CHICAGO – Acute kidney injury (AKI) doubles the risk of death among patients hospitalized for acute pancreatitis, Kalpit Devani, MD, reported at the annual Digestive Disease Week^®.

This severe complication of acute pancreatitis also significantly increases the length of stay and drives up hospital costs, said Dr. Devani of East Tennessee State University, Johnson City. Fortunately, although the risks associated with it remain high, death from AKI in the setting of acute pancreatitis has decreased significantly, from a high of 17% in 2002 to 6.4% in 2012, Dr. Devani determined in his database review.

“Increasing awareness and prompt diagnosis of AKI could be the reason for the increasing trend of prevalence of AKI in acute pancreatitis patients,” he said in an interview. “Decreasing mortality can be related to adherence to recent advances in the management approach of acute pancreatitis, such as early (within 24 hours) and aggressive intravenous hydration and early enteral feeding.”

Dr. Devani examined these trends in data extracted from the National Inpatient Sample, 2002-2012. During that 10-year period, almost 3.5 million adults were hospitalized for acute pancreatitis. These patients were a mean of 53 years old, and half were women. Their mean length of stay was just over 5 days, at a mean cost of about $12,000. Of these, 273,687 (7.9%) also developed AKI.

There were some significant differences between those who did and did not develop AKI. AKI patients were significantly older (61 vs. 53 years), and less likely to be women (43% vs. 51%). They had a higher Charlson Comorbidity Index score (1.49 vs. 0.84). They were also significantly more likely to develop a number of complications, including systemic inflammatory response syndrome (2% vs. 0.4%), septic shock (6% vs. 0.3%), sepsis (8.7% vs. 1.4%), acute respiratory failure (18% vs. 2%), and electrolyte disorder (72% vs. 30%).

Not surprisingly, their length of stay was significantly longer (10 vs. 5 days), as was hospitalization cost ($25,923 vs. $10,889). Mortality was much higher, at almost 9% vs. 0.7%.

In a propensity matching analysis, Dr. Devani matched 53,000 pairs of acute pancreatitis patients with and without AKI. This determined that those with AKI faced a doubling in the risk of in-hospital mortality.

He also examined temporal trends with regard to the complication. The rate of diagnosed AKI in hospitalized acute pancreatitis cases rose dramatically, from 4% in 2002 to 11.6% in 2012. However, mortality in acute pancreatitis patients decreased among both those with AKI (17%-6%) and those without (1%-0.4%).

The mean length of stay in patients with AKI and pancreatitis likewise fell, from 14.8 to 8.6 days. Not surprisingly, total hospitalization cost for these patients fell as well ($42,975-$20,716).

Among pancreatitis patients without AKI, length of stay and costs declined, although not as dramatically as they did among AKI patients (6-5 days; $13,654-$10,895).

Dr. Devani had no financial disclosures.

[email protected]

On Twitter @alz_gal

CHICAGO – Acute kidney injury (AKI) doubles the risk of death among patients hospitalized for acute pancreatitis, Kalpit Devani, MD, reported at the annual Digestive Disease Week^®.

This severe complication of acute pancreatitis also significantly increases the length of stay and drives up hospital costs, said Dr. Devani of East Tennessee State University, Johnson City. Fortunately, although the risks associated with it remain high, death from AKI in the setting of acute pancreatitis has decreased significantly, from a high of 17% in 2002 to 6.4% in 2012, Dr. Devani determined in his database review.

“Increasing awareness and prompt diagnosis of AKI could be the reason for the increasing trend of prevalence of AKI in acute pancreatitis patients,” he said in an interview. “Decreasing mortality can be related to adherence to recent advances in the management approach of acute pancreatitis, such as early (within 24 hours) and aggressive intravenous hydration and early enteral feeding.”

Dr. Devani examined these trends in data extracted from the National Inpatient Sample, 2002-2012. During that 10-year period, almost 3.5 million adults were hospitalized for acute pancreatitis. These patients were a mean of 53 years old, and half were women. Their mean length of stay was just over 5 days, at a mean cost of about $12,000. Of these, 273,687 (7.9%) also developed AKI.

There were some significant differences between those who did and did not develop AKI. AKI patients were significantly older (61 vs. 53 years), and less likely to be women (43% vs. 51%). They had a higher Charlson Comorbidity Index score (1.49 vs. 0.84). They were also significantly more likely to develop a number of complications, including systemic inflammatory response syndrome (2% vs. 0.4%), septic shock (6% vs. 0.3%), sepsis (8.7% vs. 1.4%), acute respiratory failure (18% vs. 2%), and electrolyte disorder (72% vs. 30%).

Not surprisingly, their length of stay was significantly longer (10 vs. 5 days), as was hospitalization cost ($25,923 vs. $10,889). Mortality was much higher, at almost 9% vs. 0.7%.

In a propensity matching analysis, Dr. Devani matched 53,000 pairs of acute pancreatitis patients with and without AKI. This determined that those with AKI faced a doubling in the risk of in-hospital mortality.

He also examined temporal trends with regard to the complication. The rate of diagnosed AKI in hospitalized acute pancreatitis cases rose dramatically, from 4% in 2002 to 11.6% in 2012. However, mortality in acute pancreatitis patients decreased among both those with AKI (17%-6%) and those without (1%-0.4%).

The mean length of stay in patients with AKI and pancreatitis likewise fell, from 14.8 to 8.6 days. Not surprisingly, total hospitalization cost for these patients fell as well ($42,975-$20,716).

Among pancreatitis patients without AKI, length of stay and costs declined, although not as dramatically as they did among AKI patients (6-5 days; $13,654-$10,895).

Dr. Devani had no financial disclosures.

[email protected]

On Twitter @alz_gal

CHICAGO – Acute kidney injury (AKI) doubles the risk of death among patients hospitalized for acute pancreatitis, Kalpit Devani, MD, reported at the annual Digestive Disease Week^®.

This severe complication of acute pancreatitis also significantly increases the length of stay and drives up hospital costs, said Dr. Devani of East Tennessee State University, Johnson City. Fortunately, although the risks associated with it remain high, death from AKI in the setting of acute pancreatitis has decreased significantly, from a high of 17% in 2002 to 6.4% in 2012, Dr. Devani determined in his database review.

“Increasing awareness and prompt diagnosis of AKI could be the reason for the increasing trend of prevalence of AKI in acute pancreatitis patients,” he said in an interview. “Decreasing mortality can be related to adherence to recent advances in the management approach of acute pancreatitis, such as early (within 24 hours) and aggressive intravenous hydration and early enteral feeding.”

Dr. Devani examined these trends in data extracted from the National Inpatient Sample, 2002-2012. During that 10-year period, almost 3.5 million adults were hospitalized for acute pancreatitis. These patients were a mean of 53 years old, and half were women. Their mean length of stay was just over 5 days, at a mean cost of about $12,000. Of these, 273,687 (7.9%) also developed AKI.

There were some significant differences between those who did and did not develop AKI. AKI patients were significantly older (61 vs. 53 years), and less likely to be women (43% vs. 51%). They had a higher Charlson Comorbidity Index score (1.49 vs. 0.84). They were also significantly more likely to develop a number of complications, including systemic inflammatory response syndrome (2% vs. 0.4%), septic shock (6% vs. 0.3%), sepsis (8.7% vs. 1.4%), acute respiratory failure (18% vs. 2%), and electrolyte disorder (72% vs. 30%).

Not surprisingly, their length of stay was significantly longer (10 vs. 5 days), as was hospitalization cost ($25,923 vs. $10,889). Mortality was much higher, at almost 9% vs. 0.7%.

In a propensity matching analysis, Dr. Devani matched 53,000 pairs of acute pancreatitis patients with and without AKI. This determined that those with AKI faced a doubling in the risk of in-hospital mortality.

He also examined temporal trends with regard to the complication. The rate of diagnosed AKI in hospitalized acute pancreatitis cases rose dramatically, from 4% in 2002 to 11.6% in 2012. However, mortality in acute pancreatitis patients decreased among both those with AKI (17%-6%) and those without (1%-0.4%).

The mean length of stay in patients with AKI and pancreatitis likewise fell, from 14.8 to 8.6 days. Not surprisingly, total hospitalization cost for these patients fell as well ($42,975-$20,716).

Among pancreatitis patients without AKI, length of stay and costs declined, although not as dramatically as they did among AKI patients (6-5 days; $13,654-$10,895).

Dr. Devani had no financial disclosures.

[email protected]

On Twitter @alz_gal

Around one-quarter of obese individuals who undergo Roux-en-Y gastric bypass had sustained, long-term remission of obesity, but far fewer achieved body mass index of under 25 kg/m² or maintained it over 5 years, new research suggests.

Researchers reported on the outcomes of a retrospective cohort study of 219 patients who underwent Roux-en-Y gastric bypass surgery at a single center between 2008 and 2010 and were followed for up to 7 years after the procedure.

