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Topics include:

• Underdiagnosis and Undertreatment of Migraine
• A Framework for Understanding Burden of Disease
• Burden and Cost
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Click Here to Read Content.

Topics include:

• Underdiagnosis and Undertreatment of Migraine
• A Framework for Understanding Burden of Disease
• Burden and Cost
• New Insights in Migraine Pathophysiology

Click Here to Read Content.

Topics include:

• Underdiagnosis and Undertreatment of Migraine
• A Framework for Understanding Burden of Disease
• Burden and Cost
• New Insights in Migraine Pathophysiology

ORLANDO – E-cigarettes are likely safer than traditional cigarettes but it depends on the user, the voltage used, and the kind of liquid, according to a panel of experts at the joint congress of the American Academy of Allergy, Asthma and Immunology and the World Asthma Organization.

Thomas Casale, MD, professor of medicine at the University of South Florida, Tampa, said studies have found that in some ways, e-cigarettes seem safer. For example, the levels of carcinogens such as formaldehyde and heavy metals are found at levels that are 9-450 times higher in combustible cigarette smoke than e-cigarette vapor, he said. And toxic compounds have been found to be significantly lower in the urine of e-cigarette users compared to traditional cigarette smokers.

Thomas R. Collins/Frontline Medical News

But it’s not so simple. While e-cigarettes typically cause lower exposure to formaldehyde, when heated at a higher voltage, exposure to formaldehyde hemiacetal, a formaldehyde precursor, is about seven times higher for someone smoking 3 mL of e-cigarette fluid a day – similar to a pack a day – than the formaldehyde exposure of someone smoking the same quantity of combustible cigarettes.

Dr. Casale added that experienced e-cigarette users typically take longer puffs than traditional smokers and that the unregulated e-cigarette industry is rife with mislabeling on things such as how much nicotine is in a given fluid.

“It’s dependent upon the device, the battery, how much it heats up and what’s in the liquid,” he said. “So in general, are they safer? Probably. But not exactly.”

There are also no long-term data on e-cigarettes, he added.

The evidence on how e-cigarettes affects traditional smoking habits is also mixed.

Some studies have indicated that e-cigarettes use can be helpful in kicking a traditional cigarette habit, said Jill Poole, MD, of the University of Nebraska, Omaha.

A survey by the U.S. Census Bureau found that, in the 2014-2015 data collection year, about 60% of smokers of combustible cigarettes who also smoked e-cigarettes tried to quit smoking combustibles, compared to 40% of those who didn’t smoke e-cigarettes. And 8% of e-cigarette users were successful over 3 months, compared to 4% of nonusers.

Thomas R. Collins/ Frontline Medical News

But data reveals risks for kids who’ve never smoked and then start using e-cigarettes.

“Does noncigarette tobacco use among never smoking youth determine subsequent smoking initiation?” she said. “The answer is yes.”

Dr. Poole added that a study published this year found that youths who’d never smoked traditional cigarettes were 87% more likely to start if they had first tried e-cigarettes (JAMA Pediatr. 2018;172(2):181-187).

And more children are using e-cigarettes frequently. The National Youth Tobacco Survey found that 16% of high schoolers in 2016 had used e-cigarettes in the past 30 days, way up from 1.5% in 2011, even as traditional cigarette use has declined from 15.8% to 9.3% among those children over that time.

Thomas R. Collins/ Frontline Medical News

Loretta Que, MD, associate professor of medicine at Duke University, Durham, N.C., noted how advertising for e-cigarettes is similar to the old ads for traditional cigarettes, attempting to convey coolness. With their wide array of colors and thousands of flavors, there is no doubt that e-cigarette pens have caught on among children, she said.

“They’re becoming something akin to an iPhone case or a handbag.”

ORLANDO – E-cigarettes are likely safer than traditional cigarettes but it depends on the user, the voltage used, and the kind of liquid, according to a panel of experts at the joint congress of the American Academy of Allergy, Asthma and Immunology and the World Asthma Organization.

Thomas Casale, MD, professor of medicine at the University of South Florida, Tampa, said studies have found that in some ways, e-cigarettes seem safer. For example, the levels of carcinogens such as formaldehyde and heavy metals are found at levels that are 9-450 times higher in combustible cigarette smoke than e-cigarette vapor, he said. And toxic compounds have been found to be significantly lower in the urine of e-cigarette users compared to traditional cigarette smokers.

Thomas R. Collins/Frontline Medical News

But it’s not so simple. While e-cigarettes typically cause lower exposure to formaldehyde, when heated at a higher voltage, exposure to formaldehyde hemiacetal, a formaldehyde precursor, is about seven times higher for someone smoking 3 mL of e-cigarette fluid a day – similar to a pack a day – than the formaldehyde exposure of someone smoking the same quantity of combustible cigarettes.

Dr. Casale added that experienced e-cigarette users typically take longer puffs than traditional smokers and that the unregulated e-cigarette industry is rife with mislabeling on things such as how much nicotine is in a given fluid.

“It’s dependent upon the device, the battery, how much it heats up and what’s in the liquid,” he said. “So in general, are they safer? Probably. But not exactly.”

There are also no long-term data on e-cigarettes, he added.

The evidence on how e-cigarettes affects traditional smoking habits is also mixed.

Some studies have indicated that e-cigarettes use can be helpful in kicking a traditional cigarette habit, said Jill Poole, MD, of the University of Nebraska, Omaha.

A survey by the U.S. Census Bureau found that, in the 2014-2015 data collection year, about 60% of smokers of combustible cigarettes who also smoked e-cigarettes tried to quit smoking combustibles, compared to 40% of those who didn’t smoke e-cigarettes. And 8% of e-cigarette users were successful over 3 months, compared to 4% of nonusers.

Thomas R. Collins/ Frontline Medical News

But data reveals risks for kids who’ve never smoked and then start using e-cigarettes.

“Does noncigarette tobacco use among never smoking youth determine subsequent smoking initiation?” she said. “The answer is yes.”

Dr. Poole added that a study published this year found that youths who’d never smoked traditional cigarettes were 87% more likely to start if they had first tried e-cigarettes (JAMA Pediatr. 2018;172(2):181-187).

And more children are using e-cigarettes frequently. The National Youth Tobacco Survey found that 16% of high schoolers in 2016 had used e-cigarettes in the past 30 days, way up from 1.5% in 2011, even as traditional cigarette use has declined from 15.8% to 9.3% among those children over that time.

Thomas R. Collins/ Frontline Medical News

Loretta Que, MD, associate professor of medicine at Duke University, Durham, N.C., noted how advertising for e-cigarettes is similar to the old ads for traditional cigarettes, attempting to convey coolness. With their wide array of colors and thousands of flavors, there is no doubt that e-cigarette pens have caught on among children, she said.

“They’re becoming something akin to an iPhone case or a handbag.”

ORLANDO – E-cigarettes are likely safer than traditional cigarettes but it depends on the user, the voltage used, and the kind of liquid, according to a panel of experts at the joint congress of the American Academy of Allergy, Asthma and Immunology and the World Asthma Organization.

Thomas Casale, MD, professor of medicine at the University of South Florida, Tampa, said studies have found that in some ways, e-cigarettes seem safer. For example, the levels of carcinogens such as formaldehyde and heavy metals are found at levels that are 9-450 times higher in combustible cigarette smoke than e-cigarette vapor, he said. And toxic compounds have been found to be significantly lower in the urine of e-cigarette users compared to traditional cigarette smokers.

Thomas R. Collins/Frontline Medical News

But it’s not so simple. While e-cigarettes typically cause lower exposure to formaldehyde, when heated at a higher voltage, exposure to formaldehyde hemiacetal, a formaldehyde precursor, is about seven times higher for someone smoking 3 mL of e-cigarette fluid a day – similar to a pack a day – than the formaldehyde exposure of someone smoking the same quantity of combustible cigarettes.

Dr. Casale added that experienced e-cigarette users typically take longer puffs than traditional smokers and that the unregulated e-cigarette industry is rife with mislabeling on things such as how much nicotine is in a given fluid.

“It’s dependent upon the device, the battery, how much it heats up and what’s in the liquid,” he said. “So in general, are they safer? Probably. But not exactly.”

There are also no long-term data on e-cigarettes, he added.

The evidence on how e-cigarettes affects traditional smoking habits is also mixed.

Some studies have indicated that e-cigarettes use can be helpful in kicking a traditional cigarette habit, said Jill Poole, MD, of the University of Nebraska, Omaha.

A survey by the U.S. Census Bureau found that, in the 2014-2015 data collection year, about 60% of smokers of combustible cigarettes who also smoked e-cigarettes tried to quit smoking combustibles, compared to 40% of those who didn’t smoke e-cigarettes. And 8% of e-cigarette users were successful over 3 months, compared to 4% of nonusers.

Thomas R. Collins/ Frontline Medical News

But data reveals risks for kids who’ve never smoked and then start using e-cigarettes.

“Does noncigarette tobacco use among never smoking youth determine subsequent smoking initiation?” she said. “The answer is yes.”

Dr. Poole added that a study published this year found that youths who’d never smoked traditional cigarettes were 87% more likely to start if they had first tried e-cigarettes (JAMA Pediatr. 2018;172(2):181-187).

And more children are using e-cigarettes frequently. The National Youth Tobacco Survey found that 16% of high schoolers in 2016 had used e-cigarettes in the past 30 days, way up from 1.5% in 2011, even as traditional cigarette use has declined from 15.8% to 9.3% among those children over that time.

Thomas R. Collins/ Frontline Medical News

Loretta Que, MD, associate professor of medicine at Duke University, Durham, N.C., noted how advertising for e-cigarettes is similar to the old ads for traditional cigarettes, attempting to convey coolness. With their wide array of colors and thousands of flavors, there is no doubt that e-cigarette pens have caught on among children, she said.

“They’re becoming something akin to an iPhone case or a handbag.”

• Sepsis response team not beneficial
• Outcomes better for patients with H1N1 vaccination
• Lung recovery high after ECMO in near-fatal asthma
• Robotic-assisted pulmonary lobectomy removes large tumors
• Aspirin responsiveness improved in some with obstructive sleep apnea
• Solriamfetol improves excessive sleepiness in OSA patients
• Acute kidney injury linked with doubled inpatient VTEs
• Alarm reductions don’t improve ICU response times
• ARDS incidence is declining. Is it a preventable syndrome?
• Balanced crystalloids protect kidney better than saline
• Omalizumab helps asthma COPD overlap patients
• Nebulized glycopyrrolate improves lung function in COPD
• Nebulized LABA safe for long-term use in COPD
• IGRA preferred test for latent TB diagnosis
• Only half of appropriate COPD patients get long-acting bronchodilators
• Rapid influenza test obviates empiric antivirals
• Remimazolam surpasses midazolam
• Revised guidelines raise lung cancer screening age ceiling
• Ultrathin bronchoscopy plus radial EBUS unreliable at making diagnoses
• Phrenic-nerve stimulator maintains benefits for 18 months
• Cardiogenic shock boosts PAH readmissions 10-fold
• Evidence mounts for pulmonary embolism benefit from catheter thrombolysis
• Tracheobronchial tree size changes may predict IPF outcomes
• Shorter walk test predicts IPF outcomes
• Comparing arterial ratios may aid risk assessment in IPF
• FDA’s standards for approving generics are questioned
• Live Streaming at CHEST 2017

