More fuel for the radiation vs. surgery in prostate cancer debate comes from a study suggesting that patients with high-risk localized prostate cancer treated with external beam radiotherapy (EBRT) plus brachytherapy – with or without androgen deprivation (AD) – have survival rates equivalent to those of patients treated with radical prostatectomy (RP).

However, patients treated with EBRT and androgen deprivation without brachytherapy had significantly worse survival compared with patients treated with surgery, according to Ronald D. Ennis, MD, of Rutgers Cancer Institute of New Jersey, New Brunswick, and his colleagues.

“The data reported herein suggest that RT plus brachytherapy with or without AD and RP are associated with similar survival. This finding reinforces the need for patients to seek opinions from both a urologic oncologic surgeon with expertise in RP and a radiation oncologist with expertise in brachytherapy. The natural human tendency for physicians to prefer their modality necessitates this dual consultation approach, preferably in a single joint consultation visit,” the researchers wrote. The report was published in the Journal of Clinical Oncology.

The investigators attempted to control for variables that could influence the results by drawing on data on a large number of patients – 42,765 – who were treated at a large number of facilities across the United States. In addition, they incorporated data on clinical stage and Gleason score for all patients, prostate-specific antigen measurements, comorbidities, and socioeconomic factors that are either known or thought to influence treatment decisions.

They used inverse probability of treatment weight to adjust for imbalances of covariables among the treatment groups, and then created weighted time-dependent Cox proportional hazard models to estimate the effects of each type of treatment on survival.

Their sample included 24,688 patients who underwent RP, 15,435 who received EBRT with AD, and 2,642 who underwent EBRT and brachytherapy with or without AD.

­They found no statistical difference in survival between RP and EBRT plus brachytherapy with/without AD in inverse probability of treatment weighted analysis. The hazard ratio for EBRT/brachytherapy was 1.17, but this was not statistically significant (95% confidence interval, 0.88-1.55).

In contrast. EBRT plus AD was associated with significantly worse survival, with a hazard ration of 1.53 (95% CI, 1.22-1.92).

The authors noted that “this finding reinforces the importance of complications, particularly in the urinary, sexual, and bowel domains, in combination with patient priorities and preferences, in determining an individual patient’s optimal choice. Significant data have been published in recent years regarding patient-reported outcomes that should be shared with all new patients to help guide them to their personal optimal treatment.”

They added that for some patients, quality of life may be a more important factor than survival when choosing a treatment modality.

SOURCE: Ennis et al. J Clin Oncol. 2018 Feb 28. doi: 10.1200/JCO.2017.75.9134

More fuel for the radiation vs. surgery in prostate cancer debate comes from a study suggesting that patients with high-risk localized prostate cancer treated with external beam radiotherapy (EBRT) plus brachytherapy – with or without androgen deprivation (AD) – have survival rates equivalent to those of patients treated with radical prostatectomy (RP).

However, patients treated with EBRT and androgen deprivation without brachytherapy had significantly worse survival compared with patients treated with surgery, according to Ronald D. Ennis, MD, of Rutgers Cancer Institute of New Jersey, New Brunswick, and his colleagues.

“The data reported herein suggest that RT plus brachytherapy with or without AD and RP are associated with similar survival. This finding reinforces the need for patients to seek opinions from both a urologic oncologic surgeon with expertise in RP and a radiation oncologist with expertise in brachytherapy. The natural human tendency for physicians to prefer their modality necessitates this dual consultation approach, preferably in a single joint consultation visit,” the researchers wrote. The report was published in the Journal of Clinical Oncology.

The investigators attempted to control for variables that could influence the results by drawing on data on a large number of patients – 42,765 – who were treated at a large number of facilities across the United States. In addition, they incorporated data on clinical stage and Gleason score for all patients, prostate-specific antigen measurements, comorbidities, and socioeconomic factors that are either known or thought to influence treatment decisions.

They used inverse probability of treatment weight to adjust for imbalances of covariables among the treatment groups, and then created weighted time-dependent Cox proportional hazard models to estimate the effects of each type of treatment on survival.

Their sample included 24,688 patients who underwent RP, 15,435 who received EBRT with AD, and 2,642 who underwent EBRT and brachytherapy with or without AD.

­They found no statistical difference in survival between RP and EBRT plus brachytherapy with/without AD in inverse probability of treatment weighted analysis. The hazard ratio for EBRT/brachytherapy was 1.17, but this was not statistically significant (95% confidence interval, 0.88-1.55).

In contrast. EBRT plus AD was associated with significantly worse survival, with a hazard ration of 1.53 (95% CI, 1.22-1.92).

The authors noted that “this finding reinforces the importance of complications, particularly in the urinary, sexual, and bowel domains, in combination with patient priorities and preferences, in determining an individual patient’s optimal choice. Significant data have been published in recent years regarding patient-reported outcomes that should be shared with all new patients to help guide them to their personal optimal treatment.”

They added that for some patients, quality of life may be a more important factor than survival when choosing a treatment modality.

SOURCE: Ennis et al. J Clin Oncol. 2018 Feb 28. doi: 10.1200/JCO.2017.75.9134

More fuel for the radiation vs. surgery in prostate cancer debate comes from a study suggesting that patients with high-risk localized prostate cancer treated with external beam radiotherapy (EBRT) plus brachytherapy – with or without androgen deprivation (AD) – have survival rates equivalent to those of patients treated with radical prostatectomy (RP).

However, patients treated with EBRT and androgen deprivation without brachytherapy had significantly worse survival compared with patients treated with surgery, according to Ronald D. Ennis, MD, of Rutgers Cancer Institute of New Jersey, New Brunswick, and his colleagues.

“The data reported herein suggest that RT plus brachytherapy with or without AD and RP are associated with similar survival. This finding reinforces the need for patients to seek opinions from both a urologic oncologic surgeon with expertise in RP and a radiation oncologist with expertise in brachytherapy. The natural human tendency for physicians to prefer their modality necessitates this dual consultation approach, preferably in a single joint consultation visit,” the researchers wrote. The report was published in the Journal of Clinical Oncology.

The investigators attempted to control for variables that could influence the results by drawing on data on a large number of patients – 42,765 – who were treated at a large number of facilities across the United States. In addition, they incorporated data on clinical stage and Gleason score for all patients, prostate-specific antigen measurements, comorbidities, and socioeconomic factors that are either known or thought to influence treatment decisions.

They used inverse probability of treatment weight to adjust for imbalances of covariables among the treatment groups, and then created weighted time-dependent Cox proportional hazard models to estimate the effects of each type of treatment on survival.

Their sample included 24,688 patients who underwent RP, 15,435 who received EBRT with AD, and 2,642 who underwent EBRT and brachytherapy with or without AD.

­They found no statistical difference in survival between RP and EBRT plus brachytherapy with/without AD in inverse probability of treatment weighted analysis. The hazard ratio for EBRT/brachytherapy was 1.17, but this was not statistically significant (95% confidence interval, 0.88-1.55).

In contrast. EBRT plus AD was associated with significantly worse survival, with a hazard ration of 1.53 (95% CI, 1.22-1.92).

The authors noted that “this finding reinforces the importance of complications, particularly in the urinary, sexual, and bowel domains, in combination with patient priorities and preferences, in determining an individual patient’s optimal choice. Significant data have been published in recent years regarding patient-reported outcomes that should be shared with all new patients to help guide them to their personal optimal treatment.”

They added that for some patients, quality of life may be a more important factor than survival when choosing a treatment modality.

SOURCE: Ennis et al. J Clin Oncol. 2018 Feb 28. doi: 10.1200/JCO.2017.75.9134

Pediatric orthopedic experts have agreed on a list of five tests and procedures that pediatric physicians and their patients should question.

The American Academy of Pediatrics–Section on Orthopaedics and the Pediatric Orthopaedic Society of North America (POSNA) provide the following list:

• Do not order a screening hip ultrasound to rule out developmental hip dysplasia or developmental hip dislocation if the baby has no risk factors and has a clinically stable hip examination.
• Do not order radiographs or advise bracing or surgery for a child less than 8 years of age with simple in-toeing gait.
• Do not order custom orthotics or shoe inserts for a child with minimally symptomatic or asymptomatic flat feet.
• Do not order advanced imaging studies (MRI or CT) for most musculoskeletal conditions in a child until all appropriate clinical, laboratory, and plain radiographic examinations have been completed.
• Do not order follow-up x-rays for buckle (or torus) fractures if they are no longer tender or painful.

