Photo by Bill Branson

Survivors of childhood Hodgkin lymphoma (HL) have a 14-fold higher risk of second cancers compared to the general population, according to new research.

The subsequent malignant neoplasms (SMNs) observed in HL survivors tended to follow specific patterns depending on the patient’s age at treatment, sex, treatment modality, and region of the body treated.

And although the risk of SMNs appears to be somewhat lower for HL patients treated in more recent decades, it is still significantly higher than the risk in the general population, according to investigators.

Anna S. Holmqvist, MD, PhD, of the University of Lund in Sweden, and her colleagues conducted this research and reported the results in Cancer.

The investigators looked at data from the Late Effects Study Group, a multinational cohort of patients age 16 or younger who were treated for HL and other cancers from 1955 through 1986.

The current report is the third update from an expanded cohort including data on 1,136 patients with a median follow-up of 26.6 years. The median patient age at diagnosis was 11 years (range, birth to 16 years), and the patients were followed for 23,212 person-years after HL diagnosis.

In all, 162 patients developed 196 SMNs, including breast cancer (n=54), basal cell carcinoma (n=34), thyroid cancer (n=30), colorectal cancer (n=15), lung cancer (n=11), and other malignancies (n=40). The disease site was not available in 12 cases.

The cumulative incidence of any SMN 40 years after HL diagnosis was 26.4%. By age 50, the cumulative incidence of any SMN was 27.2%.

The standardized incidence ratio for the entire cohort was 14.0, compared with the general population as derived from the Surveillance, Epidemiology and End Results database.

Risk factors by cancer type

Females treated with chest radiotherapy between the ages of 10 and 16 who did not receive alkylating agents or received low doses of alkylating agents had the highest risk of developing breast cancer. The cumulative incidence of breast cancer by age 50 was 45.3% in these patients.

The patients with the highest risk for subsequent lung cancer were males treated with chest radiotherapy before age 10. The cumulative incidence of lung cancer by age 50 was 4.2% in these patients.

Patients with the highest risk for colorectal cancer had received abdominal/pelvic radiotherapy and high-dose alkylating agents. The cumulative incidence of colorectal cancer by age 50 was 9.5% in these patients.

Patients with the highest risk for thyroid cancers were females who had been treated with radiotherapy to the neck before the age of 10. The cumulative incidence of thyroid cancer by age 50 was 17.3% in these patients.

The investigators noted that HL patients treated more recently are likely to have received lower doses and volumes of radiotherapy compared to patients treated in the 1950s, ’60s and ’70s.

“However, for the cohort of patients treated between 1955 and 1986, it is clear that continued surveillance for SMNs is essential because their risk continues to increase as these survivors enter their fourth and subsequent decades of life,” the investigators wrote.

They did not report a funding source for this research or make any conflict-of-interest disclosures.

Photo by Bill Branson

Survivors of childhood Hodgkin lymphoma (HL) have a 14-fold higher risk of second cancers compared to the general population, according to new research.

The subsequent malignant neoplasms (SMNs) observed in HL survivors tended to follow specific patterns depending on the patient’s age at treatment, sex, treatment modality, and region of the body treated.

And although the risk of SMNs appears to be somewhat lower for HL patients treated in more recent decades, it is still significantly higher than the risk in the general population, according to investigators.

Anna S. Holmqvist, MD, PhD, of the University of Lund in Sweden, and her colleagues conducted this research and reported the results in Cancer.

The investigators looked at data from the Late Effects Study Group, a multinational cohort of patients age 16 or younger who were treated for HL and other cancers from 1955 through 1986.

The current report is the third update from an expanded cohort including data on 1,136 patients with a median follow-up of 26.6 years. The median patient age at diagnosis was 11 years (range, birth to 16 years), and the patients were followed for 23,212 person-years after HL diagnosis.

In all, 162 patients developed 196 SMNs, including breast cancer (n=54), basal cell carcinoma (n=34), thyroid cancer (n=30), colorectal cancer (n=15), lung cancer (n=11), and other malignancies (n=40). The disease site was not available in 12 cases.

The cumulative incidence of any SMN 40 years after HL diagnosis was 26.4%. By age 50, the cumulative incidence of any SMN was 27.2%.

The standardized incidence ratio for the entire cohort was 14.0, compared with the general population as derived from the Surveillance, Epidemiology and End Results database.

Risk factors by cancer type

Females treated with chest radiotherapy between the ages of 10 and 16 who did not receive alkylating agents or received low doses of alkylating agents had the highest risk of developing breast cancer. The cumulative incidence of breast cancer by age 50 was 45.3% in these patients.

The patients with the highest risk for subsequent lung cancer were males treated with chest radiotherapy before age 10. The cumulative incidence of lung cancer by age 50 was 4.2% in these patients.

Patients with the highest risk for colorectal cancer had received abdominal/pelvic radiotherapy and high-dose alkylating agents. The cumulative incidence of colorectal cancer by age 50 was 9.5% in these patients.

Patients with the highest risk for thyroid cancers were females who had been treated with radiotherapy to the neck before the age of 10. The cumulative incidence of thyroid cancer by age 50 was 17.3% in these patients.

The investigators noted that HL patients treated more recently are likely to have received lower doses and volumes of radiotherapy compared to patients treated in the 1950s, ’60s and ’70s.

“However, for the cohort of patients treated between 1955 and 1986, it is clear that continued surveillance for SMNs is essential because their risk continues to increase as these survivors enter their fourth and subsequent decades of life,” the investigators wrote.

They did not report a funding source for this research or make any conflict-of-interest disclosures.

Photo by Bill Branson

Survivors of childhood Hodgkin lymphoma (HL) have a 14-fold higher risk of second cancers compared to the general population, according to new research.

The subsequent malignant neoplasms (SMNs) observed in HL survivors tended to follow specific patterns depending on the patient’s age at treatment, sex, treatment modality, and region of the body treated.

And although the risk of SMNs appears to be somewhat lower for HL patients treated in more recent decades, it is still significantly higher than the risk in the general population, according to investigators.

Anna S. Holmqvist, MD, PhD, of the University of Lund in Sweden, and her colleagues conducted this research and reported the results in Cancer.

The investigators looked at data from the Late Effects Study Group, a multinational cohort of patients age 16 or younger who were treated for HL and other cancers from 1955 through 1986.

The current report is the third update from an expanded cohort including data on 1,136 patients with a median follow-up of 26.6 years. The median patient age at diagnosis was 11 years (range, birth to 16 years), and the patients were followed for 23,212 person-years after HL diagnosis.

In all, 162 patients developed 196 SMNs, including breast cancer (n=54), basal cell carcinoma (n=34), thyroid cancer (n=30), colorectal cancer (n=15), lung cancer (n=11), and other malignancies (n=40). The disease site was not available in 12 cases.

The cumulative incidence of any SMN 40 years after HL diagnosis was 26.4%. By age 50, the cumulative incidence of any SMN was 27.2%.

The standardized incidence ratio for the entire cohort was 14.0, compared with the general population as derived from the Surveillance, Epidemiology and End Results database.

Risk factors by cancer type

Females treated with chest radiotherapy between the ages of 10 and 16 who did not receive alkylating agents or received low doses of alkylating agents had the highest risk of developing breast cancer. The cumulative incidence of breast cancer by age 50 was 45.3% in these patients.

The patients with the highest risk for subsequent lung cancer were males treated with chest radiotherapy before age 10. The cumulative incidence of lung cancer by age 50 was 4.2% in these patients.

Patients with the highest risk for colorectal cancer had received abdominal/pelvic radiotherapy and high-dose alkylating agents. The cumulative incidence of colorectal cancer by age 50 was 9.5% in these patients.

Patients with the highest risk for thyroid cancers were females who had been treated with radiotherapy to the neck before the age of 10. The cumulative incidence of thyroid cancer by age 50 was 17.3% in these patients.

The investigators noted that HL patients treated more recently are likely to have received lower doses and volumes of radiotherapy compared to patients treated in the 1950s, ’60s and ’70s.

“However, for the cohort of patients treated between 1955 and 1986, it is clear that continued surveillance for SMNs is essential because their risk continues to increase as these survivors enter their fourth and subsequent decades of life,” the investigators wrote.

They did not report a funding source for this research or make any conflict-of-interest disclosures.

The FP recognized that this could be a wart but was concerned that it might be a squamous cell carcinoma (SCC) related to HPV and sun exposure.

He performed a shave biopsy and the pathology report indicated it was an SCC in situ. (See the Watch & Learn video on “Shave biopsy.”)  At the follow-up visit, the FP reviewed the patient’s treatment options, which included topical 5% fluorouracil, topical imiquimod, and surgical excision. He also explained that the topical treatments were off label, so these options might have a lower success rate than the surgery.

The patient chose to have the surgery, even though he’d be out of work while the excision site was healing. The FP provided counseling about sun avoidance, the consistent use of a hat outdoors, and the use of sunscreens when exposed to the sun. He also referred the patient to a dermatologist who had extensive experience doing skin cancer surgery.

‌

Photos and text for Photo Rounds Friday courtesy of Richard P. Usatine, MD. This case was adapted from: Karnes J, Usatine R. Squamous cell carcinoma. In: Usatine R, Smith M, Mayeaux EJ, et al. Color Atlas of Family Medicine. 2nd ed. New York, NY: McGraw-Hill; 2013:999-1007.

To learn more about the Color Atlas of Family Medicine, see: www.amazon.com/Color-Family-Medicine-Richard-Usatine/dp/0071769641/.

The new third edition will be available in January 2019: https://www.amazon.com/Color-Atlas-Synopsis-Family-Medicine/dp/1259862046/.

You can also get the second edition of the Color Atlas of Family Medicine as an app by clicking on this link: usatinemedia.com.

The FP recognized that this could be a wart but was concerned that it might be a squamous cell carcinoma (SCC) related to HPV and sun exposure.

He performed a shave biopsy and the pathology report indicated it was an SCC in situ. (See the Watch & Learn video on “Shave biopsy.”)  At the follow-up visit, the FP reviewed the patient’s treatment options, which included topical 5% fluorouracil, topical imiquimod, and surgical excision. He also explained that the topical treatments were off label, so these options might have a lower success rate than the surgery.

The patient chose to have the surgery, even though he’d be out of work while the excision site was healing. The FP provided counseling about sun avoidance, the consistent use of a hat outdoors, and the use of sunscreens when exposed to the sun. He also referred the patient to a dermatologist who had extensive experience doing skin cancer surgery.

‌

Photos and text for Photo Rounds Friday courtesy of Richard P. Usatine, MD. This case was adapted from: Karnes J, Usatine R. Squamous cell carcinoma. In: Usatine R, Smith M, Mayeaux EJ, et al. Color Atlas of Family Medicine. 2nd ed. New York, NY: McGraw-Hill; 2013:999-1007.

To learn more about the Color Atlas of Family Medicine, see: www.amazon.com/Color-Family-Medicine-Richard-Usatine/dp/0071769641/.

The new third edition will be available in January 2019: https://www.amazon.com/Color-Atlas-Synopsis-Family-Medicine/dp/1259862046/.

You can also get the second edition of the Color Atlas of Family Medicine as an app by clicking on this link: usatinemedia.com.

The FP recognized that this could be a wart but was concerned that it might be a squamous cell carcinoma (SCC) related to HPV and sun exposure.

He performed a shave biopsy and the pathology report indicated it was an SCC in situ. (See the Watch & Learn video on “Shave biopsy.”)  At the follow-up visit, the FP reviewed the patient’s treatment options, which included topical 5% fluorouracil, topical imiquimod, and surgical excision. He also explained that the topical treatments were off label, so these options might have a lower success rate than the surgery.

