CASE Chronic pelvic pain from endometriosis

A 40-year-old woman (G0) has a 20-year history of chronic pelvic pain. Stage III endometriosis is diagnosed on laparoscopic excision of endometriotic tissue. Postoperative pain symptoms include dysmenorrhea and deep dyspareunia, and the patient is feeling anxious. Physical examination reveals a retroverted uterus, right adnexal fullness and tenderness, and tenderness on palpation of the right levator ani and right obturator internus; rectovaginal examination findings are unremarkable. The patient, though now engaged in a pelvic floor physical therapy program, has yet to achieve the pain control she desires. After reviewing the treatment strategies for endometriosis with the patient, she elects definitive surgical management with minimally invasive hysterectomy and salpingo-oophorectomy. What pre-, intra-, and postoperative pain management plan do you devise for this patient?

Chronic pelvic pain presents a unique clinical challenge, as pain typically is multifactorial, and several peripheral pain generators may be involved. Although surgery can be performed to manage anatomically based disease processes, it does not address pain from musculoskeletal or neuropathic sources. A complete medical history and a physical examination are of utmost importance in developing a comprehensive multimodal management plan that may include surgery as treatment for the pain.

The standard of care for surgery is a minimally invasive approach (vaginal, laparoscopic, or robot-assisted laparoscopic), as it causes the least amount of trauma. Benefits of minimally invasive surgery include shorter hospitalization and faster recovery, likely owing to improved perioperative pain control, decreased blood loss, and fewer infections. Although this approach minimizes surgical trauma and thereby helps decrease the surgical stress response, the patient experience can be optimized with use of enhanced recovery pathways (ERPs), a multimodal approach to perioperative care.

ERPs were initially proposed as a means of reducing the degree of surgical injury and the subsequent physiologic stress response.¹ This multimodal approach begins in the outpatient setting, includes preoperative and intraoperative modalities, and continues postoperatively. In patients with chronic pain, ERPs are even more important. Assigning “prehabilitation” and setting expectations for surgery goals are the first step in improving the patient experience. Intraoperative use of opioid-sparing anesthetics or regional anesthesia can improve recovery. After surgery, patients with chronic pain and/or opioid dependence receive medications on a schedule, along with short-interval follow-up. Ultimately, reducing acute postoperative pain may lower the risk of developing chronic pain.

In this article on patients with chronic pelvic pain, we highlight elements of ERPs within the framework of enhanced recovery after surgery. Many of the interventions proposed here also can be used to improve the surgical experience of patients without chronic pain.

Preadmission education, expectations, and optimization

Preoperative counseling for elective procedures generally occurs in the outpatient setting. Although discussion traditionally has covered the type of procedure and its associated risks, benefits, and alternatives, new guidelines suggest a more mindful and comprehensive approach is warranted. Individualized patient-centered education programs have a positive impact on the perioperative course, effecting reductions in preoperative anxiety, opioid requirements, and hospital length of stay.² From a pain management perspective, the clinician can take some time during preoperative counseling to inform the patient about the pain to be expected from surgery, the ways the pain will be managed intraoperatively and postoperatively, and the multimodal strategies that will be used throughout the patient’s stay² and that may allow for early discharge. Although preadmission counseling still should address expectations for the surgery, it also presents an opportunity both to assess the patient’s ability to cope with the physical and psychological stress of surgery and to offer the patient appropriate need-based interventions, such as prehabilitation and cognitive-behavioral therapy (CBT).

Prehabilitation is the process of increasing functional capacity before surgery in order to mitigate the stress of the surgery. Prehabilitation may involve aerobic exercise, strength training, or functional task training. The gynecologic surgery literature lacks prehabilitation data, but data in the colorectal literature support use of a prehabilitation program for patients having a scheduled colectomy, with improved postoperative recovery.³ Although the colectomy cohort predominantly included older men, the principle that guides program implementation is the same: improve recovery after the stress of abdominal surgery. Indeed, a patient who opts for an elective surgery may have to wait several weeks before undergoing the procedure, and during this period behavioral interventions can take effect. With postoperative complications occurring more often in patients with reduced functional capacity, the data support using prehabilitation to decrease the incidence of postoperative complications, particularly among the most vulnerable patients.⁴ However, a definitive recommendation on use of pelvic floor exercises as an adjunct to prehabilitation cannot be made.⁴ Successful prehabilitation takes at least 4 weeks and should be part of a multimodal program that addresses other behavioral risk factors that may negatively affect recovery.⁵ For example, current tobacco users have compromised pulmonary status and wound healing immediately after surgery, and use more opioids.⁶ Conversely, smoking cessation for as little as 4 weeks before surgery is associated with fewer complications.⁷ In addition, given that alcohol abuse may compromise the surgical stress response and increase the risk of opioid misuse, addressing alcohol abuse preoperatively may improve postoperative recovery.⁸

Treating mood disorders that coexist with chronic pain disorders is an important part of outpatient multimodal management—psychological intervention is a useful adjunct to prehabilitation in reducing perioperative anxiety and improving postoperative functional capacity.⁹ For patients who have chronic pain and are undergoing surgery, it is important to address any anxiety, depression, or poor coping skills (eg, pain catastrophizing) to try to reduce the postoperative pain experience and decrease the risk of chronic postsurgical pain (CPSP).^10,11

Before surgery, patients with chronic pain syndromes should be evaluated for emotional distress and pain coping ability. When possible, they should be referred to a pain psychologist, who can initiate CBT and other interventions. In addition, pain coping skills can be developed or reinforced to address preoperative anxiety and pain catastrophizing. These interventions, which may include use of visual imagery, breathing exercises, and other relaxation techniques, are applicable to the management of postoperative anxiety as well.

Read about preoperative multimodal analgesia and intra- and postoperative management.

Preoperative multimodal analgesia

Multimodal analgesia has several benefits. Simultaneous effects can be generated on multiple pain-related neurotransmitters, and a synergistic effect (eg, of acetaminophen and a nonsteroidal anti-inflammatory drug [NSAID]) can improve pain management. In addition, small doses of multiple medications can be given, instead of a large dose of a single medication. Of course, this strategy must be modified in elderly and patients with impaired renal function, who are at high risk for polypharmacy.

Preoperative administration of 3 medications—a selective cyclooxygenase 2 (COX-2) inhibitor, acetaminophen, and a gabapentinoid—is increasingly accepted as part of multimodal analgesia. The selective COX-2 inhibitor targets inflammatory prostaglandins and has anti-inflammatory and analgesic effects; acetaminophen, an effective analgesic with an unclear mechanism of action, can reduce postoperative opioid consumption¹² and works synergistically with NSAIDs¹³; and the gabapentinoid gabapentin has an analgesic effect likely contributing to decreased movement-related pain and subsequent improved functional recovery (data are mixed on whether continuing gabapentin after surgery prevents CPSP).¹⁴⁻¹⁶

Although serotonin and norepinephrine reuptake inhibitors (SNRIs) are commonly used in outpatient management of chronic pelvic pain, data suggest that their role in perioperative pain management is evolving. As SNRIs may reduce central nervous system (CNS) sensitization,¹⁷ their analgesic effect is thought to result from increased descending inhibitory tone in the CNS, which makes this class of medication ideal for patients with chronic neuropathic pain.¹⁵

Limited data also suggest a role for SNRIs in decreasing immediate postoperative pain and CPSP in high-risk patients. Studies of duloxetine use in the immediate perioperative period have found reduced postoperative acute pain and opioid use.^18,19 In addition, a short course of low-dose (37.5 mg) venlafaxine both before and after surgery has demonstrated a reduction in postoperative opioid use and a reduction in movement-related pain 6 months after surgery.²⁰

Intraoperative management

The surgical and anesthesia teams share the goal of optimizing both pain control and postoperative recovery. Surgical team members, who want longer-acting anesthetics for infiltration of incision sites, discuss with the anesthesiologist the appropriateness of using peripheral nerve blocks or neuraxial anesthesia, given the patient’s history and planned procedure. Anesthesia team members can improve anesthesia and minimize intraoperative opioid use through several methods, including total intravenous anesthesia,²¹ dexamethasone,²² ketorolac,²³ and intravenous ketamine. Ketamine, in particular, has a wide range of surgical applications and has been found to reduce postoperative pain, postoperative pain medication use, and the risk of CPSP.²

Incision sites should be infiltrated before and after surgery. Lidocaine traditionally is used for its rapid onset of action in reducing surgical site pain, but its short half-life may limit its applicability to postoperative pain. Recently, bupivacaine (half-life, 3.5 hours) and liposomal bupivacaine (24–34 hours) have gained more attention. Both of these medications appear to be as effective as lidocaine in reducing surgical site pain.²⁴

Transversus abdominis plane (TAP) blocks have been used as an adjunct in pain management during abdominopelvic surgery. Although initial data on postoperative pain and opioid use reductions with TAP blocks were inconclusive,²⁵ more recent data showed a role for TAP blocks in a multimodal approach for reducing opioid use during laparoscopic and open surgery.^26,27 Given the small number of studies on using liposomal bupivacaine for peripheral nerve blocks (eg, TAP blocks) in postoperative pain management, current data are inconclusive.²⁸

Postoperative management

The ERP approach calls for continuing multimodal analgesia after surgery—in most cases, scheduling early use of oral acetaminophen and ibuprofen, and providing short-acting, low-dose opioid analgesia as needed. All patients should be given a bowel regimen. Similar to undergoing prehabilitation for surgery, patients should prepare themselves for recovery. They should be encouraged to engage in early ambulation and oral intake and, when clinically appropriate, be given same-day discharge for minimally invasive surgical procedures.

Patients with chronic pain before surgery are at increased risk for suboptimal postoperative pain management, and those who are dependent on opioids require additional perioperative measures for adequate postoperative pain control. In these complicated cases, it is appropriate to enlist a pain specialist, potentially before surgery, to help plan perioperative and postoperative pain management.² Postoperative pain management for opioid-dependent patients should include pharmacologic and nonpharmacologic interventions, such as use of nonopioid medications (eg, gabapentin) and continuation of CBT. Patients with chronic pain should be closely followed up for assessment of postoperative pain control and recovery.

CASE Resolved

Surgical management is one aspect of the longer term multimodal pain management strategy for this patient. After preoperative pelvic floor physical therapy, she is receptive to starting a trial of an SNRI for her pain and mood symptoms. Both interventions allow for optimization of her preoperative physical and psychological status. Expectations are set that she will be discharged the day of surgery and that the surgery is but one component of her multimodal treatment plan. In addition, before surgery, she takes oral acetaminophen, gabapentin, and celecoxib—previously having had no contraindications to these medications. During surgery, bupivacaine is used for infiltration of all incision sites, and the anesthesia team administers ketamine and a TAP block. After surgery, the patient is prepared for same-day discharge and given the NSAIDs and acetaminophen she is scheduled to take over the next 72 hours. She is also given a limited prescription for oxycodone for breakthrough pain. An office visit 1 to 2 weeks after surgery is scheduled.

ERP strategies for surgical management of endometriosis have not only improved this patient’s postoperative recovery but also reduced her surgical stress response and subsequent transition to chronic postoperative pain. Many of the strategies used in this case are applicable to patients without chronic pain.

Share your thoughts! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.

CASE Chronic pelvic pain from endometriosis

A 40-year-old woman (G0) has a 20-year history of chronic pelvic pain. Stage III endometriosis is diagnosed on laparoscopic excision of endometriotic tissue. Postoperative pain symptoms include dysmenorrhea and deep dyspareunia, and the patient is feeling anxious. Physical examination reveals a retroverted uterus, right adnexal fullness and tenderness, and tenderness on palpation of the right levator ani and right obturator internus; rectovaginal examination findings are unremarkable. The patient, though now engaged in a pelvic floor physical therapy program, has yet to achieve the pain control she desires. After reviewing the treatment strategies for endometriosis with the patient, she elects definitive surgical management with minimally invasive hysterectomy and salpingo-oophorectomy. What pre-, intra-, and postoperative pain management plan do you devise for this patient?

Chronic pelvic pain presents a unique clinical challenge, as pain typically is multifactorial, and several peripheral pain generators may be involved. Although surgery can be performed to manage anatomically based disease processes, it does not address pain from musculoskeletal or neuropathic sources. A complete medical history and a physical examination are of utmost importance in developing a comprehensive multimodal management plan that may include surgery as treatment for the pain.

The standard of care for surgery is a minimally invasive approach (vaginal, laparoscopic, or robot-assisted laparoscopic), as it causes the least amount of trauma. Benefits of minimally invasive surgery include shorter hospitalization and faster recovery, likely owing to improved perioperative pain control, decreased blood loss, and fewer infections. Although this approach minimizes surgical trauma and thereby helps decrease the surgical stress response, the patient experience can be optimized with use of enhanced recovery pathways (ERPs), a multimodal approach to perioperative care.

ERPs were initially proposed as a means of reducing the degree of surgical injury and the subsequent physiologic stress response.¹ This multimodal approach begins in the outpatient setting, includes preoperative and intraoperative modalities, and continues postoperatively. In patients with chronic pain, ERPs are even more important. Assigning “prehabilitation” and setting expectations for surgery goals are the first step in improving the patient experience. Intraoperative use of opioid-sparing anesthetics or regional anesthesia can improve recovery. After surgery, patients with chronic pain and/or opioid dependence receive medications on a schedule, along with short-interval follow-up. Ultimately, reducing acute postoperative pain may lower the risk of developing chronic pain.

In this article on patients with chronic pelvic pain, we highlight elements of ERPs within the framework of enhanced recovery after surgery. Many of the interventions proposed here also can be used to improve the surgical experience of patients without chronic pain.

Preadmission education, expectations, and optimization

Preoperative counseling for elective procedures generally occurs in the outpatient setting. Although discussion traditionally has covered the type of procedure and its associated risks, benefits, and alternatives, new guidelines suggest a more mindful and comprehensive approach is warranted. Individualized patient-centered education programs have a positive impact on the perioperative course, effecting reductions in preoperative anxiety, opioid requirements, and hospital length of stay.² From a pain management perspective, the clinician can take some time during preoperative counseling to inform the patient about the pain to be expected from surgery, the ways the pain will be managed intraoperatively and postoperatively, and the multimodal strategies that will be used throughout the patient’s stay² and that may allow for early discharge. Although preadmission counseling still should address expectations for the surgery, it also presents an opportunity both to assess the patient’s ability to cope with the physical and psychological stress of surgery and to offer the patient appropriate need-based interventions, such as prehabilitation and cognitive-behavioral therapy (CBT).

