In Drs. Ali M. Hashmi and Dennis Vowell’s article “The manipulative self-harmer” (Cases That Test Your Skills, Current Psychiatry, June 2010, p. 44-48), the authors regard the patient’s outcome (“Recently she was placed in a more restrictive setting because her hostile and self-destructive behavior escalated”) as characteristic of borderline personality disorder (BPD) (“Ms. L is no different from most axis II Cluster B disordered patients.”). In my view, this is the greatest risk of calling a patient borderline—it tends to justify poor outcomes by thinking that it is just characteristic of the illness. Instead, shouldn’t we worry that our treatment may be suboptimal? Maybe we are missing something?

For example, Ms. L may have some degree of bipolarity (see the Harvard Bipolarity Index as a characterization of that concept, incorporating but going beyond the DSM-IV-TR) that could account for their observation, “Her mood and behavior continue to oscillate; she is relatively calm and satisfied 1 week, angry and assaultive the next.” Instead of concluding, “this stormy course is expected…” the authors should be wondering whether they might be contributing to it by restarting venlafaxine despite simultaneous carbamazepine initiation. Granted, the possibilities of bipolarity and antidepressant-induced rapid cycling are complex considerations, because we lack solid footing for differentiating BPD and bipolar disorder and for determining causality when a patient experiences rapid mood changes while taking an antidepressant. These are controversial issues, but why present the case as though it’s illustrative of accepted principles? I find it perfectly illustrative of how badly we’re floundering as a field.

Jim Phelps, MD
PsychEducation.org
Corvallis, OR

The authors respond

Dr. Phelps’ contention is that our observation that Ms. L’s “hostile and self-destructive behavior” makes her “no different from most axis II Cluster B disordered patients” somehow understates the extent of her illness, perhaps leading to poorer outcomes. Negative countertransference toward such patients is the norm and handling it empathically is an integral part of the treatment relationship. This is true even though the severity of Ms. L’s personality pathology, as evidenced by her placement in the “911 program,” may not be representative of all patients with BPD.

We agree that “the possibilities of…antidepressant-induced rapid cycling are complex considerations.” Even experts disagree on this. In fact, as we pointed out, Ms. L resisted medication tapers, at one point insisting that high doses of fluoxetine and venafaxine be used together for depression, a request we denied specifically for fear of worsening her mood lability. Fluoxetine was discontinued and venlafaxine restarted at a lower dose to treat her persistent depression as well as to help with her chronic back pain. Because by this time she was taking carbamazepine as well, we felt the risk was acceptable. Her positive long-term outcome has validated our approach.

We disagree that psychiatry is “floundering” as a field. In fact, exchanges like this are a core component of placing our specialty on a more solid, scientific basis to position it for future challenges.

Ali M. Hashmi, MD
Medical director
Mid-South Health Systems
Jonesboro, AR
Clinical instructor
Department of psychiatry
University of Arkansas for Medical Science
College of Medicine
Little Rock, AR

Dennis Vowell, PsyD
Clinical psychologist
Mid-South Health Systems
Paragould, AR

In Drs. Ali M. Hashmi and Dennis Vowell’s article “The manipulative self-harmer” (Cases That Test Your Skills, Current Psychiatry, June 2010, p. 44-48), the authors regard the patient’s outcome (“Recently she was placed in a more restrictive setting because her hostile and self-destructive behavior escalated”) as characteristic of borderline personality disorder (BPD) (“Ms. L is no different from most axis II Cluster B disordered patients.”). In my view, this is the greatest risk of calling a patient borderline—it tends to justify poor outcomes by thinking that it is just characteristic of the illness. Instead, shouldn’t we worry that our treatment may be suboptimal? Maybe we are missing something?

For example, Ms. L may have some degree of bipolarity (see the Harvard Bipolarity Index as a characterization of that concept, incorporating but going beyond the DSM-IV-TR) that could account for their observation, “Her mood and behavior continue to oscillate; she is relatively calm and satisfied 1 week, angry and assaultive the next.” Instead of concluding, “this stormy course is expected…” the authors should be wondering whether they might be contributing to it by restarting venlafaxine despite simultaneous carbamazepine initiation. Granted, the possibilities of bipolarity and antidepressant-induced rapid cycling are complex considerations, because we lack solid footing for differentiating BPD and bipolar disorder and for determining causality when a patient experiences rapid mood changes while taking an antidepressant. These are controversial issues, but why present the case as though it’s illustrative of accepted principles? I find it perfectly illustrative of how badly we’re floundering as a field.

Jim Phelps, MD
PsychEducation.org
Corvallis, OR

The authors respond

Dr. Phelps’ contention is that our observation that Ms. L’s “hostile and self-destructive behavior” makes her “no different from most axis II Cluster B disordered patients” somehow understates the extent of her illness, perhaps leading to poorer outcomes. Negative countertransference toward such patients is the norm and handling it empathically is an integral part of the treatment relationship. This is true even though the severity of Ms. L’s personality pathology, as evidenced by her placement in the “911 program,” may not be representative of all patients with BPD.

We agree that “the possibilities of…antidepressant-induced rapid cycling are complex considerations.” Even experts disagree on this. In fact, as we pointed out, Ms. L resisted medication tapers, at one point insisting that high doses of fluoxetine and venafaxine be used together for depression, a request we denied specifically for fear of worsening her mood lability. Fluoxetine was discontinued and venlafaxine restarted at a lower dose to treat her persistent depression as well as to help with her chronic back pain. Because by this time she was taking carbamazepine as well, we felt the risk was acceptable. Her positive long-term outcome has validated our approach.

We disagree that psychiatry is “floundering” as a field. In fact, exchanges like this are a core component of placing our specialty on a more solid, scientific basis to position it for future challenges.

Ali M. Hashmi, MD
Medical director
Mid-South Health Systems
Jonesboro, AR
Clinical instructor
Department of psychiatry
University of Arkansas for Medical Science
College of Medicine
Little Rock, AR

Dennis Vowell, PsyD
Clinical psychologist
Mid-South Health Systems
Paragould, AR

In Drs. Ali M. Hashmi and Dennis Vowell’s article “The manipulative self-harmer” (Cases That Test Your Skills, Current Psychiatry, June 2010, p. 44-48), the authors regard the patient’s outcome (“Recently she was placed in a more restrictive setting because her hostile and self-destructive behavior escalated”) as characteristic of borderline personality disorder (BPD) (“Ms. L is no different from most axis II Cluster B disordered patients.”). In my view, this is the greatest risk of calling a patient borderline—it tends to justify poor outcomes by thinking that it is just characteristic of the illness. Instead, shouldn’t we worry that our treatment may be suboptimal? Maybe we are missing something?

For example, Ms. L may have some degree of bipolarity (see the Harvard Bipolarity Index as a characterization of that concept, incorporating but going beyond the DSM-IV-TR) that could account for their observation, “Her mood and behavior continue to oscillate; she is relatively calm and satisfied 1 week, angry and assaultive the next.” Instead of concluding, “this stormy course is expected…” the authors should be wondering whether they might be contributing to it by restarting venlafaxine despite simultaneous carbamazepine initiation. Granted, the possibilities of bipolarity and antidepressant-induced rapid cycling are complex considerations, because we lack solid footing for differentiating BPD and bipolar disorder and for determining causality when a patient experiences rapid mood changes while taking an antidepressant. These are controversial issues, but why present the case as though it’s illustrative of accepted principles? I find it perfectly illustrative of how badly we’re floundering as a field.

Jim Phelps, MD
PsychEducation.org
Corvallis, OR

The authors respond

Dr. Phelps’ contention is that our observation that Ms. L’s “hostile and self-destructive behavior” makes her “no different from most axis II Cluster B disordered patients” somehow understates the extent of her illness, perhaps leading to poorer outcomes. Negative countertransference toward such patients is the norm and handling it empathically is an integral part of the treatment relationship. This is true even though the severity of Ms. L’s personality pathology, as evidenced by her placement in the “911 program,” may not be representative of all patients with BPD.

We agree that “the possibilities of…antidepressant-induced rapid cycling are complex considerations.” Even experts disagree on this. In fact, as we pointed out, Ms. L resisted medication tapers, at one point insisting that high doses of fluoxetine and venafaxine be used together for depression, a request we denied specifically for fear of worsening her mood lability. Fluoxetine was discontinued and venlafaxine restarted at a lower dose to treat her persistent depression as well as to help with her chronic back pain. Because by this time she was taking carbamazepine as well, we felt the risk was acceptable. Her positive long-term outcome has validated our approach.

We disagree that psychiatry is “floundering” as a field. In fact, exchanges like this are a core component of placing our specialty on a more solid, scientific basis to position it for future challenges.

Ali M. Hashmi, MD
Medical director
Mid-South Health Systems
Jonesboro, AR
Clinical instructor
Department of psychiatry
University of Arkansas for Medical Science
College of Medicine
Little Rock, AR

Dennis Vowell, PsyD
Clinical psychologist
Mid-South Health Systems
Paragould, AR

The number of people with psychiatric disorders who use complementary and alternative medicine (CAM) is on the rise. In surveys of patients seeking psychiatric care, estimates of CAM use range from 8% to 57%; the most frequent uses are for depression and anxiety disorders. A population-based study in the United States found that 9% of respondents had anxiety attacks and 57% of these individuals had used CAM.¹ Similarly, in a Finnish population-based study (N=5,987) 35% of subjects reported some form of CAM use in the previous year; those with comorbid anxiety and depressive disorders used CAM most frequently.²

Unfortunately, a MEDLINE search shows that the number of studies examining psychotropic medications dwarfs the number of studies on even the most common CAM treatments used for psychiatric disorders. Far more patients with diagnosed mental disorders are studied in trials of standard treatments than CAM treatments. Because very few studies evaluate the cost-effectiveness of CAM treatments for psychiatric disorders, the risk-to-benefit ratio is difficult to calculate. Although several CAM treatments for depressive disorders have enough support to be considered options,³ CAM options for anxiety disorders are fewer and have less evidence of efficacy.

For these reasons, it is hard to recommend any CAM treatment as first line. Despite the relative lack of high quality research on CAM treatment outcomes, high rates of CAM use make it critical for clinicians to understand what treatments are available—or at least which treatments should be favored if patients are intent on trying them. We review the current research for yoga, exercise, bibliotherapy, and the dietary supplements kava and inositol for treating anxiety disorders and suggest those that warrant consideration for patients who do not respond, respond partially, or suffer from side effects from selective serotonin reuptake inhibitors (SSRIs) or benzodiazepines.

Limitations of CAM research

There are several limitations to the research literature on CAM approaches for anxiety disorders.⁴ First, there is a wide diversity of practices considered alternative or complementary and various ways in which these methods are applied across cultures. Some authors consider complementary medicines to be only herbal remedies, whereas others include individual therapies such as acupuncture, aromatherapy, herbal therapy, homeopathy, iridology, naturopathy, and reflexology.⁵ This article defines “alternative” treatments as those other than a form of psychotherapy or an FDA-approved medication that substitute for standard psychiatric treatment, and “complementary” approaches as those used to augment standard psychiatric treatments.

