Patients with oligometastatic non–small cell lung cancer (NSCLC) have better outcomes when treated with local consolidative therapy than with maintenance therapy or observation, based on updated results from a phase 2 trial.

The randomized study showed that both median progression-free and overall survival were better in patients who received radiotherapy or surgery instead of maintenance therapy or observation, reported lead author Daniel R. Gomez, MD, of the University of Texas MD Anderson Cancer Center, Houston, and colleagues. These findings build on earlier results that showed the positive impact of local consolidative therapy (LCT), the investigators noted.

“The trial was closed early after it demonstrated an observed 8-month benefit in [progression-free survival] for patients who received LCT relative to patients who received maintenance therapy or observation,” the investigators wrote in Journal of Clinical Oncology.

After early closure, 49 patients remained in the dataset. All had metastatic NSCLC with three or fewer metastases that did not progress for at least 3 months after first-line systemic therapy. Most patients had adenocarcinoma (80%). Patients were randomly divided in a 1:1 ratio between radiotherapy or surgery (LCT) for all active disease sites or maintenance therapy/observation (MT/O). Progression-free survival was the primary endpoint. Overall survival and several other secondary endpoints were also evaluated.

Data analysis showed a clear benefit of LCT. Continuing the previously reported trend, median progression-free survival was extended in the LCT group, compared with the MT/O group (14.2 vs. 4.4 months; P = .022). Similarly, median overall survival showed a significant improvement (41.2 vs. 17.0 months; P = .017). Median time to appearance of new lesions also supported the advantage of LCT over MT/O, albeit with less statistical significance (14.2 vs. 6.0 months; P = .11).

The investigators suggested several mechanisms behind the efficacy of LCT, including elimination of treatment-resistant cells, potentiation of systemic therapy, and elimination of the residual tumor as a driver of distant micrometastatic disease. “Notably,” the investigators wrote, “these mechanisms are not mutually exclusive, and more than one could contribute to the benefits of LCT.”

“[A]lthough these data are compelling ... we emphasize that future studies should be supported to definitively assess the role of LCT in larger populations (e.g., phase III trials such as NRG-LU002) and in the context of novel systemic therapies,” the investigators concluded.

The study was funded by MD Anderson Cancer Center, The Mohaymen Sahebzadah Family Philanthropic Grant, and the National Cancer Institute, National Institutes of Health. The authors disclosed relationships with Merck, Bristol-Myers Squibb, AstraZeneca, and others.

SOURCE: Gomez et al. J Clin Oncol. 8 May 2019. doi:10.1200/JCO.19.00201.

Patients with oligometastatic non–small cell lung cancer (NSCLC) have better outcomes when treated with local consolidative therapy than with maintenance therapy or observation, based on updated results from a phase 2 trial.

The randomized study showed that both median progression-free and overall survival were better in patients who received radiotherapy or surgery instead of maintenance therapy or observation, reported lead author Daniel R. Gomez, MD, of the University of Texas MD Anderson Cancer Center, Houston, and colleagues. These findings build on earlier results that showed the positive impact of local consolidative therapy (LCT), the investigators noted.

“The trial was closed early after it demonstrated an observed 8-month benefit in [progression-free survival] for patients who received LCT relative to patients who received maintenance therapy or observation,” the investigators wrote in Journal of Clinical Oncology.

After early closure, 49 patients remained in the dataset. All had metastatic NSCLC with three or fewer metastases that did not progress for at least 3 months after first-line systemic therapy. Most patients had adenocarcinoma (80%). Patients were randomly divided in a 1:1 ratio between radiotherapy or surgery (LCT) for all active disease sites or maintenance therapy/observation (MT/O). Progression-free survival was the primary endpoint. Overall survival and several other secondary endpoints were also evaluated.

Data analysis showed a clear benefit of LCT. Continuing the previously reported trend, median progression-free survival was extended in the LCT group, compared with the MT/O group (14.2 vs. 4.4 months; P = .022). Similarly, median overall survival showed a significant improvement (41.2 vs. 17.0 months; P = .017). Median time to appearance of new lesions also supported the advantage of LCT over MT/O, albeit with less statistical significance (14.2 vs. 6.0 months; P = .11).

The investigators suggested several mechanisms behind the efficacy of LCT, including elimination of treatment-resistant cells, potentiation of systemic therapy, and elimination of the residual tumor as a driver of distant micrometastatic disease. “Notably,” the investigators wrote, “these mechanisms are not mutually exclusive, and more than one could contribute to the benefits of LCT.”

“[A]lthough these data are compelling ... we emphasize that future studies should be supported to definitively assess the role of LCT in larger populations (e.g., phase III trials such as NRG-LU002) and in the context of novel systemic therapies,” the investigators concluded.

The study was funded by MD Anderson Cancer Center, The Mohaymen Sahebzadah Family Philanthropic Grant, and the National Cancer Institute, National Institutes of Health. The authors disclosed relationships with Merck, Bristol-Myers Squibb, AstraZeneca, and others.

SOURCE: Gomez et al. J Clin Oncol. 8 May 2019. doi:10.1200/JCO.19.00201.

Patients with oligometastatic non–small cell lung cancer (NSCLC) have better outcomes when treated with local consolidative therapy than with maintenance therapy or observation, based on updated results from a phase 2 trial.

The randomized study showed that both median progression-free and overall survival were better in patients who received radiotherapy or surgery instead of maintenance therapy or observation, reported lead author Daniel R. Gomez, MD, of the University of Texas MD Anderson Cancer Center, Houston, and colleagues. These findings build on earlier results that showed the positive impact of local consolidative therapy (LCT), the investigators noted.

“The trial was closed early after it demonstrated an observed 8-month benefit in [progression-free survival] for patients who received LCT relative to patients who received maintenance therapy or observation,” the investigators wrote in Journal of Clinical Oncology.

After early closure, 49 patients remained in the dataset. All had metastatic NSCLC with three or fewer metastases that did not progress for at least 3 months after first-line systemic therapy. Most patients had adenocarcinoma (80%). Patients were randomly divided in a 1:1 ratio between radiotherapy or surgery (LCT) for all active disease sites or maintenance therapy/observation (MT/O). Progression-free survival was the primary endpoint. Overall survival and several other secondary endpoints were also evaluated.

Data analysis showed a clear benefit of LCT. Continuing the previously reported trend, median progression-free survival was extended in the LCT group, compared with the MT/O group (14.2 vs. 4.4 months; P = .022). Similarly, median overall survival showed a significant improvement (41.2 vs. 17.0 months; P = .017). Median time to appearance of new lesions also supported the advantage of LCT over MT/O, albeit with less statistical significance (14.2 vs. 6.0 months; P = .11).

The investigators suggested several mechanisms behind the efficacy of LCT, including elimination of treatment-resistant cells, potentiation of systemic therapy, and elimination of the residual tumor as a driver of distant micrometastatic disease. “Notably,” the investigators wrote, “these mechanisms are not mutually exclusive, and more than one could contribute to the benefits of LCT.”

“[A]lthough these data are compelling ... we emphasize that future studies should be supported to definitively assess the role of LCT in larger populations (e.g., phase III trials such as NRG-LU002) and in the context of novel systemic therapies,” the investigators concluded.

The study was funded by MD Anderson Cancer Center, The Mohaymen Sahebzadah Family Philanthropic Grant, and the National Cancer Institute, National Institutes of Health. The authors disclosed relationships with Merck, Bristol-Myers Squibb, AstraZeneca, and others.

SOURCE: Gomez et al. J Clin Oncol. 8 May 2019. doi:10.1200/JCO.19.00201.

Women with psoriatic arthritis and ankylosing spondylitis generally have favorable pregnancy outcomes, but high disease activity during pregnancy could increase the risk of adverse labor and delivery outcomes, according to 2004-2018 data from the Organization of Teratology Information Specialists (OTIS) Autoimmune Disease Project.

Corticosteroid use further increased risk for preterm delivery among women with ankylosing spondylitis.

While more research is needed, these findings suggest that better obstetric outcomes might be achieved via better disease control and minimal use of corticosteroids, according to Chelsey J. F. Smith, MD, of the University of California, San Diego, and colleagues.

“Future studies are needed to confirm the novel findings seen in our study, as well as to continue to analyze the effect of different disease activity measures and medication use on pregnancy outcomes in these two chronic conditions,” Dr. Smith and coauthors said in a report on the study in Arthritis Care and Research.

Many women affected by psoriatic arthritis and ankylosing spondylitis are of child-bearing age and consider planning a family, according to the researchers. Data on pregnancy outcomes are lacking, they said, “often making it difficult for rheumatologists and obstetricians to counsel their patients effectively.”

The study from Dr. Smith and coinvestigators comprised 963 women who enrolled in the OTIS prospective cohort study within 20 weeks of gestation and delivered at least one live-born infant. Of that cohort, 129 had ankylosing spondylitis, 117 had psoriatic arthritis, and the remaining 717 served as a control group.

Psoriatic arthritis conferred an 81% increased risk for moderate preterm delivery at 32-36 weeks gestation, compared with healthier women, 13.7% and 7.7% respectively. Risk was increased among women with psoriatic arthritis for preterm labor, 16.2% and 8.4% (adjusted risk ratio, 2.05, 95% confidence interval, 1.21-3.48), caesarean delivery, 48.7% and 26.2% (aRR, 1.63, 95% CI, 1.26-2.12), and oligohydramnios, 25% and 11% (aRR, 3.79, 95% CI, 1.34-10.74). Women with psoriatic arthritis were 2 years older on average and their average body mass index was 27 kg/m² vs. 24.5 kg/m² in the control group.

In women with ankylosing spondylitis, risk of infant hospitalization in the neonatal intensive care unit was increased by 67%, 17.2% vs. 11.9% in the control group.

Active disease measured by the Health Assessment Questionnaire (HAQ) or Routine Assessment of Patient Index Data 3 (RAPID3) was linked to increased risk of adverse obstetric outcomes in some cases, the investigators said.

For example, risk of preterm delivery was increased in women with psoriatic arthritis who had active disease at 32 weeks as measured by HAQ (27 women) and RAPID3 (28 women) scores, while in ankylosing spondylitis, active disease measured at intake by RAPID3 (46 women) was associated with increased risk of caesarean delivery.

Medication use in women with psoriatic arthritis was not associated with increased preterm delivery risk. However, women with ankylosing spondylitis who used corticosteroids in the second trimester had an increased risk of preterm delivery.

The rate of corticosteroid use was “surprisingly high” at 38% among the women with ankylosing spondylitis, Dr. Smith and coinvestigators said.

