I enjoyed Dr. Jonas’s article, “A new model of care to return holism to family medicine” (J Fam Pract. 2020;69:493-498).

However, I wanted to point out that for more than 100 years the concept of the patient-centered medical home, and the outgrowth of that, has been part of osteopathic medical education, founded by A.T. Still, MD, in the 1800s.

Congratulations to the allopathic medicine profession for recognizing its significance.

Steven Shapiro, DO
Fenton, MI

I enjoyed Dr. Jonas’s article, “A new model of care to return holism to family medicine” (J Fam Pract. 2020;69:493-498).

However, I wanted to point out that for more than 100 years the concept of the patient-centered medical home, and the outgrowth of that, has been part of osteopathic medical education, founded by A.T. Still, MD, in the 1800s.

Congratulations to the allopathic medicine profession for recognizing its significance.

Steven Shapiro, DO
Fenton, MI

I enjoyed Dr. Jonas’s article, “A new model of care to return holism to family medicine” (J Fam Pract. 2020;69:493-498).

However, I wanted to point out that for more than 100 years the concept of the patient-centered medical home, and the outgrowth of that, has been part of osteopathic medical education, founded by A.T. Still, MD, in the 1800s.

Congratulations to the allopathic medicine profession for recognizing its significance.

Steven Shapiro, DO
Fenton, MI

In the January 2019 article “Migraine: Expanding our Tx arsenal” (J Fam Pract. 2019;68:10-14,16-24), Table 2: Establishing the differential diagnosis of headache provided information that was incorrectly categorized. The table should not have included “Temporal arteritis” as a trigger for a headache caused by infection. Rather, the table should have listed “Temporal arteritis” among the triggers for a headache caused by an autoimmune disorder. In addition, “Acute and chronic sinusitis” and “Meningitis” should not have been listed as triggers for a headache with an iatrogenic or intoxication cause. Rather, they should have been the only triggers attributed to headaches with an infectious origin. The revised table can be found here.

In the January 2019 article “Migraine: Expanding our Tx arsenal” (J Fam Pract. 2019;68:10-14,16-24), Table 2: Establishing the differential diagnosis of headache provided information that was incorrectly categorized. The table should not have included “Temporal arteritis” as a trigger for a headache caused by infection. Rather, the table should have listed “Temporal arteritis” among the triggers for a headache caused by an autoimmune disorder. In addition, “Acute and chronic sinusitis” and “Meningitis” should not have been listed as triggers for a headache with an iatrogenic or intoxication cause. Rather, they should have been the only triggers attributed to headaches with an infectious origin. The revised table can be found here.

In the January 2019 article “Migraine: Expanding our Tx arsenal” (J Fam Pract. 2019;68:10-14,16-24), Table 2: Establishing the differential diagnosis of headache provided information that was incorrectly categorized. The table should not have included “Temporal arteritis” as a trigger for a headache caused by infection. Rather, the table should have listed “Temporal arteritis” among the triggers for a headache caused by an autoimmune disorder. In addition, “Acute and chronic sinusitis” and “Meningitis” should not have been listed as triggers for a headache with an iatrogenic or intoxication cause. Rather, they should have been the only triggers attributed to headaches with an infectious origin. The revised table can be found here.

In 2020, COVID-19 disrupted our medical system, and life in general. In the 1980s, the AIDS epidemic devastated communities and overwhelmed hospitals. There were lessons learned from the AIDS epidemic that can be applied to the current situation.

Patients with HIV-spectrum illness faced stigmatization and societal indifference, including rejection by family members, increased rates of suicide, fears of sexual and/or intrauterine transmission, substance abuse issues, and alterations of body image for those with wasting syndromes and disfiguring Kaposi lesions. AIDS prevention strategies such as the provision of condoms and needle exchange programs were controversial, and many caregivers exposed to contaminated fluids had to endure months of antiretroviral treatment.

Similar to the AIDS epidemic, the COVID-19 pandemic has had significant psychological implications for patients and caregivers. Patients with COVID-19 infections also face feelings of guilt over potentially exposing a family member to the virus; devastating socioeconomic issues; restrictive hospital visitation policies for family members; disease news oversaturation; and feelings of hopelessness. People with AIDS in the 1980s faced the possibility of dying alone, and there was initial skepticism about medications to treat HIV—just as some individuals are now uneasy about recently introduced coronavirus vaccines.

Looking back on the AIDS epidemic should teach us to prioritize attending to the mental health of sufferers and caregivers and depoliticizing prevention strategies.

The similarities of both diseases allow us some foresight on how to deal with current COVID-19 issues. Looking back on the AIDS epidemic should teach us to prioritize attending to the mental health of sufferers and caregivers, creating advocacy and support groups for when a patient’s family is unavailable, instilling public confidence in treatment options, maintaining staff morale, addressing substance abuse (due to COVID-related stress), and depoliticizing prevention strategies. Addressing these issues is especially critical for minority populations.

As respected medical care leaders, we can provide and draw extra attention to the needs of patients’ family members and health care personnel during this COVID-19 pandemic. Hopefully, the distribution of vaccines will shorten some of our communal and professional distress.

Robert Frierson, MD
Steven Lippmann, MD
Louisville, KY

In 2020, COVID-19 disrupted our medical system, and life in general. In the 1980s, the AIDS epidemic devastated communities and overwhelmed hospitals. There were lessons learned from the AIDS epidemic that can be applied to the current situation.

Patients with HIV-spectrum illness faced stigmatization and societal indifference, including rejection by family members, increased rates of suicide, fears of sexual and/or intrauterine transmission, substance abuse issues, and alterations of body image for those with wasting syndromes and disfiguring Kaposi lesions. AIDS prevention strategies such as the provision of condoms and needle exchange programs were controversial, and many caregivers exposed to contaminated fluids had to endure months of antiretroviral treatment.

Similar to the AIDS epidemic, the COVID-19 pandemic has had significant psychological implications for patients and caregivers. Patients with COVID-19 infections also face feelings of guilt over potentially exposing a family member to the virus; devastating socioeconomic issues; restrictive hospital visitation policies for family members; disease news oversaturation; and feelings of hopelessness. People with AIDS in the 1980s faced the possibility of dying alone, and there was initial skepticism about medications to treat HIV—just as some individuals are now uneasy about recently introduced coronavirus vaccines.

Looking back on the AIDS epidemic should teach us to prioritize attending to the mental health of sufferers and caregivers and depoliticizing prevention strategies.

The similarities of both diseases allow us some foresight on how to deal with current COVID-19 issues. Looking back on the AIDS epidemic should teach us to prioritize attending to the mental health of sufferers and caregivers, creating advocacy and support groups for when a patient’s family is unavailable, instilling public confidence in treatment options, maintaining staff morale, addressing substance abuse (due to COVID-related stress), and depoliticizing prevention strategies. Addressing these issues is especially critical for minority populations.

As respected medical care leaders, we can provide and draw extra attention to the needs of patients’ family members and health care personnel during this COVID-19 pandemic. Hopefully, the distribution of vaccines will shorten some of our communal and professional distress.

Robert Frierson, MD
Steven Lippmann, MD
Louisville, KY

In 2020, COVID-19 disrupted our medical system, and life in general. In the 1980s, the AIDS epidemic devastated communities and overwhelmed hospitals. There were lessons learned from the AIDS epidemic that can be applied to the current situation.

Patients with HIV-spectrum illness faced stigmatization and societal indifference, including rejection by family members, increased rates of suicide, fears of sexual and/or intrauterine transmission, substance abuse issues, and alterations of body image for those with wasting syndromes and disfiguring Kaposi lesions. AIDS prevention strategies such as the provision of condoms and needle exchange programs were controversial, and many caregivers exposed to contaminated fluids had to endure months of antiretroviral treatment.

Similar to the AIDS epidemic, the COVID-19 pandemic has had significant psychological implications for patients and caregivers. Patients with COVID-19 infections also face feelings of guilt over potentially exposing a family member to the virus; devastating socioeconomic issues; restrictive hospital visitation policies for family members; disease news oversaturation; and feelings of hopelessness. People with AIDS in the 1980s faced the possibility of dying alone, and there was initial skepticism about medications to treat HIV—just as some individuals are now uneasy about recently introduced coronavirus vaccines.

Looking back on the AIDS epidemic should teach us to prioritize attending to the mental health of sufferers and caregivers and depoliticizing prevention strategies.

The similarities of both diseases allow us some foresight on how to deal with current COVID-19 issues. Looking back on the AIDS epidemic should teach us to prioritize attending to the mental health of sufferers and caregivers, creating advocacy and support groups for when a patient’s family is unavailable, instilling public confidence in treatment options, maintaining staff morale, addressing substance abuse (due to COVID-related stress), and depoliticizing prevention strategies. Addressing these issues is especially critical for minority populations.

As respected medical care leaders, we can provide and draw extra attention to the needs of patients’ family members and health care personnel during this COVID-19 pandemic. Hopefully, the distribution of vaccines will shorten some of our communal and professional distress.

Robert Frierson, MD
Steven Lippmann, MD
Louisville, KY

When I sat down to watch Oprah Winfrey’s interview with Meghan Markle on Sunday night, I didn’t know what to expect. As a psychiatrist dedicated to reducing the loss of life through suicide, I homed in on the aspect of the interview in which she discussed the depth of her suffering.

AkilinaWinner/Thinkstock

Meghan Markle is one of many celebrities to speak about their experience with suicidal crisis. Those disclosures provide opportunities to increase the public’s understanding of mental health and to deepen compassion for what others may be going through. They challenge our culturally normed assumptions: false beliefs – such as the idea that beauty, wealth, and success protect people from mental health struggles. We would do well to trust that the dichotomy between external appearances and internal experiences is always at play, and we never know what someone is going through. Human beings are both enormously resilient and vulnerable.

Suicide, while complex, is a health issue. Therefore, it is important that we all do our part in approaching mental health and suicide risk in a similar manner to other health issues.

We all have a dynamic and continuous interplay going on between life circumstances and our internal biological, genetic, and psychological makeup. The more honest and the more we learn about our own vulnerabilities and strengths, the more proactive we can be in protecting and optimizing our mental health. All individuals should be able to receive support and access to care to have their mental health needs addressed.

It’s important to note that distress leads many people to instinctually withdraw, just at a time when receiving support is even more important. In addition, cultures that traditionally emphasize self-sufficiency or stoicism may unintentionally create additional barriers to reaching out for help. Therefore, many people who experience suicidal thoughts do not disclose them to anyone. If someone does mention they are struggling, you can thank them for opening up and let them know you want to support them, and that you are there to help them find the help they need.

Dr. Moutier is chief medical officer of the American Foundation for Suicide Prevention. She reported no disclosures.