Prehabilitation is the process of increasing functional capacity before surgery in order to mitigate the stress of the surgery. Prehabilitation may involve aerobic exercise, strength training, or functional task training. The gynecologic surgery literature lacks prehabilitation data, but data in the colorectal literature support use of a prehabilitation program for patients having a scheduled colectomy, with improved postoperative recovery.³ Although the colectomy cohort predominantly included older men, the principle that guides program implementation is the same: improve recovery after the stress of abdominal surgery. Indeed, a patient who opts for an elective surgery may have to wait several weeks before undergoing the procedure, and during this period behavioral interventions can take effect. With postoperative complications occurring more often in patients with reduced functional capacity, the data support using prehabilitation to decrease the incidence of postoperative complications, particularly among the most vulnerable patients.⁴ However, a definitive recommendation on use of pelvic floor exercises as an adjunct to prehabilitation cannot be made.⁴ Successful prehabilitation takes at least 4 weeks and should be part of a multimodal program that addresses other behavioral risk factors that may negatively affect recovery.⁵ For example, current tobacco users have compromised pulmonary status and wound healing immediately after surgery, and use more opioids.⁶ Conversely, smoking cessation for as little as 4 weeks before surgery is associated with fewer complications.⁷ In addition, given that alcohol abuse may compromise the surgical stress response and increase the risk of opioid misuse, addressing alcohol abuse preoperatively may improve postoperative recovery.⁸

Treating mood disorders that coexist with chronic pain disorders is an important part of outpatient multimodal management—psychological intervention is a useful adjunct to prehabilitation in reducing perioperative anxiety and improving postoperative functional capacity.⁹ For patients who have chronic pain and are undergoing surgery, it is important to address any anxiety, depression, or poor coping skills (eg, pain catastrophizing) to try to reduce the postoperative pain experience and decrease the risk of chronic postsurgical pain (CPSP).^10,11

Before surgery, patients with chronic pain syndromes should be evaluated for emotional distress and pain coping ability. When possible, they should be referred to a pain psychologist, who can initiate CBT and other interventions. In addition, pain coping skills can be developed or reinforced to address preoperative anxiety and pain catastrophizing. These interventions, which may include use of visual imagery, breathing exercises, and other relaxation techniques, are applicable to the management of postoperative anxiety as well.

Read about preoperative multimodal analgesia and intra- and postoperative management.

Preoperative multimodal analgesia

Multimodal analgesia has several benefits. Simultaneous effects can be generated on multiple pain-related neurotransmitters, and a synergistic effect (eg, of acetaminophen and a nonsteroidal anti-inflammatory drug [NSAID]) can improve pain management. In addition, small doses of multiple medications can be given, instead of a large dose of a single medication. Of course, this strategy must be modified in elderly and patients with impaired renal function, who are at high risk for polypharmacy.

Preoperative administration of 3 medications—a selective cyclooxygenase 2 (COX-2) inhibitor, acetaminophen, and a gabapentinoid—is increasingly accepted as part of multimodal analgesia. The selective COX-2 inhibitor targets inflammatory prostaglandins and has anti-inflammatory and analgesic effects; acetaminophen, an effective analgesic with an unclear mechanism of action, can reduce postoperative opioid consumption¹² and works synergistically with NSAIDs¹³; and the gabapentinoid gabapentin has an analgesic effect likely contributing to decreased movement-related pain and subsequent improved functional recovery (data are mixed on whether continuing gabapentin after surgery prevents CPSP).¹⁴⁻¹⁶

Although serotonin and norepinephrine reuptake inhibitors (SNRIs) are commonly used in outpatient management of chronic pelvic pain, data suggest that their role in perioperative pain management is evolving. As SNRIs may reduce central nervous system (CNS) sensitization,¹⁷ their analgesic effect is thought to result from increased descending inhibitory tone in the CNS, which makes this class of medication ideal for patients with chronic neuropathic pain.¹⁵

Limited data also suggest a role for SNRIs in decreasing immediate postoperative pain and CPSP in high-risk patients. Studies of duloxetine use in the immediate perioperative period have found reduced postoperative acute pain and opioid use.^18,19 In addition, a short course of low-dose (37.5 mg) venlafaxine both before and after surgery has demonstrated a reduction in postoperative opioid use and a reduction in movement-related pain 6 months after surgery.²⁰

Intraoperative management

The surgical and anesthesia teams share the goal of optimizing both pain control and postoperative recovery. Surgical team members, who want longer-acting anesthetics for infiltration of incision sites, discuss with the anesthesiologist the appropriateness of using peripheral nerve blocks or neuraxial anesthesia, given the patient’s history and planned procedure. Anesthesia team members can improve anesthesia and minimize intraoperative opioid use through several methods, including total intravenous anesthesia,²¹ dexamethasone,²² ketorolac,²³ and intravenous ketamine. Ketamine, in particular, has a wide range of surgical applications and has been found to reduce postoperative pain, postoperative pain medication use, and the risk of CPSP.²

Incision sites should be infiltrated before and after surgery. Lidocaine traditionally is used for its rapid onset of action in reducing surgical site pain, but its short half-life may limit its applicability to postoperative pain. Recently, bupivacaine (half-life, 3.5 hours) and liposomal bupivacaine (24–34 hours) have gained more attention. Both of these medications appear to be as effective as lidocaine in reducing surgical site pain.²⁴

Transversus abdominis plane (TAP) blocks have been used as an adjunct in pain management during abdominopelvic surgery. Although initial data on postoperative pain and opioid use reductions with TAP blocks were inconclusive,²⁵ more recent data showed a role for TAP blocks in a multimodal approach for reducing opioid use during laparoscopic and open surgery.^26,27 Given the small number of studies on using liposomal bupivacaine for peripheral nerve blocks (eg, TAP blocks) in postoperative pain management, current data are inconclusive.²⁸

Postoperative management

The ERP approach calls for continuing multimodal analgesia after surgery—in most cases, scheduling early use of oral acetaminophen and ibuprofen, and providing short-acting, low-dose opioid analgesia as needed. All patients should be given a bowel regimen. Similar to undergoing prehabilitation for surgery, patients should prepare themselves for recovery. They should be encouraged to engage in early ambulation and oral intake and, when clinically appropriate, be given same-day discharge for minimally invasive surgical procedures.

Patients with chronic pain before surgery are at increased risk for suboptimal postoperative pain management, and those who are dependent on opioids require additional perioperative measures for adequate postoperative pain control. In these complicated cases, it is appropriate to enlist a pain specialist, potentially before surgery, to help plan perioperative and postoperative pain management.² Postoperative pain management for opioid-dependent patients should include pharmacologic and nonpharmacologic interventions, such as use of nonopioid medications (eg, gabapentin) and continuation of CBT. Patients with chronic pain should be closely followed up for assessment of postoperative pain control and recovery.

CASE Resolved

Surgical management is one aspect of the longer term multimodal pain management strategy for this patient. After preoperative pelvic floor physical therapy, she is receptive to starting a trial of an SNRI for her pain and mood symptoms. Both interventions allow for optimization of her preoperative physical and psychological status. Expectations are set that she will be discharged the day of surgery and that the surgery is but one component of her multimodal treatment plan. In addition, before surgery, she takes oral acetaminophen, gabapentin, and celecoxib—previously having had no contraindications to these medications. During surgery, bupivacaine is used for infiltration of all incision sites, and the anesthesia team administers ketamine and a TAP block. After surgery, the patient is prepared for same-day discharge and given the NSAIDs and acetaminophen she is scheduled to take over the next 72 hours. She is also given a limited prescription for oxycodone for breakthrough pain. An office visit 1 to 2 weeks after surgery is scheduled.

ERP strategies for surgical management of endometriosis have not only improved this patient’s postoperative recovery but also reduced her surgical stress response and subsequent transition to chronic postoperative pain. Many of the strategies used in this case are applicable to patients without chronic pain.

Share your thoughts! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.

CASE Chronic pelvic pain from endometriosis

A 40-year-old woman (G0) has a 20-year history of chronic pelvic pain. Stage III endometriosis is diagnosed on laparoscopic excision of endometriotic tissue. Postoperative pain symptoms include dysmenorrhea and deep dyspareunia, and the patient is feeling anxious. Physical examination reveals a retroverted uterus, right adnexal fullness and tenderness, and tenderness on palpation of the right levator ani and right obturator internus; rectovaginal examination findings are unremarkable. The patient, though now engaged in a pelvic floor physical therapy program, has yet to achieve the pain control she desires. After reviewing the treatment strategies for endometriosis with the patient, she elects definitive surgical management with minimally invasive hysterectomy and salpingo-oophorectomy. What pre-, intra-, and postoperative pain management plan do you devise for this patient?

Chronic pelvic pain presents a unique clinical challenge, as pain typically is multifactorial, and several peripheral pain generators may be involved. Although surgery can be performed to manage anatomically based disease processes, it does not address pain from musculoskeletal or neuropathic sources. A complete medical history and a physical examination are of utmost importance in developing a comprehensive multimodal management plan that may include surgery as treatment for the pain.

The standard of care for surgery is a minimally invasive approach (vaginal, laparoscopic, or robot-assisted laparoscopic), as it causes the least amount of trauma. Benefits of minimally invasive surgery include shorter hospitalization and faster recovery, likely owing to improved perioperative pain control, decreased blood loss, and fewer infections. Although this approach minimizes surgical trauma and thereby helps decrease the surgical stress response, the patient experience can be optimized with use of enhanced recovery pathways (ERPs), a multimodal approach to perioperative care.

ERPs were initially proposed as a means of reducing the degree of surgical injury and the subsequent physiologic stress response.¹ This multimodal approach begins in the outpatient setting, includes preoperative and intraoperative modalities, and continues postoperatively. In patients with chronic pain, ERPs are even more important. Assigning “prehabilitation” and setting expectations for surgery goals are the first step in improving the patient experience. Intraoperative use of opioid-sparing anesthetics or regional anesthesia can improve recovery. After surgery, patients with chronic pain and/or opioid dependence receive medications on a schedule, along with short-interval follow-up. Ultimately, reducing acute postoperative pain may lower the risk of developing chronic pain.

In this article on patients with chronic pelvic pain, we highlight elements of ERPs within the framework of enhanced recovery after surgery. Many of the interventions proposed here also can be used to improve the surgical experience of patients without chronic pain.

Preadmission education, expectations, and optimization

Preoperative counseling for elective procedures generally occurs in the outpatient setting. Although discussion traditionally has covered the type of procedure and its associated risks, benefits, and alternatives, new guidelines suggest a more mindful and comprehensive approach is warranted. Individualized patient-centered education programs have a positive impact on the perioperative course, effecting reductions in preoperative anxiety, opioid requirements, and hospital length of stay.² From a pain management perspective, the clinician can take some time during preoperative counseling to inform the patient about the pain to be expected from surgery, the ways the pain will be managed intraoperatively and postoperatively, and the multimodal strategies that will be used throughout the patient’s stay² and that may allow for early discharge. Although preadmission counseling still should address expectations for the surgery, it also presents an opportunity both to assess the patient’s ability to cope with the physical and psychological stress of surgery and to offer the patient appropriate need-based interventions, such as prehabilitation and cognitive-behavioral therapy (CBT).

Prehabilitation is the process of increasing functional capacity before surgery in order to mitigate the stress of the surgery. Prehabilitation may involve aerobic exercise, strength training, or functional task training. The gynecologic surgery literature lacks prehabilitation data, but data in the colorectal literature support use of a prehabilitation program for patients having a scheduled colectomy, with improved postoperative recovery.³ Although the colectomy cohort predominantly included older men, the principle that guides program implementation is the same: improve recovery after the stress of abdominal surgery. Indeed, a patient who opts for an elective surgery may have to wait several weeks before undergoing the procedure, and during this period behavioral interventions can take effect. With postoperative complications occurring more often in patients with reduced functional capacity, the data support using prehabilitation to decrease the incidence of postoperative complications, particularly among the most vulnerable patients.⁴ However, a definitive recommendation on use of pelvic floor exercises as an adjunct to prehabilitation cannot be made.⁴ Successful prehabilitation takes at least 4 weeks and should be part of a multimodal program that addresses other behavioral risk factors that may negatively affect recovery.⁵ For example, current tobacco users have compromised pulmonary status and wound healing immediately after surgery, and use more opioids.⁶ Conversely, smoking cessation for as little as 4 weeks before surgery is associated with fewer complications.⁷ In addition, given that alcohol abuse may compromise the surgical stress response and increase the risk of opioid misuse, addressing alcohol abuse preoperatively may improve postoperative recovery.⁸

Treating mood disorders that coexist with chronic pain disorders is an important part of outpatient multimodal management—psychological intervention is a useful adjunct to prehabilitation in reducing perioperative anxiety and improving postoperative functional capacity.⁹ For patients who have chronic pain and are undergoing surgery, it is important to address any anxiety, depression, or poor coping skills (eg, pain catastrophizing) to try to reduce the postoperative pain experience and decrease the risk of chronic postsurgical pain (CPSP).^10,11

Before surgery, patients with chronic pain syndromes should be evaluated for emotional distress and pain coping ability. When possible, they should be referred to a pain psychologist, who can initiate CBT and other interventions. In addition, pain coping skills can be developed or reinforced to address preoperative anxiety and pain catastrophizing. These interventions, which may include use of visual imagery, breathing exercises, and other relaxation techniques, are applicable to the management of postoperative anxiety as well.

Read about preoperative multimodal analgesia and intra- and postoperative management.

Preoperative multimodal analgesia

Multimodal analgesia has several benefits. Simultaneous effects can be generated on multiple pain-related neurotransmitters, and a synergistic effect (eg, of acetaminophen and a nonsteroidal anti-inflammatory drug [NSAID]) can improve pain management. In addition, small doses of multiple medications can be given, instead of a large dose of a single medication. Of course, this strategy must be modified in elderly and patients with impaired renal function, who are at high risk for polypharmacy.

Preoperative administration of 3 medications—a selective cyclooxygenase 2 (COX-2) inhibitor, acetaminophen, and a gabapentinoid—is increasingly accepted as part of multimodal analgesia. The selective COX-2 inhibitor targets inflammatory prostaglandins and has anti-inflammatory and analgesic effects; acetaminophen, an effective analgesic with an unclear mechanism of action, can reduce postoperative opioid consumption¹² and works synergistically with NSAIDs¹³; and the gabapentinoid gabapentin has an analgesic effect likely contributing to decreased movement-related pain and subsequent improved functional recovery (data are mixed on whether continuing gabapentin after surgery prevents CPSP).¹⁴⁻¹⁶

Although serotonin and norepinephrine reuptake inhibitors (SNRIs) are commonly used in outpatient management of chronic pelvic pain, data suggest that their role in perioperative pain management is evolving. As SNRIs may reduce central nervous system (CNS) sensitization,¹⁷ their analgesic effect is thought to result from increased descending inhibitory tone in the CNS, which makes this class of medication ideal for patients with chronic neuropathic pain.¹⁵

Limited data also suggest a role for SNRIs in decreasing immediate postoperative pain and CPSP in high-risk patients. Studies of duloxetine use in the immediate perioperative period have found reduced postoperative acute pain and opioid use.^18,19 In addition, a short course of low-dose (37.5 mg) venlafaxine both before and after surgery has demonstrated a reduction in postoperative opioid use and a reduction in movement-related pain 6 months after surgery.²⁰

Intraoperative management

The surgical and anesthesia teams share the goal of optimizing both pain control and postoperative recovery. Surgical team members, who want longer-acting anesthetics for infiltration of incision sites, discuss with the anesthesiologist the appropriateness of using peripheral nerve blocks or neuraxial anesthesia, given the patient’s history and planned procedure. Anesthesia team members can improve anesthesia and minimize intraoperative opioid use through several methods, including total intravenous anesthesia,²¹ dexamethasone,²² ketorolac,²³ and intravenous ketamine. Ketamine, in particular, has a wide range of surgical applications and has been found to reduce postoperative pain, postoperative pain medication use, and the risk of CPSP.²

Incision sites should be infiltrated before and after surgery. Lidocaine traditionally is used for its rapid onset of action in reducing surgical site pain, but its short half-life may limit its applicability to postoperative pain. Recently, bupivacaine (half-life, 3.5 hours) and liposomal bupivacaine (24–34 hours) have gained more attention. Both of these medications appear to be as effective as lidocaine in reducing surgical site pain.²⁴

Transversus abdominis plane (TAP) blocks have been used as an adjunct in pain management during abdominopelvic surgery. Although initial data on postoperative pain and opioid use reductions with TAP blocks were inconclusive,²⁵ more recent data showed a role for TAP blocks in a multimodal approach for reducing opioid use during laparoscopic and open surgery.^26,27 Given the small number of studies on using liposomal bupivacaine for peripheral nerve blocks (eg, TAP blocks) in postoperative pain management, current data are inconclusive.²⁸

Postoperative management

The ERP approach calls for continuing multimodal analgesia after surgery—in most cases, scheduling early use of oral acetaminophen and ibuprofen, and providing short-acting, low-dose opioid analgesia as needed. All patients should be given a bowel regimen. Similar to undergoing prehabilitation for surgery, patients should prepare themselves for recovery. They should be encouraged to engage in early ambulation and oral intake and, when clinically appropriate, be given same-day discharge for minimally invasive surgical procedures.

