Multiaxial Assessment

All workups for headache evaluate frequency, intensity, duration, and disability. From a behavioral perspective, Dr. Baskin recommended considering a few more factors—adherence to therapy, stress-related issues, comorbid psychiatric disorders, and factors that transform migraine from episodic to chronic.

“When you talk about adherence, one of the basics of this is readiness to change,” said Dr. Baskin. “Is the patient motivated for treatment? That doesn’t necessarily happen immediately.” For example, a patient who is motivated to have an abortive agent might not be motivated to pursue prevention, lose weight, exercise, or make lifestyle changes. “Over time, that might change,” Dr. Baskin noted. Patient motivation may evolve with a greater understanding of the goals of treatment.

“Has the patient adhered to past therapy regimens? If the answer is no, then the answer will most likely be no again,” Dr. Baskin said. If medication overuse was a problem, it may be again. Whenever possible, ask open-ended questions, such as “how do you decide when to take an acute medication?” Dr. Baskin advised.

Stress and Migraine

High levels of daily stress, even daily stressors that are not catastrophic, can transform migraine from episodic to chronic. “Patients with depression show a greater effect of stress,” Dr. Baskin said. Similarly, victims of trauma or childhood maltreatment can have more disabling headaches that may be more likely to transform into daily headaches. “Many patients do not have the coping skills necessary to manage stress or recurrent headache,” Dr. Baskin said. One of the goals of behavioral therapy for migraine is to increase patients’ self-efficacy and give them the tools and the confidence to manage headaches and stressors.

Psychiatric Comorbidity

Psychiatric comorbidity may complicate differential diagnosis, and nonadherence to medication is greater in people with mood disorders and anxiety disorders. These patients may show a reduced response to pharmacologic and behavioral treatments for headache. Psychiatric comorbidities also can contribute to migraine chronification. “However, if you add a small behavioral component to your headache program, patients with psychiatric comorbidities seem to respond relatively well,” Dr. Baskin said.

Migraineurs have a two- to threefold greater prevalence of depression. There is a bidirectional relationship between migraine and depression in population studies. The relationship between migraine and depression is greater in clinic populations, in chronic migraine, and in medication overuse headache.

There is a significant relationship between migraine and anxiety disorders. Anxiety disorders entail a sense of danger, fear, or worry. “All patients with anxiety disorder have physical symptoms, and they often show avoidance behaviors,” said Dr. Baskin. For example, in generalized anxiety disorder, the object of avoidance is probably the fear of uncertainty. People worry excessively, thinking they are avoiding uncertainty. “Avoidance learning is huge in anxiety,” said Dr. Baskin. People fear unexpected events and perceive things as more unmanageable, dangerous, or threatening than they objectively are. “We see that frequently in migraineurs with anxiety disorders,” he said. Dr. Baskin noted that anxious patients tend to be sensitive to medication side effects and somatic sensations in general.

Patients with headache and anxiety often develop strong fear reactions. They identify a warning signal for headache, real or imagined, and may treat their fear, which they perceive as a headache prodrome, with a medication. “There is a preemptive strike with medicine treating a sensation that may or may not develop into headache,” Dr. Baskin said. That medication reduces their emotional distress and prevents the migraine, a powerful avoidance learning paradigm. That cycle can be a major part of medication overuse headache.

Anxiety disorders are much more prevalent than depression in migraineurs. They are associated with greater long-term persistence of headache, greater headache-related disability, and reduced satisfaction with acute therapy. “Across all emotional disorders, anxiety is the driver of distress,” Dr. Baskin said. “When you add anxiety to any disorder, it becomes much more problematic.”

The concept of interoceptive awareness—an individual’s sensitivity to bodily signals—is important in people with panic disorder. Like people with panic disorder, some migraineurs often have high interoceptive awareness. Anxiety sensitivity—fear that benign physical sensations will have harmful or catastrophic consequences—also may be a factor in panic disorder, as well as migraine. As in panic disorder, highly anxious migraineurs may develop hypervigilance to somatic sensations and conditioned fear to these internal sensations.

Dr. Baskin recommends screening patients for psychiatric comorbidity. He recommends two questions from the Patient Health Questionnaire-9 screener—“Do you have little interest or pleasure in doing things?” and “Are you feeling down, depressed, or hopeless?”—and two additional anxiety questions—“Are you feeling anxious, nervous, or on edge?” and “Are you unable to stop or control worrying?” “With just those four questions, you can capture a good number of people with anxiety or mood issues,” Dr. Baskin said.

Behavioral Therapy

“Our behavioral medicine program is time-limited and goal-oriented,” said Dr. Baskin. “We try to get people to develop self-efficacy and personal responsibility. We monitor and maximize adherence to medications and help patients to regulate their routine activities, including going to bed, getting up, and exercising on a consistent schedule. We offer biofeedback for self-regulation, relaxation and coping skills training utilizing a cognitive behavioral model, and we treat psychiatric issues,” said Dr. Baskin. Many of those things can be done by clinicians who are not behavioral clinicians, he said. “You do not necessarily have to refer all these people. Schedule frequent revisits for complicated or difficult patients. Do not overwhelm patients with too much information. Simplify jargon, provide written instructions, and make sure the patient understands the plan.”

An important component of behavioral treatment is teaching relaxation exercises, which can reduce muscle tension and autonomic arousal. There are many types of relaxation strategies. Dr. Baskin recommended breathing pacer apps, which are designed to encourage slower abdominal breathing. The goal is to gradually reduce the breathing rate to six breaths per minute for five- to 10-minute practice sessions. “If you can teach people diaphragmatic breathing—it takes about 30 seconds to begin the discussion—it is helpful.” Dr. Baskin recommended having patients do it three to five times per day for a few minutes at a time.

“We deliver relaxation training alone, sometimes with biofeedback, and teach it as a self-regulation coping skill. We try to get people to develop an internal locus of control so they can manage some of their own physiology, relax muscles, and learn a nonspecific low-arousal response and use it as a coping skill to apply in different situations,” Dr. Baskin said.

Cognitive behavioral therapy is another tool. It gives people an opportunity to modify distress-related thoughts and to examine their personal danger cognitions, their sense of threat, and the negative predictions that they may have. Dr. Baskin uses cognitive behavioral therapy to help patients develop an action plan based on their prescribed strategy to treat an acute migraine attack as well as manage concomitant emotional reactivity and maintain functionality in the presence of a significant headache disorder.

Trigger Management

Historically, migraineurs have avoided headache triggers. The down side to that strategy is that they can unnecessarily restrict themselves. Studies suggest that avoiding triggers may lead to sensitization to those triggers. Gradual exposure coping models are being developed. “Cope, do not avoid,” Dr. Baskin said.

Biofeedback

Relaxation training, EMG biofeedback, thermal biofeedback, and cognitive behavioral therapy show grade A but modest efficacy. There is recent evidence that combining behavioral therapy with preventive pharmacologic treatment improves outcomes. The behavioral section of the American Headache Society will soon be reviewing the most recent evidence on behavioral interventions in migraine.

Sleep Hygiene

Three main messages regarding sleep are to adopt a routine, consistent bedtime and wake up time, avoid all non–sleep-related activities at bedtime, and employ relaxation strategies to reduce sleep onset latency. In addition, patients should not eat or drink a lot of fluid too close to bedtime, not exercise in the evening, and avoid napping. A patient should be advised that if he or she cannot sleep, the best solution is to get out of bed, go to another room in the house, engage in a relaxing activity, and go back to bed when he or she gets tired. With these strategies, clinicians have converted chronic migraine to episodic migraine for a significant number of patients.

Combination Treatment of Migraine and Psychiatric Disorder

Many doctors support the idea that one drug should treat migraine and associated conditions whenever possible. The idea is to use one agent to treat migraine and associated conditions (“two-fer”) This strategy is simpler and may entail lower cost, fewer adverse events, and fewer potential drug interactions. “It makes sense on one level, however, there’s a risk of treating only one condition optimally or treating none of them optimally,” Dr. Baskin said. “It is important to treat both disorders the way you think they should be treated. Sometimes two drugs are better than one. You want to treat both conditions effectively.”

When treating anxiety disorders with selective serotonin reuptake inhibitors (SSRIs) or serotonin-norepinephrine reuptake inhibitors (SNRIs), prescribers should know that people with anxiety are exceptionally sensitive to side effects. Also, anxiety disorders often require higher doses than treating depression. “You should start dosing incredibly low and titrate slowly,” Dr. Baskin said.

—Glenn S. Williams

Multiaxial Assessment

All workups for headache evaluate frequency, intensity, duration, and disability. From a behavioral perspective, Dr. Baskin recommended considering a few more factors—adherence to therapy, stress-related issues, comorbid psychiatric disorders, and factors that transform migraine from episodic to chronic.