When I sat down to watch Oprah Winfrey’s interview with Meghan Markle on Sunday night, I didn’t know what to expect. As a psychiatrist dedicated to reducing the loss of life through suicide, I homed in on the aspect of the interview in which she discussed the depth of her suffering.

AkilinaWinner/Thinkstock

Meghan Markle is one of many celebrities to speak about their experience with suicidal crisis. Those disclosures provide opportunities to increase the public’s understanding of mental health and to deepen compassion for what others may be going through. They challenge our culturally normed assumptions: false beliefs – such as the idea that beauty, wealth, and success protect people from mental health struggles. We would do well to trust that the dichotomy between external appearances and internal experiences is always at play, and we never know what someone is going through. Human beings are both enormously resilient and vulnerable.

Suicide, while complex, is a health issue. Therefore, it is important that we all do our part in approaching mental health and suicide risk in a similar manner to other health issues.

We all have a dynamic and continuous interplay going on between life circumstances and our internal biological, genetic, and psychological makeup. The more honest and the more we learn about our own vulnerabilities and strengths, the more proactive we can be in protecting and optimizing our mental health. All individuals should be able to receive support and access to care to have their mental health needs addressed.

It’s important to note that distress leads many people to instinctually withdraw, just at a time when receiving support is even more important. In addition, cultures that traditionally emphasize self-sufficiency or stoicism may unintentionally create additional barriers to reaching out for help. Therefore, many people who experience suicidal thoughts do not disclose them to anyone. If someone does mention they are struggling, you can thank them for opening up and let them know you want to support them, and that you are there to help them find the help they need.

Dr. Moutier is chief medical officer of the American Foundation for Suicide Prevention. She reported no disclosures.

When I sat down to watch Oprah Winfrey’s interview with Meghan Markle on Sunday night, I didn’t know what to expect. As a psychiatrist dedicated to reducing the loss of life through suicide, I homed in on the aspect of the interview in which she discussed the depth of her suffering.

AkilinaWinner/Thinkstock

Meghan Markle is one of many celebrities to speak about their experience with suicidal crisis. Those disclosures provide opportunities to increase the public’s understanding of mental health and to deepen compassion for what others may be going through. They challenge our culturally normed assumptions: false beliefs – such as the idea that beauty, wealth, and success protect people from mental health struggles. We would do well to trust that the dichotomy between external appearances and internal experiences is always at play, and we never know what someone is going through. Human beings are both enormously resilient and vulnerable.

Suicide, while complex, is a health issue. Therefore, it is important that we all do our part in approaching mental health and suicide risk in a similar manner to other health issues.

We all have a dynamic and continuous interplay going on between life circumstances and our internal biological, genetic, and psychological makeup. The more honest and the more we learn about our own vulnerabilities and strengths, the more proactive we can be in protecting and optimizing our mental health. All individuals should be able to receive support and access to care to have their mental health needs addressed.

It’s important to note that distress leads many people to instinctually withdraw, just at a time when receiving support is even more important. In addition, cultures that traditionally emphasize self-sufficiency or stoicism may unintentionally create additional barriers to reaching out for help. Therefore, many people who experience suicidal thoughts do not disclose them to anyone. If someone does mention they are struggling, you can thank them for opening up and let them know you want to support them, and that you are there to help them find the help they need.

Dr. Moutier is chief medical officer of the American Foundation for Suicide Prevention. She reported no disclosures.

Among patients with nonalcoholic fatty liver disease (NAFLD) and compensated advanced chronic liver disease, liver stiffness measurements (LSMs) are associated with risks of hepatic events, according to a retrospective analysis of more than 1,000 patients.

“[N]oninvasive markers that can predict liver disease severity and outcomes in patients with NAFLD and advanced fibrosis are a major unmet need,” wrote lead author Salvatore Petta, MD, of the University of Palermo, Italy, and colleagues. Their report is in Clinical Gastroenterology and Hepatology. “Data about the accuracy of LSM in the prediction of events in NAFLD, and especially in patients with NAFLD and F3-F4 fibrosis, are scarce.”

To address this knowledge gap, the investigators retrospectively analyzed data from 1,039 consecutive patients with NAFLD who had baseline LSMs of more than 10 kPa and/or histologically diagnosed F3-F4 fibrosis. Patients were prospectively recruited at 10 centers in 6 countries, then followed for a median of 35 months, ranging from 19 to 63 months.

All patients had their liver stiffness measured with an M or XL probe at baseline. In addition, approximately half of the patients (n = 533) had a follow-up measurement using the same method, generating a subgroup with changes in liver stiffness. “Improved” liver stiffness was defined as a decrease in LSM greater than 20% from baseline, “impaired” liver stiffness was defined as an increase in LSM greater than 20% from baseline, and “stable” liver stiffness was defined as a change falling between 20% lower and 20% higher than baseline.

At baseline, mean LSM was 17.6 kPa. Cox regression analysis revealed that baseline LSM was independently associated with HCC (hazard ratio, 1.03; 95% confidence interval, 1.00-1.04; P = .003), liver decompensation (HR, 1.03; 95% CI, 1.02-1.04; P < .001), and liver-related death (HR, 1.02; 95% CI, 1.00-1.03; P = .005), but not extrahepatic events.

According to the investigators, the association between LSM at baseline and risk of liver decompensation was maintained after adjustment for the severity of liver disease and for surrogate markers of portal hypertension, they noted. Furthermore, patients with a baseline LSM of at least 21 kPa – which indicates high risk of clinically significant portal hypertension (CSPH) – were at greater risk of liver decompensation than were those with an LSM less than 21 kPa (HR, 3.71; 95% CI, 1.89-6.78; P = .04).

In the subgroup with follow-up measurements, approximately half of the patients had an improved LSM (53.3%), while 27.2% had a stable LSM, and 19.5% had an impaired LSM, a pattern that was significantly associated with diabetes at baseline (P = .01).

“These data agree with the available literature identifying diabetes as a risk factor for liver disease progression and liver-related complications,” the investigators wrote.

Cox regression showed that, among those with follow-up LSM, changes in LSM were independently associated with HCC (HR, 1.72; 95% CI, 1.01-3.02; P = .04), liver decompensation (HR, 1.56; 95% CI, 1.05-2.51; P = . 04), liver-related mortality (HR, 1.96; 95% CI, 1.10-3.38; P = .02), and mortality of any cause (HR, 1.73; 95% CI, 1.11-2.69; P = .01).

These risks could be further stratified by level of change in liver stiffness, with greater impairment predicting greater risk: The crude rate of liver decompensation was 14.4% among those with impaired LSM, compared with 6.2% among those with stable LSM and 3.8% among those with LSM improvement. That said, the categories of changes in LSM were not predictive of decompensation among patients with high risk of CSPH at baseline; however, they remained predictive among those with low risk of CSPH at baseline.

“[T]his study … showed that an integrated assessment of baseline LSM or [changes in LSM] can help in stratifying the risk of development of liver-related complications and of both hepatic and overall mortality,” the investigators concluded. “These data, if further validated, could help personalize prognosis and follow-up in NAFLD with [compensated advanced chronic liver disease].”

The investigators disclosed relationships with AbbVie, Novo Nordisk, Gilead, and others.

Among patients with nonalcoholic fatty liver disease (NAFLD) and compensated advanced chronic liver disease, liver stiffness measurements (LSMs) are associated with risks of hepatic events, according to a retrospective analysis of more than 1,000 patients.

“[N]oninvasive markers that can predict liver disease severity and outcomes in patients with NAFLD and advanced fibrosis are a major unmet need,” wrote lead author Salvatore Petta, MD, of the University of Palermo, Italy, and colleagues. Their report is in Clinical Gastroenterology and Hepatology. “Data about the accuracy of LSM in the prediction of events in NAFLD, and especially in patients with NAFLD and F3-F4 fibrosis, are scarce.”

To address this knowledge gap, the investigators retrospectively analyzed data from 1,039 consecutive patients with NAFLD who had baseline LSMs of more than 10 kPa and/or histologically diagnosed F3-F4 fibrosis. Patients were prospectively recruited at 10 centers in 6 countries, then followed for a median of 35 months, ranging from 19 to 63 months.

All patients had their liver stiffness measured with an M or XL probe at baseline. In addition, approximately half of the patients (n = 533) had a follow-up measurement using the same method, generating a subgroup with changes in liver stiffness. “Improved” liver stiffness was defined as a decrease in LSM greater than 20% from baseline, “impaired” liver stiffness was defined as an increase in LSM greater than 20% from baseline, and “stable” liver stiffness was defined as a change falling between 20% lower and 20% higher than baseline.

At baseline, mean LSM was 17.6 kPa. Cox regression analysis revealed that baseline LSM was independently associated with HCC (hazard ratio, 1.03; 95% confidence interval, 1.00-1.04; P = .003), liver decompensation (HR, 1.03; 95% CI, 1.02-1.04; P < .001), and liver-related death (HR, 1.02; 95% CI, 1.00-1.03; P = .005), but not extrahepatic events.

According to the investigators, the association between LSM at baseline and risk of liver decompensation was maintained after adjustment for the severity of liver disease and for surrogate markers of portal hypertension, they noted. Furthermore, patients with a baseline LSM of at least 21 kPa – which indicates high risk of clinically significant portal hypertension (CSPH) – were at greater risk of liver decompensation than were those with an LSM less than 21 kPa (HR, 3.71; 95% CI, 1.89-6.78; P = .04).

In the subgroup with follow-up measurements, approximately half of the patients had an improved LSM (53.3%), while 27.2% had a stable LSM, and 19.5% had an impaired LSM, a pattern that was significantly associated with diabetes at baseline (P = .01).

“These data agree with the available literature identifying diabetes as a risk factor for liver disease progression and liver-related complications,” the investigators wrote.

Cox regression showed that, among those with follow-up LSM, changes in LSM were independently associated with HCC (HR, 1.72; 95% CI, 1.01-3.02; P = .04), liver decompensation (HR, 1.56; 95% CI, 1.05-2.51; P = . 04), liver-related mortality (HR, 1.96; 95% CI, 1.10-3.38; P = .02), and mortality of any cause (HR, 1.73; 95% CI, 1.11-2.69; P = .01).

These risks could be further stratified by level of change in liver stiffness, with greater impairment predicting greater risk: The crude rate of liver decompensation was 14.4% among those with impaired LSM, compared with 6.2% among those with stable LSM and 3.8% among those with LSM improvement. That said, the categories of changes in LSM were not predictive of decompensation among patients with high risk of CSPH at baseline; however, they remained predictive among those with low risk of CSPH at baseline.

“[T]his study … showed that an integrated assessment of baseline LSM or [changes in LSM] can help in stratifying the risk of development of liver-related complications and of both hepatic and overall mortality,” the investigators concluded. “These data, if further validated, could help personalize prognosis and follow-up in NAFLD with [compensated advanced chronic liver disease].”

