User login
M. Alexander Otto began his reporting career early in 1999 covering the pharmaceutical industry for a national pharmacists' magazine and freelancing for the Washington Post and other newspapers. He then joined BNA, now part of Bloomberg News, covering health law and the protection of people and animals in medical research. Alex next worked for the McClatchy Company. Based on his work, Alex won a year-long Knight Science Journalism Fellowship to MIT in 2008-2009. He joined the company shortly thereafter. Alex has a newspaper journalism degree from Syracuse (N.Y.) University and a master's degree in medical science -- a physician assistant degree -- from George Washington University. Alex is based in Seattle.
Ketamine tied to remission from suicidal ideation
Report of 235 cases deemed largest series to date on impact of infusions
SAN FRANCISCO – Serial ketamine infusions eliminated suicidal ideation in more than two-thirds of patients at a psychiatry office in Connecticut but at significantly higher doses than those recently approved for Janssen’s new esketamine nasal spray (Spravato).
The patients were treated by Lori V. Calabrese, MD, at Innovative Psychiatry, her private outpatient practice in South Windsor. She presented her first 235 IV ketamine cases at the American Psychiatric Association annual meeting. It was likely the largest real-world series to date of ketamine infusions for treatment-resistant depression and suicidality.
The patients, 14-84 years old but mostly middle-aged, received six infusions over 2-3 weeks, starting at 0.5 mg/kg over 40-50 minutes, then titrated upward for dissociative effect to a maximum of 1.7 mg/kg. Subjects filled out the nine-item Patient Health Questionnaire (PHQ-9) at baseline and before each infusion. Item nine – “thoughts that you would be better off dead or of hurting yourself in some way” – was used to gauge suicidality. That item has been validated as a predictor of suicide risk.
Among 144 patients (62%) who were markedly suicidal, ketamine infusions were tied to diminished ideation in 118 (82%) and eliminated ideation in 98 (68%). They were severely depressed at baseline; PHQ-9 scores fell in 127 (89%), and depression went into remission in 89 (62%). There were no suicide attempts, ED visits, or hospitalizations during treatment and at 4-week follow-up.
“Even if they had been suicidal for a long time, been hospitalized, and made suicide attempts, 68% had full remission of suicidality. This is a life-saving treatment, a breakthrough option for psychiatrists,” Dr. Calabrese said.
The results are “fabulous,” said Jaskaran Singh, MD, who said he was clinical leader of the esketamine program at Janssen.
“You prevented hospitalizations and saved lives,” Dr. Singh said. “This is a marvelous study that we should have done.”
Dr. Calabrese’s report, however, raises the question of whether the nasal spray will be potent enough to achieve the same results. She found that cessation of suicidal thoughts required an average dose of 0.75 mg/kg IV ketamine, which is higher than the 0.5 mg/kg used by many ketamine infusion programs in the United States. It’s also significantly higher than Spravato dosing. The spray was cleared by the Food and Drug Administration in March for use with an oral antidepressant for treatment-resistant depression. It was the subject of much buzz at the APA meeting.
Esketamine is approved in doses of 56 mg, which works out to almost 0.2 mg/kg, and 84 mg, which works out to less than 4 mg/kg. Dosing is twice weekly at first, then weekly or biweekly for maintenance.
When asked whether he thought those doses would be enough to prevent suicide, Dr. Singh said his company has finished two trials in suicidal patients and would present results later in 2019.
Dr. Calabrese, meanwhile, plans to incorporate intranasal esketamine into her practice, but will continue to offer ketamine infusions. “How can I not? I’ve seen how effective they are,” she said.
She charges $500 per session, $2 for the ketamine plus nursing and other costs. Insurance companies have sometimes covered it for patients with a history of psychiatric ED visits and hospitalizations, on the grounds that infusions will prevent future admissions. But patients have to fight for coverage – and feel well enough to do so.
That’s the main reason Dr. Calabrese plans to start offering Spravato; coverage will likely be less of a hassle for patients once Janssen works out the insurance issues. Spravato has been reported to cost about $600-$900 per treatment session.
She noted that response among her infusion patients was bimodal, with suicidal ideation eliminated in some patients after one infusion, but most of the rest needed three or more. “Don’t give up,” she said.
Infusion response correlated with suicidality and depression severity, with the sickest patients having the most benefit. Among 91 moderately depressed, nonsuicidal patients, just over half responded to the infusions, and depression went into remission in about a third.
Side effects were minimal, transient, and easily handled in the office. A little bit of IV midazolam calmed patients who got too anxious, and IV ondansetron (Zofran) helped those who got nauseous. Blood pressure can bump up a bit with ketamine, so Dr. Calabrese follows it closely.
The report had no external funding and Dr. Calabrese had no disclosures.
Report of 235 cases deemed largest series to date on impact of infusions
Report of 235 cases deemed largest series to date on impact of infusions
SAN FRANCISCO – Serial ketamine infusions eliminated suicidal ideation in more than two-thirds of patients at a psychiatry office in Connecticut but at significantly higher doses than those recently approved for Janssen’s new esketamine nasal spray (Spravato).
The patients were treated by Lori V. Calabrese, MD, at Innovative Psychiatry, her private outpatient practice in South Windsor. She presented her first 235 IV ketamine cases at the American Psychiatric Association annual meeting. It was likely the largest real-world series to date of ketamine infusions for treatment-resistant depression and suicidality.
The patients, 14-84 years old but mostly middle-aged, received six infusions over 2-3 weeks, starting at 0.5 mg/kg over 40-50 minutes, then titrated upward for dissociative effect to a maximum of 1.7 mg/kg. Subjects filled out the nine-item Patient Health Questionnaire (PHQ-9) at baseline and before each infusion. Item nine – “thoughts that you would be better off dead or of hurting yourself in some way” – was used to gauge suicidality. That item has been validated as a predictor of suicide risk.
Among 144 patients (62%) who were markedly suicidal, ketamine infusions were tied to diminished ideation in 118 (82%) and eliminated ideation in 98 (68%). They were severely depressed at baseline; PHQ-9 scores fell in 127 (89%), and depression went into remission in 89 (62%). There were no suicide attempts, ED visits, or hospitalizations during treatment and at 4-week follow-up.
“Even if they had been suicidal for a long time, been hospitalized, and made suicide attempts, 68% had full remission of suicidality. This is a life-saving treatment, a breakthrough option for psychiatrists,” Dr. Calabrese said.
The results are “fabulous,” said Jaskaran Singh, MD, who said he was clinical leader of the esketamine program at Janssen.
“You prevented hospitalizations and saved lives,” Dr. Singh said. “This is a marvelous study that we should have done.”
Dr. Calabrese’s report, however, raises the question of whether the nasal spray will be potent enough to achieve the same results. She found that cessation of suicidal thoughts required an average dose of 0.75 mg/kg IV ketamine, which is higher than the 0.5 mg/kg used by many ketamine infusion programs in the United States. It’s also significantly higher than Spravato dosing. The spray was cleared by the Food and Drug Administration in March for use with an oral antidepressant for treatment-resistant depression. It was the subject of much buzz at the APA meeting.
Esketamine is approved in doses of 56 mg, which works out to almost 0.2 mg/kg, and 84 mg, which works out to less than 4 mg/kg. Dosing is twice weekly at first, then weekly or biweekly for maintenance.
When asked whether he thought those doses would be enough to prevent suicide, Dr. Singh said his company has finished two trials in suicidal patients and would present results later in 2019.
Dr. Calabrese, meanwhile, plans to incorporate intranasal esketamine into her practice, but will continue to offer ketamine infusions. “How can I not? I’ve seen how effective they are,” she said.
She charges $500 per session, $2 for the ketamine plus nursing and other costs. Insurance companies have sometimes covered it for patients with a history of psychiatric ED visits and hospitalizations, on the grounds that infusions will prevent future admissions. But patients have to fight for coverage – and feel well enough to do so.
That’s the main reason Dr. Calabrese plans to start offering Spravato; coverage will likely be less of a hassle for patients once Janssen works out the insurance issues. Spravato has been reported to cost about $600-$900 per treatment session.
She noted that response among her infusion patients was bimodal, with suicidal ideation eliminated in some patients after one infusion, but most of the rest needed three or more. “Don’t give up,” she said.
Infusion response correlated with suicidality and depression severity, with the sickest patients having the most benefit. Among 91 moderately depressed, nonsuicidal patients, just over half responded to the infusions, and depression went into remission in about a third.
Side effects were minimal, transient, and easily handled in the office. A little bit of IV midazolam calmed patients who got too anxious, and IV ondansetron (Zofran) helped those who got nauseous. Blood pressure can bump up a bit with ketamine, so Dr. Calabrese follows it closely.
The report had no external funding and Dr. Calabrese had no disclosures.
SAN FRANCISCO – Serial ketamine infusions eliminated suicidal ideation in more than two-thirds of patients at a psychiatry office in Connecticut but at significantly higher doses than those recently approved for Janssen’s new esketamine nasal spray (Spravato).
The patients were treated by Lori V. Calabrese, MD, at Innovative Psychiatry, her private outpatient practice in South Windsor. She presented her first 235 IV ketamine cases at the American Psychiatric Association annual meeting. It was likely the largest real-world series to date of ketamine infusions for treatment-resistant depression and suicidality.
The patients, 14-84 years old but mostly middle-aged, received six infusions over 2-3 weeks, starting at 0.5 mg/kg over 40-50 minutes, then titrated upward for dissociative effect to a maximum of 1.7 mg/kg. Subjects filled out the nine-item Patient Health Questionnaire (PHQ-9) at baseline and before each infusion. Item nine – “thoughts that you would be better off dead or of hurting yourself in some way” – was used to gauge suicidality. That item has been validated as a predictor of suicide risk.
Among 144 patients (62%) who were markedly suicidal, ketamine infusions were tied to diminished ideation in 118 (82%) and eliminated ideation in 98 (68%). They were severely depressed at baseline; PHQ-9 scores fell in 127 (89%), and depression went into remission in 89 (62%). There were no suicide attempts, ED visits, or hospitalizations during treatment and at 4-week follow-up.
“Even if they had been suicidal for a long time, been hospitalized, and made suicide attempts, 68% had full remission of suicidality. This is a life-saving treatment, a breakthrough option for psychiatrists,” Dr. Calabrese said.
The results are “fabulous,” said Jaskaran Singh, MD, who said he was clinical leader of the esketamine program at Janssen.
“You prevented hospitalizations and saved lives,” Dr. Singh said. “This is a marvelous study that we should have done.”
Dr. Calabrese’s report, however, raises the question of whether the nasal spray will be potent enough to achieve the same results. She found that cessation of suicidal thoughts required an average dose of 0.75 mg/kg IV ketamine, which is higher than the 0.5 mg/kg used by many ketamine infusion programs in the United States. It’s also significantly higher than Spravato dosing. The spray was cleared by the Food and Drug Administration in March for use with an oral antidepressant for treatment-resistant depression. It was the subject of much buzz at the APA meeting.
Esketamine is approved in doses of 56 mg, which works out to almost 0.2 mg/kg, and 84 mg, which works out to less than 4 mg/kg. Dosing is twice weekly at first, then weekly or biweekly for maintenance.
When asked whether he thought those doses would be enough to prevent suicide, Dr. Singh said his company has finished two trials in suicidal patients and would present results later in 2019.
Dr. Calabrese, meanwhile, plans to incorporate intranasal esketamine into her practice, but will continue to offer ketamine infusions. “How can I not? I’ve seen how effective they are,” she said.
She charges $500 per session, $2 for the ketamine plus nursing and other costs. Insurance companies have sometimes covered it for patients with a history of psychiatric ED visits and hospitalizations, on the grounds that infusions will prevent future admissions. But patients have to fight for coverage – and feel well enough to do so.
