Journal of Clinical Outcomes Management

Most people with Omicron likely don’t know it.

That’s according to a study in JAMA Network Open, which says 56% of people who have the Omicron variant of the coronavirus are unaware of their infection.

And it has an upside and a downside, depending on how you look at it, according to Time magazine.

“It’s good news, in some ways, since it underscores the fact that Omicron tends to cause relatively mild symptoms (or no symptoms at all) in vaccinated people,” Time says. “The downside is that many people are likely spreading the virus unintentionally.”

The study looked at 210 hospital patients and employees in the Los Angeles area. More than half who tested positive didn’t know it – because they had no symptoms, or they assumed they merely had a cold or allergies.

“The findings support early data from around the world suggesting that throughout the pandemic, anywhere from 25% to 40% of SARS-CoV-2 infections have been asymptomatic, which presents challenges for public health officials trying to control the spread of the virus,” Time reports.

The study found that awareness of infection rose after at-home tests became available this year. About three-quarters of people in January and February didn’t know their status, for example.

“Findings of this study suggest that low rates of Omicron variant infection awareness may be a key contributor to rapid transmission of the virus within communities,” the authors wrote. “Given that unawareness of active infection precludes self-initiated interventions, such as testing and self-isolation, even modest levels of undiagnosed infection can contribute to substantial population-level transmission.”

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

Most people with Omicron likely don’t know it.

That’s according to a study in JAMA Network Open, which says 56% of people who have the Omicron variant of the coronavirus are unaware of their infection.

And it has an upside and a downside, depending on how you look at it, according to Time magazine.

“It’s good news, in some ways, since it underscores the fact that Omicron tends to cause relatively mild symptoms (or no symptoms at all) in vaccinated people,” Time says. “The downside is that many people are likely spreading the virus unintentionally.”

The study looked at 210 hospital patients and employees in the Los Angeles area. More than half who tested positive didn’t know it – because they had no symptoms, or they assumed they merely had a cold or allergies.

“The findings support early data from around the world suggesting that throughout the pandemic, anywhere from 25% to 40% of SARS-CoV-2 infections have been asymptomatic, which presents challenges for public health officials trying to control the spread of the virus,” Time reports.

The study found that awareness of infection rose after at-home tests became available this year. About three-quarters of people in January and February didn’t know their status, for example.

“Findings of this study suggest that low rates of Omicron variant infection awareness may be a key contributor to rapid transmission of the virus within communities,” the authors wrote. “Given that unawareness of active infection precludes self-initiated interventions, such as testing and self-isolation, even modest levels of undiagnosed infection can contribute to substantial population-level transmission.”

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

Most people with Omicron likely don’t know it.

That’s according to a study in JAMA Network Open, which says 56% of people who have the Omicron variant of the coronavirus are unaware of their infection.

And it has an upside and a downside, depending on how you look at it, according to Time magazine.

“It’s good news, in some ways, since it underscores the fact that Omicron tends to cause relatively mild symptoms (or no symptoms at all) in vaccinated people,” Time says. “The downside is that many people are likely spreading the virus unintentionally.”

The study looked at 210 hospital patients and employees in the Los Angeles area. More than half who tested positive didn’t know it – because they had no symptoms, or they assumed they merely had a cold or allergies.

“The findings support early data from around the world suggesting that throughout the pandemic, anywhere from 25% to 40% of SARS-CoV-2 infections have been asymptomatic, which presents challenges for public health officials trying to control the spread of the virus,” Time reports.

The study found that awareness of infection rose after at-home tests became available this year. About three-quarters of people in January and February didn’t know their status, for example.

“Findings of this study suggest that low rates of Omicron variant infection awareness may be a key contributor to rapid transmission of the virus within communities,” the authors wrote. “Given that unawareness of active infection precludes self-initiated interventions, such as testing and self-isolation, even modest levels of undiagnosed infection can contribute to substantial population-level transmission.”

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

Symptoms of six common cardiovascular diseases (CVD) – acute coronary syndromes, heart failure, valvular disorders, stroke, rhythm disorders, and peripheral vascular disease – often overlap and may vary over time and by sex, the American Heart Association noted in a new scientific statement.

“Symptoms of these cardiovascular diseases can profoundly affect quality of life, and a clear understanding of them is critical for effective diagnosis and treatment decisions,” Corrine Y. Jurgens, PhD, chair of the writing committee, said in a news release.

Copyright pixelheadphoto/Thinkstock

This scientific statement is a “compendium detailing the symptoms associated with CVD, similarities or differences in symptoms among the conditions, and sex differences in symptom presentation and reporting,” said Dr. Jurgens, associate professor at Connell School of Nursing, Boston College.

The new statement was published online in Circulation.

The writing group noted that measuring CVD symptoms can be challenging because of their subjective nature. Symptoms may go unrecognized or unreported if people don’t think they are important or are related to an existing health condition.

“Some people may not consider symptoms like fatigue, sleep disturbance, weight gain, and depression as important or related to cardiovascular disease. However, research indicates that subtle symptoms such as these may predict acute events and the need for hospitalization,” Dr. Jurgens said.
 

ACS – chest pain and associated symptoms

The writing group noted that chest pain is the most frequently reported symptom of ACS and has often been described as substernal pressure or discomfort and may radiate to the jaw, shoulder, arm, or upper back.

The most common co-occurring symptoms are dyspnea, diaphoresis, unusual fatigue, nausea, and lightheadedness. Women are more likely than men to report additional symptoms outside of chest pain.

As a result, they have often been labeled “atypical.” However, a recent AHA advisory notes that this label may have been caused by the lack of women included in the clinical trials from which the symptom lists were derived.

The writing group said there is a need to “harmonize” ACS symptom measurement in research. The current lack of harmonization of ACS symptom measurement in research hampers growth in cumulative evidence.

“Therefore, little can be done to synthesize salient findings about symptoms across ischemic heart disease/ACS studies and to incorporate evidence-based information about symptoms into treatment guidelines and patient education materials,” they cautioned. 
 

Heart failure

Turning to heart failure (HF), the writing group noted that dyspnea is the classic symptom and a common reason adults seek medical care.

However, early, more subtle symptoms should be recognized. These include gastrointestinal symptoms such as upset stomach, nausea, vomiting, and loss of appetite; fatigue; exercise intolerance; insomnia; pain (chest and otherwise); mood disturbances (primarily depression and anxiety); and cognitive dysfunction (brain fog, memory problems).

Women with HF report a wider variety of symptoms, are more likely to have depression and anxiety, and report a lower quality of life, compared with men with HF.

“It is important to account for dyspnea heterogeneity in both clinical practice and research by using nuanced measures and probing questions to capture this common and multifaceted symptom,” the writing group said.

“Monitoring symptoms on a spectrum, versus present or not present, with reliable and valid measures may enhance clinical care by identifying more quickly those who may be at risk for poor outcomes, such as lower quality of life, hospitalization, or death,” Dr. Jurgens added.

“Ultimately, we have work to do in terms of determining who needs more frequent monitoring or intervention to avert poor HF outcomes,” she said.
 

Valvular heart disease

Valvular heart disease is a frequent cause of HF, with symptoms generally indistinguishable from other HF causes. Rheumatic heart disease is still prevalent in low- and middle-income countries but has largely disappeared in high-income countries, with population aging and cardiomyopathies now key drivers of valve disease.

In the absence of acute severe valve dysfunction, patients generally have a prolonged asymptomatic period, followed by a period of progressive symptoms, resulting from the valve lesion itself or secondary myocardial remodeling and dysfunction, the writing group said. 

Symptoms of aortic valve disease often differ between men and women. Aortic stenosis is typically silent for years. As stenosis progresses, women report dyspnea and exercise intolerance more often than men. Women are also more likely to be physically frail and to have a higher New York Heart Association class (III/IV) than men. Men are more likely to have chest pain.

“Given the importance of symptom assessment, more work is needed to determine the incremental value of quantitative symptom measurement as an aid to clinical management,” the writing group said.
 

Stroke

For clinicians, classic stroke symptoms (face drooping, arm weakness, speech difficulty), in addition to nonclassic symptoms, such as partial sensory deficit, dysarthria, vertigo, and diplopia, should be considered for activating a stroke response team, the group says.

A systematic review and meta-analysis revealed that women with stroke were more likely to present with nonfocal symptoms (for example, headache, altered mentality, and coma/stupor) than men, they noted.

To enhance public education about stroke symptoms and to facilitate the diagnosis and treatment of stroke, they say research is needed to better understand the presentation of stroke symptoms by other select demographic characteristics including race and ethnicity, age, and stroke subtype.

Poststroke screening should include assessment for anxiety, depression, fatigue, and pain, the writing group said.
 

Rhythm disorders

Turning to rhythm disorders, the writing group wrote that cardiac arrhythmias, including atrial fibrillation (AFib), atrial flutter, supraventricular tachycardia, bradyarrhythmia, and ventricular tachycardia, present with common symptoms.

Palpitations are a characteristic symptom of many cardiac arrhythmias. The most common cardiac arrhythmia, AFib, may present with palpitations or less specific symptoms (fatigue, dyspnea, dizziness) that occur with a broad range of rhythm disorders. Chest pain, dizziness, presyncope/syncope, and anxiety occur less frequently in AFib, the group said.

Palpitations are considered the typical symptom presentation for AFib, yet patients with new-onset AFib often present with nonspecific symptoms or no symptoms, they pointed out.

Women and younger individuals with AFib typically present with palpitations, whereas men are more commonly asymptomatic. Older age also increases the likelihood of a nonclassic or asymptomatic presentation of AFib.

Despite non-Hispanic Black individuals being at lower risk for development of AFib, research suggests that Black patients are burdened more with palpitations, dyspnea on exertion, exercise intolerance, dizziness, dyspnea at rest, and chest discomfort, compared with White or Hispanic patients.

Peripheral vascular disease

Classic claudication occurs in roughly one-third of patients with peripheral arterial disease (PAD) and is defined as calf pain that occurs in one or both legs with exertion (walking), does not begin at rest, and resolves within 10 minutes of standing still or rest.

However, non–calf exercise pain is reported more frequently than classic claudication symptoms. Women with PAD are more likely to have nonclassic symptoms or an absence of symptoms.

Assessing symptoms at rest, during exercise, and during recovery can assist with classifying symptoms as ischemic or not, the writing group said.

PAD with symptoms is associated with an increased risk for myocardial infarction and stroke, with men at higher risk than women.

Similar to PAD, peripheral venous disease (PVD) can be symptomatic or asymptomatic. Clinical classification of PVD includes symptoms such as leg pain, aching, fatigue, heaviness, cramping, tightness, restless legs syndrome, and skin irritation.

“Measuring vascular symptoms includes assessing quality of life and activity limitations, as well as the psychological impact of the disease. However, existing measures are often based on the clinician’s appraisal rather than the individual’s self-reported symptoms and severity of symptoms,” Dr. Jurgens commented.
 

Watch for depression

Finally, the writing group highlighted the importance of depression in cardiac patients, which occurs at about twice the rate, compared with people without any medical condition (10% vs. 5%).

In a prior statement, the AHA said depression should be considered a risk factor for worse outcomes in patients with ACS or CVD diagnosis.

The new statement highlights that people with persistent chest pain, people with HF, as well as stroke survivors and people with PAD commonly have depression and/or anxiety. In addition, cognitive changes after a stroke may affect how and whether symptoms are experienced or noticed.

While symptom relief is an important part of managing CVD, it’s also important to recognize that “factors such as depression and cognitive function may affect symptom detection and reporting,” Dr. Jurgens said.

“Monitoring and measuring symptoms with tools that appropriately account for depression and cognitive function may help to improve patient care by identifying more quickly people who may be at higher risk,” she added.

The scientific statement was prepared by the volunteer writing group on behalf of the AHA Council on Cardiovascular and Stroke Nursing; the Council on Hypertension; and the Stroke Council. The research had no commercial funding. The authors reported no relevant financial relationships.

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

Symptoms of six common cardiovascular diseases (CVD) – acute coronary syndromes, heart failure, valvular disorders, stroke, rhythm disorders, and peripheral vascular disease – often overlap and may vary over time and by sex, the American Heart Association noted in a new scientific statement.

“Symptoms of these cardiovascular diseases can profoundly affect quality of life, and a clear understanding of them is critical for effective diagnosis and treatment decisions,” Corrine Y. Jurgens, PhD, chair of the writing committee, said in a news release.

Copyright pixelheadphoto/Thinkstock

This scientific statement is a “compendium detailing the symptoms associated with CVD, similarities or differences in symptoms among the conditions, and sex differences in symptom presentation and reporting,” said Dr. Jurgens, associate professor at Connell School of Nursing, Boston College.

The new statement was published online in Circulation.

The writing group noted that measuring CVD symptoms can be challenging because of their subjective nature. Symptoms may go unrecognized or unreported if people don’t think they are important or are related to an existing health condition.

“Some people may not consider symptoms like fatigue, sleep disturbance, weight gain, and depression as important or related to cardiovascular disease. However, research indicates that subtle symptoms such as these may predict acute events and the need for hospitalization,” Dr. Jurgens said.
 

ACS – chest pain and associated symptoms

The writing group noted that chest pain is the most frequently reported symptom of ACS and has often been described as substernal pressure or discomfort and may radiate to the jaw, shoulder, arm, or upper back.

The most common co-occurring symptoms are dyspnea, diaphoresis, unusual fatigue, nausea, and lightheadedness. Women are more likely than men to report additional symptoms outside of chest pain.

As a result, they have often been labeled “atypical.” However, a recent AHA advisory notes that this label may have been caused by the lack of women included in the clinical trials from which the symptom lists were derived.

The writing group said there is a need to “harmonize” ACS symptom measurement in research. The current lack of harmonization of ACS symptom measurement in research hampers growth in cumulative evidence.

“Therefore, little can be done to synthesize salient findings about symptoms across ischemic heart disease/ACS studies and to incorporate evidence-based information about symptoms into treatment guidelines and patient education materials,” they cautioned. 
 

Heart failure

Turning to heart failure (HF), the writing group noted that dyspnea is the classic symptom and a common reason adults seek medical care.

However, early, more subtle symptoms should be recognized. These include gastrointestinal symptoms such as upset stomach, nausea, vomiting, and loss of appetite; fatigue; exercise intolerance; insomnia; pain (chest and otherwise); mood disturbances (primarily depression and anxiety); and cognitive dysfunction (brain fog, memory problems).

Women with HF report a wider variety of symptoms, are more likely to have depression and anxiety, and report a lower quality of life, compared with men with HF.

“It is important to account for dyspnea heterogeneity in both clinical practice and research by using nuanced measures and probing questions to capture this common and multifaceted symptom,” the writing group said.

“Monitoring symptoms on a spectrum, versus present or not present, with reliable and valid measures may enhance clinical care by identifying more quickly those who may be at risk for poor outcomes, such as lower quality of life, hospitalization, or death,” Dr. Jurgens added.

“Ultimately, we have work to do in terms of determining who needs more frequent monitoring or intervention to avert poor HF outcomes,” she said.
 

Valvular heart disease

Valvular heart disease is a frequent cause of HF, with symptoms generally indistinguishable from other HF causes. Rheumatic heart disease is still prevalent in low- and middle-income countries but has largely disappeared in high-income countries, with population aging and cardiomyopathies now key drivers of valve disease.

In the absence of acute severe valve dysfunction, patients generally have a prolonged asymptomatic period, followed by a period of progressive symptoms, resulting from the valve lesion itself or secondary myocardial remodeling and dysfunction, the writing group said. 

Symptoms of aortic valve disease often differ between men and women. Aortic stenosis is typically silent for years. As stenosis progresses, women report dyspnea and exercise intolerance more often than men. Women are also more likely to be physically frail and to have a higher New York Heart Association class (III/IV) than men. Men are more likely to have chest pain.

“Given the importance of symptom assessment, more work is needed to determine the incremental value of quantitative symptom measurement as an aid to clinical management,” the writing group said.
 

Stroke

For clinicians, classic stroke symptoms (face drooping, arm weakness, speech difficulty), in addition to nonclassic symptoms, such as partial sensory deficit, dysarthria, vertigo, and diplopia, should be considered for activating a stroke response team, the group says.

A systematic review and meta-analysis revealed that women with stroke were more likely to present with nonfocal symptoms (for example, headache, altered mentality, and coma/stupor) than men, they noted.

To enhance public education about stroke symptoms and to facilitate the diagnosis and treatment of stroke, they say research is needed to better understand the presentation of stroke symptoms by other select demographic characteristics including race and ethnicity, age, and stroke subtype.

Poststroke screening should include assessment for anxiety, depression, fatigue, and pain, the writing group said.
 

Rhythm disorders

Turning to rhythm disorders, the writing group wrote that cardiac arrhythmias, including atrial fibrillation (AFib), atrial flutter, supraventricular tachycardia, bradyarrhythmia, and ventricular tachycardia, present with common symptoms.

Palpitations are a characteristic symptom of many cardiac arrhythmias. The most common cardiac arrhythmia, AFib, may present with palpitations or less specific symptoms (fatigue, dyspnea, dizziness) that occur with a broad range of rhythm disorders. Chest pain, dizziness, presyncope/syncope, and anxiety occur less frequently in AFib, the group said.

Palpitations are considered the typical symptom presentation for AFib, yet patients with new-onset AFib often present with nonspecific symptoms or no symptoms, they pointed out.

Women and younger individuals with AFib typically present with palpitations, whereas men are more commonly asymptomatic. Older age also increases the likelihood of a nonclassic or asymptomatic presentation of AFib.

Despite non-Hispanic Black individuals being at lower risk for development of AFib, research suggests that Black patients are burdened more with palpitations, dyspnea on exertion, exercise intolerance, dizziness, dyspnea at rest, and chest discomfort, compared with White or Hispanic patients.

Peripheral vascular disease

Classic claudication occurs in roughly one-third of patients with peripheral arterial disease (PAD) and is defined as calf pain that occurs in one or both legs with exertion (walking), does not begin at rest, and resolves within 10 minutes of standing still or rest.

However, non–calf exercise pain is reported more frequently than classic claudication symptoms. Women with PAD are more likely to have nonclassic symptoms or an absence of symptoms.

Assessing symptoms at rest, during exercise, and during recovery can assist with classifying symptoms as ischemic or not, the writing group said.

PAD with symptoms is associated with an increased risk for myocardial infarction and stroke, with men at higher risk than women.

Similar to PAD, peripheral venous disease (PVD) can be symptomatic or asymptomatic. Clinical classification of PVD includes symptoms such as leg pain, aching, fatigue, heaviness, cramping, tightness, restless legs syndrome, and skin irritation.

“Measuring vascular symptoms includes assessing quality of life and activity limitations, as well as the psychological impact of the disease. However, existing measures are often based on the clinician’s appraisal rather than the individual’s self-reported symptoms and severity of symptoms,” Dr. Jurgens commented.
 

Watch for depression

Finally, the writing group highlighted the importance of depression in cardiac patients, which occurs at about twice the rate, compared with people without any medical condition (10% vs. 5%).

In a prior statement, the AHA said depression should be considered a risk factor for worse outcomes in patients with ACS or CVD diagnosis.

The new statement highlights that people with persistent chest pain, people with HF, as well as stroke survivors and people with PAD commonly have depression and/or anxiety. In addition, cognitive changes after a stroke may affect how and whether symptoms are experienced or noticed.

While symptom relief is an important part of managing CVD, it’s also important to recognize that “factors such as depression and cognitive function may affect symptom detection and reporting,” Dr. Jurgens said.

“Monitoring and measuring symptoms with tools that appropriately account for depression and cognitive function may help to improve patient care by identifying more quickly people who may be at higher risk,” she added.

The scientific statement was prepared by the volunteer writing group on behalf of the AHA Council on Cardiovascular and Stroke Nursing; the Council on Hypertension; and the Stroke Council. The research had no commercial funding. The authors reported no relevant financial relationships.

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

Symptoms of six common cardiovascular diseases (CVD) – acute coronary syndromes, heart failure, valvular disorders, stroke, rhythm disorders, and peripheral vascular disease – often overlap and may vary over time and by sex, the American Heart Association noted in a new scientific statement.

“Symptoms of these cardiovascular diseases can profoundly affect quality of life, and a clear understanding of them is critical for effective diagnosis and treatment decisions,” Corrine Y. Jurgens, PhD, chair of the writing committee, said in a news release.

Copyright pixelheadphoto/Thinkstock

This scientific statement is a “compendium detailing the symptoms associated with CVD, similarities or differences in symptoms among the conditions, and sex differences in symptom presentation and reporting,” said Dr. Jurgens, associate professor at Connell School of Nursing, Boston College.

The new statement was published online in Circulation.

The writing group noted that measuring CVD symptoms can be challenging because of their subjective nature. Symptoms may go unrecognized or unreported if people don’t think they are important or are related to an existing health condition.

“Some people may not consider symptoms like fatigue, sleep disturbance, weight gain, and depression as important or related to cardiovascular disease. However, research indicates that subtle symptoms such as these may predict acute events and the need for hospitalization,” Dr. Jurgens said.
 

ACS – chest pain and associated symptoms

The writing group noted that chest pain is the most frequently reported symptom of ACS and has often been described as substernal pressure or discomfort and may radiate to the jaw, shoulder, arm, or upper back.

The most common co-occurring symptoms are dyspnea, diaphoresis, unusual fatigue, nausea, and lightheadedness. Women are more likely than men to report additional symptoms outside of chest pain.

As a result, they have often been labeled “atypical.” However, a recent AHA advisory notes that this label may have been caused by the lack of women included in the clinical trials from which the symptom lists were derived.

The writing group said there is a need to “harmonize” ACS symptom measurement in research. The current lack of harmonization of ACS symptom measurement in research hampers growth in cumulative evidence.

“Therefore, little can be done to synthesize salient findings about symptoms across ischemic heart disease/ACS studies and to incorporate evidence-based information about symptoms into treatment guidelines and patient education materials,” they cautioned. 
 

Heart failure

Turning to heart failure (HF), the writing group noted that dyspnea is the classic symptom and a common reason adults seek medical care.

However, early, more subtle symptoms should be recognized. These include gastrointestinal symptoms such as upset stomach, nausea, vomiting, and loss of appetite; fatigue; exercise intolerance; insomnia; pain (chest and otherwise); mood disturbances (primarily depression and anxiety); and cognitive dysfunction (brain fog, memory problems).

Women with HF report a wider variety of symptoms, are more likely to have depression and anxiety, and report a lower quality of life, compared with men with HF.

“It is important to account for dyspnea heterogeneity in both clinical practice and research by using nuanced measures and probing questions to capture this common and multifaceted symptom,” the writing group said.

“Monitoring symptoms on a spectrum, versus present or not present, with reliable and valid measures may enhance clinical care by identifying more quickly those who may be at risk for poor outcomes, such as lower quality of life, hospitalization, or death,” Dr. Jurgens added.

“Ultimately, we have work to do in terms of determining who needs more frequent monitoring or intervention to avert poor HF outcomes,” she said.
 

Valvular heart disease

Valvular heart disease is a frequent cause of HF, with symptoms generally indistinguishable from other HF causes. Rheumatic heart disease is still prevalent in low- and middle-income countries but has largely disappeared in high-income countries, with population aging and cardiomyopathies now key drivers of valve disease.

In the absence of acute severe valve dysfunction, patients generally have a prolonged asymptomatic period, followed by a period of progressive symptoms, resulting from the valve lesion itself or secondary myocardial remodeling and dysfunction, the writing group said. 

Symptoms of aortic valve disease often differ between men and women. Aortic stenosis is typically silent for years. As stenosis progresses, women report dyspnea and exercise intolerance more often than men. Women are also more likely to be physically frail and to have a higher New York Heart Association class (III/IV) than men. Men are more likely to have chest pain.

“Given the importance of symptom assessment, more work is needed to determine the incremental value of quantitative symptom measurement as an aid to clinical management,” the writing group said.
 

Stroke

For clinicians, classic stroke symptoms (face drooping, arm weakness, speech difficulty), in addition to nonclassic symptoms, such as partial sensory deficit, dysarthria, vertigo, and diplopia, should be considered for activating a stroke response team, the group says.

