PHOENIX – When Jeffrey Dover, MD, addressed audience members gathered for a session on cutting-edge technologies at the annual conference of the American Society for Laser Medicine and Surgery, he reflected on a conversation he had with R. Rox Anderson, MD, almost 40 years ago, about eventually finding a cure for acne.

“Despite the fact that we have over-the-counter therapies, prescription therapies, and all kinds of devices available to treat acne, there are still barriers to care that get in the way of treatment,” said Dr. Dover, director of SkinCare Physicians in Chestnut Hill, Mass. “If we had a device based on innovative light science that could meet the needs of the acne patient to get rid of these barriers, wouldn’t that be something wonderful?”

Dr. Jeffrey Dover

The answer to this question, he said, is now “yes,” because of advances in lasers that target sebaceous glands.

In a seminal paper published in 2012, Fernanda H. Sakamoto, MD, PhD, Dr. Anderson, and colleagues demonstrated the potential for a free electron laser to target sebaceous glands . Following several years of refinement, there are now two 1,726-nm laser devices – the AviClear and the Accure Laser System – cleared by the Food and Drug Administration for the treatment of mild to severe acne, which have “very impressive results,” Dr. Dover said.

“With the 1,726-nm laser, there is some selective absorption in sebum in skin, which beats out absorption in the other chromophores,” he said. “But it’s not a big difference like it is, for example, for pulsed-dye lasers and vascular targets. ... This means that the therapeutic window is relatively small and protecting the rest of the epidermis and dermis is crucial to be able to target these lesions or the sebaceous gland without unnecessary damage. If we can protect the epidermis and heat just the sebaceous glands, we should be able to get Accutane-like results if we get durability [by] shrinking sebaceous glands.”

Effective cooling, whether contact cooling, bulk cooling, or air cooling, is crucial to success, he continued. “It’s got to be robust and highly specific to protect the skin, so you don’t end up with side effects that are worse than the disease.”

The AviClear laser delivers seven 3-mm spots, which takes into account the thermal relaxation times of the sebaceous glands. The algorithm delivers a treatment imprint at roughly 0.3 Hz and a 1.5-mm depth of penetration, and the device relies on contact cooling. In pivotal data submitted to the FDA, 104 individuals with moderate to severe acne received three treatments with the AviClear 1 month apart, with follow-up at 1, 3, 6, and 12 months post treatment. They had no other treatment regimens, and the primary endpoint was the percentage of patients who achieved a 50% reduction in inflammatory lesion count 3 months after the final treatment. The secondary endpoint was an Investigator’s Global Assessment (IGA) improvement of 2 or greater.

Dr. Dover, who helped design the study, said that, at 3 months, 80% of those treated achieved a 50% or greater reduction in inflammatory lesion count (P < .001). As for secondary endpoints, 36% of individuals were assessed as having clear or almost clear skin; 47% achieved a 2-point or greater improvement in IGA score, compared with baseline, and 87% achieved a 1-point or greater improvement in IGA score, compared with baseline. By 6 months, 88% of individuals achieved a 50% or greater reduction in inflammatory lesion count; this improved to 92% by 12 months (P < .001).

“All of these procedures were done with no topical anesthetic, no intralesional anesthetic, and they tolerated these quite well,” he said. “There was no down time that required medical intervention after the treatments. All posttreatment erythema and swelling resolved quickly,” and 75% of the patients were “very satisfied” with the treatments.

The Accure Laser System features a proprietary technology that precisely controls thermal gradient depth. “So instead of guessing whether you are delivering the correct amount of heat, it actually tells you,” said Dr. Dover, a past president of the ASLMS and the American Society for Dermatologic Surgery. “It correlates surface and at-depth temperatures, and there’s an infrared camera for real-time accurate temperature monitoring.” The device features highly controlled air cooling and a pulsing pattern that ensures treatment of sebaceous glands of all sizes and at all depths. The clinical end marker is peak epidermal temperature.

In a study supported by Accure, the manufacturer, researchers evaluated the efficacy of the Accure Laser System in 35 subjects with types I to VI skin, who received four monthly treatments 30-45 minutes each, and were followed 12, 26, 39, and 52 weeks following their last treatment. To date, data out to 52 weeks is available for 17 study participants. According to Dr. Dover, the researchers found 80% clearance at 12 weeks following the last treatment, with continued improvement at 52 weeks. One hundred percent of subjects responded. Side effects included erythema, edema, crusting, blisters, and inflammatory papules. “None of these were medically significant,” he said.

As dermatologists begin to incorporate the AviClear and Accure devices into their practices, Dr. Dover said that he is reminded of the conversation he had some 40 years ago with Dr. Anderson about finding a cure for acne, and he feels a bit awestruck. “These 1,726-nm lasers are effective for treating acne. I personally think they are going to revolutionize the way we treat at least some of our patients with acne. They may both be effective for treating facial acne scars. Time will tell. Further study of both scarring and acne are needed to fully categorize the benefit and to optimize treatments.”

To date no direct clinical comparisons have been made between the AviClear and Accure devices.

Dr. Dover reported that he is a consultant for Cutera, the manufacturer for AviClear. He also performs research for the company.





 

PHOENIX – When Jeffrey Dover, MD, addressed audience members gathered for a session on cutting-edge technologies at the annual conference of the American Society for Laser Medicine and Surgery, he reflected on a conversation he had with R. Rox Anderson, MD, almost 40 years ago, about eventually finding a cure for acne.

“Despite the fact that we have over-the-counter therapies, prescription therapies, and all kinds of devices available to treat acne, there are still barriers to care that get in the way of treatment,” said Dr. Dover, director of SkinCare Physicians in Chestnut Hill, Mass. “If we had a device based on innovative light science that could meet the needs of the acne patient to get rid of these barriers, wouldn’t that be something wonderful?”

Dr. Jeffrey Dover

The answer to this question, he said, is now “yes,” because of advances in lasers that target sebaceous glands.

In a seminal paper published in 2012, Fernanda H. Sakamoto, MD, PhD, Dr. Anderson, and colleagues demonstrated the potential for a free electron laser to target sebaceous glands . Following several years of refinement, there are now two 1,726-nm laser devices – the AviClear and the Accure Laser System – cleared by the Food and Drug Administration for the treatment of mild to severe acne, which have “very impressive results,” Dr. Dover said.

“With the 1,726-nm laser, there is some selective absorption in sebum in skin, which beats out absorption in the other chromophores,” he said. “But it’s not a big difference like it is, for example, for pulsed-dye lasers and vascular targets. ... This means that the therapeutic window is relatively small and protecting the rest of the epidermis and dermis is crucial to be able to target these lesions or the sebaceous gland without unnecessary damage. If we can protect the epidermis and heat just the sebaceous glands, we should be able to get Accutane-like results if we get durability [by] shrinking sebaceous glands.”

Effective cooling, whether contact cooling, bulk cooling, or air cooling, is crucial to success, he continued. “It’s got to be robust and highly specific to protect the skin, so you don’t end up with side effects that are worse than the disease.”

The AviClear laser delivers seven 3-mm spots, which takes into account the thermal relaxation times of the sebaceous glands. The algorithm delivers a treatment imprint at roughly 0.3 Hz and a 1.5-mm depth of penetration, and the device relies on contact cooling. In pivotal data submitted to the FDA, 104 individuals with moderate to severe acne received three treatments with the AviClear 1 month apart, with follow-up at 1, 3, 6, and 12 months post treatment. They had no other treatment regimens, and the primary endpoint was the percentage of patients who achieved a 50% reduction in inflammatory lesion count 3 months after the final treatment. The secondary endpoint was an Investigator’s Global Assessment (IGA) improvement of 2 or greater.

Dr. Dover, who helped design the study, said that, at 3 months, 80% of those treated achieved a 50% or greater reduction in inflammatory lesion count (P < .001). As for secondary endpoints, 36% of individuals were assessed as having clear or almost clear skin; 47% achieved a 2-point or greater improvement in IGA score, compared with baseline, and 87% achieved a 1-point or greater improvement in IGA score, compared with baseline. By 6 months, 88% of individuals achieved a 50% or greater reduction in inflammatory lesion count; this improved to 92% by 12 months (P < .001).

“All of these procedures were done with no topical anesthetic, no intralesional anesthetic, and they tolerated these quite well,” he said. “There was no down time that required medical intervention after the treatments. All posttreatment erythema and swelling resolved quickly,” and 75% of the patients were “very satisfied” with the treatments.

The Accure Laser System features a proprietary technology that precisely controls thermal gradient depth. “So instead of guessing whether you are delivering the correct amount of heat, it actually tells you,” said Dr. Dover, a past president of the ASLMS and the American Society for Dermatologic Surgery. “It correlates surface and at-depth temperatures, and there’s an infrared camera for real-time accurate temperature monitoring.” The device features highly controlled air cooling and a pulsing pattern that ensures treatment of sebaceous glands of all sizes and at all depths. The clinical end marker is peak epidermal temperature.

In a study supported by Accure, the manufacturer, researchers evaluated the efficacy of the Accure Laser System in 35 subjects with types I to VI skin, who received four monthly treatments 30-45 minutes each, and were followed 12, 26, 39, and 52 weeks following their last treatment. To date, data out to 52 weeks is available for 17 study participants. According to Dr. Dover, the researchers found 80% clearance at 12 weeks following the last treatment, with continued improvement at 52 weeks. One hundred percent of subjects responded. Side effects included erythema, edema, crusting, blisters, and inflammatory papules. “None of these were medically significant,” he said.

As dermatologists begin to incorporate the AviClear and Accure devices into their practices, Dr. Dover said that he is reminded of the conversation he had some 40 years ago with Dr. Anderson about finding a cure for acne, and he feels a bit awestruck. “These 1,726-nm lasers are effective for treating acne. I personally think they are going to revolutionize the way we treat at least some of our patients with acne. They may both be effective for treating facial acne scars. Time will tell. Further study of both scarring and acne are needed to fully categorize the benefit and to optimize treatments.”

To date no direct clinical comparisons have been made between the AviClear and Accure devices.

Dr. Dover reported that he is a consultant for Cutera, the manufacturer for AviClear. He also performs research for the company.





 

PHOENIX – When Jeffrey Dover, MD, addressed audience members gathered for a session on cutting-edge technologies at the annual conference of the American Society for Laser Medicine and Surgery, he reflected on a conversation he had with R. Rox Anderson, MD, almost 40 years ago, about eventually finding a cure for acne.

“Despite the fact that we have over-the-counter therapies, prescription therapies, and all kinds of devices available to treat acne, there are still barriers to care that get in the way of treatment,” said Dr. Dover, director of SkinCare Physicians in Chestnut Hill, Mass. “If we had a device based on innovative light science that could meet the needs of the acne patient to get rid of these barriers, wouldn’t that be something wonderful?”

Dr. Jeffrey Dover

The answer to this question, he said, is now “yes,” because of advances in lasers that target sebaceous glands.

In a seminal paper published in 2012, Fernanda H. Sakamoto, MD, PhD, Dr. Anderson, and colleagues demonstrated the potential for a free electron laser to target sebaceous glands . Following several years of refinement, there are now two 1,726-nm laser devices – the AviClear and the Accure Laser System – cleared by the Food and Drug Administration for the treatment of mild to severe acne, which have “very impressive results,” Dr. Dover said.

“With the 1,726-nm laser, there is some selective absorption in sebum in skin, which beats out absorption in the other chromophores,” he said. “But it’s not a big difference like it is, for example, for pulsed-dye lasers and vascular targets. ... This means that the therapeutic window is relatively small and protecting the rest of the epidermis and dermis is crucial to be able to target these lesions or the sebaceous gland without unnecessary damage. If we can protect the epidermis and heat just the sebaceous glands, we should be able to get Accutane-like results if we get durability [by] shrinking sebaceous glands.”

Effective cooling, whether contact cooling, bulk cooling, or air cooling, is crucial to success, he continued. “It’s got to be robust and highly specific to protect the skin, so you don’t end up with side effects that are worse than the disease.”

The AviClear laser delivers seven 3-mm spots, which takes into account the thermal relaxation times of the sebaceous glands. The algorithm delivers a treatment imprint at roughly 0.3 Hz and a 1.5-mm depth of penetration, and the device relies on contact cooling. In pivotal data submitted to the FDA, 104 individuals with moderate to severe acne received three treatments with the AviClear 1 month apart, with follow-up at 1, 3, 6, and 12 months post treatment. They had no other treatment regimens, and the primary endpoint was the percentage of patients who achieved a 50% reduction in inflammatory lesion count 3 months after the final treatment. The secondary endpoint was an Investigator’s Global Assessment (IGA) improvement of 2 or greater.

Dr. Dover, who helped design the study, said that, at 3 months, 80% of those treated achieved a 50% or greater reduction in inflammatory lesion count (P < .001). As for secondary endpoints, 36% of individuals were assessed as having clear or almost clear skin; 47% achieved a 2-point or greater improvement in IGA score, compared with baseline, and 87% achieved a 1-point or greater improvement in IGA score, compared with baseline. By 6 months, 88% of individuals achieved a 50% or greater reduction in inflammatory lesion count; this improved to 92% by 12 months (P < .001).

“All of these procedures were done with no topical anesthetic, no intralesional anesthetic, and they tolerated these quite well,” he said. “There was no down time that required medical intervention after the treatments. All posttreatment erythema and swelling resolved quickly,” and 75% of the patients were “very satisfied” with the treatments.