The investigators disclosed relationships with AbbVie, Novo Nordisk, Gilead, and others.

Among patients with nonalcoholic fatty liver disease (NAFLD) and compensated advanced chronic liver disease, liver stiffness measurements (LSMs) are associated with risks of hepatic events, according to a retrospective analysis of more than 1,000 patients.

“[N]oninvasive markers that can predict liver disease severity and outcomes in patients with NAFLD and advanced fibrosis are a major unmet need,” wrote lead author Salvatore Petta, MD, of the University of Palermo, Italy, and colleagues. Their report is in Clinical Gastroenterology and Hepatology. “Data about the accuracy of LSM in the prediction of events in NAFLD, and especially in patients with NAFLD and F3-F4 fibrosis, are scarce.”

To address this knowledge gap, the investigators retrospectively analyzed data from 1,039 consecutive patients with NAFLD who had baseline LSMs of more than 10 kPa and/or histologically diagnosed F3-F4 fibrosis. Patients were prospectively recruited at 10 centers in 6 countries, then followed for a median of 35 months, ranging from 19 to 63 months.

All patients had their liver stiffness measured with an M or XL probe at baseline. In addition, approximately half of the patients (n = 533) had a follow-up measurement using the same method, generating a subgroup with changes in liver stiffness. “Improved” liver stiffness was defined as a decrease in LSM greater than 20% from baseline, “impaired” liver stiffness was defined as an increase in LSM greater than 20% from baseline, and “stable” liver stiffness was defined as a change falling between 20% lower and 20% higher than baseline.

At baseline, mean LSM was 17.6 kPa. Cox regression analysis revealed that baseline LSM was independently associated with HCC (hazard ratio, 1.03; 95% confidence interval, 1.00-1.04; P = .003), liver decompensation (HR, 1.03; 95% CI, 1.02-1.04; P < .001), and liver-related death (HR, 1.02; 95% CI, 1.00-1.03; P = .005), but not extrahepatic events.

According to the investigators, the association between LSM at baseline and risk of liver decompensation was maintained after adjustment for the severity of liver disease and for surrogate markers of portal hypertension, they noted. Furthermore, patients with a baseline LSM of at least 21 kPa – which indicates high risk of clinically significant portal hypertension (CSPH) – were at greater risk of liver decompensation than were those with an LSM less than 21 kPa (HR, 3.71; 95% CI, 1.89-6.78; P = .04).

In the subgroup with follow-up measurements, approximately half of the patients had an improved LSM (53.3%), while 27.2% had a stable LSM, and 19.5% had an impaired LSM, a pattern that was significantly associated with diabetes at baseline (P = .01).

“These data agree with the available literature identifying diabetes as a risk factor for liver disease progression and liver-related complications,” the investigators wrote.

Cox regression showed that, among those with follow-up LSM, changes in LSM were independently associated with HCC (HR, 1.72; 95% CI, 1.01-3.02; P = .04), liver decompensation (HR, 1.56; 95% CI, 1.05-2.51; P = . 04), liver-related mortality (HR, 1.96; 95% CI, 1.10-3.38; P = .02), and mortality of any cause (HR, 1.73; 95% CI, 1.11-2.69; P = .01).

These risks could be further stratified by level of change in liver stiffness, with greater impairment predicting greater risk: The crude rate of liver decompensation was 14.4% among those with impaired LSM, compared with 6.2% among those with stable LSM and 3.8% among those with LSM improvement. That said, the categories of changes in LSM were not predictive of decompensation among patients with high risk of CSPH at baseline; however, they remained predictive among those with low risk of CSPH at baseline.

“[T]his study … showed that an integrated assessment of baseline LSM or [changes in LSM] can help in stratifying the risk of development of liver-related complications and of both hepatic and overall mortality,” the investigators concluded. “These data, if further validated, could help personalize prognosis and follow-up in NAFLD with [compensated advanced chronic liver disease].”

The investigators disclosed relationships with AbbVie, Novo Nordisk, Gilead, and others.

The first rule about infantile hemangiomas: Make sure they’re actually infantile hemangiomas, a pediatric dermatologist urged colleagues. Then watch patients closely, refer to specialists when appropriate, and consider propranolol in complicated or high-risk cases, Andrea L. Zaenglein, MD, said at MedscapeLive’s Women’s & Pediatric Dermatology Seminar.

“In my career as a pediatric dermatologist, propranolol has been a life changer for us more than any other medicine,” said Dr. Zaenglein, professor of dermatology and pediatric dermatology, Penn State University, Hershey.

Before the point where propranolol is prescribed, confirm the diagnosis and use the correct terminology, she advised. It’s still appropriate to use the International Society for the Study of Vascular Anomalies (ISSVA) vascular lesion classification system released in 1982. “For most people, it serves the purpose well,” she said. Another option is an updated and more complex classification system from 2015.

Dr. Zaenglein highlighted two studies – one published in 2011 and the other published in 2020 – that revealed high levels of misclassification of vascular malformations in research reports. The earlier study found that 21% of patients with misclassified lesions were mistreated, compared with none of those who were classified using ISSVA terminology.

“I cannot stress [proper classification] enough when you’re dealing with babies and children with vascular lesions. If not sure, be vague. Say ‘a vascular tumor’ or a ‘vascular malformation.’ But only reserve ‘infantile hemangioma’ for that very diagnosis,” she said.

As Dr. Zaenglein noted, infantile hemangiomas affect 5%-10% of 1-year-olds, of whom 20% have multiple lesions. They’re more common in females by a 3-to-1 margin, and also seen more in premature infants, and in cases of multiple births, higher maternal age, and low birth weight.

The pathogenesis of these lesions is unclear, she said, although there are hints about genetic components and tissue hypoxia, among other possible causes. “Importantly, you get 80% of the growth by 3-4 months of age. Then it’ll slow in its growth and kind of slowly go away over time, but it’s not linear regression. It’s more that you get more improvement up front, usually until about 5, and then you can get some continued gradual evolution up until about 7 or 10 years of age.”

Complications can include ulceration, infection and – in rare cases – hemorrhage and high-output cardiac failure, she said. “Knowing which ones are at high risk for complications is important, and also there are systemic associations that we have to be mindful of. We also want to think about aesthetic outcomes as well when we talk about management of infantile hemangiomas.”

High-risk infantile hemangiomas include those with the following features:

• Extensive facial involvement. Dr. Zaenglein highlighted a case of a 2-year-old baby with a large, bulky hemangioma that distorted facial features around the eye. “This would be a medical emergency” requiring immediate evaluation and treatment, she said.
• Periocular involvement. Refer to ophthalmology, she recommended. “Even smaller hemangiomas can cause refractive errors or amblyopia, and oftentimes need to be treated with either systemic or topical therapy depending on the size and extent,” she said.
• PHACE syndrome (Posterior fossa malformations, hemangiomas, arterial anomalies, coarctation of the aorta and cardiac defects, eye abnormalities). “Propranolol has been safely used in PHACE, but every patient is different,” she said. “You need to make sure to do a good risk assessment before starting because if they have narrowed blood flow or limited blood flow, there is a question of whether there is potential risk for stroke if you drop a baby’s blood pressure. Make sure that the vasculature is evaluated before started on propranolol. Also, there are recent reports of risk of long-term risk of stroke with PHACE syndrome as patients are getting into their adulthood.”
• Beard distribution. Be aware of possible airway involvement that can be revealed by biphasic stridor. In those cases, immediate treatment – perhaps even with tracheostomy – is needed to avoid mortality, she said.
• Multiple sites: Patients with five or more hemangiomas may have liver involvement, she said, and should undergo hepatic evaluation. Consider evaluating if this is suspected, even if the number of hemangiomas is under five, she said.
• Perineal/lumbosacral involvement: A third of these cases are associated with spinal dysraphism. Refer to neurosurgery, she recommended.

Dr. Zaenglein highlighted a report on the use of propranolol published in 2008 and noted that clinical practice guidelines for managing infantile hemangiomas published in 2019 are also helpful.

Flat hemangiomas, meanwhile, can benefit from timolol maleate 0.5% solution or gel-forming solution – 1 drop twice daily or 2 drops once daily, she said. This treatment should be avoided in thick hemangiomas, she said.

MedscapeLive and this news organization are owned by the same parent company. Dr. Zaenglein disclosed consulting fees (Dermata, Cassiopea, and Regeneron), and fees for contracted research support (Incyte).

The first rule about infantile hemangiomas: Make sure they’re actually infantile hemangiomas, a pediatric dermatologist urged colleagues. Then watch patients closely, refer to specialists when appropriate, and consider propranolol in complicated or high-risk cases, Andrea L. Zaenglein, MD, said at MedscapeLive’s Women’s & Pediatric Dermatology Seminar.

“In my career as a pediatric dermatologist, propranolol has been a life changer for us more than any other medicine,” said Dr. Zaenglein, professor of dermatology and pediatric dermatology, Penn State University, Hershey.

Before the point where propranolol is prescribed, confirm the diagnosis and use the correct terminology, she advised. It’s still appropriate to use the International Society for the Study of Vascular Anomalies (ISSVA) vascular lesion classification system released in 1982. “For most people, it serves the purpose well,” she said. Another option is an updated and more complex classification system from 2015.

Dr. Zaenglein highlighted two studies – one published in 2011 and the other published in 2020 – that revealed high levels of misclassification of vascular malformations in research reports. The earlier study found that 21% of patients with misclassified lesions were mistreated, compared with none of those who were classified using ISSVA terminology.

“I cannot stress [proper classification] enough when you’re dealing with babies and children with vascular lesions. If not sure, be vague. Say ‘a vascular tumor’ or a ‘vascular malformation.’ But only reserve ‘infantile hemangioma’ for that very diagnosis,” she said.

As Dr. Zaenglein noted, infantile hemangiomas affect 5%-10% of 1-year-olds, of whom 20% have multiple lesions. They’re more common in females by a 3-to-1 margin, and also seen more in premature infants, and in cases of multiple births, higher maternal age, and low birth weight.

The pathogenesis of these lesions is unclear, she said, although there are hints about genetic components and tissue hypoxia, among other possible causes. “Importantly, you get 80% of the growth by 3-4 months of age. Then it’ll slow in its growth and kind of slowly go away over time, but it’s not linear regression. It’s more that you get more improvement up front, usually until about 5, and then you can get some continued gradual evolution up until about 7 or 10 years of age.”

Complications can include ulceration, infection and – in rare cases – hemorrhage and high-output cardiac failure, she said. “Knowing which ones are at high risk for complications is important, and also there are systemic associations that we have to be mindful of. We also want to think about aesthetic outcomes as well when we talk about management of infantile hemangiomas.”

