New research shows that almost 5% of older British citizens have potentially serious brain abnormalities, including aneurysms, and about a third have blood test abnormalities. Knowing the expected prevalence of such incidental findings in the older general population is “extremely useful” for both researchers and clinicians, said study co-author Sarah Elisabeth Keuss, MBChB, clinical research associate, Dementia Research Centre, UCL Queen Square Institute of Neurology, London, UK.

“In research, the knowledge helps to inform study protocols regarding how to manage incidental findings and enables study participants to be appropriately informed,” said Dr. Keuss. Greater awareness also helps clinicians make decisions about whether or not to scan a patient, she said, adding that imaging is increasingly available to them. It allows clinicians to counsel patients regarding the probability of an incidental finding and balance that risk against the potential benefits of having a test.

The research is being presented online as part of the American Academy of Neurology 2020 Science Highlights. The incidental findings also were published last year in BMJ Open.

The new findings are from the first wave of data collection for the Insight 46 study, a neuroimaging substudy of the MRC National Survey of Health and Development (NSHD) 1946 British birth cohort, a broadly representative sample of the population born in mainland Britain during 1946. The research uses detailed brain imaging, cognitive testing, and blood and other biomarkers to investigate genetic and life-course factors associated with Alzheimer’s disease and cerebrovascular disease.

The current study included 502 individuals, aged about 71 years at the time of the analysis, and 49% were women. Almost all (93.8%) participants underwent 1-day MRI scans. Some 4.5% of these participants had an incidental finding of brain abnormality as per a prespecified standardized protocol.

Suspected vascular malformations were present in 1.9%, and suspected intracranial mass lesions were present in 1.5%. The single most common vascular abnormality was a suspected cerebral aneurysm, which affected 1.1% of participants.

Suspected meningiomas were the most common intracranial lesion, affecting 0.6% of study participants.
 

Action plan

Participants and their primary care provider were informed of findings “that were deemed to be potentially serious, or life-threatening, or could have a major impact on quality of life,” said Dr. Keuss. Relevant experts “came up with a recommended clinical action plan to help the primary care provider decide what should be the next course of action with regard to investigation or referral to another specialist,” said Dr. Keuss.

The new results are important for clinical decision-making, said Dr. Keuss. “Clinicians should consider the possibility of detecting an incidental finding whenever they’re requesting a brain scan. They should balance that risk against the possible benefits of recommending a test.”

The prevalence of incidental findings on MRI reported in the literature varies because of different methods used to review scans. “However, comparing our study with similar studies, the prevalence of the key findings with regard to aneurysms and intracranial mass lesions are very similar,” said Dr. Keuss.

Dr. Keuss and colleagues do not recommend all elderly patients get a brain scan.

“We don’t know what the long-term consequences are of being informed you have an incidental finding of an abnormality; we don’t know if it improves their outcome, and it potentially could cause anxiety,” said Dr. Keuss.
 

Psychological impact

The researchers have not looked at the psychological impact of negative findings on study participants, but they could do so at a later date.

“It would be very important to look into that given the potential to cause anxiety,” said Dr. Keuss. “It’s important to find out the potential negative consequences to inform researchers in future about how best to manage these findings.”

From blood tests, the analysis found that more than a third (34.6%) of participants had at least one related abnormality. The most common of these were kidney impairment (about 9%), thyroid function abnormalities (between 4% and 5%), anemia (about 4%), and low vitamin B₁₂ levels (about 3%).

However, few of these reached the prespecified threshold for urgent action, and Dr. Keuss noted these findings were not the focus of her AAN presentation.

A strength of the study was that participants were almost the exact same age.
 

Important issue

Commenting on the research, David S. Liebeskind, MD, professor of neurology and director, Neurovascular Imaging Research Core, University of California, Los Angeles, said it raises “a very interesting” and “important” public health issue.

“The question is whether we do things based around individual symptomatic status, or at a larger level in terms of public health, screening the larger population to figure out who is at risk for any particular disease or disorder.”

From the standpoint of imaging technologies like MRI that show details about brain structures, experts debate whether the population should be screened “before something occurs,” said Dr. Liebeskind. “Imaging has the capacity to tell us a tremendous amount; whether this implies we should therefore image everybody is a larger public health question.”

The issue is “fraught with a lot of difficulty and complexity” as treatment paradigms tend to be “built around symptomatic status,” he said. “When we sit in the office or with a patient at the bedside, we usually focus on that individual patient and not necessarily on the larger public.”

Dr. Liebeskind noted that the question of whether to put the emphasis on the individual patient or the public at large is also being discussed during the current COVID-19 pandemic.

He wasn’t surprised that the study uncovered incidental findings in almost 5% of the sample. “If you take an 80-year-old and study their brain, a good chunk, if not half or more, will have some abnormality,” he said.

Drs. Keuss and Liebeskind have reported no relevant financial relationships.

This article first appeared on Medscape.com.

New research shows that almost 5% of older British citizens have potentially serious brain abnormalities, including aneurysms, and about a third have blood test abnormalities. Knowing the expected prevalence of such incidental findings in the older general population is “extremely useful” for both researchers and clinicians, said study co-author Sarah Elisabeth Keuss, MBChB, clinical research associate, Dementia Research Centre, UCL Queen Square Institute of Neurology, London, UK.

“In research, the knowledge helps to inform study protocols regarding how to manage incidental findings and enables study participants to be appropriately informed,” said Dr. Keuss. Greater awareness also helps clinicians make decisions about whether or not to scan a patient, she said, adding that imaging is increasingly available to them. It allows clinicians to counsel patients regarding the probability of an incidental finding and balance that risk against the potential benefits of having a test.

The research is being presented online as part of the American Academy of Neurology 2020 Science Highlights. The incidental findings also were published last year in BMJ Open.

The new findings are from the first wave of data collection for the Insight 46 study, a neuroimaging substudy of the MRC National Survey of Health and Development (NSHD) 1946 British birth cohort, a broadly representative sample of the population born in mainland Britain during 1946. The research uses detailed brain imaging, cognitive testing, and blood and other biomarkers to investigate genetic and life-course factors associated with Alzheimer’s disease and cerebrovascular disease.

The current study included 502 individuals, aged about 71 years at the time of the analysis, and 49% were women. Almost all (93.8%) participants underwent 1-day MRI scans. Some 4.5% of these participants had an incidental finding of brain abnormality as per a prespecified standardized protocol.

Suspected vascular malformations were present in 1.9%, and suspected intracranial mass lesions were present in 1.5%. The single most common vascular abnormality was a suspected cerebral aneurysm, which affected 1.1% of participants.

Suspected meningiomas were the most common intracranial lesion, affecting 0.6% of study participants.
 

Action plan

Participants and their primary care provider were informed of findings “that were deemed to be potentially serious, or life-threatening, or could have a major impact on quality of life,” said Dr. Keuss. Relevant experts “came up with a recommended clinical action plan to help the primary care provider decide what should be the next course of action with regard to investigation or referral to another specialist,” said Dr. Keuss.

The new results are important for clinical decision-making, said Dr. Keuss. “Clinicians should consider the possibility of detecting an incidental finding whenever they’re requesting a brain scan. They should balance that risk against the possible benefits of recommending a test.”

The prevalence of incidental findings on MRI reported in the literature varies because of different methods used to review scans. “However, comparing our study with similar studies, the prevalence of the key findings with regard to aneurysms and intracranial mass lesions are very similar,” said Dr. Keuss.

Dr. Keuss and colleagues do not recommend all elderly patients get a brain scan.

“We don’t know what the long-term consequences are of being informed you have an incidental finding of an abnormality; we don’t know if it improves their outcome, and it potentially could cause anxiety,” said Dr. Keuss.
 

Psychological impact

The researchers have not looked at the psychological impact of negative findings on study participants, but they could do so at a later date.

“It would be very important to look into that given the potential to cause anxiety,” said Dr. Keuss. “It’s important to find out the potential negative consequences to inform researchers in future about how best to manage these findings.”

From blood tests, the analysis found that more than a third (34.6%) of participants had at least one related abnormality. The most common of these were kidney impairment (about 9%), thyroid function abnormalities (between 4% and 5%), anemia (about 4%), and low vitamin B₁₂ levels (about 3%).

However, few of these reached the prespecified threshold for urgent action, and Dr. Keuss noted these findings were not the focus of her AAN presentation.

A strength of the study was that participants were almost the exact same age.
 

Important issue

Commenting on the research, David S. Liebeskind, MD, professor of neurology and director, Neurovascular Imaging Research Core, University of California, Los Angeles, said it raises “a very interesting” and “important” public health issue.

“The question is whether we do things based around individual symptomatic status, or at a larger level in terms of public health, screening the larger population to figure out who is at risk for any particular disease or disorder.”

From the standpoint of imaging technologies like MRI that show details about brain structures, experts debate whether the population should be screened “before something occurs,” said Dr. Liebeskind. “Imaging has the capacity to tell us a tremendous amount; whether this implies we should therefore image everybody is a larger public health question.”

The issue is “fraught with a lot of difficulty and complexity” as treatment paradigms tend to be “built around symptomatic status,” he said. “When we sit in the office or with a patient at the bedside, we usually focus on that individual patient and not necessarily on the larger public.”

Dr. Liebeskind noted that the question of whether to put the emphasis on the individual patient or the public at large is also being discussed during the current COVID-19 pandemic.

He wasn’t surprised that the study uncovered incidental findings in almost 5% of the sample. “If you take an 80-year-old and study their brain, a good chunk, if not half or more, will have some abnormality,” he said.

Drs. Keuss and Liebeskind have reported no relevant financial relationships.

This article first appeared on Medscape.com.

New research shows that almost 5% of older British citizens have potentially serious brain abnormalities, including aneurysms, and about a third have blood test abnormalities. Knowing the expected prevalence of such incidental findings in the older general population is “extremely useful” for both researchers and clinicians, said study co-author Sarah Elisabeth Keuss, MBChB, clinical research associate, Dementia Research Centre, UCL Queen Square Institute of Neurology, London, UK.

“In research, the knowledge helps to inform study protocols regarding how to manage incidental findings and enables study participants to be appropriately informed,” said Dr. Keuss. Greater awareness also helps clinicians make decisions about whether or not to scan a patient, she said, adding that imaging is increasingly available to them. It allows clinicians to counsel patients regarding the probability of an incidental finding and balance that risk against the potential benefits of having a test.

The research is being presented online as part of the American Academy of Neurology 2020 Science Highlights. The incidental findings also were published last year in BMJ Open.

The new findings are from the first wave of data collection for the Insight 46 study, a neuroimaging substudy of the MRC National Survey of Health and Development (NSHD) 1946 British birth cohort, a broadly representative sample of the population born in mainland Britain during 1946. The research uses detailed brain imaging, cognitive testing, and blood and other biomarkers to investigate genetic and life-course factors associated with Alzheimer’s disease and cerebrovascular disease.

The current study included 502 individuals, aged about 71 years at the time of the analysis, and 49% were women. Almost all (93.8%) participants underwent 1-day MRI scans. Some 4.5% of these participants had an incidental finding of brain abnormality as per a prespecified standardized protocol.

Suspected vascular malformations were present in 1.9%, and suspected intracranial mass lesions were present in 1.5%. The single most common vascular abnormality was a suspected cerebral aneurysm, which affected 1.1% of participants.

Suspected meningiomas were the most common intracranial lesion, affecting 0.6% of study participants.
 

Action plan

Participants and their primary care provider were informed of findings “that were deemed to be potentially serious, or life-threatening, or could have a major impact on quality of life,” said Dr. Keuss. Relevant experts “came up with a recommended clinical action plan to help the primary care provider decide what should be the next course of action with regard to investigation or referral to another specialist,” said Dr. Keuss.

The new results are important for clinical decision-making, said Dr. Keuss. “Clinicians should consider the possibility of detecting an incidental finding whenever they’re requesting a brain scan. They should balance that risk against the possible benefits of recommending a test.”

The prevalence of incidental findings on MRI reported in the literature varies because of different methods used to review scans. “However, comparing our study with similar studies, the prevalence of the key findings with regard to aneurysms and intracranial mass lesions are very similar,” said Dr. Keuss.

Dr. Keuss and colleagues do not recommend all elderly patients get a brain scan.

“We don’t know what the long-term consequences are of being informed you have an incidental finding of an abnormality; we don’t know if it improves their outcome, and it potentially could cause anxiety,” said Dr. Keuss.
 

Psychological impact

The researchers have not looked at the psychological impact of negative findings on study participants, but they could do so at a later date.

“It would be very important to look into that given the potential to cause anxiety,” said Dr. Keuss. “It’s important to find out the potential negative consequences to inform researchers in future about how best to manage these findings.”

From blood tests, the analysis found that more than a third (34.6%) of participants had at least one related abnormality. The most common of these were kidney impairment (about 9%), thyroid function abnormalities (between 4% and 5%), anemia (about 4%), and low vitamin B₁₂ levels (about 3%).

However, few of these reached the prespecified threshold for urgent action, and Dr. Keuss noted these findings were not the focus of her AAN presentation.

A strength of the study was that participants were almost the exact same age.
 

Important issue

Commenting on the research, David S. Liebeskind, MD, professor of neurology and director, Neurovascular Imaging Research Core, University of California, Los Angeles, said it raises “a very interesting” and “important” public health issue.

“The question is whether we do things based around individual symptomatic status, or at a larger level in terms of public health, screening the larger population to figure out who is at risk for any particular disease or disorder.”

From the standpoint of imaging technologies like MRI that show details about brain structures, experts debate whether the population should be screened “before something occurs,” said Dr. Liebeskind. “Imaging has the capacity to tell us a tremendous amount; whether this implies we should therefore image everybody is a larger public health question.”

The issue is “fraught with a lot of difficulty and complexity” as treatment paradigms tend to be “built around symptomatic status,” he said. “When we sit in the office or with a patient at the bedside, we usually focus on that individual patient and not necessarily on the larger public.”

Dr. Liebeskind noted that the question of whether to put the emphasis on the individual patient or the public at large is also being discussed during the current COVID-19 pandemic.

He wasn’t surprised that the study uncovered incidental findings in almost 5% of the sample. “If you take an 80-year-old and study their brain, a good chunk, if not half or more, will have some abnormality,” he said.

Drs. Keuss and Liebeskind have reported no relevant financial relationships.

This article first appeared on Medscape.com.

Max is an 8-year-old boy in the third grade, and you have been his pediatrician since birth. Described as “emotional” and “particular” since his early years, Max is prone to prolonged tantrums that have not improved with age. Parents have described a tic that involves repeatedly touching his ear, but this has not been observed in the office setting. Max has struggled with some attention issues at school, and often needs help finishing assignments. The family is feeling increasingly desperate for ways to manage his near-daily meltdowns at home, and parenting strategies you’ve discussed thus far don’t seem to be helping much. Should obsessive-compulsive disorder be in your differential? And at what point do you seek outside evaluation?

miodrag ignjatovic/E+

OCD is a condition characterized by recurrent, intrusive, and unwanted thoughts, images, and urges (obsessions), and repetitive behaviors or mental acts performed in a particular way to reduce anxiety (compulsions). It affects 1%-3% of children, and onset can be as early as age 3-4 years. While the average age of onset in children is approximately 10 years old, average age of diagnosis is at least several years later.¹ A primary care physician’s ability to recognize OCD symptoms in children, perform an initial assessment, and connect the child to appropriate clinical care is key to reducing the years of difficulty that children and families often endure prior to beginning treatment.

Common obsessions in children include contamination, fear of harm to self or others, symmetry, and the belief that bad things will occur if rituals are performed incorrectly. Common compulsions include checking, washing, ordering, and mental acts such as praying or counting to one’s self.^1,2 In addition to the fact that OCD presentations are highly heterogeneous, early diagnosis is challenging due to significant overlap of OCD symptoms with developmentally normal behaviors. For example, magical or superstitious thinking is common among school-age children who avoid stepping on cracks or utilize lucky numbers. What differentiates OCD is the presence of obsessions and/or compulsions that are time consuming and cause subjective distress or functional impairment. Children often are adept at keeping OCD symptoms secret. At time of diagnosis, the child may have a complex array of discreet behaviors to manage distress and minimize shame. Children may not have insight into the irrationality of their thoughts or behaviors, but they are certainly aware of how terrible and confused they feel inside, and how it affects their relationship with their parents. Rituals, such as those that delay bedtime or cause school tardiness, may look like oppositional behaviors and cause immense frustration for parents.

Comorbidities are common and include ADHD, oppositional defiant disorder, depression, and Tourette syndrome.³ Nearly 60% of children with OCD meet criteria for a tic disorder at some point in their lifetime.⁴ Compulsions designed to ease a feeling of internal discomfort, such as touching or tapping, are particularly typical of patients with OCD and comorbid tics. Often these children will express a need for things to be “just right,” with lasting relief from such a feeling rarely found. While sensory intolerances are not part of OCD’s diagnostic criteria, clinical experiences and growing research point to a high prevalence in affected children.^5,6 Sensory intolerances may even be the primary presenting problem. Examples include clothing feeling uncomfortable, or inability to tolerate certain smells or innocuous sounds.

The preferred method for assessment of OCD in children is the Children’s Yale–Brown Obsessive Compulsive Scale (CY-BOCS), a semi-structured, clinician-rated interview designed to elicit symptoms, severity, and distress. While time constraints may prevent use of the CY-BOCS in the primary care setting, a handful of screening questions instead can go a long way. These might include:

• Do you have to do things in a certain way, such as washing or making things “just right?”
• What happens if you can’t do things in a certain way?
• Do you have unwanted thoughts that keep coming back and are hard to get rid of?

Equally as important as understanding a child’s OCD symptoms is understanding how the family has, often unwittingly, become intertwined in a web of OCD-driven behaviors. In an effort to soothe the child, prevent emotional outbursts, or simply get through the day, parents may find themselves accommodating behaviors that seem irrational. Despite parents’ best intentions, this is likely reinforcing OCD patterns. Parents may be asked by the child to repeat a reassuring phrase in a certain way, arrange furniture “just so,” or drive a certain route to school. In the case of contamination fears, a child may be taking several showers per day, using two bottles of shampoo per week, and demanding that his or her clothes be washed separately before a parent begins to realize the cumulative impact of these unusual behaviors on the household. In addition to exploring concerns, primary care physicians can provide a sounding board for exhausted parents wondering if other families face the same thing. While connecting the family to treatment, they also can provide reassurances that treatment can dramatically shift the trajectory of the illness.

Treatment of pediatric OCD begins with a specific form of cognitive behavioral therapy (CBT) called Exposure and Response Prevention therapy (ERP). ERP requires a skilled therapist, and a strong alliance with a child and family because the child will be asked to gradually challenge compulsions head-on and tolerate the accompanied distress. CBT/ERP is associated with a 40%-65% reduction in symptoms, but combination with SSRI therapy improves outcomes in more severe cases.³ Despite limited mental health resources and long wait lists in many parts of the country, connection to OCD-specific treatment is increasingly feasible in virtual format via online support groups and telemedicine.

“Max” may experience any number of OCD-related symptoms that a primary care physician could deftly uncover. He may become “stuck” at school because his handwriting accidentally strayed below the line. He may have hours-long meltdowns because his hair never feels right. He may touch his ear to prevent tragic harm coming to his mother. Whatever further exploration reveals, Max and his family stand to benefit immensely from early detection and intervention.
 

Dr. McGowan is assistant professor of psychiatry and pediatrics at the Vermont Center for Children, Youth, and Families, University of Vermont Medical Center, Burlington. She had no relevant financial disclosures. Email Dr. McGowan at pdnews@mdedge.com.

Resources for providers and families*

UNSTUCK: An OCD Kids Movie. Featuring a 23-minute documentary film about children living with OCD, this website also is rich in OCD-related resources.

International OCD Foundation. Has information for families about OCD. Also has a resource directory for therapists, clinics, support groups, and other organizations specializing in OCD and related disorders in different geographic areas.

*Of note, both resources above include COVID-19-specific resources for those struggling with worsening OCD symptoms as a result of the pandemic.

References

1. Lewis’s Child and Adolescent Psychiatry: A Comprehensive Textbook, 4th ed. (Baltimore: Lippincott Williams & Wilkins, 2020, pp. 518-27).

2. J Amer Acad Child Adol Psychiatry. 2012;51(1):98-113.

3. J Clin. Invest. 2009;119(4):737-46.

4. Arch Dis Child. 2015;100(5):495-9.

5. J Develop Behav Pediatr. 2019 Jun;40(5):377-82.

6. Ann Clin Psychiatry. 2008 Oct-Dec;20(4):199-203.

Max is an 8-year-old boy in the third grade, and you have been his pediatrician since birth. Described as “emotional” and “particular” since his early years, Max is prone to prolonged tantrums that have not improved with age. Parents have described a tic that involves repeatedly touching his ear, but this has not been observed in the office setting. Max has struggled with some attention issues at school, and often needs help finishing assignments. The family is feeling increasingly desperate for ways to manage his near-daily meltdowns at home, and parenting strategies you’ve discussed thus far don’t seem to be helping much. Should obsessive-compulsive disorder be in your differential? And at what point do you seek outside evaluation?

miodrag ignjatovic/E+

OCD is a condition characterized by recurrent, intrusive, and unwanted thoughts, images, and urges (obsessions), and repetitive behaviors or mental acts performed in a particular way to reduce anxiety (compulsions). It affects 1%-3% of children, and onset can be as early as age 3-4 years. While the average age of onset in children is approximately 10 years old, average age of diagnosis is at least several years later.¹ A primary care physician’s ability to recognize OCD symptoms in children, perform an initial assessment, and connect the child to appropriate clinical care is key to reducing the years of difficulty that children and families often endure prior to beginning treatment.

