The Diagnosis: Dental Sinus Secondary to Osteonecrosis of the Jaw

Cone beam computed tomography revealed an area of lucency measuring 40×20 mm in the body of the right mandible (Figure). The patient subsequently underwent curettage of the wound with sequestrectomy of the involved area.

Osteonecrosis of the jaw is a form of avascular necrosis. It is an uncommon but potentially serious side effect of bisphosphonate use.¹ Bisphosphonates commonly are used as first-line therapy for osteoporosis, with proven efficacy to reduce fracture risk by exerting an antiresorptive effect on bones.² Bisphosphonate-related osteonecrosis of the jaw (BRONJ) is defined by the American Association of Oral and Maxillofacial Surgeons as the presence of exposed necrotic bone in the maxillofacial region that has persisted for more than 8 weeks, with current or prior treatment with a bisphosphonate and absence of prior radiation therapy to the jaw.3 Bisphosphonate-related osteonecrosis of the jaw can be associated with infections, pathologic fractures, extraoral fistulae, or osteolysis extending to the inferior border.

Our patient had a dental sinus that resulted from the underlying BRONJ. The jawbones, unlike the long bones, are in a special environment in that both acute and chronic infections occur often within the bone, and surgical procedures as well as masticatory trauma expose the bone to a bacteria-laden environment.⁴ Infection around the root apex of a tooth results in a dental abscess and a sinus tract can develop from the abscess, draining either intraorally or extraorally.⁵ Facial sinus tracts can be either odontogenic or nonodontogenic, and sometimes the lesions of dental origin may be confused with dermatological lesions.

Bisphosphonates inhibit osteoclasts, which are responsible for bone resorption. Antiangiogenetic effects also have been reported in bisphosphonates, resulting in devitalized bone.⁶ The potent and prolonged inhibition of bone remodeling likely plays an important role in BRONJ. The more frequently occurring microdamage inflicted on the lower jawbone with mastication also may represent a contributory factor.⁷

Bisphosphonate-related osteonecrosis of the jaw more often is associated with the use of high-dose intravenous (IV) bisphosphonate in cancer-related hypercalcemia and less so with oral bisphosphonates, which are generally used to treat osteoporosis.³ In a Swedish study conducted from 2003 to 2010, 55 cases of BRONJ were documented in a population of 1.2 million individuals. The prevalence of BRONJ in patients on oral bisphosphonates and IV bisphosphonates was estimated to be 0.024% and 2.8%, respectively.⁸

Bisphosphonates are widely used worldwide as the main treatment of osteoporosis. The association between osteonecrosis of the jaw and oral bisphosphonates is contentious among the osteoporosis population, as most studies focus on IV bisphosphonate use in cancer patients.⁹ Bisphosphonate-related osteonecrosis of the jaw adversely affects the patient's quality of life, producing notable morbidity in afflicted patients. Thus, a complete dental assessment and treatment is recommended before the initiation of bisphosphonate treatment. The risk for developing BRONJ associated with oral bisphosphonates increases when the duration of therapy exceeds 3 years.³ It has been reported that antifracture efficacy would persist for 1 to 2 years following discontinuation of alendronate or risedronate that had been taken for 3 to 5 years, but patients with low bone mineral density at the femoral neck (T-score below -2.5) after 3 to 5 years of treatment of bisphosphonates are at the highest risk for vertebral fractures and therefore appear to benefit most from continuation of therapy.¹⁰ For dental procedures, the American Association of Oral and Maxillofacial Surgeons suggests that if systemic conditions persist, the clinician might consider discontinuation of oral bisphosphonates for a 3-month period before and after elective invasive dental surgery to lower the risk for BRONJ.³ When possible, invasive dentoalveolar procedures such as extractions should be avoided; conservative endodontic treatment is preferable.

Bisphosphonate-related osteonecrosis of the jaw is a devastating condition that is difficult to treat and manage, thus the focus should be on prevention through dental clearance prior to starting bisphosphonates. It also is crucial to have a high index of suspicion for BRONJ in patients presenting with orofacial lesions so that they can be treated expediently.

The Diagnosis: Dental Sinus Secondary to Osteonecrosis of the Jaw

Cone beam computed tomography revealed an area of lucency measuring 40×20 mm in the body of the right mandible (Figure). The patient subsequently underwent curettage of the wound with sequestrectomy of the involved area.

Osteonecrosis of the jaw is a form of avascular necrosis. It is an uncommon but potentially serious side effect of bisphosphonate use.¹ Bisphosphonates commonly are used as first-line therapy for osteoporosis, with proven efficacy to reduce fracture risk by exerting an antiresorptive effect on bones.² Bisphosphonate-related osteonecrosis of the jaw (BRONJ) is defined by the American Association of Oral and Maxillofacial Surgeons as the presence of exposed necrotic bone in the maxillofacial region that has persisted for more than 8 weeks, with current or prior treatment with a bisphosphonate and absence of prior radiation therapy to the jaw.3 Bisphosphonate-related osteonecrosis of the jaw can be associated with infections, pathologic fractures, extraoral fistulae, or osteolysis extending to the inferior border.

Our patient had a dental sinus that resulted from the underlying BRONJ. The jawbones, unlike the long bones, are in a special environment in that both acute and chronic infections occur often within the bone, and surgical procedures as well as masticatory trauma expose the bone to a bacteria-laden environment.⁴ Infection around the root apex of a tooth results in a dental abscess and a sinus tract can develop from the abscess, draining either intraorally or extraorally.⁵ Facial sinus tracts can be either odontogenic or nonodontogenic, and sometimes the lesions of dental origin may be confused with dermatological lesions.

Bisphosphonates inhibit osteoclasts, which are responsible for bone resorption. Antiangiogenetic effects also have been reported in bisphosphonates, resulting in devitalized bone.⁶ The potent and prolonged inhibition of bone remodeling likely plays an important role in BRONJ. The more frequently occurring microdamage inflicted on the lower jawbone with mastication also may represent a contributory factor.⁷

Bisphosphonate-related osteonecrosis of the jaw more often is associated with the use of high-dose intravenous (IV) bisphosphonate in cancer-related hypercalcemia and less so with oral bisphosphonates, which are generally used to treat osteoporosis.³ In a Swedish study conducted from 2003 to 2010, 55 cases of BRONJ were documented in a population of 1.2 million individuals. The prevalence of BRONJ in patients on oral bisphosphonates and IV bisphosphonates was estimated to be 0.024% and 2.8%, respectively.⁸

Bisphosphonates are widely used worldwide as the main treatment of osteoporosis. The association between osteonecrosis of the jaw and oral bisphosphonates is contentious among the osteoporosis population, as most studies focus on IV bisphosphonate use in cancer patients.⁹ Bisphosphonate-related osteonecrosis of the jaw adversely affects the patient's quality of life, producing notable morbidity in afflicted patients. Thus, a complete dental assessment and treatment is recommended before the initiation of bisphosphonate treatment. The risk for developing BRONJ associated with oral bisphosphonates increases when the duration of therapy exceeds 3 years.³ It has been reported that antifracture efficacy would persist for 1 to 2 years following discontinuation of alendronate or risedronate that had been taken for 3 to 5 years, but patients with low bone mineral density at the femoral neck (T-score below -2.5) after 3 to 5 years of treatment of bisphosphonates are at the highest risk for vertebral fractures and therefore appear to benefit most from continuation of therapy.¹⁰ For dental procedures, the American Association of Oral and Maxillofacial Surgeons suggests that if systemic conditions persist, the clinician might consider discontinuation of oral bisphosphonates for a 3-month period before and after elective invasive dental surgery to lower the risk for BRONJ.³ When possible, invasive dentoalveolar procedures such as extractions should be avoided; conservative endodontic treatment is preferable.

Bisphosphonate-related osteonecrosis of the jaw is a devastating condition that is difficult to treat and manage, thus the focus should be on prevention through dental clearance prior to starting bisphosphonates. It also is crucial to have a high index of suspicion for BRONJ in patients presenting with orofacial lesions so that they can be treated expediently.

The Diagnosis: Dental Sinus Secondary to Osteonecrosis of the Jaw

Cone beam computed tomography revealed an area of lucency measuring 40×20 mm in the body of the right mandible (Figure). The patient subsequently underwent curettage of the wound with sequestrectomy of the involved area.

Osteonecrosis of the jaw is a form of avascular necrosis. It is an uncommon but potentially serious side effect of bisphosphonate use.¹ Bisphosphonates commonly are used as first-line therapy for osteoporosis, with proven efficacy to reduce fracture risk by exerting an antiresorptive effect on bones.² Bisphosphonate-related osteonecrosis of the jaw (BRONJ) is defined by the American Association of Oral and Maxillofacial Surgeons as the presence of exposed necrotic bone in the maxillofacial region that has persisted for more than 8 weeks, with current or prior treatment with a bisphosphonate and absence of prior radiation therapy to the jaw.3 Bisphosphonate-related osteonecrosis of the jaw can be associated with infections, pathologic fractures, extraoral fistulae, or osteolysis extending to the inferior border.

Our patient had a dental sinus that resulted from the underlying BRONJ. The jawbones, unlike the long bones, are in a special environment in that both acute and chronic infections occur often within the bone, and surgical procedures as well as masticatory trauma expose the bone to a bacteria-laden environment.⁴ Infection around the root apex of a tooth results in a dental abscess and a sinus tract can develop from the abscess, draining either intraorally or extraorally.⁵ Facial sinus tracts can be either odontogenic or nonodontogenic, and sometimes the lesions of dental origin may be confused with dermatological lesions.

