcomes.
The results suggest that obstructive sleep apnea should be recognized as a major perioperative risk factor, and it should receive the same attention and optimization efforts as comorbidities such as diabetes.
Dr. Auckley is from the division of pulmonary, critical care and sleep medicine at MetroHealth Medical Center, Case Western Reserve University, Cleveland, and Dr. Memtsoudis is clinical professor of anesthesiology at Cornell University, New York. These comments are adapted from an editorial (JAMA 2019;231[18]:1775-6). Both declared board and executive positions with the Society of Anesthesia and Sleep Medicine. Dr. Auckley declared research funding from Medtronic, and Dr. Memtsoudis declared personal fees from Teikoku and Sandoz.
This study is large, prospective, and rigorous and adds important new information to the puzzle of the impact of sleep apnea on postoperative risk, Dennis Auckley, MD, and Stavros Memtsoudis, MD, wrote in an editorial accompanying this study. The study focused on predetermined clinically significant and measurable events, used standardized and objective sleep apnea testing, and attempted to control for many of the confounders that might have influenced outcomes.
The results suggest that obstructive sleep apnea should be recognized as a major perioperative risk factor, and it should receive the same attention and optimization efforts as comorbidities such as diabetes.
Dr. Auckley is from the division of pulmonary, critical care and sleep medicine at MetroHealth Medical Center, Case Western Reserve University, Cleveland, and Dr. Memtsoudis is clinical professor of anesthesiology at Cornell University, New York. These comments are adapted from an editorial (JAMA 2019;231[18]:1775-6). Both declared board and executive positions with the Society of Anesthesia and Sleep Medicine. Dr. Auckley declared research funding from Medtronic, and Dr. Memtsoudis declared personal fees from Teikoku and Sandoz.
Unrecognized severe obstructive sleep apnea is a risk factor for cardiovascular complications after major noncardiac surgery, according to a study published in JAMA.
The researchers state that perioperative mismanagement of obstructive sleep apnea can lead to serious medical consequences. “General anesthetics, sedatives, and postoperative analgesics are potent respiratory depressants that relax the upper airway dilator muscles and impair ventilatory response to hypoxemia and hypercapnia. Each of these events exacerbates [obstructive sleep apnea] and may predispose patients to postoperative cardiovascular complications,” said researchers who conducted the The Postoperative vascular complications in unrecognised Obstructive Sleep apnoea (POSA) study (NCT01494181).
They undertook a prospective observational cohort study involving 1,218 patients undergoing major noncardiac surgery, who were already considered at high risk of postoperative cardiovascular events – having, for example, a history of coronary artery disease, stroke, diabetes, or renal impairment. However, none had a prior diagnosis of obstructive sleep apnea.
Preoperative sleep monitoring revealed that two-thirds of the cohort had unrecognized and untreated obstructive sleep apnea, including 11.2% with severe obstructive sleep apnea.
At 30 days after surgery, patients with obstructive sleep apnea had a 49% higher risk of the primary outcome of myocardial injury, cardiac death, heart failure, thromboembolism, atrial fibrillation, or stroke, compared with those without obstructive sleep apnea.
However, this association was largely due to a significant 2.23-fold higher risk among patients with severe obstructive sleep apnea, while those with only moderate or mild sleep apnea did not show a significant increased risk of cardiovascular complications.
Patients in this study with severe obstructive sleep apnea had a 13-fold higher risk of cardiac death, 80% higher risk of myocardial injury, more than sixfold higher risk of heart failure, and nearly fourfold higher risk of atrial fibrillation.
Researchers also saw an association between obstructive sleep apnea and increased risk of infective outcomes, unplanned tracheal intubation, postoperative lung ventilation, and readmission to the ICU.
The majority of patients received nocturnal oximetry monitoring during their first 3 nights after surgery. This revealed that patients without obstructive sleep apnea had significant increases in oxygen desaturation index during their first night after surgery, while those with sleep apnea did not return to their baseline oxygen desaturation index until the third night after surgery.
“Despite a substantial decrease in ODI [oxygen desaturation index] with oxygen therapy in patients with OSA during the first 3 postoperative nights, supplemental oxygen did not modify the association between OSA and postoperative cardiovascular event,” wrote Matthew T.V. Chan, MD, of Chinese University of Hong Kong, Prince of Wales Hospital, and coauthors.
