Topics

• Introduction - Exploring the Role of Modified-Release
• Doxycycline in Rosacea
• Comparing Antimicrobial and Anti-Inflammatory Doses of Oral Doxycycline in the Treatment of Rosacea
• Impact of Antibiotic Resistance on Dermatologic Practice
• The Effects of Modified-Release Doxycycline on Quality of Life
• Combining Anti-Inflammatory–Dose Doxycycline With Topical Metronidazole

To view the supplement, click the image above.

Faculty/Faculty Disclosure

Brian Berman, MD, PhD
Voluntary Professor of Dermatology and Cutaneous Surgery
University of Miami, Miller School of Medicine
Co-Director
Center for Clinical and Cosmetic Research, Skin & Cancer Associates, LLP,
Aventura, FL

Dr Berman has received funding for clinical grants from, is an investigator for, and is a consultant to, Galderma Laboratories, L.P.

Copyright © 2012 by Elsevier Inc.

Topics

• Introduction - Exploring the Role of Modified-Release
• Doxycycline in Rosacea
• Comparing Antimicrobial and Anti-Inflammatory Doses of Oral Doxycycline in the Treatment of Rosacea
• Impact of Antibiotic Resistance on Dermatologic Practice
• The Effects of Modified-Release Doxycycline on Quality of Life
• Combining Anti-Inflammatory–Dose Doxycycline With Topical Metronidazole

To view the supplement, click the image above.

Faculty/Faculty Disclosure

Brian Berman, MD, PhD
Voluntary Professor of Dermatology and Cutaneous Surgery
University of Miami, Miller School of Medicine
Co-Director
Center for Clinical and Cosmetic Research, Skin & Cancer Associates, LLP,
Aventura, FL

Dr Berman has received funding for clinical grants from, is an investigator for, and is a consultant to, Galderma Laboratories, L.P.

Copyright © 2012 by Elsevier Inc.

Topics

• Introduction - Exploring the Role of Modified-Release
• Doxycycline in Rosacea
• Comparing Antimicrobial and Anti-Inflammatory Doses of Oral Doxycycline in the Treatment of Rosacea
• Impact of Antibiotic Resistance on Dermatologic Practice
• The Effects of Modified-Release Doxycycline on Quality of Life
• Combining Anti-Inflammatory–Dose Doxycycline With Topical Metronidazole

To view the supplement, click the image above.

Faculty/Faculty Disclosure

Brian Berman, MD, PhD
Voluntary Professor of Dermatology and Cutaneous Surgery
University of Miami, Miller School of Medicine
Co-Director
Center for Clinical and Cosmetic Research, Skin & Cancer Associates, LLP,
Aventura, FL

Dr Berman has received funding for clinical grants from, is an investigator for, and is a consultant to, Galderma Laboratories, L.P.

Copyright © 2012 by Elsevier Inc.

A Journal Scan supplement to Family Practice News®.  This supplement was sponsored by Galderma Laboratories, L.P. 

Topics

 

• Introduction - Exploring the Role of Modified-Release
• Doxycycline in Rosacea
• Comparing Antimicrobial and Anti-Inflammatory Doses of Oral Doxycycline in the Treatment of Rosacea
• Impact of Antibiotic Resistance on Dermatologic Practice
• The Effects of Modified-Release Doxycycline on Quality of Life
• Combining Anti-Inflammatory–Dose Doxycycline With Topical Metronidazole

To view the supplement, click the image above.

Faculty/Faculty Disclosure

Brian Berman, MD, PhD
Voluntary Professor of Dermatology and Cutaneous Surgery
University of Miami, Miller School of Medicine Co-Director
Center for Clinical and Cosmetic Research, Skin & Cancer Associates, LLP, Aventura, FL

 

Dr Berman has received funding for clinical grants from, is an investigator for, and is a consultant to, Galderma Laboratories, L.P.

Copyright (c) 2012 by Elsevier Inc.

A Journal Scan supplement to Family Practice News®.  This supplement was sponsored by Galderma Laboratories, L.P. 

Topics

 

• Introduction - Exploring the Role of Modified-Release
• Doxycycline in Rosacea
• Comparing Antimicrobial and Anti-Inflammatory Doses of Oral Doxycycline in the Treatment of Rosacea
• Impact of Antibiotic Resistance on Dermatologic Practice
• The Effects of Modified-Release Doxycycline on Quality of Life
• Combining Anti-Inflammatory–Dose Doxycycline With Topical Metronidazole

To view the supplement, click the image above.

Faculty/Faculty Disclosure

Brian Berman, MD, PhD
Voluntary Professor of Dermatology and Cutaneous Surgery
University of Miami, Miller School of Medicine Co-Director
Center for Clinical and Cosmetic Research, Skin & Cancer Associates, LLP, Aventura, FL

 

Dr Berman has received funding for clinical grants from, is an investigator for, and is a consultant to, Galderma Laboratories, L.P.

Copyright (c) 2012 by Elsevier Inc.

A Journal Scan supplement to Family Practice News®.  This supplement was sponsored by Galderma Laboratories, L.P. 

Topics

 

• Introduction - Exploring the Role of Modified-Release
• Doxycycline in Rosacea
• Comparing Antimicrobial and Anti-Inflammatory Doses of Oral Doxycycline in the Treatment of Rosacea
• Impact of Antibiotic Resistance on Dermatologic Practice
• The Effects of Modified-Release Doxycycline on Quality of Life
• Combining Anti-Inflammatory–Dose Doxycycline With Topical Metronidazole

To view the supplement, click the image above.

Faculty/Faculty Disclosure

Brian Berman, MD, PhD
Voluntary Professor of Dermatology and Cutaneous Surgery
University of Miami, Miller School of Medicine Co-Director
Center for Clinical and Cosmetic Research, Skin & Cancer Associates, LLP, Aventura, FL

 

Dr Berman has received funding for clinical grants from, is an investigator for, and is a consultant to, Galderma Laboratories, L.P.

Copyright (c) 2012 by Elsevier Inc.

"My Story: Blogs by Four Military Teens" is a book that gives voice to military teens by highlighting their feelings and experiences before, during, and after parental deployment. The four youths in "My Story" are fictional, but the stories are real in that the posts are a compilation of real life experiences of military kids.

"Adam" blogs, "My dad is one of the coolest, smartest, bravest men I’ve ever met, but sometimes I just can’t stand being around him. He’s a doctor – a surgeon – and is in the Air Force Reserves. He just returned from a second tour in Iraq, and he sure acts different. After his first tour, it took us some time to get caught up, but just when things got normal again, he got his orders to go back to Iraq. Now he’s finally home (for good?), but he just isn’t the same. He gets mad over the stupidest things and spends most of his time in his bedroom or in front of the computer.

Photo courtesy Michelle D. Sherman, Ph.D. and DeAnne M. Sherman, Ph.D.

"He’s still in ‘military mode,’ and orders us around way too much. He doesn’t joke around like before, and sometimes just hangs out in the garage by himself. We don’t talk much. I almost liked it better when he was gone. It was a lot quieter and less stressful around the house. Ashley, Lisa, and I just stay out of his way. Derrick is lucky – he’s leaving for college soon."

This book also provides support and education for military teens and preteens by honoring their unique joys and sacrifices, addressing their fears and hopes, and exploring how parental deployment affects their lives.

The book was written by Michelle D. Sherman, Ph.D., and her mother, DeAnne M. Sherman. Together, Dr. Sherman and her mother – a teacher – have written other books for teens, including "Finding My Way: A Teen’s Guide to Living with a Parent Who has Experienced Trauma" (Waco, Tex.: Seeds of Hope Publishers, 2005).

Dr. Sherman is a clinical psychologist at the Oklahoma City VA Medical Center, where she directs its Family Mental Health Program. She has dedicated her career to supporting families affected by mental illness and posttraumatic stress disorder, and has a special interest in the impact of parental mental illness and PTSD on youth.

"Think about the ... challenges facing our military teens," she writes in a guest post on the blog of an organization called Veterans Children. "Their parent(s) may be deployed once, twice, or even multiple times to a war zone. The parent may miss out on important events, such as prom, the school play, the state basketball tournament, and birthdays."

These young people are resilient, Dr. Sherman writes, but some are struggling with increased rates of anxiety, sleeping and behavioral problems, and the use of psychotropics.

"What does this tell us? ...They are affected by their parent’s deployment. We need to listen to them, provide resources, and make services available," writes Dr. Sherman, also is a clinical professor in the department of psychiatry and behavioral sciences at the University of Oklahoma Health Sciences Center and a research affiliate with the South Central Mental Illness Research, Education and Clinical Center (MIRECC).

In her work with veterans and families, Dr. Sherman has developed educational and support programs. Operation Enduring Families is a 5-session family education curriculum for Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) veterans/families, developed with Ursula B. Bowling, Psy.D., and Alan L. Doerman, Psy.D. This program is based on her S.A.F.E (Support and Family Education) program, an 18-session curriculum for those who care about someone with a mental illness/PTSD.

Dr. Sherman has developed an extensive resource list for OEF/OIF service members, and veterans and their families. (See box.) For a complete list, you can e-mail her at [email protected].

This column, "Families in Psychiatry," regularly appears in Clinical Psychiatry News, an Elsevier publication. Dr. Heru is an associate professor of psychiatry at the University of Colorado at Denver, Aurora. She has been a member of the Association of Family Psychiatrists since 2002 and currently serves as the organization’s treasurer. In addition, she is the coauthor of two books on working with families and is the author of numerous articles on this topic.

The following list of books and websites can be used to help military children of all ages cope with parental deployment:

Books

• "After the War Zone: A Practical Guide for Returning Troops and Their Families" (Cambridge, Mass.: Da Capo Press, 2008).

• "Back from the Front: Combat Trauma, Love, and the Family" (Brooklandville, Md.: Sidran Institute Press, 2007).

• "Courage After Fire: Coping Strategies for Returning Soldiers and Their Families" (Berkeley, Calif.: Ulysses Press, 2005).

• "I Miss You!: A Military Kid’s Book About Deployment" (Amherst, N.Y.: Prometheus Books, 2007).

• "Night Catch" (Jamestown, N.D.: Bubble Gum Press, 2005).

• "100 days and 99 nights" (New York: Little, Brown and Co. Books for Young Readers, 2008).

• "Sometimes We Were Brave" (Honesdale, Pa.: Boyds Mills Press, 2010).

• "The Fathers Are Coming Home" (New York: Margaret K. McElderry Books, 2010).

Websites

• "Courage to Care, Courage to Talk About War Injuries," developed by the Center for the Study of Traumatic Stress.

• "Military Child Bill of Rights."

• National Military Family Association.

• Operation Child Care.

• Operation: Military Kids.

• Song and video: "The Price of Peace."

• Video (58 minutes): "Returning From the War Zone: A Guide for Families of Military Members," created by the National Center for PTSD.

• Salute Our Services.

• SOAR (Student Online Achievement Resources).

• Students at the Center: An Education Resource for Families, the Military, and Schools.

• "Talk, Listen, Connect: Deployments, Homecomings, Changes."

• United Through Reading.

• Veteran Parenting Toolkit, created by the Oklahoma City VA Family Mental Health Program.

• "Welcome Back Parenting: A Guide for Reconnecting Families After Military Deployment."

• DVD: "Young Children on the Homefront: Family Stories, Family, Strengths," developed by the nonprofit organization Zero to Three: National Center for Infants, Toddlers, and Families.

• "Operation: Military Kids."

• "Young Heroes: Military Deployment Through the Eyes of Youth."

"My Story: Blogs by Four Military Teens" is a book that gives voice to military teens by highlighting their feelings and experiences before, during, and after parental deployment. The four youths in "My Story" are fictional, but the stories are real in that the posts are a compilation of real life experiences of military kids.

"Adam" blogs, "My dad is one of the coolest, smartest, bravest men I’ve ever met, but sometimes I just can’t stand being around him. He’s a doctor – a surgeon – and is in the Air Force Reserves. He just returned from a second tour in Iraq, and he sure acts different. After his first tour, it took us some time to get caught up, but just when things got normal again, he got his orders to go back to Iraq. Now he’s finally home (for good?), but he just isn’t the same. He gets mad over the stupidest things and spends most of his time in his bedroom or in front of the computer.

