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Steroid use in adolescents
Anabolic androgenic steroid (AAS) use in athletes is not a new topic. In fact, many teens can relate a story involving a famous athlete and use of a performance-enhancing drug and the consequences associated with it. Although published data do not support a significant increase in use of performance-enhancing drugs among adolescents,1 more recent studies show that anabolic steroids are being found in nonprescription supplements, and their use among adolescents may be substantially underestimated.
Supplements are not regulated by the Food and Drug Administration, so many of these products are easily found on the Internet and sold in local stores.2,3 Some of these are marketed for increasing muscle mass, strength, and performance, which is appealing to the young athlete. Much of the marketing of these products minimize the side effects associated with their use and, therefore, most users are unaware of their harmful effects.
Approximately 5%-11% of teen athletes use AAS to improve physique and performance.3 Given its promotion for improved physique, many nonathletes also are turning to AAS for weight loss in both males and females. Side effects of steroid use are extrapolated from the data of therapeutic use, but most adolescents using steroids are not using under medical supervision. The dosing for building muscle mass uses a pyramid type dosing over a 6- to 12-week period and can be up to forty times the therapeutic dosing; therefore, the side effects can be greater than reported.4,5 Common side effects of AAS are hypogonadism, gynecomastia, decreased sperm count and infertility, acne, and aggressiveness. Liver tumors and psychosis have been reported, and increased depressed mood have been identified with discontinuation of use.4,6 Studies suggest that these side effects are reversible with discontinuation, but more studies are needed.4,6
Given that many of the side effects are not identifiable on physical exam, pediatricians must be proactive in questioning adolescents about their knowledge and use of AAS. Testing for steroid use is difficult and not very sensitive. Urine test for carbon isotopes 13/12 is the most common test, but if not done within hours of ingestion it will not be detected. T/E test (testosterone/epitestosterone glucuronide) is another test, but also limited by the timing of the test.6 Home screening also is available but the American Academy of Pediatrics 2014 guidelines warns against parents using these given the high false positive rate and risk of confrontation.7
Home and school screening may function more to deter athletes from using steroids to avoid consequences of being caught more than actually identifying use. If an athlete is suspected of using steroids, a test should be done. If negative, it should be repeated another time, as repeated testing is more likely to identify use. Studies have shown a correlation between steroid use and use of other illicit drugs so further screening should be done to identify if other drugs are being used.8
Widespread screening has not been shown to be cost effective and, therefore, should not be encouraged. Educating the patient on the risk of use and potential side effects along with healthy alternatives that improve performance and physique is much more effective.9 Being observant to signs and symptoms of AAS use helps to initiate conversation on the risk of using anabolic steroids.
References
1. Arch Pediatr Adolesc Med. 1997 Dec;151(12):1197-206.
2. Subst Use Misuse. 2012 Feb; 47(3):329-41.
3. Am J Clin Nutr. 2000 Feb;71(2):399-400.
4. J Sports Sci Med. 2006 Jun 1;5(2):182-93.
5. Br J Sports Med. 2006 Jul; 40(Suppl 1): i21-24.
6. J Athl Train. 1994 Mar; 29(1):60-4.
7. Pediatrics. 2014;133:e1798-1807.
8. Pediatrics. 1995 Jul;96(1 Pt 1):23-8.
9. Pediatrics. 1997 Jun;99(6):904-8.
Dr. Pearce is a pediatrician in Frankfort, Ill. She said she had no relevant financial disclosures. Email her at [email protected].
Anabolic androgenic steroid (AAS) use in athletes is not a new topic. In fact, many teens can relate a story involving a famous athlete and use of a performance-enhancing drug and the consequences associated with it. Although published data do not support a significant increase in use of performance-enhancing drugs among adolescents,1 more recent studies show that anabolic steroids are being found in nonprescription supplements, and their use among adolescents may be substantially underestimated.
Supplements are not regulated by the Food and Drug Administration, so many of these products are easily found on the Internet and sold in local stores.2,3 Some of these are marketed for increasing muscle mass, strength, and performance, which is appealing to the young athlete. Much of the marketing of these products minimize the side effects associated with their use and, therefore, most users are unaware of their harmful effects.
Approximately 5%-11% of teen athletes use AAS to improve physique and performance.3 Given its promotion for improved physique, many nonathletes also are turning to AAS for weight loss in both males and females. Side effects of steroid use are extrapolated from the data of therapeutic use, but most adolescents using steroids are not using under medical supervision. The dosing for building muscle mass uses a pyramid type dosing over a 6- to 12-week period and can be up to forty times the therapeutic dosing; therefore, the side effects can be greater than reported.4,5 Common side effects of AAS are hypogonadism, gynecomastia, decreased sperm count and infertility, acne, and aggressiveness. Liver tumors and psychosis have been reported, and increased depressed mood have been identified with discontinuation of use.4,6 Studies suggest that these side effects are reversible with discontinuation, but more studies are needed.4,6
Given that many of the side effects are not identifiable on physical exam, pediatricians must be proactive in questioning adolescents about their knowledge and use of AAS. Testing for steroid use is difficult and not very sensitive. Urine test for carbon isotopes 13/12 is the most common test, but if not done within hours of ingestion it will not be detected. T/E test (testosterone/epitestosterone glucuronide) is another test, but also limited by the timing of the test.6 Home screening also is available but the American Academy of Pediatrics 2014 guidelines warns against parents using these given the high false positive rate and risk of confrontation.7
Home and school screening may function more to deter athletes from using steroids to avoid consequences of being caught more than actually identifying use. If an athlete is suspected of using steroids, a test should be done. If negative, it should be repeated another time, as repeated testing is more likely to identify use. Studies have shown a correlation between steroid use and use of other illicit drugs so further screening should be done to identify if other drugs are being used.8
Widespread screening has not been shown to be cost effective and, therefore, should not be encouraged. Educating the patient on the risk of use and potential side effects along with healthy alternatives that improve performance and physique is much more effective.9 Being observant to signs and symptoms of AAS use helps to initiate conversation on the risk of using anabolic steroids.
References
1. Arch Pediatr Adolesc Med. 1997 Dec;151(12):1197-206.
2. Subst Use Misuse. 2012 Feb; 47(3):329-41.
3. Am J Clin Nutr. 2000 Feb;71(2):399-400.
4. J Sports Sci Med. 2006 Jun 1;5(2):182-93.
5. Br J Sports Med. 2006 Jul; 40(Suppl 1): i21-24.
6. J Athl Train. 1994 Mar; 29(1):60-4.
7. Pediatrics. 2014;133:e1798-1807.
8. Pediatrics. 1995 Jul;96(1 Pt 1):23-8.
9. Pediatrics. 1997 Jun;99(6):904-8.
Dr. Pearce is a pediatrician in Frankfort, Ill. She said she had no relevant financial disclosures. Email her at [email protected].
Anabolic androgenic steroid (AAS) use in athletes is not a new topic. In fact, many teens can relate a story involving a famous athlete and use of a performance-enhancing drug and the consequences associated with it. Although published data do not support a significant increase in use of performance-enhancing drugs among adolescents,1 more recent studies show that anabolic steroids are being found in nonprescription supplements, and their use among adolescents may be substantially underestimated.
Supplements are not regulated by the Food and Drug Administration, so many of these products are easily found on the Internet and sold in local stores.2,3 Some of these are marketed for increasing muscle mass, strength, and performance, which is appealing to the young athlete. Much of the marketing of these products minimize the side effects associated with their use and, therefore, most users are unaware of their harmful effects.
Approximately 5%-11% of teen athletes use AAS to improve physique and performance.3 Given its promotion for improved physique, many nonathletes also are turning to AAS for weight loss in both males and females. Side effects of steroid use are extrapolated from the data of therapeutic use, but most adolescents using steroids are not using under medical supervision. The dosing for building muscle mass uses a pyramid type dosing over a 6- to 12-week period and can be up to forty times the therapeutic dosing; therefore, the side effects can be greater than reported.4,5 Common side effects of AAS are hypogonadism, gynecomastia, decreased sperm count and infertility, acne, and aggressiveness. Liver tumors and psychosis have been reported, and increased depressed mood have been identified with discontinuation of use.4,6 Studies suggest that these side effects are reversible with discontinuation, but more studies are needed.4,6
Given that many of the side effects are not identifiable on physical exam, pediatricians must be proactive in questioning adolescents about their knowledge and use of AAS. Testing for steroid use is difficult and not very sensitive. Urine test for carbon isotopes 13/12 is the most common test, but if not done within hours of ingestion it will not be detected. T/E test (testosterone/epitestosterone glucuronide) is another test, but also limited by the timing of the test.6 Home screening also is available but the American Academy of Pediatrics 2014 guidelines warns against parents using these given the high false positive rate and risk of confrontation.7
Home and school screening may function more to deter athletes from using steroids to avoid consequences of being caught more than actually identifying use. If an athlete is suspected of using steroids, a test should be done. If negative, it should be repeated another time, as repeated testing is more likely to identify use. Studies have shown a correlation between steroid use and use of other illicit drugs so further screening should be done to identify if other drugs are being used.8
Widespread screening has not been shown to be cost effective and, therefore, should not be encouraged. Educating the patient on the risk of use and potential side effects along with healthy alternatives that improve performance and physique is much more effective.9 Being observant to signs and symptoms of AAS use helps to initiate conversation on the risk of using anabolic steroids.
References
1. Arch Pediatr Adolesc Med. 1997 Dec;151(12):1197-206.
2. Subst Use Misuse. 2012 Feb; 47(3):329-41.
3. Am J Clin Nutr. 2000 Feb;71(2):399-400.
4. J Sports Sci Med. 2006 Jun 1;5(2):182-93.
5. Br J Sports Med. 2006 Jul; 40(Suppl 1): i21-24.
6. J Athl Train. 1994 Mar; 29(1):60-4.
7. Pediatrics. 2014;133:e1798-1807.
8. Pediatrics. 1995 Jul;96(1 Pt 1):23-8.
9. Pediatrics. 1997 Jun;99(6):904-8.
Dr. Pearce is a pediatrician in Frankfort, Ill. She said she had no relevant financial disclosures. Email her at [email protected].
Eating disorders in transgender youth
The field of transgender health is growing. What began as a lone German physician in 1918 defying the norms of treating gender identity as a disease now has burgeoned into a field that includes 1,079 PubMed articles,two medical guidelines1,2, and a multitude of books. As we learn more about the complexity of gender and gender identity, we also are discovering potential problems that occur when providing care to our transgender patients. One is eating disorders.
A systematic review by Jones et al. showed only a handful of studies on eating disorders in transgender individuals, most of them restricted to case studies.3 In some situations, the issue of gender identity arises during treatment for an eating disorder, as the individual realizes that body dissatisfaction is due to the gender identity instead of a fear of gaining weight. In other cases, a transgender person in the process of transitioning to the affirmed gender develops an eating disorder.
There are two larger quantitative studies on eating disorders among transgender individuals. One study of 289,024 college students reveals that transgender students, compared to cisgender students, are almost five times as likely to report an eating disorder and two times as likely to use unhealthy compensatory methods (e.g., vomiting) for weight control.4 Another study of almost 2,500 teenagers shows that transgender individuals are almost three times as likely to restrict their eating, almost nine times as likely to take diet pills, and seven times as likely to take laxatives.5
The most commonly suggested reason for the possible elevated risk for eating disorders among transgender individuals is that many of them are trying to achieve the unrealistic standards of the ideal masculine or feminine body type. Another explanation is that eating disorders among transgender individuals are maladaptive coping mechanisms to stress from antitrans stigma and discrimination.4 However, these explanations are not mutually exclusive and could simultaneously drive disordered eating among transgender individuals.
To further appreciate the relationship between these two conditions, one must understand their similarities and differences. The Diagnostic Statistical Manual of Mental Disorders V characterizes eating disorders as “a persistent disturbance of eating or eating-related behavior that results in the altered consumption or absorption of food and ... significantly impairs physical health or psychosocial functioning.”6 Anorexia nervosa and bulimia nervosa are driven by fear of gaining weight or by a self-esteem unduly influenced by weight or appearance.6
Gender dysphoria, in comparison, is the distress caused by the incongruence between one’s gender identity and one’s anatomy, along with the desire to have the characteristics of one’s affirmed gender identity. This condition also could severely alter physical and psychosocial functioning,7 partly because of the distress from the incongruence, and partly because of the stress from antitrans stigma and discrimination, as an individual attempts to match the body with the gender identity8 (e.g., wearing clothing to match the gender identity).
The higher risk of developing an eating disorder among transgender individuals makes sense. Dissatisfaction with one’s body characterizes both conditions. The high standards on what is masculine or feminine affects everyone, especially transgender individuals who may feel that they’re “far behind” when they begin to transition to their affirmed gender. In addition, both involve identity. Those who have anorexia nervosa also incorporate this into their own identity.9 This is why treating an eating disorder can be very difficult.
Finally, individuals afflicted by an eating disorder or gender dysphoria engage in certain behaviors to achieve their desired appearance. However, this is where the similarities end. One major distinction between an eating disorder and gender dysphoria is the treatment approach. The goal in treating an eating disorder is to discourage the disordered behavior and encourage healthier eating habits and a more positive body image. Affirming the identity of someone with an eating disorder can be deadly, as it will encourage more disordered eating.10 In contrast, affirming the identity of someone with gender dysphoria through social transition, cross-sex hormones, and/or surgical reassignment is life-saving and therapeutic.11
There is little guidance on how to treat the these disorders simultaneously. What complicates treating both conditions at the same time is that when an eating disorder is accompanied by another mental health disorder (e.g., substance use), one condition over the other is prioritized.12 There is no guidance on whether the eating disorder or gender dysphoria should take priority over the other, or if it is possible to treat both conditions at the same time.
Strandjord et al. suggest a hierarchal approach, in which life-threatening issues (such as suicide or electrolyte disturbances) take priority.13 In addition, if the patient is malnourished, weight restoration should be the initial focus. A patient who is severely malnourished may not have the cognitive capacity nor the physiological ability to manage comorbidities such as anxiety or depression,12 much less have the capacity to process something as complex as gender and gender identity, nor understand the steps necessary for a successful transition to the affirmed gender. However, this does not mean providers should wait to successfully manage an eating disorder before addressing gender dysphoria. Studies have suggested that gender-affirming medical therapies (e.g., cross sex hormones) can be therapeutic for both gender dysphoria and eating disorder symptoms.14 Finally, because of the two ways a transgender patient with an eating disorder can present, I recommend screening for eating disorders in transgender individuals and inquiring about gender identity among those with an eating disorder. Doing so may save a life.
References
1. J Clin Endocrinol Metab. 2009 Sep;94(9):3132-54.
2. Adv Urol. 2012;2012:581712.
3. Int Rev Psychiatry. 2016;28(1):81-94.
4. J Adolesc Health. 2015 Aug;57(2):144-9.
5. J Adolesc Health. 2016. doi: 10.1016/j.jadohealth.2016.08.027.
6. Feeding and Eating Disorders. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. (Washington: American Psychiatric Association, 2013).
7. Gender Dysphoria. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. (Washington: American Psychiatric Association, 2013).
8. Psychol Bull. 2003 Sep;129(5):674-97.
9. Int J Law Psychiatry. 2003 Sep-Oct;26(5):533-48.
10. Arch Gen Psychiatry. 2011 Jul;68(7):724-31.
11. Clin Endocrinol (Oxf). 2010 Feb;72(2):214-31.
12. CNS drugs. 2006;20(8):655-63.
13. Int J Eat Disord. 2015 Nov;48(7):942-5.
14. Eat Disord. 2012;20(4):300-11.
The field of transgender health is growing. What began as a lone German physician in 1918 defying the norms of treating gender identity as a disease now has burgeoned into a field that includes 1,079 PubMed articles,two medical guidelines1,2, and a multitude of books. As we learn more about the complexity of gender and gender identity, we also are discovering potential problems that occur when providing care to our transgender patients. One is eating disorders.
A systematic review by Jones et al. showed only a handful of studies on eating disorders in transgender individuals, most of them restricted to case studies.3 In some situations, the issue of gender identity arises during treatment for an eating disorder, as the individual realizes that body dissatisfaction is due to the gender identity instead of a fear of gaining weight. In other cases, a transgender person in the process of transitioning to the affirmed gender develops an eating disorder.
There are two larger quantitative studies on eating disorders among transgender individuals. One study of 289,024 college students reveals that transgender students, compared to cisgender students, are almost five times as likely to report an eating disorder and two times as likely to use unhealthy compensatory methods (e.g., vomiting) for weight control.4 Another study of almost 2,500 teenagers shows that transgender individuals are almost three times as likely to restrict their eating, almost nine times as likely to take diet pills, and seven times as likely to take laxatives.5
The most commonly suggested reason for the possible elevated risk for eating disorders among transgender individuals is that many of them are trying to achieve the unrealistic standards of the ideal masculine or feminine body type. Another explanation is that eating disorders among transgender individuals are maladaptive coping mechanisms to stress from antitrans stigma and discrimination.4 However, these explanations are not mutually exclusive and could simultaneously drive disordered eating among transgender individuals.
