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Treatment costs threaten cancer program growth
Treatment costs are the greatest threat to the growth of cancer programs, according to a survey of nearly 300 cancer program administrators and providers.
Sixty-eight percent of survey respondents said treatment costs were among the biggest threats to future cancer program growth at their organization.
Other top threats to growth included physician alignment around services and program goals—cited by 47% of respondents—and changes in healthcare coverage—cited by 46%.
This survey—the “2017 Trending Now in Cancer Care Survey”—was conducted by the Association of Community Cancer Centers (ACCC) and Advisory Board’s Oncology Roundtable. It was supported by Pfizer Oncology.
The survey was distributed via email on July 24, 2017. Respondents included 293 cancer program administrators and providers from 209 institutions. They submitted responses over 6 weeks.
Respondents identified the following “biggest threats” to cancer program growth:
- Cost of drugs and/or new treatment modalities—68%
- Physician alignment around services and program goals—47%
- Changes in healthcare coverage—46%
- Cuts to fee-for-service reimbursement—44%
- Shifting reimbursement to value-based care—43%
- Marketplace competition—35%
- Workforce planning (eg, managing staff shortages)—34%
- Network strategy and integration—33%
- Site of care policies issued by private payers—27%
- Access to capital—26%
- Quality reporting requirements—22%
- Health information technology—21%
- Other—6%.
When asked to identify their greatest opportunities for cost savings, respondents overwhelmingly pointed toward clinical standardization (63%) and drugs (62%).
Other opportunities included:
- Supplies—28%
- Capital expenses (eg, imaging technology)—24%
- Non-clinical staff (eg, billing and coding specialists)—22%
- Technology maintenance—20%
- Clinical staff—16%
- Retail pharmacy—14%
- Clinical research—10%
- Support services (eg, acupuncture)—9%
- Other—4%.
Respondents also said the investments most likely to yield a return for their cancer program were:
- Increasing the number of sub-specialists (eg, breast surgeons)—59%
- Marketing—41%
- Specialty pharmacy—36%
- Increasing the number of general oncology physicians—34%
- Screening services (eg, mobile screening unit)—29%
- Capital investments—24%
- Clinical research—16%
- Support services—15%
- Retail pharmacy—14%
- Building upgrades—14%.
More details on the “2017 Trending Now in Cancer Care Survey” can be found on the ACCC website. 
Treatment costs are the greatest threat to the growth of cancer programs, according to a survey of nearly 300 cancer program administrators and providers.
Sixty-eight percent of survey respondents said treatment costs were among the biggest threats to future cancer program growth at their organization.
Other top threats to growth included physician alignment around services and program goals—cited by 47% of respondents—and changes in healthcare coverage—cited by 46%.
This survey—the “2017 Trending Now in Cancer Care Survey”—was conducted by the Association of Community Cancer Centers (ACCC) and Advisory Board’s Oncology Roundtable. It was supported by Pfizer Oncology.
The survey was distributed via email on July 24, 2017. Respondents included 293 cancer program administrators and providers from 209 institutions. They submitted responses over 6 weeks.
Respondents identified the following “biggest threats” to cancer program growth:
- Cost of drugs and/or new treatment modalities—68%
- Physician alignment around services and program goals—47%
- Changes in healthcare coverage—46%
- Cuts to fee-for-service reimbursement—44%
- Shifting reimbursement to value-based care—43%
- Marketplace competition—35%
- Workforce planning (eg, managing staff shortages)—34%
- Network strategy and integration—33%
- Site of care policies issued by private payers—27%
- Access to capital—26%
- Quality reporting requirements—22%
- Health information technology—21%
- Other—6%.
When asked to identify their greatest opportunities for cost savings, respondents overwhelmingly pointed toward clinical standardization (63%) and drugs (62%).
Other opportunities included:
- Supplies—28%
- Capital expenses (eg, imaging technology)—24%
- Non-clinical staff (eg, billing and coding specialists)—22%
- Technology maintenance—20%
- Clinical staff—16%
- Retail pharmacy—14%
- Clinical research—10%
- Support services (eg, acupuncture)—9%
- Other—4%.
Respondents also said the investments most likely to yield a return for their cancer program were:
- Increasing the number of sub-specialists (eg, breast surgeons)—59%
- Marketing—41%
- Specialty pharmacy—36%
- Increasing the number of general oncology physicians—34%
- Screening services (eg, mobile screening unit)—29%
- Capital investments—24%
- Clinical research—16%
- Support services—15%
- Retail pharmacy—14%
- Building upgrades—14%.
More details on the “2017 Trending Now in Cancer Care Survey” can be found on the ACCC website.
Treatment costs are the greatest threat to the growth of cancer programs, according to a survey of nearly 300 cancer program administrators and providers.
Sixty-eight percent of survey respondents said treatment costs were among the biggest threats to future cancer program growth at their organization.
Other top threats to growth included physician alignment around services and program goals—cited by 47% of respondents—and changes in healthcare coverage—cited by 46%.
This survey—the “2017 Trending Now in Cancer Care Survey”—was conducted by the Association of Community Cancer Centers (ACCC) and Advisory Board’s Oncology Roundtable. It was supported by Pfizer Oncology.
The survey was distributed via email on July 24, 2017. Respondents included 293 cancer program administrators and providers from 209 institutions. They submitted responses over 6 weeks.
Respondents identified the following “biggest threats” to cancer program growth:
- Cost of drugs and/or new treatment modalities—68%
- Physician alignment around services and program goals—47%
- Changes in healthcare coverage—46%
- Cuts to fee-for-service reimbursement—44%
- Shifting reimbursement to value-based care—43%
- Marketplace competition—35%
- Workforce planning (eg, managing staff shortages)—34%
- Network strategy and integration—33%
- Site of care policies issued by private payers—27%
- Access to capital—26%
- Quality reporting requirements—22%
- Health information technology—21%
- Other—6%.
When asked to identify their greatest opportunities for cost savings, respondents overwhelmingly pointed toward clinical standardization (63%) and drugs (62%).
Other opportunities included:
- Supplies—28%
- Capital expenses (eg, imaging technology)—24%
- Non-clinical staff (eg, billing and coding specialists)—22%
- Technology maintenance—20%
- Clinical staff—16%
- Retail pharmacy—14%
- Clinical research—10%
- Support services (eg, acupuncture)—9%
- Other—4%.
Respondents also said the investments most likely to yield a return for their cancer program were:
- Increasing the number of sub-specialists (eg, breast surgeons)—59%
- Marketing—41%
- Specialty pharmacy—36%
- Increasing the number of general oncology physicians—34%
- Screening services (eg, mobile screening unit)—29%
- Capital investments—24%
- Clinical research—16%
- Support services—15%
- Retail pharmacy—14%
- Building upgrades—14%.
More details on the “2017 Trending Now in Cancer Care Survey” can be found on the ACCC website.
VIDEO: Practice changers out of ASH 2017
ATLANTA – There were a lot of new data presented during the annual meeting of the American Society of Hematology. But what findings could actually change the way you practice?
Robert A. Brodsky, MD, director of the division of hematology at Johns Hopkins University in Baltimore and the moderator for the late-breaking abstract session at ASH, highlighted results from two studies.
Data from the MURANO trial showed robust results for a combination of venetoclax and rituximab in patients with relapsed/refractory chronic lymphocytic leukemia (CLL). At a median follow-up of 23.8 months, median progression-free survival -had not been reached in patients randomized to venetoclax/rituximab, while patients who received bendamustine plus rituximab had a median PFS of 17 months.
The based on the data presented, Dr. Brodsky said.
Another “enormously exciting and practice-changing” finding is that direct oral anticoagulants can be used safely in patients with cancer, Dr. Brodsky said in an interview.
In a randomized, open-label study, 12 months of daily treatment with edoxaban was noninferior to standard subcutaneous therapy with dalteparin for treatment of venous thromboembolism in cancer patients.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
ATLANTA – There were a lot of new data presented during the annual meeting of the American Society of Hematology. But what findings could actually change the way you practice?
Robert A. Brodsky, MD, director of the division of hematology at Johns Hopkins University in Baltimore and the moderator for the late-breaking abstract session at ASH, highlighted results from two studies.
Data from the MURANO trial showed robust results for a combination of venetoclax and rituximab in patients with relapsed/refractory chronic lymphocytic leukemia (CLL). At a median follow-up of 23.8 months, median progression-free survival -had not been reached in patients randomized to venetoclax/rituximab, while patients who received bendamustine plus rituximab had a median PFS of 17 months.
The based on the data presented, Dr. Brodsky said.
Another “enormously exciting and practice-changing” finding is that direct oral anticoagulants can be used safely in patients with cancer, Dr. Brodsky said in an interview.
In a randomized, open-label study, 12 months of daily treatment with edoxaban was noninferior to standard subcutaneous therapy with dalteparin for treatment of venous thromboembolism in cancer patients.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
ATLANTA – There were a lot of new data presented during the annual meeting of the American Society of Hematology. But what findings could actually change the way you practice?
Robert A. Brodsky, MD, director of the division of hematology at Johns Hopkins University in Baltimore and the moderator for the late-breaking abstract session at ASH, highlighted results from two studies.
Data from the MURANO trial showed robust results for a combination of venetoclax and rituximab in patients with relapsed/refractory chronic lymphocytic leukemia (CLL). At a median follow-up of 23.8 months, median progression-free survival -had not been reached in patients randomized to venetoclax/rituximab, while patients who received bendamustine plus rituximab had a median PFS of 17 months.
The based on the data presented, Dr. Brodsky said.
Another “enormously exciting and practice-changing” finding is that direct oral anticoagulants can be used safely in patients with cancer, Dr. Brodsky said in an interview.
In a randomized, open-label study, 12 months of daily treatment with edoxaban was noninferior to standard subcutaneous therapy with dalteparin for treatment of venous thromboembolism in cancer patients.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
REPORTING FROM ASH 2017
CLL drug in limited supply outside U.S.
Ofatumumab (Arzerra), a monoclonal antibody treatment for chronic lymphocytic leukemia, will soon be available outside the United States through compassionate use programs only. The drug will continue to be widely available in the United States.
Novartis announced in January that it would begin limiting the availability of the drug outside of the United States and would work with regulatory authorities to set up compassionate use programs for patients who are currently being treated with the drug. Patients who use these programs will receive the drug for free.
The decision was driven by the surge in CLL drugs that have become available over the last 5 years, according to Novartis.
The decision to pull the drug from international markets will not affect its use in ongoing clinical trials, particularly two phase 3 studies in relapsing multiple sclerosis and indolent non-Hodgkin lymphoma.
Ofatumumab (Arzerra), a monoclonal antibody treatment for chronic lymphocytic leukemia, will soon be available outside the United States through compassionate use programs only. The drug will continue to be widely available in the United States.