Given that the events were associated with longer durations of severe oxyhemoglobin desaturation, more aggressive interventions such as positive airway pressure or oral appliances may be required, they noted.
“However, high-level evidence demonstrating the effect of these measures on perioperative outcomes is lacking [and] further clinical trials are now required to test if additional monitoring or alternative interventions would reduce the risk,” they wrote.
The study was supported by the Health and Medical Research Fund (Hong Kong), National Healthcare Group–Khoo Teck Puat Hospital, University Health Network Foundation, University of Malaya, Malaysian Society of Anaesthesiologists, Auckland Medical Research Foundation, and ResMed. One author declared grants from private industry and a patent pending on an obstructive sleep apnea risk questionnaire used in the study.
SOURCE: Chan M et al. JAMA 2019;321[18]:1788-98. doi: 10.1001/jama.2019.4783.
Unrecognized severe obstructive sleep apnea is a risk factor for cardiovascular complications after major noncardiac surgery, according to a study published in JAMA.
The researchers state that perioperative mismanagement of obstructive sleep apnea can lead to serious medical consequences. “General anesthetics, sedatives, and postoperative analgesics are potent respiratory depressants that relax the upper airway dilator muscles and impair ventilatory response to hypoxemia and hypercapnia. Each of these events exacerbates [obstructive sleep apnea] and may predispose patients to postoperative cardiovascular complications,” said researchers who conducted the The Postoperative vascular complications in unrecognised Obstructive Sleep apnoea (POSA) study (NCT01494181).
They undertook a prospective observational cohort study involving 1,218 patients undergoing major noncardiac surgery, who were already considered at high risk of postoperative cardiovascular events – having, for example, a history of coronary artery disease, stroke, diabetes, or renal impairment. However, none had a prior diagnosis of obstructive sleep apnea.
Preoperative sleep monitoring revealed that two-thirds of the cohort had unrecognized and untreated obstructive sleep apnea, including 11.2% with severe obstructive sleep apnea.
At 30 days after surgery, patients with obstructive sleep apnea had a 49% higher risk of the primary outcome of myocardial injury, cardiac death, heart failure, thromboembolism, atrial fibrillation, or stroke, compared with those without obstructive sleep apnea.
However, this association was largely due to a significant 2.23-fold higher risk among patients with severe obstructive sleep apnea, while those with only moderate or mild sleep apnea did not show a significant increased risk of cardiovascular complications.
Patients in this study with severe obstructive sleep apnea had a 13-fold higher risk of cardiac death, 80% higher risk of myocardial injury, more than sixfold higher risk of heart failure, and nearly fourfold higher risk of atrial fibrillation.
Researchers also saw an association between obstructive sleep apnea and increased risk of infective outcomes, unplanned tracheal intubation, postoperative lung ventilation, and readmission to the ICU.
The majority of patients received nocturnal oximetry monitoring during their first 3 nights after surgery. This revealed that patients without obstructive sleep apnea had significant increases in oxygen desaturation index during their first night after surgery, while those with sleep apnea did not return to their baseline oxygen desaturation index until the third night after surgery.
“Despite a substantial decrease in ODI [oxygen desaturation index] with oxygen therapy in patients with OSA during the first 3 postoperative nights, supplemental oxygen did not modify the association between OSA and postoperative cardiovascular event,” wrote Matthew T.V. Chan, MD, of Chinese University of Hong Kong, Prince of Wales Hospital, and coauthors.
Given that the events were associated with longer durations of severe oxyhemoglobin desaturation, more aggressive interventions such as positive airway pressure or oral appliances may be required, they noted.
“However, high-level evidence demonstrating the effect of these measures on perioperative outcomes is lacking [and] further clinical trials are now required to test if additional monitoring or alternative interventions would reduce the risk,” they wrote.
The study was supported by the Health and Medical Research Fund (Hong Kong), National Healthcare Group–Khoo Teck Puat Hospital, University Health Network Foundation, University of Malaya, Malaysian Society of Anaesthesiologists, Auckland Medical Research Foundation, and ResMed. One author declared grants from private industry and a patent pending on an obstructive sleep apnea risk questionnaire used in the study.
SOURCE: Chan M et al. JAMA 2019;321[18]:1788-98. doi: 10.1001/jama.2019.4783.
FROM JAMA