To further appreciate the relationship between these two conditions, one must understand their similarities and differences. The Diagnostic Statistical Manual of Mental Disorders V characterizes eating disorders as “a persistent disturbance of eating or eating-related behavior that results in the altered consumption or absorption of food and ... significantly impairs physical health or psychosocial functioning.”6 Anorexia nervosa and bulimia nervosa are driven by fear of gaining weight or by a self-esteem unduly influenced by weight or appearance.6
Gender dysphoria, in comparison, is the distress caused by the incongruence between one’s gender identity and one’s anatomy, along with the desire to have the characteristics of one’s affirmed gender identity. This condition also could severely alter physical and psychosocial functioning,7 partly because of the distress from the incongruence, and partly because of the stress from antitrans stigma and discrimination, as an individual attempts to match the body with the gender identity8 (e.g., wearing clothing to match the gender identity).
The higher risk of developing an eating disorder among transgender individuals makes sense. Dissatisfaction with one’s body characterizes both conditions. The high standards on what is masculine or feminine affects everyone, especially transgender individuals who may feel that they’re “far behind” when they begin to transition to their affirmed gender. In addition, both involve identity. Those who have anorexia nervosa also incorporate this into their own identity.9 This is why treating an eating disorder can be very difficult.
Finally, individuals afflicted by an eating disorder or gender dysphoria engage in certain behaviors to achieve their desired appearance. However, this is where the similarities end. One major distinction between an eating disorder and gender dysphoria is the treatment approach. The goal in treating an eating disorder is to discourage the disordered behavior and encourage healthier eating habits and a more positive body image. Affirming the identity of someone with an eating disorder can be deadly, as it will encourage more disordered eating.10 In contrast, affirming the identity of someone with gender dysphoria through social transition, cross-sex hormones, and/or surgical reassignment is life-saving and therapeutic.11
There is little guidance on how to treat the these disorders simultaneously. What complicates treating both conditions at the same time is that when an eating disorder is accompanied by another mental health disorder (e.g., substance use), one condition over the other is prioritized.12 There is no guidance on whether the eating disorder or gender dysphoria should take priority over the other, or if it is possible to treat both conditions at the same time.
Strandjord et al. suggest a hierarchal approach, in which life-threatening issues (such as suicide or electrolyte disturbances) take priority.13 In addition, if the patient is malnourished, weight restoration should be the initial focus. A patient who is severely malnourished may not have the cognitive capacity nor the physiological ability to manage comorbidities such as anxiety or depression,12 much less have the capacity to process something as complex as gender and gender identity, nor understand the steps necessary for a successful transition to the affirmed gender. However, this does not mean providers should wait to successfully manage an eating disorder before addressing gender dysphoria. Studies have suggested that gender-affirming medical therapies (e.g., cross sex hormones) can be therapeutic for both gender dysphoria and eating disorder symptoms.14 Finally, because of the two ways a transgender patient with an eating disorder can present, I recommend screening for eating disorders in transgender individuals and inquiring about gender identity among those with an eating disorder. Doing so may save a life.
References
1. J Clin Endocrinol Metab. 2009 Sep;94(9):3132-54.
2. Adv Urol. 2012;2012:581712.
3. Int Rev Psychiatry. 2016;28(1):81-94.
4. J Adolesc Health. 2015 Aug;57(2):144-9.
5. J Adolesc Health. 2016. doi: 10.1016/j.jadohealth.2016.08.027.
6. Feeding and Eating Disorders. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. (Washington: American Psychiatric Association, 2013).
7. Gender Dysphoria. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. (Washington: American Psychiatric Association, 2013).
8. Psychol Bull. 2003 Sep;129(5):674-97.
9. Int J Law Psychiatry. 2003 Sep-Oct;26(5):533-48.
10. Arch Gen Psychiatry. 2011 Jul;68(7):724-31.
11. Clin Endocrinol (Oxf). 2010 Feb;72(2):214-31.
12. CNS drugs. 2006;20(8):655-63.
13. Int J Eat Disord. 2015 Nov;48(7):942-5.
14. Eat Disord. 2012;20(4):300-11.
The field of transgender health is growing. What began as a lone German physician in 1918 defying the norms of treating gender identity as a disease now has burgeoned into a field that includes 1,079 PubMed articles,two medical guidelines1,2, and a multitude of books. As we learn more about the complexity of gender and gender identity, we also are discovering potential problems that occur when providing care to our transgender patients. One is eating disorders.
A systematic review by Jones et al. showed only a handful of studies on eating disorders in transgender individuals, most of them restricted to case studies.3 In some situations, the issue of gender identity arises during treatment for an eating disorder, as the individual realizes that body dissatisfaction is due to the gender identity instead of a fear of gaining weight. In other cases, a transgender person in the process of transitioning to the affirmed gender develops an eating disorder.
There are two larger quantitative studies on eating disorders among transgender individuals. One study of 289,024 college students reveals that transgender students, compared to cisgender students, are almost five times as likely to report an eating disorder and two times as likely to use unhealthy compensatory methods (e.g., vomiting) for weight control.4 Another study of almost 2,500 teenagers shows that transgender individuals are almost three times as likely to restrict their eating, almost nine times as likely to take diet pills, and seven times as likely to take laxatives.5
The most commonly suggested reason for the possible elevated risk for eating disorders among transgender individuals is that many of them are trying to achieve the unrealistic standards of the ideal masculine or feminine body type. Another explanation is that eating disorders among transgender individuals are maladaptive coping mechanisms to stress from antitrans stigma and discrimination.4 However, these explanations are not mutually exclusive and could simultaneously drive disordered eating among transgender individuals.
To further appreciate the relationship between these two conditions, one must understand their similarities and differences. The Diagnostic Statistical Manual of Mental Disorders V characterizes eating disorders as “a persistent disturbance of eating or eating-related behavior that results in the altered consumption or absorption of food and ... significantly impairs physical health or psychosocial functioning.”6 Anorexia nervosa and bulimia nervosa are driven by fear of gaining weight or by a self-esteem unduly influenced by weight or appearance.6
Gender dysphoria, in comparison, is the distress caused by the incongruence between one’s gender identity and one’s anatomy, along with the desire to have the characteristics of one’s affirmed gender identity. This condition also could severely alter physical and psychosocial functioning,7 partly because of the distress from the incongruence, and partly because of the stress from antitrans stigma and discrimination, as an individual attempts to match the body with the gender identity8 (e.g., wearing clothing to match the gender identity).
The higher risk of developing an eating disorder among transgender individuals makes sense. Dissatisfaction with one’s body characterizes both conditions. The high standards on what is masculine or feminine affects everyone, especially transgender individuals who may feel that they’re “far behind” when they begin to transition to their affirmed gender. In addition, both involve identity. Those who have anorexia nervosa also incorporate this into their own identity.9 This is why treating an eating disorder can be very difficult.
Finally, individuals afflicted by an eating disorder or gender dysphoria engage in certain behaviors to achieve their desired appearance. However, this is where the similarities end. One major distinction between an eating disorder and gender dysphoria is the treatment approach. The goal in treating an eating disorder is to discourage the disordered behavior and encourage healthier eating habits and a more positive body image. Affirming the identity of someone with an eating disorder can be deadly, as it will encourage more disordered eating.10 In contrast, affirming the identity of someone with gender dysphoria through social transition, cross-sex hormones, and/or surgical reassignment is life-saving and therapeutic.11
There is little guidance on how to treat the these disorders simultaneously. What complicates treating both conditions at the same time is that when an eating disorder is accompanied by another mental health disorder (e.g., substance use), one condition over the other is prioritized.12 There is no guidance on whether the eating disorder or gender dysphoria should take priority over the other, or if it is possible to treat both conditions at the same time.
Strandjord et al. suggest a hierarchal approach, in which life-threatening issues (such as suicide or electrolyte disturbances) take priority.13 In addition, if the patient is malnourished, weight restoration should be the initial focus. A patient who is severely malnourished may not have the cognitive capacity nor the physiological ability to manage comorbidities such as anxiety or depression,12 much less have the capacity to process something as complex as gender and gender identity, nor understand the steps necessary for a successful transition to the affirmed gender. However, this does not mean providers should wait to successfully manage an eating disorder before addressing gender dysphoria. Studies have suggested that gender-affirming medical therapies (e.g., cross sex hormones) can be therapeutic for both gender dysphoria and eating disorder symptoms.14 Finally, because of the two ways a transgender patient with an eating disorder can present, I recommend screening for eating disorders in transgender individuals and inquiring about gender identity among those with an eating disorder. Doing so may save a life.
References
1. J Clin Endocrinol Metab. 2009 Sep;94(9):3132-54.
2. Adv Urol. 2012;2012:581712.
3. Int Rev Psychiatry. 2016;28(1):81-94.
4. J Adolesc Health. 2015 Aug;57(2):144-9.
5. J Adolesc Health. 2016. doi: 10.1016/j.jadohealth.2016.08.027.
6. Feeding and Eating Disorders. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. (Washington: American Psychiatric Association, 2013).
7. Gender Dysphoria. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. (Washington: American Psychiatric Association, 2013).
8. Psychol Bull. 2003 Sep;129(5):674-97.
9. Int J Law Psychiatry. 2003 Sep-Oct;26(5):533-48.
10. Arch Gen Psychiatry. 2011 Jul;68(7):724-31.
11. Clin Endocrinol (Oxf). 2010 Feb;72(2):214-31.
12. CNS drugs. 2006;20(8):655-63.
13. Int J Eat Disord. 2015 Nov;48(7):942-5.
14. Eat Disord. 2012;20(4):300-11.
Not enough time? Time to rethink
Raising children is a lot like drinking out of a fire hose. Feeding, cleaning, dressing, transporting, teaching, entertaining, protecting, comforting, and managing one child is demanding, but is increased exponentially by multiple children, a spouse, and a job.
In our dataset of more than 74,900 parents of 0- to 3-year-olds completing a routine previsit questionnaire about the “best” and “hardest” parts of parenting their child, the most frequent spontaneous comment for the hardest part was “time-life balance.” The goal of asking these questions is to broaden the agenda for the pediatric visit to address stresses that are highly relevant to the child’s life in the family, and their current well-being and future outcome. The hardest part also rather succinctly captures the stress I hear every day from parents coming to me not only for health supervision, but especially for child behavior problems.
Setting limits on work to free up more time is not possible for everyone. Many people are grateful to have a job at all or need multiple jobs to make ends meet. They may not be in a position to negotiate for fewer tasks, hours, or roles. But others more fortunate may have fallen into a habit of taking on extra duties, taking work home, or simply not examining where they might set limits to preserve time for themselves and their family.
Working parents may need to prepare themselves for the onslaught when they get home. If the returning parent retreats into TV, the computer, or the bedroom, it makes the children feel angry and rejected. The parent who has been managing the household for the preceding hour(s) feels resentful, unappreciated, and often exhausted. I sometimes suggest that the returning parent pause 15 minutes to take a walk before picking children up at day care or go to the gym before coming home to be ready to engage, accept, and be present for whatever happens when they open the door.
Eliciting the “hardest part” can insert a pause for some much-needed problem-solving. Pointing out to parents the value to their child of working on their own time-life balance often gives them needed permission to make changes.
Balancing time for some parents may include setting some privacy for “alone time.” Individual desire to be alone varies, but trouble getting it is universal, especially with young children who don’t even respect a closed bathroom door! Given a young child’s need for contact about every 3-5 minutes, parents need to revise their expectations, wait until after bedtime, get some help, learn to do “token” relaxation, or all of these.
Parents often feel guilty for not attending more to their child, but then feel irritable about getting behind on other chores. It can be useful to cite the fact that mothers at home full time typically spend only 20 minutes of exclusive playtime with their child. I regularly prescribe 15 minutes of “special time” daily to break this irritability cycle for both the parent and child. Getting a babysitter does not mean that the parent has to leave the house and the undone laundry. I often suggest to resource-strapped families that they pay an 8-year-old neighbor to play with their kids for an hour several times per week. While not expecting to leave the child alone with such a “sitter,” one could relax in the tub, read a magazine, or make an uninterrupted phone call to a friend with such help.
The same parents feeling the pinch of too little time often are lacking in social support, a major buffer of stress. Sometimes, the solutions overlap. For example, trading play dates with another family by taking all their kids on a regular basis and vice versa requires no money exchange. Several kids playing together are often easier to care for than one’s own with their usual sibling struggles or boredom. And sharing of this kind can build lasting friendships and social support for the adults. Another often forgotten source of adult rest coupled with social support is religious services that offer “Sunday School.” The service has built-in cues to meditation, the kids make new friends protected by accepting teachers, and the social hour builds social support for the parents.
But we can’t really insert more hours in the day, right? Actually, one of the most valuable suggestions may be for parents to keep a diary of their activities for a few days. The average American in 2015 clocked 147 minutes watching TV, 103 minutes in front of a computer, 151 minutes on smart phones, and 43 minutes with a tablet. These time wasters may not only not feel satisfying or even relaxing, but even prompt anxiety or envy, and certainly take away from sleep, exercise, and intimacy. The American Academy of Pediatrics recently provided a Media Calculator and Family Media Plan intended to help families consider these choices for their child’s media life within all the other required activities of a day (including sleep), but adults could benefit from the same approach to making decisions about how they budget their time.
By mapping out actual time spent, parents can then reevaluate and choose differently. A useful question we might ask frazzled parents is “What fills your tank?” to help them come up with a list of activities that (used to be) regenerative to put on the new schedule. Most people blurt out “go on a cruise” (not practical) when “token” activities can suffice and be immediately possible. Coach them to be creative! Instead of a cruise, take a walk around the block; instead of going to a spa, request a back rub at bedtime; instead of a movie, watch a YouTube clip. When allowing oneself to be fully present to such “tokens,” they can have immense value. The practice of mindfulness (for which many training apps are available) can heighten awareness of each moment and expand the sense of time. Meditation and yoga training both are proven to provide benefits for relaxation and well-being that can be fit into anyone’s day.
While this column is intended to help with pediatric practice, I’ll bet you thought I was talking about you! With the pace of current health care practice and emphasis on “productivity,” many pediatricians are struggling with balancing time for themselves and their families as well. All the ideas just discussed also apply to you, but maybe, just maybe, you have the resources to insist on limits on work you haven’t seized. Cherishing the years when you have children in your life is for you, too, not just your patients. Remember, “The days are long, but the years are short.”
Dr. Howard is assistant professor of pediatrics at Johns Hopkins University, Baltimore, and creator of CHADIS. She had no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to Frontline Medical News. Email her at [email protected].
Raising children is a lot like drinking out of a fire hose. Feeding, cleaning, dressing, transporting, teaching, entertaining, protecting, comforting, and managing one child is demanding, but is increased exponentially by multiple children, a spouse, and a job.
In our dataset of more than 74,900 parents of 0- to 3-year-olds completing a routine previsit questionnaire about the “best” and “hardest” parts of parenting their child, the most frequent spontaneous comment for the hardest part was “time-life balance.” The goal of asking these questions is to broaden the agenda for the pediatric visit to address stresses that are highly relevant to the child’s life in the family, and their current well-being and future outcome. The hardest part also rather succinctly captures the stress I hear every day from parents coming to me not only for health supervision, but especially for child behavior problems.
Setting limits on work to free up more time is not possible for everyone. Many people are grateful to have a job at all or need multiple jobs to make ends meet. They may not be in a position to negotiate for fewer tasks, hours, or roles. But others more fortunate may have fallen into a habit of taking on extra duties, taking work home, or simply not examining where they might set limits to preserve time for themselves and their family.
Working parents may need to prepare themselves for the onslaught when they get home. If the returning parent retreats into TV, the computer, or the bedroom, it makes the children feel angry and rejected. The parent who has been managing the household for the preceding hour(s) feels resentful, unappreciated, and often exhausted. I sometimes suggest that the returning parent pause 15 minutes to take a walk before picking children up at day care or go to the gym before coming home to be ready to engage, accept, and be present for whatever happens when they open the door.
Eliciting the “hardest part” can insert a pause for some much-needed problem-solving. Pointing out to parents the value to their child of working on their own time-life balance often gives them needed permission to make changes.
Balancing time for some parents may include setting some privacy for “alone time.” Individual desire to be alone varies, but trouble getting it is universal, especially with young children who don’t even respect a closed bathroom door! Given a young child’s need for contact about every 3-5 minutes, parents need to revise their expectations, wait until after bedtime, get some help, learn to do “token” relaxation, or all of these.
Parents often feel guilty for not attending more to their child, but then feel irritable about getting behind on other chores. It can be useful to cite the fact that mothers at home full time typically spend only 20 minutes of exclusive playtime with their child. I regularly prescribe 15 minutes of “special time” daily to break this irritability cycle for both the parent and child. Getting a babysitter does not mean that the parent has to leave the house and the undone laundry. I often suggest to resource-strapped families that they pay an 8-year-old neighbor to play with their kids for an hour several times per week. While not expecting to leave the child alone with such a “sitter,” one could relax in the tub, read a magazine, or make an uninterrupted phone call to a friend with such help.
The same parents feeling the pinch of too little time often are lacking in social support, a major buffer of stress. Sometimes, the solutions overlap. For example, trading play dates with another family by taking all their kids on a regular basis and vice versa requires no money exchange. Several kids playing together are often easier to care for than one’s own with their usual sibling struggles or boredom. And sharing of this kind can build lasting friendships and social support for the adults. Another often forgotten source of adult rest coupled with social support is religious services that offer “Sunday School.” The service has built-in cues to meditation, the kids make new friends protected by accepting teachers, and the social hour builds social support for the parents.