• Sepsis response team not beneficial
• Outcomes better for patients with H1N1 vaccination
• Lung recovery high after ECMO in near-fatal asthma
• Robotic-assisted pulmonary lobectomy removes large tumors
• Aspirin responsiveness improved in some with obstructive sleep apnea
• Solriamfetol improves excessive sleepiness in OSA patients
• Acute kidney injury linked with doubled inpatient VTEs
• Alarm reductions don’t improve ICU response times
• ARDS incidence is declining. Is it a preventable syndrome?
• Balanced crystalloids protect kidney better than saline
• Omalizumab helps asthma COPD overlap patients
• Nebulized glycopyrrolate improves lung function in COPD
• Nebulized LABA safe for long-term use in COPD
• IGRA preferred test for latent TB diagnosis
• Only half of appropriate COPD patients get long-acting bronchodilators
• Rapid influenza test obviates empiric antivirals
• Remimazolam surpasses midazolam
• Revised guidelines raise lung cancer screening age ceiling
• Ultrathin bronchoscopy plus radial EBUS unreliable at making diagnoses
• Phrenic-nerve stimulator maintains benefits for 18 months
• Cardiogenic shock boosts PAH readmissions 10-fold
• Evidence mounts for pulmonary embolism benefit from catheter thrombolysis
• Tracheobronchial tree size changes may predict IPF outcomes
• Shorter walk test predicts IPF outcomes
• Comparing arterial ratios may aid risk assessment in IPF
• FDA’s standards for approving generics are questioned
• Live Streaming at CHEST 2017

• Sepsis response team not beneficial
• Outcomes better for patients with H1N1 vaccination
• Lung recovery high after ECMO in near-fatal asthma
• Robotic-assisted pulmonary lobectomy removes large tumors
• Aspirin responsiveness improved in some with obstructive sleep apnea
• Solriamfetol improves excessive sleepiness in OSA patients
• Acute kidney injury linked with doubled inpatient VTEs
• Alarm reductions don’t improve ICU response times
• ARDS incidence is declining. Is it a preventable syndrome?
• Balanced crystalloids protect kidney better than saline
• Omalizumab helps asthma COPD overlap patients
• Nebulized glycopyrrolate improves lung function in COPD
• Nebulized LABA safe for long-term use in COPD
• IGRA preferred test for latent TB diagnosis
• Only half of appropriate COPD patients get long-acting bronchodilators
• Rapid influenza test obviates empiric antivirals
• Remimazolam surpasses midazolam
• Revised guidelines raise lung cancer screening age ceiling
• Ultrathin bronchoscopy plus radial EBUS unreliable at making diagnoses
• Phrenic-nerve stimulator maintains benefits for 18 months
• Cardiogenic shock boosts PAH readmissions 10-fold
• Evidence mounts for pulmonary embolism benefit from catheter thrombolysis
• Tracheobronchial tree size changes may predict IPF outcomes
• Shorter walk test predicts IPF outcomes
• Comparing arterial ratios may aid risk assessment in IPF
• FDA’s standards for approving generics are questioned
• Live Streaming at CHEST 2017

LAS VEGAS – The overlap of ADHD, conduct disorder, substance use disorder, and criminality likely reflect related underlying mechanisms, which may elucidate different developmental pathways of offending.

“Early interventions are key,” Praveen R. Kambam, MD, said at an annual psychopharmacology update held by the Nevada Psychiatric Association.

According to Dr. Kambam, a clinical and forensic psychiatrist at the University of California, Los Angeles, ADHD is overrepresented in correctional settings worldwide, especially the hyperactive-impulsive subtype. “In juvenile settings, ADHD rates are 3-4 times higher than rates in the general population,” he said. “If you combine juvenile and adult prison populations worldwide, the rates are about 2-5 times higher than the general population.”

The risks are increased for comorbid oppositional defiant disorder (ODD) and conduct disorder. In fact, ADHD and conduct disorder co-occur in about 50% of cases. In girls, the prevalence rate of conduct disorder is steady at 0.8% around age 5 years and increases to 2.8% around age 15 years, while in boys, conduct disorder is steady at 2.1% around age 5 years and rises to 5.5% at age 15 years.

According to a literature review of 18 prospective studies, 13 retrospective studies, and four reviews, individuals with ADHD plus or minus conduct disorder had an increased the risk of antisocial personality disorder, and those with ADHD plus conduct disorder had an increased risk of criminality (J Atten Disord. 2016;20[10]:815-24). “So it’s a subtle difference, where antisocial personality disorder and criminality are slightly different,” Dr. Kambam said. “It could be that the diagnostic criteria are catching the same thing. However, the added [conduct disorder] suggests that there may be subpopulations that are vulnerable.”

He went on to note that individuals with ADHD and delinquency tend to have more learning problems, poor academic achievement, peer relationship problems, and risk of social rejection, while individuals with oppositional defiant disorder and delinquency tend to have peer relationship problems, a negative parent-child relationship, and increased risk of developing conduct disorder.

ADHD is associated with alcohol and drug use in adulthood and nicotine use in adolescence. “Comorbidity between ADHD and ODD/[conduct disorder] is robustly related to substance outcomes,” Dr. Kambam said. “However, both initiation and continuation of substance use disorder are more likely when ADHD symptoms are present, even when controlling for ODD/[conduct disorder]. As for substance use disorder [SUD] and delinquency, the onset of delinquency is more likely in children with onset of SUD by age 11, and SUDs are closely linked with criminality in both juveniles and adults.”

Comorbidity of SUD with conduct disorder and ADHD likely reflects multifactorial mechanisms, he said, such as inherent novelty seeking or school failure leading to association with antisocial peers. Risk factors for chronic offending include early onset of criminal behaviors, ADHD plus conduct disorder, and ODD. ADHD has an independent yet weaker relationship with antisocial behaviors as well, while ADHD, conduct disorder, and SUD are independently associated with increased recidivism.

Environmental factors for chronic offending include the home environment, peer response, parenting skills, and in utero exposures and perinatal complications. “Whether ADHD develops into more severe conduct problems depends considerably on exposure to potentiating environmental factors,” Dr. Kambam said. “The converse is also true: Low-risk environments promote desistance from this pathway in impulsive boys.” He added that the chronic offenders/criminality pathway likely stems from underlying mechanisms, such as impulsivity, low self-control, and executive dysfunction.

If left untreated, ADHD is associated with poor academic and employment outcomes, SUDs, depression, bipolar disorder, suicide attempts, vehicular accidents, and use of mental health services. “The economic costs are estimated to be $42.5 billion annually, so it has a large impact,” he said.

Limited evidence exists to support pharmacological treatments for conduct disorder, although stimulants/alpha-agonists, antipsychotics, lithium, and mood stabilizers may offer some benefit for target symptoms. “Most of the treatment data center around multisystemic therapy, including behavioral modification/parent management training, and functional family training,” Dr. Kambam said. “Treating disruptive behavior disorders and SUDs are 

likely to reduce criminality and recidivism, particularly if started early. There are many beneficial economic impacts. Think about the cost of having youth detained in the criminal justice systems. In Los Angeles County, that cost is about $230,000 per year per kid. That money can probably be better spent somewhere else.”

Numerous studies show that the nonmedical use of stimulants ranges from 25%-40%. “They’re mostly used to enhance academic and/or work performance, but some are used for euphoric effect,” he said. “Individuals in college and just out of college seem to be at the highest risk. There is a strong relationship between [conduct disorder]/[antisocial personality disorder] or SUDs and nonmedical use.”

Treatment with stimulants in correctional settings is controversial. “Some say try after failure of nonstimulants, while others say never use them due to substance abuse, misuse, intimidation of patients to surrender medication, and security/costs,” Dr. Kambam said. “The protocol for ADHD treatment in Massachusetts prisons calls for use of nonstimulants first, followed by ‘crushable’ stimulants if indicated.” The methylphenidate patch and lisdexamfetamine also can be effective in the incarcerated population.

Dr. Kambam reported having no financial disclosures.

dbrunk@frontlinemedcom.com

SOURCE: Kambam PR. NPA 2018.

LAS VEGAS – The overlap of ADHD, conduct disorder, substance use disorder, and criminality likely reflect related underlying mechanisms, which may elucidate different developmental pathways of offending.

“Early interventions are key,” Praveen R. Kambam, MD, said at an annual psychopharmacology update held by the Nevada Psychiatric Association.

According to Dr. Kambam, a clinical and forensic psychiatrist at the University of California, Los Angeles, ADHD is overrepresented in correctional settings worldwide, especially the hyperactive-impulsive subtype. “In juvenile settings, ADHD rates are 3-4 times higher than rates in the general population,” he said. “If you combine juvenile and adult prison populations worldwide, the rates are about 2-5 times higher than the general population.”

The risks are increased for comorbid oppositional defiant disorder (ODD) and conduct disorder. In fact, ADHD and conduct disorder co-occur in about 50% of cases. In girls, the prevalence rate of conduct disorder is steady at 0.8% around age 5 years and increases to 2.8% around age 15 years, while in boys, conduct disorder is steady at 2.1% around age 5 years and rises to 5.5% at age 15 years.

According to a literature review of 18 prospective studies, 13 retrospective studies, and four reviews, individuals with ADHD plus or minus conduct disorder had an increased the risk of antisocial personality disorder, and those with ADHD plus conduct disorder had an increased risk of criminality (J Atten Disord. 2016;20[10]:815-24). “So it’s a subtle difference, where antisocial personality disorder and criminality are slightly different,” Dr. Kambam said. “It could be that the diagnostic criteria are catching the same thing. However, the added [conduct disorder] suggests that there may be subpopulations that are vulnerable.”

He went on to note that individuals with ADHD and delinquency tend to have more learning problems, poor academic achievement, peer relationship problems, and risk of social rejection, while individuals with oppositional defiant disorder and delinquency tend to have peer relationship problems, a negative parent-child relationship, and increased risk of developing conduct disorder.

ADHD is associated with alcohol and drug use in adulthood and nicotine use in adolescence. “Comorbidity between ADHD and ODD/[conduct disorder] is robustly related to substance outcomes,” Dr. Kambam said. “However, both initiation and continuation of substance use disorder are more likely when ADHD symptoms are present, even when controlling for ODD/[conduct disorder]. As for substance use disorder [SUD] and delinquency, the onset of delinquency is more likely in children with onset of SUD by age 11, and SUDs are closely linked with criminality in both juveniles and adults.”

Comorbidity of SUD with conduct disorder and ADHD likely reflects multifactorial mechanisms, he said, such as inherent novelty seeking or school failure leading to association with antisocial peers. Risk factors for chronic offending include early onset of criminal behaviors, ADHD plus conduct disorder, and ODD. ADHD has an independent yet weaker relationship with antisocial behaviors as well, while ADHD, conduct disorder, and SUD are independently associated with increased recidivism.

Environmental factors for chronic offending include the home environment, peer response, parenting skills, and in utero exposures and perinatal complications. “Whether ADHD develops into more severe conduct problems depends considerably on exposure to potentiating environmental factors,” Dr. Kambam said. “The converse is also true: Low-risk environments promote desistance from this pathway in impulsive boys.” He added that the chronic offenders/criminality pathway likely stems from underlying mechanisms, such as impulsivity, low self-control, and executive dysfunction.

If left untreated, ADHD is associated with poor academic and employment outcomes, SUDs, depression, bipolar disorder, suicide attempts, vehicular accidents, and use of mental health services. “The economic costs are estimated to be $42.5 billion annually, so it has a large impact,” he said.

Limited evidence exists to support pharmacological treatments for conduct disorder, although stimulants/alpha-agonists, antipsychotics, lithium, and mood stabilizers may offer some benefit for target symptoms. “Most of the treatment data center around multisystemic therapy, including behavioral modification/parent management training, and functional family training,” Dr. Kambam said. “Treating disruptive behavior disorders and SUDs are 

likely to reduce criminality and recidivism, particularly if started early. There are many beneficial economic impacts. Think about the cost of having youth detained in the criminal justice systems. In Los Angeles County, that cost is about $230,000 per year per kid. That money can probably be better spent somewhere else.”

Numerous studies show that the nonmedical use of stimulants ranges from 25%-40%. “They’re mostly used to enhance academic and/or work performance, but some are used for euphoric effect,” he said. “Individuals in college and just out of college seem to be at the highest risk. There is a strong relationship between [conduct disorder]/[antisocial personality disorder] or SUDs and nonmedical use.”

Treatment with stimulants in correctional settings is controversial. “Some say try after failure of nonstimulants, while others say never use them due to substance abuse, misuse, intimidation of patients to surrender medication, and security/costs,” Dr. Kambam said. “The protocol for ADHD treatment in Massachusetts prisons calls for use of nonstimulants first, followed by ‘crushable’ stimulants if indicated.” The methylphenidate patch and lisdexamfetamine also can be effective in the incarcerated population.

