ATLANTA – Prenatal treatment of maternal subclinical hypothyroidism or hypothyroxinemia conferred no cognitive, behavioral, or neurodevelopmental benefit to children up to age 5.

The findings of two parallel randomized trials suggest that prenatal screening for these conditions is not necessary, Dr. Brian Casey said at the annual Pregnancy Meeting sponsored by the Society for Maternal-Fetal Medicine. The data also support the American College of Obstetricians and Gynecologists’ 2007 recommendation against routine screening, said Dr. Casey, chief of maternal-fetal medicine and obstetrics at the University of Texas Southwestern Medical Center, Dallas.

The issue of whether to treat pregnant women for subclinical hypothyroidism has been debated for years. Studies in the early 2000s suggested that prenatal levothyroxine did improve child neurocognitive outcomes, but more recent studies, including a 2012 randomized trial, do not.

These data have led both the American College of Obstetricians and Gynecologists and the Endocrine Society to recommend against screening for subclinical hypothyroidism in pregnant women.

Dr. Casey and his colleagues conducted two large parallel randomized studies, one in women with subclinical hypothyroidism and another in women with hypothyroxinemia. Subclinical hypothyroidism was defined as a thyroid stimulating hormone (TSH) level of at least 4 mU/L with normal free T4. Hypothyroxinemia was defined as a normal TSH but a free T4 of less than 0.86 ng/dL.

The primary outcome in each group was child IQ at 5 years. Secondary outcomes were scores on neurodevelopmental and behavioral measures, including the presence of attention deficit hyperactivity disorder, conducted at ages 3, 4, and 5 years.

All women in the trials had a singleton pregnancy of less than 20 weeks’ gestation, with no known history of thyroid disease.

The subclinical hypothyroidism group comprised 677 women. They were a mean of 27 years old, with a mean gestational age of 16.5 weeks. Baseline TSH was 4.5 mU/L; baseline free T4 was 1 ng/dL. All had normal urinary iodide. They were randomized to placebo or to daily 100 mcg levothyroxine. The treatment goal was a TSH of 0.1-2.5 mU/L. Most (93%) achieved this by 21 weeks’ gestation.

There was no significant difference in the primary outcome of child IQ at 5 years between the treated and untreated groups (97 vs. 94). On the Bayley Scales of Infant and Toddler Development, scores of cognition, motor skills, and language were similar in each group at both 12 and 24 months. The Differential Ability Scales scores at 3 and 4 years were also similar. The Child Behavior Checklist scores at ages 4 years and 5 years were similar. There was no indication of an increase in ADHD.

The hypothyroxinemia trial comprised 467 women. They were randomized to placebo or to 50 mcg levothyroxine. These women were a mean of 28 years old with a mean gestational age of 18 weeks. Their baseline TSH was 1.5 mU/L, and baseline free T4 was 0.8 ng/dL. All had normal urinary iodide. The treatment goal was a free T4 of between 0.86 and 1.90 ng/dL. Most (83%) achieved this by 23 weeks’ gestation.

There was no difference on the primary outcome of child IQ at 5 years (94 vs. 91). On the Bayley Scales of Infant and Toddler Development, scores of cognition, motor skills, and language were similar in each group at both 12 and 24 months. The Differential Ability Scales scores at 3 years and 4 years were also similar. The Child Behavior Checklist scores at ages 4years and 5 years were similar. There was no indication of an increase in ADHD.

Dr. Casey added that there was no interaction between gestational age at baseline and treatment outcomes, suggesting that there may be little foundation to the argument that treating earlier in pregnancy is key.

He had no financial disclosures.

[email protected]

ATLANTA – Prenatal treatment of maternal subclinical hypothyroidism or hypothyroxinemia conferred no cognitive, behavioral, or neurodevelopmental benefit to children up to age 5.

The findings of two parallel randomized trials suggest that prenatal screening for these conditions is not necessary, Dr. Brian Casey said at the annual Pregnancy Meeting sponsored by the Society for Maternal-Fetal Medicine. The data also support the American College of Obstetricians and Gynecologists’ 2007 recommendation against routine screening, said Dr. Casey, chief of maternal-fetal medicine and obstetrics at the University of Texas Southwestern Medical Center, Dallas.

The issue of whether to treat pregnant women for subclinical hypothyroidism has been debated for years. Studies in the early 2000s suggested that prenatal levothyroxine did improve child neurocognitive outcomes, but more recent studies, including a 2012 randomized trial, do not.

These data have led both the American College of Obstetricians and Gynecologists and the Endocrine Society to recommend against screening for subclinical hypothyroidism in pregnant women.

Dr. Casey and his colleagues conducted two large parallel randomized studies, one in women with subclinical hypothyroidism and another in women with hypothyroxinemia. Subclinical hypothyroidism was defined as a thyroid stimulating hormone (TSH) level of at least 4 mU/L with normal free T4. Hypothyroxinemia was defined as a normal TSH but a free T4 of less than 0.86 ng/dL.

The primary outcome in each group was child IQ at 5 years. Secondary outcomes were scores on neurodevelopmental and behavioral measures, including the presence of attention deficit hyperactivity disorder, conducted at ages 3, 4, and 5 years.

All women in the trials had a singleton pregnancy of less than 20 weeks’ gestation, with no known history of thyroid disease.

The subclinical hypothyroidism group comprised 677 women. They were a mean of 27 years old, with a mean gestational age of 16.5 weeks. Baseline TSH was 4.5 mU/L; baseline free T4 was 1 ng/dL. All had normal urinary iodide. They were randomized to placebo or to daily 100 mcg levothyroxine. The treatment goal was a TSH of 0.1-2.5 mU/L. Most (93%) achieved this by 21 weeks’ gestation.

There was no significant difference in the primary outcome of child IQ at 5 years between the treated and untreated groups (97 vs. 94). On the Bayley Scales of Infant and Toddler Development, scores of cognition, motor skills, and language were similar in each group at both 12 and 24 months. The Differential Ability Scales scores at 3 and 4 years were also similar. The Child Behavior Checklist scores at ages 4 years and 5 years were similar. There was no indication of an increase in ADHD.

The hypothyroxinemia trial comprised 467 women. They were randomized to placebo or to 50 mcg levothyroxine. These women were a mean of 28 years old with a mean gestational age of 18 weeks. Their baseline TSH was 1.5 mU/L, and baseline free T4 was 0.8 ng/dL. All had normal urinary iodide. The treatment goal was a free T4 of between 0.86 and 1.90 ng/dL. Most (83%) achieved this by 23 weeks’ gestation.

There was no difference on the primary outcome of child IQ at 5 years (94 vs. 91). On the Bayley Scales of Infant and Toddler Development, scores of cognition, motor skills, and language were similar in each group at both 12 and 24 months. The Differential Ability Scales scores at 3 years and 4 years were also similar. The Child Behavior Checklist scores at ages 4years and 5 years were similar. There was no indication of an increase in ADHD.

Dr. Casey added that there was no interaction between gestational age at baseline and treatment outcomes, suggesting that there may be little foundation to the argument that treating earlier in pregnancy is key.

He had no financial disclosures.

[email protected]

ATLANTA – Prenatal treatment of maternal subclinical hypothyroidism or hypothyroxinemia conferred no cognitive, behavioral, or neurodevelopmental benefit to children up to age 5.

The findings of two parallel randomized trials suggest that prenatal screening for these conditions is not necessary, Dr. Brian Casey said at the annual Pregnancy Meeting sponsored by the Society for Maternal-Fetal Medicine. The data also support the American College of Obstetricians and Gynecologists’ 2007 recommendation against routine screening, said Dr. Casey, chief of maternal-fetal medicine and obstetrics at the University of Texas Southwestern Medical Center, Dallas.

The issue of whether to treat pregnant women for subclinical hypothyroidism has been debated for years. Studies in the early 2000s suggested that prenatal levothyroxine did improve child neurocognitive outcomes, but more recent studies, including a 2012 randomized trial, do not.

These data have led both the American College of Obstetricians and Gynecologists and the Endocrine Society to recommend against screening for subclinical hypothyroidism in pregnant women.

Dr. Casey and his colleagues conducted two large parallel randomized studies, one in women with subclinical hypothyroidism and another in women with hypothyroxinemia. Subclinical hypothyroidism was defined as a thyroid stimulating hormone (TSH) level of at least 4 mU/L with normal free T4. Hypothyroxinemia was defined as a normal TSH but a free T4 of less than 0.86 ng/dL.

The primary outcome in each group was child IQ at 5 years. Secondary outcomes were scores on neurodevelopmental and behavioral measures, including the presence of attention deficit hyperactivity disorder, conducted at ages 3, 4, and 5 years.

All women in the trials had a singleton pregnancy of less than 20 weeks’ gestation, with no known history of thyroid disease.

The subclinical hypothyroidism group comprised 677 women. They were a mean of 27 years old, with a mean gestational age of 16.5 weeks. Baseline TSH was 4.5 mU/L; baseline free T4 was 1 ng/dL. All had normal urinary iodide. They were randomized to placebo or to daily 100 mcg levothyroxine. The treatment goal was a TSH of 0.1-2.5 mU/L. Most (93%) achieved this by 21 weeks’ gestation.

There was no significant difference in the primary outcome of child IQ at 5 years between the treated and untreated groups (97 vs. 94). On the Bayley Scales of Infant and Toddler Development, scores of cognition, motor skills, and language were similar in each group at both 12 and 24 months. The Differential Ability Scales scores at 3 and 4 years were also similar. The Child Behavior Checklist scores at ages 4 years and 5 years were similar. There was no indication of an increase in ADHD.

The hypothyroxinemia trial comprised 467 women. They were randomized to placebo or to 50 mcg levothyroxine. These women were a mean of 28 years old with a mean gestational age of 18 weeks. Their baseline TSH was 1.5 mU/L, and baseline free T4 was 0.8 ng/dL. All had normal urinary iodide. The treatment goal was a free T4 of between 0.86 and 1.90 ng/dL. Most (83%) achieved this by 23 weeks’ gestation.

There was no difference on the primary outcome of child IQ at 5 years (94 vs. 91). On the Bayley Scales of Infant and Toddler Development, scores of cognition, motor skills, and language were similar in each group at both 12 and 24 months. The Differential Ability Scales scores at 3 years and 4 years were also similar. The Child Behavior Checklist scores at ages 4years and 5 years were similar. There was no indication of an increase in ADHD.

Dr. Casey added that there was no interaction between gestational age at baseline and treatment outcomes, suggesting that there may be little foundation to the argument that treating earlier in pregnancy is key.

He had no financial disclosures.

[email protected]

Many lesbian, gay, bisexual, and transgender (LGBT) youth face misconceptions about their sexual or gender identity. This is especially true when it comes to sex and relationships. Unfortunately, many clinicians believe these myths, and they can have devastating consequences on the health of LGBT youth.

Here are some common myths about sex and relationships in LGBT youth, and how you, as a provider, can combat them with knowledge and compassion:

Myth No. 1: Bisexual youth are promiscuous. This is a stereotype that even plagues bisexual adults. There is a persistent misconception that just because bisexuals are attracted to both sexes, they are naturally promiscuous. In fact, most bisexuals describe themselves as monogamous.¹

Myth No. 2: Youth who are transgender are lesbian/gay/bisexual before transition and are straight after transition. According to the National Transgender Discrimination Survey, regardless of where they are in the transition process, 23% of transgender people identify as heterosexual, 23% identify as gay or lesbian, 25% identify as bisexual, 23% label themselves as queer, 4% describe themselves as asexual and 2% wrote in other answers.²

Myth No. 3: Gay and lesbian teens only have sex or romantic relationships with the same sex. According to the Youth Risk Behavior Survey, although 22% of lesbian and gay teens say they have sex with the same sex only, about 9% say that they have sex with both sexes.³ This shows that sexual identity does not predict sexual behavior and has important implications for the following myths.

