Many patients with early-stage HR+/HER2- breast cancer are at high risk for disease recurrence within just a few years of first-line treatment. In this ReCAP, Michelle Melisko, MD, of the University of San Francisco Medical Center, discusses strategies for reducing recurrence rates in these patients.

Dr Melisko begins by identifying the traditional criteria for selecting treatment, including age, comorbidities, tumor size, and nodal status, along with proper utilization of genomic assays. She notes that the RxPONDER and TAILORx trials have demonstrated benefits of chemotherapy plus endocrine therapy in premenopausal patients on the basis of Oncotype DX recurrence scores between 0 and 25.

Next, Dr Melisko discusses how the 2021 FDA approval of abemaciclib plus endocrine therapy in the adjuvant setting mandates that patients have a Ki-67 score of 20%. This is a more restrictive patient population than those who saw benefit in the monarchE clinical trial and presents a challenge for physicians selecting therapy for their patients.

Dr Melisko concludes by sharing 3-year data from the OlympiA trial supporting the use of olaparib in patients with BRCA1 and BRCA2 mutations, as well as findings from the SOFT/TEXT trials that demonstrated the benefit of ovarian suppression in younger patients.

--

Michelle E. Melisko, MD, Associate Clinical Professor, Department of Medicine, Division of Hematology-Oncology, University of San Francisco Medical Center; UCSF Bakar Precision Cancer Medicine, San Francisco, California

Michelle E. Melisko, MD, has disclosed no relevant financial relationships

Many patients with early-stage HR+/HER2- breast cancer are at high risk for disease recurrence within just a few years of first-line treatment. In this ReCAP, Michelle Melisko, MD, of the University of San Francisco Medical Center, discusses strategies for reducing recurrence rates in these patients.

Dr Melisko begins by identifying the traditional criteria for selecting treatment, including age, comorbidities, tumor size, and nodal status, along with proper utilization of genomic assays. She notes that the RxPONDER and TAILORx trials have demonstrated benefits of chemotherapy plus endocrine therapy in premenopausal patients on the basis of Oncotype DX recurrence scores between 0 and 25.

Next, Dr Melisko discusses how the 2021 FDA approval of abemaciclib plus endocrine therapy in the adjuvant setting mandates that patients have a Ki-67 score of 20%. This is a more restrictive patient population than those who saw benefit in the monarchE clinical trial and presents a challenge for physicians selecting therapy for their patients.

Dr Melisko concludes by sharing 3-year data from the OlympiA trial supporting the use of olaparib in patients with BRCA1 and BRCA2 mutations, as well as findings from the SOFT/TEXT trials that demonstrated the benefit of ovarian suppression in younger patients.

--

Michelle E. Melisko, MD, Associate Clinical Professor, Department of Medicine, Division of Hematology-Oncology, University of San Francisco Medical Center; UCSF Bakar Precision Cancer Medicine, San Francisco, California

Michelle E. Melisko, MD, has disclosed no relevant financial relationships

Many patients with early-stage HR+/HER2- breast cancer are at high risk for disease recurrence within just a few years of first-line treatment. In this ReCAP, Michelle Melisko, MD, of the University of San Francisco Medical Center, discusses strategies for reducing recurrence rates in these patients.

Dr Melisko begins by identifying the traditional criteria for selecting treatment, including age, comorbidities, tumor size, and nodal status, along with proper utilization of genomic assays. She notes that the RxPONDER and TAILORx trials have demonstrated benefits of chemotherapy plus endocrine therapy in premenopausal patients on the basis of Oncotype DX recurrence scores between 0 and 25.

Next, Dr Melisko discusses how the 2021 FDA approval of abemaciclib plus endocrine therapy in the adjuvant setting mandates that patients have a Ki-67 score of 20%. This is a more restrictive patient population than those who saw benefit in the monarchE clinical trial and presents a challenge for physicians selecting therapy for their patients.

Dr Melisko concludes by sharing 3-year data from the OlympiA trial supporting the use of olaparib in patients with BRCA1 and BRCA2 mutations, as well as findings from the SOFT/TEXT trials that demonstrated the benefit of ovarian suppression in younger patients.

--

Michelle E. Melisko, MD, Associate Clinical Professor, Department of Medicine, Division of Hematology-Oncology, University of San Francisco Medical Center; UCSF Bakar Precision Cancer Medicine, San Francisco, California

Michelle E. Melisko, MD, has disclosed no relevant financial relationships

CHICAGO – To give a sense of how social factors affect someone’s health, Sarah Candler, MD, MPH, described this case: A 70-year-old woman with diabetes, rheumatoid arthritis, and high blood pressure and a high hemoglobin A1C, even though she’s on insulin.

This patient is on prednisone for her RA because she can’t afford better drugs, and she has been occasionally skipping her insulin, Dr. Candler said during her presentation, at the annual meeting of the American College of Physicians

Plus, her first language is Turkish, and she’s missed many doctor appointments because she lives too far from the center-city clinics, said Dr. Candler, who is the care team medical director at Iora Primary Care in Houston.

