Tara Haelle

NEW ORLEANS – One of the most important things pediatricians can do to support their lesbian, gay, bisexual, transgender (LGBT) and other gender-nonconforming patients is to ask all their patients about their feelings, preferences and experiences when it comes to gender and sexuality, according to Julie Finger, MD, MPH.

It’s equally important not to make assumptions, she told attendees at the annual meeting of the American Academy of Pediatrics. Biology and sexual and gender identity and expression can be very diverse, she said. Specifically, doctors should not assume patients are heterosexual, that bisexuality is a phase, that orientation or attraction translates directly to behavior or vice versa, or that LGBTQ patients have unsupportive families or are engaging in risky behavior. Research suggests LGB youth have slightly higher rates of early sexual debut, sexual activity or multiple partners than straight or uncertain youth, but only marginally so.

Pediatricians also cannot assume a patient’s sexual orientation based on their partner’s gender or determine a patient’s sexual orientation or gender identity based on appearance – or even that either is the same as it was on the previous visit.

What doctors can be sure of is that they do have LGBTQ patients, said Dr. Finger, and assistant professor of clinical pediatrics at Tulane University in New Orleans. According to a 2016 Morbidity and Mortality Weekly Report (2016 Aug 12; 65[9]), about 1 in 10 students in grades 9-12 are a sexual minority. About 2% of respondents identify as gay or lesbian, 6% identify as bisexual and 3% say they aren’t sure.

Knowing the terminology

Dr. Finger defined key terminology regarding gender and sexuality. She first clarified that LGBT is not the full spectrum for sexual orientation. Pansexual (fluid attraction to any sex or gender) and asexual (lack of feeling sexual attraction) can also describe sexuality, and the Q on the end of LGBTQ is often an umbrella term for “queer” or “questioning” that encompasses anyone who fits outside conventional social norms of sexual identity and gender expression.

Sexual behaviors – which include “young men who have sex with men” and “young women who have sex with women” – do not necessarily correspond as one might expect with sexual orientation or identity, which is one’s concept of their romantic or sexual feelings, attractions and desires, again reinforcing the importance of asking patients their identity and preferences.

In terms of gender, a person’s natal or biologic gender is the one assigned people at birth based on their body parts and hormones. Gender identity is a person’s understanding of their own gender, and gender expression refers to how someone acts or presents themselves and communicates their gender within their culture.

Those who identify as “gender nonconforming, genderqueer, gender fluid, or nonbinary” see their gender on a spectrum, not within the binary “male” or “female.” A cisgender person’s gender identity matches both their biological sex assigned at birth and conventional cultural norms, while a transgender person’s gender differs from the sex they were assigned at birth. Transgender women (male to female, MTF) and men (female to men, FTM) go through the process of transition, a time that can occur in weeks or years when they shift from living as one gender to another.

While it’s unclear what leads to a person’s sexual orientation – likely a combination of genetic, hormonal and environmental factors—there is no question that sexual orientation is not a “choice,” Dr Finger said. Research has also clarified that one’s sexual orientation does not result from parenting behaviors or a history of sexual abuse.

“But I would urge all of you, instead of focusing on why someone is LGBTQ, to focus on what that means for them in their life,” Dr Finger said. “How is this bearing out in terms of their relationships and their behaviors, and how do they feel about it? How are they being supported by their family or their community, and how is it impacting their lives?”

She cited findings from a Human Rights Campaign survey in 2012 of 10,000 youth aged 13-17, which found that most LGBTQ respondents became aware of their same-sex attraction at 9 years of age, though the average age of disclosures is 16, an improvement from age 21 in the 1980s.
 

How and what to ask

Although children start becoming conscious of gender at ages 1-2, their sense of gender usually stabilizes by age 4.

“Who should we be screening for gender nonconformity? Quite frankly, all children, because all of them have some gender identity, so we should be asking them about that,” Dr Finger said.

When children are younger, doctors can ask parents about their child’s social interactions, forms of play, dress preferences, and mood. Questions for patients themselves, adapted for their age, might include, “Do you feel more like a girl, boy, neither or both?”, “How would you like to play, cut your hair and dress?” And “What name or pronoun (he or she) fits you?”

While such conversations do not necessarily need to happen annually, doctors should especially ask youth who dress or behave in non–gender-conforming ways or who appear to have mood, behavior or social difficulties.

To understand a patient’s sexuality, ask whether they are attracted to people of their own gender or sex, a different gender or sex, both or all genders or no one, or if they’re not sure yet. Doctors can then ask how comfortable they are with their attraction and whether they have told family members or friends about them.

Sexual behavior questions should be developmentally appropriate and lead to counsel but not judgment, Dr Finger said. Her method, with adjustments for age and development, starts, “There are many way of being sexual or intimate with someone: kissing, hugging and touching, and oral sex, anal sex and vaginal sex. Have you ever had any of these experiences? Which ones? With males or females or both, or other genders?”

Then she gets more specific while remaining sensitive. Doctors can ask younger children if they have held hands or cuddled with someone, if they have kissed someone, or if they have touched another person’s private parts. They can ask teens about oral sex, vaginal sex and anal sex and then gather more details about what parts went where, which helps determine what screenings or treatment options a patient may need or desire.

Doctors can use their judgment about whether to ask questions with parents in the room or not, but as kids grow older, it’s good practice to speak to patients without their caregivers present. Doctors should also explain the rules of confidentiality to their patients and be aware of the risks of “coming out,” including family discord or rejection, problems at school or work, social stigma, bullying and harassment, physical violence and risk-taking behaviors, such as substance use, self-injury and risky sexual behaviors. A HEADSSS screen can help doctors learn if any of these are present.
 

Making your practice inclusive and welcoming

Fewer than one in five teens who are “out” as LGBTQ have come out to their doctor, Dr Finger cited. Most are out to their friends and classmates, and more than half are out to their family, but teens are less likely to tell their doctors.

Research suggests one reason for this is the fact that pediatricians often don’t ask. One study found that only 20% of pediatricians discussed sexual orientation with their patients (Pediatrics 2010 Apr;125:e741-7). Similarly, only 30% of family physicians brought up sexual orientation, found another study (Fam. Med. 2001 May;33[5]:376-81). The studies found physicians more often discussed condoms, HIV, sexually transmitted infections, abstinence, violence, contraception or, in the case of family physicians, sexual behaviors, and relationships.

But another reason for not being out to doctors is a history of poor experiences. A Lambda Legal Survey in 2009 of 4,916 LGBT respondents found that 8% of LGB and 27% of transgender and gender nonconforming patients had been denied care because of their identity of orientation. Eleven percent said “providers refused to touch them or used excessive precautions,” Dr Finger reported. LGBTQ patients may fear the doctor’s reaction or not keeping their identity confidential. Patients may also have internalized shame or guilt due to societal norms or homophobia, and all these barriers can reduce LGBTQ people’s willingness to seek and access to competent care.

The first step to making LGBTQ patients comfortable in your practice is to confront your own personal biases, Dr Finger said. Understand what they are and that a provider’s discomfort, even unconscious, can be damaging to the patient-provider relationship.

“If you find that this is just not something that you’re going to be comfortable doing, at the very least, I would suggest that you find providers in your area who are comfortable working with this patient population and you refer your patients to them so that they can have a good, trusting patient-provider relationship with somebody who can provide the care that they need,” Dr Finger said.

The next step is creating a safe place with zero tolerance for insensitivity by training staff to be welcoming and inclusive, assuring patients confidentiality, providing support and resources and displaying LGBTQ-affirming materials. These youth need active, visible evidence that the office will be a safe place for them.

Ways pediatricians can communicate an inclusive environment include having gender-neutral restrooms, using “parent” instead of “mother/father” and using forms and EMR prompts with gender-neutral language or multiple options for gender selection.
 

Screening and LGBTQ patients’ health needs

LGB youth and those who aren’t sure of their sexual orientation tend to have higher rates of substance use, including tobacco, alcohol and illicit drugs, and are more often victims of rape and other sexual violence. Their rates of depressive symptoms, bullying victimization, and suicidality are also significantly higher than in their heterosexual cisgender peers. Homelessness rates are also considerably higher in LGBTQ youth than in heterosexual cisgender youth.

One thing pediatricians can do is work with parents to ensure a patient’s school is meeting their needs. The greater risks LGBTQ youth typically face are mediated by social support, resiliency, supportive friends and family and a supportive school environment, including inclusive curricula and supportive staff.

Lesbian and bisexual women are considerably more at risk for poor sexual or reproductive outcomes, Dr Finger said. Their rates of unplanned pregnancy are double that of straight women, contributing to their higher rates of emergency contraception and abortion. They are also more likely to have more partners (male and females), to have a younger sexual debut and to be forced into sex by a male partner—yet they are far less likely to perceive themselves as at risk for a sexually transmitted infection than their peers.

This patient population therefore may need contraception counseling, including discussing their current methods and reviewing their options, including emergency contraception and possibly an advance prescription. Dr Finger also suggests having male and female condoms available in the office.

Doctors should screen all their female patients, regardless of sexuality, for chlamydia and gonorrhea, and offer routine cervical cancer screening and the HPV vaccine, as recommended by the CDC. They might consider screening for trichomoniasis, bacterial vaginosis, herpes simplex, human papillomavirus and HIV.

For men who have sex with men, the CDC recommends HIV and syphilis serology, urine/pharyngeal/rectal gonorrhea nucleic acid amplification test (NAAT), urine/rectal chlamydia NAAT, and hepatitis C screening for those who are HIV-positive—all at least once a year.

For transgender patients, doctors need to assess their STI- and HIV-related risks based on their current anatomy and sexual behaviors.

Doctors should also consider discussing pre-exposure prophylaxis (PrEP) for any youth at high risk for HIV infection if they are at least 77 pounds (35 kg). Emtricitabine/tenofovir (Truvada, Descovy) reduces the chance of sexually acquired infection by 99%, and infection acquired via drug injection by 74% when taken as prescribed.

Resources

Dr Finger noted a range of resources for LGBTQ youth and their families and providers, including the Family Acceptance Project, Gay and Lesbian Medical Association, Gay, Lesbian and Straight Education Network, GLBTQ Legal Advocates and Defenders (GLAD), Human Rights Campaign, It Gets Better Project, LGBTQ Student Resources and Support, National Center for Lesbian Rights, Parents and Friends of Lesbians and Gays (PFLAG), Safe Schools Coalition and The Trevor Project (concerning suicide risk).

NEW ORLEANS – One of the most important things pediatricians can do to support their lesbian, gay, bisexual, transgender (LGBT) and other gender-nonconforming patients is to ask all their patients about their feelings, preferences and experiences when it comes to gender and sexuality, according to Julie Finger, MD, MPH.

It’s equally important not to make assumptions, she told attendees at the annual meeting of the American Academy of Pediatrics. Biology and sexual and gender identity and expression can be very diverse, she said. Specifically, doctors should not assume patients are heterosexual, that bisexuality is a phase, that orientation or attraction translates directly to behavior or vice versa, or that LGBTQ patients have unsupportive families or are engaging in risky behavior. Research suggests LGB youth have slightly higher rates of early sexual debut, sexual activity or multiple partners than straight or uncertain youth, but only marginally so.

Pediatricians also cannot assume a patient’s sexual orientation based on their partner’s gender or determine a patient’s sexual orientation or gender identity based on appearance – or even that either is the same as it was on the previous visit.

What doctors can be sure of is that they do have LGBTQ patients, said Dr. Finger, and assistant professor of clinical pediatrics at Tulane University in New Orleans. According to a 2016 Morbidity and Mortality Weekly Report (2016 Aug 12; 65[9]), about 1 in 10 students in grades 9-12 are a sexual minority. About 2% of respondents identify as gay or lesbian, 6% identify as bisexual and 3% say they aren’t sure.

Knowing the terminology

Dr. Finger defined key terminology regarding gender and sexuality. She first clarified that LGBT is not the full spectrum for sexual orientation. Pansexual (fluid attraction to any sex or gender) and asexual (lack of feeling sexual attraction) can also describe sexuality, and the Q on the end of LGBTQ is often an umbrella term for “queer” or “questioning” that encompasses anyone who fits outside conventional social norms of sexual identity and gender expression.

Sexual behaviors – which include “young men who have sex with men” and “young women who have sex with women” – do not necessarily correspond as one might expect with sexual orientation or identity, which is one’s concept of their romantic or sexual feelings, attractions and desires, again reinforcing the importance of asking patients their identity and preferences.

In terms of gender, a person’s natal or biologic gender is the one assigned people at birth based on their body parts and hormones. Gender identity is a person’s understanding of their own gender, and gender expression refers to how someone acts or presents themselves and communicates their gender within their culture.

Those who identify as “gender nonconforming, genderqueer, gender fluid, or nonbinary” see their gender on a spectrum, not within the binary “male” or “female.” A cisgender person’s gender identity matches both their biological sex assigned at birth and conventional cultural norms, while a transgender person’s gender differs from the sex they were assigned at birth. Transgender women (male to female, MTF) and men (female to men, FTM) go through the process of transition, a time that can occur in weeks or years when they shift from living as one gender to another.

While it’s unclear what leads to a person’s sexual orientation – likely a combination of genetic, hormonal and environmental factors—there is no question that sexual orientation is not a “choice,” Dr Finger said. Research has also clarified that one’s sexual orientation does not result from parenting behaviors or a history of sexual abuse.

“But I would urge all of you, instead of focusing on why someone is LGBTQ, to focus on what that means for them in their life,” Dr Finger said. “How is this bearing out in terms of their relationships and their behaviors, and how do they feel about it? How are they being supported by their family or their community, and how is it impacting their lives?”

She cited findings from a Human Rights Campaign survey in 2012 of 10,000 youth aged 13-17, which found that most LGBTQ respondents became aware of their same-sex attraction at 9 years of age, though the average age of disclosures is 16, an improvement from age 21 in the 1980s.
 

How and what to ask

Although children start becoming conscious of gender at ages 1-2, their sense of gender usually stabilizes by age 4.

“Who should we be screening for gender nonconformity? Quite frankly, all children, because all of them have some gender identity, so we should be asking them about that,” Dr Finger said.

When children are younger, doctors can ask parents about their child’s social interactions, forms of play, dress preferences, and mood. Questions for patients themselves, adapted for their age, might include, “Do you feel more like a girl, boy, neither or both?”, “How would you like to play, cut your hair and dress?” And “What name or pronoun (he or she) fits you?”

While such conversations do not necessarily need to happen annually, doctors should especially ask youth who dress or behave in non–gender-conforming ways or who appear to have mood, behavior or social difficulties.

To understand a patient’s sexuality, ask whether they are attracted to people of their own gender or sex, a different gender or sex, both or all genders or no one, or if they’re not sure yet. Doctors can then ask how comfortable they are with their attraction and whether they have told family members or friends about them.

Sexual behavior questions should be developmentally appropriate and lead to counsel but not judgment, Dr Finger said. Her method, with adjustments for age and development, starts, “There are many way of being sexual or intimate with someone: kissing, hugging and touching, and oral sex, anal sex and vaginal sex. Have you ever had any of these experiences? Which ones? With males or females or both, or other genders?”

Then she gets more specific while remaining sensitive. Doctors can ask younger children if they have held hands or cuddled with someone, if they have kissed someone, or if they have touched another person’s private parts. They can ask teens about oral sex, vaginal sex and anal sex and then gather more details about what parts went where, which helps determine what screenings or treatment options a patient may need or desire.

Doctors can use their judgment about whether to ask questions with parents in the room or not, but as kids grow older, it’s good practice to speak to patients without their caregivers present. Doctors should also explain the rules of confidentiality to their patients and be aware of the risks of “coming out,” including family discord or rejection, problems at school or work, social stigma, bullying and harassment, physical violence and risk-taking behaviors, such as substance use, self-injury and risky sexual behaviors. A HEADSSS screen can help doctors learn if any of these are present.
 

Making your practice inclusive and welcoming

Fewer than one in five teens who are “out” as LGBTQ have come out to their doctor, Dr Finger cited. Most are out to their friends and classmates, and more than half are out to their family, but teens are less likely to tell their doctors.

Research suggests one reason for this is the fact that pediatricians often don’t ask. One study found that only 20% of pediatricians discussed sexual orientation with their patients (Pediatrics 2010 Apr;125:e741-7). Similarly, only 30% of family physicians brought up sexual orientation, found another study (Fam. Med. 2001 May;33[5]:376-81). The studies found physicians more often discussed condoms, HIV, sexually transmitted infections, abstinence, violence, contraception or, in the case of family physicians, sexual behaviors, and relationships.

But another reason for not being out to doctors is a history of poor experiences. A Lambda Legal Survey in 2009 of 4,916 LGBT respondents found that 8% of LGB and 27% of transgender and gender nonconforming patients had been denied care because of their identity of orientation. Eleven percent said “providers refused to touch them or used excessive precautions,” Dr Finger reported. LGBTQ patients may fear the doctor’s reaction or not keeping their identity confidential. Patients may also have internalized shame or guilt due to societal norms or homophobia, and all these barriers can reduce LGBTQ people’s willingness to seek and access to competent care.