This list was developed based on data collected from 2014-2015 from the POSNA Evidence Based Committee and Advocacy Committee. Approximately 20 members of the two committees participated in the process. They submitted five items each from their practices and experience of tests or procedures that they found were commonly overutilized. The items were placed in order of number of times listed by each surgeon; a total of 30 items were submitted. The two committees then agreed on a final list of five procedures, based on frequency of responses and importance of the condition. After the list was reviewed and feedback provided, the POSNA board of directors voted on a final list. The AAP Executive Committee then provided final approval.

The committee noted that the list is provided for informational purposes and is not intended as a substitute for consultation with a physician.

Read the full list with more details here.

[email protected]

Pediatric orthopedic experts have agreed on a list of five tests and procedures that pediatric physicians and their patients should question.

The American Academy of Pediatrics–Section on Orthopaedics and the Pediatric Orthopaedic Society of North America (POSNA) provide the following list:

• Do not order a screening hip ultrasound to rule out developmental hip dysplasia or developmental hip dislocation if the baby has no risk factors and has a clinically stable hip examination.
• Do not order radiographs or advise bracing or surgery for a child less than 8 years of age with simple in-toeing gait.
• Do not order custom orthotics or shoe inserts for a child with minimally symptomatic or asymptomatic flat feet.
• Do not order advanced imaging studies (MRI or CT) for most musculoskeletal conditions in a child until all appropriate clinical, laboratory, and plain radiographic examinations have been completed.
• Do not order follow-up x-rays for buckle (or torus) fractures if they are no longer tender or painful.

This list was developed based on data collected from 2014-2015 from the POSNA Evidence Based Committee and Advocacy Committee. Approximately 20 members of the two committees participated in the process. They submitted five items each from their practices and experience of tests or procedures that they found were commonly overutilized. The items were placed in order of number of times listed by each surgeon; a total of 30 items were submitted. The two committees then agreed on a final list of five procedures, based on frequency of responses and importance of the condition. After the list was reviewed and feedback provided, the POSNA board of directors voted on a final list. The AAP Executive Committee then provided final approval.

The committee noted that the list is provided for informational purposes and is not intended as a substitute for consultation with a physician.

Read the full list with more details here.

[email protected]

Pediatric orthopedic experts have agreed on a list of five tests and procedures that pediatric physicians and their patients should question.

The American Academy of Pediatrics–Section on Orthopaedics and the Pediatric Orthopaedic Society of North America (POSNA) provide the following list:

• Do not order a screening hip ultrasound to rule out developmental hip dysplasia or developmental hip dislocation if the baby has no risk factors and has a clinically stable hip examination.
• Do not order radiographs or advise bracing or surgery for a child less than 8 years of age with simple in-toeing gait.
• Do not order custom orthotics or shoe inserts for a child with minimally symptomatic or asymptomatic flat feet.
• Do not order advanced imaging studies (MRI or CT) for most musculoskeletal conditions in a child until all appropriate clinical, laboratory, and plain radiographic examinations have been completed.
• Do not order follow-up x-rays for buckle (or torus) fractures if they are no longer tender or painful.

This list was developed based on data collected from 2014-2015 from the POSNA Evidence Based Committee and Advocacy Committee. Approximately 20 members of the two committees participated in the process. They submitted five items each from their practices and experience of tests or procedures that they found were commonly overutilized. The items were placed in order of number of times listed by each surgeon; a total of 30 items were submitted. The two committees then agreed on a final list of five procedures, based on frequency of responses and importance of the condition. After the list was reviewed and feedback provided, the POSNA board of directors voted on a final list. The AAP Executive Committee then provided final approval.

The committee noted that the list is provided for informational purposes and is not intended as a substitute for consultation with a physician.

Read the full list with more details here.

[email protected]

The provision of general anesthesia during endovascular therapy for acute ischemic stroke patients with large-vessel occlusions did not result in more infarct growth when compared with conscious sedation in a new randomized trial, contrary to previous findings.

Furthermore, the single-center, open-label, blinded-endpoint General or Local Anesthesia in Intra Arterial Therapy (GOLIATH) trial also reported that patients randomized to the general anesthesia (GA) group had improved functional outcomes on the modified Rankin Scale at 90 days, with a 91% greater likelihood for lower scores than with conscious sedation (CS) (odds ratio, 1.91; 95% confidence interval, 1.03-3.56).

stockce/Thinkstock

The trial’s primary endpoint results showed that although final infarct volume was smaller in the GA group, the difference in the volume of infarct growth 48-72 hours after symptom onset among patients treated under GA or CS did not reach statistical significance (median [IQR] growth, 8.2 [2.2-38.6] mL vs. 19.4 [2.4-79.0] mL; P = .10).

“Assuming a normal distribution, the mean infarct growth for CS was 57.4 mL and for GA was 34.1 mL (difference, 23.2 mL; 95% CI, –6.4 to 52.9),” the research team noted.

A higher rate of successful reperfusion in the GA arm appeared to reflect its better clinical outcomes. Successful reperfusion occurred in 76.9% of GA patients, compared with 60.3% of CS patients (P = .04).

There were no clinically meaningful differences in safety endpoints between the two arms. Four patients (6.3%) in the CS group were converted to GA.

Significantly more patients in the GA group than in the CS group experienced a decrease of greater than 20% in mean arterial pressure (MAP) (87.7% vs. 34.9%; P = .001). However, when MAP dropped below 70 mm Hg, the duration was non-significantly longer for CS patients than for GA patients (6.5 [2-13] minutes vs. 2 [1-5.5] minutes; P = .09).

A longer delay from arrival at the neurointerventional suite to groin puncture was also seen for patients in the GA group. But the median difference of 9 minutes was “acceptable in the context of the much longer overall time from stroke onset to treatment and from stroke onset to reperfusion, which was not significantly different between the competing arms,” the authors said.

The authors said that overall their findings supported GA as a viable anesthetic approach during EVT. “Contrary to numerous nonrandomized studies that have reported better outcomes with CS, the GOLIATH trial shows signals in favor of GA for multiple endpoints,” the research team wrote. “Performing EVT under GA, compared with CS, does not result in worse tissue or clinical outcomes when using a GA protocol that limits the time delay for intubation (less than 10 minutes) and blood pressure level within recommended limits (systolic blood pressure greater than 140 mm Hg and MAP greater than 70 mm Hg).”

The trial was funded by Aarhus University Hospital. One author reported research grants from Penumbra and Neuravi, and another author reported a research grant from Health Research Fund of Central Denmark Region.

SOURCE: Simonsen C et al., JAMA Neurol. 2018 Jan 16. doi: 10.1001/jamaneurol.2017.4474

The provision of general anesthesia during endovascular therapy for acute ischemic stroke patients with large-vessel occlusions did not result in more infarct growth when compared with conscious sedation in a new randomized trial, contrary to previous findings.

Furthermore, the single-center, open-label, blinded-endpoint General or Local Anesthesia in Intra Arterial Therapy (GOLIATH) trial also reported that patients randomized to the general anesthesia (GA) group had improved functional outcomes on the modified Rankin Scale at 90 days, with a 91% greater likelihood for lower scores than with conscious sedation (CS) (odds ratio, 1.91; 95% confidence interval, 1.03-3.56).

stockce/Thinkstock

The trial’s primary endpoint results showed that although final infarct volume was smaller in the GA group, the difference in the volume of infarct growth 48-72 hours after symptom onset among patients treated under GA or CS did not reach statistical significance (median [IQR] growth, 8.2 [2.2-38.6] mL vs. 19.4 [2.4-79.0] mL; P = .10).

“Assuming a normal distribution, the mean infarct growth for CS was 57.4 mL and for GA was 34.1 mL (difference, 23.2 mL; 95% CI, –6.4 to 52.9),” the research team noted.

A higher rate of successful reperfusion in the GA arm appeared to reflect its better clinical outcomes. Successful reperfusion occurred in 76.9% of GA patients, compared with 60.3% of CS patients (P = .04).

There were no clinically meaningful differences in safety endpoints between the two arms. Four patients (6.3%) in the CS group were converted to GA.

Significantly more patients in the GA group than in the CS group experienced a decrease of greater than 20% in mean arterial pressure (MAP) (87.7% vs. 34.9%; P = .001). However, when MAP dropped below 70 mm Hg, the duration was non-significantly longer for CS patients than for GA patients (6.5 [2-13] minutes vs. 2 [1-5.5] minutes; P = .09).

A longer delay from arrival at the neurointerventional suite to groin puncture was also seen for patients in the GA group. But the median difference of 9 minutes was “acceptable in the context of the much longer overall time from stroke onset to treatment and from stroke onset to reperfusion, which was not significantly different between the competing arms,” the authors said.