Patients with chronic pain before surgery are at increased risk for suboptimal postoperative pain management, and those who are dependent on opioids require additional perioperative measures for adequate postoperative pain control. In these complicated cases, it is appropriate to enlist a pain specialist, potentially before surgery, to help plan perioperative and postoperative pain management.² Postoperative pain management for opioid-dependent patients should include pharmacologic and nonpharmacologic interventions, such as use of nonopioid medications (eg, gabapentin) and continuation of CBT. Patients with chronic pain should be closely followed up for assessment of postoperative pain control and recovery.

CASE Resolved

Surgical management is one aspect of the longer term multimodal pain management strategy for this patient. After preoperative pelvic floor physical therapy, she is receptive to starting a trial of an SNRI for her pain and mood symptoms. Both interventions allow for optimization of her preoperative physical and psychological status. Expectations are set that she will be discharged the day of surgery and that the surgery is but one component of her multimodal treatment plan. In addition, before surgery, she takes oral acetaminophen, gabapentin, and celecoxib—previously having had no contraindications to these medications. During surgery, bupivacaine is used for infiltration of all incision sites, and the anesthesia team administers ketamine and a TAP block. After surgery, the patient is prepared for same-day discharge and given the NSAIDs and acetaminophen she is scheduled to take over the next 72 hours. She is also given a limited prescription for oxycodone for breakthrough pain. An office visit 1 to 2 weeks after surgery is scheduled.

ERP strategies for surgical management of endometriosis have not only improved this patient’s postoperative recovery but also reduced her surgical stress response and subsequent transition to chronic postoperative pain. Many of the strategies used in this case are applicable to patients without chronic pain.

Share your thoughts! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.

Click Here to Read Content.

Topics include:

• Underdiagnosis and Undertreatment of Migraine
• A Framework for Understanding Burden of Disease
• Burden and Cost
• New Insights in Migraine Pathophysiology

Click Here to Read Content.

Topics include:

• Underdiagnosis and Undertreatment of Migraine
• A Framework for Understanding Burden of Disease
• Burden and Cost
• New Insights in Migraine Pathophysiology

Click Here to Read Content.

Topics include:

• Underdiagnosis and Undertreatment of Migraine
• A Framework for Understanding Burden of Disease
• Burden and Cost
• New Insights in Migraine Pathophysiology

ORLANDO – E-cigarettes are likely safer than traditional cigarettes but it depends on the user, the voltage used, and the kind of liquid, according to a panel of experts at the joint congress of the American Academy of Allergy, Asthma and Immunology and the World Asthma Organization.

Thomas Casale, MD, professor of medicine at the University of South Florida, Tampa, said studies have found that in some ways, e-cigarettes seem safer. For example, the levels of carcinogens such as formaldehyde and heavy metals are found at levels that are 9-450 times higher in combustible cigarette smoke than e-cigarette vapor, he said. And toxic compounds have been found to be significantly lower in the urine of e-cigarette users compared to traditional cigarette smokers.

Thomas R. Collins/Frontline Medical News

But it’s not so simple. While e-cigarettes typically cause lower exposure to formaldehyde, when heated at a higher voltage, exposure to formaldehyde hemiacetal, a formaldehyde precursor, is about seven times higher for someone smoking 3 mL of e-cigarette fluid a day – similar to a pack a day – than the formaldehyde exposure of someone smoking the same quantity of combustible cigarettes.

Dr. Casale added that experienced e-cigarette users typically take longer puffs than traditional smokers and that the unregulated e-cigarette industry is rife with mislabeling on things such as how much nicotine is in a given fluid.

“It’s dependent upon the device, the battery, how much it heats up and what’s in the liquid,” he said. “So in general, are they safer? Probably. But not exactly.”

There are also no long-term data on e-cigarettes, he added.

The evidence on how e-cigarettes affects traditional smoking habits is also mixed.

Some studies have indicated that e-cigarettes use can be helpful in kicking a traditional cigarette habit, said Jill Poole, MD, of the University of Nebraska, Omaha.

A survey by the U.S. Census Bureau found that, in the 2014-2015 data collection year, about 60% of smokers of combustible cigarettes who also smoked e-cigarettes tried to quit smoking combustibles, compared to 40% of those who didn’t smoke e-cigarettes. And 8% of e-cigarette users were successful over 3 months, compared to 4% of nonusers.

Thomas R. Collins/ Frontline Medical News

But data reveals risks for kids who’ve never smoked and then start using e-cigarettes.

“Does noncigarette tobacco use among never smoking youth determine subsequent smoking initiation?” she said. “The answer is yes.”

Dr. Poole added that a study published this year found that youths who’d never smoked traditional cigarettes were 87% more likely to start if they had first tried e-cigarettes (JAMA Pediatr. 2018;172(2):181-187).

And more children are using e-cigarettes frequently. The National Youth Tobacco Survey found that 16% of high schoolers in 2016 had used e-cigarettes in the past 30 days, way up from 1.5% in 2011, even as traditional cigarette use has declined from 15.8% to 9.3% among those children over that time.

Thomas R. Collins/ Frontline Medical News

Loretta Que, MD, associate professor of medicine at Duke University, Durham, N.C., noted how advertising for e-cigarettes is similar to the old ads for traditional cigarettes, attempting to convey coolness. With their wide array of colors and thousands of flavors, there is no doubt that e-cigarette pens have caught on among children, she said.

“They’re becoming something akin to an iPhone case or a handbag.”

ORLANDO – E-cigarettes are likely safer than traditional cigarettes but it depends on the user, the voltage used, and the kind of liquid, according to a panel of experts at the joint congress of the American Academy of Allergy, Asthma and Immunology and the World Asthma Organization.

Thomas Casale, MD, professor of medicine at the University of South Florida, Tampa, said studies have found that in some ways, e-cigarettes seem safer. For example, the levels of carcinogens such as formaldehyde and heavy metals are found at levels that are 9-450 times higher in combustible cigarette smoke than e-cigarette vapor, he said. And toxic compounds have been found to be significantly lower in the urine of e-cigarette users compared to traditional cigarette smokers.

Thomas R. Collins/Frontline Medical News

But it’s not so simple. While e-cigarettes typically cause lower exposure to formaldehyde, when heated at a higher voltage, exposure to formaldehyde hemiacetal, a formaldehyde precursor, is about seven times higher for someone smoking 3 mL of e-cigarette fluid a day – similar to a pack a day – than the formaldehyde exposure of someone smoking the same quantity of combustible cigarettes.

Dr. Casale added that experienced e-cigarette users typically take longer puffs than traditional smokers and that the unregulated e-cigarette industry is rife with mislabeling on things such as how much nicotine is in a given fluid.

“It’s dependent upon the device, the battery, how much it heats up and what’s in the liquid,” he said. “So in general, are they safer? Probably. But not exactly.”

There are also no long-term data on e-cigarettes, he added.

The evidence on how e-cigarettes affects traditional smoking habits is also mixed.

Some studies have indicated that e-cigarettes use can be helpful in kicking a traditional cigarette habit, said Jill Poole, MD, of the University of Nebraska, Omaha.

A survey by the U.S. Census Bureau found that, in the 2014-2015 data collection year, about 60% of smokers of combustible cigarettes who also smoked e-cigarettes tried to quit smoking combustibles, compared to 40% of those who didn’t smoke e-cigarettes. And 8% of e-cigarette users were successful over 3 months, compared to 4% of nonusers.

Thomas R. Collins/ Frontline Medical News

But data reveals risks for kids who’ve never smoked and then start using e-cigarettes.

“Does noncigarette tobacco use among never smoking youth determine subsequent smoking initiation?” she said. “The answer is yes.”

Dr. Poole added that a study published this year found that youths who’d never smoked traditional cigarettes were 87% more likely to start if they had first tried e-cigarettes (JAMA Pediatr. 2018;172(2):181-187).

And more children are using e-cigarettes frequently. The National Youth Tobacco Survey found that 16% of high schoolers in 2016 had used e-cigarettes in the past 30 days, way up from 1.5% in 2011, even as traditional cigarette use has declined from 15.8% to 9.3% among those children over that time.

Thomas R. Collins/ Frontline Medical News

Loretta Que, MD, associate professor of medicine at Duke University, Durham, N.C., noted how advertising for e-cigarettes is similar to the old ads for traditional cigarettes, attempting to convey coolness. With their wide array of colors and thousands of flavors, there is no doubt that e-cigarette pens have caught on among children, she said.

“They’re becoming something akin to an iPhone case or a handbag.”

ORLANDO – E-cigarettes are likely safer than traditional cigarettes but it depends on the user, the voltage used, and the kind of liquid, according to a panel of experts at the joint congress of the American Academy of Allergy, Asthma and Immunology and the World Asthma Organization.

Thomas Casale, MD, professor of medicine at the University of South Florida, Tampa, said studies have found that in some ways, e-cigarettes seem safer. For example, the levels of carcinogens such as formaldehyde and heavy metals are found at levels that are 9-450 times higher in combustible cigarette smoke than e-cigarette vapor, he said. And toxic compounds have been found to be significantly lower in the urine of e-cigarette users compared to traditional cigarette smokers.

Thomas R. Collins/Frontline Medical News

But it’s not so simple. While e-cigarettes typically cause lower exposure to formaldehyde, when heated at a higher voltage, exposure to formaldehyde hemiacetal, a formaldehyde precursor, is about seven times higher for someone smoking 3 mL of e-cigarette fluid a day – similar to a pack a day – than the formaldehyde exposure of someone smoking the same quantity of combustible cigarettes.

Dr. Casale added that experienced e-cigarette users typically take longer puffs than traditional smokers and that the unregulated e-cigarette industry is rife with mislabeling on things such as how much nicotine is in a given fluid.

“It’s dependent upon the device, the battery, how much it heats up and what’s in the liquid,” he said. “So in general, are they safer? Probably. But not exactly.”

There are also no long-term data on e-cigarettes, he added.

The evidence on how e-cigarettes affects traditional smoking habits is also mixed.

Some studies have indicated that e-cigarettes use can be helpful in kicking a traditional cigarette habit, said Jill Poole, MD, of the University of Nebraska, Omaha.

A survey by the U.S. Census Bureau found that, in the 2014-2015 data collection year, about 60% of smokers of combustible cigarettes who also smoked e-cigarettes tried to quit smoking combustibles, compared to 40% of those who didn’t smoke e-cigarettes. And 8% of e-cigarette users were successful over 3 months, compared to 4% of nonusers.

Thomas R. Collins/ Frontline Medical News

But data reveals risks for kids who’ve never smoked and then start using e-cigarettes.

“Does noncigarette tobacco use among never smoking youth determine subsequent smoking initiation?” she said. “The answer is yes.”

Dr. Poole added that a study published this year found that youths who’d never smoked traditional cigarettes were 87% more likely to start if they had first tried e-cigarettes (JAMA Pediatr. 2018;172(2):181-187).

And more children are using e-cigarettes frequently. The National Youth Tobacco Survey found that 16% of high schoolers in 2016 had used e-cigarettes in the past 30 days, way up from 1.5% in 2011, even as traditional cigarette use has declined from 15.8% to 9.3% among those children over that time.

Thomas R. Collins/ Frontline Medical News

Loretta Que, MD, associate professor of medicine at Duke University, Durham, N.C., noted how advertising for e-cigarettes is similar to the old ads for traditional cigarettes, attempting to convey coolness. With their wide array of colors and thousands of flavors, there is no doubt that e-cigarette pens have caught on among children, she said.

“They’re becoming something akin to an iPhone case or a handbag.”