The first step to making LGBTQ patients comfortable in your practice is to confront your own personal biases, Dr Finger said. Understand what they are and that a provider’s discomfort, even unconscious, can be damaging to the patient-provider relationship.

“If you find that this is just not something that you’re going to be comfortable doing, at the very least, I would suggest that you find providers in your area who are comfortable working with this patient population and you refer your patients to them so that they can have a good, trusting patient-provider relationship with somebody who can provide the care that they need,” Dr Finger said.

The next step is creating a safe place with zero tolerance for insensitivity by training staff to be welcoming and inclusive, assuring patients confidentiality, providing support and resources and displaying LGBTQ-affirming materials. These youth need active, visible evidence that the office will be a safe place for them.

Ways pediatricians can communicate an inclusive environment include having gender-neutral restrooms, using “parent” instead of “mother/father” and using forms and EMR prompts with gender-neutral language or multiple options for gender selection.
 

Screening and LGBTQ patients’ health needs

LGB youth and those who aren’t sure of their sexual orientation tend to have higher rates of substance use, including tobacco, alcohol and illicit drugs, and are more often victims of rape and other sexual violence. Their rates of depressive symptoms, bullying victimization, and suicidality are also significantly higher than in their heterosexual cisgender peers. Homelessness rates are also considerably higher in LGBTQ youth than in heterosexual cisgender youth.

One thing pediatricians can do is work with parents to ensure a patient’s school is meeting their needs. The greater risks LGBTQ youth typically face are mediated by social support, resiliency, supportive friends and family and a supportive school environment, including inclusive curricula and supportive staff.

Lesbian and bisexual women are considerably more at risk for poor sexual or reproductive outcomes, Dr Finger said. Their rates of unplanned pregnancy are double that of straight women, contributing to their higher rates of emergency contraception and abortion. They are also more likely to have more partners (male and females), to have a younger sexual debut and to be forced into sex by a male partner—yet they are far less likely to perceive themselves as at risk for a sexually transmitted infection than their peers.

This patient population therefore may need contraception counseling, including discussing their current methods and reviewing their options, including emergency contraception and possibly an advance prescription. Dr Finger also suggests having male and female condoms available in the office.

Doctors should screen all their female patients, regardless of sexuality, for chlamydia and gonorrhea, and offer routine cervical cancer screening and the HPV vaccine, as recommended by the CDC. They might consider screening for trichomoniasis, bacterial vaginosis, herpes simplex, human papillomavirus and HIV.

For men who have sex with men, the CDC recommends HIV and syphilis serology, urine/pharyngeal/rectal gonorrhea nucleic acid amplification test (NAAT), urine/rectal chlamydia NAAT, and hepatitis C screening for those who are HIV-positive—all at least once a year.

For transgender patients, doctors need to assess their STI- and HIV-related risks based on their current anatomy and sexual behaviors.

Doctors should also consider discussing pre-exposure prophylaxis (PrEP) for any youth at high risk for HIV infection if they are at least 77 pounds (35 kg). Emtricitabine/tenofovir (Truvada, Descovy) reduces the chance of sexually acquired infection by 99%, and infection acquired via drug injection by 74% when taken as prescribed.

Resources

Dr Finger noted a range of resources for LGBTQ youth and their families and providers, including the Family Acceptance Project, Gay and Lesbian Medical Association, Gay, Lesbian and Straight Education Network, GLBTQ Legal Advocates and Defenders (GLAD), Human Rights Campaign, It Gets Better Project, LGBTQ Student Resources and Support, National Center for Lesbian Rights, Parents and Friends of Lesbians and Gays (PFLAG), Safe Schools Coalition and The Trevor Project (concerning suicide risk).

NEW ORLEANS – One of the most important things pediatricians can do to support their lesbian, gay, bisexual, transgender (LGBT) and other gender-nonconforming patients is to ask all their patients about their feelings, preferences and experiences when it comes to gender and sexuality, according to Julie Finger, MD, MPH.

It’s equally important not to make assumptions, she told attendees at the annual meeting of the American Academy of Pediatrics. Biology and sexual and gender identity and expression can be very diverse, she said. Specifically, doctors should not assume patients are heterosexual, that bisexuality is a phase, that orientation or attraction translates directly to behavior or vice versa, or that LGBTQ patients have unsupportive families or are engaging in risky behavior. Research suggests LGB youth have slightly higher rates of early sexual debut, sexual activity or multiple partners than straight or uncertain youth, but only marginally so.

Pediatricians also cannot assume a patient’s sexual orientation based on their partner’s gender or determine a patient’s sexual orientation or gender identity based on appearance – or even that either is the same as it was on the previous visit.

What doctors can be sure of is that they do have LGBTQ patients, said Dr. Finger, and assistant professor of clinical pediatrics at Tulane University in New Orleans. According to a 2016 Morbidity and Mortality Weekly Report (2016 Aug 12; 65[9]), about 1 in 10 students in grades 9-12 are a sexual minority. About 2% of respondents identify as gay or lesbian, 6% identify as bisexual and 3% say they aren’t sure.

Knowing the terminology

Dr. Finger defined key terminology regarding gender and sexuality. She first clarified that LGBT is not the full spectrum for sexual orientation. Pansexual (fluid attraction to any sex or gender) and asexual (lack of feeling sexual attraction) can also describe sexuality, and the Q on the end of LGBTQ is often an umbrella term for “queer” or “questioning” that encompasses anyone who fits outside conventional social norms of sexual identity and gender expression.

Sexual behaviors – which include “young men who have sex with men” and “young women who have sex with women” – do not necessarily correspond as one might expect with sexual orientation or identity, which is one’s concept of their romantic or sexual feelings, attractions and desires, again reinforcing the importance of asking patients their identity and preferences.

In terms of gender, a person’s natal or biologic gender is the one assigned people at birth based on their body parts and hormones. Gender identity is a person’s understanding of their own gender, and gender expression refers to how someone acts or presents themselves and communicates their gender within their culture.

Those who identify as “gender nonconforming, genderqueer, gender fluid, or nonbinary” see their gender on a spectrum, not within the binary “male” or “female.” A cisgender person’s gender identity matches both their biological sex assigned at birth and conventional cultural norms, while a transgender person’s gender differs from the sex they were assigned at birth. Transgender women (male to female, MTF) and men (female to men, FTM) go through the process of transition, a time that can occur in weeks or years when they shift from living as one gender to another.

While it’s unclear what leads to a person’s sexual orientation – likely a combination of genetic, hormonal and environmental factors—there is no question that sexual orientation is not a “choice,” Dr Finger said. Research has also clarified that one’s sexual orientation does not result from parenting behaviors or a history of sexual abuse.

“But I would urge all of you, instead of focusing on why someone is LGBTQ, to focus on what that means for them in their life,” Dr Finger said. “How is this bearing out in terms of their relationships and their behaviors, and how do they feel about it? How are they being supported by their family or their community, and how is it impacting their lives?”

She cited findings from a Human Rights Campaign survey in 2012 of 10,000 youth aged 13-17, which found that most LGBTQ respondents became aware of their same-sex attraction at 9 years of age, though the average age of disclosures is 16, an improvement from age 21 in the 1980s.
 

How and what to ask

Although children start becoming conscious of gender at ages 1-2, their sense of gender usually stabilizes by age 4.

“Who should we be screening for gender nonconformity? Quite frankly, all children, because all of them have some gender identity, so we should be asking them about that,” Dr Finger said.

When children are younger, doctors can ask parents about their child’s social interactions, forms of play, dress preferences, and mood. Questions for patients themselves, adapted for their age, might include, “Do you feel more like a girl, boy, neither or both?”, “How would you like to play, cut your hair and dress?” And “What name or pronoun (he or she) fits you?”

While such conversations do not necessarily need to happen annually, doctors should especially ask youth who dress or behave in non–gender-conforming ways or who appear to have mood, behavior or social difficulties.

To understand a patient’s sexuality, ask whether they are attracted to people of their own gender or sex, a different gender or sex, both or all genders or no one, or if they’re not sure yet. Doctors can then ask how comfortable they are with their attraction and whether they have told family members or friends about them.

Sexual behavior questions should be developmentally appropriate and lead to counsel but not judgment, Dr Finger said. Her method, with adjustments for age and development, starts, “There are many way of being sexual or intimate with someone: kissing, hugging and touching, and oral sex, anal sex and vaginal sex. Have you ever had any of these experiences? Which ones? With males or females or both, or other genders?”

Then she gets more specific while remaining sensitive. Doctors can ask younger children if they have held hands or cuddled with someone, if they have kissed someone, or if they have touched another person’s private parts. They can ask teens about oral sex, vaginal sex and anal sex and then gather more details about what parts went where, which helps determine what screenings or treatment options a patient may need or desire.

Doctors can use their judgment about whether to ask questions with parents in the room or not, but as kids grow older, it’s good practice to speak to patients without their caregivers present. Doctors should also explain the rules of confidentiality to their patients and be aware of the risks of “coming out,” including family discord or rejection, problems at school or work, social stigma, bullying and harassment, physical violence and risk-taking behaviors, such as substance use, self-injury and risky sexual behaviors. A HEADSSS screen can help doctors learn if any of these are present.
 

Making your practice inclusive and welcoming

Fewer than one in five teens who are “out” as LGBTQ have come out to their doctor, Dr Finger cited. Most are out to their friends and classmates, and more than half are out to their family, but teens are less likely to tell their doctors.

Research suggests one reason for this is the fact that pediatricians often don’t ask. One study found that only 20% of pediatricians discussed sexual orientation with their patients (Pediatrics 2010 Apr;125:e741-7). Similarly, only 30% of family physicians brought up sexual orientation, found another study (Fam. Med. 2001 May;33[5]:376-81). The studies found physicians more often discussed condoms, HIV, sexually transmitted infections, abstinence, violence, contraception or, in the case of family physicians, sexual behaviors, and relationships.

But another reason for not being out to doctors is a history of poor experiences. A Lambda Legal Survey in 2009 of 4,916 LGBT respondents found that 8% of LGB and 27% of transgender and gender nonconforming patients had been denied care because of their identity of orientation. Eleven percent said “providers refused to touch them or used excessive precautions,” Dr Finger reported. LGBTQ patients may fear the doctor’s reaction or not keeping their identity confidential. Patients may also have internalized shame or guilt due to societal norms or homophobia, and all these barriers can reduce LGBTQ people’s willingness to seek and access to competent care.

The first step to making LGBTQ patients comfortable in your practice is to confront your own personal biases, Dr Finger said. Understand what they are and that a provider’s discomfort, even unconscious, can be damaging to the patient-provider relationship.

“If you find that this is just not something that you’re going to be comfortable doing, at the very least, I would suggest that you find providers in your area who are comfortable working with this patient population and you refer your patients to them so that they can have a good, trusting patient-provider relationship with somebody who can provide the care that they need,” Dr Finger said.

The next step is creating a safe place with zero tolerance for insensitivity by training staff to be welcoming and inclusive, assuring patients confidentiality, providing support and resources and displaying LGBTQ-affirming materials. These youth need active, visible evidence that the office will be a safe place for them.

Ways pediatricians can communicate an inclusive environment include having gender-neutral restrooms, using “parent” instead of “mother/father” and using forms and EMR prompts with gender-neutral language or multiple options for gender selection.
 

Screening and LGBTQ patients’ health needs

LGB youth and those who aren’t sure of their sexual orientation tend to have higher rates of substance use, including tobacco, alcohol and illicit drugs, and are more often victims of rape and other sexual violence. Their rates of depressive symptoms, bullying victimization, and suicidality are also significantly higher than in their heterosexual cisgender peers. Homelessness rates are also considerably higher in LGBTQ youth than in heterosexual cisgender youth.

One thing pediatricians can do is work with parents to ensure a patient’s school is meeting their needs. The greater risks LGBTQ youth typically face are mediated by social support, resiliency, supportive friends and family and a supportive school environment, including inclusive curricula and supportive staff.

Lesbian and bisexual women are considerably more at risk for poor sexual or reproductive outcomes, Dr Finger said. Their rates of unplanned pregnancy are double that of straight women, contributing to their higher rates of emergency contraception and abortion. They are also more likely to have more partners (male and females), to have a younger sexual debut and to be forced into sex by a male partner—yet they are far less likely to perceive themselves as at risk for a sexually transmitted infection than their peers.

This patient population therefore may need contraception counseling, including discussing their current methods and reviewing their options, including emergency contraception and possibly an advance prescription. Dr Finger also suggests having male and female condoms available in the office.

Doctors should screen all their female patients, regardless of sexuality, for chlamydia and gonorrhea, and offer routine cervical cancer screening and the HPV vaccine, as recommended by the CDC. They might consider screening for trichomoniasis, bacterial vaginosis, herpes simplex, human papillomavirus and HIV.

For men who have sex with men, the CDC recommends HIV and syphilis serology, urine/pharyngeal/rectal gonorrhea nucleic acid amplification test (NAAT), urine/rectal chlamydia NAAT, and hepatitis C screening for those who are HIV-positive—all at least once a year.

For transgender patients, doctors need to assess their STI- and HIV-related risks based on their current anatomy and sexual behaviors.

Doctors should also consider discussing pre-exposure prophylaxis (PrEP) for any youth at high risk for HIV infection if they are at least 77 pounds (35 kg). Emtricitabine/tenofovir (Truvada, Descovy) reduces the chance of sexually acquired infection by 99%, and infection acquired via drug injection by 74% when taken as prescribed.

Resources

Dr Finger noted a range of resources for LGBTQ youth and their families and providers, including the Family Acceptance Project, Gay and Lesbian Medical Association, Gay, Lesbian and Straight Education Network, GLBTQ Legal Advocates and Defenders (GLAD), Human Rights Campaign, It Gets Better Project, LGBTQ Student Resources and Support, National Center for Lesbian Rights, Parents and Friends of Lesbians and Gays (PFLAG), Safe Schools Coalition and The Trevor Project (concerning suicide risk).

NEW ORLEANS – Nearly half of all children with autism spectrum disorder wander off from safe supervision at some point in their childhood or adolescence, reported Paul Lipkin, MD, at the annual meeting of the American Academy of Pediatrics.

Though such behavior is developmentally normal in toddlers, it’s rarer for older children to leave a supervised, safe space for a longer period than just running away for a bit, he said.

Far more than an inconvenience, wandering, also called elopement, puts these children at high risk for injury or victimization. In fact, statistics from a survey by the National Autism Foundation suggest that nearly a third of autism-related wandering cases resulted in death or serious enough injury to require medical attention, said Dr. Lipkin, an associate professor of pediatrics at the Kennedy Krieger Institute and Johns Hopkins Medicine in Baltimore.

“Drowning is overwhelmingly the main cause of death in children with autism,” he said, sharing the data from National Autism Association, which relied on parent report and media reports. In that data, 71% of deaths from autistic children who wandered from 2011-2016 were drowning, and of those deaths, 76% of the drownings occurred in a natural body of water or drainage water. At a distant second, 18% of deaths were traffic accidents. The remaining causes were being hit by a train (4%), hypothermia or hyperthermia (3%), falling (1%) or other trauma (3%) (J Autism Dev Disord. 2019 Mar 5. doi: 10.1007/s10803-019-03961-x).

Academic research has found similar statistics to those from the National Autism Association. In one study, 53% of autistic youth who attempted to run off succeeded and were missing long enough to cause safety concerns (Pediatrics. 2012 Nov;130[5]:870-7). Among these youth – representing about a quarter of all families surveyed in the study – the police were called in 31% of cases. In addition, 65% had a “close call” with a traffic injury and 24% had a close call with drowning.

The children wandered off in various settings, including home; another’s home; a store or other public place; or school, daycare or camp. A 2019 study found that 70% of parents reported their children wandering off from home at least once in the past 2 years (J Autism Dev Disorders. 2019 Mar 5; doi: 10.1107/s10803-019-03961-x).

Although most cases occur in children and teens, with the highest rate of death among children aged 5-9, the National Autism Association has received reports of wandering occur throughout autistic people’s lifetime.

Yet this issue doesn’t appear to be on the radar of many pediatricians, and those who are aware of it may not know the best strategies to share with parents to prevent wandering and subsequent injury, Dr Lipkin explained. In one study, only one-third of parents reported receiving guidance from a health provider related to wandering (J Dev Behav Pediatr. 2018 Sep;39[7]:538-46).

That research found that only 10% received advice from a pediatrician or other primary care provider, 12% received advice from a developmental pediatrician or neurologist and 10% received advance from a psychologist or psychiatrist. The largest source of guidance in that study was autism advocacy organizations, whom 22% of parents cited. Others included a teacher or other school staff member (15%), a personal contact (13%), law enforcement (8%) or another source (1%).
 

Role of the pediatrician

Pediatricians have an important role to play in prevention of elopement, Dr Lipkin said. They can screen autistic patients for wandering and elopement during visits, work with community stakeholders such as schools and law enforcement, advocate for awareness, and provider education and resources for families.

Perhaps the most valuable resource, he said, is the Big Red Safety Box, available from the National Autism Association. This resource, sponsored by more than a half dozen autism advocacy organizations, includes three digital safety toolkits: one for caregivers, one for first responders, and one for teachers. Parents can therefore share the toolkits for first responders and teachers with those respective community members.

