MDedge Neurology

A new Scandinavian study has confirmed previous data showing increased rates of cerebral venous thrombosis and thrombocytopenia after the AstraZeneca COVID-19 vaccine.

The study also showed higher rates of several thromboembolic and thrombocytopenic outcomes after the Pfizer and Moderna mRNA vaccines, although these increases were less than the rates observed after the AstraZeneca vaccine, and sensitivity analyses were not consistent.

The researchers conclude that confirmatory analysis on the two mRNA vaccines by other methods are warranted.

The study was published in the June issue of JAMA Network Open.

“This study confirms what we know from other studies: that the AstraZeneca vaccine is associated with the rare but serious side effect of vaccine-induced immune thrombotic thrombocytopenia,” lead author Jacob Dag Berild, MD, Norwegian Institute of Public Health, Oslo, told this news organization.

“Reassuringly, no consistent association was observed between the Pfizer and Moderna mRNA vaccines and these rare complications,” he added.

Dr. Dag Berild noted that in the current study there was an excess of 1.6 events of cerebral venous thrombosis per 100,000 AstraZeneca vaccine doses, which is similar to what has been previously reported.

Asked how he saw these results affecting continued use of these vaccines, Dr. Dag Berild pointed out that the risk-benefit ratio of the vaccine depends on the risk of contracting COVID-19 and the risk for a severe outcome from COVID-19 weighed against the risk for an adverse event after vaccination.

“The European Medicines Agency has concluded that the overall risk-benefit ratio remains positive for the AstraZeneca vaccine, but Norway, Finland, and Denmark no longer use the AstraZeneca vaccine in their vaccination programs because of adequate availability of alternative vaccines. I think this is a reasonable decision,” he said.

For the current study, the researchers linked individual-level data separately from national population, patient, and vaccination registers in Norway, Finland, and Denmark. Patient registers were used to identify hospital visits and admissions related to thromboembolic and thrombocytopenic disease in all three countries.

The main outcomes were relative rates of coronary artery disease, coagulation disorders, and cerebrovascular disease in the 28-day period after vaccination, compared with the control period prior to vaccination.

The authors note that a strength of this study is the use of registers with full population coverage in three countries with universal health care, ensuring equal access to care for all permanent residents. At the end of the study period, from Jan. 1, 2020 to May 16, 2021, more than 5.3 million people in the three countries were vaccinated with one or two doses.

Another strength is the inherent adjustment for time-invariant confounders in the self-controlled case series design and the resulting control of confounders that can affect the more traditional observational studies when complete data for confounders are not available, they add.

Of the 265,339 hospital contacts, 43% were made by female patients and 93% by patients born in or before 1971, and 44% were for coronary artery disease, 21% for coagulation disorders, and 35% for cerebrovascular disease.

In the 28-day period after vaccination, there was an elevated rate of coronary artery disease after the Moderna vaccine (relative rate, 1.13) but not after the AstraZeneca (RR, 0.92) or Pfizer (RR, 0.96) vaccines.

There was an observed increase in the rate of coagulation disorders after all three vaccines (AstraZeneca RR, 2.01; Pfizer RR, 1.12; and Moderna RR, 1.26).

There was also an increase in the rate of cerebrovascular disease after all three vaccines (AstraZeneca RR, 1.32; Pfizer RR, 1.09; and Moderna RR, 1.21).

For individual diseases in the main outcomes, two notably high rates were observed after the AstraZeneca vaccine, with relative rates of 12.04 for cerebral venous thrombosis and 4.29 for thrombocytopenia, corresponding to 1.6 and 4.9 excess events per 100,000 doses, respectively.

The elevated risk after the AstraZeneca vaccine was consistent across all three countries and robust in sensitivity analyses.

The researchers report that they also observed statistically significant increases in hospital contacts for thrombocytopenic and thromboembolic events after the Pfizer and Moderna vaccines. However, the risk was smaller than after the AstraZeneca vaccine.

“Additionally, the national estimates varied, increased risk [was] observed only in the oldest cohorts, and sensitivity analysis checking underlying assumptions of the analyses were not consistent. Therefore, the overall and combined increased relative risks following the Pfizer and Moderna vaccinations should be interpreted with caution,” they say.

They note that their results with the AstraZeneca vaccine are in line with a comparison of observed and historic rates performed on partly the same population in Norway and Denmark and also with a Scottish national case-control study.

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

A new Scandinavian study has confirmed previous data showing increased rates of cerebral venous thrombosis and thrombocytopenia after the AstraZeneca COVID-19 vaccine.

The study also showed higher rates of several thromboembolic and thrombocytopenic outcomes after the Pfizer and Moderna mRNA vaccines, although these increases were less than the rates observed after the AstraZeneca vaccine, and sensitivity analyses were not consistent.

The researchers conclude that confirmatory analysis on the two mRNA vaccines by other methods are warranted.

The study was published in the June issue of JAMA Network Open.

“This study confirms what we know from other studies: that the AstraZeneca vaccine is associated with the rare but serious side effect of vaccine-induced immune thrombotic thrombocytopenia,” lead author Jacob Dag Berild, MD, Norwegian Institute of Public Health, Oslo, told this news organization.

“Reassuringly, no consistent association was observed between the Pfizer and Moderna mRNA vaccines and these rare complications,” he added.

Dr. Dag Berild noted that in the current study there was an excess of 1.6 events of cerebral venous thrombosis per 100,000 AstraZeneca vaccine doses, which is similar to what has been previously reported.

Asked how he saw these results affecting continued use of these vaccines, Dr. Dag Berild pointed out that the risk-benefit ratio of the vaccine depends on the risk of contracting COVID-19 and the risk for a severe outcome from COVID-19 weighed against the risk for an adverse event after vaccination.

“The European Medicines Agency has concluded that the overall risk-benefit ratio remains positive for the AstraZeneca vaccine, but Norway, Finland, and Denmark no longer use the AstraZeneca vaccine in their vaccination programs because of adequate availability of alternative vaccines. I think this is a reasonable decision,” he said.

For the current study, the researchers linked individual-level data separately from national population, patient, and vaccination registers in Norway, Finland, and Denmark. Patient registers were used to identify hospital visits and admissions related to thromboembolic and thrombocytopenic disease in all three countries.

The main outcomes were relative rates of coronary artery disease, coagulation disorders, and cerebrovascular disease in the 28-day period after vaccination, compared with the control period prior to vaccination.

The authors note that a strength of this study is the use of registers with full population coverage in three countries with universal health care, ensuring equal access to care for all permanent residents. At the end of the study period, from Jan. 1, 2020 to May 16, 2021, more than 5.3 million people in the three countries were vaccinated with one or two doses.

Another strength is the inherent adjustment for time-invariant confounders in the self-controlled case series design and the resulting control of confounders that can affect the more traditional observational studies when complete data for confounders are not available, they add.

Of the 265,339 hospital contacts, 43% were made by female patients and 93% by patients born in or before 1971, and 44% were for coronary artery disease, 21% for coagulation disorders, and 35% for cerebrovascular disease.

In the 28-day period after vaccination, there was an elevated rate of coronary artery disease after the Moderna vaccine (relative rate, 1.13) but not after the AstraZeneca (RR, 0.92) or Pfizer (RR, 0.96) vaccines.

There was an observed increase in the rate of coagulation disorders after all three vaccines (AstraZeneca RR, 2.01; Pfizer RR, 1.12; and Moderna RR, 1.26).

There was also an increase in the rate of cerebrovascular disease after all three vaccines (AstraZeneca RR, 1.32; Pfizer RR, 1.09; and Moderna RR, 1.21).

For individual diseases in the main outcomes, two notably high rates were observed after the AstraZeneca vaccine, with relative rates of 12.04 for cerebral venous thrombosis and 4.29 for thrombocytopenia, corresponding to 1.6 and 4.9 excess events per 100,000 doses, respectively.

The elevated risk after the AstraZeneca vaccine was consistent across all three countries and robust in sensitivity analyses.

The researchers report that they also observed statistically significant increases in hospital contacts for thrombocytopenic and thromboembolic events after the Pfizer and Moderna vaccines. However, the risk was smaller than after the AstraZeneca vaccine.

“Additionally, the national estimates varied, increased risk [was] observed only in the oldest cohorts, and sensitivity analysis checking underlying assumptions of the analyses were not consistent. Therefore, the overall and combined increased relative risks following the Pfizer and Moderna vaccinations should be interpreted with caution,” they say.

They note that their results with the AstraZeneca vaccine are in line with a comparison of observed and historic rates performed on partly the same population in Norway and Denmark and also with a Scottish national case-control study.

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

A new Scandinavian study has confirmed previous data showing increased rates of cerebral venous thrombosis and thrombocytopenia after the AstraZeneca COVID-19 vaccine.

The study also showed higher rates of several thromboembolic and thrombocytopenic outcomes after the Pfizer and Moderna mRNA vaccines, although these increases were less than the rates observed after the AstraZeneca vaccine, and sensitivity analyses were not consistent.

The researchers conclude that confirmatory analysis on the two mRNA vaccines by other methods are warranted.

The study was published in the June issue of JAMA Network Open.

“This study confirms what we know from other studies: that the AstraZeneca vaccine is associated with the rare but serious side effect of vaccine-induced immune thrombotic thrombocytopenia,” lead author Jacob Dag Berild, MD, Norwegian Institute of Public Health, Oslo, told this news organization.

“Reassuringly, no consistent association was observed between the Pfizer and Moderna mRNA vaccines and these rare complications,” he added.

Dr. Dag Berild noted that in the current study there was an excess of 1.6 events of cerebral venous thrombosis per 100,000 AstraZeneca vaccine doses, which is similar to what has been previously reported.

Asked how he saw these results affecting continued use of these vaccines, Dr. Dag Berild pointed out that the risk-benefit ratio of the vaccine depends on the risk of contracting COVID-19 and the risk for a severe outcome from COVID-19 weighed against the risk for an adverse event after vaccination.

“The European Medicines Agency has concluded that the overall risk-benefit ratio remains positive for the AstraZeneca vaccine, but Norway, Finland, and Denmark no longer use the AstraZeneca vaccine in their vaccination programs because of adequate availability of alternative vaccines. I think this is a reasonable decision,” he said.

For the current study, the researchers linked individual-level data separately from national population, patient, and vaccination registers in Norway, Finland, and Denmark. Patient registers were used to identify hospital visits and admissions related to thromboembolic and thrombocytopenic disease in all three countries.

The main outcomes were relative rates of coronary artery disease, coagulation disorders, and cerebrovascular disease in the 28-day period after vaccination, compared with the control period prior to vaccination.

The authors note that a strength of this study is the use of registers with full population coverage in three countries with universal health care, ensuring equal access to care for all permanent residents. At the end of the study period, from Jan. 1, 2020 to May 16, 2021, more than 5.3 million people in the three countries were vaccinated with one or two doses.

Another strength is the inherent adjustment for time-invariant confounders in the self-controlled case series design and the resulting control of confounders that can affect the more traditional observational studies when complete data for confounders are not available, they add.

Of the 265,339 hospital contacts, 43% were made by female patients and 93% by patients born in or before 1971, and 44% were for coronary artery disease, 21% for coagulation disorders, and 35% for cerebrovascular disease.

In the 28-day period after vaccination, there was an elevated rate of coronary artery disease after the Moderna vaccine (relative rate, 1.13) but not after the AstraZeneca (RR, 0.92) or Pfizer (RR, 0.96) vaccines.

There was an observed increase in the rate of coagulation disorders after all three vaccines (AstraZeneca RR, 2.01; Pfizer RR, 1.12; and Moderna RR, 1.26).

There was also an increase in the rate of cerebrovascular disease after all three vaccines (AstraZeneca RR, 1.32; Pfizer RR, 1.09; and Moderna RR, 1.21).

For individual diseases in the main outcomes, two notably high rates were observed after the AstraZeneca vaccine, with relative rates of 12.04 for cerebral venous thrombosis and 4.29 for thrombocytopenia, corresponding to 1.6 and 4.9 excess events per 100,000 doses, respectively.

The elevated risk after the AstraZeneca vaccine was consistent across all three countries and robust in sensitivity analyses.

The researchers report that they also observed statistically significant increases in hospital contacts for thrombocytopenic and thromboembolic events after the Pfizer and Moderna vaccines. However, the risk was smaller than after the AstraZeneca vaccine.

“Additionally, the national estimates varied, increased risk [was] observed only in the oldest cohorts, and sensitivity analysis checking underlying assumptions of the analyses were not consistent. Therefore, the overall and combined increased relative risks following the Pfizer and Moderna vaccinations should be interpreted with caution,” they say.

They note that their results with the AstraZeneca vaccine are in line with a comparison of observed and historic rates performed on partly the same population in Norway and Denmark and also with a Scottish national case-control study.

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

Cognitive-behavioral therapies (CBTs) can provide relief from comorbid, persistent posttraumatic headache and posttraumatic stress disorder, new research suggests.

Results from a randomized clinical trial of almost 200 military veterans showed that, compared with usual care, CBT for headache led to significant improvement in both headache disability and PTSD symptoms. Cognitive-processing therapy (CPT) also led to significant improvement in PTSD symptoms, but it did not improve headache disability.

Lead author Donald McGeary, PhD, department of rehabilitation medicine, the University of Texas Health Science Center,San Antonio, noted the improvements shown in headache disability after CBT were likely caused by its building of patients’ confidence that they could control or manage their headaches themselves.

That sense of control was key to helping patients “get their lives back. If you can improve a person’s belief that they can control their headache, they function better,” Dr. McGeary said in a news release.

The findings were published online in JAMA Neurology.
 

Signature wounds

Both mild traumatic brain injury (TBI) and PTSD are signature wounds of post-9/11 military conflicts. The two conditions commonly occur together and can harm quality of life and functioning, the investigators noted. Following mild TBI, many veterans experience persistent posttraumatic headache, which often co-occurs with PTSD.

To gauge the impact of CBTs for this patient population, researchers recruited 193 post-9/11 combat veterans (mean age, 39.7 years) with clinically significant PTSD symptoms and posttraumatic headache that had persisted more than 3 months after TBI. Of these, 167 were men.

All participants were receiving care at the Polytrauma Rehabilitation Center of the South Texas Veterans Health Care System in Houston.

They were randomly allocated to undergo 8 sessions of manualized CBT for headache, 12 sessions of manualized CPT for PTSD, or usual headache treatment.

CBT for headache uses CBT concepts to reduce headache disability and improve mood – and includes key components, such as relaxation, setting goals for activities patients want to resume, and planning for those situations.

CPT is a leading psychotherapy for PTSD. It teaches patients how to evaluate and change upsetting and maladaptive thoughts related to their trauma. The idea is that, by changing thoughts, patients can change the way they feel.

Treatment as usual was consistent with multidisciplinary treatment in a large Veterans Affairs multiple-trauma center and could include pharmacotherapies, physical and occupational therapies, pain medications, acupuncture, and massage.

The coprimary outcomes were headache-related disability on the six-item Headache Impact Test (HIT-6) and PTSD symptom severity on the PTSD Checklist for Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (PCL-5), assessed from end of treatment to 6 months post treatment.

At baseline, all participants reported severe headache-related disability (mean HIT-6 score, 65.8 points) and severe PTSD symptoms (mean PCL-5 score, 48.4 points).
 

Significant improvement

Compared with usual care, CBT for headache led to significant improvement in headache disability (posttreatment mean change in HIT-6 score, –3.4 points; P < .01) and PTSD symptoms (posttreatment change in PCL-5, –6.5 points; P = .04).

CPT also led to significant improvement in PTSD symptoms (8.9 points lower on the PCL-5 after treatment; P = .01), but it had only a modest effect on headache disability (1.4 points lower after treatment; P = .21).

“This was a surprise,” Dr. McGeary said. “If theories about PTSD driving posttraumatic headache are correct, you’d expect CPT to help both PTSD and headache. Our findings call that into question.”

Despite improvements in headache disability, CBT for headache did not significantly reduce headache frequency or intensity.

The researchers are now hoping to replicate their findings in a larger trial at multiple military and VA sites around the United States.