• Sepsis response team not beneficial
• Outcomes better for patients with H1N1 vaccination
• Lung recovery high after ECMO in near-fatal asthma
• Robotic-assisted pulmonary lobectomy removes large tumors
• Aspirin responsiveness improved in some with obstructive sleep apnea
• Solriamfetol improves excessive sleepiness in OSA patients
• Acute kidney injury linked with doubled inpatient VTEs
• Alarm reductions don’t improve ICU response times
• ARDS incidence is declining. Is it a preventable syndrome?
• Balanced crystalloids protect kidney better than saline
• Omalizumab helps asthma COPD overlap patients
• Nebulized glycopyrrolate improves lung function in COPD
• Nebulized LABA safe for long-term use in COPD
• IGRA preferred test for latent TB diagnosis
• Only half of appropriate COPD patients get long-acting bronchodilators
• Rapid influenza test obviates empiric antivirals
• Remimazolam surpasses midazolam
• Revised guidelines raise lung cancer screening age ceiling
• Ultrathin bronchoscopy plus radial EBUS unreliable at making diagnoses
• Phrenic-nerve stimulator maintains benefits for 18 months
• Cardiogenic shock boosts PAH readmissions 10-fold
• Evidence mounts for pulmonary embolism benefit from catheter thrombolysis
• Tracheobronchial tree size changes may predict IPF outcomes
• Shorter walk test predicts IPF outcomes
• Comparing arterial ratios may aid risk assessment in IPF
• FDA’s standards for approving generics are questioned
• Live Streaming at CHEST 2017

• Sepsis response team not beneficial
• Outcomes better for patients with H1N1 vaccination
• Lung recovery high after ECMO in near-fatal asthma
• Robotic-assisted pulmonary lobectomy removes large tumors
• Aspirin responsiveness improved in some with obstructive sleep apnea
• Solriamfetol improves excessive sleepiness in OSA patients
• Acute kidney injury linked with doubled inpatient VTEs
• Alarm reductions don’t improve ICU response times
• ARDS incidence is declining. Is it a preventable syndrome?
• Balanced crystalloids protect kidney better than saline
• Omalizumab helps asthma COPD overlap patients
• Nebulized glycopyrrolate improves lung function in COPD
• Nebulized LABA safe for long-term use in COPD
• IGRA preferred test for latent TB diagnosis
• Only half of appropriate COPD patients get long-acting bronchodilators
• Rapid influenza test obviates empiric antivirals
• Remimazolam surpasses midazolam
• Revised guidelines raise lung cancer screening age ceiling
• Ultrathin bronchoscopy plus radial EBUS unreliable at making diagnoses
• Phrenic-nerve stimulator maintains benefits for 18 months
• Cardiogenic shock boosts PAH readmissions 10-fold
• Evidence mounts for pulmonary embolism benefit from catheter thrombolysis
• Tracheobronchial tree size changes may predict IPF outcomes
• Shorter walk test predicts IPF outcomes
• Comparing arterial ratios may aid risk assessment in IPF
• FDA’s standards for approving generics are questioned
• Live Streaming at CHEST 2017

• Sepsis response team not beneficial
• Outcomes better for patients with H1N1 vaccination
• Lung recovery high after ECMO in near-fatal asthma
• Robotic-assisted pulmonary lobectomy removes large tumors
• Aspirin responsiveness improved in some with obstructive sleep apnea
• Solriamfetol improves excessive sleepiness in OSA patients
• Acute kidney injury linked with doubled inpatient VTEs
• Alarm reductions don’t improve ICU response times
• ARDS incidence is declining. Is it a preventable syndrome?
• Balanced crystalloids protect kidney better than saline
• Omalizumab helps asthma COPD overlap patients
• Nebulized glycopyrrolate improves lung function in COPD
• Nebulized LABA safe for long-term use in COPD
• IGRA preferred test for latent TB diagnosis
• Only half of appropriate COPD patients get long-acting bronchodilators
• Rapid influenza test obviates empiric antivirals
• Remimazolam surpasses midazolam
• Revised guidelines raise lung cancer screening age ceiling
• Ultrathin bronchoscopy plus radial EBUS unreliable at making diagnoses
• Phrenic-nerve stimulator maintains benefits for 18 months
• Cardiogenic shock boosts PAH readmissions 10-fold
• Evidence mounts for pulmonary embolism benefit from catheter thrombolysis
• Tracheobronchial tree size changes may predict IPF outcomes
• Shorter walk test predicts IPF outcomes
• Comparing arterial ratios may aid risk assessment in IPF
• FDA’s standards for approving generics are questioned
• Live Streaming at CHEST 2017

LAS VEGAS – The overlap of ADHD, conduct disorder, substance use disorder, and criminality likely reflect related underlying mechanisms, which may elucidate different developmental pathways of offending.

“Early interventions are key,” Praveen R. Kambam, MD, said at an annual psychopharmacology update held by the Nevada Psychiatric Association.

According to Dr. Kambam, a clinical and forensic psychiatrist at the University of California, Los Angeles, ADHD is overrepresented in correctional settings worldwide, especially the hyperactive-impulsive subtype. “In juvenile settings, ADHD rates are 3-4 times higher than rates in the general population,” he said. “If you combine juvenile and adult prison populations worldwide, the rates are about 2-5 times higher than the general population.”

The risks are increased for comorbid oppositional defiant disorder (ODD) and conduct disorder. In fact, ADHD and conduct disorder co-occur in about 50% of cases. In girls, the prevalence rate of conduct disorder is steady at 0.8% around age 5 years and increases to 2.8% around age 15 years, while in boys, conduct disorder is steady at 2.1% around age 5 years and rises to 5.5% at age 15 years.

According to a literature review of 18 prospective studies, 13 retrospective studies, and four reviews, individuals with ADHD plus or minus conduct disorder had an increased the risk of antisocial personality disorder, and those with ADHD plus conduct disorder had an increased risk of criminality (J Atten Disord. 2016;20[10]:815-24). “So it’s a subtle difference, where antisocial personality disorder and criminality are slightly different,” Dr. Kambam said. “It could be that the diagnostic criteria are catching the same thing. However, the added [conduct disorder] suggests that there may be subpopulations that are vulnerable.”

He went on to note that individuals with ADHD and delinquency tend to have more learning problems, poor academic achievement, peer relationship problems, and risk of social rejection, while individuals with oppositional defiant disorder and delinquency tend to have peer relationship problems, a negative parent-child relationship, and increased risk of developing conduct disorder.

ADHD is associated with alcohol and drug use in adulthood and nicotine use in adolescence. “Comorbidity between ADHD and ODD/[conduct disorder] is robustly related to substance outcomes,” Dr. Kambam said. “However, both initiation and continuation of substance use disorder are more likely when ADHD symptoms are present, even when controlling for ODD/[conduct disorder]. As for substance use disorder [SUD] and delinquency, the onset of delinquency is more likely in children with onset of SUD by age 11, and SUDs are closely linked with criminality in both juveniles and adults.”

Comorbidity of SUD with conduct disorder and ADHD likely reflects multifactorial mechanisms, he said, such as inherent novelty seeking or school failure leading to association with antisocial peers. Risk factors for chronic offending include early onset of criminal behaviors, ADHD plus conduct disorder, and ODD. ADHD has an independent yet weaker relationship with antisocial behaviors as well, while ADHD, conduct disorder, and SUD are independently associated with increased recidivism.

Environmental factors for chronic offending include the home environment, peer response, parenting skills, and in utero exposures and perinatal complications. “Whether ADHD develops into more severe conduct problems depends considerably on exposure to potentiating environmental factors,” Dr. Kambam said. “The converse is also true: Low-risk environments promote desistance from this pathway in impulsive boys.” He added that the chronic offenders/criminality pathway likely stems from underlying mechanisms, such as impulsivity, low self-control, and executive dysfunction.

If left untreated, ADHD is associated with poor academic and employment outcomes, SUDs, depression, bipolar disorder, suicide attempts, vehicular accidents, and use of mental health services. “The economic costs are estimated to be $42.5 billion annually, so it has a large impact,” he said.

Limited evidence exists to support pharmacological treatments for conduct disorder, although stimulants/alpha-agonists, antipsychotics, lithium, and mood stabilizers may offer some benefit for target symptoms. “Most of the treatment data center around multisystemic therapy, including behavioral modification/parent management training, and functional family training,” Dr. Kambam said. “Treating disruptive behavior disorders and SUDs are 

likely to reduce criminality and recidivism, particularly if started early. There are many beneficial economic impacts. Think about the cost of having youth detained in the criminal justice systems. In Los Angeles County, that cost is about $230,000 per year per kid. That money can probably be better spent somewhere else.”

Numerous studies show that the nonmedical use of stimulants ranges from 25%-40%. “They’re mostly used to enhance academic and/or work performance, but some are used for euphoric effect,” he said. “Individuals in college and just out of college seem to be at the highest risk. There is a strong relationship between [conduct disorder]/[antisocial personality disorder] or SUDs and nonmedical use.”

Treatment with stimulants in correctional settings is controversial. “Some say try after failure of nonstimulants, while others say never use them due to substance abuse, misuse, intimidation of patients to surrender medication, and security/costs,” Dr. Kambam said. “The protocol for ADHD treatment in Massachusetts prisons calls for use of nonstimulants first, followed by ‘crushable’ stimulants if indicated.” The methylphenidate patch and lisdexamfetamine also can be effective in the incarcerated population.

Dr. Kambam reported having no financial disclosures.

[email protected]

SOURCE: Kambam PR. NPA 2018.

LAS VEGAS – The overlap of ADHD, conduct disorder, substance use disorder, and criminality likely reflect related underlying mechanisms, which may elucidate different developmental pathways of offending.

“Early interventions are key,” Praveen R. Kambam, MD, said at an annual psychopharmacology update held by the Nevada Psychiatric Association.

According to Dr. Kambam, a clinical and forensic psychiatrist at the University of California, Los Angeles, ADHD is overrepresented in correctional settings worldwide, especially the hyperactive-impulsive subtype. “In juvenile settings, ADHD rates are 3-4 times higher than rates in the general population,” he said. “If you combine juvenile and adult prison populations worldwide, the rates are about 2-5 times higher than the general population.”

The risks are increased for comorbid oppositional defiant disorder (ODD) and conduct disorder. In fact, ADHD and conduct disorder co-occur in about 50% of cases. In girls, the prevalence rate of conduct disorder is steady at 0.8% around age 5 years and increases to 2.8% around age 15 years, while in boys, conduct disorder is steady at 2.1% around age 5 years and rises to 5.5% at age 15 years.

According to a literature review of 18 prospective studies, 13 retrospective studies, and four reviews, individuals with ADHD plus or minus conduct disorder had an increased the risk of antisocial personality disorder, and those with ADHD plus conduct disorder had an increased risk of criminality (J Atten Disord. 2016;20[10]:815-24). “So it’s a subtle difference, where antisocial personality disorder and criminality are slightly different,” Dr. Kambam said. “It could be that the diagnostic criteria are catching the same thing. However, the added [conduct disorder] suggests that there may be subpopulations that are vulnerable.”

He went on to note that individuals with ADHD and delinquency tend to have more learning problems, poor academic achievement, peer relationship problems, and risk of social rejection, while individuals with oppositional defiant disorder and delinquency tend to have peer relationship problems, a negative parent-child relationship, and increased risk of developing conduct disorder.

ADHD is associated with alcohol and drug use in adulthood and nicotine use in adolescence. “Comorbidity between ADHD and ODD/[conduct disorder] is robustly related to substance outcomes,” Dr. Kambam said. “However, both initiation and continuation of substance use disorder are more likely when ADHD symptoms are present, even when controlling for ODD/[conduct disorder]. As for substance use disorder [SUD] and delinquency, the onset of delinquency is more likely in children with onset of SUD by age 11, and SUDs are closely linked with criminality in both juveniles and adults.”

Comorbidity of SUD with conduct disorder and ADHD likely reflects multifactorial mechanisms, he said, such as inherent novelty seeking or school failure leading to association with antisocial peers. Risk factors for chronic offending include early onset of criminal behaviors, ADHD plus conduct disorder, and ODD. ADHD has an independent yet weaker relationship with antisocial behaviors as well, while ADHD, conduct disorder, and SUD are independently associated with increased recidivism.

Environmental factors for chronic offending include the home environment, peer response, parenting skills, and in utero exposures and perinatal complications. “Whether ADHD develops into more severe conduct problems depends considerably on exposure to potentiating environmental factors,” Dr. Kambam said. “The converse is also true: Low-risk environments promote desistance from this pathway in impulsive boys.” He added that the chronic offenders/criminality pathway likely stems from underlying mechanisms, such as impulsivity, low self-control, and executive dysfunction.

If left untreated, ADHD is associated with poor academic and employment outcomes, SUDs, depression, bipolar disorder, suicide attempts, vehicular accidents, and use of mental health services. “The economic costs are estimated to be $42.5 billion annually, so it has a large impact,” he said.

Limited evidence exists to support pharmacological treatments for conduct disorder, although stimulants/alpha-agonists, antipsychotics, lithium, and mood stabilizers may offer some benefit for target symptoms. “Most of the treatment data center around multisystemic therapy, including behavioral modification/parent management training, and functional family training,” Dr. Kambam said. “Treating disruptive behavior disorders and SUDs are 

likely to reduce criminality and recidivism, particularly if started early. There are many beneficial economic impacts. Think about the cost of having youth detained in the criminal justice systems. In Los Angeles County, that cost is about $230,000 per year per kid. That money can probably be better spent somewhere else.”

Numerous studies show that the nonmedical use of stimulants ranges from 25%-40%. “They’re mostly used to enhance academic and/or work performance, but some are used for euphoric effect,” he said. “Individuals in college and just out of college seem to be at the highest risk. There is a strong relationship between [conduct disorder]/[antisocial personality disorder] or SUDs and nonmedical use.”

Treatment with stimulants in correctional settings is controversial. “Some say try after failure of nonstimulants, while others say never use them due to substance abuse, misuse, intimidation of patients to surrender medication, and security/costs,” Dr. Kambam said. “The protocol for ADHD treatment in Massachusetts prisons calls for use of nonstimulants first, followed by ‘crushable’ stimulants if indicated.” The methylphenidate patch and lisdexamfetamine also can be effective in the incarcerated population.

Dr. Kambam reported having no financial disclosures.

[email protected]

SOURCE: Kambam PR. NPA 2018.

LAS VEGAS – The overlap of ADHD, conduct disorder, substance use disorder, and criminality likely reflect related underlying mechanisms, which may elucidate different developmental pathways of offending.

“Early interventions are key,” Praveen R. Kambam, MD, said at an annual psychopharmacology update held by the Nevada Psychiatric Association.

According to Dr. Kambam, a clinical and forensic psychiatrist at the University of California, Los Angeles, ADHD is overrepresented in correctional settings worldwide, especially the hyperactive-impulsive subtype. “In juvenile settings, ADHD rates are 3-4 times higher than rates in the general population,” he said. “If you combine juvenile and adult prison populations worldwide, the rates are about 2-5 times higher than the general population.”

The risks are increased for comorbid oppositional defiant disorder (ODD) and conduct disorder. In fact, ADHD and conduct disorder co-occur in about 50% of cases. In girls, the prevalence rate of conduct disorder is steady at 0.8% around age 5 years and increases to 2.8% around age 15 years, while in boys, conduct disorder is steady at 2.1% around age 5 years and rises to 5.5% at age 15 years.

According to a literature review of 18 prospective studies, 13 retrospective studies, and four reviews, individuals with ADHD plus or minus conduct disorder had an increased the risk of antisocial personality disorder, and those with ADHD plus conduct disorder had an increased risk of criminality (J Atten Disord. 2016;20[10]:815-24). “So it’s a subtle difference, where antisocial personality disorder and criminality are slightly different,” Dr. Kambam said. “It could be that the diagnostic criteria are catching the same thing. However, the added [conduct disorder] suggests that there may be subpopulations that are vulnerable.”

He went on to note that individuals with ADHD and delinquency tend to have more learning problems, poor academic achievement, peer relationship problems, and risk of social rejection, while individuals with oppositional defiant disorder and delinquency tend to have peer relationship problems, a negative parent-child relationship, and increased risk of developing conduct disorder.

ADHD is associated with alcohol and drug use in adulthood and nicotine use in adolescence. “Comorbidity between ADHD and ODD/[conduct disorder] is robustly related to substance outcomes,” Dr. Kambam said. “However, both initiation and continuation of substance use disorder are more likely when ADHD symptoms are present, even when controlling for ODD/[conduct disorder]. As for substance use disorder [SUD] and delinquency, the onset of delinquency is more likely in children with onset of SUD by age 11, and SUDs are closely linked with criminality in both juveniles and adults.”

Comorbidity of SUD with conduct disorder and ADHD likely reflects multifactorial mechanisms, he said, such as inherent novelty seeking or school failure leading to association with antisocial peers. Risk factors for chronic offending include early onset of criminal behaviors, ADHD plus conduct disorder, and ODD. ADHD has an independent yet weaker relationship with antisocial behaviors as well, while ADHD, conduct disorder, and SUD are independently associated with increased recidivism.

