WASHINGTON – Universal cystoscopy at the time of hysterectomy – or at least more frequent use of the procedure – is worth considering since delayed diagnosis of urinary tract injury causes increased morbidity for patients, and in all likelihood increases litigation, Dr. Jay Goldberg and Dr. Cheung Kim suggested at the annual meeting of the American College of Obstetricians and Gynecologists.

“We’re often hesitant to do cystoscopy because we don’t want to add time,” said Dr. Kim. “But I always feel that no matter how much time it takes, I’ll be happier in the end if I do it. [And] if you have [experience], a routine, and readily available equipment, it can take as little as 10 minutes.”

Christine Kilgore/ Frontline Medical News

Universal cystoscopy to confirm ureteral patency is “fairly straightforward, low risk, and more likely to detect most injuries [than visual inspection alone], particularly ureteral injuries,” Dr. Kim said. On the other hand, it adds to operating time and increases procedure cost, and there is some research suggesting it may be relatively “low yield” and lead to some false positives.

Dr. Kim and Dr. Goldberg both practice at the Einstein Healthcare Network in Philadelphia. Here are some of the findings they shared, and advice they gave, on the use of cystoscopy – universal or selective – after hysterectomy.

Conflicting findings

There is conflicting opinion as to whether universal or selective cystoscopy after hysterectomy is best, and “there’s data on both sides,” said Dr. Goldberg, vice chairman of ob.gyn. and director of the Philadelphia Fibroid Center at Einstein.

A prospective study done at Louisiana State University, New Orleans, to evaluate the impact of a universal approach, for instance, showed an incidence of urinary tract injury of 4.3% (2.9% bladder injury, 1.8% ureteral injury, plus cases of simultaneous injury) in 839 hysterectomies for benign disease. The injury detection rate using intraoperative cystoscopy was 97.4%, and the majority of injuries – 76% – were not suspected prior to cystoscopy being performed (Obstet Gynecol. 2009 Jan;113[1]:6-10).

But researchers in Boston who looked retrospectively at 1,982 hysterectomies performed for any gynecologic indication found a much lower incidence of complications, and reported that cystoscopy did not detect any of the bladder injuries (0.71%) or ureteral injuries (0.25%) incurred in the group. Cystoscopy was performed selectively, however, in 250 of the patients, and was either normal or omitted in the patients who had complications (Obstet Gynecol. 2012 Dec;120[6]:1363-70).

Cystoscopy failed to detect any of the bladder injuries, but “all five of the ureteral injuries occurred in patients who had not undergone cystoscopy,” said Dr. Kim, chairman of ob.gyn. at Einstein Medical Center Montgomery in East Norriton, Pa.

Possible false-positives

Cystoscopy may lead on occasion to an incorrect presumption of a ureteral injury in patients with a pre-existing nonfunctional kidney, Dr. Goldberg noted.

He relayed the case of a 42-year-old patient who underwent a total abdominal hysterectomy without apparent complication. Cystoscopy was then performed with indigo carmine. An efflux of dye was seen from the left ureteral orifice but not from the right orifice.

Urology was consulted and investigated the presumed ureteral injury with additional surgical exploration. An intraoperative intravenous pyelogram (IVP) was eventually performed and was unable to identify the right kidney. A CT then showed an atrophic right kidney with compensatory hypertrophy of the left kidney, probably due to congenital right multicystic dysplastic kidney.

An estimated 0.2% of the population – 1 in 500 – will have a unilateral nonfunctional kidney, the majority of which have not been previously diagnosed. Etiologies include multicystic dysplastic kidney, congenital unilateral renal agenesis, and vascular events. “As we do more and more cystoscopies, this scenario is going to come up every so often,” said Dr. Goldberg, who reported on two such cases last year (Obstet Gynecol. 2015 Sep;126[3]:635-7).

It is also possible, Dr. Kim noted, that a weak urine jet observed on cystoscopy may not necessarily reflect injury. In the LSU study evaluating a universal approach, there was no injury detected on further evaluation in each of the 21 cases of low, subnormal dye efflux from the ureteral orifices. “So it’s not a benign process to undergo cystoscopy in terms of what the ramifications might be,” Dr. Kim said.

Increasing use

Ob.gyn. residents are required by the Accreditation Council for Graduate Medical Education to have completed 15 cystoscopies by the time they graduate, and according to recent survey findings, residents are more likely to utilize universal cystoscopy at the time of hysterectomy than currently practicing gynecologic surgeons.

The survey of ob.gyn residents (n = 56) shows universal cystoscopy (defined as greater than 90%) was performed in only a minority of cases during residency: 27% of total laparoscopic hysterectomies (TLH), 14% of laparoscopically assisted vaginal hysterectomies (LAVH), 12% of vaginal hysterectomies (VH), 2% of total abdominal hysterectomies (TAH), and 0% of supracervical hysterectomies (SCH), for instance.

Yet for every hysterectomy type, residents planned to perform universal cystoscopy post-residency more often than they had during their training (49% TLH, 34% LAVH, 34% VH, 15% TAH, 12% SCH), and “residents familiar with the literature on cystoscopy were statistically more likely to plan to perform universal cystoscopy,” said Dr. Goldberg, the senior author of the paper (Womens Health (Lond Engl). 2015 Nov;11[6]:825-31).

Litigation possible

Failure to detect a urinary tract injury at the time of hysterectomy may result in the need for future additional surgeries. Litigation in the Philadelphia market suggests that “if you have an injury that’s missed, there’s a chance that litigation may result,” Dr. Kim said.

Plaintiff’s attorneys have argued that not recognizing ureteral injury during surgery is a deviation from acceptable practice, while defense attorneys have contended that unavoidable complications occur and that no evaluation is required, or supported by the medical literature, when injury is not intraoperatively suspected. Currently, as cystoscopy is performed less than 25% of the time for all types of hysterectomy, the standard of care does not require the procedure intraoperatively if no injury is suspected, Dr. Goldberg said.

Primary prevention of urinary tract injury is most important, both physicians emphasized. The best way to accomplish this is to meticulously identify the anatomy and know the path of the ureter, and to document that the ureter has been identified and viewed as outside of the operative area, they said.

Dr. Kim and Dr. Goldberg reported having no relevant financial disclosures.

[email protected]

WASHINGTON – Universal cystoscopy at the time of hysterectomy – or at least more frequent use of the procedure – is worth considering since delayed diagnosis of urinary tract injury causes increased morbidity for patients, and in all likelihood increases litigation, Dr. Jay Goldberg and Dr. Cheung Kim suggested at the annual meeting of the American College of Obstetricians and Gynecologists.

“We’re often hesitant to do cystoscopy because we don’t want to add time,” said Dr. Kim. “But I always feel that no matter how much time it takes, I’ll be happier in the end if I do it. [And] if you have [experience], a routine, and readily available equipment, it can take as little as 10 minutes.”

Christine Kilgore/ Frontline Medical News

Universal cystoscopy to confirm ureteral patency is “fairly straightforward, low risk, and more likely to detect most injuries [than visual inspection alone], particularly ureteral injuries,” Dr. Kim said. On the other hand, it adds to operating time and increases procedure cost, and there is some research suggesting it may be relatively “low yield” and lead to some false positives.

Dr. Kim and Dr. Goldberg both practice at the Einstein Healthcare Network in Philadelphia. Here are some of the findings they shared, and advice they gave, on the use of cystoscopy – universal or selective – after hysterectomy.

Conflicting findings

There is conflicting opinion as to whether universal or selective cystoscopy after hysterectomy is best, and “there’s data on both sides,” said Dr. Goldberg, vice chairman of ob.gyn. and director of the Philadelphia Fibroid Center at Einstein.

A prospective study done at Louisiana State University, New Orleans, to evaluate the impact of a universal approach, for instance, showed an incidence of urinary tract injury of 4.3% (2.9% bladder injury, 1.8% ureteral injury, plus cases of simultaneous injury) in 839 hysterectomies for benign disease. The injury detection rate using intraoperative cystoscopy was 97.4%, and the majority of injuries – 76% – were not suspected prior to cystoscopy being performed (Obstet Gynecol. 2009 Jan;113[1]:6-10).

But researchers in Boston who looked retrospectively at 1,982 hysterectomies performed for any gynecologic indication found a much lower incidence of complications, and reported that cystoscopy did not detect any of the bladder injuries (0.71%) or ureteral injuries (0.25%) incurred in the group. Cystoscopy was performed selectively, however, in 250 of the patients, and was either normal or omitted in the patients who had complications (Obstet Gynecol. 2012 Dec;120[6]:1363-70).

Cystoscopy failed to detect any of the bladder injuries, but “all five of the ureteral injuries occurred in patients who had not undergone cystoscopy,” said Dr. Kim, chairman of ob.gyn. at Einstein Medical Center Montgomery in East Norriton, Pa.

Possible false-positives

Cystoscopy may lead on occasion to an incorrect presumption of a ureteral injury in patients with a pre-existing nonfunctional kidney, Dr. Goldberg noted.

He relayed the case of a 42-year-old patient who underwent a total abdominal hysterectomy without apparent complication. Cystoscopy was then performed with indigo carmine. An efflux of dye was seen from the left ureteral orifice but not from the right orifice.

Urology was consulted and investigated the presumed ureteral injury with additional surgical exploration. An intraoperative intravenous pyelogram (IVP) was eventually performed and was unable to identify the right kidney. A CT then showed an atrophic right kidney with compensatory hypertrophy of the left kidney, probably due to congenital right multicystic dysplastic kidney.

An estimated 0.2% of the population – 1 in 500 – will have a unilateral nonfunctional kidney, the majority of which have not been previously diagnosed. Etiologies include multicystic dysplastic kidney, congenital unilateral renal agenesis, and vascular events. “As we do more and more cystoscopies, this scenario is going to come up every so often,” said Dr. Goldberg, who reported on two such cases last year (Obstet Gynecol. 2015 Sep;126[3]:635-7).

It is also possible, Dr. Kim noted, that a weak urine jet observed on cystoscopy may not necessarily reflect injury. In the LSU study evaluating a universal approach, there was no injury detected on further evaluation in each of the 21 cases of low, subnormal dye efflux from the ureteral orifices. “So it’s not a benign process to undergo cystoscopy in terms of what the ramifications might be,” Dr. Kim said.

Increasing use

Ob.gyn. residents are required by the Accreditation Council for Graduate Medical Education to have completed 15 cystoscopies by the time they graduate, and according to recent survey findings, residents are more likely to utilize universal cystoscopy at the time of hysterectomy than currently practicing gynecologic surgeons.

The survey of ob.gyn residents (n = 56) shows universal cystoscopy (defined as greater than 90%) was performed in only a minority of cases during residency: 27% of total laparoscopic hysterectomies (TLH), 14% of laparoscopically assisted vaginal hysterectomies (LAVH), 12% of vaginal hysterectomies (VH), 2% of total abdominal hysterectomies (TAH), and 0% of supracervical hysterectomies (SCH), for instance.