Dr. Kambam reported having no financial disclosures.

dbrunk@frontlinemedcom.com

SOURCE: Kambam PR. NPA 2018.

LAS VEGAS – The overlap of ADHD, conduct disorder, substance use disorder, and criminality likely reflect related underlying mechanisms, which may elucidate different developmental pathways of offending.

“Early interventions are key,” Praveen R. Kambam, MD, said at an annual psychopharmacology update held by the Nevada Psychiatric Association.

According to Dr. Kambam, a clinical and forensic psychiatrist at the University of California, Los Angeles, ADHD is overrepresented in correctional settings worldwide, especially the hyperactive-impulsive subtype. “In juvenile settings, ADHD rates are 3-4 times higher than rates in the general population,” he said. “If you combine juvenile and adult prison populations worldwide, the rates are about 2-5 times higher than the general population.”

The risks are increased for comorbid oppositional defiant disorder (ODD) and conduct disorder. In fact, ADHD and conduct disorder co-occur in about 50% of cases. In girls, the prevalence rate of conduct disorder is steady at 0.8% around age 5 years and increases to 2.8% around age 15 years, while in boys, conduct disorder is steady at 2.1% around age 5 years and rises to 5.5% at age 15 years.

According to a literature review of 18 prospective studies, 13 retrospective studies, and four reviews, individuals with ADHD plus or minus conduct disorder had an increased the risk of antisocial personality disorder, and those with ADHD plus conduct disorder had an increased risk of criminality (J Atten Disord. 2016;20[10]:815-24). “So it’s a subtle difference, where antisocial personality disorder and criminality are slightly different,” Dr. Kambam said. “It could be that the diagnostic criteria are catching the same thing. However, the added [conduct disorder] suggests that there may be subpopulations that are vulnerable.”

He went on to note that individuals with ADHD and delinquency tend to have more learning problems, poor academic achievement, peer relationship problems, and risk of social rejection, while individuals with oppositional defiant disorder and delinquency tend to have peer relationship problems, a negative parent-child relationship, and increased risk of developing conduct disorder.

ADHD is associated with alcohol and drug use in adulthood and nicotine use in adolescence. “Comorbidity between ADHD and ODD/[conduct disorder] is robustly related to substance outcomes,” Dr. Kambam said. “However, both initiation and continuation of substance use disorder are more likely when ADHD symptoms are present, even when controlling for ODD/[conduct disorder]. As for substance use disorder [SUD] and delinquency, the onset of delinquency is more likely in children with onset of SUD by age 11, and SUDs are closely linked with criminality in both juveniles and adults.”

Comorbidity of SUD with conduct disorder and ADHD likely reflects multifactorial mechanisms, he said, such as inherent novelty seeking or school failure leading to association with antisocial peers. Risk factors for chronic offending include early onset of criminal behaviors, ADHD plus conduct disorder, and ODD. ADHD has an independent yet weaker relationship with antisocial behaviors as well, while ADHD, conduct disorder, and SUD are independently associated with increased recidivism.

Environmental factors for chronic offending include the home environment, peer response, parenting skills, and in utero exposures and perinatal complications. “Whether ADHD develops into more severe conduct problems depends considerably on exposure to potentiating environmental factors,” Dr. Kambam said. “The converse is also true: Low-risk environments promote desistance from this pathway in impulsive boys.” He added that the chronic offenders/criminality pathway likely stems from underlying mechanisms, such as impulsivity, low self-control, and executive dysfunction.

If left untreated, ADHD is associated with poor academic and employment outcomes, SUDs, depression, bipolar disorder, suicide attempts, vehicular accidents, and use of mental health services. “The economic costs are estimated to be $42.5 billion annually, so it has a large impact,” he said.

Limited evidence exists to support pharmacological treatments for conduct disorder, although stimulants/alpha-agonists, antipsychotics, lithium, and mood stabilizers may offer some benefit for target symptoms. “Most of the treatment data center around multisystemic therapy, including behavioral modification/parent management training, and functional family training,” Dr. Kambam said. “Treating disruptive behavior disorders and SUDs are 

likely to reduce criminality and recidivism, particularly if started early. There are many beneficial economic impacts. Think about the cost of having youth detained in the criminal justice systems. In Los Angeles County, that cost is about $230,000 per year per kid. That money can probably be better spent somewhere else.”

Numerous studies show that the nonmedical use of stimulants ranges from 25%-40%. “They’re mostly used to enhance academic and/or work performance, but some are used for euphoric effect,” he said. “Individuals in college and just out of college seem to be at the highest risk. There is a strong relationship between [conduct disorder]/[antisocial personality disorder] or SUDs and nonmedical use.”

Treatment with stimulants in correctional settings is controversial. “Some say try after failure of nonstimulants, while others say never use them due to substance abuse, misuse, intimidation of patients to surrender medication, and security/costs,” Dr. Kambam said. “The protocol for ADHD treatment in Massachusetts prisons calls for use of nonstimulants first, followed by ‘crushable’ stimulants if indicated.” The methylphenidate patch and lisdexamfetamine also can be effective in the incarcerated population.

Dr. Kambam reported having no financial disclosures.

dbrunk@frontlinemedcom.com

SOURCE: Kambam PR. NPA 2018.

The immune checkpoint inhibitor avelumab (Bavencio), targeted against programmed cell death protein 1 and its ligand (PD1/PD-L1), appears to be well tolerated with a manageable safety profile, pooled data from two clinical trials suggest.

Of the 1,738 patients enrolled in the phase 1 JAVELIN solid tumor trial and the phase 2 JAVELIN Merkel 200 trial, 1,164 (67%) had a treatment-related adverse event (TRAE), and 177 (10.2%) had grade 3 or greater TRAEs. Grade 3 or greater immune-related adverse events (irAEs) occurred in just 2.2% of patients, reported Karen Kelly, MD, from the University of California, Davis, and her colleagues.

“Although conclusions drawn from cross-study comparisons should be made with caution, and to the best of our knowledge the number of pan-tumor clinical studies of [immune checkpoint inhibitor] monotherapy is limited, this analysis of a large population of patients across a broad scope of tumor types suggests that avelumab was associated with an incidence of irAEs that is consistent with that of other ICIs,” they wrote in Cancer.

Adverse events common with other immune checkpoint inhibitors include low-grade fatigue, pruritus, and rash, as well as serious irAEs, including high-grade pneumonitis and autoimmune-like side effects, the authors noted.

To characterize the adverse event profile of avelumab, they reviewed safety data on 1,650 patients enrolled in the solid tumor trial and 88 enrolled in the Merkel cell carcinoma trial, which included all patients in the trial who had received at least one dose of avelumab monotherapy by the cutoff date.

At the time of the analysis, 287 patients (16.5%) were continuing treatment, and 1,451 had discontinued therapy, largely because of disease progression.

Nearly all patients – 1,697 (97.6%) – had at least one adverse event of any grade or cause.

Four patients died from what investigators determined were TRAEs, including autoimmune hepatitis with peritoneal metastases and ascites in a patient with gastric cancer, liver metastases and acute liver failure in a patient with metastatic breast cancer, respiratory distress in a patient with breast cancer and multiple comorbidities, and treatment-related pneumonitis with ongoing Clostridium difficile colitis and diverticulitis not related to study treatment in a patient with urothelial carcinoma.

An additional 59 patients (3.4%) died from adverse events not deemed to be treatment-related, and 104 patient (6%) died from unknown or undocumented causes.

Any grade of irAE occurred in 247 patients (14.2%) and were grade 3 or greater in 39 (2.2%). Management of irAEs included systemic corticosteroids and nonsteroidal immunosuppressants.

In all, 439 patients (25.3%) had infusion-related reactions, which were treated generally with systemic corticosteroid. The protocol of the solid tumor trial was amended later to include diphenhydramine and acetaminophen before the first avelumab infusion as prophylaxis.

The study was sponsored by Merck and part of an alliance between Merck and Pfizer. Dr. Kelly reported no conflicts of interest. Multiple coauthors reported research funding, consulting fees, honoraria, or other consideration from various companies, and several coauthors are Merck employees.

The immune checkpoint inhibitor avelumab (Bavencio), targeted against programmed cell death protein 1 and its ligand (PD1/PD-L1), appears to be well tolerated with a manageable safety profile, pooled data from two clinical trials suggest.

Of the 1,738 patients enrolled in the phase 1 JAVELIN solid tumor trial and the phase 2 JAVELIN Merkel 200 trial, 1,164 (67%) had a treatment-related adverse event (TRAE), and 177 (10.2%) had grade 3 or greater TRAEs. Grade 3 or greater immune-related adverse events (irAEs) occurred in just 2.2% of patients, reported Karen Kelly, MD, from the University of California, Davis, and her colleagues.

“Although conclusions drawn from cross-study comparisons should be made with caution, and to the best of our knowledge the number of pan-tumor clinical studies of [immune checkpoint inhibitor] monotherapy is limited, this analysis of a large population of patients across a broad scope of tumor types suggests that avelumab was associated with an incidence of irAEs that is consistent with that of other ICIs,” they wrote in Cancer.

Adverse events common with other immune checkpoint inhibitors include low-grade fatigue, pruritus, and rash, as well as serious irAEs, including high-grade pneumonitis and autoimmune-like side effects, the authors noted.

To characterize the adverse event profile of avelumab, they reviewed safety data on 1,650 patients enrolled in the solid tumor trial and 88 enrolled in the Merkel cell carcinoma trial, which included all patients in the trial who had received at least one dose of avelumab monotherapy by the cutoff date.

At the time of the analysis, 287 patients (16.5%) were continuing treatment, and 1,451 had discontinued therapy, largely because of disease progression.

Nearly all patients – 1,697 (97.6%) – had at least one adverse event of any grade or cause.

Four patients died from what investigators determined were TRAEs, including autoimmune hepatitis with peritoneal metastases and ascites in a patient with gastric cancer, liver metastases and acute liver failure in a patient with metastatic breast cancer, respiratory distress in a patient with breast cancer and multiple comorbidities, and treatment-related pneumonitis with ongoing Clostridium difficile colitis and diverticulitis not related to study treatment in a patient with urothelial carcinoma.

An additional 59 patients (3.4%) died from adverse events not deemed to be treatment-related, and 104 patient (6%) died from unknown or undocumented causes.

Any grade of irAE occurred in 247 patients (14.2%) and were grade 3 or greater in 39 (2.2%). Management of irAEs included systemic corticosteroids and nonsteroidal immunosuppressants.

In all, 439 patients (25.3%) had infusion-related reactions, which were treated generally with systemic corticosteroid. The protocol of the solid tumor trial was amended later to include diphenhydramine and acetaminophen before the first avelumab infusion as prophylaxis.

The study was sponsored by Merck and part of an alliance between Merck and Pfizer. Dr. Kelly reported no conflicts of interest. Multiple coauthors reported research funding, consulting fees, honoraria, or other consideration from various companies, and several coauthors are Merck employees.

The immune checkpoint inhibitor avelumab (Bavencio), targeted against programmed cell death protein 1 and its ligand (PD1/PD-L1), appears to be well tolerated with a manageable safety profile, pooled data from two clinical trials suggest.

Of the 1,738 patients enrolled in the phase 1 JAVELIN solid tumor trial and the phase 2 JAVELIN Merkel 200 trial, 1,164 (67%) had a treatment-related adverse event (TRAE), and 177 (10.2%) had grade 3 or greater TRAEs. Grade 3 or greater immune-related adverse events (irAEs) occurred in just 2.2% of patients, reported Karen Kelly, MD, from the University of California, Davis, and her colleagues.

“Although conclusions drawn from cross-study comparisons should be made with caution, and to the best of our knowledge the number of pan-tumor clinical studies of [immune checkpoint inhibitor] monotherapy is limited, this analysis of a large population of patients across a broad scope of tumor types suggests that avelumab was associated with an incidence of irAEs that is consistent with that of other ICIs,” they wrote in Cancer.

