Background: An increasing body of literature suggests that hyperoxia may be harmful, yet liberal use of supplemental oxygen remains widespread.

Much like transfusion thresholds, more may not always be better when it comes to supplemental oxygen. Hospitalists should consider the harmful effects of hyperoxia when caring for patients on supplemental oxygen. Unfortunately, median blood oxygen saturation during therapy was not available for each group in this trial, so more research is needed to clearly define the upper limit of oxygen saturation at which harm outweighs benefit.

Bottom line: When compared to conservative oxygen administration, liberal oxygen therapy increases mortality in acutely ill adults.

Citation: Chu DK et al. Mortality and morbidity in acutely ill adults treated with liberal versus conservative oxygen therapy (IOTA): a systematic review and meta-analysis. Lancet. 2018;391:1693-705.

Dr. Metter is an assistant professor in the division of hospital medicine, University of Colorado, Denver.

Background: An increasing body of literature suggests that hyperoxia may be harmful, yet liberal use of supplemental oxygen remains widespread.

Much like transfusion thresholds, more may not always be better when it comes to supplemental oxygen. Hospitalists should consider the harmful effects of hyperoxia when caring for patients on supplemental oxygen. Unfortunately, median blood oxygen saturation during therapy was not available for each group in this trial, so more research is needed to clearly define the upper limit of oxygen saturation at which harm outweighs benefit.

Bottom line: When compared to conservative oxygen administration, liberal oxygen therapy increases mortality in acutely ill adults.

Citation: Chu DK et al. Mortality and morbidity in acutely ill adults treated with liberal versus conservative oxygen therapy (IOTA): a systematic review and meta-analysis. Lancet. 2018;391:1693-705.

Dr. Metter is an assistant professor in the division of hospital medicine, University of Colorado, Denver.

Background: An increasing body of literature suggests that hyperoxia may be harmful, yet liberal use of supplemental oxygen remains widespread.

Much like transfusion thresholds, more may not always be better when it comes to supplemental oxygen. Hospitalists should consider the harmful effects of hyperoxia when caring for patients on supplemental oxygen. Unfortunately, median blood oxygen saturation during therapy was not available for each group in this trial, so more research is needed to clearly define the upper limit of oxygen saturation at which harm outweighs benefit.

Bottom line: When compared to conservative oxygen administration, liberal oxygen therapy increases mortality in acutely ill adults.

Citation: Chu DK et al. Mortality and morbidity in acutely ill adults treated with liberal versus conservative oxygen therapy (IOTA): a systematic review and meta-analysis. Lancet. 2018;391:1693-705.

Dr. Metter is an assistant professor in the division of hospital medicine, University of Colorado, Denver.

CHICAGO – The American College of Rheumatology is continuing to work on its physician-focused advanced alternative payment model (APM) pathway for RA, with hopes to send the fully developed model to the Physician-Focused Payment Model Technical Advisory Committee once financial data gathering and analysis is complete, followed by pilot testing once it is accepted by the Centers for Medicare & Medicaid Services, speakers said at the annual meeting of the ACR.

The “RA Care Team” APM is meant to be versatile and work across various practice settings, from rural Alaska and the Southwest to urban Chicago and Boston, and would consist of a rheumatologist or a nurse practitioner or physician assistant working with a rheumatologist in some areas, while in others a patient would be managed by a primary care physician who has a formal arrangement with a rheumatologist to provide early treatment of RA. Participation in the model would use a standard treatment approach pathway that follows ACR treatment guidelines and saves money by reducing the variability in initiation of expensive medications and would be versatile enough to allow for unique patients by requiring only 75% adherence to the pathway across a practice’s patients, said Kwas Huston, MD, cochair of the ACR’s APM work group and a rheumatologist with Kansas City (Mo.) Physician Partners.

The model covers four phases of care, including diagnosis and treatment planning for patients with potential RA, support for primary care practices in evaluating joint symptoms, the initial treatment of patients with RA, and the continued care of RA. For instance, a rheumatologist could receive payment for an e-consult with a primary care provider to determine if a patient has symptoms requiring an evaluation for RA. A rheumatologist could also receive a one-time payment for treatment and planning services when a diagnosis of RA cannot be established in a patient suspected of having RA, whereas the rheumatologist or a primary care provider with rheumatology support would receive monthly payments for 6 months for the initial treatment of an RA patient and then thereafter would receive monthly payments for continued care of RA. The payments would not be dependent on the number of visits or face-to-face time, would be stratified based on patient characteristics, and would include some lab testing and imaging.

Currently, the RA APM work group is analyzing financial data gathered from two large rheumatology practices for specific CPT codes matched to specific patients based on their clinical characteristics “to get a sense of how much revenue is coming in right now for practices taking care of patients with, let’s say, moderate disease activity and two comorbidities or low disease activity and no comorbidities,” Dr. Huston said. The work group is also surveying practices to estimate additional costs required to participate in the APM and thereby develop a financial model to adequately pay for APM services. They additionally plan to develop a tool kit that is designed to help individual practices determine the economic impact that the APM would have.

Notably, the cost of medications is not included in the APM. “That would be too much of a risk for small practices to take on,” Dr. Huston said.

“This model is a work in progress. We still have a lot of additional work to validate the data,” he added.

Providers who wish to participate in an advanced APM in 2019 need to have at least 25% of their Medicare Part B payments or have at least 20% of Medicare patients in their practice come through the APM in order to avoid having to submit data to comply with the performance criteria requirements of the Merit-Based Incentive Payment System, said Angus Worthing, MD, chair of the ACR’s Government Affairs Committee and a practicing rheumatologist in the Washington area.

“The ACR has advocated to reduce these thresholds over the years, but unfortunately that has not happened yet,” Dr. Worthing said.

jevans@mdedge.com

CHICAGO – The American College of Rheumatology is continuing to work on its physician-focused advanced alternative payment model (APM) pathway for RA, with hopes to send the fully developed model to the Physician-Focused Payment Model Technical Advisory Committee once financial data gathering and analysis is complete, followed by pilot testing once it is accepted by the Centers for Medicare & Medicaid Services, speakers said at the annual meeting of the ACR.

The “RA Care Team” APM is meant to be versatile and work across various practice settings, from rural Alaska and the Southwest to urban Chicago and Boston, and would consist of a rheumatologist or a nurse practitioner or physician assistant working with a rheumatologist in some areas, while in others a patient would be managed by a primary care physician who has a formal arrangement with a rheumatologist to provide early treatment of RA. Participation in the model would use a standard treatment approach pathway that follows ACR treatment guidelines and saves money by reducing the variability in initiation of expensive medications and would be versatile enough to allow for unique patients by requiring only 75% adherence to the pathway across a practice’s patients, said Kwas Huston, MD, cochair of the ACR’s APM work group and a rheumatologist with Kansas City (Mo.) Physician Partners.

The model covers four phases of care, including diagnosis and treatment planning for patients with potential RA, support for primary care practices in evaluating joint symptoms, the initial treatment of patients with RA, and the continued care of RA. For instance, a rheumatologist could receive payment for an e-consult with a primary care provider to determine if a patient has symptoms requiring an evaluation for RA. A rheumatologist could also receive a one-time payment for treatment and planning services when a diagnosis of RA cannot be established in a patient suspected of having RA, whereas the rheumatologist or a primary care provider with rheumatology support would receive monthly payments for 6 months for the initial treatment of an RA patient and then thereafter would receive monthly payments for continued care of RA. The payments would not be dependent on the number of visits or face-to-face time, would be stratified based on patient characteristics, and would include some lab testing and imaging.

Currently, the RA APM work group is analyzing financial data gathered from two large rheumatology practices for specific CPT codes matched to specific patients based on their clinical characteristics “to get a sense of how much revenue is coming in right now for practices taking care of patients with, let’s say, moderate disease activity and two comorbidities or low disease activity and no comorbidities,” Dr. Huston said. The work group is also surveying practices to estimate additional costs required to participate in the APM and thereby develop a financial model to adequately pay for APM services. They additionally plan to develop a tool kit that is designed to help individual practices determine the economic impact that the APM would have.

Notably, the cost of medications is not included in the APM. “That would be too much of a risk for small practices to take on,” Dr. Huston said.

“This model is a work in progress. We still have a lot of additional work to validate the data,” he added.

Providers who wish to participate in an advanced APM in 2019 need to have at least 25% of their Medicare Part B payments or have at least 20% of Medicare patients in their practice come through the APM in order to avoid having to submit data to comply with the performance criteria requirements of the Merit-Based Incentive Payment System, said Angus Worthing, MD, chair of the ACR’s Government Affairs Committee and a practicing rheumatologist in the Washington area.

“The ACR has advocated to reduce these thresholds over the years, but unfortunately that has not happened yet,” Dr. Worthing said.

jevans@mdedge.com

CHICAGO – The American College of Rheumatology is continuing to work on its physician-focused advanced alternative payment model (APM) pathway for RA, with hopes to send the fully developed model to the Physician-Focused Payment Model Technical Advisory Committee once financial data gathering and analysis is complete, followed by pilot testing once it is accepted by the Centers for Medicare & Medicaid Services, speakers said at the annual meeting of the ACR.