The Accure Laser System features a proprietary technology that precisely controls thermal gradient depth. “So instead of guessing whether you are delivering the correct amount of heat, it actually tells you,” said Dr. Dover, a past president of the ASLMS and the American Society for Dermatologic Surgery. “It correlates surface and at-depth temperatures, and there’s an infrared camera for real-time accurate temperature monitoring.” The device features highly controlled air cooling and a pulsing pattern that ensures treatment of sebaceous glands of all sizes and at all depths. The clinical end marker is peak epidermal temperature.

In a study supported by Accure, the manufacturer, researchers evaluated the efficacy of the Accure Laser System in 35 subjects with types I to VI skin, who received four monthly treatments 30-45 minutes each, and were followed 12, 26, 39, and 52 weeks following their last treatment. To date, data out to 52 weeks is available for 17 study participants. According to Dr. Dover, the researchers found 80% clearance at 12 weeks following the last treatment, with continued improvement at 52 weeks. One hundred percent of subjects responded. Side effects included erythema, edema, crusting, blisters, and inflammatory papules. “None of these were medically significant,” he said.

As dermatologists begin to incorporate the AviClear and Accure devices into their practices, Dr. Dover said that he is reminded of the conversation he had some 40 years ago with Dr. Anderson about finding a cure for acne, and he feels a bit awestruck. “These 1,726-nm lasers are effective for treating acne. I personally think they are going to revolutionize the way we treat at least some of our patients with acne. They may both be effective for treating facial acne scars. Time will tell. Further study of both scarring and acne are needed to fully categorize the benefit and to optimize treatments.”

To date no direct clinical comparisons have been made between the AviClear and Accure devices.

Dr. Dover reported that he is a consultant for Cutera, the manufacturer for AviClear. He also performs research for the company.





 

WASHINGTON – A nonpharmacologic, interdisciplinary program significantly improved chronic pain in children and the quality of life for their families, based on data from 115 individuals.

Up to 40% of children experience chronic pain that affects their physical, psychosocial, and educational functioning, said Jessica Campanile, BA, a medical student at the University of Pennsylvania, Philadelphia, in a presentation at the Pediatric Academic Societies annual meeting.

Although interdisciplinary pediatric pain rehabilitation programs have shown positive outcomes, very few use only nonpharmacologic treatments, said Ms. Campanile. In addition, few studies have explored the effects of a hospital-based program on the patients and their families.

Ms. Campanile and colleagues conducted a retrospective cohort study of participants in an outpatient pain rehabilitation program at the Children’s Hospital of Philadelphia between April 2016 and December 2019. Patients were evaluated by a pediatric rheumatologist, psychologist, and physical and occupational therapists.

Patients engaged in 2-3 hours of physical therapy (PT) and 2-3 hours of occupational therapy (OT) in a 1:1 ratio at least 5 days a week. Physical activities included stepping into and out of a tub, carrying laundry, and desensitizing to allodynia as needed. Participants also received individual and group cognitive-behavior therapy interventions from psychologists, and psychological support during PT and OT sessions if needed. Parents/caregivers were invited to separate individual and group therapy sessions as part of the program. The median age at admission to the program was 15 years, and 79% of the participants were female. Patients participated the program for a median of 17 days, and 87% were outpatients who came to the hospital for the program.

Pain was assessed based on the 0-10 verbal pain intensity scale, energy was assessed on a scale of 0-100, and functional disability was assessed on a scale of 0-60, with higher scores indicating more pain, more energy, and more self-perceived disability, respectively.

Overall, scores on measures of pain, disability, allodynia, and energy improved significantly from baseline to discharge from the program. Verbal pain intensity scores decreased on average from 7 to 5, disability scores decreased from 26 to 9, the proportion of patients reporting allodynia decreased from 86% to 61%, and the energy level score increased from 70 to 77. The trend continued at the first follow-up visit, conducted 2-3 months after discharge from the program. Notably, pain intensity further decreased from a median of 5 at program completion to a median of 2 at the first follow-up, Ms. Campanile said. Improvements in allodynia also were sustained at the first follow-up.

Quality of life measures related to physical, emotional, social, and cognitive function also improved significantly from baseline to completion of the program.

In addition, scores on a quality of life family impact survey improved significantly; in particular, parent health-related quality of life scores (Parent HRQoL) improved from 60 at baseline to 71 at the end of the program on a scale of 0 to 100. The study findings were limited by several factors including the relatively short duration and use of a convenience sample from a retrospective cohort, with data limited to electronic health records, Ms. Campanile said. The study also was not powered to examine differential treatments based on psychiatric conditions, and any psychiatric conditions were based on self-reports.

However, the results support the value of a nonpharmacologic interdisciplinary program as “a robust treatment for youth with chronic idiopathic pain, for both patients and the family unit,” she said.

“This study also supports the need for and benefit of additional counseling for patients and their caregivers prior to and during enrollment in a pain rehabilitation program,” she concluded.
 

Study supports effectiveness of drug-free pain management

“The management of pain in any age group can be challenging, especially with current concerns for opioid dependence and abuse,” Cathy Haut, DNP, CPNP-AC, CPNP-PC, a pediatric nurse practitioner in Rehoboth Beach, Del., said in an interview.

“Chronic pain affects daily life for all populations, but for children, adolescents, and their families, it can have a long-lasting impact on growth and development, psychosocial and physical well-being,” Dr. Haut said. “Determining and testing nonpharmacologic alternative methods of pain control are extremely important.”

Given the debilitating effects of chronic pain, and the potential side effects and dependence that have been associated with use of pharmacologic modes of pain control, unique and creative solutions have begun to emerge and need further attention and study, she said.

However, “despite published research supporting the use of alternative and complementary approaches to pain control in children and adolescents, nonpharmacologic, collaborative, interprofessional approaches to pain control have not been widely shared in the literature,” she said.

“Barriers to this type of program include first and foremost a potential lack of financial and workforce-related resources,” Dr. Haut said. “Patient and family attendance at frequent health visits, daily or even every other day, may also hinder success, but opportunities for telehealth and family training to learn physical and occupational skills within this type of program may be beginning solutions.”

Additional research should be conducted at multiple children’s hospitals, with a larger number of children and adolescents at varying ages, with pain related to different diagnoses, and with the inclusion of collaborative methodology, said Dr. Haut. “The current study had some limitations, including the small sample size, predominantly female sex, and a short participation time frame utilizing retrospective review. Completing prospective research over a longer time frame can also yield generalizable results applicable to varied populations.”

The study received no outside funding. Ms. Campanile had no financial conflicts to disclose. Dr. Haut had no financial conflicts to disclose, and serves on the editorial advisory board of Pediatric News.

WASHINGTON – A nonpharmacologic, interdisciplinary program significantly improved chronic pain in children and the quality of life for their families, based on data from 115 individuals.

Up to 40% of children experience chronic pain that affects their physical, psychosocial, and educational functioning, said Jessica Campanile, BA, a medical student at the University of Pennsylvania, Philadelphia, in a presentation at the Pediatric Academic Societies annual meeting.

Although interdisciplinary pediatric pain rehabilitation programs have shown positive outcomes, very few use only nonpharmacologic treatments, said Ms. Campanile. In addition, few studies have explored the effects of a hospital-based program on the patients and their families.

Ms. Campanile and colleagues conducted a retrospective cohort study of participants in an outpatient pain rehabilitation program at the Children’s Hospital of Philadelphia between April 2016 and December 2019. Patients were evaluated by a pediatric rheumatologist, psychologist, and physical and occupational therapists.

Patients engaged in 2-3 hours of physical therapy (PT) and 2-3 hours of occupational therapy (OT) in a 1:1 ratio at least 5 days a week. Physical activities included stepping into and out of a tub, carrying laundry, and desensitizing to allodynia as needed. Participants also received individual and group cognitive-behavior therapy interventions from psychologists, and psychological support during PT and OT sessions if needed. Parents/caregivers were invited to separate individual and group therapy sessions as part of the program. The median age at admission to the program was 15 years, and 79% of the participants were female. Patients participated the program for a median of 17 days, and 87% were outpatients who came to the hospital for the program.

Pain was assessed based on the 0-10 verbal pain intensity scale, energy was assessed on a scale of 0-100, and functional disability was assessed on a scale of 0-60, with higher scores indicating more pain, more energy, and more self-perceived disability, respectively.

Overall, scores on measures of pain, disability, allodynia, and energy improved significantly from baseline to discharge from the program. Verbal pain intensity scores decreased on average from 7 to 5, disability scores decreased from 26 to 9, the proportion of patients reporting allodynia decreased from 86% to 61%, and the energy level score increased from 70 to 77. The trend continued at the first follow-up visit, conducted 2-3 months after discharge from the program. Notably, pain intensity further decreased from a median of 5 at program completion to a median of 2 at the first follow-up, Ms. Campanile said. Improvements in allodynia also were sustained at the first follow-up.

Quality of life measures related to physical, emotional, social, and cognitive function also improved significantly from baseline to completion of the program.

In addition, scores on a quality of life family impact survey improved significantly; in particular, parent health-related quality of life scores (Parent HRQoL) improved from 60 at baseline to 71 at the end of the program on a scale of 0 to 100. The study findings were limited by several factors including the relatively short duration and use of a convenience sample from a retrospective cohort, with data limited to electronic health records, Ms. Campanile said. The study also was not powered to examine differential treatments based on psychiatric conditions, and any psychiatric conditions were based on self-reports.

However, the results support the value of a nonpharmacologic interdisciplinary program as “a robust treatment for youth with chronic idiopathic pain, for both patients and the family unit,” she said.

“This study also supports the need for and benefit of additional counseling for patients and their caregivers prior to and during enrollment in a pain rehabilitation program,” she concluded.
 

Study supports effectiveness of drug-free pain management

“The management of pain in any age group can be challenging, especially with current concerns for opioid dependence and abuse,” Cathy Haut, DNP, CPNP-AC, CPNP-PC, a pediatric nurse practitioner in Rehoboth Beach, Del., said in an interview.

“Chronic pain affects daily life for all populations, but for children, adolescents, and their families, it can have a long-lasting impact on growth and development, psychosocial and physical well-being,” Dr. Haut said. “Determining and testing nonpharmacologic alternative methods of pain control are extremely important.”

Given the debilitating effects of chronic pain, and the potential side effects and dependence that have been associated with use of pharmacologic modes of pain control, unique and creative solutions have begun to emerge and need further attention and study, she said.

However, “despite published research supporting the use of alternative and complementary approaches to pain control in children and adolescents, nonpharmacologic, collaborative, interprofessional approaches to pain control have not been widely shared in the literature,” she said.

“Barriers to this type of program include first and foremost a potential lack of financial and workforce-related resources,” Dr. Haut said. “Patient and family attendance at frequent health visits, daily or even every other day, may also hinder success, but opportunities for telehealth and family training to learn physical and occupational skills within this type of program may be beginning solutions.”

Additional research should be conducted at multiple children’s hospitals, with a larger number of children and adolescents at varying ages, with pain related to different diagnoses, and with the inclusion of collaborative methodology, said Dr. Haut. “The current study had some limitations, including the small sample size, predominantly female sex, and a short participation time frame utilizing retrospective review. Completing prospective research over a longer time frame can also yield generalizable results applicable to varied populations.”

The study received no outside funding. Ms. Campanile had no financial conflicts to disclose. Dr. Haut had no financial conflicts to disclose, and serves on the editorial advisory board of Pediatric News.

WASHINGTON – A nonpharmacologic, interdisciplinary program significantly improved chronic pain in children and the quality of life for their families, based on data from 115 individuals.

Up to 40% of children experience chronic pain that affects their physical, psychosocial, and educational functioning, said Jessica Campanile, BA, a medical student at the University of Pennsylvania, Philadelphia, in a presentation at the Pediatric Academic Societies annual meeting.

Although interdisciplinary pediatric pain rehabilitation programs have shown positive outcomes, very few use only nonpharmacologic treatments, said Ms. Campanile. In addition, few studies have explored the effects of a hospital-based program on the patients and their families.

Ms. Campanile and colleagues conducted a retrospective cohort study of participants in an outpatient pain rehabilitation program at the Children’s Hospital of Philadelphia between April 2016 and December 2019. Patients were evaluated by a pediatric rheumatologist, psychologist, and physical and occupational therapists.

Patients engaged in 2-3 hours of physical therapy (PT) and 2-3 hours of occupational therapy (OT) in a 1:1 ratio at least 5 days a week. Physical activities included stepping into and out of a tub, carrying laundry, and desensitizing to allodynia as needed. Participants also received individual and group cognitive-behavior therapy interventions from psychologists, and psychological support during PT and OT sessions if needed. Parents/caregivers were invited to separate individual and group therapy sessions as part of the program. The median age at admission to the program was 15 years, and 79% of the participants were female. Patients participated the program for a median of 17 days, and 87% were outpatients who came to the hospital for the program.

Pain was assessed based on the 0-10 verbal pain intensity scale, energy was assessed on a scale of 0-100, and functional disability was assessed on a scale of 0-60, with higher scores indicating more pain, more energy, and more self-perceived disability, respectively.

Overall, scores on measures of pain, disability, allodynia, and energy improved significantly from baseline to discharge from the program. Verbal pain intensity scores decreased on average from 7 to 5, disability scores decreased from 26 to 9, the proportion of patients reporting allodynia decreased from 86% to 61%, and the energy level score increased from 70 to 77. The trend continued at the first follow-up visit, conducted 2-3 months after discharge from the program. Notably, pain intensity further decreased from a median of 5 at program completion to a median of 2 at the first follow-up, Ms. Campanile said. Improvements in allodynia also were sustained at the first follow-up.

Quality of life measures related to physical, emotional, social, and cognitive function also improved significantly from baseline to completion of the program.