A systematic review and meta-analysis revealed that women with stroke were more likely to present with nonfocal symptoms (for example, headache, altered mentality, and coma/stupor) than men, they noted.

To enhance public education about stroke symptoms and to facilitate the diagnosis and treatment of stroke, they say research is needed to better understand the presentation of stroke symptoms by other select demographic characteristics including race and ethnicity, age, and stroke subtype.

Poststroke screening should include assessment for anxiety, depression, fatigue, and pain, the writing group said.
 

Rhythm disorders

Turning to rhythm disorders, the writing group wrote that cardiac arrhythmias, including atrial fibrillation (AFib), atrial flutter, supraventricular tachycardia, bradyarrhythmia, and ventricular tachycardia, present with common symptoms.

Palpitations are a characteristic symptom of many cardiac arrhythmias. The most common cardiac arrhythmia, AFib, may present with palpitations or less specific symptoms (fatigue, dyspnea, dizziness) that occur with a broad range of rhythm disorders. Chest pain, dizziness, presyncope/syncope, and anxiety occur less frequently in AFib, the group said.

Palpitations are considered the typical symptom presentation for AFib, yet patients with new-onset AFib often present with nonspecific symptoms or no symptoms, they pointed out.

Women and younger individuals with AFib typically present with palpitations, whereas men are more commonly asymptomatic. Older age also increases the likelihood of a nonclassic or asymptomatic presentation of AFib.

Despite non-Hispanic Black individuals being at lower risk for development of AFib, research suggests that Black patients are burdened more with palpitations, dyspnea on exertion, exercise intolerance, dizziness, dyspnea at rest, and chest discomfort, compared with White or Hispanic patients.

Peripheral vascular disease

Classic claudication occurs in roughly one-third of patients with peripheral arterial disease (PAD) and is defined as calf pain that occurs in one or both legs with exertion (walking), does not begin at rest, and resolves within 10 minutes of standing still or rest.

However, non–calf exercise pain is reported more frequently than classic claudication symptoms. Women with PAD are more likely to have nonclassic symptoms or an absence of symptoms.

Assessing symptoms at rest, during exercise, and during recovery can assist with classifying symptoms as ischemic or not, the writing group said.

PAD with symptoms is associated with an increased risk for myocardial infarction and stroke, with men at higher risk than women.

Similar to PAD, peripheral venous disease (PVD) can be symptomatic or asymptomatic. Clinical classification of PVD includes symptoms such as leg pain, aching, fatigue, heaviness, cramping, tightness, restless legs syndrome, and skin irritation.

“Measuring vascular symptoms includes assessing quality of life and activity limitations, as well as the psychological impact of the disease. However, existing measures are often based on the clinician’s appraisal rather than the individual’s self-reported symptoms and severity of symptoms,” Dr. Jurgens commented.
 

Watch for depression

Finally, the writing group highlighted the importance of depression in cardiac patients, which occurs at about twice the rate, compared with people without any medical condition (10% vs. 5%).

In a prior statement, the AHA said depression should be considered a risk factor for worse outcomes in patients with ACS or CVD diagnosis.

The new statement highlights that people with persistent chest pain, people with HF, as well as stroke survivors and people with PAD commonly have depression and/or anxiety. In addition, cognitive changes after a stroke may affect how and whether symptoms are experienced or noticed.

While symptom relief is an important part of managing CVD, it’s also important to recognize that “factors such as depression and cognitive function may affect symptom detection and reporting,” Dr. Jurgens said.

“Monitoring and measuring symptoms with tools that appropriately account for depression and cognitive function may help to improve patient care by identifying more quickly people who may be at higher risk,” she added.

The scientific statement was prepared by the volunteer writing group on behalf of the AHA Council on Cardiovascular and Stroke Nursing; the Council on Hypertension; and the Stroke Council. The research had no commercial funding. The authors reported no relevant financial relationships.

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

Hypertension is a global problem that affects poorer countries as much as it affects more affluent ones, a new study suggests.

A cross-sectional study of some 1.2 million adults in low- and middle-income countries (LMICs) found that overall, rates of hypertension were similar across all levels of education and wealth.

The one outlier was Southeast Asia. There, higher levels of education and household wealth were associated with a greater prevalence of hypertension, but the absolute difference was small.

However, the authors of the study caution that hypertension may increasingly affect adults in the lowest socioeconomic groups as LMICs develop economically.

The study is published online  in the Journal of the American College of Cardiology.
 

Assumptions about hypertension are wrong

“We found that the differences in hypertension prevalence between education and household wealth groups were small in most low- and middle-income countries, so the frequent assumption that hypertension mostly affects the wealthiest and most educated groups in low-and middle-income countries appears to be largely untenable,” senior author Pascal Geldsetzer, MD, MPH, PhD, assistant professor of medicine at Stanford (Calif.) University, told this news organization.

High blood pressure is sometimes assumed to be a result of “Westernized” lifestyles characterized by a high intake of calorie-dense foods and salt and low physical activity. As a result, the condition is frequently thought of as mainly afflicting wealthier segments of society in LMICs, which may in part be responsible for the low degree of funding and attention that hypertension in LMICs has received thus far, Dr. Geldsetzer said.

Traditionally, other global health issues, particularly HIV, tuberculosis, and malaria, have received the lion’s share of government funding. Hypertension, thought to be a condition affecting more affluent countries because it is associated with obesity and a sedentary lifestyle, was ignored, he said.

Knowing the socioeconomic gradients associated with hypertension in LMICs and how these may change in the future is important for policy makers, Dr. Geldsetzer added.

Led by Tabea K. Kirschbaum, MD, Heidelberg Institute of Global Health, University of Heidelberg, Germany, the researchers examined hypertension prevalence by education and household wealth from 76 LMICs in 1,211,386 participants and assessed whether the effect was modified by the country’s gross domestic product (GDP).

Their analysis included 76 surveys, of which 58 were World Health Organization Stepwise Approach to Surveillance surveys. The median age of the participants was 40 years, and 58.5% were women.

Overall, hypertension prevalence tended to be similar across all educational and household wealth levels and across countries with lower and higher GDPs, although there were some “negligible” country and regional variations.

Treatment rates with blood pressure–lowering drugs for participants who had hypertension were higher in countries with higher GDPs.

Women were more likely to be taking medication than were men.

In some countries, the proportion of individuals taking blood pressure–lowering medication was higher in wealthier households.

In Southeast Asia, however, there was a strong association found between the prevalence of hypertension and higher household wealth levels. Compared with the least wealthy, the risk ratio for the wealthiest was 1.28 (95% confidence interval, 1.22-1.34). A similar association was found for education levels as well.

Education was negatively associated with hypertension in the Eastern Mediterranean. Rates were higher among men than among women.

In an accompanying editorial, Yashashwi Pokharel, MBBS, MSCR, from Wake Forest School of Medicine, Winston-Salem, N.C., and colleagues write:

“Now that we know that hypertension prevalence is not different in the poorest, the least educated, or the least economically developed countries, compared with their wealthier and educated counterparts, we should develop, test, and implement effective strategies to enhance global equity in hypertension care.”

Dr. Pokharel told this news organization that, despite the study’s limitations including heterogeneous data, measurement techniques, and blood pressure monitor use across countries, the signal is loud and clear.

“We urgently need to focus on turning off the faucet by addressing the major determinants of increasing hypertension burden, including the sociocultural and political determinants,” he said. “In this regard, setting funding priorities by donors for hypertension, capacity building, and testing and scaling effective population level hypertension prevention and treatment strategies, developed together with local stakeholders, can have a long-lasting effect. If we perpetuate the neglect, we will ineffectively spend more time mopping up the floor.”

Dr. Geldsetzer is a Chan Zuckerberg Biohub investigator. Dr. Pokharel reports no relevant financial relationships.

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

Hypertension is a global problem that affects poorer countries as much as it affects more affluent ones, a new study suggests.

A cross-sectional study of some 1.2 million adults in low- and middle-income countries (LMICs) found that overall, rates of hypertension were similar across all levels of education and wealth.

The one outlier was Southeast Asia. There, higher levels of education and household wealth were associated with a greater prevalence of hypertension, but the absolute difference was small.

However, the authors of the study caution that hypertension may increasingly affect adults in the lowest socioeconomic groups as LMICs develop economically.

The study is published online  in the Journal of the American College of Cardiology.
 

Assumptions about hypertension are wrong

“We found that the differences in hypertension prevalence between education and household wealth groups were small in most low- and middle-income countries, so the frequent assumption that hypertension mostly affects the wealthiest and most educated groups in low-and middle-income countries appears to be largely untenable,” senior author Pascal Geldsetzer, MD, MPH, PhD, assistant professor of medicine at Stanford (Calif.) University, told this news organization.

High blood pressure is sometimes assumed to be a result of “Westernized” lifestyles characterized by a high intake of calorie-dense foods and salt and low physical activity. As a result, the condition is frequently thought of as mainly afflicting wealthier segments of society in LMICs, which may in part be responsible for the low degree of funding and attention that hypertension in LMICs has received thus far, Dr. Geldsetzer said.

Traditionally, other global health issues, particularly HIV, tuberculosis, and malaria, have received the lion’s share of government funding. Hypertension, thought to be a condition affecting more affluent countries because it is associated with obesity and a sedentary lifestyle, was ignored, he said.

Knowing the socioeconomic gradients associated with hypertension in LMICs and how these may change in the future is important for policy makers, Dr. Geldsetzer added.

Led by Tabea K. Kirschbaum, MD, Heidelberg Institute of Global Health, University of Heidelberg, Germany, the researchers examined hypertension prevalence by education and household wealth from 76 LMICs in 1,211,386 participants and assessed whether the effect was modified by the country’s gross domestic product (GDP).

Their analysis included 76 surveys, of which 58 were World Health Organization Stepwise Approach to Surveillance surveys. The median age of the participants was 40 years, and 58.5% were women.

Overall, hypertension prevalence tended to be similar across all educational and household wealth levels and across countries with lower and higher GDPs, although there were some “negligible” country and regional variations.

Treatment rates with blood pressure–lowering drugs for participants who had hypertension were higher in countries with higher GDPs.

Women were more likely to be taking medication than were men.

In some countries, the proportion of individuals taking blood pressure–lowering medication was higher in wealthier households.

In Southeast Asia, however, there was a strong association found between the prevalence of hypertension and higher household wealth levels. Compared with the least wealthy, the risk ratio for the wealthiest was 1.28 (95% confidence interval, 1.22-1.34). A similar association was found for education levels as well.

Education was negatively associated with hypertension in the Eastern Mediterranean. Rates were higher among men than among women.

In an accompanying editorial, Yashashwi Pokharel, MBBS, MSCR, from Wake Forest School of Medicine, Winston-Salem, N.C., and colleagues write:

“Now that we know that hypertension prevalence is not different in the poorest, the least educated, or the least economically developed countries, compared with their wealthier and educated counterparts, we should develop, test, and implement effective strategies to enhance global equity in hypertension care.”

Dr. Pokharel told this news organization that, despite the study’s limitations including heterogeneous data, measurement techniques, and blood pressure monitor use across countries, the signal is loud and clear.

“We urgently need to focus on turning off the faucet by addressing the major determinants of increasing hypertension burden, including the sociocultural and political determinants,” he said. “In this regard, setting funding priorities by donors for hypertension, capacity building, and testing and scaling effective population level hypertension prevention and treatment strategies, developed together with local stakeholders, can have a long-lasting effect. If we perpetuate the neglect, we will ineffectively spend more time mopping up the floor.”

Dr. Geldsetzer is a Chan Zuckerberg Biohub investigator. Dr. Pokharel reports no relevant financial relationships.

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

Hypertension is a global problem that affects poorer countries as much as it affects more affluent ones, a new study suggests.

A cross-sectional study of some 1.2 million adults in low- and middle-income countries (LMICs) found that overall, rates of hypertension were similar across all levels of education and wealth.

The one outlier was Southeast Asia. There, higher levels of education and household wealth were associated with a greater prevalence of hypertension, but the absolute difference was small.

However, the authors of the study caution that hypertension may increasingly affect adults in the lowest socioeconomic groups as LMICs develop economically.

The study is published online  in the Journal of the American College of Cardiology.
 

Assumptions about hypertension are wrong

“We found that the differences in hypertension prevalence between education and household wealth groups were small in most low- and middle-income countries, so the frequent assumption that hypertension mostly affects the wealthiest and most educated groups in low-and middle-income countries appears to be largely untenable,” senior author Pascal Geldsetzer, MD, MPH, PhD, assistant professor of medicine at Stanford (Calif.) University, told this news organization.

High blood pressure is sometimes assumed to be a result of “Westernized” lifestyles characterized by a high intake of calorie-dense foods and salt and low physical activity. As a result, the condition is frequently thought of as mainly afflicting wealthier segments of society in LMICs, which may in part be responsible for the low degree of funding and attention that hypertension in LMICs has received thus far, Dr. Geldsetzer said.

Traditionally, other global health issues, particularly HIV, tuberculosis, and malaria, have received the lion’s share of government funding. Hypertension, thought to be a condition affecting more affluent countries because it is associated with obesity and a sedentary lifestyle, was ignored, he said.

Knowing the socioeconomic gradients associated with hypertension in LMICs and how these may change in the future is important for policy makers, Dr. Geldsetzer added.

Led by Tabea K. Kirschbaum, MD, Heidelberg Institute of Global Health, University of Heidelberg, Germany, the researchers examined hypertension prevalence by education and household wealth from 76 LMICs in 1,211,386 participants and assessed whether the effect was modified by the country’s gross domestic product (GDP).

Their analysis included 76 surveys, of which 58 were World Health Organization Stepwise Approach to Surveillance surveys. The median age of the participants was 40 years, and 58.5% were women.

Overall, hypertension prevalence tended to be similar across all educational and household wealth levels and across countries with lower and higher GDPs, although there were some “negligible” country and regional variations.

Treatment rates with blood pressure–lowering drugs for participants who had hypertension were higher in countries with higher GDPs.

Women were more likely to be taking medication than were men.

In some countries, the proportion of individuals taking blood pressure–lowering medication was higher in wealthier households.

In Southeast Asia, however, there was a strong association found between the prevalence of hypertension and higher household wealth levels. Compared with the least wealthy, the risk ratio for the wealthiest was 1.28 (95% confidence interval, 1.22-1.34). A similar association was found for education levels as well.

Education was negatively associated with hypertension in the Eastern Mediterranean. Rates were higher among men than among women.

In an accompanying editorial, Yashashwi Pokharel, MBBS, MSCR, from Wake Forest School of Medicine, Winston-Salem, N.C., and colleagues write:

“Now that we know that hypertension prevalence is not different in the poorest, the least educated, or the least economically developed countries, compared with their wealthier and educated counterparts, we should develop, test, and implement effective strategies to enhance global equity in hypertension care.”

Dr. Pokharel told this news organization that, despite the study’s limitations including heterogeneous data, measurement techniques, and blood pressure monitor use across countries, the signal is loud and clear.

“We urgently need to focus on turning off the faucet by addressing the major determinants of increasing hypertension burden, including the sociocultural and political determinants,” he said. “In this regard, setting funding priorities by donors for hypertension, capacity building, and testing and scaling effective population level hypertension prevention and treatment strategies, developed together with local stakeholders, can have a long-lasting effect. If we perpetuate the neglect, we will ineffectively spend more time mopping up the floor.”

Dr. Geldsetzer is a Chan Zuckerberg Biohub investigator. Dr. Pokharel reports no relevant financial relationships.

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

A study aimed at determining whether behind some of the sex differences in chronic obstructive airway disease (COPD) prevalence and clinical outcomes lie structural differences in airways found that airway lumen sizes quantified through chest CT were smaller in women than in men.

The findings, published in Radiology, took into account height and lung size. The lower baseline airway lumen sizes in women conferred lower reserves against respiratory morbidity and mortality for equivalent changes, compared with men.

Alfred Pasieka/Science Source

Among key findings in a secondary analysis of consecutive participants (9,363 ever-smokers and 420 never-smokers) enrolled in the Genetic Epidemiology of COPD (COPDGene) study, airway lumen dimensions were lower in never-smoker women than in men (segmental lumen diameter, 8.1 mm vs. 9.1 mm; P < .001). Also, ever-smoker women had narrower segmental lumen diameter (7.8 mm ± 0.05 vs. 8.7 mm ± 0.04; P < .001). The investigators found also that a unit change in wall thickness or lumen area resulted in more severe airflow obstruction, more dyspnea, worse respiratory quality of life, lower 6-minute walk distance, and worse survival in women, compared with men.

While COPD is diagnosed more often in men than women, changes in smoking behavior and increasing urbanization have led to COPD prevalence in women fast approaching the rate in men. Although age-adjusted rates for COPD-related deaths have continued to decline in men, in women they have not. Indeed, never-smoking women accounted for two-thirds of COPD in a population-based study.

COPDGene, a prospective, multicenter, observational cohort study, enrolled current and former smokers, as well as never-smokers, aged 45-80 years at 21 clinical centers across the United States from January 2008 to June 2011 with longitudinal follow-up until November 2020. The investigators quantified airway disease through CT imaging using the following metrics: airway wall thickness of segmental airways, wall area percent of segmental airways, the square root of the wall area of a hypothetical airway with 10-mm internal perimeter, total airway count, lumen diameter of segmental airways, airway volume, and airway fractal dimension.

“Not all sex differences in prevalence of COPD have been explained, and structural differences may explain some of these differences. Our findings may have implications for patient selection for clinical trials,” corresponding author Surya P. Bhatt, MD, associate professor of medicine and director of the University of Alabama Imaging Core at Birmingham, said in an interview.

The investigators wrote: “Our findings have implications for airflow limitation and the consequent clinical outcomes. ... We confirmed that men have more emphysema than women with equivalent smoking burden, and our results suggest that the lower reserve conferred by smaller airways predisposes women to develop airflow limitation predominantly through the airway phenotype. All airway remodeling changes were associated with more dyspnea, worse respiratory quality of life, and lower functional capacity in women than in men. The smaller airways in women can result in higher airway resistance and more turbulent airflow, and thus place a higher ventilatory constraint during exertion. Alteration in each airway measure was also associated with worse survival in women than in men, partially explaining the comparable mortality between the sexes for COPD despite the differing degrees of emphysema.”

“I think these findings highlight underappreciated sex differences in the natural history of COPD,” Mohsen Sadatsafavi, MD, PhD, associate professor, faculty of pharmaceutical sciences, at the University of British Columbia, Vancouver, said in an interview. “To me, first and foremost, the Bhatt et al. findings highlight how the ‘one size fits all’ approach to COPD management of using exacerbation history alone to guide preventive therapies is incorrect. These findings have the potential to change the management paradigm of COPD in the long term, but before getting there, I think we need to relate these findings to clinically relevant and patient-reported outcomes.”

Noting study limitations, the authors stated that a higher proportion of men were active smokers, compared with women, and despite adjustments for smoking status, some of the airway wall differences may be from the impact of active cigarette smoking on airway wall thickness.

Five study authors reported receiving support from various government and industry sources and disclosed conflicts of interest based on relationships with industry. The rest reported no conflicts of interest.

A study aimed at determining whether behind some of the sex differences in chronic obstructive airway disease (COPD) prevalence and clinical outcomes lie structural differences in airways found that airway lumen sizes quantified through chest CT were smaller in women than in men.

The findings, published in Radiology, took into account height and lung size. The lower baseline airway lumen sizes in women conferred lower reserves against respiratory morbidity and mortality for equivalent changes, compared with men.

Alfred Pasieka/Science Source

Among key findings in a secondary analysis of consecutive participants (9,363 ever-smokers and 420 never-smokers) enrolled in the Genetic Epidemiology of COPD (COPDGene) study, airway lumen dimensions were lower in never-smoker women than in men (segmental lumen diameter, 8.1 mm vs. 9.1 mm; P < .001). Also, ever-smoker women had narrower segmental lumen diameter (7.8 mm ± 0.05 vs. 8.7 mm ± 0.04; P < .001). The investigators found also that a unit change in wall thickness or lumen area resulted in more severe airflow obstruction, more dyspnea, worse respiratory quality of life, lower 6-minute walk distance, and worse survival in women, compared with men.

While COPD is diagnosed more often in men than women, changes in smoking behavior and increasing urbanization have led to COPD prevalence in women fast approaching the rate in men. Although age-adjusted rates for COPD-related deaths have continued to decline in men, in women they have not. Indeed, never-smoking women accounted for two-thirds of COPD in a population-based study.

COPDGene, a prospective, multicenter, observational cohort study, enrolled current and former smokers, as well as never-smokers, aged 45-80 years at 21 clinical centers across the United States from January 2008 to June 2011 with longitudinal follow-up until November 2020. The investigators quantified airway disease through CT imaging using the following metrics: airway wall thickness of segmental airways, wall area percent of segmental airways, the square root of the wall area of a hypothetical airway with 10-mm internal perimeter, total airway count, lumen diameter of segmental airways, airway volume, and airway fractal dimension.

“Not all sex differences in prevalence of COPD have been explained, and structural differences may explain some of these differences. Our findings may have implications for patient selection for clinical trials,” corresponding author Surya P. Bhatt, MD, associate professor of medicine and director of the University of Alabama Imaging Core at Birmingham, said in an interview.

The investigators wrote: “Our findings have implications for airflow limitation and the consequent clinical outcomes. ... We confirmed that men have more emphysema than women with equivalent smoking burden, and our results suggest that the lower reserve conferred by smaller airways predisposes women to develop airflow limitation predominantly through the airway phenotype. All airway remodeling changes were associated with more dyspnea, worse respiratory quality of life, and lower functional capacity in women than in men. The smaller airways in women can result in higher airway resistance and more turbulent airflow, and thus place a higher ventilatory constraint during exertion. Alteration in each airway measure was also associated with worse survival in women than in men, partially explaining the comparable mortality between the sexes for COPD despite the differing degrees of emphysema.”

“I think these findings highlight underappreciated sex differences in the natural history of COPD,” Mohsen Sadatsafavi, MD, PhD, associate professor, faculty of pharmaceutical sciences, at the University of British Columbia, Vancouver, said in an interview. “To me, first and foremost, the Bhatt et al. findings highlight how the ‘one size fits all’ approach to COPD management of using exacerbation history alone to guide preventive therapies is incorrect. These findings have the potential to change the management paradigm of COPD in the long term, but before getting there, I think we need to relate these findings to clinically relevant and patient-reported outcomes.”

Noting study limitations, the authors stated that a higher proportion of men were active smokers, compared with women, and despite adjustments for smoking status, some of the airway wall differences may be from the impact of active cigarette smoking on airway wall thickness.

Five study authors reported receiving support from various government and industry sources and disclosed conflicts of interest based on relationships with industry. The rest reported no conflicts of interest.

A study aimed at determining whether behind some of the sex differences in chronic obstructive airway disease (COPD) prevalence and clinical outcomes lie structural differences in airways found that airway lumen sizes quantified through chest CT were smaller in women than in men.

The findings, published in Radiology, took into account height and lung size. The lower baseline airway lumen sizes in women conferred lower reserves against respiratory morbidity and mortality for equivalent changes, compared with men.

Alfred Pasieka/Science Source

Among key findings in a secondary analysis of consecutive participants (9,363 ever-smokers and 420 never-smokers) enrolled in the Genetic Epidemiology of COPD (COPDGene) study, airway lumen dimensions were lower in never-smoker women than in men (segmental lumen diameter, 8.1 mm vs. 9.1 mm; P < .001). Also, ever-smoker women had narrower segmental lumen diameter (7.8 mm ± 0.05 vs. 8.7 mm ± 0.04; P < .001). The investigators found also that a unit change in wall thickness or lumen area resulted in more severe airflow obstruction, more dyspnea, worse respiratory quality of life, lower 6-minute walk distance, and worse survival in women, compared with men.

While COPD is diagnosed more often in men than women, changes in smoking behavior and increasing urbanization have led to COPD prevalence in women fast approaching the rate in men. Although age-adjusted rates for COPD-related deaths have continued to decline in men, in women they have not. Indeed, never-smoking women accounted for two-thirds of COPD in a population-based study.