Myth No. 4: Lesbian and bisexual girls don’t experience intimate partner violence. Because the majority of those who perpetrate intimate partner violence are men, it is tempting to assume that lesbian and bisexual teenage girls don’t experience abuse in their relationships.

Unfortunately, one study shows that 42% of lesbian and bisexual girls experienced intimate partner violence in the past, compared with 16% of heterosexual girls.⁴ However, this study and others do not tell us whether they have experienced abuse in their relationships with girls or with boys.

Myth No. 5: Lesbian girls can’t get gonorrhea or chlamydia or pelvic inflammatory disease (PID). About 2% of young lesbians report ever having any sexually transmitted infection (STI). A small percentage of young lesbians report having chlamydia, and this is associated with PID. It is true, however, that gonorrhea is rare among lesbians,⁵ but don’t forget that young lesbian women may have had sex with men.

Interestingly, the prevalence of bacterial vaginosis, a condition characterized by overgrowth of vaginal anaerobic bacteria, is higher in young women who have sex with women.⁶ Possible sources of transmission include digital-to-vaginal contact, oral sex, or sex toys.

Myth No. 6: Young women who have sex with women can’t get pregnant, so you don’t have to worry about birth control. Don’t forget that heterosexuals use birth control for other reasons than preventing pregnancy. Some women use birth control to help regulate periods, to ease cramping, or to treat acne. Lesbians and bisexual girls are at the same risk for these problems as are heterosexual girls, so don’t assume that they’re not interested in birth control just because they are not concerned about getting pregnant.

Also, as previously mentioned, lesbian girls may be having sex with boys, so conversations about birth control should be driven by who they are having sex with, not by how they identify.

Myth No. 7: Gay boys can’t get girls pregnant. Lesbian girls can’t get pregnant. A study by the Toronto Teen Sex Survey found that 28% of sexual minority youth report involvement in pregnancy, compared with 7% of heterosexual youth.⁷

Now many who are reading this may be scratching their heads. If someone finds the same sex attractive, then why are they engaging in heterosexual sex? Some studies suggest that engaging in heterosexual sex is a way to hide their true sexual orientation,⁸ because we live in a heterosexist and homophobic environment. After all, what better way to prove that you’re heterosexual? Another study suggests that intentionally getting pregnant or getting someone pregnant is the quickest way to parenthood, and becoming a parent can compensate for one’s identity as a sexual minority.⁹

So how do you overcome these persistent myths? The most important thing to do is not assume. Identity and behaviors are not the same. Always be specific when you’re asking questions about sex and relationships in LGBT youth.

The Centers for Disease Control and Prevention (CDC) recommends the following when obtaining a sexual history:

• Ask, “Are your sexual partner’s male, female, or both?”

• Ask, “When you do have sex with your partner, what do you do?” Here, you have to be very specific. Younger teenagers tend to be concrete thinkers, so don’t just ask “Are you sexually active?” Instead, try asking, “Have you ever had a penis in your mouth, vagina, or anus?” or “Do you use sex toys?”

• In terms of protection from STIs, you might ask, “Do you use condoms or a dental dam?”

• Ask, “Have you ever had an STI, and if so, how was it treated?”

• Ask, “What do you use for birth control?” either hormonal or barrier methods.

In addition to above questions, I would also ask about intimate partner violence. Often, health care providers may ask if their patient has been hit, punch, slapped, or kicked by their partners. But intimate partner violence can go beyond physical violence. It also involves emotional manipulation or birth control sabotage. Sometimes, it is better to ask if a patient has been forced to do something sexual with her partners when she didn’t want to. The patient may deny it, however, even though you highly suspect it. So it is better to remember to build a rapport, and when the patient is ready to get out of an abusive relationship, he or she will come to you for help.

Some clinicians have told me that they have a hard time asking sexual histories in LGBT youth because they’re afraid of offending them, especially when it comes to asking about sex with the opposite sex. This is a valid concern and an area of ongoing research, but I think that by making things normative, just like with any behavior, teens and young adults are more likely to disclose critical pieces of information. It is a good idea, then, to start off with “Because of homophobia, many LGBT youth may engage in heterosexual sex. Tell me, have you ever…”

By not assuming and asking specific questions, LGBT youth are more likely to tell their health care provider important information. With that information, health care providers can prevent many adverse health outcomes like teen pregnancy, STIs, and intimate partner violence. It also will give health care providers an opportunity to address the rampant stigma and discrimination that plagues this vulnerable population.

Here are some resources on sex and relationships in LGBT youth:

• The CDC 2015 STI Guidelines have a special section on STIs in men who have sex with men, women who have sex with women, and transgender men and women.

• Bedsider.org is an excellent website about birth control options and STI prevention for all sexual orientations and gender identities.

• Futures Without Violence provides resources for health care professionals to manage and prevent intimate partner violence.

References

1. J Bisex. 2000;1(1):31-68.

2. National Transgender Discrimination Survey: Full Report. 2012.

3. MMWR Surveill Summ. 2011 Jun 10;60(7):1-133.

4. J Youth Adolesc. 2015 Jan;44(1):211-24.

5. Perspect Sex Reprod Health. 2008 Dec;40(4):212-7.

6. Sex Transm Dis. 2010 May;37(5):335-9.

7. Sexpress: The Toronto teen survey report. 2009.

8. Fletcher RC. Social context and social support: Exploring the lived experiences of LGBTQ youth who have been pregnant. [Master’s Project]: School of Public Health, University of Minnesota; 2011.

9. Can J Hum Sex. 2008;17(3):123-139.

Dr. Montano is an adolescent medicine fellow at Children’s Hospital of Pittsburgh of UPMC and a postdoctoral fellow in the department of pediatrics at the University of Pittsburgh. He has no relevant financial disclosures.

Many lesbian, gay, bisexual, and transgender (LGBT) youth face misconceptions about their sexual or gender identity. This is especially true when it comes to sex and relationships. Unfortunately, many clinicians believe these myths, and they can have devastating consequences on the health of LGBT youth.

Here are some common myths about sex and relationships in LGBT youth, and how you, as a provider, can combat them with knowledge and compassion:

Myth No. 1: Bisexual youth are promiscuous. This is a stereotype that even plagues bisexual adults. There is a persistent misconception that just because bisexuals are attracted to both sexes, they are naturally promiscuous. In fact, most bisexuals describe themselves as monogamous.¹

Myth No. 2: Youth who are transgender are lesbian/gay/bisexual before transition and are straight after transition. According to the National Transgender Discrimination Survey, regardless of where they are in the transition process, 23% of transgender people identify as heterosexual, 23% identify as gay or lesbian, 25% identify as bisexual, 23% label themselves as queer, 4% describe themselves as asexual and 2% wrote in other answers.²

Myth No. 3: Gay and lesbian teens only have sex or romantic relationships with the same sex. According to the Youth Risk Behavior Survey, although 22% of lesbian and gay teens say they have sex with the same sex only, about 9% say that they have sex with both sexes.³ This shows that sexual identity does not predict sexual behavior and has important implications for the following myths.

Myth No. 4: Lesbian and bisexual girls don’t experience intimate partner violence. Because the majority of those who perpetrate intimate partner violence are men, it is tempting to assume that lesbian and bisexual teenage girls don’t experience abuse in their relationships.

Unfortunately, one study shows that 42% of lesbian and bisexual girls experienced intimate partner violence in the past, compared with 16% of heterosexual girls.⁴ However, this study and others do not tell us whether they have experienced abuse in their relationships with girls or with boys.

Myth No. 5: Lesbian girls can’t get gonorrhea or chlamydia or pelvic inflammatory disease (PID). About 2% of young lesbians report ever having any sexually transmitted infection (STI). A small percentage of young lesbians report having chlamydia, and this is associated with PID. It is true, however, that gonorrhea is rare among lesbians,⁵ but don’t forget that young lesbian women may have had sex with men.

Interestingly, the prevalence of bacterial vaginosis, a condition characterized by overgrowth of vaginal anaerobic bacteria, is higher in young women who have sex with women.⁶ Possible sources of transmission include digital-to-vaginal contact, oral sex, or sex toys.

Myth No. 6: Young women who have sex with women can’t get pregnant, so you don’t have to worry about birth control. Don’t forget that heterosexuals use birth control for other reasons than preventing pregnancy. Some women use birth control to help regulate periods, to ease cramping, or to treat acne. Lesbians and bisexual girls are at the same risk for these problems as are heterosexual girls, so don’t assume that they’re not interested in birth control just because they are not concerned about getting pregnant.

Also, as previously mentioned, lesbian girls may be having sex with boys, so conversations about birth control should be driven by who they are having sex with, not by how they identify.

Myth No. 7: Gay boys can’t get girls pregnant. Lesbian girls can’t get pregnant. A study by the Toronto Teen Sex Survey found that 28% of sexual minority youth report involvement in pregnancy, compared with 7% of heterosexual youth.⁷

Now many who are reading this may be scratching their heads. If someone finds the same sex attractive, then why are they engaging in heterosexual sex? Some studies suggest that engaging in heterosexual sex is a way to hide their true sexual orientation,⁸ because we live in a heterosexist and homophobic environment. After all, what better way to prove that you’re heterosexual? Another study suggests that intentionally getting pregnant or getting someone pregnant is the quickest way to parenthood, and becoming a parent can compensate for one’s identity as a sexual minority.⁹

So how do you overcome these persistent myths? The most important thing to do is not assume. Identity and behaviors are not the same. Always be specific when you’re asking questions about sex and relationships in LGBT youth.

The Centers for Disease Control and Prevention (CDC) recommends the following when obtaining a sexual history:

• Ask, “Are your sexual partner’s male, female, or both?”

• Ask, “When you do have sex with your partner, what do you do?” Here, you have to be very specific. Younger teenagers tend to be concrete thinkers, so don’t just ask “Are you sexually active?” Instead, try asking, “Have you ever had a penis in your mouth, vagina, or anus?” or “Do you use sex toys?”

• In terms of protection from STIs, you might ask, “Do you use condoms or a dental dam?”

• Ask, “Have you ever had an STI, and if so, how was it treated?”

• Ask, “What do you use for birth control?” either hormonal or barrier methods.

In addition to above questions, I would also ask about intimate partner violence. Often, health care providers may ask if their patient has been hit, punch, slapped, or kicked by their partners. But intimate partner violence can go beyond physical violence. It also involves emotional manipulation or birth control sabotage. Sometimes, it is better to ask if a patient has been forced to do something sexual with her partners when she didn’t want to. The patient may deny it, however, even though you highly suspect it. So it is better to remember to build a rapport, and when the patient is ready to get out of an abusive relationship, he or she will come to you for help.

Some clinicians have told me that they have a hard time asking sexual histories in LGBT youth because they’re afraid of offending them, especially when it comes to asking about sex with the opposite sex. This is a valid concern and an area of ongoing research, but I think that by making things normative, just like with any behavior, teens and young adults are more likely to disclose critical pieces of information. It is a good idea, then, to start off with “Because of homophobia, many LGBT youth may engage in heterosexual sex. Tell me, have you ever…”

By not assuming and asking specific questions, LGBT youth are more likely to tell their health care provider important information. With that information, health care providers can prevent many adverse health outcomes like teen pregnancy, STIs, and intimate partner violence. It also will give health care providers an opportunity to address the rampant stigma and discrimination that plagues this vulnerable population.