“We need more women, more racial and ethnic diversity, veterans as well as active military of different branches with varying comorbidities in different geographic regions attached to different hospitals and medical systems, because we’re comparing to usual care,” Dr. McGeary said.
 

A step forward

Commenting on the study, retired Col. Elspeth Cameron Ritchie, MD, chair of psychiatry, MedStar Washington Hospital Center, Washington, said she was “pleased” to see that this study was conducted and that she was pleased with the results.

“It’s been 20 years since 9/11, and wars are pretty much forgotten, but people are still suffering from the effects of traumatic brain injury and posttraumatic stress disorder. These are not conditions that go away quickly or lightly. They do take work,” said Dr. Ritchie, who was not involved with the research.

Finding therapies besides medication that are helpful is “good and is a step forward. The more alternatives we have, the better,” she concluded.

The study was supported in part by the Department of Defense and the Department of Veterans Affairs. Dr. McGeary and Dr. Ritchie have reported no relevant financial relationships.

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

Cognitive-behavioral therapies (CBTs) can provide relief from comorbid, persistent posttraumatic headache and posttraumatic stress disorder, new research suggests.

Results from a randomized clinical trial of almost 200 military veterans showed that, compared with usual care, CBT for headache led to significant improvement in both headache disability and PTSD symptoms. Cognitive-processing therapy (CPT) also led to significant improvement in PTSD symptoms, but it did not improve headache disability.

Lead author Donald McGeary, PhD, department of rehabilitation medicine, the University of Texas Health Science Center,San Antonio, noted the improvements shown in headache disability after CBT were likely caused by its building of patients’ confidence that they could control or manage their headaches themselves.

That sense of control was key to helping patients “get their lives back. If you can improve a person’s belief that they can control their headache, they function better,” Dr. McGeary said in a news release.

The findings were published online in JAMA Neurology.
 

Signature wounds

Both mild traumatic brain injury (TBI) and PTSD are signature wounds of post-9/11 military conflicts. The two conditions commonly occur together and can harm quality of life and functioning, the investigators noted. Following mild TBI, many veterans experience persistent posttraumatic headache, which often co-occurs with PTSD.

To gauge the impact of CBTs for this patient population, researchers recruited 193 post-9/11 combat veterans (mean age, 39.7 years) with clinically significant PTSD symptoms and posttraumatic headache that had persisted more than 3 months after TBI. Of these, 167 were men.

All participants were receiving care at the Polytrauma Rehabilitation Center of the South Texas Veterans Health Care System in Houston.

They were randomly allocated to undergo 8 sessions of manualized CBT for headache, 12 sessions of manualized CPT for PTSD, or usual headache treatment.

CBT for headache uses CBT concepts to reduce headache disability and improve mood – and includes key components, such as relaxation, setting goals for activities patients want to resume, and planning for those situations.

CPT is a leading psychotherapy for PTSD. It teaches patients how to evaluate and change upsetting and maladaptive thoughts related to their trauma. The idea is that, by changing thoughts, patients can change the way they feel.

Treatment as usual was consistent with multidisciplinary treatment in a large Veterans Affairs multiple-trauma center and could include pharmacotherapies, physical and occupational therapies, pain medications, acupuncture, and massage.

The coprimary outcomes were headache-related disability on the six-item Headache Impact Test (HIT-6) and PTSD symptom severity on the PTSD Checklist for Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (PCL-5), assessed from end of treatment to 6 months post treatment.

At baseline, all participants reported severe headache-related disability (mean HIT-6 score, 65.8 points) and severe PTSD symptoms (mean PCL-5 score, 48.4 points).
 

Significant improvement

Compared with usual care, CBT for headache led to significant improvement in headache disability (posttreatment mean change in HIT-6 score, –3.4 points; P < .01) and PTSD symptoms (posttreatment change in PCL-5, –6.5 points; P = .04).

CPT also led to significant improvement in PTSD symptoms (8.9 points lower on the PCL-5 after treatment; P = .01), but it had only a modest effect on headache disability (1.4 points lower after treatment; P = .21).

“This was a surprise,” Dr. McGeary said. “If theories about PTSD driving posttraumatic headache are correct, you’d expect CPT to help both PTSD and headache. Our findings call that into question.”

Despite improvements in headache disability, CBT for headache did not significantly reduce headache frequency or intensity.

The researchers are now hoping to replicate their findings in a larger trial at multiple military and VA sites around the United States.

“We need more women, more racial and ethnic diversity, veterans as well as active military of different branches with varying comorbidities in different geographic regions attached to different hospitals and medical systems, because we’re comparing to usual care,” Dr. McGeary said.
 

A step forward

Commenting on the study, retired Col. Elspeth Cameron Ritchie, MD, chair of psychiatry, MedStar Washington Hospital Center, Washington, said she was “pleased” to see that this study was conducted and that she was pleased with the results.

“It’s been 20 years since 9/11, and wars are pretty much forgotten, but people are still suffering from the effects of traumatic brain injury and posttraumatic stress disorder. These are not conditions that go away quickly or lightly. They do take work,” said Dr. Ritchie, who was not involved with the research.

Finding therapies besides medication that are helpful is “good and is a step forward. The more alternatives we have, the better,” she concluded.

The study was supported in part by the Department of Defense and the Department of Veterans Affairs. Dr. McGeary and Dr. Ritchie have reported no relevant financial relationships.

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

Cognitive-behavioral therapies (CBTs) can provide relief from comorbid, persistent posttraumatic headache and posttraumatic stress disorder, new research suggests.

Results from a randomized clinical trial of almost 200 military veterans showed that, compared with usual care, CBT for headache led to significant improvement in both headache disability and PTSD symptoms. Cognitive-processing therapy (CPT) also led to significant improvement in PTSD symptoms, but it did not improve headache disability.

Lead author Donald McGeary, PhD, department of rehabilitation medicine, the University of Texas Health Science Center,San Antonio, noted the improvements shown in headache disability after CBT were likely caused by its building of patients’ confidence that they could control or manage their headaches themselves.

That sense of control was key to helping patients “get their lives back. If you can improve a person’s belief that they can control their headache, they function better,” Dr. McGeary said in a news release.

The findings were published online in JAMA Neurology.
 

Signature wounds

Both mild traumatic brain injury (TBI) and PTSD are signature wounds of post-9/11 military conflicts. The two conditions commonly occur together and can harm quality of life and functioning, the investigators noted. Following mild TBI, many veterans experience persistent posttraumatic headache, which often co-occurs with PTSD.

To gauge the impact of CBTs for this patient population, researchers recruited 193 post-9/11 combat veterans (mean age, 39.7 years) with clinically significant PTSD symptoms and posttraumatic headache that had persisted more than 3 months after TBI. Of these, 167 were men.

All participants were receiving care at the Polytrauma Rehabilitation Center of the South Texas Veterans Health Care System in Houston.

They were randomly allocated to undergo 8 sessions of manualized CBT for headache, 12 sessions of manualized CPT for PTSD, or usual headache treatment.

CBT for headache uses CBT concepts to reduce headache disability and improve mood – and includes key components, such as relaxation, setting goals for activities patients want to resume, and planning for those situations.

CPT is a leading psychotherapy for PTSD. It teaches patients how to evaluate and change upsetting and maladaptive thoughts related to their trauma. The idea is that, by changing thoughts, patients can change the way they feel.

Treatment as usual was consistent with multidisciplinary treatment in a large Veterans Affairs multiple-trauma center and could include pharmacotherapies, physical and occupational therapies, pain medications, acupuncture, and massage.

The coprimary outcomes were headache-related disability on the six-item Headache Impact Test (HIT-6) and PTSD symptom severity on the PTSD Checklist for Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (PCL-5), assessed from end of treatment to 6 months post treatment.

At baseline, all participants reported severe headache-related disability (mean HIT-6 score, 65.8 points) and severe PTSD symptoms (mean PCL-5 score, 48.4 points).
 

Significant improvement

Compared with usual care, CBT for headache led to significant improvement in headache disability (posttreatment mean change in HIT-6 score, –3.4 points; P < .01) and PTSD symptoms (posttreatment change in PCL-5, –6.5 points; P = .04).

CPT also led to significant improvement in PTSD symptoms (8.9 points lower on the PCL-5 after treatment; P = .01), but it had only a modest effect on headache disability (1.4 points lower after treatment; P = .21).

“This was a surprise,” Dr. McGeary said. “If theories about PTSD driving posttraumatic headache are correct, you’d expect CPT to help both PTSD and headache. Our findings call that into question.”

Despite improvements in headache disability, CBT for headache did not significantly reduce headache frequency or intensity.

The researchers are now hoping to replicate their findings in a larger trial at multiple military and VA sites around the United States.

“We need more women, more racial and ethnic diversity, veterans as well as active military of different branches with varying comorbidities in different geographic regions attached to different hospitals and medical systems, because we’re comparing to usual care,” Dr. McGeary said.
 

A step forward

Commenting on the study, retired Col. Elspeth Cameron Ritchie, MD, chair of psychiatry, MedStar Washington Hospital Center, Washington, said she was “pleased” to see that this study was conducted and that she was pleased with the results.

“It’s been 20 years since 9/11, and wars are pretty much forgotten, but people are still suffering from the effects of traumatic brain injury and posttraumatic stress disorder. These are not conditions that go away quickly or lightly. They do take work,” said Dr. Ritchie, who was not involved with the research.

Finding therapies besides medication that are helpful is “good and is a step forward. The more alternatives we have, the better,” she concluded.

The study was supported in part by the Department of Defense and the Department of Veterans Affairs. Dr. McGeary and Dr. Ritchie have reported no relevant financial relationships.

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

This week, we celebrate our nation’s birth in a national and individual display of our patriotic attachment to this country. To understand how that patriotic attachment arises, we need to step back and look at the ways in which our brains change and define how each of us develops a sense of Self — which includes our self-definition as Americans.

For each of us, personhood is an almost miraculous product of our brain’s plasticity — the brain’s ability to change chemically, structurally, and functionally, based on our life experiences — arising from near countless moments of change in the wiring of our brain.

The incredibly complex remodeling that created “you” is a product, of course, of your very complicated, unique passage in life. You have a repertoire of skills and ability; you have stories and understanding and a history of sensing and acting and thinking in the world that is, in detail, unique only to you and your experiences.

As your brain created its model of your world by recording “what goes with what” at each brief moment of time, your brain — that most complicated and wonderful of “machines” on planet Earth — also associated billions of moments of feeling and action and thought with their source, your Self.

Because we primarily construct our model of the world through our eyes and ears, it’s not surprising that the emergent Self that is located somewhere in the center of your head behind your eyes and between your ears. Through billions of contacts with the surfaces of your hide and sensory organs, you have embodied yourself.
 

Your sense of ‘us’

These same neurologic processes extend beyond our physical beings to incorporate other contributors to our well-being into our personhoods. Loving parents, siblings, friends — and others in your clans and tribes and nations — literally grow into your personhood by these same self-associating processes. These relationships are supported in mutual identity by all of the tokens and icons and charms and customs that collectively define you and enable a sense of “us.”

Put another way, Mother Nature (or, in another cultural perspective, our Creator) has designed our brains to incorporate all of those who are close to us — and more broadly, other individuals in our clan or tribe or nation — to be a part of each of us.

Humans are highly social creatures. When we rise up and risk our lives to defend our friends, family, or cultural “in-groups,” we are literally fighting to defend ourselves — because those other individuals have grown into our very being. In defending them, we are literally defending a part of ourselves.

From one human perspective, this attachment to family and clan and tribe and nation is obviously key for our survival. We are an individually vulnerable but collectively powerful species, and attachment and mutual support are a key to our personal and collective successes in life.

From another perspective, there is also a dark side to this “gift of nature.”

We draw lines in substantially arbitrary locations across the surface of planet Earth, or we may define our self as belonging to a group in a political or social or religious context, or sect. Our tribalism can support a generally strong level of support and succor for fellow humans on our side of that line, while we regard those just across the line as undeserving of our support. If they offend us, they may become targets of our capacity for cruelty.

Our allegiances can be both wonderful and harmful.
 

The individuality of us

As we celebrate this holiday — a favorite day on my personal calendar — I am compelled to reflect on the fact that America was designed to be fractious. We Americans are not required to all operate like “peas in the pod.”

While we, as a nation, often fail to live up to our ideals, when we pursue the highest standards of liberty, we celebrate diversity, difference, and the ability of each member of our tribe to find their own path.

In a very real sense, the great American “invention” was to create a nation in which we could all find a wonderful place of our own, with the sympathy and protection of fellow citizens, and with liberty and justice for all.

Happy Independence Day to my American tribe!



Michael Merzenich, PhD, is often credited with discovering lifelong plasticity, with being the first to harness plasticity for human benefit (in his co-invention of the cochlear implant), and for pioneering the field of plasticity-based computerized brain exercise. He is professor emeritus at UCSF and a Kavli Laureate in Neuroscience, and he has been honored by each of the US National Academies of Sciences, Engineering, and Medicine. He may be most widely known for a series of specials on the brain on public television. His current focus is BrainHQ, a brain exercise app. He has disclosed the following relevant financial relationships: Serve(d) as a director, officer, partner, employee, advisor, consultant, or trustee for: Posit Science Corporation; Stronger Brains Inc. Serve(d) as a speaker or a member of a speakers bureau for: Posit Science Corporation; Stronger Brains Inc. Received research grant from: National Institutes of Health Have a 5% or greater equity interest in: Posit Science Corporation; Stronger Brains Inc. Received income in an amount equal to or greater than $250 from: Posit Science Corporation; Stronger Brains Inc.; National Institutes of Health.

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

This week, we celebrate our nation’s birth in a national and individual display of our patriotic attachment to this country. To understand how that patriotic attachment arises, we need to step back and look at the ways in which our brains change and define how each of us develops a sense of Self — which includes our self-definition as Americans.

For each of us, personhood is an almost miraculous product of our brain’s plasticity — the brain’s ability to change chemically, structurally, and functionally, based on our life experiences — arising from near countless moments of change in the wiring of our brain.

The incredibly complex remodeling that created “you” is a product, of course, of your very complicated, unique passage in life. You have a repertoire of skills and ability; you have stories and understanding and a history of sensing and acting and thinking in the world that is, in detail, unique only to you and your experiences.

As your brain created its model of your world by recording “what goes with what” at each brief moment of time, your brain — that most complicated and wonderful of “machines” on planet Earth — also associated billions of moments of feeling and action and thought with their source, your Self.

Because we primarily construct our model of the world through our eyes and ears, it’s not surprising that the emergent Self that is located somewhere in the center of your head behind your eyes and between your ears. Through billions of contacts with the surfaces of your hide and sensory organs, you have embodied yourself.
 

Your sense of ‘us’

These same neurologic processes extend beyond our physical beings to incorporate other contributors to our well-being into our personhoods. Loving parents, siblings, friends — and others in your clans and tribes and nations — literally grow into your personhood by these same self-associating processes. These relationships are supported in mutual identity by all of the tokens and icons and charms and customs that collectively define you and enable a sense of “us.”

Put another way, Mother Nature (or, in another cultural perspective, our Creator) has designed our brains to incorporate all of those who are close to us — and more broadly, other individuals in our clan or tribe or nation — to be a part of each of us.

Humans are highly social creatures. When we rise up and risk our lives to defend our friends, family, or cultural “in-groups,” we are literally fighting to defend ourselves — because those other individuals have grown into our very being. In defending them, we are literally defending a part of ourselves.

From one human perspective, this attachment to family and clan and tribe and nation is obviously key for our survival. We are an individually vulnerable but collectively powerful species, and attachment and mutual support are a key to our personal and collective successes in life.

From another perspective, there is also a dark side to this “gift of nature.”

We draw lines in substantially arbitrary locations across the surface of planet Earth, or we may define our self as belonging to a group in a political or social or religious context, or sect. Our tribalism can support a generally strong level of support and succor for fellow humans on our side of that line, while we regard those just across the line as undeserving of our support. If they offend us, they may become targets of our capacity for cruelty.

Our allegiances can be both wonderful and harmful.
 

The individuality of us

As we celebrate this holiday — a favorite day on my personal calendar — I am compelled to reflect on the fact that America was designed to be fractious. We Americans are not required to all operate like “peas in the pod.”