Adverse events common with other immune checkpoint inhibitors include low-grade fatigue, pruritus, and rash, as well as serious irAEs, including high-grade pneumonitis and autoimmune-like side effects, the authors noted.

To characterize the adverse event profile of avelumab, they reviewed safety data on 1,650 patients enrolled in the solid tumor trial and 88 enrolled in the Merkel cell carcinoma trial, which included all patients in the trial who had received at least one dose of avelumab monotherapy by the cutoff date.

At the time of the analysis, 287 patients (16.5%) were continuing treatment, and 1,451 had discontinued therapy, largely because of disease progression.

Nearly all patients – 1,697 (97.6%) – had at least one adverse event of any grade or cause.

Four patients died from what investigators determined were TRAEs, including autoimmune hepatitis with peritoneal metastases and ascites in a patient with gastric cancer, liver metastases and acute liver failure in a patient with metastatic breast cancer, respiratory distress in a patient with breast cancer and multiple comorbidities, and treatment-related pneumonitis with ongoing Clostridium difficile colitis and diverticulitis not related to study treatment in a patient with urothelial carcinoma.

An additional 59 patients (3.4%) died from adverse events not deemed to be treatment-related, and 104 patient (6%) died from unknown or undocumented causes.

Any grade of irAE occurred in 247 patients (14.2%) and were grade 3 or greater in 39 (2.2%). Management of irAEs included systemic corticosteroids and nonsteroidal immunosuppressants.

In all, 439 patients (25.3%) had infusion-related reactions, which were treated generally with systemic corticosteroid. The protocol of the solid tumor trial was amended later to include diphenhydramine and acetaminophen before the first avelumab infusion as prophylaxis.

The study was sponsored by Merck and part of an alliance between Merck and Pfizer. Dr. Kelly reported no conflicts of interest. Multiple coauthors reported research funding, consulting fees, honoraria, or other consideration from various companies, and several coauthors are Merck employees.

Variations in the clinical presentation of immunotherapy-induced inflammatory arthritis is partly explained by which treatment regimen was used to treat the cancer, a single-center study suggests.

While immune checkpoint inhibitors (ICI) have revolutionized the field of oncology, their use for an ever-widening range of indications had created an increasing population of patients referred to rheumatologists for the management of immune-related adverse events (IrAEs), according to Laura C. Cappelli, MD, and her colleagues at John Hopkins University, Baltimore. 

Well-established guidelines exist for managing adverse events such as colitis and pneumonitis, but there are only preliminary guidelines for evaluating and treating immunotherapy-induced inflammatory arthritis (IA). “This may stem from a lack of consistent reporting of rheumatologic IrAEs in clinical trials, the non–life threatening nature of [inflammatory arthritis], or lack of recognition of musculoskeletal symptoms by treating providers,” they wrote in Seminars in Arthritis and Rheumatism.

Clinical trials have reported ranges of arthralgia in 1%-43% of patients treated with ICIs, but no accurate estimate of the incidence of IA exists. 

The researchers noted that treating patients with ICI-induced IA is complicated by a history of active or recently treated cancer and concerns over using immunosuppression in the context of ICI therapy. 

They set out to evaluate the clinical presentations of 30 patients seen in their clinic with ICI-induced IA. Patients were a median of 59 years old and 12 (40%) were female. Tumor types included metastatic melanoma, non–small cell lung cancer, small cell lung cancer, colorectal cancer, Hodgkin lymphoma, cutaneous lymphoma, renal cell carcinoma, duodenal carcinoma, Merkel cell carcinoma, cutaneous basal cell carcinoma, and cutaneous squamous cell carcinoma.

Sixteen patients were treated with anti–programmed cell death protein 1 (PD-1)/programmed death ligand 1 monotherapy, and 14 were treated with combination anti–CTLA-4/PD-1 therapy. 
Patients on combination therapy were significantly younger (7.5 years, P = 0.01) and were more likely to have metastatic melanoma as their underlying cancer.

Patients who received combination therapy were more likely to present first with knee IA (n = 10) and none had small joint involvement. In contrast, initial small joint involvement was more common in the monotherapy group (n = 6).

Most of the patients in the study had an additional IrAE, with colitis being the most common (n=10), followed by thyroid disease, pneumonitis, and rash. Patients on PD-1 or programmed death ligand 1 monotherapy were more likely to have IA as their first IrAE.

The research team noted that the median time to symptom onset was 5 months after ICI initiation.

Diagnosis of IA following patient-reported symptoms was an average of 5.2 months, with a significant difference in lag time to diagnosis depending on initial joint presentation. For example, patients with initial small joint involvement had a 10 month longer lag time to IA diagnosis than those with knees as the initial joint involved. 

In terms of treatment, 24 patients were treated with systemic corticosteroids and 10 required additional immunosuppression. The need for corticosteroids did not differ by ICI treatment regimen, but those treated with combination therapy were more likely to require additional immunosuppression (P = 0.02).

Tumor necrosis factor inhibitors with or without methotrexate were prescribed for seven patients. All of the patients had a clinical improvement in their arthritis symptoms. Four had a complete tumor response at the time of tumor necrosis factor inhibitor initiation with none having tumor progression.

The three patients treated with methotrexate monotherapy had a complete or sustained partial tumor response to ICI therapy and their cancer did not develop during IA management follow-up.  

The authors went on to look at the persistence of IA after cessation of therapy in a subset of 21 patients. They found that 18 of these patients still had IA symptoms months after stopping treatment. They suggested that the delay in diagnosis and treatment seen in their study might explain the finding. 

The study provides “critical information, not just for rheumatologists as they try to recognize subgroups in ICI-induced IA and diagnose patients with this new entity, but also for oncology providers who are usually first to encounter patients with ICI-induced IA and subsequently refer patients to rheumatology,” Dr. Cappelli and colleagues wrote.

The experience so far with using immunosuppression in ICI-induced IA “has been reassuring in terms of cancer outcomes, but more studies are needed to confirm this finding,” they concluded.

SOURCE: Cappelli LC et al. Semin Arthritis Rheum. doi: 10.1016/j.semarthrit. 2018.02.011.

Variations in the clinical presentation of immunotherapy-induced inflammatory arthritis is partly explained by which treatment regimen was used to treat the cancer, a single-center study suggests.

While immune checkpoint inhibitors (ICI) have revolutionized the field of oncology, their use for an ever-widening range of indications had created an increasing population of patients referred to rheumatologists for the management of immune-related adverse events (IrAEs), according to Laura C. Cappelli, MD, and her colleagues at John Hopkins University, Baltimore. 

Well-established guidelines exist for managing adverse events such as colitis and pneumonitis, but there are only preliminary guidelines for evaluating and treating immunotherapy-induced inflammatory arthritis (IA). “This may stem from a lack of consistent reporting of rheumatologic IrAEs in clinical trials, the non–life threatening nature of [inflammatory arthritis], or lack of recognition of musculoskeletal symptoms by treating providers,” they wrote in Seminars in Arthritis and Rheumatism.

Clinical trials have reported ranges of arthralgia in 1%-43% of patients treated with ICIs, but no accurate estimate of the incidence of IA exists. 

The researchers noted that treating patients with ICI-induced IA is complicated by a history of active or recently treated cancer and concerns over using immunosuppression in the context of ICI therapy. 

They set out to evaluate the clinical presentations of 30 patients seen in their clinic with ICI-induced IA. Patients were a median of 59 years old and 12 (40%) were female. Tumor types included metastatic melanoma, non–small cell lung cancer, small cell lung cancer, colorectal cancer, Hodgkin lymphoma, cutaneous lymphoma, renal cell carcinoma, duodenal carcinoma, Merkel cell carcinoma, cutaneous basal cell carcinoma, and cutaneous squamous cell carcinoma.

Sixteen patients were treated with anti–programmed cell death protein 1 (PD-1)/programmed death ligand 1 monotherapy, and 14 were treated with combination anti–CTLA-4/PD-1 therapy. 
Patients on combination therapy were significantly younger (7.5 years, P = 0.01) and were more likely to have metastatic melanoma as their underlying cancer.

Patients who received combination therapy were more likely to present first with knee IA (n = 10) and none had small joint involvement. In contrast, initial small joint involvement was more common in the monotherapy group (n = 6).

Most of the patients in the study had an additional IrAE, with colitis being the most common (n=10), followed by thyroid disease, pneumonitis, and rash. Patients on PD-1 or programmed death ligand 1 monotherapy were more likely to have IA as their first IrAE.

The research team noted that the median time to symptom onset was 5 months after ICI initiation.

Diagnosis of IA following patient-reported symptoms was an average of 5.2 months, with a significant difference in lag time to diagnosis depending on initial joint presentation. For example, patients with initial small joint involvement had a 10 month longer lag time to IA diagnosis than those with knees as the initial joint involved. 

In terms of treatment, 24 patients were treated with systemic corticosteroids and 10 required additional immunosuppression. The need for corticosteroids did not differ by ICI treatment regimen, but those treated with combination therapy were more likely to require additional immunosuppression (P = 0.02).

Tumor necrosis factor inhibitors with or without methotrexate were prescribed for seven patients. All of the patients had a clinical improvement in their arthritis symptoms. Four had a complete tumor response at the time of tumor necrosis factor inhibitor initiation with none having tumor progression.

The three patients treated with methotrexate monotherapy had a complete or sustained partial tumor response to ICI therapy and their cancer did not develop during IA management follow-up.  

The authors went on to look at the persistence of IA after cessation of therapy in a subset of 21 patients. They found that 18 of these patients still had IA symptoms months after stopping treatment. They suggested that the delay in diagnosis and treatment seen in their study might explain the finding. 

The study provides “critical information, not just for rheumatologists as they try to recognize subgroups in ICI-induced IA and diagnose patients with this new entity, but also for oncology providers who are usually first to encounter patients with ICI-induced IA and subsequently refer patients to rheumatology,” Dr. Cappelli and colleagues wrote.

The experience so far with using immunosuppression in ICI-induced IA “has been reassuring in terms of cancer outcomes, but more studies are needed to confirm this finding,” they concluded.

SOURCE: Cappelli LC et al. Semin Arthritis Rheum. doi: 10.1016/j.semarthrit. 2018.02.011.

Variations in the clinical presentation of immunotherapy-induced inflammatory arthritis is partly explained by which treatment regimen was used to treat the cancer, a single-center study suggests.

While immune checkpoint inhibitors (ICI) have revolutionized the field of oncology, their use for an ever-widening range of indications had created an increasing population of patients referred to rheumatologists for the management of immune-related adverse events (IrAEs), according to Laura C. Cappelli, MD, and her colleagues at John Hopkins University, Baltimore. 

Well-established guidelines exist for managing adverse events such as colitis and pneumonitis, but there are only preliminary guidelines for evaluating and treating immunotherapy-induced inflammatory arthritis (IA). “This may stem from a lack of consistent reporting of rheumatologic IrAEs in clinical trials, the non–life threatening nature of [inflammatory arthritis], or lack of recognition of musculoskeletal symptoms by treating providers,” they wrote in Seminars in Arthritis and Rheumatism.

Clinical trials have reported ranges of arthralgia in 1%-43% of patients treated with ICIs, but no accurate estimate of the incidence of IA exists. 

The researchers noted that treating patients with ICI-induced IA is complicated by a history of active or recently treated cancer and concerns over using immunosuppression in the context of ICI therapy. 

They set out to evaluate the clinical presentations of 30 patients seen in their clinic with ICI-induced IA. Patients were a median of 59 years old and 12 (40%) were female. Tumor types included metastatic melanoma, non–small cell lung cancer, small cell lung cancer, colorectal cancer, Hodgkin lymphoma, cutaneous lymphoma, renal cell carcinoma, duodenal carcinoma, Merkel cell carcinoma, cutaneous basal cell carcinoma, and cutaneous squamous cell carcinoma.

Sixteen patients were treated with anti–programmed cell death protein 1 (PD-1)/programmed death ligand 1 monotherapy, and 14 were treated with combination anti–CTLA-4/PD-1 therapy. 
Patients on combination therapy were significantly younger (7.5 years, P = 0.01) and were more likely to have metastatic melanoma as their underlying cancer.

