I hear other doctors talk about online reviews, both good and bad.

I recently read a piece where a practice gave doctors a bonus for getting 5-star reviews, though it doesn’t say if they were penalized for getting bad reviews. I assume the latter docs got a good “talking to” by someone in administration, or marketing, or both.

I get my share of them, too, both good and bad, scattered across at least a dozen sites that profess to offer accurate ratings.

I tend to ignore all of them.

Bad ratings mean nothing. They might be reasonable. They can also be from patients whom I fired for noncompliance, or from patients I refused to give an early narcotic refill to. They can also be from people who aren’t patients, such as a neighbor angry at the way I voted at a home owners association meeting, or a person who never saw me but was upset because I don’t take their insurance, or someone at the hospital whom I had to hang up on after being put on hold for 10 minutes.

Good reviews also don’t mean much, either. They might be from patients. They could also be from well-meaning family and friends. Or the waiter I left an extra-large tip for the other night.

One of my 1-star reviews even goes on to describe me in glowing terms (the lady called my office to apologize, saying the site confused her).

There’s also a whole cottage industry around this: Like restaurants, you can pay people to give you good reviews. They’re on Craig’s list and other sites. Some are freelancers. Others are actually well-organized companies, offering to give you X number of good reviews per month for a regular fee. I see ads for the latter online, usually describing themselves as “reputation recovery services.”

There was even a recent post on Sermo about this. A doctor noted he’d gotten a string of bad reviews from nonpatients, and shortly afterward was contacted by a reputation recovery service to help. He wondered if the crappy reviews were intentionally written by that business before they called him. He also questioned if it was an unspoken blackmail tactic – pay us or we’ll write more bad reviews.

Unlike a restaurant, we can’t respond because of patient confidentiality. Unless it’s something meaninglessly generic like “thank you” or “sorry you had a bad experience.”

A friend of mine (not in medicine) said that picking your doctor from online reviews is like selecting a wine recommended by a guy who lives at the train yard.

While there are pros and cons to the whole online review thing, in medicine there are mostly cons. Many reviews are anonymous, with no way to trace them. Unless details are provided, you don’t know if the reviewer is really a patient (or even a human in this bot era). Neither does the general public, reading them and presumably making decisions about who to see.

Like many things about the Internet, online reviews are the wild west. There are minimal (if any) rules, no law enforcement, and no one knows who the good guys and bad guys really are.

And there’s nothing we can do about it, either.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

I hear other doctors talk about online reviews, both good and bad.

I recently read a piece where a practice gave doctors a bonus for getting 5-star reviews, though it doesn’t say if they were penalized for getting bad reviews. I assume the latter docs got a good “talking to” by someone in administration, or marketing, or both.

I get my share of them, too, both good and bad, scattered across at least a dozen sites that profess to offer accurate ratings.

I tend to ignore all of them.

Bad ratings mean nothing. They might be reasonable. They can also be from patients whom I fired for noncompliance, or from patients I refused to give an early narcotic refill to. They can also be from people who aren’t patients, such as a neighbor angry at the way I voted at a home owners association meeting, or a person who never saw me but was upset because I don’t take their insurance, or someone at the hospital whom I had to hang up on after being put on hold for 10 minutes.

Good reviews also don’t mean much, either. They might be from patients. They could also be from well-meaning family and friends. Or the waiter I left an extra-large tip for the other night.

One of my 1-star reviews even goes on to describe me in glowing terms (the lady called my office to apologize, saying the site confused her).

There’s also a whole cottage industry around this: Like restaurants, you can pay people to give you good reviews. They’re on Craig’s list and other sites. Some are freelancers. Others are actually well-organized companies, offering to give you X number of good reviews per month for a regular fee. I see ads for the latter online, usually describing themselves as “reputation recovery services.”

There was even a recent post on Sermo about this. A doctor noted he’d gotten a string of bad reviews from nonpatients, and shortly afterward was contacted by a reputation recovery service to help. He wondered if the crappy reviews were intentionally written by that business before they called him. He also questioned if it was an unspoken blackmail tactic – pay us or we’ll write more bad reviews.

Unlike a restaurant, we can’t respond because of patient confidentiality. Unless it’s something meaninglessly generic like “thank you” or “sorry you had a bad experience.”

A friend of mine (not in medicine) said that picking your doctor from online reviews is like selecting a wine recommended by a guy who lives at the train yard.

While there are pros and cons to the whole online review thing, in medicine there are mostly cons. Many reviews are anonymous, with no way to trace them. Unless details are provided, you don’t know if the reviewer is really a patient (or even a human in this bot era). Neither does the general public, reading them and presumably making decisions about who to see.

Like many things about the Internet, online reviews are the wild west. There are minimal (if any) rules, no law enforcement, and no one knows who the good guys and bad guys really are.

And there’s nothing we can do about it, either.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

I hear other doctors talk about online reviews, both good and bad.

I recently read a piece where a practice gave doctors a bonus for getting 5-star reviews, though it doesn’t say if they were penalized for getting bad reviews. I assume the latter docs got a good “talking to” by someone in administration, or marketing, or both.

I get my share of them, too, both good and bad, scattered across at least a dozen sites that profess to offer accurate ratings.

I tend to ignore all of them.

Bad ratings mean nothing. They might be reasonable. They can also be from patients whom I fired for noncompliance, or from patients I refused to give an early narcotic refill to. They can also be from people who aren’t patients, such as a neighbor angry at the way I voted at a home owners association meeting, or a person who never saw me but was upset because I don’t take their insurance, or someone at the hospital whom I had to hang up on after being put on hold for 10 minutes.

Good reviews also don’t mean much, either. They might be from patients. They could also be from well-meaning family and friends. Or the waiter I left an extra-large tip for the other night.

One of my 1-star reviews even goes on to describe me in glowing terms (the lady called my office to apologize, saying the site confused her).

There’s also a whole cottage industry around this: Like restaurants, you can pay people to give you good reviews. They’re on Craig’s list and other sites. Some are freelancers. Others are actually well-organized companies, offering to give you X number of good reviews per month for a regular fee. I see ads for the latter online, usually describing themselves as “reputation recovery services.”

There was even a recent post on Sermo about this. A doctor noted he’d gotten a string of bad reviews from nonpatients, and shortly afterward was contacted by a reputation recovery service to help. He wondered if the crappy reviews were intentionally written by that business before they called him. He also questioned if it was an unspoken blackmail tactic – pay us or we’ll write more bad reviews.

Unlike a restaurant, we can’t respond because of patient confidentiality. Unless it’s something meaninglessly generic like “thank you” or “sorry you had a bad experience.”

A friend of mine (not in medicine) said that picking your doctor from online reviews is like selecting a wine recommended by a guy who lives at the train yard.

While there are pros and cons to the whole online review thing, in medicine there are mostly cons. Many reviews are anonymous, with no way to trace them. Unless details are provided, you don’t know if the reviewer is really a patient (or even a human in this bot era). Neither does the general public, reading them and presumably making decisions about who to see.

Like many things about the Internet, online reviews are the wild west. There are minimal (if any) rules, no law enforcement, and no one knows who the good guys and bad guys really are.

And there’s nothing we can do about it, either.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

STOCKHOLM – Recent study results confirm that two agents from the sodium-glucose cotransporter 2 (SGLT2) inhibitor class can significantly cut the incidence of adverse cardiovascular events in patients with heart failure with reduced ejection fraction (HFpEF), a disease especially common in people with type 2 diabetes, obesity, or both.

And findings from secondary analyses of the studies – including one reported at the annual meeting of the European Association for the Study of Diabetes – show that these SGLT2 inhibitors work as well for cutting incident adverse events (cardiovascular death or worsening heart failure) in patients with HFpEF and diabetes as they do for people with normal blood glucose levels.

But delivering treatment with these proven agents, dapagliflozin (Farxiga) and empagliflozin (Jardiance), first requires diagnosis of HFpEF, a task that clinicians have historically fallen short in accomplishing.

When in 2021, results from the EMPEROR-Preserved trial with empagliflozin and when in September 2022 results from the DELIVER trial with dapagliflozin established the efficacy of these two SGLT2 inhibitors as the first treatments proven to benefit patients with HFpEF, they also raised the stakes for clinicians to be much more diligent and systematic in evaluating people at high risk for developing HFpEF because of having type 2 diabetes or obesity, two of the most potent risk factors for this form of heart failure.
 

‘Vigilance ... needs to increase’

“Vigilance for HFpEF needs to increase because we can now help these patients,” declared Lars H. Lund, MD, PhD, speaking at the meeting. “Type 2 diabetes dramatically increases the incidence of HFpEF,” and the mechanisms by which it does this are “especially amenable to treatment with SGLT2 inhibitors,” said Dr. Lund, a cardiologist and heart failure specialist at the Karolinska Institute, Stockholm.

HFpEF has a history of going undetected in people with type 2 diabetes, an ironic situation given its high incidence as well as the elevated rate of adverse cardiovascular events when heart failure occurs in patients with type 2 diabetes compared with patients who do not have diabetes.

The key, say experts, is for clinicians to maintain a high index of suspicion for signs and symptoms of heart failure in people with type 2 diabetes and to regularly assess them, starting with just a few simple questions that probe for the presence of dyspnea, exertional fatigue, or both, an approach not widely employed up to now.

Clinicians who care for people with type 2 diabetes must become “alert to thinking about heart failure and alert to asking questions about signs and symptoms” that flag the presence of HFpEF, advised Naveed Sattar, MBChB, PhD, a professor of metabolic medicine at the University of Glasgow.

Soon, medical groups will issue guidelines for appropriate assessment for the presence of HFpEF in people with type 2 diabetes, Dr. Sattar predicted in an interview.
 

A need to probe

“You can’t simply ask patients with type 2 diabetes whether they have shortness of breath or exertional fatigue and stop there,” because often their first response will be no.

“Commonly, patients will initially say they have no dyspnea, but when you probe further, you find symptoms,” noted Mikhail N. Kosiborod, MD, codirector of Saint Luke’s Cardiometabolic Center of Excellence in Kansas City, Mo.

These people are often sedentary, so they frequently don’t experience shortness of breath at baseline, Dr. Kosiborod said in an interview. In some cases, they may limit their activity because of their exertional intolerance.

Once a person’s suggestive symptoms become known, the next step is to measure the serum level of N-terminal pro-B-type natriuretic peptide (NT-proBNP), a biomarker considered to be a generally reliable signal of existing heart failure when elevated.

Any value above 125 pg/mL is suggestive of prevalent heart failure and should lead to the next diagnostic step of echocardiography, Dr. Sattar said.

Elevated NT-proBNP has such good positive predictive value for identifying heart failure that it is tempting to use it broadly in people with type 2 diabetes. A 2022 consensus report from the American Diabetes Association says that “measurement of a natriuretic peptide [such as NT-proBNP] or high-sensitivity cardiac troponin is recommended on at least a yearly basis to identify the earliest HF [heart failure] stages and implement strategies to prevent transition to symptomatic HF.”
 

Test costs require targeting

But because of the relatively high current price for an NT-proBNP test, the cost-benefit ratio for widespread annual testing of all people with type 2 diabetes would be poor, some experts caution.

“Screening everyone may not be the right answer. Hundreds of millions of people worldwide” have type 2 diabetes. “You first need to target evaluation to people with symptoms,” advised Dr. Kosiborod.

He also warned that a low NT-proBNP level does not always rule out HFpEF, especially among people with type 2 diabetes who also have overweight or obesity, because NT-proBNP levels can be “artificially low” in people with obesity.

Other potential aids to diagnosis are assessment scores that researchers have developed, such as the H2FPEF score, which relies on variables that include age, obesity, and the presence of atrial fibrillation and hypertension.

However, this score also requires an echocardiography examination, another test that would have a questionable cost-benefit ratio if performed widely for patients with type 2 diabetes without targeting, Dr. Kosiborod said.
 

SGLT2 inhibitors benefit HFpEF regardless of glucose levels

A prespecified analysis of the DELIVER results that divided the study cohort on the basis of their glycemic status proved the efficacy of the SGLT2 inhibitor dapagliflozin for patients with HFpEF regardless of whether or not they had type 2 diabetes, prediabetes, or were normoglycemic at entry into the study, Silvio E. Inzucchi, MD, reported at the EASD meeting.

Mitchel L. Zoler/MDedge News

Treatment with dapagliflozin cut the incidence of the trial’s primary outcome of cardiovascular death or worsening heart failure by a significant 18% relative to placebo among all enrolled patients.

The new analysis reported by Dr. Inzucchi showed that treatment was associated with a 23% relative risk reduction among those with normoglycemia, a 13% reduction among those with prediabetes, and a 19% reduction among those with type 2 diabetes, with no signal of a significant difference among the three subgroups.

“There was no statistical interaction between categorical glycemic subgrouping and dapagliflozin’s treatment effect,” concluded Dr. Inzucchi, director of the Yale Medicine Diabetes Center, New Haven, Conn.

He also reported that, among the 6,259 people in the trial with HFpEF, 50% had diabetes, 31% had prediabetes, and a scant 19% had normoglycemia. The finding highlights once again the high prevalence of dysglycemia among people with HFpEF.

Previously, a prespecified secondary analysis of data from the EMPEROR-Preserved trial yielded similar findings for empagliflozin that showed the agent’s efficacy for people with HFpEF across the range of glucose levels.

The DELIVER trial was funded by AstraZeneca, the company that markets dapagliflozin (Farxiga). The EMPEROR-Preserved trial was sponsored by Boehringer Ingelheim and Eli Lilly, the companies that jointly market empagliflozin (Jardiance). Dr. Lund has been a consultant to AstraZeneca and Boehringer Ingelheim and to numerous other companies, and he is a stockholder in AnaCardio. Dr. Sattar has been a consultant to and has received research support from AstraZeneca and Boehringer Ingelheim, and he has been a consultant with numerous companies. Dr. Kosiborod has been a consultant to and has received research funding from AstraZeneca and Boehringer Ingelheim and has been a consultant to Eli Lilly and numerous other companies. Dr. Inzucchi has been a consultant to, given talks on behalf of, or served on trial committees for Abbott, AstraZeneca, Boehringer Ingelheim, Esperion, Lexicon, Merck, Novo Nordisk, Pfizer, and vTv Therapetics.

A version of this article first appeared on Medscape.com.

STOCKHOLM – Recent study results confirm that two agents from the sodium-glucose cotransporter 2 (SGLT2) inhibitor class can significantly cut the incidence of adverse cardiovascular events in patients with heart failure with reduced ejection fraction (HFpEF), a disease especially common in people with type 2 diabetes, obesity, or both.

And findings from secondary analyses of the studies – including one reported at the annual meeting of the European Association for the Study of Diabetes – show that these SGLT2 inhibitors work as well for cutting incident adverse events (cardiovascular death or worsening heart failure) in patients with HFpEF and diabetes as they do for people with normal blood glucose levels.

But delivering treatment with these proven agents, dapagliflozin (Farxiga) and empagliflozin (Jardiance), first requires diagnosis of HFpEF, a task that clinicians have historically fallen short in accomplishing.

When in 2021, results from the EMPEROR-Preserved trial with empagliflozin and when in September 2022 results from the DELIVER trial with dapagliflozin established the efficacy of these two SGLT2 inhibitors as the first treatments proven to benefit patients with HFpEF, they also raised the stakes for clinicians to be much more diligent and systematic in evaluating people at high risk for developing HFpEF because of having type 2 diabetes or obesity, two of the most potent risk factors for this form of heart failure.
 

‘Vigilance ... needs to increase’

“Vigilance for HFpEF needs to increase because we can now help these patients,” declared Lars H. Lund, MD, PhD, speaking at the meeting. “Type 2 diabetes dramatically increases the incidence of HFpEF,” and the mechanisms by which it does this are “especially amenable to treatment with SGLT2 inhibitors,” said Dr. Lund, a cardiologist and heart failure specialist at the Karolinska Institute, Stockholm.

HFpEF has a history of going undetected in people with type 2 diabetes, an ironic situation given its high incidence as well as the elevated rate of adverse cardiovascular events when heart failure occurs in patients with type 2 diabetes compared with patients who do not have diabetes.

The key, say experts, is for clinicians to maintain a high index of suspicion for signs and symptoms of heart failure in people with type 2 diabetes and to regularly assess them, starting with just a few simple questions that probe for the presence of dyspnea, exertional fatigue, or both, an approach not widely employed up to now.

Clinicians who care for people with type 2 diabetes must become “alert to thinking about heart failure and alert to asking questions about signs and symptoms” that flag the presence of HFpEF, advised Naveed Sattar, MBChB, PhD, a professor of metabolic medicine at the University of Glasgow.

Soon, medical groups will issue guidelines for appropriate assessment for the presence of HFpEF in people with type 2 diabetes, Dr. Sattar predicted in an interview.
 

A need to probe

“You can’t simply ask patients with type 2 diabetes whether they have shortness of breath or exertional fatigue and stop there,” because often their first response will be no.