Novartis announced in January that it would begin limiting the availability of the drug outside of the United States and would work with regulatory authorities to set up compassionate use programs for patients who are currently being treated with the drug. Patients who use these programs will receive the drug for free.
The decision was driven by the surge in CLL drugs that have become available over the last 5 years, according to Novartis.
The decision to pull the drug from international markets will not affect its use in ongoing clinical trials, particularly two phase 3 studies in relapsing multiple sclerosis and indolent non-Hodgkin lymphoma.
Ofatumumab (Arzerra), a monoclonal antibody treatment for chronic lymphocytic leukemia, will soon be available outside the United States through compassionate use programs only. The drug will continue to be widely available in the United States.
Novartis announced in January that it would begin limiting the availability of the drug outside of the United States and would work with regulatory authorities to set up compassionate use programs for patients who are currently being treated with the drug. Patients who use these programs will receive the drug for free.
The decision was driven by the surge in CLL drugs that have become available over the last 5 years, according to Novartis.
The decision to pull the drug from international markets will not affect its use in ongoing clinical trials, particularly two phase 3 studies in relapsing multiple sclerosis and indolent non-Hodgkin lymphoma.
Emergent colectomies for ulcerative colitis declining
LAS VEGAS – , a large database analysis has shown.
“Despite advances in medical therapy for ulcerative colitis (UC), many patients still need surgery,” Ryan C. Ungaro, MD, said at the Crohn’s & Colitis Congress, a partnership of the Crohn’s & Colitis Foundation and the American Gastroenterological Association. “Prior epidemiologic studies have demonstrated a decline in colectomy rates over time, particularly comparing the pre- and postbiologic eras, but less is known about rates of emergent colectomy over time,” he said. In particular, he continued, data on UC colectomy and ileal pouch anal anastomosis (IPAA) surgery rates in the United States are limited.
In an effort to examine UC emergent colectomy rates and IPAA over time, Dr. Ungaro, of the division of gastroenterology at the Icahn School of Medicine at Mount Sinai, New York, and his associates analyzed data from the U.S. Nationwide Inpatient Sample from 2000 through 2014. They defined emergent colectomy cases as admission through the emergency department and used the ICD-9-CM code for subtotal colectomy (45.8) as the outcome variable, and defined a second cohort of UC patients admitted electively with an outcome variable of ICD-9-CM code for IPAA (45.95). To evaluate temporal trends of colectomy and IPAA, the researchers used joinpoint regression analysis with calculation of annual percentage change.
They also observed disparities in IPAA surgery rates based on race and insurance type. Specifically, whites had higher rates of elective IPAA during the study period, compared with black or Hispanic patients (P less than .01), while patients with private insurance had higher rates of elective IPAA, compared with those insured by Medicare or Medicaid (P less than .01). Dr. Ungaro acknowledged certain limitations of the study, including the fact that the Nationwide Inpatient Sample relies on administrative codes, “which may increase risk of misclassification bias,” he said. They were also unable to track individual patients across time and lacked data on medication use and disease severity.
“There has been a significant decline in emergency colectomy for ulcerative colitis in the United States,” Dr. Ungaro concluded. “We expect that this is due to more effective inpatient care. However, the overall need for surgery in UC appears to be stable given unchanged IPAA rates. This suggests a limited impact on overall surgery rates with a shift from emergent to elective procedures.” He reported having no relevant financial disclosures.
*This story was updated on 3/26.
SOURCE: Ungaro RC et al. Crohn’s & Colitis Congress, Clinical Abstract 23.
LAS VEGAS – , a large database analysis has shown.
“Despite advances in medical therapy for ulcerative colitis (UC), many patients still need surgery,” Ryan C. Ungaro, MD, said at the Crohn’s & Colitis Congress, a partnership of the Crohn’s & Colitis Foundation and the American Gastroenterological Association. “Prior epidemiologic studies have demonstrated a decline in colectomy rates over time, particularly comparing the pre- and postbiologic eras, but less is known about rates of emergent colectomy over time,” he said. In particular, he continued, data on UC colectomy and ileal pouch anal anastomosis (IPAA) surgery rates in the United States are limited.
In an effort to examine UC emergent colectomy rates and IPAA over time, Dr. Ungaro, of the division of gastroenterology at the Icahn School of Medicine at Mount Sinai, New York, and his associates analyzed data from the U.S. Nationwide Inpatient Sample from 2000 through 2014. They defined emergent colectomy cases as admission through the emergency department and used the ICD-9-CM code for subtotal colectomy (45.8) as the outcome variable, and defined a second cohort of UC patients admitted electively with an outcome variable of ICD-9-CM code for IPAA (45.95). To evaluate temporal trends of colectomy and IPAA, the researchers used joinpoint regression analysis with calculation of annual percentage change.
They also observed disparities in IPAA surgery rates based on race and insurance type. Specifically, whites had higher rates of elective IPAA during the study period, compared with black or Hispanic patients (P less than .01), while patients with private insurance had higher rates of elective IPAA, compared with those insured by Medicare or Medicaid (P less than .01). Dr. Ungaro acknowledged certain limitations of the study, including the fact that the Nationwide Inpatient Sample relies on administrative codes, “which may increase risk of misclassification bias,” he said. They were also unable to track individual patients across time and lacked data on medication use and disease severity.
“There has been a significant decline in emergency colectomy for ulcerative colitis in the United States,” Dr. Ungaro concluded. “We expect that this is due to more effective inpatient care. However, the overall need for surgery in UC appears to be stable given unchanged IPAA rates. This suggests a limited impact on overall surgery rates with a shift from emergent to elective procedures.” He reported having no relevant financial disclosures.
*This story was updated on 3/26.
SOURCE: Ungaro RC et al. Crohn’s & Colitis Congress, Clinical Abstract 23.
LAS VEGAS – , a large database analysis has shown.
“Despite advances in medical therapy for ulcerative colitis (UC), many patients still need surgery,” Ryan C. Ungaro, MD, said at the Crohn’s & Colitis Congress, a partnership of the Crohn’s & Colitis Foundation and the American Gastroenterological Association. “Prior epidemiologic studies have demonstrated a decline in colectomy rates over time, particularly comparing the pre- and postbiologic eras, but less is known about rates of emergent colectomy over time,” he said. In particular, he continued, data on UC colectomy and ileal pouch anal anastomosis (IPAA) surgery rates in the United States are limited.
In an effort to examine UC emergent colectomy rates and IPAA over time, Dr. Ungaro, of the division of gastroenterology at the Icahn School of Medicine at Mount Sinai, New York, and his associates analyzed data from the U.S. Nationwide Inpatient Sample from 2000 through 2014. They defined emergent colectomy cases as admission through the emergency department and used the ICD-9-CM code for subtotal colectomy (45.8) as the outcome variable, and defined a second cohort of UC patients admitted electively with an outcome variable of ICD-9-CM code for IPAA (45.95). To evaluate temporal trends of colectomy and IPAA, the researchers used joinpoint regression analysis with calculation of annual percentage change.
They also observed disparities in IPAA surgery rates based on race and insurance type. Specifically, whites had higher rates of elective IPAA during the study period, compared with black or Hispanic patients (P less than .01), while patients with private insurance had higher rates of elective IPAA, compared with those insured by Medicare or Medicaid (P less than .01). Dr. Ungaro acknowledged certain limitations of the study, including the fact that the Nationwide Inpatient Sample relies on administrative codes, “which may increase risk of misclassification bias,” he said. They were also unable to track individual patients across time and lacked data on medication use and disease severity.
“There has been a significant decline in emergency colectomy for ulcerative colitis in the United States,” Dr. Ungaro concluded. “We expect that this is due to more effective inpatient care. However, the overall need for surgery in UC appears to be stable given unchanged IPAA rates. This suggests a limited impact on overall surgery rates with a shift from emergent to elective procedures.” He reported having no relevant financial disclosures.
*This story was updated on 3/26.
SOURCE: Ungaro RC et al. Crohn’s & Colitis Congress, Clinical Abstract 23.
REPORTING FROM THE CROHN’S & COLITIS CONGRESS
Key clinical point: There has been a significant decline in emergent ulcerative colitis colectomies in the United States.
Major finding: Between 2000 and 2014, the colectomy rate among patients emergently admitted to the hospital declined more than 7% annually (P less than .05).
Study details: An analysis of 470,720 hospital admissions from the Nationwide Inpatient Sample.
Disclosures: Dr. Ungaro reported having no financial disclosures.
Source: Ungaro RC et al. Crohn’s & Colitis Congress, Clinical Abstract 23.
Shorter walk test predicts IPF outcomes
, based on data from 179 adults. The findings were presented at the CHEST annual meeting.
The 6-minute test is often used to evaluate functional capacity in IPF patients, but is not always practical in a busy clinic setting, according to Flavia S. Nunes, MD, of Inova Fairfax Hospital in Falls Church, VA, and colleagues.
“Among the clinical and physiologic predictors associated with survival in IPF, the 6MWT has been increasingly used over the past 5 years as a secondary endpoint in the efficacy analyses of potential therapies for IPF. Validation of shorter time of walking might make the test more feasible to be applied in routine clinical care,” she said.
To determine the predictive value of the first minute of the 6-minute test, the researchers reviewed data from 142 men and 37 women at a tertiary referral center between May 2010 and February 2017. The average age of the patients was 68 years, the average body mass index was 28.3 kg/m2, and 27% used oxygen supplementation during the walk test.
Overall, the mean distance for the 6-minute test was 372 m, and the average distance for the 1-minute test was 65 m. Study participants who achieved a 6-minute walk distance greater than 372 m were defined as high walkers, and those with a 6-minute walk distance less than 372 m were defined as low walkers. A strong correlation appeared between the 6-minute distance and 1-minute distance in terms of predicting survival, and 1-year transplant-free survival was significantly better in high walkers than in low walkers (27 months vs. 22 months; P = .015).
Dr. Nunes said she was not surprised by the results, in part because previous research has shown a strong correlation among 2-minute, 6-minute, and 12-minute walking tests.
Although more research is needed to validate the findings, the results suggest that the 1-minute test might be a practical substitute for the 6-minute test by providing similar prognostic information more quickly and easily than the 6-minute test, the researchers said.
“It is important for clinicians to know that the time chosen to assess exercise tolerance by walking tests might not be critical,” said Dr. Nunes. “Shorter walks are not only less time consuming, and easier for both patients and clinicians, but are also reproducible and discriminatory of survival.