The authors said that overall their findings supported GA as a viable anesthetic approach during EVT. “Contrary to numerous nonrandomized studies that have reported better outcomes with CS, the GOLIATH trial shows signals in favor of GA for multiple endpoints,” the research team wrote. “Performing EVT under GA, compared with CS, does not result in worse tissue or clinical outcomes when using a GA protocol that limits the time delay for intubation (less than 10 minutes) and blood pressure level within recommended limits (systolic blood pressure greater than 140 mm Hg and MAP greater than 70 mm Hg).”

The trial was funded by Aarhus University Hospital. One author reported research grants from Penumbra and Neuravi, and another author reported a research grant from Health Research Fund of Central Denmark Region.

SOURCE: Simonsen C et al., JAMA Neurol. 2018 Jan 16. doi: 10.1001/jamaneurol.2017.4474

The provision of general anesthesia during endovascular therapy for acute ischemic stroke patients with large-vessel occlusions did not result in more infarct growth when compared with conscious sedation in a new randomized trial, contrary to previous findings.

Furthermore, the single-center, open-label, blinded-endpoint General or Local Anesthesia in Intra Arterial Therapy (GOLIATH) trial also reported that patients randomized to the general anesthesia (GA) group had improved functional outcomes on the modified Rankin Scale at 90 days, with a 91% greater likelihood for lower scores than with conscious sedation (CS) (odds ratio, 1.91; 95% confidence interval, 1.03-3.56).

stockce/Thinkstock

The trial’s primary endpoint results showed that although final infarct volume was smaller in the GA group, the difference in the volume of infarct growth 48-72 hours after symptom onset among patients treated under GA or CS did not reach statistical significance (median [IQR] growth, 8.2 [2.2-38.6] mL vs. 19.4 [2.4-79.0] mL; P = .10).

“Assuming a normal distribution, the mean infarct growth for CS was 57.4 mL and for GA was 34.1 mL (difference, 23.2 mL; 95% CI, –6.4 to 52.9),” the research team noted.

A higher rate of successful reperfusion in the GA arm appeared to reflect its better clinical outcomes. Successful reperfusion occurred in 76.9% of GA patients, compared with 60.3% of CS patients (P = .04).

There were no clinically meaningful differences in safety endpoints between the two arms. Four patients (6.3%) in the CS group were converted to GA.

Significantly more patients in the GA group than in the CS group experienced a decrease of greater than 20% in mean arterial pressure (MAP) (87.7% vs. 34.9%; P = .001). However, when MAP dropped below 70 mm Hg, the duration was non-significantly longer for CS patients than for GA patients (6.5 [2-13] minutes vs. 2 [1-5.5] minutes; P = .09).

A longer delay from arrival at the neurointerventional suite to groin puncture was also seen for patients in the GA group. But the median difference of 9 minutes was “acceptable in the context of the much longer overall time from stroke onset to treatment and from stroke onset to reperfusion, which was not significantly different between the competing arms,” the authors said.

The authors said that overall their findings supported GA as a viable anesthetic approach during EVT. “Contrary to numerous nonrandomized studies that have reported better outcomes with CS, the GOLIATH trial shows signals in favor of GA for multiple endpoints,” the research team wrote. “Performing EVT under GA, compared with CS, does not result in worse tissue or clinical outcomes when using a GA protocol that limits the time delay for intubation (less than 10 minutes) and blood pressure level within recommended limits (systolic blood pressure greater than 140 mm Hg and MAP greater than 70 mm Hg).”

The trial was funded by Aarhus University Hospital. One author reported research grants from Penumbra and Neuravi, and another author reported a research grant from Health Research Fund of Central Denmark Region.

SOURCE: Simonsen C et al., JAMA Neurol. 2018 Jan 16. doi: 10.1001/jamaneurol.2017.4474

ANAHEIM, CALIF. – The first-ever study to examine the clinical utility of incorporating a history of hypertensive disorders of pregnancy into the American College of Cardiology/American Heart Association Atherosclerotic Cardiovascular Disease Risk Calculator in an effort to better delineate risk in women failed to show any added benefit.

But that doesn’t mean such a history is without value in daily clinical practice, Jennifer J. Stuart, ScD, asserted at the American Heart Association scientific sessions.

“While we did not demonstrate that hypertensive disorders of pregnancy improved cardiovascular risk discrimination in women, we do still believe – and I still believe – that hypertensive disorders of pregnancy remain an important risk marker for cardiovascular disease in women,” said Dr. Stuart of the Harvard School of Public Health, Boston.

“In this latest analysis we’ve demonstrated over a fourfold increased risk of chronic hypertension in these women in the first 5 years after delivery. So we do see increased risk very soon after delivery, and it persists for decades. And hypertensive disorders of pregnancy as a risk marker does offer practical advantages: ease of ascertainment, low cost, and availability earlier in life,” the researcher noted.

Her study hypothesis was that adding hypertensive disorders of pregnancy – that is, gestational hypertension and preeclampsia – and parity to the current ACC/AHA ASCVD Risk Calculator would enhance the tool’s predictive tool’s power in women.

“We wanted to know if a history of hypertensive disorders of pregnancy can be leveraged to capture women currently being missed in screening,” she explained.

Her expectation that this would be the case was based on solid evidence that hypertensive disorders of pregnancy, which occur in 10%-15% of all pregnancies, are associated with subsequent increased risk of cardiovascular events. For example, a meta-analysis of published studies involving nearly 3.5 million women, including almost 200,000 with a history of preeclampsia, showed that preeclampsia was associated with a 2.16-fold increased risk of ischemic heart disease during 11.7 years of follow-up (BMJ. 2007 Nov 10;335[7627]:974). This meta-analysis was among the evidence that persuaded the AHA in 2011 to formally add hypertensive disorders of pregnancy to the list of risk factors for cardiovascular disease in women (Circulation. 2011 Mar 22;123[11]:1243-62).

Dr. Stuart also incorporated parity in her investigational revised ASCVD risk model, because parity has been shown to be an independent risk factor of cardiovascular disease in a relationship described by a J-shaped curve.

She put the souped-up risk prediction model to the test by separately applying it and the current version to data from the longitudinal prospective Nurses’ Health Study II. For this analysis, nearly 68,000 female registered nurses were followed for new diseases every 2 years from 1989, when they were aged 25-42, through 2013. She and her coinvestigators applied the two 10-year risk-prediction models to the overall cohort and again separately to women at aged 40-49 and 50-59.

The bottom line: Including hypertensive disorders of pregnancy and parity did not improve the risk prediction model’s discrimination or reclassification capabilities. This might be because the nurses comprise a relatively low-risk population. Also, even though hypertensive disorders of pregnancy are associated with 10-year cardiovascular disease risk independent of the established risk factors, there may be enough overlap that the standard risk factors sufficiently capture the risk.

“It may be that the information on history of hypertensive disorders of pregnancy should be ascertained in the 20s and 30s, rather than waiting until age 40 or later, when we generally apply cardiovascular risk scores in practice. That [earlier assessment] may be a really important and valuable opportunity to identify these women at high risk and utilize primary prevention,” according to Dr. Stuart.

What’s next? “I’m certainly interested in educating these women about their increased risk. This is not something that’s done consistently across the country and across practices, and we really believe this is an important message for women to get when they deliver these pregnancies,” she added.

Dr. Stuart reported having no financial conflicts of interest regarding her study.

[email protected]

SOURCE: Stuart JJ. AHA Scientific Sessions.

ANAHEIM, CALIF. – The first-ever study to examine the clinical utility of incorporating a history of hypertensive disorders of pregnancy into the American College of Cardiology/American Heart Association Atherosclerotic Cardiovascular Disease Risk Calculator in an effort to better delineate risk in women failed to show any added benefit.

But that doesn’t mean such a history is without value in daily clinical practice, Jennifer J. Stuart, ScD, asserted at the American Heart Association scientific sessions.

“While we did not demonstrate that hypertensive disorders of pregnancy improved cardiovascular risk discrimination in women, we do still believe – and I still believe – that hypertensive disorders of pregnancy remain an important risk marker for cardiovascular disease in women,” said Dr. Stuart of the Harvard School of Public Health, Boston.

“In this latest analysis we’ve demonstrated over a fourfold increased risk of chronic hypertension in these women in the first 5 years after delivery. So we do see increased risk very soon after delivery, and it persists for decades. And hypertensive disorders of pregnancy as a risk marker does offer practical advantages: ease of ascertainment, low cost, and availability earlier in life,” the researcher noted.

Her study hypothesis was that adding hypertensive disorders of pregnancy – that is, gestational hypertension and preeclampsia – and parity to the current ACC/AHA ASCVD Risk Calculator would enhance the tool’s predictive tool’s power in women.

“We wanted to know if a history of hypertensive disorders of pregnancy can be leveraged to capture women currently being missed in screening,” she explained.

