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Doug Brunk is a San Diego-based award-winning reporter who began covering health care in 1991. Before joining the company, he wrote for the health sciences division of Columbia University and was an associate editor at Contemporary Long Term Care magazine when it won a Jesse H. Neal Award. His work has been syndicated by the Los Angeles Times and he is the author of two books related to the University of Kentucky Wildcats men's basketball program. Doug has a master’s degree in magazine journalism from the S.I. Newhouse School of Public Communications at Syracuse University. Follow him on Twitter @dougbrunk.
Chronic rhinosinusitis associated with poor sleep quality
ATLANTA – Answers on a popular self-reported sleep questionnaire correlated positively with sinonasal inflammation, suggesting that patients with chronic rhinosinusitis should be assessed for sleep-related problems, results from a single-center study showed.
“We need to be recognizing the symptoms of chronic rhinosinusitis patients more in order to help them improve their quality of life,” lead study author Jessica Hui, MD, said in an interview at the annual meeting of the American Academy of Allergy, Asthma, and Immunology. “Asking them about sleep is important.”
Dr. Hui, who is a second-year pediatrics resident at Rush University Medical Center, reported that CRS patients had significant worse sleep quality, compared with controls (a mean PSQI score of 7.44 vs. 3.31, respectively) and that a higher Lund-Mackay Score correlated with greater PSQI (Pearson correlation coefficient of 0.25; P = .03).
The mean age of CRS cases without sleep disruption was 12.08 years, while the mean age of CRS cases with sleep disruption was 34.74 years.
Poor sleep quality was also associated with higher pain index scores (Pearson correlation coefficient of 0.35; P = .002) and higher scores on the SNOT-22 (Pearson correlation coefficient of 0.25; P = .025). The researchers observed that CRS patients without nasal polyps trended towards a higher PSQI, compared with controls (a mean of 8.14 vs. 6.36; P=0.10). Sinus histopathology variables and comorbid diseases did not correlate with PSQI scores.
Dr. Hui reported having no financial disclosures.
ATLANTA – Answers on a popular self-reported sleep questionnaire correlated positively with sinonasal inflammation, suggesting that patients with chronic rhinosinusitis should be assessed for sleep-related problems, results from a single-center study showed.
“We need to be recognizing the symptoms of chronic rhinosinusitis patients more in order to help them improve their quality of life,” lead study author Jessica Hui, MD, said in an interview at the annual meeting of the American Academy of Allergy, Asthma, and Immunology. “Asking them about sleep is important.”
Dr. Hui, who is a second-year pediatrics resident at Rush University Medical Center, reported that CRS patients had significant worse sleep quality, compared with controls (a mean PSQI score of 7.44 vs. 3.31, respectively) and that a higher Lund-Mackay Score correlated with greater PSQI (Pearson correlation coefficient of 0.25; P = .03).
The mean age of CRS cases without sleep disruption was 12.08 years, while the mean age of CRS cases with sleep disruption was 34.74 years.
Poor sleep quality was also associated with higher pain index scores (Pearson correlation coefficient of 0.35; P = .002) and higher scores on the SNOT-22 (Pearson correlation coefficient of 0.25; P = .025). The researchers observed that CRS patients without nasal polyps trended towards a higher PSQI, compared with controls (a mean of 8.14 vs. 6.36; P=0.10). Sinus histopathology variables and comorbid diseases did not correlate with PSQI scores.
Dr. Hui reported having no financial disclosures.
ATLANTA – Answers on a popular self-reported sleep questionnaire correlated positively with sinonasal inflammation, suggesting that patients with chronic rhinosinusitis should be assessed for sleep-related problems, results from a single-center study showed.
“We need to be recognizing the symptoms of chronic rhinosinusitis patients more in order to help them improve their quality of life,” lead study author Jessica Hui, MD, said in an interview at the annual meeting of the American Academy of Allergy, Asthma, and Immunology. “Asking them about sleep is important.”
Dr. Hui, who is a second-year pediatrics resident at Rush University Medical Center, reported that CRS patients had significant worse sleep quality, compared with controls (a mean PSQI score of 7.44 vs. 3.31, respectively) and that a higher Lund-Mackay Score correlated with greater PSQI (Pearson correlation coefficient of 0.25; P = .03).
The mean age of CRS cases without sleep disruption was 12.08 years, while the mean age of CRS cases with sleep disruption was 34.74 years.
Poor sleep quality was also associated with higher pain index scores (Pearson correlation coefficient of 0.35; P = .002) and higher scores on the SNOT-22 (Pearson correlation coefficient of 0.25; P = .025). The researchers observed that CRS patients without nasal polyps trended towards a higher PSQI, compared with controls (a mean of 8.14 vs. 6.36; P=0.10). Sinus histopathology variables and comorbid diseases did not correlate with PSQI scores.
Dr. Hui reported having no financial disclosures.
AT 2017 AAAAI ANNUAL MEETING
Key clinical point:
Major finding: CRS patients had significant worse sleep quality, compared with controls (a mean Pittsburgh Sleep Quality Index score of 7.44 vs. 3.31, respectively).
Data source: A cohort study of 125 CRS patients with refractory disease and 41 controls.
Disclosures: Dr. Hui reported having no financial disclosures.
Gender impacts risk of atopic diseases
ATLANTA – Obese females who live in urban settings are significantly more likely to develop atopic diseases, compared with their male counterparts, results from a single-center study showed.
“Some research has shown that obese girls are much more likely to be atopic, but many of them only look at one disease alone, such as atopic dermatitis or food allergies,” lead study author Sairaman Nagarajan, MD, MPH, said in an interview at the annual meeting of the American Academy of Allergy, Asthma, and Immunology. “Most of the studies are in asthma.”
The mean age of patients was 9 years, 23% were obese, and 55% were male. The researchers observed no differences in laboratory biomarkers nor in the prevalence of individual/or cumulative atopic disease in obese children, compared with controls. When stratified by gender, obese females had a significantly higher mean atopic disease score, compared with controls (4.00 vs. 2.62, respectively; P less than .001), while males had a significantly lower mean atopic disease score, compared with controls (3 vs. 3.42; P less than .001). Regression models yielded similar results; obese females had a significantly higher mean atopic disease score, compared with controls (by a mean elevation of 1.37 points; P less than .005), while males had a significantly lower mean atopic disease score (by a mean decline of -0.42 points; P less than .006). “From this we can say that female gender is a positive risk factor for atopy, and urban obese females may be particularly likely to benefit from lifestyle modification therapy like exercise and diet in controlling weight, and thereby allergies,” Dr. Nagarajan said.
He noted that it remains unclear whether the findings would apply to children who live in nonurban settings. “It’s difficult to say because there are some variables which are unique to urban minority populations like the housing that they live in and the kind of stores they buy food from,” he said.
Dr. Nagarajan reported having no financial disclosures.
ATLANTA – Obese females who live in urban settings are significantly more likely to develop atopic diseases, compared with their male counterparts, results from a single-center study showed.
“Some research has shown that obese girls are much more likely to be atopic, but many of them only look at one disease alone, such as atopic dermatitis or food allergies,” lead study author Sairaman Nagarajan, MD, MPH, said in an interview at the annual meeting of the American Academy of Allergy, Asthma, and Immunology. “Most of the studies are in asthma.”
The mean age of patients was 9 years, 23% were obese, and 55% were male. The researchers observed no differences in laboratory biomarkers nor in the prevalence of individual/or cumulative atopic disease in obese children, compared with controls. When stratified by gender, obese females had a significantly higher mean atopic disease score, compared with controls (4.00 vs. 2.62, respectively; P less than .001), while males had a significantly lower mean atopic disease score, compared with controls (3 vs. 3.42; P less than .001). Regression models yielded similar results; obese females had a significantly higher mean atopic disease score, compared with controls (by a mean elevation of 1.37 points; P less than .005), while males had a significantly lower mean atopic disease score (by a mean decline of -0.42 points; P less than .006). “From this we can say that female gender is a positive risk factor for atopy, and urban obese females may be particularly likely to benefit from lifestyle modification therapy like exercise and diet in controlling weight, and thereby allergies,” Dr. Nagarajan said.
He noted that it remains unclear whether the findings would apply to children who live in nonurban settings. “It’s difficult to say because there are some variables which are unique to urban minority populations like the housing that they live in and the kind of stores they buy food from,” he said.
Dr. Nagarajan reported having no financial disclosures.
ATLANTA – Obese females who live in urban settings are significantly more likely to develop atopic diseases, compared with their male counterparts, results from a single-center study showed.
“Some research has shown that obese girls are much more likely to be atopic, but many of them only look at one disease alone, such as atopic dermatitis or food allergies,” lead study author Sairaman Nagarajan, MD, MPH, said in an interview at the annual meeting of the American Academy of Allergy, Asthma, and Immunology. “Most of the studies are in asthma.”
The mean age of patients was 9 years, 23% were obese, and 55% were male. The researchers observed no differences in laboratory biomarkers nor in the prevalence of individual/or cumulative atopic disease in obese children, compared with controls. When stratified by gender, obese females had a significantly higher mean atopic disease score, compared with controls (4.00 vs. 2.62, respectively; P less than .001), while males had a significantly lower mean atopic disease score, compared with controls (3 vs. 3.42; P less than .001). Regression models yielded similar results; obese females had a significantly higher mean atopic disease score, compared with controls (by a mean elevation of 1.37 points; P less than .005), while males had a significantly lower mean atopic disease score (by a mean decline of -0.42 points; P less than .006). “From this we can say that female gender is a positive risk factor for atopy, and urban obese females may be particularly likely to benefit from lifestyle modification therapy like exercise and diet in controlling weight, and thereby allergies,” Dr. Nagarajan said.
He noted that it remains unclear whether the findings would apply to children who live in nonurban settings. “It’s difficult to say because there are some variables which are unique to urban minority populations like the housing that they live in and the kind of stores they buy food from,” he said.
Dr. Nagarajan reported having no financial disclosures.
AT 2017 AAAAI ANNUAL MEETING
Key clinical point:
Major finding: When stratified by gender, obese females had a significantly higher mean atopic disease score, compared with controls (4 vs. 2.62, respectively; P less than .001), while males had a significantly lower mean atopic disease score, compared with controls (3 vs. 3.42; P less than .001).
Data source: A retrospective review of 113 children who were evaluated for a history of allergic rhinitis, eczema, asthma, food allergies, and IgE, the percentage of eosinophils, and absolute eosinophil counts.
Disclosures: Dr. Nagarajan reported having no financial disclosures.
