Doug Brunk

PHOENIX – Over the past 11 years, fewer general surgery residents have participated in important types of general thoracic surgery cases, a retrospective review found.

“These findings may be the result of the work-hours reduction causing less exposure to general thoracic surgery and/or a reluctance to allow general surgery residents to perform the increasingly common minimally invasive procedures,” researchers led by Dr. William S. Ragalie wrote in an abstract presented during a poster session at the annual meeting of the Society of Thoracic Surgeons.

Dr. Ragalie of the Medical College of Wisconsin, Milwaukee, and his associates retrospectively reviewed the Accreditation Council for Graduate Medical Education resident case log database for the most recent 11 years in an effort to quantify and trend the operative experience among general surgery residents. They categorized cases by year, level of resident participation, and level of complexity. Major general thoracic cases were defined as esophagectomy, pneumonectomy, and lobectomy, while cases that did not involve hilar dissection were classified as “other thoracic.”

The researchers found that the 90th percentile of first assist thoracic surgery cases decreased significantly over the study period by an average of 1.46 cases per year (P = .0012). Decreased case volumes in pneumonectomy were also noted at the junior level (–0.012 cases per year; P less than .0001) and at the chief resident level (–0.31 cases per year; P less than .001). This was also true of open lobectomy cases (–0.14 cases per year at the junior level; P less than .001, and –3.41 cases per year at the chief resident level; P less than .0001).

As for video-assisted thoracoscopic surgery (VATS) lobectomy, the researchers observed an increase in average case volume at the junior surgeon level of .13 cases per year, but a decrease at the chief resident level of one case per year (P less than .001 for both).

©monkeybusinessimages/Thinkstock.com

Dr. Ragalie and his associates also observed a decrease in the following procedures performed by chief residents: open exploratory thoracoscopy (–3.17 cases per year; P less than .001), VATS exploratory thoracoscopy (–2.95 cases per year; P less than .0001), open wedge resection (–1.52 cases per year; P less than .0227), VATS wedge resection (–2.72 cases per year; P less than .0002), “other thoracic” (–6.3 cases per year; P = .0001), and thoracoscopic pleurodesis (–2.09 cases per year; P less than .0001).

At the same time, a significant trend of decreased case volume at the junior surgeon level was noted for open exploratory thoracoscopy (–0.10 cases per year; P less than .0001) and open wedge resection (–0.22 cases per year; P = . 0115).

The researchers reported having no financial disclosures.

[email protected]

PHOENIX – Over the past 11 years, fewer general surgery residents have participated in important types of general thoracic surgery cases, a retrospective review found.

“These findings may be the result of the work-hours reduction causing less exposure to general thoracic surgery and/or a reluctance to allow general surgery residents to perform the increasingly common minimally invasive procedures,” researchers led by Dr. William S. Ragalie wrote in an abstract presented during a poster session at the annual meeting of the Society of Thoracic Surgeons.

Dr. Ragalie of the Medical College of Wisconsin, Milwaukee, and his associates retrospectively reviewed the Accreditation Council for Graduate Medical Education resident case log database for the most recent 11 years in an effort to quantify and trend the operative experience among general surgery residents. They categorized cases by year, level of resident participation, and level of complexity. Major general thoracic cases were defined as esophagectomy, pneumonectomy, and lobectomy, while cases that did not involve hilar dissection were classified as “other thoracic.”

The researchers found that the 90th percentile of first assist thoracic surgery cases decreased significantly over the study period by an average of 1.46 cases per year (P = .0012). Decreased case volumes in pneumonectomy were also noted at the junior level (–0.012 cases per year; P less than .0001) and at the chief resident level (–0.31 cases per year; P less than .001). This was also true of open lobectomy cases (–0.14 cases per year at the junior level; P less than .001, and –3.41 cases per year at the chief resident level; P less than .0001).

As for video-assisted thoracoscopic surgery (VATS) lobectomy, the researchers observed an increase in average case volume at the junior surgeon level of .13 cases per year, but a decrease at the chief resident level of one case per year (P less than .001 for both).

©monkeybusinessimages/Thinkstock.com

Dr. Ragalie and his associates also observed a decrease in the following procedures performed by chief residents: open exploratory thoracoscopy (–3.17 cases per year; P less than .001), VATS exploratory thoracoscopy (–2.95 cases per year; P less than .0001), open wedge resection (–1.52 cases per year; P less than .0227), VATS wedge resection (–2.72 cases per year; P less than .0002), “other thoracic” (–6.3 cases per year; P = .0001), and thoracoscopic pleurodesis (–2.09 cases per year; P less than .0001).

At the same time, a significant trend of decreased case volume at the junior surgeon level was noted for open exploratory thoracoscopy (–0.10 cases per year; P less than .0001) and open wedge resection (–0.22 cases per year; P = . 0115).

The researchers reported having no financial disclosures.

[email protected]

PHOENIX – Over the past 11 years, fewer general surgery residents have participated in important types of general thoracic surgery cases, a retrospective review found.

“These findings may be the result of the work-hours reduction causing less exposure to general thoracic surgery and/or a reluctance to allow general surgery residents to perform the increasingly common minimally invasive procedures,” researchers led by Dr. William S. Ragalie wrote in an abstract presented during a poster session at the annual meeting of the Society of Thoracic Surgeons.

Dr. Ragalie of the Medical College of Wisconsin, Milwaukee, and his associates retrospectively reviewed the Accreditation Council for Graduate Medical Education resident case log database for the most recent 11 years in an effort to quantify and trend the operative experience among general surgery residents. They categorized cases by year, level of resident participation, and level of complexity. Major general thoracic cases were defined as esophagectomy, pneumonectomy, and lobectomy, while cases that did not involve hilar dissection were classified as “other thoracic.”

The researchers found that the 90th percentile of first assist thoracic surgery cases decreased significantly over the study period by an average of 1.46 cases per year (P = .0012). Decreased case volumes in pneumonectomy were also noted at the junior level (–0.012 cases per year; P less than .0001) and at the chief resident level (–0.31 cases per year; P less than .001). This was also true of open lobectomy cases (–0.14 cases per year at the junior level; P less than .001, and –3.41 cases per year at the chief resident level; P less than .0001).

As for video-assisted thoracoscopic surgery (VATS) lobectomy, the researchers observed an increase in average case volume at the junior surgeon level of .13 cases per year, but a decrease at the chief resident level of one case per year (P less than .001 for both).

©monkeybusinessimages/Thinkstock.com

Dr. Ragalie and his associates also observed a decrease in the following procedures performed by chief residents: open exploratory thoracoscopy (–3.17 cases per year; P less than .001), VATS exploratory thoracoscopy (–2.95 cases per year; P less than .0001), open wedge resection (–1.52 cases per year; P less than .0227), VATS wedge resection (–2.72 cases per year; P less than .0002), “other thoracic” (–6.3 cases per year; P = .0001), and thoracoscopic pleurodesis (–2.09 cases per year; P less than .0001).

At the same time, a significant trend of decreased case volume at the junior surgeon level was noted for open exploratory thoracoscopy (–0.10 cases per year; P less than .0001) and open wedge resection (–0.22 cases per year; P = . 0115).

The researchers reported having no financial disclosures.

[email protected]

Children aged 12-18 years should be screened for major depressive disorder, but current evidence is insufficient to advise screening children aged 11 years or younger for the condition.

Those are among the key guidelines in updated recommendations from the U.S. Preventive Services Task Force on screening for depression in children and adolescents that were published online Feb. 8 in Pediatrics and in the Annals of Internal Medicine.

“Adolescents who are depressed suffer a lot of adverse consequences from their depression,” task force member Dr. Alexander H. Krist of the department of family medicine and population health at Virginia Commonwealth University, Richmond, said in an interview. “It can affect school, their family life, and their quality of life. Being able to identify adolescents who are depressed [and] making sure that they get the care that they need can have a big benefit for adolescents and their families.”

Although little is known about the prevalence of major depressive disorder (MDD) in children, results from national surveys suggest that about 8% of adolescents have had major depression in the past year, according to the task force members, who were chaired by Dr. Albert L. Siu, an internist and geriatrician in the department of geriatrics and palliative medicine at Mount Sinai School of Medicine, New York (Pediatrics. 2016 Feb 8. doi: 10.1542/peds.2015-4467).