In addition, scores on a quality of life family impact survey improved significantly; in particular, parent health-related quality of life scores (Parent HRQoL) improved from 60 at baseline to 71 at the end of the program on a scale of 0 to 100. The study findings were limited by several factors including the relatively short duration and use of a convenience sample from a retrospective cohort, with data limited to electronic health records, Ms. Campanile said. The study also was not powered to examine differential treatments based on psychiatric conditions, and any psychiatric conditions were based on self-reports.

However, the results support the value of a nonpharmacologic interdisciplinary program as “a robust treatment for youth with chronic idiopathic pain, for both patients and the family unit,” she said.

“This study also supports the need for and benefit of additional counseling for patients and their caregivers prior to and during enrollment in a pain rehabilitation program,” she concluded.
 

Study supports effectiveness of drug-free pain management

“The management of pain in any age group can be challenging, especially with current concerns for opioid dependence and abuse,” Cathy Haut, DNP, CPNP-AC, CPNP-PC, a pediatric nurse practitioner in Rehoboth Beach, Del., said in an interview.

“Chronic pain affects daily life for all populations, but for children, adolescents, and their families, it can have a long-lasting impact on growth and development, psychosocial and physical well-being,” Dr. Haut said. “Determining and testing nonpharmacologic alternative methods of pain control are extremely important.”

Given the debilitating effects of chronic pain, and the potential side effects and dependence that have been associated with use of pharmacologic modes of pain control, unique and creative solutions have begun to emerge and need further attention and study, she said.

However, “despite published research supporting the use of alternative and complementary approaches to pain control in children and adolescents, nonpharmacologic, collaborative, interprofessional approaches to pain control have not been widely shared in the literature,” she said.

“Barriers to this type of program include first and foremost a potential lack of financial and workforce-related resources,” Dr. Haut said. “Patient and family attendance at frequent health visits, daily or even every other day, may also hinder success, but opportunities for telehealth and family training to learn physical and occupational skills within this type of program may be beginning solutions.”

Additional research should be conducted at multiple children’s hospitals, with a larger number of children and adolescents at varying ages, with pain related to different diagnoses, and with the inclusion of collaborative methodology, said Dr. Haut. “The current study had some limitations, including the small sample size, predominantly female sex, and a short participation time frame utilizing retrospective review. Completing prospective research over a longer time frame can also yield generalizable results applicable to varied populations.”

The study received no outside funding. Ms. Campanile had no financial conflicts to disclose. Dr. Haut had no financial conflicts to disclose, and serves on the editorial advisory board of Pediatric News.

When I was medical student, world famous behaviorist Dr. Joseph Wolpe was my mentor and taught me a great deal about anxiety disorders and phobias in his clinic. I did some of the original research on agoraphobias in the mid-1970s and have used the experience to treat many patients with phobias over the last 40-plus years.

Dr. Richard W. Cohen

Some of these patients with phobias had marked functional impairments in their social functioning and their adaptive skills. One such example – dental phobia – is a fear of going to the dentist and is commonly found in the general population.

Susan A. Cohen, DMD, a dentist who has practiced for more than 20 years, has seen this fear on a daily basis in her patients, ranging from mild to extreme. She says that most dental patients are able to overcome their fear and panic, but she estimates that about 5% have extreme dental phobias that prevented a patient from visiting the dentist. This can lead to poor dental health, affect self esteem, and destroy relationships.

The causes of dental phobia are multifactorial and as follows:

• Fear of pain and needles.
• Past bad experiences with dental procedures.
• Past history of abuse.
• Fear of loss of control in the dental chair.
• History of other phobias or anxiety disorders.

Dr. Cohen also states that the anticipatory anxiety of going to the dentist can be just as fearful as being in the dental chair. And she further states this anticipatory anxiety causes a great deal of noncompliance in keeping dental appointments. Patients missed dental appointments that were very necessary for their overall health. Dr. Cohen noticed that triggers to this specific dental anxiety are:

• Thoughts of being in the dental office.
• Thoughts of lying in the dental chair.
• Thoughts of hearing sounds of drills or seeing dental instruments.
• The smells of the dental office.
• Dental overhead lights.

Symptoms of dental phobias include chills, dizziness, hyperhidrosis, heart palpitations, shortness of breath, indigestion, and trembling. Dr. Cohen also notes that people with dental phobias can cry before visits, have insomnia, and experience panic attacks. These symptoms can further cause avoidance of visits, and can trigger anxiety and fears that do not match the danger.

Avoidance of treatment often leads to poor dental health, periodontal disease, tooth loss, and decayed teeth, but also may contribute to heart problems, diabetes, and undetected carcinomas. Noncompliance with dental care affects general well being and self esteem, and may cause chronic pain, sleep problems, and embarrassment. It may also affect performance in work and school, and can cause social isolation.

The good news is that psychiatric treatment can be very helpful in treating dental phobias. Exposure therapy in vivo and in vitro with systematic desensitization and flooding can decrease significantly the fears, panic, and avoidance some dental patients experience. Cognitive behavioral therapy (CBT) can change the way patients see and respond to the situations that trigger symptoms.

Additionally, acupuncture can reduce the anxiety that patients feel about dental visits, and distraction techniques such as music and television can be very helpful during dental appointments. Guided imagery using deep breathing exercises with relaxation, visualization, and positive suggestion can create a sense of well-being and calmness. Hypnosis has also been shown to decrease the stress of being in a dental office. Nitrous oxide and oral or IV sedation may be a helpful last resort.

It is important for a person with dental phobias to be referred to a caring dentist who is sensitive to anxiety, and choose a dentist who will listen to and help the patient come up with signals, such as raising their hand, to temporarily stop a dental procedure. This technique will help the dental patient to avoid experiencing a total loss of control and help them feel less overwhelmed.

Dr. Cohen also says that it is helpful to visit the dentist at a less busy time of the day so there are fewer dental sounds and anxiety triggers in the office.

I have found that behavior modification with systematic desensitization and flooding in vivo and in vitro is extremely helpful in helping patients with extreme dental phobias overcome their fears and become more compliant with their dental treatments. Through the use of these techniques, dental phobias – and their emotional and physical sequelae – may be alleviated together.

Dr. Richard W. Cohen is a psychiatrist who has been in private practice for more than 40 years and is on the editorial advisory board for Clinical Psychiatry News. Dr. Susan A. Cohen has practiced dentistry for over 20 years. The Cohens, who are married, are based in Philadelphia.

When I was medical student, world famous behaviorist Dr. Joseph Wolpe was my mentor and taught me a great deal about anxiety disorders and phobias in his clinic. I did some of the original research on agoraphobias in the mid-1970s and have used the experience to treat many patients with phobias over the last 40-plus years.

Dr. Richard W. Cohen

Some of these patients with phobias had marked functional impairments in their social functioning and their adaptive skills. One such example – dental phobia – is a fear of going to the dentist and is commonly found in the general population.

Susan A. Cohen, DMD, a dentist who has practiced for more than 20 years, has seen this fear on a daily basis in her patients, ranging from mild to extreme. She says that most dental patients are able to overcome their fear and panic, but she estimates that about 5% have extreme dental phobias that prevented a patient from visiting the dentist. This can lead to poor dental health, affect self esteem, and destroy relationships.

The causes of dental phobia are multifactorial and as follows:

• Fear of pain and needles.
• Past bad experiences with dental procedures.
• Past history of abuse.
• Fear of loss of control in the dental chair.
• History of other phobias or anxiety disorders.

Dr. Cohen also states that the anticipatory anxiety of going to the dentist can be just as fearful as being in the dental chair. And she further states this anticipatory anxiety causes a great deal of noncompliance in keeping dental appointments. Patients missed dental appointments that were very necessary for their overall health. Dr. Cohen noticed that triggers to this specific dental anxiety are:

• Thoughts of being in the dental office.
• Thoughts of lying in the dental chair.
• Thoughts of hearing sounds of drills or seeing dental instruments.
• The smells of the dental office.
• Dental overhead lights.

Symptoms of dental phobias include chills, dizziness, hyperhidrosis, heart palpitations, shortness of breath, indigestion, and trembling. Dr. Cohen also notes that people with dental phobias can cry before visits, have insomnia, and experience panic attacks. These symptoms can further cause avoidance of visits, and can trigger anxiety and fears that do not match the danger.

Avoidance of treatment often leads to poor dental health, periodontal disease, tooth loss, and decayed teeth, but also may contribute to heart problems, diabetes, and undetected carcinomas. Noncompliance with dental care affects general well being and self esteem, and may cause chronic pain, sleep problems, and embarrassment. It may also affect performance in work and school, and can cause social isolation.

The good news is that psychiatric treatment can be very helpful in treating dental phobias. Exposure therapy in vivo and in vitro with systematic desensitization and flooding can decrease significantly the fears, panic, and avoidance some dental patients experience. Cognitive behavioral therapy (CBT) can change the way patients see and respond to the situations that trigger symptoms.

Additionally, acupuncture can reduce the anxiety that patients feel about dental visits, and distraction techniques such as music and television can be very helpful during dental appointments. Guided imagery using deep breathing exercises with relaxation, visualization, and positive suggestion can create a sense of well-being and calmness. Hypnosis has also been shown to decrease the stress of being in a dental office. Nitrous oxide and oral or IV sedation may be a helpful last resort.

It is important for a person with dental phobias to be referred to a caring dentist who is sensitive to anxiety, and choose a dentist who will listen to and help the patient come up with signals, such as raising their hand, to temporarily stop a dental procedure. This technique will help the dental patient to avoid experiencing a total loss of control and help them feel less overwhelmed.

Dr. Cohen also says that it is helpful to visit the dentist at a less busy time of the day so there are fewer dental sounds and anxiety triggers in the office.

I have found that behavior modification with systematic desensitization and flooding in vivo and in vitro is extremely helpful in helping patients with extreme dental phobias overcome their fears and become more compliant with their dental treatments. Through the use of these techniques, dental phobias – and their emotional and physical sequelae – may be alleviated together.

Dr. Richard W. Cohen is a psychiatrist who has been in private practice for more than 40 years and is on the editorial advisory board for Clinical Psychiatry News. Dr. Susan A. Cohen has practiced dentistry for over 20 years. The Cohens, who are married, are based in Philadelphia.

When I was medical student, world famous behaviorist Dr. Joseph Wolpe was my mentor and taught me a great deal about anxiety disorders and phobias in his clinic. I did some of the original research on agoraphobias in the mid-1970s and have used the experience to treat many patients with phobias over the last 40-plus years.

Dr. Richard W. Cohen

Some of these patients with phobias had marked functional impairments in their social functioning and their adaptive skills. One such example – dental phobia – is a fear of going to the dentist and is commonly found in the general population.

Susan A. Cohen, DMD, a dentist who has practiced for more than 20 years, has seen this fear on a daily basis in her patients, ranging from mild to extreme. She says that most dental patients are able to overcome their fear and panic, but she estimates that about 5% have extreme dental phobias that prevented a patient from visiting the dentist. This can lead to poor dental health, affect self esteem, and destroy relationships.

The causes of dental phobia are multifactorial and as follows:

• Fear of pain and needles.
• Past bad experiences with dental procedures.
• Past history of abuse.
• Fear of loss of control in the dental chair.
• History of other phobias or anxiety disorders.

Dr. Cohen also states that the anticipatory anxiety of going to the dentist can be just as fearful as being in the dental chair. And she further states this anticipatory anxiety causes a great deal of noncompliance in keeping dental appointments. Patients missed dental appointments that were very necessary for their overall health. Dr. Cohen noticed that triggers to this specific dental anxiety are:

• Thoughts of being in the dental office.
• Thoughts of lying in the dental chair.
• Thoughts of hearing sounds of drills or seeing dental instruments.
• The smells of the dental office.
• Dental overhead lights.

Symptoms of dental phobias include chills, dizziness, hyperhidrosis, heart palpitations, shortness of breath, indigestion, and trembling. Dr. Cohen also notes that people with dental phobias can cry before visits, have insomnia, and experience panic attacks. These symptoms can further cause avoidance of visits, and can trigger anxiety and fears that do not match the danger.

Avoidance of treatment often leads to poor dental health, periodontal disease, tooth loss, and decayed teeth, but also may contribute to heart problems, diabetes, and undetected carcinomas. Noncompliance with dental care affects general well being and self esteem, and may cause chronic pain, sleep problems, and embarrassment. It may also affect performance in work and school, and can cause social isolation.

The good news is that psychiatric treatment can be very helpful in treating dental phobias. Exposure therapy in vivo and in vitro with systematic desensitization and flooding can decrease significantly the fears, panic, and avoidance some dental patients experience. Cognitive behavioral therapy (CBT) can change the way patients see and respond to the situations that trigger symptoms.

Additionally, acupuncture can reduce the anxiety that patients feel about dental visits, and distraction techniques such as music and television can be very helpful during dental appointments. Guided imagery using deep breathing exercises with relaxation, visualization, and positive suggestion can create a sense of well-being and calmness. Hypnosis has also been shown to decrease the stress of being in a dental office. Nitrous oxide and oral or IV sedation may be a helpful last resort.

It is important for a person with dental phobias to be referred to a caring dentist who is sensitive to anxiety, and choose a dentist who will listen to and help the patient come up with signals, such as raising their hand, to temporarily stop a dental procedure. This technique will help the dental patient to avoid experiencing a total loss of control and help them feel less overwhelmed.

Dr. Cohen also says that it is helpful to visit the dentist at a less busy time of the day so there are fewer dental sounds and anxiety triggers in the office.

I have found that behavior modification with systematic desensitization and flooding in vivo and in vitro is extremely helpful in helping patients with extreme dental phobias overcome their fears and become more compliant with their dental treatments. Through the use of these techniques, dental phobias – and their emotional and physical sequelae – may be alleviated together.