Pediatricians can also help families develop a Family Wandering Emergency Plan (FWEP), a template for which is in the Big Red Safety Box. Parents and community members should know the steps to take if someone wanders: Stay calm, call 911, search nearby water first and then implement the FWEP.

It’s first helpful to understand why these youth wander off. In the National Autism Association survey, the most common reasons were to escape an anxious situation, particularly for those with Asperger’s, or simply to run, explore, or go to a favorite place, particularly among those with autism or pervasive developmental disorder-not otherwise specified (PDD-NOS).

Researchers have found similar reasons: 43% of elopement situations occurred when children were trying to escape an anxious situation, 39% left while in a stressful environment, and 24% were in an environment with conflict, found one study (J Autism Dev Disord. 2019 Mar 5. doi: 10.1007/s10803-019-03961-x).

Sensory overload was also a trigger, with 38% of elopements occurring when it was too noisy, and 34% when it was a generally uncomfortable sensory experience. Just over a quarter (27%) of children left when they were understimulated or in a “boring” environment, Dr Lipkin reported. The remaining reason was goal-directed: 27% left to pursue a special interest, 18% sought a place where they enjoyed playing, and 11% were after their favorite food.
 

Prevention Strategies

Most data about effective strategies to prevent wandering comes from research that relies on parents, Dr Lipkin said. In general, environmental interventions tend to be the most effective, and medication tends to be the least effective.

One study on elopement prevention found that 96% of caregivers use at least some type of intervention, and the vast majority (83%) were using environmental interventions such as dead bolts (51%), latches (49%) and gates (36%). An equal proportion used behavioral services (83%), such as a behavioral psychologist (41%), social stories (40%) or an aide (39%). Just under a third used an ID bracelet or shoe tag (31%), and 19% used GPS trackers, according to Dr. Lipkin.

Although parents reported environmental interventions to be very effective, 68% said they were highly burdensome, though the median cost over 2 years was less than $1,000. The least expensive intervention was home behavioral specialists (when covered by insurance) and school aides, and the most expensive and burdensome – albeit highly effective – was a service animal.

Interventions with the least cost effectiveness included security cameras and GPS trackers, which only 15% of parents reported as being effective.

Although nearly half of parents reported their child had taken any psychiatric medication (48%), only 16% had taken medication explicitly to prevent wandering. Few reported the medication was very effective, however. Among the small number who did (less than 10), lorazepam, diazepam and atomoxetine appeared best.

Teaching children survival skills, as developmentally appropriate and possible, can also help. These include swimming lessons as well as learning how to interact in traffic, knowing their home address, and learning how to navigate around their neighborhood.

Dr. Lipkin no disclosures and used no external funding for this presentation.

NEW ORLEANS – Nearly half of all children with autism spectrum disorder wander off from safe supervision at some point in their childhood or adolescence, reported Paul Lipkin, MD, at the annual meeting of the American Academy of Pediatrics.

Though such behavior is developmentally normal in toddlers, it’s rarer for older children to leave a supervised, safe space for a longer period than just running away for a bit, he said.

Far more than an inconvenience, wandering, also called elopement, puts these children at high risk for injury or victimization. In fact, statistics from a survey by the National Autism Foundation suggest that nearly a third of autism-related wandering cases resulted in death or serious enough injury to require medical attention, said Dr. Lipkin, an associate professor of pediatrics at the Kennedy Krieger Institute and Johns Hopkins Medicine in Baltimore.

“Drowning is overwhelmingly the main cause of death in children with autism,” he said, sharing the data from National Autism Association, which relied on parent report and media reports. In that data, 71% of deaths from autistic children who wandered from 2011-2016 were drowning, and of those deaths, 76% of the drownings occurred in a natural body of water or drainage water. At a distant second, 18% of deaths were traffic accidents. The remaining causes were being hit by a train (4%), hypothermia or hyperthermia (3%), falling (1%) or other trauma (3%) (J Autism Dev Disord. 2019 Mar 5. doi: 10.1007/s10803-019-03961-x).

Academic research has found similar statistics to those from the National Autism Association. In one study, 53% of autistic youth who attempted to run off succeeded and were missing long enough to cause safety concerns (Pediatrics. 2012 Nov;130[5]:870-7). Among these youth – representing about a quarter of all families surveyed in the study – the police were called in 31% of cases. In addition, 65% had a “close call” with a traffic injury and 24% had a close call with drowning.

The children wandered off in various settings, including home; another’s home; a store or other public place; or school, daycare or camp. A 2019 study found that 70% of parents reported their children wandering off from home at least once in the past 2 years (J Autism Dev Disorders. 2019 Mar 5; doi: 10.1107/s10803-019-03961-x).

Although most cases occur in children and teens, with the highest rate of death among children aged 5-9, the National Autism Association has received reports of wandering occur throughout autistic people’s lifetime.

Yet this issue doesn’t appear to be on the radar of many pediatricians, and those who are aware of it may not know the best strategies to share with parents to prevent wandering and subsequent injury, Dr Lipkin explained. In one study, only one-third of parents reported receiving guidance from a health provider related to wandering (J Dev Behav Pediatr. 2018 Sep;39[7]:538-46).

That research found that only 10% received advice from a pediatrician or other primary care provider, 12% received advice from a developmental pediatrician or neurologist and 10% received advance from a psychologist or psychiatrist. The largest source of guidance in that study was autism advocacy organizations, whom 22% of parents cited. Others included a teacher or other school staff member (15%), a personal contact (13%), law enforcement (8%) or another source (1%).
 

Role of the pediatrician

Pediatricians have an important role to play in prevention of elopement, Dr Lipkin said. They can screen autistic patients for wandering and elopement during visits, work with community stakeholders such as schools and law enforcement, advocate for awareness, and provider education and resources for families.

Perhaps the most valuable resource, he said, is the Big Red Safety Box, available from the National Autism Association. This resource, sponsored by more than a half dozen autism advocacy organizations, includes three digital safety toolkits: one for caregivers, one for first responders, and one for teachers. Parents can therefore share the toolkits for first responders and teachers with those respective community members.

Pediatricians can also help families develop a Family Wandering Emergency Plan (FWEP), a template for which is in the Big Red Safety Box. Parents and community members should know the steps to take if someone wanders: Stay calm, call 911, search nearby water first and then implement the FWEP.

It’s first helpful to understand why these youth wander off. In the National Autism Association survey, the most common reasons were to escape an anxious situation, particularly for those with Asperger’s, or simply to run, explore, or go to a favorite place, particularly among those with autism or pervasive developmental disorder-not otherwise specified (PDD-NOS).

Researchers have found similar reasons: 43% of elopement situations occurred when children were trying to escape an anxious situation, 39% left while in a stressful environment, and 24% were in an environment with conflict, found one study (J Autism Dev Disord. 2019 Mar 5. doi: 10.1007/s10803-019-03961-x).

Sensory overload was also a trigger, with 38% of elopements occurring when it was too noisy, and 34% when it was a generally uncomfortable sensory experience. Just over a quarter (27%) of children left when they were understimulated or in a “boring” environment, Dr Lipkin reported. The remaining reason was goal-directed: 27% left to pursue a special interest, 18% sought a place where they enjoyed playing, and 11% were after their favorite food.
 

Prevention Strategies

Most data about effective strategies to prevent wandering comes from research that relies on parents, Dr Lipkin said. In general, environmental interventions tend to be the most effective, and medication tends to be the least effective.

One study on elopement prevention found that 96% of caregivers use at least some type of intervention, and the vast majority (83%) were using environmental interventions such as dead bolts (51%), latches (49%) and gates (36%). An equal proportion used behavioral services (83%), such as a behavioral psychologist (41%), social stories (40%) or an aide (39%). Just under a third used an ID bracelet or shoe tag (31%), and 19% used GPS trackers, according to Dr. Lipkin.

Although parents reported environmental interventions to be very effective, 68% said they were highly burdensome, though the median cost over 2 years was less than $1,000. The least expensive intervention was home behavioral specialists (when covered by insurance) and school aides, and the most expensive and burdensome – albeit highly effective – was a service animal.

Interventions with the least cost effectiveness included security cameras and GPS trackers, which only 15% of parents reported as being effective.

Although nearly half of parents reported their child had taken any psychiatric medication (48%), only 16% had taken medication explicitly to prevent wandering. Few reported the medication was very effective, however. Among the small number who did (less than 10), lorazepam, diazepam and atomoxetine appeared best.

Teaching children survival skills, as developmentally appropriate and possible, can also help. These include swimming lessons as well as learning how to interact in traffic, knowing their home address, and learning how to navigate around their neighborhood.

Dr. Lipkin no disclosures and used no external funding for this presentation.

NEW ORLEANS – Nearly half of all children with autism spectrum disorder wander off from safe supervision at some point in their childhood or adolescence, reported Paul Lipkin, MD, at the annual meeting of the American Academy of Pediatrics.

Though such behavior is developmentally normal in toddlers, it’s rarer for older children to leave a supervised, safe space for a longer period than just running away for a bit, he said.

Far more than an inconvenience, wandering, also called elopement, puts these children at high risk for injury or victimization. In fact, statistics from a survey by the National Autism Foundation suggest that nearly a third of autism-related wandering cases resulted in death or serious enough injury to require medical attention, said Dr. Lipkin, an associate professor of pediatrics at the Kennedy Krieger Institute and Johns Hopkins Medicine in Baltimore.

“Drowning is overwhelmingly the main cause of death in children with autism,” he said, sharing the data from National Autism Association, which relied on parent report and media reports. In that data, 71% of deaths from autistic children who wandered from 2011-2016 were drowning, and of those deaths, 76% of the drownings occurred in a natural body of water or drainage water. At a distant second, 18% of deaths were traffic accidents. The remaining causes were being hit by a train (4%), hypothermia or hyperthermia (3%), falling (1%) or other trauma (3%) (J Autism Dev Disord. 2019 Mar 5. doi: 10.1007/s10803-019-03961-x).

Academic research has found similar statistics to those from the National Autism Association. In one study, 53% of autistic youth who attempted to run off succeeded and were missing long enough to cause safety concerns (Pediatrics. 2012 Nov;130[5]:870-7). Among these youth – representing about a quarter of all families surveyed in the study – the police were called in 31% of cases. In addition, 65% had a “close call” with a traffic injury and 24% had a close call with drowning.

The children wandered off in various settings, including home; another’s home; a store or other public place; or school, daycare or camp. A 2019 study found that 70% of parents reported their children wandering off from home at least once in the past 2 years (J Autism Dev Disorders. 2019 Mar 5; doi: 10.1107/s10803-019-03961-x).

Although most cases occur in children and teens, with the highest rate of death among children aged 5-9, the National Autism Association has received reports of wandering occur throughout autistic people’s lifetime.

Yet this issue doesn’t appear to be on the radar of many pediatricians, and those who are aware of it may not know the best strategies to share with parents to prevent wandering and subsequent injury, Dr Lipkin explained. In one study, only one-third of parents reported receiving guidance from a health provider related to wandering (J Dev Behav Pediatr. 2018 Sep;39[7]:538-46).

That research found that only 10% received advice from a pediatrician or other primary care provider, 12% received advice from a developmental pediatrician or neurologist and 10% received advance from a psychologist or psychiatrist. The largest source of guidance in that study was autism advocacy organizations, whom 22% of parents cited. Others included a teacher or other school staff member (15%), a personal contact (13%), law enforcement (8%) or another source (1%).
 

Role of the pediatrician

Pediatricians have an important role to play in prevention of elopement, Dr Lipkin said. They can screen autistic patients for wandering and elopement during visits, work with community stakeholders such as schools and law enforcement, advocate for awareness, and provider education and resources for families.

Perhaps the most valuable resource, he said, is the Big Red Safety Box, available from the National Autism Association. This resource, sponsored by more than a half dozen autism advocacy organizations, includes three digital safety toolkits: one for caregivers, one for first responders, and one for teachers. Parents can therefore share the toolkits for first responders and teachers with those respective community members.

Pediatricians can also help families develop a Family Wandering Emergency Plan (FWEP), a template for which is in the Big Red Safety Box. Parents and community members should know the steps to take if someone wanders: Stay calm, call 911, search nearby water first and then implement the FWEP.

It’s first helpful to understand why these youth wander off. In the National Autism Association survey, the most common reasons were to escape an anxious situation, particularly for those with Asperger’s, or simply to run, explore, or go to a favorite place, particularly among those with autism or pervasive developmental disorder-not otherwise specified (PDD-NOS).

Researchers have found similar reasons: 43% of elopement situations occurred when children were trying to escape an anxious situation, 39% left while in a stressful environment, and 24% were in an environment with conflict, found one study (J Autism Dev Disord. 2019 Mar 5. doi: 10.1007/s10803-019-03961-x).

Sensory overload was also a trigger, with 38% of elopements occurring when it was too noisy, and 34% when it was a generally uncomfortable sensory experience. Just over a quarter (27%) of children left when they were understimulated or in a “boring” environment, Dr Lipkin reported. The remaining reason was goal-directed: 27% left to pursue a special interest, 18% sought a place where they enjoyed playing, and 11% were after their favorite food.
 

Prevention Strategies

Most data about effective strategies to prevent wandering comes from research that relies on parents, Dr Lipkin said. In general, environmental interventions tend to be the most effective, and medication tends to be the least effective.

One study on elopement prevention found that 96% of caregivers use at least some type of intervention, and the vast majority (83%) were using environmental interventions such as dead bolts (51%), latches (49%) and gates (36%). An equal proportion used behavioral services (83%), such as a behavioral psychologist (41%), social stories (40%) or an aide (39%). Just under a third used an ID bracelet or shoe tag (31%), and 19% used GPS trackers, according to Dr. Lipkin.

Although parents reported environmental interventions to be very effective, 68% said they were highly burdensome, though the median cost over 2 years was less than $1,000. The least expensive intervention was home behavioral specialists (when covered by insurance) and school aides, and the most expensive and burdensome – albeit highly effective – was a service animal.

Interventions with the least cost effectiveness included security cameras and GPS trackers, which only 15% of parents reported as being effective.

Although nearly half of parents reported their child had taken any psychiatric medication (48%), only 16% had taken medication explicitly to prevent wandering. Few reported the medication was very effective, however. Among the small number who did (less than 10), lorazepam, diazepam and atomoxetine appeared best.

Teaching children survival skills, as developmentally appropriate and possible, can also help. These include swimming lessons as well as learning how to interact in traffic, knowing their home address, and learning how to navigate around their neighborhood.

Dr. Lipkin no disclosures and used no external funding for this presentation.

AUSTIN, TEX. – Patients with peripheral neuropathy may benefit from genetic testing to determine of the cause of their neuropathy even if they do not have a family history of the condition, according to new research.

The same research identified more than 80 genetic variants in patients with neuropathy who lacked any other known genetic mutations, potentially representing not-yet-identified pathogenic mutations.

Sasa Zivkovic, MD, PhD, of the University of Pittsburgh Medical Center (UPMC), and associates shared a poster of their findings at the annual meeting of the American Association for Neuromuscular and Electrodiagnostic Medicine.

The researchers conducted next-generation sequencing (NGS) on 85 adult patients with peripheral neuropathy at the UPMC Neuromuscular Clinic during May 2017–Feb. 2019. The targeted NGS panel included 70 genes. The patients, aged 60 years on average, were primarily from Allegheny County, Pa., and had neuropathy either suspected to be hereditary or of unknown etiology.

Among the 19% of patients (n = 16) who tested positive for a known pathogenic mutation, half had Charcot-Marie-Tooth disease type 1A (CMT1A). Two patients – 13% of those with pathogenic variants – had hereditary neuropathy with liability to pressure palsies, and two had CMT1X. The remaining four patients had CMT1B, CMT2B1, CMT2E, and hereditary sensory and autonomic neuropathy mutations.

Another 4% of the overall patient sample (n = 3) had likely pathogenic mutations in genes associated with CMT2S, CMT4C and CMT4F. A third of the patients (32%) tested negative for the full NGS panel, and, comprising the largest proportion of patients, 46% had variants of unknown significance.

“The high occurrence of variants of unknown significance has uncertain significance but some variations may represent unrecognized pathogenic mutations,” the authors noted.

They identified 81 of these variants, with the DST, PLEKHG5, and SPG11 genes most commonly affected, each found in six patients. Four patients had a variant in the next most commonly affected gene, SBF2. The following variants occurred in three people each: BICD2, NEFL3, PRX, SCN11A, SCN9A, SLC52A2, and WNK1.

Among the 73 patients who underwent electrodiagnostic testing, 44 had sporadic axonal neuropathy, 17 had sporadic demyelinating neuropathy, and 11 had mixed neuropathies; the 1 remaining patient was not accounted for. Positive genetic testing occurred in a third (32%) of those with familial neuropathy (n = 28) and in 12% of those with sporadic neuropathy (n = 57).

No external funding was noted, and the authors had no disclosures.

SOURCE: Zivkovic S et al. AANEM 2019. Abstract 160. Targeted genetic testing in the evaluation of neuropathy .