“When you talk about adherence, one of the basics of this is readiness to change,” said Dr. Baskin. “Is the patient motivated for treatment? That doesn’t necessarily happen immediately.” For example, a patient who is motivated to have an abortive agent might not be motivated to pursue prevention, lose weight, exercise, or make lifestyle changes. “Over time, that might change,” Dr. Baskin noted. Patient motivation may evolve with a greater understanding of the goals of treatment.

“Has the patient adhered to past therapy regimens? If the answer is no, then the answer will most likely be no again,” Dr. Baskin said. If medication overuse was a problem, it may be again. Whenever possible, ask open-ended questions, such as “how do you decide when to take an acute medication?” Dr. Baskin advised.

Stress and Migraine

High levels of daily stress, even daily stressors that are not catastrophic, can transform migraine from episodic to chronic. “Patients with depression show a greater effect of stress,” Dr. Baskin said. Similarly, victims of trauma or childhood maltreatment can have more disabling headaches that may be more likely to transform into daily headaches. “Many patients do not have the coping skills necessary to manage stress or recurrent headache,” Dr. Baskin said. One of the goals of behavioral therapy for migraine is to increase patients’ self-efficacy and give them the tools and the confidence to manage headaches and stressors.

Psychiatric Comorbidity

Psychiatric comorbidity may complicate differential diagnosis, and nonadherence to medication is greater in people with mood disorders and anxiety disorders. These patients may show a reduced response to pharmacologic and behavioral treatments for headache. Psychiatric comorbidities also can contribute to migraine chronification. “However, if you add a small behavioral component to your headache program, patients with psychiatric comorbidities seem to respond relatively well,” Dr. Baskin said.

Migraineurs have a two- to threefold greater prevalence of depression. There is a bidirectional relationship between migraine and depression in population studies. The relationship between migraine and depression is greater in clinic populations, in chronic migraine, and in medication overuse headache.

There is a significant relationship between migraine and anxiety disorders. Anxiety disorders entail a sense of danger, fear, or worry. “All patients with anxiety disorder have physical symptoms, and they often show avoidance behaviors,” said Dr. Baskin. For example, in generalized anxiety disorder, the object of avoidance is probably the fear of uncertainty. People worry excessively, thinking they are avoiding uncertainty. “Avoidance learning is huge in anxiety,” said Dr. Baskin. People fear unexpected events and perceive things as more unmanageable, dangerous, or threatening than they objectively are. “We see that frequently in migraineurs with anxiety disorders,” he said. Dr. Baskin noted that anxious patients tend to be sensitive to medication side effects and somatic sensations in general.

Patients with headache and anxiety often develop strong fear reactions. They identify a warning signal for headache, real or imagined, and may treat their fear, which they perceive as a headache prodrome, with a medication. “There is a preemptive strike with medicine treating a sensation that may or may not develop into headache,” Dr. Baskin said. That medication reduces their emotional distress and prevents the migraine, a powerful avoidance learning paradigm. That cycle can be a major part of medication overuse headache.

Anxiety disorders are much more prevalent than depression in migraineurs. They are associated with greater long-term persistence of headache, greater headache-related disability, and reduced satisfaction with acute therapy. “Across all emotional disorders, anxiety is the driver of distress,” Dr. Baskin said. “When you add anxiety to any disorder, it becomes much more problematic.”

The concept of interoceptive awareness—an individual’s sensitivity to bodily signals—is important in people with panic disorder. Like people with panic disorder, some migraineurs often have high interoceptive awareness. Anxiety sensitivity—fear that benign physical sensations will have harmful or catastrophic consequences—also may be a factor in panic disorder, as well as migraine. As in panic disorder, highly anxious migraineurs may develop hypervigilance to somatic sensations and conditioned fear to these internal sensations.

Dr. Baskin recommends screening patients for psychiatric comorbidity. He recommends two questions from the Patient Health Questionnaire-9 screener—“Do you have little interest or pleasure in doing things?” and “Are you feeling down, depressed, or hopeless?”—and two additional anxiety questions—“Are you feeling anxious, nervous, or on edge?” and “Are you unable to stop or control worrying?” “With just those four questions, you can capture a good number of people with anxiety or mood issues,” Dr. Baskin said.

Behavioral Therapy

“Our behavioral medicine program is time-limited and goal-oriented,” said Dr. Baskin. “We try to get people to develop self-efficacy and personal responsibility. We monitor and maximize adherence to medications and help patients to regulate their routine activities, including going to bed, getting up, and exercising on a consistent schedule. We offer biofeedback for self-regulation, relaxation and coping skills training utilizing a cognitive behavioral model, and we treat psychiatric issues,” said Dr. Baskin. Many of those things can be done by clinicians who are not behavioral clinicians, he said. “You do not necessarily have to refer all these people. Schedule frequent revisits for complicated or difficult patients. Do not overwhelm patients with too much information. Simplify jargon, provide written instructions, and make sure the patient understands the plan.”

An important component of behavioral treatment is teaching relaxation exercises, which can reduce muscle tension and autonomic arousal. There are many types of relaxation strategies. Dr. Baskin recommended breathing pacer apps, which are designed to encourage slower abdominal breathing. The goal is to gradually reduce the breathing rate to six breaths per minute for five- to 10-minute practice sessions. “If you can teach people diaphragmatic breathing—it takes about 30 seconds to begin the discussion—it is helpful.” Dr. Baskin recommended having patients do it three to five times per day for a few minutes at a time.

“We deliver relaxation training alone, sometimes with biofeedback, and teach it as a self-regulation coping skill. We try to get people to develop an internal locus of control so they can manage some of their own physiology, relax muscles, and learn a nonspecific low-arousal response and use it as a coping skill to apply in different situations,” Dr. Baskin said.

Cognitive behavioral therapy is another tool. It gives people an opportunity to modify distress-related thoughts and to examine their personal danger cognitions, their sense of threat, and the negative predictions that they may have. Dr. Baskin uses cognitive behavioral therapy to help patients develop an action plan based on their prescribed strategy to treat an acute migraine attack as well as manage concomitant emotional reactivity and maintain functionality in the presence of a significant headache disorder.

Trigger Management

Historically, migraineurs have avoided headache triggers. The down side to that strategy is that they can unnecessarily restrict themselves. Studies suggest that avoiding triggers may lead to sensitization to those triggers. Gradual exposure coping models are being developed. “Cope, do not avoid,” Dr. Baskin said.

Biofeedback

Relaxation training, EMG biofeedback, thermal biofeedback, and cognitive behavioral therapy show grade A but modest efficacy. There is recent evidence that combining behavioral therapy with preventive pharmacologic treatment improves outcomes. The behavioral section of the American Headache Society will soon be reviewing the most recent evidence on behavioral interventions in migraine.

Sleep Hygiene

Three main messages regarding sleep are to adopt a routine, consistent bedtime and wake up time, avoid all non–sleep-related activities at bedtime, and employ relaxation strategies to reduce sleep onset latency. In addition, patients should not eat or drink a lot of fluid too close to bedtime, not exercise in the evening, and avoid napping. A patient should be advised that if he or she cannot sleep, the best solution is to get out of bed, go to another room in the house, engage in a relaxing activity, and go back to bed when he or she gets tired. With these strategies, clinicians have converted chronic migraine to episodic migraine for a significant number of patients.

Combination Treatment of Migraine and Psychiatric Disorder

Many doctors support the idea that one drug should treat migraine and associated conditions whenever possible. The idea is to use one agent to treat migraine and associated conditions (“two-fer”) This strategy is simpler and may entail lower cost, fewer adverse events, and fewer potential drug interactions. “It makes sense on one level, however, there’s a risk of treating only one condition optimally or treating none of them optimally,” Dr. Baskin said. “It is important to treat both disorders the way you think they should be treated. Sometimes two drugs are better than one. You want to treat both conditions effectively.”

When treating anxiety disorders with selective serotonin reuptake inhibitors (SSRIs) or serotonin-norepinephrine reuptake inhibitors (SNRIs), prescribers should know that people with anxiety are exceptionally sensitive to side effects. Also, anxiety disorders often require higher doses than treating depression. “You should start dosing incredibly low and titrate slowly,” Dr. Baskin said.

—Glenn S. Williams

Multiaxial Assessment

All workups for headache evaluate frequency, intensity, duration, and disability. From a behavioral perspective, Dr. Baskin recommended considering a few more factors—adherence to therapy, stress-related issues, comorbid psychiatric disorders, and factors that transform migraine from episodic to chronic.

“When you talk about adherence, one of the basics of this is readiness to change,” said Dr. Baskin. “Is the patient motivated for treatment? That doesn’t necessarily happen immediately.” For example, a patient who is motivated to have an abortive agent might not be motivated to pursue prevention, lose weight, exercise, or make lifestyle changes. “Over time, that might change,” Dr. Baskin noted. Patient motivation may evolve with a greater understanding of the goals of treatment.

“Has the patient adhered to past therapy regimens? If the answer is no, then the answer will most likely be no again,” Dr. Baskin said. If medication overuse was a problem, it may be again. Whenever possible, ask open-ended questions, such as “how do you decide when to take an acute medication?” Dr. Baskin advised.