Bisphosphonates inhibit osteoclasts, which are responsible for bone resorption. Antiangiogenetic effects also have been reported in bisphosphonates, resulting in devitalized bone.⁶ The potent and prolonged inhibition of bone remodeling likely plays an important role in BRONJ. The more frequently occurring microdamage inflicted on the lower jawbone with mastication also may represent a contributory factor.⁷

Bisphosphonate-related osteonecrosis of the jaw more often is associated with the use of high-dose intravenous (IV) bisphosphonate in cancer-related hypercalcemia and less so with oral bisphosphonates, which are generally used to treat osteoporosis.³ In a Swedish study conducted from 2003 to 2010, 55 cases of BRONJ were documented in a population of 1.2 million individuals. The prevalence of BRONJ in patients on oral bisphosphonates and IV bisphosphonates was estimated to be 0.024% and 2.8%, respectively.⁸

Bisphosphonates are widely used worldwide as the main treatment of osteoporosis. The association between osteonecrosis of the jaw and oral bisphosphonates is contentious among the osteoporosis population, as most studies focus on IV bisphosphonate use in cancer patients.⁹ Bisphosphonate-related osteonecrosis of the jaw adversely affects the patient's quality of life, producing notable morbidity in afflicted patients. Thus, a complete dental assessment and treatment is recommended before the initiation of bisphosphonate treatment. The risk for developing BRONJ associated with oral bisphosphonates increases when the duration of therapy exceeds 3 years.³ It has been reported that antifracture efficacy would persist for 1 to 2 years following discontinuation of alendronate or risedronate that had been taken for 3 to 5 years, but patients with low bone mineral density at the femoral neck (T-score below -2.5) after 3 to 5 years of treatment of bisphosphonates are at the highest risk for vertebral fractures and therefore appear to benefit most from continuation of therapy.¹⁰ For dental procedures, the American Association of Oral and Maxillofacial Surgeons suggests that if systemic conditions persist, the clinician might consider discontinuation of oral bisphosphonates for a 3-month period before and after elective invasive dental surgery to lower the risk for BRONJ.³ When possible, invasive dentoalveolar procedures such as extractions should be avoided; conservative endodontic treatment is preferable.

Bisphosphonate-related osteonecrosis of the jaw is a devastating condition that is difficult to treat and manage, thus the focus should be on prevention through dental clearance prior to starting bisphosphonates. It also is crucial to have a high index of suspicion for BRONJ in patients presenting with orofacial lesions so that they can be treated expediently.

To the Editor:

A 42-year-old woman who had a tattoo on the right wrist surgically removed 2 days prior developed severe erythema and swelling at the incision site (Figure 1). Exposure at the incision site was limited to bacitracin, poliglecaprone 25 suture, and plain cotton gauze. Patch testing of bacitracin was performed, which was ++ (moderately positive reaction) at the 96-hour reading, indicating that part of the reaction was due to the topical antibiotic. Testing of the suture was performed by tying the suture to the skin of the forearm and removing it at 48 hours. There was a ++ reaction to the suture prior to removal at 48 hours, which increased to +++ (severely positive reaction) after suture removal at 96 hours (Figure 2). Therefore, it appears that allergy to the suture also was partially responsible for the postsurgical reaction.

Poliglecaprone 25 suture is a monofilament synthetic absorbable material that is a copolymer of glycolide and ε-caprolactone. One case report of oral contact allergy to this suture material resulted in failure of an oral graft; however, no testing was performed to verify the contact allergy.¹ Caprolactam ([CH₂]₅C[O]NH) is a related chemical that can be synthesized by treating caprolactone ([CH₂]₅CO₂) with ammonia at elevated temperatures.² Contact allergy has been reported to polyamide 6 suture, which is obtained by polymerizing ε-caprolactam. This report stated that contact allergy to ε-caprolactam also has been reported occupationally during manufacture and from its use in fishing nets, socks, gloves, and stockings.³

The package insert for the poliglecaprone 25 suture states that the material is “nonantigenic, nonpyrogenic and elicits only a slight tissue reaction during absorption.”⁴ We present a case of contact allergy to poliglecaprone 25 suture that was confirmed by allergy testing.

To the Editor:

A 42-year-old woman who had a tattoo on the right wrist surgically removed 2 days prior developed severe erythema and swelling at the incision site (Figure 1). Exposure at the incision site was limited to bacitracin, poliglecaprone 25 suture, and plain cotton gauze. Patch testing of bacitracin was performed, which was ++ (moderately positive reaction) at the 96-hour reading, indicating that part of the reaction was due to the topical antibiotic. Testing of the suture was performed by tying the suture to the skin of the forearm and removing it at 48 hours. There was a ++ reaction to the suture prior to removal at 48 hours, which increased to +++ (severely positive reaction) after suture removal at 96 hours (Figure 2). Therefore, it appears that allergy to the suture also was partially responsible for the postsurgical reaction.

Poliglecaprone 25 suture is a monofilament synthetic absorbable material that is a copolymer of glycolide and ε-caprolactone. One case report of oral contact allergy to this suture material resulted in failure of an oral graft; however, no testing was performed to verify the contact allergy.¹ Caprolactam ([CH₂]₅C[O]NH) is a related chemical that can be synthesized by treating caprolactone ([CH₂]₅CO₂) with ammonia at elevated temperatures.² Contact allergy has been reported to polyamide 6 suture, which is obtained by polymerizing ε-caprolactam. This report stated that contact allergy to ε-caprolactam also has been reported occupationally during manufacture and from its use in fishing nets, socks, gloves, and stockings.³

The package insert for the poliglecaprone 25 suture states that the material is “nonantigenic, nonpyrogenic and elicits only a slight tissue reaction during absorption.”⁴ We present a case of contact allergy to poliglecaprone 25 suture that was confirmed by allergy testing.

To the Editor:

A 42-year-old woman who had a tattoo on the right wrist surgically removed 2 days prior developed severe erythema and swelling at the incision site (Figure 1). Exposure at the incision site was limited to bacitracin, poliglecaprone 25 suture, and plain cotton gauze. Patch testing of bacitracin was performed, which was ++ (moderately positive reaction) at the 96-hour reading, indicating that part of the reaction was due to the topical antibiotic. Testing of the suture was performed by tying the suture to the skin of the forearm and removing it at 48 hours. There was a ++ reaction to the suture prior to removal at 48 hours, which increased to +++ (severely positive reaction) after suture removal at 96 hours (Figure 2). Therefore, it appears that allergy to the suture also was partially responsible for the postsurgical reaction.

Poliglecaprone 25 suture is a monofilament synthetic absorbable material that is a copolymer of glycolide and ε-caprolactone. One case report of oral contact allergy to this suture material resulted in failure of an oral graft; however, no testing was performed to verify the contact allergy.¹ Caprolactam ([CH₂]₅C[O]NH) is a related chemical that can be synthesized by treating caprolactone ([CH₂]₅CO₂) with ammonia at elevated temperatures.² Contact allergy has been reported to polyamide 6 suture, which is obtained by polymerizing ε-caprolactam. This report stated that contact allergy to ε-caprolactam also has been reported occupationally during manufacture and from its use in fishing nets, socks, gloves, and stockings.³

The package insert for the poliglecaprone 25 suture states that the material is “nonantigenic, nonpyrogenic and elicits only a slight tissue reaction during absorption.”⁴ We present a case of contact allergy to poliglecaprone 25 suture that was confirmed by allergy testing.

Several years ago, pediatricians R.J. Gillespie, MD, MHPE, and Teri Pettersen, MD, piloted the use of a questionnaire about adverse childhood experiences (ACEs) and resilience at the 4-month well-child visit.

They and six other pediatricians at The Children’s Clinic in Portland, Ore., explained in a cover letter why they were posing the questions of parents, and they ended the survey by asking them about their interest in potential resources.

[[{"fid":"172157","view_mode":"medstat_image_flush_left","fields":{"format":"medstat_image_flush_left","field_file_image_alt_text[und][0][value]":"R.J. Gillespie, MD, MHPE","field_file_image_credit[und][0][value]":"Courtesy The Children's Clinic","field_file_image_caption[und][0][value]":"Dr. R.J. Gillespie "},"type":"media","attributes":{"class":"media-element file-medstat_image_flush_left"}}]]Today, all 28 of the pediatricians at the clinic screen for ACEs and resilience, and Dr. Pettersen, now retired from the practice, travels through the state conducting training for the Oregon Pediatric Society about the impact of ACEs in parents and their children, and how to go about identifying and addressing them.

“So many of our visits are about behavioral problems or emotional disturbances, and so often at the root of these issues is some sort of trauma the child is experiencing,” Dr. Gillespie said in an interview. “What we’re seeing in many of these cases really are coping strategies for that child to deal with the toxic stress in his or her life.”

By assessing parents’ exposure to ACEs, briefly talking with them about how ACEs might impact their parenting, and tailoring their counseling and anticipatory guidance, the pediatricians hope to prevent ACEs and consequent toxic stress from developing in children.

The driving science

The term ACEs entered the medical lexicon after 1998, when a landmark study called the Adverse Childhood Experiences Study showed that traumatic experiences in childhood – abuse, neglect, and other severe dysfunctions in a household – not only are common among American adults but are associated with numerous poor health outcomes.

In the study and subsequent analyses, Dr. Vincent Felitti of Kaiser Permanente in San Diego and Dr. Robert Anda of the Centers for Disease Control and Prevention surveyed more than 17,000 patients about 10 types of ACEs and their current health status and behaviors. About two-thirds reported having at least one ACE, and one in eight reported four or more (Am J Prev Med. 1998;14[4]:245-58, www.cdc.gov/violenceprevention/acestudy/about.html).

Adults with four or more ACEs were not only significantly more likely to report health risk behaviors (smoking, substance abuse) and poor mental health outcomes (depression, suicide attempt); they were also significantly more likely to have poor physical health outcomes, with 2.2 times the risk of ischemic heart disease, 1.9 times the risk of cancer, and 3.9 times the risk of chronic bronchitis or emphysema, for instance. There was a strong dose-response relationship between ACEs and poor outcomes.

The Felitti study spawned dozens of analyses and additional research – in children as well as adults – on the associations between early-life adversity and the incidence of poor behavioral, mental, and physical outcomes, as well as on potential mechanisms.

Some research suggested a direct link between ACEs and negative outcomes, independent of whether individuals adopt risky behavior. Other studies suggested what experts in child development and mental health have long argued – that the more ACEs a parent has, the more ACEs their child will have.

And a growing body of biomedical literature linked the extreme, frequent, or prolonged activation of the body’s stress response in childhood – what has come to be known as “toxic stress” – with disruptions of the developing nervous, cardiovascular, immune, and metabolic systems.

Ryan Twomey

The clinic’s roll-out

Dr. Pettersen learned about the ACE study and related research about 8 years ago while on a sabbatical to learn more about mental health issues. It “changed everything” about the way she viewed children and families and adversity. “I knew (we) didn’t have the infrastructure at the clinic, or the clinic’s support, to really start assessing children for what was happening to them,” she said, so she began thinking about ACE prevention and a focus on parenting.

Dr. Gillespie, in the meantime, was active in various quality improvement efforts at the state and national level, and had also become increasingly bothered by visits in which he saw children affected by maternal depression, abnormal attachment, and other problems. “I was seeing the consequences of ACEs, but I didn’t know specifically what was going on or how to talk about it,” he said.

The two pediatricians agreed to ask parents about ACEs at the 4-month well visit – a time when the families “knew us a little bit” and when “we could still influence parenting styles.”