But we can’t really insert more hours in the day, right? Actually, one of the most valuable suggestions may be for parents to keep a diary of their activities for a few days. The average American in 2015 clocked 147 minutes watching TV, 103 minutes in front of a computer, 151 minutes on smart phones, and 43 minutes with a tablet. These time wasters may not only not feel satisfying or even relaxing, but even prompt anxiety or envy, and certainly take away from sleep, exercise, and intimacy. The American Academy of Pediatrics recently provided a Media Calculator and Family Media Plan intended to help families consider these choices for their child’s media life within all the other required activities of a day (including sleep), but adults could benefit from the same approach to making decisions about how they budget their time.
By mapping out actual time spent, parents can then reevaluate and choose differently. A useful question we might ask frazzled parents is “What fills your tank?” to help them come up with a list of activities that (used to be) regenerative to put on the new schedule. Most people blurt out “go on a cruise” (not practical) when “token” activities can suffice and be immediately possible. Coach them to be creative! Instead of a cruise, take a walk around the block; instead of going to a spa, request a back rub at bedtime; instead of a movie, watch a YouTube clip. When allowing oneself to be fully present to such “tokens,” they can have immense value. The practice of mindfulness (for which many training apps are available) can heighten awareness of each moment and expand the sense of time. Meditation and yoga training both are proven to provide benefits for relaxation and well-being that can be fit into anyone’s day.
While this column is intended to help with pediatric practice, I’ll bet you thought I was talking about you! With the pace of current health care practice and emphasis on “productivity,” many pediatricians are struggling with balancing time for themselves and their families as well. All the ideas just discussed also apply to you, but maybe, just maybe, you have the resources to insist on limits on work you haven’t seized. Cherishing the years when you have children in your life is for you, too, not just your patients. Remember, “The days are long, but the years are short.”
Dr. Howard is assistant professor of pediatrics at Johns Hopkins University, Baltimore, and creator of CHADIS. She had no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to Frontline Medical News. Email her at [email protected].
Raising children is a lot like drinking out of a fire hose. Feeding, cleaning, dressing, transporting, teaching, entertaining, protecting, comforting, and managing one child is demanding, but is increased exponentially by multiple children, a spouse, and a job.
In our dataset of more than 74,900 parents of 0- to 3-year-olds completing a routine previsit questionnaire about the “best” and “hardest” parts of parenting their child, the most frequent spontaneous comment for the hardest part was “time-life balance.” The goal of asking these questions is to broaden the agenda for the pediatric visit to address stresses that are highly relevant to the child’s life in the family, and their current well-being and future outcome. The hardest part also rather succinctly captures the stress I hear every day from parents coming to me not only for health supervision, but especially for child behavior problems.
Setting limits on work to free up more time is not possible for everyone. Many people are grateful to have a job at all or need multiple jobs to make ends meet. They may not be in a position to negotiate for fewer tasks, hours, or roles. But others more fortunate may have fallen into a habit of taking on extra duties, taking work home, or simply not examining where they might set limits to preserve time for themselves and their family.
Working parents may need to prepare themselves for the onslaught when they get home. If the returning parent retreats into TV, the computer, or the bedroom, it makes the children feel angry and rejected. The parent who has been managing the household for the preceding hour(s) feels resentful, unappreciated, and often exhausted. I sometimes suggest that the returning parent pause 15 minutes to take a walk before picking children up at day care or go to the gym before coming home to be ready to engage, accept, and be present for whatever happens when they open the door.
Eliciting the “hardest part” can insert a pause for some much-needed problem-solving. Pointing out to parents the value to their child of working on their own time-life balance often gives them needed permission to make changes.
Balancing time for some parents may include setting some privacy for “alone time.” Individual desire to be alone varies, but trouble getting it is universal, especially with young children who don’t even respect a closed bathroom door! Given a young child’s need for contact about every 3-5 minutes, parents need to revise their expectations, wait until after bedtime, get some help, learn to do “token” relaxation, or all of these.
Parents often feel guilty for not attending more to their child, but then feel irritable about getting behind on other chores. It can be useful to cite the fact that mothers at home full time typically spend only 20 minutes of exclusive playtime with their child. I regularly prescribe 15 minutes of “special time” daily to break this irritability cycle for both the parent and child. Getting a babysitter does not mean that the parent has to leave the house and the undone laundry. I often suggest to resource-strapped families that they pay an 8-year-old neighbor to play with their kids for an hour several times per week. While not expecting to leave the child alone with such a “sitter,” one could relax in the tub, read a magazine, or make an uninterrupted phone call to a friend with such help.
The same parents feeling the pinch of too little time often are lacking in social support, a major buffer of stress. Sometimes, the solutions overlap. For example, trading play dates with another family by taking all their kids on a regular basis and vice versa requires no money exchange. Several kids playing together are often easier to care for than one’s own with their usual sibling struggles or boredom. And sharing of this kind can build lasting friendships and social support for the adults. Another often forgotten source of adult rest coupled with social support is religious services that offer “Sunday School.” The service has built-in cues to meditation, the kids make new friends protected by accepting teachers, and the social hour builds social support for the parents.
But we can’t really insert more hours in the day, right? Actually, one of the most valuable suggestions may be for parents to keep a diary of their activities for a few days. The average American in 2015 clocked 147 minutes watching TV, 103 minutes in front of a computer, 151 minutes on smart phones, and 43 minutes with a tablet. These time wasters may not only not feel satisfying or even relaxing, but even prompt anxiety or envy, and certainly take away from sleep, exercise, and intimacy. The American Academy of Pediatrics recently provided a Media Calculator and Family Media Plan intended to help families consider these choices for their child’s media life within all the other required activities of a day (including sleep), but adults could benefit from the same approach to making decisions about how they budget their time.
By mapping out actual time spent, parents can then reevaluate and choose differently. A useful question we might ask frazzled parents is “What fills your tank?” to help them come up with a list of activities that (used to be) regenerative to put on the new schedule. Most people blurt out “go on a cruise” (not practical) when “token” activities can suffice and be immediately possible. Coach them to be creative! Instead of a cruise, take a walk around the block; instead of going to a spa, request a back rub at bedtime; instead of a movie, watch a YouTube clip. When allowing oneself to be fully present to such “tokens,” they can have immense value. The practice of mindfulness (for which many training apps are available) can heighten awareness of each moment and expand the sense of time. Meditation and yoga training both are proven to provide benefits for relaxation and well-being that can be fit into anyone’s day.
While this column is intended to help with pediatric practice, I’ll bet you thought I was talking about you! With the pace of current health care practice and emphasis on “productivity,” many pediatricians are struggling with balancing time for themselves and their families as well. All the ideas just discussed also apply to you, but maybe, just maybe, you have the resources to insist on limits on work you haven’t seized. Cherishing the years when you have children in your life is for you, too, not just your patients. Remember, “The days are long, but the years are short.”
Dr. Howard is assistant professor of pediatrics at Johns Hopkins University, Baltimore, and creator of CHADIS. She had no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to Frontline Medical News. Email her at [email protected].
Breakfast and weight loss
Eating breakfast is sometimes promulgated as a component of an effective weight loss strategy. Correlational studies have suggested that breakfast consumption is associated with lower body weight. As the thinking goes, breakfast promotes morning satiety, thus suppressing caloric intake later in the day. Skipping breakfast, however, results in increased caloric intake later in the day.
But most people are breakfast eaters. Data exist suggesting that the adverse effects of skipping breakfast may occur only in habitual breakfast eaters. In other words, it may be harmful only if you suddenly change your habits.
So, what should we be telling our “breakfast-skippers” about breakfast and weight loss?
Gabrielle LeCheminant and her colleagues conducted a randomized trial of habitual breakfast skippers to evaluate the effects of eating breakfast versus not on energy, macronutrient consumption, and physical activity over 1 month (Appetite. 2017 May 1. doi: 10.1016/j.appet.2016.12.041).
Subjects were required to eat within 90 minutes of waking up and finish eating by 8:30 a.m. No eating or snack restrictions were imposed after breakfast. Subjects were 18-55 years of age, ate breakfast (at least 2 days/week), slept at least 6 hours per night, and woke up consistently before 8:00 am. Biometric and food diaries were completed.
Breakfast-skippers randomized to eat breakfast consumed more calories (266) per day and weighed more (0.7 kg) at 1 month. No changes were observed in caloric compensation with subsequent meals nor in self-reported hunger or satiety. No additional physical activity was observed with the addition of breakfast.
Weight gain was minimal, and the time frame of the study was short. Even so, I think the take-home message from this is: Don’t tell habitual breakfast skippers to start eating breakfast with the goal of losing weight. It appears that the opposite may be true.
Dr. Ebbert is a professor of medicine and general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. The opinions expressed are those of the author and do not necessarily represent the views and opinions of the Mayo Clinic. The opinions expressed in this article should not be used to diagnose or treat any medical condition, nor should they be used as a substitute for medical advice from a qualified, board-certified practicing clinician. Dr. Ebbert has no relevant financial disclosures about this article.
Eating breakfast is sometimes promulgated as a component of an effective weight loss strategy. Correlational studies have suggested that breakfast consumption is associated with lower body weight. As the thinking goes, breakfast promotes morning satiety, thus suppressing caloric intake later in the day. Skipping breakfast, however, results in increased caloric intake later in the day.
But most people are breakfast eaters. Data exist suggesting that the adverse effects of skipping breakfast may occur only in habitual breakfast eaters. In other words, it may be harmful only if you suddenly change your habits.
So, what should we be telling our “breakfast-skippers” about breakfast and weight loss?
Gabrielle LeCheminant and her colleagues conducted a randomized trial of habitual breakfast skippers to evaluate the effects of eating breakfast versus not on energy, macronutrient consumption, and physical activity over 1 month (Appetite. 2017 May 1. doi: 10.1016/j.appet.2016.12.041).
Subjects were required to eat within 90 minutes of waking up and finish eating by 8:30 a.m. No eating or snack restrictions were imposed after breakfast. Subjects were 18-55 years of age, ate breakfast (at least 2 days/week), slept at least 6 hours per night, and woke up consistently before 8:00 am. Biometric and food diaries were completed.
Breakfast-skippers randomized to eat breakfast consumed more calories (266) per day and weighed more (0.7 kg) at 1 month. No changes were observed in caloric compensation with subsequent meals nor in self-reported hunger or satiety. No additional physical activity was observed with the addition of breakfast.
Weight gain was minimal, and the time frame of the study was short. Even so, I think the take-home message from this is: Don’t tell habitual breakfast skippers to start eating breakfast with the goal of losing weight. It appears that the opposite may be true.
Dr. Ebbert is a professor of medicine and general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. The opinions expressed are those of the author and do not necessarily represent the views and opinions of the Mayo Clinic. The opinions expressed in this article should not be used to diagnose or treat any medical condition, nor should they be used as a substitute for medical advice from a qualified, board-certified practicing clinician. Dr. Ebbert has no relevant financial disclosures about this article.
Eating breakfast is sometimes promulgated as a component of an effective weight loss strategy. Correlational studies have suggested that breakfast consumption is associated with lower body weight. As the thinking goes, breakfast promotes morning satiety, thus suppressing caloric intake later in the day. Skipping breakfast, however, results in increased caloric intake later in the day.
But most people are breakfast eaters. Data exist suggesting that the adverse effects of skipping breakfast may occur only in habitual breakfast eaters. In other words, it may be harmful only if you suddenly change your habits.
So, what should we be telling our “breakfast-skippers” about breakfast and weight loss?
Gabrielle LeCheminant and her colleagues conducted a randomized trial of habitual breakfast skippers to evaluate the effects of eating breakfast versus not on energy, macronutrient consumption, and physical activity over 1 month (Appetite. 2017 May 1. doi: 10.1016/j.appet.2016.12.041).
Subjects were required to eat within 90 minutes of waking up and finish eating by 8:30 a.m. No eating or snack restrictions were imposed after breakfast. Subjects were 18-55 years of age, ate breakfast (at least 2 days/week), slept at least 6 hours per night, and woke up consistently before 8:00 am. Biometric and food diaries were completed.
Breakfast-skippers randomized to eat breakfast consumed more calories (266) per day and weighed more (0.7 kg) at 1 month. No changes were observed in caloric compensation with subsequent meals nor in self-reported hunger or satiety. No additional physical activity was observed with the addition of breakfast.
Weight gain was minimal, and the time frame of the study was short. Even so, I think the take-home message from this is: Don’t tell habitual breakfast skippers to start eating breakfast with the goal of losing weight. It appears that the opposite may be true.
Dr. Ebbert is a professor of medicine and general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. The opinions expressed are those of the author and do not necessarily represent the views and opinions of the Mayo Clinic. The opinions expressed in this article should not be used to diagnose or treat any medical condition, nor should they be used as a substitute for medical advice from a qualified, board-certified practicing clinician. Dr. Ebbert has no relevant financial disclosures about this article.
Doctors, drug reps, and free speech
Question: The First Amendment guarantees the right of free speech, but the U.S. Supreme Court has held that under a strict scrutiny standard, the government may regulate:
A. Obscenity.
B. Fighting words.
C. Professional speech.
D. A and B.
E. A, B, and C.
Answer: D. The First Amendment forbids the government from “abridging the freedom of speech,” which extends to certain nonverbal conduct, such as flag burning. At the same time, the U.S. Supreme Court has also ruled that certain categories of speech such as obscenity and fighting words can be regulated under a strict scrutiny standard. However, it remains unsettled whether and to what extent professional speech – such as in the context of the doctor-patient relationship – may be curtailed.
Two recent cases grapple with this issue of free speech – with rather unexpected results.
The first, overturning a decades-old prohibition of the off-label detailing of drugs, surprisingly was decided against the government. The second challenges a Florida statute censoring the discussion of firearms safety between a doctor and a patient. An early decision, under reconsideration, in fact supported the state’s regulation of physicians’ freedom of speech under the circumstances.
Because the FDA has no jurisdiction over physician conduct, it has no power to regulate the off-label use of an otherwise approved drug, which explains why such off-label prescriptions are widespread, especially in the oncology field.
In U.S. v. Caronia, the defendant, a pharmaceutical sales representative, was criminally prosecuted and found guilty of conspiracy in a New York court for introducing a misbranded drug into interstate commerce.1 Specifically, Alfred Caronia promoted the drug Xyrem for use in a manner not approved by the FDA.
Orphan Medical, now known as Jazz Pharmaceuticals, is the manufacturer of Xyrem, a powerful central nervous system depressant. Xyrem’s active ingredient is gamma-hydroxybutyrate, which has been federally classified as the “date rape drug” for its use in the commission of sexual assaults. The FDA had approved Xyrem for two conditions: to treat narcolepsy patients who experience cataplexy, a condition associated with weak or paralyzed muscles; and to treat those with excessive daytime sleepiness.
Caronia was found to provide off-label detailing of the drug to doctors for unapproved indications such as chronic fatigue, fibromyalgia, restless leg syndrome, and Parkinson’s disease.
Caronia argued that in promoting an FDA-approved drug, albeit for off-label use, he was within his right of free speech under the First Amendment. In overturning his conviction, a three-judge panel of the U.S. Second Circuit Court of Appeals agreed, noting the overly broad FDA regulations and specifically that nothing Caronia did constituted conspiracy to put a false or misleading or deficient label on a drug product.
The court concluded: “The government cannot prosecute pharmaceutical manufacturers and their representatives under the FDCA [Federal Food, Drug, and Cosmetic Act] for speech promoting the lawful, off-label use of an FDA-approved drug.”
In 2011, the U.S. Supreme Court had used a First Amendment argument to invalidate a Vermont law that prohibited the practice of pharmaceutical data mining – purchasing information about prescribers from pharmacies and others.2
Taken together, the FDA now appears resigned to the free speech argument.3 For example, it has decided not to appeal a judge’s ruling that the First Amendment protects Amarin from promoting its fish-oil capsules for unapproved uses. Just recently, the FDA published a draft proposal in tacit acceptance of this new policy position, merely recommending the disclosure of relevant information including limitations and unfavorable or inconsistent findings surrounding the off-label use of a drug.
The next issue concerns professional speech. It is well documented that the presence of a gun in the home increases the risk of death especially by suicide, and this serves as the impetus for the long-established recommendation that physicians discuss firearm safety with their patients.
The medical profession was therefore aghast when Florida enacted its law on “Privacy of Firearm Owners.”4 Codified on June 2, 2011, it provides that a licensed practitioner or facility may not record firearm ownership information in a patient’s medical record, and that unless information is relevant to the patient’s medical care or safety or safety of others, inquiries regarding firearm ownership or possession should not be made. A practitioner is also forbidden from unnecessarily harassing a patient about firearm ownership during an examination.
Violation can result in disciplinary action; the original intent was to make this a third-degree felony with penalties of up to $5 million in fines and 5 years of imprisonment, but the final bill was stripped of criminal penalties.
In July 2015, a panel of three judges of the U.S. 11th Circuit Court of Appeals, in a split 2-1 decision, found that the inquiry, record-keeping, and harassment provisions of the act specifically regulate professional speech, which is subject to an intermediate level of scrutiny. Under this level of scrutiny, the court found that the act was precisely tailored to directly advance the state’s substantial interests in protecting the public and patient privacy rights.