That’s the main reason Dr. Calabrese plans to start offering Spravato; coverage will likely be less of a hassle for patients once Janssen works out the insurance issues. Spravato has been reported to cost about $600-$900 per treatment session.
She noted that response among her infusion patients was bimodal, with suicidal ideation eliminated in some patients after one infusion, but most of the rest needed three or more. “Don’t give up,” she said.
Infusion response correlated with suicidality and depression severity, with the sickest patients having the most benefit. Among 91 moderately depressed, nonsuicidal patients, just over half responded to the infusions, and depression went into remission in about a third.
Side effects were minimal, transient, and easily handled in the office. A little bit of IV midazolam calmed patients who got too anxious, and IV ondansetron (Zofran) helped those who got nauseous. Blood pressure can bump up a bit with ketamine, so Dr. Calabrese follows it closely.
The report had no external funding and Dr. Calabrese had no disclosures.
REPORTING FROM APA 2019
Questions remain as marijuana enters clinic use
SAN FRANCISCO – Medical marijuana skipped the usual phased testing of pharmaceuticals, so questions abound about how to counsel patients as legalization rolls out across the country, speakers said at the American Psychiatric Association annual meeting.
Drug interactions are an issue but remain under the radar. Tetrahydrocannabinol (THC) and cannabidiol (CBD) are inhibitors of cytochrome P450, specifically the CYP2C enzyme and CYP3A liver enzymes, which means possible interactions with drug classes such as antidepressants and antipsychotics might come into play.
Concomitant use could affect, or be affected by, fluoxetine, clozapine, duloxetine, and olanzapine, among other medications. One case study suggested that warfarin doses should be reduced by 30% in a patient who had started with a liquid formulation of CBD for managing epilepsy (Basic Clin Pharmacol Toxicol. 2019 Jan;124[1]:28-31).
At this point, it’s “not clear what the clinic implications are,” but “it’s not unreasonable to consider that your patients’ response to their psychiatric medications might change based on the introduction of cannabinoids,” said Arthur Williams, MD, assistant professor of clinical psychiatry at Columbia University, New York, and one of many researchers playing catch-up as marijuana and its derivatives enter the clinic.
Another question is what, exactly, is a standard dose?
Dosing mostly has been a question of THC, the psychoactive component of marijuana. Washington state and Colorado opted for 10-mg THC when those jurisdictions legalized recreational use; Oregon chose 5 mg. Both are in line with Food and Drug Administration formulations already on the market, including dronabinol (Marinol), a synthetic THC approved in 2.5-mg, 5-mg, and 10-mg doses for AIDS wasting, and chemotherapy nausea and vomiting.
A typical .7-g joint of 8% THC delivers about 5 mg or so, but newer strains range up to 20% THC, and could deliver over 13 mg per joint; occasional users, meanwhile, feel high from just 2-3 mg.
The ratio of THC to CBD matters, as well. Generally, “whole plant marijuana on the black market is much higher in THC and much lower in CBD,” Dr. Williams said. CBD is thought to deliver most of the medical benefits of marijuana.
It’s best to ask people what they’re using, and to counsel new users – especially the elderly – to start low and go slow. But keep in mind that many medical users have years of recreational use and have built up tolerance, he said.
Vaping is not a bad idea for those interested. It heats the plant material to high enough temperatures to release cannabinoids but without combusting. It’s a much more efficient THC delivery system than smoking, and there’s no smoke in the lungs. Vape patients often feel they can titrate their dose exactly.
Edibles are another matter. It can take hours for them to hit. Although THC levels do not spike with edibles as they do when the substance is inhaled, the effects last longer. A lot depends on how much food is in the gut.
The risk with edibles is that people may keep popping gummy bears and brownies because they don’t feel anything but end up overdosing. Children might be tempted by the treats, too, and for those under 4 years old, overdose can lead to fatal encephalopathic comas, “something we never really saw until edibles came around,” Dr. Williams said.
With edibles, “you have no idea what’s actually in the product.” Labels can be “inaccurate by an order of magnitude. Patients should be cautioned about that,” he said.
Pregnant and breastfeeding women, especially, should be warned away from marijuana. Some of the literature suggests a link between exposure to marijuana and preterm birth – in addition to early psychosis in vulnerable children.
Dr. Williams had no relevant disclosures.
SAN FRANCISCO – Medical marijuana skipped the usual phased testing of pharmaceuticals, so questions abound about how to counsel patients as legalization rolls out across the country, speakers said at the American Psychiatric Association annual meeting.
Drug interactions are an issue but remain under the radar. Tetrahydrocannabinol (THC) and cannabidiol (CBD) are inhibitors of cytochrome P450, specifically the CYP2C enzyme and CYP3A liver enzymes, which means possible interactions with drug classes such as antidepressants and antipsychotics might come into play.
Concomitant use could affect, or be affected by, fluoxetine, clozapine, duloxetine, and olanzapine, among other medications. One case study suggested that warfarin doses should be reduced by 30% in a patient who had started with a liquid formulation of CBD for managing epilepsy (Basic Clin Pharmacol Toxicol. 2019 Jan;124[1]:28-31).
At this point, it’s “not clear what the clinic implications are,” but “it’s not unreasonable to consider that your patients’ response to their psychiatric medications might change based on the introduction of cannabinoids,” said Arthur Williams, MD, assistant professor of clinical psychiatry at Columbia University, New York, and one of many researchers playing catch-up as marijuana and its derivatives enter the clinic.
Another question is what, exactly, is a standard dose?
Dosing mostly has been a question of THC, the psychoactive component of marijuana. Washington state and Colorado opted for 10-mg THC when those jurisdictions legalized recreational use; Oregon chose 5 mg. Both are in line with Food and Drug Administration formulations already on the market, including dronabinol (Marinol), a synthetic THC approved in 2.5-mg, 5-mg, and 10-mg doses for AIDS wasting, and chemotherapy nausea and vomiting.
A typical .7-g joint of 8% THC delivers about 5 mg or so, but newer strains range up to 20% THC, and could deliver over 13 mg per joint; occasional users, meanwhile, feel high from just 2-3 mg.
The ratio of THC to CBD matters, as well. Generally, “whole plant marijuana on the black market is much higher in THC and much lower in CBD,” Dr. Williams said. CBD is thought to deliver most of the medical benefits of marijuana.
It’s best to ask people what they’re using, and to counsel new users – especially the elderly – to start low and go slow. But keep in mind that many medical users have years of recreational use and have built up tolerance, he said.
Vaping is not a bad idea for those interested. It heats the plant material to high enough temperatures to release cannabinoids but without combusting. It’s a much more efficient THC delivery system than smoking, and there’s no smoke in the lungs. Vape patients often feel they can titrate their dose exactly.
Edibles are another matter. It can take hours for them to hit. Although THC levels do not spike with edibles as they do when the substance is inhaled, the effects last longer. A lot depends on how much food is in the gut.
The risk with edibles is that people may keep popping gummy bears and brownies because they don’t feel anything but end up overdosing. Children might be tempted by the treats, too, and for those under 4 years old, overdose can lead to fatal encephalopathic comas, “something we never really saw until edibles came around,” Dr. Williams said.
With edibles, “you have no idea what’s actually in the product.” Labels can be “inaccurate by an order of magnitude. Patients should be cautioned about that,” he said.
Pregnant and breastfeeding women, especially, should be warned away from marijuana. Some of the literature suggests a link between exposure to marijuana and preterm birth – in addition to early psychosis in vulnerable children.
Dr. Williams had no relevant disclosures.
SAN FRANCISCO – Medical marijuana skipped the usual phased testing of pharmaceuticals, so questions abound about how to counsel patients as legalization rolls out across the country, speakers said at the American Psychiatric Association annual meeting.
Drug interactions are an issue but remain under the radar. Tetrahydrocannabinol (THC) and cannabidiol (CBD) are inhibitors of cytochrome P450, specifically the CYP2C enzyme and CYP3A liver enzymes, which means possible interactions with drug classes such as antidepressants and antipsychotics might come into play.
Concomitant use could affect, or be affected by, fluoxetine, clozapine, duloxetine, and olanzapine, among other medications. One case study suggested that warfarin doses should be reduced by 30% in a patient who had started with a liquid formulation of CBD for managing epilepsy (Basic Clin Pharmacol Toxicol. 2019 Jan;124[1]:28-31).
At this point, it’s “not clear what the clinic implications are,” but “it’s not unreasonable to consider that your patients’ response to their psychiatric medications might change based on the introduction of cannabinoids,” said Arthur Williams, MD, assistant professor of clinical psychiatry at Columbia University, New York, and one of many researchers playing catch-up as marijuana and its derivatives enter the clinic.
Another question is what, exactly, is a standard dose?
Dosing mostly has been a question of THC, the psychoactive component of marijuana. Washington state and Colorado opted for 10-mg THC when those jurisdictions legalized recreational use; Oregon chose 5 mg. Both are in line with Food and Drug Administration formulations already on the market, including dronabinol (Marinol), a synthetic THC approved in 2.5-mg, 5-mg, and 10-mg doses for AIDS wasting, and chemotherapy nausea and vomiting.
A typical .7-g joint of 8% THC delivers about 5 mg or so, but newer strains range up to 20% THC, and could deliver over 13 mg per joint; occasional users, meanwhile, feel high from just 2-3 mg.
The ratio of THC to CBD matters, as well. Generally, “whole plant marijuana on the black market is much higher in THC and much lower in CBD,” Dr. Williams said. CBD is thought to deliver most of the medical benefits of marijuana.
It’s best to ask people what they’re using, and to counsel new users – especially the elderly – to start low and go slow. But keep in mind that many medical users have years of recreational use and have built up tolerance, he said.
Vaping is not a bad idea for those interested. It heats the plant material to high enough temperatures to release cannabinoids but without combusting. It’s a much more efficient THC delivery system than smoking, and there’s no smoke in the lungs. Vape patients often feel they can titrate their dose exactly.
Edibles are another matter. It can take hours for them to hit. Although THC levels do not spike with edibles as they do when the substance is inhaled, the effects last longer. A lot depends on how much food is in the gut.
The risk with edibles is that people may keep popping gummy bears and brownies because they don’t feel anything but end up overdosing. Children might be tempted by the treats, too, and for those under 4 years old, overdose can lead to fatal encephalopathic comas, “something we never really saw until edibles came around,” Dr. Williams said.
With edibles, “you have no idea what’s actually in the product.” Labels can be “inaccurate by an order of magnitude. Patients should be cautioned about that,” he said.
Pregnant and breastfeeding women, especially, should be warned away from marijuana. Some of the literature suggests a link between exposure to marijuana and preterm birth – in addition to early psychosis in vulnerable children.
Dr. Williams had no relevant disclosures.
REPORTING FROM APA 2019
Incidence of adult diabetes drops, prevalence remains stable
according to a review of Centers for Disease Control and Prevention data.
It’s the longest plateau in prevalence since the 1980s, and the longest period of declining incidence ever recorded. The findings suggest that efforts “to stem the tide of type 2 diabetes may be working ... [but] we still have a very long way to go,” investigator Ann Albright, PhD, director of the CDC Division of Diabetes Translation, said in a press statement.
However, the authors noted that “obesity and severe obesity trends have generally increased over the past 10 years, and prediabetes remains unchanged and high, affecting 84 million U.S. adults, or 34% of the US adult population,” and they emphasized the need for continued focus on prevention for type 2 diabetes and diabetes complications, as well as better screening and detection of the disease.
Dr Albright and her colleagues reviewed the CDC’s annual National Health Interview Survey data from 1980-2017. Diabetes diagnoses were by self-report, and the data did not distinguish between type 1 and type 2 disease, although it is known that about 95% of diabetes cases are type 2 (BMJ Open Diab Res Care. 2019 May 28;7:e000657. doi:10.1136/bmjdrc-2019-000657).