The 2009 USPSTF guidelines recommended screening for MDD in adolescents “when systems for diagnosis, treatment, and follow-up are in place” and concluded that there was not enough evidence to make a recommendation regarding children aged 7-11 years. The updated recommendation reaffirms these positions but removes the mention of specific MDD therapies “in recognition of decreased concern over the harms of pharmacotherapy in adolescents when patients are adequately monitored.” In addition, more studies have been published that support the 2009 guidelines, “so that is one important change,” Dr. Krist said.

Recommendations for the new guidelines were based on a literature review conducted for the USPSTF by researchers led by Valerie Forman-Hoffman, Ph.D., of RTI International in Research Triangle Park, N.C. , and published online Feb. 8 (Ann Intern Med. 2016 Feb 8. doi: 10.7326/M15-2259). Supported by a grant from the Agency for Healthcare Research and Quality, the review involved a search for trials and systematic reviews of treatment, test-retest studies of screening, and trials and large cohort studies for harms that appeared in the medical literature between May 2007 and February 2015. No trials were found that directly assessed the benefits or harms of screening children or adolescents for MDD in primary care settings.

Here are the key recommendations:

• Screen for MDD in adolescents aged 12-18 years. Screening “should be implemented with adequate systems in place to ensure accurate diagnosis, effective treatment, and appropriate follow-up.” This is a “B” recommendation in the USPSTF grading system, which means that “there is high certainty that the net benefit is moderate or there is moderate certainty the net benefit is moderate to substantial.”

As stated in the recommendations, the phrase “adequate systems in place” refers to “having systems and clinical staff to ensure that patients are screened and, if they screen positive, are appropriately diagnosed and treated with evidence-based care or referred to a setting that can provide the necessary care.” This emphasis was made because “we now recognize that our health systems have evolved, and that it’s more the standard of care to have systems in place to care for adolescents who are depressed,” Dr. Krist explained. “The rewording stresses the importance of being able to make sure that care is given to adolescents after they’re diagnosed.”

The Affordable Care Act provides coverage for A and B recommendations of the USPSTF, so screening for MDD in adolescents would be a recommended service. “Often this type of a service would be delivered during a wellness exam,” Dr. Krist said. “That’s a commonly covered benefit right now with the ACA.”

• Current evidence “is insufficient to assess the balance of benefits and harms of screening for MDD in children aged 11 years or younger.” This is an “I” statement, which means that “evidence is lacking, of poor quality, or conflicting, and the balance of benefits and harms cannot be determined.”

The new USPSTF guidelines do no not recommend a specific instrument or screening strategy, but the review commissioned for the task force found that the Patient Health Questionnaire for Adolescents and Beck Depression Inventory outperformed other tools in adolescents.

In the opinion of Dr. Krist, a key challenge for primary care clinicians seeking to implement the recommendations is to establish a way to routinely ask adolescents about depression, “being able to systematize that so it’s done routinely and that it’s done well.” A second challenge is to establish a way to ensure proper diagnosis, proper treatment, and follow-up of adolescents who screen positive for MDD. “A lot of primary care practices may choose to do a lot of those activities themselves, or they might work out collaborations with other mental health providers and have a referral mechanism and a follow-up mechanism,” he said.

In an editorial that appeared online in the Annals of Internal Medicine, Dr. John W. Williams Jr. of the Durham (N.C.) Veterans Affairs Medical Center and Dr. Gary Maslow of Duke University, also in Durham, advised generalist physicians to “seize the day and act to implement these guidelines” (Ann Intern Med. 2016 Feb 8. doi: 10.7326/M16-0104). “Implementing high-quality depression care is not easy, but trials and demonstration projects show that it is possible and rewarding.”

Dr. Williams and Dr. Maslow went on to suggest ways that clinicians might incorporate the guidelines into their own practices. “For practices initiating screening for the first time, a pragmatic strategy might be to screen in conjunction with routine health visits and target persons with symptoms associated with depression (for example, insomnia) or risk factors, which in adolescents include female sex, older age, family history of depression, other mental health or behavioral problems, chronic medical illness, and overweight or obesity,” they wrote. “For practices with electronic health records, clinical reminders can be used to prompt staff to distribute screening questionnaires or verbally administer questions along with assessment of vital signs. The Guidelines for Adolescent Depression in Primary Care toolkit includes screening measures, screening procedures, and patient education materials to support the screening and treatment.”

The way Dr. Krist sees it, the overall message of the new recommendations is simple: Screening adolescents for depression has benefits. “We want primary care clinicians to do this, and we want to make sure that primary care practices put systems in place to care for adolescents with identified needs,” he said.

The Agency for Healthcare Research and Quality funded the review that formed the basis of the recommendations. The authors of the recommendation statement reported having no relevant financial disclosures.

Children aged 12-18 years should be screened for major depressive disorder, but current evidence is insufficient to advise screening children aged 11 years or younger for the condition.

Those are among the key guidelines in updated recommendations from the U.S. Preventive Services Task Force on screening for depression in children and adolescents that were published online Feb. 8 in Pediatrics and in the Annals of Internal Medicine.

“Adolescents who are depressed suffer a lot of adverse consequences from their depression,” task force member Dr. Alexander H. Krist of the department of family medicine and population health at Virginia Commonwealth University, Richmond, said in an interview. “It can affect school, their family life, and their quality of life. Being able to identify adolescents who are depressed [and] making sure that they get the care that they need can have a big benefit for adolescents and their families.”

Although little is known about the prevalence of major depressive disorder (MDD) in children, results from national surveys suggest that about 8% of adolescents have had major depression in the past year, according to the task force members, who were chaired by Dr. Albert L. Siu, an internist and geriatrician in the department of geriatrics and palliative medicine at Mount Sinai School of Medicine, New York (Pediatrics. 2016 Feb 8. doi: 10.1542/peds.2015-4467).

The 2009 USPSTF guidelines recommended screening for MDD in adolescents “when systems for diagnosis, treatment, and follow-up are in place” and concluded that there was not enough evidence to make a recommendation regarding children aged 7-11 years. The updated recommendation reaffirms these positions but removes the mention of specific MDD therapies “in recognition of decreased concern over the harms of pharmacotherapy in adolescents when patients are adequately monitored.” In addition, more studies have been published that support the 2009 guidelines, “so that is one important change,” Dr. Krist said.

Recommendations for the new guidelines were based on a literature review conducted for the USPSTF by researchers led by Valerie Forman-Hoffman, Ph.D., of RTI International in Research Triangle Park, N.C. , and published online Feb. 8 (Ann Intern Med. 2016 Feb 8. doi: 10.7326/M15-2259). Supported by a grant from the Agency for Healthcare Research and Quality, the review involved a search for trials and systematic reviews of treatment, test-retest studies of screening, and trials and large cohort studies for harms that appeared in the medical literature between May 2007 and February 2015. No trials were found that directly assessed the benefits or harms of screening children or adolescents for MDD in primary care settings.

Here are the key recommendations:

• Screen for MDD in adolescents aged 12-18 years. Screening “should be implemented with adequate systems in place to ensure accurate diagnosis, effective treatment, and appropriate follow-up.” This is a “B” recommendation in the USPSTF grading system, which means that “there is high certainty that the net benefit is moderate or there is moderate certainty the net benefit is moderate to substantial.”

As stated in the recommendations, the phrase “adequate systems in place” refers to “having systems and clinical staff to ensure that patients are screened and, if they screen positive, are appropriately diagnosed and treated with evidence-based care or referred to a setting that can provide the necessary care.” This emphasis was made because “we now recognize that our health systems have evolved, and that it’s more the standard of care to have systems in place to care for adolescents who are depressed,” Dr. Krist explained. “The rewording stresses the importance of being able to make sure that care is given to adolescents after they’re diagnosed.”

The Affordable Care Act provides coverage for A and B recommendations of the USPSTF, so screening for MDD in adolescents would be a recommended service. “Often this type of a service would be delivered during a wellness exam,” Dr. Krist said. “That’s a commonly covered benefit right now with the ACA.”