Patients who received combination therapy were more likely to present first with knee IA (n = 10) and none had small joint involvement. In contrast, initial small joint involvement was more common in the monotherapy group (n = 6).

Most of the patients in the study had an additional IrAE, with colitis being the most common (n=10), followed by thyroid disease, pneumonitis, and rash. Patients on PD-1 or programmed death ligand 1 monotherapy were more likely to have IA as their first IrAE.

The research team noted that the median time to symptom onset was 5 months after ICI initiation.

Diagnosis of IA following patient-reported symptoms was an average of 5.2 months, with a significant difference in lag time to diagnosis depending on initial joint presentation. For example, patients with initial small joint involvement had a 10 month longer lag time to IA diagnosis than those with knees as the initial joint involved. 

In terms of treatment, 24 patients were treated with systemic corticosteroids and 10 required additional immunosuppression. The need for corticosteroids did not differ by ICI treatment regimen, but those treated with combination therapy were more likely to require additional immunosuppression (P = 0.02).

Tumor necrosis factor inhibitors with or without methotrexate were prescribed for seven patients. All of the patients had a clinical improvement in their arthritis symptoms. Four had a complete tumor response at the time of tumor necrosis factor inhibitor initiation with none having tumor progression.

The three patients treated with methotrexate monotherapy had a complete or sustained partial tumor response to ICI therapy and their cancer did not develop during IA management follow-up.  

The authors went on to look at the persistence of IA after cessation of therapy in a subset of 21 patients. They found that 18 of these patients still had IA symptoms months after stopping treatment. They suggested that the delay in diagnosis and treatment seen in their study might explain the finding. 

The study provides “critical information, not just for rheumatologists as they try to recognize subgroups in ICI-induced IA and diagnose patients with this new entity, but also for oncology providers who are usually first to encounter patients with ICI-induced IA and subsequently refer patients to rheumatology,” Dr. Cappelli and colleagues wrote.

The experience so far with using immunosuppression in ICI-induced IA “has been reassuring in terms of cancer outcomes, but more studies are needed to confirm this finding,” they concluded.

SOURCE: Cappelli LC et al. Semin Arthritis Rheum. doi: 10.1016/j.semarthrit. 2018.02.011.

Define It, Engage, Listen, Organize, and Closure. There, You Have It!

When I was asked to give this lecture at the 2017 American College of Emergency Physicians’ (ACEP) Scientific Assembly, I literally snorted and looked over my shoulder. What? Moi give this lecture? Am I a successful emergency physician (EP)? Well, of course I am as the first emergency medicine (EM) residency-trained female professor at the University of Colorado, chair of the meetings subcommittee for the ACEP Educational Committee, and director on the American Board of Emergency Medicine.

What I have learned is that the first step to being successful is to define your personal barriers and self-defeating behaviors, and to identify and define your personal self-defeating behaviors—eg, perfectionism, procrastination, self-doubt?

My own personal self-defeating behavior is most certainly “imposter syndrome,” which is very common among professionals. I first heard about imposter syndrome on my very first day of medical school, and this behavior still follows me today. I have written some short blurbs on this topic because I want others to know they are not alone. Highly successful people have this syndrome, and it can be very debilitating. What is imposter syndrome? According to Sandberg, “Despite being high achievers, even experts in their fields, women can’t seem to shake the sense that it is only a matter of time until they are found out for who they really are- impostors with limited skills or abilities.”¹ Valerie Young, an internationally recognized expert on the subject, categorized imposter syndrome into five subgroups or habits: (1) the perfectionist; (2) the superwoman/man; (3) the natural genius; (4) the rugged individualist; and (5) the expert. In her book, The Secret Thoughts of Successful Women: Why Capable People Suffer From the Imposter Syndrome and How to Thrive in Spite of It, Young builds on decades of research studying fraudulent feelings among high achievers.²

Identify Your Self-Defeating Behaviors and Write Them Down

Regarding the top five subgroups/habits proposed by Young unfortunately, there is no evidence-based literature on imposter syndrome. Most information consists of anecdotal reports from highly successful people. When you read about successful habits from such individuals, they include such things as: efficiency; bring your A-game; embrace communication; personal wellness; and most importantly, growth mentality.³ You have most likely heard phrases such as, “Don’t touch a piece of paper more than once.” The “touch it once” philosophy maybe is efficient, but I’m not sure about it being a successful habit.⁴ The following is my list of the top five principles that I have used to guide my career.

Define

What is success to you? Are you thinking about your whole career, or just a successful shift or a successful triathlon? Do you want to win the triathlon or just finish it? Or, do you want to be a department chair? Define and set your goal(s), and make sure to reach and stretch yourself to the best of your abilities to attain your goal. To achieve your goal, you must force yourself out of your comfort zone. If you do not reach for something, chances are it is not going to drop in your lap.

When I attended my very first ACEP Scientific Assembly as a newly minted EM residency-trained EP, I thought the lectures were a bit too basic and needed to be at a higher level of knowledge. I decided I really wanted to be a part of that process. I defined my personal challenge as improving the ACEP educational content level, and I set my goal as getting on that committee. Your goal may be quite different—eg, maybe you wish to become the medical director of an ED, a residency program director, or an officer on your hospital’s medical staff. Regardless of your goal, the first step is to decide and define what it is that you desire.

Engage

After you have defined and set your goal, the first steps to attaining it are to get started on the road you’ve chosen by showing up at relevant meetings, events; being present, engaging, and demonstrating curiosity. Maybe you will have an interesting journey!

I can’t stress enough how important it is to just show up. Sometimes, you will find that you start in one direction and get pushed in another. One of the first steps I took to getting on the ACEP education committee was to ask other ACEP members and colleagues how to do so. Most told me that the education committee was a very highly regarded one and that perhaps I should start by getting on any ACEP committee—or even better, start with a section. A respected friend in the “know” suggested that I choose an ACEP committee/section of which I had high interest, and to just show up to one of the meetings. I have found this advice to be true for most of life, whether it’s your hospital medical staff, local medical society, or state specialty society, or another professional organization—just show up.

Listen

When you do show up and attend a meeting or event, sit and listen to what others have to say, and when a task comes up with which you think you could be of assistance, step up and volunteer to help. When you are involved in a project or task, or are just listening, always keep an open mind—maybe your agenda is not exactly the same as other members of the organization/committee, but you will learn and gain important experience by being open to the thoughts and opinions of others.

When you step up and offer your assistance, you should make sure you volunteer for something that interests you. In general, to do a good job, the subject matter needs to be of interest to you, and the greater the interest, the more likely you are to be successful at completing the task. It also helps to make sure what you volunteer to do is attainable and realistic.

Organize/Action

After you’ve volunteered and committed yourself to a project, always be a productive member of the group. Do what you say you are going to do, and do it on time. These two simple things, completing your assignment/fulfilling your commitment and doing so on time, will set you apart from the pack. Do not be surprised when the reward for such an accomplishment is a request for you to do more, or take on leadership responsibilities.

Regarding my own personal journey, after I found out who served on the education committee. I started to set down some of the groundwork of networking, showing interest in the committee, and letting committee members know that I was very interested in their group and capable of helping in attaining their goals. Five years after taking these first steps to become involved in the group, I was appointed to serve on the meeting subcommittee of the ACEP education committee. This is the group that sets the curriculum and speakers for the Annual ACEP Scientific Assembly. I had made it! Then, after 8 years on the committee, I was appointed chair and worked hard to bring the meeting to Denver, Colorado, my home town. I pushed hard to reduce the length of many of the 50-minute lectures to 25 minutes, and also added some “rapid-fire” lectures to the curriculum.

Failures

On the path to attaining your goals, you will often encounter failure. It is important to keep in mind that if you never fail, then you probably are not reaching high or far enough. For example, I once wanted my institution to be more integrated at the affiliated University’s campus. I had defined this as my goal. To reach it, when the annual election for the medical school faculty senate came along, I had as many of my faculty colleagues vote for me as secretary, the lowest faculty position available. To my shock, I got elected! The problem was, as the secretary, I was supposed to be present at all of the monthly meetings and actually take notes. Not only did I not know who any of the individuals speaking at these meetings were, but I could only make approximately 50% of the meetings due to scheduling conflicts and other commitments. It is my own shame for not doing my homework and learning the roles and responsibilities of the secretarial position. I had the definition of success as a vague one: I engaged but did not really have an attainable goal. After 3 months, I had to go to the dean and admit I had made a mistake and was not capable of performing the duty of secretary. Although, the dean understood and thanked me for my honesty, this was a humbling experience for me and one that also reflected poorly on my department.

However, we are all human and we do make mistakes. By acknowledging our mistakes and shortcomings, reflecting on why they happened, and learning how to handle and do things differently in the future is all part of the journey to success.

Closure

Did I find all of the time and work I put in over the years to be where I am now worth it to me personally? Was I successful? Yes on both counts! It was one long journey. In addition to the long-term journey, I also choose short ones. For example, I want a successful shift, which I now define as sitting down at least 50% of the time when taking a patient’s history. I also want to be engaged with my patients. Remember, the key to being a successful EP is to set goals, whether they are long-term, short-term, major, or minor. So, reach, define, engage, listen, organize, and attain closure. Expect and be ready for some failures—these are steps on the path to success.

Define It, Engage, Listen, Organize, and Closure. There, You Have It!

When I was asked to give this lecture at the 2017 American College of Emergency Physicians’ (ACEP) Scientific Assembly, I literally snorted and looked over my shoulder. What? Moi give this lecture? Am I a successful emergency physician (EP)? Well, of course I am as the first emergency medicine (EM) residency-trained female professor at the University of Colorado, chair of the meetings subcommittee for the ACEP Educational Committee, and director on the American Board of Emergency Medicine.

What I have learned is that the first step to being successful is to define your personal barriers and self-defeating behaviors, and to identify and define your personal self-defeating behaviors—eg, perfectionism, procrastination, self-doubt?

My own personal self-defeating behavior is most certainly “imposter syndrome,” which is very common among professionals. I first heard about imposter syndrome on my very first day of medical school, and this behavior still follows me today. I have written some short blurbs on this topic because I want others to know they are not alone. Highly successful people have this syndrome, and it can be very debilitating. What is imposter syndrome? According to Sandberg, “Despite being high achievers, even experts in their fields, women can’t seem to shake the sense that it is only a matter of time until they are found out for who they really are- impostors with limited skills or abilities.”¹ Valerie Young, an internationally recognized expert on the subject, categorized imposter syndrome into five subgroups or habits: (1) the perfectionist; (2) the superwoman/man; (3) the natural genius; (4) the rugged individualist; and (5) the expert. In her book, The Secret Thoughts of Successful Women: Why Capable People Suffer From the Imposter Syndrome and How to Thrive in Spite of It, Young builds on decades of research studying fraudulent feelings among high achievers.²

Identify Your Self-Defeating Behaviors and Write Them Down

Regarding the top five subgroups/habits proposed by Young unfortunately, there is no evidence-based literature on imposter syndrome. Most information consists of anecdotal reports from highly successful people. When you read about successful habits from such individuals, they include such things as: efficiency; bring your A-game; embrace communication; personal wellness; and most importantly, growth mentality.³ You have most likely heard phrases such as, “Don’t touch a piece of paper more than once.” The “touch it once” philosophy maybe is efficient, but I’m not sure about it being a successful habit.⁴ The following is my list of the top five principles that I have used to guide my career.

Define

What is success to you? Are you thinking about your whole career, or just a successful shift or a successful triathlon? Do you want to win the triathlon or just finish it? Or, do you want to be a department chair? Define and set your goal(s), and make sure to reach and stretch yourself to the best of your abilities to attain your goal. To achieve your goal, you must force yourself out of your comfort zone. If you do not reach for something, chances are it is not going to drop in your lap.