Common obsessions in children include contamination, fear of harm to self or others, symmetry, and the belief that bad things will occur if rituals are performed incorrectly. Common compulsions include checking, washing, ordering, and mental acts such as praying or counting to one’s self.^1,2 In addition to the fact that OCD presentations are highly heterogeneous, early diagnosis is challenging due to significant overlap of OCD symptoms with developmentally normal behaviors. For example, magical or superstitious thinking is common among school-age children who avoid stepping on cracks or utilize lucky numbers. What differentiates OCD is the presence of obsessions and/or compulsions that are time consuming and cause subjective distress or functional impairment. Children often are adept at keeping OCD symptoms secret. At time of diagnosis, the child may have a complex array of discreet behaviors to manage distress and minimize shame. Children may not have insight into the irrationality of their thoughts or behaviors, but they are certainly aware of how terrible and confused they feel inside, and how it affects their relationship with their parents. Rituals, such as those that delay bedtime or cause school tardiness, may look like oppositional behaviors and cause immense frustration for parents.

Comorbidities are common and include ADHD, oppositional defiant disorder, depression, and Tourette syndrome.³ Nearly 60% of children with OCD meet criteria for a tic disorder at some point in their lifetime.⁴ Compulsions designed to ease a feeling of internal discomfort, such as touching or tapping, are particularly typical of patients with OCD and comorbid tics. Often these children will express a need for things to be “just right,” with lasting relief from such a feeling rarely found. While sensory intolerances are not part of OCD’s diagnostic criteria, clinical experiences and growing research point to a high prevalence in affected children.^5,6 Sensory intolerances may even be the primary presenting problem. Examples include clothing feeling uncomfortable, or inability to tolerate certain smells or innocuous sounds.

The preferred method for assessment of OCD in children is the Children’s Yale–Brown Obsessive Compulsive Scale (CY-BOCS), a semi-structured, clinician-rated interview designed to elicit symptoms, severity, and distress. While time constraints may prevent use of the CY-BOCS in the primary care setting, a handful of screening questions instead can go a long way. These might include:

• Do you have to do things in a certain way, such as washing or making things “just right?”
• What happens if you can’t do things in a certain way?
• Do you have unwanted thoughts that keep coming back and are hard to get rid of?

Equally as important as understanding a child’s OCD symptoms is understanding how the family has, often unwittingly, become intertwined in a web of OCD-driven behaviors. In an effort to soothe the child, prevent emotional outbursts, or simply get through the day, parents may find themselves accommodating behaviors that seem irrational. Despite parents’ best intentions, this is likely reinforcing OCD patterns. Parents may be asked by the child to repeat a reassuring phrase in a certain way, arrange furniture “just so,” or drive a certain route to school. In the case of contamination fears, a child may be taking several showers per day, using two bottles of shampoo per week, and demanding that his or her clothes be washed separately before a parent begins to realize the cumulative impact of these unusual behaviors on the household. In addition to exploring concerns, primary care physicians can provide a sounding board for exhausted parents wondering if other families face the same thing. While connecting the family to treatment, they also can provide reassurances that treatment can dramatically shift the trajectory of the illness.

Treatment of pediatric OCD begins with a specific form of cognitive behavioral therapy (CBT) called Exposure and Response Prevention therapy (ERP). ERP requires a skilled therapist, and a strong alliance with a child and family because the child will be asked to gradually challenge compulsions head-on and tolerate the accompanied distress. CBT/ERP is associated with a 40%-65% reduction in symptoms, but combination with SSRI therapy improves outcomes in more severe cases.³ Despite limited mental health resources and long wait lists in many parts of the country, connection to OCD-specific treatment is increasingly feasible in virtual format via online support groups and telemedicine.

“Max” may experience any number of OCD-related symptoms that a primary care physician could deftly uncover. He may become “stuck” at school because his handwriting accidentally strayed below the line. He may have hours-long meltdowns because his hair never feels right. He may touch his ear to prevent tragic harm coming to his mother. Whatever further exploration reveals, Max and his family stand to benefit immensely from early detection and intervention.
 

Dr. McGowan is assistant professor of psychiatry and pediatrics at the Vermont Center for Children, Youth, and Families, University of Vermont Medical Center, Burlington. She had no relevant financial disclosures. Email Dr. McGowan at pdnews@mdedge.com.

Resources for providers and families*

UNSTUCK: An OCD Kids Movie. Featuring a 23-minute documentary film about children living with OCD, this website also is rich in OCD-related resources.

International OCD Foundation. Has information for families about OCD. Also has a resource directory for therapists, clinics, support groups, and other organizations specializing in OCD and related disorders in different geographic areas.

*Of note, both resources above include COVID-19-specific resources for those struggling with worsening OCD symptoms as a result of the pandemic.

References

1. Lewis’s Child and Adolescent Psychiatry: A Comprehensive Textbook, 4th ed. (Baltimore: Lippincott Williams & Wilkins, 2020, pp. 518-27).

2. J Amer Acad Child Adol Psychiatry. 2012;51(1):98-113.

3. J Clin. Invest. 2009;119(4):737-46.

4. Arch Dis Child. 2015;100(5):495-9.

5. J Develop Behav Pediatr. 2019 Jun;40(5):377-82.

6. Ann Clin Psychiatry. 2008 Oct-Dec;20(4):199-203.

Max is an 8-year-old boy in the third grade, and you have been his pediatrician since birth. Described as “emotional” and “particular” since his early years, Max is prone to prolonged tantrums that have not improved with age. Parents have described a tic that involves repeatedly touching his ear, but this has not been observed in the office setting. Max has struggled with some attention issues at school, and often needs help finishing assignments. The family is feeling increasingly desperate for ways to manage his near-daily meltdowns at home, and parenting strategies you’ve discussed thus far don’t seem to be helping much. Should obsessive-compulsive disorder be in your differential? And at what point do you seek outside evaluation?

miodrag ignjatovic/E+

OCD is a condition characterized by recurrent, intrusive, and unwanted thoughts, images, and urges (obsessions), and repetitive behaviors or mental acts performed in a particular way to reduce anxiety (compulsions). It affects 1%-3% of children, and onset can be as early as age 3-4 years. While the average age of onset in children is approximately 10 years old, average age of diagnosis is at least several years later.¹ A primary care physician’s ability to recognize OCD symptoms in children, perform an initial assessment, and connect the child to appropriate clinical care is key to reducing the years of difficulty that children and families often endure prior to beginning treatment.

Common obsessions in children include contamination, fear of harm to self or others, symmetry, and the belief that bad things will occur if rituals are performed incorrectly. Common compulsions include checking, washing, ordering, and mental acts such as praying or counting to one’s self.^1,2 In addition to the fact that OCD presentations are highly heterogeneous, early diagnosis is challenging due to significant overlap of OCD symptoms with developmentally normal behaviors. For example, magical or superstitious thinking is common among school-age children who avoid stepping on cracks or utilize lucky numbers. What differentiates OCD is the presence of obsessions and/or compulsions that are time consuming and cause subjective distress or functional impairment. Children often are adept at keeping OCD symptoms secret. At time of diagnosis, the child may have a complex array of discreet behaviors to manage distress and minimize shame. Children may not have insight into the irrationality of their thoughts or behaviors, but they are certainly aware of how terrible and confused they feel inside, and how it affects their relationship with their parents. Rituals, such as those that delay bedtime or cause school tardiness, may look like oppositional behaviors and cause immense frustration for parents.

Comorbidities are common and include ADHD, oppositional defiant disorder, depression, and Tourette syndrome.³ Nearly 60% of children with OCD meet criteria for a tic disorder at some point in their lifetime.⁴ Compulsions designed to ease a feeling of internal discomfort, such as touching or tapping, are particularly typical of patients with OCD and comorbid tics. Often these children will express a need for things to be “just right,” with lasting relief from such a feeling rarely found. While sensory intolerances are not part of OCD’s diagnostic criteria, clinical experiences and growing research point to a high prevalence in affected children.^5,6 Sensory intolerances may even be the primary presenting problem. Examples include clothing feeling uncomfortable, or inability to tolerate certain smells or innocuous sounds.

The preferred method for assessment of OCD in children is the Children’s Yale–Brown Obsessive Compulsive Scale (CY-BOCS), a semi-structured, clinician-rated interview designed to elicit symptoms, severity, and distress. While time constraints may prevent use of the CY-BOCS in the primary care setting, a handful of screening questions instead can go a long way. These might include:

• Do you have to do things in a certain way, such as washing or making things “just right?”
• What happens if you can’t do things in a certain way?
• Do you have unwanted thoughts that keep coming back and are hard to get rid of?

Equally as important as understanding a child’s OCD symptoms is understanding how the family has, often unwittingly, become intertwined in a web of OCD-driven behaviors. In an effort to soothe the child, prevent emotional outbursts, or simply get through the day, parents may find themselves accommodating behaviors that seem irrational. Despite parents’ best intentions, this is likely reinforcing OCD patterns. Parents may be asked by the child to repeat a reassuring phrase in a certain way, arrange furniture “just so,” or drive a certain route to school. In the case of contamination fears, a child may be taking several showers per day, using two bottles of shampoo per week, and demanding that his or her clothes be washed separately before a parent begins to realize the cumulative impact of these unusual behaviors on the household. In addition to exploring concerns, primary care physicians can provide a sounding board for exhausted parents wondering if other families face the same thing. While connecting the family to treatment, they also can provide reassurances that treatment can dramatically shift the trajectory of the illness.

Treatment of pediatric OCD begins with a specific form of cognitive behavioral therapy (CBT) called Exposure and Response Prevention therapy (ERP). ERP requires a skilled therapist, and a strong alliance with a child and family because the child will be asked to gradually challenge compulsions head-on and tolerate the accompanied distress. CBT/ERP is associated with a 40%-65% reduction in symptoms, but combination with SSRI therapy improves outcomes in more severe cases.³ Despite limited mental health resources and long wait lists in many parts of the country, connection to OCD-specific treatment is increasingly feasible in virtual format via online support groups and telemedicine.

“Max” may experience any number of OCD-related symptoms that a primary care physician could deftly uncover. He may become “stuck” at school because his handwriting accidentally strayed below the line. He may have hours-long meltdowns because his hair never feels right. He may touch his ear to prevent tragic harm coming to his mother. Whatever further exploration reveals, Max and his family stand to benefit immensely from early detection and intervention.
 

Dr. McGowan is assistant professor of psychiatry and pediatrics at the Vermont Center for Children, Youth, and Families, University of Vermont Medical Center, Burlington. She had no relevant financial disclosures. Email Dr. McGowan at pdnews@mdedge.com.

Resources for providers and families*

UNSTUCK: An OCD Kids Movie. Featuring a 23-minute documentary film about children living with OCD, this website also is rich in OCD-related resources.

International OCD Foundation. Has information for families about OCD. Also has a resource directory for therapists, clinics, support groups, and other organizations specializing in OCD and related disorders in different geographic areas.

*Of note, both resources above include COVID-19-specific resources for those struggling with worsening OCD symptoms as a result of the pandemic.

References

1. Lewis’s Child and Adolescent Psychiatry: A Comprehensive Textbook, 4th ed. (Baltimore: Lippincott Williams & Wilkins, 2020, pp. 518-27).

2. J Amer Acad Child Adol Psychiatry. 2012;51(1):98-113.

3. J Clin. Invest. 2009;119(4):737-46.

4. Arch Dis Child. 2015;100(5):495-9.

5. J Develop Behav Pediatr. 2019 Jun;40(5):377-82.

6. Ann Clin Psychiatry. 2008 Oct-Dec;20(4):199-203.

Recognizing the presence of functional heartburn is vital to prevent unnecessary acid-suppressive therapy and invasive antireflux treatments, which are ineffective and “might even lead to harm,” cautions a new clinical practice update from the American Gastroenterological Association.

Proton pump inhibitors (PPIs) “have no therapeutic value in functional heartburn,” unless patients also have gastroesophageal reflux disease (GERD), Ronnie Fass, MD, of MetroHealth System in Cleveland, and coauthors wrote in Gastroenterology. If clinical work-up finds no clear evidence of GERD, “an attempt to discontinue PPI therapy is warranted,” they added. Likewise, antireflux surgery and endoscopic treatments for GERD “have no therapeutic benefit in functional heartburn and should not be recommended.” However, histamine₂ receptor antagonists (H₂RAs) “may have an independent benefit in functional heartburn from an esophageal pain modulatory effect.”

Heartburn consists of burning or discomfort that radiates retrosternally from the epigastrium. Patients may report reflux, regurgitation, chest pain or discomfort, fullness, water brash, belching, or a sour and bitter taste in the mouth. Functional heartburn is heartburn that persists after at least 3 months of maximal (double-dose) PPIs taken before meals. Confirming functional heartburn requires high-resolution manometry to rule out major esophageal motor disorders, esophageal endoscopy with biopsy to rule out structural abnormalities and mucosal disorders (e.g., erosive esophagitis, Barrett’s esophagus, and eosinophilic esophagitis), and either pH monitoring while off PPI therapy or pH-impedance monitoring on therapy if patients have proven GERD. According to the clinical practice update, pH studies should document physiological acid exposure in the distal esophagus that is unlinked to symptoms (i.e., both a negative symptom index and a negative symptom association probability).

Functional heartburn resembles GERD, but symptoms are unrelated to acid exposure. Balloon distension studies indicate that patients with functional heartburn experience both esophageal and rectal hypersensitivity. Anxiety and mood disorders also are highly prevalent, and patients “will likely not improve unless esophageal perception and underlying affective disorders are adequately managed,” Dr. Fass and coauthors emphasized.

In keeping with this approach, limited evidence from clinical trials supports the first-line use of neuromodulator therapies, including selective serotonin reuptake inhibitors, tricyclic antidepressants, the serotonin 4 receptor antagonist tegaserod, and H₂RAs (e.g., cimetidine, famotidine, nizatidine). The only SSRI studied thus far in functional heartburn is fluoxetine. In a placebo-controlled trial of patients with normal endoscopy and heartburn that had not responded to once-daily PPI therapy, 6 weeks of fluoxetine (20 mg daily) significantly outperformed double-dose omeprazole (P < .001) for the primary endpoint of heartburn-free days. “This superior therapeutic effect of fluoxetine was seen only in the subset of patients with a normal pH test,” the experts noted.

In another placebo-controlled trial, the neuromodulator tegaserod (a serotonin 5-HT₄ receptor partial agonist) significantly improved tolerance of esophageal pressure during balloon distension and significantly decreased heartburn, regurgitation, and associated distress among patients with functional heartburn. Melatonin, which “also has a pain modulatory effect in the gastrointestinal tract,” significantly improved symptom-related quality of life, compared with nortriptyline and placebo in a randomized, three-arm trial. The patients on melatonin received a 6-mg dose at bedtime for 3 months.

Acupuncture and hypnotherapy also have shown benefit in small studies of functional heartburn patients and may be appropriate as monotherapy or adjunctive treatment, according to the clinical practice update. In a small randomized study, 10 acupuncture sessions delivered over 4 weeks significantly improved daytime and nighttime heartburn and acid regurgitation scores, compared with double-dose PPI. “Mean general health score was significantly improved only in those receiving acupuncture,” the experts noted. Hypnotherapy, the only psychological intervention to have been studied in functional heartburn, was associated with significant improvements in symptoms, visceral anxiety, and quality of life in an uncontrolled study of nine patients.

Although the overall prevalence of functional heartburn is unclear, it has been detected in 21%-39% of PPI-refractory patients evaluated with pH-impedance monitoring, Dr. Fass and associates wrote. Because functional heartburn and GERD can co-occur, some patients with functional heartburn may develop long-term complications of GERD, such as Barrett’s esophagus or peptic stricture. However, the experts noted, “this is anticipated to be rare, and the vast majority of patients with functional heartburn will have compromised quality of life, rather than organic complications over time.

Dr. Fass reported receiving consulting, research, and speaking fees from Ironwood, Takeda, and Salix, among other pharmaceutical companies; Dr. Zerbib received consulting fees from Reckitt Benckiser; and Dr. Gyawali received teaching and consulting fees from Medtronic, Diversatek, and Ironwood.

SOURCE: Fass R et al. Gastroenterology. 2020 Feb 1. doi: 10.1053/j.gastro.2020.01.034.

This story was updated on 6/11/2020.

Recognizing the presence of functional heartburn is vital to prevent unnecessary acid-suppressive therapy and invasive antireflux treatments, which are ineffective and “might even lead to harm,” cautions a new clinical practice update from the American Gastroenterological Association.

Proton pump inhibitors (PPIs) “have no therapeutic value in functional heartburn,” unless patients also have gastroesophageal reflux disease (GERD), Ronnie Fass, MD, of MetroHealth System in Cleveland, and coauthors wrote in Gastroenterology. If clinical work-up finds no clear evidence of GERD, “an attempt to discontinue PPI therapy is warranted,” they added. Likewise, antireflux surgery and endoscopic treatments for GERD “have no therapeutic benefit in functional heartburn and should not be recommended.” However, histamine₂ receptor antagonists (H₂RAs) “may have an independent benefit in functional heartburn from an esophageal pain modulatory effect.”

Heartburn consists of burning or discomfort that radiates retrosternally from the epigastrium. Patients may report reflux, regurgitation, chest pain or discomfort, fullness, water brash, belching, or a sour and bitter taste in the mouth. Functional heartburn is heartburn that persists after at least 3 months of maximal (double-dose) PPIs taken before meals. Confirming functional heartburn requires high-resolution manometry to rule out major esophageal motor disorders, esophageal endoscopy with biopsy to rule out structural abnormalities and mucosal disorders (e.g., erosive esophagitis, Barrett’s esophagus, and eosinophilic esophagitis), and either pH monitoring while off PPI therapy or pH-impedance monitoring on therapy if patients have proven GERD. According to the clinical practice update, pH studies should document physiological acid exposure in the distal esophagus that is unlinked to symptoms (i.e., both a negative symptom index and a negative symptom association probability).

Functional heartburn resembles GERD, but symptoms are unrelated to acid exposure. Balloon distension studies indicate that patients with functional heartburn experience both esophageal and rectal hypersensitivity. Anxiety and mood disorders also are highly prevalent, and patients “will likely not improve unless esophageal perception and underlying affective disorders are adequately managed,” Dr. Fass and coauthors emphasized.

In keeping with this approach, limited evidence from clinical trials supports the first-line use of neuromodulator therapies, including selective serotonin reuptake inhibitors, tricyclic antidepressants, the serotonin 4 receptor antagonist tegaserod, and H₂RAs (e.g., cimetidine, famotidine, nizatidine). The only SSRI studied thus far in functional heartburn is fluoxetine. In a placebo-controlled trial of patients with normal endoscopy and heartburn that had not responded to once-daily PPI therapy, 6 weeks of fluoxetine (20 mg daily) significantly outperformed double-dose omeprazole (P < .001) for the primary endpoint of heartburn-free days. “This superior therapeutic effect of fluoxetine was seen only in the subset of patients with a normal pH test,” the experts noted.

In another placebo-controlled trial, the neuromodulator tegaserod (a serotonin 5-HT₄ receptor partial agonist) significantly improved tolerance of esophageal pressure during balloon distension and significantly decreased heartburn, regurgitation, and associated distress among patients with functional heartburn. Melatonin, which “also has a pain modulatory effect in the gastrointestinal tract,” significantly improved symptom-related quality of life, compared with nortriptyline and placebo in a randomized, three-arm trial. The patients on melatonin received a 6-mg dose at bedtime for 3 months.

Acupuncture and hypnotherapy also have shown benefit in small studies of functional heartburn patients and may be appropriate as monotherapy or adjunctive treatment, according to the clinical practice update. In a small randomized study, 10 acupuncture sessions delivered over 4 weeks significantly improved daytime and nighttime heartburn and acid regurgitation scores, compared with double-dose PPI. “Mean general health score was significantly improved only in those receiving acupuncture,” the experts noted. Hypnotherapy, the only psychological intervention to have been studied in functional heartburn, was associated with significant improvements in symptoms, visceral anxiety, and quality of life in an uncontrolled study of nine patients.

Although the overall prevalence of functional heartburn is unclear, it has been detected in 21%-39% of PPI-refractory patients evaluated with pH-impedance monitoring, Dr. Fass and associates wrote. Because functional heartburn and GERD can co-occur, some patients with functional heartburn may develop long-term complications of GERD, such as Barrett’s esophagus or peptic stricture. However, the experts noted, “this is anticipated to be rare, and the vast majority of patients with functional heartburn will have compromised quality of life, rather than organic complications over time.

Dr. Fass reported receiving consulting, research, and speaking fees from Ironwood, Takeda, and Salix, among other pharmaceutical companies; Dr. Zerbib received consulting fees from Reckitt Benckiser; and Dr. Gyawali received teaching and consulting fees from Medtronic, Diversatek, and Ironwood.

SOURCE: Fass R et al. Gastroenterology. 2020 Feb 1. doi: 10.1053/j.gastro.2020.01.034.

This story was updated on 6/11/2020.

Recognizing the presence of functional heartburn is vital to prevent unnecessary acid-suppressive therapy and invasive antireflux treatments, which are ineffective and “might even lead to harm,” cautions a new clinical practice update from the American Gastroenterological Association.

