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Considering Eating Disorder Potential When Prescribing Weight Loss Drugs to Teens
Now, with the rising popularity of medications like Ozempic for weight loss, she fears she will care for more teens with eating disorders who are seeking glucagon-like peptide 1 (GLP-1) agonists or who have developed a disorder while taking them.
“We haven’t seen patients yet, but I’m sure they are on their way,” said Dr. Dennis, a clinical assistant professor in the Department of Psychiatry at the University of Illinois College of Medicine in Chicago. She is also the cofounder and chief medical officer of SunCloud Health, an outpatient eating disorder treatment center in Illinois.
Dr. Dennis’ concerns reflect a growing unease among eating disorder specialists as obesity medications gain traction for adolescent use. A recent study published in JAMA Pediatrics showed nearly 80% of teens in treatment for obesity reported symptoms of disordered eating at the outset of an intervention. These included signs of binge eating and loss of control.
The randomized clinical trial, conducted from 2018 to 2023, examined 141 adolescents with obesity undergoing interventions like low-energy diets or intermittent energy restriction. Almost half scored as having risk for an undiagnosed eating disorder, as defined by the Eating Disorder Examination Questionnaire (EDE-Q).
At the end of the intervention, many teens continued to have symptoms of disordered eating, while a smaller group was newly scored as having a risk for an eating disorder.
Weight Loss and Eating Disorders: A Balancing Act
The findings illuminate a significant challenge for pediatricians and primary care clinicians: Balancing effective weight management with the risk of exacerbating or triggering eating disorders, said Hiba Jebeile, PhD, a research dietitian at The Children’s Hospital at Westmead in Australia, and the study’s lead author. Adding weight loss medication on top of the equation can further complicate care.
“It is helpful for obesity and eating disorder services to work together, with clear referral pathways, to manage these adolescents,” Dr. Jebeile said.
The US Food and Drug Administration approved semaglutide for weight loss in adolescents aged 12-17 years in December 2020. One study found that the number of adolescents prescribed GLP-1 receptor agonists (GLP-1 RAs) for type 2 diabetes and weight management rose from 8722 to 60,567 between 2020 and 2023 — a nearly sevenfold increase.
“The number of adolescents taking these medications is going up because they work,” said Suzanne Cuda, MD, medical director of Alamo City Healthy Kids and Families, a medical weight management clinic in San Antonio. The medications have been shown to treat type 2 diabetes, lower blood pressure, and reduce the risk for cardiovascular diseases.
“The younger you are, the better the outcome,” Dr. Cuda said.
How GLP-1 agonists may affect adolescents in the long run is not yet clear. Existing studies on GLP-1 medications in patients with eating disorders have shown mixed results. Some studies indicate that the drugs decrease binge episodes for those with binge eating disorder or bulimia nervosa. However, these studies had small sample sizes and measured only short-term effects, leaving long-term outcomes and risks unknown.
Traditional treatments for eating disorders emphasize regular eating patterns, body acceptance, addressing weight stigma, and improving attunement to hunger and fullness cues — approaches that may conflict with the effects of GLP-1 agonists. These drugs suppress appetite, alter metabolic signals, and may unintentionally reinforce weight loss as a primary goal, creating a potential disconnect between the aims of recovery from eating disorders and the biologic effects of the medication, experts said.
Dr. Cuda said she has cared for adolescents with diagnosed eating disorders in her practice who are seeking GLP-1 agonists. She said she first works with patients to treat the underlying disorder before prescribing medication.
“One of the concerns is the extreme reductions in calories that could be induced by GLP-1 RA in children and adolescents,” she said. Unlike adults, adolescents use caloric energy not just for physical activity but also for growing and developing, she said.
“They can’t catch up on that growth and development,” she added.
Advice for Screening and Monitoring
The National Eating Disorders Association raised concerns about the potential misuse of these medications and their potential to exacerbate eating disorder behaviors in people who are already at a higher risk of developing one of the conditions, including those with existing mental health disorders, stress, who have already dieted, and who have experienced weight-centric bullying.
Clinicians should be on the lookout for patients seeking GLP-1s who present with symptoms of an eating disorder that may be less apparent, such as picky eating, insomnia or difficulty sleeping, or, for girls, irregular menstrual periods, Dr. Dennis said. These patients may be more likely to go undiagnosed or misdiagnosed. Research also suggests that people of color are less likely to be diagnosed or receive specialty care for eating disorders.
Discussions between patients and clinicians about obesity treatment prior to prescribing provide a crucial opportunity to screen and monitor for disordered eating, which Dr. Dennis said does not universally occur currently.
Dr. Dennis recommended initial assessments using validated screening tools like the EDE-Q and the Center for Epidemiologic Studies Depression Scale Revised, 10-Item Version.
Ongoing monitoring throughout treatment is essential, with initial monthly check-ins that include dietary counseling to detect subtle changes in eating behaviors or attitudes toward food and body image, Dr. Cuda said.
The Obesity Medicine Association (OMA) has stressed the importance of a collaborative approach involving connections with mental health professionals specializing in eating disorders and dietitians.
“If you have a chance to send them to an obesity medicine specialist, you should do that,” said Dr. Cuda, who coauthored the OMA statement. “It’s impractical to expect a primary care physician to do everything: Screen for dietary disorders, do a full dietary counseling, follow up on their activity.”
For patients showing signs of disordered eating, clinicians should avoid recommending restrictive dietary approaches, like cutting out food groups such as carbohydrates or a restricted calorie goal. Instead, they can suggest focusing on healthier lifestyle habits and referring to a psychotherapist, the experts said. Clinicians also should be prepared to adjust or pause GLP-1 agonists if disordered eating disorder symptoms worsen.
“I think a weight-agnostic approach where the focus of care is not weight loss but increase in health protective behaviors and nutritional intake is safest for all kids, especially those with eating disorders or eating disorder risk factors,” Dr. Dennis said.
Various authors of the eating disorder study reported receiving grants, advisory board fees, and speaker fees from entities including the National Health and Medical Research Council of Australia, Eli Lilly, Novo Nordisk, Nu-Mega Ingredients, and the National Institutes of Health, among others.
A version of this article appeared on Medscape.com.
Now, with the rising popularity of medications like Ozempic for weight loss, she fears she will care for more teens with eating disorders who are seeking glucagon-like peptide 1 (GLP-1) agonists or who have developed a disorder while taking them.
“We haven’t seen patients yet, but I’m sure they are on their way,” said Dr. Dennis, a clinical assistant professor in the Department of Psychiatry at the University of Illinois College of Medicine in Chicago. She is also the cofounder and chief medical officer of SunCloud Health, an outpatient eating disorder treatment center in Illinois.
Dr. Dennis’ concerns reflect a growing unease among eating disorder specialists as obesity medications gain traction for adolescent use. A recent study published in JAMA Pediatrics showed nearly 80% of teens in treatment for obesity reported symptoms of disordered eating at the outset of an intervention. These included signs of binge eating and loss of control.
The randomized clinical trial, conducted from 2018 to 2023, examined 141 adolescents with obesity undergoing interventions like low-energy diets or intermittent energy restriction. Almost half scored as having risk for an undiagnosed eating disorder, as defined by the Eating Disorder Examination Questionnaire (EDE-Q).
At the end of the intervention, many teens continued to have symptoms of disordered eating, while a smaller group was newly scored as having a risk for an eating disorder.
Weight Loss and Eating Disorders: A Balancing Act
The findings illuminate a significant challenge for pediatricians and primary care clinicians: Balancing effective weight management with the risk of exacerbating or triggering eating disorders, said Hiba Jebeile, PhD, a research dietitian at The Children’s Hospital at Westmead in Australia, and the study’s lead author. Adding weight loss medication on top of the equation can further complicate care.
“It is helpful for obesity and eating disorder services to work together, with clear referral pathways, to manage these adolescents,” Dr. Jebeile said.
The US Food and Drug Administration approved semaglutide for weight loss in adolescents aged 12-17 years in December 2020. One study found that the number of adolescents prescribed GLP-1 receptor agonists (GLP-1 RAs) for type 2 diabetes and weight management rose from 8722 to 60,567 between 2020 and 2023 — a nearly sevenfold increase.
“The number of adolescents taking these medications is going up because they work,” said Suzanne Cuda, MD, medical director of Alamo City Healthy Kids and Families, a medical weight management clinic in San Antonio. The medications have been shown to treat type 2 diabetes, lower blood pressure, and reduce the risk for cardiovascular diseases.
“The younger you are, the better the outcome,” Dr. Cuda said.
How GLP-1 agonists may affect adolescents in the long run is not yet clear. Existing studies on GLP-1 medications in patients with eating disorders have shown mixed results. Some studies indicate that the drugs decrease binge episodes for those with binge eating disorder or bulimia nervosa. However, these studies had small sample sizes and measured only short-term effects, leaving long-term outcomes and risks unknown.
Traditional treatments for eating disorders emphasize regular eating patterns, body acceptance, addressing weight stigma, and improving attunement to hunger and fullness cues — approaches that may conflict with the effects of GLP-1 agonists. These drugs suppress appetite, alter metabolic signals, and may unintentionally reinforce weight loss as a primary goal, creating a potential disconnect between the aims of recovery from eating disorders and the biologic effects of the medication, experts said.
Dr. Cuda said she has cared for adolescents with diagnosed eating disorders in her practice who are seeking GLP-1 agonists. She said she first works with patients to treat the underlying disorder before prescribing medication.
“One of the concerns is the extreme reductions in calories that could be induced by GLP-1 RA in children and adolescents,” she said. Unlike adults, adolescents use caloric energy not just for physical activity but also for growing and developing, she said.
“They can’t catch up on that growth and development,” she added.
Advice for Screening and Monitoring
The National Eating Disorders Association raised concerns about the potential misuse of these medications and their potential to exacerbate eating disorder behaviors in people who are already at a higher risk of developing one of the conditions, including those with existing mental health disorders, stress, who have already dieted, and who have experienced weight-centric bullying.
Clinicians should be on the lookout for patients seeking GLP-1s who present with symptoms of an eating disorder that may be less apparent, such as picky eating, insomnia or difficulty sleeping, or, for girls, irregular menstrual periods, Dr. Dennis said. These patients may be more likely to go undiagnosed or misdiagnosed. Research also suggests that people of color are less likely to be diagnosed or receive specialty care for eating disorders.
Discussions between patients and clinicians about obesity treatment prior to prescribing provide a crucial opportunity to screen and monitor for disordered eating, which Dr. Dennis said does not universally occur currently.
Dr. Dennis recommended initial assessments using validated screening tools like the EDE-Q and the Center for Epidemiologic Studies Depression Scale Revised, 10-Item Version.
Ongoing monitoring throughout treatment is essential, with initial monthly check-ins that include dietary counseling to detect subtle changes in eating behaviors or attitudes toward food and body image, Dr. Cuda said.
The Obesity Medicine Association (OMA) has stressed the importance of a collaborative approach involving connections with mental health professionals specializing in eating disorders and dietitians.
“If you have a chance to send them to an obesity medicine specialist, you should do that,” said Dr. Cuda, who coauthored the OMA statement. “It’s impractical to expect a primary care physician to do everything: Screen for dietary disorders, do a full dietary counseling, follow up on their activity.”
For patients showing signs of disordered eating, clinicians should avoid recommending restrictive dietary approaches, like cutting out food groups such as carbohydrates or a restricted calorie goal. Instead, they can suggest focusing on healthier lifestyle habits and referring to a psychotherapist, the experts said. Clinicians also should be prepared to adjust or pause GLP-1 agonists if disordered eating disorder symptoms worsen.
“I think a weight-agnostic approach where the focus of care is not weight loss but increase in health protective behaviors and nutritional intake is safest for all kids, especially those with eating disorders or eating disorder risk factors,” Dr. Dennis said.
Various authors of the eating disorder study reported receiving grants, advisory board fees, and speaker fees from entities including the National Health and Medical Research Council of Australia, Eli Lilly, Novo Nordisk, Nu-Mega Ingredients, and the National Institutes of Health, among others.
A version of this article appeared on Medscape.com.
Now, with the rising popularity of medications like Ozempic for weight loss, she fears she will care for more teens with eating disorders who are seeking glucagon-like peptide 1 (GLP-1) agonists or who have developed a disorder while taking them.
“We haven’t seen patients yet, but I’m sure they are on their way,” said Dr. Dennis, a clinical assistant professor in the Department of Psychiatry at the University of Illinois College of Medicine in Chicago. She is also the cofounder and chief medical officer of SunCloud Health, an outpatient eating disorder treatment center in Illinois.
Dr. Dennis’ concerns reflect a growing unease among eating disorder specialists as obesity medications gain traction for adolescent use. A recent study published in JAMA Pediatrics showed nearly 80% of teens in treatment for obesity reported symptoms of disordered eating at the outset of an intervention. These included signs of binge eating and loss of control.
The randomized clinical trial, conducted from 2018 to 2023, examined 141 adolescents with obesity undergoing interventions like low-energy diets or intermittent energy restriction. Almost half scored as having risk for an undiagnosed eating disorder, as defined by the Eating Disorder Examination Questionnaire (EDE-Q).
At the end of the intervention, many teens continued to have symptoms of disordered eating, while a smaller group was newly scored as having a risk for an eating disorder.
Weight Loss and Eating Disorders: A Balancing Act
The findings illuminate a significant challenge for pediatricians and primary care clinicians: Balancing effective weight management with the risk of exacerbating or triggering eating disorders, said Hiba Jebeile, PhD, a research dietitian at The Children’s Hospital at Westmead in Australia, and the study’s lead author. Adding weight loss medication on top of the equation can further complicate care.
“It is helpful for obesity and eating disorder services to work together, with clear referral pathways, to manage these adolescents,” Dr. Jebeile said.
The US Food and Drug Administration approved semaglutide for weight loss in adolescents aged 12-17 years in December 2020. One study found that the number of adolescents prescribed GLP-1 receptor agonists (GLP-1 RAs) for type 2 diabetes and weight management rose from 8722 to 60,567 between 2020 and 2023 — a nearly sevenfold increase.
“The number of adolescents taking these medications is going up because they work,” said Suzanne Cuda, MD, medical director of Alamo City Healthy Kids and Families, a medical weight management clinic in San Antonio. The medications have been shown to treat type 2 diabetes, lower blood pressure, and reduce the risk for cardiovascular diseases.
“The younger you are, the better the outcome,” Dr. Cuda said.
How GLP-1 agonists may affect adolescents in the long run is not yet clear. Existing studies on GLP-1 medications in patients with eating disorders have shown mixed results. Some studies indicate that the drugs decrease binge episodes for those with binge eating disorder or bulimia nervosa. However, these studies had small sample sizes and measured only short-term effects, leaving long-term outcomes and risks unknown.
Traditional treatments for eating disorders emphasize regular eating patterns, body acceptance, addressing weight stigma, and improving attunement to hunger and fullness cues — approaches that may conflict with the effects of GLP-1 agonists. These drugs suppress appetite, alter metabolic signals, and may unintentionally reinforce weight loss as a primary goal, creating a potential disconnect between the aims of recovery from eating disorders and the biologic effects of the medication, experts said.
Dr. Cuda said she has cared for adolescents with diagnosed eating disorders in her practice who are seeking GLP-1 agonists. She said she first works with patients to treat the underlying disorder before prescribing medication.
“One of the concerns is the extreme reductions in calories that could be induced by GLP-1 RA in children and adolescents,” she said. Unlike adults, adolescents use caloric energy not just for physical activity but also for growing and developing, she said.
“They can’t catch up on that growth and development,” she added.
Advice for Screening and Monitoring
The National Eating Disorders Association raised concerns about the potential misuse of these medications and their potential to exacerbate eating disorder behaviors in people who are already at a higher risk of developing one of the conditions, including those with existing mental health disorders, stress, who have already dieted, and who have experienced weight-centric bullying.
Clinicians should be on the lookout for patients seeking GLP-1s who present with symptoms of an eating disorder that may be less apparent, such as picky eating, insomnia or difficulty sleeping, or, for girls, irregular menstrual periods, Dr. Dennis said. These patients may be more likely to go undiagnosed or misdiagnosed. Research also suggests that people of color are less likely to be diagnosed or receive specialty care for eating disorders.
Discussions between patients and clinicians about obesity treatment prior to prescribing provide a crucial opportunity to screen and monitor for disordered eating, which Dr. Dennis said does not universally occur currently.
Dr. Dennis recommended initial assessments using validated screening tools like the EDE-Q and the Center for Epidemiologic Studies Depression Scale Revised, 10-Item Version.
Ongoing monitoring throughout treatment is essential, with initial monthly check-ins that include dietary counseling to detect subtle changes in eating behaviors or attitudes toward food and body image, Dr. Cuda said.
The Obesity Medicine Association (OMA) has stressed the importance of a collaborative approach involving connections with mental health professionals specializing in eating disorders and dietitians.
“If you have a chance to send them to an obesity medicine specialist, you should do that,” said Dr. Cuda, who coauthored the OMA statement. “It’s impractical to expect a primary care physician to do everything: Screen for dietary disorders, do a full dietary counseling, follow up on their activity.”
