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Robotic surgery technologies have unique learning curves for trainees
Training surgeons to use robotic technology involves learning curves, and a study has found that robotic technologies have unique learning curve profiles that have implications for the time and number of procedures needed to achieve competence.
Giorgio Mazzon, MD, of the Institute of Urology at University College Hospital, London, and his colleagues reviewed the literature on training surgeons in the use of a variety of technologies for urological procedures. They analyzed learning curves for virtual reality robotic simulators, robot-assisted laparoscopic radical prostatectomy (RALP), robot-assisted radical cystectomy (RARC), and robot-assisted partial nephrectomy (RAPN) (Curr Urol Rep. 2017 Sep 23;18:89).
RARC learning curves are more rapid than RALP, but this may be due to the fact that most surgeons practice RALP before learning RARC. It is estimated that it takes 21 procedures for operating time to plateau and 30 patients for proper lymph node yield and positive surgical margins of less than 5% to occur (Eur Urol. 2010 Aug;58[2]:197-202).Safety and competence in RAPN is usually defined by operating times, warm ischemic time, positive surgical margin, and complication rates. It has been reported that RAPN can be safely performed with completion of 25-30 cases (Eur Urol. 2010 Jul;58[1]:127-32).The results of the review “should inform trainers and trainees on what outcomes are expected at a given stage of training,” according to the investigators.
They reported no relevant financial disclosures.
Training surgeons to use robotic technology involves learning curves, and a study has found that robotic technologies have unique learning curve profiles that have implications for the time and number of procedures needed to achieve competence.
Giorgio Mazzon, MD, of the Institute of Urology at University College Hospital, London, and his colleagues reviewed the literature on training surgeons in the use of a variety of technologies for urological procedures. They analyzed learning curves for virtual reality robotic simulators, robot-assisted laparoscopic radical prostatectomy (RALP), robot-assisted radical cystectomy (RARC), and robot-assisted partial nephrectomy (RAPN) (Curr Urol Rep. 2017 Sep 23;18:89).
RARC learning curves are more rapid than RALP, but this may be due to the fact that most surgeons practice RALP before learning RARC. It is estimated that it takes 21 procedures for operating time to plateau and 30 patients for proper lymph node yield and positive surgical margins of less than 5% to occur (Eur Urol. 2010 Aug;58[2]:197-202).Safety and competence in RAPN is usually defined by operating times, warm ischemic time, positive surgical margin, and complication rates. It has been reported that RAPN can be safely performed with completion of 25-30 cases (Eur Urol. 2010 Jul;58[1]:127-32).The results of the review “should inform trainers and trainees on what outcomes are expected at a given stage of training,” according to the investigators.
They reported no relevant financial disclosures.
Training surgeons to use robotic technology involves learning curves, and a study has found that robotic technologies have unique learning curve profiles that have implications for the time and number of procedures needed to achieve competence.
Giorgio Mazzon, MD, of the Institute of Urology at University College Hospital, London, and his colleagues reviewed the literature on training surgeons in the use of a variety of technologies for urological procedures. They analyzed learning curves for virtual reality robotic simulators, robot-assisted laparoscopic radical prostatectomy (RALP), robot-assisted radical cystectomy (RARC), and robot-assisted partial nephrectomy (RAPN) (Curr Urol Rep. 2017 Sep 23;18:89).
RARC learning curves are more rapid than RALP, but this may be due to the fact that most surgeons practice RALP before learning RARC. It is estimated that it takes 21 procedures for operating time to plateau and 30 patients for proper lymph node yield and positive surgical margins of less than 5% to occur (Eur Urol. 2010 Aug;58[2]:197-202).Safety and competence in RAPN is usually defined by operating times, warm ischemic time, positive surgical margin, and complication rates. It has been reported that RAPN can be safely performed with completion of 25-30 cases (Eur Urol. 2010 Jul;58[1]:127-32).The results of the review “should inform trainers and trainees on what outcomes are expected at a given stage of training,” according to the investigators.
They reported no relevant financial disclosures.
FROM CURRENT UROLOGY REPORTS
Key clinical point:
Major finding: For virtual reality training programs, recommendations for achieving safety and competence is between 4 and 12 hours of training in a simulator.
Data source: Review of studies of learning curves in robotic urological surgery.
Disclosures: The researchers reported no financial disclosures.
Biophysical properties of HCV evolve over course of infection
Hepatitis C virus (HCV) particles are of lowest density and most infectious early in the course of infection, based on findings from a study of chimeric mice.
Over time, however, viral density became more heterogeneous and infectivity fell, reported Ursula Andreo, PhD, of Rockefeller University, New York, with her coinvestigators. A diet of 10% sucrose, which in rats induces hepatic secretion of very-low-density lipoprotein (VLDL), caused HCV particles to become slightly lower density and more infectious in the mice, the researchers reported. Although the shift was “minor,” it “correlated with a trend toward enhanced triglyceride and cholesterol levels in the same fractions,” they wrote. They recommended studying high-fat diets to determine whether altering the VLDL secretion pathway affects the biophysical properties of HCV. “A high-fat diet might have a more significant impact on the lipoprotein profile in this humanized mouse model,” they wrote in Cellular and Molecular Gastroenterology and Hepatology (2017 Jul;4[3]:405-17).
Because HCV tends to associate with lipoproteins, it shows a range of buoyant densities in the blood of infected patients. The “entry, replication, and assembly [of the virion] are linked closely to host lipid and lipoprotein metabolism,” wrote Dr. Andreo and her colleagues.
They created an in vivo model to study the buoyant density and infectivity of HCV particles, as well as their interaction with lipoproteins, by grafting human hepatocytes into the livers of immunodeficient mice that were homozygous recessive for fumarylacetoacetate hydrolase. Next, they infected 13 of these chimeric mice with J6-JFH1, an HCV strain that can establish long-term infections in mice that have human liver grafts (Proc Natl Acad Sci USA. 2006;103[10]:3805-9). The human liver xenograft reconstituted the FAH gene, restoring triglycerides to normal levels in the chimeric mice and creating a suitable “humanlike” model of lipoprotein metabolism, the investigators wrote.
Density fractionation of infectious mouse serum revealed higher infectivity in the low-density fractions soon after infection, which also has been observed in a human liver chimeric mouse model of severe combined immunodeficiency disease, they added. In the HCV model, the human liver grafts were conserved 5 weeks after infection, and the mice had a lower proportion of lighter, infectious HCV particles.
The researchers lacked sufficient material to directly study the composition of virions or detect viral proteins in the various density fractions. However, they determined that apolipoprotein C1 was the lightest fraction and that apolipoprotein E was mainly found in the five lightest fractions. Both these apolipoproteins are “essential factors of HCV infectivity,” and neither redistributed over time, they said. They suggested using immunoelectron microscopy or mass spectrometry to study the nature and infectivity of viral particles further.
In humans, ingesting a high-fat milkshake increases detectable HCV RNA in the VLDL fraction, the researchers noted. In rodents, a sucrose diet also has been found to increase VLDL lipidation and secretion, so they gave five of the infected chimeric mice drinking water containing 10% sucrose. After 5 weeks, these mice had increased infectivity and higher levels of triglycerides and cholesterol, but the effect was small and disappeared after the sucrose was withdrawn.
HCV “circulates as a population of particles of light, as well as dense, buoyant densities, and both are infectious,” the researchers concluded. “Changes in diet, as well as conditions such as fasting and feeding, affect the distribution of HCV buoyant density gradients.”
Funders included the National Institutes of Health and the American Association for the Study of Liver Diseases. The investigators disclosed no conflicts.
A hallmark of HCV infection is the association of virus particles with lipoproteins. The HCV virion (lipo-viro particle, LVP) is composed of nucleocapsid and envelope glycoproteins associated with very-low- and low-density lipoproteins, cholesterol, and apolipoproteins. The lipid components determine the size, density, hepatotropism, and infectivity of LVPs and play a role in cell entry, morphogenesis, release, and viral escape mechanisms. LVPs undergo dynamic changes during infection, and dietary triglycerides induce alterations in their biophysical properties and infectivity.
Dr. Andreo and colleagues used humanized Fah–/– mice to analyze the evolution of HCV particles during infection. As previously reported, two viral populations of different densities were detected in mice sera, with higher infectivity observed for the low-density population. The proportions and infectivity of these populations varied during infection, reflecting changes in biochemical features of the virus. Sucrose diet influenced the properties of virus particles; these properties’ changes correlated with a redistribution of triglycerides and cholesterol among lipoproteins.
Changes in biochemical features of the virus during infection represent a fascinating aspect of the structural heterogeneity, which influences HCV infectivity and evolution of the disease. Further studies in experimental models that reproduce the lipoprotein-dependent morphogenesis and release of virus particles, maturation, and intravascular remodeling of HCV-associated lipoproteins would help to develop novel lipid-targeting inhibitors to improve existing therapies.
Agata Budkowska, PhD, is scientific advisor for the department of international affairs at the Institut Pasteur, Paris. She has no conflicts of interest.
A hallmark of HCV infection is the association of virus particles with lipoproteins. The HCV virion (lipo-viro particle, LVP) is composed of nucleocapsid and envelope glycoproteins associated with very-low- and low-density lipoproteins, cholesterol, and apolipoproteins. The lipid components determine the size, density, hepatotropism, and infectivity of LVPs and play a role in cell entry, morphogenesis, release, and viral escape mechanisms. LVPs undergo dynamic changes during infection, and dietary triglycerides induce alterations in their biophysical properties and infectivity.
Dr. Andreo and colleagues used humanized Fah–/– mice to analyze the evolution of HCV particles during infection. As previously reported, two viral populations of different densities were detected in mice sera, with higher infectivity observed for the low-density population. The proportions and infectivity of these populations varied during infection, reflecting changes in biochemical features of the virus. Sucrose diet influenced the properties of virus particles; these properties’ changes correlated with a redistribution of triglycerides and cholesterol among lipoproteins.
Changes in biochemical features of the virus during infection represent a fascinating aspect of the structural heterogeneity, which influences HCV infectivity and evolution of the disease. Further studies in experimental models that reproduce the lipoprotein-dependent morphogenesis and release of virus particles, maturation, and intravascular remodeling of HCV-associated lipoproteins would help to develop novel lipid-targeting inhibitors to improve existing therapies.
Agata Budkowska, PhD, is scientific advisor for the department of international affairs at the Institut Pasteur, Paris. She has no conflicts of interest.
A hallmark of HCV infection is the association of virus particles with lipoproteins. The HCV virion (lipo-viro particle, LVP) is composed of nucleocapsid and envelope glycoproteins associated with very-low- and low-density lipoproteins, cholesterol, and apolipoproteins. The lipid components determine the size, density, hepatotropism, and infectivity of LVPs and play a role in cell entry, morphogenesis, release, and viral escape mechanisms. LVPs undergo dynamic changes during infection, and dietary triglycerides induce alterations in their biophysical properties and infectivity.
Dr. Andreo and colleagues used humanized Fah–/– mice to analyze the evolution of HCV particles during infection. As previously reported, two viral populations of different densities were detected in mice sera, with higher infectivity observed for the low-density population. The proportions and infectivity of these populations varied during infection, reflecting changes in biochemical features of the virus. Sucrose diet influenced the properties of virus particles; these properties’ changes correlated with a redistribution of triglycerides and cholesterol among lipoproteins.
Changes in biochemical features of the virus during infection represent a fascinating aspect of the structural heterogeneity, which influences HCV infectivity and evolution of the disease. Further studies in experimental models that reproduce the lipoprotein-dependent morphogenesis and release of virus particles, maturation, and intravascular remodeling of HCV-associated lipoproteins would help to develop novel lipid-targeting inhibitors to improve existing therapies.
Agata Budkowska, PhD, is scientific advisor for the department of international affairs at the Institut Pasteur, Paris. She has no conflicts of interest.
Hepatitis C virus (HCV) particles are of lowest density and most infectious early in the course of infection, based on findings from a study of chimeric mice.
Over time, however, viral density became more heterogeneous and infectivity fell, reported Ursula Andreo, PhD, of Rockefeller University, New York, with her coinvestigators. A diet of 10% sucrose, which in rats induces hepatic secretion of very-low-density lipoprotein (VLDL), caused HCV particles to become slightly lower density and more infectious in the mice, the researchers reported. Although the shift was “minor,” it “correlated with a trend toward enhanced triglyceride and cholesterol levels in the same fractions,” they wrote. They recommended studying high-fat diets to determine whether altering the VLDL secretion pathway affects the biophysical properties of HCV. “A high-fat diet might have a more significant impact on the lipoprotein profile in this humanized mouse model,” they wrote in Cellular and Molecular Gastroenterology and Hepatology (2017 Jul;4[3]:405-17).
Because HCV tends to associate with lipoproteins, it shows a range of buoyant densities in the blood of infected patients. The “entry, replication, and assembly [of the virion] are linked closely to host lipid and lipoprotein metabolism,” wrote Dr. Andreo and her colleagues.
They created an in vivo model to study the buoyant density and infectivity of HCV particles, as well as their interaction with lipoproteins, by grafting human hepatocytes into the livers of immunodeficient mice that were homozygous recessive for fumarylacetoacetate hydrolase. Next, they infected 13 of these chimeric mice with J6-JFH1, an HCV strain that can establish long-term infections in mice that have human liver grafts (Proc Natl Acad Sci USA. 2006;103[10]:3805-9). The human liver xenograft reconstituted the FAH gene, restoring triglycerides to normal levels in the chimeric mice and creating a suitable “humanlike” model of lipoprotein metabolism, the investigators wrote.
Density fractionation of infectious mouse serum revealed higher infectivity in the low-density fractions soon after infection, which also has been observed in a human liver chimeric mouse model of severe combined immunodeficiency disease, they added. In the HCV model, the human liver grafts were conserved 5 weeks after infection, and the mice had a lower proportion of lighter, infectious HCV particles.
The researchers lacked sufficient material to directly study the composition of virions or detect viral proteins in the various density fractions. However, they determined that apolipoprotein C1 was the lightest fraction and that apolipoprotein E was mainly found in the five lightest fractions. Both these apolipoproteins are “essential factors of HCV infectivity,” and neither redistributed over time, they said. They suggested using immunoelectron microscopy or mass spectrometry to study the nature and infectivity of viral particles further.