Proton pump inhibitors (PPIs) “have no therapeutic value in functional heartburn,” unless patients also have gastroesophageal reflux disease (GERD), Ronnie Fass, MD, of MetroHealth System in Cleveland, and coauthors wrote in Gastroenterology. If clinical work-up finds no clear evidence of GERD, “an attempt to discontinue PPI therapy is warranted,” they added. Likewise, antireflux surgery and endoscopic treatments for GERD “have no therapeutic benefit in functional heartburn and should not be recommended.” However, histamine₂ receptor antagonists (H₂RAs) “may have an independent benefit in functional heartburn from an esophageal pain modulatory effect.”

Heartburn consists of burning or discomfort that radiates retrosternally from the epigastrium. Patients may report reflux, regurgitation, chest pain or discomfort, fullness, water brash, belching, or a sour and bitter taste in the mouth. Functional heartburn is heartburn that persists after at least 3 months of maximal (double-dose) PPIs taken before meals. Confirming functional heartburn requires high-resolution manometry to rule out major esophageal motor disorders, esophageal endoscopy with biopsy to rule out structural abnormalities and mucosal disorders (e.g., erosive esophagitis, Barrett’s esophagus, and eosinophilic esophagitis), and either pH monitoring while off PPI therapy or pH-impedance monitoring on therapy if patients have proven GERD. According to the clinical practice update, pH studies should document physiological acid exposure in the distal esophagus that is unlinked to symptoms (i.e., both a negative symptom index and a negative symptom association probability).

Functional heartburn resembles GERD, but symptoms are unrelated to acid exposure. Balloon distension studies indicate that patients with functional heartburn experience both esophageal and rectal hypersensitivity. Anxiety and mood disorders also are highly prevalent, and patients “will likely not improve unless esophageal perception and underlying affective disorders are adequately managed,” Dr. Fass and coauthors emphasized.

In keeping with this approach, limited evidence from clinical trials supports the first-line use of neuromodulator therapies, including selective serotonin reuptake inhibitors, tricyclic antidepressants, the serotonin 4 receptor antagonist tegaserod, and H₂RAs (e.g., cimetidine, famotidine, nizatidine). The only SSRI studied thus far in functional heartburn is fluoxetine. In a placebo-controlled trial of patients with normal endoscopy and heartburn that had not responded to once-daily PPI therapy, 6 weeks of fluoxetine (20 mg daily) significantly outperformed double-dose omeprazole (P < .001) for the primary endpoint of heartburn-free days. “This superior therapeutic effect of fluoxetine was seen only in the subset of patients with a normal pH test,” the experts noted.

In another placebo-controlled trial, the neuromodulator tegaserod (a serotonin 5-HT₄ receptor partial agonist) significantly improved tolerance of esophageal pressure during balloon distension and significantly decreased heartburn, regurgitation, and associated distress among patients with functional heartburn. Melatonin, which “also has a pain modulatory effect in the gastrointestinal tract,” significantly improved symptom-related quality of life, compared with nortriptyline and placebo in a randomized, three-arm trial. The patients on melatonin received a 6-mg dose at bedtime for 3 months.

Acupuncture and hypnotherapy also have shown benefit in small studies of functional heartburn patients and may be appropriate as monotherapy or adjunctive treatment, according to the clinical practice update. In a small randomized study, 10 acupuncture sessions delivered over 4 weeks significantly improved daytime and nighttime heartburn and acid regurgitation scores, compared with double-dose PPI. “Mean general health score was significantly improved only in those receiving acupuncture,” the experts noted. Hypnotherapy, the only psychological intervention to have been studied in functional heartburn, was associated with significant improvements in symptoms, visceral anxiety, and quality of life in an uncontrolled study of nine patients.

Although the overall prevalence of functional heartburn is unclear, it has been detected in 21%-39% of PPI-refractory patients evaluated with pH-impedance monitoring, Dr. Fass and associates wrote. Because functional heartburn and GERD can co-occur, some patients with functional heartburn may develop long-term complications of GERD, such as Barrett’s esophagus or peptic stricture. However, the experts noted, “this is anticipated to be rare, and the vast majority of patients with functional heartburn will have compromised quality of life, rather than organic complications over time.

Dr. Fass reported receiving consulting, research, and speaking fees from Ironwood, Takeda, and Salix, among other pharmaceutical companies; Dr. Zerbib received consulting fees from Reckitt Benckiser; and Dr. Gyawali received teaching and consulting fees from Medtronic, Diversatek, and Ironwood.

SOURCE: Fass R et al. Gastroenterology. 2020 Feb 1. doi: 10.1053/j.gastro.2020.01.034.

This story was updated on 6/11/2020.

Mental illnesses are associated with a significantly increased risk of subsequent physical diseases, new research shows.

An international team of researchers has created an “atlas” that maps the relationship between specific mental disorders and the risk of subsequent physical illnesses.

The researchers found that, following the diagnosis of a mental disorder, psychiatric patients are significantly more likely than the general population to develop potentially life-threatening conditions, including heart disease and stroke.

These findings, the investigators noted, highlight the need for better medical care in this vulnerable population. They have created a website with detailed information about the risks of specific physical ailments and the link to particular mental disorders.

“We found that women with anxiety disorders have a 50% increased risk of developing a heart condition or stroke – over 15 years, one in three women with anxiety disorders will develop these medical disorders,” lead investigator John McGrath, MD, PhD, University of Queensland’s Brain Institute, Brisbane, Australia, and Aarhus (Denmark) University, said in a statement.

“We also looked at men with substance use disorders such as alcohol-related disorders and found they have a 400% increased risk of gut or liver disorders, while over 15 years, one in five of them will develop gut or liver conditions,” he added.

The study was published in the New England Journal of Medicine.
 

New ‘atlas’

It’s well known that patients with mental disorders have decreased quality of life, increased health care utilization, and a shorter life expectancy than individuals in the general population – about 10 years for men and 7 years for women.

However, the investigators noted, previous research examining the relationship between mental disorders and medical conditions only focused on “particular pairs or a small set of mental disorders and medical conditions.”

“We needed a comprehensive study to map the links between different types of mental disorders versus different types of general medical conditions. Our study has provided this atlas,” Dr. McGrath said in an interview.

The clinical utility of such a map could provide comprehensive data on relative and absolute risks of various medical conditions after a diagnosis of a mental disorder. This information, the researchers noted, would “help clinicians and health care planners identify the primary prevention needs of their patients.”

The study included 5.9 million people born in Denmark between 1900 and 2015 and followed them from 2000 to 2016, a total of 83.9 million person-years. The researchers followed patients for up to 17 years (2000-2016) for medical diagnoses and up to 48 years (1969-2016) for diagnoses of mental disorders.

The study’s large sample size allowed investigators to assess 10 broad types of mental disorders and 9 broad categories of medical conditions that encompassed 31 specific conditions.

Categories of medical conditions included circulatory, endocrine, pulmonary, gastrointestinal, urogenital, musculoskeletal, hematologic, neurologic, and cancer. Mental disorder categories included organic disorders such as Alzheimer’s, substance abuse disorders, schizophrenia, mood disorders, neurotic disorders, eating disorders, personality disorders, developmental disorders, behavioral/emotional disorders, and intellectual disabilities.

The researchers estimated associations between 90 pairs of mental disorders and broad-category medical conditions, as well as 310 pairs of mental disorders and specific medical conditions.
 

‘Curious’ finding

Individuals with mental disorders showed a higher risk of medical conditions in 76 out of 90 specific mental disorder–medical condition pairs.

After adjusting for sex, age, calendar time, and previous coexisting mental disorders, the median hazard ratio for a subsequent medical condition was 1.37 in patients with a mental disorder.

The lowest HR was 0.82 for organic mental disorders and the broad category of cancer (95% confidence interval, 0.80-0.84), and the highest was 3.62 for eating disorders and urogenital conditions (95% CI, 3.11-4.22). On the other hand, schizophrenia was associated with a reduced risk of developing musculoskeletal conditions (HR, 0.87; 95% CI, 0.84-0.91).

Dr. McGrath described this finding as “curious” and speculated it “may be related to underlying genetic risk factors.”

One of the highest cumulative associations was for mood disorders and circulatory conditions during the first 15 years following a mood disorder diagnosis, compared with the matched reference group without a mood disorder (40.9% vs. 32.6%, respectively).

The risk of developing subsequent medical conditions after a mental disorder diagnosis did not remain steady over time. For instance, although mood disorders were associated with an increased risk of developing circulatory problems (HR, 1.32; 95% CI, 1.31-1.34), the highest risk occurred during the first 6 months following diagnosis and gradually decreased over the next 15 years (HR, 2.39; 95% CI, 2.29-2.48 and HR, 1.18; 95% CI, 1.17-1.20, respectively).

“Many people with mental disorders have unhealthy lifestyle, including low exercise, poor diet, smoking, and alcohol, which may account for the increased risk of physical illness, and also they may not seek and/or may not get quick treatment for their health conditions,” said Dr. McGrath.

Additionally, “perhaps some genetic and early life exposures, such as trauma, may increase the risk of both medical conditions and mental disorders,” he added. “We need better treatments for mental disorders, so that they do not slip into unemployment or poverty.”
 

A strong case

In a comment, Roger McIntyre, MD, professor of psychiatry and pharmacology at the University of Toronto and head of the mood disorders psychopharmacology unit, University Health Network, said that the research “really makes a strong case for the fact that persons who have mental disorders are at higher risk of chronic diseases, and it’s the chronic diseases that decrease their lifespan.”

Dr. McIntyre, who is also director of the Depression and Bipolar Support Alliance, said that the “takeaway message is that mental disorders are not just brain disorders but are multisystem disorders.”

For this reason, “the most appropriate way to provide care would be to provide a holistic approach to treat and prevent the chronic diseases that lead to increase in mortality,” recommended Dr. McIntyre, who was not involved with the current study.

The study was supported by grants from the Danish National Research Foundation, the National Health and Medical Research Council, the Novo Nordisk Foundation , the European Union’s Horizon 2020 Research and Innovation Program, the Aarhus University Research Foundation, the Lundbeck Foundation, the National Institutes of Health, the European Commission, Helsefonden, the Danish Council for Independent Research, the Independent Research Fund Denmark, the National Health and Medical Research Council of Australia, and the National Institute on Drug Abuse.

Dr. McGrath has disclosed no relevant financial relationships. The other authors’ disclosures are listed on the original paper. Dr. McIntyre reports receiving grants from Stanley Medical Research Institute; the Canadian Institutes of Health Research/Global Alliance for Chronic Diseases/Chinese National Natural Research Foundation; and receiving speaking/consultation fees from Lundbeck, Janssen, Shire, Purdue, Pfizer, Otsuka, Allergan, Takeda, Neurocrine, Sunovion, and Minerva.

A version of this article originally appeared on Medscape.com.

Mental illnesses are associated with a significantly increased risk of subsequent physical diseases, new research shows.

An international team of researchers has created an “atlas” that maps the relationship between specific mental disorders and the risk of subsequent physical illnesses.

The researchers found that, following the diagnosis of a mental disorder, psychiatric patients are significantly more likely than the general population to develop potentially life-threatening conditions, including heart disease and stroke.

These findings, the investigators noted, highlight the need for better medical care in this vulnerable population. They have created a website with detailed information about the risks of specific physical ailments and the link to particular mental disorders.

“We found that women with anxiety disorders have a 50% increased risk of developing a heart condition or stroke – over 15 years, one in three women with anxiety disorders will develop these medical disorders,” lead investigator John McGrath, MD, PhD, University of Queensland’s Brain Institute, Brisbane, Australia, and Aarhus (Denmark) University, said in a statement.

“We also looked at men with substance use disorders such as alcohol-related disorders and found they have a 400% increased risk of gut or liver disorders, while over 15 years, one in five of them will develop gut or liver conditions,” he added.

The study was published in the New England Journal of Medicine.
 

New ‘atlas’

It’s well known that patients with mental disorders have decreased quality of life, increased health care utilization, and a shorter life expectancy than individuals in the general population – about 10 years for men and 7 years for women.

However, the investigators noted, previous research examining the relationship between mental disorders and medical conditions only focused on “particular pairs or a small set of mental disorders and medical conditions.”

“We needed a comprehensive study to map the links between different types of mental disorders versus different types of general medical conditions. Our study has provided this atlas,” Dr. McGrath said in an interview.

The clinical utility of such a map could provide comprehensive data on relative and absolute risks of various medical conditions after a diagnosis of a mental disorder. This information, the researchers noted, would “help clinicians and health care planners identify the primary prevention needs of their patients.”

The study included 5.9 million people born in Denmark between 1900 and 2015 and followed them from 2000 to 2016, a total of 83.9 million person-years. The researchers followed patients for up to 17 years (2000-2016) for medical diagnoses and up to 48 years (1969-2016) for diagnoses of mental disorders.

The study’s large sample size allowed investigators to assess 10 broad types of mental disorders and 9 broad categories of medical conditions that encompassed 31 specific conditions.

Categories of medical conditions included circulatory, endocrine, pulmonary, gastrointestinal, urogenital, musculoskeletal, hematologic, neurologic, and cancer. Mental disorder categories included organic disorders such as Alzheimer’s, substance abuse disorders, schizophrenia, mood disorders, neurotic disorders, eating disorders, personality disorders, developmental disorders, behavioral/emotional disorders, and intellectual disabilities.

The researchers estimated associations between 90 pairs of mental disorders and broad-category medical conditions, as well as 310 pairs of mental disorders and specific medical conditions.
 

‘Curious’ finding

Individuals with mental disorders showed a higher risk of medical conditions in 76 out of 90 specific mental disorder–medical condition pairs.

After adjusting for sex, age, calendar time, and previous coexisting mental disorders, the median hazard ratio for a subsequent medical condition was 1.37 in patients with a mental disorder.

The lowest HR was 0.82 for organic mental disorders and the broad category of cancer (95% confidence interval, 0.80-0.84), and the highest was 3.62 for eating disorders and urogenital conditions (95% CI, 3.11-4.22). On the other hand, schizophrenia was associated with a reduced risk of developing musculoskeletal conditions (HR, 0.87; 95% CI, 0.84-0.91).

Dr. McGrath described this finding as “curious” and speculated it “may be related to underlying genetic risk factors.”

One of the highest cumulative associations was for mood disorders and circulatory conditions during the first 15 years following a mood disorder diagnosis, compared with the matched reference group without a mood disorder (40.9% vs. 32.6%, respectively).

The risk of developing subsequent medical conditions after a mental disorder diagnosis did not remain steady over time. For instance, although mood disorders were associated with an increased risk of developing circulatory problems (HR, 1.32; 95% CI, 1.31-1.34), the highest risk occurred during the first 6 months following diagnosis and gradually decreased over the next 15 years (HR, 2.39; 95% CI, 2.29-2.48 and HR, 1.18; 95% CI, 1.17-1.20, respectively).

“Many people with mental disorders have unhealthy lifestyle, including low exercise, poor diet, smoking, and alcohol, which may account for the increased risk of physical illness, and also they may not seek and/or may not get quick treatment for their health conditions,” said Dr. McGrath.

Additionally, “perhaps some genetic and early life exposures, such as trauma, may increase the risk of both medical conditions and mental disorders,” he added. “We need better treatments for mental disorders, so that they do not slip into unemployment or poverty.”
 

A strong case

In a comment, Roger McIntyre, MD, professor of psychiatry and pharmacology at the University of Toronto and head of the mood disorders psychopharmacology unit, University Health Network, said that the research “really makes a strong case for the fact that persons who have mental disorders are at higher risk of chronic diseases, and it’s the chronic diseases that decrease their lifespan.”

Dr. McIntyre, who is also director of the Depression and Bipolar Support Alliance, said that the “takeaway message is that mental disorders are not just brain disorders but are multisystem disorders.”

For this reason, “the most appropriate way to provide care would be to provide a holistic approach to treat and prevent the chronic diseases that lead to increase in mortality,” recommended Dr. McIntyre, who was not involved with the current study.

The study was supported by grants from the Danish National Research Foundation, the National Health and Medical Research Council, the Novo Nordisk Foundation , the European Union’s Horizon 2020 Research and Innovation Program, the Aarhus University Research Foundation, the Lundbeck Foundation, the National Institutes of Health, the European Commission, Helsefonden, the Danish Council for Independent Research, the Independent Research Fund Denmark, the National Health and Medical Research Council of Australia, and the National Institute on Drug Abuse.

Dr. McGrath has disclosed no relevant financial relationships. The other authors’ disclosures are listed on the original paper. Dr. McIntyre reports receiving grants from Stanley Medical Research Institute; the Canadian Institutes of Health Research/Global Alliance for Chronic Diseases/Chinese National Natural Research Foundation; and receiving speaking/consultation fees from Lundbeck, Janssen, Shire, Purdue, Pfizer, Otsuka, Allergan, Takeda, Neurocrine, Sunovion, and Minerva.

A version of this article originally appeared on Medscape.com.

Mental illnesses are associated with a significantly increased risk of subsequent physical diseases, new research shows.

An international team of researchers has created an “atlas” that maps the relationship between specific mental disorders and the risk of subsequent physical illnesses.

The researchers found that, following the diagnosis of a mental disorder, psychiatric patients are significantly more likely than the general population to develop potentially life-threatening conditions, including heart disease and stroke.

These findings, the investigators noted, highlight the need for better medical care in this vulnerable population. They have created a website with detailed information about the risks of specific physical ailments and the link to particular mental disorders.

“We found that women with anxiety disorders have a 50% increased risk of developing a heart condition or stroke – over 15 years, one in three women with anxiety disorders will develop these medical disorders,” lead investigator John McGrath, MD, PhD, University of Queensland’s Brain Institute, Brisbane, Australia, and Aarhus (Denmark) University, said in a statement.

“We also looked at men with substance use disorders such as alcohol-related disorders and found they have a 400% increased risk of gut or liver disorders, while over 15 years, one in five of them will develop gut or liver conditions,” he added.

The study was published in the New England Journal of Medicine.
 

New ‘atlas’

It’s well known that patients with mental disorders have decreased quality of life, increased health care utilization, and a shorter life expectancy than individuals in the general population – about 10 years for men and 7 years for women.

However, the investigators noted, previous research examining the relationship between mental disorders and medical conditions only focused on “particular pairs or a small set of mental disorders and medical conditions.”

“We needed a comprehensive study to map the links between different types of mental disorders versus different types of general medical conditions. Our study has provided this atlas,” Dr. McGrath said in an interview.

The clinical utility of such a map could provide comprehensive data on relative and absolute risks of various medical conditions after a diagnosis of a mental disorder. This information, the researchers noted, would “help clinicians and health care planners identify the primary prevention needs of their patients.”

The study included 5.9 million people born in Denmark between 1900 and 2015 and followed them from 2000 to 2016, a total of 83.9 million person-years. The researchers followed patients for up to 17 years (2000-2016) for medical diagnoses and up to 48 years (1969-2016) for diagnoses of mental disorders.

The study’s large sample size allowed investigators to assess 10 broad types of mental disorders and 9 broad categories of medical conditions that encompassed 31 specific conditions.

Categories of medical conditions included circulatory, endocrine, pulmonary, gastrointestinal, urogenital, musculoskeletal, hematologic, neurologic, and cancer. Mental disorder categories included organic disorders such as Alzheimer’s, substance abuse disorders, schizophrenia, mood disorders, neurotic disorders, eating disorders, personality disorders, developmental disorders, behavioral/emotional disorders, and intellectual disabilities.

The researchers estimated associations between 90 pairs of mental disorders and broad-category medical conditions, as well as 310 pairs of mental disorders and specific medical conditions.
 

‘Curious’ finding

Individuals with mental disorders showed a higher risk of medical conditions in 76 out of 90 specific mental disorder–medical condition pairs.

After adjusting for sex, age, calendar time, and previous coexisting mental disorders, the median hazard ratio for a subsequent medical condition was 1.37 in patients with a mental disorder.

The lowest HR was 0.82 for organic mental disorders and the broad category of cancer (95% confidence interval, 0.80-0.84), and the highest was 3.62 for eating disorders and urogenital conditions (95% CI, 3.11-4.22). On the other hand, schizophrenia was associated with a reduced risk of developing musculoskeletal conditions (HR, 0.87; 95% CI, 0.84-0.91).

Dr. McGrath described this finding as “curious” and speculated it “may be related to underlying genetic risk factors.”

One of the highest cumulative associations was for mood disorders and circulatory conditions during the first 15 years following a mood disorder diagnosis, compared with the matched reference group without a mood disorder (40.9% vs. 32.6%, respectively).

The risk of developing subsequent medical conditions after a mental disorder diagnosis did not remain steady over time. For instance, although mood disorders were associated with an increased risk of developing circulatory problems (HR, 1.32; 95% CI, 1.31-1.34), the highest risk occurred during the first 6 months following diagnosis and gradually decreased over the next 15 years (HR, 2.39; 95% CI, 2.29-2.48 and HR, 1.18; 95% CI, 1.17-1.20, respectively).

“Many people with mental disorders have unhealthy lifestyle, including low exercise, poor diet, smoking, and alcohol, which may account for the increased risk of physical illness, and also they may not seek and/or may not get quick treatment for their health conditions,” said Dr. McGrath.