“Commonly, patients will initially say they have no dyspnea, but when you probe further, you find symptoms,” noted Mikhail N. Kosiborod, MD, codirector of Saint Luke’s Cardiometabolic Center of Excellence in Kansas City, Mo.

These people are often sedentary, so they frequently don’t experience shortness of breath at baseline, Dr. Kosiborod said in an interview. In some cases, they may limit their activity because of their exertional intolerance.

Once a person’s suggestive symptoms become known, the next step is to measure the serum level of N-terminal pro-B-type natriuretic peptide (NT-proBNP), a biomarker considered to be a generally reliable signal of existing heart failure when elevated.

Any value above 125 pg/mL is suggestive of prevalent heart failure and should lead to the next diagnostic step of echocardiography, Dr. Sattar said.

Elevated NT-proBNP has such good positive predictive value for identifying heart failure that it is tempting to use it broadly in people with type 2 diabetes. A 2022 consensus report from the American Diabetes Association says that “measurement of a natriuretic peptide [such as NT-proBNP] or high-sensitivity cardiac troponin is recommended on at least a yearly basis to identify the earliest HF [heart failure] stages and implement strategies to prevent transition to symptomatic HF.”
 

Test costs require targeting

But because of the relatively high current price for an NT-proBNP test, the cost-benefit ratio for widespread annual testing of all people with type 2 diabetes would be poor, some experts caution.

“Screening everyone may not be the right answer. Hundreds of millions of people worldwide” have type 2 diabetes. “You first need to target evaluation to people with symptoms,” advised Dr. Kosiborod.

He also warned that a low NT-proBNP level does not always rule out HFpEF, especially among people with type 2 diabetes who also have overweight or obesity, because NT-proBNP levels can be “artificially low” in people with obesity.

Other potential aids to diagnosis are assessment scores that researchers have developed, such as the H2FPEF score, which relies on variables that include age, obesity, and the presence of atrial fibrillation and hypertension.

However, this score also requires an echocardiography examination, another test that would have a questionable cost-benefit ratio if performed widely for patients with type 2 diabetes without targeting, Dr. Kosiborod said.
 

SGLT2 inhibitors benefit HFpEF regardless of glucose levels

A prespecified analysis of the DELIVER results that divided the study cohort on the basis of their glycemic status proved the efficacy of the SGLT2 inhibitor dapagliflozin for patients with HFpEF regardless of whether or not they had type 2 diabetes, prediabetes, or were normoglycemic at entry into the study, Silvio E. Inzucchi, MD, reported at the EASD meeting.

Mitchel L. Zoler/MDedge News

Treatment with dapagliflozin cut the incidence of the trial’s primary outcome of cardiovascular death or worsening heart failure by a significant 18% relative to placebo among all enrolled patients.

The new analysis reported by Dr. Inzucchi showed that treatment was associated with a 23% relative risk reduction among those with normoglycemia, a 13% reduction among those with prediabetes, and a 19% reduction among those with type 2 diabetes, with no signal of a significant difference among the three subgroups.

“There was no statistical interaction between categorical glycemic subgrouping and dapagliflozin’s treatment effect,” concluded Dr. Inzucchi, director of the Yale Medicine Diabetes Center, New Haven, Conn.

He also reported that, among the 6,259 people in the trial with HFpEF, 50% had diabetes, 31% had prediabetes, and a scant 19% had normoglycemia. The finding highlights once again the high prevalence of dysglycemia among people with HFpEF.

Previously, a prespecified secondary analysis of data from the EMPEROR-Preserved trial yielded similar findings for empagliflozin that showed the agent’s efficacy for people with HFpEF across the range of glucose levels.

The DELIVER trial was funded by AstraZeneca, the company that markets dapagliflozin (Farxiga). The EMPEROR-Preserved trial was sponsored by Boehringer Ingelheim and Eli Lilly, the companies that jointly market empagliflozin (Jardiance). Dr. Lund has been a consultant to AstraZeneca and Boehringer Ingelheim and to numerous other companies, and he is a stockholder in AnaCardio. Dr. Sattar has been a consultant to and has received research support from AstraZeneca and Boehringer Ingelheim, and he has been a consultant with numerous companies. Dr. Kosiborod has been a consultant to and has received research funding from AstraZeneca and Boehringer Ingelheim and has been a consultant to Eli Lilly and numerous other companies. Dr. Inzucchi has been a consultant to, given talks on behalf of, or served on trial committees for Abbott, AstraZeneca, Boehringer Ingelheim, Esperion, Lexicon, Merck, Novo Nordisk, Pfizer, and vTv Therapetics.

A version of this article first appeared on Medscape.com.

STOCKHOLM – Recent study results confirm that two agents from the sodium-glucose cotransporter 2 (SGLT2) inhibitor class can significantly cut the incidence of adverse cardiovascular events in patients with heart failure with reduced ejection fraction (HFpEF), a disease especially common in people with type 2 diabetes, obesity, or both.

And findings from secondary analyses of the studies – including one reported at the annual meeting of the European Association for the Study of Diabetes – show that these SGLT2 inhibitors work as well for cutting incident adverse events (cardiovascular death or worsening heart failure) in patients with HFpEF and diabetes as they do for people with normal blood glucose levels.

But delivering treatment with these proven agents, dapagliflozin (Farxiga) and empagliflozin (Jardiance), first requires diagnosis of HFpEF, a task that clinicians have historically fallen short in accomplishing.

When in 2021, results from the EMPEROR-Preserved trial with empagliflozin and when in September 2022 results from the DELIVER trial with dapagliflozin established the efficacy of these two SGLT2 inhibitors as the first treatments proven to benefit patients with HFpEF, they also raised the stakes for clinicians to be much more diligent and systematic in evaluating people at high risk for developing HFpEF because of having type 2 diabetes or obesity, two of the most potent risk factors for this form of heart failure.
 

‘Vigilance ... needs to increase’

“Vigilance for HFpEF needs to increase because we can now help these patients,” declared Lars H. Lund, MD, PhD, speaking at the meeting. “Type 2 diabetes dramatically increases the incidence of HFpEF,” and the mechanisms by which it does this are “especially amenable to treatment with SGLT2 inhibitors,” said Dr. Lund, a cardiologist and heart failure specialist at the Karolinska Institute, Stockholm.

HFpEF has a history of going undetected in people with type 2 diabetes, an ironic situation given its high incidence as well as the elevated rate of adverse cardiovascular events when heart failure occurs in patients with type 2 diabetes compared with patients who do not have diabetes.

The key, say experts, is for clinicians to maintain a high index of suspicion for signs and symptoms of heart failure in people with type 2 diabetes and to regularly assess them, starting with just a few simple questions that probe for the presence of dyspnea, exertional fatigue, or both, an approach not widely employed up to now.

Clinicians who care for people with type 2 diabetes must become “alert to thinking about heart failure and alert to asking questions about signs and symptoms” that flag the presence of HFpEF, advised Naveed Sattar, MBChB, PhD, a professor of metabolic medicine at the University of Glasgow.

Soon, medical groups will issue guidelines for appropriate assessment for the presence of HFpEF in people with type 2 diabetes, Dr. Sattar predicted in an interview.
 

A need to probe

“You can’t simply ask patients with type 2 diabetes whether they have shortness of breath or exertional fatigue and stop there,” because often their first response will be no.

“Commonly, patients will initially say they have no dyspnea, but when you probe further, you find symptoms,” noted Mikhail N. Kosiborod, MD, codirector of Saint Luke’s Cardiometabolic Center of Excellence in Kansas City, Mo.

These people are often sedentary, so they frequently don’t experience shortness of breath at baseline, Dr. Kosiborod said in an interview. In some cases, they may limit their activity because of their exertional intolerance.

Once a person’s suggestive symptoms become known, the next step is to measure the serum level of N-terminal pro-B-type natriuretic peptide (NT-proBNP), a biomarker considered to be a generally reliable signal of existing heart failure when elevated.

Any value above 125 pg/mL is suggestive of prevalent heart failure and should lead to the next diagnostic step of echocardiography, Dr. Sattar said.

Elevated NT-proBNP has such good positive predictive value for identifying heart failure that it is tempting to use it broadly in people with type 2 diabetes. A 2022 consensus report from the American Diabetes Association says that “measurement of a natriuretic peptide [such as NT-proBNP] or high-sensitivity cardiac troponin is recommended on at least a yearly basis to identify the earliest HF [heart failure] stages and implement strategies to prevent transition to symptomatic HF.”
 

Test costs require targeting

But because of the relatively high current price for an NT-proBNP test, the cost-benefit ratio for widespread annual testing of all people with type 2 diabetes would be poor, some experts caution.

“Screening everyone may not be the right answer. Hundreds of millions of people worldwide” have type 2 diabetes. “You first need to target evaluation to people with symptoms,” advised Dr. Kosiborod.

He also warned that a low NT-proBNP level does not always rule out HFpEF, especially among people with type 2 diabetes who also have overweight or obesity, because NT-proBNP levels can be “artificially low” in people with obesity.

Other potential aids to diagnosis are assessment scores that researchers have developed, such as the H2FPEF score, which relies on variables that include age, obesity, and the presence of atrial fibrillation and hypertension.

However, this score also requires an echocardiography examination, another test that would have a questionable cost-benefit ratio if performed widely for patients with type 2 diabetes without targeting, Dr. Kosiborod said.
 

SGLT2 inhibitors benefit HFpEF regardless of glucose levels

A prespecified analysis of the DELIVER results that divided the study cohort on the basis of their glycemic status proved the efficacy of the SGLT2 inhibitor dapagliflozin for patients with HFpEF regardless of whether or not they had type 2 diabetes, prediabetes, or were normoglycemic at entry into the study, Silvio E. Inzucchi, MD, reported at the EASD meeting.

Mitchel L. Zoler/MDedge News

Treatment with dapagliflozin cut the incidence of the trial’s primary outcome of cardiovascular death or worsening heart failure by a significant 18% relative to placebo among all enrolled patients.

The new analysis reported by Dr. Inzucchi showed that treatment was associated with a 23% relative risk reduction among those with normoglycemia, a 13% reduction among those with prediabetes, and a 19% reduction among those with type 2 diabetes, with no signal of a significant difference among the three subgroups.

“There was no statistical interaction between categorical glycemic subgrouping and dapagliflozin’s treatment effect,” concluded Dr. Inzucchi, director of the Yale Medicine Diabetes Center, New Haven, Conn.

He also reported that, among the 6,259 people in the trial with HFpEF, 50% had diabetes, 31% had prediabetes, and a scant 19% had normoglycemia. The finding highlights once again the high prevalence of dysglycemia among people with HFpEF.

Previously, a prespecified secondary analysis of data from the EMPEROR-Preserved trial yielded similar findings for empagliflozin that showed the agent’s efficacy for people with HFpEF across the range of glucose levels.

The DELIVER trial was funded by AstraZeneca, the company that markets dapagliflozin (Farxiga). The EMPEROR-Preserved trial was sponsored by Boehringer Ingelheim and Eli Lilly, the companies that jointly market empagliflozin (Jardiance). Dr. Lund has been a consultant to AstraZeneca and Boehringer Ingelheim and to numerous other companies, and he is a stockholder in AnaCardio. Dr. Sattar has been a consultant to and has received research support from AstraZeneca and Boehringer Ingelheim, and he has been a consultant with numerous companies. Dr. Kosiborod has been a consultant to and has received research funding from AstraZeneca and Boehringer Ingelheim and has been a consultant to Eli Lilly and numerous other companies. Dr. Inzucchi has been a consultant to, given talks on behalf of, or served on trial committees for Abbott, AstraZeneca, Boehringer Ingelheim, Esperion, Lexicon, Merck, Novo Nordisk, Pfizer, and vTv Therapetics.

A version of this article first appeared on Medscape.com.

The Asia-Pacific Colorectal Screening (APCS) scoring system, combined with a stool DNA test, could improve the detection of advanced colorectal neoplasms and limit colonoscopy use, according to a new study published in Clinical Gastroenterology and Hepatology.

Although a colonoscopy can detect both colorectal cancer and precancerous lesions, using it as the primary screening tool can cause barriers due to high costs, limited resources, and low compliance, wrote Junfeng Xu of the gastroenterology department at the First Medical Center of Chinese PLA General Hospital, Beijing, and colleagues.

ChrisChrisW/iStock/Getty Images

Avoiding complications

“Colonoscopy is expensive and time consuming for both the patient and the health care system. Colonoscopy is also not without risk since bowel perforation, post-procedural bleeding, and sedation-related complications all occur at low but measurable rates,” said Reid Ness, MD, associate professor of medicine and gastroenterologist at Vanderbilt University Medical Center, Nashville, Tenn.

“The primary strength of the study was that all patients eventually received colonoscopy, allowing for the best estimate of strategy sensitivity for advanced colorectal neoplasia,” he said.

At the same time, the cross-sectional study was unable to estimate the benefit of using this type of screening strategy over time, Dr. Ness said. With limited endoscopic resources available in many countries, however, clinicians need better modalities and strategies for noninvasive identification of advanced colorectal neoplasia, he added.

“Since less than 5% of the population will eventually develop colorectal cancer, the overwhelming majority can only be discomfited and possibly injured through colonoscopy screening,” he said. “For these reasons, the use of a CRC screening strategy that minimizes the use of colonoscopy without compromising the identification rate for advanced colorectal neoplasia is best for both the patient and the health care system.”

The study was supported by grants from the Beijing Municipal Science and Technology Commission. The authors declared no conflicts of interest. Dr. Ness reported no relevant disclosures.

This article was updated Oct. 4, 2022.

The Asia-Pacific Colorectal Screening (APCS) scoring system, combined with a stool DNA test, could improve the detection of advanced colorectal neoplasms and limit colonoscopy use, according to a new study published in Clinical Gastroenterology and Hepatology.

Although a colonoscopy can detect both colorectal cancer and precancerous lesions, using it as the primary screening tool can cause barriers due to high costs, limited resources, and low compliance, wrote Junfeng Xu of the gastroenterology department at the First Medical Center of Chinese PLA General Hospital, Beijing, and colleagues.

ChrisChrisW/iStock/Getty Images

Avoiding complications

“Colonoscopy is expensive and time consuming for both the patient and the health care system. Colonoscopy is also not without risk since bowel perforation, post-procedural bleeding, and sedation-related complications all occur at low but measurable rates,” said Reid Ness, MD, associate professor of medicine and gastroenterologist at Vanderbilt University Medical Center, Nashville, Tenn.

“The primary strength of the study was that all patients eventually received colonoscopy, allowing for the best estimate of strategy sensitivity for advanced colorectal neoplasia,” he said.

At the same time, the cross-sectional study was unable to estimate the benefit of using this type of screening strategy over time, Dr. Ness said. With limited endoscopic resources available in many countries, however, clinicians need better modalities and strategies for noninvasive identification of advanced colorectal neoplasia, he added.

“Since less than 5% of the population will eventually develop colorectal cancer, the overwhelming majority can only be discomfited and possibly injured through colonoscopy screening,” he said. “For these reasons, the use of a CRC screening strategy that minimizes the use of colonoscopy without compromising the identification rate for advanced colorectal neoplasia is best for both the patient and the health care system.”

The study was supported by grants from the Beijing Municipal Science and Technology Commission. The authors declared no conflicts of interest. Dr. Ness reported no relevant disclosures.

This article was updated Oct. 4, 2022.

The Asia-Pacific Colorectal Screening (APCS) scoring system, combined with a stool DNA test, could improve the detection of advanced colorectal neoplasms and limit colonoscopy use, according to a new study published in Clinical Gastroenterology and Hepatology.

Although a colonoscopy can detect both colorectal cancer and precancerous lesions, using it as the primary screening tool can cause barriers due to high costs, limited resources, and low compliance, wrote Junfeng Xu of the gastroenterology department at the First Medical Center of Chinese PLA General Hospital, Beijing, and colleagues.

ChrisChrisW/iStock/Getty Images

Avoiding complications

“Colonoscopy is expensive and time consuming for both the patient and the health care system. Colonoscopy is also not without risk since bowel perforation, post-procedural bleeding, and sedation-related complications all occur at low but measurable rates,” said Reid Ness, MD, associate professor of medicine and gastroenterologist at Vanderbilt University Medical Center, Nashville, Tenn.

“The primary strength of the study was that all patients eventually received colonoscopy, allowing for the best estimate of strategy sensitivity for advanced colorectal neoplasia,” he said.

At the same time, the cross-sectional study was unable to estimate the benefit of using this type of screening strategy over time, Dr. Ness said. With limited endoscopic resources available in many countries, however, clinicians need better modalities and strategies for noninvasive identification of advanced colorectal neoplasia, he added.

“Since less than 5% of the population will eventually develop colorectal cancer, the overwhelming majority can only be discomfited and possibly injured through colonoscopy screening,” he said. “For these reasons, the use of a CRC screening strategy that minimizes the use of colonoscopy without compromising the identification rate for advanced colorectal neoplasia is best for both the patient and the health care system.”

The study was supported by grants from the Beijing Municipal Science and Technology Commission. The authors declared no conflicts of interest. Dr. Ness reported no relevant disclosures.