New cases declined from a high of 1.73 million in 2008 to 1.34 million in 2017, a drop of 3.1% a year, from 7.8 to 6 new cases/1,000 adults. The findings were driven largely by decreasing incidence in non-Hispanic whites.
Prevalence peaked at 8.2/100 adults in 2009, and has remained there since, possibly because people with diabetes are living longer with the disease, the investigators said.
Similar prevalence trends were seen across age, racial, education, and ethnic groups, and in both men and women. The findings were all statistically significant.
The drop in incidence corresponds with flat or downward trends in several type 2 risk factors, including sugar, soda, and total calorie intake, and physical inactivity. In 2010, the American Diabetes Association recommended hemoglobin A1c for diabetes diagnosis, which might have also decreased the incidence because it is less sensitive than traditional fasting blood glucose. Increased screening in recent years might have depleted the pool of new cases as well, the authors said.
The CDC has been emphasizing type 2 education and prevention through its National Diabetes Prevention Program, which might also have helped.
There was no external funding for the survey, and the investigators reported no disclosures or conflicts of interest.
SOURCE: Benoit SR et al. BMJ Open Diab Res Care. 2019 May 28. doi:10.1136/bmjdrc-2019-000657
according to a review of Centers for Disease Control and Prevention data.
It’s the longest plateau in prevalence since the 1980s, and the longest period of declining incidence ever recorded. The findings suggest that efforts “to stem the tide of type 2 diabetes may be working ... [but] we still have a very long way to go,” investigator Ann Albright, PhD, director of the CDC Division of Diabetes Translation, said in a press statement.
However, the authors noted that “obesity and severe obesity trends have generally increased over the past 10 years, and prediabetes remains unchanged and high, affecting 84 million U.S. adults, or 34% of the US adult population,” and they emphasized the need for continued focus on prevention for type 2 diabetes and diabetes complications, as well as better screening and detection of the disease.
Dr Albright and her colleagues reviewed the CDC’s annual National Health Interview Survey data from 1980-2017. Diabetes diagnoses were by self-report, and the data did not distinguish between type 1 and type 2 disease, although it is known that about 95% of diabetes cases are type 2 (BMJ Open Diab Res Care. 2019 May 28;7:e000657. doi:10.1136/bmjdrc-2019-000657).
New cases declined from a high of 1.73 million in 2008 to 1.34 million in 2017, a drop of 3.1% a year, from 7.8 to 6 new cases/1,000 adults. The findings were driven largely by decreasing incidence in non-Hispanic whites.
Prevalence peaked at 8.2/100 adults in 2009, and has remained there since, possibly because people with diabetes are living longer with the disease, the investigators said.
Similar prevalence trends were seen across age, racial, education, and ethnic groups, and in both men and women. The findings were all statistically significant.
The drop in incidence corresponds with flat or downward trends in several type 2 risk factors, including sugar, soda, and total calorie intake, and physical inactivity. In 2010, the American Diabetes Association recommended hemoglobin A1c for diabetes diagnosis, which might have also decreased the incidence because it is less sensitive than traditional fasting blood glucose. Increased screening in recent years might have depleted the pool of new cases as well, the authors said.
The CDC has been emphasizing type 2 education and prevention through its National Diabetes Prevention Program, which might also have helped.
There was no external funding for the survey, and the investigators reported no disclosures or conflicts of interest.
SOURCE: Benoit SR et al. BMJ Open Diab Res Care. 2019 May 28. doi:10.1136/bmjdrc-2019-000657
according to a review of Centers for Disease Control and Prevention data.
It’s the longest plateau in prevalence since the 1980s, and the longest period of declining incidence ever recorded. The findings suggest that efforts “to stem the tide of type 2 diabetes may be working ... [but] we still have a very long way to go,” investigator Ann Albright, PhD, director of the CDC Division of Diabetes Translation, said in a press statement.
However, the authors noted that “obesity and severe obesity trends have generally increased over the past 10 years, and prediabetes remains unchanged and high, affecting 84 million U.S. adults, or 34% of the US adult population,” and they emphasized the need for continued focus on prevention for type 2 diabetes and diabetes complications, as well as better screening and detection of the disease.
Dr Albright and her colleagues reviewed the CDC’s annual National Health Interview Survey data from 1980-2017. Diabetes diagnoses were by self-report, and the data did not distinguish between type 1 and type 2 disease, although it is known that about 95% of diabetes cases are type 2 (BMJ Open Diab Res Care. 2019 May 28;7:e000657. doi:10.1136/bmjdrc-2019-000657).
New cases declined from a high of 1.73 million in 2008 to 1.34 million in 2017, a drop of 3.1% a year, from 7.8 to 6 new cases/1,000 adults. The findings were driven largely by decreasing incidence in non-Hispanic whites.
Prevalence peaked at 8.2/100 adults in 2009, and has remained there since, possibly because people with diabetes are living longer with the disease, the investigators said.
Similar prevalence trends were seen across age, racial, education, and ethnic groups, and in both men and women. The findings were all statistically significant.
The drop in incidence corresponds with flat or downward trends in several type 2 risk factors, including sugar, soda, and total calorie intake, and physical inactivity. In 2010, the American Diabetes Association recommended hemoglobin A1c for diabetes diagnosis, which might have also decreased the incidence because it is less sensitive than traditional fasting blood glucose. Increased screening in recent years might have depleted the pool of new cases as well, the authors said.
The CDC has been emphasizing type 2 education and prevention through its National Diabetes Prevention Program, which might also have helped.
There was no external funding for the survey, and the investigators reported no disclosures or conflicts of interest.
SOURCE: Benoit SR et al. BMJ Open Diab Res Care. 2019 May 28. doi:10.1136/bmjdrc-2019-000657
FROM BMJ OPEN DIABETES RESEARCH & CARE
Refractory OCD? Consider opioids, amphetamines, caffeine
SAN FRANCISCO – An expert in obsessive-compulsive disease had some surprising advice at the American Psychiatric Association annual meeting for treatment of adults with refractory illness. He endorsed amphetamines, caffeine, and once-weekly opioids in carefully selected patients.
“These are not things that will be taught to you in your residency,” said Lorrin M. Koran, MD, professor emeritus of psychiatry and behavioral sciences at Stanford (Calif.) University, and past director of the university’s OCD clinic and research program. “These are pharmacological pearls that have come to my attention over many years. I hope at the end of this talk you’ll be more comfortable, especially [with] stimulants, because [they are] very simple and very quick.”
Opioids are a last resort but can prove effective for some patients. “I had a woman who wrote me just last week who said her son’s been on an opioid for 9 years once a week,” Dr. Koran said. “He does very well, and if he stops, he relapses within a few days. He has not become dependent or abusive. You have to screen who you give these to.
“You and I are dedicated to helping people not suffer, so we might want to take a little risk” for people who are struggling, he said.
Bolus caffeine, not a casual cup
Inspired by findings from the 1980s-90s, Dr. Koran and his colleagues randomized 12 treatment-resistant adults at Stanford’s OCD clinic to dextroamphetamine (Dexedrine) 30 mg/day and 12 others to caffeine (NoDoz pills) 300 mg/day, both in pink capsules so patients couldn’t tell them apart. “They were really sick” at baseline, Dr. Koran said, with a mean Yale Brown OCD Scale (YBOCS) score of 28 points (J Clin Psychiatry. 2009 Nov;70[11]:1530-5).
Subjects remained on their antidepressants during the study. Patients with histories of substance abuse, heart disease, schizophrenia, bipolar disorder, or panic attacks were among those excluded.
Caffeine was supposed to be the placebo. But a curious thing happened: About half of patients in both groups did remarkably well after 1 week, with a mean YBOCS drop of 41% among the six amphetamine responders and 45% among seven caffeine responders – with more improvement after 5 weeks.
“I was shocked. In clinical trials, anything 25% or more is considered a response. What patients said was, ‘Gee doc, I still get my obsessions, but I can shift my attention. I can get away from them, so I don’t have to do my compulsions, anymore,’ ” Dr. Koran said.
There were a few dose reductions for insomnia and anxiety. However, overall, YBOCS improvement did not correlate with depression and anxiety scores, so responses appeared to be independent. There were no differences between the groups in liking their treatment or how high people felt.
“I encourage you to try this” – amphetamine or caffeine bolus – “for people who have not responded to say two [treatment] trials. Meanwhile, “the data for methylphenidate are less convincing,” Dr. Koran said.
He’s wondered why caffeine helps. After all, no one has ever come into the OCD clinic and said they felt better after their morning coffee. The hypothesis is that 300 mg of caffeine all at once triggers a spike of methylxanthines in the brain, which, much like amphetamines, promotes dopamine and serotonin release. Casually sipping coffee does not have the same effect.
When all else fails
Dr. Koran and his colleagues also ran a small trial of once-weekly opiates.
Spurred again by case histories and small studies, they randomized 23 refractory adults to once-weekly morphine 30 mg (with 15-mg dose adjustment as needed at 2 weeks), lorazepam 1 mg (with 0.5-mg adjustment at 2 weeks), or placebo. Subjects had OCD for at least 3 years, and had failed at least two antidepressant trials (some had been on atypicals). Median baseline YBOCS was 29 points. Subjects remained on their baseline medications during the study (J Clin Psychiatry. 2005 Mar;66[3]:353-9).
Seven patients responded to morphine with a drop of at least 25% in their YBOCS; five had at least a 40% drop. Patients who were not taking a selective serotonin or norepinephrine reuptake inhibitor did not respond to morphine.
There were four lorazepam responders, but only one with a reduction of 40% or more. There were no placebo responders.
Opioids are the “the last thing to think of” in OCD, but when all else fails, “you could try morphine in a properly screened individual,” as long as there is no personal or family history of substance abuse.
Dr. Koran said he had no conflicts of interest.
SAN FRANCISCO – An expert in obsessive-compulsive disease had some surprising advice at the American Psychiatric Association annual meeting for treatment of adults with refractory illness. He endorsed amphetamines, caffeine, and once-weekly opioids in carefully selected patients.
“These are not things that will be taught to you in your residency,” said Lorrin M. Koran, MD, professor emeritus of psychiatry and behavioral sciences at Stanford (Calif.) University, and past director of the university’s OCD clinic and research program. “These are pharmacological pearls that have come to my attention over many years. I hope at the end of this talk you’ll be more comfortable, especially [with] stimulants, because [they are] very simple and very quick.”
Opioids are a last resort but can prove effective for some patients. “I had a woman who wrote me just last week who said her son’s been on an opioid for 9 years once a week,” Dr. Koran said. “He does very well, and if he stops, he relapses within a few days. He has not become dependent or abusive. You have to screen who you give these to.
“You and I are dedicated to helping people not suffer, so we might want to take a little risk” for people who are struggling, he said.
Bolus caffeine, not a casual cup
Inspired by findings from the 1980s-90s, Dr. Koran and his colleagues randomized 12 treatment-resistant adults at Stanford’s OCD clinic to dextroamphetamine (Dexedrine) 30 mg/day and 12 others to caffeine (NoDoz pills) 300 mg/day, both in pink capsules so patients couldn’t tell them apart. “They were really sick” at baseline, Dr. Koran said, with a mean Yale Brown OCD Scale (YBOCS) score of 28 points (J Clin Psychiatry. 2009 Nov;70[11]:1530-5).
Subjects remained on their antidepressants during the study. Patients with histories of substance abuse, heart disease, schizophrenia, bipolar disorder, or panic attacks were among those excluded.
Caffeine was supposed to be the placebo. But a curious thing happened: About half of patients in both groups did remarkably well after 1 week, with a mean YBOCS drop of 41% among the six amphetamine responders and 45% among seven caffeine responders – with more improvement after 5 weeks.