Her expectation that this would be the case was based on solid evidence that hypertensive disorders of pregnancy, which occur in 10%-15% of all pregnancies, are associated with subsequent increased risk of cardiovascular events. For example, a meta-analysis of published studies involving nearly 3.5 million women, including almost 200,000 with a history of preeclampsia, showed that preeclampsia was associated with a 2.16-fold increased risk of ischemic heart disease during 11.7 years of follow-up (BMJ. 2007 Nov 10;335[7627]:974). This meta-analysis was among the evidence that persuaded the AHA in 2011 to formally add hypertensive disorders of pregnancy to the list of risk factors for cardiovascular disease in women (Circulation. 2011 Mar 22;123[11]:1243-62).

Dr. Stuart also incorporated parity in her investigational revised ASCVD risk model, because parity has been shown to be an independent risk factor of cardiovascular disease in a relationship described by a J-shaped curve.

She put the souped-up risk prediction model to the test by separately applying it and the current version to data from the longitudinal prospective Nurses’ Health Study II. For this analysis, nearly 68,000 female registered nurses were followed for new diseases every 2 years from 1989, when they were aged 25-42, through 2013. She and her coinvestigators applied the two 10-year risk-prediction models to the overall cohort and again separately to women at aged 40-49 and 50-59.

The bottom line: Including hypertensive disorders of pregnancy and parity did not improve the risk prediction model’s discrimination or reclassification capabilities. This might be because the nurses comprise a relatively low-risk population. Also, even though hypertensive disorders of pregnancy are associated with 10-year cardiovascular disease risk independent of the established risk factors, there may be enough overlap that the standard risk factors sufficiently capture the risk.

“It may be that the information on history of hypertensive disorders of pregnancy should be ascertained in the 20s and 30s, rather than waiting until age 40 or later, when we generally apply cardiovascular risk scores in practice. That [earlier assessment] may be a really important and valuable opportunity to identify these women at high risk and utilize primary prevention,” according to Dr. Stuart.

What’s next? “I’m certainly interested in educating these women about their increased risk. This is not something that’s done consistently across the country and across practices, and we really believe this is an important message for women to get when they deliver these pregnancies,” she added.

Dr. Stuart reported having no financial conflicts of interest regarding her study.

[email protected]

SOURCE: Stuart JJ. AHA Scientific Sessions.

ANAHEIM, CALIF. – The first-ever study to examine the clinical utility of incorporating a history of hypertensive disorders of pregnancy into the American College of Cardiology/American Heart Association Atherosclerotic Cardiovascular Disease Risk Calculator in an effort to better delineate risk in women failed to show any added benefit.

But that doesn’t mean such a history is without value in daily clinical practice, Jennifer J. Stuart, ScD, asserted at the American Heart Association scientific sessions.

“While we did not demonstrate that hypertensive disorders of pregnancy improved cardiovascular risk discrimination in women, we do still believe – and I still believe – that hypertensive disorders of pregnancy remain an important risk marker for cardiovascular disease in women,” said Dr. Stuart of the Harvard School of Public Health, Boston.

“In this latest analysis we’ve demonstrated over a fourfold increased risk of chronic hypertension in these women in the first 5 years after delivery. So we do see increased risk very soon after delivery, and it persists for decades. And hypertensive disorders of pregnancy as a risk marker does offer practical advantages: ease of ascertainment, low cost, and availability earlier in life,” the researcher noted.

Her study hypothesis was that adding hypertensive disorders of pregnancy – that is, gestational hypertension and preeclampsia – and parity to the current ACC/AHA ASCVD Risk Calculator would enhance the tool’s predictive tool’s power in women.

“We wanted to know if a history of hypertensive disorders of pregnancy can be leveraged to capture women currently being missed in screening,” she explained.

Her expectation that this would be the case was based on solid evidence that hypertensive disorders of pregnancy, which occur in 10%-15% of all pregnancies, are associated with subsequent increased risk of cardiovascular events. For example, a meta-analysis of published studies involving nearly 3.5 million women, including almost 200,000 with a history of preeclampsia, showed that preeclampsia was associated with a 2.16-fold increased risk of ischemic heart disease during 11.7 years of follow-up (BMJ. 2007 Nov 10;335[7627]:974). This meta-analysis was among the evidence that persuaded the AHA in 2011 to formally add hypertensive disorders of pregnancy to the list of risk factors for cardiovascular disease in women (Circulation. 2011 Mar 22;123[11]:1243-62).

Dr. Stuart also incorporated parity in her investigational revised ASCVD risk model, because parity has been shown to be an independent risk factor of cardiovascular disease in a relationship described by a J-shaped curve.

She put the souped-up risk prediction model to the test by separately applying it and the current version to data from the longitudinal prospective Nurses’ Health Study II. For this analysis, nearly 68,000 female registered nurses were followed for new diseases every 2 years from 1989, when they were aged 25-42, through 2013. She and her coinvestigators applied the two 10-year risk-prediction models to the overall cohort and again separately to women at aged 40-49 and 50-59.

The bottom line: Including hypertensive disorders of pregnancy and parity did not improve the risk prediction model’s discrimination or reclassification capabilities. This might be because the nurses comprise a relatively low-risk population. Also, even though hypertensive disorders of pregnancy are associated with 10-year cardiovascular disease risk independent of the established risk factors, there may be enough overlap that the standard risk factors sufficiently capture the risk.

“It may be that the information on history of hypertensive disorders of pregnancy should be ascertained in the 20s and 30s, rather than waiting until age 40 or later, when we generally apply cardiovascular risk scores in practice. That [earlier assessment] may be a really important and valuable opportunity to identify these women at high risk and utilize primary prevention,” according to Dr. Stuart.

What’s next? “I’m certainly interested in educating these women about their increased risk. This is not something that’s done consistently across the country and across practices, and we really believe this is an important message for women to get when they deliver these pregnancies,” she added.

Dr. Stuart reported having no financial conflicts of interest regarding her study.

[email protected]

SOURCE: Stuart JJ. AHA Scientific Sessions.

SAN DIEGO – A new study finds that primary diagnoses of atopic dermatitis (AD) are made hundreds of thousands of times in United States emergency departments each year.

The numbers appear to be rising along with costs, researchers reported, and there are signs of disparities, with poorer people more likely to have an ED visit with a primary diagnosis of AD. The study was presented in a poster at the annual meeting of the American Academy of Dermatology.

Indeed, he noted, “previous U.S. population–based studies showed that people with AD have higher odds of [ED] utilization than the rest of the population.”

He and Ms. Kwa examined 2006-2012 data from the Nationwide Emergency Department Sample, which includes information on about 20% of all emergency visits in the United States.

During that period, there were 1.86 million ED visits with a primary diagnosis of AD. The annual weighted prevalence of primary diagnoses of AD stayed fairly stable through the period, ranging from 2,589 to 2,769 per 1 million visits. However, the weighted prevalence of secondary AD diagnoses grew steadily from 1,227 per 1 million visits in 2006 to 1,533 per 1 million visits in 2012.

The researchers estimated that the total cost of annual costs of AD-related ED visits grew from $86.9 million in 2006 to $172.8 million in 2012 (P less than .05).

The study also linked primary diagnoses of AD to having Medicaid insurance or being uninsured, being poorer, or visiting hospitals in “micropolitan” areas (small urban communities such as Bozeman, Mont., and Durango, Colo.).

The study did not examine what medications were prescribed in the ED. However, Dr. Silverberg said, “my anecdotal experience has been that many AD patients are prescribed systemic steroids by nondermatologists in the [ED] setting. While these are rapidly effective, they typically have short-lived efficacy and result in rebound flares upon cessation. Patients are rarely counseled on appropriate skin care techniques or given long-term treatment approaches in the [ED] setting, which fails to achieve adequate long-term disease control.”

What’s next? “We are now studying how AD severity, disease course, and treatment impact [ED] utilization for AD,” Dr. Silverberg said.

No specific study funding was reported. He and Ms. Kwa report no relevant disclosures.

SOURCE: Silverberg, J et al. Poster 7021.

SAN DIEGO – A new study finds that primary diagnoses of atopic dermatitis (AD) are made hundreds of thousands of times in United States emergency departments each year.

The numbers appear to be rising along with costs, researchers reported, and there are signs of disparities, with poorer people more likely to have an ED visit with a primary diagnosis of AD. The study was presented in a poster at the annual meeting of the American Academy of Dermatology.

Indeed, he noted, “previous U.S. population–based studies showed that people with AD have higher odds of [ED] utilization than the rest of the population.”

He and Ms. Kwa examined 2006-2012 data from the Nationwide Emergency Department Sample, which includes information on about 20% of all emergency visits in the United States.