When I attended my very first ACEP Scientific Assembly as a newly minted EM residency-trained EP, I thought the lectures were a bit too basic and needed to be at a higher level of knowledge. I decided I really wanted to be a part of that process. I defined my personal challenge as improving the ACEP educational content level, and I set my goal as getting on that committee. Your goal may be quite different—eg, maybe you wish to become the medical director of an ED, a residency program director, or an officer on your hospital’s medical staff. Regardless of your goal, the first step is to decide and define what it is that you desire.

Engage

After you have defined and set your goal, the first steps to attaining it are to get started on the road you’ve chosen by showing up at relevant meetings, events; being present, engaging, and demonstrating curiosity. Maybe you will have an interesting journey!

I can’t stress enough how important it is to just show up. Sometimes, you will find that you start in one direction and get pushed in another. One of the first steps I took to getting on the ACEP education committee was to ask other ACEP members and colleagues how to do so. Most told me that the education committee was a very highly regarded one and that perhaps I should start by getting on any ACEP committee—or even better, start with a section. A respected friend in the “know” suggested that I choose an ACEP committee/section of which I had high interest, and to just show up to one of the meetings. I have found this advice to be true for most of life, whether it’s your hospital medical staff, local medical society, or state specialty society, or another professional organization—just show up.

Listen

When you do show up and attend a meeting or event, sit and listen to what others have to say, and when a task comes up with which you think you could be of assistance, step up and volunteer to help. When you are involved in a project or task, or are just listening, always keep an open mind—maybe your agenda is not exactly the same as other members of the organization/committee, but you will learn and gain important experience by being open to the thoughts and opinions of others.

When you step up and offer your assistance, you should make sure you volunteer for something that interests you. In general, to do a good job, the subject matter needs to be of interest to you, and the greater the interest, the more likely you are to be successful at completing the task. It also helps to make sure what you volunteer to do is attainable and realistic.

Organize/Action

After you’ve volunteered and committed yourself to a project, always be a productive member of the group. Do what you say you are going to do, and do it on time. These two simple things, completing your assignment/fulfilling your commitment and doing so on time, will set you apart from the pack. Do not be surprised when the reward for such an accomplishment is a request for you to do more, or take on leadership responsibilities.

Regarding my own personal journey, after I found out who served on the education committee. I started to set down some of the groundwork of networking, showing interest in the committee, and letting committee members know that I was very interested in their group and capable of helping in attaining their goals. Five years after taking these first steps to become involved in the group, I was appointed to serve on the meeting subcommittee of the ACEP education committee. This is the group that sets the curriculum and speakers for the Annual ACEP Scientific Assembly. I had made it! Then, after 8 years on the committee, I was appointed chair and worked hard to bring the meeting to Denver, Colorado, my home town. I pushed hard to reduce the length of many of the 50-minute lectures to 25 minutes, and also added some “rapid-fire” lectures to the curriculum.

Failures

On the path to attaining your goals, you will often encounter failure. It is important to keep in mind that if you never fail, then you probably are not reaching high or far enough. For example, I once wanted my institution to be more integrated at the affiliated University’s campus. I had defined this as my goal. To reach it, when the annual election for the medical school faculty senate came along, I had as many of my faculty colleagues vote for me as secretary, the lowest faculty position available. To my shock, I got elected! The problem was, as the secretary, I was supposed to be present at all of the monthly meetings and actually take notes. Not only did I not know who any of the individuals speaking at these meetings were, but I could only make approximately 50% of the meetings due to scheduling conflicts and other commitments. It is my own shame for not doing my homework and learning the roles and responsibilities of the secretarial position. I had the definition of success as a vague one: I engaged but did not really have an attainable goal. After 3 months, I had to go to the dean and admit I had made a mistake and was not capable of performing the duty of secretary. Although, the dean understood and thanked me for my honesty, this was a humbling experience for me and one that also reflected poorly on my department.

However, we are all human and we do make mistakes. By acknowledging our mistakes and shortcomings, reflecting on why they happened, and learning how to handle and do things differently in the future is all part of the journey to success.

Closure

Did I find all of the time and work I put in over the years to be where I am now worth it to me personally? Was I successful? Yes on both counts! It was one long journey. In addition to the long-term journey, I also choose short ones. For example, I want a successful shift, which I now define as sitting down at least 50% of the time when taking a patient’s history. I also want to be engaged with my patients. Remember, the key to being a successful EP is to set goals, whether they are long-term, short-term, major, or minor. So, reach, define, engage, listen, organize, and attain closure. Expect and be ready for some failures—these are steps on the path to success.

Define It, Engage, Listen, Organize, and Closure. There, You Have It!

When I was asked to give this lecture at the 2017 American College of Emergency Physicians’ (ACEP) Scientific Assembly, I literally snorted and looked over my shoulder. What? Moi give this lecture? Am I a successful emergency physician (EP)? Well, of course I am as the first emergency medicine (EM) residency-trained female professor at the University of Colorado, chair of the meetings subcommittee for the ACEP Educational Committee, and director on the American Board of Emergency Medicine.

What I have learned is that the first step to being successful is to define your personal barriers and self-defeating behaviors, and to identify and define your personal self-defeating behaviors—eg, perfectionism, procrastination, self-doubt?

My own personal self-defeating behavior is most certainly “imposter syndrome,” which is very common among professionals. I first heard about imposter syndrome on my very first day of medical school, and this behavior still follows me today. I have written some short blurbs on this topic because I want others to know they are not alone. Highly successful people have this syndrome, and it can be very debilitating. What is imposter syndrome? According to Sandberg, “Despite being high achievers, even experts in their fields, women can’t seem to shake the sense that it is only a matter of time until they are found out for who they really are- impostors with limited skills or abilities.”¹ Valerie Young, an internationally recognized expert on the subject, categorized imposter syndrome into five subgroups or habits: (1) the perfectionist; (2) the superwoman/man; (3) the natural genius; (4) the rugged individualist; and (5) the expert. In her book, The Secret Thoughts of Successful Women: Why Capable People Suffer From the Imposter Syndrome and How to Thrive in Spite of It, Young builds on decades of research studying fraudulent feelings among high achievers.²

Identify Your Self-Defeating Behaviors and Write Them Down

Regarding the top five subgroups/habits proposed by Young unfortunately, there is no evidence-based literature on imposter syndrome. Most information consists of anecdotal reports from highly successful people. When you read about successful habits from such individuals, they include such things as: efficiency; bring your A-game; embrace communication; personal wellness; and most importantly, growth mentality.³ You have most likely heard phrases such as, “Don’t touch a piece of paper more than once.” The “touch it once” philosophy maybe is efficient, but I’m not sure about it being a successful habit.⁴ The following is my list of the top five principles that I have used to guide my career.

Define

What is success to you? Are you thinking about your whole career, or just a successful shift or a successful triathlon? Do you want to win the triathlon or just finish it? Or, do you want to be a department chair? Define and set your goal(s), and make sure to reach and stretch yourself to the best of your abilities to attain your goal. To achieve your goal, you must force yourself out of your comfort zone. If you do not reach for something, chances are it is not going to drop in your lap.

When I attended my very first ACEP Scientific Assembly as a newly minted EM residency-trained EP, I thought the lectures were a bit too basic and needed to be at a higher level of knowledge. I decided I really wanted to be a part of that process. I defined my personal challenge as improving the ACEP educational content level, and I set my goal as getting on that committee. Your goal may be quite different—eg, maybe you wish to become the medical director of an ED, a residency program director, or an officer on your hospital’s medical staff. Regardless of your goal, the first step is to decide and define what it is that you desire.

Engage

After you have defined and set your goal, the first steps to attaining it are to get started on the road you’ve chosen by showing up at relevant meetings, events; being present, engaging, and demonstrating curiosity. Maybe you will have an interesting journey!

I can’t stress enough how important it is to just show up. Sometimes, you will find that you start in one direction and get pushed in another. One of the first steps I took to getting on the ACEP education committee was to ask other ACEP members and colleagues how to do so. Most told me that the education committee was a very highly regarded one and that perhaps I should start by getting on any ACEP committee—or even better, start with a section. A respected friend in the “know” suggested that I choose an ACEP committee/section of which I had high interest, and to just show up to one of the meetings. I have found this advice to be true for most of life, whether it’s your hospital medical staff, local medical society, or state specialty society, or another professional organization—just show up.

Listen

When you do show up and attend a meeting or event, sit and listen to what others have to say, and when a task comes up with which you think you could be of assistance, step up and volunteer to help. When you are involved in a project or task, or are just listening, always keep an open mind—maybe your agenda is not exactly the same as other members of the organization/committee, but you will learn and gain important experience by being open to the thoughts and opinions of others.

When you step up and offer your assistance, you should make sure you volunteer for something that interests you. In general, to do a good job, the subject matter needs to be of interest to you, and the greater the interest, the more likely you are to be successful at completing the task. It also helps to make sure what you volunteer to do is attainable and realistic.

Organize/Action

After you’ve volunteered and committed yourself to a project, always be a productive member of the group. Do what you say you are going to do, and do it on time. These two simple things, completing your assignment/fulfilling your commitment and doing so on time, will set you apart from the pack. Do not be surprised when the reward for such an accomplishment is a request for you to do more, or take on leadership responsibilities.

Regarding my own personal journey, after I found out who served on the education committee. I started to set down some of the groundwork of networking, showing interest in the committee, and letting committee members know that I was very interested in their group and capable of helping in attaining their goals. Five years after taking these first steps to become involved in the group, I was appointed to serve on the meeting subcommittee of the ACEP education committee. This is the group that sets the curriculum and speakers for the Annual ACEP Scientific Assembly. I had made it! Then, after 8 years on the committee, I was appointed chair and worked hard to bring the meeting to Denver, Colorado, my home town. I pushed hard to reduce the length of many of the 50-minute lectures to 25 minutes, and also added some “rapid-fire” lectures to the curriculum.

Failures

On the path to attaining your goals, you will often encounter failure. It is important to keep in mind that if you never fail, then you probably are not reaching high or far enough. For example, I once wanted my institution to be more integrated at the affiliated University’s campus. I had defined this as my goal. To reach it, when the annual election for the medical school faculty senate came along, I had as many of my faculty colleagues vote for me as secretary, the lowest faculty position available. To my shock, I got elected! The problem was, as the secretary, I was supposed to be present at all of the monthly meetings and actually take notes. Not only did I not know who any of the individuals speaking at these meetings were, but I could only make approximately 50% of the meetings due to scheduling conflicts and other commitments. It is my own shame for not doing my homework and learning the roles and responsibilities of the secretarial position. I had the definition of success as a vague one: I engaged but did not really have an attainable goal. After 3 months, I had to go to the dean and admit I had made a mistake and was not capable of performing the duty of secretary. Although, the dean understood and thanked me for my honesty, this was a humbling experience for me and one that also reflected poorly on my department.

However, we are all human and we do make mistakes. By acknowledging our mistakes and shortcomings, reflecting on why they happened, and learning how to handle and do things differently in the future is all part of the journey to success.

Closure

Did I find all of the time and work I put in over the years to be where I am now worth it to me personally? Was I successful? Yes on both counts! It was one long journey. In addition to the long-term journey, I also choose short ones. For example, I want a successful shift, which I now define as sitting down at least 50% of the time when taking a patient’s history. I also want to be engaged with my patients. Remember, the key to being a successful EP is to set goals, whether they are long-term, short-term, major, or minor. So, reach, define, engage, listen, organize, and attain closure. Expect and be ready for some failures—these are steps on the path to success.

ORLANDO – Use of an app combining patient-reported symptoms with local environmental triggers led patients to take action to improve their health, Penny Jones, PhD, reported at the joint congress of the American Academy of Allergy, Asthma, and Immunology and the World Asthma Organization.

AirRater is a smartphone app and data collection network that includes information on air particulates, daily pollen and fungi counts, temperature, and planned burn locations. Patients enter their respiratory symptoms, which are correlated with local environmental conditions, according to Dr. Jones, a postdoctoral fellow at the University of Tasmania (Australia) in Hobart.

Most of the environmental data are gathered from government agencies; however, researchers collect pollen and fungi counts at their own stations.