Dr. Richard W. Cohen is a psychiatrist who has been in private practice for more than 40 years and is on the editorial advisory board for Clinical Psychiatry News. Dr. Susan A. Cohen has practiced dentistry for over 20 years. The Cohens, who are married, are based in Philadelphia.

A primary care physician at the Veterans Affairs Medical Center in Decatur, Georgia, has been indicted on several counts of sexual assault of veteran patients. Rajesh Motibhai Patel is accused of violating his patients’ constitutional right to bodily integrity while acting under color of law and of engaging in unwanted sexual contact.

According to US Attorney Ryan Buchanan, Patel allegedly “violated his oath to do no harm to patients under his care.” He allegedly sexually touched 4 female patients during routine examinations.

Patel’s alleged crimes were “horrific and unacceptable,” US Department of Veterans Affairs (VA) press secretary Terrence Hayes said in a statement. “As soon as VA learned of these allegations, we removed this clinician from patient care and reassigned him to a role that had no patient interaction. Whenever a patient comes to VA, they deserve to know that they will be treated with care, compassion, and respect.”

The case is being investigated by the VA Office of Inspector General. Although Patel is only charged at present, not convicted, investigators believe he may have victimized other patients as well. Anyone with information is asked to call the VA-OIG tipline at (770) 758-6646.

A primary care physician at the Veterans Affairs Medical Center in Decatur, Georgia, has been indicted on several counts of sexual assault of veteran patients. Rajesh Motibhai Patel is accused of violating his patients’ constitutional right to bodily integrity while acting under color of law and of engaging in unwanted sexual contact.

According to US Attorney Ryan Buchanan, Patel allegedly “violated his oath to do no harm to patients under his care.” He allegedly sexually touched 4 female patients during routine examinations.

Patel’s alleged crimes were “horrific and unacceptable,” US Department of Veterans Affairs (VA) press secretary Terrence Hayes said in a statement. “As soon as VA learned of these allegations, we removed this clinician from patient care and reassigned him to a role that had no patient interaction. Whenever a patient comes to VA, they deserve to know that they will be treated with care, compassion, and respect.”

The case is being investigated by the VA Office of Inspector General. Although Patel is only charged at present, not convicted, investigators believe he may have victimized other patients as well. Anyone with information is asked to call the VA-OIG tipline at (770) 758-6646.

A primary care physician at the Veterans Affairs Medical Center in Decatur, Georgia, has been indicted on several counts of sexual assault of veteran patients. Rajesh Motibhai Patel is accused of violating his patients’ constitutional right to bodily integrity while acting under color of law and of engaging in unwanted sexual contact.

According to US Attorney Ryan Buchanan, Patel allegedly “violated his oath to do no harm to patients under his care.” He allegedly sexually touched 4 female patients during routine examinations.

Patel’s alleged crimes were “horrific and unacceptable,” US Department of Veterans Affairs (VA) press secretary Terrence Hayes said in a statement. “As soon as VA learned of these allegations, we removed this clinician from patient care and reassigned him to a role that had no patient interaction. Whenever a patient comes to VA, they deserve to know that they will be treated with care, compassion, and respect.”

The case is being investigated by the VA Office of Inspector General. Although Patel is only charged at present, not convicted, investigators believe he may have victimized other patients as well. Anyone with information is asked to call the VA-OIG tipline at (770) 758-6646.

The United States has often been described as a “melting pot,” defined as diverse cultures and ethnicities coming together to form the rich fabric of our nation. These days, it seems that our fabric is a bit frayed.

NY Institute of Technology College of Osteopathic Medicine

DEIB (diversity, equity, inclusion, and belonging) is dawning as a significant conversation. Each and every one of us is unique by age, gender, culture/ethnicity, religion, socioeconomic status, geographical location, race, and sexual identity – to name just a few aspects of our identity. Keeping these differences in mind, it is evident that none of us fits a “one size fits all” mold.

Some of these differences, such as cross-cultural cuisine and holidays, are enjoyed and celebrated as wonderful opportunities to learn from others, embrace our distinctions, and have them beneficially contribute to our lives. Other differences, however, are not understood or embraced and are, in fact, belittled and stigmatized. Sexual identity falls into this category. It behooves us as a country to become more aware and educated about this category in our identities, in order to understand it, quell our unfounded fear, learn to support one another, and improve our collective mental health.

Recent reports have shown that exposing students and teachers to sexual identity diversity education has sparked some backlash from parents and communities alike. Those opposed are citing concerns over introducing children to LGBTQ+ information, either embedded in the school curriculum or made available in school library reading materials. “Children should remain innocent” seems to be the message. Perhaps parents prefer to discuss this topic privately, at home. Either way, teaching about diversity does not damage one’s innocence or deprive parents of private conversations. In fact, it educates children by improving their awareness, tolerance, and acceptance of others’ differences, and can serve as a catalyst to further parental conversation.

There are kids everywhere who are starting to develop and understand their identities. Wouldn’t it be wonderful for them to know that whichever way they identify is okay, that they are not ‘weird’ or ‘different,’ but that in fact we are all different? Wouldn’t it be great for them to be able to explore and discuss their identities and journeys openly, and not have to hide for fear of retribution or bullying?

It is important for these children to know that they are not alone, that they have options, and that they don’t need to contemplate suicide because they believe that their identity makes them not worthy of being in this world.

Talking more openly about LGBTQ+ is an educational opportunity to improve understanding, tolerance, and acceptance. Starting the conversation early on in life can empower our youth by planting the seed that people are not “one size fits all,” which is the element responsible for our being unique and human. Diversity can be woven into the rich fabric that defines our nation, rather than be a factor that unravels it.

April was National Diversity Awareness Month and we took time to celebrate our country’s cultural melting pot. By embracing our differences, we can show our children and ourselves how to better navigate diversity, which can help us all fit in.

Dr. Jarkon is a psychiatrist and director of the Center for Behavioral Health at the New York Institute of Technology College of Osteopathic Medicine in Old Westbury, N.Y.

The United States has often been described as a “melting pot,” defined as diverse cultures and ethnicities coming together to form the rich fabric of our nation. These days, it seems that our fabric is a bit frayed.

NY Institute of Technology College of Osteopathic Medicine

DEIB (diversity, equity, inclusion, and belonging) is dawning as a significant conversation. Each and every one of us is unique by age, gender, culture/ethnicity, religion, socioeconomic status, geographical location, race, and sexual identity – to name just a few aspects of our identity. Keeping these differences in mind, it is evident that none of us fits a “one size fits all” mold.

Some of these differences, such as cross-cultural cuisine and holidays, are enjoyed and celebrated as wonderful opportunities to learn from others, embrace our distinctions, and have them beneficially contribute to our lives. Other differences, however, are not understood or embraced and are, in fact, belittled and stigmatized. Sexual identity falls into this category. It behooves us as a country to become more aware and educated about this category in our identities, in order to understand it, quell our unfounded fear, learn to support one another, and improve our collective mental health.

Recent reports have shown that exposing students and teachers to sexual identity diversity education has sparked some backlash from parents and communities alike. Those opposed are citing concerns over introducing children to LGBTQ+ information, either embedded in the school curriculum or made available in school library reading materials. “Children should remain innocent” seems to be the message. Perhaps parents prefer to discuss this topic privately, at home. Either way, teaching about diversity does not damage one’s innocence or deprive parents of private conversations. In fact, it educates children by improving their awareness, tolerance, and acceptance of others’ differences, and can serve as a catalyst to further parental conversation.

There are kids everywhere who are starting to develop and understand their identities. Wouldn’t it be wonderful for them to know that whichever way they identify is okay, that they are not ‘weird’ or ‘different,’ but that in fact we are all different? Wouldn’t it be great for them to be able to explore and discuss their identities and journeys openly, and not have to hide for fear of retribution or bullying?

It is important for these children to know that they are not alone, that they have options, and that they don’t need to contemplate suicide because they believe that their identity makes them not worthy of being in this world.

Talking more openly about LGBTQ+ is an educational opportunity to improve understanding, tolerance, and acceptance. Starting the conversation early on in life can empower our youth by planting the seed that people are not “one size fits all,” which is the element responsible for our being unique and human. Diversity can be woven into the rich fabric that defines our nation, rather than be a factor that unravels it.

April was National Diversity Awareness Month and we took time to celebrate our country’s cultural melting pot. By embracing our differences, we can show our children and ourselves how to better navigate diversity, which can help us all fit in.

Dr. Jarkon is a psychiatrist and director of the Center for Behavioral Health at the New York Institute of Technology College of Osteopathic Medicine in Old Westbury, N.Y.

The United States has often been described as a “melting pot,” defined as diverse cultures and ethnicities coming together to form the rich fabric of our nation. These days, it seems that our fabric is a bit frayed.

NY Institute of Technology College of Osteopathic Medicine

DEIB (diversity, equity, inclusion, and belonging) is dawning as a significant conversation. Each and every one of us is unique by age, gender, culture/ethnicity, religion, socioeconomic status, geographical location, race, and sexual identity – to name just a few aspects of our identity. Keeping these differences in mind, it is evident that none of us fits a “one size fits all” mold.

Some of these differences, such as cross-cultural cuisine and holidays, are enjoyed and celebrated as wonderful opportunities to learn from others, embrace our distinctions, and have them beneficially contribute to our lives. Other differences, however, are not understood or embraced and are, in fact, belittled and stigmatized. Sexual identity falls into this category. It behooves us as a country to become more aware and educated about this category in our identities, in order to understand it, quell our unfounded fear, learn to support one another, and improve our collective mental health.

Recent reports have shown that exposing students and teachers to sexual identity diversity education has sparked some backlash from parents and communities alike. Those opposed are citing concerns over introducing children to LGBTQ+ information, either embedded in the school curriculum or made available in school library reading materials. “Children should remain innocent” seems to be the message. Perhaps parents prefer to discuss this topic privately, at home. Either way, teaching about diversity does not damage one’s innocence or deprive parents of private conversations. In fact, it educates children by improving their awareness, tolerance, and acceptance of others’ differences, and can serve as a catalyst to further parental conversation.

There are kids everywhere who are starting to develop and understand their identities. Wouldn’t it be wonderful for them to know that whichever way they identify is okay, that they are not ‘weird’ or ‘different,’ but that in fact we are all different? Wouldn’t it be great for them to be able to explore and discuss their identities and journeys openly, and not have to hide for fear of retribution or bullying?

It is important for these children to know that they are not alone, that they have options, and that they don’t need to contemplate suicide because they believe that their identity makes them not worthy of being in this world.

Talking more openly about LGBTQ+ is an educational opportunity to improve understanding, tolerance, and acceptance. Starting the conversation early on in life can empower our youth by planting the seed that people are not “one size fits all,” which is the element responsible for our being unique and human. Diversity can be woven into the rich fabric that defines our nation, rather than be a factor that unravels it.

April was National Diversity Awareness Month and we took time to celebrate our country’s cultural melting pot. By embracing our differences, we can show our children and ourselves how to better navigate diversity, which can help us all fit in.

Dr. Jarkon is a psychiatrist and director of the Center for Behavioral Health at the New York Institute of Technology College of Osteopathic Medicine in Old Westbury, N.Y.

A recent Swedish study found that both abdominal and general obesity were independently associated with respiratory illnesses, including asthma and self-reported chronic obstructive pulmonary disease.

Relationships between respiratory conditions with characterized obesity types in adults were assessed using self-report surveys from participants originally enrolled in the European Community Respiratory Health Survey (ECRHS) investigating asthma, allergy, and risk factors. The Respiratory Health in Northern Europe (RHINE) III provides a second follow-up substudy of ECRHS focused on two forms of obesity associated with respiratory illnesses.

Obesity is a characteristic risk factor linked to respiratory ailments such as asthma and COPD. High body mass index (BMI) and waist circumference (WC) provide quantitative measurements for defining conditions of comprehensive general and abdominal obesity, respectively.

Although both types of obesity have been associated with asthma incidence, studies on their independent impact on this disease have been limited. Previous reports on abdominal obesity associated with asthma have been inconsistent when considering sexes in the analysis. Additionally, COPD and related outcomes differed between abdominal and general obesity, indicating a need to discover whether self-reported WC abdominal obesity and BMI-based general obesity are independently associated with respiratory symptoms, early- and late-onset asthma, COPD, chronic bronchitis, rhinitis, and sex, Marta A. Kisiel, MD, PhD, of the department of environmental and occupational medicine, Uppsala University, Sweden, and colleagues write.

In a prospective study published in the journal Respiratory Medicine, the researchers report on a cross-sectional investigation of responses to a questionnaire similar to one utilized 10 years earlier in the RHINE II study. Questions required simple yes/no responses that covered asthma, respiratory symptoms, allergic rhinitis, chronic bronchitis, and COPD. Additional requested information included age of asthma onset, potential confounding variables of age, smoking, physical activity, and highest education level, weight and height for BMI calculation, and WC measurement with instructions and a provided tape measure.

The population of the RHINE III study conducted from 2010 to 2012 was composed of 12,290 participants (53% response frequency) obtained from a total of seven research centers located in five northern European countries. Obesity categorization classified 1,837 (6.7%) participants as generally obese based on a high BMI ≥ 30 kg/m² and 4,261 (34.7%) as abdominally obese by WC measurements of ≥ 102 cm for men and ≥ 88 cm for women. Of the 4,261 total participants, 1,669 met both general and abdominal obesity criteria. Mean age was in the low 50s range and the obese population consisted of more women than men.