Stress and Migraine

High levels of daily stress, even daily stressors that are not catastrophic, can transform migraine from episodic to chronic. “Patients with depression show a greater effect of stress,” Dr. Baskin said. Similarly, victims of trauma or childhood maltreatment can have more disabling headaches that may be more likely to transform into daily headaches. “Many patients do not have the coping skills necessary to manage stress or recurrent headache,” Dr. Baskin said. One of the goals of behavioral therapy for migraine is to increase patients’ self-efficacy and give them the tools and the confidence to manage headaches and stressors.

Psychiatric Comorbidity

Psychiatric comorbidity may complicate differential diagnosis, and nonadherence to medication is greater in people with mood disorders and anxiety disorders. These patients may show a reduced response to pharmacologic and behavioral treatments for headache. Psychiatric comorbidities also can contribute to migraine chronification. “However, if you add a small behavioral component to your headache program, patients with psychiatric comorbidities seem to respond relatively well,” Dr. Baskin said.

Migraineurs have a two- to threefold greater prevalence of depression. There is a bidirectional relationship between migraine and depression in population studies. The relationship between migraine and depression is greater in clinic populations, in chronic migraine, and in medication overuse headache.

There is a significant relationship between migraine and anxiety disorders. Anxiety disorders entail a sense of danger, fear, or worry. “All patients with anxiety disorder have physical symptoms, and they often show avoidance behaviors,” said Dr. Baskin. For example, in generalized anxiety disorder, the object of avoidance is probably the fear of uncertainty. People worry excessively, thinking they are avoiding uncertainty. “Avoidance learning is huge in anxiety,” said Dr. Baskin. People fear unexpected events and perceive things as more unmanageable, dangerous, or threatening than they objectively are. “We see that frequently in migraineurs with anxiety disorders,” he said. Dr. Baskin noted that anxious patients tend to be sensitive to medication side effects and somatic sensations in general.

Patients with headache and anxiety often develop strong fear reactions. They identify a warning signal for headache, real or imagined, and may treat their fear, which they perceive as a headache prodrome, with a medication. “There is a preemptive strike with medicine treating a sensation that may or may not develop into headache,” Dr. Baskin said. That medication reduces their emotional distress and prevents the migraine, a powerful avoidance learning paradigm. That cycle can be a major part of medication overuse headache.

Anxiety disorders are much more prevalent than depression in migraineurs. They are associated with greater long-term persistence of headache, greater headache-related disability, and reduced satisfaction with acute therapy. “Across all emotional disorders, anxiety is the driver of distress,” Dr. Baskin said. “When you add anxiety to any disorder, it becomes much more problematic.”

The concept of interoceptive awareness—an individual’s sensitivity to bodily signals—is important in people with panic disorder. Like people with panic disorder, some migraineurs often have high interoceptive awareness. Anxiety sensitivity—fear that benign physical sensations will have harmful or catastrophic consequences—also may be a factor in panic disorder, as well as migraine. As in panic disorder, highly anxious migraineurs may develop hypervigilance to somatic sensations and conditioned fear to these internal sensations.

Dr. Baskin recommends screening patients for psychiatric comorbidity. He recommends two questions from the Patient Health Questionnaire-9 screener—“Do you have little interest or pleasure in doing things?” and “Are you feeling down, depressed, or hopeless?”—and two additional anxiety questions—“Are you feeling anxious, nervous, or on edge?” and “Are you unable to stop or control worrying?” “With just those four questions, you can capture a good number of people with anxiety or mood issues,” Dr. Baskin said.

Behavioral Therapy

“Our behavioral medicine program is time-limited and goal-oriented,” said Dr. Baskin. “We try to get people to develop self-efficacy and personal responsibility. We monitor and maximize adherence to medications and help patients to regulate their routine activities, including going to bed, getting up, and exercising on a consistent schedule. We offer biofeedback for self-regulation, relaxation and coping skills training utilizing a cognitive behavioral model, and we treat psychiatric issues,” said Dr. Baskin. Many of those things can be done by clinicians who are not behavioral clinicians, he said. “You do not necessarily have to refer all these people. Schedule frequent revisits for complicated or difficult patients. Do not overwhelm patients with too much information. Simplify jargon, provide written instructions, and make sure the patient understands the plan.”

An important component of behavioral treatment is teaching relaxation exercises, which can reduce muscle tension and autonomic arousal. There are many types of relaxation strategies. Dr. Baskin recommended breathing pacer apps, which are designed to encourage slower abdominal breathing. The goal is to gradually reduce the breathing rate to six breaths per minute for five- to 10-minute practice sessions. “If you can teach people diaphragmatic breathing—it takes about 30 seconds to begin the discussion—it is helpful.” Dr. Baskin recommended having patients do it three to five times per day for a few minutes at a time.

“We deliver relaxation training alone, sometimes with biofeedback, and teach it as a self-regulation coping skill. We try to get people to develop an internal locus of control so they can manage some of their own physiology, relax muscles, and learn a nonspecific low-arousal response and use it as a coping skill to apply in different situations,” Dr. Baskin said.

Cognitive behavioral therapy is another tool. It gives people an opportunity to modify distress-related thoughts and to examine their personal danger cognitions, their sense of threat, and the negative predictions that they may have. Dr. Baskin uses cognitive behavioral therapy to help patients develop an action plan based on their prescribed strategy to treat an acute migraine attack as well as manage concomitant emotional reactivity and maintain functionality in the presence of a significant headache disorder.

Trigger Management

Historically, migraineurs have avoided headache triggers. The down side to that strategy is that they can unnecessarily restrict themselves. Studies suggest that avoiding triggers may lead to sensitization to those triggers. Gradual exposure coping models are being developed. “Cope, do not avoid,” Dr. Baskin said.

Biofeedback

Relaxation training, EMG biofeedback, thermal biofeedback, and cognitive behavioral therapy show grade A but modest efficacy. There is recent evidence that combining behavioral therapy with preventive pharmacologic treatment improves outcomes. The behavioral section of the American Headache Society will soon be reviewing the most recent evidence on behavioral interventions in migraine.

Sleep Hygiene

Three main messages regarding sleep are to adopt a routine, consistent bedtime and wake up time, avoid all non–sleep-related activities at bedtime, and employ relaxation strategies to reduce sleep onset latency. In addition, patients should not eat or drink a lot of fluid too close to bedtime, not exercise in the evening, and avoid napping. A patient should be advised that if he or she cannot sleep, the best solution is to get out of bed, go to another room in the house, engage in a relaxing activity, and go back to bed when he or she gets tired. With these strategies, clinicians have converted chronic migraine to episodic migraine for a significant number of patients.

Combination Treatment of Migraine and Psychiatric Disorder

Many doctors support the idea that one drug should treat migraine and associated conditions whenever possible. The idea is to use one agent to treat migraine and associated conditions (“two-fer”) This strategy is simpler and may entail lower cost, fewer adverse events, and fewer potential drug interactions. “It makes sense on one level, however, there’s a risk of treating only one condition optimally or treating none of them optimally,” Dr. Baskin said. “It is important to treat both disorders the way you think they should be treated. Sometimes two drugs are better than one. You want to treat both conditions effectively.”

When treating anxiety disorders with selective serotonin reuptake inhibitors (SSRIs) or serotonin-norepinephrine reuptake inhibitors (SNRIs), prescribers should know that people with anxiety are exceptionally sensitive to side effects. Also, anxiety disorders often require higher doses than treating depression. “You should start dosing incredibly low and titrate slowly,” Dr. Baskin said.

—Glenn S. Williams

Patients with newly diagnosed Parkinson’s disease and reduced CSF amyloid β_1–42 may be more likely to develop Parkinson’s disease psychosis within three to four years, according to a study published in the April issue of the Journal of Neurology, Neurosurgery and Psychiatry. The type of psychotic symptom (eg, illusions or formed hallucinations) may indicate a specific profile of visual, cognitive, cortical, and hippocampal involvement in Parkinson’s disease, said the authors.

“Our finding may suggest [that] early-onset Parkinson’s disease psychosis is a biomarker for the subsequent development of Alzheimer pathology,” said Dominic H. Ffytche, MD, PhD, of the Department of Old Age Psychiatry and Dementia at King’s College London.

Previous studies have indicated that visual hallucinations and illusions may be caused by specific cognitive and higher visual function deficits. Patients who develop these symptoms early in the disease course have greater rates of cognitive decline and progression to dementia, said the authors. No studies have investigated whether cognitive and higher visual function deficits are found before the onset of Parkinson’s disease, however.

Dr. Ffytche and colleagues examined the profile of cognitive, biomarker, and other risk factors before the onset of illusions and hallucinations in the Parkinson’s Progression Markers Initiative (PPMI) data set.