Here are some resources on sex and relationships in LGBT youth:

• The CDC 2015 STI Guidelines have a special section on STIs in men who have sex with men, women who have sex with women, and transgender men and women.

• Bedsider.org is an excellent website about birth control options and STI prevention for all sexual orientations and gender identities.

• Futures Without Violence provides resources for health care professionals to manage and prevent intimate partner violence.

References

1. J Bisex. 2000;1(1):31-68.

2. National Transgender Discrimination Survey: Full Report. 2012.

3. MMWR Surveill Summ. 2011 Jun 10;60(7):1-133.

4. J Youth Adolesc. 2015 Jan;44(1):211-24.

5. Perspect Sex Reprod Health. 2008 Dec;40(4):212-7.

6. Sex Transm Dis. 2010 May;37(5):335-9.

7. Sexpress: The Toronto teen survey report. 2009.

8. Fletcher RC. Social context and social support: Exploring the lived experiences of LGBTQ youth who have been pregnant. [Master’s Project]: School of Public Health, University of Minnesota; 2011.

9. Can J Hum Sex. 2008;17(3):123-139.

Dr. Montano is an adolescent medicine fellow at Children’s Hospital of Pittsburgh of UPMC and a postdoctoral fellow in the department of pediatrics at the University of Pittsburgh. He has no relevant financial disclosures.

Many lesbian, gay, bisexual, and transgender (LGBT) youth face misconceptions about their sexual or gender identity. This is especially true when it comes to sex and relationships. Unfortunately, many clinicians believe these myths, and they can have devastating consequences on the health of LGBT youth.

Here are some common myths about sex and relationships in LGBT youth, and how you, as a provider, can combat them with knowledge and compassion:

Myth No. 1: Bisexual youth are promiscuous. This is a stereotype that even plagues bisexual adults. There is a persistent misconception that just because bisexuals are attracted to both sexes, they are naturally promiscuous. In fact, most bisexuals describe themselves as monogamous.¹

Myth No. 2: Youth who are transgender are lesbian/gay/bisexual before transition and are straight after transition. According to the National Transgender Discrimination Survey, regardless of where they are in the transition process, 23% of transgender people identify as heterosexual, 23% identify as gay or lesbian, 25% identify as bisexual, 23% label themselves as queer, 4% describe themselves as asexual and 2% wrote in other answers.²

Myth No. 3: Gay and lesbian teens only have sex or romantic relationships with the same sex. According to the Youth Risk Behavior Survey, although 22% of lesbian and gay teens say they have sex with the same sex only, about 9% say that they have sex with both sexes.³ This shows that sexual identity does not predict sexual behavior and has important implications for the following myths.

Myth No. 4: Lesbian and bisexual girls don’t experience intimate partner violence. Because the majority of those who perpetrate intimate partner violence are men, it is tempting to assume that lesbian and bisexual teenage girls don’t experience abuse in their relationships.

Unfortunately, one study shows that 42% of lesbian and bisexual girls experienced intimate partner violence in the past, compared with 16% of heterosexual girls.⁴ However, this study and others do not tell us whether they have experienced abuse in their relationships with girls or with boys.

Myth No. 5: Lesbian girls can’t get gonorrhea or chlamydia or pelvic inflammatory disease (PID). About 2% of young lesbians report ever having any sexually transmitted infection (STI). A small percentage of young lesbians report having chlamydia, and this is associated with PID. It is true, however, that gonorrhea is rare among lesbians,⁵ but don’t forget that young lesbian women may have had sex with men.

Interestingly, the prevalence of bacterial vaginosis, a condition characterized by overgrowth of vaginal anaerobic bacteria, is higher in young women who have sex with women.⁶ Possible sources of transmission include digital-to-vaginal contact, oral sex, or sex toys.

Myth No. 6: Young women who have sex with women can’t get pregnant, so you don’t have to worry about birth control. Don’t forget that heterosexuals use birth control for other reasons than preventing pregnancy. Some women use birth control to help regulate periods, to ease cramping, or to treat acne. Lesbians and bisexual girls are at the same risk for these problems as are heterosexual girls, so don’t assume that they’re not interested in birth control just because they are not concerned about getting pregnant.

Also, as previously mentioned, lesbian girls may be having sex with boys, so conversations about birth control should be driven by who they are having sex with, not by how they identify.

Myth No. 7: Gay boys can’t get girls pregnant. Lesbian girls can’t get pregnant. A study by the Toronto Teen Sex Survey found that 28% of sexual minority youth report involvement in pregnancy, compared with 7% of heterosexual youth.⁷

Now many who are reading this may be scratching their heads. If someone finds the same sex attractive, then why are they engaging in heterosexual sex? Some studies suggest that engaging in heterosexual sex is a way to hide their true sexual orientation,⁸ because we live in a heterosexist and homophobic environment. After all, what better way to prove that you’re heterosexual? Another study suggests that intentionally getting pregnant or getting someone pregnant is the quickest way to parenthood, and becoming a parent can compensate for one’s identity as a sexual minority.⁹

So how do you overcome these persistent myths? The most important thing to do is not assume. Identity and behaviors are not the same. Always be specific when you’re asking questions about sex and relationships in LGBT youth.

The Centers for Disease Control and Prevention (CDC) recommends the following when obtaining a sexual history:

• Ask, “Are your sexual partner’s male, female, or both?”

• Ask, “When you do have sex with your partner, what do you do?” Here, you have to be very specific. Younger teenagers tend to be concrete thinkers, so don’t just ask “Are you sexually active?” Instead, try asking, “Have you ever had a penis in your mouth, vagina, or anus?” or “Do you use sex toys?”

• In terms of protection from STIs, you might ask, “Do you use condoms or a dental dam?”

• Ask, “Have you ever had an STI, and if so, how was it treated?”

• Ask, “What do you use for birth control?” either hormonal or barrier methods.

In addition to above questions, I would also ask about intimate partner violence. Often, health care providers may ask if their patient has been hit, punch, slapped, or kicked by their partners. But intimate partner violence can go beyond physical violence. It also involves emotional manipulation or birth control sabotage. Sometimes, it is better to ask if a patient has been forced to do something sexual with her partners when she didn’t want to. The patient may deny it, however, even though you highly suspect it. So it is better to remember to build a rapport, and when the patient is ready to get out of an abusive relationship, he or she will come to you for help.

Some clinicians have told me that they have a hard time asking sexual histories in LGBT youth because they’re afraid of offending them, especially when it comes to asking about sex with the opposite sex. This is a valid concern and an area of ongoing research, but I think that by making things normative, just like with any behavior, teens and young adults are more likely to disclose critical pieces of information. It is a good idea, then, to start off with “Because of homophobia, many LGBT youth may engage in heterosexual sex. Tell me, have you ever…”

By not assuming and asking specific questions, LGBT youth are more likely to tell their health care provider important information. With that information, health care providers can prevent many adverse health outcomes like teen pregnancy, STIs, and intimate partner violence. It also will give health care providers an opportunity to address the rampant stigma and discrimination that plagues this vulnerable population.

Here are some resources on sex and relationships in LGBT youth:

• The CDC 2015 STI Guidelines have a special section on STIs in men who have sex with men, women who have sex with women, and transgender men and women.

• Bedsider.org is an excellent website about birth control options and STI prevention for all sexual orientations and gender identities.

• Futures Without Violence provides resources for health care professionals to manage and prevent intimate partner violence.

References

1. J Bisex. 2000;1(1):31-68.

2. National Transgender Discrimination Survey: Full Report. 2012.

3. MMWR Surveill Summ. 2011 Jun 10;60(7):1-133.

4. J Youth Adolesc. 2015 Jan;44(1):211-24.

5. Perspect Sex Reprod Health. 2008 Dec;40(4):212-7.

6. Sex Transm Dis. 2010 May;37(5):335-9.

7. Sexpress: The Toronto teen survey report. 2009.

8. Fletcher RC. Social context and social support: Exploring the lived experiences of LGBTQ youth who have been pregnant. [Master’s Project]: School of Public Health, University of Minnesota; 2011.

9. Can J Hum Sex. 2008;17(3):123-139.

Dr. Montano is an adolescent medicine fellow at Children’s Hospital of Pittsburgh of UPMC and a postdoctoral fellow in the department of pediatrics at the University of Pittsburgh. He has no relevant financial disclosures.

The Division of Member Services strives to educate surgical patients about what it means to be treated by a surgeon who is a Fellow of the American College of Surgeons (FACS). As part of this campaign, the College has created a poster of the Fellowship Pledge that is suitable for display in waiting areas, exam rooms, and offices, and is available for purchase or free download. The Fellowship Pledge poster—available in seven languages: English, Arabic, Chinese (both Simplified and Traditional), Japanese, German, Portuguese and Spanish—may be displayed only by surgeons with the FACS designation.

ACS Fellows are committed to providing their patients with the highest standards of surgical care and pledge to protect the welfare and rights of their patients, to respect each patient’s autonomy and individuality, and to advance their knowledge and skills throughout their careers. The Fellowship Pledge poster is available for purchase for $10.00 including standard shipping, or can be downloaded for free. Visit the ACS Online Store at https://goo.gl/sCKiUc to download your poster. Two PDF versions are available; a 22” x 32” poster that may be printed by a professional print shop, or an 11” x 17” version that may be printed on a personal color printer.

The Division of Member Services strives to educate surgical patients about what it means to be treated by a surgeon who is a Fellow of the American College of Surgeons (FACS). As part of this campaign, the College has created a poster of the Fellowship Pledge that is suitable for display in waiting areas, exam rooms, and offices, and is available for purchase or free download. The Fellowship Pledge poster—available in seven languages: English, Arabic, Chinese (both Simplified and Traditional), Japanese, German, Portuguese and Spanish—may be displayed only by surgeons with the FACS designation.

ACS Fellows are committed to providing their patients with the highest standards of surgical care and pledge to protect the welfare and rights of their patients, to respect each patient’s autonomy and individuality, and to advance their knowledge and skills throughout their careers. The Fellowship Pledge poster is available for purchase for $10.00 including standard shipping, or can be downloaded for free. Visit the ACS Online Store at https://goo.gl/sCKiUc to download your poster. Two PDF versions are available; a 22” x 32” poster that may be printed by a professional print shop, or an 11” x 17” version that may be printed on a personal color printer.

The Division of Member Services strives to educate surgical patients about what it means to be treated by a surgeon who is a Fellow of the American College of Surgeons (FACS). As part of this campaign, the College has created a poster of the Fellowship Pledge that is suitable for display in waiting areas, exam rooms, and offices, and is available for purchase or free download. The Fellowship Pledge poster—available in seven languages: English, Arabic, Chinese (both Simplified and Traditional), Japanese, German, Portuguese and Spanish—may be displayed only by surgeons with the FACS designation.

ACS Fellows are committed to providing their patients with the highest standards of surgical care and pledge to protect the welfare and rights of their patients, to respect each patient’s autonomy and individuality, and to advance their knowledge and skills throughout their careers. The Fellowship Pledge poster is available for purchase for $10.00 including standard shipping, or can be downloaded for free. Visit the ACS Online Store at https://goo.gl/sCKiUc to download your poster. Two PDF versions are available; a 22” x 32” poster that may be printed by a professional print shop, or an 11” x 17” version that may be printed on a personal color printer.

Registration is now open for the fifth annual American College of Surgeons (ACS) 2016 Leadership & Advocacy Summit, April 9–12, at the JW Marriott, Washington, DC. The Summit is a dual meeting that offers volunteer leaders and advocates educational sessions fon effective surgeon leadership, as well as interactive advocacy training with coordinated visits to congressional offices.