Yet for every hysterectomy type, residents planned to perform universal cystoscopy post-residency more often than they had during their training (49% TLH, 34% LAVH, 34% VH, 15% TAH, 12% SCH), and “residents familiar with the literature on cystoscopy were statistically more likely to plan to perform universal cystoscopy,” said Dr. Goldberg, the senior author of the paper (Womens Health (Lond Engl). 2015 Nov;11[6]:825-31).

Litigation possible

Failure to detect a urinary tract injury at the time of hysterectomy may result in the need for future additional surgeries. Litigation in the Philadelphia market suggests that “if you have an injury that’s missed, there’s a chance that litigation may result,” Dr. Kim said.

Plaintiff’s attorneys have argued that not recognizing ureteral injury during surgery is a deviation from acceptable practice, while defense attorneys have contended that unavoidable complications occur and that no evaluation is required, or supported by the medical literature, when injury is not intraoperatively suspected. Currently, as cystoscopy is performed less than 25% of the time for all types of hysterectomy, the standard of care does not require the procedure intraoperatively if no injury is suspected, Dr. Goldberg said.

Primary prevention of urinary tract injury is most important, both physicians emphasized. The best way to accomplish this is to meticulously identify the anatomy and know the path of the ureter, and to document that the ureter has been identified and viewed as outside of the operative area, they said.

Dr. Kim and Dr. Goldberg reported having no relevant financial disclosures.

[email protected]

WASHINGTON – Universal cystoscopy at the time of hysterectomy – or at least more frequent use of the procedure – is worth considering since delayed diagnosis of urinary tract injury causes increased morbidity for patients, and in all likelihood increases litigation, Dr. Jay Goldberg and Dr. Cheung Kim suggested at the annual meeting of the American College of Obstetricians and Gynecologists.

“We’re often hesitant to do cystoscopy because we don’t want to add time,” said Dr. Kim. “But I always feel that no matter how much time it takes, I’ll be happier in the end if I do it. [And] if you have [experience], a routine, and readily available equipment, it can take as little as 10 minutes.”

Christine Kilgore/ Frontline Medical News

Universal cystoscopy to confirm ureteral patency is “fairly straightforward, low risk, and more likely to detect most injuries [than visual inspection alone], particularly ureteral injuries,” Dr. Kim said. On the other hand, it adds to operating time and increases procedure cost, and there is some research suggesting it may be relatively “low yield” and lead to some false positives.

Dr. Kim and Dr. Goldberg both practice at the Einstein Healthcare Network in Philadelphia. Here are some of the findings they shared, and advice they gave, on the use of cystoscopy – universal or selective – after hysterectomy.

Conflicting findings

There is conflicting opinion as to whether universal or selective cystoscopy after hysterectomy is best, and “there’s data on both sides,” said Dr. Goldberg, vice chairman of ob.gyn. and director of the Philadelphia Fibroid Center at Einstein.

A prospective study done at Louisiana State University, New Orleans, to evaluate the impact of a universal approach, for instance, showed an incidence of urinary tract injury of 4.3% (2.9% bladder injury, 1.8% ureteral injury, plus cases of simultaneous injury) in 839 hysterectomies for benign disease. The injury detection rate using intraoperative cystoscopy was 97.4%, and the majority of injuries – 76% – were not suspected prior to cystoscopy being performed (Obstet Gynecol. 2009 Jan;113[1]:6-10).

But researchers in Boston who looked retrospectively at 1,982 hysterectomies performed for any gynecologic indication found a much lower incidence of complications, and reported that cystoscopy did not detect any of the bladder injuries (0.71%) or ureteral injuries (0.25%) incurred in the group. Cystoscopy was performed selectively, however, in 250 of the patients, and was either normal or omitted in the patients who had complications (Obstet Gynecol. 2012 Dec;120[6]:1363-70).

Cystoscopy failed to detect any of the bladder injuries, but “all five of the ureteral injuries occurred in patients who had not undergone cystoscopy,” said Dr. Kim, chairman of ob.gyn. at Einstein Medical Center Montgomery in East Norriton, Pa.

Possible false-positives

Cystoscopy may lead on occasion to an incorrect presumption of a ureteral injury in patients with a pre-existing nonfunctional kidney, Dr. Goldberg noted.

He relayed the case of a 42-year-old patient who underwent a total abdominal hysterectomy without apparent complication. Cystoscopy was then performed with indigo carmine. An efflux of dye was seen from the left ureteral orifice but not from the right orifice.

Urology was consulted and investigated the presumed ureteral injury with additional surgical exploration. An intraoperative intravenous pyelogram (IVP) was eventually performed and was unable to identify the right kidney. A CT then showed an atrophic right kidney with compensatory hypertrophy of the left kidney, probably due to congenital right multicystic dysplastic kidney.

An estimated 0.2% of the population – 1 in 500 – will have a unilateral nonfunctional kidney, the majority of which have not been previously diagnosed. Etiologies include multicystic dysplastic kidney, congenital unilateral renal agenesis, and vascular events. “As we do more and more cystoscopies, this scenario is going to come up every so often,” said Dr. Goldberg, who reported on two such cases last year (Obstet Gynecol. 2015 Sep;126[3]:635-7).

It is also possible, Dr. Kim noted, that a weak urine jet observed on cystoscopy may not necessarily reflect injury. In the LSU study evaluating a universal approach, there was no injury detected on further evaluation in each of the 21 cases of low, subnormal dye efflux from the ureteral orifices. “So it’s not a benign process to undergo cystoscopy in terms of what the ramifications might be,” Dr. Kim said.

Increasing use

Ob.gyn. residents are required by the Accreditation Council for Graduate Medical Education to have completed 15 cystoscopies by the time they graduate, and according to recent survey findings, residents are more likely to utilize universal cystoscopy at the time of hysterectomy than currently practicing gynecologic surgeons.

The survey of ob.gyn residents (n = 56) shows universal cystoscopy (defined as greater than 90%) was performed in only a minority of cases during residency: 27% of total laparoscopic hysterectomies (TLH), 14% of laparoscopically assisted vaginal hysterectomies (LAVH), 12% of vaginal hysterectomies (VH), 2% of total abdominal hysterectomies (TAH), and 0% of supracervical hysterectomies (SCH), for instance.

Yet for every hysterectomy type, residents planned to perform universal cystoscopy post-residency more often than they had during their training (49% TLH, 34% LAVH, 34% VH, 15% TAH, 12% SCH), and “residents familiar with the literature on cystoscopy were statistically more likely to plan to perform universal cystoscopy,” said Dr. Goldberg, the senior author of the paper (Womens Health (Lond Engl). 2015 Nov;11[6]:825-31).

Litigation possible

Failure to detect a urinary tract injury at the time of hysterectomy may result in the need for future additional surgeries. Litigation in the Philadelphia market suggests that “if you have an injury that’s missed, there’s a chance that litigation may result,” Dr. Kim said.

Plaintiff’s attorneys have argued that not recognizing ureteral injury during surgery is a deviation from acceptable practice, while defense attorneys have contended that unavoidable complications occur and that no evaluation is required, or supported by the medical literature, when injury is not intraoperatively suspected. Currently, as cystoscopy is performed less than 25% of the time for all types of hysterectomy, the standard of care does not require the procedure intraoperatively if no injury is suspected, Dr. Goldberg said.

Primary prevention of urinary tract injury is most important, both physicians emphasized. The best way to accomplish this is to meticulously identify the anatomy and know the path of the ureter, and to document that the ureter has been identified and viewed as outside of the operative area, they said.

Dr. Kim and Dr. Goldberg reported having no relevant financial disclosures.

[email protected]

VANCOUVER—Childhood emotional abuse may be associated with migraine in adulthood, according to data presented at the 68th Annual Meeting of the American Academy of Neurology. The research indicates that emotional abuse during childhood has a more significant effect on migraine, compared with physical and sexual abuse.

Childhood maltreatment, which includes neglect and abuse (ie, emotional, physical, and sexual), is confirmed in 12.5% of children by the age of 18, according to a report published in 2014 in JAMA Pediatrics. Previous studies have linked childhood abuse to headache, but there has been limited assessment of other major types of abuse. “In 2015, there were six different meta-analyses from all over the world linking childhood emotional abuse in particular with adult psychiatric disease,” said Gretchen Tietjen, MD, Professor and Chair of Neurology at the University of Toledo in Ohio.

Gretchen Tietjen, MD

Dr. Tietjen and her colleagues conducted a study to better understand the association between emotional abuse and migraine, independent of depression and anxiety. The study’s objectives were to examine the correlation between migraine and the number of types of abuse and frequency of abuse, and to examine the influence of sex and race on migraine. They also strove to determine the temporal relationship between age of onset of abuse, depression, and anxiety and age of onset of migraine.

There were 14,484 participants aged 24 to 32 in the study. About 14% of participants self-reported that they had been diagnosed with migraine. Fifteen percent of the population reported a diagnosis of depression (35% in the migraine sample vs 12% of controls), and 12% of the sample reported a diagnosis of anxiety (25% in the migraine sample vs 10% of controls). The mean age in the study was 29.5. Fifty-three percent of participants were women and 36% of the population was nonwhite.

All participants filled out a “Mistreatment by Adults” questionnaire about experiences before age 18. Emotional abuse was assessed by asking participants how often a parent or other adult caregiver had said things that hurt their feelings or made them feel unwanted or unloved. Physical abuse was assessed by asking whether a parent or caregiver had hit the participant with a fist, kicked him or her, or threw him or her to the floor, into a wall, or down stairs. And finally, sexual abuse was assessed by asking whether a parent or adult caregiver had touched the participant in a sexual way, forced him or her to touch him or her in a sexual way, or forced him or her to have sexual relations. The dependent variable in the study was self-reported doctor diagnosis of migraine. Sociodemographic characteristics recorded included age, sex, household income, and race. Self-reported physician diagnoses of depression and anxiety were examined as additional confounders.

Abuse was recalled by 60.5% of participants with migraine and 49% of the nonmigraine sample. Abuse increased the chance of migraine diagnosis by 55%. Emotional abuse had the strongest link to migraine, and the link was stronger in males than in females. When the researchers controlled the data for depression and anxiety, the effect of child abuse on migraine was attenuated, but remained significant. In addition, the effect of emotional abuse on migraine decreased, but remained significant when the investigators controlled for depression and anxiety. The researchers found no association between physical and sexual abuse when they adjusted for other abuse types, and there was no association with any abuse type and migraine in the non-Caucasian cohort.

Strengths of this study included its nationally representative population-based sample, its population’s relatively young mean age of 30 (which was 20–30 years younger than populations in other studies), and the inclusion of questions on three major types of abuse. Limitations of the study included its reliance on self-reported, retrospective data on abuse and on physician-diagnosed conditions; its broad definition of emotional abuse; and its potential for recall bias and reporting bias.