How are this woman’s needs supposed to be met in a fee-for-service system that allows medical staff 15 to 30 minutes to help solve her problems?

Potential regulatory fixes

A panel of experts talked about potential policies and regulatory fixes that take into account the impact of “social determinants of health.” Some of these are gaining traction, but there is still a huge gap between how medicine in practiced in the United States and the health needs of people in the community, the panelists said.

The ACO REACH (Realizing Equity, Access and Community Health) model is a recent step forward, said Josh Liao, MD, MSc, associate chair for health systems at the University of Washington, Seattle. The accountable care organization model pays doctors more for caring for Medicare patients in underserved communities.

“To me, it represents that at least we’re moving in the direction where we’re acknowledging directly that social environment matters,” he said.

The American College of Physicians’ Medical Practice and Quality Committee helped improve payment for telehealth, an important step for equity to the underserved, said William Fox, MD, at Fox and Brantley Internal Medicine in Charlottesville, Va., and chair of the committee for ACP’s Virginia chapter. But many policies require much more work, he said.

One aim is getting to universal health coverage – 31 million people in the United States still don’t have health insurance, a number that is greatly improved since the Affordable Care Act but has plateaued recently.

Another is to invest more in primary care – which accounts for about 5% of spending even though 35% of patient visits are to primary care.

Dr. Fox said the U.S. system also needs to evolve beyond fee-for-service, invest in information technology to bridge the gap between the access for the rich and poor, continue to expand telehealth, and reform payment programs to recognize social factors.

“The current finance system and the quality payment program are focused on downstream impacts of poor health,” Dr. Fox said.

Primary care needs to shed the expectation that it must show that it reduces costs in order to be valued, he continued. Care sometimes is necessary but doesn’t reduce cost. Also, cost reduction is often seen in the long run, but studied only in the short term, and therefore the evidence for cost reduction can be elusive.

What can internists do to help?

Dr. Candler said internal medicine physicians can do their part by collecting data on patients and staff and measuring outcomes to identify disparities. Additionally, they could run their practices with community and cultural needs in mind, she said.

“Some of that might mean hiring differently. Think about it – if you’re in a position to start building new practices, go where they need you,” Dr. Candler explained. “It might mean a little bit more of a commute for you. But your patients are already doing that with their untreated cataracts, so who’s safer on the roads?”

George Abraham, MD, MPH – president of ACP and professor of medicine at the University of Massachusetts , Boston, who did not present in the session – suggested physicians should be looking at their own practice style, location, and the way their practice runs, and see where there are opportunities to be more in touch.

“I’m sure we all have practices where we have a diverse patient population,” he said. What doctors can do is to specifically focus on their minority population and ask: ‘What do they experience that others don’t experience as my patient coming into my office?’ he said.

Dr. Abraham, who received his medical degree in India and is ACP’s first president who is an international medical graduate, pointed to ACP’s emphasis on diversifying the internal medicine workforce to reflect the communities.

Recent measures have included the creation of an ACP international medical graduate task force and establishing an antiharassment policy and reporting process.

“The conversation has started a lot more,” he said.

Dr. Candler reports financial relationships with Abbott, AbbVie, Johnson & Johnson, Merck, Medtronic, Pfizer, and other companies. She is also a member of the editorial advisory board of Internal Medicine News. Dr. Fox reports financial relationships with Obagi Cosmeceuticals. Dr. Liao reports financial relationships with Eli Lilly, Gilead, Johnson & Johnson, Novavax, and other companies. Dr. Abraham reports no relevant financial relationships.

CHICAGO – To give a sense of how social factors affect someone’s health, Sarah Candler, MD, MPH, described this case: A 70-year-old woman with diabetes, rheumatoid arthritis, and high blood pressure and a high hemoglobin A1C, even though she’s on insulin.

This patient is on prednisone for her RA because she can’t afford better drugs, and she has been occasionally skipping her insulin, Dr. Candler said during her presentation, at the annual meeting of the American College of Physicians

Plus, her first language is Turkish, and she’s missed many doctor appointments because she lives too far from the center-city clinics, said Dr. Candler, who is the care team medical director at Iora Primary Care in Houston.

How are this woman’s needs supposed to be met in a fee-for-service system that allows medical staff 15 to 30 minutes to help solve her problems?

Potential regulatory fixes

A panel of experts talked about potential policies and regulatory fixes that take into account the impact of “social determinants of health.” Some of these are gaining traction, but there is still a huge gap between how medicine in practiced in the United States and the health needs of people in the community, the panelists said.

The ACO REACH (Realizing Equity, Access and Community Health) model is a recent step forward, said Josh Liao, MD, MSc, associate chair for health systems at the University of Washington, Seattle. The accountable care organization model pays doctors more for caring for Medicare patients in underserved communities.