The “RA Care Team” APM is meant to be versatile and work across various practice settings, from rural Alaska and the Southwest to urban Chicago and Boston, and would consist of a rheumatologist or a nurse practitioner or physician assistant working with a rheumatologist in some areas, while in others a patient would be managed by a primary care physician who has a formal arrangement with a rheumatologist to provide early treatment of RA. Participation in the model would use a standard treatment approach pathway that follows ACR treatment guidelines and saves money by reducing the variability in initiation of expensive medications and would be versatile enough to allow for unique patients by requiring only 75% adherence to the pathway across a practice’s patients, said Kwas Huston, MD, cochair of the ACR’s APM work group and a rheumatologist with Kansas City (Mo.) Physician Partners.

The model covers four phases of care, including diagnosis and treatment planning for patients with potential RA, support for primary care practices in evaluating joint symptoms, the initial treatment of patients with RA, and the continued care of RA. For instance, a rheumatologist could receive payment for an e-consult with a primary care provider to determine if a patient has symptoms requiring an evaluation for RA. A rheumatologist could also receive a one-time payment for treatment and planning services when a diagnosis of RA cannot be established in a patient suspected of having RA, whereas the rheumatologist or a primary care provider with rheumatology support would receive monthly payments for 6 months for the initial treatment of an RA patient and then thereafter would receive monthly payments for continued care of RA. The payments would not be dependent on the number of visits or face-to-face time, would be stratified based on patient characteristics, and would include some lab testing and imaging.

Currently, the RA APM work group is analyzing financial data gathered from two large rheumatology practices for specific CPT codes matched to specific patients based on their clinical characteristics “to get a sense of how much revenue is coming in right now for practices taking care of patients with, let’s say, moderate disease activity and two comorbidities or low disease activity and no comorbidities,” Dr. Huston said. The work group is also surveying practices to estimate additional costs required to participate in the APM and thereby develop a financial model to adequately pay for APM services. They additionally plan to develop a tool kit that is designed to help individual practices determine the economic impact that the APM would have.

Notably, the cost of medications is not included in the APM. “That would be too much of a risk for small practices to take on,” Dr. Huston said.

“This model is a work in progress. We still have a lot of additional work to validate the data,” he added.

Providers who wish to participate in an advanced APM in 2019 need to have at least 25% of their Medicare Part B payments or have at least 20% of Medicare patients in their practice come through the APM in order to avoid having to submit data to comply with the performance criteria requirements of the Merit-Based Incentive Payment System, said Angus Worthing, MD, chair of the ACR’s Government Affairs Committee and a practicing rheumatologist in the Washington area.

“The ACR has advocated to reduce these thresholds over the years, but unfortunately that has not happened yet,” Dr. Worthing said.

jevans@mdedge.com

Nutritious eating need not involve counting calories, carbohydrates, or points, according to food and nutrition editor Paul Kita.

dulezidar/Thinkstock

After talking with experts and studying various diets, Mr. Kita said he found an approach that works for him.

The key is eating “real food,” such as chicken, tomatoes, eggs, and avocados; avoiding processed foods; and not demonizing anything. Approaching food this way for 10 years has allowed Mr. Kita to keep his weight at 155 pounds – give or take 5, – he wrote in Men’s Health.

“I eat cookies. I eat carbs. I even drink coffee supposedly loaded with mycotoxins,” Mr. Kita wrote. “I [eat] fruits and vegetables with every meal and cut back on booze and desserts. I have two clementines or a banana or a split broiled tomato for breakfast. I eat a big salad of mixed greens or a side of coleslaw or a ripe, juicy pear for lunch.”

He said dinner might include sautéed spinach or a carrot salad and roasted sweet potatoes. “And then I either choose to have a beer with or after dinner or a simple dessert. If I’m not craving something sweet, I’ll have a cup of tea.”

He said he tries for about 30 grams of protein at each meal.

“Here’s my main takeaway ... if the plan you have for what you feed yourself causes you more stress and adds more work to your already-busy life, you’re not eating well. The best diet ... doesn’t have celebrity endorsements. The best diet is one that is based on the inclusion of healthful foods – not the exclusion of food groups.”

Students seek to prevent suicides

The beauty of mountains can be breathtaking for someone passing through. For residents, living in the shadow of the giants, however, can be isolating, especially for small mountain communities. Grand Junction, Colo., is located in a valley ringed by tall mountains, desert mesas, and red-rock cliffs. For local residents, and especially teenagers, it can feel like the end of the world.

“I know we can’t really fix this because it’s nature,” 17-year-old Victoria Mendoza said in an NPR interview. “I feel like the people in our valley feel like there’s only life inside of Grand Junction.”

Ms. Mendoza has fought depression, as have other members of her family and others in the community. Seven student suicides occurred in the 2016-2017 school year. “It felt like there was this cloud around our whole valley,” Ms. Mendoza said. “It got to a point where we were just waiting for the next one.”

Rural settings can foster the loneliness that, for some, is only cured by self-inflicted death. Of the top 10 U.S. states with the highest rates of suicide, 8 are located in the rural mountain West. The view of mental illness as a sign of personal weakness remains prevalent, and having ready access to guns is not helpful.

In Grand Junction, students have seized the reins of a suicide prevention in which they act as peer mentors to younger students that either seek help or appear to be floundering. The approach, called the Sources of Strength suicide program, exemplifies a broader shift in public health thinking that is taking place. In Grand Junction, the strategy is to zero in on the mental health and well-being of everyone. That encourages a sense of community, even in a setting of physical isolation.

Cannabidiol and substance-free living

With cannabis use becoming more part of the norm and with its legalization, the idea of altering the way we see the world is, for some, moving from a no-go option to a practice that can help ease the strains of life. For those who struggle with PTSD or other anxieties, cannabis can be a way to alleviate paranoia, anxiety, and mood swings without the use of prescription drugs.

Of course, there will be many who will overenthusiastically embrace the chance to legally alter themselves, such as what occurs with alcohol. Sobriety means different things to different people. Some alcoholics happily live with an occasional drink. They consider themselves on a path of sobriety. Others must go cold turkey forever. This is a different sobriety. Each can be effective and can bring happiness.

“Does using cannabidiol count as a strike against recovery or a substance-free lifestyle? This can lead into particularly tricky terrain as many people turn to cannabis products as a solution for all manner of ailments – from mental health to addiction. As we reckon with cannabis legalization as a country, perhaps what we really should be asking ourselves is how we’re going to redefine the traditional meaning of sobriety,” Amanda Scriver wrote in the Walrus.

“As cannabidiol gains popularity, we must give people the capacity to examine, evaluate, and possibly amend their own health, wellness, or recovery journey in a way that feels right for them. Yes, we need better medical understanding of cannabis and its related products, and yes, we also need training in the harm-reduction model. But we also need compassion and the courage to rethink old definitions,” Ms. Scriver wrote.

Masculinity tied to mental health

As a celebrity, Lenard Larry McKelvey, aka Charlamagne Tha God, makes his living being brash and bold. On his radio show, The Breakfast Club, he asks questions some do not want asked. But, like many, he is also anxious about the world. As a father, he worries about his daughters. As a black man, he worries about police brutality.

But unlike many, he has a forum and an audience. And he is using his forum to speak out about his fears and anxieties in the hope that it helps others deal with their demons. A recent example is his book, “Shook One: Anxiety Playing Tricks On Me” (Touchstone, 2018).

He is a strong advocate of therapy. “I go to therapy just to push those negative thoughts out of my mind. None of us can escape thinking negatively. Negative thoughts are going to pop up in your head. You’re going to have self-doubt sometimes; you’re going to be insecure sometimes. You’re going to worry about your kids; you’re going to worry about your wife, but it’s about pushing that %@C# out and not holding onto it. When you hold onto it, that’s when it grows,” he explained in an interview with the Boston Globe.

He espoused the freedom that comes from self-acceptance. “My whole life, people have said to me, ‘You can’t be soft.’ I don’t care about that anymore. I don’t care about how people perceive me when it comes to masculinity. You know what’s masculine? Masculine is taking care of your mind, your body, and your soul. We spend so much time on our body. We want that six-pack. But what about your mental health? What about your mental well-being? I go to the gym three, four times a week. Why can’t I put that same effort and same energy into getting mentally strong?”

Can extremists’ mindsets change?

The recent massacre at the Pittsburgh synagogue was yet another vile example of hatred and bigotry. But, in the United States and elsewhere, the shooter was one of many. Why?

According to an NPR piece, there are several possible explanations. Those brimming with racist hated might have little opportunity to get off that track. “We haven’t wanted to acknowledge that we have a problem with violent right-wing extremism in this kind of domestic terrorism,” said sociologist Pete Simi, PhD, of Chapman University in Orange, Calif. Dr. Simi has studied violent white nationalists and other hate groups for decades.


“White supremacy is really a problem throughout the United States,” Dr. Simi said. “It doesn’t know any geographic boundaries. It’s not isolated to either urban or rural or suburban – it cuts across all.”

There is little knowledge of how to deal with home-grown hatred. Banning immigrants perceived as being a threat is one attempt to deal with foreign-born terrorism, but that doesn’t work for citizens. For them, rehabilitation is possible, according to Dr. Simi, but it comes with a big price tag of revamped social, education, housing, and employment programs. Governments are loathe to take on those costs, in part because it is an admission that society is broken.

“A big, big problem that we face as a society is abdicating our responsibility in terms of providing this kind of social support and social safety net for individuals that suffer from mental health, as well as drug problems,” Dr. Simi said in the interview.

Small-scale local efforts, such as the Chicago-based Life After Hate, are working for change. How to scale up such efforts is a vexing problem.

