The incidence of metastatic prostate cancer shot up in the United States after the U.S. Preventive Services Task Force recommended against routinely screening men with the prostate-specific antigen (PSA), shows a report published online in JAMA Network Open.

It was a consequence that many experts in prostate cancer predicted at the time the recommendation was made – initially in 2008 against routine screening in men older than 75 years, then in all men in 2012.

The thinking was that the harms of screening all men – leading to unnecessary prostatectomies and other treatments in many men – outweighed the benefits of catching early high-risk disease in fewer men. Screening rates plummeted as a result.

But experts in prostate cancer warned that the move, while reducing overdiagnosis and overtreatment, would have the unfortunate consequence of underdiagnosis and, consequently, nondetection of the cases of prostate cancer that would spread. 

The new findings are the latest to suggest that this is, in fact, what happened, and echo similar findings previously reported by this news organization.  

For this study, investigators at the University of Southern California, Los Angeles, analyzed the incidence of metastatic prostate cancer (mPCa) in the Surveillance, Epidemiology, and End Results (SEER) database from 2004-2018, with 2018 being the latest data available.

SEER captures about 28% of the U.S. population and recorded almost 50,000 new mPCa cases over the period.

Among men 45-75 years old, the incidence of mPCa increased 41% from when USPSTF recommended against screening through 2018, which translated to an annual percentage change (APC) of 5.3%.

Among men 75 years and older, mPCa rates jumped 43% through 2018, an APC of 6.5%.

The researchers did not find an increase in deaths from prostate cancer, but given the 5-7 years median survival, it might be too early to tell.

“The observation of a rising incidence of mPCa in itself does not imply that screening practices should be changed. The overall risk versus benefit of PSA-based screening is extremely complex and must take into account various other factors that impact the overall health of the community,” say investigators, led by Mihir Desai, MD, a clinical urology professor at USC. 

However, screening practices have already changed. The USPSTF withdrew its objections to screening in 2018 and instead recommended personalized decisionmaking for men 55-69 years old, citing new evidence that screening prevents metastatic disease and reduces PCa mortality more than previously recognized, Richard Hoffman, MD, MPH, an internal medicine professor at the University of Iowa, Iowa City, said in an accompanying editorial.

The study’s trends in mPCa “might be transitory because the screening guidelines have” changed, Dr. Hoffman writes.

For now, clinicians should “consistently address screening with men who are healthy enough to benefit” from catching dangerous tumors early and engage them “in shared decisionmaking discussions to” strike the right balance between minimizing overdiagnosis and catching high-risk tumors before they spread, he said.

Easier said than done, but the field is advancing. Active surveillance, instead of surgery, for what seem to be low-risk tumors is one step in the right direction, Dr. Hoffman commented. 

No external funding was reported. Dr. Desai is a consultant for Procept Biorobotics and Auris Surgical. Dr. Hoffman reported royalties from UpToDate and fees from law firms as an expert witness on prostate cancer screening cases.

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

The incidence of metastatic prostate cancer shot up in the United States after the U.S. Preventive Services Task Force recommended against routinely screening men with the prostate-specific antigen (PSA), shows a report published online in JAMA Network Open.

It was a consequence that many experts in prostate cancer predicted at the time the recommendation was made – initially in 2008 against routine screening in men older than 75 years, then in all men in 2012.

The thinking was that the harms of screening all men – leading to unnecessary prostatectomies and other treatments in many men – outweighed the benefits of catching early high-risk disease in fewer men. Screening rates plummeted as a result.

But experts in prostate cancer warned that the move, while reducing overdiagnosis and overtreatment, would have the unfortunate consequence of underdiagnosis and, consequently, nondetection of the cases of prostate cancer that would spread. 

The new findings are the latest to suggest that this is, in fact, what happened, and echo similar findings previously reported by this news organization.  

For this study, investigators at the University of Southern California, Los Angeles, analyzed the incidence of metastatic prostate cancer (mPCa) in the Surveillance, Epidemiology, and End Results (SEER) database from 2004-2018, with 2018 being the latest data available.

SEER captures about 28% of the U.S. population and recorded almost 50,000 new mPCa cases over the period.

Among men 45-75 years old, the incidence of mPCa increased 41% from when USPSTF recommended against screening through 2018, which translated to an annual percentage change (APC) of 5.3%.

Among men 75 years and older, mPCa rates jumped 43% through 2018, an APC of 6.5%.

The researchers did not find an increase in deaths from prostate cancer, but given the 5-7 years median survival, it might be too early to tell.

“The observation of a rising incidence of mPCa in itself does not imply that screening practices should be changed. The overall risk versus benefit of PSA-based screening is extremely complex and must take into account various other factors that impact the overall health of the community,” say investigators, led by Mihir Desai, MD, a clinical urology professor at USC. 

However, screening practices have already changed. The USPSTF withdrew its objections to screening in 2018 and instead recommended personalized decisionmaking for men 55-69 years old, citing new evidence that screening prevents metastatic disease and reduces PCa mortality more than previously recognized, Richard Hoffman, MD, MPH, an internal medicine professor at the University of Iowa, Iowa City, said in an accompanying editorial.

The study’s trends in mPCa “might be transitory because the screening guidelines have” changed, Dr. Hoffman writes.

For now, clinicians should “consistently address screening with men who are healthy enough to benefit” from catching dangerous tumors early and engage them “in shared decisionmaking discussions to” strike the right balance between minimizing overdiagnosis and catching high-risk tumors before they spread, he said.

Easier said than done, but the field is advancing. Active surveillance, instead of surgery, for what seem to be low-risk tumors is one step in the right direction, Dr. Hoffman commented. 

No external funding was reported. Dr. Desai is a consultant for Procept Biorobotics and Auris Surgical. Dr. Hoffman reported royalties from UpToDate and fees from law firms as an expert witness on prostate cancer screening cases.

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

The incidence of metastatic prostate cancer shot up in the United States after the U.S. Preventive Services Task Force recommended against routinely screening men with the prostate-specific antigen (PSA), shows a report published online in JAMA Network Open.

It was a consequence that many experts in prostate cancer predicted at the time the recommendation was made – initially in 2008 against routine screening in men older than 75 years, then in all men in 2012.

The thinking was that the harms of screening all men – leading to unnecessary prostatectomies and other treatments in many men – outweighed the benefits of catching early high-risk disease in fewer men. Screening rates plummeted as a result.

But experts in prostate cancer warned that the move, while reducing overdiagnosis and overtreatment, would have the unfortunate consequence of underdiagnosis and, consequently, nondetection of the cases of prostate cancer that would spread. 

The new findings are the latest to suggest that this is, in fact, what happened, and echo similar findings previously reported by this news organization.  

For this study, investigators at the University of Southern California, Los Angeles, analyzed the incidence of metastatic prostate cancer (mPCa) in the Surveillance, Epidemiology, and End Results (SEER) database from 2004-2018, with 2018 being the latest data available.

SEER captures about 28% of the U.S. population and recorded almost 50,000 new mPCa cases over the period.

Among men 45-75 years old, the incidence of mPCa increased 41% from when USPSTF recommended against screening through 2018, which translated to an annual percentage change (APC) of 5.3%.

Among men 75 years and older, mPCa rates jumped 43% through 2018, an APC of 6.5%.

The researchers did not find an increase in deaths from prostate cancer, but given the 5-7 years median survival, it might be too early to tell.

“The observation of a rising incidence of mPCa in itself does not imply that screening practices should be changed. The overall risk versus benefit of PSA-based screening is extremely complex and must take into account various other factors that impact the overall health of the community,” say investigators, led by Mihir Desai, MD, a clinical urology professor at USC. 

However, screening practices have already changed. The USPSTF withdrew its objections to screening in 2018 and instead recommended personalized decisionmaking for men 55-69 years old, citing new evidence that screening prevents metastatic disease and reduces PCa mortality more than previously recognized, Richard Hoffman, MD, MPH, an internal medicine professor at the University of Iowa, Iowa City, said in an accompanying editorial.

The study’s trends in mPCa “might be transitory because the screening guidelines have” changed, Dr. Hoffman writes.

For now, clinicians should “consistently address screening with men who are healthy enough to benefit” from catching dangerous tumors early and engage them “in shared decisionmaking discussions to” strike the right balance between minimizing overdiagnosis and catching high-risk tumors before they spread, he said.

Easier said than done, but the field is advancing. Active surveillance, instead of surgery, for what seem to be low-risk tumors is one step in the right direction, Dr. Hoffman commented. 

No external funding was reported. Dr. Desai is a consultant for Procept Biorobotics and Auris Surgical. Dr. Hoffman reported royalties from UpToDate and fees from law firms as an expert witness on prostate cancer screening cases.

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

The global burden of thyroid cancer is substantial, and incidence rates are increasing in many developed countries, including the Unites States, concluded a new analysis based on 30 years of observational data.

“We report overall increases in the burden of thyroid cancer across the majority of EU15+ countries between 1990 and 2019, evidenced by plateaus in incidence rates and reductions in mortality and DALY [disability-adjusted life-years] rates,” the authors reported.

“However, in a number of countries, including the U.S., there are unfavorable increasing mortality and DALY trends over this time period ... [and] a better understanding of the trends in the disease burden of thyroid cancer may help to inform future health system planning,” they added.

The study was published online March 10, 2022, in JAMA Otolaryngology–Head & Neck Surgery.
 

Trends in thyroid cancer

For the analysis, James Schuster-Bruce, MBChB, from St. George’s University Hospital NHS Foundation Trust, London, and colleagues compared trends in thyroid cancer across 30 years of follow-up among 15 countries of the (pre-2004) European Union as well as those in the United States, Australia, Canada, and Norway (EU15+).

Data from the Global Burden of Disease study database were used to track these trends. “We extracted age-standardized incidence rates (ASIRs), age-standardized mortality rates (ASMRs), and DALYs for thyroid cancer from EU15+ countries between 1990 and 2019 using the dedicated GBD study results tool,” the investigators explained.

In 2019, ASIRs were highest in Italy at 6.36 per 100,000 population, followed by the United States at a rate of 5.59 per 100,000 population – although incidence rates of thyroid cancer have actually recently decreased in U.S. women, they noted.

“Thirteen of 19 countries showed an average annual percentage increase in ASIR across the study period,” the investigators added. Out of all the EU15+ countries, the average annual percentage change (AAPC) was the highest in Australia at 2.5 per 100,000 population and the United States at 1.2 per 100,000.

On the other hand, a largely plateauing trend in incidence rates across the majority of EU15+ nations has been observed since 1990, as reflected by incidence rates ranging from –0.8 to 0.8 per 100,000 in the most recent period, the researchers added. ASMRs ranged from a 0.40 per 100,000 in Greece to 0.57 per 100,000 in Luxembourg.

In the United States, the ASMR in 2019 was 0.43 per 100,000 population while the ASMR was the lowest in the United Kingdom in the same year at 0.38 per 100,000 population.

Australia, Denmark, and the United States were the only countries showing positive AAPC changes, the team observed. For example, in the most recent period to 2019, Denmark and Australia had reductions in ASMR trends, whereas in the United States, the trend was toward increasing ASMRs 

In 2019, the DALYs of the EU15+ nations ranged from 9.63 per 100,000 in the United Kingdom to 14.46 per 100,000 in Luxembourg. In the most recent period, a downward trend in DALYs was observed in Australia and Denmark while it plateaued in the United States.

“Overall, we identified improvements in thyroid cancer mortality and DALYs, but overall increases in thyroid cancer incidence in EU15+ countries over the past 3 decades,” the investigators commented.

It has been widely suggested that improvements in diagnostic techniques have contributed significantly to increasing incidence rates of thyroid cancer, but there is concern about overdiagnosis.  Newer diagnostic techniques detect significant numbers of slow-growing, subclinical papillary thyroid cancers that make up at least one quarter of all thyroid cancer subtypes, the authors pointed out.

“It has therefore been suggested that an increase in subclinical disease has inflated the data to look more substantial than the clinical reality,” the authors wrote. However, they insisted that overdiagnosis alone is unlikely to account entirely for increasing incidence trends in the current analysis.

Rather, their concern for countries with high incidence rates of thyroid cancer is the surveillance burden of disease that does not affect mortality. “Close observation of future time trends in thyroid cancer disease burden should be performed in the context of recent changes in international clinical practice guidelines, which have suggested more conservative diagnostic and management strategies,” the authors suggested.

“In the context of the more conservative treatment guidelines and reported increase in true disease, it is important to closely observe mortality and DALYs over the coming years to ensure optimum thyroid cancer management in these nations,” they added.

The study had no specific funding. Dr. Schuster-Bruce disclosed no relevant financial relationships.

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

The global burden of thyroid cancer is substantial, and incidence rates are increasing in many developed countries, including the Unites States, concluded a new analysis based on 30 years of observational data.

“We report overall increases in the burden of thyroid cancer across the majority of EU15+ countries between 1990 and 2019, evidenced by plateaus in incidence rates and reductions in mortality and DALY [disability-adjusted life-years] rates,” the authors reported.

“However, in a number of countries, including the U.S., there are unfavorable increasing mortality and DALY trends over this time period ... [and] a better understanding of the trends in the disease burden of thyroid cancer may help to inform future health system planning,” they added.

The study was published online March 10, 2022, in JAMA Otolaryngology–Head & Neck Surgery.
 

Trends in thyroid cancer

For the analysis, James Schuster-Bruce, MBChB, from St. George’s University Hospital NHS Foundation Trust, London, and colleagues compared trends in thyroid cancer across 30 years of follow-up among 15 countries of the (pre-2004) European Union as well as those in the United States, Australia, Canada, and Norway (EU15+).

Data from the Global Burden of Disease study database were used to track these trends. “We extracted age-standardized incidence rates (ASIRs), age-standardized mortality rates (ASMRs), and DALYs for thyroid cancer from EU15+ countries between 1990 and 2019 using the dedicated GBD study results tool,” the investigators explained.

In 2019, ASIRs were highest in Italy at 6.36 per 100,000 population, followed by the United States at a rate of 5.59 per 100,000 population – although incidence rates of thyroid cancer have actually recently decreased in U.S. women, they noted.

“Thirteen of 19 countries showed an average annual percentage increase in ASIR across the study period,” the investigators added. Out of all the EU15+ countries, the average annual percentage change (AAPC) was the highest in Australia at 2.5 per 100,000 population and the United States at 1.2 per 100,000.

On the other hand, a largely plateauing trend in incidence rates across the majority of EU15+ nations has been observed since 1990, as reflected by incidence rates ranging from –0.8 to 0.8 per 100,000 in the most recent period, the researchers added. ASMRs ranged from a 0.40 per 100,000 in Greece to 0.57 per 100,000 in Luxembourg.

In the United States, the ASMR in 2019 was 0.43 per 100,000 population while the ASMR was the lowest in the United Kingdom in the same year at 0.38 per 100,000 population.

Australia, Denmark, and the United States were the only countries showing positive AAPC changes, the team observed. For example, in the most recent period to 2019, Denmark and Australia had reductions in ASMR trends, whereas in the United States, the trend was toward increasing ASMRs 

In 2019, the DALYs of the EU15+ nations ranged from 9.63 per 100,000 in the United Kingdom to 14.46 per 100,000 in Luxembourg. In the most recent period, a downward trend in DALYs was observed in Australia and Denmark while it plateaued in the United States.

“Overall, we identified improvements in thyroid cancer mortality and DALYs, but overall increases in thyroid cancer incidence in EU15+ countries over the past 3 decades,” the investigators commented.

It has been widely suggested that improvements in diagnostic techniques have contributed significantly to increasing incidence rates of thyroid cancer, but there is concern about overdiagnosis.  Newer diagnostic techniques detect significant numbers of slow-growing, subclinical papillary thyroid cancers that make up at least one quarter of all thyroid cancer subtypes, the authors pointed out.

“It has therefore been suggested that an increase in subclinical disease has inflated the data to look more substantial than the clinical reality,” the authors wrote. However, they insisted that overdiagnosis alone is unlikely to account entirely for increasing incidence trends in the current analysis.

Rather, their concern for countries with high incidence rates of thyroid cancer is the surveillance burden of disease that does not affect mortality. “Close observation of future time trends in thyroid cancer disease burden should be performed in the context of recent changes in international clinical practice guidelines, which have suggested more conservative diagnostic and management strategies,” the authors suggested.

“In the context of the more conservative treatment guidelines and reported increase in true disease, it is important to closely observe mortality and DALYs over the coming years to ensure optimum thyroid cancer management in these nations,” they added.

The study had no specific funding. Dr. Schuster-Bruce disclosed no relevant financial relationships.

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

The global burden of thyroid cancer is substantial, and incidence rates are increasing in many developed countries, including the Unites States, concluded a new analysis based on 30 years of observational data.

“We report overall increases in the burden of thyroid cancer across the majority of EU15+ countries between 1990 and 2019, evidenced by plateaus in incidence rates and reductions in mortality and DALY [disability-adjusted life-years] rates,” the authors reported.