“I was shocked. In clinical trials, anything 25% or more is considered a response. What patients said was, ‘Gee doc, I still get my obsessions, but I can shift my attention. I can get away from them, so I don’t have to do my compulsions, anymore,’ ” Dr. Koran said.
There were a few dose reductions for insomnia and anxiety. However, overall, YBOCS improvement did not correlate with depression and anxiety scores, so responses appeared to be independent. There were no differences between the groups in liking their treatment or how high people felt.
“I encourage you to try this” – amphetamine or caffeine bolus – “for people who have not responded to say two [treatment] trials. Meanwhile, “the data for methylphenidate are less convincing,” Dr. Koran said.
He’s wondered why caffeine helps. After all, no one has ever come into the OCD clinic and said they felt better after their morning coffee. The hypothesis is that 300 mg of caffeine all at once triggers a spike of methylxanthines in the brain, which, much like amphetamines, promotes dopamine and serotonin release. Casually sipping coffee does not have the same effect.
When all else fails
Dr. Koran and his colleagues also ran a small trial of once-weekly opiates.
Spurred again by case histories and small studies, they randomized 23 refractory adults to once-weekly morphine 30 mg (with 15-mg dose adjustment as needed at 2 weeks), lorazepam 1 mg (with 0.5-mg adjustment at 2 weeks), or placebo. Subjects had OCD for at least 3 years, and had failed at least two antidepressant trials (some had been on atypicals). Median baseline YBOCS was 29 points. Subjects remained on their baseline medications during the study (J Clin Psychiatry. 2005 Mar;66[3]:353-9).
Seven patients responded to morphine with a drop of at least 25% in their YBOCS; five had at least a 40% drop. Patients who were not taking a selective serotonin or norepinephrine reuptake inhibitor did not respond to morphine.
There were four lorazepam responders, but only one with a reduction of 40% or more. There were no placebo responders.
Opioids are the “the last thing to think of” in OCD, but when all else fails, “you could try morphine in a properly screened individual,” as long as there is no personal or family history of substance abuse.
Dr. Koran said he had no conflicts of interest.
SAN FRANCISCO – An expert in obsessive-compulsive disease had some surprising advice at the American Psychiatric Association annual meeting for treatment of adults with refractory illness. He endorsed amphetamines, caffeine, and once-weekly opioids in carefully selected patients.
“These are not things that will be taught to you in your residency,” said Lorrin M. Koran, MD, professor emeritus of psychiatry and behavioral sciences at Stanford (Calif.) University, and past director of the university’s OCD clinic and research program. “These are pharmacological pearls that have come to my attention over many years. I hope at the end of this talk you’ll be more comfortable, especially [with] stimulants, because [they are] very simple and very quick.”
Opioids are a last resort but can prove effective for some patients. “I had a woman who wrote me just last week who said her son’s been on an opioid for 9 years once a week,” Dr. Koran said. “He does very well, and if he stops, he relapses within a few days. He has not become dependent or abusive. You have to screen who you give these to.
“You and I are dedicated to helping people not suffer, so we might want to take a little risk” for people who are struggling, he said.
Bolus caffeine, not a casual cup
Inspired by findings from the 1980s-90s, Dr. Koran and his colleagues randomized 12 treatment-resistant adults at Stanford’s OCD clinic to dextroamphetamine (Dexedrine) 30 mg/day and 12 others to caffeine (NoDoz pills) 300 mg/day, both in pink capsules so patients couldn’t tell them apart. “They were really sick” at baseline, Dr. Koran said, with a mean Yale Brown OCD Scale (YBOCS) score of 28 points (J Clin Psychiatry. 2009 Nov;70[11]:1530-5).
Subjects remained on their antidepressants during the study. Patients with histories of substance abuse, heart disease, schizophrenia, bipolar disorder, or panic attacks were among those excluded.
Caffeine was supposed to be the placebo. But a curious thing happened: About half of patients in both groups did remarkably well after 1 week, with a mean YBOCS drop of 41% among the six amphetamine responders and 45% among seven caffeine responders – with more improvement after 5 weeks.
“I was shocked. In clinical trials, anything 25% or more is considered a response. What patients said was, ‘Gee doc, I still get my obsessions, but I can shift my attention. I can get away from them, so I don’t have to do my compulsions, anymore,’ ” Dr. Koran said.
There were a few dose reductions for insomnia and anxiety. However, overall, YBOCS improvement did not correlate with depression and anxiety scores, so responses appeared to be independent. There were no differences between the groups in liking their treatment or how high people felt.
“I encourage you to try this” – amphetamine or caffeine bolus – “for people who have not responded to say two [treatment] trials. Meanwhile, “the data for methylphenidate are less convincing,” Dr. Koran said.
He’s wondered why caffeine helps. After all, no one has ever come into the OCD clinic and said they felt better after their morning coffee. The hypothesis is that 300 mg of caffeine all at once triggers a spike of methylxanthines in the brain, which, much like amphetamines, promotes dopamine and serotonin release. Casually sipping coffee does not have the same effect.
When all else fails
Dr. Koran and his colleagues also ran a small trial of once-weekly opiates.
Spurred again by case histories and small studies, they randomized 23 refractory adults to once-weekly morphine 30 mg (with 15-mg dose adjustment as needed at 2 weeks), lorazepam 1 mg (with 0.5-mg adjustment at 2 weeks), or placebo. Subjects had OCD for at least 3 years, and had failed at least two antidepressant trials (some had been on atypicals). Median baseline YBOCS was 29 points. Subjects remained on their baseline medications during the study (J Clin Psychiatry. 2005 Mar;66[3]:353-9).
Seven patients responded to morphine with a drop of at least 25% in their YBOCS; five had at least a 40% drop. Patients who were not taking a selective serotonin or norepinephrine reuptake inhibitor did not respond to morphine.
There were four lorazepam responders, but only one with a reduction of 40% or more. There were no placebo responders.
Opioids are the “the last thing to think of” in OCD, but when all else fails, “you could try morphine in a properly screened individual,” as long as there is no personal or family history of substance abuse.
Dr. Koran said he had no conflicts of interest.
REPORTING FROM APA 2019
How to counsel patients interested in trying marijuana
SAN FRANCISCO – It’s a common scenario, and it’s going to become more common: Psychiatric patients will be coming into the office not quite satisfied with their current treatment and wanting to try cannabis.
With laws varying from state to state and a limited but growing body of evidence, the situation “presents a complicated, often difficult clinical situation,” said David A. Gorelick, MD, PhD, professor of psychiatry at the University of Maryland, Baltimore.
There is some evidence supporting cannabis for chronic pain, neuropathic pain, spasticity in multiple sclerosis, and chemotherapy-induced nausea and vomiting. Cannabidiol is also Food and Drug Administration approved for two severe forms of pediatric epilepsy.
When it comes to psychiatric disorders, however, evidence is largely lacking. On the other hand, some patients swear by marijuana for psychiatric symptom relief.
So what to do? Dr. Gorelick, editor of the Journal of Cannabis Research, had some advice in a video interview at the annual meeting of the American Psychiatric Association.
Where it’s legal, a cannabis recommendation for pain and sleep problems is reasonable, but it’s important to figure out what’s lacking in the patients’ treatment regimen that makes them want to try cannabis, and to first try to maximize treatment with approved, evidence-based options. As with any medication, a talk about risks and benefits is also essential. There’s an increased risk of motor vehicle accidents, acute panic attacks, and other issues with cannabis. Also, keep in mind that cannabinoids, particularly tetrahydrocannabinol, are metabolized in the liver and can interfere with concentrations of other liver-metabolized drugs, including some antidepressants and anticonvulsants. It’s not clear how significant the clinical interactions are, “but if patients are on warfarin, I would be very careful,” he said.
Dr. Gorelick disclosed speaking fees from hospitals and organizations for presentations on medical cannabis and royalties from Up-to-Date for cannabis topics. He also disclosed receiving honoraria from Colorado State University, Pueblo, and from Springer for his work on the Journal of Cannabis Research.
SAN FRANCISCO – It’s a common scenario, and it’s going to become more common: Psychiatric patients will be coming into the office not quite satisfied with their current treatment and wanting to try cannabis.
With laws varying from state to state and a limited but growing body of evidence, the situation “presents a complicated, often difficult clinical situation,” said David A. Gorelick, MD, PhD, professor of psychiatry at the University of Maryland, Baltimore.
There is some evidence supporting cannabis for chronic pain, neuropathic pain, spasticity in multiple sclerosis, and chemotherapy-induced nausea and vomiting. Cannabidiol is also Food and Drug Administration approved for two severe forms of pediatric epilepsy.
When it comes to psychiatric disorders, however, evidence is largely lacking. On the other hand, some patients swear by marijuana for psychiatric symptom relief.
So what to do? Dr. Gorelick, editor of the Journal of Cannabis Research, had some advice in a video interview at the annual meeting of the American Psychiatric Association.
Where it’s legal, a cannabis recommendation for pain and sleep problems is reasonable, but it’s important to figure out what’s lacking in the patients’ treatment regimen that makes them want to try cannabis, and to first try to maximize treatment with approved, evidence-based options. As with any medication, a talk about risks and benefits is also essential. There’s an increased risk of motor vehicle accidents, acute panic attacks, and other issues with cannabis. Also, keep in mind that cannabinoids, particularly tetrahydrocannabinol, are metabolized in the liver and can interfere with concentrations of other liver-metabolized drugs, including some antidepressants and anticonvulsants. It’s not clear how significant the clinical interactions are, “but if patients are on warfarin, I would be very careful,” he said.
Dr. Gorelick disclosed speaking fees from hospitals and organizations for presentations on medical cannabis and royalties from Up-to-Date for cannabis topics. He also disclosed receiving honoraria from Colorado State University, Pueblo, and from Springer for his work on the Journal of Cannabis Research.
SAN FRANCISCO – It’s a common scenario, and it’s going to become more common: Psychiatric patients will be coming into the office not quite satisfied with their current treatment and wanting to try cannabis.
With laws varying from state to state and a limited but growing body of evidence, the situation “presents a complicated, often difficult clinical situation,” said David A. Gorelick, MD, PhD, professor of psychiatry at the University of Maryland, Baltimore.
There is some evidence supporting cannabis for chronic pain, neuropathic pain, spasticity in multiple sclerosis, and chemotherapy-induced nausea and vomiting. Cannabidiol is also Food and Drug Administration approved for two severe forms of pediatric epilepsy.
When it comes to psychiatric disorders, however, evidence is largely lacking. On the other hand, some patients swear by marijuana for psychiatric symptom relief.
So what to do? Dr. Gorelick, editor of the Journal of Cannabis Research, had some advice in a video interview at the annual meeting of the American Psychiatric Association.
Where it’s legal, a cannabis recommendation for pain and sleep problems is reasonable, but it’s important to figure out what’s lacking in the patients’ treatment regimen that makes them want to try cannabis, and to first try to maximize treatment with approved, evidence-based options. As with any medication, a talk about risks and benefits is also essential. There’s an increased risk of motor vehicle accidents, acute panic attacks, and other issues with cannabis. Also, keep in mind that cannabinoids, particularly tetrahydrocannabinol, are metabolized in the liver and can interfere with concentrations of other liver-metabolized drugs, including some antidepressants and anticonvulsants. It’s not clear how significant the clinical interactions are, “but if patients are on warfarin, I would be very careful,” he said.
Dr. Gorelick disclosed speaking fees from hospitals and organizations for presentations on medical cannabis and royalties from Up-to-Date for cannabis topics. He also disclosed receiving honoraria from Colorado State University, Pueblo, and from Springer for his work on the Journal of Cannabis Research.
REPORTING FROM APA 2019
Weight can block psychiatric facility admission
SAN FRANCISCO – Not too long ago, a 42-year-old homeless man could not leave the Los Angeles County Hospital because he was too heavy.