AUSTIN, TEX. – Patients with peripheral neuropathy may benefit from genetic testing to determine of the cause of their neuropathy even if they do not have a family history of the condition, according to new research.

The same research identified more than 80 genetic variants in patients with neuropathy who lacked any other known genetic mutations, potentially representing not-yet-identified pathogenic mutations.

Sasa Zivkovic, MD, PhD, of the University of Pittsburgh Medical Center (UPMC), and associates shared a poster of their findings at the annual meeting of the American Association for Neuromuscular and Electrodiagnostic Medicine.

The researchers conducted next-generation sequencing (NGS) on 85 adult patients with peripheral neuropathy at the UPMC Neuromuscular Clinic during May 2017–Feb. 2019. The targeted NGS panel included 70 genes. The patients, aged 60 years on average, were primarily from Allegheny County, Pa., and had neuropathy either suspected to be hereditary or of unknown etiology.

Among the 19% of patients (n = 16) who tested positive for a known pathogenic mutation, half had Charcot-Marie-Tooth disease type 1A (CMT1A). Two patients – 13% of those with pathogenic variants – had hereditary neuropathy with liability to pressure palsies, and two had CMT1X. The remaining four patients had CMT1B, CMT2B1, CMT2E, and hereditary sensory and autonomic neuropathy mutations.

Another 4% of the overall patient sample (n = 3) had likely pathogenic mutations in genes associated with CMT2S, CMT4C and CMT4F. A third of the patients (32%) tested negative for the full NGS panel, and, comprising the largest proportion of patients, 46% had variants of unknown significance.

“The high occurrence of variants of unknown significance has uncertain significance but some variations may represent unrecognized pathogenic mutations,” the authors noted.

They identified 81 of these variants, with the DST, PLEKHG5, and SPG11 genes most commonly affected, each found in six patients. Four patients had a variant in the next most commonly affected gene, SBF2. The following variants occurred in three people each: BICD2, NEFL3, PRX, SCN11A, SCN9A, SLC52A2, and WNK1.

Among the 73 patients who underwent electrodiagnostic testing, 44 had sporadic axonal neuropathy, 17 had sporadic demyelinating neuropathy, and 11 had mixed neuropathies; the 1 remaining patient was not accounted for. Positive genetic testing occurred in a third (32%) of those with familial neuropathy (n = 28) and in 12% of those with sporadic neuropathy (n = 57).

No external funding was noted, and the authors had no disclosures.

SOURCE: Zivkovic S et al. AANEM 2019. Abstract 160. Targeted genetic testing in the evaluation of neuropathy .

AUSTIN, TEX. – Patients with peripheral neuropathy may benefit from genetic testing to determine of the cause of their neuropathy even if they do not have a family history of the condition, according to new research.

The same research identified more than 80 genetic variants in patients with neuropathy who lacked any other known genetic mutations, potentially representing not-yet-identified pathogenic mutations.

Sasa Zivkovic, MD, PhD, of the University of Pittsburgh Medical Center (UPMC), and associates shared a poster of their findings at the annual meeting of the American Association for Neuromuscular and Electrodiagnostic Medicine.

The researchers conducted next-generation sequencing (NGS) on 85 adult patients with peripheral neuropathy at the UPMC Neuromuscular Clinic during May 2017–Feb. 2019. The targeted NGS panel included 70 genes. The patients, aged 60 years on average, were primarily from Allegheny County, Pa., and had neuropathy either suspected to be hereditary or of unknown etiology.

Among the 19% of patients (n = 16) who tested positive for a known pathogenic mutation, half had Charcot-Marie-Tooth disease type 1A (CMT1A). Two patients – 13% of those with pathogenic variants – had hereditary neuropathy with liability to pressure palsies, and two had CMT1X. The remaining four patients had CMT1B, CMT2B1, CMT2E, and hereditary sensory and autonomic neuropathy mutations.

Another 4% of the overall patient sample (n = 3) had likely pathogenic mutations in genes associated with CMT2S, CMT4C and CMT4F. A third of the patients (32%) tested negative for the full NGS panel, and, comprising the largest proportion of patients, 46% had variants of unknown significance.

“The high occurrence of variants of unknown significance has uncertain significance but some variations may represent unrecognized pathogenic mutations,” the authors noted.

They identified 81 of these variants, with the DST, PLEKHG5, and SPG11 genes most commonly affected, each found in six patients. Four patients had a variant in the next most commonly affected gene, SBF2. The following variants occurred in three people each: BICD2, NEFL3, PRX, SCN11A, SCN9A, SLC52A2, and WNK1.

Among the 73 patients who underwent electrodiagnostic testing, 44 had sporadic axonal neuropathy, 17 had sporadic demyelinating neuropathy, and 11 had mixed neuropathies; the 1 remaining patient was not accounted for. Positive genetic testing occurred in a third (32%) of those with familial neuropathy (n = 28) and in 12% of those with sporadic neuropathy (n = 57).

No external funding was noted, and the authors had no disclosures.

SOURCE: Zivkovic S et al. AANEM 2019. Abstract 160. Targeted genetic testing in the evaluation of neuropathy .

AUSTIN, TEX. – Dichlorphenamide continues to reduce attacks from primary periodic paralysis (PPP) through 1 year with mild or moderate paresthesia and cognition-related adverse events, according to new research.

“These adverse events rarely resulted in discontinuation from the study and were sometimes managed by dichlorphenamide dose reductions,” concluded Nicholas E. Johnson, MD, of Virginia Commonwealth University, Richmond, and colleagues. “Reduction in dose was frequently associated with resolution of these events, suggesting a potential intervention to hasten resolution.” Dr. Johnson presented the findings in an abstract at the annual meeting of the American Association for Neuromuscular and Electrodiagnostic Medicine.

Dichlorphenamide (Keveyis) was approved by the Food and Drug Administration in 2015 for treating primary hyperkalemic and hypokalemic periodic paralysis and similar variants. The original hyperkalemic/hypokalemic PPP trial was a phase 3 randomized, double-blind, placebo-controlled trial that lasted 9 weeks and assessed the efficacy of dichlorphenamide in reducing PPP attacks and its adverse events. In the dichlorphenamide group, 47% experienced paresthesia, compared with 14% in the placebo group, and 19% experienced cognitive disorder, compared with 7% in the placebo.

In a 52-week open-label extension, participants who had been receiving the placebo switched to receiving 50 mg of dichlorphenamide twice daily. The intervention group continued with the dose they had been receiving when the 9-week double-blind phase ended. (During the initial intervention, they took either 50 mg twice daily or the dose they had at baseline for those taking it before the study began.)

The researchers then tracked rates of attacks and their severity over the next year – through week 61 after baseline – to compare these endpoints both within the intervention groups and between them.

Among the 63 predominantly white (84.1%) male (61.9%) adults who began the trial, 36 received dichlorphenamide and 27 received placebo. Just over two-thirds (68.3%) had hypokalemic PPP. Among the 47 patients (74.6%) who completed the open-label extension phase, 26 had been in the original dichlorphenamide group and 21 had been in the placebo group.

The median weekly attack rate in the dichlorphenamide group dropped from 1.75 at baseline to 0.06 at week 61 (median decrease 1.00, 93.8%; P less than .0001). In the placebo group that switched over to dichlorphenamide at week 9, the median weekly attack rate dropped from 3.00 at baseline to 0.25 at week 61 (median decrease 0.63, 75%; P = .01).

The median attack rate weighted for severity in the dichlorphenamide group dropped from 2.25 at baseline to 0.06 at week 61 (median decrease 2.25, 97.1%; P less than .0001). In the placebo group, it dropped from 5.88 to 0.50 (median decrease 1.69, 80.8%; P = .01).

No significant difference in median weekly attack rates and severity-weighted attack rates was found between the intervention groups through week 61.

Across all patients during the extension, 39.7% patients experienced at least one paresthesia adverse event, none of which were determined to be severe and resulting in one discontinuation.

A quarter of the participants (25.4%) experienced at least one cognition-related adverse event, and four patients (6.3%) discontinued because of these side effects. Most (14.3%) were mild with 7.9% reporting moderate and 3.2% reporting severe effects.

Dr. Johnson has received research support from or consulted with a variety of pharmaceutical companies including Strongbridge Biopharma, the manufacturer of the drug. Other authors consulted for several pharmaceutical companies, and one author is an employee of Strongbridge Biopharma.
 

SOURCE: Johnson NE et al. AANEM 2019. Abstract 102. Long-term efficacy and adverse event characterization of dichlorphenamide for the treatment of primary periodic paralysis.

AUSTIN, TEX. – Dichlorphenamide continues to reduce attacks from primary periodic paralysis (PPP) through 1 year with mild or moderate paresthesia and cognition-related adverse events, according to new research.

“These adverse events rarely resulted in discontinuation from the study and were sometimes managed by dichlorphenamide dose reductions,” concluded Nicholas E. Johnson, MD, of Virginia Commonwealth University, Richmond, and colleagues. “Reduction in dose was frequently associated with resolution of these events, suggesting a potential intervention to hasten resolution.” Dr. Johnson presented the findings in an abstract at the annual meeting of the American Association for Neuromuscular and Electrodiagnostic Medicine.

Dichlorphenamide (Keveyis) was approved by the Food and Drug Administration in 2015 for treating primary hyperkalemic and hypokalemic periodic paralysis and similar variants. The original hyperkalemic/hypokalemic PPP trial was a phase 3 randomized, double-blind, placebo-controlled trial that lasted 9 weeks and assessed the efficacy of dichlorphenamide in reducing PPP attacks and its adverse events. In the dichlorphenamide group, 47% experienced paresthesia, compared with 14% in the placebo group, and 19% experienced cognitive disorder, compared with 7% in the placebo.

In a 52-week open-label extension, participants who had been receiving the placebo switched to receiving 50 mg of dichlorphenamide twice daily. The intervention group continued with the dose they had been receiving when the 9-week double-blind phase ended. (During the initial intervention, they took either 50 mg twice daily or the dose they had at baseline for those taking it before the study began.)

The researchers then tracked rates of attacks and their severity over the next year – through week 61 after baseline – to compare these endpoints both within the intervention groups and between them.

Among the 63 predominantly white (84.1%) male (61.9%) adults who began the trial, 36 received dichlorphenamide and 27 received placebo. Just over two-thirds (68.3%) had hypokalemic PPP. Among the 47 patients (74.6%) who completed the open-label extension phase, 26 had been in the original dichlorphenamide group and 21 had been in the placebo group.

The median weekly attack rate in the dichlorphenamide group dropped from 1.75 at baseline to 0.06 at week 61 (median decrease 1.00, 93.8%; P less than .0001). In the placebo group that switched over to dichlorphenamide at week 9, the median weekly attack rate dropped from 3.00 at baseline to 0.25 at week 61 (median decrease 0.63, 75%; P = .01).

The median attack rate weighted for severity in the dichlorphenamide group dropped from 2.25 at baseline to 0.06 at week 61 (median decrease 2.25, 97.1%; P less than .0001). In the placebo group, it dropped from 5.88 to 0.50 (median decrease 1.69, 80.8%; P = .01).

No significant difference in median weekly attack rates and severity-weighted attack rates was found between the intervention groups through week 61.

Across all patients during the extension, 39.7% patients experienced at least one paresthesia adverse event, none of which were determined to be severe and resulting in one discontinuation.

A quarter of the participants (25.4%) experienced at least one cognition-related adverse event, and four patients (6.3%) discontinued because of these side effects. Most (14.3%) were mild with 7.9% reporting moderate and 3.2% reporting severe effects.

Dr. Johnson has received research support from or consulted with a variety of pharmaceutical companies including Strongbridge Biopharma, the manufacturer of the drug. Other authors consulted for several pharmaceutical companies, and one author is an employee of Strongbridge Biopharma.
 

SOURCE: Johnson NE et al. AANEM 2019. Abstract 102. Long-term efficacy and adverse event characterization of dichlorphenamide for the treatment of primary periodic paralysis.

AUSTIN, TEX. – Dichlorphenamide continues to reduce attacks from primary periodic paralysis (PPP) through 1 year with mild or moderate paresthesia and cognition-related adverse events, according to new research.

“These adverse events rarely resulted in discontinuation from the study and were sometimes managed by dichlorphenamide dose reductions,” concluded Nicholas E. Johnson, MD, of Virginia Commonwealth University, Richmond, and colleagues. “Reduction in dose was frequently associated with resolution of these events, suggesting a potential intervention to hasten resolution.” Dr. Johnson presented the findings in an abstract at the annual meeting of the American Association for Neuromuscular and Electrodiagnostic Medicine.

Dichlorphenamide (Keveyis) was approved by the Food and Drug Administration in 2015 for treating primary hyperkalemic and hypokalemic periodic paralysis and similar variants. The original hyperkalemic/hypokalemic PPP trial was a phase 3 randomized, double-blind, placebo-controlled trial that lasted 9 weeks and assessed the efficacy of dichlorphenamide in reducing PPP attacks and its adverse events. In the dichlorphenamide group, 47% experienced paresthesia, compared with 14% in the placebo group, and 19% experienced cognitive disorder, compared with 7% in the placebo.

In a 52-week open-label extension, participants who had been receiving the placebo switched to receiving 50 mg of dichlorphenamide twice daily. The intervention group continued with the dose they had been receiving when the 9-week double-blind phase ended. (During the initial intervention, they took either 50 mg twice daily or the dose they had at baseline for those taking it before the study began.)

The researchers then tracked rates of attacks and their severity over the next year – through week 61 after baseline – to compare these endpoints both within the intervention groups and between them.

Among the 63 predominantly white (84.1%) male (61.9%) adults who began the trial, 36 received dichlorphenamide and 27 received placebo. Just over two-thirds (68.3%) had hypokalemic PPP. Among the 47 patients (74.6%) who completed the open-label extension phase, 26 had been in the original dichlorphenamide group and 21 had been in the placebo group.

The median weekly attack rate in the dichlorphenamide group dropped from 1.75 at baseline to 0.06 at week 61 (median decrease 1.00, 93.8%; P less than .0001). In the placebo group that switched over to dichlorphenamide at week 9, the median weekly attack rate dropped from 3.00 at baseline to 0.25 at week 61 (median decrease 0.63, 75%; P = .01).

The median attack rate weighted for severity in the dichlorphenamide group dropped from 2.25 at baseline to 0.06 at week 61 (median decrease 2.25, 97.1%; P less than .0001). In the placebo group, it dropped from 5.88 to 0.50 (median decrease 1.69, 80.8%; P = .01).

No significant difference in median weekly attack rates and severity-weighted attack rates was found between the intervention groups through week 61.

Across all patients during the extension, 39.7% patients experienced at least one paresthesia adverse event, none of which were determined to be severe and resulting in one discontinuation.

A quarter of the participants (25.4%) experienced at least one cognition-related adverse event, and four patients (6.3%) discontinued because of these side effects. Most (14.3%) were mild with 7.9% reporting moderate and 3.2% reporting severe effects.

Dr. Johnson has received research support from or consulted with a variety of pharmaceutical companies including Strongbridge Biopharma, the manufacturer of the drug. Other authors consulted for several pharmaceutical companies, and one author is an employee of Strongbridge Biopharma.
 

SOURCE: Johnson NE et al. AANEM 2019. Abstract 102. Long-term efficacy and adverse event characterization of dichlorphenamide for the treatment of primary periodic paralysis.

AUSTIN, TEX. – The use of both repetitive stimulation (RS) and jitter analysis are important for accurate diagnosis of congenital myasthenic syndrome (CMS) suggests newly presented research.

“In case RS is negative, SFEMG [single fiber electromyography] alone is not very specific and cannot distinguish CMS from mitochondrial myopathies, even in the presence of impulse blocking,” Vitor Marques Caldas, MD, a neurologist at the Syrian Libanes Hospital in Brasilia, Brazil, and a PhD student at the University of São Paulo, told attendees at the annual meeting of the American Association for Neuromuscular and Electrodiagnostic Medicine. “An isolated SFEMG test can lead to a misdiagnosis of myasthenia syndrome if not interpreted in the right clinical context.”

The researchers sought to understand the relative sensitivity and specificity of low-frequency RS versus jitter analysis using disposable concentric needle electrodes (CNE).

The study involved 69 patients, of whom 19 had mitochondrial myopathy, 18 had congenital myopathy, 18 had CMS, and 14 were asymptomatic controls. The control group all tested normal with both RS and jitter analysis.

The 18 participants with CMS, average age 24 years, received low-frequency RS in at least six different muscles: two distal muscles (abductor digiti minimi and tibialis anterior), two proximal muscles (deltoid and trapezius) and two facial muscles (nasalis and orbicularis oculi). They also underwent jitter analysis of their orbicularis oculi muscle under voluntary activation using CNE.

These patients had heterogeneous genetic profiles: 11 had the CHRNE gene mutation, 2 had the RAPSN gene mutation, 2 had the COLQ gene mutation, 2 had the DOK-7 gene mutation, and 1 had the COL13A1 mutation.

All but two patients with congenital CMS tested positive (88.9%) with RS: one female with CHRNE mutation and one male with RAPSN mutation. Using mean jitter, all but one patient tested positive (94.4%): a female with DOK-7 mutation who had tested abnormal on RS.