Holding that the act was not so overly broad as to violate the First Amendment, the court ruled that laws regulating speech that occurs in the course of the physician-patient relationship are constitutional if they directly advance a substantial state interest.5
Predictably, several medical societies, including the AMA, have filed briefs arguing that the law is unconstitutional and intrudes on the practice of medicine. Effective medical care is believed to require “unfettered communications” between physicians and their patients. Besides, the law is at odds with the AMA’s longstanding policy that encourages members to inquire into the presence of firearms in households and to promote the use of safety locks on guns in an effort to reduce injuries to children.
On June 21, 2016, the full 11th Circuit Court of Appeals (sitting “en banc”) heard arguments, and the profession eagerly awaits its final opinion.
Meanwhile, commentators have expressed concerns that such laws threaten the sanctity of the physician-patient relationship, which relies on truthful communication to freely counsel patients.
This infringement may be gathering force. Missouri and Montana already have similar gun privacy laws, while other states have required physicians to keep confidential any information regarding chemicals used in fracking, or mandate the provision of various birth-related information prior to a woman’s decision to have an abortion.6
References
1. U.S. v. Caronia, 703 F.3d 149 (2d Cir. 2012).
2. Sorrell v. IMS Health, 131 S. Ct. 2653 (2011).
3. N Engl J Med. 2013 Jan 10;368(2):103-5.
4. Fla. St. 381.026, 456.072, 790.338.
5. Wollschlaeger v. Governor of Florida, 797 F.3d 859 (11th Cir. 2015).
6. N Engl J Med. 2016 Jun 16;374(24):2304-7.
Dr. Tan is emeritus professor of medicine and former adjunct professor of law at the University of Hawaii, and currently directs the St. Francis International Center for Healthcare Ethics in Honolulu. This article is meant to be educational and does not constitute medical, ethical, or legal advice. Some of the articles in this series are adapted from the author’s 2006 book, “Medical Malpractice: Understanding the Law, Managing the Risk,” and his 2012 Halsbury treatise, “Medical Negligence and Professional Misconduct.” For additional information, readers may contact the author at [email protected].
Question: The First Amendment guarantees the right of free speech, but the U.S. Supreme Court has held that under a strict scrutiny standard, the government may regulate:
A. Obscenity.
B. Fighting words.
C. Professional speech.
D. A and B.
E. A, B, and C.
Answer: D. The First Amendment forbids the government from “abridging the freedom of speech,” which extends to certain nonverbal conduct, such as flag burning. At the same time, the U.S. Supreme Court has also ruled that certain categories of speech such as obscenity and fighting words can be regulated under a strict scrutiny standard. However, it remains unsettled whether and to what extent professional speech – such as in the context of the doctor-patient relationship – may be curtailed.
Two recent cases grapple with this issue of free speech – with rather unexpected results.
The first, overturning a decades-old prohibition of the off-label detailing of drugs, surprisingly was decided against the government. The second challenges a Florida statute censoring the discussion of firearms safety between a doctor and a patient. An early decision, under reconsideration, in fact supported the state’s regulation of physicians’ freedom of speech under the circumstances.
Because the FDA has no jurisdiction over physician conduct, it has no power to regulate the off-label use of an otherwise approved drug, which explains why such off-label prescriptions are widespread, especially in the oncology field.
In U.S. v. Caronia, the defendant, a pharmaceutical sales representative, was criminally prosecuted and found guilty of conspiracy in a New York court for introducing a misbranded drug into interstate commerce.1 Specifically, Alfred Caronia promoted the drug Xyrem for use in a manner not approved by the FDA.
Orphan Medical, now known as Jazz Pharmaceuticals, is the manufacturer of Xyrem, a powerful central nervous system depressant. Xyrem’s active ingredient is gamma-hydroxybutyrate, which has been federally classified as the “date rape drug” for its use in the commission of sexual assaults. The FDA had approved Xyrem for two conditions: to treat narcolepsy patients who experience cataplexy, a condition associated with weak or paralyzed muscles; and to treat those with excessive daytime sleepiness.
Caronia was found to provide off-label detailing of the drug to doctors for unapproved indications such as chronic fatigue, fibromyalgia, restless leg syndrome, and Parkinson’s disease.
Caronia argued that in promoting an FDA-approved drug, albeit for off-label use, he was within his right of free speech under the First Amendment. In overturning his conviction, a three-judge panel of the U.S. Second Circuit Court of Appeals agreed, noting the overly broad FDA regulations and specifically that nothing Caronia did constituted conspiracy to put a false or misleading or deficient label on a drug product.
The court concluded: “The government cannot prosecute pharmaceutical manufacturers and their representatives under the FDCA [Federal Food, Drug, and Cosmetic Act] for speech promoting the lawful, off-label use of an FDA-approved drug.”
In 2011, the U.S. Supreme Court had used a First Amendment argument to invalidate a Vermont law that prohibited the practice of pharmaceutical data mining – purchasing information about prescribers from pharmacies and others.2
Taken together, the FDA now appears resigned to the free speech argument.3 For example, it has decided not to appeal a judge’s ruling that the First Amendment protects Amarin from promoting its fish-oil capsules for unapproved uses. Just recently, the FDA published a draft proposal in tacit acceptance of this new policy position, merely recommending the disclosure of relevant information including limitations and unfavorable or inconsistent findings surrounding the off-label use of a drug.
The next issue concerns professional speech. It is well documented that the presence of a gun in the home increases the risk of death especially by suicide, and this serves as the impetus for the long-established recommendation that physicians discuss firearm safety with their patients.
The medical profession was therefore aghast when Florida enacted its law on “Privacy of Firearm Owners.”4 Codified on June 2, 2011, it provides that a licensed practitioner or facility may not record firearm ownership information in a patient’s medical record, and that unless information is relevant to the patient’s medical care or safety or safety of others, inquiries regarding firearm ownership or possession should not be made. A practitioner is also forbidden from unnecessarily harassing a patient about firearm ownership during an examination.
Violation can result in disciplinary action; the original intent was to make this a third-degree felony with penalties of up to $5 million in fines and 5 years of imprisonment, but the final bill was stripped of criminal penalties.
In July 2015, a panel of three judges of the U.S. 11th Circuit Court of Appeals, in a split 2-1 decision, found that the inquiry, record-keeping, and harassment provisions of the act specifically regulate professional speech, which is subject to an intermediate level of scrutiny. Under this level of scrutiny, the court found that the act was precisely tailored to directly advance the state’s substantial interests in protecting the public and patient privacy rights.
Holding that the act was not so overly broad as to violate the First Amendment, the court ruled that laws regulating speech that occurs in the course of the physician-patient relationship are constitutional if they directly advance a substantial state interest.5
Predictably, several medical societies, including the AMA, have filed briefs arguing that the law is unconstitutional and intrudes on the practice of medicine. Effective medical care is believed to require “unfettered communications” between physicians and their patients. Besides, the law is at odds with the AMA’s longstanding policy that encourages members to inquire into the presence of firearms in households and to promote the use of safety locks on guns in an effort to reduce injuries to children.
On June 21, 2016, the full 11th Circuit Court of Appeals (sitting “en banc”) heard arguments, and the profession eagerly awaits its final opinion.
Meanwhile, commentators have expressed concerns that such laws threaten the sanctity of the physician-patient relationship, which relies on truthful communication to freely counsel patients.
This infringement may be gathering force. Missouri and Montana already have similar gun privacy laws, while other states have required physicians to keep confidential any information regarding chemicals used in fracking, or mandate the provision of various birth-related information prior to a woman’s decision to have an abortion.6
References
1. U.S. v. Caronia, 703 F.3d 149 (2d Cir. 2012).
2. Sorrell v. IMS Health, 131 S. Ct. 2653 (2011).
3. N Engl J Med. 2013 Jan 10;368(2):103-5.
4. Fla. St. 381.026, 456.072, 790.338.
5. Wollschlaeger v. Governor of Florida, 797 F.3d 859 (11th Cir. 2015).
6. N Engl J Med. 2016 Jun 16;374(24):2304-7.
Dr. Tan is emeritus professor of medicine and former adjunct professor of law at the University of Hawaii, and currently directs the St. Francis International Center for Healthcare Ethics in Honolulu. This article is meant to be educational and does not constitute medical, ethical, or legal advice. Some of the articles in this series are adapted from the author’s 2006 book, “Medical Malpractice: Understanding the Law, Managing the Risk,” and his 2012 Halsbury treatise, “Medical Negligence and Professional Misconduct.” For additional information, readers may contact the author at [email protected].
Question: The First Amendment guarantees the right of free speech, but the U.S. Supreme Court has held that under a strict scrutiny standard, the government may regulate:
A. Obscenity.
B. Fighting words.
C. Professional speech.
D. A and B.
E. A, B, and C.
Answer: D. The First Amendment forbids the government from “abridging the freedom of speech,” which extends to certain nonverbal conduct, such as flag burning. At the same time, the U.S. Supreme Court has also ruled that certain categories of speech such as obscenity and fighting words can be regulated under a strict scrutiny standard. However, it remains unsettled whether and to what extent professional speech – such as in the context of the doctor-patient relationship – may be curtailed.
Two recent cases grapple with this issue of free speech – with rather unexpected results.
The first, overturning a decades-old prohibition of the off-label detailing of drugs, surprisingly was decided against the government. The second challenges a Florida statute censoring the discussion of firearms safety between a doctor and a patient. An early decision, under reconsideration, in fact supported the state’s regulation of physicians’ freedom of speech under the circumstances.
Because the FDA has no jurisdiction over physician conduct, it has no power to regulate the off-label use of an otherwise approved drug, which explains why such off-label prescriptions are widespread, especially in the oncology field.
In U.S. v. Caronia, the defendant, a pharmaceutical sales representative, was criminally prosecuted and found guilty of conspiracy in a New York court for introducing a misbranded drug into interstate commerce.1 Specifically, Alfred Caronia promoted the drug Xyrem for use in a manner not approved by the FDA.
Orphan Medical, now known as Jazz Pharmaceuticals, is the manufacturer of Xyrem, a powerful central nervous system depressant. Xyrem’s active ingredient is gamma-hydroxybutyrate, which has been federally classified as the “date rape drug” for its use in the commission of sexual assaults. The FDA had approved Xyrem for two conditions: to treat narcolepsy patients who experience cataplexy, a condition associated with weak or paralyzed muscles; and to treat those with excessive daytime sleepiness.
Caronia was found to provide off-label detailing of the drug to doctors for unapproved indications such as chronic fatigue, fibromyalgia, restless leg syndrome, and Parkinson’s disease.
Caronia argued that in promoting an FDA-approved drug, albeit for off-label use, he was within his right of free speech under the First Amendment. In overturning his conviction, a three-judge panel of the U.S. Second Circuit Court of Appeals agreed, noting the overly broad FDA regulations and specifically that nothing Caronia did constituted conspiracy to put a false or misleading or deficient label on a drug product.
The court concluded: “The government cannot prosecute pharmaceutical manufacturers and their representatives under the FDCA [Federal Food, Drug, and Cosmetic Act] for speech promoting the lawful, off-label use of an FDA-approved drug.”
In 2011, the U.S. Supreme Court had used a First Amendment argument to invalidate a Vermont law that prohibited the practice of pharmaceutical data mining – purchasing information about prescribers from pharmacies and others.2
Taken together, the FDA now appears resigned to the free speech argument.3 For example, it has decided not to appeal a judge’s ruling that the First Amendment protects Amarin from promoting its fish-oil capsules for unapproved uses. Just recently, the FDA published a draft proposal in tacit acceptance of this new policy position, merely recommending the disclosure of relevant information including limitations and unfavorable or inconsistent findings surrounding the off-label use of a drug.
The next issue concerns professional speech. It is well documented that the presence of a gun in the home increases the risk of death especially by suicide, and this serves as the impetus for the long-established recommendation that physicians discuss firearm safety with their patients.
The medical profession was therefore aghast when Florida enacted its law on “Privacy of Firearm Owners.”4 Codified on June 2, 2011, it provides that a licensed practitioner or facility may not record firearm ownership information in a patient’s medical record, and that unless information is relevant to the patient’s medical care or safety or safety of others, inquiries regarding firearm ownership or possession should not be made. A practitioner is also forbidden from unnecessarily harassing a patient about firearm ownership during an examination.
Violation can result in disciplinary action; the original intent was to make this a third-degree felony with penalties of up to $5 million in fines and 5 years of imprisonment, but the final bill was stripped of criminal penalties.
In July 2015, a panel of three judges of the U.S. 11th Circuit Court of Appeals, in a split 2-1 decision, found that the inquiry, record-keeping, and harassment provisions of the act specifically regulate professional speech, which is subject to an intermediate level of scrutiny. Under this level of scrutiny, the court found that the act was precisely tailored to directly advance the state’s substantial interests in protecting the public and patient privacy rights.
Holding that the act was not so overly broad as to violate the First Amendment, the court ruled that laws regulating speech that occurs in the course of the physician-patient relationship are constitutional if they directly advance a substantial state interest.5
Predictably, several medical societies, including the AMA, have filed briefs arguing that the law is unconstitutional and intrudes on the practice of medicine. Effective medical care is believed to require “unfettered communications” between physicians and their patients. Besides, the law is at odds with the AMA’s longstanding policy that encourages members to inquire into the presence of firearms in households and to promote the use of safety locks on guns in an effort to reduce injuries to children.
On June 21, 2016, the full 11th Circuit Court of Appeals (sitting “en banc”) heard arguments, and the profession eagerly awaits its final opinion.
Meanwhile, commentators have expressed concerns that such laws threaten the sanctity of the physician-patient relationship, which relies on truthful communication to freely counsel patients.
This infringement may be gathering force. Missouri and Montana already have similar gun privacy laws, while other states have required physicians to keep confidential any information regarding chemicals used in fracking, or mandate the provision of various birth-related information prior to a woman’s decision to have an abortion.6
References
1. U.S. v. Caronia, 703 F.3d 149 (2d Cir. 2012).
2. Sorrell v. IMS Health, 131 S. Ct. 2653 (2011).
3. N Engl J Med. 2013 Jan 10;368(2):103-5.
4. Fla. St. 381.026, 456.072, 790.338.
5. Wollschlaeger v. Governor of Florida, 797 F.3d 859 (11th Cir. 2015).
6. N Engl J Med. 2016 Jun 16;374(24):2304-7.
Dr. Tan is emeritus professor of medicine and former adjunct professor of law at the University of Hawaii, and currently directs the St. Francis International Center for Healthcare Ethics in Honolulu. This article is meant to be educational and does not constitute medical, ethical, or legal advice. Some of the articles in this series are adapted from the author’s 2006 book, “Medical Malpractice: Understanding the Law, Managing the Risk,” and his 2012 Halsbury treatise, “Medical Negligence and Professional Misconduct.” For additional information, readers may contact the author at [email protected].
Nurse Jackie and Patrick Kennedy
Nurse Jackie is an amazing woman: She’s a fantastically competent and compassionate ER nurse who will do anything for her patients, and she is far better than the caricature ER docs she works with who all care more about their designer shoes and designer egos then about their jobs. She’s a wife – at least in the early episodes – and mother to two adorable girls with a life that includes Mommy and Me tap dancing classes. She somehow juggles it all.
In her fictional life as the star of a Showtime series, “Jackie Peyton” – played by actress Edie Falco, formerly known for her role as Tony Soprano’s wife, Carmela – manages even more: She does it all while popping pain pills by the handful throughout the work day and snorting whatever there is to snort. The interesting thing about Jackie is that her drug habit never interferes with her ability to function. There are no episodes where she makes mistakes or falls asleep. She doesn’t get too wired and is rarely irritable, and she certainly doesn’t pass out from overdoses. She shows up at work on time and never falls off her tightrope of responsibilities in the busy All Saints Hospital ER of New York City.
Without the drugs, she gets ill, but with them, she just functions. And she doesn’t just hold her own with a busy life; she also juggles the secret life of what it takes to get her daily fix, including daily lunchtime sex with the hospital pharmacist, who provides her with pain medicines for her aching back and doesn’t initially know that she’s married with children.
By Season 6, her personal life has broken down, and her daughter Grace, now an angry teenager with her own difficulties and secret life, notes that mom Jackie is incredibly good at hiding her drug use, and that no one can tell when she’s using.
With each season, Jackie’s personal life unwinds a little more, but it’s not because of the effects constant pill-popping has on her behavior; it’s because of the difficulties she has obtaining the drugs. If she could go to the store and buy large amounts of oxycontin and whatever else she takes, she’d have no problem. Her cauldron, however, is filled with constant lies and deception and the secret lives she lives to obtain drugs and to avoid boiling in her own self-made addictive mess.
You wouldn’t expect a review of a dark comedy TV series together with a review of a very serious memoir written by former Rep. Patrick J. Kennedy, but somehow, the two fit together for me.
In “A Common Struggle,” Patrick Kennedy and author Stephen Fried march through Kennedy’s long history of mental illness and substance abuse. Kennedy talks about his life in psychotherapy starting in childhood, related to his parents’ separation. He talks about the treatment he received in college and during his time as a state legislator in Providence, R.I., and how he parked far from his psychiatrist’s office so no one would learn he was in treatment.