In March 2013, they and their colleagues in the pilot group began giving parents a questionnaire that included the 10 ACE questions from Felitti’s study, questions about resilience from the Children’s Resilience Initiative, and a list of potential resources so they could understand parents’ needs.

They created a confidential field in their electronic medical record for documentation that appears during a visit, but does not print into notes and therefore will not be inadvertently released.

As they moved through the pilot phase, the pediatricians used various approaches to follow up on the assessment face-to-face. Eventually, they chose three particular questions as nonthreatening and helpful for conversation: Are there any experiences that still bother you? Of those experiences that don’t bother you, how did you get to the point where they don’t bother you? And how do these experiences affect your parenting now?

“It’s a motivational interviewing sort of style,” said Dr. Gillespie. “Parents can start identifying for themselves the solutions for the problems they’ve experienced, and they can start thinking about how their parenting might be impacted by things that have happened [or are still happening] to them.”

As the project rolled out, the physicians tweaked their process. They added four more ACE questions to address issues – community violence, extreme bullying, racism and prejudice, and foster care exposure – that they thought might lead to toxic stress in their population, for instance. And rather than ask on the written questionnaire for a “yes” or “no” to each of the ACE questions, they began asking the parent how many of the ACE questions applied to them. Moving away from the yes-no format to asking for a total count has led to more disclosures, Dr. Gillespie said.

To “keep the conversation going” in subsequent well-child visits, they developed a few questions to ask high-risk parents, like “How do you and your partner resolve conflict?” and “How did your parents resolve conflict in your household when you were a child?” And they provided training to all of the clinic’s staff on trauma-informed care and the need for support and compassion in their interactions with family members.

In the 3-plus years since incorporating ACEs assessments, the clinic’s pediatricians have made soft referrals to mental health professionals in only several cases – in each case, by suggesting that the parent contact their primary care physician. What most parents have wanted, says Dr. Gillespie, is recommendations for parenting classes and support groups. The clinic’s care manager assists the pediatricians in maintaining and providing links and handouts for various resources.

For Dr. Gillespie, the impact of the culture shift has been dramatic. “I’ve had 8-10 moms spontaneously reveal domestic violence to me in a subsequent visit, and say that they need a little help, because they’ve gotten the message that this is a safe place to talk about their experiences,” he said. “That had never happened to me in the previous 12 years of so of my career.”

Dr. Pettersen’s relationships with parents became “more intimate and more honest.” There was more trust. “If we can talk with parents [about ACEs] and not judge them for it,” she said, “then nothing is off the table.”
 

The ‘Two-Gen’ approach

Courtesy Children's Mercy Hospitals

“But I’d push back and say, parents know they have toxic stress but they don’t name it,” she said. “What we can do as trusted providers who want to advocate for families is to bear witness to their history by asking about it. Once they realize it’s not what’s wrong with [them], it’s what’s happened to [them], a shift occurs. That’s extremely validating for parents.”

That validation is part of a two-generation approach that she and Dr. Burke Harris see as part of a movement to break cycles of ACEs and toxic stress. At the California Pacific Medical Center’s Bayview Child Health Center in San Francisco, Dr. Burke Harris uses three ACE questionnaires – two of them ask parents (of children or teens) to report how many adverse experience types, or categories, apply to them and/or their child or teen, and one surveys adolescents themselves.

With the resources and clinical support of the Center for Youth Wellness, whose major funders include Google, Dr. Burke Harris can initiate a “warm hand-off” of patients with a high ACE score to a care coordinator or therapist. (The Center for Youth Wellness is beginning research to validate its ACE screening tools.) And in the meantime, the medical care she provides is trauma-informed.

“If a patient comes in for ADHD [attention-deficit/hyperactivity disorder] and has an ACE score of 6, my differential diagnosis and assessment will be different than if I see a patient sent by the school who has an ACE score of 0,” she said.

At the Portland Clinic, even though ACEs screening is now tied with the 4-month visit, pediatricians are much more attentive across the board to possible ACEs and toxic stress, and feel better able to converse with families, Dr. Gillespie said. One of his partners recently saw a 12-year-old boy who was failing in school and not making friends. Trauma-informed history-taking revealed at least several ACEs, and conversation turned to “all the resilience pieces… the connections he was missing and what he needed to cope,” he said.

References

• Resilience Project: This AAP project houses a “trauma toolkit” for primary care, case studies, and a variety of other tools.

• Center for Youth Wellness: The ACEs screening tools used by Dr. Burke Harris may be accessed at this website, along with a user guide containing sample scripts, and two white papers on ACEs and toxic stress.

• Resilience: The Biology of Stress and the Science of Hope: This documentary film, released in September 2016, is about ACEs and “a new movement” to treat and prevent toxic stress; it features the work of Dr. Burke Harris and others.

• Academy on Violence & Abuse: Various papers on ACEs screening and case finding in practice may be accessed here.

Several years ago, pediatricians R.J. Gillespie, MD, MHPE, and Teri Pettersen, MD, piloted the use of a questionnaire about adverse childhood experiences (ACEs) and resilience at the 4-month well-child visit.

They and six other pediatricians at The Children’s Clinic in Portland, Ore., explained in a cover letter why they were posing the questions of parents, and they ended the survey by asking them about their interest in potential resources.

[[{"fid":"172157","view_mode":"medstat_image_flush_left","fields":{"format":"medstat_image_flush_left","field_file_image_alt_text[und][0][value]":"R.J. Gillespie, MD, MHPE","field_file_image_credit[und][0][value]":"Courtesy The Children's Clinic","field_file_image_caption[und][0][value]":"Dr. R.J. Gillespie "},"type":"media","attributes":{"class":"media-element file-medstat_image_flush_left"}}]]Today, all 28 of the pediatricians at the clinic screen for ACEs and resilience, and Dr. Pettersen, now retired from the practice, travels through the state conducting training for the Oregon Pediatric Society about the impact of ACEs in parents and their children, and how to go about identifying and addressing them.

“So many of our visits are about behavioral problems or emotional disturbances, and so often at the root of these issues is some sort of trauma the child is experiencing,” Dr. Gillespie said in an interview. “What we’re seeing in many of these cases really are coping strategies for that child to deal with the toxic stress in his or her life.”

By assessing parents’ exposure to ACEs, briefly talking with them about how ACEs might impact their parenting, and tailoring their counseling and anticipatory guidance, the pediatricians hope to prevent ACEs and consequent toxic stress from developing in children.

The driving science

The term ACEs entered the medical lexicon after 1998, when a landmark study called the Adverse Childhood Experiences Study showed that traumatic experiences in childhood – abuse, neglect, and other severe dysfunctions in a household – not only are common among American adults but are associated with numerous poor health outcomes.

In the study and subsequent analyses, Dr. Vincent Felitti of Kaiser Permanente in San Diego and Dr. Robert Anda of the Centers for Disease Control and Prevention surveyed more than 17,000 patients about 10 types of ACEs and their current health status and behaviors. About two-thirds reported having at least one ACE, and one in eight reported four or more (Am J Prev Med. 1998;14[4]:245-58, www.cdc.gov/violenceprevention/acestudy/about.html).

Adults with four or more ACEs were not only significantly more likely to report health risk behaviors (smoking, substance abuse) and poor mental health outcomes (depression, suicide attempt); they were also significantly more likely to have poor physical health outcomes, with 2.2 times the risk of ischemic heart disease, 1.9 times the risk of cancer, and 3.9 times the risk of chronic bronchitis or emphysema, for instance. There was a strong dose-response relationship between ACEs and poor outcomes.

The Felitti study spawned dozens of analyses and additional research – in children as well as adults – on the associations between early-life adversity and the incidence of poor behavioral, mental, and physical outcomes, as well as on potential mechanisms.

Some research suggested a direct link between ACEs and negative outcomes, independent of whether individuals adopt risky behavior. Other studies suggested what experts in child development and mental health have long argued – that the more ACEs a parent has, the more ACEs their child will have.

And a growing body of biomedical literature linked the extreme, frequent, or prolonged activation of the body’s stress response in childhood – what has come to be known as “toxic stress” – with disruptions of the developing nervous, cardiovascular, immune, and metabolic systems.

Ryan Twomey

The clinic’s roll-out

Dr. Pettersen learned about the ACE study and related research about 8 years ago while on a sabbatical to learn more about mental health issues. It “changed everything” about the way she viewed children and families and adversity. “I knew (we) didn’t have the infrastructure at the clinic, or the clinic’s support, to really start assessing children for what was happening to them,” she said, so she began thinking about ACE prevention and a focus on parenting.

Dr. Gillespie, in the meantime, was active in various quality improvement efforts at the state and national level, and had also become increasingly bothered by visits in which he saw children affected by maternal depression, abnormal attachment, and other problems. “I was seeing the consequences of ACEs, but I didn’t know specifically what was going on or how to talk about it,” he said.

The two pediatricians agreed to ask parents about ACEs at the 4-month well visit – a time when the families “knew us a little bit” and when “we could still influence parenting styles.”

In March 2013, they and their colleagues in the pilot group began giving parents a questionnaire that included the 10 ACE questions from Felitti’s study, questions about resilience from the Children’s Resilience Initiative, and a list of potential resources so they could understand parents’ needs.

They created a confidential field in their electronic medical record for documentation that appears during a visit, but does not print into notes and therefore will not be inadvertently released.

As they moved through the pilot phase, the pediatricians used various approaches to follow up on the assessment face-to-face. Eventually, they chose three particular questions as nonthreatening and helpful for conversation: Are there any experiences that still bother you? Of those experiences that don’t bother you, how did you get to the point where they don’t bother you? And how do these experiences affect your parenting now?

“It’s a motivational interviewing sort of style,” said Dr. Gillespie. “Parents can start identifying for themselves the solutions for the problems they’ve experienced, and they can start thinking about how their parenting might be impacted by things that have happened [or are still happening] to them.”

As the project rolled out, the physicians tweaked their process. They added four more ACE questions to address issues – community violence, extreme bullying, racism and prejudice, and foster care exposure – that they thought might lead to toxic stress in their population, for instance. And rather than ask on the written questionnaire for a “yes” or “no” to each of the ACE questions, they began asking the parent how many of the ACE questions applied to them. Moving away from the yes-no format to asking for a total count has led to more disclosures, Dr. Gillespie said.

To “keep the conversation going” in subsequent well-child visits, they developed a few questions to ask high-risk parents, like “How do you and your partner resolve conflict?” and “How did your parents resolve conflict in your household when you were a child?” And they provided training to all of the clinic’s staff on trauma-informed care and the need for support and compassion in their interactions with family members.