For patients showing signs of disordered eating, clinicians should avoid recommending restrictive dietary approaches, like cutting out food groups such as carbohydrates or a restricted calorie goal. Instead, they can suggest focusing on healthier lifestyle habits and referring to a psychotherapist, the experts said. Clinicians also should be prepared to adjust or pause GLP-1 agonists if disordered eating disorder symptoms worsen.
“I think a weight-agnostic approach where the focus of care is not weight loss but increase in health protective behaviors and nutritional intake is safest for all kids, especially those with eating disorders or eating disorder risk factors,” Dr. Dennis said.
Various authors of the eating disorder study reported receiving grants, advisory board fees, and speaker fees from entities including the National Health and Medical Research Council of Australia, Eli Lilly, Novo Nordisk, Nu-Mega Ingredients, and the National Institutes of Health, among others.
A version of this article appeared on Medscape.com.
FROM JAMA PEDIATRICS
Biomarkers in Cord Blood May Predict AD Onset in Newborns, Study Suggests
TOPLINE:
and interleukin (IL) 31.
METHODOLOGY:
- Researchers conducted a prospective study to evaluate the predictive role of serologic biomarkers and cutaneous markers and the development of AD in 40 full-term newborns from a university hospital in Italy.
- Cord blood was collected at birth and analyzed for serum biomarkers such as CCL17/TARC and IL-31.
- TEWL and skin hydration rates were measured at 1, 6, and 12 months, and dermatological features such as dryness, cradle cap, and eczematous lesions were also monitored during visits.
TAKEAWAY:
- At 6 months, 16 infants had symptoms of AD, which included dry skin, pruritus, and keratosis pilaris, which persisted at 12 months. Their mean Eczema Area and Severity Index score was 6.6 at 6 months and 2.9 at 12 months.
- Infants with signs of AD had significantly higher TEWL levels at the anterior cubital fossa at 1, 6, and 12 months than those without AD.
- Cord blood levels of CCL17/TARC and IL-31 were significantly higher in infants with AD.
- A correlation was found between TEWL values and CCL17 levels at 1, 6, and 12 months.
IN PRACTICE:
“,” the authors wrote. “Stratified interventions based on these variables, family history, FLG [filaggrin] variations, and other biomarkers could offer more targeted approaches to AD prevention and management, especially during the first year of life,” they added.
SOURCE:
The study was led by Angelo Massimiliano D’Erme, MD, PhD, of the Dermatology Unit, in the Department of Medical and Oncology, University of Pisa, Pisa, Italy, and was published online in JAMA Dermatology.
LIMITATIONS:
The limitations included the observational design and small sample size, and it was a single-center study.
DISCLOSURES:
The authors did not disclose any funding information. One author disclosed receiving personal fees from various pharmaceutical companies and serving as a founder and chairman of a nonprofit organization.
This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication.A version of this article appeared on Medscape.com.
TOPLINE:
and interleukin (IL) 31.
METHODOLOGY:
- Researchers conducted a prospective study to evaluate the predictive role of serologic biomarkers and cutaneous markers and the development of AD in 40 full-term newborns from a university hospital in Italy.
- Cord blood was collected at birth and analyzed for serum biomarkers such as CCL17/TARC and IL-31.
- TEWL and skin hydration rates were measured at 1, 6, and 12 months, and dermatological features such as dryness, cradle cap, and eczematous lesions were also monitored during visits.
TAKEAWAY:
- At 6 months, 16 infants had symptoms of AD, which included dry skin, pruritus, and keratosis pilaris, which persisted at 12 months. Their mean Eczema Area and Severity Index score was 6.6 at 6 months and 2.9 at 12 months.
- Infants with signs of AD had significantly higher TEWL levels at the anterior cubital fossa at 1, 6, and 12 months than those without AD.
- Cord blood levels of CCL17/TARC and IL-31 were significantly higher in infants with AD.
- A correlation was found between TEWL values and CCL17 levels at 1, 6, and 12 months.
IN PRACTICE:
“,” the authors wrote. “Stratified interventions based on these variables, family history, FLG [filaggrin] variations, and other biomarkers could offer more targeted approaches to AD prevention and management, especially during the first year of life,” they added.
SOURCE:
The study was led by Angelo Massimiliano D’Erme, MD, PhD, of the Dermatology Unit, in the Department of Medical and Oncology, University of Pisa, Pisa, Italy, and was published online in JAMA Dermatology.
LIMITATIONS:
The limitations included the observational design and small sample size, and it was a single-center study.
DISCLOSURES:
The authors did not disclose any funding information. One author disclosed receiving personal fees from various pharmaceutical companies and serving as a founder and chairman of a nonprofit organization.
This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication.A version of this article appeared on Medscape.com.
TOPLINE:
and interleukin (IL) 31.
METHODOLOGY:
- Researchers conducted a prospective study to evaluate the predictive role of serologic biomarkers and cutaneous markers and the development of AD in 40 full-term newborns from a university hospital in Italy.
- Cord blood was collected at birth and analyzed for serum biomarkers such as CCL17/TARC and IL-31.
- TEWL and skin hydration rates were measured at 1, 6, and 12 months, and dermatological features such as dryness, cradle cap, and eczematous lesions were also monitored during visits.
TAKEAWAY:
- At 6 months, 16 infants had symptoms of AD, which included dry skin, pruritus, and keratosis pilaris, which persisted at 12 months. Their mean Eczema Area and Severity Index score was 6.6 at 6 months and 2.9 at 12 months.
- Infants with signs of AD had significantly higher TEWL levels at the anterior cubital fossa at 1, 6, and 12 months than those without AD.
- Cord blood levels of CCL17/TARC and IL-31 were significantly higher in infants with AD.
- A correlation was found between TEWL values and CCL17 levels at 1, 6, and 12 months.
IN PRACTICE:
“,” the authors wrote. “Stratified interventions based on these variables, family history, FLG [filaggrin] variations, and other biomarkers could offer more targeted approaches to AD prevention and management, especially during the first year of life,” they added.
SOURCE:
The study was led by Angelo Massimiliano D’Erme, MD, PhD, of the Dermatology Unit, in the Department of Medical and Oncology, University of Pisa, Pisa, Italy, and was published online in JAMA Dermatology.
LIMITATIONS:
The limitations included the observational design and small sample size, and it was a single-center study.
DISCLOSURES:
The authors did not disclose any funding information. One author disclosed receiving personal fees from various pharmaceutical companies and serving as a founder and chairman of a nonprofit organization.
This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication.A version of this article appeared on Medscape.com.
New Options for Treating Atopic Dermatitis Available, and in Development
HUNTINGTON BEACH, CALIFORNIA — If the number of recent drug approvals for atopic dermatitis (AD) is overwhelming, the future is unlikely to be any less challenging: According to the National Eczema Association, the current pipeline for AD includes 39 injectable medications, 21 oral agents, and 49 topicals, some with novel targets, like human umbilical cord blood derived stem cells.
“It’s amazing how many drugs are coming out for AD,” Robert Sidbury, MD, MPH, said at the annual meeting of the Pacific Dermatologic Association (PDA). and is approved in Europe for the treatment of moderate to severe AD in patients aged ≥ 12 years. (On September 13, after the PDA meeting, lebrikizumab was approved by the Food and Drug Administration [FDA] for treatment of moderate to severe AD in adults and adolescents aged ≥ 12 years.)
In two identical phase 3 trials known as ADvocate 1 and ADvocate 2, researchers randomly assigned 851 patients with moderate to severe AD in a 2:1 ratio to receive either lebrikizumab at a dose of 250 mg (loading dose of 500 mg at baseline and week 2) or placebo, administered subcutaneously every 2 weeks, through week 16. The primary outcome was an Investigator’s Global Assessment (IGA) score of 0 or 1, indicating clear or almost clear skin. The researchers reported that an IGA score of 0 or 1 was achieved by 43.1% of patients in the lebrikizumab arm compared with 12.7% of those in the placebo arm.
“Those are good numbers,” said Dr. Sidbury, who was not involved with the study. Conjunctivitis occurred more often in those who received lebrikizumab compared with those who received placebo (7.4% vs 2.8%, respectively), “which is not surprising because it is an IL-13 agent,” he said.
In a subsequent study presented during the Revolutionizing Atopic Dermatitis meeting in the fall of 2023, researchers presented data on Eczema Severity and Area Index (EASI)-90 responses in the ADvocate trial participants, showing EASI-90 responses were sustained up to 38 weeks after lebrikizumab withdrawal, while serum concentrations were negligible. They found that between week 14 and week 32, approximately five serum concentration half-lives of the medication had elapsed since patients randomized to the withdrawal arm received their last dose of lebrikizumab, extending to approximately 11 half-lives by week 52. “That durability of response with next to no blood levels of drug in many of the study participants is interesting,” said Dr. Sidbury, who cochairs the current iteration of the American Academy of Dermatology Atopic Dermatitis Guidelines.
Nemolizumab is a neuroimmune response modulator that inhibits the IL-31 receptor and is approved in Japan for the treatment of itch associated with AD in patients aged ≥ 13 years. Results from two identical phase 3, randomized, controlled trials known as ARCADIA 1 and ARCADIA 2 found that 36% of patients in ARCADIA 1 and 38% in ARCADIA 2 achieved clear skin, compared with 25% and 26% of patients in the placebo group, respectively. (Nemolizumab was recently approved by the FDA for treating prurigo nodularis and is under FDA review for AD.)
In terms of safety, Dr. Sidbury, who is a member of the steering committee for the ARCADIA trials, said that nemolizumab has been “generally well tolerated;” with 1%-3% of study participants experiencing at least one serious treatment-emergent adverse event that included asthma exacerbation, facial edema, and peripheral edema. “The latest data are reassuring but we are watching these safety concerns carefully,” he said.
Dr. Sidbury disclosed that he is an investigator for Regeneron, Pfizer, Galderma, UCB, and Castle; a consultant for Lilly, Leo, Arcutis, and Dermavant; and a member of the speaker’s bureau for Beiersdorf.
A version of this article appeared on Medscape.com.
HUNTINGTON BEACH, CALIFORNIA — If the number of recent drug approvals for atopic dermatitis (AD) is overwhelming, the future is unlikely to be any less challenging: According to the National Eczema Association, the current pipeline for AD includes 39 injectable medications, 21 oral agents, and 49 topicals, some with novel targets, like human umbilical cord blood derived stem cells.
“It’s amazing how many drugs are coming out for AD,” Robert Sidbury, MD, MPH, said at the annual meeting of the Pacific Dermatologic Association (PDA). and is approved in Europe for the treatment of moderate to severe AD in patients aged ≥ 12 years. (On September 13, after the PDA meeting, lebrikizumab was approved by the Food and Drug Administration [FDA] for treatment of moderate to severe AD in adults and adolescents aged ≥ 12 years.)
In two identical phase 3 trials known as ADvocate 1 and ADvocate 2, researchers randomly assigned 851 patients with moderate to severe AD in a 2:1 ratio to receive either lebrikizumab at a dose of 250 mg (loading dose of 500 mg at baseline and week 2) or placebo, administered subcutaneously every 2 weeks, through week 16. The primary outcome was an Investigator’s Global Assessment (IGA) score of 0 or 1, indicating clear or almost clear skin. The researchers reported that an IGA score of 0 or 1 was achieved by 43.1% of patients in the lebrikizumab arm compared with 12.7% of those in the placebo arm.
“Those are good numbers,” said Dr. Sidbury, who was not involved with the study. Conjunctivitis occurred more often in those who received lebrikizumab compared with those who received placebo (7.4% vs 2.8%, respectively), “which is not surprising because it is an IL-13 agent,” he said.
In a subsequent study presented during the Revolutionizing Atopic Dermatitis meeting in the fall of 2023, researchers presented data on Eczema Severity and Area Index (EASI)-90 responses in the ADvocate trial participants, showing EASI-90 responses were sustained up to 38 weeks after lebrikizumab withdrawal, while serum concentrations were negligible. They found that between week 14 and week 32, approximately five serum concentration half-lives of the medication had elapsed since patients randomized to the withdrawal arm received their last dose of lebrikizumab, extending to approximately 11 half-lives by week 52. “That durability of response with next to no blood levels of drug in many of the study participants is interesting,” said Dr. Sidbury, who cochairs the current iteration of the American Academy of Dermatology Atopic Dermatitis Guidelines.
Nemolizumab is a neuroimmune response modulator that inhibits the IL-31 receptor and is approved in Japan for the treatment of itch associated with AD in patients aged ≥ 13 years. Results from two identical phase 3, randomized, controlled trials known as ARCADIA 1 and ARCADIA 2 found that 36% of patients in ARCADIA 1 and 38% in ARCADIA 2 achieved clear skin, compared with 25% and 26% of patients in the placebo group, respectively. (Nemolizumab was recently approved by the FDA for treating prurigo nodularis and is under FDA review for AD.)
In terms of safety, Dr. Sidbury, who is a member of the steering committee for the ARCADIA trials, said that nemolizumab has been “generally well tolerated;” with 1%-3% of study participants experiencing at least one serious treatment-emergent adverse event that included asthma exacerbation, facial edema, and peripheral edema. “The latest data are reassuring but we are watching these safety concerns carefully,” he said.
Dr. Sidbury disclosed that he is an investigator for Regeneron, Pfizer, Galderma, UCB, and Castle; a consultant for Lilly, Leo, Arcutis, and Dermavant; and a member of the speaker’s bureau for Beiersdorf.
A version of this article appeared on Medscape.com.
HUNTINGTON BEACH, CALIFORNIA — If the number of recent drug approvals for atopic dermatitis (AD) is overwhelming, the future is unlikely to be any less challenging: According to the National Eczema Association, the current pipeline for AD includes 39 injectable medications, 21 oral agents, and 49 topicals, some with novel targets, like human umbilical cord blood derived stem cells.
“It’s amazing how many drugs are coming out for AD,” Robert Sidbury, MD, MPH, said at the annual meeting of the Pacific Dermatologic Association (PDA). and is approved in Europe for the treatment of moderate to severe AD in patients aged ≥ 12 years. (On September 13, after the PDA meeting, lebrikizumab was approved by the Food and Drug Administration [FDA] for treatment of moderate to severe AD in adults and adolescents aged ≥ 12 years.)
In two identical phase 3 trials known as ADvocate 1 and ADvocate 2, researchers randomly assigned 851 patients with moderate to severe AD in a 2:1 ratio to receive either lebrikizumab at a dose of 250 mg (loading dose of 500 mg at baseline and week 2) or placebo, administered subcutaneously every 2 weeks, through week 16. The primary outcome was an Investigator’s Global Assessment (IGA) score of 0 or 1, indicating clear or almost clear skin. The researchers reported that an IGA score of 0 or 1 was achieved by 43.1% of patients in the lebrikizumab arm compared with 12.7% of those in the placebo arm.
“Those are good numbers,” said Dr. Sidbury, who was not involved with the study. Conjunctivitis occurred more often in those who received lebrikizumab compared with those who received placebo (7.4% vs 2.8%, respectively), “which is not surprising because it is an IL-13 agent,” he said.
In a subsequent study presented during the Revolutionizing Atopic Dermatitis meeting in the fall of 2023, researchers presented data on Eczema Severity and Area Index (EASI)-90 responses in the ADvocate trial participants, showing EASI-90 responses were sustained up to 38 weeks after lebrikizumab withdrawal, while serum concentrations were negligible. They found that between week 14 and week 32, approximately five serum concentration half-lives of the medication had elapsed since patients randomized to the withdrawal arm received their last dose of lebrikizumab, extending to approximately 11 half-lives by week 52. “That durability of response with next to no blood levels of drug in many of the study participants is interesting,” said Dr. Sidbury, who cochairs the current iteration of the American Academy of Dermatology Atopic Dermatitis Guidelines.
Nemolizumab is a neuroimmune response modulator that inhibits the IL-31 receptor and is approved in Japan for the treatment of itch associated with AD in patients aged ≥ 13 years. Results from two identical phase 3, randomized, controlled trials known as ARCADIA 1 and ARCADIA 2 found that 36% of patients in ARCADIA 1 and 38% in ARCADIA 2 achieved clear skin, compared with 25% and 26% of patients in the placebo group, respectively. (Nemolizumab was recently approved by the FDA for treating prurigo nodularis and is under FDA review for AD.)
In terms of safety, Dr. Sidbury, who is a member of the steering committee for the ARCADIA trials, said that nemolizumab has been “generally well tolerated;” with 1%-3% of study participants experiencing at least one serious treatment-emergent adverse event that included asthma exacerbation, facial edema, and peripheral edema. “The latest data are reassuring but we are watching these safety concerns carefully,” he said.
Dr. Sidbury disclosed that he is an investigator for Regeneron, Pfizer, Galderma, UCB, and Castle; a consultant for Lilly, Leo, Arcutis, and Dermavant; and a member of the speaker’s bureau for Beiersdorf.
A version of this article appeared on Medscape.com.