SandraMatic/Thinkstock

Around one-quarter of obese individuals who undergo Roux-en-Y gastric bypass had sustained, long-term remission of obesity, but far fewer achieved body mass index of under 25 kg/m² or maintained it over 5 years, new research suggests.

Researchers reported on the outcomes of a retrospective cohort study of 219 patients who underwent Roux-en-Y gastric bypass surgery at a single center between 2008 and 2010 and were followed for up to 7 years after the procedure.

SandraMatic/Thinkstock

Around one-quarter of obese individuals who undergo Roux-en-Y gastric bypass had sustained, long-term remission of obesity, but far fewer achieved body mass index of under 25 kg/m² or maintained it over 5 years, new research suggests.

Researchers reported on the outcomes of a retrospective cohort study of 219 patients who underwent Roux-en-Y gastric bypass surgery at a single center between 2008 and 2010 and were followed for up to 7 years after the procedure.

SandraMatic/Thinkstock

SAN DIEGO – Readmission rates after discharge for patients with schizophrenia are notoriously high, with approximately a quarter of U.S. schizophrenia patients readmitted within 3 months, according to Paul A. Kurdyak, MD, PhD.

In Ontario, Canada, readmission rates for people with schizophrenia are 12.5% within 30 days of discharge. Paradoxically, however, these same patients receive less follow-up than people hospitalized for other psychiatric disorders, Dr. Kurdyak of the Institute for Clinical Evaluative Sciences in Toronto reported at the annual meeting of the American Psychiatric Association.

To explore the relationship between discharge, follow-up, and subsequent readmission in this population, he assessed the impact of physician follow-up in the month after discharge on readmission rates for schizophrenia patients, noting a lack of published evidence on whether or how it helps. “We try and use readmission as a general performance indicator, and we try and use postdischarge follow-up as a general indicator, but there was no evidence to determine whether seeing a physician following discharge has an impact on anything,” Dr. Kurdyak said.

He and his colleagues tracked primary care and outpatient psychiatric visits in the first 30 days after discharge for about 20,000 people who had been hospitalized with schizophrenia in Ontario. “We chose 30 days because we knew the rate of follow-up within 7 days was just so low,” he said.

He said more than one in three of these patients went more than 30 days without seeing any physician at all.

Schizophrenia patients “are individuals with really high needs, whose average length of stay is about 2 weeks,” he said. “It’s hard to stabilize somebody in 2 weeks, so to have so many of them drop off a cliff [after discharge] is not great.”

Another finding was that the patients who saw any doctor – whether their primary care physician or psychiatrist – saw reduced rates of readmission at 30-210 days after discharge.

Where the benefit of seeing a physician was seen in sharpest relief was among the patients deemed, by use of a validated scoring system, to be at highest risk for readmission. These patients, who made up two-thirds of the cohort, saw a 15% reduction in readmission if they’d had a visit with either a primary care physician or psychiatrist and a 19% reduction if they’d seen both types of physician relative to patients who had no physician follow-up post discharge.

“In the high-risk group, you see a very clear separation between those who saw no physician and those who saw any physician,” Dr. Kurdyak said.

Some of the limitations of the study included the fact that little was known about the quality of the follow-up physician visits or about clinical collaboration, the causes for lack of follow-up were not clear, and follow-up by nonphysician health personnel was not captured.

Nonetheless, Dr. Kurdyak said, “the moral of the story is [that] seeing a physician really differentiates from seeing no physician statistically and clinically.”

In Canada, he noted, “we like to feel comfortable with the idea of universal health care, but, when we take a closer look, we often see real inequities and disparities despite universal health care. I think this is one of these situations where, if readmission is an indicator of need, our ability to provide services to those in the greatest need falls short of the ideal.”

Dr. Kurdyak disclosed no conflicts of interest relevant to his research. 

SAN DIEGO – Readmission rates after discharge for patients with schizophrenia are notoriously high, with approximately a quarter of U.S. schizophrenia patients readmitted within 3 months, according to Paul A. Kurdyak, MD, PhD.

In Ontario, Canada, readmission rates for people with schizophrenia are 12.5% within 30 days of discharge. Paradoxically, however, these same patients receive less follow-up than people hospitalized for other psychiatric disorders, Dr. Kurdyak of the Institute for Clinical Evaluative Sciences in Toronto reported at the annual meeting of the American Psychiatric Association.

To explore the relationship between discharge, follow-up, and subsequent readmission in this population, he assessed the impact of physician follow-up in the month after discharge on readmission rates for schizophrenia patients, noting a lack of published evidence on whether or how it helps. “We try and use readmission as a general performance indicator, and we try and use postdischarge follow-up as a general indicator, but there was no evidence to determine whether seeing a physician following discharge has an impact on anything,” Dr. Kurdyak said.

He and his colleagues tracked primary care and outpatient psychiatric visits in the first 30 days after discharge for about 20,000 people who had been hospitalized with schizophrenia in Ontario. “We chose 30 days because we knew the rate of follow-up within 7 days was just so low,” he said.

He said more than one in three of these patients went more than 30 days without seeing any physician at all.

Schizophrenia patients “are individuals with really high needs, whose average length of stay is about 2 weeks,” he said. “It’s hard to stabilize somebody in 2 weeks, so to have so many of them drop off a cliff [after discharge] is not great.”

Another finding was that the patients who saw any doctor – whether their primary care physician or psychiatrist – saw reduced rates of readmission at 30-210 days after discharge.

Where the benefit of seeing a physician was seen in sharpest relief was among the patients deemed, by use of a validated scoring system, to be at highest risk for readmission. These patients, who made up two-thirds of the cohort, saw a 15% reduction in readmission if they’d had a visit with either a primary care physician or psychiatrist and a 19% reduction if they’d seen both types of physician relative to patients who had no physician follow-up post discharge.

“In the high-risk group, you see a very clear separation between those who saw no physician and those who saw any physician,” Dr. Kurdyak said.

Some of the limitations of the study included the fact that little was known about the quality of the follow-up physician visits or about clinical collaboration, the causes for lack of follow-up were not clear, and follow-up by nonphysician health personnel was not captured.

Nonetheless, Dr. Kurdyak said, “the moral of the story is [that] seeing a physician really differentiates from seeing no physician statistically and clinically.”

In Canada, he noted, “we like to feel comfortable with the idea of universal health care, but, when we take a closer look, we often see real inequities and disparities despite universal health care. I think this is one of these situations where, if readmission is an indicator of need, our ability to provide services to those in the greatest need falls short of the ideal.”

Dr. Kurdyak disclosed no conflicts of interest relevant to his research. 

SAN DIEGO – Readmission rates after discharge for patients with schizophrenia are notoriously high, with approximately a quarter of U.S. schizophrenia patients readmitted within 3 months, according to Paul A. Kurdyak, MD, PhD.

In Ontario, Canada, readmission rates for people with schizophrenia are 12.5% within 30 days of discharge. Paradoxically, however, these same patients receive less follow-up than people hospitalized for other psychiatric disorders, Dr. Kurdyak of the Institute for Clinical Evaluative Sciences in Toronto reported at the annual meeting of the American Psychiatric Association.

To explore the relationship between discharge, follow-up, and subsequent readmission in this population, he assessed the impact of physician follow-up in the month after discharge on readmission rates for schizophrenia patients, noting a lack of published evidence on whether or how it helps. “We try and use readmission as a general performance indicator, and we try and use postdischarge follow-up as a general indicator, but there was no evidence to determine whether seeing a physician following discharge has an impact on anything,” Dr. Kurdyak said.

He and his colleagues tracked primary care and outpatient psychiatric visits in the first 30 days after discharge for about 20,000 people who had been hospitalized with schizophrenia in Ontario. “We chose 30 days because we knew the rate of follow-up within 7 days was just so low,” he said.

He said more than one in three of these patients went more than 30 days without seeing any physician at all.

Schizophrenia patients “are individuals with really high needs, whose average length of stay is about 2 weeks,” he said. “It’s hard to stabilize somebody in 2 weeks, so to have so many of them drop off a cliff [after discharge] is not great.”

Another finding was that the patients who saw any doctor – whether their primary care physician or psychiatrist – saw reduced rates of readmission at 30-210 days after discharge.

Where the benefit of seeing a physician was seen in sharpest relief was among the patients deemed, by use of a validated scoring system, to be at highest risk for readmission. These patients, who made up two-thirds of the cohort, saw a 15% reduction in readmission if they’d had a visit with either a primary care physician or psychiatrist and a 19% reduction if they’d seen both types of physician relative to patients who had no physician follow-up post discharge.

“In the high-risk group, you see a very clear separation between those who saw no physician and those who saw any physician,” Dr. Kurdyak said.

Some of the limitations of the study included the fact that little was known about the quality of the follow-up physician visits or about clinical collaboration, the causes for lack of follow-up were not clear, and follow-up by nonphysician health personnel was not captured.