“However, in a number of countries, including the U.S., there are unfavorable increasing mortality and DALY trends over this time period ... [and] a better understanding of the trends in the disease burden of thyroid cancer may help to inform future health system planning,” they added.

The study was published online March 10, 2022, in JAMA Otolaryngology–Head & Neck Surgery.
 

Trends in thyroid cancer

For the analysis, James Schuster-Bruce, MBChB, from St. George’s University Hospital NHS Foundation Trust, London, and colleagues compared trends in thyroid cancer across 30 years of follow-up among 15 countries of the (pre-2004) European Union as well as those in the United States, Australia, Canada, and Norway (EU15+).

Data from the Global Burden of Disease study database were used to track these trends. “We extracted age-standardized incidence rates (ASIRs), age-standardized mortality rates (ASMRs), and DALYs for thyroid cancer from EU15+ countries between 1990 and 2019 using the dedicated GBD study results tool,” the investigators explained.

In 2019, ASIRs were highest in Italy at 6.36 per 100,000 population, followed by the United States at a rate of 5.59 per 100,000 population – although incidence rates of thyroid cancer have actually recently decreased in U.S. women, they noted.

“Thirteen of 19 countries showed an average annual percentage increase in ASIR across the study period,” the investigators added. Out of all the EU15+ countries, the average annual percentage change (AAPC) was the highest in Australia at 2.5 per 100,000 population and the United States at 1.2 per 100,000.

On the other hand, a largely plateauing trend in incidence rates across the majority of EU15+ nations has been observed since 1990, as reflected by incidence rates ranging from –0.8 to 0.8 per 100,000 in the most recent period, the researchers added. ASMRs ranged from a 0.40 per 100,000 in Greece to 0.57 per 100,000 in Luxembourg.

In the United States, the ASMR in 2019 was 0.43 per 100,000 population while the ASMR was the lowest in the United Kingdom in the same year at 0.38 per 100,000 population.

Australia, Denmark, and the United States were the only countries showing positive AAPC changes, the team observed. For example, in the most recent period to 2019, Denmark and Australia had reductions in ASMR trends, whereas in the United States, the trend was toward increasing ASMRs 

In 2019, the DALYs of the EU15+ nations ranged from 9.63 per 100,000 in the United Kingdom to 14.46 per 100,000 in Luxembourg. In the most recent period, a downward trend in DALYs was observed in Australia and Denmark while it plateaued in the United States.

“Overall, we identified improvements in thyroid cancer mortality and DALYs, but overall increases in thyroid cancer incidence in EU15+ countries over the past 3 decades,” the investigators commented.

It has been widely suggested that improvements in diagnostic techniques have contributed significantly to increasing incidence rates of thyroid cancer, but there is concern about overdiagnosis.  Newer diagnostic techniques detect significant numbers of slow-growing, subclinical papillary thyroid cancers that make up at least one quarter of all thyroid cancer subtypes, the authors pointed out.

“It has therefore been suggested that an increase in subclinical disease has inflated the data to look more substantial than the clinical reality,” the authors wrote. However, they insisted that overdiagnosis alone is unlikely to account entirely for increasing incidence trends in the current analysis.

Rather, their concern for countries with high incidence rates of thyroid cancer is the surveillance burden of disease that does not affect mortality. “Close observation of future time trends in thyroid cancer disease burden should be performed in the context of recent changes in international clinical practice guidelines, which have suggested more conservative diagnostic and management strategies,” the authors suggested.

“In the context of the more conservative treatment guidelines and reported increase in true disease, it is important to closely observe mortality and DALYs over the coming years to ensure optimum thyroid cancer management in these nations,” they added.

The study had no specific funding. Dr. Schuster-Bruce disclosed no relevant financial relationships.

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

Cancer significantly raises a patient’s risk for cardiovascular morbidity and mortality, particularly within the first year after diagnosis and irrespective of cancer type, according to a population-based study.

The retrospective analysis, which included data from more than 200,000 patients with cancer, found that a new cancer diagnosis significantly increased the risk of cardiovascular (CV) death (hazard ratio [HR], 1.33) as well as other CV events, including stroke (HR, 1.44), heart failure (HR, 1.62) and pulmonary embolism (HR, 3.43).

From the results, the researchers concluded that a “new cancer diagnosis is independently associated with a significantly increased risk for cardiovascular death and nonfatal morbidity regardless of cancer site.”

The findings were published in the Journal of the American College of Cardiology: CardioOncology (2022 Mar;4[1]:85-94).

Patients with cancer and cancer survivors are known to have an increased risk for heart failure, but evidence on the risk for other CV outcomes remains less clear. In addition, the authors noted, many cancer therapies – including chest irradiation and chemotherapy – can increase a person’s risk of incident CV disease during treatment and after, but data on the long-term CV risk among cancer survivors conflict.

D. Ian Paterson, MD, of the University of Alberta, Edmonton, and coauthors wanted to clarify how a new cancer diagnosis at various sites and stages might affect a person’s risk for fatal and nonfatal CV events over the long term.

The current analysis included data from 224,016 patients with a new cancer diagnosis identified from an administrative database of more than 4.5 million adults residing in Alberta. The researcher identified 73,360 CV deaths and 470,481 nonfatal CV events between April 2007 and December 2018.

Comparing CV events in those with and in those without cancer, the authors found that patients with cancer had a 33% increased risk for CV mortality over the 12-year study follow-up, after adjusting for sociodemographic data and comorbidities (HR, 1.33; 95% confidence interval [CI], 1.29-1.37). Patients with cancer also had an increased risk for stroke (HR, 1.44), heart failure (HR, 1.62) and pulmonary embolism (HR, 3.43), though not myocardial infarction (HR, 1.01; 95% CI, 0.97 – 1.05), compared to those without cancer.

The extent of the risk varied somewhat by cancer stage, time from diagnosis, and cancer type.

A new cancer diagnosis put patients at a significantly higher risk of CV mortality, heart failure, stroke, or pulmonary embolism, regardless of the cancer site, but the risk of CV events was highest for patients with genitourinary, gastrointestinal, thoracic, nervous system, and hematologic malignancies. These patients accounted for more than half of the cancer cohort and more than 70% of the incident CV burden.

Patients with more advanced cancer were at the highest risk for poor CV outcomes, but even those with very early-stage disease faced an elevated risk.

The risk for CV events was greatest in the first year following a cancer diagnosis for all outcomes (HRs, 1.24-8.36) but remained significantly elevated for CV death, heart failure, and pulmonary embolism a decade later.

Overall, the authors concluded that “patients with cancer constitute a high-risk population for CV disease” over the long term and suggested that those with cancer “may benefit from comanagement that includes cardiologists as well as stroke and thrombosis specialists.”

In an accompanying editorial, Hiroshi Ohtsu of Juntendo University in Tokyo, and colleagues concluded that the work “has remarkable strengths” and important clinical implications. However, they said that additional steps may be warranted before translating these findings to clinical practice.

For example, the study is limited by its retrospective population-based design and the lack of data on cancer therapy as well as on several patient factors, including ethnicity, smoking, and physical activity.

The study authors agreed, noting that future work should evaluate how cancer therapies and other potential contributors to poor CV outcomes influence patients’ risk.

“Such work would potentially lead to better prediction of CV risk for patients with cancer and survivors and improved prevention and treatment strategies,” they wrote.

The study was supported by a foundation grant from the Canadian Institutes of Health Research. The authors have disclosed no relevant financial relationships. The editorial was supported in part by funding to individual authors from the Japan Society for the Promotion of Science/Ministry of Education, Culture, Sports, Science and Technology, the Ministry of Health, Labour and Welfare, and the Agency for Medical Research and Development.

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

Cancer significantly raises a patient’s risk for cardiovascular morbidity and mortality, particularly within the first year after diagnosis and irrespective of cancer type, according to a population-based study.

The retrospective analysis, which included data from more than 200,000 patients with cancer, found that a new cancer diagnosis significantly increased the risk of cardiovascular (CV) death (hazard ratio [HR], 1.33) as well as other CV events, including stroke (HR, 1.44), heart failure (HR, 1.62) and pulmonary embolism (HR, 3.43).

From the results, the researchers concluded that a “new cancer diagnosis is independently associated with a significantly increased risk for cardiovascular death and nonfatal morbidity regardless of cancer site.”

The findings were published in the Journal of the American College of Cardiology: CardioOncology (2022 Mar;4[1]:85-94).

Patients with cancer and cancer survivors are known to have an increased risk for heart failure, but evidence on the risk for other CV outcomes remains less clear. In addition, the authors noted, many cancer therapies – including chest irradiation and chemotherapy – can increase a person’s risk of incident CV disease during treatment and after, but data on the long-term CV risk among cancer survivors conflict.

D. Ian Paterson, MD, of the University of Alberta, Edmonton, and coauthors wanted to clarify how a new cancer diagnosis at various sites and stages might affect a person’s risk for fatal and nonfatal CV events over the long term.

The current analysis included data from 224,016 patients with a new cancer diagnosis identified from an administrative database of more than 4.5 million adults residing in Alberta. The researcher identified 73,360 CV deaths and 470,481 nonfatal CV events between April 2007 and December 2018.

Comparing CV events in those with and in those without cancer, the authors found that patients with cancer had a 33% increased risk for CV mortality over the 12-year study follow-up, after adjusting for sociodemographic data and comorbidities (HR, 1.33; 95% confidence interval [CI], 1.29-1.37). Patients with cancer also had an increased risk for stroke (HR, 1.44), heart failure (HR, 1.62) and pulmonary embolism (HR, 3.43), though not myocardial infarction (HR, 1.01; 95% CI, 0.97 – 1.05), compared to those without cancer.

The extent of the risk varied somewhat by cancer stage, time from diagnosis, and cancer type.

A new cancer diagnosis put patients at a significantly higher risk of CV mortality, heart failure, stroke, or pulmonary embolism, regardless of the cancer site, but the risk of CV events was highest for patients with genitourinary, gastrointestinal, thoracic, nervous system, and hematologic malignancies. These patients accounted for more than half of the cancer cohort and more than 70% of the incident CV burden.

Patients with more advanced cancer were at the highest risk for poor CV outcomes, but even those with very early-stage disease faced an elevated risk.

The risk for CV events was greatest in the first year following a cancer diagnosis for all outcomes (HRs, 1.24-8.36) but remained significantly elevated for CV death, heart failure, and pulmonary embolism a decade later.

Overall, the authors concluded that “patients with cancer constitute a high-risk population for CV disease” over the long term and suggested that those with cancer “may benefit from comanagement that includes cardiologists as well as stroke and thrombosis specialists.”

In an accompanying editorial, Hiroshi Ohtsu of Juntendo University in Tokyo, and colleagues concluded that the work “has remarkable strengths” and important clinical implications. However, they said that additional steps may be warranted before translating these findings to clinical practice.

For example, the study is limited by its retrospective population-based design and the lack of data on cancer therapy as well as on several patient factors, including ethnicity, smoking, and physical activity.

The study authors agreed, noting that future work should evaluate how cancer therapies and other potential contributors to poor CV outcomes influence patients’ risk.

“Such work would potentially lead to better prediction of CV risk for patients with cancer and survivors and improved prevention and treatment strategies,” they wrote.

The study was supported by a foundation grant from the Canadian Institutes of Health Research. The authors have disclosed no relevant financial relationships. The editorial was supported in part by funding to individual authors from the Japan Society for the Promotion of Science/Ministry of Education, Culture, Sports, Science and Technology, the Ministry of Health, Labour and Welfare, and the Agency for Medical Research and Development.

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

Cancer significantly raises a patient’s risk for cardiovascular morbidity and mortality, particularly within the first year after diagnosis and irrespective of cancer type, according to a population-based study.

The retrospective analysis, which included data from more than 200,000 patients with cancer, found that a new cancer diagnosis significantly increased the risk of cardiovascular (CV) death (hazard ratio [HR], 1.33) as well as other CV events, including stroke (HR, 1.44), heart failure (HR, 1.62) and pulmonary embolism (HR, 3.43).

From the results, the researchers concluded that a “new cancer diagnosis is independently associated with a significantly increased risk for cardiovascular death and nonfatal morbidity regardless of cancer site.”

The findings were published in the Journal of the American College of Cardiology: CardioOncology (2022 Mar;4[1]:85-94).

Patients with cancer and cancer survivors are known to have an increased risk for heart failure, but evidence on the risk for other CV outcomes remains less clear. In addition, the authors noted, many cancer therapies – including chest irradiation and chemotherapy – can increase a person’s risk of incident CV disease during treatment and after, but data on the long-term CV risk among cancer survivors conflict.

D. Ian Paterson, MD, of the University of Alberta, Edmonton, and coauthors wanted to clarify how a new cancer diagnosis at various sites and stages might affect a person’s risk for fatal and nonfatal CV events over the long term.

The current analysis included data from 224,016 patients with a new cancer diagnosis identified from an administrative database of more than 4.5 million adults residing in Alberta. The researcher identified 73,360 CV deaths and 470,481 nonfatal CV events between April 2007 and December 2018.

Comparing CV events in those with and in those without cancer, the authors found that patients with cancer had a 33% increased risk for CV mortality over the 12-year study follow-up, after adjusting for sociodemographic data and comorbidities (HR, 1.33; 95% confidence interval [CI], 1.29-1.37). Patients with cancer also had an increased risk for stroke (HR, 1.44), heart failure (HR, 1.62) and pulmonary embolism (HR, 3.43), though not myocardial infarction (HR, 1.01; 95% CI, 0.97 – 1.05), compared to those without cancer.

The extent of the risk varied somewhat by cancer stage, time from diagnosis, and cancer type.

A new cancer diagnosis put patients at a significantly higher risk of CV mortality, heart failure, stroke, or pulmonary embolism, regardless of the cancer site, but the risk of CV events was highest for patients with genitourinary, gastrointestinal, thoracic, nervous system, and hematologic malignancies. These patients accounted for more than half of the cancer cohort and more than 70% of the incident CV burden.

Patients with more advanced cancer were at the highest risk for poor CV outcomes, but even those with very early-stage disease faced an elevated risk.

The risk for CV events was greatest in the first year following a cancer diagnosis for all outcomes (HRs, 1.24-8.36) but remained significantly elevated for CV death, heart failure, and pulmonary embolism a decade later.

Overall, the authors concluded that “patients with cancer constitute a high-risk population for CV disease” over the long term and suggested that those with cancer “may benefit from comanagement that includes cardiologists as well as stroke and thrombosis specialists.”

In an accompanying editorial, Hiroshi Ohtsu of Juntendo University in Tokyo, and colleagues concluded that the work “has remarkable strengths” and important clinical implications. However, they said that additional steps may be warranted before translating these findings to clinical practice.

For example, the study is limited by its retrospective population-based design and the lack of data on cancer therapy as well as on several patient factors, including ethnicity, smoking, and physical activity.

The study authors agreed, noting that future work should evaluate how cancer therapies and other potential contributors to poor CV outcomes influence patients’ risk.

“Such work would potentially lead to better prediction of CV risk for patients with cancer and survivors and improved prevention and treatment strategies,” they wrote.

The study was supported by a foundation grant from the Canadian Institutes of Health Research. The authors have disclosed no relevant financial relationships. The editorial was supported in part by funding to individual authors from the Japan Society for the Promotion of Science/Ministry of Education, Culture, Sports, Science and Technology, the Ministry of Health, Labour and Welfare, and the Agency for Medical Research and Development.

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

Reducing the dose of radiation to the esophagus during palliative radiotherapy for advanced lung cancer significantly reduced the incidence of esophagitis among a small group of patients, according to a new randomized study.

Even though fewer patients experienced esophagitis, the procedure did little to significantly improve quality of life for these patients.

The study, called Palliative Radiation for Advanced Central Lung Tumors with Intentional Avoidance of the Esophagus (PROACTIVE), explored the use of a technique called intensity-modulated radiotherapy (IMRT) to sculpt the radiation dose around the esophagus, reducing its exposure. IMRT is a standard technique to avoid healthy tissue with higher radiation doses in the curative setting, but it hasn’t been explored much in the palliative setting, said investigators led by Alexander V. Louie, MD, PhD, a radiation oncologist at the University of Toronto’s Odette Cancer Centre.

The study included 90 patients (mean age 70 years, 56% female) with stage 3 and 4 non–small cell lung cancer. They were randomized evenly to standard radiotherapy with the esophagus getting the same dose as the tumor, or to esophagus-sparing IMRT (ES-IMRT) with the esophagus exposed to no more than 80% of the prescribed dose.

The overall survival was similar between both groups: 8.6 months for standard therapy and 8.7 months for IMRT. Forty percent of patients received 20 Gy in 5 fractions and the rest 30 Gy in 10 fractions. The reduction in esophagitis with IMRT was most evident in the 30 Gy group.