During that period, there were 1.86 million ED visits with a primary diagnosis of AD. The annual weighted prevalence of primary diagnoses of AD stayed fairly stable through the period, ranging from 2,589 to 2,769 per 1 million visits. However, the weighted prevalence of secondary AD diagnoses grew steadily from 1,227 per 1 million visits in 2006 to 1,533 per 1 million visits in 2012.

The researchers estimated that the total cost of annual costs of AD-related ED visits grew from $86.9 million in 2006 to $172.8 million in 2012 (P less than .05).

The study also linked primary diagnoses of AD to having Medicaid insurance or being uninsured, being poorer, or visiting hospitals in “micropolitan” areas (small urban communities such as Bozeman, Mont., and Durango, Colo.).

The study did not examine what medications were prescribed in the ED. However, Dr. Silverberg said, “my anecdotal experience has been that many AD patients are prescribed systemic steroids by nondermatologists in the [ED] setting. While these are rapidly effective, they typically have short-lived efficacy and result in rebound flares upon cessation. Patients are rarely counseled on appropriate skin care techniques or given long-term treatment approaches in the [ED] setting, which fails to achieve adequate long-term disease control.”

What’s next? “We are now studying how AD severity, disease course, and treatment impact [ED] utilization for AD,” Dr. Silverberg said.

No specific study funding was reported. He and Ms. Kwa report no relevant disclosures.

SOURCE: Silverberg, J et al. Poster 7021.

SAN DIEGO – A new study finds that primary diagnoses of atopic dermatitis (AD) are made hundreds of thousands of times in United States emergency departments each year.

The numbers appear to be rising along with costs, researchers reported, and there are signs of disparities, with poorer people more likely to have an ED visit with a primary diagnosis of AD. The study was presented in a poster at the annual meeting of the American Academy of Dermatology.

Indeed, he noted, “previous U.S. population–based studies showed that people with AD have higher odds of [ED] utilization than the rest of the population.”

He and Ms. Kwa examined 2006-2012 data from the Nationwide Emergency Department Sample, which includes information on about 20% of all emergency visits in the United States.

During that period, there were 1.86 million ED visits with a primary diagnosis of AD. The annual weighted prevalence of primary diagnoses of AD stayed fairly stable through the period, ranging from 2,589 to 2,769 per 1 million visits. However, the weighted prevalence of secondary AD diagnoses grew steadily from 1,227 per 1 million visits in 2006 to 1,533 per 1 million visits in 2012.

The researchers estimated that the total cost of annual costs of AD-related ED visits grew from $86.9 million in 2006 to $172.8 million in 2012 (P less than .05).

The study also linked primary diagnoses of AD to having Medicaid insurance or being uninsured, being poorer, or visiting hospitals in “micropolitan” areas (small urban communities such as Bozeman, Mont., and Durango, Colo.).

The study did not examine what medications were prescribed in the ED. However, Dr. Silverberg said, “my anecdotal experience has been that many AD patients are prescribed systemic steroids by nondermatologists in the [ED] setting. While these are rapidly effective, they typically have short-lived efficacy and result in rebound flares upon cessation. Patients are rarely counseled on appropriate skin care techniques or given long-term treatment approaches in the [ED] setting, which fails to achieve adequate long-term disease control.”

What’s next? “We are now studying how AD severity, disease course, and treatment impact [ED] utilization for AD,” Dr. Silverberg said.

No specific study funding was reported. He and Ms. Kwa report no relevant disclosures.

SOURCE: Silverberg, J et al. Poster 7021.

MAUI, HAWAII – Could mast cell-rich synovitis become a novel target in patients with early rheumatoid arthritis?

Investigators at the University of London believe so. In a small but provocative study presented at the 2017 annual meeting of the American College of Rheumatology, they demonstrated that these mast cells are not an innocent bystander in joint inflammation; rather, they play an active albeit still incompletely understood role in the synovial inflammatory infiltrate and in disease progression, Orrin M. Troum, MD, said at the 2018 Rheumatology Winter Clinical Symposium.

Bruce Jancin/Frontline Medical News

Moreover, four of the nine patients with persistent mast cell-rich synovitis after 6 months of synthetic DMARDs had synovial lymphoid aggregates of CD20-positive B cells and/or CD138-positive plasma cells; in contrast, none of the 11 synovial mast cell-negative patients did, noted Dr. Troum, a rheumatologist at the University of Southern California, Los Angeles, who is in private practice in Santa Monica, Calif.

In theory, if a baseline synovial tissue immune cell profile could be identified that’s predictive of high-level responsiveness to synthetic DMARDs or, conversely, nonresponsiveness, tissue specimens could be used to stratify patients with early RA to different initial treatment strategies. The problem with that is few rheumatologists in the United States – and indeed worldwide – are proficient at performing ultrasound-guided synovial biopsies, according to Dr. Troum.

His description of the London study prompted a question as to whether any of the biologics used in rheumatology can inhibit mast cells. Arthur Kavanaugh, MD, symposium director, said the only agent that comes to mind is imatinib (Gleevec), a tyrosine kinase inhibitor used in the treatment of aggressive systemic mastocytosis as well as for certain leukemias.

“It has a ton of toxicity, though,” said Dr. Kavanaugh, professor of medicine and director of the Center for Innovative Therapy in the division of rheumatology, allergy, and immunology at the University of California, San Diego.

Dr. Troum reported having no financial conflicts regarding his presentation.

[email protected]

MAUI, HAWAII – Could mast cell-rich synovitis become a novel target in patients with early rheumatoid arthritis?

Investigators at the University of London believe so. In a small but provocative study presented at the 2017 annual meeting of the American College of Rheumatology, they demonstrated that these mast cells are not an innocent bystander in joint inflammation; rather, they play an active albeit still incompletely understood role in the synovial inflammatory infiltrate and in disease progression, Orrin M. Troum, MD, said at the 2018 Rheumatology Winter Clinical Symposium.

Bruce Jancin/Frontline Medical News

Moreover, four of the nine patients with persistent mast cell-rich synovitis after 6 months of synthetic DMARDs had synovial lymphoid aggregates of CD20-positive B cells and/or CD138-positive plasma cells; in contrast, none of the 11 synovial mast cell-negative patients did, noted Dr. Troum, a rheumatologist at the University of Southern California, Los Angeles, who is in private practice in Santa Monica, Calif.

In theory, if a baseline synovial tissue immune cell profile could be identified that’s predictive of high-level responsiveness to synthetic DMARDs or, conversely, nonresponsiveness, tissue specimens could be used to stratify patients with early RA to different initial treatment strategies. The problem with that is few rheumatologists in the United States – and indeed worldwide – are proficient at performing ultrasound-guided synovial biopsies, according to Dr. Troum.

His description of the London study prompted a question as to whether any of the biologics used in rheumatology can inhibit mast cells. Arthur Kavanaugh, MD, symposium director, said the only agent that comes to mind is imatinib (Gleevec), a tyrosine kinase inhibitor used in the treatment of aggressive systemic mastocytosis as well as for certain leukemias.

“It has a ton of toxicity, though,” said Dr. Kavanaugh, professor of medicine and director of the Center for Innovative Therapy in the division of rheumatology, allergy, and immunology at the University of California, San Diego.

Dr. Troum reported having no financial conflicts regarding his presentation.

[email protected]

MAUI, HAWAII – Could mast cell-rich synovitis become a novel target in patients with early rheumatoid arthritis?

Investigators at the University of London believe so. In a small but provocative study presented at the 2017 annual meeting of the American College of Rheumatology, they demonstrated that these mast cells are not an innocent bystander in joint inflammation; rather, they play an active albeit still incompletely understood role in the synovial inflammatory infiltrate and in disease progression, Orrin M. Troum, MD, said at the 2018 Rheumatology Winter Clinical Symposium.

Bruce Jancin/Frontline Medical News

Moreover, four of the nine patients with persistent mast cell-rich synovitis after 6 months of synthetic DMARDs had synovial lymphoid aggregates of CD20-positive B cells and/or CD138-positive plasma cells; in contrast, none of the 11 synovial mast cell-negative patients did, noted Dr. Troum, a rheumatologist at the University of Southern California, Los Angeles, who is in private practice in Santa Monica, Calif.

In theory, if a baseline synovial tissue immune cell profile could be identified that’s predictive of high-level responsiveness to synthetic DMARDs or, conversely, nonresponsiveness, tissue specimens could be used to stratify patients with early RA to different initial treatment strategies. The problem with that is few rheumatologists in the United States – and indeed worldwide – are proficient at performing ultrasound-guided synovial biopsies, according to Dr. Troum.