The PPMI is an observational multicenter study of newly diagnosed, untreated patients and healthy controls. It includes standardized, clinical, imaging, CSF, and cognitive assessments at three-month intervals during the first year and at six-month intervals in subsequent years. Assessment tools include the Montreal Cognitive Assessment, the Benton Judgement of Line Orientation, and the Unified Parkinson’s Disease Rating Scale.

Dr. Ffytche’s group included 195 healthy controls and 423 patients with Parkinson’s disease in its analysis. They compared baseline assessments in patients who developed illusions or hallucinations within three to four years of follow-up and in patients who did not develop these symptoms.

Of all patients with Parkinson’s disease, 115 people reported psychotic symptoms (predominantly illusions) at a median time of 19.5 months. At baseline, these patients had reduced CSF amyloid β_1–42, lower olfaction scores, higher depression scores, and increased REM sleep behavior disorder symptoms, compared with patients without early-onset Parkinson’s disease psychosis. No differences in cognitive, higher visual, or structural imaging measures were observed, however. Dr. Ffytche and colleagues also found a subset of 21 participants with early-onset formed hallucinations who had reduced higher visual function at baseline; cortical thinning in the parietal, occipital, and frontal cortex; and reduced hippocampal volume.

One limitation of the study was its lack of phenomenologic detail about the symptoms of Parkinson’s disease psychosis. In addition, information was collected about symptoms during the week before each given assessment, thus some symptoms that occurred between assessments were missed.

—Erica Tricarico

Suggested Reading

Ffytche DH, Pereira JB, Ballard C, et al. Risk factors for early psychosis in PD: insights from the Parkinson’s Progression Markers Initiative. J Neurol Neurosurg Psychiatry. 2017;88(4):325-331.

Patients with newly diagnosed Parkinson’s disease and reduced CSF amyloid β_1–42 may be more likely to develop Parkinson’s disease psychosis within three to four years, according to a study published in the April issue of the Journal of Neurology, Neurosurgery and Psychiatry. The type of psychotic symptom (eg, illusions or formed hallucinations) may indicate a specific profile of visual, cognitive, cortical, and hippocampal involvement in Parkinson’s disease, said the authors.

“Our finding may suggest [that] early-onset Parkinson’s disease psychosis is a biomarker for the subsequent development of Alzheimer pathology,” said Dominic H. Ffytche, MD, PhD, of the Department of Old Age Psychiatry and Dementia at King’s College London.

Previous studies have indicated that visual hallucinations and illusions may be caused by specific cognitive and higher visual function deficits. Patients who develop these symptoms early in the disease course have greater rates of cognitive decline and progression to dementia, said the authors. No studies have investigated whether cognitive and higher visual function deficits are found before the onset of Parkinson’s disease, however.

Dr. Ffytche and colleagues examined the profile of cognitive, biomarker, and other risk factors before the onset of illusions and hallucinations in the Parkinson’s Progression Markers Initiative (PPMI) data set.

The PPMI is an observational multicenter study of newly diagnosed, untreated patients and healthy controls. It includes standardized, clinical, imaging, CSF, and cognitive assessments at three-month intervals during the first year and at six-month intervals in subsequent years. Assessment tools include the Montreal Cognitive Assessment, the Benton Judgement of Line Orientation, and the Unified Parkinson’s Disease Rating Scale.

Dr. Ffytche’s group included 195 healthy controls and 423 patients with Parkinson’s disease in its analysis. They compared baseline assessments in patients who developed illusions or hallucinations within three to four years of follow-up and in patients who did not develop these symptoms.

Of all patients with Parkinson’s disease, 115 people reported psychotic symptoms (predominantly illusions) at a median time of 19.5 months. At baseline, these patients had reduced CSF amyloid β_1–42, lower olfaction scores, higher depression scores, and increased REM sleep behavior disorder symptoms, compared with patients without early-onset Parkinson’s disease psychosis. No differences in cognitive, higher visual, or structural imaging measures were observed, however. Dr. Ffytche and colleagues also found a subset of 21 participants with early-onset formed hallucinations who had reduced higher visual function at baseline; cortical thinning in the parietal, occipital, and frontal cortex; and reduced hippocampal volume.

One limitation of the study was its lack of phenomenologic detail about the symptoms of Parkinson’s disease psychosis. In addition, information was collected about symptoms during the week before each given assessment, thus some symptoms that occurred between assessments were missed.

—Erica Tricarico

Suggested Reading

Ffytche DH, Pereira JB, Ballard C, et al. Risk factors for early psychosis in PD: insights from the Parkinson’s Progression Markers Initiative. J Neurol Neurosurg Psychiatry. 2017;88(4):325-331.

Patients with newly diagnosed Parkinson’s disease and reduced CSF amyloid β_1–42 may be more likely to develop Parkinson’s disease psychosis within three to four years, according to a study published in the April issue of the Journal of Neurology, Neurosurgery and Psychiatry. The type of psychotic symptom (eg, illusions or formed hallucinations) may indicate a specific profile of visual, cognitive, cortical, and hippocampal involvement in Parkinson’s disease, said the authors.

“Our finding may suggest [that] early-onset Parkinson’s disease psychosis is a biomarker for the subsequent development of Alzheimer pathology,” said Dominic H. Ffytche, MD, PhD, of the Department of Old Age Psychiatry and Dementia at King’s College London.

Previous studies have indicated that visual hallucinations and illusions may be caused by specific cognitive and higher visual function deficits. Patients who develop these symptoms early in the disease course have greater rates of cognitive decline and progression to dementia, said the authors. No studies have investigated whether cognitive and higher visual function deficits are found before the onset of Parkinson’s disease, however.

Dr. Ffytche and colleagues examined the profile of cognitive, biomarker, and other risk factors before the onset of illusions and hallucinations in the Parkinson’s Progression Markers Initiative (PPMI) data set.

The PPMI is an observational multicenter study of newly diagnosed, untreated patients and healthy controls. It includes standardized, clinical, imaging, CSF, and cognitive assessments at three-month intervals during the first year and at six-month intervals in subsequent years. Assessment tools include the Montreal Cognitive Assessment, the Benton Judgement of Line Orientation, and the Unified Parkinson’s Disease Rating Scale.

Dr. Ffytche’s group included 195 healthy controls and 423 patients with Parkinson’s disease in its analysis. They compared baseline assessments in patients who developed illusions or hallucinations within three to four years of follow-up and in patients who did not develop these symptoms.

Of all patients with Parkinson’s disease, 115 people reported psychotic symptoms (predominantly illusions) at a median time of 19.5 months. At baseline, these patients had reduced CSF amyloid β_1–42, lower olfaction scores, higher depression scores, and increased REM sleep behavior disorder symptoms, compared with patients without early-onset Parkinson’s disease psychosis. No differences in cognitive, higher visual, or structural imaging measures were observed, however. Dr. Ffytche and colleagues also found a subset of 21 participants with early-onset formed hallucinations who had reduced higher visual function at baseline; cortical thinning in the parietal, occipital, and frontal cortex; and reduced hippocampal volume.

One limitation of the study was its lack of phenomenologic detail about the symptoms of Parkinson’s disease psychosis. In addition, information was collected about symptoms during the week before each given assessment, thus some symptoms that occurred between assessments were missed.

—Erica Tricarico

Suggested Reading

Ffytche DH, Pereira JB, Ballard C, et al. Risk factors for early psychosis in PD: insights from the Parkinson’s Progression Markers Initiative. J Neurol Neurosurg Psychiatry. 2017;88(4):325-331.

BOSTON – Ultra-fast door-to-needle times of 10 minutes or less for intravenous acute ischemic stroke thrombolysis can be safely achieved in carefully selected cases, according to a review of cases at an Austrian teaching hospital.

Raffi Topakian, MD, and his colleagues at the Academic Teaching Hospital Wels-Grieskirchen in Wels, Austria, followed a multidisciplinary intervention to reinforce key components of the well-known Helsinki model of acute stroke care to improve the intravenous thrombolysis rate and the median door-to-needle time (DNT) at the teaching hospital and analyzed data from 361 patients who underwent intravenous thrombolysis (IVT) for stroke there between July 2014 and September 2016. The IVT rate increased from 19% to about 27% after intervention, and the DNT during the study period was 60 minutes or less in 316 patients (87.5%), 30 minutes or less in 181 patients (50.1%), and 10 minutes or less in 63 patients (17.5%).

“Over the study period, we reduced the DNT time from 49 minutes to 25 minutes. This was significant, and the door-to-needle times were astonishingly similar for the in-hours service and the out-of-hour service,” he said at the annual meeting of the American Academy of Neurology.

Further, the rate of prenotifications from emergency medical services rose from about 30% to 63% during the study period.

Patients with ultra-fast DNT vs. those with slower DNT were older, had more chronic heart failure, had more severe stroke (National Institutes of Health Stroke Scale score of 10 vs. 5), had more anterior circulation stroke and cardioembolic stroke, and had clear onset of stroke. Independent predictors of ultra-fast DNT included prenotification by EMS, anterior circulation syndrome, chronic heart failure, and having a stroke neurologist on duty, Dr. Topakian said.