Only one patient in the esophagus-sparing group developed grade 2 esophagitis versus 11 patients (24%) in the standard radiotherapy group. There were no grade 3 or higher cases. There was also an almost 4-point improvement (54.3 points with ES-IMRT versus 50.5 points) on an esophagus-related quality of life (QOL) measure, which is a subscale of the Functional Assessment of Cancer Therapy: Esophagus questionnaire, but it wasn’t statistically significant (P = 0.06).

“The ES-IMRT technique we describe herein represents a paradigm shift in palliative radiotherapy planning,” the investigators wrote. “This technique holds merit for translation into clinical practice.”

However, in their editorial, Ashley A. Weiner, MD, PhD, and Joel E. Tepper, MD, of the Lineberger Comprehensive Cancer Center at the University of North Carolina at Chapel Hill, wrote that it is too preliminary to recommend esophagus-sparing IMRT to patients. “In the absence of meeting the primary quality of life end point and without demonstration of adequate symptom palliation, one cannot recommend ES-IMRT as a standard therapy for palliation of thoracic symptoms due to NSCLC,” they wrote.

They said the study raises an important issue: The balance between tumor coverage and sparing healthy tissue when symptom palliation instead of cure is the goal.

Striking the right balance “is challenging and part of the art of radiotherapy” particularly in the palliative setting, where there are many unanswered questions, they said.

Unlike in curative intent scenarios, “the ideal dose to the tumor to provide a maximal palliative benefit is unknown, and perhaps there is no ideal dose,” Dr. Weiner and Dr. Tepper said.

It’s also unclear whether the entire tumor needs to be irradiated to the full dose when the goal is simply to shrink the tumor and relieve symptoms. “Perhaps a lower dose to a portion of the tumor makes sense,” especially when radiation doses for palliation are “somewhat arbitrary,” they said.

Indeed, the portion of the tumor next to the esophagus in the IMRT subjects was necessarily undercovered to achieve the esophagus-sparing effect. “It seems very likely to us that underdosing a small portion of the tumor will have little adverse effect” on palliation, Dr. Weiner and Dr. Tepper wrote.

Also, “if undercovering” the tumor with lower doses “results in adequate tumor reduction for palliation,” they wondered if IMRT – a more expensive and complex technique than standard radiotherapy – is even needed.

The work was funded by the Canadian Cancer Society. Dr. Louie reported payments from AstraZeneca as an advisor and personal fees from Varian Medical Systems and Reflexion, the makers of IMRT technology. The authors of the editorial reported no conflicts of interest.

Reducing the dose of radiation to the esophagus during palliative radiotherapy for advanced lung cancer significantly reduced the incidence of esophagitis among a small group of patients, according to a new randomized study.

Even though fewer patients experienced esophagitis, the procedure did little to significantly improve quality of life for these patients.

The study, called Palliative Radiation for Advanced Central Lung Tumors with Intentional Avoidance of the Esophagus (PROACTIVE), explored the use of a technique called intensity-modulated radiotherapy (IMRT) to sculpt the radiation dose around the esophagus, reducing its exposure. IMRT is a standard technique to avoid healthy tissue with higher radiation doses in the curative setting, but it hasn’t been explored much in the palliative setting, said investigators led by Alexander V. Louie, MD, PhD, a radiation oncologist at the University of Toronto’s Odette Cancer Centre.

The study included 90 patients (mean age 70 years, 56% female) with stage 3 and 4 non–small cell lung cancer. They were randomized evenly to standard radiotherapy with the esophagus getting the same dose as the tumor, or to esophagus-sparing IMRT (ES-IMRT) with the esophagus exposed to no more than 80% of the prescribed dose.

The overall survival was similar between both groups: 8.6 months for standard therapy and 8.7 months for IMRT. Forty percent of patients received 20 Gy in 5 fractions and the rest 30 Gy in 10 fractions. The reduction in esophagitis with IMRT was most evident in the 30 Gy group.

Only one patient in the esophagus-sparing group developed grade 2 esophagitis versus 11 patients (24%) in the standard radiotherapy group. There were no grade 3 or higher cases. There was also an almost 4-point improvement (54.3 points with ES-IMRT versus 50.5 points) on an esophagus-related quality of life (QOL) measure, which is a subscale of the Functional Assessment of Cancer Therapy: Esophagus questionnaire, but it wasn’t statistically significant (P = 0.06).

“The ES-IMRT technique we describe herein represents a paradigm shift in palliative radiotherapy planning,” the investigators wrote. “This technique holds merit for translation into clinical practice.”

However, in their editorial, Ashley A. Weiner, MD, PhD, and Joel E. Tepper, MD, of the Lineberger Comprehensive Cancer Center at the University of North Carolina at Chapel Hill, wrote that it is too preliminary to recommend esophagus-sparing IMRT to patients. “In the absence of meeting the primary quality of life end point and without demonstration of adequate symptom palliation, one cannot recommend ES-IMRT as a standard therapy for palliation of thoracic symptoms due to NSCLC,” they wrote.

They said the study raises an important issue: The balance between tumor coverage and sparing healthy tissue when symptom palliation instead of cure is the goal.

Striking the right balance “is challenging and part of the art of radiotherapy” particularly in the palliative setting, where there are many unanswered questions, they said.

Unlike in curative intent scenarios, “the ideal dose to the tumor to provide a maximal palliative benefit is unknown, and perhaps there is no ideal dose,” Dr. Weiner and Dr. Tepper said.

It’s also unclear whether the entire tumor needs to be irradiated to the full dose when the goal is simply to shrink the tumor and relieve symptoms. “Perhaps a lower dose to a portion of the tumor makes sense,” especially when radiation doses for palliation are “somewhat arbitrary,” they said.

Indeed, the portion of the tumor next to the esophagus in the IMRT subjects was necessarily undercovered to achieve the esophagus-sparing effect. “It seems very likely to us that underdosing a small portion of the tumor will have little adverse effect” on palliation, Dr. Weiner and Dr. Tepper wrote.

Also, “if undercovering” the tumor with lower doses “results in adequate tumor reduction for palliation,” they wondered if IMRT – a more expensive and complex technique than standard radiotherapy – is even needed.

The work was funded by the Canadian Cancer Society. Dr. Louie reported payments from AstraZeneca as an advisor and personal fees from Varian Medical Systems and Reflexion, the makers of IMRT technology. The authors of the editorial reported no conflicts of interest.

Reducing the dose of radiation to the esophagus during palliative radiotherapy for advanced lung cancer significantly reduced the incidence of esophagitis among a small group of patients, according to a new randomized study.

Even though fewer patients experienced esophagitis, the procedure did little to significantly improve quality of life for these patients.

The study, called Palliative Radiation for Advanced Central Lung Tumors with Intentional Avoidance of the Esophagus (PROACTIVE), explored the use of a technique called intensity-modulated radiotherapy (IMRT) to sculpt the radiation dose around the esophagus, reducing its exposure. IMRT is a standard technique to avoid healthy tissue with higher radiation doses in the curative setting, but it hasn’t been explored much in the palliative setting, said investigators led by Alexander V. Louie, MD, PhD, a radiation oncologist at the University of Toronto’s Odette Cancer Centre.

The study included 90 patients (mean age 70 years, 56% female) with stage 3 and 4 non–small cell lung cancer. They were randomized evenly to standard radiotherapy with the esophagus getting the same dose as the tumor, or to esophagus-sparing IMRT (ES-IMRT) with the esophagus exposed to no more than 80% of the prescribed dose.

The overall survival was similar between both groups: 8.6 months for standard therapy and 8.7 months for IMRT. Forty percent of patients received 20 Gy in 5 fractions and the rest 30 Gy in 10 fractions. The reduction in esophagitis with IMRT was most evident in the 30 Gy group.

Only one patient in the esophagus-sparing group developed grade 2 esophagitis versus 11 patients (24%) in the standard radiotherapy group. There were no grade 3 or higher cases. There was also an almost 4-point improvement (54.3 points with ES-IMRT versus 50.5 points) on an esophagus-related quality of life (QOL) measure, which is a subscale of the Functional Assessment of Cancer Therapy: Esophagus questionnaire, but it wasn’t statistically significant (P = 0.06).

“The ES-IMRT technique we describe herein represents a paradigm shift in palliative radiotherapy planning,” the investigators wrote. “This technique holds merit for translation into clinical practice.”

However, in their editorial, Ashley A. Weiner, MD, PhD, and Joel E. Tepper, MD, of the Lineberger Comprehensive Cancer Center at the University of North Carolina at Chapel Hill, wrote that it is too preliminary to recommend esophagus-sparing IMRT to patients. “In the absence of meeting the primary quality of life end point and without demonstration of adequate symptom palliation, one cannot recommend ES-IMRT as a standard therapy for palliation of thoracic symptoms due to NSCLC,” they wrote.

They said the study raises an important issue: The balance between tumor coverage and sparing healthy tissue when symptom palliation instead of cure is the goal.

Striking the right balance “is challenging and part of the art of radiotherapy” particularly in the palliative setting, where there are many unanswered questions, they said.

Unlike in curative intent scenarios, “the ideal dose to the tumor to provide a maximal palliative benefit is unknown, and perhaps there is no ideal dose,” Dr. Weiner and Dr. Tepper said.

It’s also unclear whether the entire tumor needs to be irradiated to the full dose when the goal is simply to shrink the tumor and relieve symptoms. “Perhaps a lower dose to a portion of the tumor makes sense,” especially when radiation doses for palliation are “somewhat arbitrary,” they said.

Indeed, the portion of the tumor next to the esophagus in the IMRT subjects was necessarily undercovered to achieve the esophagus-sparing effect. “It seems very likely to us that underdosing a small portion of the tumor will have little adverse effect” on palliation, Dr. Weiner and Dr. Tepper wrote.

Also, “if undercovering” the tumor with lower doses “results in adequate tumor reduction for palliation,” they wondered if IMRT – a more expensive and complex technique than standard radiotherapy – is even needed.

The work was funded by the Canadian Cancer Society. Dr. Louie reported payments from AstraZeneca as an advisor and personal fees from Varian Medical Systems and Reflexion, the makers of IMRT technology. The authors of the editorial reported no conflicts of interest.

A visit with a friendly dog may be just what the doctor ordered for patients coming to the hospital for emergency care.

Patients in the emergency room who spent just 10 minutes with a trained therapy dog reported less pain, anxiety, and depression and improved well-being, researchers from the University of Saskatchewan in Canada found.

“The ER is an important community resource but also a scary place for most people,” James Stempien, MD, provincial department head of emergency medicine with the Saskatchewan Health Authority, who worked on the study, said in an interview.

“People tend to visit the ER on the worst day of their life, either for them or a loved one. Interacting with a therapy dog can make the ER visit a little calmer. We have also seen benefit for the staff that get to interact with the dogs as well,” he says.

“Thanks to our wonderful therapy dog volunteer teams, the cost is minimal and the result is priceless,” Dr. Stempien says.

The study, published in the journal PLOS One, builds on earlier “uncontrolled” studies by the Saskatchewan team.

Those studies showed that most ER patients wanted to visit with the therapy dog, if given a chance. After the encounter, patients reported feeling more comfortable, happier, and less distressed while waiting in the ER.

“A controlled trial was the natural next step,” says study investigator Colleen Dell, PhD, of One Health and Wellness at the University of Saskatchewan.

The study was done at the Royal University Hospital (RUH) in Saskatoon, Saskatchewan -- the first emergency department in Canada to introduce therapy dogs to improve the experience of waiting patients.

Nearly 200 adults visiting the ER received either a 10-minute visit with a therapy dog and its handler in addition to usual care or just usual care.

The therapy dog visit had a positive impact on patient pain and related measures of anxiety, depression, and well-being.

“This did not occur in patients in the ER who did not visit with a therapy dog.

“This gives us confidence in the intervention,” Dr. Dell says.

Pain is a major reason that patients come to the ER, and interactions with a therapy dog may distract from that pain, the researchers believe.

The study results lend more evidence to research that shows animals can help in medical settings, says Kara Rauscher, a licensed social worker and interim director of behavioral health for Nashville CARES in Tennessee, who wasn’t involved in the study.

“There are clearly opportunities to replicate this study in other emergency departments to strengthen our understanding of the potential benefits of these programs,” she says.

Part of her work at Nashville CARES, an AIDS service organization, has been supporting care that moves away from questions like, “What’s wrong with you?” to patient-focused questions like, “What happened to you?” It is a practice known as trauma-informed care.

“This includes bringing in therapy dogs for staff to spend time with during the workday; anecdotally, our staff reported a reduction in stress and improvements in mood,” Ms. Rauscher says.

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

A visit with a friendly dog may be just what the doctor ordered for patients coming to the hospital for emergency care.

Patients in the emergency room who spent just 10 minutes with a trained therapy dog reported less pain, anxiety, and depression and improved well-being, researchers from the University of Saskatchewan in Canada found.

“The ER is an important community resource but also a scary place for most people,” James Stempien, MD, provincial department head of emergency medicine with the Saskatchewan Health Authority, who worked on the study, said in an interview.

“People tend to visit the ER on the worst day of their life, either for them or a loved one. Interacting with a therapy dog can make the ER visit a little calmer. We have also seen benefit for the staff that get to interact with the dogs as well,” he says.

“Thanks to our wonderful therapy dog volunteer teams, the cost is minimal and the result is priceless,” Dr. Stempien says.

The study, published in the journal PLOS One, builds on earlier “uncontrolled” studies by the Saskatchewan team.

Those studies showed that most ER patients wanted to visit with the therapy dog, if given a chance. After the encounter, patients reported feeling more comfortable, happier, and less distressed while waiting in the ER.

“A controlled trial was the natural next step,” says study investigator Colleen Dell, PhD, of One Health and Wellness at the University of Saskatchewan.

The study was done at the Royal University Hospital (RUH) in Saskatoon, Saskatchewan -- the first emergency department in Canada to introduce therapy dogs to improve the experience of waiting patients.

Nearly 200 adults visiting the ER received either a 10-minute visit with a therapy dog and its handler in addition to usual care or just usual care.

The therapy dog visit had a positive impact on patient pain and related measures of anxiety, depression, and well-being.

“This did not occur in patients in the ER who did not visit with a therapy dog.

“This gives us confidence in the intervention,” Dr. Dell says.

Pain is a major reason that patients come to the ER, and interactions with a therapy dog may distract from that pain, the researchers believe.

The study results lend more evidence to research that shows animals can help in medical settings, says Kara Rauscher, a licensed social worker and interim director of behavioral health for Nashville CARES in Tennessee, who wasn’t involved in the study.

“There are clearly opportunities to replicate this study in other emergency departments to strengthen our understanding of the potential benefits of these programs,” she says.

Part of her work at Nashville CARES, an AIDS service organization, has been supporting care that moves away from questions like, “What’s wrong with you?” to patient-focused questions like, “What happened to you?” It is a practice known as trauma-informed care.

“This includes bringing in therapy dogs for staff to spend time with during the workday; anecdotally, our staff reported a reduction in stress and improvements in mood,” Ms. Rauscher says.

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

A visit with a friendly dog may be just what the doctor ordered for patients coming to the hospital for emergency care.

Patients in the emergency room who spent just 10 minutes with a trained therapy dog reported less pain, anxiety, and depression and improved well-being, researchers from the University of Saskatchewan in Canada found.

“The ER is an important community resource but also a scary place for most people,” James Stempien, MD, provincial department head of emergency medicine with the Saskatchewan Health Authority, who worked on the study, said in an interview.

“People tend to visit the ER on the worst day of their life, either for them or a loved one. Interacting with a therapy dog can make the ER visit a little calmer. We have also seen benefit for the staff that get to interact with the dogs as well,” he says.

“Thanks to our wonderful therapy dog volunteer teams, the cost is minimal and the result is priceless,” Dr. Stempien says.

The study, published in the journal PLOS One, builds on earlier “uncontrolled” studies by the Saskatchewan team.

Those studies showed that most ER patients wanted to visit with the therapy dog, if given a chance. After the encounter, patients reported feeling more comfortable, happier, and less distressed while waiting in the ER.

“A controlled trial was the natural next step,” says study investigator Colleen Dell, PhD, of One Health and Wellness at the University of Saskatchewan.

The study was done at the Royal University Hospital (RUH) in Saskatoon, Saskatchewan -- the first emergency department in Canada to introduce therapy dogs to improve the experience of waiting patients.

Nearly 200 adults visiting the ER received either a 10-minute visit with a therapy dog and its handler in addition to usual care or just usual care.

The therapy dog visit had a positive impact on patient pain and related measures of anxiety, depression, and well-being.

“This did not occur in patients in the ER who did not visit with a therapy dog.

“This gives us confidence in the intervention,” Dr. Dell says.

Pain is a major reason that patients come to the ER, and interactions with a therapy dog may distract from that pain, the researchers believe.

The study results lend more evidence to research that shows animals can help in medical settings, says Kara Rauscher, a licensed social worker and interim director of behavioral health for Nashville CARES in Tennessee, who wasn’t involved in the study.