The patient chose to have the surgery, even though he’d be out of work while the excision site was healing. The FP provided counseling about sun avoidance, the consistent use of a hat outdoors, and the use of sunscreens when exposed to the sun. He also referred the patient to a dermatologist who had extensive experience doing skin cancer surgery.

‌

Photos and text for Photo Rounds Friday courtesy of Richard P. Usatine, MD. This case was adapted from: Karnes J, Usatine R. Squamous cell carcinoma. In: Usatine R, Smith M, Mayeaux EJ, et al. Color Atlas of Family Medicine. 2nd ed. New York, NY: McGraw-Hill; 2013:999-1007.

To learn more about the Color Atlas of Family Medicine, see: www.amazon.com/Color-Family-Medicine-Richard-Usatine/dp/0071769641/.

The new third edition will be available in January 2019: https://www.amazon.com/Color-Atlas-Synopsis-Family-Medicine/dp/1259862046/.

You can also get the second edition of the Color Atlas of Family Medicine as an app by clicking on this link: usatinemedia.com.

The suicide rate among veterans is almost double that of the general American population. It has been rising among those who served in the wars in Iraq and Afghanistan.

monkeybusinessimages/ThinkStock

“At a time when 20 veterans a day still die by suicide, [the Department of Veterans Affairs] should be doing everything in its power to inform the public about the resources available to veterans in crisis,” Rep. Tim Walz, the Minnesota Democrat who requested the investigation, reportedly said in a statement. “Unfortunately, VA failed to do that.”

Mr. Walz was referring to a failure in prevention efforts that was detailed in a Government Accountability Office report released recently and was the subject of an article in the New York Times. The report blames bureaucratic confusion and an absence of leadership – epitomized by several department vacancies.

“This is such an important issue; we need to be throwing everything we can at it,” said Caitin Thompson, PhD. She was director of the VA’s suicide prevention efforts but resigned in frustration in mid-2017. “It’s so ludicrous that money would be sitting on the table. Outreach is one of the first ways to engage with veterans and families about ways to get help. If we don’t have that, what do we have?”

Surviving the holidays with depression

The postcard image of the Christmas season is that of joyous celebration with family and friends. For many people, however, this image is false. Many complain about feelings of stress imposed by familial obligations, pressure to conform to those postcard myths, and the financial toll that all of that holiday largesse can exact.

Now add depression to this mix. How can those burdened by depression find some joy at this time of year? In a recent article in the Huffington Post, author Andrea Loewen advises staying away from social media and focusing on the positive.

“[Social media] is a double-edged sword: Either I see all the amazing things everyone else is doing and feel jealous/insignificant/left out, or I see that no one else is really posting and assume they must be too busy having incredible quality time with their families while I’m the unengaged loser scrolling Instagram,” Ms. Loewen wrote. “Either way, it’s bad news.”

One concrete practice that she engages in is taking a few minutes to think about and write down the positive things that happened each day.

“The list includes everything, big and small: from the thoughtful gift I wasn’t expecting to the simple observation that a friend seemed happy to see me,” Ms. Loewen wrote. “Depending on where I’m at in my depression, those seemingly tiny details can be vital reminders I hold a valuable place in the world.”

Artist perpetuates persistent myth

In some ways, Kanye West embraces his diagnosis of bipolar disorder. He calls the illness his “superpower,” and the art on his new album, “Ye,” includes the phrase: “I hate being Bi-Polar/it’s awesome.” But his decision to abandon his medications promotes a myth, Amanda Mull wrote in an opinion piece in the Atlantic.

“In apparently quitting his psychiatric medication for the sake of his creativity, Mr. West is promoting one of mental health’s most persistent and dangerous myths: that suffering is necessary for great art,” Ms. Mull wrote.

Philip R. Muskin, MD, who is affiliated with the department of psychiatry at Columbia University in New York, agreed that linking mental turmoil with creative genius is indeed problematic. “Creative people are not creative when they’re depressed, or so manic that no one can tolerate being with them and they start to merge into psychosis, or when they’re filled with numbing anxiety,” he said in the Atlantic article.

Esmé Weijun Wang concurred and offered a counterview to that of Mr. West. A novelist who has written about living with schizoaffective disorder, she said: “It may be true that mental illness has given me insights with which to work, creatively speaking, but it’s also made me too sick to use that creativity. The voice in my head that says, ‘Die, die, die’ is not a voice that encourages putting together a short story.”

For his part, Mr. West’s decision to stop taking his medicine threatens to undermine his own mental health. And his public musings could drive others away from treatment.

“Antiopioid backlash” causes pain

An article by Fox News has highlighted the daily toll that opioid addiction is exacting on Americans. Government efforts aimed at quelling the use of opioids by targeting availability have had the unintended consequence of the cut-off of prescriptions by many physicians. With that route turned off, many people are turning to other sources for pain relief – or are being left with no relief.

One person in the article related how his wife is unable to obtain pain relief for her neurologic and spinal diseases. “A welcome death has become a discussion,” he said.

Meanwhile, a 69-year-old veteran said the Department of Veterans Affairs ended his pain medication. “I now buy heroin on the street.”

Another person in the article, Herb Erne III, wrote: “As a nurse, I have seen addicts and the other end of opioid abuse. But there is another side to this crisis that people are not talking about, those that actually need pain medications but cannot get them because of the ‘fear factor’ of running afoul of the antiopioid – including legal ones taken safely under medical supervision – backlash.

“The chronically ill who do not abuse, who do not divert, have become the unintended victims of misguided and overzealous efforts by policy- and regulation-making bodies in the government,” he said.

Grandparents filling void

An article in the Detroit News reported on more carnage of the opioid crisis. In Michigan and elsewhere nationwide, increasing numbers of parents with opioid addiction are unable to safely care for their children or have died because of an overdose. Grandparents are stepping in to assume care.

Results of a national survey involving more than 1,000 grandparents found that 20% are the daily caregivers to their grandchildren. They can be on their own, without any financial aid from state or national programs. Other children without grandparents can be diverted to foster care.

It’s a role few grandparents anticipated. “Our system as a whole is messed up. It tears at my heart,” 47-year-old Christina Wasilewski said in the article. “Everyone keeps saying children are resilient, but only to a point.”

Ms. Wasilewski and her husband assumed care for their granddaughter when they discovered her in physical distress from lack of care.

In Michigan, the increase in the rate of opioid-related deaths slowed in 2017 but deaths still rose 9% from 2016 , according to the Michigan Department of Health & Human Services. The prior year the death rate was 35%. In Michigan, grandparents raising their grandchildren do not have legal parental rights for this care, including the right to seek medical care and to pursue educational options.

Ms. Wasilewski’s concern about these trends led her to launch the Caregiver Cafe, a support group for grandparents raising their grandchildren.

The suicide rate among veterans is almost double that of the general American population. It has been rising among those who served in the wars in Iraq and Afghanistan.

monkeybusinessimages/ThinkStock

“At a time when 20 veterans a day still die by suicide, [the Department of Veterans Affairs] should be doing everything in its power to inform the public about the resources available to veterans in crisis,” Rep. Tim Walz, the Minnesota Democrat who requested the investigation, reportedly said in a statement. “Unfortunately, VA failed to do that.”

Mr. Walz was referring to a failure in prevention efforts that was detailed in a Government Accountability Office report released recently and was the subject of an article in the New York Times. The report blames bureaucratic confusion and an absence of leadership – epitomized by several department vacancies.

“This is such an important issue; we need to be throwing everything we can at it,” said Caitin Thompson, PhD. She was director of the VA’s suicide prevention efforts but resigned in frustration in mid-2017. “It’s so ludicrous that money would be sitting on the table. Outreach is one of the first ways to engage with veterans and families about ways to get help. If we don’t have that, what do we have?”

Surviving the holidays with depression

The postcard image of the Christmas season is that of joyous celebration with family and friends. For many people, however, this image is false. Many complain about feelings of stress imposed by familial obligations, pressure to conform to those postcard myths, and the financial toll that all of that holiday largesse can exact.

Now add depression to this mix. How can those burdened by depression find some joy at this time of year? In a recent article in the Huffington Post, author Andrea Loewen advises staying away from social media and focusing on the positive.

“[Social media] is a double-edged sword: Either I see all the amazing things everyone else is doing and feel jealous/insignificant/left out, or I see that no one else is really posting and assume they must be too busy having incredible quality time with their families while I’m the unengaged loser scrolling Instagram,” Ms. Loewen wrote. “Either way, it’s bad news.”

One concrete practice that she engages in is taking a few minutes to think about and write down the positive things that happened each day.

“The list includes everything, big and small: from the thoughtful gift I wasn’t expecting to the simple observation that a friend seemed happy to see me,” Ms. Loewen wrote. “Depending on where I’m at in my depression, those seemingly tiny details can be vital reminders I hold a valuable place in the world.”

Artist perpetuates persistent myth

In some ways, Kanye West embraces his diagnosis of bipolar disorder. He calls the illness his “superpower,” and the art on his new album, “Ye,” includes the phrase: “I hate being Bi-Polar/it’s awesome.” But his decision to abandon his medications promotes a myth, Amanda Mull wrote in an opinion piece in the Atlantic.

“In apparently quitting his psychiatric medication for the sake of his creativity, Mr. West is promoting one of mental health’s most persistent and dangerous myths: that suffering is necessary for great art,” Ms. Mull wrote.

Philip R. Muskin, MD, who is affiliated with the department of psychiatry at Columbia University in New York, agreed that linking mental turmoil with creative genius is indeed problematic. “Creative people are not creative when they’re depressed, or so manic that no one can tolerate being with them and they start to merge into psychosis, or when they’re filled with numbing anxiety,” he said in the Atlantic article.

Esmé Weijun Wang concurred and offered a counterview to that of Mr. West. A novelist who has written about living with schizoaffective disorder, she said: “It may be true that mental illness has given me insights with which to work, creatively speaking, but it’s also made me too sick to use that creativity. The voice in my head that says, ‘Die, die, die’ is not a voice that encourages putting together a short story.”

For his part, Mr. West’s decision to stop taking his medicine threatens to undermine his own mental health. And his public musings could drive others away from treatment.

“Antiopioid backlash” causes pain

An article by Fox News has highlighted the daily toll that opioid addiction is exacting on Americans. Government efforts aimed at quelling the use of opioids by targeting availability have had the unintended consequence of the cut-off of prescriptions by many physicians. With that route turned off, many people are turning to other sources for pain relief – or are being left with no relief.

One person in the article related how his wife is unable to obtain pain relief for her neurologic and spinal diseases. “A welcome death has become a discussion,” he said.

Meanwhile, a 69-year-old veteran said the Department of Veterans Affairs ended his pain medication. “I now buy heroin on the street.”

Another person in the article, Herb Erne III, wrote: “As a nurse, I have seen addicts and the other end of opioid abuse. But there is another side to this crisis that people are not talking about, those that actually need pain medications but cannot get them because of the ‘fear factor’ of running afoul of the antiopioid – including legal ones taken safely under medical supervision – backlash.

“The chronically ill who do not abuse, who do not divert, have become the unintended victims of misguided and overzealous efforts by policy- and regulation-making bodies in the government,” he said.

Grandparents filling void

An article in the Detroit News reported on more carnage of the opioid crisis. In Michigan and elsewhere nationwide, increasing numbers of parents with opioid addiction are unable to safely care for their children or have died because of an overdose. Grandparents are stepping in to assume care.

Results of a national survey involving more than 1,000 grandparents found that 20% are the daily caregivers to their grandchildren. They can be on their own, without any financial aid from state or national programs. Other children without grandparents can be diverted to foster care.

It’s a role few grandparents anticipated. “Our system as a whole is messed up. It tears at my heart,” 47-year-old Christina Wasilewski said in the article. “Everyone keeps saying children are resilient, but only to a point.”

Ms. Wasilewski and her husband assumed care for their granddaughter when they discovered her in physical distress from lack of care.