In humans, ingesting a high-fat milkshake increases detectable HCV RNA in the VLDL fraction, the researchers noted. In rodents, a sucrose diet also has been found to increase VLDL lipidation and secretion, so they gave five of the infected chimeric mice drinking water containing 10% sucrose. After 5 weeks, these mice had increased infectivity and higher levels of triglycerides and cholesterol, but the effect was small and disappeared after the sucrose was withdrawn.
HCV “circulates as a population of particles of light, as well as dense, buoyant densities, and both are infectious,” the researchers concluded. “Changes in diet, as well as conditions such as fasting and feeding, affect the distribution of HCV buoyant density gradients.”
Funders included the National Institutes of Health and the American Association for the Study of Liver Diseases. The investigators disclosed no conflicts.
Hepatitis C virus (HCV) particles are of lowest density and most infectious early in the course of infection, based on findings from a study of chimeric mice.
Over time, however, viral density became more heterogeneous and infectivity fell, reported Ursula Andreo, PhD, of Rockefeller University, New York, with her coinvestigators. A diet of 10% sucrose, which in rats induces hepatic secretion of very-low-density lipoprotein (VLDL), caused HCV particles to become slightly lower density and more infectious in the mice, the researchers reported. Although the shift was “minor,” it “correlated with a trend toward enhanced triglyceride and cholesterol levels in the same fractions,” they wrote. They recommended studying high-fat diets to determine whether altering the VLDL secretion pathway affects the biophysical properties of HCV. “A high-fat diet might have a more significant impact on the lipoprotein profile in this humanized mouse model,” they wrote in Cellular and Molecular Gastroenterology and Hepatology (2017 Jul;4[3]:405-17).
Because HCV tends to associate with lipoproteins, it shows a range of buoyant densities in the blood of infected patients. The “entry, replication, and assembly [of the virion] are linked closely to host lipid and lipoprotein metabolism,” wrote Dr. Andreo and her colleagues.
They created an in vivo model to study the buoyant density and infectivity of HCV particles, as well as their interaction with lipoproteins, by grafting human hepatocytes into the livers of immunodeficient mice that were homozygous recessive for fumarylacetoacetate hydrolase. Next, they infected 13 of these chimeric mice with J6-JFH1, an HCV strain that can establish long-term infections in mice that have human liver grafts (Proc Natl Acad Sci USA. 2006;103[10]:3805-9). The human liver xenograft reconstituted the FAH gene, restoring triglycerides to normal levels in the chimeric mice and creating a suitable “humanlike” model of lipoprotein metabolism, the investigators wrote.
Density fractionation of infectious mouse serum revealed higher infectivity in the low-density fractions soon after infection, which also has been observed in a human liver chimeric mouse model of severe combined immunodeficiency disease, they added. In the HCV model, the human liver grafts were conserved 5 weeks after infection, and the mice had a lower proportion of lighter, infectious HCV particles.
The researchers lacked sufficient material to directly study the composition of virions or detect viral proteins in the various density fractions. However, they determined that apolipoprotein C1 was the lightest fraction and that apolipoprotein E was mainly found in the five lightest fractions. Both these apolipoproteins are “essential factors of HCV infectivity,” and neither redistributed over time, they said. They suggested using immunoelectron microscopy or mass spectrometry to study the nature and infectivity of viral particles further.
In humans, ingesting a high-fat milkshake increases detectable HCV RNA in the VLDL fraction, the researchers noted. In rodents, a sucrose diet also has been found to increase VLDL lipidation and secretion, so they gave five of the infected chimeric mice drinking water containing 10% sucrose. After 5 weeks, these mice had increased infectivity and higher levels of triglycerides and cholesterol, but the effect was small and disappeared after the sucrose was withdrawn.
HCV “circulates as a population of particles of light, as well as dense, buoyant densities, and both are infectious,” the researchers concluded. “Changes in diet, as well as conditions such as fasting and feeding, affect the distribution of HCV buoyant density gradients.”
Funders included the National Institutes of Health and the American Association for the Study of Liver Diseases. The investigators disclosed no conflicts.
FROM CELLULAR AND MOLECULAR GASTROENTEROLOGY AND HEPATOLOGY
Key clinical point: The biophysical properties of the hepatitis C virus evolve during the course of infection and shift with dietary changes.
Major finding: Density fractionation of infectious mouse serum showed higher infectivity in the low-density fractions soon after infection, but heterogeneity subsequently increased while infectivity decreased. A 5-week diet of 10% sucrose produced a minor shift toward infectivity that correlated with redistribution of triglycerides and cholesterol.
Data source: A study of 13 human liver chimeric mice.
Disclosures: Funders included the National Institutes of Health and the American Association for the Study of Liver Diseases. The investigators disclosed no conflicts.
Personality changes may not occur before Alzheimer’s onset
Personality changes do not presage dementia, at least when examined through the lens of self-report, a large retrospective study has determined.
Dementia patients do show personality characteristics that are different from those of their cognitively normal peers, wrote Antonio Terracciano, PhD (JAMA Psychiatry. 2017 Sep 20. doi: 10.1001/jamapsychiatry.2017.2816). Notably, they tend to be more neurotic and less conscientious, he noted. But among more than 2,000 older adults with up to 36 years of data, no temporal associations were found between these traits and the onset of cognitive difficulty, even within a few years of the onset of dementia symptoms.
“From a clinical perspective, these findings suggest that tracking change in self-rated personality as an early indicator of dementia is unlikely to be fruitful, while a single assessment provides reliable information on the personality traits that increase resilience [e.g., conscientiousness] or vulnerability [e.g., neuroticism] to clinical dementia,” wrote Dr. Terracciano of Florida State University, Tallahassee, and his coauthors.
However, the authors noted, it’s possible that self-reported personality may not be as good a marker of dementia-related personality change as informant report.
“Self-rated personality provides participants’ perspectives of themselves. … Individuals with AD could be anosognosic to change in their psychological trains and functioning. Self-reported personality might remain stable and reflect premorbid functioning more than current traits,” the researchers wrote.
The study tracked 2,046 community-living older adults who were part of the Baltimore Longitudinal Study of Aging, which began in 1958. Healthy individuals of different ages are continuously enrolled in the study and assessed with regular follow-up visits. These visits include cognitive and neuropsychiatric assessments, from which data for this study were extracted. The mean follow-up time was about 12 years, but some subjects had up to 36 years. From 1980 to 2016, the group completed more than 8,000 assessments and accumulated 24,569 person/years of follow-up.
Dr. Terracciano examined the cohort’s Revised NEO Personality Inventory results, a 240-item questionnaire that assesses 30 facets of personality in the dimensions of neuroticism, extraversion, openness, agreeableness, and conscientiousness. Cognitive decline was assessed by results on the Clinical Dementia Rating Scale and the older Dementia Questionnaire.
At the end of the follow-up period, 104 subjects (5%) had developed mild cognitive impairment, and 255 (12.5%) all-cause dementia; of those, 194 (9.5%) were later diagnosed with Alzheimer’s disease. In an unadjusted analysis, the authors found that the group that eventually developed AD scored higher on neuroticism, and lower on extraversion, openness, and conscientiousness than did the nonaffected subjects.
Over time, the authors found some changes in the reference group, including small declines in neuroticism and extraversion, and small increases in agreeableness and conscientiousness. However, when they looked at the trajectory of change, they found no significant differences in the rate of any change, compared with the AD group – although that group continued to display changes in its baseline difference of neuroticism and conscientiousness.
“Although the trajectories were similar, there were significant ... differences on the intercept,” they wrote. “The AD cohort scored higher on neuroticism and lower on conscientiousness and extraversion than the nonimpaired group.”
The team ran several temporal analyses on the data, and none found any significant temporal association with accelerated personality change in the AD group, the MCI group, or the all-cause dementia groups compared with the reference group, with one exception: Subjects with MCI showed a steeper decline in openness than did nonaffected subjects.
Those results were consistent even when they examined the two assessments performed just before the onset of cognitive symptoms (a mean of 6 and 3 years). “Consistent with the results and the broader literature, the AD group scored higher on neuroticism and lower on conscientiousness. Contrary to expectations, the AD group did not increase in neuroticism and decline in conscientiousness.”
The findings may shed some light on the chicken-or-egg question of personality change and dementia, they suggested.
“This research has relevance to the question of reverse causality for the association between personality and risk of incident AD. That is, if personality changed in response to increasing neuropathology in the brain in the preclinical phase, the association between personality and AD could have been due to the disease process rather than personality as an independent risk factor. We did not, however, find any evidence that neuroticism and conscientiousness changed significantly as the onset of disease approached. Thus, rather than an effect of AD neuropathology, these traits appear to confer risk for the development of the disease.”
The Baltimore Longitudinal Study of Aging is supported by the National Institutes of Health. Neither Dr. Terracciano nor his colleagues had financial disclosures.
[email protected]
On Twitter @alz_gal
Personality changes do not presage dementia, at least when examined through the lens of self-report, a large retrospective study has determined.
Dementia patients do show personality characteristics that are different from those of their cognitively normal peers, wrote Antonio Terracciano, PhD (JAMA Psychiatry. 2017 Sep 20. doi: 10.1001/jamapsychiatry.2017.2816). Notably, they tend to be more neurotic and less conscientious, he noted. But among more than 2,000 older adults with up to 36 years of data, no temporal associations were found between these traits and the onset of cognitive difficulty, even within a few years of the onset of dementia symptoms.
“From a clinical perspective, these findings suggest that tracking change in self-rated personality as an early indicator of dementia is unlikely to be fruitful, while a single assessment provides reliable information on the personality traits that increase resilience [e.g., conscientiousness] or vulnerability [e.g., neuroticism] to clinical dementia,” wrote Dr. Terracciano of Florida State University, Tallahassee, and his coauthors.
However, the authors noted, it’s possible that self-reported personality may not be as good a marker of dementia-related personality change as informant report.
“Self-rated personality provides participants’ perspectives of themselves. … Individuals with AD could be anosognosic to change in their psychological trains and functioning. Self-reported personality might remain stable and reflect premorbid functioning more than current traits,” the researchers wrote.
The study tracked 2,046 community-living older adults who were part of the Baltimore Longitudinal Study of Aging, which began in 1958. Healthy individuals of different ages are continuously enrolled in the study and assessed with regular follow-up visits. These visits include cognitive and neuropsychiatric assessments, from which data for this study were extracted. The mean follow-up time was about 12 years, but some subjects had up to 36 years. From 1980 to 2016, the group completed more than 8,000 assessments and accumulated 24,569 person/years of follow-up.
Dr. Terracciano examined the cohort’s Revised NEO Personality Inventory results, a 240-item questionnaire that assesses 30 facets of personality in the dimensions of neuroticism, extraversion, openness, agreeableness, and conscientiousness. Cognitive decline was assessed by results on the Clinical Dementia Rating Scale and the older Dementia Questionnaire.
At the end of the follow-up period, 104 subjects (5%) had developed mild cognitive impairment, and 255 (12.5%) all-cause dementia; of those, 194 (9.5%) were later diagnosed with Alzheimer’s disease. In an unadjusted analysis, the authors found that the group that eventually developed AD scored higher on neuroticism, and lower on extraversion, openness, and conscientiousness than did the nonaffected subjects.
Over time, the authors found some changes in the reference group, including small declines in neuroticism and extraversion, and small increases in agreeableness and conscientiousness. However, when they looked at the trajectory of change, they found no significant differences in the rate of any change, compared with the AD group – although that group continued to display changes in its baseline difference of neuroticism and conscientiousness.
“Although the trajectories were similar, there were significant ... differences on the intercept,” they wrote. “The AD cohort scored higher on neuroticism and lower on conscientiousness and extraversion than the nonimpaired group.”
The team ran several temporal analyses on the data, and none found any significant temporal association with accelerated personality change in the AD group, the MCI group, or the all-cause dementia groups compared with the reference group, with one exception: Subjects with MCI showed a steeper decline in openness than did nonaffected subjects.
Those results were consistent even when they examined the two assessments performed just before the onset of cognitive symptoms (a mean of 6 and 3 years). “Consistent with the results and the broader literature, the AD group scored higher on neuroticism and lower on conscientiousness. Contrary to expectations, the AD group did not increase in neuroticism and decline in conscientiousness.”
The findings may shed some light on the chicken-or-egg question of personality change and dementia, they suggested.
“This research has relevance to the question of reverse causality for the association between personality and risk of incident AD. That is, if personality changed in response to increasing neuropathology in the brain in the preclinical phase, the association between personality and AD could have been due to the disease process rather than personality as an independent risk factor. We did not, however, find any evidence that neuroticism and conscientiousness changed significantly as the onset of disease approached. Thus, rather than an effect of AD neuropathology, these traits appear to confer risk for the development of the disease.”
The Baltimore Longitudinal Study of Aging is supported by the National Institutes of Health. Neither Dr. Terracciano nor his colleagues had financial disclosures.
[email protected]
On Twitter @alz_gal
Personality changes do not presage dementia, at least when examined through the lens of self-report, a large retrospective study has determined.
Dementia patients do show personality characteristics that are different from those of their cognitively normal peers, wrote Antonio Terracciano, PhD (JAMA Psychiatry. 2017 Sep 20. doi: 10.1001/jamapsychiatry.2017.2816). Notably, they tend to be more neurotic and less conscientious, he noted. But among more than 2,000 older adults with up to 36 years of data, no temporal associations were found between these traits and the onset of cognitive difficulty, even within a few years of the onset of dementia symptoms.
“From a clinical perspective, these findings suggest that tracking change in self-rated personality as an early indicator of dementia is unlikely to be fruitful, while a single assessment provides reliable information on the personality traits that increase resilience [e.g., conscientiousness] or vulnerability [e.g., neuroticism] to clinical dementia,” wrote Dr. Terracciano of Florida State University, Tallahassee, and his coauthors.
However, the authors noted, it’s possible that self-reported personality may not be as good a marker of dementia-related personality change as informant report.
“Self-rated personality provides participants’ perspectives of themselves. … Individuals with AD could be anosognosic to change in their psychological trains and functioning. Self-reported personality might remain stable and reflect premorbid functioning more than current traits,” the researchers wrote.