Photo courtesy Michelle D. Sherman, Ph.D. and DeAnne M. Sherman, Ph.D.

"He’s still in ‘military mode,’ and orders us around way too much. He doesn’t joke around like before, and sometimes just hangs out in the garage by himself. We don’t talk much. I almost liked it better when he was gone. It was a lot quieter and less stressful around the house. Ashley, Lisa, and I just stay out of his way. Derrick is lucky – he’s leaving for college soon."

This book also provides support and education for military teens and preteens by honoring their unique joys and sacrifices, addressing their fears and hopes, and exploring how parental deployment affects their lives.

The book was written by Michelle D. Sherman, Ph.D., and her mother, DeAnne M. Sherman. Together, Dr. Sherman and her mother – a teacher – have written other books for teens, including "Finding My Way: A Teen’s Guide to Living with a Parent Who has Experienced Trauma" (Waco, Tex.: Seeds of Hope Publishers, 2005).

Dr. Sherman is a clinical psychologist at the Oklahoma City VA Medical Center, where she directs its Family Mental Health Program. She has dedicated her career to supporting families affected by mental illness and posttraumatic stress disorder, and has a special interest in the impact of parental mental illness and PTSD on youth.

"Think about the ... challenges facing our military teens," she writes in a guest post on the blog of an organization called Veterans Children. "Their parent(s) may be deployed once, twice, or even multiple times to a war zone. The parent may miss out on important events, such as prom, the school play, the state basketball tournament, and birthdays."

These young people are resilient, Dr. Sherman writes, but some are struggling with increased rates of anxiety, sleeping and behavioral problems, and the use of psychotropics.

"What does this tell us? ...They are affected by their parent’s deployment. We need to listen to them, provide resources, and make services available," writes Dr. Sherman, also is a clinical professor in the department of psychiatry and behavioral sciences at the University of Oklahoma Health Sciences Center and a research affiliate with the South Central Mental Illness Research, Education and Clinical Center (MIRECC).

In her work with veterans and families, Dr. Sherman has developed educational and support programs. Operation Enduring Families is a 5-session family education curriculum for Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) veterans/families, developed with Ursula B. Bowling, Psy.D., and Alan L. Doerman, Psy.D. This program is based on her S.A.F.E (Support and Family Education) program, an 18-session curriculum for those who care about someone with a mental illness/PTSD.

Dr. Sherman has developed an extensive resource list for OEF/OIF service members, and veterans and their families. (See box.) For a complete list, you can e-mail her at [email protected].

This column, "Families in Psychiatry," regularly appears in Clinical Psychiatry News, an Elsevier publication. Dr. Heru is an associate professor of psychiatry at the University of Colorado at Denver, Aurora. She has been a member of the Association of Family Psychiatrists since 2002 and currently serves as the organization’s treasurer. In addition, she is the coauthor of two books on working with families and is the author of numerous articles on this topic.

The following list of books and websites can be used to help military children of all ages cope with parental deployment:

Books

• "After the War Zone: A Practical Guide for Returning Troops and Their Families" (Cambridge, Mass.: Da Capo Press, 2008).

• "Back from the Front: Combat Trauma, Love, and the Family" (Brooklandville, Md.: Sidran Institute Press, 2007).

• "Courage After Fire: Coping Strategies for Returning Soldiers and Their Families" (Berkeley, Calif.: Ulysses Press, 2005).

• "I Miss You!: A Military Kid’s Book About Deployment" (Amherst, N.Y.: Prometheus Books, 2007).

• "Night Catch" (Jamestown, N.D.: Bubble Gum Press, 2005).

• "100 days and 99 nights" (New York: Little, Brown and Co. Books for Young Readers, 2008).

• "Sometimes We Were Brave" (Honesdale, Pa.: Boyds Mills Press, 2010).

• "The Fathers Are Coming Home" (New York: Margaret K. McElderry Books, 2010).

Websites

• "Courage to Care, Courage to Talk About War Injuries," developed by the Center for the Study of Traumatic Stress.

• "Military Child Bill of Rights."

• National Military Family Association.

• Operation Child Care.

• Operation: Military Kids.

• Song and video: "The Price of Peace."

• Video (58 minutes): "Returning From the War Zone: A Guide for Families of Military Members," created by the National Center for PTSD.

• Salute Our Services.

• SOAR (Student Online Achievement Resources).

• Students at the Center: An Education Resource for Families, the Military, and Schools.

• "Talk, Listen, Connect: Deployments, Homecomings, Changes."

• United Through Reading.

• Veteran Parenting Toolkit, created by the Oklahoma City VA Family Mental Health Program.

• "Welcome Back Parenting: A Guide for Reconnecting Families After Military Deployment."

• DVD: "Young Children on the Homefront: Family Stories, Family, Strengths," developed by the nonprofit organization Zero to Three: National Center for Infants, Toddlers, and Families.

• "Operation: Military Kids."

• "Young Heroes: Military Deployment Through the Eyes of Youth."

"My Story: Blogs by Four Military Teens" is a book that gives voice to military teens by highlighting their feelings and experiences before, during, and after parental deployment. The four youths in "My Story" are fictional, but the stories are real in that the posts are a compilation of real life experiences of military kids.

"Adam" blogs, "My dad is one of the coolest, smartest, bravest men I’ve ever met, but sometimes I just can’t stand being around him. He’s a doctor – a surgeon – and is in the Air Force Reserves. He just returned from a second tour in Iraq, and he sure acts different. After his first tour, it took us some time to get caught up, but just when things got normal again, he got his orders to go back to Iraq. Now he’s finally home (for good?), but he just isn’t the same. He gets mad over the stupidest things and spends most of his time in his bedroom or in front of the computer.

Photo courtesy Michelle D. Sherman, Ph.D. and DeAnne M. Sherman, Ph.D.

"He’s still in ‘military mode,’ and orders us around way too much. He doesn’t joke around like before, and sometimes just hangs out in the garage by himself. We don’t talk much. I almost liked it better when he was gone. It was a lot quieter and less stressful around the house. Ashley, Lisa, and I just stay out of his way. Derrick is lucky – he’s leaving for college soon."

This book also provides support and education for military teens and preteens by honoring their unique joys and sacrifices, addressing their fears and hopes, and exploring how parental deployment affects their lives.

The book was written by Michelle D. Sherman, Ph.D., and her mother, DeAnne M. Sherman. Together, Dr. Sherman and her mother – a teacher – have written other books for teens, including "Finding My Way: A Teen’s Guide to Living with a Parent Who has Experienced Trauma" (Waco, Tex.: Seeds of Hope Publishers, 2005).

Dr. Sherman is a clinical psychologist at the Oklahoma City VA Medical Center, where she directs its Family Mental Health Program. She has dedicated her career to supporting families affected by mental illness and posttraumatic stress disorder, and has a special interest in the impact of parental mental illness and PTSD on youth.

"Think about the ... challenges facing our military teens," she writes in a guest post on the blog of an organization called Veterans Children. "Their parent(s) may be deployed once, twice, or even multiple times to a war zone. The parent may miss out on important events, such as prom, the school play, the state basketball tournament, and birthdays."

These young people are resilient, Dr. Sherman writes, but some are struggling with increased rates of anxiety, sleeping and behavioral problems, and the use of psychotropics.

"What does this tell us? ...They are affected by their parent’s deployment. We need to listen to them, provide resources, and make services available," writes Dr. Sherman, also is a clinical professor in the department of psychiatry and behavioral sciences at the University of Oklahoma Health Sciences Center and a research affiliate with the South Central Mental Illness Research, Education and Clinical Center (MIRECC).

In her work with veterans and families, Dr. Sherman has developed educational and support programs. Operation Enduring Families is a 5-session family education curriculum for Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) veterans/families, developed with Ursula B. Bowling, Psy.D., and Alan L. Doerman, Psy.D. This program is based on her S.A.F.E (Support and Family Education) program, an 18-session curriculum for those who care about someone with a mental illness/PTSD.

Dr. Sherman has developed an extensive resource list for OEF/OIF service members, and veterans and their families. (See box.) For a complete list, you can e-mail her at [email protected].

This column, "Families in Psychiatry," regularly appears in Clinical Psychiatry News, an Elsevier publication. Dr. Heru is an associate professor of psychiatry at the University of Colorado at Denver, Aurora. She has been a member of the Association of Family Psychiatrists since 2002 and currently serves as the organization’s treasurer. In addition, she is the coauthor of two books on working with families and is the author of numerous articles on this topic.

The following list of books and websites can be used to help military children of all ages cope with parental deployment:

Books

• "After the War Zone: A Practical Guide for Returning Troops and Their Families" (Cambridge, Mass.: Da Capo Press, 2008).

• "Back from the Front: Combat Trauma, Love, and the Family" (Brooklandville, Md.: Sidran Institute Press, 2007).

• "Courage After Fire: Coping Strategies for Returning Soldiers and Their Families" (Berkeley, Calif.: Ulysses Press, 2005).

• "I Miss You!: A Military Kid’s Book About Deployment" (Amherst, N.Y.: Prometheus Books, 2007).

• "Night Catch" (Jamestown, N.D.: Bubble Gum Press, 2005).

• "100 days and 99 nights" (New York: Little, Brown and Co. Books for Young Readers, 2008).

• "Sometimes We Were Brave" (Honesdale, Pa.: Boyds Mills Press, 2010).

• "The Fathers Are Coming Home" (New York: Margaret K. McElderry Books, 2010).

Websites

• "Courage to Care, Courage to Talk About War Injuries," developed by the Center for the Study of Traumatic Stress.

• "Military Child Bill of Rights."

• National Military Family Association.

• Operation Child Care.

• Operation: Military Kids.

• Song and video: "The Price of Peace."

• Video (58 minutes): "Returning From the War Zone: A Guide for Families of Military Members," created by the National Center for PTSD.

• Salute Our Services.

• SOAR (Student Online Achievement Resources).

• Students at the Center: An Education Resource for Families, the Military, and Schools.

• "Talk, Listen, Connect: Deployments, Homecomings, Changes."

• United Through Reading.

• Veteran Parenting Toolkit, created by the Oklahoma City VA Family Mental Health Program.

• "Welcome Back Parenting: A Guide for Reconnecting Families After Military Deployment."

• DVD: "Young Children on the Homefront: Family Stories, Family, Strengths," developed by the nonprofit organization Zero to Three: National Center for Infants, Toddlers, and Families.

• "Operation: Military Kids."

• "Young Heroes: Military Deployment Through the Eyes of Youth."

Rehospitalization within 30 days of an initial acute coronary syndrome or heart failure event has now become a CMS quality measure that will affect overall hospital Medicare payments. It has been appreciated for some time that rehospitalization for these diagnoses has been unacceptably high.

A recent report indicates that a greater percentage of U.S. patients who experienced a STEMI are more likely to be rehospitalized within 30 days, compared with other Western countries (14.5% vs. 9.9%, respectively). That report (JAMA 2012;307:66-74) indicates that the increase is directly related to the shorter length of hospital stay in the United States. Among the 17 countries included in the report, the average duration was shortest in the United States (3 days) and longest in Germany (8 days). Predictors of readmission other than length of stay include the age of the patient and the presence of heart failure. The most interesting part of the story is how we arrived at this state of affairs.

For those of you who were not yet born or are too young to remember when Medicare was passed into law in 1965, I will give you a little history. And for those of you who were around at the time, I will provide a reminder.

As you undoubtedly know, Medicare, in addition to paying physicians’ fees also pays hospital costs. In the period between 1965 and 1983, using a payment system that was defined as "reasonable and allowable costs," Medicare payments to hospitals increased 10-fold, from $3 billion to $37 billion. In consequence, Congress passed a law in 1982 that created a prospective payment system for hospitals using diagnosis-related groups establishing a payment schedule for specific diagnoses, which included acute myocardial infarction and heart failure. With this schedule, hospitals were paid a fixed rate regardless of the number of procedures performed or duration of hospitalization. In order to minimize costs, hospitals accelerated discharges and shortened hospital length of stay. Emergency admissions resulted in urgent discharge.

In order to expedite the process of admission and discharge, hospitalists were hired to accelerate that process since practicing internists and cardiologists were not available to push the paperwork through fast enough to get the patients discharged quickly. Hospitals saw this additional layer of doctors caring for patients as financially profitable. As a result, hospital stays decreased markedly and payments to hospitals decreased by 52% from 1985 to 1990 and by an additional 37% between 1990 and 1995. Everyone seemed to be very happy with this, including the hospitals, Medicare, and doctors. As far as I know, patients were not consulted.