Anxiety and stress are ubiquitous, perhaps motivating interest in CAM options and prompting research on heterogeneous groups of individuals with poorly defined clinical syndromes or with isolated symptoms of anxiety or subjective distress. Few studies examine well-defined patient groups with diagnosed anxiety disorders. There are also multiple research design problems, including poorly specified treatments, poorly chosen placebos, and interpreting nonsignificant differences from established treatments as equivalence in underpowered studies.

The CAM treatments reviewed in this article have ≥2 randomized controlled trials (RCTs) that support their use for patients with diagnosed anxiety disorders, and ≥1 study that shows that the treatment can induce remission.

Yoga

In 2005 Kirkwood et al carried out the first systematic review of research evidence for the effectiveness of yoga in anxiety treatment.⁶ Of 19 studies identified, 4 RCTs and 1 nonrandomized trial met their inclusion criteria, which were an anxiety disorder diagnosis, use of yoga or yoga-based exercises alone, and anxiety rating scales used as outcome measures. Most found significant improvement in anxiety symptoms with yoga compared with placebo. Details of the 5 trials evaluated in Kirkwood’s review are summarized in Table 1.^7-11

Since the 2005 review, 3 additional studies of yoga and anxiety have been published, but none would meet Kirkwood’s inclusion criteria. One that evaluated a heterogeneous group of patients using an intervention with multiple components—only 1 of which was yoga—found the intervention significantly reduced anxiety scores.¹² A second study comparing yoga with relaxation in 131 patients with mild-to-moderate stress but no anxiety disorder diagnosis showed yoga was as effective as relaxation in improving anxiety symptoms as measured by the anxiety subscale of the State Trait Personality Inventory.¹³ In a study of 183 nonrandomized survivors of the 2004 southeast Asia tsunami with posttraumatic stress disorder (PTSD) symptoms, yoga-based breathing either alone or paired with trauma reduction exposure techniques significantly reduced PTSD symptoms compared with wait-list controls.¹⁴

Conclusion. Few controlled studies evaluated yoga for anxiety disorders, and all have significant methodologic limitations and/or poor methodology reporting. The diagnostic conditions treated and both yoga interventions and control conditions varied. However, these limited results are encouraging, particularly for treatment of obsessive-compulsive disorder (OCD). There is little information regarding safety or contraindications of yoga. Reported attrition rates were high in most studies, which may raise concerns about patient motivation and compliance.

Table 1

Evidence on the effectiveness of yoga for anxiety disorders

Exercise

The literature examining the relationship between exercise and depression is extensive, but much less has been published about exercise in patients with anxiety disorders (Table 2).^15-17 In a 10-week trial, Broocks and colleagues compared clomipramine, exercise (running), and placebo in 46 outpatients with panic disorder.¹⁵ Both exercise and clomipramine, 112.5 mg/d, significantly reduced panic symptoms compared with placebo, but clomipramine was more effective and faster-acting.

A more recent RCT compared group cognitive-behavioral therapy (GCBT) plus a home-based walking program vs GCBT and in 21 patients with panic disorder, generalized anxiety disorder (GAD), or social phobia.¹⁶ Compared with GCBT plus educational sessions, GCBT plus walking had a significant effect on self-reported depression, anxiety, and stress. Results differed by diagnosis; the most marked effects occurred in individuals with social phobia, whereas benefits for those with panic disorder or GAD were questionable.

Fifteen patients with OCD were recruited to participate in a 12-week, moderate-intensity aerobic exercise program added to their standard behavioral and/or pharmacologic treatment.¹⁷ Subjects demonstrated improvement in negative mood, anxiety, obsessions, and compulsions after each exercise session. Changes after each session persisted over the 12-week intervention, although the magnitude attenuated over the duration of the intervention.

Conclusion. Although initial results from small trials suggest exercise may help improve anxiety symptoms, further studies are needed to determine how to best use exercise training to treat anxious patients, specifically regarding dose-response relationship, differences in effectiveness between aerobic and resistance training, and the mechanisms by which exercise improves psychiatric symptoms.

Table 2

Exercise for anxiety: More research is needed

Bibliotherapy

Investigation of bibliotherapy for treatment of anxiety disorders has been limited (Table 3).^18-20 A 2009 RCT demonstrated that for 21 patients with mild-to-moderate social phobia, bibliotherapy—in the form of an 8-week self-directed CBT program with minimal therapist involvement—was superior to a wait-list control and induced clinically significant change in approximately one-third of patients.²⁰

Rapee et al randomly assigned 267 children age 6 to 12 with anxiety disorders to bibliotherapy that consisted of parents treating their children in the home with written materials, 9 sessions of GCBT, or a wait-list control condition.¹⁹ Bibliotherapy provided by parents demonstrated benefit compared with wait-listing but was not as efficacious as GCBT at post-treatment and 3-month follow-up.

Lidren and colleagues randomly assigned 36 adult patients with panic disorder to bibliotherapy, group therapy combined with bibliotherapy, or a waitlist.¹⁸ Both treatments were more effective than wait-listing in reducing the frequency of panic attacks, severity of physical panic symptoms, catastrophic cognitions, agoraphobic avoidance, and depression. Both interventions maintained their effects at 3-and 6-month follow-up and produced clinically significant change in most patients.

Conclusion. Some preliminary evidence supports the effectiveness of bibliotherapy for social anxiety disorder, childhood anxiety disorders, and panic disorder.

Table 3

Preliminary evidence supports bibliotherapy for select anxiety disorders

Dietary supplements

Many dietary and herbal supplements are purported to have therapeutic efficacy for anxiety symptoms. Because of inadequate FDA regulation of manufacturing and marketing of these agents, most of these supplements have not been tested on patients with anxiety disorders.²¹ Limited evidence supports the use of kava for GAD and inositol for panic disorder (Table 4).^22-28

Kava. Multiple double-blind RCTs found kava (Piper methysticum)—a plant indigenous to South Pacific islands—has effects greater than placebo and comparable to standard treatments for mild to moderately severe GAD. A Cochrane meta-analysis²² of 11 trials with 645 participants concluded that kava is effective for reducing GAD symptoms, with risks comparable to standard treatments for up to 6 months of use.

Case reports of kava-associated liver toxicity led to a marketing ban in Canada in 2000, followed shortly by Germany, Australia, and the United Kingdom. In 2002 the FDA issued a Consumer Advisory²⁹ discouraging kava use. Since then a flurry of research has looked for sources of possible toxicity, including individual sensitivities,²⁹ excessive dosing, use of toxic parts of the kava plant instead of the roots,^30,31 interactions with other hepatoactive substances, and non-water based extraction methods. RCTs demonstrating kava’s efficacy and safety were characterized by careful dosing supervision, use of standardized kava extracts, and avoidance of interactions with other hepatoactive medications or CAM treatments. Doses ≤300 mg/d are recommended.²²

RCTs that used the standardized acetone extract WS1490²³ found that women and younger adults show more positive effects from kava, and showed no liver toxicity when used for 1 to 24 weeks. A recent RCT that used kava extracts obtained via water-based methods showed kava had significant anxiolytic effects.²⁴ However, a study of liver toxicity reports found that water-based extractions, acetonic extractions, and ethanol extractions all have been associated with toxic hepatic reactions.³² Aqueous extraction does not guarantee safety, and the extraction solvent does not cause toxicity. A recent report of a severe liver reaction to the native drink by a tourist in Samoa³³ suggests that aqueous extractions from the root stock— the type of kava used by South Pacific islanders—also can be unsafe.

Conclusion. Multiple RCTs have found kava relatively safe and effective for treating anxiety symptoms. Caution is necessary, however, because of reports of liver toxicity associated with its use. Physician oversight and monitoring of kava use are appropriate.

Inositol. Evidence from RCTs suggests inositol, a natural isomer of glucose and a precursor in the phosphatidylinositol cycle, can significantly improve panic disorder symptoms.^25-28 In 1 trial, efficacy and side effects were comparable to fluvoxamine.²⁸ Effective doses ranged from 12 g/d to 18 g/d. Researchers tested inositol as monotherapy or augmentation to SSRIs for patients with mild-to-moderate OCD. In small double-blind crossover RCTs, inositol monotherapy significantly reduced Yale-Brown Obsessive Compulsive Scale scores compared with placebo²⁶ but inositol augmentation added nothing to the effects of SSRIs.²⁷

Conclusion. Inositol appears to be effective in improving symptoms of panic disorder. Its use for other anxiety disorders is unproven.

Table 4

Dietary supplements for anxiety disorders

Supervision is recommended

The evidence base for most CAM interventions commonly used for anxiety is relatively poor and recent systematic reviews found few methodologically rigorous studies. This has not, however, diminished CAM treatments’ popularity. Despite a paucity of high-quality studies regarding CAM for anxiety disorders, there is enough data supporting yoga, exercise, bibliotherapy, kava, and inositol to allow psychiatrists to collaborate with patients who wish to try these treatments. Advise patients that they may need physician supervision similar to that used with standard psychiatric treatments.

Related Resources

• National Center for Complementary and Alternative Medicine. http://nccam.nih.gov.
• The Journal of Alternative and Complementary Medicine. www.liebertonline.com/loi/acm.
• MedlinePlus: Complementary and Alternative Medicine. www.nlm.nih.gov/medlineplus/complementaryandalternativemedicine.html.

Drug Brand Names

• Amitriptyline • Elavil
• Chlordiazepoxide • Librium
• Clomipramine • Anafranil
• Diazepam • Valium
• Fluvoxamine • Luvox

Disclosure

The authors report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

The number of people with psychiatric disorders who use complementary and alternative medicine (CAM) is on the rise. In surveys of patients seeking psychiatric care, estimates of CAM use range from 8% to 57%; the most frequent uses are for depression and anxiety disorders. A population-based study in the United States found that 9% of respondents had anxiety attacks and 57% of these individuals had used CAM.¹ Similarly, in a Finnish population-based study (N=5,987) 35% of subjects reported some form of CAM use in the previous year; those with comorbid anxiety and depressive disorders used CAM most frequently.²

Unfortunately, a MEDLINE search shows that the number of studies examining psychotropic medications dwarfs the number of studies on even the most common CAM treatments used for psychiatric disorders. Far more patients with diagnosed mental disorders are studied in trials of standard treatments than CAM treatments. Because very few studies evaluate the cost-effectiveness of CAM treatments for psychiatric disorders, the risk-to-benefit ratio is difficult to calculate. Although several CAM treatments for depressive disorders have enough support to be considered options,³ CAM options for anxiety disorders are fewer and have less evidence of efficacy.

For these reasons, it is hard to recommend any CAM treatment as first line. Despite the relative lack of high quality research on CAM treatment outcomes, high rates of CAM use make it critical for clinicians to understand what treatments are available—or at least which treatments should be favored if patients are intent on trying them. We review the current research for yoga, exercise, bibliotherapy, and the dietary supplements kava and inositol for treating anxiety disorders and suggest those that warrant consideration for patients who do not respond, respond partially, or suffer from side effects from selective serotonin reuptake inhibitors (SSRIs) or benzodiazepines.