COPDGene, a prospective, multicenter, observational cohort study, enrolled current and former smokers, as well as never-smokers, aged 45-80 years at 21 clinical centers across the United States from January 2008 to June 2011 with longitudinal follow-up until November 2020. The investigators quantified airway disease through CT imaging using the following metrics: airway wall thickness of segmental airways, wall area percent of segmental airways, the square root of the wall area of a hypothetical airway with 10-mm internal perimeter, total airway count, lumen diameter of segmental airways, airway volume, and airway fractal dimension.

“Not all sex differences in prevalence of COPD have been explained, and structural differences may explain some of these differences. Our findings may have implications for patient selection for clinical trials,” corresponding author Surya P. Bhatt, MD, associate professor of medicine and director of the University of Alabama Imaging Core at Birmingham, said in an interview.

The investigators wrote: “Our findings have implications for airflow limitation and the consequent clinical outcomes. ... We confirmed that men have more emphysema than women with equivalent smoking burden, and our results suggest that the lower reserve conferred by smaller airways predisposes women to develop airflow limitation predominantly through the airway phenotype. All airway remodeling changes were associated with more dyspnea, worse respiratory quality of life, and lower functional capacity in women than in men. The smaller airways in women can result in higher airway resistance and more turbulent airflow, and thus place a higher ventilatory constraint during exertion. Alteration in each airway measure was also associated with worse survival in women than in men, partially explaining the comparable mortality between the sexes for COPD despite the differing degrees of emphysema.”

“I think these findings highlight underappreciated sex differences in the natural history of COPD,” Mohsen Sadatsafavi, MD, PhD, associate professor, faculty of pharmaceutical sciences, at the University of British Columbia, Vancouver, said in an interview. “To me, first and foremost, the Bhatt et al. findings highlight how the ‘one size fits all’ approach to COPD management of using exacerbation history alone to guide preventive therapies is incorrect. These findings have the potential to change the management paradigm of COPD in the long term, but before getting there, I think we need to relate these findings to clinically relevant and patient-reported outcomes.”

Noting study limitations, the authors stated that a higher proportion of men were active smokers, compared with women, and despite adjustments for smoking status, some of the airway wall differences may be from the impact of active cigarette smoking on airway wall thickness.

Five study authors reported receiving support from various government and industry sources and disclosed conflicts of interest based on relationships with industry. The rest reported no conflicts of interest.

“A sad day. A new low point in the spiral of hate, violence, and lies. Behind every account, there is a person. Do not forget that. In loving memory,” a Twitter user wrote about the death of Lisa-Maria Kellermayr, MD.

“This outcome is very saddening indeed. It should cause everyone to reflect. About interactions in our society, about ‘social’ media, about tolerance, about consideration, and about freedom,” tweeted Dirk Heinrich, MD, chair of the Virchow Association.

The suspected suicide of Dr. Kellermayr, an Austrian vaccinator, is stirring emotions in Germany, too. The active exponent and supporter of COVID-19 measures had been seriously threatened by anti-vaxxers and pandemic deniers. Thousands of people in Vienna said goodbye to her with a solemn vigil. Dr. Kellermayr’s death raises the question of how life-threatening online hatred can be.

Dr. Kellermayr, a vaccination campaigner, had received hateful comments and death threats since the start of the pandemic. But a single post on Twitter changed everything. On Nov. 16, 2021, anti-vaxxers held a demonstration outside the Wels-Grieskirchen Hospital. Dr. Kellermayr tweeted in disgust, “Today in Wels: A demonstration by conspiracy theorists spills into the street under the gaze of the authorities and blocks both the main hospital entrance and the Red Cross ambulance exit.”

At the time of her tweet, Dr. Kellermayr was not aware of additional access that had been made available for ambulances. The police reacted to her tweet, calling it a “false report.” As Florian Klenk writes in the Austrian journal Falter, the police basically criticized Dr. Kellermayr publicly, including in front of the 12,000 Twitter users who follow the police on Twitter.

A screenshot of Dr. Kellermayr’s tweet and the authorities’ response went viral on relevant Telegram forums and triggered a flood of hatred. A COVID denier immediately posted her address online.

Dr. Kellermayr deleted her tweet and asked the police to also delete their tweet, but they did not respond, and the tweet remained online. The country physician was inundated with insults, slurs, and death threats. She was beset by alleged patients who came only to disrupt her work, take videos on their cell phones, and share the photos in anti-vaxxer groups. She privately paid for a security guard, who confiscated butterfly knives from multiple “patients” on their way into the waiting room. Dr. Kellermayr looked for help from the medical association, the police, and the Office for the Protection of the Constitution. She made her problem public.
 

Police recommend supervision

Dr. Kellermayr received emails in which the senders described in detail how they would kill her and her practice team. The physician took the threats seriously; the police did not. The officers investigated. With the evidence that the perpetrators were operating via the dark web, the officers insinuated to Dr. Kellermayr that it was not possible to find them, Klenk reported.

Dr. Kellermayr filed a complaint for the first time on Nov. 22, 2021. The law enforcement authorities in Upper Austria said they did not have domestic jurisdiction. The Austrian authorities launched another investigation. The German prosecution authorities joined the search for those posting death threats on social media. Even the Munich chief public prosecutor’s office and the Berlin public prosecutor’s office investigated the case.

According to some reports, Dr. Kellermayr did not receive police protection; a patrol was sent over from time to time. According to the police, she should “not be afraid,” and if she was, she should just call them. She was also advised to undergo supervision -- in other words, psychological treatment.

Those who had the power to help her provided no support. On the contrary, the spokesperson for the Upper Austria Police said in the Ö1 Mittagsjournal radio program that Dr. Kellermayr was “putting herself in the public eye for her own selfish benefit.” Even Peter Niedermoser, president of the Medical Association of Upper Austria, told the Austrian daily newspaper Standard, “I understand that you have to defend yourself, but it is a whole other question as to whether you have to discuss every topic to excess on Twitter. Sometimes it’s better to step away.”
 

Leaving Twitter

A German network specialist who hunts pedophiles online offered Dr. Kellermayr her help and was quickly on the trail of suspects, including a neo-Nazi from the Berlin area and a man from Upper Bavaria. Then the Office for the Protection of the Constitution stepped in. Omar Haijawi-Pirchner, head of the Austrian State Security and Intelligence Directorate, stated that the evidence provided by the network specialist would be pursued.

At the end of June, Dr. Kellermayr closed her practice. The situation was no longer tolerable for her staff, and the costs for security, €100,000 up to that point, were no longer manageable. At the start of July, she announced that she wanted to reopen the practice.

In her suicide note to the Upper Austria State Police Department, she wrote “that there was a lot of talking, but no one did anything.” In her letter to her medical association, she also made it clear that she had felt abandoned.

“Every suicide is a tragedy. This one more so: a woman in need was abandoned by the police and authorities. That is a social failure,” tweeted physicist and author Florian Aigner.

“Threatened. Ruined. Left alone by the state. Because she did her job. Because she got involved. Because she spread information. Because many want to be understanding for the self-styled ‘unconventional thinkers,’ the ‘Querdenker.’ Because many did not want to take the threat seriously. Because we tolerate them,” tweeted the intensive care physician Lämêth.

“Many colleagues using their real names get all of this outside of Twitter too: emails, phone calls, letters, or even visits by radical fanatics. If you are lucky, there is police protection, or a few reports, but often not a lot happens juridically,” tweeted Flow, anesthetist and emergency physician.

“More and more of the people who shaped Twitter by spreading reliable information voluntarily are now backing out. As long as the concept of freedom is abused here for hate and intimidation, individual responsibility can only mean self-defense. Sad,” wrote Christian Lübbers, MD, on Twitter. Since the ENT physician started vaccinating patients against COVID-19, he has been tormented with insults and death threats from anti-vaxxers and COVID deniers, this news organization has reported.

Examples of people who have backed out and deactivated their account are the virologist Isabella Eckerlek, MD, PhD, of the University of Geneva, and Natalie Grams, MD, spokesperson for the Information Network Homeopathy. For a long time, they spread information about COVID-19, corrected false assertions, and were increasingly faced with insults and hostility.

General practitioner Christian Kröner, MD, has repeatedly been the target of threats and insults and has been under police protection from time to time. He made a statement regarding Dr. Kellermayr’s death and has shut down his account for the first time following multiple instances of hostility.
 

Harassment continues

The hatred, harassment, and slander have not stopped, even after Dr. Kellermayr’s death. Harald Laatsch, who sits in the Berlin house of representatives for the Alternative for Germany party, commented that it seems “much more likely that she could no longer live with the heavy guilt of being a vaccine propagandist.”

“It is repulsive how the Querdenker deride a medical colleague who was driven to death by harassment and violence. She lost her life by saving the lives of others. Others are continuing her work. The state must protect people like her,” tweeted Karl Lauterbach, MD, PhD, who has also been overrun with hate campaigns by Querdenker and COVID deniers.

The page “Ich habe mitgemacht” – Das Archiv für Corona-Unrecht [“I Joined In” – The Archive for COVID Injustice] probably did not help to deescalate the situation on Twitter. Anonymous archivists there collect allegedly ostracizing quotes and share them, along with names. The context in which these statements were given at the time is not mentioned. Some politicians and journalists have given this online pillory the name, “We joined in! We have ostracized, defamed...”

Being humiliated and defamed is par for the course for those who spread information across social media. As doctor and politician Rainer Röver, MD, wrote, “Whoever is involved in spreading information, science, fighting against fake news, and protecting the patients, pupils, clients, or mandates entrusted to them is being shouted down, threatened in writing, or driven to suicide.” The lying, baiting mob is taking over sovereignty of the discussion. According to Röver, the politicians are doing nothing “to actually put a stop to the violent mob.”

For some time now, the Federal Criminal Police Office (BKA) of Germany has considered anti-vaxxers or COVID deniers as a “relevant risk” in connection with attacks on vaccination centers or medical practices.
 

Increasing aggression

At the start of November last year, participants at the 125th German Medical Assembly demanded that violence against health care professionals be outlawed, Mark Berger, deputy spokesperson of the German Medical Association (BÄK), recollected. At the assembly, various medical associations shared reports of an increase in aggression during the pandemic.

The State Medical Chamber of Physicians of Saxony confirmed threats of violence against physicians, death threats against employees of the Vaccination Committee of Saxony, and criminal damage to medical practices that administer vaccinations. Physicians who administer vaccines in schools receive abuse.

Owing to the increasing amount of aggression, the State Medical Association of Thuringia has set up a special email address as a first point of contact to report violence for those who are affected. “In recent months, we have received a large number of reports from physicians who have received threatening letters in relation to the COVID vaccination, or letters purporting to be liability information or notices of liability,” explained the association. In the cases of which the association becomes aware, a criminal charge is issued most of the time. The investigative proceedings are ongoing.

The State Medical Association of Hesse has devised a reporting form with which it can obtain information on the forms of violence inflicted against physicians and their teams. The reporting is anonymous, and the data are statistically analyzed.

Peter Bobbert, MD, PhD, president of the Berlin Medical Association, provided reports of threat scenarios, “the kind and frequency of which we have never experienced.” He received many messages from physicians asking for help because they had received threatening letters or because their addresses had been posted on social networks.

To date, there have only been isolated cases, said Oliver Erens, MD, spokesperson of the State Medical Association of Baden-Württemberg. “But it is true that some colleagues have already had these kinds of experiences.” Those affected have primarily reported “discussions, debates, and verbal altercations with patients on the topic of the COVID vaccination, compliance with the mask mandate, and other COVID-containment measures – definitely with a high potential for aggression from some of the patients,” said Dr. Erens. Cases of physical violence have not been reported to date.

Above all, there has been a need for advice over the phone, predominantly in the legal department of the regional medical associations. “All physicians and their teams are being recommended by their associations to consistently prosecute any cases of threat of, or use of, violence against them,” Dr. Erens said. In October 2021, the University of Heidelberg started a study on the victimization of physicians. The analysis is ongoing.
 

Staying on Twitter

Lübbers considered leaving Twitter but decided against it. “I decided not to do it and to carry on spreading information about pseudo-medicine and vaccination. I see this as necessary civic courage and will not give way to hate,” Lübbers tweeted.

As understandable as any departure is, “we must not surrender Twitter to the trolls and harassers. Who is still here? #Iamstaying,” wrote Flow. Others wrote, “I will stay on Twitter as a physician. With my real name, too. [...] We must not surrender it to the Querdenker, idiots, Nazis, and enemies of freedom.”

“We need people to share information, we need voices of reason, just as Kellermayr was. How can you say that it would be better to remain silent? Does everyone who is against idiocy, Querdenker, and conspiracy theorists now have to remain silent?” asked Janos Hegedüs, MD, in his podcast.

Hegedüs, who uncovers fake news about COVID-19 and vaccination, was and remains a frequent target of insults and threats. His attempts to take action against them has had only limited success. His conclusion is sobering. “If you decide to spread information, you should know: You are alone. You will get all of the hate and when you have a problem with it, no one will help you.”

Media attorney Chan-jo Jun, who for many years has taken a stand against hate and harassment, has deactivated his Twitter account. However, this is not a retreat, as he clarified in an interview with the German radio station Deutschlandfunk. “I do not intend to give up the fight against hate, harassment, and misinformation, but I will do it in a different place.”

He sees Dr. Kellermayr’s death as a turning point. “I thought that we had learned something after Lübcke [i.e., politician Walter Lübcke, who was murdered by a neo-Nazi]. But we are seeing that the death of a political opponent is not just the goal, but also a success for the other side. And that is shocking.”

The judicial means of taking action against hate are still not effective, said Mr. Jun. He also sees the platform operators as responsible, since they are not obliged to remove unlawful content. “German law and the German constitution hold no sway on Twitter.”
 

Right-wing extremism

What happened to Lisa-Maria Kellermayr is the same as targeted terrorism. An organized group set out to annihilate her. Social psychologist Pia Lamberty has spoken, in the context of COVID, about a pandemic of violence, the threatening nature of which has barely been recognized, both in the virtual and analog world.

In an article for the Jüdische Allgemeine, Dr. Lamberty criticizes the fact that “the mistakes made with Pegida [i.e., a far-right, Islamophobic political movement in Germany] are being made once again” in the classification of Querdenker and COVID deniers. From the very start, the protests against the COVID measures have been a rallying point in the mobilization of right-wing extremists. “The Querdenker movement is unifying radical, right-wing extremist elements. Antisemitism and racism were always welcome.” Still, the right-wing extremist motivation has not been clearly labeled as such.

The classification is not just a question of statistics. “It is also about analyzing the potential for danger and deriving political measures from this. And there is an urgent need for action here: The right-wing extremists will utilize the climate crisis, but also the war in Ukraine, attacks against refugees, and LGBTQ rights for further mobilization. Rather than the state, the focus of the attacks will be people who are labeled as the bogeyman. This also must be clearly labeled for what it is,” said Dr. Lamberty.
She wrote on Twitter, “The COVID-related attacks that took place in the last two years will not simply stop, they will shift. If we do not want more and more people to stop expressing themselves publicly, something urgently has to happen.” She added, “Once more: The next few months will be very difficult. This will probably also be accompanied by an increased level of threat for socially engaged people. More protection is urgently required.”

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

This article was translated from the Medscape German edition.

“A sad day. A new low point in the spiral of hate, violence, and lies. Behind every account, there is a person. Do not forget that. In loving memory,” a Twitter user wrote about the death of Lisa-Maria Kellermayr, MD.

“This outcome is very saddening indeed. It should cause everyone to reflect. About interactions in our society, about ‘social’ media, about tolerance, about consideration, and about freedom,” tweeted Dirk Heinrich, MD, chair of the Virchow Association.

The suspected suicide of Dr. Kellermayr, an Austrian vaccinator, is stirring emotions in Germany, too. The active exponent and supporter of COVID-19 measures had been seriously threatened by anti-vaxxers and pandemic deniers. Thousands of people in Vienna said goodbye to her with a solemn vigil. Dr. Kellermayr’s death raises the question of how life-threatening online hatred can be.

Dr. Kellermayr, a vaccination campaigner, had received hateful comments and death threats since the start of the pandemic. But a single post on Twitter changed everything. On Nov. 16, 2021, anti-vaxxers held a demonstration outside the Wels-Grieskirchen Hospital. Dr. Kellermayr tweeted in disgust, “Today in Wels: A demonstration by conspiracy theorists spills into the street under the gaze of the authorities and blocks both the main hospital entrance and the Red Cross ambulance exit.”

At the time of her tweet, Dr. Kellermayr was not aware of additional access that had been made available for ambulances. The police reacted to her tweet, calling it a “false report.” As Florian Klenk writes in the Austrian journal Falter, the police basically criticized Dr. Kellermayr publicly, including in front of the 12,000 Twitter users who follow the police on Twitter.

A screenshot of Dr. Kellermayr’s tweet and the authorities’ response went viral on relevant Telegram forums and triggered a flood of hatred. A COVID denier immediately posted her address online.

Dr. Kellermayr deleted her tweet and asked the police to also delete their tweet, but they did not respond, and the tweet remained online. The country physician was inundated with insults, slurs, and death threats. She was beset by alleged patients who came only to disrupt her work, take videos on their cell phones, and share the photos in anti-vaxxer groups. She privately paid for a security guard, who confiscated butterfly knives from multiple “patients” on their way into the waiting room. Dr. Kellermayr looked for help from the medical association, the police, and the Office for the Protection of the Constitution. She made her problem public.
 

Police recommend supervision

Dr. Kellermayr received emails in which the senders described in detail how they would kill her and her practice team. The physician took the threats seriously; the police did not. The officers investigated. With the evidence that the perpetrators were operating via the dark web, the officers insinuated to Dr. Kellermayr that it was not possible to find them, Klenk reported.

Dr. Kellermayr filed a complaint for the first time on Nov. 22, 2021. The law enforcement authorities in Upper Austria said they did not have domestic jurisdiction. The Austrian authorities launched another investigation. The German prosecution authorities joined the search for those posting death threats on social media. Even the Munich chief public prosecutor’s office and the Berlin public prosecutor’s office investigated the case.

According to some reports, Dr. Kellermayr did not receive police protection; a patrol was sent over from time to time. According to the police, she should “not be afraid,” and if she was, she should just call them. She was also advised to undergo supervision -- in other words, psychological treatment.

Those who had the power to help her provided no support. On the contrary, the spokesperson for the Upper Austria Police said in the Ö1 Mittagsjournal radio program that Dr. Kellermayr was “putting herself in the public eye for her own selfish benefit.” Even Peter Niedermoser, president of the Medical Association of Upper Austria, told the Austrian daily newspaper Standard, “I understand that you have to defend yourself, but it is a whole other question as to whether you have to discuss every topic to excess on Twitter. Sometimes it’s better to step away.”
 

Leaving Twitter

A German network specialist who hunts pedophiles online offered Dr. Kellermayr her help and was quickly on the trail of suspects, including a neo-Nazi from the Berlin area and a man from Upper Bavaria. Then the Office for the Protection of the Constitution stepped in. Omar Haijawi-Pirchner, head of the Austrian State Security and Intelligence Directorate, stated that the evidence provided by the network specialist would be pursued.

At the end of June, Dr. Kellermayr closed her practice. The situation was no longer tolerable for her staff, and the costs for security, €100,000 up to that point, were no longer manageable. At the start of July, she announced that she wanted to reopen the practice.

In her suicide note to the Upper Austria State Police Department, she wrote “that there was a lot of talking, but no one did anything.” In her letter to her medical association, she also made it clear that she had felt abandoned.

“Every suicide is a tragedy. This one more so: a woman in need was abandoned by the police and authorities. That is a social failure,” tweeted physicist and author Florian Aigner.

“Threatened. Ruined. Left alone by the state. Because she did her job. Because she got involved. Because she spread information. Because many want to be understanding for the self-styled ‘unconventional thinkers,’ the ‘Querdenker.’ Because many did not want to take the threat seriously. Because we tolerate them,” tweeted the intensive care physician Lämêth.

“Many colleagues using their real names get all of this outside of Twitter too: emails, phone calls, letters, or even visits by radical fanatics. If you are lucky, there is police protection, or a few reports, but often not a lot happens juridically,” tweeted Flow, anesthetist and emergency physician.

“More and more of the people who shaped Twitter by spreading reliable information voluntarily are now backing out. As long as the concept of freedom is abused here for hate and intimidation, individual responsibility can only mean self-defense. Sad,” wrote Christian Lübbers, MD, on Twitter. Since the ENT physician started vaccinating patients against COVID-19, he has been tormented with insults and death threats from anti-vaxxers and COVID deniers, this news organization has reported.

Examples of people who have backed out and deactivated their account are the virologist Isabella Eckerlek, MD, PhD, of the University of Geneva, and Natalie Grams, MD, spokesperson for the Information Network Homeopathy. For a long time, they spread information about COVID-19, corrected false assertions, and were increasingly faced with insults and hostility.

General practitioner Christian Kröner, MD, has repeatedly been the target of threats and insults and has been under police protection from time to time. He made a statement regarding Dr. Kellermayr’s death and has shut down his account for the first time following multiple instances of hostility.
 

Harassment continues

The hatred, harassment, and slander have not stopped, even after Dr. Kellermayr’s death. Harald Laatsch, who sits in the Berlin house of representatives for the Alternative for Germany party, commented that it seems “much more likely that she could no longer live with the heavy guilt of being a vaccine propagandist.”

“It is repulsive how the Querdenker deride a medical colleague who was driven to death by harassment and violence. She lost her life by saving the lives of others. Others are continuing her work. The state must protect people like her,” tweeted Karl Lauterbach, MD, PhD, who has also been overrun with hate campaigns by Querdenker and COVID deniers.

The page “Ich habe mitgemacht” – Das Archiv für Corona-Unrecht [“I Joined In” – The Archive for COVID Injustice] probably did not help to deescalate the situation on Twitter. Anonymous archivists there collect allegedly ostracizing quotes and share them, along with names. The context in which these statements were given at the time is not mentioned. Some politicians and journalists have given this online pillory the name, “We joined in! We have ostracized, defamed...”

Being humiliated and defamed is par for the course for those who spread information across social media. As doctor and politician Rainer Röver, MD, wrote, “Whoever is involved in spreading information, science, fighting against fake news, and protecting the patients, pupils, clients, or mandates entrusted to them is being shouted down, threatened in writing, or driven to suicide.” The lying, baiting mob is taking over sovereignty of the discussion. According to Röver, the politicians are doing nothing “to actually put a stop to the violent mob.”

For some time now, the Federal Criminal Police Office (BKA) of Germany has considered anti-vaxxers or COVID deniers as a “relevant risk” in connection with attacks on vaccination centers or medical practices.
 

Increasing aggression

At the start of November last year, participants at the 125th German Medical Assembly demanded that violence against health care professionals be outlawed, Mark Berger, deputy spokesperson of the German Medical Association (BÄK), recollected. At the assembly, various medical associations shared reports of an increase in aggression during the pandemic.

The State Medical Chamber of Physicians of Saxony confirmed threats of violence against physicians, death threats against employees of the Vaccination Committee of Saxony, and criminal damage to medical practices that administer vaccinations. Physicians who administer vaccines in schools receive abuse.

Owing to the increasing amount of aggression, the State Medical Association of Thuringia has set up a special email address as a first point of contact to report violence for those who are affected. “In recent months, we have received a large number of reports from physicians who have received threatening letters in relation to the COVID vaccination, or letters purporting to be liability information or notices of liability,” explained the association. In the cases of which the association becomes aware, a criminal charge is issued most of the time. The investigative proceedings are ongoing.

The State Medical Association of Hesse has devised a reporting form with which it can obtain information on the forms of violence inflicted against physicians and their teams. The reporting is anonymous, and the data are statistically analyzed.

Peter Bobbert, MD, PhD, president of the Berlin Medical Association, provided reports of threat scenarios, “the kind and frequency of which we have never experienced.” He received many messages from physicians asking for help because they had received threatening letters or because their addresses had been posted on social networks.

To date, there have only been isolated cases, said Oliver Erens, MD, spokesperson of the State Medical Association of Baden-Württemberg. “But it is true that some colleagues have already had these kinds of experiences.” Those affected have primarily reported “discussions, debates, and verbal altercations with patients on the topic of the COVID vaccination, compliance with the mask mandate, and other COVID-containment measures – definitely with a high potential for aggression from some of the patients,” said Dr. Erens. Cases of physical violence have not been reported to date.