The next goal for this investigation is to determine the neurophysiologic mechanisms of the relationship between migraine and emotional abuse, said Dr. Tietjen. The relationship itself needs to be confirmed. “We’re currently looking at the database for gene–environment interactions that may link abuse to migraine for persons with a specific genotype. There’s also an opportunity for investigation of other different kinds of modifications that we know occur with abuse and whether these play a role in determining migraine,” she concluded.

—Erica Robinson

VANCOUVER—Childhood emotional abuse may be associated with migraine in adulthood, according to data presented at the 68th Annual Meeting of the American Academy of Neurology. The research indicates that emotional abuse during childhood has a more significant effect on migraine, compared with physical and sexual abuse.

Childhood maltreatment, which includes neglect and abuse (ie, emotional, physical, and sexual), is confirmed in 12.5% of children by the age of 18, according to a report published in 2014 in JAMA Pediatrics. Previous studies have linked childhood abuse to headache, but there has been limited assessment of other major types of abuse. “In 2015, there were six different meta-analyses from all over the world linking childhood emotional abuse in particular with adult psychiatric disease,” said Gretchen Tietjen, MD, Professor and Chair of Neurology at the University of Toledo in Ohio.

Gretchen Tietjen, MD

Dr. Tietjen and her colleagues conducted a study to better understand the association between emotional abuse and migraine, independent of depression and anxiety. The study’s objectives were to examine the correlation between migraine and the number of types of abuse and frequency of abuse, and to examine the influence of sex and race on migraine. They also strove to determine the temporal relationship between age of onset of abuse, depression, and anxiety and age of onset of migraine.

There were 14,484 participants aged 24 to 32 in the study. About 14% of participants self-reported that they had been diagnosed with migraine. Fifteen percent of the population reported a diagnosis of depression (35% in the migraine sample vs 12% of controls), and 12% of the sample reported a diagnosis of anxiety (25% in the migraine sample vs 10% of controls). The mean age in the study was 29.5. Fifty-three percent of participants were women and 36% of the population was nonwhite.

All participants filled out a “Mistreatment by Adults” questionnaire about experiences before age 18. Emotional abuse was assessed by asking participants how often a parent or other adult caregiver had said things that hurt their feelings or made them feel unwanted or unloved. Physical abuse was assessed by asking whether a parent or caregiver had hit the participant with a fist, kicked him or her, or threw him or her to the floor, into a wall, or down stairs. And finally, sexual abuse was assessed by asking whether a parent or adult caregiver had touched the participant in a sexual way, forced him or her to touch him or her in a sexual way, or forced him or her to have sexual relations. The dependent variable in the study was self-reported doctor diagnosis of migraine. Sociodemographic characteristics recorded included age, sex, household income, and race. Self-reported physician diagnoses of depression and anxiety were examined as additional confounders.

Abuse was recalled by 60.5% of participants with migraine and 49% of the nonmigraine sample. Abuse increased the chance of migraine diagnosis by 55%. Emotional abuse had the strongest link to migraine, and the link was stronger in males than in females. When the researchers controlled the data for depression and anxiety, the effect of child abuse on migraine was attenuated, but remained significant. In addition, the effect of emotional abuse on migraine decreased, but remained significant when the investigators controlled for depression and anxiety. The researchers found no association between physical and sexual abuse when they adjusted for other abuse types, and there was no association with any abuse type and migraine in the non-Caucasian cohort.

Strengths of this study included its nationally representative population-based sample, its population’s relatively young mean age of 30 (which was 20–30 years younger than populations in other studies), and the inclusion of questions on three major types of abuse. Limitations of the study included its reliance on self-reported, retrospective data on abuse and on physician-diagnosed conditions; its broad definition of emotional abuse; and its potential for recall bias and reporting bias.

The next goal for this investigation is to determine the neurophysiologic mechanisms of the relationship between migraine and emotional abuse, said Dr. Tietjen. The relationship itself needs to be confirmed. “We’re currently looking at the database for gene–environment interactions that may link abuse to migraine for persons with a specific genotype. There’s also an opportunity for investigation of other different kinds of modifications that we know occur with abuse and whether these play a role in determining migraine,” she concluded.

—Erica Robinson

VANCOUVER—Childhood emotional abuse may be associated with migraine in adulthood, according to data presented at the 68th Annual Meeting of the American Academy of Neurology. The research indicates that emotional abuse during childhood has a more significant effect on migraine, compared with physical and sexual abuse.

Childhood maltreatment, which includes neglect and abuse (ie, emotional, physical, and sexual), is confirmed in 12.5% of children by the age of 18, according to a report published in 2014 in JAMA Pediatrics. Previous studies have linked childhood abuse to headache, but there has been limited assessment of other major types of abuse. “In 2015, there were six different meta-analyses from all over the world linking childhood emotional abuse in particular with adult psychiatric disease,” said Gretchen Tietjen, MD, Professor and Chair of Neurology at the University of Toledo in Ohio.

Gretchen Tietjen, MD

Dr. Tietjen and her colleagues conducted a study to better understand the association between emotional abuse and migraine, independent of depression and anxiety. The study’s objectives were to examine the correlation between migraine and the number of types of abuse and frequency of abuse, and to examine the influence of sex and race on migraine. They also strove to determine the temporal relationship between age of onset of abuse, depression, and anxiety and age of onset of migraine.

There were 14,484 participants aged 24 to 32 in the study. About 14% of participants self-reported that they had been diagnosed with migraine. Fifteen percent of the population reported a diagnosis of depression (35% in the migraine sample vs 12% of controls), and 12% of the sample reported a diagnosis of anxiety (25% in the migraine sample vs 10% of controls). The mean age in the study was 29.5. Fifty-three percent of participants were women and 36% of the population was nonwhite.

All participants filled out a “Mistreatment by Adults” questionnaire about experiences before age 18. Emotional abuse was assessed by asking participants how often a parent or other adult caregiver had said things that hurt their feelings or made them feel unwanted or unloved. Physical abuse was assessed by asking whether a parent or caregiver had hit the participant with a fist, kicked him or her, or threw him or her to the floor, into a wall, or down stairs. And finally, sexual abuse was assessed by asking whether a parent or adult caregiver had touched the participant in a sexual way, forced him or her to touch him or her in a sexual way, or forced him or her to have sexual relations. The dependent variable in the study was self-reported doctor diagnosis of migraine. Sociodemographic characteristics recorded included age, sex, household income, and race. Self-reported physician diagnoses of depression and anxiety were examined as additional confounders.

Abuse was recalled by 60.5% of participants with migraine and 49% of the nonmigraine sample. Abuse increased the chance of migraine diagnosis by 55%. Emotional abuse had the strongest link to migraine, and the link was stronger in males than in females. When the researchers controlled the data for depression and anxiety, the effect of child abuse on migraine was attenuated, but remained significant. In addition, the effect of emotional abuse on migraine decreased, but remained significant when the investigators controlled for depression and anxiety. The researchers found no association between physical and sexual abuse when they adjusted for other abuse types, and there was no association with any abuse type and migraine in the non-Caucasian cohort.

Strengths of this study included its nationally representative population-based sample, its population’s relatively young mean age of 30 (which was 20–30 years younger than populations in other studies), and the inclusion of questions on three major types of abuse. Limitations of the study included its reliance on self-reported, retrospective data on abuse and on physician-diagnosed conditions; its broad definition of emotional abuse; and its potential for recall bias and reporting bias.

The next goal for this investigation is to determine the neurophysiologic mechanisms of the relationship between migraine and emotional abuse, said Dr. Tietjen. The relationship itself needs to be confirmed. “We’re currently looking at the database for gene–environment interactions that may link abuse to migraine for persons with a specific genotype. There’s also an opportunity for investigation of other different kinds of modifications that we know occur with abuse and whether these play a role in determining migraine,” she concluded.

—Erica Robinson

Anti-TNF drug certolizumab pegol in combination with methotrexate achieves significantly better outcomes in early active rheumatoid arthritis than does methotrexate alone, according to researchers.

They conducted a randomized, double-blind, placebo-controlled phase III trial of certolizumab pegol (CZP) in combination with dose-optimized methotrexate (MTX) versus dose-optimized methotrexate and placebo (PBO) in 879 treatment-naive patients with moderate to severe, active, progressive RA, and with poor prognostic factors.

After 1 year of treatment, 28.9% of the 660 patients who received the CZP and MTX combination had achieved sustained remission, compared with 15% of the 219 patients in the PBO+MTX group (P less than .001) (Ann Rheum Dis. 2016 May 10. doi: 10.1136/annrheumdis-2015-209057).

The study also found that 43.8% of patients in the treatment arm achieved sustained low disease activity, compared with 28.6% of the control arm (P less than .001). Adjustment for withdrawals in each arm did not significantly bias the results.

CZP with MTX has shown efficacy both in patients with established RA who have shown an insufficient response to MTX alone, and in MTX-naive individuals with early RA, which the authors said justified further study in recently-diagnosed individuals.

“These data demonstrate that CZP+MTX combination therapy results in a significantly higher proportion of patients achieving sREM [sustained remission] than those treated with PBO+MTX, even when using a ‘treat-to-tolerance’ dosing strategy for MTX,” wrote Dr. Paul Emery of Leeds Institute of Rheumatic and Musculoskeletal Medicine at the University of Leeds, England, and coauthors.

“Consequently, for patients with poor prognostic factors for severe disease progression, treating early and aggressively may represent a unique opportunity to achieve maximal clinical benefit.”

Significantly more patients treated with CZP and MTX than with PBO achieved an ACR50 response (61.8% vs. 52.6%, P = .023), signifying at least a 50% improvement in the number of tender and swollen joints, and in the patient assessments of disease status, pain, and function.

Patients in the active group also showed greater improvements in physical function, as measured by the Health Assessment Questionnaire–Disability Index, and significantly less radiographic progression. Researchers noted that patients in the active arm of the study showed less joint erosion and less joint space narrowing compared with those in the placebo arm.

“The analysis of radiographic data in C-EARLY demonstrates that CZP+MTX therapy can inhibit structural damage significantly more than MTX alone – the percentage of patients with radiographic nonprogression was significantly higher in the CZP+MTX group compared with the PBO+MTX group,” the authors reported.

The incidence of adverse events was similar in both groups, with nausea, upper respiratory tract infection, urinary tract infection, nasopharyngitis, headache, and increased levels of alanine aminotransferase the most commonly reported events in the active arm.

One death in a patient taking CZP and MTX was caused by disseminated, noncharacterized, mycobacterium infection, which the investigators considered to be related to the study medication. However, the overall rates of serious adverse events and withdrawals due to adverse events were similar between both arms of the study.