His description of the London study prompted a question as to whether any of the biologics used in rheumatology can inhibit mast cells. Arthur Kavanaugh, MD, symposium director, said the only agent that comes to mind is imatinib (Gleevec), a tyrosine kinase inhibitor used in the treatment of aggressive systemic mastocytosis as well as for certain leukemias.

“It has a ton of toxicity, though,” said Dr. Kavanaugh, professor of medicine and director of the Center for Innovative Therapy in the division of rheumatology, allergy, and immunology at the University of California, San Diego.

Dr. Troum reported having no financial conflicts regarding his presentation.

[email protected]

Primary care providers may be the first to encounter teens with depression; updated guidelines from the American Academy of Pediatrics support their efforts.

The updated information includes recommendations on collaborative care, practice preparation, establishing networks of referrals, and much more.

AlexRaths/Thinkstock

Known as the Guidelines for Adolescent Depression in Primary Care (GLAD-PC), they consist of two parts: Practice Preparation, Identification, Assessment, and Initial Management, with Dr. Zuckerbrot as the lead author, and Treatment and Ongoing Management, led by Amy H. Cheung, MD, of the University of Toronto. They were published online in Pediatrics.

“It has been over 10 years since the [last] guidelines were published and they are supposed to be updated every 5,” Dr. Zuckerbrot said in an interview. “Given the new evidence on screening, psychopharmacology, and collaborative care, the guidelines needed to be revised. The USPSTF [United States Preventive Services Task Force ] and the AAP had already supported universal adolescent depression screening, and these guidelines are finally aligned with those positions.

“Different parts of the guidelines will be the go-to for different pediatricians, depending on where they are in their delivery of mental health care,” she explained. “Some may need help with practice preparation while others may need advice on screening; others may already be prescribing and may need advice on ongoing treatment and follow-up. I think there is something for everyone.”

Implementation of the guidelines is difficult in a short visit, Dr. Zuckerbrot acknowledged. “In addition, pediatricians may not have been well trained in the management of adolescent depression during their residencies.” However, the guidelines discuss both “real teams to support the pediatricians in their efforts, as well as virtual teams when staffing is limited.

“The guidelines advise that pediatricians learn about child psychiatry primary care consultation programs in their state and make use of those free telephone consultation programs.” The guidelines also discuss strategies for collaborative or integrative care, she said.

Part I

Part I of the guidelines, “Practice Preparation, Identification, Assessment, and Initial Management,” includes several recommendations for each topic.

For practice preparation, the guidelines recommend that clinicians seek training in the assessment, diagnosis, and treatment of depression, and that they establish a network of referrals and mental health resources in their communities. This network may include not only health professionals, but also current patients and families who are managing teen depression. If available, state-wide or regional child and adolescent psychiatry consultation programs can be included.

The identification and surveillance section of the guidelines calls for screening all patients aged 12 years and older for depression each year, using a formal screening tool on paper or online. The screening could occur at an annual wellness visit or any other medical visit, such as a sports physical. A second recommendation calls for identifying patients at increased risk for depression because of factors such as personal history, family history, substance use, other psychiatric disorders, frequent somatic complaints, or trauma, and monitoring these individuals regularly for signs of depression using a formal screening tool.

The assessment and diagnosis section states that assessment should include interviews with the patients alone as well as with their families or caregivers, and should include screening teens for functional impairment.

Primary care physicians should evaluate for depression not only if an adolescent tests positive on a screening tool, but also in children who present with any emotional problem as the chief complaint, and in those in whom depression is highly suspected even if they test negative on a formal screening tool, the guidelines state.

The three recommendations for initial management of depression in the primary care setting are educating patients and families about depression; developing a treatment plan (if the primary care clinician has had appropriate training) and setting specific treatment goals in areas of functioning such as at home, with peers, and at school; and developing a safety plan that includes restricting access to weapons or other means of self-harm, according to the guidelines.

Part II

Part II of the recommendations, “Treatment and Ongoing Management,” discusses options for managing depression in the primary care setting and utilizing outside resources.

The treatment recommendations emphasize the use of integrated models, if possible. “There is a growing recognition that complex chronic conditions, such as depression, are most successfully managed with proactive, multidisciplinary, patient-centered care teams,” Dr. Cheung and her associates said.

The recommendation for cases of mild depression calls for a period of “active support and monitoring” for 6-8 weeks before reassessing if the teen shows no improvement. By contrast, for cases of moderate to severe depression or cases with evidence of substance abuse or other psychoses, the recommendation calls for potential consultation with a mental health specialist and a discussion of the roles primary and specialty care will play in treatment. The guidelines include a flow chart for PC physicians to follow.

The guidelines suggest that PC clinicians recommend “scientifically tested and proven treatments,” such as psychotherapies, cognitive behavioral therapy (CBT) or interpersonal psychotherapy for adolescents, and/or antidepressant treatment, such as SSRIs, whenever possible and appropriate. It is important to monitor teens on antidepressants regularly to identify adverse events.

Recommendations for the ongoing management of teens with depression in the primary care setting include regular tracking of progress, reassessment if the teen shows no improvement in 6-8 weeks, and consultation with a mental health professional for those who show only partial improvement after exhausting primary care diagnostic and treatment options. Assessment of depressive symptoms is not the only thing to track. Functioning at home, school, and among peers also is important.

The final treatment recommendation is for active support of a depressed teen’s referral to mental health if necessary for best management and sharing care if possible, with an understanding of the roles of the primary and specialty clinicians, the guidelines state.

The guidelines project was funded by the Resource for Advancing Children’s Health Institute and the Bell Canada Chair in Adolescent Mood and Anxiety Disorders.

Dr. Cheung and Dr. Zuckerbrot receive book royalties. Dr Zuckerbrot works for child and adolescent psychiatry for primary care (CAP-PC), now a regional provider for Project TEACH in New York State, and she is on the steering committee as well as faculty for the REACH Institute; both of these institutions are described in the guidelines. Peter S. Jensen, MD, has received royalties from Random House, Oxford University Press, and APPI Inc. He is a part owner of a consulting company, CATCH Services LLC. He is the chief executive officer and president of a nonprofit organization, the Resource for Advancing Children’s Health Institute, but receives no compensation. The other authors indicated they have no financial relationships relevant to the guidelines.

Primary care providers may be the first to encounter teens with depression; updated guidelines from the American Academy of Pediatrics support their efforts.

The updated information includes recommendations on collaborative care, practice preparation, establishing networks of referrals, and much more.

AlexRaths/Thinkstock

Known as the Guidelines for Adolescent Depression in Primary Care (GLAD-PC), they consist of two parts: Practice Preparation, Identification, Assessment, and Initial Management, with Dr. Zuckerbrot as the lead author, and Treatment and Ongoing Management, led by Amy H. Cheung, MD, of the University of Toronto. They were published online in Pediatrics.

“It has been over 10 years since the [last] guidelines were published and they are supposed to be updated every 5,” Dr. Zuckerbrot said in an interview. “Given the new evidence on screening, psychopharmacology, and collaborative care, the guidelines needed to be revised. The USPSTF [United States Preventive Services Task Force ] and the AAP had already supported universal adolescent depression screening, and these guidelines are finally aligned with those positions.

“Different parts of the guidelines will be the go-to for different pediatricians, depending on where they are in their delivery of mental health care,” she explained. “Some may need help with practice preparation while others may need advice on screening; others may already be prescribing and may need advice on ongoing treatment and follow-up. I think there is something for everyone.”

Implementation of the guidelines is difficult in a short visit, Dr. Zuckerbrot acknowledged. “In addition, pediatricians may not have been well trained in the management of adolescent depression during their residencies.” However, the guidelines discuss both “real teams to support the pediatricians in their efforts, as well as virtual teams when staffing is limited.

“The guidelines advise that pediatricians learn about child psychiatry primary care consultation programs in their state and make use of those free telephone consultation programs.” The guidelines also discuss strategies for collaborative or integrative care, she said.

Part I

Part I of the guidelines, “Practice Preparation, Identification, Assessment, and Initial Management,” includes several recommendations for each topic.

For practice preparation, the guidelines recommend that clinicians seek training in the assessment, diagnosis, and treatment of depression, and that they establish a network of referrals and mental health resources in their communities. This network may include not only health professionals, but also current patients and families who are managing teen depression. If available, state-wide or regional child and adolescent psychiatry consultation programs can be included.

The identification and surveillance section of the guidelines calls for screening all patients aged 12 years and older for depression each year, using a formal screening tool on paper or online. The screening could occur at an annual wellness visit or any other medical visit, such as a sports physical. A second recommendation calls for identifying patients at increased risk for depression because of factors such as personal history, family history, substance use, other psychiatric disorders, frequent somatic complaints, or trauma, and monitoring these individuals regularly for signs of depression using a formal screening tool.