“There are clearly opportunities to replicate this study in other emergency departments to strengthen our understanding of the potential benefits of these programs,” she says.

Part of her work at Nashville CARES, an AIDS service organization, has been supporting care that moves away from questions like, “What’s wrong with you?” to patient-focused questions like, “What happened to you?” It is a practice known as trauma-informed care.

“This includes bringing in therapy dogs for staff to spend time with during the workday; anecdotally, our staff reported a reduction in stress and improvements in mood,” Ms. Rauscher says.

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

The use of preimplantation genetic tests (PGT) in in vitro fertilization cycles, including tests for nonmedical sex selection, increased significantly in states without mandated insurance coverage, based on data from a study of 300,000 IVF cycles.

Previous studies have shown associations between IVF insurance coverage and various IVF practice patterns, but trends in genetic testing according to state-mandated insurance have not been explored, Bronwyn S. Bedrick, MD, of Johns Hopkins University, Baltimore, and colleagues wrote.

“Preimplantation genetic testing was introduced into clinical practice to prevent transmission of genetic disease and to improve uptake of single embryo transfer, but in the real world there are many potential applications,” corresponding author Emily Jungheim, MD, of Northwestern University, Chicago, said in an interview. “We wanted to know how PGT is being applied given that its use is on the rise.”

In a study published in Obstetrics & Gynecology, the researchers analyzed genetic testing in deidentified autologous, nonbanking IVF cycles from 2014 to 2016 obtained through the Society for Assisted Reproductive Technology Clinic Outcome Reporting System (SART CORS). The data set included 301,465 IVF cycles and 224,235 unique patients over the 3-year study period. Of these, 78,578 cycles (26%) used PGT, and overall, the proportion of IVF cycles using PGT approximately doubled, from 17% in 2014 to 34% in 2016 – a significant increase over time (risk ratio, 1.37). As of 2021, 13 states had mandates that health insurance include IVF costs.

In states with insurance mandates versus nonmandated states, the proportion of any PGT was 28.8% vs. 19.6%, and the probability was 32% lower in states with mandates (RR. 0.68; P < .001).

Aneuploidy was the most common indication for PGT, and accounted for 60% of the cycles; however, the number of cycles using PGT for elective sex selection increased from 1,314 cycles in 2014 to 2,184 in 2016 (approximately 66% increase).

In a multivariate analysis, IVF cycles for elective sex selection was 56% lower in states with mandates, compared with those without (RR, 0.44; P < .001).

In addition, cycles involving nonmedical sex selection were significantly more likely to result in male offspring, the researchers said.

“The increase in the number of cycles using elective sex selection seen in this study may reflect the growing number of clinics offering [PGT] for nonmedical sex selection as well as increasing public awareness of preimplantation genetic testing,” the researchers wrote.

However, the socioeconomic characteristics of women may play a role in the use of PGT, as those living in states with no mandate must be able pay the cost of IVF procedures, as well as the cost of PGT if desired, they noted.

“Because fertility centers may offer patients the choice to select the sex of their embryo after preimplantation genetic testing, this may in effect permit elective sex selection,” the researchers said. The shift in the male-female sex ratio in these cases “is concerning given the implications for future social demographics as IVF and preimplantation genetic testing utilization increase, and the negative effect outcomes could have on medical insurance policy and allocation of resources for medically indicated IVF and preimplantation genetic testing.”

The study findings were limited by several factors including the lack of clinic identifiers and lack of data characteristics including, race, ethnicity, and previous live births, the researchers noted. Other limitations included a lack of data on the sex preferences of the couple, and whether the sex of the embryo was known, and whether male and female embryos were transferred. Also, no states have mandates to cover PGT, and the limited study period may not generalize to current practices.

However, the study strengths include the large size and comprehensive database, and have implications for future policies and expansion of insurance coverage for infertility treatment and for preventing transmission of genetic diseases, they said.
 

Be mindful of consequences of testing

In an interview, Dr. Jungheim said she was surprised by some of the findings. “I thought we would see that PGT-A utilization was lower in states without mandates given the already high cost of IVF for patients paying out of pocket. I was also surprised to see that more males were born after PGT-A; it suggests that overall, patients using PGT-A favor males.

“For clinicians, we need to be mindful of the long-term impact of our practices,” she emphasized. “Shifting the sex ratio in favor of one sex or the other is an unintended consequence of IVF with PGT-A that can have negative implications for future generations.”

In the study, the researchers proposed a revision to the American Society for Reproductive Medicine Ethics Committee opinion on sex selection to provide guidance in keeping with ASRM’s mission of “accessible, ethical, and quality reproductive care for every person.”

However, “even if the ASRM Ethics Committee Opinion was revised, it’s up to clinicians to decide what they are comfortable with,” said Dr. Jungheim. “When patients are paying out of pocket for expensive treatments that require emotional investment and time, it can be difficult to keep medical decision making strictly evidence based.” Improved insurance coverage and access to fertility care may help with some of these decisions, but more real-world evidence is needed. 
 

Let’s talk about sex (selection)

The study findings are both “novel and sobering,” and enhance the current body of evidence of associations between state insurance mandates and IVF outcomes, Jennifer Eaton, MD, of Brown University, Providence, R.I., wrote in an accompanying editorial.

“The association between mandate status and elective sex selection is particularly eye-opening,” said Dr. Eaton. The overall increased use of PGT for sex selection does not account for sex selection as part of testing for aneuploidy. In fact, “patients with euploid embryos of both sexes are frequently given the opportunity to select which embryo to transfer.”

The current study provides “compelling evidence that it is time to revisit the ethical dilemma of elective sex selection in the United States,” Dr. Eaton emphasized. The current ASRM guidance states that IVF clinics are not obligated to provide or refuse to provide nonmedically indicated methods of sex selection, but in light of the current study and other studies, a revision to the existing ASRM Ethics Committee opinion is needed.

The study received no outside funding. Neither the researchers nor Dr. Eaton had any financial conflicts to disclose.

The use of preimplantation genetic tests (PGT) in in vitro fertilization cycles, including tests for nonmedical sex selection, increased significantly in states without mandated insurance coverage, based on data from a study of 300,000 IVF cycles.

Previous studies have shown associations between IVF insurance coverage and various IVF practice patterns, but trends in genetic testing according to state-mandated insurance have not been explored, Bronwyn S. Bedrick, MD, of Johns Hopkins University, Baltimore, and colleagues wrote.

“Preimplantation genetic testing was introduced into clinical practice to prevent transmission of genetic disease and to improve uptake of single embryo transfer, but in the real world there are many potential applications,” corresponding author Emily Jungheim, MD, of Northwestern University, Chicago, said in an interview. “We wanted to know how PGT is being applied given that its use is on the rise.”

In a study published in Obstetrics & Gynecology, the researchers analyzed genetic testing in deidentified autologous, nonbanking IVF cycles from 2014 to 2016 obtained through the Society for Assisted Reproductive Technology Clinic Outcome Reporting System (SART CORS). The data set included 301,465 IVF cycles and 224,235 unique patients over the 3-year study period. Of these, 78,578 cycles (26%) used PGT, and overall, the proportion of IVF cycles using PGT approximately doubled, from 17% in 2014 to 34% in 2016 – a significant increase over time (risk ratio, 1.37). As of 2021, 13 states had mandates that health insurance include IVF costs.

In states with insurance mandates versus nonmandated states, the proportion of any PGT was 28.8% vs. 19.6%, and the probability was 32% lower in states with mandates (RR. 0.68; P < .001).

Aneuploidy was the most common indication for PGT, and accounted for 60% of the cycles; however, the number of cycles using PGT for elective sex selection increased from 1,314 cycles in 2014 to 2,184 in 2016 (approximately 66% increase).

In a multivariate analysis, IVF cycles for elective sex selection was 56% lower in states with mandates, compared with those without (RR, 0.44; P < .001).

In addition, cycles involving nonmedical sex selection were significantly more likely to result in male offspring, the researchers said.

“The increase in the number of cycles using elective sex selection seen in this study may reflect the growing number of clinics offering [PGT] for nonmedical sex selection as well as increasing public awareness of preimplantation genetic testing,” the researchers wrote.

However, the socioeconomic characteristics of women may play a role in the use of PGT, as those living in states with no mandate must be able pay the cost of IVF procedures, as well as the cost of PGT if desired, they noted.

“Because fertility centers may offer patients the choice to select the sex of their embryo after preimplantation genetic testing, this may in effect permit elective sex selection,” the researchers said. The shift in the male-female sex ratio in these cases “is concerning given the implications for future social demographics as IVF and preimplantation genetic testing utilization increase, and the negative effect outcomes could have on medical insurance policy and allocation of resources for medically indicated IVF and preimplantation genetic testing.”

The study findings were limited by several factors including the lack of clinic identifiers and lack of data characteristics including, race, ethnicity, and previous live births, the researchers noted. Other limitations included a lack of data on the sex preferences of the couple, and whether the sex of the embryo was known, and whether male and female embryos were transferred. Also, no states have mandates to cover PGT, and the limited study period may not generalize to current practices.

However, the study strengths include the large size and comprehensive database, and have implications for future policies and expansion of insurance coverage for infertility treatment and for preventing transmission of genetic diseases, they said.
 

Be mindful of consequences of testing

In an interview, Dr. Jungheim said she was surprised by some of the findings. “I thought we would see that PGT-A utilization was lower in states without mandates given the already high cost of IVF for patients paying out of pocket. I was also surprised to see that more males were born after PGT-A; it suggests that overall, patients using PGT-A favor males.

“For clinicians, we need to be mindful of the long-term impact of our practices,” she emphasized. “Shifting the sex ratio in favor of one sex or the other is an unintended consequence of IVF with PGT-A that can have negative implications for future generations.”

In the study, the researchers proposed a revision to the American Society for Reproductive Medicine Ethics Committee opinion on sex selection to provide guidance in keeping with ASRM’s mission of “accessible, ethical, and quality reproductive care for every person.”

However, “even if the ASRM Ethics Committee Opinion was revised, it’s up to clinicians to decide what they are comfortable with,” said Dr. Jungheim. “When patients are paying out of pocket for expensive treatments that require emotional investment and time, it can be difficult to keep medical decision making strictly evidence based.” Improved insurance coverage and access to fertility care may help with some of these decisions, but more real-world evidence is needed. 
 

Let’s talk about sex (selection)

The study findings are both “novel and sobering,” and enhance the current body of evidence of associations between state insurance mandates and IVF outcomes, Jennifer Eaton, MD, of Brown University, Providence, R.I., wrote in an accompanying editorial.

“The association between mandate status and elective sex selection is particularly eye-opening,” said Dr. Eaton. The overall increased use of PGT for sex selection does not account for sex selection as part of testing for aneuploidy. In fact, “patients with euploid embryos of both sexes are frequently given the opportunity to select which embryo to transfer.”

The current study provides “compelling evidence that it is time to revisit the ethical dilemma of elective sex selection in the United States,” Dr. Eaton emphasized. The current ASRM guidance states that IVF clinics are not obligated to provide or refuse to provide nonmedically indicated methods of sex selection, but in light of the current study and other studies, a revision to the existing ASRM Ethics Committee opinion is needed.

The study received no outside funding. Neither the researchers nor Dr. Eaton had any financial conflicts to disclose.

The use of preimplantation genetic tests (PGT) in in vitro fertilization cycles, including tests for nonmedical sex selection, increased significantly in states without mandated insurance coverage, based on data from a study of 300,000 IVF cycles.

Previous studies have shown associations between IVF insurance coverage and various IVF practice patterns, but trends in genetic testing according to state-mandated insurance have not been explored, Bronwyn S. Bedrick, MD, of Johns Hopkins University, Baltimore, and colleagues wrote.

“Preimplantation genetic testing was introduced into clinical practice to prevent transmission of genetic disease and to improve uptake of single embryo transfer, but in the real world there are many potential applications,” corresponding author Emily Jungheim, MD, of Northwestern University, Chicago, said in an interview. “We wanted to know how PGT is being applied given that its use is on the rise.”

In a study published in Obstetrics & Gynecology, the researchers analyzed genetic testing in deidentified autologous, nonbanking IVF cycles from 2014 to 2016 obtained through the Society for Assisted Reproductive Technology Clinic Outcome Reporting System (SART CORS). The data set included 301,465 IVF cycles and 224,235 unique patients over the 3-year study period. Of these, 78,578 cycles (26%) used PGT, and overall, the proportion of IVF cycles using PGT approximately doubled, from 17% in 2014 to 34% in 2016 – a significant increase over time (risk ratio, 1.37). As of 2021, 13 states had mandates that health insurance include IVF costs.

In states with insurance mandates versus nonmandated states, the proportion of any PGT was 28.8% vs. 19.6%, and the probability was 32% lower in states with mandates (RR. 0.68; P < .001).

Aneuploidy was the most common indication for PGT, and accounted for 60% of the cycles; however, the number of cycles using PGT for elective sex selection increased from 1,314 cycles in 2014 to 2,184 in 2016 (approximately 66% increase).

In a multivariate analysis, IVF cycles for elective sex selection was 56% lower in states with mandates, compared with those without (RR, 0.44; P < .001).

In addition, cycles involving nonmedical sex selection were significantly more likely to result in male offspring, the researchers said.

“The increase in the number of cycles using elective sex selection seen in this study may reflect the growing number of clinics offering [PGT] for nonmedical sex selection as well as increasing public awareness of preimplantation genetic testing,” the researchers wrote.

However, the socioeconomic characteristics of women may play a role in the use of PGT, as those living in states with no mandate must be able pay the cost of IVF procedures, as well as the cost of PGT if desired, they noted.

“Because fertility centers may offer patients the choice to select the sex of their embryo after preimplantation genetic testing, this may in effect permit elective sex selection,” the researchers said. The shift in the male-female sex ratio in these cases “is concerning given the implications for future social demographics as IVF and preimplantation genetic testing utilization increase, and the negative effect outcomes could have on medical insurance policy and allocation of resources for medically indicated IVF and preimplantation genetic testing.”

The study findings were limited by several factors including the lack of clinic identifiers and lack of data characteristics including, race, ethnicity, and previous live births, the researchers noted. Other limitations included a lack of data on the sex preferences of the couple, and whether the sex of the embryo was known, and whether male and female embryos were transferred. Also, no states have mandates to cover PGT, and the limited study period may not generalize to current practices.

However, the study strengths include the large size and comprehensive database, and have implications for future policies and expansion of insurance coverage for infertility treatment and for preventing transmission of genetic diseases, they said.
 

Be mindful of consequences of testing

In an interview, Dr. Jungheim said she was surprised by some of the findings. “I thought we would see that PGT-A utilization was lower in states without mandates given the already high cost of IVF for patients paying out of pocket. I was also surprised to see that more males were born after PGT-A; it suggests that overall, patients using PGT-A favor males.

“For clinicians, we need to be mindful of the long-term impact of our practices,” she emphasized. “Shifting the sex ratio in favor of one sex or the other is an unintended consequence of IVF with PGT-A that can have negative implications for future generations.”

In the study, the researchers proposed a revision to the American Society for Reproductive Medicine Ethics Committee opinion on sex selection to provide guidance in keeping with ASRM’s mission of “accessible, ethical, and quality reproductive care for every person.”

However, “even if the ASRM Ethics Committee Opinion was revised, it’s up to clinicians to decide what they are comfortable with,” said Dr. Jungheim. “When patients are paying out of pocket for expensive treatments that require emotional investment and time, it can be difficult to keep medical decision making strictly evidence based.” Improved insurance coverage and access to fertility care may help with some of these decisions, but more real-world evidence is needed. 
 

Let’s talk about sex (selection)

The study findings are both “novel and sobering,” and enhance the current body of evidence of associations between state insurance mandates and IVF outcomes, Jennifer Eaton, MD, of Brown University, Providence, R.I., wrote in an accompanying editorial.

“The association between mandate status and elective sex selection is particularly eye-opening,” said Dr. Eaton. The overall increased use of PGT for sex selection does not account for sex selection as part of testing for aneuploidy. In fact, “patients with euploid embryos of both sexes are frequently given the opportunity to select which embryo to transfer.”

The current study provides “compelling evidence that it is time to revisit the ethical dilemma of elective sex selection in the United States,” Dr. Eaton emphasized. The current ASRM guidance states that IVF clinics are not obligated to provide or refuse to provide nonmedically indicated methods of sex selection, but in light of the current study and other studies, a revision to the existing ASRM Ethics Committee opinion is needed.

The study received no outside funding. Neither the researchers nor Dr. Eaton had any financial conflicts to disclose.

Psychiatry may be emerging from the era of psychopharmacology and entering the era of the brain, but these reductionist, jingoistic labels do little justice to the need to acknowledge and incorporate the context of our lives into our theories and treatments. Yet psychiatrists who embrace context have much to celebrate in evolving neuroscience research.