Patients given CZP began on a dose of 400 mg at baseline, week 2 and week 4, then 200 mg every 2 weeks until week 52, while the dose of oral MTX used in the study was titrated up from an initial dose of 10 mg/week by 5 mg every 2 weeks, to a maximum of 25 mg/week by week 8.

The authors suggested that the methotrexate titration was an important part of the treatment because it ensured each patient received the maximum-tolerated dose within 8 weeks.

“To our knowledge, there are no previous studies in MTX-naive or DMARD-naive patients with RA where MTX doses have been optimized per-protocol to the levels achieved in C-EARLY,” they wrote. “This optimization may have been responsible, in part, for the response observed for the PBO+MTX and CZP+MTX arms.”

The study and manuscript development was sponsored by UCB Pharma, which also signed off on the manuscript after a review. The authors declared consultancy, speaker’s fees, grants and other funding from a range of pharmaceutical companies including UCB Pharma, and five authors were employees of UCB Pharma.

Anti-TNF drug certolizumab pegol in combination with methotrexate achieves significantly better outcomes in early active rheumatoid arthritis than does methotrexate alone, according to researchers.

They conducted a randomized, double-blind, placebo-controlled phase III trial of certolizumab pegol (CZP) in combination with dose-optimized methotrexate (MTX) versus dose-optimized methotrexate and placebo (PBO) in 879 treatment-naive patients with moderate to severe, active, progressive RA, and with poor prognostic factors.

After 1 year of treatment, 28.9% of the 660 patients who received the CZP and MTX combination had achieved sustained remission, compared with 15% of the 219 patients in the PBO+MTX group (P less than .001) (Ann Rheum Dis. 2016 May 10. doi: 10.1136/annrheumdis-2015-209057).

The study also found that 43.8% of patients in the treatment arm achieved sustained low disease activity, compared with 28.6% of the control arm (P less than .001). Adjustment for withdrawals in each arm did not significantly bias the results.

CZP with MTX has shown efficacy both in patients with established RA who have shown an insufficient response to MTX alone, and in MTX-naive individuals with early RA, which the authors said justified further study in recently-diagnosed individuals.

“These data demonstrate that CZP+MTX combination therapy results in a significantly higher proportion of patients achieving sREM [sustained remission] than those treated with PBO+MTX, even when using a ‘treat-to-tolerance’ dosing strategy for MTX,” wrote Dr. Paul Emery of Leeds Institute of Rheumatic and Musculoskeletal Medicine at the University of Leeds, England, and coauthors.

“Consequently, for patients with poor prognostic factors for severe disease progression, treating early and aggressively may represent a unique opportunity to achieve maximal clinical benefit.”

Significantly more patients treated with CZP and MTX than with PBO achieved an ACR50 response (61.8% vs. 52.6%, P = .023), signifying at least a 50% improvement in the number of tender and swollen joints, and in the patient assessments of disease status, pain, and function.

Patients in the active group also showed greater improvements in physical function, as measured by the Health Assessment Questionnaire–Disability Index, and significantly less radiographic progression. Researchers noted that patients in the active arm of the study showed less joint erosion and less joint space narrowing compared with those in the placebo arm.

“The analysis of radiographic data in C-EARLY demonstrates that CZP+MTX therapy can inhibit structural damage significantly more than MTX alone – the percentage of patients with radiographic nonprogression was significantly higher in the CZP+MTX group compared with the PBO+MTX group,” the authors reported.

The incidence of adverse events was similar in both groups, with nausea, upper respiratory tract infection, urinary tract infection, nasopharyngitis, headache, and increased levels of alanine aminotransferase the most commonly reported events in the active arm.

One death in a patient taking CZP and MTX was caused by disseminated, noncharacterized, mycobacterium infection, which the investigators considered to be related to the study medication. However, the overall rates of serious adverse events and withdrawals due to adverse events were similar between both arms of the study.

Patients given CZP began on a dose of 400 mg at baseline, week 2 and week 4, then 200 mg every 2 weeks until week 52, while the dose of oral MTX used in the study was titrated up from an initial dose of 10 mg/week by 5 mg every 2 weeks, to a maximum of 25 mg/week by week 8.

The authors suggested that the methotrexate titration was an important part of the treatment because it ensured each patient received the maximum-tolerated dose within 8 weeks.

“To our knowledge, there are no previous studies in MTX-naive or DMARD-naive patients with RA where MTX doses have been optimized per-protocol to the levels achieved in C-EARLY,” they wrote. “This optimization may have been responsible, in part, for the response observed for the PBO+MTX and CZP+MTX arms.”

The study and manuscript development was sponsored by UCB Pharma, which also signed off on the manuscript after a review. The authors declared consultancy, speaker’s fees, grants and other funding from a range of pharmaceutical companies including UCB Pharma, and five authors were employees of UCB Pharma.

Anti-TNF drug certolizumab pegol in combination with methotrexate achieves significantly better outcomes in early active rheumatoid arthritis than does methotrexate alone, according to researchers.

They conducted a randomized, double-blind, placebo-controlled phase III trial of certolizumab pegol (CZP) in combination with dose-optimized methotrexate (MTX) versus dose-optimized methotrexate and placebo (PBO) in 879 treatment-naive patients with moderate to severe, active, progressive RA, and with poor prognostic factors.

After 1 year of treatment, 28.9% of the 660 patients who received the CZP and MTX combination had achieved sustained remission, compared with 15% of the 219 patients in the PBO+MTX group (P less than .001) (Ann Rheum Dis. 2016 May 10. doi: 10.1136/annrheumdis-2015-209057).

The study also found that 43.8% of patients in the treatment arm achieved sustained low disease activity, compared with 28.6% of the control arm (P less than .001). Adjustment for withdrawals in each arm did not significantly bias the results.

CZP with MTX has shown efficacy both in patients with established RA who have shown an insufficient response to MTX alone, and in MTX-naive individuals with early RA, which the authors said justified further study in recently-diagnosed individuals.

“These data demonstrate that CZP+MTX combination therapy results in a significantly higher proportion of patients achieving sREM [sustained remission] than those treated with PBO+MTX, even when using a ‘treat-to-tolerance’ dosing strategy for MTX,” wrote Dr. Paul Emery of Leeds Institute of Rheumatic and Musculoskeletal Medicine at the University of Leeds, England, and coauthors.

“Consequently, for patients with poor prognostic factors for severe disease progression, treating early and aggressively may represent a unique opportunity to achieve maximal clinical benefit.”

Significantly more patients treated with CZP and MTX than with PBO achieved an ACR50 response (61.8% vs. 52.6%, P = .023), signifying at least a 50% improvement in the number of tender and swollen joints, and in the patient assessments of disease status, pain, and function.

Patients in the active group also showed greater improvements in physical function, as measured by the Health Assessment Questionnaire–Disability Index, and significantly less radiographic progression. Researchers noted that patients in the active arm of the study showed less joint erosion and less joint space narrowing compared with those in the placebo arm.

“The analysis of radiographic data in C-EARLY demonstrates that CZP+MTX therapy can inhibit structural damage significantly more than MTX alone – the percentage of patients with radiographic nonprogression was significantly higher in the CZP+MTX group compared with the PBO+MTX group,” the authors reported.

The incidence of adverse events was similar in both groups, with nausea, upper respiratory tract infection, urinary tract infection, nasopharyngitis, headache, and increased levels of alanine aminotransferase the most commonly reported events in the active arm.

One death in a patient taking CZP and MTX was caused by disseminated, noncharacterized, mycobacterium infection, which the investigators considered to be related to the study medication. However, the overall rates of serious adverse events and withdrawals due to adverse events were similar between both arms of the study.

Patients given CZP began on a dose of 400 mg at baseline, week 2 and week 4, then 200 mg every 2 weeks until week 52, while the dose of oral MTX used in the study was titrated up from an initial dose of 10 mg/week by 5 mg every 2 weeks, to a maximum of 25 mg/week by week 8.

The authors suggested that the methotrexate titration was an important part of the treatment because it ensured each patient received the maximum-tolerated dose within 8 weeks.

“To our knowledge, there are no previous studies in MTX-naive or DMARD-naive patients with RA where MTX doses have been optimized per-protocol to the levels achieved in C-EARLY,” they wrote. “This optimization may have been responsible, in part, for the response observed for the PBO+MTX and CZP+MTX arms.”

The study and manuscript development was sponsored by UCB Pharma, which also signed off on the manuscript after a review. The authors declared consultancy, speaker’s fees, grants and other funding from a range of pharmaceutical companies including UCB Pharma, and five authors were employees of UCB Pharma.

I get the occasional heartfelt thank you note from a patient. I also get hate mail, but fortunately the thank yous predominate.

I still have all of them, going back to residency, in an old Nike box. They sit in a closet at home, taken out here and there. On bad days.

You know what I mean. The days where you screwed up, or had an angry patient get on your nerves and/or in your face. Where the schedule was accidentally double-booked and you were running behind from the start. When you question your abilities and wonder why you are still doing this to yourself.

At the end of those days, I go home, dig out the box, and quietly read a few of the notes. Their neatly folded pages of gratitude remind me why I’m here, why I chose this path, why I need to be clear and ready for the patients depending on me the next day. They help me to realize that there’s more good than bad in this job, and that an unhappy, albeit vocal, few don’t represent most patients. That I really do know what I’m doing, regardless of what Mr. I’m-going-to-complain-about-you-on-Yelp says.

Of course, there are other reminders of what you have be thankfu for, like families and dogs. But sometimes you need a reminder directly from the people for whom you make a difference every day, to let you know that this isn’t just a job. It’s why you once volunteered at a hospital, fought through lorganic chemistry, wrote out 20 (or more) drafts of a personal statement, and studied for the MCAT. Because, once upon a time, this job was just a dream.

I don’t spend a lot of time with the notes – maybe 10 minutes reading a randomly pulled handful, but it’s enough to get me out of a funk. Then the old shoe box is carefully returned to my closet. Until I need it again.

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

I get the occasional heartfelt thank you note from a patient. I also get hate mail, but fortunately the thank yous predominate.

I still have all of them, going back to residency, in an old Nike box. They sit in a closet at home, taken out here and there. On bad days.

You know what I mean. The days where you screwed up, or had an angry patient get on your nerves and/or in your face. Where the schedule was accidentally double-booked and you were running behind from the start. When you question your abilities and wonder why you are still doing this to yourself.

At the end of those days, I go home, dig out the box, and quietly read a few of the notes. Their neatly folded pages of gratitude remind me why I’m here, why I chose this path, why I need to be clear and ready for the patients depending on me the next day. They help me to realize that there’s more good than bad in this job, and that an unhappy, albeit vocal, few don’t represent most patients. That I really do know what I’m doing, regardless of what Mr. I’m-going-to-complain-about-you-on-Yelp says.

Of course, there are other reminders of what you have be thankfu for, like families and dogs. But sometimes you need a reminder directly from the people for whom you make a difference every day, to let you know that this isn’t just a job. It’s why you once volunteered at a hospital, fought through lorganic chemistry, wrote out 20 (or more) drafts of a personal statement, and studied for the MCAT. Because, once upon a time, this job was just a dream.

