Despite popular belief, the absence of a strong link between mental illness and violence has been well studied and established. In summary, in a small subset of patients, mental illness provides a minor increase in the risk of committing violence.¹

In part as a result of this research, police departments across the country have established programs and protocols to divert patients with mental illness out of the legal system and into mental hospitals. Instead of accepting the common refrain that mental illness is the explanation and best predictor of all atrocious behaviors, police departments have correctly referred patients with mental illness to mental hospitals. We commend those initiatives and encourage their adoption in all locales. Yet, to safeguard such programs, we would like to warn of a potential pitfall and offer possible remedies.

Having worked in both correctional and clinical settings, we are saddened by the similar nature of the work with respect to the management of mental illness. It should defy logic to assume the need for mental health care in our jails is in any way comparable to the one in mental hospitals. However, we have grown accustomed to seeing large numbers of our most vulnerable patients with severe mental illness accumulating in our jails and correctional facilities, which often are the largest employers of mental health clinicians. The reasons correctional institutions have become so reliant on psychiatric clinicians are vast and complex. Incarceration is tremendously destabilizing and can lead to the onset or relapse of mental illness – even in the most resilient patients. In addition, mental illness is undertreated in our communities yet inescapable in the confined settings of our jails. Furthermore, our mass incarceration problems have resulted in the most disenfranchised populations, including our patients with mental illness, becoming the targets of policies criminalizing poverty.²

To prevent furthering the process by which our correctional facilities have become the new asylums,³ law enforcement agencies have enacted a vast array of initiatives. Some include the placement of mental health staff within emergency response teams. Some include training police officers in how to talk to patients with mental illness as well as how to deescalate mental health crises. Most of the initiatives have one common goal: diverting patients with mental illness who are better treated in mental hospitals from going to jail. However, herein lies the problem: If mental illness is an explanation for only a small subset of criminal behavior, why is there a large need to divert patients with mental illness from jails to mental hospitals?

Over the past few years, psychiatrists in emergency departments have noted a concerning trend: an increase in referrals to mental hospitals by law enforcement for what appears to be a crime with only a vague or obscure link to mental illness. Most psychiatrists who regularly work in emergency departments will witness many examples. Some might be fairly benign: “They were going to arrest me for trespassing; I was yelling at a coffee shop. But when I told them that I had run out of meds, they brought me here instead.”

However, some stories are more chilling, including the case of an older male who had made threats while shooting his gun in the air and was brought to the emergency department because, as the police officer told us, “I think that he is just depressed; you guys can keep him safe till he is better.”

We applaud society’s desire to reduce the criminalization of mental illness. We think that psychiatry should be deeply involved in the attempts to resolve this problem. Furthermore, we are cognizant that the number of patients with mental illness unnecessarily imprisoned as a result of prosecutorial zealousness is a larger problem than criminals inappropriately brought to mental hospitals. However, we also are aware of the limitation of psychiatric hospitals in solving nonpsychiatric problems.

If mental illness (for the most part) does not cause violence, then when patients with or without mental illness commit a violent act, the response (for the most part) should not be a psychiatric one. Recent studies have demonstrated the need to examine criminogenic needs before psychiatric ones when attempting to reduce recidivism in all offenders, including those with mental illnesses.⁴ The emphasis on addressing psychiatric needs over criminogenic ones is misguided and not based on evidence. Yet, we appreciate the complexity of those questions and of individual cases.

Substance use disorders are emblematic of this problem. Psychiatry has now communicated the position that substance use disorders are mental illness and not a moral failing. However, are the crimes committed by individuals with substance use disorders, whether in a state of intoxication or driven by the cycles of addiction, the blameless result of mental illness? The legal system struggles with this question, trying to determine when addiction-related crimes should be referred to a diversion program or treated as a straightforward criminal prosecution. Those who favor diversion for addiction can point out that many criminal acts are associated with mitigating factors that are no less valid than is addiction.

However, those mitigating factors, such as poverty, childhood deprivation, or a violence-infused sociological milieu, cannot be found in the Diagnostic and Statistical Manual of Mental Disorders. As such, if those factors alone were considered, no diversion would be offered by the courts. There also can be unforeseen consequences to this bias for diversion or criminal prosecution. Violent outbursts are a recognized part of PTSD in veterans. Psychiatrists who work at Veterans Affairs can be faced with the diagnosis of PTSD being used as an excuse for violent behavior, which may, at some level be valid, but which can be dangerous in that labeling a patient with that diagnosis might lower the barriers to violent behavior by providing a ready-made explanation already internalized by the patient through unspoken, sociocultural norms.

With the awareness of the complex nature of the intersectionality of mental illness and criminality, we recommend improvements to current diversion programs. As diversion programs rightfully continue to expand across the country, we likely will see an increase in the number of referrals by police officers to our emergency departments. Some of the referrals will be considered “inappropriate” after thorough and thoughtful clinical evaluation by emergency psychiatrists. The inappropriateness might be secondary to an absence of active symptoms, an absence of correlation between the illness and the offense, or a more urgent criminogenic need.

When faced with someone who will not benefit from diversion to a psychiatric emergency department, psychiatrists should have the tools to revert the person back into the legal system. Those tools could come in many forms – law enforcement liaison, prosecution liaison, or simply the presence of officers who are mandated to wait for the approval of the clinician prior to dismissing legal charges. Whatever the solution might be for any particular locale, policy makers should not wait for adverse events to realize the potential pitfalls of the important work being done in developing our country’s diversion programs.

References

1. Swanson JW et al. Mental illness and reduction of gun violence and suicide: Bringing epidemiologic research to policy. Ann Epidemiol. 2015 May;25(5):366-76.

2. Ehrenreich B. “How America criminalized poverty.” The Guardian. 2011 Aug 10.

3. Roth A. “Prisons are the new asylums.” The Atlantic. 2018 April.

4. Latessa EJ et al. “What works (and doesn’t) in reducing recidivism.” New York: Routledge, 2015.
 

Dr. Badre is a forensic psychiatrist in San Diego and an expert in correctional mental health. He holds teaching positions at the University of California, San Diego, and the University of San Diego. Dr. Badre can be reached at his website, BadreMD.com. Dr. Lehman is an associate professor of psychiatry at the University of California, San Diego. He is codirector of all acute and intensive psychiatric treatment at the Veterans Affairs Medical Center in San Diego, where he practices clinical psychiatry. He also is the course director for the UCSD third-year medical student psychiatry clerkship.

Despite popular belief, the absence of a strong link between mental illness and violence has been well studied and established. In summary, in a small subset of patients, mental illness provides a minor increase in the risk of committing violence.¹

In part as a result of this research, police departments across the country have established programs and protocols to divert patients with mental illness out of the legal system and into mental hospitals. Instead of accepting the common refrain that mental illness is the explanation and best predictor of all atrocious behaviors, police departments have correctly referred patients with mental illness to mental hospitals. We commend those initiatives and encourage their adoption in all locales. Yet, to safeguard such programs, we would like to warn of a potential pitfall and offer possible remedies.

Having worked in both correctional and clinical settings, we are saddened by the similar nature of the work with respect to the management of mental illness. It should defy logic to assume the need for mental health care in our jails is in any way comparable to the one in mental hospitals. However, we have grown accustomed to seeing large numbers of our most vulnerable patients with severe mental illness accumulating in our jails and correctional facilities, which often are the largest employers of mental health clinicians. The reasons correctional institutions have become so reliant on psychiatric clinicians are vast and complex. Incarceration is tremendously destabilizing and can lead to the onset or relapse of mental illness – even in the most resilient patients. In addition, mental illness is undertreated in our communities yet inescapable in the confined settings of our jails. Furthermore, our mass incarceration problems have resulted in the most disenfranchised populations, including our patients with mental illness, becoming the targets of policies criminalizing poverty.²

To prevent furthering the process by which our correctional facilities have become the new asylums,³ law enforcement agencies have enacted a vast array of initiatives. Some include the placement of mental health staff within emergency response teams. Some include training police officers in how to talk to patients with mental illness as well as how to deescalate mental health crises. Most of the initiatives have one common goal: diverting patients with mental illness who are better treated in mental hospitals from going to jail. However, herein lies the problem: If mental illness is an explanation for only a small subset of criminal behavior, why is there a large need to divert patients with mental illness from jails to mental hospitals?

Over the past few years, psychiatrists in emergency departments have noted a concerning trend: an increase in referrals to mental hospitals by law enforcement for what appears to be a crime with only a vague or obscure link to mental illness. Most psychiatrists who regularly work in emergency departments will witness many examples. Some might be fairly benign: “They were going to arrest me for trespassing; I was yelling at a coffee shop. But when I told them that I had run out of meds, they brought me here instead.”

However, some stories are more chilling, including the case of an older male who had made threats while shooting his gun in the air and was brought to the emergency department because, as the police officer told us, “I think that he is just depressed; you guys can keep him safe till he is better.”

We applaud society’s desire to reduce the criminalization of mental illness. We think that psychiatry should be deeply involved in the attempts to resolve this problem. Furthermore, we are cognizant that the number of patients with mental illness unnecessarily imprisoned as a result of prosecutorial zealousness is a larger problem than criminals inappropriately brought to mental hospitals. However, we also are aware of the limitation of psychiatric hospitals in solving nonpsychiatric problems.

If mental illness (for the most part) does not cause violence, then when patients with or without mental illness commit a violent act, the response (for the most part) should not be a psychiatric one. Recent studies have demonstrated the need to examine criminogenic needs before psychiatric ones when attempting to reduce recidivism in all offenders, including those with mental illnesses.⁴ The emphasis on addressing psychiatric needs over criminogenic ones is misguided and not based on evidence. Yet, we appreciate the complexity of those questions and of individual cases.

Substance use disorders are emblematic of this problem. Psychiatry has now communicated the position that substance use disorders are mental illness and not a moral failing. However, are the crimes committed by individuals with substance use disorders, whether in a state of intoxication or driven by the cycles of addiction, the blameless result of mental illness? The legal system struggles with this question, trying to determine when addiction-related crimes should be referred to a diversion program or treated as a straightforward criminal prosecution. Those who favor diversion for addiction can point out that many criminal acts are associated with mitigating factors that are no less valid than is addiction.

However, those mitigating factors, such as poverty, childhood deprivation, or a violence-infused sociological milieu, cannot be found in the Diagnostic and Statistical Manual of Mental Disorders. As such, if those factors alone were considered, no diversion would be offered by the courts. There also can be unforeseen consequences to this bias for diversion or criminal prosecution. Violent outbursts are a recognized part of PTSD in veterans. Psychiatrists who work at Veterans Affairs can be faced with the diagnosis of PTSD being used as an excuse for violent behavior, which may, at some level be valid, but which can be dangerous in that labeling a patient with that diagnosis might lower the barriers to violent behavior by providing a ready-made explanation already internalized by the patient through unspoken, sociocultural norms.

With the awareness of the complex nature of the intersectionality of mental illness and criminality, we recommend improvements to current diversion programs. As diversion programs rightfully continue to expand across the country, we likely will see an increase in the number of referrals by police officers to our emergency departments. Some of the referrals will be considered “inappropriate” after thorough and thoughtful clinical evaluation by emergency psychiatrists. The inappropriateness might be secondary to an absence of active symptoms, an absence of correlation between the illness and the offense, or a more urgent criminogenic need.

When faced with someone who will not benefit from diversion to a psychiatric emergency department, psychiatrists should have the tools to revert the person back into the legal system. Those tools could come in many forms – law enforcement liaison, prosecution liaison, or simply the presence of officers who are mandated to wait for the approval of the clinician prior to dismissing legal charges. Whatever the solution might be for any particular locale, policy makers should not wait for adverse events to realize the potential pitfalls of the important work being done in developing our country’s diversion programs.

References

1. Swanson JW et al. Mental illness and reduction of gun violence and suicide: Bringing epidemiologic research to policy. Ann Epidemiol. 2015 May;25(5):366-76.

2. Ehrenreich B. “How America criminalized poverty.” The Guardian. 2011 Aug 10.

3. Roth A. “Prisons are the new asylums.” The Atlantic. 2018 April.

4. Latessa EJ et al. “What works (and doesn’t) in reducing recidivism.” New York: Routledge, 2015.
 

Dr. Badre is a forensic psychiatrist in San Diego and an expert in correctional mental health. He holds teaching positions at the University of California, San Diego, and the University of San Diego. Dr. Badre can be reached at his website, BadreMD.com. Dr. Lehman is an associate professor of psychiatry at the University of California, San Diego. He is codirector of all acute and intensive psychiatric treatment at the Veterans Affairs Medical Center in San Diego, where he practices clinical psychiatry. He also is the course director for the UCSD third-year medical student psychiatry clerkship.

Despite popular belief, the absence of a strong link between mental illness and violence has been well studied and established. In summary, in a small subset of patients, mental illness provides a minor increase in the risk of committing violence.¹

In part as a result of this research, police departments across the country have established programs and protocols to divert patients with mental illness out of the legal system and into mental hospitals. Instead of accepting the common refrain that mental illness is the explanation and best predictor of all atrocious behaviors, police departments have correctly referred patients with mental illness to mental hospitals. We commend those initiatives and encourage their adoption in all locales. Yet, to safeguard such programs, we would like to warn of a potential pitfall and offer possible remedies.