The 2016 Leadership Summit

(https://www.facs.org/advocacy/participate/summit-2016) will commence the evening of Saturday, April 9, with a Welcome Reception and continue the morning of April 12 with presentations on conflict management, managing difficult or “courageous” conversations, and emotional intelligence. In addition, Adil Haider, MD, MPH, FACS, director, Kessler Center for Surgery and Public Health (CSPH), a joint initiative of Brigham and Women’s Hospital, Harvard Medical School, and the Harvard T.H. Chan School of Public Health, Boston, MA, will discuss unconscious bias and cultural competency in surgical care. During lunch, attendees will meet in small groups by state/region to identify areas for unified efforts in the upcoming year.

The Advocacy Summit will begin the evening of Sunday, April 10, with a keynote address by MSNBC Hardball host, Chris Matthews, who is also a frequent commentator and expert analyst on NBC’s TODAY Show. Monday, April 11, attendees will hear from speakers examining the political environment in Washington, DC, and across the nation, and vital health care issues.

Tuesday morning, attendees will use the knowledge gathered at the Summit when they meet with their senators and representative and/or congressional staff. Tuesday’s meetings provide an opportunity to rally surgery’s collective grassroots advocacy voice on vital issues.

For more information or to register for the 2016 Leadership & Advocacy Summit, go to the ACS website. (https://www.facs.org/advocacy/participate/summit-2016 ) The conference hotel reservation deadline is Friday, March 4.

Registration is now open for the fifth annual American College of Surgeons (ACS) 2016 Leadership & Advocacy Summit, April 9–12, at the JW Marriott, Washington, DC. The Summit is a dual meeting that offers volunteer leaders and advocates educational sessions fon effective surgeon leadership, as well as interactive advocacy training with coordinated visits to congressional offices.

The 2016 Leadership Summit

(https://www.facs.org/advocacy/participate/summit-2016) will commence the evening of Saturday, April 9, with a Welcome Reception and continue the morning of April 12 with presentations on conflict management, managing difficult or “courageous” conversations, and emotional intelligence. In addition, Adil Haider, MD, MPH, FACS, director, Kessler Center for Surgery and Public Health (CSPH), a joint initiative of Brigham and Women’s Hospital, Harvard Medical School, and the Harvard T.H. Chan School of Public Health, Boston, MA, will discuss unconscious bias and cultural competency in surgical care. During lunch, attendees will meet in small groups by state/region to identify areas for unified efforts in the upcoming year.

The Advocacy Summit will begin the evening of Sunday, April 10, with a keynote address by MSNBC Hardball host, Chris Matthews, who is also a frequent commentator and expert analyst on NBC’s TODAY Show. Monday, April 11, attendees will hear from speakers examining the political environment in Washington, DC, and across the nation, and vital health care issues.

Tuesday morning, attendees will use the knowledge gathered at the Summit when they meet with their senators and representative and/or congressional staff. Tuesday’s meetings provide an opportunity to rally surgery’s collective grassroots advocacy voice on vital issues.

For more information or to register for the 2016 Leadership & Advocacy Summit, go to the ACS website. (https://www.facs.org/advocacy/participate/summit-2016 ) The conference hotel reservation deadline is Friday, March 4.

Registration is now open for the fifth annual American College of Surgeons (ACS) 2016 Leadership & Advocacy Summit, April 9–12, at the JW Marriott, Washington, DC. The Summit is a dual meeting that offers volunteer leaders and advocates educational sessions fon effective surgeon leadership, as well as interactive advocacy training with coordinated visits to congressional offices.

The 2016 Leadership Summit

(https://www.facs.org/advocacy/participate/summit-2016) will commence the evening of Saturday, April 9, with a Welcome Reception and continue the morning of April 12 with presentations on conflict management, managing difficult or “courageous” conversations, and emotional intelligence. In addition, Adil Haider, MD, MPH, FACS, director, Kessler Center for Surgery and Public Health (CSPH), a joint initiative of Brigham and Women’s Hospital, Harvard Medical School, and the Harvard T.H. Chan School of Public Health, Boston, MA, will discuss unconscious bias and cultural competency in surgical care. During lunch, attendees will meet in small groups by state/region to identify areas for unified efforts in the upcoming year.

The Advocacy Summit will begin the evening of Sunday, April 10, with a keynote address by MSNBC Hardball host, Chris Matthews, who is also a frequent commentator and expert analyst on NBC’s TODAY Show. Monday, April 11, attendees will hear from speakers examining the political environment in Washington, DC, and across the nation, and vital health care issues.

Tuesday morning, attendees will use the knowledge gathered at the Summit when they meet with their senators and representative and/or congressional staff. Tuesday’s meetings provide an opportunity to rally surgery’s collective grassroots advocacy voice on vital issues.

For more information or to register for the 2016 Leadership & Advocacy Summit, go to the ACS website. (https://www.facs.org/advocacy/participate/summit-2016 ) The conference hotel reservation deadline is Friday, March 4.

Lead poisoning is a well-established cause of serious and permanent neurological, cognitive, and behavioral problems, particularly in exposed children.

Children can be exposed to lead from ingesting paint chips in their homes, when old paint is scrapped from the exterior of houses or bridges, and through the water they drink. The damage caused by lead poisoning was first recognized in the United States in the early 20th century, although lead was added to gasoline and paint until the 1970’s. Since then, regulations for lead in consumer products have become increasingly strict, and the Centers for Disease Control and Prevention’s definition of a toxic lead level has shifted from 60 micrograms/deciliter (mcg/dL) in 1970 to 5 mcg/dL in 2012. In many communities, removing lead paint up to the height of a young child is a requirement whenever an older home is sold.

Unfortunately, these regulations did not protect the families in Flint, Michigan from being exposed to high levels of lead when a change in water supply and inadequate water treatment allowed lead to enter the system from decaying water pipes. It is worth reviewing what is known about the short- and long-term consequences of lead exposure, and what lies ahead for the children of Flint.

Lead is a naturally occurring element that is not metabolized, but rather absorbed, distributed to tissues, and excreted. Lead can be inhaled (with 100% absorption) and introduced through the GI tract (with about 70% absorption in children and 20% absorption in adults). GI absorption is enhanced by calcium or iron deficiency, both conditions that are relatively common, especially in poor children and can lead to pica (or eating of non-nutritious materials), further increasing the chances of lead exposure. Absorbed lead is distributed to blood (for 28-36 days), soft tissue, including the nervous system (40 days), and to bone (where it lasts for over 25 years). Blood that is retained in growing bones can be mobilized during periods of physiologic stress (such as illness, injury, or pregnancy), meaning children exposed to lead during a period of rapid bone growth are at long-term risk for acute lead poisoning from their endogenous reservoir without a new exposure. What lead is not retained by tissues is excreted by the kidneys, with adults retaining about 1% of absorbed lead, while children younger than 2 years retain over 30% of absorbed lead. So children, especially toddlers, have a greater likelihood to absorb lead from the GI tract and to retain lead in their tissues, both due to active mineralization of bone and the permeability of the blood brain barrier, primarily in children under 3 years old. This is why we are addressing what will happen to the children of Flint and not to all the residents of Flint.

Lead competitively inhibits interactions between cations and sulfhydryl groups, which are present in most human biochemical reactions. This leads to irreversible cell damage and often cell death, especially within the central nervous system. Lead exposure is associated with particular dysfunction within dopaminergic pathways within the brain, and has been associated in a dose-dependent fashion with decreased prefrontal gray matter volume. Lead poisoning also has hematologic consequences (anemia), renal consequences (interstitial nephritis), gastrointestinal symptoms (vomiting, constipation), and endocrine consequences (reversible inhibition of Vitamin D metabolism and permanently short stature). But the CNS consequences of lead exposure are particularly devastating, as they appear to have no threshold and are permanent. Their incidence is the driving force for the CDC’s lowering of the official toxic lead level and the public health efforts to screen children and educate parents about the risk of lead exposure.

So what do these serious consequences look like? People with severe lead intoxication (blood lead levels greater than 70 mcg/dL) typically present with signs of acute encephalopathy (headache, vomiting, seizures, or coma) and require intensive medical management including chelation therapy. More typically, exposed children have low but accumulating levels of lead and present with nonspecific symptoms, including lost appetite, fatigue, irritability, and insomnia, which gradually worsen.

Behavior

High levels of impulsivity, aggression, and impaired attention are the prototypical sequelae of lead poisoning (following recovery from the acute intoxication). Multiple studies have demonstrated these high levels of aggressive and impulsive behaviors in preschoolers who were exposed to lead, and these behaviors appear to continue into adolescence and adulthood. Indeed, one study found that compared with children with the lowest measurable blood lead levels (0.2-0.7 mcg/dL), those children who were in the next two quartiles had seven and twelve times the odds of meeting diagnostic criteria for conduct disorder.¹ There have even been studies which correlated atmospheric lead levels (when leaded gasoline was common) with crime rates 20 years later, which supported an association between childhood lead exposure and adult criminal activity.^2-4.

Multiple studies have demonstrated higher rates of inattention, distractibility, and impulsivity in lead-exposed children than would be expected given the prevalence of attention-deficit/hyperactivity disorder (ADHD) in the general population. The incidence of these symptoms goes up in a dose-dependent fashion and appears to have no threshold (so they occur at even the lowest measurable blood lead levels). In a 2006 study of nearly 5,000 children between ages 4-15 years, those with blood lead levels greater than 2 mcg/dL (still below the level the CDC deems toxic) were four times more likely to be carrying a diagnosis of ADHD and be on stimulant medication than their peers with blood lead levels less than 0.8mcg/dL.

Cognition

Closely related to impulse control and attention, the cognitive domains of intelligence and executive function are clearly damaged by lead exposure. Poor performance on tasks requiring focus, cognitive flexibility, and inhibition of automatic responses was directly associated with higher blood lead levels in a group of preschoolers with levels between 0 and 13 mcg/dL.⁵

IQ has been found to be so consistently diminished by increasing blood lead levels that it is used as an overall index of neurodevelopmental morbidity of lead exposure, leading to the CDC’s adoption of a lower standard definition of toxic lead levels. Even very low blood lead levels are associated with decrements in IQ: children with blood lead levels less than 7.5 mcg/dL lost an average of 3 IQ points for every 1 mcg/dL increase in blood lead levels.⁶ In a study of 57,000 elementary school students in 2009, Miranda et al. found that those who had a blood lead level of 4 mcg/dL at 3 years old were significantly more likely to be diagnosed with a learning disability in elementary school. Another study of 48,000 children who had a blood lead level of 5 mcg/dL were 30% more likely to fail third grade reading and math tests than their peers without measurable lead levels.

Speech and language

More recent studies have demonstrated that children with higher bone lead concentrations had poorer performance on several language-processing measures, suggesting that childhood lead exposure damages language processing and function as the young people grow. These deficits in language processing can make social development and self-regulation much more challenging in adolescence, and make school and work settings much more challenging. These findings also have implications for the utility of psychotherapy, a language-based treatment, for the other behavioral problems of lead exposure.

Motor skills

Several recent studies have assessed both fine and gross motor skills in lead-exposed children. Findings have demonstrated that balance, coordination, gross motor and fine motor skills all appear to be compromised in a dose-dependent fashion by childhood lead exposure. These findings suggest that not only are children at greater risk for accident and injury through childhood and into adulthood, a risk already increased by their compromised attention and impulse control. But they also are likely to be physically clumsy, compromising an opportunity to cultivate strengths or experience mastery when cognitive tasks may prove frustrating for them.