Environmental factors for chronic offending include the home environment, peer response, parenting skills, and in utero exposures and perinatal complications. “Whether ADHD develops into more severe conduct problems depends considerably on exposure to potentiating environmental factors,” Dr. Kambam said. “The converse is also true: Low-risk environments promote desistance from this pathway in impulsive boys.” He added that the chronic offenders/criminality pathway likely stems from underlying mechanisms, such as impulsivity, low self-control, and executive dysfunction.

If left untreated, ADHD is associated with poor academic and employment outcomes, SUDs, depression, bipolar disorder, suicide attempts, vehicular accidents, and use of mental health services. “The economic costs are estimated to be $42.5 billion annually, so it has a large impact,” he said.

Limited evidence exists to support pharmacological treatments for conduct disorder, although stimulants/alpha-agonists, antipsychotics, lithium, and mood stabilizers may offer some benefit for target symptoms. “Most of the treatment data center around multisystemic therapy, including behavioral modification/parent management training, and functional family training,” Dr. Kambam said. “Treating disruptive behavior disorders and SUDs are 

likely to reduce criminality and recidivism, particularly if started early. There are many beneficial economic impacts. Think about the cost of having youth detained in the criminal justice systems. In Los Angeles County, that cost is about $230,000 per year per kid. That money can probably be better spent somewhere else.”

Numerous studies show that the nonmedical use of stimulants ranges from 25%-40%. “They’re mostly used to enhance academic and/or work performance, but some are used for euphoric effect,” he said. “Individuals in college and just out of college seem to be at the highest risk. There is a strong relationship between [conduct disorder]/[antisocial personality disorder] or SUDs and nonmedical use.”

Treatment with stimulants in correctional settings is controversial. “Some say try after failure of nonstimulants, while others say never use them due to substance abuse, misuse, intimidation of patients to surrender medication, and security/costs,” Dr. Kambam said. “The protocol for ADHD treatment in Massachusetts prisons calls for use of nonstimulants first, followed by ‘crushable’ stimulants if indicated.” The methylphenidate patch and lisdexamfetamine also can be effective in the incarcerated population.

Dr. Kambam reported having no financial disclosures.

[email protected]

SOURCE: Kambam PR. NPA 2018.

The immune checkpoint inhibitor avelumab (Bavencio), targeted against programmed cell death protein 1 and its ligand (PD1/PD-L1), appears to be well tolerated with a manageable safety profile, pooled data from two clinical trials suggest.

Of the 1,738 patients enrolled in the phase 1 JAVELIN solid tumor trial and the phase 2 JAVELIN Merkel 200 trial, 1,164 (67%) had a treatment-related adverse event (TRAE), and 177 (10.2%) had grade 3 or greater TRAEs. Grade 3 or greater immune-related adverse events (irAEs) occurred in just 2.2% of patients, reported Karen Kelly, MD, from the University of California, Davis, and her colleagues.

“Although conclusions drawn from cross-study comparisons should be made with caution, and to the best of our knowledge the number of pan-tumor clinical studies of [immune checkpoint inhibitor] monotherapy is limited, this analysis of a large population of patients across a broad scope of tumor types suggests that avelumab was associated with an incidence of irAEs that is consistent with that of other ICIs,” they wrote in Cancer.

Adverse events common with other immune checkpoint inhibitors include low-grade fatigue, pruritus, and rash, as well as serious irAEs, including high-grade pneumonitis and autoimmune-like side effects, the authors noted.

To characterize the adverse event profile of avelumab, they reviewed safety data on 1,650 patients enrolled in the solid tumor trial and 88 enrolled in the Merkel cell carcinoma trial, which included all patients in the trial who had received at least one dose of avelumab monotherapy by the cutoff date.

At the time of the analysis, 287 patients (16.5%) were continuing treatment, and 1,451 had discontinued therapy, largely because of disease progression.

Nearly all patients – 1,697 (97.6%) – had at least one adverse event of any grade or cause.

Four patients died from what investigators determined were TRAEs, including autoimmune hepatitis with peritoneal metastases and ascites in a patient with gastric cancer, liver metastases and acute liver failure in a patient with metastatic breast cancer, respiratory distress in a patient with breast cancer and multiple comorbidities, and treatment-related pneumonitis with ongoing Clostridium difficile colitis and diverticulitis not related to study treatment in a patient with urothelial carcinoma.

An additional 59 patients (3.4%) died from adverse events not deemed to be treatment-related, and 104 patient (6%) died from unknown or undocumented causes.

Any grade of irAE occurred in 247 patients (14.2%) and were grade 3 or greater in 39 (2.2%). Management of irAEs included systemic corticosteroids and nonsteroidal immunosuppressants.

In all, 439 patients (25.3%) had infusion-related reactions, which were treated generally with systemic corticosteroid. The protocol of the solid tumor trial was amended later to include diphenhydramine and acetaminophen before the first avelumab infusion as prophylaxis.

The study was sponsored by Merck and part of an alliance between Merck and Pfizer. Dr. Kelly reported no conflicts of interest. Multiple coauthors reported research funding, consulting fees, honoraria, or other consideration from various companies, and several coauthors are Merck employees.

The immune checkpoint inhibitor avelumab (Bavencio), targeted against programmed cell death protein 1 and its ligand (PD1/PD-L1), appears to be well tolerated with a manageable safety profile, pooled data from two clinical trials suggest.

Of the 1,738 patients enrolled in the phase 1 JAVELIN solid tumor trial and the phase 2 JAVELIN Merkel 200 trial, 1,164 (67%) had a treatment-related adverse event (TRAE), and 177 (10.2%) had grade 3 or greater TRAEs. Grade 3 or greater immune-related adverse events (irAEs) occurred in just 2.2% of patients, reported Karen Kelly, MD, from the University of California, Davis, and her colleagues.

“Although conclusions drawn from cross-study comparisons should be made with caution, and to the best of our knowledge the number of pan-tumor clinical studies of [immune checkpoint inhibitor] monotherapy is limited, this analysis of a large population of patients across a broad scope of tumor types suggests that avelumab was associated with an incidence of irAEs that is consistent with that of other ICIs,” they wrote in Cancer.

Adverse events common with other immune checkpoint inhibitors include low-grade fatigue, pruritus, and rash, as well as serious irAEs, including high-grade pneumonitis and autoimmune-like side effects, the authors noted.

To characterize the adverse event profile of avelumab, they reviewed safety data on 1,650 patients enrolled in the solid tumor trial and 88 enrolled in the Merkel cell carcinoma trial, which included all patients in the trial who had received at least one dose of avelumab monotherapy by the cutoff date.

At the time of the analysis, 287 patients (16.5%) were continuing treatment, and 1,451 had discontinued therapy, largely because of disease progression.

Nearly all patients – 1,697 (97.6%) – had at least one adverse event of any grade or cause.

Four patients died from what investigators determined were TRAEs, including autoimmune hepatitis with peritoneal metastases and ascites in a patient with gastric cancer, liver metastases and acute liver failure in a patient with metastatic breast cancer, respiratory distress in a patient with breast cancer and multiple comorbidities, and treatment-related pneumonitis with ongoing Clostridium difficile colitis and diverticulitis not related to study treatment in a patient with urothelial carcinoma.

An additional 59 patients (3.4%) died from adverse events not deemed to be treatment-related, and 104 patient (6%) died from unknown or undocumented causes.

Any grade of irAE occurred in 247 patients (14.2%) and were grade 3 or greater in 39 (2.2%). Management of irAEs included systemic corticosteroids and nonsteroidal immunosuppressants.

In all, 439 patients (25.3%) had infusion-related reactions, which were treated generally with systemic corticosteroid. The protocol of the solid tumor trial was amended later to include diphenhydramine and acetaminophen before the first avelumab infusion as prophylaxis.

The study was sponsored by Merck and part of an alliance between Merck and Pfizer. Dr. Kelly reported no conflicts of interest. Multiple coauthors reported research funding, consulting fees, honoraria, or other consideration from various companies, and several coauthors are Merck employees.

The immune checkpoint inhibitor avelumab (Bavencio), targeted against programmed cell death protein 1 and its ligand (PD1/PD-L1), appears to be well tolerated with a manageable safety profile, pooled data from two clinical trials suggest.

Of the 1,738 patients enrolled in the phase 1 JAVELIN solid tumor trial and the phase 2 JAVELIN Merkel 200 trial, 1,164 (67%) had a treatment-related adverse event (TRAE), and 177 (10.2%) had grade 3 or greater TRAEs. Grade 3 or greater immune-related adverse events (irAEs) occurred in just 2.2% of patients, reported Karen Kelly, MD, from the University of California, Davis, and her colleagues.

“Although conclusions drawn from cross-study comparisons should be made with caution, and to the best of our knowledge the number of pan-tumor clinical studies of [immune checkpoint inhibitor] monotherapy is limited, this analysis of a large population of patients across a broad scope of tumor types suggests that avelumab was associated with an incidence of irAEs that is consistent with that of other ICIs,” they wrote in Cancer.

Adverse events common with other immune checkpoint inhibitors include low-grade fatigue, pruritus, and rash, as well as serious irAEs, including high-grade pneumonitis and autoimmune-like side effects, the authors noted.

To characterize the adverse event profile of avelumab, they reviewed safety data on 1,650 patients enrolled in the solid tumor trial and 88 enrolled in the Merkel cell carcinoma trial, which included all patients in the trial who had received at least one dose of avelumab monotherapy by the cutoff date.

At the time of the analysis, 287 patients (16.5%) were continuing treatment, and 1,451 had discontinued therapy, largely because of disease progression.

Nearly all patients – 1,697 (97.6%) – had at least one adverse event of any grade or cause.

Four patients died from what investigators determined were TRAEs, including autoimmune hepatitis with peritoneal metastases and ascites in a patient with gastric cancer, liver metastases and acute liver failure in a patient with metastatic breast cancer, respiratory distress in a patient with breast cancer and multiple comorbidities, and treatment-related pneumonitis with ongoing Clostridium difficile colitis and diverticulitis not related to study treatment in a patient with urothelial carcinoma.

An additional 59 patients (3.4%) died from adverse events not deemed to be treatment-related, and 104 patient (6%) died from unknown or undocumented causes.

Any grade of irAE occurred in 247 patients (14.2%) and were grade 3 or greater in 39 (2.2%). Management of irAEs included systemic corticosteroids and nonsteroidal immunosuppressants.

In all, 439 patients (25.3%) had infusion-related reactions, which were treated generally with systemic corticosteroid. The protocol of the solid tumor trial was amended later to include diphenhydramine and acetaminophen before the first avelumab infusion as prophylaxis.

The study was sponsored by Merck and part of an alliance between Merck and Pfizer. Dr. Kelly reported no conflicts of interest. Multiple coauthors reported research funding, consulting fees, honoraria, or other consideration from various companies, and several coauthors are Merck employees.

Variations in the clinical presentation of immunotherapy-induced inflammatory arthritis is partly explained by which treatment regimen was used to treat the cancer, a single-center study suggests.

While immune checkpoint inhibitors (ICI) have revolutionized the field of oncology, their use for an ever-widening range of indications had created an increasing population of patients referred to rheumatologists for the management of immune-related adverse events (IrAEs), according to Laura C. Cappelli, MD, and her colleagues at John Hopkins University, Baltimore. 

Well-established guidelines exist for managing adverse events such as colitis and pneumonitis, but there are only preliminary guidelines for evaluating and treating immunotherapy-induced inflammatory arthritis (IA). “This may stem from a lack of consistent reporting of rheumatologic IrAEs in clinical trials, the non–life threatening nature of [inflammatory arthritis], or lack of recognition of musculoskeletal symptoms by treating providers,” they wrote in Seminars in Arthritis and Rheumatism.

Clinical trials have reported ranges of arthralgia in 1%-43% of patients treated with ICIs, but no accurate estimate of the incidence of IA exists. 

The researchers noted that treating patients with ICI-induced IA is complicated by a history of active or recently treated cancer and concerns over using immunosuppression in the context of ICI therapy. 

They set out to evaluate the clinical presentations of 30 patients seen in their clinic with ICI-induced IA. Patients were a median of 59 years old and 12 (40%) were female. Tumor types included metastatic melanoma, non–small cell lung cancer, small cell lung cancer, colorectal cancer, Hodgkin lymphoma, cutaneous lymphoma, renal cell carcinoma, duodenal carcinoma, Merkel cell carcinoma, cutaneous basal cell carcinoma, and cutaneous squamous cell carcinoma.

Sixteen patients were treated with anti–programmed cell death protein 1 (PD-1)/programmed death ligand 1 monotherapy, and 14 were treated with combination anti–CTLA-4/PD-1 therapy. 
Patients on combination therapy were significantly younger (7.5 years, P = 0.01) and were more likely to have metastatic melanoma as their underlying cancer.

Patients who received combination therapy were more likely to present first with knee IA (n = 10) and none had small joint involvement. In contrast, initial small joint involvement was more common in the monotherapy group (n = 6).

Most of the patients in the study had an additional IrAE, with colitis being the most common (n=10), followed by thyroid disease, pneumonitis, and rash. Patients on PD-1 or programmed death ligand 1 monotherapy were more likely to have IA as their first IrAE.

The research team noted that the median time to symptom onset was 5 months after ICI initiation.

Diagnosis of IA following patient-reported symptoms was an average of 5.2 months, with a significant difference in lag time to diagnosis depending on initial joint presentation. For example, patients with initial small joint involvement had a 10 month longer lag time to IA diagnosis than those with knees as the initial joint involved. 

In terms of treatment, 24 patients were treated with systemic corticosteroids and 10 required additional immunosuppression. The need for corticosteroids did not differ by ICI treatment regimen, but those treated with combination therapy were more likely to require additional immunosuppression (P = 0.02).

Tumor necrosis factor inhibitors with or without methotrexate were prescribed for seven patients. All of the patients had a clinical improvement in their arthritis symptoms. Four had a complete tumor response at the time of tumor necrosis factor inhibitor initiation with none having tumor progression.

The three patients treated with methotrexate monotherapy had a complete or sustained partial tumor response to ICI therapy and their cancer did not develop during IA management follow-up.  

The authors went on to look at the persistence of IA after cessation of therapy in a subset of 21 patients. They found that 18 of these patients still had IA symptoms months after stopping treatment. They suggested that the delay in diagnosis and treatment seen in their study might explain the finding. 

The study provides “critical information, not just for rheumatologists as they try to recognize subgroups in ICI-induced IA and diagnose patients with this new entity, but also for oncology providers who are usually first to encounter patients with ICI-induced IA and subsequently refer patients to rheumatology,” Dr. Cappelli and colleagues wrote.

The experience so far with using immunosuppression in ICI-induced IA “has been reassuring in terms of cancer outcomes, but more studies are needed to confirm this finding,” they concluded.

SOURCE: Cappelli LC et al. Semin Arthritis Rheum. doi: 10.1016/j.semarthrit. 2018.02.011.

Variations in the clinical presentation of immunotherapy-induced inflammatory arthritis is partly explained by which treatment regimen was used to treat the cancer, a single-center study suggests.

While immune checkpoint inhibitors (ICI) have revolutionized the field of oncology, their use for an ever-widening range of indications had created an increasing population of patients referred to rheumatologists for the management of immune-related adverse events (IrAEs), according to Laura C. Cappelli, MD, and her colleagues at John Hopkins University, Baltimore. 