Having worked in both correctional and clinical settings, we are saddened by the similar nature of the work with respect to the management of mental illness. It should defy logic to assume the need for mental health care in our jails is in any way comparable to the one in mental hospitals. However, we have grown accustomed to seeing large numbers of our most vulnerable patients with severe mental illness accumulating in our jails and correctional facilities, which often are the largest employers of mental health clinicians. The reasons correctional institutions have become so reliant on psychiatric clinicians are vast and complex. Incarceration is tremendously destabilizing and can lead to the onset or relapse of mental illness – even in the most resilient patients. In addition, mental illness is undertreated in our communities yet inescapable in the confined settings of our jails. Furthermore, our mass incarceration problems have resulted in the most disenfranchised populations, including our patients with mental illness, becoming the targets of policies criminalizing poverty.²

To prevent furthering the process by which our correctional facilities have become the new asylums,³ law enforcement agencies have enacted a vast array of initiatives. Some include the placement of mental health staff within emergency response teams. Some include training police officers in how to talk to patients with mental illness as well as how to deescalate mental health crises. Most of the initiatives have one common goal: diverting patients with mental illness who are better treated in mental hospitals from going to jail. However, herein lies the problem: If mental illness is an explanation for only a small subset of criminal behavior, why is there a large need to divert patients with mental illness from jails to mental hospitals?

Over the past few years, psychiatrists in emergency departments have noted a concerning trend: an increase in referrals to mental hospitals by law enforcement for what appears to be a crime with only a vague or obscure link to mental illness. Most psychiatrists who regularly work in emergency departments will witness many examples. Some might be fairly benign: “They were going to arrest me for trespassing; I was yelling at a coffee shop. But when I told them that I had run out of meds, they brought me here instead.”

However, some stories are more chilling, including the case of an older male who had made threats while shooting his gun in the air and was brought to the emergency department because, as the police officer told us, “I think that he is just depressed; you guys can keep him safe till he is better.”

We applaud society’s desire to reduce the criminalization of mental illness. We think that psychiatry should be deeply involved in the attempts to resolve this problem. Furthermore, we are cognizant that the number of patients with mental illness unnecessarily imprisoned as a result of prosecutorial zealousness is a larger problem than criminals inappropriately brought to mental hospitals. However, we also are aware of the limitation of psychiatric hospitals in solving nonpsychiatric problems.

If mental illness (for the most part) does not cause violence, then when patients with or without mental illness commit a violent act, the response (for the most part) should not be a psychiatric one. Recent studies have demonstrated the need to examine criminogenic needs before psychiatric ones when attempting to reduce recidivism in all offenders, including those with mental illnesses.⁴ The emphasis on addressing psychiatric needs over criminogenic ones is misguided and not based on evidence. Yet, we appreciate the complexity of those questions and of individual cases.

Substance use disorders are emblematic of this problem. Psychiatry has now communicated the position that substance use disorders are mental illness and not a moral failing. However, are the crimes committed by individuals with substance use disorders, whether in a state of intoxication or driven by the cycles of addiction, the blameless result of mental illness? The legal system struggles with this question, trying to determine when addiction-related crimes should be referred to a diversion program or treated as a straightforward criminal prosecution. Those who favor diversion for addiction can point out that many criminal acts are associated with mitigating factors that are no less valid than is addiction.

However, those mitigating factors, such as poverty, childhood deprivation, or a violence-infused sociological milieu, cannot be found in the Diagnostic and Statistical Manual of Mental Disorders. As such, if those factors alone were considered, no diversion would be offered by the courts. There also can be unforeseen consequences to this bias for diversion or criminal prosecution. Violent outbursts are a recognized part of PTSD in veterans. Psychiatrists who work at Veterans Affairs can be faced with the diagnosis of PTSD being used as an excuse for violent behavior, which may, at some level be valid, but which can be dangerous in that labeling a patient with that diagnosis might lower the barriers to violent behavior by providing a ready-made explanation already internalized by the patient through unspoken, sociocultural norms.

With the awareness of the complex nature of the intersectionality of mental illness and criminality, we recommend improvements to current diversion programs. As diversion programs rightfully continue to expand across the country, we likely will see an increase in the number of referrals by police officers to our emergency departments. Some of the referrals will be considered “inappropriate” after thorough and thoughtful clinical evaluation by emergency psychiatrists. The inappropriateness might be secondary to an absence of active symptoms, an absence of correlation between the illness and the offense, or a more urgent criminogenic need.

When faced with someone who will not benefit from diversion to a psychiatric emergency department, psychiatrists should have the tools to revert the person back into the legal system. Those tools could come in many forms – law enforcement liaison, prosecution liaison, or simply the presence of officers who are mandated to wait for the approval of the clinician prior to dismissing legal charges. Whatever the solution might be for any particular locale, policy makers should not wait for adverse events to realize the potential pitfalls of the important work being done in developing our country’s diversion programs.

References

1. Swanson JW et al. Mental illness and reduction of gun violence and suicide: Bringing epidemiologic research to policy. Ann Epidemiol. 2015 May;25(5):366-76.

2. Ehrenreich B. “How America criminalized poverty.” The Guardian. 2011 Aug 10.

3. Roth A. “Prisons are the new asylums.” The Atlantic. 2018 April.

4. Latessa EJ et al. “What works (and doesn’t) in reducing recidivism.” New York: Routledge, 2015.
 

Dr. Badre is a forensic psychiatrist in San Diego and an expert in correctional mental health. He holds teaching positions at the University of California, San Diego, and the University of San Diego. Dr. Badre can be reached at his website, BadreMD.com. Dr. Lehman is an associate professor of psychiatry at the University of California, San Diego. He is codirector of all acute and intensive psychiatric treatment at the Veterans Affairs Medical Center in San Diego, where he practices clinical psychiatry. He also is the course director for the UCSD third-year medical student psychiatry clerkship.

Stop the selfies

If you’re a selfie aficionado, this is crucial information. People hate your selfies, and people hate you.

Okay, maybe that’s being a little aggressive, but a new study from Washington State University has shown that, if you’re a chronic selfie poster, people (aka your loyal Instagram audience) are more likely to view you as unlikable, unsuccessful, insecure, and closed off to new experiences.

The study was born from the idea that chronic selfie takers are more narcissistic than the rest of us. Chris Barry, PhD, the lead author of this study, conducted research into that hypothesis and found inconclusive results: Selfie prevalence just wasn’t indicative of personality. However, Dr. Barry realized there may be a stronger link between the amount of selfies posted and how people (whom the selfies are forced upon) perceive the selfie taker. [Editor’s note: I am more tired of reading the word “selfie” than of seeing them at this point.]

Study participants were asked to rate the Instagram profiles of 30 undergrad students on attributes such as low self-esteem, self-absorption, and success. The profiles with more posed photos were viewed as being more adventurous, more outgoing, and having high self-esteem, while the reverse was true for profiles with lots of selfies. And for the men trying online dating: Flexing-in-the-mirror selfies were viewed extra negatively.

So what have we learned from this all-important selfie study? If you want to step up your online profile, start by deleting a few of those selfies. Send them to Grandma instead, who will really appreciate your pretty face.
 

Emoji emotion

You’re setting up your online dating profile. You’ve removed all the selfies and have only the most flattering posed photos of yourself: with your dog, climbing a mountain, at the beach, all the greatest hits. You’ve been messaging the ladies nonstop, impressing them with your witty wordplay and impeccable spelling. But so far, not much is happening. What gives? According to a study from the Kinsey Institute, you’ve got to use more emojis.

Surveying more than 5,000 adults, researchers found that frequent emoji use predicted more first dates and more frequent sexual activity. The findings suggest that people who use emojis often might be better at forming connections with other people than those who eschew those ubiquitous smileys.

Is an emoji worth a thousand words? For some, apparently. The authors noted that emojis can be used in addition to words to strategically infuse digital communication with expression and emotion that typed words often lack. For many, a smiley emoji carries more emotional weight than writing that you’re happy. If you’re looking to spice up your love life, say it with emojis instead. And if you’re not well-versed in emoji speak, make sure to look up the meaning of the eggplant emoji before you use it.
 

The nomination would have been enough, really

We here at LOTME love a good survey ... Okay, most of us here at LOTME love a good survey ... All right, it looks like three out of four LOTME staffers surveyed are quite fond of a good survey.

Here, now, finally, is some news about a survey. The good folks at Crestline – whose custom-imprinted promotional products “bring your logo to life!” – asked 1,630 U.S. residents about “America’s Most Memorable Mascots.” The respondents were asked to identify and rate 82 characters representing the best of American marketing, including Colonel Sanders, Little Debbie, Chuck E. Cheese, and the Aflac duck.

In a sweep of epic proportions, the top ranking in each of five measures – least likable, least persuasive, least trustworthy, most annoying, and most creepy – went to the same character: Mr. Mucus, the face of the Mucinex brand.

Lucas Franki/MDedge News

Not so sexy after all

Another day, another organism being marketed as an aphrodisiac thanks to some dubious science, according to a report from the New Zealand Newsroom. To be fair, though, advertising a product called sexy pavement lichen as a natural male enhancement isn’t the worst-sounding idea in the world.

carstenbrandt/iStock/Getty Images Plus

The sexy lichen in question, Xanthoparmelia scabrosa, most commonly found in Australia and New Zealand, isn’t that much more attractive than any other lichen. It’s more of a nuisance than anything else, as it loves to grow in pavement and makes roads covered in the stuff dangerously slick when it rains.

As for any benefit as an aphrodisiac, the plant does contain a PDE5 inhibitor, which can inhibit an enzyme causing impotence but may also be toxic on its own. Plus you’ll be getting a dose of such heavy metals as copper, lead, cadmium, mercury, and basically anything else you’d find in asphalt.

The “legitimate” business people involved claim to grind up the actual lichen, and their product is then marketed as an ancient Chinese therapy for erectile dysfunction. A thriving market has been built around sexy pavement lichen, with thousands of tons available on websites such as Alibaba at the premium price of $100 per kg.

In reality, people are buying a combination of Viagra and grass clippings, as harvesting that much lichen would be both unfeasible and unsustainable, according to the Newsroom report. Sadly, it seems that “legitimate” business people have once again let us all down. But hey, at least they’re not selling poisonous lichen.

Stop the selfies

If you’re a selfie aficionado, this is crucial information. People hate your selfies, and people hate you.

Okay, maybe that’s being a little aggressive, but a new study from Washington State University has shown that, if you’re a chronic selfie poster, people (aka your loyal Instagram audience) are more likely to view you as unlikable, unsuccessful, insecure, and closed off to new experiences.

The study was born from the idea that chronic selfie takers are more narcissistic than the rest of us. Chris Barry, PhD, the lead author of this study, conducted research into that hypothesis and found inconclusive results: Selfie prevalence just wasn’t indicative of personality. However, Dr. Barry realized there may be a stronger link between the amount of selfies posted and how people (whom the selfies are forced upon) perceive the selfie taker. [Editor’s note: I am more tired of reading the word “selfie” than of seeing them at this point.]

Study participants were asked to rate the Instagram profiles of 30 undergrad students on attributes such as low self-esteem, self-absorption, and success. The profiles with more posed photos were viewed as being more adventurous, more outgoing, and having high self-esteem, while the reverse was true for profiles with lots of selfies. And for the men trying online dating: Flexing-in-the-mirror selfies were viewed extra negatively.

So what have we learned from this all-important selfie study? If you want to step up your online profile, start by deleting a few of those selfies. Send them to Grandma instead, who will really appreciate your pretty face.
 

Emoji emotion

You’re setting up your online dating profile. You’ve removed all the selfies and have only the most flattering posed photos of yourself: with your dog, climbing a mountain, at the beach, all the greatest hits. You’ve been messaging the ladies nonstop, impressing them with your witty wordplay and impeccable spelling. But so far, not much is happening. What gives? According to a study from the Kinsey Institute, you’ve got to use more emojis.

Surveying more than 5,000 adults, researchers found that frequent emoji use predicted more first dates and more frequent sexual activity. The findings suggest that people who use emojis often might be better at forming connections with other people than those who eschew those ubiquitous smileys.

Is an emoji worth a thousand words? For some, apparently. The authors noted that emojis can be used in addition to words to strategically infuse digital communication with expression and emotion that typed words often lack. For many, a smiley emoji carries more emotional weight than writing that you’re happy. If you’re looking to spice up your love life, say it with emojis instead. And if you’re not well-versed in emoji speak, make sure to look up the meaning of the eggplant emoji before you use it.
 

The nomination would have been enough, really

We here at LOTME love a good survey ... Okay, most of us here at LOTME love a good survey ... All right, it looks like three out of four LOTME staffers surveyed are quite fond of a good survey.