I don’t spend a lot of time with the notes – maybe 10 minutes reading a randomly pulled handful, but it’s enough to get me out of a funk. Then the old shoe box is carefully returned to my closet. Until I need it again.

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

I get the occasional heartfelt thank you note from a patient. I also get hate mail, but fortunately the thank yous predominate.

I still have all of them, going back to residency, in an old Nike box. They sit in a closet at home, taken out here and there. On bad days.

You know what I mean. The days where you screwed up, or had an angry patient get on your nerves and/or in your face. Where the schedule was accidentally double-booked and you were running behind from the start. When you question your abilities and wonder why you are still doing this to yourself.

At the end of those days, I go home, dig out the box, and quietly read a few of the notes. Their neatly folded pages of gratitude remind me why I’m here, why I chose this path, why I need to be clear and ready for the patients depending on me the next day. They help me to realize that there’s more good than bad in this job, and that an unhappy, albeit vocal, few don’t represent most patients. That I really do know what I’m doing, regardless of what Mr. I’m-going-to-complain-about-you-on-Yelp says.

Of course, there are other reminders of what you have be thankfu for, like families and dogs. But sometimes you need a reminder directly from the people for whom you make a difference every day, to let you know that this isn’t just a job. It’s why you once volunteered at a hospital, fought through lorganic chemistry, wrote out 20 (or more) drafts of a personal statement, and studied for the MCAT. Because, once upon a time, this job was just a dream.

I don’t spend a lot of time with the notes – maybe 10 minutes reading a randomly pulled handful, but it’s enough to get me out of a funk. Then the old shoe box is carefully returned to my closet. Until I need it again.

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

Your year-round, members-only online networking platform opened to all AGA members last month, right in time for Digestive Disease Week® (DDW) 2016. AGA Community has opened the floor for conversations that build connections and collaborations.

In its first month, AGA Community had 42 new discussion threads, 326 public replies, 77 private replies, and 42 “recommends” (which are equivalent to a “like” on Facebook).

Here are the top discussions happening in the forum, many of which contain topical content from DDW:

• Recertification Board Exam

• Interested in Obesity Management?

• Ask the Expert: Legal Implications of Clinical Practice Guidelines

• Propofol for Colonoscopy

• When Would You Perform the Next Colonoscopy?

Have something to say? Join in or start your own discussion on topics that matter to you. Visit http://community.gastro.org/and sign in to start your AGA Community experience.

Your year-round, members-only online networking platform opened to all AGA members last month, right in time for Digestive Disease Week® (DDW) 2016. AGA Community has opened the floor for conversations that build connections and collaborations.

In its first month, AGA Community had 42 new discussion threads, 326 public replies, 77 private replies, and 42 “recommends” (which are equivalent to a “like” on Facebook).

Here are the top discussions happening in the forum, many of which contain topical content from DDW:

• Recertification Board Exam

• Interested in Obesity Management?

• Ask the Expert: Legal Implications of Clinical Practice Guidelines

• Propofol for Colonoscopy

• When Would You Perform the Next Colonoscopy?

Have something to say? Join in or start your own discussion on topics that matter to you. Visit http://community.gastro.org/and sign in to start your AGA Community experience.

Your year-round, members-only online networking platform opened to all AGA members last month, right in time for Digestive Disease Week® (DDW) 2016. AGA Community has opened the floor for conversations that build connections and collaborations.

In its first month, AGA Community had 42 new discussion threads, 326 public replies, 77 private replies, and 42 “recommends” (which are equivalent to a “like” on Facebook).

Here are the top discussions happening in the forum, many of which contain topical content from DDW:

• Recertification Board Exam

• Interested in Obesity Management?

• Ask the Expert: Legal Implications of Clinical Practice Guidelines

• Propofol for Colonoscopy

• When Would You Perform the Next Colonoscopy?

Have something to say? Join in or start your own discussion on topics that matter to you. Visit http://community.gastro.org/and sign in to start your AGA Community experience.

Fear is an intrinsic reaction evolved to protect us from harm. Unsurprisingly, anxiety disorders are common, affecting as many as 25% of children. On average, children have 2-14 fears typical for thinking at their age, from separation (1 year), animals (6 years), environment (dark or storms), medical intrusions or injury (9 years) to social disgrace (16 years). But about one-fifth of children with typical fear topics qualify as having a disorder; that is, they have impairment in functioning.

I wonder daily in my care of anxious children: Is this amount of fear really inevitable? Are there things we can do to avoid this burden on children?

For everyone, genetics predispose fear of things that are dangerous, such as snakes. (Tell me that they don’t make you startle!) Genetic influences account for about 50% of the variance in significant fearfulness as evidenced by parent-child patterns, and the fact that monozygotic twins are more highly concordant in fearfulness than dizygotic. Not much we can do about that!

So, if evolution armed humans with fear for protection, how is it that everyone is not impaired?

In combination with genetic vulnerabilities, fears are learned in three ways: experiential conditioning, modeling, and threat information transmission. These frequently co-occur because bad things happen, genetically anxious parents show a fear reaction, and the same parents warn their children frequently and expressively about potential dangers.

As for avoiding fear conditioning, all parents want to protect their children from scary experiences, but it is not always possible. Car crashes and other bad things happen. Even viewing events that threaten injury or death, such as 9/11, can be sufficient to induce post-traumatic stress disorder (18% of children in New York City). The closer and more severe a scary event is, the more it injures or has potential to injure the child or the child’s loved ones; the more expressive the family members are and the more it is repeated (abuse, for example), the greater the likelihood of it lasting and having impairing effects.

Conditioned fears from real experiences are not entirely random. Low-income children are more likely to experience frightening events from rat bites to house fires to domestic violence to gunshots. Asking about environmental factors or using screening tools such as Safe Environment for Every Kid to evaluate the home environment, and referring families for assistance are steps relevant to every child, but especially anxious ones.

You and I need to continue to advocate for safer communities for all children. In the meantime, it is important to know that encouraging a child to describe in detail to a caring adult – verbally and/or by drawing – traumas they experienced is significantly therapeutic. It might not seem intuitive to parents to promote “reliving the experience,” especially because they may have been traumatized themselves. So providing this opportunity ourselves or through a friend, teacher, or counselor who can calmly answer questions and put the event in perspective, is important advice.

But even simply viewing disasters, violence, or artificial frightening events on television or film can produce lasting fears. While inherently anxious children are more vulnerable to fears induced by media, 90% of undergraduates report at least one enduring fear that started this way, and 26% report persistence to the present. At least one-third of youth have fear reactions to media. Simply the number of hours watching television is associated with a child’s increased perception of personal vulnerability. While 8- to 10-year-olds had reduced fear when parents explained news events, more realistic and serious coverage (the Iraq War, for example) and older age predicted more severe fear reactions not similarly reassured. With this high prevalence of anxiety, I encourage parents to avoid media whose content is not known to them for all children, but especially for those already anxious or traumatized. It amazes me how many families of anxious children have the Weather Channel on constantly, showing devastation all over the world, oblivious that the child is internalizing the risk as though it was outside their window! When media trauma exposure can’t be avoided, parents need to show calm and provide explanation to the child to put it in perspective, as we saw the father do on TV after the Paris massacre.

Modeling of fearful reactions is the second powerful influence on the development of fears. How caregivers react when they encounter a situation such as an approaching dog is quickly modeled by the child. This vicarious learning by watching others’ reactions evolved as preferable to having to chance it yourself. Mothers’ voices and actions are especially salient to children, compared with fathers’ voices and actions. Unfortunately, females tend to be both more fearful and more expressive of fear than males. Some approaches you can suggest regarding modeling include coaching parents (sometimes even sitters) to dampen or mask their reactions, provide other adults without a similar fear to model for the child, or at least not tell the child why they are walking a different route to avoid a dog!

How information about threats is transmitted is the third and perhaps most modifiable influence on a child’s development of fears. Parents talk to children constantly, and a lot of it is warnings! This too may be genetic/cultural as evidenced by the 41% of nursery rhymes across cultures that include violence! Children who have been told potentially bad things about an animal, person, or event show a stronger fear response as measured by self-report, physiological reaction, and behavioral avoidance than when not primed. Conversely, children told positive things react with less fear immediately and are less likely to learn a fear response at later exposures. Once fear has been promoted by negative information, the child’s actual ways of thinking (cognitive biases) are shifted. Attention to forewarned stimuli is increased, the use of reasoning is limited to verifying that fear was warranted rather than alternatively looking for evidence against it, and over estimation of the likelihood of bad outcomes occurs. Children with an overly aroused brain behavioral inhibition system (inherent tendency to react to novelty with physiological arousal and fear) are more influenced by negative verbal information to have fear, cognitive distortions, and avoidance.¹

Not surprisingly, anxious parents give more negative information, particularly about ambiguous situations, than other parents. Children living in homes with more negative interactions with fathers or more punitive or neglectful mothers also are more susceptible to increased fears from verbal threat information. Unfortunately, parents generally do not perceive their own role in transmitting threat information. In contrast, one-quarter to one-third of children with significant fears relate onset or intensification of their fears to things they heard. While possibly not relevant for innate fears such as of spiders, this is important information for prevention of fears in general. A child’s development of excessive fear can be somewhat dampened by adult verbal explanations, a focus on the positives, and reassurance, especially if this is done routinely.

The “30 Million Word Gap”² in total word exposure before age 3 years of children in families on welfare vs. professionals found that higher-income parents provided far more words of praise and six encouragements for every discouragement vs. more total negative vocabulary and two discouragements for every encouragement. The same children more likely to be exposed to trauma also may have less positive preparation to reduce their development of significant fears with the associated stress effects. You and I see this during visits – take the opportunity to discuss and model an alternative.

References

1. Clin Child Fam Psychol Rev. 2010 Jun;13(2):129-50.

2. “The Early Catastrophe: The 30 Million Word Gap by Age 3” (Washington: American Educator, Spring 2003).

Dr. Howard is assistant professor of pediatrics at Johns Hopkins University School of Medicine, Baltimore, and creator of CHADIS. She has no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to Frontline Medical News. Email her at [email protected].

Fear is an intrinsic reaction evolved to protect us from harm. Unsurprisingly, anxiety disorders are common, affecting as many as 25% of children. On average, children have 2-14 fears typical for thinking at their age, from separation (1 year), animals (6 years), environment (dark or storms), medical intrusions or injury (9 years) to social disgrace (16 years). But about one-fifth of children with typical fear topics qualify as having a disorder; that is, they have impairment in functioning.

I wonder daily in my care of anxious children: Is this amount of fear really inevitable? Are there things we can do to avoid this burden on children?