Above all, there has been a need for advice over the phone, predominantly in the legal department of the regional medical associations. “All physicians and their teams are being recommended by their associations to consistently prosecute any cases of threat of, or use of, violence against them,” Dr. Erens said. In October 2021, the University of Heidelberg started a study on the victimization of physicians. The analysis is ongoing.
 

Staying on Twitter

Lübbers considered leaving Twitter but decided against it. “I decided not to do it and to carry on spreading information about pseudo-medicine and vaccination. I see this as necessary civic courage and will not give way to hate,” Lübbers tweeted.

As understandable as any departure is, “we must not surrender Twitter to the trolls and harassers. Who is still here? #Iamstaying,” wrote Flow. Others wrote, “I will stay on Twitter as a physician. With my real name, too. [...] We must not surrender it to the Querdenker, idiots, Nazis, and enemies of freedom.”

“We need people to share information, we need voices of reason, just as Kellermayr was. How can you say that it would be better to remain silent? Does everyone who is against idiocy, Querdenker, and conspiracy theorists now have to remain silent?” asked Janos Hegedüs, MD, in his podcast.

Hegedüs, who uncovers fake news about COVID-19 and vaccination, was and remains a frequent target of insults and threats. His attempts to take action against them has had only limited success. His conclusion is sobering. “If you decide to spread information, you should know: You are alone. You will get all of the hate and when you have a problem with it, no one will help you.”

Media attorney Chan-jo Jun, who for many years has taken a stand against hate and harassment, has deactivated his Twitter account. However, this is not a retreat, as he clarified in an interview with the German radio station Deutschlandfunk. “I do not intend to give up the fight against hate, harassment, and misinformation, but I will do it in a different place.”

He sees Dr. Kellermayr’s death as a turning point. “I thought that we had learned something after Lübcke [i.e., politician Walter Lübcke, who was murdered by a neo-Nazi]. But we are seeing that the death of a political opponent is not just the goal, but also a success for the other side. And that is shocking.”

The judicial means of taking action against hate are still not effective, said Mr. Jun. He also sees the platform operators as responsible, since they are not obliged to remove unlawful content. “German law and the German constitution hold no sway on Twitter.”
 

Right-wing extremism

What happened to Lisa-Maria Kellermayr is the same as targeted terrorism. An organized group set out to annihilate her. Social psychologist Pia Lamberty has spoken, in the context of COVID, about a pandemic of violence, the threatening nature of which has barely been recognized, both in the virtual and analog world.

In an article for the Jüdische Allgemeine, Dr. Lamberty criticizes the fact that “the mistakes made with Pegida [i.e., a far-right, Islamophobic political movement in Germany] are being made once again” in the classification of Querdenker and COVID deniers. From the very start, the protests against the COVID measures have been a rallying point in the mobilization of right-wing extremists. “The Querdenker movement is unifying radical, right-wing extremist elements. Antisemitism and racism were always welcome.” Still, the right-wing extremist motivation has not been clearly labeled as such.

The classification is not just a question of statistics. “It is also about analyzing the potential for danger and deriving political measures from this. And there is an urgent need for action here: The right-wing extremists will utilize the climate crisis, but also the war in Ukraine, attacks against refugees, and LGBTQ rights for further mobilization. Rather than the state, the focus of the attacks will be people who are labeled as the bogeyman. This also must be clearly labeled for what it is,” said Dr. Lamberty.
She wrote on Twitter, “The COVID-related attacks that took place in the last two years will not simply stop, they will shift. If we do not want more and more people to stop expressing themselves publicly, something urgently has to happen.” She added, “Once more: The next few months will be very difficult. This will probably also be accompanied by an increased level of threat for socially engaged people. More protection is urgently required.”

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

This article was translated from the Medscape German edition.

“A sad day. A new low point in the spiral of hate, violence, and lies. Behind every account, there is a person. Do not forget that. In loving memory,” a Twitter user wrote about the death of Lisa-Maria Kellermayr, MD.

“This outcome is very saddening indeed. It should cause everyone to reflect. About interactions in our society, about ‘social’ media, about tolerance, about consideration, and about freedom,” tweeted Dirk Heinrich, MD, chair of the Virchow Association.

The suspected suicide of Dr. Kellermayr, an Austrian vaccinator, is stirring emotions in Germany, too. The active exponent and supporter of COVID-19 measures had been seriously threatened by anti-vaxxers and pandemic deniers. Thousands of people in Vienna said goodbye to her with a solemn vigil. Dr. Kellermayr’s death raises the question of how life-threatening online hatred can be.

Dr. Kellermayr, a vaccination campaigner, had received hateful comments and death threats since the start of the pandemic. But a single post on Twitter changed everything. On Nov. 16, 2021, anti-vaxxers held a demonstration outside the Wels-Grieskirchen Hospital. Dr. Kellermayr tweeted in disgust, “Today in Wels: A demonstration by conspiracy theorists spills into the street under the gaze of the authorities and blocks both the main hospital entrance and the Red Cross ambulance exit.”

At the time of her tweet, Dr. Kellermayr was not aware of additional access that had been made available for ambulances. The police reacted to her tweet, calling it a “false report.” As Florian Klenk writes in the Austrian journal Falter, the police basically criticized Dr. Kellermayr publicly, including in front of the 12,000 Twitter users who follow the police on Twitter.

A screenshot of Dr. Kellermayr’s tweet and the authorities’ response went viral on relevant Telegram forums and triggered a flood of hatred. A COVID denier immediately posted her address online.

Dr. Kellermayr deleted her tweet and asked the police to also delete their tweet, but they did not respond, and the tweet remained online. The country physician was inundated with insults, slurs, and death threats. She was beset by alleged patients who came only to disrupt her work, take videos on their cell phones, and share the photos in anti-vaxxer groups. She privately paid for a security guard, who confiscated butterfly knives from multiple “patients” on their way into the waiting room. Dr. Kellermayr looked for help from the medical association, the police, and the Office for the Protection of the Constitution. She made her problem public.
 

Police recommend supervision

Dr. Kellermayr received emails in which the senders described in detail how they would kill her and her practice team. The physician took the threats seriously; the police did not. The officers investigated. With the evidence that the perpetrators were operating via the dark web, the officers insinuated to Dr. Kellermayr that it was not possible to find them, Klenk reported.

Dr. Kellermayr filed a complaint for the first time on Nov. 22, 2021. The law enforcement authorities in Upper Austria said they did not have domestic jurisdiction. The Austrian authorities launched another investigation. The German prosecution authorities joined the search for those posting death threats on social media. Even the Munich chief public prosecutor’s office and the Berlin public prosecutor’s office investigated the case.

According to some reports, Dr. Kellermayr did not receive police protection; a patrol was sent over from time to time. According to the police, she should “not be afraid,” and if she was, she should just call them. She was also advised to undergo supervision -- in other words, psychological treatment.

Those who had the power to help her provided no support. On the contrary, the spokesperson for the Upper Austria Police said in the Ö1 Mittagsjournal radio program that Dr. Kellermayr was “putting herself in the public eye for her own selfish benefit.” Even Peter Niedermoser, president of the Medical Association of Upper Austria, told the Austrian daily newspaper Standard, “I understand that you have to defend yourself, but it is a whole other question as to whether you have to discuss every topic to excess on Twitter. Sometimes it’s better to step away.”
 

Leaving Twitter

A German network specialist who hunts pedophiles online offered Dr. Kellermayr her help and was quickly on the trail of suspects, including a neo-Nazi from the Berlin area and a man from Upper Bavaria. Then the Office for the Protection of the Constitution stepped in. Omar Haijawi-Pirchner, head of the Austrian State Security and Intelligence Directorate, stated that the evidence provided by the network specialist would be pursued.

At the end of June, Dr. Kellermayr closed her practice. The situation was no longer tolerable for her staff, and the costs for security, €100,000 up to that point, were no longer manageable. At the start of July, she announced that she wanted to reopen the practice.

In her suicide note to the Upper Austria State Police Department, she wrote “that there was a lot of talking, but no one did anything.” In her letter to her medical association, she also made it clear that she had felt abandoned.

“Every suicide is a tragedy. This one more so: a woman in need was abandoned by the police and authorities. That is a social failure,” tweeted physicist and author Florian Aigner.

“Threatened. Ruined. Left alone by the state. Because she did her job. Because she got involved. Because she spread information. Because many want to be understanding for the self-styled ‘unconventional thinkers,’ the ‘Querdenker.’ Because many did not want to take the threat seriously. Because we tolerate them,” tweeted the intensive care physician Lämêth.

“Many colleagues using their real names get all of this outside of Twitter too: emails, phone calls, letters, or even visits by radical fanatics. If you are lucky, there is police protection, or a few reports, but often not a lot happens juridically,” tweeted Flow, anesthetist and emergency physician.

“More and more of the people who shaped Twitter by spreading reliable information voluntarily are now backing out. As long as the concept of freedom is abused here for hate and intimidation, individual responsibility can only mean self-defense. Sad,” wrote Christian Lübbers, MD, on Twitter. Since the ENT physician started vaccinating patients against COVID-19, he has been tormented with insults and death threats from anti-vaxxers and COVID deniers, this news organization has reported.

Examples of people who have backed out and deactivated their account are the virologist Isabella Eckerlek, MD, PhD, of the University of Geneva, and Natalie Grams, MD, spokesperson for the Information Network Homeopathy. For a long time, they spread information about COVID-19, corrected false assertions, and were increasingly faced with insults and hostility.

General practitioner Christian Kröner, MD, has repeatedly been the target of threats and insults and has been under police protection from time to time. He made a statement regarding Dr. Kellermayr’s death and has shut down his account for the first time following multiple instances of hostility.
 

Harassment continues

The hatred, harassment, and slander have not stopped, even after Dr. Kellermayr’s death. Harald Laatsch, who sits in the Berlin house of representatives for the Alternative for Germany party, commented that it seems “much more likely that she could no longer live with the heavy guilt of being a vaccine propagandist.”

“It is repulsive how the Querdenker deride a medical colleague who was driven to death by harassment and violence. She lost her life by saving the lives of others. Others are continuing her work. The state must protect people like her,” tweeted Karl Lauterbach, MD, PhD, who has also been overrun with hate campaigns by Querdenker and COVID deniers.

The page “Ich habe mitgemacht” – Das Archiv für Corona-Unrecht [“I Joined In” – The Archive for COVID Injustice] probably did not help to deescalate the situation on Twitter. Anonymous archivists there collect allegedly ostracizing quotes and share them, along with names. The context in which these statements were given at the time is not mentioned. Some politicians and journalists have given this online pillory the name, “We joined in! We have ostracized, defamed...”

Being humiliated and defamed is par for the course for those who spread information across social media. As doctor and politician Rainer Röver, MD, wrote, “Whoever is involved in spreading information, science, fighting against fake news, and protecting the patients, pupils, clients, or mandates entrusted to them is being shouted down, threatened in writing, or driven to suicide.” The lying, baiting mob is taking over sovereignty of the discussion. According to Röver, the politicians are doing nothing “to actually put a stop to the violent mob.”

For some time now, the Federal Criminal Police Office (BKA) of Germany has considered anti-vaxxers or COVID deniers as a “relevant risk” in connection with attacks on vaccination centers or medical practices.
 

Increasing aggression

At the start of November last year, participants at the 125th German Medical Assembly demanded that violence against health care professionals be outlawed, Mark Berger, deputy spokesperson of the German Medical Association (BÄK), recollected. At the assembly, various medical associations shared reports of an increase in aggression during the pandemic.

The State Medical Chamber of Physicians of Saxony confirmed threats of violence against physicians, death threats against employees of the Vaccination Committee of Saxony, and criminal damage to medical practices that administer vaccinations. Physicians who administer vaccines in schools receive abuse.

Owing to the increasing amount of aggression, the State Medical Association of Thuringia has set up a special email address as a first point of contact to report violence for those who are affected. “In recent months, we have received a large number of reports from physicians who have received threatening letters in relation to the COVID vaccination, or letters purporting to be liability information or notices of liability,” explained the association. In the cases of which the association becomes aware, a criminal charge is issued most of the time. The investigative proceedings are ongoing.

The State Medical Association of Hesse has devised a reporting form with which it can obtain information on the forms of violence inflicted against physicians and their teams. The reporting is anonymous, and the data are statistically analyzed.

Peter Bobbert, MD, PhD, president of the Berlin Medical Association, provided reports of threat scenarios, “the kind and frequency of which we have never experienced.” He received many messages from physicians asking for help because they had received threatening letters or because their addresses had been posted on social networks.

To date, there have only been isolated cases, said Oliver Erens, MD, spokesperson of the State Medical Association of Baden-Württemberg. “But it is true that some colleagues have already had these kinds of experiences.” Those affected have primarily reported “discussions, debates, and verbal altercations with patients on the topic of the COVID vaccination, compliance with the mask mandate, and other COVID-containment measures – definitely with a high potential for aggression from some of the patients,” said Dr. Erens. Cases of physical violence have not been reported to date.

Above all, there has been a need for advice over the phone, predominantly in the legal department of the regional medical associations. “All physicians and their teams are being recommended by their associations to consistently prosecute any cases of threat of, or use of, violence against them,” Dr. Erens said. In October 2021, the University of Heidelberg started a study on the victimization of physicians. The analysis is ongoing.
 

Staying on Twitter

Lübbers considered leaving Twitter but decided against it. “I decided not to do it and to carry on spreading information about pseudo-medicine and vaccination. I see this as necessary civic courage and will not give way to hate,” Lübbers tweeted.

As understandable as any departure is, “we must not surrender Twitter to the trolls and harassers. Who is still here? #Iamstaying,” wrote Flow. Others wrote, “I will stay on Twitter as a physician. With my real name, too. [...] We must not surrender it to the Querdenker, idiots, Nazis, and enemies of freedom.”

“We need people to share information, we need voices of reason, just as Kellermayr was. How can you say that it would be better to remain silent? Does everyone who is against idiocy, Querdenker, and conspiracy theorists now have to remain silent?” asked Janos Hegedüs, MD, in his podcast.

Hegedüs, who uncovers fake news about COVID-19 and vaccination, was and remains a frequent target of insults and threats. His attempts to take action against them has had only limited success. His conclusion is sobering. “If you decide to spread information, you should know: You are alone. You will get all of the hate and when you have a problem with it, no one will help you.”

Media attorney Chan-jo Jun, who for many years has taken a stand against hate and harassment, has deactivated his Twitter account. However, this is not a retreat, as he clarified in an interview with the German radio station Deutschlandfunk. “I do not intend to give up the fight against hate, harassment, and misinformation, but I will do it in a different place.”

He sees Dr. Kellermayr’s death as a turning point. “I thought that we had learned something after Lübcke [i.e., politician Walter Lübcke, who was murdered by a neo-Nazi]. But we are seeing that the death of a political opponent is not just the goal, but also a success for the other side. And that is shocking.”

The judicial means of taking action against hate are still not effective, said Mr. Jun. He also sees the platform operators as responsible, since they are not obliged to remove unlawful content. “German law and the German constitution hold no sway on Twitter.”
 

Right-wing extremism

What happened to Lisa-Maria Kellermayr is the same as targeted terrorism. An organized group set out to annihilate her. Social psychologist Pia Lamberty has spoken, in the context of COVID, about a pandemic of violence, the threatening nature of which has barely been recognized, both in the virtual and analog world.

In an article for the Jüdische Allgemeine, Dr. Lamberty criticizes the fact that “the mistakes made with Pegida [i.e., a far-right, Islamophobic political movement in Germany] are being made once again” in the classification of Querdenker and COVID deniers. From the very start, the protests against the COVID measures have been a rallying point in the mobilization of right-wing extremists. “The Querdenker movement is unifying radical, right-wing extremist elements. Antisemitism and racism were always welcome.” Still, the right-wing extremist motivation has not been clearly labeled as such.

The classification is not just a question of statistics. “It is also about analyzing the potential for danger and deriving political measures from this. And there is an urgent need for action here: The right-wing extremists will utilize the climate crisis, but also the war in Ukraine, attacks against refugees, and LGBTQ rights for further mobilization. Rather than the state, the focus of the attacks will be people who are labeled as the bogeyman. This also must be clearly labeled for what it is,” said Dr. Lamberty.
She wrote on Twitter, “The COVID-related attacks that took place in the last two years will not simply stop, they will shift. If we do not want more and more people to stop expressing themselves publicly, something urgently has to happen.” She added, “Once more: The next few months will be very difficult. This will probably also be accompanied by an increased level of threat for socially engaged people. More protection is urgently required.”

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

This article was translated from the Medscape German edition.

Many medical associations have publicly announced their determination to help eliminate racial disparities – from health care outcomes, from the level and quality of patient treatment, from their own memberships. How have those pronouncements translated into programs that could have, or even have had, positive impacts?

For this article, this news organization asked several associations about tangible actions behind their vows to combat racism in health care. Meanwhile, a recent Medscape report focused on the degree to which physicians prioritize racial disparities as a leading social issue.
 

American Academy of Family Physicians

The American Academy of Family Physicians’ approach is to integrate diversity, equity, and inclusion (DEI) efforts into all existing and new projects rather than tackle racial disparities as a discrete problem.

“Our policies, our advocacy efforts, everything our commissions and staff do ... is through a lens of diversity, equity, and inclusiveness,” said AAFP Board Chair Ada D. Stewart, MD, FAAP.

That lens is ground by a DEI center the AAFP created in 2017. Run by AAFP staff, members, and chapters, the center focuses on five areas: policy, education and training, practice, diversifying the workplace, and strategic partnerships.

The center has established a special project called EveryONE to provide AAFP members with relevant research, policy templates, and other resources to address patient needs. One example is the Neighborhood Navigator, an online tool that shows food, housing, transportation, and other needs in a patient’s neighborhood.

Meanwhile, the DEI center has created training programs for AAFP members on topics like unconscious and implicit racial biases. And the AAFP has implemented several relevant governing policies regarding pushes to improve childbirth conditions and limit race-based treatment, among other areas.

In January, the AAFP established a new DEI commission for family medicine to set the academy’s agenda on racial issues moving forward. “We only had 10 physician positions available on the commission, and over 100 individuals applied, which gave us comfort that we were going in the right direction,” Dr. Stewart said.
 

Association of American Medical Colleges

The Association of American Medical Colleges, which represents nearly 600 U.S. and Canadian medical schools and teaching hospitals, has a “longstanding” focus on racial equity, said Philip Alberti, founder of the AAMC Center for Health Justice. However, in 2020 that focus became more detailed and layered.

Those layers include:

• Encouraging self-reflection by members on how personal racial biases and stereotypes can lead to systemic racism in health care.
• Working on the AAMC organizational structure. Priorities range from hiring a consultant to help guide antiracism efforts, to establishing a DEI council and advisors, to regularly seeking input from staff. In 2021, the AAMC launched a Center for Health Justice to work more closely with communities.
• Ramping up collaboration with national and local academic medicine organizations and partners. As one example, the AAMC and American Medical Association released a guide for physicians and health care professionals on language that could be interpreted as racist or disrespectful.
• Continuing to be outspoken about racial disparities in health care in society generally.

Meanwhile, the AAMC is supporting more specific, localized health equity efforts in cities such as Cincinnati and Boston.

Cincinnati Children’s Hospital research has found that children in poor neighborhoods are five times more likely to need hospital stays. AAMC members have helped identify “hot spots” for social needs among children and focused specifically on two neighborhoods in the city. The initiative has roped in partnerships with community and social service organizations as well as health care providers, and proponents say the number of child hospital stays in those neighborhoods has dropped by 20%.

Boston Medical Center researchers learned that Black and Latino patients experiencing problems with heart failure were less likely to be referred to a cardiologist. AAMC members assisted with a program to encourage physicians to make medically necessary referrals more often.
 

National Health Council

The National Health Council, an umbrella association of health organizations, similarly has made a “commitment, not just around policy work but anytime and anything the NHC is doing, to build around trying to identify and solve issues of health equity,” CEO Randall Rutta said.

The NHC has identified four strategic policy areas including race and in 2021 issued a statement signed by 45 other health care organizations vowing to take on systemic racism and advance equity, through public policy and law.

In relation to policy, Mr. Rutta said his organization is lobbying Congress and federal agencies to diversify clinical trials.

“We want to make sure that clinical trials are inclusive of people from different racial and ethnic groups, in order to understand how [they are] affected by a particular condition,” he said. “As you would imagine, some conditions hit certain groups harder than others for genetic or other reasons, or it may just be a reflection of other disparities that occur across health care.”

The organization has issued suggestions for policy change in the Food and Drug Administration’s clinical trial policy and separately targeted telemedicine policy to promote equity and greater patient access. For example, one initiative aims to ensure patients’ privacy and civil rights as telemedicine’s popularity grows after the COVID-19 pandemic. The NHC presented the initiative in a congressional briefing last year.
 

American Public Health Association

The American Public Health Association says it started focusing on racial disparities in health care in 2015, following a series of racially fueled violent acts. The APHA started with a four-part webinar series on racism in health (more than 10,000 live participants and 40,000 replays to date).

Shortly afterward, then-APHA President Camara Jones, MD, MPH, PhD, launched a national campaign encouraging APHA members, affiliates, and partners to name and address racism as a determinant of health.

More recently in 2021, the APHA adopted a “Truth, Racial Healing & Transformation” guiding framework and “Healing Through Policy” initiative that offer local leaders policy templates and best practices.

“We have identified a suite of policies that have actually been implemented successfully and are advancing racial equity,” said Regina Davis Moss, APHA’s associate executive director of health policy and practice. “You can’t advance health without having a policy that supports it.”

Montgomery County, Md., is one community that has used the framework (for racial equity training of county employees). Leaders in Evanston, Ill., also used it in crafting a resolution to end structural racism in the city.

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

Many medical associations have publicly announced their determination to help eliminate racial disparities – from health care outcomes, from the level and quality of patient treatment, from their own memberships. How have those pronouncements translated into programs that could have, or even have had, positive impacts?

For this article, this news organization asked several associations about tangible actions behind their vows to combat racism in health care. Meanwhile, a recent Medscape report focused on the degree to which physicians prioritize racial disparities as a leading social issue.
 

American Academy of Family Physicians

The American Academy of Family Physicians’ approach is to integrate diversity, equity, and inclusion (DEI) efforts into all existing and new projects rather than tackle racial disparities as a discrete problem.

“Our policies, our advocacy efforts, everything our commissions and staff do ... is through a lens of diversity, equity, and inclusiveness,” said AAFP Board Chair Ada D. Stewart, MD, FAAP.

That lens is ground by a DEI center the AAFP created in 2017. Run by AAFP staff, members, and chapters, the center focuses on five areas: policy, education and training, practice, diversifying the workplace, and strategic partnerships.

The center has established a special project called EveryONE to provide AAFP members with relevant research, policy templates, and other resources to address patient needs. One example is the Neighborhood Navigator, an online tool that shows food, housing, transportation, and other needs in a patient’s neighborhood.

Meanwhile, the DEI center has created training programs for AAFP members on topics like unconscious and implicit racial biases. And the AAFP has implemented several relevant governing policies regarding pushes to improve childbirth conditions and limit race-based treatment, among other areas.

In January, the AAFP established a new DEI commission for family medicine to set the academy’s agenda on racial issues moving forward. “We only had 10 physician positions available on the commission, and over 100 individuals applied, which gave us comfort that we were going in the right direction,” Dr. Stewart said.
 

Association of American Medical Colleges

The Association of American Medical Colleges, which represents nearly 600 U.S. and Canadian medical schools and teaching hospitals, has a “longstanding” focus on racial equity, said Philip Alberti, founder of the AAMC Center for Health Justice. However, in 2020 that focus became more detailed and layered.

Those layers include:

• Encouraging self-reflection by members on how personal racial biases and stereotypes can lead to systemic racism in health care.
• Working on the AAMC organizational structure. Priorities range from hiring a consultant to help guide antiracism efforts, to establishing a DEI council and advisors, to regularly seeking input from staff. In 2021, the AAMC launched a Center for Health Justice to work more closely with communities.
• Ramping up collaboration with national and local academic medicine organizations and partners. As one example, the AAMC and American Medical Association released a guide for physicians and health care professionals on language that could be interpreted as racist or disrespectful.
• Continuing to be outspoken about racial disparities in health care in society generally.