With deficits in such fundamental cognitive, motor, and behavioral processes, exposed children are clearly vulnerable to more than ADHD, conduct disorder, and learning disabilities. These struggles may lead to secondary vulnerabilities to anxiety or mood symptoms or substance abuse as these children grow into teenagers who face frustration at every turn. In addition to treatment for their deficits in attention and executive function, these children will ideally receive specialized supports in school and at home, to be able to master cognitive tasks, manage new social circumstances and make friends, discover their interests and talents, and generally stay on their best developmental trajectories. Lastly, the specific consequences of lead exposure will vary for any individual child, so parents will have to deal with the uncertainty of their child’s behavior and development over many years. Clearly, the children of Flint face a long road that has been substantially impacted by their lead exposure. The only good that can come from the exposure in Flint is to heighten efforts to ensure that it never happens again.

1. Environ Health Perspect. 2008 Jul;116(7):956-62.

2. Environ Res. 2000 May;83(1):1-22.

3. Environ Res. 2007 Jul;104(3):315-36.

4. Arch Pediatr Adolesc Med. 2001 May;155(5):579-82.

5. Dev Neuropsychol. 2004;26(1):513-40.

6. Environ Health Perspect. 2005 Jul;113(7):894-9.

Dr. Swick is an attending psychiatrist in the division of child psychiatry at Massachusetts General Hospital, Boston, and director of the Parenting at a Challenging Time (PACT) Program at the Vernon Cancer Center at Newton (Mass.) Wellesley Hospital. Dr. Jellinek is professor of psychiatry and of pediatrics at Harvard Medical School, Boston.

Lead poisoning is a well-established cause of serious and permanent neurological, cognitive, and behavioral problems, particularly in exposed children.

Children can be exposed to lead from ingesting paint chips in their homes, when old paint is scrapped from the exterior of houses or bridges, and through the water they drink. The damage caused by lead poisoning was first recognized in the United States in the early 20th century, although lead was added to gasoline and paint until the 1970’s. Since then, regulations for lead in consumer products have become increasingly strict, and the Centers for Disease Control and Prevention’s definition of a toxic lead level has shifted from 60 micrograms/deciliter (mcg/dL) in 1970 to 5 mcg/dL in 2012. In many communities, removing lead paint up to the height of a young child is a requirement whenever an older home is sold.

Unfortunately, these regulations did not protect the families in Flint, Michigan from being exposed to high levels of lead when a change in water supply and inadequate water treatment allowed lead to enter the system from decaying water pipes. It is worth reviewing what is known about the short- and long-term consequences of lead exposure, and what lies ahead for the children of Flint.

Lead is a naturally occurring element that is not metabolized, but rather absorbed, distributed to tissues, and excreted. Lead can be inhaled (with 100% absorption) and introduced through the GI tract (with about 70% absorption in children and 20% absorption in adults). GI absorption is enhanced by calcium or iron deficiency, both conditions that are relatively common, especially in poor children and can lead to pica (or eating of non-nutritious materials), further increasing the chances of lead exposure. Absorbed lead is distributed to blood (for 28-36 days), soft tissue, including the nervous system (40 days), and to bone (where it lasts for over 25 years). Blood that is retained in growing bones can be mobilized during periods of physiologic stress (such as illness, injury, or pregnancy), meaning children exposed to lead during a period of rapid bone growth are at long-term risk for acute lead poisoning from their endogenous reservoir without a new exposure. What lead is not retained by tissues is excreted by the kidneys, with adults retaining about 1% of absorbed lead, while children younger than 2 years retain over 30% of absorbed lead. So children, especially toddlers, have a greater likelihood to absorb lead from the GI tract and to retain lead in their tissues, both due to active mineralization of bone and the permeability of the blood brain barrier, primarily in children under 3 years old. This is why we are addressing what will happen to the children of Flint and not to all the residents of Flint.

Lead competitively inhibits interactions between cations and sulfhydryl groups, which are present in most human biochemical reactions. This leads to irreversible cell damage and often cell death, especially within the central nervous system. Lead exposure is associated with particular dysfunction within dopaminergic pathways within the brain, and has been associated in a dose-dependent fashion with decreased prefrontal gray matter volume. Lead poisoning also has hematologic consequences (anemia), renal consequences (interstitial nephritis), gastrointestinal symptoms (vomiting, constipation), and endocrine consequences (reversible inhibition of Vitamin D metabolism and permanently short stature). But the CNS consequences of lead exposure are particularly devastating, as they appear to have no threshold and are permanent. Their incidence is the driving force for the CDC’s lowering of the official toxic lead level and the public health efforts to screen children and educate parents about the risk of lead exposure.

So what do these serious consequences look like? People with severe lead intoxication (blood lead levels greater than 70 mcg/dL) typically present with signs of acute encephalopathy (headache, vomiting, seizures, or coma) and require intensive medical management including chelation therapy. More typically, exposed children have low but accumulating levels of lead and present with nonspecific symptoms, including lost appetite, fatigue, irritability, and insomnia, which gradually worsen.

Behavior

High levels of impulsivity, aggression, and impaired attention are the prototypical sequelae of lead poisoning (following recovery from the acute intoxication). Multiple studies have demonstrated these high levels of aggressive and impulsive behaviors in preschoolers who were exposed to lead, and these behaviors appear to continue into adolescence and adulthood. Indeed, one study found that compared with children with the lowest measurable blood lead levels (0.2-0.7 mcg/dL), those children who were in the next two quartiles had seven and twelve times the odds of meeting diagnostic criteria for conduct disorder.¹ There have even been studies which correlated atmospheric lead levels (when leaded gasoline was common) with crime rates 20 years later, which supported an association between childhood lead exposure and adult criminal activity.^2-4.

Multiple studies have demonstrated higher rates of inattention, distractibility, and impulsivity in lead-exposed children than would be expected given the prevalence of attention-deficit/hyperactivity disorder (ADHD) in the general population. The incidence of these symptoms goes up in a dose-dependent fashion and appears to have no threshold (so they occur at even the lowest measurable blood lead levels). In a 2006 study of nearly 5,000 children between ages 4-15 years, those with blood lead levels greater than 2 mcg/dL (still below the level the CDC deems toxic) were four times more likely to be carrying a diagnosis of ADHD and be on stimulant medication than their peers with blood lead levels less than 0.8mcg/dL.

Cognition

Closely related to impulse control and attention, the cognitive domains of intelligence and executive function are clearly damaged by lead exposure. Poor performance on tasks requiring focus, cognitive flexibility, and inhibition of automatic responses was directly associated with higher blood lead levels in a group of preschoolers with levels between 0 and 13 mcg/dL.⁵

IQ has been found to be so consistently diminished by increasing blood lead levels that it is used as an overall index of neurodevelopmental morbidity of lead exposure, leading to the CDC’s adoption of a lower standard definition of toxic lead levels. Even very low blood lead levels are associated with decrements in IQ: children with blood lead levels less than 7.5 mcg/dL lost an average of 3 IQ points for every 1 mcg/dL increase in blood lead levels.⁶ In a study of 57,000 elementary school students in 2009, Miranda et al. found that those who had a blood lead level of 4 mcg/dL at 3 years old were significantly more likely to be diagnosed with a learning disability in elementary school. Another study of 48,000 children who had a blood lead level of 5 mcg/dL were 30% more likely to fail third grade reading and math tests than their peers without measurable lead levels.

Speech and language

More recent studies have demonstrated that children with higher bone lead concentrations had poorer performance on several language-processing measures, suggesting that childhood lead exposure damages language processing and function as the young people grow. These deficits in language processing can make social development and self-regulation much more challenging in adolescence, and make school and work settings much more challenging. These findings also have implications for the utility of psychotherapy, a language-based treatment, for the other behavioral problems of lead exposure.

Motor skills

Several recent studies have assessed both fine and gross motor skills in lead-exposed children. Findings have demonstrated that balance, coordination, gross motor and fine motor skills all appear to be compromised in a dose-dependent fashion by childhood lead exposure. These findings suggest that not only are children at greater risk for accident and injury through childhood and into adulthood, a risk already increased by their compromised attention and impulse control. But they also are likely to be physically clumsy, compromising an opportunity to cultivate strengths or experience mastery when cognitive tasks may prove frustrating for them.

With deficits in such fundamental cognitive, motor, and behavioral processes, exposed children are clearly vulnerable to more than ADHD, conduct disorder, and learning disabilities. These struggles may lead to secondary vulnerabilities to anxiety or mood symptoms or substance abuse as these children grow into teenagers who face frustration at every turn. In addition to treatment for their deficits in attention and executive function, these children will ideally receive specialized supports in school and at home, to be able to master cognitive tasks, manage new social circumstances and make friends, discover their interests and talents, and generally stay on their best developmental trajectories. Lastly, the specific consequences of lead exposure will vary for any individual child, so parents will have to deal with the uncertainty of their child’s behavior and development over many years. Clearly, the children of Flint face a long road that has been substantially impacted by their lead exposure. The only good that can come from the exposure in Flint is to heighten efforts to ensure that it never happens again.

1. Environ Health Perspect. 2008 Jul;116(7):956-62.

2. Environ Res. 2000 May;83(1):1-22.

3. Environ Res. 2007 Jul;104(3):315-36.

4. Arch Pediatr Adolesc Med. 2001 May;155(5):579-82.

5. Dev Neuropsychol. 2004;26(1):513-40.

6. Environ Health Perspect. 2005 Jul;113(7):894-9.

Dr. Swick is an attending psychiatrist in the division of child psychiatry at Massachusetts General Hospital, Boston, and director of the Parenting at a Challenging Time (PACT) Program at the Vernon Cancer Center at Newton (Mass.) Wellesley Hospital. Dr. Jellinek is professor of psychiatry and of pediatrics at Harvard Medical School, Boston.

Lead poisoning is a well-established cause of serious and permanent neurological, cognitive, and behavioral problems, particularly in exposed children.

Children can be exposed to lead from ingesting paint chips in their homes, when old paint is scrapped from the exterior of houses or bridges, and through the water they drink. The damage caused by lead poisoning was first recognized in the United States in the early 20th century, although lead was added to gasoline and paint until the 1970’s. Since then, regulations for lead in consumer products have become increasingly strict, and the Centers for Disease Control and Prevention’s definition of a toxic lead level has shifted from 60 micrograms/deciliter (mcg/dL) in 1970 to 5 mcg/dL in 2012. In many communities, removing lead paint up to the height of a young child is a requirement whenever an older home is sold.

Unfortunately, these regulations did not protect the families in Flint, Michigan from being exposed to high levels of lead when a change in water supply and inadequate water treatment allowed lead to enter the system from decaying water pipes. It is worth reviewing what is known about the short- and long-term consequences of lead exposure, and what lies ahead for the children of Flint.

Lead is a naturally occurring element that is not metabolized, but rather absorbed, distributed to tissues, and excreted. Lead can be inhaled (with 100% absorption) and introduced through the GI tract (with about 70% absorption in children and 20% absorption in adults). GI absorption is enhanced by calcium or iron deficiency, both conditions that are relatively common, especially in poor children and can lead to pica (or eating of non-nutritious materials), further increasing the chances of lead exposure. Absorbed lead is distributed to blood (for 28-36 days), soft tissue, including the nervous system (40 days), and to bone (where it lasts for over 25 years). Blood that is retained in growing bones can be mobilized during periods of physiologic stress (such as illness, injury, or pregnancy), meaning children exposed to lead during a period of rapid bone growth are at long-term risk for acute lead poisoning from their endogenous reservoir without a new exposure. What lead is not retained by tissues is excreted by the kidneys, with adults retaining about 1% of absorbed lead, while children younger than 2 years retain over 30% of absorbed lead. So children, especially toddlers, have a greater likelihood to absorb lead from the GI tract and to retain lead in their tissues, both due to active mineralization of bone and the permeability of the blood brain barrier, primarily in children under 3 years old. This is why we are addressing what will happen to the children of Flint and not to all the residents of Flint.