“We need to validate the test performance characteristics and prognostic value of distance walked in a 1MWT compared to the standard 6MWT in an independent cohort of patients with IPF,” Dr. Nunes noted. “Additionally, the evaluation of alternate instruction, for example changing the wording from ‘walk as far’ to ‘walk as fast’ might facilitate a better effort, and a greater distance with improved reproducibility. Other novel parameters and modifications to the 6MWT or 1MWT might further improve the utility of these tests in the management of IPF and other patients,” she added.
The researchers had no financial conflicts to disclose.
, based on data from 179 adults. The findings were presented at the CHEST annual meeting.
The 6-minute test is often used to evaluate functional capacity in IPF patients, but is not always practical in a busy clinic setting, according to Flavia S. Nunes, MD, of Inova Fairfax Hospital in Falls Church, VA, and colleagues.
“Among the clinical and physiologic predictors associated with survival in IPF, the 6MWT has been increasingly used over the past 5 years as a secondary endpoint in the efficacy analyses of potential therapies for IPF. Validation of shorter time of walking might make the test more feasible to be applied in routine clinical care,” she said.
To determine the predictive value of the first minute of the 6-minute test, the researchers reviewed data from 142 men and 37 women at a tertiary referral center between May 2010 and February 2017. The average age of the patients was 68 years, the average body mass index was 28.3 kg/m2, and 27% used oxygen supplementation during the walk test.
Overall, the mean distance for the 6-minute test was 372 m, and the average distance for the 1-minute test was 65 m. Study participants who achieved a 6-minute walk distance greater than 372 m were defined as high walkers, and those with a 6-minute walk distance less than 372 m were defined as low walkers. A strong correlation appeared between the 6-minute distance and 1-minute distance in terms of predicting survival, and 1-year transplant-free survival was significantly better in high walkers than in low walkers (27 months vs. 22 months; P = .015).
Dr. Nunes said she was not surprised by the results, in part because previous research has shown a strong correlation among 2-minute, 6-minute, and 12-minute walking tests.
Although more research is needed to validate the findings, the results suggest that the 1-minute test might be a practical substitute for the 6-minute test by providing similar prognostic information more quickly and easily than the 6-minute test, the researchers said.
“It is important for clinicians to know that the time chosen to assess exercise tolerance by walking tests might not be critical,” said Dr. Nunes. “Shorter walks are not only less time consuming, and easier for both patients and clinicians, but are also reproducible and discriminatory of survival.
“We need to validate the test performance characteristics and prognostic value of distance walked in a 1MWT compared to the standard 6MWT in an independent cohort of patients with IPF,” Dr. Nunes noted. “Additionally, the evaluation of alternate instruction, for example changing the wording from ‘walk as far’ to ‘walk as fast’ might facilitate a better effort, and a greater distance with improved reproducibility. Other novel parameters and modifications to the 6MWT or 1MWT might further improve the utility of these tests in the management of IPF and other patients,” she added.
The researchers had no financial conflicts to disclose.
, based on data from 179 adults. The findings were presented at the CHEST annual meeting.
The 6-minute test is often used to evaluate functional capacity in IPF patients, but is not always practical in a busy clinic setting, according to Flavia S. Nunes, MD, of Inova Fairfax Hospital in Falls Church, VA, and colleagues.
“Among the clinical and physiologic predictors associated with survival in IPF, the 6MWT has been increasingly used over the past 5 years as a secondary endpoint in the efficacy analyses of potential therapies for IPF. Validation of shorter time of walking might make the test more feasible to be applied in routine clinical care,” she said.
To determine the predictive value of the first minute of the 6-minute test, the researchers reviewed data from 142 men and 37 women at a tertiary referral center between May 2010 and February 2017. The average age of the patients was 68 years, the average body mass index was 28.3 kg/m2, and 27% used oxygen supplementation during the walk test.
Overall, the mean distance for the 6-minute test was 372 m, and the average distance for the 1-minute test was 65 m. Study participants who achieved a 6-minute walk distance greater than 372 m were defined as high walkers, and those with a 6-minute walk distance less than 372 m were defined as low walkers. A strong correlation appeared between the 6-minute distance and 1-minute distance in terms of predicting survival, and 1-year transplant-free survival was significantly better in high walkers than in low walkers (27 months vs. 22 months; P = .015).
Dr. Nunes said she was not surprised by the results, in part because previous research has shown a strong correlation among 2-minute, 6-minute, and 12-minute walking tests.
Although more research is needed to validate the findings, the results suggest that the 1-minute test might be a practical substitute for the 6-minute test by providing similar prognostic information more quickly and easily than the 6-minute test, the researchers said.
“It is important for clinicians to know that the time chosen to assess exercise tolerance by walking tests might not be critical,” said Dr. Nunes. “Shorter walks are not only less time consuming, and easier for both patients and clinicians, but are also reproducible and discriminatory of survival.
“We need to validate the test performance characteristics and prognostic value of distance walked in a 1MWT compared to the standard 6MWT in an independent cohort of patients with IPF,” Dr. Nunes noted. “Additionally, the evaluation of alternate instruction, for example changing the wording from ‘walk as far’ to ‘walk as fast’ might facilitate a better effort, and a greater distance with improved reproducibility. Other novel parameters and modifications to the 6MWT or 1MWT might further improve the utility of these tests in the management of IPF and other patients,” she added.
The researchers had no financial conflicts to disclose.
FROM CHEST 2017
2017 GI thought leaders
Trainee and early-career members made an impact in the GI field this past year, especially through contributing to and engaging in various collaborations via the American Gastroenterological Association’s member-only online discussion forum – the AGA Community.
We’re proud to announce that the title of 2017 top contributor is held by an early-career member: Meet Dmitriy Kedrin, MD, PhD, of Elliot Hospital in Manchester, N.H., and find out a little more about how the AGA Community is an important part of his routine in this brief Q&A session.
Thanks for being such an active member of the AGA Community! Why do you contribute?
“I think it is important for GI docs to be a part of a larger community, stay informed on the latest guidelines, research publications, and approaches to difficult cases, where more than one road can be taken. I feel that it is a great forum for someone like me, a relatively junior gastroenterologist.”
Why do you enjoy being part of the AGA Community?
“I find the case discussions informative. I learn a great deal about current trends and opinions on important topics in the GI world.”
What do you like to do in your free time?
“I bake bread and run a gastroenterology literature review podcast called ‘GI Pearls.’ ”
What’s your approach to handling a difficult patient case you come across in your practice?
“I often seek advice of other clinicians, some with more expertise in a particular area. I also go to the literature and try to learn more that way, to help expand my differential as well as figure out the best therapeutic approach.”
Was there a conversation in the AGA Community in 2017 that was your favorite?
“Oh, there were several. I recall a patient case where there were several thought leaders in the field who had a disagreement about the best approach to treatment. The work-life balance conversation was also very good. I also enjoyed reading about different opinions regarding the values of clinical versus observational trials that happened a while back.”
Here are other trainee and early-career members who made the list of top contributors in the AGA Community last year:
- Avinash Ketwaroo, MD
- Hüseyin Bozkurt, MD
- Peter Liang, MD, MPH
- Fola May, MD, PhD
- Richa Shukla, MD
- Arthur Beyder, MD, PhD
- Shazia Siddique, MD
- Brigid Boland, MD
Check the achievements section of your AGA Community profile to see whether you made the list. We look forward to seeing you all in the forum in 2018!
Trainee and early-career members made an impact in the GI field this past year, especially through contributing to and engaging in various collaborations via the American Gastroenterological Association’s member-only online discussion forum – the AGA Community.
We’re proud to announce that the title of 2017 top contributor is held by an early-career member: Meet Dmitriy Kedrin, MD, PhD, of Elliot Hospital in Manchester, N.H., and find out a little more about how the AGA Community is an important part of his routine in this brief Q&A session.
Thanks for being such an active member of the AGA Community! Why do you contribute?
“I think it is important for GI docs to be a part of a larger community, stay informed on the latest guidelines, research publications, and approaches to difficult cases, where more than one road can be taken. I feel that it is a great forum for someone like me, a relatively junior gastroenterologist.”
Why do you enjoy being part of the AGA Community?
“I find the case discussions informative. I learn a great deal about current trends and opinions on important topics in the GI world.”
What do you like to do in your free time?
“I bake bread and run a gastroenterology literature review podcast called ‘GI Pearls.’ ”
What’s your approach to handling a difficult patient case you come across in your practice?
“I often seek advice of other clinicians, some with more expertise in a particular area. I also go to the literature and try to learn more that way, to help expand my differential as well as figure out the best therapeutic approach.”
Was there a conversation in the AGA Community in 2017 that was your favorite?
“Oh, there were several. I recall a patient case where there were several thought leaders in the field who had a disagreement about the best approach to treatment. The work-life balance conversation was also very good. I also enjoyed reading about different opinions regarding the values of clinical versus observational trials that happened a while back.”
Here are other trainee and early-career members who made the list of top contributors in the AGA Community last year:
- Avinash Ketwaroo, MD
- Hüseyin Bozkurt, MD
- Peter Liang, MD, MPH
- Fola May, MD, PhD
- Richa Shukla, MD
- Arthur Beyder, MD, PhD
- Shazia Siddique, MD
- Brigid Boland, MD
Check the achievements section of your AGA Community profile to see whether you made the list. We look forward to seeing you all in the forum in 2018!
Trainee and early-career members made an impact in the GI field this past year, especially through contributing to and engaging in various collaborations via the American Gastroenterological Association’s member-only online discussion forum – the AGA Community.
We’re proud to announce that the title of 2017 top contributor is held by an early-career member: Meet Dmitriy Kedrin, MD, PhD, of Elliot Hospital in Manchester, N.H., and find out a little more about how the AGA Community is an important part of his routine in this brief Q&A session.
Thanks for being such an active member of the AGA Community! Why do you contribute?
“I think it is important for GI docs to be a part of a larger community, stay informed on the latest guidelines, research publications, and approaches to difficult cases, where more than one road can be taken. I feel that it is a great forum for someone like me, a relatively junior gastroenterologist.”
Why do you enjoy being part of the AGA Community?
“I find the case discussions informative. I learn a great deal about current trends and opinions on important topics in the GI world.”
What do you like to do in your free time?
“I bake bread and run a gastroenterology literature review podcast called ‘GI Pearls.’ ”
What’s your approach to handling a difficult patient case you come across in your practice?
“I often seek advice of other clinicians, some with more expertise in a particular area. I also go to the literature and try to learn more that way, to help expand my differential as well as figure out the best therapeutic approach.”
Was there a conversation in the AGA Community in 2017 that was your favorite?
“Oh, there were several. I recall a patient case where there were several thought leaders in the field who had a disagreement about the best approach to treatment. The work-life balance conversation was also very good. I also enjoyed reading about different opinions regarding the values of clinical versus observational trials that happened a while back.”