The study tracked 2,046 community-living older adults who were part of the Baltimore Longitudinal Study of Aging, which began in 1958. Healthy individuals of different ages are continuously enrolled in the study and assessed with regular follow-up visits. These visits include cognitive and neuropsychiatric assessments, from which data for this study were extracted. The mean follow-up time was about 12 years, but some subjects had up to 36 years. From 1980 to 2016, the group completed more than 8,000 assessments and accumulated 24,569 person/years of follow-up.
Dr. Terracciano examined the cohort’s Revised NEO Personality Inventory results, a 240-item questionnaire that assesses 30 facets of personality in the dimensions of neuroticism, extraversion, openness, agreeableness, and conscientiousness. Cognitive decline was assessed by results on the Clinical Dementia Rating Scale and the older Dementia Questionnaire.
At the end of the follow-up period, 104 subjects (5%) had developed mild cognitive impairment, and 255 (12.5%) all-cause dementia; of those, 194 (9.5%) were later diagnosed with Alzheimer’s disease. In an unadjusted analysis, the authors found that the group that eventually developed AD scored higher on neuroticism, and lower on extraversion, openness, and conscientiousness than did the nonaffected subjects.
Over time, the authors found some changes in the reference group, including small declines in neuroticism and extraversion, and small increases in agreeableness and conscientiousness. However, when they looked at the trajectory of change, they found no significant differences in the rate of any change, compared with the AD group – although that group continued to display changes in its baseline difference of neuroticism and conscientiousness.
“Although the trajectories were similar, there were significant ... differences on the intercept,” they wrote. “The AD cohort scored higher on neuroticism and lower on conscientiousness and extraversion than the nonimpaired group.”
The team ran several temporal analyses on the data, and none found any significant temporal association with accelerated personality change in the AD group, the MCI group, or the all-cause dementia groups compared with the reference group, with one exception: Subjects with MCI showed a steeper decline in openness than did nonaffected subjects.
Those results were consistent even when they examined the two assessments performed just before the onset of cognitive symptoms (a mean of 6 and 3 years). “Consistent with the results and the broader literature, the AD group scored higher on neuroticism and lower on conscientiousness. Contrary to expectations, the AD group did not increase in neuroticism and decline in conscientiousness.”
The findings may shed some light on the chicken-or-egg question of personality change and dementia, they suggested.
“This research has relevance to the question of reverse causality for the association between personality and risk of incident AD. That is, if personality changed in response to increasing neuropathology in the brain in the preclinical phase, the association between personality and AD could have been due to the disease process rather than personality as an independent risk factor. We did not, however, find any evidence that neuroticism and conscientiousness changed significantly as the onset of disease approached. Thus, rather than an effect of AD neuropathology, these traits appear to confer risk for the development of the disease.”
The Baltimore Longitudinal Study of Aging is supported by the National Institutes of Health. Neither Dr. Terracciano nor his colleagues had financial disclosures.
[email protected]
On Twitter @alz_gal
FROM JAMA PSYCHIATRY
Key clinical point:
Major finding: Although patients with AD scored higher on neuroticism and lower on conscientiousness, those traits did not change any faster than personality traits in the nonaffected subjects.
Data source: The study comprised 2,046 subjects with up to 36 years’ follow-up.
Disclosures: The Baltimore Longitudinal Study on Aging is funded by the National Institutes of Health. Neither Dr. Terracciano nor his coauthors had financial disclosures.
Insist on flu vaccination for all, say experts
sponsored by the National Foundation for Infectious Diseases.
Some good news about the flu – vaccination rates increased slightly last year, compared with the previous year among all individuals aged 6 months and older without contraindications, according to data from the Centers for Disease Control and Prevention.
Experts continue to recommend annual influenza vaccination for all persons aged 6 months and older, but they emphasize the need to identify those at risk of not getting vaccinated and develop strategies to increase vaccination coverage.
“Vaccines are among the greatest public health achievements of modern times, but they are only as useful as we as a society take advantage of them,” Secretary of Health & Human Services Thomas E. Price, MD, said at the briefing.
Overall flu vaccination in the United States was 47% for the 2016-2017 season, compared with 46% during the 2015-2016 season, according to data from the Centers for Disease Control and Prevention.
Dr. Price emphasized that vaccination is only part of a successful flu prevention strategy. Stay home when you are sick to help avoid spreading germs to others and take antiviral drugs if a doctor prescribes them to help reduce and avoid complications from flu, he said.
Children aged 6-23 months were the only population subgroup to meet the 70% Healthy People 2020 goal last year, with a rate of 73%, said Patricia A. Stinchfield, RN, CPNP, senior director of infection prevention and control at Children’s Hospital Minnesota, Minneapolis.
“Our goal is to increase coverage for children of all ages,” she said. But it’s not just about the kids themselves, she emphasized.
“If your child gets the flu, they expose babies, grandparents, pregnant women. We need to vaccinate children to protect the public at large,” she said. In addition, health care professionals must be clear about recommending vaccination. The research shows that a specific recommendation often makes the difference for vaccinating families.
Pregnant women are among those who can and should safely be vaccinated, Ms. Stinchfield emphasized. Flu vaccination among pregnant women was 54% in 2016-2017, similar to the past three flu seasons, and approximately two-thirds (67%) of pregnant women in 2016-2017 reported that a health care provider recommended and offered flu vaccination, according to CDC data.
Older adults also are important targets for flu vaccination, noted Kathleen M. Neuzil, MD, director of the Center for Vaccine Development at the University of Maryland, Baltimore. Last year, approximately 65% of U.S. adults aged 65 years and older were vaccinated, which was the largest subgroup of adults aged 18 years and older, she said. Older adults may be caring for frail spouses or infant grandchildren, so protecting others should be a motivating factor in continuing to encourage vaccination in this age group, she noted.
The flu vaccine supply is plentiful going into the start of the 2016-2017 flu season, with an estimated 166 million doses available in several formulations, said Daniel B. Jernigan, MD, director of the CDC’s Influenza Division.
Options for vaccination include the standard vaccine, a cell-based vaccine, and a recombinant vaccine. In addition, an adjuvanted vaccine and a high-dose vaccine are available specifically for adults aged 65 years and older; these vaccines are designed to provoke a stronger immune response, Dr. Jernigan said.
However, the briefing participants agreed that the best strategy is to get vaccinated as soon as possible, rather than postponing vaccination in order to secure a particular vaccine type.
Clinicians should not underestimate the power of leading by example when it comes to flu vaccination, Dr. Schaffner noted. Support from the highest levels of administration is important to help overcome barriers to vaccination coverage for health care workers by making vaccination easy and accessible, he said.
The overall influenza vaccination coverage estimate among health care providers was 79% for the 2016-2017 season, similar to the 2014-2015 and 2015-2016 seasons, but representing a 15% increase since 2010-2011. Vaccination coverage was highest among health care personnel whose workplaces required it.
Complete data on 2016-2017 vaccination coverage in health care workers and in pregnant women were published in the CDC’s Morbidity and Mortality Weekly Report on Sept. 29.
The CDC’s complete flu vaccination recommendations are available online.
The briefing participants had no relevant financial conflicts to disclose.
sponsored by the National Foundation for Infectious Diseases.
Some good news about the flu – vaccination rates increased slightly last year, compared with the previous year among all individuals aged 6 months and older without contraindications, according to data from the Centers for Disease Control and Prevention.
Experts continue to recommend annual influenza vaccination for all persons aged 6 months and older, but they emphasize the need to identify those at risk of not getting vaccinated and develop strategies to increase vaccination coverage.
“Vaccines are among the greatest public health achievements of modern times, but they are only as useful as we as a society take advantage of them,” Secretary of Health & Human Services Thomas E. Price, MD, said at the briefing.
Overall flu vaccination in the United States was 47% for the 2016-2017 season, compared with 46% during the 2015-2016 season, according to data from the Centers for Disease Control and Prevention.
Dr. Price emphasized that vaccination is only part of a successful flu prevention strategy. Stay home when you are sick to help avoid spreading germs to others and take antiviral drugs if a doctor prescribes them to help reduce and avoid complications from flu, he said.
Children aged 6-23 months were the only population subgroup to meet the 70% Healthy People 2020 goal last year, with a rate of 73%, said Patricia A. Stinchfield, RN, CPNP, senior director of infection prevention and control at Children’s Hospital Minnesota, Minneapolis.
“Our goal is to increase coverage for children of all ages,” she said. But it’s not just about the kids themselves, she emphasized.
“If your child gets the flu, they expose babies, grandparents, pregnant women. We need to vaccinate children to protect the public at large,” she said. In addition, health care professionals must be clear about recommending vaccination. The research shows that a specific recommendation often makes the difference for vaccinating families.
Pregnant women are among those who can and should safely be vaccinated, Ms. Stinchfield emphasized. Flu vaccination among pregnant women was 54% in 2016-2017, similar to the past three flu seasons, and approximately two-thirds (67%) of pregnant women in 2016-2017 reported that a health care provider recommended and offered flu vaccination, according to CDC data.
Older adults also are important targets for flu vaccination, noted Kathleen M. Neuzil, MD, director of the Center for Vaccine Development at the University of Maryland, Baltimore. Last year, approximately 65% of U.S. adults aged 65 years and older were vaccinated, which was the largest subgroup of adults aged 18 years and older, she said. Older adults may be caring for frail spouses or infant grandchildren, so protecting others should be a motivating factor in continuing to encourage vaccination in this age group, she noted.
The flu vaccine supply is plentiful going into the start of the 2016-2017 flu season, with an estimated 166 million doses available in several formulations, said Daniel B. Jernigan, MD, director of the CDC’s Influenza Division.
Options for vaccination include the standard vaccine, a cell-based vaccine, and a recombinant vaccine. In addition, an adjuvanted vaccine and a high-dose vaccine are available specifically for adults aged 65 years and older; these vaccines are designed to provoke a stronger immune response, Dr. Jernigan said.
However, the briefing participants agreed that the best strategy is to get vaccinated as soon as possible, rather than postponing vaccination in order to secure a particular vaccine type.
Clinicians should not underestimate the power of leading by example when it comes to flu vaccination, Dr. Schaffner noted. Support from the highest levels of administration is important to help overcome barriers to vaccination coverage for health care workers by making vaccination easy and accessible, he said.
The overall influenza vaccination coverage estimate among health care providers was 79% for the 2016-2017 season, similar to the 2014-2015 and 2015-2016 seasons, but representing a 15% increase since 2010-2011. Vaccination coverage was highest among health care personnel whose workplaces required it.
Complete data on 2016-2017 vaccination coverage in health care workers and in pregnant women were published in the CDC’s Morbidity and Mortality Weekly Report on Sept. 29.
The CDC’s complete flu vaccination recommendations are available online.
The briefing participants had no relevant financial conflicts to disclose.
sponsored by the National Foundation for Infectious Diseases.
Some good news about the flu – vaccination rates increased slightly last year, compared with the previous year among all individuals aged 6 months and older without contraindications, according to data from the Centers for Disease Control and Prevention.
Experts continue to recommend annual influenza vaccination for all persons aged 6 months and older, but they emphasize the need to identify those at risk of not getting vaccinated and develop strategies to increase vaccination coverage.
“Vaccines are among the greatest public health achievements of modern times, but they are only as useful as we as a society take advantage of them,” Secretary of Health & Human Services Thomas E. Price, MD, said at the briefing.
Overall flu vaccination in the United States was 47% for the 2016-2017 season, compared with 46% during the 2015-2016 season, according to data from the Centers for Disease Control and Prevention.
Dr. Price emphasized that vaccination is only part of a successful flu prevention strategy. Stay home when you are sick to help avoid spreading germs to others and take antiviral drugs if a doctor prescribes them to help reduce and avoid complications from flu, he said.
Children aged 6-23 months were the only population subgroup to meet the 70% Healthy People 2020 goal last year, with a rate of 73%, said Patricia A. Stinchfield, RN, CPNP, senior director of infection prevention and control at Children’s Hospital Minnesota, Minneapolis.
“Our goal is to increase coverage for children of all ages,” she said. But it’s not just about the kids themselves, she emphasized.
“If your child gets the flu, they expose babies, grandparents, pregnant women. We need to vaccinate children to protect the public at large,” she said. In addition, health care professionals must be clear about recommending vaccination. The research shows that a specific recommendation often makes the difference for vaccinating families.
Pregnant women are among those who can and should safely be vaccinated, Ms. Stinchfield emphasized. Flu vaccination among pregnant women was 54% in 2016-2017, similar to the past three flu seasons, and approximately two-thirds (67%) of pregnant women in 2016-2017 reported that a health care provider recommended and offered flu vaccination, according to CDC data.
Older adults also are important targets for flu vaccination, noted Kathleen M. Neuzil, MD, director of the Center for Vaccine Development at the University of Maryland, Baltimore. Last year, approximately 65% of U.S. adults aged 65 years and older were vaccinated, which was the largest subgroup of adults aged 18 years and older, she said. Older adults may be caring for frail spouses or infant grandchildren, so protecting others should be a motivating factor in continuing to encourage vaccination in this age group, she noted.
The flu vaccine supply is plentiful going into the start of the 2016-2017 flu season, with an estimated 166 million doses available in several formulations, said Daniel B. Jernigan, MD, director of the CDC’s Influenza Division.
Options for vaccination include the standard vaccine, a cell-based vaccine, and a recombinant vaccine. In addition, an adjuvanted vaccine and a high-dose vaccine are available specifically for adults aged 65 years and older; these vaccines are designed to provoke a stronger immune response, Dr. Jernigan said.
However, the briefing participants agreed that the best strategy is to get vaccinated as soon as possible, rather than postponing vaccination in order to secure a particular vaccine type.
Clinicians should not underestimate the power of leading by example when it comes to flu vaccination, Dr. Schaffner noted. Support from the highest levels of administration is important to help overcome barriers to vaccination coverage for health care workers by making vaccination easy and accessible, he said.
The overall influenza vaccination coverage estimate among health care providers was 79% for the 2016-2017 season, similar to the 2014-2015 and 2015-2016 seasons, but representing a 15% increase since 2010-2011. Vaccination coverage was highest among health care personnel whose workplaces required it.