While we, as a nation, often fail to live up to our ideals, when we pursue the highest standards of liberty, we celebrate diversity, difference, and the ability of each member of our tribe to find their own path.

In a very real sense, the great American “invention” was to create a nation in which we could all find a wonderful place of our own, with the sympathy and protection of fellow citizens, and with liberty and justice for all.

Happy Independence Day to my American tribe!



Michael Merzenich, PhD, is often credited with discovering lifelong plasticity, with being the first to harness plasticity for human benefit (in his co-invention of the cochlear implant), and for pioneering the field of plasticity-based computerized brain exercise. He is professor emeritus at UCSF and a Kavli Laureate in Neuroscience, and he has been honored by each of the US National Academies of Sciences, Engineering, and Medicine. He may be most widely known for a series of specials on the brain on public television. His current focus is BrainHQ, a brain exercise app. He has disclosed the following relevant financial relationships: Serve(d) as a director, officer, partner, employee, advisor, consultant, or trustee for: Posit Science Corporation; Stronger Brains Inc. Serve(d) as a speaker or a member of a speakers bureau for: Posit Science Corporation; Stronger Brains Inc. Received research grant from: National Institutes of Health Have a 5% or greater equity interest in: Posit Science Corporation; Stronger Brains Inc. Received income in an amount equal to or greater than $250 from: Posit Science Corporation; Stronger Brains Inc.; National Institutes of Health.

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

This week, we celebrate our nation’s birth in a national and individual display of our patriotic attachment to this country. To understand how that patriotic attachment arises, we need to step back and look at the ways in which our brains change and define how each of us develops a sense of Self — which includes our self-definition as Americans.

For each of us, personhood is an almost miraculous product of our brain’s plasticity — the brain’s ability to change chemically, structurally, and functionally, based on our life experiences — arising from near countless moments of change in the wiring of our brain.

The incredibly complex remodeling that created “you” is a product, of course, of your very complicated, unique passage in life. You have a repertoire of skills and ability; you have stories and understanding and a history of sensing and acting and thinking in the world that is, in detail, unique only to you and your experiences.

As your brain created its model of your world by recording “what goes with what” at each brief moment of time, your brain — that most complicated and wonderful of “machines” on planet Earth — also associated billions of moments of feeling and action and thought with their source, your Self.

Because we primarily construct our model of the world through our eyes and ears, it’s not surprising that the emergent Self that is located somewhere in the center of your head behind your eyes and between your ears. Through billions of contacts with the surfaces of your hide and sensory organs, you have embodied yourself.
 

Your sense of ‘us’

These same neurologic processes extend beyond our physical beings to incorporate other contributors to our well-being into our personhoods. Loving parents, siblings, friends — and others in your clans and tribes and nations — literally grow into your personhood by these same self-associating processes. These relationships are supported in mutual identity by all of the tokens and icons and charms and customs that collectively define you and enable a sense of “us.”

Put another way, Mother Nature (or, in another cultural perspective, our Creator) has designed our brains to incorporate all of those who are close to us — and more broadly, other individuals in our clan or tribe or nation — to be a part of each of us.

Humans are highly social creatures. When we rise up and risk our lives to defend our friends, family, or cultural “in-groups,” we are literally fighting to defend ourselves — because those other individuals have grown into our very being. In defending them, we are literally defending a part of ourselves.

From one human perspective, this attachment to family and clan and tribe and nation is obviously key for our survival. We are an individually vulnerable but collectively powerful species, and attachment and mutual support are a key to our personal and collective successes in life.

From another perspective, there is also a dark side to this “gift of nature.”

We draw lines in substantially arbitrary locations across the surface of planet Earth, or we may define our self as belonging to a group in a political or social or religious context, or sect. Our tribalism can support a generally strong level of support and succor for fellow humans on our side of that line, while we regard those just across the line as undeserving of our support. If they offend us, they may become targets of our capacity for cruelty.

Our allegiances can be both wonderful and harmful.
 

The individuality of us

As we celebrate this holiday — a favorite day on my personal calendar — I am compelled to reflect on the fact that America was designed to be fractious. We Americans are not required to all operate like “peas in the pod.”

While we, as a nation, often fail to live up to our ideals, when we pursue the highest standards of liberty, we celebrate diversity, difference, and the ability of each member of our tribe to find their own path.

In a very real sense, the great American “invention” was to create a nation in which we could all find a wonderful place of our own, with the sympathy and protection of fellow citizens, and with liberty and justice for all.

Happy Independence Day to my American tribe!



Michael Merzenich, PhD, is often credited with discovering lifelong plasticity, with being the first to harness plasticity for human benefit (in his co-invention of the cochlear implant), and for pioneering the field of plasticity-based computerized brain exercise. He is professor emeritus at UCSF and a Kavli Laureate in Neuroscience, and he has been honored by each of the US National Academies of Sciences, Engineering, and Medicine. He may be most widely known for a series of specials on the brain on public television. His current focus is BrainHQ, a brain exercise app. He has disclosed the following relevant financial relationships: Serve(d) as a director, officer, partner, employee, advisor, consultant, or trustee for: Posit Science Corporation; Stronger Brains Inc. Serve(d) as a speaker or a member of a speakers bureau for: Posit Science Corporation; Stronger Brains Inc. Received research grant from: National Institutes of Health Have a 5% or greater equity interest in: Posit Science Corporation; Stronger Brains Inc. Received income in an amount equal to or greater than $250 from: Posit Science Corporation; Stronger Brains Inc.; National Institutes of Health.

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

Children and adolescents with migraine are about twice as likely to have an anxiety or depressive disorder as those without migraine, results from a new review and meta-analysis suggest.

“This is compelling, high-level evidence showing there’s this established comorbidity between migraine and anxiety and depressive symptoms and disorders in this age group,” co-investigator Serena L. Orr, MD, a pediatric neurologist and headache specialist at Alberta Children’s Hospital and assistant professor in the department of pediatrics, University of Calgary (Alta.), told this news organization.

The results “should compel every clinician who is seeing a child or adolescent with migraine to screen for anxiety and depression and to manage that if it’s present. That should be the standard of care with this level of evidence,” Dr. Orr said.

The findings were presented at the American Headache Society (AHS) Annual Meeting 2022.
 

Incidence divergence

Previous studies have suggested that 10%-20% of children and adolescents will experience migraine at some point before adulthood, with the prevalence increasing after puberty.

While the female-to-male ratio is about 1:1 before puberty, there is a “big divergence in incidence curves” afterward – with the female-to-male ratio reaching 2-3:1 in adulthood, Dr. Orr noted. Experts believe hormones drive this divergence, she said, noting that male adults with migraine have lower testosterone levels than male adults without migraine.

Dr. Orr and her colleagues were keen to investigate the relationship between child migraine and anxiety symptoms and disorders, as well as between child migraine and depression symptoms and disorders. They searched the literature for related case-control, cross-sectional, and cohort studies with participants of ages up to 18 years.

The researchers selected 80 studies to include in the review. Most of the studies were carried out in the past 30 to 40 years and were in English and other languages. Both community-based and clinical studies were included.

Of the total, 73 studies reported on the association between the exposures and migraine, and 51 were amenable to quantitative pooling.

Results from a meta-analysis that included 16 studies that compared children and adolescents who had migraine with their healthy peers showed a significant association between migraine and anxiety symptoms (standardized mean difference, 1.13; 95% confidence interval, 0.64-1.63; P < .0001).

Compared with children who did not have migraine, those with migraine had almost twice the odds of an anxiety disorder in 15 studies (odds ratio, 1.93; 95% CI, 1.49-2.50; P < .0001).

In addition, there was an association between migraine and depressive symptoms in 17 relevant studies (SMD, 0.67; 95% CI, 0.46-0.87; P < .0001). Participants with versus without migraine also had higher odds of depressive disorders in 18 studies (OR, 2.01; 95% CI, 1.46-2.78; P < .0001).

Effect sizes were similar between community-based and clinic studies. Dr. Orr said it is important to note that the analysis wasn’t restricted to studies with “just kids with really high disease burden who are going to naturally be more predisposed to psychiatric comorbidity.”
 

‘Shocking’ lack of research

The researchers were also interested in determining whether having migraine along with anxiety or depression symptoms or disorders could affect headache-specific outcomes and whether such patients’ conditions would be more refractory to treatment. However, these outcomes were “all over the place” in the 18 relevant studies, Dr. Orr reported.

“Some looked at headache frequency, some at disability, some at school functioning; so, we were not able to put them into a meta-analysis,” she said.

Only two studies examined whether anxiety or depression earlier in childhood predisposes to subsequent migraine, so that issue is still unresolved, Dr. Orr added.

The investigators also assessed whether outcomes with migraine are similar to those with other headache types, such as tension-type headaches. “We did not find a difference at the symptom or disorder level, but there were fewer of those studies” – and these, too, were heterogeneous, said Dr. Orr.

The researchers did not find any studies of the association between migraine and trauma, which Dr. Orr said was “shocking.”

“In the broader pediatric chronic-pain literature, there’s research showing that having a trauma or stress-related disorder is associated with more chronic pain and worse chronic pain outcomes, but we could not find a study that specifically looked at that question in migraine,” she added.

Emerging evidence suggests there may be a bidirectional relationship between migraine and anxiety/depression, at least in adults. Dr. Orr said having these symptoms appears to raise the risk for migraine, but whether that’s environmental or driven by shared genetics isn’t clear.

Experiencing chronic pain may also predispose individuals to anxiety and depression, “but we need more studies on this.”

In addition to screening children with migraine for anxiety and depression, clinicians should advocate for better access to mental health resources for patients with these comorbidities, Dr. Orr noted.

She added that a limitation of the review was that 82.5% of the studies reported unadjusted associations and that 26.3% of the studies were of low quality.
 

High-level evidence

Sara Pavitt, MD, chief of the Pediatric Headache Program and assistant professor in the department of neurology, the University of Texas at Austin, said the investigators “should be applauded” for providing “high-level evidence” to better understand the relationship between migraine and anxiety and depression in pediatric patients.

Such information has been “lacking” for this patient population, said Dr. Pavitt, who was not involved with the research.

She noted that screening kids for mood disorders is challenging, given the relatively few pediatric mental health care providers. A referral for a psychiatric follow-up can mean a 9- to 12-month wait – or even longer for children who do not have insurance or use Medicare.

“Providers need to have more incentives to care for patients with Medicare or lack of insurance – these patients are often excluded from practices because reimbursement is so poor,” Dr. Pavitt said.

Additional pediatric studies are needed to understand how other mental health disorders, such as panic disorder, phobias, and posttraumatic stress disorder, may be related to migraine, she added.

The study received no outside funding. Dr. Orr has received grants from the Canadian Institutes of Health Research and royalties from Cambridge University Press for book publication, and she is on editorial boards of Headache, Neurology, and the American Migraine Foundation. Dr. Pavitt serves on an advisory board for Theranica, which produces a neuromodulation device for acute migraine treatment, although this is not directly relevant to this review.

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

Children and adolescents with migraine are about twice as likely to have an anxiety or depressive disorder as those without migraine, results from a new review and meta-analysis suggest.

“This is compelling, high-level evidence showing there’s this established comorbidity between migraine and anxiety and depressive symptoms and disorders in this age group,” co-investigator Serena L. Orr, MD, a pediatric neurologist and headache specialist at Alberta Children’s Hospital and assistant professor in the department of pediatrics, University of Calgary (Alta.), told this news organization.

The results “should compel every clinician who is seeing a child or adolescent with migraine to screen for anxiety and depression and to manage that if it’s present. That should be the standard of care with this level of evidence,” Dr. Orr said.

The findings were presented at the American Headache Society (AHS) Annual Meeting 2022.
 

Incidence divergence

Previous studies have suggested that 10%-20% of children and adolescents will experience migraine at some point before adulthood, with the prevalence increasing after puberty.

While the female-to-male ratio is about 1:1 before puberty, there is a “big divergence in incidence curves” afterward – with the female-to-male ratio reaching 2-3:1 in adulthood, Dr. Orr noted. Experts believe hormones drive this divergence, she said, noting that male adults with migraine have lower testosterone levels than male adults without migraine.

Dr. Orr and her colleagues were keen to investigate the relationship between child migraine and anxiety symptoms and disorders, as well as between child migraine and depression symptoms and disorders. They searched the literature for related case-control, cross-sectional, and cohort studies with participants of ages up to 18 years.

The researchers selected 80 studies to include in the review. Most of the studies were carried out in the past 30 to 40 years and were in English and other languages. Both community-based and clinical studies were included.

Of the total, 73 studies reported on the association between the exposures and migraine, and 51 were amenable to quantitative pooling.

Results from a meta-analysis that included 16 studies that compared children and adolescents who had migraine with their healthy peers showed a significant association between migraine and anxiety symptoms (standardized mean difference, 1.13; 95% confidence interval, 0.64-1.63; P < .0001).

Compared with children who did not have migraine, those with migraine had almost twice the odds of an anxiety disorder in 15 studies (odds ratio, 1.93; 95% CI, 1.49-2.50; P < .0001).

In addition, there was an association between migraine and depressive symptoms in 17 relevant studies (SMD, 0.67; 95% CI, 0.46-0.87; P < .0001). Participants with versus without migraine also had higher odds of depressive disorders in 18 studies (OR, 2.01; 95% CI, 1.46-2.78; P < .0001).

Effect sizes were similar between community-based and clinic studies. Dr. Orr said it is important to note that the analysis wasn’t restricted to studies with “just kids with really high disease burden who are going to naturally be more predisposed to psychiatric comorbidity.”
 

‘Shocking’ lack of research

The researchers were also interested in determining whether having migraine along with anxiety or depression symptoms or disorders could affect headache-specific outcomes and whether such patients’ conditions would be more refractory to treatment. However, these outcomes were “all over the place” in the 18 relevant studies, Dr. Orr reported.

“Some looked at headache frequency, some at disability, some at school functioning; so, we were not able to put them into a meta-analysis,” she said.

Only two studies examined whether anxiety or depression earlier in childhood predisposes to subsequent migraine, so that issue is still unresolved, Dr. Orr added.

The investigators also assessed whether outcomes with migraine are similar to those with other headache types, such as tension-type headaches. “We did not find a difference at the symptom or disorder level, but there were fewer of those studies” – and these, too, were heterogeneous, said Dr. Orr.

The researchers did not find any studies of the association between migraine and trauma, which Dr. Orr said was “shocking.”

“In the broader pediatric chronic-pain literature, there’s research showing that having a trauma or stress-related disorder is associated with more chronic pain and worse chronic pain outcomes, but we could not find a study that specifically looked at that question in migraine,” she added.

Emerging evidence suggests there may be a bidirectional relationship between migraine and anxiety/depression, at least in adults. Dr. Orr said having these symptoms appears to raise the risk for migraine, but whether that’s environmental or driven by shared genetics isn’t clear.

Experiencing chronic pain may also predispose individuals to anxiety and depression, “but we need more studies on this.”

In addition to screening children with migraine for anxiety and depression, clinicians should advocate for better access to mental health resources for patients with these comorbidities, Dr. Orr noted.

She added that a limitation of the review was that 82.5% of the studies reported unadjusted associations and that 26.3% of the studies were of low quality.
 

High-level evidence

Sara Pavitt, MD, chief of the Pediatric Headache Program and assistant professor in the department of neurology, the University of Texas at Austin, said the investigators “should be applauded” for providing “high-level evidence” to better understand the relationship between migraine and anxiety and depression in pediatric patients.

Such information has been “lacking” for this patient population, said Dr. Pavitt, who was not involved with the research.

She noted that screening kids for mood disorders is challenging, given the relatively few pediatric mental health care providers. A referral for a psychiatric follow-up can mean a 9- to 12-month wait – or even longer for children who do not have insurance or use Medicare.

“Providers need to have more incentives to care for patients with Medicare or lack of insurance – these patients are often excluded from practices because reimbursement is so poor,” Dr. Pavitt said.

Additional pediatric studies are needed to understand how other mental health disorders, such as panic disorder, phobias, and posttraumatic stress disorder, may be related to migraine, she added.