“Ultra short DNTs can be achieved safely. The key is that we are prenotified by the EMS, that we can get all the relevant history details during transport, that there is a dedicated multidisciplinary stroke team and EMS staff, and that we have a seemingly unequivocal clinical scenario,” he said. “Out-of-hours DNT matched in-hours DNT, but the caveat is we’re talking about highly selected candidates; safety must not be sacrificed for the sake of speed, in all of our patients.”

Dr. Topakian has received personal compensation for activities with Novartis and Shire-Baxalta as an advisory board member; from Novartis, Pfizer, AbbVie, and Bayer for conference support; and from Pfizer as a speaker.

[email protected]

BOSTON – Ultra-fast door-to-needle times of 10 minutes or less for intravenous acute ischemic stroke thrombolysis can be safely achieved in carefully selected cases, according to a review of cases at an Austrian teaching hospital.

Raffi Topakian, MD, and his colleagues at the Academic Teaching Hospital Wels-Grieskirchen in Wels, Austria, followed a multidisciplinary intervention to reinforce key components of the well-known Helsinki model of acute stroke care to improve the intravenous thrombolysis rate and the median door-to-needle time (DNT) at the teaching hospital and analyzed data from 361 patients who underwent intravenous thrombolysis (IVT) for stroke there between July 2014 and September 2016. The IVT rate increased from 19% to about 27% after intervention, and the DNT during the study period was 60 minutes or less in 316 patients (87.5%), 30 minutes or less in 181 patients (50.1%), and 10 minutes or less in 63 patients (17.5%).

“Over the study period, we reduced the DNT time from 49 minutes to 25 minutes. This was significant, and the door-to-needle times were astonishingly similar for the in-hours service and the out-of-hour service,” he said at the annual meeting of the American Academy of Neurology.

Further, the rate of prenotifications from emergency medical services rose from about 30% to 63% during the study period.

Patients with ultra-fast DNT vs. those with slower DNT were older, had more chronic heart failure, had more severe stroke (National Institutes of Health Stroke Scale score of 10 vs. 5), had more anterior circulation stroke and cardioembolic stroke, and had clear onset of stroke. Independent predictors of ultra-fast DNT included prenotification by EMS, anterior circulation syndrome, chronic heart failure, and having a stroke neurologist on duty, Dr. Topakian said.

“Ultra short DNTs can be achieved safely. The key is that we are prenotified by the EMS, that we can get all the relevant history details during transport, that there is a dedicated multidisciplinary stroke team and EMS staff, and that we have a seemingly unequivocal clinical scenario,” he said. “Out-of-hours DNT matched in-hours DNT, but the caveat is we’re talking about highly selected candidates; safety must not be sacrificed for the sake of speed, in all of our patients.”

Dr. Topakian has received personal compensation for activities with Novartis and Shire-Baxalta as an advisory board member; from Novartis, Pfizer, AbbVie, and Bayer for conference support; and from Pfizer as a speaker.

[email protected]

BOSTON – Ultra-fast door-to-needle times of 10 minutes or less for intravenous acute ischemic stroke thrombolysis can be safely achieved in carefully selected cases, according to a review of cases at an Austrian teaching hospital.

Raffi Topakian, MD, and his colleagues at the Academic Teaching Hospital Wels-Grieskirchen in Wels, Austria, followed a multidisciplinary intervention to reinforce key components of the well-known Helsinki model of acute stroke care to improve the intravenous thrombolysis rate and the median door-to-needle time (DNT) at the teaching hospital and analyzed data from 361 patients who underwent intravenous thrombolysis (IVT) for stroke there between July 2014 and September 2016. The IVT rate increased from 19% to about 27% after intervention, and the DNT during the study period was 60 minutes or less in 316 patients (87.5%), 30 minutes or less in 181 patients (50.1%), and 10 minutes or less in 63 patients (17.5%).

“Over the study period, we reduced the DNT time from 49 minutes to 25 minutes. This was significant, and the door-to-needle times were astonishingly similar for the in-hours service and the out-of-hour service,” he said at the annual meeting of the American Academy of Neurology.

Further, the rate of prenotifications from emergency medical services rose from about 30% to 63% during the study period.

Patients with ultra-fast DNT vs. those with slower DNT were older, had more chronic heart failure, had more severe stroke (National Institutes of Health Stroke Scale score of 10 vs. 5), had more anterior circulation stroke and cardioembolic stroke, and had clear onset of stroke. Independent predictors of ultra-fast DNT included prenotification by EMS, anterior circulation syndrome, chronic heart failure, and having a stroke neurologist on duty, Dr. Topakian said.

“Ultra short DNTs can be achieved safely. The key is that we are prenotified by the EMS, that we can get all the relevant history details during transport, that there is a dedicated multidisciplinary stroke team and EMS staff, and that we have a seemingly unequivocal clinical scenario,” he said. “Out-of-hours DNT matched in-hours DNT, but the caveat is we’re talking about highly selected candidates; safety must not be sacrificed for the sake of speed, in all of our patients.”

Dr. Topakian has received personal compensation for activities with Novartis and Shire-Baxalta as an advisory board member; from Novartis, Pfizer, AbbVie, and Bayer for conference support; and from Pfizer as a speaker.

[email protected]

Veterans Health Administration monitoring of carbapenem-resistant Enterobacteriaceae (CRE) trends from 2006 to 2015 shows a rise in resistance rates of E. cloacae complex nationwide.

The first major CRE outbreak, Klebsiella pneumoniae, occurred in the eastern United States in the early 2000s and has since spread across the country. K. pneumoniae has recently shown a decrease in resistance rates in the region including New York, both in the current VHA-based study and in a 2016 study of three New York City hospitals.

“CRE trends during 2006-2015 in the VHA recapitulate the epidemic of carbapenem-resistant K. pneumoniae in the United States and indicate that a ‘second epidemic’ of carbapenem-resistant E. cloacae complex appears to be unfolding,” wrote Brigid M. Wilson, PhD, of Louis Stokes Cleveland Department of Veterans Affairs Medical Center, and her coauthors.

The researchers used VHA network data to identify 128,431 K. pneumoniae and 38,219 E. cloacae complex (which refers to the species E. cloacae, E. asburiae, E. kobei, E. hormaechei, and E. xiafangensis) isolates from patients hospitalized in 140 facilities in 40 states, the District of Columbia, and Puerto Rico from 2006 to 2015. These isolates, paired with their carbapenem susceptibility test results, show the rise and geographic concentration of the CRE cases over the decade.

The increased E. cloacae complex resistance in 2014-2015 was centered around the Pacific Coast and Southwest regions. The researchers noted that E. cloacae complex has a less well defined genetic makeup, compared with K. pneumoniae.

“We hypothesize that E. cloacae complex contains genotypes with epidemic potential associated with increasing rates of carbapenem resistance observed in the VHA,” they wrote, concluding that “the VHA may serve as a vantage point for detecting nationwide trends in antimicrobial drug resistance” (Emerg Infect Dis. 2017 Mar. doi: 10.3201/eid2305.162034).

[email protected]

Veterans Health Administration monitoring of carbapenem-resistant Enterobacteriaceae (CRE) trends from 2006 to 2015 shows a rise in resistance rates of E. cloacae complex nationwide.

The first major CRE outbreak, Klebsiella pneumoniae, occurred in the eastern United States in the early 2000s and has since spread across the country. K. pneumoniae has recently shown a decrease in resistance rates in the region including New York, both in the current VHA-based study and in a 2016 study of three New York City hospitals.

“CRE trends during 2006-2015 in the VHA recapitulate the epidemic of carbapenem-resistant K. pneumoniae in the United States and indicate that a ‘second epidemic’ of carbapenem-resistant E. cloacae complex appears to be unfolding,” wrote Brigid M. Wilson, PhD, of Louis Stokes Cleveland Department of Veterans Affairs Medical Center, and her coauthors.

The researchers used VHA network data to identify 128,431 K. pneumoniae and 38,219 E. cloacae complex (which refers to the species E. cloacae, E. asburiae, E. kobei, E. hormaechei, and E. xiafangensis) isolates from patients hospitalized in 140 facilities in 40 states, the District of Columbia, and Puerto Rico from 2006 to 2015. These isolates, paired with their carbapenem susceptibility test results, show the rise and geographic concentration of the CRE cases over the decade.

The increased E. cloacae complex resistance in 2014-2015 was centered around the Pacific Coast and Southwest regions. The researchers noted that E. cloacae complex has a less well defined genetic makeup, compared with K. pneumoniae.

“We hypothesize that E. cloacae complex contains genotypes with epidemic potential associated with increasing rates of carbapenem resistance observed in the VHA,” they wrote, concluding that “the VHA may serve as a vantage point for detecting nationwide trends in antimicrobial drug resistance” (Emerg Infect Dis. 2017 Mar. doi: 10.3201/eid2305.162034).