Here, now, finally, is some news about a survey. The good folks at Crestline – whose custom-imprinted promotional products “bring your logo to life!” – asked 1,630 U.S. residents about “America’s Most Memorable Mascots.” The respondents were asked to identify and rate 82 characters representing the best of American marketing, including Colonel Sanders, Little Debbie, Chuck E. Cheese, and the Aflac duck.

In a sweep of epic proportions, the top ranking in each of five measures – least likable, least persuasive, least trustworthy, most annoying, and most creepy – went to the same character: Mr. Mucus, the face of the Mucinex brand.

Lucas Franki/MDedge News

Not so sexy after all

Another day, another organism being marketed as an aphrodisiac thanks to some dubious science, according to a report from the New Zealand Newsroom. To be fair, though, advertising a product called sexy pavement lichen as a natural male enhancement isn’t the worst-sounding idea in the world.

carstenbrandt/iStock/Getty Images Plus

The sexy lichen in question, Xanthoparmelia scabrosa, most commonly found in Australia and New Zealand, isn’t that much more attractive than any other lichen. It’s more of a nuisance than anything else, as it loves to grow in pavement and makes roads covered in the stuff dangerously slick when it rains.

As for any benefit as an aphrodisiac, the plant does contain a PDE5 inhibitor, which can inhibit an enzyme causing impotence but may also be toxic on its own. Plus you’ll be getting a dose of such heavy metals as copper, lead, cadmium, mercury, and basically anything else you’d find in asphalt.

The “legitimate” business people involved claim to grind up the actual lichen, and their product is then marketed as an ancient Chinese therapy for erectile dysfunction. A thriving market has been built around sexy pavement lichen, with thousands of tons available on websites such as Alibaba at the premium price of $100 per kg.

In reality, people are buying a combination of Viagra and grass clippings, as harvesting that much lichen would be both unfeasible and unsustainable, according to the Newsroom report. Sadly, it seems that “legitimate” business people have once again let us all down. But hey, at least they’re not selling poisonous lichen.

Stop the selfies

If you’re a selfie aficionado, this is crucial information. People hate your selfies, and people hate you.

Okay, maybe that’s being a little aggressive, but a new study from Washington State University has shown that, if you’re a chronic selfie poster, people (aka your loyal Instagram audience) are more likely to view you as unlikable, unsuccessful, insecure, and closed off to new experiences.

The study was born from the idea that chronic selfie takers are more narcissistic than the rest of us. Chris Barry, PhD, the lead author of this study, conducted research into that hypothesis and found inconclusive results: Selfie prevalence just wasn’t indicative of personality. However, Dr. Barry realized there may be a stronger link between the amount of selfies posted and how people (whom the selfies are forced upon) perceive the selfie taker. [Editor’s note: I am more tired of reading the word “selfie” than of seeing them at this point.]

Study participants were asked to rate the Instagram profiles of 30 undergrad students on attributes such as low self-esteem, self-absorption, and success. The profiles with more posed photos were viewed as being more adventurous, more outgoing, and having high self-esteem, while the reverse was true for profiles with lots of selfies. And for the men trying online dating: Flexing-in-the-mirror selfies were viewed extra negatively.

So what have we learned from this all-important selfie study? If you want to step up your online profile, start by deleting a few of those selfies. Send them to Grandma instead, who will really appreciate your pretty face.
 

Emoji emotion

You’re setting up your online dating profile. You’ve removed all the selfies and have only the most flattering posed photos of yourself: with your dog, climbing a mountain, at the beach, all the greatest hits. You’ve been messaging the ladies nonstop, impressing them with your witty wordplay and impeccable spelling. But so far, not much is happening. What gives? According to a study from the Kinsey Institute, you’ve got to use more emojis.

Surveying more than 5,000 adults, researchers found that frequent emoji use predicted more first dates and more frequent sexual activity. The findings suggest that people who use emojis often might be better at forming connections with other people than those who eschew those ubiquitous smileys.

Is an emoji worth a thousand words? For some, apparently. The authors noted that emojis can be used in addition to words to strategically infuse digital communication with expression and emotion that typed words often lack. For many, a smiley emoji carries more emotional weight than writing that you’re happy. If you’re looking to spice up your love life, say it with emojis instead. And if you’re not well-versed in emoji speak, make sure to look up the meaning of the eggplant emoji before you use it.
 

The nomination would have been enough, really

We here at LOTME love a good survey ... Okay, most of us here at LOTME love a good survey ... All right, it looks like three out of four LOTME staffers surveyed are quite fond of a good survey.

Here, now, finally, is some news about a survey. The good folks at Crestline – whose custom-imprinted promotional products “bring your logo to life!” – asked 1,630 U.S. residents about “America’s Most Memorable Mascots.” The respondents were asked to identify and rate 82 characters representing the best of American marketing, including Colonel Sanders, Little Debbie, Chuck E. Cheese, and the Aflac duck.

In a sweep of epic proportions, the top ranking in each of five measures – least likable, least persuasive, least trustworthy, most annoying, and most creepy – went to the same character: Mr. Mucus, the face of the Mucinex brand.

Lucas Franki/MDedge News

Not so sexy after all

Another day, another organism being marketed as an aphrodisiac thanks to some dubious science, according to a report from the New Zealand Newsroom. To be fair, though, advertising a product called sexy pavement lichen as a natural male enhancement isn’t the worst-sounding idea in the world.

carstenbrandt/iStock/Getty Images Plus

The sexy lichen in question, Xanthoparmelia scabrosa, most commonly found in Australia and New Zealand, isn’t that much more attractive than any other lichen. It’s more of a nuisance than anything else, as it loves to grow in pavement and makes roads covered in the stuff dangerously slick when it rains.

As for any benefit as an aphrodisiac, the plant does contain a PDE5 inhibitor, which can inhibit an enzyme causing impotence but may also be toxic on its own. Plus you’ll be getting a dose of such heavy metals as copper, lead, cadmium, mercury, and basically anything else you’d find in asphalt.

The “legitimate” business people involved claim to grind up the actual lichen, and their product is then marketed as an ancient Chinese therapy for erectile dysfunction. A thriving market has been built around sexy pavement lichen, with thousands of tons available on websites such as Alibaba at the premium price of $100 per kg.

In reality, people are buying a combination of Viagra and grass clippings, as harvesting that much lichen would be both unfeasible and unsustainable, according to the Newsroom report. Sadly, it seems that “legitimate” business people have once again let us all down. But hey, at least they’re not selling poisonous lichen.

Hidradenitis suppurativa is associated with more than a 600% higher risk of nonalcoholic fatty liver disease, independent of other metabolic risk factors, a study has found.

The results of the case-control study of 70 individuals with hidradenitis suppurativa (HS) and 150 age- and gender-matched controls were published in the Journal of the European Academy of Dermatology and Venereology. Using hepatic ultrasonography and transient elastography, the investigators found that 51 (72.9%) the participants with HS also had nonalcoholic fatty liver disease (NAFLD), compared with 37 (24.7%) of the controls (P less than .001).

Those with HS and NAFLD were more likely to be obese, have more central adiposity, and meet more of the criteria for metabolic syndrome than those with HS but without NAFLD. They also showed higher serum ALT levels, higher triglycerides, and higher controlled attenuation parameter scores, which is a surrogate marker of liver steatosis.

However, the HS plus NAFLD group had similar rates of active smoking, diabetes, dyslipidemia, hypertension, and cardiovascular events, compared with those who had HS only. They also showed no differences in hemoglobin A_1c, serum insulin, insulin resistance, or liver stiffness, compared with the HS-only group.

When researchers compared the participants with HS plus NAFLD with controls with NAFLD, they found the HS group had significantly higher levels of liver stiffness measurement, which is a surrogate marker of liver fibrosis and severity, but there were no differences in the degree of hepatic steatosis.

The individuals with HS plus NAFLD had significantly lower serum albumin, but significantly higher serum gamma–glutamyl transpeptidase and ferritin, compared with controls who had NAFLD. They were also more likely to have metabolic risk factors such as hypertension, dyslipidemia, and metabolic syndrome.

The multivariate analysis also showed that male sex was a protective factor, because the prevalence of obesity was higher in women.

After adjusting for classic cardiovascular and steatosis risk factors, the researchers calculated that HS was a significant and independent risk factor for NAFLD, with an odds ratio of 7.75 (P less than .001). The results provide “the first evidence that patients with HS have a significant high prevalence of NAFLD, which is independent of classic metabolic risk factors and, according to our results, probably not related to the severity of the disease,” wrote Carlos Durán-Vian, MD, from the department of dermatology at the University of Cantabria, Santander, Spain, and coauthors.

“We think that our findings might have potential clinical implications, and physicians involved in the care of patients with HS should be aware of the link between this entity and NAFLD, in order to improve the overall management of these patients,” they wrote, noting that HS is often associated with the same metabolic disorders that can promote fatty liver disease, such as obesity and metabolic syndrome. But the discovery that it is an independent risk factor demands other hypotheses to explain the association between the two conditions.

“In this sense, a possible explanation to deeper understanding the link between HS and NAFLD could be the presence of chronic inflammation due to persistent and abnormal secretion of adipokines (i.e. adiponectin, leptin, resistin) and several proinflammatory cytokines,” the authors wrote, pointing out that NAFLD is also common among people with immune-mediated inflammatory disorders.

The study had the limitation of being an observational, cross-sectional design, and the authors acknowledged that the cohort was relatively small. They also were unable to use liver biopsies to confirm the NAFLD diagnosis.

No funding or conflicts of interest were reported.

SOURCE: Durán-Vian C et al. J Eur Acad Dermatol Venereol. 2019 Jul 1. doi: 10.1111/jdv.15764.

Hidradenitis suppurativa is associated with more than a 600% higher risk of nonalcoholic fatty liver disease, independent of other metabolic risk factors, a study has found.

The results of the case-control study of 70 individuals with hidradenitis suppurativa (HS) and 150 age- and gender-matched controls were published in the Journal of the European Academy of Dermatology and Venereology. Using hepatic ultrasonography and transient elastography, the investigators found that 51 (72.9%) the participants with HS also had nonalcoholic fatty liver disease (NAFLD), compared with 37 (24.7%) of the controls (P less than .001).

Those with HS and NAFLD were more likely to be obese, have more central adiposity, and meet more of the criteria for metabolic syndrome than those with HS but without NAFLD. They also showed higher serum ALT levels, higher triglycerides, and higher controlled attenuation parameter scores, which is a surrogate marker of liver steatosis.

However, the HS plus NAFLD group had similar rates of active smoking, diabetes, dyslipidemia, hypertension, and cardiovascular events, compared with those who had HS only. They also showed no differences in hemoglobin A_1c, serum insulin, insulin resistance, or liver stiffness, compared with the HS-only group.

When researchers compared the participants with HS plus NAFLD with controls with NAFLD, they found the HS group had significantly higher levels of liver stiffness measurement, which is a surrogate marker of liver fibrosis and severity, but there were no differences in the degree of hepatic steatosis.

The individuals with HS plus NAFLD had significantly lower serum albumin, but significantly higher serum gamma–glutamyl transpeptidase and ferritin, compared with controls who had NAFLD. They were also more likely to have metabolic risk factors such as hypertension, dyslipidemia, and metabolic syndrome.

The multivariate analysis also showed that male sex was a protective factor, because the prevalence of obesity was higher in women.

After adjusting for classic cardiovascular and steatosis risk factors, the researchers calculated that HS was a significant and independent risk factor for NAFLD, with an odds ratio of 7.75 (P less than .001). The results provide “the first evidence that patients with HS have a significant high prevalence of NAFLD, which is independent of classic metabolic risk factors and, according to our results, probably not related to the severity of the disease,” wrote Carlos Durán-Vian, MD, from the department of dermatology at the University of Cantabria, Santander, Spain, and coauthors.

“We think that our findings might have potential clinical implications, and physicians involved in the care of patients with HS should be aware of the link between this entity and NAFLD, in order to improve the overall management of these patients,” they wrote, noting that HS is often associated with the same metabolic disorders that can promote fatty liver disease, such as obesity and metabolic syndrome. But the discovery that it is an independent risk factor demands other hypotheses to explain the association between the two conditions.

“In this sense, a possible explanation to deeper understanding the link between HS and NAFLD could be the presence of chronic inflammation due to persistent and abnormal secretion of adipokines (i.e. adiponectin, leptin, resistin) and several proinflammatory cytokines,” the authors wrote, pointing out that NAFLD is also common among people with immune-mediated inflammatory disorders.

The study had the limitation of being an observational, cross-sectional design, and the authors acknowledged that the cohort was relatively small. They also were unable to use liver biopsies to confirm the NAFLD diagnosis.

No funding or conflicts of interest were reported.

SOURCE: Durán-Vian C et al. J Eur Acad Dermatol Venereol. 2019 Jul 1. doi: 10.1111/jdv.15764.

Hidradenitis suppurativa is associated with more than a 600% higher risk of nonalcoholic fatty liver disease, independent of other metabolic risk factors, a study has found.