The study received no outside funding. Dr. Orr has received grants from the Canadian Institutes of Health Research and royalties from Cambridge University Press for book publication, and she is on editorial boards of Headache, Neurology, and the American Migraine Foundation. Dr. Pavitt serves on an advisory board for Theranica, which produces a neuromodulation device for acute migraine treatment, although this is not directly relevant to this review.

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

Children and adolescents with migraine are about twice as likely to have an anxiety or depressive disorder as those without migraine, results from a new review and meta-analysis suggest.

“This is compelling, high-level evidence showing there’s this established comorbidity between migraine and anxiety and depressive symptoms and disorders in this age group,” co-investigator Serena L. Orr, MD, a pediatric neurologist and headache specialist at Alberta Children’s Hospital and assistant professor in the department of pediatrics, University of Calgary (Alta.), told this news organization.

The results “should compel every clinician who is seeing a child or adolescent with migraine to screen for anxiety and depression and to manage that if it’s present. That should be the standard of care with this level of evidence,” Dr. Orr said.

The findings were presented at the American Headache Society (AHS) Annual Meeting 2022.
 

Incidence divergence

Previous studies have suggested that 10%-20% of children and adolescents will experience migraine at some point before adulthood, with the prevalence increasing after puberty.

While the female-to-male ratio is about 1:1 before puberty, there is a “big divergence in incidence curves” afterward – with the female-to-male ratio reaching 2-3:1 in adulthood, Dr. Orr noted. Experts believe hormones drive this divergence, she said, noting that male adults with migraine have lower testosterone levels than male adults without migraine.

Dr. Orr and her colleagues were keen to investigate the relationship between child migraine and anxiety symptoms and disorders, as well as between child migraine and depression symptoms and disorders. They searched the literature for related case-control, cross-sectional, and cohort studies with participants of ages up to 18 years.

The researchers selected 80 studies to include in the review. Most of the studies were carried out in the past 30 to 40 years and were in English and other languages. Both community-based and clinical studies were included.

Of the total, 73 studies reported on the association between the exposures and migraine, and 51 were amenable to quantitative pooling.

Results from a meta-analysis that included 16 studies that compared children and adolescents who had migraine with their healthy peers showed a significant association between migraine and anxiety symptoms (standardized mean difference, 1.13; 95% confidence interval, 0.64-1.63; P < .0001).

Compared with children who did not have migraine, those with migraine had almost twice the odds of an anxiety disorder in 15 studies (odds ratio, 1.93; 95% CI, 1.49-2.50; P < .0001).

In addition, there was an association between migraine and depressive symptoms in 17 relevant studies (SMD, 0.67; 95% CI, 0.46-0.87; P < .0001). Participants with versus without migraine also had higher odds of depressive disorders in 18 studies (OR, 2.01; 95% CI, 1.46-2.78; P < .0001).

Effect sizes were similar between community-based and clinic studies. Dr. Orr said it is important to note that the analysis wasn’t restricted to studies with “just kids with really high disease burden who are going to naturally be more predisposed to psychiatric comorbidity.”
 

‘Shocking’ lack of research

The researchers were also interested in determining whether having migraine along with anxiety or depression symptoms or disorders could affect headache-specific outcomes and whether such patients’ conditions would be more refractory to treatment. However, these outcomes were “all over the place” in the 18 relevant studies, Dr. Orr reported.

“Some looked at headache frequency, some at disability, some at school functioning; so, we were not able to put them into a meta-analysis,” she said.

Only two studies examined whether anxiety or depression earlier in childhood predisposes to subsequent migraine, so that issue is still unresolved, Dr. Orr added.

The investigators also assessed whether outcomes with migraine are similar to those with other headache types, such as tension-type headaches. “We did not find a difference at the symptom or disorder level, but there were fewer of those studies” – and these, too, were heterogeneous, said Dr. Orr.

The researchers did not find any studies of the association between migraine and trauma, which Dr. Orr said was “shocking.”

“In the broader pediatric chronic-pain literature, there’s research showing that having a trauma or stress-related disorder is associated with more chronic pain and worse chronic pain outcomes, but we could not find a study that specifically looked at that question in migraine,” she added.

Emerging evidence suggests there may be a bidirectional relationship between migraine and anxiety/depression, at least in adults. Dr. Orr said having these symptoms appears to raise the risk for migraine, but whether that’s environmental or driven by shared genetics isn’t clear.

Experiencing chronic pain may also predispose individuals to anxiety and depression, “but we need more studies on this.”

In addition to screening children with migraine for anxiety and depression, clinicians should advocate for better access to mental health resources for patients with these comorbidities, Dr. Orr noted.

She added that a limitation of the review was that 82.5% of the studies reported unadjusted associations and that 26.3% of the studies were of low quality.
 

High-level evidence

Sara Pavitt, MD, chief of the Pediatric Headache Program and assistant professor in the department of neurology, the University of Texas at Austin, said the investigators “should be applauded” for providing “high-level evidence” to better understand the relationship between migraine and anxiety and depression in pediatric patients.

Such information has been “lacking” for this patient population, said Dr. Pavitt, who was not involved with the research.

She noted that screening kids for mood disorders is challenging, given the relatively few pediatric mental health care providers. A referral for a psychiatric follow-up can mean a 9- to 12-month wait – or even longer for children who do not have insurance or use Medicare.

“Providers need to have more incentives to care for patients with Medicare or lack of insurance – these patients are often excluded from practices because reimbursement is so poor,” Dr. Pavitt said.

Additional pediatric studies are needed to understand how other mental health disorders, such as panic disorder, phobias, and posttraumatic stress disorder, may be related to migraine, she added.

The study received no outside funding. Dr. Orr has received grants from the Canadian Institutes of Health Research and royalties from Cambridge University Press for book publication, and she is on editorial boards of Headache, Neurology, and the American Migraine Foundation. Dr. Pavitt serves on an advisory board for Theranica, which produces a neuromodulation device for acute migraine treatment, although this is not directly relevant to this review.

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

Republican and Democratic members of the House called for changes in how insurer-run Medicare plans manage the prior authorization process, following testimony from a federal watchdog organization about improper denials of payment for care.

About 18% of payment denials in a sample examined by the Office of Inspector General (OIG) of the Department of Health and Human Services (HHS) either met Medicare coverage rules or the rules of the insurance plan.

As such, they should not have been denied, according to the OIG. That was the finding of an April OIG report, based on a sample of 2019 denials from large insurer-run Medicare plans.

Erin Bliss, an assistant inspector general with the OIG, appeared as a witness at a June 28 Energy and Commerce Subcommittee on Oversight and Investigations hearing to discuss this investigation and other issues with prior authorization and insurer-run Medicare, also known as the Advantage plans.

Most of these payment denials of appropriate services were due to human error during manual claims-processing reviews, Ms. Bliss told the subcommittee, such as overlooking a document, and to system processing errors, such as a Medicare insurance plan failing to program or update a system correctly.

In many cases, these denials were reversed, but patient care was still disrupted and clinicians lost time chasing clearances for services that plans already had covered, Ms. Bliss said in her testimony.

The April report was not the OIG’s first look into concerns about insurer-run plans inappropriately denying care through prior authorizations. The OIG in 2018 reported that insurer-run Medicare plans overturned 75% of their own denials during 2014-2016 when patients and clinicians appealed these decisions, overturning approximately 216,000 denials each year.

‘Numerous hoops’ unnecessary for doctors, patients

Lawmakers at the hearing supported the idea of the need for prior authorization as a screening tool to prevent unneeded care.

But they chided insurance companies for their execution of this process, with clinicians and patients often frustrated by complex steps needed. Medicare Advantage plans sometimes require prior authorization for “relatively standard medical services,” said Subcommittee on Oversight and Investigations Chair Diana DeGette (D-Colo.).

“Our seniors and their doctors should not be required to jump through numerous hoops to ensure coverage for straightforward and medically necessary procedures,” Rep. DeGette said.

Several lawmakers spoke at the hearing about the need for changes to prior authorization, including calling for action on a pending bill intended to compel insurers to streamline the review process. The Improving Seniors’ Timely Access to Care Act of 2021 already has attracted more than 300 bipartisan sponsors. A companion Senate bill has more than 30 sponsors.

The bill’s aim is to shift this process away from faxes and phone calls while also encouraging plans to adhere to evidence-based medical guidelines in consultation with physicians. The bill calls for the establishment of an electronic prior authorization program that could issue real-time decisions.

“The result will be less administrative burden for providers and more information in the hands of patients. It will allow more patients to receive care when they need it, reducing the likelihood of additional, often more severe complications,” said Rep. Larry Bucshon, MD, (R-Ind.) who is among the active sponsors of the bill.

“In the long term, I believe it would also result in cost savings for the health care system at large by identifying problems earlier and getting them treated before their patients have more complications,” Rep. Bucshon added.
 

Finding ‘room for improvement’ for prior authorizations

There’s strong bipartisan support in Congress for insurer-run Medicare, which has grown by 10% per year over the last several years and has doubled since 2010, according to the Medicare Payment Advisory Commission (MedPAC). About 27 million people are now enrolled in these plans.

But for that reason, insurer-run Medicare may also need more careful watching, lawmakers made clear at the hearing.

“We’ve heard quite a bit of evidence today that there is room for improvement,” said Rep. Bucshon, a strong supporter of insurer-run Medicare, which can offer patients added benefits such as dental coverage.

Rep. Ann Kuster (D-N.H.) said simplifying prior authorization would reduce stress on clinicians already dealing with burnout.

“They’re just so tired of all this paperwork and red tape,” Rep. Kuster said. “In 2022 can’t we at least consider electronic prior authorization?”

At the hearing, Rep. Michael C. Burgess, MD, (R-Tex.) noted that his home state already has taken a step toward reducing the burden of prior authorization with its “gold card” program.

In 2021, a new Texas law called on the state department of insurance to develop rules to require health plans to provide an exemption from preauthorization requirements for a particular health care service if the issuer has approved, or would have approved, at least 90% of the preauthorization requests submitted by the physician or provider for that service. The law also mandates that a physician participating in a peer-to-peer review on behalf of a health benefit plan issuer must be a Texas-licensed physician who has the same or similar specialty as the physician or clinician requesting the service, according to the state insurance department.

Separately, Rep. Suzan DelBene (D-Wash.), the sponsor of the Improving Seniors’ Timely Access to Care Act, told the American Medical Association in a recent interview that she expects the House Ways and Means Committee, on which she serves, to mark up her bill in July. (A mark-up is the process by which a House or Senate committee considers and often amends a bill and then sends it to the chamber’s leadership for a floor vote.)

In a statement issued about the hearing, America’s Health Insurance Plans (AHIP) noted that there has been work in recent years toward streamlining prior authorization. AHIP said it launched the Fast Prior Authorization Technology Highway (Fast PATH) initiative in 2020 to study electronic procedures for handling these reviews.

“The findings of this study showed that ePA delivered improvements with a strong majority of experienced providers reporting faster time to patient care, fewer phone calls and faxes, better understanding of [prior authorization] requirements, and faster time to decisions,” AHIP said.

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

Republican and Democratic members of the House called for changes in how insurer-run Medicare plans manage the prior authorization process, following testimony from a federal watchdog organization about improper denials of payment for care.

About 18% of payment denials in a sample examined by the Office of Inspector General (OIG) of the Department of Health and Human Services (HHS) either met Medicare coverage rules or the rules of the insurance plan.

As such, they should not have been denied, according to the OIG. That was the finding of an April OIG report, based on a sample of 2019 denials from large insurer-run Medicare plans.

Erin Bliss, an assistant inspector general with the OIG, appeared as a witness at a June 28 Energy and Commerce Subcommittee on Oversight and Investigations hearing to discuss this investigation and other issues with prior authorization and insurer-run Medicare, also known as the Advantage plans.

Most of these payment denials of appropriate services were due to human error during manual claims-processing reviews, Ms. Bliss told the subcommittee, such as overlooking a document, and to system processing errors, such as a Medicare insurance plan failing to program or update a system correctly.

In many cases, these denials were reversed, but patient care was still disrupted and clinicians lost time chasing clearances for services that plans already had covered, Ms. Bliss said in her testimony.

The April report was not the OIG’s first look into concerns about insurer-run plans inappropriately denying care through prior authorizations. The OIG in 2018 reported that insurer-run Medicare plans overturned 75% of their own denials during 2014-2016 when patients and clinicians appealed these decisions, overturning approximately 216,000 denials each year.

‘Numerous hoops’ unnecessary for doctors, patients

Lawmakers at the hearing supported the idea of the need for prior authorization as a screening tool to prevent unneeded care.

But they chided insurance companies for their execution of this process, with clinicians and patients often frustrated by complex steps needed. Medicare Advantage plans sometimes require prior authorization for “relatively standard medical services,” said Subcommittee on Oversight and Investigations Chair Diana DeGette (D-Colo.).

“Our seniors and their doctors should not be required to jump through numerous hoops to ensure coverage for straightforward and medically necessary procedures,” Rep. DeGette said.

Several lawmakers spoke at the hearing about the need for changes to prior authorization, including calling for action on a pending bill intended to compel insurers to streamline the review process. The Improving Seniors’ Timely Access to Care Act of 2021 already has attracted more than 300 bipartisan sponsors. A companion Senate bill has more than 30 sponsors.

The bill’s aim is to shift this process away from faxes and phone calls while also encouraging plans to adhere to evidence-based medical guidelines in consultation with physicians. The bill calls for the establishment of an electronic prior authorization program that could issue real-time decisions.

“The result will be less administrative burden for providers and more information in the hands of patients. It will allow more patients to receive care when they need it, reducing the likelihood of additional, often more severe complications,” said Rep. Larry Bucshon, MD, (R-Ind.) who is among the active sponsors of the bill.

“In the long term, I believe it would also result in cost savings for the health care system at large by identifying problems earlier and getting them treated before their patients have more complications,” Rep. Bucshon added.
 

Finding ‘room for improvement’ for prior authorizations

There’s strong bipartisan support in Congress for insurer-run Medicare, which has grown by 10% per year over the last several years and has doubled since 2010, according to the Medicare Payment Advisory Commission (MedPAC). About 27 million people are now enrolled in these plans.

But for that reason, insurer-run Medicare may also need more careful watching, lawmakers made clear at the hearing.

“We’ve heard quite a bit of evidence today that there is room for improvement,” said Rep. Bucshon, a strong supporter of insurer-run Medicare, which can offer patients added benefits such as dental coverage.

Rep. Ann Kuster (D-N.H.) said simplifying prior authorization would reduce stress on clinicians already dealing with burnout.

“They’re just so tired of all this paperwork and red tape,” Rep. Kuster said. “In 2022 can’t we at least consider electronic prior authorization?”

At the hearing, Rep. Michael C. Burgess, MD, (R-Tex.) noted that his home state already has taken a step toward reducing the burden of prior authorization with its “gold card” program.

In 2021, a new Texas law called on the state department of insurance to develop rules to require health plans to provide an exemption from preauthorization requirements for a particular health care service if the issuer has approved, or would have approved, at least 90% of the preauthorization requests submitted by the physician or provider for that service. The law also mandates that a physician participating in a peer-to-peer review on behalf of a health benefit plan issuer must be a Texas-licensed physician who has the same or similar specialty as the physician or clinician requesting the service, according to the state insurance department.

Separately, Rep. Suzan DelBene (D-Wash.), the sponsor of the Improving Seniors’ Timely Access to Care Act, told the American Medical Association in a recent interview that she expects the House Ways and Means Committee, on which she serves, to mark up her bill in July. (A mark-up is the process by which a House or Senate committee considers and often amends a bill and then sends it to the chamber’s leadership for a floor vote.)

In a statement issued about the hearing, America’s Health Insurance Plans (AHIP) noted that there has been work in recent years toward streamlining prior authorization. AHIP said it launched the Fast Prior Authorization Technology Highway (Fast PATH) initiative in 2020 to study electronic procedures for handling these reviews.

“The findings of this study showed that ePA delivered improvements with a strong majority of experienced providers reporting faster time to patient care, fewer phone calls and faxes, better understanding of [prior authorization] requirements, and faster time to decisions,” AHIP said.

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

Republican and Democratic members of the House called for changes in how insurer-run Medicare plans manage the prior authorization process, following testimony from a federal watchdog organization about improper denials of payment for care.