FROM PDA 2024
Whooping Cough Rising Fast, Especially Among Teens
Whooping cough is surging in the United States, with four times as many cases reported so far this year, compared to all of 2023.
The CDC said 14,569 cases had been reported as of Sept. 14, compared to 3475 in all of 2023.
Whooping cough, also called pertussis, is a respiratory illness spread through coughing, sneezing, or breathing very close to another person. Babies are given the DTaP vaccine to protect against whooping cough, diphtheria, and tetanus. Because the vaccine effectiveness wanes faster for whooping cough than the two other illnesses, boosters are recommended every decade or so.
Why the Whooping Cough Vaccine Is Important
Whooping cough is a very contagious bacteria, so vaccination is an important step to avoid it.
But many children in their tweens aren’t getting boosters, and that age group is driving the whooping cough outbreak.
“With the increase in vaccine hesitancy that has been going on since the COVID-19 pandemic, we’re seeing outbreaks occurring in kids who are not vaccinated,” Tina Tan, MD, president-elect of the Infectious Diseases Society of America, told NBC News.
Also, people are not social distancing the way they did during the height of the COVID pandemic, when whooping cough numbers went down.
“Levels of pertussis dropped dramatically when we were all masking, and now this huge increase is getting us back to pre-pandemic levels, and probably a little above that,” Thomas Murray, MD, a Yale Medicine pediatric infectious diseases specialist, said in a news release from the school. “It’s a contagious respiratory virus that can spread fairly quickly through the population.”
FDA advisers were scheduled to meet Sept. 20 to discuss developing more effective boosters for whooping cough.
A version of this article appeared on WebMD.com.
Whooping cough is surging in the United States, with four times as many cases reported so far this year, compared to all of 2023.
The CDC said 14,569 cases had been reported as of Sept. 14, compared to 3475 in all of 2023.
Whooping cough, also called pertussis, is a respiratory illness spread through coughing, sneezing, or breathing very close to another person. Babies are given the DTaP vaccine to protect against whooping cough, diphtheria, and tetanus. Because the vaccine effectiveness wanes faster for whooping cough than the two other illnesses, boosters are recommended every decade or so.
Why the Whooping Cough Vaccine Is Important
Whooping cough is a very contagious bacteria, so vaccination is an important step to avoid it.
But many children in their tweens aren’t getting boosters, and that age group is driving the whooping cough outbreak.
“With the increase in vaccine hesitancy that has been going on since the COVID-19 pandemic, we’re seeing outbreaks occurring in kids who are not vaccinated,” Tina Tan, MD, president-elect of the Infectious Diseases Society of America, told NBC News.
Also, people are not social distancing the way they did during the height of the COVID pandemic, when whooping cough numbers went down.
“Levels of pertussis dropped dramatically when we were all masking, and now this huge increase is getting us back to pre-pandemic levels, and probably a little above that,” Thomas Murray, MD, a Yale Medicine pediatric infectious diseases specialist, said in a news release from the school. “It’s a contagious respiratory virus that can spread fairly quickly through the population.”
FDA advisers were scheduled to meet Sept. 20 to discuss developing more effective boosters for whooping cough.
A version of this article appeared on WebMD.com.
Whooping cough is surging in the United States, with four times as many cases reported so far this year, compared to all of 2023.
The CDC said 14,569 cases had been reported as of Sept. 14, compared to 3475 in all of 2023.
Whooping cough, also called pertussis, is a respiratory illness spread through coughing, sneezing, or breathing very close to another person. Babies are given the DTaP vaccine to protect against whooping cough, diphtheria, and tetanus. Because the vaccine effectiveness wanes faster for whooping cough than the two other illnesses, boosters are recommended every decade or so.
Why the Whooping Cough Vaccine Is Important
Whooping cough is a very contagious bacteria, so vaccination is an important step to avoid it.
But many children in their tweens aren’t getting boosters, and that age group is driving the whooping cough outbreak.
“With the increase in vaccine hesitancy that has been going on since the COVID-19 pandemic, we’re seeing outbreaks occurring in kids who are not vaccinated,” Tina Tan, MD, president-elect of the Infectious Diseases Society of America, told NBC News.
Also, people are not social distancing the way they did during the height of the COVID pandemic, when whooping cough numbers went down.
“Levels of pertussis dropped dramatically when we were all masking, and now this huge increase is getting us back to pre-pandemic levels, and probably a little above that,” Thomas Murray, MD, a Yale Medicine pediatric infectious diseases specialist, said in a news release from the school. “It’s a contagious respiratory virus that can spread fairly quickly through the population.”
FDA advisers were scheduled to meet Sept. 20 to discuss developing more effective boosters for whooping cough.
A version of this article appeared on WebMD.com.
Guidance Will Aid Pediatric to Adult Diabetes Care Transfer
MADRID — A new consensus statement in development will aim to advise on best practices for navigating the transition of youth with diabetes from pediatric to adult diabetes care, despite limited data.
Expected to be released in early 2025, the statement will be a joint effort of the International Society for Pediatric and Adolescent Diabetes (ISPAD), the American Diabetes Association (ADA), and the European Association for the Study of Diabetes (EASD). It will provide guidance on advance transition planning, the care transfer itself, and follow-up. Writing panel members presented an update on the statement’s development on September 13, 2024, at EASD’s annual meeting.
The care transition period is critical because “adolescents and young adults are the least likely of all age groups to achieve glycemic targets for a variety of physiological and psychosocial reasons ... Up to 60% of these individuals don’t transfer successfully from pediatric to adult care, with declines in attendance, adverse medical outcomes, and mental health challenges,” Frank J. Snoek, PhD, emeritus professor of medical psychology at Amsterdam University Medical College, Amsterdam, the Netherlands, said in introductory remarks at the EASD session.
Session chair Carine De Beaufort, MD, a pediatric endocrinologist in Luxembourg City, Luxembourg, told this news organization, “We know it’s a continuing process, which is extremely important for young people to move into the world. The last formal recommendations were published in 2011, so we thought it was time for an update. What we realized in doing a systematic review and scoping review is that there are a lot of suggestions and ideas not really associated with robust data, and it’s not so easy to get good outcome indicators.”
The final statement will provide clinical guidance but, at the same time, “will be very transparent where more work is needed,” she said.
Sarah Lyons, MD, associate professor of pediatrics at Baylor College of Medicine, Houston, broadly outlined the document. Pre-transition planning will include readiness assessments for transfer from pediatric to adult care. The transfer phase will include measures to prevent gaps in care. And the post-transition phase will cover incorporation into adult care, with follow-up of the individual’s progress for a period.
Across the three stages, the document is expected to recommend a multidisciplinary team approach including psychological support, education and assessment, family and peer support, and care coordination. It will also address practical considerations for patients and professionals including costs and insurance.
It will build upon previous guidelines, including those of ADA and general guidance on transition from pediatric to adult healthcare from the American Academy of Pediatrics. “Ideally, this process will be continuous, comprehensive, coordinated, individualized, and developmentally appropriate,” Dr. Lyons said.
‘It Shouldn’t Be Just One Conversation ... It Needs to Be a Process’
Asked to comment, ISPAD president David Maahs, MD, the Lucile Salter Packard Professor of Pediatrics and Division Chief of Pediatric Endocrinology at Stanford University, Palo Alto, California, told this news organization, “It shouldn’t be just one conversation and one visit. It needs to be a process where you talk about the need to transition to adult endocrine care and prepare the person with diabetes and their family for that transition. One of the challenges is if they don’t make it to that first appointment and you assume that they did, and then that’s one place where there can be a gap that people fall through the two systems.”
Dr. Maahs added, “Another issue that’s a big problem in the United States is that children lose their parents’ insurance at 26 ... Some become uninsured after that, or their insurance plan isn’t accepted by the adult provider.”
‘There Does Not Appear to Be Sufficient Data’
Steven James, PhD, RN, of the University of the Sunshine Coast, Brisbane, Australia, presented the limited data upon which the statement will be based. A systematic literature review yielded just 26 intervention trials looking at care transition for youth with type 1 or type 2 diabetes, including seven clinical trials with only one randomized.
In that trial, in which 205 youth aged 17-20 years were randomized to a structured 18-month transition program with a transition coordinator, the intervention was associated with increased clinic attendance, improved satisfaction with care, and decreased diabetes-related distress, but the benefits weren’t maintained 12 months after completion of the intervention.
The other trials produced mixed results in terms of metabolic outcomes, with improvements in A1c and reductions in diabetic ketoacidosis and hospitalizations seen in some but not others. Healthcare outcomes and utilization, psychosocial outcomes, transition-related knowledge, self-care, and care satisfaction were only occasionally assessed, Dr. James noted.
“The field is lacking empirically supported interventions that can improve patient physiologic and psychologic outcomes, prevent poor clinic attendance, and improve patient satisfaction in medical care ... There still does not appear to be sufficient data related to the impact of transition readiness or transfer-to-adult care programs.”
‘Quite a Lot of Variation in Practices Worldwide’
Dr. James also presented results from two online surveys undertaken by the document writing panel. One recently published survey in Diabetes Research and Clinical Practice examined healthcare professionals’ experiences and perceptions around diabetes care transitions. Of 372 respondents (75% physicians) from around the world — including a third in low-middle-income countries — fewer than half reported using transition readiness checklists (32.8%), provided written transition information (29.6%), or had a dedicated staff member to aid in the process (23.7%).
Similarly, few involved a psychologist (25.3%) or had a structured transition education program (22.6%). Even in high-income countries, fewer than half reported using these measures. Overall, a majority (91.9%) reported barriers to offering patients a positive transition experience.
“This shows to me that there is quite a lot of variation in practices worldwide ... There is a pressing need for an international consensus transition guideline,” Dr. James said.
Among the respondents’ beliefs, 53.8% thought that discussions about transitioning should be initiated at ages 15-17 years, while 27.8% thought 12-14 years was more appropriate. Large majorities favored use of a transition readiness checklist (93.6%), combined transition clinics (80.6%), having a dedicated transition coordinator/staff member available (85.8%), and involving a psychologist in the transition process (80.6%).
A similar survey of patients and carers will be published soon and will be included in the new statement’s evidence base, Dr. James said.
Dr. Maahs said that endorsement of the upcoming guidance from three different medical societies should help raise the profile of the issue. “Hopefully three professional organizations are able to speak with a united and louder voice than if it was just one group or one set of authors. I think this consensus statement can raise awareness, improve care, and help advocate for better care.”
Dr. De Beaufort, Dr. James, and Dr. Lyons had no disclosures. Dr. Snoek is an adviser/speaker for Abbott, Lilly, Novo Nordisk, and Sanofi and receives funding from Breakthrough T1D, Sanofi, and Novo Nordisk. Dr. Maahs has had research support from the National Institutes of Health, Breakthrough T1D, National Science Foundation, and the Helmsley Charitable Trust, and his institution has had research support from Medtronic, Dexcom, Insulet, Bigfoot Biomedical, Tandem, and Roche. He has consulted for Abbott, Aditxt, the Helmsley Charitable Trust, LifeScan, MannKind, Sanofi, Novo Nordisk, Eli Lilly, Medtronic, Insulet, Dompe, BioSpex, Provention Bio, Kriya, Enable Biosciences, and Bayer.
A version of this article first appeared on Medscape.com.
MADRID — A new consensus statement in development will aim to advise on best practices for navigating the transition of youth with diabetes from pediatric to adult diabetes care, despite limited data.
Expected to be released in early 2025, the statement will be a joint effort of the International Society for Pediatric and Adolescent Diabetes (ISPAD), the American Diabetes Association (ADA), and the European Association for the Study of Diabetes (EASD). It will provide guidance on advance transition planning, the care transfer itself, and follow-up. Writing panel members presented an update on the statement’s development on September 13, 2024, at EASD’s annual meeting.
The care transition period is critical because “adolescents and young adults are the least likely of all age groups to achieve glycemic targets for a variety of physiological and psychosocial reasons ... Up to 60% of these individuals don’t transfer successfully from pediatric to adult care, with declines in attendance, adverse medical outcomes, and mental health challenges,” Frank J. Snoek, PhD, emeritus professor of medical psychology at Amsterdam University Medical College, Amsterdam, the Netherlands, said in introductory remarks at the EASD session.
Session chair Carine De Beaufort, MD, a pediatric endocrinologist in Luxembourg City, Luxembourg, told this news organization, “We know it’s a continuing process, which is extremely important for young people to move into the world. The last formal recommendations were published in 2011, so we thought it was time for an update. What we realized in doing a systematic review and scoping review is that there are a lot of suggestions and ideas not really associated with robust data, and it’s not so easy to get good outcome indicators.”
The final statement will provide clinical guidance but, at the same time, “will be very transparent where more work is needed,” she said.
Sarah Lyons, MD, associate professor of pediatrics at Baylor College of Medicine, Houston, broadly outlined the document. Pre-transition planning will include readiness assessments for transfer from pediatric to adult care. The transfer phase will include measures to prevent gaps in care. And the post-transition phase will cover incorporation into adult care, with follow-up of the individual’s progress for a period.
Across the three stages, the document is expected to recommend a multidisciplinary team approach including psychological support, education and assessment, family and peer support, and care coordination. It will also address practical considerations for patients and professionals including costs and insurance.
It will build upon previous guidelines, including those of ADA and general guidance on transition from pediatric to adult healthcare from the American Academy of Pediatrics. “Ideally, this process will be continuous, comprehensive, coordinated, individualized, and developmentally appropriate,” Dr. Lyons said.
‘It Shouldn’t Be Just One Conversation ... It Needs to Be a Process’
Asked to comment, ISPAD president David Maahs, MD, the Lucile Salter Packard Professor of Pediatrics and Division Chief of Pediatric Endocrinology at Stanford University, Palo Alto, California, told this news organization, “It shouldn’t be just one conversation and one visit. It needs to be a process where you talk about the need to transition to adult endocrine care and prepare the person with diabetes and their family for that transition. One of the challenges is if they don’t make it to that first appointment and you assume that they did, and then that’s one place where there can be a gap that people fall through the two systems.”
Dr. Maahs added, “Another issue that’s a big problem in the United States is that children lose their parents’ insurance at 26 ... Some become uninsured after that, or their insurance plan isn’t accepted by the adult provider.”
‘There Does Not Appear to Be Sufficient Data’
Steven James, PhD, RN, of the University of the Sunshine Coast, Brisbane, Australia, presented the limited data upon which the statement will be based. A systematic literature review yielded just 26 intervention trials looking at care transition for youth with type 1 or type 2 diabetes, including seven clinical trials with only one randomized.
In that trial, in which 205 youth aged 17-20 years were randomized to a structured 18-month transition program with a transition coordinator, the intervention was associated with increased clinic attendance, improved satisfaction with care, and decreased diabetes-related distress, but the benefits weren’t maintained 12 months after completion of the intervention.
The other trials produced mixed results in terms of metabolic outcomes, with improvements in A1c and reductions in diabetic ketoacidosis and hospitalizations seen in some but not others. Healthcare outcomes and utilization, psychosocial outcomes, transition-related knowledge, self-care, and care satisfaction were only occasionally assessed, Dr. James noted.
“The field is lacking empirically supported interventions that can improve patient physiologic and psychologic outcomes, prevent poor clinic attendance, and improve patient satisfaction in medical care ... There still does not appear to be sufficient data related to the impact of transition readiness or transfer-to-adult care programs.”
‘Quite a Lot of Variation in Practices Worldwide’
Dr. James also presented results from two online surveys undertaken by the document writing panel. One recently published survey in Diabetes Research and Clinical Practice examined healthcare professionals’ experiences and perceptions around diabetes care transitions. Of 372 respondents (75% physicians) from around the world — including a third in low-middle-income countries — fewer than half reported using transition readiness checklists (32.8%), provided written transition information (29.6%), or had a dedicated staff member to aid in the process (23.7%).
Similarly, few involved a psychologist (25.3%) or had a structured transition education program (22.6%). Even in high-income countries, fewer than half reported using these measures. Overall, a majority (91.9%) reported barriers to offering patients a positive transition experience.
“This shows to me that there is quite a lot of variation in practices worldwide ... There is a pressing need for an international consensus transition guideline,” Dr. James said.
Among the respondents’ beliefs, 53.8% thought that discussions about transitioning should be initiated at ages 15-17 years, while 27.8% thought 12-14 years was more appropriate. Large majorities favored use of a transition readiness checklist (93.6%), combined transition clinics (80.6%), having a dedicated transition coordinator/staff member available (85.8%), and involving a psychologist in the transition process (80.6%).
A similar survey of patients and carers will be published soon and will be included in the new statement’s evidence base, Dr. James said.
Dr. Maahs said that endorsement of the upcoming guidance from three different medical societies should help raise the profile of the issue. “Hopefully three professional organizations are able to speak with a united and louder voice than if it was just one group or one set of authors. I think this consensus statement can raise awareness, improve care, and help advocate for better care.”