• Current evidence “is insufficient to assess the balance of benefits and harms of screening for MDD in children aged 11 years or younger.” This is an “I” statement, which means that “evidence is lacking, of poor quality, or conflicting, and the balance of benefits and harms cannot be determined.”

The new USPSTF guidelines do no not recommend a specific instrument or screening strategy, but the review commissioned for the task force found that the Patient Health Questionnaire for Adolescents and Beck Depression Inventory outperformed other tools in adolescents.

In the opinion of Dr. Krist, a key challenge for primary care clinicians seeking to implement the recommendations is to establish a way to routinely ask adolescents about depression, “being able to systematize that so it’s done routinely and that it’s done well.” A second challenge is to establish a way to ensure proper diagnosis, proper treatment, and follow-up of adolescents who screen positive for MDD. “A lot of primary care practices may choose to do a lot of those activities themselves, or they might work out collaborations with other mental health providers and have a referral mechanism and a follow-up mechanism,” he said.

In an editorial that appeared online in the Annals of Internal Medicine, Dr. John W. Williams Jr. of the Durham (N.C.) Veterans Affairs Medical Center and Dr. Gary Maslow of Duke University, also in Durham, advised generalist physicians to “seize the day and act to implement these guidelines” (Ann Intern Med. 2016 Feb 8. doi: 10.7326/M16-0104). “Implementing high-quality depression care is not easy, but trials and demonstration projects show that it is possible and rewarding.”

Dr. Williams and Dr. Maslow went on to suggest ways that clinicians might incorporate the guidelines into their own practices. “For practices initiating screening for the first time, a pragmatic strategy might be to screen in conjunction with routine health visits and target persons with symptoms associated with depression (for example, insomnia) or risk factors, which in adolescents include female sex, older age, family history of depression, other mental health or behavioral problems, chronic medical illness, and overweight or obesity,” they wrote. “For practices with electronic health records, clinical reminders can be used to prompt staff to distribute screening questionnaires or verbally administer questions along with assessment of vital signs. The Guidelines for Adolescent Depression in Primary Care toolkit includes screening measures, screening procedures, and patient education materials to support the screening and treatment.”

The way Dr. Krist sees it, the overall message of the new recommendations is simple: Screening adolescents for depression has benefits. “We want primary care clinicians to do this, and we want to make sure that primary care practices put systems in place to care for adolescents with identified needs,” he said.

The Agency for Healthcare Research and Quality funded the review that formed the basis of the recommendations. The authors of the recommendation statement reported having no relevant financial disclosures.

Children aged 12-18 years should be screened for major depressive disorder, but current evidence is insufficient to advise screening children aged 11 years or younger for the condition.

Those are among the key guidelines in updated recommendations from the U.S. Preventive Services Task Force on screening for depression in children and adolescents that were published online Feb. 8 in Pediatrics and in the Annals of Internal Medicine.

“Adolescents who are depressed suffer a lot of adverse consequences from their depression,” task force member Dr. Alexander H. Krist of the department of family medicine and population health at Virginia Commonwealth University, Richmond, said in an interview. “It can affect school, their family life, and their quality of life. Being able to identify adolescents who are depressed [and] making sure that they get the care that they need can have a big benefit for adolescents and their families.”

Although little is known about the prevalence of major depressive disorder (MDD) in children, results from national surveys suggest that about 8% of adolescents have had major depression in the past year, according to the task force members, who were chaired by Dr. Albert L. Siu, an internist and geriatrician in the department of geriatrics and palliative medicine at Mount Sinai School of Medicine, New York (Pediatrics. 2016 Feb 8. doi: 10.1542/peds.2015-4467).

The 2009 USPSTF guidelines recommended screening for MDD in adolescents “when systems for diagnosis, treatment, and follow-up are in place” and concluded that there was not enough evidence to make a recommendation regarding children aged 7-11 years. The updated recommendation reaffirms these positions but removes the mention of specific MDD therapies “in recognition of decreased concern over the harms of pharmacotherapy in adolescents when patients are adequately monitored.” In addition, more studies have been published that support the 2009 guidelines, “so that is one important change,” Dr. Krist said.

Recommendations for the new guidelines were based on a literature review conducted for the USPSTF by researchers led by Valerie Forman-Hoffman, Ph.D., of RTI International in Research Triangle Park, N.C. , and published online Feb. 8 (Ann Intern Med. 2016 Feb 8. doi: 10.7326/M15-2259). Supported by a grant from the Agency for Healthcare Research and Quality, the review involved a search for trials and systematic reviews of treatment, test-retest studies of screening, and trials and large cohort studies for harms that appeared in the medical literature between May 2007 and February 2015. No trials were found that directly assessed the benefits or harms of screening children or adolescents for MDD in primary care settings.

Here are the key recommendations:

• Screen for MDD in adolescents aged 12-18 years. Screening “should be implemented with adequate systems in place to ensure accurate diagnosis, effective treatment, and appropriate follow-up.” This is a “B” recommendation in the USPSTF grading system, which means that “there is high certainty that the net benefit is moderate or there is moderate certainty the net benefit is moderate to substantial.”

As stated in the recommendations, the phrase “adequate systems in place” refers to “having systems and clinical staff to ensure that patients are screened and, if they screen positive, are appropriately diagnosed and treated with evidence-based care or referred to a setting that can provide the necessary care.” This emphasis was made because “we now recognize that our health systems have evolved, and that it’s more the standard of care to have systems in place to care for adolescents who are depressed,” Dr. Krist explained. “The rewording stresses the importance of being able to make sure that care is given to adolescents after they’re diagnosed.”

The Affordable Care Act provides coverage for A and B recommendations of the USPSTF, so screening for MDD in adolescents would be a recommended service. “Often this type of a service would be delivered during a wellness exam,” Dr. Krist said. “That’s a commonly covered benefit right now with the ACA.”

• Current evidence “is insufficient to assess the balance of benefits and harms of screening for MDD in children aged 11 years or younger.” This is an “I” statement, which means that “evidence is lacking, of poor quality, or conflicting, and the balance of benefits and harms cannot be determined.”

The new USPSTF guidelines do no not recommend a specific instrument or screening strategy, but the review commissioned for the task force found that the Patient Health Questionnaire for Adolescents and Beck Depression Inventory outperformed other tools in adolescents.

In the opinion of Dr. Krist, a key challenge for primary care clinicians seeking to implement the recommendations is to establish a way to routinely ask adolescents about depression, “being able to systematize that so it’s done routinely and that it’s done well.” A second challenge is to establish a way to ensure proper diagnosis, proper treatment, and follow-up of adolescents who screen positive for MDD. “A lot of primary care practices may choose to do a lot of those activities themselves, or they might work out collaborations with other mental health providers and have a referral mechanism and a follow-up mechanism,” he said.

In an editorial that appeared online in the Annals of Internal Medicine, Dr. John W. Williams Jr. of the Durham (N.C.) Veterans Affairs Medical Center and Dr. Gary Maslow of Duke University, also in Durham, advised generalist physicians to “seize the day and act to implement these guidelines” (Ann Intern Med. 2016 Feb 8. doi: 10.7326/M16-0104). “Implementing high-quality depression care is not easy, but trials and demonstration projects show that it is possible and rewarding.”

Dr. Williams and Dr. Maslow went on to suggest ways that clinicians might incorporate the guidelines into their own practices. “For practices initiating screening for the first time, a pragmatic strategy might be to screen in conjunction with routine health visits and target persons with symptoms associated with depression (for example, insomnia) or risk factors, which in adolescents include female sex, older age, family history of depression, other mental health or behavioral problems, chronic medical illness, and overweight or obesity,” they wrote. “For practices with electronic health records, clinical reminders can be used to prompt staff to distribute screening questionnaires or verbally administer questions along with assessment of vital signs. The Guidelines for Adolescent Depression in Primary Care toolkit includes screening measures, screening procedures, and patient education materials to support the screening and treatment.”

The way Dr. Krist sees it, the overall message of the new recommendations is simple: Screening adolescents for depression has benefits. “We want primary care clinicians to do this, and we want to make sure that primary care practices put systems in place to care for adolescents with identified needs,” he said.

The Agency for Healthcare Research and Quality funded the review that formed the basis of the recommendations. The authors of the recommendation statement reported having no relevant financial disclosures.