Cardiologists at that time were telling themselves how benign an acute MI is and began doing accelerated discharge after percutaneous coronary intervention. We prided ourselves on how patients could be discharged to home within 24-36 hours, but never actually reached the ultimate goal of a "drive-through PCI." The fact that patients with acute MI and heart failure were frequently readmitted was good business since each admission resulted in further Medicare payments both to the hospital and the doctors. Urging by some physicians to develop plans that could educate patients and develop discharge follow-up systems was met with incredulity by hospital administrators who saw readmission as a revenue source and discharge planning as costly.

It is important to emphasize that readmission not only reflects an important morbidity event, it also carries with it the potential for increased risk of mortality. In the report cited above, one-third of the deaths after hospitalization for a STEMI occurred within the same 30-day post-event period. The recent emphasis on decreasing door-to-balloon time, although effective in shortening that period, has had little effect on the mortality associated with an acute myocardial infarction. It is reasonable to assume that in placing a greater emphasis on insuring that patients are ready to leave the hospital, we can improve mortality and morbidity of both the ACS and heart failure patient. There really is no urgency to discharge patients other than improving the bottom line, and that imperative may no longer be relevant.

Dr. Goldstein, medical editor of Cardiology News, is professor of medicine at Wayne State University and division head emeritus of cardiovascular medicine at Henry Ford Hospital, both in Detroit. He is on data safety monitoring committees for the National Institutes of Health and several pharmaceutical companies.

Rehospitalization within 30 days of an initial acute coronary syndrome or heart failure event has now become a CMS quality measure that will affect overall hospital Medicare payments. It has been appreciated for some time that rehospitalization for these diagnoses has been unacceptably high.

A recent report indicates that a greater percentage of U.S. patients who experienced a STEMI are more likely to be rehospitalized within 30 days, compared with other Western countries (14.5% vs. 9.9%, respectively). That report (JAMA 2012;307:66-74) indicates that the increase is directly related to the shorter length of hospital stay in the United States. Among the 17 countries included in the report, the average duration was shortest in the United States (3 days) and longest in Germany (8 days). Predictors of readmission other than length of stay include the age of the patient and the presence of heart failure. The most interesting part of the story is how we arrived at this state of affairs.

For those of you who were not yet born or are too young to remember when Medicare was passed into law in 1965, I will give you a little history. And for those of you who were around at the time, I will provide a reminder.

As you undoubtedly know, Medicare, in addition to paying physicians’ fees also pays hospital costs. In the period between 1965 and 1983, using a payment system that was defined as "reasonable and allowable costs," Medicare payments to hospitals increased 10-fold, from $3 billion to $37 billion. In consequence, Congress passed a law in 1982 that created a prospective payment system for hospitals using diagnosis-related groups establishing a payment schedule for specific diagnoses, which included acute myocardial infarction and heart failure. With this schedule, hospitals were paid a fixed rate regardless of the number of procedures performed or duration of hospitalization. In order to minimize costs, hospitals accelerated discharges and shortened hospital length of stay. Emergency admissions resulted in urgent discharge.

In order to expedite the process of admission and discharge, hospitalists were hired to accelerate that process since practicing internists and cardiologists were not available to push the paperwork through fast enough to get the patients discharged quickly. Hospitals saw this additional layer of doctors caring for patients as financially profitable. As a result, hospital stays decreased markedly and payments to hospitals decreased by 52% from 1985 to 1990 and by an additional 37% between 1990 and 1995. Everyone seemed to be very happy with this, including the hospitals, Medicare, and doctors. As far as I know, patients were not consulted.

Cardiologists at that time were telling themselves how benign an acute MI is and began doing accelerated discharge after percutaneous coronary intervention. We prided ourselves on how patients could be discharged to home within 24-36 hours, but never actually reached the ultimate goal of a "drive-through PCI." The fact that patients with acute MI and heart failure were frequently readmitted was good business since each admission resulted in further Medicare payments both to the hospital and the doctors. Urging by some physicians to develop plans that could educate patients and develop discharge follow-up systems was met with incredulity by hospital administrators who saw readmission as a revenue source and discharge planning as costly.

It is important to emphasize that readmission not only reflects an important morbidity event, it also carries with it the potential for increased risk of mortality. In the report cited above, one-third of the deaths after hospitalization for a STEMI occurred within the same 30-day post-event period. The recent emphasis on decreasing door-to-balloon time, although effective in shortening that period, has had little effect on the mortality associated with an acute myocardial infarction. It is reasonable to assume that in placing a greater emphasis on insuring that patients are ready to leave the hospital, we can improve mortality and morbidity of both the ACS and heart failure patient. There really is no urgency to discharge patients other than improving the bottom line, and that imperative may no longer be relevant.

Dr. Goldstein, medical editor of Cardiology News, is professor of medicine at Wayne State University and division head emeritus of cardiovascular medicine at Henry Ford Hospital, both in Detroit. He is on data safety monitoring committees for the National Institutes of Health and several pharmaceutical companies.

Rehospitalization within 30 days of an initial acute coronary syndrome or heart failure event has now become a CMS quality measure that will affect overall hospital Medicare payments. It has been appreciated for some time that rehospitalization for these diagnoses has been unacceptably high.

A recent report indicates that a greater percentage of U.S. patients who experienced a STEMI are more likely to be rehospitalized within 30 days, compared with other Western countries (14.5% vs. 9.9%, respectively). That report (JAMA 2012;307:66-74) indicates that the increase is directly related to the shorter length of hospital stay in the United States. Among the 17 countries included in the report, the average duration was shortest in the United States (3 days) and longest in Germany (8 days). Predictors of readmission other than length of stay include the age of the patient and the presence of heart failure. The most interesting part of the story is how we arrived at this state of affairs.

For those of you who were not yet born or are too young to remember when Medicare was passed into law in 1965, I will give you a little history. And for those of you who were around at the time, I will provide a reminder.

As you undoubtedly know, Medicare, in addition to paying physicians’ fees also pays hospital costs. In the period between 1965 and 1983, using a payment system that was defined as "reasonable and allowable costs," Medicare payments to hospitals increased 10-fold, from $3 billion to $37 billion. In consequence, Congress passed a law in 1982 that created a prospective payment system for hospitals using diagnosis-related groups establishing a payment schedule for specific diagnoses, which included acute myocardial infarction and heart failure. With this schedule, hospitals were paid a fixed rate regardless of the number of procedures performed or duration of hospitalization. In order to minimize costs, hospitals accelerated discharges and shortened hospital length of stay. Emergency admissions resulted in urgent discharge.

In order to expedite the process of admission and discharge, hospitalists were hired to accelerate that process since practicing internists and cardiologists were not available to push the paperwork through fast enough to get the patients discharged quickly. Hospitals saw this additional layer of doctors caring for patients as financially profitable. As a result, hospital stays decreased markedly and payments to hospitals decreased by 52% from 1985 to 1990 and by an additional 37% between 1990 and 1995. Everyone seemed to be very happy with this, including the hospitals, Medicare, and doctors. As far as I know, patients were not consulted.

Cardiologists at that time were telling themselves how benign an acute MI is and began doing accelerated discharge after percutaneous coronary intervention. We prided ourselves on how patients could be discharged to home within 24-36 hours, but never actually reached the ultimate goal of a "drive-through PCI." The fact that patients with acute MI and heart failure were frequently readmitted was good business since each admission resulted in further Medicare payments both to the hospital and the doctors. Urging by some physicians to develop plans that could educate patients and develop discharge follow-up systems was met with incredulity by hospital administrators who saw readmission as a revenue source and discharge planning as costly.

It is important to emphasize that readmission not only reflects an important morbidity event, it also carries with it the potential for increased risk of mortality. In the report cited above, one-third of the deaths after hospitalization for a STEMI occurred within the same 30-day post-event period. The recent emphasis on decreasing door-to-balloon time, although effective in shortening that period, has had little effect on the mortality associated with an acute myocardial infarction. It is reasonable to assume that in placing a greater emphasis on insuring that patients are ready to leave the hospital, we can improve mortality and morbidity of both the ACS and heart failure patient. There really is no urgency to discharge patients other than improving the bottom line, and that imperative may no longer be relevant.

Dr. Goldstein, medical editor of Cardiology News, is professor of medicine at Wayne State University and division head emeritus of cardiovascular medicine at Henry Ford Hospital, both in Detroit. He is on data safety monitoring committees for the National Institutes of Health and several pharmaceutical companies.

NATIONAL HARBOR, MD. – When a child needs fluids or drugs but you can’t find a good vein, turn to bone.

Intraosseous (IO) access was pioneered during World War I, and it’s aged well – although peripheral IVs pushed it out of the limelight for several decades. But IO access remains the standard of care in emergency situations where IVs can’t be used, Dr. Angela Ellison said at a meeting sponsored by the American College of Emergency Physicians.

A 1988 review of 33 pediatric cardiac arrests showed that IO is the quickest way to go. Although a successful IO attempt took about 5 minutes, compared with 3 minutes for a peripheral IV, the success rate for an IO placement was much greater – 83% vs. 17%, said Dr. Ellison of the University of Pennsylvania, Philadelphia (Am. J. Emerg. Med. 1988;6:577-9).

"In difficult cases, the investigators recommended that IV attempts be very brief, and if unsuccessful, you should move on to IO right away," she said.

IO access works for children of all sizes, even newborns, she said, and in children with all kinds of emergencies, including shock, trauma, status epilepticus, and severe dehydration. IO access can be established by emergency medical technicians and nurses as well as physicians. With a preprocedural shot of lidocaine, IO catheters can easily be placed in conscious as well as unconscious patients.

For patients who need drugs urgently, IO is superior to IV; animal studies have shown that drugs reach the heart in 10-20 seconds, and there is no need to change the dose from a normal IV concentration.

Technical advances have made IO access easier, she added. "Over the past few decades, we’ve gotten a number of powered devices that have contributed to the rise of IO." Some can be placed in the sternum and others in long bones. Studies have shown that the complication rate is not increased when the needles are placed near a growth plate.

IO access is not for everyone or every bone, however. Contraindications include long bone fracture, vascular injury in the extremity, an overlying skin infection, a burn at the access site, 10 or more previous placements or attempts, and fragile bones (osteogenesis imperfecta or osteoporosis).

For the most part, however, IO access is very safe. Studies conducted in the late 1980s and early 1990s show an overall complication rate of less than 1%. Osteomyelitis occurred in 0.6%, and cellulitis or skin abscess developed in 0.7%. No evidence of bone deformity or growth arrest was seen in long-term follow-up studies.

Dr. Ellison had no financial conflicts.

NATIONAL HARBOR, MD. – When a child needs fluids or drugs but you can’t find a good vein, turn to bone.

Intraosseous (IO) access was pioneered during World War I, and it’s aged well – although peripheral IVs pushed it out of the limelight for several decades. But IO access remains the standard of care in emergency situations where IVs can’t be used, Dr. Angela Ellison said at a meeting sponsored by the American College of Emergency Physicians.

A 1988 review of 33 pediatric cardiac arrests showed that IO is the quickest way to go. Although a successful IO attempt took about 5 minutes, compared with 3 minutes for a peripheral IV, the success rate for an IO placement was much greater – 83% vs. 17%, said Dr. Ellison of the University of Pennsylvania, Philadelphia (Am. J. Emerg. Med. 1988;6:577-9).

"In difficult cases, the investigators recommended that IV attempts be very brief, and if unsuccessful, you should move on to IO right away," she said.

IO access works for children of all sizes, even newborns, she said, and in children with all kinds of emergencies, including shock, trauma, status epilepticus, and severe dehydration. IO access can be established by emergency medical technicians and nurses as well as physicians. With a preprocedural shot of lidocaine, IO catheters can easily be placed in conscious as well as unconscious patients.

For patients who need drugs urgently, IO is superior to IV; animal studies have shown that drugs reach the heart in 10-20 seconds, and there is no need to change the dose from a normal IV concentration.

Technical advances have made IO access easier, she added. "Over the past few decades, we’ve gotten a number of powered devices that have contributed to the rise of IO." Some can be placed in the sternum and others in long bones. Studies have shown that the complication rate is not increased when the needles are placed near a growth plate.