Nonetheless, Dr. Kurdyak said, “the moral of the story is [that] seeing a physician really differentiates from seeing no physician statistically and clinically.”

In Canada, he noted, “we like to feel comfortable with the idea of universal health care, but, when we take a closer look, we often see real inequities and disparities despite universal health care. I think this is one of these situations where, if readmission is an indicator of need, our ability to provide services to those in the greatest need falls short of the ideal.”

Dr. Kurdyak disclosed no conflicts of interest relevant to his research. 

The elevated risk of death for patients with clinically diagnosed synucleinopathies and symptoms of parkinsonism is highest for those with multiple system atrophy with predominant parkinsonism (MSA-p), followed by dementia with Lewy bodies (DLB), Parkinson’s disease dementia (PDD), and Parkinson’s disease (PD), according to Rodolfo Savica, MD, PhD, and his associates.

The investigators compared 461 patients who had onset of a clinically presumed synucleinopathy manifesting as parkinsonism from 1991 to 2010 with 452 age- and sex-matched referent participants from the general population who were free of parkinsonism and tremor of any type in the year of onset of the other patients’ synucleinopathies. Of the 461 patients with the presumed synucleinopathies, 316 (68.6%) died during follow-up and 311 had a known cause of death (98.4%). Of the 452 referent participants, 220 (48.7%) died during follow-up and 216 had a known cause of death (98.2%). The highest risk of death was among patients with MSA-p (hazard ratio, 10.51) when compared with referent participants. The remaining patients also had elevated risk of death: DLB (HR, 3.94), PDD (HR, 3.86), and PD (HR, 1.75).

Neurodegenerative disease was the most frequent cause of death among patients for all synucleinopathies (31.5%) and in PD alone (25.6%), and cardiovascular events were the second most common cause of death (15.7%). Among the referent participants, cardiovascular events were the most common cause of death (25.5%).

The results were consistent with the causes of death observed among patients with DLB, PDD, and MSA-p; however, the researchers said the sample size was too limited to observe a sufficient number of events. They also noted that there was no significant interaction with sex and age in predicting survival rates for any type of synucleinopathy.

“Our findings contribute important new evidence about the natural history and survival of people affected by synucleinopathies of various types,” the researchers concluded. “Our results may be helpful to guide clinicians counseling patients and caregivers.”

Find the full study in JAMA Neurology (doi: 10.1001/jamaneurol.2017.0603).

[email protected]

The elevated risk of death for patients with clinically diagnosed synucleinopathies and symptoms of parkinsonism is highest for those with multiple system atrophy with predominant parkinsonism (MSA-p), followed by dementia with Lewy bodies (DLB), Parkinson’s disease dementia (PDD), and Parkinson’s disease (PD), according to Rodolfo Savica, MD, PhD, and his associates.

The investigators compared 461 patients who had onset of a clinically presumed synucleinopathy manifesting as parkinsonism from 1991 to 2010 with 452 age- and sex-matched referent participants from the general population who were free of parkinsonism and tremor of any type in the year of onset of the other patients’ synucleinopathies. Of the 461 patients with the presumed synucleinopathies, 316 (68.6%) died during follow-up and 311 had a known cause of death (98.4%). Of the 452 referent participants, 220 (48.7%) died during follow-up and 216 had a known cause of death (98.2%). The highest risk of death was among patients with MSA-p (hazard ratio, 10.51) when compared with referent participants. The remaining patients also had elevated risk of death: DLB (HR, 3.94), PDD (HR, 3.86), and PD (HR, 1.75).

Neurodegenerative disease was the most frequent cause of death among patients for all synucleinopathies (31.5%) and in PD alone (25.6%), and cardiovascular events were the second most common cause of death (15.7%). Among the referent participants, cardiovascular events were the most common cause of death (25.5%).

The results were consistent with the causes of death observed among patients with DLB, PDD, and MSA-p; however, the researchers said the sample size was too limited to observe a sufficient number of events. They also noted that there was no significant interaction with sex and age in predicting survival rates for any type of synucleinopathy.

“Our findings contribute important new evidence about the natural history and survival of people affected by synucleinopathies of various types,” the researchers concluded. “Our results may be helpful to guide clinicians counseling patients and caregivers.”

Find the full study in JAMA Neurology (doi: 10.1001/jamaneurol.2017.0603).

[email protected]

The elevated risk of death for patients with clinically diagnosed synucleinopathies and symptoms of parkinsonism is highest for those with multiple system atrophy with predominant parkinsonism (MSA-p), followed by dementia with Lewy bodies (DLB), Parkinson’s disease dementia (PDD), and Parkinson’s disease (PD), according to Rodolfo Savica, MD, PhD, and his associates.

The investigators compared 461 patients who had onset of a clinically presumed synucleinopathy manifesting as parkinsonism from 1991 to 2010 with 452 age- and sex-matched referent participants from the general population who were free of parkinsonism and tremor of any type in the year of onset of the other patients’ synucleinopathies. Of the 461 patients with the presumed synucleinopathies, 316 (68.6%) died during follow-up and 311 had a known cause of death (98.4%). Of the 452 referent participants, 220 (48.7%) died during follow-up and 216 had a known cause of death (98.2%). The highest risk of death was among patients with MSA-p (hazard ratio, 10.51) when compared with referent participants. The remaining patients also had elevated risk of death: DLB (HR, 3.94), PDD (HR, 3.86), and PD (HR, 1.75).

Neurodegenerative disease was the most frequent cause of death among patients for all synucleinopathies (31.5%) and in PD alone (25.6%), and cardiovascular events were the second most common cause of death (15.7%). Among the referent participants, cardiovascular events were the most common cause of death (25.5%).

The results were consistent with the causes of death observed among patients with DLB, PDD, and MSA-p; however, the researchers said the sample size was too limited to observe a sufficient number of events. They also noted that there was no significant interaction with sex and age in predicting survival rates for any type of synucleinopathy.

“Our findings contribute important new evidence about the natural history and survival of people affected by synucleinopathies of various types,” the researchers concluded. “Our results may be helpful to guide clinicians counseling patients and caregivers.”

Find the full study in JAMA Neurology (doi: 10.1001/jamaneurol.2017.0603).

[email protected]

Pretreatment with microneedles provided a faster, less painful, way to treat facial actinic keratoses (AKs) with photodynamic therapy, with similar clearance rates as would be expected with traditional therapy, in a study of 33 patients.

This approach reduced the incubation time of aminolevulinic acid (ALA) to 20 minutes, with comparable results to one-hour ALA incubation times. “Interestingly, the secondary outcome of pain associated with blue light exposure during photodynamic therapy was nominal and not significantly different from the sham side,” reported Tatyana A. Petukhova, MD, and her associates in the department of dermatology at the University of California, Davis (JAMA Dermatol. 2017 May 17. doi: 10.1001/jamadermatol.2017.0849).

“Pain associated with PDT is the most severe adverse effect and may lead to interruption or discontinuation of treatment, resulting in refusal to repeat the process at a future date owing to unbearable discomfort,” they wrote. Patients also reported little to no swelling or pain after treatment and minimal erythema and peeling.

The randomized, split-face, single-blinded controlled trial enrolled 33 patients, with at least eight AKs on their faces, from a university dermatology outpatient clinic from 2015 to 2016. They were randomized to receive either 10 minutes or 20 minutes incubation time with ALA, and 32 completed the study. Those in the 20-minute group had a mean of 25 grade II facial AKs, and those in the 10-minute group had an average of 31 grade II facial AKs.

Before administration of ALA, each patient received pretreatment with a microneedle roller on one side of their face and a sham roller on the other side. On each half of their faces, the microneedle device (a single-use sterile array of microneedles measuring 200 mcm) or sham roller was rolled forward and backward eight times in four directions.

They were exposed to blue light for 1,000 seconds at an average wavelength of 478 nm, an overall fluence of 10 J/cm², and advised to avoid sun exposure for 36 hours after treatment.

At follow-up one month later, among the patients with a 20-minute ALA incubation time, the mean AK clearance rate was 76% on the side with microneedle pretreatment, compared with 58% on the sham side (P less than .01). This included three patients with complete clearance. The efficacy of microneedle pretreatment with a 20-minute incubation time is similar to that of 1-hour incubation times with ALA. PDT typically uses 1-4 hours of incubation time.

Among the patients who received a 10-minute ALA incubation time, a mean of 43% of AKs on the microneedle side and 38% on the sham side cleared, a difference that was not statistically significant. Participants did not rate the pain as significantly different between each side of their face and both groups reported low levels of pain overall.

One limitation of the study was the short follow-up time. “Because actinic damage is cumulative, there is potential for thicker AKs to recur or for new lesions to develop during a longer follow-up period,” the authors noted.

The research was partly funded by an author’s University of California, Davis, Medical Student Research Fellowship. The authors reported having no disclosures.

Pretreatment with microneedles provided a faster, less painful, way to treat facial actinic keratoses (AKs) with photodynamic therapy, with similar clearance rates as would be expected with traditional therapy, in a study of 33 patients.

