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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.
Expect tricky journey with BDD patients
LAS VEGAS – When working with patients referred for suspected body dysmorphic disorder, expect the initial groundwork to take more time than for other disorders.
“I think that these patients are among the most severely ill that we see in clinical practice – although body dysmorphic disorder often goes unrecognized, because patients are often very ashamed of their concerns, and they find it hard to talk about them,” Katharine A. Phillips, MD, said at the annual psychopharmacology update held by the Nevada Psychiatric Association.
Defined in the DSM-5 as preoccupation with one or more perceived defects or flaws in physical appearance that are not observable or that appear slight to others, body dysmorphic disorder (BDD) often causes substantial distress and impairment of day-to-day functioning and is associated with a high rate of suicidality. “When these patients walk into your office, you cannot tell by looking at them what their appearance concern is going to be,” said Dr. Phillips, professor of psychiatry and human behavior at Brown University, Providence, R.I. “Sometimes they point it out to you and you can see that their nostrils are a tiny bit asymmetrical or that they have a little scar on their chin, but it’s not very noticeable. It’s not noticeable until the patient points it out, and even then it’s a slight flaw. But in most cases, the body areas that the patient is preoccupied with look entirely normal.”
BDD affects an estimated 1.7%-2.9% of the general population; about 60% are female. In two-thirds of cases, it onsets during childhood or adolescence. The preoccupations about physical appearance that are associated with the disorder “are very obsessional and distressing,” Dr. Phillips said. “They may think ‘I look ugly. People are laughing at me. I look like a freak.’ They can be focused on any part of their appearance, but most often it’s the face or head. Skin is No. 1, followed by hair and nose.” Complaints may include perceptions of scarring, perceptions of skin color, too much facial hair, or hair that’s too curly or straight. On average, BDD patients report thinking about their perceived flaws for 3-8 hours a day. “Some say it’s all they think about all day long,” said Dr. Phillips, who also directs the Body Dysmorphic Disorder Program at Rhode Island Hospital, in Providence.
“Insight is usually absent or poor, and BDD-related ideas or delusions of reference are common. A majority mistakenly think that other people are taking special notice of them in a negative way because of how they look. If they walk down the street, for example, they may misperceive people as staring at them. If they hear people talking to one another they may think, ‘They must be talking about how ugly my nose is.’ I have patients who have physically assaulted strangers on the street because they’re so certain that they’re being made fun of because of their appearance flaws, which exist in their mind.”
Functional MRI studies of BDD patients demonstrate aberrant visual processing. “They overfocus on tiny details, so the brain is trying to extract detail where there isn’t any,” she explained. “A complementary finding is that they have reduced visual processing of holistic visual stimuli (“seeing the big picture”), compared with healthy controls. One of my patients said to me, ‘When I look at myself I’m just one big pimple without any feet or even any toes.’ They focus in on the body areas they hate and have trouble perceiving the rest of themselves.”
Compulsive repetitive behaviors that are done in response to the appearance preoccupations may include camouflaging (for example, covering perceived hair thinning with a hat), comparing their appearance with that of other people, mirror checking, excessive grooming, questioning others about their appearance or seeking reassurance about the perceived flaws, skin picking, and tanning (often to darken “pale” skin). Functional impairment varies but is usually substantial. For example, in several studies, Dr. Phillips and her associates found that 39% of BDD patients were currently not working because of psychopathology (for most, BDD was their primary diagnosis), about 20% had dropped out of school primarily because of BDD symptoms, 29% had been housebound for at least a week because of their BDD symptoms, 38% had been psychiatrically hospitalized, and the rates of lifetime suicidal ideation ranged from 71% to 81%. “More than one-quarter have attempted suicide,” she said.
About three-quarters seek and two-thirds receive some kind of cosmetic treatment for BDD, most commonly dermatologic treatment and plastic surgery (most often rhinoplasty). “General recommendations are that cosmetic treatment should not be done on these patients,” Dr. Phillips said. A recent practice guideline from the American Academy of Otolaryngology–Head and Neck Surgery recommends that surgeons not operate on a rhinoplasty candidate who screens positive for BDD (Otolaryngol Head Neck Surg. 2017 Feb;156 [2 _suppl]:S1-30).
Serotonin reuptake inhibitors (SRIs) at a high enough dose and for a trial duration of 12-16 weeks are the first-line medications for both nondelusional BDD and delusional BDD. “Most patients with BDD don’t receive adequate first-line pharmacotherapy,” Dr. Phillips said. “Often, high doses of SRIs are needed, sometimes above the [Food and Drug Administration]-approved limits, but I don’t exceed these limits for clomipramine or citalopram.” Recommended SRI doses for BDD are similar to those in the American Psychiatric Association’s practice guideline for obsessive-compulsive disorder. She recommends checking an EKG when patients take a high dose of escitalopram.
In cases of partial or no response to an SRI, consider whether the dose was high enough. “In the vast majority of patients I see for consultation, it wasn’t,” Dr. Phillips said. “Check adherence, and extend the trial if necessary, with 3-4 weeks at the maximum recommended tolerated dose.” In her clinical experience, atypical antipsychotics can sometimes help when added to an SRI, especially in patients who are agitated, aggressive, impulsive, or severely anxious, but antipsychotics are not currently recommended as monotherapy. “In my view, the most pressing need in the BDD field is for research on the efficacy of antipsychotics, especially as SRI augmentation agents,” she said. “We have so little data.” SRI augmentation of buspirone also can prove helpful.
Cognitive-behavioral therapy is the psychosocial treatment of choice for BDD. However, Dr. Phillips cautioned that if BDD patients receive treatment comparable to that of patients with OCD or depression, they probably won’t get better. “It needs to be tailored to BDD symptoms, which are unique in many ways,” she said. “As you would with any patient, express empathy, instill hope, and attend to the therapeutic alliance.”
She recommended using one of the two published evidence-based CBT manuals for BDD: “Cognitive-Behavioral Therapy for Body Dysmorphic Disorder: A Treatment Manual,” by Sabine Wilhelm, PhD, Dr. Phillips, and Gail Steketee, PhD (New York: Guilford Press, 2013) and “Body Dysmorphic Disorder” by David Veale, MD and Fugen Neziroglu, PhD (West Sussex, U.K.: 2010).
Key CBT principles include helping patients cut down on BDD rituals – for example, by spending less time in front of mirrors or discarding their pocket mirrors. Gradual exposure to social situations, combined with behavioral experiments, also is recommended. Other core CBT components include cognitive therapy, perceptual retraining, motivational interviewing, and providing psychoeducation about BDD.
“I explain to patients that people with BDD see themselves differently than others do, which is supported by visual processing studies,” Dr. Phillips said. “They don’t necessarily buy it, but I think it’s worth putting it out there. Instead of trying to convince them that they look fine, focus on their suffering, preoccupation, and the effect of symptoms on their life. They will usually agree that they are suffering a lot, and that may motivate them for treatment.”
These questions that can help you better understand and diagnose the concerns of BDD patients: “Are you very worried about your appearance in any way?” If yes, “Can you tell me about your concern?”
Suggested questions regarding preoccupations about appearance (DSM-5 criteria A) are: “Does this concern preoccupy you? Do you think about it a lot and wish you could think about it less?” To elicit discussion on the topic of repetitive behaviors (DSM-5 criteria B), consider asking, “Is there anything you feel an urge to do over and over again in response to your appearance concerns?” To determine whether the preoccupations cause clinically significant distress or impairment in functioning (DSM-5 criteria C), ask, “How much does this concern upset you? Does it cause you any problems – socially, in relationships, or with school or work?”
Dr. Phillips disclosed that during the past year, she has received honoraria from the Merck Manual and from Royal Pharma as well as royalties from Oxford University Press, International Creative Management, American Psychiatric Publishing, Guilford Press, and UpToDate.
LAS VEGAS – When working with patients referred for suspected body dysmorphic disorder, expect the initial groundwork to take more time than for other disorders.
“I think that these patients are among the most severely ill that we see in clinical practice – although body dysmorphic disorder often goes unrecognized, because patients are often very ashamed of their concerns, and they find it hard to talk about them,” Katharine A. Phillips, MD, said at the annual psychopharmacology update held by the Nevada Psychiatric Association.
Defined in the DSM-5 as preoccupation with one or more perceived defects or flaws in physical appearance that are not observable or that appear slight to others, body dysmorphic disorder (BDD) often causes substantial distress and impairment of day-to-day functioning and is associated with a high rate of suicidality. “When these patients walk into your office, you cannot tell by looking at them what their appearance concern is going to be,” said Dr. Phillips, professor of psychiatry and human behavior at Brown University, Providence, R.I. “Sometimes they point it out to you and you can see that their nostrils are a tiny bit asymmetrical or that they have a little scar on their chin, but it’s not very noticeable. It’s not noticeable until the patient points it out, and even then it’s a slight flaw. But in most cases, the body areas that the patient is preoccupied with look entirely normal.”
BDD affects an estimated 1.7%-2.9% of the general population; about 60% are female. In two-thirds of cases, it onsets during childhood or adolescence. The preoccupations about physical appearance that are associated with the disorder “are very obsessional and distressing,” Dr. Phillips said. “They may think ‘I look ugly. People are laughing at me. I look like a freak.’ They can be focused on any part of their appearance, but most often it’s the face or head. Skin is No. 1, followed by hair and nose.” Complaints may include perceptions of scarring, perceptions of skin color, too much facial hair, or hair that’s too curly or straight. On average, BDD patients report thinking about their perceived flaws for 3-8 hours a day. “Some say it’s all they think about all day long,” said Dr. Phillips, who also directs the Body Dysmorphic Disorder Program at Rhode Island Hospital, in Providence.
“Insight is usually absent or poor, and BDD-related ideas or delusions of reference are common. A majority mistakenly think that other people are taking special notice of them in a negative way because of how they look. If they walk down the street, for example, they may misperceive people as staring at them. If they hear people talking to one another they may think, ‘They must be talking about how ugly my nose is.’ I have patients who have physically assaulted strangers on the street because they’re so certain that they’re being made fun of because of their appearance flaws, which exist in their mind.”
Functional MRI studies of BDD patients demonstrate aberrant visual processing. “They overfocus on tiny details, so the brain is trying to extract detail where there isn’t any,” she explained. “A complementary finding is that they have reduced visual processing of holistic visual stimuli (“seeing the big picture”), compared with healthy controls. One of my patients said to me, ‘When I look at myself I’m just one big pimple without any feet or even any toes.’ They focus in on the body areas they hate and have trouble perceiving the rest of themselves.”
Compulsive repetitive behaviors that are done in response to the appearance preoccupations may include camouflaging (for example, covering perceived hair thinning with a hat), comparing their appearance with that of other people, mirror checking, excessive grooming, questioning others about their appearance or seeking reassurance about the perceived flaws, skin picking, and tanning (often to darken “pale” skin). Functional impairment varies but is usually substantial. For example, in several studies, Dr. Phillips and her associates found that 39% of BDD patients were currently not working because of psychopathology (for most, BDD was their primary diagnosis), about 20% had dropped out of school primarily because of BDD symptoms, 29% had been housebound for at least a week because of their BDD symptoms, 38% had been psychiatrically hospitalized, and the rates of lifetime suicidal ideation ranged from 71% to 81%. “More than one-quarter have attempted suicide,” she said.
About three-quarters seek and two-thirds receive some kind of cosmetic treatment for BDD, most commonly dermatologic treatment and plastic surgery (most often rhinoplasty). “General recommendations are that cosmetic treatment should not be done on these patients,” Dr. Phillips said. A recent practice guideline from the American Academy of Otolaryngology–Head and Neck Surgery recommends that surgeons not operate on a rhinoplasty candidate who screens positive for BDD (Otolaryngol Head Neck Surg. 2017 Feb;156 [2 _suppl]:S1-30).
Serotonin reuptake inhibitors (SRIs) at a high enough dose and for a trial duration of 12-16 weeks are the first-line medications for both nondelusional BDD and delusional BDD. “Most patients with BDD don’t receive adequate first-line pharmacotherapy,” Dr. Phillips said. “Often, high doses of SRIs are needed, sometimes above the [Food and Drug Administration]-approved limits, but I don’t exceed these limits for clomipramine or citalopram.” Recommended SRI doses for BDD are similar to those in the American Psychiatric Association’s practice guideline for obsessive-compulsive disorder. She recommends checking an EKG when patients take a high dose of escitalopram.
In cases of partial or no response to an SRI, consider whether the dose was high enough. “In the vast majority of patients I see for consultation, it wasn’t,” Dr. Phillips said. “Check adherence, and extend the trial if necessary, with 3-4 weeks at the maximum recommended tolerated dose.” In her clinical experience, atypical antipsychotics can sometimes help when added to an SRI, especially in patients who are agitated, aggressive, impulsive, or severely anxious, but antipsychotics are not currently recommended as monotherapy. “In my view, the most pressing need in the BDD field is for research on the efficacy of antipsychotics, especially as SRI augmentation agents,” she said. “We have so little data.” SRI augmentation of buspirone also can prove helpful.
Cognitive-behavioral therapy is the psychosocial treatment of choice for BDD. However, Dr. Phillips cautioned that if BDD patients receive treatment comparable to that of patients with OCD or depression, they probably won’t get better. “It needs to be tailored to BDD symptoms, which are unique in many ways,” she said. “As you would with any patient, express empathy, instill hope, and attend to the therapeutic alliance.”
She recommended using one of the two published evidence-based CBT manuals for BDD: “Cognitive-Behavioral Therapy for Body Dysmorphic Disorder: A Treatment Manual,” by Sabine Wilhelm, PhD, Dr. Phillips, and Gail Steketee, PhD (New York: Guilford Press, 2013) and “Body Dysmorphic Disorder” by David Veale, MD and Fugen Neziroglu, PhD (West Sussex, U.K.: 2010).
Key CBT principles include helping patients cut down on BDD rituals – for example, by spending less time in front of mirrors or discarding their pocket mirrors. Gradual exposure to social situations, combined with behavioral experiments, also is recommended. Other core CBT components include cognitive therapy, perceptual retraining, motivational interviewing, and providing psychoeducation about BDD.