In children, peanut IgE levels increase over time
ATLANTA – Within a cohort of children diagnosed with peanut allergy who were followed since 2001, peanut IgE levels increased significantly over time in all races, according to a preliminary analysis of data.
In an interview in advance of the annual meeting of the American Academy of Allergy, Asthma, and Immunology, lead study author Yasmin Hamzavi, MD, said that recent publications have implicated race as a factor in food sensitization, but how this may impact the management of food allergy has not been elucidated. “The novel aspect of this study is that we are not just looking at the baseline peanut IgE levels between the races, but at the rate of change in peanut IgE over time between the different races,” said Dr. Hamzavi, a fellow in the division of allergy and immunology at Northwell Health, Great Neck, N.Y. “My question was, does the level of peanut IgE decrease or increase faster in one race versus another?”
A significant increase in peanut IgE over time was observed among all races (P less than .0002). In addition, white and Asian children showed an increasing trend in peanut IgE, while black children demonstrated a decreasing trend over time (P less than .099), a finding that Dr. Hamzavi described as “surprising and unusual.” She called for larger studies exploring factors for the noted increase among all races, such as changes in testing methods, food avoidance, and increasing sensitization. “Understanding the changes in peanut sensitization over time is a crucial step in determining the likelihood of clinical reactivity,” she said.
Dr. Hamzavi is reviewing data for a similar analysis of children with milk and egg allergy. She reported having no financial disclosures.
ATLANTA – Within a cohort of children diagnosed with peanut allergy who were followed since 2001, peanut IgE levels increased significantly over time in all races, according to a preliminary analysis of data.
In an interview in advance of the annual meeting of the American Academy of Allergy, Asthma, and Immunology, lead study author Yasmin Hamzavi, MD, said that recent publications have implicated race as a factor in food sensitization, but how this may impact the management of food allergy has not been elucidated. “The novel aspect of this study is that we are not just looking at the baseline peanut IgE levels between the races, but at the rate of change in peanut IgE over time between the different races,” said Dr. Hamzavi, a fellow in the division of allergy and immunology at Northwell Health, Great Neck, N.Y. “My question was, does the level of peanut IgE decrease or increase faster in one race versus another?”
A significant increase in peanut IgE over time was observed among all races (P less than .0002). In addition, white and Asian children showed an increasing trend in peanut IgE, while black children demonstrated a decreasing trend over time (P less than .099), a finding that Dr. Hamzavi described as “surprising and unusual.” She called for larger studies exploring factors for the noted increase among all races, such as changes in testing methods, food avoidance, and increasing sensitization. “Understanding the changes in peanut sensitization over time is a crucial step in determining the likelihood of clinical reactivity,” she said.
Dr. Hamzavi is reviewing data for a similar analysis of children with milk and egg allergy. She reported having no financial disclosures.
ATLANTA – Within a cohort of children diagnosed with peanut allergy who were followed since 2001, peanut IgE levels increased significantly over time in all races, according to a preliminary analysis of data.
In an interview in advance of the annual meeting of the American Academy of Allergy, Asthma, and Immunology, lead study author Yasmin Hamzavi, MD, said that recent publications have implicated race as a factor in food sensitization, but how this may impact the management of food allergy has not been elucidated. “The novel aspect of this study is that we are not just looking at the baseline peanut IgE levels between the races, but at the rate of change in peanut IgE over time between the different races,” said Dr. Hamzavi, a fellow in the division of allergy and immunology at Northwell Health, Great Neck, N.Y. “My question was, does the level of peanut IgE decrease or increase faster in one race versus another?”
A significant increase in peanut IgE over time was observed among all races (P less than .0002). In addition, white and Asian children showed an increasing trend in peanut IgE, while black children demonstrated a decreasing trend over time (P less than .099), a finding that Dr. Hamzavi described as “surprising and unusual.” She called for larger studies exploring factors for the noted increase among all races, such as changes in testing methods, food avoidance, and increasing sensitization. “Understanding the changes in peanut sensitization over time is a crucial step in determining the likelihood of clinical reactivity,” she said.
Dr. Hamzavi is reviewing data for a similar analysis of children with milk and egg allergy. She reported having no financial disclosures.
AT 2017 AAAAI ANNUAL MEETING
Key clinical point:
Major finding: A significant increase in peanut IgE over time was observed among white, black, and Asian children (P less than .0002).
Data source: A retrospective review of 193 children diagnosed with peanut allergy .
Disclosures: Dr. Hamzavi reported having no financial disclosures.
Tree nut allergy responds to immunotherapy
AT 2017 AAAAI ANNUAL MEETING
ATLANTA – Long-term walnut oral immunotherapy induces clinically relevant treatment response in children with tree nut allergy, results from a small ongoing study showed.
“Tree nut allergy is a generally life-long and potentially life-threatening disorder without an active therapy,” study author Amy M. Scurlock, MD, said in an interview in advance of the annual meeting of the American Academy of Allergy, Asthma, and Immunology. “Significant clinical, immunologic, and serologic cross reactivity has been described among tree nut families. Multi–tree nut allergen sensitization is common with 46% reporting allergy to more than one tree nut.”
Dr. Scurlock reported on results from 9 of 14 children with allergy to walnuts and another test tree nut (pecans, cashews, hazelnuts, or pistachios) who received open-label walnut oral immunotherapy after completing 38 weeks of blinded, placebo-controlled treatment. Walnut and test tree nut desensitization oral food challenges were performed by 142 weeks. If they passed, the subjects stopped their treatment for four weeks. Next, they underwent another oral food challenge to determine if they continued to be sensitized or if they had developed sustained unresponsiveness.
The median age of the 14 randomized subjects was 9 years, 75% were male, and 9 (64%) underwent an oral food challenge by week 142. (Two subjects dropped out after randomization, and three have yet to reach the week 142 time point.) Desensitization to both walnut and a test tree nut was observed in seven out of the nine subjects (78%). After 4 weeks off of walnut oral immunotherapy, four out of those seven patients who were desensitized (57%) also demonstrated sustained unresponsiveness to both walnuts and test tree nuts, and six out of seven subjects (86%) had sustained unresponsiveness to just walnuts.
“I am always amazed by the commitment of our food allergic subjects and their families in immunotherapy trials, and this study is no exception,” Dr. Scurlock commented. “Subjects had to undergo an increased number of oral food challenges (walnut, test tree nut, placebo) at protocol-specified time points in addition to daily home dosing. While walnut oral immunotherapy was generally well tolerated, we frequently observed oral allergy/itching associated with dosing in our cohort, which was an atopic group (75% allergic rhinitis). These symptoms can complicate assessment during dosing and oral food challenges. We observed that, with long-term therapy, there were some subjects who developed ‘dosing fatigue’ that could adversely affect adherence. Future studies will need to focus on strategies that optimize long-term sustainability/tolerability of dosing.”
She acknowledged certain limitations of the study, including its single-center design and small sample size. “While the findings are encouraging and similar to outcomes observed in other oral immunotherapy trials, further study in larger cohorts is critical before advancing toward broad clinical implementation. Specific issues regarding complexity of cross-reactivity and the efficacy of specific tree nuts to induce immunomodulation across tree nut families require future study. In addition, improving the long-term sustainability/tolerability of dosing and examining novel approaches is important.”
Dr. Scurlock disclosed that she has received funding from National Institutes of Health/National Institute of Allergy and Infectious Diseases and Food Allergy Research and Education (FARE). She is also medical director for the FARE Clinical Network Center of Excellence at Arkansas Children’s Hospital.
AT 2017 AAAAI ANNUAL MEETING
ATLANTA – Long-term walnut oral immunotherapy induces clinically relevant treatment response in children with tree nut allergy, results from a small ongoing study showed.
“Tree nut allergy is a generally life-long and potentially life-threatening disorder without an active therapy,” study author Amy M. Scurlock, MD, said in an interview in advance of the annual meeting of the American Academy of Allergy, Asthma, and Immunology. “Significant clinical, immunologic, and serologic cross reactivity has been described among tree nut families. Multi–tree nut allergen sensitization is common with 46% reporting allergy to more than one tree nut.”
Dr. Scurlock reported on results from 9 of 14 children with allergy to walnuts and another test tree nut (pecans, cashews, hazelnuts, or pistachios) who received open-label walnut oral immunotherapy after completing 38 weeks of blinded, placebo-controlled treatment. Walnut and test tree nut desensitization oral food challenges were performed by 142 weeks. If they passed, the subjects stopped their treatment for four weeks. Next, they underwent another oral food challenge to determine if they continued to be sensitized or if they had developed sustained unresponsiveness.
The median age of the 14 randomized subjects was 9 years, 75% were male, and 9 (64%) underwent an oral food challenge by week 142. (Two subjects dropped out after randomization, and three have yet to reach the week 142 time point.) Desensitization to both walnut and a test tree nut was observed in seven out of the nine subjects (78%). After 4 weeks off of walnut oral immunotherapy, four out of those seven patients who were desensitized (57%) also demonstrated sustained unresponsiveness to both walnuts and test tree nuts, and six out of seven subjects (86%) had sustained unresponsiveness to just walnuts.
“I am always amazed by the commitment of our food allergic subjects and their families in immunotherapy trials, and this study is no exception,” Dr. Scurlock commented. “Subjects had to undergo an increased number of oral food challenges (walnut, test tree nut, placebo) at protocol-specified time points in addition to daily home dosing. While walnut oral immunotherapy was generally well tolerated, we frequently observed oral allergy/itching associated with dosing in our cohort, which was an atopic group (75% allergic rhinitis). These symptoms can complicate assessment during dosing and oral food challenges. We observed that, with long-term therapy, there were some subjects who developed ‘dosing fatigue’ that could adversely affect adherence. Future studies will need to focus on strategies that optimize long-term sustainability/tolerability of dosing.”
She acknowledged certain limitations of the study, including its single-center design and small sample size. “While the findings are encouraging and similar to outcomes observed in other oral immunotherapy trials, further study in larger cohorts is critical before advancing toward broad clinical implementation. Specific issues regarding complexity of cross-reactivity and the efficacy of specific tree nuts to induce immunomodulation across tree nut families require future study. In addition, improving the long-term sustainability/tolerability of dosing and examining novel approaches is important.”
Dr. Scurlock disclosed that she has received funding from National Institutes of Health/National Institute of Allergy and Infectious Diseases and Food Allergy Research and Education (FARE). She is also medical director for the FARE Clinical Network Center of Excellence at Arkansas Children’s Hospital.