The results of the case-control study of 70 individuals with hidradenitis suppurativa (HS) and 150 age- and gender-matched controls were published in the Journal of the European Academy of Dermatology and Venereology. Using hepatic ultrasonography and transient elastography, the investigators found that 51 (72.9%) the participants with HS also had nonalcoholic fatty liver disease (NAFLD), compared with 37 (24.7%) of the controls (P less than .001).

Those with HS and NAFLD were more likely to be obese, have more central adiposity, and meet more of the criteria for metabolic syndrome than those with HS but without NAFLD. They also showed higher serum ALT levels, higher triglycerides, and higher controlled attenuation parameter scores, which is a surrogate marker of liver steatosis.

However, the HS plus NAFLD group had similar rates of active smoking, diabetes, dyslipidemia, hypertension, and cardiovascular events, compared with those who had HS only. They also showed no differences in hemoglobin A_1c, serum insulin, insulin resistance, or liver stiffness, compared with the HS-only group.

When researchers compared the participants with HS plus NAFLD with controls with NAFLD, they found the HS group had significantly higher levels of liver stiffness measurement, which is a surrogate marker of liver fibrosis and severity, but there were no differences in the degree of hepatic steatosis.

The individuals with HS plus NAFLD had significantly lower serum albumin, but significantly higher serum gamma–glutamyl transpeptidase and ferritin, compared with controls who had NAFLD. They were also more likely to have metabolic risk factors such as hypertension, dyslipidemia, and metabolic syndrome.

The multivariate analysis also showed that male sex was a protective factor, because the prevalence of obesity was higher in women.

After adjusting for classic cardiovascular and steatosis risk factors, the researchers calculated that HS was a significant and independent risk factor for NAFLD, with an odds ratio of 7.75 (P less than .001). The results provide “the first evidence that patients with HS have a significant high prevalence of NAFLD, which is independent of classic metabolic risk factors and, according to our results, probably not related to the severity of the disease,” wrote Carlos Durán-Vian, MD, from the department of dermatology at the University of Cantabria, Santander, Spain, and coauthors.

“We think that our findings might have potential clinical implications, and physicians involved in the care of patients with HS should be aware of the link between this entity and NAFLD, in order to improve the overall management of these patients,” they wrote, noting that HS is often associated with the same metabolic disorders that can promote fatty liver disease, such as obesity and metabolic syndrome. But the discovery that it is an independent risk factor demands other hypotheses to explain the association between the two conditions.

“In this sense, a possible explanation to deeper understanding the link between HS and NAFLD could be the presence of chronic inflammation due to persistent and abnormal secretion of adipokines (i.e. adiponectin, leptin, resistin) and several proinflammatory cytokines,” the authors wrote, pointing out that NAFLD is also common among people with immune-mediated inflammatory disorders.

The study had the limitation of being an observational, cross-sectional design, and the authors acknowledged that the cohort was relatively small. They also were unable to use liver biopsies to confirm the NAFLD diagnosis.

No funding or conflicts of interest were reported.

SOURCE: Durán-Vian C et al. J Eur Acad Dermatol Venereol. 2019 Jul 1. doi: 10.1111/jdv.15764.

Many patients with spinal cord injury (SCI) need mechanical ventilatory support. One type of support is diaphragm pacing, which stimulates the diaphragm, helping the person breathe. A minimally invasive form of diaphragm pacing via laparoscopically placed intramuscular diaphragm electrodes has “liberated thousands of patients from mechanical ventilation,” says Anthony DiMarco, MD. He and VA colleague Krzysztof Kowalski, PhD, have found a way to completely restore respiratory muscle function in patients with SCI safely and effectively.

In mid-thoracic and higher level SCIs, the expiratory muscles are paralyzed, putting patients at risk for respiratory tract infections and atelectasis, a major cause of morbidity and mortality in that population. The research team, led by DiMarco and Kowalski, combined diaphragm pacing with a minimally invasive system that allows the patient—simply with the press of a button—to cough effectively, reducing the risk of aspiration and infections. It is the first method in the world, says Dr. Kowalski, that activates abdominal and lower rib cage muscles to produce an effective cough.

An interventional clinical trial in 3 patients demonstrated that using the 2 systems in tandem was safe. The new system was implanted surgically, with disc electrodes placed on the dorsal surface of the spinal cord via laminectomy. Participants in the study used a stimulator to produce several different cough efforts from light to strong.

Mean peak expiratory airflow and airway pressure generation during spontaneous efforts were 1.7 ± 0.2 L/s and 31 ± 7 cmH₂O, respectively. After the spinal cord stimulation was applied, peak expiratory airflow was 9.0 ± 1.9 L/s and airway pressure generation was 90 ± 6 cmH₂O. In other words, results “characteristic of a normal cough,” the researchers concluded. Moreover, each patient raised secretions much more easily.

The research is being done at the Cleveland Functional Electrical Stimulation Center, a consortium of MetroHealth Medical Center, Case Western Reserve University, and Louis Stokes Cleveland VA Medical Center.

Army veteran David Powers, one of the study participants, in an interview with the VAntage Point blog, says, “Being a part of this research trial has made me feel great. For not only my own health but helping to improve the lives of others as well.”

Many patients with spinal cord injury (SCI) need mechanical ventilatory support. One type of support is diaphragm pacing, which stimulates the diaphragm, helping the person breathe. A minimally invasive form of diaphragm pacing via laparoscopically placed intramuscular diaphragm electrodes has “liberated thousands of patients from mechanical ventilation,” says Anthony DiMarco, MD. He and VA colleague Krzysztof Kowalski, PhD, have found a way to completely restore respiratory muscle function in patients with SCI safely and effectively.

In mid-thoracic and higher level SCIs, the expiratory muscles are paralyzed, putting patients at risk for respiratory tract infections and atelectasis, a major cause of morbidity and mortality in that population. The research team, led by DiMarco and Kowalski, combined diaphragm pacing with a minimally invasive system that allows the patient—simply with the press of a button—to cough effectively, reducing the risk of aspiration and infections. It is the first method in the world, says Dr. Kowalski, that activates abdominal and lower rib cage muscles to produce an effective cough.

An interventional clinical trial in 3 patients demonstrated that using the 2 systems in tandem was safe. The new system was implanted surgically, with disc electrodes placed on the dorsal surface of the spinal cord via laminectomy. Participants in the study used a stimulator to produce several different cough efforts from light to strong.

Mean peak expiratory airflow and airway pressure generation during spontaneous efforts were 1.7 ± 0.2 L/s and 31 ± 7 cmH₂O, respectively. After the spinal cord stimulation was applied, peak expiratory airflow was 9.0 ± 1.9 L/s and airway pressure generation was 90 ± 6 cmH₂O. In other words, results “characteristic of a normal cough,” the researchers concluded. Moreover, each patient raised secretions much more easily.

The research is being done at the Cleveland Functional Electrical Stimulation Center, a consortium of MetroHealth Medical Center, Case Western Reserve University, and Louis Stokes Cleveland VA Medical Center.

Army veteran David Powers, one of the study participants, in an interview with the VAntage Point blog, says, “Being a part of this research trial has made me feel great. For not only my own health but helping to improve the lives of others as well.”

Many patients with spinal cord injury (SCI) need mechanical ventilatory support. One type of support is diaphragm pacing, which stimulates the diaphragm, helping the person breathe. A minimally invasive form of diaphragm pacing via laparoscopically placed intramuscular diaphragm electrodes has “liberated thousands of patients from mechanical ventilation,” says Anthony DiMarco, MD. He and VA colleague Krzysztof Kowalski, PhD, have found a way to completely restore respiratory muscle function in patients with SCI safely and effectively.

In mid-thoracic and higher level SCIs, the expiratory muscles are paralyzed, putting patients at risk for respiratory tract infections and atelectasis, a major cause of morbidity and mortality in that population. The research team, led by DiMarco and Kowalski, combined diaphragm pacing with a minimally invasive system that allows the patient—simply with the press of a button—to cough effectively, reducing the risk of aspiration and infections. It is the first method in the world, says Dr. Kowalski, that activates abdominal and lower rib cage muscles to produce an effective cough.

An interventional clinical trial in 3 patients demonstrated that using the 2 systems in tandem was safe. The new system was implanted surgically, with disc electrodes placed on the dorsal surface of the spinal cord via laminectomy. Participants in the study used a stimulator to produce several different cough efforts from light to strong.

Mean peak expiratory airflow and airway pressure generation during spontaneous efforts were 1.7 ± 0.2 L/s and 31 ± 7 cmH₂O, respectively. After the spinal cord stimulation was applied, peak expiratory airflow was 9.0 ± 1.9 L/s and airway pressure generation was 90 ± 6 cmH₂O. In other words, results “characteristic of a normal cough,” the researchers concluded. Moreover, each patient raised secretions much more easily.

The research is being done at the Cleveland Functional Electrical Stimulation Center, a consortium of MetroHealth Medical Center, Case Western Reserve University, and Louis Stokes Cleveland VA Medical Center.

Army veteran David Powers, one of the study participants, in an interview with the VAntage Point blog, says, “Being a part of this research trial has made me feel great. For not only my own health but helping to improve the lives of others as well.”

The Psychosocial Assessment Tool (PAT) is a promising tool for screening psychosocial risk that could potentially facilitate identification of psychosocial treatment needs among youth with recurrent headache at risk for poor outcomes, a new study found. Youth with recurrent migraine or tension-type headache completed the PAT and validated measures of adolescent emotional and behavioral functioning, parent emotional functioning, and family functioning at baseline (n=239) and 6-month follow-up (n=221). Researchers found:

• Internal consistency for the PAT total score was strong (α = .88).
• At baseline, the PAT total score was significantly associated in the expected direction with established measures of child emotional and behavioral functioning, parent anxiety and depressive symptoms, and family functioning.
• Predictive validity was demonstrated by a significant association between the PAT total scores at baseline with child emotional and behavioral functioning, parent anxiety, parent depression, and family functioning at 6-month follow-up.

Law EF, et al. Screening family and psychosocial risk in pediatric migraine and tension-type headache: Validation of the Psychosocial Assessment Tool (PAT). [Published online ahead of print July 18, 2019]. Headache. doi: 10.1111/head.13599.

The Psychosocial Assessment Tool (PAT) is a promising tool for screening psychosocial risk that could potentially facilitate identification of psychosocial treatment needs among youth with recurrent headache at risk for poor outcomes, a new study found. Youth with recurrent migraine or tension-type headache completed the PAT and validated measures of adolescent emotional and behavioral functioning, parent emotional functioning, and family functioning at baseline (n=239) and 6-month follow-up (n=221). Researchers found:

• Internal consistency for the PAT total score was strong (α = .88).
• At baseline, the PAT total score was significantly associated in the expected direction with established measures of child emotional and behavioral functioning, parent anxiety and depressive symptoms, and family functioning.
• Predictive validity was demonstrated by a significant association between the PAT total scores at baseline with child emotional and behavioral functioning, parent anxiety, parent depression, and family functioning at 6-month follow-up.

Law EF, et al. Screening family and psychosocial risk in pediatric migraine and tension-type headache: Validation of the Psychosocial Assessment Tool (PAT). [Published online ahead of print July 18, 2019]. Headache. doi: 10.1111/head.13599.

The Psychosocial Assessment Tool (PAT) is a promising tool for screening psychosocial risk that could potentially facilitate identification of psychosocial treatment needs among youth with recurrent headache at risk for poor outcomes, a new study found. Youth with recurrent migraine or tension-type headache completed the PAT and validated measures of adolescent emotional and behavioral functioning, parent emotional functioning, and family functioning at baseline (n=239) and 6-month follow-up (n=221). Researchers found:

• Internal consistency for the PAT total score was strong (α = .88).
• At baseline, the PAT total score was significantly associated in the expected direction with established measures of child emotional and behavioral functioning, parent anxiety and depressive symptoms, and family functioning.
• Predictive validity was demonstrated by a significant association between the PAT total scores at baseline with child emotional and behavioral functioning, parent anxiety, parent depression, and family functioning at 6-month follow-up.

Law EF, et al. Screening family and psychosocial risk in pediatric migraine and tension-type headache: Validation of the Psychosocial Assessment Tool (PAT). [Published online ahead of print July 18, 2019]. Headache. doi: 10.1111/head.13599.

Hospitalists cannot bill for everything they do, but they can document and code to obtain appropriate reimbursements. It is important for hospitalists to know the factors that influence coding to ensure accuracy and compliance.

The Society of Hospital Medicine developed the Clinical Documentation & Coding for Hospitalists webinar series (formerly known as CODE-H) to provide hospitalists with the latest information on best practices in coding, documentation, and compliance from nationally recognized experts, along with the opportunity to claim CME.

The Hospitalist recently spoke with Carol Pohlig, BSN, RN, CPC, ACS, course director of the webinar series and a coding and documentation expert at the University of Pennsylvania Medical Center in Philadelphia. She was instrumental in developing the content in the series to ensure it was specifically designed to address challenges regularly faced by hospitalists.
 