Meanwhile, the AAMC is supporting more specific, localized health equity efforts in cities such as Cincinnati and Boston.

Cincinnati Children’s Hospital research has found that children in poor neighborhoods are five times more likely to need hospital stays. AAMC members have helped identify “hot spots” for social needs among children and focused specifically on two neighborhoods in the city. The initiative has roped in partnerships with community and social service organizations as well as health care providers, and proponents say the number of child hospital stays in those neighborhoods has dropped by 20%.

Boston Medical Center researchers learned that Black and Latino patients experiencing problems with heart failure were less likely to be referred to a cardiologist. AAMC members assisted with a program to encourage physicians to make medically necessary referrals more often.
 

National Health Council

The National Health Council, an umbrella association of health organizations, similarly has made a “commitment, not just around policy work but anytime and anything the NHC is doing, to build around trying to identify and solve issues of health equity,” CEO Randall Rutta said.

The NHC has identified four strategic policy areas including race and in 2021 issued a statement signed by 45 other health care organizations vowing to take on systemic racism and advance equity, through public policy and law.

In relation to policy, Mr. Rutta said his organization is lobbying Congress and federal agencies to diversify clinical trials.

“We want to make sure that clinical trials are inclusive of people from different racial and ethnic groups, in order to understand how [they are] affected by a particular condition,” he said. “As you would imagine, some conditions hit certain groups harder than others for genetic or other reasons, or it may just be a reflection of other disparities that occur across health care.”

The organization has issued suggestions for policy change in the Food and Drug Administration’s clinical trial policy and separately targeted telemedicine policy to promote equity and greater patient access. For example, one initiative aims to ensure patients’ privacy and civil rights as telemedicine’s popularity grows after the COVID-19 pandemic. The NHC presented the initiative in a congressional briefing last year.
 

American Public Health Association

The American Public Health Association says it started focusing on racial disparities in health care in 2015, following a series of racially fueled violent acts. The APHA started with a four-part webinar series on racism in health (more than 10,000 live participants and 40,000 replays to date).

Shortly afterward, then-APHA President Camara Jones, MD, MPH, PhD, launched a national campaign encouraging APHA members, affiliates, and partners to name and address racism as a determinant of health.

More recently in 2021, the APHA adopted a “Truth, Racial Healing & Transformation” guiding framework and “Healing Through Policy” initiative that offer local leaders policy templates and best practices.

“We have identified a suite of policies that have actually been implemented successfully and are advancing racial equity,” said Regina Davis Moss, APHA’s associate executive director of health policy and practice. “You can’t advance health without having a policy that supports it.”

Montgomery County, Md., is one community that has used the framework (for racial equity training of county employees). Leaders in Evanston, Ill., also used it in crafting a resolution to end structural racism in the city.

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

Many medical associations have publicly announced their determination to help eliminate racial disparities – from health care outcomes, from the level and quality of patient treatment, from their own memberships. How have those pronouncements translated into programs that could have, or even have had, positive impacts?

For this article, this news organization asked several associations about tangible actions behind their vows to combat racism in health care. Meanwhile, a recent Medscape report focused on the degree to which physicians prioritize racial disparities as a leading social issue.
 

American Academy of Family Physicians

The American Academy of Family Physicians’ approach is to integrate diversity, equity, and inclusion (DEI) efforts into all existing and new projects rather than tackle racial disparities as a discrete problem.

“Our policies, our advocacy efforts, everything our commissions and staff do ... is through a lens of diversity, equity, and inclusiveness,” said AAFP Board Chair Ada D. Stewart, MD, FAAP.

That lens is ground by a DEI center the AAFP created in 2017. Run by AAFP staff, members, and chapters, the center focuses on five areas: policy, education and training, practice, diversifying the workplace, and strategic partnerships.

The center has established a special project called EveryONE to provide AAFP members with relevant research, policy templates, and other resources to address patient needs. One example is the Neighborhood Navigator, an online tool that shows food, housing, transportation, and other needs in a patient’s neighborhood.

Meanwhile, the DEI center has created training programs for AAFP members on topics like unconscious and implicit racial biases. And the AAFP has implemented several relevant governing policies regarding pushes to improve childbirth conditions and limit race-based treatment, among other areas.

In January, the AAFP established a new DEI commission for family medicine to set the academy’s agenda on racial issues moving forward. “We only had 10 physician positions available on the commission, and over 100 individuals applied, which gave us comfort that we were going in the right direction,” Dr. Stewart said.
 

Association of American Medical Colleges

The Association of American Medical Colleges, which represents nearly 600 U.S. and Canadian medical schools and teaching hospitals, has a “longstanding” focus on racial equity, said Philip Alberti, founder of the AAMC Center for Health Justice. However, in 2020 that focus became more detailed and layered.

Those layers include:

• Encouraging self-reflection by members on how personal racial biases and stereotypes can lead to systemic racism in health care.
• Working on the AAMC organizational structure. Priorities range from hiring a consultant to help guide antiracism efforts, to establishing a DEI council and advisors, to regularly seeking input from staff. In 2021, the AAMC launched a Center for Health Justice to work more closely with communities.
• Ramping up collaboration with national and local academic medicine organizations and partners. As one example, the AAMC and American Medical Association released a guide for physicians and health care professionals on language that could be interpreted as racist or disrespectful.
• Continuing to be outspoken about racial disparities in health care in society generally.

Meanwhile, the AAMC is supporting more specific, localized health equity efforts in cities such as Cincinnati and Boston.

Cincinnati Children’s Hospital research has found that children in poor neighborhoods are five times more likely to need hospital stays. AAMC members have helped identify “hot spots” for social needs among children and focused specifically on two neighborhoods in the city. The initiative has roped in partnerships with community and social service organizations as well as health care providers, and proponents say the number of child hospital stays in those neighborhoods has dropped by 20%.

Boston Medical Center researchers learned that Black and Latino patients experiencing problems with heart failure were less likely to be referred to a cardiologist. AAMC members assisted with a program to encourage physicians to make medically necessary referrals more often.
 

National Health Council

The National Health Council, an umbrella association of health organizations, similarly has made a “commitment, not just around policy work but anytime and anything the NHC is doing, to build around trying to identify and solve issues of health equity,” CEO Randall Rutta said.

The NHC has identified four strategic policy areas including race and in 2021 issued a statement signed by 45 other health care organizations vowing to take on systemic racism and advance equity, through public policy and law.

In relation to policy, Mr. Rutta said his organization is lobbying Congress and federal agencies to diversify clinical trials.

“We want to make sure that clinical trials are inclusive of people from different racial and ethnic groups, in order to understand how [they are] affected by a particular condition,” he said. “As you would imagine, some conditions hit certain groups harder than others for genetic or other reasons, or it may just be a reflection of other disparities that occur across health care.”

The organization has issued suggestions for policy change in the Food and Drug Administration’s clinical trial policy and separately targeted telemedicine policy to promote equity and greater patient access. For example, one initiative aims to ensure patients’ privacy and civil rights as telemedicine’s popularity grows after the COVID-19 pandemic. The NHC presented the initiative in a congressional briefing last year.
 

American Public Health Association

The American Public Health Association says it started focusing on racial disparities in health care in 2015, following a series of racially fueled violent acts. The APHA started with a four-part webinar series on racism in health (more than 10,000 live participants and 40,000 replays to date).

Shortly afterward, then-APHA President Camara Jones, MD, MPH, PhD, launched a national campaign encouraging APHA members, affiliates, and partners to name and address racism as a determinant of health.

More recently in 2021, the APHA adopted a “Truth, Racial Healing & Transformation” guiding framework and “Healing Through Policy” initiative that offer local leaders policy templates and best practices.

“We have identified a suite of policies that have actually been implemented successfully and are advancing racial equity,” said Regina Davis Moss, APHA’s associate executive director of health policy and practice. “You can’t advance health without having a policy that supports it.”

Montgomery County, Md., is one community that has used the framework (for racial equity training of county employees). Leaders in Evanston, Ill., also used it in crafting a resolution to end structural racism in the city.

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

It seems that everyone’s nerves are on edge right now, and people are often behaving in surprising ways. Physicians are no exception.

“The days of surgeons throwing retractors across the OR and screaming at nurses and medical students are hopefully gone now,” said Barron Lerner, MD, PhD, professor of medicine at New York University Langone Health and author of “The Good Doctor: A Father, a Son, and the Evolution of Medical Ethics” (Boston: Beacon Press, 2014). “We’re not going to tolerate that as an institution.”

But, Dr. Lerner said, bad behavior still happens. And according to a recent Medscape survey, it seems to be on the rise.

For the 2022 Physicians Behaving Badly Report, more than 1,500 physicians shared how often they see fellow doctors misbehaving in person or on social media, and shared some of the worse behavior they’ve seen.

Though misconduct is still relatively uncommon among doctors, and most physicians say they’re proud of the high standards and attitudes of their colleagues, respondents to the survey did say that they’re seeing more frequent incidents of other doctors acting disrespectfully toward patients and coworkers, taking too casual an approach to patient privacy, and even acting angrily or aggressively at work. While the uptick is not substantial, it’s nonetheless worrying.

“I have increased concern for my colleagues,” said Drew Ramsey, MD, an assistant clinical professor of psychiatry at Columbia University, New York. “People forget that COVID has made the physician workplace incredibly stressful. Physicians are struggling with their mental health.”
 

Bullying and harassment top bad behavior

When it comes to what kind of bad behavior was reported, bullying or harassing clinicians and staff was the runaway winner, with 86% of respondents saying they’d seen this type of behavior at work at some time. Making fun of or disparaging patients behind their backs was a close second, at 82%.

Dr. Ramsey thinks that these figures may reflect a deeper understanding of and sensitivity to harassment and bullying. “Five years ago, we weren’t talking about microaggression,” he said. This heightened awareness might explain the fact that doctors reported witnessing physicians mistreating other medical personnel and/or bullying or harassing patients somewhat more often than in 2021’s report.

Docs were caught using racist language by 55% of respondents, and 44% reported seeing colleagues becoming physically aggressive with patients, clinicians, or staff. Other disturbing behaviors respondents witnessed included bullying or harassing patients (45%), inebriation at work (43%), lying about credentials (34%), trying to date a patient (30%), and committing a crime, such as embezzling or stealing (27%).

Women were seen misbehaving about one-third as often as their male counterparts. This could be because women are more likely to seek help, rather than the bottle, when the stress piles up. “Some misbehavior stems from alcohol abuse, and a higher percentage of men have an alcoholism problem,” Dr. Ramsey pointed out. “Also, male physicians have historically been reluctant to seek mental health assistance.”
 

Speaking up

Doctors are behaving badly slightly more often, and their colleagues are slightly more willing to speak up about that behavior. In 2021, 35% of physicians said they did nothing upon witnessing inappropriate behavior. In 2022’s survey, that number fell to 29%.

Respondents largely agreed (49%) that doctors should be verbally warned when they’ve behaved badly at work, yet only 39% reported speaking to a colleague who acted inappropriately, and only 27% reported the bad behavior to an authority.

Dr. Lerner pointed out that it is very difficult for doctors to speak up, even though they know they should. There are several reasons for their reticence.

“For one thing, we all have bad days, and the reporting physician may worry that he or she could do something similar in the future,” he said. “Also, there is the liability question. A doctor might think: ‘What if I’m wrong? What if I think someone has a drinking problem and they don’t, or I can’t prove it?’ If you’re the doctor who reported the misbehavior, you’re potentially opening a can of worms. So there’s all sorts of reasons people convince themselves they don’t have to report it.” But, he added, “if you see it and don’t report it, you’re in the wrong.”
 

Off the job

Work isn’t the only place where doctors observe their colleagues misbehaving. About 66% of respondents had seen disparaging behavior, and 42% had heard racist language, away from the hospital or clinic, according to the survey.

Bullying and harassment weren’t limited to work, either, with 45% reporting seeing a colleague engage in this behavior off campus, and 52% reporting witnessing a colleague inebriated in public. That’s actually down from 2021 when 58% of respondents said they witnessed inebriated doctors in public.

The public sphere has broadened in recent years to include social media, and there, too, doctors sometimes behave badly. However, 47% of doctors surveyed said they saw more inappropriate behavior in person than on social media.

When doctors do act out online, they make the same mistakes other professionals make. One respondent reported seeing a fellow physician “copying and posting an interoffice memo from work and badmouthing the company and the person who wrote the memo.” Another said: “Someone got fired and stalked the supervisor and posted aggressive things.”

Not all social media transgressions were work related. One respondent reported that “a physician posted pictures of herself at a bar with multiple ER staff members, without masks during COVID restriction,” and another reported a colleague posting “unbelievable, antiscientific information expressed as valid, factual material.”

Though posting nonfactual, unscientific, and potentially unsafe information is clearly an ethics violation, Dr. Lerner said, the boundaries around posting personal peccadillos are less clear. This is a part of “digital professionalism,” he explained, adding that there is a broad range of opinions on this. “I think it’s important to discuss these things. Interestingly, while the rules for behavior at the hospital have become more strict, the culture has become less strict.”

As one respondent put it: “What exactly is bad behavior? If you’re saying physicians should be allowed to sexually assault people and use drugs, then no. Can they wear a tiny bathing suit on vacation and drink cocktails with friends? Yeah.”

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

It seems that everyone’s nerves are on edge right now, and people are often behaving in surprising ways. Physicians are no exception.

“The days of surgeons throwing retractors across the OR and screaming at nurses and medical students are hopefully gone now,” said Barron Lerner, MD, PhD, professor of medicine at New York University Langone Health and author of “The Good Doctor: A Father, a Son, and the Evolution of Medical Ethics” (Boston: Beacon Press, 2014). “We’re not going to tolerate that as an institution.”

But, Dr. Lerner said, bad behavior still happens. And according to a recent Medscape survey, it seems to be on the rise.

For the 2022 Physicians Behaving Badly Report, more than 1,500 physicians shared how often they see fellow doctors misbehaving in person or on social media, and shared some of the worse behavior they’ve seen.

Though misconduct is still relatively uncommon among doctors, and most physicians say they’re proud of the high standards and attitudes of their colleagues, respondents to the survey did say that they’re seeing more frequent incidents of other doctors acting disrespectfully toward patients and coworkers, taking too casual an approach to patient privacy, and even acting angrily or aggressively at work. While the uptick is not substantial, it’s nonetheless worrying.

“I have increased concern for my colleagues,” said Drew Ramsey, MD, an assistant clinical professor of psychiatry at Columbia University, New York. “People forget that COVID has made the physician workplace incredibly stressful. Physicians are struggling with their mental health.”
 

Bullying and harassment top bad behavior

When it comes to what kind of bad behavior was reported, bullying or harassing clinicians and staff was the runaway winner, with 86% of respondents saying they’d seen this type of behavior at work at some time. Making fun of or disparaging patients behind their backs was a close second, at 82%.

Dr. Ramsey thinks that these figures may reflect a deeper understanding of and sensitivity to harassment and bullying. “Five years ago, we weren’t talking about microaggression,” he said. This heightened awareness might explain the fact that doctors reported witnessing physicians mistreating other medical personnel and/or bullying or harassing patients somewhat more often than in 2021’s report.

Docs were caught using racist language by 55% of respondents, and 44% reported seeing colleagues becoming physically aggressive with patients, clinicians, or staff. Other disturbing behaviors respondents witnessed included bullying or harassing patients (45%), inebriation at work (43%), lying about credentials (34%), trying to date a patient (30%), and committing a crime, such as embezzling or stealing (27%).

Women were seen misbehaving about one-third as often as their male counterparts. This could be because women are more likely to seek help, rather than the bottle, when the stress piles up. “Some misbehavior stems from alcohol abuse, and a higher percentage of men have an alcoholism problem,” Dr. Ramsey pointed out. “Also, male physicians have historically been reluctant to seek mental health assistance.”
 

Speaking up

Doctors are behaving badly slightly more often, and their colleagues are slightly more willing to speak up about that behavior. In 2021, 35% of physicians said they did nothing upon witnessing inappropriate behavior. In 2022’s survey, that number fell to 29%.

Respondents largely agreed (49%) that doctors should be verbally warned when they’ve behaved badly at work, yet only 39% reported speaking to a colleague who acted inappropriately, and only 27% reported the bad behavior to an authority.

Dr. Lerner pointed out that it is very difficult for doctors to speak up, even though they know they should. There are several reasons for their reticence.

“For one thing, we all have bad days, and the reporting physician may worry that he or she could do something similar in the future,” he said. “Also, there is the liability question. A doctor might think: ‘What if I’m wrong? What if I think someone has a drinking problem and they don’t, or I can’t prove it?’ If you’re the doctor who reported the misbehavior, you’re potentially opening a can of worms. So there’s all sorts of reasons people convince themselves they don’t have to report it.” But, he added, “if you see it and don’t report it, you’re in the wrong.”
 

Off the job

Work isn’t the only place where doctors observe their colleagues misbehaving. About 66% of respondents had seen disparaging behavior, and 42% had heard racist language, away from the hospital or clinic, according to the survey.

Bullying and harassment weren’t limited to work, either, with 45% reporting seeing a colleague engage in this behavior off campus, and 52% reporting witnessing a colleague inebriated in public. That’s actually down from 2021 when 58% of respondents said they witnessed inebriated doctors in public.

The public sphere has broadened in recent years to include social media, and there, too, doctors sometimes behave badly. However, 47% of doctors surveyed said they saw more inappropriate behavior in person than on social media.

When doctors do act out online, they make the same mistakes other professionals make. One respondent reported seeing a fellow physician “copying and posting an interoffice memo from work and badmouthing the company and the person who wrote the memo.” Another said: “Someone got fired and stalked the supervisor and posted aggressive things.”

Not all social media transgressions were work related. One respondent reported that “a physician posted pictures of herself at a bar with multiple ER staff members, without masks during COVID restriction,” and another reported a colleague posting “unbelievable, antiscientific information expressed as valid, factual material.”

Though posting nonfactual, unscientific, and potentially unsafe information is clearly an ethics violation, Dr. Lerner said, the boundaries around posting personal peccadillos are less clear. This is a part of “digital professionalism,” he explained, adding that there is a broad range of opinions on this. “I think it’s important to discuss these things. Interestingly, while the rules for behavior at the hospital have become more strict, the culture has become less strict.”

As one respondent put it: “What exactly is bad behavior? If you’re saying physicians should be allowed to sexually assault people and use drugs, then no. Can they wear a tiny bathing suit on vacation and drink cocktails with friends? Yeah.”

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

It seems that everyone’s nerves are on edge right now, and people are often behaving in surprising ways. Physicians are no exception.

“The days of surgeons throwing retractors across the OR and screaming at nurses and medical students are hopefully gone now,” said Barron Lerner, MD, PhD, professor of medicine at New York University Langone Health and author of “The Good Doctor: A Father, a Son, and the Evolution of Medical Ethics” (Boston: Beacon Press, 2014). “We’re not going to tolerate that as an institution.”

But, Dr. Lerner said, bad behavior still happens. And according to a recent Medscape survey, it seems to be on the rise.

For the 2022 Physicians Behaving Badly Report, more than 1,500 physicians shared how often they see fellow doctors misbehaving in person or on social media, and shared some of the worse behavior they’ve seen.

Though misconduct is still relatively uncommon among doctors, and most physicians say they’re proud of the high standards and attitudes of their colleagues, respondents to the survey did say that they’re seeing more frequent incidents of other doctors acting disrespectfully toward patients and coworkers, taking too casual an approach to patient privacy, and even acting angrily or aggressively at work. While the uptick is not substantial, it’s nonetheless worrying.

“I have increased concern for my colleagues,” said Drew Ramsey, MD, an assistant clinical professor of psychiatry at Columbia University, New York. “People forget that COVID has made the physician workplace incredibly stressful. Physicians are struggling with their mental health.”
 

Bullying and harassment top bad behavior

When it comes to what kind of bad behavior was reported, bullying or harassing clinicians and staff was the runaway winner, with 86% of respondents saying they’d seen this type of behavior at work at some time. Making fun of or disparaging patients behind their backs was a close second, at 82%.

Dr. Ramsey thinks that these figures may reflect a deeper understanding of and sensitivity to harassment and bullying. “Five years ago, we weren’t talking about microaggression,” he said. This heightened awareness might explain the fact that doctors reported witnessing physicians mistreating other medical personnel and/or bullying or harassing patients somewhat more often than in 2021’s report.

Docs were caught using racist language by 55% of respondents, and 44% reported seeing colleagues becoming physically aggressive with patients, clinicians, or staff. Other disturbing behaviors respondents witnessed included bullying or harassing patients (45%), inebriation at work (43%), lying about credentials (34%), trying to date a patient (30%), and committing a crime, such as embezzling or stealing (27%).

Women were seen misbehaving about one-third as often as their male counterparts. This could be because women are more likely to seek help, rather than the bottle, when the stress piles up. “Some misbehavior stems from alcohol abuse, and a higher percentage of men have an alcoholism problem,” Dr. Ramsey pointed out. “Also, male physicians have historically been reluctant to seek mental health assistance.”
 

Speaking up

Doctors are behaving badly slightly more often, and their colleagues are slightly more willing to speak up about that behavior. In 2021, 35% of physicians said they did nothing upon witnessing inappropriate behavior. In 2022’s survey, that number fell to 29%.

Respondents largely agreed (49%) that doctors should be verbally warned when they’ve behaved badly at work, yet only 39% reported speaking to a colleague who acted inappropriately, and only 27% reported the bad behavior to an authority.

Dr. Lerner pointed out that it is very difficult for doctors to speak up, even though they know they should. There are several reasons for their reticence.

“For one thing, we all have bad days, and the reporting physician may worry that he or she could do something similar in the future,” he said. “Also, there is the liability question. A doctor might think: ‘What if I’m wrong? What if I think someone has a drinking problem and they don’t, or I can’t prove it?’ If you’re the doctor who reported the misbehavior, you’re potentially opening a can of worms. So there’s all sorts of reasons people convince themselves they don’t have to report it.” But, he added, “if you see it and don’t report it, you’re in the wrong.”
 

Off the job

Work isn’t the only place where doctors observe their colleagues misbehaving. About 66% of respondents had seen disparaging behavior, and 42% had heard racist language, away from the hospital or clinic, according to the survey.

Bullying and harassment weren’t limited to work, either, with 45% reporting seeing a colleague engage in this behavior off campus, and 52% reporting witnessing a colleague inebriated in public. That’s actually down from 2021 when 58% of respondents said they witnessed inebriated doctors in public.

The public sphere has broadened in recent years to include social media, and there, too, doctors sometimes behave badly. However, 47% of doctors surveyed said they saw more inappropriate behavior in person than on social media.

When doctors do act out online, they make the same mistakes other professionals make. One respondent reported seeing a fellow physician “copying and posting an interoffice memo from work and badmouthing the company and the person who wrote the memo.” Another said: “Someone got fired and stalked the supervisor and posted aggressive things.”

Not all social media transgressions were work related. One respondent reported that “a physician posted pictures of herself at a bar with multiple ER staff members, without masks during COVID restriction,” and another reported a colleague posting “unbelievable, antiscientific information expressed as valid, factual material.”

Though posting nonfactual, unscientific, and potentially unsafe information is clearly an ethics violation, Dr. Lerner said, the boundaries around posting personal peccadillos are less clear. This is a part of “digital professionalism,” he explained, adding that there is a broad range of opinions on this. “I think it’s important to discuss these things. Interestingly, while the rules for behavior at the hospital have become more strict, the culture has become less strict.”

As one respondent put it: “What exactly is bad behavior? If you’re saying physicians should be allowed to sexually assault people and use drugs, then no. Can they wear a tiny bathing suit on vacation and drink cocktails with friends? Yeah.”

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

For about the past year, Priya Goel, MD, can be seen cruising around the island of Manhattan as she makes her way between visits to some of New York City’s most treasured residents: a small but essential group of patients born before the Empire State Building scraped the sky and the old Yankee Stadium had become the House That Ruth Built.