IO access is not for everyone or every bone, however. Contraindications include long bone fracture, vascular injury in the extremity, an overlying skin infection, a burn at the access site, 10 or more previous placements or attempts, and fragile bones (osteogenesis imperfecta or osteoporosis).

For the most part, however, IO access is very safe. Studies conducted in the late 1980s and early 1990s show an overall complication rate of less than 1%. Osteomyelitis occurred in 0.6%, and cellulitis or skin abscess developed in 0.7%. No evidence of bone deformity or growth arrest was seen in long-term follow-up studies.

Dr. Ellison had no financial conflicts.

NATIONAL HARBOR, MD. – When a child needs fluids or drugs but you can’t find a good vein, turn to bone.

Intraosseous (IO) access was pioneered during World War I, and it’s aged well – although peripheral IVs pushed it out of the limelight for several decades. But IO access remains the standard of care in emergency situations where IVs can’t be used, Dr. Angela Ellison said at a meeting sponsored by the American College of Emergency Physicians.

A 1988 review of 33 pediatric cardiac arrests showed that IO is the quickest way to go. Although a successful IO attempt took about 5 minutes, compared with 3 minutes for a peripheral IV, the success rate for an IO placement was much greater – 83% vs. 17%, said Dr. Ellison of the University of Pennsylvania, Philadelphia (Am. J. Emerg. Med. 1988;6:577-9).

"In difficult cases, the investigators recommended that IV attempts be very brief, and if unsuccessful, you should move on to IO right away," she said.

IO access works for children of all sizes, even newborns, she said, and in children with all kinds of emergencies, including shock, trauma, status epilepticus, and severe dehydration. IO access can be established by emergency medical technicians and nurses as well as physicians. With a preprocedural shot of lidocaine, IO catheters can easily be placed in conscious as well as unconscious patients.

For patients who need drugs urgently, IO is superior to IV; animal studies have shown that drugs reach the heart in 10-20 seconds, and there is no need to change the dose from a normal IV concentration.

Technical advances have made IO access easier, she added. "Over the past few decades, we’ve gotten a number of powered devices that have contributed to the rise of IO." Some can be placed in the sternum and others in long bones. Studies have shown that the complication rate is not increased when the needles are placed near a growth plate.

IO access is not for everyone or every bone, however. Contraindications include long bone fracture, vascular injury in the extremity, an overlying skin infection, a burn at the access site, 10 or more previous placements or attempts, and fragile bones (osteogenesis imperfecta or osteoporosis).

For the most part, however, IO access is very safe. Studies conducted in the late 1980s and early 1990s show an overall complication rate of less than 1%. Osteomyelitis occurred in 0.6%, and cellulitis or skin abscess developed in 0.7%. No evidence of bone deformity or growth arrest was seen in long-term follow-up studies.

Dr. Ellison had no financial conflicts.

Although based in an academic hospital program at the University of Colorado Denver, new SHM board member Jeffrey Glasheen, MD, SFHM, does not view himself as representative of only academic hospitalist groups on the board.

"I'd like to say I represent the constituency that cares about the quality, safety, and efficiency of healthcare delivery—and that includes every hospitalist,” says Dr. Glasheen, who has played major roles in developing SHM's Academic Hospitalist Academy and Academic Hospital Medicine Leadership Summit, and now chairs its Academic Committee.

Dr. Glasheen, who recently resigned as physician editor of the The Hospitalist is a senior deputy editor of the Journal of Hospital Medicine and was course director of HM12 in San Diego earlier this month. He intends to "push the envelope" for quality issues in his service on the board. "Quality is the best conceivable care you can provide, and clearly, where we are today is not there yet," he says.

Dr. Glasheen, who is committed to giving hospitalists the skills they need to elevate the quality of hospital care, says that starts with redesigning residency programs and medical school curriculums to teach quality improvement (QI). He believes that payment and healthcare reform will put hospitalists in a great position to serve as their hospitals' quality leaders, "but it's also going to take inspired leadership," he says. Hospitalists and hospitals need to make quality a major priority, which he recognizes is hard to do when groups are understaffed. As such, he hopes to find solutions to HM's pipeline issues—how to fill the hospitalist positions that will be needed in the future.

"I've been blessed in my situation [at my institution] to have an administration that's really supportive of hospital medicine," he says. "Our administration really gets the value equation, and we as hospitalists do, too. But as I travel around the country, I don't always see that."

Although based in an academic hospital program at the University of Colorado Denver, new SHM board member Jeffrey Glasheen, MD, SFHM, does not view himself as representative of only academic hospitalist groups on the board.

"I'd like to say I represent the constituency that cares about the quality, safety, and efficiency of healthcare delivery—and that includes every hospitalist,” says Dr. Glasheen, who has played major roles in developing SHM's Academic Hospitalist Academy and Academic Hospital Medicine Leadership Summit, and now chairs its Academic Committee.

Dr. Glasheen, who recently resigned as physician editor of the The Hospitalist is a senior deputy editor of the Journal of Hospital Medicine and was course director of HM12 in San Diego earlier this month. He intends to "push the envelope" for quality issues in his service on the board. "Quality is the best conceivable care you can provide, and clearly, where we are today is not there yet," he says.

Dr. Glasheen, who is committed to giving hospitalists the skills they need to elevate the quality of hospital care, says that starts with redesigning residency programs and medical school curriculums to teach quality improvement (QI). He believes that payment and healthcare reform will put hospitalists in a great position to serve as their hospitals' quality leaders, "but it's also going to take inspired leadership," he says. Hospitalists and hospitals need to make quality a major priority, which he recognizes is hard to do when groups are understaffed. As such, he hopes to find solutions to HM's pipeline issues—how to fill the hospitalist positions that will be needed in the future.

"I've been blessed in my situation [at my institution] to have an administration that's really supportive of hospital medicine," he says. "Our administration really gets the value equation, and we as hospitalists do, too. But as I travel around the country, I don't always see that."

Although based in an academic hospital program at the University of Colorado Denver, new SHM board member Jeffrey Glasheen, MD, SFHM, does not view himself as representative of only academic hospitalist groups on the board.

"I'd like to say I represent the constituency that cares about the quality, safety, and efficiency of healthcare delivery—and that includes every hospitalist,” says Dr. Glasheen, who has played major roles in developing SHM's Academic Hospitalist Academy and Academic Hospital Medicine Leadership Summit, and now chairs its Academic Committee.

Dr. Glasheen, who recently resigned as physician editor of the The Hospitalist is a senior deputy editor of the Journal of Hospital Medicine and was course director of HM12 in San Diego earlier this month. He intends to "push the envelope" for quality issues in his service on the board. "Quality is the best conceivable care you can provide, and clearly, where we are today is not there yet," he says.

Dr. Glasheen, who is committed to giving hospitalists the skills they need to elevate the quality of hospital care, says that starts with redesigning residency programs and medical school curriculums to teach quality improvement (QI). He believes that payment and healthcare reform will put hospitalists in a great position to serve as their hospitals' quality leaders, "but it's also going to take inspired leadership," he says. Hospitalists and hospitals need to make quality a major priority, which he recognizes is hard to do when groups are understaffed. As such, he hopes to find solutions to HM's pipeline issues—how to fill the hospitalist positions that will be needed in the future.

"I've been blessed in my situation [at my institution] to have an administration that's really supportive of hospital medicine," he says. "Our administration really gets the value equation, and we as hospitalists do, too. But as I travel around the country, I don't always see that."

The creators of the first measurement tool for hospitalist programs hope that it becomes a standardized gauge for HM practice performance.

The Greeno-Hawley Hospital Medicine Index, unveiled earlier this month by Cogent HMG, uses a 26-question survey to measure HM group performance in five categories: alignment, performance management, infrastructure, operational processes, and leadership and people. The score will offer HM leaders a perspective on where their group stands in comparison with other hospitalist programs.

"It's meant to be a snapshot in time," says Beth Hawley, MBA, FACHE, Cogent's chief customer experience officer, who helped develop the index with Ron Greeno, MD, MHM, the company's chief medical officer. It is intended to help programs pinpoint the areas on which they need to focus in order to improve their performance, she says.

The index will be formally demonstrated at the American College of Physician Executives meeting April 30 in San Francisco. It will be available online in May.

Hawley says that once programs begin using the index, Cogent can assimilate and review the data to determine whether the tool can serve as a predictive model. Until then, it can be a guidepost for practice improvement for HM leaders who have never before had comparative tools.

"People would sit there thinking they're doing a great job but they only know their little market or their hospital," she says, "and really don’t see the broad picture of where hospital medicine is going and what a hospital medicine program can do for a hospital."

The creators of the first measurement tool for hospitalist programs hope that it becomes a standardized gauge for HM practice performance.

The Greeno-Hawley Hospital Medicine Index, unveiled earlier this month by Cogent HMG, uses a 26-question survey to measure HM group performance in five categories: alignment, performance management, infrastructure, operational processes, and leadership and people. The score will offer HM leaders a perspective on where their group stands in comparison with other hospitalist programs.

"It's meant to be a snapshot in time," says Beth Hawley, MBA, FACHE, Cogent's chief customer experience officer, who helped develop the index with Ron Greeno, MD, MHM, the company's chief medical officer. It is intended to help programs pinpoint the areas on which they need to focus in order to improve their performance, she says.

The index will be formally demonstrated at the American College of Physician Executives meeting April 30 in San Francisco. It will be available online in May.

Hawley says that once programs begin using the index, Cogent can assimilate and review the data to determine whether the tool can serve as a predictive model. Until then, it can be a guidepost for practice improvement for HM leaders who have never before had comparative tools.

"People would sit there thinking they're doing a great job but they only know their little market or their hospital," she says, "and really don’t see the broad picture of where hospital medicine is going and what a hospital medicine program can do for a hospital."

The creators of the first measurement tool for hospitalist programs hope that it becomes a standardized gauge for HM practice performance.

The Greeno-Hawley Hospital Medicine Index, unveiled earlier this month by Cogent HMG, uses a 26-question survey to measure HM group performance in five categories: alignment, performance management, infrastructure, operational processes, and leadership and people. The score will offer HM leaders a perspective on where their group stands in comparison with other hospitalist programs.

"It's meant to be a snapshot in time," says Beth Hawley, MBA, FACHE, Cogent's chief customer experience officer, who helped develop the index with Ron Greeno, MD, MHM, the company's chief medical officer. It is intended to help programs pinpoint the areas on which they need to focus in order to improve their performance, she says.

The index will be formally demonstrated at the American College of Physician Executives meeting April 30 in San Francisco. It will be available online in May.

Hawley says that once programs begin using the index, Cogent can assimilate and review the data to determine whether the tool can serve as a predictive model. Until then, it can be a guidepost for practice improvement for HM leaders who have never before had comparative tools.

"People would sit there thinking they're doing a great job but they only know their little market or their hospital," she says, "and really don’t see the broad picture of where hospital medicine is going and what a hospital medicine program can do for a hospital."

Fewer children died from unintentional injuries between 2000 and 2009, but death rates from suffocation and poisoning increased, according to a report from the Centers for Disease Control and Prevention.

The overall death rate from unintentional injuries among children dropped by nearly 30% during the 10-year period, according to an analysis of national mortality data. There were 9,143 childhood deaths from unintentional injuries in 2009, down from 12,441 in 2000. Yet, that’s about one child death per hour caused by unintentional injury, whether it’s a traffic crash, drowning, poisoning, or fire.

CDC/Amanda Mills

"One child’s death is still one too many," said Ileana Arias, Ph.D., principal deputy director at CDC, in a news conference. "We know most of these events are predictable and preventable."

Traffic crashes were the leading cause of death among children and adolescents (4,564 deaths), followed by suffocation (1,160), drowning (983), poisoning (824), fire/burn (391), and falls (151), according to the report.

Despite a drop in most of the mechanisms, the authors noted the increase in poisoning and suffocation death rates.

There was a 91% increase in poisoning death rate among adolescents aged 15-19 years over the 10-year period. The authors attributed the rise to prescription drug overdoses. Painkillers seem to be replacing marijuana as a gateway drug, said Dr. Arias.