Here are other trainee and early-career members who made the list of top contributors in the AGA Community last year:
- Avinash Ketwaroo, MD
- Hüseyin Bozkurt, MD
- Peter Liang, MD, MPH
- Fola May, MD, PhD
- Richa Shukla, MD
- Arthur Beyder, MD, PhD
- Shazia Siddique, MD
- Brigid Boland, MD
Check the achievements section of your AGA Community profile to see whether you made the list. We look forward to seeing you all in the forum in 2018!
Nutrition early in life has long-term effects on neurodevelopment
Nutrition within the first 1,000 days of childhood are pivotal in a child’s neurodevelopment and lifelong health, according to an American Academy of Pediatrics policy statement.
“Healthy, normal neurodevelopment is a complex process involving cellular and structural changes in the brain that proceed in a specified sequence,” wrote Sara Jane Schwarzenberg, MD and Michael K. Georgieff, MD, both of the University of Minnesota Masonic Children’s Hospital, Minneapolis, and the AAP Committee on Nutrition. “Changes that are too rapid or too slow in one part of the brain may result in the failure of crucial pathway connections to other parts of the brain. Timing is crucial; once a particular developmental sequence fails, it may not be possible to retrieve all the lost function,” the investigators and committee noted in a report published in Pediatrics (Pediatrics. 2018; 141[2]:e20173716).
The importance of macronutrients was highlighted in a study of rural Guatemalan children during 1969-1989 who received high-calorie or low-calorie protein supplements. Children who received the high-calorie/high protein supplements before age 2 years had higher test scores, better reading and vocabulary skills, and faster information processing abilities, compared with their low-calorie/low-protein counterparts.
Like the low-calorie/low-protein Guatemalans, there are many populations that lack access to high-quality macronutrient sources or have access to only low-quality macronutrients. In the United States in 2015, 16.6% of households (6.4 million) were food insecure. This was even more pronounced in households with incomes below the poverty line, with 36.8% being food insecure, according to studies from the Department of Agriculture.
Food insecurity is not limited to macronutrients but extends to micronutrients such as vitamins and minerals like zinc; iron; choline; folate; iodine; vitamins A, D, B6, and B12; and long-chain polyunsaturated fatty acids. A lack of any of these micronutrients in early childhood can lead to neurodevelopmental issues later in life, Dr. Schwarzenberg, Dr. Georgieff, and the committee emphasized. An important source of micronutrients is human milk, provided by breastfeeding. Studies have shown that breastfeeding of preterm and term infants improves cognitive performance, compared with infants who consume formula (J Pediatr. 2016;177:133-9.e1; Curr Opin Pediatr. 2016;28[4]:559-66).
Because proper consumption of macronutrients and micronutrients is so important, a number of government-sponsored programs exist that provide nutritional support to women, infants, and young children. The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) is one of the most important programs, helping 53% of children under the age of 1 year. The Supplemental Nutrition Assistance Program (SNAP) also supplies economic aid to buy nutritious foods; it kept approximately 4.9 million children out of poverty in 2012, the researchers said. SNAP Nutrition Education, a partnership between SNAP and the Department of Agriculture, gives SNAP participants and eligible nonparticipants skills and information to help them to make healthy food choices with limited money.
The article highlights some important information, but is not an exhaustive discussion of the AAP policy statement. To make the information from the policy statement more applicable, Dr. Schwarzenberg, Dr. Georgieff, and the committee provided 10 takeaway recommendations for pediatricians.
1. Be knowledgeable about breastfeeding and help breastfeeding mothers. The AAP recommends exclusive breastfeeding for the first 6 months of a child’s life and to continue breastfeeding with the addition of food for at least the first year of life, and even after that if the mother and child so desire.
2. Advocate at the local, state, and federal levels to preserve and strengthen nutritional and assistance programs focusing on prenatal and neonatal nutrition. This can help support proper neurodevelopment and minimize negative environmental factors.
3. Openly discuss proper nutritions effects on infant neurodevelopment with parents. Know which nutrients are at risk in the breastfed infant after 6 months, such as zinc, iron, and vitamin D. A good resource is “Pediatric Nutrition, 7th edition” (Itasca, Ill. American Academy of Pediatrics, 2014).
4. Convey that eating healthy is a positive choice, not just an avoidance of unhealthy foods.
5. Inform food pantries and soup kitchens that the food packages and meals they provide should have higher levels of macronutrients and micronutrients.
6. Encourage parents to make use of programs like WIC and SNAP, and advocate for removing barriers that parents face in enrolling or reenrolling in such programs.
7. Oppose changes in eligibility to assistance programs that would adversely affect children.
8. Anticipate neurodevelopmental issues with children and address the issue early. For example, educate yourself about which nutrients are at risk for deficiency and at what ages.
9. Work with obstetricians to encourage improvements in maternal diet, which will affect the micronutrients available for the developing fetus.
10. Become advocates in the “Hunger Community,” working to reduce hunger at the local level across the United States. A chart in the article lists organizations focused on hunger, such as Feeding America, 1,000 Days, Share Our Strength, and others.
There was no external funding for this research, and the authors had no relevant financial disclosures or potential conflicts of interest to report.
While you might not typically put chopped or blended, unsalted, boiled canned oysters on your usual list of recommended infant and toddler foods, maybe you should.
The AAP just published a new policy statement on advocacy to improve child nutrition in the first 1,000 days (from conception to age 2 years). The statement emphasizes the importance of nutrition to optimal brain development. Pediatricians are encouraged to be familiar with community services to support optimal nutrition such as the Special Supplemental Nutrition Program for Women, Infants, and Children, the Supplemental Nutrition Assistance Program, the Child and Adult Care Food Program, and food pantries and soup kitchens, but also to get beyond recommending a “good diet” to something more specific which is high in key nutrients important for brain development such as protein; zinc; iron; choline; folate; iodine; vitamins A, D, B6, and B12; and polyunsaturated fatty acids. That’s where the boiled oysters, a decent source of the listed nutrients and especially loaded with zinc, iron, and vitamin B12, come in. While not everyone is going to rush out to buy their baby such an unexpected (and for many, unfamiliar) food, the statement reminds pediatricians to recommend foods that are good sources of the nutrients that babies and toddlers need most. Other foods that fit the bill include oatmeal, meat and poultry, fish like salmon and tuna, eggs, tofu and soybeans, and other legumes and beans like chickpeas and lentils.
Natalie D. Muth, MD, is a pediatrician at Children’s Primary Care Medical Group in Carlsbad, Calif. She has no relevant financial disclosures.
While you might not typically put chopped or blended, unsalted, boiled canned oysters on your usual list of recommended infant and toddler foods, maybe you should.
The AAP just published a new policy statement on advocacy to improve child nutrition in the first 1,000 days (from conception to age 2 years). The statement emphasizes the importance of nutrition to optimal brain development. Pediatricians are encouraged to be familiar with community services to support optimal nutrition such as the Special Supplemental Nutrition Program for Women, Infants, and Children, the Supplemental Nutrition Assistance Program, the Child and Adult Care Food Program, and food pantries and soup kitchens, but also to get beyond recommending a “good diet” to something more specific which is high in key nutrients important for brain development such as protein; zinc; iron; choline; folate; iodine; vitamins A, D, B6, and B12; and polyunsaturated fatty acids. That’s where the boiled oysters, a decent source of the listed nutrients and especially loaded with zinc, iron, and vitamin B12, come in. While not everyone is going to rush out to buy their baby such an unexpected (and for many, unfamiliar) food, the statement reminds pediatricians to recommend foods that are good sources of the nutrients that babies and toddlers need most. Other foods that fit the bill include oatmeal, meat and poultry, fish like salmon and tuna, eggs, tofu and soybeans, and other legumes and beans like chickpeas and lentils.
Natalie D. Muth, MD, is a pediatrician at Children’s Primary Care Medical Group in Carlsbad, Calif. She has no relevant financial disclosures.
While you might not typically put chopped or blended, unsalted, boiled canned oysters on your usual list of recommended infant and toddler foods, maybe you should.
The AAP just published a new policy statement on advocacy to improve child nutrition in the first 1,000 days (from conception to age 2 years). The statement emphasizes the importance of nutrition to optimal brain development. Pediatricians are encouraged to be familiar with community services to support optimal nutrition such as the Special Supplemental Nutrition Program for Women, Infants, and Children, the Supplemental Nutrition Assistance Program, the Child and Adult Care Food Program, and food pantries and soup kitchens, but also to get beyond recommending a “good diet” to something more specific which is high in key nutrients important for brain development such as protein; zinc; iron; choline; folate; iodine; vitamins A, D, B6, and B12; and polyunsaturated fatty acids. That’s where the boiled oysters, a decent source of the listed nutrients and especially loaded with zinc, iron, and vitamin B12, come in. While not everyone is going to rush out to buy their baby such an unexpected (and for many, unfamiliar) food, the statement reminds pediatricians to recommend foods that are good sources of the nutrients that babies and toddlers need most. Other foods that fit the bill include oatmeal, meat and poultry, fish like salmon and tuna, eggs, tofu and soybeans, and other legumes and beans like chickpeas and lentils.
Natalie D. Muth, MD, is a pediatrician at Children’s Primary Care Medical Group in Carlsbad, Calif. She has no relevant financial disclosures.
Nutrition within the first 1,000 days of childhood are pivotal in a child’s neurodevelopment and lifelong health, according to an American Academy of Pediatrics policy statement.
“Healthy, normal neurodevelopment is a complex process involving cellular and structural changes in the brain that proceed in a specified sequence,” wrote Sara Jane Schwarzenberg, MD and Michael K. Georgieff, MD, both of the University of Minnesota Masonic Children’s Hospital, Minneapolis, and the AAP Committee on Nutrition. “Changes that are too rapid or too slow in one part of the brain may result in the failure of crucial pathway connections to other parts of the brain. Timing is crucial; once a particular developmental sequence fails, it may not be possible to retrieve all the lost function,” the investigators and committee noted in a report published in Pediatrics (Pediatrics. 2018; 141[2]:e20173716).
The importance of macronutrients was highlighted in a study of rural Guatemalan children during 1969-1989 who received high-calorie or low-calorie protein supplements. Children who received the high-calorie/high protein supplements before age 2 years had higher test scores, better reading and vocabulary skills, and faster information processing abilities, compared with their low-calorie/low-protein counterparts.
Like the low-calorie/low-protein Guatemalans, there are many populations that lack access to high-quality macronutrient sources or have access to only low-quality macronutrients. In the United States in 2015, 16.6% of households (6.4 million) were food insecure. This was even more pronounced in households with incomes below the poverty line, with 36.8% being food insecure, according to studies from the Department of Agriculture.