[email protected]

Veterans Health Administration monitoring of carbapenem-resistant Enterobacteriaceae (CRE) trends from 2006 to 2015 shows a rise in resistance rates of E. cloacae complex nationwide.

The first major CRE outbreak, Klebsiella pneumoniae, occurred in the eastern United States in the early 2000s and has since spread across the country. K. pneumoniae has recently shown a decrease in resistance rates in the region including New York, both in the current VHA-based study and in a 2016 study of three New York City hospitals.

“CRE trends during 2006-2015 in the VHA recapitulate the epidemic of carbapenem-resistant K. pneumoniae in the United States and indicate that a ‘second epidemic’ of carbapenem-resistant E. cloacae complex appears to be unfolding,” wrote Brigid M. Wilson, PhD, of Louis Stokes Cleveland Department of Veterans Affairs Medical Center, and her coauthors.

The researchers used VHA network data to identify 128,431 K. pneumoniae and 38,219 E. cloacae complex (which refers to the species E. cloacae, E. asburiae, E. kobei, E. hormaechei, and E. xiafangensis) isolates from patients hospitalized in 140 facilities in 40 states, the District of Columbia, and Puerto Rico from 2006 to 2015. These isolates, paired with their carbapenem susceptibility test results, show the rise and geographic concentration of the CRE cases over the decade.

The increased E. cloacae complex resistance in 2014-2015 was centered around the Pacific Coast and Southwest regions. The researchers noted that E. cloacae complex has a less well defined genetic makeup, compared with K. pneumoniae.

“We hypothesize that E. cloacae complex contains genotypes with epidemic potential associated with increasing rates of carbapenem resistance observed in the VHA,” they wrote, concluding that “the VHA may serve as a vantage point for detecting nationwide trends in antimicrobial drug resistance” (Emerg Infect Dis. 2017 Mar. doi: 10.3201/eid2305.162034).

[email protected]

WASHINGTON – Crowds of protesters packed the Washington’s National Mall for the March for Science, joining participants in 600 cities across the world on Saturday, April 22.

Advocates came in droves, braving the rain armed with homemade signs, chants, and a passion for peer review, to champion the scientific method and the importance of its role in society and policy making.

The event, organized by March for Science, Earth Day Network, and a robust list of advocacy groups and think tanks, started with learning sessions hosted in tents located beyond the Washington Monument, where experts in topics from physics to environmental science informed attendees about the importance of their subjects.

Eli Zimmerman/Fronline Medical News

Eli Zimmerman/Fronline Medical News

“A strong commitment to research is absolutely essential to crafting evidence-based policies to protect us from serious health threats,” said Georges C. Benjamin, MD, executive director of the America Public Health Association. “A nation that ignores science, that denies science, that underfunds science, does so at its own peril.”

Speakers like Kellan Baker, senior fellow with the LGBT Research and Communications Project at the Center for American Progress, promoted political action, echoing organizers’ intentions of being bipartisan but not shying away from promoting political action.

“Advocacy is not a dirty word” said Mr. Baker. “Science is objective, but it is not neutral.”

Other speakers included Mona Hanna-Attisha, MD, the pediatrician who helped expose the lead poisoning situation in Flint, Mich., and Bill Nye, CEO of the Planetary Society and host of the Netflix series “Bill Nye Saves the World.”

After speeches, protesters marched from the Washington Monument to the U.S. Capitol, chanting loudly and waving signs.

March for Science and its partners are continuing to promote advocacy through a “week of action” scheduled to run through April 29.

*This article was updated May 2, 2017.

[email protected]

On Twitter @eaztweets

WASHINGTON – Crowds of protesters packed the Washington’s National Mall for the March for Science, joining participants in 600 cities across the world on Saturday, April 22.

Advocates came in droves, braving the rain armed with homemade signs, chants, and a passion for peer review, to champion the scientific method and the importance of its role in society and policy making.

The event, organized by March for Science, Earth Day Network, and a robust list of advocacy groups and think tanks, started with learning sessions hosted in tents located beyond the Washington Monument, where experts in topics from physics to environmental science informed attendees about the importance of their subjects.

Eli Zimmerman/Fronline Medical News

Eli Zimmerman/Fronline Medical News

“A strong commitment to research is absolutely essential to crafting evidence-based policies to protect us from serious health threats,” said Georges C. Benjamin, MD, executive director of the America Public Health Association. “A nation that ignores science, that denies science, that underfunds science, does so at its own peril.”

Speakers like Kellan Baker, senior fellow with the LGBT Research and Communications Project at the Center for American Progress, promoted political action, echoing organizers’ intentions of being bipartisan but not shying away from promoting political action.

“Advocacy is not a dirty word” said Mr. Baker. “Science is objective, but it is not neutral.”

Other speakers included Mona Hanna-Attisha, MD, the pediatrician who helped expose the lead poisoning situation in Flint, Mich., and Bill Nye, CEO of the Planetary Society and host of the Netflix series “Bill Nye Saves the World.”

After speeches, protesters marched from the Washington Monument to the U.S. Capitol, chanting loudly and waving signs.

March for Science and its partners are continuing to promote advocacy through a “week of action” scheduled to run through April 29.

*This article was updated May 2, 2017.

[email protected]

On Twitter @eaztweets

WASHINGTON – Crowds of protesters packed the Washington’s National Mall for the March for Science, joining participants in 600 cities across the world on Saturday, April 22.

Advocates came in droves, braving the rain armed with homemade signs, chants, and a passion for peer review, to champion the scientific method and the importance of its role in society and policy making.

The event, organized by March for Science, Earth Day Network, and a robust list of advocacy groups and think tanks, started with learning sessions hosted in tents located beyond the Washington Monument, where experts in topics from physics to environmental science informed attendees about the importance of their subjects.

Eli Zimmerman/Fronline Medical News

Eli Zimmerman/Fronline Medical News

“A strong commitment to research is absolutely essential to crafting evidence-based policies to protect us from serious health threats,” said Georges C. Benjamin, MD, executive director of the America Public Health Association. “A nation that ignores science, that denies science, that underfunds science, does so at its own peril.”

Speakers like Kellan Baker, senior fellow with the LGBT Research and Communications Project at the Center for American Progress, promoted political action, echoing organizers’ intentions of being bipartisan but not shying away from promoting political action.

“Advocacy is not a dirty word” said Mr. Baker. “Science is objective, but it is not neutral.”

Other speakers included Mona Hanna-Attisha, MD, the pediatrician who helped expose the lead poisoning situation in Flint, Mich., and Bill Nye, CEO of the Planetary Society and host of the Netflix series “Bill Nye Saves the World.”

After speeches, protesters marched from the Washington Monument to the U.S. Capitol, chanting loudly and waving signs.

March for Science and its partners are continuing to promote advocacy through a “week of action” scheduled to run through April 29.

*This article was updated May 2, 2017.

[email protected]

On Twitter @eaztweets

BOSTON – Survivors of sepsis face a significantly increased risk of seizures following an index hospitalization, regardless of any previous history of seizures or seizures occurring during hospitalization, according to findings from a retrospective, population-based cohort study.

The risk for having subsequent seizures was highest for patients younger than 65 years but was still elevated above the general population for those aged 65 years or older, Michael Reznik, MD, reported at the annual meeting of the American Academy of Neurology.

[email protected]

BOSTON – Survivors of sepsis face a significantly increased risk of seizures following an index hospitalization, regardless of any previous history of seizures or seizures occurring during hospitalization, according to findings from a retrospective, population-based cohort study.

The risk for having subsequent seizures was highest for patients younger than 65 years but was still elevated above the general population for those aged 65 years or older, Michael Reznik, MD, reported at the annual meeting of the American Academy of Neurology.

[email protected]

BOSTON – Survivors of sepsis face a significantly increased risk of seizures following an index hospitalization, regardless of any previous history of seizures or seizures occurring during hospitalization, according to findings from a retrospective, population-based cohort study.

The risk for having subsequent seizures was highest for patients younger than 65 years but was still elevated above the general population for those aged 65 years or older, Michael Reznik, MD, reported at the annual meeting of the American Academy of Neurology.

[email protected]

WASHINGTON – Peaceful protesters in hundreds of cities around the globe gathered on Earth Day, April 22, to voice their support for evidence-based policies and funding for scientific research at the March for Science.

In Washington, thousands of participants gathered on the rainy National Mall for teach-ins and speeches, then marched from the Washington Monument to Capitol Hill. A key concern for marchers here was cuts in science agency funding in the Trump administration’s budget proposal for fiscal year 2018.

Organizers now are calling on supporters to participate in a week of action to continue to demonstrate widespread support for their positions.

On Twitter @denisefulton

WASHINGTON – Peaceful protesters in hundreds of cities around the globe gathered on Earth Day, April 22, to voice their support for evidence-based policies and funding for scientific research at the March for Science.