This approach reduced the incubation time of aminolevulinic acid (ALA) to 20 minutes, with comparable results to one-hour ALA incubation times. “Interestingly, the secondary outcome of pain associated with blue light exposure during photodynamic therapy was nominal and not significantly different from the sham side,” reported Tatyana A. Petukhova, MD, and her associates in the department of dermatology at the University of California, Davis (JAMA Dermatol. 2017 May 17. doi: 10.1001/jamadermatol.2017.0849).

“Pain associated with PDT is the most severe adverse effect and may lead to interruption or discontinuation of treatment, resulting in refusal to repeat the process at a future date owing to unbearable discomfort,” they wrote. Patients also reported little to no swelling or pain after treatment and minimal erythema and peeling.

The randomized, split-face, single-blinded controlled trial enrolled 33 patients, with at least eight AKs on their faces, from a university dermatology outpatient clinic from 2015 to 2016. They were randomized to receive either 10 minutes or 20 minutes incubation time with ALA, and 32 completed the study. Those in the 20-minute group had a mean of 25 grade II facial AKs, and those in the 10-minute group had an average of 31 grade II facial AKs.

Before administration of ALA, each patient received pretreatment with a microneedle roller on one side of their face and a sham roller on the other side. On each half of their faces, the microneedle device (a single-use sterile array of microneedles measuring 200 mcm) or sham roller was rolled forward and backward eight times in four directions.

They were exposed to blue light for 1,000 seconds at an average wavelength of 478 nm, an overall fluence of 10 J/cm², and advised to avoid sun exposure for 36 hours after treatment.

At follow-up one month later, among the patients with a 20-minute ALA incubation time, the mean AK clearance rate was 76% on the side with microneedle pretreatment, compared with 58% on the sham side (P less than .01). This included three patients with complete clearance. The efficacy of microneedle pretreatment with a 20-minute incubation time is similar to that of 1-hour incubation times with ALA. PDT typically uses 1-4 hours of incubation time.

Among the patients who received a 10-minute ALA incubation time, a mean of 43% of AKs on the microneedle side and 38% on the sham side cleared, a difference that was not statistically significant. Participants did not rate the pain as significantly different between each side of their face and both groups reported low levels of pain overall.

One limitation of the study was the short follow-up time. “Because actinic damage is cumulative, there is potential for thicker AKs to recur or for new lesions to develop during a longer follow-up period,” the authors noted.

The research was partly funded by an author’s University of California, Davis, Medical Student Research Fellowship. The authors reported having no disclosures.

Pretreatment with microneedles provided a faster, less painful, way to treat facial actinic keratoses (AKs) with photodynamic therapy, with similar clearance rates as would be expected with traditional therapy, in a study of 33 patients.

This approach reduced the incubation time of aminolevulinic acid (ALA) to 20 minutes, with comparable results to one-hour ALA incubation times. “Interestingly, the secondary outcome of pain associated with blue light exposure during photodynamic therapy was nominal and not significantly different from the sham side,” reported Tatyana A. Petukhova, MD, and her associates in the department of dermatology at the University of California, Davis (JAMA Dermatol. 2017 May 17. doi: 10.1001/jamadermatol.2017.0849).

“Pain associated with PDT is the most severe adverse effect and may lead to interruption or discontinuation of treatment, resulting in refusal to repeat the process at a future date owing to unbearable discomfort,” they wrote. Patients also reported little to no swelling or pain after treatment and minimal erythema and peeling.

The randomized, split-face, single-blinded controlled trial enrolled 33 patients, with at least eight AKs on their faces, from a university dermatology outpatient clinic from 2015 to 2016. They were randomized to receive either 10 minutes or 20 minutes incubation time with ALA, and 32 completed the study. Those in the 20-minute group had a mean of 25 grade II facial AKs, and those in the 10-minute group had an average of 31 grade II facial AKs.

Before administration of ALA, each patient received pretreatment with a microneedle roller on one side of their face and a sham roller on the other side. On each half of their faces, the microneedle device (a single-use sterile array of microneedles measuring 200 mcm) or sham roller was rolled forward and backward eight times in four directions.

They were exposed to blue light for 1,000 seconds at an average wavelength of 478 nm, an overall fluence of 10 J/cm², and advised to avoid sun exposure for 36 hours after treatment.

At follow-up one month later, among the patients with a 20-minute ALA incubation time, the mean AK clearance rate was 76% on the side with microneedle pretreatment, compared with 58% on the sham side (P less than .01). This included three patients with complete clearance. The efficacy of microneedle pretreatment with a 20-minute incubation time is similar to that of 1-hour incubation times with ALA. PDT typically uses 1-4 hours of incubation time.

Among the patients who received a 10-minute ALA incubation time, a mean of 43% of AKs on the microneedle side and 38% on the sham side cleared, a difference that was not statistically significant. Participants did not rate the pain as significantly different between each side of their face and both groups reported low levels of pain overall.

One limitation of the study was the short follow-up time. “Because actinic damage is cumulative, there is potential for thicker AKs to recur or for new lesions to develop during a longer follow-up period,” the authors noted.

The research was partly funded by an author’s University of California, Davis, Medical Student Research Fellowship. The authors reported having no disclosures.

Open a magazine or turn on the radio and you are likely to hear someone extolling the benefits of mindfulness for any number of purposes, conditions, or age groups. Businesses, schools, and health care organizations are incorporating mindfulness techniques to boost employee, student, and patient well-being and engagement, as well as to help employers, teachers, and providers to thrive. In this two-part series, part 1 will attempt to distill some of the fundamentals with regard to the following questions: 1. What is mindfulness? 2. What is the evidence for mindfulness, particularly in youth? and 3. How would you apply mindfulness techniques in your office setting?

Mindfulness was largely brought into the mainstream health care world by Jon Kabat-Zinn, PhD, of the University of Massachusetts Medical Center, Worcester. Drawing on Buddhist traditions, he created a secularized version of meditative and movement techniques used for thousands of years to promote healthy living. A growing evidence base showed that these practices, combined in a formal curriculum dubbed mindfulness-based stress reduction (MBSR), could alleviate symptoms and distress in conditions as diverse as chronic pain, psoriasis, and anxiety. This has spawned numerous research programs and spin-offs, and remains a foundational approach to utilizing mindfulness in medical care. Dr. Kabat-Zinn’s definition of the term is thus worth noting – mindfulness is “the awareness that arises by paying attention on purpose, in the present moment, and nonjudgmentally.”¹ Put simply, mindfulness means having your mind and your body in the same place at the same time. If your mind is wandering to what happened yesterday or planning for what might happen later today, then your mind and body are not in the same time. If your mind is thinking about what is going on at home while you are at work, or what your friends are doing, your mind and body are not in the same place.

Dr. Rosenfeld is an assistant professor in the departments of psychiatry and pediatrics at the University of Vermont Medical Center, Robert Larner College of Medicine, Burlington. He said he has no relevant disclosures.

References

1. Full Catastrophe Living: Using the Wisdom of Your Body and Mind to Face Stress, Pain, and Illness (New York: Bantam Books, Penguin Random House, 2013).

2. J Pers Soc Psychol. 2003 Apr;84(4):822-48.

3. Gen Hosp Psychiatry. 1982 Apr;4(1):33-47.

4. Am J Psychiatry. 1992 Jul;149(7):936-43.

5. Clin Psychol Rev. 2011 Aug;31(6):1041-56.

6. Neuroreport. 2005 Nov 28;16(17):1893-7.

7. Soc Cogn Affect Neurosci. 2010 Mar;5(1):11-7.

8. Neuroimage. 2009 Apr 15;45(3):672-8.

9. Psychiatry Res. 2011 Jan 30;191(1):36-43.

10. Pediatrics. 2016 Jan;137(1):e20152532.

11. J Atten Disord. 2008 May;11(6):737-46.

12. J Child Fam Stud. 2012 Oct;21(5):775-87.

13. J Consult Clin Psychol. 2009 Oct;77(5):855-66.

14. Biol Psychiatry. 2016 Jul 1;80(1):53-61.

Open a magazine or turn on the radio and you are likely to hear someone extolling the benefits of mindfulness for any number of purposes, conditions, or age groups. Businesses, schools, and health care organizations are incorporating mindfulness techniques to boost employee, student, and patient well-being and engagement, as well as to help employers, teachers, and providers to thrive. In this two-part series, part 1 will attempt to distill some of the fundamentals with regard to the following questions: 1. What is mindfulness? 2. What is the evidence for mindfulness, particularly in youth? and 3. How would you apply mindfulness techniques in your office setting?