For everyone, genetics predispose fear of things that are dangerous, such as snakes. (Tell me that they don’t make you startle!) Genetic influences account for about 50% of the variance in significant fearfulness as evidenced by parent-child patterns, and the fact that monozygotic twins are more highly concordant in fearfulness than dizygotic. Not much we can do about that!

So, if evolution armed humans with fear for protection, how is it that everyone is not impaired?

In combination with genetic vulnerabilities, fears are learned in three ways: experiential conditioning, modeling, and threat information transmission. These frequently co-occur because bad things happen, genetically anxious parents show a fear reaction, and the same parents warn their children frequently and expressively about potential dangers.

As for avoiding fear conditioning, all parents want to protect their children from scary experiences, but it is not always possible. Car crashes and other bad things happen. Even viewing events that threaten injury or death, such as 9/11, can be sufficient to induce post-traumatic stress disorder (18% of children in New York City). The closer and more severe a scary event is, the more it injures or has potential to injure the child or the child’s loved ones; the more expressive the family members are and the more it is repeated (abuse, for example), the greater the likelihood of it lasting and having impairing effects.

Conditioned fears from real experiences are not entirely random. Low-income children are more likely to experience frightening events from rat bites to house fires to domestic violence to gunshots. Asking about environmental factors or using screening tools such as Safe Environment for Every Kid to evaluate the home environment, and referring families for assistance are steps relevant to every child, but especially anxious ones.

You and I need to continue to advocate for safer communities for all children. In the meantime, it is important to know that encouraging a child to describe in detail to a caring adult – verbally and/or by drawing – traumas they experienced is significantly therapeutic. It might not seem intuitive to parents to promote “reliving the experience,” especially because they may have been traumatized themselves. So providing this opportunity ourselves or through a friend, teacher, or counselor who can calmly answer questions and put the event in perspective, is important advice.

But even simply viewing disasters, violence, or artificial frightening events on television or film can produce lasting fears. While inherently anxious children are more vulnerable to fears induced by media, 90% of undergraduates report at least one enduring fear that started this way, and 26% report persistence to the present. At least one-third of youth have fear reactions to media. Simply the number of hours watching television is associated with a child’s increased perception of personal vulnerability. While 8- to 10-year-olds had reduced fear when parents explained news events, more realistic and serious coverage (the Iraq War, for example) and older age predicted more severe fear reactions not similarly reassured. With this high prevalence of anxiety, I encourage parents to avoid media whose content is not known to them for all children, but especially for those already anxious or traumatized. It amazes me how many families of anxious children have the Weather Channel on constantly, showing devastation all over the world, oblivious that the child is internalizing the risk as though it was outside their window! When media trauma exposure can’t be avoided, parents need to show calm and provide explanation to the child to put it in perspective, as we saw the father do on TV after the Paris massacre.

Modeling of fearful reactions is the second powerful influence on the development of fears. How caregivers react when they encounter a situation such as an approaching dog is quickly modeled by the child. This vicarious learning by watching others’ reactions evolved as preferable to having to chance it yourself. Mothers’ voices and actions are especially salient to children, compared with fathers’ voices and actions. Unfortunately, females tend to be both more fearful and more expressive of fear than males. Some approaches you can suggest regarding modeling include coaching parents (sometimes even sitters) to dampen or mask their reactions, provide other adults without a similar fear to model for the child, or at least not tell the child why they are walking a different route to avoid a dog!

How information about threats is transmitted is the third and perhaps most modifiable influence on a child’s development of fears. Parents talk to children constantly, and a lot of it is warnings! This too may be genetic/cultural as evidenced by the 41% of nursery rhymes across cultures that include violence! Children who have been told potentially bad things about an animal, person, or event show a stronger fear response as measured by self-report, physiological reaction, and behavioral avoidance than when not primed. Conversely, children told positive things react with less fear immediately and are less likely to learn a fear response at later exposures. Once fear has been promoted by negative information, the child’s actual ways of thinking (cognitive biases) are shifted. Attention to forewarned stimuli is increased, the use of reasoning is limited to verifying that fear was warranted rather than alternatively looking for evidence against it, and over estimation of the likelihood of bad outcomes occurs. Children with an overly aroused brain behavioral inhibition system (inherent tendency to react to novelty with physiological arousal and fear) are more influenced by negative verbal information to have fear, cognitive distortions, and avoidance.¹

Not surprisingly, anxious parents give more negative information, particularly about ambiguous situations, than other parents. Children living in homes with more negative interactions with fathers or more punitive or neglectful mothers also are more susceptible to increased fears from verbal threat information. Unfortunately, parents generally do not perceive their own role in transmitting threat information. In contrast, one-quarter to one-third of children with significant fears relate onset or intensification of their fears to things they heard. While possibly not relevant for innate fears such as of spiders, this is important information for prevention of fears in general. A child’s development of excessive fear can be somewhat dampened by adult verbal explanations, a focus on the positives, and reassurance, especially if this is done routinely.

The “30 Million Word Gap”² in total word exposure before age 3 years of children in families on welfare vs. professionals found that higher-income parents provided far more words of praise and six encouragements for every discouragement vs. more total negative vocabulary and two discouragements for every encouragement. The same children more likely to be exposed to trauma also may have less positive preparation to reduce their development of significant fears with the associated stress effects. You and I see this during visits – take the opportunity to discuss and model an alternative.

References

1. Clin Child Fam Psychol Rev. 2010 Jun;13(2):129-50.

2. “The Early Catastrophe: The 30 Million Word Gap by Age 3” (Washington: American Educator, Spring 2003).

Dr. Howard is assistant professor of pediatrics at Johns Hopkins University School of Medicine, Baltimore, and creator of CHADIS. She has no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to Frontline Medical News. Email her at [email protected].

Fear is an intrinsic reaction evolved to protect us from harm. Unsurprisingly, anxiety disorders are common, affecting as many as 25% of children. On average, children have 2-14 fears typical for thinking at their age, from separation (1 year), animals (6 years), environment (dark or storms), medical intrusions or injury (9 years) to social disgrace (16 years). But about one-fifth of children with typical fear topics qualify as having a disorder; that is, they have impairment in functioning.

I wonder daily in my care of anxious children: Is this amount of fear really inevitable? Are there things we can do to avoid this burden on children?

For everyone, genetics predispose fear of things that are dangerous, such as snakes. (Tell me that they don’t make you startle!) Genetic influences account for about 50% of the variance in significant fearfulness as evidenced by parent-child patterns, and the fact that monozygotic twins are more highly concordant in fearfulness than dizygotic. Not much we can do about that!

So, if evolution armed humans with fear for protection, how is it that everyone is not impaired?

In combination with genetic vulnerabilities, fears are learned in three ways: experiential conditioning, modeling, and threat information transmission. These frequently co-occur because bad things happen, genetically anxious parents show a fear reaction, and the same parents warn their children frequently and expressively about potential dangers.

As for avoiding fear conditioning, all parents want to protect their children from scary experiences, but it is not always possible. Car crashes and other bad things happen. Even viewing events that threaten injury or death, such as 9/11, can be sufficient to induce post-traumatic stress disorder (18% of children in New York City). The closer and more severe a scary event is, the more it injures or has potential to injure the child or the child’s loved ones; the more expressive the family members are and the more it is repeated (abuse, for example), the greater the likelihood of it lasting and having impairing effects.

Conditioned fears from real experiences are not entirely random. Low-income children are more likely to experience frightening events from rat bites to house fires to domestic violence to gunshots. Asking about environmental factors or using screening tools such as Safe Environment for Every Kid to evaluate the home environment, and referring families for assistance are steps relevant to every child, but especially anxious ones.

You and I need to continue to advocate for safer communities for all children. In the meantime, it is important to know that encouraging a child to describe in detail to a caring adult – verbally and/or by drawing – traumas they experienced is significantly therapeutic. It might not seem intuitive to parents to promote “reliving the experience,” especially because they may have been traumatized themselves. So providing this opportunity ourselves or through a friend, teacher, or counselor who can calmly answer questions and put the event in perspective, is important advice.

But even simply viewing disasters, violence, or artificial frightening events on television or film can produce lasting fears. While inherently anxious children are more vulnerable to fears induced by media, 90% of undergraduates report at least one enduring fear that started this way, and 26% report persistence to the present. At least one-third of youth have fear reactions to media. Simply the number of hours watching television is associated with a child’s increased perception of personal vulnerability. While 8- to 10-year-olds had reduced fear when parents explained news events, more realistic and serious coverage (the Iraq War, for example) and older age predicted more severe fear reactions not similarly reassured. With this high prevalence of anxiety, I encourage parents to avoid media whose content is not known to them for all children, but especially for those already anxious or traumatized. It amazes me how many families of anxious children have the Weather Channel on constantly, showing devastation all over the world, oblivious that the child is internalizing the risk as though it was outside their window! When media trauma exposure can’t be avoided, parents need to show calm and provide explanation to the child to put it in perspective, as we saw the father do on TV after the Paris massacre.

Modeling of fearful reactions is the second powerful influence on the development of fears. How caregivers react when they encounter a situation such as an approaching dog is quickly modeled by the child. This vicarious learning by watching others’ reactions evolved as preferable to having to chance it yourself. Mothers’ voices and actions are especially salient to children, compared with fathers’ voices and actions. Unfortunately, females tend to be both more fearful and more expressive of fear than males. Some approaches you can suggest regarding modeling include coaching parents (sometimes even sitters) to dampen or mask their reactions, provide other adults without a similar fear to model for the child, or at least not tell the child why they are walking a different route to avoid a dog!

How information about threats is transmitted is the third and perhaps most modifiable influence on a child’s development of fears. Parents talk to children constantly, and a lot of it is warnings! This too may be genetic/cultural as evidenced by the 41% of nursery rhymes across cultures that include violence! Children who have been told potentially bad things about an animal, person, or event show a stronger fear response as measured by self-report, physiological reaction, and behavioral avoidance than when not primed. Conversely, children told positive things react with less fear immediately and are less likely to learn a fear response at later exposures. Once fear has been promoted by negative information, the child’s actual ways of thinking (cognitive biases) are shifted. Attention to forewarned stimuli is increased, the use of reasoning is limited to verifying that fear was warranted rather than alternatively looking for evidence against it, and over estimation of the likelihood of bad outcomes occurs. Children with an overly aroused brain behavioral inhibition system (inherent tendency to react to novelty with physiological arousal and fear) are more influenced by negative verbal information to have fear, cognitive distortions, and avoidance.¹

Not surprisingly, anxious parents give more negative information, particularly about ambiguous situations, than other parents. Children living in homes with more negative interactions with fathers or more punitive or neglectful mothers also are more susceptible to increased fears from verbal threat information. Unfortunately, parents generally do not perceive their own role in transmitting threat information. In contrast, one-quarter to one-third of children with significant fears relate onset or intensification of their fears to things they heard. While possibly not relevant for innate fears such as of spiders, this is important information for prevention of fears in general. A child’s development of excessive fear can be somewhat dampened by adult verbal explanations, a focus on the positives, and reassurance, especially if this is done routinely.