Simple linear regression revealed that BMI and WC were highly correlated, and both were associated with tested respiratory conditions when adjusted for confounding variables. Differences with respect to WC and BMI were independently associated with most of the examined respiratory conditions when WC was adjusted for BMI and vice versa. Neither early-onset asthma nor allergic rhinitis were associated with WC, BMI, or abdominal or general obesity.

A significantly high proportion of individuals with general and abdominal obesity experienced a variety of defined respiratory symptoms, and asthma, chronic bronchitis, or COPD. An independent association of abdominal obesity (with or without general obesity) was found to occur with respiratory symptoms, asthma, late-onset asthma, and chronic bronchitis.

After adjusting for abdominal obesity, general obesity showed an independent and significant association with respiratory symptoms, asthma, adult-onset asthma, and COPD. An analysis stratified by sex indicated a significant association of abdominal and general obesity with asthma in women presented as an odds ratio of 1.56 (95% confidence interval, 1.30-1.87) and 1.95 (95% CI, 1.56-2.43), respectively, compared with men, with an OR of 1.22 (95% CI, 0.97-3.17) and 1.28 (95% CI, 0.97-1.68), respectively. The association of abdominal and general obesity with COPD was also stronger in women, compared with men.

The researchers conclude that “both general and abdominal obesity [were], independent of each other, associated with respiratory symptoms in adults.” There is also a distinct difference between women and men for the association of self-reported asthma and COPD with abdominal and general obesity.

The large randomly selected sample size of participants from research centers located in five northern European countries was considered a major strength of this study as it permitted simultaneous adjustment for multiple potential confounders. Several limitations were acknowledged, including absence of data on obstructive respiratory disease severity, WC measurements not being performed by trained staff, and self-reported height and weight measurements.

The authors have disclosed no relevant financial relationships.

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

A recent Swedish study found that both abdominal and general obesity were independently associated with respiratory illnesses, including asthma and self-reported chronic obstructive pulmonary disease.

Relationships between respiratory conditions with characterized obesity types in adults were assessed using self-report surveys from participants originally enrolled in the European Community Respiratory Health Survey (ECRHS) investigating asthma, allergy, and risk factors. The Respiratory Health in Northern Europe (RHINE) III provides a second follow-up substudy of ECRHS focused on two forms of obesity associated with respiratory illnesses.

Obesity is a characteristic risk factor linked to respiratory ailments such as asthma and COPD. High body mass index (BMI) and waist circumference (WC) provide quantitative measurements for defining conditions of comprehensive general and abdominal obesity, respectively.

Although both types of obesity have been associated with asthma incidence, studies on their independent impact on this disease have been limited. Previous reports on abdominal obesity associated with asthma have been inconsistent when considering sexes in the analysis. Additionally, COPD and related outcomes differed between abdominal and general obesity, indicating a need to discover whether self-reported WC abdominal obesity and BMI-based general obesity are independently associated with respiratory symptoms, early- and late-onset asthma, COPD, chronic bronchitis, rhinitis, and sex, Marta A. Kisiel, MD, PhD, of the department of environmental and occupational medicine, Uppsala University, Sweden, and colleagues write.

In a prospective study published in the journal Respiratory Medicine, the researchers report on a cross-sectional investigation of responses to a questionnaire similar to one utilized 10 years earlier in the RHINE II study. Questions required simple yes/no responses that covered asthma, respiratory symptoms, allergic rhinitis, chronic bronchitis, and COPD. Additional requested information included age of asthma onset, potential confounding variables of age, smoking, physical activity, and highest education level, weight and height for BMI calculation, and WC measurement with instructions and a provided tape measure.

The population of the RHINE III study conducted from 2010 to 2012 was composed of 12,290 participants (53% response frequency) obtained from a total of seven research centers located in five northern European countries. Obesity categorization classified 1,837 (6.7%) participants as generally obese based on a high BMI ≥ 30 kg/m² and 4,261 (34.7%) as abdominally obese by WC measurements of ≥ 102 cm for men and ≥ 88 cm for women. Of the 4,261 total participants, 1,669 met both general and abdominal obesity criteria. Mean age was in the low 50s range and the obese population consisted of more women than men.

Simple linear regression revealed that BMI and WC were highly correlated, and both were associated with tested respiratory conditions when adjusted for confounding variables. Differences with respect to WC and BMI were independently associated with most of the examined respiratory conditions when WC was adjusted for BMI and vice versa. Neither early-onset asthma nor allergic rhinitis were associated with WC, BMI, or abdominal or general obesity.

A significantly high proportion of individuals with general and abdominal obesity experienced a variety of defined respiratory symptoms, and asthma, chronic bronchitis, or COPD. An independent association of abdominal obesity (with or without general obesity) was found to occur with respiratory symptoms, asthma, late-onset asthma, and chronic bronchitis.

After adjusting for abdominal obesity, general obesity showed an independent and significant association with respiratory symptoms, asthma, adult-onset asthma, and COPD. An analysis stratified by sex indicated a significant association of abdominal and general obesity with asthma in women presented as an odds ratio of 1.56 (95% confidence interval, 1.30-1.87) and 1.95 (95% CI, 1.56-2.43), respectively, compared with men, with an OR of 1.22 (95% CI, 0.97-3.17) and 1.28 (95% CI, 0.97-1.68), respectively. The association of abdominal and general obesity with COPD was also stronger in women, compared with men.

The researchers conclude that “both general and abdominal obesity [were], independent of each other, associated with respiratory symptoms in adults.” There is also a distinct difference between women and men for the association of self-reported asthma and COPD with abdominal and general obesity.

The large randomly selected sample size of participants from research centers located in five northern European countries was considered a major strength of this study as it permitted simultaneous adjustment for multiple potential confounders. Several limitations were acknowledged, including absence of data on obstructive respiratory disease severity, WC measurements not being performed by trained staff, and self-reported height and weight measurements.

The authors have disclosed no relevant financial relationships.

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

A recent Swedish study found that both abdominal and general obesity were independently associated with respiratory illnesses, including asthma and self-reported chronic obstructive pulmonary disease.

Relationships between respiratory conditions with characterized obesity types in adults were assessed using self-report surveys from participants originally enrolled in the European Community Respiratory Health Survey (ECRHS) investigating asthma, allergy, and risk factors. The Respiratory Health in Northern Europe (RHINE) III provides a second follow-up substudy of ECRHS focused on two forms of obesity associated with respiratory illnesses.

Obesity is a characteristic risk factor linked to respiratory ailments such as asthma and COPD. High body mass index (BMI) and waist circumference (WC) provide quantitative measurements for defining conditions of comprehensive general and abdominal obesity, respectively.

Although both types of obesity have been associated with asthma incidence, studies on their independent impact on this disease have been limited. Previous reports on abdominal obesity associated with asthma have been inconsistent when considering sexes in the analysis. Additionally, COPD and related outcomes differed between abdominal and general obesity, indicating a need to discover whether self-reported WC abdominal obesity and BMI-based general obesity are independently associated with respiratory symptoms, early- and late-onset asthma, COPD, chronic bronchitis, rhinitis, and sex, Marta A. Kisiel, MD, PhD, of the department of environmental and occupational medicine, Uppsala University, Sweden, and colleagues write.

In a prospective study published in the journal Respiratory Medicine, the researchers report on a cross-sectional investigation of responses to a questionnaire similar to one utilized 10 years earlier in the RHINE II study. Questions required simple yes/no responses that covered asthma, respiratory symptoms, allergic rhinitis, chronic bronchitis, and COPD. Additional requested information included age of asthma onset, potential confounding variables of age, smoking, physical activity, and highest education level, weight and height for BMI calculation, and WC measurement with instructions and a provided tape measure.

The population of the RHINE III study conducted from 2010 to 2012 was composed of 12,290 participants (53% response frequency) obtained from a total of seven research centers located in five northern European countries. Obesity categorization classified 1,837 (6.7%) participants as generally obese based on a high BMI ≥ 30 kg/m² and 4,261 (34.7%) as abdominally obese by WC measurements of ≥ 102 cm for men and ≥ 88 cm for women. Of the 4,261 total participants, 1,669 met both general and abdominal obesity criteria. Mean age was in the low 50s range and the obese population consisted of more women than men.

Simple linear regression revealed that BMI and WC were highly correlated, and both were associated with tested respiratory conditions when adjusted for confounding variables. Differences with respect to WC and BMI were independently associated with most of the examined respiratory conditions when WC was adjusted for BMI and vice versa. Neither early-onset asthma nor allergic rhinitis were associated with WC, BMI, or abdominal or general obesity.

A significantly high proportion of individuals with general and abdominal obesity experienced a variety of defined respiratory symptoms, and asthma, chronic bronchitis, or COPD. An independent association of abdominal obesity (with or without general obesity) was found to occur with respiratory symptoms, asthma, late-onset asthma, and chronic bronchitis.

After adjusting for abdominal obesity, general obesity showed an independent and significant association with respiratory symptoms, asthma, adult-onset asthma, and COPD. An analysis stratified by sex indicated a significant association of abdominal and general obesity with asthma in women presented as an odds ratio of 1.56 (95% confidence interval, 1.30-1.87) and 1.95 (95% CI, 1.56-2.43), respectively, compared with men, with an OR of 1.22 (95% CI, 0.97-3.17) and 1.28 (95% CI, 0.97-1.68), respectively. The association of abdominal and general obesity with COPD was also stronger in women, compared with men.

The researchers conclude that “both general and abdominal obesity [were], independent of each other, associated with respiratory symptoms in adults.” There is also a distinct difference between women and men for the association of self-reported asthma and COPD with abdominal and general obesity.

The large randomly selected sample size of participants from research centers located in five northern European countries was considered a major strength of this study as it permitted simultaneous adjustment for multiple potential confounders. Several limitations were acknowledged, including absence of data on obstructive respiratory disease severity, WC measurements not being performed by trained staff, and self-reported height and weight measurements.

The authors have disclosed no relevant financial relationships.

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

To see the harmful effects of climate change firsthand, you need look no farther than the nearest pulmonary clinic.

The causes and effects are unmistakable: pollen storms leading to allergy sufferers flooding into allergists’ offices; rising air pollution levels increasing risk for obstructive airway diseases, cardiopulmonary complications, and non–small cell lung cancer; melting snowpacks and atmospheric rivers inundating neighborhoods and leaving moldy debris and incipient fungal infections in their wake.

“The reason why we think climate change is going to change the type of disease patterns and the severity of illness that we see in patients with respiratory diseases is that it changes a lot of the environment as well as the exposures,” said Bathmapriya Balakrishnan, BMedSci, BMBS, from the section of Pulmonary, Critical Care, and Sleep Medicine in the department of medicine at West Virginia University, Morgantown.

“What we’re going to see is not just new diseases but also exacerbation of chronic diseases, things like asthma [and] COPD. And there’s also concern that patients who are otherwise healthy, because they now have more exposures that are due to climate change, can then develop these diseases,” she said in an interview.

Ms. Balakrishnan is the lead author of a comprehensive, evidence-based review focused on the effects of climate change and air pollution across the spectrum of pulmonary disorders. The review is published online ahead of print in the journal Chest.

“As pulmonologists, understanding and improving awareness of the adverse effects of climate change and air pollution are crucial steps. To inform health care providers of evidence-based methods and improve patient counselling, further research regarding measures that limit exposure is needed. Empowering patients with resources to monitor air quality and minimize exposure is a key preventative measure for decreasing morbidity and mortality while improving quality of  life,” Ms. Balakrishnan and colleagues write.

Similarly, in a statement on the effects of climate change on respiratory health, the American Public Health Association succinctly summarized the problem: “Warmer temperatures lead to an increase in pollutants and allergens. Poor air quality leads to reduced lung function, increased risk of asthma complications, heart attacks, heart failure, and death. Air pollution and allergens are the main exposures affecting lung and heart health in this changing climate.”
 

Early spring

Stanley Fineman, MD, MBA, a past president of the American College of Allergy, Asthma, & Immunology and an allergist in private practice in Atlanta, has seen firsthand how global warming and an earlier start to spring allergy season is affecting his patients.

“The season, at least in our area metro Atlanta, started earlier and has been lasting longer. The pollen counts are very high,” he told this news organization.

“In February we started seeing pollen counts over 1,000 [grams per cubic meter], which is unheard of, and in March about half the days we counted levels that were over 1,000, which is also unheard of. In April it was over 1,000 almost half the days.”

Dr. Fineman and colleagues both in Atlanta and across the country have reported sharp increases in the proportion of new adult patients and in existing patients who have experienced exacerbation of previously mild disease.

“Probably what’s happened is that they may have had some allergic sensitivity that resulted in milder manifestations, but this year they’re getting major manifestations,” Dr. Fineman said.

In a 2014 article in the journal European Respiratory Review, Gennaro D’Amato, MD, from High Speciality Hospital Antonio Cardarelli, Naples, Italy, and colleagues outlined the main effects of climate on pollen levels: “1) an increase in plant growth and faster plant growth; 2) an increase in the amount of pollen produced by each plant; 3) an increase in the amount of allergenic proteins contained in pollen; 4) an increase in the start time of plant growth and, therefore, the start of pollen production; 5) an earlier and longer pollen season; 6) change in the geospatial distribution of pollen, that is plant ranges and long-distance atmospheric transport moving polewards,” they write.
 

Bad air

In addition to pollen, the ambient air in many places is increasingly becoming saturated with bioallergenic proteins such as bacteria, viruses, animal dander, insects, molds, and plant species, Ms. Balakrishnan and colleagues noted, adding that “atmospheric levels of carbon dioxide have also been found to increase pollen productivity. These changes result in greater over-the-counter medication use, emergency department visits, and outpatient visits for respiratory illnesses.”