Food insecurity is not limited to macronutrients but extends to micronutrients such as vitamins and minerals like zinc; iron; choline; folate; iodine; vitamins A, D, B6, and B12; and long-chain polyunsaturated fatty acids. A lack of any of these micronutrients in early childhood can lead to neurodevelopmental issues later in life, Dr. Schwarzenberg, Dr. Georgieff, and the committee emphasized. An important source of micronutrients is human milk, provided by breastfeeding. Studies have shown that breastfeeding of preterm and term infants improves cognitive performance, compared with infants who consume formula (J Pediatr. 2016;177:133-9.e1; Curr Opin Pediatr. 2016;28[4]:559-66).
Because proper consumption of macronutrients and micronutrients is so important, a number of government-sponsored programs exist that provide nutritional support to women, infants, and young children. The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) is one of the most important programs, helping 53% of children under the age of 1 year. The Supplemental Nutrition Assistance Program (SNAP) also supplies economic aid to buy nutritious foods; it kept approximately 4.9 million children out of poverty in 2012, the researchers said. SNAP Nutrition Education, a partnership between SNAP and the Department of Agriculture, gives SNAP participants and eligible nonparticipants skills and information to help them to make healthy food choices with limited money.
The article highlights some important information, but is not an exhaustive discussion of the AAP policy statement. To make the information from the policy statement more applicable, Dr. Schwarzenberg, Dr. Georgieff, and the committee provided 10 takeaway recommendations for pediatricians.
1. Be knowledgeable about breastfeeding and help breastfeeding mothers. The AAP recommends exclusive breastfeeding for the first 6 months of a child’s life and to continue breastfeeding with the addition of food for at least the first year of life, and even after that if the mother and child so desire.
2. Advocate at the local, state, and federal levels to preserve and strengthen nutritional and assistance programs focusing on prenatal and neonatal nutrition. This can help support proper neurodevelopment and minimize negative environmental factors.
3. Openly discuss proper nutritions effects on infant neurodevelopment with parents. Know which nutrients are at risk in the breastfed infant after 6 months, such as zinc, iron, and vitamin D. A good resource is “Pediatric Nutrition, 7th edition” (Itasca, Ill. American Academy of Pediatrics, 2014).
4. Convey that eating healthy is a positive choice, not just an avoidance of unhealthy foods.
5. Inform food pantries and soup kitchens that the food packages and meals they provide should have higher levels of macronutrients and micronutrients.
6. Encourage parents to make use of programs like WIC and SNAP, and advocate for removing barriers that parents face in enrolling or reenrolling in such programs.
7. Oppose changes in eligibility to assistance programs that would adversely affect children.
8. Anticipate neurodevelopmental issues with children and address the issue early. For example, educate yourself about which nutrients are at risk for deficiency and at what ages.
9. Work with obstetricians to encourage improvements in maternal diet, which will affect the micronutrients available for the developing fetus.
10. Become advocates in the “Hunger Community,” working to reduce hunger at the local level across the United States. A chart in the article lists organizations focused on hunger, such as Feeding America, 1,000 Days, Share Our Strength, and others.
There was no external funding for this research, and the authors had no relevant financial disclosures or potential conflicts of interest to report.
Nutrition within the first 1,000 days of childhood are pivotal in a child’s neurodevelopment and lifelong health, according to an American Academy of Pediatrics policy statement.
“Healthy, normal neurodevelopment is a complex process involving cellular and structural changes in the brain that proceed in a specified sequence,” wrote Sara Jane Schwarzenberg, MD and Michael K. Georgieff, MD, both of the University of Minnesota Masonic Children’s Hospital, Minneapolis, and the AAP Committee on Nutrition. “Changes that are too rapid or too slow in one part of the brain may result in the failure of crucial pathway connections to other parts of the brain. Timing is crucial; once a particular developmental sequence fails, it may not be possible to retrieve all the lost function,” the investigators and committee noted in a report published in Pediatrics (Pediatrics. 2018; 141[2]:e20173716).
The importance of macronutrients was highlighted in a study of rural Guatemalan children during 1969-1989 who received high-calorie or low-calorie protein supplements. Children who received the high-calorie/high protein supplements before age 2 years had higher test scores, better reading and vocabulary skills, and faster information processing abilities, compared with their low-calorie/low-protein counterparts.
Like the low-calorie/low-protein Guatemalans, there are many populations that lack access to high-quality macronutrient sources or have access to only low-quality macronutrients. In the United States in 2015, 16.6% of households (6.4 million) were food insecure. This was even more pronounced in households with incomes below the poverty line, with 36.8% being food insecure, according to studies from the Department of Agriculture.
Food insecurity is not limited to macronutrients but extends to micronutrients such as vitamins and minerals like zinc; iron; choline; folate; iodine; vitamins A, D, B6, and B12; and long-chain polyunsaturated fatty acids. A lack of any of these micronutrients in early childhood can lead to neurodevelopmental issues later in life, Dr. Schwarzenberg, Dr. Georgieff, and the committee emphasized. An important source of micronutrients is human milk, provided by breastfeeding. Studies have shown that breastfeeding of preterm and term infants improves cognitive performance, compared with infants who consume formula (J Pediatr. 2016;177:133-9.e1; Curr Opin Pediatr. 2016;28[4]:559-66).
Because proper consumption of macronutrients and micronutrients is so important, a number of government-sponsored programs exist that provide nutritional support to women, infants, and young children. The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) is one of the most important programs, helping 53% of children under the age of 1 year. The Supplemental Nutrition Assistance Program (SNAP) also supplies economic aid to buy nutritious foods; it kept approximately 4.9 million children out of poverty in 2012, the researchers said. SNAP Nutrition Education, a partnership between SNAP and the Department of Agriculture, gives SNAP participants and eligible nonparticipants skills and information to help them to make healthy food choices with limited money.
The article highlights some important information, but is not an exhaustive discussion of the AAP policy statement. To make the information from the policy statement more applicable, Dr. Schwarzenberg, Dr. Georgieff, and the committee provided 10 takeaway recommendations for pediatricians.
1. Be knowledgeable about breastfeeding and help breastfeeding mothers. The AAP recommends exclusive breastfeeding for the first 6 months of a child’s life and to continue breastfeeding with the addition of food for at least the first year of life, and even after that if the mother and child so desire.
2. Advocate at the local, state, and federal levels to preserve and strengthen nutritional and assistance programs focusing on prenatal and neonatal nutrition. This can help support proper neurodevelopment and minimize negative environmental factors.
3. Openly discuss proper nutritions effects on infant neurodevelopment with parents. Know which nutrients are at risk in the breastfed infant after 6 months, such as zinc, iron, and vitamin D. A good resource is “Pediatric Nutrition, 7th edition” (Itasca, Ill. American Academy of Pediatrics, 2014).
4. Convey that eating healthy is a positive choice, not just an avoidance of unhealthy foods.
5. Inform food pantries and soup kitchens that the food packages and meals they provide should have higher levels of macronutrients and micronutrients.
6. Encourage parents to make use of programs like WIC and SNAP, and advocate for removing barriers that parents face in enrolling or reenrolling in such programs.
7. Oppose changes in eligibility to assistance programs that would adversely affect children.
8. Anticipate neurodevelopmental issues with children and address the issue early. For example, educate yourself about which nutrients are at risk for deficiency and at what ages.
9. Work with obstetricians to encourage improvements in maternal diet, which will affect the micronutrients available for the developing fetus.
10. Become advocates in the “Hunger Community,” working to reduce hunger at the local level across the United States. A chart in the article lists organizations focused on hunger, such as Feeding America, 1,000 Days, Share Our Strength, and others.
There was no external funding for this research, and the authors had no relevant financial disclosures or potential conflicts of interest to report.
FROM PEDIATRICS
Junk food, energy drinks may damage teen brains
.
The latest evidence on how the teenage brain is particularly vulnerable to environmental influences, both good and bad, as it matures into adulthood is marshaled into review articles featured in a special issue of the journal Birth Defects Research entitled “The dynamic and vulnerable teenage brain” issued by the Teratology Society.
Junk food – soda, potato chips, and the like – is one of the bad influences, and not just on the waistline, according to a review by Amy Reichelt, PhD, and Michelle M. Rank, PhD, of the Royal Melbourne Institute of Technology University in Melbourne (Birth Defects Res. 2017 Dec 1. doi: 10.1002/bdr2.1173).
Under construction
“Because key neurotransmitter systems in the brain responsible for inhibition and reward signaling are still developing during the teen years, existing primarily on junk food could negatively affect decision making, increase reward-seeking behavior and influence poor eating habits throughout adulthood,” Dr. Reichelt said in a press release about the special issue.
The good news is that “the heightened neuroplasticity during adolescence ... offers a window in which diet-induced cognitive decline may be particularly amenable to intervention. This provides opportunities for nutritional intervention strategies in high-risk individuals,” she and Dr. Rank concluded in the review.
Although the literature is thinner than with junk food, there are similar concerns about the effects of energy drinks and their high levels of caffeine and taurine. Energy drinks likely are detrimental to the brain function of children and adolescents, especially when mixed with alcohol, according a second review by Christine Perdan Curran, PhD, and Cécile A. Marczinski, PhD, of Northern Kentucky University, Highland Heights. (Birth Defects Res. 2017 Dec 1. doi: 10.1002/bdr2.1177).
“We don’t know enough about the effects of high consumption of energy drinks and the ingredients found in them at this critical time in mammalian brain development,” but “our recent findings in adolescent and young adult mice exposed to high taurine levels indicate there can be adverse effects on learning and memory and increased alcohol consumption in females,” Dr. Curran said in the press release.
In short, energy drinks in adolescence raise “serious concerns about adverse effects on the brain,” the researchers concluded in their review.
It’s a happier story with exercise, according to two more reviews in the teenage brain issue.
Less couch time
“It is clear that helping adolescents dedicate more of their time to exercise, especially high intensity or aerobic activities, may not only better their physical health but also positively influence the way their brain is structured and how it functions,” said Megan Herting, PhD, and Xiaofang Chu of the University of Southern California, Los Angeles (Birth Defects Res. 2017 Dec 1. doi: 10.1002/bdr2.1178).
Aerobic exercise in the teenage years seems to improve attention, planning, problem solving, working memory, and inhibitory control. MRI studies, meanwhile, suggest that higher aerobic fitness correlates with beneficial cortical, subcortical, and white matter structural connectivity profiles in older adolescents. In a functional MRI study of 15- to 18-year-old boys, Dr. Herting and B.J. Nagel, PhD, found that the hippocampus of 17 less fit adolescents was significantly more active than that their 17 fitter peers during a word recall test, suggesting “that exercise may influence how the brain encodes new memories and that lower-fit teens may need to utilize additional brain resources to learn something new” (J Cogn Neurosci. 2013 Apr;25[4]:595-612).