“The 2016 American College of Rheumatology guidelines in fact recommend against the use of systemic corticosteroids for the treatment of ankylosing spondylitis, with the exception of short-term treatment with rapid tapering in circumstances such as flares during pregnancy, flares of concomitant inflammatory bowel disease, or flare of peripheral arthritis,” they said in their report.

Dr. Smith and coauthors reported no conflicts of interest. The OTIS Collaborative Research Group has received research funding from AbbVie, Amgen, Bristol-Myers Squibb, Janssen, Pfizer, and others.

SOURCE: Smith CJF et al. Arthritis Care Res. 2019 May 10. doi: 10.1002/acr.23924.

Women with psoriatic arthritis and ankylosing spondylitis generally have favorable pregnancy outcomes, but high disease activity during pregnancy could increase the risk of adverse labor and delivery outcomes, according to 2004-2018 data from the Organization of Teratology Information Specialists (OTIS) Autoimmune Disease Project.

Corticosteroid use further increased risk for preterm delivery among women with ankylosing spondylitis.

While more research is needed, these findings suggest that better obstetric outcomes might be achieved via better disease control and minimal use of corticosteroids, according to Chelsey J. F. Smith, MD, of the University of California, San Diego, and colleagues.

“Future studies are needed to confirm the novel findings seen in our study, as well as to continue to analyze the effect of different disease activity measures and medication use on pregnancy outcomes in these two chronic conditions,” Dr. Smith and coauthors said in a report on the study in Arthritis Care and Research.

Many women affected by psoriatic arthritis and ankylosing spondylitis are of child-bearing age and consider planning a family, according to the researchers. Data on pregnancy outcomes are lacking, they said, “often making it difficult for rheumatologists and obstetricians to counsel their patients effectively.”

The study from Dr. Smith and coinvestigators comprised 963 women who enrolled in the OTIS prospective cohort study within 20 weeks of gestation and delivered at least one live-born infant. Of that cohort, 129 had ankylosing spondylitis, 117 had psoriatic arthritis, and the remaining 717 served as a control group.

Psoriatic arthritis conferred an 81% increased risk for moderate preterm delivery at 32-36 weeks gestation, compared with healthier women, 13.7% and 7.7% respectively. Risk was increased among women with psoriatic arthritis for preterm labor, 16.2% and 8.4% (adjusted risk ratio, 2.05, 95% confidence interval, 1.21-3.48), caesarean delivery, 48.7% and 26.2% (aRR, 1.63, 95% CI, 1.26-2.12), and oligohydramnios, 25% and 11% (aRR, 3.79, 95% CI, 1.34-10.74). Women with psoriatic arthritis were 2 years older on average and their average body mass index was 27 kg/m² vs. 24.5 kg/m² in the control group.

In women with ankylosing spondylitis, risk of infant hospitalization in the neonatal intensive care unit was increased by 67%, 17.2% vs. 11.9% in the control group.

Active disease measured by the Health Assessment Questionnaire (HAQ) or Routine Assessment of Patient Index Data 3 (RAPID3) was linked to increased risk of adverse obstetric outcomes in some cases, the investigators said.

For example, risk of preterm delivery was increased in women with psoriatic arthritis who had active disease at 32 weeks as measured by HAQ (27 women) and RAPID3 (28 women) scores, while in ankylosing spondylitis, active disease measured at intake by RAPID3 (46 women) was associated with increased risk of caesarean delivery.

Medication use in women with psoriatic arthritis was not associated with increased preterm delivery risk. However, women with ankylosing spondylitis who used corticosteroids in the second trimester had an increased risk of preterm delivery.

The rate of corticosteroid use was “surprisingly high” at 38% among the women with ankylosing spondylitis, Dr. Smith and coinvestigators said.

“The 2016 American College of Rheumatology guidelines in fact recommend against the use of systemic corticosteroids for the treatment of ankylosing spondylitis, with the exception of short-term treatment with rapid tapering in circumstances such as flares during pregnancy, flares of concomitant inflammatory bowel disease, or flare of peripheral arthritis,” they said in their report.

Dr. Smith and coauthors reported no conflicts of interest. The OTIS Collaborative Research Group has received research funding from AbbVie, Amgen, Bristol-Myers Squibb, Janssen, Pfizer, and others.

SOURCE: Smith CJF et al. Arthritis Care Res. 2019 May 10. doi: 10.1002/acr.23924.

Women with psoriatic arthritis and ankylosing spondylitis generally have favorable pregnancy outcomes, but high disease activity during pregnancy could increase the risk of adverse labor and delivery outcomes, according to 2004-2018 data from the Organization of Teratology Information Specialists (OTIS) Autoimmune Disease Project.

Corticosteroid use further increased risk for preterm delivery among women with ankylosing spondylitis.

While more research is needed, these findings suggest that better obstetric outcomes might be achieved via better disease control and minimal use of corticosteroids, according to Chelsey J. F. Smith, MD, of the University of California, San Diego, and colleagues.

“Future studies are needed to confirm the novel findings seen in our study, as well as to continue to analyze the effect of different disease activity measures and medication use on pregnancy outcomes in these two chronic conditions,” Dr. Smith and coauthors said in a report on the study in Arthritis Care and Research.

Many women affected by psoriatic arthritis and ankylosing spondylitis are of child-bearing age and consider planning a family, according to the researchers. Data on pregnancy outcomes are lacking, they said, “often making it difficult for rheumatologists and obstetricians to counsel their patients effectively.”

The study from Dr. Smith and coinvestigators comprised 963 women who enrolled in the OTIS prospective cohort study within 20 weeks of gestation and delivered at least one live-born infant. Of that cohort, 129 had ankylosing spondylitis, 117 had psoriatic arthritis, and the remaining 717 served as a control group.

Psoriatic arthritis conferred an 81% increased risk for moderate preterm delivery at 32-36 weeks gestation, compared with healthier women, 13.7% and 7.7% respectively. Risk was increased among women with psoriatic arthritis for preterm labor, 16.2% and 8.4% (adjusted risk ratio, 2.05, 95% confidence interval, 1.21-3.48), caesarean delivery, 48.7% and 26.2% (aRR, 1.63, 95% CI, 1.26-2.12), and oligohydramnios, 25% and 11% (aRR, 3.79, 95% CI, 1.34-10.74). Women with psoriatic arthritis were 2 years older on average and their average body mass index was 27 kg/m² vs. 24.5 kg/m² in the control group.

In women with ankylosing spondylitis, risk of infant hospitalization in the neonatal intensive care unit was increased by 67%, 17.2% vs. 11.9% in the control group.

Active disease measured by the Health Assessment Questionnaire (HAQ) or Routine Assessment of Patient Index Data 3 (RAPID3) was linked to increased risk of adverse obstetric outcomes in some cases, the investigators said.

For example, risk of preterm delivery was increased in women with psoriatic arthritis who had active disease at 32 weeks as measured by HAQ (27 women) and RAPID3 (28 women) scores, while in ankylosing spondylitis, active disease measured at intake by RAPID3 (46 women) was associated with increased risk of caesarean delivery.

Medication use in women with psoriatic arthritis was not associated with increased preterm delivery risk. However, women with ankylosing spondylitis who used corticosteroids in the second trimester had an increased risk of preterm delivery.

The rate of corticosteroid use was “surprisingly high” at 38% among the women with ankylosing spondylitis, Dr. Smith and coinvestigators said.

“The 2016 American College of Rheumatology guidelines in fact recommend against the use of systemic corticosteroids for the treatment of ankylosing spondylitis, with the exception of short-term treatment with rapid tapering in circumstances such as flares during pregnancy, flares of concomitant inflammatory bowel disease, or flare of peripheral arthritis,” they said in their report.

Dr. Smith and coauthors reported no conflicts of interest. The OTIS Collaborative Research Group has received research funding from AbbVie, Amgen, Bristol-Myers Squibb, Janssen, Pfizer, and others.

SOURCE: Smith CJF et al. Arthritis Care Res. 2019 May 10. doi: 10.1002/acr.23924.

SAN FRANCISCO – Veterans who are survivors of military sexual trauma during their service face unique challenges in their treatment and recovery. They are often reluctant to report their experiences – and understandably so.

“Military sexual assault represents a huge violation of that trust and safety. That’s what makes it so toxic and hard for participants to [come] forward, because they’re accused of breaking cohesion of their unit and breaking morale, and yet they have been mistreated,” Niranjan Karnik, MD, PhD, associate dean for community behavioral health at Rush Medical College, Chicago, said in an interview.

Dr. Karnik moderated a session on the prevalence and treatment of military sexual assault at the annual meeting of the American Psychiatric Association. Although the Department of Veterans Affairs treats many survivors of sexual assault, not all of them feel comfortable in that environment. “A VA hospital has a quasi-military feel to it, and that’s a reflection of what it is and the people who are there. That can be an inhibition – and can even be a trigger for [PTSD] symptoms,” Dr. Karnik said.

Survivors may also worry about being labeled, or about adverse entries going into their official record and how that could affect them in the future. “I don’t think there are [VA] policies that put them at risk, but they can perceive that,” Dr. Karnik said. The issue is a stark contrast to veterans who are suffering from combat-related trauma.

“When a combat trauma survivor goes to the VA, they feel protected because their colleagues are there. With military sexual trauma, because of that violation of trust from their peers, it can really exacerbate things,” Dr. Karnik said.

Fortunately, there are alternatives, such as the Road Home* Program at Rush Hospital, which has a few military accoutrements but more closely resembles a civilian center. “It can be an easier access point. The VA is taking care of a large majority of patients. We are a boutique program for the vets who can’t or feel unable to go through the VA program,” Dr. Karnik said.

Overall, 52.5% of women and 8.9% of men in the military report sexual harassment, and 23.6% of women and 1.9% of men report being sexually assaulted. That amounts to 14,900 service members, 8,600 women, and 6,300 men who were assaulted in 2016, according to Neeral K. Sheth, DO, assistant professor of psychiatry at Rush Medical College, who also presented at the session. The frequency of assault is higher among LGBTQ individuals, and African American men and women are more likely to experience sexual harassment.

There are options for treatment of military sexual trauma (MST). The 3-week Road Home intensive outpatient treatment program at Rush Hospital combines group and individual cognitive-processing therapy, which is a cognitive-behavioral therapy that has been shown to improve PTSD resulting from MST. The program places combat trauma and MST trauma patients into separate cohorts, each containing individual and group components. Individual sessions closely follow a manualized protocol, while group sessions offer an opportunity to practice cognitive-processing therapy skills.

The team adapted the program to MST treatment by incorporating dialectical-behavioral therapy skills modules in the first week of the program, and implemented one-on-one skills consultation by request throughout the program.

An analysis of 191 subjects participating in 19 cohorts (12 combat, 9 MST cohorts) showed a 92% completion rate, which was similar, regardless of gender or cohort type. Both cohorts had significant reductions in PTSD severity as measured by the PTSD Checklist for DSM-5, and depression symptoms as measured by the Patient Health Questionnaire–9.