The assessment and diagnosis section states that assessment should include interviews with the patients alone as well as with their families or caregivers, and should include screening teens for functional impairment.

Primary care physicians should evaluate for depression not only if an adolescent tests positive on a screening tool, but also in children who present with any emotional problem as the chief complaint, and in those in whom depression is highly suspected even if they test negative on a formal screening tool, the guidelines state.

The three recommendations for initial management of depression in the primary care setting are educating patients and families about depression; developing a treatment plan (if the primary care clinician has had appropriate training) and setting specific treatment goals in areas of functioning such as at home, with peers, and at school; and developing a safety plan that includes restricting access to weapons or other means of self-harm, according to the guidelines.

Part II

Part II of the recommendations, “Treatment and Ongoing Management,” discusses options for managing depression in the primary care setting and utilizing outside resources.

The treatment recommendations emphasize the use of integrated models, if possible. “There is a growing recognition that complex chronic conditions, such as depression, are most successfully managed with proactive, multidisciplinary, patient-centered care teams,” Dr. Cheung and her associates said.

The recommendation for cases of mild depression calls for a period of “active support and monitoring” for 6-8 weeks before reassessing if the teen shows no improvement. By contrast, for cases of moderate to severe depression or cases with evidence of substance abuse or other psychoses, the recommendation calls for potential consultation with a mental health specialist and a discussion of the roles primary and specialty care will play in treatment. The guidelines include a flow chart for PC physicians to follow.

The guidelines suggest that PC clinicians recommend “scientifically tested and proven treatments,” such as psychotherapies, cognitive behavioral therapy (CBT) or interpersonal psychotherapy for adolescents, and/or antidepressant treatment, such as SSRIs, whenever possible and appropriate. It is important to monitor teens on antidepressants regularly to identify adverse events.

Recommendations for the ongoing management of teens with depression in the primary care setting include regular tracking of progress, reassessment if the teen shows no improvement in 6-8 weeks, and consultation with a mental health professional for those who show only partial improvement after exhausting primary care diagnostic and treatment options. Assessment of depressive symptoms is not the only thing to track. Functioning at home, school, and among peers also is important.

The final treatment recommendation is for active support of a depressed teen’s referral to mental health if necessary for best management and sharing care if possible, with an understanding of the roles of the primary and specialty clinicians, the guidelines state.

The guidelines project was funded by the Resource for Advancing Children’s Health Institute and the Bell Canada Chair in Adolescent Mood and Anxiety Disorders.

Dr. Cheung and Dr. Zuckerbrot receive book royalties. Dr Zuckerbrot works for child and adolescent psychiatry for primary care (CAP-PC), now a regional provider for Project TEACH in New York State, and she is on the steering committee as well as faculty for the REACH Institute; both of these institutions are described in the guidelines. Peter S. Jensen, MD, has received royalties from Random House, Oxford University Press, and APPI Inc. He is a part owner of a consulting company, CATCH Services LLC. He is the chief executive officer and president of a nonprofit organization, the Resource for Advancing Children’s Health Institute, but receives no compensation. The other authors indicated they have no financial relationships relevant to the guidelines.

Primary care providers may be the first to encounter teens with depression; updated guidelines from the American Academy of Pediatrics support their efforts.

The updated information includes recommendations on collaborative care, practice preparation, establishing networks of referrals, and much more.

AlexRaths/Thinkstock

Known as the Guidelines for Adolescent Depression in Primary Care (GLAD-PC), they consist of two parts: Practice Preparation, Identification, Assessment, and Initial Management, with Dr. Zuckerbrot as the lead author, and Treatment and Ongoing Management, led by Amy H. Cheung, MD, of the University of Toronto. They were published online in Pediatrics.

“It has been over 10 years since the [last] guidelines were published and they are supposed to be updated every 5,” Dr. Zuckerbrot said in an interview. “Given the new evidence on screening, psychopharmacology, and collaborative care, the guidelines needed to be revised. The USPSTF [United States Preventive Services Task Force ] and the AAP had already supported universal adolescent depression screening, and these guidelines are finally aligned with those positions.

“Different parts of the guidelines will be the go-to for different pediatricians, depending on where they are in their delivery of mental health care,” she explained. “Some may need help with practice preparation while others may need advice on screening; others may already be prescribing and may need advice on ongoing treatment and follow-up. I think there is something for everyone.”

Implementation of the guidelines is difficult in a short visit, Dr. Zuckerbrot acknowledged. “In addition, pediatricians may not have been well trained in the management of adolescent depression during their residencies.” However, the guidelines discuss both “real teams to support the pediatricians in their efforts, as well as virtual teams when staffing is limited.

“The guidelines advise that pediatricians learn about child psychiatry primary care consultation programs in their state and make use of those free telephone consultation programs.” The guidelines also discuss strategies for collaborative or integrative care, she said.

Part I

Part I of the guidelines, “Practice Preparation, Identification, Assessment, and Initial Management,” includes several recommendations for each topic.

For practice preparation, the guidelines recommend that clinicians seek training in the assessment, diagnosis, and treatment of depression, and that they establish a network of referrals and mental health resources in their communities. This network may include not only health professionals, but also current patients and families who are managing teen depression. If available, state-wide or regional child and adolescent psychiatry consultation programs can be included.

The identification and surveillance section of the guidelines calls for screening all patients aged 12 years and older for depression each year, using a formal screening tool on paper or online. The screening could occur at an annual wellness visit or any other medical visit, such as a sports physical. A second recommendation calls for identifying patients at increased risk for depression because of factors such as personal history, family history, substance use, other psychiatric disorders, frequent somatic complaints, or trauma, and monitoring these individuals regularly for signs of depression using a formal screening tool.

The assessment and diagnosis section states that assessment should include interviews with the patients alone as well as with their families or caregivers, and should include screening teens for functional impairment.

Primary care physicians should evaluate for depression not only if an adolescent tests positive on a screening tool, but also in children who present with any emotional problem as the chief complaint, and in those in whom depression is highly suspected even if they test negative on a formal screening tool, the guidelines state.

The three recommendations for initial management of depression in the primary care setting are educating patients and families about depression; developing a treatment plan (if the primary care clinician has had appropriate training) and setting specific treatment goals in areas of functioning such as at home, with peers, and at school; and developing a safety plan that includes restricting access to weapons or other means of self-harm, according to the guidelines.

Part II

Part II of the recommendations, “Treatment and Ongoing Management,” discusses options for managing depression in the primary care setting and utilizing outside resources.

The treatment recommendations emphasize the use of integrated models, if possible. “There is a growing recognition that complex chronic conditions, such as depression, are most successfully managed with proactive, multidisciplinary, patient-centered care teams,” Dr. Cheung and her associates said.

The recommendation for cases of mild depression calls for a period of “active support and monitoring” for 6-8 weeks before reassessing if the teen shows no improvement. By contrast, for cases of moderate to severe depression or cases with evidence of substance abuse or other psychoses, the recommendation calls for potential consultation with a mental health specialist and a discussion of the roles primary and specialty care will play in treatment. The guidelines include a flow chart for PC physicians to follow.

The guidelines suggest that PC clinicians recommend “scientifically tested and proven treatments,” such as psychotherapies, cognitive behavioral therapy (CBT) or interpersonal psychotherapy for adolescents, and/or antidepressant treatment, such as SSRIs, whenever possible and appropriate. It is important to monitor teens on antidepressants regularly to identify adverse events.

Recommendations for the ongoing management of teens with depression in the primary care setting include regular tracking of progress, reassessment if the teen shows no improvement in 6-8 weeks, and consultation with a mental health professional for those who show only partial improvement after exhausting primary care diagnostic and treatment options. Assessment of depressive symptoms is not the only thing to track. Functioning at home, school, and among peers also is important.

The final treatment recommendation is for active support of a depressed teen’s referral to mental health if necessary for best management and sharing care if possible, with an understanding of the roles of the primary and specialty clinicians, the guidelines state.

The guidelines project was funded by the Resource for Advancing Children’s Health Institute and the Bell Canada Chair in Adolescent Mood and Anxiety Disorders.

Dr. Cheung and Dr. Zuckerbrot receive book royalties. Dr Zuckerbrot works for child and adolescent psychiatry for primary care (CAP-PC), now a regional provider for Project TEACH in New York State, and she is on the steering committee as well as faculty for the REACH Institute; both of these institutions are described in the guidelines. Peter S. Jensen, MD, has received royalties from Random House, Oxford University Press, and APPI Inc. He is a part owner of a consulting company, CATCH Services LLC. He is the chief executive officer and president of a nonprofit organization, the Resource for Advancing Children’s Health Institute, but receives no compensation. The other authors indicated they have no financial relationships relevant to the guidelines.