Patients do not see the environmental data until they’ve logged in their symptoms so that their reports aren’t biased by that information, Dr. Jones said, adding that the app also sends notifications when pollen and pollutant levels are high.

“It’s an environmental monitoring system coupled with a smartphone app designed to help people with allergies and asthma make better decisions around their health,” Dr. Jones said.

Thomas R. Collins/Frontline Medical News

There are more than 6,000 users, and data from surveys show that it is having an effect, Dr. Jones said. About 40% of users said they have changed their behavior in some way because of information provided by the app, including staying indoors, taking preventive medication, or speaking with their doctors.“It does appear that people are generally finding it a useful tool,” she said.

In a pilot study, researchers found that several environmental triggers were significantly correlated with exacerbation of patient symptoms, including maximum temperature (P < .001), particulate pollution (P < .001), relative humidity (P = .01), birch pollen (P = .006), and cypress pollen (P = .004).
Researchers plan to expand use of the network and app to other parts of Australia and are working to refine the understanding of aerobiological symptom drivers through DNA analysis of airborne particles. Their goal is to be able to identify personalized drivers of sensitivities, she said.
“We’ll keep working on this,” Dr. Jones said. “But we think that certainly has promise.”

The investigators reported no financial conflicts of interest, and the study had no outside funding.
 

SOURCE: Jones P et al. AAAAI/WAO Joint Congress, Abstract 270. 

ORLANDO – Use of an app combining patient-reported symptoms with local environmental triggers led patients to take action to improve their health, Penny Jones, PhD, reported at the joint congress of the American Academy of Allergy, Asthma, and Immunology and the World Asthma Organization.

AirRater is a smartphone app and data collection network that includes information on air particulates, daily pollen and fungi counts, temperature, and planned burn locations. Patients enter their respiratory symptoms, which are correlated with local environmental conditions, according to Dr. Jones, a postdoctoral fellow at the University of Tasmania (Australia) in Hobart.

Most of the environmental data are gathered from government agencies; however, researchers collect pollen and fungi counts at their own stations.

Patients do not see the environmental data until they’ve logged in their symptoms so that their reports aren’t biased by that information, Dr. Jones said, adding that the app also sends notifications when pollen and pollutant levels are high.

“It’s an environmental monitoring system coupled with a smartphone app designed to help people with allergies and asthma make better decisions around their health,” Dr. Jones said.

Thomas R. Collins/Frontline Medical News

There are more than 6,000 users, and data from surveys show that it is having an effect, Dr. Jones said. About 40% of users said they have changed their behavior in some way because of information provided by the app, including staying indoors, taking preventive medication, or speaking with their doctors.“It does appear that people are generally finding it a useful tool,” she said.

In a pilot study, researchers found that several environmental triggers were significantly correlated with exacerbation of patient symptoms, including maximum temperature (P < .001), particulate pollution (P < .001), relative humidity (P = .01), birch pollen (P = .006), and cypress pollen (P = .004).
Researchers plan to expand use of the network and app to other parts of Australia and are working to refine the understanding of aerobiological symptom drivers through DNA analysis of airborne particles. Their goal is to be able to identify personalized drivers of sensitivities, she said.
“We’ll keep working on this,” Dr. Jones said. “But we think that certainly has promise.”

The investigators reported no financial conflicts of interest, and the study had no outside funding.
 

SOURCE: Jones P et al. AAAAI/WAO Joint Congress, Abstract 270. 

ORLANDO – Use of an app combining patient-reported symptoms with local environmental triggers led patients to take action to improve their health, Penny Jones, PhD, reported at the joint congress of the American Academy of Allergy, Asthma, and Immunology and the World Asthma Organization.

AirRater is a smartphone app and data collection network that includes information on air particulates, daily pollen and fungi counts, temperature, and planned burn locations. Patients enter their respiratory symptoms, which are correlated with local environmental conditions, according to Dr. Jones, a postdoctoral fellow at the University of Tasmania (Australia) in Hobart.

Most of the environmental data are gathered from government agencies; however, researchers collect pollen and fungi counts at their own stations.

Patients do not see the environmental data until they’ve logged in their symptoms so that their reports aren’t biased by that information, Dr. Jones said, adding that the app also sends notifications when pollen and pollutant levels are high.

“It’s an environmental monitoring system coupled with a smartphone app designed to help people with allergies and asthma make better decisions around their health,” Dr. Jones said.

Thomas R. Collins/Frontline Medical News

There are more than 6,000 users, and data from surveys show that it is having an effect, Dr. Jones said. About 40% of users said they have changed their behavior in some way because of information provided by the app, including staying indoors, taking preventive medication, or speaking with their doctors.“It does appear that people are generally finding it a useful tool,” she said.

In a pilot study, researchers found that several environmental triggers were significantly correlated with exacerbation of patient symptoms, including maximum temperature (P < .001), particulate pollution (P < .001), relative humidity (P = .01), birch pollen (P = .006), and cypress pollen (P = .004).
Researchers plan to expand use of the network and app to other parts of Australia and are working to refine the understanding of aerobiological symptom drivers through DNA analysis of airborne particles. Their goal is to be able to identify personalized drivers of sensitivities, she said.
“We’ll keep working on this,” Dr. Jones said. “But we think that certainly has promise.”

The investigators reported no financial conflicts of interest, and the study had no outside funding.
 

SOURCE: Jones P et al. AAAAI/WAO Joint Congress, Abstract 270. 

LOS ANGELES—The American Heart Association (AHA) and the American Stroke Association (ASA) updated their guidelines for the early management of patients with acute ischemic stroke. In contrast with the previous guidelines, the new guidelines address the comprehensive management of patients when they are hospitalized, including the initiation of treatments to prevent further stroke that are usually instituted within the first two weeks, said William J. Powers, MD, Chair of Neurology at the University of North Carolina School of Medicine in Chapel Hill, and chair of the guidelines writing group. The guidelines were presented at the International Stroke Conference 2018 and published online ahead of print January 24 in Stroke.

The new guidelines supersede the 2013 guidelines and subsequent updates and were created for all healthcare providers who care for patients with acute ischemic stroke, said Dr. Powers. The new guidelines do not address children or clots in the veins, he added.

Prehospital Care

The new guidelines strongly recommend that each region in the country create systems in which patients receive emergency treatment in small hospitals and are rapidly moved to large hospitals for more comprehensive therapy. “We want the patients who do have a stroke to get to the hospital as fast as possible. This means some kind of screening in the field by emergency medical services…. They need to go to the closest hospital that can adequately evaluate them and give them IV alteplase if they are eligible for it,” said Dr. Powers.

IV and Intra-Arterial Therapies

IV alteplase remains the first-line treatment for patients with acute ischemic stroke. “Everyone who is eligible for this should get it, and this should not be delayed to determine if they are eligible for other treatment,” said Dr. Powers. The new criteria recommend IV alteplase treatment within four and a half hours of acute ischemic stroke onset for an increased number of eligible patients. New data suggest that patients with mild stroke also benefit from IV alteplase within the three-hour-to-four-and-a-half-hour treatment window.

The new guidelines also reduce the number of contraindications for IV alteplase. Under the old guidelines, if patients had had a dural puncture or arterial puncture in the previous seven days, or major trauma not involving the head in the previous 14 days, they were ineligible to receive IV alteplase treatment. Now physicians are advised to use judgment and weigh the risks and benefits of providing this treatment to the patient.

The guidelines also cite evidence for performing a mechanical thrombectomy. The guidelines recommend using eligibility criteria derived from clinical trials to select patients. For those patients who can be treated within six hours or less, eligibility criteria are derived from five trials published in 2015. DAWN and DEFUSE 3 trial eligibility criteria are recommended to select patients for thrombectomy from six to 24 hours. DEFUSE 3 treated patients within six to 16 hours after onset, and the DAWN trial treated patients within six to 24 hours after onset.

In addition, the document’s revised blood pressure guidelines acknowledge that few data can support the choice of effective blood pressure treatment in patients with acute ischemic stroke. Understanding this limitation is important for avoiding overtreatment in patients with high blood pressure, said Dr. Powers.

The new guidelines also provide updated recommendations for deep vein thrombosis prophylaxis. Blood thinners have been advocated as the most effective way to prevent this complication, but the new recommendations state that intermittent pneumatic compression is the best preventive measure.

Diagnostic Tests

Finally, the new guidelines examined the benefits of diagnostic tests and concluded that routinely performing multiple diagnostic tests in every stroke patient is not good medical practice. Not only is this practice expensive, but there are no data to indicate that such indiscriminate testing “will improve overall patient outcome. It actually can lead to further testing and things that could adversely affect patient outcomes,” said Dr. Powers. “We made recommendations that diagnostic testing be individualized … and restricted to answering those questions that will lead to a treatment change of proven benefit.”

—Erica Tricarico

Suggested Reading

Powers WJ, Rabinstein AA, Ackerson T, et al. 2018 Guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2018 Jan 24 [Epub ahead of print].

LOS ANGELES—The American Heart Association (AHA) and the American Stroke Association (ASA) updated their guidelines for the early management of patients with acute ischemic stroke. In contrast with the previous guidelines, the new guidelines address the comprehensive management of patients when they are hospitalized, including the initiation of treatments to prevent further stroke that are usually instituted within the first two weeks, said William J. Powers, MD, Chair of Neurology at the University of North Carolina School of Medicine in Chapel Hill, and chair of the guidelines writing group. The guidelines were presented at the International Stroke Conference 2018 and published online ahead of print January 24 in Stroke.

The new guidelines supersede the 2013 guidelines and subsequent updates and were created for all healthcare providers who care for patients with acute ischemic stroke, said Dr. Powers. The new guidelines do not address children or clots in the veins, he added.

Prehospital Care

The new guidelines strongly recommend that each region in the country create systems in which patients receive emergency treatment in small hospitals and are rapidly moved to large hospitals for more comprehensive therapy. “We want the patients who do have a stroke to get to the hospital as fast as possible. This means some kind of screening in the field by emergency medical services…. They need to go to the closest hospital that can adequately evaluate them and give them IV alteplase if they are eligible for it,” said Dr. Powers.

IV and Intra-Arterial Therapies

IV alteplase remains the first-line treatment for patients with acute ischemic stroke. “Everyone who is eligible for this should get it, and this should not be delayed to determine if they are eligible for other treatment,” said Dr. Powers. The new criteria recommend IV alteplase treatment within four and a half hours of acute ischemic stroke onset for an increased number of eligible patients. New data suggest that patients with mild stroke also benefit from IV alteplase within the three-hour-to-four-and-a-half-hour treatment window.

The new guidelines also reduce the number of contraindications for IV alteplase. Under the old guidelines, if patients had had a dural puncture or arterial puncture in the previous seven days, or major trauma not involving the head in the previous 14 days, they were ineligible to receive IV alteplase treatment. Now physicians are advised to use judgment and weigh the risks and benefits of providing this treatment to the patient.

The guidelines also cite evidence for performing a mechanical thrombectomy. The guidelines recommend using eligibility criteria derived from clinical trials to select patients. For those patients who can be treated within six hours or less, eligibility criteria are derived from five trials published in 2015. DAWN and DEFUSE 3 trial eligibility criteria are recommended to select patients for thrombectomy from six to 24 hours. DEFUSE 3 treated patients within six to 16 hours after onset, and the DAWN trial treated patients within six to 24 hours after onset.

In addition, the document’s revised blood pressure guidelines acknowledge that few data can support the choice of effective blood pressure treatment in patients with acute ischemic stroke. Understanding this limitation is important for avoiding overtreatment in patients with high blood pressure, said Dr. Powers.

The new guidelines also provide updated recommendations for deep vein thrombosis prophylaxis. Blood thinners have been advocated as the most effective way to prevent this complication, but the new recommendations state that intermittent pneumatic compression is the best preventive measure.