He had been admitted on a 72-hour involuntary psychiatric hold because he was suicidal; he had a history of severe depression and had made several attempts in the past. He had few social connections and had come in covered in lice after sleeping outdoors for months. He was mobile, but barely so, with the help of a walker.
He was cleaned up and medically stabilized at the hospital, but when it came time to transfer him to a psychiatric facility, no one would take him because he was morbidly obese, with a body mass index (BMI) of 53 mg/m2.
“We noticed this had happened with other patients. It wasn’t just this one case, so we” decided to take a closer look, said Katherine Camfield, MD, a psychiatric resident at Los Angeles County Hospital.
She and her colleagues called 43 inpatient psychiatric facilities in L.A. County. It turned out that 41, more than 60% of the total and including both public and private facilities, had weight restrictions. Staff members at the remaining two facilities were unsure.
For 2 hospitals, it was a BMI above 50; for 17, a weight above 350 pounds; and for 6, a weight above 300 pounds. Three had a limit of just 250 pounds. Others decided on a case-by-case basis. About 10% of the people put on psychiatric holds at the L.A. County Hospital weigh 250 pounds or more and therefore would not meet the weight limits at many facilities.
Some hospitals cited concerns about staff injuries from moving – or trying to calm – a large patient. Others said they did not have lifts and other specialized equipment or that their beds could not handle the weight. Others did not really give a reason.
County hospitals “are not a very therapeutic milieu; staff and nursing aren’t necessarily trained for unstable psychiatric patients,” Dr. Camfield said at the American Psychiatric Association annual meeting.
“Honestly, having a mental illness alone increases your risk of obesity, and then we give a lot of medications that increase the risk” even more. “It’s a vicious cycle,” and one that raises the issue of discrimination, although “whether these routine denials to access psychiatric hospitalization violate antidiscrimination laws is unclear,” she said.
She and her colleagues plan to take a deeper dive into the issue, to find out how widespread the problem is, and the reasons behind it. They are also interested in cost; “a county facility has limited resources; are they being misallocated because these patients are stuck in the hospital?” Dr. Camfield wondered.
The homeless man never made to a psychiatric facility. He was put on antidepressants and stayed in the county hospital for 20 days, until he was no longer suicidal. He then was transferred to skilled nursing facility.
There was no external funding, and Dr. Camfield had no disclosures.
SAN FRANCISCO – Not too long ago, a 42-year-old homeless man could not leave the Los Angeles County Hospital because he was too heavy.
He had been admitted on a 72-hour involuntary psychiatric hold because he was suicidal; he had a history of severe depression and had made several attempts in the past. He had few social connections and had come in covered in lice after sleeping outdoors for months. He was mobile, but barely so, with the help of a walker.
He was cleaned up and medically stabilized at the hospital, but when it came time to transfer him to a psychiatric facility, no one would take him because he was morbidly obese, with a body mass index (BMI) of 53 mg/m2.
“We noticed this had happened with other patients. It wasn’t just this one case, so we” decided to take a closer look, said Katherine Camfield, MD, a psychiatric resident at Los Angeles County Hospital.
She and her colleagues called 43 inpatient psychiatric facilities in L.A. County. It turned out that 41, more than 60% of the total and including both public and private facilities, had weight restrictions. Staff members at the remaining two facilities were unsure.
For 2 hospitals, it was a BMI above 50; for 17, a weight above 350 pounds; and for 6, a weight above 300 pounds. Three had a limit of just 250 pounds. Others decided on a case-by-case basis. About 10% of the people put on psychiatric holds at the L.A. County Hospital weigh 250 pounds or more and therefore would not meet the weight limits at many facilities.
Some hospitals cited concerns about staff injuries from moving – or trying to calm – a large patient. Others said they did not have lifts and other specialized equipment or that their beds could not handle the weight. Others did not really give a reason.
County hospitals “are not a very therapeutic milieu; staff and nursing aren’t necessarily trained for unstable psychiatric patients,” Dr. Camfield said at the American Psychiatric Association annual meeting.
“Honestly, having a mental illness alone increases your risk of obesity, and then we give a lot of medications that increase the risk” even more. “It’s a vicious cycle,” and one that raises the issue of discrimination, although “whether these routine denials to access psychiatric hospitalization violate antidiscrimination laws is unclear,” she said.
She and her colleagues plan to take a deeper dive into the issue, to find out how widespread the problem is, and the reasons behind it. They are also interested in cost; “a county facility has limited resources; are they being misallocated because these patients are stuck in the hospital?” Dr. Camfield wondered.
The homeless man never made to a psychiatric facility. He was put on antidepressants and stayed in the county hospital for 20 days, until he was no longer suicidal. He then was transferred to skilled nursing facility.
There was no external funding, and Dr. Camfield had no disclosures.
SAN FRANCISCO – Not too long ago, a 42-year-old homeless man could not leave the Los Angeles County Hospital because he was too heavy.
He had been admitted on a 72-hour involuntary psychiatric hold because he was suicidal; he had a history of severe depression and had made several attempts in the past. He had few social connections and had come in covered in lice after sleeping outdoors for months. He was mobile, but barely so, with the help of a walker.
He was cleaned up and medically stabilized at the hospital, but when it came time to transfer him to a psychiatric facility, no one would take him because he was morbidly obese, with a body mass index (BMI) of 53 mg/m2.
“We noticed this had happened with other patients. It wasn’t just this one case, so we” decided to take a closer look, said Katherine Camfield, MD, a psychiatric resident at Los Angeles County Hospital.
She and her colleagues called 43 inpatient psychiatric facilities in L.A. County. It turned out that 41, more than 60% of the total and including both public and private facilities, had weight restrictions. Staff members at the remaining two facilities were unsure.
For 2 hospitals, it was a BMI above 50; for 17, a weight above 350 pounds; and for 6, a weight above 300 pounds. Three had a limit of just 250 pounds. Others decided on a case-by-case basis. About 10% of the people put on psychiatric holds at the L.A. County Hospital weigh 250 pounds or more and therefore would not meet the weight limits at many facilities.
Some hospitals cited concerns about staff injuries from moving – or trying to calm – a large patient. Others said they did not have lifts and other specialized equipment or that their beds could not handle the weight. Others did not really give a reason.
County hospitals “are not a very therapeutic milieu; staff and nursing aren’t necessarily trained for unstable psychiatric patients,” Dr. Camfield said at the American Psychiatric Association annual meeting.
“Honestly, having a mental illness alone increases your risk of obesity, and then we give a lot of medications that increase the risk” even more. “It’s a vicious cycle,” and one that raises the issue of discrimination, although “whether these routine denials to access psychiatric hospitalization violate antidiscrimination laws is unclear,” she said.
She and her colleagues plan to take a deeper dive into the issue, to find out how widespread the problem is, and the reasons behind it. They are also interested in cost; “a county facility has limited resources; are they being misallocated because these patients are stuck in the hospital?” Dr. Camfield wondered.
The homeless man never made to a psychiatric facility. He was put on antidepressants and stayed in the county hospital for 20 days, until he was no longer suicidal. He then was transferred to skilled nursing facility.
There was no external funding, and Dr. Camfield had no disclosures.
REPORTING FROM APA 2019
The effects persist for children who witnessed 9/11
SAN FRANCISCO – according to a case-control study presented at the American Psychiatric Association annual meeting.
The investigation included 942 people who, as children under 18 years old, were in school below Canal Street in lower Manhattan when the World Trade Center was attacked. They saw the towers collapse and were evacuated from the area, but did not lose a parent. Now 18-36 years old, they were interviewed in their homes and asked to filled out questionnaires about psychiatric and physical problems. The outcomes were compared with 563 age- and gender-matched controls who were in school in Queens at the time.
In turns out that “it made a huge difference whether you were there or not. Being there had much more impact than hearing about it or watching it on TV,” said lead investigator Lawrence Amsel, MD, an assistant professor of clinical psychiatry at Columbia University in New York.
Adults who witnessed the attacks as children were more than twice as likely to have panic disorder, marijuana use disorder, and separation anxiety, which is uncommon in adults; anxiety disorders were more prevalent, as well.
They also were almost half as likely to be living with a spouse or partner, and half as likely to be living independently. “That kind of goes along with the separation anxiety; these kids were more likely to be afraid of moving away from their family and breaking out into their own lives,” Dr. Amsel said.
Overall, 36% had a psychiatric disorder, and 27% had a physical problem, such as diabetes, asthma, or eczema; 14% had both. Among adults who were in Queens during the attacks, 28% had a psychiatric disorder, and 11% a physical problem; 4% were comorbid.
The increased odds of physical-psychiatric comorbidity among witnesses (adjusted odds ratio, 4.60; 95% confidence interval, 2.75- 7.71; P less than .0001) “was not due simply to an increase in physical conditions,” according to the study team.
“This was a single event,” Dr. Amsel said, but for children who witnessed it, “it’s had effects for decades. There were huge amounts of money sent in, and lots of health care for kids who were down there, but despite that, we have this. We think the PTSD morphed into” long-term issues, Dr. Amsel said.
“We know that one of the reasons people get psychiatric disorders” after trauma “is that they generalize the fear; the message to your brain is that everything is dangerous. You’ve got to intervene there and break the association between the fear system and everything else, so that life is still safe,” he said.
There’s an added element with human violence. “Life may be unsafe” after a natural disaster, “but you know that human beings are good and helpful. With a terrorist attack, you stop trusting people,” he said.
Cognitive behavioral therapy could help, among other approaches. It also might be helpful to teach resilience to schoolchildren, just like biology and algebra, he said.
Cases and controls were evenly split between the sexes. Just over 40% of subjects in both groups were white, followed by Hispanics, Asians, and blacks. The majority of households were middle income.
The next step is to break the results down by age, ethnicity, socioeconomic factors, and support systems. The team will run blood work and heart and lung tests on the subjects to nail down the physical problems reported by witnesses. There are concerns about the lingering effects of the dust plume.
The work is funded by the federal government. Dr. Amsel didn’t have any relevant financial disclosures.
SAN FRANCISCO – according to a case-control study presented at the American Psychiatric Association annual meeting.
The investigation included 942 people who, as children under 18 years old, were in school below Canal Street in lower Manhattan when the World Trade Center was attacked. They saw the towers collapse and were evacuated from the area, but did not lose a parent. Now 18-36 years old, they were interviewed in their homes and asked to filled out questionnaires about psychiatric and physical problems. The outcomes were compared with 563 age- and gender-matched controls who were in school in Queens at the time.
In turns out that “it made a huge difference whether you were there or not. Being there had much more impact than hearing about it or watching it on TV,” said lead investigator Lawrence Amsel, MD, an assistant professor of clinical psychiatry at Columbia University in New York.
Adults who witnessed the attacks as children were more than twice as likely to have panic disorder, marijuana use disorder, and separation anxiety, which is uncommon in adults; anxiety disorders were more prevalent, as well.
They also were almost half as likely to be living with a spouse or partner, and half as likely to be living independently. “That kind of goes along with the separation anxiety; these kids were more likely to be afraid of moving away from their family and breaking out into their own lives,” Dr. Amsel said.
Overall, 36% had a psychiatric disorder, and 27% had a physical problem, such as diabetes, asthma, or eczema; 14% had both. Among adults who were in Queens during the attacks, 28% had a psychiatric disorder, and 11% a physical problem; 4% were comorbid.
The increased odds of physical-psychiatric comorbidity among witnesses (adjusted odds ratio, 4.60; 95% confidence interval, 2.75- 7.71; P less than .0001) “was not due simply to an increase in physical conditions,” according to the study team.
“This was a single event,” Dr. Amsel said, but for children who witnessed it, “it’s had effects for decades. There were huge amounts of money sent in, and lots of health care for kids who were down there, but despite that, we have this. We think the PTSD morphed into” long-term issues, Dr. Amsel said.