Limitations of CAM research

There are several limitations to the research literature on CAM approaches for anxiety disorders.⁴ First, there is a wide diversity of practices considered alternative or complementary and various ways in which these methods are applied across cultures. Some authors consider complementary medicines to be only herbal remedies, whereas others include individual therapies such as acupuncture, aromatherapy, herbal therapy, homeopathy, iridology, naturopathy, and reflexology.⁵ This article defines “alternative” treatments as those other than a form of psychotherapy or an FDA-approved medication that substitute for standard psychiatric treatment, and “complementary” approaches as those used to augment standard psychiatric treatments.

Anxiety and stress are ubiquitous, perhaps motivating interest in CAM options and prompting research on heterogeneous groups of individuals with poorly defined clinical syndromes or with isolated symptoms of anxiety or subjective distress. Few studies examine well-defined patient groups with diagnosed anxiety disorders. There are also multiple research design problems, including poorly specified treatments, poorly chosen placebos, and interpreting nonsignificant differences from established treatments as equivalence in underpowered studies.

The CAM treatments reviewed in this article have ≥2 randomized controlled trials (RCTs) that support their use for patients with diagnosed anxiety disorders, and ≥1 study that shows that the treatment can induce remission.

Yoga

In 2005 Kirkwood et al carried out the first systematic review of research evidence for the effectiveness of yoga in anxiety treatment.⁶ Of 19 studies identified, 4 RCTs and 1 nonrandomized trial met their inclusion criteria, which were an anxiety disorder diagnosis, use of yoga or yoga-based exercises alone, and anxiety rating scales used as outcome measures. Most found significant improvement in anxiety symptoms with yoga compared with placebo. Details of the 5 trials evaluated in Kirkwood’s review are summarized in Table 1.^7-11

Since the 2005 review, 3 additional studies of yoga and anxiety have been published, but none would meet Kirkwood’s inclusion criteria. One that evaluated a heterogeneous group of patients using an intervention with multiple components—only 1 of which was yoga—found the intervention significantly reduced anxiety scores.¹² A second study comparing yoga with relaxation in 131 patients with mild-to-moderate stress but no anxiety disorder diagnosis showed yoga was as effective as relaxation in improving anxiety symptoms as measured by the anxiety subscale of the State Trait Personality Inventory.¹³ In a study of 183 nonrandomized survivors of the 2004 southeast Asia tsunami with posttraumatic stress disorder (PTSD) symptoms, yoga-based breathing either alone or paired with trauma reduction exposure techniques significantly reduced PTSD symptoms compared with wait-list controls.¹⁴

Conclusion. Few controlled studies evaluated yoga for anxiety disorders, and all have significant methodologic limitations and/or poor methodology reporting. The diagnostic conditions treated and both yoga interventions and control conditions varied. However, these limited results are encouraging, particularly for treatment of obsessive-compulsive disorder (OCD). There is little information regarding safety or contraindications of yoga. Reported attrition rates were high in most studies, which may raise concerns about patient motivation and compliance.

Table 1

Evidence on the effectiveness of yoga for anxiety disorders

Exercise

The literature examining the relationship between exercise and depression is extensive, but much less has been published about exercise in patients with anxiety disorders (Table 2).^15-17 In a 10-week trial, Broocks and colleagues compared clomipramine, exercise (running), and placebo in 46 outpatients with panic disorder.¹⁵ Both exercise and clomipramine, 112.5 mg/d, significantly reduced panic symptoms compared with placebo, but clomipramine was more effective and faster-acting.

A more recent RCT compared group cognitive-behavioral therapy (GCBT) plus a home-based walking program vs GCBT and in 21 patients with panic disorder, generalized anxiety disorder (GAD), or social phobia.¹⁶ Compared with GCBT plus educational sessions, GCBT plus walking had a significant effect on self-reported depression, anxiety, and stress. Results differed by diagnosis; the most marked effects occurred in individuals with social phobia, whereas benefits for those with panic disorder or GAD were questionable.

Fifteen patients with OCD were recruited to participate in a 12-week, moderate-intensity aerobic exercise program added to their standard behavioral and/or pharmacologic treatment.¹⁷ Subjects demonstrated improvement in negative mood, anxiety, obsessions, and compulsions after each exercise session. Changes after each session persisted over the 12-week intervention, although the magnitude attenuated over the duration of the intervention.

Conclusion. Although initial results from small trials suggest exercise may help improve anxiety symptoms, further studies are needed to determine how to best use exercise training to treat anxious patients, specifically regarding dose-response relationship, differences in effectiveness between aerobic and resistance training, and the mechanisms by which exercise improves psychiatric symptoms.

Table 2

Exercise for anxiety: More research is needed

Bibliotherapy

Investigation of bibliotherapy for treatment of anxiety disorders has been limited (Table 3).^18-20 A 2009 RCT demonstrated that for 21 patients with mild-to-moderate social phobia, bibliotherapy—in the form of an 8-week self-directed CBT program with minimal therapist involvement—was superior to a wait-list control and induced clinically significant change in approximately one-third of patients.²⁰

Rapee et al randomly assigned 267 children age 6 to 12 with anxiety disorders to bibliotherapy that consisted of parents treating their children in the home with written materials, 9 sessions of GCBT, or a wait-list control condition.¹⁹ Bibliotherapy provided by parents demonstrated benefit compared with wait-listing but was not as efficacious as GCBT at post-treatment and 3-month follow-up.

Lidren and colleagues randomly assigned 36 adult patients with panic disorder to bibliotherapy, group therapy combined with bibliotherapy, or a waitlist.¹⁸ Both treatments were more effective than wait-listing in reducing the frequency of panic attacks, severity of physical panic symptoms, catastrophic cognitions, agoraphobic avoidance, and depression. Both interventions maintained their effects at 3-and 6-month follow-up and produced clinically significant change in most patients.

Conclusion. Some preliminary evidence supports the effectiveness of bibliotherapy for social anxiety disorder, childhood anxiety disorders, and panic disorder.

Table 3

Preliminary evidence supports bibliotherapy for select anxiety disorders

Dietary supplements

Many dietary and herbal supplements are purported to have therapeutic efficacy for anxiety symptoms. Because of inadequate FDA regulation of manufacturing and marketing of these agents, most of these supplements have not been tested on patients with anxiety disorders.²¹ Limited evidence supports the use of kava for GAD and inositol for panic disorder (Table 4).^22-28

Kava. Multiple double-blind RCTs found kava (Piper methysticum)—a plant indigenous to South Pacific islands—has effects greater than placebo and comparable to standard treatments for mild to moderately severe GAD. A Cochrane meta-analysis²² of 11 trials with 645 participants concluded that kava is effective for reducing GAD symptoms, with risks comparable to standard treatments for up to 6 months of use.

Case reports of kava-associated liver toxicity led to a marketing ban in Canada in 2000, followed shortly by Germany, Australia, and the United Kingdom. In 2002 the FDA issued a Consumer Advisory²⁹ discouraging kava use. Since then a flurry of research has looked for sources of possible toxicity, including individual sensitivities,²⁹ excessive dosing, use of toxic parts of the kava plant instead of the roots,^30,31 interactions with other hepatoactive substances, and non-water based extraction methods. RCTs demonstrating kava’s efficacy and safety were characterized by careful dosing supervision, use of standardized kava extracts, and avoidance of interactions with other hepatoactive medications or CAM treatments. Doses ≤300 mg/d are recommended.²²

RCTs that used the standardized acetone extract WS1490²³ found that women and younger adults show more positive effects from kava, and showed no liver toxicity when used for 1 to 24 weeks. A recent RCT that used kava extracts obtained via water-based methods showed kava had significant anxiolytic effects.²⁴ However, a study of liver toxicity reports found that water-based extractions, acetonic extractions, and ethanol extractions all have been associated with toxic hepatic reactions.³² Aqueous extraction does not guarantee safety, and the extraction solvent does not cause toxicity. A recent report of a severe liver reaction to the native drink by a tourist in Samoa³³ suggests that aqueous extractions from the root stock— the type of kava used by South Pacific islanders—also can be unsafe.

Conclusion. Multiple RCTs have found kava relatively safe and effective for treating anxiety symptoms. Caution is necessary, however, because of reports of liver toxicity associated with its use. Physician oversight and monitoring of kava use are appropriate.

Inositol. Evidence from RCTs suggests inositol, a natural isomer of glucose and a precursor in the phosphatidylinositol cycle, can significantly improve panic disorder symptoms.^25-28 In 1 trial, efficacy and side effects were comparable to fluvoxamine.²⁸ Effective doses ranged from 12 g/d to 18 g/d. Researchers tested inositol as monotherapy or augmentation to SSRIs for patients with mild-to-moderate OCD. In small double-blind crossover RCTs, inositol monotherapy significantly reduced Yale-Brown Obsessive Compulsive Scale scores compared with placebo²⁶ but inositol augmentation added nothing to the effects of SSRIs.²⁷

Conclusion. Inositol appears to be effective in improving symptoms of panic disorder. Its use for other anxiety disorders is unproven.

Table 4

Dietary supplements for anxiety disorders

Supervision is recommended

The evidence base for most CAM interventions commonly used for anxiety is relatively poor and recent systematic reviews found few methodologically rigorous studies. This has not, however, diminished CAM treatments’ popularity. Despite a paucity of high-quality studies regarding CAM for anxiety disorders, there is enough data supporting yoga, exercise, bibliotherapy, kava, and inositol to allow psychiatrists to collaborate with patients who wish to try these treatments. Advise patients that they may need physician supervision similar to that used with standard psychiatric treatments.

Related Resources

• National Center for Complementary and Alternative Medicine. http://nccam.nih.gov.
• The Journal of Alternative and Complementary Medicine. www.liebertonline.com/loi/acm.
• MedlinePlus: Complementary and Alternative Medicine. www.nlm.nih.gov/medlineplus/complementaryandalternativemedicine.html.

Drug Brand Names

• Amitriptyline • Elavil
• Chlordiazepoxide • Librium
• Clomipramine • Anafranil
• Diazepam • Valium
• Fluvoxamine • Luvox

Disclosure

The authors report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

The number of people with psychiatric disorders who use complementary and alternative medicine (CAM) is on the rise. In surveys of patients seeking psychiatric care, estimates of CAM use range from 8% to 57%; the most frequent uses are for depression and anxiety disorders. A population-based study in the United States found that 9% of respondents had anxiety attacks and 57% of these individuals had used CAM.¹ Similarly, in a Finnish population-based study (N=5,987) 35% of subjects reported some form of CAM use in the previous year; those with comorbid anxiety and depressive disorders used CAM most frequently.²

Unfortunately, a MEDLINE search shows that the number of studies examining psychotropic medications dwarfs the number of studies on even the most common CAM treatments used for psychiatric disorders. Far more patients with diagnosed mental disorders are studied in trials of standard treatments than CAM treatments. Because very few studies evaluate the cost-effectiveness of CAM treatments for psychiatric disorders, the risk-to-benefit ratio is difficult to calculate. Although several CAM treatments for depressive disorders have enough support to be considered options,³ CAM options for anxiety disorders are fewer and have less evidence of efficacy.