Well-established guidelines exist for managing adverse events such as colitis and pneumonitis, but there are only preliminary guidelines for evaluating and treating immunotherapy-induced inflammatory arthritis (IA). “This may stem from a lack of consistent reporting of rheumatologic IrAEs in clinical trials, the non–life threatening nature of [inflammatory arthritis], or lack of recognition of musculoskeletal symptoms by treating providers,” they wrote in Seminars in Arthritis and Rheumatism.

Clinical trials have reported ranges of arthralgia in 1%-43% of patients treated with ICIs, but no accurate estimate of the incidence of IA exists. 

The researchers noted that treating patients with ICI-induced IA is complicated by a history of active or recently treated cancer and concerns over using immunosuppression in the context of ICI therapy. 

They set out to evaluate the clinical presentations of 30 patients seen in their clinic with ICI-induced IA. Patients were a median of 59 years old and 12 (40%) were female. Tumor types included metastatic melanoma, non–small cell lung cancer, small cell lung cancer, colorectal cancer, Hodgkin lymphoma, cutaneous lymphoma, renal cell carcinoma, duodenal carcinoma, Merkel cell carcinoma, cutaneous basal cell carcinoma, and cutaneous squamous cell carcinoma.

Sixteen patients were treated with anti–programmed cell death protein 1 (PD-1)/programmed death ligand 1 monotherapy, and 14 were treated with combination anti–CTLA-4/PD-1 therapy. 
Patients on combination therapy were significantly younger (7.5 years, P = 0.01) and were more likely to have metastatic melanoma as their underlying cancer.

Patients who received combination therapy were more likely to present first with knee IA (n = 10) and none had small joint involvement. In contrast, initial small joint involvement was more common in the monotherapy group (n = 6).

Most of the patients in the study had an additional IrAE, with colitis being the most common (n=10), followed by thyroid disease, pneumonitis, and rash. Patients on PD-1 or programmed death ligand 1 monotherapy were more likely to have IA as their first IrAE.

The research team noted that the median time to symptom onset was 5 months after ICI initiation.

Diagnosis of IA following patient-reported symptoms was an average of 5.2 months, with a significant difference in lag time to diagnosis depending on initial joint presentation. For example, patients with initial small joint involvement had a 10 month longer lag time to IA diagnosis than those with knees as the initial joint involved. 

In terms of treatment, 24 patients were treated with systemic corticosteroids and 10 required additional immunosuppression. The need for corticosteroids did not differ by ICI treatment regimen, but those treated with combination therapy were more likely to require additional immunosuppression (P = 0.02).

Tumor necrosis factor inhibitors with or without methotrexate were prescribed for seven patients. All of the patients had a clinical improvement in their arthritis symptoms. Four had a complete tumor response at the time of tumor necrosis factor inhibitor initiation with none having tumor progression.

The three patients treated with methotrexate monotherapy had a complete or sustained partial tumor response to ICI therapy and their cancer did not develop during IA management follow-up.  

The authors went on to look at the persistence of IA after cessation of therapy in a subset of 21 patients. They found that 18 of these patients still had IA symptoms months after stopping treatment. They suggested that the delay in diagnosis and treatment seen in their study might explain the finding. 

The study provides “critical information, not just for rheumatologists as they try to recognize subgroups in ICI-induced IA and diagnose patients with this new entity, but also for oncology providers who are usually first to encounter patients with ICI-induced IA and subsequently refer patients to rheumatology,” Dr. Cappelli and colleagues wrote.

The experience so far with using immunosuppression in ICI-induced IA “has been reassuring in terms of cancer outcomes, but more studies are needed to confirm this finding,” they concluded.

SOURCE: Cappelli LC et al. Semin Arthritis Rheum. doi: 10.1016/j.semarthrit. 2018.02.011.

Variations in the clinical presentation of immunotherapy-induced inflammatory arthritis is partly explained by which treatment regimen was used to treat the cancer, a single-center study suggests.

While immune checkpoint inhibitors (ICI) have revolutionized the field of oncology, their use for an ever-widening range of indications had created an increasing population of patients referred to rheumatologists for the management of immune-related adverse events (IrAEs), according to Laura C. Cappelli, MD, and her colleagues at John Hopkins University, Baltimore. 

Well-established guidelines exist for managing adverse events such as colitis and pneumonitis, but there are only preliminary guidelines for evaluating and treating immunotherapy-induced inflammatory arthritis (IA). “This may stem from a lack of consistent reporting of rheumatologic IrAEs in clinical trials, the non–life threatening nature of [inflammatory arthritis], or lack of recognition of musculoskeletal symptoms by treating providers,” they wrote in Seminars in Arthritis and Rheumatism.

Clinical trials have reported ranges of arthralgia in 1%-43% of patients treated with ICIs, but no accurate estimate of the incidence of IA exists. 

The researchers noted that treating patients with ICI-induced IA is complicated by a history of active or recently treated cancer and concerns over using immunosuppression in the context of ICI therapy. 

They set out to evaluate the clinical presentations of 30 patients seen in their clinic with ICI-induced IA. Patients were a median of 59 years old and 12 (40%) were female. Tumor types included metastatic melanoma, non–small cell lung cancer, small cell lung cancer, colorectal cancer, Hodgkin lymphoma, cutaneous lymphoma, renal cell carcinoma, duodenal carcinoma, Merkel cell carcinoma, cutaneous basal cell carcinoma, and cutaneous squamous cell carcinoma.

Sixteen patients were treated with anti–programmed cell death protein 1 (PD-1)/programmed death ligand 1 monotherapy, and 14 were treated with combination anti–CTLA-4/PD-1 therapy. 
Patients on combination therapy were significantly younger (7.5 years, P = 0.01) and were more likely to have metastatic melanoma as their underlying cancer.

Patients who received combination therapy were more likely to present first with knee IA (n = 10) and none had small joint involvement. In contrast, initial small joint involvement was more common in the monotherapy group (n = 6).

Most of the patients in the study had an additional IrAE, with colitis being the most common (n=10), followed by thyroid disease, pneumonitis, and rash. Patients on PD-1 or programmed death ligand 1 monotherapy were more likely to have IA as their first IrAE.

The research team noted that the median time to symptom onset was 5 months after ICI initiation.

Diagnosis of IA following patient-reported symptoms was an average of 5.2 months, with a significant difference in lag time to diagnosis depending on initial joint presentation. For example, patients with initial small joint involvement had a 10 month longer lag time to IA diagnosis than those with knees as the initial joint involved. 

In terms of treatment, 24 patients were treated with systemic corticosteroids and 10 required additional immunosuppression. The need for corticosteroids did not differ by ICI treatment regimen, but those treated with combination therapy were more likely to require additional immunosuppression (P = 0.02).

Tumor necrosis factor inhibitors with or without methotrexate were prescribed for seven patients. All of the patients had a clinical improvement in their arthritis symptoms. Four had a complete tumor response at the time of tumor necrosis factor inhibitor initiation with none having tumor progression.

The three patients treated with methotrexate monotherapy had a complete or sustained partial tumor response to ICI therapy and their cancer did not develop during IA management follow-up.  

The authors went on to look at the persistence of IA after cessation of therapy in a subset of 21 patients. They found that 18 of these patients still had IA symptoms months after stopping treatment. They suggested that the delay in diagnosis and treatment seen in their study might explain the finding. 

The study provides “critical information, not just for rheumatologists as they try to recognize subgroups in ICI-induced IA and diagnose patients with this new entity, but also for oncology providers who are usually first to encounter patients with ICI-induced IA and subsequently refer patients to rheumatology,” Dr. Cappelli and colleagues wrote.

The experience so far with using immunosuppression in ICI-induced IA “has been reassuring in terms of cancer outcomes, but more studies are needed to confirm this finding,” they concluded.

SOURCE: Cappelli LC et al. Semin Arthritis Rheum. doi: 10.1016/j.semarthrit. 2018.02.011.

Define It, Engage, Listen, Organize, and Closure. There, You Have It!

When I was asked to give this lecture at the 2017 American College of Emergency Physicians’ (ACEP) Scientific Assembly, I literally snorted and looked over my shoulder. What? Moi give this lecture? Am I a successful emergency physician (EP)? Well, of course I am as the first emergency medicine (EM) residency-trained female professor at the University of Colorado, chair of the meetings subcommittee for the ACEP Educational Committee, and director on the American Board of Emergency Medicine.

What I have learned is that the first step to being successful is to define your personal barriers and self-defeating behaviors, and to identify and define your personal self-defeating behaviors—eg, perfectionism, procrastination, self-doubt?

My own personal self-defeating behavior is most certainly “imposter syndrome,” which is very common among professionals. I first heard about imposter syndrome on my very first day of medical school, and this behavior still follows me today. I have written some short blurbs on this topic because I want others to know they are not alone. Highly successful people have this syndrome, and it can be very debilitating. What is imposter syndrome? According to Sandberg, “Despite being high achievers, even experts in their fields, women can’t seem to shake the sense that it is only a matter of time until they are found out for who they really are- impostors with limited skills or abilities.”¹ Valerie Young, an internationally recognized expert on the subject, categorized imposter syndrome into five subgroups or habits: (1) the perfectionist; (2) the superwoman/man; (3) the natural genius; (4) the rugged individualist; and (5) the expert. In her book, The Secret Thoughts of Successful Women: Why Capable People Suffer From the Imposter Syndrome and How to Thrive in Spite of It, Young builds on decades of research studying fraudulent feelings among high achievers.²

Identify Your Self-Defeating Behaviors and Write Them Down

Regarding the top five subgroups/habits proposed by Young unfortunately, there is no evidence-based literature on imposter syndrome. Most information consists of anecdotal reports from highly successful people. When you read about successful habits from such individuals, they include such things as: efficiency; bring your A-game; embrace communication; personal wellness; and most importantly, growth mentality.³ You have most likely heard phrases such as, “Don’t touch a piece of paper more than once.” The “touch it once” philosophy maybe is efficient, but I’m not sure about it being a successful habit.⁴ The following is my list of the top five principles that I have used to guide my career.

Define

What is success to you? Are you thinking about your whole career, or just a successful shift or a successful triathlon? Do you want to win the triathlon or just finish it? Or, do you want to be a department chair? Define and set your goal(s), and make sure to reach and stretch yourself to the best of your abilities to attain your goal. To achieve your goal, you must force yourself out of your comfort zone. If you do not reach for something, chances are it is not going to drop in your lap.

When I attended my very first ACEP Scientific Assembly as a newly minted EM residency-trained EP, I thought the lectures were a bit too basic and needed to be at a higher level of knowledge. I decided I really wanted to be a part of that process. I defined my personal challenge as improving the ACEP educational content level, and I set my goal as getting on that committee. Your goal may be quite different—eg, maybe you wish to become the medical director of an ED, a residency program director, or an officer on your hospital’s medical staff. Regardless of your goal, the first step is to decide and define what it is that you desire.

Engage

After you have defined and set your goal, the first steps to attaining it are to get started on the road you’ve chosen by showing up at relevant meetings, events; being present, engaging, and demonstrating curiosity. Maybe you will have an interesting journey!

I can’t stress enough how important it is to just show up. Sometimes, you will find that you start in one direction and get pushed in another. One of the first steps I took to getting on the ACEP education committee was to ask other ACEP members and colleagues how to do so. Most told me that the education committee was a very highly regarded one and that perhaps I should start by getting on any ACEP committee—or even better, start with a section. A respected friend in the “know” suggested that I choose an ACEP committee/section of which I had high interest, and to just show up to one of the meetings. I have found this advice to be true for most of life, whether it’s your hospital medical staff, local medical society, or state specialty society, or another professional organization—just show up.

Listen

When you do show up and attend a meeting or event, sit and listen to what others have to say, and when a task comes up with which you think you could be of assistance, step up and volunteer to help. When you are involved in a project or task, or are just listening, always keep an open mind—maybe your agenda is not exactly the same as other members of the organization/committee, but you will learn and gain important experience by being open to the thoughts and opinions of others.

When you step up and offer your assistance, you should make sure you volunteer for something that interests you. In general, to do a good job, the subject matter needs to be of interest to you, and the greater the interest, the more likely you are to be successful at completing the task. It also helps to make sure what you volunteer to do is attainable and realistic.

Organize/Action

After you’ve volunteered and committed yourself to a project, always be a productive member of the group. Do what you say you are going to do, and do it on time. These two simple things, completing your assignment/fulfilling your commitment and doing so on time, will set you apart from the pack. Do not be surprised when the reward for such an accomplishment is a request for you to do more, or take on leadership responsibilities.

Regarding my own personal journey, after I found out who served on the education committee. I started to set down some of the groundwork of networking, showing interest in the committee, and letting committee members know that I was very interested in their group and capable of helping in attaining their goals. Five years after taking these first steps to become involved in the group, I was appointed to serve on the meeting subcommittee of the ACEP education committee. This is the group that sets the curriculum and speakers for the Annual ACEP Scientific Assembly. I had made it! Then, after 8 years on the committee, I was appointed chair and worked hard to bring the meeting to Denver, Colorado, my home town. I pushed hard to reduce the length of many of the 50-minute lectures to 25 minutes, and also added some “rapid-fire” lectures to the curriculum.

Failures

On the path to attaining your goals, you will often encounter failure. It is important to keep in mind that if you never fail, then you probably are not reaching high or far enough. For example, I once wanted my institution to be more integrated at the affiliated University’s campus. I had defined this as my goal. To reach it, when the annual election for the medical school faculty senate came along, I had as many of my faculty colleagues vote for me as secretary, the lowest faculty position available. To my shock, I got elected! The problem was, as the secretary, I was supposed to be present at all of the monthly meetings and actually take notes. Not only did I not know who any of the individuals speaking at these meetings were, but I could only make approximately 50% of the meetings due to scheduling conflicts and other commitments. It is my own shame for not doing my homework and learning the roles and responsibilities of the secretarial position. I had the definition of success as a vague one: I engaged but did not really have an attainable goal. After 3 months, I had to go to the dean and admit I had made a mistake and was not capable of performing the duty of secretary. Although, the dean understood and thanked me for my honesty, this was a humbling experience for me and one that also reflected poorly on my department.

However, we are all human and we do make mistakes. By acknowledging our mistakes and shortcomings, reflecting on why they happened, and learning how to handle and do things differently in the future is all part of the journey to success.

Closure

Did I find all of the time and work I put in over the years to be where I am now worth it to me personally? Was I successful? Yes on both counts! It was one long journey. In addition to the long-term journey, I also choose short ones. For example, I want a successful shift, which I now define as sitting down at least 50% of the time when taking a patient’s history. I also want to be engaged with my patients. Remember, the key to being a successful EP is to set goals, whether they are long-term, short-term, major, or minor. So, reach, define, engage, listen, organize, and attain closure. Expect and be ready for some failures—these are steps on the path to success.

Define It, Engage, Listen, Organize, and Closure. There, You Have It!

When I was asked to give this lecture at the 2017 American College of Emergency Physicians’ (ACEP) Scientific Assembly, I literally snorted and looked over my shoulder. What? Moi give this lecture? Am I a successful emergency physician (EP)? Well, of course I am as the first emergency medicine (EM) residency-trained female professor at the University of Colorado, chair of the meetings subcommittee for the ACEP Educational Committee, and director on the American Board of Emergency Medicine.