Another program, Families OverComing Under Stress, can also be adapted to MST. It is designed to build resiliency and wellness within families dealing with trauma or loss. It incorporates family assessment, psychoeducation tailored to the needs of the entire family, family-level resilience skills, and a narrative component.

An important element is the identification and management of stress reminders – triggers that remind the individual of a trauma and may cause a sudden shift in mood or behavior. A family member’s knowledge that the survivor is experiencing a stress reminder can reduce misunderstandings or unhelpful interpretations of behavior.

In fact, family considerations are often what bring veterans in for help in the first place, according to Dr. Karnik. He or she may be concerned about behavioral problems in a child, which the VA cannot address because its federal funding dictates a sole focus on the veteran. “We will take care of the whole family,” Dr. Karnik said. “Often that’s the entry point, and that allows us to do some engagement with the veteran, and things start to get uncovered.”

Dr. Karnik has no relevant financial disclosures.

*CORRECTION,  5/21/2019

SAN FRANCISCO – Veterans who are survivors of military sexual trauma during their service face unique challenges in their treatment and recovery. They are often reluctant to report their experiences – and understandably so.

“Military sexual assault represents a huge violation of that trust and safety. That’s what makes it so toxic and hard for participants to [come] forward, because they’re accused of breaking cohesion of their unit and breaking morale, and yet they have been mistreated,” Niranjan Karnik, MD, PhD, associate dean for community behavioral health at Rush Medical College, Chicago, said in an interview.

Dr. Karnik moderated a session on the prevalence and treatment of military sexual assault at the annual meeting of the American Psychiatric Association. Although the Department of Veterans Affairs treats many survivors of sexual assault, not all of them feel comfortable in that environment. “A VA hospital has a quasi-military feel to it, and that’s a reflection of what it is and the people who are there. That can be an inhibition – and can even be a trigger for [PTSD] symptoms,” Dr. Karnik said.

Survivors may also worry about being labeled, or about adverse entries going into their official record and how that could affect them in the future. “I don’t think there are [VA] policies that put them at risk, but they can perceive that,” Dr. Karnik said. The issue is a stark contrast to veterans who are suffering from combat-related trauma.

“When a combat trauma survivor goes to the VA, they feel protected because their colleagues are there. With military sexual trauma, because of that violation of trust from their peers, it can really exacerbate things,” Dr. Karnik said.

Fortunately, there are alternatives, such as the Road Home* Program at Rush Hospital, which has a few military accoutrements but more closely resembles a civilian center. “It can be an easier access point. The VA is taking care of a large majority of patients. We are a boutique program for the vets who can’t or feel unable to go through the VA program,” Dr. Karnik said.

Overall, 52.5% of women and 8.9% of men in the military report sexual harassment, and 23.6% of women and 1.9% of men report being sexually assaulted. That amounts to 14,900 service members, 8,600 women, and 6,300 men who were assaulted in 2016, according to Neeral K. Sheth, DO, assistant professor of psychiatry at Rush Medical College, who also presented at the session. The frequency of assault is higher among LGBTQ individuals, and African American men and women are more likely to experience sexual harassment.

There are options for treatment of military sexual trauma (MST). The 3-week Road Home intensive outpatient treatment program at Rush Hospital combines group and individual cognitive-processing therapy, which is a cognitive-behavioral therapy that has been shown to improve PTSD resulting from MST. The program places combat trauma and MST trauma patients into separate cohorts, each containing individual and group components. Individual sessions closely follow a manualized protocol, while group sessions offer an opportunity to practice cognitive-processing therapy skills.

The team adapted the program to MST treatment by incorporating dialectical-behavioral therapy skills modules in the first week of the program, and implemented one-on-one skills consultation by request throughout the program.

An analysis of 191 subjects participating in 19 cohorts (12 combat, 9 MST cohorts) showed a 92% completion rate, which was similar, regardless of gender or cohort type. Both cohorts had significant reductions in PTSD severity as measured by the PTSD Checklist for DSM-5, and depression symptoms as measured by the Patient Health Questionnaire–9.

Another program, Families OverComing Under Stress, can also be adapted to MST. It is designed to build resiliency and wellness within families dealing with trauma or loss. It incorporates family assessment, psychoeducation tailored to the needs of the entire family, family-level resilience skills, and a narrative component.

An important element is the identification and management of stress reminders – triggers that remind the individual of a trauma and may cause a sudden shift in mood or behavior. A family member’s knowledge that the survivor is experiencing a stress reminder can reduce misunderstandings or unhelpful interpretations of behavior.

In fact, family considerations are often what bring veterans in for help in the first place, according to Dr. Karnik. He or she may be concerned about behavioral problems in a child, which the VA cannot address because its federal funding dictates a sole focus on the veteran. “We will take care of the whole family,” Dr. Karnik said. “Often that’s the entry point, and that allows us to do some engagement with the veteran, and things start to get uncovered.”

Dr. Karnik has no relevant financial disclosures.

*CORRECTION,  5/21/2019

SAN FRANCISCO – Veterans who are survivors of military sexual trauma during their service face unique challenges in their treatment and recovery. They are often reluctant to report their experiences – and understandably so.

“Military sexual assault represents a huge violation of that trust and safety. That’s what makes it so toxic and hard for participants to [come] forward, because they’re accused of breaking cohesion of their unit and breaking morale, and yet they have been mistreated,” Niranjan Karnik, MD, PhD, associate dean for community behavioral health at Rush Medical College, Chicago, said in an interview.

Dr. Karnik moderated a session on the prevalence and treatment of military sexual assault at the annual meeting of the American Psychiatric Association. Although the Department of Veterans Affairs treats many survivors of sexual assault, not all of them feel comfortable in that environment. “A VA hospital has a quasi-military feel to it, and that’s a reflection of what it is and the people who are there. That can be an inhibition – and can even be a trigger for [PTSD] symptoms,” Dr. Karnik said.

Survivors may also worry about being labeled, or about adverse entries going into their official record and how that could affect them in the future. “I don’t think there are [VA] policies that put them at risk, but they can perceive that,” Dr. Karnik said. The issue is a stark contrast to veterans who are suffering from combat-related trauma.

“When a combat trauma survivor goes to the VA, they feel protected because their colleagues are there. With military sexual trauma, because of that violation of trust from their peers, it can really exacerbate things,” Dr. Karnik said.

Fortunately, there are alternatives, such as the Road Home* Program at Rush Hospital, which has a few military accoutrements but more closely resembles a civilian center. “It can be an easier access point. The VA is taking care of a large majority of patients. We are a boutique program for the vets who can’t or feel unable to go through the VA program,” Dr. Karnik said.

Overall, 52.5% of women and 8.9% of men in the military report sexual harassment, and 23.6% of women and 1.9% of men report being sexually assaulted. That amounts to 14,900 service members, 8,600 women, and 6,300 men who were assaulted in 2016, according to Neeral K. Sheth, DO, assistant professor of psychiatry at Rush Medical College, who also presented at the session. The frequency of assault is higher among LGBTQ individuals, and African American men and women are more likely to experience sexual harassment.

There are options for treatment of military sexual trauma (MST). The 3-week Road Home intensive outpatient treatment program at Rush Hospital combines group and individual cognitive-processing therapy, which is a cognitive-behavioral therapy that has been shown to improve PTSD resulting from MST. The program places combat trauma and MST trauma patients into separate cohorts, each containing individual and group components. Individual sessions closely follow a manualized protocol, while group sessions offer an opportunity to practice cognitive-processing therapy skills.

The team adapted the program to MST treatment by incorporating dialectical-behavioral therapy skills modules in the first week of the program, and implemented one-on-one skills consultation by request throughout the program.

An analysis of 191 subjects participating in 19 cohorts (12 combat, 9 MST cohorts) showed a 92% completion rate, which was similar, regardless of gender or cohort type. Both cohorts had significant reductions in PTSD severity as measured by the PTSD Checklist for DSM-5, and depression symptoms as measured by the Patient Health Questionnaire–9.

Another program, Families OverComing Under Stress, can also be adapted to MST. It is designed to build resiliency and wellness within families dealing with trauma or loss. It incorporates family assessment, psychoeducation tailored to the needs of the entire family, family-level resilience skills, and a narrative component.

An important element is the identification and management of stress reminders – triggers that remind the individual of a trauma and may cause a sudden shift in mood or behavior. A family member’s knowledge that the survivor is experiencing a stress reminder can reduce misunderstandings or unhelpful interpretations of behavior.

In fact, family considerations are often what bring veterans in for help in the first place, according to Dr. Karnik. He or she may be concerned about behavioral problems in a child, which the VA cannot address because its federal funding dictates a sole focus on the veteran. “We will take care of the whole family,” Dr. Karnik said. “Often that’s the entry point, and that allows us to do some engagement with the veteran, and things start to get uncovered.”

Dr. Karnik has no relevant financial disclosures.

*CORRECTION,  5/21/2019

The National Comprehensive Cancer Network (NCCN) and the University of Texas MD Anderson Cancer Center have awarded funding to investigators conducting a range of research projects looking at everything from chimeric antigen receptor T-cell therapy in lung cancer to financial toxicity to fecal microbiota transplantation.

Four researchers won funding through the NCCN Young Investigator Awards, which are supported by the NCCN Foundation, Astra Zeneca, Merck & Co., Genentech, Pfizer, and Incyte.

Prasanna Ananth, MD, of Yale Cancer Center in New Haven, Conn., won funding for her work investigating benchmarks for high quality end-of-life care in children with cancer.

Jaehyuk Choi, MD, PhD, of Northwestern University in Chicago won for his research investigating genomic determinants of response to immunotherapy in Merkel cell carcinoma.

Kedar Kirtane, MD, of Moffitt Cancer Center in Tampa won for his work on a digitized peer-to-peer patient support system for patients with locally advanced head and neck cancer who are receiving chemoradiation.

Yanming Li, PhD, of the University of Michigan in Ann Arbor won for network genome-wide association studies for early detection of cancers.

Meanwhile, the University of Texas MD Anderson Cancer Center named eight researchers to this year’s class of Andrew Sabin Family Fellows. Each researcher will receive $100,000 in funding over 2 years through a $30-million endowment from the Andrew Sabin Family Foundation.

Lauren Averett Byers, MD, is conducting research on the first chimeric antigen receptor T-cell therapy for small cell lung cancer.

Florencia McAllister, MD, is studying the intratumoral bacteria detected in pancreatic cancer patients and the use of fecal microbial transplants to improve treatment outcomes.

Jose Alejandro Rauh-Hain, MD, is attempting to improve gynecologic genetic testing and risk-reduction interventions in underserved populations.

