Diagnosing Santa

Published December 3, 2022

Morning Report — Not Your Typical Medical Newsletter

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Mind Over Medication for Anxiety Relief?

MENTAL HEALTH MUSINGS

Though an ancient practice, mindfulness meditation has been rising in popularity these days like it’s pickleball. Those who engage in this calming technique (mindfulness, not pickleball) swear by its power to reduce their anxiety and help them stay present. We’re intrigued. After all, could 500 million people and Oprah be wrong? Yes, of course. So, scientists flexed their research muscle and conducted a clinical trial comparing mindfulness meditation with the commonly used antidepressant escitalopram.

Researchers randomly assigned nearly 300 adults with anxiety disorder to eight weeks of either a daily dose of escitalopram (flexibly dosed from 10 to 20 mg) or a weekly mindfulness-based stress reduction (MBSR) class with daily meditation “homework.” Both groups achieved a 30% reduction in anxiety symptom severity, with vastly fewer side effects occurring in the MBSR's group. Perhaps Oprah had been steering us right all along. But hasn’t she always?

Key takeaway

While this trial showed MBSR to be noninferior to escitalopram, the study authors do not suggest replacing pharmacotherapy with mindfulness. They simply ask clinicians to keep an open mind to mindfulness as an intervention option for anxiety. It may work for some but be impractical for others. Or it may prove effective as a complement to pharmacotherapy. So, how can you help patients with anxiety put mindfulness into practice? Start by searching for MBSR programs in your area or check out UMass’ online and in-person MBSR program, developed by MBSR’s founder, Jon Kabat-Zinn. And for the CliffsNotes version of mindfulness, watch Oprah’s conversation with Dr. Kabat-Zinn, in which she distills this complex concept as only she can. We’ll never doubt her again. 

USPSTF Recommendations for Anxiety and Depression Screening in Younger Population

GUIDELINE GUIDANCE

Speaking of anxiety, the US Preventive Services Task Force (USPSTF) has new screening recommendations to share. After recently releasing its draft recommendation encouraging anxiety screening in all adults, the task force turned its focus toward the younger population. In another first, the members recommend screening children and adolescents aged 8 to 18 years for anxiety (B recommendation). Evidence is insufficient in those <8 years.

The task force also reinforced its 2016 recommendation to screen adolescents ≥12 years for depression (B recommendation). Evidence for or against screening children <12 years is lacking.

These screening recommendations apply to children and adolescents who do not show symptoms of anxiety or depression and have not received a previous diagnosis of either condition.
Of note, the USPSTF found insufficient evidence to balance the benefits and harms of suicide screening in this age group, so they stopped short of making that screening recommendation.

Key takeaway

The USPSTF recommends that you continue to screen patients ≥12 years for depression and that you now screen those ≥8 years for anxiety as well. The task force was unable to deliver evidence-based guidance on how often to screen but suggests a reasonable approach may be to offer opportunistic screening in those who present to your practice less frequently and to conduct repeated screening in patients with risk factors.

Patient Case: Kris Kringle

1,750-year-old man with facial erythema and truncal obesity; exhausted but jolly

In the spirit of the holidays, clinicians with too much time on their hands have taken to the internet to diagnose conditions possibly afflicting Santa Claus. While Father Christmas may be the picture on every wrapping paper, he’s far from the picture of health, given his advanced age, pipe smoking habit, and demanding job. After conducting a thorough literature review (and meta-analysis) of all suggested diagnoses, we feel confident in sharing the following differential diagnosis:

1. Lumbar back strain from repetitive hoisting of a 660-million-pound toy sack
2. Calcaneus fracture from high-impact falls via chimney descent or roof jump
3. Soot-induced nasal pharyngitis
4. Rosacea—see those classic rosy cheeks
5. Lyme disease from traveling with nine reindeer—we hear Rudolph is a tick magnet
6. Gravitational edema from hours of flying
7. COPD from repeated chimney travel and a lifetime of pipe smoking
8. Insomnia—third-shift jobs wreak havoc on the circadian rhythm
9. Dorsomedial hypothalamic nucleus (DMH) lesion, given that the DMH nucleus is responsible for the emotion of rage—an emotion Santa self-reports not experiencing
10. Cardiomegaly—whose heart is bigger than Santa’s?

When advised to slow down and practice self-care, Santa ho-ho-ho’d, “I’m no spring chicken, but I plan on outlasting the Easter Bunny.” Bold words from the man in red, but so far, he’s backed them up. Immortality seems to be his thing.