One aptly named article – ’Families that fire together smile together’ – illustrates the fundamental connection between parent and child.¹ In the functional MRIs (fMRIs) taken of these parent-child dyads (n = 76), the dyads with similar resting state connectomes also have similar day-to-day emotional states, as reflected in their diary entries. Their empathic states were identified in the multivoxel patterns in the fusiform face area of the brain.² Another study of fMRIs and parent-child dyads (n = 93) found that the parental functional connectomes (fbc) predicted their children’s externalizing and internalizing problems. The maternal fbcs were correlated with the daughter-mother relationship, and to the daughter’s internalizing problems, suggesting a potential future focus on gendered relationships.³

The implications for psychotherapy are clear: These studies show that empathic connection between parent and child results in a better outcome for the child. Patient and psychotherapist can choose from a range of psychotherapeutic interventions that promote empathy, from providing behavioral tasks that support connection between parent and child to more in-depth family interventions. Family interventions that promote empathy include increasing the family’s understanding of the importance of empathic connection and providing a safe space to help establish empathic connection.

Studying prosocial behavior, Lukas Lengersdorff and colleagues found that fMRIs of male participants (n = 96) reflected stronger activity when they were acting on behalf of the other, rather than when acting for themselves.⁴ During this prosocial learning fMRI study, there was stronger engagement of the ventromedial prefrontal cortex (PFC) and higher connectivity between the ventromedial PFC and the right temporoparietal junction (rTPJ). Protecting others from harm appears to be associated with neural mechanisms that support self-relevant learning, but with the added recruitment of structures associated with the social brain. This study shows what we already know – that our brains are wired for social context. This research supports psychotherapeutic interventions aimed at creating interpersonal connection, not just at an intimate level, but also at the prosocial level, such as caring and helping others.

When social interactions are coded, the default mode network (DMN) shows increased activity. Participants (n = 11) in another study had heightened medial PFC–rTPJ connectivity, not only during rest that followed the experimental social encoding, but also during rest that followed a subsequent, nonsocial task.⁵ Engaging portions of the DMN during live social interactions when actively decoding the social environment, and later engaging these regions when relaxing after the social interaction, appears to facilitate social functioning. Our brains are wired to respond to context. This research underscores the positive impact of interventions such as group therapy and support groups, two underutilized modalities.

Neuroscience evaluation of our relationships provides depth to studies that fall under the medical paradigm of the gene/environment interaction. One of the most elegant in psychiatry is the Finnish study of a sample of offspring of mothers with schizophrenia who gave their children up for adoption.⁶ This sample of index offspring (n = 155) was compared blindly with matched controls (n = 186) of adopted/away offspring of parents without schizophrenia. The genetic effect manifested only as a psychiatric disorder in the presence of a disturbed family environment. We can now extrapolate certain possible mechanisms from the studies mentioned above: That the deficits lie in the activity or lack of activity in the DMN and associated areas, and in the generation of connectomes responsible for empathic connections.

Neuroscience expands our knowledge of our relational and social worlds, but can psychiatry make the case for inclusion of context in our conceptualization of psychiatric distress? From time to time, inroads are made, for example, the Global Assessment of Relational Functioning was incorporated into the DSM-IV-R and the Cultural Formulation Interview is in the DSM-5. However, without a sustained paradigm shift that places the gene/environment paradigm at the core of psychiatry, these efforts will rise and fall as the pioneers in these fields rise and fall.

A major barrier to moving the gene/environment paradigm more centrally in psychiatry is the prominence of individualism as an American ideal. As the neuroscience of context develops, we will be able to argue more robustly for a contextual approach to patient care.

A second barrier is the difficulty of teaching and learning about complexity. It is easy to learn how to use the DSM to make a diagnosis, to understand when and how to prescribe medications, but it is much more difficult to understand how to incorporate the complexity of life and the context within which we live, into our lexicon of psychiatric theories and treatments. As Tanya Luhrmann, PhD, points out in her study of the process of psychiatric training, residents are intimidated by the need to learn the many psychological theories and their practice; learning about medications is much simpler and takes much less time and effort.⁷

Nevertheless, context is embraced by several psychiatric subspecialties. Family psychiatrists recognize the power of relational dynamics in the family, and their role in shaping the individual. From understanding family communication patterns, to understanding how roles in the family get allocated, family psychiatry has well established tools for assessment and many evidence-based treatments that focus on changing relational dynamics. Social and community psychiatrists emphasize the role of race, poverty, and access, and support the assessment and treatment of the underprivileged. Cultural psychiatrists recognize that each culture has its own way of constructing identities and shaping our experiences, its own conceptualization of illness and specific idioms of distress. Cultural psychiatrists focus on sensitizing the general psychiatrist to these nuances. Child psychiatrists involve parents, and geriatric psychiatrists involve guardians. General psychiatrists understand context when, for example, understanding the role of trauma in the development of an individual, recognizing that its impact is contingent on the context within which the trauma occurs.

Neuroscience clarifies the neural pathways involved in the development of empathic and social behaviors. Our psychological theories and practice must reflect this advancement. We can teach the relevant neuroscience along with basic concepts such as child-parent relationships. We must assess an individual’s degree of fit within their family and community. Apart from asking relational questions, such as who in your world is important to you, we can use well recognized tools to help us bring context to the forefront. An easy tool is the three generational genogram, or an ecomap, which allows each individual to see where they sit in the context of their world.⁸ Cultural influences, societal, religious, and family influences can be drawn on the genogram, highlighting both formal and hidden family narratives. In addition, we can share how the brain works with our patients; the science of empathy and social behaviors shows us that our need for interpersonal connection is hardwired.

Dr. Heru is professor of psychiatry at the University of Colorado Denver, Aurora. She is editor of “Working With Families in Medical Settings: A Multidisciplinary Guide for Psychiatrists and Other Health Professionals” (New York: Routledge, 2013). She has no conflicts of interest to disclose. Contact Dr. Heru at alison.heru@ucdenver.edu.

References

1. Lee TH et al. Families that fire together smile together: Resting state connectome similarity and daily emotional synchrony in parent-child dyads. Neuroimage. 2017 May 15;152:31-37. doi: 10.1016/j.neuroimage.2017.02.078.

2. Lee TH et al. Love flows downstream: Mothers’ and children’s neural representation similarity in perceiving distress of self and family. Soc Cogn Affect Neurosci. 2017 Dec 1;12(12):1916-27. doi: 10.1093/scan/nsx125.

3. Itahashi T et al. Functional connectomes linking child-parent relationships with psychological problems in adolescence. Neuroimage. 2020 Oct 1;219:117013. doi: 10.1016/j.neuroimage.2020.117013.

4. Lengersdorff LL et al. When implicit prosociality trumps selfishness: The neural valuation system underpins more optimal choices when learning to avoid harm to others than to oneself. J Neurosci. 2020 Sep 16;40(38):7286-99. doi: 10.1523/JNEUROSCI.0842-20.2020.

5. Meyer ML et al. Evidence that default network connectivity during rest consolidates social information. Cereb Cortex. 2019 May 1;29(5):1910-20. doi: 10.1093/cercor/bhy071.

6. Tienari P et al. The Finnish adoptive family study of schizophrenia. Implications for family research. Br J Psychiatry Suppl. 1994 Apr;(23):20-6.

7. Luhrmann, TM. Of two minds: The growing disorder in American psychiatry. New York, NY: Alfred A. Knopf, 2000.

8. Libbon R et al. Family skills for the resident toolbox: The 10-min. Genogram, Ecomap, and Prescribing Homework. Acad Psychiatry. 2019 Aug;43(4):435-439. doi: 10.1007/s40596-019-01054-6.

Psychiatry may be emerging from the era of psychopharmacology and entering the era of the brain, but these reductionist, jingoistic labels do little justice to the need to acknowledge and incorporate the context of our lives into our theories and treatments. Yet psychiatrists who embrace context have much to celebrate in evolving neuroscience research.

One aptly named article – ’Families that fire together smile together’ – illustrates the fundamental connection between parent and child.¹ In the functional MRIs (fMRIs) taken of these parent-child dyads (n = 76), the dyads with similar resting state connectomes also have similar day-to-day emotional states, as reflected in their diary entries. Their empathic states were identified in the multivoxel patterns in the fusiform face area of the brain.² Another study of fMRIs and parent-child dyads (n = 93) found that the parental functional connectomes (fbc) predicted their children’s externalizing and internalizing problems. The maternal fbcs were correlated with the daughter-mother relationship, and to the daughter’s internalizing problems, suggesting a potential future focus on gendered relationships.³

The implications for psychotherapy are clear: These studies show that empathic connection between parent and child results in a better outcome for the child. Patient and psychotherapist can choose from a range of psychotherapeutic interventions that promote empathy, from providing behavioral tasks that support connection between parent and child to more in-depth family interventions. Family interventions that promote empathy include increasing the family’s understanding of the importance of empathic connection and providing a safe space to help establish empathic connection.

Studying prosocial behavior, Lukas Lengersdorff and colleagues found that fMRIs of male participants (n = 96) reflected stronger activity when they were acting on behalf of the other, rather than when acting for themselves.⁴ During this prosocial learning fMRI study, there was stronger engagement of the ventromedial prefrontal cortex (PFC) and higher connectivity between the ventromedial PFC and the right temporoparietal junction (rTPJ). Protecting others from harm appears to be associated with neural mechanisms that support self-relevant learning, but with the added recruitment of structures associated with the social brain. This study shows what we already know – that our brains are wired for social context. This research supports psychotherapeutic interventions aimed at creating interpersonal connection, not just at an intimate level, but also at the prosocial level, such as caring and helping others.

When social interactions are coded, the default mode network (DMN) shows increased activity. Participants (n = 11) in another study had heightened medial PFC–rTPJ connectivity, not only during rest that followed the experimental social encoding, but also during rest that followed a subsequent, nonsocial task.⁵ Engaging portions of the DMN during live social interactions when actively decoding the social environment, and later engaging these regions when relaxing after the social interaction, appears to facilitate social functioning. Our brains are wired to respond to context. This research underscores the positive impact of interventions such as group therapy and support groups, two underutilized modalities.

Neuroscience evaluation of our relationships provides depth to studies that fall under the medical paradigm of the gene/environment interaction. One of the most elegant in psychiatry is the Finnish study of a sample of offspring of mothers with schizophrenia who gave their children up for adoption.⁶ This sample of index offspring (n = 155) was compared blindly with matched controls (n = 186) of adopted/away offspring of parents without schizophrenia. The genetic effect manifested only as a psychiatric disorder in the presence of a disturbed family environment. We can now extrapolate certain possible mechanisms from the studies mentioned above: That the deficits lie in the activity or lack of activity in the DMN and associated areas, and in the generation of connectomes responsible for empathic connections.

Neuroscience expands our knowledge of our relational and social worlds, but can psychiatry make the case for inclusion of context in our conceptualization of psychiatric distress? From time to time, inroads are made, for example, the Global Assessment of Relational Functioning was incorporated into the DSM-IV-R and the Cultural Formulation Interview is in the DSM-5. However, without a sustained paradigm shift that places the gene/environment paradigm at the core of psychiatry, these efforts will rise and fall as the pioneers in these fields rise and fall.

A major barrier to moving the gene/environment paradigm more centrally in psychiatry is the prominence of individualism as an American ideal. As the neuroscience of context develops, we will be able to argue more robustly for a contextual approach to patient care.

A second barrier is the difficulty of teaching and learning about complexity. It is easy to learn how to use the DSM to make a diagnosis, to understand when and how to prescribe medications, but it is much more difficult to understand how to incorporate the complexity of life and the context within which we live, into our lexicon of psychiatric theories and treatments. As Tanya Luhrmann, PhD, points out in her study of the process of psychiatric training, residents are intimidated by the need to learn the many psychological theories and their practice; learning about medications is much simpler and takes much less time and effort.⁷

Nevertheless, context is embraced by several psychiatric subspecialties. Family psychiatrists recognize the power of relational dynamics in the family, and their role in shaping the individual. From understanding family communication patterns, to understanding how roles in the family get allocated, family psychiatry has well established tools for assessment and many evidence-based treatments that focus on changing relational dynamics. Social and community psychiatrists emphasize the role of race, poverty, and access, and support the assessment and treatment of the underprivileged. Cultural psychiatrists recognize that each culture has its own way of constructing identities and shaping our experiences, its own conceptualization of illness and specific idioms of distress. Cultural psychiatrists focus on sensitizing the general psychiatrist to these nuances. Child psychiatrists involve parents, and geriatric psychiatrists involve guardians. General psychiatrists understand context when, for example, understanding the role of trauma in the development of an individual, recognizing that its impact is contingent on the context within which the trauma occurs.

Neuroscience clarifies the neural pathways involved in the development of empathic and social behaviors. Our psychological theories and practice must reflect this advancement. We can teach the relevant neuroscience along with basic concepts such as child-parent relationships. We must assess an individual’s degree of fit within their family and community. Apart from asking relational questions, such as who in your world is important to you, we can use well recognized tools to help us bring context to the forefront. An easy tool is the three generational genogram, or an ecomap, which allows each individual to see where they sit in the context of their world.⁸ Cultural influences, societal, religious, and family influences can be drawn on the genogram, highlighting both formal and hidden family narratives. In addition, we can share how the brain works with our patients; the science of empathy and social behaviors shows us that our need for interpersonal connection is hardwired.

Dr. Heru is professor of psychiatry at the University of Colorado Denver, Aurora. She is editor of “Working With Families in Medical Settings: A Multidisciplinary Guide for Psychiatrists and Other Health Professionals” (New York: Routledge, 2013). She has no conflicts of interest to disclose. Contact Dr. Heru at alison.heru@ucdenver.edu.

References

1. Lee TH et al. Families that fire together smile together: Resting state connectome similarity and daily emotional synchrony in parent-child dyads. Neuroimage. 2017 May 15;152:31-37. doi: 10.1016/j.neuroimage.2017.02.078.

2. Lee TH et al. Love flows downstream: Mothers’ and children’s neural representation similarity in perceiving distress of self and family. Soc Cogn Affect Neurosci. 2017 Dec 1;12(12):1916-27. doi: 10.1093/scan/nsx125.

3. Itahashi T et al. Functional connectomes linking child-parent relationships with psychological problems in adolescence. Neuroimage. 2020 Oct 1;219:117013. doi: 10.1016/j.neuroimage.2020.117013.

4. Lengersdorff LL et al. When implicit prosociality trumps selfishness: The neural valuation system underpins more optimal choices when learning to avoid harm to others than to oneself. J Neurosci. 2020 Sep 16;40(38):7286-99. doi: 10.1523/JNEUROSCI.0842-20.2020.

5. Meyer ML et al. Evidence that default network connectivity during rest consolidates social information. Cereb Cortex. 2019 May 1;29(5):1910-20. doi: 10.1093/cercor/bhy071.

6. Tienari P et al. The Finnish adoptive family study of schizophrenia. Implications for family research. Br J Psychiatry Suppl. 1994 Apr;(23):20-6.

7. Luhrmann, TM. Of two minds: The growing disorder in American psychiatry. New York, NY: Alfred A. Knopf, 2000.

8. Libbon R et al. Family skills for the resident toolbox: The 10-min. Genogram, Ecomap, and Prescribing Homework. Acad Psychiatry. 2019 Aug;43(4):435-439. doi: 10.1007/s40596-019-01054-6.

Psychiatry may be emerging from the era of psychopharmacology and entering the era of the brain, but these reductionist, jingoistic labels do little justice to the need to acknowledge and incorporate the context of our lives into our theories and treatments. Yet psychiatrists who embrace context have much to celebrate in evolving neuroscience research.

One aptly named article – ’Families that fire together smile together’ – illustrates the fundamental connection between parent and child.¹ In the functional MRIs (fMRIs) taken of these parent-child dyads (n = 76), the dyads with similar resting state connectomes also have similar day-to-day emotional states, as reflected in their diary entries. Their empathic states were identified in the multivoxel patterns in the fusiform face area of the brain.² Another study of fMRIs and parent-child dyads (n = 93) found that the parental functional connectomes (fbc) predicted their children’s externalizing and internalizing problems. The maternal fbcs were correlated with the daughter-mother relationship, and to the daughter’s internalizing problems, suggesting a potential future focus on gendered relationships.³

The implications for psychotherapy are clear: These studies show that empathic connection between parent and child results in a better outcome for the child. Patient and psychotherapist can choose from a range of psychotherapeutic interventions that promote empathy, from providing behavioral tasks that support connection between parent and child to more in-depth family interventions. Family interventions that promote empathy include increasing the family’s understanding of the importance of empathic connection and providing a safe space to help establish empathic connection.