For these reasons, it is hard to recommend any CAM treatment as first line. Despite the relative lack of high quality research on CAM treatment outcomes, high rates of CAM use make it critical for clinicians to understand what treatments are available—or at least which treatments should be favored if patients are intent on trying them. We review the current research for yoga, exercise, bibliotherapy, and the dietary supplements kava and inositol for treating anxiety disorders and suggest those that warrant consideration for patients who do not respond, respond partially, or suffer from side effects from selective serotonin reuptake inhibitors (SSRIs) or benzodiazepines.

Limitations of CAM research

There are several limitations to the research literature on CAM approaches for anxiety disorders.⁴ First, there is a wide diversity of practices considered alternative or complementary and various ways in which these methods are applied across cultures. Some authors consider complementary medicines to be only herbal remedies, whereas others include individual therapies such as acupuncture, aromatherapy, herbal therapy, homeopathy, iridology, naturopathy, and reflexology.⁵ This article defines “alternative” treatments as those other than a form of psychotherapy or an FDA-approved medication that substitute for standard psychiatric treatment, and “complementary” approaches as those used to augment standard psychiatric treatments.

Anxiety and stress are ubiquitous, perhaps motivating interest in CAM options and prompting research on heterogeneous groups of individuals with poorly defined clinical syndromes or with isolated symptoms of anxiety or subjective distress. Few studies examine well-defined patient groups with diagnosed anxiety disorders. There are also multiple research design problems, including poorly specified treatments, poorly chosen placebos, and interpreting nonsignificant differences from established treatments as equivalence in underpowered studies.

The CAM treatments reviewed in this article have ≥2 randomized controlled trials (RCTs) that support their use for patients with diagnosed anxiety disorders, and ≥1 study that shows that the treatment can induce remission.

Yoga

In 2005 Kirkwood et al carried out the first systematic review of research evidence for the effectiveness of yoga in anxiety treatment.⁶ Of 19 studies identified, 4 RCTs and 1 nonrandomized trial met their inclusion criteria, which were an anxiety disorder diagnosis, use of yoga or yoga-based exercises alone, and anxiety rating scales used as outcome measures. Most found significant improvement in anxiety symptoms with yoga compared with placebo. Details of the 5 trials evaluated in Kirkwood’s review are summarized in Table 1.^7-11

Since the 2005 review, 3 additional studies of yoga and anxiety have been published, but none would meet Kirkwood’s inclusion criteria. One that evaluated a heterogeneous group of patients using an intervention with multiple components—only 1 of which was yoga—found the intervention significantly reduced anxiety scores.¹² A second study comparing yoga with relaxation in 131 patients with mild-to-moderate stress but no anxiety disorder diagnosis showed yoga was as effective as relaxation in improving anxiety symptoms as measured by the anxiety subscale of the State Trait Personality Inventory.¹³ In a study of 183 nonrandomized survivors of the 2004 southeast Asia tsunami with posttraumatic stress disorder (PTSD) symptoms, yoga-based breathing either alone or paired with trauma reduction exposure techniques significantly reduced PTSD symptoms compared with wait-list controls.¹⁴

Conclusion. Few controlled studies evaluated yoga for anxiety disorders, and all have significant methodologic limitations and/or poor methodology reporting. The diagnostic conditions treated and both yoga interventions and control conditions varied. However, these limited results are encouraging, particularly for treatment of obsessive-compulsive disorder (OCD). There is little information regarding safety or contraindications of yoga. Reported attrition rates were high in most studies, which may raise concerns about patient motivation and compliance.

Table 1

Evidence on the effectiveness of yoga for anxiety disorders

Exercise

The literature examining the relationship between exercise and depression is extensive, but much less has been published about exercise in patients with anxiety disorders (Table 2).^15-17 In a 10-week trial, Broocks and colleagues compared clomipramine, exercise (running), and placebo in 46 outpatients with panic disorder.¹⁵ Both exercise and clomipramine, 112.5 mg/d, significantly reduced panic symptoms compared with placebo, but clomipramine was more effective and faster-acting.

A more recent RCT compared group cognitive-behavioral therapy (GCBT) plus a home-based walking program vs GCBT and in 21 patients with panic disorder, generalized anxiety disorder (GAD), or social phobia.¹⁶ Compared with GCBT plus educational sessions, GCBT plus walking had a significant effect on self-reported depression, anxiety, and stress. Results differed by diagnosis; the most marked effects occurred in individuals with social phobia, whereas benefits for those with panic disorder or GAD were questionable.

Fifteen patients with OCD were recruited to participate in a 12-week, moderate-intensity aerobic exercise program added to their standard behavioral and/or pharmacologic treatment.¹⁷ Subjects demonstrated improvement in negative mood, anxiety, obsessions, and compulsions after each exercise session. Changes after each session persisted over the 12-week intervention, although the magnitude attenuated over the duration of the intervention.

Conclusion. Although initial results from small trials suggest exercise may help improve anxiety symptoms, further studies are needed to determine how to best use exercise training to treat anxious patients, specifically regarding dose-response relationship, differences in effectiveness between aerobic and resistance training, and the mechanisms by which exercise improves psychiatric symptoms.

Table 2

Exercise for anxiety: More research is needed

Bibliotherapy

Investigation of bibliotherapy for treatment of anxiety disorders has been limited (Table 3).^18-20 A 2009 RCT demonstrated that for 21 patients with mild-to-moderate social phobia, bibliotherapy—in the form of an 8-week self-directed CBT program with minimal therapist involvement—was superior to a wait-list control and induced clinically significant change in approximately one-third of patients.²⁰

Rapee et al randomly assigned 267 children age 6 to 12 with anxiety disorders to bibliotherapy that consisted of parents treating their children in the home with written materials, 9 sessions of GCBT, or a wait-list control condition.¹⁹ Bibliotherapy provided by parents demonstrated benefit compared with wait-listing but was not as efficacious as GCBT at post-treatment and 3-month follow-up.

Lidren and colleagues randomly assigned 36 adult patients with panic disorder to bibliotherapy, group therapy combined with bibliotherapy, or a waitlist.¹⁸ Both treatments were more effective than wait-listing in reducing the frequency of panic attacks, severity of physical panic symptoms, catastrophic cognitions, agoraphobic avoidance, and depression. Both interventions maintained their effects at 3-and 6-month follow-up and produced clinically significant change in most patients.

Conclusion. Some preliminary evidence supports the effectiveness of bibliotherapy for social anxiety disorder, childhood anxiety disorders, and panic disorder.

Table 3

Preliminary evidence supports bibliotherapy for select anxiety disorders

Dietary supplements

Many dietary and herbal supplements are purported to have therapeutic efficacy for anxiety symptoms. Because of inadequate FDA regulation of manufacturing and marketing of these agents, most of these supplements have not been tested on patients with anxiety disorders.²¹ Limited evidence supports the use of kava for GAD and inositol for panic disorder (Table 4).^22-28

Kava. Multiple double-blind RCTs found kava (Piper methysticum)—a plant indigenous to South Pacific islands—has effects greater than placebo and comparable to standard treatments for mild to moderately severe GAD. A Cochrane meta-analysis²² of 11 trials with 645 participants concluded that kava is effective for reducing GAD symptoms, with risks comparable to standard treatments for up to 6 months of use.

Case reports of kava-associated liver toxicity led to a marketing ban in Canada in 2000, followed shortly by Germany, Australia, and the United Kingdom. In 2002 the FDA issued a Consumer Advisory²⁹ discouraging kava use. Since then a flurry of research has looked for sources of possible toxicity, including individual sensitivities,²⁹ excessive dosing, use of toxic parts of the kava plant instead of the roots,^30,31 interactions with other hepatoactive substances, and non-water based extraction methods. RCTs demonstrating kava’s efficacy and safety were characterized by careful dosing supervision, use of standardized kava extracts, and avoidance of interactions with other hepatoactive medications or CAM treatments. Doses ≤300 mg/d are recommended.²²

RCTs that used the standardized acetone extract WS1490²³ found that women and younger adults show more positive effects from kava, and showed no liver toxicity when used for 1 to 24 weeks. A recent RCT that used kava extracts obtained via water-based methods showed kava had significant anxiolytic effects.²⁴ However, a study of liver toxicity reports found that water-based extractions, acetonic extractions, and ethanol extractions all have been associated with toxic hepatic reactions.³² Aqueous extraction does not guarantee safety, and the extraction solvent does not cause toxicity. A recent report of a severe liver reaction to the native drink by a tourist in Samoa³³ suggests that aqueous extractions from the root stock— the type of kava used by South Pacific islanders—also can be unsafe.

Conclusion. Multiple RCTs have found kava relatively safe and effective for treating anxiety symptoms. Caution is necessary, however, because of reports of liver toxicity associated with its use. Physician oversight and monitoring of kava use are appropriate.

Inositol. Evidence from RCTs suggests inositol, a natural isomer of glucose and a precursor in the phosphatidylinositol cycle, can significantly improve panic disorder symptoms.^25-28 In 1 trial, efficacy and side effects were comparable to fluvoxamine.²⁸ Effective doses ranged from 12 g/d to 18 g/d. Researchers tested inositol as monotherapy or augmentation to SSRIs for patients with mild-to-moderate OCD. In small double-blind crossover RCTs, inositol monotherapy significantly reduced Yale-Brown Obsessive Compulsive Scale scores compared with placebo²⁶ but inositol augmentation added nothing to the effects of SSRIs.²⁷

Conclusion. Inositol appears to be effective in improving symptoms of panic disorder. Its use for other anxiety disorders is unproven.

Table 4

Dietary supplements for anxiety disorders

Supervision is recommended

The evidence base for most CAM interventions commonly used for anxiety is relatively poor and recent systematic reviews found few methodologically rigorous studies. This has not, however, diminished CAM treatments’ popularity. Despite a paucity of high-quality studies regarding CAM for anxiety disorders, there is enough data supporting yoga, exercise, bibliotherapy, kava, and inositol to allow psychiatrists to collaborate with patients who wish to try these treatments. Advise patients that they may need physician supervision similar to that used with standard psychiatric treatments.

Related Resources

• National Center for Complementary and Alternative Medicine. http://nccam.nih.gov.
• The Journal of Alternative and Complementary Medicine. www.liebertonline.com/loi/acm.
• MedlinePlus: Complementary and Alternative Medicine. www.nlm.nih.gov/medlineplus/complementaryandalternativemedicine.html.

Drug Brand Names

• Amitriptyline • Elavil
• Chlordiazepoxide • Librium
• Clomipramine • Anafranil
• Diazepam • Valium
• Fluvoxamine • Luvox

Disclosure

The authors report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

[email protected]

As general pediatricians, you should feel confident in your ability to diagnose and manage dental trauma and emergencies. Bumped teeth that are not loose, bruised gums, and aphthous ulcers are dental emergencies that you can evaluate and treat in your office, for example.

In contrast, referral is warranted after trauma loosens a tooth, breaks it, or causes the tooth to come out (avulsion). In addition, a child who presents with extreme pain, an abscessed tooth, or a tooth pushed out of position should be referred to a specialist. Dental cellulitis and severe soft tissue injuries of the mouth are other reasons I typically see these children.