In Washington, thousands of participants gathered on the rainy National Mall for teach-ins and speeches, then marched from the Washington Monument to Capitol Hill. A key concern for marchers here was cuts in science agency funding in the Trump administration’s budget proposal for fiscal year 2018.

Organizers now are calling on supporters to participate in a week of action to continue to demonstrate widespread support for their positions.

On Twitter @denisefulton

WASHINGTON – Peaceful protesters in hundreds of cities around the globe gathered on Earth Day, April 22, to voice their support for evidence-based policies and funding for scientific research at the March for Science.

In Washington, thousands of participants gathered on the rainy National Mall for teach-ins and speeches, then marched from the Washington Monument to Capitol Hill. A key concern for marchers here was cuts in science agency funding in the Trump administration’s budget proposal for fiscal year 2018.

Organizers now are calling on supporters to participate in a week of action to continue to demonstrate widespread support for their positions.

On Twitter @denisefulton

Editor’s note: “Everything We Say and Do” is an informational series developed by SHM’s Patient Experience Committee to provide readers with thoughtful and actionable communication tactics that have great potential to positively affect patients’ experience of care. This column highlights key takeaways from the SHM track of the upcoming 2017 Cleveland Clinic Patient Experience Empathy and Innovation Summit, May 22-24. Three hospitalist leaders describe their approach to leading the design of the inpatient experience.

What we say and do, and why

Like many forms of care improvement, we have found that health care providers and patients alike engage most proactively when they are directly involved in codesigning an approach or intervention for improving the experience of care. Here are some examples of how hospitalists can be effective leaders in cocreating the inpatient experience with patients and interdisciplinary colleagues.

Dr. Patrick Kneeland: User-centered design retreats.

Dr. Rob Hoffman: Partnering with patient and family advisers.

Dr. Sliwka is medical director of patient and provider experience at University of California, San Francisco, Health; Dr. Kneeland is medical director for patient and provider experience at University of Colorado, Aurora, Hospital; Dr. Hoffman is medical director for patient relations at University of Wisconsin-Madison, Health.

Editor’s note: “Everything We Say and Do” is an informational series developed by SHM’s Patient Experience Committee to provide readers with thoughtful and actionable communication tactics that have great potential to positively affect patients’ experience of care. This column highlights key takeaways from the SHM track of the upcoming 2017 Cleveland Clinic Patient Experience Empathy and Innovation Summit, May 22-24. Three hospitalist leaders describe their approach to leading the design of the inpatient experience.

What we say and do, and why

Like many forms of care improvement, we have found that health care providers and patients alike engage most proactively when they are directly involved in codesigning an approach or intervention for improving the experience of care. Here are some examples of how hospitalists can be effective leaders in cocreating the inpatient experience with patients and interdisciplinary colleagues.

Dr. Patrick Kneeland: User-centered design retreats.

Dr. Rob Hoffman: Partnering with patient and family advisers.

Dr. Sliwka is medical director of patient and provider experience at University of California, San Francisco, Health; Dr. Kneeland is medical director for patient and provider experience at University of Colorado, Aurora, Hospital; Dr. Hoffman is medical director for patient relations at University of Wisconsin-Madison, Health.

Editor’s note: “Everything We Say and Do” is an informational series developed by SHM’s Patient Experience Committee to provide readers with thoughtful and actionable communication tactics that have great potential to positively affect patients’ experience of care. This column highlights key takeaways from the SHM track of the upcoming 2017 Cleveland Clinic Patient Experience Empathy and Innovation Summit, May 22-24. Three hospitalist leaders describe their approach to leading the design of the inpatient experience.

What we say and do, and why

Like many forms of care improvement, we have found that health care providers and patients alike engage most proactively when they are directly involved in codesigning an approach or intervention for improving the experience of care. Here are some examples of how hospitalists can be effective leaders in cocreating the inpatient experience with patients and interdisciplinary colleagues.

Dr. Patrick Kneeland: User-centered design retreats.

Dr. Rob Hoffman: Partnering with patient and family advisers.

Dr. Sliwka is medical director of patient and provider experience at University of California, San Francisco, Health; Dr. Kneeland is medical director for patient and provider experience at University of Colorado, Aurora, Hospital; Dr. Hoffman is medical director for patient relations at University of Wisconsin-Madison, Health.

B-cell precursor ALL

The European Medicines Agency’s Committee for Medicinal Products for Human Use (CHMP) has adopted a positive opinion of inotuzumab ozogamicin (Besponsa®).

The CHMP is recommending approval of inotuzumab ozogamicin for the treatment of adults with relapsed or refractory CD22-positive B-cell precursor acute lymphoblastic leukemia (ALL), including patients with Philadelphia chromosome-positive ALL who have failed treatment with at least one tyrosine kinase inhibitor.

The CHMP’s opinion will be reviewed by the European Commission, which is expected to issue a decision on approval within 67 days from adoption of the opinion.

Inotuzumab ozogamicin is an antibody-drug conjugate that consists of a monoclonal antibody targeting CD22 and a cytotoxic agent known as calicheamicin.

The product originates from a collaboration between Pfizer and Celltech (now UCB), but Pfizer has sole responsibility for all manufacturing and clinical development activities.

The application for inotuzumab ozogamicin is supported by results from a phase 3 trial, which were published in NEJM in June 2016.

The trial enrolled 326 adult patients with relapsed or refractory B-cell ALL and compared inotuzumab ozogamicin to standard of care chemotherapy.

The rate of complete remission, including incomplete hematologic recovery, was 80.7% in the inotuzumab ozogamicin arm and 29.4% in the chemotherapy arm (P<0.001). The median duration of remission was 4.6 months and 3.1 months, respectively (P=0.03).

Forty-one percent of patients treated with inotuzumab ozogamicin and 11% of those who received chemotherapy proceeded to stem cell transplant directly after treatment (P<0.001).

The median progression-free survival was 5.0 months in the inotuzumab ozogamicin arm and 1.8 months in the chemotherapy arm (P<0.001).

The median overall survival was 7.7 months and 6.7 months, respectively (P=0.04). This did not meet the prespecified boundary of significance (P=0.0208).

Liver-related adverse events were more common in the inotuzumab ozogamicin arm than the chemotherapy arm. The most frequent of these were increased aspartate aminotransferase level (20% vs 10%), hyperbilirubinemia (15% vs 10%), and increased alanine aminotransferase level (14% vs 11%).

Veno-occlusive liver disease occurred in 11% of patients in the inotuzumab ozogamicin arm and 1% in the chemotherapy arm.

There were 17 deaths during treatment in the inotuzumab ozogamicin arm and 11 in the chemotherapy arm. Four deaths were considered related to inotuzumab ozogamicin, and 2 were thought to be related to chemotherapy.

B-cell precursor ALL

The European Medicines Agency’s Committee for Medicinal Products for Human Use (CHMP) has adopted a positive opinion of inotuzumab ozogamicin (Besponsa®).

The CHMP is recommending approval of inotuzumab ozogamicin for the treatment of adults with relapsed or refractory CD22-positive B-cell precursor acute lymphoblastic leukemia (ALL), including patients with Philadelphia chromosome-positive ALL who have failed treatment with at least one tyrosine kinase inhibitor.

The CHMP’s opinion will be reviewed by the European Commission, which is expected to issue a decision on approval within 67 days from adoption of the opinion.

Inotuzumab ozogamicin is an antibody-drug conjugate that consists of a monoclonal antibody targeting CD22 and a cytotoxic agent known as calicheamicin.

The product originates from a collaboration between Pfizer and Celltech (now UCB), but Pfizer has sole responsibility for all manufacturing and clinical development activities.

The application for inotuzumab ozogamicin is supported by results from a phase 3 trial, which were published in NEJM in June 2016.

The trial enrolled 326 adult patients with relapsed or refractory B-cell ALL and compared inotuzumab ozogamicin to standard of care chemotherapy.

The rate of complete remission, including incomplete hematologic recovery, was 80.7% in the inotuzumab ozogamicin arm and 29.4% in the chemotherapy arm (P<0.001). The median duration of remission was 4.6 months and 3.1 months, respectively (P=0.03).

Forty-one percent of patients treated with inotuzumab ozogamicin and 11% of those who received chemotherapy proceeded to stem cell transplant directly after treatment (P<0.001).

The median progression-free survival was 5.0 months in the inotuzumab ozogamicin arm and 1.8 months in the chemotherapy arm (P<0.001).

The median overall survival was 7.7 months and 6.7 months, respectively (P=0.04). This did not meet the prespecified boundary of significance (P=0.0208).

Liver-related adverse events were more common in the inotuzumab ozogamicin arm than the chemotherapy arm. The most frequent of these were increased aspartate aminotransferase level (20% vs 10%), hyperbilirubinemia (15% vs 10%), and increased alanine aminotransferase level (14% vs 11%).

Veno-occlusive liver disease occurred in 11% of patients in the inotuzumab ozogamicin arm and 1% in the chemotherapy arm.