This article was updated Oct. 4, 2022.

John worked as a handyman and lived on a small sailboat in a marina. When he was diagnosed with metastatic kidney cancer at age 48, he quickly fell through the cracks. He failed to show to appointments and took oral anticancer treatments, but just sporadically. He had Medicaid, so insurance wasn’t the issue. It was everything else.

John was behind on his slip fees; he hadn’t been able to work for some time because of his progressive weakness and pain. He was chronically in danger of getting kicked out of his makeshift home aboard the boat. He had no reliable transportation to the clinic and so he didn’t come to appointments regularly. The specialty pharmacy refused to deliver his expensive oral chemotherapy to his address at the marina. He went days without eating full meals because he was too weak to cook for himself. Plus, he was estranged from his family who were unaware of his illness. His oncologist was overwhelmed trying to take care of him. He had a reasonable chance of achieving disease control on first-line oral therapy, but his problems seemed to hinder these chances at every turn. She was distraught – what could she do?

Enter the team approach. John’s oncologist reached out to our palliative care program for help. We recognized that this was a job too big for us alone so we connected John with the Extensivist Medicine program at UCLA Health, a high-intensity primary care program led by a physician specializing in primary care for high-risk individuals. The program provides wraparound outpatient services for chronically and seriously ill patients, like John, who are at risk for falling through the cracks. John went from receiving very little support to now having an entire team of caring professionals focused on helping him achieve his best possible outcome despite the seriousness of his disease.

He now had the support of a high-functioning team with clearly defined roles. Social work connected him with housing, food, and transportation resources. A nurse called him every day to check in and make sure he was taking medications and reminded him about his upcoming appointments. Case management helped him get needed equipment, such as grab bars and a walker. As his palliative care nurse practitioner, I counseled him on understanding his prognosis and planning ahead for medical emergencies. Our psycho-oncology clinicians helped John reconcile with his family, who were more than willing to take him in once they realized how ill he was. Once these social factors were addressed, John could more easily stay current with his oral chemotherapy, giving him the best chance possible to achieve a robust treatment response that could buy him more time.

And, John did get that time – he got 6 months of improved quality of life, during which he reconnected with his family, including his children, and rebuilt these important relationships. Eventually treatment failed him. His disease, already widely metastatic, became more active and painful. He accepted hospice care at his sister’s house and we transitioned him from our team to the hospice team. He died peacefully surrounded by family.
 

Interprofessional teamwork is fundamental to treat ‘total pain’

None of this would have been possible without the work of high-functioning teams. It is a commonly held belief that interprofessional teamwork is fundamental to the care of patients and families living with serious illness. But why? How did this idea come about? And what evidence is there to support teamwork?

Dame Cicely Saunders, who founded the modern hospice movement in mid-20th century England, embodied the interdisciplinary team by working first as a nurse, then a social worker, and finally as a physician. She wrote about patients’ “total pain,” the crisis of physical, spiritual, social, and emotional distress that many people have at the end of life. She understood that no single health care discipline was adequate to the task of addressing each of these domains equally well. Thus, hospice became synonymous with care provided by a quartet of specialists – physicians, nurses, social workers, and chaplains. Nowadays, there are other specialists that are added to the mix – home health aides, pharmacists, physical and occupational therapists, music and pet therapists, and so on.

But in medicine, like all areas of science, convention and tradition only go so far. What evidence is there to support the work of an interdisciplinary team in managing the distress of patients and families living with advanced illnesses? It turns out that there is good evidence to support the use of high-functioning interdisciplinary teams in the care of the seriously ill. Palliative care is associated with improved patient outcomes, including improvements in symptom control, quality of life, and end of life care, when it is delivered by an interdisciplinary team rather than by a solo practitioner.

You may think that teamwork is most useful for patients like John who have seemingly intractable social barriers. But it is also true that for even patients with many more social advantages teamwork improves quality of life. I got to see this up close recently in my own life.
 

Teamwork improves quality of life

My father recently passed away after a 9-month battle with advanced cancer. He had every advantage possible – financial stability, high health literacy, an incredibly devoted spouse who happens to be an RN, good insurance, and access to top-notch medical care. Yet, even he benefited from a team approach. It started small, with the oncologist and oncology NP providing excellent, patient-centered care. Then it grew to include myself as the daughter/palliative care nurse practitioner who made recommendations for treating his nausea and ensured that his advance directive was completed and uploaded to his chart. When my dad needed physical therapy, the home health agency sent a wonderful physical therapist, who brought all sorts of equipment that kept him more functional than he would have been otherwise. Other family members helped out – my sisters helped connect my dad with a priest who came to the home to provide spiritual care, which was crucial to ensuring that he was at peace. And, in his final days, my dad had the hospice team to help manage his symptoms and his family members to provide hands-on care.

Cancer, as one of my patients once remarked to me, is a “full-contact sport.” Living with advanced cancer touches nearly every aspect of a person’s life. The complexity of cancer care has long necessitated a team approach to planning cancer treatment – known as a tumor board – with medical oncology, radiation oncology, surgery, and pathology all weighing in. It makes sense that patients and their families would also need a team of clinicians representing different specialty areas to assist with the wide array of physical, psychosocial, practical, and spiritual concerns that arise throughout the cancer disease trajectory.

Ms. D’Ambruoso is a hospice and palliative care nurse practitioner for UCLA Health Cancer Care, Santa Monica, Calif.

John worked as a handyman and lived on a small sailboat in a marina. When he was diagnosed with metastatic kidney cancer at age 48, he quickly fell through the cracks. He failed to show to appointments and took oral anticancer treatments, but just sporadically. He had Medicaid, so insurance wasn’t the issue. It was everything else.

John was behind on his slip fees; he hadn’t been able to work for some time because of his progressive weakness and pain. He was chronically in danger of getting kicked out of his makeshift home aboard the boat. He had no reliable transportation to the clinic and so he didn’t come to appointments regularly. The specialty pharmacy refused to deliver his expensive oral chemotherapy to his address at the marina. He went days without eating full meals because he was too weak to cook for himself. Plus, he was estranged from his family who were unaware of his illness. His oncologist was overwhelmed trying to take care of him. He had a reasonable chance of achieving disease control on first-line oral therapy, but his problems seemed to hinder these chances at every turn. She was distraught – what could she do?

Enter the team approach. John’s oncologist reached out to our palliative care program for help. We recognized that this was a job too big for us alone so we connected John with the Extensivist Medicine program at UCLA Health, a high-intensity primary care program led by a physician specializing in primary care for high-risk individuals. The program provides wraparound outpatient services for chronically and seriously ill patients, like John, who are at risk for falling through the cracks. John went from receiving very little support to now having an entire team of caring professionals focused on helping him achieve his best possible outcome despite the seriousness of his disease.

He now had the support of a high-functioning team with clearly defined roles. Social work connected him with housing, food, and transportation resources. A nurse called him every day to check in and make sure he was taking medications and reminded him about his upcoming appointments. Case management helped him get needed equipment, such as grab bars and a walker. As his palliative care nurse practitioner, I counseled him on understanding his prognosis and planning ahead for medical emergencies. Our psycho-oncology clinicians helped John reconcile with his family, who were more than willing to take him in once they realized how ill he was. Once these social factors were addressed, John could more easily stay current with his oral chemotherapy, giving him the best chance possible to achieve a robust treatment response that could buy him more time.

And, John did get that time – he got 6 months of improved quality of life, during which he reconnected with his family, including his children, and rebuilt these important relationships. Eventually treatment failed him. His disease, already widely metastatic, became more active and painful. He accepted hospice care at his sister’s house and we transitioned him from our team to the hospice team. He died peacefully surrounded by family.
 

Interprofessional teamwork is fundamental to treat ‘total pain’

None of this would have been possible without the work of high-functioning teams. It is a commonly held belief that interprofessional teamwork is fundamental to the care of patients and families living with serious illness. But why? How did this idea come about? And what evidence is there to support teamwork?

Dame Cicely Saunders, who founded the modern hospice movement in mid-20th century England, embodied the interdisciplinary team by working first as a nurse, then a social worker, and finally as a physician. She wrote about patients’ “total pain,” the crisis of physical, spiritual, social, and emotional distress that many people have at the end of life. She understood that no single health care discipline was adequate to the task of addressing each of these domains equally well. Thus, hospice became synonymous with care provided by a quartet of specialists – physicians, nurses, social workers, and chaplains. Nowadays, there are other specialists that are added to the mix – home health aides, pharmacists, physical and occupational therapists, music and pet therapists, and so on.

But in medicine, like all areas of science, convention and tradition only go so far. What evidence is there to support the work of an interdisciplinary team in managing the distress of patients and families living with advanced illnesses? It turns out that there is good evidence to support the use of high-functioning interdisciplinary teams in the care of the seriously ill. Palliative care is associated with improved patient outcomes, including improvements in symptom control, quality of life, and end of life care, when it is delivered by an interdisciplinary team rather than by a solo practitioner.

You may think that teamwork is most useful for patients like John who have seemingly intractable social barriers. But it is also true that for even patients with many more social advantages teamwork improves quality of life. I got to see this up close recently in my own life.
 

Teamwork improves quality of life

My father recently passed away after a 9-month battle with advanced cancer. He had every advantage possible – financial stability, high health literacy, an incredibly devoted spouse who happens to be an RN, good insurance, and access to top-notch medical care. Yet, even he benefited from a team approach. It started small, with the oncologist and oncology NP providing excellent, patient-centered care. Then it grew to include myself as the daughter/palliative care nurse practitioner who made recommendations for treating his nausea and ensured that his advance directive was completed and uploaded to his chart. When my dad needed physical therapy, the home health agency sent a wonderful physical therapist, who brought all sorts of equipment that kept him more functional than he would have been otherwise. Other family members helped out – my sisters helped connect my dad with a priest who came to the home to provide spiritual care, which was crucial to ensuring that he was at peace. And, in his final days, my dad had the hospice team to help manage his symptoms and his family members to provide hands-on care.

Cancer, as one of my patients once remarked to me, is a “full-contact sport.” Living with advanced cancer touches nearly every aspect of a person’s life. The complexity of cancer care has long necessitated a team approach to planning cancer treatment – known as a tumor board – with medical oncology, radiation oncology, surgery, and pathology all weighing in. It makes sense that patients and their families would also need a team of clinicians representing different specialty areas to assist with the wide array of physical, psychosocial, practical, and spiritual concerns that arise throughout the cancer disease trajectory.

Ms. D’Ambruoso is a hospice and palliative care nurse practitioner for UCLA Health Cancer Care, Santa Monica, Calif.

John worked as a handyman and lived on a small sailboat in a marina. When he was diagnosed with metastatic kidney cancer at age 48, he quickly fell through the cracks. He failed to show to appointments and took oral anticancer treatments, but just sporadically. He had Medicaid, so insurance wasn’t the issue. It was everything else.

John was behind on his slip fees; he hadn’t been able to work for some time because of his progressive weakness and pain. He was chronically in danger of getting kicked out of his makeshift home aboard the boat. He had no reliable transportation to the clinic and so he didn’t come to appointments regularly. The specialty pharmacy refused to deliver his expensive oral chemotherapy to his address at the marina. He went days without eating full meals because he was too weak to cook for himself. Plus, he was estranged from his family who were unaware of his illness. His oncologist was overwhelmed trying to take care of him. He had a reasonable chance of achieving disease control on first-line oral therapy, but his problems seemed to hinder these chances at every turn. She was distraught – what could she do?

Enter the team approach. John’s oncologist reached out to our palliative care program for help. We recognized that this was a job too big for us alone so we connected John with the Extensivist Medicine program at UCLA Health, a high-intensity primary care program led by a physician specializing in primary care for high-risk individuals. The program provides wraparound outpatient services for chronically and seriously ill patients, like John, who are at risk for falling through the cracks. John went from receiving very little support to now having an entire team of caring professionals focused on helping him achieve his best possible outcome despite the seriousness of his disease.

He now had the support of a high-functioning team with clearly defined roles. Social work connected him with housing, food, and transportation resources. A nurse called him every day to check in and make sure he was taking medications and reminded him about his upcoming appointments. Case management helped him get needed equipment, such as grab bars and a walker. As his palliative care nurse practitioner, I counseled him on understanding his prognosis and planning ahead for medical emergencies. Our psycho-oncology clinicians helped John reconcile with his family, who were more than willing to take him in once they realized how ill he was. Once these social factors were addressed, John could more easily stay current with his oral chemotherapy, giving him the best chance possible to achieve a robust treatment response that could buy him more time.

And, John did get that time – he got 6 months of improved quality of life, during which he reconnected with his family, including his children, and rebuilt these important relationships. Eventually treatment failed him. His disease, already widely metastatic, became more active and painful. He accepted hospice care at his sister’s house and we transitioned him from our team to the hospice team. He died peacefully surrounded by family.
 

Interprofessional teamwork is fundamental to treat ‘total pain’

None of this would have been possible without the work of high-functioning teams. It is a commonly held belief that interprofessional teamwork is fundamental to the care of patients and families living with serious illness. But why? How did this idea come about? And what evidence is there to support teamwork?

Dame Cicely Saunders, who founded the modern hospice movement in mid-20th century England, embodied the interdisciplinary team by working first as a nurse, then a social worker, and finally as a physician. She wrote about patients’ “total pain,” the crisis of physical, spiritual, social, and emotional distress that many people have at the end of life. She understood that no single health care discipline was adequate to the task of addressing each of these domains equally well. Thus, hospice became synonymous with care provided by a quartet of specialists – physicians, nurses, social workers, and chaplains. Nowadays, there are other specialists that are added to the mix – home health aides, pharmacists, physical and occupational therapists, music and pet therapists, and so on.

But in medicine, like all areas of science, convention and tradition only go so far. What evidence is there to support the work of an interdisciplinary team in managing the distress of patients and families living with advanced illnesses? It turns out that there is good evidence to support the use of high-functioning interdisciplinary teams in the care of the seriously ill. Palliative care is associated with improved patient outcomes, including improvements in symptom control, quality of life, and end of life care, when it is delivered by an interdisciplinary team rather than by a solo practitioner.

You may think that teamwork is most useful for patients like John who have seemingly intractable social barriers. But it is also true that for even patients with many more social advantages teamwork improves quality of life. I got to see this up close recently in my own life.
 

Teamwork improves quality of life

My father recently passed away after a 9-month battle with advanced cancer. He had every advantage possible – financial stability, high health literacy, an incredibly devoted spouse who happens to be an RN, good insurance, and access to top-notch medical care. Yet, even he benefited from a team approach. It started small, with the oncologist and oncology NP providing excellent, patient-centered care. Then it grew to include myself as the daughter/palliative care nurse practitioner who made recommendations for treating his nausea and ensured that his advance directive was completed and uploaded to his chart. When my dad needed physical therapy, the home health agency sent a wonderful physical therapist, who brought all sorts of equipment that kept him more functional than he would have been otherwise. Other family members helped out – my sisters helped connect my dad with a priest who came to the home to provide spiritual care, which was crucial to ensuring that he was at peace. And, in his final days, my dad had the hospice team to help manage his symptoms and his family members to provide hands-on care.

Cancer, as one of my patients once remarked to me, is a “full-contact sport.” Living with advanced cancer touches nearly every aspect of a person’s life. The complexity of cancer care has long necessitated a team approach to planning cancer treatment – known as a tumor board – with medical oncology, radiation oncology, surgery, and pathology all weighing in. It makes sense that patients and their families would also need a team of clinicians representing different specialty areas to assist with the wide array of physical, psychosocial, practical, and spiritual concerns that arise throughout the cancer disease trajectory.

Ms. D’Ambruoso is a hospice and palliative care nurse practitioner for UCLA Health Cancer Care, Santa Monica, Calif.

MILAN – In the current spread of monkeypox among countries outside of Africa, this zoonotic orthopox DNA virus is sexually transmitted in more than 90% of cases, mostly among men having sex with men (MSM), and can produce severe skin and systemic symptoms but is rarely fatal, according to a breaking news presentation at the annual congress of the European Academy of Dermatology and Venereology.

Synthesizing data from 185 cases in Spain with several sets of recently published data, Alba Català, MD, a dermatologist at Centro Médico Teknon, Barcelona, said at the meeting that there have been only two deaths in Spain in the current epidemic. (As of Sept. 30, after the EADV meeting had concluded, a total of three deaths related to monkeypox in Spain and one death in the United States had been reported, according to the Centers for Disease Control and Prevention).

Hospitalizations have been uncommon, and in Spain, there were only four hospitalizations, according to data collected from the beginning of May through early August, she said. Almost all cases in this Spanish series were from men having high-risk sex with men. Upon screening, 76% had another sexually transmitted disease, including 41% infected with human immunodeficiency virus.
 