In the 3-plus years since incorporating ACEs assessments, the clinic’s pediatricians have made soft referrals to mental health professionals in only several cases – in each case, by suggesting that the parent contact their primary care physician. What most parents have wanted, says Dr. Gillespie, is recommendations for parenting classes and support groups. The clinic’s care manager assists the pediatricians in maintaining and providing links and handouts for various resources.

For Dr. Gillespie, the impact of the culture shift has been dramatic. “I’ve had 8-10 moms spontaneously reveal domestic violence to me in a subsequent visit, and say that they need a little help, because they’ve gotten the message that this is a safe place to talk about their experiences,” he said. “That had never happened to me in the previous 12 years of so of my career.”

Dr. Pettersen’s relationships with parents became “more intimate and more honest.” There was more trust. “If we can talk with parents [about ACEs] and not judge them for it,” she said, “then nothing is off the table.”
 

The ‘Two-Gen’ approach

Courtesy Children's Mercy Hospitals

“But I’d push back and say, parents know they have toxic stress but they don’t name it,” she said. “What we can do as trusted providers who want to advocate for families is to bear witness to their history by asking about it. Once they realize it’s not what’s wrong with [them], it’s what’s happened to [them], a shift occurs. That’s extremely validating for parents.”

That validation is part of a two-generation approach that she and Dr. Burke Harris see as part of a movement to break cycles of ACEs and toxic stress. At the California Pacific Medical Center’s Bayview Child Health Center in San Francisco, Dr. Burke Harris uses three ACE questionnaires – two of them ask parents (of children or teens) to report how many adverse experience types, or categories, apply to them and/or their child or teen, and one surveys adolescents themselves.

With the resources and clinical support of the Center for Youth Wellness, whose major funders include Google, Dr. Burke Harris can initiate a “warm hand-off” of patients with a high ACE score to a care coordinator or therapist. (The Center for Youth Wellness is beginning research to validate its ACE screening tools.) And in the meantime, the medical care she provides is trauma-informed.

“If a patient comes in for ADHD [attention-deficit/hyperactivity disorder] and has an ACE score of 6, my differential diagnosis and assessment will be different than if I see a patient sent by the school who has an ACE score of 0,” she said.

At the Portland Clinic, even though ACEs screening is now tied with the 4-month visit, pediatricians are much more attentive across the board to possible ACEs and toxic stress, and feel better able to converse with families, Dr. Gillespie said. One of his partners recently saw a 12-year-old boy who was failing in school and not making friends. Trauma-informed history-taking revealed at least several ACEs, and conversation turned to “all the resilience pieces… the connections he was missing and what he needed to cope,” he said.

References

• Resilience Project: This AAP project houses a “trauma toolkit” for primary care, case studies, and a variety of other tools.

• Center for Youth Wellness: The ACEs screening tools used by Dr. Burke Harris may be accessed at this website, along with a user guide containing sample scripts, and two white papers on ACEs and toxic stress.

• Resilience: The Biology of Stress and the Science of Hope: This documentary film, released in September 2016, is about ACEs and “a new movement” to treat and prevent toxic stress; it features the work of Dr. Burke Harris and others.

• Academy on Violence & Abuse: Various papers on ACEs screening and case finding in practice may be accessed here.

Several years ago, pediatricians R.J. Gillespie, MD, MHPE, and Teri Pettersen, MD, piloted the use of a questionnaire about adverse childhood experiences (ACEs) and resilience at the 4-month well-child visit.

They and six other pediatricians at The Children’s Clinic in Portland, Ore., explained in a cover letter why they were posing the questions of parents, and they ended the survey by asking them about their interest in potential resources.

[[{"fid":"172157","view_mode":"medstat_image_flush_left","fields":{"format":"medstat_image_flush_left","field_file_image_alt_text[und][0][value]":"R.J. Gillespie, MD, MHPE","field_file_image_credit[und][0][value]":"Courtesy The Children's Clinic","field_file_image_caption[und][0][value]":"Dr. R.J. Gillespie "},"type":"media","attributes":{"class":"media-element file-medstat_image_flush_left"}}]]Today, all 28 of the pediatricians at the clinic screen for ACEs and resilience, and Dr. Pettersen, now retired from the practice, travels through the state conducting training for the Oregon Pediatric Society about the impact of ACEs in parents and their children, and how to go about identifying and addressing them.

“So many of our visits are about behavioral problems or emotional disturbances, and so often at the root of these issues is some sort of trauma the child is experiencing,” Dr. Gillespie said in an interview. “What we’re seeing in many of these cases really are coping strategies for that child to deal with the toxic stress in his or her life.”

By assessing parents’ exposure to ACEs, briefly talking with them about how ACEs might impact their parenting, and tailoring their counseling and anticipatory guidance, the pediatricians hope to prevent ACEs and consequent toxic stress from developing in children.

The driving science

The term ACEs entered the medical lexicon after 1998, when a landmark study called the Adverse Childhood Experiences Study showed that traumatic experiences in childhood – abuse, neglect, and other severe dysfunctions in a household – not only are common among American adults but are associated with numerous poor health outcomes.

In the study and subsequent analyses, Dr. Vincent Felitti of Kaiser Permanente in San Diego and Dr. Robert Anda of the Centers for Disease Control and Prevention surveyed more than 17,000 patients about 10 types of ACEs and their current health status and behaviors. About two-thirds reported having at least one ACE, and one in eight reported four or more (Am J Prev Med. 1998;14[4]:245-58, www.cdc.gov/violenceprevention/acestudy/about.html).

Adults with four or more ACEs were not only significantly more likely to report health risk behaviors (smoking, substance abuse) and poor mental health outcomes (depression, suicide attempt); they were also significantly more likely to have poor physical health outcomes, with 2.2 times the risk of ischemic heart disease, 1.9 times the risk of cancer, and 3.9 times the risk of chronic bronchitis or emphysema, for instance. There was a strong dose-response relationship between ACEs and poor outcomes.

The Felitti study spawned dozens of analyses and additional research – in children as well as adults – on the associations between early-life adversity and the incidence of poor behavioral, mental, and physical outcomes, as well as on potential mechanisms.

Some research suggested a direct link between ACEs and negative outcomes, independent of whether individuals adopt risky behavior. Other studies suggested what experts in child development and mental health have long argued – that the more ACEs a parent has, the more ACEs their child will have.

And a growing body of biomedical literature linked the extreme, frequent, or prolonged activation of the body’s stress response in childhood – what has come to be known as “toxic stress” – with disruptions of the developing nervous, cardiovascular, immune, and metabolic systems.

Ryan Twomey

The clinic’s roll-out

Dr. Pettersen learned about the ACE study and related research about 8 years ago while on a sabbatical to learn more about mental health issues. It “changed everything” about the way she viewed children and families and adversity. “I knew (we) didn’t have the infrastructure at the clinic, or the clinic’s support, to really start assessing children for what was happening to them,” she said, so she began thinking about ACE prevention and a focus on parenting.

Dr. Gillespie, in the meantime, was active in various quality improvement efforts at the state and national level, and had also become increasingly bothered by visits in which he saw children affected by maternal depression, abnormal attachment, and other problems. “I was seeing the consequences of ACEs, but I didn’t know specifically what was going on or how to talk about it,” he said.

The two pediatricians agreed to ask parents about ACEs at the 4-month well visit – a time when the families “knew us a little bit” and when “we could still influence parenting styles.”

In March 2013, they and their colleagues in the pilot group began giving parents a questionnaire that included the 10 ACE questions from Felitti’s study, questions about resilience from the Children’s Resilience Initiative, and a list of potential resources so they could understand parents’ needs.

They created a confidential field in their electronic medical record for documentation that appears during a visit, but does not print into notes and therefore will not be inadvertently released.

As they moved through the pilot phase, the pediatricians used various approaches to follow up on the assessment face-to-face. Eventually, they chose three particular questions as nonthreatening and helpful for conversation: Are there any experiences that still bother you? Of those experiences that don’t bother you, how did you get to the point where they don’t bother you? And how do these experiences affect your parenting now?

“It’s a motivational interviewing sort of style,” said Dr. Gillespie. “Parents can start identifying for themselves the solutions for the problems they’ve experienced, and they can start thinking about how their parenting might be impacted by things that have happened [or are still happening] to them.”

As the project rolled out, the physicians tweaked their process. They added four more ACE questions to address issues – community violence, extreme bullying, racism and prejudice, and foster care exposure – that they thought might lead to toxic stress in their population, for instance. And rather than ask on the written questionnaire for a “yes” or “no” to each of the ACE questions, they began asking the parent how many of the ACE questions applied to them. Moving away from the yes-no format to asking for a total count has led to more disclosures, Dr. Gillespie said.

To “keep the conversation going” in subsequent well-child visits, they developed a few questions to ask high-risk parents, like “How do you and your partner resolve conflict?” and “How did your parents resolve conflict in your household when you were a child?” And they provided training to all of the clinic’s staff on trauma-informed care and the need for support and compassion in their interactions with family members.

In the 3-plus years since incorporating ACEs assessments, the clinic’s pediatricians have made soft referrals to mental health professionals in only several cases – in each case, by suggesting that the parent contact their primary care physician. What most parents have wanted, says Dr. Gillespie, is recommendations for parenting classes and support groups. The clinic’s care manager assists the pediatricians in maintaining and providing links and handouts for various resources.

For Dr. Gillespie, the impact of the culture shift has been dramatic. “I’ve had 8-10 moms spontaneously reveal domestic violence to me in a subsequent visit, and say that they need a little help, because they’ve gotten the message that this is a safe place to talk about their experiences,” he said. “That had never happened to me in the previous 12 years of so of my career.”

Dr. Pettersen’s relationships with parents became “more intimate and more honest.” There was more trust. “If we can talk with parents [about ACEs] and not judge them for it,” she said, “then nothing is off the table.”
 

The ‘Two-Gen’ approach

Courtesy Children's Mercy Hospitals

“But I’d push back and say, parents know they have toxic stress but they don’t name it,” she said. “What we can do as trusted providers who want to advocate for families is to bear witness to their history by asking about it. Once they realize it’s not what’s wrong with [them], it’s what’s happened to [them], a shift occurs. That’s extremely validating for parents.”

That validation is part of a two-generation approach that she and Dr. Burke Harris see as part of a movement to break cycles of ACEs and toxic stress. At the California Pacific Medical Center’s Bayview Child Health Center in San Francisco, Dr. Burke Harris uses three ACE questionnaires – two of them ask parents (of children or teens) to report how many adverse experience types, or categories, apply to them and/or their child or teen, and one surveys adolescents themselves.