Grace Li Smith, MD, PhD, is researching financial toxicity in patients with early-stage breast cancer who are treated with short-course versus standard adjuvant radiation.

Ishwaria Mohan Subbiah, MD, is investigating a personalized, technology-enhanced symptom-management strategy to provide holistic care for patients on phase 1 trials.

Andrea Viale, MD, is studying the effects of transient inflammation and the role of epithelial memory during progression of pancreatic ductal adenocarcinoma.

Linghua Wang, PhD, is investigating TIM-3 as a potential target for treating peritoneal carcinomatosis in patients with advanced gastric cancer.

Yinghong Wang, MD, PhD, is researching fecal microbiota transplantation as an option for managing immune-mediated colitis following cancer immunotherapy.

Movers in Medicine highlights career moves and personal achievements by hematologists and oncologists. Did you switch jobs, take on a new role, climb a mountain? Tell us all about it at [email protected], and you could be featured in Movers in Medicine.

[email protected]

The National Comprehensive Cancer Network (NCCN) and the University of Texas MD Anderson Cancer Center have awarded funding to investigators conducting a range of research projects looking at everything from chimeric antigen receptor T-cell therapy in lung cancer to financial toxicity to fecal microbiota transplantation.

Four researchers won funding through the NCCN Young Investigator Awards, which are supported by the NCCN Foundation, Astra Zeneca, Merck & Co., Genentech, Pfizer, and Incyte.

Prasanna Ananth, MD, of Yale Cancer Center in New Haven, Conn., won funding for her work investigating benchmarks for high quality end-of-life care in children with cancer.

Jaehyuk Choi, MD, PhD, of Northwestern University in Chicago won for his research investigating genomic determinants of response to immunotherapy in Merkel cell carcinoma.

Kedar Kirtane, MD, of Moffitt Cancer Center in Tampa won for his work on a digitized peer-to-peer patient support system for patients with locally advanced head and neck cancer who are receiving chemoradiation.

Yanming Li, PhD, of the University of Michigan in Ann Arbor won for network genome-wide association studies for early detection of cancers.

Meanwhile, the University of Texas MD Anderson Cancer Center named eight researchers to this year’s class of Andrew Sabin Family Fellows. Each researcher will receive $100,000 in funding over 2 years through a $30-million endowment from the Andrew Sabin Family Foundation.

Lauren Averett Byers, MD, is conducting research on the first chimeric antigen receptor T-cell therapy for small cell lung cancer.

Florencia McAllister, MD, is studying the intratumoral bacteria detected in pancreatic cancer patients and the use of fecal microbial transplants to improve treatment outcomes.

Jose Alejandro Rauh-Hain, MD, is attempting to improve gynecologic genetic testing and risk-reduction interventions in underserved populations.

Grace Li Smith, MD, PhD, is researching financial toxicity in patients with early-stage breast cancer who are treated with short-course versus standard adjuvant radiation.

Ishwaria Mohan Subbiah, MD, is investigating a personalized, technology-enhanced symptom-management strategy to provide holistic care for patients on phase 1 trials.

Andrea Viale, MD, is studying the effects of transient inflammation and the role of epithelial memory during progression of pancreatic ductal adenocarcinoma.

Linghua Wang, PhD, is investigating TIM-3 as a potential target for treating peritoneal carcinomatosis in patients with advanced gastric cancer.

Yinghong Wang, MD, PhD, is researching fecal microbiota transplantation as an option for managing immune-mediated colitis following cancer immunotherapy.

Movers in Medicine highlights career moves and personal achievements by hematologists and oncologists. Did you switch jobs, take on a new role, climb a mountain? Tell us all about it at [email protected], and you could be featured in Movers in Medicine.

[email protected]

The National Comprehensive Cancer Network (NCCN) and the University of Texas MD Anderson Cancer Center have awarded funding to investigators conducting a range of research projects looking at everything from chimeric antigen receptor T-cell therapy in lung cancer to financial toxicity to fecal microbiota transplantation.

Four researchers won funding through the NCCN Young Investigator Awards, which are supported by the NCCN Foundation, Astra Zeneca, Merck & Co., Genentech, Pfizer, and Incyte.

Prasanna Ananth, MD, of Yale Cancer Center in New Haven, Conn., won funding for her work investigating benchmarks for high quality end-of-life care in children with cancer.

Jaehyuk Choi, MD, PhD, of Northwestern University in Chicago won for his research investigating genomic determinants of response to immunotherapy in Merkel cell carcinoma.

Kedar Kirtane, MD, of Moffitt Cancer Center in Tampa won for his work on a digitized peer-to-peer patient support system for patients with locally advanced head and neck cancer who are receiving chemoradiation.

Yanming Li, PhD, of the University of Michigan in Ann Arbor won for network genome-wide association studies for early detection of cancers.

Meanwhile, the University of Texas MD Anderson Cancer Center named eight researchers to this year’s class of Andrew Sabin Family Fellows. Each researcher will receive $100,000 in funding over 2 years through a $30-million endowment from the Andrew Sabin Family Foundation.

Lauren Averett Byers, MD, is conducting research on the first chimeric antigen receptor T-cell therapy for small cell lung cancer.

Florencia McAllister, MD, is studying the intratumoral bacteria detected in pancreatic cancer patients and the use of fecal microbial transplants to improve treatment outcomes.

Jose Alejandro Rauh-Hain, MD, is attempting to improve gynecologic genetic testing and risk-reduction interventions in underserved populations.

Grace Li Smith, MD, PhD, is researching financial toxicity in patients with early-stage breast cancer who are treated with short-course versus standard adjuvant radiation.

Ishwaria Mohan Subbiah, MD, is investigating a personalized, technology-enhanced symptom-management strategy to provide holistic care for patients on phase 1 trials.

Andrea Viale, MD, is studying the effects of transient inflammation and the role of epithelial memory during progression of pancreatic ductal adenocarcinoma.

Linghua Wang, PhD, is investigating TIM-3 as a potential target for treating peritoneal carcinomatosis in patients with advanced gastric cancer.

Yinghong Wang, MD, PhD, is researching fecal microbiota transplantation as an option for managing immune-mediated colitis following cancer immunotherapy.

Movers in Medicine highlights career moves and personal achievements by hematologists and oncologists. Did you switch jobs, take on a new role, climb a mountain? Tell us all about it at [email protected], and you could be featured in Movers in Medicine.

[email protected]

Stroke centers need to collaborate within their regions to assure best practices and optimal access to comprehensive stroke centers as well as newly-designated thrombectomy-capable stroke centers, according to an updated policy statement from the American Stroke Association published in Stroke.

Opeolu Adeoye, MD, associate professor of emergency medicine and neurosurgery at the University of Cincinnati – and chair of the policy statement writing group – and coauthors updated the ASA’s 2005 recommendations for policy makers and public health care agencies to reflect current evidence, the increased availability of endovascular therapy, and new stroke center certifications.

“We have seen monumental advancements in acute stroke care over the past 14 years, and our concept of a comprehensive stroke system of care has evolved as a result,” Dr. Adeoye said in a news release.

While a recommendation to support the initiation of stroke prevention regimens remains unchanged from the 2005 recommendations, the 2019 update emphasizes a need to support long-term adherence to such regimens. To that end, researchers should examine the potential benefits of stroke prevention efforts that incorporate social media, gamification, and other technologies and principles to promote healthy behavior, the authors suggested. Furthermore, technology may allow for the passive surveillance of baseline behaviors and enable researchers to track changes in behavior over time.

Thrombectomy-capable centers

Thrombectomy-capable stroke centers, which have capabilities between those of primary stroke centers and comprehensive stroke centers, provide a relatively new level of acute stroke care. In communities that do not otherwise have access to thrombectomy, these centers play a clear role. In communities with comprehensive stroke centers, their role “is more controversial, and routing plans for patients with a suspected LVO [large vessel occlusion] should always seek the center of highest capability when travel time differences are short,” the statement says.

Timely parenchymal and arterial imaging via CT or MRI are needed to identify the subset of patients who may benefit from thrombectomy. All centers managing stroke patients should develop a plan for the definitive identification and treatment of these patients. Imaging techniques that assess penumbral patterns to identify candidates for endovascular therapy between 6 and 24 hours after patients were last known to be normal “merit broader adoption,” the statement says.

Hospitals without thrombectomy capability should have transfer protocols to allow the rapid treatment of these patients to hospitals with the appropriate level of care. In rural facilities that lack 24/7 imaging and radiology capabilities, this may mean rapid transfer of patients with clinically suspected LVO to hospitals where their work-up may be expedited.

To improve process, centers providing thrombectomy should rigorously track patient flow at all time points from presentation to imaging to intervention. Reperfusion rates, procedural complications, and patient clinical outcomes must be tracked and reported.

Travel times

Triage paradigms and protocols should be developed to ensure that emergency medical service (EMS) providers are able to rapidly identify all patients with a known or suspected stroke and to assess them with a validated and standardized instrument for stroke screening such as FAST (Face, Arm, Speech, Time), Los Angeles Prehospital Stroke Screen, or Cincinnati Prehospital Stroke Scale.

In prehospital patients who screen positive for suspected stroke, a standard prehospital stroke severity assessment tool such as the Cincinnati Stroke Triage Assessment Tool, Rapid Arterial Occlusion Evaluation, Los Angeles Motor Scale, or Field Assessment Stroke Triage for Emergency Destination should be used. “Further research is needed to establish the most effective prehospital stroke severity triage scale,” the authors noted. In all cases, EMS should notify hospitals that a stroke patient is en route.

“When there are several intravenous alteplase–capable hospitals in a well-defined geographic region, extra transportation times to reach a facility capable of endovascular thrombectomy should be limited to no more than 15 minutes in patients with a prehospital stroke severity score suggestive of LVO,” according to the recommendations. “When several hospital options exist within similar travel times, EMS should seek care at the facility capable of offering the highest level of stroke care. Further research is needed to establish travel time parameters for hospital bypass in cases of prehospital suspicion of LVO.”

Outcomes and discharge

Centers should track various treatment and patient outcomes, and all patients discharged to their homes should have appropriate follow-up with specialized stroke services and primary care and be screened for postacute complications.

Government institutions should standardize the organization of stroke care, ensure that stroke patients receive timely care at appropriate hospitals, and facilitate access to secondary prevention and rehabilitation resources after stroke, the authors wrote.

“Programs geared at further improving the knowledge of the public, encouraging primordial and primary prevention, advancing and facilitating acute therapy, improving secondary prevention and recovery from stroke, and reducing disparities in stroke care should be actively developed in a coordinated and collaborative fashion by providers and policymakers at the local, state, and national levels,” the authors concluded. “Such efforts will continue to mitigate the effects of stroke on society.”