More than 40% of patients with monkeypox have HIV

These data are consistent with several other recently published studies, such as one that evaluated 528 infections in 16 non-African countries, including those in North America, South America, Europe, the Mideast, as well as Australia. In that survey, published in the New England Journal of Medicine, and covering cases between late April and late June, 2022, 41% were HIV positive. Of those who were HIV negative, 57% were taking a pre-exposure prophylaxis regimen of antiretroviral drugs to prevent HIV infection.

However, these data do not preclude a significant risk of nonsexual transmission, according to Dr. Català, who noted that respiratory transmission and transmission through nonsexual skin contact is well documented in endemic areas.

“The virus has no preference for a sexual orientation,” Dr. Català cautioned. Despite the consistency of the data in regard to a largely MSM transmission in the epidemic so far, “these data may change with further spread of infection in the community.”

Typically, the incubation period of monkeypox lasts several days before the invasive period, which is commonly accompanied by systemic complaints, particularly fever, headache, and often lymphadenopathy. These systemic features usually but not always precede cutaneous involvement, which is seen in more than 90% of patients, according to Dr. Català. In the Spanish series, mucocutaneous involvement was recorded in 100% of patients.

Monkeypox and smallpox

“The differential diagnosis might include other vesicular eruptions, such as those caused by varicella or smallpox,” reported Dr. Català, who noted that monkeypox and smallpox are related.

Cutaneous lesions often appear first at the site of infection, such as the genitalia, but typically spread in a secondary eruption that is pruritic and may take days to resolve, according to Dr. Català. She reported that single lesions are less common but do occur. While hundreds of lesions have been reported among cases in endemic areas, most patients had 25 lesions or fewer in the Spanish epidemic and other recent series.

Even though there is a common progression in which lesions begin in a papular stage before the vesicular and pustular stages in a given area, new eruptions can occur before a prior eruption develops scabs.

“Frequently, not all the patient’s lesions are in the same stage of development,” said Dr. Català, who explained that disease activity and its complications, such as proctitis, pharyngitis, and penile edema, can take weeks to resolve. Because of the highly invasive nature of monkeypox, it is appropriate to be alert to less common manifestations, such as ocular involvement.

Many of these and other complications, such as secondary bacterial infections, will require targeted treatment, but the mainstay of therapy for the dermatologic manifestations of monkeypox is symptomatic treatment that includes nonsteroidal anti-inflammatory drugs and analgesics.
 

Re-epithelialization reduces transmission risk

“A clean, moist environment can mitigate transmission potential by covering infectious sores and promoting the re-epithelialization of the damaged exanthem,” Dr. Català advised. Tecovirimat (TPOXX, ST-246), an antiviral drug for smallpox, is approved for treating monkeypox in Europe but not in the United States (but it is approved for smallpox in the United States). Another antiviral drug, brincidofovir (CMX001 or Tembexa), is approved for smallpox in the United States, but not in Europe, according to Dr. Català. (In the United States, no treatment is specifically approved for treating monkeypox, but antivirals developed for smallpox “may prove beneficial against monkeypox,” according to the CDC.)

But she advised weighing the risks and benefits of using either drug in any individual patient.

The data suggest that the risk of viral shedding persists until the late stages of the disease trajectory. “A person is considered infectious from the onset of clinical manifestations until all skin lesions have scabbed over and re-epithelization has occurred,” Dr. Català said.

The prolonged period of contagion might be one reason to expect monkeypox to be transmitted more generally than it is now, according to Boghuma K. Titanji, MD, PhD, assistant professor of infectious diseases, Emory University, Atlanta.

“The longer the outbreak persists, the more likely we will see cases reported in groups other than MSM who have been most affected so far,” said Dr. Titanji, the first author of a recently published review article on monkeypox in Open Forum Infectious Diseases.

However, he acknowledged that a COVID-like spread is not expected. “The spread of monkeypox requires close and prolonged contact and is generally inefficient via fomites and droplet modes of transmission,” Dr. Titanji said in an interview. “Spread in heterosexual networks and congregate settings like crowded jails where close contact is unavoidable remains a concern that we need to educate the public about and maintain a high level of vigilance for.”

Dr. Català and Dr. Titanji report no potential conflicts of interest.

MILAN – In the current spread of monkeypox among countries outside of Africa, this zoonotic orthopox DNA virus is sexually transmitted in more than 90% of cases, mostly among men having sex with men (MSM), and can produce severe skin and systemic symptoms but is rarely fatal, according to a breaking news presentation at the annual congress of the European Academy of Dermatology and Venereology.

Synthesizing data from 185 cases in Spain with several sets of recently published data, Alba Català, MD, a dermatologist at Centro Médico Teknon, Barcelona, said at the meeting that there have been only two deaths in Spain in the current epidemic. (As of Sept. 30, after the EADV meeting had concluded, a total of three deaths related to monkeypox in Spain and one death in the United States had been reported, according to the Centers for Disease Control and Prevention).

Hospitalizations have been uncommon, and in Spain, there were only four hospitalizations, according to data collected from the beginning of May through early August, she said. Almost all cases in this Spanish series were from men having high-risk sex with men. Upon screening, 76% had another sexually transmitted disease, including 41% infected with human immunodeficiency virus.
 

More than 40% of patients with monkeypox have HIV

These data are consistent with several other recently published studies, such as one that evaluated 528 infections in 16 non-African countries, including those in North America, South America, Europe, the Mideast, as well as Australia. In that survey, published in the New England Journal of Medicine, and covering cases between late April and late June, 2022, 41% were HIV positive. Of those who were HIV negative, 57% were taking a pre-exposure prophylaxis regimen of antiretroviral drugs to prevent HIV infection.

However, these data do not preclude a significant risk of nonsexual transmission, according to Dr. Català, who noted that respiratory transmission and transmission through nonsexual skin contact is well documented in endemic areas.

“The virus has no preference for a sexual orientation,” Dr. Català cautioned. Despite the consistency of the data in regard to a largely MSM transmission in the epidemic so far, “these data may change with further spread of infection in the community.”

Typically, the incubation period of monkeypox lasts several days before the invasive period, which is commonly accompanied by systemic complaints, particularly fever, headache, and often lymphadenopathy. These systemic features usually but not always precede cutaneous involvement, which is seen in more than 90% of patients, according to Dr. Català. In the Spanish series, mucocutaneous involvement was recorded in 100% of patients.

Monkeypox and smallpox

“The differential diagnosis might include other vesicular eruptions, such as those caused by varicella or smallpox,” reported Dr. Català, who noted that monkeypox and smallpox are related.

Cutaneous lesions often appear first at the site of infection, such as the genitalia, but typically spread in a secondary eruption that is pruritic and may take days to resolve, according to Dr. Català. She reported that single lesions are less common but do occur. While hundreds of lesions have been reported among cases in endemic areas, most patients had 25 lesions or fewer in the Spanish epidemic and other recent series.

Even though there is a common progression in which lesions begin in a papular stage before the vesicular and pustular stages in a given area, new eruptions can occur before a prior eruption develops scabs.

“Frequently, not all the patient’s lesions are in the same stage of development,” said Dr. Català, who explained that disease activity and its complications, such as proctitis, pharyngitis, and penile edema, can take weeks to resolve. Because of the highly invasive nature of monkeypox, it is appropriate to be alert to less common manifestations, such as ocular involvement.

Many of these and other complications, such as secondary bacterial infections, will require targeted treatment, but the mainstay of therapy for the dermatologic manifestations of monkeypox is symptomatic treatment that includes nonsteroidal anti-inflammatory drugs and analgesics.
 

Re-epithelialization reduces transmission risk

“A clean, moist environment can mitigate transmission potential by covering infectious sores and promoting the re-epithelialization of the damaged exanthem,” Dr. Català advised. Tecovirimat (TPOXX, ST-246), an antiviral drug for smallpox, is approved for treating monkeypox in Europe but not in the United States (but it is approved for smallpox in the United States). Another antiviral drug, brincidofovir (CMX001 or Tembexa), is approved for smallpox in the United States, but not in Europe, according to Dr. Català. (In the United States, no treatment is specifically approved for treating monkeypox, but antivirals developed for smallpox “may prove beneficial against monkeypox,” according to the CDC.)

But she advised weighing the risks and benefits of using either drug in any individual patient.

The data suggest that the risk of viral shedding persists until the late stages of the disease trajectory. “A person is considered infectious from the onset of clinical manifestations until all skin lesions have scabbed over and re-epithelization has occurred,” Dr. Català said.

The prolonged period of contagion might be one reason to expect monkeypox to be transmitted more generally than it is now, according to Boghuma K. Titanji, MD, PhD, assistant professor of infectious diseases, Emory University, Atlanta.

“The longer the outbreak persists, the more likely we will see cases reported in groups other than MSM who have been most affected so far,” said Dr. Titanji, the first author of a recently published review article on monkeypox in Open Forum Infectious Diseases.

However, he acknowledged that a COVID-like spread is not expected. “The spread of monkeypox requires close and prolonged contact and is generally inefficient via fomites and droplet modes of transmission,” Dr. Titanji said in an interview. “Spread in heterosexual networks and congregate settings like crowded jails where close contact is unavoidable remains a concern that we need to educate the public about and maintain a high level of vigilance for.”

Dr. Català and Dr. Titanji report no potential conflicts of interest.

MILAN – In the current spread of monkeypox among countries outside of Africa, this zoonotic orthopox DNA virus is sexually transmitted in more than 90% of cases, mostly among men having sex with men (MSM), and can produce severe skin and systemic symptoms but is rarely fatal, according to a breaking news presentation at the annual congress of the European Academy of Dermatology and Venereology.

Synthesizing data from 185 cases in Spain with several sets of recently published data, Alba Català, MD, a dermatologist at Centro Médico Teknon, Barcelona, said at the meeting that there have been only two deaths in Spain in the current epidemic. (As of Sept. 30, after the EADV meeting had concluded, a total of three deaths related to monkeypox in Spain and one death in the United States had been reported, according to the Centers for Disease Control and Prevention).

Hospitalizations have been uncommon, and in Spain, there were only four hospitalizations, according to data collected from the beginning of May through early August, she said. Almost all cases in this Spanish series were from men having high-risk sex with men. Upon screening, 76% had another sexually transmitted disease, including 41% infected with human immunodeficiency virus.
 

More than 40% of patients with monkeypox have HIV

These data are consistent with several other recently published studies, such as one that evaluated 528 infections in 16 non-African countries, including those in North America, South America, Europe, the Mideast, as well as Australia. In that survey, published in the New England Journal of Medicine, and covering cases between late April and late June, 2022, 41% were HIV positive. Of those who were HIV negative, 57% were taking a pre-exposure prophylaxis regimen of antiretroviral drugs to prevent HIV infection.

However, these data do not preclude a significant risk of nonsexual transmission, according to Dr. Català, who noted that respiratory transmission and transmission through nonsexual skin contact is well documented in endemic areas.

“The virus has no preference for a sexual orientation,” Dr. Català cautioned. Despite the consistency of the data in regard to a largely MSM transmission in the epidemic so far, “these data may change with further spread of infection in the community.”

Typically, the incubation period of monkeypox lasts several days before the invasive period, which is commonly accompanied by systemic complaints, particularly fever, headache, and often lymphadenopathy. These systemic features usually but not always precede cutaneous involvement, which is seen in more than 90% of patients, according to Dr. Català. In the Spanish series, mucocutaneous involvement was recorded in 100% of patients.

Monkeypox and smallpox

“The differential diagnosis might include other vesicular eruptions, such as those caused by varicella or smallpox,” reported Dr. Català, who noted that monkeypox and smallpox are related.

Cutaneous lesions often appear first at the site of infection, such as the genitalia, but typically spread in a secondary eruption that is pruritic and may take days to resolve, according to Dr. Català. She reported that single lesions are less common but do occur. While hundreds of lesions have been reported among cases in endemic areas, most patients had 25 lesions or fewer in the Spanish epidemic and other recent series.

Even though there is a common progression in which lesions begin in a papular stage before the vesicular and pustular stages in a given area, new eruptions can occur before a prior eruption develops scabs.

“Frequently, not all the patient’s lesions are in the same stage of development,” said Dr. Català, who explained that disease activity and its complications, such as proctitis, pharyngitis, and penile edema, can take weeks to resolve. Because of the highly invasive nature of monkeypox, it is appropriate to be alert to less common manifestations, such as ocular involvement.

Many of these and other complications, such as secondary bacterial infections, will require targeted treatment, but the mainstay of therapy for the dermatologic manifestations of monkeypox is symptomatic treatment that includes nonsteroidal anti-inflammatory drugs and analgesics.
 

Re-epithelialization reduces transmission risk

“A clean, moist environment can mitigate transmission potential by covering infectious sores and promoting the re-epithelialization of the damaged exanthem,” Dr. Català advised. Tecovirimat (TPOXX, ST-246), an antiviral drug for smallpox, is approved for treating monkeypox in Europe but not in the United States (but it is approved for smallpox in the United States). Another antiviral drug, brincidofovir (CMX001 or Tembexa), is approved for smallpox in the United States, but not in Europe, according to Dr. Català. (In the United States, no treatment is specifically approved for treating monkeypox, but antivirals developed for smallpox “may prove beneficial against monkeypox,” according to the CDC.)

But she advised weighing the risks and benefits of using either drug in any individual patient.

The data suggest that the risk of viral shedding persists until the late stages of the disease trajectory. “A person is considered infectious from the onset of clinical manifestations until all skin lesions have scabbed over and re-epithelization has occurred,” Dr. Català said.

The prolonged period of contagion might be one reason to expect monkeypox to be transmitted more generally than it is now, according to Boghuma K. Titanji, MD, PhD, assistant professor of infectious diseases, Emory University, Atlanta.

“The longer the outbreak persists, the more likely we will see cases reported in groups other than MSM who have been most affected so far,” said Dr. Titanji, the first author of a recently published review article on monkeypox in Open Forum Infectious Diseases.

However, he acknowledged that a COVID-like spread is not expected. “The spread of monkeypox requires close and prolonged contact and is generally inefficient via fomites and droplet modes of transmission,” Dr. Titanji said in an interview. “Spread in heterosexual networks and congregate settings like crowded jails where close contact is unavoidable remains a concern that we need to educate the public about and maintain a high level of vigilance for.”

Dr. Català and Dr. Titanji report no potential conflicts of interest.

While great strides have been made in children’s leukemia care during the past 50 years, statistics have remained grim. For acute myeloid leukemia (AML), the most common type, 5-year survival rates were just 69% for children younger than 15 between 2009 and 2015. Patients who do survive past adolescence face high risks of future complications.

Specialists say the challenges hindering more progress include a lack of clinical research, an emphasis on competition over cooperation, and sparse insight into how best to adjust adult leukemia treatments to children. Now, a large clinical trial launched by the Leukemia & Lymphoma Society (LLS) seeks to revolutionize pediatric AML care by testing multiple experimental treatments across the globe. Its goal goes beyond simply boosting survival.

“Our project aims to find better treatments, more targeted treatments, that will leave children with fewer long-term health problems as adults. We want them to not just survive but thrive,” Gwen Nichols, MD, chief medical officer of LLS, said in an interview. “What we’ve had was not working for anybody. So we have to try a different approach.”

The LLS Pediatric Acute Leukemia (PedAL) Master Trial launched in spring of 2022. Seventy-five study locations from Nova Scotia to Hawaii are now recruiting patients up to age 22 with known or suspected relapsed/refractory AML, mixed phenotype acute leukemia, or relapsed acute lymphoblastic leukemia (ALL).

The 5-year trial expects to recruit 960 participants in the United States and Canada. Clinics in Europe, Australia, and New Zealand also are taking part.

“Pediatric oncologists should know that PedAL, for the first time, is providing a cooperative, seamless way to interrogate [the genomics of] a child’s leukemia,” hematologist/oncologist Todd Cooper, DO, section chief of pediatric oncology at Seattle Children’s Cancer and Blood Disorders Center, said in an interview. “It is also providing a seamless and efficient way for children to be assigned to clinical trials that are going to be tailored towards a particular child’s leukemia. This is something that’s never been done.”

In North America, all trial participants with relapsed AML will undergo genetic sequencing for free as part of the screening process. Clinics “can’t always access genomic screening for their patients,” Dr. Nichols said. “We’re providing that even if they don’t participate in any other part of the trial, even if they go and get another available therapy or go on a different trial. We want them to know that this is available, and they will get the results. And if they’re looking for a trial when they get those results, we have trained oncology nurses who will help them navigate and find clinical trials.”

In PedAL itself, one subtrial is now in progress: An open-label phase 3 randomized multicenter analysis of whether the oral leukemia drug venetoclax combined with the intensive infused chemotherapy treatment FLA+GO (fludarabine, high-dose cytarabine, and gemtuzumab ozogamicin) will improve overall survival compared to FLA+GO alone. Ninety-eight subjects are expected to join the 5-year subtrial.

“We expect within the next year to open three or four different subtrials of targeted therapies for specific groups of patients,” E. Anders Kolb, MD, chief of oncology and hematology at Nemours Children’s Health in Delaware and cochair of the PedAL trial, said in an interview. “Over the course of the next few years, we’re going to learn a lot about the natural history of relapsed leukemia – we don’t have a ton of data on that – and then how targeted therapies may alter some of those outcomes.”