There were 17 deaths during treatment in the inotuzumab ozogamicin arm and 11 in the chemotherapy arm. Four deaths were considered related to inotuzumab ozogamicin, and 2 were thought to be related to chemotherapy.

B-cell precursor ALL

The European Medicines Agency’s Committee for Medicinal Products for Human Use (CHMP) has adopted a positive opinion of inotuzumab ozogamicin (Besponsa®).

The CHMP is recommending approval of inotuzumab ozogamicin for the treatment of adults with relapsed or refractory CD22-positive B-cell precursor acute lymphoblastic leukemia (ALL), including patients with Philadelphia chromosome-positive ALL who have failed treatment with at least one tyrosine kinase inhibitor.

The CHMP’s opinion will be reviewed by the European Commission, which is expected to issue a decision on approval within 67 days from adoption of the opinion.

Inotuzumab ozogamicin is an antibody-drug conjugate that consists of a monoclonal antibody targeting CD22 and a cytotoxic agent known as calicheamicin.

The product originates from a collaboration between Pfizer and Celltech (now UCB), but Pfizer has sole responsibility for all manufacturing and clinical development activities.

The application for inotuzumab ozogamicin is supported by results from a phase 3 trial, which were published in NEJM in June 2016.

The trial enrolled 326 adult patients with relapsed or refractory B-cell ALL and compared inotuzumab ozogamicin to standard of care chemotherapy.

The rate of complete remission, including incomplete hematologic recovery, was 80.7% in the inotuzumab ozogamicin arm and 29.4% in the chemotherapy arm (P<0.001). The median duration of remission was 4.6 months and 3.1 months, respectively (P=0.03).

Forty-one percent of patients treated with inotuzumab ozogamicin and 11% of those who received chemotherapy proceeded to stem cell transplant directly after treatment (P<0.001).

The median progression-free survival was 5.0 months in the inotuzumab ozogamicin arm and 1.8 months in the chemotherapy arm (P<0.001).

The median overall survival was 7.7 months and 6.7 months, respectively (P=0.04). This did not meet the prespecified boundary of significance (P=0.0208).

Liver-related adverse events were more common in the inotuzumab ozogamicin arm than the chemotherapy arm. The most frequent of these were increased aspartate aminotransferase level (20% vs 10%), hyperbilirubinemia (15% vs 10%), and increased alanine aminotransferase level (14% vs 11%).

Veno-occlusive liver disease occurred in 11% of patients in the inotuzumab ozogamicin arm and 1% in the chemotherapy arm.

There were 17 deaths during treatment in the inotuzumab ozogamicin arm and 11 in the chemotherapy arm. Four deaths were considered related to inotuzumab ozogamicin, and 2 were thought to be related to chemotherapy.

Clinical question: What is the clinical impact of implementing a policy to no longer process urine specimens for perioperative screening in patients undergoing elective joint arthroplasty (EJA)?

Background: Despite prior studies indicating the lack of clinical benefit, preoperative urine cultures are still frequently obtained in patients undergoing EJA in attempts to reduce the risk of periprosthetic joint infections (PJI).

Study Design: Time series analysis.

Setting: Holland Orthopedic and Arthritic Center (HOAC) of Sunnybrook Health Sciences Centre.

Synopsis: After a multidisciplinary meeting, obtaining routine urine culture screening was removed from the preoperative order set. A time series analysis was performed to review the frequency of screening urine cultures obtained and processed, the number of patients treated for asymptomatic bacteriuria (ASB), and the incidence of PJI before and after the new policy was implemented. After the policy change, only 129 screening urine cultures were obtained prior to 1,891 EJAs (7 per 100 EJA; 95% CI 6-8; P less than .0001) which is a drastic decrease from the 3,069 screening urine cultures obtained prior to 3,523 EJAs (87 per 100 EJA; 95% CI, 86-88) before the policy change. Prior to the policy change, of the 352 positive urine cultures, 43 received perioperative treatment for ASB, and PJI incidence was 1/3523 (0.03%; 95% CI, 0.001-02). After the policy change, no perioperative antibiotics were prescribed for ASB, and PJI rate did not significantly change at 3/1891 (0.2%; 95% CI, 0.05-0.5; P = .1).

The study was limited by its low power to detect for small differences in rates because of its small PJI rate occurrence.

Bottom Line: A multidisciplinary approach in eliminating routine urine screening prior to EJA resulted in a decrease of urine cultures obtained and a decrease in treatment for asymptomatic bacteriuria, with no significant change in PJI rate. This change in clinical practice is supported by current evidence and has a significant impact on cost savings.

References: Lamb MJ, Baillie L, Pajak D, et al. “Elimination of Screening Urine Cultures Prior to Elective Joint Arthroplasty.”

Dr. Libot is assistant professor in the division of hospital medicine, Loyola University Chicago, Maywood, Ill.

Clinical question: What is the clinical impact of implementing a policy to no longer process urine specimens for perioperative screening in patients undergoing elective joint arthroplasty (EJA)?

Background: Despite prior studies indicating the lack of clinical benefit, preoperative urine cultures are still frequently obtained in patients undergoing EJA in attempts to reduce the risk of periprosthetic joint infections (PJI).

Study Design: Time series analysis.

Setting: Holland Orthopedic and Arthritic Center (HOAC) of Sunnybrook Health Sciences Centre.

Synopsis: After a multidisciplinary meeting, obtaining routine urine culture screening was removed from the preoperative order set. A time series analysis was performed to review the frequency of screening urine cultures obtained and processed, the number of patients treated for asymptomatic bacteriuria (ASB), and the incidence of PJI before and after the new policy was implemented. After the policy change, only 129 screening urine cultures were obtained prior to 1,891 EJAs (7 per 100 EJA; 95% CI 6-8; P less than .0001) which is a drastic decrease from the 3,069 screening urine cultures obtained prior to 3,523 EJAs (87 per 100 EJA; 95% CI, 86-88) before the policy change. Prior to the policy change, of the 352 positive urine cultures, 43 received perioperative treatment for ASB, and PJI incidence was 1/3523 (0.03%; 95% CI, 0.001-02). After the policy change, no perioperative antibiotics were prescribed for ASB, and PJI rate did not significantly change at 3/1891 (0.2%; 95% CI, 0.05-0.5; P = .1).

The study was limited by its low power to detect for small differences in rates because of its small PJI rate occurrence.

Bottom Line: A multidisciplinary approach in eliminating routine urine screening prior to EJA resulted in a decrease of urine cultures obtained and a decrease in treatment for asymptomatic bacteriuria, with no significant change in PJI rate. This change in clinical practice is supported by current evidence and has a significant impact on cost savings.

References: Lamb MJ, Baillie L, Pajak D, et al. “Elimination of Screening Urine Cultures Prior to Elective Joint Arthroplasty.”

Dr. Libot is assistant professor in the division of hospital medicine, Loyola University Chicago, Maywood, Ill.

Clinical question: What is the clinical impact of implementing a policy to no longer process urine specimens for perioperative screening in patients undergoing elective joint arthroplasty (EJA)?

Background: Despite prior studies indicating the lack of clinical benefit, preoperative urine cultures are still frequently obtained in patients undergoing EJA in attempts to reduce the risk of periprosthetic joint infections (PJI).

Study Design: Time series analysis.

Setting: Holland Orthopedic and Arthritic Center (HOAC) of Sunnybrook Health Sciences Centre.

Synopsis: After a multidisciplinary meeting, obtaining routine urine culture screening was removed from the preoperative order set. A time series analysis was performed to review the frequency of screening urine cultures obtained and processed, the number of patients treated for asymptomatic bacteriuria (ASB), and the incidence of PJI before and after the new policy was implemented. After the policy change, only 129 screening urine cultures were obtained prior to 1,891 EJAs (7 per 100 EJA; 95% CI 6-8; P less than .0001) which is a drastic decrease from the 3,069 screening urine cultures obtained prior to 3,523 EJAs (87 per 100 EJA; 95% CI, 86-88) before the policy change. Prior to the policy change, of the 352 positive urine cultures, 43 received perioperative treatment for ASB, and PJI incidence was 1/3523 (0.03%; 95% CI, 0.001-02). After the policy change, no perioperative antibiotics were prescribed for ASB, and PJI rate did not significantly change at 3/1891 (0.2%; 95% CI, 0.05-0.5; P = .1).

The study was limited by its low power to detect for small differences in rates because of its small PJI rate occurrence.

Bottom Line: A multidisciplinary approach in eliminating routine urine screening prior to EJA resulted in a decrease of urine cultures obtained and a decrease in treatment for asymptomatic bacteriuria, with no significant change in PJI rate. This change in clinical practice is supported by current evidence and has a significant impact on cost savings.

References: Lamb MJ, Baillie L, Pajak D, et al. “Elimination of Screening Urine Cultures Prior to Elective Joint Arthroplasty.”

Dr. Libot is assistant professor in the division of hospital medicine, Loyola University Chicago, Maywood, Ill.