High-risk infantile hemangiomas include those with the following features:

• Extensive facial involvement. Dr. Zaenglein highlighted a case of a 2-year-old baby with a large, bulky hemangioma that distorted facial features around the eye. “This would be a medical emergency” requiring immediate evaluation and treatment, she said.
• Periocular involvement. Refer to ophthalmology, she recommended. “Even smaller hemangiomas can cause refractive errors or amblyopia, and oftentimes need to be treated with either systemic or topical therapy depending on the size and extent,” she said.
• PHACE syndrome (Posterior fossa malformations, hemangiomas, arterial anomalies, coarctation of the aorta and cardiac defects, eye abnormalities). “Propranolol has been safely used in PHACE, but every patient is different,” she said. “You need to make sure to do a good risk assessment before starting because if they have narrowed blood flow or limited blood flow, there is a question of whether there is potential risk for stroke if you drop a baby’s blood pressure. Make sure that the vasculature is evaluated before started on propranolol. Also, there are recent reports of risk of long-term risk of stroke with PHACE syndrome as patients are getting into their adulthood.”
• Beard distribution. Be aware of possible airway involvement that can be revealed by biphasic stridor. In those cases, immediate treatment – perhaps even with tracheostomy – is needed to avoid mortality, she said.
• Multiple sites: Patients with five or more hemangiomas may have liver involvement, she said, and should undergo hepatic evaluation. Consider evaluating if this is suspected, even if the number of hemangiomas is under five, she said.
• Perineal/lumbosacral involvement: A third of these cases are associated with spinal dysraphism. Refer to neurosurgery, she recommended.

Dr. Zaenglein highlighted a report on the use of propranolol published in 2008 and noted that clinical practice guidelines for managing infantile hemangiomas published in 2019 are also helpful.

Flat hemangiomas, meanwhile, can benefit from timolol maleate 0.5% solution or gel-forming solution – 1 drop twice daily or 2 drops once daily, she said. This treatment should be avoided in thick hemangiomas, she said.

MedscapeLive and this news organization are owned by the same parent company. Dr. Zaenglein disclosed consulting fees (Dermata, Cassiopea, and Regeneron), and fees for contracted research support (Incyte).

The first rule about infantile hemangiomas: Make sure they’re actually infantile hemangiomas, a pediatric dermatologist urged colleagues. Then watch patients closely, refer to specialists when appropriate, and consider propranolol in complicated or high-risk cases, Andrea L. Zaenglein, MD, said at MedscapeLive’s Women’s & Pediatric Dermatology Seminar.

“In my career as a pediatric dermatologist, propranolol has been a life changer for us more than any other medicine,” said Dr. Zaenglein, professor of dermatology and pediatric dermatology, Penn State University, Hershey.

Before the point where propranolol is prescribed, confirm the diagnosis and use the correct terminology, she advised. It’s still appropriate to use the International Society for the Study of Vascular Anomalies (ISSVA) vascular lesion classification system released in 1982. “For most people, it serves the purpose well,” she said. Another option is an updated and more complex classification system from 2015.

Dr. Zaenglein highlighted two studies – one published in 2011 and the other published in 2020 – that revealed high levels of misclassification of vascular malformations in research reports. The earlier study found that 21% of patients with misclassified lesions were mistreated, compared with none of those who were classified using ISSVA terminology.

“I cannot stress [proper classification] enough when you’re dealing with babies and children with vascular lesions. If not sure, be vague. Say ‘a vascular tumor’ or a ‘vascular malformation.’ But only reserve ‘infantile hemangioma’ for that very diagnosis,” she said.

As Dr. Zaenglein noted, infantile hemangiomas affect 5%-10% of 1-year-olds, of whom 20% have multiple lesions. They’re more common in females by a 3-to-1 margin, and also seen more in premature infants, and in cases of multiple births, higher maternal age, and low birth weight.

The pathogenesis of these lesions is unclear, she said, although there are hints about genetic components and tissue hypoxia, among other possible causes. “Importantly, you get 80% of the growth by 3-4 months of age. Then it’ll slow in its growth and kind of slowly go away over time, but it’s not linear regression. It’s more that you get more improvement up front, usually until about 5, and then you can get some continued gradual evolution up until about 7 or 10 years of age.”

Complications can include ulceration, infection and – in rare cases – hemorrhage and high-output cardiac failure, she said. “Knowing which ones are at high risk for complications is important, and also there are systemic associations that we have to be mindful of. We also want to think about aesthetic outcomes as well when we talk about management of infantile hemangiomas.”

High-risk infantile hemangiomas include those with the following features:

• Extensive facial involvement. Dr. Zaenglein highlighted a case of a 2-year-old baby with a large, bulky hemangioma that distorted facial features around the eye. “This would be a medical emergency” requiring immediate evaluation and treatment, she said.
• Periocular involvement. Refer to ophthalmology, she recommended. “Even smaller hemangiomas can cause refractive errors or amblyopia, and oftentimes need to be treated with either systemic or topical therapy depending on the size and extent,” she said.
• PHACE syndrome (Posterior fossa malformations, hemangiomas, arterial anomalies, coarctation of the aorta and cardiac defects, eye abnormalities). “Propranolol has been safely used in PHACE, but every patient is different,” she said. “You need to make sure to do a good risk assessment before starting because if they have narrowed blood flow or limited blood flow, there is a question of whether there is potential risk for stroke if you drop a baby’s blood pressure. Make sure that the vasculature is evaluated before started on propranolol. Also, there are recent reports of risk of long-term risk of stroke with PHACE syndrome as patients are getting into their adulthood.”
• Beard distribution. Be aware of possible airway involvement that can be revealed by biphasic stridor. In those cases, immediate treatment – perhaps even with tracheostomy – is needed to avoid mortality, she said.
• Multiple sites: Patients with five or more hemangiomas may have liver involvement, she said, and should undergo hepatic evaluation. Consider evaluating if this is suspected, even if the number of hemangiomas is under five, she said.
• Perineal/lumbosacral involvement: A third of these cases are associated with spinal dysraphism. Refer to neurosurgery, she recommended.

Dr. Zaenglein highlighted a report on the use of propranolol published in 2008 and noted that clinical practice guidelines for managing infantile hemangiomas published in 2019 are also helpful.

Flat hemangiomas, meanwhile, can benefit from timolol maleate 0.5% solution or gel-forming solution – 1 drop twice daily or 2 drops once daily, she said. This treatment should be avoided in thick hemangiomas, she said.

MedscapeLive and this news organization are owned by the same parent company. Dr. Zaenglein disclosed consulting fees (Dermata, Cassiopea, and Regeneron), and fees for contracted research support (Incyte).

This spring may bring an unusual transition for families: a return to in-person school after nearly a year in a virtual classroom. This will undoubtedly come as a welcome relief to many parents worried about their children’s education and development and struggling with running school from home. But it is important for parents to remember that transitions, even happy ones, are difficult. You can help parents to anticipate what may be challenging about this transition for their children so that they are all prepared and can diminish struggles and support their children’s mastery.

Be curious about their children’s thoughts and feelings

Parents should adopt a truly curious and open-minded approach with their children. Remind parents that, while they are experts on their own children, they should not assume they know what their children are thinking or feeling about the return to school. Some children, especially ones struggling with learning problems or difficulty with peers, will have grown very comfortable being at home with parents or siblings. Some children, especially pre- and early teens, may have changed substantially in the year and might feel uncertain about returning to a prior team or group of friends. Some children may feel concerned about leaving a pet at home alone. Some children may be going to a new school and be anxious about facing such a big transition without the usual planning and supports. Those on a college track may be worried they are “behind” academically or in college preparation.

Parents can show up when and where their children are most likely to talk, perhaps bath time or bedtime for younger children or in the car together with their adolescents. They can ask: “Have you been thinking about what it might be like to go back to school? Have your friends been chatting about it?” They might be curious together about what might have changed in a year. What might be really great about being back in a classroom? What might they miss about home school? And what might be new? Are you worried about the work, any of your friends, or not being home? If children can begin to anticipate both the good and the difficult, they will be better equipped to face and manage the challenges and appreciate the delights.

Children in elementary school are built to master new situations but are also prone to anxiety about new expectations and demands. Parents can be calmly curious about what their thoughts, feelings, and questions are and look for answers together. Often all they need is to see parents being calm in the face of uncertainty, bearing the strong feelings that may come, and preserving curiosity and compassion. Adolescents may be grieving the things they have missed, or they may have concerns about relationships and practical matters such as the implications for applying to college. Parents can offer compassion and validation and help them to devise their own strategies to face the practical challenges they are concerned about.
 

Be mindful of their children’s vulnerabilities

While most children will find the transition back to school easier than they may anticipate, there will be some for whom the transition will be very challenging. Children who have been bullied at school may have found themselves able to concentrate and learn free of the fear and stress of a classmate’s taunts or stares. Children with learning disabilities or ADHD have probably struggled with online school, but they have also likely established strategies and supports during the year that have enabled them to get enough individualized help to get their work done. These children are vulnerable to falling behind and getting discouraged when these supports are lost, and possibly not replaced with new ones in the chaos of transition. Parents should reassure their children that they will work with the school to make sure that they can succeed in the classroom as they did at home.

Children with an inhibited or shy temperament might have found that it was easier to focus and listen in the comfortable setting of home than in a busy, stimulating classroom. Children who suffer from anxiety disorders that may make separating from parents or managing the performance and social demands of school extra difficult will find the return to school especially challenging. Some younger children may have experienced the emergence of an anxiety disorder during the past year, and the return to school may mark the challenge that brings heretofore quiet symptoms into full relief.

These children have all enjoyed being able to avoid the discomfort of certain anxiety-provoking situations, and they may be particularly stressed by anticipating a return to school. Younger children may begin to have stomach aches and other physical complaints as the return to school gets close, older children may seem more withdrawn or irritable or begin discussing ways to continue school from home. Parents should help their children try to identify and describe their worries. For anxious children, having a chance to practice may be very helpful. Visiting their school, especially if it is a new school, or having a planned hangout with a friend (with appropriate precautions) is the kind of exposure that can lessen anticipatory anxiety. If this is not enough, parents should not hesitate to bring in other caring, supportive adults, such as school counselors or therapists that may be essential to helping their children face and manage what may be intense anxiety.
 

Consider routines to support their transition

Just as parents begin to return their children to an earlier bedtime toward the end of summer, it will be helpful to consider how changing certain routines will support their children now. If children will need to get up earlier to be ready for a bus or a team practice, they should start moving bedtime and wake-up time earlier gradually. Uniforms or backpacks that have not been seen for a year should be dug out. Children who are planning a return to a sport may benefit from gradually increasing their exercise or starting training now. This will have the added benefit of improving sleep and energy and fortifying children for the challenges of change. Parents might consider reaching out to other parents in the same class as their children and having a virtual conversation to share their thoughts.