Nutritious eating need not involve counting calories, carbohydrates, or points, according to food and nutrition editor Paul Kita.

dulezidar/Thinkstock

After talking with experts and studying various diets, Mr. Kita said he found an approach that works for him.

The key is eating “real food,” such as chicken, tomatoes, eggs, and avocados; avoiding processed foods; and not demonizing anything. Approaching food this way for 10 years has allowed Mr. Kita to keep his weight at 155 pounds – give or take 5, – he wrote in Men’s Health.

“I eat cookies. I eat carbs. I even drink coffee supposedly loaded with mycotoxins,” Mr. Kita wrote. “I [eat] fruits and vegetables with every meal and cut back on booze and desserts. I have two clementines or a banana or a split broiled tomato for breakfast. I eat a big salad of mixed greens or a side of coleslaw or a ripe, juicy pear for lunch.”

He said dinner might include sautéed spinach or a carrot salad and roasted sweet potatoes. “And then I either choose to have a beer with or after dinner or a simple dessert. If I’m not craving something sweet, I’ll have a cup of tea.”

He said he tries for about 30 grams of protein at each meal.

“Here’s my main takeaway ... if the plan you have for what you feed yourself causes you more stress and adds more work to your already-busy life, you’re not eating well. The best diet ... doesn’t have celebrity endorsements. The best diet is one that is based on the inclusion of healthful foods – not the exclusion of food groups.”

Students seek to prevent suicides

The beauty of mountains can be breathtaking for someone passing through. For residents, living in the shadow of the giants, however, can be isolating, especially for small mountain communities. Grand Junction, Colo., is located in a valley ringed by tall mountains, desert mesas, and red-rock cliffs. For local residents, and especially teenagers, it can feel like the end of the world.

“I know we can’t really fix this because it’s nature,” 17-year-old Victoria Mendoza said in an NPR interview. “I feel like the people in our valley feel like there’s only life inside of Grand Junction.”

Ms. Mendoza has fought depression, as have other members of her family and others in the community. Seven student suicides occurred in the 2016-2017 school year. “It felt like there was this cloud around our whole valley,” Ms. Mendoza said. “It got to a point where we were just waiting for the next one.”

Rural settings can foster the loneliness that, for some, is only cured by self-inflicted death. Of the top 10 U.S. states with the highest rates of suicide, 8 are located in the rural mountain West. The view of mental illness as a sign of personal weakness remains prevalent, and having ready access to guns is not helpful.

In Grand Junction, students have seized the reins of a suicide prevention in which they act as peer mentors to younger students that either seek help or appear to be floundering. The approach, called the Sources of Strength suicide program, exemplifies a broader shift in public health thinking that is taking place. In Grand Junction, the strategy is to zero in on the mental health and well-being of everyone. That encourages a sense of community, even in a setting of physical isolation.

Cannabidiol and substance-free living

With cannabis use becoming more part of the norm and with its legalization, the idea of altering the way we see the world is, for some, moving from a no-go option to a practice that can help ease the strains of life. For those who struggle with PTSD or other anxieties, cannabis can be a way to alleviate paranoia, anxiety, and mood swings without the use of prescription drugs.

Of course, there will be many who will overenthusiastically embrace the chance to legally alter themselves, such as what occurs with alcohol. Sobriety means different things to different people. Some alcoholics happily live with an occasional drink. They consider themselves on a path of sobriety. Others must go cold turkey forever. This is a different sobriety. Each can be effective and can bring happiness.

“Does using cannabidiol count as a strike against recovery or a substance-free lifestyle? This can lead into particularly tricky terrain as many people turn to cannabis products as a solution for all manner of ailments – from mental health to addiction. As we reckon with cannabis legalization as a country, perhaps what we really should be asking ourselves is how we’re going to redefine the traditional meaning of sobriety,” Amanda Scriver wrote in the Walrus.

“As cannabidiol gains popularity, we must give people the capacity to examine, evaluate, and possibly amend their own health, wellness, or recovery journey in a way that feels right for them. Yes, we need better medical understanding of cannabis and its related products, and yes, we also need training in the harm-reduction model. But we also need compassion and the courage to rethink old definitions,” Ms. Scriver wrote.

Masculinity tied to mental health

As a celebrity, Lenard Larry McKelvey, aka Charlamagne Tha God, makes his living being brash and bold. On his radio show, The Breakfast Club, he asks questions some do not want asked. But, like many, he is also anxious about the world. As a father, he worries about his daughters. As a black man, he worries about police brutality.

But unlike many, he has a forum and an audience. And he is using his forum to speak out about his fears and anxieties in the hope that it helps others deal with their demons. A recent example is his book, “Shook One: Anxiety Playing Tricks On Me” (Touchstone, 2018).

He is a strong advocate of therapy. “I go to therapy just to push those negative thoughts out of my mind. None of us can escape thinking negatively. Negative thoughts are going to pop up in your head. You’re going to have self-doubt sometimes; you’re going to be insecure sometimes. You’re going to worry about your kids; you’re going to worry about your wife, but it’s about pushing that %@C# out and not holding onto it. When you hold onto it, that’s when it grows,” he explained in an interview with the Boston Globe.

He espoused the freedom that comes from self-acceptance. “My whole life, people have said to me, ‘You can’t be soft.’ I don’t care about that anymore. I don’t care about how people perceive me when it comes to masculinity. You know what’s masculine? Masculine is taking care of your mind, your body, and your soul. We spend so much time on our body. We want that six-pack. But what about your mental health? What about your mental well-being? I go to the gym three, four times a week. Why can’t I put that same effort and same energy into getting mentally strong?”

Can extremists’ mindsets change?

The recent massacre at the Pittsburgh synagogue was yet another vile example of hatred and bigotry. But, in the United States and elsewhere, the shooter was one of many. Why?

According to an NPR piece, there are several possible explanations. Those brimming with racist hated might have little opportunity to get off that track. “We haven’t wanted to acknowledge that we have a problem with violent right-wing extremism in this kind of domestic terrorism,” said sociologist Pete Simi, PhD, of Chapman University in Orange, Calif. Dr. Simi has studied violent white nationalists and other hate groups for decades.


“White supremacy is really a problem throughout the United States,” Dr. Simi said. “It doesn’t know any geographic boundaries. It’s not isolated to either urban or rural or suburban – it cuts across all.”

There is little knowledge of how to deal with home-grown hatred. Banning immigrants perceived as being a threat is one attempt to deal with foreign-born terrorism, but that doesn’t work for citizens. For them, rehabilitation is possible, according to Dr. Simi, but it comes with a big price tag of revamped social, education, housing, and employment programs. Governments are loathe to take on those costs, in part because it is an admission that society is broken.

“A big, big problem that we face as a society is abdicating our responsibility in terms of providing this kind of social support and social safety net for individuals that suffer from mental health, as well as drug problems,” Dr. Simi said in the interview.

Small-scale local efforts, such as the Chicago-based Life After Hate, are working for change. How to scale up such efforts is a vexing problem.

Nutritious eating need not involve counting calories, carbohydrates, or points, according to food and nutrition editor Paul Kita.

dulezidar/Thinkstock

After talking with experts and studying various diets, Mr. Kita said he found an approach that works for him.

The key is eating “real food,” such as chicken, tomatoes, eggs, and avocados; avoiding processed foods; and not demonizing anything. Approaching food this way for 10 years has allowed Mr. Kita to keep his weight at 155 pounds – give or take 5, – he wrote in Men’s Health.

“I eat cookies. I eat carbs. I even drink coffee supposedly loaded with mycotoxins,” Mr. Kita wrote. “I [eat] fruits and vegetables with every meal and cut back on booze and desserts. I have two clementines or a banana or a split broiled tomato for breakfast. I eat a big salad of mixed greens or a side of coleslaw or a ripe, juicy pear for lunch.”

He said dinner might include sautéed spinach or a carrot salad and roasted sweet potatoes. “And then I either choose to have a beer with or after dinner or a simple dessert. If I’m not craving something sweet, I’ll have a cup of tea.”

He said he tries for about 30 grams of protein at each meal.

“Here’s my main takeaway ... if the plan you have for what you feed yourself causes you more stress and adds more work to your already-busy life, you’re not eating well. The best diet ... doesn’t have celebrity endorsements. The best diet is one that is based on the inclusion of healthful foods – not the exclusion of food groups.”

Students seek to prevent suicides

The beauty of mountains can be breathtaking for someone passing through. For residents, living in the shadow of the giants, however, can be isolating, especially for small mountain communities. Grand Junction, Colo., is located in a valley ringed by tall mountains, desert mesas, and red-rock cliffs. For local residents, and especially teenagers, it can feel like the end of the world.

“I know we can’t really fix this because it’s nature,” 17-year-old Victoria Mendoza said in an NPR interview. “I feel like the people in our valley feel like there’s only life inside of Grand Junction.”

Ms. Mendoza has fought depression, as have other members of her family and others in the community. Seven student suicides occurred in the 2016-2017 school year. “It felt like there was this cloud around our whole valley,” Ms. Mendoza said. “It got to a point where we were just waiting for the next one.”

Rural settings can foster the loneliness that, for some, is only cured by self-inflicted death. Of the top 10 U.S. states with the highest rates of suicide, 8 are located in the rural mountain West. The view of mental illness as a sign of personal weakness remains prevalent, and having ready access to guns is not helpful.