“I explain to patients that people with BDD see themselves differently than others do, which is supported by visual processing studies,” Dr. Phillips said. “They don’t necessarily buy it, but I think it’s worth putting it out there. Instead of trying to convince them that they look fine, focus on their suffering, preoccupation, and the effect of symptoms on their life. They will usually agree that they are suffering a lot, and that may motivate them for treatment.”
These questions that can help you better understand and diagnose the concerns of BDD patients: “Are you very worried about your appearance in any way?” If yes, “Can you tell me about your concern?”
Suggested questions regarding preoccupations about appearance (DSM-5 criteria A) are: “Does this concern preoccupy you? Do you think about it a lot and wish you could think about it less?” To elicit discussion on the topic of repetitive behaviors (DSM-5 criteria B), consider asking, “Is there anything you feel an urge to do over and over again in response to your appearance concerns?” To determine whether the preoccupations cause clinically significant distress or impairment in functioning (DSM-5 criteria C), ask, “How much does this concern upset you? Does it cause you any problems – socially, in relationships, or with school or work?”
Dr. Phillips disclosed that during the past year, she has received honoraria from the Merck Manual and from Royal Pharma as well as royalties from Oxford University Press, International Creative Management, American Psychiatric Publishing, Guilford Press, and UpToDate.
LAS VEGAS – When working with patients referred for suspected body dysmorphic disorder, expect the initial groundwork to take more time than for other disorders.
“I think that these patients are among the most severely ill that we see in clinical practice – although body dysmorphic disorder often goes unrecognized, because patients are often very ashamed of their concerns, and they find it hard to talk about them,” Katharine A. Phillips, MD, said at the annual psychopharmacology update held by the Nevada Psychiatric Association.
Defined in the DSM-5 as preoccupation with one or more perceived defects or flaws in physical appearance that are not observable or that appear slight to others, body dysmorphic disorder (BDD) often causes substantial distress and impairment of day-to-day functioning and is associated with a high rate of suicidality. “When these patients walk into your office, you cannot tell by looking at them what their appearance concern is going to be,” said Dr. Phillips, professor of psychiatry and human behavior at Brown University, Providence, R.I. “Sometimes they point it out to you and you can see that their nostrils are a tiny bit asymmetrical or that they have a little scar on their chin, but it’s not very noticeable. It’s not noticeable until the patient points it out, and even then it’s a slight flaw. But in most cases, the body areas that the patient is preoccupied with look entirely normal.”
BDD affects an estimated 1.7%-2.9% of the general population; about 60% are female. In two-thirds of cases, it onsets during childhood or adolescence. The preoccupations about physical appearance that are associated with the disorder “are very obsessional and distressing,” Dr. Phillips said. “They may think ‘I look ugly. People are laughing at me. I look like a freak.’ They can be focused on any part of their appearance, but most often it’s the face or head. Skin is No. 1, followed by hair and nose.” Complaints may include perceptions of scarring, perceptions of skin color, too much facial hair, or hair that’s too curly or straight. On average, BDD patients report thinking about their perceived flaws for 3-8 hours a day. “Some say it’s all they think about all day long,” said Dr. Phillips, who also directs the Body Dysmorphic Disorder Program at Rhode Island Hospital, in Providence.
“Insight is usually absent or poor, and BDD-related ideas or delusions of reference are common. A majority mistakenly think that other people are taking special notice of them in a negative way because of how they look. If they walk down the street, for example, they may misperceive people as staring at them. If they hear people talking to one another they may think, ‘They must be talking about how ugly my nose is.’ I have patients who have physically assaulted strangers on the street because they’re so certain that they’re being made fun of because of their appearance flaws, which exist in their mind.”
Functional MRI studies of BDD patients demonstrate aberrant visual processing. “They overfocus on tiny details, so the brain is trying to extract detail where there isn’t any,” she explained. “A complementary finding is that they have reduced visual processing of holistic visual stimuli (“seeing the big picture”), compared with healthy controls. One of my patients said to me, ‘When I look at myself I’m just one big pimple without any feet or even any toes.’ They focus in on the body areas they hate and have trouble perceiving the rest of themselves.”
Compulsive repetitive behaviors that are done in response to the appearance preoccupations may include camouflaging (for example, covering perceived hair thinning with a hat), comparing their appearance with that of other people, mirror checking, excessive grooming, questioning others about their appearance or seeking reassurance about the perceived flaws, skin picking, and tanning (often to darken “pale” skin). Functional impairment varies but is usually substantial. For example, in several studies, Dr. Phillips and her associates found that 39% of BDD patients were currently not working because of psychopathology (for most, BDD was their primary diagnosis), about 20% had dropped out of school primarily because of BDD symptoms, 29% had been housebound for at least a week because of their BDD symptoms, 38% had been psychiatrically hospitalized, and the rates of lifetime suicidal ideation ranged from 71% to 81%. “More than one-quarter have attempted suicide,” she said.
About three-quarters seek and two-thirds receive some kind of cosmetic treatment for BDD, most commonly dermatologic treatment and plastic surgery (most often rhinoplasty). “General recommendations are that cosmetic treatment should not be done on these patients,” Dr. Phillips said. A recent practice guideline from the American Academy of Otolaryngology–Head and Neck Surgery recommends that surgeons not operate on a rhinoplasty candidate who screens positive for BDD (Otolaryngol Head Neck Surg. 2017 Feb;156 [2 _suppl]:S1-30).
Serotonin reuptake inhibitors (SRIs) at a high enough dose and for a trial duration of 12-16 weeks are the first-line medications for both nondelusional BDD and delusional BDD. “Most patients with BDD don’t receive adequate first-line pharmacotherapy,” Dr. Phillips said. “Often, high doses of SRIs are needed, sometimes above the [Food and Drug Administration]-approved limits, but I don’t exceed these limits for clomipramine or citalopram.” Recommended SRI doses for BDD are similar to those in the American Psychiatric Association’s practice guideline for obsessive-compulsive disorder. She recommends checking an EKG when patients take a high dose of escitalopram.
In cases of partial or no response to an SRI, consider whether the dose was high enough. “In the vast majority of patients I see for consultation, it wasn’t,” Dr. Phillips said. “Check adherence, and extend the trial if necessary, with 3-4 weeks at the maximum recommended tolerated dose.” In her clinical experience, atypical antipsychotics can sometimes help when added to an SRI, especially in patients who are agitated, aggressive, impulsive, or severely anxious, but antipsychotics are not currently recommended as monotherapy. “In my view, the most pressing need in the BDD field is for research on the efficacy of antipsychotics, especially as SRI augmentation agents,” she said. “We have so little data.” SRI augmentation of buspirone also can prove helpful.
Cognitive-behavioral therapy is the psychosocial treatment of choice for BDD. However, Dr. Phillips cautioned that if BDD patients receive treatment comparable to that of patients with OCD or depression, they probably won’t get better. “It needs to be tailored to BDD symptoms, which are unique in many ways,” she said. “As you would with any patient, express empathy, instill hope, and attend to the therapeutic alliance.”
She recommended using one of the two published evidence-based CBT manuals for BDD: “Cognitive-Behavioral Therapy for Body Dysmorphic Disorder: A Treatment Manual,” by Sabine Wilhelm, PhD, Dr. Phillips, and Gail Steketee, PhD (New York: Guilford Press, 2013) and “Body Dysmorphic Disorder” by David Veale, MD and Fugen Neziroglu, PhD (West Sussex, U.K.: 2010).
Key CBT principles include helping patients cut down on BDD rituals – for example, by spending less time in front of mirrors or discarding their pocket mirrors. Gradual exposure to social situations, combined with behavioral experiments, also is recommended. Other core CBT components include cognitive therapy, perceptual retraining, motivational interviewing, and providing psychoeducation about BDD.
“I explain to patients that people with BDD see themselves differently than others do, which is supported by visual processing studies,” Dr. Phillips said. “They don’t necessarily buy it, but I think it’s worth putting it out there. Instead of trying to convince them that they look fine, focus on their suffering, preoccupation, and the effect of symptoms on their life. They will usually agree that they are suffering a lot, and that may motivate them for treatment.”
These questions that can help you better understand and diagnose the concerns of BDD patients: “Are you very worried about your appearance in any way?” If yes, “Can you tell me about your concern?”
Suggested questions regarding preoccupations about appearance (DSM-5 criteria A) are: “Does this concern preoccupy you? Do you think about it a lot and wish you could think about it less?” To elicit discussion on the topic of repetitive behaviors (DSM-5 criteria B), consider asking, “Is there anything you feel an urge to do over and over again in response to your appearance concerns?” To determine whether the preoccupations cause clinically significant distress or impairment in functioning (DSM-5 criteria C), ask, “How much does this concern upset you? Does it cause you any problems – socially, in relationships, or with school or work?”
Dr. Phillips disclosed that during the past year, she has received honoraria from the Merck Manual and from Royal Pharma as well as royalties from Oxford University Press, International Creative Management, American Psychiatric Publishing, Guilford Press, and UpToDate.
EXPERT ANALYSIS AT THE NPA PSYCHOPHARMACOLOGY UPDATE
Risk considerations for suicidal physicians
EXPERT ANALYSIS AT THE NPA PSYCHOPHARMACOLOGY UPDATE
LAS VEGAS – Michael F. Myers, MD, found a common thread in interviews with loved ones, friends, and colleagues of physicians who have taken their own lives: About 10%-15% of the decedents never sought help beforehand.
“They’ve gone from illness to death without any care,” Dr. Myers, a psychiatrist, said at the annual psychopharmacology update held by the Nevada Psychiatric Association.
In a new book based on the interviews, “Why Physicians Die by Suicide: Lessons Learned From Their Families and Others Who Cared” (Amazon, 2017), Dr. Myers combined stories from his own clinical practice and qualitative interviews with about 75 men and women to explore reasons why physicians might choose to take their own lives. “Our nonpsychiatric medical colleagues are really anxious to have information from us, because we’re living in an age of burnout; roughly 50% of U.S. physicians suffer from burnout,” he said. In addition to perspectives from bereaved loved ones and former medical colleagues, the book includes insights from others who are affected when doctors die by suicide: their medical training directors, employers, medical students, treating psychiatrists, and patients.
According to the American Foundation for Suicide Prevention, 300-400 physicians take their own lives every year, the equivalent of two to three medical school classes. “That’s a doctor a day we lose to suicide,” said Dr. Myers, a professor of clinical psychiatry at State University of New York, Brooklyn, who specializes in physician health. Compared with the general population, the suicide rate ratio is 2.27 among female physicians and 1.41 among male physicians (Am J Psychiatry. 2004;161[12]:2295-2302), and an estimated 85%-90% of those who carry out a suicide have a psychiatric illness such as major depressive disorder, bipolar disorder, alcohol use and substance use disorder, and borderline personality disorder. Other triggers common to physicians, Dr. Myers said, include other kinds of personality disorders, burnout, untreated anxiety disorders, substance/medication-induced depressive disorder (especially in clinicians who have been self-medicating), and posttraumatic stress disorder.
Additional risk considerations to keep in mind for physician patients include a family history of mood disorders, a sense of professional isolation, coping with lawsuits and/or medical license investigations, previous history of a depressive episode, and a previous suicide attempt. “Sometimes, it’s hard to get this information from a new physician who’s sitting opposite you,” Dr. Myers noted. “We mustn’t forget that there’s a lot of shame, embarrassment, and guilt that’s attached to previous suicide attempts.”
Suicide risk also is elevated for physicians with treatment-refractory psychiatric illness. “It troubles me when a physician is being treated by a generalist, the patient is not doing well, and he or she is not being referred for a second opinion or has never been referred to a psychopharmacologist,” he said. “It’s important that be done, because you know how difficult many of your patients can be. It’s important to have the expertise of a psychopharmacologist. I believe that physician patients will welcome that [second opinion], even if they have to travel 200 miles for it.”
The list of risk considerations for suicidal physicians also includes undiagnosed and untreated bipolar I or II disorder, rapid cycling bipolar disorder, and mixed affective states. “These are important things that can make our patients ill very quickly,” he said. Impulsivity is another consideration, as are severe sleep deprivation, circadian rhythm disturbances, and acute suicidal affective disturbance, which has emerged as a condition to consider in future revisions of DSM-5. “What you see in this condition is an individual becoming suicidal within minutes or hours,” Dr. Myers explained. “It’s usually an agitated state with insomnia and overvalued ideas or delusions that they are completely untreatable and hopeless. Physicians are no different than anyone else in that kind of state.” He emphasized that the stigma attached to mental illness in physicians is pernicious, because untreated mental illness is a key driver of suicide. After one of Dr. Myers’s patients took his own life, his son told Dr. Myers, “My father just hated being a patient. He felt so ashamed. I tried hard, too, but my support wasn’t enough.”
Inadequate treatment can occur for physician patients because of transference and countertransference dynamics “that muddle the treatment dyad,” Dr. Myers added. “We must be mindful of the many issues that are going on when we treat our own.”
In his 2005 book “Why People Die By Suicide,” psychologist Thomas Joiner, PhD, described three key reasons why people choose to take their own lives. The first is “perceived burdensomeness,” or a sense that one is a burden on others. “When I see it in my physician patients, it’s when they have a sense of being a burden on their family and feel they are no longer serving a purpose,” Dr. Myers said. The second reason is “failed belongingness,” or a sense that one does not belong to a valued social group. “This resonates with me,” Dr. Myers said. “Sometimes in therapy sessions, my physician patients will say ‘Don’t call me Dr. Smith anymore; I’m Mr. Smith.’ They’ve removed themselves from the field because they don’t feel like they belong anymore. That’s the unworthiness that physicians can feel.”
The third reason is “learned fearlessness,” or the acquired capability to enact self-injury. Dr. Myers likened it to “the kind of exposure to pain and fear that people also might learn through such experiences as mountain climbing, performing surgery, fighting in wars, or being afflicted with anorexia.”
