Women undergoing open descending thoracic aortic aneurysm (DTA) and open thoracoabdominal aortic aneurysm (TAAA) repair are not at greater risk for operative mortality than their male counterparts. However, they are at significantly greater risk for major adverse events and have significantly lower 5-year survival, according to the results of a single institution database review of 738 surgery patients.

From May 1997 to June 2017, there were 462 men (59%) and 321 women (41%) who underwent open repair of DTA or TAAA, according to Leonard N. Girardi, MD, and colleagues from Weill Cornell Medicine, New York, who performed the study published in the Journal of Vascular Surgery. The researchers used logistic regression and Cox regression analyses to assess the effect of sex on perioperative and long-term outcomes.

Demographically, women were significantly older (67.6 years vs. 62.6 years), with a significantly higher incidence of chronic obstructive pulmonary disease (47.0% vs. 35.7%) and a significantly greater percentage of patients with a forced expiratory volume in 1 second less than 50% (28.3% vs 18.2%). Degenerative aneurysms were significantly more common in women (61.7% vs. 41.6%), whereas chronic dissections significantly predominated in men (42.4% vs. 23.1%). Operative mortality was not significantly different between women and men (5.6% vs. 6.2%); however, women were significantly more likely to require a tracheostomy after surgery (10.6% vs. 5.0%).

Logistic regression found that being a woman was an independent risk factor for a composite of major adverse events (odds ratio, 2.68) and need for tracheostomy (OR, 3.73). In addition, women had significantly worse 5-year survival than men undergoing DTA or TAAA repair (59.7% vs. 66.2%, P =.025). There was no difference in overall survival between 1997-2007 and 2008-2017.

“Women and men undergoing TAAA repair have significant and consistent differences in preoperative characteristics. Despite these differences, operative mortality is similar between the two groups. However, women are at significantly increased risk of [major adverse events], especially respiratory failure, because of those differences in risk factors, including age, pulmonary function, and aneurysm etiology,” the researchers concluded.

The authors reported that they had no conflicts of interest.

[email protected]

SOURCE: Girardi LN et al. J Vasc Surg 2019;69:1028-35.

Women undergoing open descending thoracic aortic aneurysm (DTA) and open thoracoabdominal aortic aneurysm (TAAA) repair are not at greater risk for operative mortality than their male counterparts. However, they are at significantly greater risk for major adverse events and have significantly lower 5-year survival, according to the results of a single institution database review of 738 surgery patients.

From May 1997 to June 2017, there were 462 men (59%) and 321 women (41%) who underwent open repair of DTA or TAAA, according to Leonard N. Girardi, MD, and colleagues from Weill Cornell Medicine, New York, who performed the study published in the Journal of Vascular Surgery. The researchers used logistic regression and Cox regression analyses to assess the effect of sex on perioperative and long-term outcomes.

Demographically, women were significantly older (67.6 years vs. 62.6 years), with a significantly higher incidence of chronic obstructive pulmonary disease (47.0% vs. 35.7%) and a significantly greater percentage of patients with a forced expiratory volume in 1 second less than 50% (28.3% vs 18.2%). Degenerative aneurysms were significantly more common in women (61.7% vs. 41.6%), whereas chronic dissections significantly predominated in men (42.4% vs. 23.1%). Operative mortality was not significantly different between women and men (5.6% vs. 6.2%); however, women were significantly more likely to require a tracheostomy after surgery (10.6% vs. 5.0%).

Logistic regression found that being a woman was an independent risk factor for a composite of major adverse events (odds ratio, 2.68) and need for tracheostomy (OR, 3.73). In addition, women had significantly worse 5-year survival than men undergoing DTA or TAAA repair (59.7% vs. 66.2%, P =.025). There was no difference in overall survival between 1997-2007 and 2008-2017.

“Women and men undergoing TAAA repair have significant and consistent differences in preoperative characteristics. Despite these differences, operative mortality is similar between the two groups. However, women are at significantly increased risk of [major adverse events], especially respiratory failure, because of those differences in risk factors, including age, pulmonary function, and aneurysm etiology,” the researchers concluded.

The authors reported that they had no conflicts of interest.

[email protected]

SOURCE: Girardi LN et al. J Vasc Surg 2019;69:1028-35.

Women undergoing open descending thoracic aortic aneurysm (DTA) and open thoracoabdominal aortic aneurysm (TAAA) repair are not at greater risk for operative mortality than their male counterparts. However, they are at significantly greater risk for major adverse events and have significantly lower 5-year survival, according to the results of a single institution database review of 738 surgery patients.

From May 1997 to June 2017, there were 462 men (59%) and 321 women (41%) who underwent open repair of DTA or TAAA, according to Leonard N. Girardi, MD, and colleagues from Weill Cornell Medicine, New York, who performed the study published in the Journal of Vascular Surgery. The researchers used logistic regression and Cox regression analyses to assess the effect of sex on perioperative and long-term outcomes.

Demographically, women were significantly older (67.6 years vs. 62.6 years), with a significantly higher incidence of chronic obstructive pulmonary disease (47.0% vs. 35.7%) and a significantly greater percentage of patients with a forced expiratory volume in 1 second less than 50% (28.3% vs 18.2%). Degenerative aneurysms were significantly more common in women (61.7% vs. 41.6%), whereas chronic dissections significantly predominated in men (42.4% vs. 23.1%). Operative mortality was not significantly different between women and men (5.6% vs. 6.2%); however, women were significantly more likely to require a tracheostomy after surgery (10.6% vs. 5.0%).

Logistic regression found that being a woman was an independent risk factor for a composite of major adverse events (odds ratio, 2.68) and need for tracheostomy (OR, 3.73). In addition, women had significantly worse 5-year survival than men undergoing DTA or TAAA repair (59.7% vs. 66.2%, P =.025). There was no difference in overall survival between 1997-2007 and 2008-2017.

“Women and men undergoing TAAA repair have significant and consistent differences in preoperative characteristics. Despite these differences, operative mortality is similar between the two groups. However, women are at significantly increased risk of [major adverse events], especially respiratory failure, because of those differences in risk factors, including age, pulmonary function, and aneurysm etiology,” the researchers concluded.

The authors reported that they had no conflicts of interest.

[email protected]

SOURCE: Girardi LN et al. J Vasc Surg 2019;69:1028-35.

NEW ORLEANS – In a survey of pediatric hematologists, quality of life was the most frequently cited reason for starting second-line therapy in children with immune thrombocytopenia.

Jennifer Smith/MDedge News

Quality of life (QOL) was an indication for second-line treatment in nearly three-quarters of patients studied, and it ranked among the top three indications – along with bleeding frequency and bleeding severity – for treatment in more than half of patients.

Kristin A. Shimano, MD, of the department of pediatrics at the University of California, San Francisco, presented these results at the annual meeting of the American Society of Pediatric Hematology/Oncology.

Dr. Shimano and colleagues surveyed hematologists treating children in the ICON1 study (Am J Hematol. 2019 Apr 3. doi: 10.1002/ajh.25479).

The study enrolled 120 children receiving second-line immune thrombocytopenia (ITP) treatment at 21 centers. The median age at enrollment was 11.7 years (range, 1.2-17.8 years). About half of patients (53%) had chronic ITP, 31% had persistent ITP, and 16% had newly diagnosed ITP. The median number of prior treatments was three (range, zero to eight).

At study entry, the hematologists were asked to provide reasons that patients required second-line treatment. The list of 12 possible reasons included patient or parent QOL; bleeding severity; bleeding frequency; severity of thrombocytopenia; chronicity of ITP; high baseline activity level; involvement in sports; patient age; distance from medical center; and parent, patient, or physician anxiety. The hematologists were asked to choose all reasons that applied and to rank the top three reasons.

QOL was chosen as a reason to treat in 73% of patients (n = 88). QOL was among the top three reasons in 57% of patients (n = 68) and was the most important reason in 27% of patients (n = 32).

The severity and frequency of bleeding were ranked among the top three indications as well. Bleeding severity was a top indication in 29% of cases (n = 35), and bleeding frequency was a top indication in 40% of cases (n = 48).

Reasons for starting second-line treatment varied depending on patients’ phase of disease.

Bleeding severity was significantly more likely to be an indication for treatment among patients who had newly diagnosed or persistent ITP (69%), rather than chronic ITP (31%; P = .0025). Bleeding frequency was also significantly more likely to be an indication among patients with newly diagnosed or persistent ITP (63% vs. 37%; P = .0054).

Conversely, QOL was significantly more likely to be an indication for patients with chronic ITP (65%) rather than newly diagnosed or persistent ITP (35%, P = .0056). Sports participation was a more likely indication among patients with chronic ITP as well (75% vs. 26%, P = .017).

Indications for treatment also varied according to baseline platelet counts. For example, QOL was an indication for treatment in 42% of patients with baseline platelet counts less than 10 x 10⁹/L and 78% of patients with platelet counts of 20 x 10⁹/L or greater. So the higher the baseline platelet count, the more likely QOL was an indication for treatment (P = .006).

On the other hand, the importance hematologists placed on QOL did not appear to correlate with actual health-related QOL as assessed by the Kids ITP Tool. There was no difference reported in baseline health-related QOL, according to the tool, in children for whom QOL was ranked versus unranked by hematologists.

This finding suggests physicians may not be adequately assessing the impact of ITP on QOL, Dr. Shimano said.

“Better clinical measures of the impact of ITP on patient quality of life are needed to assess both need for treatment and treatment response,” she said. “Understanding the effects of individual second-line treatments on quality of life is critical for this patient population in order to best tailor therapy for each patient.”

Dr. Shimano reported involvement in an investigator-initiated trial for eltrombopag in children with ITP. The study, which has not yet opened, is funded by Novartis.

[email protected]

SOURCE: Shimano KA et al. ASPHO 2019, Abstract 2012.

NEW ORLEANS – In a survey of pediatric hematologists, quality of life was the most frequently cited reason for starting second-line therapy in children with immune thrombocytopenia.

Jennifer Smith/MDedge News

Quality of life (QOL) was an indication for second-line treatment in nearly three-quarters of patients studied, and it ranked among the top three indications – along with bleeding frequency and bleeding severity – for treatment in more than half of patients.

Kristin A. Shimano, MD, of the department of pediatrics at the University of California, San Francisco, presented these results at the annual meeting of the American Society of Pediatric Hematology/Oncology.

Dr. Shimano and colleagues surveyed hematologists treating children in the ICON1 study (Am J Hematol. 2019 Apr 3. doi: 10.1002/ajh.25479).

The study enrolled 120 children receiving second-line immune thrombocytopenia (ITP) treatment at 21 centers. The median age at enrollment was 11.7 years (range, 1.2-17.8 years). About half of patients (53%) had chronic ITP, 31% had persistent ITP, and 16% had newly diagnosed ITP. The median number of prior treatments was three (range, zero to eight).

At study entry, the hematologists were asked to provide reasons that patients required second-line treatment. The list of 12 possible reasons included patient or parent QOL; bleeding severity; bleeding frequency; severity of thrombocytopenia; chronicity of ITP; high baseline activity level; involvement in sports; patient age; distance from medical center; and parent, patient, or physician anxiety. The hematologists were asked to choose all reasons that applied and to rank the top three reasons.

QOL was chosen as a reason to treat in 73% of patients (n = 88). QOL was among the top three reasons in 57% of patients (n = 68) and was the most important reason in 27% of patients (n = 32).

The severity and frequency of bleeding were ranked among the top three indications as well. Bleeding severity was a top indication in 29% of cases (n = 35), and bleeding frequency was a top indication in 40% of cases (n = 48).

Reasons for starting second-line treatment varied depending on patients’ phase of disease.

Bleeding severity was significantly more likely to be an indication for treatment among patients who had newly diagnosed or persistent ITP (69%), rather than chronic ITP (31%; P = .0025). Bleeding frequency was also significantly more likely to be an indication among patients with newly diagnosed or persistent ITP (63% vs. 37%; P = .0054).

Conversely, QOL was significantly more likely to be an indication for patients with chronic ITP (65%) rather than newly diagnosed or persistent ITP (35%, P = .0056). Sports participation was a more likely indication among patients with chronic ITP as well (75% vs. 26%, P = .017).

Indications for treatment also varied according to baseline platelet counts. For example, QOL was an indication for treatment in 42% of patients with baseline platelet counts less than 10 x 10⁹/L and 78% of patients with platelet counts of 20 x 10⁹/L or greater. So the higher the baseline platelet count, the more likely QOL was an indication for treatment (P = .006).

On the other hand, the importance hematologists placed on QOL did not appear to correlate with actual health-related QOL as assessed by the Kids ITP Tool. There was no difference reported in baseline health-related QOL, according to the tool, in children for whom QOL was ranked versus unranked by hematologists.

This finding suggests physicians may not be adequately assessing the impact of ITP on QOL, Dr. Shimano said.

“Better clinical measures of the impact of ITP on patient quality of life are needed to assess both need for treatment and treatment response,” she said. “Understanding the effects of individual second-line treatments on quality of life is critical for this patient population in order to best tailor therapy for each patient.”

Dr. Shimano reported involvement in an investigator-initiated trial for eltrombopag in children with ITP. The study, which has not yet opened, is funded by Novartis.

[email protected]

SOURCE: Shimano KA et al. ASPHO 2019, Abstract 2012.

NEW ORLEANS – In a survey of pediatric hematologists, quality of life was the most frequently cited reason for starting second-line therapy in children with immune thrombocytopenia.

Jennifer Smith/MDedge News

Quality of life (QOL) was an indication for second-line treatment in nearly three-quarters of patients studied, and it ranked among the top three indications – along with bleeding frequency and bleeding severity – for treatment in more than half of patients.

Kristin A. Shimano, MD, of the department of pediatrics at the University of California, San Francisco, presented these results at the annual meeting of the American Society of Pediatric Hematology/Oncology.

Dr. Shimano and colleagues surveyed hematologists treating children in the ICON1 study (Am J Hematol. 2019 Apr 3. doi: 10.1002/ajh.25479).

The study enrolled 120 children receiving second-line immune thrombocytopenia (ITP) treatment at 21 centers. The median age at enrollment was 11.7 years (range, 1.2-17.8 years). About half of patients (53%) had chronic ITP, 31% had persistent ITP, and 16% had newly diagnosed ITP. The median number of prior treatments was three (range, zero to eight).

At study entry, the hematologists were asked to provide reasons that patients required second-line treatment. The list of 12 possible reasons included patient or parent QOL; bleeding severity; bleeding frequency; severity of thrombocytopenia; chronicity of ITP; high baseline activity level; involvement in sports; patient age; distance from medical center; and parent, patient, or physician anxiety. The hematologists were asked to choose all reasons that applied and to rank the top three reasons.

QOL was chosen as a reason to treat in 73% of patients (n = 88). QOL was among the top three reasons in 57% of patients (n = 68) and was the most important reason in 27% of patients (n = 32).

The severity and frequency of bleeding were ranked among the top three indications as well. Bleeding severity was a top indication in 29% of cases (n = 35), and bleeding frequency was a top indication in 40% of cases (n = 48).

Reasons for starting second-line treatment varied depending on patients’ phase of disease.

Bleeding severity was significantly more likely to be an indication for treatment among patients who had newly diagnosed or persistent ITP (69%), rather than chronic ITP (31%; P = .0025). Bleeding frequency was also significantly more likely to be an indication among patients with newly diagnosed or persistent ITP (63% vs. 37%; P = .0054).