Additionally, “perhaps some genetic and early life exposures, such as trauma, may increase the risk of both medical conditions and mental disorders,” he added. “We need better treatments for mental disorders, so that they do not slip into unemployment or poverty.”
 

A strong case

In a comment, Roger McIntyre, MD, professor of psychiatry and pharmacology at the University of Toronto and head of the mood disorders psychopharmacology unit, University Health Network, said that the research “really makes a strong case for the fact that persons who have mental disorders are at higher risk of chronic diseases, and it’s the chronic diseases that decrease their lifespan.”

Dr. McIntyre, who is also director of the Depression and Bipolar Support Alliance, said that the “takeaway message is that mental disorders are not just brain disorders but are multisystem disorders.”

For this reason, “the most appropriate way to provide care would be to provide a holistic approach to treat and prevent the chronic diseases that lead to increase in mortality,” recommended Dr. McIntyre, who was not involved with the current study.

The study was supported by grants from the Danish National Research Foundation, the National Health and Medical Research Council, the Novo Nordisk Foundation , the European Union’s Horizon 2020 Research and Innovation Program, the Aarhus University Research Foundation, the Lundbeck Foundation, the National Institutes of Health, the European Commission, Helsefonden, the Danish Council for Independent Research, the Independent Research Fund Denmark, the National Health and Medical Research Council of Australia, and the National Institute on Drug Abuse.

Dr. McGrath has disclosed no relevant financial relationships. The other authors’ disclosures are listed on the original paper. Dr. McIntyre reports receiving grants from Stanley Medical Research Institute; the Canadian Institutes of Health Research/Global Alliance for Chronic Diseases/Chinese National Natural Research Foundation; and receiving speaking/consultation fees from Lundbeck, Janssen, Shire, Purdue, Pfizer, Otsuka, Allergan, Takeda, Neurocrine, Sunovion, and Minerva.

A version of this article originally appeared on Medscape.com.

James V. Hennessey, MD, has been working from home, like so many others, since the lockdowns went into effect. The director of clinical endocrinology at Beth Israel Deaconess Medical Center in Boston has felt surprisingly heartened by his experience.

verbaska_studio/Getty Images

“So far, these [video-based] discussions have been reassuring,” he said in an interview. “The images generating the referral have been available for review, and we’ve been able to reassure the patients that there are no danger signs in their histories.” Dr. Hennessey noted that for patients who agree to thyroid nodule consultations via video consult, the arrangement has allowed for the assessment of difficulty swallowing and other obvious difficulties.

While Dr. Hennessey has not yet encountered anything serious during his virtual consults, such as a rapidly growing anaplastic thyroid cancer, “it will only take some time before we hear of one, I’m sure,” he observed.
 

Surprisingly productive

During the COVID-19 pandemic, many physicians have been forced to innovate and turn aspects of their practices virtual. Use of telehealth services has increased by 50% in the United States since the start of the pandemic, according to research by Frost and Sullivan consultants. Three endocrinologists report that telehealth, although not always ideal, may provide more information than expected.

Recent recommendations say physicians should defer biopsies of asymptomatic thyroid nodules until the risk for COVID-19 has passed. As a result, some patients may experience increased anxiety because of such delays. But cases determined to require more urgent care should not be delayed, says the guidance.

Trevor E. Angell, MD, concurred that it’s possible to safely defer thyroid nodule assessment. “I would agree that with appropriate risk stratification by symptom assessment, ultrasound, and lab testing, thyroid nodules can be safely triaged for delayed evaluation,” said Dr. Angell, an assistant professor of clinical medicine and associate medical director of the thyroid center at the University of Southern California, in Los Angeles.

“I have found that patients with thyroid nodules that are not highly suspicious are reasonably reassured that the delay in obtaining FNA [fine needle aspiration] is very unlikely to have an impact on the ultimate outcome,” he said in an interview.

But he does have concerns that many of the investigations needed to make a decision about whether treatment can be deferred are also on hold.

“In many settings, including my own institution, nonurgent radiology studies are not being performed,” he noted. And “patients are reluctant to go to an ultrasound evaluation or a laboratory to perform testing” because of worries about COVID-19. “For possible thyroid nodules that have not yet been evaluated, this presents difficulty in getting the accurate ultrasound risk stratification and/or calcitonin testing that would help determine the need for immediate FNA biopsy or surgical consideration.”

And for patients in whom surgery has already been recommended, because of “indeterminate FNA cytology or suspicious molecular test result,” there is likely to be even more anxiety, Dr. Angell said.
 

“Most patients happy” with video visits

Victor J. Bernet, MD, American Thyroid Association president-elect, noted that, while his practice already had planned to start doing some video visits in April, the process was by necessity jump-started in March.

“Currently, about 90%-95% of our appointments are video visit or phone-call based,” he said in an interview. “Most patients seem to actually be happy with the video visit experience,” he said. “Some patients were very happy that they were given the opportunity to not have to come into the clinic in person at this point in time.”

Dr. Bernet agreed that video consults can be productive in identifying some important clinical information. “I have had at least a few patients with obvious goiter or nodule,” said Dr. Bernet, an associate professor and chair of the division of endocrinology at the Mayo Clinic in Jacksonville, Fla. “I also had a patient with hyperthyroidism from Graves disease and we were able to assess her for tremor over video.”

In the latter case, “we had the patient place a sheet of paper on the top of her hand while her arm was extended, which is the technique that can be used in person as well, and helps amplify the ability to detect if a fine tremor is present.”

“It was obvious that this patient had a tremor by video,” Dr. Bernet said.

In addition to tremor, video visits can be helpful in “looking for the presence of thyroid eye disease, enlarged thyroid, and possibly even skin changes.” Video may also be useful in evaluating respiratory effort and some cognitive behaviors, Dr. Bernet noted.

Starting to think about elective procedures again

As centers in the United States begin to reopen and permit elective procedures again, patients being considered for FNAs will likely be reintroduced according to the level of need, Dr. Hennessey noted. “Those with clear indications for FNA will be the first (to be scheduled),” while those who had very-low-risk findings, such as small nodules and cysts, “have already been deferred to 6- or 12-month follow-up ultrasounds, and decisions regarding FNAs will be made based on clinical course.”

Dr. Angell agrees that efforts to address the most urgent cases once centers reopen will be of the utmost importance. “To the greatest extent possible, providers should work together to coordinate the rescheduling of patients for FNA or surgery to avoid any further delay for those at most risk,” he said.Dr. Hennessey, Dr. Angell, and Dr. Bernet have disclosed no relevant financial relationships.

A version of this article first appeared on Medscape.com.

James V. Hennessey, MD, has been working from home, like so many others, since the lockdowns went into effect. The director of clinical endocrinology at Beth Israel Deaconess Medical Center in Boston has felt surprisingly heartened by his experience.

verbaska_studio/Getty Images

“So far, these [video-based] discussions have been reassuring,” he said in an interview. “The images generating the referral have been available for review, and we’ve been able to reassure the patients that there are no danger signs in their histories.” Dr. Hennessey noted that for patients who agree to thyroid nodule consultations via video consult, the arrangement has allowed for the assessment of difficulty swallowing and other obvious difficulties.

While Dr. Hennessey has not yet encountered anything serious during his virtual consults, such as a rapidly growing anaplastic thyroid cancer, “it will only take some time before we hear of one, I’m sure,” he observed.
 

Surprisingly productive

During the COVID-19 pandemic, many physicians have been forced to innovate and turn aspects of their practices virtual. Use of telehealth services has increased by 50% in the United States since the start of the pandemic, according to research by Frost and Sullivan consultants. Three endocrinologists report that telehealth, although not always ideal, may provide more information than expected.

Recent recommendations say physicians should defer biopsies of asymptomatic thyroid nodules until the risk for COVID-19 has passed. As a result, some patients may experience increased anxiety because of such delays. But cases determined to require more urgent care should not be delayed, says the guidance.

Trevor E. Angell, MD, concurred that it’s possible to safely defer thyroid nodule assessment. “I would agree that with appropriate risk stratification by symptom assessment, ultrasound, and lab testing, thyroid nodules can be safely triaged for delayed evaluation,” said Dr. Angell, an assistant professor of clinical medicine and associate medical director of the thyroid center at the University of Southern California, in Los Angeles.

“I have found that patients with thyroid nodules that are not highly suspicious are reasonably reassured that the delay in obtaining FNA [fine needle aspiration] is very unlikely to have an impact on the ultimate outcome,” he said in an interview.

But he does have concerns that many of the investigations needed to make a decision about whether treatment can be deferred are also on hold.

“In many settings, including my own institution, nonurgent radiology studies are not being performed,” he noted. And “patients are reluctant to go to an ultrasound evaluation or a laboratory to perform testing” because of worries about COVID-19. “For possible thyroid nodules that have not yet been evaluated, this presents difficulty in getting the accurate ultrasound risk stratification and/or calcitonin testing that would help determine the need for immediate FNA biopsy or surgical consideration.”

And for patients in whom surgery has already been recommended, because of “indeterminate FNA cytology or suspicious molecular test result,” there is likely to be even more anxiety, Dr. Angell said.
 

“Most patients happy” with video visits

Victor J. Bernet, MD, American Thyroid Association president-elect, noted that, while his practice already had planned to start doing some video visits in April, the process was by necessity jump-started in March.

“Currently, about 90%-95% of our appointments are video visit or phone-call based,” he said in an interview. “Most patients seem to actually be happy with the video visit experience,” he said. “Some patients were very happy that they were given the opportunity to not have to come into the clinic in person at this point in time.”

Dr. Bernet agreed that video consults can be productive in identifying some important clinical information. “I have had at least a few patients with obvious goiter or nodule,” said Dr. Bernet, an associate professor and chair of the division of endocrinology at the Mayo Clinic in Jacksonville, Fla. “I also had a patient with hyperthyroidism from Graves disease and we were able to assess her for tremor over video.”

In the latter case, “we had the patient place a sheet of paper on the top of her hand while her arm was extended, which is the technique that can be used in person as well, and helps amplify the ability to detect if a fine tremor is present.”

“It was obvious that this patient had a tremor by video,” Dr. Bernet said.

In addition to tremor, video visits can be helpful in “looking for the presence of thyroid eye disease, enlarged thyroid, and possibly even skin changes.” Video may also be useful in evaluating respiratory effort and some cognitive behaviors, Dr. Bernet noted.

Starting to think about elective procedures again

As centers in the United States begin to reopen and permit elective procedures again, patients being considered for FNAs will likely be reintroduced according to the level of need, Dr. Hennessey noted. “Those with clear indications for FNA will be the first (to be scheduled),” while those who had very-low-risk findings, such as small nodules and cysts, “have already been deferred to 6- or 12-month follow-up ultrasounds, and decisions regarding FNAs will be made based on clinical course.”

Dr. Angell agrees that efforts to address the most urgent cases once centers reopen will be of the utmost importance. “To the greatest extent possible, providers should work together to coordinate the rescheduling of patients for FNA or surgery to avoid any further delay for those at most risk,” he said.Dr. Hennessey, Dr. Angell, and Dr. Bernet have disclosed no relevant financial relationships.

A version of this article first appeared on Medscape.com.

James V. Hennessey, MD, has been working from home, like so many others, since the lockdowns went into effect. The director of clinical endocrinology at Beth Israel Deaconess Medical Center in Boston has felt surprisingly heartened by his experience.

verbaska_studio/Getty Images

“So far, these [video-based] discussions have been reassuring,” he said in an interview. “The images generating the referral have been available for review, and we’ve been able to reassure the patients that there are no danger signs in their histories.” Dr. Hennessey noted that for patients who agree to thyroid nodule consultations via video consult, the arrangement has allowed for the assessment of difficulty swallowing and other obvious difficulties.

While Dr. Hennessey has not yet encountered anything serious during his virtual consults, such as a rapidly growing anaplastic thyroid cancer, “it will only take some time before we hear of one, I’m sure,” he observed.
 

Surprisingly productive

During the COVID-19 pandemic, many physicians have been forced to innovate and turn aspects of their practices virtual. Use of telehealth services has increased by 50% in the United States since the start of the pandemic, according to research by Frost and Sullivan consultants. Three endocrinologists report that telehealth, although not always ideal, may provide more information than expected.

Recent recommendations say physicians should defer biopsies of asymptomatic thyroid nodules until the risk for COVID-19 has passed. As a result, some patients may experience increased anxiety because of such delays. But cases determined to require more urgent care should not be delayed, says the guidance.

Trevor E. Angell, MD, concurred that it’s possible to safely defer thyroid nodule assessment. “I would agree that with appropriate risk stratification by symptom assessment, ultrasound, and lab testing, thyroid nodules can be safely triaged for delayed evaluation,” said Dr. Angell, an assistant professor of clinical medicine and associate medical director of the thyroid center at the University of Southern California, in Los Angeles.

“I have found that patients with thyroid nodules that are not highly suspicious are reasonably reassured that the delay in obtaining FNA [fine needle aspiration] is very unlikely to have an impact on the ultimate outcome,” he said in an interview.

But he does have concerns that many of the investigations needed to make a decision about whether treatment can be deferred are also on hold.

“In many settings, including my own institution, nonurgent radiology studies are not being performed,” he noted. And “patients are reluctant to go to an ultrasound evaluation or a laboratory to perform testing” because of worries about COVID-19. “For possible thyroid nodules that have not yet been evaluated, this presents difficulty in getting the accurate ultrasound risk stratification and/or calcitonin testing that would help determine the need for immediate FNA biopsy or surgical consideration.”

And for patients in whom surgery has already been recommended, because of “indeterminate FNA cytology or suspicious molecular test result,” there is likely to be even more anxiety, Dr. Angell said.
 

“Most patients happy” with video visits

Victor J. Bernet, MD, American Thyroid Association president-elect, noted that, while his practice already had planned to start doing some video visits in April, the process was by necessity jump-started in March.

“Currently, about 90%-95% of our appointments are video visit or phone-call based,” he said in an interview. “Most patients seem to actually be happy with the video visit experience,” he said. “Some patients were very happy that they were given the opportunity to not have to come into the clinic in person at this point in time.”

Dr. Bernet agreed that video consults can be productive in identifying some important clinical information. “I have had at least a few patients with obvious goiter or nodule,” said Dr. Bernet, an associate professor and chair of the division of endocrinology at the Mayo Clinic in Jacksonville, Fla. “I also had a patient with hyperthyroidism from Graves disease and we were able to assess her for tremor over video.”

In the latter case, “we had the patient place a sheet of paper on the top of her hand while her arm was extended, which is the technique that can be used in person as well, and helps amplify the ability to detect if a fine tremor is present.”

“It was obvious that this patient had a tremor by video,” Dr. Bernet said.

In addition to tremor, video visits can be helpful in “looking for the presence of thyroid eye disease, enlarged thyroid, and possibly even skin changes.” Video may also be useful in evaluating respiratory effort and some cognitive behaviors, Dr. Bernet noted.

Starting to think about elective procedures again

As centers in the United States begin to reopen and permit elective procedures again, patients being considered for FNAs will likely be reintroduced according to the level of need, Dr. Hennessey noted. “Those with clear indications for FNA will be the first (to be scheduled),” while those who had very-low-risk findings, such as small nodules and cysts, “have already been deferred to 6- or 12-month follow-up ultrasounds, and decisions regarding FNAs will be made based on clinical course.”

Dr. Angell agrees that efforts to address the most urgent cases once centers reopen will be of the utmost importance. “To the greatest extent possible, providers should work together to coordinate the rescheduling of patients for FNA or surgery to avoid any further delay for those at most risk,” he said.Dr. Hennessey, Dr. Angell, and Dr. Bernet have disclosed no relevant financial relationships.

A version of this article first appeared on Medscape.com.

Over the last several weeks, hospitals and health systems have focused on the COVID-19 epidemic, preparing and expanding bed capacities for the surge of admissions both in intensive care and medical units. An indirect impact of this has been the reduction in outpatient staffing and resources, with the shifting of staff for inpatient care. Many areas seem to have passed the peak in the number of cases and are now seeing a plateau or downward trend in the admissions to acute care facilities.

During this period, there has been a noticeable downtrend in patients being evaluated in the ED, or admitted for decompensation of chronic conditions like heart failure, COPD and diabetes mellitus, or such acute conditions as stroke and MI. Studies from Italy and Spain, and closer to home from Atlanta and Boston, point to a significant decrease in numbers of ST-elevation myocardial infarction (STEMI) admissions.¹ Duke Health saw a decrease in stroke admissions in their hospitals by 34%.²

One could argue that these patients are in fact presenting with COVID-19 or similar symptoms as is evidenced by the studies linking the severity of SARS-Co-V2 infection to chronic conditions like diabetes mellitus and obesity.² On the other hand, the message of social isolation and avoidance of nonurgent visits could lead to delays in care resulting in patients presenting sicker and in advanced stages.³ Also, this has not been limited to the adult population. For example, reports indicate that visits to WakeMed’s pediatric emergency rooms in Wake County, N.C., were down by 60%.²

We could well be seeing a calm before the storm. While it is anticipated that there may be a second surge of COVID-19 cases, health systems would do well to be prepared for the “third surge,” consisting of patients coming in with chronic medical conditions for which they have been, so far, avoiding follow-up and managing at home, and acute medical conditions with delayed diagnoses. The impact could likely be more in the subset of patients with limited access to health care, including medications and follow-up, resulting in a disproportionate burden on safety-net hospitals.

Compounding this issue would be the economic impact of the current crisis on health systems, their staffing, and resources. Several major organizations have already proposed budget cuts and reduction of the workforce, raising significant concerns about the future of health care workers who put their lives at risk during this pandemic.⁴ There is no guarantee that the federal funding provided by the stimulus packages will save jobs in the health care industry. This problem needs new leadership thinking, and every organization that puts employees over profits margins will have a long-term impact on communities.

Another area of concern is a shift in resources and workflow from ambulatory to inpatient settings for the COVID-19 pandemic, and the need for revamping the ambulatory services with reshifting the workforce. As COVID-19 cases plateau, the resurgence of non-COVID–related admissions will require additional help in inpatient settings. Prioritizing the ambulatory services based on financial benefits versus patient outcomes is also a major challenge to leadership.⁵

Lastly, the current health care crisis has led to significant stress, both emotional and physical, among frontline caregivers, increasing the risk of burnout.⁶ How leadership helps health care workers to cope with these stressors, and the resources they provide, is going to play a key role in long term retention of their talent, and will reflect on the organizational culture. Though it might seem trivial, posttraumatic stress disorder related to this is already obvious, and health care leadership needs to put every effort in providing the resources to help prevent burnout, in partnership with national organizations like the Society of Hospital Medicine and the American College of Physicians.

The expansion of telemedicine has provided a unique opportunity to address several of these issues while maintaining the nonpharmacologic interventions to fight the epidemic, and keeping the cost curve as low as possible.⁷ Extension of these services to all ambulatory service lines, including home health and therapy, is the next big step in the new health care era. Virtual check-ins by physicians, advance practice clinicians, and home care nurses could help alleviate the concerns regarding delays in care of patients with chronic conditions, and help identify those at risk. This would also be of help with staffing shortages, and possibly provide much needed support to frontline providers.

Dr. Prasad is currently medical director of care management and a hospitalist at Advocate Aurora Health in Milwaukee. He was previously quality and utilization officer and chief of the medical staff at Aurora Sinai Medical Center. Dr. Prasad is cochair of SHM’s IT Special Interest Group, sits on the HQPS Committee, and is president of SHM’s Wisconsin Chapter. Dr. Palabindala is the medical director, utilization management and physician advisory services, at the University of Mississippi Medical Center, Jackson. He is an associate professor of medicine and academic hospitalist in the UMMC School of Medicine.

References

1. Wood S. TCTMD. 2020 Apr 2. “The mystery of the missing STEMIs during the COVID-19 pandemic.”

2. Stradling R. The News & Observer. 2020 Apr 21. “Fewer people are going to Triangle [N.C.] emergency rooms, and that could be a bad thing.”

3. Kasanagottu K. USA Today. 2020 Apr 15. “Don’t delay care for chronic illness over coronavirus. It’s bad for you and for hospitals.”

4. Snowbeck C. The Star Tribune. 2020 Apr 11. “Mayo Clinic cutting pay for more than 20,000 workers.”

5. LaPointe J. RevCycle Intelligence. 2020 Mar 31. “How much will the COVID-19 pandemic cost hospitals?”

6. Gavidia M. AJMC. 2020 Mar 31. “Sleep, physician burnout linked amid COVID-19 pandemic.”

7. Hollander JE and Carr BG. N Engl J Med. 2020 Apr 30;382(18):1679-81. “Virtually perfect? Telemedicine for COVID-19.”

Over the last several weeks, hospitals and health systems have focused on the COVID-19 epidemic, preparing and expanding bed capacities for the surge of admissions both in intensive care and medical units. An indirect impact of this has been the reduction in outpatient staffing and resources, with the shifting of staff for inpatient care. Many areas seem to have passed the peak in the number of cases and are now seeing a plateau or downward trend in the admissions to acute care facilities.