Studying prosocial behavior, Lukas Lengersdorff and colleagues found that fMRIs of male participants (n = 96) reflected stronger activity when they were acting on behalf of the other, rather than when acting for themselves.⁴ During this prosocial learning fMRI study, there was stronger engagement of the ventromedial prefrontal cortex (PFC) and higher connectivity between the ventromedial PFC and the right temporoparietal junction (rTPJ). Protecting others from harm appears to be associated with neural mechanisms that support self-relevant learning, but with the added recruitment of structures associated with the social brain. This study shows what we already know – that our brains are wired for social context. This research supports psychotherapeutic interventions aimed at creating interpersonal connection, not just at an intimate level, but also at the prosocial level, such as caring and helping others.

When social interactions are coded, the default mode network (DMN) shows increased activity. Participants (n = 11) in another study had heightened medial PFC–rTPJ connectivity, not only during rest that followed the experimental social encoding, but also during rest that followed a subsequent, nonsocial task.⁵ Engaging portions of the DMN during live social interactions when actively decoding the social environment, and later engaging these regions when relaxing after the social interaction, appears to facilitate social functioning. Our brains are wired to respond to context. This research underscores the positive impact of interventions such as group therapy and support groups, two underutilized modalities.

Neuroscience evaluation of our relationships provides depth to studies that fall under the medical paradigm of the gene/environment interaction. One of the most elegant in psychiatry is the Finnish study of a sample of offspring of mothers with schizophrenia who gave their children up for adoption.⁶ This sample of index offspring (n = 155) was compared blindly with matched controls (n = 186) of adopted/away offspring of parents without schizophrenia. The genetic effect manifested only as a psychiatric disorder in the presence of a disturbed family environment. We can now extrapolate certain possible mechanisms from the studies mentioned above: That the deficits lie in the activity or lack of activity in the DMN and associated areas, and in the generation of connectomes responsible for empathic connections.

Neuroscience expands our knowledge of our relational and social worlds, but can psychiatry make the case for inclusion of context in our conceptualization of psychiatric distress? From time to time, inroads are made, for example, the Global Assessment of Relational Functioning was incorporated into the DSM-IV-R and the Cultural Formulation Interview is in the DSM-5. However, without a sustained paradigm shift that places the gene/environment paradigm at the core of psychiatry, these efforts will rise and fall as the pioneers in these fields rise and fall.

A major barrier to moving the gene/environment paradigm more centrally in psychiatry is the prominence of individualism as an American ideal. As the neuroscience of context develops, we will be able to argue more robustly for a contextual approach to patient care.

A second barrier is the difficulty of teaching and learning about complexity. It is easy to learn how to use the DSM to make a diagnosis, to understand when and how to prescribe medications, but it is much more difficult to understand how to incorporate the complexity of life and the context within which we live, into our lexicon of psychiatric theories and treatments. As Tanya Luhrmann, PhD, points out in her study of the process of psychiatric training, residents are intimidated by the need to learn the many psychological theories and their practice; learning about medications is much simpler and takes much less time and effort.⁷

Nevertheless, context is embraced by several psychiatric subspecialties. Family psychiatrists recognize the power of relational dynamics in the family, and their role in shaping the individual. From understanding family communication patterns, to understanding how roles in the family get allocated, family psychiatry has well established tools for assessment and many evidence-based treatments that focus on changing relational dynamics. Social and community psychiatrists emphasize the role of race, poverty, and access, and support the assessment and treatment of the underprivileged. Cultural psychiatrists recognize that each culture has its own way of constructing identities and shaping our experiences, its own conceptualization of illness and specific idioms of distress. Cultural psychiatrists focus on sensitizing the general psychiatrist to these nuances. Child psychiatrists involve parents, and geriatric psychiatrists involve guardians. General psychiatrists understand context when, for example, understanding the role of trauma in the development of an individual, recognizing that its impact is contingent on the context within which the trauma occurs.

Neuroscience clarifies the neural pathways involved in the development of empathic and social behaviors. Our psychological theories and practice must reflect this advancement. We can teach the relevant neuroscience along with basic concepts such as child-parent relationships. We must assess an individual’s degree of fit within their family and community. Apart from asking relational questions, such as who in your world is important to you, we can use well recognized tools to help us bring context to the forefront. An easy tool is the three generational genogram, or an ecomap, which allows each individual to see where they sit in the context of their world.⁸ Cultural influences, societal, religious, and family influences can be drawn on the genogram, highlighting both formal and hidden family narratives. In addition, we can share how the brain works with our patients; the science of empathy and social behaviors shows us that our need for interpersonal connection is hardwired.

Dr. Heru is professor of psychiatry at the University of Colorado Denver, Aurora. She is editor of “Working With Families in Medical Settings: A Multidisciplinary Guide for Psychiatrists and Other Health Professionals” (New York: Routledge, 2013). She has no conflicts of interest to disclose. Contact Dr. Heru at alison.heru@ucdenver.edu.

References

1. Lee TH et al. Families that fire together smile together: Resting state connectome similarity and daily emotional synchrony in parent-child dyads. Neuroimage. 2017 May 15;152:31-37. doi: 10.1016/j.neuroimage.2017.02.078.

2. Lee TH et al. Love flows downstream: Mothers’ and children’s neural representation similarity in perceiving distress of self and family. Soc Cogn Affect Neurosci. 2017 Dec 1;12(12):1916-27. doi: 10.1093/scan/nsx125.

3. Itahashi T et al. Functional connectomes linking child-parent relationships with psychological problems in adolescence. Neuroimage. 2020 Oct 1;219:117013. doi: 10.1016/j.neuroimage.2020.117013.

4. Lengersdorff LL et al. When implicit prosociality trumps selfishness: The neural valuation system underpins more optimal choices when learning to avoid harm to others than to oneself. J Neurosci. 2020 Sep 16;40(38):7286-99. doi: 10.1523/JNEUROSCI.0842-20.2020.

5. Meyer ML et al. Evidence that default network connectivity during rest consolidates social information. Cereb Cortex. 2019 May 1;29(5):1910-20. doi: 10.1093/cercor/bhy071.

6. Tienari P et al. The Finnish adoptive family study of schizophrenia. Implications for family research. Br J Psychiatry Suppl. 1994 Apr;(23):20-6.

7. Luhrmann, TM. Of two minds: The growing disorder in American psychiatry. New York, NY: Alfred A. Knopf, 2000.

8. Libbon R et al. Family skills for the resident toolbox: The 10-min. Genogram, Ecomap, and Prescribing Homework. Acad Psychiatry. 2019 Aug;43(4):435-439. doi: 10.1007/s40596-019-01054-6.

Loss of vestibular function is a key contributor to a well-documented increased risk for falls in patients with Alzheimer’s disease (AD), new research confirms.

Falls are twice as common in patients with AD versu older individuals without the disorder and significantly increase the likelihood of institutionalization.

However, researchers recorded fewer falls in patients with a better functioning vestibular system, which detects head movements and plays a critical role in spatial orientation, posture, gait, and balance.

The results suggest that improving vestibular function with currently available therapies may prevent falls, something the researchers will investigate in a new clinical trial launching next month.

“One of the most dangerous and impactful symptoms in terms of function in patients with Alzheimer’s disease is their increased predisposition to falls,” study investigator Yuri Agrawal, MD, department of otolaryngology–head and neck surgery, Johns Hopkins University School of Medicine, Baltimore, said in an interview. “Alzheimer’s is the sixth leading cause of death in the U.S., and some people actually say that that high mortality rate is because of their predisposition to falls and the injuries that occur.”

The study was published online Feb. 14 in the Journal of Alzheimer’s Disease.
 

The ‘sixth hidden sense’

The vestibular system consists of three semicircular canals, which detect rotational head movement, and two otolith organs called the utricle and the saccule, which sense linear head movements and the orientation of the head with respect to gravity.

“We call the vestibular system the sixth hidden sense because it’s not a conscious perception like taste or smell,” Dr. Agrawal said. “It’s constantly providing input to our brain about where we are in space.”

Dr. Agrawal and colleagues previously reported that vestibular loss is twice as common in Alzheimer’s patients as in cognitively unimpaired age-matched controls. Now, they wanted to know if this sensory loss was associated with an increased risk for falls in this population.

The study included 48 patients age greater than or equal to 60 years with mild-to-moderate AD between 2018 and 2020. They also included an age-matched control group of healthy controls with no cognitive impairment.

Researchers assessed vestibular function at baseline by measuring semicircular canal and saccular function. One test required participants to wear goggles and complete a series of tests with their eyes open and closed while researchers recorded their eye movement with video-oculography. They also measured participants’ balance using the Berg Balance Scale.

Relative to matched controls, AD patients exhibited increased lateral instability when their eyes were open (P = .033) and closed (P = .042). Studies suggest that lateral stability declines more quickly with age and that instability with eyes closed is the single biggest predictor of incident falls in community-dwelling adults.

To determine if poor vestibular function increased fall risk in patients with AD, researchers followed the cohort for up to 2 years.

“We found that patients with vestibular loss at baseline were 50% more likely to fall, adjusting for other factors that could contribute to that,” Dr. Agrawal said.

Specifically, better semicircular canal function was significantly associated with lower likelihood of falls, even after adjusting for confounders (adjusted hazard ratio, 0.65; P = .009).
 

Can therapy help?

Commenting on the findings, James Burke, MD, PhD, professor of neurology at Duke University Medical Center, Durham, N.C., said that the finding that impaired vestibular function is associated with increased falls “significantly advances our understanding of the topic” and suggests that treating vestibular dysfunction could reduce falls in Alzheimer’s patients.

“Screening patients with Alzheimer’s disease for impaired vestibular function could lead to identification of individuals at high risk of falls and target those who would benefit from vestibular therapy,” he said.

Vestibular rehabilitation therapy is often used to treat a number of disorders related to vestibular function loss. There are also studies underway to measure the efficacy of a vestibular implant that works much like a cochlear implant.

While evaluation of vestibular function is currently not routinely included in AD care, studies such as these suggest it may be time to consider adding it to the standard of care, Jennifer Coto, PhD, assistant professor of otolaryngology at the University of Miami Miller School of Medicine, said in an interview.

“Best practice guidelines for management of Alzheimer’s patients should be revised to include routine vestibular evaluation and support from a multidisciplinary team that may address other crucial areas of functioning, particularly psychological functioning, sleep, and independence,” she said.

“Future research also needs to evaluate the effectiveness of vestibular therapy in patients with Alzheimer’s and the benefits of early identification and intervention for preventing recurrent falls.”

Dr. Agrawal is leading a 5-year, $3.5 million National Institute on Aging study that seeks to do just that. Enrollment in the study begins next month. Patients will complete an initial in-person screening, but the remainder of the study will be conducted virtually.

Therapies will be noninvasive, nonpharmaceutical, and performed in participants’ homes. If the therapy is successful at reducing falls, Dr. Agrawal said the virtual design would significantly broaden its potential patient reach.

The study was funded by the National Institute on Aging. Study authors’ disclosures are reported in the original article. Dr. Coto and Dr. Burke report no relevant financial relationships.

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

Loss of vestibular function is a key contributor to a well-documented increased risk for falls in patients with Alzheimer’s disease (AD), new research confirms.

Falls are twice as common in patients with AD versu older individuals without the disorder and significantly increase the likelihood of institutionalization.

However, researchers recorded fewer falls in patients with a better functioning vestibular system, which detects head movements and plays a critical role in spatial orientation, posture, gait, and balance.

The results suggest that improving vestibular function with currently available therapies may prevent falls, something the researchers will investigate in a new clinical trial launching next month.

“One of the most dangerous and impactful symptoms in terms of function in patients with Alzheimer’s disease is their increased predisposition to falls,” study investigator Yuri Agrawal, MD, department of otolaryngology–head and neck surgery, Johns Hopkins University School of Medicine, Baltimore, said in an interview. “Alzheimer’s is the sixth leading cause of death in the U.S., and some people actually say that that high mortality rate is because of their predisposition to falls and the injuries that occur.”

The study was published online Feb. 14 in the Journal of Alzheimer’s Disease.
 

The ‘sixth hidden sense’

The vestibular system consists of three semicircular canals, which detect rotational head movement, and two otolith organs called the utricle and the saccule, which sense linear head movements and the orientation of the head with respect to gravity.

“We call the vestibular system the sixth hidden sense because it’s not a conscious perception like taste or smell,” Dr. Agrawal said. “It’s constantly providing input to our brain about where we are in space.”

Dr. Agrawal and colleagues previously reported that vestibular loss is twice as common in Alzheimer’s patients as in cognitively unimpaired age-matched controls. Now, they wanted to know if this sensory loss was associated with an increased risk for falls in this population.

The study included 48 patients age greater than or equal to 60 years with mild-to-moderate AD between 2018 and 2020. They also included an age-matched control group of healthy controls with no cognitive impairment.

Researchers assessed vestibular function at baseline by measuring semicircular canal and saccular function. One test required participants to wear goggles and complete a series of tests with their eyes open and closed while researchers recorded their eye movement with video-oculography. They also measured participants’ balance using the Berg Balance Scale.

Relative to matched controls, AD patients exhibited increased lateral instability when their eyes were open (P = .033) and closed (P = .042). Studies suggest that lateral stability declines more quickly with age and that instability with eyes closed is the single biggest predictor of incident falls in community-dwelling adults.

To determine if poor vestibular function increased fall risk in patients with AD, researchers followed the cohort for up to 2 years.

“We found that patients with vestibular loss at baseline were 50% more likely to fall, adjusting for other factors that could contribute to that,” Dr. Agrawal said.

Specifically, better semicircular canal function was significantly associated with lower likelihood of falls, even after adjusting for confounders (adjusted hazard ratio, 0.65; P = .009).
 

Can therapy help?

Commenting on the findings, James Burke, MD, PhD, professor of neurology at Duke University Medical Center, Durham, N.C., said that the finding that impaired vestibular function is associated with increased falls “significantly advances our understanding of the topic” and suggests that treating vestibular dysfunction could reduce falls in Alzheimer’s patients.

“Screening patients with Alzheimer’s disease for impaired vestibular function could lead to identification of individuals at high risk of falls and target those who would benefit from vestibular therapy,” he said.

Vestibular rehabilitation therapy is often used to treat a number of disorders related to vestibular function loss. There are also studies underway to measure the efficacy of a vestibular implant that works much like a cochlear implant.

While evaluation of vestibular function is currently not routinely included in AD care, studies such as these suggest it may be time to consider adding it to the standard of care, Jennifer Coto, PhD, assistant professor of otolaryngology at the University of Miami Miller School of Medicine, said in an interview.

“Best practice guidelines for management of Alzheimer’s patients should be revised to include routine vestibular evaluation and support from a multidisciplinary team that may address other crucial areas of functioning, particularly psychological functioning, sleep, and independence,” she said.

“Future research also needs to evaluate the effectiveness of vestibular therapy in patients with Alzheimer’s and the benefits of early identification and intervention for preventing recurrent falls.”

Dr. Agrawal is leading a 5-year, $3.5 million National Institute on Aging study that seeks to do just that. Enrollment in the study begins next month. Patients will complete an initial in-person screening, but the remainder of the study will be conducted virtually.

Therapies will be noninvasive, nonpharmaceutical, and performed in participants’ homes. If the therapy is successful at reducing falls, Dr. Agrawal said the virtual design would significantly broaden its potential patient reach.

The study was funded by the National Institute on Aging. Study authors’ disclosures are reported in the original article. Dr. Coto and Dr. Burke report no relevant financial relationships.

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

Loss of vestibular function is a key contributor to a well-documented increased risk for falls in patients with Alzheimer’s disease (AD), new research confirms.

Falls are twice as common in patients with AD versu older individuals without the disorder and significantly increase the likelihood of institutionalization.

However, researchers recorded fewer falls in patients with a better functioning vestibular system, which detects head movements and plays a critical role in spatial orientation, posture, gait, and balance.

The results suggest that improving vestibular function with currently available therapies may prevent falls, something the researchers will investigate in a new clinical trial launching next month.

“One of the most dangerous and impactful symptoms in terms of function in patients with Alzheimer’s disease is their increased predisposition to falls,” study investigator Yuri Agrawal, MD, department of otolaryngology–head and neck surgery, Johns Hopkins University School of Medicine, Baltimore, said in an interview. “Alzheimer’s is the sixth leading cause of death in the U.S., and some people actually say that that high mortality rate is because of their predisposition to falls and the injuries that occur.”

The study was published online Feb. 14 in the Journal of Alzheimer’s Disease.
 

The ‘sixth hidden sense’

The vestibular system consists of three semicircular canals, which detect rotational head movement, and two otolith organs called the utricle and the saccule, which sense linear head movements and the orientation of the head with respect to gravity.

“We call the vestibular system the sixth hidden sense because it’s not a conscious perception like taste or smell,” Dr. Agrawal said. “It’s constantly providing input to our brain about where we are in space.”

Dr. Agrawal and colleagues previously reported that vestibular loss is twice as common in Alzheimer’s patients as in cognitively unimpaired age-matched controls. Now, they wanted to know if this sensory loss was associated with an increased risk for falls in this population.