AT 2017 AAAAI ANNUAL MEETING
ATLANTA – Long-term walnut oral immunotherapy induces clinically relevant treatment response in children with tree nut allergy, results from a small ongoing study showed.
“Tree nut allergy is a generally life-long and potentially life-threatening disorder without an active therapy,” study author Amy M. Scurlock, MD, said in an interview in advance of the annual meeting of the American Academy of Allergy, Asthma, and Immunology. “Significant clinical, immunologic, and serologic cross reactivity has been described among tree nut families. Multi–tree nut allergen sensitization is common with 46% reporting allergy to more than one tree nut.”
Dr. Scurlock reported on results from 9 of 14 children with allergy to walnuts and another test tree nut (pecans, cashews, hazelnuts, or pistachios) who received open-label walnut oral immunotherapy after completing 38 weeks of blinded, placebo-controlled treatment. Walnut and test tree nut desensitization oral food challenges were performed by 142 weeks. If they passed, the subjects stopped their treatment for four weeks. Next, they underwent another oral food challenge to determine if they continued to be sensitized or if they had developed sustained unresponsiveness.
The median age of the 14 randomized subjects was 9 years, 75% were male, and 9 (64%) underwent an oral food challenge by week 142. (Two subjects dropped out after randomization, and three have yet to reach the week 142 time point.) Desensitization to both walnut and a test tree nut was observed in seven out of the nine subjects (78%). After 4 weeks off of walnut oral immunotherapy, four out of those seven patients who were desensitized (57%) also demonstrated sustained unresponsiveness to both walnuts and test tree nuts, and six out of seven subjects (86%) had sustained unresponsiveness to just walnuts.
“I am always amazed by the commitment of our food allergic subjects and their families in immunotherapy trials, and this study is no exception,” Dr. Scurlock commented. “Subjects had to undergo an increased number of oral food challenges (walnut, test tree nut, placebo) at protocol-specified time points in addition to daily home dosing. While walnut oral immunotherapy was generally well tolerated, we frequently observed oral allergy/itching associated with dosing in our cohort, which was an atopic group (75% allergic rhinitis). These symptoms can complicate assessment during dosing and oral food challenges. We observed that, with long-term therapy, there were some subjects who developed ‘dosing fatigue’ that could adversely affect adherence. Future studies will need to focus on strategies that optimize long-term sustainability/tolerability of dosing.”
She acknowledged certain limitations of the study, including its single-center design and small sample size. “While the findings are encouraging and similar to outcomes observed in other oral immunotherapy trials, further study in larger cohorts is critical before advancing toward broad clinical implementation. Specific issues regarding complexity of cross-reactivity and the efficacy of specific tree nuts to induce immunomodulation across tree nut families require future study. In addition, improving the long-term sustainability/tolerability of dosing and examining novel approaches is important.”
Dr. Scurlock disclosed that she has received funding from National Institutes of Health/National Institute of Allergy and Infectious Diseases and Food Allergy Research and Education (FARE). She is also medical director for the FARE Clinical Network Center of Excellence at Arkansas Children’s Hospital.
Key clinical point:
Major finding: Of nine subjects who underwent walnut and test tree nut desensitization oral food challenges by week 142, desensitization to both was observed in seven (78%).
Data source: A review of 14 children with allergy to walnuts and another test tree nut who received open-label walnut oral immunotherapy after completing 38 weeks of blinded, placebo-controlled treatment.
Disclosures: Dr. Scurlock disclosed that she has received funding from National Institutes of Health/National Institute of Allergy and Infectious Diseases and Food Allergy Research and Education (FARE). She is also medical director for the FARE Clinical Network Center of Excellence at Arkansas Children’s Hospital.
Ask patients about sexual function at first visit
LAS VEGAS – A brief sexual history should be part of the first patient visit, according to Anita H. Clayton, MD. However, addressing sexual health can prove challenging, especially if the patient is experiencing difficulty in that aspect of life.
“In America, we don’t talk about sex in a serious kind of way,” Dr. Clayton said at an annual psychopharmacology update held by the Nevada Psychiatric Association. “If people are talking about sex they’re either bragging or lying.”
Sexual functioning assessment tools to consider using include the Changes in Sexual Functioning Questionnaire, the Sexual Interest and Desire Inventory for females, and the Decreased Sexual Desire Screener. In premenopausal women, hypoactive sexual desire disorder is a common primary sexual dysfunction. Hypoactive sexual desire disorder is equally common in postmenopausal women, Dr. Clayton said, with the addition of complaints related to vaginal atrophy or genitourinary symptoms of menopause. In men, erectile dysfunction ranks as the most common primary sexual dysfunction. It can occur at any time but tends to increase in frequency at midlife.
Dr. Clayton recommends opening the dialogue with a brief questionnaire or an open-ended question, while maintaining cultural sensitivity, including references to sexual orientation and age. “It can be helpful to define terms,” she added. “I find that people often say, ‘I don’t get aroused anymore,’ but it could possibly mean that they’re not interested in sex anymore. You have to delineate what they’re talking about. Find out if they’re doing the kind of things that previously led them to having a satisfying sexual life. If they’re dissatisfied now, what is the issue? Desire? Arousal?” Taking a ubiquity-style approach to questions also can prove helpful: “Many people with depression experience sexual dysfunction. Do you have any complaints?” Or, “As people get older, sometimes they experience problems in their sexual function or changes in their level of desire. Have you had any such changes?”
The discussion itself might be therapeutic for the patient. “You may find out that what they’re experiencing. It’s not an unusual phenomenon,” said Dr. Clayton, who is a member of the board of directors of the International Society for the Study of Women’s Sexual Health. “For example, if women at midlife are having difficulty with arousal, they might try lubricants. Or, in talking with a younger woman who may not have yet experienced an orgasm, you can tell her it’s not that uncommon and talk about how that can be helped.”
If a sexual problem persists, ask about the nature and duration of the problem and/or changes. Ask about possible stressors and try to rule out any relationship issues or situational problems. “Is the problem generalized or does it occur in all situations? If it’s situational, you probably should work on that first,” said Dr. Clayton, who also has a secondary appointment at the university as professor of clinical obstetrics and gynecology.
Diagnosis of a primary sexual dysfunction is based on clinical presentation, not on testosterone levels or other laboratory values.
Dr. Clayton disclosed having received research grants from several entities, including Forest Research Institute, Janssen, and Takeda Pharmaceuticals. She also has received advisory board fees and/or consulting fees from several companies, including Fabre-Kramer, Takeda, S1 Biopharma, and Sprout Pharmaceuticals, a division of Valeant Pharmaceuticals. Dr. Clayton also has ownership interest in Euthymics Bioscience and S1 Biopharma.
LAS VEGAS – A brief sexual history should be part of the first patient visit, according to Anita H. Clayton, MD. However, addressing sexual health can prove challenging, especially if the patient is experiencing difficulty in that aspect of life.
“In America, we don’t talk about sex in a serious kind of way,” Dr. Clayton said at an annual psychopharmacology update held by the Nevada Psychiatric Association. “If people are talking about sex they’re either bragging or lying.”
Sexual functioning assessment tools to consider using include the Changes in Sexual Functioning Questionnaire, the Sexual Interest and Desire Inventory for females, and the Decreased Sexual Desire Screener. In premenopausal women, hypoactive sexual desire disorder is a common primary sexual dysfunction. Hypoactive sexual desire disorder is equally common in postmenopausal women, Dr. Clayton said, with the addition of complaints related to vaginal atrophy or genitourinary symptoms of menopause. In men, erectile dysfunction ranks as the most common primary sexual dysfunction. It can occur at any time but tends to increase in frequency at midlife.
Dr. Clayton recommends opening the dialogue with a brief questionnaire or an open-ended question, while maintaining cultural sensitivity, including references to sexual orientation and age. “It can be helpful to define terms,” she added. “I find that people often say, ‘I don’t get aroused anymore,’ but it could possibly mean that they’re not interested in sex anymore. You have to delineate what they’re talking about. Find out if they’re doing the kind of things that previously led them to having a satisfying sexual life. If they’re dissatisfied now, what is the issue? Desire? Arousal?” Taking a ubiquity-style approach to questions also can prove helpful: “Many people with depression experience sexual dysfunction. Do you have any complaints?” Or, “As people get older, sometimes they experience problems in their sexual function or changes in their level of desire. Have you had any such changes?”
The discussion itself might be therapeutic for the patient. “You may find out that what they’re experiencing. It’s not an unusual phenomenon,” said Dr. Clayton, who is a member of the board of directors of the International Society for the Study of Women’s Sexual Health. “For example, if women at midlife are having difficulty with arousal, they might try lubricants. Or, in talking with a younger woman who may not have yet experienced an orgasm, you can tell her it’s not that uncommon and talk about how that can be helped.”
If a sexual problem persists, ask about the nature and duration of the problem and/or changes. Ask about possible stressors and try to rule out any relationship issues or situational problems. “Is the problem generalized or does it occur in all situations? If it’s situational, you probably should work on that first,” said Dr. Clayton, who also has a secondary appointment at the university as professor of clinical obstetrics and gynecology.
Diagnosis of a primary sexual dysfunction is based on clinical presentation, not on testosterone levels or other laboratory values.
Dr. Clayton disclosed having received research grants from several entities, including Forest Research Institute, Janssen, and Takeda Pharmaceuticals. She also has received advisory board fees and/or consulting fees from several companies, including Fabre-Kramer, Takeda, S1 Biopharma, and Sprout Pharmaceuticals, a division of Valeant Pharmaceuticals. Dr. Clayton also has ownership interest in Euthymics Bioscience and S1 Biopharma.
LAS VEGAS – A brief sexual history should be part of the first patient visit, according to Anita H. Clayton, MD. However, addressing sexual health can prove challenging, especially if the patient is experiencing difficulty in that aspect of life.
“In America, we don’t talk about sex in a serious kind of way,” Dr. Clayton said at an annual psychopharmacology update held by the Nevada Psychiatric Association. “If people are talking about sex they’re either bragging or lying.”
Sexual functioning assessment tools to consider using include the Changes in Sexual Functioning Questionnaire, the Sexual Interest and Desire Inventory for females, and the Decreased Sexual Desire Screener. In premenopausal women, hypoactive sexual desire disorder is a common primary sexual dysfunction. Hypoactive sexual desire disorder is equally common in postmenopausal women, Dr. Clayton said, with the addition of complaints related to vaginal atrophy or genitourinary symptoms of menopause. In men, erectile dysfunction ranks as the most common primary sexual dysfunction. It can occur at any time but tends to increase in frequency at midlife.