The rash of violent storms that has washed over much of the United States in recent months is also likely to increase the incidence of so-called “thunderstorm asthma,” caused when large quantities of respirable particulate matter are released before or during a thunderstorm.

Air pollution from the burning of carbon-based fuels and from wildfires sparked by hotter and drier conditions increase airborne particulate matter that can seriously exacerbate asthma, COPD, and other obstructive airway conditions.

In addition, as previously reported by Medscape, exposure to particulate matter has been implicated as a possible cause of non–small cell lung cancer in persons who have never smoked.
 

Critical care challenges

Among the myriad other effects of climate change postulated in evidence enumerated by Ms. Balakrishnan and colleagues are chest infections and pleural diseases, such as aspergillosis infections that occur after catastrophic flooding; increased incidence of Mycobacterium avium complex infections and hypersensitivity pneumonitis; increased demands on critical care specialists from natural disasters; pollution-induced cardiac arrest; and heat prostration and heat stroke from increasingly prevalent heat waves.

The reviewers also examined evidence suggesting links between climate change and pulmonary hypertension, interstitial lung disease, sleep disorders, and occupational pulmonary disorders.
 

Power to the patients

“Pulmonologists should counsel patients on ways to minimize outdoor and indoor pollution, using tight-fitting respirators and home air-purifying systems without encroaching on patients’ beliefs and choices,” the authors advise.

“Empowering patients with resources to monitor air quality daily, in inclement weather, and during disasters would help minimize exposure and thus improve overall health. The pulmonologist can play an important role in emphasizing the impact of climate change on pulmonary disorders during patient care encounters,” they write.

Ms. Balakrishan adds that another important mitigation measure that can be taken today is education.

“In medical school we don’t really learn about the impact of climate change – at least in my generation of physicians, climate change or global warming weren’t part of the medical curriculum – but now I think that there’s a lot of advocacy work being done by medical students who actually want more education on climate change and its effects on pulmonary diseases,” she said.

The study by Ms. Balakrishnan and colleagues was unfunded. Ms. Balakrishnan reports no relevant financial relationships. Co-author Mary-Beth Scholand, MD, has received personal fees from serving on advisory boards and speakers bureaus for Genentech, Boehringer Ingelheim, Veracyte, and United Therapeutics. Co-author Sean Callahan, MD, has received personal fees for serving on advisory boards for Gilead and Boehringer Ingelheim. Dr. Fineman reports no relevant financial relationships.

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

To see the harmful effects of climate change firsthand, you need look no farther than the nearest pulmonary clinic.

The causes and effects are unmistakable: pollen storms leading to allergy sufferers flooding into allergists’ offices; rising air pollution levels increasing risk for obstructive airway diseases, cardiopulmonary complications, and non–small cell lung cancer; melting snowpacks and atmospheric rivers inundating neighborhoods and leaving moldy debris and incipient fungal infections in their wake.

“The reason why we think climate change is going to change the type of disease patterns and the severity of illness that we see in patients with respiratory diseases is that it changes a lot of the environment as well as the exposures,” said Bathmapriya Balakrishnan, BMedSci, BMBS, from the section of Pulmonary, Critical Care, and Sleep Medicine in the department of medicine at West Virginia University, Morgantown.

“What we’re going to see is not just new diseases but also exacerbation of chronic diseases, things like asthma [and] COPD. And there’s also concern that patients who are otherwise healthy, because they now have more exposures that are due to climate change, can then develop these diseases,” she said in an interview.

Ms. Balakrishnan is the lead author of a comprehensive, evidence-based review focused on the effects of climate change and air pollution across the spectrum of pulmonary disorders. The review is published online ahead of print in the journal Chest.

“As pulmonologists, understanding and improving awareness of the adverse effects of climate change and air pollution are crucial steps. To inform health care providers of evidence-based methods and improve patient counselling, further research regarding measures that limit exposure is needed. Empowering patients with resources to monitor air quality and minimize exposure is a key preventative measure for decreasing morbidity and mortality while improving quality of  life,” Ms. Balakrishnan and colleagues write.

Similarly, in a statement on the effects of climate change on respiratory health, the American Public Health Association succinctly summarized the problem: “Warmer temperatures lead to an increase in pollutants and allergens. Poor air quality leads to reduced lung function, increased risk of asthma complications, heart attacks, heart failure, and death. Air pollution and allergens are the main exposures affecting lung and heart health in this changing climate.”
 

Early spring

Stanley Fineman, MD, MBA, a past president of the American College of Allergy, Asthma, & Immunology and an allergist in private practice in Atlanta, has seen firsthand how global warming and an earlier start to spring allergy season is affecting his patients.

“The season, at least in our area metro Atlanta, started earlier and has been lasting longer. The pollen counts are very high,” he told this news organization.

“In February we started seeing pollen counts over 1,000 [grams per cubic meter], which is unheard of, and in March about half the days we counted levels that were over 1,000, which is also unheard of. In April it was over 1,000 almost half the days.”

Dr. Fineman and colleagues both in Atlanta and across the country have reported sharp increases in the proportion of new adult patients and in existing patients who have experienced exacerbation of previously mild disease.

“Probably what’s happened is that they may have had some allergic sensitivity that resulted in milder manifestations, but this year they’re getting major manifestations,” Dr. Fineman said.

In a 2014 article in the journal European Respiratory Review, Gennaro D’Amato, MD, from High Speciality Hospital Antonio Cardarelli, Naples, Italy, and colleagues outlined the main effects of climate on pollen levels: “1) an increase in plant growth and faster plant growth; 2) an increase in the amount of pollen produced by each plant; 3) an increase in the amount of allergenic proteins contained in pollen; 4) an increase in the start time of plant growth and, therefore, the start of pollen production; 5) an earlier and longer pollen season; 6) change in the geospatial distribution of pollen, that is plant ranges and long-distance atmospheric transport moving polewards,” they write.
 

Bad air

In addition to pollen, the ambient air in many places is increasingly becoming saturated with bioallergenic proteins such as bacteria, viruses, animal dander, insects, molds, and plant species, Ms. Balakrishnan and colleagues noted, adding that “atmospheric levels of carbon dioxide have also been found to increase pollen productivity. These changes result in greater over-the-counter medication use, emergency department visits, and outpatient visits for respiratory illnesses.”

The rash of violent storms that has washed over much of the United States in recent months is also likely to increase the incidence of so-called “thunderstorm asthma,” caused when large quantities of respirable particulate matter are released before or during a thunderstorm.

Air pollution from the burning of carbon-based fuels and from wildfires sparked by hotter and drier conditions increase airborne particulate matter that can seriously exacerbate asthma, COPD, and other obstructive airway conditions.

In addition, as previously reported by Medscape, exposure to particulate matter has been implicated as a possible cause of non–small cell lung cancer in persons who have never smoked.
 

Critical care challenges

Among the myriad other effects of climate change postulated in evidence enumerated by Ms. Balakrishnan and colleagues are chest infections and pleural diseases, such as aspergillosis infections that occur after catastrophic flooding; increased incidence of Mycobacterium avium complex infections and hypersensitivity pneumonitis; increased demands on critical care specialists from natural disasters; pollution-induced cardiac arrest; and heat prostration and heat stroke from increasingly prevalent heat waves.

The reviewers also examined evidence suggesting links between climate change and pulmonary hypertension, interstitial lung disease, sleep disorders, and occupational pulmonary disorders.
 

Power to the patients

“Pulmonologists should counsel patients on ways to minimize outdoor and indoor pollution, using tight-fitting respirators and home air-purifying systems without encroaching on patients’ beliefs and choices,” the authors advise.

“Empowering patients with resources to monitor air quality daily, in inclement weather, and during disasters would help minimize exposure and thus improve overall health. The pulmonologist can play an important role in emphasizing the impact of climate change on pulmonary disorders during patient care encounters,” they write.

Ms. Balakrishan adds that another important mitigation measure that can be taken today is education.

“In medical school we don’t really learn about the impact of climate change – at least in my generation of physicians, climate change or global warming weren’t part of the medical curriculum – but now I think that there’s a lot of advocacy work being done by medical students who actually want more education on climate change and its effects on pulmonary diseases,” she said.

The study by Ms. Balakrishnan and colleagues was unfunded. Ms. Balakrishnan reports no relevant financial relationships. Co-author Mary-Beth Scholand, MD, has received personal fees from serving on advisory boards and speakers bureaus for Genentech, Boehringer Ingelheim, Veracyte, and United Therapeutics. Co-author Sean Callahan, MD, has received personal fees for serving on advisory boards for Gilead and Boehringer Ingelheim. Dr. Fineman reports no relevant financial relationships.

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

To see the harmful effects of climate change firsthand, you need look no farther than the nearest pulmonary clinic.

The causes and effects are unmistakable: pollen storms leading to allergy sufferers flooding into allergists’ offices; rising air pollution levels increasing risk for obstructive airway diseases, cardiopulmonary complications, and non–small cell lung cancer; melting snowpacks and atmospheric rivers inundating neighborhoods and leaving moldy debris and incipient fungal infections in their wake.

“The reason why we think climate change is going to change the type of disease patterns and the severity of illness that we see in patients with respiratory diseases is that it changes a lot of the environment as well as the exposures,” said Bathmapriya Balakrishnan, BMedSci, BMBS, from the section of Pulmonary, Critical Care, and Sleep Medicine in the department of medicine at West Virginia University, Morgantown.

“What we’re going to see is not just new diseases but also exacerbation of chronic diseases, things like asthma [and] COPD. And there’s also concern that patients who are otherwise healthy, because they now have more exposures that are due to climate change, can then develop these diseases,” she said in an interview.

Ms. Balakrishnan is the lead author of a comprehensive, evidence-based review focused on the effects of climate change and air pollution across the spectrum of pulmonary disorders. The review is published online ahead of print in the journal Chest.

“As pulmonologists, understanding and improving awareness of the adverse effects of climate change and air pollution are crucial steps. To inform health care providers of evidence-based methods and improve patient counselling, further research regarding measures that limit exposure is needed. Empowering patients with resources to monitor air quality and minimize exposure is a key preventative measure for decreasing morbidity and mortality while improving quality of  life,” Ms. Balakrishnan and colleagues write.

Similarly, in a statement on the effects of climate change on respiratory health, the American Public Health Association succinctly summarized the problem: “Warmer temperatures lead to an increase in pollutants and allergens. Poor air quality leads to reduced lung function, increased risk of asthma complications, heart attacks, heart failure, and death. Air pollution and allergens are the main exposures affecting lung and heart health in this changing climate.”
 

Early spring

Stanley Fineman, MD, MBA, a past president of the American College of Allergy, Asthma, & Immunology and an allergist in private practice in Atlanta, has seen firsthand how global warming and an earlier start to spring allergy season is affecting his patients.

“The season, at least in our area metro Atlanta, started earlier and has been lasting longer. The pollen counts are very high,” he told this news organization.

“In February we started seeing pollen counts over 1,000 [grams per cubic meter], which is unheard of, and in March about half the days we counted levels that were over 1,000, which is also unheard of. In April it was over 1,000 almost half the days.”

Dr. Fineman and colleagues both in Atlanta and across the country have reported sharp increases in the proportion of new adult patients and in existing patients who have experienced exacerbation of previously mild disease.

“Probably what’s happened is that they may have had some allergic sensitivity that resulted in milder manifestations, but this year they’re getting major manifestations,” Dr. Fineman said.

In a 2014 article in the journal European Respiratory Review, Gennaro D’Amato, MD, from High Speciality Hospital Antonio Cardarelli, Naples, Italy, and colleagues outlined the main effects of climate on pollen levels: “1) an increase in plant growth and faster plant growth; 2) an increase in the amount of pollen produced by each plant; 3) an increase in the amount of allergenic proteins contained in pollen; 4) an increase in the start time of plant growth and, therefore, the start of pollen production; 5) an earlier and longer pollen season; 6) change in the geospatial distribution of pollen, that is plant ranges and long-distance atmospheric transport moving polewards,” they write.
 

Bad air

In addition to pollen, the ambient air in many places is increasingly becoming saturated with bioallergenic proteins such as bacteria, viruses, animal dander, insects, molds, and plant species, Ms. Balakrishnan and colleagues noted, adding that “atmospheric levels of carbon dioxide have also been found to increase pollen productivity. These changes result in greater over-the-counter medication use, emergency department visits, and outpatient visits for respiratory illnesses.”

The rash of violent storms that has washed over much of the United States in recent months is also likely to increase the incidence of so-called “thunderstorm asthma,” caused when large quantities of respirable particulate matter are released before or during a thunderstorm.

Air pollution from the burning of carbon-based fuels and from wildfires sparked by hotter and drier conditions increase airborne particulate matter that can seriously exacerbate asthma, COPD, and other obstructive airway conditions.

In addition, as previously reported by Medscape, exposure to particulate matter has been implicated as a possible cause of non–small cell lung cancer in persons who have never smoked.
 

Critical care challenges

Among the myriad other effects of climate change postulated in evidence enumerated by Ms. Balakrishnan and colleagues are chest infections and pleural diseases, such as aspergillosis infections that occur after catastrophic flooding; increased incidence of Mycobacterium avium complex infections and hypersensitivity pneumonitis; increased demands on critical care specialists from natural disasters; pollution-induced cardiac arrest; and heat prostration and heat stroke from increasingly prevalent heat waves.

The reviewers also examined evidence suggesting links between climate change and pulmonary hypertension, interstitial lung disease, sleep disorders, and occupational pulmonary disorders.
 