The study included 48 patients age greater than or equal to 60 years with mild-to-moderate AD between 2018 and 2020. They also included an age-matched control group of healthy controls with no cognitive impairment.

Researchers assessed vestibular function at baseline by measuring semicircular canal and saccular function. One test required participants to wear goggles and complete a series of tests with their eyes open and closed while researchers recorded their eye movement with video-oculography. They also measured participants’ balance using the Berg Balance Scale.

Relative to matched controls, AD patients exhibited increased lateral instability when their eyes were open (P = .033) and closed (P = .042). Studies suggest that lateral stability declines more quickly with age and that instability with eyes closed is the single biggest predictor of incident falls in community-dwelling adults.

To determine if poor vestibular function increased fall risk in patients with AD, researchers followed the cohort for up to 2 years.

“We found that patients with vestibular loss at baseline were 50% more likely to fall, adjusting for other factors that could contribute to that,” Dr. Agrawal said.

Specifically, better semicircular canal function was significantly associated with lower likelihood of falls, even after adjusting for confounders (adjusted hazard ratio, 0.65; P = .009).
 

Can therapy help?

Commenting on the findings, James Burke, MD, PhD, professor of neurology at Duke University Medical Center, Durham, N.C., said that the finding that impaired vestibular function is associated with increased falls “significantly advances our understanding of the topic” and suggests that treating vestibular dysfunction could reduce falls in Alzheimer’s patients.

“Screening patients with Alzheimer’s disease for impaired vestibular function could lead to identification of individuals at high risk of falls and target those who would benefit from vestibular therapy,” he said.

Vestibular rehabilitation therapy is often used to treat a number of disorders related to vestibular function loss. There are also studies underway to measure the efficacy of a vestibular implant that works much like a cochlear implant.

While evaluation of vestibular function is currently not routinely included in AD care, studies such as these suggest it may be time to consider adding it to the standard of care, Jennifer Coto, PhD, assistant professor of otolaryngology at the University of Miami Miller School of Medicine, said in an interview.

“Best practice guidelines for management of Alzheimer’s patients should be revised to include routine vestibular evaluation and support from a multidisciplinary team that may address other crucial areas of functioning, particularly psychological functioning, sleep, and independence,” she said.

“Future research also needs to evaluate the effectiveness of vestibular therapy in patients with Alzheimer’s and the benefits of early identification and intervention for preventing recurrent falls.”

Dr. Agrawal is leading a 5-year, $3.5 million National Institute on Aging study that seeks to do just that. Enrollment in the study begins next month. Patients will complete an initial in-person screening, but the remainder of the study will be conducted virtually.

Therapies will be noninvasive, nonpharmaceutical, and performed in participants’ homes. If the therapy is successful at reducing falls, Dr. Agrawal said the virtual design would significantly broaden its potential patient reach.

The study was funded by the National Institute on Aging. Study authors’ disclosures are reported in the original article. Dr. Coto and Dr. Burke report no relevant financial relationships.

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

When Serena-Lian Sakheim-Devine’s best friend from childhood died of cancer, she felt sad and lonely while away at college. Wanting something warm to snuggle, she got a guinea pig and named her Basil. Then she got two more and called them Nutmeg and Paprika. The three became her Spice Girls.

“They were of great comfort to me, but also to others at times of need,” said Ms. Sakheim-Devine, 26, who lived with them in a dormitory at Smith College, an all-women’s institution in Northampton, Mass.

Her therapist wrote a letter and sent it to the disability office at Smith, which permitted the guinea pigs as emotional support animals (ESAs). Eventually, though, she wanted a dog to help manage her PTSD, depression, anxiety, and panic attacks. So, she adopted a beagle from a shelter.

Once again, a therapist provided a letter, and Ms. Sakheim-Devine was allowed to keep the beagle, Finnian, then about 13 years old, in her dorm room on the condition that she give up the guinea pigs, which she did.

She and Finnian bonded almost instantly. When she woke up drenched in sweat, unable to move or speak, the dog sensed how tense she was. Finnian licked her hands, got her fingers moving, and helped ground her.

“I didn’t really teach her that. She just knew,” said Ms. Sakheim-Devine, now a safety engineer who lives in New Haven, Conn. “It was incredible how well connected we were, even from the get-go.”
 

The therapeutic benefits of four-legged friends

Although there is limited scientific literature on the therapeutic use of ESAs, there are well-established benefits of having pets that also apply in these situations. Animals can provide distraction from stress, alleviate loneliness, and instill a sense of responsibility, said Rachel A. Davis, MD, associate professor of psychiatry and neurosurgery at the University of Colorado at Denver, Aurora.

They add structure to a person’s day by needing to be fed at specific times, and they can help the human get exercise. “Patients have reported improved sense of meaning in life and purpose,” Dr. Davis said.

A mental health clinician can recommend an ESA to help mitigate symptoms of a disability related to a mental illness as described in the DSM. Examples include depression, anxiety, obsessive-compulsive disorder, panic attacks, and PTSD.

ESAs differ from psychiatric service animals, which are trained to perform specific tasks, such as applying deep pressure that calms the owner. By their mere existence, ESAs provide emotional benefits to a person with a mental health disability.

“Social support, even from an animal, can really help people feel less alone, better about themselves, and safer from unpleasantness or even a physical attack,” said David Spiegel, MD, professor and associate chair of psychiatry and behavioral sciences and director of the Center on Stress and Health at Stanford (Calif.) University.
 

Writing a letter on your patient’s behalf

Writing a letter that serves as proof of a person’s need for an ESA is a request that mental health professionals sometimes receive from patients. The letter can grant access to housing without additional cost regardless of no-pet polices, and some employers may allow an ESA at work as a reasonable accommodation for a psychological disability. Until recently, an ESA could accompany its owner on a plane, but most airlines no longer permit this, partly because some passengers falsely claim their pets as ESAs.

Before crafting a letter for someone with an ESA, Dr. Spiegel asks for the patient’s permission to elaborate on the clinical condition that merits professional help and to explain how the animal relieves associated symptoms.

The Fair Housing Act, a federal law, requires a landlord to grant a reasonable accommodation involving an emotional support or other assistance animal. Such an accommodation honors a request to live on the property despite a no-pets policy. It also waives a pet deposit, fee, or other rules involving animals on the premises.

Landlords are usually supportive of a request to permit an ESA, said Jonathan Betlinski, MD, associate professor and director of the public psychiatry division at Oregon Health and Science University, Portland. None of his patients have experienced any difficulties once they obtained a letter from him.

However, “anytime somebody asks me about a letter for an ESA, that’s the time to have a conversation. It’s not automatic,” Dr. Betlinski said. The discussion involves learning about the type of animal a patient has and how it helps his or her emotional state.

Because of privacy concerns, Dr. Betlinski doesn’t disclose the specific diagnosis in the letter unless the patient signs a release of information. The laws pertaining to ESAs only require his letter to note that an individual has a qualifying diagnosis and that an ESA helps improve symptoms, but it’s not necessary to explain how.

“You can see where writing the letter is a fine balancing act,” he said. But he finds it helpful to mention any training the animal has completed, such as the Canine Good Citizen course sponsored by the American Kennel Club.

Most of the letters Luis Anez, PsyD, a clinical psychologist and associate professor of psychiatry at Yale University, New Haven, Conn., has written for this purpose were in support of ESAs in housing. But he also recalled providing a letter for a patient who was flying to Puerto Rico with an ESA. The letters are generally provided only to established patients with psychiatric diagnoses.

Without a letter, “we’ve seen people say: ‘I’d rather be homeless than part with my dog,’ ”said Dr. Anez, who is also director of Hispanic services at Connecticut Mental Health Center in New Haven, a partnership between Yale and the Connecticut Department of Mental Health and Addiction Services. Before getting an ESA, Dr. Anez recommends that individuals become aware of their landlord’s policies on possible restrictions relating to dog sizes and breeds.
 

Additional considerations

An ESA doesn’t necessarily have to be a dog. “It certainly could be a cat. It could be a parrot, too,” said Stephen Stern, MD, a psychiatrist in private practice in Mount Kisco, N.Y. But, “if they say that their emotional support animal is an earthworm, that would make you wonder,” he added half-jokingly.

Dr. Stern only writes an ESA letter for a patient with whom he has an ongoing professional relationship. For instance, if he’s treating someone for depression and that patient tells him how the animal helps relieve symptoms, then that is sufficient justification to write a letter.

“Because you know them, you’ve assessed that what they’re saying is plausible,” said Dr. Stern, who is also an adjunct professor of psychiatry at the University of Texas Health Science in San Antonio, where he conducted research on companion dogs for veterans with PTSD and continues to collaborate with colleagues via email and Zoom.

While veterans benefit from ESAs, some live in housing that doesn’t permit animals, said Beth Zimmerman, founder and executive director of Pets for Patriots, a nationally operating nonprofit organization in Long Beach, N.Y., that partners with shelters and animal welfare groups to adopt dogs and cats for companionship and emotional support. She said an ESA can be “a wonderful complement to other forms of therapy that a veteran may undertake.

“Most of the time when the veteran encounters a problem, it’s because the landlord is ill-informed of the law,” Dr. Zimmerman said. “We provide information to the veteran to share with the landlord or building management, and always recommend taking a very amicable approach. In our experience, with very few exceptions, once the landlord understands his or her responsibilities under the law, they will permit the veteran to have that emotional support animal in their dwelling.”

For Kristin Lowe, a chocolate Labrador-Weimaraner mix named Lola provided emotional support from her puppy days until her death at age 12 in May 2021. Ms. Lowe’s psychiatrist provided letters that allowed Lola to live in her apartment and to travel on commercial airline flights.

“She was so connected to me,” said Ms. Lowe, 34, who lives in Denver and works as an administrative office worker in physical therapy. “She was a part of me. She could read every emotion that I had.”

Now, Ms. Lowe relies on Henry, an Australian shepherd puppy, to help her cope with obsessive-compulsive disorder, major depressive disorder, and an eating disorder. She described him as “a very happy little guy and a constant tail wagger – and that lights up something in me.”

More information, which is provided by the U.S. Department of Housing and Urban Development, can be found here.

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

When Serena-Lian Sakheim-Devine’s best friend from childhood died of cancer, she felt sad and lonely while away at college. Wanting something warm to snuggle, she got a guinea pig and named her Basil. Then she got two more and called them Nutmeg and Paprika. The three became her Spice Girls.

“They were of great comfort to me, but also to others at times of need,” said Ms. Sakheim-Devine, 26, who lived with them in a dormitory at Smith College, an all-women’s institution in Northampton, Mass.

Her therapist wrote a letter and sent it to the disability office at Smith, which permitted the guinea pigs as emotional support animals (ESAs). Eventually, though, she wanted a dog to help manage her PTSD, depression, anxiety, and panic attacks. So, she adopted a beagle from a shelter.

Once again, a therapist provided a letter, and Ms. Sakheim-Devine was allowed to keep the beagle, Finnian, then about 13 years old, in her dorm room on the condition that she give up the guinea pigs, which she did.

She and Finnian bonded almost instantly. When she woke up drenched in sweat, unable to move or speak, the dog sensed how tense she was. Finnian licked her hands, got her fingers moving, and helped ground her.

“I didn’t really teach her that. She just knew,” said Ms. Sakheim-Devine, now a safety engineer who lives in New Haven, Conn. “It was incredible how well connected we were, even from the get-go.”
 

The therapeutic benefits of four-legged friends

Although there is limited scientific literature on the therapeutic use of ESAs, there are well-established benefits of having pets that also apply in these situations. Animals can provide distraction from stress, alleviate loneliness, and instill a sense of responsibility, said Rachel A. Davis, MD, associate professor of psychiatry and neurosurgery at the University of Colorado at Denver, Aurora.

They add structure to a person’s day by needing to be fed at specific times, and they can help the human get exercise. “Patients have reported improved sense of meaning in life and purpose,” Dr. Davis said.

A mental health clinician can recommend an ESA to help mitigate symptoms of a disability related to a mental illness as described in the DSM. Examples include depression, anxiety, obsessive-compulsive disorder, panic attacks, and PTSD.

ESAs differ from psychiatric service animals, which are trained to perform specific tasks, such as applying deep pressure that calms the owner. By their mere existence, ESAs provide emotional benefits to a person with a mental health disability.

“Social support, even from an animal, can really help people feel less alone, better about themselves, and safer from unpleasantness or even a physical attack,” said David Spiegel, MD, professor and associate chair of psychiatry and behavioral sciences and director of the Center on Stress and Health at Stanford (Calif.) University.
 

Writing a letter on your patient’s behalf

Writing a letter that serves as proof of a person’s need for an ESA is a request that mental health professionals sometimes receive from patients. The letter can grant access to housing without additional cost regardless of no-pet polices, and some employers may allow an ESA at work as a reasonable accommodation for a psychological disability. Until recently, an ESA could accompany its owner on a plane, but most airlines no longer permit this, partly because some passengers falsely claim their pets as ESAs.

Before crafting a letter for someone with an ESA, Dr. Spiegel asks for the patient’s permission to elaborate on the clinical condition that merits professional help and to explain how the animal relieves associated symptoms.

The Fair Housing Act, a federal law, requires a landlord to grant a reasonable accommodation involving an emotional support or other assistance animal. Such an accommodation honors a request to live on the property despite a no-pets policy. It also waives a pet deposit, fee, or other rules involving animals on the premises.

Landlords are usually supportive of a request to permit an ESA, said Jonathan Betlinski, MD, associate professor and director of the public psychiatry division at Oregon Health and Science University, Portland. None of his patients have experienced any difficulties once they obtained a letter from him.

However, “anytime somebody asks me about a letter for an ESA, that’s the time to have a conversation. It’s not automatic,” Dr. Betlinski said. The discussion involves learning about the type of animal a patient has and how it helps his or her emotional state.

Because of privacy concerns, Dr. Betlinski doesn’t disclose the specific diagnosis in the letter unless the patient signs a release of information. The laws pertaining to ESAs only require his letter to note that an individual has a qualifying diagnosis and that an ESA helps improve symptoms, but it’s not necessary to explain how.

“You can see where writing the letter is a fine balancing act,” he said. But he finds it helpful to mention any training the animal has completed, such as the Canine Good Citizen course sponsored by the American Kennel Club.

Most of the letters Luis Anez, PsyD, a clinical psychologist and associate professor of psychiatry at Yale University, New Haven, Conn., has written for this purpose were in support of ESAs in housing. But he also recalled providing a letter for a patient who was flying to Puerto Rico with an ESA. The letters are generally provided only to established patients with psychiatric diagnoses.

Without a letter, “we’ve seen people say: ‘I’d rather be homeless than part with my dog,’ ”said Dr. Anez, who is also director of Hispanic services at Connecticut Mental Health Center in New Haven, a partnership between Yale and the Connecticut Department of Mental Health and Addiction Services. Before getting an ESA, Dr. Anez recommends that individuals become aware of their landlord’s policies on possible restrictions relating to dog sizes and breeds.
 

Additional considerations

An ESA doesn’t necessarily have to be a dog. “It certainly could be a cat. It could be a parrot, too,” said Stephen Stern, MD, a psychiatrist in private practice in Mount Kisco, N.Y. But, “if they say that their emotional support animal is an earthworm, that would make you wonder,” he added half-jokingly.

Dr. Stern only writes an ESA letter for a patient with whom he has an ongoing professional relationship. For instance, if he’s treating someone for depression and that patient tells him how the animal helps relieve symptoms, then that is sufficient justification to write a letter.

“Because you know them, you’ve assessed that what they’re saying is plausible,” said Dr. Stern, who is also an adjunct professor of psychiatry at the University of Texas Health Science in San Antonio, where he conducted research on companion dogs for veterans with PTSD and continues to collaborate with colleagues via email and Zoom.

While veterans benefit from ESAs, some live in housing that doesn’t permit animals, said Beth Zimmerman, founder and executive director of Pets for Patriots, a nationally operating nonprofit organization in Long Beach, N.Y., that partners with shelters and animal welfare groups to adopt dogs and cats for companionship and emotional support. She said an ESA can be “a wonderful complement to other forms of therapy that a veteran may undertake.

“Most of the time when the veteran encounters a problem, it’s because the landlord is ill-informed of the law,” Dr. Zimmerman said. “We provide information to the veteran to share with the landlord or building management, and always recommend taking a very amicable approach. In our experience, with very few exceptions, once the landlord understands his or her responsibilities under the law, they will permit the veteran to have that emotional support animal in their dwelling.”

For Kristin Lowe, a chocolate Labrador-Weimaraner mix named Lola provided emotional support from her puppy days until her death at age 12 in May 2021. Ms. Lowe’s psychiatrist provided letters that allowed Lola to live in her apartment and to travel on commercial airline flights.

“She was so connected to me,” said Ms. Lowe, 34, who lives in Denver and works as an administrative office worker in physical therapy. “She was a part of me. She could read every emotion that I had.”