All patients with CMS tested positive with at least one of the two tests, but only 83.3% tested positive with both tests, resulting in a sensitivity of 83.3%, a specificity of 100%, and overall accuracy of 95.6% using both tests.

Among the 19 patients with mitochondrial myopathy, 5 had abnormal jitter analysis.

When the researchers looked only at participants with abnormal jitter analysis but normal RS, two of these were patients with CMS, but another seven had congenital or mitochondrial myopathies. Using abnormal jitter alone therefore resulted in a sensitivity of 100% but a specificity of only 86%, for overall 86.5% accuracy.

“It’s important to notice that if you have an abnormal jitter, we have to look at the clinical symptoms of the patients,” Dr. Marques Caldas said in an interview. “Jitter abnormalities are not enough to distinguish between myasthenic disorder and a myopathic disorder.”

The research used no external funding, and Dr. Marques Caldas had no disclosures.
 

SOURCE: Caldas VM et al. AANEM 2019. Unnumbered Abstract: Sensitivity of neurophysiologic tests regarding the neuromuscular junction in patients with congenital myasthenic syndromes.

AUSTIN, TEX. – The use of both repetitive stimulation (RS) and jitter analysis are important for accurate diagnosis of congenital myasthenic syndrome (CMS) suggests newly presented research.

“In case RS is negative, SFEMG [single fiber electromyography] alone is not very specific and cannot distinguish CMS from mitochondrial myopathies, even in the presence of impulse blocking,” Vitor Marques Caldas, MD, a neurologist at the Syrian Libanes Hospital in Brasilia, Brazil, and a PhD student at the University of São Paulo, told attendees at the annual meeting of the American Association for Neuromuscular and Electrodiagnostic Medicine. “An isolated SFEMG test can lead to a misdiagnosis of myasthenia syndrome if not interpreted in the right clinical context.”

The researchers sought to understand the relative sensitivity and specificity of low-frequency RS versus jitter analysis using disposable concentric needle electrodes (CNE).

The study involved 69 patients, of whom 19 had mitochondrial myopathy, 18 had congenital myopathy, 18 had CMS, and 14 were asymptomatic controls. The control group all tested normal with both RS and jitter analysis.

The 18 participants with CMS, average age 24 years, received low-frequency RS in at least six different muscles: two distal muscles (abductor digiti minimi and tibialis anterior), two proximal muscles (deltoid and trapezius) and two facial muscles (nasalis and orbicularis oculi). They also underwent jitter analysis of their orbicularis oculi muscle under voluntary activation using CNE.

These patients had heterogeneous genetic profiles: 11 had the CHRNE gene mutation, 2 had the RAPSN gene mutation, 2 had the COLQ gene mutation, 2 had the DOK-7 gene mutation, and 1 had the COL13A1 mutation.

All but two patients with congenital CMS tested positive (88.9%) with RS: one female with CHRNE mutation and one male with RAPSN mutation. Using mean jitter, all but one patient tested positive (94.4%): a female with DOK-7 mutation who had tested abnormal on RS.

All patients with CMS tested positive with at least one of the two tests, but only 83.3% tested positive with both tests, resulting in a sensitivity of 83.3%, a specificity of 100%, and overall accuracy of 95.6% using both tests.

Among the 19 patients with mitochondrial myopathy, 5 had abnormal jitter analysis.

When the researchers looked only at participants with abnormal jitter analysis but normal RS, two of these were patients with CMS, but another seven had congenital or mitochondrial myopathies. Using abnormal jitter alone therefore resulted in a sensitivity of 100% but a specificity of only 86%, for overall 86.5% accuracy.

“It’s important to notice that if you have an abnormal jitter, we have to look at the clinical symptoms of the patients,” Dr. Marques Caldas said in an interview. “Jitter abnormalities are not enough to distinguish between myasthenic disorder and a myopathic disorder.”

The research used no external funding, and Dr. Marques Caldas had no disclosures.
 

SOURCE: Caldas VM et al. AANEM 2019. Unnumbered Abstract: Sensitivity of neurophysiologic tests regarding the neuromuscular junction in patients with congenital myasthenic syndromes.

AUSTIN, TEX. – The use of both repetitive stimulation (RS) and jitter analysis are important for accurate diagnosis of congenital myasthenic syndrome (CMS) suggests newly presented research.

“In case RS is negative, SFEMG [single fiber electromyography] alone is not very specific and cannot distinguish CMS from mitochondrial myopathies, even in the presence of impulse blocking,” Vitor Marques Caldas, MD, a neurologist at the Syrian Libanes Hospital in Brasilia, Brazil, and a PhD student at the University of São Paulo, told attendees at the annual meeting of the American Association for Neuromuscular and Electrodiagnostic Medicine. “An isolated SFEMG test can lead to a misdiagnosis of myasthenia syndrome if not interpreted in the right clinical context.”

The researchers sought to understand the relative sensitivity and specificity of low-frequency RS versus jitter analysis using disposable concentric needle electrodes (CNE).

The study involved 69 patients, of whom 19 had mitochondrial myopathy, 18 had congenital myopathy, 18 had CMS, and 14 were asymptomatic controls. The control group all tested normal with both RS and jitter analysis.

The 18 participants with CMS, average age 24 years, received low-frequency RS in at least six different muscles: two distal muscles (abductor digiti minimi and tibialis anterior), two proximal muscles (deltoid and trapezius) and two facial muscles (nasalis and orbicularis oculi). They also underwent jitter analysis of their orbicularis oculi muscle under voluntary activation using CNE.

These patients had heterogeneous genetic profiles: 11 had the CHRNE gene mutation, 2 had the RAPSN gene mutation, 2 had the COLQ gene mutation, 2 had the DOK-7 gene mutation, and 1 had the COL13A1 mutation.

All but two patients with congenital CMS tested positive (88.9%) with RS: one female with CHRNE mutation and one male with RAPSN mutation. Using mean jitter, all but one patient tested positive (94.4%): a female with DOK-7 mutation who had tested abnormal on RS.

All patients with CMS tested positive with at least one of the two tests, but only 83.3% tested positive with both tests, resulting in a sensitivity of 83.3%, a specificity of 100%, and overall accuracy of 95.6% using both tests.

Among the 19 patients with mitochondrial myopathy, 5 had abnormal jitter analysis.

When the researchers looked only at participants with abnormal jitter analysis but normal RS, two of these were patients with CMS, but another seven had congenital or mitochondrial myopathies. Using abnormal jitter alone therefore resulted in a sensitivity of 100% but a specificity of only 86%, for overall 86.5% accuracy.

“It’s important to notice that if you have an abnormal jitter, we have to look at the clinical symptoms of the patients,” Dr. Marques Caldas said in an interview. “Jitter abnormalities are not enough to distinguish between myasthenic disorder and a myopathic disorder.”

The research used no external funding, and Dr. Marques Caldas had no disclosures.
 

SOURCE: Caldas VM et al. AANEM 2019. Unnumbered Abstract: Sensitivity of neurophysiologic tests regarding the neuromuscular junction in patients with congenital myasthenic syndromes.

Transgender adolescents are more likely to report all types of lifetime suicidality risk than are their cisgender peers, and transgender youth as well as nonbinary adolescents assigned female at birth are at markedly high risk for suicidal ideation and attempt, new research suggests.

The study, which included more than 2,000 adolescents and was published in the October 14 issue of Pediatrics, provides new insights into suicide risk in gender identity subgroups, according to the investigators.

“Limited measures of gender identity may have led to inaccurate estimates of suicidality among transgender females in previous studies,” wrote Brian C. Thoma, PhD, and his colleagues at the University of Pittsburgh. The researchers noted that transgender females and nonbinary adolescents assigned male at birth are frequently combined in studies.

“However, our results indicate transgender females have higher risk for suicidal ideation and attempt compared with cisgender adolescents, whereas nonbinary adolescents assigned male at birth do not,” they wrote. “It is possible that estimates of suicidality that aggregate all transgender adolescents assigned male at birth into one group underestimate rates of suicidality among transgender females.”

The study, which analyzed results from a cross-sectional online survey from July to October 2018, was comprised of 2,020 adolescents, including 1,134 transgender adolescents.

The researchers divided respondents into seven categories: Cisgender males, cisgender females, transgender males, transgender females, nonbinary adolescents assigned female at birth, nonbinary adolescents assigned male at birth, and questioning gender identity. They then assessed non-suicidal self-injury (NSSI) and lifetime suicidality.

Compared to cisgender youth, transgender adolescents overall were more likely to report all outcomes: passive death wish (odds ratio [OR]=2.60), suicidal ideation (OR=2.20), suicide plan (OR=1.82), suicide attempt (OR=1.65), attempt requiring medical care (OR=2.01), and NSSI (OR=2.88).

Using cisgender males as reference after adjustment for all demographics, “cisgender females, transgender males, and nonbinary adolescents assigned female at birth had higher odds of each suicidality outcome” (OR= 1.49-5.85; OR=2.72-12.12; OR=1.84-8.59, respectively), the authors reported. “Transgender females had higher odds of each outcome [OR=2.73-6.30] except for suicide attempt requiring medical care. Nonbinary adolescents assigned male at birth had higher odds of suicide attempt requiring medical care [OR=10.13] and NSSI [OR=3.79]. Adolescents questioning their gender identity had higher odds of all outcomes [OR=3.23-7.59] except for suicide attempt.”

When compared to cisgender females as reference, however, only transgender males and transgender females had higher odds of suicidal ideation and attempts.

The overall findings were unsurprising since the higher rates of suicidality among transgender youth have already been documented, but the classification of participants was interesting, Gerald Montano, DO, an assistant professor of pediatrics at the University of Pittsburgh School of Medicine, said in an interview. Dr Montano was not involved in the study.

“It’s always been a challenge because, in the past, they always lumped transgender youth along with lesbian, gay, and bisexual youth,” Dr Montano said. This study is one of the few to go into more detail in considering participants’ gender identity, which was wise given that suicidal risk may differ accordingly.

The biggest take-home message of this study is the importance of screening for suicidality after informing adolescent patients of the limits of confidentiality, Dr Montano said.

“I think it’s very important for the physician to be aware of the reasons for those thoughts of suicide,” he continued. “A lot of it has to do with their gender identity and from discrimination and stigma from the general population.”

The research was funded by the University of Pittsburgh Central Research Development Fund and the National Institutes of Health. The authors reported no conflicts of interest.

SOURCE: Thoma BC et al, Pediatrics, October 14, 2019. DOI: 10.1542/peds.2019-1183

Transgender adolescents are more likely to report all types of lifetime suicidality risk than are their cisgender peers, and transgender youth as well as nonbinary adolescents assigned female at birth are at markedly high risk for suicidal ideation and attempt, new research suggests.

The study, which included more than 2,000 adolescents and was published in the October 14 issue of Pediatrics, provides new insights into suicide risk in gender identity subgroups, according to the investigators.

“Limited measures of gender identity may have led to inaccurate estimates of suicidality among transgender females in previous studies,” wrote Brian C. Thoma, PhD, and his colleagues at the University of Pittsburgh. The researchers noted that transgender females and nonbinary adolescents assigned male at birth are frequently combined in studies.

“However, our results indicate transgender females have higher risk for suicidal ideation and attempt compared with cisgender adolescents, whereas nonbinary adolescents assigned male at birth do not,” they wrote. “It is possible that estimates of suicidality that aggregate all transgender adolescents assigned male at birth into one group underestimate rates of suicidality among transgender females.”

The study, which analyzed results from a cross-sectional online survey from July to October 2018, was comprised of 2,020 adolescents, including 1,134 transgender adolescents.

The researchers divided respondents into seven categories: Cisgender males, cisgender females, transgender males, transgender females, nonbinary adolescents assigned female at birth, nonbinary adolescents assigned male at birth, and questioning gender identity. They then assessed non-suicidal self-injury (NSSI) and lifetime suicidality.

Compared to cisgender youth, transgender adolescents overall were more likely to report all outcomes: passive death wish (odds ratio [OR]=2.60), suicidal ideation (OR=2.20), suicide plan (OR=1.82), suicide attempt (OR=1.65), attempt requiring medical care (OR=2.01), and NSSI (OR=2.88).

Using cisgender males as reference after adjustment for all demographics, “cisgender females, transgender males, and nonbinary adolescents assigned female at birth had higher odds of each suicidality outcome” (OR= 1.49-5.85; OR=2.72-12.12; OR=1.84-8.59, respectively), the authors reported. “Transgender females had higher odds of each outcome [OR=2.73-6.30] except for suicide attempt requiring medical care. Nonbinary adolescents assigned male at birth had higher odds of suicide attempt requiring medical care [OR=10.13] and NSSI [OR=3.79]. Adolescents questioning their gender identity had higher odds of all outcomes [OR=3.23-7.59] except for suicide attempt.”

When compared to cisgender females as reference, however, only transgender males and transgender females had higher odds of suicidal ideation and attempts.

The overall findings were unsurprising since the higher rates of suicidality among transgender youth have already been documented, but the classification of participants was interesting, Gerald Montano, DO, an assistant professor of pediatrics at the University of Pittsburgh School of Medicine, said in an interview. Dr Montano was not involved in the study.

“It’s always been a challenge because, in the past, they always lumped transgender youth along with lesbian, gay, and bisexual youth,” Dr Montano said. This study is one of the few to go into more detail in considering participants’ gender identity, which was wise given that suicidal risk may differ accordingly.

The biggest take-home message of this study is the importance of screening for suicidality after informing adolescent patients of the limits of confidentiality, Dr Montano said.

“I think it’s very important for the physician to be aware of the reasons for those thoughts of suicide,” he continued. “A lot of it has to do with their gender identity and from discrimination and stigma from the general population.”

The research was funded by the University of Pittsburgh Central Research Development Fund and the National Institutes of Health. The authors reported no conflicts of interest.

SOURCE: Thoma BC et al, Pediatrics, October 14, 2019. DOI: 10.1542/peds.2019-1183

Transgender adolescents are more likely to report all types of lifetime suicidality risk than are their cisgender peers, and transgender youth as well as nonbinary adolescents assigned female at birth are at markedly high risk for suicidal ideation and attempt, new research suggests.

The study, which included more than 2,000 adolescents and was published in the October 14 issue of Pediatrics, provides new insights into suicide risk in gender identity subgroups, according to the investigators.

“Limited measures of gender identity may have led to inaccurate estimates of suicidality among transgender females in previous studies,” wrote Brian C. Thoma, PhD, and his colleagues at the University of Pittsburgh. The researchers noted that transgender females and nonbinary adolescents assigned male at birth are frequently combined in studies.

“However, our results indicate transgender females have higher risk for suicidal ideation and attempt compared with cisgender adolescents, whereas nonbinary adolescents assigned male at birth do not,” they wrote. “It is possible that estimates of suicidality that aggregate all transgender adolescents assigned male at birth into one group underestimate rates of suicidality among transgender females.”

The study, which analyzed results from a cross-sectional online survey from July to October 2018, was comprised of 2,020 adolescents, including 1,134 transgender adolescents.

The researchers divided respondents into seven categories: Cisgender males, cisgender females, transgender males, transgender females, nonbinary adolescents assigned female at birth, nonbinary adolescents assigned male at birth, and questioning gender identity. They then assessed non-suicidal self-injury (NSSI) and lifetime suicidality.

Compared to cisgender youth, transgender adolescents overall were more likely to report all outcomes: passive death wish (odds ratio [OR]=2.60), suicidal ideation (OR=2.20), suicide plan (OR=1.82), suicide attempt (OR=1.65), attempt requiring medical care (OR=2.01), and NSSI (OR=2.88).

Using cisgender males as reference after adjustment for all demographics, “cisgender females, transgender males, and nonbinary adolescents assigned female at birth had higher odds of each suicidality outcome” (OR= 1.49-5.85; OR=2.72-12.12; OR=1.84-8.59, respectively), the authors reported. “Transgender females had higher odds of each outcome [OR=2.73-6.30] except for suicide attempt requiring medical care. Nonbinary adolescents assigned male at birth had higher odds of suicide attempt requiring medical care [OR=10.13] and NSSI [OR=3.79]. Adolescents questioning their gender identity had higher odds of all outcomes [OR=3.23-7.59] except for suicide attempt.”

When compared to cisgender females as reference, however, only transgender males and transgender females had higher odds of suicidal ideation and attempts.

The overall findings were unsurprising since the higher rates of suicidality among transgender youth have already been documented, but the classification of participants was interesting, Gerald Montano, DO, an assistant professor of pediatrics at the University of Pittsburgh School of Medicine, said in an interview. Dr Montano was not involved in the study.

“It’s always been a challenge because, in the past, they always lumped transgender youth along with lesbian, gay, and bisexual youth,” Dr Montano said. This study is one of the few to go into more detail in considering participants’ gender identity, which was wise given that suicidal risk may differ accordingly.

The biggest take-home message of this study is the importance of screening for suicidality after informing adolescent patients of the limits of confidentiality, Dr Montano said.

“I think it’s very important for the physician to be aware of the reasons for those thoughts of suicide,” he continued. “A lot of it has to do with their gender identity and from discrimination and stigma from the general population.”