"Strategies to reduce the misuse of prescription drugs include appropriate prescribing, proper storage and disposal, discouraging medication sharing, and state-based prescription drug monitoring programs," the report’s authors wrote (MMWR 2012;61:1-7).

Also, unintentional infant suffocation rates increased 54% between 2000 and 2009. The increase "underscores the importance of safe sleeping environments as recommended by the American Academy of Pediatrics, which includes supine positioning, a firm sleep surface, room-sharing without bed-sharing, and avoiding loose bedding," the investigators noted.

There was nearly a 41% decrease in deaths from traffic crashes during the 10-year-period, which could be due to several factors, including improvements in seat belt use, child safety seat and booster seat use, licensing requirements, and vehicle design, according to the report.

Drowning deaths decreased 28%; deaths from fire/burn decreased 45%, and deaths from accidental falls dropped 19%.

Despite the declines, injury remains the leading cause of death among children in the United States. The nation also ranks worst among all high-income countries when it comes to injury deaths among 0 to 14-year-olds, according to the CDC report, which is the first of its kind to describe trends among 0 to 19-year-olds by mechanism and by state.

Unintentional injury rates varied widely among states, suggesting that "environment, exposure to hazards, and difference in public policy might play a role," the authors wrote. The variation also "demonstrated that it is possible to prevent these injuries," said Dr. Arias. Massachusetts had the lowest unintentional injury death rate (4/100,000), and Mississippi had the highest (25.1/100,000).

The report is based on analysis of national mortality data collected in the CDC’s National Vital Statistics Systems. 

The authors said the report has at least two limitations. First, the report is based on death certificate data, which are subject to misclassification errors. In addition, the report is limited to unintentional injury deaths and excludes nonfatal injuries. Thus, it underreports "the total burden from injury on the society and the medical care system."

CDC officials and their partners released the National Action Plan for Child Injury Prevention along with this report, hoping that the plan’s implementation "could result in significant reductions in needless deaths, injuries, and costs associated with injuries among children and adolescents in the United States."

Fewer children died from unintentional injuries between 2000 and 2009, but death rates from suffocation and poisoning increased, according to a report from the Centers for Disease Control and Prevention.

The overall death rate from unintentional injuries among children dropped by nearly 30% during the 10-year period, according to an analysis of national mortality data. There were 9,143 childhood deaths from unintentional injuries in 2009, down from 12,441 in 2000. Yet, that’s about one child death per hour caused by unintentional injury, whether it’s a traffic crash, drowning, poisoning, or fire.

CDC/Amanda Mills

"One child’s death is still one too many," said Ileana Arias, Ph.D., principal deputy director at CDC, in a news conference. "We know most of these events are predictable and preventable."

Traffic crashes were the leading cause of death among children and adolescents (4,564 deaths), followed by suffocation (1,160), drowning (983), poisoning (824), fire/burn (391), and falls (151), according to the report.

Despite a drop in most of the mechanisms, the authors noted the increase in poisoning and suffocation death rates.

There was a 91% increase in poisoning death rate among adolescents aged 15-19 years over the 10-year period. The authors attributed the rise to prescription drug overdoses. Painkillers seem to be replacing marijuana as a gateway drug, said Dr. Arias.

"Strategies to reduce the misuse of prescription drugs include appropriate prescribing, proper storage and disposal, discouraging medication sharing, and state-based prescription drug monitoring programs," the report’s authors wrote (MMWR 2012;61:1-7).

Also, unintentional infant suffocation rates increased 54% between 2000 and 2009. The increase "underscores the importance of safe sleeping environments as recommended by the American Academy of Pediatrics, which includes supine positioning, a firm sleep surface, room-sharing without bed-sharing, and avoiding loose bedding," the investigators noted.

There was nearly a 41% decrease in deaths from traffic crashes during the 10-year-period, which could be due to several factors, including improvements in seat belt use, child safety seat and booster seat use, licensing requirements, and vehicle design, according to the report.

Drowning deaths decreased 28%; deaths from fire/burn decreased 45%, and deaths from accidental falls dropped 19%.

Despite the declines, injury remains the leading cause of death among children in the United States. The nation also ranks worst among all high-income countries when it comes to injury deaths among 0 to 14-year-olds, according to the CDC report, which is the first of its kind to describe trends among 0 to 19-year-olds by mechanism and by state.

Unintentional injury rates varied widely among states, suggesting that "environment, exposure to hazards, and difference in public policy might play a role," the authors wrote. The variation also "demonstrated that it is possible to prevent these injuries," said Dr. Arias. Massachusetts had the lowest unintentional injury death rate (4/100,000), and Mississippi had the highest (25.1/100,000).

The report is based on analysis of national mortality data collected in the CDC’s National Vital Statistics Systems. 

The authors said the report has at least two limitations. First, the report is based on death certificate data, which are subject to misclassification errors. In addition, the report is limited to unintentional injury deaths and excludes nonfatal injuries. Thus, it underreports "the total burden from injury on the society and the medical care system."

CDC officials and their partners released the National Action Plan for Child Injury Prevention along with this report, hoping that the plan’s implementation "could result in significant reductions in needless deaths, injuries, and costs associated with injuries among children and adolescents in the United States."

Fewer children died from unintentional injuries between 2000 and 2009, but death rates from suffocation and poisoning increased, according to a report from the Centers for Disease Control and Prevention.

The overall death rate from unintentional injuries among children dropped by nearly 30% during the 10-year period, according to an analysis of national mortality data. There were 9,143 childhood deaths from unintentional injuries in 2009, down from 12,441 in 2000. Yet, that’s about one child death per hour caused by unintentional injury, whether it’s a traffic crash, drowning, poisoning, or fire.

CDC/Amanda Mills

"One child’s death is still one too many," said Ileana Arias, Ph.D., principal deputy director at CDC, in a news conference. "We know most of these events are predictable and preventable."

Traffic crashes were the leading cause of death among children and adolescents (4,564 deaths), followed by suffocation (1,160), drowning (983), poisoning (824), fire/burn (391), and falls (151), according to the report.

Despite a drop in most of the mechanisms, the authors noted the increase in poisoning and suffocation death rates.

There was a 91% increase in poisoning death rate among adolescents aged 15-19 years over the 10-year period. The authors attributed the rise to prescription drug overdoses. Painkillers seem to be replacing marijuana as a gateway drug, said Dr. Arias.

"Strategies to reduce the misuse of prescription drugs include appropriate prescribing, proper storage and disposal, discouraging medication sharing, and state-based prescription drug monitoring programs," the report’s authors wrote (MMWR 2012;61:1-7).

Also, unintentional infant suffocation rates increased 54% between 2000 and 2009. The increase "underscores the importance of safe sleeping environments as recommended by the American Academy of Pediatrics, which includes supine positioning, a firm sleep surface, room-sharing without bed-sharing, and avoiding loose bedding," the investigators noted.

There was nearly a 41% decrease in deaths from traffic crashes during the 10-year-period, which could be due to several factors, including improvements in seat belt use, child safety seat and booster seat use, licensing requirements, and vehicle design, according to the report.

Drowning deaths decreased 28%; deaths from fire/burn decreased 45%, and deaths from accidental falls dropped 19%.

Despite the declines, injury remains the leading cause of death among children in the United States. The nation also ranks worst among all high-income countries when it comes to injury deaths among 0 to 14-year-olds, according to the CDC report, which is the first of its kind to describe trends among 0 to 19-year-olds by mechanism and by state.

Unintentional injury rates varied widely among states, suggesting that "environment, exposure to hazards, and difference in public policy might play a role," the authors wrote. The variation also "demonstrated that it is possible to prevent these injuries," said Dr. Arias. Massachusetts had the lowest unintentional injury death rate (4/100,000), and Mississippi had the highest (25.1/100,000).

The report is based on analysis of national mortality data collected in the CDC’s National Vital Statistics Systems. 

The authors said the report has at least two limitations. First, the report is based on death certificate data, which are subject to misclassification errors. In addition, the report is limited to unintentional injury deaths and excludes nonfatal injuries. Thus, it underreports "the total burden from injury on the society and the medical care system."

CDC officials and their partners released the National Action Plan for Child Injury Prevention along with this report, hoping that the plan’s implementation "could result in significant reductions in needless deaths, injuries, and costs associated with injuries among children and adolescents in the United States."

Migraine is a common neurologic disorder that occurs in approximately 3 times as many females as males in the United States. Among 30,000 respondents, the American Migraine Study II found that the prevalence of migraine was 18.2% among females and 6.5% among males, and was much higher in females from age 12 across the lifespan.¹ In comparison, for tension-type headache the female to male ratio of occurrence is 5:4, occurring only slightly more in females.² The reasons for this disparity in migraine prevalence are not well understood. The disproportionate number of women of reproductive age with migraine suggests that hormonal factors may play a role, but the complex pathophysiology of migraine indicates additional factors are involved.³

     Recent research on menstrual-related migraine and two significant comorbidities of migraine—obesity and posttraumatic stress disorder (PTSD)—shed new light on the differences in how men and women present with and experience this often disabling disorder.

Epidemiologic differences

The incidence of migraine, defined here as age of first onset, is different in boys and girls. For migraine without aura, age of first onset is approximately 10 to 11 years in boys versus 14 to 17 years in girls. For migraine with aura, age of first onset is approximately 5 years in boys and 12 to 13 years in girls.⁴

     The picture of migraine differs by sex before and after puberty. Before age 12, boys have a higher incidence and prevalence of migraine. After age 12, prevalence increases for both sexes, peaking between age 35 to 45, with an increase in the female-to-male ratio from 2:1 at age 20 to 3.3:1 at age 40.^5,6

Disparities in migraine symptoms

Common symptoms associated with severe or unilateral migraine pain include photophobia, phonophobia, and nausea. In the American Migraine Study II, the most frequently reported symptoms were pulsatile pain (85%of migraineurs), light sensitivity (80%), sound sensitivity (76%), nausea (73%), unilateral pain (59%), blurred vision (44%), aura (36%), and vomiting (29%).¹ Females were more likely than males to report light sensitivity, sound sensitivity, and nausea. More females experienced 1 to 2 days of migraine-associated activity restriction than males (30.5% vs 22.9%).¹ Separate studies have shown neck pain to be second after menstruation in its predictive value for onset of migraine, and to be more prevalent than nausea at the time of treatment.^7,8

Migraine comorbidities

Migraine is known to be comorbid with a variety of disorders including psychiatric conditions such as depression and anxiety,^9,10 and medical comorbidities such as stroke, epilepsy, and hypothyroidism.^11-13 In women, migraine is also comorbid with endometriosis.¹⁴

Hormonal factors: Menstrual-related migraine

With migraine disproportionately affecting women of reproductive age, as many as 70% of female migraineurs are aware of a menstrual association with their headaches.¹⁵ A menstrual migraine is defined as migraine without aura that occurs during the 5-day window that begins 2 days before the onset of bleeding and extends through the third day of active bleeding—and that occurs in at least two-thirds of menstrual cycles.¹⁶ Approximately 14% of women experience what is termed pure menstrual migraine, meaning the only time they experience migraine is during menstruation. For women who also have migraines triggered by other mechanisms, the menstrual migraine is typically their most severe migraine of the month.

     For many women, menstrual migraines are more painful, longer lasting, and more resistant to acute therapy than migraines occurring at other times.^17,18 It is specifically the reduction in estradiol in the late luteal phase that appears to be the greatest trigger for menstrual migraine. 

     About two-thirds of women with migraine improve in menopause, particularly those for whom migraine attacks were associated with menstruation.^19,20 As disabling as menstrual related migraine can be, clinically it is often found to coexist with chronic migraine and medication overuse headache.²¹

     In a study that looked at the impact of eliminating menstrual migraine, investigators treated women with hormonal preventives based on the hypothesis that, because these agents confer no known benefit for migraines that are not hormonally triggered, use of these agents might allow them to separate out menstrual-related migraine and its effect on the overall clinical picture.²¹ Among 229 consecutive women seen in follow-up, 81% of those patients who were taking the hormonal preventive as prescribed had a complete resolution of menstrual-related migraine. Among those in whom menstrual migraine was eliminated, 58.9% reverted back to episodic migraine, compared with only 11% of patients whose menstrual-migraine was not eliminated.²¹ Resolution of menstrual-related migraine also was associated with resolution of medication overuse. Patients in whom menstrual-related migraine resolved were >2 times as likely to stop medication overuse as those in whom the migraines were not eliminated. The results offer preliminary evidence that hormonal regimens may be of benefit in preventing menstrual-related migraine.