What inspired the creation of Clinical Documentation & Coding for Hospitalists?

Providers are so busy trying to keep up with regulations for their institution, such as malpractice and quality issues, that the focus isn’t always on the documentation required for reimbursement. The creation of the series rose out of a need for providers to understand key issues related to documentation and billing and some of the hurdles that they need to overcome – or need to be aware of in the first place.

This series brings awareness and solutions to some of these problems. It is available on an ongoing basis, so viewers can move at their own pace. Given the wealth of information in the series, it made sense to create it in this format.
 

What are some common challenges that hospitalists encounter when coding, and how does this webinar series help to address these challenges?

Some common challenges relate to concurrent care or comanagement. Hospitalists are hired to be the gatekeepers – the ones overseeing patient care. When other consultants are on board, they wind up sharing responsibilities, which can muddy the waters at times, especially with billing and coding. It is important for hospitalists to understand their role in comanagement and, in turn, how the payers view their role.

We highlight everything – including requirements for history, exam, and medical decision making – and review each component in depth. We also discuss billing based on these key components or, when it is appropriate, billing based on time. However, when billing time-based services, you have to meet certain qualifications because it is different from the standard way of reporting, which is something we break down in the series.

Related to mitigating risk, EMRs and their copy and paste function is another topic we delve into. It’s easy to copy and paste and pull forward information from a previous note to help save time. However, it is important to understand what the ramifications are. Each of these copied and pasted encounters must be modified to make it applicable to the current day’s patient and ensure care is not being misrepresented.

Those are just a few of the items covered, but we believe that each of the eight modules in the series offers something unique that will help improve documentation and coding practices.
 

How can this webinar series go beyond the hospital medicine care team and more broadly affect the institution as a whole?

Hospitalists are often involved in a number of different categories of services, including observation and same-day admission/discharge. The series reviews rules and challenges specific to those sites of service, which on a broader scale, impact not only providers in other service lines but also those who work in the revenue cycle at the parent institution. How each of these parties understands the nuances explained in the series can directly affect the successful processing of the submitted claims.

In addition, interpretation of rules when it comes to coding and documentation can vary at a local level. We raise awareness of local interpretations to ensure everyone involved in the documentation and coding process knows things to look out for when reading rules. You might think it means one thing when, in reality, it could mean another. With this series, everyone involved with billing and coding can reflect on the implications that incorrect or inaccurate coding may have on their hospital.

Who would benefit from viewing this webinar series?

Although we primarily had hospitalists of all types – including physicians, nurse practitioners, and physician assistants – in mind during the development of course content, anyone who works as a practice manager, biller, coder, or internal auditor has the potential to benefit from the series. If they understand broader challenges in coding, it could help them proactively prevent issues throughout the process with more accurate documentation that could reduce claims denials.

Let SHM’s Clinical Documentation & Coding for Hospitalists webinar series bolster your and your team’s accuracy and compliance. Individual and group subscriptions are available. For more information, visit hospitalmedicine.org/coding.

Hospitalists cannot bill for everything they do, but they can document and code to obtain appropriate reimbursements. It is important for hospitalists to know the factors that influence coding to ensure accuracy and compliance.

The Society of Hospital Medicine developed the Clinical Documentation & Coding for Hospitalists webinar series (formerly known as CODE-H) to provide hospitalists with the latest information on best practices in coding, documentation, and compliance from nationally recognized experts, along with the opportunity to claim CME.

The Hospitalist recently spoke with Carol Pohlig, BSN, RN, CPC, ACS, course director of the webinar series and a coding and documentation expert at the University of Pennsylvania Medical Center in Philadelphia. She was instrumental in developing the content in the series to ensure it was specifically designed to address challenges regularly faced by hospitalists.
 

What inspired the creation of Clinical Documentation & Coding for Hospitalists?

Providers are so busy trying to keep up with regulations for their institution, such as malpractice and quality issues, that the focus isn’t always on the documentation required for reimbursement. The creation of the series rose out of a need for providers to understand key issues related to documentation and billing and some of the hurdles that they need to overcome – or need to be aware of in the first place.

This series brings awareness and solutions to some of these problems. It is available on an ongoing basis, so viewers can move at their own pace. Given the wealth of information in the series, it made sense to create it in this format.
 

What are some common challenges that hospitalists encounter when coding, and how does this webinar series help to address these challenges?

Some common challenges relate to concurrent care or comanagement. Hospitalists are hired to be the gatekeepers – the ones overseeing patient care. When other consultants are on board, they wind up sharing responsibilities, which can muddy the waters at times, especially with billing and coding. It is important for hospitalists to understand their role in comanagement and, in turn, how the payers view their role.

We highlight everything – including requirements for history, exam, and medical decision making – and review each component in depth. We also discuss billing based on these key components or, when it is appropriate, billing based on time. However, when billing time-based services, you have to meet certain qualifications because it is different from the standard way of reporting, which is something we break down in the series.

Related to mitigating risk, EMRs and their copy and paste function is another topic we delve into. It’s easy to copy and paste and pull forward information from a previous note to help save time. However, it is important to understand what the ramifications are. Each of these copied and pasted encounters must be modified to make it applicable to the current day’s patient and ensure care is not being misrepresented.

Those are just a few of the items covered, but we believe that each of the eight modules in the series offers something unique that will help improve documentation and coding practices.
 

How can this webinar series go beyond the hospital medicine care team and more broadly affect the institution as a whole?

Hospitalists are often involved in a number of different categories of services, including observation and same-day admission/discharge. The series reviews rules and challenges specific to those sites of service, which on a broader scale, impact not only providers in other service lines but also those who work in the revenue cycle at the parent institution. How each of these parties understands the nuances explained in the series can directly affect the successful processing of the submitted claims.

In addition, interpretation of rules when it comes to coding and documentation can vary at a local level. We raise awareness of local interpretations to ensure everyone involved in the documentation and coding process knows things to look out for when reading rules. You might think it means one thing when, in reality, it could mean another. With this series, everyone involved with billing and coding can reflect on the implications that incorrect or inaccurate coding may have on their hospital.

Who would benefit from viewing this webinar series?

Although we primarily had hospitalists of all types – including physicians, nurse practitioners, and physician assistants – in mind during the development of course content, anyone who works as a practice manager, biller, coder, or internal auditor has the potential to benefit from the series. If they understand broader challenges in coding, it could help them proactively prevent issues throughout the process with more accurate documentation that could reduce claims denials.

Let SHM’s Clinical Documentation & Coding for Hospitalists webinar series bolster your and your team’s accuracy and compliance. Individual and group subscriptions are available. For more information, visit hospitalmedicine.org/coding.

Hospitalists cannot bill for everything they do, but they can document and code to obtain appropriate reimbursements. It is important for hospitalists to know the factors that influence coding to ensure accuracy and compliance.

The Society of Hospital Medicine developed the Clinical Documentation & Coding for Hospitalists webinar series (formerly known as CODE-H) to provide hospitalists with the latest information on best practices in coding, documentation, and compliance from nationally recognized experts, along with the opportunity to claim CME.

The Hospitalist recently spoke with Carol Pohlig, BSN, RN, CPC, ACS, course director of the webinar series and a coding and documentation expert at the University of Pennsylvania Medical Center in Philadelphia. She was instrumental in developing the content in the series to ensure it was specifically designed to address challenges regularly faced by hospitalists.
 

What inspired the creation of Clinical Documentation & Coding for Hospitalists?

Providers are so busy trying to keep up with regulations for their institution, such as malpractice and quality issues, that the focus isn’t always on the documentation required for reimbursement. The creation of the series rose out of a need for providers to understand key issues related to documentation and billing and some of the hurdles that they need to overcome – or need to be aware of in the first place.

This series brings awareness and solutions to some of these problems. It is available on an ongoing basis, so viewers can move at their own pace. Given the wealth of information in the series, it made sense to create it in this format.
 

What are some common challenges that hospitalists encounter when coding, and how does this webinar series help to address these challenges?

Some common challenges relate to concurrent care or comanagement. Hospitalists are hired to be the gatekeepers – the ones overseeing patient care. When other consultants are on board, they wind up sharing responsibilities, which can muddy the waters at times, especially with billing and coding. It is important for hospitalists to understand their role in comanagement and, in turn, how the payers view their role.

We highlight everything – including requirements for history, exam, and medical decision making – and review each component in depth. We also discuss billing based on these key components or, when it is appropriate, billing based on time. However, when billing time-based services, you have to meet certain qualifications because it is different from the standard way of reporting, which is something we break down in the series.

Related to mitigating risk, EMRs and their copy and paste function is another topic we delve into. It’s easy to copy and paste and pull forward information from a previous note to help save time. However, it is important to understand what the ramifications are. Each of these copied and pasted encounters must be modified to make it applicable to the current day’s patient and ensure care is not being misrepresented.

Those are just a few of the items covered, but we believe that each of the eight modules in the series offers something unique that will help improve documentation and coding practices.
 

How can this webinar series go beyond the hospital medicine care team and more broadly affect the institution as a whole?

Hospitalists are often involved in a number of different categories of services, including observation and same-day admission/discharge. The series reviews rules and challenges specific to those sites of service, which on a broader scale, impact not only providers in other service lines but also those who work in the revenue cycle at the parent institution. How each of these parties understands the nuances explained in the series can directly affect the successful processing of the submitted claims.

In addition, interpretation of rules when it comes to coding and documentation can vary at a local level. We raise awareness of local interpretations to ensure everyone involved in the documentation and coding process knows things to look out for when reading rules. You might think it means one thing when, in reality, it could mean another. With this series, everyone involved with billing and coding can reflect on the implications that incorrect or inaccurate coding may have on their hospital.

Who would benefit from viewing this webinar series?

Although we primarily had hospitalists of all types – including physicians, nurse practitioners, and physician assistants – in mind during the development of course content, anyone who works as a practice manager, biller, coder, or internal auditor has the potential to benefit from the series. If they understand broader challenges in coding, it could help them proactively prevent issues throughout the process with more accurate documentation that could reduce claims denials.

Let SHM’s Clinical Documentation & Coding for Hospitalists webinar series bolster your and your team’s accuracy and compliance. Individual and group subscriptions are available. For more information, visit hospitalmedicine.org/coding.

CHICAGO – Dietary therapies can form a beneficial part of personalized treatment for gastroesophageal reflux disease (GERD), according to an overview presented at the meeting, sponsored by the American Gastroenterological Association. Modifying diet may reduce lower esophageal sphincter (LES) pressure and decrease the number of reflux events. Prescribing an overly restrictive diet, however, can promote hypervigilance and overwhelm patients. Successful dietary therapy requires balancing expectations and maintaining cognitive flexibility, said John E. Pandolfino, MD, Hans Popper Professor of Medicine at Northwestern University in Chicago.

When a patient presents with GERD and does not have warning signs such as dysphagia or odynophagia, the initial treatment typically is a proton pump inhibitor (PPI). This therapy effectively reduces the acidity of the gastric juice and improves acid clearance. It does not, however, change the number of reflux events or affect tissue permeability, said Dr. Pandolfino. Dietary therapy has the potential to address these outcomes.
 

Diets can facilitate weight loss

The first mechanism by which dietary therapies reduce GERD is by facilitating weight loss. “Obesity is associated with reflux. If you reduce that gastroesophageal pressure gradient that is generated by truncal obesity, you will improve reflux,” said Dr. Pandolfino. Second, reducing the intake of alcohol, coffee, or carbohydrates can decrease the acidity of the gastric juice. Certain foods can reduce the number of reflux events, and others can strengthen the LES.

The increasing incidence of obesity is associated with increasing incidence of GERD. Exacerbations of GERD increase the number of transient LES relaxations (TLESRs), increase the amount of liquid refluxate, and promote the formation of a hiatus hernia, said Dr. Pandolfino. One study found that moderate weight gain can cause or worsen reflux symptoms among patients of normal weight (N Engl J Med. 2006;354[22]:2340-8.). Weight loss was associated with a decreased risk of GERD symptoms. Another analysis found that reducing body mass index by 3.5 points is associated with “a dramatic reduction in overall symptoms,” said Dr. Pandolfino (Am J Gastroenterol. 2013;108[3]:376-82). Weight loss enhanced the effects of medication and reduced the gastroesophageal pressure gradient.

Dr. Pandolfino and colleagues developed and studied the Reflux Improvement and Monitoring (TRIM) program as a treatment for GERD. In this program, patients with GERD who had a BMI above 30 and were taking a PPI were referred to health coaches for weight loss treatment. Participants’ GERD Q scores decreased from 8.7 at baseline to 7.5 at 3 months and 7.4 at 6 months. Furthermore, percentage of excess body weight continued to decline for 12 months among patients who participated in TRIM, compared with controls (Am J Gastroenterol. 2018;113[1]:23-30.).

“These patients learn healthier habits [such as] walking a little bit more and watching the overall volume of food that they’re taking in,” said Dr. Pandolfino. “This was a simple thing to focus on, diet and exercise, that dramatically reduced overall severity of reflux. The interesting thing here is that we got 30% of people off their PPI therapy.”
 