The “30 Million Word Gap”² in total word exposure before age 3 years of children in families on welfare vs. professionals found that higher-income parents provided far more words of praise and six encouragements for every discouragement vs. more total negative vocabulary and two discouragements for every encouragement. The same children more likely to be exposed to trauma also may have less positive preparation to reduce their development of significant fears with the associated stress effects. You and I see this during visits – take the opportunity to discuss and model an alternative.

References

1. Clin Child Fam Psychol Rev. 2010 Jun;13(2):129-50.

2. “The Early Catastrophe: The 30 Million Word Gap by Age 3” (Washington: American Educator, Spring 2003).

Dr. Howard is assistant professor of pediatrics at Johns Hopkins University School of Medicine, Baltimore, and creator of CHADIS. She has no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to Frontline Medical News. Email her at [email protected].

VANCOUVER—Patients may have impairments in their daily activities six years before they receive a diagnosis of Parkinson’s disease, according to an analysis presented at the 68th Annual Meeting of the American Academy of Neurology. These problems typically involve instrumental activities, which require motor and nonmotor skills. Subtle motor and cognitive deficits also may be observable six years before diagnosis. As the time of diagnosis approaches, additional motor symptoms arise, and patients report symptoms of anxiety and depression more frequently than people who do not develop Parkinson’s disease, said Sirwan Darweesh, MD, of the Erasmus MC University Medical Center in Rotterdam, the Netherlands. In addition, patients’ problems in daily functioning begin to affect basic activities.

Among researchers, interest in defining earlier stages of Parkinson’s disease is increasing, under the assumption that it may enable effective neuroprotection. Dr. Darweesh and colleagues conducted a nested case–control study within the population-based Rotterdam Study. The latter study was initiated in 1990 among inhabitants of a district of Rotterdam. All persons age 55 or older were invited to participate. Dr. Darweesh and colleagues excluded people with Parkinson’s disease at the time of enrollment from their analyses.

Approximately 8,000 people (about 80% of the eligible population) participated in the study. Individuals who did not participate tended to be slightly older and to have more locomotor diseases and more cardiovascular diseases.

At baseline, participants underwent a battery of assessments for potential prediagnostic features of Parkinson’s disease. The tests represented the three broad categories of activities of daily living, motor features, and nonmotor features. The investigators also assessed symptoms of depression and anxiety with the Center for Epidemiologic Studies Depression Scale and the Hospital Anxiety and Depression Scale. These assessments were repeated every four years.

In addition, the researchers evaluated whether participants had developed Parkinson’s disease during follow-up. Research physicians conducted repeated in person examinations and had complete access to participants’ medical files, which included diagnostic codes, specialist letters, and free text entries by neurologists and other physicians.

To identify differences between prediagnostic patients with Parkinson’s disease and controls, Dr. Darweesh and colleagues matched every person with incident Parkinson’s disease with 15 controls, based on age and sex. They analyzed the data to determine when prediagnostic features differed significantly between cases and controls during the prediagnostic period. In all, 107 people (approximately 50% women) developed incident Parkinson’s disease at a mean age of 77.

Movement and Postural Problems Emerged

At six years before Parkinson’s disease diagnosis, prediagnostic patients reported problems with daily activities, specifically instrumental activities such as traveling, more frequently than controls did. At about three years before diagnosis, problems in daily functioning extended to basic tasks such as eating, said Dr. Darweesh.

At about five to six years before diagnosis, prediagnostic patients showed signs of hypokinesia, bradykinesia, or tremor more frequently than controls did. In the last few years before diagnosis, patients also showed signs of cogwheel rigidity, postural abnormality, and postural imbalance more frequently than controls did.

When the investigators examined nonmotor features, they found that at about five years before diagnosis, patients with Parkinson’s disease already had significantly lower Mini-Mental State Examination scores than controls did. In the years before diagnosis, patients were also more likely to report anxiety symptoms and depressive symptoms than controls were. During follow-up, the researchers found that patients with Parkinson’s disease used laxatives more frequently than controls did, although differences only became significant in the last few years before diagnosis. “We believe that these data add important information to our knowledge of prediagnostic Parkinson’s disease,” said Dr. Darweesh. “We hope that these data can contribute to a better understanding of how to define earlier stages of this disease.”

—Erik Greb

VANCOUVER—Patients may have impairments in their daily activities six years before they receive a diagnosis of Parkinson’s disease, according to an analysis presented at the 68th Annual Meeting of the American Academy of Neurology. These problems typically involve instrumental activities, which require motor and nonmotor skills. Subtle motor and cognitive deficits also may be observable six years before diagnosis. As the time of diagnosis approaches, additional motor symptoms arise, and patients report symptoms of anxiety and depression more frequently than people who do not develop Parkinson’s disease, said Sirwan Darweesh, MD, of the Erasmus MC University Medical Center in Rotterdam, the Netherlands. In addition, patients’ problems in daily functioning begin to affect basic activities.

Among researchers, interest in defining earlier stages of Parkinson’s disease is increasing, under the assumption that it may enable effective neuroprotection. Dr. Darweesh and colleagues conducted a nested case–control study within the population-based Rotterdam Study. The latter study was initiated in 1990 among inhabitants of a district of Rotterdam. All persons age 55 or older were invited to participate. Dr. Darweesh and colleagues excluded people with Parkinson’s disease at the time of enrollment from their analyses.

Approximately 8,000 people (about 80% of the eligible population) participated in the study. Individuals who did not participate tended to be slightly older and to have more locomotor diseases and more cardiovascular diseases.

At baseline, participants underwent a battery of assessments for potential prediagnostic features of Parkinson’s disease. The tests represented the three broad categories of activities of daily living, motor features, and nonmotor features. The investigators also assessed symptoms of depression and anxiety with the Center for Epidemiologic Studies Depression Scale and the Hospital Anxiety and Depression Scale. These assessments were repeated every four years.

In addition, the researchers evaluated whether participants had developed Parkinson’s disease during follow-up. Research physicians conducted repeated in person examinations and had complete access to participants’ medical files, which included diagnostic codes, specialist letters, and free text entries by neurologists and other physicians.

To identify differences between prediagnostic patients with Parkinson’s disease and controls, Dr. Darweesh and colleagues matched every person with incident Parkinson’s disease with 15 controls, based on age and sex. They analyzed the data to determine when prediagnostic features differed significantly between cases and controls during the prediagnostic period. In all, 107 people (approximately 50% women) developed incident Parkinson’s disease at a mean age of 77.

Movement and Postural Problems Emerged

At six years before Parkinson’s disease diagnosis, prediagnostic patients reported problems with daily activities, specifically instrumental activities such as traveling, more frequently than controls did. At about three years before diagnosis, problems in daily functioning extended to basic tasks such as eating, said Dr. Darweesh.

At about five to six years before diagnosis, prediagnostic patients showed signs of hypokinesia, bradykinesia, or tremor more frequently than controls did. In the last few years before diagnosis, patients also showed signs of cogwheel rigidity, postural abnormality, and postural imbalance more frequently than controls did.

When the investigators examined nonmotor features, they found that at about five years before diagnosis, patients with Parkinson’s disease already had significantly lower Mini-Mental State Examination scores than controls did. In the years before diagnosis, patients were also more likely to report anxiety symptoms and depressive symptoms than controls were. During follow-up, the researchers found that patients with Parkinson’s disease used laxatives more frequently than controls did, although differences only became significant in the last few years before diagnosis. “We believe that these data add important information to our knowledge of prediagnostic Parkinson’s disease,” said Dr. Darweesh. “We hope that these data can contribute to a better understanding of how to define earlier stages of this disease.”

—Erik Greb

VANCOUVER—Patients may have impairments in their daily activities six years before they receive a diagnosis of Parkinson’s disease, according to an analysis presented at the 68th Annual Meeting of the American Academy of Neurology. These problems typically involve instrumental activities, which require motor and nonmotor skills. Subtle motor and cognitive deficits also may be observable six years before diagnosis. As the time of diagnosis approaches, additional motor symptoms arise, and patients report symptoms of anxiety and depression more frequently than people who do not develop Parkinson’s disease, said Sirwan Darweesh, MD, of the Erasmus MC University Medical Center in Rotterdam, the Netherlands. In addition, patients’ problems in daily functioning begin to affect basic activities.

Among researchers, interest in defining earlier stages of Parkinson’s disease is increasing, under the assumption that it may enable effective neuroprotection. Dr. Darweesh and colleagues conducted a nested case–control study within the population-based Rotterdam Study. The latter study was initiated in 1990 among inhabitants of a district of Rotterdam. All persons age 55 or older were invited to participate. Dr. Darweesh and colleagues excluded people with Parkinson’s disease at the time of enrollment from their analyses.

Approximately 8,000 people (about 80% of the eligible population) participated in the study. Individuals who did not participate tended to be slightly older and to have more locomotor diseases and more cardiovascular diseases.

At baseline, participants underwent a battery of assessments for potential prediagnostic features of Parkinson’s disease. The tests represented the three broad categories of activities of daily living, motor features, and nonmotor features. The investigators also assessed symptoms of depression and anxiety with the Center for Epidemiologic Studies Depression Scale and the Hospital Anxiety and Depression Scale. These assessments were repeated every four years.

In addition, the researchers evaluated whether participants had developed Parkinson’s disease during follow-up. Research physicians conducted repeated in person examinations and had complete access to participants’ medical files, which included diagnostic codes, specialist letters, and free text entries by neurologists and other physicians.

To identify differences between prediagnostic patients with Parkinson’s disease and controls, Dr. Darweesh and colleagues matched every person with incident Parkinson’s disease with 15 controls, based on age and sex. They analyzed the data to determine when prediagnostic features differed significantly between cases and controls during the prediagnostic period. In all, 107 people (approximately 50% women) developed incident Parkinson’s disease at a mean age of 77.

Movement and Postural Problems Emerged

At six years before Parkinson’s disease diagnosis, prediagnostic patients reported problems with daily activities, specifically instrumental activities such as traveling, more frequently than controls did. At about three years before diagnosis, problems in daily functioning extended to basic tasks such as eating, said Dr. Darweesh.

At about five to six years before diagnosis, prediagnostic patients showed signs of hypokinesia, bradykinesia, or tremor more frequently than controls did. In the last few years before diagnosis, patients also showed signs of cogwheel rigidity, postural abnormality, and postural imbalance more frequently than controls did.

When the investigators examined nonmotor features, they found that at about five years before diagnosis, patients with Parkinson’s disease already had significantly lower Mini-Mental State Examination scores than controls did. In the years before diagnosis, patients were also more likely to report anxiety symptoms and depressive symptoms than controls were. During follow-up, the researchers found that patients with Parkinson’s disease used laxatives more frequently than controls did, although differences only became significant in the last few years before diagnosis. “We believe that these data add important information to our knowledge of prediagnostic Parkinson’s disease,” said Dr. Darweesh. “We hope that these data can contribute to a better understanding of how to define earlier stages of this disease.”