Boosting the benefit
Exercise also helps with substance abuse, an effect that “appears to be attributable to more than just time occupied by the activities,” according to a review led by Nora L. Nock, PhD, of Case Western Reserve University, Cleveland (Birth Defects Res. 2017 Dec 1. doi: 10.1002/bdr2.1182).
“Substance use in adolescence has been associated with adverse structural and functional brain changes, and may further exacerbate the natural imbalance” between inhibitory and excitatory neurotransmitters, “leading to further heightened impulsive and reward-driven behaviors,” the authors said.
Exercise offsets the effects by inducing structural and functional changes in the brain, including neurogenesis and angiogenesis. “If integrated during adolescence, a window of heightened reward sensitivity and neural plasticity, exercise may help to reinforce ‘naïve’ or underdeveloped connections between neurological reward and regulatory processes ... and, in turn, help offset or dampen reward seeking from substances while concomitantly improving cardiovascular health as well as academic and social achievement,” Dr. Nock and her colleagues said.
The team is studying “assisted exercise,” which helps people peddle about 35% faster on a stationary bike than they would be able to on their own. “It may be able to provide even greater effects in suppressing reward from substance use due to potentially larger increases in neurotransmitters (e.g., dopamine) and neurotrophic factors (e.g., BDNF [brain-derived neurotrophic factor]), which may be particularly beneficial in adolescents with SUD (substance use disorder) having a dopamine deficit due to genetic variation and/or lower levels of striatal dopamine receptors ... during substance abstinence,” they said.
Given those and other findings, Dr. Nock and her colleagues proposed that exercise “be initiated during early abstinence and, potentially, started before integrating other cognitive behavioral treatment components” in adolescents with SUDs.
The authors did not report any industry disclosures.
.
The latest evidence on how the teenage brain is particularly vulnerable to environmental influences, both good and bad, as it matures into adulthood is marshaled into review articles featured in a special issue of the journal Birth Defects Research entitled “The dynamic and vulnerable teenage brain” issued by the Teratology Society.
Junk food – soda, potato chips, and the like – is one of the bad influences, and not just on the waistline, according to a review by Amy Reichelt, PhD, and Michelle M. Rank, PhD, of the Royal Melbourne Institute of Technology University in Melbourne (Birth Defects Res. 2017 Dec 1. doi: 10.1002/bdr2.1173).
Under construction
“Because key neurotransmitter systems in the brain responsible for inhibition and reward signaling are still developing during the teen years, existing primarily on junk food could negatively affect decision making, increase reward-seeking behavior and influence poor eating habits throughout adulthood,” Dr. Reichelt said in a press release about the special issue.
The good news is that “the heightened neuroplasticity during adolescence ... offers a window in which diet-induced cognitive decline may be particularly amenable to intervention. This provides opportunities for nutritional intervention strategies in high-risk individuals,” she and Dr. Rank concluded in the review.
Although the literature is thinner than with junk food, there are similar concerns about the effects of energy drinks and their high levels of caffeine and taurine. Energy drinks likely are detrimental to the brain function of children and adolescents, especially when mixed with alcohol, according a second review by Christine Perdan Curran, PhD, and Cécile A. Marczinski, PhD, of Northern Kentucky University, Highland Heights. (Birth Defects Res. 2017 Dec 1. doi: 10.1002/bdr2.1177).
“We don’t know enough about the effects of high consumption of energy drinks and the ingredients found in them at this critical time in mammalian brain development,” but “our recent findings in adolescent and young adult mice exposed to high taurine levels indicate there can be adverse effects on learning and memory and increased alcohol consumption in females,” Dr. Curran said in the press release.
In short, energy drinks in adolescence raise “serious concerns about adverse effects on the brain,” the researchers concluded in their review.
It’s a happier story with exercise, according to two more reviews in the teenage brain issue.
Less couch time
“It is clear that helping adolescents dedicate more of their time to exercise, especially high intensity or aerobic activities, may not only better their physical health but also positively influence the way their brain is structured and how it functions,” said Megan Herting, PhD, and Xiaofang Chu of the University of Southern California, Los Angeles (Birth Defects Res. 2017 Dec 1. doi: 10.1002/bdr2.1178).
Aerobic exercise in the teenage years seems to improve attention, planning, problem solving, working memory, and inhibitory control. MRI studies, meanwhile, suggest that higher aerobic fitness correlates with beneficial cortical, subcortical, and white matter structural connectivity profiles in older adolescents. In a functional MRI study of 15- to 18-year-old boys, Dr. Herting and B.J. Nagel, PhD, found that the hippocampus of 17 less fit adolescents was significantly more active than that their 17 fitter peers during a word recall test, suggesting “that exercise may influence how the brain encodes new memories and that lower-fit teens may need to utilize additional brain resources to learn something new” (J Cogn Neurosci. 2013 Apr;25[4]:595-612).
Boosting the benefit
Exercise also helps with substance abuse, an effect that “appears to be attributable to more than just time occupied by the activities,” according to a review led by Nora L. Nock, PhD, of Case Western Reserve University, Cleveland (Birth Defects Res. 2017 Dec 1. doi: 10.1002/bdr2.1182).
“Substance use in adolescence has been associated with adverse structural and functional brain changes, and may further exacerbate the natural imbalance” between inhibitory and excitatory neurotransmitters, “leading to further heightened impulsive and reward-driven behaviors,” the authors said.
Exercise offsets the effects by inducing structural and functional changes in the brain, including neurogenesis and angiogenesis. “If integrated during adolescence, a window of heightened reward sensitivity and neural plasticity, exercise may help to reinforce ‘naïve’ or underdeveloped connections between neurological reward and regulatory processes ... and, in turn, help offset or dampen reward seeking from substances while concomitantly improving cardiovascular health as well as academic and social achievement,” Dr. Nock and her colleagues said.
The team is studying “assisted exercise,” which helps people peddle about 35% faster on a stationary bike than they would be able to on their own. “It may be able to provide even greater effects in suppressing reward from substance use due to potentially larger increases in neurotransmitters (e.g., dopamine) and neurotrophic factors (e.g., BDNF [brain-derived neurotrophic factor]), which may be particularly beneficial in adolescents with SUD (substance use disorder) having a dopamine deficit due to genetic variation and/or lower levels of striatal dopamine receptors ... during substance abstinence,” they said.
Given those and other findings, Dr. Nock and her colleagues proposed that exercise “be initiated during early abstinence and, potentially, started before integrating other cognitive behavioral treatment components” in adolescents with SUDs.
The authors did not report any industry disclosures.
.
The latest evidence on how the teenage brain is particularly vulnerable to environmental influences, both good and bad, as it matures into adulthood is marshaled into review articles featured in a special issue of the journal Birth Defects Research entitled “The dynamic and vulnerable teenage brain” issued by the Teratology Society.
Junk food – soda, potato chips, and the like – is one of the bad influences, and not just on the waistline, according to a review by Amy Reichelt, PhD, and Michelle M. Rank, PhD, of the Royal Melbourne Institute of Technology University in Melbourne (Birth Defects Res. 2017 Dec 1. doi: 10.1002/bdr2.1173).
Under construction
“Because key neurotransmitter systems in the brain responsible for inhibition and reward signaling are still developing during the teen years, existing primarily on junk food could negatively affect decision making, increase reward-seeking behavior and influence poor eating habits throughout adulthood,” Dr. Reichelt said in a press release about the special issue.
The good news is that “the heightened neuroplasticity during adolescence ... offers a window in which diet-induced cognitive decline may be particularly amenable to intervention. This provides opportunities for nutritional intervention strategies in high-risk individuals,” she and Dr. Rank concluded in the review.
Although the literature is thinner than with junk food, there are similar concerns about the effects of energy drinks and their high levels of caffeine and taurine. Energy drinks likely are detrimental to the brain function of children and adolescents, especially when mixed with alcohol, according a second review by Christine Perdan Curran, PhD, and Cécile A. Marczinski, PhD, of Northern Kentucky University, Highland Heights. (Birth Defects Res. 2017 Dec 1. doi: 10.1002/bdr2.1177).
“We don’t know enough about the effects of high consumption of energy drinks and the ingredients found in them at this critical time in mammalian brain development,” but “our recent findings in adolescent and young adult mice exposed to high taurine levels indicate there can be adverse effects on learning and memory and increased alcohol consumption in females,” Dr. Curran said in the press release.
In short, energy drinks in adolescence raise “serious concerns about adverse effects on the brain,” the researchers concluded in their review.
It’s a happier story with exercise, according to two more reviews in the teenage brain issue.
Less couch time
“It is clear that helping adolescents dedicate more of their time to exercise, especially high intensity or aerobic activities, may not only better their physical health but also positively influence the way their brain is structured and how it functions,” said Megan Herting, PhD, and Xiaofang Chu of the University of Southern California, Los Angeles (Birth Defects Res. 2017 Dec 1. doi: 10.1002/bdr2.1178).
Aerobic exercise in the teenage years seems to improve attention, planning, problem solving, working memory, and inhibitory control. MRI studies, meanwhile, suggest that higher aerobic fitness correlates with beneficial cortical, subcortical, and white matter structural connectivity profiles in older adolescents. In a functional MRI study of 15- to 18-year-old boys, Dr. Herting and B.J. Nagel, PhD, found that the hippocampus of 17 less fit adolescents was significantly more active than that their 17 fitter peers during a word recall test, suggesting “that exercise may influence how the brain encodes new memories and that lower-fit teens may need to utilize additional brain resources to learn something new” (J Cogn Neurosci. 2013 Apr;25[4]:595-612).
Boosting the benefit
Exercise also helps with substance abuse, an effect that “appears to be attributable to more than just time occupied by the activities,” according to a review led by Nora L. Nock, PhD, of Case Western Reserve University, Cleveland (Birth Defects Res. 2017 Dec 1. doi: 10.1002/bdr2.1182).
“Substance use in adolescence has been associated with adverse structural and functional brain changes, and may further exacerbate the natural imbalance” between inhibitory and excitatory neurotransmitters, “leading to further heightened impulsive and reward-driven behaviors,” the authors said.
Exercise offsets the effects by inducing structural and functional changes in the brain, including neurogenesis and angiogenesis. “If integrated during adolescence, a window of heightened reward sensitivity and neural plasticity, exercise may help to reinforce ‘naïve’ or underdeveloped connections between neurological reward and regulatory processes ... and, in turn, help offset or dampen reward seeking from substances while concomitantly improving cardiovascular health as well as academic and social achievement,” Dr. Nock and her colleagues said.