If their family has developed some new “COVID routines” that they have come to enjoy, they should find a way to preserve them. Perhaps they are having dinner together more often or have established a family game night or Netflix night. Help parents consider how to avoid falling back into overscheduling their children and themselves. If they created a time to Zoom with distant or vulnerable loved ones, they might decide to continue this. School may determine some of their routines, but they should also prioritize their family connections and well-being in deciding how to schedule their days.
 

Find opportunity for mastery and meaning

As parents are listening, validating, and planning with their children, they might use this time to reflect on valuable lessons. They might point out the value of patience: Adjusting to change takes time and happens in fits and starts. It has been 12 months since many of the pandemic changes started and it will take more than a few days to adjust as schools reopen. They might point out how proud they are of what their children have been able to learn, build, or do during this year, what they admire about them. It may be a time to consider what their family may have lost and gained during the past year, what they are eager to leave behind, and what they might like to keep. And it is also a chance for parents to observe that change is an inevitable part of life (especially when growing up). It is always challenging, and often brings loss and sadness. But if we pay attention, there are also the green shoots of what is new and possible.

Dr. Swick is physician in chief at Ohana, Center for Child and Adolescent Behavioral Health, Community Hospital of the Monterey (Calif.) Peninsula. Dr. Jellinek is professor emeritus of psychiatry and pediatrics, Harvard Medical School, Boston. Email them at pdnews@mdedge.com.

This spring may bring an unusual transition for families: a return to in-person school after nearly a year in a virtual classroom. This will undoubtedly come as a welcome relief to many parents worried about their children’s education and development and struggling with running school from home. But it is important for parents to remember that transitions, even happy ones, are difficult. You can help parents to anticipate what may be challenging about this transition for their children so that they are all prepared and can diminish struggles and support their children’s mastery.

Be curious about their children’s thoughts and feelings

Parents should adopt a truly curious and open-minded approach with their children. Remind parents that, while they are experts on their own children, they should not assume they know what their children are thinking or feeling about the return to school. Some children, especially ones struggling with learning problems or difficulty with peers, will have grown very comfortable being at home with parents or siblings. Some children, especially pre- and early teens, may have changed substantially in the year and might feel uncertain about returning to a prior team or group of friends. Some children may feel concerned about leaving a pet at home alone. Some children may be going to a new school and be anxious about facing such a big transition without the usual planning and supports. Those on a college track may be worried they are “behind” academically or in college preparation.

Parents can show up when and where their children are most likely to talk, perhaps bath time or bedtime for younger children or in the car together with their adolescents. They can ask: “Have you been thinking about what it might be like to go back to school? Have your friends been chatting about it?” They might be curious together about what might have changed in a year. What might be really great about being back in a classroom? What might they miss about home school? And what might be new? Are you worried about the work, any of your friends, or not being home? If children can begin to anticipate both the good and the difficult, they will be better equipped to face and manage the challenges and appreciate the delights.

Children in elementary school are built to master new situations but are also prone to anxiety about new expectations and demands. Parents can be calmly curious about what their thoughts, feelings, and questions are and look for answers together. Often all they need is to see parents being calm in the face of uncertainty, bearing the strong feelings that may come, and preserving curiosity and compassion. Adolescents may be grieving the things they have missed, or they may have concerns about relationships and practical matters such as the implications for applying to college. Parents can offer compassion and validation and help them to devise their own strategies to face the practical challenges they are concerned about.
 

Be mindful of their children’s vulnerabilities

While most children will find the transition back to school easier than they may anticipate, there will be some for whom the transition will be very challenging. Children who have been bullied at school may have found themselves able to concentrate and learn free of the fear and stress of a classmate’s taunts or stares. Children with learning disabilities or ADHD have probably struggled with online school, but they have also likely established strategies and supports during the year that have enabled them to get enough individualized help to get their work done. These children are vulnerable to falling behind and getting discouraged when these supports are lost, and possibly not replaced with new ones in the chaos of transition. Parents should reassure their children that they will work with the school to make sure that they can succeed in the classroom as they did at home.

Children with an inhibited or shy temperament might have found that it was easier to focus and listen in the comfortable setting of home than in a busy, stimulating classroom. Children who suffer from anxiety disorders that may make separating from parents or managing the performance and social demands of school extra difficult will find the return to school especially challenging. Some younger children may have experienced the emergence of an anxiety disorder during the past year, and the return to school may mark the challenge that brings heretofore quiet symptoms into full relief.

These children have all enjoyed being able to avoid the discomfort of certain anxiety-provoking situations, and they may be particularly stressed by anticipating a return to school. Younger children may begin to have stomach aches and other physical complaints as the return to school gets close, older children may seem more withdrawn or irritable or begin discussing ways to continue school from home. Parents should help their children try to identify and describe their worries. For anxious children, having a chance to practice may be very helpful. Visiting their school, especially if it is a new school, or having a planned hangout with a friend (with appropriate precautions) is the kind of exposure that can lessen anticipatory anxiety. If this is not enough, parents should not hesitate to bring in other caring, supportive adults, such as school counselors or therapists that may be essential to helping their children face and manage what may be intense anxiety.
 

Consider routines to support their transition

Just as parents begin to return their children to an earlier bedtime toward the end of summer, it will be helpful to consider how changing certain routines will support their children now. If children will need to get up earlier to be ready for a bus or a team practice, they should start moving bedtime and wake-up time earlier gradually. Uniforms or backpacks that have not been seen for a year should be dug out. Children who are planning a return to a sport may benefit from gradually increasing their exercise or starting training now. This will have the added benefit of improving sleep and energy and fortifying children for the challenges of change. Parents might consider reaching out to other parents in the same class as their children and having a virtual conversation to share their thoughts.

If their family has developed some new “COVID routines” that they have come to enjoy, they should find a way to preserve them. Perhaps they are having dinner together more often or have established a family game night or Netflix night. Help parents consider how to avoid falling back into overscheduling their children and themselves. If they created a time to Zoom with distant or vulnerable loved ones, they might decide to continue this. School may determine some of their routines, but they should also prioritize their family connections and well-being in deciding how to schedule their days.
 

Find opportunity for mastery and meaning

As parents are listening, validating, and planning with their children, they might use this time to reflect on valuable lessons. They might point out the value of patience: Adjusting to change takes time and happens in fits and starts. It has been 12 months since many of the pandemic changes started and it will take more than a few days to adjust as schools reopen. They might point out how proud they are of what their children have been able to learn, build, or do during this year, what they admire about them. It may be a time to consider what their family may have lost and gained during the past year, what they are eager to leave behind, and what they might like to keep. And it is also a chance for parents to observe that change is an inevitable part of life (especially when growing up). It is always challenging, and often brings loss and sadness. But if we pay attention, there are also the green shoots of what is new and possible.

Dr. Swick is physician in chief at Ohana, Center for Child and Adolescent Behavioral Health, Community Hospital of the Monterey (Calif.) Peninsula. Dr. Jellinek is professor emeritus of psychiatry and pediatrics, Harvard Medical School, Boston. Email them at pdnews@mdedge.com.

This spring may bring an unusual transition for families: a return to in-person school after nearly a year in a virtual classroom. This will undoubtedly come as a welcome relief to many parents worried about their children’s education and development and struggling with running school from home. But it is important for parents to remember that transitions, even happy ones, are difficult. You can help parents to anticipate what may be challenging about this transition for their children so that they are all prepared and can diminish struggles and support their children’s mastery.

Be curious about their children’s thoughts and feelings

Parents should adopt a truly curious and open-minded approach with their children. Remind parents that, while they are experts on their own children, they should not assume they know what their children are thinking or feeling about the return to school. Some children, especially ones struggling with learning problems or difficulty with peers, will have grown very comfortable being at home with parents or siblings. Some children, especially pre- and early teens, may have changed substantially in the year and might feel uncertain about returning to a prior team or group of friends. Some children may feel concerned about leaving a pet at home alone. Some children may be going to a new school and be anxious about facing such a big transition without the usual planning and supports. Those on a college track may be worried they are “behind” academically or in college preparation.

Parents can show up when and where their children are most likely to talk, perhaps bath time or bedtime for younger children or in the car together with their adolescents. They can ask: “Have you been thinking about what it might be like to go back to school? Have your friends been chatting about it?” They might be curious together about what might have changed in a year. What might be really great about being back in a classroom? What might they miss about home school? And what might be new? Are you worried about the work, any of your friends, or not being home? If children can begin to anticipate both the good and the difficult, they will be better equipped to face and manage the challenges and appreciate the delights.

Children in elementary school are built to master new situations but are also prone to anxiety about new expectations and demands. Parents can be calmly curious about what their thoughts, feelings, and questions are and look for answers together. Often all they need is to see parents being calm in the face of uncertainty, bearing the strong feelings that may come, and preserving curiosity and compassion. Adolescents may be grieving the things they have missed, or they may have concerns about relationships and practical matters such as the implications for applying to college. Parents can offer compassion and validation and help them to devise their own strategies to face the practical challenges they are concerned about.
 

Be mindful of their children’s vulnerabilities

While most children will find the transition back to school easier than they may anticipate, there will be some for whom the transition will be very challenging. Children who have been bullied at school may have found themselves able to concentrate and learn free of the fear and stress of a classmate’s taunts or stares. Children with learning disabilities or ADHD have probably struggled with online school, but they have also likely established strategies and supports during the year that have enabled them to get enough individualized help to get their work done. These children are vulnerable to falling behind and getting discouraged when these supports are lost, and possibly not replaced with new ones in the chaos of transition. Parents should reassure their children that they will work with the school to make sure that they can succeed in the classroom as they did at home.

Children with an inhibited or shy temperament might have found that it was easier to focus and listen in the comfortable setting of home than in a busy, stimulating classroom. Children who suffer from anxiety disorders that may make separating from parents or managing the performance and social demands of school extra difficult will find the return to school especially challenging. Some younger children may have experienced the emergence of an anxiety disorder during the past year, and the return to school may mark the challenge that brings heretofore quiet symptoms into full relief.

These children have all enjoyed being able to avoid the discomfort of certain anxiety-provoking situations, and they may be particularly stressed by anticipating a return to school. Younger children may begin to have stomach aches and other physical complaints as the return to school gets close, older children may seem more withdrawn or irritable or begin discussing ways to continue school from home. Parents should help their children try to identify and describe their worries. For anxious children, having a chance to practice may be very helpful. Visiting their school, especially if it is a new school, or having a planned hangout with a friend (with appropriate precautions) is the kind of exposure that can lessen anticipatory anxiety. If this is not enough, parents should not hesitate to bring in other caring, supportive adults, such as school counselors or therapists that may be essential to helping their children face and manage what may be intense anxiety.
 