Conversely, QOL was significantly more likely to be an indication for patients with chronic ITP (65%) rather than newly diagnosed or persistent ITP (35%, P = .0056). Sports participation was a more likely indication among patients with chronic ITP as well (75% vs. 26%, P = .017).

Indications for treatment also varied according to baseline platelet counts. For example, QOL was an indication for treatment in 42% of patients with baseline platelet counts less than 10 x 10⁹/L and 78% of patients with platelet counts of 20 x 10⁹/L or greater. So the higher the baseline platelet count, the more likely QOL was an indication for treatment (P = .006).

On the other hand, the importance hematologists placed on QOL did not appear to correlate with actual health-related QOL as assessed by the Kids ITP Tool. There was no difference reported in baseline health-related QOL, according to the tool, in children for whom QOL was ranked versus unranked by hematologists.

This finding suggests physicians may not be adequately assessing the impact of ITP on QOL, Dr. Shimano said.

“Better clinical measures of the impact of ITP on patient quality of life are needed to assess both need for treatment and treatment response,” she said. “Understanding the effects of individual second-line treatments on quality of life is critical for this patient population in order to best tailor therapy for each patient.”

Dr. Shimano reported involvement in an investigator-initiated trial for eltrombopag in children with ITP. The study, which has not yet opened, is funded by Novartis.

[email protected]

SOURCE: Shimano KA et al. ASPHO 2019, Abstract 2012.

SAN FRANCISCO – As a tool for the screening and diagnosis of diseases in the gastrointestinal (GI) tract, artificial intelligence (AI) is advancing rapidly, according to a review of this technology presented at the 2019 AGA Tech Summit, sponsored by the AGA Center for GI Innovation and Technology.

Much of the focus of the update was on screening colonoscopy, but the same principles are relevant and being pursued for other GI conditions, such as dysplasia screening in patients with Barrett’s esophagus and the assessment of mucosal healing in inflammatory bowel disease, according to Michael F. Byrne, MD, a clinical professor in the division of gastroenterology at Vancouver General Hospital.

“There are many technologies [to improve screening and diagnosis of GI diseases], but I believe these will struggle if they do not also have some kind of built-in machine intelligence,” Dr. Byrne said. In addition to his practice in gastroenterology, Dr. Byrne is CEO of Satis Operations and founder of AI4GI, a commercial joint venture focused on clinical applications of AI in colon polyp disease.

In this context, AI is being built on the principle of deep learning, which employs neural networks or a set of algorithms that permits a computer to recognize patterns when “trained” with data. In the machine learning process, the computer can use a large number of features in the task of discrimination.

This might suggest that AI could, in turn, train physicians to recognize the same features, but this underestimates the complexity and sophistication of machine learning, according to Dr. Byrne. The current status of machine learning for screening colonoscopy underscores this point.

“A computer can consider a thousand features when evaluating a polyp, which is way beyond what we can do,” Dr. Byrne said. Even with advances to improve visualization in screening colonoscopy, such as improved resolution and better lighting, the reason that AI is expected to prevail is that “the human eye is just not accurate enough.”

Many groups have developed advanced machine learning systems for screening colonoscopy. Dr. Byrne reviewed some of the early work done in Japan and that performed with a system in development by his group. In a study with the AI4GI model, published recently in Gut (2019;68:94-100), greater than 94% accuracy was achieved in distinguishing adenomas from hyperplastic polyps using histopathology as a gold standard.

Because of the ability of machine learning to see what the human eye cannot, Dr. Byrne predicts that AI-centric classification will replace current polyp classification systems, which could offer categories that are more clinically useful and reliable.

However, the work in screening colonoscopy is just the beginning, according to Dr. Byrne. “The opportunity of machine learning goes way beyond polyps.”

Recognizing dysplasia associated with Barrett’s esophagus has parallels with identifying adenomatous polyps in screening colonoscopy, but Dr. Byrne also discussed machine learning as an “optical biopsy” for evaluating the mucosa of patients with IBD. No longer a screening approach, the characterization of IBD tissue could help with therapeutic decisions.

With an AI approach to optical biopsy, “there is a great opportunity to assign an inflammatory burden in IBD,” he suggested, explaining how evidence of disease activity could guide escalation or de-escalation of treatment within the context of the treat-to-target approach to prolonging remission.

Overall, there is abundant evidence that “optical biopsy is feasible,” Dr. Byrne said. He indicated that clinical applications are approaching quickly. While he acknowledged that the technology “will need a human in the loop” as it enters clinical practice initially, he believes that this technology will play a significant role in GI practice because of the clear limitations of the human eye in assessing endoscopic images of GI tissue.

SAN FRANCISCO – As a tool for the screening and diagnosis of diseases in the gastrointestinal (GI) tract, artificial intelligence (AI) is advancing rapidly, according to a review of this technology presented at the 2019 AGA Tech Summit, sponsored by the AGA Center for GI Innovation and Technology.

Much of the focus of the update was on screening colonoscopy, but the same principles are relevant and being pursued for other GI conditions, such as dysplasia screening in patients with Barrett’s esophagus and the assessment of mucosal healing in inflammatory bowel disease, according to Michael F. Byrne, MD, a clinical professor in the division of gastroenterology at Vancouver General Hospital.

“There are many technologies [to improve screening and diagnosis of GI diseases], but I believe these will struggle if they do not also have some kind of built-in machine intelligence,” Dr. Byrne said. In addition to his practice in gastroenterology, Dr. Byrne is CEO of Satis Operations and founder of AI4GI, a commercial joint venture focused on clinical applications of AI in colon polyp disease.

In this context, AI is being built on the principle of deep learning, which employs neural networks or a set of algorithms that permits a computer to recognize patterns when “trained” with data. In the machine learning process, the computer can use a large number of features in the task of discrimination.

This might suggest that AI could, in turn, train physicians to recognize the same features, but this underestimates the complexity and sophistication of machine learning, according to Dr. Byrne. The current status of machine learning for screening colonoscopy underscores this point.

“A computer can consider a thousand features when evaluating a polyp, which is way beyond what we can do,” Dr. Byrne said. Even with advances to improve visualization in screening colonoscopy, such as improved resolution and better lighting, the reason that AI is expected to prevail is that “the human eye is just not accurate enough.”

Many groups have developed advanced machine learning systems for screening colonoscopy. Dr. Byrne reviewed some of the early work done in Japan and that performed with a system in development by his group. In a study with the AI4GI model, published recently in Gut (2019;68:94-100), greater than 94% accuracy was achieved in distinguishing adenomas from hyperplastic polyps using histopathology as a gold standard.

Because of the ability of machine learning to see what the human eye cannot, Dr. Byrne predicts that AI-centric classification will replace current polyp classification systems, which could offer categories that are more clinically useful and reliable.

However, the work in screening colonoscopy is just the beginning, according to Dr. Byrne. “The opportunity of machine learning goes way beyond polyps.”

Recognizing dysplasia associated with Barrett’s esophagus has parallels with identifying adenomatous polyps in screening colonoscopy, but Dr. Byrne also discussed machine learning as an “optical biopsy” for evaluating the mucosa of patients with IBD. No longer a screening approach, the characterization of IBD tissue could help with therapeutic decisions.

With an AI approach to optical biopsy, “there is a great opportunity to assign an inflammatory burden in IBD,” he suggested, explaining how evidence of disease activity could guide escalation or de-escalation of treatment within the context of the treat-to-target approach to prolonging remission.

Overall, there is abundant evidence that “optical biopsy is feasible,” Dr. Byrne said. He indicated that clinical applications are approaching quickly. While he acknowledged that the technology “will need a human in the loop” as it enters clinical practice initially, he believes that this technology will play a significant role in GI practice because of the clear limitations of the human eye in assessing endoscopic images of GI tissue.

SAN FRANCISCO – As a tool for the screening and diagnosis of diseases in the gastrointestinal (GI) tract, artificial intelligence (AI) is advancing rapidly, according to a review of this technology presented at the 2019 AGA Tech Summit, sponsored by the AGA Center for GI Innovation and Technology.

Much of the focus of the update was on screening colonoscopy, but the same principles are relevant and being pursued for other GI conditions, such as dysplasia screening in patients with Barrett’s esophagus and the assessment of mucosal healing in inflammatory bowel disease, according to Michael F. Byrne, MD, a clinical professor in the division of gastroenterology at Vancouver General Hospital.

“There are many technologies [to improve screening and diagnosis of GI diseases], but I believe these will struggle if they do not also have some kind of built-in machine intelligence,” Dr. Byrne said. In addition to his practice in gastroenterology, Dr. Byrne is CEO of Satis Operations and founder of AI4GI, a commercial joint venture focused on clinical applications of AI in colon polyp disease.

In this context, AI is being built on the principle of deep learning, which employs neural networks or a set of algorithms that permits a computer to recognize patterns when “trained” with data. In the machine learning process, the computer can use a large number of features in the task of discrimination.

This might suggest that AI could, in turn, train physicians to recognize the same features, but this underestimates the complexity and sophistication of machine learning, according to Dr. Byrne. The current status of machine learning for screening colonoscopy underscores this point.

“A computer can consider a thousand features when evaluating a polyp, which is way beyond what we can do,” Dr. Byrne said. Even with advances to improve visualization in screening colonoscopy, such as improved resolution and better lighting, the reason that AI is expected to prevail is that “the human eye is just not accurate enough.”

Many groups have developed advanced machine learning systems for screening colonoscopy. Dr. Byrne reviewed some of the early work done in Japan and that performed with a system in development by his group. In a study with the AI4GI model, published recently in Gut (2019;68:94-100), greater than 94% accuracy was achieved in distinguishing adenomas from hyperplastic polyps using histopathology as a gold standard.

Because of the ability of machine learning to see what the human eye cannot, Dr. Byrne predicts that AI-centric classification will replace current polyp classification systems, which could offer categories that are more clinically useful and reliable.

However, the work in screening colonoscopy is just the beginning, according to Dr. Byrne. “The opportunity of machine learning goes way beyond polyps.”

Recognizing dysplasia associated with Barrett’s esophagus has parallels with identifying adenomatous polyps in screening colonoscopy, but Dr. Byrne also discussed machine learning as an “optical biopsy” for evaluating the mucosa of patients with IBD. No longer a screening approach, the characterization of IBD tissue could help with therapeutic decisions.

With an AI approach to optical biopsy, “there is a great opportunity to assign an inflammatory burden in IBD,” he suggested, explaining how evidence of disease activity could guide escalation or de-escalation of treatment within the context of the treat-to-target approach to prolonging remission.

Overall, there is abundant evidence that “optical biopsy is feasible,” Dr. Byrne said. He indicated that clinical applications are approaching quickly. While he acknowledged that the technology “will need a human in the loop” as it enters clinical practice initially, he believes that this technology will play a significant role in GI practice because of the clear limitations of the human eye in assessing endoscopic images of GI tissue.

LOS ANGELES – Recent research, a new test, and upcoming guidelines are providing insight into the diagnosis of adult growth hormone deficiency and the importance of treatment, Kevin C.J. Yuen, MD, FRCP(UK), FACE, told colleagues at the annual scientific and clinical congress of the American Association of Clinical Endocrinologists (AACE).

“The data show that growth hormone replacement is safe and may improve survival,” said Dr Yuen, professor of medicine and medical director at Barrow Neurological Institute Pituitary Center in Phoenix.

Dr. Yuen is chair of the AACE’s growth hormone task force and coauthored both the 2009 and soon-to-be-published 2019 AACE guidelines for the treatment of adult growth hormone deficiency (AGHD).

Updated AGHD guidelines were needed for a variety of reasons, including a greater awareness of the benefits of hormone replacement in these patients and new developments in areas such as testing, he said. The guidelines also are also necessary because of the skepticism about the cost and benefits of AGHD therapy, concerns about the safety of long-term therapy, and the misuse of treatment in certain patients, he added.

On the treatment front, Dr. Yuen said it has become more clear over recent years that patients with AGHD benefit from hormone replacement. Findings from two studies have linked treatment to improvements in exercise capacity (Clin Endocrinol [Oxf]. 2016;85[4]:660-8) and patient quality of life (Eur J Endocrinol. 2017;176:99-109). “Even just after 6 months there’s an improvement in aerobic power,” he said.

And, he continued, other findings have suggested that treatment could lower mortality in men and reduce the number of deaths from malignant neoplasms in all patients (Eur J Endocrinol. 2017;176[1]:67-75).

However, Dr. Yuen cautioned that the confirmation of a survival benefit from hormone replacement will be speculative as long as there are no prospective data available.

He offered five tips about diagnosing and treating AGHD:

First, be aware that a number of conditions other than AGHD can cause low levels of insulin-like growth factor 1, including malnutrition, diabetes, untreated hypothyroidism, liver disease, and kidney failure.

Second, follow recommended algorithms for testing adult patients and transition those pediatric patients who seem to be at risk of having the condition. (Those moving from pediatric to adult care are known as transition patients.) The algorithms suggest that three diagnostic tests can be helpful, depending on the situation: the macimorelin test, the insulin tolerance test, and the glucagon stimulation test.

In 2017, the Food and Drug Administration approved the macimorelin (Macrilen) test, which requires the administration of an oral medication before a blood test. Dr. Yuen cited a phase 3 study that demonstrated that the test was “highly reproducible” and has a “good safety profile” (J Clin Endocrinol Metab. 2018;103[8]:3083-93). Dr. Yuen believes the test will become the preferred alternative to the insulin tolerance test.

Third, transition patients require special care as they move from pediatric care. “The handover is still very challenging,” Dr. Yuen said. “There’s still much to be done to improve the quality of treatment for these patients.” Challenges during the transition can include the patient’s reluctance to continue taking hormones in adulthood, he said. “Encourage pediatricians to start educating patients from early on that they’ll need to remain on hormones,” he advised, and help patients take accountability for their health in areas such as self-injection.

Patients may suffer from “injection fatigue,” they may be concerned about the side effects of the therapy, and/or they may be overwhelmed by the cost of care, he said. They may not understand how to manage their care and lack insight into the consequences of treatment cessation.

He advised endocrinologists to monitor transition patients who aren’t growth-hormone deficient because their status may change in the future.

Fourth, start treatment in adults with recommended doses of growth hormone. For those younger than 30 years, use 0.4-0.5 mg/day (higher for transition patients); for those aged between 30 and 60 years, use 0.2-0.3 mg/day; and for those who are older than 60 years, use 0.1-0.2 mg/day. Doses should be adjusted to 0.1-0.2 mg/day in patients with diabetes, obesity, and/or previous gestational diabetes.

Fifth, treat patients with growth hormone indefinitely if benefits are seen, but consider stopping treatment after a year if there doesn’t seem to be a benefit, Dr. Yuen advised. Follow up at 6 months, he recommended.

Dr. Yuen disclosed receiving research grants from and consulting for Pfizer, Novo Nordisk, and Aeterna Zentaris. He has also consulted for Strongbridge.

LOS ANGELES – Recent research, a new test, and upcoming guidelines are providing insight into the diagnosis of adult growth hormone deficiency and the importance of treatment, Kevin C.J. Yuen, MD, FRCP(UK), FACE, told colleagues at the annual scientific and clinical congress of the American Association of Clinical Endocrinologists (AACE).

“The data show that growth hormone replacement is safe and may improve survival,” said Dr Yuen, professor of medicine and medical director at Barrow Neurological Institute Pituitary Center in Phoenix.