Mindfulness was largely brought into the mainstream health care world by Jon Kabat-Zinn, PhD, of the University of Massachusetts Medical Center, Worcester. Drawing on Buddhist traditions, he created a secularized version of meditative and movement techniques used for thousands of years to promote healthy living. A growing evidence base showed that these practices, combined in a formal curriculum dubbed mindfulness-based stress reduction (MBSR), could alleviate symptoms and distress in conditions as diverse as chronic pain, psoriasis, and anxiety. This has spawned numerous research programs and spin-offs, and remains a foundational approach to utilizing mindfulness in medical care. Dr. Kabat-Zinn’s definition of the term is thus worth noting – mindfulness is “the awareness that arises by paying attention on purpose, in the present moment, and nonjudgmentally.”¹ Put simply, mindfulness means having your mind and your body in the same place at the same time. If your mind is wandering to what happened yesterday or planning for what might happen later today, then your mind and body are not in the same time. If your mind is thinking about what is going on at home while you are at work, or what your friends are doing, your mind and body are not in the same place.

Dr. Rosenfeld is an assistant professor in the departments of psychiatry and pediatrics at the University of Vermont Medical Center, Robert Larner College of Medicine, Burlington. He said he has no relevant disclosures.

References

1. Full Catastrophe Living: Using the Wisdom of Your Body and Mind to Face Stress, Pain, and Illness (New York: Bantam Books, Penguin Random House, 2013).

2. J Pers Soc Psychol. 2003 Apr;84(4):822-48.

3. Gen Hosp Psychiatry. 1982 Apr;4(1):33-47.

4. Am J Psychiatry. 1992 Jul;149(7):936-43.

5. Clin Psychol Rev. 2011 Aug;31(6):1041-56.

6. Neuroreport. 2005 Nov 28;16(17):1893-7.

7. Soc Cogn Affect Neurosci. 2010 Mar;5(1):11-7.

8. Neuroimage. 2009 Apr 15;45(3):672-8.

9. Psychiatry Res. 2011 Jan 30;191(1):36-43.

10. Pediatrics. 2016 Jan;137(1):e20152532.

11. J Atten Disord. 2008 May;11(6):737-46.

12. J Child Fam Stud. 2012 Oct;21(5):775-87.

13. J Consult Clin Psychol. 2009 Oct;77(5):855-66.

14. Biol Psychiatry. 2016 Jul 1;80(1):53-61.

Open a magazine or turn on the radio and you are likely to hear someone extolling the benefits of mindfulness for any number of purposes, conditions, or age groups. Businesses, schools, and health care organizations are incorporating mindfulness techniques to boost employee, student, and patient well-being and engagement, as well as to help employers, teachers, and providers to thrive. In this two-part series, part 1 will attempt to distill some of the fundamentals with regard to the following questions: 1. What is mindfulness? 2. What is the evidence for mindfulness, particularly in youth? and 3. How would you apply mindfulness techniques in your office setting?

Mindfulness was largely brought into the mainstream health care world by Jon Kabat-Zinn, PhD, of the University of Massachusetts Medical Center, Worcester. Drawing on Buddhist traditions, he created a secularized version of meditative and movement techniques used for thousands of years to promote healthy living. A growing evidence base showed that these practices, combined in a formal curriculum dubbed mindfulness-based stress reduction (MBSR), could alleviate symptoms and distress in conditions as diverse as chronic pain, psoriasis, and anxiety. This has spawned numerous research programs and spin-offs, and remains a foundational approach to utilizing mindfulness in medical care. Dr. Kabat-Zinn’s definition of the term is thus worth noting – mindfulness is “the awareness that arises by paying attention on purpose, in the present moment, and nonjudgmentally.”¹ Put simply, mindfulness means having your mind and your body in the same place at the same time. If your mind is wandering to what happened yesterday or planning for what might happen later today, then your mind and body are not in the same time. If your mind is thinking about what is going on at home while you are at work, or what your friends are doing, your mind and body are not in the same place.

Dr. Rosenfeld is an assistant professor in the departments of psychiatry and pediatrics at the University of Vermont Medical Center, Robert Larner College of Medicine, Burlington. He said he has no relevant disclosures.

References

1. Full Catastrophe Living: Using the Wisdom of Your Body and Mind to Face Stress, Pain, and Illness (New York: Bantam Books, Penguin Random House, 2013).

2. J Pers Soc Psychol. 2003 Apr;84(4):822-48.

3. Gen Hosp Psychiatry. 1982 Apr;4(1):33-47.

4. Am J Psychiatry. 1992 Jul;149(7):936-43.

5. Clin Psychol Rev. 2011 Aug;31(6):1041-56.

6. Neuroreport. 2005 Nov 28;16(17):1893-7.

7. Soc Cogn Affect Neurosci. 2010 Mar;5(1):11-7.

8. Neuroimage. 2009 Apr 15;45(3):672-8.

9. Psychiatry Res. 2011 Jan 30;191(1):36-43.

10. Pediatrics. 2016 Jan;137(1):e20152532.

11. J Atten Disord. 2008 May;11(6):737-46.

12. J Child Fam Stud. 2012 Oct;21(5):775-87.

13. J Consult Clin Psychol. 2009 Oct;77(5):855-66.

14. Biol Psychiatry. 2016 Jul 1;80(1):53-61.

In this follow-up to last month’s column on mindfulness, in which the evidence base makes a compelling argument for incorporating mindfulness into our list of healthy practices for youth brain development, the challenge of implementing mindfulness “prescriptions” in practice is considered in more depth. As a reminder, a working definition of mindfulness was offered as, “the awareness that arises by paying attention on purpose, in the present moment, and nonjudgmentally.”¹

An important piece of prescribing, either pharmaceuticals or health-promoting practices, is sharing the risks, benefits, and alternatives to the recommended treatment. Last month’s article considered the potential benefits of cultivating a mindfulness practice. Few risks have been well-documented, particularly in the pediatric population. While some case reports describe adults having profoundly disturbing emotional reactions,these are in the context of intensive meditation experiences (think 10-day silent retreat).² While there is not evidence of harm in youth, the lesson to be learned from adult experiences may be to consult with an advanced teacher if a patient chooses to become intensely involved in any meditative practice.

1. Show me how you breathe. Now let’s practice belly (abdominal/diaphragmatic) breathing.
2. Move both hands to your belly. Imagine you are breathing behind your belly button. Feel your belly rise like a balloon.
3. As you breathe out, feel your belly drop as you let air out.
4. Bonus: Now breathe through your nose only as you continue belly breathing. Next, notice your belly rising and falling without placing your hands on it.

In a physical exam, the following might work: When you place your stethoscope on the chest and back to auscultate the lungs, instruct the child to “place a hand on your belly and take a deep breath into your belly button so that your hand moves out. Keep taking slow, deep belly breaths while I listen.”

This breathing technique activates the parasympathetic nervous system, quelling the fight-or-flight response that may contribute to anxiety, aggressive reactivity, and interfere with sleep. Prescribing five of these belly breaths before bedtime is a good beginning, increasing frequency and duration over time as the practice becomes routine, then adding the “bonus” techniques. Introducing abdominal breathing also makes a good opportunity to ask the child about sources of stress in their lives.

For the distracted or stressed-out youth, focus is key. Those children who seem to be always multitasking or never sit still may benefit from cultivating a focus practice. It also may help still the mind before bedtime. A mindfulness prescription for focus is as follows:

1. The rays of the sun are much more powerful when they are brought into focus. Just like building a muscle, focus can be built up to be stronger. Let’s practice focusing.
2. As you breathe in, count slowly to 5, raising one finger for each count. As you breathe out, count down to 0, lowering each finger.
3. Notice when you get distracted during the counting. Exercise your focus by coming back to counting your breath.
4. Let your hands rest in your lap. Then, move to counting silently in your head.

Alternative options for focus objects include watching the secondhand on a clock, balancing a peacock feather on a fingertip, listening to a bell or chime until it can no longer be heard, watching a sand timer until every grain falls.

In a physical exam, the following might work: During the neurologic exam for cranial nerves (eye movements), direct the child to focus on your finger. Hold it still for 10 seconds, gently reminding them to keep their focus on your finger if needed. Then, as you move to each quadrant, move slowly and stay in each quadrant for 5 seconds. Encourage them to “keep your focus on my finger.”

After practicing a focus exercise, inquire about the patient’s focus during school, homework, and activities. Suggest making the focused breathing, or an alternative focus activity, part of the daily routine. Parents are encouraged to participate alongside their children.

Depending on the amount of time you have in the visit, your mindfulness intervention may simply be how you conduct the physical exam. With more time or a child or family who seems to have an indication for prescribing mindfulness (stress, anxiety, inattention, insomnia, etc.), a more didactic approach toward mindfulness techniques accompanied by a specific prescription may be in order. Developmentally, clinicians in our practice have found that hands-on activities and games can help involve younger children, while teens can get into one of the apps developed to facilitate mindful practices. (See Online resources.) Diagnostically, more hyperactive or distractible children may mesh better with movement-based practices. Depressed or anxious children may enjoy quieter activities or benefit from small incentives to increase motivation. Children with traumatic histories may benefit from a slow pace, keeping their eyes open and looking at the floor rather than eyes closed and avoiding physical contact initially.