In Michigan, the increase in the rate of opioid-related deaths slowed in 2017 but deaths still rose 9% from 2016 , according to the Michigan Department of Health & Human Services. The prior year the death rate was 35%. In Michigan, grandparents raising their grandchildren do not have legal parental rights for this care, including the right to seek medical care and to pursue educational options.

Ms. Wasilewski’s concern about these trends led her to launch the Caregiver Cafe, a support group for grandparents raising their grandchildren.

The suicide rate among veterans is almost double that of the general American population. It has been rising among those who served in the wars in Iraq and Afghanistan.

monkeybusinessimages/ThinkStock

“At a time when 20 veterans a day still die by suicide, [the Department of Veterans Affairs] should be doing everything in its power to inform the public about the resources available to veterans in crisis,” Rep. Tim Walz, the Minnesota Democrat who requested the investigation, reportedly said in a statement. “Unfortunately, VA failed to do that.”

Mr. Walz was referring to a failure in prevention efforts that was detailed in a Government Accountability Office report released recently and was the subject of an article in the New York Times. The report blames bureaucratic confusion and an absence of leadership – epitomized by several department vacancies.

“This is such an important issue; we need to be throwing everything we can at it,” said Caitin Thompson, PhD. She was director of the VA’s suicide prevention efforts but resigned in frustration in mid-2017. “It’s so ludicrous that money would be sitting on the table. Outreach is one of the first ways to engage with veterans and families about ways to get help. If we don’t have that, what do we have?”

Surviving the holidays with depression

The postcard image of the Christmas season is that of joyous celebration with family and friends. For many people, however, this image is false. Many complain about feelings of stress imposed by familial obligations, pressure to conform to those postcard myths, and the financial toll that all of that holiday largesse can exact.

Now add depression to this mix. How can those burdened by depression find some joy at this time of year? In a recent article in the Huffington Post, author Andrea Loewen advises staying away from social media and focusing on the positive.

“[Social media] is a double-edged sword: Either I see all the amazing things everyone else is doing and feel jealous/insignificant/left out, or I see that no one else is really posting and assume they must be too busy having incredible quality time with their families while I’m the unengaged loser scrolling Instagram,” Ms. Loewen wrote. “Either way, it’s bad news.”

One concrete practice that she engages in is taking a few minutes to think about and write down the positive things that happened each day.

“The list includes everything, big and small: from the thoughtful gift I wasn’t expecting to the simple observation that a friend seemed happy to see me,” Ms. Loewen wrote. “Depending on where I’m at in my depression, those seemingly tiny details can be vital reminders I hold a valuable place in the world.”

Artist perpetuates persistent myth

In some ways, Kanye West embraces his diagnosis of bipolar disorder. He calls the illness his “superpower,” and the art on his new album, “Ye,” includes the phrase: “I hate being Bi-Polar/it’s awesome.” But his decision to abandon his medications promotes a myth, Amanda Mull wrote in an opinion piece in the Atlantic.

“In apparently quitting his psychiatric medication for the sake of his creativity, Mr. West is promoting one of mental health’s most persistent and dangerous myths: that suffering is necessary for great art,” Ms. Mull wrote.

Philip R. Muskin, MD, who is affiliated with the department of psychiatry at Columbia University in New York, agreed that linking mental turmoil with creative genius is indeed problematic. “Creative people are not creative when they’re depressed, or so manic that no one can tolerate being with them and they start to merge into psychosis, or when they’re filled with numbing anxiety,” he said in the Atlantic article.

Esmé Weijun Wang concurred and offered a counterview to that of Mr. West. A novelist who has written about living with schizoaffective disorder, she said: “It may be true that mental illness has given me insights with which to work, creatively speaking, but it’s also made me too sick to use that creativity. The voice in my head that says, ‘Die, die, die’ is not a voice that encourages putting together a short story.”

For his part, Mr. West’s decision to stop taking his medicine threatens to undermine his own mental health. And his public musings could drive others away from treatment.

“Antiopioid backlash” causes pain

An article by Fox News has highlighted the daily toll that opioid addiction is exacting on Americans. Government efforts aimed at quelling the use of opioids by targeting availability have had the unintended consequence of the cut-off of prescriptions by many physicians. With that route turned off, many people are turning to other sources for pain relief – or are being left with no relief.

One person in the article related how his wife is unable to obtain pain relief for her neurologic and spinal diseases. “A welcome death has become a discussion,” he said.

Meanwhile, a 69-year-old veteran said the Department of Veterans Affairs ended his pain medication. “I now buy heroin on the street.”

Another person in the article, Herb Erne III, wrote: “As a nurse, I have seen addicts and the other end of opioid abuse. But there is another side to this crisis that people are not talking about, those that actually need pain medications but cannot get them because of the ‘fear factor’ of running afoul of the antiopioid – including legal ones taken safely under medical supervision – backlash.

“The chronically ill who do not abuse, who do not divert, have become the unintended victims of misguided and overzealous efforts by policy- and regulation-making bodies in the government,” he said.

Grandparents filling void

An article in the Detroit News reported on more carnage of the opioid crisis. In Michigan and elsewhere nationwide, increasing numbers of parents with opioid addiction are unable to safely care for their children or have died because of an overdose. Grandparents are stepping in to assume care.

Results of a national survey involving more than 1,000 grandparents found that 20% are the daily caregivers to their grandchildren. They can be on their own, without any financial aid from state or national programs. Other children without grandparents can be diverted to foster care.

It’s a role few grandparents anticipated. “Our system as a whole is messed up. It tears at my heart,” 47-year-old Christina Wasilewski said in the article. “Everyone keeps saying children are resilient, but only to a point.”

Ms. Wasilewski and her husband assumed care for their granddaughter when they discovered her in physical distress from lack of care.

In Michigan, the increase in the rate of opioid-related deaths slowed in 2017 but deaths still rose 9% from 2016 , according to the Michigan Department of Health & Human Services. The prior year the death rate was 35%. In Michigan, grandparents raising their grandchildren do not have legal parental rights for this care, including the right to seek medical care and to pursue educational options.

Ms. Wasilewski’s concern about these trends led her to launch the Caregiver Cafe, a support group for grandparents raising their grandchildren.

Tofacitinib significantly improved skin lesions associated with cutaneous sarcoidosis, according to a case report published in the New England Journal of Medicine.

Treatment options for cutaneous sarcoidosis are limited, as are data on the effectiveness of alternatives to prednisone, which is often the first choice despite adverse effects, wrote William Damsky, MD, of Yale University in New Haven, Conn., and his colleagues.

Previous studies have suggested involvement of the JAK-STAT pathway in sarcoidosis; therefore, the researchers treated a patient who had refractory cutaneous sarcoidosis with oral tofacitinib. The treatment significantly improved the patient’s skin lesions both clinically and histologically.

The patient was a 48-year-old woman with a history of cutaneous and pulmonary sarcoidosis and treatment-resistant skin lesions. At the time of the case report, she had no pulmonary symptoms and no ophthalmologic issues, but presented with pink-brown indurated papules and plaques, and some alopecia on her scalp (N Engl J Med. 2018;379:2540-6).

The patient had not responded to other medications including glucocorticoids, minocycline, hydroxychloroquine, methotrexate, adalimumab, tacrolimus, and apremilast. With her consent, the patient received off-label tofacitinib at 5 mg twice daily. The lesions began to improve, but treatment was discontinued because of insurance issues. When treatment resumed, the patient’s Cutaneous Sarcoidosis Activity and Morphology Instrument (CSAMI) score, used to assess disease activity, was 85 on a scale of 0 to 165; this score dropped to 53 after 4 months of treatment.

In addition, two samples collected after 10 months of treatment showed histologic resolution of granulomas.

Although the findings must be replicated in other patients, the results suggest that “the dysregulation of JAK-STAT–dependent cytokines (e.g., interferon-gamma) is pathogenically involved in cutaneous sarcoidosis and, probably, in sarcoidosis in general,” the researchers said.

Dr. Damsky disclosed a financial relationship with Eli Lilly, and research funding from the Dermatology Foundation and the National Institutes of Health. The study was supported by the Ranjini and Ajay Poddar Resource Fund for Dermatologic Diseases Research, the National Institutes of Health, and the Dermatology Foundation.
 

SOURCE: Damsky W et al. N Engl J Med. 2018;379:2540-6.

Tofacitinib significantly improved skin lesions associated with cutaneous sarcoidosis, according to a case report published in the New England Journal of Medicine.

Treatment options for cutaneous sarcoidosis are limited, as are data on the effectiveness of alternatives to prednisone, which is often the first choice despite adverse effects, wrote William Damsky, MD, of Yale University in New Haven, Conn., and his colleagues.

Previous studies have suggested involvement of the JAK-STAT pathway in sarcoidosis; therefore, the researchers treated a patient who had refractory cutaneous sarcoidosis with oral tofacitinib. The treatment significantly improved the patient’s skin lesions both clinically and histologically.

The patient was a 48-year-old woman with a history of cutaneous and pulmonary sarcoidosis and treatment-resistant skin lesions. At the time of the case report, she had no pulmonary symptoms and no ophthalmologic issues, but presented with pink-brown indurated papules and plaques, and some alopecia on her scalp (N Engl J Med. 2018;379:2540-6).

The patient had not responded to other medications including glucocorticoids, minocycline, hydroxychloroquine, methotrexate, adalimumab, tacrolimus, and apremilast. With her consent, the patient received off-label tofacitinib at 5 mg twice daily. The lesions began to improve, but treatment was discontinued because of insurance issues. When treatment resumed, the patient’s Cutaneous Sarcoidosis Activity and Morphology Instrument (CSAMI) score, used to assess disease activity, was 85 on a scale of 0 to 165; this score dropped to 53 after 4 months of treatment.

In addition, two samples collected after 10 months of treatment showed histologic resolution of granulomas.

Although the findings must be replicated in other patients, the results suggest that “the dysregulation of JAK-STAT–dependent cytokines (e.g., interferon-gamma) is pathogenically involved in cutaneous sarcoidosis and, probably, in sarcoidosis in general,” the researchers said.

Dr. Damsky disclosed a financial relationship with Eli Lilly, and research funding from the Dermatology Foundation and the National Institutes of Health. The study was supported by the Ranjini and Ajay Poddar Resource Fund for Dermatologic Diseases Research, the National Institutes of Health, and the Dermatology Foundation.
 

SOURCE: Damsky W et al. N Engl J Med. 2018;379:2540-6.

Tofacitinib significantly improved skin lesions associated with cutaneous sarcoidosis, according to a case report published in the New England Journal of Medicine.

Treatment options for cutaneous sarcoidosis are limited, as are data on the effectiveness of alternatives to prednisone, which is often the first choice despite adverse effects, wrote William Damsky, MD, of Yale University in New Haven, Conn., and his colleagues.

Previous studies have suggested involvement of the JAK-STAT pathway in sarcoidosis; therefore, the researchers treated a patient who had refractory cutaneous sarcoidosis with oral tofacitinib. The treatment significantly improved the patient’s skin lesions both clinically and histologically.

The patient was a 48-year-old woman with a history of cutaneous and pulmonary sarcoidosis and treatment-resistant skin lesions. At the time of the case report, she had no pulmonary symptoms and no ophthalmologic issues, but presented with pink-brown indurated papules and plaques, and some alopecia on her scalp (N Engl J Med. 2018;379:2540-6).

The patient had not responded to other medications including glucocorticoids, minocycline, hydroxychloroquine, methotrexate, adalimumab, tacrolimus, and apremilast. With her consent, the patient received off-label tofacitinib at 5 mg twice daily. The lesions began to improve, but treatment was discontinued because of insurance issues. When treatment resumed, the patient’s Cutaneous Sarcoidosis Activity and Morphology Instrument (CSAMI) score, used to assess disease activity, was 85 on a scale of 0 to 165; this score dropped to 53 after 4 months of treatment.