Lead competitively inhibits interactions between cations and sulfhydryl groups, which are present in most human biochemical reactions. This leads to irreversible cell damage and often cell death, especially within the central nervous system. Lead exposure is associated with particular dysfunction within dopaminergic pathways within the brain, and has been associated in a dose-dependent fashion with decreased prefrontal gray matter volume. Lead poisoning also has hematologic consequences (anemia), renal consequences (interstitial nephritis), gastrointestinal symptoms (vomiting, constipation), and endocrine consequences (reversible inhibition of Vitamin D metabolism and permanently short stature). But the CNS consequences of lead exposure are particularly devastating, as they appear to have no threshold and are permanent. Their incidence is the driving force for the CDC’s lowering of the official toxic lead level and the public health efforts to screen children and educate parents about the risk of lead exposure.

So what do these serious consequences look like? People with severe lead intoxication (blood lead levels greater than 70 mcg/dL) typically present with signs of acute encephalopathy (headache, vomiting, seizures, or coma) and require intensive medical management including chelation therapy. More typically, exposed children have low but accumulating levels of lead and present with nonspecific symptoms, including lost appetite, fatigue, irritability, and insomnia, which gradually worsen.

Behavior

High levels of impulsivity, aggression, and impaired attention are the prototypical sequelae of lead poisoning (following recovery from the acute intoxication). Multiple studies have demonstrated these high levels of aggressive and impulsive behaviors in preschoolers who were exposed to lead, and these behaviors appear to continue into adolescence and adulthood. Indeed, one study found that compared with children with the lowest measurable blood lead levels (0.2-0.7 mcg/dL), those children who were in the next two quartiles had seven and twelve times the odds of meeting diagnostic criteria for conduct disorder.¹ There have even been studies which correlated atmospheric lead levels (when leaded gasoline was common) with crime rates 20 years later, which supported an association between childhood lead exposure and adult criminal activity.^2-4.

Multiple studies have demonstrated higher rates of inattention, distractibility, and impulsivity in lead-exposed children than would be expected given the prevalence of attention-deficit/hyperactivity disorder (ADHD) in the general population. The incidence of these symptoms goes up in a dose-dependent fashion and appears to have no threshold (so they occur at even the lowest measurable blood lead levels). In a 2006 study of nearly 5,000 children between ages 4-15 years, those with blood lead levels greater than 2 mcg/dL (still below the level the CDC deems toxic) were four times more likely to be carrying a diagnosis of ADHD and be on stimulant medication than their peers with blood lead levels less than 0.8mcg/dL.

Cognition

Closely related to impulse control and attention, the cognitive domains of intelligence and executive function are clearly damaged by lead exposure. Poor performance on tasks requiring focus, cognitive flexibility, and inhibition of automatic responses was directly associated with higher blood lead levels in a group of preschoolers with levels between 0 and 13 mcg/dL.⁵

IQ has been found to be so consistently diminished by increasing blood lead levels that it is used as an overall index of neurodevelopmental morbidity of lead exposure, leading to the CDC’s adoption of a lower standard definition of toxic lead levels. Even very low blood lead levels are associated with decrements in IQ: children with blood lead levels less than 7.5 mcg/dL lost an average of 3 IQ points for every 1 mcg/dL increase in blood lead levels.⁶ In a study of 57,000 elementary school students in 2009, Miranda et al. found that those who had a blood lead level of 4 mcg/dL at 3 years old were significantly more likely to be diagnosed with a learning disability in elementary school. Another study of 48,000 children who had a blood lead level of 5 mcg/dL were 30% more likely to fail third grade reading and math tests than their peers without measurable lead levels.

Speech and language

More recent studies have demonstrated that children with higher bone lead concentrations had poorer performance on several language-processing measures, suggesting that childhood lead exposure damages language processing and function as the young people grow. These deficits in language processing can make social development and self-regulation much more challenging in adolescence, and make school and work settings much more challenging. These findings also have implications for the utility of psychotherapy, a language-based treatment, for the other behavioral problems of lead exposure.

Motor skills

Several recent studies have assessed both fine and gross motor skills in lead-exposed children. Findings have demonstrated that balance, coordination, gross motor and fine motor skills all appear to be compromised in a dose-dependent fashion by childhood lead exposure. These findings suggest that not only are children at greater risk for accident and injury through childhood and into adulthood, a risk already increased by their compromised attention and impulse control. But they also are likely to be physically clumsy, compromising an opportunity to cultivate strengths or experience mastery when cognitive tasks may prove frustrating for them.

With deficits in such fundamental cognitive, motor, and behavioral processes, exposed children are clearly vulnerable to more than ADHD, conduct disorder, and learning disabilities. These struggles may lead to secondary vulnerabilities to anxiety or mood symptoms or substance abuse as these children grow into teenagers who face frustration at every turn. In addition to treatment for their deficits in attention and executive function, these children will ideally receive specialized supports in school and at home, to be able to master cognitive tasks, manage new social circumstances and make friends, discover their interests and talents, and generally stay on their best developmental trajectories. Lastly, the specific consequences of lead exposure will vary for any individual child, so parents will have to deal with the uncertainty of their child’s behavior and development over many years. Clearly, the children of Flint face a long road that has been substantially impacted by their lead exposure. The only good that can come from the exposure in Flint is to heighten efforts to ensure that it never happens again.

1. Environ Health Perspect. 2008 Jul;116(7):956-62.

2. Environ Res. 2000 May;83(1):1-22.

3. Environ Res. 2007 Jul;104(3):315-36.

4. Arch Pediatr Adolesc Med. 2001 May;155(5):579-82.

5. Dev Neuropsychol. 2004;26(1):513-40.

6. Environ Health Perspect. 2005 Jul;113(7):894-9.

Dr. Swick is an attending psychiatrist in the division of child psychiatry at Massachusetts General Hospital, Boston, and director of the Parenting at a Challenging Time (PACT) Program at the Vernon Cancer Center at Newton (Mass.) Wellesley Hospital. Dr. Jellinek is professor of psychiatry and of pediatrics at Harvard Medical School, Boston.

The Recovery Audit Contractor (RAC) program was launched in 2010 by the Centers for Medicare and Medicaid Services (CMS) with the intention of identifying and preventing improper payments to Medicare providers. Recovery Audit Contractors are paid on “contingency fee” basis, i.e. a commission on each claim that they deny. Some have thus likened their actions to those of ‘bounty hunters.” Though there is an appeals process, hospitals and physicians bear the cost of audits, denials, and appeals, regardless of the ultimate outcome of the appeals process.

Because of the lack of accountability in the RAC process, concern has been expressed about both the number of inaccurate findings as well as the high volume of appeals. As evidence, the American Hospital Association (AHA) reported that the Office of the Inspector General (OIG) found that 49% of hospital denials are appealed and 72% of the appeals brought before an Administrative Law Judge are overturned in favor of the hospital.

In response to these concerns, Rep. George Holding (R-NC) introduced the H.R. 2568, the Fair Medical Audits Act in May 2015. The bill was jointly referred to the Ways and Means and Energy and Commerce committees in the House of Representatives for further consideration. Currently, H.R. 2568 has 23 cosponsors.

H.R. 2568 addresses many of the concerns in the RAC program by:

• Enhancing transparency in the audit process to improve compliance.

• Improving the claims-review process by mandating that contractors meet appropriate knowledge and experience requirements.

• Promoting provider education while increasing RAC accountability for inaccurate audit findings.

• Ensuring accuracy of those overpayment amounts calculated by contractors using extrapolation methodology.

• Requiring contractors to reimburse certain documentation requests to reduce provider burdens.

• Delaying payment to RACs until after external appeal.

• Reducing the appeals backlog by shortening the “look-back” period.

On Dec. 3, 2015, the American College of Surgeons joined 10 other surgical associations in sending a letter of support to Representative Holding thanking him for introducing the Fair Medical Audits Act. In addition, an ACTION ALERT was posted on the SurgeonsVoice website to facilitate the efforts of Fellows in contacting their individual representatives urging they support the legislation. I would urge all Fellows to log onto www.surgeonsvoice.org, and then click on the “TAKE ACTION” tab on the right side of the screen. It takes only a few moments to send a message to your Member of Congress requesting their assistance in passing this sensible legislation increasing accountability in the Medicare Recovery Audit Contractor program.

Until next month …

Dr. Patrick V. Bailey is an ACS Fellow, a pediatric surgeon, and Medical Director, Advocacy, for the Division of Advocacy and Health Policy, in the ACS offices in Washington, D.C.

The Recovery Audit Contractor (RAC) program was launched in 2010 by the Centers for Medicare and Medicaid Services (CMS) with the intention of identifying and preventing improper payments to Medicare providers. Recovery Audit Contractors are paid on “contingency fee” basis, i.e. a commission on each claim that they deny. Some have thus likened their actions to those of ‘bounty hunters.” Though there is an appeals process, hospitals and physicians bear the cost of audits, denials, and appeals, regardless of the ultimate outcome of the appeals process.

Because of the lack of accountability in the RAC process, concern has been expressed about both the number of inaccurate findings as well as the high volume of appeals. As evidence, the American Hospital Association (AHA) reported that the Office of the Inspector General (OIG) found that 49% of hospital denials are appealed and 72% of the appeals brought before an Administrative Law Judge are overturned in favor of the hospital.

In response to these concerns, Rep. George Holding (R-NC) introduced the H.R. 2568, the Fair Medical Audits Act in May 2015. The bill was jointly referred to the Ways and Means and Energy and Commerce committees in the House of Representatives for further consideration. Currently, H.R. 2568 has 23 cosponsors.

H.R. 2568 addresses many of the concerns in the RAC program by:

• Enhancing transparency in the audit process to improve compliance.

• Improving the claims-review process by mandating that contractors meet appropriate knowledge and experience requirements.

• Promoting provider education while increasing RAC accountability for inaccurate audit findings.

• Ensuring accuracy of those overpayment amounts calculated by contractors using extrapolation methodology.

• Requiring contractors to reimburse certain documentation requests to reduce provider burdens.

• Delaying payment to RACs until after external appeal.

• Reducing the appeals backlog by shortening the “look-back” period.

On Dec. 3, 2015, the American College of Surgeons joined 10 other surgical associations in sending a letter of support to Representative Holding thanking him for introducing the Fair Medical Audits Act. In addition, an ACTION ALERT was posted on the SurgeonsVoice website to facilitate the efforts of Fellows in contacting their individual representatives urging they support the legislation. I would urge all Fellows to log onto www.surgeonsvoice.org, and then click on the “TAKE ACTION” tab on the right side of the screen. It takes only a few moments to send a message to your Member of Congress requesting their assistance in passing this sensible legislation increasing accountability in the Medicare Recovery Audit Contractor program.

Until next month …

Dr. Patrick V. Bailey is an ACS Fellow, a pediatric surgeon, and Medical Director, Advocacy, for the Division of Advocacy and Health Policy, in the ACS offices in Washington, D.C.

The Recovery Audit Contractor (RAC) program was launched in 2010 by the Centers for Medicare and Medicaid Services (CMS) with the intention of identifying and preventing improper payments to Medicare providers. Recovery Audit Contractors are paid on “contingency fee” basis, i.e. a commission on each claim that they deny. Some have thus likened their actions to those of ‘bounty hunters.” Though there is an appeals process, hospitals and physicians bear the cost of audits, denials, and appeals, regardless of the ultimate outcome of the appeals process.