In Grand Junction, students have seized the reins of a suicide prevention in which they act as peer mentors to younger students that either seek help or appear to be floundering. The approach, called the Sources of Strength suicide program, exemplifies a broader shift in public health thinking that is taking place. In Grand Junction, the strategy is to zero in on the mental health and well-being of everyone. That encourages a sense of community, even in a setting of physical isolation.

Cannabidiol and substance-free living

With cannabis use becoming more part of the norm and with its legalization, the idea of altering the way we see the world is, for some, moving from a no-go option to a practice that can help ease the strains of life. For those who struggle with PTSD or other anxieties, cannabis can be a way to alleviate paranoia, anxiety, and mood swings without the use of prescription drugs.

Of course, there will be many who will overenthusiastically embrace the chance to legally alter themselves, such as what occurs with alcohol. Sobriety means different things to different people. Some alcoholics happily live with an occasional drink. They consider themselves on a path of sobriety. Others must go cold turkey forever. This is a different sobriety. Each can be effective and can bring happiness.

“Does using cannabidiol count as a strike against recovery or a substance-free lifestyle? This can lead into particularly tricky terrain as many people turn to cannabis products as a solution for all manner of ailments – from mental health to addiction. As we reckon with cannabis legalization as a country, perhaps what we really should be asking ourselves is how we’re going to redefine the traditional meaning of sobriety,” Amanda Scriver wrote in the Walrus.

“As cannabidiol gains popularity, we must give people the capacity to examine, evaluate, and possibly amend their own health, wellness, or recovery journey in a way that feels right for them. Yes, we need better medical understanding of cannabis and its related products, and yes, we also need training in the harm-reduction model. But we also need compassion and the courage to rethink old definitions,” Ms. Scriver wrote.

Masculinity tied to mental health

As a celebrity, Lenard Larry McKelvey, aka Charlamagne Tha God, makes his living being brash and bold. On his radio show, The Breakfast Club, he asks questions some do not want asked. But, like many, he is also anxious about the world. As a father, he worries about his daughters. As a black man, he worries about police brutality.

But unlike many, he has a forum and an audience. And he is using his forum to speak out about his fears and anxieties in the hope that it helps others deal with their demons. A recent example is his book, “Shook One: Anxiety Playing Tricks On Me” (Touchstone, 2018).

He is a strong advocate of therapy. “I go to therapy just to push those negative thoughts out of my mind. None of us can escape thinking negatively. Negative thoughts are going to pop up in your head. You’re going to have self-doubt sometimes; you’re going to be insecure sometimes. You’re going to worry about your kids; you’re going to worry about your wife, but it’s about pushing that %@C# out and not holding onto it. When you hold onto it, that’s when it grows,” he explained in an interview with the Boston Globe.

He espoused the freedom that comes from self-acceptance. “My whole life, people have said to me, ‘You can’t be soft.’ I don’t care about that anymore. I don’t care about how people perceive me when it comes to masculinity. You know what’s masculine? Masculine is taking care of your mind, your body, and your soul. We spend so much time on our body. We want that six-pack. But what about your mental health? What about your mental well-being? I go to the gym three, four times a week. Why can’t I put that same effort and same energy into getting mentally strong?”

Can extremists’ mindsets change?

The recent massacre at the Pittsburgh synagogue was yet another vile example of hatred and bigotry. But, in the United States and elsewhere, the shooter was one of many. Why?

According to an NPR piece, there are several possible explanations. Those brimming with racist hated might have little opportunity to get off that track. “We haven’t wanted to acknowledge that we have a problem with violent right-wing extremism in this kind of domestic terrorism,” said sociologist Pete Simi, PhD, of Chapman University in Orange, Calif. Dr. Simi has studied violent white nationalists and other hate groups for decades.


“White supremacy is really a problem throughout the United States,” Dr. Simi said. “It doesn’t know any geographic boundaries. It’s not isolated to either urban or rural or suburban – it cuts across all.”

There is little knowledge of how to deal with home-grown hatred. Banning immigrants perceived as being a threat is one attempt to deal with foreign-born terrorism, but that doesn’t work for citizens. For them, rehabilitation is possible, according to Dr. Simi, but it comes with a big price tag of revamped social, education, housing, and employment programs. Governments are loathe to take on those costs, in part because it is an admission that society is broken.

“A big, big problem that we face as a society is abdicating our responsibility in terms of providing this kind of social support and social safety net for individuals that suffer from mental health, as well as drug problems,” Dr. Simi said in the interview.

Small-scale local efforts, such as the Chicago-based Life After Hate, are working for change. How to scale up such efforts is a vexing problem.

Denosumab can be effective against osteoporosis caused by transfusion-dependent thalassemia (TDT), according to new research.

The study authors found that patients who received twice-yearly injections of denosumab experienced a significant increase in bone density and reduction in bone pain. Their findings were published in Blood Advances.

“Not only is denosumab associated with improved bone health and reduced pain, but its ease of administration may very well make this drug superior to bisphosphonates for the treatment of osteoporosis in patients with TDT and osteoporosis,” senior study author Evangelos Terpos, MD, of the National and Kapodistrian University of Athens, said in a statement.

For this phase 2b study, Dr. Terpos and his colleagues evaluated 63 patients with TDT and osteoporosis, randomized to receive 60 mg of denosumab (n = 32) or placebo (n = 31) on days 0 and 180 of a 12-month period. Patients in both arms also received daily supplements of calcium and vitamin D.

Baseline characteristics were largely similar between the treatment arms. However, the mean value of bone-specific alkaline phosphatase (bALP) was significantly lower in the placebo arm than the denosumab arm – 68.48 IU/L versus 85.45 IU/L (P = .013). And the mean value of the tartrate-resistant acid phosphatase isoform–5b (TRACP-5b) marker was significantly higher in the denosumab arm than in the placebo arm – 0.42 IU/L versus 0.16 IU/L (P = .026).


The researchers measured bone mineral density in the L1-L4 lumbar spine, wrist, and femoral neck. At 12 months, the mean increase in L1-L4 bone mineral density was 5.92% in the denosumab arm and 2.92% in the placebo arm (P = .043). The mean decrease in wrist bone mineral density was –0.26% and –3.92%, respectively (P = .035).

Femoral neck bone mineral density was increased in the denosumab arm (4.08%), compared with the placebo arm (1.96%), but the difference between the two groups was not statistically significant.

Patients in the denosumab arm had a significant reduction in bone pain at 12 months, according to the McGill-Melzack scoring system and the Huskisson visual analog scale (P less than .001 for both). There was no significant change in pain for patients in the placebo arm on either scale.

At 12 months, patients in the denosumab arm had experienced a significant reduction from baseline in several markers of bone remodeling, including soluble receptor activator of nuclear factor–kappa B ligand (sRANKL), osteoprotegerin (OPG), sRANKL/OPG ratio, C-terminal telopeptide of type I collagen (CTx), TRACP-5b, and bALP.

There were no significant changes in dickkopf-1, sclerostin, or osteocalcin in the denosumab arm.

In the placebo arm, patients had a significant increase from baseline in several markers of bone remodeling, including sRANKL, OPG, dickkopf-1, sclerostin, CTx, TRACP-5b, and bALP. There was no significant change from baseline in the sRANKL/OPG ratio or osteocalcin.

In all, there were 17 adverse events in 14 patients. There were three serious adverse events in the denosumab arm – pleural effusion (grade 3), atrial fibrillation (grade 3), and supraventricular tachycardia (grade 4). All three of these adverse events were considered unrelated to denosumab.

The study was funded by Amgen, which markets denosumab. The authors reported that they had no competing financial interests.

SOURCE: Terpos E et al. Blood Adv. 2018;2:2837-47.

Denosumab can be effective against osteoporosis caused by transfusion-dependent thalassemia (TDT), according to new research.

The study authors found that patients who received twice-yearly injections of denosumab experienced a significant increase in bone density and reduction in bone pain. Their findings were published in Blood Advances.

“Not only is denosumab associated with improved bone health and reduced pain, but its ease of administration may very well make this drug superior to bisphosphonates for the treatment of osteoporosis in patients with TDT and osteoporosis,” senior study author Evangelos Terpos, MD, of the National and Kapodistrian University of Athens, said in a statement.

For this phase 2b study, Dr. Terpos and his colleagues evaluated 63 patients with TDT and osteoporosis, randomized to receive 60 mg of denosumab (n = 32) or placebo (n = 31) on days 0 and 180 of a 12-month period. Patients in both arms also received daily supplements of calcium and vitamin D.

Baseline characteristics were largely similar between the treatment arms. However, the mean value of bone-specific alkaline phosphatase (bALP) was significantly lower in the placebo arm than the denosumab arm – 68.48 IU/L versus 85.45 IU/L (P = .013). And the mean value of the tartrate-resistant acid phosphatase isoform–5b (TRACP-5b) marker was significantly higher in the denosumab arm than in the placebo arm – 0.42 IU/L versus 0.16 IU/L (P = .026).


The researchers measured bone mineral density in the L1-L4 lumbar spine, wrist, and femoral neck. At 12 months, the mean increase in L1-L4 bone mineral density was 5.92% in the denosumab arm and 2.92% in the placebo arm (P = .043). The mean decrease in wrist bone mineral density was –0.26% and –3.92%, respectively (P = .035).

Femoral neck bone mineral density was increased in the denosumab arm (4.08%), compared with the placebo arm (1.96%), but the difference between the two groups was not statistically significant.

