The Diagnosis: Epithelioid Histiocytoma 

Epithelioid histiocytoma (EH), also known as epithelioid cell histiocytoma or epithelioid fibrous histiocytoma, is a rare benign fibrohistiocytic tumor first described in 1989.¹ Epithelioid histiocytoma commonly presents in middle-aged adults with a slight predilection for males.² The most frequently affected site is the lower extremity. The arms, trunk, head and neck, groin, and tongue also can be involved.^3,4 It usually presents as a solitary asymptomatic papule or nodule, though cases with multiple lesions have been reported.⁵ Anaplastic lymphoma kinase rearrangement and overexpression have been confirmed and suggest that EH is distinct from conventional cutaneous fibrous histiocytoma.⁵  

Histologically, EH appears as an exophytic, symmetric, and well-demarcated dermal nodule with a classic epidermal collarette. Prominent vascularity with perivascular accentuation of the epithelioid tumor cells is common. Older lesions may be hyalinized and sclerotic. Epithelioid cells commonly account for more than 50% of the tumor and are characterized by eosinophilic cytoplasm, vesicular nuclei, and small eosinophilic nucleoli. A small population of lymphocytes and mast cells are variably present (quiz image, bottom).^1-3,7 A predominantly spindle cell variant has been reported.⁸ Other histopathologic variants include granular cell,⁹ cellular,¹⁰ and EH with perineuriomalike growth.¹¹ Immunohistochemical staining shows anaplastic lymphoma kinase positivity in most cases, and more than half of cases stain positive for factor XIIIa and epithelial membrane antigen. Tumor cells consistently are negative for desmin and cytokeratins.^6,10,12 Excision is curative.⁸  

Polypoid Spitz nevus (PSN) is a benign nevus with a conspicuous polypoid or papillary exophytic architecture. The term was coined in 2000 by Fabrizi and Massi.¹³ Spitz nevus is a benign acquired melanocytic tumor that typically presents in children and adolescents and has a wide histologic spectrum.¹⁴ There is some debate on this entity, as some authors do not regard PSN as a distinct histologic variant; thus, it seems underreported in the literature.¹⁵ In a review of 349 cases of Spitz nevi, the authors found 7 cases of PSN.¹⁶ In another review of 74 cases of intradermal Spitz nevi, 14 cases of PSN were identified.¹⁴ This polypoid variant is easily mistaken for a polypoid melanoma because it can show cytologic atypia with large nuclei. Polypoid Spitz nevus usually lacks mitoses, notable pleomorphism, and sheetlike growth, unlike melanoma (Figure 1).^13,14  

Myopericytoma is an uncommon benign mesenchymal neoplasm that typically presents as a solitary, slowly enlarging and painless nodule with a predilection for the lower extremities, usually in adult males.^17-20 Histologically, it consists of a well-circumscribed nodule with numerous thin-walled vessels and a proliferation of ovoid to spindled myopericytes exhibiting a concentric perivascular growth pattern (Figure 2). Myopericytoma usually is positive for smooth muscle actin and h-caldesmon but is negative or only focally positive for desmin. The prognosis is good with rare recurrence, despite incomplete excision.^17,18 

Solitary reticulohistiocytoma is a rare benign form of non-Langerhans cell histiocytosis.^21,22 Unlike its multicentric counterpart, solitary reticulohistiocytoma rarely is associated with systemic disease. It presents as a small, dome-shaped, painless papule or nodule that can affect any part of the body.^22,23 Solitary reticulohistiocytoma characteristically demonstrates cells with a ground glass-like appearance and 2-toned cytoplasm. A mixed inflammatory infiltrate including neutrophils, eosinophils, and lymphocytes commonly is present (Figure 3). The epithelioid histiocytes are positive for vimentin and histiocytic markers including CD68 and CD163.²²  

Solitary fibrous tumor (SFT) is an uncommon mesenchymal fibroblastic neoplasm that can arise at almost any anatomic site.²⁴ Cutaneous SFTs are more common in women, most often involve the head, and appear to behave in an indolent manner.²⁵ Solitary fibrous tumors are translocation-associated neoplasms with a NAB2-STAT6 gene fusion.²⁶ The classic histology of SFT is a spindled fibroblastic proliferation arranged in a "patternless pattern" with interspersed stag horn-like, thin-walled blood vessels (Figure 4). Tumor cells usually are positive for CD34, CD99, and Bcl-2.²⁷ In addition, STAT6 immunoreactivity is useful in diagnosis of SFT.²⁵

The Diagnosis: Epithelioid Histiocytoma 

Epithelioid histiocytoma (EH), also known as epithelioid cell histiocytoma or epithelioid fibrous histiocytoma, is a rare benign fibrohistiocytic tumor first described in 1989.¹ Epithelioid histiocytoma commonly presents in middle-aged adults with a slight predilection for males.² The most frequently affected site is the lower extremity. The arms, trunk, head and neck, groin, and tongue also can be involved.^3,4 It usually presents as a solitary asymptomatic papule or nodule, though cases with multiple lesions have been reported.⁵ Anaplastic lymphoma kinase rearrangement and overexpression have been confirmed and suggest that EH is distinct from conventional cutaneous fibrous histiocytoma.⁵  

Histologically, EH appears as an exophytic, symmetric, and well-demarcated dermal nodule with a classic epidermal collarette. Prominent vascularity with perivascular accentuation of the epithelioid tumor cells is common. Older lesions may be hyalinized and sclerotic. Epithelioid cells commonly account for more than 50% of the tumor and are characterized by eosinophilic cytoplasm, vesicular nuclei, and small eosinophilic nucleoli. A small population of lymphocytes and mast cells are variably present (quiz image, bottom).^1-3,7 A predominantly spindle cell variant has been reported.⁸ Other histopathologic variants include granular cell,⁹ cellular,¹⁰ and EH with perineuriomalike growth.¹¹ Immunohistochemical staining shows anaplastic lymphoma kinase positivity in most cases, and more than half of cases stain positive for factor XIIIa and epithelial membrane antigen. Tumor cells consistently are negative for desmin and cytokeratins.^6,10,12 Excision is curative.⁸  

Polypoid Spitz nevus (PSN) is a benign nevus with a conspicuous polypoid or papillary exophytic architecture. The term was coined in 2000 by Fabrizi and Massi.¹³ Spitz nevus is a benign acquired melanocytic tumor that typically presents in children and adolescents and has a wide histologic spectrum.¹⁴ There is some debate on this entity, as some authors do not regard PSN as a distinct histologic variant; thus, it seems underreported in the literature.¹⁵ In a review of 349 cases of Spitz nevi, the authors found 7 cases of PSN.¹⁶ In another review of 74 cases of intradermal Spitz nevi, 14 cases of PSN were identified.¹⁴ This polypoid variant is easily mistaken for a polypoid melanoma because it can show cytologic atypia with large nuclei. Polypoid Spitz nevus usually lacks mitoses, notable pleomorphism, and sheetlike growth, unlike melanoma (Figure 1).^13,14  

Myopericytoma is an uncommon benign mesenchymal neoplasm that typically presents as a solitary, slowly enlarging and painless nodule with a predilection for the lower extremities, usually in adult males.^17-20 Histologically, it consists of a well-circumscribed nodule with numerous thin-walled vessels and a proliferation of ovoid to spindled myopericytes exhibiting a concentric perivascular growth pattern (Figure 2). Myopericytoma usually is positive for smooth muscle actin and h-caldesmon but is negative or only focally positive for desmin. The prognosis is good with rare recurrence, despite incomplete excision.^17,18 

Solitary reticulohistiocytoma is a rare benign form of non-Langerhans cell histiocytosis.^21,22 Unlike its multicentric counterpart, solitary reticulohistiocytoma rarely is associated with systemic disease. It presents as a small, dome-shaped, painless papule or nodule that can affect any part of the body.^22,23 Solitary reticulohistiocytoma characteristically demonstrates cells with a ground glass-like appearance and 2-toned cytoplasm. A mixed inflammatory infiltrate including neutrophils, eosinophils, and lymphocytes commonly is present (Figure 3). The epithelioid histiocytes are positive for vimentin and histiocytic markers including CD68 and CD163.²²  

Solitary fibrous tumor (SFT) is an uncommon mesenchymal fibroblastic neoplasm that can arise at almost any anatomic site.²⁴ Cutaneous SFTs are more common in women, most often involve the head, and appear to behave in an indolent manner.²⁵ Solitary fibrous tumors are translocation-associated neoplasms with a NAB2-STAT6 gene fusion.²⁶ The classic histology of SFT is a spindled fibroblastic proliferation arranged in a "patternless pattern" with interspersed stag horn-like, thin-walled blood vessels (Figure 4). Tumor cells usually are positive for CD34, CD99, and Bcl-2.²⁷ In addition, STAT6 immunoreactivity is useful in diagnosis of SFT.²⁵

The Diagnosis: Epithelioid Histiocytoma 

Epithelioid histiocytoma (EH), also known as epithelioid cell histiocytoma or epithelioid fibrous histiocytoma, is a rare benign fibrohistiocytic tumor first described in 1989.¹ Epithelioid histiocytoma commonly presents in middle-aged adults with a slight predilection for males.² The most frequently affected site is the lower extremity. The arms, trunk, head and neck, groin, and tongue also can be involved.^3,4 It usually presents as a solitary asymptomatic papule or nodule, though cases with multiple lesions have been reported.⁵ Anaplastic lymphoma kinase rearrangement and overexpression have been confirmed and suggest that EH is distinct from conventional cutaneous fibrous histiocytoma.⁵  