Because of the lack of accountability in the RAC process, concern has been expressed about both the number of inaccurate findings as well as the high volume of appeals. As evidence, the American Hospital Association (AHA) reported that the Office of the Inspector General (OIG) found that 49% of hospital denials are appealed and 72% of the appeals brought before an Administrative Law Judge are overturned in favor of the hospital.

In response to these concerns, Rep. George Holding (R-NC) introduced the H.R. 2568, the Fair Medical Audits Act in May 2015. The bill was jointly referred to the Ways and Means and Energy and Commerce committees in the House of Representatives for further consideration. Currently, H.R. 2568 has 23 cosponsors.

H.R. 2568 addresses many of the concerns in the RAC program by:

• Enhancing transparency in the audit process to improve compliance.

• Improving the claims-review process by mandating that contractors meet appropriate knowledge and experience requirements.

• Promoting provider education while increasing RAC accountability for inaccurate audit findings.

• Ensuring accuracy of those overpayment amounts calculated by contractors using extrapolation methodology.

• Requiring contractors to reimburse certain documentation requests to reduce provider burdens.

• Delaying payment to RACs until after external appeal.

• Reducing the appeals backlog by shortening the “look-back” period.

On Dec. 3, 2015, the American College of Surgeons joined 10 other surgical associations in sending a letter of support to Representative Holding thanking him for introducing the Fair Medical Audits Act. In addition, an ACTION ALERT was posted on the SurgeonsVoice website to facilitate the efforts of Fellows in contacting their individual representatives urging they support the legislation. I would urge all Fellows to log onto www.surgeonsvoice.org, and then click on the “TAKE ACTION” tab on the right side of the screen. It takes only a few moments to send a message to your Member of Congress requesting their assistance in passing this sensible legislation increasing accountability in the Medicare Recovery Audit Contractor program.

Until next month …

Dr. Patrick V. Bailey is an ACS Fellow, a pediatric surgeon, and Medical Director, Advocacy, for the Division of Advocacy and Health Policy, in the ACS offices in Washington, D.C.

The primary comorbidity of psoriasis is psoriatic arthritis (PsA). The true incidence of PsA has long been an issue of debate. To estimate the incidence of PsA in patients with psoriasis and to identify risk factors for its development, Eder at al conducted a prospective cohort study involving psoriasis patients without arthritis at study entry that was published online in Arthritis & Rheumatology.

The investigators collected information from patients concerning lifestyle habits, comorbidities, psoriasis activity, and medications. The patients were evaluated at enrollment and annually. A general physical examination, assessment of psoriasis severity, and assessment for the development of musculoskeletal symptoms were conducted at each visit. A diagnosis of PsA was determined by a rheumatologist on the basis of clinical, laboratory, and imaging data; patients also had to fulfill the CASPAR (Classification Criteria for Psoriatic Arthritis) criteria (confirmed cases). The annual incidence of PsA was estimated using an event per person-years analysis.

The results from 464 patients who were followed for 8 years were analyzed. The annual incidence of confirmed PsA was 2.7 per 100 patients with psoriasis (95% CI, 2.1-3.6). Overall, 51 patients developed PsA over the course of the study and an additional 9 were considered suspect cases.

The following baseline variables were associated with the development of PsA in multivariate analysis: severe psoriasis (relative risk [RR], 5.4; P=.006), low level of education (college/university vs high school incomplete: RR, 4.5; P=.005; high school education vs high school incomplete: RR, 3.3; P=.049), and use of retinoid medications (RR, 3.4; P=.02). In addition, psoriatic nail pitting (RR, 2.5; P=.002) and uveitis (RR, 31.5; P<.001) were time-dependent predictors for PsA development.

The authors concluded that the incidence of PsA in patients with psoriasis was higher than previously reported. Possible factors for this finding might include differences in patient recruitment as well as self-reported PsA diagnoses.

What’s the issue?

This prospective analysis is interesting. The incidence of PsA was higher than reported. It reinforces the need for continual evaluation of joint symptoms in patients with psoriasis, even if they have had psoriasis for many years. How will this analysis impact your evaluation of psoriatic patients?

We want to know your views! Tell us what you think.

The primary comorbidity of psoriasis is psoriatic arthritis (PsA). The true incidence of PsA has long been an issue of debate. To estimate the incidence of PsA in patients with psoriasis and to identify risk factors for its development, Eder at al conducted a prospective cohort study involving psoriasis patients without arthritis at study entry that was published online in Arthritis & Rheumatology.

The investigators collected information from patients concerning lifestyle habits, comorbidities, psoriasis activity, and medications. The patients were evaluated at enrollment and annually. A general physical examination, assessment of psoriasis severity, and assessment for the development of musculoskeletal symptoms were conducted at each visit. A diagnosis of PsA was determined by a rheumatologist on the basis of clinical, laboratory, and imaging data; patients also had to fulfill the CASPAR (Classification Criteria for Psoriatic Arthritis) criteria (confirmed cases). The annual incidence of PsA was estimated using an event per person-years analysis.

The results from 464 patients who were followed for 8 years were analyzed. The annual incidence of confirmed PsA was 2.7 per 100 patients with psoriasis (95% CI, 2.1-3.6). Overall, 51 patients developed PsA over the course of the study and an additional 9 were considered suspect cases.

The following baseline variables were associated with the development of PsA in multivariate analysis: severe psoriasis (relative risk [RR], 5.4; P=.006), low level of education (college/university vs high school incomplete: RR, 4.5; P=.005; high school education vs high school incomplete: RR, 3.3; P=.049), and use of retinoid medications (RR, 3.4; P=.02). In addition, psoriatic nail pitting (RR, 2.5; P=.002) and uveitis (RR, 31.5; P<.001) were time-dependent predictors for PsA development.

The authors concluded that the incidence of PsA in patients with psoriasis was higher than previously reported. Possible factors for this finding might include differences in patient recruitment as well as self-reported PsA diagnoses.

What’s the issue?

This prospective analysis is interesting. The incidence of PsA was higher than reported. It reinforces the need for continual evaluation of joint symptoms in patients with psoriasis, even if they have had psoriasis for many years. How will this analysis impact your evaluation of psoriatic patients?

We want to know your views! Tell us what you think.

The primary comorbidity of psoriasis is psoriatic arthritis (PsA). The true incidence of PsA has long been an issue of debate. To estimate the incidence of PsA in patients with psoriasis and to identify risk factors for its development, Eder at al conducted a prospective cohort study involving psoriasis patients without arthritis at study entry that was published online in Arthritis & Rheumatology.

The investigators collected information from patients concerning lifestyle habits, comorbidities, psoriasis activity, and medications. The patients were evaluated at enrollment and annually. A general physical examination, assessment of psoriasis severity, and assessment for the development of musculoskeletal symptoms were conducted at each visit. A diagnosis of PsA was determined by a rheumatologist on the basis of clinical, laboratory, and imaging data; patients also had to fulfill the CASPAR (Classification Criteria for Psoriatic Arthritis) criteria (confirmed cases). The annual incidence of PsA was estimated using an event per person-years analysis.

The results from 464 patients who were followed for 8 years were analyzed. The annual incidence of confirmed PsA was 2.7 per 100 patients with psoriasis (95% CI, 2.1-3.6). Overall, 51 patients developed PsA over the course of the study and an additional 9 were considered suspect cases.

The following baseline variables were associated with the development of PsA in multivariate analysis: severe psoriasis (relative risk [RR], 5.4; P=.006), low level of education (college/university vs high school incomplete: RR, 4.5; P=.005; high school education vs high school incomplete: RR, 3.3; P=.049), and use of retinoid medications (RR, 3.4; P=.02). In addition, psoriatic nail pitting (RR, 2.5; P=.002) and uveitis (RR, 31.5; P<.001) were time-dependent predictors for PsA development.

The authors concluded that the incidence of PsA in patients with psoriasis was higher than previously reported. Possible factors for this finding might include differences in patient recruitment as well as self-reported PsA diagnoses.

What’s the issue?

This prospective analysis is interesting. The incidence of PsA was higher than reported. It reinforces the need for continual evaluation of joint symptoms in patients with psoriasis, even if they have had psoriasis for many years. How will this analysis impact your evaluation of psoriatic patients?

We want to know your views! Tell us what you think.

The photo challenge “Sessile Pink Plaque on the Lower Back” (Cutis. 2015;96:E3-E5) contained an error in the byline. The author names should have read:

Robyn Marszalek, MD; Phyu P. Aung, MD, PhD; Deon Wolpowitz, MD, PhD; Amy Yuntzu-Yen Chen, MD

The staff of Cutis^® makes every possible effort to ensure accuracy in its articles and apologizes for the mistake.

The photo challenge “Sessile Pink Plaque on the Lower Back” (Cutis. 2015;96:E3-E5) contained an error in the byline. The author names should have read:

Robyn Marszalek, MD; Phyu P. Aung, MD, PhD; Deon Wolpowitz, MD, PhD; Amy Yuntzu-Yen Chen, MD

The staff of Cutis^® makes every possible effort to ensure accuracy in its articles and apologizes for the mistake.

The photo challenge “Sessile Pink Plaque on the Lower Back” (Cutis. 2015;96:E3-E5) contained an error in the byline. The author names should have read:

Robyn Marszalek, MD; Phyu P. Aung, MD, PhD; Deon Wolpowitz, MD, PhD; Amy Yuntzu-Yen Chen, MD

The staff of Cutis^® makes every possible effort to ensure accuracy in its articles and apologizes for the mistake.

WAIKOLOA, HAWAII – Two new topical treatments for nail fungal infections are more effective than previous topical therapies, but the key to successful results is picking the right onychomycosis patient, according to Dr. Theodore Rosen.

The two new agents, tavaborole and efinaconazole, “are both better than what we had previously, especially considering topical agents don’t do quite as well as oral agents do,” explained Dr. Rosen, professor of dermatology at Baylor College of Medicine, Houston.

The new topicals are “very convenient, in that it’s an easy-to-do regimen, once a day,” Dr. Rosen noted. But “they are inconvenient, in that they both have to be used about 48 weeks. So, that’s about a year’s worth of therapy.”

In an interview at the Hawaii Dermatology Seminar provided by Global Academy for Medical Education/Skin Disease Education Foundation, Dr. Rosen discussed approaches to achieving the best outcomes with the new agents, and he outlined other practical steps patients can take to prevent the return of nail fungal infections.

SDEF and this news organization are owned by the same parent company.

WAIKOLOA, HAWAII – Two new topical treatments for nail fungal infections are more effective than previous topical therapies, but the key to successful results is picking the right onychomycosis patient, according to Dr. Theodore Rosen.

The two new agents, tavaborole and efinaconazole, “are both better than what we had previously, especially considering topical agents don’t do quite as well as oral agents do,” explained Dr. Rosen, professor of dermatology at Baylor College of Medicine, Houston.

The new topicals are “very convenient, in that it’s an easy-to-do regimen, once a day,” Dr. Rosen noted. But “they are inconvenient, in that they both have to be used about 48 weeks. So, that’s about a year’s worth of therapy.”

In an interview at the Hawaii Dermatology Seminar provided by Global Academy for Medical Education/Skin Disease Education Foundation, Dr. Rosen discussed approaches to achieving the best outcomes with the new agents, and he outlined other practical steps patients can take to prevent the return of nail fungal infections.

SDEF and this news organization are owned by the same parent company.