Dr. De Beaufort, Dr. James, and Dr. Lyons had no disclosures. Dr. Snoek is an adviser/speaker for Abbott, Lilly, Novo Nordisk, and Sanofi and receives funding from Breakthrough T1D, Sanofi, and Novo Nordisk. Dr. Maahs has had research support from the National Institutes of Health, Breakthrough T1D, National Science Foundation, and the Helmsley Charitable Trust, and his institution has had research support from Medtronic, Dexcom, Insulet, Bigfoot Biomedical, Tandem, and Roche. He has consulted for Abbott, Aditxt, the Helmsley Charitable Trust, LifeScan, MannKind, Sanofi, Novo Nordisk, Eli Lilly, Medtronic, Insulet, Dompe, BioSpex, Provention Bio, Kriya, Enable Biosciences, and Bayer.
A version of this article first appeared on Medscape.com.
MADRID — A new consensus statement in development will aim to advise on best practices for navigating the transition of youth with diabetes from pediatric to adult diabetes care, despite limited data.
Expected to be released in early 2025, the statement will be a joint effort of the International Society for Pediatric and Adolescent Diabetes (ISPAD), the American Diabetes Association (ADA), and the European Association for the Study of Diabetes (EASD). It will provide guidance on advance transition planning, the care transfer itself, and follow-up. Writing panel members presented an update on the statement’s development on September 13, 2024, at EASD’s annual meeting.
The care transition period is critical because “adolescents and young adults are the least likely of all age groups to achieve glycemic targets for a variety of physiological and psychosocial reasons ... Up to 60% of these individuals don’t transfer successfully from pediatric to adult care, with declines in attendance, adverse medical outcomes, and mental health challenges,” Frank J. Snoek, PhD, emeritus professor of medical psychology at Amsterdam University Medical College, Amsterdam, the Netherlands, said in introductory remarks at the EASD session.
Session chair Carine De Beaufort, MD, a pediatric endocrinologist in Luxembourg City, Luxembourg, told this news organization, “We know it’s a continuing process, which is extremely important for young people to move into the world. The last formal recommendations were published in 2011, so we thought it was time for an update. What we realized in doing a systematic review and scoping review is that there are a lot of suggestions and ideas not really associated with robust data, and it’s not so easy to get good outcome indicators.”
The final statement will provide clinical guidance but, at the same time, “will be very transparent where more work is needed,” she said.
Sarah Lyons, MD, associate professor of pediatrics at Baylor College of Medicine, Houston, broadly outlined the document. Pre-transition planning will include readiness assessments for transfer from pediatric to adult care. The transfer phase will include measures to prevent gaps in care. And the post-transition phase will cover incorporation into adult care, with follow-up of the individual’s progress for a period.
Across the three stages, the document is expected to recommend a multidisciplinary team approach including psychological support, education and assessment, family and peer support, and care coordination. It will also address practical considerations for patients and professionals including costs and insurance.
It will build upon previous guidelines, including those of ADA and general guidance on transition from pediatric to adult healthcare from the American Academy of Pediatrics. “Ideally, this process will be continuous, comprehensive, coordinated, individualized, and developmentally appropriate,” Dr. Lyons said.
‘It Shouldn’t Be Just One Conversation ... It Needs to Be a Process’
Asked to comment, ISPAD president David Maahs, MD, the Lucile Salter Packard Professor of Pediatrics and Division Chief of Pediatric Endocrinology at Stanford University, Palo Alto, California, told this news organization, “It shouldn’t be just one conversation and one visit. It needs to be a process where you talk about the need to transition to adult endocrine care and prepare the person with diabetes and their family for that transition. One of the challenges is if they don’t make it to that first appointment and you assume that they did, and then that’s one place where there can be a gap that people fall through the two systems.”
Dr. Maahs added, “Another issue that’s a big problem in the United States is that children lose their parents’ insurance at 26 ... Some become uninsured after that, or their insurance plan isn’t accepted by the adult provider.”
‘There Does Not Appear to Be Sufficient Data’
Steven James, PhD, RN, of the University of the Sunshine Coast, Brisbane, Australia, presented the limited data upon which the statement will be based. A systematic literature review yielded just 26 intervention trials looking at care transition for youth with type 1 or type 2 diabetes, including seven clinical trials with only one randomized.
In that trial, in which 205 youth aged 17-20 years were randomized to a structured 18-month transition program with a transition coordinator, the intervention was associated with increased clinic attendance, improved satisfaction with care, and decreased diabetes-related distress, but the benefits weren’t maintained 12 months after completion of the intervention.
The other trials produced mixed results in terms of metabolic outcomes, with improvements in A1c and reductions in diabetic ketoacidosis and hospitalizations seen in some but not others. Healthcare outcomes and utilization, psychosocial outcomes, transition-related knowledge, self-care, and care satisfaction were only occasionally assessed, Dr. James noted.
“The field is lacking empirically supported interventions that can improve patient physiologic and psychologic outcomes, prevent poor clinic attendance, and improve patient satisfaction in medical care ... There still does not appear to be sufficient data related to the impact of transition readiness or transfer-to-adult care programs.”
‘Quite a Lot of Variation in Practices Worldwide’
Dr. James also presented results from two online surveys undertaken by the document writing panel. One recently published survey in Diabetes Research and Clinical Practice examined healthcare professionals’ experiences and perceptions around diabetes care transitions. Of 372 respondents (75% physicians) from around the world — including a third in low-middle-income countries — fewer than half reported using transition readiness checklists (32.8%), provided written transition information (29.6%), or had a dedicated staff member to aid in the process (23.7%).
Similarly, few involved a psychologist (25.3%) or had a structured transition education program (22.6%). Even in high-income countries, fewer than half reported using these measures. Overall, a majority (91.9%) reported barriers to offering patients a positive transition experience.
“This shows to me that there is quite a lot of variation in practices worldwide ... There is a pressing need for an international consensus transition guideline,” Dr. James said.
Among the respondents’ beliefs, 53.8% thought that discussions about transitioning should be initiated at ages 15-17 years, while 27.8% thought 12-14 years was more appropriate. Large majorities favored use of a transition readiness checklist (93.6%), combined transition clinics (80.6%), having a dedicated transition coordinator/staff member available (85.8%), and involving a psychologist in the transition process (80.6%).
A similar survey of patients and carers will be published soon and will be included in the new statement’s evidence base, Dr. James said.
Dr. Maahs said that endorsement of the upcoming guidance from three different medical societies should help raise the profile of the issue. “Hopefully three professional organizations are able to speak with a united and louder voice than if it was just one group or one set of authors. I think this consensus statement can raise awareness, improve care, and help advocate for better care.”
Dr. De Beaufort, Dr. James, and Dr. Lyons had no disclosures. Dr. Snoek is an adviser/speaker for Abbott, Lilly, Novo Nordisk, and Sanofi and receives funding from Breakthrough T1D, Sanofi, and Novo Nordisk. Dr. Maahs has had research support from the National Institutes of Health, Breakthrough T1D, National Science Foundation, and the Helmsley Charitable Trust, and his institution has had research support from Medtronic, Dexcom, Insulet, Bigfoot Biomedical, Tandem, and Roche. He has consulted for Abbott, Aditxt, the Helmsley Charitable Trust, LifeScan, MannKind, Sanofi, Novo Nordisk, Eli Lilly, Medtronic, Insulet, Dompe, BioSpex, Provention Bio, Kriya, Enable Biosciences, and Bayer.
A version of this article first appeared on Medscape.com.
FROM EASD 2024
Study Reports Safety Data in Children on JAK Inhibitors
TOPLINE:
which also found that acne was the most common skin-related AE in children, and serious AEs were less common.
METHODOLOGY:
- Researchers analyzed 399,649 AEs in 133,216 adult patients and 2883 AEs in 955 pediatric patients (age, < 18 years) from November 2011 to February 2023 using the US Food and Drug Administration Adverse Event Reporting System and the Canada Vigilance Adverse Reaction Online Database.
- AEs were categorized on the basis of the Medical Dictionary for Regulatory Activities system organ class.
- Five JAK inhibitors approved for use in children were included in the study: Baricitinib, upadacitinib, abrocitinib, ruxolitinib, and tofacitinib.
TAKEAWAY:
- The most frequently reported AEs in children were blood and lymphatic system disorders, including neutropenia, thrombocytopenia, and anemia (24%); viral, fungal, and bacterial infections, such as pneumonia and sepsis (17.2%); constitutional symptoms and administrative concerns, including pyrexia and fatigue (15.7%); gastrointestinal disorders, such as vomiting and abdominal pain (13.6%); and respiratory disorders, such as cough and respiratory distress (5.3%).
- In adults, the most common AEs were viral, fungal, and bacterial infections (16.8%); constitutional symptoms and administrative concerns (13.5%); musculoskeletal and connective tissue disorders (7.04%); and gastrointestinal (5.8%) and nervous system (5%) disorders.
- Acne (30.6%), atopic dermatitis (22.2%), and psoriasis (16.7%) were the most common skin and subcutaneous tissue AEs reported in children. Skin and subcutaneous AEs were more common with upadacitinib (21.1%), abrocitinib (9.1%), and tofacitinib (6.3%) in children.
- Serious AEs included in the boxed warning for JAK inhibitors — serious infection, mortality, malignancy, cardiovascular events, and thrombosis — were similar for baricitinib in children (4 of 49 patients, 8.2%) and adults (325 of 3707, 8.8%). For other JAK inhibitors, absolute numbers of these AEs in children were small and rates were lower in children than in adults.
IN PRACTICE:
“This information can support customized treatment and minimize the potential for undesired or intolerable AEs,” the authors wrote.
SOURCE:
This study was led by Sahithi Talasila, BS, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, and was published online in Pediatric Dermatology.
LIMITATIONS:
Pharmacovigilance registries did not fully capture the complete range of AEs because of potential reporting bias or recall bias. Additionally, events lacking sufficient objective evidence were underreported, while common AEs associated with JAK inhibitor therapy were overreported.
DISCLOSURES:
No specific funding sources for the study were reported. One author reported being a consultant, one reported serving as a principal investigator in clinical trials, and another reported serving on data and safety monitoring boards of various pharmaceutical companies.
This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication. A version of this article first appeared on Medscape.com.
TOPLINE:
which also found that acne was the most common skin-related AE in children, and serious AEs were less common.
METHODOLOGY:
- Researchers analyzed 399,649 AEs in 133,216 adult patients and 2883 AEs in 955 pediatric patients (age, < 18 years) from November 2011 to February 2023 using the US Food and Drug Administration Adverse Event Reporting System and the Canada Vigilance Adverse Reaction Online Database.
- AEs were categorized on the basis of the Medical Dictionary for Regulatory Activities system organ class.
- Five JAK inhibitors approved for use in children were included in the study: Baricitinib, upadacitinib, abrocitinib, ruxolitinib, and tofacitinib.
TAKEAWAY:
- The most frequently reported AEs in children were blood and lymphatic system disorders, including neutropenia, thrombocytopenia, and anemia (24%); viral, fungal, and bacterial infections, such as pneumonia and sepsis (17.2%); constitutional symptoms and administrative concerns, including pyrexia and fatigue (15.7%); gastrointestinal disorders, such as vomiting and abdominal pain (13.6%); and respiratory disorders, such as cough and respiratory distress (5.3%).
- In adults, the most common AEs were viral, fungal, and bacterial infections (16.8%); constitutional symptoms and administrative concerns (13.5%); musculoskeletal and connective tissue disorders (7.04%); and gastrointestinal (5.8%) and nervous system (5%) disorders.
- Acne (30.6%), atopic dermatitis (22.2%), and psoriasis (16.7%) were the most common skin and subcutaneous tissue AEs reported in children. Skin and subcutaneous AEs were more common with upadacitinib (21.1%), abrocitinib (9.1%), and tofacitinib (6.3%) in children.
- Serious AEs included in the boxed warning for JAK inhibitors — serious infection, mortality, malignancy, cardiovascular events, and thrombosis — were similar for baricitinib in children (4 of 49 patients, 8.2%) and adults (325 of 3707, 8.8%). For other JAK inhibitors, absolute numbers of these AEs in children were small and rates were lower in children than in adults.
IN PRACTICE:
“This information can support customized treatment and minimize the potential for undesired or intolerable AEs,” the authors wrote.
SOURCE:
This study was led by Sahithi Talasila, BS, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, and was published online in Pediatric Dermatology.
LIMITATIONS:
Pharmacovigilance registries did not fully capture the complete range of AEs because of potential reporting bias or recall bias. Additionally, events lacking sufficient objective evidence were underreported, while common AEs associated with JAK inhibitor therapy were overreported.
DISCLOSURES:
No specific funding sources for the study were reported. One author reported being a consultant, one reported serving as a principal investigator in clinical trials, and another reported serving on data and safety monitoring boards of various pharmaceutical companies.
This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication. A version of this article first appeared on Medscape.com.
TOPLINE:
which also found that acne was the most common skin-related AE in children, and serious AEs were less common.
METHODOLOGY:
- Researchers analyzed 399,649 AEs in 133,216 adult patients and 2883 AEs in 955 pediatric patients (age, < 18 years) from November 2011 to February 2023 using the US Food and Drug Administration Adverse Event Reporting System and the Canada Vigilance Adverse Reaction Online Database.
- AEs were categorized on the basis of the Medical Dictionary for Regulatory Activities system organ class.
- Five JAK inhibitors approved for use in children were included in the study: Baricitinib, upadacitinib, abrocitinib, ruxolitinib, and tofacitinib.
TAKEAWAY:
- The most frequently reported AEs in children were blood and lymphatic system disorders, including neutropenia, thrombocytopenia, and anemia (24%); viral, fungal, and bacterial infections, such as pneumonia and sepsis (17.2%); constitutional symptoms and administrative concerns, including pyrexia and fatigue (15.7%); gastrointestinal disorders, such as vomiting and abdominal pain (13.6%); and respiratory disorders, such as cough and respiratory distress (5.3%).
- In adults, the most common AEs were viral, fungal, and bacterial infections (16.8%); constitutional symptoms and administrative concerns (13.5%); musculoskeletal and connective tissue disorders (7.04%); and gastrointestinal (5.8%) and nervous system (5%) disorders.
- Acne (30.6%), atopic dermatitis (22.2%), and psoriasis (16.7%) were the most common skin and subcutaneous tissue AEs reported in children. Skin and subcutaneous AEs were more common with upadacitinib (21.1%), abrocitinib (9.1%), and tofacitinib (6.3%) in children.
- Serious AEs included in the boxed warning for JAK inhibitors — serious infection, mortality, malignancy, cardiovascular events, and thrombosis — were similar for baricitinib in children (4 of 49 patients, 8.2%) and adults (325 of 3707, 8.8%). For other JAK inhibitors, absolute numbers of these AEs in children were small and rates were lower in children than in adults.
IN PRACTICE:
“This information can support customized treatment and minimize the potential for undesired or intolerable AEs,” the authors wrote.
SOURCE:
This study was led by Sahithi Talasila, BS, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, and was published online in Pediatric Dermatology.
LIMITATIONS:
Pharmacovigilance registries did not fully capture the complete range of AEs because of potential reporting bias or recall bias. Additionally, events lacking sufficient objective evidence were underreported, while common AEs associated with JAK inhibitor therapy were overreported.
DISCLOSURES:
No specific funding sources for the study were reported. One author reported being a consultant, one reported serving as a principal investigator in clinical trials, and another reported serving on data and safety monitoring boards of various pharmaceutical companies.
This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication. A version of this article first appeared on Medscape.com.
Oropouche Virus
The pediatrician’s first patient of the day was a 15-year-old boy complaining of fever, chills, and profound arthralgias. His exam, including a careful assessment of his joints, yielded no clues, and the pediatrician was ready to diagnose this as a routine viral illness. An additional bit of history provided by the patient’s mother prompted the pediatrician to pause and reconsider.
“A week ago, we returned from a visit to Cuba,” the mother reported. “Could this be Oropouche virus infection?”
Oropouche virus disease is an arboviral disease caused by the Oropouche virus (OROV). It is transmitted to humans through midge or mosquito bites. Although largely unknown to most United States clinicians until recently, this vector-borne virus is not new. The first human Oropouche virus infection was identified in Trinidad and Tobago in 1955 and since then, there have been intermittent outbreaks in the Amazon region. In recent months, though, the epidemiology of Oropouche virus infections has changed. Infections are being identified in new geographic areas, including Cuba. According to the Pan American Health Organization, 506 cases of Oropouche virus infection have been identified in Cuba since May 27, 2024.
Two deaths from Oropouche virus infection have been reported in previously healthy people. Evolving data suggests adverse outcomes associated with vertical transmission during pregnancy. One fetal death and child with congenital anomalies have been reported in Brazil. Additional fetal deaths, miscarriages, and congenital anomalies are under investigation.
Travel-associated cases have been reported in the United States. As of September 10, 2024, 52 Oropouche virus disease cases had been reported from five states in the United States. The Centers for Disease Control and Prevention confirmed that the first 31 of these cases were travelers returning from Cuba. The CDC issued a health advisory on August 16, 2024: Increased Oropouche Virus Activity and Associated Risk to Travelers.