KAUAI, HAWAII – Children born with two or more melanocytic nevi of any size should have an MRI to check for brain lesions, ideally within the first 6 months, according to Jennifer Huang, MD, a pediatric dermatologist at Boston Children’s Hospital.

Two or more nevi increase the risk of CNS involvement, which in turn increases the risk of malignant conversion by more than 16-fold.

“If the scanning brain MRI is normal, [children] might not have congenital melanocytic nevus syndrome, and would be at low risk for melanoma,” Dr. Huang said. “If it’s abnormal, they might be at high risk for melanoma.” In the 2017 study, the odds ratio for melanoma with an abnormal MRI was 16.7 (P = .001).

Both melanocytes and neuronal cells arise from the embryonic neural crest, which explains the link between congenital nevi and brain lesions. Almost all congenital nevi are associated with early postzygotic mutations in the NRAS gene, and it’s possible the mutations affect other neural crest cell lines, including in the CNS, she said.

It’s also important to remember that childhood melanoma often doesn’t follow the ABCDE (asymmetry, border irregularity, color not uniform, diameter greater than 6 mm, and evolving) signs of melanoma common in adults.

In a retrospective study of 70 children with melanoma or ambiguous melanocytic tumors, 40% of pubertal subjects and 60% of prepubertal participants did not meet conventional adult ABCDE criteria. The majority of cases were raised, even in color, less than 6 mm across, symmetric, and de novo (J Am Acad Dermatol. 2013 Jun;68[6]:913-25).

It turns out that rapid evolution in size, shape, and color is the number one, unifying factor in childhood melanomas. Other key clues include raised lesions with uniform color or no pigmentation at all. A modified ABCDE for pediatric melanoma has been proposed: amelanotic, bump/bleeding, color uniform, diameter variable, de novo, and evolution.

“The lesson to learn is not to ignore the traditional ABCDEs of melanoma, but to recognize that pediatric melanoma may present with different clinical characteristics, and to incorporate this awareness into our practice,” Dr. Huang said.

She did not have any disclosures. SDEF/Global Academy for Medical Education and this news organization are owned by the same parent company.

[email protected]

KAUAI, HAWAII – Children born with two or more melanocytic nevi of any size should have an MRI to check for brain lesions, ideally within the first 6 months, according to Jennifer Huang, MD, a pediatric dermatologist at Boston Children’s Hospital.

Two or more nevi increase the risk of CNS involvement, which in turn increases the risk of malignant conversion by more than 16-fold.

“If the scanning brain MRI is normal, [children] might not have congenital melanocytic nevus syndrome, and would be at low risk for melanoma,” Dr. Huang said. “If it’s abnormal, they might be at high risk for melanoma.” In the 2017 study, the odds ratio for melanoma with an abnormal MRI was 16.7 (P = .001).

Both melanocytes and neuronal cells arise from the embryonic neural crest, which explains the link between congenital nevi and brain lesions. Almost all congenital nevi are associated with early postzygotic mutations in the NRAS gene, and it’s possible the mutations affect other neural crest cell lines, including in the CNS, she said.

It’s also important to remember that childhood melanoma often doesn’t follow the ABCDE (asymmetry, border irregularity, color not uniform, diameter greater than 6 mm, and evolving) signs of melanoma common in adults.

In a retrospective study of 70 children with melanoma or ambiguous melanocytic tumors, 40% of pubertal subjects and 60% of prepubertal participants did not meet conventional adult ABCDE criteria. The majority of cases were raised, even in color, less than 6 mm across, symmetric, and de novo (J Am Acad Dermatol. 2013 Jun;68[6]:913-25).

It turns out that rapid evolution in size, shape, and color is the number one, unifying factor in childhood melanomas. Other key clues include raised lesions with uniform color or no pigmentation at all. A modified ABCDE for pediatric melanoma has been proposed: amelanotic, bump/bleeding, color uniform, diameter variable, de novo, and evolution.

“The lesson to learn is not to ignore the traditional ABCDEs of melanoma, but to recognize that pediatric melanoma may present with different clinical characteristics, and to incorporate this awareness into our practice,” Dr. Huang said.

She did not have any disclosures. SDEF/Global Academy for Medical Education and this news organization are owned by the same parent company.

[email protected]

KAUAI, HAWAII – Children born with two or more melanocytic nevi of any size should have an MRI to check for brain lesions, ideally within the first 6 months, according to Jennifer Huang, MD, a pediatric dermatologist at Boston Children’s Hospital.

Two or more nevi increase the risk of CNS involvement, which in turn increases the risk of malignant conversion by more than 16-fold.

“If the scanning brain MRI is normal, [children] might not have congenital melanocytic nevus syndrome, and would be at low risk for melanoma,” Dr. Huang said. “If it’s abnormal, they might be at high risk for melanoma.” In the 2017 study, the odds ratio for melanoma with an abnormal MRI was 16.7 (P = .001).

Both melanocytes and neuronal cells arise from the embryonic neural crest, which explains the link between congenital nevi and brain lesions. Almost all congenital nevi are associated with early postzygotic mutations in the NRAS gene, and it’s possible the mutations affect other neural crest cell lines, including in the CNS, she said.

It’s also important to remember that childhood melanoma often doesn’t follow the ABCDE (asymmetry, border irregularity, color not uniform, diameter greater than 6 mm, and evolving) signs of melanoma common in adults.

In a retrospective study of 70 children with melanoma or ambiguous melanocytic tumors, 40% of pubertal subjects and 60% of prepubertal participants did not meet conventional adult ABCDE criteria. The majority of cases were raised, even in color, less than 6 mm across, symmetric, and de novo (J Am Acad Dermatol. 2013 Jun;68[6]:913-25).

It turns out that rapid evolution in size, shape, and color is the number one, unifying factor in childhood melanomas. Other key clues include raised lesions with uniform color or no pigmentation at all. A modified ABCDE for pediatric melanoma has been proposed: amelanotic, bump/bleeding, color uniform, diameter variable, de novo, and evolution.

“The lesson to learn is not to ignore the traditional ABCDEs of melanoma, but to recognize that pediatric melanoma may present with different clinical characteristics, and to incorporate this awareness into our practice,” Dr. Huang said.

She did not have any disclosures. SDEF/Global Academy for Medical Education and this news organization are owned by the same parent company.

[email protected]

Heart failure, with 42 medicines currently in development, is the leading area for new treatments of cardiovascular disease, according to Pharmaceutical Research and Manufacturers of America.

One of those 42 treatments is “a nonviral gene therapy that targets a tissue repair and regeneration pathway in the body,” PhRMA noted. A total of 200 medicines, including those for lipid disorders and hypertension, were either in clinical trials or undergoing regulatory review as of Jan. 24, 2018, the group reported. Some treatments are being considered for more than one condition.

[email protected]

Heart failure, with 42 medicines currently in development, is the leading area for new treatments of cardiovascular disease, according to Pharmaceutical Research and Manufacturers of America.

One of those 42 treatments is “a nonviral gene therapy that targets a tissue repair and regeneration pathway in the body,” PhRMA noted. A total of 200 medicines, including those for lipid disorders and hypertension, were either in clinical trials or undergoing regulatory review as of Jan. 24, 2018, the group reported. Some treatments are being considered for more than one condition.

[email protected]

Heart failure, with 42 medicines currently in development, is the leading area for new treatments of cardiovascular disease, according to Pharmaceutical Research and Manufacturers of America.

One of those 42 treatments is “a nonviral gene therapy that targets a tissue repair and regeneration pathway in the body,” PhRMA noted. A total of 200 medicines, including those for lipid disorders and hypertension, were either in clinical trials or undergoing regulatory review as of Jan. 24, 2018, the group reported. Some treatments are being considered for more than one condition.

[email protected]

Federal scientists advance a plan for a universal flu vaccine, making health care affordable has broad support, some encouraging news about proton pump inhibitors and myocardial infarction, and how obesity affects cardiovascular risk.

Listen to the MDedge Daily News podcast for all the details on today’s top news.

Federal scientists advance a plan for a universal flu vaccine, making health care affordable has broad support, some encouraging news about proton pump inhibitors and myocardial infarction, and how obesity affects cardiovascular risk.

Listen to the MDedge Daily News podcast for all the details on today’s top news.

Federal scientists advance a plan for a universal flu vaccine, making health care affordable has broad support, some encouraging news about proton pump inhibitors and myocardial infarction, and how obesity affects cardiovascular risk.

Listen to the MDedge Daily News podcast for all the details on today’s top news.