Lifestyle changes may benefit patients

Several common lifestyle recommendations for patients with GERD relate to diet. Such recommendations include avoiding alcohol; eating smaller, more frequent meals; and avoiding food within 3 hours of bedtime. But data suggest that it is not effective to recommend the avoidance of acidic or irritative foods (e.g., citrus fruits, tomatoes, and carbonated beverages) or refluxogenic foods (e.g., fatty or fried foods, coffee, and chocolate) to all patients. Genetic predispositions may cause these foods to be irritants to certain patients, but “I don’t globally tell people to avoid things unless they irritate them,” said Dr. Pandolfino.

Understanding the mechanism by which certain foods trigger GERD can aid in appropriate therapy. For example, coffee can reduce LES pressure and increase gastric acid production. “If you have someone who already has low LES pressure, reducing coffee consumption might help that patient,” said Dr. Pandolfino. Data suggest that certain elimination diets are ineffective, however. Clinical trials do not suggest that eliminating carbonated beverages affects symptoms, and the data about eliminating alcohol, citrus, spicy foods, and chocolate are conflicting (Curr Gastroenterol Rep. 2017;19[8]:38.).

In a 2018 study, investigators gave patients with GERD 5 g of psyllium t.i.d. They performed physiologic testing on the patients at baseline and after 10 days of the diet. The intervention was associated with a significant increase in LES pressure and a reduction in overall reflux (World J Gastroenterol. 2018;24[21]:2291-9.). “This was one of the first studies that showed a dramatic improvement in physiology,” said Dr. Pandolfino. “Certainly, this is provocative, and I think that this is not an unreasonable thing to do in someone who’s not getting enough fiber.”

In addition to improving cardiovascular disease and diabetes, the Mediterranean diet reduces reflux symptoms and complications. When the researchers controlled for eating habits, the association persisted (Dis Esophagus. 2016;29[7]:794-800.).

Optimal GERD therapy follows from an analysis of patient-centered foci, such as obesity and triggers, and specific functional defects. In the quest for personalized therapy, a clinician should not discount the underlying pathogenesis, because some patients may require medications or surgery, said Dr. Pandolfino.

[email protected]

CHICAGO – Dietary therapies can form a beneficial part of personalized treatment for gastroesophageal reflux disease (GERD), according to an overview presented at the meeting, sponsored by the American Gastroenterological Association. Modifying diet may reduce lower esophageal sphincter (LES) pressure and decrease the number of reflux events. Prescribing an overly restrictive diet, however, can promote hypervigilance and overwhelm patients. Successful dietary therapy requires balancing expectations and maintaining cognitive flexibility, said John E. Pandolfino, MD, Hans Popper Professor of Medicine at Northwestern University in Chicago.

When a patient presents with GERD and does not have warning signs such as dysphagia or odynophagia, the initial treatment typically is a proton pump inhibitor (PPI). This therapy effectively reduces the acidity of the gastric juice and improves acid clearance. It does not, however, change the number of reflux events or affect tissue permeability, said Dr. Pandolfino. Dietary therapy has the potential to address these outcomes.
 

Diets can facilitate weight loss

The first mechanism by which dietary therapies reduce GERD is by facilitating weight loss. “Obesity is associated with reflux. If you reduce that gastroesophageal pressure gradient that is generated by truncal obesity, you will improve reflux,” said Dr. Pandolfino. Second, reducing the intake of alcohol, coffee, or carbohydrates can decrease the acidity of the gastric juice. Certain foods can reduce the number of reflux events, and others can strengthen the LES.

The increasing incidence of obesity is associated with increasing incidence of GERD. Exacerbations of GERD increase the number of transient LES relaxations (TLESRs), increase the amount of liquid refluxate, and promote the formation of a hiatus hernia, said Dr. Pandolfino. One study found that moderate weight gain can cause or worsen reflux symptoms among patients of normal weight (N Engl J Med. 2006;354[22]:2340-8.). Weight loss was associated with a decreased risk of GERD symptoms. Another analysis found that reducing body mass index by 3.5 points is associated with “a dramatic reduction in overall symptoms,” said Dr. Pandolfino (Am J Gastroenterol. 2013;108[3]:376-82). Weight loss enhanced the effects of medication and reduced the gastroesophageal pressure gradient.

Dr. Pandolfino and colleagues developed and studied the Reflux Improvement and Monitoring (TRIM) program as a treatment for GERD. In this program, patients with GERD who had a BMI above 30 and were taking a PPI were referred to health coaches for weight loss treatment. Participants’ GERD Q scores decreased from 8.7 at baseline to 7.5 at 3 months and 7.4 at 6 months. Furthermore, percentage of excess body weight continued to decline for 12 months among patients who participated in TRIM, compared with controls (Am J Gastroenterol. 2018;113[1]:23-30.).

“These patients learn healthier habits [such as] walking a little bit more and watching the overall volume of food that they’re taking in,” said Dr. Pandolfino. “This was a simple thing to focus on, diet and exercise, that dramatically reduced overall severity of reflux. The interesting thing here is that we got 30% of people off their PPI therapy.”
 

Lifestyle changes may benefit patients

Several common lifestyle recommendations for patients with GERD relate to diet. Such recommendations include avoiding alcohol; eating smaller, more frequent meals; and avoiding food within 3 hours of bedtime. But data suggest that it is not effective to recommend the avoidance of acidic or irritative foods (e.g., citrus fruits, tomatoes, and carbonated beverages) or refluxogenic foods (e.g., fatty or fried foods, coffee, and chocolate) to all patients. Genetic predispositions may cause these foods to be irritants to certain patients, but “I don’t globally tell people to avoid things unless they irritate them,” said Dr. Pandolfino.

Understanding the mechanism by which certain foods trigger GERD can aid in appropriate therapy. For example, coffee can reduce LES pressure and increase gastric acid production. “If you have someone who already has low LES pressure, reducing coffee consumption might help that patient,” said Dr. Pandolfino. Data suggest that certain elimination diets are ineffective, however. Clinical trials do not suggest that eliminating carbonated beverages affects symptoms, and the data about eliminating alcohol, citrus, spicy foods, and chocolate are conflicting (Curr Gastroenterol Rep. 2017;19[8]:38.).

In a 2018 study, investigators gave patients with GERD 5 g of psyllium t.i.d. They performed physiologic testing on the patients at baseline and after 10 days of the diet. The intervention was associated with a significant increase in LES pressure and a reduction in overall reflux (World J Gastroenterol. 2018;24[21]:2291-9.). “This was one of the first studies that showed a dramatic improvement in physiology,” said Dr. Pandolfino. “Certainly, this is provocative, and I think that this is not an unreasonable thing to do in someone who’s not getting enough fiber.”

In addition to improving cardiovascular disease and diabetes, the Mediterranean diet reduces reflux symptoms and complications. When the researchers controlled for eating habits, the association persisted (Dis Esophagus. 2016;29[7]:794-800.).

Optimal GERD therapy follows from an analysis of patient-centered foci, such as obesity and triggers, and specific functional defects. In the quest for personalized therapy, a clinician should not discount the underlying pathogenesis, because some patients may require medications or surgery, said Dr. Pandolfino.

[email protected]

CHICAGO – Dietary therapies can form a beneficial part of personalized treatment for gastroesophageal reflux disease (GERD), according to an overview presented at the meeting, sponsored by the American Gastroenterological Association. Modifying diet may reduce lower esophageal sphincter (LES) pressure and decrease the number of reflux events. Prescribing an overly restrictive diet, however, can promote hypervigilance and overwhelm patients. Successful dietary therapy requires balancing expectations and maintaining cognitive flexibility, said John E. Pandolfino, MD, Hans Popper Professor of Medicine at Northwestern University in Chicago.

When a patient presents with GERD and does not have warning signs such as dysphagia or odynophagia, the initial treatment typically is a proton pump inhibitor (PPI). This therapy effectively reduces the acidity of the gastric juice and improves acid clearance. It does not, however, change the number of reflux events or affect tissue permeability, said Dr. Pandolfino. Dietary therapy has the potential to address these outcomes.
 

Diets can facilitate weight loss

The first mechanism by which dietary therapies reduce GERD is by facilitating weight loss. “Obesity is associated with reflux. If you reduce that gastroesophageal pressure gradient that is generated by truncal obesity, you will improve reflux,” said Dr. Pandolfino. Second, reducing the intake of alcohol, coffee, or carbohydrates can decrease the acidity of the gastric juice. Certain foods can reduce the number of reflux events, and others can strengthen the LES.

The increasing incidence of obesity is associated with increasing incidence of GERD. Exacerbations of GERD increase the number of transient LES relaxations (TLESRs), increase the amount of liquid refluxate, and promote the formation of a hiatus hernia, said Dr. Pandolfino. One study found that moderate weight gain can cause or worsen reflux symptoms among patients of normal weight (N Engl J Med. 2006;354[22]:2340-8.). Weight loss was associated with a decreased risk of GERD symptoms. Another analysis found that reducing body mass index by 3.5 points is associated with “a dramatic reduction in overall symptoms,” said Dr. Pandolfino (Am J Gastroenterol. 2013;108[3]:376-82). Weight loss enhanced the effects of medication and reduced the gastroesophageal pressure gradient.

Dr. Pandolfino and colleagues developed and studied the Reflux Improvement and Monitoring (TRIM) program as a treatment for GERD. In this program, patients with GERD who had a BMI above 30 and were taking a PPI were referred to health coaches for weight loss treatment. Participants’ GERD Q scores decreased from 8.7 at baseline to 7.5 at 3 months and 7.4 at 6 months. Furthermore, percentage of excess body weight continued to decline for 12 months among patients who participated in TRIM, compared with controls (Am J Gastroenterol. 2018;113[1]:23-30.).

“These patients learn healthier habits [such as] walking a little bit more and watching the overall volume of food that they’re taking in,” said Dr. Pandolfino. “This was a simple thing to focus on, diet and exercise, that dramatically reduced overall severity of reflux. The interesting thing here is that we got 30% of people off their PPI therapy.”
 

Lifestyle changes may benefit patients

Several common lifestyle recommendations for patients with GERD relate to diet. Such recommendations include avoiding alcohol; eating smaller, more frequent meals; and avoiding food within 3 hours of bedtime. But data suggest that it is not effective to recommend the avoidance of acidic or irritative foods (e.g., citrus fruits, tomatoes, and carbonated beverages) or refluxogenic foods (e.g., fatty or fried foods, coffee, and chocolate) to all patients. Genetic predispositions may cause these foods to be irritants to certain patients, but “I don’t globally tell people to avoid things unless they irritate them,” said Dr. Pandolfino.

Understanding the mechanism by which certain foods trigger GERD can aid in appropriate therapy. For example, coffee can reduce LES pressure and increase gastric acid production. “If you have someone who already has low LES pressure, reducing coffee consumption might help that patient,” said Dr. Pandolfino. Data suggest that certain elimination diets are ineffective, however. Clinical trials do not suggest that eliminating carbonated beverages affects symptoms, and the data about eliminating alcohol, citrus, spicy foods, and chocolate are conflicting (Curr Gastroenterol Rep. 2017;19[8]:38.).

In a 2018 study, investigators gave patients with GERD 5 g of psyllium t.i.d. They performed physiologic testing on the patients at baseline and after 10 days of the diet. The intervention was associated with a significant increase in LES pressure and a reduction in overall reflux (World J Gastroenterol. 2018;24[21]:2291-9.). “This was one of the first studies that showed a dramatic improvement in physiology,” said Dr. Pandolfino. “Certainly, this is provocative, and I think that this is not an unreasonable thing to do in someone who’s not getting enough fiber.”

In addition to improving cardiovascular disease and diabetes, the Mediterranean diet reduces reflux symptoms and complications. When the researchers controlled for eating habits, the association persisted (Dis Esophagus. 2016;29[7]:794-800.).

Optimal GERD therapy follows from an analysis of patient-centered foci, such as obesity and triggers, and specific functional defects. In the quest for personalized therapy, a clinician should not discount the underlying pathogenesis, because some patients may require medications or surgery, said Dr. Pandolfino.

[email protected]

Sodium divalproate (SD) in low alternating doses appears to be effective as with higher doses, but may induce modest weight gain, a new study found. Consecutive migraineurs to whom SD was prescribed as monotherapy were studied retrospectively. The doses were 250 mg alternated with 500 mg. Headache frequency compared to baseline, adherence expressed by returning to a visit after 2 and 4 months, and side effects reported by patients were evaluated. The study included 68 patients (53 women, 15 men) aged 18 to 58 years.
 

Researchers found:

• The average headache frequency (HF) during baseline was decreased from 8.2 to 5.1 headache days/month among the 50 out of 68 patients returning at 2 months, with adherence rate at 73.5%.
• Weight gain was reported in 30% of patients.
• At 4 months, HF was reduced to 4.2 days/month, with adherence rate at 61.8%, and weight gain reported by 42.8% of patients.