The pediatrician quickly reviewed the signs and symptoms of Oropouche virus infection. Disease typically presents as an abrupt onset of fever, severe headache, chills, myalgia, and arthralgia 3 to 10 days after the bite of infected mosquito. Some patients develop a maculopapular rash that starts on the trunk and spreads to the extremities. Meningitis and encephalitis develop in less than 1 in 20 people. The symptoms of Oropouche virus infection overlap with those of other arboviruses such as dengue, chikungunya, and Zika viruses. The disease can also mimic malaria or rickettsial infection. Approximately 60% of people with Oropouche virus infection experience a recurrence of symptoms within days to weeks of the initial resolution of symptoms.
Testing for Oropouche virus infection is available through the CDC’s Arbovirus Diagnostic Laboratory. In people who are acutely ill, reverse transcription-polymerase chain reaction testing can be used to identify the virus in serum and cerebrospinal fluid. Serologic testing is also available for people who have been symptomatic for at least 6 days.
The pediatrician contacted his local health department to discuss the possibility of Oropouche virus infection. After reviewing the case definition, public health authorities recommended laboratory testing for Oropouche virus, dengue, and Zika virus.
Back in the exam room, the pediatrician provided anticipatory guidance to the patient and his mother. There are no antiviral medications to treat Oropouche virus infection, so the pediatrician recommended supportive care, including acetaminophen for fever and pain. He also advised avoiding aspirin or other nonsteroidal anti-inflammatory drugs (NSAIDs) until dengue could be ruled out to reduce the risk of bleeding. After confirming that no one else in the home was sick with similar symptoms, he counseled about prevention strategies.
To date, transmission of Oropouche virus in the United States has not been documented, but vectors potentially capable of transmitting the virus are present in some areas of the United States. When people who are infected with Oropouche are bitten, they can spread the virus through their blood to biting midges or mosquitoes. The insects can then spread the virus to other people. To reduce to potential for local transmission, people who are sick with suspected Oropouche virus infection are advised to avoid biting-midge and mosquito bites for the first week of their illness. Any person who has recently traveled to an area where Oropouche virus transmission is occurring should also avoid insect bites for 3 weeks after returning home to account for the potential incubation period of the virus. This includes wearing an EPA-registered insect repellent.
A suspect case is a patient who has been in an area with documented or suspected OROV circulation* within 2 weeks of initial symptom onset (as patients may experience recurrent symptoms) and the following:
- Abrupt onset of reported fever, headache, and one or more of the following: myalgia, arthralgia, photophobia, retro-orbital/eye pain, or signs and symptoms of neuroinvasive disease (eg, stiff neck, altered mental status, seizures, limb weakness, or cerebrospinal fluid pleocytosis).
- Tested negative for other possible diseases, in particular dengue.†
- Absence of a more likely clinical explanation.
*If concern exists for local transmission in a nonendemic area, consider if the patient shared an exposure location with a person with confirmed OROV infection, lives in an area where travel-related cases have been identified, or has known vector exposure (eg, mosquitoes or biting midges).
†If strong suspicion of OROV disease exists based on the patient’s clinical features and history of travel to an area with virus circulation, do not wait on negative testing before sending specimens to CDC.
Adapted from: Centers for Disease Control and Prevention. Response to Oropouche Virus Disease Cases in U.S. States and Territories in the Americas. Available at: https.//www.cdc.gov/oropouche/media/pdfs/2024/09/response-to-oropouche-virus-disease.pdf
Dr. Bryant is a pediatrician specializing in infectious diseases at the University of Louisville (Ky.) and Norton Children’s Hospital, also in Louisville. She is a member of the AAP’s Committee on Infectious Diseases and one of the lead authors of the AAP’s Recommendations for Prevention and Control of Influenza in Children, 2022-2023. The opinions expressed in this article are her own. Dr. Bryant discloses that she has served as an investigator on clinical trials funded by Pfizer, Enanta and Gilead. Email her at [email protected]. (Also [email protected])
The pediatrician’s first patient of the day was a 15-year-old boy complaining of fever, chills, and profound arthralgias. His exam, including a careful assessment of his joints, yielded no clues, and the pediatrician was ready to diagnose this as a routine viral illness. An additional bit of history provided by the patient’s mother prompted the pediatrician to pause and reconsider.
“A week ago, we returned from a visit to Cuba,” the mother reported. “Could this be Oropouche virus infection?”
Oropouche virus disease is an arboviral disease caused by the Oropouche virus (OROV). It is transmitted to humans through midge or mosquito bites. Although largely unknown to most United States clinicians until recently, this vector-borne virus is not new. The first human Oropouche virus infection was identified in Trinidad and Tobago in 1955 and since then, there have been intermittent outbreaks in the Amazon region. In recent months, though, the epidemiology of Oropouche virus infections has changed. Infections are being identified in new geographic areas, including Cuba. According to the Pan American Health Organization, 506 cases of Oropouche virus infection have been identified in Cuba since May 27, 2024.
Two deaths from Oropouche virus infection have been reported in previously healthy people. Evolving data suggests adverse outcomes associated with vertical transmission during pregnancy. One fetal death and child with congenital anomalies have been reported in Brazil. Additional fetal deaths, miscarriages, and congenital anomalies are under investigation.
Travel-associated cases have been reported in the United States. As of September 10, 2024, 52 Oropouche virus disease cases had been reported from five states in the United States. The Centers for Disease Control and Prevention confirmed that the first 31 of these cases were travelers returning from Cuba. The CDC issued a health advisory on August 16, 2024: Increased Oropouche Virus Activity and Associated Risk to Travelers.
The pediatrician quickly reviewed the signs and symptoms of Oropouche virus infection. Disease typically presents as an abrupt onset of fever, severe headache, chills, myalgia, and arthralgia 3 to 10 days after the bite of infected mosquito. Some patients develop a maculopapular rash that starts on the trunk and spreads to the extremities. Meningitis and encephalitis develop in less than 1 in 20 people. The symptoms of Oropouche virus infection overlap with those of other arboviruses such as dengue, chikungunya, and Zika viruses. The disease can also mimic malaria or rickettsial infection. Approximately 60% of people with Oropouche virus infection experience a recurrence of symptoms within days to weeks of the initial resolution of symptoms.
Testing for Oropouche virus infection is available through the CDC’s Arbovirus Diagnostic Laboratory. In people who are acutely ill, reverse transcription-polymerase chain reaction testing can be used to identify the virus in serum and cerebrospinal fluid. Serologic testing is also available for people who have been symptomatic for at least 6 days.
The pediatrician contacted his local health department to discuss the possibility of Oropouche virus infection. After reviewing the case definition, public health authorities recommended laboratory testing for Oropouche virus, dengue, and Zika virus.
Back in the exam room, the pediatrician provided anticipatory guidance to the patient and his mother. There are no antiviral medications to treat Oropouche virus infection, so the pediatrician recommended supportive care, including acetaminophen for fever and pain. He also advised avoiding aspirin or other nonsteroidal anti-inflammatory drugs (NSAIDs) until dengue could be ruled out to reduce the risk of bleeding. After confirming that no one else in the home was sick with similar symptoms, he counseled about prevention strategies.
To date, transmission of Oropouche virus in the United States has not been documented, but vectors potentially capable of transmitting the virus are present in some areas of the United States. When people who are infected with Oropouche are bitten, they can spread the virus through their blood to biting midges or mosquitoes. The insects can then spread the virus to other people. To reduce to potential for local transmission, people who are sick with suspected Oropouche virus infection are advised to avoid biting-midge and mosquito bites for the first week of their illness. Any person who has recently traveled to an area where Oropouche virus transmission is occurring should also avoid insect bites for 3 weeks after returning home to account for the potential incubation period of the virus. This includes wearing an EPA-registered insect repellent.
A suspect case is a patient who has been in an area with documented or suspected OROV circulation* within 2 weeks of initial symptom onset (as patients may experience recurrent symptoms) and the following:
- Abrupt onset of reported fever, headache, and one or more of the following: myalgia, arthralgia, photophobia, retro-orbital/eye pain, or signs and symptoms of neuroinvasive disease (eg, stiff neck, altered mental status, seizures, limb weakness, or cerebrospinal fluid pleocytosis).
- Tested negative for other possible diseases, in particular dengue.†
- Absence of a more likely clinical explanation.
*If concern exists for local transmission in a nonendemic area, consider if the patient shared an exposure location with a person with confirmed OROV infection, lives in an area where travel-related cases have been identified, or has known vector exposure (eg, mosquitoes or biting midges).
†If strong suspicion of OROV disease exists based on the patient’s clinical features and history of travel to an area with virus circulation, do not wait on negative testing before sending specimens to CDC.
Adapted from: Centers for Disease Control and Prevention. Response to Oropouche Virus Disease Cases in U.S. States and Territories in the Americas. Available at: https.//www.cdc.gov/oropouche/media/pdfs/2024/09/response-to-oropouche-virus-disease.pdf
Dr. Bryant is a pediatrician specializing in infectious diseases at the University of Louisville (Ky.) and Norton Children’s Hospital, also in Louisville. She is a member of the AAP’s Committee on Infectious Diseases and one of the lead authors of the AAP’s Recommendations for Prevention and Control of Influenza in Children, 2022-2023. The opinions expressed in this article are her own. Dr. Bryant discloses that she has served as an investigator on clinical trials funded by Pfizer, Enanta and Gilead. Email her at [email protected]. (Also [email protected])
The pediatrician’s first patient of the day was a 15-year-old boy complaining of fever, chills, and profound arthralgias. His exam, including a careful assessment of his joints, yielded no clues, and the pediatrician was ready to diagnose this as a routine viral illness. An additional bit of history provided by the patient’s mother prompted the pediatrician to pause and reconsider.
“A week ago, we returned from a visit to Cuba,” the mother reported. “Could this be Oropouche virus infection?”
Oropouche virus disease is an arboviral disease caused by the Oropouche virus (OROV). It is transmitted to humans through midge or mosquito bites. Although largely unknown to most United States clinicians until recently, this vector-borne virus is not new. The first human Oropouche virus infection was identified in Trinidad and Tobago in 1955 and since then, there have been intermittent outbreaks in the Amazon region. In recent months, though, the epidemiology of Oropouche virus infections has changed. Infections are being identified in new geographic areas, including Cuba. According to the Pan American Health Organization, 506 cases of Oropouche virus infection have been identified in Cuba since May 27, 2024.
Two deaths from Oropouche virus infection have been reported in previously healthy people. Evolving data suggests adverse outcomes associated with vertical transmission during pregnancy. One fetal death and child with congenital anomalies have been reported in Brazil. Additional fetal deaths, miscarriages, and congenital anomalies are under investigation.
Travel-associated cases have been reported in the United States. As of September 10, 2024, 52 Oropouche virus disease cases had been reported from five states in the United States. The Centers for Disease Control and Prevention confirmed that the first 31 of these cases were travelers returning from Cuba. The CDC issued a health advisory on August 16, 2024: Increased Oropouche Virus Activity and Associated Risk to Travelers.
The pediatrician quickly reviewed the signs and symptoms of Oropouche virus infection. Disease typically presents as an abrupt onset of fever, severe headache, chills, myalgia, and arthralgia 3 to 10 days after the bite of infected mosquito. Some patients develop a maculopapular rash that starts on the trunk and spreads to the extremities. Meningitis and encephalitis develop in less than 1 in 20 people. The symptoms of Oropouche virus infection overlap with those of other arboviruses such as dengue, chikungunya, and Zika viruses. The disease can also mimic malaria or rickettsial infection. Approximately 60% of people with Oropouche virus infection experience a recurrence of symptoms within days to weeks of the initial resolution of symptoms.
Testing for Oropouche virus infection is available through the CDC’s Arbovirus Diagnostic Laboratory. In people who are acutely ill, reverse transcription-polymerase chain reaction testing can be used to identify the virus in serum and cerebrospinal fluid. Serologic testing is also available for people who have been symptomatic for at least 6 days.
The pediatrician contacted his local health department to discuss the possibility of Oropouche virus infection. After reviewing the case definition, public health authorities recommended laboratory testing for Oropouche virus, dengue, and Zika virus.
Back in the exam room, the pediatrician provided anticipatory guidance to the patient and his mother. There are no antiviral medications to treat Oropouche virus infection, so the pediatrician recommended supportive care, including acetaminophen for fever and pain. He also advised avoiding aspirin or other nonsteroidal anti-inflammatory drugs (NSAIDs) until dengue could be ruled out to reduce the risk of bleeding. After confirming that no one else in the home was sick with similar symptoms, he counseled about prevention strategies.
To date, transmission of Oropouche virus in the United States has not been documented, but vectors potentially capable of transmitting the virus are present in some areas of the United States. When people who are infected with Oropouche are bitten, they can spread the virus through their blood to biting midges or mosquitoes. The insects can then spread the virus to other people. To reduce to potential for local transmission, people who are sick with suspected Oropouche virus infection are advised to avoid biting-midge and mosquito bites for the first week of their illness. Any person who has recently traveled to an area where Oropouche virus transmission is occurring should also avoid insect bites for 3 weeks after returning home to account for the potential incubation period of the virus. This includes wearing an EPA-registered insect repellent.
A suspect case is a patient who has been in an area with documented or suspected OROV circulation* within 2 weeks of initial symptom onset (as patients may experience recurrent symptoms) and the following:
- Abrupt onset of reported fever, headache, and one or more of the following: myalgia, arthralgia, photophobia, retro-orbital/eye pain, or signs and symptoms of neuroinvasive disease (eg, stiff neck, altered mental status, seizures, limb weakness, or cerebrospinal fluid pleocytosis).
- Tested negative for other possible diseases, in particular dengue.†
- Absence of a more likely clinical explanation.
*If concern exists for local transmission in a nonendemic area, consider if the patient shared an exposure location with a person with confirmed OROV infection, lives in an area where travel-related cases have been identified, or has known vector exposure (eg, mosquitoes or biting midges).
†If strong suspicion of OROV disease exists based on the patient’s clinical features and history of travel to an area with virus circulation, do not wait on negative testing before sending specimens to CDC.
Adapted from: Centers for Disease Control and Prevention. Response to Oropouche Virus Disease Cases in U.S. States and Territories in the Americas. Available at: https.//www.cdc.gov/oropouche/media/pdfs/2024/09/response-to-oropouche-virus-disease.pdf
Dr. Bryant is a pediatrician specializing in infectious diseases at the University of Louisville (Ky.) and Norton Children’s Hospital, also in Louisville. She is a member of the AAP’s Committee on Infectious Diseases and one of the lead authors of the AAP’s Recommendations for Prevention and Control of Influenza in Children, 2022-2023. The opinions expressed in this article are her own. Dr. Bryant discloses that she has served as an investigator on clinical trials funded by Pfizer, Enanta and Gilead. Email her at [email protected]. (Also [email protected])
Stress Management
With the changing leaves and cooling temperatures, early autumn also brings the excitement of the new school year. While returning to sports, mastering new subjects, and spending time with old and new friends is exhilarating, this season can also be a time of intense stress.
For those high school students who are especially ambitious, the school year presents the challenge of a very high stakes performance, one whose success will be measured by admission to a prized college. Not only are there classes to study for, but schedules are packed with a maximum number of subjects, a maximum number of Advanced Placement courses and a maximum number of impressive extra-curricular activities. Varsity sports practice, SAT prep, Debate Club, volunteer hours, and on and on.
What is often missing is enough time for sleep, socializing, exploring new interests, and unwinding. When you hear your patients (or parents) describing the intense stress of their overloaded schedules compounded by a sense that “I have no choice,” you have an opportunity to complicate their thinking. Introduce the idea that there are smart approaches to performing your best under stress. Pushing themselves relentlessly will inevitably lead to burnout and exhaustion. This approach will help them learn to make wise choices and will better serve their healthy development.
Start by acknowledging the stress of high-stakes performance. Telling your patients that they need to lower the temperature by not putting so much pressure on themselves is likely to be experienced as a lack of confidence in them and is unlikely to get any traction. Instead, ask your patients what matters to them the most: Is it admission to the college of their choice? Achieving a certain score or GPA? Is it their competitiveness and drive to win? There is no wrong answer, but it is helpful for them to be able to reflect on what matters to them. Are they hoping to impress someone else? Are they worried about their future financial health and convinced that getting into a certain college will secure their financial success? Do they think this matters more to their parents than to themselves? Or have they discovered an intense interest in theoretical physics and want to be able to study at Caltech? If their ambition is meaningfully connected to an authentic interest or to their emerging identity, their sense of purpose will be much deeper and able to sustain them.
Even with talent and a strong sense of purpose, performing well is very difficult and demanding. It is important to consider the cycle of performance as including preparation, performance itself, and effective rest and recovery, just as with athletic performance. Whether the performance is the SATs, an AP test, a debate or big game, there were probably hours of preparation for every hour of performance. Help them to consider the importance of this practice or preparation time, and how to use that time effectively. Are they able to work in environments where there are few distractions? Do they have the support or useful feedback they need? How are they able to know when it is time for a break or when they are ready? It can be helpful for them to appreciate whether preparation or performance is more challenging for them, as the former requires focus and patience, while the latter requires courage and tenacity. If they are aware of which is harder for them, they can be thoughtful about how to effectively handle those challenges.