Consider routines to support their transition

Just as parents begin to return their children to an earlier bedtime toward the end of summer, it will be helpful to consider how changing certain routines will support their children now. If children will need to get up earlier to be ready for a bus or a team practice, they should start moving bedtime and wake-up time earlier gradually. Uniforms or backpacks that have not been seen for a year should be dug out. Children who are planning a return to a sport may benefit from gradually increasing their exercise or starting training now. This will have the added benefit of improving sleep and energy and fortifying children for the challenges of change. Parents might consider reaching out to other parents in the same class as their children and having a virtual conversation to share their thoughts.

If their family has developed some new “COVID routines” that they have come to enjoy, they should find a way to preserve them. Perhaps they are having dinner together more often or have established a family game night or Netflix night. Help parents consider how to avoid falling back into overscheduling their children and themselves. If they created a time to Zoom with distant or vulnerable loved ones, they might decide to continue this. School may determine some of their routines, but they should also prioritize their family connections and well-being in deciding how to schedule their days.
 

Find opportunity for mastery and meaning

As parents are listening, validating, and planning with their children, they might use this time to reflect on valuable lessons. They might point out the value of patience: Adjusting to change takes time and happens in fits and starts. It has been 12 months since many of the pandemic changes started and it will take more than a few days to adjust as schools reopen. They might point out how proud they are of what their children have been able to learn, build, or do during this year, what they admire about them. It may be a time to consider what their family may have lost and gained during the past year, what they are eager to leave behind, and what they might like to keep. And it is also a chance for parents to observe that change is an inevitable part of life (especially when growing up). It is always challenging, and often brings loss and sadness. But if we pay attention, there are also the green shoots of what is new and possible.

Dr. Swick is physician in chief at Ohana, Center for Child and Adolescent Behavioral Health, Community Hospital of the Monterey (Calif.) Peninsula. Dr. Jellinek is professor emeritus of psychiatry and pediatrics, Harvard Medical School, Boston. Email them at pdnews@mdedge.com.

A miniature camera the size of a capsule that is swallowed and then transmits images of the inside of the gut can reveal cancer and gastrointestinal diseases. The device, which will be studied in a trial conducted by the National Health Service in England, is used by patients at home as a substitute for endoscopy.

“What sounds like sci-fi is now becoming a reality,” said Sir Simon Stevens, chief executive of NHS England. “These minute cameras pass through your body. They take two pictures per second, checking for signs of cancer and other conditions like Crohn’s disease.”

The trial, announced on March 11, 2021, will initially involve 11,000 patients from 40 regions in England. Participants will be sent the colon capsule endoscopy to use at home.

The capsule typically takes 5-8 hours to pass through the digestive system. As the capsule passes through the bowel, images are sent to a data recorder in a shoulder bag.

The trial is being conducted by the University College London Hospitals NHS Foundation Trust. The investigators have created a guide on using the device at home.

“Not only does colon capsule increase our diagnostic capacity, because it doesn’t require the resources of a dedicated hospital space to do the examination, it also allows us to do the examination in the patient’s home, so patients who may be shielding or cautious about going to a hospital can perform the procedure in the comfort of their own homes,” commented Ed Seward, MD, PhD, endoscopy lead at UCL.

The move is in response to a surge in patients coming forward for cancer checks after the slowdown in cancer services caused by the COVID-19 pandemic. In December 2020, more than 200,000 people came forward, an increase of 13,000 over the same month the previous year.

Traditional endoscopy services are still being offered, although endoscopies take longer to conduct because of infection control measures that must be employed to ensure that patients who undergo endoscopies do not develop COVID-19. This, in turn, means fewer people can undergo endoscopies over a given period.

“We welcome any initiative that seeks to simplify and improve the early diagnosis of gastrointestinal disease and, in particular, colorectal cancer, which unfortunately is still responsible for many avoidable deaths,” said Alastair McKinlay, MD, president of the British Society of Gastroenterology.

“Colon capsule is a promising new technology that may offer a real advantage for some patients. For this reason, we welcome the opportunity for a proper service evaluation so that both the limitations and advantages of this technique can be properly assessed,” he said.

“This has the potential to make a huge difference for people with bowel cancer symptoms and could help the NHS to prioritize those who urgently need further tests,” added Genevieve Edwards, chief executive at Bowel Cancer UK.

No funding for the study has been disclosed. No relevant financial relationships have been disclosed.

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

A miniature camera the size of a capsule that is swallowed and then transmits images of the inside of the gut can reveal cancer and gastrointestinal diseases. The device, which will be studied in a trial conducted by the National Health Service in England, is used by patients at home as a substitute for endoscopy.

“What sounds like sci-fi is now becoming a reality,” said Sir Simon Stevens, chief executive of NHS England. “These minute cameras pass through your body. They take two pictures per second, checking for signs of cancer and other conditions like Crohn’s disease.”

The trial, announced on March 11, 2021, will initially involve 11,000 patients from 40 regions in England. Participants will be sent the colon capsule endoscopy to use at home.

The capsule typically takes 5-8 hours to pass through the digestive system. As the capsule passes through the bowel, images are sent to a data recorder in a shoulder bag.

The trial is being conducted by the University College London Hospitals NHS Foundation Trust. The investigators have created a guide on using the device at home.

“Not only does colon capsule increase our diagnostic capacity, because it doesn’t require the resources of a dedicated hospital space to do the examination, it also allows us to do the examination in the patient’s home, so patients who may be shielding or cautious about going to a hospital can perform the procedure in the comfort of their own homes,” commented Ed Seward, MD, PhD, endoscopy lead at UCL.

The move is in response to a surge in patients coming forward for cancer checks after the slowdown in cancer services caused by the COVID-19 pandemic. In December 2020, more than 200,000 people came forward, an increase of 13,000 over the same month the previous year.

Traditional endoscopy services are still being offered, although endoscopies take longer to conduct because of infection control measures that must be employed to ensure that patients who undergo endoscopies do not develop COVID-19. This, in turn, means fewer people can undergo endoscopies over a given period.

“We welcome any initiative that seeks to simplify and improve the early diagnosis of gastrointestinal disease and, in particular, colorectal cancer, which unfortunately is still responsible for many avoidable deaths,” said Alastair McKinlay, MD, president of the British Society of Gastroenterology.

“Colon capsule is a promising new technology that may offer a real advantage for some patients. For this reason, we welcome the opportunity for a proper service evaluation so that both the limitations and advantages of this technique can be properly assessed,” he said.

“This has the potential to make a huge difference for people with bowel cancer symptoms and could help the NHS to prioritize those who urgently need further tests,” added Genevieve Edwards, chief executive at Bowel Cancer UK.

No funding for the study has been disclosed. No relevant financial relationships have been disclosed.

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

A miniature camera the size of a capsule that is swallowed and then transmits images of the inside of the gut can reveal cancer and gastrointestinal diseases. The device, which will be studied in a trial conducted by the National Health Service in England, is used by patients at home as a substitute for endoscopy.

“What sounds like sci-fi is now becoming a reality,” said Sir Simon Stevens, chief executive of NHS England. “These minute cameras pass through your body. They take two pictures per second, checking for signs of cancer and other conditions like Crohn’s disease.”

The trial, announced on March 11, 2021, will initially involve 11,000 patients from 40 regions in England. Participants will be sent the colon capsule endoscopy to use at home.

The capsule typically takes 5-8 hours to pass through the digestive system. As the capsule passes through the bowel, images are sent to a data recorder in a shoulder bag.

The trial is being conducted by the University College London Hospitals NHS Foundation Trust. The investigators have created a guide on using the device at home.

“Not only does colon capsule increase our diagnostic capacity, because it doesn’t require the resources of a dedicated hospital space to do the examination, it also allows us to do the examination in the patient’s home, so patients who may be shielding or cautious about going to a hospital can perform the procedure in the comfort of their own homes,” commented Ed Seward, MD, PhD, endoscopy lead at UCL.

The move is in response to a surge in patients coming forward for cancer checks after the slowdown in cancer services caused by the COVID-19 pandemic. In December 2020, more than 200,000 people came forward, an increase of 13,000 over the same month the previous year.

Traditional endoscopy services are still being offered, although endoscopies take longer to conduct because of infection control measures that must be employed to ensure that patients who undergo endoscopies do not develop COVID-19. This, in turn, means fewer people can undergo endoscopies over a given period.

“We welcome any initiative that seeks to simplify and improve the early diagnosis of gastrointestinal disease and, in particular, colorectal cancer, which unfortunately is still responsible for many avoidable deaths,” said Alastair McKinlay, MD, president of the British Society of Gastroenterology.

“Colon capsule is a promising new technology that may offer a real advantage for some patients. For this reason, we welcome the opportunity for a proper service evaluation so that both the limitations and advantages of this technique can be properly assessed,” he said.

“This has the potential to make a huge difference for people with bowel cancer symptoms and could help the NHS to prioritize those who urgently need further tests,” added Genevieve Edwards, chief executive at Bowel Cancer UK.

No funding for the study has been disclosed. No relevant financial relationships have been disclosed.

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

Colorectal cancer (CRC) screening is now recommended for average-risk individuals starting at age 45 years, according to the American College of Gastroenterology’s updated guideline.

The starting age was previously 50 years for most patients. However, for Black patients, the starting age was lowered to 45 years in 2005.

The new guidance brings the ACG in line with recommendations of the American Cancer Society, which lowered the starting age to 45 years for average-risk individuals in 2018.

However, the U.S. Preventive Services Task Force, the Multi-Specialty Task Force, and the American College of Physicians still recommend that CRC screening begin at the age of 50.

The new ACG guideline were published in March 2021 in the American Journal of Gastroenterology. The last time they were updated was in 2009.

The ACG said that the move was made in light of reports of an increase in the incidence of CRC in adults younger than 50.

“It has been estimated that [in the United States] persons born around 1990 have twice the risk of colon cancer and four times the risk of rectal cancer, compared with those born around 1950,” guideline author Aasma Shaukat, MD, MPH, University of Minnesota, Minneapolis, and colleagues pointed out.

“The fact that other developed countries are reporting similar increases in early-onset CRC and birth-cohort effects suggests that the Western lifestyle (especially exemplified by the obesity epidemic) is a significant contributor,” the authors added.

The new ACG guideline emphasize the importance of initiating CRC screening for average-risk patients aged 50-75 years. “Given that current rates of screening uptake are close to 60% (57.9% ages 50-64 and 62.4% ages 50-75), expanding the population to be screened may reduce these rates as emphasis shifts to screening 45- to 49-year-olds at the expense of efforts to screen the unscreened 50- to 75-year-olds,” the authors commented.

Now, however, the guideline suggests that the decision to continue screening after age 75 should be individualized. It notes that the benefits of screening are limited for those who are not expected to live for another 7-10 years. For patients with a family history of CRC, the guideline authors recommended initiating CRC screening at the age of 40 for patients with one or two first-degree relatives with either CRC or advanced colorectal polyps.

They also recommend screening colonoscopy over any other screening modality if the first-degree relative is younger than 60 or if two or more first-degree relatives of any age have CRC or advanced colorectal polyps. For such patients, screening should be repeated every 5 years.