Unfortunately, while he found treatment to be very helpful, he stopped when his doctor, Peter Kramer, became a celebrity in his own right after the publication of “Listening to Prozac” (New York: Penguin Books, 1997), and Kennedy became “spooked.” He goes on to talk about the many treatments – including lists of medications – he received over the years and his diagnosis of bipolar disorder, type II. But he doesn’t document what symptoms or episodes led to this diagnosis, and I couldn’t help but wonder how much of his mood disorder was part and parcel of his substance abuse problem. I imagine his doctors may have had the same problem.
So while Kennedy is vague about his psychiatric illness, he is much more forthcoming with his substance abuse problem. Like Nurse Jackie, he has the constant flow of pills – prescribed opiates starting with the diagnosis of a spinal tumor, a handful of Adderall here, some benzodiazepines there, and an enormous issue with alcohol on top of all that. Unlike Nurse Jackie, Kennedy wears the results of his addictions openly. He sleeps through mornings, and his schedulers know to accommodate this. He says things he otherwise wouldn’t while intoxicated, and he embarrasses himself and has others on edge. His mentor in the House of Representatives was Dick Gephardt, and Gephardt’s chief of staff summoned Kennedy to ask him to become chairman of the Democratic Congressional Campaign Committee – a tremendous honor for a 31-year-old congressman.
“There was, however, one catch,” the authors wrote. “ ‘If you do this,’ he said, ‘you can’t drink.’ ” Kennedy notes that he didn’t have the insight to realize how odd this was, and in reflection calls it his first intervention.
While most of his difficulties remained relatively private, one night he mixed Ambien and Phenergan, and in a state of confusion, he went for a drive and crashed into a Capitol Hill concrete barrier – an event that led to media coverage, scandal, and, as his chief of staff put it, “ ‘Patrick,’ he said, ‘we have a problem.’ ” While his father, Sen. Ted Kennedy, dismissed this as “a little fendah bendah,” the son made a public statement and checked himself into a rehab unit at the Mayo Clinic. It was to be the second of many attempts at rehab, his first having been in high school.
What makes “A Common Struggle” (New York: Blue Rider Press, 2015) so special is not just that it is a strikingly candid memoir of addiction and illness in a successful congressman, nor that the congressman happens to be a Kennedy with all the glamour and tragedy that come with being born into that family. What makes it special is the way that Kennedy and Fried weave so much more into this riveting book. It’s the story of one man’s life, taken in the full context of a family bound by tragedies: the assassinations of two of his uncles before his birth, an aunt who’d had a lobotomy and inspired a whole advocacy organization for developmental disabilities, two siblings who struggled with cancer, and two parents with their own addictions and scandalous behaviors. His mother’s psychiatric illness was severe enough that her children obtained guardianship, and that’s just a smattering of all the Kennedy family events that are reported here.
The story unfolds against the backdrop of major news events in America, and combines itself with the complex story of parity legislation and the struggle to legitimize brain diseases as worthy of funding, awareness, and destigmatization. And if that’s not enough for one book to do, it all takes place within Patrick Kennedy’s poignant and powerful desire to gain his father’s approval. Ultimately, the son achieves an extended period of sobriety in the context of falling in love and starting a family, well into his 40s.
Nurse Jackie, despite her drug use and personal woes, is fictional and entertaining. “A Common Struggle” is a serious book and heartfelt look at how addiction and mental illness destroy lives; there is little doubt here that without the Kennedy machine for support and privilege, a 20-year-old compromised college student would not have been able to start or maintain a successful political career. Kudos to Mr. Kennedy for sharing his pain and for helping to break the stereotype that those with mental illness and substance abuse can only be found in jails or under bridges.
Dr. Miller is coauthor of “Committed: The Battle Over Involuntary Care,” which was released last fall (Baltimore: Johns Hopkins University Press).
Nurse Jackie is an amazing woman: She’s a fantastically competent and compassionate ER nurse who will do anything for her patients, and she is far better than the caricature ER docs she works with who all care more about their designer shoes and designer egos then about their jobs. She’s a wife – at least in the early episodes – and mother to two adorable girls with a life that includes Mommy and Me tap dancing classes. She somehow juggles it all.
In her fictional life as the star of a Showtime series, “Jackie Peyton” – played by actress Edie Falco, formerly known for her role as Tony Soprano’s wife, Carmela – manages even more: She does it all while popping pain pills by the handful throughout the work day and snorting whatever there is to snort. The interesting thing about Jackie is that her drug habit never interferes with her ability to function. There are no episodes where she makes mistakes or falls asleep. She doesn’t get too wired and is rarely irritable, and she certainly doesn’t pass out from overdoses. She shows up at work on time and never falls off her tightrope of responsibilities in the busy All Saints Hospital ER of New York City.
Without the drugs, she gets ill, but with them, she just functions. And she doesn’t just hold her own with a busy life; she also juggles the secret life of what it takes to get her daily fix, including daily lunchtime sex with the hospital pharmacist, who provides her with pain medicines for her aching back and doesn’t initially know that she’s married with children.
By Season 6, her personal life has broken down, and her daughter Grace, now an angry teenager with her own difficulties and secret life, notes that mom Jackie is incredibly good at hiding her drug use, and that no one can tell when she’s using.
With each season, Jackie’s personal life unwinds a little more, but it’s not because of the effects constant pill-popping has on her behavior; it’s because of the difficulties she has obtaining the drugs. If she could go to the store and buy large amounts of oxycontin and whatever else she takes, she’d have no problem. Her cauldron, however, is filled with constant lies and deception and the secret lives she lives to obtain drugs and to avoid boiling in her own self-made addictive mess.
You wouldn’t expect a review of a dark comedy TV series together with a review of a very serious memoir written by former Rep. Patrick J. Kennedy, but somehow, the two fit together for me.
In “A Common Struggle,” Patrick Kennedy and author Stephen Fried march through Kennedy’s long history of mental illness and substance abuse. Kennedy talks about his life in psychotherapy starting in childhood, related to his parents’ separation. He talks about the treatment he received in college and during his time as a state legislator in Providence, R.I., and how he parked far from his psychiatrist’s office so no one would learn he was in treatment.
Unfortunately, while he found treatment to be very helpful, he stopped when his doctor, Peter Kramer, became a celebrity in his own right after the publication of “Listening to Prozac” (New York: Penguin Books, 1997), and Kennedy became “spooked.” He goes on to talk about the many treatments – including lists of medications – he received over the years and his diagnosis of bipolar disorder, type II. But he doesn’t document what symptoms or episodes led to this diagnosis, and I couldn’t help but wonder how much of his mood disorder was part and parcel of his substance abuse problem. I imagine his doctors may have had the same problem.
So while Kennedy is vague about his psychiatric illness, he is much more forthcoming with his substance abuse problem. Like Nurse Jackie, he has the constant flow of pills – prescribed opiates starting with the diagnosis of a spinal tumor, a handful of Adderall here, some benzodiazepines there, and an enormous issue with alcohol on top of all that. Unlike Nurse Jackie, Kennedy wears the results of his addictions openly. He sleeps through mornings, and his schedulers know to accommodate this. He says things he otherwise wouldn’t while intoxicated, and he embarrasses himself and has others on edge. His mentor in the House of Representatives was Dick Gephardt, and Gephardt’s chief of staff summoned Kennedy to ask him to become chairman of the Democratic Congressional Campaign Committee – a tremendous honor for a 31-year-old congressman.
“There was, however, one catch,” the authors wrote. “ ‘If you do this,’ he said, ‘you can’t drink.’ ” Kennedy notes that he didn’t have the insight to realize how odd this was, and in reflection calls it his first intervention.
While most of his difficulties remained relatively private, one night he mixed Ambien and Phenergan, and in a state of confusion, he went for a drive and crashed into a Capitol Hill concrete barrier – an event that led to media coverage, scandal, and, as his chief of staff put it, “ ‘Patrick,’ he said, ‘we have a problem.’ ” While his father, Sen. Ted Kennedy, dismissed this as “a little fendah bendah,” the son made a public statement and checked himself into a rehab unit at the Mayo Clinic. It was to be the second of many attempts at rehab, his first having been in high school.
What makes “A Common Struggle” (New York: Blue Rider Press, 2015) so special is not just that it is a strikingly candid memoir of addiction and illness in a successful congressman, nor that the congressman happens to be a Kennedy with all the glamour and tragedy that come with being born into that family. What makes it special is the way that Kennedy and Fried weave so much more into this riveting book. It’s the story of one man’s life, taken in the full context of a family bound by tragedies: the assassinations of two of his uncles before his birth, an aunt who’d had a lobotomy and inspired a whole advocacy organization for developmental disabilities, two siblings who struggled with cancer, and two parents with their own addictions and scandalous behaviors. His mother’s psychiatric illness was severe enough that her children obtained guardianship, and that’s just a smattering of all the Kennedy family events that are reported here.
The story unfolds against the backdrop of major news events in America, and combines itself with the complex story of parity legislation and the struggle to legitimize brain diseases as worthy of funding, awareness, and destigmatization. And if that’s not enough for one book to do, it all takes place within Patrick Kennedy’s poignant and powerful desire to gain his father’s approval. Ultimately, the son achieves an extended period of sobriety in the context of falling in love and starting a family, well into his 40s.
Nurse Jackie, despite her drug use and personal woes, is fictional and entertaining. “A Common Struggle” is a serious book and heartfelt look at how addiction and mental illness destroy lives; there is little doubt here that without the Kennedy machine for support and privilege, a 20-year-old compromised college student would not have been able to start or maintain a successful political career. Kudos to Mr. Kennedy for sharing his pain and for helping to break the stereotype that those with mental illness and substance abuse can only be found in jails or under bridges.
Dr. Miller is coauthor of “Committed: The Battle Over Involuntary Care,” which was released last fall (Baltimore: Johns Hopkins University Press).
Nurse Jackie is an amazing woman: She’s a fantastically competent and compassionate ER nurse who will do anything for her patients, and she is far better than the caricature ER docs she works with who all care more about their designer shoes and designer egos then about their jobs. She’s a wife – at least in the early episodes – and mother to two adorable girls with a life that includes Mommy and Me tap dancing classes. She somehow juggles it all.
In her fictional life as the star of a Showtime series, “Jackie Peyton” – played by actress Edie Falco, formerly known for her role as Tony Soprano’s wife, Carmela – manages even more: She does it all while popping pain pills by the handful throughout the work day and snorting whatever there is to snort. The interesting thing about Jackie is that her drug habit never interferes with her ability to function. There are no episodes where she makes mistakes or falls asleep. She doesn’t get too wired and is rarely irritable, and she certainly doesn’t pass out from overdoses. She shows up at work on time and never falls off her tightrope of responsibilities in the busy All Saints Hospital ER of New York City.
Without the drugs, she gets ill, but with them, she just functions. And she doesn’t just hold her own with a busy life; she also juggles the secret life of what it takes to get her daily fix, including daily lunchtime sex with the hospital pharmacist, who provides her with pain medicines for her aching back and doesn’t initially know that she’s married with children.
By Season 6, her personal life has broken down, and her daughter Grace, now an angry teenager with her own difficulties and secret life, notes that mom Jackie is incredibly good at hiding her drug use, and that no one can tell when she’s using.
With each season, Jackie’s personal life unwinds a little more, but it’s not because of the effects constant pill-popping has on her behavior; it’s because of the difficulties she has obtaining the drugs. If she could go to the store and buy large amounts of oxycontin and whatever else she takes, she’d have no problem. Her cauldron, however, is filled with constant lies and deception and the secret lives she lives to obtain drugs and to avoid boiling in her own self-made addictive mess.
You wouldn’t expect a review of a dark comedy TV series together with a review of a very serious memoir written by former Rep. Patrick J. Kennedy, but somehow, the two fit together for me.
In “A Common Struggle,” Patrick Kennedy and author Stephen Fried march through Kennedy’s long history of mental illness and substance abuse. Kennedy talks about his life in psychotherapy starting in childhood, related to his parents’ separation. He talks about the treatment he received in college and during his time as a state legislator in Providence, R.I., and how he parked far from his psychiatrist’s office so no one would learn he was in treatment.
Unfortunately, while he found treatment to be very helpful, he stopped when his doctor, Peter Kramer, became a celebrity in his own right after the publication of “Listening to Prozac” (New York: Penguin Books, 1997), and Kennedy became “spooked.” He goes on to talk about the many treatments – including lists of medications – he received over the years and his diagnosis of bipolar disorder, type II. But he doesn’t document what symptoms or episodes led to this diagnosis, and I couldn’t help but wonder how much of his mood disorder was part and parcel of his substance abuse problem. I imagine his doctors may have had the same problem.
So while Kennedy is vague about his psychiatric illness, he is much more forthcoming with his substance abuse problem. Like Nurse Jackie, he has the constant flow of pills – prescribed opiates starting with the diagnosis of a spinal tumor, a handful of Adderall here, some benzodiazepines there, and an enormous issue with alcohol on top of all that. Unlike Nurse Jackie, Kennedy wears the results of his addictions openly. He sleeps through mornings, and his schedulers know to accommodate this. He says things he otherwise wouldn’t while intoxicated, and he embarrasses himself and has others on edge. His mentor in the House of Representatives was Dick Gephardt, and Gephardt’s chief of staff summoned Kennedy to ask him to become chairman of the Democratic Congressional Campaign Committee – a tremendous honor for a 31-year-old congressman.
“There was, however, one catch,” the authors wrote. “ ‘If you do this,’ he said, ‘you can’t drink.’ ” Kennedy notes that he didn’t have the insight to realize how odd this was, and in reflection calls it his first intervention.
While most of his difficulties remained relatively private, one night he mixed Ambien and Phenergan, and in a state of confusion, he went for a drive and crashed into a Capitol Hill concrete barrier – an event that led to media coverage, scandal, and, as his chief of staff put it, “ ‘Patrick,’ he said, ‘we have a problem.’ ” While his father, Sen. Ted Kennedy, dismissed this as “a little fendah bendah,” the son made a public statement and checked himself into a rehab unit at the Mayo Clinic. It was to be the second of many attempts at rehab, his first having been in high school.
What makes “A Common Struggle” (New York: Blue Rider Press, 2015) so special is not just that it is a strikingly candid memoir of addiction and illness in a successful congressman, nor that the congressman happens to be a Kennedy with all the glamour and tragedy that come with being born into that family. What makes it special is the way that Kennedy and Fried weave so much more into this riveting book. It’s the story of one man’s life, taken in the full context of a family bound by tragedies: the assassinations of two of his uncles before his birth, an aunt who’d had a lobotomy and inspired a whole advocacy organization for developmental disabilities, two siblings who struggled with cancer, and two parents with their own addictions and scandalous behaviors. His mother’s psychiatric illness was severe enough that her children obtained guardianship, and that’s just a smattering of all the Kennedy family events that are reported here.
The story unfolds against the backdrop of major news events in America, and combines itself with the complex story of parity legislation and the struggle to legitimize brain diseases as worthy of funding, awareness, and destigmatization. And if that’s not enough for one book to do, it all takes place within Patrick Kennedy’s poignant and powerful desire to gain his father’s approval. Ultimately, the son achieves an extended period of sobriety in the context of falling in love and starting a family, well into his 40s.
Nurse Jackie, despite her drug use and personal woes, is fictional and entertaining. “A Common Struggle” is a serious book and heartfelt look at how addiction and mental illness destroy lives; there is little doubt here that without the Kennedy machine for support and privilege, a 20-year-old compromised college student would not have been able to start or maintain a successful political career. Kudos to Mr. Kennedy for sharing his pain and for helping to break the stereotype that those with mental illness and substance abuse can only be found in jails or under bridges.
Dr. Miller is coauthor of “Committed: The Battle Over Involuntary Care,” which was released last fall (Baltimore: Johns Hopkins University Press).
The last call
It’s 7:30 on a Tuesday evening, and you will be on call until 8 o’clock the next morning. You have already been in the office 9 hours. Usual start time is 8 a.m., but that extra hour at home is a perk you have earned by being on call tonight.
A quick glance at the schedule screen suggests that if nothing ugly crops up, you will finish seeing your last patient and be out the door and on your way home by 8:15 p.m. The phone has been quiet for the last half hour, but as you are making your quickstep transition between exam rooms, the nurse tells you that the receptionist has received a call from a very anxious mother who has just discovered that her 6-year-old has a fever of 103° F. The child didn’t eat any dinner and is now complaining that he has a sore throat. The mother is worried because the child had a couple of febrile seizures when he was a toddler, and she has heard of several cases of strep in his class at school.
On the other hand, you could ask the nurse to reassure the mother that a febrile seizure at age 6 is very unlikely and encourage the mother to call you if she continues to be concerned. The problem here hinges on the experience and skills of the nurse. Even if your office has a well-vetted portfolio of clinical algorithms, you may be relying on a nurse with whom you aren’t familiar. Or maybe your past experience makes you uncomfortable with this particular nurse. She or he may have missed some obvious red flags in the past or may be so unskillful at reassurance that it is very likely that you will be getting a 2 a.m. call from this worried parent.
Another option could be to suggest that after reassuring the mother, the nurse offer her a first of the morning appointment tomorrow. There are several problems with this strategy, and I have always discouraged our office staff from making these next morning appointments for sick children. The offer of the appointment seldom reassures the very anxious parents nor does it prevent the middle of the night calls. More importantly, our experience, and I suspect yours, is that half of those newly sick children with fevers will be better by the next morning or their parents ended up going to the emergency room. This will leave you with a wasted appointment slot that you would really like to have available when the phones heat up in the morning. A more efficient strategy is to promise parents that if the child is still sick in the morning, you can guarantee them a timely appointment.