Histologically, EH appears as an exophytic, symmetric, and well-demarcated dermal nodule with a classic epidermal collarette. Prominent vascularity with perivascular accentuation of the epithelioid tumor cells is common. Older lesions may be hyalinized and sclerotic. Epithelioid cells commonly account for more than 50% of the tumor and are characterized by eosinophilic cytoplasm, vesicular nuclei, and small eosinophilic nucleoli. A small population of lymphocytes and mast cells are variably present (quiz image, bottom).^1-3,7 A predominantly spindle cell variant has been reported.⁸ Other histopathologic variants include granular cell,⁹ cellular,¹⁰ and EH with perineuriomalike growth.¹¹ Immunohistochemical staining shows anaplastic lymphoma kinase positivity in most cases, and more than half of cases stain positive for factor XIIIa and epithelial membrane antigen. Tumor cells consistently are negative for desmin and cytokeratins.^6,10,12 Excision is curative.⁸  

Polypoid Spitz nevus (PSN) is a benign nevus with a conspicuous polypoid or papillary exophytic architecture. The term was coined in 2000 by Fabrizi and Massi.¹³ Spitz nevus is a benign acquired melanocytic tumor that typically presents in children and adolescents and has a wide histologic spectrum.¹⁴ There is some debate on this entity, as some authors do not regard PSN as a distinct histologic variant; thus, it seems underreported in the literature.¹⁵ In a review of 349 cases of Spitz nevi, the authors found 7 cases of PSN.¹⁶ In another review of 74 cases of intradermal Spitz nevi, 14 cases of PSN were identified.¹⁴ This polypoid variant is easily mistaken for a polypoid melanoma because it can show cytologic atypia with large nuclei. Polypoid Spitz nevus usually lacks mitoses, notable pleomorphism, and sheetlike growth, unlike melanoma (Figure 1).^13,14  

Myopericytoma is an uncommon benign mesenchymal neoplasm that typically presents as a solitary, slowly enlarging and painless nodule with a predilection for the lower extremities, usually in adult males.^17-20 Histologically, it consists of a well-circumscribed nodule with numerous thin-walled vessels and a proliferation of ovoid to spindled myopericytes exhibiting a concentric perivascular growth pattern (Figure 2). Myopericytoma usually is positive for smooth muscle actin and h-caldesmon but is negative or only focally positive for desmin. The prognosis is good with rare recurrence, despite incomplete excision.^17,18 

Solitary reticulohistiocytoma is a rare benign form of non-Langerhans cell histiocytosis.^21,22 Unlike its multicentric counterpart, solitary reticulohistiocytoma rarely is associated with systemic disease. It presents as a small, dome-shaped, painless papule or nodule that can affect any part of the body.^22,23 Solitary reticulohistiocytoma characteristically demonstrates cells with a ground glass-like appearance and 2-toned cytoplasm. A mixed inflammatory infiltrate including neutrophils, eosinophils, and lymphocytes commonly is present (Figure 3). The epithelioid histiocytes are positive for vimentin and histiocytic markers including CD68 and CD163.²²  

Solitary fibrous tumor (SFT) is an uncommon mesenchymal fibroblastic neoplasm that can arise at almost any anatomic site.²⁴ Cutaneous SFTs are more common in women, most often involve the head, and appear to behave in an indolent manner.²⁵ Solitary fibrous tumors are translocation-associated neoplasms with a NAB2-STAT6 gene fusion.²⁶ The classic histology of SFT is a spindled fibroblastic proliferation arranged in a "patternless pattern" with interspersed stag horn-like, thin-walled blood vessels (Figure 4). Tumor cells usually are positive for CD34, CD99, and Bcl-2.²⁷ In addition, STAT6 immunoreactivity is useful in diagnosis of SFT.²⁵

While ankylosing spondylitis may be more common among whites, black patients have more comorbidities and express higher disease activity, Dilpreet Kaur Singh, MD, and Marina Magrey, MBBS, reported in The Journal of Rheumatology.

A retrospective review of a large U.S. medical database conducted by Dr. Singh and Dr. Magrey of MetroHealth Medical Center, Cleveland, found that black patients had higher erythrocyte sedimentation rates and C-reactive protein, and a higher prevalence of anterior uveitis, hypertension, diabetes, and depression, compared with white patients. (Dr. Singh, who was a rheumatology fellow at MetroHealth at the time of the study, is now a practicing rheumatologist in Springfield, Mass.)

Disease severity in AS is “thought to be genetically mediated but cultural, social, or economic factors may also be contributing to this racial disparity,” the investigators wrote. “Further research is needed to determine the role of factors other than genetic factors like HLA-B27 positivity that contribute to worsening disease severity.”

The authors extracted data recorded during 1999-2017 from the Explorys platform, a clinical research informatics tool with data from more than 50 million patients in 26 major integrated health care systems in the United States.

The current study comprised 10,990 AS patients with at least two visits to a rheumatologist. Most (84%) were white; 8% were black. Sex was equally distributed in both groups. Positivity for HLA-B27 was similar among whites (26%) and blacks (20%). A majority of patients smoked (65%), and smoking was more common among whites than among blacks (67% vs. 59%).

Disease characteristics suggested that AS was more severe among blacks. Significantly greater proportions of black patients had elevated erythrocyte sedimentation rate (62% vs. 48% of whites) and C-reactive protein (68% vs. 54%). Blacks also experienced significantly greater rates of anterior uveitis (8% vs. 4%), hypertension (29% vs. 22%), diabetes (27% vs. 17%), and depression (36% vs. 32%).

Blacks experienced higher rates of peripheral arthritis, enthesopathy, dactylitis, and inflammatory bowel disease, although these differences were not statistically significant when compared with whites.

Whites, however, had significantly higher rates of psoriasis (10% vs. 6.5%).

Most of the cohort (87%) received NSAIDs; 39% used tumor necrosis factor inhibitors. There were no significant between-group treatment differences.

The authors reported no potential conflicts of interest and no source of financial support.

[email protected]

SOURCE: Singh DK et al. J Rheumatol. 2019 Sep 1. doi: 10.3899/jrheum.181019.

While ankylosing spondylitis may be more common among whites, black patients have more comorbidities and express higher disease activity, Dilpreet Kaur Singh, MD, and Marina Magrey, MBBS, reported in The Journal of Rheumatology.

A retrospective review of a large U.S. medical database conducted by Dr. Singh and Dr. Magrey of MetroHealth Medical Center, Cleveland, found that black patients had higher erythrocyte sedimentation rates and C-reactive protein, and a higher prevalence of anterior uveitis, hypertension, diabetes, and depression, compared with white patients. (Dr. Singh, who was a rheumatology fellow at MetroHealth at the time of the study, is now a practicing rheumatologist in Springfield, Mass.)

Disease severity in AS is “thought to be genetically mediated but cultural, social, or economic factors may also be contributing to this racial disparity,” the investigators wrote. “Further research is needed to determine the role of factors other than genetic factors like HLA-B27 positivity that contribute to worsening disease severity.”

The authors extracted data recorded during 1999-2017 from the Explorys platform, a clinical research informatics tool with data from more than 50 million patients in 26 major integrated health care systems in the United States.

The current study comprised 10,990 AS patients with at least two visits to a rheumatologist. Most (84%) were white; 8% were black. Sex was equally distributed in both groups. Positivity for HLA-B27 was similar among whites (26%) and blacks (20%). A majority of patients smoked (65%), and smoking was more common among whites than among blacks (67% vs. 59%).

Disease characteristics suggested that AS was more severe among blacks. Significantly greater proportions of black patients had elevated erythrocyte sedimentation rate (62% vs. 48% of whites) and C-reactive protein (68% vs. 54%). Blacks also experienced significantly greater rates of anterior uveitis (8% vs. 4%), hypertension (29% vs. 22%), diabetes (27% vs. 17%), and depression (36% vs. 32%).

Blacks experienced higher rates of peripheral arthritis, enthesopathy, dactylitis, and inflammatory bowel disease, although these differences were not statistically significant when compared with whites.

Whites, however, had significantly higher rates of psoriasis (10% vs. 6.5%).

Most of the cohort (87%) received NSAIDs; 39% used tumor necrosis factor inhibitors. There were no significant between-group treatment differences.

The authors reported no potential conflicts of interest and no source of financial support.

[email protected]

SOURCE: Singh DK et al. J Rheumatol. 2019 Sep 1. doi: 10.3899/jrheum.181019.

While ankylosing spondylitis may be more common among whites, black patients have more comorbidities and express higher disease activity, Dilpreet Kaur Singh, MD, and Marina Magrey, MBBS, reported in The Journal of Rheumatology.

A retrospective review of a large U.S. medical database conducted by Dr. Singh and Dr. Magrey of MetroHealth Medical Center, Cleveland, found that black patients had higher erythrocyte sedimentation rates and C-reactive protein, and a higher prevalence of anterior uveitis, hypertension, diabetes, and depression, compared with white patients. (Dr. Singh, who was a rheumatology fellow at MetroHealth at the time of the study, is now a practicing rheumatologist in Springfield, Mass.)

Disease severity in AS is “thought to be genetically mediated but cultural, social, or economic factors may also be contributing to this racial disparity,” the investigators wrote. “Further research is needed to determine the role of factors other than genetic factors like HLA-B27 positivity that contribute to worsening disease severity.”

The authors extracted data recorded during 1999-2017 from the Explorys platform, a clinical research informatics tool with data from more than 50 million patients in 26 major integrated health care systems in the United States.