Complete data on 2016-2017 vaccination coverage in health care workers and in pregnant women were published in the CDC’s Morbidity and Mortality Weekly Report on Sept. 29.
The CDC’s complete flu vaccination recommendations are available online.
The briefing participants had no relevant financial conflicts to disclose.
ADHD meds don’t raise seizure risk in epilepsy patients
PARIS – The use of attention-deficit/hyperactivity disorder medications is not associated with increased risk of epileptic seizures in patients with both disorders, according to an analysis of Swedish national registry data.
“Seizure history should not exempt patients from ADHD medication treatment,” Isabell Brikell stated at the annual congress of the European College of Neuropsychopharmacology.
“That’s why it’s such an important question, whether ADHD medications increase the risk of seizures,” observed Ms. Brikell, a PhD candidate in psychiatric genetics and epidemiology at the Karolinska Institute in Stockholm.
Swedish health care registries are famously comprehensive. For example, the Swedish prescription medication registry that Ms. Brikell and her coinvestigators tapped into for their ADHD/epilepsy study contains information on 99% of all prescriptions ordered in the country since 2005.
She reported on 38,247 Swedish patients with epilepsy born during 1976-2008 and followed during 2006-2013. Forty-eight percent were female. They collectively experienced 30,093 acute epileptic seizures of sufficient severity that they presented to a hospital for an unplanned visit. When the investigators compared the rate of seizures while the patients with ADHD were on a collective 4,248 ADHD medication exposure periods to that of epilepsy patients without ADHD, they found that the seizure risk was actually 17% lower in ADHD patients while on medication. This difference fell just shy of statistical significance. The analysis was adjusted for gender, age, and time on ADHD medications.
However, Ms. Brikell and her coworkers also performed a separate analysis for each individual with ADHD in which they compared seizure rates when a given patient was on ADHD medication versus off medication, a design that controls for many of the potential confounding factors that can occur with observational data. The seizure risk proved to be 19% lower while an individual was on ADHD medication – and this difference was indeed statistically significant.
In an interview, Ms. Brikell noted that the Swedish data are confirmed by a much larger National Institute of Mental Health–sponsored American study she was involved with that is now under review for publication. The U.S. study, which used the enormous MarketScan private health insurance database, demonstrated with the power provided by very large patient numbers that the seizure risk was convincingly lower while dual-diagnosis patients were on ADHD medication than when they were off.
“It’s reassuring to see the same effect across two countries with such different health care systems,” she commented.
Epilepsy is known to be inherently associated with a threefold increased prevalence of ADHD.
Ms. Brikell’s study was funded by the Swedish Research Council, the U.S. National Institute of Mental Health, and the Swedish Initiative for Research on Microdata in the Social and Medical Sciences. She reported having no financial conflicts of interest.
PARIS – The use of attention-deficit/hyperactivity disorder medications is not associated with increased risk of epileptic seizures in patients with both disorders, according to an analysis of Swedish national registry data.
“Seizure history should not exempt patients from ADHD medication treatment,” Isabell Brikell stated at the annual congress of the European College of Neuropsychopharmacology.
“That’s why it’s such an important question, whether ADHD medications increase the risk of seizures,” observed Ms. Brikell, a PhD candidate in psychiatric genetics and epidemiology at the Karolinska Institute in Stockholm.
Swedish health care registries are famously comprehensive. For example, the Swedish prescription medication registry that Ms. Brikell and her coinvestigators tapped into for their ADHD/epilepsy study contains information on 99% of all prescriptions ordered in the country since 2005.
She reported on 38,247 Swedish patients with epilepsy born during 1976-2008 and followed during 2006-2013. Forty-eight percent were female. They collectively experienced 30,093 acute epileptic seizures of sufficient severity that they presented to a hospital for an unplanned visit. When the investigators compared the rate of seizures while the patients with ADHD were on a collective 4,248 ADHD medication exposure periods to that of epilepsy patients without ADHD, they found that the seizure risk was actually 17% lower in ADHD patients while on medication. This difference fell just shy of statistical significance. The analysis was adjusted for gender, age, and time on ADHD medications.
However, Ms. Brikell and her coworkers also performed a separate analysis for each individual with ADHD in which they compared seizure rates when a given patient was on ADHD medication versus off medication, a design that controls for many of the potential confounding factors that can occur with observational data. The seizure risk proved to be 19% lower while an individual was on ADHD medication – and this difference was indeed statistically significant.
In an interview, Ms. Brikell noted that the Swedish data are confirmed by a much larger National Institute of Mental Health–sponsored American study she was involved with that is now under review for publication. The U.S. study, which used the enormous MarketScan private health insurance database, demonstrated with the power provided by very large patient numbers that the seizure risk was convincingly lower while dual-diagnosis patients were on ADHD medication than when they were off.
“It’s reassuring to see the same effect across two countries with such different health care systems,” she commented.
Epilepsy is known to be inherently associated with a threefold increased prevalence of ADHD.
Ms. Brikell’s study was funded by the Swedish Research Council, the U.S. National Institute of Mental Health, and the Swedish Initiative for Research on Microdata in the Social and Medical Sciences. She reported having no financial conflicts of interest.
PARIS – The use of attention-deficit/hyperactivity disorder medications is not associated with increased risk of epileptic seizures in patients with both disorders, according to an analysis of Swedish national registry data.
“Seizure history should not exempt patients from ADHD medication treatment,” Isabell Brikell stated at the annual congress of the European College of Neuropsychopharmacology.
“That’s why it’s such an important question, whether ADHD medications increase the risk of seizures,” observed Ms. Brikell, a PhD candidate in psychiatric genetics and epidemiology at the Karolinska Institute in Stockholm.
Swedish health care registries are famously comprehensive. For example, the Swedish prescription medication registry that Ms. Brikell and her coinvestigators tapped into for their ADHD/epilepsy study contains information on 99% of all prescriptions ordered in the country since 2005.
She reported on 38,247 Swedish patients with epilepsy born during 1976-2008 and followed during 2006-2013. Forty-eight percent were female. They collectively experienced 30,093 acute epileptic seizures of sufficient severity that they presented to a hospital for an unplanned visit. When the investigators compared the rate of seizures while the patients with ADHD were on a collective 4,248 ADHD medication exposure periods to that of epilepsy patients without ADHD, they found that the seizure risk was actually 17% lower in ADHD patients while on medication. This difference fell just shy of statistical significance. The analysis was adjusted for gender, age, and time on ADHD medications.
However, Ms. Brikell and her coworkers also performed a separate analysis for each individual with ADHD in which they compared seizure rates when a given patient was on ADHD medication versus off medication, a design that controls for many of the potential confounding factors that can occur with observational data. The seizure risk proved to be 19% lower while an individual was on ADHD medication – and this difference was indeed statistically significant.
In an interview, Ms. Brikell noted that the Swedish data are confirmed by a much larger National Institute of Mental Health–sponsored American study she was involved with that is now under review for publication. The U.S. study, which used the enormous MarketScan private health insurance database, demonstrated with the power provided by very large patient numbers that the seizure risk was convincingly lower while dual-diagnosis patients were on ADHD medication than when they were off.
“It’s reassuring to see the same effect across two countries with such different health care systems,” she commented.
Epilepsy is known to be inherently associated with a threefold increased prevalence of ADHD.
Ms. Brikell’s study was funded by the Swedish Research Council, the U.S. National Institute of Mental Health, and the Swedish Initiative for Research on Microdata in the Social and Medical Sciences. She reported having no financial conflicts of interest.
AT THE ECNP CONGRESS
Key clinical point:
Major finding: Patients with ADHD and a history of epilepsy were at 19% lower risk of experiencing seizures while on ADHD medication than when off it.
Data source: This was an observational study of prospectively collected data on all of the nearly 40,000 Swedish patients with epilepsy born during 1976-2008.
Disclosures: The study was funded by the Swedish Research Council, the U.S. National Institute of Mental Health, and the Swedish Initiative for Research on Microdata in the Social and Medical Sciences. The presenter reported having no financial conflicts of interest.
Atypical Fibroxanthoma Arising Within Erosive Pustular Dermatosis of the Scalp
Atypical fibroxanthoma (AFX) is a low-grade dermal malignancy comprised of atypical spindle cells.1 Classified as a superficial fibrohistiocytic tumor with intermediate malignant potential, AFX has an incidence of approximately 0.24% worldwide.2 The tumor appears mainly on the head and neck in sun-exposed areas but can occur less frequently on the trunk and limbs in non–sun-exposed areas. There is a 70% to 80% predominance in men aged 69 to 77 years, with lesions primarily occurring in sun-exposed areas of the head and neck.3 A median period of 4 months between time of onset and time of diagnosis has been previously established.4
When AFX does occur in non–sun-exposed areas, it tends to be in a younger patient population. Clinically, it presents as a rather nondescript, firm, erythematous papule or nodule less than 2 cm in diameter. Atypical fibroxanthoma most often presents asymptomatically, but the tumor may ulcerate and bleed, though pain and pruritus are uncommon.5 Findings are nonspecific, and the diagnosis must be confirmed with biopsy, as it can resemble other common dermatological lesions. The pathogenesis of AFX has been controversial. Two different studies looked at AFX using electron microscopy and concluded that the tumor most closely resembled a myofibroblast,6,7 which is consistent with current thinking today.
Atypical fibroxanthoma is believed to be associated with p53 mutation and is closely linked with exposure to UV radiation due to its predominance in sun-exposed areas. Other predisposing factors may include prior exposure to UV radiation, history of organ transplantation, immunosuppression, advanced age in men, and xeroderma pigmentosum. The differential diagnosis for AFX encompasses basal cell carcinoma, squamous cell carcinoma, Merkel cell carcinoma, adnexal tumor, and pyogenic granuloma.
Case Report
On physical examination, the lesions appeared erosive with crusting and granulation tissue (Figure 1A). The presentation was consistent with erosive pustular dermatosis of the scalp. Biopsy revealed granulation tissue. The patient underwent PDT and prednisone treatment with improvement. Additional biopsies revealed AKs. His condition improved with 2 PDT sessions but never fully cleared. During the PDT sessions, the patient reported intense unilateral headaches without visual changes. The headaches were intermittent and not apparently related to the treatments. He was referred for a temporal artery biopsy and rebiopsy of the remaining lesion on the scalp. The temporal artery biopsy was negative. The lesion that remained was a large nodule on the vertex scalp, and biopsy revealed AFX.
Immunohistochemical marker studies for S-100 and cytokeratin were negative. Invasion into subcutaneous fat was encountered (Figure 2A). Highly atypical spindle cells and mitoses were present (Figure 2B). Neoplastic cells were noted adjacent to nerve (Figure 2C). Excision of the lesion was curative, and his symptoms of pain and erosive pustular dermatosis resolved weeks thereafter (Figure 1B). The area of erosive pustular dermatosis was not excised, but symptoms resolved weeks following excision of the AFX.
Comment
Our case of AFX is unique due to the patient’s atypical presentation of severe pain. Because AFX usually presents asymptomatically, pain is an uncommon symptom. Based on the histologic findings in our case, we suspected that neural involvement of the tumor most likely explained the intense pain that our patient experienced.
The presence of erosive pustular dermatosis of the scalp also is interesting in our case. This elderly man had an extensive history of actinic damage and had reported pustules, scaling, itching, and scabbing of the scalp. It is possible that erosive pustular dermatosis was superimposed over the tumor and could have been the reason that multiple biopsies were needed to eventually arrive at a diagnosis. The coexistence of the 2 entities suggests that the chronic actinic damage played a role in the etiology of both.
Classification
There is a question regarding nomenclature when discussing AFX. Atypical fibroxanthoma has been referred to as a variant of undifferentiated pleomorphic sarcoma, which is a type of soft tissue sarcoma. Atypical fibroxanthoma can be referred to as undifferentiated pleomorphic sarcoma if it is more than 2 cm in diameter, if it involves the fascia or subcutaneous tissue, or if there is evidence of necrosis.3 Atypical fibroxanthoma generally is confined to the head and neck region and usually is less than 2 cm in diameter. In this patient, the presentation was consistent with AFX, as there was evidence of necrosis and invasion into the subcutaneous fat. The fact that the lesion also appeared on the scalp further supported the diagnosis of AFX.
Pathology
Biopsy of AFX typically reveals a spindle cell proliferation that usually arises in the setting of profound actinic damage. The epidermis may or may not be ulcerated, and in most cases, it is seen in close proximity to the overlying epidermis but not arising from it.8 Classic AFX is composed of highly atypical histiocytelike (epithelioid) cells admixed with pleomorphic spindle cells and giant cells, all showing frequent mitoses including atypical ones.9 Several histologic subtypes of AFX have been described, including clear cell, granular cell, pigmented cell, chondroid, osteoid, osteoclastic, and the most common spindle cell subtype.9 Features that indicate potential aggressive behavior include infiltration into the subcutaneous tissue, vascular invasion, and presence of necrosis. A diagnosis of AFX is made by exclusion of other malignant neoplasms with similar morphology, namely spindle cell squamous cell carcinoma, spindle cell melanoma, and leiomyoscarcoma.9 As such, immunohistochemistry plays a critical role in distinguishing these lesions, as they arise as part of the differential diagnosis. A panel of immunohistochemical stains is helpful for diagnosis and commonly includes but is not limited to S-100, Melan-A, smooth muscle actin, desmin, and cytokeratin.
Sampling error is an inherent flaw in any biopsy specimen. The eventual diagnosis of AFX in our case supports the argument for multiple biopsies of an unknown lesion, seeing as the affected area was interpreted as both granulation tissue and AK prior to the eventual diagnosis. Repeat biopsies, especially if a lesion is nonhealing, often can help clinicians arrive at a definitive diagnosis.
Treatment
Different treatment options have been used to manage AFX. Mohs micrographic surgery is most often used because of its tissue-sparing potential, often giving the most cosmetically appealing result. Wide local excision is another surgical technique utilized, generally with fixed margins of at least 1 cm.10 Radiation at the tumor site is used as a treatment method but most often during cases of reoccurrence. Cryotherapy as well as electrodesiccation and curettage are possible treatment options but are not the standard of care.