With the resources and clinical support of the Center for Youth Wellness, whose major funders include Google, Dr. Burke Harris can initiate a “warm hand-off” of patients with a high ACE score to a care coordinator or therapist. (The Center for Youth Wellness is beginning research to validate its ACE screening tools.) And in the meantime, the medical care she provides is trauma-informed.

“If a patient comes in for ADHD [attention-deficit/hyperactivity disorder] and has an ACE score of 6, my differential diagnosis and assessment will be different than if I see a patient sent by the school who has an ACE score of 0,” she said.

At the Portland Clinic, even though ACEs screening is now tied with the 4-month visit, pediatricians are much more attentive across the board to possible ACEs and toxic stress, and feel better able to converse with families, Dr. Gillespie said. One of his partners recently saw a 12-year-old boy who was failing in school and not making friends. Trauma-informed history-taking revealed at least several ACEs, and conversation turned to “all the resilience pieces… the connections he was missing and what he needed to cope,” he said.

References

• Resilience Project: This AAP project houses a “trauma toolkit” for primary care, case studies, and a variety of other tools.

• Center for Youth Wellness: The ACEs screening tools used by Dr. Burke Harris may be accessed at this website, along with a user guide containing sample scripts, and two white papers on ACEs and toxic stress.

• Resilience: The Biology of Stress and the Science of Hope: This documentary film, released in September 2016, is about ACEs and “a new movement” to treat and prevent toxic stress; it features the work of Dr. Burke Harris and others.

• Academy on Violence & Abuse: Various papers on ACEs screening and case finding in practice may be accessed here.

EXPERT ANALYSIS FROM CHEST 2016

LOS ANGELES – The optimal management of gastroesophageal reflux disease in patients with idiopathic pulmonary fibrosis has yet to be determined, according to Joyce S. Lee, MD.

“We need strong randomized clinical trial data to tell us whether or not medical or surgical treatment of GERD in IPF is indicated,” she said at the annual meeting of the American College of Chest Physicians.

EXPERT ANALYSIS FROM CHEST 2016

LOS ANGELES – The optimal management of gastroesophageal reflux disease in patients with idiopathic pulmonary fibrosis has yet to be determined, according to Joyce S. Lee, MD.

“We need strong randomized clinical trial data to tell us whether or not medical or surgical treatment of GERD in IPF is indicated,” she said at the annual meeting of the American College of Chest Physicians.

EXPERT ANALYSIS FROM CHEST 2016

LOS ANGELES – The optimal management of gastroesophageal reflux disease in patients with idiopathic pulmonary fibrosis has yet to be determined, according to Joyce S. Lee, MD.

“We need strong randomized clinical trial data to tell us whether or not medical or surgical treatment of GERD in IPF is indicated,” she said at the annual meeting of the American College of Chest Physicians.

PORTLAND, OR—Amantadine hydrochloride extended-release capsules, compared with placebo, result in a statistically significant and clinically meaningful improvement in levodopa-induced dyskinesia in patients with Parkinson’s disease, according to phase III trial results presented at the Fourth World Parkinson Congress. The drug also reduces daily off time and is generally well tolerated, researchers said.

Amantadine hydrochloride extended-release capsules, known as ADS-5102, are being developed by Adamas Pharmaceuticals with the aim of improving the pharmacokinetic profile of immediate-release amantadine.

Rajesh Pahwa, MD, Professor of Neurology at University of Kansas Medical Center in Kansas City, and colleagues reported efficacy and safety results from the EASE LID 3 trial, one of three phase III trials of the drug.

EASE LID 3 was a randomized, double-blind, placebo-controlled study conducted at 39 sites in the United States and Europe. Seventy-seven patients with Parkinson’s disease were randomized to receive 340 mg of amantadine hydrochloride or placebo once daily at bedtime for the treatment of levodopa-induced dyskinesia. Participants had an average age of 64.8, 52% were men, and they had been diagnosed with Parkinson’s disease for an average of 10.6 years. They had received levodopa treatment for an average of 8.1 years. Patients’ mean duration of levodopa-induced dyskinesia was 3.9 years.

Treatment Improved Outcomes

The primary efficacy analysis compared the least square mean change from baseline to week 12 in Unified Dyskinesia Rating Scale total score in the ADS-5102 group with that in the placebo group. Key secondary efficacy analyses compared the least square mean change from baseline to week 12 in on time without troublesome dyskinesia and off time, as recorded in participants’ home diaries.

Thirty-eight patients were randomized to receive ADS-5102 and 39 patients were randomized to receive placebo. In the ADS-5102 group, the observed mean Unified Dyskinesia Rating Scale total score from baseline to week 12 decreased by 46%, compared with a 16% reduction in the placebo group. At 12 weeks, daily on time without troublesome dyskinesia increased by 4.0 hours in the ADS-5102 group and by 2.1 hours in the placebo group. Daily off time decreased by 0.5 hours in the ADS-5102 group and increased by 0.6 hours in the placebo group.

Adverse Events

Four patients, all in the ADS-5102 group, experienced serious adverse events. In one patient, the serious adverse event was considered related to the study drug (ie, constipation and urinary retention). The patient completed study treatment and did not discontinue participation in the trial.

Seven patients in the ADS-5102 group (19%) versus three patients in the placebo group (8%) discontinued treatment due to adverse events. In the ADS-5102 group, the most frequent adverse events (ie, they occurred in more than two patients) were dry mouth, nausea, decreased appetite, insomnia, orthostatic hypotension, constipation, fall, and hallucination.

“ADS-5102 resulted in statistically significant and clinically meaningful improvement in levodopa-induced dyskinesia, confirming results from earlier controlled clinical trials,” the researchers concluded.

Investigators are conducting an open-label safety study of ADS-5102 that includes patients from the phase III trials as well as patients with levodopa-induced dyskinesia who have undergone deep brain stimulation. Adamas also is investigating ADS-5102 for use in patients with multiple sclerosis with walking impairment.

—Jake Remaly

PORTLAND, OR—Amantadine hydrochloride extended-release capsules, compared with placebo, result in a statistically significant and clinically meaningful improvement in levodopa-induced dyskinesia in patients with Parkinson’s disease, according to phase III trial results presented at the Fourth World Parkinson Congress. The drug also reduces daily off time and is generally well tolerated, researchers said.

Amantadine hydrochloride extended-release capsules, known as ADS-5102, are being developed by Adamas Pharmaceuticals with the aim of improving the pharmacokinetic profile of immediate-release amantadine.

Rajesh Pahwa, MD, Professor of Neurology at University of Kansas Medical Center in Kansas City, and colleagues reported efficacy and safety results from the EASE LID 3 trial, one of three phase III trials of the drug.

EASE LID 3 was a randomized, double-blind, placebo-controlled study conducted at 39 sites in the United States and Europe. Seventy-seven patients with Parkinson’s disease were randomized to receive 340 mg of amantadine hydrochloride or placebo once daily at bedtime for the treatment of levodopa-induced dyskinesia. Participants had an average age of 64.8, 52% were men, and they had been diagnosed with Parkinson’s disease for an average of 10.6 years. They had received levodopa treatment for an average of 8.1 years. Patients’ mean duration of levodopa-induced dyskinesia was 3.9 years.

Treatment Improved Outcomes

The primary efficacy analysis compared the least square mean change from baseline to week 12 in Unified Dyskinesia Rating Scale total score in the ADS-5102 group with that in the placebo group. Key secondary efficacy analyses compared the least square mean change from baseline to week 12 in on time without troublesome dyskinesia and off time, as recorded in participants’ home diaries.

Thirty-eight patients were randomized to receive ADS-5102 and 39 patients were randomized to receive placebo. In the ADS-5102 group, the observed mean Unified Dyskinesia Rating Scale total score from baseline to week 12 decreased by 46%, compared with a 16% reduction in the placebo group. At 12 weeks, daily on time without troublesome dyskinesia increased by 4.0 hours in the ADS-5102 group and by 2.1 hours in the placebo group. Daily off time decreased by 0.5 hours in the ADS-5102 group and increased by 0.6 hours in the placebo group.

Adverse Events

Four patients, all in the ADS-5102 group, experienced serious adverse events. In one patient, the serious adverse event was considered related to the study drug (ie, constipation and urinary retention). The patient completed study treatment and did not discontinue participation in the trial.

Seven patients in the ADS-5102 group (19%) versus three patients in the placebo group (8%) discontinued treatment due to adverse events. In the ADS-5102 group, the most frequent adverse events (ie, they occurred in more than two patients) were dry mouth, nausea, decreased appetite, insomnia, orthostatic hypotension, constipation, fall, and hallucination.

“ADS-5102 resulted in statistically significant and clinically meaningful improvement in levodopa-induced dyskinesia, confirming results from earlier controlled clinical trials,” the researchers concluded.

Investigators are conducting an open-label safety study of ADS-5102 that includes patients from the phase III trials as well as patients with levodopa-induced dyskinesia who have undergone deep brain stimulation. Adamas also is investigating ADS-5102 for use in patients with multiple sclerosis with walking impairment.

—Jake Remaly

PORTLAND, OR—Amantadine hydrochloride extended-release capsules, compared with placebo, result in a statistically significant and clinically meaningful improvement in levodopa-induced dyskinesia in patients with Parkinson’s disease, according to phase III trial results presented at the Fourth World Parkinson Congress. The drug also reduces daily off time and is generally well tolerated, researchers said.

Amantadine hydrochloride extended-release capsules, known as ADS-5102, are being developed by Adamas Pharmaceuticals with the aim of improving the pharmacokinetic profile of immediate-release amantadine.

Rajesh Pahwa, MD, Professor of Neurology at University of Kansas Medical Center in Kansas City, and colleagues reported efficacy and safety results from the EASE LID 3 trial, one of three phase III trials of the drug.

EASE LID 3 was a randomized, double-blind, placebo-controlled study conducted at 39 sites in the United States and Europe. Seventy-seven patients with Parkinson’s disease were randomized to receive 340 mg of amantadine hydrochloride or placebo once daily at bedtime for the treatment of levodopa-induced dyskinesia. Participants had an average age of 64.8, 52% were men, and they had been diagnosed with Parkinson’s disease for an average of 10.6 years. They had received levodopa treatment for an average of 8.1 years. Patients’ mean duration of levodopa-induced dyskinesia was 3.9 years.

Treatment Improved Outcomes

The primary efficacy analysis compared the least square mean change from baseline to week 12 in Unified Dyskinesia Rating Scale total score in the ADS-5102 group with that in the placebo group. Key secondary efficacy analyses compared the least square mean change from baseline to week 12 in on time without troublesome dyskinesia and off time, as recorded in participants’ home diaries.