Dr. Clayton recommends opening the dialogue with a brief questionnaire or an open-ended question, while maintaining cultural sensitivity, including references to sexual orientation and age. “It can be helpful to define terms,” she added. “I find that people often say, ‘I don’t get aroused anymore,’ but it could possibly mean that they’re not interested in sex anymore. You have to delineate what they’re talking about. Find out if they’re doing the kind of things that previously led them to having a satisfying sexual life. If they’re dissatisfied now, what is the issue? Desire? Arousal?” Taking a ubiquity-style approach to questions also can prove helpful: “Many people with depression experience sexual dysfunction. Do you have any complaints?” Or, “As people get older, sometimes they experience problems in their sexual function or changes in their level of desire. Have you had any such changes?”
The discussion itself might be therapeutic for the patient. “You may find out that what they’re experiencing. It’s not an unusual phenomenon,” said Dr. Clayton, who is a member of the board of directors of the International Society for the Study of Women’s Sexual Health. “For example, if women at midlife are having difficulty with arousal, they might try lubricants. Or, in talking with a younger woman who may not have yet experienced an orgasm, you can tell her it’s not that uncommon and talk about how that can be helped.”
If a sexual problem persists, ask about the nature and duration of the problem and/or changes. Ask about possible stressors and try to rule out any relationship issues or situational problems. “Is the problem generalized or does it occur in all situations? If it’s situational, you probably should work on that first,” said Dr. Clayton, who also has a secondary appointment at the university as professor of clinical obstetrics and gynecology.
Diagnosis of a primary sexual dysfunction is based on clinical presentation, not on testosterone levels or other laboratory values.
Dr. Clayton disclosed having received research grants from several entities, including Forest Research Institute, Janssen, and Takeda Pharmaceuticals. She also has received advisory board fees and/or consulting fees from several companies, including Fabre-Kramer, Takeda, S1 Biopharma, and Sprout Pharmaceuticals, a division of Valeant Pharmaceuticals. Dr. Clayton also has ownership interest in Euthymics Bioscience and S1 Biopharma.
EXPERT ANALYSIS AT THE NPA PSYCHOPHARMACOLOGY UPDATE
When atopic dermatitis is really contact dermatitis
ATLANTA – When patients present with atopic dermatitis that worsens, changes distribution, fails to improve, or immediately rebounds, think contact dermatitis, Luz Fonacier, MD, advised at the annual meeting of the American Academy of Allergy, Asthma, and Immunology.
Clinical signs of contact dermatitis include lesions with an atypical distribution/pattern, such as head, eyelid, or cheilitis/perioral predominance, or lesions on the hand or foot. Also elevate your suspicion in patients with therapy-resistant hand eczema, adult- or childhood-onset atopic dermatitis without childhood eczema, as well as in cases of severe or widespread dermatitis prior to initiating a systemic immunosuppressant. The list of potential allergens to consider includes metal (especially nickel, cobalt, and potassium dichromate), fragrances such as formaldehyde and balsam of Peru, preservatives, as well as topical emollients, corticosteroids, antibiotics, and antiseptics.
Dr. Fonacier, professor of medicine at the State University of New York at Stony Brook and section head of allergy at Winthrop University Hospital, Mineola, N.Y., recommends loading acrylates, fragrances, and allergens in an aqueous vehicle immediately before application. She noted that delayed patch test readings are common to metals, topical antibiotics, and topical corticosteroids, and that positive reactions to gold are often not clinically relevant. “The patch test positivity of gold can be as high as 30% in adults and a little bit less in children, but results from two large studies show clinical relevance in only 10%-15% of cases,” she said. A trial of gold avoidance may be warranted in patients with suspected jewelry allergy, facial or eyelid dermatitis, or exposure through gold dental restorations.
She went on to share tips for reading skin patch tests. The first reading should be done after 48 hours, while the second should be done 3, 4, or 7 days after application. “The second reading helps distinguish irritant from allergic responses,” she said. “Thirty percent of negative tests at 48 hours may be positive on delayed readings.” Most true allergic reactions occur between 72 and 96 hours. Allergens that may peak early include thiuram mix, carba mix, and balsam of Peru. Those that disappear after 5 days include balsam of Peru, benzoic acid, disperse blue #124, fragrance mix, mercury, methyldibromo glutaronitrile, phenoxyethanol, and octyl gallate. Delayed patch test reactions after five days include metals (gold potassium dichromate, nickel, and cobalt), topical antibiotics (neomycin and bacitracin) as well as topic corticosteroids.
Resources she recommended to attendees include the American Contact Dermatitis Society and the Contact Dermatitis Institute. Health and safety information about household products can be found here.
Dr. Fonacier disclosed that she has received research and educational grants from Baxter and Genentech. She is also a consultant to Church and Dwight and Regeneron.
ATLANTA – When patients present with atopic dermatitis that worsens, changes distribution, fails to improve, or immediately rebounds, think contact dermatitis, Luz Fonacier, MD, advised at the annual meeting of the American Academy of Allergy, Asthma, and Immunology.
Clinical signs of contact dermatitis include lesions with an atypical distribution/pattern, such as head, eyelid, or cheilitis/perioral predominance, or lesions on the hand or foot. Also elevate your suspicion in patients with therapy-resistant hand eczema, adult- or childhood-onset atopic dermatitis without childhood eczema, as well as in cases of severe or widespread dermatitis prior to initiating a systemic immunosuppressant. The list of potential allergens to consider includes metal (especially nickel, cobalt, and potassium dichromate), fragrances such as formaldehyde and balsam of Peru, preservatives, as well as topical emollients, corticosteroids, antibiotics, and antiseptics.
Dr. Fonacier, professor of medicine at the State University of New York at Stony Brook and section head of allergy at Winthrop University Hospital, Mineola, N.Y., recommends loading acrylates, fragrances, and allergens in an aqueous vehicle immediately before application. She noted that delayed patch test readings are common to metals, topical antibiotics, and topical corticosteroids, and that positive reactions to gold are often not clinically relevant. “The patch test positivity of gold can be as high as 30% in adults and a little bit less in children, but results from two large studies show clinical relevance in only 10%-15% of cases,” she said. A trial of gold avoidance may be warranted in patients with suspected jewelry allergy, facial or eyelid dermatitis, or exposure through gold dental restorations.
She went on to share tips for reading skin patch tests. The first reading should be done after 48 hours, while the second should be done 3, 4, or 7 days after application. “The second reading helps distinguish irritant from allergic responses,” she said. “Thirty percent of negative tests at 48 hours may be positive on delayed readings.” Most true allergic reactions occur between 72 and 96 hours. Allergens that may peak early include thiuram mix, carba mix, and balsam of Peru. Those that disappear after 5 days include balsam of Peru, benzoic acid, disperse blue #124, fragrance mix, mercury, methyldibromo glutaronitrile, phenoxyethanol, and octyl gallate. Delayed patch test reactions after five days include metals (gold potassium dichromate, nickel, and cobalt), topical antibiotics (neomycin and bacitracin) as well as topic corticosteroids.
Resources she recommended to attendees include the American Contact Dermatitis Society and the Contact Dermatitis Institute. Health and safety information about household products can be found here.
Dr. Fonacier disclosed that she has received research and educational grants from Baxter and Genentech. She is also a consultant to Church and Dwight and Regeneron.
ATLANTA – When patients present with atopic dermatitis that worsens, changes distribution, fails to improve, or immediately rebounds, think contact dermatitis, Luz Fonacier, MD, advised at the annual meeting of the American Academy of Allergy, Asthma, and Immunology.
Clinical signs of contact dermatitis include lesions with an atypical distribution/pattern, such as head, eyelid, or cheilitis/perioral predominance, or lesions on the hand or foot. Also elevate your suspicion in patients with therapy-resistant hand eczema, adult- or childhood-onset atopic dermatitis without childhood eczema, as well as in cases of severe or widespread dermatitis prior to initiating a systemic immunosuppressant. The list of potential allergens to consider includes metal (especially nickel, cobalt, and potassium dichromate), fragrances such as formaldehyde and balsam of Peru, preservatives, as well as topical emollients, corticosteroids, antibiotics, and antiseptics.
Dr. Fonacier, professor of medicine at the State University of New York at Stony Brook and section head of allergy at Winthrop University Hospital, Mineola, N.Y., recommends loading acrylates, fragrances, and allergens in an aqueous vehicle immediately before application. She noted that delayed patch test readings are common to metals, topical antibiotics, and topical corticosteroids, and that positive reactions to gold are often not clinically relevant. “The patch test positivity of gold can be as high as 30% in adults and a little bit less in children, but results from two large studies show clinical relevance in only 10%-15% of cases,” she said. A trial of gold avoidance may be warranted in patients with suspected jewelry allergy, facial or eyelid dermatitis, or exposure through gold dental restorations.
She went on to share tips for reading skin patch tests. The first reading should be done after 48 hours, while the second should be done 3, 4, or 7 days after application. “The second reading helps distinguish irritant from allergic responses,” she said. “Thirty percent of negative tests at 48 hours may be positive on delayed readings.” Most true allergic reactions occur between 72 and 96 hours. Allergens that may peak early include thiuram mix, carba mix, and balsam of Peru. Those that disappear after 5 days include balsam of Peru, benzoic acid, disperse blue #124, fragrance mix, mercury, methyldibromo glutaronitrile, phenoxyethanol, and octyl gallate. Delayed patch test reactions after five days include metals (gold potassium dichromate, nickel, and cobalt), topical antibiotics (neomycin and bacitracin) as well as topic corticosteroids.
Resources she recommended to attendees include the American Contact Dermatitis Society and the Contact Dermatitis Institute. Health and safety information about household products can be found here.
Dr. Fonacier disclosed that she has received research and educational grants from Baxter and Genentech. She is also a consultant to Church and Dwight and Regeneron.
EXPERT ANALYSIS AT THE 2017 AAAAI ANNUAL MEETING
Long-term peanut sublingual immunotherapy found safe
ATLANTA – Peanut sublingual immunotherapy induces clinically significant desensitization in the majority of subjects and can induce sustained unresponsiveness in a subset of children treated for 36-60 months, results from a small study suggest.
“Sublingual immunotherapy [SLIT] is an easy-to-administer treatment that appears to be safe, and with extended treatment, may provide a clinically significant amount of protection with the potential for a lasting effect,” one of the study authors, Edwin H. Kim, MD, said in an interview in advance of the annual meeting of the American Academy of Allergy, Asthma, and Immunology.