The research was funded by the University of Pittsburgh Central Research Development Fund and the National Institutes of Health. The authors reported no conflicts of interest.

SOURCE: Thoma BC et al, Pediatrics, October 14, 2019. DOI: 10.1542/peds.2019-1183

A little over half of pregnant women get the Tdap vaccine during pregnancy or the influenza vaccine before or during pregnancy, but only 35% get both, according to a Morbidity and Mortality Weekly Report published by the Centers for Disease Control and Prevention.

AvailableLight/istockphoto.com

The CDC recommends that all pregnant women receive the Tdap vaccine, preferably between 27 and 36 weeks’ gestation. The flu vaccine is recommended for all women at any point in pregnancy if the pregnancy falls within flu season. Women do not need a second flu shot if they received the vaccine before pregnancy in the same influenza season. Both vaccines provide protection to infants after birth.

“Clinicians caring for women who are pregnant have a huge role in helping women understand risks and benefits and the value of vaccines,” Anne Schuchat, MD, principal deputy director of the CDC, Atlanta, said in a telebriefing about the new report. “A lot of women are worried about taking any extra medicine or getting shots during pregnancy, and clinicians can let them know about the large data available showing the safety of the vaccine as well as the effectiveness. We also think it’s important to let people know about the risk of not vaccinating.”

Pregnant women are at higher risk for influenza complications and represent a disproportionate number of flu-related hospitalizations. From the 2010-2011 to 2017-2018 influenza seasons, 24%-34% of influenza hospitalizations each season were pregnant women aged 15-44, yet only 9% of women in this age group are pregnant at any point each year, according to the report.

Similarly, infants under 6 months have the greatest risk of hospitalization from influenza, and half of pertussis hospitalizations and 69% of pertussis deaths occur in infants under 2 months old. But a fetus receives protective maternal antibodies from flu and pertussis vaccines about 2 weeks after the mother is vaccinated.

Influenza hospitalization is 40% lower among pregnant women vaccinated against flu and 72% lower in infants under 6 months who received maternal influenza antibodies during gestation. Similarly, Tdap vaccination during the third trimester of pregnancy reduces pertussis infection risk by 78% and pertussis hospitalization by 91% in infants under 2 months.

“Infant protection can motivate pregnant women to receive recommended vaccines, and intention to vaccinate is higher among women who perceive more serious consequences of influenza or pertussis disease for their own or their infant’s health,” Megan C. Lindley, MPH, of the CDC’s Immunization Services Division, and colleagues wrote in the MMWR report.

In March-April 2019, Ms. Lindley and associates conducted an Internet survey about flu and Tdap immunizations among women aged 18-49 who had been pregnant at any point since August 1, 2018. A total of 2,626 women completed the survey of 2,762 invitations (95% response rate).

Among 817 women who knew their Tdap status during pregnancy, 55% received the Tdap vaccine. Among 2,097 women who reported a pregnancy between October 2018 and January 2019, 54% received the flu vaccine before or during pregnancy.

But many women received one vaccine without the other: 65% of women surveyed had not received both vaccines during pregnancy. Higher immunization rates occurred among women whose clinicians recommended the vaccines: 66% received a flu shot and 71% received Tdap.

“We’re learning a lot about improved communication between clinicians and patients. One thing we suggest is to begin the conversations early.” Dr Schuchat said. “If you begin talking early in the pregnancy about the things you’ll be looking forward to and provide information, by the time it is flu season or it is that third trimester, they’re prepared to make a good choice.”

Most women surveyed (75%) said their providers did offer a flu or Tdap vaccine in the office or a referral for one. Yet more than 30% of these women did not get the recommended vaccine.

The most common reason for not getting the Tdap during pregnancy, cited by 38% of women who didn’t receive it, was not knowing about the recommendation. Those who did not receive flu vaccination, however, cited concerns about effectiveness (18%) or safety for the baby (16%). A similar proportion of women cited safety concerns for not getting the Tdap (17%).

Sharing information early and engaging respectfully with patients are key to successful provider recommendations, Dr Schuchat said.

“It’s really important for clinicians to begin by listening to women, asking, ‘Can I answer your questions? What are the concerns that you have?’ ” she said. “We find that, when a clinician validates a patient’s concerns and really shows that they’re listening, they can build trust and respect.”

Providers’ sharing their personal experience can help as well, Dr Schuchat added. Clinicians can let patients know if they themselves, or their partner, received the vaccines during pregnancy.

Rates for turning down vaccines were higher for black women: 47% received the flu vaccine after a recommendation, compared with 69% of white women. Among those receiving a Tdap recommendation, 53% of black women accepted it, compared with 77% of white women and 66% of Latina women. The authors noted a past study showing black adults had a higher distrust of flu vaccination, their doctor, and CDC information than white adults.

“Differential effects of provider vaccination offers or referrals might also be explained by less patient-centered provider communication with black patients,” Ms. Lindley and associates wrote.

SOURCE: Lindley MC. MMWR Morb Mortal Wkly Rep. 2019 Oct 8. doi: 10.15585/mmwr.mm6840e1.

A little over half of pregnant women get the Tdap vaccine during pregnancy or the influenza vaccine before or during pregnancy, but only 35% get both, according to a Morbidity and Mortality Weekly Report published by the Centers for Disease Control and Prevention.

AvailableLight/istockphoto.com

The CDC recommends that all pregnant women receive the Tdap vaccine, preferably between 27 and 36 weeks’ gestation. The flu vaccine is recommended for all women at any point in pregnancy if the pregnancy falls within flu season. Women do not need a second flu shot if they received the vaccine before pregnancy in the same influenza season. Both vaccines provide protection to infants after birth.

“Clinicians caring for women who are pregnant have a huge role in helping women understand risks and benefits and the value of vaccines,” Anne Schuchat, MD, principal deputy director of the CDC, Atlanta, said in a telebriefing about the new report. “A lot of women are worried about taking any extra medicine or getting shots during pregnancy, and clinicians can let them know about the large data available showing the safety of the vaccine as well as the effectiveness. We also think it’s important to let people know about the risk of not vaccinating.”

Pregnant women are at higher risk for influenza complications and represent a disproportionate number of flu-related hospitalizations. From the 2010-2011 to 2017-2018 influenza seasons, 24%-34% of influenza hospitalizations each season were pregnant women aged 15-44, yet only 9% of women in this age group are pregnant at any point each year, according to the report.

Similarly, infants under 6 months have the greatest risk of hospitalization from influenza, and half of pertussis hospitalizations and 69% of pertussis deaths occur in infants under 2 months old. But a fetus receives protective maternal antibodies from flu and pertussis vaccines about 2 weeks after the mother is vaccinated.

Influenza hospitalization is 40% lower among pregnant women vaccinated against flu and 72% lower in infants under 6 months who received maternal influenza antibodies during gestation. Similarly, Tdap vaccination during the third trimester of pregnancy reduces pertussis infection risk by 78% and pertussis hospitalization by 91% in infants under 2 months.

“Infant protection can motivate pregnant women to receive recommended vaccines, and intention to vaccinate is higher among women who perceive more serious consequences of influenza or pertussis disease for their own or their infant’s health,” Megan C. Lindley, MPH, of the CDC’s Immunization Services Division, and colleagues wrote in the MMWR report.

In March-April 2019, Ms. Lindley and associates conducted an Internet survey about flu and Tdap immunizations among women aged 18-49 who had been pregnant at any point since August 1, 2018. A total of 2,626 women completed the survey of 2,762 invitations (95% response rate).

Among 817 women who knew their Tdap status during pregnancy, 55% received the Tdap vaccine. Among 2,097 women who reported a pregnancy between October 2018 and January 2019, 54% received the flu vaccine before or during pregnancy.

But many women received one vaccine without the other: 65% of women surveyed had not received both vaccines during pregnancy. Higher immunization rates occurred among women whose clinicians recommended the vaccines: 66% received a flu shot and 71% received Tdap.

“We’re learning a lot about improved communication between clinicians and patients. One thing we suggest is to begin the conversations early.” Dr Schuchat said. “If you begin talking early in the pregnancy about the things you’ll be looking forward to and provide information, by the time it is flu season or it is that third trimester, they’re prepared to make a good choice.”

Most women surveyed (75%) said their providers did offer a flu or Tdap vaccine in the office or a referral for one. Yet more than 30% of these women did not get the recommended vaccine.

The most common reason for not getting the Tdap during pregnancy, cited by 38% of women who didn’t receive it, was not knowing about the recommendation. Those who did not receive flu vaccination, however, cited concerns about effectiveness (18%) or safety for the baby (16%). A similar proportion of women cited safety concerns for not getting the Tdap (17%).

Sharing information early and engaging respectfully with patients are key to successful provider recommendations, Dr Schuchat said.

“It’s really important for clinicians to begin by listening to women, asking, ‘Can I answer your questions? What are the concerns that you have?’ ” she said. “We find that, when a clinician validates a patient’s concerns and really shows that they’re listening, they can build trust and respect.”

Providers’ sharing their personal experience can help as well, Dr Schuchat added. Clinicians can let patients know if they themselves, or their partner, received the vaccines during pregnancy.

Rates for turning down vaccines were higher for black women: 47% received the flu vaccine after a recommendation, compared with 69% of white women. Among those receiving a Tdap recommendation, 53% of black women accepted it, compared with 77% of white women and 66% of Latina women. The authors noted a past study showing black adults had a higher distrust of flu vaccination, their doctor, and CDC information than white adults.

“Differential effects of provider vaccination offers or referrals might also be explained by less patient-centered provider communication with black patients,” Ms. Lindley and associates wrote.

SOURCE: Lindley MC. MMWR Morb Mortal Wkly Rep. 2019 Oct 8. doi: 10.15585/mmwr.mm6840e1.

A little over half of pregnant women get the Tdap vaccine during pregnancy or the influenza vaccine before or during pregnancy, but only 35% get both, according to a Morbidity and Mortality Weekly Report published by the Centers for Disease Control and Prevention.

AvailableLight/istockphoto.com

The CDC recommends that all pregnant women receive the Tdap vaccine, preferably between 27 and 36 weeks’ gestation. The flu vaccine is recommended for all women at any point in pregnancy if the pregnancy falls within flu season. Women do not need a second flu shot if they received the vaccine before pregnancy in the same influenza season. Both vaccines provide protection to infants after birth.

“Clinicians caring for women who are pregnant have a huge role in helping women understand risks and benefits and the value of vaccines,” Anne Schuchat, MD, principal deputy director of the CDC, Atlanta, said in a telebriefing about the new report. “A lot of women are worried about taking any extra medicine or getting shots during pregnancy, and clinicians can let them know about the large data available showing the safety of the vaccine as well as the effectiveness. We also think it’s important to let people know about the risk of not vaccinating.”

Pregnant women are at higher risk for influenza complications and represent a disproportionate number of flu-related hospitalizations. From the 2010-2011 to 2017-2018 influenza seasons, 24%-34% of influenza hospitalizations each season were pregnant women aged 15-44, yet only 9% of women in this age group are pregnant at any point each year, according to the report.

Similarly, infants under 6 months have the greatest risk of hospitalization from influenza, and half of pertussis hospitalizations and 69% of pertussis deaths occur in infants under 2 months old. But a fetus receives protective maternal antibodies from flu and pertussis vaccines about 2 weeks after the mother is vaccinated.

Influenza hospitalization is 40% lower among pregnant women vaccinated against flu and 72% lower in infants under 6 months who received maternal influenza antibodies during gestation. Similarly, Tdap vaccination during the third trimester of pregnancy reduces pertussis infection risk by 78% and pertussis hospitalization by 91% in infants under 2 months.

“Infant protection can motivate pregnant women to receive recommended vaccines, and intention to vaccinate is higher among women who perceive more serious consequences of influenza or pertussis disease for their own or their infant’s health,” Megan C. Lindley, MPH, of the CDC’s Immunization Services Division, and colleagues wrote in the MMWR report.

In March-April 2019, Ms. Lindley and associates conducted an Internet survey about flu and Tdap immunizations among women aged 18-49 who had been pregnant at any point since August 1, 2018. A total of 2,626 women completed the survey of 2,762 invitations (95% response rate).

Among 817 women who knew their Tdap status during pregnancy, 55% received the Tdap vaccine. Among 2,097 women who reported a pregnancy between October 2018 and January 2019, 54% received the flu vaccine before or during pregnancy.

But many women received one vaccine without the other: 65% of women surveyed had not received both vaccines during pregnancy. Higher immunization rates occurred among women whose clinicians recommended the vaccines: 66% received a flu shot and 71% received Tdap.

“We’re learning a lot about improved communication between clinicians and patients. One thing we suggest is to begin the conversations early.” Dr Schuchat said. “If you begin talking early in the pregnancy about the things you’ll be looking forward to and provide information, by the time it is flu season or it is that third trimester, they’re prepared to make a good choice.”

Most women surveyed (75%) said their providers did offer a flu or Tdap vaccine in the office or a referral for one. Yet more than 30% of these women did not get the recommended vaccine.

The most common reason for not getting the Tdap during pregnancy, cited by 38% of women who didn’t receive it, was not knowing about the recommendation. Those who did not receive flu vaccination, however, cited concerns about effectiveness (18%) or safety for the baby (16%). A similar proportion of women cited safety concerns for not getting the Tdap (17%).

Sharing information early and engaging respectfully with patients are key to successful provider recommendations, Dr Schuchat said.

“It’s really important for clinicians to begin by listening to women, asking, ‘Can I answer your questions? What are the concerns that you have?’ ” she said. “We find that, when a clinician validates a patient’s concerns and really shows that they’re listening, they can build trust and respect.”

Providers’ sharing their personal experience can help as well, Dr Schuchat added. Clinicians can let patients know if they themselves, or their partner, received the vaccines during pregnancy.

Rates for turning down vaccines were higher for black women: 47% received the flu vaccine after a recommendation, compared with 69% of white women. Among those receiving a Tdap recommendation, 53% of black women accepted it, compared with 77% of white women and 66% of Latina women. The authors noted a past study showing black adults had a higher distrust of flu vaccination, their doctor, and CDC information than white adults.

“Differential effects of provider vaccination offers or referrals might also be explained by less patient-centered provider communication with black patients,” Ms. Lindley and associates wrote.

SOURCE: Lindley MC. MMWR Morb Mortal Wkly Rep. 2019 Oct 8. doi: 10.15585/mmwr.mm6840e1.

Children born to mothers with high blood levels of lead have an increased risk of being overweight or obese, particularly if their mothers are also overweight, according to new research.

Creatas Images

Adequate maternal plasma levels of folate, however, mitigated this risk.

“When considered simultaneously, maternal lead exposure, rather than early childhood lead exposure, contributed to overweight/obesity risk in a dose-response fashion across multiple developmental stages (preschool age, school age and early adolescence) and amplified intergenerational overweight/obesity risk (additively with maternal overweight/obesity),” Guoying Wang, MD, PhD, of Johns Hopkins Bloomberg School of Public Health, Baltimore, and associates, reported in JAMA Network Open.

“These findings support the hypothesis that the obesity epidemic could be related to environmental chemical exposures in utero and raise the possibility that optimal maternal folate supplementation may help counteract the adverse effects of environmental lead exposure,” the authors wrote.

The prospective urban, low-income cohort study, which ran from 2002 to 2013, involved 1,442 mother-child pairs who joined the study when the children were born and attended follow-up visits at Boston Medical Center. The mean age of the mothers was 29 years, and the children were, on average, 8 years old at follow-up. Half the children were male; 67% of mothers were black, and 20% were Latina.

The researchers collected maternal blood samples within 24-72 hours after birth to measure red blood cell lead levels and plasma folate levels. Children’s whole-blood lead levels were measured during the first lead screening of their well child visits, at a median 10 months of age. Researchers tracked children’s body mass index Z-score and defined overweight/obesity as exceeding the 85th national percentile for their age and sex.

Detectable lead was present in all the mothers’ blood samples. The median maternal red blood cell lead level was 2.5 mcg/dL, although black mothers tended to have higher lead exposure than that of other racial groups. Median maternal plasma folate level was 32 nmol/L. Children’s blood lead levels were a median 1.4 mcg/dL, and their median BMI Z-score was 0.78.

Children whose mothers had red blood cell lead levels of 5.0 mcg/dL or greater (16%) had 65% greater odds of being overweight or obese compared with children whose mothers’ lead level was less than 2 mcg/dL, after adjustment for maternal education, race/ethnicity, smoking status, parity, diabetes, hypertensive disorder, preterm birth, fetal growth, and breastfeeding status (odds ratio [OR], 1.65; 95% confidence internal [CI], 1.18-2.32). Only 5.2% of children had whole-blood lead levels of 5 mcg/dL or greater.

“Mothers with the highest red blood cell lead levels were older and multiparous, were more likely to be black and nonsmokers, had lower plasma folate levels and were more likely to have prepregnancy overweight/obesity and diabetes,” the authors reported.

The dose-response association did not lose significance when the researchers adjusted for children’s blood lead levels, maternal age, cesarean delivery, term births only, and black race. Nor did it change in a subset of children when the researchers adjusted for children’s physical activity.