Power to the patients

“Pulmonologists should counsel patients on ways to minimize outdoor and indoor pollution, using tight-fitting respirators and home air-purifying systems without encroaching on patients’ beliefs and choices,” the authors advise.

“Empowering patients with resources to monitor air quality daily, in inclement weather, and during disasters would help minimize exposure and thus improve overall health. The pulmonologist can play an important role in emphasizing the impact of climate change on pulmonary disorders during patient care encounters,” they write.

Ms. Balakrishan adds that another important mitigation measure that can be taken today is education.

“In medical school we don’t really learn about the impact of climate change – at least in my generation of physicians, climate change or global warming weren’t part of the medical curriculum – but now I think that there’s a lot of advocacy work being done by medical students who actually want more education on climate change and its effects on pulmonary diseases,” she said.

The study by Ms. Balakrishnan and colleagues was unfunded. Ms. Balakrishnan reports no relevant financial relationships. Co-author Mary-Beth Scholand, MD, has received personal fees from serving on advisory boards and speakers bureaus for Genentech, Boehringer Ingelheim, Veracyte, and United Therapeutics. Co-author Sean Callahan, MD, has received personal fees for serving on advisory boards for Gilead and Boehringer Ingelheim. Dr. Fineman reports no relevant financial relationships.

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

Dysphagia treatment may be a way to reduce risk for chronic obstructive pulmonary disease (COPD) exacerbations, according to Yoshitaka Oku, MD, of Hyogo Medical University, Nishinomiya, Japan.

Gastroesophageal regurgitation disease (GERD) is known to be associated with exacerbations in COPD, but previous studies have shown little impact of standard GERD therapy on COPD exacerbations. However, additional research indicates that delayed swallowing contributes to COPD exacerbations, as reported in a research review.

In an article published recently in Respiratory Physiology & Neurobiology, Dr. Oku hypothesized that swallowing abnormalities are a confounding factor in the association between GERD and COPD exacerbation, and that counteracting swallowing disorders may reduce COPD exacerbations.

Swallowing disorder (dysphagia) is a common comorbidity in patients with COPD and has been reported at a 17%-20% greater prevalence in those with COPD, compared with controls, the researchers said.

Patients with COPD have altered swallowing behavior because of several factors, including decreased maximal laryngeal elevation, Dr. Oku said. Individuals with COPD “are also prone to laryngeal penetration and aspiration when swallowing large volumes of liquid and tend to follow an inspiratory-swallow-expiratory (I-SW-E) pattern when swallowing large volumes,” he explained.

Dr. Oku conducted prospective studies to investigate the impact of breathing-swallowing discoordination on COPD exacerbation. He found that discoordination in swallowing patterns and the inability to produce airway protective mechanism (such as the I-SW-E pattern) may contribute to more frequent aspirations and more frequent exacerbations.

Dr. Oku also examined whether CPAP and bilevel positive airway pressure (BiPAP) might affect breathing-swallowing coordination in healthy controls and patients with COPD. They found a decrease in breathing-swallowing coordination with CPAP, but not BiPAP, in both controls and stable COPD patients. “During BiPAP, a brief negative flow associated with relaxation of the pharyngeal constrictor muscle triggers inspiratory support, which results in the SW-I pattern,” Dr. Oku noted.

Dr. Oku also wrote that interferential current stimulation (IFC) has been used to stimulate muscles. Studies of transcutaneous electrical sensory stimulation using IFC (IFC-TESS) as an intervention to improve swallowing have shown some success, and also may improve airway protection.

“However, its safety and efficacy in patients with COPD remains unknown,” he wrote. Dr. Oku conducted a study of stable COPD patients and found that repeated salivary swallow test (RSST) scores improved significantly after an IFC-TESS intervention.

Breathing-swallowing discoordination may be an early indicator of swallowing disorder in COPD, and interventions can improve these disorders, Dr. Oku added. However, more research is needed to explore whether interventions to improve dysphagia reduce the frequency of exacerbations in COPD patients, he concluded.

The study was supported by a grant from JSPS KAKENHI. Dr. Oku serves as a senior managing director at EuSense Medical Co.

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

Dysphagia treatment may be a way to reduce risk for chronic obstructive pulmonary disease (COPD) exacerbations, according to Yoshitaka Oku, MD, of Hyogo Medical University, Nishinomiya, Japan.

Gastroesophageal regurgitation disease (GERD) is known to be associated with exacerbations in COPD, but previous studies have shown little impact of standard GERD therapy on COPD exacerbations. However, additional research indicates that delayed swallowing contributes to COPD exacerbations, as reported in a research review.

In an article published recently in Respiratory Physiology & Neurobiology, Dr. Oku hypothesized that swallowing abnormalities are a confounding factor in the association between GERD and COPD exacerbation, and that counteracting swallowing disorders may reduce COPD exacerbations.

Swallowing disorder (dysphagia) is a common comorbidity in patients with COPD and has been reported at a 17%-20% greater prevalence in those with COPD, compared with controls, the researchers said.

Patients with COPD have altered swallowing behavior because of several factors, including decreased maximal laryngeal elevation, Dr. Oku said. Individuals with COPD “are also prone to laryngeal penetration and aspiration when swallowing large volumes of liquid and tend to follow an inspiratory-swallow-expiratory (I-SW-E) pattern when swallowing large volumes,” he explained.

Dr. Oku conducted prospective studies to investigate the impact of breathing-swallowing discoordination on COPD exacerbation. He found that discoordination in swallowing patterns and the inability to produce airway protective mechanism (such as the I-SW-E pattern) may contribute to more frequent aspirations and more frequent exacerbations.

Dr. Oku also examined whether CPAP and bilevel positive airway pressure (BiPAP) might affect breathing-swallowing coordination in healthy controls and patients with COPD. They found a decrease in breathing-swallowing coordination with CPAP, but not BiPAP, in both controls and stable COPD patients. “During BiPAP, a brief negative flow associated with relaxation of the pharyngeal constrictor muscle triggers inspiratory support, which results in the SW-I pattern,” Dr. Oku noted.

Dr. Oku also wrote that interferential current stimulation (IFC) has been used to stimulate muscles. Studies of transcutaneous electrical sensory stimulation using IFC (IFC-TESS) as an intervention to improve swallowing have shown some success, and also may improve airway protection.

“However, its safety and efficacy in patients with COPD remains unknown,” he wrote. Dr. Oku conducted a study of stable COPD patients and found that repeated salivary swallow test (RSST) scores improved significantly after an IFC-TESS intervention.

Breathing-swallowing discoordination may be an early indicator of swallowing disorder in COPD, and interventions can improve these disorders, Dr. Oku added. However, more research is needed to explore whether interventions to improve dysphagia reduce the frequency of exacerbations in COPD patients, he concluded.

The study was supported by a grant from JSPS KAKENHI. Dr. Oku serves as a senior managing director at EuSense Medical Co.

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

Dysphagia treatment may be a way to reduce risk for chronic obstructive pulmonary disease (COPD) exacerbations, according to Yoshitaka Oku, MD, of Hyogo Medical University, Nishinomiya, Japan.

Gastroesophageal regurgitation disease (GERD) is known to be associated with exacerbations in COPD, but previous studies have shown little impact of standard GERD therapy on COPD exacerbations. However, additional research indicates that delayed swallowing contributes to COPD exacerbations, as reported in a research review.

In an article published recently in Respiratory Physiology & Neurobiology, Dr. Oku hypothesized that swallowing abnormalities are a confounding factor in the association between GERD and COPD exacerbation, and that counteracting swallowing disorders may reduce COPD exacerbations.

Swallowing disorder (dysphagia) is a common comorbidity in patients with COPD and has been reported at a 17%-20% greater prevalence in those with COPD, compared with controls, the researchers said.

Patients with COPD have altered swallowing behavior because of several factors, including decreased maximal laryngeal elevation, Dr. Oku said. Individuals with COPD “are also prone to laryngeal penetration and aspiration when swallowing large volumes of liquid and tend to follow an inspiratory-swallow-expiratory (I-SW-E) pattern when swallowing large volumes,” he explained.

Dr. Oku conducted prospective studies to investigate the impact of breathing-swallowing discoordination on COPD exacerbation. He found that discoordination in swallowing patterns and the inability to produce airway protective mechanism (such as the I-SW-E pattern) may contribute to more frequent aspirations and more frequent exacerbations.

Dr. Oku also examined whether CPAP and bilevel positive airway pressure (BiPAP) might affect breathing-swallowing coordination in healthy controls and patients with COPD. They found a decrease in breathing-swallowing coordination with CPAP, but not BiPAP, in both controls and stable COPD patients. “During BiPAP, a brief negative flow associated with relaxation of the pharyngeal constrictor muscle triggers inspiratory support, which results in the SW-I pattern,” Dr. Oku noted.

Dr. Oku also wrote that interferential current stimulation (IFC) has been used to stimulate muscles. Studies of transcutaneous electrical sensory stimulation using IFC (IFC-TESS) as an intervention to improve swallowing have shown some success, and also may improve airway protection.

“However, its safety and efficacy in patients with COPD remains unknown,” he wrote. Dr. Oku conducted a study of stable COPD patients and found that repeated salivary swallow test (RSST) scores improved significantly after an IFC-TESS intervention.

Breathing-swallowing discoordination may be an early indicator of swallowing disorder in COPD, and interventions can improve these disorders, Dr. Oku added. However, more research is needed to explore whether interventions to improve dysphagia reduce the frequency of exacerbations in COPD patients, he concluded.

The study was supported by a grant from JSPS KAKENHI. Dr. Oku serves as a senior managing director at EuSense Medical Co.

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

In case anybody hasn’t noticed, the good ole days are long gone in which pediatric patients with mental health challenges could be simply referred out to be promptly assessed and treated by specialists. Due to a shortage of psychiatrists coupled with large increases in the number of youth presenting with emotional-behavioral difficulties, primary care clinicians are now called upon to fill in much of this gap, with professional organizations like the AAP articulating that mental health treatment, within reason, is squarely in the primary care clinician’s “lane” and scope of treatment.¹

Dr. Rettew

To meet this need, new models of integrated or collaborative care between primary care and mental health clinicians have been attempted and tested. While these initiatives have certainly been a welcome advance to many pediatricians, the large numbers of different models and initiatives out there have made for a rather confusing landscape that many busy primary care clinicians have found difficult to navigate.

In an attempt to offer some guidance on the subject, the American Academy of Child and Adolescent Psychiatry recently published a clinical update on pediatric collaborative care.² The report is rich with resources and ideas. One of the main points of the document is that there are different levels of integration that exist. Kind of like the situation with recycling and household waste reduction, it is possible to make valuable improvements at any level of participation, although evidence suggests that more extensive efforts offer the most benefits. At one end of the spectrum, psychiatrists and primary care clinicians maintain separate practices and medical records and occasionally discuss mutual patients. Middle levels may include “colocation” with mental health and primary care professionals sharing a building and/or being part of the same overall system but continuing to work mainly independently. At the highest levels of integration, there is a coordinated and collaborative team that supports an intentional system of care with consistent communication about individual patients and general workflows. These approaches vary in the amount that the following four core areas of integrated care are incorporated.

• Direct service. Many integrated care initiatives heavily rely on the services of an on-site mental health care manager or behavioral health consultant who can provide a number of important functions such as overseeing of the integrated care program, conducting brief therapy with youth and parents, overseeing mental health screenings at the clinic, and providing general mental health promotion guidance.
• Care coordination. Helping patients and families find needed mental health, social services, and educational resources is a key component of integrated care. This task can fall to the practice’s behavioral health consultant, if there is one, but more general care coordinators can also be trained for this important role. The University of Washington’s Center for Advancing Integrated Mental Health Solutions has some published guidelines in this area.³
• Consultation. More advanced integrated care models often have established relationships to specific child psychiatric clinicians who are able to meet with the primary care team to discuss cases and general approaches to various problems. Alternatively, a number of states have implemented what are called Child Psychiatry Access Programs that give primary care clinicians a phone number to an organization (often affiliated with an academic medical center) that can provide quick and even immediate access to a child psychiatry provider for specific questions. Recent federal grants have led to many if not most states now having one of these programs in place, and a website listing these programs and their contact information is available.⁴
• Education. As mental health training was traditionally not part of a typical pediatrics residency, there have been a number of strategies introduced to help primary care clinicians increase their proficiency and comfort level when it comes to assessing and treating emotional-behavioral problems. These include specific conferences, online programs, and case-based training through mechanisms like the ECHO program.^5,6 The AAP itself has released a number of toolkits and training materials related to mental health care that are available.⁷

The report also outlines some obstacles that continue to get in the way of more extensive integrative care efforts. Chief among them are financial concerns, including how to pay for what often are traditionally nonbillable efforts, particularly those that involve the communication of two expensive health care professionals. Some improvements have been made, however, such as the creation of some relatively new codes (such as 99451 and 99452) that can be submitted by both a primary care and mental health professional when there is a consultation that occurs that does not involve an actual face-to-face encounter.

One area that, in my view, has not received the level of attention it deserves when it comes to integrated care is the degree to which these programs have the potential not only to improve the care of children and adolescents already struggling with mental health challenges but also to serve as a powerful prevention tool to lower the risk of being diagnosed with a psychiatric disorder in the future and generally to improve levels of well-being. Thus far, however, research on various integrated programs has shown promising results that indicate that overall care for patients with mental health challenges improves.⁸ Further, when it comes to costs, there is some evidence to suggest that some of the biggest financial gains associated with integrated care has to do with reduced nonpsychiatric medical expenses of patients.⁹ This, then, suggests that practices that participate in capitated or accountable care organization structures could particularly benefit both clinically and financially from these collaborations.