During this period, there has been a noticeable downtrend in patients being evaluated in the ED, or admitted for decompensation of chronic conditions like heart failure, COPD and diabetes mellitus, or such acute conditions as stroke and MI. Studies from Italy and Spain, and closer to home from Atlanta and Boston, point to a significant decrease in numbers of ST-elevation myocardial infarction (STEMI) admissions.¹ Duke Health saw a decrease in stroke admissions in their hospitals by 34%.²

One could argue that these patients are in fact presenting with COVID-19 or similar symptoms as is evidenced by the studies linking the severity of SARS-Co-V2 infection to chronic conditions like diabetes mellitus and obesity.² On the other hand, the message of social isolation and avoidance of nonurgent visits could lead to delays in care resulting in patients presenting sicker and in advanced stages.³ Also, this has not been limited to the adult population. For example, reports indicate that visits to WakeMed’s pediatric emergency rooms in Wake County, N.C., were down by 60%.²

We could well be seeing a calm before the storm. While it is anticipated that there may be a second surge of COVID-19 cases, health systems would do well to be prepared for the “third surge,” consisting of patients coming in with chronic medical conditions for which they have been, so far, avoiding follow-up and managing at home, and acute medical conditions with delayed diagnoses. The impact could likely be more in the subset of patients with limited access to health care, including medications and follow-up, resulting in a disproportionate burden on safety-net hospitals.

Compounding this issue would be the economic impact of the current crisis on health systems, their staffing, and resources. Several major organizations have already proposed budget cuts and reduction of the workforce, raising significant concerns about the future of health care workers who put their lives at risk during this pandemic.⁴ There is no guarantee that the federal funding provided by the stimulus packages will save jobs in the health care industry. This problem needs new leadership thinking, and every organization that puts employees over profits margins will have a long-term impact on communities.

Another area of concern is a shift in resources and workflow from ambulatory to inpatient settings for the COVID-19 pandemic, and the need for revamping the ambulatory services with reshifting the workforce. As COVID-19 cases plateau, the resurgence of non-COVID–related admissions will require additional help in inpatient settings. Prioritizing the ambulatory services based on financial benefits versus patient outcomes is also a major challenge to leadership.⁵

Lastly, the current health care crisis has led to significant stress, both emotional and physical, among frontline caregivers, increasing the risk of burnout.⁶ How leadership helps health care workers to cope with these stressors, and the resources they provide, is going to play a key role in long term retention of their talent, and will reflect on the organizational culture. Though it might seem trivial, posttraumatic stress disorder related to this is already obvious, and health care leadership needs to put every effort in providing the resources to help prevent burnout, in partnership with national organizations like the Society of Hospital Medicine and the American College of Physicians.

The expansion of telemedicine has provided a unique opportunity to address several of these issues while maintaining the nonpharmacologic interventions to fight the epidemic, and keeping the cost curve as low as possible.⁷ Extension of these services to all ambulatory service lines, including home health and therapy, is the next big step in the new health care era. Virtual check-ins by physicians, advance practice clinicians, and home care nurses could help alleviate the concerns regarding delays in care of patients with chronic conditions, and help identify those at risk. This would also be of help with staffing shortages, and possibly provide much needed support to frontline providers.

Dr. Prasad is currently medical director of care management and a hospitalist at Advocate Aurora Health in Milwaukee. He was previously quality and utilization officer and chief of the medical staff at Aurora Sinai Medical Center. Dr. Prasad is cochair of SHM’s IT Special Interest Group, sits on the HQPS Committee, and is president of SHM’s Wisconsin Chapter. Dr. Palabindala is the medical director, utilization management and physician advisory services, at the University of Mississippi Medical Center, Jackson. He is an associate professor of medicine and academic hospitalist in the UMMC School of Medicine.

References

1. Wood S. TCTMD. 2020 Apr 2. “The mystery of the missing STEMIs during the COVID-19 pandemic.”

2. Stradling R. The News & Observer. 2020 Apr 21. “Fewer people are going to Triangle [N.C.] emergency rooms, and that could be a bad thing.”

3. Kasanagottu K. USA Today. 2020 Apr 15. “Don’t delay care for chronic illness over coronavirus. It’s bad for you and for hospitals.”

4. Snowbeck C. The Star Tribune. 2020 Apr 11. “Mayo Clinic cutting pay for more than 20,000 workers.”

5. LaPointe J. RevCycle Intelligence. 2020 Mar 31. “How much will the COVID-19 pandemic cost hospitals?”

6. Gavidia M. AJMC. 2020 Mar 31. “Sleep, physician burnout linked amid COVID-19 pandemic.”

7. Hollander JE and Carr BG. N Engl J Med. 2020 Apr 30;382(18):1679-81. “Virtually perfect? Telemedicine for COVID-19.”

Over the last several weeks, hospitals and health systems have focused on the COVID-19 epidemic, preparing and expanding bed capacities for the surge of admissions both in intensive care and medical units. An indirect impact of this has been the reduction in outpatient staffing and resources, with the shifting of staff for inpatient care. Many areas seem to have passed the peak in the number of cases and are now seeing a plateau or downward trend in the admissions to acute care facilities.

During this period, there has been a noticeable downtrend in patients being evaluated in the ED, or admitted for decompensation of chronic conditions like heart failure, COPD and diabetes mellitus, or such acute conditions as stroke and MI. Studies from Italy and Spain, and closer to home from Atlanta and Boston, point to a significant decrease in numbers of ST-elevation myocardial infarction (STEMI) admissions.¹ Duke Health saw a decrease in stroke admissions in their hospitals by 34%.²

One could argue that these patients are in fact presenting with COVID-19 or similar symptoms as is evidenced by the studies linking the severity of SARS-Co-V2 infection to chronic conditions like diabetes mellitus and obesity.² On the other hand, the message of social isolation and avoidance of nonurgent visits could lead to delays in care resulting in patients presenting sicker and in advanced stages.³ Also, this has not been limited to the adult population. For example, reports indicate that visits to WakeMed’s pediatric emergency rooms in Wake County, N.C., were down by 60%.²

We could well be seeing a calm before the storm. While it is anticipated that there may be a second surge of COVID-19 cases, health systems would do well to be prepared for the “third surge,” consisting of patients coming in with chronic medical conditions for which they have been, so far, avoiding follow-up and managing at home, and acute medical conditions with delayed diagnoses. The impact could likely be more in the subset of patients with limited access to health care, including medications and follow-up, resulting in a disproportionate burden on safety-net hospitals.

Compounding this issue would be the economic impact of the current crisis on health systems, their staffing, and resources. Several major organizations have already proposed budget cuts and reduction of the workforce, raising significant concerns about the future of health care workers who put their lives at risk during this pandemic.⁴ There is no guarantee that the federal funding provided by the stimulus packages will save jobs in the health care industry. This problem needs new leadership thinking, and every organization that puts employees over profits margins will have a long-term impact on communities.

Another area of concern is a shift in resources and workflow from ambulatory to inpatient settings for the COVID-19 pandemic, and the need for revamping the ambulatory services with reshifting the workforce. As COVID-19 cases plateau, the resurgence of non-COVID–related admissions will require additional help in inpatient settings. Prioritizing the ambulatory services based on financial benefits versus patient outcomes is also a major challenge to leadership.⁵

Lastly, the current health care crisis has led to significant stress, both emotional and physical, among frontline caregivers, increasing the risk of burnout.⁶ How leadership helps health care workers to cope with these stressors, and the resources they provide, is going to play a key role in long term retention of their talent, and will reflect on the organizational culture. Though it might seem trivial, posttraumatic stress disorder related to this is already obvious, and health care leadership needs to put every effort in providing the resources to help prevent burnout, in partnership with national organizations like the Society of Hospital Medicine and the American College of Physicians.

The expansion of telemedicine has provided a unique opportunity to address several of these issues while maintaining the nonpharmacologic interventions to fight the epidemic, and keeping the cost curve as low as possible.⁷ Extension of these services to all ambulatory service lines, including home health and therapy, is the next big step in the new health care era. Virtual check-ins by physicians, advance practice clinicians, and home care nurses could help alleviate the concerns regarding delays in care of patients with chronic conditions, and help identify those at risk. This would also be of help with staffing shortages, and possibly provide much needed support to frontline providers.

Dr. Prasad is currently medical director of care management and a hospitalist at Advocate Aurora Health in Milwaukee. He was previously quality and utilization officer and chief of the medical staff at Aurora Sinai Medical Center. Dr. Prasad is cochair of SHM’s IT Special Interest Group, sits on the HQPS Committee, and is president of SHM’s Wisconsin Chapter. Dr. Palabindala is the medical director, utilization management and physician advisory services, at the University of Mississippi Medical Center, Jackson. He is an associate professor of medicine and academic hospitalist in the UMMC School of Medicine.

References

1. Wood S. TCTMD. 2020 Apr 2. “The mystery of the missing STEMIs during the COVID-19 pandemic.”

2. Stradling R. The News & Observer. 2020 Apr 21. “Fewer people are going to Triangle [N.C.] emergency rooms, and that could be a bad thing.”

3. Kasanagottu K. USA Today. 2020 Apr 15. “Don’t delay care for chronic illness over coronavirus. It’s bad for you and for hospitals.”

4. Snowbeck C. The Star Tribune. 2020 Apr 11. “Mayo Clinic cutting pay for more than 20,000 workers.”

5. LaPointe J. RevCycle Intelligence. 2020 Mar 31. “How much will the COVID-19 pandemic cost hospitals?”

6. Gavidia M. AJMC. 2020 Mar 31. “Sleep, physician burnout linked amid COVID-19 pandemic.”

7. Hollander JE and Carr BG. N Engl J Med. 2020 Apr 30;382(18):1679-81. “Virtually perfect? Telemedicine for COVID-19.”

Depression is associated with decreased neurologic function and new brain lesions in patients with multiple sclerosis (MS), new research suggests.

In an observational study of more than 2500 patients with relapsing-remitting MS (RRMS), participants with self-reported depression were more likely to have worse scores on neuroperformance measures, such as processing speed tests, than their peers without depression.

At baseline, the group with depression also had greater odds of having at least one new contrast-enhancing lesion on MRI.

“Our results suggest that depression is not merely a reactive symptom but indicates increased risk of future MS disease activity,” the investigators note.

Lead author Jenny Feng, MD, clinical associate at the Mellen Center for MS Treatment and Research at Cleveland Clinic, added that depression should be routinely screened for in all patients with MS, something done routinely at her center.

“Every single patient that comes through the door with newly diagnosed MS, we refer to neuropsychology to screen for depression; and if there is depression, then we actively manage it because it does have an effect” on patients, she told Medscape Medical News.

“Depression isn’t just a neuropsychiatric disease,” Feng added. As shown in their study, “it may have effects on MS, especially with regards to performance in neurological function testing.”

The research is presented on AAN.com as part of the American Academy of Neurology 2020 Science Highlights. Because of the COVID-19 pandemic, the AAN had to cancel its 2020 annual meeting.

Associations Have Been “Unclear”

Although inflammatory, psychosocial, and neurodegenerative factors “have been hypothesized as etiologies” for why depression is commonly found in patients with MS, the full association between depression and MS disease activity “is not clear,” the investigators note.

For the current study, they assessed data from the Partners Advancing Technology and Health Solutions (MS-PATHS) database, an ongoing collaborative network of seven MS centers in the United States and three in Europe.

MS disease history and MRI data were examined, as well as 12-month scores on neuroperformance tests measuring processing speed (Symbol Digit Modalities Test), walking speed (Timed 25-Foot Walk), and manual dexterity (Nine-Hole Peg Test).

Patient-reported outcomes (PROs), as measured with the Quality of Life in Neurological Disorders (Neuro-QoL) and patient-determined disease steps, were also assessed. Depression was defined as a depression T score at baseline greater than “the 50th percentile” on the Neuro-QoL.

In the patient sample, 1333 of the participants with RRMS were classified as “not depressed” (73.7% women; mean age, 45.6 years; disease duration, 13.7 years) while 1172 were “depressed” (78.4% women; mean age, 45.9 years; disease duration, 14.3 years).

“To balance for baseline variances in the observational cohort between group with depression and group without depression, propensity score analysis was used to adjust for potential confounding factors,” the investigators report.

Worse Performance

After adjustment for baseline covariates, results showed that the depressed patients performed worse on the walking speed test (0.48; 95% confidence interval, 0.038-0.918) and processing speed test (–1.899; 95% CI, –3.548 to –0.250).

The depressed group also had increased odds at baseline of having new contrast-enhancing lesions (odds ratio, 5.89; 95% CI, 2.236-15.517). This demonstrated an “association of depression and neuroinflammatory activity” in the central nervous system, the investigators note.

At 12 months, processing speed continued to be worse in the depressed group (–1.68; 95% CI, –3.254 to –0.105).

There were trends, albeit insignificant, for decreased walking speed scores at 12 months and for decreased manual dexterity scores at both baseline and at 12 months for the participants who were depressed.

Interestingly, there were “no significant differences in PROs at month 12, despite worsening neuroperformance,” the investigators report.

“This means that patients themselves may not even realize that they were getting worse,” Feng said.

Underpowered Study?

Further results showed nonsignificant trends for increased T2 lesion volume and white matter fraction and decreased brain volume, gray matter fraction, and cortical gray matter volume at baseline and at 12 months in the depressed group.

The researchers note that study limitations include the unavailability of information on treatment compliance for depression or date of depression onset.

Feng added that because this was an observational study, other missing data included depression status for some patients at year 1 and some MRI metrics.

“So this may have been underpowered to detect some of the results. The power may have been inadequate to detect all changes,” she said.

The investigators write that future research should assess larger sample sizes with longer follow-ups and should use more advanced MRI measures, such as diffusion tensor imaging or functional MRI.

In addition, they will continue examining data from MS-PATHS. “With the newest data cut, we have new patients that we can analyze. So perhaps that can provide sufficient power to detect [more MRI] changes,” Feng said.

Unusual, Intriguing Findings

Commenting on the study for Medscape Medical News, Mark Freedman, MD, professor of neurology at the University of Ottawa and director of the Multiple Sclerosis Research Clinic at the Ottawa Hospital Research Institute, noted that he wasn’t terribly surprised” by the overall findings.

“We’ve known for years that patients who are depressed don’t do as well on our performance methods,” said Freedman, who was not involved with the research.

However, the current investigators “took a huge number of patients in this multicenter study and started using some of the statistical methods we’ve seen in the use of real-world evidence,” he noted.

“So you’re looking at some outcome measures and you have to ask yourself, ‘Why would it influence that?’ and ‘Did it happen by chance or not?’ And you ask why it is that depressed people might actually have more lesions on their MRI, which is something that is unusual,” Freedman said.

“When you start to look at this, even when you’re trying to standardize things for the differences that we know of, there are some stuff that comes out as intriguing. In general, I think those depressed patients did worse on several outcome measures that one would say, ‘That’s somewhat surprising.’ That’s why this group was very careful to not conclude absolutely that depression drives this disease. But it was consistently trending in the direction that it looks like there was more inflammatory activity in these people,” he said.

He echoed the investigators’ note that drug adherence and which depression treatment was used wasn’t controlled for; and he added that depression in the study was not based on receiving a diagnosis of clinical depression but on self-report.

Still, the patients classified as depressed “did worse. They didn’t walk as fast, which was interesting; and we know that cognitive performance is often damped because of poor concentration. But how do you get worse MRIs? This study is raising a question and [the researchers] conclude that it may be that depression might be an independent factor” for that outcome, Freedman said.

“It might be that you could get more out of a particular [MS] medicine if you pay attention to depression; and if that’s the investigators’ conclusion, and I think it is, then I certainly agree with it.”

Freedman noted that, instead of a blanket recommendation that all patients with MS should be screened for depression, he thinks clinicians, especially those at smaller centers, should focus on what’s best for treating all aspects of an individual patient.

“Don’t try to manage them if you’re not going to manage the entire picture. Looking at depression and mood and other things is very important. And if you have the capacity for an official screening, I think it’s wonderful; but not everybody does,” he said.

Feng and Freedman have disclosed no relevant financial relationships. Freedman is currently a member of the Medscape Neurology Advisory Board.
 

This article appeared on Medscape.com.

Depression is associated with decreased neurologic function and new brain lesions in patients with multiple sclerosis (MS), new research suggests.

In an observational study of more than 2500 patients with relapsing-remitting MS (RRMS), participants with self-reported depression were more likely to have worse scores on neuroperformance measures, such as processing speed tests, than their peers without depression.

At baseline, the group with depression also had greater odds of having at least one new contrast-enhancing lesion on MRI.

“Our results suggest that depression is not merely a reactive symptom but indicates increased risk of future MS disease activity,” the investigators note.

Lead author Jenny Feng, MD, clinical associate at the Mellen Center for MS Treatment and Research at Cleveland Clinic, added that depression should be routinely screened for in all patients with MS, something done routinely at her center.

“Every single patient that comes through the door with newly diagnosed MS, we refer to neuropsychology to screen for depression; and if there is depression, then we actively manage it because it does have an effect” on patients, she told Medscape Medical News.

“Depression isn’t just a neuropsychiatric disease,” Feng added. As shown in their study, “it may have effects on MS, especially with regards to performance in neurological function testing.”

The research is presented on AAN.com as part of the American Academy of Neurology 2020 Science Highlights. Because of the COVID-19 pandemic, the AAN had to cancel its 2020 annual meeting.

Associations Have Been “Unclear”

Although inflammatory, psychosocial, and neurodegenerative factors “have been hypothesized as etiologies” for why depression is commonly found in patients with MS, the full association between depression and MS disease activity “is not clear,” the investigators note.

For the current study, they assessed data from the Partners Advancing Technology and Health Solutions (MS-PATHS) database, an ongoing collaborative network of seven MS centers in the United States and three in Europe.

MS disease history and MRI data were examined, as well as 12-month scores on neuroperformance tests measuring processing speed (Symbol Digit Modalities Test), walking speed (Timed 25-Foot Walk), and manual dexterity (Nine-Hole Peg Test).

Patient-reported outcomes (PROs), as measured with the Quality of Life in Neurological Disorders (Neuro-QoL) and patient-determined disease steps, were also assessed. Depression was defined as a depression T score at baseline greater than “the 50th percentile” on the Neuro-QoL.

In the patient sample, 1333 of the participants with RRMS were classified as “not depressed” (73.7% women; mean age, 45.6 years; disease duration, 13.7 years) while 1172 were “depressed” (78.4% women; mean age, 45.9 years; disease duration, 14.3 years).

“To balance for baseline variances in the observational cohort between group with depression and group without depression, propensity score analysis was used to adjust for potential confounding factors,” the investigators report.

Worse Performance

After adjustment for baseline covariates, results showed that the depressed patients performed worse on the walking speed test (0.48; 95% confidence interval, 0.038-0.918) and processing speed test (–1.899; 95% CI, –3.548 to –0.250).

The depressed group also had increased odds at baseline of having new contrast-enhancing lesions (odds ratio, 5.89; 95% CI, 2.236-15.517). This demonstrated an “association of depression and neuroinflammatory activity” in the central nervous system, the investigators note.

At 12 months, processing speed continued to be worse in the depressed group (–1.68; 95% CI, –3.254 to –0.105).

There were trends, albeit insignificant, for decreased walking speed scores at 12 months and for decreased manual dexterity scores at both baseline and at 12 months for the participants who were depressed.

Interestingly, there were “no significant differences in PROs at month 12, despite worsening neuroperformance,” the investigators report.

“This means that patients themselves may not even realize that they were getting worse,” Feng said.

Underpowered Study?

Further results showed nonsignificant trends for increased T2 lesion volume and white matter fraction and decreased brain volume, gray matter fraction, and cortical gray matter volume at baseline and at 12 months in the depressed group.

The researchers note that study limitations include the unavailability of information on treatment compliance for depression or date of depression onset.

Feng added that because this was an observational study, other missing data included depression status for some patients at year 1 and some MRI metrics.

“So this may have been underpowered to detect some of the results. The power may have been inadequate to detect all changes,” she said.

The investigators write that future research should assess larger sample sizes with longer follow-ups and should use more advanced MRI measures, such as diffusion tensor imaging or functional MRI.

In addition, they will continue examining data from MS-PATHS. “With the newest data cut, we have new patients that we can analyze. So perhaps that can provide sufficient power to detect [more MRI] changes,” Feng said.

Unusual, Intriguing Findings

Commenting on the study for Medscape Medical News, Mark Freedman, MD, professor of neurology at the University of Ottawa and director of the Multiple Sclerosis Research Clinic at the Ottawa Hospital Research Institute, noted that he wasn’t terribly surprised” by the overall findings.

“We’ve known for years that patients who are depressed don’t do as well on our performance methods,” said Freedman, who was not involved with the research.

However, the current investigators “took a huge number of patients in this multicenter study and started using some of the statistical methods we’ve seen in the use of real-world evidence,” he noted.

“So you’re looking at some outcome measures and you have to ask yourself, ‘Why would it influence that?’ and ‘Did it happen by chance or not?’ And you ask why it is that depressed people might actually have more lesions on their MRI, which is something that is unusual,” Freedman said.

“When you start to look at this, even when you’re trying to standardize things for the differences that we know of, there are some stuff that comes out as intriguing. In general, I think those depressed patients did worse on several outcome measures that one would say, ‘That’s somewhat surprising.’ That’s why this group was very careful to not conclude absolutely that depression drives this disease. But it was consistently trending in the direction that it looks like there was more inflammatory activity in these people,” he said.

He echoed the investigators’ note that drug adherence and which depression treatment was used wasn’t controlled for; and he added that depression in the study was not based on receiving a diagnosis of clinical depression but on self-report.

Still, the patients classified as depressed “did worse. They didn’t walk as fast, which was interesting; and we know that cognitive performance is often damped because of poor concentration. But how do you get worse MRIs? This study is raising a question and [the researchers] conclude that it may be that depression might be an independent factor” for that outcome, Freedman said.