Migraine and obesity

Obesity, which results from excessive adipose tissue in relation to fat free mass, has been shown in clinical and population-based studies to be associated with migraine.^22-25 Both migraine and the distribution of adipose tissue change substantially based on age and sex.²⁵ Following puberty, girls have an increase in the subcutaneous to visceral adipose tissue ratio as compared with boys, a pattern that continues through the reproductive years for women. Postmenopausal women see an increase in visceral

adipose tissue volume and a decrease in the subcutaneous to visceral adipose tissue volume compared with premenopausal women. Similarly, migraine prevalence increases in women of reproductive age as compared with those of postreproductive age and it is greater in women of reproductive age as compared with men.²⁵

     To evaluate the prevalence of migraine and severe headaches in men and women with and without total body obesity (TBO), as measured by body mass index (BMI) and abdominal obesity (Abd-O), Peterlin and colleagues analyzed data from 21,783 participants in the National Health and Nutrition Examination Survey.²⁶ The investigators found that the relationship between migraine and obesity varies by age, sex, and the distribution of adipose tissue. For men and women of reproductive age, migraine prevalence increased in those with either TBO or Abd-O compared with those without. For postreproductive aged men and women (>55 years), migraine prevalence was not increased in those with either Abd-O or TBO. [Figure 1]

FIGURE 1: Migraine prevalence in men and women in relation to TBO and Abd-O

Total body obesity (TBO) was estimated based on BMI. Abdominal obesity (Abd-O) was estimated

based on waist circumference.

*P ≤ .001; † P ≤ .01; ‡ P ≤ .05

Source: Adapted with permission from Peterlin BL, et al. Migraine and obesity: Epidemiology,

mechanisms, and implications. Headache. 2010;50:631-636.

     Vo et al observed similar findings for women of reproductive age in analyses of data from the Omega study. In a cohort of 3,733 women during early pregnancy, researchers found that obesity was associated with increased odds for migraine and that the risk of migraine increased with increasing obesity.²⁷ Specifically, while the overall odds of migraine in women with obesity of any level was 48% greater than in women without obesity (OR 1.48; 95%CI: 1.12-1.96), those women with severe or class II obesity (BMI 35 to 39.9) had a >200% increased risk (OR 2.07; 95%CI: 1.27-3.39), and those with morbid or class III obesity (BMI ≥40) had a 275% increased risk of migraine, (OR 2.75; 95%CI: 1.60-4.70).27 Furthermore, Vo et al demonstrated that women with a history of pediatric migraine had 67% increased odds of gaining ≥22 pounds above their weight at the age of 18 (OR 1.67; 95% CI:1.13-2.47).²⁷

     An association between obesity and migraine was also found in two small studies that assessed the effects of bariatric surgery on headache frequency in morbidly obese, episodic migraineurs.^28,29 In these studies, at 6 months after surgery the monthly headache frequency declined from approximately 4 headache days per month at baseline to just 1 to 2 headache days per month. Researchers also noted that following bariatric surgery, the migraine-associated symptoms were reduced and headache related disability improved significantly. Larger, controlled studies will be needed to substantiate these findings and determine the true effect size before bariatric surgery could be considered as a component of migraine therapy.³⁰ However, these results highlight the observation that clinicians should give consideration to obesity as a potentially modifiable risk factor for episodic migraine.

Migraine and PTSD

Posttraumatic stress disorder (PTSD), the result of traumatic life stressors, has a lifetime prevalence of approximately 7%—3.6% among men and 9.7% among women—according to the National Comorbidity Survey Replication (NCS-R), a cross-sectional, general population survey of mental disorders.³¹ Interpersonal trauma (such as physical or sexual abuse) is the most common cause of PTSD, but it can also result from life-threatening situations such as natural and man-made disasters or military combat.^32,33 In a secondary analysis of a the NCS-R, Peterlin and colleagues and found that 21.5% of episodic migraineurs and 19.2% of chronic daily headache sufferers fulfilled PTSD criteria.³⁴

     Although both migraine and PTSD are up to 3 times more common in women than men, recent data suggest that the association between migraine and PTSD is stronger in men.^34,35 Using the NCS-R data, Peterlin and colleagues found a more than 3-4 fold increase in the odds ratio of PTSD in men with migraine versus women with migraine—a result that renders PTSD, to the knowledge of the investigators, the first mental disorder to be reported as having a greater prevalence in men with migraine than women with migraine.³⁴[Figure 2]

FIGURE 2: Sex-specific odds ratio of PTSD in episodic migraine

Source: Adapted with permission from Peterlin BL, et al. Post-traumatic distress disorder and migraine:

Epidemiology, sex differences, and potential mechanisms. Headache. 2011;51(6)860-868.

     The neurobiological mechanism linking PTSD to migraine is not known. Although a variety of theories exist—including low serotonin levels, dysfunctions of the autonomic system and hypothalamic-pituitary-adrenal axis (HPA) in both migraine and PTSD, and elevated baseline cortisol levels in migraineurs—it remains unclear why the association is stronger in men than in women.³⁴ Some studies suggest that sex-related differences of the HPA axis may play a role.^36,37 Others consider fMRI findings of sex differences in cerebral blood flow to pain centers in response to psychological distress.³⁷ Further research into the sex-related differences of migraineurs with PTSD will likely reveal insights into new therapeutic directions for men and women with these disorders.

Implications for clinicians

The preceding data add to the understanding that numerous comorbidities exist in individuals with migraine. If a patient is a migraineur, screen for PTSD as well as depression and anxiety. Treatment with cognitive behavioral therapy—alone or in combination with pharmacological therapy—should be considered, since treatment of PTSD alone has been shown to have a beneficial effect on both pain and disability in chronic pain patients.³⁸

     Given that obesity is a modifiable risk factor, educate all migraine patients about the association with obesity in general, the increasing risk of migraine associated with increasing obesity, and the potential effect of weight gain/loss on headache frequency.^26,27 Also inform patients about the potential effects migraine medications may have on their weight, and encourage them to eat a healthy diet, exercise, and avoid gaining excessive weight. If other comorbidities are involved, tailor the therapeutic regimen based on that combination. If a migraine patient is obese and has high blood pressure, look for an antihypertensive agent that is relatively weight-neutral. 

     Eliminating menstrual migraine should be an important treatment goal for patients in whom it is the most disabling migraine of the month. Hormonal preventives may be the best approach for women whose menstrual attacks are resistant to acute treatment.²¹

Disclosures

B. Lee Peterlin, DO, has received grant/research support from GlaxoSmithKline, has served as a consultant to Nautilus, and has served on the speaker’s bureau of Zogenix. She holds a provisional patent for use of adiponectin-modulating drugs for migraine.

Anne H. Calhoun, MD, has no conflicts of interest to report.

Fred Balzac has no conflicts of interest to report.

Migraine is a common neurologic disorder that occurs in approximately 3 times as many females as males in the United States. Among 30,000 respondents, the American Migraine Study II found that the prevalence of migraine was 18.2% among females and 6.5% among males, and was much higher in females from age 12 across the lifespan.¹ In comparison, for tension-type headache the female to male ratio of occurrence is 5:4, occurring only slightly more in females.² The reasons for this disparity in migraine prevalence are not well understood. The disproportionate number of women of reproductive age with migraine suggests that hormonal factors may play a role, but the complex pathophysiology of migraine indicates additional factors are involved.³

     Recent research on menstrual-related migraine and two significant comorbidities of migraine—obesity and posttraumatic stress disorder (PTSD)—shed new light on the differences in how men and women present with and experience this often disabling disorder.

Epidemiologic differences

The incidence of migraine, defined here as age of first onset, is different in boys and girls. For migraine without aura, age of first onset is approximately 10 to 11 years in boys versus 14 to 17 years in girls. For migraine with aura, age of first onset is approximately 5 years in boys and 12 to 13 years in girls.⁴

     The picture of migraine differs by sex before and after puberty. Before age 12, boys have a higher incidence and prevalence of migraine. After age 12, prevalence increases for both sexes, peaking between age 35 to 45, with an increase in the female-to-male ratio from 2:1 at age 20 to 3.3:1 at age 40.^5,6

Disparities in migraine symptoms

Common symptoms associated with severe or unilateral migraine pain include photophobia, phonophobia, and nausea. In the American Migraine Study II, the most frequently reported symptoms were pulsatile pain (85%of migraineurs), light sensitivity (80%), sound sensitivity (76%), nausea (73%), unilateral pain (59%), blurred vision (44%), aura (36%), and vomiting (29%).¹ Females were more likely than males to report light sensitivity, sound sensitivity, and nausea. More females experienced 1 to 2 days of migraine-associated activity restriction than males (30.5% vs 22.9%).¹ Separate studies have shown neck pain to be second after menstruation in its predictive value for onset of migraine, and to be more prevalent than nausea at the time of treatment.^7,8

Migraine comorbidities

Migraine is known to be comorbid with a variety of disorders including psychiatric conditions such as depression and anxiety,^9,10 and medical comorbidities such as stroke, epilepsy, and hypothyroidism.^11-13 In women, migraine is also comorbid with endometriosis.¹⁴

Hormonal factors: Menstrual-related migraine

With migraine disproportionately affecting women of reproductive age, as many as 70% of female migraineurs are aware of a menstrual association with their headaches.¹⁵ A menstrual migraine is defined as migraine without aura that occurs during the 5-day window that begins 2 days before the onset of bleeding and extends through the third day of active bleeding—and that occurs in at least two-thirds of menstrual cycles.¹⁶ Approximately 14% of women experience what is termed pure menstrual migraine, meaning the only time they experience migraine is during menstruation. For women who also have migraines triggered by other mechanisms, the menstrual migraine is typically their most severe migraine of the month.

     For many women, menstrual migraines are more painful, longer lasting, and more resistant to acute therapy than migraines occurring at other times.^17,18 It is specifically the reduction in estradiol in the late luteal phase that appears to be the greatest trigger for menstrual migraine. 

     About two-thirds of women with migraine improve in menopause, particularly those for whom migraine attacks were associated with menstruation.^19,20 As disabling as menstrual related migraine can be, clinically it is often found to coexist with chronic migraine and medication overuse headache.²¹

     In a study that looked at the impact of eliminating menstrual migraine, investigators treated women with hormonal preventives based on the hypothesis that, because these agents confer no known benefit for migraines that are not hormonally triggered, use of these agents might allow them to separate out menstrual-related migraine and its effect on the overall clinical picture.²¹ Among 229 consecutive women seen in follow-up, 81% of those patients who were taking the hormonal preventive as prescribed had a complete resolution of menstrual-related migraine. Among those in whom menstrual migraine was eliminated, 58.9% reverted back to episodic migraine, compared with only 11% of patients whose menstrual-migraine was not eliminated.²¹ Resolution of menstrual-related migraine also was associated with resolution of medication overuse. Patients in whom menstrual-related migraine resolved were >2 times as likely to stop medication overuse as those in whom the migraines were not eliminated. The results offer preliminary evidence that hormonal regimens may be of benefit in preventing menstrual-related migraine.

Migraine and obesity

Obesity, which results from excessive adipose tissue in relation to fat free mass, has been shown in clinical and population-based studies to be associated with migraine.^22-25 Both migraine and the distribution of adipose tissue change substantially based on age and sex.²⁵ Following puberty, girls have an increase in the subcutaneous to visceral adipose tissue ratio as compared with boys, a pattern that continues through the reproductive years for women. Postmenopausal women see an increase in visceral

adipose tissue volume and a decrease in the subcutaneous to visceral adipose tissue volume compared with premenopausal women. Similarly, migraine prevalence increases in women of reproductive age as compared with those of postreproductive age and it is greater in women of reproductive age as compared with men.²⁵

     To evaluate the prevalence of migraine and severe headaches in men and women with and without total body obesity (TBO), as measured by body mass index (BMI) and abdominal obesity (Abd-O), Peterlin and colleagues analyzed data from 21,783 participants in the National Health and Nutrition Examination Survey.²⁶ The investigators found that the relationship between migraine and obesity varies by age, sex, and the distribution of adipose tissue. For men and women of reproductive age, migraine prevalence increased in those with either TBO or Abd-O compared with those without. For postreproductive aged men and women (>55 years), migraine prevalence was not increased in those with either Abd-O or TBO. [Figure 1]

FIGURE 1: Migraine prevalence in men and women in relation to TBO and Abd-O

Total body obesity (TBO) was estimated based on BMI. Abdominal obesity (Abd-O) was estimated

based on waist circumference.