An avulsed permanent tooth should be replaced quickly, within seconds or minutes. The longer the tooth is out of the mouth, the poorer the prognosis. Do not handle the root surface, but do rinse lightly and quickly to remove foreign material. If it is impossible to reimplant the tooth immediately, instruct parents to store the tooth in milk or saline for transport to the dentist.

Once the child reaches a specialist, treatment may include reimplantation with a splint to stabilize the tooth, prescriptions for systemic antibiotics and oral antimicrobials, and pulp therapy. Inform parents that most displaced permanent teeth undergo pulpal necrosis and require initiation of root canal therapy 1 week after stabilization.

In contrast, primary teeth usually are not reimplanted. If a patient comes in with a “baby tooth” that has been knocked out, then just pass it on to the tooth fairy.

The good news is most tooth injuries are self-evident. Signs of trauma include discoloration and patient reports of pain associated with tooth movement, chewing, palpation, and/or sensitivity to hot or cold food or drinks.

If you see facial swelling, however, expand your differential diagnosis to include etiologies beyond the teeth or gingival tissue. Infections and allergic reactions, for example, also can cause substantial gingival swelling. Rule out ear infections, swollen lymph nodes, and strep throat and viral infections, because these can mimic dental concerns.

If a child presents after trauma with a fractured tooth, make sure to remove any tooth fragments before suturing nearby tissue, including lacerated lips. Hemorrhage control, cleansing, and suturing, as indicated, are important management tips for such soft tissue wounds. Antibiotics are recommended for all “through and through” lacerations.

Establish a working relationship with pediatric dentists and oral surgeons in your community. When a child requires immediate care, these specialists can provide telephone advice on how to handle the emergency and/or be a source of immediate referral for the patient.

A dentist never wants to see a child for the first time during a traumatic situation. Instead, each patient should see a dentist by age 1 to establish a dental home. A child who visits the dentist on a regular basis will become familiar with the provider and more comfortable in the event of a dental emergency. Education of parents on optimal oral health, prevention of problems, and appropriate dental development are other benefits of early, routine dental care.

I recommend the American Academy of Pediatrics Section on Pediatric Dentistry and Oral Health's new curriculum called Protecting All Children's Teeth (PACT): A Pediatric Oral Health Training Program (www.aap.org/oralhealth/pact.cfm

Some dental emergencies can be evaluated and treated in your office, according to Tonya Fuqua, D.D.S.

Source Courtesy Cook Children's Hospital

[email protected]

As general pediatricians, you should feel confident in your ability to diagnose and manage dental trauma and emergencies. Bumped teeth that are not loose, bruised gums, and aphthous ulcers are dental emergencies that you can evaluate and treat in your office, for example.

In contrast, referral is warranted after trauma loosens a tooth, breaks it, or causes the tooth to come out (avulsion). In addition, a child who presents with extreme pain, an abscessed tooth, or a tooth pushed out of position should be referred to a specialist. Dental cellulitis and severe soft tissue injuries of the mouth are other reasons I typically see these children.

An avulsed permanent tooth should be replaced quickly, within seconds or minutes. The longer the tooth is out of the mouth, the poorer the prognosis. Do not handle the root surface, but do rinse lightly and quickly to remove foreign material. If it is impossible to reimplant the tooth immediately, instruct parents to store the tooth in milk or saline for transport to the dentist.

Once the child reaches a specialist, treatment may include reimplantation with a splint to stabilize the tooth, prescriptions for systemic antibiotics and oral antimicrobials, and pulp therapy. Inform parents that most displaced permanent teeth undergo pulpal necrosis and require initiation of root canal therapy 1 week after stabilization.

In contrast, primary teeth usually are not reimplanted. If a patient comes in with a “baby tooth” that has been knocked out, then just pass it on to the tooth fairy.

The good news is most tooth injuries are self-evident. Signs of trauma include discoloration and patient reports of pain associated with tooth movement, chewing, palpation, and/or sensitivity to hot or cold food or drinks.

If you see facial swelling, however, expand your differential diagnosis to include etiologies beyond the teeth or gingival tissue. Infections and allergic reactions, for example, also can cause substantial gingival swelling. Rule out ear infections, swollen lymph nodes, and strep throat and viral infections, because these can mimic dental concerns.

If a child presents after trauma with a fractured tooth, make sure to remove any tooth fragments before suturing nearby tissue, including lacerated lips. Hemorrhage control, cleansing, and suturing, as indicated, are important management tips for such soft tissue wounds. Antibiotics are recommended for all “through and through” lacerations.

Establish a working relationship with pediatric dentists and oral surgeons in your community. When a child requires immediate care, these specialists can provide telephone advice on how to handle the emergency and/or be a source of immediate referral for the patient.

A dentist never wants to see a child for the first time during a traumatic situation. Instead, each patient should see a dentist by age 1 to establish a dental home. A child who visits the dentist on a regular basis will become familiar with the provider and more comfortable in the event of a dental emergency. Education of parents on optimal oral health, prevention of problems, and appropriate dental development are other benefits of early, routine dental care.

I recommend the American Academy of Pediatrics Section on Pediatric Dentistry and Oral Health's new curriculum called Protecting All Children's Teeth (PACT): A Pediatric Oral Health Training Program (www.aap.org/oralhealth/pact.cfm

Some dental emergencies can be evaluated and treated in your office, according to Tonya Fuqua, D.D.S.

Source Courtesy Cook Children's Hospital

[email protected]

As general pediatricians, you should feel confident in your ability to diagnose and manage dental trauma and emergencies. Bumped teeth that are not loose, bruised gums, and aphthous ulcers are dental emergencies that you can evaluate and treat in your office, for example.

In contrast, referral is warranted after trauma loosens a tooth, breaks it, or causes the tooth to come out (avulsion). In addition, a child who presents with extreme pain, an abscessed tooth, or a tooth pushed out of position should be referred to a specialist. Dental cellulitis and severe soft tissue injuries of the mouth are other reasons I typically see these children.

An avulsed permanent tooth should be replaced quickly, within seconds or minutes. The longer the tooth is out of the mouth, the poorer the prognosis. Do not handle the root surface, but do rinse lightly and quickly to remove foreign material. If it is impossible to reimplant the tooth immediately, instruct parents to store the tooth in milk or saline for transport to the dentist.

Once the child reaches a specialist, treatment may include reimplantation with a splint to stabilize the tooth, prescriptions for systemic antibiotics and oral antimicrobials, and pulp therapy. Inform parents that most displaced permanent teeth undergo pulpal necrosis and require initiation of root canal therapy 1 week after stabilization.

In contrast, primary teeth usually are not reimplanted. If a patient comes in with a “baby tooth” that has been knocked out, then just pass it on to the tooth fairy.

The good news is most tooth injuries are self-evident. Signs of trauma include discoloration and patient reports of pain associated with tooth movement, chewing, palpation, and/or sensitivity to hot or cold food or drinks.

If you see facial swelling, however, expand your differential diagnosis to include etiologies beyond the teeth or gingival tissue. Infections and allergic reactions, for example, also can cause substantial gingival swelling. Rule out ear infections, swollen lymph nodes, and strep throat and viral infections, because these can mimic dental concerns.

If a child presents after trauma with a fractured tooth, make sure to remove any tooth fragments before suturing nearby tissue, including lacerated lips. Hemorrhage control, cleansing, and suturing, as indicated, are important management tips for such soft tissue wounds. Antibiotics are recommended for all “through and through” lacerations.

Establish a working relationship with pediatric dentists and oral surgeons in your community. When a child requires immediate care, these specialists can provide telephone advice on how to handle the emergency and/or be a source of immediate referral for the patient.

A dentist never wants to see a child for the first time during a traumatic situation. Instead, each patient should see a dentist by age 1 to establish a dental home. A child who visits the dentist on a regular basis will become familiar with the provider and more comfortable in the event of a dental emergency. Education of parents on optimal oral health, prevention of problems, and appropriate dental development are other benefits of early, routine dental care.

I recommend the American Academy of Pediatrics Section on Pediatric Dentistry and Oral Health's new curriculum called Protecting All Children's Teeth (PACT): A Pediatric Oral Health Training Program (www.aap.org/oralhealth/pact.cfm

Some dental emergencies can be evaluated and treated in your office, according to Tonya Fuqua, D.D.S.

Source Courtesy Cook Children's Hospital

[email protected]

Divorce is so common in the United States – ending about half of all marriages – that it will affect many patients and families in your practice. If your practice has about 2,000 children and adolescents from about 1,500 families, for example, hundreds of families will be dealing with predivorce marital tension, the divorce itself, or postdivorce concerns.

Start by screening for family functioning at every annual visit. Specifically, try to identify strife and stress early on, at a time when your inventions have the greatest preventive impact. Ask open-ended questions such as, “How are things going in the family?” or “Is there any tension or discord in the family or in the marriage?”

I recommend using the broader term “discord” because it will pick up a pending divorce and also identify other family stressors for the child. For example, research indicates that the years of arguing and fighting that often precede divorce may be more damaging to the child in the long term than the divorce itself.

Once you identify marital or family stress, strive for the following three long-term goals to optimize a healthy outcome for the child.

▸ First, make sure the child continues to function well in school, with peers, in activities, and in areas of self-esteem. The firr certain key signs that a child is not functioning well. Persistently lower school performance is one sign. Most children are't concentrate or perform as well at school in the year of the divorce, but it is a warning sign if the problems persist. Determine whether the child is still having difficulty adjusting to the divorce, and assess if there is ongoing discord or fighting about visitation, custody, child rearing, or finances after the divorce. Another warning sign is the child who drops an after-school activity during a divorce crisis, and fails to retume itin the next school year.

How a child relates to friends after the divorce can be important. In particular, ascertain how young or midadolescents treat members of the opposite sex. Look for patterns in their relationships that repeat some of the dysfunctional behaviors of their parents' marriage. Keep in mind that children are often unaware that they are repeating these family patterns.

For example, are girls who are adversely affected by divorce especially vulnerable to getting involved with older teenagers who might take advantage of them? Do you see any evidence of longing in the girls, or signs that they are seeking to replace something missing in their paternal relationship? This type of behavior is much less likely if the girl has had a good relationship with her father before, during, and after the divorce.

With teenage boys, consider how they treat their girlfriends. Is the boy supportive in his relationships, or does he have girlfriend after girlfriend because of a callous or insensitive attitude?

Referral for a mental health evaluation might be appropriate if you see a pattern of continuing dysfunction in a major area of the child's life or of unsatisfactory relationships as these younger teenagers enter high school, particularly if they are alienated from a parent.

▸ Second, ensure that parents are open and willing to answer the child's questions as the child tries to make sense of the divorce at each developmental stage. Help postdivorce families encourage the child to ask questions on an ongoing basis. If divorce happened when the child was a toddler, for example, they are going to have questions 5, 10, and 15 years later that they could not conceptualize until they reached the appropriate developmental point.