“We know that one of the reasons people get psychiatric disorders” after trauma “is that they generalize the fear; the message to your brain is that everything is dangerous. You’ve got to intervene there and break the association between the fear system and everything else, so that life is still safe,” he said.
There’s an added element with human violence. “Life may be unsafe” after a natural disaster, “but you know that human beings are good and helpful. With a terrorist attack, you stop trusting people,” he said.
Cognitive behavioral therapy could help, among other approaches. It also might be helpful to teach resilience to schoolchildren, just like biology and algebra, he said.
Cases and controls were evenly split between the sexes. Just over 40% of subjects in both groups were white, followed by Hispanics, Asians, and blacks. The majority of households were middle income.
The next step is to break the results down by age, ethnicity, socioeconomic factors, and support systems. The team will run blood work and heart and lung tests on the subjects to nail down the physical problems reported by witnesses. There are concerns about the lingering effects of the dust plume.
The work is funded by the federal government. Dr. Amsel didn’t have any relevant financial disclosures.
SAN FRANCISCO – according to a case-control study presented at the American Psychiatric Association annual meeting.
The investigation included 942 people who, as children under 18 years old, were in school below Canal Street in lower Manhattan when the World Trade Center was attacked. They saw the towers collapse and were evacuated from the area, but did not lose a parent. Now 18-36 years old, they were interviewed in their homes and asked to filled out questionnaires about psychiatric and physical problems. The outcomes were compared with 563 age- and gender-matched controls who were in school in Queens at the time.
In turns out that “it made a huge difference whether you were there or not. Being there had much more impact than hearing about it or watching it on TV,” said lead investigator Lawrence Amsel, MD, an assistant professor of clinical psychiatry at Columbia University in New York.
Adults who witnessed the attacks as children were more than twice as likely to have panic disorder, marijuana use disorder, and separation anxiety, which is uncommon in adults; anxiety disorders were more prevalent, as well.
They also were almost half as likely to be living with a spouse or partner, and half as likely to be living independently. “That kind of goes along with the separation anxiety; these kids were more likely to be afraid of moving away from their family and breaking out into their own lives,” Dr. Amsel said.
Overall, 36% had a psychiatric disorder, and 27% had a physical problem, such as diabetes, asthma, or eczema; 14% had both. Among adults who were in Queens during the attacks, 28% had a psychiatric disorder, and 11% a physical problem; 4% were comorbid.
The increased odds of physical-psychiatric comorbidity among witnesses (adjusted odds ratio, 4.60; 95% confidence interval, 2.75- 7.71; P less than .0001) “was not due simply to an increase in physical conditions,” according to the study team.
“This was a single event,” Dr. Amsel said, but for children who witnessed it, “it’s had effects for decades. There were huge amounts of money sent in, and lots of health care for kids who were down there, but despite that, we have this. We think the PTSD morphed into” long-term issues, Dr. Amsel said.
“We know that one of the reasons people get psychiatric disorders” after trauma “is that they generalize the fear; the message to your brain is that everything is dangerous. You’ve got to intervene there and break the association between the fear system and everything else, so that life is still safe,” he said.
There’s an added element with human violence. “Life may be unsafe” after a natural disaster, “but you know that human beings are good and helpful. With a terrorist attack, you stop trusting people,” he said.
Cognitive behavioral therapy could help, among other approaches. It also might be helpful to teach resilience to schoolchildren, just like biology and algebra, he said.
Cases and controls were evenly split between the sexes. Just over 40% of subjects in both groups were white, followed by Hispanics, Asians, and blacks. The majority of households were middle income.
The next step is to break the results down by age, ethnicity, socioeconomic factors, and support systems. The team will run blood work and heart and lung tests on the subjects to nail down the physical problems reported by witnesses. There are concerns about the lingering effects of the dust plume.
The work is funded by the federal government. Dr. Amsel didn’t have any relevant financial disclosures.
REPORTING FROM APA 2019
Significant increase in low-attenuation coronary plaques found in lupus
SAN FRANCISCO – according to an investigation from Johns Hopkins University, Baltimore.
All of the 102 lupus patients in the coronary artery CT angiography study also had positive plaque remodeling, meaning that at least one low-attenuation plaque was growing into the lumen wall, not the lumen itself, which makes them difficult to detect on standard imaging. Low-attenuation plaques were defined in the study as a plaque larger than 1 mm2 with a radiodensity below 30 Hounsfield units.
Low-attenuation plaques are inherently unstable; they’re fatty, necrotic, and have a high risk of rupturing; their presence in the lumen wall is especially worrisome. In the general population, they sometimes regress, scarring down over time and no longer posing a threat. That didn’t happen in the 30 lupus patients who had follow-up CT angiographies, some 9 years after their first.
The team conducted the study to help understand why cardiovascular disease is so common in lupus, and the leading cause of death. Hopkins investigators have shown previously that statins have no effect on the risk or plaque occurrence and progression, and the cardiovascular risk doesn’t always seem to correlate with disease control. For those and other reasons, the current thinking at Hopkins is that cardiovascular disease in lupus is somehow different than in the general population, said George Stojan, MD, an assistant professor of rheumatology at the school and codirector of the Hopkins Lupus Center.
The goal is “to figure out exactly what to look for when we assess the risk; I don’t think we understand that at this point. We assume patients with lupus behave exactly like patients who don’t have lupus, but they obviously don’t. They do not respond to statins. They have a higher risk no matter what you do for them, even when their disease activity is low, and how much plaque they have over time doesn’t really correlate with disease activity,” he said at an international conference on systemic lupus erythematosus.
“Once we understand” the mechanism, “then we can try to [alter] it. Maybe we can look at new drugs, like the PCSK9 inhibitors which have shown a lot of promise in the general population.” At this point, however, “we don’t really know how to intervene,” Dr. Stojan said.
In the meantime, positive remodeling and low-attenuation, noncalcified plaques (LANCPs) might be something to look for when assessing systemic lupus erythematosus cardiovascular risk. “A simple coronary calcium score, something that all doctors do,” is not enough in lupus, nor is simply checking for lumen obstruction. Also, it’s important not to be misled by an overall reduction in noncalcified plaques. “Low-attenuation, noncalcified plaques don’t [regress] over time in lupus, and they are the ones that lead to cardiovascular events,” he said.
The CT angiography findings were compared with findings in 100 healthy controls who had two CT angiograms in a University of California, Los Angeles, cohort. Overall, there was a mean of 458 LANCPs among lupus patients, versus 42 among controls, a more than 900% difference (P less than .001).
Women with lupus aged under 44 years had a mean of 63 LANCPs; none were detected in healthy women under 44 years. Among women aged 45-59 years, there was a mean of 451 LANCPs in the lupus group versus 53 in the control arm. The findings were highly statistically significant, and almost statistically significant for women 60 years or older, 695 lesions among lupus patients versus 22 (P = .0576).
There were only nine men with lupus in the study, but the findings were similar versus male controls.
While mean LANCP volume regressed over time in the control group (mean, –6.90 mm3; P = .0002), a mean regression of –13.56 mm3 in the lupus group was not statistically significant (P = .4570).
Both controls and lupus patients had a positive remodeling index. It progressed in the lupus group over time, and regressed in controls, but the findings were not statistically significant.
“Statins did nothing for the lupus patients. They didn’t affect progress of coronary plaques at all. We still treat patients because theoretically we don’t have anything better, but we know that they don’t really work in this population,” Dr. Stojan said
The work is funded by the National Institutes of Health. Dr. Stojan didn’t report any relevant disclosures.
SOURCE: Stojan G et al. Lupus Sci Med. 2019;6[suppl 1]:A200, Abstract 274.
SAN FRANCISCO – according to an investigation from Johns Hopkins University, Baltimore.
All of the 102 lupus patients in the coronary artery CT angiography study also had positive plaque remodeling, meaning that at least one low-attenuation plaque was growing into the lumen wall, not the lumen itself, which makes them difficult to detect on standard imaging. Low-attenuation plaques were defined in the study as a plaque larger than 1 mm2 with a radiodensity below 30 Hounsfield units.
Low-attenuation plaques are inherently unstable; they’re fatty, necrotic, and have a high risk of rupturing; their presence in the lumen wall is especially worrisome. In the general population, they sometimes regress, scarring down over time and no longer posing a threat. That didn’t happen in the 30 lupus patients who had follow-up CT angiographies, some 9 years after their first.
The team conducted the study to help understand why cardiovascular disease is so common in lupus, and the leading cause of death. Hopkins investigators have shown previously that statins have no effect on the risk or plaque occurrence and progression, and the cardiovascular risk doesn’t always seem to correlate with disease control. For those and other reasons, the current thinking at Hopkins is that cardiovascular disease in lupus is somehow different than in the general population, said George Stojan, MD, an assistant professor of rheumatology at the school and codirector of the Hopkins Lupus Center.
The goal is “to figure out exactly what to look for when we assess the risk; I don’t think we understand that at this point. We assume patients with lupus behave exactly like patients who don’t have lupus, but they obviously don’t. They do not respond to statins. They have a higher risk no matter what you do for them, even when their disease activity is low, and how much plaque they have over time doesn’t really correlate with disease activity,” he said at an international conference on systemic lupus erythematosus.
“Once we understand” the mechanism, “then we can try to [alter] it. Maybe we can look at new drugs, like the PCSK9 inhibitors which have shown a lot of promise in the general population.” At this point, however, “we don’t really know how to intervene,” Dr. Stojan said.
In the meantime, positive remodeling and low-attenuation, noncalcified plaques (LANCPs) might be something to look for when assessing systemic lupus erythematosus cardiovascular risk. “A simple coronary calcium score, something that all doctors do,” is not enough in lupus, nor is simply checking for lumen obstruction. Also, it’s important not to be misled by an overall reduction in noncalcified plaques. “Low-attenuation, noncalcified plaques don’t [regress] over time in lupus, and they are the ones that lead to cardiovascular events,” he said.
The CT angiography findings were compared with findings in 100 healthy controls who had two CT angiograms in a University of California, Los Angeles, cohort. Overall, there was a mean of 458 LANCPs among lupus patients, versus 42 among controls, a more than 900% difference (P less than .001).
Women with lupus aged under 44 years had a mean of 63 LANCPs; none were detected in healthy women under 44 years. Among women aged 45-59 years, there was a mean of 451 LANCPs in the lupus group versus 53 in the control arm. The findings were highly statistically significant, and almost statistically significant for women 60 years or older, 695 lesions among lupus patients versus 22 (P = .0576).
There were only nine men with lupus in the study, but the findings were similar versus male controls.
While mean LANCP volume regressed over time in the control group (mean, –6.90 mm3; P = .0002), a mean regression of –13.56 mm3 in the lupus group was not statistically significant (P = .4570).
Both controls and lupus patients had a positive remodeling index. It progressed in the lupus group over time, and regressed in controls, but the findings were not statistically significant.
“Statins did nothing for the lupus patients. They didn’t affect progress of coronary plaques at all. We still treat patients because theoretically we don’t have anything better, but we know that they don’t really work in this population,” Dr. Stojan said
The work is funded by the National Institutes of Health. Dr. Stojan didn’t report any relevant disclosures.
SOURCE: Stojan G et al. Lupus Sci Med. 2019;6[suppl 1]:A200, Abstract 274.
SAN FRANCISCO – according to an investigation from Johns Hopkins University, Baltimore.
All of the 102 lupus patients in the coronary artery CT angiography study also had positive plaque remodeling, meaning that at least one low-attenuation plaque was growing into the lumen wall, not the lumen itself, which makes them difficult to detect on standard imaging. Low-attenuation plaques were defined in the study as a plaque larger than 1 mm2 with a radiodensity below 30 Hounsfield units.