Methods of meditation and mindfulness exist in most every philosophical and religious tradition, but the neuroscientific value of these practices is a more recent take on these wisdom traditions. As we follow the growing research literature on mindfulness, consider incorporating this “new” prescription into your toolbox of healthy practices for the developing brain.

Dr. Rosenfeld is assistant professor in the departments of psychiatry and pediatrics at the University of Vermont Medical Center and the university’s Robert Larner College of Medicine, Burlington. He reported no relevant disclosures. Email him at [email protected].

Online resources:

• A Sesame Street video on belly breathing (for younger children): “Belly Breathe” with Elmo at www.youtube.com/watch?v=_mZbzDOpylA.
• Card decks: Growing Mindful: Mindfulness Practices for All Ages; Be Mindful Card Deck for Teens; Yoga 4 Classrooms Activity Card Deck.
• Apps: Smiling Mind (differentiated by age); Calm; Breathe; Breathe2Relax; Insight Timer; Grow (mindfulness for teens).
• Props: peacock feathers; sand timers; clock with secondhand; Tibetan singing bell or other; Hoberman spheres (“breathing balls”) to visualize belly breathing.

References

1. Full Catastrophe Living: Using the Wisdom of Your Body and Mind to Face Stress, Pain, and Illness. (New York: Bantam Books, Penguin Random House, 2013).

2. Rocha, Tomas. “The Dark Knight of the Soul.” The Atlantic. June 25, 2014.
 

In this follow-up to last month’s column on mindfulness, in which the evidence base makes a compelling argument for incorporating mindfulness into our list of healthy practices for youth brain development, the challenge of implementing mindfulness “prescriptions” in practice is considered in more depth. As a reminder, a working definition of mindfulness was offered as, “the awareness that arises by paying attention on purpose, in the present moment, and nonjudgmentally.”¹

An important piece of prescribing, either pharmaceuticals or health-promoting practices, is sharing the risks, benefits, and alternatives to the recommended treatment. Last month’s article considered the potential benefits of cultivating a mindfulness practice. Few risks have been well-documented, particularly in the pediatric population. While some case reports describe adults having profoundly disturbing emotional reactions,these are in the context of intensive meditation experiences (think 10-day silent retreat).² While there is not evidence of harm in youth, the lesson to be learned from adult experiences may be to consult with an advanced teacher if a patient chooses to become intensely involved in any meditative practice.

1. Show me how you breathe. Now let’s practice belly (abdominal/diaphragmatic) breathing.
2. Move both hands to your belly. Imagine you are breathing behind your belly button. Feel your belly rise like a balloon.
3. As you breathe out, feel your belly drop as you let air out.
4. Bonus: Now breathe through your nose only as you continue belly breathing. Next, notice your belly rising and falling without placing your hands on it.

In a physical exam, the following might work: When you place your stethoscope on the chest and back to auscultate the lungs, instruct the child to “place a hand on your belly and take a deep breath into your belly button so that your hand moves out. Keep taking slow, deep belly breaths while I listen.”

This breathing technique activates the parasympathetic nervous system, quelling the fight-or-flight response that may contribute to anxiety, aggressive reactivity, and interfere with sleep. Prescribing five of these belly breaths before bedtime is a good beginning, increasing frequency and duration over time as the practice becomes routine, then adding the “bonus” techniques. Introducing abdominal breathing also makes a good opportunity to ask the child about sources of stress in their lives.

For the distracted or stressed-out youth, focus is key. Those children who seem to be always multitasking or never sit still may benefit from cultivating a focus practice. It also may help still the mind before bedtime. A mindfulness prescription for focus is as follows:

1. The rays of the sun are much more powerful when they are brought into focus. Just like building a muscle, focus can be built up to be stronger. Let’s practice focusing.
2. As you breathe in, count slowly to 5, raising one finger for each count. As you breathe out, count down to 0, lowering each finger.
3. Notice when you get distracted during the counting. Exercise your focus by coming back to counting your breath.
4. Let your hands rest in your lap. Then, move to counting silently in your head.

Alternative options for focus objects include watching the secondhand on a clock, balancing a peacock feather on a fingertip, listening to a bell or chime until it can no longer be heard, watching a sand timer until every grain falls.

In a physical exam, the following might work: During the neurologic exam for cranial nerves (eye movements), direct the child to focus on your finger. Hold it still for 10 seconds, gently reminding them to keep their focus on your finger if needed. Then, as you move to each quadrant, move slowly and stay in each quadrant for 5 seconds. Encourage them to “keep your focus on my finger.”

After practicing a focus exercise, inquire about the patient’s focus during school, homework, and activities. Suggest making the focused breathing, or an alternative focus activity, part of the daily routine. Parents are encouraged to participate alongside their children.

Depending on the amount of time you have in the visit, your mindfulness intervention may simply be how you conduct the physical exam. With more time or a child or family who seems to have an indication for prescribing mindfulness (stress, anxiety, inattention, insomnia, etc.), a more didactic approach toward mindfulness techniques accompanied by a specific prescription may be in order. Developmentally, clinicians in our practice have found that hands-on activities and games can help involve younger children, while teens can get into one of the apps developed to facilitate mindful practices. (See Online resources.) Diagnostically, more hyperactive or distractible children may mesh better with movement-based practices. Depressed or anxious children may enjoy quieter activities or benefit from small incentives to increase motivation. Children with traumatic histories may benefit from a slow pace, keeping their eyes open and looking at the floor rather than eyes closed and avoiding physical contact initially.

Methods of meditation and mindfulness exist in most every philosophical and religious tradition, but the neuroscientific value of these practices is a more recent take on these wisdom traditions. As we follow the growing research literature on mindfulness, consider incorporating this “new” prescription into your toolbox of healthy practices for the developing brain.

Dr. Rosenfeld is assistant professor in the departments of psychiatry and pediatrics at the University of Vermont Medical Center and the university’s Robert Larner College of Medicine, Burlington. He reported no relevant disclosures. Email him at [email protected].

Online resources:

• A Sesame Street video on belly breathing (for younger children): “Belly Breathe” with Elmo at www.youtube.com/watch?v=_mZbzDOpylA.
• Card decks: Growing Mindful: Mindfulness Practices for All Ages; Be Mindful Card Deck for Teens; Yoga 4 Classrooms Activity Card Deck.
• Apps: Smiling Mind (differentiated by age); Calm; Breathe; Breathe2Relax; Insight Timer; Grow (mindfulness for teens).
• Props: peacock feathers; sand timers; clock with secondhand; Tibetan singing bell or other; Hoberman spheres (“breathing balls”) to visualize belly breathing.

References

1. Full Catastrophe Living: Using the Wisdom of Your Body and Mind to Face Stress, Pain, and Illness. (New York: Bantam Books, Penguin Random House, 2013).

2. Rocha, Tomas. “The Dark Knight of the Soul.” The Atlantic. June 25, 2014.
 

In this follow-up to last month’s column on mindfulness, in which the evidence base makes a compelling argument for incorporating mindfulness into our list of healthy practices for youth brain development, the challenge of implementing mindfulness “prescriptions” in practice is considered in more depth. As a reminder, a working definition of mindfulness was offered as, “the awareness that arises by paying attention on purpose, in the present moment, and nonjudgmentally.”¹

An important piece of prescribing, either pharmaceuticals or health-promoting practices, is sharing the risks, benefits, and alternatives to the recommended treatment. Last month’s article considered the potential benefits of cultivating a mindfulness practice. Few risks have been well-documented, particularly in the pediatric population. While some case reports describe adults having profoundly disturbing emotional reactions,these are in the context of intensive meditation experiences (think 10-day silent retreat).² While there is not evidence of harm in youth, the lesson to be learned from adult experiences may be to consult with an advanced teacher if a patient chooses to become intensely involved in any meditative practice.

1. Show me how you breathe. Now let’s practice belly (abdominal/diaphragmatic) breathing.
2. Move both hands to your belly. Imagine you are breathing behind your belly button. Feel your belly rise like a balloon.
3. As you breathe out, feel your belly drop as you let air out.
4. Bonus: Now breathe through your nose only as you continue belly breathing. Next, notice your belly rising and falling without placing your hands on it.

In a physical exam, the following might work: When you place your stethoscope on the chest and back to auscultate the lungs, instruct the child to “place a hand on your belly and take a deep breath into your belly button so that your hand moves out. Keep taking slow, deep belly breaths while I listen.”

This breathing technique activates the parasympathetic nervous system, quelling the fight-or-flight response that may contribute to anxiety, aggressive reactivity, and interfere with sleep. Prescribing five of these belly breaths before bedtime is a good beginning, increasing frequency and duration over time as the practice becomes routine, then adding the “bonus” techniques. Introducing abdominal breathing also makes a good opportunity to ask the child about sources of stress in their lives.