Dr. Yuen is chair of the AACE’s growth hormone task force and coauthored both the 2009 and soon-to-be-published 2019 AACE guidelines for the treatment of adult growth hormone deficiency (AGHD).

Updated AGHD guidelines were needed for a variety of reasons, including a greater awareness of the benefits of hormone replacement in these patients and new developments in areas such as testing, he said. The guidelines also are also necessary because of the skepticism about the cost and benefits of AGHD therapy, concerns about the safety of long-term therapy, and the misuse of treatment in certain patients, he added.

On the treatment front, Dr. Yuen said it has become more clear over recent years that patients with AGHD benefit from hormone replacement. Findings from two studies have linked treatment to improvements in exercise capacity (Clin Endocrinol [Oxf]. 2016;85[4]:660-8) and patient quality of life (Eur J Endocrinol. 2017;176:99-109). “Even just after 6 months there’s an improvement in aerobic power,” he said.

And, he continued, other findings have suggested that treatment could lower mortality in men and reduce the number of deaths from malignant neoplasms in all patients (Eur J Endocrinol. 2017;176[1]:67-75).

However, Dr. Yuen cautioned that the confirmation of a survival benefit from hormone replacement will be speculative as long as there are no prospective data available.

He offered five tips about diagnosing and treating AGHD:

First, be aware that a number of conditions other than AGHD can cause low levels of insulin-like growth factor 1, including malnutrition, diabetes, untreated hypothyroidism, liver disease, and kidney failure.

Second, follow recommended algorithms for testing adult patients and transition those pediatric patients who seem to be at risk of having the condition. (Those moving from pediatric to adult care are known as transition patients.) The algorithms suggest that three diagnostic tests can be helpful, depending on the situation: the macimorelin test, the insulin tolerance test, and the glucagon stimulation test.

In 2017, the Food and Drug Administration approved the macimorelin (Macrilen) test, which requires the administration of an oral medication before a blood test. Dr. Yuen cited a phase 3 study that demonstrated that the test was “highly reproducible” and has a “good safety profile” (J Clin Endocrinol Metab. 2018;103[8]:3083-93). Dr. Yuen believes the test will become the preferred alternative to the insulin tolerance test.

Third, transition patients require special care as they move from pediatric care. “The handover is still very challenging,” Dr. Yuen said. “There’s still much to be done to improve the quality of treatment for these patients.” Challenges during the transition can include the patient’s reluctance to continue taking hormones in adulthood, he said. “Encourage pediatricians to start educating patients from early on that they’ll need to remain on hormones,” he advised, and help patients take accountability for their health in areas such as self-injection.

Patients may suffer from “injection fatigue,” they may be concerned about the side effects of the therapy, and/or they may be overwhelmed by the cost of care, he said. They may not understand how to manage their care and lack insight into the consequences of treatment cessation.

He advised endocrinologists to monitor transition patients who aren’t growth-hormone deficient because their status may change in the future.

Fourth, start treatment in adults with recommended doses of growth hormone. For those younger than 30 years, use 0.4-0.5 mg/day (higher for transition patients); for those aged between 30 and 60 years, use 0.2-0.3 mg/day; and for those who are older than 60 years, use 0.1-0.2 mg/day. Doses should be adjusted to 0.1-0.2 mg/day in patients with diabetes, obesity, and/or previous gestational diabetes.

Fifth, treat patients with growth hormone indefinitely if benefits are seen, but consider stopping treatment after a year if there doesn’t seem to be a benefit, Dr. Yuen advised. Follow up at 6 months, he recommended.

Dr. Yuen disclosed receiving research grants from and consulting for Pfizer, Novo Nordisk, and Aeterna Zentaris. He has also consulted for Strongbridge.

LOS ANGELES – Recent research, a new test, and upcoming guidelines are providing insight into the diagnosis of adult growth hormone deficiency and the importance of treatment, Kevin C.J. Yuen, MD, FRCP(UK), FACE, told colleagues at the annual scientific and clinical congress of the American Association of Clinical Endocrinologists (AACE).

“The data show that growth hormone replacement is safe and may improve survival,” said Dr Yuen, professor of medicine and medical director at Barrow Neurological Institute Pituitary Center in Phoenix.

Dr. Yuen is chair of the AACE’s growth hormone task force and coauthored both the 2009 and soon-to-be-published 2019 AACE guidelines for the treatment of adult growth hormone deficiency (AGHD).

Updated AGHD guidelines were needed for a variety of reasons, including a greater awareness of the benefits of hormone replacement in these patients and new developments in areas such as testing, he said. The guidelines also are also necessary because of the skepticism about the cost and benefits of AGHD therapy, concerns about the safety of long-term therapy, and the misuse of treatment in certain patients, he added.

On the treatment front, Dr. Yuen said it has become more clear over recent years that patients with AGHD benefit from hormone replacement. Findings from two studies have linked treatment to improvements in exercise capacity (Clin Endocrinol [Oxf]. 2016;85[4]:660-8) and patient quality of life (Eur J Endocrinol. 2017;176:99-109). “Even just after 6 months there’s an improvement in aerobic power,” he said.

And, he continued, other findings have suggested that treatment could lower mortality in men and reduce the number of deaths from malignant neoplasms in all patients (Eur J Endocrinol. 2017;176[1]:67-75).

However, Dr. Yuen cautioned that the confirmation of a survival benefit from hormone replacement will be speculative as long as there are no prospective data available.

He offered five tips about diagnosing and treating AGHD:

First, be aware that a number of conditions other than AGHD can cause low levels of insulin-like growth factor 1, including malnutrition, diabetes, untreated hypothyroidism, liver disease, and kidney failure.

Second, follow recommended algorithms for testing adult patients and transition those pediatric patients who seem to be at risk of having the condition. (Those moving from pediatric to adult care are known as transition patients.) The algorithms suggest that three diagnostic tests can be helpful, depending on the situation: the macimorelin test, the insulin tolerance test, and the glucagon stimulation test.

In 2017, the Food and Drug Administration approved the macimorelin (Macrilen) test, which requires the administration of an oral medication before a blood test. Dr. Yuen cited a phase 3 study that demonstrated that the test was “highly reproducible” and has a “good safety profile” (J Clin Endocrinol Metab. 2018;103[8]:3083-93). Dr. Yuen believes the test will become the preferred alternative to the insulin tolerance test.

Third, transition patients require special care as they move from pediatric care. “The handover is still very challenging,” Dr. Yuen said. “There’s still much to be done to improve the quality of treatment for these patients.” Challenges during the transition can include the patient’s reluctance to continue taking hormones in adulthood, he said. “Encourage pediatricians to start educating patients from early on that they’ll need to remain on hormones,” he advised, and help patients take accountability for their health in areas such as self-injection.

Patients may suffer from “injection fatigue,” they may be concerned about the side effects of the therapy, and/or they may be overwhelmed by the cost of care, he said. They may not understand how to manage their care and lack insight into the consequences of treatment cessation.

He advised endocrinologists to monitor transition patients who aren’t growth-hormone deficient because their status may change in the future.

Fourth, start treatment in adults with recommended doses of growth hormone. For those younger than 30 years, use 0.4-0.5 mg/day (higher for transition patients); for those aged between 30 and 60 years, use 0.2-0.3 mg/day; and for those who are older than 60 years, use 0.1-0.2 mg/day. Doses should be adjusted to 0.1-0.2 mg/day in patients with diabetes, obesity, and/or previous gestational diabetes.

Fifth, treat patients with growth hormone indefinitely if benefits are seen, but consider stopping treatment after a year if there doesn’t seem to be a benefit, Dr. Yuen advised. Follow up at 6 months, he recommended.

Dr. Yuen disclosed receiving research grants from and consulting for Pfizer, Novo Nordisk, and Aeterna Zentaris. He has also consulted for Strongbridge.

BALTIMORE – An analysis of malpractice claims paid for hernia operations found that breach of informed consent was a reason for more than 15% of cases, and intraoperative damage to surrounding structures was the leading reason for such lawsuits, according to research presented at the annual meeting of the American Gastrointestinal and Endoscopic Surgeons.

The purpose of the study was to identify leading causes of litigation for hernia repair as the volume of hernia repairs in the United States increases with a trend toward minimally invasive and robotic surgery, said Asad Choudhry, MBBS, of the State University of New York, Syracuse.“In terms of the hernia itself, inguinal hernia operations were found to be the most common hernia procedure that led to pursuance of litigation, and laparoscopy was the most common type of procedure rather than open in terms of patients pursuing litigation.”

The study sampled the WestLawNext legal database for medical malpractice abdominal wall procedures, and evaluated 430 cases of abdominopelvic wall hernias that fit the study criteria – inguinal, femoral, ventral, umbilical, parastomal, spigelian, obturator, epigastric, incisional, paraumbilical, and pantaloon hernias, Dr. Choudhry said. Hiatal, diaphragmatic, sciatic, gluteal, and lumbar hernias were excluded. He noted that abdominal wall hernia have been reported to be the second most common abdominopelvic procedure performed in the United States after C-section, with more than 1 million procedures done annually (Surg Clin N Am. 2003;83:1045-51).

While most malpractice hernia cases were decided in favor of the defendant surgeon, settlements and cases with a jury verdict in favor of the plaintiff were costly. Dr. Choudhry cited awards of $6.8 million, $12 million, and $3 million in specific hernia cases.

“In terms of the type of repair itself, elective operations were more common, and mesh was used in approximately 27% of cases in which there was a defendant verdict and 18% of cases in which there was a plaintiff verdict,” he said.

For inguinal hernia, 61% of cases were decided for the defendant surgeon. With regards to type of procedure, laparoscopic surgery resulted in defendant verdicts in 31% of cases versus 23% for the plaintiff, and open operations resulted in a ruling favoring the defendant surgeon in 26% versus 15% for the plaintiff. (The remainder were lap-converted-to-open operations, with 2% for the defendant and 1% for the plaintiff.)

Mortality was a key determinant of verdict, Dr. Choudhry added. “Cases with no mortality were more likely of having an outcome in favor of the defendant surgeon.”

The researchers also looked at litigation arising from the phase of care – before, during, or after surgery. “In the preoperative time setting, delay or failure to diagnose or manage a hernia was the leading cause of malpractice,” Dr. Choudhry said. “These cases were mainly emergent patients presenting to the emergency department where the intervention was not performed in a timely manner and leading to some form of complication.”

In the intraoperative period, damage to surrounding structures was by far the leading cause of malpractice, but incomplete procedure or improper surgical technique and use of improper surgical materials also were significant causes in this period. Postoperatively, failure to timely detect and/or repair a surgical complication was the most common cause of litigation. “However, it’s important to note that persistent pain, such as nerve entrapment syndrome, is also noted in the postoperative time period as a cause of litigation,” he added.

The study also evaluated injury severity in the context of a claim outcome. “Most claims where there was an insignificant or minor injury were decided for the defendant surgeon,” Dr. Choudhry said. “But as you start moving higher on the injury scale toward death, these cases were more likely to favor the plaintiff, and that’s correlative because patients tend to sue more when there’s a more significant complication, such as when there’s a death of a family member.” In cases involving death, 41% resulted in a verdict for the defendant surgery, 35% in a plaintiff verdict, and 23% in a settlement, whereas in cases involving insignificant temporary injury, 90% were ruled for the defendant surgeon, with none going to settlement.

The research also found another mitigating factor in malpractice lawsuits: the number of lawyers in a state. “We noted that specific states such as California, New York, Texas, and Florida were bound to have a higher number of lawsuits per population, and this was correlative with the number of lawyers practicing within that state,” Dr. Choudhry said. New York led the nation with 46 cases, followed by California with 42, Florida with 27 ,and Texas and Pennsylvania with 17 each.

Session moderator Heather Logghe, MD, of Jefferson Medical College, Philadelphia, questioned Dr. Choudhry on how surgeons can improve their informed consent process to protect against potential litigation.

“The most important thing we can do is document and explain the risk, benefits, and alternatives, and use an inclusive informed consent that will allow the patients to have a complete understanding of the procedure that is to be done and the complications that may result,” he said. This process needs to be tailored to individual hospital systems. “This may allow for better documentation, and it may not decrease the number of malpractice lawsuits but it may decrease the outcomes not in favor of physicians.”

The researchers also identified trends in the broader context of medical malpractice. Citing data from the National Practitioner Data Bank, Dr. Choudhry noted that malpractice payouts have been increasing since 2012 after a steady 9-year decline. In addition, general surgeons are at greater risk than all but two other types of specialists – neurosurgeons and thoracic-cardiovascular surgeons (N Engl J Med. 2011;365:629-36). “Fifteen percent of general surgeons will be facing malpractice claims annually across the United States. Physicians in high-legal-risk specialties, such as the surgical specialties, are 99% likely to face a claim over their careers.”

The next step for the researchers is to use malpractice insurance data to study medical liability on a larger scale and identify methods physicians can use to improve patient care and mitigate risk, Dr. Choudhry said.

Dr. Choudhry had no relevant financial relationships to disclose.

SOURCE: Choudhry A et al. SAGES 2109, Abstract S104.

BALTIMORE – An analysis of malpractice claims paid for hernia operations found that breach of informed consent was a reason for more than 15% of cases, and intraoperative damage to surrounding structures was the leading reason for such lawsuits, according to research presented at the annual meeting of the American Gastrointestinal and Endoscopic Surgeons.

The purpose of the study was to identify leading causes of litigation for hernia repair as the volume of hernia repairs in the United States increases with a trend toward minimally invasive and robotic surgery, said Asad Choudhry, MBBS, of the State University of New York, Syracuse.“In terms of the hernia itself, inguinal hernia operations were found to be the most common hernia procedure that led to pursuance of litigation, and laparoscopy was the most common type of procedure rather than open in terms of patients pursuing litigation.”

The study sampled the WestLawNext legal database for medical malpractice abdominal wall procedures, and evaluated 430 cases of abdominopelvic wall hernias that fit the study criteria – inguinal, femoral, ventral, umbilical, parastomal, spigelian, obturator, epigastric, incisional, paraumbilical, and pantaloon hernias, Dr. Choudhry said. Hiatal, diaphragmatic, sciatic, gluteal, and lumbar hernias were excluded. He noted that abdominal wall hernia have been reported to be the second most common abdominopelvic procedure performed in the United States after C-section, with more than 1 million procedures done annually (Surg Clin N Am. 2003;83:1045-51).

While most malpractice hernia cases were decided in favor of the defendant surgeon, settlements and cases with a jury verdict in favor of the plaintiff were costly. Dr. Choudhry cited awards of $6.8 million, $12 million, and $3 million in specific hernia cases.

“In terms of the type of repair itself, elective operations were more common, and mesh was used in approximately 27% of cases in which there was a defendant verdict and 18% of cases in which there was a plaintiff verdict,” he said.

For inguinal hernia, 61% of cases were decided for the defendant surgeon. With regards to type of procedure, laparoscopic surgery resulted in defendant verdicts in 31% of cases versus 23% for the plaintiff, and open operations resulted in a ruling favoring the defendant surgeon in 26% versus 15% for the plaintiff. (The remainder were lap-converted-to-open operations, with 2% for the defendant and 1% for the plaintiff.)

Mortality was a key determinant of verdict, Dr. Choudhry added. “Cases with no mortality were more likely of having an outcome in favor of the defendant surgeon.”