About 18% of payment denials in a sample examined by the Office of Inspector General (OIG) of the Department of Health and Human Services (HHS) either met Medicare coverage rules or the rules of the insurance plan.

As such, they should not have been denied, according to the OIG. That was the finding of an April OIG report, based on a sample of 2019 denials from large insurer-run Medicare plans.

Erin Bliss, an assistant inspector general with the OIG, appeared as a witness at a June 28 Energy and Commerce Subcommittee on Oversight and Investigations hearing to discuss this investigation and other issues with prior authorization and insurer-run Medicare, also known as the Advantage plans.

Most of these payment denials of appropriate services were due to human error during manual claims-processing reviews, Ms. Bliss told the subcommittee, such as overlooking a document, and to system processing errors, such as a Medicare insurance plan failing to program or update a system correctly.

In many cases, these denials were reversed, but patient care was still disrupted and clinicians lost time chasing clearances for services that plans already had covered, Ms. Bliss said in her testimony.

The April report was not the OIG’s first look into concerns about insurer-run plans inappropriately denying care through prior authorizations. The OIG in 2018 reported that insurer-run Medicare plans overturned 75% of their own denials during 2014-2016 when patients and clinicians appealed these decisions, overturning approximately 216,000 denials each year.

‘Numerous hoops’ unnecessary for doctors, patients

Lawmakers at the hearing supported the idea of the need for prior authorization as a screening tool to prevent unneeded care.

But they chided insurance companies for their execution of this process, with clinicians and patients often frustrated by complex steps needed. Medicare Advantage plans sometimes require prior authorization for “relatively standard medical services,” said Subcommittee on Oversight and Investigations Chair Diana DeGette (D-Colo.).

“Our seniors and their doctors should not be required to jump through numerous hoops to ensure coverage for straightforward and medically necessary procedures,” Rep. DeGette said.

Several lawmakers spoke at the hearing about the need for changes to prior authorization, including calling for action on a pending bill intended to compel insurers to streamline the review process. The Improving Seniors’ Timely Access to Care Act of 2021 already has attracted more than 300 bipartisan sponsors. A companion Senate bill has more than 30 sponsors.

The bill’s aim is to shift this process away from faxes and phone calls while also encouraging plans to adhere to evidence-based medical guidelines in consultation with physicians. The bill calls for the establishment of an electronic prior authorization program that could issue real-time decisions.

“The result will be less administrative burden for providers and more information in the hands of patients. It will allow more patients to receive care when they need it, reducing the likelihood of additional, often more severe complications,” said Rep. Larry Bucshon, MD, (R-Ind.) who is among the active sponsors of the bill.

“In the long term, I believe it would also result in cost savings for the health care system at large by identifying problems earlier and getting them treated before their patients have more complications,” Rep. Bucshon added.
 

Finding ‘room for improvement’ for prior authorizations

There’s strong bipartisan support in Congress for insurer-run Medicare, which has grown by 10% per year over the last several years and has doubled since 2010, according to the Medicare Payment Advisory Commission (MedPAC). About 27 million people are now enrolled in these plans.

But for that reason, insurer-run Medicare may also need more careful watching, lawmakers made clear at the hearing.

“We’ve heard quite a bit of evidence today that there is room for improvement,” said Rep. Bucshon, a strong supporter of insurer-run Medicare, which can offer patients added benefits such as dental coverage.

Rep. Ann Kuster (D-N.H.) said simplifying prior authorization would reduce stress on clinicians already dealing with burnout.

“They’re just so tired of all this paperwork and red tape,” Rep. Kuster said. “In 2022 can’t we at least consider electronic prior authorization?”

At the hearing, Rep. Michael C. Burgess, MD, (R-Tex.) noted that his home state already has taken a step toward reducing the burden of prior authorization with its “gold card” program.

In 2021, a new Texas law called on the state department of insurance to develop rules to require health plans to provide an exemption from preauthorization requirements for a particular health care service if the issuer has approved, or would have approved, at least 90% of the preauthorization requests submitted by the physician or provider for that service. The law also mandates that a physician participating in a peer-to-peer review on behalf of a health benefit plan issuer must be a Texas-licensed physician who has the same or similar specialty as the physician or clinician requesting the service, according to the state insurance department.

Separately, Rep. Suzan DelBene (D-Wash.), the sponsor of the Improving Seniors’ Timely Access to Care Act, told the American Medical Association in a recent interview that she expects the House Ways and Means Committee, on which she serves, to mark up her bill in July. (A mark-up is the process by which a House or Senate committee considers and often amends a bill and then sends it to the chamber’s leadership for a floor vote.)

In a statement issued about the hearing, America’s Health Insurance Plans (AHIP) noted that there has been work in recent years toward streamlining prior authorization. AHIP said it launched the Fast Prior Authorization Technology Highway (Fast PATH) initiative in 2020 to study electronic procedures for handling these reviews.

“The findings of this study showed that ePA delivered improvements with a strong majority of experienced providers reporting faster time to patient care, fewer phone calls and faxes, better understanding of [prior authorization] requirements, and faster time to decisions,” AHIP said.

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

Physician stress – indeed, the stress level for all medical personnel – has reached new heights.

As if it weren’t enough that doctors work in a profession where it’s almost more a question of when they’ll be sued than if they’ll be sued – where COVID, staff shortages, long hours, and patients frustrated over canceled procedures have caused unrelenting fatigue and stress – they now have to worry that an unhappy patient is going to buy a gun, walk into their office, and kill them.

That’s exactly what happened in Tulsa, Okla., where a patient complaining of pain after back surgery murdered his doctor and several others who happened to be in the wrong place at the wrong time. 

The temptation in the aftermath of such tragedies is to think about preventive measures: Make medical facilities “hardened” targets, like schools have become, with armed guards, metal detectors, automatically locking doors, physical barriers within, security cameras, and buzzers for entry – although hardening a large medical center where members of the community routinely come and go would be challenging.

What about the enormous stress on doctors, nurses, and others in the medical workplace? Physicians who have been sued for malpractice often describe how it changes the way they interact with patients: They now size patients up and make judgments about their potential litigiousness. Will the physicians now look over their patients’ shoulders at the video feed from a security camera when they’re taking a history? Will medical professionals be forced to make snap judgments about patients’ psychological state before deciding whether to treat them?

Remember, there was a time when school shootings were unimaginable. Once one person crosses that line, others inevitably follow.

It could be a drug-seeking patient complaining of ongoing pain, angry because he can’t get a new prescription. It could be a patient whose unpaid bill was turned over to a collection agency, angry because he’s now getting calls from collectors. It could be someone who blames a physician for the loss of a loved one. It could be someone who would otherwise have filed a lawsuit, who now thinks he has a more effective option for exacting retribution.

Most of us would find it unbearable to live and work under the kind of stress faced by medical professionals today. And unfortunately, there is no short-term, systemic relief on the horizon. But there are methods of relieving at least some of the psychological burden being carried by these dedicated individuals.

For starters, the government should provide funds to improve safety and security at medical facilities. It’s sad but it’s a fact of life. The physical structure of schools, along with emergency procedures, have been changed since Columbine and Sandy Hook, and our children and their teachers undergo active shooter drills. Health care facilities will need to adopt similar strategies.

But if we don’t also support the individuals who work in health care, we’ll no longer have even partially staffed health care facilities. Hospitals and medical groups need to be conscious of the effects stress may have on them. Medical staff and administrators need to recognize changes in their colleagues’ behavior and refer those cohorts to professional stress coaches who can get them back on track.

Medical personnel should be picking up on warning signs, like irritability, depression, sudden weight gain or loss, lack of motivation and job satisfaction, obsessiveness, unusual levels of fatigue, alcohol or drug use, and, of course, avoidable medical errors.

In addition, colleagues in the medical workplace need to know each other well. They are usually the first ones to notice if something is off and may be in the best position to refer coworkers for help. Also, medical malpractice insurance carriers should consider encouraging and covering coaching sessions, because helping physicians cope with this heightened stress will prevent medical errors and the lawsuits that inevitably accompany mistakes.

This needn’t be a long-term process like ongoing psychotherapy; a few sessions with a well-trained coach may help psychologically challenged peers restore their focus and perspective. It won’t eliminate the threat any more than litigation stress coaching eliminates the threat of being sued, but it can prevent that stress from leading to avoidable errors. It also can prevent physicians’ personal lives and relationships from going off the rails and driving them out of the medical profession.

None of us can afford to ignore the impacts that these new stressors are having and simply act as if it’s business as usual. The people in the trenches need our help.

Ms. Fiore is President of Winning Focus in Murrysville, Pa. She has disclosed no relevant financial relationships.

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

Physician stress – indeed, the stress level for all medical personnel – has reached new heights.

As if it weren’t enough that doctors work in a profession where it’s almost more a question of when they’ll be sued than if they’ll be sued – where COVID, staff shortages, long hours, and patients frustrated over canceled procedures have caused unrelenting fatigue and stress – they now have to worry that an unhappy patient is going to buy a gun, walk into their office, and kill them.

That’s exactly what happened in Tulsa, Okla., where a patient complaining of pain after back surgery murdered his doctor and several others who happened to be in the wrong place at the wrong time. 

The temptation in the aftermath of such tragedies is to think about preventive measures: Make medical facilities “hardened” targets, like schools have become, with armed guards, metal detectors, automatically locking doors, physical barriers within, security cameras, and buzzers for entry – although hardening a large medical center where members of the community routinely come and go would be challenging.

What about the enormous stress on doctors, nurses, and others in the medical workplace? Physicians who have been sued for malpractice often describe how it changes the way they interact with patients: They now size patients up and make judgments about their potential litigiousness. Will the physicians now look over their patients’ shoulders at the video feed from a security camera when they’re taking a history? Will medical professionals be forced to make snap judgments about patients’ psychological state before deciding whether to treat them?

Remember, there was a time when school shootings were unimaginable. Once one person crosses that line, others inevitably follow.

It could be a drug-seeking patient complaining of ongoing pain, angry because he can’t get a new prescription. It could be a patient whose unpaid bill was turned over to a collection agency, angry because he’s now getting calls from collectors. It could be someone who blames a physician for the loss of a loved one. It could be someone who would otherwise have filed a lawsuit, who now thinks he has a more effective option for exacting retribution.

Most of us would find it unbearable to live and work under the kind of stress faced by medical professionals today. And unfortunately, there is no short-term, systemic relief on the horizon. But there are methods of relieving at least some of the psychological burden being carried by these dedicated individuals.

For starters, the government should provide funds to improve safety and security at medical facilities. It’s sad but it’s a fact of life. The physical structure of schools, along with emergency procedures, have been changed since Columbine and Sandy Hook, and our children and their teachers undergo active shooter drills. Health care facilities will need to adopt similar strategies.

But if we don’t also support the individuals who work in health care, we’ll no longer have even partially staffed health care facilities. Hospitals and medical groups need to be conscious of the effects stress may have on them. Medical staff and administrators need to recognize changes in their colleagues’ behavior and refer those cohorts to professional stress coaches who can get them back on track.

Medical personnel should be picking up on warning signs, like irritability, depression, sudden weight gain or loss, lack of motivation and job satisfaction, obsessiveness, unusual levels of fatigue, alcohol or drug use, and, of course, avoidable medical errors.

In addition, colleagues in the medical workplace need to know each other well. They are usually the first ones to notice if something is off and may be in the best position to refer coworkers for help. Also, medical malpractice insurance carriers should consider encouraging and covering coaching sessions, because helping physicians cope with this heightened stress will prevent medical errors and the lawsuits that inevitably accompany mistakes.

This needn’t be a long-term process like ongoing psychotherapy; a few sessions with a well-trained coach may help psychologically challenged peers restore their focus and perspective. It won’t eliminate the threat any more than litigation stress coaching eliminates the threat of being sued, but it can prevent that stress from leading to avoidable errors. It also can prevent physicians’ personal lives and relationships from going off the rails and driving them out of the medical profession.

None of us can afford to ignore the impacts that these new stressors are having and simply act as if it’s business as usual. The people in the trenches need our help.

Ms. Fiore is President of Winning Focus in Murrysville, Pa. She has disclosed no relevant financial relationships.

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

Physician stress – indeed, the stress level for all medical personnel – has reached new heights.

As if it weren’t enough that doctors work in a profession where it’s almost more a question of when they’ll be sued than if they’ll be sued – where COVID, staff shortages, long hours, and patients frustrated over canceled procedures have caused unrelenting fatigue and stress – they now have to worry that an unhappy patient is going to buy a gun, walk into their office, and kill them.

That’s exactly what happened in Tulsa, Okla., where a patient complaining of pain after back surgery murdered his doctor and several others who happened to be in the wrong place at the wrong time. 

The temptation in the aftermath of such tragedies is to think about preventive measures: Make medical facilities “hardened” targets, like schools have become, with armed guards, metal detectors, automatically locking doors, physical barriers within, security cameras, and buzzers for entry – although hardening a large medical center where members of the community routinely come and go would be challenging.

What about the enormous stress on doctors, nurses, and others in the medical workplace? Physicians who have been sued for malpractice often describe how it changes the way they interact with patients: They now size patients up and make judgments about their potential litigiousness. Will the physicians now look over their patients’ shoulders at the video feed from a security camera when they’re taking a history? Will medical professionals be forced to make snap judgments about patients’ psychological state before deciding whether to treat them?

Remember, there was a time when school shootings were unimaginable. Once one person crosses that line, others inevitably follow.

It could be a drug-seeking patient complaining of ongoing pain, angry because he can’t get a new prescription. It could be a patient whose unpaid bill was turned over to a collection agency, angry because he’s now getting calls from collectors. It could be someone who blames a physician for the loss of a loved one. It could be someone who would otherwise have filed a lawsuit, who now thinks he has a more effective option for exacting retribution.

Most of us would find it unbearable to live and work under the kind of stress faced by medical professionals today. And unfortunately, there is no short-term, systemic relief on the horizon. But there are methods of relieving at least some of the psychological burden being carried by these dedicated individuals.

For starters, the government should provide funds to improve safety and security at medical facilities. It’s sad but it’s a fact of life. The physical structure of schools, along with emergency procedures, have been changed since Columbine and Sandy Hook, and our children and their teachers undergo active shooter drills. Health care facilities will need to adopt similar strategies.

But if we don’t also support the individuals who work in health care, we’ll no longer have even partially staffed health care facilities. Hospitals and medical groups need to be conscious of the effects stress may have on them. Medical staff and administrators need to recognize changes in their colleagues’ behavior and refer those cohorts to professional stress coaches who can get them back on track.

Medical personnel should be picking up on warning signs, like irritability, depression, sudden weight gain or loss, lack of motivation and job satisfaction, obsessiveness, unusual levels of fatigue, alcohol or drug use, and, of course, avoidable medical errors.

In addition, colleagues in the medical workplace need to know each other well. They are usually the first ones to notice if something is off and may be in the best position to refer coworkers for help. Also, medical malpractice insurance carriers should consider encouraging and covering coaching sessions, because helping physicians cope with this heightened stress will prevent medical errors and the lawsuits that inevitably accompany mistakes.

This needn’t be a long-term process like ongoing psychotherapy; a few sessions with a well-trained coach may help psychologically challenged peers restore their focus and perspective. It won’t eliminate the threat any more than litigation stress coaching eliminates the threat of being sued, but it can prevent that stress from leading to avoidable errors. It also can prevent physicians’ personal lives and relationships from going off the rails and driving them out of the medical profession.

None of us can afford to ignore the impacts that these new stressors are having and simply act as if it’s business as usual. The people in the trenches need our help.

Ms. Fiore is President of Winning Focus in Murrysville, Pa. She has disclosed no relevant financial relationships.

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

An international consortium of Huntington’s disease experts has developed the first-ever staging system for the genetic neurologic condition – an important step toward developing new therapeutics to treat the disease before symptoms present.

Researchers liken the Huntington’s disease Integrated Staging System (HD-ISS) to the system currently used to stage cancer. It groups patients according to their underlying biological, clinical, and functional characteristics.

It also includes criteria to biologically define Huntington’s disease stages across the entire disease spectrum, from birth to death, which is something that has not been done before. For now, the HD-ISS is only intended for research, but it could one day be modified for use in the clinic, investigators wrote.