Discussions with multiple drugmakers are in progress regarding the potential subtrials, he said.

The PedAL strategy addresses the lack of new drugs for children with AML, Seattle Children’s Dr. Cooper said. One main reason for the gap is that childhood leukemia is much less common than the adult form, he said, so a lot of drug development is geared toward adults. As a result, he said, new drugs “are geared towards adults whose leukemia is not as aggressive. Whereas in children, the acute leukemias, especially AML, are quite aggressive and need therapies that are often more intense.”

In addition, he said, “we have only recently become aware of how AML is biologically much different than in adults.”

In AML, Delaware’s Dr. Kolb explained, “there are many different phenotypes – ways that these cells can look and behave. But we treat them with a single regimen. What I like to tell families is that we’ve got a few tools in our toolbox, but they all happen to be sledgehammers. The key to the challenge in AML is that it is a molecular disease, but we’re treating it with therapies that were developed 40-50 years ago.”

In PedAL, the goal is to figure out the best ways to target therapy for the specific types that patients have. On this front, the genomic screening in the trial is crucial because it will identify which patients express certain targets and allow them to be assigned to appropriate sub-trials, Dr. Coooper said.

What’s next? “LLS has planned for this to be ongoing for the next 5 to 7 years, so that we can get a number of studies up and running,” Dr. Nichols said. “After that, those studies will continue. We will hope that most of them can be self-funded by then.”

As for cost, she noted that the PedAL trial is part of the society’s Dare to Dream Project, formerly known as the Children’s Initiative, which focuses on pediatric blood cancers. The project, with a fundraising goal of $175 million, focuses on research, patient services and survivorship.

”We have a whole range of services, travel assistance, copay programs and educational resources that doctors may want to use as a valid source of information,” she said. ‘When I was in practice, patients were always asking me, ‘Do you have anything I can read or take home to give my son something about his disease?’ LLS has good-quality, patient-level information for patients. We welcome people contacting us or going to our website and taking advantage of that for free.”

Dr. Nichols and Dr. Kolb report no disclosures. Dr. Cooper reports academic funding from LLS.

While great strides have been made in children’s leukemia care during the past 50 years, statistics have remained grim. For acute myeloid leukemia (AML), the most common type, 5-year survival rates were just 69% for children younger than 15 between 2009 and 2015. Patients who do survive past adolescence face high risks of future complications.

Specialists say the challenges hindering more progress include a lack of clinical research, an emphasis on competition over cooperation, and sparse insight into how best to adjust adult leukemia treatments to children. Now, a large clinical trial launched by the Leukemia & Lymphoma Society (LLS) seeks to revolutionize pediatric AML care by testing multiple experimental treatments across the globe. Its goal goes beyond simply boosting survival.

“Our project aims to find better treatments, more targeted treatments, that will leave children with fewer long-term health problems as adults. We want them to not just survive but thrive,” Gwen Nichols, MD, chief medical officer of LLS, said in an interview. “What we’ve had was not working for anybody. So we have to try a different approach.”

The LLS Pediatric Acute Leukemia (PedAL) Master Trial launched in spring of 2022. Seventy-five study locations from Nova Scotia to Hawaii are now recruiting patients up to age 22 with known or suspected relapsed/refractory AML, mixed phenotype acute leukemia, or relapsed acute lymphoblastic leukemia (ALL).

The 5-year trial expects to recruit 960 participants in the United States and Canada. Clinics in Europe, Australia, and New Zealand also are taking part.

“Pediatric oncologists should know that PedAL, for the first time, is providing a cooperative, seamless way to interrogate [the genomics of] a child’s leukemia,” hematologist/oncologist Todd Cooper, DO, section chief of pediatric oncology at Seattle Children’s Cancer and Blood Disorders Center, said in an interview. “It is also providing a seamless and efficient way for children to be assigned to clinical trials that are going to be tailored towards a particular child’s leukemia. This is something that’s never been done.”

In North America, all trial participants with relapsed AML will undergo genetic sequencing for free as part of the screening process. Clinics “can’t always access genomic screening for their patients,” Dr. Nichols said. “We’re providing that even if they don’t participate in any other part of the trial, even if they go and get another available therapy or go on a different trial. We want them to know that this is available, and they will get the results. And if they’re looking for a trial when they get those results, we have trained oncology nurses who will help them navigate and find clinical trials.”

In PedAL itself, one subtrial is now in progress: An open-label phase 3 randomized multicenter analysis of whether the oral leukemia drug venetoclax combined with the intensive infused chemotherapy treatment FLA+GO (fludarabine, high-dose cytarabine, and gemtuzumab ozogamicin) will improve overall survival compared to FLA+GO alone. Ninety-eight subjects are expected to join the 5-year subtrial.

“We expect within the next year to open three or four different subtrials of targeted therapies for specific groups of patients,” E. Anders Kolb, MD, chief of oncology and hematology at Nemours Children’s Health in Delaware and cochair of the PedAL trial, said in an interview. “Over the course of the next few years, we’re going to learn a lot about the natural history of relapsed leukemia – we don’t have a ton of data on that – and then how targeted therapies may alter some of those outcomes.”

Discussions with multiple drugmakers are in progress regarding the potential subtrials, he said.

The PedAL strategy addresses the lack of new drugs for children with AML, Seattle Children’s Dr. Cooper said. One main reason for the gap is that childhood leukemia is much less common than the adult form, he said, so a lot of drug development is geared toward adults. As a result, he said, new drugs “are geared towards adults whose leukemia is not as aggressive. Whereas in children, the acute leukemias, especially AML, are quite aggressive and need therapies that are often more intense.”

In addition, he said, “we have only recently become aware of how AML is biologically much different than in adults.”

In AML, Delaware’s Dr. Kolb explained, “there are many different phenotypes – ways that these cells can look and behave. But we treat them with a single regimen. What I like to tell families is that we’ve got a few tools in our toolbox, but they all happen to be sledgehammers. The key to the challenge in AML is that it is a molecular disease, but we’re treating it with therapies that were developed 40-50 years ago.”

In PedAL, the goal is to figure out the best ways to target therapy for the specific types that patients have. On this front, the genomic screening in the trial is crucial because it will identify which patients express certain targets and allow them to be assigned to appropriate sub-trials, Dr. Coooper said.

What’s next? “LLS has planned for this to be ongoing for the next 5 to 7 years, so that we can get a number of studies up and running,” Dr. Nichols said. “After that, those studies will continue. We will hope that most of them can be self-funded by then.”

As for cost, she noted that the PedAL trial is part of the society’s Dare to Dream Project, formerly known as the Children’s Initiative, which focuses on pediatric blood cancers. The project, with a fundraising goal of $175 million, focuses on research, patient services and survivorship.

”We have a whole range of services, travel assistance, copay programs and educational resources that doctors may want to use as a valid source of information,” she said. ‘When I was in practice, patients were always asking me, ‘Do you have anything I can read or take home to give my son something about his disease?’ LLS has good-quality, patient-level information for patients. We welcome people contacting us or going to our website and taking advantage of that for free.”

Dr. Nichols and Dr. Kolb report no disclosures. Dr. Cooper reports academic funding from LLS.

While great strides have been made in children’s leukemia care during the past 50 years, statistics have remained grim. For acute myeloid leukemia (AML), the most common type, 5-year survival rates were just 69% for children younger than 15 between 2009 and 2015. Patients who do survive past adolescence face high risks of future complications.

Specialists say the challenges hindering more progress include a lack of clinical research, an emphasis on competition over cooperation, and sparse insight into how best to adjust adult leukemia treatments to children. Now, a large clinical trial launched by the Leukemia & Lymphoma Society (LLS) seeks to revolutionize pediatric AML care by testing multiple experimental treatments across the globe. Its goal goes beyond simply boosting survival.

“Our project aims to find better treatments, more targeted treatments, that will leave children with fewer long-term health problems as adults. We want them to not just survive but thrive,” Gwen Nichols, MD, chief medical officer of LLS, said in an interview. “What we’ve had was not working for anybody. So we have to try a different approach.”

The LLS Pediatric Acute Leukemia (PedAL) Master Trial launched in spring of 2022. Seventy-five study locations from Nova Scotia to Hawaii are now recruiting patients up to age 22 with known or suspected relapsed/refractory AML, mixed phenotype acute leukemia, or relapsed acute lymphoblastic leukemia (ALL).

The 5-year trial expects to recruit 960 participants in the United States and Canada. Clinics in Europe, Australia, and New Zealand also are taking part.

“Pediatric oncologists should know that PedAL, for the first time, is providing a cooperative, seamless way to interrogate [the genomics of] a child’s leukemia,” hematologist/oncologist Todd Cooper, DO, section chief of pediatric oncology at Seattle Children’s Cancer and Blood Disorders Center, said in an interview. “It is also providing a seamless and efficient way for children to be assigned to clinical trials that are going to be tailored towards a particular child’s leukemia. This is something that’s never been done.”

In North America, all trial participants with relapsed AML will undergo genetic sequencing for free as part of the screening process. Clinics “can’t always access genomic screening for their patients,” Dr. Nichols said. “We’re providing that even if they don’t participate in any other part of the trial, even if they go and get another available therapy or go on a different trial. We want them to know that this is available, and they will get the results. And if they’re looking for a trial when they get those results, we have trained oncology nurses who will help them navigate and find clinical trials.”

In PedAL itself, one subtrial is now in progress: An open-label phase 3 randomized multicenter analysis of whether the oral leukemia drug venetoclax combined with the intensive infused chemotherapy treatment FLA+GO (fludarabine, high-dose cytarabine, and gemtuzumab ozogamicin) will improve overall survival compared to FLA+GO alone. Ninety-eight subjects are expected to join the 5-year subtrial.

“We expect within the next year to open three or four different subtrials of targeted therapies for specific groups of patients,” E. Anders Kolb, MD, chief of oncology and hematology at Nemours Children’s Health in Delaware and cochair of the PedAL trial, said in an interview. “Over the course of the next few years, we’re going to learn a lot about the natural history of relapsed leukemia – we don’t have a ton of data on that – and then how targeted therapies may alter some of those outcomes.”

Discussions with multiple drugmakers are in progress regarding the potential subtrials, he said.

The PedAL strategy addresses the lack of new drugs for children with AML, Seattle Children’s Dr. Cooper said. One main reason for the gap is that childhood leukemia is much less common than the adult form, he said, so a lot of drug development is geared toward adults. As a result, he said, new drugs “are geared towards adults whose leukemia is not as aggressive. Whereas in children, the acute leukemias, especially AML, are quite aggressive and need therapies that are often more intense.”

In addition, he said, “we have only recently become aware of how AML is biologically much different than in adults.”

In AML, Delaware’s Dr. Kolb explained, “there are many different phenotypes – ways that these cells can look and behave. But we treat them with a single regimen. What I like to tell families is that we’ve got a few tools in our toolbox, but they all happen to be sledgehammers. The key to the challenge in AML is that it is a molecular disease, but we’re treating it with therapies that were developed 40-50 years ago.”

In PedAL, the goal is to figure out the best ways to target therapy for the specific types that patients have. On this front, the genomic screening in the trial is crucial because it will identify which patients express certain targets and allow them to be assigned to appropriate sub-trials, Dr. Coooper said.

What’s next? “LLS has planned for this to be ongoing for the next 5 to 7 years, so that we can get a number of studies up and running,” Dr. Nichols said. “After that, those studies will continue. We will hope that most of them can be self-funded by then.”

As for cost, she noted that the PedAL trial is part of the society’s Dare to Dream Project, formerly known as the Children’s Initiative, which focuses on pediatric blood cancers. The project, with a fundraising goal of $175 million, focuses on research, patient services and survivorship.

”We have a whole range of services, travel assistance, copay programs and educational resources that doctors may want to use as a valid source of information,” she said. ‘When I was in practice, patients were always asking me, ‘Do you have anything I can read or take home to give my son something about his disease?’ LLS has good-quality, patient-level information for patients. We welcome people contacting us or going to our website and taking advantage of that for free.”

Dr. Nichols and Dr. Kolb report no disclosures. Dr. Cooper reports academic funding from LLS.

Patients undergoing chimeric antigen receptor (CAR) T-cell therapy who develop potentially serious neurotoxicity from the therapy show elevated plasma levels of neurofilament light chain (NfL) prior to the treatment, suggesting a possibly important predictor of risk for the side effect.

“This is the first study to show NfL levels are elevated even before CAR T treatment is given,” first author Omar H. Butt, MD, PhD, of the Siteman Cancer Center at Barnes-Jewish Hospital and Washington University in St. Louis, said in an interview.

“While unlikely to be the sole driver of [the neurotoxicity], neural injury reflected by NfL may aid in identifying a high-risk subset of patients undergoing cellular therapy,” the authors concluded in the study, published in JAMA Oncology.

CAR T-cell therapy has gained favor for virtually revolutionizing the treatment of some leukemias and lymphomas, however, as many as 40%-60% of patients develop the neurotoxicity side effect, called immune effector cell–associated neurotoxicity syndrome (ICANS), which, though usually low grade, in more severe cases can cause substantial morbidity and even mortality.

Hence, “the early identification of patients at risk for ICANS is critical for preemptive management,” the authors noted.

NfL, an established marker of neuroaxonal injury in neurodegenerative diseases including multiple sclerosis and Alzheimer’s disease, has been shown in previous studies to be elevated following the development of ICANS and up to 5 days prior to its peak symptoms.

To further evaluate NfL elevations in relation to ICANS, Dr. Butt and colleagues identified 30 patients undergoing CD19 CART-cell therapy, including 77% for diffuse large B-cell lymphoma, at two U.S. centers: Washington University in St. Louis and Case Western Reserve University, Cleveland.

The patients had a median age of 64 and were 40% female.

Among them, four developed low-grade ICANS grade 1-2, and 7 developed ICANS grade 3 or higher.

Of those developing any-grade ICANS, baseline elevations of NfL prior to the CAR T-cell treatment, were significantly higher, compared with those who did not develop ICANs (mean 87.6 pg/mL vs. 29.4 pg/mL, P < .001), with no significant differences between the low-grade (1 and 2) and higher-grade (3 or higher) ICANS groups.

A receiver operating characteristic analysis showed baseline NfL levels significantly predicted the development of ICANS with high accuracy (area under the ROC curve, 0.96), as well as sensitivity (AUROC, 0.91) and specificity (AUROC, 0.95).

Notably, baseline NfL levels were associated with ICANS severity, but did not correlate with other factors including demographic, oncologic history, nononcologic neurologic history, or history of exposure to neurotoxic therapies.

However, Dr. Butt added, “it is important to note that our study was insufficiently powered to examine those relationships in earnest. Therefore, [a correlation between NfL and those factors] remains possible,” he said.

The elevated NfL levels observed prior to the development of ICANS remained high across the study’s seven time points, up to day 30 post infusion.
 

Interest in NfL levels on the rise

NfL assessment is currently only clinically validated in amyotrophic lateral sclerosis, where it is used to assess neuroaxonal health and integrity. However, testing is available as interest and evidence of NfL’s potential role in other settings grows.

Meanwhile, Dr. Butt and associates are themselves developing an assay to predict the development of ICANS, which will likely include NfL, if the role is validated in further studies.

“Future studies will explore validating NfL for ICANS and additional indications,” he said.

ICANS symptoms can range from headaches and confusion to seizures or strokes in more severe cases.

The current gold standard for treatment includes early intervention with high-dose steroids and careful monitoring, but there is reluctance to use such therapies because of concerns about their blunting the anticancer effects of the CAR T cells.

Importantly, if validated, elevations in NfL could signal the need for more precautionary measures with CAR T-cell therapy, Dr. Butt noted.

“Our data suggests patients with high NfL levels at baseline would benefit most from perhaps closer monitoring with frequent checks and possible early intervention at the first sign of symptoms, a period of time when it may be hard to distinguish ICANS from other causes of confusion, such as delirium,” he explained.
 

Limitations: Validation, preventive measures needed

Commenting on the study, Sattva S. Neelapu, MD, a professor and deputy chair of the department of lymphoma and myeloma at the University of Texas MD Anderson Cancer Center, Houston, agreed that the findings have potentially important implications.

“I think this is a very intriguing and novel finding that needs to be investigated further prospectively in a larger cohort and across different CAR T products in patients with lymphoma, leukemia, and myeloma,” Dr. Neelapu said in an interview.

The NfL elevations observed even before CAR T-cell therapy among those who went on to develop ICANS are notable, he added.

“This is the surprising finding in the study,” Dr. Neelapu said. “It raises the question whether neurologic injury is caused by prior therapies that these patients received or whether it is an age-related phenomenon, as we do see higher incidence and severity of ICANS in older patients or some other mechanisms.”

A key caveat, however, is that even if a risk is identified, options to prevent ICANS are currently limited, Dr. Neelapu noted.

“I think it is too early to implement this into clinical practice,” he said. In addition to needing further validation, “assessing NfL levels would be useful when there is an effective prophylactic or therapeutic strategy – both of which also need to be investigated.”