The current study comprised 10,990 AS patients with at least two visits to a rheumatologist. Most (84%) were white; 8% were black. Sex was equally distributed in both groups. Positivity for HLA-B27 was similar among whites (26%) and blacks (20%). A majority of patients smoked (65%), and smoking was more common among whites than among blacks (67% vs. 59%).

Disease characteristics suggested that AS was more severe among blacks. Significantly greater proportions of black patients had elevated erythrocyte sedimentation rate (62% vs. 48% of whites) and C-reactive protein (68% vs. 54%). Blacks also experienced significantly greater rates of anterior uveitis (8% vs. 4%), hypertension (29% vs. 22%), diabetes (27% vs. 17%), and depression (36% vs. 32%).

Blacks experienced higher rates of peripheral arthritis, enthesopathy, dactylitis, and inflammatory bowel disease, although these differences were not statistically significant when compared with whites.

Whites, however, had significantly higher rates of psoriasis (10% vs. 6.5%).

Most of the cohort (87%) received NSAIDs; 39% used tumor necrosis factor inhibitors. There were no significant between-group treatment differences.

The authors reported no potential conflicts of interest and no source of financial support.

[email protected]

SOURCE: Singh DK et al. J Rheumatol. 2019 Sep 1. doi: 10.3899/jrheum.181019.

Gender identity conversion efforts during early childhood quadruple lifetime risk of suicidal behavior for transgender people, a study of almost 28,000 adults has determined.

The findings prompted the authors to issue a blanket warning against the controversial treatment, which already has been decried by several medical associations.

“Our results support policy positions … which state that gender identity–conversion therapy should not be conducted for transgender patients at any age, Jack L. Turban, MD, and colleagues wrote in JAMA Psychiatry.

The American Academy of Child and Adolescent Psychiatry, the American Psychiatric Association, the American Academy of Pediatrics, and the American Medical Association all strongly warn against any kind of gender conversion efforts.

The significantly increased risk of suicidal behavior was similar whether the gender identity–conversion effort (GICE) was administered by a clinician or a cleric. “This suggests that any process of intervening to alter gender identity is associated with poorer mental health regardless of whether the intervention occurred within a secular or religious framework,” wrote Dr. Turban of Massachusetts General Hospital, Boston, and coauthors.

The study – the largest of its kind thus far – comprised 27,715 transgender adults included in the 2015 U.S. Transgender Survey, conducted by the National Center for Transgender Equality.

In the current study, investigators focused on the question: “Did any professional (such as a psychologist, counselor, or religious advisor) try to make you identify only with your sex assigned at birth (in other words, try to stop you being trans)?”

They compared responses among subjects who reported exposure to GICE before age 10 years with those who did not.

Subjects were aged a mean of 31 years when they participated in the survey. Slightly less than half (42.8%) were assigned male sex at birth. Most (19,751) had discussed their gender identity with a professional. Nearly 20% (3,869) reported some exposure to GICE; 35% said a religious adviser had conducted the effort.

In this group, exposure had significant negative lifetime effects on mental health. These subjects were at a 56% increased risk of psychological distress within the month before taking the survey (odds ratio, 1.56), and more than twice as likely to have tried at least once to end their lives by suicide (OR, 2.27).

But the negative effects were even more pronounced among the small group of 206 who reported exposure to GICE before they were 10 years old. In a multivariate analysis adjusted for demographics, GICE before age 10 more than quadrupled the risk of lifetime suicide attempts (OR, 4.15). Again, it didn’t matter whether a medical or religious professional administered GICE.

“A plausible association of these practices with poor mental health outcomes can be conceptualized through the minority stress framework; that is, elevated stigma-related stress from exposure to GICE may increase general emotion dysregulation, interpersonal dysfunction, and maladaptive cognitions,” the investigators wrote. “Although this study suggests that exposure to GICE is associated with increased odds of suicide attempts, GICE are not the only way in which minority group stress manifests, and thus, other factors are also likely to be associated with suicidality among gender-diverse people.”

The rate at which transgender people are exposed to GICE appears to be higher than that experienced by cisgender nonheterosexual people, the authors noted. “One potential explanation for this is that, compared with persons in the sexual-minority group, many persons in the gender-minority group must interact with clinical professionals to be medically and surgically affirmed in their identities. This higher prevalence of interactions with clinical professionals among people in the gender minority group may lead to greater risk of experiencing conversion effort.”

The authors cited the sample size of the study as one of its many strengths. One limitation includes the study’s cross-sectional design.

Dr. Turban reported collecting royalties from Springer for an upcoming textbook about pediatric gender identity. The other coauthors reported no disclosures.

[email protected]

SOURCE: Turban JL et al. JAMA Psychiatry. 2019 Sep 11. doi: 10.1001/jamapsychiatry.2019.2285.
 

Gender identity conversion efforts during early childhood quadruple lifetime risk of suicidal behavior for transgender people, a study of almost 28,000 adults has determined.

The findings prompted the authors to issue a blanket warning against the controversial treatment, which already has been decried by several medical associations.

“Our results support policy positions … which state that gender identity–conversion therapy should not be conducted for transgender patients at any age, Jack L. Turban, MD, and colleagues wrote in JAMA Psychiatry.

The American Academy of Child and Adolescent Psychiatry, the American Psychiatric Association, the American Academy of Pediatrics, and the American Medical Association all strongly warn against any kind of gender conversion efforts.

The significantly increased risk of suicidal behavior was similar whether the gender identity–conversion effort (GICE) was administered by a clinician or a cleric. “This suggests that any process of intervening to alter gender identity is associated with poorer mental health regardless of whether the intervention occurred within a secular or religious framework,” wrote Dr. Turban of Massachusetts General Hospital, Boston, and coauthors.

The study – the largest of its kind thus far – comprised 27,715 transgender adults included in the 2015 U.S. Transgender Survey, conducted by the National Center for Transgender Equality.

In the current study, investigators focused on the question: “Did any professional (such as a psychologist, counselor, or religious advisor) try to make you identify only with your sex assigned at birth (in other words, try to stop you being trans)?”

They compared responses among subjects who reported exposure to GICE before age 10 years with those who did not.

Subjects were aged a mean of 31 years when they participated in the survey. Slightly less than half (42.8%) were assigned male sex at birth. Most (19,751) had discussed their gender identity with a professional. Nearly 20% (3,869) reported some exposure to GICE; 35% said a religious adviser had conducted the effort.

In this group, exposure had significant negative lifetime effects on mental health. These subjects were at a 56% increased risk of psychological distress within the month before taking the survey (odds ratio, 1.56), and more than twice as likely to have tried at least once to end their lives by suicide (OR, 2.27).

But the negative effects were even more pronounced among the small group of 206 who reported exposure to GICE before they were 10 years old. In a multivariate analysis adjusted for demographics, GICE before age 10 more than quadrupled the risk of lifetime suicide attempts (OR, 4.15). Again, it didn’t matter whether a medical or religious professional administered GICE.

“A plausible association of these practices with poor mental health outcomes can be conceptualized through the minority stress framework; that is, elevated stigma-related stress from exposure to GICE may increase general emotion dysregulation, interpersonal dysfunction, and maladaptive cognitions,” the investigators wrote. “Although this study suggests that exposure to GICE is associated with increased odds of suicide attempts, GICE are not the only way in which minority group stress manifests, and thus, other factors are also likely to be associated with suicidality among gender-diverse people.”

The rate at which transgender people are exposed to GICE appears to be higher than that experienced by cisgender nonheterosexual people, the authors noted. “One potential explanation for this is that, compared with persons in the sexual-minority group, many persons in the gender-minority group must interact with clinical professionals to be medically and surgically affirmed in their identities. This higher prevalence of interactions with clinical professionals among people in the gender minority group may lead to greater risk of experiencing conversion effort.”

The authors cited the sample size of the study as one of its many strengths. One limitation includes the study’s cross-sectional design.

Dr. Turban reported collecting royalties from Springer for an upcoming textbook about pediatric gender identity. The other coauthors reported no disclosures.

[email protected]

SOURCE: Turban JL et al. JAMA Psychiatry. 2019 Sep 11. doi: 10.1001/jamapsychiatry.2019.2285.
 

Gender identity conversion efforts during early childhood quadruple lifetime risk of suicidal behavior for transgender people, a study of almost 28,000 adults has determined.

The findings prompted the authors to issue a blanket warning against the controversial treatment, which already has been decried by several medical associations.

“Our results support policy positions … which state that gender identity–conversion therapy should not be conducted for transgender patients at any age, Jack L. Turban, MD, and colleagues wrote in JAMA Psychiatry.

The American Academy of Child and Adolescent Psychiatry, the American Psychiatric Association, the American Academy of Pediatrics, and the American Medical Association all strongly warn against any kind of gender conversion efforts.

The significantly increased risk of suicidal behavior was similar whether the gender identity–conversion effort (GICE) was administered by a clinician or a cleric. “This suggests that any process of intervening to alter gender identity is associated with poorer mental health regardless of whether the intervention occurred within a secular or religious framework,” wrote Dr. Turban of Massachusetts General Hospital, Boston, and coauthors.

The study – the largest of its kind thus far – comprised 27,715 transgender adults included in the 2015 U.S. Transgender Survey, conducted by the National Center for Transgender Equality.

In the current study, investigators focused on the question: “Did any professional (such as a psychologist, counselor, or religious advisor) try to make you identify only with your sex assigned at birth (in other words, try to stop you being trans)?”