What I have learned is that the first step to being successful is to define your personal barriers and self-defeating behaviors, and to identify and define your personal self-defeating behaviors—eg, perfectionism, procrastination, self-doubt?

My own personal self-defeating behavior is most certainly “imposter syndrome,” which is very common among professionals. I first heard about imposter syndrome on my very first day of medical school, and this behavior still follows me today. I have written some short blurbs on this topic because I want others to know they are not alone. Highly successful people have this syndrome, and it can be very debilitating. What is imposter syndrome? According to Sandberg, “Despite being high achievers, even experts in their fields, women can’t seem to shake the sense that it is only a matter of time until they are found out for who they really are- impostors with limited skills or abilities.”¹ Valerie Young, an internationally recognized expert on the subject, categorized imposter syndrome into five subgroups or habits: (1) the perfectionist; (2) the superwoman/man; (3) the natural genius; (4) the rugged individualist; and (5) the expert. In her book, The Secret Thoughts of Successful Women: Why Capable People Suffer From the Imposter Syndrome and How to Thrive in Spite of It, Young builds on decades of research studying fraudulent feelings among high achievers.²

Identify Your Self-Defeating Behaviors and Write Them Down

Regarding the top five subgroups/habits proposed by Young unfortunately, there is no evidence-based literature on imposter syndrome. Most information consists of anecdotal reports from highly successful people. When you read about successful habits from such individuals, they include such things as: efficiency; bring your A-game; embrace communication; personal wellness; and most importantly, growth mentality.³ You have most likely heard phrases such as, “Don’t touch a piece of paper more than once.” The “touch it once” philosophy maybe is efficient, but I’m not sure about it being a successful habit.⁴ The following is my list of the top five principles that I have used to guide my career.

Define

What is success to you? Are you thinking about your whole career, or just a successful shift or a successful triathlon? Do you want to win the triathlon or just finish it? Or, do you want to be a department chair? Define and set your goal(s), and make sure to reach and stretch yourself to the best of your abilities to attain your goal. To achieve your goal, you must force yourself out of your comfort zone. If you do not reach for something, chances are it is not going to drop in your lap.

When I attended my very first ACEP Scientific Assembly as a newly minted EM residency-trained EP, I thought the lectures were a bit too basic and needed to be at a higher level of knowledge. I decided I really wanted to be a part of that process. I defined my personal challenge as improving the ACEP educational content level, and I set my goal as getting on that committee. Your goal may be quite different—eg, maybe you wish to become the medical director of an ED, a residency program director, or an officer on your hospital’s medical staff. Regardless of your goal, the first step is to decide and define what it is that you desire.

Engage

After you have defined and set your goal, the first steps to attaining it are to get started on the road you’ve chosen by showing up at relevant meetings, events; being present, engaging, and demonstrating curiosity. Maybe you will have an interesting journey!

I can’t stress enough how important it is to just show up. Sometimes, you will find that you start in one direction and get pushed in another. One of the first steps I took to getting on the ACEP education committee was to ask other ACEP members and colleagues how to do so. Most told me that the education committee was a very highly regarded one and that perhaps I should start by getting on any ACEP committee—or even better, start with a section. A respected friend in the “know” suggested that I choose an ACEP committee/section of which I had high interest, and to just show up to one of the meetings. I have found this advice to be true for most of life, whether it’s your hospital medical staff, local medical society, or state specialty society, or another professional organization—just show up.

Listen

When you do show up and attend a meeting or event, sit and listen to what others have to say, and when a task comes up with which you think you could be of assistance, step up and volunteer to help. When you are involved in a project or task, or are just listening, always keep an open mind—maybe your agenda is not exactly the same as other members of the organization/committee, but you will learn and gain important experience by being open to the thoughts and opinions of others.

When you step up and offer your assistance, you should make sure you volunteer for something that interests you. In general, to do a good job, the subject matter needs to be of interest to you, and the greater the interest, the more likely you are to be successful at completing the task. It also helps to make sure what you volunteer to do is attainable and realistic.

Organize/Action

After you’ve volunteered and committed yourself to a project, always be a productive member of the group. Do what you say you are going to do, and do it on time. These two simple things, completing your assignment/fulfilling your commitment and doing so on time, will set you apart from the pack. Do not be surprised when the reward for such an accomplishment is a request for you to do more, or take on leadership responsibilities.

Regarding my own personal journey, after I found out who served on the education committee. I started to set down some of the groundwork of networking, showing interest in the committee, and letting committee members know that I was very interested in their group and capable of helping in attaining their goals. Five years after taking these first steps to become involved in the group, I was appointed to serve on the meeting subcommittee of the ACEP education committee. This is the group that sets the curriculum and speakers for the Annual ACEP Scientific Assembly. I had made it! Then, after 8 years on the committee, I was appointed chair and worked hard to bring the meeting to Denver, Colorado, my home town. I pushed hard to reduce the length of many of the 50-minute lectures to 25 minutes, and also added some “rapid-fire” lectures to the curriculum.

Failures

On the path to attaining your goals, you will often encounter failure. It is important to keep in mind that if you never fail, then you probably are not reaching high or far enough. For example, I once wanted my institution to be more integrated at the affiliated University’s campus. I had defined this as my goal. To reach it, when the annual election for the medical school faculty senate came along, I had as many of my faculty colleagues vote for me as secretary, the lowest faculty position available. To my shock, I got elected! The problem was, as the secretary, I was supposed to be present at all of the monthly meetings and actually take notes. Not only did I not know who any of the individuals speaking at these meetings were, but I could only make approximately 50% of the meetings due to scheduling conflicts and other commitments. It is my own shame for not doing my homework and learning the roles and responsibilities of the secretarial position. I had the definition of success as a vague one: I engaged but did not really have an attainable goal. After 3 months, I had to go to the dean and admit I had made a mistake and was not capable of performing the duty of secretary. Although, the dean understood and thanked me for my honesty, this was a humbling experience for me and one that also reflected poorly on my department.

However, we are all human and we do make mistakes. By acknowledging our mistakes and shortcomings, reflecting on why they happened, and learning how to handle and do things differently in the future is all part of the journey to success.

Closure

Did I find all of the time and work I put in over the years to be where I am now worth it to me personally? Was I successful? Yes on both counts! It was one long journey. In addition to the long-term journey, I also choose short ones. For example, I want a successful shift, which I now define as sitting down at least 50% of the time when taking a patient’s history. I also want to be engaged with my patients. Remember, the key to being a successful EP is to set goals, whether they are long-term, short-term, major, or minor. So, reach, define, engage, listen, organize, and attain closure. Expect and be ready for some failures—these are steps on the path to success.

Define It, Engage, Listen, Organize, and Closure. There, You Have It!

When I was asked to give this lecture at the 2017 American College of Emergency Physicians’ (ACEP) Scientific Assembly, I literally snorted and looked over my shoulder. What? Moi give this lecture? Am I a successful emergency physician (EP)? Well, of course I am as the first emergency medicine (EM) residency-trained female professor at the University of Colorado, chair of the meetings subcommittee for the ACEP Educational Committee, and director on the American Board of Emergency Medicine.

What I have learned is that the first step to being successful is to define your personal barriers and self-defeating behaviors, and to identify and define your personal self-defeating behaviors—eg, perfectionism, procrastination, self-doubt?

My own personal self-defeating behavior is most certainly “imposter syndrome,” which is very common among professionals. I first heard about imposter syndrome on my very first day of medical school, and this behavior still follows me today. I have written some short blurbs on this topic because I want others to know they are not alone. Highly successful people have this syndrome, and it can be very debilitating. What is imposter syndrome? According to Sandberg, “Despite being high achievers, even experts in their fields, women can’t seem to shake the sense that it is only a matter of time until they are found out for who they really are- impostors with limited skills or abilities.”¹ Valerie Young, an internationally recognized expert on the subject, categorized imposter syndrome into five subgroups or habits: (1) the perfectionist; (2) the superwoman/man; (3) the natural genius; (4) the rugged individualist; and (5) the expert. In her book, The Secret Thoughts of Successful Women: Why Capable People Suffer From the Imposter Syndrome and How to Thrive in Spite of It, Young builds on decades of research studying fraudulent feelings among high achievers.²

Identify Your Self-Defeating Behaviors and Write Them Down

Regarding the top five subgroups/habits proposed by Young unfortunately, there is no evidence-based literature on imposter syndrome. Most information consists of anecdotal reports from highly successful people. When you read about successful habits from such individuals, they include such things as: efficiency; bring your A-game; embrace communication; personal wellness; and most importantly, growth mentality.³ You have most likely heard phrases such as, “Don’t touch a piece of paper more than once.” The “touch it once” philosophy maybe is efficient, but I’m not sure about it being a successful habit.⁴ The following is my list of the top five principles that I have used to guide my career.

Define

What is success to you? Are you thinking about your whole career, or just a successful shift or a successful triathlon? Do you want to win the triathlon or just finish it? Or, do you want to be a department chair? Define and set your goal(s), and make sure to reach and stretch yourself to the best of your abilities to attain your goal. To achieve your goal, you must force yourself out of your comfort zone. If you do not reach for something, chances are it is not going to drop in your lap.

When I attended my very first ACEP Scientific Assembly as a newly minted EM residency-trained EP, I thought the lectures were a bit too basic and needed to be at a higher level of knowledge. I decided I really wanted to be a part of that process. I defined my personal challenge as improving the ACEP educational content level, and I set my goal as getting on that committee. Your goal may be quite different—eg, maybe you wish to become the medical director of an ED, a residency program director, or an officer on your hospital’s medical staff. Regardless of your goal, the first step is to decide and define what it is that you desire.

Engage

After you have defined and set your goal, the first steps to attaining it are to get started on the road you’ve chosen by showing up at relevant meetings, events; being present, engaging, and demonstrating curiosity. Maybe you will have an interesting journey!

I can’t stress enough how important it is to just show up. Sometimes, you will find that you start in one direction and get pushed in another. One of the first steps I took to getting on the ACEP education committee was to ask other ACEP members and colleagues how to do so. Most told me that the education committee was a very highly regarded one and that perhaps I should start by getting on any ACEP committee—or even better, start with a section. A respected friend in the “know” suggested that I choose an ACEP committee/section of which I had high interest, and to just show up to one of the meetings. I have found this advice to be true for most of life, whether it’s your hospital medical staff, local medical society, or state specialty society, or another professional organization—just show up.

Listen

When you do show up and attend a meeting or event, sit and listen to what others have to say, and when a task comes up with which you think you could be of assistance, step up and volunteer to help. When you are involved in a project or task, or are just listening, always keep an open mind—maybe your agenda is not exactly the same as other members of the organization/committee, but you will learn and gain important experience by being open to the thoughts and opinions of others.

When you step up and offer your assistance, you should make sure you volunteer for something that interests you. In general, to do a good job, the subject matter needs to be of interest to you, and the greater the interest, the more likely you are to be successful at completing the task. It also helps to make sure what you volunteer to do is attainable and realistic.

Organize/Action

After you’ve volunteered and committed yourself to a project, always be a productive member of the group. Do what you say you are going to do, and do it on time. These two simple things, completing your assignment/fulfilling your commitment and doing so on time, will set you apart from the pack. Do not be surprised when the reward for such an accomplishment is a request for you to do more, or take on leadership responsibilities.

Regarding my own personal journey, after I found out who served on the education committee. I started to set down some of the groundwork of networking, showing interest in the committee, and letting committee members know that I was very interested in their group and capable of helping in attaining their goals. Five years after taking these first steps to become involved in the group, I was appointed to serve on the meeting subcommittee of the ACEP education committee. This is the group that sets the curriculum and speakers for the Annual ACEP Scientific Assembly. I had made it! Then, after 8 years on the committee, I was appointed chair and worked hard to bring the meeting to Denver, Colorado, my home town. I pushed hard to reduce the length of many of the 50-minute lectures to 25 minutes, and also added some “rapid-fire” lectures to the curriculum.

Failures

On the path to attaining your goals, you will often encounter failure. It is important to keep in mind that if you never fail, then you probably are not reaching high or far enough. For example, I once wanted my institution to be more integrated at the affiliated University’s campus. I had defined this as my goal. To reach it, when the annual election for the medical school faculty senate came along, I had as many of my faculty colleagues vote for me as secretary, the lowest faculty position available. To my shock, I got elected! The problem was, as the secretary, I was supposed to be present at all of the monthly meetings and actually take notes. Not only did I not know who any of the individuals speaking at these meetings were, but I could only make approximately 50% of the meetings due to scheduling conflicts and other commitments. It is my own shame for not doing my homework and learning the roles and responsibilities of the secretarial position. I had the definition of success as a vague one: I engaged but did not really have an attainable goal. After 3 months, I had to go to the dean and admit I had made a mistake and was not capable of performing the duty of secretary. Although, the dean understood and thanked me for my honesty, this was a humbling experience for me and one that also reflected poorly on my department.

However, we are all human and we do make mistakes. By acknowledging our mistakes and shortcomings, reflecting on why they happened, and learning how to handle and do things differently in the future is all part of the journey to success.

Closure

Did I find all of the time and work I put in over the years to be where I am now worth it to me personally? Was I successful? Yes on both counts! It was one long journey. In addition to the long-term journey, I also choose short ones. For example, I want a successful shift, which I now define as sitting down at least 50% of the time when taking a patient’s history. I also want to be engaged with my patients. Remember, the key to being a successful EP is to set goals, whether they are long-term, short-term, major, or minor. So, reach, define, engage, listen, organize, and attain closure. Expect and be ready for some failures—these are steps on the path to success.

ORLANDO – Use of an app combining patient-reported symptoms with local environmental triggers led patients to take action to improve their health, Penny Jones, PhD, reported at the joint congress of the American Academy of Allergy, Asthma, and Immunology and the World Asthma Organization.

AirRater is a smartphone app and data collection network that includes information on air particulates, daily pollen and fungi counts, temperature, and planned burn locations. Patients enter their respiratory symptoms, which are correlated with local environmental conditions, according to Dr. Jones, a postdoctoral fellow at the University of Tasmania (Australia) in Hobart.

Most of the environmental data are gathered from government agencies; however, researchers collect pollen and fungi counts at their own stations.

Patients do not see the environmental data until they’ve logged in their symptoms so that their reports aren’t biased by that information, Dr. Jones said, adding that the app also sends notifications when pollen and pollutant levels are high.

“It’s an environmental monitoring system coupled with a smartphone app designed to help people with allergies and asthma make better decisions around their health,” Dr. Jones said.

Thomas R. Collins/Frontline Medical News

There are more than 6,000 users, and data from surveys show that it is having an effect, Dr. Jones said. About 40% of users said they have changed their behavior in some way because of information provided by the app, including staying indoors, taking preventive medication, or speaking with their doctors.“It does appear that people are generally finding it a useful tool,” she said.