Finally, there are two responses that worked best for me. The first is to have the nurse ask the parents how long it will take them to get to the office. Add 15 minutes to their estimate, and if you can accept that estimated time of arrival, have the nurse tell that family to hustle on in. Send the staff home unless they want the overtime, and see the patient yourself.
The second response is to get on the phone yourself and talk directly to the mother. You were probably going to end up speaking with her in the middle of the night anyway, so you might as well invest the time now in taking your own history. Even if your own version of reassurance fails to prevent a 2 a.m. call, at least you will have some frame of reference when you need to make one of those dangerous middle of the night clinical decisions. A quiet night may depend on how you manage that last call of the day.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics including “How to Say No to Your Toddler.” Email him at [email protected].
It’s 7:30 on a Tuesday evening, and you will be on call until 8 o’clock the next morning. You have already been in the office 9 hours. Usual start time is 8 a.m., but that extra hour at home is a perk you have earned by being on call tonight.
A quick glance at the schedule screen suggests that if nothing ugly crops up, you will finish seeing your last patient and be out the door and on your way home by 8:15 p.m. The phone has been quiet for the last half hour, but as you are making your quickstep transition between exam rooms, the nurse tells you that the receptionist has received a call from a very anxious mother who has just discovered that her 6-year-old has a fever of 103° F. The child didn’t eat any dinner and is now complaining that he has a sore throat. The mother is worried because the child had a couple of febrile seizures when he was a toddler, and she has heard of several cases of strep in his class at school.
On the other hand, you could ask the nurse to reassure the mother that a febrile seizure at age 6 is very unlikely and encourage the mother to call you if she continues to be concerned. The problem here hinges on the experience and skills of the nurse. Even if your office has a well-vetted portfolio of clinical algorithms, you may be relying on a nurse with whom you aren’t familiar. Or maybe your past experience makes you uncomfortable with this particular nurse. She or he may have missed some obvious red flags in the past or may be so unskillful at reassurance that it is very likely that you will be getting a 2 a.m. call from this worried parent.
Another option could be to suggest that after reassuring the mother, the nurse offer her a first of the morning appointment tomorrow. There are several problems with this strategy, and I have always discouraged our office staff from making these next morning appointments for sick children. The offer of the appointment seldom reassures the very anxious parents nor does it prevent the middle of the night calls. More importantly, our experience, and I suspect yours, is that half of those newly sick children with fevers will be better by the next morning or their parents ended up going to the emergency room. This will leave you with a wasted appointment slot that you would really like to have available when the phones heat up in the morning. A more efficient strategy is to promise parents that if the child is still sick in the morning, you can guarantee them a timely appointment.
Finally, there are two responses that worked best for me. The first is to have the nurse ask the parents how long it will take them to get to the office. Add 15 minutes to their estimate, and if you can accept that estimated time of arrival, have the nurse tell that family to hustle on in. Send the staff home unless they want the overtime, and see the patient yourself.
The second response is to get on the phone yourself and talk directly to the mother. You were probably going to end up speaking with her in the middle of the night anyway, so you might as well invest the time now in taking your own history. Even if your own version of reassurance fails to prevent a 2 a.m. call, at least you will have some frame of reference when you need to make one of those dangerous middle of the night clinical decisions. A quiet night may depend on how you manage that last call of the day.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics including “How to Say No to Your Toddler.” Email him at [email protected].
It’s 7:30 on a Tuesday evening, and you will be on call until 8 o’clock the next morning. You have already been in the office 9 hours. Usual start time is 8 a.m., but that extra hour at home is a perk you have earned by being on call tonight.
A quick glance at the schedule screen suggests that if nothing ugly crops up, you will finish seeing your last patient and be out the door and on your way home by 8:15 p.m. The phone has been quiet for the last half hour, but as you are making your quickstep transition between exam rooms, the nurse tells you that the receptionist has received a call from a very anxious mother who has just discovered that her 6-year-old has a fever of 103° F. The child didn’t eat any dinner and is now complaining that he has a sore throat. The mother is worried because the child had a couple of febrile seizures when he was a toddler, and she has heard of several cases of strep in his class at school.
On the other hand, you could ask the nurse to reassure the mother that a febrile seizure at age 6 is very unlikely and encourage the mother to call you if she continues to be concerned. The problem here hinges on the experience and skills of the nurse. Even if your office has a well-vetted portfolio of clinical algorithms, you may be relying on a nurse with whom you aren’t familiar. Or maybe your past experience makes you uncomfortable with this particular nurse. She or he may have missed some obvious red flags in the past or may be so unskillful at reassurance that it is very likely that you will be getting a 2 a.m. call from this worried parent.
Another option could be to suggest that after reassuring the mother, the nurse offer her a first of the morning appointment tomorrow. There are several problems with this strategy, and I have always discouraged our office staff from making these next morning appointments for sick children. The offer of the appointment seldom reassures the very anxious parents nor does it prevent the middle of the night calls. More importantly, our experience, and I suspect yours, is that half of those newly sick children with fevers will be better by the next morning or their parents ended up going to the emergency room. This will leave you with a wasted appointment slot that you would really like to have available when the phones heat up in the morning. A more efficient strategy is to promise parents that if the child is still sick in the morning, you can guarantee them a timely appointment.
Finally, there are two responses that worked best for me. The first is to have the nurse ask the parents how long it will take them to get to the office. Add 15 minutes to their estimate, and if you can accept that estimated time of arrival, have the nurse tell that family to hustle on in. Send the staff home unless they want the overtime, and see the patient yourself.
The second response is to get on the phone yourself and talk directly to the mother. You were probably going to end up speaking with her in the middle of the night anyway, so you might as well invest the time now in taking your own history. Even if your own version of reassurance fails to prevent a 2 a.m. call, at least you will have some frame of reference when you need to make one of those dangerous middle of the night clinical decisions. A quiet night may depend on how you manage that last call of the day.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics including “How to Say No to Your Toddler.” Email him at [email protected].
Dropping the A-bomb
Your first patient of the day is a 2½-year-old who has a runny nose and a cough. His mother has brought him in because his cough is more frequent and persistent than she is accustomed to hearing. He is happy and playful, and has a low-grade fever. You notice that he is slightly tachypneic, and you hear fine wheezes scattered throughout his lung fields. You also recall that at age 6 months, he was diagnosed with bronchiolitis but was never hospitalized.
Will you give him antibiotics and send him home with a nebulizer? Just the nebulizer? Just the antibiotics? Neither? We can debate those answers for hours, and you can plead for more information before you commit to an answer. But let’s skip over the question about what you are going to do and focus on what you are going to say. I want to know what diagnosis you are going to share with this mother.
Or are you going to try a pseudoscientific smoke screen and tell her that her that her son has “reactive airway disease”? You could soften it even further by reassuring her that his diagnosis is so common that it has an abbreviation: “We usually just call it RAD.”
You may not have trouble telling a parent that her child has asthma, but most clinicians struggle with dropping the A-bomb. Why? It may be that we don’t want the family to freak out. You could end up spending the rest of the morning coaxing them back off the ledge because you have diagnosed their child with a chronic illness that could kill him. This kind of exaggerated reaction is far less of a problem now than it was 30 or 40 years ago. Almost every parent knows at least one family with an asthmatic child who seems to be doing just fine. In my opinion, this apparent increase in prevalence of asthma is primarily the result of an improved awareness and a relabeling phenomenon.
Your own experience probably reflects the national statistics that less than a third of preschoolers with recurrent wheezing still have asthma by the time they finish kindergarten. And you may be hesitant to use the asthma diagnosis because you don’t want to be labeled as a clinician who cries wolf.
It may be that subconsciously you are afraid that by raising the asthma red flag you will be committing yourself to the time gobbling task of managing another patient with a chronic disease. You could gamble that he will only have one or two more episodes of wheezing, and you will be able to treat his illnesses simply as a short series of unconnected events.
Is there any harm in dancing around the asthma diagnosis? The authors of a Perspectives article in the January 2017 issue of Pediatrics argue persuasively that vague descriptive and nondiagnostic terms such as “reactive airways disease” are confusing and should be abandoned (“RAD: Reactive Airway Disease or Really Asthma Disease?” Pediatrics. 2017 Jan. doi: 10.1542/peds.2016-0625). They question why we would treat a condition with asthma medications and not call it asthma just because a child will probably out grow it later.
It’s more than just about sloppy language. Jose A. Castro-Rodriguez, MD, a physician who has pioneered one of the tools than can be used to predict persistent asthma in young children, observes that by failing to signal to parents that the child has a chronic condition, we run the risk that the child will be less adherent to the medication and management program we recommend. (“The Asthma Predictive Index,” Curr Opin Allergy Clin Immunol. 2011;11[3]:157-61).
If we are going to tighten up our language and drop the vague substitute terms like RAD, and if we are hesitant to drop the A-bomb because it sounds too much like a lifelong disease when the truth is that most young children will outgrow asthma, what should we tell all those parents of wheezing preschoolers? The authors of the article in Pediatrics have several suggestions. Their favorite and the one that appeals most to me is toddler asthma. As they observe, the term “toddler asthma” implies an endpoint and the need for reevaluation to determine if the child is one of the minority who has “real” asthma.
Although it’s almost always about the money. When it's not about the money, it's usually about the labels we use.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics including “How to Say No to Your Toddler.” Email him at [email protected].
Your first patient of the day is a 2½-year-old who has a runny nose and a cough. His mother has brought him in because his cough is more frequent and persistent than she is accustomed to hearing. He is happy and playful, and has a low-grade fever. You notice that he is slightly tachypneic, and you hear fine wheezes scattered throughout his lung fields. You also recall that at age 6 months, he was diagnosed with bronchiolitis but was never hospitalized.
Will you give him antibiotics and send him home with a nebulizer? Just the nebulizer? Just the antibiotics? Neither? We can debate those answers for hours, and you can plead for more information before you commit to an answer. But let’s skip over the question about what you are going to do and focus on what you are going to say. I want to know what diagnosis you are going to share with this mother.
Or are you going to try a pseudoscientific smoke screen and tell her that her that her son has “reactive airway disease”? You could soften it even further by reassuring her that his diagnosis is so common that it has an abbreviation: “We usually just call it RAD.”
You may not have trouble telling a parent that her child has asthma, but most clinicians struggle with dropping the A-bomb. Why? It may be that we don’t want the family to freak out. You could end up spending the rest of the morning coaxing them back off the ledge because you have diagnosed their child with a chronic illness that could kill him. This kind of exaggerated reaction is far less of a problem now than it was 30 or 40 years ago. Almost every parent knows at least one family with an asthmatic child who seems to be doing just fine. In my opinion, this apparent increase in prevalence of asthma is primarily the result of an improved awareness and a relabeling phenomenon.
Your own experience probably reflects the national statistics that less than a third of preschoolers with recurrent wheezing still have asthma by the time they finish kindergarten. And you may be hesitant to use the asthma diagnosis because you don’t want to be labeled as a clinician who cries wolf.
It may be that subconsciously you are afraid that by raising the asthma red flag you will be committing yourself to the time gobbling task of managing another patient with a chronic disease. You could gamble that he will only have one or two more episodes of wheezing, and you will be able to treat his illnesses simply as a short series of unconnected events.
Is there any harm in dancing around the asthma diagnosis? The authors of a Perspectives article in the January 2017 issue of Pediatrics argue persuasively that vague descriptive and nondiagnostic terms such as “reactive airways disease” are confusing and should be abandoned (“RAD: Reactive Airway Disease or Really Asthma Disease?” Pediatrics. 2017 Jan. doi: 10.1542/peds.2016-0625). They question why we would treat a condition with asthma medications and not call it asthma just because a child will probably out grow it later.
It’s more than just about sloppy language. Jose A. Castro-Rodriguez, MD, a physician who has pioneered one of the tools than can be used to predict persistent asthma in young children, observes that by failing to signal to parents that the child has a chronic condition, we run the risk that the child will be less adherent to the medication and management program we recommend. (“The Asthma Predictive Index,” Curr Opin Allergy Clin Immunol. 2011;11[3]:157-61).
If we are going to tighten up our language and drop the vague substitute terms like RAD, and if we are hesitant to drop the A-bomb because it sounds too much like a lifelong disease when the truth is that most young children will outgrow asthma, what should we tell all those parents of wheezing preschoolers? The authors of the article in Pediatrics have several suggestions. Their favorite and the one that appeals most to me is toddler asthma. As they observe, the term “toddler asthma” implies an endpoint and the need for reevaluation to determine if the child is one of the minority who has “real” asthma.
Although it’s almost always about the money. When it's not about the money, it's usually about the labels we use.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics including “How to Say No to Your Toddler.” Email him at [email protected].
Your first patient of the day is a 2½-year-old who has a runny nose and a cough. His mother has brought him in because his cough is more frequent and persistent than she is accustomed to hearing. He is happy and playful, and has a low-grade fever. You notice that he is slightly tachypneic, and you hear fine wheezes scattered throughout his lung fields. You also recall that at age 6 months, he was diagnosed with bronchiolitis but was never hospitalized.
Will you give him antibiotics and send him home with a nebulizer? Just the nebulizer? Just the antibiotics? Neither? We can debate those answers for hours, and you can plead for more information before you commit to an answer. But let’s skip over the question about what you are going to do and focus on what you are going to say. I want to know what diagnosis you are going to share with this mother.
Or are you going to try a pseudoscientific smoke screen and tell her that her that her son has “reactive airway disease”? You could soften it even further by reassuring her that his diagnosis is so common that it has an abbreviation: “We usually just call it RAD.”
You may not have trouble telling a parent that her child has asthma, but most clinicians struggle with dropping the A-bomb. Why? It may be that we don’t want the family to freak out. You could end up spending the rest of the morning coaxing them back off the ledge because you have diagnosed their child with a chronic illness that could kill him. This kind of exaggerated reaction is far less of a problem now than it was 30 or 40 years ago. Almost every parent knows at least one family with an asthmatic child who seems to be doing just fine. In my opinion, this apparent increase in prevalence of asthma is primarily the result of an improved awareness and a relabeling phenomenon.
Your own experience probably reflects the national statistics that less than a third of preschoolers with recurrent wheezing still have asthma by the time they finish kindergarten. And you may be hesitant to use the asthma diagnosis because you don’t want to be labeled as a clinician who cries wolf.
It may be that subconsciously you are afraid that by raising the asthma red flag you will be committing yourself to the time gobbling task of managing another patient with a chronic disease. You could gamble that he will only have one or two more episodes of wheezing, and you will be able to treat his illnesses simply as a short series of unconnected events.
Is there any harm in dancing around the asthma diagnosis? The authors of a Perspectives article in the January 2017 issue of Pediatrics argue persuasively that vague descriptive and nondiagnostic terms such as “reactive airways disease” are confusing and should be abandoned (“RAD: Reactive Airway Disease or Really Asthma Disease?” Pediatrics. 2017 Jan. doi: 10.1542/peds.2016-0625). They question why we would treat a condition with asthma medications and not call it asthma just because a child will probably out grow it later.
It’s more than just about sloppy language. Jose A. Castro-Rodriguez, MD, a physician who has pioneered one of the tools than can be used to predict persistent asthma in young children, observes that by failing to signal to parents that the child has a chronic condition, we run the risk that the child will be less adherent to the medication and management program we recommend. (“The Asthma Predictive Index,” Curr Opin Allergy Clin Immunol. 2011;11[3]:157-61).
If we are going to tighten up our language and drop the vague substitute terms like RAD, and if we are hesitant to drop the A-bomb because it sounds too much like a lifelong disease when the truth is that most young children will outgrow asthma, what should we tell all those parents of wheezing preschoolers? The authors of the article in Pediatrics have several suggestions. Their favorite and the one that appeals most to me is toddler asthma. As they observe, the term “toddler asthma” implies an endpoint and the need for reevaluation to determine if the child is one of the minority who has “real” asthma.
Although it’s almost always about the money. When it's not about the money, it's usually about the labels we use.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics including “How to Say No to Your Toddler.” Email him at [email protected].
Out to lunch
I’m sure there are folks here in town who wondered how I could keep up a professional pace that often included being on call 2 nights a week and working every third weekend. Even when I was in my early 50s, people asked me if I was getting ready to retire. I hope it wasn’t because I appeared unhappy or looked 15 years older than I was. I suspect that some parents who didn’t know me well predicted that my career would have ended far short of 40 years.
One of the secrets of what appeared to be my superhuman stamina was that almost every day at noon I was out to lunch. That doesn’t mean that I always took time to eat lunch. In fact, I must admit that more often than not my midday diet consisted of several handfuls of cashews or an energy bar eaten on the fly.
The feeling of invigoration and renewal that came in its wake fueled my commitment to my habit of lunchtime outdoor activity. Although to some people it may be counterintuitive, the physical activity energized me. The second half of my workday was no more fatiguing than the morning. However, if some thoughtless hospital or practice administrator scheduled a noon meeting, the rest of my day was a grump fest.
A recent study has demonstrated just how powerful lunchtime exercise can be in improving worker attitude and mood, even if the activity is just going for a walk. (“Changes in work affect in response to lunchtime walking in previously physically inactive employees: A randomized trial” (Scand J Med Sci Sports. 2015 Dec;25[6]:778-87). There have been other studies that have pointed to the value of an activity break, but these investigators collected real-time reports from subjects using their cell phones. “Lunchtime walks improved enthusiasm, relaxation, and nervousness at work,” the researchers noted.