Dr. Goel, a family physician, works for Heal, a national home health care company that primarily serves people older than 65. Her practice has 10 patients older than 100 – the oldest is a 108-year-old man – whom she visits monthly.
 

The gray wave

Dr. Goel’s charges are among America’s latest baby boom – babies born a century ago, that is.

Between 1980 and 2019, the share of American centenarians, those aged 100 and up, grew faster than the total population. In 2019, 100,322 persons in the United States were at least 100 years old – more than triple the 1980 figure of 32,194, according to the U.S. Administration on Aging. By 2060, experts predict, the U.S. centenarian population will reach nearly 600,000.

Although some of the ultra-aged live in nursing homes, many continue to live independently. They require both routine and acute medical care. So, what does it take to be a physician for a centenarian?

Dr. Goel, who is in her mid-30s and could well be the great-granddaughter of some of her patients, urged her colleagues not to stereotype patients on the basis of age.

“You have to consider their functional and cognitive abilities, their ability to understand disease processes and make decisions for themselves,” Dr. Goel said. “Age is just one factor in the grand scheme of things.”

Visiting patients in their homes provides her with insights into how well they’re doing, including the safety of their environments and the depth of their social networks.

New York City has its peculiar demands. Heal provides Dr. Goel with a driver who chauffeurs her to her patient visits. She takes notes between stops.

“The idea is to have these patients remain in an environment where they’re comfortable, in surroundings where they’ve grown up or lived for many years,” she said. “A lot of them are in elevator buildings and they are wheelchair-bound or bed-bound and they physically can’t leave.”

She said she gets a far different view of the patient than does an office-based physician.

“When you go into their home, it’s very personal. You’re seeing what their daily environment is like, what their diet is like. You can see their food on the counter. You can see the level of hygiene,” Dr. Goel said. “You get to see their social support. Are their kids involved? Are they hoarding? Stuff that they wouldn’t just necessarily disclose but on a visit you get to see going into the home. It’s an extra layer of understanding that patient.”

Dr. Goel contrasted home care from care in a nursing home, where the patients are seen daily. On the basis of her observations, she decides whether to see her patients every month or every 3 months.

She applies this strategy to everyone from age 60 to over 100.
 

Tracking a growing group

Since 1995, geriatrician Thomas Perls, MD, has directed the New England Centenarian Study at Boston University. The study, largely funded by the National Institute on Aging, has enrolled 2,599 centenarian persons and 700 of their offspring. At any given time in the study, about 10% of the centenarians are alive. The study has a high mortality rate.

The people in Dr. Perls’s study range in age, but they top out at 119, the third oldest person ever in the world. Most centenarians are women.

“When we first began the study in 1995, the prevalence of centenarians in the United States was about 1 per 10,000 in the population,” Perls told this news organization. “And now, that prevalence has doubled to 1 per 5,000.”

Even if no one has achieved the record of Methuselah, the Biblical patriarch who was purported to have lived to the age of 969, some people always have lived into their 90s and beyond. Dr. Perls attributed the increase in longevity to control at the turn of the 20th century of typhoid fever, diphtheria, and other infectious diseases with effective public health measures, including the availability of clean water and improvement in socioeconomic conditions.

“Infant mortality just plummeted. So, come around 1915, 1920, we were no longer losing a quarter of our population to these diseases. That meant a quarter more of the population could age into adulthood and middle age,” he said. “A certain component of that group was, therefore, able to continue to age to a very, very old age.”

Other advances, such as antibiotics and vaccinations in the 1960s; the availability in the 1970s of much better detection and effective treatment of high blood pressure; the recognition of the harms of smoking; and much more effective treatment of cardiovascular disease and cancer have allowed many people who would have otherwise died in their 70s and 80s to live much longer. “I think what this means is that there is a substantial proportion of the population that has the biology to get to 100,” Dr. Perls said.

Perls said the Latino population and Blacks have a better track record than Whites in reaching the 100-year milestone. “The average life expectancy might be lower in these populations because of socioeconomic factors, but if they are able to get to around their early 80s, compared to Whites, their ability to get to 100 is actually better,” he said.

Asians fare best when it comes to longevity. While around 1% of White women in the United States live to 100, 10% of Asian women in Hong Kong hit that mark.

“I think some of that is better environment and health habits in Hong Kong than in the United States,” Dr. Perls said. “I think another piece may be a genetic advantage in East Asians. We’re looking into that.”

Dr. Perls said he agreed with Dr. Goel that health care providers and the lay public should not make assumptions on the basis of age alone as to how a person is doing. “People can age so very differently from one another,” he said.

Up to about age 90, the vast majority of those differences are determined by our health behaviors, such as smoking, alcohol use, exercise, sleep, the effect of our diets on weight, and access to good health care, including regular screening for problems such as high blood pressure, diabetes, and cancer. “People who are able to do everything right generally add healthy years to their lives, while those who do not have shorter life expectancies and longer periods of chronic diseases,” Dr. Perls said.

Paying diligent attention to these behaviors over the long run can have a huge payoff.

Dr. Perls’s team has found that to live beyond age 90 and on into the early 100s, protective genes can play a strong role. These genes help slow aging and decrease one’s risk for aging-related diseases. Centenarians usually have a history of aging very slowly and greatly delaying aging-related diseases and disability toward the ends of their lives.

Centenarians are the antithesis of the misguided belief that the older you get, the sicker you get. Quite the opposite occurs. For Dr. Perls, “the older you get, the healthier you’ve been.”
 

MD bias against the elderly?

Care of elderly patients is becoming essential in the practice of primary care physicians – but not all of them enjoy the work.

To be effective, physicians who treat centenarians must get a better idea of the individual patient’s functional status and comorbidities. “You absolutely cannot make assumptions on age alone,” Dr. Perls said.

The so-called “normal” temperature, 98.6° F, can spell trouble for centenarians and other very old patients, warned Natalie Baker, DNP, CRNP, an associate professor of nursing at the University of Alabama, Birmingham, and president of the 3,000-member Gerontological Advanced Practice Nurses Association.

“We have to be very cognizant of what we call a typical presentation of disease or illness and that a very subtle change in an older adult can signal a serious infection or illness,” Dr. Baker said. “If your patient has a high fever, that is a potential problem.”

The average temperature of an older adult is lower than the accepted 98.6° F, and their body’s response to an infection is slow to exhibit an increase in temperature, Dr. Baker said. “When treating centenarians, clinicians must be cognizant of other subtle signs of infection, such as decreased appetite or change in mentation,” she cautioned.

A decline in appetite or insomnia may be a subtle sign that these patients need to be evaluated, she added.
 

COVID-19 and centenarians

Three-quarters of the 1 million U.S. deaths from COVID-19 occurred in people aged 65 and older. However, Dr. Perls said centenarians may be a special subpopulation when it comes to COVID.

The Japanese Health Ministry, which follows the large centenarian population in that country, noted a marked jump in the number of centenarians during the pandemic – although the reasons for the increase aren’t clear.

Centenarians may be a bit different. Dr. Perls said some evidence suggests that the over-100 crowd may have better immune systems than younger people. “Part of the trick of getting to 100 is having a pretty good immune system,” he said.
 

Don’t mess with success

“There is no need at that point for us to try to alter their diet to what we think it might be,” Dr. Baker said. “There’s no need to start with diabetic education. They may tell you their secret is a shot of vodka every day. Why should we stop it at that age? Accept their lifestyles, because they’ve done something right to get to that age.”

Opinions differ on how to approach screening for centenarians.

Dr. Goel said guidelines for routine screening, such as colonoscopies, mammograms, and PAP smears, drop off for patients starting at 75. Dr. Perls said this strategy stems from the belief that people will die from other things first, so screening is no longer needed. Dr. Perls said he disagrees with this approach.

“Again, we can’t base our screening and health care decisions on age alone. If I have an independently functioning and robust 95-year-old man in my office, you can be sure I am going to continue recommending regular screening for colon cancer and other screenings that are normal for people who are 30 years younger,” he said.

Justin Zaghi, MD, chief medical officer at Heal, said screening patients in their late 90s and 100s for cancer generally doesn’t make sense except in some rare circumstances in which the cancer would be unlikely to be a cause of death. “However, if we are talking about screening for fall risks, hearing difficulties, poor vision, pain, and malnutrition, those screenings still absolutely make sense for patients in their late 90s and 100s,” Dr. Zaghi said.

One high-functioning 104-year-old patient of Dr. Perls underwent a total hip replacement for a hip fracture and is faring well. “Obviously, if she had end-stage dementia, we’d do everything to keep the person comfortable, or if they had medical problems that made surgery too high risk, then you don’t do it,” he said. “But if they’re otherwise, I would proceed.”
 

Avoid the ED

Dr. Goel said doctors should avoid sending patients to the emergency department, an often chaotic place that is especially unfriendly to centenarians and the very old. “Sometimes I’ve seen older patients who are being rushed to the ER, and I ask, What are the goals of care?” she said.

Clinicians caring for seniors should keep in mind that infections can cause seniors to appear confused – and this may lead the clinician to think the patient has dementia. Or, Dr. Goel said, a patient with dementia may suddenly experience much worse dementia.

“In either case, you want to make sure you’re not dealing with any underlying infection, like urinary tract infection, or pneumonia brewing, or skin infections,” she said. “Their skin is so much frailer. You want to make sure there are no bedsores.”

She has had patients whose children report that their usually placid centenarian parents are suddenly acting out. “We’ll do a urinary test and it definitely shows a urinary tract infection. You want to make sure you’re not missing out on something else before you attribute it to dementia,” she said.

Environmental changes, such as moving a patient to a new room in a hospital setting, can trigger an acute mental status change, such as delirium, she added. Helping older patients feel in control as much as possible is important.

“You want to make sure you’re orienting them to the time of day. Make sure they get up at the same time, go to bed at the same time, have clocks and calendars present – just making sure that they feel like they’re still in control of their body and their day,” she said.

Physicians should be aware of potential depression in these patients, whose experience of loss – an unavoidable consequence of outliving family and friends – can result in problems with sleep and diet, as well as a sense of social isolation.

Neal Flomenbaum, MD, professor and emergency physician-in-chief emeritus, New York–Presbyterian/Weill Cornell Medical Center in New York, said sometimes the best thing for these very elderly patients is to “get them in and out of ED as quickly as possible, and do what you can diagnostically.”

He noted that EDs have been making accommodations to serve the elderly, such as using LEDs that replicate outdoor lighting conditions, as well as providing seniors with separate rooms with glass doors to protect them from noise, separate air handlers to prevent infections, and adequate space for visitors.

These patients often are subject to trauma from falls.

“The bones don’t heal as well as in younger people, and treating their comorbidities is essential. Once they have trouble with one area and they’re lying in bed and can’t move much, they can get bedsores,” Dr. Flomenbaum said. “In the hospital, they are vulnerable to infections. So, you’re thinking of all of these things at the same time and how to treat them appropriately and then get them out of the hospital as soon as possible with whatever care that they need in their own homes if at all possible.”

“I always err on the side of less is more,” Dr. Goel said. “Obviously, if there is something – if they have a cough, they need an x-ray. That’s very basic. We want to take care of that. Give them the antibiotic if they need that. But rushing them in and out of the hospital doesn’t add to their quality of life.”

Dr. Flomenbaum, a pioneer in geriatric emergency medicine, says physicians need to be aware that centenarians and other very old patients don’t present the same way as younger adults.

He began to notice more than 20 years ago that every night, patients would turn up in his ED who were in their late 90s into their 100s. Some would come in with what their children identified as sudden-onset dementia – they didn’t know their own names and couldn’t identify their kids. They didn’t know the time or day. Dr. Flomenbaum said the children often asked whether their parents should enter a nursing home.

“And I’d say, ‘Not so fast. Well, let’s take a look at this.’ You don’t develop that kind of dementia overnight. It usually takes a while,” he said.

He said he ordered complete blood cell counts and oxygen saturation tests that frequently turned out to be abnormal. They didn’t have a fever, and infiltrates initially weren’t seen on chest x-rays.

With rehydration and supplemental oxygen, their symptoms started to improve, and it became obvious that the symptoms were not of dementia but of pneumonia, and that they required antibiotics, Dr. Flomenbaum said.
 

Dementia dilemma

Too often, on the basis of age, doctors assume patients have dementia or other cognitive impairments.

“What a shock and a surprise when doctors actually talk to folks and do a neurocognitive screen and find they’re just fine,” Dr. Perls said.

The decline in hearing and vision can lead to a misdiagnosis of cognitive impairment because the patients are not able to hear what you’re asking them. “It’s really important that the person can hear you – whether you use an amplifying device or they have hearing aids, that’s critical,” he said. “You just have to be a good doctor.”

Often the physical toll of aging exacerbates social difficulties. Poor hearing, for example, can accelerate cognitive impairment and cause people to interact less often, and less meaningfully, with their environment. For some, wearing hearing aids seems demeaning – until they hear what they’ve been missing.

“I get them to wear their hearing aids and, lo and behold, they’re a whole new person because they’re now able to take in their environment and interact with others,” Dr. Perls said.

Dr. Flomenbaum said alcohol abuse and drug reactions can cause delirium, which, unlike dementia, is potentially reversible. Yet many physicians cannot reliably differentiate between dementia and delirium, he added.

The geriatric specialists talk about the lessons they’ve learned and the gratification they get from caring for centenarians.

“I have come to realize the importance of family, of having a close circle, whether that’s through friends or neighbors,” Dr. Goel said. “This work is very rewarding because, if it wasn’t for homebound organizations, how would these people get care or get access to care?”

For Dr. Baker, a joy of the job is hearing centenarians share their life stories.

“I love to hear their stories about how they’ve overcome adversity, living through the depression and living through different wars,” she said. “I love talking to veterans, and I think that oftentimes, we do not value our older adults in our society as we should. Sometimes they are dismissed because they move slowly or are hard to communicate with due to hearing deficits. But they are, I think, a very important part of our lives.”
 

‘They’ve already won’

Most centenarians readily offer the secrets to their longevity. Aline Jacobsohn, of Boca Raton, Fla., is no different.

Ms. Jacobsohn, who will be 101 in October, thinks a diet of small portions of fish, vegetables, and fruit, which she has followed since her husband Leo died in 1982, has helped keep her healthy. She eats lots of salmon and herring and is a fan of spinach sautéed with olive oil. “The only thing I don’t eat is meat,” the trim and active Ms. Jacobsohn said in a recent interview over Zoom.

Her other secret: “Doctors. I like to stay away from them as much as possible.”

Shari Rosenbaum, MD, Jacobsohn’s internist, doesn’t dismiss that approach. She uses a version of it when managing her three centenarian patients, the oldest of whom is 103.

“Let them smoke! Let them drink! They’re happy. It’s not causing harm. Let them eat cake! They’ve already won,” said Dr. Rosenbaum, who is affiliated with Boca Raton–based MDVIP, a national membership-based network of 1,100 primary care physicians serving 368,000 patients. Of those, nearly 460 are centenarians.

“You’re not preventing those problems in this population,” she said. “They’re here to enjoy every moment that they have, and they might as well.”

Dr. Rosenbaum sees a divergence in her patients – those who will reach very old age, and those who won’t – starting in their 60s.

“The centenarians don’t have medical problems,” she said. “They don’t get cancer. They don’t get diabetes. Some of them take good care of themselves. Some don’t take such good care of themselves. But they are all optimists. They all see the glass half full. They all participate in life. They all have excellent support systems. They have good genes, a positive attitude toward life, and a strong social network.”

Ms. Jacobsohn – whose surname at the time was Bakst – grew up in Frankfurt am Main, Germany, during the rise of the Nazi regime. The family fled to Columbia in 1938, where she met and eventually married her husband, Leo, who ran a business importing clocks and watches in Cali.

In 1989, the Jacobsohns and their three children moved to south Florida to escape the dangers of kidnappings and ransoms posed by the drug cartels.

Ms. Jacobsohn agreed that she appears to have longevity genes – “good stock,” she calls it. “My mother died 23 days before she was 100. My grandmother lived till 99, almost 100,” she said.

Two years ago, she donated her car to a charity and stopped driving in the interest of her own safety and that of other drivers and pedestrians.

Ms. Jacobsohn has a strong support system. Two of her children live nearby and visit her nearly every day. A live-in companion helps her with the activities of daily life, including preparing meals.

Ms. Jacobsohn plays bridge regularly, and well. “I’m sorry to say that I’m a very good bridge player,” she said, frankly. “How is it possible that I’ve played bridge so well and then I don’t remember what I had for lunch yesterday?”

She reads, mainly a diet of history but occasionally novels, too. “They have to be engaging,” she said.

The loss of loved ones is an inevitable part of very old age. Her husband of 47 years died of emphysema, and one of her sons died in his 70s of prostate cancer.

She knows well the fate that awaits us all and accepts it philosophically.

“It’s a very normal thing that people die. You don’t live forever. So, whenever it comes, it’s okay. Enough is enough. Dayenu,” she said, using the Hebrew word for, “It would have been enough” – a favorite in the Passover Seder celebrating the ancient Jews’ liberation from slavery in Egypt.

Ms. Jacobsohn sang the song and then took a reporter on a Zoom tour of her tidy home and her large flower garden featuring Cattleya orchids from Colombia.

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

For about the past year, Priya Goel, MD, can be seen cruising around the island of Manhattan as she makes her way between visits to some of New York City’s most treasured residents: a small but essential group of patients born before the Empire State Building scraped the sky and the old Yankee Stadium had become the House That Ruth Built.

Dr. Goel, a family physician, works for Heal, a national home health care company that primarily serves people older than 65. Her practice has 10 patients older than 100 – the oldest is a 108-year-old man – whom she visits monthly.
 

The gray wave

Dr. Goel’s charges are among America’s latest baby boom – babies born a century ago, that is.

Between 1980 and 2019, the share of American centenarians, those aged 100 and up, grew faster than the total population. In 2019, 100,322 persons in the United States were at least 100 years old – more than triple the 1980 figure of 32,194, according to the U.S. Administration on Aging. By 2060, experts predict, the U.S. centenarian population will reach nearly 600,000.

Although some of the ultra-aged live in nursing homes, many continue to live independently. They require both routine and acute medical care. So, what does it take to be a physician for a centenarian?

Dr. Goel, who is in her mid-30s and could well be the great-granddaughter of some of her patients, urged her colleagues not to stereotype patients on the basis of age.

“You have to consider their functional and cognitive abilities, their ability to understand disease processes and make decisions for themselves,” Dr. Goel said. “Age is just one factor in the grand scheme of things.”

Visiting patients in their homes provides her with insights into how well they’re doing, including the safety of their environments and the depth of their social networks.

New York City has its peculiar demands. Heal provides Dr. Goel with a driver who chauffeurs her to her patient visits. She takes notes between stops.

“The idea is to have these patients remain in an environment where they’re comfortable, in surroundings where they’ve grown up or lived for many years,” she said. “A lot of them are in elevator buildings and they are wheelchair-bound or bed-bound and they physically can’t leave.”

She said she gets a far different view of the patient than does an office-based physician.

“When you go into their home, it’s very personal. You’re seeing what their daily environment is like, what their diet is like. You can see their food on the counter. You can see the level of hygiene,” Dr. Goel said. “You get to see their social support. Are their kids involved? Are they hoarding? Stuff that they wouldn’t just necessarily disclose but on a visit you get to see going into the home. It’s an extra layer of understanding that patient.”

Dr. Goel contrasted home care from care in a nursing home, where the patients are seen daily. On the basis of her observations, she decides whether to see her patients every month or every 3 months.

She applies this strategy to everyone from age 60 to over 100.
 

Tracking a growing group

Since 1995, geriatrician Thomas Perls, MD, has directed the New England Centenarian Study at Boston University. The study, largely funded by the National Institute on Aging, has enrolled 2,599 centenarian persons and 700 of their offspring. At any given time in the study, about 10% of the centenarians are alive. The study has a high mortality rate.

The people in Dr. Perls’s study range in age, but they top out at 119, the third oldest person ever in the world. Most centenarians are women.

“When we first began the study in 1995, the prevalence of centenarians in the United States was about 1 per 10,000 in the population,” Perls told this news organization. “And now, that prevalence has doubled to 1 per 5,000.”

Even if no one has achieved the record of Methuselah, the Biblical patriarch who was purported to have lived to the age of 969, some people always have lived into their 90s and beyond. Dr. Perls attributed the increase in longevity to control at the turn of the 20th century of typhoid fever, diphtheria, and other infectious diseases with effective public health measures, including the availability of clean water and improvement in socioeconomic conditions.

“Infant mortality just plummeted. So, come around 1915, 1920, we were no longer losing a quarter of our population to these diseases. That meant a quarter more of the population could age into adulthood and middle age,” he said. “A certain component of that group was, therefore, able to continue to age to a very, very old age.”

Other advances, such as antibiotics and vaccinations in the 1960s; the availability in the 1970s of much better detection and effective treatment of high blood pressure; the recognition of the harms of smoking; and much more effective treatment of cardiovascular disease and cancer have allowed many people who would have otherwise died in their 70s and 80s to live much longer. “I think what this means is that there is a substantial proportion of the population that has the biology to get to 100,” Dr. Perls said.

Perls said the Latino population and Blacks have a better track record than Whites in reaching the 100-year milestone. “The average life expectancy might be lower in these populations because of socioeconomic factors, but if they are able to get to around their early 80s, compared to Whites, their ability to get to 100 is actually better,” he said.

Asians fare best when it comes to longevity. While around 1% of White women in the United States live to 100, 10% of Asian women in Hong Kong hit that mark.

“I think some of that is better environment and health habits in Hong Kong than in the United States,” Dr. Perls said. “I think another piece may be a genetic advantage in East Asians. We’re looking into that.”

Dr. Perls said he agreed with Dr. Goel that health care providers and the lay public should not make assumptions on the basis of age alone as to how a person is doing. “People can age so very differently from one another,” he said.

Up to about age 90, the vast majority of those differences are determined by our health behaviors, such as smoking, alcohol use, exercise, sleep, the effect of our diets on weight, and access to good health care, including regular screening for problems such as high blood pressure, diabetes, and cancer. “People who are able to do everything right generally add healthy years to their lives, while those who do not have shorter life expectancies and longer periods of chronic diseases,” Dr. Perls said.

Paying diligent attention to these behaviors over the long run can have a huge payoff.

Dr. Perls’s team has found that to live beyond age 90 and on into the early 100s, protective genes can play a strong role. These genes help slow aging and decrease one’s risk for aging-related diseases. Centenarians usually have a history of aging very slowly and greatly delaying aging-related diseases and disability toward the ends of their lives.

Centenarians are the antithesis of the misguided belief that the older you get, the sicker you get. Quite the opposite occurs. For Dr. Perls, “the older you get, the healthier you’ve been.”
 

MD bias against the elderly?

Care of elderly patients is becoming essential in the practice of primary care physicians – but not all of them enjoy the work.

To be effective, physicians who treat centenarians must get a better idea of the individual patient’s functional status and comorbidities. “You absolutely cannot make assumptions on age alone,” Dr. Perls said.

The so-called “normal” temperature, 98.6° F, can spell trouble for centenarians and other very old patients, warned Natalie Baker, DNP, CRNP, an associate professor of nursing at the University of Alabama, Birmingham, and president of the 3,000-member Gerontological Advanced Practice Nurses Association.

“We have to be very cognizant of what we call a typical presentation of disease or illness and that a very subtle change in an older adult can signal a serious infection or illness,” Dr. Baker said. “If your patient has a high fever, that is a potential problem.”

The average temperature of an older adult is lower than the accepted 98.6° F, and their body’s response to an infection is slow to exhibit an increase in temperature, Dr. Baker said. “When treating centenarians, clinicians must be cognizant of other subtle signs of infection, such as decreased appetite or change in mentation,” she cautioned.

A decline in appetite or insomnia may be a subtle sign that these patients need to be evaluated, she added.
 

COVID-19 and centenarians

Three-quarters of the 1 million U.S. deaths from COVID-19 occurred in people aged 65 and older. However, Dr. Perls said centenarians may be a special subpopulation when it comes to COVID.