Children aged 12-18 years should be screened for major depressive disorder, but current evidence is insufficient to advise screening children aged 11 years or younger for the condition.

Those are among the key guidelines in updated recommendations from the U.S. Preventive Services Task Force on screening for depression in children and adolescents that were published online Feb. 8 in Pediatrics and in the Annals of Internal Medicine.

“Adolescents who are depressed suffer a lot of adverse consequences from their depression,” task force member Dr. Alexander H. Krist of the department of family medicine and population health at Virginia Commonwealth University, Richmond, said in an interview. “It can affect school, their family life, and their quality of life. Being able to identify adolescents who are depressed [and] making sure that they get the care that they need can have a big benefit for adolescents and their families.”

Although little is known about the prevalence of major depressive disorder (MDD) in children, results from national surveys suggest that about 8% of adolescents have had major depression in the past year, according to the task force members, who were chaired by Dr. Albert L. Siu, an internist and geriatrician in the department of geriatrics and palliative medicine at Mount Sinai School of Medicine, New York (Pediatrics. 2016 Feb 8. doi: 10.1542/peds.2015-4467).

The 2009 USPSTF guidelines recommended screening for MDD in adolescents “when systems for diagnosis, treatment, and follow-up are in place” and concluded that there was not enough evidence to make a recommendation regarding children aged 7-11 years. The updated recommendation reaffirms these positions but removes the mention of specific MDD therapies “in recognition of decreased concern over the harms of pharmacotherapy in adolescents when patients are adequately monitored.” In addition, more studies have been published that support the 2009 guidelines, “so that is one important change,” Dr. Krist said.

Recommendations for the new guidelines were based on a literature review conducted for the USPSTF by researchers led by Valerie Forman-Hoffman, Ph.D., of RTI International in Research Triangle Park, N.C. , and published online Feb. 8 (Ann Intern Med. 2016 Feb 8. doi: 10.7326/M15-2259). Supported by a grant from the Agency for Healthcare Research and Quality, the review involved a search for trials and systematic reviews of treatment, test-retest studies of screening, and trials and large cohort studies for harms that appeared in the medical literature between May 2007 and February 2015. No trials were found that directly assessed the benefits or harms of screening children or adolescents for MDD in primary care settings.

Here are the key recommendations:

• Screen for MDD in adolescents aged 12-18 years. Screening “should be implemented with adequate systems in place to ensure accurate diagnosis, effective treatment, and appropriate follow-up.” This is a “B” recommendation in the USPSTF grading system, which means that “there is high certainty that the net benefit is moderate or there is moderate certainty the net benefit is moderate to substantial.”

As stated in the recommendations, the phrase “adequate systems in place” refers to “having systems and clinical staff to ensure that patients are screened and, if they screen positive, are appropriately diagnosed and treated with evidence-based care or referred to a setting that can provide the necessary care.” This emphasis was made because “we now recognize that our health systems have evolved, and that it’s more the standard of care to have systems in place to care for adolescents who are depressed,” Dr. Krist explained. “The rewording stresses the importance of being able to make sure that care is given to adolescents after they’re diagnosed.”

The Affordable Care Act provides coverage for A and B recommendations of the USPSTF, so screening for MDD in adolescents would be a recommended service. “Often this type of a service would be delivered during a wellness exam,” Dr. Krist said. “That’s a commonly covered benefit right now with the ACA.”

• Current evidence “is insufficient to assess the balance of benefits and harms of screening for MDD in children aged 11 years or younger.” This is an “I” statement, which means that “evidence is lacking, of poor quality, or conflicting, and the balance of benefits and harms cannot be determined.”

The new USPSTF guidelines do no not recommend a specific instrument or screening strategy, but the review commissioned for the task force found that the Patient Health Questionnaire for Adolescents and Beck Depression Inventory outperformed other tools in adolescents.

In the opinion of Dr. Krist, a key challenge for primary care clinicians seeking to implement the recommendations is to establish a way to routinely ask adolescents about depression, “being able to systematize that so it’s done routinely and that it’s done well.” A second challenge is to establish a way to ensure proper diagnosis, proper treatment, and follow-up of adolescents who screen positive for MDD. “A lot of primary care practices may choose to do a lot of those activities themselves, or they might work out collaborations with other mental health providers and have a referral mechanism and a follow-up mechanism,” he said.

In an editorial that appeared online in the Annals of Internal Medicine, Dr. John W. Williams Jr. of the Durham (N.C.) Veterans Affairs Medical Center and Dr. Gary Maslow of Duke University, also in Durham, advised generalist physicians to “seize the day and act to implement these guidelines” (Ann Intern Med. 2016 Feb 8. doi: 10.7326/M16-0104). “Implementing high-quality depression care is not easy, but trials and demonstration projects show that it is possible and rewarding.”

Dr. Williams and Dr. Maslow went on to suggest ways that clinicians might incorporate the guidelines into their own practices. “For practices initiating screening for the first time, a pragmatic strategy might be to screen in conjunction with routine health visits and target persons with symptoms associated with depression (for example, insomnia) or risk factors, which in adolescents include female sex, older age, family history of depression, other mental health or behavioral problems, chronic medical illness, and overweight or obesity,” they wrote. “For practices with electronic health records, clinical reminders can be used to prompt staff to distribute screening questionnaires or verbally administer questions along with assessment of vital signs. The Guidelines for Adolescent Depression in Primary Care toolkit includes screening measures, screening procedures, and patient education materials to support the screening and treatment.”

The way Dr. Krist sees it, the overall message of the new recommendations is simple: Screening adolescents for depression has benefits. “We want primary care clinicians to do this, and we want to make sure that primary care practices put systems in place to care for adolescents with identified needs,” he said.

The Agency for Healthcare Research and Quality funded the review that formed the basis of the recommendations. The authors of the recommendation statement reported having no relevant financial disclosures.

[email protected]

On Twitter @dougbrunk

Children aged 12-18 years should be screened for major depressive disorder, but current evidence is insufficient to advise screening children aged 11 years or younger for the condition.

Those are among the key guidelines in updated recommendations from the U.S. Preventive Services Task Force on screening for depression in children and adolescents that were published online Feb. 8 in Pediatrics and in the Annals of Internal Medicine.

“Adolescents who are depressed suffer a lot of adverse consequences from their depression,” task force member Dr. Alexander H. Krist of the department of family medicine and population health at Virginia Commonwealth University, Richmond, said in an interview. “It can affect school, their family life, and their quality of life. Being able to identify adolescents who are depressed [and] making sure that they get the care that they need can have a big benefit for adolescents and their families.”

Although little is known about the prevalence of major depressive disorder (MDD) in children, results from national surveys suggest that about 8% of adolescents have had major depression in the past year, according to the task force members, who were chaired by Dr. Albert L. Siu, an internist and geriatrician in the department of geriatrics and palliative medicine at Mount Sinai School of Medicine, New York (Pediatrics. 2016 Feb 8. doi: 10.1542/peds.2015-4467).

The 2009 USPSTF guidelines recommended screening for MDD in adolescents “when systems for diagnosis, treatment, and follow-up are in place” and concluded that there was not enough evidence to make a recommendation regarding children aged 7-11 years. The updated recommendation reaffirms these positions but removes the mention of specific MDD therapies “in recognition of decreased concern over the harms of pharmacotherapy in adolescents when patients are adequately monitored.” In addition, more studies have been published that support the 2009 guidelines, “so that is one important change,” Dr. Krist said.

Recommendations for the new guidelines were based on a literature review conducted for the USPSTF by researchers led by Valerie Forman-Hoffman, Ph.D., of RTI International in Research Triangle Park, N.C. , and published online Feb. 8 (Ann Intern Med. 2016 Feb 8. doi: 10.7326/M15-2259). Supported by a grant from the Agency for Healthcare Research and Quality, the review involved a search for trials and systematic reviews of treatment, test-retest studies of screening, and trials and large cohort studies for harms that appeared in the medical literature between May 2007 and February 2015. No trials were found that directly assessed the benefits or harms of screening children or adolescents for MDD in primary care settings.