If you suspect that a physician patient is engaged in suicidal thinking and planning, Dr. Myers advises framing your mental health assessment in the context of trust and mutual respect. “Please don’t be seduced by somebody who’s squeaky clean in the area of suicidality,” he said. “That individual may just not be sharing with you yet. You’re going to have to be firm and parental at times. There’s a lot of terror and shame that can lurk behind those symptomatic behaviors. That’s where you’ll use your expertise. I have found that there are many physicians out there who welcome you to go in that ‘dark place’ with them. For them to be able to share those scary thoughts with someone can enhance the therapeutic alliance.” The inquiry should include questions about potential means and methods, including access to firearms, stockpiled and/or self-prescribed medications, and medications ordered online or stolen/diverted from the workplace. Timely and careful documentation are essential, he said.
The plan for treating suicidal physicians should include obtaining old records and speaking with former treating professionals. “If you get pushback from the patient, say, ‘This is about me wanting to be thorough in my assessment and treatment plan with you,’ ” Dr. Myers said. “There is no substitute for a detailed mental status evaluation, collateral information, clinical intuition, experience, and consultation.” Hospitalizing the physician patient should be judicious and in consultation with others. “If you’re not sure, get a second opinion, because it can be life-saving,” he said, “but if done inappropriately, you can turn them off psychiatry for the rest of their lives. Make sure you’re not just panicking and worrying about some sort of medical-legal risk.”
In cases of split treatment, ensure regular contact with the psychotherapist and document all communication and any changes in status, medication, or psychotherapy modality change.
Dr. Myers cited many ways that psychiatrists can educate their colleagues about burnout, depression, and the risk of suicide. These include offering to give grand rounds or a lecture on the topic, serving on your local CME planning committee, joining your institute’s physician wellness team, serving on your state’s physician health program, and offering to facilitate a group for physicians after a physician colleague has died by suicide. “Postvention is prevention for the next generation,” Dr. Myers said, quoting Edwin S. Shneidman, PhD, founder of the American Association of Suicidology. “By taking care of ourselves and accepting the painful reality of physician suicide, we reach out to those left behind and make a difference. You become a change agent – someone who is part of the movement to stop doctors from killing themselves.”
Dr. Myers disclosed that he has received funding from the Medical Education Speakers Network.
EXPERT ANALYSIS AT THE NPA PSYCHOPHARMACOLOGY UPDATE
LAS VEGAS – Michael F. Myers, MD, found a common thread in interviews with loved ones, friends, and colleagues of physicians who have taken their own lives: About 10%-15% of the decedents never sought help beforehand.
“They’ve gone from illness to death without any care,” Dr. Myers, a psychiatrist, said at the annual psychopharmacology update held by the Nevada Psychiatric Association.
In a new book based on the interviews, “Why Physicians Die by Suicide: Lessons Learned From Their Families and Others Who Cared” (Amazon, 2017), Dr. Myers combined stories from his own clinical practice and qualitative interviews with about 75 men and women to explore reasons why physicians might choose to take their own lives. “Our nonpsychiatric medical colleagues are really anxious to have information from us, because we’re living in an age of burnout; roughly 50% of U.S. physicians suffer from burnout,” he said. In addition to perspectives from bereaved loved ones and former medical colleagues, the book includes insights from others who are affected when doctors die by suicide: their medical training directors, employers, medical students, treating psychiatrists, and patients.
According to the American Foundation for Suicide Prevention, 300-400 physicians take their own lives every year, the equivalent of two to three medical school classes. “That’s a doctor a day we lose to suicide,” said Dr. Myers, a professor of clinical psychiatry at State University of New York, Brooklyn, who specializes in physician health. Compared with the general population, the suicide rate ratio is 2.27 among female physicians and 1.41 among male physicians (Am J Psychiatry. 2004;161[12]:2295-2302), and an estimated 85%-90% of those who carry out a suicide have a psychiatric illness such as major depressive disorder, bipolar disorder, alcohol use and substance use disorder, and borderline personality disorder. Other triggers common to physicians, Dr. Myers said, include other kinds of personality disorders, burnout, untreated anxiety disorders, substance/medication-induced depressive disorder (especially in clinicians who have been self-medicating), and posttraumatic stress disorder.
Additional risk considerations to keep in mind for physician patients include a family history of mood disorders, a sense of professional isolation, coping with lawsuits and/or medical license investigations, previous history of a depressive episode, and a previous suicide attempt. “Sometimes, it’s hard to get this information from a new physician who’s sitting opposite you,” Dr. Myers noted. “We mustn’t forget that there’s a lot of shame, embarrassment, and guilt that’s attached to previous suicide attempts.”
Suicide risk also is elevated for physicians with treatment-refractory psychiatric illness. “It troubles me when a physician is being treated by a generalist, the patient is not doing well, and he or she is not being referred for a second opinion or has never been referred to a psychopharmacologist,” he said. “It’s important that be done, because you know how difficult many of your patients can be. It’s important to have the expertise of a psychopharmacologist. I believe that physician patients will welcome that [second opinion], even if they have to travel 200 miles for it.”
The list of risk considerations for suicidal physicians also includes undiagnosed and untreated bipolar I or II disorder, rapid cycling bipolar disorder, and mixed affective states. “These are important things that can make our patients ill very quickly,” he said. Impulsivity is another consideration, as are severe sleep deprivation, circadian rhythm disturbances, and acute suicidal affective disturbance, which has emerged as a condition to consider in future revisions of DSM-5. “What you see in this condition is an individual becoming suicidal within minutes or hours,” Dr. Myers explained. “It’s usually an agitated state with insomnia and overvalued ideas or delusions that they are completely untreatable and hopeless. Physicians are no different than anyone else in that kind of state.” He emphasized that the stigma attached to mental illness in physicians is pernicious, because untreated mental illness is a key driver of suicide. After one of Dr. Myers’s patients took his own life, his son told Dr. Myers, “My father just hated being a patient. He felt so ashamed. I tried hard, too, but my support wasn’t enough.”
Inadequate treatment can occur for physician patients because of transference and countertransference dynamics “that muddle the treatment dyad,” Dr. Myers added. “We must be mindful of the many issues that are going on when we treat our own.”
In his 2005 book “Why People Die By Suicide,” psychologist Thomas Joiner, PhD, described three key reasons why people choose to take their own lives. The first is “perceived burdensomeness,” or a sense that one is a burden on others. “When I see it in my physician patients, it’s when they have a sense of being a burden on their family and feel they are no longer serving a purpose,” Dr. Myers said. The second reason is “failed belongingness,” or a sense that one does not belong to a valued social group. “This resonates with me,” Dr. Myers said. “Sometimes in therapy sessions, my physician patients will say ‘Don’t call me Dr. Smith anymore; I’m Mr. Smith.’ They’ve removed themselves from the field because they don’t feel like they belong anymore. That’s the unworthiness that physicians can feel.”
The third reason is “learned fearlessness,” or the acquired capability to enact self-injury. Dr. Myers likened it to “the kind of exposure to pain and fear that people also might learn through such experiences as mountain climbing, performing surgery, fighting in wars, or being afflicted with anorexia.”
If you suspect that a physician patient is engaged in suicidal thinking and planning, Dr. Myers advises framing your mental health assessment in the context of trust and mutual respect. “Please don’t be seduced by somebody who’s squeaky clean in the area of suicidality,” he said. “That individual may just not be sharing with you yet. You’re going to have to be firm and parental at times. There’s a lot of terror and shame that can lurk behind those symptomatic behaviors. That’s where you’ll use your expertise. I have found that there are many physicians out there who welcome you to go in that ‘dark place’ with them. For them to be able to share those scary thoughts with someone can enhance the therapeutic alliance.” The inquiry should include questions about potential means and methods, including access to firearms, stockpiled and/or self-prescribed medications, and medications ordered online or stolen/diverted from the workplace. Timely and careful documentation are essential, he said.
The plan for treating suicidal physicians should include obtaining old records and speaking with former treating professionals. “If you get pushback from the patient, say, ‘This is about me wanting to be thorough in my assessment and treatment plan with you,’ ” Dr. Myers said. “There is no substitute for a detailed mental status evaluation, collateral information, clinical intuition, experience, and consultation.” Hospitalizing the physician patient should be judicious and in consultation with others. “If you’re not sure, get a second opinion, because it can be life-saving,” he said, “but if done inappropriately, you can turn them off psychiatry for the rest of their lives. Make sure you’re not just panicking and worrying about some sort of medical-legal risk.”
In cases of split treatment, ensure regular contact with the psychotherapist and document all communication and any changes in status, medication, or psychotherapy modality change.
Dr. Myers cited many ways that psychiatrists can educate their colleagues about burnout, depression, and the risk of suicide. These include offering to give grand rounds or a lecture on the topic, serving on your local CME planning committee, joining your institute’s physician wellness team, serving on your state’s physician health program, and offering to facilitate a group for physicians after a physician colleague has died by suicide. “Postvention is prevention for the next generation,” Dr. Myers said, quoting Edwin S. Shneidman, PhD, founder of the American Association of Suicidology. “By taking care of ourselves and accepting the painful reality of physician suicide, we reach out to those left behind and make a difference. You become a change agent – someone who is part of the movement to stop doctors from killing themselves.”
Dr. Myers disclosed that he has received funding from the Medical Education Speakers Network.
EXPERT ANALYSIS AT THE NPA PSYCHOPHARMACOLOGY UPDATE
LAS VEGAS – Michael F. Myers, MD, found a common thread in interviews with loved ones, friends, and colleagues of physicians who have taken their own lives: About 10%-15% of the decedents never sought help beforehand.
“They’ve gone from illness to death without any care,” Dr. Myers, a psychiatrist, said at the annual psychopharmacology update held by the Nevada Psychiatric Association.
In a new book based on the interviews, “Why Physicians Die by Suicide: Lessons Learned From Their Families and Others Who Cared” (Amazon, 2017), Dr. Myers combined stories from his own clinical practice and qualitative interviews with about 75 men and women to explore reasons why physicians might choose to take their own lives. “Our nonpsychiatric medical colleagues are really anxious to have information from us, because we’re living in an age of burnout; roughly 50% of U.S. physicians suffer from burnout,” he said. In addition to perspectives from bereaved loved ones and former medical colleagues, the book includes insights from others who are affected when doctors die by suicide: their medical training directors, employers, medical students, treating psychiatrists, and patients.
According to the American Foundation for Suicide Prevention, 300-400 physicians take their own lives every year, the equivalent of two to three medical school classes. “That’s a doctor a day we lose to suicide,” said Dr. Myers, a professor of clinical psychiatry at State University of New York, Brooklyn, who specializes in physician health. Compared with the general population, the suicide rate ratio is 2.27 among female physicians and 1.41 among male physicians (Am J Psychiatry. 2004;161[12]:2295-2302), and an estimated 85%-90% of those who carry out a suicide have a psychiatric illness such as major depressive disorder, bipolar disorder, alcohol use and substance use disorder, and borderline personality disorder. Other triggers common to physicians, Dr. Myers said, include other kinds of personality disorders, burnout, untreated anxiety disorders, substance/medication-induced depressive disorder (especially in clinicians who have been self-medicating), and posttraumatic stress disorder.
Additional risk considerations to keep in mind for physician patients include a family history of mood disorders, a sense of professional isolation, coping with lawsuits and/or medical license investigations, previous history of a depressive episode, and a previous suicide attempt. “Sometimes, it’s hard to get this information from a new physician who’s sitting opposite you,” Dr. Myers noted. “We mustn’t forget that there’s a lot of shame, embarrassment, and guilt that’s attached to previous suicide attempts.”
Suicide risk also is elevated for physicians with treatment-refractory psychiatric illness. “It troubles me when a physician is being treated by a generalist, the patient is not doing well, and he or she is not being referred for a second opinion or has never been referred to a psychopharmacologist,” he said. “It’s important that be done, because you know how difficult many of your patients can be. It’s important to have the expertise of a psychopharmacologist. I believe that physician patients will welcome that [second opinion], even if they have to travel 200 miles for it.”
The list of risk considerations for suicidal physicians also includes undiagnosed and untreated bipolar I or II disorder, rapid cycling bipolar disorder, and mixed affective states. “These are important things that can make our patients ill very quickly,” he said. Impulsivity is another consideration, as are severe sleep deprivation, circadian rhythm disturbances, and acute suicidal affective disturbance, which has emerged as a condition to consider in future revisions of DSM-5. “What you see in this condition is an individual becoming suicidal within minutes or hours,” Dr. Myers explained. “It’s usually an agitated state with insomnia and overvalued ideas or delusions that they are completely untreatable and hopeless. Physicians are no different than anyone else in that kind of state.” He emphasized that the stigma attached to mental illness in physicians is pernicious, because untreated mental illness is a key driver of suicide. After one of Dr. Myers’s patients took his own life, his son told Dr. Myers, “My father just hated being a patient. He felt so ashamed. I tried hard, too, but my support wasn’t enough.”
Inadequate treatment can occur for physician patients because of transference and countertransference dynamics “that muddle the treatment dyad,” Dr. Myers added. “We must be mindful of the many issues that are going on when we treat our own.”
In his 2005 book “Why People Die By Suicide,” psychologist Thomas Joiner, PhD, described three key reasons why people choose to take their own lives. The first is “perceived burdensomeness,” or a sense that one is a burden on others. “When I see it in my physician patients, it’s when they have a sense of being a burden on their family and feel they are no longer serving a purpose,” Dr. Myers said. The second reason is “failed belongingness,” or a sense that one does not belong to a valued social group. “This resonates with me,” Dr. Myers said. “Sometimes in therapy sessions, my physician patients will say ‘Don’t call me Dr. Smith anymore; I’m Mr. Smith.’ They’ve removed themselves from the field because they don’t feel like they belong anymore. That’s the unworthiness that physicians can feel.”
The third reason is “learned fearlessness,” or the acquired capability to enact self-injury. Dr. Myers likened it to “the kind of exposure to pain and fear that people also might learn through such experiences as mountain climbing, performing surgery, fighting in wars, or being afflicted with anorexia.”