What can be most valuable for your patients is hearing from their pediatricians that they need to have time protected for rest and recharging, and not only for preparation and performance. Any athlete knows that failing to do so will lead to exhaustion and injury, and performance inevitably suffers. Rest is unwinding and slowing down, and a restful activity will leave them feeling calm, relaxed, and ready for sleep. A recharging activity is one that leaves them feeling refreshed and energized. Some common restful activities are a hot bath or shower, a distracting activity such as watching a show or surfing the web, playing a simple video game or puzzle or listening to music. Some recharging activities are creative ones (making art or music), engaging in hobbies, reading, or talking with a good friend. A few activities — sleep, exercise, and mindfulness meditation, are powerful in that they pack both rest and recharge into the same activity. Your patients should be discovering and learning which activities they find restful or recharging. The college application process or preparing for a varsity tryout will both add stress and give them an opportunity to learn what rests and recharges them. They should aim to have a list of at least five effective strategies that they can turn to when it’s time to rest or to recharge. Help them turn their work ethic to building a deeper well of self-knowledge that will serve them when they face challenges in high school or when they are on their own in college. This time of stress can be a time of growth, too.
Of course, remind your patients that this is a critical time to focus on basic self-care: They need consistently adequate, restful sleep, good nutrition, and physical activity. They will benefit from regular time in nature and time spent with friends that nourish them. They can find ways to compound these activities: Go for a walk with a friend, eat dinner with family, play a relaxing game while enjoying music. Lastly, ask your patients what is the last new thing they tried. It is easy to become so focused on an ambitious project that there is no time for exploration and play. Play is important throughout life, but adolescents are actively discovering their interests, talents, tastes, and values. To do this they need to be trying things that are new and maybe less purpose-driven. I call this type of activity “senseless fun.” Splashing in the pool is senseless fun, swimming laps is purposeful exercise that my contribute to recharging, and competing in a swim meet is often more on the stressful side. As they discover new talents, deeply engaging interests, what relaxes and recharges them, they will be learning who they are. Regardless of the outcome of a test, a big game, or where they go to college, it is this emerging knowledge about themselves that will carry them into adulthood. The pediatrician’s goal: Encouraging aspiration, exploration, and self-awareness in the context of giving permission for rest, recharging, and senseless fun.
Dr. Swick is physician in chief at Ohana, Center for Child and Adolescent Behavioral Health, Community Hospital of the Monterey (Calif.) Peninsula. Dr. Jellinek is professor emeritus of psychiatry and pediatrics, Harvard Medical School, Boston. Email them at [email protected].
With the changing leaves and cooling temperatures, early autumn also brings the excitement of the new school year. While returning to sports, mastering new subjects, and spending time with old and new friends is exhilarating, this season can also be a time of intense stress.
For those high school students who are especially ambitious, the school year presents the challenge of a very high stakes performance, one whose success will be measured by admission to a prized college. Not only are there classes to study for, but schedules are packed with a maximum number of subjects, a maximum number of Advanced Placement courses and a maximum number of impressive extra-curricular activities. Varsity sports practice, SAT prep, Debate Club, volunteer hours, and on and on.
What is often missing is enough time for sleep, socializing, exploring new interests, and unwinding. When you hear your patients (or parents) describing the intense stress of their overloaded schedules compounded by a sense that “I have no choice,” you have an opportunity to complicate their thinking. Introduce the idea that there are smart approaches to performing your best under stress. Pushing themselves relentlessly will inevitably lead to burnout and exhaustion. This approach will help them learn to make wise choices and will better serve their healthy development.
Start by acknowledging the stress of high-stakes performance. Telling your patients that they need to lower the temperature by not putting so much pressure on themselves is likely to be experienced as a lack of confidence in them and is unlikely to get any traction. Instead, ask your patients what matters to them the most: Is it admission to the college of their choice? Achieving a certain score or GPA? Is it their competitiveness and drive to win? There is no wrong answer, but it is helpful for them to be able to reflect on what matters to them. Are they hoping to impress someone else? Are they worried about their future financial health and convinced that getting into a certain college will secure their financial success? Do they think this matters more to their parents than to themselves? Or have they discovered an intense interest in theoretical physics and want to be able to study at Caltech? If their ambition is meaningfully connected to an authentic interest or to their emerging identity, their sense of purpose will be much deeper and able to sustain them.
Even with talent and a strong sense of purpose, performing well is very difficult and demanding. It is important to consider the cycle of performance as including preparation, performance itself, and effective rest and recovery, just as with athletic performance. Whether the performance is the SATs, an AP test, a debate or big game, there were probably hours of preparation for every hour of performance. Help them to consider the importance of this practice or preparation time, and how to use that time effectively. Are they able to work in environments where there are few distractions? Do they have the support or useful feedback they need? How are they able to know when it is time for a break or when they are ready? It can be helpful for them to appreciate whether preparation or performance is more challenging for them, as the former requires focus and patience, while the latter requires courage and tenacity. If they are aware of which is harder for them, they can be thoughtful about how to effectively handle those challenges.
What can be most valuable for your patients is hearing from their pediatricians that they need to have time protected for rest and recharging, and not only for preparation and performance. Any athlete knows that failing to do so will lead to exhaustion and injury, and performance inevitably suffers. Rest is unwinding and slowing down, and a restful activity will leave them feeling calm, relaxed, and ready for sleep. A recharging activity is one that leaves them feeling refreshed and energized. Some common restful activities are a hot bath or shower, a distracting activity such as watching a show or surfing the web, playing a simple video game or puzzle or listening to music. Some recharging activities are creative ones (making art or music), engaging in hobbies, reading, or talking with a good friend. A few activities — sleep, exercise, and mindfulness meditation, are powerful in that they pack both rest and recharge into the same activity. Your patients should be discovering and learning which activities they find restful or recharging. The college application process or preparing for a varsity tryout will both add stress and give them an opportunity to learn what rests and recharges them. They should aim to have a list of at least five effective strategies that they can turn to when it’s time to rest or to recharge. Help them turn their work ethic to building a deeper well of self-knowledge that will serve them when they face challenges in high school or when they are on their own in college. This time of stress can be a time of growth, too.
Of course, remind your patients that this is a critical time to focus on basic self-care: They need consistently adequate, restful sleep, good nutrition, and physical activity. They will benefit from regular time in nature and time spent with friends that nourish them. They can find ways to compound these activities: Go for a walk with a friend, eat dinner with family, play a relaxing game while enjoying music. Lastly, ask your patients what is the last new thing they tried. It is easy to become so focused on an ambitious project that there is no time for exploration and play. Play is important throughout life, but adolescents are actively discovering their interests, talents, tastes, and values. To do this they need to be trying things that are new and maybe less purpose-driven. I call this type of activity “senseless fun.” Splashing in the pool is senseless fun, swimming laps is purposeful exercise that my contribute to recharging, and competing in a swim meet is often more on the stressful side. As they discover new talents, deeply engaging interests, what relaxes and recharges them, they will be learning who they are. Regardless of the outcome of a test, a big game, or where they go to college, it is this emerging knowledge about themselves that will carry them into adulthood. The pediatrician’s goal: Encouraging aspiration, exploration, and self-awareness in the context of giving permission for rest, recharging, and senseless fun.
Dr. Swick is physician in chief at Ohana, Center for Child and Adolescent Behavioral Health, Community Hospital of the Monterey (Calif.) Peninsula. Dr. Jellinek is professor emeritus of psychiatry and pediatrics, Harvard Medical School, Boston. Email them at [email protected].
With the changing leaves and cooling temperatures, early autumn also brings the excitement of the new school year. While returning to sports, mastering new subjects, and spending time with old and new friends is exhilarating, this season can also be a time of intense stress.
For those high school students who are especially ambitious, the school year presents the challenge of a very high stakes performance, one whose success will be measured by admission to a prized college. Not only are there classes to study for, but schedules are packed with a maximum number of subjects, a maximum number of Advanced Placement courses and a maximum number of impressive extra-curricular activities. Varsity sports practice, SAT prep, Debate Club, volunteer hours, and on and on.
What is often missing is enough time for sleep, socializing, exploring new interests, and unwinding. When you hear your patients (or parents) describing the intense stress of their overloaded schedules compounded by a sense that “I have no choice,” you have an opportunity to complicate their thinking. Introduce the idea that there are smart approaches to performing your best under stress. Pushing themselves relentlessly will inevitably lead to burnout and exhaustion. This approach will help them learn to make wise choices and will better serve their healthy development.
Start by acknowledging the stress of high-stakes performance. Telling your patients that they need to lower the temperature by not putting so much pressure on themselves is likely to be experienced as a lack of confidence in them and is unlikely to get any traction. Instead, ask your patients what matters to them the most: Is it admission to the college of their choice? Achieving a certain score or GPA? Is it their competitiveness and drive to win? There is no wrong answer, but it is helpful for them to be able to reflect on what matters to them. Are they hoping to impress someone else? Are they worried about their future financial health and convinced that getting into a certain college will secure their financial success? Do they think this matters more to their parents than to themselves? Or have they discovered an intense interest in theoretical physics and want to be able to study at Caltech? If their ambition is meaningfully connected to an authentic interest or to their emerging identity, their sense of purpose will be much deeper and able to sustain them.
Even with talent and a strong sense of purpose, performing well is very difficult and demanding. It is important to consider the cycle of performance as including preparation, performance itself, and effective rest and recovery, just as with athletic performance. Whether the performance is the SATs, an AP test, a debate or big game, there were probably hours of preparation for every hour of performance. Help them to consider the importance of this practice or preparation time, and how to use that time effectively. Are they able to work in environments where there are few distractions? Do they have the support or useful feedback they need? How are they able to know when it is time for a break or when they are ready? It can be helpful for them to appreciate whether preparation or performance is more challenging for them, as the former requires focus and patience, while the latter requires courage and tenacity. If they are aware of which is harder for them, they can be thoughtful about how to effectively handle those challenges.
What can be most valuable for your patients is hearing from their pediatricians that they need to have time protected for rest and recharging, and not only for preparation and performance. Any athlete knows that failing to do so will lead to exhaustion and injury, and performance inevitably suffers. Rest is unwinding and slowing down, and a restful activity will leave them feeling calm, relaxed, and ready for sleep. A recharging activity is one that leaves them feeling refreshed and energized. Some common restful activities are a hot bath or shower, a distracting activity such as watching a show or surfing the web, playing a simple video game or puzzle or listening to music. Some recharging activities are creative ones (making art or music), engaging in hobbies, reading, or talking with a good friend. A few activities — sleep, exercise, and mindfulness meditation, are powerful in that they pack both rest and recharge into the same activity. Your patients should be discovering and learning which activities they find restful or recharging. The college application process or preparing for a varsity tryout will both add stress and give them an opportunity to learn what rests and recharges them. They should aim to have a list of at least five effective strategies that they can turn to when it’s time to rest or to recharge. Help them turn their work ethic to building a deeper well of self-knowledge that will serve them when they face challenges in high school or when they are on their own in college. This time of stress can be a time of growth, too.
Of course, remind your patients that this is a critical time to focus on basic self-care: They need consistently adequate, restful sleep, good nutrition, and physical activity. They will benefit from regular time in nature and time spent with friends that nourish them. They can find ways to compound these activities: Go for a walk with a friend, eat dinner with family, play a relaxing game while enjoying music. Lastly, ask your patients what is the last new thing they tried. It is easy to become so focused on an ambitious project that there is no time for exploration and play. Play is important throughout life, but adolescents are actively discovering their interests, talents, tastes, and values. To do this they need to be trying things that are new and maybe less purpose-driven. I call this type of activity “senseless fun.” Splashing in the pool is senseless fun, swimming laps is purposeful exercise that my contribute to recharging, and competing in a swim meet is often more on the stressful side. As they discover new talents, deeply engaging interests, what relaxes and recharges them, they will be learning who they are. Regardless of the outcome of a test, a big game, or where they go to college, it is this emerging knowledge about themselves that will carry them into adulthood. The pediatrician’s goal: Encouraging aspiration, exploration, and self-awareness in the context of giving permission for rest, recharging, and senseless fun.
Dr. Swick is physician in chief at Ohana, Center for Child and Adolescent Behavioral Health, Community Hospital of the Monterey (Calif.) Peninsula. Dr. Jellinek is professor emeritus of psychiatry and pediatrics, Harvard Medical School, Boston. Email them at [email protected].
Is It Time for Universal Suicide Screening?
US suicide rates have reached alarming levels, with data from Centers for Disease Control and Prevention (CDC) showing a 37% increase from 2000 to 2022. Nearly 49,000 people died by suicide in 2022 alone, translating to one death every 11 minutes.
The increase in suicide rates has prompted calls for expansion of universal suicide screening, in which all individuals in medical or mental health care settings are screened for suicide risk, regardless of the purpose for their visit. But the psychiatric field is split on the issue, with some experts citing false positives and a lack of mental health care resources for those deemed at risk.
In 2022, when the US Preventative Services Task Force released its recommendations on suicide prevention, first in children and adolescents, and then in adults, the authors said there was insufficient evidence to support universal suicide screening.
Proponents of the practice pushed back on that finding, arguing that universal suicide screening could help identify those at high risk who might otherwise go undiagnosed, leading to earlier, potentially lifesaving, intervention.
So, what is the case for — and against — universal screening?
Sounding an Alert
The introduction of universal screening was driven by a confluence of factors that began with a 1999 report by then-US Surgeon General David Satcher, MD. This was followed by a report in 2016 from the Joint Commission on Detecting and Treating Suicidal Ideation that called for healthcare organizations to improve detection and treatment of suicidal ideation in all healthcare care settings.
Data from the alert showed that a significant number of people who died by suicide had a healthcare visit before their death. Half had seen a clinician a month before their death; nearly 30% had a medical visit just the week before — all with no detection of increased suicide risk.
It was that sort of finding that led Parkland Health and Hospital System in Dallas to become the first US hospital to implement universal suicide screening. Since the program launched in 2015, the system has screened more than 4.3 million patients in its emergency department, inpatient units, and 20 primary care clinics.
“Since the program began, we’ve completed between 40,000 to 50,000 screenings per month,” said Kimberly Roaten, PhD, associate chief quality and safety officer for behavioral health at Parkland Health.
Clinicians at Parkland use the five-item Ask Suicide-Screening Questions to assess suicidal intent, a commonly used tool that was originally developed for use in pediatric emergency rooms (ERs). The tool, which takes about 20 seconds to administer, has since been validated in both children and adults.
Based on a patient’s response, a clinical decision support system integrated into the electronic health record classifies suicide risk as none, moderate, or high.
Patients identified as moderate risk are offered a more in-depth assessment with a mental health clinician, though participation is not mandatory, said Dr. Roaten. Those at high risk receive a more thorough evaluation.
The proportion of ER patients at Parkland who screen positive for any suicidal intent has consistently remained at about 7%, and at 2% in the primary care clinics, she said.
To better understand what the program may have had on suicide prevention, Dr. Roaten is leading a National Institute of Mental Health–funded study to link a decade of mortality data from the state of Texas to patient data from Parkland Health. Investigators will analyze information about patients identified at risk for suicide, those patients’ characteristics, and who dies by suicide.
Universal Screening Expands
Other health systems have adopted universal suicide screening including the Indian Health Service and the US Veterans Health Administration. Universal suicide screening is also in place in a growing number of primary care practices and hospitals throughout the United States and will be mandatory for patients aged 12 years and older in all acute care hospitals in California beginning in 2025.
There is also a push for universal screening to be coordinated through local, state, and federal government, nonprofit, and private sectors. The National Action Alliance for Suicide Prevention is charged with advancing the White House’s 2024 National Strategy for Suicide Prevention, a 10-year plan to address gaps in suicide prevention in the United States.
Sarah Brummett, JD, director of the National Action Alliance for Suicide Prevention’s executive committee, said that universal suicide screening is part of the 2024 strategy. “We know there are barriers to universal screening, and so it’s important to recognize what they are so we can address them,” said Ms. Brummett.
Barriers may include adequate staffing, or a system in place to triage patients who screen positive.
At Parkland, cost and workload have been minimal, Dr. Roaten said. “We built a model that only dedicates our highest-value resources to the most at-risk patients.”
She also noted that relief may be on the horizon for health systems where cost is an obstacle to universal screening and subsequent intervention. “There are efforts at the federal level to increase funding for suicide assessment and crisis response,” she said.
Pushback on Universal Screening
Universal suicide screening has its detractors, including critics who say expansion is unlikely to reduce suicide rates.
“The issue with suicidal ideation is that it is very dynamic. Suicidal ideation changes very quickly — sometimes within hours,” said Craig Bryan, PsyD, professor of psychiatry and behavioral health at Ohio State University in Columbus, Ohio.