Patients in the denosumab arm had a significant reduction in bone pain at 12 months, according to the McGill-Melzack scoring system and the Huskisson visual analog scale (P less than .001 for both). There was no significant change in pain for patients in the placebo arm on either scale.

At 12 months, patients in the denosumab arm had experienced a significant reduction from baseline in several markers of bone remodeling, including soluble receptor activator of nuclear factor–kappa B ligand (sRANKL), osteoprotegerin (OPG), sRANKL/OPG ratio, C-terminal telopeptide of type I collagen (CTx), TRACP-5b, and bALP.

There were no significant changes in dickkopf-1, sclerostin, or osteocalcin in the denosumab arm.

In the placebo arm, patients had a significant increase from baseline in several markers of bone remodeling, including sRANKL, OPG, dickkopf-1, sclerostin, CTx, TRACP-5b, and bALP. There was no significant change from baseline in the sRANKL/OPG ratio or osteocalcin.

In all, there were 17 adverse events in 14 patients. There were three serious adverse events in the denosumab arm – pleural effusion (grade 3), atrial fibrillation (grade 3), and supraventricular tachycardia (grade 4). All three of these adverse events were considered unrelated to denosumab.

The study was funded by Amgen, which markets denosumab. The authors reported that they had no competing financial interests.

SOURCE: Terpos E et al. Blood Adv. 2018;2:2837-47.

Denosumab can be effective against osteoporosis caused by transfusion-dependent thalassemia (TDT), according to new research.

The study authors found that patients who received twice-yearly injections of denosumab experienced a significant increase in bone density and reduction in bone pain. Their findings were published in Blood Advances.

“Not only is denosumab associated with improved bone health and reduced pain, but its ease of administration may very well make this drug superior to bisphosphonates for the treatment of osteoporosis in patients with TDT and osteoporosis,” senior study author Evangelos Terpos, MD, of the National and Kapodistrian University of Athens, said in a statement.

For this phase 2b study, Dr. Terpos and his colleagues evaluated 63 patients with TDT and osteoporosis, randomized to receive 60 mg of denosumab (n = 32) or placebo (n = 31) on days 0 and 180 of a 12-month period. Patients in both arms also received daily supplements of calcium and vitamin D.

Baseline characteristics were largely similar between the treatment arms. However, the mean value of bone-specific alkaline phosphatase (bALP) was significantly lower in the placebo arm than the denosumab arm – 68.48 IU/L versus 85.45 IU/L (P = .013). And the mean value of the tartrate-resistant acid phosphatase isoform–5b (TRACP-5b) marker was significantly higher in the denosumab arm than in the placebo arm – 0.42 IU/L versus 0.16 IU/L (P = .026).


The researchers measured bone mineral density in the L1-L4 lumbar spine, wrist, and femoral neck. At 12 months, the mean increase in L1-L4 bone mineral density was 5.92% in the denosumab arm and 2.92% in the placebo arm (P = .043). The mean decrease in wrist bone mineral density was –0.26% and –3.92%, respectively (P = .035).

Femoral neck bone mineral density was increased in the denosumab arm (4.08%), compared with the placebo arm (1.96%), but the difference between the two groups was not statistically significant.

Patients in the denosumab arm had a significant reduction in bone pain at 12 months, according to the McGill-Melzack scoring system and the Huskisson visual analog scale (P less than .001 for both). There was no significant change in pain for patients in the placebo arm on either scale.

At 12 months, patients in the denosumab arm had experienced a significant reduction from baseline in several markers of bone remodeling, including soluble receptor activator of nuclear factor–kappa B ligand (sRANKL), osteoprotegerin (OPG), sRANKL/OPG ratio, C-terminal telopeptide of type I collagen (CTx), TRACP-5b, and bALP.

There were no significant changes in dickkopf-1, sclerostin, or osteocalcin in the denosumab arm.

In the placebo arm, patients had a significant increase from baseline in several markers of bone remodeling, including sRANKL, OPG, dickkopf-1, sclerostin, CTx, TRACP-5b, and bALP. There was no significant change from baseline in the sRANKL/OPG ratio or osteocalcin.

In all, there were 17 adverse events in 14 patients. There were three serious adverse events in the denosumab arm – pleural effusion (grade 3), atrial fibrillation (grade 3), and supraventricular tachycardia (grade 4). All three of these adverse events were considered unrelated to denosumab.

The study was funded by Amgen, which markets denosumab. The authors reported that they had no competing financial interests.

SOURCE: Terpos E et al. Blood Adv. 2018;2:2837-47.

Pediatric headache and migraine are associated with a variety of conditions including respiratory, gastrointestinal, neurologic, and mood disorders, according to findings published in the Journal of Pediatrics.

Marta Ortiz/iStock/Getty Images Plus

In a study of 9,329 pediatric patients from the Philadelphia Neurodevelopmental Cohort, at the University of Pennsylvania, children with any headache type were more likely to have cardiovascular (odds ratio, 1.4; 95% confidence interval, 1.1-1.7) and gastrointestinal (OR, 1.2; 95% CI, 1.1-1.4) problems than did those without headache. In addition, they were more likely to have attention deficit hyperactivity disorder (OR, 1.2; 95% CI, 1.1-1.4), wrote Tarannum M. Lateef, MD, MPH, of the Center for Neuroscience and Behavioral Medicine at Children’s National Medical Center in Washington, and her coauthors.

Study participants were aged 8-21 years and were enrolled in the cohort from November 2009 to November 2011. Physical conditions were identified using EMRs and interviews and were later grouped together by general category.

Patients were asked about lifetime headache and migraine symptoms including sensitivity to light and noise, gastrointestinal symptoms, unilateral pain, throbbing and pulsation, and interference at school or work. Migraine was defined as headache accompanied by any three of these symptoms. Mental disorders were identified using an abbreviated version of the Kiddie-Schedule for Affective Disorders and Schizophrenia, reported Dr. Lateef and her associates.

Lifetime prevalence of any headache was 45.5%, and 22.6% for migraine. Migraine was more common in female patients (25.5%) than in male patients (19.4%).

Compared with nonmigraine headache patients, those with migraine more frequently had neurologic/central nervous system disorders (OR, 1.7; 95% CI, 1.4-2.0), developmental disorders (OR, 1.3; 95% CI, 1.1-1.6), respiratory problems (OR, 1.3; 95% CI, 1.1-1.6), anxiety (OR, 1.6; 95% CI, 1.3-2), mood disorders (OR, 2; 95% CI, 1.6-2.3), and behavioral disorders (OR, 1.3; 95% CI, 1.1-1.6).

The results suggest that “headache, particularly migraine, is associated with respiratory and other neurologic and developmental disorders, as well as with anxiety and mood disorders,” the authors wrote.

“Comorbidity may be an important index of heterogeneity … that can guide clinical management, genetic investigation, and future research on shared pathophysiology” with other disorders, they concluded.

No disclosures were reported.
 

SOURCE: Lateef T et al. J Pediatr. 2018 Oct 29. doi: 10.1016/j.jpeds.2018.09.033.

Pediatric headache and migraine are associated with a variety of conditions including respiratory, gastrointestinal, neurologic, and mood disorders, according to findings published in the Journal of Pediatrics.

Marta Ortiz/iStock/Getty Images Plus

In a study of 9,329 pediatric patients from the Philadelphia Neurodevelopmental Cohort, at the University of Pennsylvania, children with any headache type were more likely to have cardiovascular (odds ratio, 1.4; 95% confidence interval, 1.1-1.7) and gastrointestinal (OR, 1.2; 95% CI, 1.1-1.4) problems than did those without headache. In addition, they were more likely to have attention deficit hyperactivity disorder (OR, 1.2; 95% CI, 1.1-1.4), wrote Tarannum M. Lateef, MD, MPH, of the Center for Neuroscience and Behavioral Medicine at Children’s National Medical Center in Washington, and her coauthors.

Study participants were aged 8-21 years and were enrolled in the cohort from November 2009 to November 2011. Physical conditions were identified using EMRs and interviews and were later grouped together by general category.

Patients were asked about lifetime headache and migraine symptoms including sensitivity to light and noise, gastrointestinal symptoms, unilateral pain, throbbing and pulsation, and interference at school or work. Migraine was defined as headache accompanied by any three of these symptoms. Mental disorders were identified using an abbreviated version of the Kiddie-Schedule for Affective Disorders and Schizophrenia, reported Dr. Lateef and her associates.

Lifetime prevalence of any headache was 45.5%, and 22.6% for migraine. Migraine was more common in female patients (25.5%) than in male patients (19.4%).

Compared with nonmigraine headache patients, those with migraine more frequently had neurologic/central nervous system disorders (OR, 1.7; 95% CI, 1.4-2.0), developmental disorders (OR, 1.3; 95% CI, 1.1-1.6), respiratory problems (OR, 1.3; 95% CI, 1.1-1.6), anxiety (OR, 1.6; 95% CI, 1.3-2), mood disorders (OR, 2; 95% CI, 1.6-2.3), and behavioral disorders (OR, 1.3; 95% CI, 1.1-1.6).

The results suggest that “headache, particularly migraine, is associated with respiratory and other neurologic and developmental disorders, as well as with anxiety and mood disorders,” the authors wrote.

“Comorbidity may be an important index of heterogeneity … that can guide clinical management, genetic investigation, and future research on shared pathophysiology” with other disorders, they concluded.

No disclosures were reported.
 