If you suspect that a physician patient is engaged in suicidal thinking and planning, Dr. Myers advises framing your mental health assessment in the context of trust and mutual respect. “Please don’t be seduced by somebody who’s squeaky clean in the area of suicidality,” he said. “That individual may just not be sharing with you yet. You’re going to have to be firm and parental at times. There’s a lot of terror and shame that can lurk behind those symptomatic behaviors. That’s where you’ll use your expertise. I have found that there are many physicians out there who welcome you to go in that ‘dark place’ with them. For them to be able to share those scary thoughts with someone can enhance the therapeutic alliance.” The inquiry should include questions about potential means and methods, including access to firearms, stockpiled and/or self-prescribed medications, and medications ordered online or stolen/diverted from the workplace. Timely and careful documentation are essential, he said.
The plan for treating suicidal physicians should include obtaining old records and speaking with former treating professionals. “If you get pushback from the patient, say, ‘This is about me wanting to be thorough in my assessment and treatment plan with you,’ ” Dr. Myers said. “There is no substitute for a detailed mental status evaluation, collateral information, clinical intuition, experience, and consultation.” Hospitalizing the physician patient should be judicious and in consultation with others. “If you’re not sure, get a second opinion, because it can be life-saving,” he said, “but if done inappropriately, you can turn them off psychiatry for the rest of their lives. Make sure you’re not just panicking and worrying about some sort of medical-legal risk.”
In cases of split treatment, ensure regular contact with the psychotherapist and document all communication and any changes in status, medication, or psychotherapy modality change.
Dr. Myers cited many ways that psychiatrists can educate their colleagues about burnout, depression, and the risk of suicide. These include offering to give grand rounds or a lecture on the topic, serving on your local CME planning committee, joining your institute’s physician wellness team, serving on your state’s physician health program, and offering to facilitate a group for physicians after a physician colleague has died by suicide. “Postvention is prevention for the next generation,” Dr. Myers said, quoting Edwin S. Shneidman, PhD, founder of the American Association of Suicidology. “By taking care of ourselves and accepting the painful reality of physician suicide, we reach out to those left behind and make a difference. You become a change agent – someone who is part of the movement to stop doctors from killing themselves.”
Dr. Myers disclosed that he has received funding from the Medical Education Speakers Network.
Second-generation antipsychotics effective for stuttering
LAS VEGAS – There currently is no Food and Drug Administration–approved medication for the symptomatic treatment of stuttering, but current evidence suggests that second-generation antipsychotics risperidone, olanzapine, and asenapine are beneficial, according to Gerald A. Maguire, MD.
At an annual psychopharmacology update held by the Nevada Psychiatric Association, Dr. Maguire, who is a stutterer himself, said current clinical trials in adults with childhood onset fluency disorder support the dopamine hypothesis of stuttering, where abnormal elevated cerebral dopaminergic activity is implicated.
Older studies found haloperidol to be effective for the treatment of stuttering, but long-term patient outlook is poor because of side effects such as sedation and sexual dysfunction. In a study led by Dr. Maguire, risperidone at a dose of 0.5-2 mg daily for 6 weeks was shown to decrease the percentage of syllables stuttered, time stuttered as a percentage of total time speaking, and overall stuttering severity, compared with placebo (J Clin Psychopharmacol. 2000;20[4]:479-82). A more recent study he also led found that olanzapine at a dose of 2.5-5 mg daily for 90 days showed a significant reduction in symptoms as measured by multiple tools, including the Stuttering Severity Instrument–Third Edition, the Clinical Global Impression scale, and the subject-rated self-assessment of stuttering scale (Ann Clin Psychiatry. 2004;16[2]:63-7).
Dr. Maguire, also associate dean of graduate medical education at the University of California, Riverside medical school, added that findings from several case reports suggest that asenapine and aripiprazole also are effective for managing stuttering symptoms. “Further studies of these drugs are warranted given better side-effect profiles as compared to other second-generation antipsychotics,” he said. There are ongoing investigations of other medications for the treatment of stuttering, including ecopipam, a D-1 dopamine receptor antagonist. An open-label study of ecopipam in adults who stutter is currently under way.
Dr. Maguire disclosed that he has received grant or research support from Intracellular, the Stanley Foundation, and Sunovion. He also is a consultant for Lundbeck, Otsuka, Sunovion, Takeda, and is a member of the speakers’ bureau or has received honoraria from Acadia, Lundbeck, Otsuka, Sunovion, Takeda, and Vanda.
LAS VEGAS – There currently is no Food and Drug Administration–approved medication for the symptomatic treatment of stuttering, but current evidence suggests that second-generation antipsychotics risperidone, olanzapine, and asenapine are beneficial, according to Gerald A. Maguire, MD.
At an annual psychopharmacology update held by the Nevada Psychiatric Association, Dr. Maguire, who is a stutterer himself, said current clinical trials in adults with childhood onset fluency disorder support the dopamine hypothesis of stuttering, where abnormal elevated cerebral dopaminergic activity is implicated.
Older studies found haloperidol to be effective for the treatment of stuttering, but long-term patient outlook is poor because of side effects such as sedation and sexual dysfunction. In a study led by Dr. Maguire, risperidone at a dose of 0.5-2 mg daily for 6 weeks was shown to decrease the percentage of syllables stuttered, time stuttered as a percentage of total time speaking, and overall stuttering severity, compared with placebo (J Clin Psychopharmacol. 2000;20[4]:479-82). A more recent study he also led found that olanzapine at a dose of 2.5-5 mg daily for 90 days showed a significant reduction in symptoms as measured by multiple tools, including the Stuttering Severity Instrument–Third Edition, the Clinical Global Impression scale, and the subject-rated self-assessment of stuttering scale (Ann Clin Psychiatry. 2004;16[2]:63-7).
Dr. Maguire, also associate dean of graduate medical education at the University of California, Riverside medical school, added that findings from several case reports suggest that asenapine and aripiprazole also are effective for managing stuttering symptoms. “Further studies of these drugs are warranted given better side-effect profiles as compared to other second-generation antipsychotics,” he said. There are ongoing investigations of other medications for the treatment of stuttering, including ecopipam, a D-1 dopamine receptor antagonist. An open-label study of ecopipam in adults who stutter is currently under way.
Dr. Maguire disclosed that he has received grant or research support from Intracellular, the Stanley Foundation, and Sunovion. He also is a consultant for Lundbeck, Otsuka, Sunovion, Takeda, and is a member of the speakers’ bureau or has received honoraria from Acadia, Lundbeck, Otsuka, Sunovion, Takeda, and Vanda.
LAS VEGAS – There currently is no Food and Drug Administration–approved medication for the symptomatic treatment of stuttering, but current evidence suggests that second-generation antipsychotics risperidone, olanzapine, and asenapine are beneficial, according to Gerald A. Maguire, MD.
At an annual psychopharmacology update held by the Nevada Psychiatric Association, Dr. Maguire, who is a stutterer himself, said current clinical trials in adults with childhood onset fluency disorder support the dopamine hypothesis of stuttering, where abnormal elevated cerebral dopaminergic activity is implicated.
Older studies found haloperidol to be effective for the treatment of stuttering, but long-term patient outlook is poor because of side effects such as sedation and sexual dysfunction. In a study led by Dr. Maguire, risperidone at a dose of 0.5-2 mg daily for 6 weeks was shown to decrease the percentage of syllables stuttered, time stuttered as a percentage of total time speaking, and overall stuttering severity, compared with placebo (J Clin Psychopharmacol. 2000;20[4]:479-82). A more recent study he also led found that olanzapine at a dose of 2.5-5 mg daily for 90 days showed a significant reduction in symptoms as measured by multiple tools, including the Stuttering Severity Instrument–Third Edition, the Clinical Global Impression scale, and the subject-rated self-assessment of stuttering scale (Ann Clin Psychiatry. 2004;16[2]:63-7).
Dr. Maguire, also associate dean of graduate medical education at the University of California, Riverside medical school, added that findings from several case reports suggest that asenapine and aripiprazole also are effective for managing stuttering symptoms. “Further studies of these drugs are warranted given better side-effect profiles as compared to other second-generation antipsychotics,” he said. There are ongoing investigations of other medications for the treatment of stuttering, including ecopipam, a D-1 dopamine receptor antagonist. An open-label study of ecopipam in adults who stutter is currently under way.
Dr. Maguire disclosed that he has received grant or research support from Intracellular, the Stanley Foundation, and Sunovion. He also is a consultant for Lundbeck, Otsuka, Sunovion, Takeda, and is a member of the speakers’ bureau or has received honoraria from Acadia, Lundbeck, Otsuka, Sunovion, Takeda, and Vanda.
AT THE NPA PSYCHOPHARMACOLOGY UPDATE
Treating psychopathology in developmentally disabled tricky
LAS VEGAS – Individuals with intellectual disability experience behavioral and psychiatric illness at higher rates than the general population, according to Bryan H. King, MD.
“Increasingly, these individuals are showing up in all of our clinical practices,” Dr. King said at an annual psychopharmacology update held by the Nevada Psychiatric Association. “In this area, it’s not so much that the population doesn’t experience psychiatric illness, but the diagnosis can be challenging because the presentation of symptoms may be different. For someone who can’t articulate whether they’re feeling anxious, fearful, or nervous, it’s more challenging to make a diagnosis.”
More than 10 years ago, researchers from the University of North Carolina at Chapel Hill compared health disparities between adults with developmental disabilities in North Carolina and adults in the state with other disabilities and adults without disabilities (Public Health Rep. 2004;114[4]:418-26). They found those in the developmental disability group had a similar or greater risk of having high blood pressure, cardiovascular disease, diabetes, and chronic pain, compared with nondisabled adults. In addition, 24% of adults in the developmental disability group reported having either no one to talk to about personal things or often felt lonely.
A more recent, large national study found that, compared with adults with no autism diagnoses, those diagnosed with autism had significantly increased rates for all psychiatric disorders, including depression, anxiety, bipolar disorder, obsessive-compulsive disorder, schizophrenia (a more than 20-fold increased rate), and suicide attempts (Autism. 2015;19[7]:814-23). In addition, nearly all medical conditions such as obesity and dyslipidemia were significantly more common in adults with autism.
Results from a separate study of 371 adults with intellectual disabilities found that 40% had at least one mental health disorder and 45% had at least one moderate or severe behavior problem (Soc Psychiatry Psychiatr Epidemiol. 2016;51:767-76). In addition, the highest ratios of unmet to met need were found with respect to sexuality issues and with respect to mental health problems.
Once a diagnosis is made, Dr. King said patients who have developmental disabilities should be treated in the same way as patients who do not. “There is a tremendous amount of heterogeneity in this population,” he said. “If you are confident that you have someone before you who has depression, the treatment for depression is going to proceed in the same ways it does for someone without the condition. Let that guide the way for medications you are going to use.”
In a recent edition of Current Opinion in Psychiatry, authors Na Young Ji, MD, and Robert L. Findling, MD, reviewed current evidence-based pharmacotherapy options for mental health problems in people with intellectual disability (Curr Opin Psychiatry. 2016;29:103-25). Their five key points were:
1. “Antipsychotics, particularly risperidone, appear to be effective in reducing problem behaviors associated with intellectual disability.
2. “For attention-deficit/hyperactivity disorder symptoms, methylphenidate has been shown to be effective, and atomoxetine and alpha-agonists might be beneficial.
3. “Lithium might be effective in reducing aggression. Evidence for the use of antiepileptic drugs, anxiolytics, and naltrexone for management of problem behaviors is insufficient to draw conclusions.
4. “Antidepressants are often poorly tolerated and do not appear to be effective in decreasing repetitive or stereotypic behaviors associated with intellectual disability.
5. “Melatonin appears to improve sleep in people with intellectual disability.”
Dr. King noted that the data for using lithium in people with intellectual disability “are very old. There’s been nothing recent to help us fine-tune the indications.” He said naltrexone is among the best studied in this population, “especially for self-injurious behavior. The two large placebo-controlled trials were negative. In my own clinical experience, I have not seen it helpful.”
Dr. King disclosed that he has received research funding from the National Institutes of Health, Janssen, and Roche. He also is a consultant for Care Management Technologies and Neurotrope.
LAS VEGAS – Individuals with intellectual disability experience behavioral and psychiatric illness at higher rates than the general population, according to Bryan H. King, MD.
“Increasingly, these individuals are showing up in all of our clinical practices,” Dr. King said at an annual psychopharmacology update held by the Nevada Psychiatric Association. “In this area, it’s not so much that the population doesn’t experience psychiatric illness, but the diagnosis can be challenging because the presentation of symptoms may be different. For someone who can’t articulate whether they’re feeling anxious, fearful, or nervous, it’s more challenging to make a diagnosis.”
More than 10 years ago, researchers from the University of North Carolina at Chapel Hill compared health disparities between adults with developmental disabilities in North Carolina and adults in the state with other disabilities and adults without disabilities (Public Health Rep. 2004;114[4]:418-26). They found those in the developmental disability group had a similar or greater risk of having high blood pressure, cardiovascular disease, diabetes, and chronic pain, compared with nondisabled adults. In addition, 24% of adults in the developmental disability group reported having either no one to talk to about personal things or often felt lonely.
A more recent, large national study found that, compared with adults with no autism diagnoses, those diagnosed with autism had significantly increased rates for all psychiatric disorders, including depression, anxiety, bipolar disorder, obsessive-compulsive disorder, schizophrenia (a more than 20-fold increased rate), and suicide attempts (Autism. 2015;19[7]:814-23). In addition, nearly all medical conditions such as obesity and dyslipidemia were significantly more common in adults with autism.
Results from a separate study of 371 adults with intellectual disabilities found that 40% had at least one mental health disorder and 45% had at least one moderate or severe behavior problem (Soc Psychiatry Psychiatr Epidemiol. 2016;51:767-76). In addition, the highest ratios of unmet to met need were found with respect to sexuality issues and with respect to mental health problems.