In addition, two samples collected after 10 months of treatment showed histologic resolution of granulomas.

Although the findings must be replicated in other patients, the results suggest that “the dysregulation of JAK-STAT–dependent cytokines (e.g., interferon-gamma) is pathogenically involved in cutaneous sarcoidosis and, probably, in sarcoidosis in general,” the researchers said.

Dr. Damsky disclosed a financial relationship with Eli Lilly, and research funding from the Dermatology Foundation and the National Institutes of Health. The study was supported by the Ranjini and Ajay Poddar Resource Fund for Dermatologic Diseases Research, the National Institutes of Health, and the Dermatology Foundation.
 

SOURCE: Damsky W et al. N Engl J Med. 2018;379:2540-6.

ADHD is significantly more common and is associated with worse outcomes in patients with bipolar disorder, according to Ross J. Baldessarini, MD, of McLean Hospital and Harvard Medical School, Boston, and his associates.

In a study of 703 patients diagnosed with bipolar disorder (BD) type I or II who were evaluated, treated, and followed at the Lucio Bini Mood Disorder Centers in Rome and Cagliari, Italy, 173 patients had co-occurring lifetime ADHD. Co-occurring conditions were more likely in men and in those with BD-I. The lifetime ADHD prevalence rate of 24.6% in patients with bipolar disorder is significantly higher than the incidence in the general population, the investigators wrote in the Journal of Affective Disorders.

Patients with co-occurring ADHD and BD were more likely to have performed worse in school, have higher Adult ADHD Self-Report Scale scores, be unemployed, have lower socioeconomic status, be married, have separated, have substance abuse, have attempted suicide, and have hypomania, compared with patients with only BD. However, they were less likely to have an anxiety disorder or a family history of mood disorders.

“The association of ADHD with a less successful and stable educational history, more unemployment, lack of or failed marriages, and greater risk of suicide attempts and substance abuse indicates unfavorable effects of having ADHD with BD. Such effects may arise by the impact of ADHD early during development,” the investigators concluded.

The study was partly supported by a research award from the Aretaeus Association of Rome and grants from the Bruce J. Anderson Foundation and the McLean Private Donors Research Fund. No conflicts of interest were reported.

[email protected]

SOURCE: Baldessarini RJ et al. J Affect Disord. 2018 Sep 17. doi: 10.1016/j.jad.2018.09.038.

ADHD is significantly more common and is associated with worse outcomes in patients with bipolar disorder, according to Ross J. Baldessarini, MD, of McLean Hospital and Harvard Medical School, Boston, and his associates.

In a study of 703 patients diagnosed with bipolar disorder (BD) type I or II who were evaluated, treated, and followed at the Lucio Bini Mood Disorder Centers in Rome and Cagliari, Italy, 173 patients had co-occurring lifetime ADHD. Co-occurring conditions were more likely in men and in those with BD-I. The lifetime ADHD prevalence rate of 24.6% in patients with bipolar disorder is significantly higher than the incidence in the general population, the investigators wrote in the Journal of Affective Disorders.

Patients with co-occurring ADHD and BD were more likely to have performed worse in school, have higher Adult ADHD Self-Report Scale scores, be unemployed, have lower socioeconomic status, be married, have separated, have substance abuse, have attempted suicide, and have hypomania, compared with patients with only BD. However, they were less likely to have an anxiety disorder or a family history of mood disorders.

“The association of ADHD with a less successful and stable educational history, more unemployment, lack of or failed marriages, and greater risk of suicide attempts and substance abuse indicates unfavorable effects of having ADHD with BD. Such effects may arise by the impact of ADHD early during development,” the investigators concluded.

The study was partly supported by a research award from the Aretaeus Association of Rome and grants from the Bruce J. Anderson Foundation and the McLean Private Donors Research Fund. No conflicts of interest were reported.

[email protected]

SOURCE: Baldessarini RJ et al. J Affect Disord. 2018 Sep 17. doi: 10.1016/j.jad.2018.09.038.

ADHD is significantly more common and is associated with worse outcomes in patients with bipolar disorder, according to Ross J. Baldessarini, MD, of McLean Hospital and Harvard Medical School, Boston, and his associates.

In a study of 703 patients diagnosed with bipolar disorder (BD) type I or II who were evaluated, treated, and followed at the Lucio Bini Mood Disorder Centers in Rome and Cagliari, Italy, 173 patients had co-occurring lifetime ADHD. Co-occurring conditions were more likely in men and in those with BD-I. The lifetime ADHD prevalence rate of 24.6% in patients with bipolar disorder is significantly higher than the incidence in the general population, the investigators wrote in the Journal of Affective Disorders.

Patients with co-occurring ADHD and BD were more likely to have performed worse in school, have higher Adult ADHD Self-Report Scale scores, be unemployed, have lower socioeconomic status, be married, have separated, have substance abuse, have attempted suicide, and have hypomania, compared with patients with only BD. However, they were less likely to have an anxiety disorder or a family history of mood disorders.

“The association of ADHD with a less successful and stable educational history, more unemployment, lack of or failed marriages, and greater risk of suicide attempts and substance abuse indicates unfavorable effects of having ADHD with BD. Such effects may arise by the impact of ADHD early during development,” the investigators concluded.

The study was partly supported by a research award from the Aretaeus Association of Rome and grants from the Bruce J. Anderson Foundation and the McLean Private Donors Research Fund. No conflicts of interest were reported.

[email protected]

SOURCE: Baldessarini RJ et al. J Affect Disord. 2018 Sep 17. doi: 10.1016/j.jad.2018.09.038.

LOS ANGELES – Mounting evidence indicates that obesity in childhood and adolescence increases the risk for future cardiovascular disease (CVD), according to Stephen R. Daniels, MD, PhD.

Doug Brunk/MDedge News

“Some of this increased risk is related to the high level of tracking of obesity from childhood to adolescence to adulthood,” Dr. Daniels, who chairs the department of pediatrics at the University of Colorado, Aurora, said at the World Congress on Insulin Resistance, Diabetes & Cardiovascular Disease. “But I think it’s also clear that childhood obesity is associated with risk factors for adult CVD, including hypertension, dyslipidemia, and type 2 diabetes. There’s a combination of things going on over the life course.”

Numerous studies have demonstrated a dose-response relationship between increased weight and all-cause mortality in cardiovascular disease for men and women. This operates through a variety of mechanisms, Dr. Daniels said, including hypertension, dyslipidemia, left ventricular hypertrophy, vascular inflammation, type 2 diabetes, and obstructive sleep apnea. “While overt cardiovascular disease does not occur in children, many of the mechanisms recognized in adults are also present in children and adolescents,” he said. “The trends for increasing prevalence and severity of obesity in children and the comorbid conditions associated with obesity are worrisome.”

The current prevalence of obesity in children and adolescents stands at about 18%, according to the latest National Health and Nutrition Examination Survey. However, the prevalence of severe obesity in youth aged 2-19 years has been increasing “fairly dramatically,” and now stands at 9% among girls and 8% among boys. Hispanics and non-Hispanic blacks are disproportionately affected. That may turn out to be important in terms of the future, Dr. Daniels said, because according to simulation models, childhood obesity and overweight will continue to be a major public health problem in the future (N Engl J Med. 2017;377:2145-53).


Direct evidence is also beginning to emerge of a link between obesity in youth and adult cardiovascular disease. The factors in childhood that predict adult obesity include a higher level of body mass index, obesity present at an older age (adolescence vs. childhood), and the presence of obesity in parents, which reflects both genes and environment. Researchers led by Paul W. Franks, PhD, evaluated 4,857 American Indian children without diabetes who were born between 1945 and 1984 and followed them for death before age 55 (N Engl J Med. 2010;362[6]:485-93). They assessed whether BMI, glucose tolerance, blood pressure, and cholesterol levels predicted premature death. There were 166 deaths from endogenous causes (3.4%) over a median follow-up of 24 years. Factors significantly associated with mortality included obesity (incident rate ratio 2.30), glucose tolerance (IRR 1.73), and hypertension (IRR 1.57).

In a separate analysis, researchers investigated the long-term effects of childhood weight on coronary heart disease (CHD) by studying 276,835 Danish schoolchildren for whom measurements of height and weight were available. They followed the individuals until they turned age 25 or older and used national registries to assess the fatal and nonfatal rates of CHD events (N Engl J Med. 2007;357:2329-37). The researchers found that higher BMI during childhood was associated with an increased risk of CVD in adulthood. However, they did not have data on BMI in adulthood, “which leaves open the question of whether childhood obesity works through adult obesity or also has an independent effect,” said Dr. Daniels, who is also pediatrician-in-chief at Children’s Hospital Colorado, Denver.

More recently, investigators studied 37,674 apparently healthy Israeli men from age 17 into adulthood (N Engl J Med. 2011;364:1315-25). Outcomes were coronary disease and diabetes. They found that an elevated BMI in adolescence is an independent risk factor for CVD in later life, while an elevated BMI in adulthood is an independent risk factor for both CVD and diabetes.

In the Fels Longitudinal Study, researchers enrolled 151 adults with metabolic syndrome and 154 without metabolic syndrome, with a mean age of 51 years (J Pediatr. 2008;152:191-200). “The idea was to look back at this cohort and see when the first differences might be observable between boys and girls who ultimately would develop metabolic syndrome and those who would not,” said Dr. Daniels, who was one of the study investigators. The first appearance of differences between adults with and without metabolic syndrome occurred at ages 8 and 13 for BMI and 6 and 13 for waist circumference in boys and girls, respectively. Odds ratios (ORs) for the metabolic syndrome in adulthood if BMI were elevated in childhood ranged from 1.4 to 1.9 in boys and from 0.8 to 2.8 in girls. At the same time, odds ratios for the metabolic syndrome in adulthood if waist circumference was elevated ranged from 2.5 to 31.4 in boys and 1.7 to 2.5 in girls.

“I think it’s safe to say that BMI and waist circumference may be important in predicting metabolic syndrome later in life and, ultimately, cardiovascular disease,” Dr. Daniels said.

He noted that as the prevalence and severity of obesity have increased in childhood, the prevalence of type 2 diabetes has also increased. “The time from diagnosis of diabetes to a CVD event is approximately 10-15 years in adults, and there is often a prediagnosis period of hyperglycemia, which ranges from 5-10 years,” Dr. Daniels said. “If the time course of CVD related to diabetes is the same for adolescents as adults, it is anticipated that adolescents with diabetes will begin having substantial CVD morbidity and mortality in their 30s or 40s. This will be a public health disaster. Emerging evidence from the TODAY study (Treatment Options for type 2 Diabetes in Adolescents and Youth) and other studies is emphasizing that at least some individuals with adolescent type 2 diabetes may have a more malignant form of disease than in adults. This is striking and important to consider as we look at how to prevent cardiovascular disease.”

Obesity in childhood is also associated with structural and functional abnormalities of the vasculature, according to studies that measure vascular structure via intima-media thickness of the carotid arteries, femoral arteries, abdominal aorta, or other arteries, as well as those that measure vascular stiffness via measures of intrinsic “visco-elastic” properties of the arterial wall. In one study of individuals aged 10-24 years, Dr. Daniels and his associates performed carotid ultrasound for carotid intima-media thickness on 182 patients who were lean, 136 who were obese, and 128 who had type 2 diabetes (Circulation 2009;119(22):2913-9). It demonstrated that youth with obesity and obesity-related type 2 diabetes have abnormalities in carotid thickness and stiffness that are only partially explained by traditional cardiovascular risk factors.