Dr. Adeoye had no disclosures. Some coauthors reported research grants and consultant or advisory board positions.

[email protected]

SOURCE: Adeoye O et al. Stroke. 2019 May 20. doi: 10.1161/STR.0000000000000173.

Stroke centers need to collaborate within their regions to assure best practices and optimal access to comprehensive stroke centers as well as newly-designated thrombectomy-capable stroke centers, according to an updated policy statement from the American Stroke Association published in Stroke.

Opeolu Adeoye, MD, associate professor of emergency medicine and neurosurgery at the University of Cincinnati – and chair of the policy statement writing group – and coauthors updated the ASA’s 2005 recommendations for policy makers and public health care agencies to reflect current evidence, the increased availability of endovascular therapy, and new stroke center certifications.

“We have seen monumental advancements in acute stroke care over the past 14 years, and our concept of a comprehensive stroke system of care has evolved as a result,” Dr. Adeoye said in a news release.

While a recommendation to support the initiation of stroke prevention regimens remains unchanged from the 2005 recommendations, the 2019 update emphasizes a need to support long-term adherence to such regimens. To that end, researchers should examine the potential benefits of stroke prevention efforts that incorporate social media, gamification, and other technologies and principles to promote healthy behavior, the authors suggested. Furthermore, technology may allow for the passive surveillance of baseline behaviors and enable researchers to track changes in behavior over time.

Thrombectomy-capable centers

Thrombectomy-capable stroke centers, which have capabilities between those of primary stroke centers and comprehensive stroke centers, provide a relatively new level of acute stroke care. In communities that do not otherwise have access to thrombectomy, these centers play a clear role. In communities with comprehensive stroke centers, their role “is more controversial, and routing plans for patients with a suspected LVO [large vessel occlusion] should always seek the center of highest capability when travel time differences are short,” the statement says.

Timely parenchymal and arterial imaging via CT or MRI are needed to identify the subset of patients who may benefit from thrombectomy. All centers managing stroke patients should develop a plan for the definitive identification and treatment of these patients. Imaging techniques that assess penumbral patterns to identify candidates for endovascular therapy between 6 and 24 hours after patients were last known to be normal “merit broader adoption,” the statement says.

Hospitals without thrombectomy capability should have transfer protocols to allow the rapid treatment of these patients to hospitals with the appropriate level of care. In rural facilities that lack 24/7 imaging and radiology capabilities, this may mean rapid transfer of patients with clinically suspected LVO to hospitals where their work-up may be expedited.

To improve process, centers providing thrombectomy should rigorously track patient flow at all time points from presentation to imaging to intervention. Reperfusion rates, procedural complications, and patient clinical outcomes must be tracked and reported.

Travel times

Triage paradigms and protocols should be developed to ensure that emergency medical service (EMS) providers are able to rapidly identify all patients with a known or suspected stroke and to assess them with a validated and standardized instrument for stroke screening such as FAST (Face, Arm, Speech, Time), Los Angeles Prehospital Stroke Screen, or Cincinnati Prehospital Stroke Scale.

In prehospital patients who screen positive for suspected stroke, a standard prehospital stroke severity assessment tool such as the Cincinnati Stroke Triage Assessment Tool, Rapid Arterial Occlusion Evaluation, Los Angeles Motor Scale, or Field Assessment Stroke Triage for Emergency Destination should be used. “Further research is needed to establish the most effective prehospital stroke severity triage scale,” the authors noted. In all cases, EMS should notify hospitals that a stroke patient is en route.

“When there are several intravenous alteplase–capable hospitals in a well-defined geographic region, extra transportation times to reach a facility capable of endovascular thrombectomy should be limited to no more than 15 minutes in patients with a prehospital stroke severity score suggestive of LVO,” according to the recommendations. “When several hospital options exist within similar travel times, EMS should seek care at the facility capable of offering the highest level of stroke care. Further research is needed to establish travel time parameters for hospital bypass in cases of prehospital suspicion of LVO.”

Outcomes and discharge

Centers should track various treatment and patient outcomes, and all patients discharged to their homes should have appropriate follow-up with specialized stroke services and primary care and be screened for postacute complications.

Government institutions should standardize the organization of stroke care, ensure that stroke patients receive timely care at appropriate hospitals, and facilitate access to secondary prevention and rehabilitation resources after stroke, the authors wrote.

“Programs geared at further improving the knowledge of the public, encouraging primordial and primary prevention, advancing and facilitating acute therapy, improving secondary prevention and recovery from stroke, and reducing disparities in stroke care should be actively developed in a coordinated and collaborative fashion by providers and policymakers at the local, state, and national levels,” the authors concluded. “Such efforts will continue to mitigate the effects of stroke on society.”

Dr. Adeoye had no disclosures. Some coauthors reported research grants and consultant or advisory board positions.

[email protected]

SOURCE: Adeoye O et al. Stroke. 2019 May 20. doi: 10.1161/STR.0000000000000173.

Stroke centers need to collaborate within their regions to assure best practices and optimal access to comprehensive stroke centers as well as newly-designated thrombectomy-capable stroke centers, according to an updated policy statement from the American Stroke Association published in Stroke.

Opeolu Adeoye, MD, associate professor of emergency medicine and neurosurgery at the University of Cincinnati – and chair of the policy statement writing group – and coauthors updated the ASA’s 2005 recommendations for policy makers and public health care agencies to reflect current evidence, the increased availability of endovascular therapy, and new stroke center certifications.

“We have seen monumental advancements in acute stroke care over the past 14 years, and our concept of a comprehensive stroke system of care has evolved as a result,” Dr. Adeoye said in a news release.

While a recommendation to support the initiation of stroke prevention regimens remains unchanged from the 2005 recommendations, the 2019 update emphasizes a need to support long-term adherence to such regimens. To that end, researchers should examine the potential benefits of stroke prevention efforts that incorporate social media, gamification, and other technologies and principles to promote healthy behavior, the authors suggested. Furthermore, technology may allow for the passive surveillance of baseline behaviors and enable researchers to track changes in behavior over time.

Thrombectomy-capable centers

Thrombectomy-capable stroke centers, which have capabilities between those of primary stroke centers and comprehensive stroke centers, provide a relatively new level of acute stroke care. In communities that do not otherwise have access to thrombectomy, these centers play a clear role. In communities with comprehensive stroke centers, their role “is more controversial, and routing plans for patients with a suspected LVO [large vessel occlusion] should always seek the center of highest capability when travel time differences are short,” the statement says.

Timely parenchymal and arterial imaging via CT or MRI are needed to identify the subset of patients who may benefit from thrombectomy. All centers managing stroke patients should develop a plan for the definitive identification and treatment of these patients. Imaging techniques that assess penumbral patterns to identify candidates for endovascular therapy between 6 and 24 hours after patients were last known to be normal “merit broader adoption,” the statement says.

Hospitals without thrombectomy capability should have transfer protocols to allow the rapid treatment of these patients to hospitals with the appropriate level of care. In rural facilities that lack 24/7 imaging and radiology capabilities, this may mean rapid transfer of patients with clinically suspected LVO to hospitals where their work-up may be expedited.

To improve process, centers providing thrombectomy should rigorously track patient flow at all time points from presentation to imaging to intervention. Reperfusion rates, procedural complications, and patient clinical outcomes must be tracked and reported.

Travel times

Triage paradigms and protocols should be developed to ensure that emergency medical service (EMS) providers are able to rapidly identify all patients with a known or suspected stroke and to assess them with a validated and standardized instrument for stroke screening such as FAST (Face, Arm, Speech, Time), Los Angeles Prehospital Stroke Screen, or Cincinnati Prehospital Stroke Scale.

In prehospital patients who screen positive for suspected stroke, a standard prehospital stroke severity assessment tool such as the Cincinnati Stroke Triage Assessment Tool, Rapid Arterial Occlusion Evaluation, Los Angeles Motor Scale, or Field Assessment Stroke Triage for Emergency Destination should be used. “Further research is needed to establish the most effective prehospital stroke severity triage scale,” the authors noted. In all cases, EMS should notify hospitals that a stroke patient is en route.

“When there are several intravenous alteplase–capable hospitals in a well-defined geographic region, extra transportation times to reach a facility capable of endovascular thrombectomy should be limited to no more than 15 minutes in patients with a prehospital stroke severity score suggestive of LVO,” according to the recommendations. “When several hospital options exist within similar travel times, EMS should seek care at the facility capable of offering the highest level of stroke care. Further research is needed to establish travel time parameters for hospital bypass in cases of prehospital suspicion of LVO.”

Outcomes and discharge

Centers should track various treatment and patient outcomes, and all patients discharged to their homes should have appropriate follow-up with specialized stroke services and primary care and be screened for postacute complications.

Government institutions should standardize the organization of stroke care, ensure that stroke patients receive timely care at appropriate hospitals, and facilitate access to secondary prevention and rehabilitation resources after stroke, the authors wrote.

“Programs geared at further improving the knowledge of the public, encouraging primordial and primary prevention, advancing and facilitating acute therapy, improving secondary prevention and recovery from stroke, and reducing disparities in stroke care should be actively developed in a coordinated and collaborative fashion by providers and policymakers at the local, state, and national levels,” the authors concluded. “Such efforts will continue to mitigate the effects of stroke on society.”

Dr. Adeoye had no disclosures. Some coauthors reported research grants and consultant or advisory board positions.

[email protected]

SOURCE: Adeoye O et al. Stroke. 2019 May 20. doi: 10.1161/STR.0000000000000173.

Liver transplantation (LT) is “one of the most resource-intense procedures despite significant improvements in procedures and protocols,” say researchers from Seoul National University Hospital in South Korea. But little is known about the “practical aspects of life after liver transplantation,” such as unplanned visits to the emergency department (ED) or readmission for complications. So the researchers conducted a study to find out what health care resources are used after discharge.

Of 430 patients, half visited the ED at least once, and 57% were readmitted at least once. The rate of ED visits rose from 15% at 30 days after discharge to 44% at 1 year. Readmission rates more than tripled, from 16% at 30 days to 49% at 1 year.

Contrary to other research, living donor liver transplantation was not a risk factor of readmission. Emergency LT was a risk factor for ED visits and readmission within 30 days of discharge. And although LT using the left liver lobe and pre-existing hepatitis C are known risk factors for long-term graft failure, at the researchers’ hospital hepatitis B is the most common indication for living donor LT. Most of their patients undergo LT using the right liver lobe.

Some of the identified risk factors were unexpected, the researchers say. One was donor age of < 60 years. Warm ischemic time of 15 minutes or longer was another. The researchers note that prolonged warm ischemic time increases hepatic ischemia and reperfusion injury and is related to postoperative complications, which can be a cause of frequent readmission.