They compared responses among subjects who reported exposure to GICE before age 10 years with those who did not.

Subjects were aged a mean of 31 years when they participated in the survey. Slightly less than half (42.8%) were assigned male sex at birth. Most (19,751) had discussed their gender identity with a professional. Nearly 20% (3,869) reported some exposure to GICE; 35% said a religious adviser had conducted the effort.

In this group, exposure had significant negative lifetime effects on mental health. These subjects were at a 56% increased risk of psychological distress within the month before taking the survey (odds ratio, 1.56), and more than twice as likely to have tried at least once to end their lives by suicide (OR, 2.27).

But the negative effects were even more pronounced among the small group of 206 who reported exposure to GICE before they were 10 years old. In a multivariate analysis adjusted for demographics, GICE before age 10 more than quadrupled the risk of lifetime suicide attempts (OR, 4.15). Again, it didn’t matter whether a medical or religious professional administered GICE.

“A plausible association of these practices with poor mental health outcomes can be conceptualized through the minority stress framework; that is, elevated stigma-related stress from exposure to GICE may increase general emotion dysregulation, interpersonal dysfunction, and maladaptive cognitions,” the investigators wrote. “Although this study suggests that exposure to GICE is associated with increased odds of suicide attempts, GICE are not the only way in which minority group stress manifests, and thus, other factors are also likely to be associated with suicidality among gender-diverse people.”

The rate at which transgender people are exposed to GICE appears to be higher than that experienced by cisgender nonheterosexual people, the authors noted. “One potential explanation for this is that, compared with persons in the sexual-minority group, many persons in the gender-minority group must interact with clinical professionals to be medically and surgically affirmed in their identities. This higher prevalence of interactions with clinical professionals among people in the gender minority group may lead to greater risk of experiencing conversion effort.”

The authors cited the sample size of the study as one of its many strengths. One limitation includes the study’s cross-sectional design.

Dr. Turban reported collecting royalties from Springer for an upcoming textbook about pediatric gender identity. The other coauthors reported no disclosures.

[email protected]

SOURCE: Turban JL et al. JAMA Psychiatry. 2019 Sep 11. doi: 10.1001/jamapsychiatry.2019.2285.
 

For the first time in a decade, the number of Americans without health insurance has risen – by about 2 million people in 2018 – according to the annual U.S. Census Bureau report released Sept. 10, 2019.

The Census found that 8.5% of the U.S. population went without medical insurance for all of 2018, up from 7.9% in 2017. By contrast, in 2013, before the Affordable Care Act took full effect, 13.3% were uninsured. It was the first year-to-year increase since 2008-09, Census officials said, adding that most of the drop in health coverage was related to a 0.7% decline in Medicaid participants. The number of people with private insurance remained steady and there was a 0.4% increase in those on Medicare.

Many of those losing coverage were noncitizens, a possible fallout from the Trump administration’s tough immigration policies and rhetoric. About 574,000 noncitizens lost coverage in 2018, a drop of about 2.3%, the report found.

“Uninsured noncitizens account for almost a third of the increase in uninsured, which may reflect the administration’s more aggressive stance on immigration,” said Joseph Antos, a health economist at the American Enterprise Institute.

The increase in the number of uninsured people in 2018 was remarkable because uninsured rates typically fall or hold steady when unemployment rates drop. The U.S. unemployment rate fell slightly from about 4.3% in 2017 to 4% in 2018.

The uninsured rate continued to vary by poverty status and whether a state expanded its Medicaid program under Obamacare. Texas (17.7%), Oklahoma (14.2%), Georgia (13.7%), and Florida (13%) had the highest uninsured rates in 2018, according to the report. None of those states have expanded Medicaid under Obamacare.

The percentage of uninsured children aged under 19 years increased by 0.6 percentage points from 2017 to 2018, to 5.5%.

“The Census data are clear – the uninsured rate for kids is up sharply and it’s due to a loss of public coverage – mostly Medicaid,” Joan Alker, executive director of Georgetown University Center for Children and Families, said in a statement.

“These children are not getting private coverage as the Trump administration has suggested but rather becoming uninsured,” she said. “This serious erosion of children’s health coverage is due in large part to the Trump administration’s actions that have made health care harder to access and have deterred families from enrolling their children.”

The share of Americans without medical insurance fell steadily since 2014 but then leveled off in 2017, the year Mr. Trump became president.

Health care advocates have complained that efforts by the Trump administration and Congress are jeopardizing insurance enrollment. They point to cuts in outreach programs that aim to tell consumers about their health care options under Obamacare and the elimination of the ACA’s tax penalty for people who don’t have health coverage.

Ms. Alker complained that the administration’s policies are causing the loss of children’s coverage. “In a period of continued economic and job growth, we shouldn’t be going backwards on health coverage,” said Judy Solomon, a senior fellow for the Center on Budget and Policy Priorities, a left-leaning think tank. “This backsliding almost certainly reflects, at least in part, Trump administration policies to weaken public health coverage.”

She attributed the drop to the Trump administration making it harder for families to enroll for coverage in Medicaid by curtailing outreach efforts, allowing states to ask for more paperwork and proposing a so-called public charge rule that would make it harder for legal immigrants to get permanent resident status if they have received certain kinds of public assistance – including Medicaid.

Tom Miller, a resident fellow at the American Enterprise Institute, a conservative think tank, said the drop in Medicaid coverage “is a positive.”

“When the economy grows Medicaid eventually drops,” he said.

One reason for the drop in health coverage is that middle-income families can’t afford the rising cost of insurance in the individual market, particularly if they don’t qualify for government subsidies, he added.

“On balance, this is some short-term noise,” he said of the uptick in the uninsured rate. “I would put more stake in it if happens for several years.”

Chris Pope, a senior fellow with the conservative Manhattan Institute, also said he considered the change “fairly small” and likely caused by increasing wages “pushing people above the income eligibility cutoff in Medicaid expansion states.”

But he suggested that next year would be a better indicator of how changes in the ACA are playing out. “I expect that the mandate repeal will make next year’s increase in the uninsured more significant.”

Kaiser Health News is a nonprofit national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation that is not affiliated with Kaiser Permanente.

For the first time in a decade, the number of Americans without health insurance has risen – by about 2 million people in 2018 – according to the annual U.S. Census Bureau report released Sept. 10, 2019.

The Census found that 8.5% of the U.S. population went without medical insurance for all of 2018, up from 7.9% in 2017. By contrast, in 2013, before the Affordable Care Act took full effect, 13.3% were uninsured. It was the first year-to-year increase since 2008-09, Census officials said, adding that most of the drop in health coverage was related to a 0.7% decline in Medicaid participants. The number of people with private insurance remained steady and there was a 0.4% increase in those on Medicare.

Many of those losing coverage were noncitizens, a possible fallout from the Trump administration’s tough immigration policies and rhetoric. About 574,000 noncitizens lost coverage in 2018, a drop of about 2.3%, the report found.

“Uninsured noncitizens account for almost a third of the increase in uninsured, which may reflect the administration’s more aggressive stance on immigration,” said Joseph Antos, a health economist at the American Enterprise Institute.

The increase in the number of uninsured people in 2018 was remarkable because uninsured rates typically fall or hold steady when unemployment rates drop. The U.S. unemployment rate fell slightly from about 4.3% in 2017 to 4% in 2018.

The uninsured rate continued to vary by poverty status and whether a state expanded its Medicaid program under Obamacare. Texas (17.7%), Oklahoma (14.2%), Georgia (13.7%), and Florida (13%) had the highest uninsured rates in 2018, according to the report. None of those states have expanded Medicaid under Obamacare.

The percentage of uninsured children aged under 19 years increased by 0.6 percentage points from 2017 to 2018, to 5.5%.

“The Census data are clear – the uninsured rate for kids is up sharply and it’s due to a loss of public coverage – mostly Medicaid,” Joan Alker, executive director of Georgetown University Center for Children and Families, said in a statement.

“These children are not getting private coverage as the Trump administration has suggested but rather becoming uninsured,” she said. “This serious erosion of children’s health coverage is due in large part to the Trump administration’s actions that have made health care harder to access and have deterred families from enrolling their children.”

The share of Americans without medical insurance fell steadily since 2014 but then leveled off in 2017, the year Mr. Trump became president.

Health care advocates have complained that efforts by the Trump administration and Congress are jeopardizing insurance enrollment. They point to cuts in outreach programs that aim to tell consumers about their health care options under Obamacare and the elimination of the ACA’s tax penalty for people who don’t have health coverage.

Ms. Alker complained that the administration’s policies are causing the loss of children’s coverage. “In a period of continued economic and job growth, we shouldn’t be going backwards on health coverage,” said Judy Solomon, a senior fellow for the Center on Budget and Policy Priorities, a left-leaning think tank. “This backsliding almost certainly reflects, at least in part, Trump administration policies to weaken public health coverage.”

She attributed the drop to the Trump administration making it harder for families to enroll for coverage in Medicaid by curtailing outreach efforts, allowing states to ask for more paperwork and proposing a so-called public charge rule that would make it harder for legal immigrants to get permanent resident status if they have received certain kinds of public assistance – including Medicaid.

Tom Miller, a resident fellow at the American Enterprise Institute, a conservative think tank, said the drop in Medicaid coverage “is a positive.”

“When the economy grows Medicaid eventually drops,” he said.

One reason for the drop in health coverage is that middle-income families can’t afford the rising cost of insurance in the individual market, particularly if they don’t qualify for government subsidies, he added.