- Helwig EB. Atypical fibroxanthoma, in tumor seminar. proceedings of 18th Annual Seminar of San Antonio Society of Pathologists, 1961. Tex State J Med. 1963;59:664-667.
- Anderson HL, Joseph AK. A pilot feasibility study of a rare skin tumor database. Dermatol Surg. 2007;33:693-696.
- Iorizzo LJ 3rd, Brown MD. Atypical fibroxanthoma: a review of the literature. Dermatol Surg. 2011;37:146-157.
- Fretzin DF, Helwig EB. Atypical fibroxanthoma of the skin. a clinicopathologic study of 140 cases. Cancer. 1973;31:1541-1552.
- Vandergriff TW, Reed JA, Orengo IF. An unusual presentation of atypical fibroxanthoma. Dermatol Online J. 2008;14:6.
- Weedon D, Kerr JF. Atypical fibroxanthoma of skin: an electron microscope study. Pathology. 1975;7:173-177.
- Woyke S, Domagala W, Olszewski W, et al. Pseudosarcoma of the skin. an electron microscopic study and comparison with the fine structure of spindle-cell variant of squamous carcinoma. Cancer. 1974;33:970-980.
- Edward S, Yung A. Essential Dermatopathology. Philadelphia, PA: Lippincott Williams & Wilkins; 2012.
- Luzar B, Calonje E. Morphologic and immunohistochemical characteristics of atypical fibroxanthoma with a special emphasis on potential diagnostic pitfalls: a review. J Cutan Pathol. 2010;37:301-309.
- González-García R, Nam-Cha SH, Muñoz-Guerra MF, et al. Atypical fibroxanthoma of the head and neck: report of 5 cases. J Oral Maxillofac Surg. 2007;65:526-531.
Atypical fibroxanthoma (AFX) is a low-grade dermal malignancy comprised of atypical spindle cells.1 Classified as a superficial fibrohistiocytic tumor with intermediate malignant potential, AFX has an incidence of approximately 0.24% worldwide.2 The tumor appears mainly on the head and neck in sun-exposed areas but can occur less frequently on the trunk and limbs in non–sun-exposed areas. There is a 70% to 80% predominance in men aged 69 to 77 years, with lesions primarily occurring in sun-exposed areas of the head and neck.3 A median period of 4 months between time of onset and time of diagnosis has been previously established.4
When AFX does occur in non–sun-exposed areas, it tends to be in a younger patient population. Clinically, it presents as a rather nondescript, firm, erythematous papule or nodule less than 2 cm in diameter. Atypical fibroxanthoma most often presents asymptomatically, but the tumor may ulcerate and bleed, though pain and pruritus are uncommon.5 Findings are nonspecific, and the diagnosis must be confirmed with biopsy, as it can resemble other common dermatological lesions. The pathogenesis of AFX has been controversial. Two different studies looked at AFX using electron microscopy and concluded that the tumor most closely resembled a myofibroblast,6,7 which is consistent with current thinking today.
Atypical fibroxanthoma is believed to be associated with p53 mutation and is closely linked with exposure to UV radiation due to its predominance in sun-exposed areas. Other predisposing factors may include prior exposure to UV radiation, history of organ transplantation, immunosuppression, advanced age in men, and xeroderma pigmentosum. The differential diagnosis for AFX encompasses basal cell carcinoma, squamous cell carcinoma, Merkel cell carcinoma, adnexal tumor, and pyogenic granuloma.
Case Report
On physical examination, the lesions appeared erosive with crusting and granulation tissue (Figure 1A). The presentation was consistent with erosive pustular dermatosis of the scalp. Biopsy revealed granulation tissue. The patient underwent PDT and prednisone treatment with improvement. Additional biopsies revealed AKs. His condition improved with 2 PDT sessions but never fully cleared. During the PDT sessions, the patient reported intense unilateral headaches without visual changes. The headaches were intermittent and not apparently related to the treatments. He was referred for a temporal artery biopsy and rebiopsy of the remaining lesion on the scalp. The temporal artery biopsy was negative. The lesion that remained was a large nodule on the vertex scalp, and biopsy revealed AFX.
Immunohistochemical marker studies for S-100 and cytokeratin were negative. Invasion into subcutaneous fat was encountered (Figure 2A). Highly atypical spindle cells and mitoses were present (Figure 2B). Neoplastic cells were noted adjacent to nerve (Figure 2C). Excision of the lesion was curative, and his symptoms of pain and erosive pustular dermatosis resolved weeks thereafter (Figure 1B). The area of erosive pustular dermatosis was not excised, but symptoms resolved weeks following excision of the AFX.
Comment
Our case of AFX is unique due to the patient’s atypical presentation of severe pain. Because AFX usually presents asymptomatically, pain is an uncommon symptom. Based on the histologic findings in our case, we suspected that neural involvement of the tumor most likely explained the intense pain that our patient experienced.
The presence of erosive pustular dermatosis of the scalp also is interesting in our case. This elderly man had an extensive history of actinic damage and had reported pustules, scaling, itching, and scabbing of the scalp. It is possible that erosive pustular dermatosis was superimposed over the tumor and could have been the reason that multiple biopsies were needed to eventually arrive at a diagnosis. The coexistence of the 2 entities suggests that the chronic actinic damage played a role in the etiology of both.
Classification
There is a question regarding nomenclature when discussing AFX. Atypical fibroxanthoma has been referred to as a variant of undifferentiated pleomorphic sarcoma, which is a type of soft tissue sarcoma. Atypical fibroxanthoma can be referred to as undifferentiated pleomorphic sarcoma if it is more than 2 cm in diameter, if it involves the fascia or subcutaneous tissue, or if there is evidence of necrosis.3 Atypical fibroxanthoma generally is confined to the head and neck region and usually is less than 2 cm in diameter. In this patient, the presentation was consistent with AFX, as there was evidence of necrosis and invasion into the subcutaneous fat. The fact that the lesion also appeared on the scalp further supported the diagnosis of AFX.
Pathology
Biopsy of AFX typically reveals a spindle cell proliferation that usually arises in the setting of profound actinic damage. The epidermis may or may not be ulcerated, and in most cases, it is seen in close proximity to the overlying epidermis but not arising from it.8 Classic AFX is composed of highly atypical histiocytelike (epithelioid) cells admixed with pleomorphic spindle cells and giant cells, all showing frequent mitoses including atypical ones.9 Several histologic subtypes of AFX have been described, including clear cell, granular cell, pigmented cell, chondroid, osteoid, osteoclastic, and the most common spindle cell subtype.9 Features that indicate potential aggressive behavior include infiltration into the subcutaneous tissue, vascular invasion, and presence of necrosis. A diagnosis of AFX is made by exclusion of other malignant neoplasms with similar morphology, namely spindle cell squamous cell carcinoma, spindle cell melanoma, and leiomyoscarcoma.9 As such, immunohistochemistry plays a critical role in distinguishing these lesions, as they arise as part of the differential diagnosis. A panel of immunohistochemical stains is helpful for diagnosis and commonly includes but is not limited to S-100, Melan-A, smooth muscle actin, desmin, and cytokeratin.
Sampling error is an inherent flaw in any biopsy specimen. The eventual diagnosis of AFX in our case supports the argument for multiple biopsies of an unknown lesion, seeing as the affected area was interpreted as both granulation tissue and AK prior to the eventual diagnosis. Repeat biopsies, especially if a lesion is nonhealing, often can help clinicians arrive at a definitive diagnosis.
Treatment
Different treatment options have been used to manage AFX. Mohs micrographic surgery is most often used because of its tissue-sparing potential, often giving the most cosmetically appealing result. Wide local excision is another surgical technique utilized, generally with fixed margins of at least 1 cm.10 Radiation at the tumor site is used as a treatment method but most often during cases of reoccurrence. Cryotherapy as well as electrodesiccation and curettage are possible treatment options but are not the standard of care.
Atypical fibroxanthoma (AFX) is a low-grade dermal malignancy comprised of atypical spindle cells.1 Classified as a superficial fibrohistiocytic tumor with intermediate malignant potential, AFX has an incidence of approximately 0.24% worldwide.2 The tumor appears mainly on the head and neck in sun-exposed areas but can occur less frequently on the trunk and limbs in non–sun-exposed areas. There is a 70% to 80% predominance in men aged 69 to 77 years, with lesions primarily occurring in sun-exposed areas of the head and neck.3 A median period of 4 months between time of onset and time of diagnosis has been previously established.4
When AFX does occur in non–sun-exposed areas, it tends to be in a younger patient population. Clinically, it presents as a rather nondescript, firm, erythematous papule or nodule less than 2 cm in diameter. Atypical fibroxanthoma most often presents asymptomatically, but the tumor may ulcerate and bleed, though pain and pruritus are uncommon.5 Findings are nonspecific, and the diagnosis must be confirmed with biopsy, as it can resemble other common dermatological lesions. The pathogenesis of AFX has been controversial. Two different studies looked at AFX using electron microscopy and concluded that the tumor most closely resembled a myofibroblast,6,7 which is consistent with current thinking today.
Atypical fibroxanthoma is believed to be associated with p53 mutation and is closely linked with exposure to UV radiation due to its predominance in sun-exposed areas. Other predisposing factors may include prior exposure to UV radiation, history of organ transplantation, immunosuppression, advanced age in men, and xeroderma pigmentosum. The differential diagnosis for AFX encompasses basal cell carcinoma, squamous cell carcinoma, Merkel cell carcinoma, adnexal tumor, and pyogenic granuloma.
Case Report
On physical examination, the lesions appeared erosive with crusting and granulation tissue (Figure 1A). The presentation was consistent with erosive pustular dermatosis of the scalp. Biopsy revealed granulation tissue. The patient underwent PDT and prednisone treatment with improvement. Additional biopsies revealed AKs. His condition improved with 2 PDT sessions but never fully cleared. During the PDT sessions, the patient reported intense unilateral headaches without visual changes. The headaches were intermittent and not apparently related to the treatments. He was referred for a temporal artery biopsy and rebiopsy of the remaining lesion on the scalp. The temporal artery biopsy was negative. The lesion that remained was a large nodule on the vertex scalp, and biopsy revealed AFX.
Immunohistochemical marker studies for S-100 and cytokeratin were negative. Invasion into subcutaneous fat was encountered (Figure 2A). Highly atypical spindle cells and mitoses were present (Figure 2B). Neoplastic cells were noted adjacent to nerve (Figure 2C). Excision of the lesion was curative, and his symptoms of pain and erosive pustular dermatosis resolved weeks thereafter (Figure 1B). The area of erosive pustular dermatosis was not excised, but symptoms resolved weeks following excision of the AFX.
Comment
Our case of AFX is unique due to the patient’s atypical presentation of severe pain. Because AFX usually presents asymptomatically, pain is an uncommon symptom. Based on the histologic findings in our case, we suspected that neural involvement of the tumor most likely explained the intense pain that our patient experienced.
The presence of erosive pustular dermatosis of the scalp also is interesting in our case. This elderly man had an extensive history of actinic damage and had reported pustules, scaling, itching, and scabbing of the scalp. It is possible that erosive pustular dermatosis was superimposed over the tumor and could have been the reason that multiple biopsies were needed to eventually arrive at a diagnosis. The coexistence of the 2 entities suggests that the chronic actinic damage played a role in the etiology of both.
Classification
There is a question regarding nomenclature when discussing AFX. Atypical fibroxanthoma has been referred to as a variant of undifferentiated pleomorphic sarcoma, which is a type of soft tissue sarcoma. Atypical fibroxanthoma can be referred to as undifferentiated pleomorphic sarcoma if it is more than 2 cm in diameter, if it involves the fascia or subcutaneous tissue, or if there is evidence of necrosis.3 Atypical fibroxanthoma generally is confined to the head and neck region and usually is less than 2 cm in diameter. In this patient, the presentation was consistent with AFX, as there was evidence of necrosis and invasion into the subcutaneous fat. The fact that the lesion also appeared on the scalp further supported the diagnosis of AFX.
Pathology
Biopsy of AFX typically reveals a spindle cell proliferation that usually arises in the setting of profound actinic damage. The epidermis may or may not be ulcerated, and in most cases, it is seen in close proximity to the overlying epidermis but not arising from it.8 Classic AFX is composed of highly atypical histiocytelike (epithelioid) cells admixed with pleomorphic spindle cells and giant cells, all showing frequent mitoses including atypical ones.9 Several histologic subtypes of AFX have been described, including clear cell, granular cell, pigmented cell, chondroid, osteoid, osteoclastic, and the most common spindle cell subtype.9 Features that indicate potential aggressive behavior include infiltration into the subcutaneous tissue, vascular invasion, and presence of necrosis. A diagnosis of AFX is made by exclusion of other malignant neoplasms with similar morphology, namely spindle cell squamous cell carcinoma, spindle cell melanoma, and leiomyoscarcoma.9 As such, immunohistochemistry plays a critical role in distinguishing these lesions, as they arise as part of the differential diagnosis. A panel of immunohistochemical stains is helpful for diagnosis and commonly includes but is not limited to S-100, Melan-A, smooth muscle actin, desmin, and cytokeratin.
Sampling error is an inherent flaw in any biopsy specimen. The eventual diagnosis of AFX in our case supports the argument for multiple biopsies of an unknown lesion, seeing as the affected area was interpreted as both granulation tissue and AK prior to the eventual diagnosis. Repeat biopsies, especially if a lesion is nonhealing, often can help clinicians arrive at a definitive diagnosis.
Treatment
Different treatment options have been used to manage AFX. Mohs micrographic surgery is most often used because of its tissue-sparing potential, often giving the most cosmetically appealing result. Wide local excision is another surgical technique utilized, generally with fixed margins of at least 1 cm.10 Radiation at the tumor site is used as a treatment method but most often during cases of reoccurrence. Cryotherapy as well as electrodesiccation and curettage are possible treatment options but are not the standard of care.
- Helwig EB. Atypical fibroxanthoma, in tumor seminar. proceedings of 18th Annual Seminar of San Antonio Society of Pathologists, 1961. Tex State J Med. 1963;59:664-667.
- Anderson HL, Joseph AK. A pilot feasibility study of a rare skin tumor database. Dermatol Surg. 2007;33:693-696.