Low-attenuation plaques are inherently unstable; they’re fatty, necrotic, and have a high risk of rupturing; their presence in the lumen wall is especially worrisome. In the general population, they sometimes regress, scarring down over time and no longer posing a threat. That didn’t happen in the 30 lupus patients who had follow-up CT angiographies, some 9 years after their first.
The team conducted the study to help understand why cardiovascular disease is so common in lupus, and the leading cause of death. Hopkins investigators have shown previously that statins have no effect on the risk or plaque occurrence and progression, and the cardiovascular risk doesn’t always seem to correlate with disease control. For those and other reasons, the current thinking at Hopkins is that cardiovascular disease in lupus is somehow different than in the general population, said George Stojan, MD, an assistant professor of rheumatology at the school and codirector of the Hopkins Lupus Center.
The goal is “to figure out exactly what to look for when we assess the risk; I don’t think we understand that at this point. We assume patients with lupus behave exactly like patients who don’t have lupus, but they obviously don’t. They do not respond to statins. They have a higher risk no matter what you do for them, even when their disease activity is low, and how much plaque they have over time doesn’t really correlate with disease activity,” he said at an international conference on systemic lupus erythematosus.
“Once we understand” the mechanism, “then we can try to [alter] it. Maybe we can look at new drugs, like the PCSK9 inhibitors which have shown a lot of promise in the general population.” At this point, however, “we don’t really know how to intervene,” Dr. Stojan said.
In the meantime, positive remodeling and low-attenuation, noncalcified plaques (LANCPs) might be something to look for when assessing systemic lupus erythematosus cardiovascular risk. “A simple coronary calcium score, something that all doctors do,” is not enough in lupus, nor is simply checking for lumen obstruction. Also, it’s important not to be misled by an overall reduction in noncalcified plaques. “Low-attenuation, noncalcified plaques don’t [regress] over time in lupus, and they are the ones that lead to cardiovascular events,” he said.
The CT angiography findings were compared with findings in 100 healthy controls who had two CT angiograms in a University of California, Los Angeles, cohort. Overall, there was a mean of 458 LANCPs among lupus patients, versus 42 among controls, a more than 900% difference (P less than .001).
Women with lupus aged under 44 years had a mean of 63 LANCPs; none were detected in healthy women under 44 years. Among women aged 45-59 years, there was a mean of 451 LANCPs in the lupus group versus 53 in the control arm. The findings were highly statistically significant, and almost statistically significant for women 60 years or older, 695 lesions among lupus patients versus 22 (P = .0576).
There were only nine men with lupus in the study, but the findings were similar versus male controls.
While mean LANCP volume regressed over time in the control group (mean, –6.90 mm3; P = .0002), a mean regression of –13.56 mm3 in the lupus group was not statistically significant (P = .4570).
Both controls and lupus patients had a positive remodeling index. It progressed in the lupus group over time, and regressed in controls, but the findings were not statistically significant.
“Statins did nothing for the lupus patients. They didn’t affect progress of coronary plaques at all. We still treat patients because theoretically we don’t have anything better, but we know that they don’t really work in this population,” Dr. Stojan said
The work is funded by the National Institutes of Health. Dr. Stojan didn’t report any relevant disclosures.
SOURCE: Stojan G et al. Lupus Sci Med. 2019;6[suppl 1]:A200, Abstract 274.
REPORTING FROM LUPUS 2019
Key clinical point: Positive remodeling and low-attenuation, noncalcified plaques might be something to look for when assessing systemic lupus erythematosus cardiovascular risk.
Major finding: There was a mean of 458 low-attenuation, noncalcified plaques among lupus patients versus 42 among controls, a more than 900% difference (P less than .001)
Study details: Coronary CT angiography in 102 lupus patients and 100 healthy controls
Disclosures: The National Institutes of Health funded the work. The lead investigator didn’t report any relevant disclosures.
Source: Stojan G et al. Lupus Sci Med. 2019;6[suppl 1]:A200, Abstract 274.
Minimize iatrogenic neonatal abstinence syndrome
BALTIMORE – Some infants, especially among those with persistent pulmonary hypertension, are at risk for developing iatrogenic neonatal abstinence syndrome, according to Amber Dave, MD, a neonatal-perinatal medicine fellow at Georgetown University Hospital in Washington.
Of 70 infants administered morphine or fentanyl for longer than a day in the neonatal ICU, almost a third (22, or 31%) developed iatrogenic neonatal abstinence syndrome (INAS). As a result, they needed prolonged respiratory support, more time to reach full feeds, and extended lengths of stay. Children exposed to opioids before birth were excluded from the analysis.
The greatest risk was in infants with persistent pulmonary hypertension; INAS was diagnosed in 13 of 22 (57%).
Opioid dosing also was all over the map for a given Neonatal Pain, Agitation, and Sedation Scale (N-PASS) score, Dr. Dave said. Some infants with an N-PASS pain score of 2, for instance, received no opioids, while others received up to 1,500 mg/kg morphine equivalents.
N-PASS is used in NICUs nationwide to guide dosing, but the variability seen in the study suggests that there’s need for a more objective measure of neonatal distress and for neonatologists to establish ground rules for NICU opioid use, she added.
The use of opioids has been increasing in NICUs for years (J Opioid Manag. 2015 Jul-Aug;11[4]:305-12), and at least one institution (J Perinatol. 2017 Sep;37[9]:1038-42) already has established guidelines to curb overuse. Dr. Dave said that several neonatologists, after viewing her poster at the Pediatric Academic Societies annual meeting, told her that they probably had the same problem at their NICUs but had not examined their data.
“We are using” these medications more in the NICU, “but how much is too much? We need to find that balance. We need to improve our practice.”
“The overarching question is if there are better alternatives for treating pain and stress in critically ill neonates.” Dexmedetomidine, an opioid-sparing alpha-2 agonist adrenoreceptor sedative, analgesic, and anxiolytic, is one of several options “being looked at closely in this population. We also need to think of nonpharmacologic measures,” Dr. Dave said.
In addition to infants with persistent pulmonary hypertension, the 22 INAS cases at the study site included, among others, three children on extracorporeal membrane oxygenation, one with meconium aspiration syndrome, and one surgical case, out of the 15 included in the study. The common denominator was the need to keep infants calm and comfortable during prolonged intubation, which was a mean of 10.5 days among INAS infants versus 5 among children who didn’t go into opioid withdrawal.
INAS infants had a daily mean morphine-equivalent dose of 106.6 mg/kg, with a mean exposure of 17 days and mean cumulative dose of 1,515 mg/kg. The daily mean morphine-equivalent dose among infants who didn’t develop INAS was 42.4 mg/kg, with a mean exposure of 4 days and mean cumulative dose of 246 mg/kg.
INAS infants spent a mean of 27 days in the hospital, and it took them a mean of almost 6 days to reach full feeds, versus 15 days for the other infants full feeds by day 4. Over half of the INAS infants (12) also were on midazolam, and they had higher cumulative doses of the sedative than infants who didn’t develop INAS (mean, 2.64 mg/kg vs. 0.19 mg/kg). The findings all were statistically significant.
Dr. Dave said the most surprising finding was the variability in opioid dosing. In another example, some infants received up to 1,400 mg/kg morphine equivalents even when their fraction of inspired oxygen requirement fell below 60%, which meant that they were getting better. Other infants by that point were off opioids altogether.
“This has definitely brought awareness to my practice. Before I would say, ‘Okay, let’s just go up,’ ” when a nurse requested an opioid increase based on N-PASS scores. Now, “I try to really figure out why they think the baby needs an increase, and I may say ‘Actually, we are turning a corner now, and maybe the baby can be a little bit more awake. How do you feel about that?’ ” she said.
“My long-term goal for this project is putting some guidelines in place,” she said.
There was no industry funding for the work, and Dr. Dave didn’t have any disclosures.
BALTIMORE – Some infants, especially among those with persistent pulmonary hypertension, are at risk for developing iatrogenic neonatal abstinence syndrome, according to Amber Dave, MD, a neonatal-perinatal medicine fellow at Georgetown University Hospital in Washington.
Of 70 infants administered morphine or fentanyl for longer than a day in the neonatal ICU, almost a third (22, or 31%) developed iatrogenic neonatal abstinence syndrome (INAS). As a result, they needed prolonged respiratory support, more time to reach full feeds, and extended lengths of stay. Children exposed to opioids before birth were excluded from the analysis.
The greatest risk was in infants with persistent pulmonary hypertension; INAS was diagnosed in 13 of 22 (57%).
Opioid dosing also was all over the map for a given Neonatal Pain, Agitation, and Sedation Scale (N-PASS) score, Dr. Dave said. Some infants with an N-PASS pain score of 2, for instance, received no opioids, while others received up to 1,500 mg/kg morphine equivalents.
N-PASS is used in NICUs nationwide to guide dosing, but the variability seen in the study suggests that there’s need for a more objective measure of neonatal distress and for neonatologists to establish ground rules for NICU opioid use, she added.
The use of opioids has been increasing in NICUs for years (J Opioid Manag. 2015 Jul-Aug;11[4]:305-12), and at least one institution (J Perinatol. 2017 Sep;37[9]:1038-42) already has established guidelines to curb overuse. Dr. Dave said that several neonatologists, after viewing her poster at the Pediatric Academic Societies annual meeting, told her that they probably had the same problem at their NICUs but had not examined their data.
“We are using” these medications more in the NICU, “but how much is too much? We need to find that balance. We need to improve our practice.”
“The overarching question is if there are better alternatives for treating pain and stress in critically ill neonates.” Dexmedetomidine, an opioid-sparing alpha-2 agonist adrenoreceptor sedative, analgesic, and anxiolytic, is one of several options “being looked at closely in this population. We also need to think of nonpharmacologic measures,” Dr. Dave said.
In addition to infants with persistent pulmonary hypertension, the 22 INAS cases at the study site included, among others, three children on extracorporeal membrane oxygenation, one with meconium aspiration syndrome, and one surgical case, out of the 15 included in the study. The common denominator was the need to keep infants calm and comfortable during prolonged intubation, which was a mean of 10.5 days among INAS infants versus 5 among children who didn’t go into opioid withdrawal.
INAS infants had a daily mean morphine-equivalent dose of 106.6 mg/kg, with a mean exposure of 17 days and mean cumulative dose of 1,515 mg/kg. The daily mean morphine-equivalent dose among infants who didn’t develop INAS was 42.4 mg/kg, with a mean exposure of 4 days and mean cumulative dose of 246 mg/kg.
INAS infants spent a mean of 27 days in the hospital, and it took them a mean of almost 6 days to reach full feeds, versus 15 days for the other infants full feeds by day 4. Over half of the INAS infants (12) also were on midazolam, and they had higher cumulative doses of the sedative than infants who didn’t develop INAS (mean, 2.64 mg/kg vs. 0.19 mg/kg). The findings all were statistically significant.
Dr. Dave said the most surprising finding was the variability in opioid dosing. In another example, some infants received up to 1,400 mg/kg morphine equivalents even when their fraction of inspired oxygen requirement fell below 60%, which meant that they were getting better. Other infants by that point were off opioids altogether.
“This has definitely brought awareness to my practice. Before I would say, ‘Okay, let’s just go up,’ ” when a nurse requested an opioid increase based on N-PASS scores. Now, “I try to really figure out why they think the baby needs an increase, and I may say ‘Actually, we are turning a corner now, and maybe the baby can be a little bit more awake. How do you feel about that?’ ” she said.
“My long-term goal for this project is putting some guidelines in place,” she said.
There was no industry funding for the work, and Dr. Dave didn’t have any disclosures.
BALTIMORE – Some infants, especially among those with persistent pulmonary hypertension, are at risk for developing iatrogenic neonatal abstinence syndrome, according to Amber Dave, MD, a neonatal-perinatal medicine fellow at Georgetown University Hospital in Washington.