To find out, the researchers treated 37 patients with 2 mg of peanut SLIT for 36-60 months and then assessed a 5,000-mg peanut oral food challenge to further assess desensitization. Those who passed the challenge discontinued SLIT for 2-4 weeks and were then re-challenged with 5,000 mg of peanut protein to assess for sustained unresponsiveness.
“Existing data suggested that about 50% of patients on oral immunotherapy develop sustained unresponsiveness, which was defined by being able to tolerate the same full amount of peanut 1 month after stopping therapy,” Dr. Kim said. “As the assumption was that SLIT would have a more modest effect, it was unclear if any patients at all on SLIT would develop sustained unresponsiveness.”
Of the 37 subjects who completed the study, 32 (86%) safely ingested more than 300 mg of peanut and 12 (32%) passed the oral food challenge at the end of SLIT therapy. The median amount of peanut tolerated was 1,750 mg (compared with 1,710 mg in the original 12-month paper). The 12 subjects who passed the oral food challenge were re-challenged with 5,000 mg of peanut 2-4 weeks after discontinuing SLIT. Of these, 10 (27%) demonstrated sustained unresponsiveness. Dr. Kim characterized the results as “better than we would have expected.”
He acknowledged certain limitations to the study, including the lack of an entry food challenge to determine a baseline reaction threshold and the lack of a placebo arm for the study’s extended maintenance phase.
Dr. Kim reported having no financial disclosures.
dbrunk@frontlinemedcom.com
ATLANTA – Peanut sublingual immunotherapy induces clinically significant desensitization in the majority of subjects and can induce sustained unresponsiveness in a subset of children treated for 36-60 months, results from a small study suggest.
“Sublingual immunotherapy [SLIT] is an easy-to-administer treatment that appears to be safe, and with extended treatment, may provide a clinically significant amount of protection with the potential for a lasting effect,” one of the study authors, Edwin H. Kim, MD, said in an interview in advance of the annual meeting of the American Academy of Allergy, Asthma, and Immunology.
To find out, the researchers treated 37 patients with 2 mg of peanut SLIT for 36-60 months and then assessed a 5,000-mg peanut oral food challenge to further assess desensitization. Those who passed the challenge discontinued SLIT for 2-4 weeks and were then re-challenged with 5,000 mg of peanut protein to assess for sustained unresponsiveness.
“Existing data suggested that about 50% of patients on oral immunotherapy develop sustained unresponsiveness, which was defined by being able to tolerate the same full amount of peanut 1 month after stopping therapy,” Dr. Kim said. “As the assumption was that SLIT would have a more modest effect, it was unclear if any patients at all on SLIT would develop sustained unresponsiveness.”
Of the 37 subjects who completed the study, 32 (86%) safely ingested more than 300 mg of peanut and 12 (32%) passed the oral food challenge at the end of SLIT therapy. The median amount of peanut tolerated was 1,750 mg (compared with 1,710 mg in the original 12-month paper). The 12 subjects who passed the oral food challenge were re-challenged with 5,000 mg of peanut 2-4 weeks after discontinuing SLIT. Of these, 10 (27%) demonstrated sustained unresponsiveness. Dr. Kim characterized the results as “better than we would have expected.”
He acknowledged certain limitations to the study, including the lack of an entry food challenge to determine a baseline reaction threshold and the lack of a placebo arm for the study’s extended maintenance phase.
Dr. Kim reported having no financial disclosures.
dbrunk@frontlinemedcom.com
ATLANTA – Peanut sublingual immunotherapy induces clinically significant desensitization in the majority of subjects and can induce sustained unresponsiveness in a subset of children treated for 36-60 months, results from a small study suggest.
“Sublingual immunotherapy [SLIT] is an easy-to-administer treatment that appears to be safe, and with extended treatment, may provide a clinically significant amount of protection with the potential for a lasting effect,” one of the study authors, Edwin H. Kim, MD, said in an interview in advance of the annual meeting of the American Academy of Allergy, Asthma, and Immunology.
To find out, the researchers treated 37 patients with 2 mg of peanut SLIT for 36-60 months and then assessed a 5,000-mg peanut oral food challenge to further assess desensitization. Those who passed the challenge discontinued SLIT for 2-4 weeks and were then re-challenged with 5,000 mg of peanut protein to assess for sustained unresponsiveness.
“Existing data suggested that about 50% of patients on oral immunotherapy develop sustained unresponsiveness, which was defined by being able to tolerate the same full amount of peanut 1 month after stopping therapy,” Dr. Kim said. “As the assumption was that SLIT would have a more modest effect, it was unclear if any patients at all on SLIT would develop sustained unresponsiveness.”
Of the 37 subjects who completed the study, 32 (86%) safely ingested more than 300 mg of peanut and 12 (32%) passed the oral food challenge at the end of SLIT therapy. The median amount of peanut tolerated was 1,750 mg (compared with 1,710 mg in the original 12-month paper). The 12 subjects who passed the oral food challenge were re-challenged with 5,000 mg of peanut 2-4 weeks after discontinuing SLIT. Of these, 10 (27%) demonstrated sustained unresponsiveness. Dr. Kim characterized the results as “better than we would have expected.”
He acknowledged certain limitations to the study, including the lack of an entry food challenge to determine a baseline reaction threshold and the lack of a placebo arm for the study’s extended maintenance phase.
Dr. Kim reported having no financial disclosures.
dbrunk@frontlinemedcom.com
AT THE 2017 AAAAI ANNUAL MEETING
Key clinical point:
Major finding: Of the children who completed the study, 86% safely ingested more than 300 mg of peanut and 32% passed the oral food challenge at the end of SLIT therapy.
Data source: A study of 37 patients who were treated with 2 mg of peanut SLIT for 36-60 months.
Disclosures: Dr. Kim reported having no financial disclosures.
Chronic rhinosinusitis exacerbation factors identified
ATLANTA – Clinical factors associated with acute exacerbations of chronic rhinosinusitis include female sex, nonwhite race, and a higher body mass index, results from a retrospective study suggest.
“Previous research has shown associations between various risk factors and the development of chronic rhinosinusitis,” study author Jason H. Kwah, MD, said in an interview in advance of the annual meeting of the American Academy of Allergy, Asthma, and Immunology. “However, there is minimal data regarding risk factor associations with frequent acute exacerbations of chronic rhinosinusitis. This is an important question as much of the morbidity and financial burden of this disease stems from costs and symptoms related to the management of acute exacerbations with antibiotics and steroids. If associations can be identified, the hope would be that modification of some of these risk factors could lead to improved control of the condition.”
Of the 3,109 CRS patients, 936 were frequent exacerbators while 2,173 were infrequent exacerbators. Univariate analysis revealed that the following factors were associated with frequent exacerbations, compared with infrequent exacerbations: female sex, nonwhite race, higher body mass index, having any drug allergy, allergic rhinitis, peripheral eosinophilia, asthma, lower forced expiratory volume in 1 second, previous sinus surgery, severe sinusitis on CT, one or more steroid prescriptions, and the presence of autoimmune disease. Multivariate analysis adjusted for race and sex revealed that allergic rhinitis (odds ratio, 1.48), peripheral eosinophilia (OR, 1.30), asthma (OR, 1.90), and autoimmune disease (OR, 1.61) remained significantly associated with frequent CRS exacerbations.
“We found it surprising that there were so many risk factors associated with frequent acute exacerbations of CRS, as well as the strengths of these associations,” Dr. Kwah said. “Acute exacerbations of CRS cause significant morbidity and financial burden, and based on the results of our study, are likely associated with many clinically relevant risk factors. Further study is needed to confirm the presence of these associations, study the mechanism of disease, and ultimately establish treatment protocols that can improve the control of frequent acute exacerbations of CRS.”
He acknowledged certain limitations of the study, including the challenges of establishing an accurate definition for acute exacerbations of CRS in a retrospective study. “While we felt our protocol for retrospective analysis was sufficient given our inclusion criteria, a prospective trial would be helpful in further delineating the presence of acute exacerbations of CRS and how they are associated with clinical risk factors,” he said.
The study was supported in part by the NIH National Center for Advancing Translational Sciences, the Chronic Rhinosinusitis Integrative Studies Program, the Ernest Bazley Foundation, and the Division of Allergy and Immunology at the Northwestern Feinberg School of Medicine. Dr. Kwah reported having no financial disclosures.
dbrunk@frontlinemedcom.com
ATLANTA – Clinical factors associated with acute exacerbations of chronic rhinosinusitis include female sex, nonwhite race, and a higher body mass index, results from a retrospective study suggest.
“Previous research has shown associations between various risk factors and the development of chronic rhinosinusitis,” study author Jason H. Kwah, MD, said in an interview in advance of the annual meeting of the American Academy of Allergy, Asthma, and Immunology. “However, there is minimal data regarding risk factor associations with frequent acute exacerbations of chronic rhinosinusitis. This is an important question as much of the morbidity and financial burden of this disease stems from costs and symptoms related to the management of acute exacerbations with antibiotics and steroids. If associations can be identified, the hope would be that modification of some of these risk factors could lead to improved control of the condition.”
Of the 3,109 CRS patients, 936 were frequent exacerbators while 2,173 were infrequent exacerbators. Univariate analysis revealed that the following factors were associated with frequent exacerbations, compared with infrequent exacerbations: female sex, nonwhite race, higher body mass index, having any drug allergy, allergic rhinitis, peripheral eosinophilia, asthma, lower forced expiratory volume in 1 second, previous sinus surgery, severe sinusitis on CT, one or more steroid prescriptions, and the presence of autoimmune disease. Multivariate analysis adjusted for race and sex revealed that allergic rhinitis (odds ratio, 1.48), peripheral eosinophilia (OR, 1.30), asthma (OR, 1.90), and autoimmune disease (OR, 1.61) remained significantly associated with frequent CRS exacerbations.
“We found it surprising that there were so many risk factors associated with frequent acute exacerbations of CRS, as well as the strengths of these associations,” Dr. Kwah said. “Acute exacerbations of CRS cause significant morbidity and financial burden, and based on the results of our study, are likely associated with many clinically relevant risk factors. Further study is needed to confirm the presence of these associations, study the mechanism of disease, and ultimately establish treatment protocols that can improve the control of frequent acute exacerbations of CRS.”
He acknowledged certain limitations of the study, including the challenges of establishing an accurate definition for acute exacerbations of CRS in a retrospective study. “While we felt our protocol for retrospective analysis was sufficient given our inclusion criteria, a prospective trial would be helpful in further delineating the presence of acute exacerbations of CRS and how they are associated with clinical risk factors,” he said.