“On balance, this is some short-term noise,” he said of the uptick in the uninsured rate. “I would put more stake in it if happens for several years.”

Chris Pope, a senior fellow with the conservative Manhattan Institute, also said he considered the change “fairly small” and likely caused by increasing wages “pushing people above the income eligibility cutoff in Medicaid expansion states.”

But he suggested that next year would be a better indicator of how changes in the ACA are playing out. “I expect that the mandate repeal will make next year’s increase in the uninsured more significant.”

Kaiser Health News is a nonprofit national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation that is not affiliated with Kaiser Permanente.

For the first time in a decade, the number of Americans without health insurance has risen – by about 2 million people in 2018 – according to the annual U.S. Census Bureau report released Sept. 10, 2019.

The Census found that 8.5% of the U.S. population went without medical insurance for all of 2018, up from 7.9% in 2017. By contrast, in 2013, before the Affordable Care Act took full effect, 13.3% were uninsured. It was the first year-to-year increase since 2008-09, Census officials said, adding that most of the drop in health coverage was related to a 0.7% decline in Medicaid participants. The number of people with private insurance remained steady and there was a 0.4% increase in those on Medicare.

Many of those losing coverage were noncitizens, a possible fallout from the Trump administration’s tough immigration policies and rhetoric. About 574,000 noncitizens lost coverage in 2018, a drop of about 2.3%, the report found.

“Uninsured noncitizens account for almost a third of the increase in uninsured, which may reflect the administration’s more aggressive stance on immigration,” said Joseph Antos, a health economist at the American Enterprise Institute.

The increase in the number of uninsured people in 2018 was remarkable because uninsured rates typically fall or hold steady when unemployment rates drop. The U.S. unemployment rate fell slightly from about 4.3% in 2017 to 4% in 2018.

The uninsured rate continued to vary by poverty status and whether a state expanded its Medicaid program under Obamacare. Texas (17.7%), Oklahoma (14.2%), Georgia (13.7%), and Florida (13%) had the highest uninsured rates in 2018, according to the report. None of those states have expanded Medicaid under Obamacare.

The percentage of uninsured children aged under 19 years increased by 0.6 percentage points from 2017 to 2018, to 5.5%.

“The Census data are clear – the uninsured rate for kids is up sharply and it’s due to a loss of public coverage – mostly Medicaid,” Joan Alker, executive director of Georgetown University Center for Children and Families, said in a statement.

“These children are not getting private coverage as the Trump administration has suggested but rather becoming uninsured,” she said. “This serious erosion of children’s health coverage is due in large part to the Trump administration’s actions that have made health care harder to access and have deterred families from enrolling their children.”

The share of Americans without medical insurance fell steadily since 2014 but then leveled off in 2017, the year Mr. Trump became president.

Health care advocates have complained that efforts by the Trump administration and Congress are jeopardizing insurance enrollment. They point to cuts in outreach programs that aim to tell consumers about their health care options under Obamacare and the elimination of the ACA’s tax penalty for people who don’t have health coverage.

Ms. Alker complained that the administration’s policies are causing the loss of children’s coverage. “In a period of continued economic and job growth, we shouldn’t be going backwards on health coverage,” said Judy Solomon, a senior fellow for the Center on Budget and Policy Priorities, a left-leaning think tank. “This backsliding almost certainly reflects, at least in part, Trump administration policies to weaken public health coverage.”

She attributed the drop to the Trump administration making it harder for families to enroll for coverage in Medicaid by curtailing outreach efforts, allowing states to ask for more paperwork and proposing a so-called public charge rule that would make it harder for legal immigrants to get permanent resident status if they have received certain kinds of public assistance – including Medicaid.

Tom Miller, a resident fellow at the American Enterprise Institute, a conservative think tank, said the drop in Medicaid coverage “is a positive.”

“When the economy grows Medicaid eventually drops,” he said.

One reason for the drop in health coverage is that middle-income families can’t afford the rising cost of insurance in the individual market, particularly if they don’t qualify for government subsidies, he added.

“On balance, this is some short-term noise,” he said of the uptick in the uninsured rate. “I would put more stake in it if happens for several years.”

Chris Pope, a senior fellow with the conservative Manhattan Institute, also said he considered the change “fairly small” and likely caused by increasing wages “pushing people above the income eligibility cutoff in Medicaid expansion states.”

But he suggested that next year would be a better indicator of how changes in the ACA are playing out. “I expect that the mandate repeal will make next year’s increase in the uninsured more significant.”

Kaiser Health News is a nonprofit national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation that is not affiliated with Kaiser Permanente.

Patients with psoriatic arthritis who participated in a tight control program for 48 weeks showed no clinical advantage over patients who received usual care when reviewed again 5 years after having gone back to standard rheumatology care outside of the study, based on data from 110 patients in the TIght COntrol of inflammation in early Psoriatic Arthritis (TICOPA) study.

In the original study, significantly more adults with psoriatic arthritis (PsA) who were randomized to a tight control, treat-to-target group achieved minimal disease activity criteria after 48 weeks, compared with a standard care group (40% vs. 25%).

“Following exit from this study, we hypothesized that this advantage would translate to a clinical advantage in the medium term,” wrote Laura C. Coates, MBChB, PhD, of the University of Oxford (England) and colleagues.

In a study published in Rheumatology, the researchers examined data from 54 patients in the tight control arm of TICOPA and 56 patients in the standard care arm.

At 5 years after the completion of the TICOPA study, 69% of patients in the tight control group and 76% of patients in the standard care group were considered to be in low disease activity. In addition, methotrexate use after 5 years was similar between the tight control and standard care groups (44% and 54%, respectively) and both groups had reduced methotrexate use since the study’s end.

Overall use of biologic drugs was similar between the tight control and standard care groups after 5 years (54% and 52%, respectively), although overall use of biologics was higher in the tight control group at the end of the original study, compared with the standard care group (33% vs. 9%).

The findings were limited by several factors, notably the lack of intention to continue treatment or observations beyond the end of the original TICOPA study, and the patients’ status at 5 years was based on routine clinician notes with no formal assessment of minimal disease activity or objective measure of disease status, the researchers noted.

However, “this result reflects clinical practice in routine rheumatology care,” and any benefit of early tight control on later disease activity could not be determined, they added.

The current study was funded by the National Institute for Health Research infrastructure at Leeds and Oxford (England). The original TICOPA study was funded by Arthritis Research UK (now called Versus Arthritis) and Pfizer. Some of the investigators disclosed financial relationships with companies that market drugs for PsA.

SOURCE: Coates LC et al. Rheumatology. 2019 Aug 31. doi: 10.1093/rheumatology/kez369.

Patients with psoriatic arthritis who participated in a tight control program for 48 weeks showed no clinical advantage over patients who received usual care when reviewed again 5 years after having gone back to standard rheumatology care outside of the study, based on data from 110 patients in the TIght COntrol of inflammation in early Psoriatic Arthritis (TICOPA) study.

In the original study, significantly more adults with psoriatic arthritis (PsA) who were randomized to a tight control, treat-to-target group achieved minimal disease activity criteria after 48 weeks, compared with a standard care group (40% vs. 25%).

“Following exit from this study, we hypothesized that this advantage would translate to a clinical advantage in the medium term,” wrote Laura C. Coates, MBChB, PhD, of the University of Oxford (England) and colleagues.

In a study published in Rheumatology, the researchers examined data from 54 patients in the tight control arm of TICOPA and 56 patients in the standard care arm.

At 5 years after the completion of the TICOPA study, 69% of patients in the tight control group and 76% of patients in the standard care group were considered to be in low disease activity. In addition, methotrexate use after 5 years was similar between the tight control and standard care groups (44% and 54%, respectively) and both groups had reduced methotrexate use since the study’s end.

Overall use of biologic drugs was similar between the tight control and standard care groups after 5 years (54% and 52%, respectively), although overall use of biologics was higher in the tight control group at the end of the original study, compared with the standard care group (33% vs. 9%).

The findings were limited by several factors, notably the lack of intention to continue treatment or observations beyond the end of the original TICOPA study, and the patients’ status at 5 years was based on routine clinician notes with no formal assessment of minimal disease activity or objective measure of disease status, the researchers noted.

However, “this result reflects clinical practice in routine rheumatology care,” and any benefit of early tight control on later disease activity could not be determined, they added.

The current study was funded by the National Institute for Health Research infrastructure at Leeds and Oxford (England). The original TICOPA study was funded by Arthritis Research UK (now called Versus Arthritis) and Pfizer. Some of the investigators disclosed financial relationships with companies that market drugs for PsA.

SOURCE: Coates LC et al. Rheumatology. 2019 Aug 31. doi: 10.1093/rheumatology/kez369.

Patients with psoriatic arthritis who participated in a tight control program for 48 weeks showed no clinical advantage over patients who received usual care when reviewed again 5 years after having gone back to standard rheumatology care outside of the study, based on data from 110 patients in the TIght COntrol of inflammation in early Psoriatic Arthritis (TICOPA) study.

In the original study, significantly more adults with psoriatic arthritis (PsA) who were randomized to a tight control, treat-to-target group achieved minimal disease activity criteria after 48 weeks, compared with a standard care group (40% vs. 25%).

“Following exit from this study, we hypothesized that this advantage would translate to a clinical advantage in the medium term,” wrote Laura C. Coates, MBChB, PhD, of the University of Oxford (England) and colleagues.

In a study published in Rheumatology, the researchers examined data from 54 patients in the tight control arm of TICOPA and 56 patients in the standard care arm.