The researchers also looked at litigation arising from the phase of care – before, during, or after surgery. “In the preoperative time setting, delay or failure to diagnose or manage a hernia was the leading cause of malpractice,” Dr. Choudhry said. “These cases were mainly emergent patients presenting to the emergency department where the intervention was not performed in a timely manner and leading to some form of complication.”

In the intraoperative period, damage to surrounding structures was by far the leading cause of malpractice, but incomplete procedure or improper surgical technique and use of improper surgical materials also were significant causes in this period. Postoperatively, failure to timely detect and/or repair a surgical complication was the most common cause of litigation. “However, it’s important to note that persistent pain, such as nerve entrapment syndrome, is also noted in the postoperative time period as a cause of litigation,” he added.

The study also evaluated injury severity in the context of a claim outcome. “Most claims where there was an insignificant or minor injury were decided for the defendant surgeon,” Dr. Choudhry said. “But as you start moving higher on the injury scale toward death, these cases were more likely to favor the plaintiff, and that’s correlative because patients tend to sue more when there’s a more significant complication, such as when there’s a death of a family member.” In cases involving death, 41% resulted in a verdict for the defendant surgery, 35% in a plaintiff verdict, and 23% in a settlement, whereas in cases involving insignificant temporary injury, 90% were ruled for the defendant surgeon, with none going to settlement.

The research also found another mitigating factor in malpractice lawsuits: the number of lawyers in a state. “We noted that specific states such as California, New York, Texas, and Florida were bound to have a higher number of lawsuits per population, and this was correlative with the number of lawyers practicing within that state,” Dr. Choudhry said. New York led the nation with 46 cases, followed by California with 42, Florida with 27 ,and Texas and Pennsylvania with 17 each.

Session moderator Heather Logghe, MD, of Jefferson Medical College, Philadelphia, questioned Dr. Choudhry on how surgeons can improve their informed consent process to protect against potential litigation.

“The most important thing we can do is document and explain the risk, benefits, and alternatives, and use an inclusive informed consent that will allow the patients to have a complete understanding of the procedure that is to be done and the complications that may result,” he said. This process needs to be tailored to individual hospital systems. “This may allow for better documentation, and it may not decrease the number of malpractice lawsuits but it may decrease the outcomes not in favor of physicians.”

The researchers also identified trends in the broader context of medical malpractice. Citing data from the National Practitioner Data Bank, Dr. Choudhry noted that malpractice payouts have been increasing since 2012 after a steady 9-year decline. In addition, general surgeons are at greater risk than all but two other types of specialists – neurosurgeons and thoracic-cardiovascular surgeons (N Engl J Med. 2011;365:629-36). “Fifteen percent of general surgeons will be facing malpractice claims annually across the United States. Physicians in high-legal-risk specialties, such as the surgical specialties, are 99% likely to face a claim over their careers.”

The next step for the researchers is to use malpractice insurance data to study medical liability on a larger scale and identify methods physicians can use to improve patient care and mitigate risk, Dr. Choudhry said.

Dr. Choudhry had no relevant financial relationships to disclose.

SOURCE: Choudhry A et al. SAGES 2109, Abstract S104.

BALTIMORE – An analysis of malpractice claims paid for hernia operations found that breach of informed consent was a reason for more than 15% of cases, and intraoperative damage to surrounding structures was the leading reason for such lawsuits, according to research presented at the annual meeting of the American Gastrointestinal and Endoscopic Surgeons.

The purpose of the study was to identify leading causes of litigation for hernia repair as the volume of hernia repairs in the United States increases with a trend toward minimally invasive and robotic surgery, said Asad Choudhry, MBBS, of the State University of New York, Syracuse.“In terms of the hernia itself, inguinal hernia operations were found to be the most common hernia procedure that led to pursuance of litigation, and laparoscopy was the most common type of procedure rather than open in terms of patients pursuing litigation.”

The study sampled the WestLawNext legal database for medical malpractice abdominal wall procedures, and evaluated 430 cases of abdominopelvic wall hernias that fit the study criteria – inguinal, femoral, ventral, umbilical, parastomal, spigelian, obturator, epigastric, incisional, paraumbilical, and pantaloon hernias, Dr. Choudhry said. Hiatal, diaphragmatic, sciatic, gluteal, and lumbar hernias were excluded. He noted that abdominal wall hernia have been reported to be the second most common abdominopelvic procedure performed in the United States after C-section, with more than 1 million procedures done annually (Surg Clin N Am. 2003;83:1045-51).

While most malpractice hernia cases were decided in favor of the defendant surgeon, settlements and cases with a jury verdict in favor of the plaintiff were costly. Dr. Choudhry cited awards of $6.8 million, $12 million, and $3 million in specific hernia cases.

“In terms of the type of repair itself, elective operations were more common, and mesh was used in approximately 27% of cases in which there was a defendant verdict and 18% of cases in which there was a plaintiff verdict,” he said.

For inguinal hernia, 61% of cases were decided for the defendant surgeon. With regards to type of procedure, laparoscopic surgery resulted in defendant verdicts in 31% of cases versus 23% for the plaintiff, and open operations resulted in a ruling favoring the defendant surgeon in 26% versus 15% for the plaintiff. (The remainder were lap-converted-to-open operations, with 2% for the defendant and 1% for the plaintiff.)

Mortality was a key determinant of verdict, Dr. Choudhry added. “Cases with no mortality were more likely of having an outcome in favor of the defendant surgeon.”

The researchers also looked at litigation arising from the phase of care – before, during, or after surgery. “In the preoperative time setting, delay or failure to diagnose or manage a hernia was the leading cause of malpractice,” Dr. Choudhry said. “These cases were mainly emergent patients presenting to the emergency department where the intervention was not performed in a timely manner and leading to some form of complication.”

In the intraoperative period, damage to surrounding structures was by far the leading cause of malpractice, but incomplete procedure or improper surgical technique and use of improper surgical materials also were significant causes in this period. Postoperatively, failure to timely detect and/or repair a surgical complication was the most common cause of litigation. “However, it’s important to note that persistent pain, such as nerve entrapment syndrome, is also noted in the postoperative time period as a cause of litigation,” he added.

The study also evaluated injury severity in the context of a claim outcome. “Most claims where there was an insignificant or minor injury were decided for the defendant surgeon,” Dr. Choudhry said. “But as you start moving higher on the injury scale toward death, these cases were more likely to favor the plaintiff, and that’s correlative because patients tend to sue more when there’s a more significant complication, such as when there’s a death of a family member.” In cases involving death, 41% resulted in a verdict for the defendant surgery, 35% in a plaintiff verdict, and 23% in a settlement, whereas in cases involving insignificant temporary injury, 90% were ruled for the defendant surgeon, with none going to settlement.

The research also found another mitigating factor in malpractice lawsuits: the number of lawyers in a state. “We noted that specific states such as California, New York, Texas, and Florida were bound to have a higher number of lawsuits per population, and this was correlative with the number of lawyers practicing within that state,” Dr. Choudhry said. New York led the nation with 46 cases, followed by California with 42, Florida with 27 ,and Texas and Pennsylvania with 17 each.

Session moderator Heather Logghe, MD, of Jefferson Medical College, Philadelphia, questioned Dr. Choudhry on how surgeons can improve their informed consent process to protect against potential litigation.

“The most important thing we can do is document and explain the risk, benefits, and alternatives, and use an inclusive informed consent that will allow the patients to have a complete understanding of the procedure that is to be done and the complications that may result,” he said. This process needs to be tailored to individual hospital systems. “This may allow for better documentation, and it may not decrease the number of malpractice lawsuits but it may decrease the outcomes not in favor of physicians.”

The researchers also identified trends in the broader context of medical malpractice. Citing data from the National Practitioner Data Bank, Dr. Choudhry noted that malpractice payouts have been increasing since 2012 after a steady 9-year decline. In addition, general surgeons are at greater risk than all but two other types of specialists – neurosurgeons and thoracic-cardiovascular surgeons (N Engl J Med. 2011;365:629-36). “Fifteen percent of general surgeons will be facing malpractice claims annually across the United States. Physicians in high-legal-risk specialties, such as the surgical specialties, are 99% likely to face a claim over their careers.”

The next step for the researchers is to use malpractice insurance data to study medical liability on a larger scale and identify methods physicians can use to improve patient care and mitigate risk, Dr. Choudhry said.

Dr. Choudhry had no relevant financial relationships to disclose.

SOURCE: Choudhry A et al. SAGES 2109, Abstract S104.

Patients with intrahepatic cholestasis of pregnancy (ICP) were nearly six times more likely to have a diagnosis of nonalcoholic fatty liver disease (NAFLD) than were controls, results from a retrospective, single-center study demonstrated.

“If this connection is confirmed with future studies, intrahepatic cholestasis of pregnancy may prove a novel model through which to investigate bile acid metabolism in patients with fatty liver disease,” one of the study authors, Tatyana Kushner, MD, MSCE, said during a media briefing in advance of the annual Digestive Disease Week. “This could have implications for future management of fatty liver disease. Additionally, these findings suggest that ICP patients should be seen by a liver specialist because they may go on to develop chronic liver disease or may already have already existing underlying liver disease.”

ICP is characterized by a build-up of bile acids during pregnancy and is associated with an increased risk of negative fetal outcomes and fetal death if left untreated, said Dr. Kushner, of the division of liver diseases at the Icahn School of Medicine at Mount Sinai, New York. The most notable symptom during pregnancy is severe pruritus. In what is believed to be the first study of its kind, Dr. Kushner and colleagues set out to evaluate the association between ICP and NAFLD and associated metabolic risk factors, including obesity, dyslipidemia, hypertension, and diabetes. Between January and December of 2017, they drew from the electronic medical records of a New York City health system to identify 149 pregnancies complicated by ICP and compared them to a control group of 200 pregnancies without an ICP diagnosis. The researchers used Pearson’s chi-square or Fisher’s exact test and Wilcoxon rank-sum tests to evaluate association of ICP with categorical variables and continuous variables, respectively, and unadjusted odds ratios to compare the ICP and control groups for clinically significant outcomes.

The median age of the study population was 30 years, their mean body mass index was 27.5 kg/m², and there was a higher proportion of Hispanic women in the ICP group, compared with the control group (75% vs. 62%, respectively). Dr. Kushner and colleagues found that Hispanic women were nearly twice as likely to be diagnosed with ICP than non-Hispanic women (OR, 1.90; 95% confidence interval, 1.87-3.03). However, patients in both the ICP and control groups were similar for median age (OR, 1.02; 95% CI, 0.99-1.06), nulliparity (OR, 0.79; 95% CI, 0.48-1.30), and prevalence of hepatitis C (OR, 1.35; 95% CI, 0.08-21.67). The two groups were also similar for certain metabolic risk factors, including prevalence of obesity (OR, 1.01; 95% CI, 0.62-1.61), hypertension (OR, 0.69; 95% CI, 0.31-1.52), hemoglobin A_1c greater than 5.5% (OR, 0.80; 95% CI, 0.34-1.9), and total cholesterol above 200 mg/dL (OR, 4.15; 95% CI, 0.83-20.84). Median bile acid levels were 30.6 micromoles (interquartile range, 11.6, 32.7) in the ICP group.

Compared with patients in the control group, those in the ICP group had higher median levels of alanine aminotransferase (ALT) (32 vs. 16 U/L; P less than .0001), alkaline phosphatase (181 vs. 128 U/L; P less than .0001), and total bilirubin (0.5 vs. 0.35 mg/dL; P less than .0001). ICP patients were also more likely than their counterparts to have ALT levels above 50 U/L (two times the upper limit of normal; OR, 3.22; 95% CI, 1.48-7.03), a history of biliary disease (OR, 3.29; 95% CI, 1.39-7.80), and to have evidence of steatosis on liver imaging (OR, 4.69; 95% CI, 1.68-13.12). When the researchers evaluated a diagnosis of NAFLD based on ICD-10 codes or evidence of steatosis on liver imaging, ICP patients were significantly more likely to have a diagnosis of NAFLD than controls (OR, 5.7; 95% CI, 2.08-15.65).

“We recommend additional research to look at differences in NAFLD progression in women who had NAFLD and were later diagnosed with ICP, compared to women with NAFLD who did not go on to develop ICP, because that may be a reflection of the role that bile acid metabolism plays in these particular patients,” Dr. Kushner said.

Digestive Disease Week is jointly sponsored by the American Association for the Study of Liver Diseases (AASLD), the American Gastroenterological Association (AGA) Institute, the American Society for Gastrointestinal Endoscopy (ASGE), and the Society for Surgery of the Alimentary Tract (SSAT).  

The study’s primary author was Erica Monrose, MD. The researchers reported having no financial disclosures.

[email protected]

SOURCE: Monrose E et al. DDW 2019, Abstract Sa1562.

Patients with intrahepatic cholestasis of pregnancy (ICP) were nearly six times more likely to have a diagnosis of nonalcoholic fatty liver disease (NAFLD) than were controls, results from a retrospective, single-center study demonstrated.

“If this connection is confirmed with future studies, intrahepatic cholestasis of pregnancy may prove a novel model through which to investigate bile acid metabolism in patients with fatty liver disease,” one of the study authors, Tatyana Kushner, MD, MSCE, said during a media briefing in advance of the annual Digestive Disease Week. “This could have implications for future management of fatty liver disease. Additionally, these findings suggest that ICP patients should be seen by a liver specialist because they may go on to develop chronic liver disease or may already have already existing underlying liver disease.”

ICP is characterized by a build-up of bile acids during pregnancy and is associated with an increased risk of negative fetal outcomes and fetal death if left untreated, said Dr. Kushner, of the division of liver diseases at the Icahn School of Medicine at Mount Sinai, New York. The most notable symptom during pregnancy is severe pruritus. In what is believed to be the first study of its kind, Dr. Kushner and colleagues set out to evaluate the association between ICP and NAFLD and associated metabolic risk factors, including obesity, dyslipidemia, hypertension, and diabetes. Between January and December of 2017, they drew from the electronic medical records of a New York City health system to identify 149 pregnancies complicated by ICP and compared them to a control group of 200 pregnancies without an ICP diagnosis. The researchers used Pearson’s chi-square or Fisher’s exact test and Wilcoxon rank-sum tests to evaluate association of ICP with categorical variables and continuous variables, respectively, and unadjusted odds ratios to compare the ICP and control groups for clinically significant outcomes.

The median age of the study population was 30 years, their mean body mass index was 27.5 kg/m², and there was a higher proportion of Hispanic women in the ICP group, compared with the control group (75% vs. 62%, respectively). Dr. Kushner and colleagues found that Hispanic women were nearly twice as likely to be diagnosed with ICP than non-Hispanic women (OR, 1.90; 95% confidence interval, 1.87-3.03). However, patients in both the ICP and control groups were similar for median age (OR, 1.02; 95% CI, 0.99-1.06), nulliparity (OR, 0.79; 95% CI, 0.48-1.30), and prevalence of hepatitis C (OR, 1.35; 95% CI, 0.08-21.67). The two groups were also similar for certain metabolic risk factors, including prevalence of obesity (OR, 1.01; 95% CI, 0.62-1.61), hypertension (OR, 0.69; 95% CI, 0.31-1.52), hemoglobin A_1c greater than 5.5% (OR, 0.80; 95% CI, 0.34-1.9), and total cholesterol above 200 mg/dL (OR, 4.15; 95% CI, 0.83-20.84). Median bile acid levels were 30.6 micromoles (interquartile range, 11.6, 32.7) in the ICP group.