*P ≤ .001; † P ≤ .01; ‡ P ≤ .05

Source: Adapted with permission from Peterlin BL, et al. Migraine and obesity: Epidemiology,

mechanisms, and implications. Headache. 2010;50:631-636.

     Vo et al observed similar findings for women of reproductive age in analyses of data from the Omega study. In a cohort of 3,733 women during early pregnancy, researchers found that obesity was associated with increased odds for migraine and that the risk of migraine increased with increasing obesity.²⁷ Specifically, while the overall odds of migraine in women with obesity of any level was 48% greater than in women without obesity (OR 1.48; 95%CI: 1.12-1.96), those women with severe or class II obesity (BMI 35 to 39.9) had a >200% increased risk (OR 2.07; 95%CI: 1.27-3.39), and those with morbid or class III obesity (BMI ≥40) had a 275% increased risk of migraine, (OR 2.75; 95%CI: 1.60-4.70).27 Furthermore, Vo et al demonstrated that women with a history of pediatric migraine had 67% increased odds of gaining ≥22 pounds above their weight at the age of 18 (OR 1.67; 95% CI:1.13-2.47).²⁷

     An association between obesity and migraine was also found in two small studies that assessed the effects of bariatric surgery on headache frequency in morbidly obese, episodic migraineurs.^28,29 In these studies, at 6 months after surgery the monthly headache frequency declined from approximately 4 headache days per month at baseline to just 1 to 2 headache days per month. Researchers also noted that following bariatric surgery, the migraine-associated symptoms were reduced and headache related disability improved significantly. Larger, controlled studies will be needed to substantiate these findings and determine the true effect size before bariatric surgery could be considered as a component of migraine therapy.³⁰ However, these results highlight the observation that clinicians should give consideration to obesity as a potentially modifiable risk factor for episodic migraine.

Migraine and PTSD

Posttraumatic stress disorder (PTSD), the result of traumatic life stressors, has a lifetime prevalence of approximately 7%—3.6% among men and 9.7% among women—according to the National Comorbidity Survey Replication (NCS-R), a cross-sectional, general population survey of mental disorders.³¹ Interpersonal trauma (such as physical or sexual abuse) is the most common cause of PTSD, but it can also result from life-threatening situations such as natural and man-made disasters or military combat.^32,33 In a secondary analysis of a the NCS-R, Peterlin and colleagues and found that 21.5% of episodic migraineurs and 19.2% of chronic daily headache sufferers fulfilled PTSD criteria.³⁴

     Although both migraine and PTSD are up to 3 times more common in women than men, recent data suggest that the association between migraine and PTSD is stronger in men.^34,35 Using the NCS-R data, Peterlin and colleagues found a more than 3-4 fold increase in the odds ratio of PTSD in men with migraine versus women with migraine—a result that renders PTSD, to the knowledge of the investigators, the first mental disorder to be reported as having a greater prevalence in men with migraine than women with migraine.³⁴[Figure 2]

FIGURE 2: Sex-specific odds ratio of PTSD in episodic migraine

Source: Adapted with permission from Peterlin BL, et al. Post-traumatic distress disorder and migraine:

Epidemiology, sex differences, and potential mechanisms. Headache. 2011;51(6)860-868.

     The neurobiological mechanism linking PTSD to migraine is not known. Although a variety of theories exist—including low serotonin levels, dysfunctions of the autonomic system and hypothalamic-pituitary-adrenal axis (HPA) in both migraine and PTSD, and elevated baseline cortisol levels in migraineurs—it remains unclear why the association is stronger in men than in women.³⁴ Some studies suggest that sex-related differences of the HPA axis may play a role.^36,37 Others consider fMRI findings of sex differences in cerebral blood flow to pain centers in response to psychological distress.³⁷ Further research into the sex-related differences of migraineurs with PTSD will likely reveal insights into new therapeutic directions for men and women with these disorders.

Implications for clinicians

The preceding data add to the understanding that numerous comorbidities exist in individuals with migraine. If a patient is a migraineur, screen for PTSD as well as depression and anxiety. Treatment with cognitive behavioral therapy—alone or in combination with pharmacological therapy—should be considered, since treatment of PTSD alone has been shown to have a beneficial effect on both pain and disability in chronic pain patients.³⁸

     Given that obesity is a modifiable risk factor, educate all migraine patients about the association with obesity in general, the increasing risk of migraine associated with increasing obesity, and the potential effect of weight gain/loss on headache frequency.^26,27 Also inform patients about the potential effects migraine medications may have on their weight, and encourage them to eat a healthy diet, exercise, and avoid gaining excessive weight. If other comorbidities are involved, tailor the therapeutic regimen based on that combination. If a migraine patient is obese and has high blood pressure, look for an antihypertensive agent that is relatively weight-neutral. 

     Eliminating menstrual migraine should be an important treatment goal for patients in whom it is the most disabling migraine of the month. Hormonal preventives may be the best approach for women whose menstrual attacks are resistant to acute treatment.²¹

Disclosures

B. Lee Peterlin, DO, has received grant/research support from GlaxoSmithKline, has served as a consultant to Nautilus, and has served on the speaker’s bureau of Zogenix. She holds a provisional patent for use of adiponectin-modulating drugs for migraine.

Anne H. Calhoun, MD, has no conflicts of interest to report.

Fred Balzac has no conflicts of interest to report.

Migraine is a common neurologic disorder that occurs in approximately 3 times as many females as males in the United States. Among 30,000 respondents, the American Migraine Study II found that the prevalence of migraine was 18.2% among females and 6.5% among males, and was much higher in females from age 12 across the lifespan.¹ In comparison, for tension-type headache the female to male ratio of occurrence is 5:4, occurring only slightly more in females.² The reasons for this disparity in migraine prevalence are not well understood. The disproportionate number of women of reproductive age with migraine suggests that hormonal factors may play a role, but the complex pathophysiology of migraine indicates additional factors are involved.³

     Recent research on menstrual-related migraine and two significant comorbidities of migraine—obesity and posttraumatic stress disorder (PTSD)—shed new light on the differences in how men and women present with and experience this often disabling disorder.

Epidemiologic differences

The incidence of migraine, defined here as age of first onset, is different in boys and girls. For migraine without aura, age of first onset is approximately 10 to 11 years in boys versus 14 to 17 years in girls. For migraine with aura, age of first onset is approximately 5 years in boys and 12 to 13 years in girls.⁴

     The picture of migraine differs by sex before and after puberty. Before age 12, boys have a higher incidence and prevalence of migraine. After age 12, prevalence increases for both sexes, peaking between age 35 to 45, with an increase in the female-to-male ratio from 2:1 at age 20 to 3.3:1 at age 40.^5,6

Disparities in migraine symptoms

Common symptoms associated with severe or unilateral migraine pain include photophobia, phonophobia, and nausea. In the American Migraine Study II, the most frequently reported symptoms were pulsatile pain (85%of migraineurs), light sensitivity (80%), sound sensitivity (76%), nausea (73%), unilateral pain (59%), blurred vision (44%), aura (36%), and vomiting (29%).¹ Females were more likely than males to report light sensitivity, sound sensitivity, and nausea. More females experienced 1 to 2 days of migraine-associated activity restriction than males (30.5% vs 22.9%).¹ Separate studies have shown neck pain to be second after menstruation in its predictive value for onset of migraine, and to be more prevalent than nausea at the time of treatment.^7,8

Migraine comorbidities

Migraine is known to be comorbid with a variety of disorders including psychiatric conditions such as depression and anxiety,^9,10 and medical comorbidities such as stroke, epilepsy, and hypothyroidism.^11-13 In women, migraine is also comorbid with endometriosis.¹⁴

Hormonal factors: Menstrual-related migraine

With migraine disproportionately affecting women of reproductive age, as many as 70% of female migraineurs are aware of a menstrual association with their headaches.¹⁵ A menstrual migraine is defined as migraine without aura that occurs during the 5-day window that begins 2 days before the onset of bleeding and extends through the third day of active bleeding—and that occurs in at least two-thirds of menstrual cycles.¹⁶ Approximately 14% of women experience what is termed pure menstrual migraine, meaning the only time they experience migraine is during menstruation. For women who also have migraines triggered by other mechanisms, the menstrual migraine is typically their most severe migraine of the month.

     For many women, menstrual migraines are more painful, longer lasting, and more resistant to acute therapy than migraines occurring at other times.^17,18 It is specifically the reduction in estradiol in the late luteal phase that appears to be the greatest trigger for menstrual migraine. 

     About two-thirds of women with migraine improve in menopause, particularly those for whom migraine attacks were associated with menstruation.^19,20 As disabling as menstrual related migraine can be, clinically it is often found to coexist with chronic migraine and medication overuse headache.²¹

     In a study that looked at the impact of eliminating menstrual migraine, investigators treated women with hormonal preventives based on the hypothesis that, because these agents confer no known benefit for migraines that are not hormonally triggered, use of these agents might allow them to separate out menstrual-related migraine and its effect on the overall clinical picture.²¹ Among 229 consecutive women seen in follow-up, 81% of those patients who were taking the hormonal preventive as prescribed had a complete resolution of menstrual-related migraine. Among those in whom menstrual migraine was eliminated, 58.9% reverted back to episodic migraine, compared with only 11% of patients whose menstrual-migraine was not eliminated.²¹ Resolution of menstrual-related migraine also was associated with resolution of medication overuse. Patients in whom menstrual-related migraine resolved were >2 times as likely to stop medication overuse as those in whom the migraines were not eliminated. The results offer preliminary evidence that hormonal regimens may be of benefit in preventing menstrual-related migraine.

Migraine and obesity

Obesity, which results from excessive adipose tissue in relation to fat free mass, has been shown in clinical and population-based studies to be associated with migraine.^22-25 Both migraine and the distribution of adipose tissue change substantially based on age and sex.²⁵ Following puberty, girls have an increase in the subcutaneous to visceral adipose tissue ratio as compared with boys, a pattern that continues through the reproductive years for women. Postmenopausal women see an increase in visceral

adipose tissue volume and a decrease in the subcutaneous to visceral adipose tissue volume compared with premenopausal women. Similarly, migraine prevalence increases in women of reproductive age as compared with those of postreproductive age and it is greater in women of reproductive age as compared with men.²⁵

     To evaluate the prevalence of migraine and severe headaches in men and women with and without total body obesity (TBO), as measured by body mass index (BMI) and abdominal obesity (Abd-O), Peterlin and colleagues analyzed data from 21,783 participants in the National Health and Nutrition Examination Survey.²⁶ The investigators found that the relationship between migraine and obesity varies by age, sex, and the distribution of adipose tissue. For men and women of reproductive age, migraine prevalence increased in those with either TBO or Abd-O compared with those without. For postreproductive aged men and women (>55 years), migraine prevalence was not increased in those with either Abd-O or TBO. [Figure 1]

FIGURE 1: Migraine prevalence in men and women in relation to TBO and Abd-O

Total body obesity (TBO) was estimated based on BMI. Abdominal obesity (Abd-O) was estimated

based on waist circumference.

*P ≤ .001; † P ≤ .01; ‡ P ≤ .05

Source: Adapted with permission from Peterlin BL, et al. Migraine and obesity: Epidemiology,

mechanisms, and implications. Headache. 2010;50:631-636.