“This systematization is of critical importance to select the most appropriate target population for clinical trials and studies,” said co-investigator Cristina Sampaio, MD, chief medical officer at the CHDI Foundation, Princeton, N.J.

“By providing a methodology to precisely define cases early in the neurodegenerative process, the HD-ISS will be instrumental in conducting trials in the very early disease stages,” Dr. Sampaio added.

The position paper was published in the July issue of the Lancet Neurology.
 

New approach needed

There is no approved therapy to slow Huntington’s disease progression. Clinical trials currently enroll patients with demonstrable symptoms, which limits the ability to test therapeutics that could delay or prevent neurodegeneration.

Huntington’s disease is rare, occurring in about 2.7 per 100,000 individuals worldwide. It is caused by a mutation in the HTT gene involving a DNA segment known as a CAG trinucleotide repeat.

Currently, Huntington’s disease is diagnosed on the basis of clinical signs that emerge late in the disease course, an approach developed before the discovery of the HTT gene and the development of the genetic test for the CAG mutation.

The disease phase prior to diagnosis has been described as presymptomatic, premanifest, or prodromal. However, the three terms have varying definitions that make it difficult to compare study results across trials.

Because drug development had focused on the overt motor sign phase of the disease, there was no real need for an evidence-based staging system that classified disease phases from birth, the investigators noted.

“Now, the research community and regulators recognize that it is critical to conduct trials early in the disease when no signs or overt symptoms are measurable,” Dr. Sampaio said.
 

Defining disease stages

Work on the staging system was done through the Huntington’s Disease Regulatory Science Consortium, an international project begun in 2018 among biotech and pharma companies, academic institutions, and nonprofit research and advocacy organizations.

Overall, more than 50 clinicians and researchers were involved in developing the HD-ISS.

Using modeling data from four large observational studies that included patients with Huntington’s disease and control groups, researchers identified four different stages of Huntington’s disease:

• Stage 0: Begins at birth with identification of HTT gene mutations but no detectable pathologic changes.
• Stage 1: Begins when biomarker changes are detected via MRI by a volume decrease in six brain areas.
• Stage 2: Begins when clinical signs of Huntington’s disease are present, as determined through motor and cognitive assessments.
• Stage 3: Begins when functional decline is evident, with worsening on the Independence Scale and the Total Functional Capacity of the Unified Huntington’s Disease Rating Scale.

Applying the HD-ISS to clinical trials requires the collection of information routinely recorded in Huntington’s disease research, as well as some additional data, but researchers say its application is straightforward.

The HD-ISS uses a numerical staging system similar to that used in the U.S. Food and Drug Administration’s guidance for Alzheimer’s disease (AD) and integrates the prodromal, presymptomatic, or premanifest phase of the disease. This distinguishes it from earlier classification systems.

The HD-ISS can be adapted if new Huntington’s disease biomarkers are identified.

“As research results are generated, this will further validate the HD-ISS and potentially lead to the development of a derivative, and possibly simplified, system for clinical practice,” Dr. Sampaio said.

The new system goes further than a more recent proposal from the Movement Disorder Society task force, which addresses earlier stages in Huntington’s disease but doesn’t consider objective biomarker data.
 

Question of timing

Commenting on the findings, Erin Furr-Stimming, MD, neurologist and director of the Huntington’s Disease Society of America Center of Excellence with McGovern Medical School, UTHealth, Houston, said targeting early-stage disease will be key.

“Similar to more common neurodegenerative diseases such as Alzheimer’s disease and Parkinson’s disease, there is a period of at least a decade when changes are occurring in the nervous system, prior to the manifestation of clinical symptoms and signs significant enough to warrant a clinical diagnosis,” Dr. Furr-Stimming said.

She noted that multiple trials of disease-modifying agents for Alzheimer’s disease, Parkinson’s disease, and Huntington’s disease have failed for a multitude of reasons, “but one consistent question that is relevant to all these diseases is that of timing: Should we intervene and test these therapies earlier?

“The premanifest or prodromal period may be the ideal time to intervene with a disease-modifying therapy, prior to onset of any neurodegeneration,” Dr. Furr-Stimming said.

The CHDI Foundation provided financial support to the Critical Path Institute for the Huntington’s Disease Regulatory Science Consortium, including all working group efforts. Dr. Sampio is an employee of and receives salary from CHDI Management. She has also received consultancy honorariums (unrelated to HD) from Pfizer, Kyowa Kirin, vTv Therapeutics, GW Pharmaceuticals, Neuraly, Neuroderm, Green Valley Pharmaceuticals, and Pinteon Pharmaceuticals. A full list of disclosures for the other researchers is in the original article. Dr. Furr-Stimming reported no relevant financial relationships.

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

An international consortium of Huntington’s disease experts has developed the first-ever staging system for the genetic neurologic condition – an important step toward developing new therapeutics to treat the disease before symptoms present.

Researchers liken the Huntington’s disease Integrated Staging System (HD-ISS) to the system currently used to stage cancer. It groups patients according to their underlying biological, clinical, and functional characteristics.

It also includes criteria to biologically define Huntington’s disease stages across the entire disease spectrum, from birth to death, which is something that has not been done before. For now, the HD-ISS is only intended for research, but it could one day be modified for use in the clinic, investigators wrote.

“This systematization is of critical importance to select the most appropriate target population for clinical trials and studies,” said co-investigator Cristina Sampaio, MD, chief medical officer at the CHDI Foundation, Princeton, N.J.

“By providing a methodology to precisely define cases early in the neurodegenerative process, the HD-ISS will be instrumental in conducting trials in the very early disease stages,” Dr. Sampaio added.

The position paper was published in the July issue of the Lancet Neurology.
 

New approach needed

There is no approved therapy to slow Huntington’s disease progression. Clinical trials currently enroll patients with demonstrable symptoms, which limits the ability to test therapeutics that could delay or prevent neurodegeneration.

Huntington’s disease is rare, occurring in about 2.7 per 100,000 individuals worldwide. It is caused by a mutation in the HTT gene involving a DNA segment known as a CAG trinucleotide repeat.

Currently, Huntington’s disease is diagnosed on the basis of clinical signs that emerge late in the disease course, an approach developed before the discovery of the HTT gene and the development of the genetic test for the CAG mutation.

The disease phase prior to diagnosis has been described as presymptomatic, premanifest, or prodromal. However, the three terms have varying definitions that make it difficult to compare study results across trials.

Because drug development had focused on the overt motor sign phase of the disease, there was no real need for an evidence-based staging system that classified disease phases from birth, the investigators noted.

“Now, the research community and regulators recognize that it is critical to conduct trials early in the disease when no signs or overt symptoms are measurable,” Dr. Sampaio said.
 

Defining disease stages

Work on the staging system was done through the Huntington’s Disease Regulatory Science Consortium, an international project begun in 2018 among biotech and pharma companies, academic institutions, and nonprofit research and advocacy organizations.

Overall, more than 50 clinicians and researchers were involved in developing the HD-ISS.

Using modeling data from four large observational studies that included patients with Huntington’s disease and control groups, researchers identified four different stages of Huntington’s disease:

• Stage 0: Begins at birth with identification of HTT gene mutations but no detectable pathologic changes.
• Stage 1: Begins when biomarker changes are detected via MRI by a volume decrease in six brain areas.
• Stage 2: Begins when clinical signs of Huntington’s disease are present, as determined through motor and cognitive assessments.
• Stage 3: Begins when functional decline is evident, with worsening on the Independence Scale and the Total Functional Capacity of the Unified Huntington’s Disease Rating Scale.

Applying the HD-ISS to clinical trials requires the collection of information routinely recorded in Huntington’s disease research, as well as some additional data, but researchers say its application is straightforward.

The HD-ISS uses a numerical staging system similar to that used in the U.S. Food and Drug Administration’s guidance for Alzheimer’s disease (AD) and integrates the prodromal, presymptomatic, or premanifest phase of the disease. This distinguishes it from earlier classification systems.

The HD-ISS can be adapted if new Huntington’s disease biomarkers are identified.

“As research results are generated, this will further validate the HD-ISS and potentially lead to the development of a derivative, and possibly simplified, system for clinical practice,” Dr. Sampaio said.

The new system goes further than a more recent proposal from the Movement Disorder Society task force, which addresses earlier stages in Huntington’s disease but doesn’t consider objective biomarker data.
 

Question of timing

Commenting on the findings, Erin Furr-Stimming, MD, neurologist and director of the Huntington’s Disease Society of America Center of Excellence with McGovern Medical School, UTHealth, Houston, said targeting early-stage disease will be key.

“Similar to more common neurodegenerative diseases such as Alzheimer’s disease and Parkinson’s disease, there is a period of at least a decade when changes are occurring in the nervous system, prior to the manifestation of clinical symptoms and signs significant enough to warrant a clinical diagnosis,” Dr. Furr-Stimming said.

She noted that multiple trials of disease-modifying agents for Alzheimer’s disease, Parkinson’s disease, and Huntington’s disease have failed for a multitude of reasons, “but one consistent question that is relevant to all these diseases is that of timing: Should we intervene and test these therapies earlier?

“The premanifest or prodromal period may be the ideal time to intervene with a disease-modifying therapy, prior to onset of any neurodegeneration,” Dr. Furr-Stimming said.

The CHDI Foundation provided financial support to the Critical Path Institute for the Huntington’s Disease Regulatory Science Consortium, including all working group efforts. Dr. Sampio is an employee of and receives salary from CHDI Management. She has also received consultancy honorariums (unrelated to HD) from Pfizer, Kyowa Kirin, vTv Therapeutics, GW Pharmaceuticals, Neuraly, Neuroderm, Green Valley Pharmaceuticals, and Pinteon Pharmaceuticals. A full list of disclosures for the other researchers is in the original article. Dr. Furr-Stimming reported no relevant financial relationships.

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

An international consortium of Huntington’s disease experts has developed the first-ever staging system for the genetic neurologic condition – an important step toward developing new therapeutics to treat the disease before symptoms present.

Researchers liken the Huntington’s disease Integrated Staging System (HD-ISS) to the system currently used to stage cancer. It groups patients according to their underlying biological, clinical, and functional characteristics.

It also includes criteria to biologically define Huntington’s disease stages across the entire disease spectrum, from birth to death, which is something that has not been done before. For now, the HD-ISS is only intended for research, but it could one day be modified for use in the clinic, investigators wrote.

“This systematization is of critical importance to select the most appropriate target population for clinical trials and studies,” said co-investigator Cristina Sampaio, MD, chief medical officer at the CHDI Foundation, Princeton, N.J.

“By providing a methodology to precisely define cases early in the neurodegenerative process, the HD-ISS will be instrumental in conducting trials in the very early disease stages,” Dr. Sampaio added.

The position paper was published in the July issue of the Lancet Neurology.
 

New approach needed

There is no approved therapy to slow Huntington’s disease progression. Clinical trials currently enroll patients with demonstrable symptoms, which limits the ability to test therapeutics that could delay or prevent neurodegeneration.

Huntington’s disease is rare, occurring in about 2.7 per 100,000 individuals worldwide. It is caused by a mutation in the HTT gene involving a DNA segment known as a CAG trinucleotide repeat.

Currently, Huntington’s disease is diagnosed on the basis of clinical signs that emerge late in the disease course, an approach developed before the discovery of the HTT gene and the development of the genetic test for the CAG mutation.

The disease phase prior to diagnosis has been described as presymptomatic, premanifest, or prodromal. However, the three terms have varying definitions that make it difficult to compare study results across trials.

Because drug development had focused on the overt motor sign phase of the disease, there was no real need for an evidence-based staging system that classified disease phases from birth, the investigators noted.

“Now, the research community and regulators recognize that it is critical to conduct trials early in the disease when no signs or overt symptoms are measurable,” Dr. Sampaio said.
 

Defining disease stages

Work on the staging system was done through the Huntington’s Disease Regulatory Science Consortium, an international project begun in 2018 among biotech and pharma companies, academic institutions, and nonprofit research and advocacy organizations.

Overall, more than 50 clinicians and researchers were involved in developing the HD-ISS.

Using modeling data from four large observational studies that included patients with Huntington’s disease and control groups, researchers identified four different stages of Huntington’s disease:

• Stage 0: Begins at birth with identification of HTT gene mutations but no detectable pathologic changes.
• Stage 1: Begins when biomarker changes are detected via MRI by a volume decrease in six brain areas.
• Stage 2: Begins when clinical signs of Huntington’s disease are present, as determined through motor and cognitive assessments.
• Stage 3: Begins when functional decline is evident, with worsening on the Independence Scale and the Total Functional Capacity of the Unified Huntington’s Disease Rating Scale.

Applying the HD-ISS to clinical trials requires the collection of information routinely recorded in Huntington’s disease research, as well as some additional data, but researchers say its application is straightforward.

The HD-ISS uses a numerical staging system similar to that used in the U.S. Food and Drug Administration’s guidance for Alzheimer’s disease (AD) and integrates the prodromal, presymptomatic, or premanifest phase of the disease. This distinguishes it from earlier classification systems.

The HD-ISS can be adapted if new Huntington’s disease biomarkers are identified.

“As research results are generated, this will further validate the HD-ISS and potentially lead to the development of a derivative, and possibly simplified, system for clinical practice,” Dr. Sampaio said.

The new system goes further than a more recent proposal from the Movement Disorder Society task force, which addresses earlier stages in Huntington’s disease but doesn’t consider objective biomarker data.
 

Question of timing

Commenting on the findings, Erin Furr-Stimming, MD, neurologist and director of the Huntington’s Disease Society of America Center of Excellence with McGovern Medical School, UTHealth, Houston, said targeting early-stage disease will be key.

“Similar to more common neurodegenerative diseases such as Alzheimer’s disease and Parkinson’s disease, there is a period of at least a decade when changes are occurring in the nervous system, prior to the manifestation of clinical symptoms and signs significant enough to warrant a clinical diagnosis,” Dr. Furr-Stimming said.

She noted that multiple trials of disease-modifying agents for Alzheimer’s disease, Parkinson’s disease, and Huntington’s disease have failed for a multitude of reasons, “but one consistent question that is relevant to all these diseases is that of timing: Should we intervene and test these therapies earlier?

“The premanifest or prodromal period may be the ideal time to intervene with a disease-modifying therapy, prior to onset of any neurodegeneration,” Dr. Furr-Stimming said.

The CHDI Foundation provided financial support to the Critical Path Institute for the Huntington’s Disease Regulatory Science Consortium, including all working group efforts. Dr. Sampio is an employee of and receives salary from CHDI Management. She has also received consultancy honorariums (unrelated to HD) from Pfizer, Kyowa Kirin, vTv Therapeutics, GW Pharmaceuticals, Neuraly, Neuroderm, Green Valley Pharmaceuticals, and Pinteon Pharmaceuticals. A full list of disclosures for the other researchers is in the original article. Dr. Furr-Stimming reported no relevant financial relationships.

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

Ain’t gastroenteritis grand?

The Grand Canyon is perhaps America’s greatest natural wonder. The mile-deep gorge of epic proportions, carved over eons by the Colorado River, elicits superlatives of the highest order from those seeing it for the first time. In the past few months, though, visitors to the Grand Canyon have been experiencing a rather more unpleasant sort of reaction: Involuntary bowel evacuation.

Since April, more than 150 river rafters and backcountry campers have fallen ill with bouts of acute gastroenteritis, likely caused by norovirus. Hey, a viral outbreak and our old friend SARS-CoV-2 isn’t involved! Hopefully it won’t get jealous. Whatever the culprit is, however, it got everywhere, as clusters of illness have popped up in unconnected parts of the park and some hikers have been restricted to a smaller portion of the park to avoid further disease spread. The majority of cases occurred in May, so it’s hoped that the outbreak is dying down, but the park remains on alert.

Jon Sullivan/Pixnio

Now, acute gastroenteritis is certainly an unpleasant disease, but it isn’t typically a life-threatening one. There are, however, a couple of unique factors complicating this outbreak. For one, the Grand Canyon is in Arizona (duh), which can get rather hot in the summer months. Expelling waste from both ends becomes rather more dangerous when the thermometer reads over a hundred degrees, and there have been reports of multiple helicopter rescues.