At 5 years after the completion of the TICOPA study, 69% of patients in the tight control group and 76% of patients in the standard care group were considered to be in low disease activity. In addition, methotrexate use after 5 years was similar between the tight control and standard care groups (44% and 54%, respectively) and both groups had reduced methotrexate use since the study’s end.

Overall use of biologic drugs was similar between the tight control and standard care groups after 5 years (54% and 52%, respectively), although overall use of biologics was higher in the tight control group at the end of the original study, compared with the standard care group (33% vs. 9%).

The findings were limited by several factors, notably the lack of intention to continue treatment or observations beyond the end of the original TICOPA study, and the patients’ status at 5 years was based on routine clinician notes with no formal assessment of minimal disease activity or objective measure of disease status, the researchers noted.

However, “this result reflects clinical practice in routine rheumatology care,” and any benefit of early tight control on later disease activity could not be determined, they added.

The current study was funded by the National Institute for Health Research infrastructure at Leeds and Oxford (England). The original TICOPA study was funded by Arthritis Research UK (now called Versus Arthritis) and Pfizer. Some of the investigators disclosed financial relationships with companies that market drugs for PsA.

SOURCE: Coates LC et al. Rheumatology. 2019 Aug 31. doi: 10.1093/rheumatology/kez369.

Leadership is both a science and an art, requiring a process, influence, and vision.¹ And—coincidentally?—we could also define nursing in those terms. After all, health care leaders must possess the vision and ability to translate their passion and establish an environment of trust with their teams to achieve the desired outcome.

When I reflect on my experiences as an NP, I think about those who influenced me to pursue this career. My mentors were both scientists and artists who translated their passion to me. Without their combination of caring and competence, I wouldn’t be where I am today. There’d be one less NP—and for me, part of being an NP is showing others the essential value of our profession.

Throughout my career, my mission was to bring NPs into more health care settings—such as urgent care and emergency departments in rural areas—where greater access to care was needed and where NPs were woefully underutilized. Advocating for NPs also led me into nonclinical settings, such as my time as a Health Policy Coordinator. As mentioned last week, this position required me to communicate the needs of both patients and health care providers to multiple groups, including industry associations, federal agencies, and professional licensure boards. No matter the setting, I had to understand its specific function and needs in order to envision and then explain how it would benefit from a stronger NP presence. This always included how NPs would complement other health care providers and professionals.

My mission to bring the NP role to new settings led me to surprising places. For example, I had the opportunity to be the first NP to serve as a Medical Officer on an expedition for JASON Learning—a pioneering nonprofit organization established to engage students in scientific research and expeditions led by leading scientists.² How did I do that, you ask? Well, as a graduate student, I worked on a project with the JASON team. When I had the chance to speak with the expedition coordinator, I mentioned my interest in marine biology. I then asked about the composition of the expedition support team and discovered that they didn’t have an NP. Here was the chance to utilize my communication skills to sell the idea of having a pediatric NP (PNP) on an expedition! I explained my vision of the role a PNP could play, emphasizing how an expedition would benefit from an NP with experience in caring for teenagers.

I must have been persuasive, because that conversation landed me with a primary role as the health care provider on an expedition to the Everglades National Park in Florida. In addition to reviewing the medical history of each “Argonaut” (participant), I treated minor illnesses and injuries and prevented sunburn during the expedition. I also had the opportunity to become certified in Snorkel and SCUBA—and I still use the former today. As a bonus, I met Bob Ballard (known for finding the wreckage of the RMS Titanic) and learned how to tag an alligator.

The excursion to the Everglades was an accomplishment that needed a process, influence, and vision. Later, when championing the creation of AANP, I was able to put these skills into action again. In 1984, when there was no group dedicated to representing NPs, I challenged an audience of colleagues to start a new organization and offered up seed money. A small group of us soon banded together and eventually rallied other NPs to embrace the concept of an NP-specific organization. We developed bylaws, and a year later, our organization was incorporated as a 501(c)(3). The legal address was my home in Lowell, Massachusetts.

Each of these situations required a relationship with the people on the team and a mission to expand the NP profession. In every situation, I translated my vision to others, and we worked together to achieve goals—just as I had been taught through the example of my own mentors.

Continue to: Keep the concepts of...

Keep the concepts of relationship and vison in mind as we continue discussing leadership next Thursday in Part 3. In the meantime, please share your thoughts, approaches, and accomplishments as a leader.

Leadership is both a science and an art, requiring a process, influence, and vision.¹ And—coincidentally?—we could also define nursing in those terms. After all, health care leaders must possess the vision and ability to translate their passion and establish an environment of trust with their teams to achieve the desired outcome.

When I reflect on my experiences as an NP, I think about those who influenced me to pursue this career. My mentors were both scientists and artists who translated their passion to me. Without their combination of caring and competence, I wouldn’t be where I am today. There’d be one less NP—and for me, part of being an NP is showing others the essential value of our profession.

Throughout my career, my mission was to bring NPs into more health care settings—such as urgent care and emergency departments in rural areas—where greater access to care was needed and where NPs were woefully underutilized. Advocating for NPs also led me into nonclinical settings, such as my time as a Health Policy Coordinator. As mentioned last week, this position required me to communicate the needs of both patients and health care providers to multiple groups, including industry associations, federal agencies, and professional licensure boards. No matter the setting, I had to understand its specific function and needs in order to envision and then explain how it would benefit from a stronger NP presence. This always included how NPs would complement other health care providers and professionals.

My mission to bring the NP role to new settings led me to surprising places. For example, I had the opportunity to be the first NP to serve as a Medical Officer on an expedition for JASON Learning—a pioneering nonprofit organization established to engage students in scientific research and expeditions led by leading scientists.² How did I do that, you ask? Well, as a graduate student, I worked on a project with the JASON team. When I had the chance to speak with the expedition coordinator, I mentioned my interest in marine biology. I then asked about the composition of the expedition support team and discovered that they didn’t have an NP. Here was the chance to utilize my communication skills to sell the idea of having a pediatric NP (PNP) on an expedition! I explained my vision of the role a PNP could play, emphasizing how an expedition would benefit from an NP with experience in caring for teenagers.

I must have been persuasive, because that conversation landed me with a primary role as the health care provider on an expedition to the Everglades National Park in Florida. In addition to reviewing the medical history of each “Argonaut” (participant), I treated minor illnesses and injuries and prevented sunburn during the expedition. I also had the opportunity to become certified in Snorkel and SCUBA—and I still use the former today. As a bonus, I met Bob Ballard (known for finding the wreckage of the RMS Titanic) and learned how to tag an alligator.

The excursion to the Everglades was an accomplishment that needed a process, influence, and vision. Later, when championing the creation of AANP, I was able to put these skills into action again. In 1984, when there was no group dedicated to representing NPs, I challenged an audience of colleagues to start a new organization and offered up seed money. A small group of us soon banded together and eventually rallied other NPs to embrace the concept of an NP-specific organization. We developed bylaws, and a year later, our organization was incorporated as a 501(c)(3). The legal address was my home in Lowell, Massachusetts.

Each of these situations required a relationship with the people on the team and a mission to expand the NP profession. In every situation, I translated my vision to others, and we worked together to achieve goals—just as I had been taught through the example of my own mentors.

Continue to: Keep the concepts of...

Keep the concepts of relationship and vison in mind as we continue discussing leadership next Thursday in Part 3. In the meantime, please share your thoughts, approaches, and accomplishments as a leader.

Leadership is both a science and an art, requiring a process, influence, and vision.¹ And—coincidentally?—we could also define nursing in those terms. After all, health care leaders must possess the vision and ability to translate their passion and establish an environment of trust with their teams to achieve the desired outcome.

When I reflect on my experiences as an NP, I think about those who influenced me to pursue this career. My mentors were both scientists and artists who translated their passion to me. Without their combination of caring and competence, I wouldn’t be where I am today. There’d be one less NP—and for me, part of being an NP is showing others the essential value of our profession.

Throughout my career, my mission was to bring NPs into more health care settings—such as urgent care and emergency departments in rural areas—where greater access to care was needed and where NPs were woefully underutilized. Advocating for NPs also led me into nonclinical settings, such as my time as a Health Policy Coordinator. As mentioned last week, this position required me to communicate the needs of both patients and health care providers to multiple groups, including industry associations, federal agencies, and professional licensure boards. No matter the setting, I had to understand its specific function and needs in order to envision and then explain how it would benefit from a stronger NP presence. This always included how NPs would complement other health care providers and professionals.

My mission to bring the NP role to new settings led me to surprising places. For example, I had the opportunity to be the first NP to serve as a Medical Officer on an expedition for JASON Learning—a pioneering nonprofit organization established to engage students in scientific research and expeditions led by leading scientists.² How did I do that, you ask? Well, as a graduate student, I worked on a project with the JASON team. When I had the chance to speak with the expedition coordinator, I mentioned my interest in marine biology. I then asked about the composition of the expedition support team and discovered that they didn’t have an NP. Here was the chance to utilize my communication skills to sell the idea of having a pediatric NP (PNP) on an expedition! I explained my vision of the role a PNP could play, emphasizing how an expedition would benefit from an NP with experience in caring for teenagers.

I must have been persuasive, because that conversation landed me with a primary role as the health care provider on an expedition to the Everglades National Park in Florida. In addition to reviewing the medical history of each “Argonaut” (participant), I treated minor illnesses and injuries and prevented sunburn during the expedition. I also had the opportunity to become certified in Snorkel and SCUBA—and I still use the former today. As a bonus, I met Bob Ballard (known for finding the wreckage of the RMS Titanic) and learned how to tag an alligator.