Universal screening can also lead to false positives, where a patient who screens positive for suicidal ideation has no actual intention of attempting suicide, potentially creating unnecessary concern and burden on health care resources, Dr. Bryan noted.
“What do you do with everyone who screens positive?” Dr. Bryan said. “I’ve spoken with leaders of many health systems in the United States, and there is pushback against universal screening because they don’t have enough mental health resources to handle all of the referrals.”
Suicide screening also doesn’t predict who will die by suicide, Dr. Bryan added. It only identifies those willing to disclose suicidal thoughts. There is a significant number of people without mental illness who may never seek medical care, so “the warning signs we’re teaching people to recognize — depression, anxiety, and substance abuse — might not be evident in these individuals,” he said.
“Life sideswipes them suddenly, and they go from 0 to 60 ... and they may have access to a highly lethal method [of suicide] which weaponizes that moment of despair,” said Dr. Bryan. No amount of screening could possibly predict those types of suicides, he added.
Paul Nestadt, MD, associate professor of psychiatry and behavioral sciences at Johns Hopkins School of Medicine, agrees with Dr. Bryan and noted there isn’t a strong correlation between suicidal ideation and death by suicide.
“Suicidal thoughts are very common, but suicide is a rare event,” he said.
He cited a study that showed that two thirds of individuals who died by suicide had denied experiencing suicidal thoughts when asked, and half of them died within 2 days of this denial. Other research suggests that as many as 98% of people who express suicidal ideation do not die by suicide, Dr. Nestadt said.
A Public Health Issue
If universal screening is not the answer to predicting and preventing suicide, what is? One way would be to approach suicide as a public health issue, Dr. Nestadt said.
“How did we reduce the rate of motor vehicle deaths? We didn’t test each driver’s reaction time behind the wheel,” he said. “Instead, we passed seatbelt and airbag legislation, implemented federal speed limits, and as a result, the number of motor vehicle fatalities decreased.”
Dr. Nestadt is an advocate for stronger gun safety legislation, which has proven effective in reducing suicide rates. A study published this year showed that states with child access prevention laws, negligent storage laws, and mandatory waiting periods for gun purchases reported fewer suicide deaths than those without that legislation.
Other measures might be applied in cases of extreme individual suicide risk, including extreme risk protection orders, also known as “red flag” laws, he added. This type of legislation provides a pathway for law enforcement to temporarily remove firearms from individuals who pose a risk to themselves or others.
“These have been shown to be very effective in saving lives,” Dr. Nestadt said.
Dr. Nestadt and others are also using machine learning models to predict suicide risk. Those identified as high-risk may be flagged on their electronic medical record. Ideally, when the algorithm becomes more accurate at predicting suicide, anyone treating this patient can then decide if action is needed, said Dr. Nestadt.
In his work with suicidal military personnel, Dr. Bryan and his colleagues established a brief form of cognitive behavioral therapy (BCBT) to help participants challenge cognitive distortions and build coping strategies to deal with feel with intense feelings of distress. Data show that BCBT reduced suicide attempts among active-duty soldiers by 60% compared with standard mental health treatment. It has since been shown to work in civilians as well.
Dr. Bryan is also researching fluctuations in the wish to live versus the wish to die relative to one another and mapping the trajectory of risk states along the way.
The goal is that these and other suicide prevention strategies currently under study by his team and others will help stem the rise in suicide deaths.
“Overall, we need to train mental health providers to implement suicide prevention therapies and establish suicide risk programs,” Dr. Bryan said. “But until we build one of these suicide prevention interventions to scale, we’re putting the cart before the horse.”
Dr. Roaten, Ms. Brummett, Dr. Bryan, and Dr. Nestadt reported no relevant disclosures.
A version of this article appeared on Medscape.com.
US suicide rates have reached alarming levels, with data from Centers for Disease Control and Prevention (CDC) showing a 37% increase from 2000 to 2022. Nearly 49,000 people died by suicide in 2022 alone, translating to one death every 11 minutes.
The increase in suicide rates has prompted calls for expansion of universal suicide screening, in which all individuals in medical or mental health care settings are screened for suicide risk, regardless of the purpose for their visit. But the psychiatric field is split on the issue, with some experts citing false positives and a lack of mental health care resources for those deemed at risk.
In 2022, when the US Preventative Services Task Force released its recommendations on suicide prevention, first in children and adolescents, and then in adults, the authors said there was insufficient evidence to support universal suicide screening.
Proponents of the practice pushed back on that finding, arguing that universal suicide screening could help identify those at high risk who might otherwise go undiagnosed, leading to earlier, potentially lifesaving, intervention.
So, what is the case for — and against — universal screening?
Sounding an Alert
The introduction of universal screening was driven by a confluence of factors that began with a 1999 report by then-US Surgeon General David Satcher, MD. This was followed by a report in 2016 from the Joint Commission on Detecting and Treating Suicidal Ideation that called for healthcare organizations to improve detection and treatment of suicidal ideation in all healthcare care settings.
Data from the alert showed that a significant number of people who died by suicide had a healthcare visit before their death. Half had seen a clinician a month before their death; nearly 30% had a medical visit just the week before — all with no detection of increased suicide risk.
It was that sort of finding that led Parkland Health and Hospital System in Dallas to become the first US hospital to implement universal suicide screening. Since the program launched in 2015, the system has screened more than 4.3 million patients in its emergency department, inpatient units, and 20 primary care clinics.
“Since the program began, we’ve completed between 40,000 to 50,000 screenings per month,” said Kimberly Roaten, PhD, associate chief quality and safety officer for behavioral health at Parkland Health.
Clinicians at Parkland use the five-item Ask Suicide-Screening Questions to assess suicidal intent, a commonly used tool that was originally developed for use in pediatric emergency rooms (ERs). The tool, which takes about 20 seconds to administer, has since been validated in both children and adults.
Based on a patient’s response, a clinical decision support system integrated into the electronic health record classifies suicide risk as none, moderate, or high.
Patients identified as moderate risk are offered a more in-depth assessment with a mental health clinician, though participation is not mandatory, said Dr. Roaten. Those at high risk receive a more thorough evaluation.
The proportion of ER patients at Parkland who screen positive for any suicidal intent has consistently remained at about 7%, and at 2% in the primary care clinics, she said.
To better understand what the program may have had on suicide prevention, Dr. Roaten is leading a National Institute of Mental Health–funded study to link a decade of mortality data from the state of Texas to patient data from Parkland Health. Investigators will analyze information about patients identified at risk for suicide, those patients’ characteristics, and who dies by suicide.
Universal Screening Expands
Other health systems have adopted universal suicide screening including the Indian Health Service and the US Veterans Health Administration. Universal suicide screening is also in place in a growing number of primary care practices and hospitals throughout the United States and will be mandatory for patients aged 12 years and older in all acute care hospitals in California beginning in 2025.
There is also a push for universal screening to be coordinated through local, state, and federal government, nonprofit, and private sectors. The National Action Alliance for Suicide Prevention is charged with advancing the White House’s 2024 National Strategy for Suicide Prevention, a 10-year plan to address gaps in suicide prevention in the United States.
Sarah Brummett, JD, director of the National Action Alliance for Suicide Prevention’s executive committee, said that universal suicide screening is part of the 2024 strategy. “We know there are barriers to universal screening, and so it’s important to recognize what they are so we can address them,” said Ms. Brummett.
Barriers may include adequate staffing, or a system in place to triage patients who screen positive.
At Parkland, cost and workload have been minimal, Dr. Roaten said. “We built a model that only dedicates our highest-value resources to the most at-risk patients.”
She also noted that relief may be on the horizon for health systems where cost is an obstacle to universal screening and subsequent intervention. “There are efforts at the federal level to increase funding for suicide assessment and crisis response,” she said.
Pushback on Universal Screening
Universal suicide screening has its detractors, including critics who say expansion is unlikely to reduce suicide rates.
“The issue with suicidal ideation is that it is very dynamic. Suicidal ideation changes very quickly — sometimes within hours,” said Craig Bryan, PsyD, professor of psychiatry and behavioral health at Ohio State University in Columbus, Ohio.
Universal screening can also lead to false positives, where a patient who screens positive for suicidal ideation has no actual intention of attempting suicide, potentially creating unnecessary concern and burden on health care resources, Dr. Bryan noted.
“What do you do with everyone who screens positive?” Dr. Bryan said. “I’ve spoken with leaders of many health systems in the United States, and there is pushback against universal screening because they don’t have enough mental health resources to handle all of the referrals.”
Suicide screening also doesn’t predict who will die by suicide, Dr. Bryan added. It only identifies those willing to disclose suicidal thoughts. There is a significant number of people without mental illness who may never seek medical care, so “the warning signs we’re teaching people to recognize — depression, anxiety, and substance abuse — might not be evident in these individuals,” he said.
“Life sideswipes them suddenly, and they go from 0 to 60 ... and they may have access to a highly lethal method [of suicide] which weaponizes that moment of despair,” said Dr. Bryan. No amount of screening could possibly predict those types of suicides, he added.
Paul Nestadt, MD, associate professor of psychiatry and behavioral sciences at Johns Hopkins School of Medicine, agrees with Dr. Bryan and noted there isn’t a strong correlation between suicidal ideation and death by suicide.
“Suicidal thoughts are very common, but suicide is a rare event,” he said.
He cited a study that showed that two thirds of individuals who died by suicide had denied experiencing suicidal thoughts when asked, and half of them died within 2 days of this denial. Other research suggests that as many as 98% of people who express suicidal ideation do not die by suicide, Dr. Nestadt said.
A Public Health Issue
If universal screening is not the answer to predicting and preventing suicide, what is? One way would be to approach suicide as a public health issue, Dr. Nestadt said.
“How did we reduce the rate of motor vehicle deaths? We didn’t test each driver’s reaction time behind the wheel,” he said. “Instead, we passed seatbelt and airbag legislation, implemented federal speed limits, and as a result, the number of motor vehicle fatalities decreased.”
Dr. Nestadt is an advocate for stronger gun safety legislation, which has proven effective in reducing suicide rates. A study published this year showed that states with child access prevention laws, negligent storage laws, and mandatory waiting periods for gun purchases reported fewer suicide deaths than those without that legislation.
Other measures might be applied in cases of extreme individual suicide risk, including extreme risk protection orders, also known as “red flag” laws, he added. This type of legislation provides a pathway for law enforcement to temporarily remove firearms from individuals who pose a risk to themselves or others.
“These have been shown to be very effective in saving lives,” Dr. Nestadt said.
Dr. Nestadt and others are also using machine learning models to predict suicide risk. Those identified as high-risk may be flagged on their electronic medical record. Ideally, when the algorithm becomes more accurate at predicting suicide, anyone treating this patient can then decide if action is needed, said Dr. Nestadt.
In his work with suicidal military personnel, Dr. Bryan and his colleagues established a brief form of cognitive behavioral therapy (BCBT) to help participants challenge cognitive distortions and build coping strategies to deal with feel with intense feelings of distress. Data show that BCBT reduced suicide attempts among active-duty soldiers by 60% compared with standard mental health treatment. It has since been shown to work in civilians as well.
Dr. Bryan is also researching fluctuations in the wish to live versus the wish to die relative to one another and mapping the trajectory of risk states along the way.
The goal is that these and other suicide prevention strategies currently under study by his team and others will help stem the rise in suicide deaths.
“Overall, we need to train mental health providers to implement suicide prevention therapies and establish suicide risk programs,” Dr. Bryan said. “But until we build one of these suicide prevention interventions to scale, we’re putting the cart before the horse.”
Dr. Roaten, Ms. Brummett, Dr. Bryan, and Dr. Nestadt reported no relevant disclosures.
A version of this article appeared on Medscape.com.
US suicide rates have reached alarming levels, with data from Centers for Disease Control and Prevention (CDC) showing a 37% increase from 2000 to 2022. Nearly 49,000 people died by suicide in 2022 alone, translating to one death every 11 minutes.
The increase in suicide rates has prompted calls for expansion of universal suicide screening, in which all individuals in medical or mental health care settings are screened for suicide risk, regardless of the purpose for their visit. But the psychiatric field is split on the issue, with some experts citing false positives and a lack of mental health care resources for those deemed at risk.
In 2022, when the US Preventative Services Task Force released its recommendations on suicide prevention, first in children and adolescents, and then in adults, the authors said there was insufficient evidence to support universal suicide screening.
Proponents of the practice pushed back on that finding, arguing that universal suicide screening could help identify those at high risk who might otherwise go undiagnosed, leading to earlier, potentially lifesaving, intervention.
So, what is the case for — and against — universal screening?
Sounding an Alert
The introduction of universal screening was driven by a confluence of factors that began with a 1999 report by then-US Surgeon General David Satcher, MD. This was followed by a report in 2016 from the Joint Commission on Detecting and Treating Suicidal Ideation that called for healthcare organizations to improve detection and treatment of suicidal ideation in all healthcare care settings.
Data from the alert showed that a significant number of people who died by suicide had a healthcare visit before their death. Half had seen a clinician a month before their death; nearly 30% had a medical visit just the week before — all with no detection of increased suicide risk.
It was that sort of finding that led Parkland Health and Hospital System in Dallas to become the first US hospital to implement universal suicide screening. Since the program launched in 2015, the system has screened more than 4.3 million patients in its emergency department, inpatient units, and 20 primary care clinics.
“Since the program began, we’ve completed between 40,000 to 50,000 screenings per month,” said Kimberly Roaten, PhD, associate chief quality and safety officer for behavioral health at Parkland Health.
Clinicians at Parkland use the five-item Ask Suicide-Screening Questions to assess suicidal intent, a commonly used tool that was originally developed for use in pediatric emergency rooms (ERs). The tool, which takes about 20 seconds to administer, has since been validated in both children and adults.
Based on a patient’s response, a clinical decision support system integrated into the electronic health record classifies suicide risk as none, moderate, or high.
Patients identified as moderate risk are offered a more in-depth assessment with a mental health clinician, though participation is not mandatory, said Dr. Roaten. Those at high risk receive a more thorough evaluation.
The proportion of ER patients at Parkland who screen positive for any suicidal intent has consistently remained at about 7%, and at 2% in the primary care clinics, she said.
To better understand what the program may have had on suicide prevention, Dr. Roaten is leading a National Institute of Mental Health–funded study to link a decade of mortality data from the state of Texas to patient data from Parkland Health. Investigators will analyze information about patients identified at risk for suicide, those patients’ characteristics, and who dies by suicide.
Universal Screening Expands
Other health systems have adopted universal suicide screening including the Indian Health Service and the US Veterans Health Administration. Universal suicide screening is also in place in a growing number of primary care practices and hospitals throughout the United States and will be mandatory for patients aged 12 years and older in all acute care hospitals in California beginning in 2025.
There is also a push for universal screening to be coordinated through local, state, and federal government, nonprofit, and private sectors. The National Action Alliance for Suicide Prevention is charged with advancing the White House’s 2024 National Strategy for Suicide Prevention, a 10-year plan to address gaps in suicide prevention in the United States.
Sarah Brummett, JD, director of the National Action Alliance for Suicide Prevention’s executive committee, said that universal suicide screening is part of the 2024 strategy. “We know there are barriers to universal screening, and so it’s important to recognize what they are so we can address them,” said Ms. Brummett.
Barriers may include adequate staffing, or a system in place to triage patients who screen positive.
At Parkland, cost and workload have been minimal, Dr. Roaten said. “We built a model that only dedicates our highest-value resources to the most at-risk patients.”
She also noted that relief may be on the horizon for health systems where cost is an obstacle to universal screening and subsequent intervention. “There are efforts at the federal level to increase funding for suicide assessment and crisis response,” she said.
Pushback on Universal Screening
Universal suicide screening has its detractors, including critics who say expansion is unlikely to reduce suicide rates.
“The issue with suicidal ideation is that it is very dynamic. Suicidal ideation changes very quickly — sometimes within hours,” said Craig Bryan, PsyD, professor of psychiatry and behavioral health at Ohio State University in Columbus, Ohio.
Universal screening can also lead to false positives, where a patient who screens positive for suicidal ideation has no actual intention of attempting suicide, potentially creating unnecessary concern and burden on health care resources, Dr. Bryan noted.
“What do you do with everyone who screens positive?” Dr. Bryan said. “I’ve spoken with leaders of many health systems in the United States, and there is pushback against universal screening because they don’t have enough mental health resources to handle all of the referrals.”
Suicide screening also doesn’t predict who will die by suicide, Dr. Bryan added. It only identifies those willing to disclose suicidal thoughts. There is a significant number of people without mental illness who may never seek medical care, so “the warning signs we’re teaching people to recognize — depression, anxiety, and substance abuse — might not be evident in these individuals,” he said.
“Life sideswipes them suddenly, and they go from 0 to 60 ... and they may have access to a highly lethal method [of suicide] which weaponizes that moment of despair,” said Dr. Bryan. No amount of screening could possibly predict those types of suicides, he added.
Paul Nestadt, MD, associate professor of psychiatry and behavioral sciences at Johns Hopkins School of Medicine, agrees with Dr. Bryan and noted there isn’t a strong correlation between suicidal ideation and death by suicide.