Thirty-eight patients were randomized to receive ADS-5102 and 39 patients were randomized to receive placebo. In the ADS-5102 group, the observed mean Unified Dyskinesia Rating Scale total score from baseline to week 12 decreased by 46%, compared with a 16% reduction in the placebo group. At 12 weeks, daily on time without troublesome dyskinesia increased by 4.0 hours in the ADS-5102 group and by 2.1 hours in the placebo group. Daily off time decreased by 0.5 hours in the ADS-5102 group and increased by 0.6 hours in the placebo group.

Adverse Events

Four patients, all in the ADS-5102 group, experienced serious adverse events. In one patient, the serious adverse event was considered related to the study drug (ie, constipation and urinary retention). The patient completed study treatment and did not discontinue participation in the trial.

Seven patients in the ADS-5102 group (19%) versus three patients in the placebo group (8%) discontinued treatment due to adverse events. In the ADS-5102 group, the most frequent adverse events (ie, they occurred in more than two patients) were dry mouth, nausea, decreased appetite, insomnia, orthostatic hypotension, constipation, fall, and hallucination.

“ADS-5102 resulted in statistically significant and clinically meaningful improvement in levodopa-induced dyskinesia, confirming results from earlier controlled clinical trials,” the researchers concluded.

Investigators are conducting an open-label safety study of ADS-5102 that includes patients from the phase III trials as well as patients with levodopa-induced dyskinesia who have undergone deep brain stimulation. Adamas also is investigating ADS-5102 for use in patients with multiple sclerosis with walking impairment.

—Jake Remaly

PORTLAND, OR—High-intensity exercise is feasible and safe in patients with Parkinson's disease, according to trial results presented at the Fourth World Parkinson Congress. An eight-week high-intensity exercise and fall-prevention boot camp was well attended, and participants tolerated high-intensity aerobic, strength, and balance training exercises, researchers said.

Most contemporary exercise programs for people with Parkinson's disease are low to moderate in intensity. Recent studies, however, suggest that older adults can safely tolerate high-intensity exercise programs and attain more meaningful benefits. "The optimal parameters of exercise for Parkinson's disease have not been thoroughly explored," said Merrill R. Landers, PT, DPT, PhD, OCS, Professor of Physical Therapy, and James Navalta, PhD, Associate Professor of Kinesiology, both at the University of Nevada in Las Vegas.

To test the feasibility and safety of a high-intensity exercise and fall-prevention boot camp in people with Parkinson's disease, Drs. Landers and Navalta conducted a phase II, pragmatic, randomized clinical trial.

Twenty-seven participants were included in the study. Fourteen patients were randomized to the high-intensity exercise program, and 13 patients were randomized to a low-intensity control program (ie, Fitness Counts Exercise Program). Physiotherapists supervised the exercise programs at community exercise gyms.

Patients had an average age of about 64 and disease duration of nearly five years. Nineteen men and eight women enrolled in the study. Most patients were Hoehn and Yahr stage 2.

The high-intensity boot camp sessions consisted of 30 minutes of aerobic exercise (70% of heart rate maximum), 30 minutes of strengthening (50% to 80% of one-repetition maximum), 15 minutes of balance training, and 15 minutes of active rest and stretching. The control sessions consisted of 15 minutes of aerobic exercise (60% of heart rate maximum), 15 minutes of strengthening (less than 50% of one-repetition maximum), 10 minutes of balance training, 10 minutes of rest, and 10 minutes of stretching. There was not a significant difference in the rate of injuries, falls, or exercise side effects between groups. Adverse events were similar in the two arms. Compared with low-intensity exercise, high-intensity exercise produced greater improvements in balance, physical activity, parkinsonian symptoms, endurance, fatigue, and bone health.

"These results warrant further investigation in a large-scale comparative effectiveness trial," the researchers concluded.

—Jake Remaly

PORTLAND, OR—High-intensity exercise is feasible and safe in patients with Parkinson's disease, according to trial results presented at the Fourth World Parkinson Congress. An eight-week high-intensity exercise and fall-prevention boot camp was well attended, and participants tolerated high-intensity aerobic, strength, and balance training exercises, researchers said.

Most contemporary exercise programs for people with Parkinson's disease are low to moderate in intensity. Recent studies, however, suggest that older adults can safely tolerate high-intensity exercise programs and attain more meaningful benefits. "The optimal parameters of exercise for Parkinson's disease have not been thoroughly explored," said Merrill R. Landers, PT, DPT, PhD, OCS, Professor of Physical Therapy, and James Navalta, PhD, Associate Professor of Kinesiology, both at the University of Nevada in Las Vegas.

To test the feasibility and safety of a high-intensity exercise and fall-prevention boot camp in people with Parkinson's disease, Drs. Landers and Navalta conducted a phase II, pragmatic, randomized clinical trial.

Twenty-seven participants were included in the study. Fourteen patients were randomized to the high-intensity exercise program, and 13 patients were randomized to a low-intensity control program (ie, Fitness Counts Exercise Program). Physiotherapists supervised the exercise programs at community exercise gyms.

Patients had an average age of about 64 and disease duration of nearly five years. Nineteen men and eight women enrolled in the study. Most patients were Hoehn and Yahr stage 2.

The high-intensity boot camp sessions consisted of 30 minutes of aerobic exercise (70% of heart rate maximum), 30 minutes of strengthening (50% to 80% of one-repetition maximum), 15 minutes of balance training, and 15 minutes of active rest and stretching. The control sessions consisted of 15 minutes of aerobic exercise (60% of heart rate maximum), 15 minutes of strengthening (less than 50% of one-repetition maximum), 10 minutes of balance training, 10 minutes of rest, and 10 minutes of stretching. There was not a significant difference in the rate of injuries, falls, or exercise side effects between groups. Adverse events were similar in the two arms. Compared with low-intensity exercise, high-intensity exercise produced greater improvements in balance, physical activity, parkinsonian symptoms, endurance, fatigue, and bone health.

"These results warrant further investigation in a large-scale comparative effectiveness trial," the researchers concluded.

—Jake Remaly

PORTLAND, OR—High-intensity exercise is feasible and safe in patients with Parkinson's disease, according to trial results presented at the Fourth World Parkinson Congress. An eight-week high-intensity exercise and fall-prevention boot camp was well attended, and participants tolerated high-intensity aerobic, strength, and balance training exercises, researchers said.

Most contemporary exercise programs for people with Parkinson's disease are low to moderate in intensity. Recent studies, however, suggest that older adults can safely tolerate high-intensity exercise programs and attain more meaningful benefits. "The optimal parameters of exercise for Parkinson's disease have not been thoroughly explored," said Merrill R. Landers, PT, DPT, PhD, OCS, Professor of Physical Therapy, and James Navalta, PhD, Associate Professor of Kinesiology, both at the University of Nevada in Las Vegas.

To test the feasibility and safety of a high-intensity exercise and fall-prevention boot camp in people with Parkinson's disease, Drs. Landers and Navalta conducted a phase II, pragmatic, randomized clinical trial.

Twenty-seven participants were included in the study. Fourteen patients were randomized to the high-intensity exercise program, and 13 patients were randomized to a low-intensity control program (ie, Fitness Counts Exercise Program). Physiotherapists supervised the exercise programs at community exercise gyms.

Patients had an average age of about 64 and disease duration of nearly five years. Nineteen men and eight women enrolled in the study. Most patients were Hoehn and Yahr stage 2.

The high-intensity boot camp sessions consisted of 30 minutes of aerobic exercise (70% of heart rate maximum), 30 minutes of strengthening (50% to 80% of one-repetition maximum), 15 minutes of balance training, and 15 minutes of active rest and stretching. The control sessions consisted of 15 minutes of aerobic exercise (60% of heart rate maximum), 15 minutes of strengthening (less than 50% of one-repetition maximum), 10 minutes of balance training, 10 minutes of rest, and 10 minutes of stretching. There was not a significant difference in the rate of injuries, falls, or exercise side effects between groups. Adverse events were similar in the two arms. Compared with low-intensity exercise, high-intensity exercise produced greater improvements in balance, physical activity, parkinsonian symptoms, endurance, fatigue, and bone health.

"These results warrant further investigation in a large-scale comparative effectiveness trial," the researchers concluded.

—Jake Remaly

PORTLAND, OR—Autonomic symptoms are present in a majority of patients with early Parkinson's disease, and symptoms correlate with markers of disease severity and impaired quality of life, according to research presented at the Fourth World Parkinson Congress.

Although autonomic dysfunction is common in the later stages of Parkinson's disease, less is known about autonomic symptom presence and severity in early stages of Parkinson's disease. Naveed Malek, MD, Department of Neurology, Institute of Neurological Sciences, Queen Elizabeth University Hospital, in Glasgow, and colleagues conducted a study to explore the prevalence, range, and severity of autonomic symptoms in a cohort of patients who had been diagnosed with Parkinson's disease in the preceding 3.5 years.

The researchers analyzed detailed patient-reported symptoms of autonomic dysfunction that were assessed in the multicenter United Kingdom Tracking Parkinson's study using the Scale for Outcomes in Parkinson's Disease for Autonomic Symptoms (SCOPA-AUT).

The researchers assessed the relationship between baseline SCOPA-AUT score and baseline motor, nonmotor, and quality of life scores. The researchers adjusted for sex, age, and disease duration differences across groups.

A total of 1,738 patients (65.1% male, mean age 67.6) were included in the main analysis. Patients had a mean disease duration of 1.3 years and mean Movement Disorder Society Unified Parkinson's Disease Rating Scale motor score of 22.5. Hoehn and Yahr was stage 1 or 1.5 in 855 cases (49.2%), stage 2 or 2.5 in 783 cases (45.1%), and stage 3 or higher in 100 cases (5.8%).

Autonomic severity by SCOPA-AUT score increased significantly across the motor severity stages, from 10.7 for Hoehn and Yahr stages 1 and 1.5, to 12.7 for Hoehn and Yahr stages 2 and 2.5, and to 13.5 for Hoehn and Yahr stages 3 and higher. Urinary, bowel, and sexual dysfunctions were the most commonly reported autonomic symptoms. The results were between those previously reported in controls and in patients with Parkinson's disease at a mean duration of 10 years. Positive associations were present between autonomic severity and depression, sleep disturbance, and postural instability motor subtype.

"Our study highlights the extent to which we may expect to see autonomic features in early Parkinson's disease, and the relationship between autonomic features and diagnostic consideration, which is important in the balanced diagnostic judgment approach emphasized in recent consensus guidelines," Dr. Malek concluded.                     