The strength of the association increased when mothers also had a BMI greater than the average/healthy range. Children were more than four times more likely to be overweight or obese if their mothers were overweight or obese and had lead levels greater than 5.0 mcg/dL, compared with nonoverweight mothers with levels below 2 mcg/dL (OR, 4.24; 95% CI, 2.64-6.82).

Among children whose mothers were overweight/obese and had high blood lead levels, however, high folate levels appeared protective against obesity. These children had a 41% lower risk of being overweight or obese, compared with others in their group, if their mothers had plasma folate levels of at least 20 nmol/L (OR, 0.59 CI, 0.36-0.95; P = .03).

According to an invited commentary, “approximately 140,000 new chemicals and pesticides have appeared since 1950,” with “universal human exposure to approximately 5,000 of those,” wrote Marco Sanchez-Guerra, PhD, of the National Institute of Perinatology in Mexico City, and coauthors Andres Cardenas, PhD, of the University of California, Berkeley, and Citlalli Osorio-Yáñez, PhD, of the National Autonomous University of Mexico in Mexico City. Yet fewer than half of those chemicals have been tested for safety or toxic effect, the editorialists wrote, and scientists know little of their potential reproductive harm.

Dr. Sanchez-Guerra, Dr. Cardenas, and Dr. Osorio-Yáñez agreed with the study authors that elevated lead exposures, especially from gasoline before lead was removed in the United States in 1975, may partly explain the current epidemic of obesity.

“Identifying preventable prenatal causes of obesity is a cornerstone in the fight against the obesity epidemic,” the editorialists said. While most recommendations center on changes to diet and physical activity, environmental factors during pregnancy could be involved in childhood obesity as well.

“The study by Wang et al. opens the door to new questions about whether adequate folate intake might modify the adverse effects of other chemical exposures,” they continued, noting other research suggesting a protective effect from folate against health effects of air pollution exposure. “These efforts could yield substantial public health benefits and represent novel tools in fighting the obesity epidemic,” they concluded.

The research was funded by the National Institutes of Health and the U.S. Department of Health and Human Services. Neither the study authors nor the editorialists had industry financial disclosures.

SOURCES: Wang G et al. JAMA Netw Open. 2019;2(10):e1912343. doi: 10.1001/jamanetworkopen.2019.12343; Sanchez-Guerra M et al. JAMA Netw Open. 2019;2(10):e1912334. doi: 10.1001/jamanetworkopen.2019.12334.

Children born to mothers with high blood levels of lead have an increased risk of being overweight or obese, particularly if their mothers are also overweight, according to new research.

Creatas Images

Adequate maternal plasma levels of folate, however, mitigated this risk.

“When considered simultaneously, maternal lead exposure, rather than early childhood lead exposure, contributed to overweight/obesity risk in a dose-response fashion across multiple developmental stages (preschool age, school age and early adolescence) and amplified intergenerational overweight/obesity risk (additively with maternal overweight/obesity),” Guoying Wang, MD, PhD, of Johns Hopkins Bloomberg School of Public Health, Baltimore, and associates, reported in JAMA Network Open.

“These findings support the hypothesis that the obesity epidemic could be related to environmental chemical exposures in utero and raise the possibility that optimal maternal folate supplementation may help counteract the adverse effects of environmental lead exposure,” the authors wrote.

The prospective urban, low-income cohort study, which ran from 2002 to 2013, involved 1,442 mother-child pairs who joined the study when the children were born and attended follow-up visits at Boston Medical Center. The mean age of the mothers was 29 years, and the children were, on average, 8 years old at follow-up. Half the children were male; 67% of mothers were black, and 20% were Latina.

The researchers collected maternal blood samples within 24-72 hours after birth to measure red blood cell lead levels and plasma folate levels. Children’s whole-blood lead levels were measured during the first lead screening of their well child visits, at a median 10 months of age. Researchers tracked children’s body mass index Z-score and defined overweight/obesity as exceeding the 85th national percentile for their age and sex.

Detectable lead was present in all the mothers’ blood samples. The median maternal red blood cell lead level was 2.5 mcg/dL, although black mothers tended to have higher lead exposure than that of other racial groups. Median maternal plasma folate level was 32 nmol/L. Children’s blood lead levels were a median 1.4 mcg/dL, and their median BMI Z-score was 0.78.

Children whose mothers had red blood cell lead levels of 5.0 mcg/dL or greater (16%) had 65% greater odds of being overweight or obese compared with children whose mothers’ lead level was less than 2 mcg/dL, after adjustment for maternal education, race/ethnicity, smoking status, parity, diabetes, hypertensive disorder, preterm birth, fetal growth, and breastfeeding status (odds ratio [OR], 1.65; 95% confidence internal [CI], 1.18-2.32). Only 5.2% of children had whole-blood lead levels of 5 mcg/dL or greater.

“Mothers with the highest red blood cell lead levels were older and multiparous, were more likely to be black and nonsmokers, had lower plasma folate levels and were more likely to have prepregnancy overweight/obesity and diabetes,” the authors reported.

The dose-response association did not lose significance when the researchers adjusted for children’s blood lead levels, maternal age, cesarean delivery, term births only, and black race. Nor did it change in a subset of children when the researchers adjusted for children’s physical activity.

The strength of the association increased when mothers also had a BMI greater than the average/healthy range. Children were more than four times more likely to be overweight or obese if their mothers were overweight or obese and had lead levels greater than 5.0 mcg/dL, compared with nonoverweight mothers with levels below 2 mcg/dL (OR, 4.24; 95% CI, 2.64-6.82).

Among children whose mothers were overweight/obese and had high blood lead levels, however, high folate levels appeared protective against obesity. These children had a 41% lower risk of being overweight or obese, compared with others in their group, if their mothers had plasma folate levels of at least 20 nmol/L (OR, 0.59 CI, 0.36-0.95; P = .03).

According to an invited commentary, “approximately 140,000 new chemicals and pesticides have appeared since 1950,” with “universal human exposure to approximately 5,000 of those,” wrote Marco Sanchez-Guerra, PhD, of the National Institute of Perinatology in Mexico City, and coauthors Andres Cardenas, PhD, of the University of California, Berkeley, and Citlalli Osorio-Yáñez, PhD, of the National Autonomous University of Mexico in Mexico City. Yet fewer than half of those chemicals have been tested for safety or toxic effect, the editorialists wrote, and scientists know little of their potential reproductive harm.

Dr. Sanchez-Guerra, Dr. Cardenas, and Dr. Osorio-Yáñez agreed with the study authors that elevated lead exposures, especially from gasoline before lead was removed in the United States in 1975, may partly explain the current epidemic of obesity.

“Identifying preventable prenatal causes of obesity is a cornerstone in the fight against the obesity epidemic,” the editorialists said. While most recommendations center on changes to diet and physical activity, environmental factors during pregnancy could be involved in childhood obesity as well.

“The study by Wang et al. opens the door to new questions about whether adequate folate intake might modify the adverse effects of other chemical exposures,” they continued, noting other research suggesting a protective effect from folate against health effects of air pollution exposure. “These efforts could yield substantial public health benefits and represent novel tools in fighting the obesity epidemic,” they concluded.

The research was funded by the National Institutes of Health and the U.S. Department of Health and Human Services. Neither the study authors nor the editorialists had industry financial disclosures.

SOURCES: Wang G et al. JAMA Netw Open. 2019;2(10):e1912343. doi: 10.1001/jamanetworkopen.2019.12343; Sanchez-Guerra M et al. JAMA Netw Open. 2019;2(10):e1912334. doi: 10.1001/jamanetworkopen.2019.12334.

Children born to mothers with high blood levels of lead have an increased risk of being overweight or obese, particularly if their mothers are also overweight, according to new research.

Creatas Images

Adequate maternal plasma levels of folate, however, mitigated this risk.

“When considered simultaneously, maternal lead exposure, rather than early childhood lead exposure, contributed to overweight/obesity risk in a dose-response fashion across multiple developmental stages (preschool age, school age and early adolescence) and amplified intergenerational overweight/obesity risk (additively with maternal overweight/obesity),” Guoying Wang, MD, PhD, of Johns Hopkins Bloomberg School of Public Health, Baltimore, and associates, reported in JAMA Network Open.

“These findings support the hypothesis that the obesity epidemic could be related to environmental chemical exposures in utero and raise the possibility that optimal maternal folate supplementation may help counteract the adverse effects of environmental lead exposure,” the authors wrote.

The prospective urban, low-income cohort study, which ran from 2002 to 2013, involved 1,442 mother-child pairs who joined the study when the children were born and attended follow-up visits at Boston Medical Center. The mean age of the mothers was 29 years, and the children were, on average, 8 years old at follow-up. Half the children were male; 67% of mothers were black, and 20% were Latina.

The researchers collected maternal blood samples within 24-72 hours after birth to measure red blood cell lead levels and plasma folate levels. Children’s whole-blood lead levels were measured during the first lead screening of their well child visits, at a median 10 months of age. Researchers tracked children’s body mass index Z-score and defined overweight/obesity as exceeding the 85th national percentile for their age and sex.

Detectable lead was present in all the mothers’ blood samples. The median maternal red blood cell lead level was 2.5 mcg/dL, although black mothers tended to have higher lead exposure than that of other racial groups. Median maternal plasma folate level was 32 nmol/L. Children’s blood lead levels were a median 1.4 mcg/dL, and their median BMI Z-score was 0.78.

Children whose mothers had red blood cell lead levels of 5.0 mcg/dL or greater (16%) had 65% greater odds of being overweight or obese compared with children whose mothers’ lead level was less than 2 mcg/dL, after adjustment for maternal education, race/ethnicity, smoking status, parity, diabetes, hypertensive disorder, preterm birth, fetal growth, and breastfeeding status (odds ratio [OR], 1.65; 95% confidence internal [CI], 1.18-2.32). Only 5.2% of children had whole-blood lead levels of 5 mcg/dL or greater.

“Mothers with the highest red blood cell lead levels were older and multiparous, were more likely to be black and nonsmokers, had lower plasma folate levels and were more likely to have prepregnancy overweight/obesity and diabetes,” the authors reported.

The dose-response association did not lose significance when the researchers adjusted for children’s blood lead levels, maternal age, cesarean delivery, term births only, and black race. Nor did it change in a subset of children when the researchers adjusted for children’s physical activity.

The strength of the association increased when mothers also had a BMI greater than the average/healthy range. Children were more than four times more likely to be overweight or obese if their mothers were overweight or obese and had lead levels greater than 5.0 mcg/dL, compared with nonoverweight mothers with levels below 2 mcg/dL (OR, 4.24; 95% CI, 2.64-6.82).

Among children whose mothers were overweight/obese and had high blood lead levels, however, high folate levels appeared protective against obesity. These children had a 41% lower risk of being overweight or obese, compared with others in their group, if their mothers had plasma folate levels of at least 20 nmol/L (OR, 0.59 CI, 0.36-0.95; P = .03).

According to an invited commentary, “approximately 140,000 new chemicals and pesticides have appeared since 1950,” with “universal human exposure to approximately 5,000 of those,” wrote Marco Sanchez-Guerra, PhD, of the National Institute of Perinatology in Mexico City, and coauthors Andres Cardenas, PhD, of the University of California, Berkeley, and Citlalli Osorio-Yáñez, PhD, of the National Autonomous University of Mexico in Mexico City. Yet fewer than half of those chemicals have been tested for safety or toxic effect, the editorialists wrote, and scientists know little of their potential reproductive harm.

Dr. Sanchez-Guerra, Dr. Cardenas, and Dr. Osorio-Yáñez agreed with the study authors that elevated lead exposures, especially from gasoline before lead was removed in the United States in 1975, may partly explain the current epidemic of obesity.

“Identifying preventable prenatal causes of obesity is a cornerstone in the fight against the obesity epidemic,” the editorialists said. While most recommendations center on changes to diet and physical activity, environmental factors during pregnancy could be involved in childhood obesity as well.

“The study by Wang et al. opens the door to new questions about whether adequate folate intake might modify the adverse effects of other chemical exposures,” they continued, noting other research suggesting a protective effect from folate against health effects of air pollution exposure. “These efforts could yield substantial public health benefits and represent novel tools in fighting the obesity epidemic,” they concluded.

The research was funded by the National Institutes of Health and the U.S. Department of Health and Human Services. Neither the study authors nor the editorialists had industry financial disclosures.

SOURCES: Wang G et al. JAMA Netw Open. 2019;2(10):e1912343. doi: 10.1001/jamanetworkopen.2019.12343; Sanchez-Guerra M et al. JAMA Netw Open. 2019;2(10):e1912334. doi: 10.1001/jamanetworkopen.2019.12334.

Regardless of where people live in the world, air pollution is linked to increased rates of cardiovascular disease, respiratory problems, and all-cause mortality, according to one of the largest studies ever to assess the effects of inhalable particulate matter (PM), published Aug. 21 in the New England Journal of Medicine.

“These data reinforce the evidence of a link between mortality and PM concentration established in regional and local studies,” reported Cong Liu of the Huazhong University of Science and Technology in Wuhan, China, and an international team of researchers.

“Many people are experiencing worse allergy and asthma symptoms in the setting of increased heat and worse air quality,” Caren G. Solomon, MD, of Harvard Medical School, Boston, said in an interview. “It is often not appreciated that these are complications of climate change.”

Other such complications include heat-related illnesses and severe weather events, as well as the less visible manifestations, such as shifts in the epidemiology of vector-borne infectious disease, Dr. Solomon and colleagues wrote in an editorial accompanying Mr. Liu’s study.

“The stark reality is that high levels of greenhouse gases caused by the combustion of fossil fuels – and the resulting rise in temperature and sea levels and intensification of extreme weather – are having profound consequences for human health and health systems,” Dr. Solomon and colleagues wrote (N Engl J Med. 2019;381:773-4.).

In the new air pollution study, Mr. Liu and colleagues analyzed 59.6 million deaths from 652 cities across 24 countries, “thereby greatly increasing the generalizability of the association and decreasing the likelihood that the reported associations are subject to confounding bias,” wrote John R. Balmes, MD, of the University of California, San Francisco, and the University of California, Berkeley, in an editorial about the study (N Engl J Med. 2019;381:774-6).

The researchers compared air pollution data from 1986-2015 from the Multi-City Multi-Country (MCC) Collaborative Research Network to mortality data reported from individual countries. They assessed PM with an aerodynamic diameter of 10 mcg or less (PM10; n = 598 cities) and PM with an aerodynamic diameter of 2.5 mcg or less (PM_2.5; n=499 cities).

Mr. Liu’s team used a time-series analysis – a standard upon which the majority of air pollution research relies. These studies “include daily measures of health events (e.g., daily mortality), regressed against concentrations of PM (e.g., 24-hour average PM_2.5) and weather variables (e.g., daily average temperature) for a given geographic area,” Dr. Balmes wrote. “The population serves as its own control, and confounding by population characteristics is negligible because these are stable over short time frames.”

The researchers found a 0.44% increase in daily all-cause mortality for each 10-mcg/m³ increase in the 2-day moving average (current and previous day) of PM₁₀. The same increase was linked to a 0.36% increase in daily cardiovascular mortality and a 0.47% increase in daily respiratory mortality. Similarly, a 10-mcg/m³ increase in the PM_2.5 average was linked to 0.68% increase in all-cause mortality, a 0.55% increase in cardiovascular mortality, and 0.74% increase in respiratory mortality.

Locations with higher annual mean temperatures showed stronger associations, and all these associations remained statistically significant after the researchers adjusted for gaseous pollutants.

Although the majority of countries and cities included in the study came from the northern hemisphere, the researchers noted that the magnitude of effect they found, particularly for PM₁₀ concentrations, matched up with that seen in previous studies of multiple cities or countries.

Still, they found “significant evidence of spatial heterogeneity in the associations between PM concentration and daily mortality across countries and regions.” Among the factors that could contribute to those variations are “different PM components, long-term air pollution levels, population susceptibility, and different lengths of study periods,” they speculated.

What makes this study remarkable – despite decades of previous similar studies – is its size and the implications of a curvilinear shape in its concentration-response relation, according to Dr. Balmes.

“The current study of PM data from many regions around the world provides the strongest evidence to date that higher levels of exposure may be associated with a lower per-unit risk,” Dr. Balmes wrote. “Regions that have lower exposures had a higher per-unit risk. This finding has profound policy implications, especially given that no threshold of effect was found. Even high-income countries, such as the United States, with relatively good air quality could still see public health benefits from further reduction of ambient PM concentrations.”

The policy implications, however, extend well beyond clean air regulations because the findings represent just one aspect of climate change’s negative effects on health, which are “frighteningly broad,” Dr. Solomon and colleagues wrote.

“As climate change continues to alter disease patterns and disrupt health systems, its effects on human health will become harder to ignore,” they wrote. “We, as a medical community, have the responsibility and the opportunity to mobilize the urgent, large-scale climate action required to protect health – as well as the ingenuity to develop novel and bold interventions to avert the most catastrophic outcomes.”

The new research and associated commentary marked the introduction of a new NEJM topic on climate change effects on health and health systems.
 

SOURCE: Liu C et al. N Engl J Med. 2019;381:705-15.

This article was updated 8/22/19.