That’s pretty bad, but in a way, they’re the lucky ones. How can we explain this … see, when you visit the Grand Canyon, you’re expected to follow the general rules of Leave No Trace. That means several things, but essentially, if you bring it in, you have to bring it out. Yes, that includes the various consequences of an acute gastroenteritis attack.

Forget spooky campfire stories and hungry wildlife lurking in the night, because true horror is scraping your friend’s diarrhea off the walls of the Grand Canyon into a plastic bag and stuffing it into your backpack. Probably not the sublime one-on-one Grand Canyon experience that people are expecting.
 

Give us a pee! ... for stem cell retrieval

Getting cells for regenerative stem cell treatment has traditionally been painful and difficult – usually they are retrieved by surgical means from bone marrow or fat tissue – but there may be an easier way.

Just pee in a cup.

toeytoey2530/Thinkstock

Apparently, human urine contains stem cells with the potential to be used for regenerative effects. The magic ingredient? The enzyme telomerase, which “is essential for the self-renewal and potential of different types of stem cells” and is related to longevity, according to researchers at Wake Forest Institute for Regenerative Medicine.

They looked into how regenerative telomerase activity is for various capabilities beyond chromosomal stability, and whether these stem cells can become other kinds of cells for optimal tissue repair. Turns out they could, acting as a “distinct subpopulation” that has the ability not only to grow cells but also to morph into other cells, they said in a written statement.

Safety is also an issue. “Being able to use a patient’s own stem cells for therapy is considered advantageous because they do not induce immune responses or rejection,” said Anthony Atala, MD, a coauthor of the study published in Frontiers in Cell and Developmental Biology.

So less risk, easier retrieval, and great regenerative results. If this takes off, the other methods of retrieval could get flushed down the toilet.
 

Politicians playing the long game, literally

Before we get started with actual information, here’s a joke about politicians:

What do you call a lawyer with an IQ of 100? Your Honor.

What do you call a lawyer with an IQ of 50? Senator.

Politics is a dirty business, no doubt, so why do people do it? Is it for the prestige? Seems like everyone hates politicians, so it’s probably not that. Is it their selfless concern for the well-being of others? Probably not that either. Is it for the money? Most members of Congress have more corporate sponsors than a NASCAR driver, but we’re going to pass on that one as well.

Phi Nguyen/House of Representatives

Once again, science gives us the real answer: Longevity. Politicians live longer than the rest of us, and that longevity gap is getting wider.

Investigators looked at data from 11 industrialized countries, some of it going back to 1817, and found that politicians in the United States can expect to live about 7 years longer than the national average. The difference is around 3 years in Switzerland, 4.5 years in Germany, and 6 years in France.

“For almost all countries, politicians had similar rates of mortality to the general population in the late 19th and early 20th centuries. Throughout the 20th century, differences in mortality rates widened significantly across all countries, so that politicians had an increasing survival advantage over the general population,” they said in a written statement.

Income inequality could be a factor, but the longevity gains made by politicians, which started before the 1940s, predate the rise of their earnings relative to the rest of the population, which didn’t really get going until the 1980s, the investigators noted.

Whatever the reason, we have this closing thought regarding our long-lived lawmakers: What’s the difference between a politician and a snail? One is a slimy pest that leaves a trail everywhere. The other is a snail.
 

Land of the free, home of obesity

In the United States, it seems, people are becoming more comfortable with obesity. TikTok and Instagram trends often try to show the world that all sizes are beautiful. There’s also the growing popularity of the dad bod.

PxHere

America, it has been said, is the land of the free. We love our freedom, and we value our individualism. If an obese man orders three meals from McDonald’s just for himself, no one is going to stop him. Many Americans also have more access to the food they want at any given time, even while they are moving around a lot less because of their sedentary lifestyles.

According to a recent study cited by the New York Post, however, America is not the only country battling obesity. Egypt and Mexico, for example, also have men with higher BMIs who cherish their individualism and the right to eat what they want, Plamen Akaliyski, PhD, of University Carlos III of Madrid, and associates, said in Social Science & Medicine.

Women are not as likely to think the same way. “Men in particular think, ‘I’m an individual, don’t tell me what to do. I’m going to eat what I want,’ ” bariatric surgeon George A. Fielding, MD, said in the Post article. Dr. Fielding also noted that women are three times more likely than men to seek bariatric surgery.

Dr. Akaliyski and associates found that Asian countries such as Japan, Singapore, and South Korea – countries that value thrift, discipline, self control, and delaying gratification – have lower rates of obesity.

So yes, we can go to the drive through of a fast food restaurant whenever we want and order whatever we want, but can doesn’t always mean should.

Ain’t gastroenteritis grand?

The Grand Canyon is perhaps America’s greatest natural wonder. The mile-deep gorge of epic proportions, carved over eons by the Colorado River, elicits superlatives of the highest order from those seeing it for the first time. In the past few months, though, visitors to the Grand Canyon have been experiencing a rather more unpleasant sort of reaction: Involuntary bowel evacuation.

Since April, more than 150 river rafters and backcountry campers have fallen ill with bouts of acute gastroenteritis, likely caused by norovirus. Hey, a viral outbreak and our old friend SARS-CoV-2 isn’t involved! Hopefully it won’t get jealous. Whatever the culprit is, however, it got everywhere, as clusters of illness have popped up in unconnected parts of the park and some hikers have been restricted to a smaller portion of the park to avoid further disease spread. The majority of cases occurred in May, so it’s hoped that the outbreak is dying down, but the park remains on alert.

Jon Sullivan/Pixnio

Now, acute gastroenteritis is certainly an unpleasant disease, but it isn’t typically a life-threatening one. There are, however, a couple of unique factors complicating this outbreak. For one, the Grand Canyon is in Arizona (duh), which can get rather hot in the summer months. Expelling waste from both ends becomes rather more dangerous when the thermometer reads over a hundred degrees, and there have been reports of multiple helicopter rescues.

That’s pretty bad, but in a way, they’re the lucky ones. How can we explain this … see, when you visit the Grand Canyon, you’re expected to follow the general rules of Leave No Trace. That means several things, but essentially, if you bring it in, you have to bring it out. Yes, that includes the various consequences of an acute gastroenteritis attack.

Forget spooky campfire stories and hungry wildlife lurking in the night, because true horror is scraping your friend’s diarrhea off the walls of the Grand Canyon into a plastic bag and stuffing it into your backpack. Probably not the sublime one-on-one Grand Canyon experience that people are expecting.
 

Give us a pee! ... for stem cell retrieval

Getting cells for regenerative stem cell treatment has traditionally been painful and difficult – usually they are retrieved by surgical means from bone marrow or fat tissue – but there may be an easier way.

Just pee in a cup.

toeytoey2530/Thinkstock

Apparently, human urine contains stem cells with the potential to be used for regenerative effects. The magic ingredient? The enzyme telomerase, which “is essential for the self-renewal and potential of different types of stem cells” and is related to longevity, according to researchers at Wake Forest Institute for Regenerative Medicine.

They looked into how regenerative telomerase activity is for various capabilities beyond chromosomal stability, and whether these stem cells can become other kinds of cells for optimal tissue repair. Turns out they could, acting as a “distinct subpopulation” that has the ability not only to grow cells but also to morph into other cells, they said in a written statement.

Safety is also an issue. “Being able to use a patient’s own stem cells for therapy is considered advantageous because they do not induce immune responses or rejection,” said Anthony Atala, MD, a coauthor of the study published in Frontiers in Cell and Developmental Biology.

So less risk, easier retrieval, and great regenerative results. If this takes off, the other methods of retrieval could get flushed down the toilet.
 

Politicians playing the long game, literally

Before we get started with actual information, here’s a joke about politicians:

What do you call a lawyer with an IQ of 100? Your Honor.

What do you call a lawyer with an IQ of 50? Senator.

Politics is a dirty business, no doubt, so why do people do it? Is it for the prestige? Seems like everyone hates politicians, so it’s probably not that. Is it their selfless concern for the well-being of others? Probably not that either. Is it for the money? Most members of Congress have more corporate sponsors than a NASCAR driver, but we’re going to pass on that one as well.

Phi Nguyen/House of Representatives

Once again, science gives us the real answer: Longevity. Politicians live longer than the rest of us, and that longevity gap is getting wider.

Investigators looked at data from 11 industrialized countries, some of it going back to 1817, and found that politicians in the United States can expect to live about 7 years longer than the national average. The difference is around 3 years in Switzerland, 4.5 years in Germany, and 6 years in France.

“For almost all countries, politicians had similar rates of mortality to the general population in the late 19th and early 20th centuries. Throughout the 20th century, differences in mortality rates widened significantly across all countries, so that politicians had an increasing survival advantage over the general population,” they said in a written statement.

Income inequality could be a factor, but the longevity gains made by politicians, which started before the 1940s, predate the rise of their earnings relative to the rest of the population, which didn’t really get going until the 1980s, the investigators noted.

Whatever the reason, we have this closing thought regarding our long-lived lawmakers: What’s the difference between a politician and a snail? One is a slimy pest that leaves a trail everywhere. The other is a snail.
 

Land of the free, home of obesity

In the United States, it seems, people are becoming more comfortable with obesity. TikTok and Instagram trends often try to show the world that all sizes are beautiful. There’s also the growing popularity of the dad bod.

PxHere

America, it has been said, is the land of the free. We love our freedom, and we value our individualism. If an obese man orders three meals from McDonald’s just for himself, no one is going to stop him. Many Americans also have more access to the food they want at any given time, even while they are moving around a lot less because of their sedentary lifestyles.

According to a recent study cited by the New York Post, however, America is not the only country battling obesity. Egypt and Mexico, for example, also have men with higher BMIs who cherish their individualism and the right to eat what they want, Plamen Akaliyski, PhD, of University Carlos III of Madrid, and associates, said in Social Science & Medicine.

Women are not as likely to think the same way. “Men in particular think, ‘I’m an individual, don’t tell me what to do. I’m going to eat what I want,’ ” bariatric surgeon George A. Fielding, MD, said in the Post article. Dr. Fielding also noted that women are three times more likely than men to seek bariatric surgery.

Dr. Akaliyski and associates found that Asian countries such as Japan, Singapore, and South Korea – countries that value thrift, discipline, self control, and delaying gratification – have lower rates of obesity.

So yes, we can go to the drive through of a fast food restaurant whenever we want and order whatever we want, but can doesn’t always mean should.

Ain’t gastroenteritis grand?

The Grand Canyon is perhaps America’s greatest natural wonder. The mile-deep gorge of epic proportions, carved over eons by the Colorado River, elicits superlatives of the highest order from those seeing it for the first time. In the past few months, though, visitors to the Grand Canyon have been experiencing a rather more unpleasant sort of reaction: Involuntary bowel evacuation.

Since April, more than 150 river rafters and backcountry campers have fallen ill with bouts of acute gastroenteritis, likely caused by norovirus. Hey, a viral outbreak and our old friend SARS-CoV-2 isn’t involved! Hopefully it won’t get jealous. Whatever the culprit is, however, it got everywhere, as clusters of illness have popped up in unconnected parts of the park and some hikers have been restricted to a smaller portion of the park to avoid further disease spread. The majority of cases occurred in May, so it’s hoped that the outbreak is dying down, but the park remains on alert.

Jon Sullivan/Pixnio

Now, acute gastroenteritis is certainly an unpleasant disease, but it isn’t typically a life-threatening one. There are, however, a couple of unique factors complicating this outbreak. For one, the Grand Canyon is in Arizona (duh), which can get rather hot in the summer months. Expelling waste from both ends becomes rather more dangerous when the thermometer reads over a hundred degrees, and there have been reports of multiple helicopter rescues.

That’s pretty bad, but in a way, they’re the lucky ones. How can we explain this … see, when you visit the Grand Canyon, you’re expected to follow the general rules of Leave No Trace. That means several things, but essentially, if you bring it in, you have to bring it out. Yes, that includes the various consequences of an acute gastroenteritis attack.

Forget spooky campfire stories and hungry wildlife lurking in the night, because true horror is scraping your friend’s diarrhea off the walls of the Grand Canyon into a plastic bag and stuffing it into your backpack. Probably not the sublime one-on-one Grand Canyon experience that people are expecting.
 

Give us a pee! ... for stem cell retrieval

Getting cells for regenerative stem cell treatment has traditionally been painful and difficult – usually they are retrieved by surgical means from bone marrow or fat tissue – but there may be an easier way.

Just pee in a cup.

toeytoey2530/Thinkstock

Apparently, human urine contains stem cells with the potential to be used for regenerative effects. The magic ingredient? The enzyme telomerase, which “is essential for the self-renewal and potential of different types of stem cells” and is related to longevity, according to researchers at Wake Forest Institute for Regenerative Medicine.

They looked into how regenerative telomerase activity is for various capabilities beyond chromosomal stability, and whether these stem cells can become other kinds of cells for optimal tissue repair. Turns out they could, acting as a “distinct subpopulation” that has the ability not only to grow cells but also to morph into other cells, they said in a written statement.

Safety is also an issue. “Being able to use a patient’s own stem cells for therapy is considered advantageous because they do not induce immune responses or rejection,” said Anthony Atala, MD, a coauthor of the study published in Frontiers in Cell and Developmental Biology.

So less risk, easier retrieval, and great regenerative results. If this takes off, the other methods of retrieval could get flushed down the toilet.
 

Politicians playing the long game, literally

Before we get started with actual information, here’s a joke about politicians:

What do you call a lawyer with an IQ of 100? Your Honor.

What do you call a lawyer with an IQ of 50? Senator.

Politics is a dirty business, no doubt, so why do people do it? Is it for the prestige? Seems like everyone hates politicians, so it’s probably not that. Is it their selfless concern for the well-being of others? Probably not that either. Is it for the money? Most members of Congress have more corporate sponsors than a NASCAR driver, but we’re going to pass on that one as well.

Phi Nguyen/House of Representatives

Once again, science gives us the real answer: Longevity. Politicians live longer than the rest of us, and that longevity gap is getting wider.

Investigators looked at data from 11 industrialized countries, some of it going back to 1817, and found that politicians in the United States can expect to live about 7 years longer than the national average. The difference is around 3 years in Switzerland, 4.5 years in Germany, and 6 years in France.

“For almost all countries, politicians had similar rates of mortality to the general population in the late 19th and early 20th centuries. Throughout the 20th century, differences in mortality rates widened significantly across all countries, so that politicians had an increasing survival advantage over the general population,” they said in a written statement.

Income inequality could be a factor, but the longevity gains made by politicians, which started before the 1940s, predate the rise of their earnings relative to the rest of the population, which didn’t really get going until the 1980s, the investigators noted.

Whatever the reason, we have this closing thought regarding our long-lived lawmakers: What’s the difference between a politician and a snail? One is a slimy pest that leaves a trail everywhere. The other is a snail.
 

Land of the free, home of obesity

In the United States, it seems, people are becoming more comfortable with obesity. TikTok and Instagram trends often try to show the world that all sizes are beautiful. There’s also the growing popularity of the dad bod.

PxHere

America, it has been said, is the land of the free. We love our freedom, and we value our individualism. If an obese man orders three meals from McDonald’s just for himself, no one is going to stop him. Many Americans also have more access to the food they want at any given time, even while they are moving around a lot less because of their sedentary lifestyles.

According to a recent study cited by the New York Post, however, America is not the only country battling obesity. Egypt and Mexico, for example, also have men with higher BMIs who cherish their individualism and the right to eat what they want, Plamen Akaliyski, PhD, of University Carlos III of Madrid, and associates, said in Social Science & Medicine.

Women are not as likely to think the same way. “Men in particular think, ‘I’m an individual, don’t tell me what to do. I’m going to eat what I want,’ ” bariatric surgeon George A. Fielding, MD, said in the Post article. Dr. Fielding also noted that women are three times more likely than men to seek bariatric surgery.

Dr. Akaliyski and associates found that Asian countries such as Japan, Singapore, and South Korea – countries that value thrift, discipline, self control, and delaying gratification – have lower rates of obesity.

So yes, we can go to the drive through of a fast food restaurant whenever we want and order whatever we want, but can doesn’t always mean should.