“We all know that obesity is very difficult to treat,” he concluded. “That’s true in children and adolescents as it is in adults. I think this argues for prevention of obesity, for us starting earlier, creating an optimal cardiovascular health situation that we can maintain during the course of childhood and adolescence. The payoff will be great if we can accomplish that.”

Dr. Daniels reported having no disclosures.

[email protected]

LOS ANGELES – Mounting evidence indicates that obesity in childhood and adolescence increases the risk for future cardiovascular disease (CVD), according to Stephen R. Daniels, MD, PhD.

Doug Brunk/MDedge News

“Some of this increased risk is related to the high level of tracking of obesity from childhood to adolescence to adulthood,” Dr. Daniels, who chairs the department of pediatrics at the University of Colorado, Aurora, said at the World Congress on Insulin Resistance, Diabetes & Cardiovascular Disease. “But I think it’s also clear that childhood obesity is associated with risk factors for adult CVD, including hypertension, dyslipidemia, and type 2 diabetes. There’s a combination of things going on over the life course.”

Numerous studies have demonstrated a dose-response relationship between increased weight and all-cause mortality in cardiovascular disease for men and women. This operates through a variety of mechanisms, Dr. Daniels said, including hypertension, dyslipidemia, left ventricular hypertrophy, vascular inflammation, type 2 diabetes, and obstructive sleep apnea. “While overt cardiovascular disease does not occur in children, many of the mechanisms recognized in adults are also present in children and adolescents,” he said. “The trends for increasing prevalence and severity of obesity in children and the comorbid conditions associated with obesity are worrisome.”

The current prevalence of obesity in children and adolescents stands at about 18%, according to the latest National Health and Nutrition Examination Survey. However, the prevalence of severe obesity in youth aged 2-19 years has been increasing “fairly dramatically,” and now stands at 9% among girls and 8% among boys. Hispanics and non-Hispanic blacks are disproportionately affected. That may turn out to be important in terms of the future, Dr. Daniels said, because according to simulation models, childhood obesity and overweight will continue to be a major public health problem in the future (N Engl J Med. 2017;377:2145-53).


Direct evidence is also beginning to emerge of a link between obesity in youth and adult cardiovascular disease. The factors in childhood that predict adult obesity include a higher level of body mass index, obesity present at an older age (adolescence vs. childhood), and the presence of obesity in parents, which reflects both genes and environment. Researchers led by Paul W. Franks, PhD, evaluated 4,857 American Indian children without diabetes who were born between 1945 and 1984 and followed them for death before age 55 (N Engl J Med. 2010;362[6]:485-93). They assessed whether BMI, glucose tolerance, blood pressure, and cholesterol levels predicted premature death. There were 166 deaths from endogenous causes (3.4%) over a median follow-up of 24 years. Factors significantly associated with mortality included obesity (incident rate ratio 2.30), glucose tolerance (IRR 1.73), and hypertension (IRR 1.57).

In a separate analysis, researchers investigated the long-term effects of childhood weight on coronary heart disease (CHD) by studying 276,835 Danish schoolchildren for whom measurements of height and weight were available. They followed the individuals until they turned age 25 or older and used national registries to assess the fatal and nonfatal rates of CHD events (N Engl J Med. 2007;357:2329-37). The researchers found that higher BMI during childhood was associated with an increased risk of CVD in adulthood. However, they did not have data on BMI in adulthood, “which leaves open the question of whether childhood obesity works through adult obesity or also has an independent effect,” said Dr. Daniels, who is also pediatrician-in-chief at Children’s Hospital Colorado, Denver.

More recently, investigators studied 37,674 apparently healthy Israeli men from age 17 into adulthood (N Engl J Med. 2011;364:1315-25). Outcomes were coronary disease and diabetes. They found that an elevated BMI in adolescence is an independent risk factor for CVD in later life, while an elevated BMI in adulthood is an independent risk factor for both CVD and diabetes.

In the Fels Longitudinal Study, researchers enrolled 151 adults with metabolic syndrome and 154 without metabolic syndrome, with a mean age of 51 years (J Pediatr. 2008;152:191-200). “The idea was to look back at this cohort and see when the first differences might be observable between boys and girls who ultimately would develop metabolic syndrome and those who would not,” said Dr. Daniels, who was one of the study investigators. The first appearance of differences between adults with and without metabolic syndrome occurred at ages 8 and 13 for BMI and 6 and 13 for waist circumference in boys and girls, respectively. Odds ratios (ORs) for the metabolic syndrome in adulthood if BMI were elevated in childhood ranged from 1.4 to 1.9 in boys and from 0.8 to 2.8 in girls. At the same time, odds ratios for the metabolic syndrome in adulthood if waist circumference was elevated ranged from 2.5 to 31.4 in boys and 1.7 to 2.5 in girls.

“I think it’s safe to say that BMI and waist circumference may be important in predicting metabolic syndrome later in life and, ultimately, cardiovascular disease,” Dr. Daniels said.

He noted that as the prevalence and severity of obesity have increased in childhood, the prevalence of type 2 diabetes has also increased. “The time from diagnosis of diabetes to a CVD event is approximately 10-15 years in adults, and there is often a prediagnosis period of hyperglycemia, which ranges from 5-10 years,” Dr. Daniels said. “If the time course of CVD related to diabetes is the same for adolescents as adults, it is anticipated that adolescents with diabetes will begin having substantial CVD morbidity and mortality in their 30s or 40s. This will be a public health disaster. Emerging evidence from the TODAY study (Treatment Options for type 2 Diabetes in Adolescents and Youth) and other studies is emphasizing that at least some individuals with adolescent type 2 diabetes may have a more malignant form of disease than in adults. This is striking and important to consider as we look at how to prevent cardiovascular disease.”

Obesity in childhood is also associated with structural and functional abnormalities of the vasculature, according to studies that measure vascular structure via intima-media thickness of the carotid arteries, femoral arteries, abdominal aorta, or other arteries, as well as those that measure vascular stiffness via measures of intrinsic “visco-elastic” properties of the arterial wall. In one study of individuals aged 10-24 years, Dr. Daniels and his associates performed carotid ultrasound for carotid intima-media thickness on 182 patients who were lean, 136 who were obese, and 128 who had type 2 diabetes (Circulation 2009;119(22):2913-9). It demonstrated that youth with obesity and obesity-related type 2 diabetes have abnormalities in carotid thickness and stiffness that are only partially explained by traditional cardiovascular risk factors.

“We all know that obesity is very difficult to treat,” he concluded. “That’s true in children and adolescents as it is in adults. I think this argues for prevention of obesity, for us starting earlier, creating an optimal cardiovascular health situation that we can maintain during the course of childhood and adolescence. The payoff will be great if we can accomplish that.”

Dr. Daniels reported having no disclosures.

[email protected]

LOS ANGELES – Mounting evidence indicates that obesity in childhood and adolescence increases the risk for future cardiovascular disease (CVD), according to Stephen R. Daniels, MD, PhD.

Doug Brunk/MDedge News

“Some of this increased risk is related to the high level of tracking of obesity from childhood to adolescence to adulthood,” Dr. Daniels, who chairs the department of pediatrics at the University of Colorado, Aurora, said at the World Congress on Insulin Resistance, Diabetes & Cardiovascular Disease. “But I think it’s also clear that childhood obesity is associated with risk factors for adult CVD, including hypertension, dyslipidemia, and type 2 diabetes. There’s a combination of things going on over the life course.”

Numerous studies have demonstrated a dose-response relationship between increased weight and all-cause mortality in cardiovascular disease for men and women. This operates through a variety of mechanisms, Dr. Daniels said, including hypertension, dyslipidemia, left ventricular hypertrophy, vascular inflammation, type 2 diabetes, and obstructive sleep apnea. “While overt cardiovascular disease does not occur in children, many of the mechanisms recognized in adults are also present in children and adolescents,” he said. “The trends for increasing prevalence and severity of obesity in children and the comorbid conditions associated with obesity are worrisome.”

The current prevalence of obesity in children and adolescents stands at about 18%, according to the latest National Health and Nutrition Examination Survey. However, the prevalence of severe obesity in youth aged 2-19 years has been increasing “fairly dramatically,” and now stands at 9% among girls and 8% among boys. Hispanics and non-Hispanic blacks are disproportionately affected. That may turn out to be important in terms of the future, Dr. Daniels said, because according to simulation models, childhood obesity and overweight will continue to be a major public health problem in the future (N Engl J Med. 2017;377:2145-53).


Direct evidence is also beginning to emerge of a link between obesity in youth and adult cardiovascular disease. The factors in childhood that predict adult obesity include a higher level of body mass index, obesity present at an older age (adolescence vs. childhood), and the presence of obesity in parents, which reflects both genes and environment. Researchers led by Paul W. Franks, PhD, evaluated 4,857 American Indian children without diabetes who were born between 1945 and 1984 and followed them for death before age 55 (N Engl J Med. 2010;362[6]:485-93). They assessed whether BMI, glucose tolerance, blood pressure, and cholesterol levels predicted premature death. There were 166 deaths from endogenous causes (3.4%) over a median follow-up of 24 years. Factors significantly associated with mortality included obesity (incident rate ratio 2.30), glucose tolerance (IRR 1.73), and hypertension (IRR 1.57).

In a separate analysis, researchers investigated the long-term effects of childhood weight on coronary heart disease (CHD) by studying 276,835 Danish schoolchildren for whom measurements of height and weight were available. They followed the individuals until they turned age 25 or older and used national registries to assess the fatal and nonfatal rates of CHD events (N Engl J Med. 2007;357:2329-37). The researchers found that higher BMI during childhood was associated with an increased risk of CVD in adulthood. However, they did not have data on BMI in adulthood, “which leaves open the question of whether childhood obesity works through adult obesity or also has an independent effect,” said Dr. Daniels, who is also pediatrician-in-chief at Children’s Hospital Colorado, Denver.

More recently, investigators studied 37,674 apparently healthy Israeli men from age 17 into adulthood (N Engl J Med. 2011;364:1315-25). Outcomes were coronary disease and diabetes. They found that an elevated BMI in adolescence is an independent risk factor for CVD in later life, while an elevated BMI in adulthood is an independent risk factor for both CVD and diabetes.

In the Fels Longitudinal Study, researchers enrolled 151 adults with metabolic syndrome and 154 without metabolic syndrome, with a mean age of 51 years (J Pediatr. 2008;152:191-200). “The idea was to look back at this cohort and see when the first differences might be observable between boys and girls who ultimately would develop metabolic syndrome and those who would not,” said Dr. Daniels, who was one of the study investigators. The first appearance of differences between adults with and without metabolic syndrome occurred at ages 8 and 13 for BMI and 6 and 13 for waist circumference in boys and girls, respectively. Odds ratios (ORs) for the metabolic syndrome in adulthood if BMI were elevated in childhood ranged from 1.4 to 1.9 in boys and from 0.8 to 2.8 in girls. At the same time, odds ratios for the metabolic syndrome in adulthood if waist circumference was elevated ranged from 2.5 to 31.4 in boys and 1.7 to 2.5 in girls.

“I think it’s safe to say that BMI and waist circumference may be important in predicting metabolic syndrome later in life and, ultimately, cardiovascular disease,” Dr. Daniels said.

He noted that as the prevalence and severity of obesity have increased in childhood, the prevalence of type 2 diabetes has also increased. “The time from diagnosis of diabetes to a CVD event is approximately 10-15 years in adults, and there is often a prediagnosis period of hyperglycemia, which ranges from 5-10 years,” Dr. Daniels said. “If the time course of CVD related to diabetes is the same for adolescents as adults, it is anticipated that adolescents with diabetes will begin having substantial CVD morbidity and mortality in their 30s or 40s. This will be a public health disaster. Emerging evidence from the TODAY study (Treatment Options for type 2 Diabetes in Adolescents and Youth) and other studies is emphasizing that at least some individuals with adolescent type 2 diabetes may have a more malignant form of disease than in adults. This is striking and important to consider as we look at how to prevent cardiovascular disease.”