Parents may need your advice on how best to talk to their 5- or 8-year-old, a time when information should be concrete and straightforward. In contrast, a 14-year-old may be able to understand more conceptual and nuanced answers to their questions. For example, a younger child is unlikely to think about the divorce in terms of an extramarital affair or the impact on their college finances, but that may not be the case when the child is 14 or 15 years old. Keep in mind that many adolescents do not ask parents such difficult questions unless they are given permission in advance, and it's at a time when they feel safe and at ease.

▸ Third, counsel the family to facilitate a good relationship between the child and each parent over the long term. When families come to me and there is a lot of tension about visitation, custody, and money, I often focus them on the long-term goals. I ask, “What kind of relationship do you want with your child 10 and 15 years from now?”; “What is likely to result in a good long-term relationship with them?”; “Do you want to be able to be at their wedding?”; “Do you want to be close to your grandchildren?” Going all out for an extra few hours of visitation or not paying a bill is not likely to help achieve these long-term goals.

Again, early screening and intervention make your job easier. If a patient or family comes to you after years of negativity and a court fight over a bitter divorce, your ability to intervene effectively is already very limited.

Divorce is often an angry and divisive time. You can advise parents not to act out of anger by offering examples of divorcing parents who invested a lot of time and energy into winning short-term victories, only to see their efforts backfire later. Some parents believe that the child will be closer to them if they can make the child angry at the spouse. But children who feel they have to betray one parent to please the other often become resentful of this role over time.

In contrast, children who observe their parents working together with a sense of harmony and cooperation to make the custody, visitation, financial, and other arrangements successful are much less likely to blame themselves for the divorce. They also are much less likely to feel guilty when they connect more to one parent or the other at different points in their development.

It is important to monitor your patients for long-term effects of divorce up to and including the time you transition them to an adult care provider. Ask the older adolescent questions such as, “How do you feel about the divorce now, looking back on it [5, 10, or 15] years later?”; “How do you think it's affected you?”; and “Are there any things you'd like to change?”

If you do a review of how they integrated the divorce when they are in 10th or 11th grade, you will still have time to address any unresolved issues. If the child is distant with one parent, you can at least wonder if this is a point in time to reconnect and repair that relationship before the teenager goes to work or college and moves to being fully independent.

Pediatricians often have limited time to intervene. Some find this work very gratifying and feel comfortable with divorce-related issues. Others may choose to refer the patient to a social worker, psychologist, or child and adolescent psychiatrist, according to the severity of the situation. Some pediatric practices are fortunate to have a full- or part-time social worker.

If you want to counsel but your time is limited, consider offering a divorced-parent discussion and education group in your practice. You and/or a social worker could facilitate this forum. This resource can help parents share their experiences and strategies to ensure that children emerge as happy and healthy as possible after a divorce. In addition, this intervention can be cost-neutral if you charge parents a nominal fee.

[email protected]

Divorce is so common in the United States – ending about half of all marriages – that it will affect many patients and families in your practice. If your practice has about 2,000 children and adolescents from about 1,500 families, for example, hundreds of families will be dealing with predivorce marital tension, the divorce itself, or postdivorce concerns.

Start by screening for family functioning at every annual visit. Specifically, try to identify strife and stress early on, at a time when your inventions have the greatest preventive impact. Ask open-ended questions such as, “How are things going in the family?” or “Is there any tension or discord in the family or in the marriage?”

I recommend using the broader term “discord” because it will pick up a pending divorce and also identify other family stressors for the child. For example, research indicates that the years of arguing and fighting that often precede divorce may be more damaging to the child in the long term than the divorce itself.

Once you identify marital or family stress, strive for the following three long-term goals to optimize a healthy outcome for the child.

▸ First, make sure the child continues to function well in school, with peers, in activities, and in areas of self-esteem. The firr certain key signs that a child is not functioning well. Persistently lower school performance is one sign. Most children are't concentrate or perform as well at school in the year of the divorce, but it is a warning sign if the problems persist. Determine whether the child is still having difficulty adjusting to the divorce, and assess if there is ongoing discord or fighting about visitation, custody, child rearing, or finances after the divorce. Another warning sign is the child who drops an after-school activity during a divorce crisis, and fails to retume itin the next school year.

How a child relates to friends after the divorce can be important. In particular, ascertain how young or midadolescents treat members of the opposite sex. Look for patterns in their relationships that repeat some of the dysfunctional behaviors of their parents' marriage. Keep in mind that children are often unaware that they are repeating these family patterns.

For example, are girls who are adversely affected by divorce especially vulnerable to getting involved with older teenagers who might take advantage of them? Do you see any evidence of longing in the girls, or signs that they are seeking to replace something missing in their paternal relationship? This type of behavior is much less likely if the girl has had a good relationship with her father before, during, and after the divorce.

With teenage boys, consider how they treat their girlfriends. Is the boy supportive in his relationships, or does he have girlfriend after girlfriend because of a callous or insensitive attitude?

Referral for a mental health evaluation might be appropriate if you see a pattern of continuing dysfunction in a major area of the child's life or of unsatisfactory relationships as these younger teenagers enter high school, particularly if they are alienated from a parent.

▸ Second, ensure that parents are open and willing to answer the child's questions as the child tries to make sense of the divorce at each developmental stage. Help postdivorce families encourage the child to ask questions on an ongoing basis. If divorce happened when the child was a toddler, for example, they are going to have questions 5, 10, and 15 years later that they could not conceptualize until they reached the appropriate developmental point.

Parents may need your advice on how best to talk to their 5- or 8-year-old, a time when information should be concrete and straightforward. In contrast, a 14-year-old may be able to understand more conceptual and nuanced answers to their questions. For example, a younger child is unlikely to think about the divorce in terms of an extramarital affair or the impact on their college finances, but that may not be the case when the child is 14 or 15 years old. Keep in mind that many adolescents do not ask parents such difficult questions unless they are given permission in advance, and it's at a time when they feel safe and at ease.

▸ Third, counsel the family to facilitate a good relationship between the child and each parent over the long term. When families come to me and there is a lot of tension about visitation, custody, and money, I often focus them on the long-term goals. I ask, “What kind of relationship do you want with your child 10 and 15 years from now?”; “What is likely to result in a good long-term relationship with them?”; “Do you want to be able to be at their wedding?”; “Do you want to be close to your grandchildren?” Going all out for an extra few hours of visitation or not paying a bill is not likely to help achieve these long-term goals.

Again, early screening and intervention make your job easier. If a patient or family comes to you after years of negativity and a court fight over a bitter divorce, your ability to intervene effectively is already very limited.

Divorce is often an angry and divisive time. You can advise parents not to act out of anger by offering examples of divorcing parents who invested a lot of time and energy into winning short-term victories, only to see their efforts backfire later. Some parents believe that the child will be closer to them if they can make the child angry at the spouse. But children who feel they have to betray one parent to please the other often become resentful of this role over time.

In contrast, children who observe their parents working together with a sense of harmony and cooperation to make the custody, visitation, financial, and other arrangements successful are much less likely to blame themselves for the divorce. They also are much less likely to feel guilty when they connect more to one parent or the other at different points in their development.

It is important to monitor your patients for long-term effects of divorce up to and including the time you transition them to an adult care provider. Ask the older adolescent questions such as, “How do you feel about the divorce now, looking back on it [5, 10, or 15] years later?”; “How do you think it's affected you?”; and “Are there any things you'd like to change?”

If you do a review of how they integrated the divorce when they are in 10th or 11th grade, you will still have time to address any unresolved issues. If the child is distant with one parent, you can at least wonder if this is a point in time to reconnect and repair that relationship before the teenager goes to work or college and moves to being fully independent.

Pediatricians often have limited time to intervene. Some find this work very gratifying and feel comfortable with divorce-related issues. Others may choose to refer the patient to a social worker, psychologist, or child and adolescent psychiatrist, according to the severity of the situation. Some pediatric practices are fortunate to have a full- or part-time social worker.

If you want to counsel but your time is limited, consider offering a divorced-parent discussion and education group in your practice. You and/or a social worker could facilitate this forum. This resource can help parents share their experiences and strategies to ensure that children emerge as happy and healthy as possible after a divorce. In addition, this intervention can be cost-neutral if you charge parents a nominal fee.

[email protected]

Divorce is so common in the United States – ending about half of all marriages – that it will affect many patients and families in your practice. If your practice has about 2,000 children and adolescents from about 1,500 families, for example, hundreds of families will be dealing with predivorce marital tension, the divorce itself, or postdivorce concerns.

Start by screening for family functioning at every annual visit. Specifically, try to identify strife and stress early on, at a time when your inventions have the greatest preventive impact. Ask open-ended questions such as, “How are things going in the family?” or “Is there any tension or discord in the family or in the marriage?”

I recommend using the broader term “discord” because it will pick up a pending divorce and also identify other family stressors for the child. For example, research indicates that the years of arguing and fighting that often precede divorce may be more damaging to the child in the long term than the divorce itself.

Once you identify marital or family stress, strive for the following three long-term goals to optimize a healthy outcome for the child.

▸ First, make sure the child continues to function well in school, with peers, in activities, and in areas of self-esteem. The firr certain key signs that a child is not functioning well. Persistently lower school performance is one sign. Most children are't concentrate or perform as well at school in the year of the divorce, but it is a warning sign if the problems persist. Determine whether the child is still having difficulty adjusting to the divorce, and assess if there is ongoing discord or fighting about visitation, custody, child rearing, or finances after the divorce. Another warning sign is the child who drops an after-school activity during a divorce crisis, and fails to retume itin the next school year.

How a child relates to friends after the divorce can be important. In particular, ascertain how young or midadolescents treat members of the opposite sex. Look for patterns in their relationships that repeat some of the dysfunctional behaviors of their parents' marriage. Keep in mind that children are often unaware that they are repeating these family patterns.

For example, are girls who are adversely affected by divorce especially vulnerable to getting involved with older teenagers who might take advantage of them? Do you see any evidence of longing in the girls, or signs that they are seeking to replace something missing in their paternal relationship? This type of behavior is much less likely if the girl has had a good relationship with her father before, during, and after the divorce.

With teenage boys, consider how they treat their girlfriends. Is the boy supportive in his relationships, or does he have girlfriend after girlfriend because of a callous or insensitive attitude?

Referral for a mental health evaluation might be appropriate if you see a pattern of continuing dysfunction in a major area of the child's life or of unsatisfactory relationships as these younger teenagers enter high school, particularly if they are alienated from a parent.

▸ Second, ensure that parents are open and willing to answer the child's questions as the child tries to make sense of the divorce at each developmental stage. Help postdivorce families encourage the child to ask questions on an ongoing basis. If divorce happened when the child was a toddler, for example, they are going to have questions 5, 10, and 15 years later that they could not conceptualize until they reached the appropriate developmental point.

Parents may need your advice on how best to talk to their 5- or 8-year-old, a time when information should be concrete and straightforward. In contrast, a 14-year-old may be able to understand more conceptual and nuanced answers to their questions. For example, a younger child is unlikely to think about the divorce in terms of an extramarital affair or the impact on their college finances, but that may not be the case when the child is 14 or 15 years old. Keep in mind that many adolescents do not ask parents such difficult questions unless they are given permission in advance, and it's at a time when they feel safe and at ease.