The team is studying “assisted exercise,” which helps people peddle about 35% faster on a stationary bike than they would be able to on their own. “It may be able to provide even greater effects in suppressing reward from substance use due to potentially larger increases in neurotransmitters (e.g., dopamine) and neurotrophic factors (e.g., BDNF [brain-derived neurotrophic factor]), which may be particularly beneficial in adolescents with SUD (substance use disorder) having a dopamine deficit due to genetic variation and/or lower levels of striatal dopamine receptors ... during substance abstinence,” they said.
Given those and other findings, Dr. Nock and her colleagues proposed that exercise “be initiated during early abstinence and, potentially, started before integrating other cognitive behavioral treatment components” in adolescents with SUDs.
The authors did not report any industry disclosures.
FROM BIRTH DEFECTS RESEARCH
Anxiety disorders: Psychopharmacologic treatment update
Anxiety disorders, including separation anxiety disorder, social anxiety disorder, and generalized anxiety disorder, are some of the most common psychiatric conditions of childhood and adolescence, affecting up to 20% of youth.1 Patients commonly present with a mix of symptoms that often span multiple anxiety disorder diagnoses. While this pattern can present somewhat of a diagnostic conundrum, it can be reassuring to know that such constellations of symptoms are the rule rather than the exception. Further, given that both the pharmacologic and nonpharmacologic treatment strategies don’t change much among the various anxiety disorders, the lack of a definitive single diagnosis should not delay intervention. Be alert to the possibility that anxiety and anxiety disorders can be the engine that drives what on the surface appears to be more disruptive and oppositional behavior.
Although medications can be a useful part of treatment, they are not recommended as a stand-alone intervention. Nonpharmacologic treatments generally should be tried before medications are considered. Among the different types of psychotherapy, cognitive-behavioral therapy (CBT) has the most empirical support from research trials, although other modalities such as mindfulness-based treatments show some promise. As anxiety disorders often run in families, it also can be very useful to explore the possibility that one or more parents also struggle with an anxiety disorder, which, if untreated, might complicate the child’s course.
With regard to medications, it is being increasingly appreciated that, despite SSRIs being most popularly known as antidepressants, these medications actually may be as efficacious or even more efficacious in the management of anxiety disorders. This class remains the cornerstone of medication treatment, and a brief review of current options follows.
SSRIs and SNRIs
A 2015 meta-analysis that examined nine randomized controlled trials of SSRIs and serotonin and norepinephrine reuptake inhibitors (SNRIs) for pediatric anxiety disorders concluded that these agents provided a benefit of modest effect size. No significant increase in treatment-emergent suicidality was found, and the medications were generally well tolerated.2 This analysis also found some evidence that greater efficacy was related to a medication with more specific serotonergic properties, suggesting improved response with “true” SSRIs versus SNRIs such as venlafaxine and duloxetine. One major study using sertraline found that, at least in the short term, combined use of sertraline with CBT resulted in better efficacy than either treatment alone.3 Dosing of SSRIs should start low: A general rule is to begin at half of the smallest dosage made, depending on the age and size of the patient. One question that often comes up after a successful trial is how long to continue the medications. A recent meta-analysis in adults concluded that there was evidence that stopping medication prior to 1 year resulted in an increased risk of relapse with little to guide clinicians after that 1-year mark.4
Benzodiazepines
Even though benzodiazepines have been around for a long time, data supporting their efficacy and safety in pediatric populations remain extremely limited, and what has been reported has not been particularly positive. Thus, most experts do not suggest using benzodiazepines for anxiety disorders, with the exception of helping children through single or rare events, such as medical procedures or enabling an adolescent who has been fearful of attending school to get to the building on the first day back after a long absence.
Guanfacine
In a recent exploratory trial of guanfacine for children with mixed anxiety disorders,5 the medication was well tolerated overall but did not result in statistically significant improvement relative to placebo on primary anxiety rating scales. However, a higher number of children were rated as improved on a clinician-rated scale. This medication is usually started at 0.5 mg/day and increased as tolerated, while checking vital signs, to a maximum of 4 mg/day.
Atomoxetine
A randomized control trial of pediatric patients with both ADHD and an anxiety disorder showed reductions in both symptom domains with atomoxetine dosed at an average of 1.3 mg/kg per day.6 There is little evidence to suggest its use in primary anxiety disorders without comorbid ADHD.
Buspirone
This 5-hydroxytryptamine 1a agonist has Food and Drug Administration approval for generalized anxiety disorder in adults and is generally well tolerated. Unfortunately, two randomized controlled studies in children and adolescents did not find statistically significant improvement relative to placebo, although some methodological problems may have played a role.7
Antipsychotics
Although sometimes used to augment an SSRI in adult anxiety disorders, there are little data to support the use of antipsychotics in pediatric populations, especially given the antecedent risks of the drugs.
Summary
Pharmacotherapy for anxiety disorders often includes the advice that, if medications are indicated in conjunction with psychotherapy, to start with an SSRI; and if that is not effective to try a different one.7 An SNRI such as venlafaxine or duloxetine may then be a third-line alternative, although for youth with comorbid ADHD, consideration of either atomoxetine or guanfacine is also reasonable. Beyond that point, there unfortunately are little systematic data to guide pharmacologic decision making, and increased potential risks of other classes of medications suggest the need for caution and consultation.
Looking for more mental health training? Attend the 12th annual Child Psychiatry in Primary Care conference in Burlington, on May 4, 2018,organized by the University of Vermont with Dr. Rettew as course director. Go to http://www.med.uvm.edu/cme/conferences.
References
1. Merikangas KR et al. J Am Acad Child Adolesc Psychiatry. 2010 Oct;49(10):980-9.
2. Strawn JR et al. Depress Anxiety. 2015 Mar;32(3):149-57.
3. Walkup J et al. N Engl J Med. 2008 Dec 25;359(26):2753-66.
4. Batelaan N et al. BMJ. 2017 Sep 13;358:j3927.
5. Strawn JR et al. J Child Adolesc Psychopharm. 2017 Feb;27(1): 29-37..
6. Geller D et al. J Am Acad Child Adolesc Psychiatry. 2007 Sep;46(9):1119-27.
7. Strawn JR et al. J Child Adolesc Psychopharm. 2017 Feb;28(1): 2-9.
Anxiety disorders, including separation anxiety disorder, social anxiety disorder, and generalized anxiety disorder, are some of the most common psychiatric conditions of childhood and adolescence, affecting up to 20% of youth.1 Patients commonly present with a mix of symptoms that often span multiple anxiety disorder diagnoses. While this pattern can present somewhat of a diagnostic conundrum, it can be reassuring to know that such constellations of symptoms are the rule rather than the exception. Further, given that both the pharmacologic and nonpharmacologic treatment strategies don’t change much among the various anxiety disorders, the lack of a definitive single diagnosis should not delay intervention. Be alert to the possibility that anxiety and anxiety disorders can be the engine that drives what on the surface appears to be more disruptive and oppositional behavior.
Although medications can be a useful part of treatment, they are not recommended as a stand-alone intervention. Nonpharmacologic treatments generally should be tried before medications are considered. Among the different types of psychotherapy, cognitive-behavioral therapy (CBT) has the most empirical support from research trials, although other modalities such as mindfulness-based treatments show some promise. As anxiety disorders often run in families, it also can be very useful to explore the possibility that one or more parents also struggle with an anxiety disorder, which, if untreated, might complicate the child’s course.
With regard to medications, it is being increasingly appreciated that, despite SSRIs being most popularly known as antidepressants, these medications actually may be as efficacious or even more efficacious in the management of anxiety disorders. This class remains the cornerstone of medication treatment, and a brief review of current options follows.
SSRIs and SNRIs
A 2015 meta-analysis that examined nine randomized controlled trials of SSRIs and serotonin and norepinephrine reuptake inhibitors (SNRIs) for pediatric anxiety disorders concluded that these agents provided a benefit of modest effect size. No significant increase in treatment-emergent suicidality was found, and the medications were generally well tolerated.2 This analysis also found some evidence that greater efficacy was related to a medication with more specific serotonergic properties, suggesting improved response with “true” SSRIs versus SNRIs such as venlafaxine and duloxetine. One major study using sertraline found that, at least in the short term, combined use of sertraline with CBT resulted in better efficacy than either treatment alone.3 Dosing of SSRIs should start low: A general rule is to begin at half of the smallest dosage made, depending on the age and size of the patient. One question that often comes up after a successful trial is how long to continue the medications. A recent meta-analysis in adults concluded that there was evidence that stopping medication prior to 1 year resulted in an increased risk of relapse with little to guide clinicians after that 1-year mark.4
Benzodiazepines
Even though benzodiazepines have been around for a long time, data supporting their efficacy and safety in pediatric populations remain extremely limited, and what has been reported has not been particularly positive. Thus, most experts do not suggest using benzodiazepines for anxiety disorders, with the exception of helping children through single or rare events, such as medical procedures or enabling an adolescent who has been fearful of attending school to get to the building on the first day back after a long absence.
Guanfacine
In a recent exploratory trial of guanfacine for children with mixed anxiety disorders,5 the medication was well tolerated overall but did not result in statistically significant improvement relative to placebo on primary anxiety rating scales. However, a higher number of children were rated as improved on a clinician-rated scale. This medication is usually started at 0.5 mg/day and increased as tolerated, while checking vital signs, to a maximum of 4 mg/day.
Atomoxetine
A randomized control trial of pediatric patients with both ADHD and an anxiety disorder showed reductions in both symptom domains with atomoxetine dosed at an average of 1.3 mg/kg per day.6 There is little evidence to suggest its use in primary anxiety disorders without comorbid ADHD.
Buspirone
This 5-hydroxytryptamine 1a agonist has Food and Drug Administration approval for generalized anxiety disorder in adults and is generally well tolerated. Unfortunately, two randomized controlled studies in children and adolescents did not find statistically significant improvement relative to placebo, although some methodological problems may have played a role.7
Antipsychotics
Although sometimes used to augment an SSRI in adult anxiety disorders, there are little data to support the use of antipsychotics in pediatric populations, especially given the antecedent risks of the drugs.
Summary
Pharmacotherapy for anxiety disorders often includes the advice that, if medications are indicated in conjunction with psychotherapy, to start with an SSRI; and if that is not effective to try a different one.7 An SNRI such as venlafaxine or duloxetine may then be a third-line alternative, although for youth with comorbid ADHD, consideration of either atomoxetine or guanfacine is also reasonable. Beyond that point, there unfortunately are little systematic data to guide pharmacologic decision making, and increased potential risks of other classes of medications suggest the need for caution and consultation.
Looking for more mental health training? Attend the 12th annual Child Psychiatry in Primary Care conference in Burlington, on May 4, 2018,organized by the University of Vermont with Dr. Rettew as course director. Go to http://www.med.uvm.edu/cme/conferences.