The Japanese Health Ministry, which follows the large centenarian population in that country, noted a marked jump in the number of centenarians during the pandemic – although the reasons for the increase aren’t clear.

Centenarians may be a bit different. Dr. Perls said some evidence suggests that the over-100 crowd may have better immune systems than younger people. “Part of the trick of getting to 100 is having a pretty good immune system,” he said.
 

Don’t mess with success

“There is no need at that point for us to try to alter their diet to what we think it might be,” Dr. Baker said. “There’s no need to start with diabetic education. They may tell you their secret is a shot of vodka every day. Why should we stop it at that age? Accept their lifestyles, because they’ve done something right to get to that age.”

Opinions differ on how to approach screening for centenarians.

Dr. Goel said guidelines for routine screening, such as colonoscopies, mammograms, and PAP smears, drop off for patients starting at 75. Dr. Perls said this strategy stems from the belief that people will die from other things first, so screening is no longer needed. Dr. Perls said he disagrees with this approach.

“Again, we can’t base our screening and health care decisions on age alone. If I have an independently functioning and robust 95-year-old man in my office, you can be sure I am going to continue recommending regular screening for colon cancer and other screenings that are normal for people who are 30 years younger,” he said.

Justin Zaghi, MD, chief medical officer at Heal, said screening patients in their late 90s and 100s for cancer generally doesn’t make sense except in some rare circumstances in which the cancer would be unlikely to be a cause of death. “However, if we are talking about screening for fall risks, hearing difficulties, poor vision, pain, and malnutrition, those screenings still absolutely make sense for patients in their late 90s and 100s,” Dr. Zaghi said.

One high-functioning 104-year-old patient of Dr. Perls underwent a total hip replacement for a hip fracture and is faring well. “Obviously, if she had end-stage dementia, we’d do everything to keep the person comfortable, or if they had medical problems that made surgery too high risk, then you don’t do it,” he said. “But if they’re otherwise, I would proceed.”
 

Avoid the ED

Dr. Goel said doctors should avoid sending patients to the emergency department, an often chaotic place that is especially unfriendly to centenarians and the very old. “Sometimes I’ve seen older patients who are being rushed to the ER, and I ask, What are the goals of care?” she said.

Clinicians caring for seniors should keep in mind that infections can cause seniors to appear confused – and this may lead the clinician to think the patient has dementia. Or, Dr. Goel said, a patient with dementia may suddenly experience much worse dementia.

“In either case, you want to make sure you’re not dealing with any underlying infection, like urinary tract infection, or pneumonia brewing, or skin infections,” she said. “Their skin is so much frailer. You want to make sure there are no bedsores.”

She has had patients whose children report that their usually placid centenarian parents are suddenly acting out. “We’ll do a urinary test and it definitely shows a urinary tract infection. You want to make sure you’re not missing out on something else before you attribute it to dementia,” she said.

Environmental changes, such as moving a patient to a new room in a hospital setting, can trigger an acute mental status change, such as delirium, she added. Helping older patients feel in control as much as possible is important.

“You want to make sure you’re orienting them to the time of day. Make sure they get up at the same time, go to bed at the same time, have clocks and calendars present – just making sure that they feel like they’re still in control of their body and their day,” she said.

Physicians should be aware of potential depression in these patients, whose experience of loss – an unavoidable consequence of outliving family and friends – can result in problems with sleep and diet, as well as a sense of social isolation.

Neal Flomenbaum, MD, professor and emergency physician-in-chief emeritus, New York–Presbyterian/Weill Cornell Medical Center in New York, said sometimes the best thing for these very elderly patients is to “get them in and out of ED as quickly as possible, and do what you can diagnostically.”

He noted that EDs have been making accommodations to serve the elderly, such as using LEDs that replicate outdoor lighting conditions, as well as providing seniors with separate rooms with glass doors to protect them from noise, separate air handlers to prevent infections, and adequate space for visitors.

These patients often are subject to trauma from falls.

“The bones don’t heal as well as in younger people, and treating their comorbidities is essential. Once they have trouble with one area and they’re lying in bed and can’t move much, they can get bedsores,” Dr. Flomenbaum said. “In the hospital, they are vulnerable to infections. So, you’re thinking of all of these things at the same time and how to treat them appropriately and then get them out of the hospital as soon as possible with whatever care that they need in their own homes if at all possible.”

“I always err on the side of less is more,” Dr. Goel said. “Obviously, if there is something – if they have a cough, they need an x-ray. That’s very basic. We want to take care of that. Give them the antibiotic if they need that. But rushing them in and out of the hospital doesn’t add to their quality of life.”

Dr. Flomenbaum, a pioneer in geriatric emergency medicine, says physicians need to be aware that centenarians and other very old patients don’t present the same way as younger adults.

He began to notice more than 20 years ago that every night, patients would turn up in his ED who were in their late 90s into their 100s. Some would come in with what their children identified as sudden-onset dementia – they didn’t know their own names and couldn’t identify their kids. They didn’t know the time or day. Dr. Flomenbaum said the children often asked whether their parents should enter a nursing home.

“And I’d say, ‘Not so fast. Well, let’s take a look at this.’ You don’t develop that kind of dementia overnight. It usually takes a while,” he said.

He said he ordered complete blood cell counts and oxygen saturation tests that frequently turned out to be abnormal. They didn’t have a fever, and infiltrates initially weren’t seen on chest x-rays.

With rehydration and supplemental oxygen, their symptoms started to improve, and it became obvious that the symptoms were not of dementia but of pneumonia, and that they required antibiotics, Dr. Flomenbaum said.
 

Dementia dilemma

Too often, on the basis of age, doctors assume patients have dementia or other cognitive impairments.

“What a shock and a surprise when doctors actually talk to folks and do a neurocognitive screen and find they’re just fine,” Dr. Perls said.

The decline in hearing and vision can lead to a misdiagnosis of cognitive impairment because the patients are not able to hear what you’re asking them. “It’s really important that the person can hear you – whether you use an amplifying device or they have hearing aids, that’s critical,” he said. “You just have to be a good doctor.”

Often the physical toll of aging exacerbates social difficulties. Poor hearing, for example, can accelerate cognitive impairment and cause people to interact less often, and less meaningfully, with their environment. For some, wearing hearing aids seems demeaning – until they hear what they’ve been missing.

“I get them to wear their hearing aids and, lo and behold, they’re a whole new person because they’re now able to take in their environment and interact with others,” Dr. Perls said.

Dr. Flomenbaum said alcohol abuse and drug reactions can cause delirium, which, unlike dementia, is potentially reversible. Yet many physicians cannot reliably differentiate between dementia and delirium, he added.

The geriatric specialists talk about the lessons they’ve learned and the gratification they get from caring for centenarians.

“I have come to realize the importance of family, of having a close circle, whether that’s through friends or neighbors,” Dr. Goel said. “This work is very rewarding because, if it wasn’t for homebound organizations, how would these people get care or get access to care?”

For Dr. Baker, a joy of the job is hearing centenarians share their life stories.

“I love to hear their stories about how they’ve overcome adversity, living through the depression and living through different wars,” she said. “I love talking to veterans, and I think that oftentimes, we do not value our older adults in our society as we should. Sometimes they are dismissed because they move slowly or are hard to communicate with due to hearing deficits. But they are, I think, a very important part of our lives.”
 

‘They’ve already won’

Most centenarians readily offer the secrets to their longevity. Aline Jacobsohn, of Boca Raton, Fla., is no different.

Ms. Jacobsohn, who will be 101 in October, thinks a diet of small portions of fish, vegetables, and fruit, which she has followed since her husband Leo died in 1982, has helped keep her healthy. She eats lots of salmon and herring and is a fan of spinach sautéed with olive oil. “The only thing I don’t eat is meat,” the trim and active Ms. Jacobsohn said in a recent interview over Zoom.

Her other secret: “Doctors. I like to stay away from them as much as possible.”

Shari Rosenbaum, MD, Jacobsohn’s internist, doesn’t dismiss that approach. She uses a version of it when managing her three centenarian patients, the oldest of whom is 103.

“Let them smoke! Let them drink! They’re happy. It’s not causing harm. Let them eat cake! They’ve already won,” said Dr. Rosenbaum, who is affiliated with Boca Raton–based MDVIP, a national membership-based network of 1,100 primary care physicians serving 368,000 patients. Of those, nearly 460 are centenarians.

“You’re not preventing those problems in this population,” she said. “They’re here to enjoy every moment that they have, and they might as well.”

Dr. Rosenbaum sees a divergence in her patients – those who will reach very old age, and those who won’t – starting in their 60s.

“The centenarians don’t have medical problems,” she said. “They don’t get cancer. They don’t get diabetes. Some of them take good care of themselves. Some don’t take such good care of themselves. But they are all optimists. They all see the glass half full. They all participate in life. They all have excellent support systems. They have good genes, a positive attitude toward life, and a strong social network.”

Ms. Jacobsohn – whose surname at the time was Bakst – grew up in Frankfurt am Main, Germany, during the rise of the Nazi regime. The family fled to Columbia in 1938, where she met and eventually married her husband, Leo, who ran a business importing clocks and watches in Cali.

In 1989, the Jacobsohns and their three children moved to south Florida to escape the dangers of kidnappings and ransoms posed by the drug cartels.

Ms. Jacobsohn agreed that she appears to have longevity genes – “good stock,” she calls it. “My mother died 23 days before she was 100. My grandmother lived till 99, almost 100,” she said.

Two years ago, she donated her car to a charity and stopped driving in the interest of her own safety and that of other drivers and pedestrians.

Ms. Jacobsohn has a strong support system. Two of her children live nearby and visit her nearly every day. A live-in companion helps her with the activities of daily life, including preparing meals.

Ms. Jacobsohn plays bridge regularly, and well. “I’m sorry to say that I’m a very good bridge player,” she said, frankly. “How is it possible that I’ve played bridge so well and then I don’t remember what I had for lunch yesterday?”

She reads, mainly a diet of history but occasionally novels, too. “They have to be engaging,” she said.

The loss of loved ones is an inevitable part of very old age. Her husband of 47 years died of emphysema, and one of her sons died in his 70s of prostate cancer.

She knows well the fate that awaits us all and accepts it philosophically.

“It’s a very normal thing that people die. You don’t live forever. So, whenever it comes, it’s okay. Enough is enough. Dayenu,” she said, using the Hebrew word for, “It would have been enough” – a favorite in the Passover Seder celebrating the ancient Jews’ liberation from slavery in Egypt.

Ms. Jacobsohn sang the song and then took a reporter on a Zoom tour of her tidy home and her large flower garden featuring Cattleya orchids from Colombia.

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

For about the past year, Priya Goel, MD, can be seen cruising around the island of Manhattan as she makes her way between visits to some of New York City’s most treasured residents: a small but essential group of patients born before the Empire State Building scraped the sky and the old Yankee Stadium had become the House That Ruth Built.

Dr. Goel, a family physician, works for Heal, a national home health care company that primarily serves people older than 65. Her practice has 10 patients older than 100 – the oldest is a 108-year-old man – whom she visits monthly.
 

The gray wave

Dr. Goel’s charges are among America’s latest baby boom – babies born a century ago, that is.

Between 1980 and 2019, the share of American centenarians, those aged 100 and up, grew faster than the total population. In 2019, 100,322 persons in the United States were at least 100 years old – more than triple the 1980 figure of 32,194, according to the U.S. Administration on Aging. By 2060, experts predict, the U.S. centenarian population will reach nearly 600,000.

Although some of the ultra-aged live in nursing homes, many continue to live independently. They require both routine and acute medical care. So, what does it take to be a physician for a centenarian?

Dr. Goel, who is in her mid-30s and could well be the great-granddaughter of some of her patients, urged her colleagues not to stereotype patients on the basis of age.

“You have to consider their functional and cognitive abilities, their ability to understand disease processes and make decisions for themselves,” Dr. Goel said. “Age is just one factor in the grand scheme of things.”

Visiting patients in their homes provides her with insights into how well they’re doing, including the safety of their environments and the depth of their social networks.

New York City has its peculiar demands. Heal provides Dr. Goel with a driver who chauffeurs her to her patient visits. She takes notes between stops.

“The idea is to have these patients remain in an environment where they’re comfortable, in surroundings where they’ve grown up or lived for many years,” she said. “A lot of them are in elevator buildings and they are wheelchair-bound or bed-bound and they physically can’t leave.”

She said she gets a far different view of the patient than does an office-based physician.

“When you go into their home, it’s very personal. You’re seeing what their daily environment is like, what their diet is like. You can see their food on the counter. You can see the level of hygiene,” Dr. Goel said. “You get to see their social support. Are their kids involved? Are they hoarding? Stuff that they wouldn’t just necessarily disclose but on a visit you get to see going into the home. It’s an extra layer of understanding that patient.”

Dr. Goel contrasted home care from care in a nursing home, where the patients are seen daily. On the basis of her observations, she decides whether to see her patients every month or every 3 months.

She applies this strategy to everyone from age 60 to over 100.
 

Tracking a growing group

Since 1995, geriatrician Thomas Perls, MD, has directed the New England Centenarian Study at Boston University. The study, largely funded by the National Institute on Aging, has enrolled 2,599 centenarian persons and 700 of their offspring. At any given time in the study, about 10% of the centenarians are alive. The study has a high mortality rate.

The people in Dr. Perls’s study range in age, but they top out at 119, the third oldest person ever in the world. Most centenarians are women.

“When we first began the study in 1995, the prevalence of centenarians in the United States was about 1 per 10,000 in the population,” Perls told this news organization. “And now, that prevalence has doubled to 1 per 5,000.”

Even if no one has achieved the record of Methuselah, the Biblical patriarch who was purported to have lived to the age of 969, some people always have lived into their 90s and beyond. Dr. Perls attributed the increase in longevity to control at the turn of the 20th century of typhoid fever, diphtheria, and other infectious diseases with effective public health measures, including the availability of clean water and improvement in socioeconomic conditions.

“Infant mortality just plummeted. So, come around 1915, 1920, we were no longer losing a quarter of our population to these diseases. That meant a quarter more of the population could age into adulthood and middle age,” he said. “A certain component of that group was, therefore, able to continue to age to a very, very old age.”

Other advances, such as antibiotics and vaccinations in the 1960s; the availability in the 1970s of much better detection and effective treatment of high blood pressure; the recognition of the harms of smoking; and much more effective treatment of cardiovascular disease and cancer have allowed many people who would have otherwise died in their 70s and 80s to live much longer. “I think what this means is that there is a substantial proportion of the population that has the biology to get to 100,” Dr. Perls said.

Perls said the Latino population and Blacks have a better track record than Whites in reaching the 100-year milestone. “The average life expectancy might be lower in these populations because of socioeconomic factors, but if they are able to get to around their early 80s, compared to Whites, their ability to get to 100 is actually better,” he said.

Asians fare best when it comes to longevity. While around 1% of White women in the United States live to 100, 10% of Asian women in Hong Kong hit that mark.

“I think some of that is better environment and health habits in Hong Kong than in the United States,” Dr. Perls said. “I think another piece may be a genetic advantage in East Asians. We’re looking into that.”

Dr. Perls said he agreed with Dr. Goel that health care providers and the lay public should not make assumptions on the basis of age alone as to how a person is doing. “People can age so very differently from one another,” he said.

Up to about age 90, the vast majority of those differences are determined by our health behaviors, such as smoking, alcohol use, exercise, sleep, the effect of our diets on weight, and access to good health care, including regular screening for problems such as high blood pressure, diabetes, and cancer. “People who are able to do everything right generally add healthy years to their lives, while those who do not have shorter life expectancies and longer periods of chronic diseases,” Dr. Perls said.

Paying diligent attention to these behaviors over the long run can have a huge payoff.

Dr. Perls’s team has found that to live beyond age 90 and on into the early 100s, protective genes can play a strong role. These genes help slow aging and decrease one’s risk for aging-related diseases. Centenarians usually have a history of aging very slowly and greatly delaying aging-related diseases and disability toward the ends of their lives.

Centenarians are the antithesis of the misguided belief that the older you get, the sicker you get. Quite the opposite occurs. For Dr. Perls, “the older you get, the healthier you’ve been.”
 

MD bias against the elderly?

Care of elderly patients is becoming essential in the practice of primary care physicians – but not all of them enjoy the work.

To be effective, physicians who treat centenarians must get a better idea of the individual patient’s functional status and comorbidities. “You absolutely cannot make assumptions on age alone,” Dr. Perls said.

The so-called “normal” temperature, 98.6° F, can spell trouble for centenarians and other very old patients, warned Natalie Baker, DNP, CRNP, an associate professor of nursing at the University of Alabama, Birmingham, and president of the 3,000-member Gerontological Advanced Practice Nurses Association.

“We have to be very cognizant of what we call a typical presentation of disease or illness and that a very subtle change in an older adult can signal a serious infection or illness,” Dr. Baker said. “If your patient has a high fever, that is a potential problem.”

The average temperature of an older adult is lower than the accepted 98.6° F, and their body’s response to an infection is slow to exhibit an increase in temperature, Dr. Baker said. “When treating centenarians, clinicians must be cognizant of other subtle signs of infection, such as decreased appetite or change in mentation,” she cautioned.

A decline in appetite or insomnia may be a subtle sign that these patients need to be evaluated, she added.
 

COVID-19 and centenarians

Three-quarters of the 1 million U.S. deaths from COVID-19 occurred in people aged 65 and older. However, Dr. Perls said centenarians may be a special subpopulation when it comes to COVID.

The Japanese Health Ministry, which follows the large centenarian population in that country, noted a marked jump in the number of centenarians during the pandemic – although the reasons for the increase aren’t clear.

Centenarians may be a bit different. Dr. Perls said some evidence suggests that the over-100 crowd may have better immune systems than younger people. “Part of the trick of getting to 100 is having a pretty good immune system,” he said.
 

Don’t mess with success

“There is no need at that point for us to try to alter their diet to what we think it might be,” Dr. Baker said. “There’s no need to start with diabetic education. They may tell you their secret is a shot of vodka every day. Why should we stop it at that age? Accept their lifestyles, because they’ve done something right to get to that age.”

Opinions differ on how to approach screening for centenarians.

Dr. Goel said guidelines for routine screening, such as colonoscopies, mammograms, and PAP smears, drop off for patients starting at 75. Dr. Perls said this strategy stems from the belief that people will die from other things first, so screening is no longer needed. Dr. Perls said he disagrees with this approach.

“Again, we can’t base our screening and health care decisions on age alone. If I have an independently functioning and robust 95-year-old man in my office, you can be sure I am going to continue recommending regular screening for colon cancer and other screenings that are normal for people who are 30 years younger,” he said.

Justin Zaghi, MD, chief medical officer at Heal, said screening patients in their late 90s and 100s for cancer generally doesn’t make sense except in some rare circumstances in which the cancer would be unlikely to be a cause of death. “However, if we are talking about screening for fall risks, hearing difficulties, poor vision, pain, and malnutrition, those screenings still absolutely make sense for patients in their late 90s and 100s,” Dr. Zaghi said.

One high-functioning 104-year-old patient of Dr. Perls underwent a total hip replacement for a hip fracture and is faring well. “Obviously, if she had end-stage dementia, we’d do everything to keep the person comfortable, or if they had medical problems that made surgery too high risk, then you don’t do it,” he said. “But if they’re otherwise, I would proceed.”
 

Avoid the ED

Dr. Goel said doctors should avoid sending patients to the emergency department, an often chaotic place that is especially unfriendly to centenarians and the very old. “Sometimes I’ve seen older patients who are being rushed to the ER, and I ask, What are the goals of care?” she said.

Clinicians caring for seniors should keep in mind that infections can cause seniors to appear confused – and this may lead the clinician to think the patient has dementia. Or, Dr. Goel said, a patient with dementia may suddenly experience much worse dementia.

“In either case, you want to make sure you’re not dealing with any underlying infection, like urinary tract infection, or pneumonia brewing, or skin infections,” she said. “Their skin is so much frailer. You want to make sure there are no bedsores.”

She has had patients whose children report that their usually placid centenarian parents are suddenly acting out. “We’ll do a urinary test and it definitely shows a urinary tract infection. You want to make sure you’re not missing out on something else before you attribute it to dementia,” she said.

Environmental changes, such as moving a patient to a new room in a hospital setting, can trigger an acute mental status change, such as delirium, she added. Helping older patients feel in control as much as possible is important.

“You want to make sure you’re orienting them to the time of day. Make sure they get up at the same time, go to bed at the same time, have clocks and calendars present – just making sure that they feel like they’re still in control of their body and their day,” she said.

Physicians should be aware of potential depression in these patients, whose experience of loss – an unavoidable consequence of outliving family and friends – can result in problems with sleep and diet, as well as a sense of social isolation.

Neal Flomenbaum, MD, professor and emergency physician-in-chief emeritus, New York–Presbyterian/Weill Cornell Medical Center in New York, said sometimes the best thing for these very elderly patients is to “get them in and out of ED as quickly as possible, and do what you can diagnostically.”

He noted that EDs have been making accommodations to serve the elderly, such as using LEDs that replicate outdoor lighting conditions, as well as providing seniors with separate rooms with glass doors to protect them from noise, separate air handlers to prevent infections, and adequate space for visitors.

These patients often are subject to trauma from falls.

“The bones don’t heal as well as in younger people, and treating their comorbidities is essential. Once they have trouble with one area and they’re lying in bed and can’t move much, they can get bedsores,” Dr. Flomenbaum said. “In the hospital, they are vulnerable to infections. So, you’re thinking of all of these things at the same time and how to treat them appropriately and then get them out of the hospital as soon as possible with whatever care that they need in their own homes if at all possible.”

“I always err on the side of less is more,” Dr. Goel said. “Obviously, if there is something – if they have a cough, they need an x-ray. That’s very basic. We want to take care of that. Give them the antibiotic if they need that. But rushing them in and out of the hospital doesn’t add to their quality of life.”

Dr. Flomenbaum, a pioneer in geriatric emergency medicine, says physicians need to be aware that centenarians and other very old patients don’t present the same way as younger adults.

He began to notice more than 20 years ago that every night, patients would turn up in his ED who were in their late 90s into their 100s. Some would come in with what their children identified as sudden-onset dementia – they didn’t know their own names and couldn’t identify their kids. They didn’t know the time or day. Dr. Flomenbaum said the children often asked whether their parents should enter a nursing home.

“And I’d say, ‘Not so fast. Well, let’s take a look at this.’ You don’t develop that kind of dementia overnight. It usually takes a while,” he said.

He said he ordered complete blood cell counts and oxygen saturation tests that frequently turned out to be abnormal. They didn’t have a fever, and infiltrates initially weren’t seen on chest x-rays.

With rehydration and supplemental oxygen, their symptoms started to improve, and it became obvious that the symptoms were not of dementia but of pneumonia, and that they required antibiotics, Dr. Flomenbaum said.
 

Dementia dilemma

Too often, on the basis of age, doctors assume patients have dementia or other cognitive impairments.

“What a shock and a surprise when doctors actually talk to folks and do a neurocognitive screen and find they’re just fine,” Dr. Perls said.

The decline in hearing and vision can lead to a misdiagnosis of cognitive impairment because the patients are not able to hear what you’re asking them. “It’s really important that the person can hear you – whether you use an amplifying device or they have hearing aids, that’s critical,” he said. “You just have to be a good doctor.”

Often the physical toll of aging exacerbates social difficulties. Poor hearing, for example, can accelerate cognitive impairment and cause people to interact less often, and less meaningfully, with their environment. For some, wearing hearing aids seems demeaning – until they hear what they’ve been missing.

“I get them to wear their hearing aids and, lo and behold, they’re a whole new person because they’re now able to take in their environment and interact with others,” Dr. Perls said.

Dr. Flomenbaum said alcohol abuse and drug reactions can cause delirium, which, unlike dementia, is potentially reversible. Yet many physicians cannot reliably differentiate between dementia and delirium, he added.

The geriatric specialists talk about the lessons they’ve learned and the gratification they get from caring for centenarians.

“I have come to realize the importance of family, of having a close circle, whether that’s through friends or neighbors,” Dr. Goel said. “This work is very rewarding because, if it wasn’t for homebound organizations, how would these people get care or get access to care?”