—Erik Greb

LOS ANGELES – Implementation of a perioperative protocol designed to enhance recovery in patients undergoing elective laparoscopic colorectal surgery decreased hospital length of stay, the rate of complications, and overall direct costs, results from a single-center study showed.

“Until recently patients undergoing colorectal surgery were counseled to accept a 20%-25% risk of complications and a 7- to 10-day postoperative stay in the hospital,” lead study author Dr. Daniel S. Lavy said at the annual meeting of the American Society of Colon and Rectal Surgeons. “Studies from the 1990s have shown that length of stay rates improved when one single component of care was changed.”

©Andrei Malov/Thinkstock

Dr. Lavy of the department of surgery at Monmouth Medical Center, Long Branch, N.J., discussed results from a study of Enhanced Recovery After Surgery (ERAS), which he described as “a multimodal perioperative care pathway designed to achieve early recovery for patients undergoing major surgery. Many of its elements challenge existing surgical doctrine, including optimizing nutrition, standardized nonnarcotic and anesthetic regimens, early mobilization, and early initiation of enteral feeding.” The protocol also includes multimodal analgesia aimed at reducing the use of narcotics by intravenous Toradol (ketorolac), intravenous Tylenol (acetaminophen), and a transverse abdominis plane block; preoperative intravenous Solu-Medrol (methylprednisolone); prevention of fluid overload; preoperative and postoperative Entereg (alvimopan); preoperative enteral feedings and early postoperative diet initiation; and aggressive postoperative rehabilitation.

In an effort to evaluate the impact of the protocol in patients undergoing colorectal surgery, Dr. Lavy and his associates analyzed records from 283 elective laparoscopic colon procedures performed at Monmouth Medical Center from July 2013 to December 2015, a time period that included 11 months prior to implementation of ERAS and 18 months after implementation. The data were analyzed using control charts to assess for process changes, while open or emergent procedures were excluded from review. Key measures assessed included hospital length of stay, direct hospital costs, 30-day readmissions, and complications.

Dr. Lavy reported that following implementation of the ERAS protocol, the median length of stay decreased from 3.8 days to 2.8 days; the median direct hospital costs fell 8.5%, resulting in a savings of $876 per case; and the complication rate dropped from 20% to 16%. No changes were observed in the 30-day readmission rate, which held steady at 8%.

“This multifaceted approach has decreased hospital stay, decreased hospital cost and complication rate, did not change the 30-day readmission rate, and maintained patient safety while improving patient care,” Dr. Lavy said. “We suggest research be conducted to determine how this pathway can be altered to further improve quality of care given to patients while simultaneously reducing hospital costs. Also, these methods may be able to be applied to other surgical subspecialties, including ob.gyn., orthopedics, and urology.”

Dr. Lavy reported having no relevant financial disclosures.

[email protected]

LOS ANGELES – Implementation of a perioperative protocol designed to enhance recovery in patients undergoing elective laparoscopic colorectal surgery decreased hospital length of stay, the rate of complications, and overall direct costs, results from a single-center study showed.

“Until recently patients undergoing colorectal surgery were counseled to accept a 20%-25% risk of complications and a 7- to 10-day postoperative stay in the hospital,” lead study author Dr. Daniel S. Lavy said at the annual meeting of the American Society of Colon and Rectal Surgeons. “Studies from the 1990s have shown that length of stay rates improved when one single component of care was changed.”

©Andrei Malov/Thinkstock

Dr. Lavy of the department of surgery at Monmouth Medical Center, Long Branch, N.J., discussed results from a study of Enhanced Recovery After Surgery (ERAS), which he described as “a multimodal perioperative care pathway designed to achieve early recovery for patients undergoing major surgery. Many of its elements challenge existing surgical doctrine, including optimizing nutrition, standardized nonnarcotic and anesthetic regimens, early mobilization, and early initiation of enteral feeding.” The protocol also includes multimodal analgesia aimed at reducing the use of narcotics by intravenous Toradol (ketorolac), intravenous Tylenol (acetaminophen), and a transverse abdominis plane block; preoperative intravenous Solu-Medrol (methylprednisolone); prevention of fluid overload; preoperative and postoperative Entereg (alvimopan); preoperative enteral feedings and early postoperative diet initiation; and aggressive postoperative rehabilitation.

In an effort to evaluate the impact of the protocol in patients undergoing colorectal surgery, Dr. Lavy and his associates analyzed records from 283 elective laparoscopic colon procedures performed at Monmouth Medical Center from July 2013 to December 2015, a time period that included 11 months prior to implementation of ERAS and 18 months after implementation. The data were analyzed using control charts to assess for process changes, while open or emergent procedures were excluded from review. Key measures assessed included hospital length of stay, direct hospital costs, 30-day readmissions, and complications.

Dr. Lavy reported that following implementation of the ERAS protocol, the median length of stay decreased from 3.8 days to 2.8 days; the median direct hospital costs fell 8.5%, resulting in a savings of $876 per case; and the complication rate dropped from 20% to 16%. No changes were observed in the 30-day readmission rate, which held steady at 8%.

“This multifaceted approach has decreased hospital stay, decreased hospital cost and complication rate, did not change the 30-day readmission rate, and maintained patient safety while improving patient care,” Dr. Lavy said. “We suggest research be conducted to determine how this pathway can be altered to further improve quality of care given to patients while simultaneously reducing hospital costs. Also, these methods may be able to be applied to other surgical subspecialties, including ob.gyn., orthopedics, and urology.”

Dr. Lavy reported having no relevant financial disclosures.

[email protected]

LOS ANGELES – Implementation of a perioperative protocol designed to enhance recovery in patients undergoing elective laparoscopic colorectal surgery decreased hospital length of stay, the rate of complications, and overall direct costs, results from a single-center study showed.

“Until recently patients undergoing colorectal surgery were counseled to accept a 20%-25% risk of complications and a 7- to 10-day postoperative stay in the hospital,” lead study author Dr. Daniel S. Lavy said at the annual meeting of the American Society of Colon and Rectal Surgeons. “Studies from the 1990s have shown that length of stay rates improved when one single component of care was changed.”

©Andrei Malov/Thinkstock

Dr. Lavy of the department of surgery at Monmouth Medical Center, Long Branch, N.J., discussed results from a study of Enhanced Recovery After Surgery (ERAS), which he described as “a multimodal perioperative care pathway designed to achieve early recovery for patients undergoing major surgery. Many of its elements challenge existing surgical doctrine, including optimizing nutrition, standardized nonnarcotic and anesthetic regimens, early mobilization, and early initiation of enteral feeding.” The protocol also includes multimodal analgesia aimed at reducing the use of narcotics by intravenous Toradol (ketorolac), intravenous Tylenol (acetaminophen), and a transverse abdominis plane block; preoperative intravenous Solu-Medrol (methylprednisolone); prevention of fluid overload; preoperative and postoperative Entereg (alvimopan); preoperative enteral feedings and early postoperative diet initiation; and aggressive postoperative rehabilitation.

In an effort to evaluate the impact of the protocol in patients undergoing colorectal surgery, Dr. Lavy and his associates analyzed records from 283 elective laparoscopic colon procedures performed at Monmouth Medical Center from July 2013 to December 2015, a time period that included 11 months prior to implementation of ERAS and 18 months after implementation. The data were analyzed using control charts to assess for process changes, while open or emergent procedures were excluded from review. Key measures assessed included hospital length of stay, direct hospital costs, 30-day readmissions, and complications.

Dr. Lavy reported that following implementation of the ERAS protocol, the median length of stay decreased from 3.8 days to 2.8 days; the median direct hospital costs fell 8.5%, resulting in a savings of $876 per case; and the complication rate dropped from 20% to 16%. No changes were observed in the 30-day readmission rate, which held steady at 8%.

“This multifaceted approach has decreased hospital stay, decreased hospital cost and complication rate, did not change the 30-day readmission rate, and maintained patient safety while improving patient care,” Dr. Lavy said. “We suggest research be conducted to determine how this pathway can be altered to further improve quality of care given to patients while simultaneously reducing hospital costs. Also, these methods may be able to be applied to other surgical subspecialties, including ob.gyn., orthopedics, and urology.”

Dr. Lavy reported having no relevant financial disclosures.

[email protected]

ATLANTA – Increasingly, data support taking an integrated approach to care in the intervention of first-episode psychosis.

But what are the key components of such treatment?

Dr. Charles Schulz, who initiated an integrated care clinic for first-episode psychosis at the University of Minnesota, Minneapolis, outlined the steps in an integrated care approach.

In an interview at the annual meeting of the American Psychiatric Association, Dr. Schulz reviewed the importance of intervening in the prodromal phase whenever possible, as well as offering cognitive-behavioral and remediation therapies along with medication management.

He also addressed the need for family psychoeducation and group therapy. And Dr. Schulz explained what to do when there might be a differential that manifests with psychiatric presentations that are not psychosis.

Dr. Schulz said he has industry relationships with Forum Pharmaceuticals and Myriad.

[email protected]

On Twitter @whitneymcknight

ATLANTA – Increasingly, data support taking an integrated approach to care in the intervention of first-episode psychosis.

But what are the key components of such treatment?

Dr. Charles Schulz, who initiated an integrated care clinic for first-episode psychosis at the University of Minnesota, Minneapolis, outlined the steps in an integrated care approach.

In an interview at the annual meeting of the American Psychiatric Association, Dr. Schulz reviewed the importance of intervening in the prodromal phase whenever possible, as well as offering cognitive-behavioral and remediation therapies along with medication management.

He also addressed the need for family psychoeducation and group therapy. And Dr. Schulz explained what to do when there might be a differential that manifests with psychiatric presentations that are not psychosis.

Dr. Schulz said he has industry relationships with Forum Pharmaceuticals and Myriad.

[email protected]

On Twitter @whitneymcknight

ATLANTA – Increasingly, data support taking an integrated approach to care in the intervention of first-episode psychosis.

But what are the key components of such treatment?

Dr. Charles Schulz, who initiated an integrated care clinic for first-episode psychosis at the University of Minnesota, Minneapolis, outlined the steps in an integrated care approach.

In an interview at the annual meeting of the American Psychiatric Association, Dr. Schulz reviewed the importance of intervening in the prodromal phase whenever possible, as well as offering cognitive-behavioral and remediation therapies along with medication management.

He also addressed the need for family psychoeducation and group therapy. And Dr. Schulz explained what to do when there might be a differential that manifests with psychiatric presentations that are not psychosis.

Dr. Schulz said he has industry relationships with Forum Pharmaceuticals and Myriad.

[email protected]

On Twitter @whitneymcknight