The excursion to the Everglades was an accomplishment that needed a process, influence, and vision. Later, when championing the creation of AANP, I was able to put these skills into action again. In 1984, when there was no group dedicated to representing NPs, I challenged an audience of colleagues to start a new organization and offered up seed money. A small group of us soon banded together and eventually rallied other NPs to embrace the concept of an NP-specific organization. We developed bylaws, and a year later, our organization was incorporated as a 501(c)(3). The legal address was my home in Lowell, Massachusetts.

Each of these situations required a relationship with the people on the team and a mission to expand the NP profession. In every situation, I translated my vision to others, and we worked together to achieve goals—just as I had been taught through the example of my own mentors.

Continue to: Keep the concepts of...

Keep the concepts of relationship and vison in mind as we continue discussing leadership next Thursday in Part 3. In the meantime, please share your thoughts, approaches, and accomplishments as a leader.

A new Streptococcus pyogenes genotype (designated M1_UK) emerged in 2014 in England causing an increase in scarlet fever “unprecedented in modern times.” Researchers discovered that this new genotype became dominant during this increased period of scarlet fever. This new genotype was characterized by an increased production of streptococcal pyrogenic exotoxin A (SpeA, also known as scarlet fever or erythrogenic toxin A) compared to previous isolates, according to a report in The Lancet Infectious Diseases.

CDC

[email protected]

SOURCE: Linskey NN et al. Lancet Infect Dis. 2019. doi: 10.1016/S1473-3099(19)30446-3.

A new Streptococcus pyogenes genotype (designated M1_UK) emerged in 2014 in England causing an increase in scarlet fever “unprecedented in modern times.” Researchers discovered that this new genotype became dominant during this increased period of scarlet fever. This new genotype was characterized by an increased production of streptococcal pyrogenic exotoxin A (SpeA, also known as scarlet fever or erythrogenic toxin A) compared to previous isolates, according to a report in The Lancet Infectious Diseases.

CDC

[email protected]

SOURCE: Linskey NN et al. Lancet Infect Dis. 2019. doi: 10.1016/S1473-3099(19)30446-3.

A new Streptococcus pyogenes genotype (designated M1_UK) emerged in 2014 in England causing an increase in scarlet fever “unprecedented in modern times.” Researchers discovered that this new genotype became dominant during this increased period of scarlet fever. This new genotype was characterized by an increased production of streptococcal pyrogenic exotoxin A (SpeA, also known as scarlet fever or erythrogenic toxin A) compared to previous isolates, according to a report in The Lancet Infectious Diseases.

CDC

[email protected]

SOURCE: Linskey NN et al. Lancet Infect Dis. 2019. doi: 10.1016/S1473-3099(19)30446-3.

A district judge has temporarily blocked a North Dakota law that forces physicians to tell patients that medication abortions may be reversed, calling the measure devoid of scientific support.

In a Sept. 10 ruling, Judge Daniel Hovland of the U.S. District Court for the District of North Dakota temporarily halted enforcement of North Dakota House Bill 1336, a law that required doctors to tell women that reversing the effects of abortion-inducing drugs is possible if patients changed their minds, but that “time is of the essence.” In his 24-page decision, Judge Hovland said the North Dakota law violates a physician’s right not to speak and goes far beyond any informed consent laws addressed by the U.S. Supreme Court or other courts to date.

“Legislation which forces physicians to tell their patients, as part of informed consent, that ‘it may be possible’ to reverse or cure an ailment, disease, illness, surgical procedure, or the effects of any medication – in the absence of any medical or scientific evidence to support such a message – is unsound, misplaced, and would not survive a constitutional challenge under any level of scrutiny,” Judge Hovland wrote in his ruling. “State legislatures should not be mandating unproven medical treatments, or requiring physicians to provide patients with misleading and inaccurate information.”

North Dakota Governor Doug Burgum (R), signed HB 1336 into law in March. The measure requires that physicians inform patients at least 24 hours before a medication abortion that it may be possible to reverse the effects if they change their mind, and also mandates that doctors provide printed materials to patients with information about reversing the effects of an abortion-inducing drug.

The American Medical Association and the Red River Women’s Clinic based in Fargo, issued a joint legal challenge against North Dakota Attorney General Wayne Stenehjem in June over the law. The plaintiffs contend the North Dakota law violates physicians’ First Amendment rights that protect doctors from being compelled to speak against their will. The plaintiffs also argued that so-called abortion reversals are based on controversial, unproven theories that are rejected by major medical organizations.

The lawsuit also challenges an existing North Dakota law called the Abortion Control Act, that requires physicians to tell patients that abortion terminates “the life of a whole, separate, unique, living human being,” which the plaintiffs contend is a controversial, ideological, and nonmedical message that forces physicians to act as the mouthpiece of the state. That part of the lawsuit was not addressed in Judge Hovland’s ruling.

AMA President Patrice A. Harris, MD, said the association was pleased that the judge blocked enforcement of HB 1336 while the case advances in the court system.

“The AMA filed this lawsuit in North Dakota because we strongly believe the government should not dictate what physicians say to their patients,” Dr. Harris said in a statement. “With this ruling, physicians in North Dakota will not be forced by law to provide patients with false, misleading, non-medical information about reproductive health that contradicts reality and science.”

A spokeswoman for Mr. Stenehjem’s office said the attorney general is reviewing the order and declined to comment further.

At least seven other states have passed similar laws requiring physicians to tell patients about the possibility of medication abortion reversals, including Arkansas, Idaho, Kentucky, Nebraska, Oklahoma, South Dakota, and Utah.

[email protected]

A district judge has temporarily blocked a North Dakota law that forces physicians to tell patients that medication abortions may be reversed, calling the measure devoid of scientific support.

In a Sept. 10 ruling, Judge Daniel Hovland of the U.S. District Court for the District of North Dakota temporarily halted enforcement of North Dakota House Bill 1336, a law that required doctors to tell women that reversing the effects of abortion-inducing drugs is possible if patients changed their minds, but that “time is of the essence.” In his 24-page decision, Judge Hovland said the North Dakota law violates a physician’s right not to speak and goes far beyond any informed consent laws addressed by the U.S. Supreme Court or other courts to date.

“Legislation which forces physicians to tell their patients, as part of informed consent, that ‘it may be possible’ to reverse or cure an ailment, disease, illness, surgical procedure, or the effects of any medication – in the absence of any medical or scientific evidence to support such a message – is unsound, misplaced, and would not survive a constitutional challenge under any level of scrutiny,” Judge Hovland wrote in his ruling. “State legislatures should not be mandating unproven medical treatments, or requiring physicians to provide patients with misleading and inaccurate information.”

North Dakota Governor Doug Burgum (R), signed HB 1336 into law in March. The measure requires that physicians inform patients at least 24 hours before a medication abortion that it may be possible to reverse the effects if they change their mind, and also mandates that doctors provide printed materials to patients with information about reversing the effects of an abortion-inducing drug.

The American Medical Association and the Red River Women’s Clinic based in Fargo, issued a joint legal challenge against North Dakota Attorney General Wayne Stenehjem in June over the law. The plaintiffs contend the North Dakota law violates physicians’ First Amendment rights that protect doctors from being compelled to speak against their will. The plaintiffs also argued that so-called abortion reversals are based on controversial, unproven theories that are rejected by major medical organizations.

The lawsuit also challenges an existing North Dakota law called the Abortion Control Act, that requires physicians to tell patients that abortion terminates “the life of a whole, separate, unique, living human being,” which the plaintiffs contend is a controversial, ideological, and nonmedical message that forces physicians to act as the mouthpiece of the state. That part of the lawsuit was not addressed in Judge Hovland’s ruling.

AMA President Patrice A. Harris, MD, said the association was pleased that the judge blocked enforcement of HB 1336 while the case advances in the court system.

“The AMA filed this lawsuit in North Dakota because we strongly believe the government should not dictate what physicians say to their patients,” Dr. Harris said in a statement. “With this ruling, physicians in North Dakota will not be forced by law to provide patients with false, misleading, non-medical information about reproductive health that contradicts reality and science.”

A spokeswoman for Mr. Stenehjem’s office said the attorney general is reviewing the order and declined to comment further.

At least seven other states have passed similar laws requiring physicians to tell patients about the possibility of medication abortion reversals, including Arkansas, Idaho, Kentucky, Nebraska, Oklahoma, South Dakota, and Utah.

[email protected]

A district judge has temporarily blocked a North Dakota law that forces physicians to tell patients that medication abortions may be reversed, calling the measure devoid of scientific support.

In a Sept. 10 ruling, Judge Daniel Hovland of the U.S. District Court for the District of North Dakota temporarily halted enforcement of North Dakota House Bill 1336, a law that required doctors to tell women that reversing the effects of abortion-inducing drugs is possible if patients changed their minds, but that “time is of the essence.” In his 24-page decision, Judge Hovland said the North Dakota law violates a physician’s right not to speak and goes far beyond any informed consent laws addressed by the U.S. Supreme Court or other courts to date.

“Legislation which forces physicians to tell their patients, as part of informed consent, that ‘it may be possible’ to reverse or cure an ailment, disease, illness, surgical procedure, or the effects of any medication – in the absence of any medical or scientific evidence to support such a message – is unsound, misplaced, and would not survive a constitutional challenge under any level of scrutiny,” Judge Hovland wrote in his ruling. “State legislatures should not be mandating unproven medical treatments, or requiring physicians to provide patients with misleading and inaccurate information.”