For the distracted or stressed-out youth, focus is key. Those children who seem to be always multitasking or never sit still may benefit from cultivating a focus practice. It also may help still the mind before bedtime. A mindfulness prescription for focus is as follows:

1. The rays of the sun are much more powerful when they are brought into focus. Just like building a muscle, focus can be built up to be stronger. Let’s practice focusing.
2. As you breathe in, count slowly to 5, raising one finger for each count. As you breathe out, count down to 0, lowering each finger.
3. Notice when you get distracted during the counting. Exercise your focus by coming back to counting your breath.
4. Let your hands rest in your lap. Then, move to counting silently in your head.

Alternative options for focus objects include watching the secondhand on a clock, balancing a peacock feather on a fingertip, listening to a bell or chime until it can no longer be heard, watching a sand timer until every grain falls.

In a physical exam, the following might work: During the neurologic exam for cranial nerves (eye movements), direct the child to focus on your finger. Hold it still for 10 seconds, gently reminding them to keep their focus on your finger if needed. Then, as you move to each quadrant, move slowly and stay in each quadrant for 5 seconds. Encourage them to “keep your focus on my finger.”

After practicing a focus exercise, inquire about the patient’s focus during school, homework, and activities. Suggest making the focused breathing, or an alternative focus activity, part of the daily routine. Parents are encouraged to participate alongside their children.

Depending on the amount of time you have in the visit, your mindfulness intervention may simply be how you conduct the physical exam. With more time or a child or family who seems to have an indication for prescribing mindfulness (stress, anxiety, inattention, insomnia, etc.), a more didactic approach toward mindfulness techniques accompanied by a specific prescription may be in order. Developmentally, clinicians in our practice have found that hands-on activities and games can help involve younger children, while teens can get into one of the apps developed to facilitate mindful practices. (See Online resources.) Diagnostically, more hyperactive or distractible children may mesh better with movement-based practices. Depressed or anxious children may enjoy quieter activities or benefit from small incentives to increase motivation. Children with traumatic histories may benefit from a slow pace, keeping their eyes open and looking at the floor rather than eyes closed and avoiding physical contact initially.

Methods of meditation and mindfulness exist in most every philosophical and religious tradition, but the neuroscientific value of these practices is a more recent take on these wisdom traditions. As we follow the growing research literature on mindfulness, consider incorporating this “new” prescription into your toolbox of healthy practices for the developing brain.

Dr. Rosenfeld is assistant professor in the departments of psychiatry and pediatrics at the University of Vermont Medical Center and the university’s Robert Larner College of Medicine, Burlington. He reported no relevant disclosures. Email him at [email protected].

Online resources:

• A Sesame Street video on belly breathing (for younger children): “Belly Breathe” with Elmo at www.youtube.com/watch?v=_mZbzDOpylA.
• Card decks: Growing Mindful: Mindfulness Practices for All Ages; Be Mindful Card Deck for Teens; Yoga 4 Classrooms Activity Card Deck.
• Apps: Smiling Mind (differentiated by age); Calm; Breathe; Breathe2Relax; Insight Timer; Grow (mindfulness for teens).
• Props: peacock feathers; sand timers; clock with secondhand; Tibetan singing bell or other; Hoberman spheres (“breathing balls”) to visualize belly breathing.

References

1. Full Catastrophe Living: Using the Wisdom of Your Body and Mind to Face Stress, Pain, and Illness. (New York: Bantam Books, Penguin Random House, 2013).

2. Rocha, Tomas. “The Dark Knight of the Soul.” The Atlantic. June 25, 2014.
 

The Food and Drug Administration has approved sarilumab (Kevzara), a human monoclonal antibody against the interleukin-6 receptor, for the treatment of adult patients with rheumatoid arthritis (RA), the manufacturer Regeneron Pharmaceuticals announced May 22.

Interleukin-6 is an important factor in RA, as excess amounts of IL-6 build up in the body and contribute to RA-associated inflammation. Sarilumab has been shown to bind to and reduce IL-6R signaling, and is intended for people who have shown inadequate response to or are intolerant to conventional synthetic disease-modifying antirheumatic drugs (DMARDs).

Courtesy Wikimedia Commons/FitzColinGerald/Creative Commons License

[email protected]

The Food and Drug Administration has approved sarilumab (Kevzara), a human monoclonal antibody against the interleukin-6 receptor, for the treatment of adult patients with rheumatoid arthritis (RA), the manufacturer Regeneron Pharmaceuticals announced May 22.

Interleukin-6 is an important factor in RA, as excess amounts of IL-6 build up in the body and contribute to RA-associated inflammation. Sarilumab has been shown to bind to and reduce IL-6R signaling, and is intended for people who have shown inadequate response to or are intolerant to conventional synthetic disease-modifying antirheumatic drugs (DMARDs).

Courtesy Wikimedia Commons/FitzColinGerald/Creative Commons License

[email protected]

The Food and Drug Administration has approved sarilumab (Kevzara), a human monoclonal antibody against the interleukin-6 receptor, for the treatment of adult patients with rheumatoid arthritis (RA), the manufacturer Regeneron Pharmaceuticals announced May 22.

Interleukin-6 is an important factor in RA, as excess amounts of IL-6 build up in the body and contribute to RA-associated inflammation. Sarilumab has been shown to bind to and reduce IL-6R signaling, and is intended for people who have shown inadequate response to or are intolerant to conventional synthetic disease-modifying antirheumatic drugs (DMARDs).

Courtesy Wikimedia Commons/FitzColinGerald/Creative Commons License

[email protected]

Three physician-created advanced alternative payment models have been recommended for approval by an advisory committee of the Health & Human Services department. Their path to this milestone can help guide organizations and groups who want to benefit from the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA)–based Quality Payment Program on a more intense scale.

Advanced alternative payment models (APMs) involve physicians taking on two-sided risk along with Medicare in exchange for the potential for higher bonus payments for delivering higher value care to patients. Officials at the Centers for Medicare & Medicaid Services have created seven APMs (some primary care and some specialty focused), but they may not appeal to everyone. That’s where physician-created APMs come in.

• Scope of proposed PFPM (high priority)
• Quality and cost (high priority)
• Payment methodology (high priority)
• Value over volume
• Flexibility
• Ability to be evaluated
• Integration and care coordination
• Patient choice
• Patient safety
• Health information technology

While each proposal met a few of the criteria, none met all three high priority criteria and none were recommended for approval by its preliminary reviewers; however, after committee deliberation, two received provisional recommendation.

“We are recommending the two models for small-scale testing,” PTAC Vice-Chairman Elizabeth Mitchell said in an interview. “Even though we think they are very good ideas, we know that more experience and evidence is required before they may be ready.”

The two models that got the limited recommendation were

• Project Sonar, submitted by the Illinois Gastroenterology Group and SonarMD, a web-based platform that queries patients with inflammatory bowel disease monthly to determine which are in need of more hands-on care.
• APM, submitted by the American College of Surgeons, an episode-based payment model that uses claims data but expands on existing CMS value-based models by not requiring hospitalizations. It creates an episodic payment using outpatient settings, including acute and chronic care.

The COPD [chronic obstructive pulmonary disease] and Asthma Monitoring Project (CAMP), a smartphone app to remotely monitor and guide treatment of patients with asthma and chronic obstructive pulmonary disease, was not recommended. It was submitted by Pulmonary Medicine, Infectious Disease and Critical Care Consultants Medical Group of Sacremento, Calif.

PTAC has received more than 20 letters of intent from physicians and aims to hold another round of public hearings in September to determine their usefulness.

“I think it is very safe to say that our whole committee has been really gratified with the level of interest and engagement,” said Ms. Mitchell, president and CEO of Network for Regional Healthcare Improvement in Portland, Maine. The volume of applications “underscores the level of interest from the field. The entire reason PTAC was established was to get those good ideas from practicing physicians and others who are identifying better ways to deliver care but are facing barriers in the current payment system.”

She offered advice to those who are contemplating submission of a payment model.

“Really understand the criteria and review the request for proposals,” she said. “I think the committee lays out what we are looking for in terms of information, and we are hoping that it is really straight forward.”

She also stressed that successful models need to work broadly. “We are not talking about something that works for a single practice,” she said. “We are talking about models that are ready for inclusion in the whole CMS portfolio. It is helpful if there is experience to draw from that informs our deliberations, but we recognize that, in some cases, there has not been the opportunity to test these models broadly.”

Most of all, the highest priority when it comes to the models is related to quality of care and cost.

“We are not soliciting models that are essentially tweaks to fee-for-service. We are looking for changes that cannot be made without a new method of payment,” she said, adding that the models “have to either reduce cost while maintaining quality or improve quality without raising cost.”

Meeting transcripts and video are posted online and can help potential applicants see how the committee came to its recommendations.

“The committee does not deliberate on the proposals except in public,” Ms. Mitchell said. “So, those public meetings were the first time we had deliberated on any of the proposals we have considered. The preliminary review teams have discussed it [in depth], but the full committee can only deliberate in public.”