Now, Ms. Lowe relies on Henry, an Australian shepherd puppy, to help her cope with obsessive-compulsive disorder, major depressive disorder, and an eating disorder. She described him as “a very happy little guy and a constant tail wagger – and that lights up something in me.”

More information, which is provided by the U.S. Department of Housing and Urban Development, can be found here.

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

When Serena-Lian Sakheim-Devine’s best friend from childhood died of cancer, she felt sad and lonely while away at college. Wanting something warm to snuggle, she got a guinea pig and named her Basil. Then she got two more and called them Nutmeg and Paprika. The three became her Spice Girls.

“They were of great comfort to me, but also to others at times of need,” said Ms. Sakheim-Devine, 26, who lived with them in a dormitory at Smith College, an all-women’s institution in Northampton, Mass.

Her therapist wrote a letter and sent it to the disability office at Smith, which permitted the guinea pigs as emotional support animals (ESAs). Eventually, though, she wanted a dog to help manage her PTSD, depression, anxiety, and panic attacks. So, she adopted a beagle from a shelter.

Once again, a therapist provided a letter, and Ms. Sakheim-Devine was allowed to keep the beagle, Finnian, then about 13 years old, in her dorm room on the condition that she give up the guinea pigs, which she did.

She and Finnian bonded almost instantly. When she woke up drenched in sweat, unable to move or speak, the dog sensed how tense she was. Finnian licked her hands, got her fingers moving, and helped ground her.

“I didn’t really teach her that. She just knew,” said Ms. Sakheim-Devine, now a safety engineer who lives in New Haven, Conn. “It was incredible how well connected we were, even from the get-go.”
 

The therapeutic benefits of four-legged friends

Although there is limited scientific literature on the therapeutic use of ESAs, there are well-established benefits of having pets that also apply in these situations. Animals can provide distraction from stress, alleviate loneliness, and instill a sense of responsibility, said Rachel A. Davis, MD, associate professor of psychiatry and neurosurgery at the University of Colorado at Denver, Aurora.

They add structure to a person’s day by needing to be fed at specific times, and they can help the human get exercise. “Patients have reported improved sense of meaning in life and purpose,” Dr. Davis said.

A mental health clinician can recommend an ESA to help mitigate symptoms of a disability related to a mental illness as described in the DSM. Examples include depression, anxiety, obsessive-compulsive disorder, panic attacks, and PTSD.

ESAs differ from psychiatric service animals, which are trained to perform specific tasks, such as applying deep pressure that calms the owner. By their mere existence, ESAs provide emotional benefits to a person with a mental health disability.

“Social support, even from an animal, can really help people feel less alone, better about themselves, and safer from unpleasantness or even a physical attack,” said David Spiegel, MD, professor and associate chair of psychiatry and behavioral sciences and director of the Center on Stress and Health at Stanford (Calif.) University.
 

Writing a letter on your patient’s behalf

Writing a letter that serves as proof of a person’s need for an ESA is a request that mental health professionals sometimes receive from patients. The letter can grant access to housing without additional cost regardless of no-pet polices, and some employers may allow an ESA at work as a reasonable accommodation for a psychological disability. Until recently, an ESA could accompany its owner on a plane, but most airlines no longer permit this, partly because some passengers falsely claim their pets as ESAs.

Before crafting a letter for someone with an ESA, Dr. Spiegel asks for the patient’s permission to elaborate on the clinical condition that merits professional help and to explain how the animal relieves associated symptoms.

The Fair Housing Act, a federal law, requires a landlord to grant a reasonable accommodation involving an emotional support or other assistance animal. Such an accommodation honors a request to live on the property despite a no-pets policy. It also waives a pet deposit, fee, or other rules involving animals on the premises.

Landlords are usually supportive of a request to permit an ESA, said Jonathan Betlinski, MD, associate professor and director of the public psychiatry division at Oregon Health and Science University, Portland. None of his patients have experienced any difficulties once they obtained a letter from him.

However, “anytime somebody asks me about a letter for an ESA, that’s the time to have a conversation. It’s not automatic,” Dr. Betlinski said. The discussion involves learning about the type of animal a patient has and how it helps his or her emotional state.

Because of privacy concerns, Dr. Betlinski doesn’t disclose the specific diagnosis in the letter unless the patient signs a release of information. The laws pertaining to ESAs only require his letter to note that an individual has a qualifying diagnosis and that an ESA helps improve symptoms, but it’s not necessary to explain how.

“You can see where writing the letter is a fine balancing act,” he said. But he finds it helpful to mention any training the animal has completed, such as the Canine Good Citizen course sponsored by the American Kennel Club.

Most of the letters Luis Anez, PsyD, a clinical psychologist and associate professor of psychiatry at Yale University, New Haven, Conn., has written for this purpose were in support of ESAs in housing. But he also recalled providing a letter for a patient who was flying to Puerto Rico with an ESA. The letters are generally provided only to established patients with psychiatric diagnoses.

Without a letter, “we’ve seen people say: ‘I’d rather be homeless than part with my dog,’ ”said Dr. Anez, who is also director of Hispanic services at Connecticut Mental Health Center in New Haven, a partnership between Yale and the Connecticut Department of Mental Health and Addiction Services. Before getting an ESA, Dr. Anez recommends that individuals become aware of their landlord’s policies on possible restrictions relating to dog sizes and breeds.
 

Additional considerations

An ESA doesn’t necessarily have to be a dog. “It certainly could be a cat. It could be a parrot, too,” said Stephen Stern, MD, a psychiatrist in private practice in Mount Kisco, N.Y. But, “if they say that their emotional support animal is an earthworm, that would make you wonder,” he added half-jokingly.

Dr. Stern only writes an ESA letter for a patient with whom he has an ongoing professional relationship. For instance, if he’s treating someone for depression and that patient tells him how the animal helps relieve symptoms, then that is sufficient justification to write a letter.

“Because you know them, you’ve assessed that what they’re saying is plausible,” said Dr. Stern, who is also an adjunct professor of psychiatry at the University of Texas Health Science in San Antonio, where he conducted research on companion dogs for veterans with PTSD and continues to collaborate with colleagues via email and Zoom.

While veterans benefit from ESAs, some live in housing that doesn’t permit animals, said Beth Zimmerman, founder and executive director of Pets for Patriots, a nationally operating nonprofit organization in Long Beach, N.Y., that partners with shelters and animal welfare groups to adopt dogs and cats for companionship and emotional support. She said an ESA can be “a wonderful complement to other forms of therapy that a veteran may undertake.

“Most of the time when the veteran encounters a problem, it’s because the landlord is ill-informed of the law,” Dr. Zimmerman said. “We provide information to the veteran to share with the landlord or building management, and always recommend taking a very amicable approach. In our experience, with very few exceptions, once the landlord understands his or her responsibilities under the law, they will permit the veteran to have that emotional support animal in their dwelling.”

For Kristin Lowe, a chocolate Labrador-Weimaraner mix named Lola provided emotional support from her puppy days until her death at age 12 in May 2021. Ms. Lowe’s psychiatrist provided letters that allowed Lola to live in her apartment and to travel on commercial airline flights.

“She was so connected to me,” said Ms. Lowe, 34, who lives in Denver and works as an administrative office worker in physical therapy. “She was a part of me. She could read every emotion that I had.”

Now, Ms. Lowe relies on Henry, an Australian shepherd puppy, to help her cope with obsessive-compulsive disorder, major depressive disorder, and an eating disorder. She described him as “a very happy little guy and a constant tail wagger – and that lights up something in me.”

More information, which is provided by the U.S. Department of Housing and Urban Development, can be found here.

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

Many older patients with advanced kidney disease who decide to forgo dialysis still survive for several years after making their decision and have a good quality of life until their final days, a new systematic review of cohort studies suggests.

“Our findings challenge the common misconception that the only alternative to dialysis for many patients with advanced chronic kidney disease is no care or death,” say Susan Wong, MD, of the Renal Dialysis Unit, Seattle, and colleagues in their review, published online March 14 in JAMA Network Open.

In an accompanying commentary, Christine Liu, MD, and Kurella Tamura, MD, MPH, note: “The decision to initiate dialysis or focus on active alleviation of symptoms, known as conservative care … is likely one of the consequential decisions [patients] will face.”

“[But] in reality, dialysis is viewed as the default treatment for kidney failure, and the option to forgo dialysis treatment is often not explicitly discussed,” they add.

“We believe it is time to broaden the scope of kidney replacement therapy registries to include persons who receive conservative treatment of kidney failure … and we need to address the conservative care information gap so that lack of awareness is no longer a barrier to informed decision-making,” Dr. Liu and Dr. Tamura, both from Stanford (Calif.) University, note.

The work by Dr. Wong and colleagues “dispels the notion that conservative care for kidney failure means a grim and near-immediate death. The study advances the idea that a conservative care approach can provide time and sustain quality of life to support patients’ life goals,” they emphasize.
 

Conservative care assessed in 41 studies

The review included 41 studies involving 5,102 patients with a mean age ranging from 60 to 87 years conducted in the United Kingdom, Europe, and Asia.

Median survival of cohorts ranged from 1 to 41 months as measured from a baseline mean estimated glomerular filtration rate (eGFR) ranging from 7 to 19 mL/min/1.73m².

Younger patients between 70 and 79 years of age had a median survival of 7 to 41 months, the authors note, while cohorts consisting of patients 80 years of age and older had a median survival of 1 to 37 months despite overlapping ranges of baseline mean eGFRs.

During an observation period of 8-24 months, mental well-being improved, and physical well-being and overall quality of life were largely stable until late in the course of illness.

“Ten studies … provided information on the use of health care resources during follow-up,” the researchers say. Patients generally experienced one to two hospital admissions, 6-16 in-hospital days, seven to eight clinic visits, and two emergency department visits per person-year. Use of acute care services was “therefore common,” they note.

Not all studies provided information about end-of-life care, but those that did reported rates of hospice enrollment that ranged from 20% to 76%; hospitalization rates during the final month of life from 57% to 76%; in-hospital death rates of 27%-68%, and in-home death rates ranging from 12% to 71%.

This indicates substantial disparity in access to supportive care near the end of life across cohorts, the authors observe.

Nevertheless, “Most patients survived several years after the decision to forgo dialysis was made,” they stress.

“These findings not only suggest that conservative kidney management may be a viable and positive therapeutic alternative to dialysis, they also highlight the strengths of its multidisciplinary approach to care and aggressive symptom management.”

“Collectively, our findings demonstrate the need to implement systematic and unified research methods for conservative kidney management and to develop models of care and the care infrastructure to advance practice and outcomes of conservative kidney management,” they conclude.

Dr. Wong has no financial ties to industry. Dr. Tamura has reported receiving personal fees from the American Federation for Aging Research.

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

Many older patients with advanced kidney disease who decide to forgo dialysis still survive for several years after making their decision and have a good quality of life until their final days, a new systematic review of cohort studies suggests.

“Our findings challenge the common misconception that the only alternative to dialysis for many patients with advanced chronic kidney disease is no care or death,” say Susan Wong, MD, of the Renal Dialysis Unit, Seattle, and colleagues in their review, published online March 14 in JAMA Network Open.

In an accompanying commentary, Christine Liu, MD, and Kurella Tamura, MD, MPH, note: “The decision to initiate dialysis or focus on active alleviation of symptoms, known as conservative care … is likely one of the consequential decisions [patients] will face.”

“[But] in reality, dialysis is viewed as the default treatment for kidney failure, and the option to forgo dialysis treatment is often not explicitly discussed,” they add.

“We believe it is time to broaden the scope of kidney replacement therapy registries to include persons who receive conservative treatment of kidney failure … and we need to address the conservative care information gap so that lack of awareness is no longer a barrier to informed decision-making,” Dr. Liu and Dr. Tamura, both from Stanford (Calif.) University, note.

The work by Dr. Wong and colleagues “dispels the notion that conservative care for kidney failure means a grim and near-immediate death. The study advances the idea that a conservative care approach can provide time and sustain quality of life to support patients’ life goals,” they emphasize.
 

Conservative care assessed in 41 studies

The review included 41 studies involving 5,102 patients with a mean age ranging from 60 to 87 years conducted in the United Kingdom, Europe, and Asia.

Median survival of cohorts ranged from 1 to 41 months as measured from a baseline mean estimated glomerular filtration rate (eGFR) ranging from 7 to 19 mL/min/1.73m².

Younger patients between 70 and 79 years of age had a median survival of 7 to 41 months, the authors note, while cohorts consisting of patients 80 years of age and older had a median survival of 1 to 37 months despite overlapping ranges of baseline mean eGFRs.

During an observation period of 8-24 months, mental well-being improved, and physical well-being and overall quality of life were largely stable until late in the course of illness.

“Ten studies … provided information on the use of health care resources during follow-up,” the researchers say. Patients generally experienced one to two hospital admissions, 6-16 in-hospital days, seven to eight clinic visits, and two emergency department visits per person-year. Use of acute care services was “therefore common,” they note.

Not all studies provided information about end-of-life care, but those that did reported rates of hospice enrollment that ranged from 20% to 76%; hospitalization rates during the final month of life from 57% to 76%; in-hospital death rates of 27%-68%, and in-home death rates ranging from 12% to 71%.

This indicates substantial disparity in access to supportive care near the end of life across cohorts, the authors observe.

Nevertheless, “Most patients survived several years after the decision to forgo dialysis was made,” they stress.

“These findings not only suggest that conservative kidney management may be a viable and positive therapeutic alternative to dialysis, they also highlight the strengths of its multidisciplinary approach to care and aggressive symptom management.”

“Collectively, our findings demonstrate the need to implement systematic and unified research methods for conservative kidney management and to develop models of care and the care infrastructure to advance practice and outcomes of conservative kidney management,” they conclude.

Dr. Wong has no financial ties to industry. Dr. Tamura has reported receiving personal fees from the American Federation for Aging Research.

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

Many older patients with advanced kidney disease who decide to forgo dialysis still survive for several years after making their decision and have a good quality of life until their final days, a new systematic review of cohort studies suggests.

“Our findings challenge the common misconception that the only alternative to dialysis for many patients with advanced chronic kidney disease is no care or death,” say Susan Wong, MD, of the Renal Dialysis Unit, Seattle, and colleagues in their review, published online March 14 in JAMA Network Open.

In an accompanying commentary, Christine Liu, MD, and Kurella Tamura, MD, MPH, note: “The decision to initiate dialysis or focus on active alleviation of symptoms, known as conservative care … is likely one of the consequential decisions [patients] will face.”

“[But] in reality, dialysis is viewed as the default treatment for kidney failure, and the option to forgo dialysis treatment is often not explicitly discussed,” they add.

“We believe it is time to broaden the scope of kidney replacement therapy registries to include persons who receive conservative treatment of kidney failure … and we need to address the conservative care information gap so that lack of awareness is no longer a barrier to informed decision-making,” Dr. Liu and Dr. Tamura, both from Stanford (Calif.) University, note.

The work by Dr. Wong and colleagues “dispels the notion that conservative care for kidney failure means a grim and near-immediate death. The study advances the idea that a conservative care approach can provide time and sustain quality of life to support patients’ life goals,” they emphasize.
 

Conservative care assessed in 41 studies

The review included 41 studies involving 5,102 patients with a mean age ranging from 60 to 87 years conducted in the United Kingdom, Europe, and Asia.

Median survival of cohorts ranged from 1 to 41 months as measured from a baseline mean estimated glomerular filtration rate (eGFR) ranging from 7 to 19 mL/min/1.73m².

Younger patients between 70 and 79 years of age had a median survival of 7 to 41 months, the authors note, while cohorts consisting of patients 80 years of age and older had a median survival of 1 to 37 months despite overlapping ranges of baseline mean eGFRs.

During an observation period of 8-24 months, mental well-being improved, and physical well-being and overall quality of life were largely stable until late in the course of illness.

“Ten studies … provided information on the use of health care resources during follow-up,” the researchers say. Patients generally experienced one to two hospital admissions, 6-16 in-hospital days, seven to eight clinic visits, and two emergency department visits per person-year. Use of acute care services was “therefore common,” they note.

Not all studies provided information about end-of-life care, but those that did reported rates of hospice enrollment that ranged from 20% to 76%; hospitalization rates during the final month of life from 57% to 76%; in-hospital death rates of 27%-68%, and in-home death rates ranging from 12% to 71%.

This indicates substantial disparity in access to supportive care near the end of life across cohorts, the authors observe.

Nevertheless, “Most patients survived several years after the decision to forgo dialysis was made,” they stress.

“These findings not only suggest that conservative kidney management may be a viable and positive therapeutic alternative to dialysis, they also highlight the strengths of its multidisciplinary approach to care and aggressive symptom management.”

“Collectively, our findings demonstrate the need to implement systematic and unified research methods for conservative kidney management and to develop models of care and the care infrastructure to advance practice and outcomes of conservative kidney management,” they conclude.

Dr. Wong has no financial ties to industry. Dr. Tamura has reported receiving personal fees from the American Federation for Aging Research.

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