Obesity in childhood is also associated with structural and functional abnormalities of the vasculature, according to studies that measure vascular structure via intima-media thickness of the carotid arteries, femoral arteries, abdominal aorta, or other arteries, as well as those that measure vascular stiffness via measures of intrinsic “visco-elastic” properties of the arterial wall. In one study of individuals aged 10-24 years, Dr. Daniels and his associates performed carotid ultrasound for carotid intima-media thickness on 182 patients who were lean, 136 who were obese, and 128 who had type 2 diabetes (Circulation 2009;119(22):2913-9). It demonstrated that youth with obesity and obesity-related type 2 diabetes have abnormalities in carotid thickness and stiffness that are only partially explained by traditional cardiovascular risk factors.

“We all know that obesity is very difficult to treat,” he concluded. “That’s true in children and adolescents as it is in adults. I think this argues for prevention of obesity, for us starting earlier, creating an optimal cardiovascular health situation that we can maintain during the course of childhood and adolescence. The payoff will be great if we can accomplish that.”

Dr. Daniels reported having no disclosures.

[email protected]

Physicians who experience stress related to the use of health information technology are twice as likely to experience burnout.

©Leah-Anne Thompson/Thinkstock

Rebekah Gardner, MD, of Brown University in Providence, R.I., and her colleagues surveyed all 4,197 Rhode Island physicians in 2017 to learn how the use of electronic health records affected their practices and their job satisfaction.

Just over a quarter (25.0%) of 1,792 respondents reported burnout. Among electronic health record users (91% of respondents), 70% reported health IT-related stress (J Am Med Inform Assoc. doi: 10.1093/jamia/ocy145).

“After adjustment, physicians reporting poor/marginal time for documentation had 2.8 times the odds of burnout (95% confidence interval, 2.0-4.1; P less than .0001) compared to those reporting sufficient time,” according to the researchers.

The team looked at three stress-related variables: whether the EHR adds to the frustration of one’s day; whether physicians felt they had sufficient time for documentation; and the amount of time spent on the EHR at home. Variables were measured on a four- or five-point scale depending on the question related to the specific stress variable.

Almost two-thirds (64.2%) of respondents “agreed” or “strongly agreed” that EHRs add to the frustration of their day.

“It was the most commonly cited HIT-related stress measure in almost every specialty, with the highest prevalence among emergency physicians (77.6%),” the investigators wrote.

More than a third of physicians (37.7%) reported “moderately high” or “excessive” time spent on EHRs at home; this metric was the most commonly cited stress measure among pediatricians (63.6%).

Nearly half (46.4%) of physicians reported “poor” or “marginal” sufficiency of time for documentation.

“Presence of any 1 of the HIT-related stress measures was associated with approximately twice the odds of burnout among physician respondents,” Dr. Gardner and her colleagues noted, adding that “measuring and addressing HIT-related stress is an important step in reducing workforce burden and improving the care of our patients.”

To alleviate burnout, the authors recommended increased use of scribes, use of medical assistants to help create a more team-based documentation function, improved EHR training, providing more time during the day for documentation, and streamlining documentation expectations, with certain culture shifts needed in some cases (i.e., banning work-related email and clinical tasks for vacationing physicians).

[email protected]

SOURCE: Gardner R et al. J Am Med Inform Assoc. doi: 10.1093/jamia/ocy145.

Physicians who experience stress related to the use of health information technology are twice as likely to experience burnout.

©Leah-Anne Thompson/Thinkstock

Rebekah Gardner, MD, of Brown University in Providence, R.I., and her colleagues surveyed all 4,197 Rhode Island physicians in 2017 to learn how the use of electronic health records affected their practices and their job satisfaction.

Just over a quarter (25.0%) of 1,792 respondents reported burnout. Among electronic health record users (91% of respondents), 70% reported health IT-related stress (J Am Med Inform Assoc. doi: 10.1093/jamia/ocy145).

“After adjustment, physicians reporting poor/marginal time for documentation had 2.8 times the odds of burnout (95% confidence interval, 2.0-4.1; P less than .0001) compared to those reporting sufficient time,” according to the researchers.

The team looked at three stress-related variables: whether the EHR adds to the frustration of one’s day; whether physicians felt they had sufficient time for documentation; and the amount of time spent on the EHR at home. Variables were measured on a four- or five-point scale depending on the question related to the specific stress variable.

Almost two-thirds (64.2%) of respondents “agreed” or “strongly agreed” that EHRs add to the frustration of their day.

“It was the most commonly cited HIT-related stress measure in almost every specialty, with the highest prevalence among emergency physicians (77.6%),” the investigators wrote.

More than a third of physicians (37.7%) reported “moderately high” or “excessive” time spent on EHRs at home; this metric was the most commonly cited stress measure among pediatricians (63.6%).

Nearly half (46.4%) of physicians reported “poor” or “marginal” sufficiency of time for documentation.

“Presence of any 1 of the HIT-related stress measures was associated with approximately twice the odds of burnout among physician respondents,” Dr. Gardner and her colleagues noted, adding that “measuring and addressing HIT-related stress is an important step in reducing workforce burden and improving the care of our patients.”

To alleviate burnout, the authors recommended increased use of scribes, use of medical assistants to help create a more team-based documentation function, improved EHR training, providing more time during the day for documentation, and streamlining documentation expectations, with certain culture shifts needed in some cases (i.e., banning work-related email and clinical tasks for vacationing physicians).

[email protected]

SOURCE: Gardner R et al. J Am Med Inform Assoc. doi: 10.1093/jamia/ocy145.

Physicians who experience stress related to the use of health information technology are twice as likely to experience burnout.

©Leah-Anne Thompson/Thinkstock

Rebekah Gardner, MD, of Brown University in Providence, R.I., and her colleagues surveyed all 4,197 Rhode Island physicians in 2017 to learn how the use of electronic health records affected their practices and their job satisfaction.

Just over a quarter (25.0%) of 1,792 respondents reported burnout. Among electronic health record users (91% of respondents), 70% reported health IT-related stress (J Am Med Inform Assoc. doi: 10.1093/jamia/ocy145).

“After adjustment, physicians reporting poor/marginal time for documentation had 2.8 times the odds of burnout (95% confidence interval, 2.0-4.1; P less than .0001) compared to those reporting sufficient time,” according to the researchers.

The team looked at three stress-related variables: whether the EHR adds to the frustration of one’s day; whether physicians felt they had sufficient time for documentation; and the amount of time spent on the EHR at home. Variables were measured on a four- or five-point scale depending on the question related to the specific stress variable.

Almost two-thirds (64.2%) of respondents “agreed” or “strongly agreed” that EHRs add to the frustration of their day.

“It was the most commonly cited HIT-related stress measure in almost every specialty, with the highest prevalence among emergency physicians (77.6%),” the investigators wrote.

More than a third of physicians (37.7%) reported “moderately high” or “excessive” time spent on EHRs at home; this metric was the most commonly cited stress measure among pediatricians (63.6%).

Nearly half (46.4%) of physicians reported “poor” or “marginal” sufficiency of time for documentation.

“Presence of any 1 of the HIT-related stress measures was associated with approximately twice the odds of burnout among physician respondents,” Dr. Gardner and her colleagues noted, adding that “measuring and addressing HIT-related stress is an important step in reducing workforce burden and improving the care of our patients.”

To alleviate burnout, the authors recommended increased use of scribes, use of medical assistants to help create a more team-based documentation function, improved EHR training, providing more time during the day for documentation, and streamlining documentation expectations, with certain culture shifts needed in some cases (i.e., banning work-related email and clinical tasks for vacationing physicians).

[email protected]

SOURCE: Gardner R et al. J Am Med Inform Assoc. doi: 10.1093/jamia/ocy145.

National flu activity moved solidly into above-average territory during the week ending Dec. 15, as Colorado and Georgia took the lead with the highest activity levels in the country, according to the Centers for Disease Control and Prevention.

The proportion of outpatient visits for influenza-like illness (ILI) was 2.7% for the week, which was up from 2.3% the previous week and above the national baseline of 2.2%, the CDC reported. ILI is defined “as fever (temperature of 100°F [37.8°C] or greater) and cough and/or sore throat.”

Colorado and Georgia both reported ILI activity of 10 on the CDC’s 1-10 scale, making them the only states in the “high” range (8-10). Nine states and New York City had activity levels in the “moderate” range (6-7), Puerto Rico and 11 states were in the “low” range (4-5), and 28 states and the District of Columbia were in the “minimal” range (1-3), the CDC said.

During the comparable period of last year’s high-severity flu season, which ultimately resulted in 900,000 flu-related hospitalizations and 80,000 deaths (185 pediatric), nine states were already at level 10. For the 2018-2019 season so far, there have been seven ILI-related pediatric deaths, CDC data show.

[email protected]

National flu activity moved solidly into above-average territory during the week ending Dec. 15, as Colorado and Georgia took the lead with the highest activity levels in the country, according to the Centers for Disease Control and Prevention.

The proportion of outpatient visits for influenza-like illness (ILI) was 2.7% for the week, which was up from 2.3% the previous week and above the national baseline of 2.2%, the CDC reported. ILI is defined “as fever (temperature of 100°F [37.8°C] or greater) and cough and/or sore throat.”

Colorado and Georgia both reported ILI activity of 10 on the CDC’s 1-10 scale, making them the only states in the “high” range (8-10). Nine states and New York City had activity levels in the “moderate” range (6-7), Puerto Rico and 11 states were in the “low” range (4-5), and 28 states and the District of Columbia were in the “minimal” range (1-3), the CDC said.

During the comparable period of last year’s high-severity flu season, which ultimately resulted in 900,000 flu-related hospitalizations and 80,000 deaths (185 pediatric), nine states were already at level 10. For the 2018-2019 season so far, there have been seven ILI-related pediatric deaths, CDC data show.

[email protected]

National flu activity moved solidly into above-average territory during the week ending Dec. 15, as Colorado and Georgia took the lead with the highest activity levels in the country, according to the Centers for Disease Control and Prevention.

The proportion of outpatient visits for influenza-like illness (ILI) was 2.7% for the week, which was up from 2.3% the previous week and above the national baseline of 2.2%, the CDC reported. ILI is defined “as fever (temperature of 100°F [37.8°C] or greater) and cough and/or sore throat.”

Colorado and Georgia both reported ILI activity of 10 on the CDC’s 1-10 scale, making them the only states in the “high” range (8-10). Nine states and New York City had activity levels in the “moderate” range (6-7), Puerto Rico and 11 states were in the “low” range (4-5), and 28 states and the District of Columbia were in the “minimal” range (1-3), the CDC said.

During the comparable period of last year’s high-severity flu season, which ultimately resulted in 900,000 flu-related hospitalizations and 80,000 deaths (185 pediatric), nine states were already at level 10. For the 2018-2019 season so far, there have been seven ILI-related pediatric deaths, CDC data show.

[email protected]

Responding to a police call can prove dangerous. In those kinds of high-pressure situations, agitation or other manifestations of mental illness might be mistaken for violent intent – with disastrous results.

Antonprado/iStock.com

In Kalamazoo, Mich., crime response training now includes subduing suspects without using violent force. “Through training and education, and scenarios that we use in the training, [the officers] start to detect the different cues or indicators where they start to see that this is really a crisis event. And we treat it as a medical issue and get that person the help that they need,” said Rafael Diaz, executive lieutenant with the Kalamazoo Department of Public Safety in an interview on Michigan NPR.

In the training, called the Crisis Intervention Team model, the goal is to slow down the pace of the interaction and keep some distance between themselves and the suspect after officers recognize signs of mental illness. Both responses can lower the chances of a lash-out response.