If your practice has been challenged with the level of mental health care you are now expected to provide and has been contemplating even some small moves toward integrated care, now may the time to put those thoughts into action.

References

1. Foy JM et al. American Academy of Pediatrics policy statement. Mental health competencies for pediatric practice. Pediatrics. 2019;144(5):e20192757.

2. AACAP Committee on Collaborative and Integrated Care and AACAP Committee on Quality Issues. Clinical update: Collaborative mental health care for children and adolescents in pediatric primary care. J Am Acad Child Adolesc Psychiatry. 2023;62(2):91-119.

3. Behavioral health care managers. AIMS Center, University of Washington. Accessed May 5, 2023. Available at https://aims.uw.edu/online-bhcm-modules.

4. National Network of Child Psychiatry Access Programs. Accessed May 5, 2023. Available at https://www.nncpap.org/.

5. Project Echo Programs. Accessed May 5, 2023. https://hsc.unm.edu/echo.

6. Project TEACH. Accessed May 5, 2023. https://projectteachny.org.

7. Earls MF et al. Addressing mental health concerns in pediatrics: A practical resource toolkit for clinicians, 2nd edition. Itasca, Ill.: American Academy of Pediatrics, 2021.

8. Asarnow JR et al. Integrated medical-behavioral care compared with usual primary care for child and adolescent behavioral health: A meta analysis. JAMA Pediatr. 2015;169(10):929-37.

9. Unutzer J et al. Long-term costs effects of collaborative care for late-life depression. Am J Manag Care. 2008.14(2):95-100.
 

Dr. Rettew is a child and adolescent psychiatrist with Lane County Behavioral Health in Eugene, Ore., and Oregon Health & Science University, Portland. His latest book is “Parenting Made Complicated: What Science Really Knows about the Greatest Debates of Early Childhood.” You can follow him on Twitter and Facebook @PediPsych.

In case anybody hasn’t noticed, the good ole days are long gone in which pediatric patients with mental health challenges could be simply referred out to be promptly assessed and treated by specialists. Due to a shortage of psychiatrists coupled with large increases in the number of youth presenting with emotional-behavioral difficulties, primary care clinicians are now called upon to fill in much of this gap, with professional organizations like the AAP articulating that mental health treatment, within reason, is squarely in the primary care clinician’s “lane” and scope of treatment.¹

Dr. Rettew

To meet this need, new models of integrated or collaborative care between primary care and mental health clinicians have been attempted and tested. While these initiatives have certainly been a welcome advance to many pediatricians, the large numbers of different models and initiatives out there have made for a rather confusing landscape that many busy primary care clinicians have found difficult to navigate.

In an attempt to offer some guidance on the subject, the American Academy of Child and Adolescent Psychiatry recently published a clinical update on pediatric collaborative care.² The report is rich with resources and ideas. One of the main points of the document is that there are different levels of integration that exist. Kind of like the situation with recycling and household waste reduction, it is possible to make valuable improvements at any level of participation, although evidence suggests that more extensive efforts offer the most benefits. At one end of the spectrum, psychiatrists and primary care clinicians maintain separate practices and medical records and occasionally discuss mutual patients. Middle levels may include “colocation” with mental health and primary care professionals sharing a building and/or being part of the same overall system but continuing to work mainly independently. At the highest levels of integration, there is a coordinated and collaborative team that supports an intentional system of care with consistent communication about individual patients and general workflows. These approaches vary in the amount that the following four core areas of integrated care are incorporated.

• Direct service. Many integrated care initiatives heavily rely on the services of an on-site mental health care manager or behavioral health consultant who can provide a number of important functions such as overseeing of the integrated care program, conducting brief therapy with youth and parents, overseeing mental health screenings at the clinic, and providing general mental health promotion guidance.
• Care coordination. Helping patients and families find needed mental health, social services, and educational resources is a key component of integrated care. This task can fall to the practice’s behavioral health consultant, if there is one, but more general care coordinators can also be trained for this important role. The University of Washington’s Center for Advancing Integrated Mental Health Solutions has some published guidelines in this area.³
• Consultation. More advanced integrated care models often have established relationships to specific child psychiatric clinicians who are able to meet with the primary care team to discuss cases and general approaches to various problems. Alternatively, a number of states have implemented what are called Child Psychiatry Access Programs that give primary care clinicians a phone number to an organization (often affiliated with an academic medical center) that can provide quick and even immediate access to a child psychiatry provider for specific questions. Recent federal grants have led to many if not most states now having one of these programs in place, and a website listing these programs and their contact information is available.⁴
• Education. As mental health training was traditionally not part of a typical pediatrics residency, there have been a number of strategies introduced to help primary care clinicians increase their proficiency and comfort level when it comes to assessing and treating emotional-behavioral problems. These include specific conferences, online programs, and case-based training through mechanisms like the ECHO program.^5,6 The AAP itself has released a number of toolkits and training materials related to mental health care that are available.⁷

The report also outlines some obstacles that continue to get in the way of more extensive integrative care efforts. Chief among them are financial concerns, including how to pay for what often are traditionally nonbillable efforts, particularly those that involve the communication of two expensive health care professionals. Some improvements have been made, however, such as the creation of some relatively new codes (such as 99451 and 99452) that can be submitted by both a primary care and mental health professional when there is a consultation that occurs that does not involve an actual face-to-face encounter.

One area that, in my view, has not received the level of attention it deserves when it comes to integrated care is the degree to which these programs have the potential not only to improve the care of children and adolescents already struggling with mental health challenges but also to serve as a powerful prevention tool to lower the risk of being diagnosed with a psychiatric disorder in the future and generally to improve levels of well-being. Thus far, however, research on various integrated programs has shown promising results that indicate that overall care for patients with mental health challenges improves.⁸ Further, when it comes to costs, there is some evidence to suggest that some of the biggest financial gains associated with integrated care has to do with reduced nonpsychiatric medical expenses of patients.⁹ This, then, suggests that practices that participate in capitated or accountable care organization structures could particularly benefit both clinically and financially from these collaborations.

If your practice has been challenged with the level of mental health care you are now expected to provide and has been contemplating even some small moves toward integrated care, now may the time to put those thoughts into action.

References

1. Foy JM et al. American Academy of Pediatrics policy statement. Mental health competencies for pediatric practice. Pediatrics. 2019;144(5):e20192757.

2. AACAP Committee on Collaborative and Integrated Care and AACAP Committee on Quality Issues. Clinical update: Collaborative mental health care for children and adolescents in pediatric primary care. J Am Acad Child Adolesc Psychiatry. 2023;62(2):91-119.

3. Behavioral health care managers. AIMS Center, University of Washington. Accessed May 5, 2023. Available at https://aims.uw.edu/online-bhcm-modules.

4. National Network of Child Psychiatry Access Programs. Accessed May 5, 2023. Available at https://www.nncpap.org/.

5. Project Echo Programs. Accessed May 5, 2023. https://hsc.unm.edu/echo.

6. Project TEACH. Accessed May 5, 2023. https://projectteachny.org.

7. Earls MF et al. Addressing mental health concerns in pediatrics: A practical resource toolkit for clinicians, 2nd edition. Itasca, Ill.: American Academy of Pediatrics, 2021.

8. Asarnow JR et al. Integrated medical-behavioral care compared with usual primary care for child and adolescent behavioral health: A meta analysis. JAMA Pediatr. 2015;169(10):929-37.

9. Unutzer J et al. Long-term costs effects of collaborative care for late-life depression. Am J Manag Care. 2008.14(2):95-100.
 

Dr. Rettew is a child and adolescent psychiatrist with Lane County Behavioral Health in Eugene, Ore., and Oregon Health & Science University, Portland. His latest book is “Parenting Made Complicated: What Science Really Knows about the Greatest Debates of Early Childhood.” You can follow him on Twitter and Facebook @PediPsych.

In case anybody hasn’t noticed, the good ole days are long gone in which pediatric patients with mental health challenges could be simply referred out to be promptly assessed and treated by specialists. Due to a shortage of psychiatrists coupled with large increases in the number of youth presenting with emotional-behavioral difficulties, primary care clinicians are now called upon to fill in much of this gap, with professional organizations like the AAP articulating that mental health treatment, within reason, is squarely in the primary care clinician’s “lane” and scope of treatment.¹

Dr. Rettew

To meet this need, new models of integrated or collaborative care between primary care and mental health clinicians have been attempted and tested. While these initiatives have certainly been a welcome advance to many pediatricians, the large numbers of different models and initiatives out there have made for a rather confusing landscape that many busy primary care clinicians have found difficult to navigate.

In an attempt to offer some guidance on the subject, the American Academy of Child and Adolescent Psychiatry recently published a clinical update on pediatric collaborative care.² The report is rich with resources and ideas. One of the main points of the document is that there are different levels of integration that exist. Kind of like the situation with recycling and household waste reduction, it is possible to make valuable improvements at any level of participation, although evidence suggests that more extensive efforts offer the most benefits. At one end of the spectrum, psychiatrists and primary care clinicians maintain separate practices and medical records and occasionally discuss mutual patients. Middle levels may include “colocation” with mental health and primary care professionals sharing a building and/or being part of the same overall system but continuing to work mainly independently. At the highest levels of integration, there is a coordinated and collaborative team that supports an intentional system of care with consistent communication about individual patients and general workflows. These approaches vary in the amount that the following four core areas of integrated care are incorporated.

• Direct service. Many integrated care initiatives heavily rely on the services of an on-site mental health care manager or behavioral health consultant who can provide a number of important functions such as overseeing of the integrated care program, conducting brief therapy with youth and parents, overseeing mental health screenings at the clinic, and providing general mental health promotion guidance.
• Care coordination. Helping patients and families find needed mental health, social services, and educational resources is a key component of integrated care. This task can fall to the practice’s behavioral health consultant, if there is one, but more general care coordinators can also be trained for this important role. The University of Washington’s Center for Advancing Integrated Mental Health Solutions has some published guidelines in this area.³
• Consultation. More advanced integrated care models often have established relationships to specific child psychiatric clinicians who are able to meet with the primary care team to discuss cases and general approaches to various problems. Alternatively, a number of states have implemented what are called Child Psychiatry Access Programs that give primary care clinicians a phone number to an organization (often affiliated with an academic medical center) that can provide quick and even immediate access to a child psychiatry provider for specific questions. Recent federal grants have led to many if not most states now having one of these programs in place, and a website listing these programs and their contact information is available.⁴
• Education. As mental health training was traditionally not part of a typical pediatrics residency, there have been a number of strategies introduced to help primary care clinicians increase their proficiency and comfort level when it comes to assessing and treating emotional-behavioral problems. These include specific conferences, online programs, and case-based training through mechanisms like the ECHO program.^5,6 The AAP itself has released a number of toolkits and training materials related to mental health care that are available.⁷

The report also outlines some obstacles that continue to get in the way of more extensive integrative care efforts. Chief among them are financial concerns, including how to pay for what often are traditionally nonbillable efforts, particularly those that involve the communication of two expensive health care professionals. Some improvements have been made, however, such as the creation of some relatively new codes (such as 99451 and 99452) that can be submitted by both a primary care and mental health professional when there is a consultation that occurs that does not involve an actual face-to-face encounter.

One area that, in my view, has not received the level of attention it deserves when it comes to integrated care is the degree to which these programs have the potential not only to improve the care of children and adolescents already struggling with mental health challenges but also to serve as a powerful prevention tool to lower the risk of being diagnosed with a psychiatric disorder in the future and generally to improve levels of well-being. Thus far, however, research on various integrated programs has shown promising results that indicate that overall care for patients with mental health challenges improves.⁸ Further, when it comes to costs, there is some evidence to suggest that some of the biggest financial gains associated with integrated care has to do with reduced nonpsychiatric medical expenses of patients.⁹ This, then, suggests that practices that participate in capitated or accountable care organization structures could particularly benefit both clinically and financially from these collaborations.

If your practice has been challenged with the level of mental health care you are now expected to provide and has been contemplating even some small moves toward integrated care, now may the time to put those thoughts into action.

References

1. Foy JM et al. American Academy of Pediatrics policy statement. Mental health competencies for pediatric practice. Pediatrics. 2019;144(5):e20192757.

2. AACAP Committee on Collaborative and Integrated Care and AACAP Committee on Quality Issues. Clinical update: Collaborative mental health care for children and adolescents in pediatric primary care. J Am Acad Child Adolesc Psychiatry. 2023;62(2):91-119.

3. Behavioral health care managers. AIMS Center, University of Washington. Accessed May 5, 2023. Available at https://aims.uw.edu/online-bhcm-modules.

4. National Network of Child Psychiatry Access Programs. Accessed May 5, 2023. Available at https://www.nncpap.org/.

5. Project Echo Programs. Accessed May 5, 2023. https://hsc.unm.edu/echo.

6. Project TEACH. Accessed May 5, 2023. https://projectteachny.org.

7. Earls MF et al. Addressing mental health concerns in pediatrics: A practical resource toolkit for clinicians, 2nd edition. Itasca, Ill.: American Academy of Pediatrics, 2021.

8. Asarnow JR et al. Integrated medical-behavioral care compared with usual primary care for child and adolescent behavioral health: A meta analysis. JAMA Pediatr. 2015;169(10):929-37.

9. Unutzer J et al. Long-term costs effects of collaborative care for late-life depression. Am J Manag Care. 2008.14(2):95-100.
 

Dr. Rettew is a child and adolescent psychiatrist with Lane County Behavioral Health in Eugene, Ore., and Oregon Health & Science University, Portland. His latest book is “Parenting Made Complicated: What Science Really Knows about the Greatest Debates of Early Childhood.” You can follow him on Twitter and Facebook @PediPsych.