Regardless of where people live in the world, air pollution is linked to increased rates of cardiovascular disease, respiratory problems, and all-cause mortality, according to one of the largest studies ever to assess the effects of inhalable particulate matter (PM), published Aug. 21 in the New England Journal of Medicine.

“These data reinforce the evidence of a link between mortality and PM concentration established in regional and local studies,” reported Cong Liu of the Huazhong University of Science and Technology in Wuhan, China, and an international team of researchers.

“Many people are experiencing worse allergy and asthma symptoms in the setting of increased heat and worse air quality,” Caren G. Solomon, MD, of Harvard Medical School, Boston, said in an interview. “It is often not appreciated that these are complications of climate change.”

Other such complications include heat-related illnesses and severe weather events, as well as the less visible manifestations, such as shifts in the epidemiology of vector-borne infectious disease, Dr. Solomon and colleagues wrote in an editorial accompanying Mr. Liu’s study.

“The stark reality is that high levels of greenhouse gases caused by the combustion of fossil fuels – and the resulting rise in temperature and sea levels and intensification of extreme weather – are having profound consequences for human health and health systems,” Dr. Solomon and colleagues wrote (N Engl J Med. 2019;381:773-4.).

In the new air pollution study, Mr. Liu and colleagues analyzed 59.6 million deaths from 652 cities across 24 countries, “thereby greatly increasing the generalizability of the association and decreasing the likelihood that the reported associations are subject to confounding bias,” wrote John R. Balmes, MD, of the University of California, San Francisco, and the University of California, Berkeley, in an editorial about the study (N Engl J Med. 2019;381:774-6).

The researchers compared air pollution data from 1986-2015 from the Multi-City Multi-Country (MCC) Collaborative Research Network to mortality data reported from individual countries. They assessed PM with an aerodynamic diameter of 10 mcg or less (PM10; n = 598 cities) and PM with an aerodynamic diameter of 2.5 mcg or less (PM_2.5; n=499 cities).

Mr. Liu’s team used a time-series analysis – a standard upon which the majority of air pollution research relies. These studies “include daily measures of health events (e.g., daily mortality), regressed against concentrations of PM (e.g., 24-hour average PM_2.5) and weather variables (e.g., daily average temperature) for a given geographic area,” Dr. Balmes wrote. “The population serves as its own control, and confounding by population characteristics is negligible because these are stable over short time frames.”

The researchers found a 0.44% increase in daily all-cause mortality for each 10-mcg/m³ increase in the 2-day moving average (current and previous day) of PM₁₀. The same increase was linked to a 0.36% increase in daily cardiovascular mortality and a 0.47% increase in daily respiratory mortality. Similarly, a 10-mcg/m³ increase in the PM_2.5 average was linked to 0.68% increase in all-cause mortality, a 0.55% increase in cardiovascular mortality, and 0.74% increase in respiratory mortality.

Locations with higher annual mean temperatures showed stronger associations, and all these associations remained statistically significant after the researchers adjusted for gaseous pollutants.

Although the majority of countries and cities included in the study came from the northern hemisphere, the researchers noted that the magnitude of effect they found, particularly for PM₁₀ concentrations, matched up with that seen in previous studies of multiple cities or countries.

Still, they found “significant evidence of spatial heterogeneity in the associations between PM concentration and daily mortality across countries and regions.” Among the factors that could contribute to those variations are “different PM components, long-term air pollution levels, population susceptibility, and different lengths of study periods,” they speculated.

What makes this study remarkable – despite decades of previous similar studies – is its size and the implications of a curvilinear shape in its concentration-response relation, according to Dr. Balmes.

“The current study of PM data from many regions around the world provides the strongest evidence to date that higher levels of exposure may be associated with a lower per-unit risk,” Dr. Balmes wrote. “Regions that have lower exposures had a higher per-unit risk. This finding has profound policy implications, especially given that no threshold of effect was found. Even high-income countries, such as the United States, with relatively good air quality could still see public health benefits from further reduction of ambient PM concentrations.”

The policy implications, however, extend well beyond clean air regulations because the findings represent just one aspect of climate change’s negative effects on health, which are “frighteningly broad,” Dr. Solomon and colleagues wrote.

“As climate change continues to alter disease patterns and disrupt health systems, its effects on human health will become harder to ignore,” they wrote. “We, as a medical community, have the responsibility and the opportunity to mobilize the urgent, large-scale climate action required to protect health – as well as the ingenuity to develop novel and bold interventions to avert the most catastrophic outcomes.”

The new research and associated commentary marked the introduction of a new NEJM topic on climate change effects on health and health systems.
 

SOURCE: Liu C et al. N Engl J Med. 2019;381:705-15.

This article was updated 8/22/19.

Regardless of where people live in the world, air pollution is linked to increased rates of cardiovascular disease, respiratory problems, and all-cause mortality, according to one of the largest studies ever to assess the effects of inhalable particulate matter (PM), published Aug. 21 in the New England Journal of Medicine.

“These data reinforce the evidence of a link between mortality and PM concentration established in regional and local studies,” reported Cong Liu of the Huazhong University of Science and Technology in Wuhan, China, and an international team of researchers.

“Many people are experiencing worse allergy and asthma symptoms in the setting of increased heat and worse air quality,” Caren G. Solomon, MD, of Harvard Medical School, Boston, said in an interview. “It is often not appreciated that these are complications of climate change.”

Other such complications include heat-related illnesses and severe weather events, as well as the less visible manifestations, such as shifts in the epidemiology of vector-borne infectious disease, Dr. Solomon and colleagues wrote in an editorial accompanying Mr. Liu’s study.

“The stark reality is that high levels of greenhouse gases caused by the combustion of fossil fuels – and the resulting rise in temperature and sea levels and intensification of extreme weather – are having profound consequences for human health and health systems,” Dr. Solomon and colleagues wrote (N Engl J Med. 2019;381:773-4.).

In the new air pollution study, Mr. Liu and colleagues analyzed 59.6 million deaths from 652 cities across 24 countries, “thereby greatly increasing the generalizability of the association and decreasing the likelihood that the reported associations are subject to confounding bias,” wrote John R. Balmes, MD, of the University of California, San Francisco, and the University of California, Berkeley, in an editorial about the study (N Engl J Med. 2019;381:774-6).

The researchers compared air pollution data from 1986-2015 from the Multi-City Multi-Country (MCC) Collaborative Research Network to mortality data reported from individual countries. They assessed PM with an aerodynamic diameter of 10 mcg or less (PM10; n = 598 cities) and PM with an aerodynamic diameter of 2.5 mcg or less (PM_2.5; n=499 cities).

Mr. Liu’s team used a time-series analysis – a standard upon which the majority of air pollution research relies. These studies “include daily measures of health events (e.g., daily mortality), regressed against concentrations of PM (e.g., 24-hour average PM_2.5) and weather variables (e.g., daily average temperature) for a given geographic area,” Dr. Balmes wrote. “The population serves as its own control, and confounding by population characteristics is negligible because these are stable over short time frames.”

The researchers found a 0.44% increase in daily all-cause mortality for each 10-mcg/m³ increase in the 2-day moving average (current and previous day) of PM₁₀. The same increase was linked to a 0.36% increase in daily cardiovascular mortality and a 0.47% increase in daily respiratory mortality. Similarly, a 10-mcg/m³ increase in the PM_2.5 average was linked to 0.68% increase in all-cause mortality, a 0.55% increase in cardiovascular mortality, and 0.74% increase in respiratory mortality.

Locations with higher annual mean temperatures showed stronger associations, and all these associations remained statistically significant after the researchers adjusted for gaseous pollutants.

Although the majority of countries and cities included in the study came from the northern hemisphere, the researchers noted that the magnitude of effect they found, particularly for PM₁₀ concentrations, matched up with that seen in previous studies of multiple cities or countries.

Still, they found “significant evidence of spatial heterogeneity in the associations between PM concentration and daily mortality across countries and regions.” Among the factors that could contribute to those variations are “different PM components, long-term air pollution levels, population susceptibility, and different lengths of study periods,” they speculated.

What makes this study remarkable – despite decades of previous similar studies – is its size and the implications of a curvilinear shape in its concentration-response relation, according to Dr. Balmes.

“The current study of PM data from many regions around the world provides the strongest evidence to date that higher levels of exposure may be associated with a lower per-unit risk,” Dr. Balmes wrote. “Regions that have lower exposures had a higher per-unit risk. This finding has profound policy implications, especially given that no threshold of effect was found. Even high-income countries, such as the United States, with relatively good air quality could still see public health benefits from further reduction of ambient PM concentrations.”

The policy implications, however, extend well beyond clean air regulations because the findings represent just one aspect of climate change’s negative effects on health, which are “frighteningly broad,” Dr. Solomon and colleagues wrote.

“As climate change continues to alter disease patterns and disrupt health systems, its effects on human health will become harder to ignore,” they wrote. “We, as a medical community, have the responsibility and the opportunity to mobilize the urgent, large-scale climate action required to protect health – as well as the ingenuity to develop novel and bold interventions to avert the most catastrophic outcomes.”

The new research and associated commentary marked the introduction of a new NEJM topic on climate change effects on health and health systems.
 

SOURCE: Liu C et al. N Engl J Med. 2019;381:705-15.

This article was updated 8/22/19.

Fewer than one in five oncologic phase 3 randomized controlled trials (RCTs) had female corresponding authors, but the proportion of women in this authorship role appears to be gradually increasing, investigators report.

“Through identification of the factors associated with gender disparities in RCT leadership, we hope that the academic oncology community will work to better understand and address the underlying reasons for such imbalances,” wrote Ethan B. Ludmir, MD, of the University of Texas MD Anderson Cancer Center, Houston, and associates. The report is in JAMA Oncology.

The authors searched ClinicalTrials.gov in late 2017 for all oncologic phase 3 RCTs. Of the 1,239 they initially turned up, the authors narrowed them down to the 598 that used multiple arms to test a therapeutic intervention, underwent peer review, and published results of primary endpoints. Among the trials, all published between 2003 and 2018, 17.9% had female corresponding authors.

Industry-funded trials, which comprised 77.8% of the sample, had half as many female corresponding authors (14.4%) as those not funded by industry (30.1%) (P less than .001), “possibly reflecting gender biases that are enhanced in the context of industry relationships with academic medicine,” the authors wrote. The opposite trend appeared in cooperative group trials, a quarter of which (25.9%) had female corresponding authors, compared with 14.3% of noncooperative trials (P = .001).

Trials for breast cancer and head and neck cancer were most likely to have female corresponding authors, while the trials with the lowest rates were those for gastrointestinal, genitourinary, and hematologic cancers (P less than .001). The researchers also found gender disparities in the type of intervention tested: Radiotherapy and supportive care studies were more likely to have female corresponding authors, yet none of the surgical trials had any (P less than .001).

In addition, female corresponding authorship was more likely when the institutions were based in the United States (n = 329) than when they were overseas (P = .001). Women were corresponding authors in 22.5% of U.S. studies and 20% of Canadian studies but only 12% of European trials and 2.3% of Asian trials (P = .001).

Within the United States, more than a third of studies from institutions in the Southeast had female corresponding authors (34.1%), followed by those in the Midwest (27.5%) and West (25.9%). Southwestern institutions were least likely to have female corresponding authors (8.7%). Approximately twice as many studies came from Northeastern institutions as from other regions (n = 112), but only 18.8% of these had female corresponding authors (P = .03).

The frequency of female corresponding authors has been increasing, however: The authors calculated a 1.2% increase each year, “echoing data showing an approximate 1.0% annual increase in the number of female academic hematologist-oncologists,” they noted. “However, the absolute female corresponding author rate for these trials is still lower than the percentage of female academic oncologists in this general study period, ranging from 27% in 2000 to 39% in 2015.”

SOURCE: Ludmir EB et al. JAMA Oncology. 8 Aug 2019. doi: 10.1001/jamaoncol.2019.2196.

Fewer than one in five oncologic phase 3 randomized controlled trials (RCTs) had female corresponding authors, but the proportion of women in this authorship role appears to be gradually increasing, investigators report.

“Through identification of the factors associated with gender disparities in RCT leadership, we hope that the academic oncology community will work to better understand and address the underlying reasons for such imbalances,” wrote Ethan B. Ludmir, MD, of the University of Texas MD Anderson Cancer Center, Houston, and associates. The report is in JAMA Oncology.

The authors searched ClinicalTrials.gov in late 2017 for all oncologic phase 3 RCTs. Of the 1,239 they initially turned up, the authors narrowed them down to the 598 that used multiple arms to test a therapeutic intervention, underwent peer review, and published results of primary endpoints. Among the trials, all published between 2003 and 2018, 17.9% had female corresponding authors.

Industry-funded trials, which comprised 77.8% of the sample, had half as many female corresponding authors (14.4%) as those not funded by industry (30.1%) (P less than .001), “possibly reflecting gender biases that are enhanced in the context of industry relationships with academic medicine,” the authors wrote. The opposite trend appeared in cooperative group trials, a quarter of which (25.9%) had female corresponding authors, compared with 14.3% of noncooperative trials (P = .001).

Trials for breast cancer and head and neck cancer were most likely to have female corresponding authors, while the trials with the lowest rates were those for gastrointestinal, genitourinary, and hematologic cancers (P less than .001). The researchers also found gender disparities in the type of intervention tested: Radiotherapy and supportive care studies were more likely to have female corresponding authors, yet none of the surgical trials had any (P less than .001).

In addition, female corresponding authorship was more likely when the institutions were based in the United States (n = 329) than when they were overseas (P = .001). Women were corresponding authors in 22.5% of U.S. studies and 20% of Canadian studies but only 12% of European trials and 2.3% of Asian trials (P = .001).

Within the United States, more than a third of studies from institutions in the Southeast had female corresponding authors (34.1%), followed by those in the Midwest (27.5%) and West (25.9%). Southwestern institutions were least likely to have female corresponding authors (8.7%). Approximately twice as many studies came from Northeastern institutions as from other regions (n = 112), but only 18.8% of these had female corresponding authors (P = .03).

The frequency of female corresponding authors has been increasing, however: The authors calculated a 1.2% increase each year, “echoing data showing an approximate 1.0% annual increase in the number of female academic hematologist-oncologists,” they noted. “However, the absolute female corresponding author rate for these trials is still lower than the percentage of female academic oncologists in this general study period, ranging from 27% in 2000 to 39% in 2015.”

SOURCE: Ludmir EB et al. JAMA Oncology. 8 Aug 2019. doi: 10.1001/jamaoncol.2019.2196.

Fewer than one in five oncologic phase 3 randomized controlled trials (RCTs) had female corresponding authors, but the proportion of women in this authorship role appears to be gradually increasing, investigators report.

“Through identification of the factors associated with gender disparities in RCT leadership, we hope that the academic oncology community will work to better understand and address the underlying reasons for such imbalances,” wrote Ethan B. Ludmir, MD, of the University of Texas MD Anderson Cancer Center, Houston, and associates. The report is in JAMA Oncology.

The authors searched ClinicalTrials.gov in late 2017 for all oncologic phase 3 RCTs. Of the 1,239 they initially turned up, the authors narrowed them down to the 598 that used multiple arms to test a therapeutic intervention, underwent peer review, and published results of primary endpoints. Among the trials, all published between 2003 and 2018, 17.9% had female corresponding authors.

Industry-funded trials, which comprised 77.8% of the sample, had half as many female corresponding authors (14.4%) as those not funded by industry (30.1%) (P less than .001), “possibly reflecting gender biases that are enhanced in the context of industry relationships with academic medicine,” the authors wrote. The opposite trend appeared in cooperative group trials, a quarter of which (25.9%) had female corresponding authors, compared with 14.3% of noncooperative trials (P = .001).

Trials for breast cancer and head and neck cancer were most likely to have female corresponding authors, while the trials with the lowest rates were those for gastrointestinal, genitourinary, and hematologic cancers (P less than .001). The researchers also found gender disparities in the type of intervention tested: Radiotherapy and supportive care studies were more likely to have female corresponding authors, yet none of the surgical trials had any (P less than .001).

In addition, female corresponding authorship was more likely when the institutions were based in the United States (n = 329) than when they were overseas (P = .001). Women were corresponding authors in 22.5% of U.S. studies and 20% of Canadian studies but only 12% of European trials and 2.3% of Asian trials (P = .001).

Within the United States, more than a third of studies from institutions in the Southeast had female corresponding authors (34.1%), followed by those in the Midwest (27.5%) and West (25.9%). Southwestern institutions were least likely to have female corresponding authors (8.7%). Approximately twice as many studies came from Northeastern institutions as from other regions (n = 112), but only 18.8% of these had female corresponding authors (P = .03).

The frequency of female corresponding authors has been increasing, however: The authors calculated a 1.2% increase each year, “echoing data showing an approximate 1.0% annual increase in the number of female academic hematologist-oncologists,” they noted. “However, the absolute female corresponding author rate for these trials is still lower than the percentage of female academic oncologists in this general study period, ranging from 27% in 2000 to 39% in 2015.”

SOURCE: Ludmir EB et al. JAMA Oncology. 8 Aug 2019. doi: 10.1001/jamaoncol.2019.2196.