SOURCE: Lateef T et al. J Pediatr. 2018 Oct 29. doi: 10.1016/j.jpeds.2018.09.033.

Pediatric headache and migraine are associated with a variety of conditions including respiratory, gastrointestinal, neurologic, and mood disorders, according to findings published in the Journal of Pediatrics.

Marta Ortiz/iStock/Getty Images Plus

In a study of 9,329 pediatric patients from the Philadelphia Neurodevelopmental Cohort, at the University of Pennsylvania, children with any headache type were more likely to have cardiovascular (odds ratio, 1.4; 95% confidence interval, 1.1-1.7) and gastrointestinal (OR, 1.2; 95% CI, 1.1-1.4) problems than did those without headache. In addition, they were more likely to have attention deficit hyperactivity disorder (OR, 1.2; 95% CI, 1.1-1.4), wrote Tarannum M. Lateef, MD, MPH, of the Center for Neuroscience and Behavioral Medicine at Children’s National Medical Center in Washington, and her coauthors.

Study participants were aged 8-21 years and were enrolled in the cohort from November 2009 to November 2011. Physical conditions were identified using EMRs and interviews and were later grouped together by general category.

Patients were asked about lifetime headache and migraine symptoms including sensitivity to light and noise, gastrointestinal symptoms, unilateral pain, throbbing and pulsation, and interference at school or work. Migraine was defined as headache accompanied by any three of these symptoms. Mental disorders were identified using an abbreviated version of the Kiddie-Schedule for Affective Disorders and Schizophrenia, reported Dr. Lateef and her associates.

Lifetime prevalence of any headache was 45.5%, and 22.6% for migraine. Migraine was more common in female patients (25.5%) than in male patients (19.4%).

Compared with nonmigraine headache patients, those with migraine more frequently had neurologic/central nervous system disorders (OR, 1.7; 95% CI, 1.4-2.0), developmental disorders (OR, 1.3; 95% CI, 1.1-1.6), respiratory problems (OR, 1.3; 95% CI, 1.1-1.6), anxiety (OR, 1.6; 95% CI, 1.3-2), mood disorders (OR, 2; 95% CI, 1.6-2.3), and behavioral disorders (OR, 1.3; 95% CI, 1.1-1.6).

The results suggest that “headache, particularly migraine, is associated with respiratory and other neurologic and developmental disorders, as well as with anxiety and mood disorders,” the authors wrote.

“Comorbidity may be an important index of heterogeneity … that can guide clinical management, genetic investigation, and future research on shared pathophysiology” with other disorders, they concluded.

No disclosures were reported.
 

SOURCE: Lateef T et al. J Pediatr. 2018 Oct 29. doi: 10.1016/j.jpeds.2018.09.033.

Part II of Nick’s conversation with Samuel Shem. Mr. Shem is the author of the satirical novel The House of God, which examined medical residency in the United States in the 1970s.

Part II of Nick’s conversation with Samuel Shem. Mr. Shem is the author of the satirical novel The House of God, which examined medical residency in the United States in the 1970s.

Part II of Nick’s conversation with Samuel Shem. Mr. Shem is the author of the satirical novel The House of God, which examined medical residency in the United States in the 1970s.

SAN FRANCISCO – Chronic liver disease mortality continues to rise in the United States, driven largely by a spike in nonalcoholic fatty liver disease (NAFLD), according to results from an analysis of national data.

“I believe it’s all related to a big increase in obesity and type 2 diabetes in this country,” lead study author Zobair M. Younossi, MD, MPH, said in an interview in advance of the annual meeting of the American Association for the Study of Liver Diseases. “Those two risk factors drive NAFLD and its progressive type, nonalcoholic steatohepatitis (NASH). That accounts for at least part of the increase in mortality related to liver disease.”

In an effort to evaluate recent mortality trends in chronic liver disease in the United States, Dr. Younossi and his colleagues drew from National Vital Statistics Data during 2007-2016. They used ICD-10 codes to select mortality data for alcoholic liver disease, chronic hepatitis B and C, iron overload, NAFLD, cirrhosis, and hepatocellular carcinoma. NAFLD cases were defined as those having an ICD-10 code for NAFLD/NASH or an ICD-10 code for “cirrhosis of unknown etiology.” Next, the researchers adjusted age-standardized death rates to the 2000 U.S. Census population and used logistic regression and propensity scores to estimate predictors of chronic liver disease-related deaths.

Dr. Younossi, who chairs the department of medicine at Inova Fairfax Medical Campus, in Falls Church, Va., and his colleagues reported findings from 838,809 chronic liver disease–related deaths during the study period. They found that the age-standardized death rate for chronic liver disease increased from 21.9/100,000 population in 2007 to 24.9/100,000 population in 2016, which translated into an annual percentage change of 1.3% for males and 2.5% for females. Chronic liver disease–related deaths increased with age and were highest among those aged 55-64 years, followed by those aged 65-74 years – an average annual percentage change of 3.4% and 3.1% in each group.

Among chronic liver disease–related deaths, the most common diagnostic etiology was NAFLD (34.7%), followed by alcoholic liver disease (28.8%) and chronic hepatitis C (21.1%). Between 2007 and 2016, death rates increased from 7.6 to 9.0 per 100,000 population for NAFLD (an average annual percentage change of 2.1%) and from 6.1 to 7.9 per 100,000 population for alcoholic liver disease (an average annual percentage change of 3.1%). “What surprised me was that, despite highly effective treatment for HCV, we still have a burden of hepatitis C in this country,” Dr. Younossi said. “It’s still the most common cause of liver disease in the U.S. But it seems like hepatitis C–related liver disease is being replaced quickly by liver disease from nonalcoholic steatohepatitis. This transition between hepatitis C as the most important cause of liver disease and liver mortality to NASH or obesity-related NASH is becoming more rapid than I expected.”

On multivariate analysis, three factors were independently associated with an increased risk of death in NAFLD: the presence of type 2 diabetes (odds ratio, 1.78), cardiovascular disease (OR, 1.07), and renal failure (OR, 1.08).

“One important message from this study is that NASH is very common in the U.S. population,” said Dr. Younossi, who is also a professor of medicine at Virginia Commonwealth University, Richmond. “These patients are underrecognized and underdiagnosed because they are asymptomatic. The second message is that there is a subtype of patients with fatty liver disease – even a subtype of NASH – that can progress to cirrhosis and its complications. We have to pay attention to this silent disease to identify patients who are at risk for progressive liver disease and try to address some of the risk issues, such as tight control of diabetes, obesity, and control of hypertension and hyperlipidemia. Short of that, right now we have very few medical treatments such as vitamin E and pioglitazone recommended for a very selected group. In contrast, there are plenty of new medications that are being developed. The first step in tackling this disease is to identify who the patients are with fatty liver disease who are at risk for bad outcomes and make sure they’re linked to care by a knowledgeable caregiver [who] understands the importance of NASH.”

Dr. Younossi acknowledged certain limitations of the study, including the fact that liver disease diagnoses were based on ICD-10 coding. He disclosed that he is a consultant for Gilead, Intercept, Novo Nordisk, BMS, AbbVie, Viking, Term Quest Diagnostics, Echosens,and Shionogi. He has also received grant/research support from Gilead, Intercept, and BMS.

dbrunk@mdedge.com

Source: Hepatol. 2018;68[S1], Abstract 763.

SAN FRANCISCO – Chronic liver disease mortality continues to rise in the United States, driven largely by a spike in nonalcoholic fatty liver disease (NAFLD), according to results from an analysis of national data.

“I believe it’s all related to a big increase in obesity and type 2 diabetes in this country,” lead study author Zobair M. Younossi, MD, MPH, said in an interview in advance of the annual meeting of the American Association for the Study of Liver Diseases. “Those two risk factors drive NAFLD and its progressive type, nonalcoholic steatohepatitis (NASH). That accounts for at least part of the increase in mortality related to liver disease.”

In an effort to evaluate recent mortality trends in chronic liver disease in the United States, Dr. Younossi and his colleagues drew from National Vital Statistics Data during 2007-2016. They used ICD-10 codes to select mortality data for alcoholic liver disease, chronic hepatitis B and C, iron overload, NAFLD, cirrhosis, and hepatocellular carcinoma. NAFLD cases were defined as those having an ICD-10 code for NAFLD/NASH or an ICD-10 code for “cirrhosis of unknown etiology.” Next, the researchers adjusted age-standardized death rates to the 2000 U.S. Census population and used logistic regression and propensity scores to estimate predictors of chronic liver disease-related deaths.

Dr. Younossi, who chairs the department of medicine at Inova Fairfax Medical Campus, in Falls Church, Va., and his colleagues reported findings from 838,809 chronic liver disease–related deaths during the study period. They found that the age-standardized death rate for chronic liver disease increased from 21.9/100,000 population in 2007 to 24.9/100,000 population in 2016, which translated into an annual percentage change of 1.3% for males and 2.5% for females. Chronic liver disease–related deaths increased with age and were highest among those aged 55-64 years, followed by those aged 65-74 years – an average annual percentage change of 3.4% and 3.1% in each group.