Once a diagnosis is made, Dr. King said patients who have developmental disabilities should be treated in the same way as patients who do not. “There is a tremendous amount of heterogeneity in this population,” he said. “If you are confident that you have someone before you who has depression, the treatment for depression is going to proceed in the same ways it does for someone without the condition. Let that guide the way for medications you are going to use.”
In a recent edition of Current Opinion in Psychiatry, authors Na Young Ji, MD, and Robert L. Findling, MD, reviewed current evidence-based pharmacotherapy options for mental health problems in people with intellectual disability (Curr Opin Psychiatry. 2016;29:103-25). Their five key points were:
1. “Antipsychotics, particularly risperidone, appear to be effective in reducing problem behaviors associated with intellectual disability.
2. “For attention-deficit/hyperactivity disorder symptoms, methylphenidate has been shown to be effective, and atomoxetine and alpha-agonists might be beneficial.
3. “Lithium might be effective in reducing aggression. Evidence for the use of antiepileptic drugs, anxiolytics, and naltrexone for management of problem behaviors is insufficient to draw conclusions.
4. “Antidepressants are often poorly tolerated and do not appear to be effective in decreasing repetitive or stereotypic behaviors associated with intellectual disability.
5. “Melatonin appears to improve sleep in people with intellectual disability.”
Dr. King noted that the data for using lithium in people with intellectual disability “are very old. There’s been nothing recent to help us fine-tune the indications.” He said naltrexone is among the best studied in this population, “especially for self-injurious behavior. The two large placebo-controlled trials were negative. In my own clinical experience, I have not seen it helpful.”
Dr. King disclosed that he has received research funding from the National Institutes of Health, Janssen, and Roche. He also is a consultant for Care Management Technologies and Neurotrope.
LAS VEGAS – Individuals with intellectual disability experience behavioral and psychiatric illness at higher rates than the general population, according to Bryan H. King, MD.
“Increasingly, these individuals are showing up in all of our clinical practices,” Dr. King said at an annual psychopharmacology update held by the Nevada Psychiatric Association. “In this area, it’s not so much that the population doesn’t experience psychiatric illness, but the diagnosis can be challenging because the presentation of symptoms may be different. For someone who can’t articulate whether they’re feeling anxious, fearful, or nervous, it’s more challenging to make a diagnosis.”
More than 10 years ago, researchers from the University of North Carolina at Chapel Hill compared health disparities between adults with developmental disabilities in North Carolina and adults in the state with other disabilities and adults without disabilities (Public Health Rep. 2004;114[4]:418-26). They found those in the developmental disability group had a similar or greater risk of having high blood pressure, cardiovascular disease, diabetes, and chronic pain, compared with nondisabled adults. In addition, 24% of adults in the developmental disability group reported having either no one to talk to about personal things or often felt lonely.
A more recent, large national study found that, compared with adults with no autism diagnoses, those diagnosed with autism had significantly increased rates for all psychiatric disorders, including depression, anxiety, bipolar disorder, obsessive-compulsive disorder, schizophrenia (a more than 20-fold increased rate), and suicide attempts (Autism. 2015;19[7]:814-23). In addition, nearly all medical conditions such as obesity and dyslipidemia were significantly more common in adults with autism.
Results from a separate study of 371 adults with intellectual disabilities found that 40% had at least one mental health disorder and 45% had at least one moderate or severe behavior problem (Soc Psychiatry Psychiatr Epidemiol. 2016;51:767-76). In addition, the highest ratios of unmet to met need were found with respect to sexuality issues and with respect to mental health problems.
Once a diagnosis is made, Dr. King said patients who have developmental disabilities should be treated in the same way as patients who do not. “There is a tremendous amount of heterogeneity in this population,” he said. “If you are confident that you have someone before you who has depression, the treatment for depression is going to proceed in the same ways it does for someone without the condition. Let that guide the way for medications you are going to use.”
In a recent edition of Current Opinion in Psychiatry, authors Na Young Ji, MD, and Robert L. Findling, MD, reviewed current evidence-based pharmacotherapy options for mental health problems in people with intellectual disability (Curr Opin Psychiatry. 2016;29:103-25). Their five key points were:
1. “Antipsychotics, particularly risperidone, appear to be effective in reducing problem behaviors associated with intellectual disability.
2. “For attention-deficit/hyperactivity disorder symptoms, methylphenidate has been shown to be effective, and atomoxetine and alpha-agonists might be beneficial.
3. “Lithium might be effective in reducing aggression. Evidence for the use of antiepileptic drugs, anxiolytics, and naltrexone for management of problem behaviors is insufficient to draw conclusions.
4. “Antidepressants are often poorly tolerated and do not appear to be effective in decreasing repetitive or stereotypic behaviors associated with intellectual disability.
5. “Melatonin appears to improve sleep in people with intellectual disability.”
Dr. King noted that the data for using lithium in people with intellectual disability “are very old. There’s been nothing recent to help us fine-tune the indications.” He said naltrexone is among the best studied in this population, “especially for self-injurious behavior. The two large placebo-controlled trials were negative. In my own clinical experience, I have not seen it helpful.”
Dr. King disclosed that he has received research funding from the National Institutes of Health, Janssen, and Roche. He also is a consultant for Care Management Technologies and Neurotrope.
EXPERT ANALYSIS AT THE NPA PSYCHOPHARMACOLOGY UPDATE
Hope on the horizon for novel antidepressants
LAS VEGAS – There remains a great unmet need for more effective and rapidly acting treatments for major depressive disorder, and research is revealing that both new and existing drugs may help, according to one expert.
One argument for additional treatment options is the current rate of suicide in the United States, which ranks as the 10th leading cause of death among persons aged 10 years and older, Gerard Sanacora, MD, PhD, said at an annual psychopharmacology update held by the Nevada Psychiatric Association. Another argument for new antidepressants stems from the results of the STAR*D trial, which found that 37% of patients with major depressive disorder who were treated with citalopram monotherapy had remission with the first treatment.
Dr. Sanacora, who is also director of the Yale Depression Research Program, said that there is a reconceptualization of how clinicians think about the pathophysiology of depression and the path to novel treatment development. A variety of novel pharmacologic and somatic treatments, with new mechanisms of action, are currently undergoing validation for treatment-resistant depression. These include glutamatergic, GABAergic, opioid, and anti‐inflammatory drugs.
Drugs that modulate GABAergic and glutamatergic neurotransmission have anxiolytic and antidepressant activities in rodent models of depression. In addition, the robust, rapid, and relatively sustained antidepressant effects of low-dose ketamine have been observed in double-blind placebo crossover trials in patients with treatment-resistant major depression (Biol Psych. 2000 Feb 15;47[4]:351-4 and Arch Gen Psych. 2006 Aug;63[8]:856-64). Currently, Dr. Sanacora said, more than 80 clinics in the United States provide ketamine therapy, yet clinicians face balancing the potential benefits of the drug with inherent limitations of the ketamine studies to date. These include the fact that the study drug blinding is ineffective; the optimal dose, route, or frequency has not been determined; the duration of effect is unknown; the long-term effectiveness and safety are unclear; and the moderators and mediators of response are unknown.
Results from a National Institutes of Mental Health–funded double-blind, placebo-controlled study examining various doses of ketamine in treatment-resistant depression are anticipated sometime this year. In 2013, a trial sponsored by Janssen Research & Development titled a Study to Evaluate the Safety and Efficacy of Intranasal Esketamine in Treatment-Resistant Depression (SYNAPSE) set out to assess the efficacy and dose response of intranasal esketamine (panel A: 28 mg, 56 mg, and 84 mg; panel B: 14 mg and 56 mg), compared with placebo, in improving depressive symptoms in participants with treatment-resistant depression. The researchers found a positive effect of esketamine vs. saline placebo with some evidence of a dose-response curve, suggesting higher doses to be more effective. Some published studies suggest that chronic ketamine use causes impairments in working memory and other cognitive effects (Addiction. 2009 Jan;104[1]:77-87 and Front Psych. 2014 Dec 4;5:149), while others have found that ketamine does not cause memory deficits when given on up to six occasions (Int J Neuropsychopharmacol. 2014 Jun 25;17[11]:1805-13 and J Psychopharmacol. 2014 Apr 3;28[6]:536-44).
Another drug being studied for major depressive disorder is the investigational agent SAGE-547, an allosteric neurosteroid modulator of both synaptic and extrasynaptic GABA receptors. Preliminary results from a double-blind, placebo-controlled phase II trial in 21 patients with postpartum depression showed that the Hamilton Rating Scale for Depression (HAM-D) total score was reduced by SAGE-547, compared with placebo, at 60 hours (P = .008).
Buprenorphine, a partial mu opioid agonist commonly used in addiction treatment, may also play a future role in helping patients with treatment-resistant depression. One randomized study of 88 patients found that those who took very low doses of buprenorphine for 2 or 4 weeks had significantly lower scores on the Beck Suicide Ideation Scale, compared with their counterparts on placebo (Am J Psychiatry. 2016 May 1;173[5]491-8).
Drugs with anti-inflammatory properties may also have a role. One study of 60 patients found that the tumor necrosis factor–alpha antagonist infliximab may benefit patients with treatment-resistant depression who have high inflammatory biomarkers at baseline (JAMA Psychiatry. 2013 Jan;70[1]:31-41).
“Active participation in clinical research efforts is critical to the advancement of future treatment approaches,” he said.
Dr. Sanacora disclosed having received consulting fees and/or research agreements from numerous industry sources. In addition, free medication was provided to Dr. Sanacora by sanofi‐aventis for a study sponsored by the National Institutes of Health.
LAS VEGAS – There remains a great unmet need for more effective and rapidly acting treatments for major depressive disorder, and research is revealing that both new and existing drugs may help, according to one expert.
One argument for additional treatment options is the current rate of suicide in the United States, which ranks as the 10th leading cause of death among persons aged 10 years and older, Gerard Sanacora, MD, PhD, said at an annual psychopharmacology update held by the Nevada Psychiatric Association. Another argument for new antidepressants stems from the results of the STAR*D trial, which found that 37% of patients with major depressive disorder who were treated with citalopram monotherapy had remission with the first treatment.
Dr. Sanacora, who is also director of the Yale Depression Research Program, said that there is a reconceptualization of how clinicians think about the pathophysiology of depression and the path to novel treatment development. A variety of novel pharmacologic and somatic treatments, with new mechanisms of action, are currently undergoing validation for treatment-resistant depression. These include glutamatergic, GABAergic, opioid, and anti‐inflammatory drugs.
Drugs that modulate GABAergic and glutamatergic neurotransmission have anxiolytic and antidepressant activities in rodent models of depression. In addition, the robust, rapid, and relatively sustained antidepressant effects of low-dose ketamine have been observed in double-blind placebo crossover trials in patients with treatment-resistant major depression (Biol Psych. 2000 Feb 15;47[4]:351-4 and Arch Gen Psych. 2006 Aug;63[8]:856-64). Currently, Dr. Sanacora said, more than 80 clinics in the United States provide ketamine therapy, yet clinicians face balancing the potential benefits of the drug with inherent limitations of the ketamine studies to date. These include the fact that the study drug blinding is ineffective; the optimal dose, route, or frequency has not been determined; the duration of effect is unknown; the long-term effectiveness and safety are unclear; and the moderators and mediators of response are unknown.
Results from a National Institutes of Mental Health–funded double-blind, placebo-controlled study examining various doses of ketamine in treatment-resistant depression are anticipated sometime this year. In 2013, a trial sponsored by Janssen Research & Development titled a Study to Evaluate the Safety and Efficacy of Intranasal Esketamine in Treatment-Resistant Depression (SYNAPSE) set out to assess the efficacy and dose response of intranasal esketamine (panel A: 28 mg, 56 mg, and 84 mg; panel B: 14 mg and 56 mg), compared with placebo, in improving depressive symptoms in participants with treatment-resistant depression. The researchers found a positive effect of esketamine vs. saline placebo with some evidence of a dose-response curve, suggesting higher doses to be more effective. Some published studies suggest that chronic ketamine use causes impairments in working memory and other cognitive effects (Addiction. 2009 Jan;104[1]:77-87 and Front Psych. 2014 Dec 4;5:149), while others have found that ketamine does not cause memory deficits when given on up to six occasions (Int J Neuropsychopharmacol. 2014 Jun 25;17[11]:1805-13 and J Psychopharmacol. 2014 Apr 3;28[6]:536-44).
Another drug being studied for major depressive disorder is the investigational agent SAGE-547, an allosteric neurosteroid modulator of both synaptic and extrasynaptic GABA receptors. Preliminary results from a double-blind, placebo-controlled phase II trial in 21 patients with postpartum depression showed that the Hamilton Rating Scale for Depression (HAM-D) total score was reduced by SAGE-547, compared with placebo, at 60 hours (P = .008).
Buprenorphine, a partial mu opioid agonist commonly used in addiction treatment, may also play a future role in helping patients with treatment-resistant depression. One randomized study of 88 patients found that those who took very low doses of buprenorphine for 2 or 4 weeks had significantly lower scores on the Beck Suicide Ideation Scale, compared with their counterparts on placebo (Am J Psychiatry. 2016 May 1;173[5]491-8).
Drugs with anti-inflammatory properties may also have a role. One study of 60 patients found that the tumor necrosis factor–alpha antagonist infliximab may benefit patients with treatment-resistant depression who have high inflammatory biomarkers at baseline (JAMA Psychiatry. 2013 Jan;70[1]:31-41).
“Active participation in clinical research efforts is critical to the advancement of future treatment approaches,” he said.
Dr. Sanacora disclosed having received consulting fees and/or research agreements from numerous industry sources. In addition, free medication was provided to Dr. Sanacora by sanofi‐aventis for a study sponsored by the National Institutes of Health.
LAS VEGAS – There remains a great unmet need for more effective and rapidly acting treatments for major depressive disorder, and research is revealing that both new and existing drugs may help, according to one expert.