Here are the key recommendations:

• Screen for MDD in adolescents aged 12-18 years. Screening “should be implemented with adequate systems in place to ensure accurate diagnosis, effective treatment, and appropriate follow-up.” This is a “B” recommendation in the USPSTF grading system, which means that “there is high certainty that the net benefit is moderate or there is moderate certainty the net benefit is moderate to substantial.”

As stated in the recommendations, the phrase “adequate systems in place” refers to “having systems and clinical staff to ensure that patients are screened and, if they screen positive, are appropriately diagnosed and treated with evidence-based care or referred to a setting that can provide the necessary care.” This emphasis was made because “we now recognize that our health systems have evolved, and that it’s more the standard of care to have systems in place to care for adolescents who are depressed,” Dr. Krist explained. “The rewording stresses the importance of being able to make sure that care is given to adolescents after they’re diagnosed.”

The Affordable Care Act provides coverage for A and B recommendations of the USPSTF, so screening for MDD in adolescents would be a recommended service. “Often this type of a service would be delivered during a wellness exam,” Dr. Krist said. “That’s a commonly covered benefit right now with the ACA.”

• Current evidence “is insufficient to assess the balance of benefits and harms of screening for MDD in children aged 11 years or younger.” This is an “I” statement, which means that “evidence is lacking, of poor quality, or conflicting, and the balance of benefits and harms cannot be determined.”

The new USPSTF guidelines do no not recommend a specific instrument or screening strategy, but the review commissioned for the task force found that the Patient Health Questionnaire for Adolescents and Beck Depression Inventory outperformed other tools in adolescents.

In the opinion of Dr. Krist, a key challenge for primary care clinicians seeking to implement the recommendations is to establish a way to routinely ask adolescents about depression, “being able to systematize that so it’s done routinely and that it’s done well.” A second challenge is to establish a way to ensure proper diagnosis, proper treatment, and follow-up of adolescents who screen positive for MDD. “A lot of primary care practices may choose to do a lot of those activities themselves, or they might work out collaborations with other mental health providers and have a referral mechanism and a follow-up mechanism,” he said.

In an editorial that appeared online in the Annals of Internal Medicine, Dr. John W. Williams Jr. of the Durham (N.C.) Veterans Affairs Medical Center and Dr. Gary Maslow of Duke University, also in Durham, advised generalist physicians to “seize the day and act to implement these guidelines” (Ann Intern Med. 2016 Feb 8. doi: 10.7326/M16-0104). “Implementing high-quality depression care is not easy, but trials and demonstration projects show that it is possible and rewarding.”

Dr. Williams and Dr. Maslow went on to suggest ways that clinicians might incorporate the guidelines into their own practices. “For practices initiating screening for the first time, a pragmatic strategy might be to screen in conjunction with routine health visits and target persons with symptoms associated with depression (for example, insomnia) or risk factors, which in adolescents include female sex, older age, family history of depression, other mental health or behavioral problems, chronic medical illness, and overweight or obesity,” they wrote. “For practices with electronic health records, clinical reminders can be used to prompt staff to distribute screening questionnaires or verbally administer questions along with assessment of vital signs. The Guidelines for Adolescent Depression in Primary Care toolkit includes screening measures, screening procedures, and patient education materials to support the screening and treatment.”

The way Dr. Krist sees it, the overall message of the new recommendations is simple: Screening adolescents for depression has benefits. “We want primary care clinicians to do this, and we want to make sure that primary care practices put systems in place to care for adolescents with identified needs,” he said.

The Agency for Healthcare Research and Quality funded the review that formed the basis of the recommendations. The authors of the recommendation statement reported having no relevant financial disclosures.

[email protected]

On Twitter @dougbrunk

Children aged 12-18 years should be screened for major depressive disorder, but current evidence is insufficient to advise screening children aged 11 years or younger for the condition.

Those are among the key guidelines in updated recommendations from the U.S. Preventive Services Task Force on screening for depression in children and adolescents that were published online Feb. 8 in Pediatrics and in the Annals of Internal Medicine.

“Adolescents who are depressed suffer a lot of adverse consequences from their depression,” task force member Dr. Alexander H. Krist of the department of family medicine and population health at Virginia Commonwealth University, Richmond, said in an interview. “It can affect school, their family life, and their quality of life. Being able to identify adolescents who are depressed [and] making sure that they get the care that they need can have a big benefit for adolescents and their families.”

Although little is known about the prevalence of major depressive disorder (MDD) in children, results from national surveys suggest that about 8% of adolescents have had major depression in the past year, according to the task force members, who were chaired by Dr. Albert L. Siu, an internist and geriatrician in the department of geriatrics and palliative medicine at Mount Sinai School of Medicine, New York (Pediatrics. 2016 Feb 8. doi: 10.1542/peds.2015-4467).

The 2009 USPSTF guidelines recommended screening for MDD in adolescents “when systems for diagnosis, treatment, and follow-up are in place” and concluded that there was not enough evidence to make a recommendation regarding children aged 7-11 years. The updated recommendation reaffirms these positions but removes the mention of specific MDD therapies “in recognition of decreased concern over the harms of pharmacotherapy in adolescents when patients are adequately monitored.” In addition, more studies have been published that support the 2009 guidelines, “so that is one important change,” Dr. Krist said.

Recommendations for the new guidelines were based on a literature review conducted for the USPSTF by researchers led by Valerie Forman-Hoffman, Ph.D., of RTI International in Research Triangle Park, N.C. , and published online Feb. 8 (Ann Intern Med. 2016 Feb 8. doi: 10.7326/M15-2259). Supported by a grant from the Agency for Healthcare Research and Quality, the review involved a search for trials and systematic reviews of treatment, test-retest studies of screening, and trials and large cohort studies for harms that appeared in the medical literature between May 2007 and February 2015. No trials were found that directly assessed the benefits or harms of screening children or adolescents for MDD in primary care settings.

Here are the key recommendations:

• Screen for MDD in adolescents aged 12-18 years. Screening “should be implemented with adequate systems in place to ensure accurate diagnosis, effective treatment, and appropriate follow-up.” This is a “B” recommendation in the USPSTF grading system, which means that “there is high certainty that the net benefit is moderate or there is moderate certainty the net benefit is moderate to substantial.”

As stated in the recommendations, the phrase “adequate systems in place” refers to “having systems and clinical staff to ensure that patients are screened and, if they screen positive, are appropriately diagnosed and treated with evidence-based care or referred to a setting that can provide the necessary care.” This emphasis was made because “we now recognize that our health systems have evolved, and that it’s more the standard of care to have systems in place to care for adolescents who are depressed,” Dr. Krist explained. “The rewording stresses the importance of being able to make sure that care is given to adolescents after they’re diagnosed.”

The Affordable Care Act provides coverage for A and B recommendations of the USPSTF, so screening for MDD in adolescents would be a recommended service. “Often this type of a service would be delivered during a wellness exam,” Dr. Krist said. “That’s a commonly covered benefit right now with the ACA.”

• Current evidence “is insufficient to assess the balance of benefits and harms of screening for MDD in children aged 11 years or younger.” This is an “I” statement, which means that “evidence is lacking, of poor quality, or conflicting, and the balance of benefits and harms cannot be determined.”

The new USPSTF guidelines do no not recommend a specific instrument or screening strategy, but the review commissioned for the task force found that the Patient Health Questionnaire for Adolescents and Beck Depression Inventory outperformed other tools in adolescents.

In the opinion of Dr. Krist, a key challenge for primary care clinicians seeking to implement the recommendations is to establish a way to routinely ask adolescents about depression, “being able to systematize that so it’s done routinely and that it’s done well.” A second challenge is to establish a way to ensure proper diagnosis, proper treatment, and follow-up of adolescents who screen positive for MDD. “A lot of primary care practices may choose to do a lot of those activities themselves, or they might work out collaborations with other mental health providers and have a referral mechanism and a follow-up mechanism,” he said.

In an editorial that appeared online in the Annals of Internal Medicine, Dr. John W. Williams Jr. of the Durham (N.C.) Veterans Affairs Medical Center and Dr. Gary Maslow of Duke University, also in Durham, advised generalist physicians to “seize the day and act to implement these guidelines” (Ann Intern Med. 2016 Feb 8. doi: 10.7326/M16-0104). “Implementing high-quality depression care is not easy, but trials and demonstration projects show that it is possible and rewarding.”