Among chronic liver disease–related deaths, the most common diagnostic etiology was NAFLD (34.7%), followed by alcoholic liver disease (28.8%) and chronic hepatitis C (21.1%). Between 2007 and 2016, death rates increased from 7.6 to 9.0 per 100,000 population for NAFLD (an average annual percentage change of 2.1%) and from 6.1 to 7.9 per 100,000 population for alcoholic liver disease (an average annual percentage change of 3.1%). “What surprised me was that, despite highly effective treatment for HCV, we still have a burden of hepatitis C in this country,” Dr. Younossi said. “It’s still the most common cause of liver disease in the U.S. But it seems like hepatitis C–related liver disease is being replaced quickly by liver disease from nonalcoholic steatohepatitis. This transition between hepatitis C as the most important cause of liver disease and liver mortality to NASH or obesity-related NASH is becoming more rapid than I expected.”

On multivariate analysis, three factors were independently associated with an increased risk of death in NAFLD: the presence of type 2 diabetes (odds ratio, 1.78), cardiovascular disease (OR, 1.07), and renal failure (OR, 1.08).

“One important message from this study is that NASH is very common in the U.S. population,” said Dr. Younossi, who is also a professor of medicine at Virginia Commonwealth University, Richmond. “These patients are underrecognized and underdiagnosed because they are asymptomatic. The second message is that there is a subtype of patients with fatty liver disease – even a subtype of NASH – that can progress to cirrhosis and its complications. We have to pay attention to this silent disease to identify patients who are at risk for progressive liver disease and try to address some of the risk issues, such as tight control of diabetes, obesity, and control of hypertension and hyperlipidemia. Short of that, right now we have very few medical treatments such as vitamin E and pioglitazone recommended for a very selected group. In contrast, there are plenty of new medications that are being developed. The first step in tackling this disease is to identify who the patients are with fatty liver disease who are at risk for bad outcomes and make sure they’re linked to care by a knowledgeable caregiver [who] understands the importance of NASH.”

Dr. Younossi acknowledged certain limitations of the study, including the fact that liver disease diagnoses were based on ICD-10 coding. He disclosed that he is a consultant for Gilead, Intercept, Novo Nordisk, BMS, AbbVie, Viking, Term Quest Diagnostics, Echosens,and Shionogi. He has also received grant/research support from Gilead, Intercept, and BMS.

dbrunk@mdedge.com

Source: Hepatol. 2018;68[S1], Abstract 763.

SAN FRANCISCO – Chronic liver disease mortality continues to rise in the United States, driven largely by a spike in nonalcoholic fatty liver disease (NAFLD), according to results from an analysis of national data.

“I believe it’s all related to a big increase in obesity and type 2 diabetes in this country,” lead study author Zobair M. Younossi, MD, MPH, said in an interview in advance of the annual meeting of the American Association for the Study of Liver Diseases. “Those two risk factors drive NAFLD and its progressive type, nonalcoholic steatohepatitis (NASH). That accounts for at least part of the increase in mortality related to liver disease.”

In an effort to evaluate recent mortality trends in chronic liver disease in the United States, Dr. Younossi and his colleagues drew from National Vital Statistics Data during 2007-2016. They used ICD-10 codes to select mortality data for alcoholic liver disease, chronic hepatitis B and C, iron overload, NAFLD, cirrhosis, and hepatocellular carcinoma. NAFLD cases were defined as those having an ICD-10 code for NAFLD/NASH or an ICD-10 code for “cirrhosis of unknown etiology.” Next, the researchers adjusted age-standardized death rates to the 2000 U.S. Census population and used logistic regression and propensity scores to estimate predictors of chronic liver disease-related deaths.

Dr. Younossi, who chairs the department of medicine at Inova Fairfax Medical Campus, in Falls Church, Va., and his colleagues reported findings from 838,809 chronic liver disease–related deaths during the study period. They found that the age-standardized death rate for chronic liver disease increased from 21.9/100,000 population in 2007 to 24.9/100,000 population in 2016, which translated into an annual percentage change of 1.3% for males and 2.5% for females. Chronic liver disease–related deaths increased with age and were highest among those aged 55-64 years, followed by those aged 65-74 years – an average annual percentage change of 3.4% and 3.1% in each group.

Among chronic liver disease–related deaths, the most common diagnostic etiology was NAFLD (34.7%), followed by alcoholic liver disease (28.8%) and chronic hepatitis C (21.1%). Between 2007 and 2016, death rates increased from 7.6 to 9.0 per 100,000 population for NAFLD (an average annual percentage change of 2.1%) and from 6.1 to 7.9 per 100,000 population for alcoholic liver disease (an average annual percentage change of 3.1%). “What surprised me was that, despite highly effective treatment for HCV, we still have a burden of hepatitis C in this country,” Dr. Younossi said. “It’s still the most common cause of liver disease in the U.S. But it seems like hepatitis C–related liver disease is being replaced quickly by liver disease from nonalcoholic steatohepatitis. This transition between hepatitis C as the most important cause of liver disease and liver mortality to NASH or obesity-related NASH is becoming more rapid than I expected.”

On multivariate analysis, three factors were independently associated with an increased risk of death in NAFLD: the presence of type 2 diabetes (odds ratio, 1.78), cardiovascular disease (OR, 1.07), and renal failure (OR, 1.08).

“One important message from this study is that NASH is very common in the U.S. population,” said Dr. Younossi, who is also a professor of medicine at Virginia Commonwealth University, Richmond. “These patients are underrecognized and underdiagnosed because they are asymptomatic. The second message is that there is a subtype of patients with fatty liver disease – even a subtype of NASH – that can progress to cirrhosis and its complications. We have to pay attention to this silent disease to identify patients who are at risk for progressive liver disease and try to address some of the risk issues, such as tight control of diabetes, obesity, and control of hypertension and hyperlipidemia. Short of that, right now we have very few medical treatments such as vitamin E and pioglitazone recommended for a very selected group. In contrast, there are plenty of new medications that are being developed. The first step in tackling this disease is to identify who the patients are with fatty liver disease who are at risk for bad outcomes and make sure they’re linked to care by a knowledgeable caregiver [who] understands the importance of NASH.”

Dr. Younossi acknowledged certain limitations of the study, including the fact that liver disease diagnoses were based on ICD-10 coding. He disclosed that he is a consultant for Gilead, Intercept, Novo Nordisk, BMS, AbbVie, Viking, Term Quest Diagnostics, Echosens,and Shionogi. He has also received grant/research support from Gilead, Intercept, and BMS.

dbrunk@mdedge.com

Source: Hepatol. 2018;68[S1], Abstract 763.

Three studies showed that some serum markers are associated with concussion, but can vary considerably. A novel theory explains the variable efficacy of SSRIs, single-dose zoliflodacin is successful for uncomplicated urogenital gonorrhea, and drinking regular, caffeinated coffee is linked with a decreased risk of rosacea.

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Three studies showed that some serum markers are associated with concussion, but can vary considerably. A novel theory explains the variable efficacy of SSRIs, single-dose zoliflodacin is successful for uncomplicated urogenital gonorrhea, and drinking regular, caffeinated coffee is linked with a decreased risk of rosacea.

Amazon Alexa
Apple Podcasts
Spotify

Three studies showed that some serum markers are associated with concussion, but can vary considerably. A novel theory explains the variable efficacy of SSRIs, single-dose zoliflodacin is successful for uncomplicated urogenital gonorrhea, and drinking regular, caffeinated coffee is linked with a decreased risk of rosacea.

Amazon Alexa
Apple Podcasts
Spotify

MD Anderson Cancer Center

The combination of azacitidine and nivolumab produced “encouraging” results in a phase 2 trial of patients with relapsed or refractory acute myeloid leukemia (AML), according to researchers.

The overall response rate was 33%, and the median overall survival (OS) was 6.3 months.

However, the researchers identified factors associated with improved response and survival that they believe could be used to select patients for this treatment.

A quarter of patients on this trial had immune-related adverse events (AEs) that were considered related to treatment, and two patients died of AEs that may have been treatment-related.

Naval Daver, MD, of The University of Texas MD Anderson Cancer Center in Houston, and his colleagues reported these results in Cancer Discovery.

The trial included 70 patients with a median age of 70 (range, 22-90). Fifty-six percent had de novo AML, and 44% had secondary AML.

The median number of prior therapies was 2 (range, 1 to 7). Sixty-four percent of patients had received hypomethylating agents, 47% had received targeted therapies, and 19% had received allogeneic stem cell transplant (SCT).

For this trial, patients received azacitidine at 75 mg/m² on days 1 to 7 and nivolumab at 3 mg/kg on days 1 and 14 of each cycle. The median number of cycles was 3 (range, 1 to 25).

Patients had a median time on study of 3.5 months (range, 0.3 to 26.3 months). Reasons for discontinuation included primary refractory disease (n=27), relapse after initial response (n=19), death (n=16), proceeding to SCT (n=3), and patient preference (n=3).

Safety

The most common treatment-related, non-hematologic AEs were constipation (26%), diarrhea (20%), pneumonitis (13%), nausea (11%), and lung infection (11%).

The rate of immune-related AEs was 25% (n=18), with grade 2-4 immune-related AEs occurring in 16 patients (8 with grade 3-4). Fourteen of these patients responded to steroids and were safely re-challenged with nivolumab, according to the researchers.

Nine patients (13%) discontinued nivolumab (but continued with azacitidine) due to AEs—pneumonitis (n=7), cytokine release syndrome (n=1), and immune nephritis (n=1).

Two patients died of AEs that were considered possibly related to treatment. One death was due to progressive pneumonia/pneumonitis, and one was due to hemophagocytosis lymphohistiocytosis.

Response

The overall response rate was 33% (n=23). Four patients had a complete response (CR), and 11 had a CR with incomplete count recovery (CRi).