Length of stay (LOS)  > 2 weeks also was a risk factor for readmission. In their institution, the average LOS for patients with a warm ischemic time of < 15 minutes was 15.6 days, shorter than the overall average LOS. Shorter LOS, the researchers add, may reflect fewer immediate postoperative complications.

Although they identified no specific complication as a risk factor for readmission, the researchers found specific conditions that accounted for a relatively high proportion of readmissions and repeated readmission, including abnormal liver function test  (32% of readmissions) and fever (17% of readmissions and 39% of repeated readmissions). The researchers suggest those are conditions to monitor and manage.

Notably, patients who did not require readmission or ED visits in the first 20 months almost never required unplanned health care resources thereafter.

Liver transplantation (LT) is “one of the most resource-intense procedures despite significant improvements in procedures and protocols,” say researchers from Seoul National University Hospital in South Korea. But little is known about the “practical aspects of life after liver transplantation,” such as unplanned visits to the emergency department (ED) or readmission for complications. So the researchers conducted a study to find out what health care resources are used after discharge.

Of 430 patients, half visited the ED at least once, and 57% were readmitted at least once. The rate of ED visits rose from 15% at 30 days after discharge to 44% at 1 year. Readmission rates more than tripled, from 16% at 30 days to 49% at 1 year.

Contrary to other research, living donor liver transplantation was not a risk factor of readmission. Emergency LT was a risk factor for ED visits and readmission within 30 days of discharge. And although LT using the left liver lobe and pre-existing hepatitis C are known risk factors for long-term graft failure, at the researchers’ hospital hepatitis B is the most common indication for living donor LT. Most of their patients undergo LT using the right liver lobe.

Some of the identified risk factors were unexpected, the researchers say. One was donor age of < 60 years. Warm ischemic time of 15 minutes or longer was another. The researchers note that prolonged warm ischemic time increases hepatic ischemia and reperfusion injury and is related to postoperative complications, which can be a cause of frequent readmission.

Length of stay (LOS)  > 2 weeks also was a risk factor for readmission. In their institution, the average LOS for patients with a warm ischemic time of < 15 minutes was 15.6 days, shorter than the overall average LOS. Shorter LOS, the researchers add, may reflect fewer immediate postoperative complications.

Although they identified no specific complication as a risk factor for readmission, the researchers found specific conditions that accounted for a relatively high proportion of readmissions and repeated readmission, including abnormal liver function test  (32% of readmissions) and fever (17% of readmissions and 39% of repeated readmissions). The researchers suggest those are conditions to monitor and manage.

Notably, patients who did not require readmission or ED visits in the first 20 months almost never required unplanned health care resources thereafter.

Liver transplantation (LT) is “one of the most resource-intense procedures despite significant improvements in procedures and protocols,” say researchers from Seoul National University Hospital in South Korea. But little is known about the “practical aspects of life after liver transplantation,” such as unplanned visits to the emergency department (ED) or readmission for complications. So the researchers conducted a study to find out what health care resources are used after discharge.

Of 430 patients, half visited the ED at least once, and 57% were readmitted at least once. The rate of ED visits rose from 15% at 30 days after discharge to 44% at 1 year. Readmission rates more than tripled, from 16% at 30 days to 49% at 1 year.

Contrary to other research, living donor liver transplantation was not a risk factor of readmission. Emergency LT was a risk factor for ED visits and readmission within 30 days of discharge. And although LT using the left liver lobe and pre-existing hepatitis C are known risk factors for long-term graft failure, at the researchers’ hospital hepatitis B is the most common indication for living donor LT. Most of their patients undergo LT using the right liver lobe.

Some of the identified risk factors were unexpected, the researchers say. One was donor age of < 60 years. Warm ischemic time of 15 minutes or longer was another. The researchers note that prolonged warm ischemic time increases hepatic ischemia and reperfusion injury and is related to postoperative complications, which can be a cause of frequent readmission.

Length of stay (LOS)  > 2 weeks also was a risk factor for readmission. In their institution, the average LOS for patients with a warm ischemic time of < 15 minutes was 15.6 days, shorter than the overall average LOS. Shorter LOS, the researchers add, may reflect fewer immediate postoperative complications.

Although they identified no specific complication as a risk factor for readmission, the researchers found specific conditions that accounted for a relatively high proportion of readmissions and repeated readmission, including abnormal liver function test  (32% of readmissions) and fever (17% of readmissions and 39% of repeated readmissions). The researchers suggest those are conditions to monitor and manage.

Notably, patients who did not require readmission or ED visits in the first 20 months almost never required unplanned health care resources thereafter.

Dexmedetomidine fell short for reducing 90-day mortality as the primary sedative for patients on mechanical ventilation, according to results of the randomized, controlled, open-label SPICE III trial, which was presented at the annual meeting of the American Thoracic Society and simultaneously published in the New England Journal of Medicine.

“Among patients undergoing mechanical ventilation in the ICU, those who received early dexmedetomidine for sedation had a rate of death at 90 days similar to that in the usual-care group and required supplemental sedatives to achieve the prescribed level of sedation,” Yahya Shehabi, PhD, of Monash University in Clayton, Australia, and colleagues wrote.

The study was conducted in 74 ICUs in eight countries. Researchers randomly assigned 4,000 patients who were critically ill, had received ventilation for less than 12 hours, and were likely to require mechanical ventilation for at least the next day to either dexmedetomidine or usual care (propofol, midazolam, or another sedative). The sedation goal was a Richmond Agitation and Sedation Scale (RASS) score of –2 (lightly sedated) to +1 (restless), and was assessed every 4 hours. Intravenous dexmedetomidine was administered at 1 mcg/kg of body weight per hour without a loading dose and adjusted to a maximum dose of 1.5 mcg/kg per hour to achieve a RASS score in the target range. Use was continued as clinically required for up to 28 days.

The modified intention-to-treat analysis included 3,904 patients. The 90-day mortality rate was 29.1% (556 of 1,948 patients) for patients who received dexmedetomidine and 29.1% (569 of 1,956 patients) for those who received usual care. There was no significant difference for patients with suspected or proven sepsis at randomization and those without sepsis. Mortality did not vary based on country, cause of death, or discharge destination.

Dr. Shehabi and colleagues noted that, for 2 days after randomization, patients who received dexmedetomidine were also given propofol (64% of patients), midazolam (3%), or both (7%) as supplemental sedation. In the control group, 60% of the patients received propofol, 12% received midazolam, and 20% received both. About 80% of patients in both groups received fentanyl. The use of multiple agents may reflect sedation requirements during the acute phase of critical illness.

With regard to adverse events, the patients receiving dexmedetomidine more commonly experienced bradycardia and hypotension than the usual-care group.

SPICE III was funded in part by a grant from the National Health and Medical Research Council of Australia and the National Heart Institute of Malaysia. Dr. Shehabi reports grants from the National Health and Medical Research Council of Australia, nonfinancial and other support from Pfizer, and nonfinancial and other support from Orion Pharma.

SOURCE: Shehabi Y et al. N Eng J Med. 2019 May 19. doi: 10.1056/NEJMoa1904710.

Dexmedetomidine fell short for reducing 90-day mortality as the primary sedative for patients on mechanical ventilation, according to results of the randomized, controlled, open-label SPICE III trial, which was presented at the annual meeting of the American Thoracic Society and simultaneously published in the New England Journal of Medicine.

“Among patients undergoing mechanical ventilation in the ICU, those who received early dexmedetomidine for sedation had a rate of death at 90 days similar to that in the usual-care group and required supplemental sedatives to achieve the prescribed level of sedation,” Yahya Shehabi, PhD, of Monash University in Clayton, Australia, and colleagues wrote.

The study was conducted in 74 ICUs in eight countries. Researchers randomly assigned 4,000 patients who were critically ill, had received ventilation for less than 12 hours, and were likely to require mechanical ventilation for at least the next day to either dexmedetomidine or usual care (propofol, midazolam, or another sedative). The sedation goal was a Richmond Agitation and Sedation Scale (RASS) score of –2 (lightly sedated) to +1 (restless), and was assessed every 4 hours. Intravenous dexmedetomidine was administered at 1 mcg/kg of body weight per hour without a loading dose and adjusted to a maximum dose of 1.5 mcg/kg per hour to achieve a RASS score in the target range. Use was continued as clinically required for up to 28 days.

The modified intention-to-treat analysis included 3,904 patients. The 90-day mortality rate was 29.1% (556 of 1,948 patients) for patients who received dexmedetomidine and 29.1% (569 of 1,956 patients) for those who received usual care. There was no significant difference for patients with suspected or proven sepsis at randomization and those without sepsis. Mortality did not vary based on country, cause of death, or discharge destination.

Dr. Shehabi and colleagues noted that, for 2 days after randomization, patients who received dexmedetomidine were also given propofol (64% of patients), midazolam (3%), or both (7%) as supplemental sedation. In the control group, 60% of the patients received propofol, 12% received midazolam, and 20% received both. About 80% of patients in both groups received fentanyl. The use of multiple agents may reflect sedation requirements during the acute phase of critical illness.

With regard to adverse events, the patients receiving dexmedetomidine more commonly experienced bradycardia and hypotension than the usual-care group.

SPICE III was funded in part by a grant from the National Health and Medical Research Council of Australia and the National Heart Institute of Malaysia. Dr. Shehabi reports grants from the National Health and Medical Research Council of Australia, nonfinancial and other support from Pfizer, and nonfinancial and other support from Orion Pharma.

SOURCE: Shehabi Y et al. N Eng J Med. 2019 May 19. doi: 10.1056/NEJMoa1904710.

Dexmedetomidine fell short for reducing 90-day mortality as the primary sedative for patients on mechanical ventilation, according to results of the randomized, controlled, open-label SPICE III trial, which was presented at the annual meeting of the American Thoracic Society and simultaneously published in the New England Journal of Medicine.

“Among patients undergoing mechanical ventilation in the ICU, those who received early dexmedetomidine for sedation had a rate of death at 90 days similar to that in the usual-care group and required supplemental sedatives to achieve the prescribed level of sedation,” Yahya Shehabi, PhD, of Monash University in Clayton, Australia, and colleagues wrote.

The study was conducted in 74 ICUs in eight countries. Researchers randomly assigned 4,000 patients who were critically ill, had received ventilation for less than 12 hours, and were likely to require mechanical ventilation for at least the next day to either dexmedetomidine or usual care (propofol, midazolam, or another sedative). The sedation goal was a Richmond Agitation and Sedation Scale (RASS) score of –2 (lightly sedated) to +1 (restless), and was assessed every 4 hours. Intravenous dexmedetomidine was administered at 1 mcg/kg of body weight per hour without a loading dose and adjusted to a maximum dose of 1.5 mcg/kg per hour to achieve a RASS score in the target range. Use was continued as clinically required for up to 28 days.