In a pilot study, researchers found that several environmental triggers were significantly correlated with exacerbation of patient symptoms, including maximum temperature (P < .001), particulate pollution (P < .001), relative humidity (P = .01), birch pollen (P = .006), and cypress pollen (P = .004).
Researchers plan to expand use of the network and app to other parts of Australia and are working to refine the understanding of aerobiological symptom drivers through DNA analysis of airborne particles. Their goal is to be able to identify personalized drivers of sensitivities, she said.
“We’ll keep working on this,” Dr. Jones said. “But we think that certainly has promise.”

The investigators reported no financial conflicts of interest, and the study had no outside funding.
 

SOURCE: Jones P et al. AAAAI/WAO Joint Congress, Abstract 270. 

ORLANDO – Use of an app combining patient-reported symptoms with local environmental triggers led patients to take action to improve their health, Penny Jones, PhD, reported at the joint congress of the American Academy of Allergy, Asthma, and Immunology and the World Asthma Organization.

AirRater is a smartphone app and data collection network that includes information on air particulates, daily pollen and fungi counts, temperature, and planned burn locations. Patients enter their respiratory symptoms, which are correlated with local environmental conditions, according to Dr. Jones, a postdoctoral fellow at the University of Tasmania (Australia) in Hobart.

Most of the environmental data are gathered from government agencies; however, researchers collect pollen and fungi counts at their own stations.

Patients do not see the environmental data until they’ve logged in their symptoms so that their reports aren’t biased by that information, Dr. Jones said, adding that the app also sends notifications when pollen and pollutant levels are high.

“It’s an environmental monitoring system coupled with a smartphone app designed to help people with allergies and asthma make better decisions around their health,” Dr. Jones said.

Thomas R. Collins/Frontline Medical News

There are more than 6,000 users, and data from surveys show that it is having an effect, Dr. Jones said. About 40% of users said they have changed their behavior in some way because of information provided by the app, including staying indoors, taking preventive medication, or speaking with their doctors.“It does appear that people are generally finding it a useful tool,” she said.

In a pilot study, researchers found that several environmental triggers were significantly correlated with exacerbation of patient symptoms, including maximum temperature (P < .001), particulate pollution (P < .001), relative humidity (P = .01), birch pollen (P = .006), and cypress pollen (P = .004).
Researchers plan to expand use of the network and app to other parts of Australia and are working to refine the understanding of aerobiological symptom drivers through DNA analysis of airborne particles. Their goal is to be able to identify personalized drivers of sensitivities, she said.
“We’ll keep working on this,” Dr. Jones said. “But we think that certainly has promise.”

The investigators reported no financial conflicts of interest, and the study had no outside funding.
 

SOURCE: Jones P et al. AAAAI/WAO Joint Congress, Abstract 270. 

ORLANDO – Use of an app combining patient-reported symptoms with local environmental triggers led patients to take action to improve their health, Penny Jones, PhD, reported at the joint congress of the American Academy of Allergy, Asthma, and Immunology and the World Asthma Organization.

AirRater is a smartphone app and data collection network that includes information on air particulates, daily pollen and fungi counts, temperature, and planned burn locations. Patients enter their respiratory symptoms, which are correlated with local environmental conditions, according to Dr. Jones, a postdoctoral fellow at the University of Tasmania (Australia) in Hobart.

Most of the environmental data are gathered from government agencies; however, researchers collect pollen and fungi counts at their own stations.

Patients do not see the environmental data until they’ve logged in their symptoms so that their reports aren’t biased by that information, Dr. Jones said, adding that the app also sends notifications when pollen and pollutant levels are high.

“It’s an environmental monitoring system coupled with a smartphone app designed to help people with allergies and asthma make better decisions around their health,” Dr. Jones said.

Thomas R. Collins/Frontline Medical News

There are more than 6,000 users, and data from surveys show that it is having an effect, Dr. Jones said. About 40% of users said they have changed their behavior in some way because of information provided by the app, including staying indoors, taking preventive medication, or speaking with their doctors.“It does appear that people are generally finding it a useful tool,” she said.

In a pilot study, researchers found that several environmental triggers were significantly correlated with exacerbation of patient symptoms, including maximum temperature (P < .001), particulate pollution (P < .001), relative humidity (P = .01), birch pollen (P = .006), and cypress pollen (P = .004).
Researchers plan to expand use of the network and app to other parts of Australia and are working to refine the understanding of aerobiological symptom drivers through DNA analysis of airborne particles. Their goal is to be able to identify personalized drivers of sensitivities, she said.
“We’ll keep working on this,” Dr. Jones said. “But we think that certainly has promise.”

The investigators reported no financial conflicts of interest, and the study had no outside funding.
 

SOURCE: Jones P et al. AAAAI/WAO Joint Congress, Abstract 270. 

LOS ANGELES—The American Heart Association (AHA) and the American Stroke Association (ASA) updated their guidelines for the early management of patients with acute ischemic stroke. In contrast with the previous guidelines, the new guidelines address the comprehensive management of patients when they are hospitalized, including the initiation of treatments to prevent further stroke that are usually instituted within the first two weeks, said William J. Powers, MD, Chair of Neurology at the University of North Carolina School of Medicine in Chapel Hill, and chair of the guidelines writing group. The guidelines were presented at the International Stroke Conference 2018 and published online ahead of print January 24 in Stroke.

The new guidelines supersede the 2013 guidelines and subsequent updates and were created for all healthcare providers who care for patients with acute ischemic stroke, said Dr. Powers. The new guidelines do not address children or clots in the veins, he added.

Prehospital Care

The new guidelines strongly recommend that each region in the country create systems in which patients receive emergency treatment in small hospitals and are rapidly moved to large hospitals for more comprehensive therapy. “We want the patients who do have a stroke to get to the hospital as fast as possible. This means some kind of screening in the field by emergency medical services…. They need to go to the closest hospital that can adequately evaluate them and give them IV alteplase if they are eligible for it,” said Dr. Powers.

IV and Intra-Arterial Therapies

IV alteplase remains the first-line treatment for patients with acute ischemic stroke. “Everyone who is eligible for this should get it, and this should not be delayed to determine if they are eligible for other treatment,” said Dr. Powers. The new criteria recommend IV alteplase treatment within four and a half hours of acute ischemic stroke onset for an increased number of eligible patients. New data suggest that patients with mild stroke also benefit from IV alteplase within the three-hour-to-four-and-a-half-hour treatment window.

The new guidelines also reduce the number of contraindications for IV alteplase. Under the old guidelines, if patients had had a dural puncture or arterial puncture in the previous seven days, or major trauma not involving the head in the previous 14 days, they were ineligible to receive IV alteplase treatment. Now physicians are advised to use judgment and weigh the risks and benefits of providing this treatment to the patient.

The guidelines also cite evidence for performing a mechanical thrombectomy. The guidelines recommend using eligibility criteria derived from clinical trials to select patients. For those patients who can be treated within six hours or less, eligibility criteria are derived from five trials published in 2015. DAWN and DEFUSE 3 trial eligibility criteria are recommended to select patients for thrombectomy from six to 24 hours. DEFUSE 3 treated patients within six to 16 hours after onset, and the DAWN trial treated patients within six to 24 hours after onset.

In addition, the document’s revised blood pressure guidelines acknowledge that few data can support the choice of effective blood pressure treatment in patients with acute ischemic stroke. Understanding this limitation is important for avoiding overtreatment in patients with high blood pressure, said Dr. Powers.

The new guidelines also provide updated recommendations for deep vein thrombosis prophylaxis. Blood thinners have been advocated as the most effective way to prevent this complication, but the new recommendations state that intermittent pneumatic compression is the best preventive measure.

Diagnostic Tests

Finally, the new guidelines examined the benefits of diagnostic tests and concluded that routinely performing multiple diagnostic tests in every stroke patient is not good medical practice. Not only is this practice expensive, but there are no data to indicate that such indiscriminate testing “will improve overall patient outcome. It actually can lead to further testing and things that could adversely affect patient outcomes,” said Dr. Powers. “We made recommendations that diagnostic testing be individualized … and restricted to answering those questions that will lead to a treatment change of proven benefit.”

—Erica Tricarico

Suggested Reading

Powers WJ, Rabinstein AA, Ackerson T, et al. 2018 Guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2018 Jan 24 [Epub ahead of print].

LOS ANGELES—The American Heart Association (AHA) and the American Stroke Association (ASA) updated their guidelines for the early management of patients with acute ischemic stroke. In contrast with the previous guidelines, the new guidelines address the comprehensive management of patients when they are hospitalized, including the initiation of treatments to prevent further stroke that are usually instituted within the first two weeks, said William J. Powers, MD, Chair of Neurology at the University of North Carolina School of Medicine in Chapel Hill, and chair of the guidelines writing group. The guidelines were presented at the International Stroke Conference 2018 and published online ahead of print January 24 in Stroke.

The new guidelines supersede the 2013 guidelines and subsequent updates and were created for all healthcare providers who care for patients with acute ischemic stroke, said Dr. Powers. The new guidelines do not address children or clots in the veins, he added.

Prehospital Care

The new guidelines strongly recommend that each region in the country create systems in which patients receive emergency treatment in small hospitals and are rapidly moved to large hospitals for more comprehensive therapy. “We want the patients who do have a stroke to get to the hospital as fast as possible. This means some kind of screening in the field by emergency medical services…. They need to go to the closest hospital that can adequately evaluate them and give them IV alteplase if they are eligible for it,” said Dr. Powers.

IV and Intra-Arterial Therapies

IV alteplase remains the first-line treatment for patients with acute ischemic stroke. “Everyone who is eligible for this should get it, and this should not be delayed to determine if they are eligible for other treatment,” said Dr. Powers. The new criteria recommend IV alteplase treatment within four and a half hours of acute ischemic stroke onset for an increased number of eligible patients. New data suggest that patients with mild stroke also benefit from IV alteplase within the three-hour-to-four-and-a-half-hour treatment window.

The new guidelines also reduce the number of contraindications for IV alteplase. Under the old guidelines, if patients had had a dural puncture or arterial puncture in the previous seven days, or major trauma not involving the head in the previous 14 days, they were ineligible to receive IV alteplase treatment. Now physicians are advised to use judgment and weigh the risks and benefits of providing this treatment to the patient.

The guidelines also cite evidence for performing a mechanical thrombectomy. The guidelines recommend using eligibility criteria derived from clinical trials to select patients. For those patients who can be treated within six hours or less, eligibility criteria are derived from five trials published in 2015. DAWN and DEFUSE 3 trial eligibility criteria are recommended to select patients for thrombectomy from six to 24 hours. DEFUSE 3 treated patients within six to 16 hours after onset, and the DAWN trial treated patients within six to 24 hours after onset.

In addition, the document’s revised blood pressure guidelines acknowledge that few data can support the choice of effective blood pressure treatment in patients with acute ischemic stroke. Understanding this limitation is important for avoiding overtreatment in patients with high blood pressure, said Dr. Powers.

The new guidelines also provide updated recommendations for deep vein thrombosis prophylaxis. Blood thinners have been advocated as the most effective way to prevent this complication, but the new recommendations state that intermittent pneumatic compression is the best preventive measure.

Diagnostic Tests

Finally, the new guidelines examined the benefits of diagnostic tests and concluded that routinely performing multiple diagnostic tests in every stroke patient is not good medical practice. Not only is this practice expensive, but there are no data to indicate that such indiscriminate testing “will improve overall patient outcome. It actually can lead to further testing and things that could adversely affect patient outcomes,” said Dr. Powers. “We made recommendations that diagnostic testing be individualized … and restricted to answering those questions that will lead to a treatment change of proven benefit.”

—Erica Tricarico

Suggested Reading

Powers WJ, Rabinstein AA, Ackerson T, et al. 2018 Guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2018 Jan 24 [Epub ahead of print].

LOS ANGELES—The American Heart Association (AHA) and the American Stroke Association (ASA) updated their guidelines for the early management of patients with acute ischemic stroke. In contrast with the previous guidelines, the new guidelines address the comprehensive management of patients when they are hospitalized, including the initiation of treatments to prevent further stroke that are usually instituted within the first two weeks, said William J. Powers, MD, Chair of Neurology at the University of North Carolina School of Medicine in Chapel Hill, and chair of the guidelines writing group. The guidelines were presented at the International Stroke Conference 2018 and published online ahead of print January 24 in Stroke.

The new guidelines supersede the 2013 guidelines and subsequent updates and were created for all healthcare providers who care for patients with acute ischemic stroke, said Dr. Powers. The new guidelines do not address children or clots in the veins, he added.

Prehospital Care

The new guidelines strongly recommend that each region in the country create systems in which patients receive emergency treatment in small hospitals and are rapidly moved to large hospitals for more comprehensive therapy. “We want the patients who do have a stroke to get to the hospital as fast as possible. This means some kind of screening in the field by emergency medical services…. They need to go to the closest hospital that can adequately evaluate them and give them IV alteplase if they are eligible for it,” said Dr. Powers.

IV and Intra-Arterial Therapies

IV alteplase remains the first-line treatment for patients with acute ischemic stroke. “Everyone who is eligible for this should get it, and this should not be delayed to determine if they are eligible for other treatment,” said Dr. Powers. The new criteria recommend IV alteplase treatment within four and a half hours of acute ischemic stroke onset for an increased number of eligible patients. New data suggest that patients with mild stroke also benefit from IV alteplase within the three-hour-to-four-and-a-half-hour treatment window.

The new guidelines also reduce the number of contraindications for IV alteplase. Under the old guidelines, if patients had had a dural puncture or arterial puncture in the previous seven days, or major trauma not involving the head in the previous 14 days, they were ineligible to receive IV alteplase treatment. Now physicians are advised to use judgment and weigh the risks and benefits of providing this treatment to the patient.

The guidelines also cite evidence for performing a mechanical thrombectomy. The guidelines recommend using eligibility criteria derived from clinical trials to select patients. For those patients who can be treated within six hours or less, eligibility criteria are derived from five trials published in 2015. DAWN and DEFUSE 3 trial eligibility criteria are recommended to select patients for thrombectomy from six to 24 hours. DEFUSE 3 treated patients within six to 16 hours after onset, and the DAWN trial treated patients within six to 24 hours after onset.

In addition, the document’s revised blood pressure guidelines acknowledge that few data can support the choice of effective blood pressure treatment in patients with acute ischemic stroke. Understanding this limitation is important for avoiding overtreatment in patients with high blood pressure, said Dr. Powers.

The new guidelines also provide updated recommendations for deep vein thrombosis prophylaxis. Blood thinners have been advocated as the most effective way to prevent this complication, but the new recommendations state that intermittent pneumatic compression is the best preventive measure.

Diagnostic Tests

Finally, the new guidelines examined the benefits of diagnostic tests and concluded that routinely performing multiple diagnostic tests in every stroke patient is not good medical practice. Not only is this practice expensive, but there are no data to indicate that such indiscriminate testing “will improve overall patient outcome. It actually can lead to further testing and things that could adversely affect patient outcomes,” said Dr. Powers. “We made recommendations that diagnostic testing be individualized … and restricted to answering those questions that will lead to a treatment change of proven benefit.”

—Erica Tricarico

Suggested Reading

Powers WJ, Rabinstein AA, Ackerson T, et al. 2018 Guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2018 Jan 24 [Epub ahead of print].