▸ Third, counsel the family to facilitate a good relationship between the child and each parent over the long term. When families come to me and there is a lot of tension about visitation, custody, and money, I often focus them on the long-term goals. I ask, “What kind of relationship do you want with your child 10 and 15 years from now?”; “What is likely to result in a good long-term relationship with them?”; “Do you want to be able to be at their wedding?”; “Do you want to be close to your grandchildren?” Going all out for an extra few hours of visitation or not paying a bill is not likely to help achieve these long-term goals.

Again, early screening and intervention make your job easier. If a patient or family comes to you after years of negativity and a court fight over a bitter divorce, your ability to intervene effectively is already very limited.

Divorce is often an angry and divisive time. You can advise parents not to act out of anger by offering examples of divorcing parents who invested a lot of time and energy into winning short-term victories, only to see their efforts backfire later. Some parents believe that the child will be closer to them if they can make the child angry at the spouse. But children who feel they have to betray one parent to please the other often become resentful of this role over time.

In contrast, children who observe their parents working together with a sense of harmony and cooperation to make the custody, visitation, financial, and other arrangements successful are much less likely to blame themselves for the divorce. They also are much less likely to feel guilty when they connect more to one parent or the other at different points in their development.

It is important to monitor your patients for long-term effects of divorce up to and including the time you transition them to an adult care provider. Ask the older adolescent questions such as, “How do you feel about the divorce now, looking back on it [5, 10, or 15] years later?”; “How do you think it's affected you?”; and “Are there any things you'd like to change?”

If you do a review of how they integrated the divorce when they are in 10th or 11th grade, you will still have time to address any unresolved issues. If the child is distant with one parent, you can at least wonder if this is a point in time to reconnect and repair that relationship before the teenager goes to work or college and moves to being fully independent.

Pediatricians often have limited time to intervene. Some find this work very gratifying and feel comfortable with divorce-related issues. Others may choose to refer the patient to a social worker, psychologist, or child and adolescent psychiatrist, according to the severity of the situation. Some pediatric practices are fortunate to have a full- or part-time social worker.

If you want to counsel but your time is limited, consider offering a divorced-parent discussion and education group in your practice. You and/or a social worker could facilitate this forum. This resource can help parents share their experiences and strategies to ensure that children emerge as happy and healthy as possible after a divorce. In addition, this intervention can be cost-neutral if you charge parents a nominal fee.

Hospitalists should take care to remember the potentially violent offenders and situations that surround them daily at work, says a member of SHM's Practice Management Committee.

Michael Radzienda, MD, SFHM, vice president of hospital medicine and clinical effectiveness at Vanguard Health System in Southborough, Mass., says the recent shooting of a doctor at Johns Hopkins Hospital in Baltimore serves as a stark reminder that violence in the hospital is a concern for providers more than ever. To Dr. Radzienda's mind, that includes patients attacking doctors or patients attacking other patients.

"It's a newer issue for hospitalists, but one that they need to pay attention to," Dr. Radzienda says. "The volume of high-risk interactions that a hospitalist might have is significant compared to what that volume might have looked like 10 years ago before the hospitalist (model) took off."

And while one might think the incident at Johns Hopkins is enough to shine a lasting spotlight on the issue, a report from The Joint Commission this summer on hospital violence faded relatively quickly after its issuance. The commission's Sentinel Event Database, in fact, includes a category of assault, rape, and homicide (combined) with 256 reports since 1995, a number the organization suggests is under-reported. The commission's latest report, published in June, found that since 2004, hospitals have reported "significant increases in reports of assault, rape, and homicide, with the greater number of reports in the last three years."

The report recommends physicians learn techniques to identify potentially violent patients, implement violence de-escalation approaches, and even conduct violence audits to help determine an institution’s safety protocols.

Dr. Radzienda understands that training time and resources are stretched thin, but he says more focus on violence would be helpful to institutions and individual physicians. "The problem is someone needs to recognize this type of thing," he says. "But how do you prioritize that?"

Hospitalists should take care to remember the potentially violent offenders and situations that surround them daily at work, says a member of SHM's Practice Management Committee.

Michael Radzienda, MD, SFHM, vice president of hospital medicine and clinical effectiveness at Vanguard Health System in Southborough, Mass., says the recent shooting of a doctor at Johns Hopkins Hospital in Baltimore serves as a stark reminder that violence in the hospital is a concern for providers more than ever. To Dr. Radzienda's mind, that includes patients attacking doctors or patients attacking other patients.

"It's a newer issue for hospitalists, but one that they need to pay attention to," Dr. Radzienda says. "The volume of high-risk interactions that a hospitalist might have is significant compared to what that volume might have looked like 10 years ago before the hospitalist (model) took off."

And while one might think the incident at Johns Hopkins is enough to shine a lasting spotlight on the issue, a report from The Joint Commission this summer on hospital violence faded relatively quickly after its issuance. The commission's Sentinel Event Database, in fact, includes a category of assault, rape, and homicide (combined) with 256 reports since 1995, a number the organization suggests is under-reported. The commission's latest report, published in June, found that since 2004, hospitals have reported "significant increases in reports of assault, rape, and homicide, with the greater number of reports in the last three years."

The report recommends physicians learn techniques to identify potentially violent patients, implement violence de-escalation approaches, and even conduct violence audits to help determine an institution’s safety protocols.

Dr. Radzienda understands that training time and resources are stretched thin, but he says more focus on violence would be helpful to institutions and individual physicians. "The problem is someone needs to recognize this type of thing," he says. "But how do you prioritize that?"

Hospitalists should take care to remember the potentially violent offenders and situations that surround them daily at work, says a member of SHM's Practice Management Committee.

Michael Radzienda, MD, SFHM, vice president of hospital medicine and clinical effectiveness at Vanguard Health System in Southborough, Mass., says the recent shooting of a doctor at Johns Hopkins Hospital in Baltimore serves as a stark reminder that violence in the hospital is a concern for providers more than ever. To Dr. Radzienda's mind, that includes patients attacking doctors or patients attacking other patients.

"It's a newer issue for hospitalists, but one that they need to pay attention to," Dr. Radzienda says. "The volume of high-risk interactions that a hospitalist might have is significant compared to what that volume might have looked like 10 years ago before the hospitalist (model) took off."

And while one might think the incident at Johns Hopkins is enough to shine a lasting spotlight on the issue, a report from The Joint Commission this summer on hospital violence faded relatively quickly after its issuance. The commission's Sentinel Event Database, in fact, includes a category of assault, rape, and homicide (combined) with 256 reports since 1995, a number the organization suggests is under-reported. The commission's latest report, published in June, found that since 2004, hospitals have reported "significant increases in reports of assault, rape, and homicide, with the greater number of reports in the last three years."

The report recommends physicians learn techniques to identify potentially violent patients, implement violence de-escalation approaches, and even conduct violence audits to help determine an institution’s safety protocols.

Dr. Radzienda understands that training time and resources are stretched thin, but he says more focus on violence would be helpful to institutions and individual physicians. "The problem is someone needs to recognize this type of thing," he says. "But how do you prioritize that?"

There is going to be a healthcare crisis in Haiti in the next few years if things don’t markedly improve, says Jocelyn David, MD, chief hospitalist at the Miami VA Healthcare System in Miami, who has traveled to the island nation four times since the Jan. 12 earthquake.

Dr. David returned on Aug. 15 from a four-day trip she took with the Haitian Resource Development Foundation to assess the needs of smaller hospitals outside the capital of Port-au-Prince.

"People are traveling from the capital to these hospitals because the hospitals in the city are overwhelmed and struggling due to a lack of funds," Dr. David says.

Some city hospitals, such as CDTI du Sacre Coeur Hospital, one of the country’s more modern medical facilities, have outright closed, she says.

“I was surprised that I didn’t see any improvement,” says Mario A. Reyes, MD, FAAP, FHM, director of Pediatric Hospital Medicine at Miami Children’s Hospital, who volunteered in Haiti in January and went back in August to visit the Children’s Hospital of the Hopital de l’Universite d’Etat d’Haiti (HUEH), the largest academic public pediatric hospital in the capital.

The Children's Hospital is uninhabitable; medical staff are treating patients in makeshift wood houses provided by the United Nations, he says. Children sleep in hospital beds without mattresses, and oxygen tanks are shared by four or five children. There are no ultrasounds, and ventilators, IV lines, and antibiotics are in short supply, he says.

"There is a frustration among Haitian physicians that things aren't being done as quickly as they should," Dr. Reyes says. "The needs are immense."

Dr. David plans another trip to Haiti in October to train healthcare providers in BLS, ALS, and intubations in order to expand the limited emergency care. Meanwhile, Dr. Reyes and a group of physicians who work at Miami Children's Hospital are organizing professional and academic trips to HUEH so physicians can lend their expertise.

"That's what the Haitian providers want," he says. "They want us to teach and work with them."

The first trip is planned for December, and the group hopes the American Academy of Pediatrics will endorse their effort, which likely will include donating medical equipment and developing a telemedicine program.

Pediatric hospitalists who are interested in joining one of the trips to the Children’s Hospital of the Hopital de l’Universite d’Etat d’Haiti can contact Dr. Reyes at 305-668-5500 or at [email protected].

There is going to be a healthcare crisis in Haiti in the next few years if things don’t markedly improve, says Jocelyn David, MD, chief hospitalist at the Miami VA Healthcare System in Miami, who has traveled to the island nation four times since the Jan. 12 earthquake.

Dr. David returned on Aug. 15 from a four-day trip she took with the Haitian Resource Development Foundation to assess the needs of smaller hospitals outside the capital of Port-au-Prince.

"People are traveling from the capital to these hospitals because the hospitals in the city are overwhelmed and struggling due to a lack of funds," Dr. David says.

Some city hospitals, such as CDTI du Sacre Coeur Hospital, one of the country’s more modern medical facilities, have outright closed, she says.

“I was surprised that I didn’t see any improvement,” says Mario A. Reyes, MD, FAAP, FHM, director of Pediatric Hospital Medicine at Miami Children’s Hospital, who volunteered in Haiti in January and went back in August to visit the Children’s Hospital of the Hopital de l’Universite d’Etat d’Haiti (HUEH), the largest academic public pediatric hospital in the capital.

The Children's Hospital is uninhabitable; medical staff are treating patients in makeshift wood houses provided by the United Nations, he says. Children sleep in hospital beds without mattresses, and oxygen tanks are shared by four or five children. There are no ultrasounds, and ventilators, IV lines, and antibiotics are in short supply, he says.

"There is a frustration among Haitian physicians that things aren't being done as quickly as they should," Dr. Reyes says. "The needs are immense."

Dr. David plans another trip to Haiti in October to train healthcare providers in BLS, ALS, and intubations in order to expand the limited emergency care. Meanwhile, Dr. Reyes and a group of physicians who work at Miami Children's Hospital are organizing professional and academic trips to HUEH so physicians can lend their expertise.

"That's what the Haitian providers want," he says. "They want us to teach and work with them."

The first trip is planned for December, and the group hopes the American Academy of Pediatrics will endorse their effort, which likely will include donating medical equipment and developing a telemedicine program.