Compared with patients in the control group, those in the ICP group had higher median levels of alanine aminotransferase (ALT) (32 vs. 16 U/L; P less than .0001), alkaline phosphatase (181 vs. 128 U/L; P less than .0001), and total bilirubin (0.5 vs. 0.35 mg/dL; P less than .0001). ICP patients were also more likely than their counterparts to have ALT levels above 50 U/L (two times the upper limit of normal; OR, 3.22; 95% CI, 1.48-7.03), a history of biliary disease (OR, 3.29; 95% CI, 1.39-7.80), and to have evidence of steatosis on liver imaging (OR, 4.69; 95% CI, 1.68-13.12). When the researchers evaluated a diagnosis of NAFLD based on ICD-10 codes or evidence of steatosis on liver imaging, ICP patients were significantly more likely to have a diagnosis of NAFLD than controls (OR, 5.7; 95% CI, 2.08-15.65).

“We recommend additional research to look at differences in NAFLD progression in women who had NAFLD and were later diagnosed with ICP, compared to women with NAFLD who did not go on to develop ICP, because that may be a reflection of the role that bile acid metabolism plays in these particular patients,” Dr. Kushner said.

Digestive Disease Week is jointly sponsored by the American Association for the Study of Liver Diseases (AASLD), the American Gastroenterological Association (AGA) Institute, the American Society for Gastrointestinal Endoscopy (ASGE), and the Society for Surgery of the Alimentary Tract (SSAT).  

The study’s primary author was Erica Monrose, MD. The researchers reported having no financial disclosures.

[email protected]

SOURCE: Monrose E et al. DDW 2019, Abstract Sa1562.

Patients with intrahepatic cholestasis of pregnancy (ICP) were nearly six times more likely to have a diagnosis of nonalcoholic fatty liver disease (NAFLD) than were controls, results from a retrospective, single-center study demonstrated.

“If this connection is confirmed with future studies, intrahepatic cholestasis of pregnancy may prove a novel model through which to investigate bile acid metabolism in patients with fatty liver disease,” one of the study authors, Tatyana Kushner, MD, MSCE, said during a media briefing in advance of the annual Digestive Disease Week. “This could have implications for future management of fatty liver disease. Additionally, these findings suggest that ICP patients should be seen by a liver specialist because they may go on to develop chronic liver disease or may already have already existing underlying liver disease.”

ICP is characterized by a build-up of bile acids during pregnancy and is associated with an increased risk of negative fetal outcomes and fetal death if left untreated, said Dr. Kushner, of the division of liver diseases at the Icahn School of Medicine at Mount Sinai, New York. The most notable symptom during pregnancy is severe pruritus. In what is believed to be the first study of its kind, Dr. Kushner and colleagues set out to evaluate the association between ICP and NAFLD and associated metabolic risk factors, including obesity, dyslipidemia, hypertension, and diabetes. Between January and December of 2017, they drew from the electronic medical records of a New York City health system to identify 149 pregnancies complicated by ICP and compared them to a control group of 200 pregnancies without an ICP diagnosis. The researchers used Pearson’s chi-square or Fisher’s exact test and Wilcoxon rank-sum tests to evaluate association of ICP with categorical variables and continuous variables, respectively, and unadjusted odds ratios to compare the ICP and control groups for clinically significant outcomes.

The median age of the study population was 30 years, their mean body mass index was 27.5 kg/m², and there was a higher proportion of Hispanic women in the ICP group, compared with the control group (75% vs. 62%, respectively). Dr. Kushner and colleagues found that Hispanic women were nearly twice as likely to be diagnosed with ICP than non-Hispanic women (OR, 1.90; 95% confidence interval, 1.87-3.03). However, patients in both the ICP and control groups were similar for median age (OR, 1.02; 95% CI, 0.99-1.06), nulliparity (OR, 0.79; 95% CI, 0.48-1.30), and prevalence of hepatitis C (OR, 1.35; 95% CI, 0.08-21.67). The two groups were also similar for certain metabolic risk factors, including prevalence of obesity (OR, 1.01; 95% CI, 0.62-1.61), hypertension (OR, 0.69; 95% CI, 0.31-1.52), hemoglobin A_1c greater than 5.5% (OR, 0.80; 95% CI, 0.34-1.9), and total cholesterol above 200 mg/dL (OR, 4.15; 95% CI, 0.83-20.84). Median bile acid levels were 30.6 micromoles (interquartile range, 11.6, 32.7) in the ICP group.

Compared with patients in the control group, those in the ICP group had higher median levels of alanine aminotransferase (ALT) (32 vs. 16 U/L; P less than .0001), alkaline phosphatase (181 vs. 128 U/L; P less than .0001), and total bilirubin (0.5 vs. 0.35 mg/dL; P less than .0001). ICP patients were also more likely than their counterparts to have ALT levels above 50 U/L (two times the upper limit of normal; OR, 3.22; 95% CI, 1.48-7.03), a history of biliary disease (OR, 3.29; 95% CI, 1.39-7.80), and to have evidence of steatosis on liver imaging (OR, 4.69; 95% CI, 1.68-13.12). When the researchers evaluated a diagnosis of NAFLD based on ICD-10 codes or evidence of steatosis on liver imaging, ICP patients were significantly more likely to have a diagnosis of NAFLD than controls (OR, 5.7; 95% CI, 2.08-15.65).

“We recommend additional research to look at differences in NAFLD progression in women who had NAFLD and were later diagnosed with ICP, compared to women with NAFLD who did not go on to develop ICP, because that may be a reflection of the role that bile acid metabolism plays in these particular patients,” Dr. Kushner said.

Digestive Disease Week is jointly sponsored by the American Association for the Study of Liver Diseases (AASLD), the American Gastroenterological Association (AGA) Institute, the American Society for Gastrointestinal Endoscopy (ASGE), and the Society for Surgery of the Alimentary Tract (SSAT).  

The study’s primary author was Erica Monrose, MD. The researchers reported having no financial disclosures.

[email protected]

SOURCE: Monrose E et al. DDW 2019, Abstract Sa1562.

Research suggests that nearly 40% of children and adolescents with autism spectrum disorder (ASD) may have a co-occurring anxiety disorder.¹ As ASD by definition involves deficits in communication and interaction, as well as restricted, repetitive patterns of behavior, interests, or activities, diagnosis and treatment of anxiety disorders in this population can present a significant challenge.

martinedoucet/E+/Getty Images

Clinical vignette

Sean is a 9-year-old boy in the fourth grade diagnosed with ASD. He is in a regular education classroom setting. Until this year, his grades have been above average. This year his mother has been getting calls from the teachers reporting that he is disruptive in class, and is having difficulty paying attention unless the subject relates to a specific interest of his. At home, his mother has been struggling to get him to do chores and homework, and even sitting at the dinner table is now a battle. He is significantly more irritable than usual. While he always preferred routines and familiar activities, deviations from them now trigger strong reactions and sometimes tantrums. He has started to insist on staying up late, and refuses to go to bed without his mother present. Notably his mother reports that she and Sean’s father recently separated, and that she believes he is very upset by this, although he refuses to talk about it.

Discussion

This case highlights the diagnostic complexity with which children with ASD may present. With the overlap between some of the core symptoms of ASD and anxiety, as well as the potential for other co-occurring disorders, a number of factors need to be explored before arriving at a treatment plan.

In evaluating behavior changes in children with ASD, I find it most helpful to start by looking for any medical or environmental factors. Medical problems such as illness or gastrointestinal difficulties may contribute to behavioral challenges and anxiety. Also, be sure to inquire if there are any precipitating events or change in the environment which might correlate with the change in behavior. In this case, we do have a situation – namely Sean’s parents separating – that may be contributing. While addressing Sean’s thoughts and feelings about this remains challenging, awareness of this factor certainly is important.

Understanding the educational setting and supports of a child with ASD is of significant importance. Academic challenges may result from learning or language difficulties, which can result in significant stress. While the vignette mentions that Sean’s grades had previously been above average, it is possible that increased complexity of material is contributing to his school struggles.

Next, it is worth looking at the question of whether Sean meets criteria for ADHD, which is estimated to occur in 30%-61% of people with ASD. In the case vignette, the mention of disruptions and attentional difficulties in the classroom warrant further investigation.

Finally, the question of whether insistence on routine, strong reactions to unfamiliar circumstances, disruptive behavior, and irritability meet criteria for an anxiety disorder is a complex one. Children with ASD may have difficulty communicating that they are anxious, making the behavioral observations of those around them especially important. An advantage pediatric primary care providers have in this circumstance is longitudinal experience with the child and family, which can help confirm whether the problem perceived as anxiety is a manifestation of core autism symptoms, or newer-onset phenomena. Assessing the severity and settings of the behavior also is necessary to guide treatment decisions. In the vignette, Sean’s irritability, acting out, and bedtime difficulties all are of relatively new onset, and occurring across multiple settings with significant functional consequences, making a diagnosis of an anxiety disorder the likely explanation.

As for treatment, cognitive behavioral therapy has been shown to be effective for anxiety in children with high functioning ASD.² If a clinician with experience with this population is available, that certainly is preferred. If medication is being considered, there are no randomized controlled trials that have demonstrated efficacy of medication for anxiety specifically in children with co-occurring ASD. Treatment recommendations are taken from studies in typically developing children,³ where the SSRIs fluoxetine and sertraline have demonstrated efficacy in treatment of anxiety. When opting for pharmacotherapy in children with ASD, starting low, going slow, and carefully monitoring for side effects is recommended. Regardless of the method of treatment, a clear definition of the target symptoms ahead of time is critical for monitoring response and evaluating treatment effect.
 

Dr. Hoffnung is a pediatric psychiatrist at the University of Vermont Children’s Hospital and an assistant professor of psychiatry at the Robert Larner, M.D. College of Medicine at the University of Vermont, both in Burlington. He said he had no relevant financial disclosures. Email him at [email protected].

References

1. Clin Child Fam Psychol Rev. 2011 Sep;14(3):302-17.

2. Child Psychiatry Hum Dev. 2015 Aug;46(4):533-47.

3. Pediatrics. 2016 Feb;137 Suppl 2:S115-23.

Research suggests that nearly 40% of children and adolescents with autism spectrum disorder (ASD) may have a co-occurring anxiety disorder.¹ As ASD by definition involves deficits in communication and interaction, as well as restricted, repetitive patterns of behavior, interests, or activities, diagnosis and treatment of anxiety disorders in this population can present a significant challenge.

martinedoucet/E+/Getty Images

Clinical vignette

Sean is a 9-year-old boy in the fourth grade diagnosed with ASD. He is in a regular education classroom setting. Until this year, his grades have been above average. This year his mother has been getting calls from the teachers reporting that he is disruptive in class, and is having difficulty paying attention unless the subject relates to a specific interest of his. At home, his mother has been struggling to get him to do chores and homework, and even sitting at the dinner table is now a battle. He is significantly more irritable than usual. While he always preferred routines and familiar activities, deviations from them now trigger strong reactions and sometimes tantrums. He has started to insist on staying up late, and refuses to go to bed without his mother present. Notably his mother reports that she and Sean’s father recently separated, and that she believes he is very upset by this, although he refuses to talk about it.

Discussion

This case highlights the diagnostic complexity with which children with ASD may present. With the overlap between some of the core symptoms of ASD and anxiety, as well as the potential for other co-occurring disorders, a number of factors need to be explored before arriving at a treatment plan.

In evaluating behavior changes in children with ASD, I find it most helpful to start by looking for any medical or environmental factors. Medical problems such as illness or gastrointestinal difficulties may contribute to behavioral challenges and anxiety. Also, be sure to inquire if there are any precipitating events or change in the environment which might correlate with the change in behavior. In this case, we do have a situation – namely Sean’s parents separating – that may be contributing. While addressing Sean’s thoughts and feelings about this remains challenging, awareness of this factor certainly is important.

Understanding the educational setting and supports of a child with ASD is of significant importance. Academic challenges may result from learning or language difficulties, which can result in significant stress. While the vignette mentions that Sean’s grades had previously been above average, it is possible that increased complexity of material is contributing to his school struggles.

Next, it is worth looking at the question of whether Sean meets criteria for ADHD, which is estimated to occur in 30%-61% of people with ASD. In the case vignette, the mention of disruptions and attentional difficulties in the classroom warrant further investigation.

Finally, the question of whether insistence on routine, strong reactions to unfamiliar circumstances, disruptive behavior, and irritability meet criteria for an anxiety disorder is a complex one. Children with ASD may have difficulty communicating that they are anxious, making the behavioral observations of those around them especially important. An advantage pediatric primary care providers have in this circumstance is longitudinal experience with the child and family, which can help confirm whether the problem perceived as anxiety is a manifestation of core autism symptoms, or newer-onset phenomena. Assessing the severity and settings of the behavior also is necessary to guide treatment decisions. In the vignette, Sean’s irritability, acting out, and bedtime difficulties all are of relatively new onset, and occurring across multiple settings with significant functional consequences, making a diagnosis of an anxiety disorder the likely explanation.

As for treatment, cognitive behavioral therapy has been shown to be effective for anxiety in children with high functioning ASD.² If a clinician with experience with this population is available, that certainly is preferred. If medication is being considered, there are no randomized controlled trials that have demonstrated efficacy of medication for anxiety specifically in children with co-occurring ASD. Treatment recommendations are taken from studies in typically developing children,³ where the SSRIs fluoxetine and sertraline have demonstrated efficacy in treatment of anxiety. When opting for pharmacotherapy in children with ASD, starting low, going slow, and carefully monitoring for side effects is recommended. Regardless of the method of treatment, a clear definition of the target symptoms ahead of time is critical for monitoring response and evaluating treatment effect.
 

Dr. Hoffnung is a pediatric psychiatrist at the University of Vermont Children’s Hospital and an assistant professor of psychiatry at the Robert Larner, M.D. College of Medicine at the University of Vermont, both in Burlington. He said he had no relevant financial disclosures. Email him at [email protected].

References

1. Clin Child Fam Psychol Rev. 2011 Sep;14(3):302-17.

2. Child Psychiatry Hum Dev. 2015 Aug;46(4):533-47.

3. Pediatrics. 2016 Feb;137 Suppl 2:S115-23.

Research suggests that nearly 40% of children and adolescents with autism spectrum disorder (ASD) may have a co-occurring anxiety disorder.¹ As ASD by definition involves deficits in communication and interaction, as well as restricted, repetitive patterns of behavior, interests, or activities, diagnosis and treatment of anxiety disorders in this population can present a significant challenge.

martinedoucet/E+/Getty Images

Clinical vignette

Sean is a 9-year-old boy in the fourth grade diagnosed with ASD. He is in a regular education classroom setting. Until this year, his grades have been above average. This year his mother has been getting calls from the teachers reporting that he is disruptive in class, and is having difficulty paying attention unless the subject relates to a specific interest of his. At home, his mother has been struggling to get him to do chores and homework, and even sitting at the dinner table is now a battle. He is significantly more irritable than usual. While he always preferred routines and familiar activities, deviations from them now trigger strong reactions and sometimes tantrums. He has started to insist on staying up late, and refuses to go to bed without his mother present. Notably his mother reports that she and Sean’s father recently separated, and that she believes he is very upset by this, although he refuses to talk about it.

Discussion

This case highlights the diagnostic complexity with which children with ASD may present. With the overlap between some of the core symptoms of ASD and anxiety, as well as the potential for other co-occurring disorders, a number of factors need to be explored before arriving at a treatment plan.