An Ounce of Prevention in Type 1 Diabetes Mellitus

ENDO END POINTS

The headline “FDA approves first treatment to delay onset of type 1 diabetes” went viral faster than RSV this month. The monoclonal antibody teplizumab, a first-in-class biologic therapy, may delay the onset of type 1 diabetes mellitus (T1DM) in patients ≥8 years of age who are at elevated risk of developing the disease. The therapy serves as a roadblock for T-cell−mediated autoimmune destruction of pancreatic beta cells.

The FDA approval of teplizumab marks a significant shift in the research and management of T1DM and has many clinicians and patients cheering. However, frequent Morning Report contributor Debbie Downer—with her unflagging commitment to “keeping it real”—offers a series of caveats to tame our alacrity. (1) The wholesale cost is an astronomical $194,000. (2) In the clinical trial, the average delay to developing symptomatic T1DM was two years, which may or may not be clinically relevant. (3) The therapy is effective for only a small subset of patients with knowledge of their increased risk and with appropriate genetic markers. (4) Trial participants experienced headaches, rash, and low white blood cells and lymph cells, and specific warnings exist for certain patient groups. All true, Debbie, but have you considered the upside?

The FDA approval of teplizumab comes on the heels of a clinical trial showing that intravenous administration of the drug for 14 days can impede the progression from stage 2 T1DM (asymptomatic beta-cell autoimmunity with dysglycemia) to stage 3 T1DM (the onset of symptomatic disease). This drug may afford patients months or years without the burdens and risks associated with stage 3. Naturally, eligible patients must first be identified—we’re all ears on screening changes for T1DM. In the meantime, a multitude of diabetes experts are encouraged by this breakthrough approval. Colin Dayan, professor of clinical diabetes and metabolism at Cardiff University School of Medicine, said, “This will lead to many more people being identified who are in the earliest stages of losing their β cells, which could prevent up to a thousand people a year from having emergency hospital admissions to start insulin.”

Rapid-Fire COVID-19 Updates

COVID QUICK HITS 

Pearls from the AHA 2022 Scientific Sessions 

CARDIO CORNER

The American Heart Association (AHA) 2022 Scientific Sessions in Chicago was the place to be last month. It boasted a who’s who of thought leaders and groundbreaking education, and—unlike a Taylor Swift concert—you could actually get tickets to it. But in case you couldn’t attend, here are two shiny pearls from the event:

One in five people who experience a myocardial infarction will be hospitalized with a second one within five years. Fortunately, most of these second events can be avoided if the patient’s PCP takes these two steps: (1) prescribes a statin and (2) administers a cholesterol-measuring blood test. A retrospective study of nearly 70,000 people found that these two interventions dropped the risk of a second cardiac event (within three years) from 60% down to 6%. Heartening news for all high-risk patients! We hope this reinforces what you’re already doing for this patient population and helps patients take heart that interventions can change their fate.

In a small prospective trial, researchers randomly assigned patients with elevated LDL cholesterol to the statin rosuvastatin (5 mg daily), placebo, or one of six dietary supplements claiming cholesterol-lowering benefits: fish oil, cinnamon, garlic, turmeric, plant sterols, and red yeast rice. It was no contest—much like the PR battle between Swifties and Ticketmaster. The statin performed as advertised, showing a 35% relative reduction in LDL-C, whereas the supplements fared no better than snake oil (or placebo, in this case). Given these findings and the high cost of these supplements, patients may want to spend their money elsewhere.

Based on this small sample of sessions, the big winner at AHA 2022 was statins. Both studies reinforced not only the efficacy of this powerhouse therapy but also the importance of diligent clinical care in the prevention of cardiovascular disease. The findings serve as a reminder to carefully follow up after a first cardiac event and to dispel potentially false advertising claims about “cholesterol-lowering” dietary supplements. “These are timely reminders given that the incidence of heart attacks significantly increases around the holidays, peaking on Christmas Eve,” interjects Debbie Downer once again, always available to ruin the holidays.

Interested in more healthcare news? Here are some other articles we don’t want you to miss:

• WHO recommends new name for monkeypox
• Lecanemab in early Alzheimer’s disease
• Grip strength is inversely associated with DNA methylation age acceleration
• We’ve been studying the same people for 76 years—this is what we’ve found out about Alzheimer's disease
• An exercise-induced metabolic shield in distant organs blocks cancer progression and metastatic dissemination
• Once-weekly semaglutide in adolescents with obesity
• Vigorous physical activity, incident heart disease, and cancer: how little is enough?

Morning Report is written by:

• Alissa Scott, Author
• Aylin Madore, MD, MEd, Editor
• Eleni Scott, MD, Editor

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Please note that the summaries in Morning Report are intended to provide clinicians with a brief overview of an article, and while we do our best to select the most salient points, we ask that you please read the full article linked in each summary for clarification before making any practice-changing decisions.

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