References
1. Merikangas KR et al. J Am Acad Child Adolesc Psychiatry. 2010 Oct;49(10):980-9.
2. Strawn JR et al. Depress Anxiety. 2015 Mar;32(3):149-57.
3. Walkup J et al. N Engl J Med. 2008 Dec 25;359(26):2753-66.
4. Batelaan N et al. BMJ. 2017 Sep 13;358:j3927.
5. Strawn JR et al. J Child Adolesc Psychopharm. 2017 Feb;27(1): 29-37..
6. Geller D et al. J Am Acad Child Adolesc Psychiatry. 2007 Sep;46(9):1119-27.
7. Strawn JR et al. J Child Adolesc Psychopharm. 2017 Feb;28(1): 2-9.
Anxiety disorders, including separation anxiety disorder, social anxiety disorder, and generalized anxiety disorder, are some of the most common psychiatric conditions of childhood and adolescence, affecting up to 20% of youth.1 Patients commonly present with a mix of symptoms that often span multiple anxiety disorder diagnoses. While this pattern can present somewhat of a diagnostic conundrum, it can be reassuring to know that such constellations of symptoms are the rule rather than the exception. Further, given that both the pharmacologic and nonpharmacologic treatment strategies don’t change much among the various anxiety disorders, the lack of a definitive single diagnosis should not delay intervention. Be alert to the possibility that anxiety and anxiety disorders can be the engine that drives what on the surface appears to be more disruptive and oppositional behavior.
Although medications can be a useful part of treatment, they are not recommended as a stand-alone intervention. Nonpharmacologic treatments generally should be tried before medications are considered. Among the different types of psychotherapy, cognitive-behavioral therapy (CBT) has the most empirical support from research trials, although other modalities such as mindfulness-based treatments show some promise. As anxiety disorders often run in families, it also can be very useful to explore the possibility that one or more parents also struggle with an anxiety disorder, which, if untreated, might complicate the child’s course.
With regard to medications, it is being increasingly appreciated that, despite SSRIs being most popularly known as antidepressants, these medications actually may be as efficacious or even more efficacious in the management of anxiety disorders. This class remains the cornerstone of medication treatment, and a brief review of current options follows.
SSRIs and SNRIs
A 2015 meta-analysis that examined nine randomized controlled trials of SSRIs and serotonin and norepinephrine reuptake inhibitors (SNRIs) for pediatric anxiety disorders concluded that these agents provided a benefit of modest effect size. No significant increase in treatment-emergent suicidality was found, and the medications were generally well tolerated.2 This analysis also found some evidence that greater efficacy was related to a medication with more specific serotonergic properties, suggesting improved response with “true” SSRIs versus SNRIs such as venlafaxine and duloxetine. One major study using sertraline found that, at least in the short term, combined use of sertraline with CBT resulted in better efficacy than either treatment alone.3 Dosing of SSRIs should start low: A general rule is to begin at half of the smallest dosage made, depending on the age and size of the patient. One question that often comes up after a successful trial is how long to continue the medications. A recent meta-analysis in adults concluded that there was evidence that stopping medication prior to 1 year resulted in an increased risk of relapse with little to guide clinicians after that 1-year mark.4
Benzodiazepines
Even though benzodiazepines have been around for a long time, data supporting their efficacy and safety in pediatric populations remain extremely limited, and what has been reported has not been particularly positive. Thus, most experts do not suggest using benzodiazepines for anxiety disorders, with the exception of helping children through single or rare events, such as medical procedures or enabling an adolescent who has been fearful of attending school to get to the building on the first day back after a long absence.
Guanfacine
In a recent exploratory trial of guanfacine for children with mixed anxiety disorders,5 the medication was well tolerated overall but did not result in statistically significant improvement relative to placebo on primary anxiety rating scales. However, a higher number of children were rated as improved on a clinician-rated scale. This medication is usually started at 0.5 mg/day and increased as tolerated, while checking vital signs, to a maximum of 4 mg/day.
Atomoxetine
A randomized control trial of pediatric patients with both ADHD and an anxiety disorder showed reductions in both symptom domains with atomoxetine dosed at an average of 1.3 mg/kg per day.6 There is little evidence to suggest its use in primary anxiety disorders without comorbid ADHD.
Buspirone
This 5-hydroxytryptamine 1a agonist has Food and Drug Administration approval for generalized anxiety disorder in adults and is generally well tolerated. Unfortunately, two randomized controlled studies in children and adolescents did not find statistically significant improvement relative to placebo, although some methodological problems may have played a role.7
Antipsychotics
Although sometimes used to augment an SSRI in adult anxiety disorders, there are little data to support the use of antipsychotics in pediatric populations, especially given the antecedent risks of the drugs.
Summary
Pharmacotherapy for anxiety disorders often includes the advice that, if medications are indicated in conjunction with psychotherapy, to start with an SSRI; and if that is not effective to try a different one.7 An SNRI such as venlafaxine or duloxetine may then be a third-line alternative, although for youth with comorbid ADHD, consideration of either atomoxetine or guanfacine is also reasonable. Beyond that point, there unfortunately are little systematic data to guide pharmacologic decision making, and increased potential risks of other classes of medications suggest the need for caution and consultation.
Looking for more mental health training? Attend the 12th annual Child Psychiatry in Primary Care conference in Burlington, on May 4, 2018,organized by the University of Vermont with Dr. Rettew as course director. Go to http://www.med.uvm.edu/cme/conferences.
References
1. Merikangas KR et al. J Am Acad Child Adolesc Psychiatry. 2010 Oct;49(10):980-9.
2. Strawn JR et al. Depress Anxiety. 2015 Mar;32(3):149-57.
3. Walkup J et al. N Engl J Med. 2008 Dec 25;359(26):2753-66.
4. Batelaan N et al. BMJ. 2017 Sep 13;358:j3927.
5. Strawn JR et al. J Child Adolesc Psychopharm. 2017 Feb;27(1): 29-37..
6. Geller D et al. J Am Acad Child Adolesc Psychiatry. 2007 Sep;46(9):1119-27.
7. Strawn JR et al. J Child Adolesc Psychopharm. 2017 Feb;28(1): 2-9.
Topics rarely discussed during fellowship
Each year, the American Gastroenterological Association travels throughout the country, hosting Regional Practice Skills Workshops to answer tough and practical questions that are rarely addressed during fellowship. Presentations from several of the 2017 workshops are now available on the AGA website for you to watch at your leisure (login required). Each presentation is 20 minutes or less and provides expert advice to help you succeed in your career.
Here’s a selection of what you’ll find at www.gastro.org/education:
- Physician Contracts and Negotiations – Jon Appino from Contract Diagnostics discusses the anatomy of physician employment agreements. He shares questions that are important for you to ask when reviewing a contract.
- Career in Hybrid Practice – John S. Hanson, MD, AGAF, from Carolinas HealthCare System reviews different practice types and provides insight into “hybrid practice” and how it compares to private practice and academic practice.
- Career in Private Practice – Rig S. Patel, MD, the president of Digestive Healthcare PA, builds a clear picture of what life is like in private practice and shares nine things to consider when reviewing a private practice.
- Wealth Management Perspectives – Two financial advisors from Morgan Stanley provide tips and strategies to help early career physicians stay “financially fit.”
See all of AGA’s on-demand education for trainees and early career GIs by visiting www.gastro.org/education and searching for the series Trainees and Early Career GIs.
The AGA Regional Practice Skills Workshops are organized by the AGA Trainee & Early Career Committee in support of early career GIs. In December 2017, workshops were held in California, Iowa, and New York. The spring 2018 workshops will take place in Columbus, Ohio (Feb. 24), and Philadelphia, Penn. (April 11).
Each year, the American Gastroenterological Association travels throughout the country, hosting Regional Practice Skills Workshops to answer tough and practical questions that are rarely addressed during fellowship. Presentations from several of the 2017 workshops are now available on the AGA website for you to watch at your leisure (login required). Each presentation is 20 minutes or less and provides expert advice to help you succeed in your career.
Here’s a selection of what you’ll find at www.gastro.org/education:
- Physician Contracts and Negotiations – Jon Appino from Contract Diagnostics discusses the anatomy of physician employment agreements. He shares questions that are important for you to ask when reviewing a contract.
- Career in Hybrid Practice – John S. Hanson, MD, AGAF, from Carolinas HealthCare System reviews different practice types and provides insight into “hybrid practice” and how it compares to private practice and academic practice.
- Career in Private Practice – Rig S. Patel, MD, the president of Digestive Healthcare PA, builds a clear picture of what life is like in private practice and shares nine things to consider when reviewing a private practice.
- Wealth Management Perspectives – Two financial advisors from Morgan Stanley provide tips and strategies to help early career physicians stay “financially fit.”
See all of AGA’s on-demand education for trainees and early career GIs by visiting www.gastro.org/education and searching for the series Trainees and Early Career GIs.
The AGA Regional Practice Skills Workshops are organized by the AGA Trainee & Early Career Committee in support of early career GIs. In December 2017, workshops were held in California, Iowa, and New York. The spring 2018 workshops will take place in Columbus, Ohio (Feb. 24), and Philadelphia, Penn. (April 11).
Each year, the American Gastroenterological Association travels throughout the country, hosting Regional Practice Skills Workshops to answer tough and practical questions that are rarely addressed during fellowship. Presentations from several of the 2017 workshops are now available on the AGA website for you to watch at your leisure (login required). Each presentation is 20 minutes or less and provides expert advice to help you succeed in your career.
Here’s a selection of what you’ll find at www.gastro.org/education:
- Physician Contracts and Negotiations – Jon Appino from Contract Diagnostics discusses the anatomy of physician employment agreements. He shares questions that are important for you to ask when reviewing a contract.
- Career in Hybrid Practice – John S. Hanson, MD, AGAF, from Carolinas HealthCare System reviews different practice types and provides insight into “hybrid practice” and how it compares to private practice and academic practice.
- Career in Private Practice – Rig S. Patel, MD, the president of Digestive Healthcare PA, builds a clear picture of what life is like in private practice and shares nine things to consider when reviewing a private practice.
- Wealth Management Perspectives – Two financial advisors from Morgan Stanley provide tips and strategies to help early career physicians stay “financially fit.”
See all of AGA’s on-demand education for trainees and early career GIs by visiting www.gastro.org/education and searching for the series Trainees and Early Career GIs.
The AGA Regional Practice Skills Workshops are organized by the AGA Trainee & Early Career Committee in support of early career GIs. In December 2017, workshops were held in California, Iowa, and New York. The spring 2018 workshops will take place in Columbus, Ohio (Feb. 24), and Philadelphia, Penn. (April 11).