Dr. Butt and colleagues are developing a clinical assay for ICANS and reported a provisional patent pending on the use of plasma NfL as a predictive biomarker for ICANS. The study received support from the Washington University in St. Louis, the Paula and Rodger O. Riney Fund, the Daniel J. Brennan MD Fund, the Fred Simmons and Olga Mohan Fund; the National Cancer Institute, the National Multiple Sclerosis Society, and the National Institute of Neurological Disorders and Stroke. Dr. Neelapu reported conflicts of interest with numerous pharmaceutical companies.

Patients undergoing chimeric antigen receptor (CAR) T-cell therapy who develop potentially serious neurotoxicity from the therapy show elevated plasma levels of neurofilament light chain (NfL) prior to the treatment, suggesting a possibly important predictor of risk for the side effect.

“This is the first study to show NfL levels are elevated even before CAR T treatment is given,” first author Omar H. Butt, MD, PhD, of the Siteman Cancer Center at Barnes-Jewish Hospital and Washington University in St. Louis, said in an interview.

“While unlikely to be the sole driver of [the neurotoxicity], neural injury reflected by NfL may aid in identifying a high-risk subset of patients undergoing cellular therapy,” the authors concluded in the study, published in JAMA Oncology.

CAR T-cell therapy has gained favor for virtually revolutionizing the treatment of some leukemias and lymphomas, however, as many as 40%-60% of patients develop the neurotoxicity side effect, called immune effector cell–associated neurotoxicity syndrome (ICANS), which, though usually low grade, in more severe cases can cause substantial morbidity and even mortality.

Hence, “the early identification of patients at risk for ICANS is critical for preemptive management,” the authors noted.

NfL, an established marker of neuroaxonal injury in neurodegenerative diseases including multiple sclerosis and Alzheimer’s disease, has been shown in previous studies to be elevated following the development of ICANS and up to 5 days prior to its peak symptoms.

To further evaluate NfL elevations in relation to ICANS, Dr. Butt and colleagues identified 30 patients undergoing CD19 CART-cell therapy, including 77% for diffuse large B-cell lymphoma, at two U.S. centers: Washington University in St. Louis and Case Western Reserve University, Cleveland.

The patients had a median age of 64 and were 40% female.

Among them, four developed low-grade ICANS grade 1-2, and 7 developed ICANS grade 3 or higher.

Of those developing any-grade ICANS, baseline elevations of NfL prior to the CAR T-cell treatment, were significantly higher, compared with those who did not develop ICANs (mean 87.6 pg/mL vs. 29.4 pg/mL, P < .001), with no significant differences between the low-grade (1 and 2) and higher-grade (3 or higher) ICANS groups.

A receiver operating characteristic analysis showed baseline NfL levels significantly predicted the development of ICANS with high accuracy (area under the ROC curve, 0.96), as well as sensitivity (AUROC, 0.91) and specificity (AUROC, 0.95).

Notably, baseline NfL levels were associated with ICANS severity, but did not correlate with other factors including demographic, oncologic history, nononcologic neurologic history, or history of exposure to neurotoxic therapies.

However, Dr. Butt added, “it is important to note that our study was insufficiently powered to examine those relationships in earnest. Therefore, [a correlation between NfL and those factors] remains possible,” he said.

The elevated NfL levels observed prior to the development of ICANS remained high across the study’s seven time points, up to day 30 post infusion.
 

Interest in NfL levels on the rise

NfL assessment is currently only clinically validated in amyotrophic lateral sclerosis, where it is used to assess neuroaxonal health and integrity. However, testing is available as interest and evidence of NfL’s potential role in other settings grows.

Meanwhile, Dr. Butt and associates are themselves developing an assay to predict the development of ICANS, which will likely include NfL, if the role is validated in further studies.

“Future studies will explore validating NfL for ICANS and additional indications,” he said.

ICANS symptoms can range from headaches and confusion to seizures or strokes in more severe cases.

The current gold standard for treatment includes early intervention with high-dose steroids and careful monitoring, but there is reluctance to use such therapies because of concerns about their blunting the anticancer effects of the CAR T cells.

Importantly, if validated, elevations in NfL could signal the need for more precautionary measures with CAR T-cell therapy, Dr. Butt noted.

“Our data suggests patients with high NfL levels at baseline would benefit most from perhaps closer monitoring with frequent checks and possible early intervention at the first sign of symptoms, a period of time when it may be hard to distinguish ICANS from other causes of confusion, such as delirium,” he explained.
 

Limitations: Validation, preventive measures needed

Commenting on the study, Sattva S. Neelapu, MD, a professor and deputy chair of the department of lymphoma and myeloma at the University of Texas MD Anderson Cancer Center, Houston, agreed that the findings have potentially important implications.

“I think this is a very intriguing and novel finding that needs to be investigated further prospectively in a larger cohort and across different CAR T products in patients with lymphoma, leukemia, and myeloma,” Dr. Neelapu said in an interview.

The NfL elevations observed even before CAR T-cell therapy among those who went on to develop ICANS are notable, he added.

“This is the surprising finding in the study,” Dr. Neelapu said. “It raises the question whether neurologic injury is caused by prior therapies that these patients received or whether it is an age-related phenomenon, as we do see higher incidence and severity of ICANS in older patients or some other mechanisms.”

A key caveat, however, is that even if a risk is identified, options to prevent ICANS are currently limited, Dr. Neelapu noted.

“I think it is too early to implement this into clinical practice,” he said. In addition to needing further validation, “assessing NfL levels would be useful when there is an effective prophylactic or therapeutic strategy – both of which also need to be investigated.”

Dr. Butt and colleagues are developing a clinical assay for ICANS and reported a provisional patent pending on the use of plasma NfL as a predictive biomarker for ICANS. The study received support from the Washington University in St. Louis, the Paula and Rodger O. Riney Fund, the Daniel J. Brennan MD Fund, the Fred Simmons and Olga Mohan Fund; the National Cancer Institute, the National Multiple Sclerosis Society, and the National Institute of Neurological Disorders and Stroke. Dr. Neelapu reported conflicts of interest with numerous pharmaceutical companies.

Patients undergoing chimeric antigen receptor (CAR) T-cell therapy who develop potentially serious neurotoxicity from the therapy show elevated plasma levels of neurofilament light chain (NfL) prior to the treatment, suggesting a possibly important predictor of risk for the side effect.

“This is the first study to show NfL levels are elevated even before CAR T treatment is given,” first author Omar H. Butt, MD, PhD, of the Siteman Cancer Center at Barnes-Jewish Hospital and Washington University in St. Louis, said in an interview.

“While unlikely to be the sole driver of [the neurotoxicity], neural injury reflected by NfL may aid in identifying a high-risk subset of patients undergoing cellular therapy,” the authors concluded in the study, published in JAMA Oncology.

CAR T-cell therapy has gained favor for virtually revolutionizing the treatment of some leukemias and lymphomas, however, as many as 40%-60% of patients develop the neurotoxicity side effect, called immune effector cell–associated neurotoxicity syndrome (ICANS), which, though usually low grade, in more severe cases can cause substantial morbidity and even mortality.

Hence, “the early identification of patients at risk for ICANS is critical for preemptive management,” the authors noted.

NfL, an established marker of neuroaxonal injury in neurodegenerative diseases including multiple sclerosis and Alzheimer’s disease, has been shown in previous studies to be elevated following the development of ICANS and up to 5 days prior to its peak symptoms.

To further evaluate NfL elevations in relation to ICANS, Dr. Butt and colleagues identified 30 patients undergoing CD19 CART-cell therapy, including 77% for diffuse large B-cell lymphoma, at two U.S. centers: Washington University in St. Louis and Case Western Reserve University, Cleveland.

The patients had a median age of 64 and were 40% female.

Among them, four developed low-grade ICANS grade 1-2, and 7 developed ICANS grade 3 or higher.

Of those developing any-grade ICANS, baseline elevations of NfL prior to the CAR T-cell treatment, were significantly higher, compared with those who did not develop ICANs (mean 87.6 pg/mL vs. 29.4 pg/mL, P < .001), with no significant differences between the low-grade (1 and 2) and higher-grade (3 or higher) ICANS groups.

A receiver operating characteristic analysis showed baseline NfL levels significantly predicted the development of ICANS with high accuracy (area under the ROC curve, 0.96), as well as sensitivity (AUROC, 0.91) and specificity (AUROC, 0.95).

Notably, baseline NfL levels were associated with ICANS severity, but did not correlate with other factors including demographic, oncologic history, nononcologic neurologic history, or history of exposure to neurotoxic therapies.

However, Dr. Butt added, “it is important to note that our study was insufficiently powered to examine those relationships in earnest. Therefore, [a correlation between NfL and those factors] remains possible,” he said.

The elevated NfL levels observed prior to the development of ICANS remained high across the study’s seven time points, up to day 30 post infusion.
 

Interest in NfL levels on the rise

NfL assessment is currently only clinically validated in amyotrophic lateral sclerosis, where it is used to assess neuroaxonal health and integrity. However, testing is available as interest and evidence of NfL’s potential role in other settings grows.

Meanwhile, Dr. Butt and associates are themselves developing an assay to predict the development of ICANS, which will likely include NfL, if the role is validated in further studies.

“Future studies will explore validating NfL for ICANS and additional indications,” he said.

ICANS symptoms can range from headaches and confusion to seizures or strokes in more severe cases.

The current gold standard for treatment includes early intervention with high-dose steroids and careful monitoring, but there is reluctance to use such therapies because of concerns about their blunting the anticancer effects of the CAR T cells.

Importantly, if validated, elevations in NfL could signal the need for more precautionary measures with CAR T-cell therapy, Dr. Butt noted.

“Our data suggests patients with high NfL levels at baseline would benefit most from perhaps closer monitoring with frequent checks and possible early intervention at the first sign of symptoms, a period of time when it may be hard to distinguish ICANS from other causes of confusion, such as delirium,” he explained.
 

Limitations: Validation, preventive measures needed

Commenting on the study, Sattva S. Neelapu, MD, a professor and deputy chair of the department of lymphoma and myeloma at the University of Texas MD Anderson Cancer Center, Houston, agreed that the findings have potentially important implications.

“I think this is a very intriguing and novel finding that needs to be investigated further prospectively in a larger cohort and across different CAR T products in patients with lymphoma, leukemia, and myeloma,” Dr. Neelapu said in an interview.

The NfL elevations observed even before CAR T-cell therapy among those who went on to develop ICANS are notable, he added.

“This is the surprising finding in the study,” Dr. Neelapu said. “It raises the question whether neurologic injury is caused by prior therapies that these patients received or whether it is an age-related phenomenon, as we do see higher incidence and severity of ICANS in older patients or some other mechanisms.”

A key caveat, however, is that even if a risk is identified, options to prevent ICANS are currently limited, Dr. Neelapu noted.

“I think it is too early to implement this into clinical practice,” he said. In addition to needing further validation, “assessing NfL levels would be useful when there is an effective prophylactic or therapeutic strategy – both of which also need to be investigated.”

Dr. Butt and colleagues are developing a clinical assay for ICANS and reported a provisional patent pending on the use of plasma NfL as a predictive biomarker for ICANS. The study received support from the Washington University in St. Louis, the Paula and Rodger O. Riney Fund, the Daniel J. Brennan MD Fund, the Fred Simmons and Olga Mohan Fund; the National Cancer Institute, the National Multiple Sclerosis Society, and the National Institute of Neurological Disorders and Stroke. Dr. Neelapu reported conflicts of interest with numerous pharmaceutical companies.

Increased levels of air pollution were linked to a slight uptick in new diagnoses of irritable bowel syndrome (IBS) in California residents, according to an ecologic study published in Clinical Gastroenterology and Hepatology.

“These data provide support for the role of environmental pollutants, especially air pollutants, in the development of IBS,” Philip N. Okafor, MD, MPH, of Stanford (Calif.) University, and colleagues wrote. “In contrast, we found no significant relationships between the seven environmental exposures and the ZIP-code level incidence of functional dyspepsia, ulcerative colitis, Crohn’s disease, and eosinophilic esophagitis.”

Thomas321/iStock/Getty Images Plus

Increased levels of air pollution were linked to a slight uptick in new diagnoses of irritable bowel syndrome (IBS) in California residents, according to an ecologic study published in Clinical Gastroenterology and Hepatology.

“These data provide support for the role of environmental pollutants, especially air pollutants, in the development of IBS,” Philip N. Okafor, MD, MPH, of Stanford (Calif.) University, and colleagues wrote. “In contrast, we found no significant relationships between the seven environmental exposures and the ZIP-code level incidence of functional dyspepsia, ulcerative colitis, Crohn’s disease, and eosinophilic esophagitis.”

Thomas321/iStock/Getty Images Plus

Increased levels of air pollution were linked to a slight uptick in new diagnoses of irritable bowel syndrome (IBS) in California residents, according to an ecologic study published in Clinical Gastroenterology and Hepatology.

“These data provide support for the role of environmental pollutants, especially air pollutants, in the development of IBS,” Philip N. Okafor, MD, MPH, of Stanford (Calif.) University, and colleagues wrote. “In contrast, we found no significant relationships between the seven environmental exposures and the ZIP-code level incidence of functional dyspepsia, ulcerative colitis, Crohn’s disease, and eosinophilic esophagitis.”

Thomas321/iStock/Getty Images Plus

Historically, psychology and psychiatry have mostly focused on negative emotions and pathological states. However, during the last few decades, new developments in both disciplines have created novel vistas for a more comprehensive understanding of human behavior.^1,2 These developments have taken on the names of positive psychology and positive psychiatry, respectively. Positive psychiatry is the science and practice of psychiatry that focuses on psycho-bio-social study and promotion of well-being and health through enhancement of positive psychosocial factors (eg, resilience, optimism, wisdom, social support) in people with illnesses or disabilities as well as in the community at large.³ This new perspective is aimed at enhancing and enriching psychiatric practice and research rather than replacing our stated aim of providing reliable and valid diagnostic categories along with effective therapeutic interventions.

In this issue of Current Psychiatry, we introduce a new type of article series, Trending Topics. The inaugural series consists of 4 articles that demonstrate the growth of the field of positive psychiatry and its more recent developments. The 4 parts of this series will be published in consecutive issues.

In Part 1, Boardman et al describe positive psychiatry tools to enhance clinical practice through positive interventions in several categories: adopting a positive orientation, harnessing strengths, mobilizing values, cultivating social connections, and optimizing health habits. The authors show how positive psychiatry aims to create a balance between pathogenesis (the study and understanding of diseases) and salutogenesis (the study and creation of health).⁴

In Part 2, Rettew discusses applying positive psychiatry principles and practices when working with children, adolescents, and their families. The author demonstrates how the principles and practices associated with positive psychiatry represent a natural and highly needed extension of the traditional work within child and adolescent psychiatry, and not a radical transformation of thought or effort. Rettew provides a case example in which he compares traditional and positive psychiatry approaches.

In Part 3, Oughli et al describe resilience in older adults with late-life depression, its clinical and neurocognitive correlates, and associated neurobiological and immunological biomarkers. The authors also narrate resilience-building interventions such as mind-body therapies, which have been reported to enhance resilience through promoting positive perceptions of various experiences and challenges. Evidence suggests that stress reduction, decreased inflammation, and improved emotional regulation may have direct neuro­plastic effects on the brain, resulting in greater resilience.

Finally, in Part 4, Hamid Peseschkian summarizes the ideas and practices of positive psychotherapy (PPT) as practiced in Germany since its introduction by Nossrat Peseschkian in 1977. Based on a resource-oriented conception of human beings, PPT combines humanistic, systemic, psychodynamic, and cognitive-behavioral aspects. This short-term method can be readily understood by patients from diverse cultures and social backgrounds.

Taken together, these articles present recent advances in positive psychiatry, especially from an intervention perspective. This is a timely development in view of the evidence of rising global rates of suicide, substance use, anxiety, depression, and perceived stress. By uniting a positive perspective, along with studying its neuro­biological underpinnings, and taking a life-long approach, we can now apply these innovations to children, young adults, and older adults, thus providing clinicians with tools to enhance well-being and promote mental health in people with and without mental or physical illnesses.

Historically, psychology and psychiatry have mostly focused on negative emotions and pathological states. However, during the last few decades, new developments in both disciplines have created novel vistas for a more comprehensive understanding of human behavior.^1,2 These developments have taken on the names of positive psychology and positive psychiatry, respectively. Positive psychiatry is the science and practice of psychiatry that focuses on psycho-bio-social study and promotion of well-being and health through enhancement of positive psychosocial factors (eg, resilience, optimism, wisdom, social support) in people with illnesses or disabilities as well as in the community at large.³ This new perspective is aimed at enhancing and enriching psychiatric practice and research rather than replacing our stated aim of providing reliable and valid diagnostic categories along with effective therapeutic interventions.

In this issue of Current Psychiatry, we introduce a new type of article series, Trending Topics. The inaugural series consists of 4 articles that demonstrate the growth of the field of positive psychiatry and its more recent developments. The 4 parts of this series will be published in consecutive issues.