One patient had a partial response, and seven had hematologic improvement in one or more parameter maintained for more than 6 months. Six patients had stable disease lasting more than 6 months.

The researchers noted that the response rate was higher among patients who had not received prior treatment with hypomethylating agents. In addition, a higher frequency of pre-therapy CD3 and CD8 cells in the bone marrow or peripheral blood appeared to predict response.

“In particular, CD3 appeared to have a high sensitivity and specificity rate for predicting response, indicating it might serve as a reliable biomarker for selecting patients for this combination therapy,” Dr. Daver said.

Survival

At a median follow-up of 21.4 months, 81% of patients (n=57) had died. Sixteen patients died on study treatment, and 41 died after discontinuation.

The median OS was 6.3 months, and the median event-free survival was 4.5 months.

The median OS was 16.1 months in patients with CR/CRi,  partial response, hematologic improvement, or stable disease and 4.1 months in non-responders (P<0.0001). This difference was still significant after the researchers censored the three patients who had gone on to SCT in CR/CRi (P<0.001).

The researchers also found that being in first salvage was associated with improved OS in a univariate analysis and in a comparison with historical controls.

Dr. Daver and his colleagues concluded that azacitidine and nivolumab “produced an encouraging response rate and overall survival” in patients with relapsed/refractory AML.

“We believe that implementation of clinical and immune biomarkers to select patients are likely to yield further improved outcomes with these types of therapies in AML,” Dr. Daver noted.

This research was supported by Bristol-Myers Squibb, MD Anderson, and the Dick Clark Immunotherapy Research Fund. In addition, individual researchers reported financial relationships with Bristol-Myers Squibb.

MD Anderson Cancer Center

The combination of azacitidine and nivolumab produced “encouraging” results in a phase 2 trial of patients with relapsed or refractory acute myeloid leukemia (AML), according to researchers.

The overall response rate was 33%, and the median overall survival (OS) was 6.3 months.

However, the researchers identified factors associated with improved response and survival that they believe could be used to select patients for this treatment.

A quarter of patients on this trial had immune-related adverse events (AEs) that were considered related to treatment, and two patients died of AEs that may have been treatment-related.

Naval Daver, MD, of The University of Texas MD Anderson Cancer Center in Houston, and his colleagues reported these results in Cancer Discovery.

The trial included 70 patients with a median age of 70 (range, 22-90). Fifty-six percent had de novo AML, and 44% had secondary AML.

The median number of prior therapies was 2 (range, 1 to 7). Sixty-four percent of patients had received hypomethylating agents, 47% had received targeted therapies, and 19% had received allogeneic stem cell transplant (SCT).

For this trial, patients received azacitidine at 75 mg/m² on days 1 to 7 and nivolumab at 3 mg/kg on days 1 and 14 of each cycle. The median number of cycles was 3 (range, 1 to 25).

Patients had a median time on study of 3.5 months (range, 0.3 to 26.3 months). Reasons for discontinuation included primary refractory disease (n=27), relapse after initial response (n=19), death (n=16), proceeding to SCT (n=3), and patient preference (n=3).

Safety

The most common treatment-related, non-hematologic AEs were constipation (26%), diarrhea (20%), pneumonitis (13%), nausea (11%), and lung infection (11%).

The rate of immune-related AEs was 25% (n=18), with grade 2-4 immune-related AEs occurring in 16 patients (8 with grade 3-4). Fourteen of these patients responded to steroids and were safely re-challenged with nivolumab, according to the researchers.

Nine patients (13%) discontinued nivolumab (but continued with azacitidine) due to AEs—pneumonitis (n=7), cytokine release syndrome (n=1), and immune nephritis (n=1).

Two patients died of AEs that were considered possibly related to treatment. One death was due to progressive pneumonia/pneumonitis, and one was due to hemophagocytosis lymphohistiocytosis.

Response

The overall response rate was 33% (n=23). Four patients had a complete response (CR), and 11 had a CR with incomplete count recovery (CRi).

One patient had a partial response, and seven had hematologic improvement in one or more parameter maintained for more than 6 months. Six patients had stable disease lasting more than 6 months.

The researchers noted that the response rate was higher among patients who had not received prior treatment with hypomethylating agents. In addition, a higher frequency of pre-therapy CD3 and CD8 cells in the bone marrow or peripheral blood appeared to predict response.

“In particular, CD3 appeared to have a high sensitivity and specificity rate for predicting response, indicating it might serve as a reliable biomarker for selecting patients for this combination therapy,” Dr. Daver said.

Survival

At a median follow-up of 21.4 months, 81% of patients (n=57) had died. Sixteen patients died on study treatment, and 41 died after discontinuation.

The median OS was 6.3 months, and the median event-free survival was 4.5 months.

The median OS was 16.1 months in patients with CR/CRi,  partial response, hematologic improvement, or stable disease and 4.1 months in non-responders (P<0.0001). This difference was still significant after the researchers censored the three patients who had gone on to SCT in CR/CRi (P<0.001).

The researchers also found that being in first salvage was associated with improved OS in a univariate analysis and in a comparison with historical controls.

Dr. Daver and his colleagues concluded that azacitidine and nivolumab “produced an encouraging response rate and overall survival” in patients with relapsed/refractory AML.

“We believe that implementation of clinical and immune biomarkers to select patients are likely to yield further improved outcomes with these types of therapies in AML,” Dr. Daver noted.

This research was supported by Bristol-Myers Squibb, MD Anderson, and the Dick Clark Immunotherapy Research Fund. In addition, individual researchers reported financial relationships with Bristol-Myers Squibb.

MD Anderson Cancer Center

The combination of azacitidine and nivolumab produced “encouraging” results in a phase 2 trial of patients with relapsed or refractory acute myeloid leukemia (AML), according to researchers.

The overall response rate was 33%, and the median overall survival (OS) was 6.3 months.

However, the researchers identified factors associated with improved response and survival that they believe could be used to select patients for this treatment.

A quarter of patients on this trial had immune-related adverse events (AEs) that were considered related to treatment, and two patients died of AEs that may have been treatment-related.

Naval Daver, MD, of The University of Texas MD Anderson Cancer Center in Houston, and his colleagues reported these results in Cancer Discovery.

The trial included 70 patients with a median age of 70 (range, 22-90). Fifty-six percent had de novo AML, and 44% had secondary AML.

The median number of prior therapies was 2 (range, 1 to 7). Sixty-four percent of patients had received hypomethylating agents, 47% had received targeted therapies, and 19% had received allogeneic stem cell transplant (SCT).

For this trial, patients received azacitidine at 75 mg/m² on days 1 to 7 and nivolumab at 3 mg/kg on days 1 and 14 of each cycle. The median number of cycles was 3 (range, 1 to 25).

Patients had a median time on study of 3.5 months (range, 0.3 to 26.3 months). Reasons for discontinuation included primary refractory disease (n=27), relapse after initial response (n=19), death (n=16), proceeding to SCT (n=3), and patient preference (n=3).

Safety

The most common treatment-related, non-hematologic AEs were constipation (26%), diarrhea (20%), pneumonitis (13%), nausea (11%), and lung infection (11%).

The rate of immune-related AEs was 25% (n=18), with grade 2-4 immune-related AEs occurring in 16 patients (8 with grade 3-4). Fourteen of these patients responded to steroids and were safely re-challenged with nivolumab, according to the researchers.

Nine patients (13%) discontinued nivolumab (but continued with azacitidine) due to AEs—pneumonitis (n=7), cytokine release syndrome (n=1), and immune nephritis (n=1).

Two patients died of AEs that were considered possibly related to treatment. One death was due to progressive pneumonia/pneumonitis, and one was due to hemophagocytosis lymphohistiocytosis.

Response

The overall response rate was 33% (n=23). Four patients had a complete response (CR), and 11 had a CR with incomplete count recovery (CRi).

One patient had a partial response, and seven had hematologic improvement in one or more parameter maintained for more than 6 months. Six patients had stable disease lasting more than 6 months.

The researchers noted that the response rate was higher among patients who had not received prior treatment with hypomethylating agents. In addition, a higher frequency of pre-therapy CD3 and CD8 cells in the bone marrow or peripheral blood appeared to predict response.

“In particular, CD3 appeared to have a high sensitivity and specificity rate for predicting response, indicating it might serve as a reliable biomarker for selecting patients for this combination therapy,” Dr. Daver said.

Survival

At a median follow-up of 21.4 months, 81% of patients (n=57) had died. Sixteen patients died on study treatment, and 41 died after discontinuation.

The median OS was 6.3 months, and the median event-free survival was 4.5 months.

The median OS was 16.1 months in patients with CR/CRi,  partial response, hematologic improvement, or stable disease and 4.1 months in non-responders (P<0.0001). This difference was still significant after the researchers censored the three patients who had gone on to SCT in CR/CRi (P<0.001).

The researchers also found that being in first salvage was associated with improved OS in a univariate analysis and in a comparison with historical controls.

Dr. Daver and his colleagues concluded that azacitidine and nivolumab “produced an encouraging response rate and overall survival” in patients with relapsed/refractory AML.

“We believe that implementation of clinical and immune biomarkers to select patients are likely to yield further improved outcomes with these types of therapies in AML,” Dr. Daver noted.

This research was supported by Bristol-Myers Squibb, MD Anderson, and the Dick Clark Immunotherapy Research Fund. In addition, individual researchers reported financial relationships with Bristol-Myers Squibb.