North Dakota Governor Doug Burgum (R), signed HB 1336 into law in March. The measure requires that physicians inform patients at least 24 hours before a medication abortion that it may be possible to reverse the effects if they change their mind, and also mandates that doctors provide printed materials to patients with information about reversing the effects of an abortion-inducing drug.

The American Medical Association and the Red River Women’s Clinic based in Fargo, issued a joint legal challenge against North Dakota Attorney General Wayne Stenehjem in June over the law. The plaintiffs contend the North Dakota law violates physicians’ First Amendment rights that protect doctors from being compelled to speak against their will. The plaintiffs also argued that so-called abortion reversals are based on controversial, unproven theories that are rejected by major medical organizations.

The lawsuit also challenges an existing North Dakota law called the Abortion Control Act, that requires physicians to tell patients that abortion terminates “the life of a whole, separate, unique, living human being,” which the plaintiffs contend is a controversial, ideological, and nonmedical message that forces physicians to act as the mouthpiece of the state. That part of the lawsuit was not addressed in Judge Hovland’s ruling.

AMA President Patrice A. Harris, MD, said the association was pleased that the judge blocked enforcement of HB 1336 while the case advances in the court system.

“The AMA filed this lawsuit in North Dakota because we strongly believe the government should not dictate what physicians say to their patients,” Dr. Harris said in a statement. “With this ruling, physicians in North Dakota will not be forced by law to provide patients with false, misleading, non-medical information about reproductive health that contradicts reality and science.”

A spokeswoman for Mr. Stenehjem’s office said the attorney general is reviewing the order and declined to comment further.

At least seven other states have passed similar laws requiring physicians to tell patients about the possibility of medication abortion reversals, including Arkansas, Idaho, Kentucky, Nebraska, Oklahoma, South Dakota, and Utah.

[email protected]

Researchers from University College London in the United Kingdom and University of Amsterdam in the Netherlands who conducted a systematic review of available research found a “striking” lack of evidence, considering the vast interest in the potential of the treatment and the “overwhelming demand by veterans.”

The researchers wanted to conduct a “fine-grained evaluation” of cannabinoid effectiveness in posttraumatic stress disorder (PTSD). They identified 10 studies investigating medicinal cannabinoids for patients with PTSD who were experiencing symptoms that were measured by a clinical psychometric, such as the Clinician-Administered PTSD Scale. Only 1 was a randomized, double-blind, placebo-controlled crossover clinical trial. Three studies used nabilone, a synthetic delta9-tetrahydrocannabinol (THC) analog; 1 used oral THC; 2 used cannabidiol (CBD) oil, and 4 used smoked herbal preparations of cannabis.

In line with previous reviews, the researchers found insufficient evidence to support the use of cannabinoids as a psychopharmacologic treatment for PTSD. In fact, they suggest that the lack of evidence poses a public health risk. However, the researchers say, this is mainly because the available support so far has been limited to small, “low-quality” studies, anecdotal reports, and some experimental evidence. There are reasons to keep investigating the possibilities, they conclude.

For instance, there is concurrence among studies that medicinal cannabinoids can help with sleep disturbances, and thus may be more effective, with less risk of addiction than benzodiazepines or opiate-based medications. Self-reports, anecdotal accounts, and case reports suggest that medical cannabis can dramatically reduce not only sleep symptoms, such as insomnia and nightmares, but may help with traumatic intrusions, hyperarousal, stress, anxiety, and depression.

The researchers also cite a study that found veterans who use cannabis believe it to be more effective and less complicated by adverse effects (AEs) than are alcohol and other psychopharmaceuticals. The AEs are generally mild to moderate, such as dry mouth and feeling “stoned,” but compared with the AEs of currently prescribed drugs are considered less burdensome.

Safety concerns are particularly critical in this population, though. Some research has shown that rates of cannabis use disorder are greater among patients who have PTSD compared with those who do not. A study of veterans admitted to US Department of Veterans Affairs treatment programs found recreational cannabis users with PTSD had poorer outcomes on severity of symptoms, violent behavior, and other drug use. Cannabinoids have also been associated with severe AEs in people with a history of psychosis—a consideration in combat veterans who have hallucinations or delusions.

Although they used strict inclusion criteria, the researchers say the studies they used still had “significant” limitations. Future well-controlled, randomized, double-blind clinical trials are highly warranted, they add, to address the “large unmet need” for effective PTSD treatments.

Researchers from University College London in the United Kingdom and University of Amsterdam in the Netherlands who conducted a systematic review of available research found a “striking” lack of evidence, considering the vast interest in the potential of the treatment and the “overwhelming demand by veterans.”

The researchers wanted to conduct a “fine-grained evaluation” of cannabinoid effectiveness in posttraumatic stress disorder (PTSD). They identified 10 studies investigating medicinal cannabinoids for patients with PTSD who were experiencing symptoms that were measured by a clinical psychometric, such as the Clinician-Administered PTSD Scale. Only 1 was a randomized, double-blind, placebo-controlled crossover clinical trial. Three studies used nabilone, a synthetic delta9-tetrahydrocannabinol (THC) analog; 1 used oral THC; 2 used cannabidiol (CBD) oil, and 4 used smoked herbal preparations of cannabis.

In line with previous reviews, the researchers found insufficient evidence to support the use of cannabinoids as a psychopharmacologic treatment for PTSD. In fact, they suggest that the lack of evidence poses a public health risk. However, the researchers say, this is mainly because the available support so far has been limited to small, “low-quality” studies, anecdotal reports, and some experimental evidence. There are reasons to keep investigating the possibilities, they conclude.

For instance, there is concurrence among studies that medicinal cannabinoids can help with sleep disturbances, and thus may be more effective, with less risk of addiction than benzodiazepines or opiate-based medications. Self-reports, anecdotal accounts, and case reports suggest that medical cannabis can dramatically reduce not only sleep symptoms, such as insomnia and nightmares, but may help with traumatic intrusions, hyperarousal, stress, anxiety, and depression.

The researchers also cite a study that found veterans who use cannabis believe it to be more effective and less complicated by adverse effects (AEs) than are alcohol and other psychopharmaceuticals. The AEs are generally mild to moderate, such as dry mouth and feeling “stoned,” but compared with the AEs of currently prescribed drugs are considered less burdensome.

Safety concerns are particularly critical in this population, though. Some research has shown that rates of cannabis use disorder are greater among patients who have PTSD compared with those who do not. A study of veterans admitted to US Department of Veterans Affairs treatment programs found recreational cannabis users with PTSD had poorer outcomes on severity of symptoms, violent behavior, and other drug use. Cannabinoids have also been associated with severe AEs in people with a history of psychosis—a consideration in combat veterans who have hallucinations or delusions.

Although they used strict inclusion criteria, the researchers say the studies they used still had “significant” limitations. Future well-controlled, randomized, double-blind clinical trials are highly warranted, they add, to address the “large unmet need” for effective PTSD treatments.

Researchers from University College London in the United Kingdom and University of Amsterdam in the Netherlands who conducted a systematic review of available research found a “striking” lack of evidence, considering the vast interest in the potential of the treatment and the “overwhelming demand by veterans.”

The researchers wanted to conduct a “fine-grained evaluation” of cannabinoid effectiveness in posttraumatic stress disorder (PTSD). They identified 10 studies investigating medicinal cannabinoids for patients with PTSD who were experiencing symptoms that were measured by a clinical psychometric, such as the Clinician-Administered PTSD Scale. Only 1 was a randomized, double-blind, placebo-controlled crossover clinical trial. Three studies used nabilone, a synthetic delta9-tetrahydrocannabinol (THC) analog; 1 used oral THC; 2 used cannabidiol (CBD) oil, and 4 used smoked herbal preparations of cannabis.

In line with previous reviews, the researchers found insufficient evidence to support the use of cannabinoids as a psychopharmacologic treatment for PTSD. In fact, they suggest that the lack of evidence poses a public health risk. However, the researchers say, this is mainly because the available support so far has been limited to small, “low-quality” studies, anecdotal reports, and some experimental evidence. There are reasons to keep investigating the possibilities, they conclude.

For instance, there is concurrence among studies that medicinal cannabinoids can help with sleep disturbances, and thus may be more effective, with less risk of addiction than benzodiazepines or opiate-based medications. Self-reports, anecdotal accounts, and case reports suggest that medical cannabis can dramatically reduce not only sleep symptoms, such as insomnia and nightmares, but may help with traumatic intrusions, hyperarousal, stress, anxiety, and depression.

The researchers also cite a study that found veterans who use cannabis believe it to be more effective and less complicated by adverse effects (AEs) than are alcohol and other psychopharmaceuticals. The AEs are generally mild to moderate, such as dry mouth and feeling “stoned,” but compared with the AEs of currently prescribed drugs are considered less burdensome.

Safety concerns are particularly critical in this population, though. Some research has shown that rates of cannabis use disorder are greater among patients who have PTSD compared with those who do not. A study of veterans admitted to US Department of Veterans Affairs treatment programs found recreational cannabis users with PTSD had poorer outcomes on severity of symptoms, violent behavior, and other drug use. Cannabinoids have also been associated with severe AEs in people with a history of psychosis—a consideration in combat veterans who have hallucinations or delusions.

Although they used strict inclusion criteria, the researchers say the studies they used still had “significant” limitations. Future well-controlled, randomized, double-blind clinical trials are highly warranted, they add, to address the “large unmet need” for effective PTSD treatments.