Dr. Williams and Dr. Maslow went on to suggest ways that clinicians might incorporate the guidelines into their own practices. “For practices initiating screening for the first time, a pragmatic strategy might be to screen in conjunction with routine health visits and target persons with symptoms associated with depression (for example, insomnia) or risk factors, which in adolescents include female sex, older age, family history of depression, other mental health or behavioral problems, chronic medical illness, and overweight or obesity,” they wrote. “For practices with electronic health records, clinical reminders can be used to prompt staff to distribute screening questionnaires or verbally administer questions along with assessment of vital signs. The Guidelines for Adolescent Depression in Primary Care toolkit includes screening measures, screening procedures, and patient education materials to support the screening and treatment.”

The way Dr. Krist sees it, the overall message of the new recommendations is simple: Screening adolescents for depression has benefits. “We want primary care clinicians to do this, and we want to make sure that primary care practices put systems in place to care for adolescents with identified needs,” he said.

The Agency for Healthcare Research and Quality funded the review that formed the basis of the recommendations. The authors of the recommendation statement reported having no relevant financial disclosures.

[email protected]

On Twitter @dougbrunk

Versions of the complement component 4 (C4) gene demonstrated distinct relationships with schizophrenia risk, with the strongest association linked to a variation that increased expression of C4A, results from a novel study showed.

“Although treatments exist for the psychotic symptoms of schizophrenia, there is no mechanistic understanding of, nor effective therapies to prevent or treat, the cognitive impairments and deficit symptoms of schizophrenia, which are the earliest and most constant features of the disorder,” researchers led by Steven A. McCarroll, Ph.D., wrote online in Nature. “An important goal in human genetics is to find the biological processes that underlie such disorders.”

In a study funded by the National Institutes of Health, Dr. McCarroll of the Broad Institute, Cambridge, Mass., and Harvard Medical School, Boston, and his associates analyzed the genomes of 65,000 people, 700 postmortem brains, and mouse genetic engineering to link specific gene versions of C4 (C4A and C4B) to a biological process that could be responsible for at least some cases of schizophrenia. The discovery came about when the team began to search for “cryptic genetic influences that might generate unconventional genetic signals.” They focused on C4 in part because of the association between the protein-coding gene CSMD1 and schizophrenia, which encodes a regulator of C4. They found that the more a version resulted in expression of C4A, the more it was associated with schizophrenia (Nature. 2016 Jan 27. doi: 10.1038/nature16549).

“The more a person had the suspect versions, the more C4 switched on and the higher their risk of developing schizophrenia,” according to a written statement generated by the NIH announcing the work. “Moreover, in the human brain, the C4 protein turned out to be most prevalent in the cellular machinery that supports connections between neurons.”

After adapting mouse molecular genetics techniques as a way to study synaptic pruning and C4’s role in immune function, the researchers also discovered that C4 promoted synapse elimination, or “pruning,” during the developmentally timed maturation of a neuronal circuit. The overall findings “could help explain schizophrenia’s delayed age-of-onset of symptoms in late adolescence/early adulthood and shrinkage of the brain’s working tissue,” Thomas Lehner, Ph.D., director of the Office of Genomics Research Coordination at the National Institute of Mental Health, said in the NIH statement. “Interventions that put the brakes on this pruning process-gone-awry could prove transformative.”

Dr. William T. Carpenter Jr., professor of psychiatry and pharmacology at the University of Maryland, Baltimore, who was not involved in the study, said in an interview that, if synaptic pruning is an aspect of schizophrenia pathophysiology, it’s “important to think of timing and what aspect of schizophrenia would be relevant. For example, cognition impairment is early, years in advance of psychotic symptoms and diagnosis, and not a good target for explaining late adolescent/early adulthood onset of this aspect. Primary negative symptoms may also be present well in advance of psychosis. For present purposes, hallucinations, delusions and thought disorder may be more likely clinical targets.”

Dr. Carpenter, who is also editor-in-chief of Schizophrenia Bulletin, went on to note that synaptic pruning pathology “could be either too much, too little, or simply suboptimal pruning, leaving connectivity inefficient,” adding that “here, a mechanism for excessive pruning is provided that may be relevant to the observed decrease in neutrophil. Having a mechanism hypothesis advances hypothesis testing research and is a valuable contribution.”

The researchers, including members of the NIMH-funded Schizophrenia Working Group of the Psychiatric Genomics Consortium, concluded their article by noting that the human genome “contains hundreds of other genes with complex, multi-allelic forms of structural variation. It will be important to learn the extent to which such variation contributes to brain diseases and to all human phenotypes.”

The study was funded by the NIH. The authors reported having no financial disclosures.

[email protected]

Versions of the complement component 4 (C4) gene demonstrated distinct relationships with schizophrenia risk, with the strongest association linked to a variation that increased expression of C4A, results from a novel study showed.

“Although treatments exist for the psychotic symptoms of schizophrenia, there is no mechanistic understanding of, nor effective therapies to prevent or treat, the cognitive impairments and deficit symptoms of schizophrenia, which are the earliest and most constant features of the disorder,” researchers led by Steven A. McCarroll, Ph.D., wrote online in Nature. “An important goal in human genetics is to find the biological processes that underlie such disorders.”

In a study funded by the National Institutes of Health, Dr. McCarroll of the Broad Institute, Cambridge, Mass., and Harvard Medical School, Boston, and his associates analyzed the genomes of 65,000 people, 700 postmortem brains, and mouse genetic engineering to link specific gene versions of C4 (C4A and C4B) to a biological process that could be responsible for at least some cases of schizophrenia. The discovery came about when the team began to search for “cryptic genetic influences that might generate unconventional genetic signals.” They focused on C4 in part because of the association between the protein-coding gene CSMD1 and schizophrenia, which encodes a regulator of C4. They found that the more a version resulted in expression of C4A, the more it was associated with schizophrenia (Nature. 2016 Jan 27. doi: 10.1038/nature16549).

“The more a person had the suspect versions, the more C4 switched on and the higher their risk of developing schizophrenia,” according to a written statement generated by the NIH announcing the work. “Moreover, in the human brain, the C4 protein turned out to be most prevalent in the cellular machinery that supports connections between neurons.”

After adapting mouse molecular genetics techniques as a way to study synaptic pruning and C4’s role in immune function, the researchers also discovered that C4 promoted synapse elimination, or “pruning,” during the developmentally timed maturation of a neuronal circuit. The overall findings “could help explain schizophrenia’s delayed age-of-onset of symptoms in late adolescence/early adulthood and shrinkage of the brain’s working tissue,” Thomas Lehner, Ph.D., director of the Office of Genomics Research Coordination at the National Institute of Mental Health, said in the NIH statement. “Interventions that put the brakes on this pruning process-gone-awry could prove transformative.”

Dr. William T. Carpenter Jr., professor of psychiatry and pharmacology at the University of Maryland, Baltimore, who was not involved in the study, said in an interview that, if synaptic pruning is an aspect of schizophrenia pathophysiology, it’s “important to think of timing and what aspect of schizophrenia would be relevant. For example, cognition impairment is early, years in advance of psychotic symptoms and diagnosis, and not a good target for explaining late adolescent/early adulthood onset of this aspect. Primary negative symptoms may also be present well in advance of psychosis. For present purposes, hallucinations, delusions and thought disorder may be more likely clinical targets.”

Dr. Carpenter, who is also editor-in-chief of Schizophrenia Bulletin, went on to note that synaptic pruning pathology “could be either too much, too little, or simply suboptimal pruning, leaving connectivity inefficient,” adding that “here, a mechanism for excessive pruning is provided that may be relevant to the observed decrease in neutrophil. Having a mechanism hypothesis advances hypothesis testing research and is a valuable contribution.”

The researchers, including members of the NIMH-funded Schizophrenia Working Group of the Psychiatric Genomics Consortium, concluded their article by noting that the human genome “contains hundreds of other genes with complex, multi-allelic forms of structural variation. It will be important to learn the extent to which such variation contributes to brain diseases and to all human phenotypes.”

The study was funded by the NIH. The authors reported having no financial disclosures.