Diagnostic Tests

Finally, the new guidelines examined the benefits of diagnostic tests and concluded that routinely performing multiple diagnostic tests in every stroke patient is not good medical practice. Not only is this practice expensive, but there are no data to indicate that such indiscriminate testing “will improve overall patient outcome. It actually can lead to further testing and things that could adversely affect patient outcomes,” said Dr. Powers. “We made recommendations that diagnostic testing be individualized … and restricted to answering those questions that will lead to a treatment change of proven benefit.”

—Erica Tricarico

Suggested Reading

Powers WJ, Rabinstein AA, Ackerson T, et al. 2018 Guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2018 Jan 24 [Epub ahead of print].

LOS ANGELES—The American Heart Association (AHA) and the American Stroke Association (ASA) updated their guidelines for the early management of patients with acute ischemic stroke. In contrast with the previous guidelines, the new guidelines address the comprehensive management of patients when they are hospitalized, including the initiation of treatments to prevent further stroke that are usually instituted within the first two weeks, said William J. Powers, MD, Chair of Neurology at the University of North Carolina School of Medicine in Chapel Hill, and chair of the guidelines writing group. The guidelines were presented at the International Stroke Conference 2018 and published online ahead of print January 24 in Stroke.

The new guidelines supersede the 2013 guidelines and subsequent updates and were created for all healthcare providers who care for patients with acute ischemic stroke, said Dr. Powers. The new guidelines do not address children or clots in the veins, he added.

Prehospital Care

The new guidelines strongly recommend that each region in the country create systems in which patients receive emergency treatment in small hospitals and are rapidly moved to large hospitals for more comprehensive therapy. “We want the patients who do have a stroke to get to the hospital as fast as possible. This means some kind of screening in the field by emergency medical services…. They need to go to the closest hospital that can adequately evaluate them and give them IV alteplase if they are eligible for it,” said Dr. Powers.

IV and Intra-Arterial Therapies

IV alteplase remains the first-line treatment for patients with acute ischemic stroke. “Everyone who is eligible for this should get it, and this should not be delayed to determine if they are eligible for other treatment,” said Dr. Powers. The new criteria recommend IV alteplase treatment within four and a half hours of acute ischemic stroke onset for an increased number of eligible patients. New data suggest that patients with mild stroke also benefit from IV alteplase within the three-hour-to-four-and-a-half-hour treatment window.

The new guidelines also reduce the number of contraindications for IV alteplase. Under the old guidelines, if patients had had a dural puncture or arterial puncture in the previous seven days, or major trauma not involving the head in the previous 14 days, they were ineligible to receive IV alteplase treatment. Now physicians are advised to use judgment and weigh the risks and benefits of providing this treatment to the patient.

The guidelines also cite evidence for performing a mechanical thrombectomy. The guidelines recommend using eligibility criteria derived from clinical trials to select patients. For those patients who can be treated within six hours or less, eligibility criteria are derived from five trials published in 2015. DAWN and DEFUSE 3 trial eligibility criteria are recommended to select patients for thrombectomy from six to 24 hours. DEFUSE 3 treated patients within six to 16 hours after onset, and the DAWN trial treated patients within six to 24 hours after onset.

In addition, the document’s revised blood pressure guidelines acknowledge that few data can support the choice of effective blood pressure treatment in patients with acute ischemic stroke. Understanding this limitation is important for avoiding overtreatment in patients with high blood pressure, said Dr. Powers.

The new guidelines also provide updated recommendations for deep vein thrombosis prophylaxis. Blood thinners have been advocated as the most effective way to prevent this complication, but the new recommendations state that intermittent pneumatic compression is the best preventive measure.

Diagnostic Tests

Finally, the new guidelines examined the benefits of diagnostic tests and concluded that routinely performing multiple diagnostic tests in every stroke patient is not good medical practice. Not only is this practice expensive, but there are no data to indicate that such indiscriminate testing “will improve overall patient outcome. It actually can lead to further testing and things that could adversely affect patient outcomes,” said Dr. Powers. “We made recommendations that diagnostic testing be individualized … and restricted to answering those questions that will lead to a treatment change of proven benefit.”

—Erica Tricarico

Suggested Reading

Powers WJ, Rabinstein AA, Ackerson T, et al. 2018 Guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2018 Jan 24 [Epub ahead of print].

ORLANDO – Patients with allergic rhinitis undergoing allergen immunotherapy achieved the goal of their monthly maintenance dose at a 20% higher rate when they underwent went a “modified rush” protocol, compared with those who received the therapy with the much slower conventional approach.

The findings offer proof that the faster approach is safe, more effective, and should be more widely used even though many allergists continue to be hesitant to do so, according to Christine Schafer, MD, clinical assistant professor at Michigan State University, East Lansing and a private practice allergist in Grand Rapids, Mich.

Thomas R. Collins/Frontline Medical News

“The beauty of it is you’ve consolidated 3 months into a day,” said Dr. Schafer, who added that patients also feel better faster. “They don’t have to have this going every week for 3 months not feeling any better.”

Dr. Schafer and her colleagues reviewed a year’s worth of results for patients undergoing conventional immunotherapy or a “modified rush” protocol in 2014. They found that the conventional approach produced a 64.5% success rate, compared with an 84.4% success rate for those doing the faster protocol (P less than .001).

Typically, allergen immunotherapy takes 6 months, with patients making weekly visits with gradually increasing doses. The weekly visits can be a burden, and many patients drop out. The modified rush protocol seems to be easier for patients to accomplish, Dr. Schafer said at the joint congress of the American Academy of Allergy, Asthma, and Immunology and the World Asthma Organization.

The study compared 231 patients on the faster protocol with 392 treated with the traditional approach.

On the “modified rush” protocol, patients aged 12-15 years took preventive medications – 20 mg of prednisone and 150 mg of ranitidine 2 days before their appointment and again the day after. In addition, they took 10 mg of cetirizine and 5 mg of montelukast 2 days before their appointment. Patients also took those same medications the morning of the treatment.

For patients 16 and older, the dose of prednisone was 30 mg and the dose of montelukast was 10 mg.

The protocol consisted of eight shots, starting at a more diluted dose than the conventional protocol, as an additional safety precaution. The shots were given first every 15 minutes, then every 30 minutes or an hour as the dose increases. Once the treatment was over, the dilution was 1:10, a milestone not reached until 3 months under the conventional approach.

An hour or two after the treatment, all patients received 20 mg of prednisone.

Patients resumed the normal conventional protocol after the first visit.

Reactions were rare under the “modified rush” protocol, with 6 patients experiencing flushing but nothing else, 21 with grade 1 reactions, 3 with grade 2, and no reactions worse than that. Five patients needed epinephrine.

Dr. Schafer said the approach may hold appeal because, even though it’s accelerated, there is a slower lead-in to the maintenance dose.

“If you ask allergists, ‘Do you rush?’ they’ll say, ‘No, no, no, I don’t rush. It’s too risky.’” she said. “Hence, modified rush.”

ORLANDO – Patients with allergic rhinitis undergoing allergen immunotherapy achieved the goal of their monthly maintenance dose at a 20% higher rate when they underwent went a “modified rush” protocol, compared with those who received the therapy with the much slower conventional approach.

The findings offer proof that the faster approach is safe, more effective, and should be more widely used even though many allergists continue to be hesitant to do so, according to Christine Schafer, MD, clinical assistant professor at Michigan State University, East Lansing and a private practice allergist in Grand Rapids, Mich.

Thomas R. Collins/Frontline Medical News

“The beauty of it is you’ve consolidated 3 months into a day,” said Dr. Schafer, who added that patients also feel better faster. “They don’t have to have this going every week for 3 months not feeling any better.”

Dr. Schafer and her colleagues reviewed a year’s worth of results for patients undergoing conventional immunotherapy or a “modified rush” protocol in 2014. They found that the conventional approach produced a 64.5% success rate, compared with an 84.4% success rate for those doing the faster protocol (P less than .001).

Typically, allergen immunotherapy takes 6 months, with patients making weekly visits with gradually increasing doses. The weekly visits can be a burden, and many patients drop out. The modified rush protocol seems to be easier for patients to accomplish, Dr. Schafer said at the joint congress of the American Academy of Allergy, Asthma, and Immunology and the World Asthma Organization.

The study compared 231 patients on the faster protocol with 392 treated with the traditional approach.

On the “modified rush” protocol, patients aged 12-15 years took preventive medications – 20 mg of prednisone and 150 mg of ranitidine 2 days before their appointment and again the day after. In addition, they took 10 mg of cetirizine and 5 mg of montelukast 2 days before their appointment. Patients also took those same medications the morning of the treatment.

For patients 16 and older, the dose of prednisone was 30 mg and the dose of montelukast was 10 mg.

The protocol consisted of eight shots, starting at a more diluted dose than the conventional protocol, as an additional safety precaution. The shots were given first every 15 minutes, then every 30 minutes or an hour as the dose increases. Once the treatment was over, the dilution was 1:10, a milestone not reached until 3 months under the conventional approach.

An hour or two after the treatment, all patients received 20 mg of prednisone.

Patients resumed the normal conventional protocol after the first visit.

Reactions were rare under the “modified rush” protocol, with 6 patients experiencing flushing but nothing else, 21 with grade 1 reactions, 3 with grade 2, and no reactions worse than that. Five patients needed epinephrine.

Dr. Schafer said the approach may hold appeal because, even though it’s accelerated, there is a slower lead-in to the maintenance dose.

“If you ask allergists, ‘Do you rush?’ they’ll say, ‘No, no, no, I don’t rush. It’s too risky.’” she said. “Hence, modified rush.”

ORLANDO – Patients with allergic rhinitis undergoing allergen immunotherapy achieved the goal of their monthly maintenance dose at a 20% higher rate when they underwent went a “modified rush” protocol, compared with those who received the therapy with the much slower conventional approach.

The findings offer proof that the faster approach is safe, more effective, and should be more widely used even though many allergists continue to be hesitant to do so, according to Christine Schafer, MD, clinical assistant professor at Michigan State University, East Lansing and a private practice allergist in Grand Rapids, Mich.

Thomas R. Collins/Frontline Medical News

“The beauty of it is you’ve consolidated 3 months into a day,” said Dr. Schafer, who added that patients also feel better faster. “They don’t have to have this going every week for 3 months not feeling any better.”

Dr. Schafer and her colleagues reviewed a year’s worth of results for patients undergoing conventional immunotherapy or a “modified rush” protocol in 2014. They found that the conventional approach produced a 64.5% success rate, compared with an 84.4% success rate for those doing the faster protocol (P less than .001).

Typically, allergen immunotherapy takes 6 months, with patients making weekly visits with gradually increasing doses. The weekly visits can be a burden, and many patients drop out. The modified rush protocol seems to be easier for patients to accomplish, Dr. Schafer said at the joint congress of the American Academy of Allergy, Asthma, and Immunology and the World Asthma Organization.

The study compared 231 patients on the faster protocol with 392 treated with the traditional approach.

On the “modified rush” protocol, patients aged 12-15 years took preventive medications – 20 mg of prednisone and 150 mg of ranitidine 2 days before their appointment and again the day after. In addition, they took 10 mg of cetirizine and 5 mg of montelukast 2 days before their appointment. Patients also took those same medications the morning of the treatment.

For patients 16 and older, the dose of prednisone was 30 mg and the dose of montelukast was 10 mg.

The protocol consisted of eight shots, starting at a more diluted dose than the conventional protocol, as an additional safety precaution. The shots were given first every 15 minutes, then every 30 minutes or an hour as the dose increases. Once the treatment was over, the dilution was 1:10, a milestone not reached until 3 months under the conventional approach.

An hour or two after the treatment, all patients received 20 mg of prednisone.

Patients resumed the normal conventional protocol after the first visit.

Reactions were rare under the “modified rush” protocol, with 6 patients experiencing flushing but nothing else, 21 with grade 1 reactions, 3 with grade 2, and no reactions worse than that. Five patients needed epinephrine.

Dr. Schafer said the approach may hold appeal because, even though it’s accelerated, there is a slower lead-in to the maintenance dose.

“If you ask allergists, ‘Do you rush?’ they’ll say, ‘No, no, no, I don’t rush. It’s too risky.’” she said. “Hence, modified rush.”