One argument for additional treatment options is the current rate of suicide in the United States, which ranks as the 10th leading cause of death among persons aged 10 years and older, Gerard Sanacora, MD, PhD, said at an annual psychopharmacology update held by the Nevada Psychiatric Association. Another argument for new antidepressants stems from the results of the STAR*D trial, which found that 37% of patients with major depressive disorder who were treated with citalopram monotherapy had remission with the first treatment.
Dr. Sanacora, who is also director of the Yale Depression Research Program, said that there is a reconceptualization of how clinicians think about the pathophysiology of depression and the path to novel treatment development. A variety of novel pharmacologic and somatic treatments, with new mechanisms of action, are currently undergoing validation for treatment-resistant depression. These include glutamatergic, GABAergic, opioid, and anti‐inflammatory drugs.
Drugs that modulate GABAergic and glutamatergic neurotransmission have anxiolytic and antidepressant activities in rodent models of depression. In addition, the robust, rapid, and relatively sustained antidepressant effects of low-dose ketamine have been observed in double-blind placebo crossover trials in patients with treatment-resistant major depression (Biol Psych. 2000 Feb 15;47[4]:351-4 and Arch Gen Psych. 2006 Aug;63[8]:856-64). Currently, Dr. Sanacora said, more than 80 clinics in the United States provide ketamine therapy, yet clinicians face balancing the potential benefits of the drug with inherent limitations of the ketamine studies to date. These include the fact that the study drug blinding is ineffective; the optimal dose, route, or frequency has not been determined; the duration of effect is unknown; the long-term effectiveness and safety are unclear; and the moderators and mediators of response are unknown.
Results from a National Institutes of Mental Health–funded double-blind, placebo-controlled study examining various doses of ketamine in treatment-resistant depression are anticipated sometime this year. In 2013, a trial sponsored by Janssen Research & Development titled a Study to Evaluate the Safety and Efficacy of Intranasal Esketamine in Treatment-Resistant Depression (SYNAPSE) set out to assess the efficacy and dose response of intranasal esketamine (panel A: 28 mg, 56 mg, and 84 mg; panel B: 14 mg and 56 mg), compared with placebo, in improving depressive symptoms in participants with treatment-resistant depression. The researchers found a positive effect of esketamine vs. saline placebo with some evidence of a dose-response curve, suggesting higher doses to be more effective. Some published studies suggest that chronic ketamine use causes impairments in working memory and other cognitive effects (Addiction. 2009 Jan;104[1]:77-87 and Front Psych. 2014 Dec 4;5:149), while others have found that ketamine does not cause memory deficits when given on up to six occasions (Int J Neuropsychopharmacol. 2014 Jun 25;17[11]:1805-13 and J Psychopharmacol. 2014 Apr 3;28[6]:536-44).
Another drug being studied for major depressive disorder is the investigational agent SAGE-547, an allosteric neurosteroid modulator of both synaptic and extrasynaptic GABA receptors. Preliminary results from a double-blind, placebo-controlled phase II trial in 21 patients with postpartum depression showed that the Hamilton Rating Scale for Depression (HAM-D) total score was reduced by SAGE-547, compared with placebo, at 60 hours (P = .008).
Buprenorphine, a partial mu opioid agonist commonly used in addiction treatment, may also play a future role in helping patients with treatment-resistant depression. One randomized study of 88 patients found that those who took very low doses of buprenorphine for 2 or 4 weeks had significantly lower scores on the Beck Suicide Ideation Scale, compared with their counterparts on placebo (Am J Psychiatry. 2016 May 1;173[5]491-8).
Drugs with anti-inflammatory properties may also have a role. One study of 60 patients found that the tumor necrosis factor–alpha antagonist infliximab may benefit patients with treatment-resistant depression who have high inflammatory biomarkers at baseline (JAMA Psychiatry. 2013 Jan;70[1]:31-41).
“Active participation in clinical research efforts is critical to the advancement of future treatment approaches,” he said.
Dr. Sanacora disclosed having received consulting fees and/or research agreements from numerous industry sources. In addition, free medication was provided to Dr. Sanacora by sanofi‐aventis for a study sponsored by the National Institutes of Health.
EXPERT ANALYSIS FROM THE NPA PSYCHOPHARMACOLOGY UPDATE
Use of bilateral internal mammary arteries in CABG stagnates
HOUSTON – Over the past 5 years there has been no growth in bilateral internal mammary artery use among Medicare beneficiaries, and the frequency of bilateral internal mammary artery use during coronary artery bypass grafting remained low, according to a large observational analysis.
“Despite a growing evidence base supporting bilateral internal mammary artery use with regard to long-term survival and freedom from repeat revascularization, rates of bilateral internal mammary artery [BIMA] use remain low, with no evidence of growth,” Alexander Iribarne, MD, said during an interview at the annual meeting of the Society of Thoracic Surgeons. “Therefore, there is significant opportunity for adoption of bilateral internal mammary artery grafting in the United States.”
The most recent report of CABG trends in the United States published from the STS database showed that in 2009, fewer than 5% of patients who underwent CABG received a BIMA (J Thorac Cardiovasc Surg. 2012 Feb;143[2]:273-81). In an effort to characterize the adoption rate and regional variation of BIMA use in the United States, Dr. Iribarne, director of cardiac surgical research in the section of cardiac surgery at Dartmouth-Hitchcock Medical Center, Lebanon, N.H., and his associates examined records from nearly 150 million Medicare beneficiaries from 2009-2014. “This work is unique in that we not only looked at trends in rates of usage but also how this varied by geographic location,” he said.
“I was surprised to find that despite the growing literature supporting BIMA use, there was no growth in rates of usage over the 5-year study period, with rates remaining low,” Dr. Iribarne said. “I was also surprised to see that there was significant regional variation in use that appeared to correlate, in part, with overall CABG volume, although the moderate correlation coefficient indicates that additional factors beyond CABG volume are involved.”
A key limitation of the study, he said, was that its patients were aged 65 and older. Dr. Iribarne disclosed that he receives grant funding from the American Association for Thoracic Surgery Graham Foundation and the Dartmouth SYNERGY Clinical and Translational Science Institute.
HOUSTON – Over the past 5 years there has been no growth in bilateral internal mammary artery use among Medicare beneficiaries, and the frequency of bilateral internal mammary artery use during coronary artery bypass grafting remained low, according to a large observational analysis.
“Despite a growing evidence base supporting bilateral internal mammary artery use with regard to long-term survival and freedom from repeat revascularization, rates of bilateral internal mammary artery [BIMA] use remain low, with no evidence of growth,” Alexander Iribarne, MD, said during an interview at the annual meeting of the Society of Thoracic Surgeons. “Therefore, there is significant opportunity for adoption of bilateral internal mammary artery grafting in the United States.”
The most recent report of CABG trends in the United States published from the STS database showed that in 2009, fewer than 5% of patients who underwent CABG received a BIMA (J Thorac Cardiovasc Surg. 2012 Feb;143[2]:273-81). In an effort to characterize the adoption rate and regional variation of BIMA use in the United States, Dr. Iribarne, director of cardiac surgical research in the section of cardiac surgery at Dartmouth-Hitchcock Medical Center, Lebanon, N.H., and his associates examined records from nearly 150 million Medicare beneficiaries from 2009-2014. “This work is unique in that we not only looked at trends in rates of usage but also how this varied by geographic location,” he said.
“I was surprised to find that despite the growing literature supporting BIMA use, there was no growth in rates of usage over the 5-year study period, with rates remaining low,” Dr. Iribarne said. “I was also surprised to see that there was significant regional variation in use that appeared to correlate, in part, with overall CABG volume, although the moderate correlation coefficient indicates that additional factors beyond CABG volume are involved.”
A key limitation of the study, he said, was that its patients were aged 65 and older. Dr. Iribarne disclosed that he receives grant funding from the American Association for Thoracic Surgery Graham Foundation and the Dartmouth SYNERGY Clinical and Translational Science Institute.
HOUSTON – Over the past 5 years there has been no growth in bilateral internal mammary artery use among Medicare beneficiaries, and the frequency of bilateral internal mammary artery use during coronary artery bypass grafting remained low, according to a large observational analysis.
“Despite a growing evidence base supporting bilateral internal mammary artery use with regard to long-term survival and freedom from repeat revascularization, rates of bilateral internal mammary artery [BIMA] use remain low, with no evidence of growth,” Alexander Iribarne, MD, said during an interview at the annual meeting of the Society of Thoracic Surgeons. “Therefore, there is significant opportunity for adoption of bilateral internal mammary artery grafting in the United States.”
The most recent report of CABG trends in the United States published from the STS database showed that in 2009, fewer than 5% of patients who underwent CABG received a BIMA (J Thorac Cardiovasc Surg. 2012 Feb;143[2]:273-81). In an effort to characterize the adoption rate and regional variation of BIMA use in the United States, Dr. Iribarne, director of cardiac surgical research in the section of cardiac surgery at Dartmouth-Hitchcock Medical Center, Lebanon, N.H., and his associates examined records from nearly 150 million Medicare beneficiaries from 2009-2014. “This work is unique in that we not only looked at trends in rates of usage but also how this varied by geographic location,” he said.
“I was surprised to find that despite the growing literature supporting BIMA use, there was no growth in rates of usage over the 5-year study period, with rates remaining low,” Dr. Iribarne said. “I was also surprised to see that there was significant regional variation in use that appeared to correlate, in part, with overall CABG volume, although the moderate correlation coefficient indicates that additional factors beyond CABG volume are involved.”
A key limitation of the study, he said, was that its patients were aged 65 and older. Dr. Iribarne disclosed that he receives grant funding from the American Association for Thoracic Surgery Graham Foundation and the Dartmouth SYNERGY Clinical and Translational Science Institute.
AT THE STS ANNUAL MEETING
Key clinical point:
Major finding: The absolute national rate of BIMA use fell from 0.216 claims per 1,000 beneficiaries in 2009 to 0.143 in 2014 (P less than .001).
Data source: An analysis of medical records from nearly 150 million Medicare beneficiaries during 2009-2014.
Disclosures: Dr. Iribarne disclosed that he receives grant funding from the American Association for Thoracic Surgery Graham Foundation and the Dartmouth SYNERGY Clinical and Translational Science Institute.
Outpatient visits for CNS polypharmacy rising among elderly
The number of outpatient visits for CNS polypharmacy by adults aged 65 and older more than doubled between 2004 and 2013, especially among those who reside in rural areas, results from a large analysis of national data showed.
“With each new revision of the Beers Criteria, the list of psychotropic medications considered potentially inappropriate in the elderly has grown,” researchers led by Donovan T. Maust, MD, wrote in a research letter published online Feb. 13, 2017, in JAMA Internal Medicine. “Opioids have recently been included in a Beers measure of central nervous system polypharmacy. Prescribing related drug combinations also received increased regulatory attention when the U.S. Food and Drug Administration recently ordered a black box warning to alert patients of serious risks, including death, caused by opioids coprescribed with CNS depressants.”
Dr. Maust and his associates found that annual CNS polypharmacy visits by adults 65 years or older increased from 1.50 million in 2004 to 3.68 million in 2013, or 0.6% of visits in 2004 to 1.4% in 2013 (adjusted odds ratio of 3.12; P less than .001). The largest increases were observed among rural visits and those for visits with no mental health or pain diagnoses (aOR of 4.99 and 2.65, respectively.)
More than two-thirds of polypharmacy visits (68%) were by women, and 17% were by those who lived in rural areas. In addition, nearly half of polypharmacy visits studied (46%) included neither mental health nor pain diagnoses. No significant demographic differences were observed between polypharmacy visits with and without opioids. “Older adults have become more open to mental health treatment,” the researchers concluded. “Because of limited access to specialty care and a preference to receive treatment in primary care settings, it is unsurprising that mental health treatment has expanded in nonpsychiatric settings.”
Dr. Maust was supported by the Beeson Career Development Award Program. The other researchers reported having no financial disclosures.
The number of outpatient visits for CNS polypharmacy by adults aged 65 and older more than doubled between 2004 and 2013, especially among those who reside in rural areas, results from a large analysis of national data showed.
“With each new revision of the Beers Criteria, the list of psychotropic medications considered potentially inappropriate in the elderly has grown,” researchers led by Donovan T. Maust, MD, wrote in a research letter published online Feb. 13, 2017, in JAMA Internal Medicine. “Opioids have recently been included in a Beers measure of central nervous system polypharmacy. Prescribing related drug combinations also received increased regulatory attention when the U.S. Food and Drug Administration recently ordered a black box warning to alert patients of serious risks, including death, caused by opioids coprescribed with CNS depressants.”
Dr. Maust and his associates found that annual CNS polypharmacy visits by adults 65 years or older increased from 1.50 million in 2004 to 3.68 million in 2013, or 0.6% of visits in 2004 to 1.4% in 2013 (adjusted odds ratio of 3.12; P less than .001). The largest increases were observed among rural visits and those for visits with no mental health or pain diagnoses (aOR of 4.99 and 2.65, respectively.)
More than two-thirds of polypharmacy visits (68%) were by women, and 17% were by those who lived in rural areas. In addition, nearly half of polypharmacy visits studied (46%) included neither mental health nor pain diagnoses. No significant demographic differences were observed between polypharmacy visits with and without opioids. “Older adults have become more open to mental health treatment,” the researchers concluded. “Because of limited access to specialty care and a preference to receive treatment in primary care settings, it is unsurprising that mental health treatment has expanded in nonpsychiatric settings.”
Dr. Maust was supported by the Beeson Career Development Award Program. The other researchers reported having no financial disclosures.
The number of outpatient visits for CNS polypharmacy by adults aged 65 and older more than doubled between 2004 and 2013, especially among those who reside in rural areas, results from a large analysis of national data showed.
“With each new revision of the Beers Criteria, the list of psychotropic medications considered potentially inappropriate in the elderly has grown,” researchers led by Donovan T. Maust, MD, wrote in a research letter published online Feb. 13, 2017, in JAMA Internal Medicine. “Opioids have recently been included in a Beers measure of central nervous system polypharmacy. Prescribing related drug combinations also received increased regulatory attention when the U.S. Food and Drug Administration recently ordered a black box warning to alert patients of serious risks, including death, caused by opioids coprescribed with CNS depressants.”