[email protected]

Versions of the complement component 4 (C4) gene demonstrated distinct relationships with schizophrenia risk, with the strongest association linked to a variation that increased expression of C4A, results from a novel study showed.

“Although treatments exist for the psychotic symptoms of schizophrenia, there is no mechanistic understanding of, nor effective therapies to prevent or treat, the cognitive impairments and deficit symptoms of schizophrenia, which are the earliest and most constant features of the disorder,” researchers led by Steven A. McCarroll, Ph.D., wrote online in Nature. “An important goal in human genetics is to find the biological processes that underlie such disorders.”

In a study funded by the National Institutes of Health, Dr. McCarroll of the Broad Institute, Cambridge, Mass., and Harvard Medical School, Boston, and his associates analyzed the genomes of 65,000 people, 700 postmortem brains, and mouse genetic engineering to link specific gene versions of C4 (C4A and C4B) to a biological process that could be responsible for at least some cases of schizophrenia. The discovery came about when the team began to search for “cryptic genetic influences that might generate unconventional genetic signals.” They focused on C4 in part because of the association between the protein-coding gene CSMD1 and schizophrenia, which encodes a regulator of C4. They found that the more a version resulted in expression of C4A, the more it was associated with schizophrenia (Nature. 2016 Jan 27. doi: 10.1038/nature16549).

“The more a person had the suspect versions, the more C4 switched on and the higher their risk of developing schizophrenia,” according to a written statement generated by the NIH announcing the work. “Moreover, in the human brain, the C4 protein turned out to be most prevalent in the cellular machinery that supports connections between neurons.”

After adapting mouse molecular genetics techniques as a way to study synaptic pruning and C4’s role in immune function, the researchers also discovered that C4 promoted synapse elimination, or “pruning,” during the developmentally timed maturation of a neuronal circuit. The overall findings “could help explain schizophrenia’s delayed age-of-onset of symptoms in late adolescence/early adulthood and shrinkage of the brain’s working tissue,” Thomas Lehner, Ph.D., director of the Office of Genomics Research Coordination at the National Institute of Mental Health, said in the NIH statement. “Interventions that put the brakes on this pruning process-gone-awry could prove transformative.”

Dr. William T. Carpenter Jr., professor of psychiatry and pharmacology at the University of Maryland, Baltimore, who was not involved in the study, said in an interview that, if synaptic pruning is an aspect of schizophrenia pathophysiology, it’s “important to think of timing and what aspect of schizophrenia would be relevant. For example, cognition impairment is early, years in advance of psychotic symptoms and diagnosis, and not a good target for explaining late adolescent/early adulthood onset of this aspect. Primary negative symptoms may also be present well in advance of psychosis. For present purposes, hallucinations, delusions and thought disorder may be more likely clinical targets.”

Dr. Carpenter, who is also editor-in-chief of Schizophrenia Bulletin, went on to note that synaptic pruning pathology “could be either too much, too little, or simply suboptimal pruning, leaving connectivity inefficient,” adding that “here, a mechanism for excessive pruning is provided that may be relevant to the observed decrease in neutrophil. Having a mechanism hypothesis advances hypothesis testing research and is a valuable contribution.”

The researchers, including members of the NIMH-funded Schizophrenia Working Group of the Psychiatric Genomics Consortium, concluded their article by noting that the human genome “contains hundreds of other genes with complex, multi-allelic forms of structural variation. It will be important to learn the extent to which such variation contributes to brain diseases and to all human phenotypes.”

The study was funded by the NIH. The authors reported having no financial disclosures.

[email protected]

PHOENIX – If you happen to believe that the impact of health care–acquired infections is insignificant, think again. According to Dr. Kevin W. Lobdell, health care–acquired infections (HAIs) cause more deaths each year in the United States than breast cancer, lung cancer, and AIDS combined.

“If you look at hospitalized patients, one in five will acquire a health care–acquired infection,” Dr. Lobdell of the Sanger Heart and Vascular Institute at Carolinas Health System, Charlotte, N.C., said in a video interview at the annual meeting of the Society of Thoracic Surgeons. “With respect to length of stay, that goes from 5 days on average for a normal, uninfected patient, to 22 days if they’ve had an infection. The mortality rate can be as high as 6% in those people that have developed infections, so that in itself is an enormous burden.”

He went on to discuss the most common HAIs in the hospital setting and noted that combating them involves strategies that consider people, the environment, and technology. He predicted that in coming years clinicians will have a better “analytic capability to understand what we’ve done in the past and what correlates with success in the future, and then be able to implement and learn from that.”

Dr. Lobdell reported having no financial disclosures.

[email protected]

PHOENIX – If you happen to believe that the impact of health care–acquired infections is insignificant, think again. According to Dr. Kevin W. Lobdell, health care–acquired infections (HAIs) cause more deaths each year in the United States than breast cancer, lung cancer, and AIDS combined.

“If you look at hospitalized patients, one in five will acquire a health care–acquired infection,” Dr. Lobdell of the Sanger Heart and Vascular Institute at Carolinas Health System, Charlotte, N.C., said in a video interview at the annual meeting of the Society of Thoracic Surgeons. “With respect to length of stay, that goes from 5 days on average for a normal, uninfected patient, to 22 days if they’ve had an infection. The mortality rate can be as high as 6% in those people that have developed infections, so that in itself is an enormous burden.”

He went on to discuss the most common HAIs in the hospital setting and noted that combating them involves strategies that consider people, the environment, and technology. He predicted that in coming years clinicians will have a better “analytic capability to understand what we’ve done in the past and what correlates with success in the future, and then be able to implement and learn from that.”

Dr. Lobdell reported having no financial disclosures.

[email protected]

PHOENIX – If you happen to believe that the impact of health care–acquired infections is insignificant, think again. According to Dr. Kevin W. Lobdell, health care–acquired infections (HAIs) cause more deaths each year in the United States than breast cancer, lung cancer, and AIDS combined.

“If you look at hospitalized patients, one in five will acquire a health care–acquired infection,” Dr. Lobdell of the Sanger Heart and Vascular Institute at Carolinas Health System, Charlotte, N.C., said in a video interview at the annual meeting of the Society of Thoracic Surgeons. “With respect to length of stay, that goes from 5 days on average for a normal, uninfected patient, to 22 days if they’ve had an infection. The mortality rate can be as high as 6% in those people that have developed infections, so that in itself is an enormous burden.”

He went on to discuss the most common HAIs in the hospital setting and noted that combating them involves strategies that consider people, the environment, and technology. He predicted that in coming years clinicians will have a better “analytic capability to understand what we’ve done in the past and what correlates with success in the future, and then be able to implement and learn from that.”

Dr. Lobdell reported having no financial disclosures.

[email protected]

PHOENIX – According to Dr. Moishe Liberman, promising lesions for bronchoscopic endoluminal treatment include endobronchial lesions and intraluminal exophytic tumors within the trachea or main bronchus, provided that the distal airway lumen is visible and you can get past the tumor with a flexible endoscope.

“We always teach the fellows that if you get pus back when you’re trying to get around the tumor or play with the tumor, you’re usually going to have a very good result,” said Dr. Liberman, a thoracic surgeon who directs the endoscopic tracheo-bronchial and oesophageal center at the Centre hospitalier de l’Université de Montréal, Quebec, Canada. “If you play with the tumor and you get the tumor out and you get nothing back, usually the CT scan or the X-ray postoperatively is going to look just like it did preoperatively, even though endoscopically you might have a good result.”

Central lesions are also excellent candidates for endoluminal therapy, he said in a video interview at the meeting. Distal lesions in the small bronchi “are candidates but are much more difficult and require more specialized tools. The shorter the lesion, the more likely you are to have good success.”

Available options for delivering energy endoscopically include electrocautery, argon plasma coagulation, laser, and cryotherapy. A disadvantage of all of the thermal modalities except for cryotherapy “include the potential for airway fire and you have to work with low FiO2s [fraction of inspired oxygen],” Dr. Liberman noted. “A lot of these patients need high FiO2s to saturate, so I think that’s always an issue. We never go on cardiopulmonary bypass to do these cases and we never cannulate patients to do these cases. You also have to worry about gas emboli, especially when you open up big vessels. These modalities can also cause inadvertent airway injury, delayed effects, and bronchoscope damage.”