In evaluating behavior changes in children with ASD, I find it most helpful to start by looking for any medical or environmental factors. Medical problems such as illness or gastrointestinal difficulties may contribute to behavioral challenges and anxiety. Also, be sure to inquire if there are any precipitating events or change in the environment which might correlate with the change in behavior. In this case, we do have a situation – namely Sean’s parents separating – that may be contributing. While addressing Sean’s thoughts and feelings about this remains challenging, awareness of this factor certainly is important.

Understanding the educational setting and supports of a child with ASD is of significant importance. Academic challenges may result from learning or language difficulties, which can result in significant stress. While the vignette mentions that Sean’s grades had previously been above average, it is possible that increased complexity of material is contributing to his school struggles.

Next, it is worth looking at the question of whether Sean meets criteria for ADHD, which is estimated to occur in 30%-61% of people with ASD. In the case vignette, the mention of disruptions and attentional difficulties in the classroom warrant further investigation.

Finally, the question of whether insistence on routine, strong reactions to unfamiliar circumstances, disruptive behavior, and irritability meet criteria for an anxiety disorder is a complex one. Children with ASD may have difficulty communicating that they are anxious, making the behavioral observations of those around them especially important. An advantage pediatric primary care providers have in this circumstance is longitudinal experience with the child and family, which can help confirm whether the problem perceived as anxiety is a manifestation of core autism symptoms, or newer-onset phenomena. Assessing the severity and settings of the behavior also is necessary to guide treatment decisions. In the vignette, Sean’s irritability, acting out, and bedtime difficulties all are of relatively new onset, and occurring across multiple settings with significant functional consequences, making a diagnosis of an anxiety disorder the likely explanation.

As for treatment, cognitive behavioral therapy has been shown to be effective for anxiety in children with high functioning ASD.² If a clinician with experience with this population is available, that certainly is preferred. If medication is being considered, there are no randomized controlled trials that have demonstrated efficacy of medication for anxiety specifically in children with co-occurring ASD. Treatment recommendations are taken from studies in typically developing children,³ where the SSRIs fluoxetine and sertraline have demonstrated efficacy in treatment of anxiety. When opting for pharmacotherapy in children with ASD, starting low, going slow, and carefully monitoring for side effects is recommended. Regardless of the method of treatment, a clear definition of the target symptoms ahead of time is critical for monitoring response and evaluating treatment effect.
 

Dr. Hoffnung is a pediatric psychiatrist at the University of Vermont Children’s Hospital and an assistant professor of psychiatry at the Robert Larner, M.D. College of Medicine at the University of Vermont, both in Burlington. He said he had no relevant financial disclosures. Email him at [email protected].

References

1. Clin Child Fam Psychol Rev. 2011 Sep;14(3):302-17.

2. Child Psychiatry Hum Dev. 2015 Aug;46(4):533-47.

3. Pediatrics. 2016 Feb;137 Suppl 2:S115-23.

Session presenters

Surekha Bhamidipati, MD, FACP; Preetham Talari, MD, FACP, SFHM; Mark V. Williams, MD, FACP, MHM
 

Session title

Interprofessional rounds: What’s the right way?
 

Session summary

Interprofessional or multidisciplinary rounds involve all members of the care delivery team, including physicians, nurses, case managers, social workers, pharmacists, nurse facilitators, and of course, patients. The primary goal for these rounds is patient-centered care, and to improve communication among the health care team members, as well as with patients and their families.

At HM19, Dr. Preetham Talari and Dr. Mark Williams of the University of Kentucky, and Dr. Surekha Bhamidipati of Christiana Care Health System in Newark, Del., discussed their system-based efforts to try to implement interprofessional rounds, and the role of these rounds in improving patient outcome measures.

The presenters noted that the purpose of these rounds is effective communication and efficient patient care. As shown by multiple studies, there is significant impact in team member satisfaction, decrease in length of stay,¹ reduction in adverse events² and improvement in patient experience.³ They emphasized the importance of implementing these rounds at the bedside, so that patients and families can be engaged in the patient’s care, thereby improving closed communication among the team and the patient. These rounds always offer an opportunity for the patient to ask questions of multiple health care team members as they are gathered together at the same time.

The University of Kentucky named these rounds the “Interprofessional Teamwork Innovation Model (ITIM),” to promote communication and patient-centered coordinated care. Their model showed a significant reduction in readmission rates, and no increase in costs despite adding pharmacy and case managers to the rounds.

Dr. Bhamidipati described how Christiana Care Health System designed multidisciplinary rounds based on the application of Team STEPPS 2.0, a teamwork system developed by the Department of Defense and the Agency for Healthcare Research and Quality to improve the institutional collaboration and communication relating to patient safety.

The Christiana Care model is based on a few principles of team structure, communication, leadership, situation monitoring, and mutual support. The interprofessional team was trained and observed, and a short video recording was made. This video was used as an educational tool in coaching the rest of the team. Dr. Bhamidipati described the importance of interprofessional leaders as coaches to train other team members, and highlighted the engagement of unit leaders in successfully implementing these rounds. The Christiana Care team used its informational technology system to collect real-time data, which was then used for team review.

In summary, the presenters from both the University of Kentucky and Christiana Care highlighted the importance of interprofessional rounds, as well as the need for continued measurement of process and outcome metrics.
 

Dr. Jonnalagadda is a physician advisor, and Dr. Medarametla is medical director, Hospital Medicine, at Baystate Medical Center, Springfield, Mass.

References

1. Yoo JW et al. Effects of an internal medicine floor interdisciplinary team on hospital and clinical outcomes of seniors with acute medical illness. Geriatr Gerontol Int. 2013 Oct;13(4):942-8. doi: 10.1111/ggi.12035. Epub 2013 Feb 26.

2. O’Leary KJ et al. Structured interdisciplinary rounds in a medical teaching unit: improving patient safety. Arch Intern Med. 2011 Apr 11;171(7):678-84. doi: 10.1001/archinternmed.2011.128.

3. Ratelle JT et al. Implementing bedside rounds to improve patient-centred outcomes: a systematic review. BMJ Qual Saf. 2019;28:317-326.

Session presenters

Surekha Bhamidipati, MD, FACP; Preetham Talari, MD, FACP, SFHM; Mark V. Williams, MD, FACP, MHM
 

Session title

Interprofessional rounds: What’s the right way?
 

Session summary

Interprofessional or multidisciplinary rounds involve all members of the care delivery team, including physicians, nurses, case managers, social workers, pharmacists, nurse facilitators, and of course, patients. The primary goal for these rounds is patient-centered care, and to improve communication among the health care team members, as well as with patients and their families.

At HM19, Dr. Preetham Talari and Dr. Mark Williams of the University of Kentucky, and Dr. Surekha Bhamidipati of Christiana Care Health System in Newark, Del., discussed their system-based efforts to try to implement interprofessional rounds, and the role of these rounds in improving patient outcome measures.

The presenters noted that the purpose of these rounds is effective communication and efficient patient care. As shown by multiple studies, there is significant impact in team member satisfaction, decrease in length of stay,¹ reduction in adverse events² and improvement in patient experience.³ They emphasized the importance of implementing these rounds at the bedside, so that patients and families can be engaged in the patient’s care, thereby improving closed communication among the team and the patient. These rounds always offer an opportunity for the patient to ask questions of multiple health care team members as they are gathered together at the same time.

The University of Kentucky named these rounds the “Interprofessional Teamwork Innovation Model (ITIM),” to promote communication and patient-centered coordinated care. Their model showed a significant reduction in readmission rates, and no increase in costs despite adding pharmacy and case managers to the rounds.

Dr. Bhamidipati described how Christiana Care Health System designed multidisciplinary rounds based on the application of Team STEPPS 2.0, a teamwork system developed by the Department of Defense and the Agency for Healthcare Research and Quality to improve the institutional collaboration and communication relating to patient safety.

The Christiana Care model is based on a few principles of team structure, communication, leadership, situation monitoring, and mutual support. The interprofessional team was trained and observed, and a short video recording was made. This video was used as an educational tool in coaching the rest of the team. Dr. Bhamidipati described the importance of interprofessional leaders as coaches to train other team members, and highlighted the engagement of unit leaders in successfully implementing these rounds. The Christiana Care team used its informational technology system to collect real-time data, which was then used for team review.

In summary, the presenters from both the University of Kentucky and Christiana Care highlighted the importance of interprofessional rounds, as well as the need for continued measurement of process and outcome metrics.
 

Dr. Jonnalagadda is a physician advisor, and Dr. Medarametla is medical director, Hospital Medicine, at Baystate Medical Center, Springfield, Mass.

References

1. Yoo JW et al. Effects of an internal medicine floor interdisciplinary team on hospital and clinical outcomes of seniors with acute medical illness. Geriatr Gerontol Int. 2013 Oct;13(4):942-8. doi: 10.1111/ggi.12035. Epub 2013 Feb 26.

2. O’Leary KJ et al. Structured interdisciplinary rounds in a medical teaching unit: improving patient safety. Arch Intern Med. 2011 Apr 11;171(7):678-84. doi: 10.1001/archinternmed.2011.128.

3. Ratelle JT et al. Implementing bedside rounds to improve patient-centred outcomes: a systematic review. BMJ Qual Saf. 2019;28:317-326.

Session presenters

Surekha Bhamidipati, MD, FACP; Preetham Talari, MD, FACP, SFHM; Mark V. Williams, MD, FACP, MHM
 

Session title

Interprofessional rounds: What’s the right way?
 

Session summary

Interprofessional or multidisciplinary rounds involve all members of the care delivery team, including physicians, nurses, case managers, social workers, pharmacists, nurse facilitators, and of course, patients. The primary goal for these rounds is patient-centered care, and to improve communication among the health care team members, as well as with patients and their families.

At HM19, Dr. Preetham Talari and Dr. Mark Williams of the University of Kentucky, and Dr. Surekha Bhamidipati of Christiana Care Health System in Newark, Del., discussed their system-based efforts to try to implement interprofessional rounds, and the role of these rounds in improving patient outcome measures.

The presenters noted that the purpose of these rounds is effective communication and efficient patient care. As shown by multiple studies, there is significant impact in team member satisfaction, decrease in length of stay,¹ reduction in adverse events² and improvement in patient experience.³ They emphasized the importance of implementing these rounds at the bedside, so that patients and families can be engaged in the patient’s care, thereby improving closed communication among the team and the patient. These rounds always offer an opportunity for the patient to ask questions of multiple health care team members as they are gathered together at the same time.

The University of Kentucky named these rounds the “Interprofessional Teamwork Innovation Model (ITIM),” to promote communication and patient-centered coordinated care. Their model showed a significant reduction in readmission rates, and no increase in costs despite adding pharmacy and case managers to the rounds.

Dr. Bhamidipati described how Christiana Care Health System designed multidisciplinary rounds based on the application of Team STEPPS 2.0, a teamwork system developed by the Department of Defense and the Agency for Healthcare Research and Quality to improve the institutional collaboration and communication relating to patient safety.

The Christiana Care model is based on a few principles of team structure, communication, leadership, situation monitoring, and mutual support. The interprofessional team was trained and observed, and a short video recording was made. This video was used as an educational tool in coaching the rest of the team. Dr. Bhamidipati described the importance of interprofessional leaders as coaches to train other team members, and highlighted the engagement of unit leaders in successfully implementing these rounds. The Christiana Care team used its informational technology system to collect real-time data, which was then used for team review.

In summary, the presenters from both the University of Kentucky and Christiana Care highlighted the importance of interprofessional rounds, as well as the need for continued measurement of process and outcome metrics.
 

Dr. Jonnalagadda is a physician advisor, and Dr. Medarametla is medical director, Hospital Medicine, at Baystate Medical Center, Springfield, Mass.

References

1. Yoo JW et al. Effects of an internal medicine floor interdisciplinary team on hospital and clinical outcomes of seniors with acute medical illness. Geriatr Gerontol Int. 2013 Oct;13(4):942-8. doi: 10.1111/ggi.12035. Epub 2013 Feb 26.

2. O’Leary KJ et al. Structured interdisciplinary rounds in a medical teaching unit: improving patient safety. Arch Intern Med. 2011 Apr 11;171(7):678-84. doi: 10.1001/archinternmed.2011.128.

3. Ratelle JT et al. Implementing bedside rounds to improve patient-centred outcomes: a systematic review. BMJ Qual Saf. 2019;28:317-326.

It seems that every week there are fresh headlines about a mental health crisis in children and adolescents, reporting exploding rates of severe anxiety and depression in youth. These reports raise the question of whether or not there has been a significant change in their incidence: Are more children developing depressive and anxiety disorders? Are they having greater difficulty accessing care? Are the disorders more severe than they were in the past? Or are young people failing to develop appropriate skills to manage anxiety, sadness, and other forms of distress that are a normal (if unpleasant) part of life? These are important questions, as they will help us to advocate for the proper services to address the public health challenge that underlies this “epidemic.”

Slavica/Getty Images

What do the data show?

It is important to start by noting that epidemiologic data on child psychiatry in the United States are not as robust as we might like. It was only in 1999 that the Surgeon General’s Report on Mental Health articulated that there was a need for a more systematic approach to collecting epidemiologic data on psychiatric illness in children and adolescents. At that time, the consensus was that approximately one in five children would develop a psychiatric illness by the age of 18 and that approximately 5% of all children would experience a severe or persistent mental illness.¹ In the 2 decades since then there have been expanded efforts to collect data, including the addition of an adolescent supplement to the National Comorbidity Survey sponsored by the National Institute of Mental Health, although our current estimates still are based on representative surveys of thousands of U.S. children and teenagers, often with questionnaires filled out by their parents. Thus, we may have overestimates of some behavioral disorders that are obvious and of concern to parents or underestimates of certain internalizing disorders such as depression that can remain unstated and contained in the mind of the adolescent. And even with accurate current estimates, our ability to make statements about trends or changes in rates of disease is limited by the very short period of time in which we have been studying these disease rates in U.S. youth, some changes in definitions, and the unknown impact of increasing recognition rather than true change in incidence.

What is unequivocally clear is that psychiatric illnesses usually present in youth and that these illnesses are among the most common illnesses of youth. Current estimates are that nearly one in four young people will have a psychiatric illness (by The Diagnostic and Statistical Manual of Mental Disorders [DSM], Fifth Edition criteria) by the time they turn 18,² although only 10% of youth will experience an illness that meets the Substance Abuse and Mental Health Services Administration criteria for a serious emotional disturbance, or one that has a substantial impact on a child’s ability to function socially, emotionally, and academically.³

While it once was believed that children did not experience psychiatric illness, we now know that the majority of psychiatric illnesses present during childhood, adolescence, and young adulthood. The Centers for Disease Control and Prevention estimates that 50% of lifetime psychiatric illness has presented by the age of 15 years and 75% by the age of 24. Only one-quarter of all lifetime psychiatric illnesses emerge in full adulthood, or after the age of 24. Early diagnosis and treatment can make a significant difference in the overall impact of serious illnesses such as schizophrenia and bipolar disorder. We also can state with confidence that anxiety disorders are the most common psychiatric illnesses of youth, making up over 30% of all diagnoses, followed by disorders of behavior (19%), mood (14%), and then substance use (11%).⁴ Even compared with asthma (with a prevalence of approximately 11%), widely considered to be among the most common disease of childhood, psychiatric illnesses are the most common in youth.