The study was supported in part by the NIH National Center for Advancing Translational Sciences, the Chronic Rhinosinusitis Integrative Studies Program, the Ernest Bazley Foundation, and the Division of Allergy and Immunology at the Northwestern Feinberg School of Medicine. Dr. Kwah reported having no financial disclosures.
dbrunk@frontlinemedcom.com
ATLANTA – Clinical factors associated with acute exacerbations of chronic rhinosinusitis include female sex, nonwhite race, and a higher body mass index, results from a retrospective study suggest.
“Previous research has shown associations between various risk factors and the development of chronic rhinosinusitis,” study author Jason H. Kwah, MD, said in an interview in advance of the annual meeting of the American Academy of Allergy, Asthma, and Immunology. “However, there is minimal data regarding risk factor associations with frequent acute exacerbations of chronic rhinosinusitis. This is an important question as much of the morbidity and financial burden of this disease stems from costs and symptoms related to the management of acute exacerbations with antibiotics and steroids. If associations can be identified, the hope would be that modification of some of these risk factors could lead to improved control of the condition.”
Of the 3,109 CRS patients, 936 were frequent exacerbators while 2,173 were infrequent exacerbators. Univariate analysis revealed that the following factors were associated with frequent exacerbations, compared with infrequent exacerbations: female sex, nonwhite race, higher body mass index, having any drug allergy, allergic rhinitis, peripheral eosinophilia, asthma, lower forced expiratory volume in 1 second, previous sinus surgery, severe sinusitis on CT, one or more steroid prescriptions, and the presence of autoimmune disease. Multivariate analysis adjusted for race and sex revealed that allergic rhinitis (odds ratio, 1.48), peripheral eosinophilia (OR, 1.30), asthma (OR, 1.90), and autoimmune disease (OR, 1.61) remained significantly associated with frequent CRS exacerbations.
“We found it surprising that there were so many risk factors associated with frequent acute exacerbations of CRS, as well as the strengths of these associations,” Dr. Kwah said. “Acute exacerbations of CRS cause significant morbidity and financial burden, and based on the results of our study, are likely associated with many clinically relevant risk factors. Further study is needed to confirm the presence of these associations, study the mechanism of disease, and ultimately establish treatment protocols that can improve the control of frequent acute exacerbations of CRS.”
He acknowledged certain limitations of the study, including the challenges of establishing an accurate definition for acute exacerbations of CRS in a retrospective study. “While we felt our protocol for retrospective analysis was sufficient given our inclusion criteria, a prospective trial would be helpful in further delineating the presence of acute exacerbations of CRS and how they are associated with clinical risk factors,” he said.
The study was supported in part by the NIH National Center for Advancing Translational Sciences, the Chronic Rhinosinusitis Integrative Studies Program, the Ernest Bazley Foundation, and the Division of Allergy and Immunology at the Northwestern Feinberg School of Medicine. Dr. Kwah reported having no financial disclosures.
dbrunk@frontlinemedcom.com
AT THE 2017 AAAAI ANNUAL MEETING
Key clinical point:
Major finding: On multivariate analysis, allergic rhinitis (odds ratio, 1.48), peripheral eosinophilia (OR, 1.30), asthma (OR, 1.90), and autoimmune disease (OR, 1.61) remained significantly associated with frequent CRS exacerbations.
Data source: A retrospective review of 3,109 patients who were treated for CRS from January 2014 to December 2015.
Disclosures: The study was supported in part by the NIH National Center for Advancing Translational Sciences, the Chronic Rhinosinusitis Integrative Studies Program, the Ernest Bazley Foundation, and the Division of Allergy and Immunology at the Northwestern Feinberg School of Medicine. Dr. Kwah reported having no financial disclosures.
Maternal vitamin E isoform levels possible marker for infant wheezing risk
ATLANTA – Increasing maternal postpartum–plasma alpha-tocopherol isoform concentration was associated with a decreased likelihood of wheezing at age 2 years, defined as wheezing in the past 12 months, use of asthma medications in the past 12 months, or diagnosis of asthma, results from a large analysis showed.
“For now, this is an association and not causation,” study author Cosby Stone, MD, MPH, said in an interview in advance of the annual meeting of the American Academy of Allergy, Asthma, and Immunology. “We need a clinical trial to evaluate the effect of giving more alpha-tocopherol to mothers during pregnancy before anyone should jump to giving supplements.”
The median age of children at the time of maternal sample collection was 50 days. 47% were female, and 61% were white. Of the 652 children, 167 (26%) met criteria for wheezing at age 2 years. These children had mothers with significantly lower postpartum concentrations of plasma alpha-tocopherol, compared with those who did not meet criteria for wheezing at 2 years (a mean of 69 micromol/L vs. 75 micromol/L, respectively; P = .02). In multivariable regression analysis, the researchers detected a significant interaction between gamma-tocopherol and alpha-tocopherol, where the highest amounts of maternal gamma-tocopherol modified and mitigated the protective association of maternal alpha-tocopherol with risk of wheezing at 2 years (P = .05).
Dr. Stone cautioned that, what is currently labeled as vitamin E or alpha-tocopherol in foods and supplements, “could be any of eight different isoforms, and alpha-tocopherol may not actually be the dominant isoform being provided. In addition, the oils that we eat are the main sources of tocopherols in our diet, and they vary widely in terms of their tocopherol isoforms. Sunflower and safflower oil, for example, provide predominantly alpha-tocopherol as their isoform of vitamin E, while corn and soy oil provide predominantly gamma-tocopherol.”
For now, he continued, correcting maternal alpha-tocopherol deficiency, currently defined by a serum alpha-tocopherol concentration less than 11.6 micromol/L, is certainly reasonable. Down the road, modification of maternal alpha-tocopherol or gamma-tocopherol concentrations through dietary counseling may provide clinicians with a tool to prevent wheezing or asthma in affected children. “In the future there may be a role for checking tocopherol isoforms in pregnant women and then modifying dietary oil consumption to protect the health of their children,” he said.
He acknowledged certain limitations of the study, including that researchers obtained maternal vitamin E isoform measurements at enrollment, when the infants were, on average, 6 weeks post partum, and not during pregnancy. “However, the literature has shown that postpartum vitamin E levels at this time point are very similar to those during the second trimester of pregnancy,” Dr. Stone said. “The literature has also shown that plasma vitamin E isoform concentrations are tightly tied to diet and body stores and do not change very rapidly (such that a woman would not be likely to go from the highest quartile to the lowest, or vice versa). People’s diets don’t tend to change that much, in general.”
INSPIRE is funded by the National Institutes of Health. Dr. Stone is funded by an NIH training grant through Vanderbilt University. He reported having no relevant financial disclosures.
ATLANTA – Increasing maternal postpartum–plasma alpha-tocopherol isoform concentration was associated with a decreased likelihood of wheezing at age 2 years, defined as wheezing in the past 12 months, use of asthma medications in the past 12 months, or diagnosis of asthma, results from a large analysis showed.
“For now, this is an association and not causation,” study author Cosby Stone, MD, MPH, said in an interview in advance of the annual meeting of the American Academy of Allergy, Asthma, and Immunology. “We need a clinical trial to evaluate the effect of giving more alpha-tocopherol to mothers during pregnancy before anyone should jump to giving supplements.”
The median age of children at the time of maternal sample collection was 50 days. 47% were female, and 61% were white. Of the 652 children, 167 (26%) met criteria for wheezing at age 2 years. These children had mothers with significantly lower postpartum concentrations of plasma alpha-tocopherol, compared with those who did not meet criteria for wheezing at 2 years (a mean of 69 micromol/L vs. 75 micromol/L, respectively; P = .02). In multivariable regression analysis, the researchers detected a significant interaction between gamma-tocopherol and alpha-tocopherol, where the highest amounts of maternal gamma-tocopherol modified and mitigated the protective association of maternal alpha-tocopherol with risk of wheezing at 2 years (P = .05).
Dr. Stone cautioned that, what is currently labeled as vitamin E or alpha-tocopherol in foods and supplements, “could be any of eight different isoforms, and alpha-tocopherol may not actually be the dominant isoform being provided. In addition, the oils that we eat are the main sources of tocopherols in our diet, and they vary widely in terms of their tocopherol isoforms. Sunflower and safflower oil, for example, provide predominantly alpha-tocopherol as their isoform of vitamin E, while corn and soy oil provide predominantly gamma-tocopherol.”
For now, he continued, correcting maternal alpha-tocopherol deficiency, currently defined by a serum alpha-tocopherol concentration less than 11.6 micromol/L, is certainly reasonable. Down the road, modification of maternal alpha-tocopherol or gamma-tocopherol concentrations through dietary counseling may provide clinicians with a tool to prevent wheezing or asthma in affected children. “In the future there may be a role for checking tocopherol isoforms in pregnant women and then modifying dietary oil consumption to protect the health of their children,” he said.
He acknowledged certain limitations of the study, including that researchers obtained maternal vitamin E isoform measurements at enrollment, when the infants were, on average, 6 weeks post partum, and not during pregnancy. “However, the literature has shown that postpartum vitamin E levels at this time point are very similar to those during the second trimester of pregnancy,” Dr. Stone said. “The literature has also shown that plasma vitamin E isoform concentrations are tightly tied to diet and body stores and do not change very rapidly (such that a woman would not be likely to go from the highest quartile to the lowest, or vice versa). People’s diets don’t tend to change that much, in general.”
INSPIRE is funded by the National Institutes of Health. Dr. Stone is funded by an NIH training grant through Vanderbilt University. He reported having no relevant financial disclosures.
ATLANTA – Increasing maternal postpartum–plasma alpha-tocopherol isoform concentration was associated with a decreased likelihood of wheezing at age 2 years, defined as wheezing in the past 12 months, use of asthma medications in the past 12 months, or diagnosis of asthma, results from a large analysis showed.
“For now, this is an association and not causation,” study author Cosby Stone, MD, MPH, said in an interview in advance of the annual meeting of the American Academy of Allergy, Asthma, and Immunology. “We need a clinical trial to evaluate the effect of giving more alpha-tocopherol to mothers during pregnancy before anyone should jump to giving supplements.”