Of 70 infants administered morphine or fentanyl for longer than a day in the neonatal ICU, almost a third (22, or 31%) developed iatrogenic neonatal abstinence syndrome (INAS). As a result, they needed prolonged respiratory support, more time to reach full feeds, and extended lengths of stay. Children exposed to opioids before birth were excluded from the analysis.
The greatest risk was in infants with persistent pulmonary hypertension; INAS was diagnosed in 13 of 22 (57%).
Opioid dosing also was all over the map for a given Neonatal Pain, Agitation, and Sedation Scale (N-PASS) score, Dr. Dave said. Some infants with an N-PASS pain score of 2, for instance, received no opioids, while others received up to 1,500 mg/kg morphine equivalents.
N-PASS is used in NICUs nationwide to guide dosing, but the variability seen in the study suggests that there’s need for a more objective measure of neonatal distress and for neonatologists to establish ground rules for NICU opioid use, she added.
The use of opioids has been increasing in NICUs for years (J Opioid Manag. 2015 Jul-Aug;11[4]:305-12), and at least one institution (J Perinatol. 2017 Sep;37[9]:1038-42) already has established guidelines to curb overuse. Dr. Dave said that several neonatologists, after viewing her poster at the Pediatric Academic Societies annual meeting, told her that they probably had the same problem at their NICUs but had not examined their data.
“We are using” these medications more in the NICU, “but how much is too much? We need to find that balance. We need to improve our practice.”
“The overarching question is if there are better alternatives for treating pain and stress in critically ill neonates.” Dexmedetomidine, an opioid-sparing alpha-2 agonist adrenoreceptor sedative, analgesic, and anxiolytic, is one of several options “being looked at closely in this population. We also need to think of nonpharmacologic measures,” Dr. Dave said.
In addition to infants with persistent pulmonary hypertension, the 22 INAS cases at the study site included, among others, three children on extracorporeal membrane oxygenation, one with meconium aspiration syndrome, and one surgical case, out of the 15 included in the study. The common denominator was the need to keep infants calm and comfortable during prolonged intubation, which was a mean of 10.5 days among INAS infants versus 5 among children who didn’t go into opioid withdrawal.
INAS infants had a daily mean morphine-equivalent dose of 106.6 mg/kg, with a mean exposure of 17 days and mean cumulative dose of 1,515 mg/kg. The daily mean morphine-equivalent dose among infants who didn’t develop INAS was 42.4 mg/kg, with a mean exposure of 4 days and mean cumulative dose of 246 mg/kg.
INAS infants spent a mean of 27 days in the hospital, and it took them a mean of almost 6 days to reach full feeds, versus 15 days for the other infants full feeds by day 4. Over half of the INAS infants (12) also were on midazolam, and they had higher cumulative doses of the sedative than infants who didn’t develop INAS (mean, 2.64 mg/kg vs. 0.19 mg/kg). The findings all were statistically significant.
Dr. Dave said the most surprising finding was the variability in opioid dosing. In another example, some infants received up to 1,400 mg/kg morphine equivalents even when their fraction of inspired oxygen requirement fell below 60%, which meant that they were getting better. Other infants by that point were off opioids altogether.
“This has definitely brought awareness to my practice. Before I would say, ‘Okay, let’s just go up,’ ” when a nurse requested an opioid increase based on N-PASS scores. Now, “I try to really figure out why they think the baby needs an increase, and I may say ‘Actually, we are turning a corner now, and maybe the baby can be a little bit more awake. How do you feel about that?’ ” she said.
“My long-term goal for this project is putting some guidelines in place,” she said.
There was no industry funding for the work, and Dr. Dave didn’t have any disclosures.
REPORTING FROM PAS 2019
Key clinical point: Some infants in the NICU, especially those with persistent pulmonary hypertension, are at risk for iatrogenic neonatal abstinence syndrome.
Major finding: Of 70 infants administered morphine or fentanyl for longer than a day, almost a third (22) developed iatrogenic neonatal abstinence syndrome.
Study details: Single-center NICU chart review.
Disclosures: There was no industry funding, and the lead investigator didn’t have any relevant financial disclosures.
N.Y. hospitals report near-universal CMV screening when newborns fail hearing tests
BALTIMORE – Over the past 2 years, Northwell Health, a large medical system in the metropolitan New York area, increased cytomegalovirus screening for infants who fail hearing tests from 6.6% to 95% at five of its birth hospitals, according to a presentation at the Pediatric Academic Societies annual meeting.
Three cases of congenital cytomegalovirus (CMV) have been picked up so far. The plan is to roll the program out to all 10 of the system’s birth hospitals, where over 40,000 children are born each year.
“We feel very satisfied and proud” of the progress that’s been made at Northwell in such a short time, said Alia Chauhan, MD, a Northwell pediatrician who presented the findings.
Northwell launched its “Hearing Plus” program in 2017 to catch the infection before infants leave the hospital. Several other health systems around the country have launched similar programs, and a handful of states – including New York – now require CMV screening for infants who fail mandated hearing tests.
The issue is gaining traction because hearing loss is often the only sign of congenital CMV, so it’s a bellwether for infection. Screening children with hearing loss is an easy way to pick it up early, so steps can be taken to prevent problems down the road. As it is, congenital CMV is the leading nongenetic cause of hearing loss in infants, accounting for at least 10% of cases.
The Northwell program kicked off with an education campaign to build consensus among pediatricians, hospitalists, and nurses. A flyer was made about CMV screening for moms whose infants fail hearing tests, printed in both English and Spanish.
Initially, the program used urine PCR [polymerase chain reaction] to screen for CMV, but waiting for infants to produce a sample often delayed discharge, so a switch was soon made to saliva swab PCRs, which take seconds, with urine PCR held in reserve to confirm positive swabs.
To streamline the process, a standing order was added to the electronic records system so nurses could order saliva PCRs without having to get physician approval. “I think [that] was one of the biggest things that’s helped us,” Dr. Chauhan said.
Children who test positive must have urine confirmation within 21 days of birth; most are long gone from the hospital by then and have to be called back in. “We haven’t lost anyone to follow-up, but it can be stressful trying to get someone to come back,” she said.
Six of 449 infants have screened positive on saliva – three were false positives with negative urine screens. Of the three confirmed cases, two infants later turned out to have normal hearing on repeat testing and were otherwise asymptomatic.
These days, Dr. Chauhan said, if children have a positive saliva PCR but later turn out to have normal hearing, and are otherwise free of symptoms with no CMV risk factors, “we are not confirming with urine.”
Dr. Chauhan did not have any disclosures. No funding source was mentioned.
SOURCE: Chauhan A et al. PAS 2019. Abstract 306
BALTIMORE – Over the past 2 years, Northwell Health, a large medical system in the metropolitan New York area, increased cytomegalovirus screening for infants who fail hearing tests from 6.6% to 95% at five of its birth hospitals, according to a presentation at the Pediatric Academic Societies annual meeting.
Three cases of congenital cytomegalovirus (CMV) have been picked up so far. The plan is to roll the program out to all 10 of the system’s birth hospitals, where over 40,000 children are born each year.
“We feel very satisfied and proud” of the progress that’s been made at Northwell in such a short time, said Alia Chauhan, MD, a Northwell pediatrician who presented the findings.
Northwell launched its “Hearing Plus” program in 2017 to catch the infection before infants leave the hospital. Several other health systems around the country have launched similar programs, and a handful of states – including New York – now require CMV screening for infants who fail mandated hearing tests.
The issue is gaining traction because hearing loss is often the only sign of congenital CMV, so it’s a bellwether for infection. Screening children with hearing loss is an easy way to pick it up early, so steps can be taken to prevent problems down the road. As it is, congenital CMV is the leading nongenetic cause of hearing loss in infants, accounting for at least 10% of cases.
The Northwell program kicked off with an education campaign to build consensus among pediatricians, hospitalists, and nurses. A flyer was made about CMV screening for moms whose infants fail hearing tests, printed in both English and Spanish.
Initially, the program used urine PCR [polymerase chain reaction] to screen for CMV, but waiting for infants to produce a sample often delayed discharge, so a switch was soon made to saliva swab PCRs, which take seconds, with urine PCR held in reserve to confirm positive swabs.
To streamline the process, a standing order was added to the electronic records system so nurses could order saliva PCRs without having to get physician approval. “I think [that] was one of the biggest things that’s helped us,” Dr. Chauhan said.
Children who test positive must have urine confirmation within 21 days of birth; most are long gone from the hospital by then and have to be called back in. “We haven’t lost anyone to follow-up, but it can be stressful trying to get someone to come back,” she said.
Six of 449 infants have screened positive on saliva – three were false positives with negative urine screens. Of the three confirmed cases, two infants later turned out to have normal hearing on repeat testing and were otherwise asymptomatic.
These days, Dr. Chauhan said, if children have a positive saliva PCR but later turn out to have normal hearing, and are otherwise free of symptoms with no CMV risk factors, “we are not confirming with urine.”
Dr. Chauhan did not have any disclosures. No funding source was mentioned.
SOURCE: Chauhan A et al. PAS 2019. Abstract 306
BALTIMORE – Over the past 2 years, Northwell Health, a large medical system in the metropolitan New York area, increased cytomegalovirus screening for infants who fail hearing tests from 6.6% to 95% at five of its birth hospitals, according to a presentation at the Pediatric Academic Societies annual meeting.
Three cases of congenital cytomegalovirus (CMV) have been picked up so far. The plan is to roll the program out to all 10 of the system’s birth hospitals, where over 40,000 children are born each year.
“We feel very satisfied and proud” of the progress that’s been made at Northwell in such a short time, said Alia Chauhan, MD, a Northwell pediatrician who presented the findings.
Northwell launched its “Hearing Plus” program in 2017 to catch the infection before infants leave the hospital. Several other health systems around the country have launched similar programs, and a handful of states – including New York – now require CMV screening for infants who fail mandated hearing tests.
The issue is gaining traction because hearing loss is often the only sign of congenital CMV, so it’s a bellwether for infection. Screening children with hearing loss is an easy way to pick it up early, so steps can be taken to prevent problems down the road. As it is, congenital CMV is the leading nongenetic cause of hearing loss in infants, accounting for at least 10% of cases.
The Northwell program kicked off with an education campaign to build consensus among pediatricians, hospitalists, and nurses. A flyer was made about CMV screening for moms whose infants fail hearing tests, printed in both English and Spanish.
Initially, the program used urine PCR [polymerase chain reaction] to screen for CMV, but waiting for infants to produce a sample often delayed discharge, so a switch was soon made to saliva swab PCRs, which take seconds, with urine PCR held in reserve to confirm positive swabs.
To streamline the process, a standing order was added to the electronic records system so nurses could order saliva PCRs without having to get physician approval. “I think [that] was one of the biggest things that’s helped us,” Dr. Chauhan said.
Children who test positive must have urine confirmation within 21 days of birth; most are long gone from the hospital by then and have to be called back in. “We haven’t lost anyone to follow-up, but it can be stressful trying to get someone to come back,” she said.
Six of 449 infants have screened positive on saliva – three were false positives with negative urine screens. Of the three confirmed cases, two infants later turned out to have normal hearing on repeat testing and were otherwise asymptomatic.
These days, Dr. Chauhan said, if children have a positive saliva PCR but later turn out to have normal hearing, and are otherwise free of symptoms with no CMV risk factors, “we are not confirming with urine.”
Dr. Chauhan did not have any disclosures. No funding source was mentioned.
SOURCE: Chauhan A et al. PAS 2019. Abstract 306
REPORTING FROM PAS 2019
Key clinical point: A metropolitan N.Y. health system provides a model for how to implement cytomegalovirus screening for infants who fail hearing tests.
Major finding: .
Study details: Pre-post quality improvement project.
Disclosures: The lead investigator had no disclosures. No funding source was mentioned.
Source: Chauhan A et al. PAS 2019. Abstract 306.