The problem comes in getting employees to take that first step toward developing a lunchtime activity habit. A few, usually women, have discovered the value for themselves and enjoy the social interaction as much as they do the affect-improving aspects of the activity and change of scene. I have tried to encourage lunchtime walking in the workplace with several strategies, including small monetary rewards, prizes, and contests between groups of workers. One year we even bought umbrellas to encourage employees to walk even if it was raining. But without a vigorous and persistent support system, inertia wins, and only those who have discovered the benefits of lunchtime activity for themselves persist.
You may be asking yourself how I managed to find time in my schedule for that hour of lunchtime activity; actually it was usually an hour and half to include a shower. The answer is that I built my schedule around it, and that meant getting to the office earlier and working later. But in my mind that was a small price to pay for the benefits I received. The other secret to my apparent stamina was that I lived a 5-minute bike ride from both hospitals and my office. Don’t underestimate the toll your commute is taking on your life and happiness.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.”
I’m sure there are folks here in town who wondered how I could keep up a professional pace that often included being on call 2 nights a week and working every third weekend. Even when I was in my early 50s, people asked me if I was getting ready to retire. I hope it wasn’t because I appeared unhappy or looked 15 years older than I was. I suspect that some parents who didn’t know me well predicted that my career would have ended far short of 40 years.
One of the secrets of what appeared to be my superhuman stamina was that almost every day at noon I was out to lunch. That doesn’t mean that I always took time to eat lunch. In fact, I must admit that more often than not my midday diet consisted of several handfuls of cashews or an energy bar eaten on the fly.
The feeling of invigoration and renewal that came in its wake fueled my commitment to my habit of lunchtime outdoor activity. Although to some people it may be counterintuitive, the physical activity energized me. The second half of my workday was no more fatiguing than the morning. However, if some thoughtless hospital or practice administrator scheduled a noon meeting, the rest of my day was a grump fest.
A recent study has demonstrated just how powerful lunchtime exercise can be in improving worker attitude and mood, even if the activity is just going for a walk. (“Changes in work affect in response to lunchtime walking in previously physically inactive employees: A randomized trial” (Scand J Med Sci Sports. 2015 Dec;25[6]:778-87). There have been other studies that have pointed to the value of an activity break, but these investigators collected real-time reports from subjects using their cell phones. “Lunchtime walks improved enthusiasm, relaxation, and nervousness at work,” the researchers noted.
The problem comes in getting employees to take that first step toward developing a lunchtime activity habit. A few, usually women, have discovered the value for themselves and enjoy the social interaction as much as they do the affect-improving aspects of the activity and change of scene. I have tried to encourage lunchtime walking in the workplace with several strategies, including small monetary rewards, prizes, and contests between groups of workers. One year we even bought umbrellas to encourage employees to walk even if it was raining. But without a vigorous and persistent support system, inertia wins, and only those who have discovered the benefits of lunchtime activity for themselves persist.
You may be asking yourself how I managed to find time in my schedule for that hour of lunchtime activity; actually it was usually an hour and half to include a shower. The answer is that I built my schedule around it, and that meant getting to the office earlier and working later. But in my mind that was a small price to pay for the benefits I received. The other secret to my apparent stamina was that I lived a 5-minute bike ride from both hospitals and my office. Don’t underestimate the toll your commute is taking on your life and happiness.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.”
I’m sure there are folks here in town who wondered how I could keep up a professional pace that often included being on call 2 nights a week and working every third weekend. Even when I was in my early 50s, people asked me if I was getting ready to retire. I hope it wasn’t because I appeared unhappy or looked 15 years older than I was. I suspect that some parents who didn’t know me well predicted that my career would have ended far short of 40 years.
One of the secrets of what appeared to be my superhuman stamina was that almost every day at noon I was out to lunch. That doesn’t mean that I always took time to eat lunch. In fact, I must admit that more often than not my midday diet consisted of several handfuls of cashews or an energy bar eaten on the fly.
The feeling of invigoration and renewal that came in its wake fueled my commitment to my habit of lunchtime outdoor activity. Although to some people it may be counterintuitive, the physical activity energized me. The second half of my workday was no more fatiguing than the morning. However, if some thoughtless hospital or practice administrator scheduled a noon meeting, the rest of my day was a grump fest.
A recent study has demonstrated just how powerful lunchtime exercise can be in improving worker attitude and mood, even if the activity is just going for a walk. (“Changes in work affect in response to lunchtime walking in previously physically inactive employees: A randomized trial” (Scand J Med Sci Sports. 2015 Dec;25[6]:778-87). There have been other studies that have pointed to the value of an activity break, but these investigators collected real-time reports from subjects using their cell phones. “Lunchtime walks improved enthusiasm, relaxation, and nervousness at work,” the researchers noted.
The problem comes in getting employees to take that first step toward developing a lunchtime activity habit. A few, usually women, have discovered the value for themselves and enjoy the social interaction as much as they do the affect-improving aspects of the activity and change of scene. I have tried to encourage lunchtime walking in the workplace with several strategies, including small monetary rewards, prizes, and contests between groups of workers. One year we even bought umbrellas to encourage employees to walk even if it was raining. But without a vigorous and persistent support system, inertia wins, and only those who have discovered the benefits of lunchtime activity for themselves persist.
You may be asking yourself how I managed to find time in my schedule for that hour of lunchtime activity; actually it was usually an hour and half to include a shower. The answer is that I built my schedule around it, and that meant getting to the office earlier and working later. But in my mind that was a small price to pay for the benefits I received. The other secret to my apparent stamina was that I lived a 5-minute bike ride from both hospitals and my office. Don’t underestimate the toll your commute is taking on your life and happiness.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.”
Open vs. endovascular for chronic mesenteric ischemia
Chronic mesenteric ischemia is best treated in an open operation.
Chronic mesenteric ischemia is a rare disorder accounting for about 1 out of 100,000 admissions.1 Because of the rarity of this disease, diagnosis is often delayed. Patients are often evaluated for other gastrointestinal diseases and/or malignancies, which in turn contributes to significant delays in diagnosis. Additionally, there are no prospective, randomized trials on which to base decisions regarding treatment; and it is unlikely that such studies will ever be undertaken.
Chronic mesenteric ischemia develops when two or more of the mesenteric vessels (celiac, superior mesenteric [SMA], or inferior mesenteric [IMA]) become occluded or develop severe stenosis. In my experience, patients most often develop occlusion (as opposed to stenosis) of their mesenteric vessels. The atherosclerotic plaque responsible for the disease originates within the aorta and the stenosis/occlusion develops at the vessel origin.
As a whole, these comorbidities would suggest that a more minimally invasive approach would be preferred. Yet, an open operation for chronic mesenteric ischemia should not be discarded as an initial operation.
Endovascular treatment of mesenteric ischemia is not without risk. As in all endovascular procedures there are complications associated with the access vessels. The orientation of the mesenteric vessels as they arise from the aorta often favors an approach from the left arm. The brachial artery is smaller than the femoral artery, and it is more difficult to apply pressure to the brachial artery to control the puncture site. This leads to a higher rate of access site complications including hemorrhage, pseudoaneurysm and thrombosis of the vessel. Bleeding or hematoma formation within the brachial neurovascular sheath can result in significant neurologic dysfunction of the arm and hand. There is risk of stroke, especially when the access vessel is the brachial artery. There are also complications directly related to the endovascular procedure.
Atheroembolism of plaque can result in occlusion of small mesenteric vessels and focal areas of bowel necrosis. Dissection of the mesenteric vessel can occur. Oderich has advocated for the use of a covered stent.2 A covered stent could cover proximal branches, and thus, in theory, the treatment itself could cause bowel ischemia or infarction. Many series that have compared open and endovascular surgery show no difference in early outcomes, but demonstrate early restenosis, decreased primary patency, and decreased assisted primary patency with endovascular treatment as compared with open operations.3-5
Another concern regarding the treatment of mesenteric ischemia is the status of the end organ, the bowel. Successful treatment of mesenteric ischemia cannot only assess the atherosclerotic lesion, but requires the surgeon to be cognizant of the condition of the bowel.
This concern is especially true for acute mesenteric ischemia,6 but the status of the bowel must also be kept in mind for chronic mesenteric ischemia. Unlike the lower extremity where the results of treatment are easily observed by inspection (color, evidence of atheroembolization), palpation (temperature, pulse), and physiologic testing (ABI), the bowel is not accessible. There are no highly accurate tests to determine if the patient has on-going bowel ischemia or has developed infarction. Should a complication occur, physical examination findings and laboratory changes often become apparent late in the course of the disease. As previously noted, these patients are often physiologically compromised and have little reserve and may not survive such complications. An open operation allows visualization of the bowel, before and after revascularization.
Traditional teaching for the surgical treatment of chronic mesenteric ischemia has emphasized that two mesenteric vessels, usually the celiac and SMA, should be revascularized.7,8 Various approaches to revascularization have been suggested including transaortic endarterectomy and an antegrade bifurcated bypass originating from the supraceliac aorta. These operations are effective in restoring flow to the mesenteric circulation, but both of these approaches involve aortic cross-clamping and are physiologically challenging for patients.
There are alternatives for open revascularization of the mesenteric vessels. The infrarenal aorta, iliac vessels, and even renal arteries can be, and have been used as the inflow source. It has been my experience that a bypass graft using an iliac artery (common or external) as the inflow source is well tolerated by patients. I have preferentially used either great saphenous vein or femoral-popliteal vein as the conduit. In many cases, the distal anastomosis is simply the SMA. However, both the celiac and SMA can be revascularized by creating a side-side anastomosis to the SMA and an end-side anastomosis to the common or proper hepatic artery. Such procedures have been durable, providing relief of symptoms and allowing patients to regain weight.9
In reality, I believe that an endovascular approach for the treatment of chronic mesenteric ischemia has a role. Vascular surgeons are uniquely positioned to carefully evaluate each patient and recommend what they feel is most appropriate. I tend to feel that an endovascular approach is less likely to be successful for patients with occluded vessels, especially those with a flush occlusion, and so will preferentially recommend an open operation for these patients. On the other hand, in my practice, I have used an endovascular approach for patients with severe stenosis, and as Dr. Harris states, know that a bypass is always an option should this be unsuccessful or ultimately fail.
References
1. Ann Vasc Surg. 1991;5:403-6
2. J Vasc Surg. 2013;58:1316-23
3. Ann Vasc Surg. 2015:29;934-40
4. World J Gastroenerol. 2013;19:1333-7
5. J Vasc Surg. 2007;45:1162-71
6. J Vasc Surg. 2015;62:767-72
7. J Vasc Surg. 2002:35:853-9
8. Surgery. 1981;90:940-6
9. J Vasc Surg. 2000;32:37-47
Eric Endean, MD, is the director of the aortic center, Gordon L. Hyde Endowed Professor and Chair, and vascular surgery section head, vascular and endovascular surgery at UK HealthCare, University of Kentucky, Lexington. He had no relevant disclosures.
Presenting the case for endovascular intervention
Chronic mesenteric ischemia (CMI) is an uncommon, but lethal, problem when left untreated. Before the endovascular era, the only option was open revascularization, which is challenging in this chronically ill, malnourished population with diffuse, systemic, atherosclerotic disease. Morbidity and mortality was relatively high because of the comorbid conditions and chronically ill status of the patients. The first mesenteric bypass was performed in 1958 by Maynard and Shaw.1
Options for open repair include transaortic endarterectomy, antegrade bypass from the supraceliac aorta or distal thoracic aorta, or retrograde bypass from the iliac artery, all of which are major abdominal procedures. Endovascular interventions are now the most commonly performed procedures for CMI in the United States based on national studies.2
Technical success with endovascular interventions can be achieved in well over 90% of patients, and multiple vessels can be treated simultaneously from either a femoral or brachial approach. The primary concern with endovascular interventions has been long-term patency, with restenosis from intimal hyperplasia or thrombosis causing recurrent symptoms in up to 30%-50% at 3-5 years.5-7 However, these rates are based on use of bare metal stents, rather than covered stents. Recent studies8 suggest that stent grafts have markedly improved outcomes over bare metal stents for ostial lesions, decreasing recurrence. Oderich found that freedom from recurrence was 92% with stent grafts as compared with 53% for bare metal stents, with primary patency rates of 92%, at 3 years8, comparable to even the best open bypass results. Schoch first reported the use of covered stents in the mesenteric circulation, and found that no patients developed recurrent stenosis at 2 years.9 Other concerns with endovascular intervention include embolization and dissection, which have not been frequently reported.
Mortality from open surgery ranges from 5% to 15%, with morbidity of 30%-40%.4 Mortality from endovascular intervention is markedly lower, in the range of 3.56% vs. 7.23%.5 Long-term survival is not different between endovascular vs. open repair (69% vs. 65%),4 with the majority of deaths related to cardiac, pulmonary, or malignancy issues. Moghadamyeghaneh, in a review of the Nationwide Inpatient Sample database, found that open surgery was one of the major predictors for higher morbidity (odds ratio, 5.07) and mortality (OR, 5.13), despite the fact that endovascular patients were older (another risk factor for adverse outcomes) and had more comorbidities in this nonrandomized, real-world study.2
Further, if one considers cost as a metric for decision making, a Markov clinical decision model by Hogendoorn et al suggests an endovascular first approach is preferred, despite the presumed higher rate of recurrence expected with use of bare metal stents, rather than covered stents, utilized for this analysis.10 Clearly, the financial advantage would be even greater for endovascular with the lower rates of recurrence with covered stents more recently reported.
If a patient develops recurrent stenosis after endovascular intervention, open bypass may be considered as an alternate to repeat endovascular intervention, dependent on the nutritional status, life expectancy, and initial intervention undertaken. Alternately, patients who undergo open repair are not immune to restenosis, with a recurrence rate of 10%-20%.11,12 Oderich found that there was a 22% mortality in those treated with repeat open interventions, with a 47% complication rate. Endovascular interventions, however, had a significantly lower rate of complications, 16%, and mortality. For patients with recurrent disease after open revascularization for CMI, the endovascular approach should also be the preferred approach.
Any lesion which is anatomically suitable for endovascular repair should first have an attempt made via this approach, utilizing covered stents. While there is a role for open revascularization, endovascular interventions can be safely performed, with minimal morbidity and mortality, and good long-term patency, even in the sickest patients. Endovascular intervention should be the procedure of choice for chronic mesenteric ischemia and recurrent chronic mesenteric ischemia.
References
1. NEJM. 1958;258:874-8
2. Am Surg. 2015;81:1149-56
3. Cardiovasc Intervent Radiol. 1980;3:43-4
4. Ann Vasc Surg. 2009;23:700-12
5. Ann Vasc Surg. 2013;27:113-22
6. J Vasc Surg. 2011;54:1422-29
7. J Vasc Surg. 2010;51:140-7
8. J Vasc Surg. 2013;58:1316-24
9. JACS. 2001;212:668-75
10. J Vasc Surg. 2014;60;715-25
11. J Vasc Surg. 200;49:1472-9
12. J Vasc Surg. 2007;45:1162-71
Linda Harris, MD, is professor of surgery; chief, division of vascular surgery; program director, vascular surgery residency & fellowship at the State University of New York at Buffalo; and an associate medical editor for Vascular Specialist. She had no relevant disclosures.
Chronic mesenteric ischemia is best treated in an open operation.
Chronic mesenteric ischemia is a rare disorder accounting for about 1 out of 100,000 admissions.1 Because of the rarity of this disease, diagnosis is often delayed. Patients are often evaluated for other gastrointestinal diseases and/or malignancies, which in turn contributes to significant delays in diagnosis. Additionally, there are no prospective, randomized trials on which to base decisions regarding treatment; and it is unlikely that such studies will ever be undertaken.
Chronic mesenteric ischemia develops when two or more of the mesenteric vessels (celiac, superior mesenteric [SMA], or inferior mesenteric [IMA]) become occluded or develop severe stenosis. In my experience, patients most often develop occlusion (as opposed to stenosis) of their mesenteric vessels. The atherosclerotic plaque responsible for the disease originates within the aorta and the stenosis/occlusion develops at the vessel origin.
As a whole, these comorbidities would suggest that a more minimally invasive approach would be preferred. Yet, an open operation for chronic mesenteric ischemia should not be discarded as an initial operation.
Endovascular treatment of mesenteric ischemia is not without risk. As in all endovascular procedures there are complications associated with the access vessels. The orientation of the mesenteric vessels as they arise from the aorta often favors an approach from the left arm. The brachial artery is smaller than the femoral artery, and it is more difficult to apply pressure to the brachial artery to control the puncture site. This leads to a higher rate of access site complications including hemorrhage, pseudoaneurysm and thrombosis of the vessel. Bleeding or hematoma formation within the brachial neurovascular sheath can result in significant neurologic dysfunction of the arm and hand. There is risk of stroke, especially when the access vessel is the brachial artery. There are also complications directly related to the endovascular procedure.