Dr. Maust and his associates found that annual CNS polypharmacy visits by adults 65 years or older increased from 1.50 million in 2004 to 3.68 million in 2013, or 0.6% of visits in 2004 to 1.4% in 2013 (adjusted odds ratio of 3.12; P less than .001). The largest increases were observed among rural visits and those for visits with no mental health or pain diagnoses (aOR of 4.99 and 2.65, respectively.)
More than two-thirds of polypharmacy visits (68%) were by women, and 17% were by those who lived in rural areas. In addition, nearly half of polypharmacy visits studied (46%) included neither mental health nor pain diagnoses. No significant demographic differences were observed between polypharmacy visits with and without opioids. “Older adults have become more open to mental health treatment,” the researchers concluded. “Because of limited access to specialty care and a preference to receive treatment in primary care settings, it is unsurprising that mental health treatment has expanded in nonpsychiatric settings.”
Dr. Maust was supported by the Beeson Career Development Award Program. The other researchers reported having no financial disclosures.
FROM JAMA INTERNAL MEDICINE
Key clinical point:
Major finding: Annual CNS polypharmacy visits by adults 65 years or older increased from 1.50 million in 2004 to 3.68 million in 2013.
Data source: An analysis of 97,910 outpatients aged 65 and older from the National Ambulatory Medical Care Survey (NAMCS) from 2004 through 2013.
Disclosures: Dr. Maust was supported by the Beeson Career Development Award Program. The other researchers reported having no financial disclosures.
Lipid-lowering meds benefit some breast cancer patients
Patients with early-stage, hormone-receptor positive breast cancer who used cholesterol-lowering medication at baseline of a long-term randomized study had more beneficial tumor characteristics and improved outcomes, compared with nonusers.
The findings come from an observation study of a randomized, phase III, double-blind trial conducted by the Breast International Group (BIG) known as BIG 1-98, which enrolled 8,010 postmenopausal women with early-stage, hormone receptor–positive invasive breast cancer from 1998 to 2003. As reported online in the Feb. 13, 2017 issue of the Journal of Clinical Oncology, researchers measured systemic levels of total cholesterol and use of cholesterol-lowering medication at study entry and every 6 months up to 5.5 years. Endpoints of interest were disease-free survival, breast cancer–free interval, and distant recurrence–free interval.
Of the 789 patients who initiated cholesterol-lowering medication during endocrine therapy, most were assigned to letrozole monotherapy (318), followed by sequential tamoxifen-letrozole (189), letrozole-tamoxifen (176), and tamoxifen monotherapy (106).
The results showed that initiation of cholesterol-lowering medication during endocrine therapy was related to improved disease-free survival (hazard ratio 0.79; P = .01), breast cancer–free interval (HR, 0.76; P = .02), and distant recurrence–free interval (HR, 0.74; P = .03).
“The evidence from our observational study warrants consideration of a large, prospective, randomized clinical trial to confirm the value of CLM concomitant with endocrine treatment of breast cancer,” corresponding author Signe Borgquist, MD, PhD, of the division of oncology and pathology at Lund University, Sweden, and her associates concluded. “Further elucidation of the effect upon outcome of the clinical interaction between CLM and endocrine agents – both widely used by patients with breast cancer – will provide exclusive insight to future trial designs.”
The BIG 1-98 trial was supported by Novartis and coordinated by the International Breast Cancer Study Group (IBCSG). Of the 17 study authors, 7 reported having relevant financial disclosures.
dbrunk@frontlinemedcom.com
Patients with early-stage, hormone-receptor positive breast cancer who used cholesterol-lowering medication at baseline of a long-term randomized study had more beneficial tumor characteristics and improved outcomes, compared with nonusers.
The findings come from an observation study of a randomized, phase III, double-blind trial conducted by the Breast International Group (BIG) known as BIG 1-98, which enrolled 8,010 postmenopausal women with early-stage, hormone receptor–positive invasive breast cancer from 1998 to 2003. As reported online in the Feb. 13, 2017 issue of the Journal of Clinical Oncology, researchers measured systemic levels of total cholesterol and use of cholesterol-lowering medication at study entry and every 6 months up to 5.5 years. Endpoints of interest were disease-free survival, breast cancer–free interval, and distant recurrence–free interval.
Of the 789 patients who initiated cholesterol-lowering medication during endocrine therapy, most were assigned to letrozole monotherapy (318), followed by sequential tamoxifen-letrozole (189), letrozole-tamoxifen (176), and tamoxifen monotherapy (106).
The results showed that initiation of cholesterol-lowering medication during endocrine therapy was related to improved disease-free survival (hazard ratio 0.79; P = .01), breast cancer–free interval (HR, 0.76; P = .02), and distant recurrence–free interval (HR, 0.74; P = .03).
“The evidence from our observational study warrants consideration of a large, prospective, randomized clinical trial to confirm the value of CLM concomitant with endocrine treatment of breast cancer,” corresponding author Signe Borgquist, MD, PhD, of the division of oncology and pathology at Lund University, Sweden, and her associates concluded. “Further elucidation of the effect upon outcome of the clinical interaction between CLM and endocrine agents – both widely used by patients with breast cancer – will provide exclusive insight to future trial designs.”
The BIG 1-98 trial was supported by Novartis and coordinated by the International Breast Cancer Study Group (IBCSG). Of the 17 study authors, 7 reported having relevant financial disclosures.
dbrunk@frontlinemedcom.com
Patients with early-stage, hormone-receptor positive breast cancer who used cholesterol-lowering medication at baseline of a long-term randomized study had more beneficial tumor characteristics and improved outcomes, compared with nonusers.
The findings come from an observation study of a randomized, phase III, double-blind trial conducted by the Breast International Group (BIG) known as BIG 1-98, which enrolled 8,010 postmenopausal women with early-stage, hormone receptor–positive invasive breast cancer from 1998 to 2003. As reported online in the Feb. 13, 2017 issue of the Journal of Clinical Oncology, researchers measured systemic levels of total cholesterol and use of cholesterol-lowering medication at study entry and every 6 months up to 5.5 years. Endpoints of interest were disease-free survival, breast cancer–free interval, and distant recurrence–free interval.
Of the 789 patients who initiated cholesterol-lowering medication during endocrine therapy, most were assigned to letrozole monotherapy (318), followed by sequential tamoxifen-letrozole (189), letrozole-tamoxifen (176), and tamoxifen monotherapy (106).
The results showed that initiation of cholesterol-lowering medication during endocrine therapy was related to improved disease-free survival (hazard ratio 0.79; P = .01), breast cancer–free interval (HR, 0.76; P = .02), and distant recurrence–free interval (HR, 0.74; P = .03).
“The evidence from our observational study warrants consideration of a large, prospective, randomized clinical trial to confirm the value of CLM concomitant with endocrine treatment of breast cancer,” corresponding author Signe Borgquist, MD, PhD, of the division of oncology and pathology at Lund University, Sweden, and her associates concluded. “Further elucidation of the effect upon outcome of the clinical interaction between CLM and endocrine agents – both widely used by patients with breast cancer – will provide exclusive insight to future trial designs.”
The BIG 1-98 trial was supported by Novartis and coordinated by the International Breast Cancer Study Group (IBCSG). Of the 17 study authors, 7 reported having relevant financial disclosures.
dbrunk@frontlinemedcom.com
FROM THE JOURNAL OF CLINICAL ONCOLOGY
Fecal microbiota transplantation a decolonization treatment option
The use of fecal microbiota transplantation is an option to eradicate highly drug-resistant enteric bacteria carriage, according to results from a small pilot study conducted by French investigators.
“A rapid and dramatic emergence of highly drug-resistant enteric bacteria (HDREB), i.e., carbapenem-resistant Enterobacteriaceae (CRE) and vancomycin-resistant enterococci (VRE), is occurring worldwide,” researchers led by Benjamin Davido, MD, of the infectious diseases unit at Raymond Poincaré Teaching Hospital, Garches, France, wrote in a study published online Feb. 1 in the Journal of Hospital Infection. “Patients carrying these bacteria are at risk of developing severe infections due to these bacteria; these infections are associated with a high mortality rate, partially because of inappropriate antimicrobial treatment.”
Citing recent studies that have demonstrated the efficacy of fecal microbiota transplant (FMT) as an accepted therapy to prevent recurrent Clostridium difficile infection, Dr. Davido and his associates prospectively identified eight different case reports of FMT used in adults for intestinal decolonization from extended-spectrum beta-lactamase (ESBL)–producing Enterobacteriaceae, VRE, or methicillin-resistant Staphylococcus aureus. Patients on immunosuppressive agents were excluded from the study, as were those taking antibiotics at the time of FMT (J Hosp Infect. 2017 Feb. 1. doi: 10.1016/j.jhin.2017.02.001).
The protocol for the procedure involved insertion of a nasoduodenal tube the day before FMT in order to perform a bowel lavage with XPrep solution. FMT was performed using a frozen preparation of fecal microbiota from a universal donor who was previously screened for potential diseases. The main outcome of interest was time to successful decolonization following FMT, which was determined by at least two consecutive negative rectal swabs at a 1-week interval during a follow-up of 3 months.
The mean age of the eight patients was 70 years, their median Charlson comorbidity index score was 5, and the median duration of carriage of HDREB before FMT was 83 days. The researchers observed that 1 month after FMT, two patients were free from CRE colonization, while one more patient was free from VRE after 3 months. Five patients received antibiotic during follow-up. Among them, one patient was decolonized at 1 month, while another was decolonized at 3 months. One patient with cirrhosis and persistent VRE carriage died 3 months after FMT from ascetic fluid infection and VRE bacteremia. No other adverse events were reported.
“In a context where no other efficient strategy is available, our first results show that FMT seems to be safe, with an impact on CRE decolonization at 1 month and on VRE decolonization at 3 months,” the researchers concluded. “Of particular importance, there was no recolonization after the intervention, which is contrary to decolonization with antibiotics. However, our study has important limitations in that the sample size was very small, it was nonrandomized, and follow-up was limited to a 3-month period.” They noted that at least five trials are underway to investigate the impact of FMT on multidrug resistant organism bacterial decolonization. The researchers reported having no financial disclosures.
The use of fecal microbiota transplantation is an option to eradicate highly drug-resistant enteric bacteria carriage, according to results from a small pilot study conducted by French investigators.
“A rapid and dramatic emergence of highly drug-resistant enteric bacteria (HDREB), i.e., carbapenem-resistant Enterobacteriaceae (CRE) and vancomycin-resistant enterococci (VRE), is occurring worldwide,” researchers led by Benjamin Davido, MD, of the infectious diseases unit at Raymond Poincaré Teaching Hospital, Garches, France, wrote in a study published online Feb. 1 in the Journal of Hospital Infection. “Patients carrying these bacteria are at risk of developing severe infections due to these bacteria; these infections are associated with a high mortality rate, partially because of inappropriate antimicrobial treatment.”
Citing recent studies that have demonstrated the efficacy of fecal microbiota transplant (FMT) as an accepted therapy to prevent recurrent Clostridium difficile infection, Dr. Davido and his associates prospectively identified eight different case reports of FMT used in adults for intestinal decolonization from extended-spectrum beta-lactamase (ESBL)–producing Enterobacteriaceae, VRE, or methicillin-resistant Staphylococcus aureus. Patients on immunosuppressive agents were excluded from the study, as were those taking antibiotics at the time of FMT (J Hosp Infect. 2017 Feb. 1. doi: 10.1016/j.jhin.2017.02.001).
The protocol for the procedure involved insertion of a nasoduodenal tube the day before FMT in order to perform a bowel lavage with XPrep solution. FMT was performed using a frozen preparation of fecal microbiota from a universal donor who was previously screened for potential diseases. The main outcome of interest was time to successful decolonization following FMT, which was determined by at least two consecutive negative rectal swabs at a 1-week interval during a follow-up of 3 months.
The mean age of the eight patients was 70 years, their median Charlson comorbidity index score was 5, and the median duration of carriage of HDREB before FMT was 83 days. The researchers observed that 1 month after FMT, two patients were free from CRE colonization, while one more patient was free from VRE after 3 months. Five patients received antibiotic during follow-up. Among them, one patient was decolonized at 1 month, while another was decolonized at 3 months. One patient with cirrhosis and persistent VRE carriage died 3 months after FMT from ascetic fluid infection and VRE bacteremia. No other adverse events were reported.
“In a context where no other efficient strategy is available, our first results show that FMT seems to be safe, with an impact on CRE decolonization at 1 month and on VRE decolonization at 3 months,” the researchers concluded. “Of particular importance, there was no recolonization after the intervention, which is contrary to decolonization with antibiotics. However, our study has important limitations in that the sample size was very small, it was nonrandomized, and follow-up was limited to a 3-month period.” They noted that at least five trials are underway to investigate the impact of FMT on multidrug resistant organism bacterial decolonization. The researchers reported having no financial disclosures.
The use of fecal microbiota transplantation is an option to eradicate highly drug-resistant enteric bacteria carriage, according to results from a small pilot study conducted by French investigators.
“A rapid and dramatic emergence of highly drug-resistant enteric bacteria (HDREB), i.e., carbapenem-resistant Enterobacteriaceae (CRE) and vancomycin-resistant enterococci (VRE), is occurring worldwide,” researchers led by Benjamin Davido, MD, of the infectious diseases unit at Raymond Poincaré Teaching Hospital, Garches, France, wrote in a study published online Feb. 1 in the Journal of Hospital Infection. “Patients carrying these bacteria are at risk of developing severe infections due to these bacteria; these infections are associated with a high mortality rate, partially because of inappropriate antimicrobial treatment.”