The median age of children at the time of maternal sample collection was 50 days. 47% were female, and 61% were white. Of the 652 children, 167 (26%) met criteria for wheezing at age 2 years. These children had mothers with significantly lower postpartum concentrations of plasma alpha-tocopherol, compared with those who did not meet criteria for wheezing at 2 years (a mean of 69 micromol/L vs. 75 micromol/L, respectively; P = .02). In multivariable regression analysis, the researchers detected a significant interaction between gamma-tocopherol and alpha-tocopherol, where the highest amounts of maternal gamma-tocopherol modified and mitigated the protective association of maternal alpha-tocopherol with risk of wheezing at 2 years (P = .05).
Dr. Stone cautioned that, what is currently labeled as vitamin E or alpha-tocopherol in foods and supplements, “could be any of eight different isoforms, and alpha-tocopherol may not actually be the dominant isoform being provided. In addition, the oils that we eat are the main sources of tocopherols in our diet, and they vary widely in terms of their tocopherol isoforms. Sunflower and safflower oil, for example, provide predominantly alpha-tocopherol as their isoform of vitamin E, while corn and soy oil provide predominantly gamma-tocopherol.”
For now, he continued, correcting maternal alpha-tocopherol deficiency, currently defined by a serum alpha-tocopherol concentration less than 11.6 micromol/L, is certainly reasonable. Down the road, modification of maternal alpha-tocopherol or gamma-tocopherol concentrations through dietary counseling may provide clinicians with a tool to prevent wheezing or asthma in affected children. “In the future there may be a role for checking tocopherol isoforms in pregnant women and then modifying dietary oil consumption to protect the health of their children,” he said.
He acknowledged certain limitations of the study, including that researchers obtained maternal vitamin E isoform measurements at enrollment, when the infants were, on average, 6 weeks post partum, and not during pregnancy. “However, the literature has shown that postpartum vitamin E levels at this time point are very similar to those during the second trimester of pregnancy,” Dr. Stone said. “The literature has also shown that plasma vitamin E isoform concentrations are tightly tied to diet and body stores and do not change very rapidly (such that a woman would not be likely to go from the highest quartile to the lowest, or vice versa). People’s diets don’t tend to change that much, in general.”
INSPIRE is funded by the National Institutes of Health. Dr. Stone is funded by an NIH training grant through Vanderbilt University. He reported having no relevant financial disclosures.
AT THE 2017 AAAAI ANNUAL MEETING
Key clinical point:
Major finding: Increasing maternal postpartum–plasma alpha-tocopherol concentration was associated with a decreased likelihood of wheezing requiring asthma medications at 2 years (P = .02).
Data source: A prospective evaluation of 652 children with maternal postpartum–plasma vitamin E isoforms measured at study enrollment.
Disclosures: INSPIRE is funded by the National Institutes of Health. Dr. Stone is funded by an NIH training grant through Vanderbilt University. He reported having no relevant financial disclosures.
Family-based treatment of anorexia promising
LAS VEGAS – Mounting evidence demonstrates that a family-based approach to treating adolescents with anorexia nervosa usually is more effective than hospitalization.
“In the history of psychiatric literature, families have been blamed a lot for psychiatric problems in their children,” James Lock, MD, PhD, said at the annual psychopharmacology update held by the Nevada Psychiatric Association. “Parents are put off by anorexia nervosa, because it’s a very confusing illness and terrifying for them to have their children radically change their behavior. These are kids who are often high achieving and have generally been easy to manage: self-starters, self-directors. Then, suddenly, over a period of 6-7 months, they go from being very well to being at death’s door.”
Enter family-based treatment (FBT) for anorexia nervosa, an outpatient intervention appropriate for children and adolescents who are medically stable. Developed around 2001, FBT is designed to restore weight and put the patient’s development back on track. It’s a team approach consisting of a primary therapist, a pediatrician, and a child and adolescent psychiatrist. Brief hospitalization sometimes is used to resolve medical concerns. Dr. Lock, professor of psychiatry and behavioral sciences at Stanford (Calif.) University, described FBT as “a highly focused staged treatment that emphasizes behavioral recovery rather than insight and understanding or cognitive change. This approach might indirectly improve family functioning and reduce eating-related cognitive distortions for the adolescent.”
According to Dr. Lock, coauthor with Daniel Le Grange, PhD, of “Treatment Manual for Anorexia Nervosa: A Family-Based Approach” second edition, (New York: Guilford Press, 2015), the current evidence base for FBT is limited, consisting of 879 patients enrolled in 11 studies at 12 different sites in four countries, as well as one meta-analysis. “We have not done the kind of research in anorexia nervosa that we need to do,” he said. “Parents ask me this every time I sit down with them: ‘Why don’t we know more? Why don’t we have more clinical guidance?’ It’s not been a priority despite the seriousness of this problem [and the] lifelong impact it has.”
Interest in FBT emerged in part because of studies demonstrating the limitations of hospitalizing patients with the disorder. One trial from the United Kingdom found that, among 90 children who were randomized to one of two outpatient treatments, to an inpatient arm, or to no treatment, no differences in outcomes were observed among the treatment groups (Br J Psychiatry. 1991;159:325-33). Similar results were found in a trial of 167 children who were randomized to either inpatient psychiatric treatment or two forms of outpatient management (Br J Psychiatry. 2007;191[5]:427-35). “If you think hospitalization will cure kids with anorexia, this study tells you that isn’t true,” Dr. Lock said. “It doesn’t say that it doesn’t benefit some people. What it says is that, on average, it’s not better than outpatient treatment for adolescents with anorexia nervosa. It’s important to build systems of care around that knowledge.”
Dr. Lock has his own opinion as to why inpatient psychiatric treatment alone usually doesn’t help anorexia nervosa patients in the long-term. “Learning in an inpatient setting is not generalizable,” he said. “You cannot learn and apply the learning that you get in the hospital to your real life: in your family and your school and your social processes. You can dress up psychotherapy any way you want to, but ultimately, it’s about learning. Can parents learn to be effective at helping their children with anorexia nervosa recover?”
In general, FBT is delivered in three phases over the course of 6-12 months. Phase I involves helping parents assume control of weight restoration in their child. “It tries to accomplish at home what could have been accomplished at a hospital by a nursing staff who are trained and able to disrupt and manage destructive behaviors that lead to weight loss and reinforce cognitive distortions,” Dr. Lock said. In phase II, parents gradually hand control over eating back to their child, while phase III involves shifting the family back to discussing adolescent issues without anorexia nervosa at the center of their concern. One fundamental assumption of FBT, he continued, is that it takes an agnostic view as to the cause of anorexia.
“We don’t have to address cause in order to have an effective treatment,” said Dr. Lock, also a professor of pediatrics at the university. “We are going to try to help patients and parents feel valued, not blamed. Secondly, we need to engage parents in a consultative way, recognizing their skills around their family, and help them apply that to anorexia nervosa.” The expected outcome should be a healthy weight, based on the child’s age. According to Dr. Lock, 79% of patients who have gained at least 4 pounds after 4 weeks of FBT will have a favorable treatment response, while 71% of those who don’t meet that benchmark are likely to fail treatment. “The therapeutic alliance is important in treatment outcome, but our studies suggest it is not enough,” he said. “You have to engage people in treatment to get them started, but if you don’t help the parents be effective in promoting weight gain, your therapeutic alliance will diminish.”
In a randomized trial that compared FBT with adolescent-focused individual therapy (AFT) for adolescents with anorexia nervosa, Dr. Lock and his associates found that, at both 6- and 12-month follow-up, FBT was significantly superior to AFT in helping patients achieve full remission, which was defined as normal weight for age and a mean global Eating Disorder Examination score within one standard deviation of published means (Arch Gen Psychiatry. 2010;67[10]:1025-32). A separate trial found that, after FBT was implemented at the Royal Children’s Hospital, Melbourne, admissions decreased by 50%, readmissions decreased by 75%, and the overall number of days patients spent in the hospital fell by 51% (J Pediatr Health Care. 2014 Jul-Aug 28[4]:322-30).
During the first FBT meeting with patients and their families, Dr. Lock discusses the hazards of anorexia nervosa, including the increased risk of death by cardiac arrest and suicide. “I instill the fact that we have a crisis on our hands, and we need to block the development of anorexia nervosa,” he said. “We have no evidence-based treatments for anorexia nervosa once it becomes chronic, and that occurs after about 5 years. The onset is about age 14. At age 19, on average, your chances of complete recovery are greatly diminished. Of course, you can still be of help by supporting improvement in the quality of their lives; you may help improve their thinking and you may help them restore weight, but many will live with the ongoing anorexia nervosa. So, our greatest chance to be effective is early intervention and the window of opportunity is 3-4 years.” Emphasizing these realities “stops people,” he said. “It’s meant to bring them into clear awareness of what they’re facing.”
Dr. Lock disclosed that he has received grant or research support from the National Institute of Mental Health. He also is a consultant for the Training Institute for Child and Adolescent Eating Disorders and has received royalties from Guilford Press and Oxford Press.
LAS VEGAS – Mounting evidence demonstrates that a family-based approach to treating adolescents with anorexia nervosa usually is more effective than hospitalization.
“In the history of psychiatric literature, families have been blamed a lot for psychiatric problems in their children,” James Lock, MD, PhD, said at the annual psychopharmacology update held by the Nevada Psychiatric Association. “Parents are put off by anorexia nervosa, because it’s a very confusing illness and terrifying for them to have their children radically change their behavior. These are kids who are often high achieving and have generally been easy to manage: self-starters, self-directors. Then, suddenly, over a period of 6-7 months, they go from being very well to being at death’s door.”
Enter family-based treatment (FBT) for anorexia nervosa, an outpatient intervention appropriate for children and adolescents who are medically stable. Developed around 2001, FBT is designed to restore weight and put the patient’s development back on track. It’s a team approach consisting of a primary therapist, a pediatrician, and a child and adolescent psychiatrist. Brief hospitalization sometimes is used to resolve medical concerns. Dr. Lock, professor of psychiatry and behavioral sciences at Stanford (Calif.) University, described FBT as “a highly focused staged treatment that emphasizes behavioral recovery rather than insight and understanding or cognitive change. This approach might indirectly improve family functioning and reduce eating-related cognitive distortions for the adolescent.”
According to Dr. Lock, coauthor with Daniel Le Grange, PhD, of “Treatment Manual for Anorexia Nervosa: A Family-Based Approach” second edition, (New York: Guilford Press, 2015), the current evidence base for FBT is limited, consisting of 879 patients enrolled in 11 studies at 12 different sites in four countries, as well as one meta-analysis. “We have not done the kind of research in anorexia nervosa that we need to do,” he said. “Parents ask me this every time I sit down with them: ‘Why don’t we know more? Why don’t we have more clinical guidance?’ It’s not been a priority despite the seriousness of this problem [and the] lifelong impact it has.”