A new tool can help streamline diagnosis and treatment of migraine in the primary care setting, research suggests.

Early results from a small pilot study showed that the tool, essentially a medical record “best-practice alert,” reduces specialist referrals and MRI studies.

The idea behind the tool is to give primary care physicians “fingertip access” to prompts on patients’ electronic health record, leading to best migraine management and treatment, said coinvestigator, Scott M. Friedenberg, MD, vice chair of clinical practice, Geisinger Medical Center, Danville, Pa.

When clinicians enter a headache diagnosis into a patient’s EHR, a pop-up asks a handful of questions and “prompts them with the right medications so if they just click a button, they can order the medications straight away,” Dr. Friedenberg said.

The findings were presented at the annual meeting of the American Headache Society.
 

Fewer referrals, MRI testing

Researchers reviewed charts for 693 general neurology referrals. About 20% of the patients were referred for headache. In about 80% of these cases, the final diagnosis was migraine and/or chronic daily headache.

The physicians had documented criteria for identifying migraine, such as sensitivity to light, nausea, and missed social activity or work, in fewer than 1% of cases. There’s roughly an 80% chance that if a headache meets two of these three criteria, it is a migraine, Dr. Friedenberg noted.

About 60% of the participants with headache were referred with no treatment trial. About 20% were referred after having tried two medicines, and 30% were referred after trying one medicine.

“In many cases, we’re being asked to evaluate people with primary headache or uncomplicated headache that has not been treated,” said Dr. Friedenberg.

The investigators developed the tool, and its most recent iteration was tested by 10 physicians at two sites for 3 months. These doctors did not receive education on headache, they were just taught how to use the tool.

Results showed that referrals for neurology consults dropped 77% and MRI ordering dropped 35% after use of the tool. This translated into a savings of $192,000.

However, using the tool didn’t significantly affect prescribing habits of the physicians.
 

Migraine frequently undertreated

“When you drill it down, the only thing that changed were medications they were comfortable with, so they increased steroids and nonsteroidal prescribing, but preventives didn’t change, narcotics didn’t change, and CGRP [calcitonin gene-related peptide] inhibitors didn’t change,” Dr. Friedenberg said.

Although believing patients are “not bad enough to treat” might help explain why clinicians did not change prescribing habits, the reality is that many patients have migraine and should be treated, he added.

Dr. Friedenberg pointed out that previous research suggests that 60% or more of patients with a primary headache or migraine are undertreated.

The tool should increase awareness about, and comfort level with, diagnosing and treating migraine among primary care doctors, he noted. “We hope it will make it easier for them to do the right thing and have neurology as a readily available partner,” said Dr. Friedenberg.

“Primary care doctors are incredibly busy and incredibly pressured, and anything you can do to help facilitate that is a positive,” he added.

The researchers now plan to train pharmacists to comanage headache along with primary care doctors, as is done, for example, for patients with diabetes. This should result in a reduction in physician burden, said Dr. Friedenberg.

The next step is to conduct a larger study at the 38 sites in the Geisinger health complex. Half the sites will use the new tool, and the other half will continue to use their current headache management process.

“The study will compare everything from MRI ordering to neurology referrals and prescribing, how often patients go to the emergency department, how often they have a clinic visit, whether the provider is satisfied with the tool, and if the patient’s headaches are getting better,” Dr. Friedenberg said.
 

Lessons for clinical practice

Jessica Ailani, MD, director at MedStar Georgetown Headache Center and associate professor in the department of neurology at Georgetown University, cochaired the session in which the research was presented and called the project “really fantastic.”

The study offers “many lessons” for clinical practice and showed that the tool was effective in improving diagnosis of migraine, said Dr. Ailani, who is also secretary of the American Headache Society.

“There’s a long wait time to see specialists, and most migraine can be diagnosed and basic management can be done by primary care physicians,” she said.

“The next step would be to work on a way to improve prescriptions of migraine-specific treatments,” she added.

Dr. Ailani noted that the AHS would be keen to find ways to engage in “collaborative work” with the investigators.

The investigators and Dr. Ailani reported no relevant financial relationships.

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

A new tool can help streamline diagnosis and treatment of migraine in the primary care setting, research suggests.

Early results from a small pilot study showed that the tool, essentially a medical record “best-practice alert,” reduces specialist referrals and MRI studies.

The idea behind the tool is to give primary care physicians “fingertip access” to prompts on patients’ electronic health record, leading to best migraine management and treatment, said coinvestigator, Scott M. Friedenberg, MD, vice chair of clinical practice, Geisinger Medical Center, Danville, Pa.

When clinicians enter a headache diagnosis into a patient’s EHR, a pop-up asks a handful of questions and “prompts them with the right medications so if they just click a button, they can order the medications straight away,” Dr. Friedenberg said.

The findings were presented at the annual meeting of the American Headache Society.
 

Fewer referrals, MRI testing

Researchers reviewed charts for 693 general neurology referrals. About 20% of the patients were referred for headache. In about 80% of these cases, the final diagnosis was migraine and/or chronic daily headache.

The physicians had documented criteria for identifying migraine, such as sensitivity to light, nausea, and missed social activity or work, in fewer than 1% of cases. There’s roughly an 80% chance that if a headache meets two of these three criteria, it is a migraine, Dr. Friedenberg noted.

About 60% of the participants with headache were referred with no treatment trial. About 20% were referred after having tried two medicines, and 30% were referred after trying one medicine.

“In many cases, we’re being asked to evaluate people with primary headache or uncomplicated headache that has not been treated,” said Dr. Friedenberg.

The investigators developed the tool, and its most recent iteration was tested by 10 physicians at two sites for 3 months. These doctors did not receive education on headache, they were just taught how to use the tool.

Results showed that referrals for neurology consults dropped 77% and MRI ordering dropped 35% after use of the tool. This translated into a savings of $192,000.

However, using the tool didn’t significantly affect prescribing habits of the physicians.
 

Migraine frequently undertreated

“When you drill it down, the only thing that changed were medications they were comfortable with, so they increased steroids and nonsteroidal prescribing, but preventives didn’t change, narcotics didn’t change, and CGRP [calcitonin gene-related peptide] inhibitors didn’t change,” Dr. Friedenberg said.

Although believing patients are “not bad enough to treat” might help explain why clinicians did not change prescribing habits, the reality is that many patients have migraine and should be treated, he added.

Dr. Friedenberg pointed out that previous research suggests that 60% or more of patients with a primary headache or migraine are undertreated.

The tool should increase awareness about, and comfort level with, diagnosing and treating migraine among primary care doctors, he noted. “We hope it will make it easier for them to do the right thing and have neurology as a readily available partner,” said Dr. Friedenberg.

“Primary care doctors are incredibly busy and incredibly pressured, and anything you can do to help facilitate that is a positive,” he added.

The researchers now plan to train pharmacists to comanage headache along with primary care doctors, as is done, for example, for patients with diabetes. This should result in a reduction in physician burden, said Dr. Friedenberg.

The next step is to conduct a larger study at the 38 sites in the Geisinger health complex. Half the sites will use the new tool, and the other half will continue to use their current headache management process.

“The study will compare everything from MRI ordering to neurology referrals and prescribing, how often patients go to the emergency department, how often they have a clinic visit, whether the provider is satisfied with the tool, and if the patient’s headaches are getting better,” Dr. Friedenberg said.
 

Lessons for clinical practice

Jessica Ailani, MD, director at MedStar Georgetown Headache Center and associate professor in the department of neurology at Georgetown University, cochaired the session in which the research was presented and called the project “really fantastic.”

The study offers “many lessons” for clinical practice and showed that the tool was effective in improving diagnosis of migraine, said Dr. Ailani, who is also secretary of the American Headache Society.

“There’s a long wait time to see specialists, and most migraine can be diagnosed and basic management can be done by primary care physicians,” she said.

“The next step would be to work on a way to improve prescriptions of migraine-specific treatments,” she added.

Dr. Ailani noted that the AHS would be keen to find ways to engage in “collaborative work” with the investigators.

The investigators and Dr. Ailani reported no relevant financial relationships.

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

A new tool can help streamline diagnosis and treatment of migraine in the primary care setting, research suggests.

Early results from a small pilot study showed that the tool, essentially a medical record “best-practice alert,” reduces specialist referrals and MRI studies.

The idea behind the tool is to give primary care physicians “fingertip access” to prompts on patients’ electronic health record, leading to best migraine management and treatment, said coinvestigator, Scott M. Friedenberg, MD, vice chair of clinical practice, Geisinger Medical Center, Danville, Pa.

When clinicians enter a headache diagnosis into a patient’s EHR, a pop-up asks a handful of questions and “prompts them with the right medications so if they just click a button, they can order the medications straight away,” Dr. Friedenberg said.

The findings were presented at the annual meeting of the American Headache Society.
 

Fewer referrals, MRI testing

Researchers reviewed charts for 693 general neurology referrals. About 20% of the patients were referred for headache. In about 80% of these cases, the final diagnosis was migraine and/or chronic daily headache.

The physicians had documented criteria for identifying migraine, such as sensitivity to light, nausea, and missed social activity or work, in fewer than 1% of cases. There’s roughly an 80% chance that if a headache meets two of these three criteria, it is a migraine, Dr. Friedenberg noted.

About 60% of the participants with headache were referred with no treatment trial. About 20% were referred after having tried two medicines, and 30% were referred after trying one medicine.

“In many cases, we’re being asked to evaluate people with primary headache or uncomplicated headache that has not been treated,” said Dr. Friedenberg.

The investigators developed the tool, and its most recent iteration was tested by 10 physicians at two sites for 3 months. These doctors did not receive education on headache, they were just taught how to use the tool.

Results showed that referrals for neurology consults dropped 77% and MRI ordering dropped 35% after use of the tool. This translated into a savings of $192,000.

However, using the tool didn’t significantly affect prescribing habits of the physicians.
 

Migraine frequently undertreated

“When you drill it down, the only thing that changed were medications they were comfortable with, so they increased steroids and nonsteroidal prescribing, but preventives didn’t change, narcotics didn’t change, and CGRP [calcitonin gene-related peptide] inhibitors didn’t change,” Dr. Friedenberg said.

Although believing patients are “not bad enough to treat” might help explain why clinicians did not change prescribing habits, the reality is that many patients have migraine and should be treated, he added.

Dr. Friedenberg pointed out that previous research suggests that 60% or more of patients with a primary headache or migraine are undertreated.

The tool should increase awareness about, and comfort level with, diagnosing and treating migraine among primary care doctors, he noted. “We hope it will make it easier for them to do the right thing and have neurology as a readily available partner,” said Dr. Friedenberg.

“Primary care doctors are incredibly busy and incredibly pressured, and anything you can do to help facilitate that is a positive,” he added.

The researchers now plan to train pharmacists to comanage headache along with primary care doctors, as is done, for example, for patients with diabetes. This should result in a reduction in physician burden, said Dr. Friedenberg.

The next step is to conduct a larger study at the 38 sites in the Geisinger health complex. Half the sites will use the new tool, and the other half will continue to use their current headache management process.

“The study will compare everything from MRI ordering to neurology referrals and prescribing, how often patients go to the emergency department, how often they have a clinic visit, whether the provider is satisfied with the tool, and if the patient’s headaches are getting better,” Dr. Friedenberg said.
 

Lessons for clinical practice

Jessica Ailani, MD, director at MedStar Georgetown Headache Center and associate professor in the department of neurology at Georgetown University, cochaired the session in which the research was presented and called the project “really fantastic.”

The study offers “many lessons” for clinical practice and showed that the tool was effective in improving diagnosis of migraine, said Dr. Ailani, who is also secretary of the American Headache Society.

“There’s a long wait time to see specialists, and most migraine can be diagnosed and basic management can be done by primary care physicians,” she said.

“The next step would be to work on a way to improve prescriptions of migraine-specific treatments,” she added.

Dr. Ailani noted that the AHS would be keen to find ways to engage in “collaborative work” with the investigators.

The investigators and Dr. Ailani reported no relevant financial relationships.

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

Dr Robert Shin, from Georgetown University Hospital, highlights key presentations in disease-modifying therapy for multiple sclerosis (MS) presented at the 2022 annual meeting of the Consortium of Multiple Sclerosis Centers. 

First, Dr Shin discusses BTK inhibitors as an emerging treatment for multiple forms of MS, including progressive MS. 

Next, he shares preliminary results from the DISCOMS trial, which studied the safety of discontinuing vs continuing disease-modifying therapy in older MS patients. Although discontinuation was associated with more disease, Dr Shin suggests that a rigorous review of the data reveals no significant difference between the two groups. He comments that more data are needed. 

Dr Shin closes his commentary by highlighting a presentation focused on COVID and MS patients, specifically covering immune response to the COVID-19 vaccine in people being treated for MS.  

--

Professor, Department of Neurology, MedStar Georgetown University Hospital; Director, Georgetown MS and Neuroimmunology Center, Washington, DC 

Robert Shin, MD, has disclosed the following relevant financial relationships: 

Serve(d) as a director, officer, partner, employee, advisor, consultant, or trustee for: Alexion; Biogen; Bristol Myers Squibb; EMD Serono; Genentech; Horizon; Novartis; Roche; Sanofi Genzyme 

Serve(d) as a speaker or a member of a speakers bureau for: Alexion; Biogen; Bristol Myers Squibb; EMD Serono; Genentech; Horizon; Novartis; Roche; Sanofi Genzyme 

Dr Robert Shin, from Georgetown University Hospital, highlights key presentations in disease-modifying therapy for multiple sclerosis (MS) presented at the 2022 annual meeting of the Consortium of Multiple Sclerosis Centers. 

First, Dr Shin discusses BTK inhibitors as an emerging treatment for multiple forms of MS, including progressive MS. 

Next, he shares preliminary results from the DISCOMS trial, which studied the safety of discontinuing vs continuing disease-modifying therapy in older MS patients. Although discontinuation was associated with more disease, Dr Shin suggests that a rigorous review of the data reveals no significant difference between the two groups. He comments that more data are needed. 

Dr Shin closes his commentary by highlighting a presentation focused on COVID and MS patients, specifically covering immune response to the COVID-19 vaccine in people being treated for MS.  

--

Professor, Department of Neurology, MedStar Georgetown University Hospital; Director, Georgetown MS and Neuroimmunology Center, Washington, DC 

Robert Shin, MD, has disclosed the following relevant financial relationships: 

Serve(d) as a director, officer, partner, employee, advisor, consultant, or trustee for: Alexion; Biogen; Bristol Myers Squibb; EMD Serono; Genentech; Horizon; Novartis; Roche; Sanofi Genzyme 

Serve(d) as a speaker or a member of a speakers bureau for: Alexion; Biogen; Bristol Myers Squibb; EMD Serono; Genentech; Horizon; Novartis; Roche; Sanofi Genzyme 

Dr Robert Shin, from Georgetown University Hospital, highlights key presentations in disease-modifying therapy for multiple sclerosis (MS) presented at the 2022 annual meeting of the Consortium of Multiple Sclerosis Centers. 

First, Dr Shin discusses BTK inhibitors as an emerging treatment for multiple forms of MS, including progressive MS. 

Next, he shares preliminary results from the DISCOMS trial, which studied the safety of discontinuing vs continuing disease-modifying therapy in older MS patients. Although discontinuation was associated with more disease, Dr Shin suggests that a rigorous review of the data reveals no significant difference between the two groups. He comments that more data are needed. 

Dr Shin closes his commentary by highlighting a presentation focused on COVID and MS patients, specifically covering immune response to the COVID-19 vaccine in people being treated for MS.  

--

Professor, Department of Neurology, MedStar Georgetown University Hospital; Director, Georgetown MS and Neuroimmunology Center, Washington, DC 

Robert Shin, MD, has disclosed the following relevant financial relationships: 

Serve(d) as a director, officer, partner, employee, advisor, consultant, or trustee for: Alexion; Biogen; Bristol Myers Squibb; EMD Serono; Genentech; Horizon; Novartis; Roche; Sanofi Genzyme 

Serve(d) as a speaker or a member of a speakers bureau for: Alexion; Biogen; Bristol Myers Squibb; EMD Serono; Genentech; Horizon; Novartis; Roche; Sanofi Genzyme