“It might be that you could get more out of a particular [MS] medicine if you pay attention to depression; and if that’s the investigators’ conclusion, and I think it is, then I certainly agree with it.”

Freedman noted that, instead of a blanket recommendation that all patients with MS should be screened for depression, he thinks clinicians, especially those at smaller centers, should focus on what’s best for treating all aspects of an individual patient.

“Don’t try to manage them if you’re not going to manage the entire picture. Looking at depression and mood and other things is very important. And if you have the capacity for an official screening, I think it’s wonderful; but not everybody does,” he said.

Feng and Freedman have disclosed no relevant financial relationships. Freedman is currently a member of the Medscape Neurology Advisory Board.
 

This article appeared on Medscape.com.

Depression is associated with decreased neurologic function and new brain lesions in patients with multiple sclerosis (MS), new research suggests.

In an observational study of more than 2500 patients with relapsing-remitting MS (RRMS), participants with self-reported depression were more likely to have worse scores on neuroperformance measures, such as processing speed tests, than their peers without depression.

At baseline, the group with depression also had greater odds of having at least one new contrast-enhancing lesion on MRI.

“Our results suggest that depression is not merely a reactive symptom but indicates increased risk of future MS disease activity,” the investigators note.

Lead author Jenny Feng, MD, clinical associate at the Mellen Center for MS Treatment and Research at Cleveland Clinic, added that depression should be routinely screened for in all patients with MS, something done routinely at her center.

“Every single patient that comes through the door with newly diagnosed MS, we refer to neuropsychology to screen for depression; and if there is depression, then we actively manage it because it does have an effect” on patients, she told Medscape Medical News.

“Depression isn’t just a neuropsychiatric disease,” Feng added. As shown in their study, “it may have effects on MS, especially with regards to performance in neurological function testing.”

The research is presented on AAN.com as part of the American Academy of Neurology 2020 Science Highlights. Because of the COVID-19 pandemic, the AAN had to cancel its 2020 annual meeting.

Associations Have Been “Unclear”

Although inflammatory, psychosocial, and neurodegenerative factors “have been hypothesized as etiologies” for why depression is commonly found in patients with MS, the full association between depression and MS disease activity “is not clear,” the investigators note.

For the current study, they assessed data from the Partners Advancing Technology and Health Solutions (MS-PATHS) database, an ongoing collaborative network of seven MS centers in the United States and three in Europe.

MS disease history and MRI data were examined, as well as 12-month scores on neuroperformance tests measuring processing speed (Symbol Digit Modalities Test), walking speed (Timed 25-Foot Walk), and manual dexterity (Nine-Hole Peg Test).

Patient-reported outcomes (PROs), as measured with the Quality of Life in Neurological Disorders (Neuro-QoL) and patient-determined disease steps, were also assessed. Depression was defined as a depression T score at baseline greater than “the 50th percentile” on the Neuro-QoL.

In the patient sample, 1333 of the participants with RRMS were classified as “not depressed” (73.7% women; mean age, 45.6 years; disease duration, 13.7 years) while 1172 were “depressed” (78.4% women; mean age, 45.9 years; disease duration, 14.3 years).

“To balance for baseline variances in the observational cohort between group with depression and group without depression, propensity score analysis was used to adjust for potential confounding factors,” the investigators report.

Worse Performance

After adjustment for baseline covariates, results showed that the depressed patients performed worse on the walking speed test (0.48; 95% confidence interval, 0.038-0.918) and processing speed test (–1.899; 95% CI, –3.548 to –0.250).

The depressed group also had increased odds at baseline of having new contrast-enhancing lesions (odds ratio, 5.89; 95% CI, 2.236-15.517). This demonstrated an “association of depression and neuroinflammatory activity” in the central nervous system, the investigators note.

At 12 months, processing speed continued to be worse in the depressed group (–1.68; 95% CI, –3.254 to –0.105).

There were trends, albeit insignificant, for decreased walking speed scores at 12 months and for decreased manual dexterity scores at both baseline and at 12 months for the participants who were depressed.

Interestingly, there were “no significant differences in PROs at month 12, despite worsening neuroperformance,” the investigators report.

“This means that patients themselves may not even realize that they were getting worse,” Feng said.

Underpowered Study?

Further results showed nonsignificant trends for increased T2 lesion volume and white matter fraction and decreased brain volume, gray matter fraction, and cortical gray matter volume at baseline and at 12 months in the depressed group.

The researchers note that study limitations include the unavailability of information on treatment compliance for depression or date of depression onset.

Feng added that because this was an observational study, other missing data included depression status for some patients at year 1 and some MRI metrics.

“So this may have been underpowered to detect some of the results. The power may have been inadequate to detect all changes,” she said.

The investigators write that future research should assess larger sample sizes with longer follow-ups and should use more advanced MRI measures, such as diffusion tensor imaging or functional MRI.

In addition, they will continue examining data from MS-PATHS. “With the newest data cut, we have new patients that we can analyze. So perhaps that can provide sufficient power to detect [more MRI] changes,” Feng said.

Unusual, Intriguing Findings

Commenting on the study for Medscape Medical News, Mark Freedman, MD, professor of neurology at the University of Ottawa and director of the Multiple Sclerosis Research Clinic at the Ottawa Hospital Research Institute, noted that he wasn’t terribly surprised” by the overall findings.

“We’ve known for years that patients who are depressed don’t do as well on our performance methods,” said Freedman, who was not involved with the research.

However, the current investigators “took a huge number of patients in this multicenter study and started using some of the statistical methods we’ve seen in the use of real-world evidence,” he noted.

“So you’re looking at some outcome measures and you have to ask yourself, ‘Why would it influence that?’ and ‘Did it happen by chance or not?’ And you ask why it is that depressed people might actually have more lesions on their MRI, which is something that is unusual,” Freedman said.

“When you start to look at this, even when you’re trying to standardize things for the differences that we know of, there are some stuff that comes out as intriguing. In general, I think those depressed patients did worse on several outcome measures that one would say, ‘That’s somewhat surprising.’ That’s why this group was very careful to not conclude absolutely that depression drives this disease. But it was consistently trending in the direction that it looks like there was more inflammatory activity in these people,” he said.

He echoed the investigators’ note that drug adherence and which depression treatment was used wasn’t controlled for; and he added that depression in the study was not based on receiving a diagnosis of clinical depression but on self-report.

Still, the patients classified as depressed “did worse. They didn’t walk as fast, which was interesting; and we know that cognitive performance is often damped because of poor concentration. But how do you get worse MRIs? This study is raising a question and [the researchers] conclude that it may be that depression might be an independent factor” for that outcome, Freedman said.

“It might be that you could get more out of a particular [MS] medicine if you pay attention to depression; and if that’s the investigators’ conclusion, and I think it is, then I certainly agree with it.”

Freedman noted that, instead of a blanket recommendation that all patients with MS should be screened for depression, he thinks clinicians, especially those at smaller centers, should focus on what’s best for treating all aspects of an individual patient.

“Don’t try to manage them if you’re not going to manage the entire picture. Looking at depression and mood and other things is very important. And if you have the capacity for an official screening, I think it’s wonderful; but not everybody does,” he said.

Feng and Freedman have disclosed no relevant financial relationships. Freedman is currently a member of the Medscape Neurology Advisory Board.
 

This article appeared on Medscape.com.

Kind wishes and donations worldwide came to help Australian communities and wildlife affected by the extreme drought and uncontrollable bushfires. Indeed, Australians have become a warning beacon for the planet to recognize how factors associated with global warming can morph rapidly into runaway national emergencies.

Little attention, however, has addressed the extreme vulnerability of Australia’s First Nations people, the Aboriginal & Torres Strait Islander communities, to the climate crisis. U.N. reports conclude that “Indigenous people with close emotional and ancestral ties to the land are also likely to be disproportionately affected by environmental change and extreme weather events.”¹

In fact, Indigenous peoples, whether living traditionally or assimilated, are among the first to be adversely affected by climate change. This is because, in part, of extreme poverty, inadequate housing, unemployment and other social determinants, transgenerational cultural losses of life and culture, dislocations, traumatic experiences of child removal, overrepresentation in the prison system, and chronic diseases already leading to dramatic disparities in life expectancy and other health outcomes.

Research confirms that rural and remote Aboriginal communities will be Australia’s first mass climate refugees. “Without action to stop climate change, people will be forced to leave their country and leave behind much of what makes them Aboriginal.”² This is because of hotter temperatures, poorly built and unstable homes more vulnerable to heat, and longer and drier droughts. Their communities, in fire-prone townships, are running out of water. Abject poverty severely limits their options, aggravated by government inaction because of ideological climate change denialism. And now we have the overlay of COVID-19 threatening these communities.³

Human pandemics are potentially more likely to occur with climate change. Pandemics also are more apt to be associated with population growth, human settlement encroaching on forests, increasing wild animal or intermediary vector contact, and growth in global travel.

Subsequently, our Indigenous communities have had the most to lose if COVID-19 is let loose in their midst. Spatial separation is difficult in overcrowded, multigenerational households. It is hard to keep your hands washed with soap where reliable water supply is sometimes only communal. Their health workers’ access to protective and lifesaving ICU equipment and expertise may be extremely limited or erratic.

Much of the population is classified as highly vulnerable to COVID-19 because of chronic health disorders (for example, cardiovascular, respiratory, and renal issues; diabetes, and suicidality) and preexisting much shorter life expectancies. Their health workers’ access to protective and lifesaving ICU equipment and expertise is extremely limited. There are fears that, if COVID-19 gains a foothold, they may lose a whole generation of revered elders, who often are also the last fluent tribal language speakers and carriers of life-enhancing cultural stories, traditions, and rites. More urban-living Indigenous families may yet have a rough time avoiding these ravages.

In Australia, COVID-19 has been largely held at bay so far by state and territory governments that have closed borders, restricted nonessential travel, and discouraged or excluded outsiders from visiting remote Indigenous communities wherever possible. There have been complaints that such restrictions occasionally had been applied in these communities in a heavy-handed way by police and other authorities, and may be resisted if enforced unilaterally. They will work only if applied with cultural sensitivity, full Indigenous community consultation, and collaboration. So far, COVID-19 infection rates have been kept very low, with no Indigenous deaths. In Brazil, by contrast, infections and deaths are more than double the national average, itinerant missionaries have only just been excluded from Amazonian tribal lands so far by independent judicial intervention, while loggers and miners come and go freely, as sources of contagion.⁴  Some Indigenous peoples in the United States have experienced among the highest COVID-19 infection and death rates in the country (for example, the Navajo Nation in New Mexico, Arizona, and Utah), amounting to catastrophic loss and grief.

"Black Lives Matter" marches protesting the filmed police killing of George Floyd in the USA have spread worldwide, in the wake of ultra-high rates of police brutality and killings with impunity of non-white individuals.

Many Australians, including considerable numbers of Indigenous people, marched here in sympathy, despite their infective risk and vulnerabilities. They were also protesting the excessive rates of Aboriginal imprisonment, deaths in custody, and police killings without consequences. Both internationally and here, there was an apparent sense of release of pent-up anger and frustrations at both these injustices and the extra susceptibility of poor and non-white people to severe illness, death and dire economic consequences because of the pandemic. It is a deceptive myth that "we are all in this together." So it is encouraging that there is also forming a widespread sense of collective purpose and determination to get governments to address these iniquities and inequities at last.*

I have worked as a community psychiatrist in Barkinje Aboriginal tribal lands of the Far West region of New South Wales (NSW) regularly for 35 years, much of this time while also leading Royal North Shore University General Hospital & Community Mental Health Services in Sydney. Barkinje translates as “River People,” but local media mainly talk about the impact of prolonged drought on farmers and ranchers, who certainly are deeply affected by it. However, the media rarely mention the calamitous impacts on Aboriginal communities. The drought effects are exacerbated by multinational corporate irrigators that divert and allegedly steal river water with tacit encouragement from ostensibly responsible government ministers. The rivers dry up into algal ponds with millions of bloated, rotting dead fish, and entire communities’ water supplies fail.

Researchers have reported on the mental health impacts of prolonged drought and diversion of river water on rural and remote indigenous communities throughout the state of NSW.⁵ We have heard Barkinje and neighboring Wiradjuri people say, “if the land is sick, we are sick,” and, “if the river dries up, there’s nowhere to meet.” Fishing, a popular recreational activity and source of nutrition is now denied to these communities. Unlike farmers, they receive no governmental exceptional circumstance compensation payments during droughts. Instead, they lose their farming jobs, so there is no disposable income and loss of capacity to travel to connect to their extended kinship system and cultural roots (e.g., for funerals or football matches) in other remote townships. Such droughts exacerbate wildfires, loss of fish and birdlife, some of which are sacred spiritual totems; dying of traditional “lifeblood” rivers, decimating precious ancient red-river gumtrees that line the shores; and irreversible damage to other sacred sites (e.g., melting ancient rock art).

So, loss of sustainable food sources, meaningful livelihood, and cultural and leisure pursuits could create an existential threat to Aboriginal identity. However, rural Indigenous communities also told us “whatever you do to us, we will survive and persist, as we have done in the past.”⁶ This is comparable with the tenacity and resilience of other ancient cultures that have suffered genocidal persecution and discrimination in the past, and have stubbornly regrown and persisted and regrown into the future.

They yearn to care for their lands, rivers, and seas of their traditions and upbringing, whether as “saltwater” coastal or “freshwater” inland peoples. They value their extended families, honor their elders and their collective wisdom, while also living in “two worlds.” They often encourage their children to get educated and pursue individualistic aspirations to help their communities by training as tradespeople and professionals who may be better trusted to look after their own. As Charles Perkins, a most celebrated Aboriginal role model for living in both worlds, famously said: “We know we can’t live in the past, but the past lives in us.”

As anxiety and depression, psychological trauma, drug and alcohol misuse, family and communal violence, ecological grief,and suicidal vulnerability are precipitated or exacerbated by the stress of extreme environmental adversity, significant investment in ameliorating these harms is essential, not just for farmers, town businesspeople and their families, but for all those affected, especially these most vulnerable members of the community.⁷ We must provide more essential community services controlled by Aboriginal community members themselves. We must also train and support more Aboriginal mental health workers, healers, mental health educators, peer workers and Aboriginal liaison officers, to work alongside other mental health, and health and social service professionals. Aboriginal people need stable local employment opportunities in their communities. There is a huge opportunity to synergize traditional indigenous fire management with Western techniques, creating and consolidating more valued jobs and respected land management roles for Aboriginal rangers, vital for the future of both Aboriginal and wider communities. Pilot programs are emerging.

Aboriginal communities also need a more preventive, whole-of-life approach to social determinants, lifestyle factors, trauma, and political decisions associated with compromised neurodevelopment, and increased subsequent incidence and severity of mental illnesses in their communities.⁷

As Alexander Solzhenitsyn observed: “On our crowded planet there are no longer any ‘internal affairs.’ ”⁸ Climate change is the ultimate form of globalization: What we each do about it affects all others’ lives. We can only insist that, alongside adequate resourcing of our most evidence-based methods of fire, water, and climate control, our governments consult and listen to our Indigenous elders about applying climate management methods. These have been demonstrated to be sustainable and effective, possibly over 60,000 years – which is the longest established record of continuous Indigenous culture worldwide.

References

1. Ten impacts of the Australian bushfires. U.N. Environment Programme. 2020 Jan 20.

2. Allam L, Evershed N. “Too hot for humans? First Nations people fear becoming Australia’s first climate refugees.” The Guardian. 2019 Dec 17.

3. National Indigenous Australians Agency. “Coronavirus (COVID-19).”

4. Phillips D. “Brazil: Judge bans missionaries from Indigenous reserve over COVID-19 fears.” The Guardian. 2020 Apr 17.

5. Rigby CW et al. Aust J Rural Health. 2011 Oct;19(5):249-54.

6. Cunsolo A, Ellis NR. Nature Clim Change. 2018 Apr 3;8:275-81.

7. Gynther B et al. EClinicalMedicine. 2019 Apr 26;10:68-77.

8. Solzhenitsyn A. “Warning to the West,” speech delivered 30 Jun 1975. New York: Fararr, Straux & Girous, 1976.

Dr. Rosen, an officer of the Order of Australia and a Fellow of the Royal Australian and New Zealand College of Psychiatrists, is affiliated with the Brain & Mind Centre, University of Sydney, and the Institute of Mental Health at the University of Wollongong (Australia). He also is a community psychiatrist in a remote region of New South Wales. Dr. Rosen has no conflicts of interest.

*This article was updated 6/16/2020.

Kind wishes and donations worldwide came to help Australian communities and wildlife affected by the extreme drought and uncontrollable bushfires. Indeed, Australians have become a warning beacon for the planet to recognize how factors associated with global warming can morph rapidly into runaway national emergencies.

Little attention, however, has addressed the extreme vulnerability of Australia’s First Nations people, the Aboriginal & Torres Strait Islander communities, to the climate crisis. U.N. reports conclude that “Indigenous people with close emotional and ancestral ties to the land are also likely to be disproportionately affected by environmental change and extreme weather events.”¹

In fact, Indigenous peoples, whether living traditionally or assimilated, are among the first to be adversely affected by climate change. This is because, in part, of extreme poverty, inadequate housing, unemployment and other social determinants, transgenerational cultural losses of life and culture, dislocations, traumatic experiences of child removal, overrepresentation in the prison system, and chronic diseases already leading to dramatic disparities in life expectancy and other health outcomes.

Research confirms that rural and remote Aboriginal communities will be Australia’s first mass climate refugees. “Without action to stop climate change, people will be forced to leave their country and leave behind much of what makes them Aboriginal.”² This is because of hotter temperatures, poorly built and unstable homes more vulnerable to heat, and longer and drier droughts. Their communities, in fire-prone townships, are running out of water. Abject poverty severely limits their options, aggravated by government inaction because of ideological climate change denialism. And now we have the overlay of COVID-19 threatening these communities.³

Human pandemics are potentially more likely to occur with climate change. Pandemics also are more apt to be associated with population growth, human settlement encroaching on forests, increasing wild animal or intermediary vector contact, and growth in global travel.

Subsequently, our Indigenous communities have had the most to lose if COVID-19 is let loose in their midst. Spatial separation is difficult in overcrowded, multigenerational households. It is hard to keep your hands washed with soap where reliable water supply is sometimes only communal. Their health workers’ access to protective and lifesaving ICU equipment and expertise may be extremely limited or erratic.

Much of the population is classified as highly vulnerable to COVID-19 because of chronic health disorders (for example, cardiovascular, respiratory, and renal issues; diabetes, and suicidality) and preexisting much shorter life expectancies. Their health workers’ access to protective and lifesaving ICU equipment and expertise is extremely limited. There are fears that, if COVID-19 gains a foothold, they may lose a whole generation of revered elders, who often are also the last fluent tribal language speakers and carriers of life-enhancing cultural stories, traditions, and rites. More urban-living Indigenous families may yet have a rough time avoiding these ravages.

In Australia, COVID-19 has been largely held at bay so far by state and territory governments that have closed borders, restricted nonessential travel, and discouraged or excluded outsiders from visiting remote Indigenous communities wherever possible. There have been complaints that such restrictions occasionally had been applied in these communities in a heavy-handed way by police and other authorities, and may be resisted if enforced unilaterally. They will work only if applied with cultural sensitivity, full Indigenous community consultation, and collaboration. So far, COVID-19 infection rates have been kept very low, with no Indigenous deaths. In Brazil, by contrast, infections and deaths are more than double the national average, itinerant missionaries have only just been excluded from Amazonian tribal lands so far by independent judicial intervention, while loggers and miners come and go freely, as sources of contagion.⁴  Some Indigenous peoples in the United States have experienced among the highest COVID-19 infection and death rates in the country (for example, the Navajo Nation in New Mexico, Arizona, and Utah), amounting to catastrophic loss and grief.

"Black Lives Matter" marches protesting the filmed police killing of George Floyd in the USA have spread worldwide, in the wake of ultra-high rates of police brutality and killings with impunity of non-white individuals.

Many Australians, including considerable numbers of Indigenous people, marched here in sympathy, despite their infective risk and vulnerabilities. They were also protesting the excessive rates of Aboriginal imprisonment, deaths in custody, and police killings without consequences. Both internationally and here, there was an apparent sense of release of pent-up anger and frustrations at both these injustices and the extra susceptibility of poor and non-white people to severe illness, death and dire economic consequences because of the pandemic. It is a deceptive myth that "we are all in this together." So it is encouraging that there is also forming a widespread sense of collective purpose and determination to get governments to address these iniquities and inequities at last.*

I have worked as a community psychiatrist in Barkinje Aboriginal tribal lands of the Far West region of New South Wales (NSW) regularly for 35 years, much of this time while also leading Royal North Shore University General Hospital & Community Mental Health Services in Sydney. Barkinje translates as “River People,” but local media mainly talk about the impact of prolonged drought on farmers and ranchers, who certainly are deeply affected by it. However, the media rarely mention the calamitous impacts on Aboriginal communities. The drought effects are exacerbated by multinational corporate irrigators that divert and allegedly steal river water with tacit encouragement from ostensibly responsible government ministers. The rivers dry up into algal ponds with millions of bloated, rotting dead fish, and entire communities’ water supplies fail.