Interest in FBT emerged in part because of studies demonstrating the limitations of hospitalizing patients with the disorder. One trial from the United Kingdom found that, among 90 children who were randomized to one of two outpatient treatments, to an inpatient arm, or to no treatment, no differences in outcomes were observed among the treatment groups (Br J Psychiatry. 1991;159:325-33). Similar results were found in a trial of 167 children who were randomized to either inpatient psychiatric treatment or two forms of outpatient management (Br J Psychiatry. 2007;191[5]:427-35). “If you think hospitalization will cure kids with anorexia, this study tells you that isn’t true,” Dr. Lock said. “It doesn’t say that it doesn’t benefit some people. What it says is that, on average, it’s not better than outpatient treatment for adolescents with anorexia nervosa. It’s important to build systems of care around that knowledge.”
Dr. Lock has his own opinion as to why inpatient psychiatric treatment alone usually doesn’t help anorexia nervosa patients in the long-term. “Learning in an inpatient setting is not generalizable,” he said. “You cannot learn and apply the learning that you get in the hospital to your real life: in your family and your school and your social processes. You can dress up psychotherapy any way you want to, but ultimately, it’s about learning. Can parents learn to be effective at helping their children with anorexia nervosa recover?”
In general, FBT is delivered in three phases over the course of 6-12 months. Phase I involves helping parents assume control of weight restoration in their child. “It tries to accomplish at home what could have been accomplished at a hospital by a nursing staff who are trained and able to disrupt and manage destructive behaviors that lead to weight loss and reinforce cognitive distortions,” Dr. Lock said. In phase II, parents gradually hand control over eating back to their child, while phase III involves shifting the family back to discussing adolescent issues without anorexia nervosa at the center of their concern. One fundamental assumption of FBT, he continued, is that it takes an agnostic view as to the cause of anorexia.
“We don’t have to address cause in order to have an effective treatment,” said Dr. Lock, also a professor of pediatrics at the university. “We are going to try to help patients and parents feel valued, not blamed. Secondly, we need to engage parents in a consultative way, recognizing their skills around their family, and help them apply that to anorexia nervosa.” The expected outcome should be a healthy weight, based on the child’s age. According to Dr. Lock, 79% of patients who have gained at least 4 pounds after 4 weeks of FBT will have a favorable treatment response, while 71% of those who don’t meet that benchmark are likely to fail treatment. “The therapeutic alliance is important in treatment outcome, but our studies suggest it is not enough,” he said. “You have to engage people in treatment to get them started, but if you don’t help the parents be effective in promoting weight gain, your therapeutic alliance will diminish.”
In a randomized trial that compared FBT with adolescent-focused individual therapy (AFT) for adolescents with anorexia nervosa, Dr. Lock and his associates found that, at both 6- and 12-month follow-up, FBT was significantly superior to AFT in helping patients achieve full remission, which was defined as normal weight for age and a mean global Eating Disorder Examination score within one standard deviation of published means (Arch Gen Psychiatry. 2010;67[10]:1025-32). A separate trial found that, after FBT was implemented at the Royal Children’s Hospital, Melbourne, admissions decreased by 50%, readmissions decreased by 75%, and the overall number of days patients spent in the hospital fell by 51% (J Pediatr Health Care. 2014 Jul-Aug 28[4]:322-30).
During the first FBT meeting with patients and their families, Dr. Lock discusses the hazards of anorexia nervosa, including the increased risk of death by cardiac arrest and suicide. “I instill the fact that we have a crisis on our hands, and we need to block the development of anorexia nervosa,” he said. “We have no evidence-based treatments for anorexia nervosa once it becomes chronic, and that occurs after about 5 years. The onset is about age 14. At age 19, on average, your chances of complete recovery are greatly diminished. Of course, you can still be of help by supporting improvement in the quality of their lives; you may help improve their thinking and you may help them restore weight, but many will live with the ongoing anorexia nervosa. So, our greatest chance to be effective is early intervention and the window of opportunity is 3-4 years.” Emphasizing these realities “stops people,” he said. “It’s meant to bring them into clear awareness of what they’re facing.”
Dr. Lock disclosed that he has received grant or research support from the National Institute of Mental Health. He also is a consultant for the Training Institute for Child and Adolescent Eating Disorders and has received royalties from Guilford Press and Oxford Press.
LAS VEGAS – Mounting evidence demonstrates that a family-based approach to treating adolescents with anorexia nervosa usually is more effective than hospitalization.
“In the history of psychiatric literature, families have been blamed a lot for psychiatric problems in their children,” James Lock, MD, PhD, said at the annual psychopharmacology update held by the Nevada Psychiatric Association. “Parents are put off by anorexia nervosa, because it’s a very confusing illness and terrifying for them to have their children radically change their behavior. These are kids who are often high achieving and have generally been easy to manage: self-starters, self-directors. Then, suddenly, over a period of 6-7 months, they go from being very well to being at death’s door.”
Enter family-based treatment (FBT) for anorexia nervosa, an outpatient intervention appropriate for children and adolescents who are medically stable. Developed around 2001, FBT is designed to restore weight and put the patient’s development back on track. It’s a team approach consisting of a primary therapist, a pediatrician, and a child and adolescent psychiatrist. Brief hospitalization sometimes is used to resolve medical concerns. Dr. Lock, professor of psychiatry and behavioral sciences at Stanford (Calif.) University, described FBT as “a highly focused staged treatment that emphasizes behavioral recovery rather than insight and understanding or cognitive change. This approach might indirectly improve family functioning and reduce eating-related cognitive distortions for the adolescent.”
According to Dr. Lock, coauthor with Daniel Le Grange, PhD, of “Treatment Manual for Anorexia Nervosa: A Family-Based Approach” second edition, (New York: Guilford Press, 2015), the current evidence base for FBT is limited, consisting of 879 patients enrolled in 11 studies at 12 different sites in four countries, as well as one meta-analysis. “We have not done the kind of research in anorexia nervosa that we need to do,” he said. “Parents ask me this every time I sit down with them: ‘Why don’t we know more? Why don’t we have more clinical guidance?’ It’s not been a priority despite the seriousness of this problem [and the] lifelong impact it has.”
Interest in FBT emerged in part because of studies demonstrating the limitations of hospitalizing patients with the disorder. One trial from the United Kingdom found that, among 90 children who were randomized to one of two outpatient treatments, to an inpatient arm, or to no treatment, no differences in outcomes were observed among the treatment groups (Br J Psychiatry. 1991;159:325-33). Similar results were found in a trial of 167 children who were randomized to either inpatient psychiatric treatment or two forms of outpatient management (Br J Psychiatry. 2007;191[5]:427-35). “If you think hospitalization will cure kids with anorexia, this study tells you that isn’t true,” Dr. Lock said. “It doesn’t say that it doesn’t benefit some people. What it says is that, on average, it’s not better than outpatient treatment for adolescents with anorexia nervosa. It’s important to build systems of care around that knowledge.”
Dr. Lock has his own opinion as to why inpatient psychiatric treatment alone usually doesn’t help anorexia nervosa patients in the long-term. “Learning in an inpatient setting is not generalizable,” he said. “You cannot learn and apply the learning that you get in the hospital to your real life: in your family and your school and your social processes. You can dress up psychotherapy any way you want to, but ultimately, it’s about learning. Can parents learn to be effective at helping their children with anorexia nervosa recover?”
In general, FBT is delivered in three phases over the course of 6-12 months. Phase I involves helping parents assume control of weight restoration in their child. “It tries to accomplish at home what could have been accomplished at a hospital by a nursing staff who are trained and able to disrupt and manage destructive behaviors that lead to weight loss and reinforce cognitive distortions,” Dr. Lock said. In phase II, parents gradually hand control over eating back to their child, while phase III involves shifting the family back to discussing adolescent issues without anorexia nervosa at the center of their concern. One fundamental assumption of FBT, he continued, is that it takes an agnostic view as to the cause of anorexia.
“We don’t have to address cause in order to have an effective treatment,” said Dr. Lock, also a professor of pediatrics at the university. “We are going to try to help patients and parents feel valued, not blamed. Secondly, we need to engage parents in a consultative way, recognizing their skills around their family, and help them apply that to anorexia nervosa.” The expected outcome should be a healthy weight, based on the child’s age. According to Dr. Lock, 79% of patients who have gained at least 4 pounds after 4 weeks of FBT will have a favorable treatment response, while 71% of those who don’t meet that benchmark are likely to fail treatment. “The therapeutic alliance is important in treatment outcome, but our studies suggest it is not enough,” he said. “You have to engage people in treatment to get them started, but if you don’t help the parents be effective in promoting weight gain, your therapeutic alliance will diminish.”
In a randomized trial that compared FBT with adolescent-focused individual therapy (AFT) for adolescents with anorexia nervosa, Dr. Lock and his associates found that, at both 6- and 12-month follow-up, FBT was significantly superior to AFT in helping patients achieve full remission, which was defined as normal weight for age and a mean global Eating Disorder Examination score within one standard deviation of published means (Arch Gen Psychiatry. 2010;67[10]:1025-32). A separate trial found that, after FBT was implemented at the Royal Children’s Hospital, Melbourne, admissions decreased by 50%, readmissions decreased by 75%, and the overall number of days patients spent in the hospital fell by 51% (J Pediatr Health Care. 2014 Jul-Aug 28[4]:322-30).
During the first FBT meeting with patients and their families, Dr. Lock discusses the hazards of anorexia nervosa, including the increased risk of death by cardiac arrest and suicide. “I instill the fact that we have a crisis on our hands, and we need to block the development of anorexia nervosa,” he said. “We have no evidence-based treatments for anorexia nervosa once it becomes chronic, and that occurs after about 5 years. The onset is about age 14. At age 19, on average, your chances of complete recovery are greatly diminished. Of course, you can still be of help by supporting improvement in the quality of their lives; you may help improve their thinking and you may help them restore weight, but many will live with the ongoing anorexia nervosa. So, our greatest chance to be effective is early intervention and the window of opportunity is 3-4 years.” Emphasizing these realities “stops people,” he said. “It’s meant to bring them into clear awareness of what they’re facing.”
Dr. Lock disclosed that he has received grant or research support from the National Institute of Mental Health. He also is a consultant for the Training Institute for Child and Adolescent Eating Disorders and has received royalties from Guilford Press and Oxford Press.