The modified intention-to-treat analysis included 3,904 patients. The 90-day mortality rate was 29.1% (556 of 1,948 patients) for patients who received dexmedetomidine and 29.1% (569 of 1,956 patients) for those who received usual care. There was no significant difference for patients with suspected or proven sepsis at randomization and those without sepsis. Mortality did not vary based on country, cause of death, or discharge destination.

Dr. Shehabi and colleagues noted that, for 2 days after randomization, patients who received dexmedetomidine were also given propofol (64% of patients), midazolam (3%), or both (7%) as supplemental sedation. In the control group, 60% of the patients received propofol, 12% received midazolam, and 20% received both. About 80% of patients in both groups received fentanyl. The use of multiple agents may reflect sedation requirements during the acute phase of critical illness.

With regard to adverse events, the patients receiving dexmedetomidine more commonly experienced bradycardia and hypotension than the usual-care group.

SPICE III was funded in part by a grant from the National Health and Medical Research Council of Australia and the National Heart Institute of Malaysia. Dr. Shehabi reports grants from the National Health and Medical Research Council of Australia, nonfinancial and other support from Pfizer, and nonfinancial and other support from Orion Pharma.

SOURCE: Shehabi Y et al. N Eng J Med. 2019 May 19. doi: 10.1056/NEJMoa1904710.

SAN FRANCISCO – A toolkit that seeks to help clinicians provide culturally and religiously informed mental health care for Muslim patients was officially launched at the annual meeting of the American Psychiatric Association.

Rania Awaad, MD, and Belinda S. Bandstra, MD, sat down at the annual meeting of the American Psychiatric Association to discuss how to use the toolkit and why it – and other resources on providing nuanced mental health care – are needed.

Vidyard Video

In this video, Dr. Awaad explores some of the origins of Islamophobia in the United States and how she came to do this work while in medical school. The travel ban affecting mostly Muslim countries has had a ripple effect on community members, she said. “The feeling is ‘My country isn’t named in the travel ban, but will I be next?’ ”

In addition to the fear and distrust fostered by the political climate are the challenges of abiding by the Islamic faith’s precepts.

“Patients will just do things on their own – and not consult their clinician,” Dr. Awaad said, referring to those might change the times in which they take medication during the sacred month of Ramadan because of fasting that is expected of observant Muslims. “It’s important for the patients to know that anyone acutely ill is exempt from fasting.” Medical- and faith-based consultation are important for these patients, Dr. Awaad said, pointing to a recent article that outlines best practices for treating patients with psychiatric disorders during Ramadan (Lancet Psychiatry. 2019 May 2. doi: 10.1016/S2215-0366[19]30161-0).

She also discussed “Islamophobia and Psychiatry” (Springer, 2019), a book she coedited that she said provides evidence of the detrimental effect that Islamophobia has on the mental health of Muslims.

Dr. Awaad is director of the Muslim Mental Health Lab and Wellness Program and codirector of the Diversity Clinic at Stanford (Calif.) University. Dr. Bandstra is assistant director of residency training in Stanford’s department of psychiatry and behavioral sciences. Dr. Awaad and Dr. Bandstra had no relevant disclosures.

[email protected]

SAN FRANCISCO – A toolkit that seeks to help clinicians provide culturally and religiously informed mental health care for Muslim patients was officially launched at the annual meeting of the American Psychiatric Association.

Rania Awaad, MD, and Belinda S. Bandstra, MD, sat down at the annual meeting of the American Psychiatric Association to discuss how to use the toolkit and why it – and other resources on providing nuanced mental health care – are needed.

Vidyard Video

In this video, Dr. Awaad explores some of the origins of Islamophobia in the United States and how she came to do this work while in medical school. The travel ban affecting mostly Muslim countries has had a ripple effect on community members, she said. “The feeling is ‘My country isn’t named in the travel ban, but will I be next?’ ”

In addition to the fear and distrust fostered by the political climate are the challenges of abiding by the Islamic faith’s precepts.

“Patients will just do things on their own – and not consult their clinician,” Dr. Awaad said, referring to those might change the times in which they take medication during the sacred month of Ramadan because of fasting that is expected of observant Muslims. “It’s important for the patients to know that anyone acutely ill is exempt from fasting.” Medical- and faith-based consultation are important for these patients, Dr. Awaad said, pointing to a recent article that outlines best practices for treating patients with psychiatric disorders during Ramadan (Lancet Psychiatry. 2019 May 2. doi: 10.1016/S2215-0366[19]30161-0).

She also discussed “Islamophobia and Psychiatry” (Springer, 2019), a book she coedited that she said provides evidence of the detrimental effect that Islamophobia has on the mental health of Muslims.

Dr. Awaad is director of the Muslim Mental Health Lab and Wellness Program and codirector of the Diversity Clinic at Stanford (Calif.) University. Dr. Bandstra is assistant director of residency training in Stanford’s department of psychiatry and behavioral sciences. Dr. Awaad and Dr. Bandstra had no relevant disclosures.

[email protected]

SAN FRANCISCO – A toolkit that seeks to help clinicians provide culturally and religiously informed mental health care for Muslim patients was officially launched at the annual meeting of the American Psychiatric Association.

Rania Awaad, MD, and Belinda S. Bandstra, MD, sat down at the annual meeting of the American Psychiatric Association to discuss how to use the toolkit and why it – and other resources on providing nuanced mental health care – are needed.

Vidyard Video

In this video, Dr. Awaad explores some of the origins of Islamophobia in the United States and how she came to do this work while in medical school. The travel ban affecting mostly Muslim countries has had a ripple effect on community members, she said. “The feeling is ‘My country isn’t named in the travel ban, but will I be next?’ ”

In addition to the fear and distrust fostered by the political climate are the challenges of abiding by the Islamic faith’s precepts.

“Patients will just do things on their own – and not consult their clinician,” Dr. Awaad said, referring to those might change the times in which they take medication during the sacred month of Ramadan because of fasting that is expected of observant Muslims. “It’s important for the patients to know that anyone acutely ill is exempt from fasting.” Medical- and faith-based consultation are important for these patients, Dr. Awaad said, pointing to a recent article that outlines best practices for treating patients with psychiatric disorders during Ramadan (Lancet Psychiatry. 2019 May 2. doi: 10.1016/S2215-0366[19]30161-0).

She also discussed “Islamophobia and Psychiatry” (Springer, 2019), a book she coedited that she said provides evidence of the detrimental effect that Islamophobia has on the mental health of Muslims.

Dr. Awaad is director of the Muslim Mental Health Lab and Wellness Program and codirector of the Diversity Clinic at Stanford (Calif.) University. Dr. Bandstra is assistant director of residency training in Stanford’s department of psychiatry and behavioral sciences. Dr. Awaad and Dr. Bandstra had no relevant disclosures.

[email protected]

At the risk of too much personal self-disclosure, I feel the need to write about my having developed more empathy for women. Having been described as a “manly man,” by a woman who feels she knows me, it has always been difficult for me to understand women. Fortunately, an experience I’ve had has given me more insight into women – shallow though it may still be.

About a year ago, I had learned I had prostate carcinoma, which is now in remission – thanks to a proctectomy, radiation, and hormone therapy. The antitestosterone hormones I need to take for 2 years are turning me into an old woman, thus my newfound empathy.

After the surgery, I found myself leaking – something that I probably only experienced as a child and of which I have little memory. I now have some more empathy for the problems women have with leaking each month or in general – it is a constant preoccupation. The leuprolide shots I am taking are giving me hot flashes, causing me to be more emotional about things I really don’t understand, and apparently I am at risk for getting osteoporosis – all things that happen to women that have been mildly on my radar for years but for which I lacked direct and personal experience.

Since having my testosterone turned off by the leuprolide, my joints are more prone to aches and pains from various injuries over the years. Because I understand that “motion is lotion,” I have some control of this problem. However, the hormone therapy has greatly reduced my endurance, so my exercise tolerance is far more limited – I understand fatigue now. When I was telling another woman who feels she knows me about my experience, she told me it was hormones that made it more difficult to lose weight. And, I am gaining weight.

All in all, I believe my experience has given me more empathy for women, but I realize I still have a very long way to go. Nonetheless, I will continue in my quest to understand the opposite sex, as I am told “women hold up half the sky,” and I have always believed that to be true.

Fortunately, women are ascending in psychiatry and, with some serious dedication, the dearth of scientific understanding of women’s issues will be a thing of the past. I am hoping that women psychiatrists will answer questions that men never even thought of asking, and fill that void of knowledge that we men psychiatrists have in our testosterone-bathed brains.

Dr. Bell is a staff psychiatrist at Jackson Park Hospital’s Medical/Surgical-Psychiatry Inpatient Unit in Chicago, clinical psychiatrist emeritus in the department of psychiatry at the University of Illinois at Chicago, former president/CEO of Community Mental Health Council, and former director of the Institute for Juvenile Research (birthplace of child psychiatry), also in Chicago.

At the risk of too much personal self-disclosure, I feel the need to write about my having developed more empathy for women. Having been described as a “manly man,” by a woman who feels she knows me, it has always been difficult for me to understand women. Fortunately, an experience I’ve had has given me more insight into women – shallow though it may still be.

About a year ago, I had learned I had prostate carcinoma, which is now in remission – thanks to a proctectomy, radiation, and hormone therapy. The antitestosterone hormones I need to take for 2 years are turning me into an old woman, thus my newfound empathy.

After the surgery, I found myself leaking – something that I probably only experienced as a child and of which I have little memory. I now have some more empathy for the problems women have with leaking each month or in general – it is a constant preoccupation. The leuprolide shots I am taking are giving me hot flashes, causing me to be more emotional about things I really don’t understand, and apparently I am at risk for getting osteoporosis – all things that happen to women that have been mildly on my radar for years but for which I lacked direct and personal experience.

Since having my testosterone turned off by the leuprolide, my joints are more prone to aches and pains from various injuries over the years. Because I understand that “motion is lotion,” I have some control of this problem. However, the hormone therapy has greatly reduced my endurance, so my exercise tolerance is far more limited – I understand fatigue now. When I was telling another woman who feels she knows me about my experience, she told me it was hormones that made it more difficult to lose weight. And, I am gaining weight.

All in all, I believe my experience has given me more empathy for women, but I realize I still have a very long way to go. Nonetheless, I will continue in my quest to understand the opposite sex, as I am told “women hold up half the sky,” and I have always believed that to be true.

Fortunately, women are ascending in psychiatry and, with some serious dedication, the dearth of scientific understanding of women’s issues will be a thing of the past. I am hoping that women psychiatrists will answer questions that men never even thought of asking, and fill that void of knowledge that we men psychiatrists have in our testosterone-bathed brains.