Researchers have reported on the mental health impacts of prolonged drought and diversion of river water on rural and remote indigenous communities throughout the state of NSW.⁵ We have heard Barkinje and neighboring Wiradjuri people say, “if the land is sick, we are sick,” and, “if the river dries up, there’s nowhere to meet.” Fishing, a popular recreational activity and source of nutrition is now denied to these communities. Unlike farmers, they receive no governmental exceptional circumstance compensation payments during droughts. Instead, they lose their farming jobs, so there is no disposable income and loss of capacity to travel to connect to their extended kinship system and cultural roots (e.g., for funerals or football matches) in other remote townships. Such droughts exacerbate wildfires, loss of fish and birdlife, some of which are sacred spiritual totems; dying of traditional “lifeblood” rivers, decimating precious ancient red-river gumtrees that line the shores; and irreversible damage to other sacred sites (e.g., melting ancient rock art).

So, loss of sustainable food sources, meaningful livelihood, and cultural and leisure pursuits could create an existential threat to Aboriginal identity. However, rural Indigenous communities also told us “whatever you do to us, we will survive and persist, as we have done in the past.”⁶ This is comparable with the tenacity and resilience of other ancient cultures that have suffered genocidal persecution and discrimination in the past, and have stubbornly regrown and persisted and regrown into the future.

They yearn to care for their lands, rivers, and seas of their traditions and upbringing, whether as “saltwater” coastal or “freshwater” inland peoples. They value their extended families, honor their elders and their collective wisdom, while also living in “two worlds.” They often encourage their children to get educated and pursue individualistic aspirations to help their communities by training as tradespeople and professionals who may be better trusted to look after their own. As Charles Perkins, a most celebrated Aboriginal role model for living in both worlds, famously said: “We know we can’t live in the past, but the past lives in us.”

As anxiety and depression, psychological trauma, drug and alcohol misuse, family and communal violence, ecological grief,and suicidal vulnerability are precipitated or exacerbated by the stress of extreme environmental adversity, significant investment in ameliorating these harms is essential, not just for farmers, town businesspeople and their families, but for all those affected, especially these most vulnerable members of the community.⁷ We must provide more essential community services controlled by Aboriginal community members themselves. We must also train and support more Aboriginal mental health workers, healers, mental health educators, peer workers and Aboriginal liaison officers, to work alongside other mental health, and health and social service professionals. Aboriginal people need stable local employment opportunities in their communities. There is a huge opportunity to synergize traditional indigenous fire management with Western techniques, creating and consolidating more valued jobs and respected land management roles for Aboriginal rangers, vital for the future of both Aboriginal and wider communities. Pilot programs are emerging.

Aboriginal communities also need a more preventive, whole-of-life approach to social determinants, lifestyle factors, trauma, and political decisions associated with compromised neurodevelopment, and increased subsequent incidence and severity of mental illnesses in their communities.⁷

As Alexander Solzhenitsyn observed: “On our crowded planet there are no longer any ‘internal affairs.’ ”⁸ Climate change is the ultimate form of globalization: What we each do about it affects all others’ lives. We can only insist that, alongside adequate resourcing of our most evidence-based methods of fire, water, and climate control, our governments consult and listen to our Indigenous elders about applying climate management methods. These have been demonstrated to be sustainable and effective, possibly over 60,000 years – which is the longest established record of continuous Indigenous culture worldwide.

References

1. Ten impacts of the Australian bushfires. U.N. Environment Programme. 2020 Jan 20.

2. Allam L, Evershed N. “Too hot for humans? First Nations people fear becoming Australia’s first climate refugees.” The Guardian. 2019 Dec 17.

3. National Indigenous Australians Agency. “Coronavirus (COVID-19).”

4. Phillips D. “Brazil: Judge bans missionaries from Indigenous reserve over COVID-19 fears.” The Guardian. 2020 Apr 17.

5. Rigby CW et al. Aust J Rural Health. 2011 Oct;19(5):249-54.

6. Cunsolo A, Ellis NR. Nature Clim Change. 2018 Apr 3;8:275-81.

7. Gynther B et al. EClinicalMedicine. 2019 Apr 26;10:68-77.

8. Solzhenitsyn A. “Warning to the West,” speech delivered 30 Jun 1975. New York: Fararr, Straux & Girous, 1976.

Dr. Rosen, an officer of the Order of Australia and a Fellow of the Royal Australian and New Zealand College of Psychiatrists, is affiliated with the Brain & Mind Centre, University of Sydney, and the Institute of Mental Health at the University of Wollongong (Australia). He also is a community psychiatrist in a remote region of New South Wales. Dr. Rosen has no conflicts of interest.

*This article was updated 6/16/2020.

Kind wishes and donations worldwide came to help Australian communities and wildlife affected by the extreme drought and uncontrollable bushfires. Indeed, Australians have become a warning beacon for the planet to recognize how factors associated with global warming can morph rapidly into runaway national emergencies.

Little attention, however, has addressed the extreme vulnerability of Australia’s First Nations people, the Aboriginal & Torres Strait Islander communities, to the climate crisis. U.N. reports conclude that “Indigenous people with close emotional and ancestral ties to the land are also likely to be disproportionately affected by environmental change and extreme weather events.”¹

In fact, Indigenous peoples, whether living traditionally or assimilated, are among the first to be adversely affected by climate change. This is because, in part, of extreme poverty, inadequate housing, unemployment and other social determinants, transgenerational cultural losses of life and culture, dislocations, traumatic experiences of child removal, overrepresentation in the prison system, and chronic diseases already leading to dramatic disparities in life expectancy and other health outcomes.

Research confirms that rural and remote Aboriginal communities will be Australia’s first mass climate refugees. “Without action to stop climate change, people will be forced to leave their country and leave behind much of what makes them Aboriginal.”² This is because of hotter temperatures, poorly built and unstable homes more vulnerable to heat, and longer and drier droughts. Their communities, in fire-prone townships, are running out of water. Abject poverty severely limits their options, aggravated by government inaction because of ideological climate change denialism. And now we have the overlay of COVID-19 threatening these communities.³

Human pandemics are potentially more likely to occur with climate change. Pandemics also are more apt to be associated with population growth, human settlement encroaching on forests, increasing wild animal or intermediary vector contact, and growth in global travel.

Subsequently, our Indigenous communities have had the most to lose if COVID-19 is let loose in their midst. Spatial separation is difficult in overcrowded, multigenerational households. It is hard to keep your hands washed with soap where reliable water supply is sometimes only communal. Their health workers’ access to protective and lifesaving ICU equipment and expertise may be extremely limited or erratic.

Much of the population is classified as highly vulnerable to COVID-19 because of chronic health disorders (for example, cardiovascular, respiratory, and renal issues; diabetes, and suicidality) and preexisting much shorter life expectancies. Their health workers’ access to protective and lifesaving ICU equipment and expertise is extremely limited. There are fears that, if COVID-19 gains a foothold, they may lose a whole generation of revered elders, who often are also the last fluent tribal language speakers and carriers of life-enhancing cultural stories, traditions, and rites. More urban-living Indigenous families may yet have a rough time avoiding these ravages.

In Australia, COVID-19 has been largely held at bay so far by state and territory governments that have closed borders, restricted nonessential travel, and discouraged or excluded outsiders from visiting remote Indigenous communities wherever possible. There have been complaints that such restrictions occasionally had been applied in these communities in a heavy-handed way by police and other authorities, and may be resisted if enforced unilaterally. They will work only if applied with cultural sensitivity, full Indigenous community consultation, and collaboration. So far, COVID-19 infection rates have been kept very low, with no Indigenous deaths. In Brazil, by contrast, infections and deaths are more than double the national average, itinerant missionaries have only just been excluded from Amazonian tribal lands so far by independent judicial intervention, while loggers and miners come and go freely, as sources of contagion.⁴  Some Indigenous peoples in the United States have experienced among the highest COVID-19 infection and death rates in the country (for example, the Navajo Nation in New Mexico, Arizona, and Utah), amounting to catastrophic loss and grief.

"Black Lives Matter" marches protesting the filmed police killing of George Floyd in the USA have spread worldwide, in the wake of ultra-high rates of police brutality and killings with impunity of non-white individuals.

Many Australians, including considerable numbers of Indigenous people, marched here in sympathy, despite their infective risk and vulnerabilities. They were also protesting the excessive rates of Aboriginal imprisonment, deaths in custody, and police killings without consequences. Both internationally and here, there was an apparent sense of release of pent-up anger and frustrations at both these injustices and the extra susceptibility of poor and non-white people to severe illness, death and dire economic consequences because of the pandemic. It is a deceptive myth that "we are all in this together." So it is encouraging that there is also forming a widespread sense of collective purpose and determination to get governments to address these iniquities and inequities at last.*

I have worked as a community psychiatrist in Barkinje Aboriginal tribal lands of the Far West region of New South Wales (NSW) regularly for 35 years, much of this time while also leading Royal North Shore University General Hospital & Community Mental Health Services in Sydney. Barkinje translates as “River People,” but local media mainly talk about the impact of prolonged drought on farmers and ranchers, who certainly are deeply affected by it. However, the media rarely mention the calamitous impacts on Aboriginal communities. The drought effects are exacerbated by multinational corporate irrigators that divert and allegedly steal river water with tacit encouragement from ostensibly responsible government ministers. The rivers dry up into algal ponds with millions of bloated, rotting dead fish, and entire communities’ water supplies fail.

Researchers have reported on the mental health impacts of prolonged drought and diversion of river water on rural and remote indigenous communities throughout the state of NSW.⁵ We have heard Barkinje and neighboring Wiradjuri people say, “if the land is sick, we are sick,” and, “if the river dries up, there’s nowhere to meet.” Fishing, a popular recreational activity and source of nutrition is now denied to these communities. Unlike farmers, they receive no governmental exceptional circumstance compensation payments during droughts. Instead, they lose their farming jobs, so there is no disposable income and loss of capacity to travel to connect to their extended kinship system and cultural roots (e.g., for funerals or football matches) in other remote townships. Such droughts exacerbate wildfires, loss of fish and birdlife, some of which are sacred spiritual totems; dying of traditional “lifeblood” rivers, decimating precious ancient red-river gumtrees that line the shores; and irreversible damage to other sacred sites (e.g., melting ancient rock art).

So, loss of sustainable food sources, meaningful livelihood, and cultural and leisure pursuits could create an existential threat to Aboriginal identity. However, rural Indigenous communities also told us “whatever you do to us, we will survive and persist, as we have done in the past.”⁶ This is comparable with the tenacity and resilience of other ancient cultures that have suffered genocidal persecution and discrimination in the past, and have stubbornly regrown and persisted and regrown into the future.

They yearn to care for their lands, rivers, and seas of their traditions and upbringing, whether as “saltwater” coastal or “freshwater” inland peoples. They value their extended families, honor their elders and their collective wisdom, while also living in “two worlds.” They often encourage their children to get educated and pursue individualistic aspirations to help their communities by training as tradespeople and professionals who may be better trusted to look after their own. As Charles Perkins, a most celebrated Aboriginal role model for living in both worlds, famously said: “We know we can’t live in the past, but the past lives in us.”

As anxiety and depression, psychological trauma, drug and alcohol misuse, family and communal violence, ecological grief,and suicidal vulnerability are precipitated or exacerbated by the stress of extreme environmental adversity, significant investment in ameliorating these harms is essential, not just for farmers, town businesspeople and their families, but for all those affected, especially these most vulnerable members of the community.⁷ We must provide more essential community services controlled by Aboriginal community members themselves. We must also train and support more Aboriginal mental health workers, healers, mental health educators, peer workers and Aboriginal liaison officers, to work alongside other mental health, and health and social service professionals. Aboriginal people need stable local employment opportunities in their communities. There is a huge opportunity to synergize traditional indigenous fire management with Western techniques, creating and consolidating more valued jobs and respected land management roles for Aboriginal rangers, vital for the future of both Aboriginal and wider communities. Pilot programs are emerging.

Aboriginal communities also need a more preventive, whole-of-life approach to social determinants, lifestyle factors, trauma, and political decisions associated with compromised neurodevelopment, and increased subsequent incidence and severity of mental illnesses in their communities.⁷

As Alexander Solzhenitsyn observed: “On our crowded planet there are no longer any ‘internal affairs.’ ”⁸ Climate change is the ultimate form of globalization: What we each do about it affects all others’ lives. We can only insist that, alongside adequate resourcing of our most evidence-based methods of fire, water, and climate control, our governments consult and listen to our Indigenous elders about applying climate management methods. These have been demonstrated to be sustainable and effective, possibly over 60,000 years – which is the longest established record of continuous Indigenous culture worldwide.

References

1. Ten impacts of the Australian bushfires. U.N. Environment Programme. 2020 Jan 20.

2. Allam L, Evershed N. “Too hot for humans? First Nations people fear becoming Australia’s first climate refugees.” The Guardian. 2019 Dec 17.

3. National Indigenous Australians Agency. “Coronavirus (COVID-19).”

4. Phillips D. “Brazil: Judge bans missionaries from Indigenous reserve over COVID-19 fears.” The Guardian. 2020 Apr 17.

5. Rigby CW et al. Aust J Rural Health. 2011 Oct;19(5):249-54.

6. Cunsolo A, Ellis NR. Nature Clim Change. 2018 Apr 3;8:275-81.

7. Gynther B et al. EClinicalMedicine. 2019 Apr 26;10:68-77.

8. Solzhenitsyn A. “Warning to the West,” speech delivered 30 Jun 1975. New York: Fararr, Straux & Girous, 1976.

Dr. Rosen, an officer of the Order of Australia and a Fellow of the Royal Australian and New Zealand College of Psychiatrists, is affiliated with the Brain & Mind Centre, University of Sydney, and the Institute of Mental Health at the University of Wollongong (Australia). He also is a community psychiatrist in a remote region of New South Wales. Dr. Rosen has no conflicts of interest.

*This article was updated 6/16/2020.

A blood test detected 11 of 11 cases of colorectal cancer in a study involving 354 patients, and also spotted a majority of cases – 40 out of 53 – in which participants had advanced adenomas, an investigator said.

Results from a single-center study of CellMax Life’s FirstSight blood test were released as a poster as part of the annual Digestive Disease Week^®, which was canceled because of COVID-19.

For a study conducted at one site, the Veterans Affairs Palo Alto (Calif.) Healthcare System, Shai Friedland, MD, and colleagues recruited 354 patients between ages 45 and 80 who were scheduled for elective colonoscopy. The researchers excluded people with a personal history of cancer or inflammatory bowel disease. They used CellMax’s FirstSight test on blood samples from the study participants.

The FirstSight test result was positive for colorectal cancer in all 11 patients in the study who were found by colonoscopy to have this condition, said Dr. Friedland, who is a professor of medicine at Stanford (Calif.) University and chief of gastroenterology at the VA Palo Alto Healthcare System. Thus, the test showed a sensitivity of 100% in this instance.

Among the 53 study participants found by colonoscopy to have advanced adenoma, 40 were positive on FirstSight; thus, so the test has a sensitivity of 75.5% for this result.

Among 79 patients who had negative colonoscopy results, meaning they were judged free of cancer or polyps, the test showed 8 as having signs of disease or growths.

“If you had a large adenoma that was removed years ago and now you have a negative colonoscopy, your score might still be high,” Dr. Friedland said in a recorded presentation for DDW. “In other words, the changes that are detectable in your blood might persist even after the polypectomy.”

He said there are plans to soon start a large-scale multicenter study of the CellMax assay.

“The blood test has the potential to fill an unmet need by giving patients a highly sensitive convenient option for colorectal cancer screening,” he said.

CellMax already is seeking to position its test as a more convenient alternative to either colonoscopy or the Cologuard screening test. Many patients put off cancer screening because of the need to take time off from work and the invasive nature of colonoscopy. Exact Sciences has used direct-to-consumer advertising to promote its Cologuard home-based test as a more convenient alternative to colonoscopy, but its product requires patients to collect their own stool samples and mail them to a lab, a process many people find off-putting.

Public health advocates, including the U.S. Preventive Services Task Force (USPSTF), have for years been pressing for wider screening of American adults for colon cancer. USPSTF is in the midst of updating its recommendations on colon cancer. In announcing its latest update of these recommendations in 2016, USPSTF said “the best screening test is the one that gets done” (JAMA. 2016;315[23]:2564-75).

USPSTF pressed for maximizing the total proportion of the eligible population, a point Dr. Friedland echoed in a CellMax press release.

“For colon cancer screening to be most effective, it is essential to detect precancerous polyps and then perform a colonoscopy to remove the polyps,” said Dr. Friedland in the CellMax press release. “Giving patients the option of getting a blood test for screening would undoubtedly increase compliance and thereby reduce mortality from colorectal cancer.”

In the DDW presentation, Dr. Friedland and colleagues also said the CellMax test showed greater sensitivity (100%) for colorectal cancer and advanced precancerous lesions (75.5%) than did Cologuard (92.3% for colorectal cancer and 42.4% for advanced precancerous lesions).

Cara Connelly, Director of Public Relations and Corporate Communications for Exact Sciences said that the company “is dedicated to getting more people screened for colorectal cancer and applaud the researchers for their efforts. We look forward to hearing more about the performance of this test in a prospective multisite study with nonsymptomatic patients.”

Naresh T. Gunaratnam, MD, a gastroenterologist and research director at Huron Gastro in Ypsilanti, Mich., said he is concerned that aggressive promotion of alternative tests may obscure the benefits of colonoscopy. Dr. Gunaratnam, a 2019 winner of the American Gastroenterological Association (AGA) Distinguished Clinician Award, has been a public critic of the marketing of colon cancer tests, which emphasize the convenience of these products. When asked by MDedge to comment on the CellMax-funded study, Dr. Gunaratnam said alternative tests do have a place for the care of patients who cannot or will not have a colonoscopy.

“But if you convince a patient who would be willing to have a colonoscopy not to, that’s a disservice,” he said.

“If you want the best test, the one that is best at finding cancers and finding polyps and the only one that can remove the polyp, that’s colonoscopy,” Dr. Gunaratnam added. “One day there may be a pill you can swallow that blows up the polyps, but we’re not there yet. We have to mechanically remove them.”

SOURCE: Friedland S et al. DDW 2020, eposter 575.

A blood test detected 11 of 11 cases of colorectal cancer in a study involving 354 patients, and also spotted a majority of cases – 40 out of 53 – in which participants had advanced adenomas, an investigator said.

Results from a single-center study of CellMax Life’s FirstSight blood test were released as a poster as part of the annual Digestive Disease Week^®, which was canceled because of COVID-19.

For a study conducted at one site, the Veterans Affairs Palo Alto (Calif.) Healthcare System, Shai Friedland, MD, and colleagues recruited 354 patients between ages 45 and 80 who were scheduled for elective colonoscopy. The researchers excluded people with a personal history of cancer or inflammatory bowel disease. They used CellMax’s FirstSight test on blood samples from the study participants.

The FirstSight test result was positive for colorectal cancer in all 11 patients in the study who were found by colonoscopy to have this condition, said Dr. Friedland, who is a professor of medicine at Stanford (Calif.) University and chief of gastroenterology at the VA Palo Alto Healthcare System. Thus, the test showed a sensitivity of 100% in this instance.

Among the 53 study participants found by colonoscopy to have advanced adenoma, 40 were positive on FirstSight; thus, so the test has a sensitivity of 75.5% for this result.

Among 79 patients who had negative colonoscopy results, meaning they were judged free of cancer or polyps, the test showed 8 as having signs of disease or growths.

“If you had a large adenoma that was removed years ago and now you have a negative colonoscopy, your score might still be high,” Dr. Friedland said in a recorded presentation for DDW. “In other words, the changes that are detectable in your blood might persist even after the polypectomy.”

He said there are plans to soon start a large-scale multicenter study of the CellMax assay.

“The blood test has the potential to fill an unmet need by giving patients a highly sensitive convenient option for colorectal cancer screening,” he said.

CellMax already is seeking to position its test as a more convenient alternative to either colonoscopy or the Cologuard screening test. Many patients put off cancer screening because of the need to take time off from work and the invasive nature of colonoscopy. Exact Sciences has used direct-to-consumer advertising to promote its Cologuard home-based test as a more convenient alternative to colonoscopy, but its product requires patients to collect their own stool samples and mail them to a lab, a process many people find off-putting.

Public health advocates, including the U.S. Preventive Services Task Force (USPSTF), have for years been pressing for wider screening of American adults for colon cancer. USPSTF is in the midst of updating its recommendations on colon cancer. In announcing its latest update of these recommendations in 2016, USPSTF said “the best screening test is the one that gets done” (JAMA. 2016;315[23]:2564-75).

USPSTF pressed for maximizing the total proportion of the eligible population, a point Dr. Friedland echoed in a CellMax press release.

“For colon cancer screening to be most effective, it is essential to detect precancerous polyps and then perform a colonoscopy to remove the polyps,” said Dr. Friedland in the CellMax press release. “Giving patients the option of getting a blood test for screening would undoubtedly increase compliance and thereby reduce mortality from colorectal cancer.”

In the DDW presentation, Dr. Friedland and colleagues also said the CellMax test showed greater sensitivity (100%) for colorectal cancer and advanced precancerous lesions (75.5%) than did Cologuard (92.3% for colorectal cancer and 42.4% for advanced precancerous lesions).

Cara Connelly, Director of Public Relations and Corporate Communications for Exact Sciences said that the company “is dedicated to getting more people screened for colorectal cancer and applaud the researchers for their efforts. We look forward to hearing more about the performance of this test in a prospective multisite study with nonsymptomatic patients.”