Krymchantowski AV, et al. Sodium divalproate in low alternating daily doses for migraine prevention: A retrospective study. [Published online ahead of print July 1, 2019]. Headache. doi:  10.1111/head.13579.

Sodium divalproate (SD) in low alternating doses appears to be effective as with higher doses, but may induce modest weight gain, a new study found. Consecutive migraineurs to whom SD was prescribed as monotherapy were studied retrospectively. The doses were 250 mg alternated with 500 mg. Headache frequency compared to baseline, adherence expressed by returning to a visit after 2 and 4 months, and side effects reported by patients were evaluated. The study included 68 patients (53 women, 15 men) aged 18 to 58 years.
 

Researchers found:

• The average headache frequency (HF) during baseline was decreased from 8.2 to 5.1 headache days/month among the 50 out of 68 patients returning at 2 months, with adherence rate at 73.5%.
• Weight gain was reported in 30% of patients.
• At 4 months, HF was reduced to 4.2 days/month, with adherence rate at 61.8%, and weight gain reported by 42.8% of patients.

Krymchantowski AV, et al. Sodium divalproate in low alternating daily doses for migraine prevention: A retrospective study. [Published online ahead of print July 1, 2019]. Headache. doi:  10.1111/head.13579.

Sodium divalproate (SD) in low alternating doses appears to be effective as with higher doses, but may induce modest weight gain, a new study found. Consecutive migraineurs to whom SD was prescribed as monotherapy were studied retrospectively. The doses were 250 mg alternated with 500 mg. Headache frequency compared to baseline, adherence expressed by returning to a visit after 2 and 4 months, and side effects reported by patients were evaluated. The study included 68 patients (53 women, 15 men) aged 18 to 58 years.
 

Researchers found:

• The average headache frequency (HF) during baseline was decreased from 8.2 to 5.1 headache days/month among the 50 out of 68 patients returning at 2 months, with adherence rate at 73.5%.
• Weight gain was reported in 30% of patients.
• At 4 months, HF was reduced to 4.2 days/month, with adherence rate at 61.8%, and weight gain reported by 42.8% of patients.

Krymchantowski AV, et al. Sodium divalproate in low alternating daily doses for migraine prevention: A retrospective study. [Published online ahead of print July 1, 2019]. Headache. doi:  10.1111/head.13579.

Migraine-associated vertigo and motion sickness may involve distinct susceptibility genes, according to a new study. Researchers identified a large American family of 29 individuals of which 17 members suffered from at least 1 of the following disorders: migraine, vertigo, or motion sickness. Many suffered from several simultaneously. Family members were phenotyped for each condition and analyzed separately. Among the findings:

• A novel locus for migraine, 9q13-q22 was identified.
• Suggestive LOD scores localized to different chromosomes for each phenotype; vertigo (chromosome 18, LOD score 1.82) and motion sickness (chromosome 4, LOD score 2.09).

Peddareddygari LR, et al. Genetic analysis of a large family with migraine, vertigo, and motion sickness. [Published online ahead of print July 1, 2019]. Can J Neuro Sci. doi: 10.1017/cjn.2019.64.

Migraine-associated vertigo and motion sickness may involve distinct susceptibility genes, according to a new study. Researchers identified a large American family of 29 individuals of which 17 members suffered from at least 1 of the following disorders: migraine, vertigo, or motion sickness. Many suffered from several simultaneously. Family members were phenotyped for each condition and analyzed separately. Among the findings:

• A novel locus for migraine, 9q13-q22 was identified.
• Suggestive LOD scores localized to different chromosomes for each phenotype; vertigo (chromosome 18, LOD score 1.82) and motion sickness (chromosome 4, LOD score 2.09).

Peddareddygari LR, et al. Genetic analysis of a large family with migraine, vertigo, and motion sickness. [Published online ahead of print July 1, 2019]. Can J Neuro Sci. doi: 10.1017/cjn.2019.64.

Migraine-associated vertigo and motion sickness may involve distinct susceptibility genes, according to a new study. Researchers identified a large American family of 29 individuals of which 17 members suffered from at least 1 of the following disorders: migraine, vertigo, or motion sickness. Many suffered from several simultaneously. Family members were phenotyped for each condition and analyzed separately. Among the findings:

• A novel locus for migraine, 9q13-q22 was identified.
• Suggestive LOD scores localized to different chromosomes for each phenotype; vertigo (chromosome 18, LOD score 1.82) and motion sickness (chromosome 4, LOD score 2.09).

Peddareddygari LR, et al. Genetic analysis of a large family with migraine, vertigo, and motion sickness. [Published online ahead of print July 1, 2019]. Can J Neuro Sci. doi: 10.1017/cjn.2019.64.

LJUBLJANA, SLOVENIA – The 4CMenB vaccine didn’t affect carriage of disease-causing genogroups of Neisseria meningitidis in adolescents in the landmark Australian cluster-randomized trial of herd immunity known as the “B Part of It” study, Helen S. Marshall, MD, reported at the annual meeting of the European Society for Paediatric Infectious Diseases.

This was the largest-ever randomized trial of adolescents vaccinated against meningococcal disease, and the message, albeit somewhat disappointing, is clear: “MenB [Meningococcal serogroup B] vaccine programs should be designed to provide direct protection for those at highest risk of disease,” declared Dr. Marshall, professor of vaccinology and deputy director of the Robinson Research Institute at the University of Adelaide.

In other words, a protein antigen–based MenB vaccine doesn’t provide indirect protection to unvaccinated adolescents through herd immunity. Youths in the age groups at highest risk of disease – infants and adolescents – need to routinely receive the vaccine.

The B Part of It study, whose sheer scope and rigor drew the attention of infectious disease clinical trialists the world over, randomized nearly 35,000 students at all high schools in the state of South Australia – whether urban, rural, or remote – to two doses of the 4CMenB vaccine known as Bexsero or to a nonvaccinated control group. This massive trial entailed training more than 250 nurses in the study procedures and involved 3,100 miles of travel to transport oropharyngeal swab samples obtained from students in outlying areas for centralized laboratory analysis using real-time polymerase chain reaction with meningococcal genotyping, culture for N. meningitidis, and whole-genome sequencing. Samples were obtained on day 1 of the study and 12 months later.

The investigators created widespread regional enthusiasm for this project through adept use of social media and other methods. As a result, 99.5% of students randomized to the intervention arm received one dose, while 97% got two doses. A gratifying unintended consequence of the study was that parents who’d never previously vaccinated their children enrolled them in B Part of It, Dr. Marshall noted.

The impetus for B Part of It was that, while the Australian national health insurance program covers a single dose of meningococcal conjugate MenACWY vaccine given at age 12 months and 14-19 years, MenB vaccine isn’t covered because of uncertainties about cost effectiveness and the vaccine’s impact on meningococcal carriage and herd immunity. B Part of It was designed to resolve those uncertainties.

South Australia has the highest rate of invasive meningococcal disease in the country, and more than 80% of cases there are caused by meningococcal serogroup B. Moreover, 75% of group B cases in South Australia involve the nasty hypervirulent New Zealand strain known as CC 41/44.

The primary outcome in B Part of It was the difference in carriage of the major disease-causing serotypes – groups A, B, C, W, X, and Y – between vaccinated and unvaccinated students at the 1-year follow-up mark. The carriage prevalence of all N. meningitidis in the vaccinated students went from 2.8% at baseline to 4.0% at 12 months, and similarly from 2.6% to 4.7% in unvaccinated controls. More importantly, the prevalence of disease-causing genotypes rose from 1.3% at baseline to 2.4% at follow-up in the vaccinated subjects, with a near-identical pattern seen in controls, where the prevalence rose from 1.4% to 2.4%. In an as-treated analysis, the rate of acquisition of carriage of disease-causing genotypes was identical at 2.0% in both study arms.

The 4CMenB vaccine proved reassuringly safe and effective in preventing meningococcal disease in vaccinated teens. With more than 58,000 doses of the vaccine given in the study, no new safety concerns or signals emerged. And the observed number of cases of invasive meningococcal disease in South Australian adolescent vaccine recipients to date has been significantly lower than expected.

Secondary and exploratory outcomes

Independent risk factors associated with N. meningitidis carriage in the study participants at the 1-year mark included smoking cigarettes or hookah, intimate kissing within the last week, and being in grades 11-12, as opposed to grade 10.

The vaccine had no significant impact on the carriage rate of the hypervirulent New Zealand serogroup B strain. Nor was there a vaccine impact on carriage density, as Mark McMillan, MD, reported elsewhere at ESPID 2019. But while the 4CMenB vaccine had minimal impact upon N. meningitidis carriage density, it was associated with a significant 41% increase in the likelihood of cleared carriage of disease-causing strains at 12 months, added Dr. McMillan, Dr. Marshall’s coinvestigator at University of Adelaide.

What’s next

The ongoing B Part of It School Leaver study is assessing carriage prevalence in vaccinated versus unvaccinated high schoolers in their first year after graduating.

In addition, the B Part of It investigators plan to prospectively study the impact of the 4CMen B vaccine on N. gonorrhoeae disease in an effort to confirm the intriguing findings of an earlier large, retrospective New Zealand case-control study. The Kiwis found that recipients of an outer membrane vesicle MenB vaccine had an adjusted 31% reduction in the risk of gonorrhea. This was the first-ever report of any vaccine effectiveness against this major global public health problem, in which antibiotic resistance is a growing concern (Lancet. 2017 Sep 30;390[10102]:1603-10). Dr. Marshall reported receiving research funding from GlaxoSmithKline, which markets Bexsero and was the major financial supporter of the B Part of It study.

But wait a minute...

Following Dr. Marshall’s report on the B Part of It study, outgoing ESPID president Adam Finn, MD, PhD, presented longitudinal data that he believes raise the possibility that protein-antigen vaccines such as Bexsero, which promote naturally acquired mucosal immunity, may impact on transmission population wide without reliably preventing acquisition. This would stand in stark contrast to conjugate meningococcus vaccines, which have a well-established massive impact on carriage and acquisition of N. meningitidis.

Bruce Jancin/MDedge News

It may be that in studying throat carriage rates once in individuals immunized 12 months earlier, as in the B Part of It study, investigators are not asking the right question, proposed Dr. Finn, professor of pediatrics at the University of Bristol (England).

His research team has been obtaining throat swabs at monthly intervals in a population of 917 high schoolers aged 16-17 years. In 416 of the students, they also have collected saliva samples weekly both before and after immunization with 4CMenB vaccine, analyzing the samples for N. meningitidis by polymerase chain reaction. This is a novel method of studying meningococcal carriage they have found to be both reliable and far more acceptable to patients than oropharyngeal swabbing, which adolescents balk at if asked to do with any frequency (PLoS One. 2019 Feb 11;14[2]:e0209905).

Dr. Finn said that their findings, which need confirmation, suggest that N. meningitidis carriage is usually brief and dynamic. They also have found that carriage density varies markedly from month to month.

“We see much higher-density carriage in the adolescent population in the early months of the year in conjunction, we think, with viral infection with influenza and so forth,” he said, adding that this could have clinical implications. “It feels sort of intuitive that someone walking around with 1,000 or 10,000 times as many meningococci in their throat is more likely to be more infectious to people around them with a very small number, although this hasn’t been formally proven.”

He hopes that the Be on the TEAM (Teenagers Against Meningitis) study will help provide answers. The study is randomizing 24,000 U.K. high school students to vaccination with the meningococcal B protein–antigen vaccines Bexsero or Trumenba or to no vaccine in order to learn if there are significant herd immunity effects.

Dr. Finn’s meningococcal carriage research is funded by the Meningitis Research Foundation and the National Institute for Health Research. Dr. Marshall reported receiving research funding from GlaxoSmithKline, the major sponsor of the B Part of It study.

[email protected]

LJUBLJANA, SLOVENIA – The 4CMenB vaccine didn’t affect carriage of disease-causing genogroups of Neisseria meningitidis in adolescents in the landmark Australian cluster-randomized trial of herd immunity known as the “B Part of It” study, Helen S. Marshall, MD, reported at the annual meeting of the European Society for Paediatric Infectious Diseases.

This was the largest-ever randomized trial of adolescents vaccinated against meningococcal disease, and the message, albeit somewhat disappointing, is clear: “MenB [Meningococcal serogroup B] vaccine programs should be designed to provide direct protection for those at highest risk of disease,” declared Dr. Marshall, professor of vaccinology and deputy director of the Robinson Research Institute at the University of Adelaide.

In other words, a protein antigen–based MenB vaccine doesn’t provide indirect protection to unvaccinated adolescents through herd immunity. Youths in the age groups at highest risk of disease – infants and adolescents – need to routinely receive the vaccine.

The B Part of It study, whose sheer scope and rigor drew the attention of infectious disease clinical trialists the world over, randomized nearly 35,000 students at all high schools in the state of South Australia – whether urban, rural, or remote – to two doses of the 4CMenB vaccine known as Bexsero or to a nonvaccinated control group. This massive trial entailed training more than 250 nurses in the study procedures and involved 3,100 miles of travel to transport oropharyngeal swab samples obtained from students in outlying areas for centralized laboratory analysis using real-time polymerase chain reaction with meningococcal genotyping, culture for N. meningitidis, and whole-genome sequencing. Samples were obtained on day 1 of the study and 12 months later.