- Iorizzo LJ 3rd, Brown MD. Atypical fibroxanthoma: a review of the literature. Dermatol Surg. 2011;37:146-157.
- Fretzin DF, Helwig EB. Atypical fibroxanthoma of the skin. a clinicopathologic study of 140 cases. Cancer. 1973;31:1541-1552.
- Vandergriff TW, Reed JA, Orengo IF. An unusual presentation of atypical fibroxanthoma. Dermatol Online J. 2008;14:6.
- Weedon D, Kerr JF. Atypical fibroxanthoma of skin: an electron microscope study. Pathology. 1975;7:173-177.
- Woyke S, Domagala W, Olszewski W, et al. Pseudosarcoma of the skin. an electron microscopic study and comparison with the fine structure of spindle-cell variant of squamous carcinoma. Cancer. 1974;33:970-980.
- Edward S, Yung A. Essential Dermatopathology. Philadelphia, PA: Lippincott Williams & Wilkins; 2012.
- Luzar B, Calonje E. Morphologic and immunohistochemical characteristics of atypical fibroxanthoma with a special emphasis on potential diagnostic pitfalls: a review. J Cutan Pathol. 2010;37:301-309.
- González-García R, Nam-Cha SH, Muñoz-Guerra MF, et al. Atypical fibroxanthoma of the head and neck: report of 5 cases. J Oral Maxillofac Surg. 2007;65:526-531.
- Helwig EB. Atypical fibroxanthoma, in tumor seminar. proceedings of 18th Annual Seminar of San Antonio Society of Pathologists, 1961. Tex State J Med. 1963;59:664-667.
- Anderson HL, Joseph AK. A pilot feasibility study of a rare skin tumor database. Dermatol Surg. 2007;33:693-696.
- Iorizzo LJ 3rd, Brown MD. Atypical fibroxanthoma: a review of the literature. Dermatol Surg. 2011;37:146-157.
- Fretzin DF, Helwig EB. Atypical fibroxanthoma of the skin. a clinicopathologic study of 140 cases. Cancer. 1973;31:1541-1552.
- Vandergriff TW, Reed JA, Orengo IF. An unusual presentation of atypical fibroxanthoma. Dermatol Online J. 2008;14:6.
- Weedon D, Kerr JF. Atypical fibroxanthoma of skin: an electron microscope study. Pathology. 1975;7:173-177.
- Woyke S, Domagala W, Olszewski W, et al. Pseudosarcoma of the skin. an electron microscopic study and comparison with the fine structure of spindle-cell variant of squamous carcinoma. Cancer. 1974;33:970-980.
- Edward S, Yung A. Essential Dermatopathology. Philadelphia, PA: Lippincott Williams & Wilkins; 2012.
- Luzar B, Calonje E. Morphologic and immunohistochemical characteristics of atypical fibroxanthoma with a special emphasis on potential diagnostic pitfalls: a review. J Cutan Pathol. 2010;37:301-309.
- González-García R, Nam-Cha SH, Muñoz-Guerra MF, et al. Atypical fibroxanthoma of the head and neck: report of 5 cases. J Oral Maxillofac Surg. 2007;65:526-531.
Practice Points
- Atypical fibroxanthoma predominantly occurs in older men on the head and neck.
- Erosive pustular dermatosis may be a benign entity, but if it does not resolve, continue to rebiopsy, as rare tumors may mimic this condition.
Clinicians: Be clear about flu vaccine’s value
WASHINGTON – Flu vaccination rates remain below the 70% Healthy People 2020 goal for most of the U.S. population, but data show that a recommendation from a clinician can encourage individuals to get vaccinated and to vaccinate their children, according to a panel of experts who spoke at a press briefing sponsored by the National Foundation for Infectious Diseases.
“Annual vaccination is our first line of defense against the flu,” William Schaffner, MD, of Vanderbilt University, Nashville, Tenn., said at the briefing. The unpredictable nature of the flu makes annual vaccination even more important – and the earlier, the better, said Dr. Schaffner. “If you have seen one flu season, you have seen ... one flu season.”
In a video interview at the briefing, experts emphasized the safety and effectiveness of the flu vaccine for a range of populations, including children, pregnant women, and older adults. And they offered tips to convince patients of the importance of vaccination, as well as the need to make sure health care staff are protected.
Briefing participants included former Department of Health and Human Services Secretary Thomas A. Price, MD; Patricia A. Stinchfield, RN, MS, CPNP, CIC of Children’s Hospitals and Clinics of Minnesota, St. Paul; Kathleen M. Neuzil, MD, of the University of Maryland; and Daniel B. Jernigan, MD, of the Centers for Disease Control and Prevention.
The clinicians interviewed had no financial conflicts to disclose.
WASHINGTON – Flu vaccination rates remain below the 70% Healthy People 2020 goal for most of the U.S. population, but data show that a recommendation from a clinician can encourage individuals to get vaccinated and to vaccinate their children, according to a panel of experts who spoke at a press briefing sponsored by the National Foundation for Infectious Diseases.
“Annual vaccination is our first line of defense against the flu,” William Schaffner, MD, of Vanderbilt University, Nashville, Tenn., said at the briefing. The unpredictable nature of the flu makes annual vaccination even more important – and the earlier, the better, said Dr. Schaffner. “If you have seen one flu season, you have seen ... one flu season.”
In a video interview at the briefing, experts emphasized the safety and effectiveness of the flu vaccine for a range of populations, including children, pregnant women, and older adults. And they offered tips to convince patients of the importance of vaccination, as well as the need to make sure health care staff are protected.
Briefing participants included former Department of Health and Human Services Secretary Thomas A. Price, MD; Patricia A. Stinchfield, RN, MS, CPNP, CIC of Children’s Hospitals and Clinics of Minnesota, St. Paul; Kathleen M. Neuzil, MD, of the University of Maryland; and Daniel B. Jernigan, MD, of the Centers for Disease Control and Prevention.
The clinicians interviewed had no financial conflicts to disclose.
WASHINGTON – Flu vaccination rates remain below the 70% Healthy People 2020 goal for most of the U.S. population, but data show that a recommendation from a clinician can encourage individuals to get vaccinated and to vaccinate their children, according to a panel of experts who spoke at a press briefing sponsored by the National Foundation for Infectious Diseases.
“Annual vaccination is our first line of defense against the flu,” William Schaffner, MD, of Vanderbilt University, Nashville, Tenn., said at the briefing. The unpredictable nature of the flu makes annual vaccination even more important – and the earlier, the better, said Dr. Schaffner. “If you have seen one flu season, you have seen ... one flu season.”
In a video interview at the briefing, experts emphasized the safety and effectiveness of the flu vaccine for a range of populations, including children, pregnant women, and older adults. And they offered tips to convince patients of the importance of vaccination, as well as the need to make sure health care staff are protected.
Briefing participants included former Department of Health and Human Services Secretary Thomas A. Price, MD; Patricia A. Stinchfield, RN, MS, CPNP, CIC of Children’s Hospitals and Clinics of Minnesota, St. Paul; Kathleen M. Neuzil, MD, of the University of Maryland; and Daniel B. Jernigan, MD, of the Centers for Disease Control and Prevention.
The clinicians interviewed had no financial conflicts to disclose.
AT A PRESS BRIEFING BY THE NATIONAL FOUNDATION FOR INFECTIOUS DISEASES
Deep brain stimulation shows promise in treating Tourette syndrome
Deep brain stimulation (DBS) showed promise in improving tic severity in patients with Tourette syndrome in a prospective, open-label registry study, but the treatment was associated with adverse events in a substantial number of patients.
“The first-year results of this multinational electronic collaboration strengthen the notion that DBS could be a potential surgical treatment for select patients with Tourette syndrome,” Daniel Martinez-Ramirez, MD, of the University of Florida, Gainesville, and his colleagues wrote in their study published online Jan. 16 in JAMA Neurology. “Practitioners should be aware of the high number of stimulation-related adverse events and that these are likely reversible.”
The research team studied data from 185 patients with bilateral Tourette syndrome in 10 countries who had undergone DBS implantation between Jan. 1, 2012, and Dec. 31, 2016, and found that DBS significantly improved the Yale Global Tic Severity Scale scores of patients in the study for both motor and phonic tics. Mean motor tic scores improved 38.2% at 6 months, compared with baseline, and 38.5% at 12 months. A similar effect was observed for phonic tic scores, with improvements of 44.2% and 42.7% at 6 and 12 months, compared with baseline, respectively. While there was slight variation between the 6- and 12-month follow-ups for both phonic and motor tic scores, these changes were not statistically significant.
Despite the improvement of Yale Global Tic Severity Scale scores, adverse events were prevalent among patients in the study. Of 158 patients, 56 (35.4%) reported a total of 160 adverse events during the first follow-up year. Of those events reported, 48 (30.8%) were stimulation related, while 6 (3.8%) were surgically related, and 2 (1.3%) were related to issues with the device. The most common adverse events were dysarthria, reported by 10 patients (6.3%), and paresthesias, reported by 13 patients (8.2%). These events were not permanent and did not involve any major complications.
There are a number of limitations when using data from a multinational registry and database, according to the authors. Using information from different sites may affect results because surgical and treatment techniques may differ by location. Additionally, the lack of standardized inclusion criteria for the registry may have affected the results.
Despite the study’s limitations and the adverse events were observed, DBS still appeared effective in improving motor and phonic tics in Tourette syndrome patients. With these results, Dr. Martinez-Ramirez and his associates recommended what needs to be done to further research into DBS.
“Larger numbers of patients will need to receive DBS implants across multiple targets, and comparison of center-to-center outcomes could help refine the therapy,” they wrote. “Publishing multiyear outcomes to a public website (https://tourettedeepbrainstimulationregistry.ese.ufhealth.org) will improve access to information, improve data sharing, and, we hope, contribute to improvement in outcomes.”
Two investigators reported receiving grants from various pharmaceutical companies, government agencies, and foundations. Both also served as consultants to major pharmaceutical companies. All other researchers had no relevant financial conflicts to disclose.
SOURCE: Martinez-Ramirez D et al. JAMA Neurol. 2018 Jan 16. doi: 10.1001/jamaneurol.2017.4317.
Deep brain stimulation (DBS) showed promise in improving tic severity in patients with Tourette syndrome in a prospective, open-label registry study, but the treatment was associated with adverse events in a substantial number of patients.
“The first-year results of this multinational electronic collaboration strengthen the notion that DBS could be a potential surgical treatment for select patients with Tourette syndrome,” Daniel Martinez-Ramirez, MD, of the University of Florida, Gainesville, and his colleagues wrote in their study published online Jan. 16 in JAMA Neurology. “Practitioners should be aware of the high number of stimulation-related adverse events and that these are likely reversible.”
The research team studied data from 185 patients with bilateral Tourette syndrome in 10 countries who had undergone DBS implantation between Jan. 1, 2012, and Dec. 31, 2016, and found that DBS significantly improved the Yale Global Tic Severity Scale scores of patients in the study for both motor and phonic tics. Mean motor tic scores improved 38.2% at 6 months, compared with baseline, and 38.5% at 12 months. A similar effect was observed for phonic tic scores, with improvements of 44.2% and 42.7% at 6 and 12 months, compared with baseline, respectively. While there was slight variation between the 6- and 12-month follow-ups for both phonic and motor tic scores, these changes were not statistically significant.
Despite the improvement of Yale Global Tic Severity Scale scores, adverse events were prevalent among patients in the study. Of 158 patients, 56 (35.4%) reported a total of 160 adverse events during the first follow-up year. Of those events reported, 48 (30.8%) were stimulation related, while 6 (3.8%) were surgically related, and 2 (1.3%) were related to issues with the device. The most common adverse events were dysarthria, reported by 10 patients (6.3%), and paresthesias, reported by 13 patients (8.2%). These events were not permanent and did not involve any major complications.
There are a number of limitations when using data from a multinational registry and database, according to the authors. Using information from different sites may affect results because surgical and treatment techniques may differ by location. Additionally, the lack of standardized inclusion criteria for the registry may have affected the results.
Despite the study’s limitations and the adverse events were observed, DBS still appeared effective in improving motor and phonic tics in Tourette syndrome patients. With these results, Dr. Martinez-Ramirez and his associates recommended what needs to be done to further research into DBS.
“Larger numbers of patients will need to receive DBS implants across multiple targets, and comparison of center-to-center outcomes could help refine the therapy,” they wrote. “Publishing multiyear outcomes to a public website (https://tourettedeepbrainstimulationregistry.ese.ufhealth.org) will improve access to information, improve data sharing, and, we hope, contribute to improvement in outcomes.”
Two investigators reported receiving grants from various pharmaceutical companies, government agencies, and foundations. Both also served as consultants to major pharmaceutical companies. All other researchers had no relevant financial conflicts to disclose.
SOURCE: Martinez-Ramirez D et al. JAMA Neurol. 2018 Jan 16. doi: 10.1001/jamaneurol.2017.4317.
Deep brain stimulation (DBS) showed promise in improving tic severity in patients with Tourette syndrome in a prospective, open-label registry study, but the treatment was associated with adverse events in a substantial number of patients.
“The first-year results of this multinational electronic collaboration strengthen the notion that DBS could be a potential surgical treatment for select patients with Tourette syndrome,” Daniel Martinez-Ramirez, MD, of the University of Florida, Gainesville, and his colleagues wrote in their study published online Jan. 16 in JAMA Neurology. “Practitioners should be aware of the high number of stimulation-related adverse events and that these are likely reversible.”
The research team studied data from 185 patients with bilateral Tourette syndrome in 10 countries who had undergone DBS implantation between Jan. 1, 2012, and Dec. 31, 2016, and found that DBS significantly improved the Yale Global Tic Severity Scale scores of patients in the study for both motor and phonic tics. Mean motor tic scores improved 38.2% at 6 months, compared with baseline, and 38.5% at 12 months. A similar effect was observed for phonic tic scores, with improvements of 44.2% and 42.7% at 6 and 12 months, compared with baseline, respectively. While there was slight variation between the 6- and 12-month follow-ups for both phonic and motor tic scores, these changes were not statistically significant.