For screening average-risk individuals, either colonoscopy or fecal immunochemical testing (FIT) is recommended. If colonoscopy is used, it should be repeated every 10 years. FIT should be conducted on an annual basis.

This is somewhat in contrast to recent changes proposed by the American Gastroenterological Association. The AGA recommends greater use of noninvasive testing, such as with fecal occult blood tests, initially. It recommends that initial colonoscopy be used only for patients at high risk for CRC.

For individuals unwilling or unable to undergo colonoscopy or FIT, the ACG suggests flexible sigmoidoscopy, multitarget stool DNA testing, CT colonography, or colon capsule. Only colonoscopy is a single-step test; all other screening modalities require a follow-up colonoscopy if test results are positive.

“We recommend against the use of aspirin as a substitute for CRC screening,” the ACG members emphasized. Rather, they suggest that the use of low-dose aspirin be considered only for patients aged 50-69 years whose risk for cardiovascular disease over the next 10 years is at least 10% and who are at low risk for bleeding.

To reduce their risk for CRC, patients need to take aspirin for at least 10 years, they pointed out.
 

Quality indicators

For endoscopists who perform colonoscopy, the ACG recommended that all operators determine their individual cecal intubation rates, adenoma detection rates, and withdrawal times. They also recommended that endoscopists spend at least 6 minutes inspecting the mucosa during withdrawal and achieve a cecal intubation rate of at least 95% for all patients screened.

The ACG recommended remedial training for any provider whose adenoma detection rate is less than 25%.
 

Screening rates dropped during pandemic

The authors of the new recommendations also pointed out that, despite public health initiatives to boost CRC screening in the United States and the availability of multiple screening modalities, almost one-third of individuals who are eligible for CRC screening do not undergo screening.

Moreover, the proportion of individuals not being screened has reportedly increased during the pandemic. In one report, claims data for colonoscopies dropped by 90% during April. “Colorectal cancer screening rates must be optimized to reach the aspirational target of >80%,” the authors emphasized.

“A recommendation to be screened by a PCP [primary care provider] – who is known and trusted by the person – is clearly effective in raising participation,” they added.

Dr. Shaukat has served as a scientific consultant for Iterative Scopes and Freenome. Other ACG guideline authors reported numerous financial relationships.

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

Colorectal cancer (CRC) screening is now recommended for average-risk individuals starting at age 45 years, according to the American College of Gastroenterology’s updated guideline.

The starting age was previously 50 years for most patients. However, for Black patients, the starting age was lowered to 45 years in 2005.

The new guidance brings the ACG in line with recommendations of the American Cancer Society, which lowered the starting age to 45 years for average-risk individuals in 2018.

However, the U.S. Preventive Services Task Force, the Multi-Specialty Task Force, and the American College of Physicians still recommend that CRC screening begin at the age of 50.

The new ACG guideline were published in March 2021 in the American Journal of Gastroenterology. The last time they were updated was in 2009.

The ACG said that the move was made in light of reports of an increase in the incidence of CRC in adults younger than 50.

“It has been estimated that [in the United States] persons born around 1990 have twice the risk of colon cancer and four times the risk of rectal cancer, compared with those born around 1950,” guideline author Aasma Shaukat, MD, MPH, University of Minnesota, Minneapolis, and colleagues pointed out.

“The fact that other developed countries are reporting similar increases in early-onset CRC and birth-cohort effects suggests that the Western lifestyle (especially exemplified by the obesity epidemic) is a significant contributor,” the authors added.

The new ACG guideline emphasize the importance of initiating CRC screening for average-risk patients aged 50-75 years. “Given that current rates of screening uptake are close to 60% (57.9% ages 50-64 and 62.4% ages 50-75), expanding the population to be screened may reduce these rates as emphasis shifts to screening 45- to 49-year-olds at the expense of efforts to screen the unscreened 50- to 75-year-olds,” the authors commented.

Now, however, the guideline suggests that the decision to continue screening after age 75 should be individualized. It notes that the benefits of screening are limited for those who are not expected to live for another 7-10 years. For patients with a family history of CRC, the guideline authors recommended initiating CRC screening at the age of 40 for patients with one or two first-degree relatives with either CRC or advanced colorectal polyps.

They also recommend screening colonoscopy over any other screening modality if the first-degree relative is younger than 60 or if two or more first-degree relatives of any age have CRC or advanced colorectal polyps. For such patients, screening should be repeated every 5 years.

For screening average-risk individuals, either colonoscopy or fecal immunochemical testing (FIT) is recommended. If colonoscopy is used, it should be repeated every 10 years. FIT should be conducted on an annual basis.

This is somewhat in contrast to recent changes proposed by the American Gastroenterological Association. The AGA recommends greater use of noninvasive testing, such as with fecal occult blood tests, initially. It recommends that initial colonoscopy be used only for patients at high risk for CRC.

For individuals unwilling or unable to undergo colonoscopy or FIT, the ACG suggests flexible sigmoidoscopy, multitarget stool DNA testing, CT colonography, or colon capsule. Only colonoscopy is a single-step test; all other screening modalities require a follow-up colonoscopy if test results are positive.

“We recommend against the use of aspirin as a substitute for CRC screening,” the ACG members emphasized. Rather, they suggest that the use of low-dose aspirin be considered only for patients aged 50-69 years whose risk for cardiovascular disease over the next 10 years is at least 10% and who are at low risk for bleeding.

To reduce their risk for CRC, patients need to take aspirin for at least 10 years, they pointed out.
 

Quality indicators

For endoscopists who perform colonoscopy, the ACG recommended that all operators determine their individual cecal intubation rates, adenoma detection rates, and withdrawal times. They also recommended that endoscopists spend at least 6 minutes inspecting the mucosa during withdrawal and achieve a cecal intubation rate of at least 95% for all patients screened.

The ACG recommended remedial training for any provider whose adenoma detection rate is less than 25%.
 

Screening rates dropped during pandemic

The authors of the new recommendations also pointed out that, despite public health initiatives to boost CRC screening in the United States and the availability of multiple screening modalities, almost one-third of individuals who are eligible for CRC screening do not undergo screening.

Moreover, the proportion of individuals not being screened has reportedly increased during the pandemic. In one report, claims data for colonoscopies dropped by 90% during April. “Colorectal cancer screening rates must be optimized to reach the aspirational target of >80%,” the authors emphasized.

“A recommendation to be screened by a PCP [primary care provider] – who is known and trusted by the person – is clearly effective in raising participation,” they added.

Dr. Shaukat has served as a scientific consultant for Iterative Scopes and Freenome. Other ACG guideline authors reported numerous financial relationships.

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

Colorectal cancer (CRC) screening is now recommended for average-risk individuals starting at age 45 years, according to the American College of Gastroenterology’s updated guideline.

The starting age was previously 50 years for most patients. However, for Black patients, the starting age was lowered to 45 years in 2005.

The new guidance brings the ACG in line with recommendations of the American Cancer Society, which lowered the starting age to 45 years for average-risk individuals in 2018.

However, the U.S. Preventive Services Task Force, the Multi-Specialty Task Force, and the American College of Physicians still recommend that CRC screening begin at the age of 50.

The new ACG guideline were published in March 2021 in the American Journal of Gastroenterology. The last time they were updated was in 2009.

The ACG said that the move was made in light of reports of an increase in the incidence of CRC in adults younger than 50.

“It has been estimated that [in the United States] persons born around 1990 have twice the risk of colon cancer and four times the risk of rectal cancer, compared with those born around 1950,” guideline author Aasma Shaukat, MD, MPH, University of Minnesota, Minneapolis, and colleagues pointed out.

“The fact that other developed countries are reporting similar increases in early-onset CRC and birth-cohort effects suggests that the Western lifestyle (especially exemplified by the obesity epidemic) is a significant contributor,” the authors added.

The new ACG guideline emphasize the importance of initiating CRC screening for average-risk patients aged 50-75 years. “Given that current rates of screening uptake are close to 60% (57.9% ages 50-64 and 62.4% ages 50-75), expanding the population to be screened may reduce these rates as emphasis shifts to screening 45- to 49-year-olds at the expense of efforts to screen the unscreened 50- to 75-year-olds,” the authors commented.

Now, however, the guideline suggests that the decision to continue screening after age 75 should be individualized. It notes that the benefits of screening are limited for those who are not expected to live for another 7-10 years. For patients with a family history of CRC, the guideline authors recommended initiating CRC screening at the age of 40 for patients with one or two first-degree relatives with either CRC or advanced colorectal polyps.

They also recommend screening colonoscopy over any other screening modality if the first-degree relative is younger than 60 or if two or more first-degree relatives of any age have CRC or advanced colorectal polyps. For such patients, screening should be repeated every 5 years.

For screening average-risk individuals, either colonoscopy or fecal immunochemical testing (FIT) is recommended. If colonoscopy is used, it should be repeated every 10 years. FIT should be conducted on an annual basis.

This is somewhat in contrast to recent changes proposed by the American Gastroenterological Association. The AGA recommends greater use of noninvasive testing, such as with fecal occult blood tests, initially. It recommends that initial colonoscopy be used only for patients at high risk for CRC.

For individuals unwilling or unable to undergo colonoscopy or FIT, the ACG suggests flexible sigmoidoscopy, multitarget stool DNA testing, CT colonography, or colon capsule. Only colonoscopy is a single-step test; all other screening modalities require a follow-up colonoscopy if test results are positive.

“We recommend against the use of aspirin as a substitute for CRC screening,” the ACG members emphasized. Rather, they suggest that the use of low-dose aspirin be considered only for patients aged 50-69 years whose risk for cardiovascular disease over the next 10 years is at least 10% and who are at low risk for bleeding.

To reduce their risk for CRC, patients need to take aspirin for at least 10 years, they pointed out.
 

Quality indicators

For endoscopists who perform colonoscopy, the ACG recommended that all operators determine their individual cecal intubation rates, adenoma detection rates, and withdrawal times. They also recommended that endoscopists spend at least 6 minutes inspecting the mucosa during withdrawal and achieve a cecal intubation rate of at least 95% for all patients screened.

The ACG recommended remedial training for any provider whose adenoma detection rate is less than 25%.
 

Screening rates dropped during pandemic

The authors of the new recommendations also pointed out that, despite public health initiatives to boost CRC screening in the United States and the availability of multiple screening modalities, almost one-third of individuals who are eligible for CRC screening do not undergo screening.

Moreover, the proportion of individuals not being screened has reportedly increased during the pandemic. In one report, claims data for colonoscopies dropped by 90% during April. “Colorectal cancer screening rates must be optimized to reach the aspirational target of >80%,” the authors emphasized.

“A recommendation to be screened by a PCP [primary care provider] – who is known and trusted by the person – is clearly effective in raising participation,” they added.