[email protected]

Three physician-created advanced alternative payment models have been recommended for approval by an advisory committee of the Health & Human Services department. Their path to this milestone can help guide organizations and groups who want to benefit from the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA)–based Quality Payment Program on a more intense scale.

Advanced alternative payment models (APMs) involve physicians taking on two-sided risk along with Medicare in exchange for the potential for higher bonus payments for delivering higher value care to patients. Officials at the Centers for Medicare & Medicaid Services have created seven APMs (some primary care and some specialty focused), but they may not appeal to everyone. That’s where physician-created APMs come in.

• Scope of proposed PFPM (high priority)
• Quality and cost (high priority)
• Payment methodology (high priority)
• Value over volume
• Flexibility
• Ability to be evaluated
• Integration and care coordination
• Patient choice
• Patient safety
• Health information technology

While each proposal met a few of the criteria, none met all three high priority criteria and none were recommended for approval by its preliminary reviewers; however, after committee deliberation, two received provisional recommendation.

“We are recommending the two models for small-scale testing,” PTAC Vice-Chairman Elizabeth Mitchell said in an interview. “Even though we think they are very good ideas, we know that more experience and evidence is required before they may be ready.”

The two models that got the limited recommendation were

• Project Sonar, submitted by the Illinois Gastroenterology Group and SonarMD, a web-based platform that queries patients with inflammatory bowel disease monthly to determine which are in need of more hands-on care.
• APM, submitted by the American College of Surgeons, an episode-based payment model that uses claims data but expands on existing CMS value-based models by not requiring hospitalizations. It creates an episodic payment using outpatient settings, including acute and chronic care.

The COPD [chronic obstructive pulmonary disease] and Asthma Monitoring Project (CAMP), a smartphone app to remotely monitor and guide treatment of patients with asthma and chronic obstructive pulmonary disease, was not recommended. It was submitted by Pulmonary Medicine, Infectious Disease and Critical Care Consultants Medical Group of Sacremento, Calif.

PTAC has received more than 20 letters of intent from physicians and aims to hold another round of public hearings in September to determine their usefulness.

“I think it is very safe to say that our whole committee has been really gratified with the level of interest and engagement,” said Ms. Mitchell, president and CEO of Network for Regional Healthcare Improvement in Portland, Maine. The volume of applications “underscores the level of interest from the field. The entire reason PTAC was established was to get those good ideas from practicing physicians and others who are identifying better ways to deliver care but are facing barriers in the current payment system.”

She offered advice to those who are contemplating submission of a payment model.

“Really understand the criteria and review the request for proposals,” she said. “I think the committee lays out what we are looking for in terms of information, and we are hoping that it is really straight forward.”

She also stressed that successful models need to work broadly. “We are not talking about something that works for a single practice,” she said. “We are talking about models that are ready for inclusion in the whole CMS portfolio. It is helpful if there is experience to draw from that informs our deliberations, but we recognize that, in some cases, there has not been the opportunity to test these models broadly.”

Most of all, the highest priority when it comes to the models is related to quality of care and cost.

“We are not soliciting models that are essentially tweaks to fee-for-service. We are looking for changes that cannot be made without a new method of payment,” she said, adding that the models “have to either reduce cost while maintaining quality or improve quality without raising cost.”

Meeting transcripts and video are posted online and can help potential applicants see how the committee came to its recommendations.

“The committee does not deliberate on the proposals except in public,” Ms. Mitchell said. “So, those public meetings were the first time we had deliberated on any of the proposals we have considered. The preliminary review teams have discussed it [in depth], but the full committee can only deliberate in public.”

[email protected]

Three physician-created advanced alternative payment models have been recommended for approval by an advisory committee of the Health & Human Services department. Their path to this milestone can help guide organizations and groups who want to benefit from the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA)–based Quality Payment Program on a more intense scale.

Advanced alternative payment models (APMs) involve physicians taking on two-sided risk along with Medicare in exchange for the potential for higher bonus payments for delivering higher value care to patients. Officials at the Centers for Medicare & Medicaid Services have created seven APMs (some primary care and some specialty focused), but they may not appeal to everyone. That’s where physician-created APMs come in.

• Scope of proposed PFPM (high priority)
• Quality and cost (high priority)
• Payment methodology (high priority)
• Value over volume
• Flexibility
• Ability to be evaluated
• Integration and care coordination
• Patient choice
• Patient safety
• Health information technology

While each proposal met a few of the criteria, none met all three high priority criteria and none were recommended for approval by its preliminary reviewers; however, after committee deliberation, two received provisional recommendation.

“We are recommending the two models for small-scale testing,” PTAC Vice-Chairman Elizabeth Mitchell said in an interview. “Even though we think they are very good ideas, we know that more experience and evidence is required before they may be ready.”

The two models that got the limited recommendation were

• Project Sonar, submitted by the Illinois Gastroenterology Group and SonarMD, a web-based platform that queries patients with inflammatory bowel disease monthly to determine which are in need of more hands-on care.
• APM, submitted by the American College of Surgeons, an episode-based payment model that uses claims data but expands on existing CMS value-based models by not requiring hospitalizations. It creates an episodic payment using outpatient settings, including acute and chronic care.

The COPD [chronic obstructive pulmonary disease] and Asthma Monitoring Project (CAMP), a smartphone app to remotely monitor and guide treatment of patients with asthma and chronic obstructive pulmonary disease, was not recommended. It was submitted by Pulmonary Medicine, Infectious Disease and Critical Care Consultants Medical Group of Sacremento, Calif.

PTAC has received more than 20 letters of intent from physicians and aims to hold another round of public hearings in September to determine their usefulness.

“I think it is very safe to say that our whole committee has been really gratified with the level of interest and engagement,” said Ms. Mitchell, president and CEO of Network for Regional Healthcare Improvement in Portland, Maine. The volume of applications “underscores the level of interest from the field. The entire reason PTAC was established was to get those good ideas from practicing physicians and others who are identifying better ways to deliver care but are facing barriers in the current payment system.”

She offered advice to those who are contemplating submission of a payment model.

“Really understand the criteria and review the request for proposals,” she said. “I think the committee lays out what we are looking for in terms of information, and we are hoping that it is really straight forward.”

She also stressed that successful models need to work broadly. “We are not talking about something that works for a single practice,” she said. “We are talking about models that are ready for inclusion in the whole CMS portfolio. It is helpful if there is experience to draw from that informs our deliberations, but we recognize that, in some cases, there has not been the opportunity to test these models broadly.”

Most of all, the highest priority when it comes to the models is related to quality of care and cost.

“We are not soliciting models that are essentially tweaks to fee-for-service. We are looking for changes that cannot be made without a new method of payment,” she said, adding that the models “have to either reduce cost while maintaining quality or improve quality without raising cost.”

Meeting transcripts and video are posted online and can help potential applicants see how the committee came to its recommendations.

“The committee does not deliberate on the proposals except in public,” Ms. Mitchell said. “So, those public meetings were the first time we had deliberated on any of the proposals we have considered. The preliminary review teams have discussed it [in depth], but the full committee can only deliberate in public.”

[email protected]

Vaccination against human papillomavirus (HPV) appears to be highly effective at preventing oral infection with oncogenic types of the virus, based on the results of a cohort study of a nationally representative sample of more than 2,600 U.S. young adults.

“HPV-positive oropharynx cancer is the fastest rising cancer among young white men in the United States. Over 90% of these cancers are caused by HPV type 16,” said senior study author Maura L. Gillison, MD, PhD, who conducted the research at Ohio State University, Columbus. “HPV 16 is one of the types covered in currently recommended HPV vaccines that have been shown to be safe and effective in the prevention of anogenital infections and associated cancers.

jarun011/Thinkstock

Vaccination against human papillomavirus (HPV) appears to be highly effective at preventing oral infection with oncogenic types of the virus, based on the results of a cohort study of a nationally representative sample of more than 2,600 U.S. young adults.

“HPV-positive oropharynx cancer is the fastest rising cancer among young white men in the United States. Over 90% of these cancers are caused by HPV type 16,” said senior study author Maura L. Gillison, MD, PhD, who conducted the research at Ohio State University, Columbus. “HPV 16 is one of the types covered in currently recommended HPV vaccines that have been shown to be safe and effective in the prevention of anogenital infections and associated cancers.

jarun011/Thinkstock

Vaccination against human papillomavirus (HPV) appears to be highly effective at preventing oral infection with oncogenic types of the virus, based on the results of a cohort study of a nationally representative sample of more than 2,600 U.S. young adults.

“HPV-positive oropharynx cancer is the fastest rising cancer among young white men in the United States. Over 90% of these cancers are caused by HPV type 16,” said senior study author Maura L. Gillison, MD, PhD, who conducted the research at Ohio State University, Columbus. “HPV 16 is one of the types covered in currently recommended HPV vaccines that have been shown to be safe and effective in the prevention of anogenital infections and associated cancers.

jarun011/Thinkstock