The question then is whether these numbers are changing. The National Comorbidity Survey conducted in 2014 found that the incidence of major depressive episodes in adolescents had increased significantly between 2005 and 2014, from 9% to 11%.⁵ This is a survey of nearly 200,000 youth across the United States, interviewed by phone with a structured questionnaire assessing their (self-reported) DSM criteria for a major depressive episode, along with other illnesses. During this time frame, access to specialty mental health providers increased among adolescents, alongside their rate of use of psychiatric medications and inpatient hospitalization.

In Europe, where they have more robust epidemiological data, there also has been a public perception of an increase in depression in adolescents. Studies there have suggested that prevalence rates have not changed significantly, and that the problem actually may be a function of a growing population, greater public awareness, and higher rates of psychological distress.⁶

In the United States, it is difficult to place the prevalence rates in a meaningful context, given the shorter time frame during which we have been following these rates in young people. It is worth highlighting that although the rates at which young people are gaining access to mental health clinicians, being prescribed medications, and being admitted to psychiatric hospitals all have increased, there has not been an associated decrease in the rate of illness or in the severity of symptoms. It certainly is possible that the increase in use of services by youth is being driven by the increased prevalence of this diagnosis, or it may be that other factors, such as those detailed in international studies, are driving this increase in the incidence of depression.
 

What about the suicide rate?

Another statistic that addressed the question of whether there may be an epidemic of anxiety and depression in adolescents is the recent increase in the suicide rate. While the rate of completed suicide in 15- to 24-year-olds has been trending upward over the last decade, it is worth noting that this phenomenon appears to be occurring across age groups and is not isolated to adolescents. While adolescents may have a unique underlying set of issues driving the increase, it also may be that factors affecting the entire population (access to firearms, the epidemic of opioid addiction) may be at the core of this worrisome trend.

What about the role of stress?

It is worth noting that there is evidence of an increased rate of psychological distress in adolescents and young adults separate from any increase in the rate of psychiatric illness. Surveys of adolescents in high school and entering college demonstrate higher self-reported rates of severe stress and anxiety. One survey from the American Psychological Association from August 2018 found teenagers reporting higher levels of stress and related sadness and anxiety than the levels among the adults who were surveyed. So more young people are struggling with feelings of anxiety and sadness, without necessarily meeting criteria for a psychiatric illness. This suggests that levels of external stressors may have increased, or that the establishment of healthy coping skills has somehow been compromised in young people, or both.

What can you do as a clinician?

While the broader question of whether actual incidence rates of depression are on the rise will not be settled any time soon, when a patient of yours complains of high levels of stress, anxiety, or feelings of depression, it is very possible that the individual has a psychiatric diagnosis. A quick screening evaluation, using a questionnaire such as the Pediatric Symptom Checklist and/or a brief interview, can indicate if the patient may benefit from a referral.

In addition, all children, including those who have a psychiatric diagnosis, will benefit from a calm, patient, supportive adult who is interested in their distress. It would be very helpful if you are ready to talk about healthy coping skills, and how they are developed over time and only in the setting of actually struggling with some adversity. Help them frame their source of stress as a challenge rather than a threat. Help them identify their meaningful supports, particularly adults who know them well, and offer concrete and practical advice and motivation. And remind them about how self-care is essential to managing the normal stress of adolescence. Have handouts (or virtual ones) ready on good sleep hygiene, the value of exercise, and fact-based nutritional guidance. Offer strategies to manage screen time so that it is a recharging break and not a time sink. Support their identification of other strategies to decompress and manage stress: Are they recharged by time with friends? Exercise? Playing music? Listening to music? Playing video games? They should be building their personalized list, and it should include more active as well as passive strategies. Educate them about the risks of using drugs and alcohol “to relax,” or only having one way of unwinding. Educate your patients and parents about the special value of a mindfulness practice, whether meditation, yoga, or any activity in which they practice a nonjudgmental observation and acceptance of strong emotions.

Accurate prevalence rates can help us consider the statistical probability of a psychiatric diagnosis. By talking with your patients about stressful feelings, you can consider the individual need for a fuller psychiatric evaluation while also helping them reframe their approach to stress to one that is more empowering, adaptive, and healthy.

Dr. Swick is physician in chief at Ohana, Center for Child and Adolescent Behavioral Health, Community Hospital of the Monterey (Calif.) Peninsula. Dr. Jellinek is professor emeritus of psychiatry and pediatrics, Harvard Medical School, Boston. Email them at [email protected].

References

1. Mental Health: A Report of the Surgeon General, National Institutes of Mental Health (1999).

2. Prevalence of psychiatric disorders in childhood and adolescence, in “Mental Health Services: A Public Health Perspective,” 2nd ed. (Oxford, UK: Oxford University Press; 2004, pp. 111-28).

3. Public Health Rep. 2006 May-Jun;121(3):303-10.

4. J Am Acad Child Adolesc Psychiatry. 2010 Oct;49(10):980-9.

5. Pediatrics. 2016 Dec;138(6):e20161878.

6. Depress Anxiety. 2014 Jun;31(6):506-16.

It seems that every week there are fresh headlines about a mental health crisis in children and adolescents, reporting exploding rates of severe anxiety and depression in youth. These reports raise the question of whether or not there has been a significant change in their incidence: Are more children developing depressive and anxiety disorders? Are they having greater difficulty accessing care? Are the disorders more severe than they were in the past? Or are young people failing to develop appropriate skills to manage anxiety, sadness, and other forms of distress that are a normal (if unpleasant) part of life? These are important questions, as they will help us to advocate for the proper services to address the public health challenge that underlies this “epidemic.”

Slavica/Getty Images

What do the data show?

It is important to start by noting that epidemiologic data on child psychiatry in the United States are not as robust as we might like. It was only in 1999 that the Surgeon General’s Report on Mental Health articulated that there was a need for a more systematic approach to collecting epidemiologic data on psychiatric illness in children and adolescents. At that time, the consensus was that approximately one in five children would develop a psychiatric illness by the age of 18 and that approximately 5% of all children would experience a severe or persistent mental illness.¹ In the 2 decades since then there have been expanded efforts to collect data, including the addition of an adolescent supplement to the National Comorbidity Survey sponsored by the National Institute of Mental Health, although our current estimates still are based on representative surveys of thousands of U.S. children and teenagers, often with questionnaires filled out by their parents. Thus, we may have overestimates of some behavioral disorders that are obvious and of concern to parents or underestimates of certain internalizing disorders such as depression that can remain unstated and contained in the mind of the adolescent. And even with accurate current estimates, our ability to make statements about trends or changes in rates of disease is limited by the very short period of time in which we have been studying these disease rates in U.S. youth, some changes in definitions, and the unknown impact of increasing recognition rather than true change in incidence.

What is unequivocally clear is that psychiatric illnesses usually present in youth and that these illnesses are among the most common illnesses of youth. Current estimates are that nearly one in four young people will have a psychiatric illness (by The Diagnostic and Statistical Manual of Mental Disorders [DSM], Fifth Edition criteria) by the time they turn 18,² although only 10% of youth will experience an illness that meets the Substance Abuse and Mental Health Services Administration criteria for a serious emotional disturbance, or one that has a substantial impact on a child’s ability to function socially, emotionally, and academically.³

While it once was believed that children did not experience psychiatric illness, we now know that the majority of psychiatric illnesses present during childhood, adolescence, and young adulthood. The Centers for Disease Control and Prevention estimates that 50% of lifetime psychiatric illness has presented by the age of 15 years and 75% by the age of 24. Only one-quarter of all lifetime psychiatric illnesses emerge in full adulthood, or after the age of 24. Early diagnosis and treatment can make a significant difference in the overall impact of serious illnesses such as schizophrenia and bipolar disorder. We also can state with confidence that anxiety disorders are the most common psychiatric illnesses of youth, making up over 30% of all diagnoses, followed by disorders of behavior (19%), mood (14%), and then substance use (11%).⁴ Even compared with asthma (with a prevalence of approximately 11%), widely considered to be among the most common disease of childhood, psychiatric illnesses are the most common in youth.

The question then is whether these numbers are changing. The National Comorbidity Survey conducted in 2014 found that the incidence of major depressive episodes in adolescents had increased significantly between 2005 and 2014, from 9% to 11%.⁵ This is a survey of nearly 200,000 youth across the United States, interviewed by phone with a structured questionnaire assessing their (self-reported) DSM criteria for a major depressive episode, along with other illnesses. During this time frame, access to specialty mental health providers increased among adolescents, alongside their rate of use of psychiatric medications and inpatient hospitalization.

In Europe, where they have more robust epidemiological data, there also has been a public perception of an increase in depression in adolescents. Studies there have suggested that prevalence rates have not changed significantly, and that the problem actually may be a function of a growing population, greater public awareness, and higher rates of psychological distress.⁶

In the United States, it is difficult to place the prevalence rates in a meaningful context, given the shorter time frame during which we have been following these rates in young people. It is worth highlighting that although the rates at which young people are gaining access to mental health clinicians, being prescribed medications, and being admitted to psychiatric hospitals all have increased, there has not been an associated decrease in the rate of illness or in the severity of symptoms. It certainly is possible that the increase in use of services by youth is being driven by the increased prevalence of this diagnosis, or it may be that other factors, such as those detailed in international studies, are driving this increase in the incidence of depression.
 

What about the suicide rate?

Another statistic that addressed the question of whether there may be an epidemic of anxiety and depression in adolescents is the recent increase in the suicide rate. While the rate of completed suicide in 15- to 24-year-olds has been trending upward over the last decade, it is worth noting that this phenomenon appears to be occurring across age groups and is not isolated to adolescents. While adolescents may have a unique underlying set of issues driving the increase, it also may be that factors affecting the entire population (access to firearms, the epidemic of opioid addiction) may be at the core of this worrisome trend.

What about the role of stress?

It is worth noting that there is evidence of an increased rate of psychological distress in adolescents and young adults separate from any increase in the rate of psychiatric illness. Surveys of adolescents in high school and entering college demonstrate higher self-reported rates of severe stress and anxiety. One survey from the American Psychological Association from August 2018 found teenagers reporting higher levels of stress and related sadness and anxiety than the levels among the adults who were surveyed. So more young people are struggling with feelings of anxiety and sadness, without necessarily meeting criteria for a psychiatric illness. This suggests that levels of external stressors may have increased, or that the establishment of healthy coping skills has somehow been compromised in young people, or both.

What can you do as a clinician?

While the broader question of whether actual incidence rates of depression are on the rise will not be settled any time soon, when a patient of yours complains of high levels of stress, anxiety, or feelings of depression, it is very possible that the individual has a psychiatric diagnosis. A quick screening evaluation, using a questionnaire such as the Pediatric Symptom Checklist and/or a brief interview, can indicate if the patient may benefit from a referral.

In addition, all children, including those who have a psychiatric diagnosis, will benefit from a calm, patient, supportive adult who is interested in their distress. It would be very helpful if you are ready to talk about healthy coping skills, and how they are developed over time and only in the setting of actually struggling with some adversity. Help them frame their source of stress as a challenge rather than a threat. Help them identify their meaningful supports, particularly adults who know them well, and offer concrete and practical advice and motivation. And remind them about how self-care is essential to managing the normal stress of adolescence. Have handouts (or virtual ones) ready on good sleep hygiene, the value of exercise, and fact-based nutritional guidance. Offer strategies to manage screen time so that it is a recharging break and not a time sink. Support their identification of other strategies to decompress and manage stress: Are they recharged by time with friends? Exercise? Playing music? Listening to music? Playing video games? They should be building their personalized list, and it should include more active as well as passive strategies. Educate them about the risks of using drugs and alcohol “to relax,” or only having one way of unwinding. Educate your patients and parents about the special value of a mindfulness practice, whether meditation, yoga, or any activity in which they practice a nonjudgmental observation and acceptance of strong emotions.

Accurate prevalence rates can help us consider the statistical probability of a psychiatric diagnosis. By talking with your patients about stressful feelings, you can consider the individual need for a fuller psychiatric evaluation while also helping them reframe their approach to stress to one that is more empowering, adaptive, and healthy.

Dr. Swick is physician in chief at Ohana, Center for Child and Adolescent Behavioral Health, Community Hospital of the Monterey (Calif.) Peninsula. Dr. Jellinek is professor emeritus of psychiatry and pediatrics, Harvard Medical School, Boston. Email them at [email protected].

References

1. Mental Health: A Report of the Surgeon General, National Institutes of Mental Health (1999).

2. Prevalence of psychiatric disorders in childhood and adolescence, in “Mental Health Services: A Public Health Perspective,” 2nd ed. (Oxford, UK: Oxford University Press; 2004, pp. 111-28).

3. Public Health Rep. 2006 May-Jun;121(3):303-10.

4. J Am Acad Child Adolesc Psychiatry. 2010 Oct;49(10):980-9.

5. Pediatrics. 2016 Dec;138(6):e20161878.

6. Depress Anxiety. 2014 Jun;31(6):506-16.

It seems that every week there are fresh headlines about a mental health crisis in children and adolescents, reporting exploding rates of severe anxiety and depression in youth. These reports raise the question of whether or not there has been a significant change in their incidence: Are more children developing depressive and anxiety disorders? Are they having greater difficulty accessing care? Are the disorders more severe than they were in the past? Or are young people failing to develop appropriate skills to manage anxiety, sadness, and other forms of distress that are a normal (if unpleasant) part of life? These are important questions, as they will help us to advocate for the proper services to address the public health challenge that underlies this “epidemic.”

Slavica/Getty Images

What do the data show?

It is important to start by noting that epidemiologic data on child psychiatry in the United States are not as robust as we might like. It was only in 1999 that the Surgeon General’s Report on Mental Health articulated that there was a need for a more systematic approach to collecting epidemiologic data on psychiatric illness in children and adolescents. At that time, the consensus was that approximately one in five children would develop a psychiatric illness by the age of 18 and that approximately 5% of all children would experience a severe or persistent mental illness.¹ In the 2 decades since then there have been expanded efforts to collect data, including the addition of an adolescent supplement to the National Comorbidity Survey sponsored by the National Institute of Mental Health, although our current estimates still are based on representative surveys of thousands of U.S. children and teenagers, often with questionnaires filled out by their parents. Thus, we may have overestimates of some behavioral disorders that are obvious and of concern to parents or underestimates of certain internalizing disorders such as depression that can remain unstated and contained in the mind of the adolescent. And even with accurate current estimates, our ability to make statements about trends or changes in rates of disease is limited by the very short period of time in which we have been studying these disease rates in U.S. youth, some changes in definitions, and the unknown impact of increasing recognition rather than true change in incidence.

What is unequivocally clear is that psychiatric illnesses usually present in youth and that these illnesses are among the most common illnesses of youth. Current estimates are that nearly one in four young people will have a psychiatric illness (by The Diagnostic and Statistical Manual of Mental Disorders [DSM], Fifth Edition criteria) by the time they turn 18,² although only 10% of youth will experience an illness that meets the Substance Abuse and Mental Health Services Administration criteria for a serious emotional disturbance, or one that has a substantial impact on a child’s ability to function socially, emotionally, and academically.³

While it once was believed that children did not experience psychiatric illness, we now know that the majority of psychiatric illnesses present during childhood, adolescence, and young adulthood. The Centers for Disease Control and Prevention estimates that 50% of lifetime psychiatric illness has presented by the age of 15 years and 75% by the age of 24. Only one-quarter of all lifetime psychiatric illnesses emerge in full adulthood, or after the age of 24. Early diagnosis and treatment can make a significant difference in the overall impact of serious illnesses such as schizophrenia and bipolar disorder. We also can state with confidence that anxiety disorders are the most common psychiatric illnesses of youth, making up over 30% of all diagnoses, followed by disorders of behavior (19%), mood (14%), and then substance use (11%).⁴ Even compared with asthma (with a prevalence of approximately 11%), widely considered to be among the most common disease of childhood, psychiatric illnesses are the most common in youth.