The result has been a drop in violent engagements between officers and suspects. “The number of injuries to officers goes down, the number of injuries to the person in crisis goes down, and there is a huge benefit to society there if you don’t have to use physical force,” Mr. Diaz said.

Animal neglect and mental health

Images of neglected and abused livestock on farms can inspire thoughts of how someone could mistreat the animals in their care. “Frankly, if you can’t understand that, it’s probably a good thing. It means you haven’t been in the depths of low, low mental health, depression, and anxiety,” Andria Jones-Bitton, DVM, PhD, said in an interview with the Western Producer.

Dr. Jones-Bitton is a veterinarian and epidemiologist at the Ontario Veterinary College in Guelph. She is studying the mental health and mental resilience of farmers and veterinarians.

“If farmers are struggling with their own well-being and motivation, they’re likely going to find it difficult to invest in improving animal welfare. When we’re mentally unwell, it’s hard to care for ourselves, let alone to care for others, even when those others are really important to us,” she said.

A national survey of Canadian farmers by Dr. Jones-Bitton showed high levels of stress and diminished ability to cope with the pressures that come with running a livestock farm. “What makes me the most upset is I have everything I’ve ever dreamed of – love, family, and a farm, and all I feel is overwhelmed out of control and sad,” one respondent said.

The problems are not unique to Canada. Studies from Ireland, for example, documented an association between animal neglect cases and the mental health, drug/alcohol addiction, and social problems of farmers.

“Even if you didn’t care about the humans that were struggling and you only cared about the animal welfare, you’d be wise to address the issue of farmer stress,” Dr. Jones-Britton said.

Depression and rural America

A recent “Farming in Tough Times” workshop that convened in Minnesota focused on the mental health of farmers. Making a living is challenging for many reasons. One is that prices for commodities are set by others.

“I realized that I can’t change the situation that we’re in. I can’t change milk prices. I can’t stop farms from going bankrupt. But I can change how we are. And we are together, and that really does matter,” said dairy farmer Brenda Rudolph during the workshop, according to a report from the St. Cloud Times, which is part of the USA Today network.

“There is a conversation you people have to have in America, rural America, that says, depression is part of your life. It is not a sign of weakness. It’s a sign of reality,” said Dennis Hoiberg, a farming consultant based in Australia who spoke at the workshop. He added that, from his perspective, the United States still tends to be more repressed about mental health issues than elsewhere in the world – with the focus on stress and not on resiliency.

“Most of you folk are proud folk, and most you folk are very proud of what you do,” Mr. Hoiberg said. “You’re also psychologically exposed because you are a true believer [in what you do].”

Advice offered to lessen the tough times included noticing the beauty in the world, breaking down problems into small chunks that are more easily dealt with and then moving on to the next, sleep, and a good diet.

People with mental illness languishing

Public defenders in Colorado are seeking to have dozens of people diagnosed with mental illness who are in jail awaiting trial set free until their court date. The usual scenario in Colorado for someone charged with a crime and jailed who is deemed mentally incompetent is treatment within 28 days. However, this system is broken and wait times are far longer – in one instance 270 days.

“Many of them are there for very, very low level offenses and they’re holding in jail for way longer than a person who did not suffer from mental illness would be in custody,” said Maureen Cain, policy liaison for the public defender’s office in an interview with the Denver Post. “They are being incarcerated for their mental illness, not really because of the crime they committed.” Responses from judges have ranged from immediate release to finding the incarcerated person guilty of contempt and sending them back to jail.

The Colorado Department of Human Services is in charge of people who have been jailed but have been found to be incompetent to stand trial. Officials there have say they do not have enough bed space or capacity to get people moved out of jail within 28 days.

“We are in a situation where [the human services department] is in breach, and I need to know what efforts are being made to bring it back into compliance,” said federal Judge Nina Y. Wang. “These individuals are not being served, and frankly, the state is not being served.”

“Cruel” practice confined youth

A federal class action lawsuit filed against the Departmental of Children and Family Services (DCFS) in the Chicago area alleges that, from 2015 to 2017, more than 800 youth were being confined to psychiatric hospitals even when they were cleared for discharge. The problem goes back decades and is getting worse, the lawsuit contends.

“I spent Thanksgiving, Christmas, New Year’s, Easter, and my 16th birthday in the hospital,” said Skylar, who’s now 19 years old. “I only got to go outside one time. I felt like a prisoner; I felt very depressed.”

As reported on Chicago’s WGN9 News, the delay between clearance for discharge and actual freedom is a month or more in many of the cases. Acting Cook County Public Guardian Charles Golbert said the practice is “cruel, unusual, and illegal. It’s a violation of the children’s civil and most basic human rights.”

Many of the youth had been incarcerated for setting fires and self-harm and had been rejected by foster parents and other providers, in some cases their own families, who were concerned with the possible behavior of the youth after their release.

“Blame the children is the wrong response from DCFS,” said attorney Russell Ainsworth. “DCFS should be apologizing for not addressing this issue and for violating the Constitution.”

Responding to a police call can prove dangerous. In those kinds of high-pressure situations, agitation or other manifestations of mental illness might be mistaken for violent intent – with disastrous results.

Antonprado/iStock.com

In Kalamazoo, Mich., crime response training now includes subduing suspects without using violent force. “Through training and education, and scenarios that we use in the training, [the officers] start to detect the different cues or indicators where they start to see that this is really a crisis event. And we treat it as a medical issue and get that person the help that they need,” said Rafael Diaz, executive lieutenant with the Kalamazoo Department of Public Safety in an interview on Michigan NPR.

In the training, called the Crisis Intervention Team model, the goal is to slow down the pace of the interaction and keep some distance between themselves and the suspect after officers recognize signs of mental illness. Both responses can lower the chances of a lash-out response.

The result has been a drop in violent engagements between officers and suspects. “The number of injuries to officers goes down, the number of injuries to the person in crisis goes down, and there is a huge benefit to society there if you don’t have to use physical force,” Mr. Diaz said.

Animal neglect and mental health

Images of neglected and abused livestock on farms can inspire thoughts of how someone could mistreat the animals in their care. “Frankly, if you can’t understand that, it’s probably a good thing. It means you haven’t been in the depths of low, low mental health, depression, and anxiety,” Andria Jones-Bitton, DVM, PhD, said in an interview with the Western Producer.

Dr. Jones-Bitton is a veterinarian and epidemiologist at the Ontario Veterinary College in Guelph. She is studying the mental health and mental resilience of farmers and veterinarians.

“If farmers are struggling with their own well-being and motivation, they’re likely going to find it difficult to invest in improving animal welfare. When we’re mentally unwell, it’s hard to care for ourselves, let alone to care for others, even when those others are really important to us,” she said.

A national survey of Canadian farmers by Dr. Jones-Bitton showed high levels of stress and diminished ability to cope with the pressures that come with running a livestock farm. “What makes me the most upset is I have everything I’ve ever dreamed of – love, family, and a farm, and all I feel is overwhelmed out of control and sad,” one respondent said.

The problems are not unique to Canada. Studies from Ireland, for example, documented an association between animal neglect cases and the mental health, drug/alcohol addiction, and social problems of farmers.

“Even if you didn’t care about the humans that were struggling and you only cared about the animal welfare, you’d be wise to address the issue of farmer stress,” Dr. Jones-Britton said.

Depression and rural America

A recent “Farming in Tough Times” workshop that convened in Minnesota focused on the mental health of farmers. Making a living is challenging for many reasons. One is that prices for commodities are set by others.

“I realized that I can’t change the situation that we’re in. I can’t change milk prices. I can’t stop farms from going bankrupt. But I can change how we are. And we are together, and that really does matter,” said dairy farmer Brenda Rudolph during the workshop, according to a report from the St. Cloud Times, which is part of the USA Today network.

“There is a conversation you people have to have in America, rural America, that says, depression is part of your life. It is not a sign of weakness. It’s a sign of reality,” said Dennis Hoiberg, a farming consultant based in Australia who spoke at the workshop. He added that, from his perspective, the United States still tends to be more repressed about mental health issues than elsewhere in the world – with the focus on stress and not on resiliency.

“Most of you folk are proud folk, and most you folk are very proud of what you do,” Mr. Hoiberg said. “You’re also psychologically exposed because you are a true believer [in what you do].”

Advice offered to lessen the tough times included noticing the beauty in the world, breaking down problems into small chunks that are more easily dealt with and then moving on to the next, sleep, and a good diet.

People with mental illness languishing

Public defenders in Colorado are seeking to have dozens of people diagnosed with mental illness who are in jail awaiting trial set free until their court date. The usual scenario in Colorado for someone charged with a crime and jailed who is deemed mentally incompetent is treatment within 28 days. However, this system is broken and wait times are far longer – in one instance 270 days.

“Many of them are there for very, very low level offenses and they’re holding in jail for way longer than a person who did not suffer from mental illness would be in custody,” said Maureen Cain, policy liaison for the public defender’s office in an interview with the Denver Post. “They are being incarcerated for their mental illness, not really because of the crime they committed.” Responses from judges have ranged from immediate release to finding the incarcerated person guilty of contempt and sending them back to jail.

The Colorado Department of Human Services is in charge of people who have been jailed but have been found to be incompetent to stand trial. Officials there have say they do not have enough bed space or capacity to get people moved out of jail within 28 days.

“We are in a situation where [the human services department] is in breach, and I need to know what efforts are being made to bring it back into compliance,” said federal Judge Nina Y. Wang. “These individuals are not being served, and frankly, the state is not being served.”

“Cruel” practice confined youth

A federal class action lawsuit filed against the Departmental of Children and Family Services (DCFS) in the Chicago area alleges that, from 2015 to 2017, more than 800 youth were being confined to psychiatric hospitals even when they were cleared for discharge. The problem goes back decades and is getting worse, the lawsuit contends.

“I spent Thanksgiving, Christmas, New Year’s, Easter, and my 16th birthday in the hospital,” said Skylar, who’s now 19 years old. “I only got to go outside one time. I felt like a prisoner; I felt very depressed.”

As reported on Chicago’s WGN9 News, the delay between clearance for discharge and actual freedom is a month or more in many of the cases. Acting Cook County Public Guardian Charles Golbert said the practice is “cruel, unusual, and illegal. It’s a violation of the children’s civil and most basic human rights.”

Many of the youth had been incarcerated for setting fires and self-harm and had been rejected by foster parents and other providers, in some cases their own families, who were concerned with the possible behavior of the youth after their release.

“Blame the children is the wrong response from DCFS,” said attorney Russell Ainsworth. “DCFS should be apologizing for not addressing this issue and for violating the Constitution.”

Responding to a police call can prove dangerous. In those kinds of high-pressure situations, agitation or other manifestations of mental illness might be mistaken for violent intent – with disastrous results.

Antonprado/iStock.com

In Kalamazoo, Mich., crime response training now includes subduing suspects without using violent force. “Through training and education, and scenarios that we use in the training, [the officers] start to detect the different cues or indicators where they start to see that this is really a crisis event. And we treat it as a medical issue and get that person the help that they need,” said Rafael Diaz, executive lieutenant with the Kalamazoo Department of Public Safety in an interview on Michigan NPR.

In the training, called the Crisis Intervention Team model, the goal is to slow down the pace of the interaction and keep some distance between themselves and the suspect after officers recognize signs of mental illness. Both responses can lower the chances of a lash-out response.

The result has been a drop in violent engagements between officers and suspects. “The number of injuries to officers goes down, the number of injuries to the person in crisis goes down, and there is a huge benefit to society there if you don’t have to use physical force,” Mr. Diaz said.

Animal neglect and mental health

Images of neglected and abused livestock on farms can inspire thoughts of how someone could mistreat the animals in their care. “Frankly, if you can’t understand that, it’s probably a good thing. It means you haven’t been in the depths of low, low mental health, depression, and anxiety,” Andria Jones-Bitton, DVM, PhD, said in an interview with the Western Producer.