Pediatric hospitalists who are interested in joining one of the trips to the Children’s Hospital of the Hopital de l’Universite d’Etat d’Haiti can contact Dr. Reyes at 305-668-5500 or at [email protected].

There is going to be a healthcare crisis in Haiti in the next few years if things don’t markedly improve, says Jocelyn David, MD, chief hospitalist at the Miami VA Healthcare System in Miami, who has traveled to the island nation four times since the Jan. 12 earthquake.

Dr. David returned on Aug. 15 from a four-day trip she took with the Haitian Resource Development Foundation to assess the needs of smaller hospitals outside the capital of Port-au-Prince.

"People are traveling from the capital to these hospitals because the hospitals in the city are overwhelmed and struggling due to a lack of funds," Dr. David says.

Some city hospitals, such as CDTI du Sacre Coeur Hospital, one of the country’s more modern medical facilities, have outright closed, she says.

“I was surprised that I didn’t see any improvement,” says Mario A. Reyes, MD, FAAP, FHM, director of Pediatric Hospital Medicine at Miami Children’s Hospital, who volunteered in Haiti in January and went back in August to visit the Children’s Hospital of the Hopital de l’Universite d’Etat d’Haiti (HUEH), the largest academic public pediatric hospital in the capital.

The Children's Hospital is uninhabitable; medical staff are treating patients in makeshift wood houses provided by the United Nations, he says. Children sleep in hospital beds without mattresses, and oxygen tanks are shared by four or five children. There are no ultrasounds, and ventilators, IV lines, and antibiotics are in short supply, he says.

"There is a frustration among Haitian physicians that things aren't being done as quickly as they should," Dr. Reyes says. "The needs are immense."

Dr. David plans another trip to Haiti in October to train healthcare providers in BLS, ALS, and intubations in order to expand the limited emergency care. Meanwhile, Dr. Reyes and a group of physicians who work at Miami Children's Hospital are organizing professional and academic trips to HUEH so physicians can lend their expertise.

"That's what the Haitian providers want," he says. "They want us to teach and work with them."

The first trip is planned for December, and the group hopes the American Academy of Pediatrics will endorse their effort, which likely will include donating medical equipment and developing a telemedicine program.

Pediatric hospitalists who are interested in joining one of the trips to the Children’s Hospital of the Hopital de l’Universite d’Etat d’Haiti can contact Dr. Reyes at 305-668-5500 or at [email protected].

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The advisory panel for the US Food and Drug Administration (FDA) voted unanimously on September 20 to recommend approval of dabigatran, an anticoagulant under investigation for the reduction of stroke risk and non-CNS systemic embolism in patients with atrial fibrillation.

The advisory board only voted that dabigatran works at least as well as warfarin. But unlike warfarin, dabigatran does not require laboratory monitoring. Therefore, dabigatran is less difficult to use than the current standard of care.

The decision was based on the randomized, noninferiority RE-LY (Randomized Evaluation of Long-Term Anticoagulation Therapy) trial of 18,000 patients. The trial compared unblinded warfarin administration with blinded doses of dabigatran at 110 mg and 150 mg.

The hazard ratio of dabigatran compared with warfarin was 0.66 (P<0.003) in the 150 mg dabigatran arm and 0.91 (P<0.0001) in the 110 mg dabigatran arm.

Bleeding risk remains the top safety concern. Receiving 150 mg of dabigatran seems to run the same risk as warfarin for bleeding complications, but in 110 mg doses of dabigatran, the risk was less than warfarin.

Conflict arose among committee members regarding whether or not to approve both doses. Some members disagreed, seeing that the 110 mg dose was only noninferior to warfarin, not superior. Other members believed that approving both doses would ensure wider use of the drug leading to the prevention of a greater number of strokes in atrial fibrillation patients.

There is one unexplained finding of the RE-LY study. Myocardial infarction rates were higher on dabigatran compared with warfarin. For every 1000 patients treated with dabigatran, there may be 2 more myocardial infarctions than in patients treated with warfarin.

The FDA often follows the advice of the panel of experts, although it is not required to.

The advisory panel for the US Food and Drug Administration (FDA) voted unanimously on September 20 to recommend approval of dabigatran, an anticoagulant under investigation for the reduction of stroke risk and non-CNS systemic embolism in patients with atrial fibrillation.

The advisory board only voted that dabigatran works at least as well as warfarin. But unlike warfarin, dabigatran does not require laboratory monitoring. Therefore, dabigatran is less difficult to use than the current standard of care.

The decision was based on the randomized, noninferiority RE-LY (Randomized Evaluation of Long-Term Anticoagulation Therapy) trial of 18,000 patients. The trial compared unblinded warfarin administration with blinded doses of dabigatran at 110 mg and 150 mg.

The hazard ratio of dabigatran compared with warfarin was 0.66 (P<0.003) in the 150 mg dabigatran arm and 0.91 (P<0.0001) in the 110 mg dabigatran arm.

Bleeding risk remains the top safety concern. Receiving 150 mg of dabigatran seems to run the same risk as warfarin for bleeding complications, but in 110 mg doses of dabigatran, the risk was less than warfarin.

Conflict arose among committee members regarding whether or not to approve both doses. Some members disagreed, seeing that the 110 mg dose was only noninferior to warfarin, not superior. Other members believed that approving both doses would ensure wider use of the drug leading to the prevention of a greater number of strokes in atrial fibrillation patients.

There is one unexplained finding of the RE-LY study. Myocardial infarction rates were higher on dabigatran compared with warfarin. For every 1000 patients treated with dabigatran, there may be 2 more myocardial infarctions than in patients treated with warfarin.

The FDA often follows the advice of the panel of experts, although it is not required to.

The advisory panel for the US Food and Drug Administration (FDA) voted unanimously on September 20 to recommend approval of dabigatran, an anticoagulant under investigation for the reduction of stroke risk and non-CNS systemic embolism in patients with atrial fibrillation.

The advisory board only voted that dabigatran works at least as well as warfarin. But unlike warfarin, dabigatran does not require laboratory monitoring. Therefore, dabigatran is less difficult to use than the current standard of care.

The decision was based on the randomized, noninferiority RE-LY (Randomized Evaluation of Long-Term Anticoagulation Therapy) trial of 18,000 patients. The trial compared unblinded warfarin administration with blinded doses of dabigatran at 110 mg and 150 mg.

The hazard ratio of dabigatran compared with warfarin was 0.66 (P<0.003) in the 150 mg dabigatran arm and 0.91 (P<0.0001) in the 110 mg dabigatran arm.

Bleeding risk remains the top safety concern. Receiving 150 mg of dabigatran seems to run the same risk as warfarin for bleeding complications, but in 110 mg doses of dabigatran, the risk was less than warfarin.

Conflict arose among committee members regarding whether or not to approve both doses. Some members disagreed, seeing that the 110 mg dose was only noninferior to warfarin, not superior. Other members believed that approving both doses would ensure wider use of the drug leading to the prevention of a greater number of strokes in atrial fibrillation patients.

There is one unexplained finding of the RE-LY study. Myocardial infarction rates were higher on dabigatran compared with warfarin. For every 1000 patients treated with dabigatran, there may be 2 more myocardial infarctions than in patients treated with warfarin.

The FDA often follows the advice of the panel of experts, although it is not required to.

Hospitalists might be able to help reduce their institutions' readmission rate by adding in targeted screenings for depressive symptoms, according to the author of a study in this month’s Journal of Hospital Medicine.

The report found that patients surveyed with said symptoms had a higher rate of readmission at 30 days after discharge (0.563 vs. 0.296) (DOI: 10.1002/jhm.673). Similar data were found at both 60 and 90 days after discharge.

Suzanne Mitchell, MD, MS, an instructor at Boston University School of Medicine/Boston Medical Center and one of the authors of the study, thinks the work should be a first step toward creating transitional-care programs that target depressive symptoms. “If we just screen and have nothing to offer, we’re not really helping patients out,” Dr. Mitchell says. “It’s an important piece to have some kind of program available to help bridge the transition process.”

Dr. Mitchell says that as more research associates depression with readmission rates, HM leaders will begin to see the value in creating programs to better communicate with patients about it. Ideas include follow-up phone calls with a PCP to discuss mental-health support options.

She adds that while hospitalists taking patient histories might glean information about depressive symptoms, HM groups can consider more targeted questions to determine a patient’s risk.

“Being able to open that conversation and having it on your radar is very important,” Dr. Mitchell says. “I find that if I don’t open the conversation, it doesn’t happen. But once I do, the patient is open to disclosing.”

Hospitalists might be able to help reduce their institutions' readmission rate by adding in targeted screenings for depressive symptoms, according to the author of a study in this month’s Journal of Hospital Medicine.

The report found that patients surveyed with said symptoms had a higher rate of readmission at 30 days after discharge (0.563 vs. 0.296) (DOI: 10.1002/jhm.673). Similar data were found at both 60 and 90 days after discharge.

Suzanne Mitchell, MD, MS, an instructor at Boston University School of Medicine/Boston Medical Center and one of the authors of the study, thinks the work should be a first step toward creating transitional-care programs that target depressive symptoms. “If we just screen and have nothing to offer, we’re not really helping patients out,” Dr. Mitchell says. “It’s an important piece to have some kind of program available to help bridge the transition process.”

Dr. Mitchell says that as more research associates depression with readmission rates, HM leaders will begin to see the value in creating programs to better communicate with patients about it. Ideas include follow-up phone calls with a PCP to discuss mental-health support options.

She adds that while hospitalists taking patient histories might glean information about depressive symptoms, HM groups can consider more targeted questions to determine a patient’s risk.

“Being able to open that conversation and having it on your radar is very important,” Dr. Mitchell says. “I find that if I don’t open the conversation, it doesn’t happen. But once I do, the patient is open to disclosing.”

Hospitalists might be able to help reduce their institutions' readmission rate by adding in targeted screenings for depressive symptoms, according to the author of a study in this month’s Journal of Hospital Medicine.

The report found that patients surveyed with said symptoms had a higher rate of readmission at 30 days after discharge (0.563 vs. 0.296) (DOI: 10.1002/jhm.673). Similar data were found at both 60 and 90 days after discharge.

Suzanne Mitchell, MD, MS, an instructor at Boston University School of Medicine/Boston Medical Center and one of the authors of the study, thinks the work should be a first step toward creating transitional-care programs that target depressive symptoms. “If we just screen and have nothing to offer, we’re not really helping patients out,” Dr. Mitchell says. “It’s an important piece to have some kind of program available to help bridge the transition process.”

Dr. Mitchell says that as more research associates depression with readmission rates, HM leaders will begin to see the value in creating programs to better communicate with patients about it. Ideas include follow-up phone calls with a PCP to discuss mental-health support options.

She adds that while hospitalists taking patient histories might glean information about depressive symptoms, HM groups can consider more targeted questions to determine a patient’s risk.

“Being able to open that conversation and having it on your radar is very important,” Dr. Mitchell says. “I find that if I don’t open the conversation, it doesn’t happen. But once I do, the patient is open to disclosing.”