WAIKOLOA, HAWAII – Two new topical treatments for nail fungal infections are more effective than previous topical therapies, but the key to successful results is picking the right onychomycosis patient, according to Dr. Theodore Rosen.

The two new agents, tavaborole and efinaconazole, “are both better than what we had previously, especially considering topical agents don’t do quite as well as oral agents do,” explained Dr. Rosen, professor of dermatology at Baylor College of Medicine, Houston.

The new topicals are “very convenient, in that it’s an easy-to-do regimen, once a day,” Dr. Rosen noted. But “they are inconvenient, in that they both have to be used about 48 weeks. So, that’s about a year’s worth of therapy.”

In an interview at the Hawaii Dermatology Seminar provided by Global Academy for Medical Education/Skin Disease Education Foundation, Dr. Rosen discussed approaches to achieving the best outcomes with the new agents, and he outlined other practical steps patients can take to prevent the return of nail fungal infections.

SDEF and this news organization are owned by the same parent company.

Cosentyx

Novartis Pharmaceuticals Corporation announces US Food and Drug Administration approval of 2 new indications for Cosentyx (secukinumab): to treat patients with active ankylosing spondylitis and active psoriatic arthritis. Cosentyx is a human monoclonal antibody that selectively binds to IL-17A and inhibits its interaction with the IL-17 receptor. Research suggests that IL-17A may play an important role in driving the body’s immune response in psoriasis, psoriatic arthritis, and ankylosing spondylitis. Cosentyx was approved in January 2015 for the treatment of moderate to severe plaque psoriasis in adult patients who are candidates for systemic therapy or phototherapy. For more information, visit www.cosentyx.com.

Emverm

Impax Laboratories, Inc, receives US Food and Drug Administration approval for the supplemental new drug application of Emverm (mebendazole) 100-mg chewable tablets for the treatment of pinworm and certain worm infections. Emverm is indicated for treatment of pinworm, whipworm, common roundworm, common hookworm, and American hookworm in single or mixed infections. Emverm is expected to become available early in the second quarter of 2016. For more information, visit www.impaxlabs.com.

Keytruda

Merck & Co, Inc, announces US Food and Drug Administration approval of an expanded indication for Keytruda (pembrolizumab) that includes the first-line treatment of patients with unresectable or metastatic melanoma. Keytruda is indicated in the United States at a dose of 2 mg/kg administered as an intravenous infusion over 30 minutes every 3 weeks. Keytruda is an anti–programmed death receptor-1 therapy that works by increasing the ability of the body’s immune system to help detect and fight tumor cells. For more information, visit www.keytruda.com.

Opdivo + Yervoy Regimen

The US Food and Drug Administration has granted accelerated approval of nivolumab (Opdivo) in combination with ipilimumab (Yervoy) for the treatment of patients with BRAF V600 wild-type unresectable or metastatic melanoma. An international, multicenter, double-blind, randomized, active-controlled trial in patients who were previously untreated for unresectable or metastatic BRAF V600 wild-type melanoma demonstrated an increase in the objective response rate, prolonged response durations, and improvement in progression-free survival. When used in combination with ipilimumab, the recommended dose and schedule is nivolumab 1 mg/kg administered as an intravenous infusion over 60 minutes, followed by ipilimumab on the same day every 3 weeks for 4 doses. The recommended subsequent dose of nivolumab, as a single agent, is 3 mg/kg as an intravenous infusion over 60 minutes every 2 weeks until disease progression or unacceptable toxicity. For more information, visit www.opdivoyervoyhcp.com.

TriAcnéal Day Mattifying Lotion and Night Smoothing Lotion

Pierre Fabre Dermo-Cosmetique USA introduces 2 TriAcnéal lotions in the Avène line for the treatment and prevention of acne. TriAcnéal Day Mattifying Lotion provides hydrating and mattifying care. It is gentle enough for daily use and can be used alone or in combination with topical acne prescriptions. A trio of ingredients target acne: PCC enzyme (consisting of papain, sodium alginate, caprylyl glycol, and hexanediol) for exfoliation to counteract the formation of new comedones, Diolényl (consisting of caprylyl glycol linseedate and potassium sorbate)to treat existing blemishes and prevent new lesions, and glyceryl laurate to reduce oil production. TriAcnéal Night Smoothing Lotion works to reduce the appearance of acne scars and provides moisturization and redness-reduction benefits. The nighttime formula contains PCC enzyme and Diolényl as well as retinaldehyde to diminish visible signs of aging. For more information, visit www.aveneusa.com.

If you would like your product included in Product News, please e-mail a press release to the Editorial Office at [email protected].

Cosentyx

Novartis Pharmaceuticals Corporation announces US Food and Drug Administration approval of 2 new indications for Cosentyx (secukinumab): to treat patients with active ankylosing spondylitis and active psoriatic arthritis. Cosentyx is a human monoclonal antibody that selectively binds to IL-17A and inhibits its interaction with the IL-17 receptor. Research suggests that IL-17A may play an important role in driving the body’s immune response in psoriasis, psoriatic arthritis, and ankylosing spondylitis. Cosentyx was approved in January 2015 for the treatment of moderate to severe plaque psoriasis in adult patients who are candidates for systemic therapy or phototherapy. For more information, visit www.cosentyx.com.

Emverm

Impax Laboratories, Inc, receives US Food and Drug Administration approval for the supplemental new drug application of Emverm (mebendazole) 100-mg chewable tablets for the treatment of pinworm and certain worm infections. Emverm is indicated for treatment of pinworm, whipworm, common roundworm, common hookworm, and American hookworm in single or mixed infections. Emverm is expected to become available early in the second quarter of 2016. For more information, visit www.impaxlabs.com.

Keytruda

Merck & Co, Inc, announces US Food and Drug Administration approval of an expanded indication for Keytruda (pembrolizumab) that includes the first-line treatment of patients with unresectable or metastatic melanoma. Keytruda is indicated in the United States at a dose of 2 mg/kg administered as an intravenous infusion over 30 minutes every 3 weeks. Keytruda is an anti–programmed death receptor-1 therapy that works by increasing the ability of the body’s immune system to help detect and fight tumor cells. For more information, visit www.keytruda.com.

Opdivo + Yervoy Regimen

The US Food and Drug Administration has granted accelerated approval of nivolumab (Opdivo) in combination with ipilimumab (Yervoy) for the treatment of patients with BRAF V600 wild-type unresectable or metastatic melanoma. An international, multicenter, double-blind, randomized, active-controlled trial in patients who were previously untreated for unresectable or metastatic BRAF V600 wild-type melanoma demonstrated an increase in the objective response rate, prolonged response durations, and improvement in progression-free survival. When used in combination with ipilimumab, the recommended dose and schedule is nivolumab 1 mg/kg administered as an intravenous infusion over 60 minutes, followed by ipilimumab on the same day every 3 weeks for 4 doses. The recommended subsequent dose of nivolumab, as a single agent, is 3 mg/kg as an intravenous infusion over 60 minutes every 2 weeks until disease progression or unacceptable toxicity. For more information, visit www.opdivoyervoyhcp.com.

TriAcnéal Day Mattifying Lotion and Night Smoothing Lotion

Pierre Fabre Dermo-Cosmetique USA introduces 2 TriAcnéal lotions in the Avène line for the treatment and prevention of acne. TriAcnéal Day Mattifying Lotion provides hydrating and mattifying care. It is gentle enough for daily use and can be used alone or in combination with topical acne prescriptions. A trio of ingredients target acne: PCC enzyme (consisting of papain, sodium alginate, caprylyl glycol, and hexanediol) for exfoliation to counteract the formation of new comedones, Diolényl (consisting of caprylyl glycol linseedate and potassium sorbate)to treat existing blemishes and prevent new lesions, and glyceryl laurate to reduce oil production. TriAcnéal Night Smoothing Lotion works to reduce the appearance of acne scars and provides moisturization and redness-reduction benefits. The nighttime formula contains PCC enzyme and Diolényl as well as retinaldehyde to diminish visible signs of aging. For more information, visit www.aveneusa.com.

If you would like your product included in Product News, please e-mail a press release to the Editorial Office at [email protected].

Cosentyx

Novartis Pharmaceuticals Corporation announces US Food and Drug Administration approval of 2 new indications for Cosentyx (secukinumab): to treat patients with active ankylosing spondylitis and active psoriatic arthritis. Cosentyx is a human monoclonal antibody that selectively binds to IL-17A and inhibits its interaction with the IL-17 receptor. Research suggests that IL-17A may play an important role in driving the body’s immune response in psoriasis, psoriatic arthritis, and ankylosing spondylitis. Cosentyx was approved in January 2015 for the treatment of moderate to severe plaque psoriasis in adult patients who are candidates for systemic therapy or phototherapy. For more information, visit www.cosentyx.com.

Emverm

Impax Laboratories, Inc, receives US Food and Drug Administration approval for the supplemental new drug application of Emverm (mebendazole) 100-mg chewable tablets for the treatment of pinworm and certain worm infections. Emverm is indicated for treatment of pinworm, whipworm, common roundworm, common hookworm, and American hookworm in single or mixed infections. Emverm is expected to become available early in the second quarter of 2016. For more information, visit www.impaxlabs.com.

Keytruda

Merck & Co, Inc, announces US Food and Drug Administration approval of an expanded indication for Keytruda (pembrolizumab) that includes the first-line treatment of patients with unresectable or metastatic melanoma. Keytruda is indicated in the United States at a dose of 2 mg/kg administered as an intravenous infusion over 30 minutes every 3 weeks. Keytruda is an anti–programmed death receptor-1 therapy that works by increasing the ability of the body’s immune system to help detect and fight tumor cells. For more information, visit www.keytruda.com.

Opdivo + Yervoy Regimen

The US Food and Drug Administration has granted accelerated approval of nivolumab (Opdivo) in combination with ipilimumab (Yervoy) for the treatment of patients with BRAF V600 wild-type unresectable or metastatic melanoma. An international, multicenter, double-blind, randomized, active-controlled trial in patients who were previously untreated for unresectable or metastatic BRAF V600 wild-type melanoma demonstrated an increase in the objective response rate, prolonged response durations, and improvement in progression-free survival. When used in combination with ipilimumab, the recommended dose and schedule is nivolumab 1 mg/kg administered as an intravenous infusion over 60 minutes, followed by ipilimumab on the same day every 3 weeks for 4 doses. The recommended subsequent dose of nivolumab, as a single agent, is 3 mg/kg as an intravenous infusion over 60 minutes every 2 weeks until disease progression or unacceptable toxicity. For more information, visit www.opdivoyervoyhcp.com.

TriAcnéal Day Mattifying Lotion and Night Smoothing Lotion

Pierre Fabre Dermo-Cosmetique USA introduces 2 TriAcnéal lotions in the Avène line for the treatment and prevention of acne. TriAcnéal Day Mattifying Lotion provides hydrating and mattifying care. It is gentle enough for daily use and can be used alone or in combination with topical acne prescriptions. A trio of ingredients target acne: PCC enzyme (consisting of papain, sodium alginate, caprylyl glycol, and hexanediol) for exfoliation to counteract the formation of new comedones, Diolényl (consisting of caprylyl glycol linseedate and potassium sorbate)to treat existing blemishes and prevent new lesions, and glyceryl laurate to reduce oil production. TriAcnéal Night Smoothing Lotion works to reduce the appearance of acne scars and provides moisturization and redness-reduction benefits. The nighttime formula contains PCC enzyme and Diolényl as well as retinaldehyde to diminish visible signs of aging. For more information, visit www.aveneusa.com.

If you would like your product included in Product News, please e-mail a press release to the Editorial Office at [email protected].