“Suicidal thoughts are very common, but suicide is a rare event,” he said.
He cited a study that showed that two thirds of individuals who died by suicide had denied experiencing suicidal thoughts when asked, and half of them died within 2 days of this denial. Other research suggests that as many as 98% of people who express suicidal ideation do not die by suicide, Dr. Nestadt said.
A Public Health Issue
If universal screening is not the answer to predicting and preventing suicide, what is? One way would be to approach suicide as a public health issue, Dr. Nestadt said.
“How did we reduce the rate of motor vehicle deaths? We didn’t test each driver’s reaction time behind the wheel,” he said. “Instead, we passed seatbelt and airbag legislation, implemented federal speed limits, and as a result, the number of motor vehicle fatalities decreased.”
Dr. Nestadt is an advocate for stronger gun safety legislation, which has proven effective in reducing suicide rates. A study published this year showed that states with child access prevention laws, negligent storage laws, and mandatory waiting periods for gun purchases reported fewer suicide deaths than those without that legislation.
Other measures might be applied in cases of extreme individual suicide risk, including extreme risk protection orders, also known as “red flag” laws, he added. This type of legislation provides a pathway for law enforcement to temporarily remove firearms from individuals who pose a risk to themselves or others.
“These have been shown to be very effective in saving lives,” Dr. Nestadt said.
Dr. Nestadt and others are also using machine learning models to predict suicide risk. Those identified as high-risk may be flagged on their electronic medical record. Ideally, when the algorithm becomes more accurate at predicting suicide, anyone treating this patient can then decide if action is needed, said Dr. Nestadt.
In his work with suicidal military personnel, Dr. Bryan and his colleagues established a brief form of cognitive behavioral therapy (BCBT) to help participants challenge cognitive distortions and build coping strategies to deal with feel with intense feelings of distress. Data show that BCBT reduced suicide attempts among active-duty soldiers by 60% compared with standard mental health treatment. It has since been shown to work in civilians as well.
Dr. Bryan is also researching fluctuations in the wish to live versus the wish to die relative to one another and mapping the trajectory of risk states along the way.
The goal is that these and other suicide prevention strategies currently under study by his team and others will help stem the rise in suicide deaths.
“Overall, we need to train mental health providers to implement suicide prevention therapies and establish suicide risk programs,” Dr. Bryan said. “But until we build one of these suicide prevention interventions to scale, we’re putting the cart before the horse.”
Dr. Roaten, Ms. Brummett, Dr. Bryan, and Dr. Nestadt reported no relevant disclosures.
A version of this article appeared on Medscape.com.
Playing the ‘Doctor’ Card: A Lesson in Three Hypotheticals
Scenario I. Let’s say you wake with a collection of symptoms. None of them is concerning, but the combination seems a bit unusual, or at least confusing. You would like to speak to your PCP, whom you have known for a long time, and ask for either reassurance or advice on whether you should make an appointment. However, your experience with the front office’s organization tells you that the quick 4-minute conversation you’re looking for is not going to happen easily.
You have that robotic phone message memorized. It begins suggesting that you think you have an emergency to call 911. Then it reminds you that if have a question about COVID to press “2,” which will take you to a recorded message and eventually link you to a triage nurse if the recording doesn’t answer your questions. If you need a prescription refill you should press “3.” If you are a doctor’s office and wish speak to the doctor press “4.” If you know you need an appointment press “5.” And finally if you have a question press “6” and leave a message and a nurse will get back to you before the end of the day.
The good news is that your PCP’s office is good to its word and will return your call the same day, but the bad news is that it is likely to be well into the afternoon. And, while you don’t consider your symptoms life-threatening, you don’t want getting an answer to be an exercise in schedule disruption.
You were a doctor before you retired and you still have an “office.” It’s really more of a combination den and studio. So, technically you are a doctor’s office wanting to speak to the doctor. And, you know that pressing “4” will get you the answer you are looking for in a matter of minutes.
Scenario II. Your spouse, or your aunt, or the elderly widow next door asks you to accompany her at an upcoming doctor’s visit because she had been having trouble understanding the physician’s plan regarding further diagnosis and possible treatment. She believes having you along as kind of an interpreter/advocate would be a big help. Do you agree and do you make any stipulations?
Scenario III. Your PCP has referred you to a specialist. You are filling out the previsit form(s). Do you list your occupation as “retired physician” or just “retired”? Or just leave it blank?
Whether you deserve it or not, graduating from medical school has conferred on you a specialness in the eyes of many people. It is assumed you are smarter than the average bear and in taking the Hippocratic oath you have joined an elite club. And, with that membership comes some special undefined privileges.
But with that specialness there are are some downsides. For example, in some states being a physician once allowed you to have a license plate with “MD” in the number sequence. Sometimes that helped you avoid the occasional parking ticket. That is until folks realized the “MD” made you a target for car thieves and drug seekers who mistakenly believe we all carry drugs in our glove compartments.
So what about that first scenario? Do you press “4” to jump yourself to the head of the queue and avoid the inconvenience of having to wait for a reasonably timely response from your PCP? After all, you are fellow physicians and you’ve known her for a decade or two. If you are retired is your time any more valuable than that of her other patients? If you are still in active practice you can argue that getting special attention will benefit your patients. But, if it’s a weekend and you are off it’s a bit harder to rationalize special treatment. Playing the doctor card in this situation is your own decision but you must be prepared to shoulder the perceptions by your PCP and her staff as well as your own sense of fairness.
The other two scenarios are much different. In neither are you risking the impression that you are asking for a favor. But, they each have their downsides. In the second scenario you are doing someone a favor to act as an interpreter. How could this have downside? Unfortunately, what happens too often in situations like this is that when the patient’s physician learns that you are a fellow physician, the rest of the visit becomes a dialogue in doctor-speak between the two physicians with the patient sitting by as an observer. In the end this discussion may benefit the patient by creating a treatment plan that the patient can understand either because they overheard it or more likely because you eventually explained it to them.
On the other the hand, this doctor-to-doctor chat has done nothing to build a doctor-patient relationship that had obviously been lacking something. In situations like this it is probably better to keep the doctor card up your sleeve to be played at the end of the visit or maybe not at all. Before agreeing to be an interpreter/advocate, ask the patient to avoid mentioning that you are a physician. Instead, ask that she introduce you as a friend or relative that she has asked to come along to serve as a memory bank. During the visit it may be helpful to occasionally interject and suggest that the patient ask a question that hasn’t been adequately addressed. While some physicians may be upset when they belatedly find you have not revealed up front that you are a physician, I find this a harmless omission that has the benefit of improving patient care.
The final scenario — in which you are the patient — is likely to occur more often as you get older. When filling out a previsit form, I often simply put retired or leave it blank. But, how I answer the question often seems to be irrelevant because I have learned that physicians and their staff read those boilerplate forms so cursorily that even when I report my status as “retired physician” everyone seems surprised if and when it later comes to light.
My rationale in keeping the doctor card close to my vest in these situations is that I want to be addressed without any assumptions regarding my medical knowledge, which in my situation is well over half a century old and spotty at best. I don’t want my physicians to say “I’m sure you understand.” Because I often don’t. I would like them to learn about who I am just as I hope they would other patients. I won’t be offended if they “talk down” to me. If this specialist is as good as I’ve heard she is, I want to hear her full performance, not one edited for fellow and former physicians.
It doesn’t arrive gold edged with a list of special privileges. If it comes with any extras, they are risks that must be avoided.
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.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at [email protected].
Scenario I. Let’s say you wake with a collection of symptoms. None of them is concerning, but the combination seems a bit unusual, or at least confusing. You would like to speak to your PCP, whom you have known for a long time, and ask for either reassurance or advice on whether you should make an appointment. However, your experience with the front office’s organization tells you that the quick 4-minute conversation you’re looking for is not going to happen easily.
You have that robotic phone message memorized. It begins suggesting that you think you have an emergency to call 911. Then it reminds you that if have a question about COVID to press “2,” which will take you to a recorded message and eventually link you to a triage nurse if the recording doesn’t answer your questions. If you need a prescription refill you should press “3.” If you are a doctor’s office and wish speak to the doctor press “4.” If you know you need an appointment press “5.” And finally if you have a question press “6” and leave a message and a nurse will get back to you before the end of the day.
The good news is that your PCP’s office is good to its word and will return your call the same day, but the bad news is that it is likely to be well into the afternoon. And, while you don’t consider your symptoms life-threatening, you don’t want getting an answer to be an exercise in schedule disruption.
You were a doctor before you retired and you still have an “office.” It’s really more of a combination den and studio. So, technically you are a doctor’s office wanting to speak to the doctor. And, you know that pressing “4” will get you the answer you are looking for in a matter of minutes.
Scenario II. Your spouse, or your aunt, or the elderly widow next door asks you to accompany her at an upcoming doctor’s visit because she had been having trouble understanding the physician’s plan regarding further diagnosis and possible treatment. She believes having you along as kind of an interpreter/advocate would be a big help. Do you agree and do you make any stipulations?
Scenario III. Your PCP has referred you to a specialist. You are filling out the previsit form(s). Do you list your occupation as “retired physician” or just “retired”? Or just leave it blank?
Whether you deserve it or not, graduating from medical school has conferred on you a specialness in the eyes of many people. It is assumed you are smarter than the average bear and in taking the Hippocratic oath you have joined an elite club. And, with that membership comes some special undefined privileges.
But with that specialness there are are some downsides. For example, in some states being a physician once allowed you to have a license plate with “MD” in the number sequence. Sometimes that helped you avoid the occasional parking ticket. That is until folks realized the “MD” made you a target for car thieves and drug seekers who mistakenly believe we all carry drugs in our glove compartments.
So what about that first scenario? Do you press “4” to jump yourself to the head of the queue and avoid the inconvenience of having to wait for a reasonably timely response from your PCP? After all, you are fellow physicians and you’ve known her for a decade or two. If you are retired is your time any more valuable than that of her other patients? If you are still in active practice you can argue that getting special attention will benefit your patients. But, if it’s a weekend and you are off it’s a bit harder to rationalize special treatment. Playing the doctor card in this situation is your own decision but you must be prepared to shoulder the perceptions by your PCP and her staff as well as your own sense of fairness.
The other two scenarios are much different. In neither are you risking the impression that you are asking for a favor. But, they each have their downsides. In the second scenario you are doing someone a favor to act as an interpreter. How could this have downside? Unfortunately, what happens too often in situations like this is that when the patient’s physician learns that you are a fellow physician, the rest of the visit becomes a dialogue in doctor-speak between the two physicians with the patient sitting by as an observer. In the end this discussion may benefit the patient by creating a treatment plan that the patient can understand either because they overheard it or more likely because you eventually explained it to them.
On the other the hand, this doctor-to-doctor chat has done nothing to build a doctor-patient relationship that had obviously been lacking something. In situations like this it is probably better to keep the doctor card up your sleeve to be played at the end of the visit or maybe not at all. Before agreeing to be an interpreter/advocate, ask the patient to avoid mentioning that you are a physician. Instead, ask that she introduce you as a friend or relative that she has asked to come along to serve as a memory bank. During the visit it may be helpful to occasionally interject and suggest that the patient ask a question that hasn’t been adequately addressed. While some physicians may be upset when they belatedly find you have not revealed up front that you are a physician, I find this a harmless omission that has the benefit of improving patient care.
The final scenario — in which you are the patient — is likely to occur more often as you get older. When filling out a previsit form, I often simply put retired or leave it blank. But, how I answer the question often seems to be irrelevant because I have learned that physicians and their staff read those boilerplate forms so cursorily that even when I report my status as “retired physician” everyone seems surprised if and when it later comes to light.
My rationale in keeping the doctor card close to my vest in these situations is that I want to be addressed without any assumptions regarding my medical knowledge, which in my situation is well over half a century old and spotty at best. I don’t want my physicians to say “I’m sure you understand.” Because I often don’t. I would like them to learn about who I am just as I hope they would other patients. I won’t be offended if they “talk down” to me. If this specialist is as good as I’ve heard she is, I want to hear her full performance, not one edited for fellow and former physicians.
It doesn’t arrive gold edged with a list of special privileges. If it comes with any extras, they are risks that must be avoided.
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.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at [email protected].
Scenario I. Let’s say you wake with a collection of symptoms. None of them is concerning, but the combination seems a bit unusual, or at least confusing. You would like to speak to your PCP, whom you have known for a long time, and ask for either reassurance or advice on whether you should make an appointment. However, your experience with the front office’s organization tells you that the quick 4-minute conversation you’re looking for is not going to happen easily.
You have that robotic phone message memorized. It begins suggesting that you think you have an emergency to call 911. Then it reminds you that if have a question about COVID to press “2,” which will take you to a recorded message and eventually link you to a triage nurse if the recording doesn’t answer your questions. If you need a prescription refill you should press “3.” If you are a doctor’s office and wish speak to the doctor press “4.” If you know you need an appointment press “5.” And finally if you have a question press “6” and leave a message and a nurse will get back to you before the end of the day.
The good news is that your PCP’s office is good to its word and will return your call the same day, but the bad news is that it is likely to be well into the afternoon. And, while you don’t consider your symptoms life-threatening, you don’t want getting an answer to be an exercise in schedule disruption.
You were a doctor before you retired and you still have an “office.” It’s really more of a combination den and studio. So, technically you are a doctor’s office wanting to speak to the doctor. And, you know that pressing “4” will get you the answer you are looking for in a matter of minutes.
Scenario II. Your spouse, or your aunt, or the elderly widow next door asks you to accompany her at an upcoming doctor’s visit because she had been having trouble understanding the physician’s plan regarding further diagnosis and possible treatment. She believes having you along as kind of an interpreter/advocate would be a big help. Do you agree and do you make any stipulations?
Scenario III. Your PCP has referred you to a specialist. You are filling out the previsit form(s). Do you list your occupation as “retired physician” or just “retired”? Or just leave it blank?
Whether you deserve it or not, graduating from medical school has conferred on you a specialness in the eyes of many people. It is assumed you are smarter than the average bear and in taking the Hippocratic oath you have joined an elite club. And, with that membership comes some special undefined privileges.
But with that specialness there are are some downsides. For example, in some states being a physician once allowed you to have a license plate with “MD” in the number sequence. Sometimes that helped you avoid the occasional parking ticket. That is until folks realized the “MD” made you a target for car thieves and drug seekers who mistakenly believe we all carry drugs in our glove compartments.
So what about that first scenario? Do you press “4” to jump yourself to the head of the queue and avoid the inconvenience of having to wait for a reasonably timely response from your PCP? After all, you are fellow physicians and you’ve known her for a decade or two. If you are retired is your time any more valuable than that of her other patients? If you are still in active practice you can argue that getting special attention will benefit your patients. But, if it’s a weekend and you are off it’s a bit harder to rationalize special treatment. Playing the doctor card in this situation is your own decision but you must be prepared to shoulder the perceptions by your PCP and her staff as well as your own sense of fairness.
The other two scenarios are much different. In neither are you risking the impression that you are asking for a favor. But, they each have their downsides. In the second scenario you are doing someone a favor to act as an interpreter. How could this have downside? Unfortunately, what happens too often in situations like this is that when the patient’s physician learns that you are a fellow physician, the rest of the visit becomes a dialogue in doctor-speak between the two physicians with the patient sitting by as an observer. In the end this discussion may benefit the patient by creating a treatment plan that the patient can understand either because they overheard it or more likely because you eventually explained it to them.
On the other the hand, this doctor-to-doctor chat has done nothing to build a doctor-patient relationship that had obviously been lacking something. In situations like this it is probably better to keep the doctor card up your sleeve to be played at the end of the visit or maybe not at all. Before agreeing to be an interpreter/advocate, ask the patient to avoid mentioning that you are a physician. Instead, ask that she introduce you as a friend or relative that she has asked to come along to serve as a memory bank. During the visit it may be helpful to occasionally interject and suggest that the patient ask a question that hasn’t been adequately addressed. While some physicians may be upset when they belatedly find you have not revealed up front that you are a physician, I find this a harmless omission that has the benefit of improving patient care.
The final scenario — in which you are the patient — is likely to occur more often as you get older. When filling out a previsit form, I often simply put retired or leave it blank. But, how I answer the question often seems to be irrelevant because I have learned that physicians and their staff read those boilerplate forms so cursorily that even when I report my status as “retired physician” everyone seems surprised if and when it later comes to light.
My rationale in keeping the doctor card close to my vest in these situations is that I want to be addressed without any assumptions regarding my medical knowledge, which in my situation is well over half a century old and spotty at best. I don’t want my physicians to say “I’m sure you understand.” Because I often don’t. I would like them to learn about who I am just as I hope they would other patients. I won’t be offended if they “talk down” to me. If this specialist is as good as I’ve heard she is, I want to hear her full performance, not one edited for fellow and former physicians.
It doesn’t arrive gold edged with a list of special privileges. If it comes with any extras, they are risks that must be avoided.
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.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at [email protected].