In general, he continued, laser-tissue interactions depend on the power and the wavelength of the laser as well as the color and the water content of the target tissue. “The power density of the wavelength you choose determines its ability to cut, coagulate, or vaporize the tissue,” he said.

“As the power density increases, the laser fiber approaches the target tissue. Power density is more important than the energy delivered.”

The Nd:YAG (neodymium-doped yttrium aluminium garnet) laser, which causes more destruction in the deep tissue than on the surface, is the most common laser used in interventional airway procedures, he said. Two other commonly used lasers include the KTP (potassium titanyl phosphate) and the CO₂. “I like CO₂s a lot for upper airway and subglottic problems as well as vocal cord problems,” Dr. Liberman said. “It’s very precise and has low penetration. The Nd:YAG is very good for deep penetration. You need familiarity with these. I don’t think you can just take one of these off the shelf if you’ve never used it before. Sometimes your ENT [ear nose and throat] or urology colleagues can help you, because they’re using a lot more of these lasers than we are.”

Contraindications for laser bronchoscopy include operable lesions. Dr. Liberman said that while he and his associates use lasers in a preoperative setting, “we’re very careful not to damage proximal or distal airway when we know we’re going to do a sleeve resection or pneumonectomy.”

Other contraindications for laser bronchoscopy include patients with a poor short-term prognosis, severe coagulation disorder, extrinsic airway obstruction, tracheoesophageal fistula or T-Med fistula, those with extensive submucosal disease causing obstruction, and those with lesion adjacent to the esophagus or to a major vessel.

Dr. Liberman reported having received research grants from Ethicon, Boston Scientific, Olympus, Covidien, and Baxter.

[email protected]

PHOENIX – According to Dr. Moishe Liberman, promising lesions for bronchoscopic endoluminal treatment include endobronchial lesions and intraluminal exophytic tumors within the trachea or main bronchus, provided that the distal airway lumen is visible and you can get past the tumor with a flexible endoscope.

“We always teach the fellows that if you get pus back when you’re trying to get around the tumor or play with the tumor, you’re usually going to have a very good result,” said Dr. Liberman, a thoracic surgeon who directs the endoscopic tracheo-bronchial and oesophageal center at the Centre hospitalier de l’Université de Montréal, Quebec, Canada. “If you play with the tumor and you get the tumor out and you get nothing back, usually the CT scan or the X-ray postoperatively is going to look just like it did preoperatively, even though endoscopically you might have a good result.”

Central lesions are also excellent candidates for endoluminal therapy, he said in a video interview at the meeting. Distal lesions in the small bronchi “are candidates but are much more difficult and require more specialized tools. The shorter the lesion, the more likely you are to have good success.”

Available options for delivering energy endoscopically include electrocautery, argon plasma coagulation, laser, and cryotherapy. A disadvantage of all of the thermal modalities except for cryotherapy “include the potential for airway fire and you have to work with low FiO2s [fraction of inspired oxygen],” Dr. Liberman noted. “A lot of these patients need high FiO2s to saturate, so I think that’s always an issue. We never go on cardiopulmonary bypass to do these cases and we never cannulate patients to do these cases. You also have to worry about gas emboli, especially when you open up big vessels. These modalities can also cause inadvertent airway injury, delayed effects, and bronchoscope damage.”

In general, he continued, laser-tissue interactions depend on the power and the wavelength of the laser as well as the color and the water content of the target tissue. “The power density of the wavelength you choose determines its ability to cut, coagulate, or vaporize the tissue,” he said.

“As the power density increases, the laser fiber approaches the target tissue. Power density is more important than the energy delivered.”

The Nd:YAG (neodymium-doped yttrium aluminium garnet) laser, which causes more destruction in the deep tissue than on the surface, is the most common laser used in interventional airway procedures, he said. Two other commonly used lasers include the KTP (potassium titanyl phosphate) and the CO₂. “I like CO₂s a lot for upper airway and subglottic problems as well as vocal cord problems,” Dr. Liberman said. “It’s very precise and has low penetration. The Nd:YAG is very good for deep penetration. You need familiarity with these. I don’t think you can just take one of these off the shelf if you’ve never used it before. Sometimes your ENT [ear nose and throat] or urology colleagues can help you, because they’re using a lot more of these lasers than we are.”

Contraindications for laser bronchoscopy include operable lesions. Dr. Liberman said that while he and his associates use lasers in a preoperative setting, “we’re very careful not to damage proximal or distal airway when we know we’re going to do a sleeve resection or pneumonectomy.”

Other contraindications for laser bronchoscopy include patients with a poor short-term prognosis, severe coagulation disorder, extrinsic airway obstruction, tracheoesophageal fistula or T-Med fistula, those with extensive submucosal disease causing obstruction, and those with lesion adjacent to the esophagus or to a major vessel.

Dr. Liberman reported having received research grants from Ethicon, Boston Scientific, Olympus, Covidien, and Baxter.

[email protected]

PHOENIX – According to Dr. Moishe Liberman, promising lesions for bronchoscopic endoluminal treatment include endobronchial lesions and intraluminal exophytic tumors within the trachea or main bronchus, provided that the distal airway lumen is visible and you can get past the tumor with a flexible endoscope.

“We always teach the fellows that if you get pus back when you’re trying to get around the tumor or play with the tumor, you’re usually going to have a very good result,” said Dr. Liberman, a thoracic surgeon who directs the endoscopic tracheo-bronchial and oesophageal center at the Centre hospitalier de l’Université de Montréal, Quebec, Canada. “If you play with the tumor and you get the tumor out and you get nothing back, usually the CT scan or the X-ray postoperatively is going to look just like it did preoperatively, even though endoscopically you might have a good result.”

Central lesions are also excellent candidates for endoluminal therapy, he said in a video interview at the meeting. Distal lesions in the small bronchi “are candidates but are much more difficult and require more specialized tools. The shorter the lesion, the more likely you are to have good success.”

Available options for delivering energy endoscopically include electrocautery, argon plasma coagulation, laser, and cryotherapy. A disadvantage of all of the thermal modalities except for cryotherapy “include the potential for airway fire and you have to work with low FiO2s [fraction of inspired oxygen],” Dr. Liberman noted. “A lot of these patients need high FiO2s to saturate, so I think that’s always an issue. We never go on cardiopulmonary bypass to do these cases and we never cannulate patients to do these cases. You also have to worry about gas emboli, especially when you open up big vessels. These modalities can also cause inadvertent airway injury, delayed effects, and bronchoscope damage.”

In general, he continued, laser-tissue interactions depend on the power and the wavelength of the laser as well as the color and the water content of the target tissue. “The power density of the wavelength you choose determines its ability to cut, coagulate, or vaporize the tissue,” he said.

“As the power density increases, the laser fiber approaches the target tissue. Power density is more important than the energy delivered.”

The Nd:YAG (neodymium-doped yttrium aluminium garnet) laser, which causes more destruction in the deep tissue than on the surface, is the most common laser used in interventional airway procedures, he said. Two other commonly used lasers include the KTP (potassium titanyl phosphate) and the CO₂. “I like CO₂s a lot for upper airway and subglottic problems as well as vocal cord problems,” Dr. Liberman said. “It’s very precise and has low penetration. The Nd:YAG is very good for deep penetration. You need familiarity with these. I don’t think you can just take one of these off the shelf if you’ve never used it before. Sometimes your ENT [ear nose and throat] or urology colleagues can help you, because they’re using a lot more of these lasers than we are.”

Contraindications for laser bronchoscopy include operable lesions. Dr. Liberman said that while he and his associates use lasers in a preoperative setting, “we’re very careful not to damage proximal or distal airway when we know we’re going to do a sleeve resection or pneumonectomy.”

Other contraindications for laser bronchoscopy include patients with a poor short-term prognosis, severe coagulation disorder, extrinsic airway obstruction, tracheoesophageal fistula or T-Med fistula, those with extensive submucosal disease causing obstruction, and those with lesion adjacent to the esophagus or to a major vessel.

Dr. Liberman reported having received research grants from Ethicon, Boston Scientific, Olympus, Covidien, and Baxter.

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