Atheroembolism of plaque can result in occlusion of small mesenteric vessels and focal areas of bowel necrosis. Dissection of the mesenteric vessel can occur. Oderich has advocated for the use of a covered stent.2 A covered stent could cover proximal branches, and thus, in theory, the treatment itself could cause bowel ischemia or infarction. Many series that have compared open and endovascular surgery show no difference in early outcomes, but demonstrate early restenosis, decreased primary patency, and decreased assisted primary patency with endovascular treatment as compared with open operations.3-5
Another concern regarding the treatment of mesenteric ischemia is the status of the end organ, the bowel. Successful treatment of mesenteric ischemia cannot only assess the atherosclerotic lesion, but requires the surgeon to be cognizant of the condition of the bowel.
This concern is especially true for acute mesenteric ischemia,6 but the status of the bowel must also be kept in mind for chronic mesenteric ischemia. Unlike the lower extremity where the results of treatment are easily observed by inspection (color, evidence of atheroembolization), palpation (temperature, pulse), and physiologic testing (ABI), the bowel is not accessible. There are no highly accurate tests to determine if the patient has on-going bowel ischemia or has developed infarction. Should a complication occur, physical examination findings and laboratory changes often become apparent late in the course of the disease. As previously noted, these patients are often physiologically compromised and have little reserve and may not survive such complications. An open operation allows visualization of the bowel, before and after revascularization.
Traditional teaching for the surgical treatment of chronic mesenteric ischemia has emphasized that two mesenteric vessels, usually the celiac and SMA, should be revascularized.7,8 Various approaches to revascularization have been suggested including transaortic endarterectomy and an antegrade bifurcated bypass originating from the supraceliac aorta. These operations are effective in restoring flow to the mesenteric circulation, but both of these approaches involve aortic cross-clamping and are physiologically challenging for patients.
There are alternatives for open revascularization of the mesenteric vessels. The infrarenal aorta, iliac vessels, and even renal arteries can be, and have been used as the inflow source. It has been my experience that a bypass graft using an iliac artery (common or external) as the inflow source is well tolerated by patients. I have preferentially used either great saphenous vein or femoral-popliteal vein as the conduit. In many cases, the distal anastomosis is simply the SMA. However, both the celiac and SMA can be revascularized by creating a side-side anastomosis to the SMA and an end-side anastomosis to the common or proper hepatic artery. Such procedures have been durable, providing relief of symptoms and allowing patients to regain weight.9
In reality, I believe that an endovascular approach for the treatment of chronic mesenteric ischemia has a role. Vascular surgeons are uniquely positioned to carefully evaluate each patient and recommend what they feel is most appropriate. I tend to feel that an endovascular approach is less likely to be successful for patients with occluded vessels, especially those with a flush occlusion, and so will preferentially recommend an open operation for these patients. On the other hand, in my practice, I have used an endovascular approach for patients with severe stenosis, and as Dr. Harris states, know that a bypass is always an option should this be unsuccessful or ultimately fail.
References
1. Ann Vasc Surg. 1991;5:403-6
2. J Vasc Surg. 2013;58:1316-23
3. Ann Vasc Surg. 2015:29;934-40
4. World J Gastroenerol. 2013;19:1333-7
5. J Vasc Surg. 2007;45:1162-71
6. J Vasc Surg. 2015;62:767-72
7. J Vasc Surg. 2002:35:853-9
8. Surgery. 1981;90:940-6
9. J Vasc Surg. 2000;32:37-47
Eric Endean, MD, is the director of the aortic center, Gordon L. Hyde Endowed Professor and Chair, and vascular surgery section head, vascular and endovascular surgery at UK HealthCare, University of Kentucky, Lexington. He had no relevant disclosures.
Presenting the case for endovascular intervention
Chronic mesenteric ischemia (CMI) is an uncommon, but lethal, problem when left untreated. Before the endovascular era, the only option was open revascularization, which is challenging in this chronically ill, malnourished population with diffuse, systemic, atherosclerotic disease. Morbidity and mortality was relatively high because of the comorbid conditions and chronically ill status of the patients. The first mesenteric bypass was performed in 1958 by Maynard and Shaw.1
Options for open repair include transaortic endarterectomy, antegrade bypass from the supraceliac aorta or distal thoracic aorta, or retrograde bypass from the iliac artery, all of which are major abdominal procedures. Endovascular interventions are now the most commonly performed procedures for CMI in the United States based on national studies.2
Technical success with endovascular interventions can be achieved in well over 90% of patients, and multiple vessels can be treated simultaneously from either a femoral or brachial approach. The primary concern with endovascular interventions has been long-term patency, with restenosis from intimal hyperplasia or thrombosis causing recurrent symptoms in up to 30%-50% at 3-5 years.5-7 However, these rates are based on use of bare metal stents, rather than covered stents. Recent studies8 suggest that stent grafts have markedly improved outcomes over bare metal stents for ostial lesions, decreasing recurrence. Oderich found that freedom from recurrence was 92% with stent grafts as compared with 53% for bare metal stents, with primary patency rates of 92%, at 3 years8, comparable to even the best open bypass results. Schoch first reported the use of covered stents in the mesenteric circulation, and found that no patients developed recurrent stenosis at 2 years.9 Other concerns with endovascular intervention include embolization and dissection, which have not been frequently reported.
Mortality from open surgery ranges from 5% to 15%, with morbidity of 30%-40%.4 Mortality from endovascular intervention is markedly lower, in the range of 3.56% vs. 7.23%.5 Long-term survival is not different between endovascular vs. open repair (69% vs. 65%),4 with the majority of deaths related to cardiac, pulmonary, or malignancy issues. Moghadamyeghaneh, in a review of the Nationwide Inpatient Sample database, found that open surgery was one of the major predictors for higher morbidity (odds ratio, 5.07) and mortality (OR, 5.13), despite the fact that endovascular patients were older (another risk factor for adverse outcomes) and had more comorbidities in this nonrandomized, real-world study.2
Further, if one considers cost as a metric for decision making, a Markov clinical decision model by Hogendoorn et al suggests an endovascular first approach is preferred, despite the presumed higher rate of recurrence expected with use of bare metal stents, rather than covered stents, utilized for this analysis.10 Clearly, the financial advantage would be even greater for endovascular with the lower rates of recurrence with covered stents more recently reported.
If a patient develops recurrent stenosis after endovascular intervention, open bypass may be considered as an alternate to repeat endovascular intervention, dependent on the nutritional status, life expectancy, and initial intervention undertaken. Alternately, patients who undergo open repair are not immune to restenosis, with a recurrence rate of 10%-20%.11,12 Oderich found that there was a 22% mortality in those treated with repeat open interventions, with a 47% complication rate. Endovascular interventions, however, had a significantly lower rate of complications, 16%, and mortality. For patients with recurrent disease after open revascularization for CMI, the endovascular approach should also be the preferred approach.
Any lesion which is anatomically suitable for endovascular repair should first have an attempt made via this approach, utilizing covered stents. While there is a role for open revascularization, endovascular interventions can be safely performed, with minimal morbidity and mortality, and good long-term patency, even in the sickest patients. Endovascular intervention should be the procedure of choice for chronic mesenteric ischemia and recurrent chronic mesenteric ischemia.
References
1. NEJM. 1958;258:874-8
2. Am Surg. 2015;81:1149-56
3. Cardiovasc Intervent Radiol. 1980;3:43-4
4. Ann Vasc Surg. 2009;23:700-12
5. Ann Vasc Surg. 2013;27:113-22
6. J Vasc Surg. 2011;54:1422-29
7. J Vasc Surg. 2010;51:140-7
8. J Vasc Surg. 2013;58:1316-24
9. JACS. 2001;212:668-75
10. J Vasc Surg. 2014;60;715-25
11. J Vasc Surg. 200;49:1472-9
12. J Vasc Surg. 2007;45:1162-71
Linda Harris, MD, is professor of surgery; chief, division of vascular surgery; program director, vascular surgery residency & fellowship at the State University of New York at Buffalo; and an associate medical editor for Vascular Specialist. She had no relevant disclosures.
Chronic mesenteric ischemia is best treated in an open operation.
Chronic mesenteric ischemia is a rare disorder accounting for about 1 out of 100,000 admissions.1 Because of the rarity of this disease, diagnosis is often delayed. Patients are often evaluated for other gastrointestinal diseases and/or malignancies, which in turn contributes to significant delays in diagnosis. Additionally, there are no prospective, randomized trials on which to base decisions regarding treatment; and it is unlikely that such studies will ever be undertaken.
Chronic mesenteric ischemia develops when two or more of the mesenteric vessels (celiac, superior mesenteric [SMA], or inferior mesenteric [IMA]) become occluded or develop severe stenosis. In my experience, patients most often develop occlusion (as opposed to stenosis) of their mesenteric vessels. The atherosclerotic plaque responsible for the disease originates within the aorta and the stenosis/occlusion develops at the vessel origin.
As a whole, these comorbidities would suggest that a more minimally invasive approach would be preferred. Yet, an open operation for chronic mesenteric ischemia should not be discarded as an initial operation.
Endovascular treatment of mesenteric ischemia is not without risk. As in all endovascular procedures there are complications associated with the access vessels. The orientation of the mesenteric vessels as they arise from the aorta often favors an approach from the left arm. The brachial artery is smaller than the femoral artery, and it is more difficult to apply pressure to the brachial artery to control the puncture site. This leads to a higher rate of access site complications including hemorrhage, pseudoaneurysm and thrombosis of the vessel. Bleeding or hematoma formation within the brachial neurovascular sheath can result in significant neurologic dysfunction of the arm and hand. There is risk of stroke, especially when the access vessel is the brachial artery. There are also complications directly related to the endovascular procedure.
Atheroembolism of plaque can result in occlusion of small mesenteric vessels and focal areas of bowel necrosis. Dissection of the mesenteric vessel can occur. Oderich has advocated for the use of a covered stent.2 A covered stent could cover proximal branches, and thus, in theory, the treatment itself could cause bowel ischemia or infarction. Many series that have compared open and endovascular surgery show no difference in early outcomes, but demonstrate early restenosis, decreased primary patency, and decreased assisted primary patency with endovascular treatment as compared with open operations.3-5
Another concern regarding the treatment of mesenteric ischemia is the status of the end organ, the bowel. Successful treatment of mesenteric ischemia cannot only assess the atherosclerotic lesion, but requires the surgeon to be cognizant of the condition of the bowel.
This concern is especially true for acute mesenteric ischemia,6 but the status of the bowel must also be kept in mind for chronic mesenteric ischemia. Unlike the lower extremity where the results of treatment are easily observed by inspection (color, evidence of atheroembolization), palpation (temperature, pulse), and physiologic testing (ABI), the bowel is not accessible. There are no highly accurate tests to determine if the patient has on-going bowel ischemia or has developed infarction. Should a complication occur, physical examination findings and laboratory changes often become apparent late in the course of the disease. As previously noted, these patients are often physiologically compromised and have little reserve and may not survive such complications. An open operation allows visualization of the bowel, before and after revascularization.
Traditional teaching for the surgical treatment of chronic mesenteric ischemia has emphasized that two mesenteric vessels, usually the celiac and SMA, should be revascularized.7,8 Various approaches to revascularization have been suggested including transaortic endarterectomy and an antegrade bifurcated bypass originating from the supraceliac aorta. These operations are effective in restoring flow to the mesenteric circulation, but both of these approaches involve aortic cross-clamping and are physiologically challenging for patients.
There are alternatives for open revascularization of the mesenteric vessels. The infrarenal aorta, iliac vessels, and even renal arteries can be, and have been used as the inflow source. It has been my experience that a bypass graft using an iliac artery (common or external) as the inflow source is well tolerated by patients. I have preferentially used either great saphenous vein or femoral-popliteal vein as the conduit. In many cases, the distal anastomosis is simply the SMA. However, both the celiac and SMA can be revascularized by creating a side-side anastomosis to the SMA and an end-side anastomosis to the common or proper hepatic artery. Such procedures have been durable, providing relief of symptoms and allowing patients to regain weight.9
In reality, I believe that an endovascular approach for the treatment of chronic mesenteric ischemia has a role. Vascular surgeons are uniquely positioned to carefully evaluate each patient and recommend what they feel is most appropriate. I tend to feel that an endovascular approach is less likely to be successful for patients with occluded vessels, especially those with a flush occlusion, and so will preferentially recommend an open operation for these patients. On the other hand, in my practice, I have used an endovascular approach for patients with severe stenosis, and as Dr. Harris states, know that a bypass is always an option should this be unsuccessful or ultimately fail.
References
1. Ann Vasc Surg. 1991;5:403-6
2. J Vasc Surg. 2013;58:1316-23
3. Ann Vasc Surg. 2015:29;934-40
4. World J Gastroenerol. 2013;19:1333-7
5. J Vasc Surg. 2007;45:1162-71
6. J Vasc Surg. 2015;62:767-72
7. J Vasc Surg. 2002:35:853-9
8. Surgery. 1981;90:940-6
9. J Vasc Surg. 2000;32:37-47
Eric Endean, MD, is the director of the aortic center, Gordon L. Hyde Endowed Professor and Chair, and vascular surgery section head, vascular and endovascular surgery at UK HealthCare, University of Kentucky, Lexington. He had no relevant disclosures.
Presenting the case for endovascular intervention
Chronic mesenteric ischemia (CMI) is an uncommon, but lethal, problem when left untreated. Before the endovascular era, the only option was open revascularization, which is challenging in this chronically ill, malnourished population with diffuse, systemic, atherosclerotic disease. Morbidity and mortality was relatively high because of the comorbid conditions and chronically ill status of the patients. The first mesenteric bypass was performed in 1958 by Maynard and Shaw.1
Options for open repair include transaortic endarterectomy, antegrade bypass from the supraceliac aorta or distal thoracic aorta, or retrograde bypass from the iliac artery, all of which are major abdominal procedures. Endovascular interventions are now the most commonly performed procedures for CMI in the United States based on national studies.2
Technical success with endovascular interventions can be achieved in well over 90% of patients, and multiple vessels can be treated simultaneously from either a femoral or brachial approach. The primary concern with endovascular interventions has been long-term patency, with restenosis from intimal hyperplasia or thrombosis causing recurrent symptoms in up to 30%-50% at 3-5 years.5-7 However, these rates are based on use of bare metal stents, rather than covered stents. Recent studies8 suggest that stent grafts have markedly improved outcomes over bare metal stents for ostial lesions, decreasing recurrence. Oderich found that freedom from recurrence was 92% with stent grafts as compared with 53% for bare metal stents, with primary patency rates of 92%, at 3 years8, comparable to even the best open bypass results. Schoch first reported the use of covered stents in the mesenteric circulation, and found that no patients developed recurrent stenosis at 2 years.9 Other concerns with endovascular intervention include embolization and dissection, which have not been frequently reported.
Mortality from open surgery ranges from 5% to 15%, with morbidity of 30%-40%.4 Mortality from endovascular intervention is markedly lower, in the range of 3.56% vs. 7.23%.5 Long-term survival is not different between endovascular vs. open repair (69% vs. 65%),4 with the majority of deaths related to cardiac, pulmonary, or malignancy issues. Moghadamyeghaneh, in a review of the Nationwide Inpatient Sample database, found that open surgery was one of the major predictors for higher morbidity (odds ratio, 5.07) and mortality (OR, 5.13), despite the fact that endovascular patients were older (another risk factor for adverse outcomes) and had more comorbidities in this nonrandomized, real-world study.2
Further, if one considers cost as a metric for decision making, a Markov clinical decision model by Hogendoorn et al suggests an endovascular first approach is preferred, despite the presumed higher rate of recurrence expected with use of bare metal stents, rather than covered stents, utilized for this analysis.10 Clearly, the financial advantage would be even greater for endovascular with the lower rates of recurrence with covered stents more recently reported.
If a patient develops recurrent stenosis after endovascular intervention, open bypass may be considered as an alternate to repeat endovascular intervention, dependent on the nutritional status, life expectancy, and initial intervention undertaken. Alternately, patients who undergo open repair are not immune to restenosis, with a recurrence rate of 10%-20%.11,12 Oderich found that there was a 22% mortality in those treated with repeat open interventions, with a 47% complication rate. Endovascular interventions, however, had a significantly lower rate of complications, 16%, and mortality. For patients with recurrent disease after open revascularization for CMI, the endovascular approach should also be the preferred approach.
Any lesion which is anatomically suitable for endovascular repair should first have an attempt made via this approach, utilizing covered stents. While there is a role for open revascularization, endovascular interventions can be safely performed, with minimal morbidity and mortality, and good long-term patency, even in the sickest patients. Endovascular intervention should be the procedure of choice for chronic mesenteric ischemia and recurrent chronic mesenteric ischemia.
References
1. NEJM. 1958;258:874-8
2. Am Surg. 2015;81:1149-56
3. Cardiovasc Intervent Radiol. 1980;3:43-4
4. Ann Vasc Surg. 2009;23:700-12
5. Ann Vasc Surg. 2013;27:113-22
6. J Vasc Surg. 2011;54:1422-29
7. J Vasc Surg. 2010;51:140-7
8. J Vasc Surg. 2013;58:1316-24
9. JACS. 2001;212:668-75
10. J Vasc Surg. 2014;60;715-25
11. J Vasc Surg. 200;49:1472-9
12. J Vasc Surg. 2007;45:1162-71
Linda Harris, MD, is professor of surgery; chief, division of vascular surgery; program director, vascular surgery residency & fellowship at the State University of New York at Buffalo; and an associate medical editor for Vascular Specialist. She had no relevant disclosures.