Citing recent studies that have demonstrated the efficacy of fecal microbiota transplant (FMT) as an accepted therapy to prevent recurrent Clostridium difficile infection, Dr. Davido and his associates prospectively identified eight different case reports of FMT used in adults for intestinal decolonization from extended-spectrum beta-lactamase (ESBL)–producing Enterobacteriaceae, VRE, or methicillin-resistant Staphylococcus aureus. Patients on immunosuppressive agents were excluded from the study, as were those taking antibiotics at the time of FMT (J Hosp Infect. 2017 Feb. 1. doi: 10.1016/j.jhin.2017.02.001).
The protocol for the procedure involved insertion of a nasoduodenal tube the day before FMT in order to perform a bowel lavage with XPrep solution. FMT was performed using a frozen preparation of fecal microbiota from a universal donor who was previously screened for potential diseases. The main outcome of interest was time to successful decolonization following FMT, which was determined by at least two consecutive negative rectal swabs at a 1-week interval during a follow-up of 3 months.
The mean age of the eight patients was 70 years, their median Charlson comorbidity index score was 5, and the median duration of carriage of HDREB before FMT was 83 days. The researchers observed that 1 month after FMT, two patients were free from CRE colonization, while one more patient was free from VRE after 3 months. Five patients received antibiotic during follow-up. Among them, one patient was decolonized at 1 month, while another was decolonized at 3 months. One patient with cirrhosis and persistent VRE carriage died 3 months after FMT from ascetic fluid infection and VRE bacteremia. No other adverse events were reported.
“In a context where no other efficient strategy is available, our first results show that FMT seems to be safe, with an impact on CRE decolonization at 1 month and on VRE decolonization at 3 months,” the researchers concluded. “Of particular importance, there was no recolonization after the intervention, which is contrary to decolonization with antibiotics. However, our study has important limitations in that the sample size was very small, it was nonrandomized, and follow-up was limited to a 3-month period.” They noted that at least five trials are underway to investigate the impact of FMT on multidrug resistant organism bacterial decolonization. The researchers reported having no financial disclosures.
FROM THE JOURNAL OF HOSPITAL INFECTION
Key clinical point:
Major finding: Of eight patients who underwent fecal microbiota transplantation (FMT) for carbapenem-resistant Enterobacteriaceae (CRE) and vancomycin-resistant enterococci (VRE) digestive tract decolonization, three achieved decolonization after 3 months.
Data source: A prospective study of eight cases of FMT used in adults for intestinal decolonization from drug-resistant enteric bacteria carriage.
Disclosures: The researchers reported having no financial disclosures.
Moderate stenosis in coronary arteries grows severe over time
HOUSTON – Most nongrafted, moderately stenosed coronary arteries progress to severe stenosis or occlusion in the long term, results from a large, long-term study have shown.
“Not uncommonly, patients referred for coronary surgery have one or more coronary arteries with only moderate stenosis,” Joseph F. Sabik III, MD, said at the annual meeting of the Society of Thoracic Surgeons.
“There is controversy as to whether arteries with only moderate stenosis should be grafted during coronary surgery, and if it should be grafted, with what conduit?” For example, the Fractional Flow Reserve-Guided PCI versus Medical Therapy in Stable Coronary Disease study, known as FAME, suggests not intervening on moderate stenosis, since stenting non–ischemia-producing lesions led to worse outcomes (N Engl J Med. 2012 Sep 13;367:991-1001). However, Dr. Sabik, who chairs the department of surgery at University Hospitals Cleveland Medical Center, and his associates recently reported that grafting moderately stenosed coronary arteries during surgical revascularization is not harmful and can be beneficial by improving survival if an internal thoracic artery graft is used (J. Thoracic Cardiovasc Surg. 2016 Mar;151[3]:806-11).
In an effort to determine how grafting moderately stenosed coronary arteries influences native-vessel disease progression, and whether grafting may be protective from late ischemia, Dr. Sabik and his associates evaluated the medical records of 55,567 patients who underwent primary isolated coronary artery bypass graft (CABG) surgery at the Cleveland Clinic from 1972 to 2011. Of the 55,567 patients, 1,902 had a single coronary artery with angiographically moderate stenosis (defined as a narrowing of 50%-69%) and results of at least one postoperative angiogram available. Of these moderately stenosed coronary arteries (MSCAs), 488 were not grafted, 385 were internal thoracic artery (ITA)–grafted, and 1,028 were saphenous vein (SV)–grafted. At follow-up angiograms, information about disease progression was available for 488 nongrafted, 371 ITA-grafted, and 957 SV-grafted MSCAs, and patency information was available for 376 ITA and 1,016 SV grafts to these MSCAs. Grafts were considered patent if they were not occluded. Severe occlusion was defined as a narrowing of more than 70%.
The researchers found that at 1, 5, 10, and 15 years, native-vessel disease progressed from moderate to severe stenosis/occlusion in 32%, 52%, 66%, and 72% of nongrafted MSCAs, respectively; in 55%, 73%, 84%, and 87% of ITA-grafted MSCAs, and in 67%, 82%, 90%, and 92% of SV-grafted MSCAs. After Dr. Sabik and his associates adjusted for patient characteristics, disease progression in MSCAs was significantly higher with ITA and SV grafting, compared with nongrafting (odds ratios, 3.6 and 9.9, respectively). At 1, 5, 10, and 15 years, occlusion in grafts to MSCAs was 8%, 9%, 11%, and 15%, respectively, for ITA grafts and 13%, 32%, 46%, and 56% for SV grafts. At these same time points, protection from myocardial ischemia in ITA-grafted vs. nongrafted MSCAs was 29%, 47%, 59%, and 61%.
“Our opinion is you that shouldn’t ignore moderate lesions,” Dr. Sabik, surgeon-in-chief and vice president for surgical operations for the University Hospitals system, said in an interview at the meeting. “Although it may not help that patient over the next short period of time, over their lifespan it will. What works for intervention doesn’t necessarily mean it’s right for bypass surgery. If you have a vessel that’s only moderately stenosed you should at least consider grafting it, because moderate lesions progress over time. Bypassing it helps people live longer when you use an internal thoracic artery graft, because they are likely to remain patent. You always have to individualize the therapy, but the key is to use your grafts in the best way possible.”
Dr. Sabik disclosed that he has received research grants from Medtronic, Abbott Vascular, and Edwards Lifesciences.
HOUSTON – Most nongrafted, moderately stenosed coronary arteries progress to severe stenosis or occlusion in the long term, results from a large, long-term study have shown.
“Not uncommonly, patients referred for coronary surgery have one or more coronary arteries with only moderate stenosis,” Joseph F. Sabik III, MD, said at the annual meeting of the Society of Thoracic Surgeons.
“There is controversy as to whether arteries with only moderate stenosis should be grafted during coronary surgery, and if it should be grafted, with what conduit?” For example, the Fractional Flow Reserve-Guided PCI versus Medical Therapy in Stable Coronary Disease study, known as FAME, suggests not intervening on moderate stenosis, since stenting non–ischemia-producing lesions led to worse outcomes (N Engl J Med. 2012 Sep 13;367:991-1001). However, Dr. Sabik, who chairs the department of surgery at University Hospitals Cleveland Medical Center, and his associates recently reported that grafting moderately stenosed coronary arteries during surgical revascularization is not harmful and can be beneficial by improving survival if an internal thoracic artery graft is used (J. Thoracic Cardiovasc Surg. 2016 Mar;151[3]:806-11).
In an effort to determine how grafting moderately stenosed coronary arteries influences native-vessel disease progression, and whether grafting may be protective from late ischemia, Dr. Sabik and his associates evaluated the medical records of 55,567 patients who underwent primary isolated coronary artery bypass graft (CABG) surgery at the Cleveland Clinic from 1972 to 2011. Of the 55,567 patients, 1,902 had a single coronary artery with angiographically moderate stenosis (defined as a narrowing of 50%-69%) and results of at least one postoperative angiogram available. Of these moderately stenosed coronary arteries (MSCAs), 488 were not grafted, 385 were internal thoracic artery (ITA)–grafted, and 1,028 were saphenous vein (SV)–grafted. At follow-up angiograms, information about disease progression was available for 488 nongrafted, 371 ITA-grafted, and 957 SV-grafted MSCAs, and patency information was available for 376 ITA and 1,016 SV grafts to these MSCAs. Grafts were considered patent if they were not occluded. Severe occlusion was defined as a narrowing of more than 70%.
The researchers found that at 1, 5, 10, and 15 years, native-vessel disease progressed from moderate to severe stenosis/occlusion in 32%, 52%, 66%, and 72% of nongrafted MSCAs, respectively; in 55%, 73%, 84%, and 87% of ITA-grafted MSCAs, and in 67%, 82%, 90%, and 92% of SV-grafted MSCAs. After Dr. Sabik and his associates adjusted for patient characteristics, disease progression in MSCAs was significantly higher with ITA and SV grafting, compared with nongrafting (odds ratios, 3.6 and 9.9, respectively). At 1, 5, 10, and 15 years, occlusion in grafts to MSCAs was 8%, 9%, 11%, and 15%, respectively, for ITA grafts and 13%, 32%, 46%, and 56% for SV grafts. At these same time points, protection from myocardial ischemia in ITA-grafted vs. nongrafted MSCAs was 29%, 47%, 59%, and 61%.
“Our opinion is you that shouldn’t ignore moderate lesions,” Dr. Sabik, surgeon-in-chief and vice president for surgical operations for the University Hospitals system, said in an interview at the meeting. “Although it may not help that patient over the next short period of time, over their lifespan it will. What works for intervention doesn’t necessarily mean it’s right for bypass surgery. If you have a vessel that’s only moderately stenosed you should at least consider grafting it, because moderate lesions progress over time. Bypassing it helps people live longer when you use an internal thoracic artery graft, because they are likely to remain patent. You always have to individualize the therapy, but the key is to use your grafts in the best way possible.”
Dr. Sabik disclosed that he has received research grants from Medtronic, Abbott Vascular, and Edwards Lifesciences.
HOUSTON – Most nongrafted, moderately stenosed coronary arteries progress to severe stenosis or occlusion in the long term, results from a large, long-term study have shown.
“Not uncommonly, patients referred for coronary surgery have one or more coronary arteries with only moderate stenosis,” Joseph F. Sabik III, MD, said at the annual meeting of the Society of Thoracic Surgeons.
“There is controversy as to whether arteries with only moderate stenosis should be grafted during coronary surgery, and if it should be grafted, with what conduit?” For example, the Fractional Flow Reserve-Guided PCI versus Medical Therapy in Stable Coronary Disease study, known as FAME, suggests not intervening on moderate stenosis, since stenting non–ischemia-producing lesions led to worse outcomes (N Engl J Med. 2012 Sep 13;367:991-1001). However, Dr. Sabik, who chairs the department of surgery at University Hospitals Cleveland Medical Center, and his associates recently reported that grafting moderately stenosed coronary arteries during surgical revascularization is not harmful and can be beneficial by improving survival if an internal thoracic artery graft is used (J. Thoracic Cardiovasc Surg. 2016 Mar;151[3]:806-11).
In an effort to determine how grafting moderately stenosed coronary arteries influences native-vessel disease progression, and whether grafting may be protective from late ischemia, Dr. Sabik and his associates evaluated the medical records of 55,567 patients who underwent primary isolated coronary artery bypass graft (CABG) surgery at the Cleveland Clinic from 1972 to 2011. Of the 55,567 patients, 1,902 had a single coronary artery with angiographically moderate stenosis (defined as a narrowing of 50%-69%) and results of at least one postoperative angiogram available. Of these moderately stenosed coronary arteries (MSCAs), 488 were not grafted, 385 were internal thoracic artery (ITA)–grafted, and 1,028 were saphenous vein (SV)–grafted. At follow-up angiograms, information about disease progression was available for 488 nongrafted, 371 ITA-grafted, and 957 SV-grafted MSCAs, and patency information was available for 376 ITA and 1,016 SV grafts to these MSCAs. Grafts were considered patent if they were not occluded. Severe occlusion was defined as a narrowing of more than 70%.
The researchers found that at 1, 5, 10, and 15 years, native-vessel disease progressed from moderate to severe stenosis/occlusion in 32%, 52%, 66%, and 72% of nongrafted MSCAs, respectively; in 55%, 73%, 84%, and 87% of ITA-grafted MSCAs, and in 67%, 82%, 90%, and 92% of SV-grafted MSCAs. After Dr. Sabik and his associates adjusted for patient characteristics, disease progression in MSCAs was significantly higher with ITA and SV grafting, compared with nongrafting (odds ratios, 3.6 and 9.9, respectively). At 1, 5, 10, and 15 years, occlusion in grafts to MSCAs was 8%, 9%, 11%, and 15%, respectively, for ITA grafts and 13%, 32%, 46%, and 56% for SV grafts. At these same time points, protection from myocardial ischemia in ITA-grafted vs. nongrafted MSCAs was 29%, 47%, 59%, and 61%.
“Our opinion is you that shouldn’t ignore moderate lesions,” Dr. Sabik, surgeon-in-chief and vice president for surgical operations for the University Hospitals system, said in an interview at the meeting. “Although it may not help that patient over the next short period of time, over their lifespan it will. What works for intervention doesn’t necessarily mean it’s right for bypass surgery. If you have a vessel that’s only moderately stenosed you should at least consider grafting it, because moderate lesions progress over time. Bypassing it helps people live longer when you use an internal thoracic artery graft, because they are likely to remain patent. You always have to individualize the therapy, but the key is to use your grafts in the best way possible.”
Dr. Sabik disclosed that he has received research grants from Medtronic, Abbott Vascular, and Edwards Lifesciences.
AT THE STS ANNUAL MEETING
Key clinical point:
Major finding: At 15 years, native-vessel disease progressed from moderate to severe stenosis/occlusion in 72% of nongrafted coronary arteries, in 87% of internal thoracic artery–grafted arteries, and in 92% of saphenous vein–grafted moderately stenosed coronary arteries.
Data source: An analysis of medical records from 55,567 patients who underwent primary isolated CABG at the Cleveland Clinic from 1972 to 2011.
Disclosures: Dr. Sabik disclosed that he has received research grants from Medtronic, Abbott Vascular, and Edwards Lifesciences.