In Part 1, Boardman et al describe positive psychiatry tools to enhance clinical practice through positive interventions in several categories: adopting a positive orientation, harnessing strengths, mobilizing values, cultivating social connections, and optimizing health habits. The authors show how positive psychiatry aims to create a balance between pathogenesis (the study and understanding of diseases) and salutogenesis (the study and creation of health).⁴

In Part 2, Rettew discusses applying positive psychiatry principles and practices when working with children, adolescents, and their families. The author demonstrates how the principles and practices associated with positive psychiatry represent a natural and highly needed extension of the traditional work within child and adolescent psychiatry, and not a radical transformation of thought or effort. Rettew provides a case example in which he compares traditional and positive psychiatry approaches.

In Part 3, Oughli et al describe resilience in older adults with late-life depression, its clinical and neurocognitive correlates, and associated neurobiological and immunological biomarkers. The authors also narrate resilience-building interventions such as mind-body therapies, which have been reported to enhance resilience through promoting positive perceptions of various experiences and challenges. Evidence suggests that stress reduction, decreased inflammation, and improved emotional regulation may have direct neuro­plastic effects on the brain, resulting in greater resilience.

Finally, in Part 4, Hamid Peseschkian summarizes the ideas and practices of positive psychotherapy (PPT) as practiced in Germany since its introduction by Nossrat Peseschkian in 1977. Based on a resource-oriented conception of human beings, PPT combines humanistic, systemic, psychodynamic, and cognitive-behavioral aspects. This short-term method can be readily understood by patients from diverse cultures and social backgrounds.

Taken together, these articles present recent advances in positive psychiatry, especially from an intervention perspective. This is a timely development in view of the evidence of rising global rates of suicide, substance use, anxiety, depression, and perceived stress. By uniting a positive perspective, along with studying its neuro­biological underpinnings, and taking a life-long approach, we can now apply these innovations to children, young adults, and older adults, thus providing clinicians with tools to enhance well-being and promote mental health in people with and without mental or physical illnesses.

Historically, psychology and psychiatry have mostly focused on negative emotions and pathological states. However, during the last few decades, new developments in both disciplines have created novel vistas for a more comprehensive understanding of human behavior.^1,2 These developments have taken on the names of positive psychology and positive psychiatry, respectively. Positive psychiatry is the science and practice of psychiatry that focuses on psycho-bio-social study and promotion of well-being and health through enhancement of positive psychosocial factors (eg, resilience, optimism, wisdom, social support) in people with illnesses or disabilities as well as in the community at large.³ This new perspective is aimed at enhancing and enriching psychiatric practice and research rather than replacing our stated aim of providing reliable and valid diagnostic categories along with effective therapeutic interventions.

In this issue of Current Psychiatry, we introduce a new type of article series, Trending Topics. The inaugural series consists of 4 articles that demonstrate the growth of the field of positive psychiatry and its more recent developments. The 4 parts of this series will be published in consecutive issues.

In Part 1, Boardman et al describe positive psychiatry tools to enhance clinical practice through positive interventions in several categories: adopting a positive orientation, harnessing strengths, mobilizing values, cultivating social connections, and optimizing health habits. The authors show how positive psychiatry aims to create a balance between pathogenesis (the study and understanding of diseases) and salutogenesis (the study and creation of health).⁴

In Part 2, Rettew discusses applying positive psychiatry principles and practices when working with children, adolescents, and their families. The author demonstrates how the principles and practices associated with positive psychiatry represent a natural and highly needed extension of the traditional work within child and adolescent psychiatry, and not a radical transformation of thought or effort. Rettew provides a case example in which he compares traditional and positive psychiatry approaches.

In Part 3, Oughli et al describe resilience in older adults with late-life depression, its clinical and neurocognitive correlates, and associated neurobiological and immunological biomarkers. The authors also narrate resilience-building interventions such as mind-body therapies, which have been reported to enhance resilience through promoting positive perceptions of various experiences and challenges. Evidence suggests that stress reduction, decreased inflammation, and improved emotional regulation may have direct neuro­plastic effects on the brain, resulting in greater resilience.

Finally, in Part 4, Hamid Peseschkian summarizes the ideas and practices of positive psychotherapy (PPT) as practiced in Germany since its introduction by Nossrat Peseschkian in 1977. Based on a resource-oriented conception of human beings, PPT combines humanistic, systemic, psychodynamic, and cognitive-behavioral aspects. This short-term method can be readily understood by patients from diverse cultures and social backgrounds.

Taken together, these articles present recent advances in positive psychiatry, especially from an intervention perspective. This is a timely development in view of the evidence of rising global rates of suicide, substance use, anxiety, depression, and perceived stress. By uniting a positive perspective, along with studying its neuro­biological underpinnings, and taking a life-long approach, we can now apply these innovations to children, young adults, and older adults, thus providing clinicians with tools to enhance well-being and promote mental health in people with and without mental or physical illnesses.

FIRST OF 4 PARTS

What does wellness mean to you? A 2018 survey posed this question to more than 6,000 people living with depression and bipolar disorder. In addition to better treatment and greater understanding of their illnesses, other priorities emerged: a longing for better days, a sense of purpose, and a longing to function well and be happy.¹ As one respondent explained, “Wellness means stability; well enough to hold a job, well enough to enjoy activities, well enough to feel joy and hope.” Traditional treatment that focuses on alleviating symptoms may not sufficiently address outcomes patients value. When the focus is primarily deficit-based, clinicians and patients may miss opportunities for optimization and transformation.

Positive psychiatry is the science and practice of psychiatry that seeks to enhance and promote well-being and health through the enhancement of positive psychosocial factors such as resilience, optimism, wisdom, and social support in people with illnesses or disabilities as well as those in the community at large.² It is based on the principles that there is no health without mental health, and that mental health can improve through preventive, therapeutic, and rehabilitative interventions.³

Positive interventions are defined as “treatment methods or intentional activities that aim to cultivate positive feelings, behaviors, or cognitions.”⁴ They are evidence-based intentional exercises designed to increase well-being and enhance flourishing. Although positive interventions were originally studied as activities for nonclinical populations and for helping healthy people thrive, they are increasingly being valued for their therapeutic role in treating psychopathology.⁵ By adding positive interventions to their toolbox, psychiatrists can expand the range of treatment options, better engage patients during the treatment process, and bolster positive mental health.

In this article, we provide practical ways to integrate the tools and principles of positive psychiatry into everyday clinical practice. The goal is to broaden how clinicians think about mental health and therapeutic options and, above all, enhance our patients’ everyday well-being. Teaching patients to adopt a positive orientation, harness strengths, mobilize values, cultivate social connections, and optimize healthy habits are strategies clinicians can apply not only to provide a counterweight to the traditional emphasis on illness, but also to enhance the range and richness of their patients’ everyday experience.

Adopt a positive orientation

When a clinician first meets a patient, “What’s wrong?” is a typical conversation starter, and conversations tend to revolve around problems, failures, and negative experiences. Positive psychiatry posits that there is therapeutic benefit to emphasizing and exploring a patient’s positive emotions, experiences, and aspirations. Questions such as “What was your sense of well-being this week? What is your goal for today’s session? What is your goal for the coming week?” can reorient a session towards an individual’s potential and promote exploration of what’s possible.

To promote a positive orientation, clinicians may consider integrating the Savoring and Three Good Things exercises—2 well-studied interventions—into their repertoire to activate and enhance positive emotional states such as gratitude and joy.⁶ An example of a Savoring activity is taking a 20-minute daily walk while trying to notice as many positive elements as possible. Similarly, the Three Good Things exercise, in which patients are asked to notice and write down 3 positive events and reflect on why they happened, promotes positive reflection and gratitude. A 14-day daily diary study conducted during the COVID-19 pandemic found that higher levels of gratitude were associated with higher levels of positive affect, lower levels of perceived stress related to COVID-19, and better subjective health.⁷ In addition to coping with life’s negative events, deliberately enhancing the impact of good things is a positive emotion amplifier. As French writer François de La Rochefoucauld argued, “Happiness does not consist in things themselves but in the relish we have of them.”⁸

Continue to: Harness strengths

Harness strengths

A growing body of evidence suggests that in addition to focusing on a patient’s chief concern, identifying and cultivating an individual’s signature strengths can mitigate stress and enhance well-being. Signature strengths are positive personality qualities that reflect our core identity and are morally valued. The VIA Character Strengths Survey is the most used and validated psychometric instrument to measure and identify signature strengths such as curiosity, self-regulation, honesty, and teamwork.⁹

To incorporate this tool into clinical practice, ask patients to complete a strengths survey using a validated assessment tool such as the VIA survey (www.viacharacter.org). After a patient identifies their signature strengths, encourage them to explore and apply these strengths in everyday life and in new ways. In addition to becoming aware of and using their signature strengths, encourage patients to “strengths spot” in others. “What strengths did you notice your coworker, family, or friend using today?” is a potential question to explore with patients. A strengths-based approach may be particularly helpful in uncovering motivation and fully engaging patients in treatment. Moreover, integrating strengths into the typically negatively skewed narrative underscores to patients that therapy isn’t only about untwisting distorted thinking, but also about harnessing one’s strengths, talents, and abilities. Strengths expressed through pragmatic actions can boost coping skills as well as enhance well-being.

Mobilize values

Value affirmation exercises have been shown to generate lasting benefits in creating positive feelings and behaviors.¹⁰ Encouraging patients to think about what they genuinely value redirects their gaze towards possibility and diverts self-focus. For instance, ask a patient to identify 2 or 3 values and write about why they are important. By reflecting on their values in writing, they affirm their identity and self-worth, thus creating a virtuous cycle of confidence, effort, and achievement. People who put their values front and center are more attuned to the needs of others as well as their own needs, and they make better connections.¹¹ Including a patient’s values in the treatment plan may increase problem-solving skills, boost motivation, and build better stress management skills.

The “life review” is another intervention that facilitates exploration of a patient’s values. This exercise involves asking patients to recount the story of their life and the experiences that were most meaningful to them. This process allows clinicians to gain a deeper understanding of the patient’s values, which can help guide treatment. Meta-analytic evidence has demonstrated these reminiscence-based interventions have significant effects on well-being.⁶ As Mahatma Gandhi famously said, “Happiness is when what you think, what you say, and what you do are in harmony.” Creating more overlap between a patient’s values and their everyday actions and behaviors bolsters resilience, buffers against stress, and can restore a healthier self-concept.

Cultivate social connections

Social connection is recognized as a core psycho­logical need and essential for well-being. The opposite of connection—social isolation—has negative effects on overall health, including increases in inflammatory markers, depression rates, and even all-cause mortality.¹² A 2015 meta-analytic review demonstrated that loneliness increased the likelihood of mortality by 26%—a similar increase as seen with smoking 15 cigarettes a day.¹³

Continue to: As with any vital sign...

As with any vital sign, exploring a patient’s number of social contacts, quantity of social visits per week, and quality of relationships is an important indicator of health. Giving patients tools to cultivate social connection and deepen their relationships can enhance therapeutic outcomes. Asking patients to perform acts of kindness is one example of a “social prescription.” Feeding a stranger’s parking meter, picking up litter, helping a friend with a chore, providing a meal to a person in need, and volunteering are potential ways for patients to engage in kind deeds. After each act, encourage the patient to write down what they did and how it made them feel.

“Prescribing” positive communication is another way to enhance a patient’s social connections. For instance, teaching them about active constructive responding (ACR)—responding with enthusiasm when another person shares information or good news—has been shown to strengthen bonds with friends and family.¹⁴ Making eye contact, giving the other person one’s full attention, inquiring about details, and responding with enthusiasm and interest are simple ways patients can apply ACR in their daily lives. Counseling a patient on increasing social connections, prescribing connections, and inquiring about quantity and quality of social interactions can help them not only add years to their life but also add health and well-being to those years.

Optimize healthy habits

Mounting research demonstrates that exercise, sleep, and nutrition are important for well-being. Evidence shows that therapeutic lifestyle changes can reduce depressive symptoms and boost positive feelings. Numerous meta-analyses have demonstrated the benefits of sleep and exercise interventions for reducing depressive symptoms in psychiatric patients.^15,16 Longitudinal studies have provided evidence that healthy diets increase happiness, even after controlling for potential confounders such as socioeconomic factors.¹⁷ Other lifestyle factors—including financial stability, pet ownership, decreased social media use, and spending time in nature—have been shown to contribute to well-being.¹⁸

Despite the substantial evidence that lifestyle factors can improve health outcomes, few clinicians ask about, focus on, or promote positive habits.¹⁹ Positive psychiatry seeks to reorient clinicians towards lifestyle factors that enhance well-being. Clinicians can deploy a variety of strategies to support patients in making healthy and sustainable changes. Assessing readiness for change, motivational interviewing, setting SMART (specific, measurable, assignable, realistic, and time-related) goals, and referring patients to relevant community resources are ways to encourage and promote therapeutic lifestyle changes. Inquiring about a patient’s typical day—such as how they spend their free time, what they eat, when they go to bed, and how much time they spend outdoors—opens conversations about general well-being and shows the patient that therapy is about the whole person, and not only symptom management. Helping patients have better days can empower them to lead more satisfied lives.²⁰

The Table^6,17,21-23 summarizes the scientific evidence for the strategies described in this article. The Figure provides a flowchart for using these strategies in clinical practice.

Continue to: Balancing pathogenesis with salutogenesis

By exploring and emphasizing potential and possibility, positive psychiatry aims to create a balance between pathogenesis (the study and understanding of disease) with salutogenesis (the study and creation of health²⁴). Clinicians are well positioned to manage symptoms and bolster positive states. Rather than an either/or approach to well-being, positive psychiatry strives for a both/and approach to well-being. By adding positive interventions to their toolbox, clinicians can expand the range of treatment options, better engage patients in the treatment process, and bolster mental health.

Bottom Line

Clinicians can integrate the tools and principles of positive psychiatry into clinical practice. Teaching patients to adopt a positive orientation, harness strengths, mobilize values, cultivate social connections, and optimize healthy habits can not only provide a counterweight to the traditional emphasis on illness, but also can enhance the range and richness of patients’ everyday experience.

Related Resources

• University of Pennsylvania. Authentic happiness. https://www.authentichappiness.sas.upenn.edu
• Jeste DV, Palmer BW (eds). Positive Psychiatry: A Clinical Handbook. American Psychiatric Publishing; 2015.
• Jeste DV, Palmer BW, Rettew DC, et al. Positive psychiatry: its time has come. J Clin Psychiatry. 2015;76(6):675-683.

FIRST OF 4 PARTS

What does wellness mean to you? A 2018 survey posed this question to more than 6,000 people living with depression and bipolar disorder. In addition to better treatment and greater understanding of their illnesses, other priorities emerged: a longing for better days, a sense of purpose, and a longing to function well and be happy.¹ As one respondent explained, “Wellness means stability; well enough to hold a job, well enough to enjoy activities, well enough to feel joy and hope.” Traditional treatment that focuses on alleviating symptoms may not sufficiently address outcomes patients value. When the focus is primarily deficit-based, clinicians and patients may miss opportunities for optimization and transformation.

Positive psychiatry is the science and practice of psychiatry that seeks to enhance and promote well-being and health through the enhancement of positive psychosocial factors such as resilience, optimism, wisdom, and social support in people with illnesses or disabilities as well as those in the community at large.² It is based on the principles that there is no health without mental health, and that mental health can improve through preventive, therapeutic, and rehabilitative interventions.³

Positive interventions are defined as “treatment methods or intentional activities that aim to cultivate positive feelings, behaviors, or cognitions.”⁴ They are evidence-based intentional exercises designed to increase well-being and enhance flourishing. Although positive interventions were originally studied as activities for nonclinical populations and for helping healthy people thrive, they are increasingly being valued for their therapeutic role in treating psychopathology.⁵ By adding positive interventions to their toolbox, psychiatrists can expand the range of treatment options, better engage patients during the treatment process, and bolster positive mental health.

In this article, we provide practical ways to integrate the tools and principles of positive psychiatry into everyday clinical practice. The goal is to broaden how clinicians think about mental health and therapeutic options and, above all, enhance our patients’ everyday well-being. Teaching patients to adopt a positive orientation, harness strengths, mobilize values, cultivate social connections, and optimize healthy habits are strategies clinicians can apply not only to provide a counterweight to the traditional emphasis on illness, but also to enhance the range and richness of their patients’ everyday experience.

Adopt a positive orientation

When a clinician first meets a patient, “What’s wrong?” is a typical conversation starter, and conversations tend to revolve around problems, failures, and negative experiences. Positive psychiatry posits that there is therapeutic benefit to emphasizing and exploring a patient’s positive emotions, experiences, and aspirations. Questions such as “What was your sense of well-being this week? What is your goal for today’s session? What is your goal for the coming week?” can reorient a session towards an individual’s potential and promote exploration of what’s possible.