The question then is whether these numbers are changing. The National Comorbidity Survey conducted in 2014 found that the incidence of major depressive episodes in adolescents had increased significantly between 2005 and 2014, from 9% to 11%.⁵ This is a survey of nearly 200,000 youth across the United States, interviewed by phone with a structured questionnaire assessing their (self-reported) DSM criteria for a major depressive episode, along with other illnesses. During this time frame, access to specialty mental health providers increased among adolescents, alongside their rate of use of psychiatric medications and inpatient hospitalization.

In Europe, where they have more robust epidemiological data, there also has been a public perception of an increase in depression in adolescents. Studies there have suggested that prevalence rates have not changed significantly, and that the problem actually may be a function of a growing population, greater public awareness, and higher rates of psychological distress.⁶

In the United States, it is difficult to place the prevalence rates in a meaningful context, given the shorter time frame during which we have been following these rates in young people. It is worth highlighting that although the rates at which young people are gaining access to mental health clinicians, being prescribed medications, and being admitted to psychiatric hospitals all have increased, there has not been an associated decrease in the rate of illness or in the severity of symptoms. It certainly is possible that the increase in use of services by youth is being driven by the increased prevalence of this diagnosis, or it may be that other factors, such as those detailed in international studies, are driving this increase in the incidence of depression.
 

What about the suicide rate?

Another statistic that addressed the question of whether there may be an epidemic of anxiety and depression in adolescents is the recent increase in the suicide rate. While the rate of completed suicide in 15- to 24-year-olds has been trending upward over the last decade, it is worth noting that this phenomenon appears to be occurring across age groups and is not isolated to adolescents. While adolescents may have a unique underlying set of issues driving the increase, it also may be that factors affecting the entire population (access to firearms, the epidemic of opioid addiction) may be at the core of this worrisome trend.

What about the role of stress?

It is worth noting that there is evidence of an increased rate of psychological distress in adolescents and young adults separate from any increase in the rate of psychiatric illness. Surveys of adolescents in high school and entering college demonstrate higher self-reported rates of severe stress and anxiety. One survey from the American Psychological Association from August 2018 found teenagers reporting higher levels of stress and related sadness and anxiety than the levels among the adults who were surveyed. So more young people are struggling with feelings of anxiety and sadness, without necessarily meeting criteria for a psychiatric illness. This suggests that levels of external stressors may have increased, or that the establishment of healthy coping skills has somehow been compromised in young people, or both.

What can you do as a clinician?

While the broader question of whether actual incidence rates of depression are on the rise will not be settled any time soon, when a patient of yours complains of high levels of stress, anxiety, or feelings of depression, it is very possible that the individual has a psychiatric diagnosis. A quick screening evaluation, using a questionnaire such as the Pediatric Symptom Checklist and/or a brief interview, can indicate if the patient may benefit from a referral.

In addition, all children, including those who have a psychiatric diagnosis, will benefit from a calm, patient, supportive adult who is interested in their distress. It would be very helpful if you are ready to talk about healthy coping skills, and how they are developed over time and only in the setting of actually struggling with some adversity. Help them frame their source of stress as a challenge rather than a threat. Help them identify their meaningful supports, particularly adults who know them well, and offer concrete and practical advice and motivation. And remind them about how self-care is essential to managing the normal stress of adolescence. Have handouts (or virtual ones) ready on good sleep hygiene, the value of exercise, and fact-based nutritional guidance. Offer strategies to manage screen time so that it is a recharging break and not a time sink. Support their identification of other strategies to decompress and manage stress: Are they recharged by time with friends? Exercise? Playing music? Listening to music? Playing video games? They should be building their personalized list, and it should include more active as well as passive strategies. Educate them about the risks of using drugs and alcohol “to relax,” or only having one way of unwinding. Educate your patients and parents about the special value of a mindfulness practice, whether meditation, yoga, or any activity in which they practice a nonjudgmental observation and acceptance of strong emotions.

Accurate prevalence rates can help us consider the statistical probability of a psychiatric diagnosis. By talking with your patients about stressful feelings, you can consider the individual need for a fuller psychiatric evaluation while also helping them reframe their approach to stress to one that is more empowering, adaptive, and healthy.

Dr. Swick is physician in chief at Ohana, Center for Child and Adolescent Behavioral Health, Community Hospital of the Monterey (Calif.) Peninsula. Dr. Jellinek is professor emeritus of psychiatry and pediatrics, Harvard Medical School, Boston. Email them at [email protected].

References

1. Mental Health: A Report of the Surgeon General, National Institutes of Mental Health (1999).

2. Prevalence of psychiatric disorders in childhood and adolescence, in “Mental Health Services: A Public Health Perspective,” 2nd ed. (Oxford, UK: Oxford University Press; 2004, pp. 111-28).

3. Public Health Rep. 2006 May-Jun;121(3):303-10.

4. J Am Acad Child Adolesc Psychiatry. 2010 Oct;49(10):980-9.

5. Pediatrics. 2016 Dec;138(6):e20161878.

6. Depress Anxiety. 2014 Jun;31(6):506-16.

My medical office in Cincinnati isn’t in the best part of town. It’s next to a busy bus stop, a block from the medical center, behind a McDonald’s, and next to a convenience store. Ohio is the epicenter for the opioid crisis, and there are three drug treatment centers within a mile of my office. Hungry “ghosts” drift through my office parking lot. (See “In the Realm of Hungry Ghosts – Introduction,” Gabor Maté, MD).

I tell you these things because it helps me to rationalize how I missed something one day that should have been obvious to me at the time. I’ve been grappling for some time with my belated realization of what I may have seen that day, and what I wished I had done in response.

I mentioned that my office is next to a convenience store, and I’ve been a regular customer there over the years. One day when I was in there, paying for something, a swaggering guy in his 50s – reddish comb-over, glasses, muscular – came in with a young blond girl. I guessed her to be his 14- or 15-year-old daughter. I paid for my purchase, and glanced over to see them standing at the ice cream counter. That’s nice, I thought, he is buying his daughter an ice cream cone. I used to buy my kids ice cream here. But then I noticed that the girl was trembling, quaking really, and crying softly. I stopped, and noticed that the man had his arm around her. His grip was way too tight and his arm was draped too low. I stepped back, and I swear I saw blood running down from her scalp and behind her ear.

coldsnowstorm/iStock/Getty Images Plus

Good grief, this isn’t right! I was paralyzed. Maybe she wasn’t his daughter. Maybe she was some sort of a captive, a victim? Maybe he had just beaten her and was now rewarding her? I knew something was wrong, and I did not know what to do. The store was busy, and I looked around at the other people there but no one else seemed to notice her unhappiness or the blood.

I did not say ‘unhand that girl.’ I did not say ‘I am a doctor, can I help you?’ I did not even ask her if she was OK. Instead, I walked back next door to my office and started making phone calls. I called the police and got a recording. Eventually I spoke to someone, but I had no proof. I was angry with myself for not taking a picture – my phone was in my pocket. Did I observe a crime being committed? Were there other witnesses? The sorry truth is that I had walked away, the man and girl were gone, and any others who may have seen what I saw also had left. This could have been a case of human trafficking, I said, and recommended that they follow up with the store and any evidence that they could pick up from its video cameras. It’s been nearly a year, and I have heard nothing.

My failure to act at the time has tormented me for months. I have sought out more information about human trafficking, and the event I witnessed is what human trafficking looks like.


Maybe that girl was his daughter. Maybe she fell and cut her head. Maybe I was jumping to conclusions. But I am never again going to walk away from a girl who is clearly injured and potentially in trouble. I am going ask that girl if she’s OK, I am going to take a picture, and I am going to dial 911 immediately.

Don’t be a failure like me. Call 911. Take a picture. Take the risk, embarrass yourself or you will be tormented by your conscience as I am. We all must all step up, learn the signs of potential human trafficking, and stop allowing our young people to be fed to monsters.

The Centers for Disease Control and Prevention offers information and resources on human trafficking at www.cdc.gov/violenceprevention/sexualviolence/trafficking.html.

Dr. Coldiron is in private practice but maintains a clinical assistant professorship at the University of Cincinnati. He cares for patients, teaches medical students and residents, and has several active clinical research projects. Dr. Coldiron is the author of more than 80 scientific letters, papers, and several book chapters, and he speaks frequently on a variety of topics. He is a past president of the American Academy of Dermatology. Write to him at [email protected].

My medical office in Cincinnati isn’t in the best part of town. It’s next to a busy bus stop, a block from the medical center, behind a McDonald’s, and next to a convenience store. Ohio is the epicenter for the opioid crisis, and there are three drug treatment centers within a mile of my office. Hungry “ghosts” drift through my office parking lot. (See “In the Realm of Hungry Ghosts – Introduction,” Gabor Maté, MD).

I tell you these things because it helps me to rationalize how I missed something one day that should have been obvious to me at the time. I’ve been grappling for some time with my belated realization of what I may have seen that day, and what I wished I had done in response.

I mentioned that my office is next to a convenience store, and I’ve been a regular customer there over the years. One day when I was in there, paying for something, a swaggering guy in his 50s – reddish comb-over, glasses, muscular – came in with a young blond girl. I guessed her to be his 14- or 15-year-old daughter. I paid for my purchase, and glanced over to see them standing at the ice cream counter. That’s nice, I thought, he is buying his daughter an ice cream cone. I used to buy my kids ice cream here. But then I noticed that the girl was trembling, quaking really, and crying softly. I stopped, and noticed that the man had his arm around her. His grip was way too tight and his arm was draped too low. I stepped back, and I swear I saw blood running down from her scalp and behind her ear.

coldsnowstorm/iStock/Getty Images Plus

Good grief, this isn’t right! I was paralyzed. Maybe she wasn’t his daughter. Maybe she was some sort of a captive, a victim? Maybe he had just beaten her and was now rewarding her? I knew something was wrong, and I did not know what to do. The store was busy, and I looked around at the other people there but no one else seemed to notice her unhappiness or the blood.

I did not say ‘unhand that girl.’ I did not say ‘I am a doctor, can I help you?’ I did not even ask her if she was OK. Instead, I walked back next door to my office and started making phone calls. I called the police and got a recording. Eventually I spoke to someone, but I had no proof. I was angry with myself for not taking a picture – my phone was in my pocket. Did I observe a crime being committed? Were there other witnesses? The sorry truth is that I had walked away, the man and girl were gone, and any others who may have seen what I saw also had left. This could have been a case of human trafficking, I said, and recommended that they follow up with the store and any evidence that they could pick up from its video cameras. It’s been nearly a year, and I have heard nothing.

My failure to act at the time has tormented me for months. I have sought out more information about human trafficking, and the event I witnessed is what human trafficking looks like.


Maybe that girl was his daughter. Maybe she fell and cut her head. Maybe I was jumping to conclusions. But I am never again going to walk away from a girl who is clearly injured and potentially in trouble. I am going ask that girl if she’s OK, I am going to take a picture, and I am going to dial 911 immediately.

Don’t be a failure like me. Call 911. Take a picture. Take the risk, embarrass yourself or you will be tormented by your conscience as I am. We all must all step up, learn the signs of potential human trafficking, and stop allowing our young people to be fed to monsters.

The Centers for Disease Control and Prevention offers information and resources on human trafficking at www.cdc.gov/violenceprevention/sexualviolence/trafficking.html.

Dr. Coldiron is in private practice but maintains a clinical assistant professorship at the University of Cincinnati. He cares for patients, teaches medical students and residents, and has several active clinical research projects. Dr. Coldiron is the author of more than 80 scientific letters, papers, and several book chapters, and he speaks frequently on a variety of topics. He is a past president of the American Academy of Dermatology. Write to him at [email protected].

My medical office in Cincinnati isn’t in the best part of town. It’s next to a busy bus stop, a block from the medical center, behind a McDonald’s, and next to a convenience store. Ohio is the epicenter for the opioid crisis, and there are three drug treatment centers within a mile of my office. Hungry “ghosts” drift through my office parking lot. (See “In the Realm of Hungry Ghosts – Introduction,” Gabor Maté, MD).

I tell you these things because it helps me to rationalize how I missed something one day that should have been obvious to me at the time. I’ve been grappling for some time with my belated realization of what I may have seen that day, and what I wished I had done in response.

I mentioned that my office is next to a convenience store, and I’ve been a regular customer there over the years. One day when I was in there, paying for something, a swaggering guy in his 50s – reddish comb-over, glasses, muscular – came in with a young blond girl. I guessed her to be his 14- or 15-year-old daughter. I paid for my purchase, and glanced over to see them standing at the ice cream counter. That’s nice, I thought, he is buying his daughter an ice cream cone. I used to buy my kids ice cream here. But then I noticed that the girl was trembling, quaking really, and crying softly. I stopped, and noticed that the man had his arm around her. His grip was way too tight and his arm was draped too low. I stepped back, and I swear I saw blood running down from her scalp and behind her ear.

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Good grief, this isn’t right! I was paralyzed. Maybe she wasn’t his daughter. Maybe she was some sort of a captive, a victim? Maybe he had just beaten her and was now rewarding her? I knew something was wrong, and I did not know what to do. The store was busy, and I looked around at the other people there but no one else seemed to notice her unhappiness or the blood.

I did not say ‘unhand that girl.’ I did not say ‘I am a doctor, can I help you?’ I did not even ask her if she was OK. Instead, I walked back next door to my office and started making phone calls. I called the police and got a recording. Eventually I spoke to someone, but I had no proof. I was angry with myself for not taking a picture – my phone was in my pocket. Did I observe a crime being committed? Were there other witnesses? The sorry truth is that I had walked away, the man and girl were gone, and any others who may have seen what I saw also had left. This could have been a case of human trafficking, I said, and recommended that they follow up with the store and any evidence that they could pick up from its video cameras. It’s been nearly a year, and I have heard nothing.

My failure to act at the time has tormented me for months. I have sought out more information about human trafficking, and the event I witnessed is what human trafficking looks like.


Maybe that girl was his daughter. Maybe she fell and cut her head. Maybe I was jumping to conclusions. But I am never again going to walk away from a girl who is clearly injured and potentially in trouble. I am going ask that girl if she’s OK, I am going to take a picture, and I am going to dial 911 immediately.

Don’t be a failure like me. Call 911. Take a picture. Take the risk, embarrass yourself or you will be tormented by your conscience as I am. We all must all step up, learn the signs of potential human trafficking, and stop allowing our young people to be fed to monsters.

The Centers for Disease Control and Prevention offers information and resources on human trafficking at www.cdc.gov/violenceprevention/sexualviolence/trafficking.html.

Dr. Coldiron is in private practice but maintains a clinical assistant professorship at the University of Cincinnati. He cares for patients, teaches medical students and residents, and has several active clinical research projects. Dr. Coldiron is the author of more than 80 scientific letters, papers, and several book chapters, and he speaks frequently on a variety of topics. He is a past president of the American Academy of Dermatology. Write to him at [email protected].