The investigators created widespread regional enthusiasm for this project through adept use of social media and other methods. As a result, 99.5% of students randomized to the intervention arm received one dose, while 97% got two doses. A gratifying unintended consequence of the study was that parents who’d never previously vaccinated their children enrolled them in B Part of It, Dr. Marshall noted.

The impetus for B Part of It was that, while the Australian national health insurance program covers a single dose of meningococcal conjugate MenACWY vaccine given at age 12 months and 14-19 years, MenB vaccine isn’t covered because of uncertainties about cost effectiveness and the vaccine’s impact on meningococcal carriage and herd immunity. B Part of It was designed to resolve those uncertainties.

South Australia has the highest rate of invasive meningococcal disease in the country, and more than 80% of cases there are caused by meningococcal serogroup B. Moreover, 75% of group B cases in South Australia involve the nasty hypervirulent New Zealand strain known as CC 41/44.

The primary outcome in B Part of It was the difference in carriage of the major disease-causing serotypes – groups A, B, C, W, X, and Y – between vaccinated and unvaccinated students at the 1-year follow-up mark. The carriage prevalence of all N. meningitidis in the vaccinated students went from 2.8% at baseline to 4.0% at 12 months, and similarly from 2.6% to 4.7% in unvaccinated controls. More importantly, the prevalence of disease-causing genotypes rose from 1.3% at baseline to 2.4% at follow-up in the vaccinated subjects, with a near-identical pattern seen in controls, where the prevalence rose from 1.4% to 2.4%. In an as-treated analysis, the rate of acquisition of carriage of disease-causing genotypes was identical at 2.0% in both study arms.

The 4CMenB vaccine proved reassuringly safe and effective in preventing meningococcal disease in vaccinated teens. With more than 58,000 doses of the vaccine given in the study, no new safety concerns or signals emerged. And the observed number of cases of invasive meningococcal disease in South Australian adolescent vaccine recipients to date has been significantly lower than expected.

Secondary and exploratory outcomes

Independent risk factors associated with N. meningitidis carriage in the study participants at the 1-year mark included smoking cigarettes or hookah, intimate kissing within the last week, and being in grades 11-12, as opposed to grade 10.

The vaccine had no significant impact on the carriage rate of the hypervirulent New Zealand serogroup B strain. Nor was there a vaccine impact on carriage density, as Mark McMillan, MD, reported elsewhere at ESPID 2019. But while the 4CMenB vaccine had minimal impact upon N. meningitidis carriage density, it was associated with a significant 41% increase in the likelihood of cleared carriage of disease-causing strains at 12 months, added Dr. McMillan, Dr. Marshall’s coinvestigator at University of Adelaide.

What’s next

The ongoing B Part of It School Leaver study is assessing carriage prevalence in vaccinated versus unvaccinated high schoolers in their first year after graduating.

In addition, the B Part of It investigators plan to prospectively study the impact of the 4CMen B vaccine on N. gonorrhoeae disease in an effort to confirm the intriguing findings of an earlier large, retrospective New Zealand case-control study. The Kiwis found that recipients of an outer membrane vesicle MenB vaccine had an adjusted 31% reduction in the risk of gonorrhea. This was the first-ever report of any vaccine effectiveness against this major global public health problem, in which antibiotic resistance is a growing concern (Lancet. 2017 Sep 30;390[10102]:1603-10). Dr. Marshall reported receiving research funding from GlaxoSmithKline, which markets Bexsero and was the major financial supporter of the B Part of It study.

But wait a minute...

Following Dr. Marshall’s report on the B Part of It study, outgoing ESPID president Adam Finn, MD, PhD, presented longitudinal data that he believes raise the possibility that protein-antigen vaccines such as Bexsero, which promote naturally acquired mucosal immunity, may impact on transmission population wide without reliably preventing acquisition. This would stand in stark contrast to conjugate meningococcus vaccines, which have a well-established massive impact on carriage and acquisition of N. meningitidis.

Bruce Jancin/MDedge News

It may be that in studying throat carriage rates once in individuals immunized 12 months earlier, as in the B Part of It study, investigators are not asking the right question, proposed Dr. Finn, professor of pediatrics at the University of Bristol (England).

His research team has been obtaining throat swabs at monthly intervals in a population of 917 high schoolers aged 16-17 years. In 416 of the students, they also have collected saliva samples weekly both before and after immunization with 4CMenB vaccine, analyzing the samples for N. meningitidis by polymerase chain reaction. This is a novel method of studying meningococcal carriage they have found to be both reliable and far more acceptable to patients than oropharyngeal swabbing, which adolescents balk at if asked to do with any frequency (PLoS One. 2019 Feb 11;14[2]:e0209905).

Dr. Finn said that their findings, which need confirmation, suggest that N. meningitidis carriage is usually brief and dynamic. They also have found that carriage density varies markedly from month to month.

“We see much higher-density carriage in the adolescent population in the early months of the year in conjunction, we think, with viral infection with influenza and so forth,” he said, adding that this could have clinical implications. “It feels sort of intuitive that someone walking around with 1,000 or 10,000 times as many meningococci in their throat is more likely to be more infectious to people around them with a very small number, although this hasn’t been formally proven.”

He hopes that the Be on the TEAM (Teenagers Against Meningitis) study will help provide answers. The study is randomizing 24,000 U.K. high school students to vaccination with the meningococcal B protein–antigen vaccines Bexsero or Trumenba or to no vaccine in order to learn if there are significant herd immunity effects.

Dr. Finn’s meningococcal carriage research is funded by the Meningitis Research Foundation and the National Institute for Health Research. Dr. Marshall reported receiving research funding from GlaxoSmithKline, the major sponsor of the B Part of It study.

[email protected]

LJUBLJANA, SLOVENIA – The 4CMenB vaccine didn’t affect carriage of disease-causing genogroups of Neisseria meningitidis in adolescents in the landmark Australian cluster-randomized trial of herd immunity known as the “B Part of It” study, Helen S. Marshall, MD, reported at the annual meeting of the European Society for Paediatric Infectious Diseases.

This was the largest-ever randomized trial of adolescents vaccinated against meningococcal disease, and the message, albeit somewhat disappointing, is clear: “MenB [Meningococcal serogroup B] vaccine programs should be designed to provide direct protection for those at highest risk of disease,” declared Dr. Marshall, professor of vaccinology and deputy director of the Robinson Research Institute at the University of Adelaide.

In other words, a protein antigen–based MenB vaccine doesn’t provide indirect protection to unvaccinated adolescents through herd immunity. Youths in the age groups at highest risk of disease – infants and adolescents – need to routinely receive the vaccine.

The B Part of It study, whose sheer scope and rigor drew the attention of infectious disease clinical trialists the world over, randomized nearly 35,000 students at all high schools in the state of South Australia – whether urban, rural, or remote – to two doses of the 4CMenB vaccine known as Bexsero or to a nonvaccinated control group. This massive trial entailed training more than 250 nurses in the study procedures and involved 3,100 miles of travel to transport oropharyngeal swab samples obtained from students in outlying areas for centralized laboratory analysis using real-time polymerase chain reaction with meningococcal genotyping, culture for N. meningitidis, and whole-genome sequencing. Samples were obtained on day 1 of the study and 12 months later.

The investigators created widespread regional enthusiasm for this project through adept use of social media and other methods. As a result, 99.5% of students randomized to the intervention arm received one dose, while 97% got two doses. A gratifying unintended consequence of the study was that parents who’d never previously vaccinated their children enrolled them in B Part of It, Dr. Marshall noted.

The impetus for B Part of It was that, while the Australian national health insurance program covers a single dose of meningococcal conjugate MenACWY vaccine given at age 12 months and 14-19 years, MenB vaccine isn’t covered because of uncertainties about cost effectiveness and the vaccine’s impact on meningococcal carriage and herd immunity. B Part of It was designed to resolve those uncertainties.

South Australia has the highest rate of invasive meningococcal disease in the country, and more than 80% of cases there are caused by meningococcal serogroup B. Moreover, 75% of group B cases in South Australia involve the nasty hypervirulent New Zealand strain known as CC 41/44.

The primary outcome in B Part of It was the difference in carriage of the major disease-causing serotypes – groups A, B, C, W, X, and Y – between vaccinated and unvaccinated students at the 1-year follow-up mark. The carriage prevalence of all N. meningitidis in the vaccinated students went from 2.8% at baseline to 4.0% at 12 months, and similarly from 2.6% to 4.7% in unvaccinated controls. More importantly, the prevalence of disease-causing genotypes rose from 1.3% at baseline to 2.4% at follow-up in the vaccinated subjects, with a near-identical pattern seen in controls, where the prevalence rose from 1.4% to 2.4%. In an as-treated analysis, the rate of acquisition of carriage of disease-causing genotypes was identical at 2.0% in both study arms.

The 4CMenB vaccine proved reassuringly safe and effective in preventing meningococcal disease in vaccinated teens. With more than 58,000 doses of the vaccine given in the study, no new safety concerns or signals emerged. And the observed number of cases of invasive meningococcal disease in South Australian adolescent vaccine recipients to date has been significantly lower than expected.

Secondary and exploratory outcomes

Independent risk factors associated with N. meningitidis carriage in the study participants at the 1-year mark included smoking cigarettes or hookah, intimate kissing within the last week, and being in grades 11-12, as opposed to grade 10.

The vaccine had no significant impact on the carriage rate of the hypervirulent New Zealand serogroup B strain. Nor was there a vaccine impact on carriage density, as Mark McMillan, MD, reported elsewhere at ESPID 2019. But while the 4CMenB vaccine had minimal impact upon N. meningitidis carriage density, it was associated with a significant 41% increase in the likelihood of cleared carriage of disease-causing strains at 12 months, added Dr. McMillan, Dr. Marshall’s coinvestigator at University of Adelaide.

What’s next

The ongoing B Part of It School Leaver study is assessing carriage prevalence in vaccinated versus unvaccinated high schoolers in their first year after graduating.

In addition, the B Part of It investigators plan to prospectively study the impact of the 4CMen B vaccine on N. gonorrhoeae disease in an effort to confirm the intriguing findings of an earlier large, retrospective New Zealand case-control study. The Kiwis found that recipients of an outer membrane vesicle MenB vaccine had an adjusted 31% reduction in the risk of gonorrhea. This was the first-ever report of any vaccine effectiveness against this major global public health problem, in which antibiotic resistance is a growing concern (Lancet. 2017 Sep 30;390[10102]:1603-10). Dr. Marshall reported receiving research funding from GlaxoSmithKline, which markets Bexsero and was the major financial supporter of the B Part of It study.

But wait a minute...

Following Dr. Marshall’s report on the B Part of It study, outgoing ESPID president Adam Finn, MD, PhD, presented longitudinal data that he believes raise the possibility that protein-antigen vaccines such as Bexsero, which promote naturally acquired mucosal immunity, may impact on transmission population wide without reliably preventing acquisition. This would stand in stark contrast to conjugate meningococcus vaccines, which have a well-established massive impact on carriage and acquisition of N. meningitidis.

Bruce Jancin/MDedge News

It may be that in studying throat carriage rates once in individuals immunized 12 months earlier, as in the B Part of It study, investigators are not asking the right question, proposed Dr. Finn, professor of pediatrics at the University of Bristol (England).

His research team has been obtaining throat swabs at monthly intervals in a population of 917 high schoolers aged 16-17 years. In 416 of the students, they also have collected saliva samples weekly both before and after immunization with 4CMenB vaccine, analyzing the samples for N. meningitidis by polymerase chain reaction. This is a novel method of studying meningococcal carriage they have found to be both reliable and far more acceptable to patients than oropharyngeal swabbing, which adolescents balk at if asked to do with any frequency (PLoS One. 2019 Feb 11;14[2]:e0209905).

Dr. Finn said that their findings, which need confirmation, suggest that N. meningitidis carriage is usually brief and dynamic. They also have found that carriage density varies markedly from month to month.

“We see much higher-density carriage in the adolescent population in the early months of the year in conjunction, we think, with viral infection with influenza and so forth,” he said, adding that this could have clinical implications. “It feels sort of intuitive that someone walking around with 1,000 or 10,000 times as many meningococci in their throat is more likely to be more infectious to people around them with a very small number, although this hasn’t been formally proven.”

He hopes that the Be on the TEAM (Teenagers Against Meningitis) study will help provide answers. The study is randomizing 24,000 U.K. high school students to vaccination with the meningococcal B protein–antigen vaccines Bexsero or Trumenba or to no vaccine in order to learn if there are significant herd immunity effects.

Dr. Finn’s meningococcal carriage research is funded by the Meningitis Research Foundation and the National Institute for Health Research. Dr. Marshall reported receiving research funding from GlaxoSmithKline, the major sponsor of the B Part of It study.

[email protected]