For Dr. Baker, a joy of the job is hearing centenarians share their life stories.

“I love to hear their stories about how they’ve overcome adversity, living through the depression and living through different wars,” she said. “I love talking to veterans, and I think that oftentimes, we do not value our older adults in our society as we should. Sometimes they are dismissed because they move slowly or are hard to communicate with due to hearing deficits. But they are, I think, a very important part of our lives.”
 

‘They’ve already won’

Most centenarians readily offer the secrets to their longevity. Aline Jacobsohn, of Boca Raton, Fla., is no different.

Ms. Jacobsohn, who will be 101 in October, thinks a diet of small portions of fish, vegetables, and fruit, which she has followed since her husband Leo died in 1982, has helped keep her healthy. She eats lots of salmon and herring and is a fan of spinach sautéed with olive oil. “The only thing I don’t eat is meat,” the trim and active Ms. Jacobsohn said in a recent interview over Zoom.

Her other secret: “Doctors. I like to stay away from them as much as possible.”

Shari Rosenbaum, MD, Jacobsohn’s internist, doesn’t dismiss that approach. She uses a version of it when managing her three centenarian patients, the oldest of whom is 103.

“Let them smoke! Let them drink! They’re happy. It’s not causing harm. Let them eat cake! They’ve already won,” said Dr. Rosenbaum, who is affiliated with Boca Raton–based MDVIP, a national membership-based network of 1,100 primary care physicians serving 368,000 patients. Of those, nearly 460 are centenarians.

“You’re not preventing those problems in this population,” she said. “They’re here to enjoy every moment that they have, and they might as well.”

Dr. Rosenbaum sees a divergence in her patients – those who will reach very old age, and those who won’t – starting in their 60s.

“The centenarians don’t have medical problems,” she said. “They don’t get cancer. They don’t get diabetes. Some of them take good care of themselves. Some don’t take such good care of themselves. But they are all optimists. They all see the glass half full. They all participate in life. They all have excellent support systems. They have good genes, a positive attitude toward life, and a strong social network.”

Ms. Jacobsohn – whose surname at the time was Bakst – grew up in Frankfurt am Main, Germany, during the rise of the Nazi regime. The family fled to Columbia in 1938, where she met and eventually married her husband, Leo, who ran a business importing clocks and watches in Cali.

In 1989, the Jacobsohns and their three children moved to south Florida to escape the dangers of kidnappings and ransoms posed by the drug cartels.

Ms. Jacobsohn agreed that she appears to have longevity genes – “good stock,” she calls it. “My mother died 23 days before she was 100. My grandmother lived till 99, almost 100,” she said.

Two years ago, she donated her car to a charity and stopped driving in the interest of her own safety and that of other drivers and pedestrians.

Ms. Jacobsohn has a strong support system. Two of her children live nearby and visit her nearly every day. A live-in companion helps her with the activities of daily life, including preparing meals.

Ms. Jacobsohn plays bridge regularly, and well. “I’m sorry to say that I’m a very good bridge player,” she said, frankly. “How is it possible that I’ve played bridge so well and then I don’t remember what I had for lunch yesterday?”

She reads, mainly a diet of history but occasionally novels, too. “They have to be engaging,” she said.

The loss of loved ones is an inevitable part of very old age. Her husband of 47 years died of emphysema, and one of her sons died in his 70s of prostate cancer.

She knows well the fate that awaits us all and accepts it philosophically.

“It’s a very normal thing that people die. You don’t live forever. So, whenever it comes, it’s okay. Enough is enough. Dayenu,” she said, using the Hebrew word for, “It would have been enough” – a favorite in the Passover Seder celebrating the ancient Jews’ liberation from slavery in Egypt.

Ms. Jacobsohn sang the song and then took a reporter on a Zoom tour of her tidy home and her large flower garden featuring Cattleya orchids from Colombia.

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

COVID-19 can cause disorders of gut-brain interaction, including postinfection irritable bowel syndrome (IBS), researchers say.

Gastrointestinal symptoms are common with long COVID, also known as post-acute COVID-19 syndrome, according to Walter Chan, MD, MPH, and Madhusudan Grover, MBBS.

Dr. Chan, an assistant professor at Harvard Medical School, Boston, and Dr. Grover, an associate professor of medicine and physiology at Mayo Clinic, Rochester, Minn., conducted a review of the literature on COVID-19’s long-term gastrointestinal effects. Their review was published in Clinical Gastroenterology and Hepatology.

Estimates of the prevalence of gastrointestinal symptoms with COVID-19 have ranged as high as 60%, Dr. Chan and Dr. Grover report, and the symptoms may be present in patients with long COVID, a syndrome that continues 4 weeks or longer.

In one survey of 749 COVID-19 survivors, 29% reported at least one new chronic gastrointestinal symptom. The most common were heartburn, constipation, diarrhea, and abdominal pain. Of those with abdominal pain, 39% had symptoms that met Rome IV criteria for irritable bowel syndrome.

People who have gastrointestinal symptoms after their initial SARS-CoV-2 infection are more likely to have them with long COVID. Psychiatric diagnoses, hospitalization, and the loss of smell and taste are predictors of gastrointestinal symptoms.

Infectious gastroenteritis can increase the risk for disorders of gut-brain interaction, especially postinfection IBS, Dr. Chan and Dr. Grover write.

COVID-19 likely causes gastrointestinal symptoms through multiple mechanisms. It may suppress angiotensin-converting enzyme 2, which protects intestinal cells. It can alter the microbiome. It can cause or worsen weight gain and diabetes. It may disrupt the immune system and trigger an autoimmune reaction. It can cause depression and anxiety, and it can alter dietary habits.

No specific treatments for gastrointestinal symptoms associated with long COVID have emerged, so clinicians should make use of established therapies for disorders of gut-brain interaction, Dr. Chan and Dr. Grover recommend.

Beyond adequate sleep and exercise, these may include high-fiber, low FODMAP (fermentable oligosaccharides, disaccharides, monosaccharides, and polyols), gluten-free, low-carbohydrate, or elimination diets.

For diarrhea, they list loperamide, ondansetron, alosetron, eluxadoline, antispasmodics, rifaximin, and bile acid sequestrants.

For constipation, they mention fiber supplements, polyethylene glycol, linaclotide, plecanatide, lubiprostone, tenapanor, tegaserod, and prucalopride.

For modulating intestinal permeability, they recommend glutamine.

Neuromodulation may be achieved with tricyclic antidepressants, selective serotonin reuptake inhibitors, serotonin norepinephrine reuptake inhibitors, azaperones, and delta ligands, they write.

For psychological therapy, they recommend cognitive-behavioral therapy and gut-directed hypnotherapy.

A handful of studies have suggested benefits from Lactiplantibacillus plantarum and Pediococcus acidilactici as probiotic therapies. Additionally, one study showed positive results with a high-fiber formula, perhaps by nourishing short-chain fatty acid-producing bacteria, Dr. Chan and Dr. Grover write.

Dr. Chan reported financial relationships with Ironwood, Takeda, and Phathom Pharmaceuticals. Dr. Grover reported financial relationships with Takeda, Donga, Alexza Pharmaceuticals, and Alfasigma.

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

COVID-19 can cause disorders of gut-brain interaction, including postinfection irritable bowel syndrome (IBS), researchers say.

Gastrointestinal symptoms are common with long COVID, also known as post-acute COVID-19 syndrome, according to Walter Chan, MD, MPH, and Madhusudan Grover, MBBS.

Dr. Chan, an assistant professor at Harvard Medical School, Boston, and Dr. Grover, an associate professor of medicine and physiology at Mayo Clinic, Rochester, Minn., conducted a review of the literature on COVID-19’s long-term gastrointestinal effects. Their review was published in Clinical Gastroenterology and Hepatology.

Estimates of the prevalence of gastrointestinal symptoms with COVID-19 have ranged as high as 60%, Dr. Chan and Dr. Grover report, and the symptoms may be present in patients with long COVID, a syndrome that continues 4 weeks or longer.

In one survey of 749 COVID-19 survivors, 29% reported at least one new chronic gastrointestinal symptom. The most common were heartburn, constipation, diarrhea, and abdominal pain. Of those with abdominal pain, 39% had symptoms that met Rome IV criteria for irritable bowel syndrome.

People who have gastrointestinal symptoms after their initial SARS-CoV-2 infection are more likely to have them with long COVID. Psychiatric diagnoses, hospitalization, and the loss of smell and taste are predictors of gastrointestinal symptoms.

Infectious gastroenteritis can increase the risk for disorders of gut-brain interaction, especially postinfection IBS, Dr. Chan and Dr. Grover write.

COVID-19 likely causes gastrointestinal symptoms through multiple mechanisms. It may suppress angiotensin-converting enzyme 2, which protects intestinal cells. It can alter the microbiome. It can cause or worsen weight gain and diabetes. It may disrupt the immune system and trigger an autoimmune reaction. It can cause depression and anxiety, and it can alter dietary habits.

No specific treatments for gastrointestinal symptoms associated with long COVID have emerged, so clinicians should make use of established therapies for disorders of gut-brain interaction, Dr. Chan and Dr. Grover recommend.

Beyond adequate sleep and exercise, these may include high-fiber, low FODMAP (fermentable oligosaccharides, disaccharides, monosaccharides, and polyols), gluten-free, low-carbohydrate, or elimination diets.

For diarrhea, they list loperamide, ondansetron, alosetron, eluxadoline, antispasmodics, rifaximin, and bile acid sequestrants.

For constipation, they mention fiber supplements, polyethylene glycol, linaclotide, plecanatide, lubiprostone, tenapanor, tegaserod, and prucalopride.

For modulating intestinal permeability, they recommend glutamine.

Neuromodulation may be achieved with tricyclic antidepressants, selective serotonin reuptake inhibitors, serotonin norepinephrine reuptake inhibitors, azaperones, and delta ligands, they write.

For psychological therapy, they recommend cognitive-behavioral therapy and gut-directed hypnotherapy.

A handful of studies have suggested benefits from Lactiplantibacillus plantarum and Pediococcus acidilactici as probiotic therapies. Additionally, one study showed positive results with a high-fiber formula, perhaps by nourishing short-chain fatty acid-producing bacteria, Dr. Chan and Dr. Grover write.

Dr. Chan reported financial relationships with Ironwood, Takeda, and Phathom Pharmaceuticals. Dr. Grover reported financial relationships with Takeda, Donga, Alexza Pharmaceuticals, and Alfasigma.

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

COVID-19 can cause disorders of gut-brain interaction, including postinfection irritable bowel syndrome (IBS), researchers say.

Gastrointestinal symptoms are common with long COVID, also known as post-acute COVID-19 syndrome, according to Walter Chan, MD, MPH, and Madhusudan Grover, MBBS.

Dr. Chan, an assistant professor at Harvard Medical School, Boston, and Dr. Grover, an associate professor of medicine and physiology at Mayo Clinic, Rochester, Minn., conducted a review of the literature on COVID-19’s long-term gastrointestinal effects. Their review was published in Clinical Gastroenterology and Hepatology.

Estimates of the prevalence of gastrointestinal symptoms with COVID-19 have ranged as high as 60%, Dr. Chan and Dr. Grover report, and the symptoms may be present in patients with long COVID, a syndrome that continues 4 weeks or longer.

In one survey of 749 COVID-19 survivors, 29% reported at least one new chronic gastrointestinal symptom. The most common were heartburn, constipation, diarrhea, and abdominal pain. Of those with abdominal pain, 39% had symptoms that met Rome IV criteria for irritable bowel syndrome.

People who have gastrointestinal symptoms after their initial SARS-CoV-2 infection are more likely to have them with long COVID. Psychiatric diagnoses, hospitalization, and the loss of smell and taste are predictors of gastrointestinal symptoms.

Infectious gastroenteritis can increase the risk for disorders of gut-brain interaction, especially postinfection IBS, Dr. Chan and Dr. Grover write.

COVID-19 likely causes gastrointestinal symptoms through multiple mechanisms. It may suppress angiotensin-converting enzyme 2, which protects intestinal cells. It can alter the microbiome. It can cause or worsen weight gain and diabetes. It may disrupt the immune system and trigger an autoimmune reaction. It can cause depression and anxiety, and it can alter dietary habits.

No specific treatments for gastrointestinal symptoms associated with long COVID have emerged, so clinicians should make use of established therapies for disorders of gut-brain interaction, Dr. Chan and Dr. Grover recommend.

Beyond adequate sleep and exercise, these may include high-fiber, low FODMAP (fermentable oligosaccharides, disaccharides, monosaccharides, and polyols), gluten-free, low-carbohydrate, or elimination diets.

For diarrhea, they list loperamide, ondansetron, alosetron, eluxadoline, antispasmodics, rifaximin, and bile acid sequestrants.

For constipation, they mention fiber supplements, polyethylene glycol, linaclotide, plecanatide, lubiprostone, tenapanor, tegaserod, and prucalopride.

For modulating intestinal permeability, they recommend glutamine.

Neuromodulation may be achieved with tricyclic antidepressants, selective serotonin reuptake inhibitors, serotonin norepinephrine reuptake inhibitors, azaperones, and delta ligands, they write.

For psychological therapy, they recommend cognitive-behavioral therapy and gut-directed hypnotherapy.

A handful of studies have suggested benefits from Lactiplantibacillus plantarum and Pediococcus acidilactici as probiotic therapies. Additionally, one study showed positive results with a high-fiber formula, perhaps by nourishing short-chain fatty acid-producing bacteria, Dr. Chan and Dr. Grover write.

Dr. Chan reported financial relationships with Ironwood, Takeda, and Phathom Pharmaceuticals. Dr. Grover reported financial relationships with Takeda, Donga, Alexza Pharmaceuticals, and Alfasigma.

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

A case study of a 65-year-old man in Japan with long COVID describes how he recovered from certain impaired hormone deficiencies that persisted for more than a year.

Days after the patient recovered from respiratory failure and came off a ventilator, he had a sudden drop in blood pressure, which responded to hydrocortisone.

The patient was found to have low levels of growth hormone and adrenocorticotropic hormone (ACTH), hypopituitarism, that persisted for more than a year. He also had low levels of testosterone that remained low at 15 months (the study end).

“An important finding in the present case is the eventual recovery from hypopituitarism over time but not from hypogonadism,” the researchers write in their study published in Endocrine Journal.

This is the first published case of secondary adrenal insufficiency after recovery from COVID-19, which was confirmed using an insulin tolerance test, Kai Yoshimura, Kakogawa Medical Center, Japan, and colleagues report.

The findings show that “pituitary insufficiency should be considered in patients with prolonged symptoms of COVID-19,” they report, since it can be treated with hormone supplements that markedly improve symptoms and quality of life.

“It might be worthwhile to screen for endocrine dysfunction in patients with such persistent symptoms after their recovery from the acute disease,” the researchers conclude.
 

Case study timeline

The patient in this study was healthy without obesity, previous endocrine disease, or steroid use. He was admitted to hospital because he had dyspnea and fever for 8 days and a reverse transcription-polymerase chain reaction (RT-PCR) test that was positive for COVID-19.

He received ciclesonide 200 mcg/day for 2 days. Then he was put on a ventilator and the drug was discontinued and “favipiravir, ritonavir, and lopinavir, a standard regimen during the early phase of the COVID-19 pandemic, were initiated;” the researchers explain.

On day 25 of his hospital stay the patient had recovered from respiratory failure and was extubated.

On day 31, he had a negative PCR test for COVID-19.

On day 36, the patient’s blood pressure suddenly dropped from 120/80 mmHg to 80/50 mmHg. His plasma ACTH and serum cortisol levels were low, suggesting secondary adrenal insufficiency. The low blood pressure responded to hydrocortisone 100 mg, which was gradually tapered.

At day 96, the patient was discharged from hospital with a dose of 15 mg/day hydrocortisone.

At 3 months after discharge, an insulin tolerance test revealed that the patient’s ACTH and cortisol responses were blunted, suggestive of adrenal insufficiency. The patient also had moderate growth hormone deficiency and symptoms of hypogonadism.

At 6 months after discharge, the patient started testosterone therapy because his dysspermatism had worsened.

At 12 months after discharge, a repeat insulin tolerance test showed that both ACTH and cortisol responses were low but improved. The patient was no longer deficient in growth hormone.

At 15 months after discharge, early morning levels of ACTH and cortisol were now in the normal range. The patient discontinued testosterone treatment, but the symptoms returned, so he resumed it.
 

Long COVID symptoms, possible biological mechanism

The present case shows how certain COVID-19–associated conditions develop after the onset of, or the recovery from, respiratory disorders, the authors note.

Symptoms of long COVID-19 include fatigue, weakness, hair loss, diarrhea, arthralgia, and depression, and these symptoms are associated with pituitary insufficiency, especially secondary adrenocortical insufficiency.

In addition, an estimated 25% of sexually active men who recover from COVID have semen disorders such as azoospermia and oligospermia.

The underlying mechanism by which COVID-19 might trigger pituitary insufficiency is unknown, but other viral infections such as influenza-A and herpes simplex are also associated with transient hypopituitarism. An exaggerated immune response triggered by SARS-CoV-2 may explain the dysfunction of multiple endocrine organs, the researchers write.  

The researchers have declared no conflicts of interest.

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

A case study of a 65-year-old man in Japan with long COVID describes how he recovered from certain impaired hormone deficiencies that persisted for more than a year.

Days after the patient recovered from respiratory failure and came off a ventilator, he had a sudden drop in blood pressure, which responded to hydrocortisone.

The patient was found to have low levels of growth hormone and adrenocorticotropic hormone (ACTH), hypopituitarism, that persisted for more than a year. He also had low levels of testosterone that remained low at 15 months (the study end).

“An important finding in the present case is the eventual recovery from hypopituitarism over time but not from hypogonadism,” the researchers write in their study published in Endocrine Journal.

This is the first published case of secondary adrenal insufficiency after recovery from COVID-19, which was confirmed using an insulin tolerance test, Kai Yoshimura, Kakogawa Medical Center, Japan, and colleagues report.

The findings show that “pituitary insufficiency should be considered in patients with prolonged symptoms of COVID-19,” they report, since it can be treated with hormone supplements that markedly improve symptoms and quality of life.

“It might be worthwhile to screen for endocrine dysfunction in patients with such persistent symptoms after their recovery from the acute disease,” the researchers conclude.
 

Case study timeline

The patient in this study was healthy without obesity, previous endocrine disease, or steroid use. He was admitted to hospital because he had dyspnea and fever for 8 days and a reverse transcription-polymerase chain reaction (RT-PCR) test that was positive for COVID-19.

He received ciclesonide 200 mcg/day for 2 days. Then he was put on a ventilator and the drug was discontinued and “favipiravir, ritonavir, and lopinavir, a standard regimen during the early phase of the COVID-19 pandemic, were initiated;” the researchers explain.

On day 25 of his hospital stay the patient had recovered from respiratory failure and was extubated.

On day 31, he had a negative PCR test for COVID-19.

On day 36, the patient’s blood pressure suddenly dropped from 120/80 mmHg to 80/50 mmHg. His plasma ACTH and serum cortisol levels were low, suggesting secondary adrenal insufficiency. The low blood pressure responded to hydrocortisone 100 mg, which was gradually tapered.

At day 96, the patient was discharged from hospital with a dose of 15 mg/day hydrocortisone.

At 3 months after discharge, an insulin tolerance test revealed that the patient’s ACTH and cortisol responses were blunted, suggestive of adrenal insufficiency. The patient also had moderate growth hormone deficiency and symptoms of hypogonadism.

At 6 months after discharge, the patient started testosterone therapy because his dysspermatism had worsened.

At 12 months after discharge, a repeat insulin tolerance test showed that both ACTH and cortisol responses were low but improved. The patient was no longer deficient in growth hormone.

At 15 months after discharge, early morning levels of ACTH and cortisol were now in the normal range. The patient discontinued testosterone treatment, but the symptoms returned, so he resumed it.
 

Long COVID symptoms, possible biological mechanism

The present case shows how certain COVID-19–associated conditions develop after the onset of, or the recovery from, respiratory disorders, the authors note.

Symptoms of long COVID-19 include fatigue, weakness, hair loss, diarrhea, arthralgia, and depression, and these symptoms are associated with pituitary insufficiency, especially secondary adrenocortical insufficiency.

In addition, an estimated 25% of sexually active men who recover from COVID have semen disorders such as azoospermia and oligospermia.

The underlying mechanism by which COVID-19 might trigger pituitary insufficiency is unknown, but other viral infections such as influenza-A and herpes simplex are also associated with transient hypopituitarism. An exaggerated immune response triggered by SARS-CoV-2 may explain the dysfunction of multiple endocrine organs, the researchers write.  

The researchers have declared no conflicts of interest.

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

A case study of a 65-year-old man in Japan with long COVID describes how he recovered from certain impaired hormone deficiencies that persisted for more than a year.

Days after the patient recovered from respiratory failure and came off a ventilator, he had a sudden drop in blood pressure, which responded to hydrocortisone.

The patient was found to have low levels of growth hormone and adrenocorticotropic hormone (ACTH), hypopituitarism, that persisted for more than a year. He also had low levels of testosterone that remained low at 15 months (the study end).

“An important finding in the present case is the eventual recovery from hypopituitarism over time but not from hypogonadism,” the researchers write in their study published in Endocrine Journal.

This is the first published case of secondary adrenal insufficiency after recovery from COVID-19, which was confirmed using an insulin tolerance test, Kai Yoshimura, Kakogawa Medical Center, Japan, and colleagues report.

The findings show that “pituitary insufficiency should be considered in patients with prolonged symptoms of COVID-19,” they report, since it can be treated with hormone supplements that markedly improve symptoms and quality of life.

“It might be worthwhile to screen for endocrine dysfunction in patients with such persistent symptoms after their recovery from the acute disease,” the researchers conclude.
 

Case study timeline

The patient in this study was healthy without obesity, previous endocrine disease, or steroid use. He was admitted to hospital because he had dyspnea and fever for 8 days and a reverse transcription-polymerase chain reaction (RT-PCR) test that was positive for COVID-19.

He received ciclesonide 200 mcg/day for 2 days. Then he was put on a ventilator and the drug was discontinued and “favipiravir, ritonavir, and lopinavir, a standard regimen during the early phase of the COVID-19 pandemic, were initiated;” the researchers explain.

On day 25 of his hospital stay the patient had recovered from respiratory failure and was extubated.

On day 31, he had a negative PCR test for COVID-19.

On day 36, the patient’s blood pressure suddenly dropped from 120/80 mmHg to 80/50 mmHg. His plasma ACTH and serum cortisol levels were low, suggesting secondary adrenal insufficiency. The low blood pressure responded to hydrocortisone 100 mg, which was gradually tapered.

At day 96, the patient was discharged from hospital with a dose of 15 mg/day hydrocortisone.

At 3 months after discharge, an insulin tolerance test revealed that the patient’s ACTH and cortisol responses were blunted, suggestive of adrenal insufficiency. The patient also had moderate growth hormone deficiency and symptoms of hypogonadism.

At 6 months after discharge, the patient started testosterone therapy because his dysspermatism had worsened.

At 12 months after discharge, a repeat insulin tolerance test showed that both ACTH and cortisol responses were low but improved. The patient was no longer deficient in growth hormone.

At 15 months after discharge, early morning levels of ACTH and cortisol were now in the normal range. The patient discontinued testosterone treatment, but the symptoms returned, so he resumed it.
 

Long COVID symptoms, possible biological mechanism

The present case shows how certain COVID-19–associated conditions develop after the onset of, or the recovery from, respiratory disorders, the authors note.

Symptoms of long COVID-19 include fatigue, weakness, hair loss, diarrhea, arthralgia, and depression, and these symptoms are associated with pituitary insufficiency, especially secondary adrenocortical insufficiency.

In addition, an estimated 25% of sexually active men who recover from COVID have semen disorders such as azoospermia and oligospermia.

The underlying mechanism by which COVID-19 might trigger pituitary insufficiency is unknown, but other viral infections such as influenza-A and herpes simplex are also associated with transient hypopituitarism. An exaggerated immune response triggered by SARS-CoV-2 may explain the dysfunction of multiple endocrine organs, the researchers write.  

The researchers have declared no conflicts of interest.

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