Naresh T. Gunaratnam, MD, a gastroenterologist and research director at Huron Gastro in Ypsilanti, Mich., said he is concerned that aggressive promotion of alternative tests may obscure the benefits of colonoscopy. Dr. Gunaratnam, a 2019 winner of the American Gastroenterological Association (AGA) Distinguished Clinician Award, has been a public critic of the marketing of colon cancer tests, which emphasize the convenience of these products. When asked by MDedge to comment on the CellMax-funded study, Dr. Gunaratnam said alternative tests do have a place for the care of patients who cannot or will not have a colonoscopy.

“But if you convince a patient who would be willing to have a colonoscopy not to, that’s a disservice,” he said.

“If you want the best test, the one that is best at finding cancers and finding polyps and the only one that can remove the polyp, that’s colonoscopy,” Dr. Gunaratnam added. “One day there may be a pill you can swallow that blows up the polyps, but we’re not there yet. We have to mechanically remove them.”

SOURCE: Friedland S et al. DDW 2020, eposter 575.

A blood test detected 11 of 11 cases of colorectal cancer in a study involving 354 patients, and also spotted a majority of cases – 40 out of 53 – in which participants had advanced adenomas, an investigator said.

Results from a single-center study of CellMax Life’s FirstSight blood test were released as a poster as part of the annual Digestive Disease Week^®, which was canceled because of COVID-19.

For a study conducted at one site, the Veterans Affairs Palo Alto (Calif.) Healthcare System, Shai Friedland, MD, and colleagues recruited 354 patients between ages 45 and 80 who were scheduled for elective colonoscopy. The researchers excluded people with a personal history of cancer or inflammatory bowel disease. They used CellMax’s FirstSight test on blood samples from the study participants.

The FirstSight test result was positive for colorectal cancer in all 11 patients in the study who were found by colonoscopy to have this condition, said Dr. Friedland, who is a professor of medicine at Stanford (Calif.) University and chief of gastroenterology at the VA Palo Alto Healthcare System. Thus, the test showed a sensitivity of 100% in this instance.

Among the 53 study participants found by colonoscopy to have advanced adenoma, 40 were positive on FirstSight; thus, so the test has a sensitivity of 75.5% for this result.

Among 79 patients who had negative colonoscopy results, meaning they were judged free of cancer or polyps, the test showed 8 as having signs of disease or growths.

“If you had a large adenoma that was removed years ago and now you have a negative colonoscopy, your score might still be high,” Dr. Friedland said in a recorded presentation for DDW. “In other words, the changes that are detectable in your blood might persist even after the polypectomy.”

He said there are plans to soon start a large-scale multicenter study of the CellMax assay.

“The blood test has the potential to fill an unmet need by giving patients a highly sensitive convenient option for colorectal cancer screening,” he said.

CellMax already is seeking to position its test as a more convenient alternative to either colonoscopy or the Cologuard screening test. Many patients put off cancer screening because of the need to take time off from work and the invasive nature of colonoscopy. Exact Sciences has used direct-to-consumer advertising to promote its Cologuard home-based test as a more convenient alternative to colonoscopy, but its product requires patients to collect their own stool samples and mail them to a lab, a process many people find off-putting.

Public health advocates, including the U.S. Preventive Services Task Force (USPSTF), have for years been pressing for wider screening of American adults for colon cancer. USPSTF is in the midst of updating its recommendations on colon cancer. In announcing its latest update of these recommendations in 2016, USPSTF said “the best screening test is the one that gets done” (JAMA. 2016;315[23]:2564-75).

USPSTF pressed for maximizing the total proportion of the eligible population, a point Dr. Friedland echoed in a CellMax press release.

“For colon cancer screening to be most effective, it is essential to detect precancerous polyps and then perform a colonoscopy to remove the polyps,” said Dr. Friedland in the CellMax press release. “Giving patients the option of getting a blood test for screening would undoubtedly increase compliance and thereby reduce mortality from colorectal cancer.”

In the DDW presentation, Dr. Friedland and colleagues also said the CellMax test showed greater sensitivity (100%) for colorectal cancer and advanced precancerous lesions (75.5%) than did Cologuard (92.3% for colorectal cancer and 42.4% for advanced precancerous lesions).

Cara Connelly, Director of Public Relations and Corporate Communications for Exact Sciences said that the company “is dedicated to getting more people screened for colorectal cancer and applaud the researchers for their efforts. We look forward to hearing more about the performance of this test in a prospective multisite study with nonsymptomatic patients.”

Naresh T. Gunaratnam, MD, a gastroenterologist and research director at Huron Gastro in Ypsilanti, Mich., said he is concerned that aggressive promotion of alternative tests may obscure the benefits of colonoscopy. Dr. Gunaratnam, a 2019 winner of the American Gastroenterological Association (AGA) Distinguished Clinician Award, has been a public critic of the marketing of colon cancer tests, which emphasize the convenience of these products. When asked by MDedge to comment on the CellMax-funded study, Dr. Gunaratnam said alternative tests do have a place for the care of patients who cannot or will not have a colonoscopy.

“But if you convince a patient who would be willing to have a colonoscopy not to, that’s a disservice,” he said.

“If you want the best test, the one that is best at finding cancers and finding polyps and the only one that can remove the polyp, that’s colonoscopy,” Dr. Gunaratnam added. “One day there may be a pill you can swallow that blows up the polyps, but we’re not there yet. We have to mechanically remove them.”

SOURCE: Friedland S et al. DDW 2020, eposter 575.

As the COVID-19 pandemic continues to spread across the United States, several members of the Pediatric News Editorial Advisory Board shared how practices have been adapting to the pandemic, especially in terms of immunization.

Karalyn Kinsella, MD, a member of a four-pediatrician private practice in Cheshire, Conn., said in an interview that “we have been seeing only children under age 2 years for their well visits to keep them up to date on their vaccinations” as recommended by infectious disease departments at nearby hospitals such as Connecticut Children’s Medical Center. “We also are seeing the 4- and 5-year-old children for vaccinations.”

Dr. Kinsella explained that, in case parents don’t want to bring their children into the office, her staff is offering to give the vaccinations in the parking lot. But most families are coming into the office.

“We are only seeing well babies and take the parent and child back to a room as soon as they come in the office to avoid having patients sit in the waiting room. At this point, both parents and office staff are wearing masks; we are cleaning the rooms between patients,” Dr. Kinsella said.

“Most of our patients are coming in for their vaccines, so I don’t anticipate a lot of kids being behind. However, we will have a surge of all the physicals that need to be done prior to school in the fall. We have thought about opening up for the weekends for physicals to accommodate this. We also may need to start the day earlier and end later. I have heard some schools may be postponing the date the physicals are due.”

Because of a lack of full personal protective equipment, the practice has not been seeing sick visits in the office, but they have been doing a lot of telehealth visits. “We have been using doxy.me for that, which is free, incredibly easy to use, and Health Insurance Portability and Accountability Act (HIPAA)–compliant,” she said. “I am finding some visits, such as ADHD follow-ups and mental health follow-ups, very amenable to telehealth.”

“The hardest part – as I am sure is for most pediatricians – is the financial strain to a small business,” Dr. Kinsella noted. “We are down about 70% in revenue from this time last year. We have had to lay-off half our staff, and those who are working have much-reduced hours. We did not get the first round of funding for the paycheck protection program loan from the government and are waiting on the second round. We are trying to recoup some business by doing telehealth, but [the insurance companies] are only paying about 75%-80%. We also are charging for phone calls over 5 minutes. It will take a long time once we are up and running to recoup the losses.

“When this is all over, I’m hoping that we will be able to continue to incorporate telehealth into our schedules as I think it is convenient for families. I also am hoping that pediatricians continue to bill for phone calls as we have been giving out a lot of free care prior to this. I hope the American Academy of Pediatrics and all pediatricians work together to advocate for payment of these modalities,” she said.

J. Howard Smart, MD, who is chairman of the department of pediatrics at Sharp Rees-Stealy Medical Group in San Diego, said in an interview, “We have been bringing all of the infants and toddlers in for checkups and vaccines up to age 18 months.” These visits are scheduled in the morning, and sick patients are scheduled in the afternoon. “Well-child visits for older ages are being done by video, and the kindergarten and adolescent vaccines can be done by quick nurse visits. We will have some catching up to do once restrictions are lifted.”

“A fair amount of discussion went into these decisions. Is a video checkup better than no checkup? There is no clear-cut answer. Important things can be addressed by video: lifestyle, diet, exercise, family coping with stay-at-home orders, maintaining healthy childhood relationships, Internet use, ongoing education, among others. We know that we may miss things that can only be picked up by physical examination: hypertension, heart murmurs, abnormal growth, sexual development, abdominal masses, subtle strabismus. This is why we need to bring these children back for the physical exam later,” Dr. Smart emphasized.

“One possible negative result of doing the ‘well-child check’ by video would be if the parent assumed that the ‘checkup’ was done, never brought the child back for the exam, and something was missed that needed intervention. It will be important to get the message across that the return visit is needed. The American Academy of Pediatrics made this a part of their recommendations. It is going to be important for payers to realize that we need to do both visits – and to pay accordingly,” he concluded.

Francis E. Rushton Jr., MD, of Birmingham, Ala., described in an interview how the pediatricians in his former practice are looking for new ways to encourage shot administration in a timely manner during the COVID-19 pandemic, as well as exploring ways to partner with home visitors in encouraging timely infant and toddler vaccinations.

At South Carolina’s Beaufort Pediatrics, Joseph Floyd, MD, described a multipronged initiative. The practice’s well-child visit reminder system is being reprogrammed to check for lapses in vaccinations rather than just well-child visit attendance. For the most part, Dr. Floyd stated parents appreciate the reminders and accept the need for vaccination: “In the absence of immunizations for coronavirus, families seem to be more cognizant of the value of the vaccines we do have.” Beaufort Pediatrics is also partnering with their local hospital on a publicity campaign stressing the importance of staying up to date with currently available and recommended vaccines.

Other child-service organizations are concerned as well. Dr. Francis E. Rushton Jr., as faculty with the Education Development Center’s Health Resources and Services Administration–funded home-visiting quality improvement collaborative (HV CoIIN 2.0), described efforts with home visitors in Alabama and other states. “Home visitors understand the importance of immunizations to the health and welfare of the infants they care for. They’re looking for opportunities to improve compliance with vaccination regimens.” Some of these home-visiting agencies are employing quality improvement technique to improve compliance. One idea they are working on is documenting annual training on updated vaccines for the home visitors. They are working on protocols for linking their clients with primary health care providers, referral relations, and relationship development with local pediatric offices. Motivational interviewing techniques for home visitors focused on immunizations are being considered. For families who are hesitant, home visitors are considering accompanying the family when they come to the doctor’s office while paying attention to COVID-19 social distancing policies at medical facilities.

As the COVID-19 pandemic continues to spread across the United States, several members of the Pediatric News Editorial Advisory Board shared how practices have been adapting to the pandemic, especially in terms of immunization.

Karalyn Kinsella, MD, a member of a four-pediatrician private practice in Cheshire, Conn., said in an interview that “we have been seeing only children under age 2 years for their well visits to keep them up to date on their vaccinations” as recommended by infectious disease departments at nearby hospitals such as Connecticut Children’s Medical Center. “We also are seeing the 4- and 5-year-old children for vaccinations.”

Dr. Kinsella explained that, in case parents don’t want to bring their children into the office, her staff is offering to give the vaccinations in the parking lot. But most families are coming into the office.

“We are only seeing well babies and take the parent and child back to a room as soon as they come in the office to avoid having patients sit in the waiting room. At this point, both parents and office staff are wearing masks; we are cleaning the rooms between patients,” Dr. Kinsella said.

“Most of our patients are coming in for their vaccines, so I don’t anticipate a lot of kids being behind. However, we will have a surge of all the physicals that need to be done prior to school in the fall. We have thought about opening up for the weekends for physicals to accommodate this. We also may need to start the day earlier and end later. I have heard some schools may be postponing the date the physicals are due.”

Because of a lack of full personal protective equipment, the practice has not been seeing sick visits in the office, but they have been doing a lot of telehealth visits. “We have been using doxy.me for that, which is free, incredibly easy to use, and Health Insurance Portability and Accountability Act (HIPAA)–compliant,” she said. “I am finding some visits, such as ADHD follow-ups and mental health follow-ups, very amenable to telehealth.”

“The hardest part – as I am sure is for most pediatricians – is the financial strain to a small business,” Dr. Kinsella noted. “We are down about 70% in revenue from this time last year. We have had to lay-off half our staff, and those who are working have much-reduced hours. We did not get the first round of funding for the paycheck protection program loan from the government and are waiting on the second round. We are trying to recoup some business by doing telehealth, but [the insurance companies] are only paying about 75%-80%. We also are charging for phone calls over 5 minutes. It will take a long time once we are up and running to recoup the losses.

“When this is all over, I’m hoping that we will be able to continue to incorporate telehealth into our schedules as I think it is convenient for families. I also am hoping that pediatricians continue to bill for phone calls as we have been giving out a lot of free care prior to this. I hope the American Academy of Pediatrics and all pediatricians work together to advocate for payment of these modalities,” she said.

J. Howard Smart, MD, who is chairman of the department of pediatrics at Sharp Rees-Stealy Medical Group in San Diego, said in an interview, “We have been bringing all of the infants and toddlers in for checkups and vaccines up to age 18 months.” These visits are scheduled in the morning, and sick patients are scheduled in the afternoon. “Well-child visits for older ages are being done by video, and the kindergarten and adolescent vaccines can be done by quick nurse visits. We will have some catching up to do once restrictions are lifted.”

“A fair amount of discussion went into these decisions. Is a video checkup better than no checkup? There is no clear-cut answer. Important things can be addressed by video: lifestyle, diet, exercise, family coping with stay-at-home orders, maintaining healthy childhood relationships, Internet use, ongoing education, among others. We know that we may miss things that can only be picked up by physical examination: hypertension, heart murmurs, abnormal growth, sexual development, abdominal masses, subtle strabismus. This is why we need to bring these children back for the physical exam later,” Dr. Smart emphasized.

“One possible negative result of doing the ‘well-child check’ by video would be if the parent assumed that the ‘checkup’ was done, never brought the child back for the exam, and something was missed that needed intervention. It will be important to get the message across that the return visit is needed. The American Academy of Pediatrics made this a part of their recommendations. It is going to be important for payers to realize that we need to do both visits – and to pay accordingly,” he concluded.

Francis E. Rushton Jr., MD, of Birmingham, Ala., described in an interview how the pediatricians in his former practice are looking for new ways to encourage shot administration in a timely manner during the COVID-19 pandemic, as well as exploring ways to partner with home visitors in encouraging timely infant and toddler vaccinations.

At South Carolina’s Beaufort Pediatrics, Joseph Floyd, MD, described a multipronged initiative. The practice’s well-child visit reminder system is being reprogrammed to check for lapses in vaccinations rather than just well-child visit attendance. For the most part, Dr. Floyd stated parents appreciate the reminders and accept the need for vaccination: “In the absence of immunizations for coronavirus, families seem to be more cognizant of the value of the vaccines we do have.” Beaufort Pediatrics is also partnering with their local hospital on a publicity campaign stressing the importance of staying up to date with currently available and recommended vaccines.

Other child-service organizations are concerned as well. Dr. Francis E. Rushton Jr., as faculty with the Education Development Center’s Health Resources and Services Administration–funded home-visiting quality improvement collaborative (HV CoIIN 2.0), described efforts with home visitors in Alabama and other states. “Home visitors understand the importance of immunizations to the health and welfare of the infants they care for. They’re looking for opportunities to improve compliance with vaccination regimens.” Some of these home-visiting agencies are employing quality improvement technique to improve compliance. One idea they are working on is documenting annual training on updated vaccines for the home visitors. They are working on protocols for linking their clients with primary health care providers, referral relations, and relationship development with local pediatric offices. Motivational interviewing techniques for home visitors focused on immunizations are being considered. For families who are hesitant, home visitors are considering accompanying the family when they come to the doctor’s office while paying attention to COVID-19 social distancing policies at medical facilities.

As the COVID-19 pandemic continues to spread across the United States, several members of the Pediatric News Editorial Advisory Board shared how practices have been adapting to the pandemic, especially in terms of immunization.

Karalyn Kinsella, MD, a member of a four-pediatrician private practice in Cheshire, Conn., said in an interview that “we have been seeing only children under age 2 years for their well visits to keep them up to date on their vaccinations” as recommended by infectious disease departments at nearby hospitals such as Connecticut Children’s Medical Center. “We also are seeing the 4- and 5-year-old children for vaccinations.”

Dr. Kinsella explained that, in case parents don’t want to bring their children into the office, her staff is offering to give the vaccinations in the parking lot. But most families are coming into the office.

“We are only seeing well babies and take the parent and child back to a room as soon as they come in the office to avoid having patients sit in the waiting room. At this point, both parents and office staff are wearing masks; we are cleaning the rooms between patients,” Dr. Kinsella said.

“Most of our patients are coming in for their vaccines, so I don’t anticipate a lot of kids being behind. However, we will have a surge of all the physicals that need to be done prior to school in the fall. We have thought about opening up for the weekends for physicals to accommodate this. We also may need to start the day earlier and end later. I have heard some schools may be postponing the date the physicals are due.”

Because of a lack of full personal protective equipment, the practice has not been seeing sick visits in the office, but they have been doing a lot of telehealth visits. “We have been using doxy.me for that, which is free, incredibly easy to use, and Health Insurance Portability and Accountability Act (HIPAA)–compliant,” she said. “I am finding some visits, such as ADHD follow-ups and mental health follow-ups, very amenable to telehealth.”

“The hardest part – as I am sure is for most pediatricians – is the financial strain to a small business,” Dr. Kinsella noted. “We are down about 70% in revenue from this time last year. We have had to lay-off half our staff, and those who are working have much-reduced hours. We did not get the first round of funding for the paycheck protection program loan from the government and are waiting on the second round. We are trying to recoup some business by doing telehealth, but [the insurance companies] are only paying about 75%-80%. We also are charging for phone calls over 5 minutes. It will take a long time once we are up and running to recoup the losses.

“When this is all over, I’m hoping that we will be able to continue to incorporate telehealth into our schedules as I think it is convenient for families. I also am hoping that pediatricians continue to bill for phone calls as we have been giving out a lot of free care prior to this. I hope the American Academy of Pediatrics and all pediatricians work together to advocate for payment of these modalities,” she said.

J. Howard Smart, MD, who is chairman of the department of pediatrics at Sharp Rees-Stealy Medical Group in San Diego, said in an interview, “We have been bringing all of the infants and toddlers in for checkups and vaccines up to age 18 months.” These visits are scheduled in the morning, and sick patients are scheduled in the afternoon. “Well-child visits for older ages are being done by video, and the kindergarten and adolescent vaccines can be done by quick nurse visits. We will have some catching up to do once restrictions are lifted.”

“A fair amount of discussion went into these decisions. Is a video checkup better than no checkup? There is no clear-cut answer. Important things can be addressed by video: lifestyle, diet, exercise, family coping with stay-at-home orders, maintaining healthy childhood relationships, Internet use, ongoing education, among others. We know that we may miss things that can only be picked up by physical examination: hypertension, heart murmurs, abnormal growth, sexual development, abdominal masses, subtle strabismus. This is why we need to bring these children back for the physical exam later,” Dr. Smart emphasized.

“One possible negative result of doing the ‘well-child check’ by video would be if the parent assumed that the ‘checkup’ was done, never brought the child back for the exam, and something was missed that needed intervention. It will be important to get the message across that the return visit is needed. The American Academy of Pediatrics made this a part of their recommendations. It is going to be important for payers to realize that we need to do both visits – and to pay accordingly,” he concluded.

Francis E. Rushton Jr., MD, of Birmingham, Ala., described in an interview how the pediatricians in his former practice are looking for new ways to encourage shot administration in a timely manner during the COVID-19 pandemic, as well as exploring ways to partner with home visitors in encouraging timely infant and toddler vaccinations.

At South Carolina’s Beaufort Pediatrics, Joseph Floyd, MD, described a multipronged initiative. The practice’s well-child visit reminder system is being reprogrammed to check for lapses in vaccinations rather than just well-child visit attendance. For the most part, Dr. Floyd stated parents appreciate the reminders and accept the need for vaccination: “In the absence of immunizations for coronavirus, families seem to be more cognizant of the value of the vaccines we do have.” Beaufort Pediatrics is also partnering with their local hospital on a publicity campaign stressing the importance of staying up to date with currently available and recommended vaccines.

Other child-service organizations are concerned as well. Dr. Francis E. Rushton Jr., as faculty with the Education Development Center’s Health Resources and Services Administration–funded home-visiting quality improvement collaborative (HV CoIIN 2.0), described efforts with home visitors in Alabama and other states. “Home visitors understand the importance of immunizations to the health and welfare of the infants they care for. They’re looking for opportunities to improve compliance with vaccination regimens.” Some of these home-visiting agencies are employing quality improvement technique to improve compliance. One idea they are working on is documenting annual training on updated vaccines for the home visitors. They are working on protocols for linking their clients with primary health care providers, referral relations, and relationship development with local pediatric offices. Motivational interviewing techniques for home visitors focused on immunizations are being considered. For families who are hesitant, home visitors are considering accompanying the family when they come to the doctor’s office while paying attention to COVID-19 social distancing policies at medical facilities.