Despite the improvement of Yale Global Tic Severity Scale scores, adverse events were prevalent among patients in the study. Of 158 patients, 56 (35.4%) reported a total of 160 adverse events during the first follow-up year. Of those events reported, 48 (30.8%) were stimulation related, while 6 (3.8%) were surgically related, and 2 (1.3%) were related to issues with the device. The most common adverse events were dysarthria, reported by 10 patients (6.3%), and paresthesias, reported by 13 patients (8.2%). These events were not permanent and did not involve any major complications.
There are a number of limitations when using data from a multinational registry and database, according to the authors. Using information from different sites may affect results because surgical and treatment techniques may differ by location. Additionally, the lack of standardized inclusion criteria for the registry may have affected the results.
Despite the study’s limitations and the adverse events were observed, DBS still appeared effective in improving motor and phonic tics in Tourette syndrome patients. With these results, Dr. Martinez-Ramirez and his associates recommended what needs to be done to further research into DBS.
“Larger numbers of patients will need to receive DBS implants across multiple targets, and comparison of center-to-center outcomes could help refine the therapy,” they wrote. “Publishing multiyear outcomes to a public website (https://tourettedeepbrainstimulationregistry.ese.ufhealth.org) will improve access to information, improve data sharing, and, we hope, contribute to improvement in outcomes.”
Two investigators reported receiving grants from various pharmaceutical companies, government agencies, and foundations. Both also served as consultants to major pharmaceutical companies. All other researchers had no relevant financial conflicts to disclose.
SOURCE: Martinez-Ramirez D et al. JAMA Neurol. 2018 Jan 16. doi: 10.1001/jamaneurol.2017.4317.
FROM JAMA NEUROLOGY
Key clinical point: Deep brain stimulation improved motor and phonic tics in Tourette syndrome patients but may come with a substantial number of reversible adverse events.
Major finding: At a 6-month follow-up, motor and phonic Yale Global Tic Severity Scale scores improved 38.2% and 44.2%, respectively.
Study details: Analysis of 185 patients with medically refractory Tourette syndrome who underwent deep brain stimulation implantation between Jan. 1, 2012, and Dec. 31, 2016, at 31 sites in 10 countries.
Disclosures: Two investigators reported receiving grants from various pharmaceutical companies, government agencies, and foundations. Both also served as consultants to major pharmaceutical companies. All other researchers reported no relevant financial disclosures.
Source: Martinez-Ramirez D et al. JAMA Neurol. 2018 Jan 16. doi: 10.1001/jamaneurol.2017.4317.
Swedish study finds low risk of developing psoriasis in bariatric surgery patients
Obese patients who undergo bariatric surgery have a lower risk of later developing psoriasis, according to results of nonrandomized, longitudinal intervention trial.
Cristina Maglio, MD, of the University of Gothenburg, Sweden, and her associates found that over a 26-year follow-up period, the adjusted hazard ratio (HR) of developing psoriasis was 0.65 (95% confidence interval [CI], 0.47-0.89; P = .008) for patients who underwent bariatric surgery, compared with those who received conventional, nonsurgical obesity treatments. Psoriasis developed in 3.6% of 1,991 patients in the surgery group during follow-up and in 5.1% of 2,018 control patients during follow-up.
Conversely, the difference in the risk of developing psoriatic arthritis (PsA), experienced by up to one-third of patients with psoriasis, was not statistically significant (HR, 0.77; 95% CI, 0.43-1.37; P = .287). PsA developed in 1% of subjects from the surgery group and 1.3% from the control group.
To understand how surgery affected the development of psoriasis or psoriatic arthritis, the researchers conducted a trial with a control group and surgery group. In the control group, 2,018 patients received standard obesity treatments that included recommendations on eating behavior, food selection, and physical activity. The 1,991 patients in the surgery group underwent gastric banding (375), vertical banded gastroplasty (1,354), or gastric bypass (262). At the start of the study, patients were evaluated for baseline measurements, then again at 6 months. After the 6-month mark, patients were reevaluated at 1, 2, 3, 4, 6, 8, 10, 15, and 20 years, respectively. All study participants, regardless of trial group, were examined and presented patient health questionnaires at each follow-up. The endpoint for this study was the first diagnosis of either psoriasis or PsA. Body mass index decreased significantly in the surgery group, compared with virtually no change in the control group.
Vertical banded gastroplasty was found to significantly lower the incidence of psoriasis, compared with usual treatment. But using gastric banding as a reference, vertical banded gastroplasty (HR, 0.80; 95% CI, 0.46-1.39; P = .418) and gastric bypass (HR, 0.71; 95% CI, 0.29-1.71; P = 0.439) were found to have similar effects on the prevention of psoriasis.
The researchers also identified several risk factors that significantly increased the risk of developing psoriasis. Smoking (HR, 1.75; 95% CI, 1.26-2.42; P = .001), a known risk factor in the development of psoriasis, and the length of time a patient had been obese (HR, 1.28; 95% CI, 1.05-1.55; P = .014) were found to be independently associated with an increased risk of psoriasis.
As part of their risk analysis, Dr. Maglio and her colleagues analyzed the interactions of baseline risk factors such as BMI and obesity duration with the bariatric surgery. This analysis found no significant interactions between baseline risk factors and bariatric surgery. It did reveal that patients who were older at baseline evaluation had slightly better responses to bariatric surgery with lower incidences of psoriasis, compared with younger patients, but the differences were not statistically significant.
“The preventive role of bariatric surgery on the risk of psoriasis has been recently highlighted by a retrospective Danish study (JAMA Surg. 2017 Apr 1;152[4]:344-9),” noted Dr. Maglio and her colleagues. “However, we lent strength to the previous results by confirming this association in a large prospective intervention trial designed to examine the effect of bariatric surgery on obesity-related comorbidities in comparison with usual obesity care.
This study was funded in part by the National Institutes of Diabetes and Digestive and Kidney Diseases, the Swedish Rheumatism association, the Swedish Research Council, the University of Gothenburg, and the Swedish federal government. Dr. Anna Rudin reported that part of her salary at Sahlgrenska University is supported by a grant from AstraZeneca. Dr. Lena M.S. Carlsson has received lecture fees from AstraZeneca, Johnson & Johnson, and Merck Sharp and Dohme. Dr. Maglio and Dr. Markku Peltonen had no relevant financial disclosures.
SOURCE: Maglio et al. Obesity. 2017. Dec; 25[12]:2068-73.
Obese patients who undergo bariatric surgery have a lower risk of later developing psoriasis, according to results of nonrandomized, longitudinal intervention trial.
Cristina Maglio, MD, of the University of Gothenburg, Sweden, and her associates found that over a 26-year follow-up period, the adjusted hazard ratio (HR) of developing psoriasis was 0.65 (95% confidence interval [CI], 0.47-0.89; P = .008) for patients who underwent bariatric surgery, compared with those who received conventional, nonsurgical obesity treatments. Psoriasis developed in 3.6% of 1,991 patients in the surgery group during follow-up and in 5.1% of 2,018 control patients during follow-up.
Conversely, the difference in the risk of developing psoriatic arthritis (PsA), experienced by up to one-third of patients with psoriasis, was not statistically significant (HR, 0.77; 95% CI, 0.43-1.37; P = .287). PsA developed in 1% of subjects from the surgery group and 1.3% from the control group.
To understand how surgery affected the development of psoriasis or psoriatic arthritis, the researchers conducted a trial with a control group and surgery group. In the control group, 2,018 patients received standard obesity treatments that included recommendations on eating behavior, food selection, and physical activity. The 1,991 patients in the surgery group underwent gastric banding (375), vertical banded gastroplasty (1,354), or gastric bypass (262). At the start of the study, patients were evaluated for baseline measurements, then again at 6 months. After the 6-month mark, patients were reevaluated at 1, 2, 3, 4, 6, 8, 10, 15, and 20 years, respectively. All study participants, regardless of trial group, were examined and presented patient health questionnaires at each follow-up. The endpoint for this study was the first diagnosis of either psoriasis or PsA. Body mass index decreased significantly in the surgery group, compared with virtually no change in the control group.
Vertical banded gastroplasty was found to significantly lower the incidence of psoriasis, compared with usual treatment. But using gastric banding as a reference, vertical banded gastroplasty (HR, 0.80; 95% CI, 0.46-1.39; P = .418) and gastric bypass (HR, 0.71; 95% CI, 0.29-1.71; P = 0.439) were found to have similar effects on the prevention of psoriasis.
The researchers also identified several risk factors that significantly increased the risk of developing psoriasis. Smoking (HR, 1.75; 95% CI, 1.26-2.42; P = .001), a known risk factor in the development of psoriasis, and the length of time a patient had been obese (HR, 1.28; 95% CI, 1.05-1.55; P = .014) were found to be independently associated with an increased risk of psoriasis.
As part of their risk analysis, Dr. Maglio and her colleagues analyzed the interactions of baseline risk factors such as BMI and obesity duration with the bariatric surgery. This analysis found no significant interactions between baseline risk factors and bariatric surgery. It did reveal that patients who were older at baseline evaluation had slightly better responses to bariatric surgery with lower incidences of psoriasis, compared with younger patients, but the differences were not statistically significant.
“The preventive role of bariatric surgery on the risk of psoriasis has been recently highlighted by a retrospective Danish study (JAMA Surg. 2017 Apr 1;152[4]:344-9),” noted Dr. Maglio and her colleagues. “However, we lent strength to the previous results by confirming this association in a large prospective intervention trial designed to examine the effect of bariatric surgery on obesity-related comorbidities in comparison with usual obesity care.
This study was funded in part by the National Institutes of Diabetes and Digestive and Kidney Diseases, the Swedish Rheumatism association, the Swedish Research Council, the University of Gothenburg, and the Swedish federal government. Dr. Anna Rudin reported that part of her salary at Sahlgrenska University is supported by a grant from AstraZeneca. Dr. Lena M.S. Carlsson has received lecture fees from AstraZeneca, Johnson & Johnson, and Merck Sharp and Dohme. Dr. Maglio and Dr. Markku Peltonen had no relevant financial disclosures.
SOURCE: Maglio et al. Obesity. 2017. Dec; 25[12]:2068-73.
Obese patients who undergo bariatric surgery have a lower risk of later developing psoriasis, according to results of nonrandomized, longitudinal intervention trial.
Cristina Maglio, MD, of the University of Gothenburg, Sweden, and her associates found that over a 26-year follow-up period, the adjusted hazard ratio (HR) of developing psoriasis was 0.65 (95% confidence interval [CI], 0.47-0.89; P = .008) for patients who underwent bariatric surgery, compared with those who received conventional, nonsurgical obesity treatments. Psoriasis developed in 3.6% of 1,991 patients in the surgery group during follow-up and in 5.1% of 2,018 control patients during follow-up.
Conversely, the difference in the risk of developing psoriatic arthritis (PsA), experienced by up to one-third of patients with psoriasis, was not statistically significant (HR, 0.77; 95% CI, 0.43-1.37; P = .287). PsA developed in 1% of subjects from the surgery group and 1.3% from the control group.
To understand how surgery affected the development of psoriasis or psoriatic arthritis, the researchers conducted a trial with a control group and surgery group. In the control group, 2,018 patients received standard obesity treatments that included recommendations on eating behavior, food selection, and physical activity. The 1,991 patients in the surgery group underwent gastric banding (375), vertical banded gastroplasty (1,354), or gastric bypass (262). At the start of the study, patients were evaluated for baseline measurements, then again at 6 months. After the 6-month mark, patients were reevaluated at 1, 2, 3, 4, 6, 8, 10, 15, and 20 years, respectively. All study participants, regardless of trial group, were examined and presented patient health questionnaires at each follow-up. The endpoint for this study was the first diagnosis of either psoriasis or PsA. Body mass index decreased significantly in the surgery group, compared with virtually no change in the control group.
Vertical banded gastroplasty was found to significantly lower the incidence of psoriasis, compared with usual treatment. But using gastric banding as a reference, vertical banded gastroplasty (HR, 0.80; 95% CI, 0.46-1.39; P = .418) and gastric bypass (HR, 0.71; 95% CI, 0.29-1.71; P = 0.439) were found to have similar effects on the prevention of psoriasis.
The researchers also identified several risk factors that significantly increased the risk of developing psoriasis. Smoking (HR, 1.75; 95% CI, 1.26-2.42; P = .001), a known risk factor in the development of psoriasis, and the length of time a patient had been obese (HR, 1.28; 95% CI, 1.05-1.55; P = .014) were found to be independently associated with an increased risk of psoriasis.
As part of their risk analysis, Dr. Maglio and her colleagues analyzed the interactions of baseline risk factors such as BMI and obesity duration with the bariatric surgery. This analysis found no significant interactions between baseline risk factors and bariatric surgery. It did reveal that patients who were older at baseline evaluation had slightly better responses to bariatric surgery with lower incidences of psoriasis, compared with younger patients, but the differences were not statistically significant.
“The preventive role of bariatric surgery on the risk of psoriasis has been recently highlighted by a retrospective Danish study (JAMA Surg. 2017 Apr 1;152[4]:344-9),” noted Dr. Maglio and her colleagues. “However, we lent strength to the previous results by confirming this association in a large prospective intervention trial designed to examine the effect of bariatric surgery on obesity-related comorbidities in comparison with usual obesity care.
This study was funded in part by the National Institutes of Diabetes and Digestive and Kidney Diseases, the Swedish Rheumatism association, the Swedish Research Council, the University of Gothenburg, and the Swedish federal government. Dr. Anna Rudin reported that part of her salary at Sahlgrenska University is supported by a grant from AstraZeneca. Dr. Lena M.S. Carlsson has received lecture fees from AstraZeneca, Johnson & Johnson, and Merck Sharp and Dohme. Dr. Maglio and Dr. Markku Peltonen had no relevant financial disclosures.
SOURCE: Maglio et al. Obesity. 2017. Dec; 25[12]:2068-73.
FROM OBESITY
Key clinical point:
Major finding: Obese patients who underwent bariatric surgery had a lower incidence of psoriasis over a 26-year period (HR, 0.65; 95% CI: 0.47-0.89; P = .008), compared with usual care.
Study details: Swedish Obese Subjects study, a longitudinal, nonrandomized intervention trial comprising 1,991 surgery group patients and 2,018 control patients.