To promote a positive orientation, clinicians may consider integrating the Savoring and Three Good Things exercises—2 well-studied interventions—into their repertoire to activate and enhance positive emotional states such as gratitude and joy.⁶ An example of a Savoring activity is taking a 20-minute daily walk while trying to notice as many positive elements as possible. Similarly, the Three Good Things exercise, in which patients are asked to notice and write down 3 positive events and reflect on why they happened, promotes positive reflection and gratitude. A 14-day daily diary study conducted during the COVID-19 pandemic found that higher levels of gratitude were associated with higher levels of positive affect, lower levels of perceived stress related to COVID-19, and better subjective health.⁷ In addition to coping with life’s negative events, deliberately enhancing the impact of good things is a positive emotion amplifier. As French writer François de La Rochefoucauld argued, “Happiness does not consist in things themselves but in the relish we have of them.”⁸

Continue to: Harness strengths

Harness strengths

A growing body of evidence suggests that in addition to focusing on a patient’s chief concern, identifying and cultivating an individual’s signature strengths can mitigate stress and enhance well-being. Signature strengths are positive personality qualities that reflect our core identity and are morally valued. The VIA Character Strengths Survey is the most used and validated psychometric instrument to measure and identify signature strengths such as curiosity, self-regulation, honesty, and teamwork.⁹

To incorporate this tool into clinical practice, ask patients to complete a strengths survey using a validated assessment tool such as the VIA survey (www.viacharacter.org). After a patient identifies their signature strengths, encourage them to explore and apply these strengths in everyday life and in new ways. In addition to becoming aware of and using their signature strengths, encourage patients to “strengths spot” in others. “What strengths did you notice your coworker, family, or friend using today?” is a potential question to explore with patients. A strengths-based approach may be particularly helpful in uncovering motivation and fully engaging patients in treatment. Moreover, integrating strengths into the typically negatively skewed narrative underscores to patients that therapy isn’t only about untwisting distorted thinking, but also about harnessing one’s strengths, talents, and abilities. Strengths expressed through pragmatic actions can boost coping skills as well as enhance well-being.

Mobilize values

Value affirmation exercises have been shown to generate lasting benefits in creating positive feelings and behaviors.¹⁰ Encouraging patients to think about what they genuinely value redirects their gaze towards possibility and diverts self-focus. For instance, ask a patient to identify 2 or 3 values and write about why they are important. By reflecting on their values in writing, they affirm their identity and self-worth, thus creating a virtuous cycle of confidence, effort, and achievement. People who put their values front and center are more attuned to the needs of others as well as their own needs, and they make better connections.¹¹ Including a patient’s values in the treatment plan may increase problem-solving skills, boost motivation, and build better stress management skills.

The “life review” is another intervention that facilitates exploration of a patient’s values. This exercise involves asking patients to recount the story of their life and the experiences that were most meaningful to them. This process allows clinicians to gain a deeper understanding of the patient’s values, which can help guide treatment. Meta-analytic evidence has demonstrated these reminiscence-based interventions have significant effects on well-being.⁶ As Mahatma Gandhi famously said, “Happiness is when what you think, what you say, and what you do are in harmony.” Creating more overlap between a patient’s values and their everyday actions and behaviors bolsters resilience, buffers against stress, and can restore a healthier self-concept.

Cultivate social connections

Social connection is recognized as a core psycho­logical need and essential for well-being. The opposite of connection—social isolation—has negative effects on overall health, including increases in inflammatory markers, depression rates, and even all-cause mortality.¹² A 2015 meta-analytic review demonstrated that loneliness increased the likelihood of mortality by 26%—a similar increase as seen with smoking 15 cigarettes a day.¹³

Continue to: As with any vital sign...

As with any vital sign, exploring a patient’s number of social contacts, quantity of social visits per week, and quality of relationships is an important indicator of health. Giving patients tools to cultivate social connection and deepen their relationships can enhance therapeutic outcomes. Asking patients to perform acts of kindness is one example of a “social prescription.” Feeding a stranger’s parking meter, picking up litter, helping a friend with a chore, providing a meal to a person in need, and volunteering are potential ways for patients to engage in kind deeds. After each act, encourage the patient to write down what they did and how it made them feel.

“Prescribing” positive communication is another way to enhance a patient’s social connections. For instance, teaching them about active constructive responding (ACR)—responding with enthusiasm when another person shares information or good news—has been shown to strengthen bonds with friends and family.¹⁴ Making eye contact, giving the other person one’s full attention, inquiring about details, and responding with enthusiasm and interest are simple ways patients can apply ACR in their daily lives. Counseling a patient on increasing social connections, prescribing connections, and inquiring about quantity and quality of social interactions can help them not only add years to their life but also add health and well-being to those years.

Optimize healthy habits

Mounting research demonstrates that exercise, sleep, and nutrition are important for well-being. Evidence shows that therapeutic lifestyle changes can reduce depressive symptoms and boost positive feelings. Numerous meta-analyses have demonstrated the benefits of sleep and exercise interventions for reducing depressive symptoms in psychiatric patients.^15,16 Longitudinal studies have provided evidence that healthy diets increase happiness, even after controlling for potential confounders such as socioeconomic factors.¹⁷ Other lifestyle factors—including financial stability, pet ownership, decreased social media use, and spending time in nature—have been shown to contribute to well-being.¹⁸

Despite the substantial evidence that lifestyle factors can improve health outcomes, few clinicians ask about, focus on, or promote positive habits.¹⁹ Positive psychiatry seeks to reorient clinicians towards lifestyle factors that enhance well-being. Clinicians can deploy a variety of strategies to support patients in making healthy and sustainable changes. Assessing readiness for change, motivational interviewing, setting SMART (specific, measurable, assignable, realistic, and time-related) goals, and referring patients to relevant community resources are ways to encourage and promote therapeutic lifestyle changes. Inquiring about a patient’s typical day—such as how they spend their free time, what they eat, when they go to bed, and how much time they spend outdoors—opens conversations about general well-being and shows the patient that therapy is about the whole person, and not only symptom management. Helping patients have better days can empower them to lead more satisfied lives.²⁰

The Table^6,17,21-23 summarizes the scientific evidence for the strategies described in this article. The Figure provides a flowchart for using these strategies in clinical practice.

Continue to: Balancing pathogenesis with salutogenesis

By exploring and emphasizing potential and possibility, positive psychiatry aims to create a balance between pathogenesis (the study and understanding of disease) with salutogenesis (the study and creation of health²⁴). Clinicians are well positioned to manage symptoms and bolster positive states. Rather than an either/or approach to well-being, positive psychiatry strives for a both/and approach to well-being. By adding positive interventions to their toolbox, clinicians can expand the range of treatment options, better engage patients in the treatment process, and bolster mental health.

Bottom Line

Clinicians can integrate the tools and principles of positive psychiatry into clinical practice. Teaching patients to adopt a positive orientation, harness strengths, mobilize values, cultivate social connections, and optimize healthy habits can not only provide a counterweight to the traditional emphasis on illness, but also can enhance the range and richness of patients’ everyday experience.

Related Resources

• University of Pennsylvania. Authentic happiness. https://www.authentichappiness.sas.upenn.edu
• Jeste DV, Palmer BW (eds). Positive Psychiatry: A Clinical Handbook. American Psychiatric Publishing; 2015.
• Jeste DV, Palmer BW, Rettew DC, et al. Positive psychiatry: its time has come. J Clin Psychiatry. 2015;76(6):675-683.

FIRST OF 4 PARTS

What does wellness mean to you? A 2018 survey posed this question to more than 6,000 people living with depression and bipolar disorder. In addition to better treatment and greater understanding of their illnesses, other priorities emerged: a longing for better days, a sense of purpose, and a longing to function well and be happy.¹ As one respondent explained, “Wellness means stability; well enough to hold a job, well enough to enjoy activities, well enough to feel joy and hope.” Traditional treatment that focuses on alleviating symptoms may not sufficiently address outcomes patients value. When the focus is primarily deficit-based, clinicians and patients may miss opportunities for optimization and transformation.

Positive psychiatry is the science and practice of psychiatry that seeks to enhance and promote well-being and health through the enhancement of positive psychosocial factors such as resilience, optimism, wisdom, and social support in people with illnesses or disabilities as well as those in the community at large.² It is based on the principles that there is no health without mental health, and that mental health can improve through preventive, therapeutic, and rehabilitative interventions.³

Positive interventions are defined as “treatment methods or intentional activities that aim to cultivate positive feelings, behaviors, or cognitions.”⁴ They are evidence-based intentional exercises designed to increase well-being and enhance flourishing. Although positive interventions were originally studied as activities for nonclinical populations and for helping healthy people thrive, they are increasingly being valued for their therapeutic role in treating psychopathology.⁵ By adding positive interventions to their toolbox, psychiatrists can expand the range of treatment options, better engage patients during the treatment process, and bolster positive mental health.

In this article, we provide practical ways to integrate the tools and principles of positive psychiatry into everyday clinical practice. The goal is to broaden how clinicians think about mental health and therapeutic options and, above all, enhance our patients’ everyday well-being. Teaching patients to adopt a positive orientation, harness strengths, mobilize values, cultivate social connections, and optimize healthy habits are strategies clinicians can apply not only to provide a counterweight to the traditional emphasis on illness, but also to enhance the range and richness of their patients’ everyday experience.

Adopt a positive orientation

When a clinician first meets a patient, “What’s wrong?” is a typical conversation starter, and conversations tend to revolve around problems, failures, and negative experiences. Positive psychiatry posits that there is therapeutic benefit to emphasizing and exploring a patient’s positive emotions, experiences, and aspirations. Questions such as “What was your sense of well-being this week? What is your goal for today’s session? What is your goal for the coming week?” can reorient a session towards an individual’s potential and promote exploration of what’s possible.

To promote a positive orientation, clinicians may consider integrating the Savoring and Three Good Things exercises—2 well-studied interventions—into their repertoire to activate and enhance positive emotional states such as gratitude and joy.⁶ An example of a Savoring activity is taking a 20-minute daily walk while trying to notice as many positive elements as possible. Similarly, the Three Good Things exercise, in which patients are asked to notice and write down 3 positive events and reflect on why they happened, promotes positive reflection and gratitude. A 14-day daily diary study conducted during the COVID-19 pandemic found that higher levels of gratitude were associated with higher levels of positive affect, lower levels of perceived stress related to COVID-19, and better subjective health.⁷ In addition to coping with life’s negative events, deliberately enhancing the impact of good things is a positive emotion amplifier. As French writer François de La Rochefoucauld argued, “Happiness does not consist in things themselves but in the relish we have of them.”⁸

Continue to: Harness strengths

Harness strengths

A growing body of evidence suggests that in addition to focusing on a patient’s chief concern, identifying and cultivating an individual’s signature strengths can mitigate stress and enhance well-being. Signature strengths are positive personality qualities that reflect our core identity and are morally valued. The VIA Character Strengths Survey is the most used and validated psychometric instrument to measure and identify signature strengths such as curiosity, self-regulation, honesty, and teamwork.⁹

To incorporate this tool into clinical practice, ask patients to complete a strengths survey using a validated assessment tool such as the VIA survey (www.viacharacter.org). After a patient identifies their signature strengths, encourage them to explore and apply these strengths in everyday life and in new ways. In addition to becoming aware of and using their signature strengths, encourage patients to “strengths spot” in others. “What strengths did you notice your coworker, family, or friend using today?” is a potential question to explore with patients. A strengths-based approach may be particularly helpful in uncovering motivation and fully engaging patients in treatment. Moreover, integrating strengths into the typically negatively skewed narrative underscores to patients that therapy isn’t only about untwisting distorted thinking, but also about harnessing one’s strengths, talents, and abilities. Strengths expressed through pragmatic actions can boost coping skills as well as enhance well-being.

Mobilize values

Value affirmation exercises have been shown to generate lasting benefits in creating positive feelings and behaviors.¹⁰ Encouraging patients to think about what they genuinely value redirects their gaze towards possibility and diverts self-focus. For instance, ask a patient to identify 2 or 3 values and write about why they are important. By reflecting on their values in writing, they affirm their identity and self-worth, thus creating a virtuous cycle of confidence, effort, and achievement. People who put their values front and center are more attuned to the needs of others as well as their own needs, and they make better connections.¹¹ Including a patient’s values in the treatment plan may increase problem-solving skills, boost motivation, and build better stress management skills.

The “life review” is another intervention that facilitates exploration of a patient’s values. This exercise involves asking patients to recount the story of their life and the experiences that were most meaningful to them. This process allows clinicians to gain a deeper understanding of the patient’s values, which can help guide treatment. Meta-analytic evidence has demonstrated these reminiscence-based interventions have significant effects on well-being.⁶ As Mahatma Gandhi famously said, “Happiness is when what you think, what you say, and what you do are in harmony.” Creating more overlap between a patient’s values and their everyday actions and behaviors bolsters resilience, buffers against stress, and can restore a healthier self-concept.

Cultivate social connections

Social connection is recognized as a core psycho­logical need and essential for well-being. The opposite of connection—social isolation—has negative effects on overall health, including increases in inflammatory markers, depression rates, and even all-cause mortality.¹² A 2015 meta-analytic review demonstrated that loneliness increased the likelihood of mortality by 26%—a similar increase as seen with smoking 15 cigarettes a day.¹³

Continue to: As with any vital sign...

As with any vital sign, exploring a patient’s number of social contacts, quantity of social visits per week, and quality of relationships is an important indicator of health. Giving patients tools to cultivate social connection and deepen their relationships can enhance therapeutic outcomes. Asking patients to perform acts of kindness is one example of a “social prescription.” Feeding a stranger’s parking meter, picking up litter, helping a friend with a chore, providing a meal to a person in need, and volunteering are potential ways for patients to engage in kind deeds. After each act, encourage the patient to write down what they did and how it made them feel.

“Prescribing” positive communication is another way to enhance a patient’s social connections. For instance, teaching them about active constructive responding (ACR)—responding with enthusiasm when another person shares information or good news—has been shown to strengthen bonds with friends and family.¹⁴ Making eye contact, giving the other person one’s full attention, inquiring about details, and responding with enthusiasm and interest are simple ways patients can apply ACR in their daily lives. Counseling a patient on increasing social connections, prescribing connections, and inquiring about quantity and quality of social interactions can help them not only add years to their life but also add health and well-being to those years.

Optimize healthy habits

Mounting research demonstrates that exercise, sleep, and nutrition are important for well-being. Evidence shows that therapeutic lifestyle changes can reduce depressive symptoms and boost positive feelings. Numerous meta-analyses have demonstrated the benefits of sleep and exercise interventions for reducing depressive symptoms in psychiatric patients.^15,16 Longitudinal studies have provided evidence that healthy diets increase happiness, even after controlling for potential confounders such as socioeconomic factors.¹⁷ Other lifestyle factors—including financial stability, pet ownership, decreased social media use, and spending time in nature—have been shown to contribute to well-being.¹⁸

Despite the substantial evidence that lifestyle factors can improve health outcomes, few clinicians ask about, focus on, or promote positive habits.¹⁹ Positive psychiatry seeks to reorient clinicians towards lifestyle factors that enhance well-being. Clinicians can deploy a variety of strategies to support patients in making healthy and sustainable changes. Assessing readiness for change, motivational interviewing, setting SMART (specific, measurable, assignable, realistic, and time-related) goals, and referring patients to relevant community resources are ways to encourage and promote therapeutic lifestyle changes. Inquiring about a patient’s typical day—such as how they spend their free time, what they eat, when they go to bed, and how much time they spend outdoors—opens conversations about general well-being and shows the patient that therapy is about the whole person, and not only symptom management. Helping patients have better days can empower them to lead more satisfied lives.²⁰

The Table^6,17,21-23 summarizes the scientific evidence for the strategies described in this article. The Figure provides a flowchart for using these strategies in clinical practice.

Continue to: Balancing pathogenesis with salutogenesis

By exploring and emphasizing potential and possibility, positive psychiatry aims to create a balance between pathogenesis (the study and understanding of disease) with salutogenesis (the study and creation of health²⁴). Clinicians are well positioned to manage symptoms and bolster positive states. Rather than an either/or approach to well-being, positive psychiatry strives for a both/and approach to well-being. By adding positive interventions to their toolbox, clinicians can expand the range of treatment options, better engage patients in the treatment process, and bolster mental health.

Bottom Line

Clinicians can integrate the tools and principles of positive psychiatry into clinical practice. Teaching patients to adopt a positive orientation, harness strengths, mobilize values, cultivate social connections, and optimize healthy habits can not only provide a counterweight to the traditional emphasis on illness, but also can enhance the range and richness of patients’ everyday experience.

Related Resources

• University of Pennsylvania. Authentic happiness. https://www.authentichappiness.sas.upenn.edu
• Jeste DV, Palmer BW (eds). Positive Psychiatry: A Clinical Handbook. American Psychiatric Publishing; 2015.
• Jeste DV, Palmer BW, Rettew DC, et al. Positive psychiatry: its time has come. J Clin Psychiatry. 2015;76(6):675-683.