—Jake Remaly

PORTLAND, OR—Autonomic symptoms are present in a majority of patients with early Parkinson's disease, and symptoms correlate with markers of disease severity and impaired quality of life, according to research presented at the Fourth World Parkinson Congress.

Although autonomic dysfunction is common in the later stages of Parkinson's disease, less is known about autonomic symptom presence and severity in early stages of Parkinson's disease. Naveed Malek, MD, Department of Neurology, Institute of Neurological Sciences, Queen Elizabeth University Hospital, in Glasgow, and colleagues conducted a study to explore the prevalence, range, and severity of autonomic symptoms in a cohort of patients who had been diagnosed with Parkinson's disease in the preceding 3.5 years.

The researchers analyzed detailed patient-reported symptoms of autonomic dysfunction that were assessed in the multicenter United Kingdom Tracking Parkinson's study using the Scale for Outcomes in Parkinson's Disease for Autonomic Symptoms (SCOPA-AUT).

The researchers assessed the relationship between baseline SCOPA-AUT score and baseline motor, nonmotor, and quality of life scores. The researchers adjusted for sex, age, and disease duration differences across groups.

A total of 1,738 patients (65.1% male, mean age 67.6) were included in the main analysis. Patients had a mean disease duration of 1.3 years and mean Movement Disorder Society Unified Parkinson's Disease Rating Scale motor score of 22.5. Hoehn and Yahr was stage 1 or 1.5 in 855 cases (49.2%), stage 2 or 2.5 in 783 cases (45.1%), and stage 3 or higher in 100 cases (5.8%).

Autonomic severity by SCOPA-AUT score increased significantly across the motor severity stages, from 10.7 for Hoehn and Yahr stages 1 and 1.5, to 12.7 for Hoehn and Yahr stages 2 and 2.5, and to 13.5 for Hoehn and Yahr stages 3 and higher. Urinary, bowel, and sexual dysfunctions were the most commonly reported autonomic symptoms. The results were between those previously reported in controls and in patients with Parkinson's disease at a mean duration of 10 years. Positive associations were present between autonomic severity and depression, sleep disturbance, and postural instability motor subtype.

"Our study highlights the extent to which we may expect to see autonomic features in early Parkinson's disease, and the relationship between autonomic features and diagnostic consideration, which is important in the balanced diagnostic judgment approach emphasized in recent consensus guidelines," Dr. Malek concluded.                     

—Jake Remaly

PORTLAND, OR—Autonomic symptoms are present in a majority of patients with early Parkinson's disease, and symptoms correlate with markers of disease severity and impaired quality of life, according to research presented at the Fourth World Parkinson Congress.

Although autonomic dysfunction is common in the later stages of Parkinson's disease, less is known about autonomic symptom presence and severity in early stages of Parkinson's disease. Naveed Malek, MD, Department of Neurology, Institute of Neurological Sciences, Queen Elizabeth University Hospital, in Glasgow, and colleagues conducted a study to explore the prevalence, range, and severity of autonomic symptoms in a cohort of patients who had been diagnosed with Parkinson's disease in the preceding 3.5 years.

The researchers analyzed detailed patient-reported symptoms of autonomic dysfunction that were assessed in the multicenter United Kingdom Tracking Parkinson's study using the Scale for Outcomes in Parkinson's Disease for Autonomic Symptoms (SCOPA-AUT).

The researchers assessed the relationship between baseline SCOPA-AUT score and baseline motor, nonmotor, and quality of life scores. The researchers adjusted for sex, age, and disease duration differences across groups.

A total of 1,738 patients (65.1% male, mean age 67.6) were included in the main analysis. Patients had a mean disease duration of 1.3 years and mean Movement Disorder Society Unified Parkinson's Disease Rating Scale motor score of 22.5. Hoehn and Yahr was stage 1 or 1.5 in 855 cases (49.2%), stage 2 or 2.5 in 783 cases (45.1%), and stage 3 or higher in 100 cases (5.8%).

Autonomic severity by SCOPA-AUT score increased significantly across the motor severity stages, from 10.7 for Hoehn and Yahr stages 1 and 1.5, to 12.7 for Hoehn and Yahr stages 2 and 2.5, and to 13.5 for Hoehn and Yahr stages 3 and higher. Urinary, bowel, and sexual dysfunctions were the most commonly reported autonomic symptoms. The results were between those previously reported in controls and in patients with Parkinson's disease at a mean duration of 10 years. Positive associations were present between autonomic severity and depression, sleep disturbance, and postural instability motor subtype.

"Our study highlights the extent to which we may expect to see autonomic features in early Parkinson's disease, and the relationship between autonomic features and diagnostic consideration, which is important in the balanced diagnostic judgment approach emphasized in recent consensus guidelines," Dr. Malek concluded.                     

—Jake Remaly

PORTLAND, OR—A large-scale analysis has identified several new putative susceptibility genes that may affect cognitive impairment in Parkinson's disease, researchers reported at the Fourth World Parkinson Congress.

Cognitive impairment is a common and disabling nonmotor feature of Parkinson's disease. Identifying genetic variants that influence cognitive deficits could clarify the pathophysiology of cognitive impairment, help identify potential therapies, and be useful when considering patient prognosis, said Ignacio F. Mata, PhD, Research Biologist at the Veterans Affairs Puget Sound Health Care System and Acting Assistant Professor of Neurology at the University of Washington in Seattle. Rate of cognitive decline in Parkinson's disease varies. "We are trying to understand why," Dr. Mata said.

Dr. Mata and colleagues conducted a genome-wide exploratory analysis of genetic risk factors for cognitive impairment in a multisite cohort. The investigators genotyped 1,105 patients from the Parkinson's Disease Cognitive Genetics Consortium for 249,336 variants using the NeuroX array, which includes variants that have been linked to neurologic diseases.

Participants completed tests of learning and memory (Hopkins Verbal Learning Test-Revised), working memory and executive function (Letter-Number Sequencing and Trail Making Test Parts A and B), language processing (semantic and phonemic verbal fluency), visuospatial abilities (Benton Judgment of Line Orientation), and global cognitive function (Montreal Cognitive Assessment).

The researchers used linear regression to test for associations between common variants and cognitive performance, with adjustment for important covariates (eg, age, sex, disease duration, and years of education). They analyzed rare variants using the optimal unified sequence kernel association test.

Participants' mean age was 68.8, 67.8% were male, and 17.5% had dementia. Mean disease duration was 8.4 years. Participants had 15.5 years of education on average.

The researchers identified 17 common genetic variants associated with cognitive performance. Three variants were associated with total recall, and two variants were associated with delayed recall on the revised Hopkins Verbal Learning Test. Five variants were associated with performance on the Trail Making Test, and seven variants were associated with performance on the Benton Judgment of Line Orientation test.

The researchers aim to perform a similar analysis using longitudinal data. They also plan to see if these findings can be replicated in an independent cohort.             

—Jake Remaly

PORTLAND, OR—A large-scale analysis has identified several new putative susceptibility genes that may affect cognitive impairment in Parkinson's disease, researchers reported at the Fourth World Parkinson Congress.

Cognitive impairment is a common and disabling nonmotor feature of Parkinson's disease. Identifying genetic variants that influence cognitive deficits could clarify the pathophysiology of cognitive impairment, help identify potential therapies, and be useful when considering patient prognosis, said Ignacio F. Mata, PhD, Research Biologist at the Veterans Affairs Puget Sound Health Care System and Acting Assistant Professor of Neurology at the University of Washington in Seattle. Rate of cognitive decline in Parkinson's disease varies. "We are trying to understand why," Dr. Mata said.

Dr. Mata and colleagues conducted a genome-wide exploratory analysis of genetic risk factors for cognitive impairment in a multisite cohort. The investigators genotyped 1,105 patients from the Parkinson's Disease Cognitive Genetics Consortium for 249,336 variants using the NeuroX array, which includes variants that have been linked to neurologic diseases.

Participants completed tests of learning and memory (Hopkins Verbal Learning Test-Revised), working memory and executive function (Letter-Number Sequencing and Trail Making Test Parts A and B), language processing (semantic and phonemic verbal fluency), visuospatial abilities (Benton Judgment of Line Orientation), and global cognitive function (Montreal Cognitive Assessment).

The researchers used linear regression to test for associations between common variants and cognitive performance, with adjustment for important covariates (eg, age, sex, disease duration, and years of education). They analyzed rare variants using the optimal unified sequence kernel association test.

Participants' mean age was 68.8, 67.8% were male, and 17.5% had dementia. Mean disease duration was 8.4 years. Participants had 15.5 years of education on average.

The researchers identified 17 common genetic variants associated with cognitive performance. Three variants were associated with total recall, and two variants were associated with delayed recall on the revised Hopkins Verbal Learning Test. Five variants were associated with performance on the Trail Making Test, and seven variants were associated with performance on the Benton Judgment of Line Orientation test.

The researchers aim to perform a similar analysis using longitudinal data. They also plan to see if these findings can be replicated in an independent cohort.             

—Jake Remaly

PORTLAND, OR—A large-scale analysis has identified several new putative susceptibility genes that may affect cognitive impairment in Parkinson's disease, researchers reported at the Fourth World Parkinson Congress.

Cognitive impairment is a common and disabling nonmotor feature of Parkinson's disease. Identifying genetic variants that influence cognitive deficits could clarify the pathophysiology of cognitive impairment, help identify potential therapies, and be useful when considering patient prognosis, said Ignacio F. Mata, PhD, Research Biologist at the Veterans Affairs Puget Sound Health Care System and Acting Assistant Professor of Neurology at the University of Washington in Seattle. Rate of cognitive decline in Parkinson's disease varies. "We are trying to understand why," Dr. Mata said.

Dr. Mata and colleagues conducted a genome-wide exploratory analysis of genetic risk factors for cognitive impairment in a multisite cohort. The investigators genotyped 1,105 patients from the Parkinson's Disease Cognitive Genetics Consortium for 249,336 variants using the NeuroX array, which includes variants that have been linked to neurologic diseases.

Participants completed tests of learning and memory (Hopkins Verbal Learning Test-Revised), working memory and executive function (Letter-Number Sequencing and Trail Making Test Parts A and B), language processing (semantic and phonemic verbal fluency), visuospatial abilities (Benton Judgment of Line Orientation), and global cognitive function (Montreal Cognitive Assessment).

The researchers used linear regression to test for associations between common variants and cognitive performance, with adjustment for important covariates (eg, age, sex, disease duration, and years of education). They analyzed rare variants using the optimal unified sequence kernel association test.