Dr. Bell is a staff psychiatrist at Jackson Park Hospital’s Medical/Surgical-Psychiatry Inpatient Unit in Chicago, clinical psychiatrist emeritus in the department of psychiatry at the University of Illinois at Chicago, former president/CEO of Community Mental Health Council, and former director of the Institute for Juvenile Research (birthplace of child psychiatry), also in Chicago.

At the risk of too much personal self-disclosure, I feel the need to write about my having developed more empathy for women. Having been described as a “manly man,” by a woman who feels she knows me, it has always been difficult for me to understand women. Fortunately, an experience I’ve had has given me more insight into women – shallow though it may still be.

About a year ago, I had learned I had prostate carcinoma, which is now in remission – thanks to a proctectomy, radiation, and hormone therapy. The antitestosterone hormones I need to take for 2 years are turning me into an old woman, thus my newfound empathy.

After the surgery, I found myself leaking – something that I probably only experienced as a child and of which I have little memory. I now have some more empathy for the problems women have with leaking each month or in general – it is a constant preoccupation. The leuprolide shots I am taking are giving me hot flashes, causing me to be more emotional about things I really don’t understand, and apparently I am at risk for getting osteoporosis – all things that happen to women that have been mildly on my radar for years but for which I lacked direct and personal experience.

Since having my testosterone turned off by the leuprolide, my joints are more prone to aches and pains from various injuries over the years. Because I understand that “motion is lotion,” I have some control of this problem. However, the hormone therapy has greatly reduced my endurance, so my exercise tolerance is far more limited – I understand fatigue now. When I was telling another woman who feels she knows me about my experience, she told me it was hormones that made it more difficult to lose weight. And, I am gaining weight.

All in all, I believe my experience has given me more empathy for women, but I realize I still have a very long way to go. Nonetheless, I will continue in my quest to understand the opposite sex, as I am told “women hold up half the sky,” and I have always believed that to be true.

Fortunately, women are ascending in psychiatry and, with some serious dedication, the dearth of scientific understanding of women’s issues will be a thing of the past. I am hoping that women psychiatrists will answer questions that men never even thought of asking, and fill that void of knowledge that we men psychiatrists have in our testosterone-bathed brains.

Dr. Bell is a staff psychiatrist at Jackson Park Hospital’s Medical/Surgical-Psychiatry Inpatient Unit in Chicago, clinical psychiatrist emeritus in the department of psychiatry at the University of Illinois at Chicago, former president/CEO of Community Mental Health Council, and former director of the Institute for Juvenile Research (birthplace of child psychiatry), also in Chicago.

Alzheimer’s disease is recognized as the most common cause of dementia, and many in the laity use the two terms almost interchangeably. However, there is increasing recognition that dementia in old age is a complex disorder, with mixed neuropathologies being the norm rather than the exception (Ann Neurol. 2018 Jan;83[1]:74-83).

Alzheimer’s disease (AD) and cerebrovascular pathologies are the most common, but another pathology is receiving increasing attention in relation to cognitive disorders in very old individuals – that related to the transactive response DNA binding protein of 43 kDa (TDP-43). This protein is expressed in most human tissues, including the brain, is localized mostly in nuclei, and binds to RNA and DNA as well as numerous proteins, with the role of regulating gene expression.

It has been known for nearly 2 decades that TDP-43 can become abnormally phosphorylated and translocated to the cytoplasm to produce a proteinopathy that forms the basis of a significant proportion of frontotemporal dementia (FTD) and the majority of amyotrophic lateral sclerosis. More recently, it has also been reported to be common in the brains of older people (over age 80 years) and associated with a cognitive disorder characterized by an amnestic picture that mimics AD. Since the protein deposition is predominantly in the limbic regions (amygdala, hippocampus, insula), it has been termed “‘limbic-predominant, age-related TDP-43 encephalopathy”, or LATE.

A recently convened international working group has published consensus criteria for LATE and provided guidelines for its staging. Community-based autopsy studies suggest that 20%-50% of people aged over 80 years have the neuropathologic change associated with LATE. The clinical presentation resembles amnestic dementia syndrome, much like AD. Both LATE and AD pathologies often occur in the same individual, but the relative predominance of one or the other varies greatly between individuals. The genetic risks of LATE overlap with those for FTD and AD, and other risk factors may also be shared with AD, which remains an area for further investigation. There are at present no specific biomarkers of LATE. It is associated with hippocampal sclerosis in some cases, which may be visible on MRI, but hippocampal sclerosis itself is not specific to TDP-43 pathology.

The LATE consensus working group report ^{(Brain. 2019 Apr 30. d}oi: 10.1093/brain/awz099⁾ underlines several gaps in our understanding of LATE and calls for systematic study of the causes of dementia – which may be nearly as common as AD in the very old. The report should be read widely and should remind us of the diverse pathologies that contribute to cognitive disorders, alone and in combination with one another.

Dr. Sachdev is Scientia Professor of Neuropsychiatry and codirector of the Center for Healthy Brain Aging at the University of New South Wales, Sydney; and clinical director of the Neuropsychiatric Institute at the Prince of Wales Hospital, also in Sydney. His major areas of research are drug-induced movement disorders, brain imaging, cognitive aging and dementia. Dr. Sachdev also served on the Neurocognitive Disorders Work Group of the DSM-5.

Alzheimer’s disease is recognized as the most common cause of dementia, and many in the laity use the two terms almost interchangeably. However, there is increasing recognition that dementia in old age is a complex disorder, with mixed neuropathologies being the norm rather than the exception (Ann Neurol. 2018 Jan;83[1]:74-83).

Alzheimer’s disease (AD) and cerebrovascular pathologies are the most common, but another pathology is receiving increasing attention in relation to cognitive disorders in very old individuals – that related to the transactive response DNA binding protein of 43 kDa (TDP-43). This protein is expressed in most human tissues, including the brain, is localized mostly in nuclei, and binds to RNA and DNA as well as numerous proteins, with the role of regulating gene expression.

It has been known for nearly 2 decades that TDP-43 can become abnormally phosphorylated and translocated to the cytoplasm to produce a proteinopathy that forms the basis of a significant proportion of frontotemporal dementia (FTD) and the majority of amyotrophic lateral sclerosis. More recently, it has also been reported to be common in the brains of older people (over age 80 years) and associated with a cognitive disorder characterized by an amnestic picture that mimics AD. Since the protein deposition is predominantly in the limbic regions (amygdala, hippocampus, insula), it has been termed “‘limbic-predominant, age-related TDP-43 encephalopathy”, or LATE.

A recently convened international working group has published consensus criteria for LATE and provided guidelines for its staging. Community-based autopsy studies suggest that 20%-50% of people aged over 80 years have the neuropathologic change associated with LATE. The clinical presentation resembles amnestic dementia syndrome, much like AD. Both LATE and AD pathologies often occur in the same individual, but the relative predominance of one or the other varies greatly between individuals. The genetic risks of LATE overlap with those for FTD and AD, and other risk factors may also be shared with AD, which remains an area for further investigation. There are at present no specific biomarkers of LATE. It is associated with hippocampal sclerosis in some cases, which may be visible on MRI, but hippocampal sclerosis itself is not specific to TDP-43 pathology.

The LATE consensus working group report ^{(Brain. 2019 Apr 30. d}oi: 10.1093/brain/awz099⁾ underlines several gaps in our understanding of LATE and calls for systematic study of the causes of dementia – which may be nearly as common as AD in the very old. The report should be read widely and should remind us of the diverse pathologies that contribute to cognitive disorders, alone and in combination with one another.

Dr. Sachdev is Scientia Professor of Neuropsychiatry and codirector of the Center for Healthy Brain Aging at the University of New South Wales, Sydney; and clinical director of the Neuropsychiatric Institute at the Prince of Wales Hospital, also in Sydney. His major areas of research are drug-induced movement disorders, brain imaging, cognitive aging and dementia. Dr. Sachdev also served on the Neurocognitive Disorders Work Group of the DSM-5.

Alzheimer’s disease is recognized as the most common cause of dementia, and many in the laity use the two terms almost interchangeably. However, there is increasing recognition that dementia in old age is a complex disorder, with mixed neuropathologies being the norm rather than the exception (Ann Neurol. 2018 Jan;83[1]:74-83).

Alzheimer’s disease (AD) and cerebrovascular pathologies are the most common, but another pathology is receiving increasing attention in relation to cognitive disorders in very old individuals – that related to the transactive response DNA binding protein of 43 kDa (TDP-43). This protein is expressed in most human tissues, including the brain, is localized mostly in nuclei, and binds to RNA and DNA as well as numerous proteins, with the role of regulating gene expression.

It has been known for nearly 2 decades that TDP-43 can become abnormally phosphorylated and translocated to the cytoplasm to produce a proteinopathy that forms the basis of a significant proportion of frontotemporal dementia (FTD) and the majority of amyotrophic lateral sclerosis. More recently, it has also been reported to be common in the brains of older people (over age 80 years) and associated with a cognitive disorder characterized by an amnestic picture that mimics AD. Since the protein deposition is predominantly in the limbic regions (amygdala, hippocampus, insula), it has been termed “‘limbic-predominant, age-related TDP-43 encephalopathy”, or LATE.

A recently convened international working group has published consensus criteria for LATE and provided guidelines for its staging. Community-based autopsy studies suggest that 20%-50% of people aged over 80 years have the neuropathologic change associated with LATE. The clinical presentation resembles amnestic dementia syndrome, much like AD. Both LATE and AD pathologies often occur in the same individual, but the relative predominance of one or the other varies greatly between individuals. The genetic risks of LATE overlap with those for FTD and AD, and other risk factors may also be shared with AD, which remains an area for further investigation. There are at present no specific biomarkers of LATE. It is associated with hippocampal sclerosis in some cases, which may be visible on MRI, but hippocampal sclerosis itself is not specific to TDP-43 pathology.

The LATE consensus working group report ^{(Brain. 2019 Apr 30. d}oi: 10.1093/brain/awz099⁾ underlines several gaps in our understanding of LATE and calls for systematic study of the causes of dementia – which may be nearly as common as AD in the very old. The report should be read widely and should remind us of the diverse pathologies that contribute to cognitive disorders, alone and in combination with one another.

Dr. Sachdev is Scientia Professor of Neuropsychiatry and codirector of the Center for Healthy Brain Aging at the University of New South Wales, Sydney; and clinical director of the Neuropsychiatric Institute at the Prince of Wales Hospital, also in Sydney. His major areas of research are drug-induced movement disorders, brain imaging, cognitive aging and dementia. Dr. Sachdev also served on the Neurocognitive Disorders Work Group of the DSM-5.