Disclosures: This study was funded in part by the National Institutes of Diabetes and Digestive and Kidney Diseases, the Swedish Rheumatism association, the Swedish Research Council, the University of Gothenburg, and the Swedish federal government. Dr. Anna Rudin reported that part of her salary at Sahlgrenska University is supported by a grant from AstraZeneca. Dr. Lena M.S. Carlsson has received lecture fees from AstraZeneca, Johnson & Johnson, and Merck Sharp and Dohme. Dr. Maglio and Dr. Markku Peltonen had no relevant financial disclosures.
Source: Maglio et al. Obesity. 2017. Dec; 25[12]:2068-2073.
Early start to puberty increases likelihood of depression in girls
, a prospective study found
“Earlier pubertal timing in girls is often accompanied by distinct rises in the prevalence, severity, and onset of psychopathology,” wrote Jane Mendle, PhD, of Cornell University, Ithaca, N.Y., and her associates. “It is difficult to know whether, when, and on what processes to intervene if we cannot establish how much pubertal timing matters for well-being later in life.”
Patients were evaluated in four waves, with average ages of 15.8 years, 16.1 years, 21.7 years, and 28.7 years for waves one through four, respectively.
Symptoms for depression and antisocial behavior were evaluated using the Center for Epidemiologic Studies Depression Scale, a self-reported survey, and a self-reported questionnaire on recent antisocial behaviors including theft, property damage, and selling drugs. The youngest girls also were asked about running away from home, lying to parents, shoplifting, and driving a car without the owner’s permission, while the oldest participants were asked about deliberately writing a bad check, using someone else’s debit card without permission, and buying or selling stolen property. Those participating were mostly white (66%) and on average experienced menarche at age 12 years.
Older age at menarche was significantly associated with lower levels of symptoms of depression (b = –0.87, P less than .05), when data were analyzed in a proximal influences model.
“To illustrate, a girl who reached menarche at age 10 years (approximately 2 years earlier than the mean) would have depressive symptoms 8% of 1 SD [standard deviation] greater in adolescence, whereas a girl who reached menarche at age 8 years would have depressive symptoms 25% of 1 SD greater,” the investigators wrote.
A linear and quadratic association between early menarche and depressive symptoms persisted as patients reached their 30s, suggesting girls who matured earlier are more likely to display symptoms of depression as an adult because they became depressed as teenagers and they remain vulnerable, Dr. Mendle and her colleagues reported.
Early maturation also was associated with a higher frequency of antisocial behavior in both proximal (b = –.009, P less than .05) and lingering (b = –0.02, P less than .05) models.
Dr. Mendle and her colleagues found the gap in antisocial activity between those who matured early and those who did not was more pronounced in adulthood than adolescence, and the effects of antisocial behavior were smaller than the effects of depressive symptoms.
The investigators said they were limited by an incomplete understanding of why these longitudinal effects continue. Also, because they used age at menarche as an indicator of pubertal timing, the investigators said they could not capture the social, emotional, or hormonal processes present earlier in puberty.
“Results from the current study suggest that girls who experienced earlier menarche continued to report elevated psychopathology in early-to-middle adulthood even after accounting for demographic and contextual variables commonly associated with vulnerability for mental health. These findings align with the broad body of work linking early puberty with higher psychopathology during adolescence as well as with the few studies showing longer-term associations with mental health in adulthood,” Dr. Mendle and her associates wrote.
“Understanding the longevity of these associations offers new challenges to researchers, [and] practical information for pediatricians and adolescent health care providers, and highlights that the emotional sequelae of puberty may endure well past the proximal period of adolescence,” they concluded. There also may be other disorders beyond depression and antisocial behavior associated with early puberty, which should be explored.
This study was funded by the National Institutes of Health. The investigators reported no relevant financial disclosures.
SOURCE: Mendle J et al. Pediatrics. 2017 Dec 26. doi: 10.1542/peds.2017-1703.
Puberty is a complex time for teenagers, especially young girls, and biological factors and chronic stress such as early childhood abuse or neglect can lead to the early onset of puberty, and subsequently depression and antisocial behavior. A link between obesity and an early start to puberty has been established in previous studies as well.
Adding poor body image and possible bullying to the stresses of puberty can create an increased risk for mental health problems. There are also the added pressures of looking older physically, but socially not having matured enough; young girls may seek out friends who are older than them to fit in with peers who look like them, and then feel pressured to engage in risky activities to fit in.
It is important for us as pediatricians to intervene when these situations arise. Having a thorough history of trauma when counseling patients on their pubescent time line can be essential. Screen for depression and antisocial behavior in girls with early puberty, and refer to developmentally appropriate community and mental health resources for additional support if necessary. Talk with parents about close monitoring of friend groups and about encouraging their children to spend time with age-appropriate friends. Our mission is to guide children and adolescents into healthy adulthood.
Ellen Selkie, MD, MPH, is an adolescent medicine specialist at the University of Michigan, Ann Arbor. She commented on the article by Mendle et al. in an accompanying editorial (Pediatrics. 2017 Jan 1. doi: 10.1542/peds.2017-3460 .) She had no relevant financial disclosures.
Puberty is a complex time for teenagers, especially young girls, and biological factors and chronic stress such as early childhood abuse or neglect can lead to the early onset of puberty, and subsequently depression and antisocial behavior. A link between obesity and an early start to puberty has been established in previous studies as well.
Adding poor body image and possible bullying to the stresses of puberty can create an increased risk for mental health problems. There are also the added pressures of looking older physically, but socially not having matured enough; young girls may seek out friends who are older than them to fit in with peers who look like them, and then feel pressured to engage in risky activities to fit in.
It is important for us as pediatricians to intervene when these situations arise. Having a thorough history of trauma when counseling patients on their pubescent time line can be essential. Screen for depression and antisocial behavior in girls with early puberty, and refer to developmentally appropriate community and mental health resources for additional support if necessary. Talk with parents about close monitoring of friend groups and about encouraging their children to spend time with age-appropriate friends. Our mission is to guide children and adolescents into healthy adulthood.
Ellen Selkie, MD, MPH, is an adolescent medicine specialist at the University of Michigan, Ann Arbor. She commented on the article by Mendle et al. in an accompanying editorial (Pediatrics. 2017 Jan 1. doi: 10.1542/peds.2017-3460 .) She had no relevant financial disclosures.
Puberty is a complex time for teenagers, especially young girls, and biological factors and chronic stress such as early childhood abuse or neglect can lead to the early onset of puberty, and subsequently depression and antisocial behavior. A link between obesity and an early start to puberty has been established in previous studies as well.
Adding poor body image and possible bullying to the stresses of puberty can create an increased risk for mental health problems. There are also the added pressures of looking older physically, but socially not having matured enough; young girls may seek out friends who are older than them to fit in with peers who look like them, and then feel pressured to engage in risky activities to fit in.
It is important for us as pediatricians to intervene when these situations arise. Having a thorough history of trauma when counseling patients on their pubescent time line can be essential. Screen for depression and antisocial behavior in girls with early puberty, and refer to developmentally appropriate community and mental health resources for additional support if necessary. Talk with parents about close monitoring of friend groups and about encouraging their children to spend time with age-appropriate friends. Our mission is to guide children and adolescents into healthy adulthood.
Ellen Selkie, MD, MPH, is an adolescent medicine specialist at the University of Michigan, Ann Arbor. She commented on the article by Mendle et al. in an accompanying editorial (Pediatrics. 2017 Jan 1. doi: 10.1542/peds.2017-3460 .) She had no relevant financial disclosures.
, a prospective study found
“Earlier pubertal timing in girls is often accompanied by distinct rises in the prevalence, severity, and onset of psychopathology,” wrote Jane Mendle, PhD, of Cornell University, Ithaca, N.Y., and her associates. “It is difficult to know whether, when, and on what processes to intervene if we cannot establish how much pubertal timing matters for well-being later in life.”
Patients were evaluated in four waves, with average ages of 15.8 years, 16.1 years, 21.7 years, and 28.7 years for waves one through four, respectively.
Symptoms for depression and antisocial behavior were evaluated using the Center for Epidemiologic Studies Depression Scale, a self-reported survey, and a self-reported questionnaire on recent antisocial behaviors including theft, property damage, and selling drugs. The youngest girls also were asked about running away from home, lying to parents, shoplifting, and driving a car without the owner’s permission, while the oldest participants were asked about deliberately writing a bad check, using someone else’s debit card without permission, and buying or selling stolen property. Those participating were mostly white (66%) and on average experienced menarche at age 12 years.
Older age at menarche was significantly associated with lower levels of symptoms of depression (b = –0.87, P less than .05), when data were analyzed in a proximal influences model.
“To illustrate, a girl who reached menarche at age 10 years (approximately 2 years earlier than the mean) would have depressive symptoms 8% of 1 SD [standard deviation] greater in adolescence, whereas a girl who reached menarche at age 8 years would have depressive symptoms 25% of 1 SD greater,” the investigators wrote.
A linear and quadratic association between early menarche and depressive symptoms persisted as patients reached their 30s, suggesting girls who matured earlier are more likely to display symptoms of depression as an adult because they became depressed as teenagers and they remain vulnerable, Dr. Mendle and her colleagues reported.
Early maturation also was associated with a higher frequency of antisocial behavior in both proximal (b = –.009, P less than .05) and lingering (b = –0.02, P less than .05) models.
Dr. Mendle and her colleagues found the gap in antisocial activity between those who matured early and those who did not was more pronounced in adulthood than adolescence, and the effects of antisocial behavior were smaller than the effects of depressive symptoms.
The investigators said they were limited by an incomplete understanding of why these longitudinal effects continue. Also, because they used age at menarche as an indicator of pubertal timing, the investigators said they could not capture the social, emotional, or hormonal processes present earlier in puberty.
“Results from the current study suggest that girls who experienced earlier menarche continued to report elevated psychopathology in early-to-middle adulthood even after accounting for demographic and contextual variables commonly associated with vulnerability for mental health. These findings align with the broad body of work linking early puberty with higher psychopathology during adolescence as well as with the few studies showing longer-term associations with mental health in adulthood,” Dr. Mendle and her associates wrote.
“Understanding the longevity of these associations offers new challenges to researchers, [and] practical information for pediatricians and adolescent health care providers, and highlights that the emotional sequelae of puberty may endure well past the proximal period of adolescence,” they concluded. There also may be other disorders beyond depression and antisocial behavior associated with early puberty, which should be explored.
This study was funded by the National Institutes of Health. The investigators reported no relevant financial disclosures.
SOURCE: Mendle J et al. Pediatrics. 2017 Dec 26. doi: 10.1542/peds.2017-1703.
, a prospective study found
“Earlier pubertal timing in girls is often accompanied by distinct rises in the prevalence, severity, and onset of psychopathology,” wrote Jane Mendle, PhD, of Cornell University, Ithaca, N.Y., and her associates. “It is difficult to know whether, when, and on what processes to intervene if we cannot establish how much pubertal timing matters for well-being later in life.”
Patients were evaluated in four waves, with average ages of 15.8 years, 16.1 years, 21.7 years, and 28.7 years for waves one through four, respectively.
Symptoms for depression and antisocial behavior were evaluated using the Center for Epidemiologic Studies Depression Scale, a self-reported survey, and a self-reported questionnaire on recent antisocial behaviors including theft, property damage, and selling drugs. The youngest girls also were asked about running away from home, lying to parents, shoplifting, and driving a car without the owner’s permission, while the oldest participants were asked about deliberately writing a bad check, using someone else’s debit card without permission, and buying or selling stolen property. Those participating were mostly white (66%) and on average experienced menarche at age 12 years.
Older age at menarche was significantly associated with lower levels of symptoms of depression (b = –0.87, P less than .05), when data were analyzed in a proximal influences model.
“To illustrate, a girl who reached menarche at age 10 years (approximately 2 years earlier than the mean) would have depressive symptoms 8% of 1 SD [standard deviation] greater in adolescence, whereas a girl who reached menarche at age 8 years would have depressive symptoms 25% of 1 SD greater,” the investigators wrote.
A linear and quadratic association between early menarche and depressive symptoms persisted as patients reached their 30s, suggesting girls who matured earlier are more likely to display symptoms of depression as an adult because they became depressed as teenagers and they remain vulnerable, Dr. Mendle and her colleagues reported.
Early maturation also was associated with a higher frequency of antisocial behavior in both proximal (b = –.009, P less than .05) and lingering (b = –0.02, P less than .05) models.
Dr. Mendle and her colleagues found the gap in antisocial activity between those who matured early and those who did not was more pronounced in adulthood than adolescence, and the effects of antisocial behavior were smaller than the effects of depressive symptoms.
The investigators said they were limited by an incomplete understanding of why these longitudinal effects continue. Also, because they used age at menarche as an indicator of pubertal timing, the investigators said they could not capture the social, emotional, or hormonal processes present earlier in puberty.
“Results from the current study suggest that girls who experienced earlier menarche continued to report elevated psychopathology in early-to-middle adulthood even after accounting for demographic and contextual variables commonly associated with vulnerability for mental health. These findings align with the broad body of work linking early puberty with higher psychopathology during adolescence as well as with the few studies showing longer-term associations with mental health in adulthood,” Dr. Mendle and her associates wrote.
“Understanding the longevity of these associations offers new challenges to researchers, [and] practical information for pediatricians and adolescent health care providers, and highlights that the emotional sequelae of puberty may endure well past the proximal period of adolescence,” they concluded. There also may be other disorders beyond depression and antisocial behavior associated with early puberty, which should be explored.
This study was funded by the National Institutes of Health. The investigators reported no relevant financial disclosures.
SOURCE: Mendle J et al. Pediatrics. 2017 Dec 26. doi: 10.1542/peds.2017-1703.
FROM PEDIATRICS
Key clinical point: Girls who start puberty earlier are more likely to develop depression or antisocial behavior.
Major finding: Patients who reached menarche at 8 years of age showed depressive symptoms 25% of 1 standard deviation greater than those at 12 years of age.
Study details: A prospective study of 7,802 women gathered from the National Longitudinal Study of Adolescent Health between 1994 and 2008.
Disclosures: The investigators reported no relevant financial disclosures. This study was funded by the National Institutes of Health.Source: Mendle J et al. Pediatrics. 2017 Dec 26. doi: 10.1542/peds.2017-1703.