Dr. Jones-Bitton is a veterinarian and epidemiologist at the Ontario Veterinary College in Guelph. She is studying the mental health and mental resilience of farmers and veterinarians.

“If farmers are struggling with their own well-being and motivation, they’re likely going to find it difficult to invest in improving animal welfare. When we’re mentally unwell, it’s hard to care for ourselves, let alone to care for others, even when those others are really important to us,” she said.

A national survey of Canadian farmers by Dr. Jones-Bitton showed high levels of stress and diminished ability to cope with the pressures that come with running a livestock farm. “What makes me the most upset is I have everything I’ve ever dreamed of – love, family, and a farm, and all I feel is overwhelmed out of control and sad,” one respondent said.

The problems are not unique to Canada. Studies from Ireland, for example, documented an association between animal neglect cases and the mental health, drug/alcohol addiction, and social problems of farmers.

“Even if you didn’t care about the humans that were struggling and you only cared about the animal welfare, you’d be wise to address the issue of farmer stress,” Dr. Jones-Britton said.

Depression and rural America

A recent “Farming in Tough Times” workshop that convened in Minnesota focused on the mental health of farmers. Making a living is challenging for many reasons. One is that prices for commodities are set by others.

“I realized that I can’t change the situation that we’re in. I can’t change milk prices. I can’t stop farms from going bankrupt. But I can change how we are. And we are together, and that really does matter,” said dairy farmer Brenda Rudolph during the workshop, according to a report from the St. Cloud Times, which is part of the USA Today network.

“There is a conversation you people have to have in America, rural America, that says, depression is part of your life. It is not a sign of weakness. It’s a sign of reality,” said Dennis Hoiberg, a farming consultant based in Australia who spoke at the workshop. He added that, from his perspective, the United States still tends to be more repressed about mental health issues than elsewhere in the world – with the focus on stress and not on resiliency.

“Most of you folk are proud folk, and most you folk are very proud of what you do,” Mr. Hoiberg said. “You’re also psychologically exposed because you are a true believer [in what you do].”

Advice offered to lessen the tough times included noticing the beauty in the world, breaking down problems into small chunks that are more easily dealt with and then moving on to the next, sleep, and a good diet.

People with mental illness languishing

Public defenders in Colorado are seeking to have dozens of people diagnosed with mental illness who are in jail awaiting trial set free until their court date. The usual scenario in Colorado for someone charged with a crime and jailed who is deemed mentally incompetent is treatment within 28 days. However, this system is broken and wait times are far longer – in one instance 270 days.

“Many of them are there for very, very low level offenses and they’re holding in jail for way longer than a person who did not suffer from mental illness would be in custody,” said Maureen Cain, policy liaison for the public defender’s office in an interview with the Denver Post. “They are being incarcerated for their mental illness, not really because of the crime they committed.” Responses from judges have ranged from immediate release to finding the incarcerated person guilty of contempt and sending them back to jail.

The Colorado Department of Human Services is in charge of people who have been jailed but have been found to be incompetent to stand trial. Officials there have say they do not have enough bed space or capacity to get people moved out of jail within 28 days.

“We are in a situation where [the human services department] is in breach, and I need to know what efforts are being made to bring it back into compliance,” said federal Judge Nina Y. Wang. “These individuals are not being served, and frankly, the state is not being served.”

“Cruel” practice confined youth

A federal class action lawsuit filed against the Departmental of Children and Family Services (DCFS) in the Chicago area alleges that, from 2015 to 2017, more than 800 youth were being confined to psychiatric hospitals even when they were cleared for discharge. The problem goes back decades and is getting worse, the lawsuit contends.

“I spent Thanksgiving, Christmas, New Year’s, Easter, and my 16th birthday in the hospital,” said Skylar, who’s now 19 years old. “I only got to go outside one time. I felt like a prisoner; I felt very depressed.”

As reported on Chicago’s WGN9 News, the delay between clearance for discharge and actual freedom is a month or more in many of the cases. Acting Cook County Public Guardian Charles Golbert said the practice is “cruel, unusual, and illegal. It’s a violation of the children’s civil and most basic human rights.”

Many of the youth had been incarcerated for setting fires and self-harm and had been rejected by foster parents and other providers, in some cases their own families, who were concerned with the possible behavior of the youth after their release.

“Blame the children is the wrong response from DCFS,” said attorney Russell Ainsworth. “DCFS should be apologizing for not addressing this issue and for violating the Constitution.”

Vasculitis is a process in which blood vessels become inflamed and necrotic. Classic small-vessel vasculitis reveals a leukocytoclastic vasculitis and most commonly presents as palpable purpura. In addition to skin, organs such as joints, kidneys, and intestines can be involved.

Henoch-Schönlein Purpura (HSP), also called anaphylactoid purpura, is a subtype of small-vessel vasculitis where immunoglobulin A (IgA) is deposited in the vessel walls. It is the most common form of vasculitis in children (usually aged 4-8 years). The incidence is higher in the winter. Some patients experience a prodrome of fever, colicky abdominal pain, and joint pain prior to the development of cutaneous symptoms. Disease in children tends to be self-limited. Adults may present with HSP as well, and often exhibit more severe disease that may become chronic with relapses and is more difficult to treat. In both children and adults, infectious causes, such as streptococcus pharyngitis, are the most common trigger. In adults, malignancy may be associated with HSP. A literature search revealed medications implicated in HSP such as antibiotics (vancomycin, penicillin, cephalosporins, clarithromycin), ACE inhibitors, and nonsteroidal anti-inflammatories. Many cases of HSP are idiopathic.

Patients present with erythematous macules that progress to purpura on the extremities. Lesions may be vesicular or bullous and may become necrotic and ulcerate. Arthralgias, often of lower-extremity joints, may be present. Abdominal pain and renal disease may occur in both children and adults. Adults are more likely to develop chronic kidney disease and must be followed carefully with serial blood work and urinalysis to evaluate for hematuria and proteinuria. Severe abdominal pain is an emergency as intussusception may occur.

Histologically, leukocytoclastic vasculitis of small vessels is present. On direct immunofluorescence of perilesional skin, IgA, C3, and fibrin deposits can be seen. Serum IgA is unreliable and may be seen in healthy adults as well.

Treatment is generally supportive as the disease is self-limited. The use of corticosteroids is controversial. This may be effective for joint inflammation, abdominal disease, active nephritis, and ulcerated skin lesions, but doesn’t prevent the recurrence of skin lesions. Dapsone or colchicine can be used for resistant cutaneous lesions. In severe cases, intravenous immunoglobulin may be warranted.

This case and photo were submitted by Dr. Bilu Martin.

Dr. Bilu Martin is a board-certified dermatologist in private practice at Premier Dermatology, MD, in Aventura, Fla. More diagnostic cases are available at edermatologynews.com. To submit a case for possible publication, send an email to [email protected].

Vasculitis is a process in which blood vessels become inflamed and necrotic. Classic small-vessel vasculitis reveals a leukocytoclastic vasculitis and most commonly presents as palpable purpura. In addition to skin, organs such as joints, kidneys, and intestines can be involved.

Henoch-Schönlein Purpura (HSP), also called anaphylactoid purpura, is a subtype of small-vessel vasculitis where immunoglobulin A (IgA) is deposited in the vessel walls. It is the most common form of vasculitis in children (usually aged 4-8 years). The incidence is higher in the winter. Some patients experience a prodrome of fever, colicky abdominal pain, and joint pain prior to the development of cutaneous symptoms. Disease in children tends to be self-limited. Adults may present with HSP as well, and often exhibit more severe disease that may become chronic with relapses and is more difficult to treat. In both children and adults, infectious causes, such as streptococcus pharyngitis, are the most common trigger. In adults, malignancy may be associated with HSP. A literature search revealed medications implicated in HSP such as antibiotics (vancomycin, penicillin, cephalosporins, clarithromycin), ACE inhibitors, and nonsteroidal anti-inflammatories. Many cases of HSP are idiopathic.

Patients present with erythematous macules that progress to purpura on the extremities. Lesions may be vesicular or bullous and may become necrotic and ulcerate. Arthralgias, often of lower-extremity joints, may be present. Abdominal pain and renal disease may occur in both children and adults. Adults are more likely to develop chronic kidney disease and must be followed carefully with serial blood work and urinalysis to evaluate for hematuria and proteinuria. Severe abdominal pain is an emergency as intussusception may occur.

Histologically, leukocytoclastic vasculitis of small vessels is present. On direct immunofluorescence of perilesional skin, IgA, C3, and fibrin deposits can be seen. Serum IgA is unreliable and may be seen in healthy adults as well.

Treatment is generally supportive as the disease is self-limited. The use of corticosteroids is controversial. This may be effective for joint inflammation, abdominal disease, active nephritis, and ulcerated skin lesions, but doesn’t prevent the recurrence of skin lesions. Dapsone or colchicine can be used for resistant cutaneous lesions. In severe cases, intravenous immunoglobulin may be warranted.

This case and photo were submitted by Dr. Bilu Martin.

Dr. Bilu Martin is a board-certified dermatologist in private practice at Premier Dermatology, MD, in Aventura, Fla. More diagnostic cases are available at edermatologynews.com. To submit a case for possible publication, send an email to [email protected].

Vasculitis is a process in which blood vessels become inflamed and necrotic. Classic small-vessel vasculitis reveals a leukocytoclastic vasculitis and most commonly presents as palpable purpura. In addition to skin, organs such as joints, kidneys, and intestines can be involved.

Henoch-Schönlein Purpura (HSP), also called anaphylactoid purpura, is a subtype of small-vessel vasculitis where immunoglobulin A (IgA) is deposited in the vessel walls. It is the most common form of vasculitis in children (usually aged 4-8 years). The incidence is higher in the winter. Some patients experience a prodrome of fever, colicky abdominal pain, and joint pain prior to the development of cutaneous symptoms. Disease in children tends to be self-limited. Adults may present with HSP as well, and often exhibit more severe disease that may become chronic with relapses and is more difficult to treat. In both children and adults, infectious causes, such as streptococcus pharyngitis, are the most common trigger. In adults, malignancy may be associated with HSP. A literature search revealed medications implicated in HSP such as antibiotics (vancomycin, penicillin, cephalosporins, clarithromycin), ACE inhibitors, and nonsteroidal anti-inflammatories. Many cases of HSP are idiopathic.

Patients present with erythematous macules that progress to purpura on the extremities. Lesions may be vesicular or bullous and may become necrotic and ulcerate. Arthralgias, often of lower-extremity joints, may be present. Abdominal pain and renal disease may occur in both children and adults. Adults are more likely to develop chronic kidney disease and must be followed carefully with serial blood work and urinalysis to evaluate for hematuria and proteinuria. Severe abdominal pain is an emergency as intussusception may occur.

Histologically, leukocytoclastic vasculitis of small vessels is present. On direct immunofluorescence of perilesional skin, IgA, C3, and fibrin deposits can be seen. Serum IgA is unreliable and may be seen in healthy adults as well.

Treatment is generally supportive as the disease is self-limited. The use of corticosteroids is controversial. This may be effective for joint inflammation, abdominal disease, active nephritis, and ulcerated skin lesions, but doesn’t prevent the recurrence of skin lesions. Dapsone or colchicine can be used for resistant cutaneous lesions. In severe cases, intravenous immunoglobulin may be warranted.

This case and photo were submitted by Dr. Bilu Martin.

Dr. Bilu Martin is a board-certified dermatologist in private practice at Premier Dermatology, MD, in Aventura, Fla. More diagnostic cases are available at edermatologynews.com. To submit a case for possible publication, send an email to [email protected].