     Vo et al observed similar findings for women of reproductive age in analyses of data from the Omega study. In a cohort of 3,733 women during early pregnancy, researchers found that obesity was associated with increased odds for migraine and that the risk of migraine increased with increasing obesity.²⁷ Specifically, while the overall odds of migraine in women with obesity of any level was 48% greater than in women without obesity (OR 1.48; 95%CI: 1.12-1.96), those women with severe or class II obesity (BMI 35 to 39.9) had a >200% increased risk (OR 2.07; 95%CI: 1.27-3.39), and those with morbid or class III obesity (BMI ≥40) had a 275% increased risk of migraine, (OR 2.75; 95%CI: 1.60-4.70).27 Furthermore, Vo et al demonstrated that women with a history of pediatric migraine had 67% increased odds of gaining ≥22 pounds above their weight at the age of 18 (OR 1.67; 95% CI:1.13-2.47).²⁷

     An association between obesity and migraine was also found in two small studies that assessed the effects of bariatric surgery on headache frequency in morbidly obese, episodic migraineurs.^28,29 In these studies, at 6 months after surgery the monthly headache frequency declined from approximately 4 headache days per month at baseline to just 1 to 2 headache days per month. Researchers also noted that following bariatric surgery, the migraine-associated symptoms were reduced and headache related disability improved significantly. Larger, controlled studies will be needed to substantiate these findings and determine the true effect size before bariatric surgery could be considered as a component of migraine therapy.³⁰ However, these results highlight the observation that clinicians should give consideration to obesity as a potentially modifiable risk factor for episodic migraine.

Migraine and PTSD

Posttraumatic stress disorder (PTSD), the result of traumatic life stressors, has a lifetime prevalence of approximately 7%—3.6% among men and 9.7% among women—according to the National Comorbidity Survey Replication (NCS-R), a cross-sectional, general population survey of mental disorders.³¹ Interpersonal trauma (such as physical or sexual abuse) is the most common cause of PTSD, but it can also result from life-threatening situations such as natural and man-made disasters or military combat.^32,33 In a secondary analysis of a the NCS-R, Peterlin and colleagues and found that 21.5% of episodic migraineurs and 19.2% of chronic daily headache sufferers fulfilled PTSD criteria.³⁴

     Although both migraine and PTSD are up to 3 times more common in women than men, recent data suggest that the association between migraine and PTSD is stronger in men.^34,35 Using the NCS-R data, Peterlin and colleagues found a more than 3-4 fold increase in the odds ratio of PTSD in men with migraine versus women with migraine—a result that renders PTSD, to the knowledge of the investigators, the first mental disorder to be reported as having a greater prevalence in men with migraine than women with migraine.³⁴[Figure 2]

FIGURE 2: Sex-specific odds ratio of PTSD in episodic migraine

Source: Adapted with permission from Peterlin BL, et al. Post-traumatic distress disorder and migraine:

Epidemiology, sex differences, and potential mechanisms. Headache. 2011;51(6)860-868.

     The neurobiological mechanism linking PTSD to migraine is not known. Although a variety of theories exist—including low serotonin levels, dysfunctions of the autonomic system and hypothalamic-pituitary-adrenal axis (HPA) in both migraine and PTSD, and elevated baseline cortisol levels in migraineurs—it remains unclear why the association is stronger in men than in women.³⁴ Some studies suggest that sex-related differences of the HPA axis may play a role.^36,37 Others consider fMRI findings of sex differences in cerebral blood flow to pain centers in response to psychological distress.³⁷ Further research into the sex-related differences of migraineurs with PTSD will likely reveal insights into new therapeutic directions for men and women with these disorders.

Implications for clinicians

The preceding data add to the understanding that numerous comorbidities exist in individuals with migraine. If a patient is a migraineur, screen for PTSD as well as depression and anxiety. Treatment with cognitive behavioral therapy—alone or in combination with pharmacological therapy—should be considered, since treatment of PTSD alone has been shown to have a beneficial effect on both pain and disability in chronic pain patients.³⁸

     Given that obesity is a modifiable risk factor, educate all migraine patients about the association with obesity in general, the increasing risk of migraine associated with increasing obesity, and the potential effect of weight gain/loss on headache frequency.^26,27 Also inform patients about the potential effects migraine medications may have on their weight, and encourage them to eat a healthy diet, exercise, and avoid gaining excessive weight. If other comorbidities are involved, tailor the therapeutic regimen based on that combination. If a migraine patient is obese and has high blood pressure, look for an antihypertensive agent that is relatively weight-neutral. 

     Eliminating menstrual migraine should be an important treatment goal for patients in whom it is the most disabling migraine of the month. Hormonal preventives may be the best approach for women whose menstrual attacks are resistant to acute treatment.²¹

Disclosures

B. Lee Peterlin, DO, has received grant/research support from GlaxoSmithKline, has served as a consultant to Nautilus, and has served on the speaker’s bureau of Zogenix. She holds a provisional patent for use of adiponectin-modulating drugs for migraine.

Anne H. Calhoun, MD, has no conflicts of interest to report.

Fred Balzac has no conflicts of interest to report.

NATIONAL HARBOR, MD. – You may think that child’s cough is due to a respiratory infection. But it could be due to a peanut.

Peanuts, little plastic toys, apples, and especially pieces of hot dog: These are the things of which emergency department nightmares are made.

"Close to a million children visit emergency departments every year due to concerns over foreign bodies" in the airway or esophagus, Dr. Patrick C. Barth said at a meeting sponsored by the American College of Emergency Physicians. "And about 100 of those kids die from airway obstruction."

It’s not surprising that most of the choking incidents occur in young children – those between 3 and 4 years old. Learning how to chew, swallow, and breathe at the same time is a complicated physiologic task that takes a while to master, said Dr. Barth, an otolaryngologist at the Nemours/Alfred I. duPont Hospital for Children in Wilmington, Del.

Toddlers also explore all kinds of objects with their mouths as well as their hands, increasing the likelihood that they will swallow or inhale an object.

"If there is a history of a prior airway obstruction, you need to have a high level of suspicion."

"Seeds, popcorn, chunks of apple, or any foods with two different consistencies are hard for kids to manage. The slippery surface causes the food to quickly pass out of the mouth and they don’t have molars yet, so [they] can’t masticate well."

Peanuts, even though they are not large enough to block the trachea, can be really problematic, he added. "The oils set up a significant inflammatory reaction in the airways, so these kids can look really sick. And the inflammation makes endoscopy really difficult."

Children don’t always present in acute respiratory distress; they could just have a nagging wheeze or cough with no obvious illness. But if you think there might be a choking problem, look for one. "If there is a history of a prior airway obstruction, you need to have a high level of suspicion," he said.

A plain radiograph is usually the first diagnostic tool, although an x-ray won’t show radiolucent items, such as those made of plastic. But inspiratory and expiratory films might increase suspicion if there is asymmetric collapse when the child exhales.

CT may also be helpful, but the need should be balanced against the risks, since young children need to be sedated to acquire quality images.

The rigid bronchoscope is a good tool for both diagnosis and extraction of a foreign body, Dr. Barth said. The rigid type allows for simultaneous ventilation and the passage of instruments to remove the object. A flexible scope lacks this ability, and adequate ventilation is critically important in a child whose breathing may already be compromised. "If there’s a sharp object in the airway, the rigid bronchoscope also lets you sheathe it, so you don’t cause airway injury as you’re extracting it," he said.

In 30% of suspected cases, the bronchoscopy turns out to be negative. But in the case of airway obstruction, it’s better to be safe than sorry.

"This is a reasonable rate, because you really do not want to miss one of these. If you have a high level of suspicion, it’s not wrong to do a bronchoscopy."

Dr. Barth had no financial disclosures.

NATIONAL HARBOR, MD. – You may think that child’s cough is due to a respiratory infection. But it could be due to a peanut.

Peanuts, little plastic toys, apples, and especially pieces of hot dog: These are the things of which emergency department nightmares are made.

"Close to a million children visit emergency departments every year due to concerns over foreign bodies" in the airway or esophagus, Dr. Patrick C. Barth said at a meeting sponsored by the American College of Emergency Physicians. "And about 100 of those kids die from airway obstruction."

It’s not surprising that most of the choking incidents occur in young children – those between 3 and 4 years old. Learning how to chew, swallow, and breathe at the same time is a complicated physiologic task that takes a while to master, said Dr. Barth, an otolaryngologist at the Nemours/Alfred I. duPont Hospital for Children in Wilmington, Del.

Toddlers also explore all kinds of objects with their mouths as well as their hands, increasing the likelihood that they will swallow or inhale an object.

"If there is a history of a prior airway obstruction, you need to have a high level of suspicion."

"Seeds, popcorn, chunks of apple, or any foods with two different consistencies are hard for kids to manage. The slippery surface causes the food to quickly pass out of the mouth and they don’t have molars yet, so [they] can’t masticate well."

Peanuts, even though they are not large enough to block the trachea, can be really problematic, he added. "The oils set up a significant inflammatory reaction in the airways, so these kids can look really sick. And the inflammation makes endoscopy really difficult."

Children don’t always present in acute respiratory distress; they could just have a nagging wheeze or cough with no obvious illness. But if you think there might be a choking problem, look for one. "If there is a history of a prior airway obstruction, you need to have a high level of suspicion," he said.

A plain radiograph is usually the first diagnostic tool, although an x-ray won’t show radiolucent items, such as those made of plastic. But inspiratory and expiratory films might increase suspicion if there is asymmetric collapse when the child exhales.

CT may also be helpful, but the need should be balanced against the risks, since young children need to be sedated to acquire quality images.

The rigid bronchoscope is a good tool for both diagnosis and extraction of a foreign body, Dr. Barth said. The rigid type allows for simultaneous ventilation and the passage of instruments to remove the object. A flexible scope lacks this ability, and adequate ventilation is critically important in a child whose breathing may already be compromised. "If there’s a sharp object in the airway, the rigid bronchoscope also lets you sheathe it, so you don’t cause airway injury as you’re extracting it," he said.

In 30% of suspected cases, the bronchoscopy turns out to be negative. But in the case of airway obstruction, it’s better to be safe than sorry.

"This is a reasonable rate, because you really do not want to miss one of these. If you have a high level of suspicion, it’s not wrong to do a bronchoscopy."

Dr. Barth had no financial disclosures.

NATIONAL HARBOR, MD. – You may think that child’s cough is due to a respiratory infection. But it could be due to a peanut.

Peanuts, little plastic toys, apples, and especially pieces of hot dog: These are the things of which emergency department nightmares are made.

"Close to a million children visit emergency departments every year due to concerns over foreign bodies" in the airway or esophagus, Dr. Patrick C. Barth said at a meeting sponsored by the American College of Emergency Physicians. "And about 100 of those kids die from airway obstruction."

It’s not surprising that most of the choking incidents occur in young children – those between 3 and 4 years old. Learning how to chew, swallow, and breathe at the same time is a complicated physiologic task that takes a while to master, said Dr. Barth, an otolaryngologist at the Nemours/Alfred I. duPont Hospital for Children in Wilmington, Del.

Toddlers also explore all kinds of objects with their mouths as well as their hands, increasing the likelihood that they will swallow or inhale an object.

"If there is a history of a prior airway obstruction, you need to have a high level of suspicion."

"Seeds, popcorn, chunks of apple, or any foods with two different consistencies are hard for kids to manage. The slippery surface causes the food to quickly pass out of the mouth and they don’t have molars yet, so [they] can’t masticate well."

Peanuts, even though they are not large enough to block the trachea, can be really problematic, he added. "The oils set up a significant inflammatory reaction in the airways, so these kids can look really sick. And the inflammation makes endoscopy really difficult."

Children don’t always present in acute respiratory distress; they could just have a nagging wheeze or cough with no obvious illness. But if you think there might be a choking problem, look for one. "If there is a history of a prior airway obstruction, you need to have a high level of suspicion," he said.

A plain radiograph is usually the first diagnostic tool, although an x-ray won’t show radiolucent items, such as those made of plastic. But inspiratory and expiratory films might increase suspicion if there is asymmetric collapse when the child exhales.

CT may also be helpful, but the need should be balanced against the risks, since young children need to be sedated to acquire quality images.

The rigid bronchoscope is a good tool for both diagnosis and extraction of a foreign body, Dr. Barth said. The rigid type allows for simultaneous ventilation and the passage of instruments to remove the object. A flexible scope lacks this ability, and adequate ventilation is critically important in a child whose breathing may already be compromised. "If there’s a sharp object in the airway, the rigid bronchoscope also lets you sheathe it, so you don’t cause airway injury as you’re extracting it," he said.

In 30% of suspected cases, the bronchoscopy turns out to be negative. But in the case of airway obstruction, it’s better to be safe than sorry.

"This is a reasonable rate, because you really do not want to miss one of these. If you have a high level of suspicion, it’s not wrong to do a bronchoscopy."

Dr. Barth had no financial disclosures.