Participants' mean age was 68.8, 67.8% were male, and 17.5% had dementia. Mean disease duration was 8.4 years. Participants had 15.5 years of education on average.

The researchers identified 17 common genetic variants associated with cognitive performance. Three variants were associated with total recall, and two variants were associated with delayed recall on the revised Hopkins Verbal Learning Test. Five variants were associated with performance on the Trail Making Test, and seven variants were associated with performance on the Benton Judgment of Line Orientation test.

The researchers aim to perform a similar analysis using longitudinal data. They also plan to see if these findings can be replicated in an independent cohort.             

—Jake Remaly

The Centers for Disease Control and Prevention released results from the first nationally representative study on health risk behaviors of gay, lesbian, and bisexual (GLB) high school students in August 2016.

These data were collected through the Youth Risk Behavior Survey (YRBS) questionnaire. The YRBS questionnaire was developed in 1990 as a way to monitor health-related behaviors that contribute to the leading causes of mortality and morbidity in youth and young adults. Areas covered by the survey include behaviors related to unintentional injuries and violence, tobacco use, alcohol and other drug use, sexual behaviors, dietary behaviors, and physical activity. Data are collected every 2 years through national, state, territorial, tribal government, and local school-based surveys of representative samples of 9th-12th grade students.

Selected questionnaire results

Sexual identity

• 88.8% of students identified as heterosexual.

• 6.0% identified as bisexual.

• 3.2% were not sure.

• 2.0% identified as gay or lesbian.

Sexual behaviors

• 48% had had sexual contact with the opposite sex only.

• 4.6% had sexual contact with both sexes.

• 1.7% had had sexual contact with the same sex only.

• 45.7% had no sexual contact.

Mental health

Percent of students who reported making a suicide plan in the 12 months preceding the survey:

• 11.9% of heterosexual students.

• 27.9% of students not sure of sexual identity.

• 38.2% of gay, lesbian, bisexual (GLB) students.

Percent of students who attempted suicide in the 12 months preceding the survey:

• 6.4% of heterosexual students.

• 13.7% of students not sure of sexual identity.

• 29.4% of GLB students.

Sexual Behaviors

First sex before the age of 13:

• 3.4% of heterosexual students.

• 8.8% of students not sure of their sexual identity.

• 7.3% of GLB students.

Drank alcohol or used drugs before last sex:

• 20.0% of heterosexual students.

• 44.5% of students not sure of their sexual identity.

• 22.4% of GLB students.

Tested for HIV:

• 9.3% of heterosexual students.

• 12.8% of students not sure of their sexual identity.

• 18.2% of GLB students.

Substance use

Currently smoking cigarettes daily:

• 1.9% of heterosexual students.

• 7.0% of students not sure of their sexual identity.

• 4.0% of GLB students.

Current alcohol use:

• 32.1% of heterosexual students.

• 34.6% of students not sure of their sexual identity.

• 40.5% of GLB students.

Current marijuana use:

• 20.7% of heterosexual students.

• 26.0% of students not sure of their sexual identity.

• 32.0% of GLB students.

Used hallucinogenic drugs (such as LSD, acid, PCP, angel dust, mescaline, or mushrooms):

• 5.5% of heterosexual students.

• 15.7% of students not sure of their sexual identity.

• 11.5% of GLB students.

Ever used heroin:

• 1.3% of heterosexual students.

• 9.3% of students not sure of their sexual identity.

• 6.0% of GLB students.

Ever took prescription drugs without a doctor’s prescription:

15.5% of heterosexual students.

24.3% of students not sure of their sexual identity.

27.5% of GLB students.

Physical Activity

Did not participate in at least 60 minutes of physical activity on at least 1 day in past week:

• 12.6% of heterosexual students.

• 27.0% of students not sure of their sexual identity.

• 25.7% of GLB students.

Dr. Chelvakumar is an attending physician in the division of adolescent medicine at Nationwide Children’s Hospital and an assistant professor of clinical pediatrics at the Ohio State University, both in Columbus.

The Centers for Disease Control and Prevention released results from the first nationally representative study on health risk behaviors of gay, lesbian, and bisexual (GLB) high school students in August 2016.

These data were collected through the Youth Risk Behavior Survey (YRBS) questionnaire. The YRBS questionnaire was developed in 1990 as a way to monitor health-related behaviors that contribute to the leading causes of mortality and morbidity in youth and young adults. Areas covered by the survey include behaviors related to unintentional injuries and violence, tobacco use, alcohol and other drug use, sexual behaviors, dietary behaviors, and physical activity. Data are collected every 2 years through national, state, territorial, tribal government, and local school-based surveys of representative samples of 9th-12th grade students.

Selected questionnaire results

Sexual identity

• 88.8% of students identified as heterosexual.

• 6.0% identified as bisexual.

• 3.2% were not sure.

• 2.0% identified as gay or lesbian.

Sexual behaviors

• 48% had had sexual contact with the opposite sex only.

• 4.6% had sexual contact with both sexes.

• 1.7% had had sexual contact with the same sex only.

• 45.7% had no sexual contact.

Mental health

Percent of students who reported making a suicide plan in the 12 months preceding the survey:

• 11.9% of heterosexual students.

• 27.9% of students not sure of sexual identity.

• 38.2% of gay, lesbian, bisexual (GLB) students.

Percent of students who attempted suicide in the 12 months preceding the survey:

• 6.4% of heterosexual students.

• 13.7% of students not sure of sexual identity.

• 29.4% of GLB students.

Sexual Behaviors

First sex before the age of 13:

• 3.4% of heterosexual students.

• 8.8% of students not sure of their sexual identity.

• 7.3% of GLB students.

Drank alcohol or used drugs before last sex:

• 20.0% of heterosexual students.

• 44.5% of students not sure of their sexual identity.

• 22.4% of GLB students.

Tested for HIV:

• 9.3% of heterosexual students.

• 12.8% of students not sure of their sexual identity.

• 18.2% of GLB students.

Substance use

Currently smoking cigarettes daily:

• 1.9% of heterosexual students.

• 7.0% of students not sure of their sexual identity.

• 4.0% of GLB students.

Current alcohol use:

• 32.1% of heterosexual students.

• 34.6% of students not sure of their sexual identity.

• 40.5% of GLB students.

Current marijuana use:

• 20.7% of heterosexual students.

• 26.0% of students not sure of their sexual identity.

• 32.0% of GLB students.

Used hallucinogenic drugs (such as LSD, acid, PCP, angel dust, mescaline, or mushrooms):

• 5.5% of heterosexual students.

• 15.7% of students not sure of their sexual identity.

• 11.5% of GLB students.

Ever used heroin:

• 1.3% of heterosexual students.

• 9.3% of students not sure of their sexual identity.

• 6.0% of GLB students.

Ever took prescription drugs without a doctor’s prescription:

15.5% of heterosexual students.

24.3% of students not sure of their sexual identity.

27.5% of GLB students.

Physical Activity

Did not participate in at least 60 minutes of physical activity on at least 1 day in past week:

• 12.6% of heterosexual students.

• 27.0% of students not sure of their sexual identity.

• 25.7% of GLB students.

Dr. Chelvakumar is an attending physician in the division of adolescent medicine at Nationwide Children’s Hospital and an assistant professor of clinical pediatrics at the Ohio State University, both in Columbus.

The Centers for Disease Control and Prevention released results from the first nationally representative study on health risk behaviors of gay, lesbian, and bisexual (GLB) high school students in August 2016.

These data were collected through the Youth Risk Behavior Survey (YRBS) questionnaire. The YRBS questionnaire was developed in 1990 as a way to monitor health-related behaviors that contribute to the leading causes of mortality and morbidity in youth and young adults. Areas covered by the survey include behaviors related to unintentional injuries and violence, tobacco use, alcohol and other drug use, sexual behaviors, dietary behaviors, and physical activity. Data are collected every 2 years through national, state, territorial, tribal government, and local school-based surveys of representative samples of 9th-12th grade students.

Selected questionnaire results

Sexual identity

• 88.8% of students identified as heterosexual.

• 6.0% identified as bisexual.

• 3.2% were not sure.

• 2.0% identified as gay or lesbian.

Sexual behaviors

• 48% had had sexual contact with the opposite sex only.

• 4.6% had sexual contact with both sexes.

• 1.7% had had sexual contact with the same sex only.

• 45.7% had no sexual contact.

Mental health

Percent of students who reported making a suicide plan in the 12 months preceding the survey:

• 11.9% of heterosexual students.

• 27.9% of students not sure of sexual identity.

• 38.2% of gay, lesbian, bisexual (GLB) students.

Percent of students who attempted suicide in the 12 months preceding the survey:

• 6.4% of heterosexual students.

• 13.7% of students not sure of sexual identity.

• 29.4% of GLB students.

Sexual Behaviors

First sex before the age of 13:

• 3.4% of heterosexual students.

• 8.8% of students not sure of their sexual identity.

• 7.3% of GLB students.

Drank alcohol or used drugs before last sex:

• 20.0% of heterosexual students.

• 44.5% of students not sure of their sexual identity.

• 22.4% of GLB students.

Tested for HIV:

• 9.3% of heterosexual students.

• 12.8% of students not sure of their sexual identity.

• 18.2% of GLB students.

Substance use

Currently smoking cigarettes daily:

• 1.9% of heterosexual students.

• 7.0% of students not sure of their sexual identity.

• 4.0% of GLB students.

Current alcohol use:

• 32.1% of heterosexual students.

• 34.6% of students not sure of their sexual identity.

• 40.5% of GLB students.

Current marijuana use:

• 20.7% of heterosexual students.

• 26.0% of students not sure of their sexual identity.

• 32.0% of GLB students.

Used hallucinogenic drugs (such as LSD, acid, PCP, angel dust, mescaline, or mushrooms):

• 5.5% of heterosexual students.

• 15.7% of students not sure of their sexual identity.

• 11.5% of GLB students.

Ever used heroin:

• 1.3% of heterosexual students.

• 9.3% of students not sure of their sexual identity.

• 6.0% of GLB students.

Ever took prescription drugs without a doctor’s prescription:

15.5% of heterosexual students.

24.3% of students not sure of their sexual identity.

27.5% of GLB students.

Physical Activity

Did not participate in at least 60 minutes of physical activity on at least 1 day in past week:

• 12.6% of heterosexual students.

• 27.0% of students not sure of their sexual identity.

• 25.7% of GLB students.

Dr. Chelvakumar is an attending physician in the division of adolescent medicine at Nationwide Children’s Hospital and an assistant professor of clinical pediatrics at the Ohio State University, both in Columbus.