Dr. Shaukat has served as a scientific consultant for Iterative Scopes and Freenome. Other ACG guideline authors reported numerous financial relationships.

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

A mitochondrial DNA variant may increase the risk of gallstone disease more than fourfold, according to investigators.

wir0man/GettyImages

Mitochondrial DNA 827A>G disrupts mitochondrial function and leads to abnormal cholesterol transport, which increases gallstone development, reported Dayan Sun, of Fudan University, Shanghai, China, and colleagues.

The investigators noted that the findings add support to a genetic role in gallstone development, which could allow for identification of at-risk individuals and implementation of preventive measures.

“The etiology of gallstone disease is multifactorial; age, sex, pregnancy, diet (macronutrients, alcohol, and coffee), and other factors are involved,” the investigators wrote in Cellular and Molecular Gastroenterology and Hepatology. “Moreover, the significant familial predisposition and ethnic differences in prevalence of this disease indicate the potential influences of genetic factors.”

In 2002, Nakeeb and colleagues reported that at least 30% of gallstone disease cases stemmed from genetic factors. And genetics may play an even greater role in certain populations, such as Native Americans, among whom more than 70% of women have gallstone disease, based on a study by Everhart and colleagues.

According to Ms. Sun and colleagues, a variety of genetic drivers of gallstone disease have been identified, such as ABCG8, identified as the most common genetic risk factor by at least one study, along with a list of other rare mutations, such as one affecting CFTR that leads to altered bile composition.

Based on previous research that linked mitochondrial DNA variants with metabolic defects and, more specifically, aberrations in lipid metabolism, as well as an observed “maternal bias in the maternal transmission of gallstone disease” that suggest mitochondrial influence, the investigators looked for patterns specifically in mitochondrial DNA variants among patients with gallstones.

The study enrolled 104 probands with confirmed gallstone disease and 300 unrelated controls. After collecting DNA samples from all participants, the investigators sequenced mitochondrial DNA HVS1 regions. A comparison of haplogroups showed that B4b’d’e’j was more common among patients with gallstone disease than among controls (odds ratio, 4.428; P = .00012), and further analysis pinpointed 827A>G, a variant in 12S ribosomal RNA.

“During the evolutionary history of modern humans, haplogroup B4 might have originated in East Asia approximately 40,000 years ago,” the investigators wrote, noting that B2, a subhaplogroup of B4, “was a founder haplogroup and expanded in the Americas after the Last Glacial Maximum (approximately 20,000 years ago).”

According to the investigators, this may explain why Native Americans have a higher prevalence of gallstones than East Asians (14%-35% vs. 3%-12%) because they are more often carriers of B4 (14%-44% vs. 2%-8%).

The investigators sought to characterize the impact that the 827A>G variant has on mitochondrial function and found effects ranging from lower respiratory chain complex activity, diminished mitochondrial function, activated mitochondrial protein quality control and retrograde signaling pathways, abnormal lipid metabolism, and abnormal cholesterol transport processes.

For example, the investigators investigated respiratory chain complex activity by creating two sister branch haplogroup cell models, including six cybrids for 827A and six more for 827G, which is how they detected the lower activity. Another step the investigators took was corroborating this finding by detecting OXPHOS function in the 827A and 827G cybrids to determine mitochondrial function.

“In summary, our study demonstrates a potential link between mitochondrial DNA 827A>G and gallstone disease,” the investigators wrote. “Our findings provide a significant biological basis for the clinical diagnosis and prevention of gallstone disease in the future.”

The study was funded by the National Natural Science Foundation of China, the 111 Project, the Shanghai Municipal Science and Technology Major Project, the Scientific and Technology Committee of Shanghai Municipality, and the CAMS Innovation Fund for Medical Sciences. The investigators reported no conflicts of interest.

A mitochondrial DNA variant may increase the risk of gallstone disease more than fourfold, according to investigators.

wir0man/GettyImages

Mitochondrial DNA 827A>G disrupts mitochondrial function and leads to abnormal cholesterol transport, which increases gallstone development, reported Dayan Sun, of Fudan University, Shanghai, China, and colleagues.

The investigators noted that the findings add support to a genetic role in gallstone development, which could allow for identification of at-risk individuals and implementation of preventive measures.

“The etiology of gallstone disease is multifactorial; age, sex, pregnancy, diet (macronutrients, alcohol, and coffee), and other factors are involved,” the investigators wrote in Cellular and Molecular Gastroenterology and Hepatology. “Moreover, the significant familial predisposition and ethnic differences in prevalence of this disease indicate the potential influences of genetic factors.”

In 2002, Nakeeb and colleagues reported that at least 30% of gallstone disease cases stemmed from genetic factors. And genetics may play an even greater role in certain populations, such as Native Americans, among whom more than 70% of women have gallstone disease, based on a study by Everhart and colleagues.

According to Ms. Sun and colleagues, a variety of genetic drivers of gallstone disease have been identified, such as ABCG8, identified as the most common genetic risk factor by at least one study, along with a list of other rare mutations, such as one affecting CFTR that leads to altered bile composition.

Based on previous research that linked mitochondrial DNA variants with metabolic defects and, more specifically, aberrations in lipid metabolism, as well as an observed “maternal bias in the maternal transmission of gallstone disease” that suggest mitochondrial influence, the investigators looked for patterns specifically in mitochondrial DNA variants among patients with gallstones.

The study enrolled 104 probands with confirmed gallstone disease and 300 unrelated controls. After collecting DNA samples from all participants, the investigators sequenced mitochondrial DNA HVS1 regions. A comparison of haplogroups showed that B4b’d’e’j was more common among patients with gallstone disease than among controls (odds ratio, 4.428; P = .00012), and further analysis pinpointed 827A>G, a variant in 12S ribosomal RNA.

“During the evolutionary history of modern humans, haplogroup B4 might have originated in East Asia approximately 40,000 years ago,” the investigators wrote, noting that B2, a subhaplogroup of B4, “was a founder haplogroup and expanded in the Americas after the Last Glacial Maximum (approximately 20,000 years ago).”

According to the investigators, this may explain why Native Americans have a higher prevalence of gallstones than East Asians (14%-35% vs. 3%-12%) because they are more often carriers of B4 (14%-44% vs. 2%-8%).

The investigators sought to characterize the impact that the 827A>G variant has on mitochondrial function and found effects ranging from lower respiratory chain complex activity, diminished mitochondrial function, activated mitochondrial protein quality control and retrograde signaling pathways, abnormal lipid metabolism, and abnormal cholesterol transport processes.

For example, the investigators investigated respiratory chain complex activity by creating two sister branch haplogroup cell models, including six cybrids for 827A and six more for 827G, which is how they detected the lower activity. Another step the investigators took was corroborating this finding by detecting OXPHOS function in the 827A and 827G cybrids to determine mitochondrial function.

“In summary, our study demonstrates a potential link between mitochondrial DNA 827A>G and gallstone disease,” the investigators wrote. “Our findings provide a significant biological basis for the clinical diagnosis and prevention of gallstone disease in the future.”

The study was funded by the National Natural Science Foundation of China, the 111 Project, the Shanghai Municipal Science and Technology Major Project, the Scientific and Technology Committee of Shanghai Municipality, and the CAMS Innovation Fund for Medical Sciences. The investigators reported no conflicts of interest.

A mitochondrial DNA variant may increase the risk of gallstone disease more than fourfold, according to investigators.

wir0man/GettyImages

Mitochondrial DNA 827A>G disrupts mitochondrial function and leads to abnormal cholesterol transport, which increases gallstone development, reported Dayan Sun, of Fudan University, Shanghai, China, and colleagues.

The investigators noted that the findings add support to a genetic role in gallstone development, which could allow for identification of at-risk individuals and implementation of preventive measures.

“The etiology of gallstone disease is multifactorial; age, sex, pregnancy, diet (macronutrients, alcohol, and coffee), and other factors are involved,” the investigators wrote in Cellular and Molecular Gastroenterology and Hepatology. “Moreover, the significant familial predisposition and ethnic differences in prevalence of this disease indicate the potential influences of genetic factors.”

In 2002, Nakeeb and colleagues reported that at least 30% of gallstone disease cases stemmed from genetic factors. And genetics may play an even greater role in certain populations, such as Native Americans, among whom more than 70% of women have gallstone disease, based on a study by Everhart and colleagues.

According to Ms. Sun and colleagues, a variety of genetic drivers of gallstone disease have been identified, such as ABCG8, identified as the most common genetic risk factor by at least one study, along with a list of other rare mutations, such as one affecting CFTR that leads to altered bile composition.

Based on previous research that linked mitochondrial DNA variants with metabolic defects and, more specifically, aberrations in lipid metabolism, as well as an observed “maternal bias in the maternal transmission of gallstone disease” that suggest mitochondrial influence, the investigators looked for patterns specifically in mitochondrial DNA variants among patients with gallstones.

The study enrolled 104 probands with confirmed gallstone disease and 300 unrelated controls. After collecting DNA samples from all participants, the investigators sequenced mitochondrial DNA HVS1 regions. A comparison of haplogroups showed that B4b’d’e’j was more common among patients with gallstone disease than among controls (odds ratio, 4.428; P = .00012), and further analysis pinpointed 827A>G, a variant in 12S ribosomal RNA.

“During the evolutionary history of modern humans, haplogroup B4 might have originated in East Asia approximately 40,000 years ago,” the investigators wrote, noting that B2, a subhaplogroup of B4, “was a founder haplogroup and expanded in the Americas after the Last Glacial Maximum (approximately 20,000 years ago).”

According to the investigators, this may explain why Native Americans have a higher prevalence of gallstones than East Asians (14%-35% vs. 3%-12%) because they are more often carriers of B4 (14%-44% vs. 2%-8%).

The investigators sought to characterize the impact that the 827A>G variant has on mitochondrial function and found effects ranging from lower respiratory chain complex activity, diminished mitochondrial function, activated mitochondrial protein quality control and retrograde signaling pathways, abnormal lipid metabolism, and abnormal cholesterol transport processes.

For example, the investigators investigated respiratory chain complex activity by creating two sister branch haplogroup cell models, including six cybrids for 827A and six more for 827G, which is how they detected the lower activity. Another step the investigators took was corroborating this finding by detecting OXPHOS function in the 827A and 827G cybrids to determine mitochondrial function.

“In summary, our study demonstrates a potential link between mitochondrial DNA 827A>G and gallstone disease,” the investigators wrote. “Our findings provide a significant biological basis for the clinical diagnosis and prevention of gallstone disease in the future.”

The study was funded by the National Natural Science Foundation of China, the 111 Project, the Shanghai Municipal Science and Technology Major Project, the Scientific and Technology Committee of Shanghai Municipality, and the CAMS Innovation Fund for Medical Sciences. The investigators reported no conflicts of interest.