“To me, it represents that at least we’re moving in the direction where we’re acknowledging directly that social environment matters,” he said.

The American College of Physicians’ Medical Practice and Quality Committee helped improve payment for telehealth, an important step for equity to the underserved, said William Fox, MD, at Fox and Brantley Internal Medicine in Charlottesville, Va., and chair of the committee for ACP’s Virginia chapter. But many policies require much more work, he said.

One aim is getting to universal health coverage – 31 million people in the United States still don’t have health insurance, a number that is greatly improved since the Affordable Care Act but has plateaued recently.

Another is to invest more in primary care – which accounts for about 5% of spending even though 35% of patient visits are to primary care.

Dr. Fox said the U.S. system also needs to evolve beyond fee-for-service, invest in information technology to bridge the gap between the access for the rich and poor, continue to expand telehealth, and reform payment programs to recognize social factors.

“The current finance system and the quality payment program are focused on downstream impacts of poor health,” Dr. Fox said.

Primary care needs to shed the expectation that it must show that it reduces costs in order to be valued, he continued. Care sometimes is necessary but doesn’t reduce cost. Also, cost reduction is often seen in the long run, but studied only in the short term, and therefore the evidence for cost reduction can be elusive.

What can internists do to help?

Dr. Candler said internal medicine physicians can do their part by collecting data on patients and staff and measuring outcomes to identify disparities. Additionally, they could run their practices with community and cultural needs in mind, she said.

“Some of that might mean hiring differently. Think about it – if you’re in a position to start building new practices, go where they need you,” Dr. Candler explained. “It might mean a little bit more of a commute for you. But your patients are already doing that with their untreated cataracts, so who’s safer on the roads?”

George Abraham, MD, MPH – president of ACP and professor of medicine at the University of Massachusetts , Boston, who did not present in the session – suggested physicians should be looking at their own practice style, location, and the way their practice runs, and see where there are opportunities to be more in touch.

“I’m sure we all have practices where we have a diverse patient population,” he said. What doctors can do is to specifically focus on their minority population and ask: ‘What do they experience that others don’t experience as my patient coming into my office?’ he said.

Dr. Abraham, who received his medical degree in India and is ACP’s first president who is an international medical graduate, pointed to ACP’s emphasis on diversifying the internal medicine workforce to reflect the communities.

Recent measures have included the creation of an ACP international medical graduate task force and establishing an antiharassment policy and reporting process.

“The conversation has started a lot more,” he said.

Dr. Candler reports financial relationships with Abbott, AbbVie, Johnson & Johnson, Merck, Medtronic, Pfizer, and other companies. She is also a member of the editorial advisory board of Internal Medicine News. Dr. Fox reports financial relationships with Obagi Cosmeceuticals. Dr. Liao reports financial relationships with Eli Lilly, Gilead, Johnson & Johnson, Novavax, and other companies. Dr. Abraham reports no relevant financial relationships.

CHICAGO – To give a sense of how social factors affect someone’s health, Sarah Candler, MD, MPH, described this case: A 70-year-old woman with diabetes, rheumatoid arthritis, and high blood pressure and a high hemoglobin A1C, even though she’s on insulin.

This patient is on prednisone for her RA because she can’t afford better drugs, and she has been occasionally skipping her insulin, Dr. Candler said during her presentation, at the annual meeting of the American College of Physicians

Plus, her first language is Turkish, and she’s missed many doctor appointments because she lives too far from the center-city clinics, said Dr. Candler, who is the care team medical director at Iora Primary Care in Houston.

How are this woman’s needs supposed to be met in a fee-for-service system that allows medical staff 15 to 30 minutes to help solve her problems?

Potential regulatory fixes

A panel of experts talked about potential policies and regulatory fixes that take into account the impact of “social determinants of health.” Some of these are gaining traction, but there is still a huge gap between how medicine in practiced in the United States and the health needs of people in the community, the panelists said.

The ACO REACH (Realizing Equity, Access and Community Health) model is a recent step forward, said Josh Liao, MD, MSc, associate chair for health systems at the University of Washington, Seattle. The accountable care organization model pays doctors more for caring for Medicare patients in underserved communities.

“To me, it represents that at least we’re moving in the direction where we’re acknowledging directly that social environment matters,” he said.

The American College of Physicians’ Medical Practice and Quality Committee helped improve payment for telehealth, an important step for equity to the underserved, said William Fox, MD, at Fox and Brantley Internal Medicine in Charlottesville, Va., and chair of the committee for ACP’s Virginia chapter. But many policies require much more work, he said.

One aim is getting to universal health coverage – 31 million people in the United States still don’t have health insurance, a number that is greatly improved since the Affordable Care Act but has plateaued recently.

Another is to invest more in primary care – which accounts for about 5% of spending even though 35% of patient visits are to primary care.

Dr. Fox said the U.S. system also needs to evolve beyond fee-for-service, invest in information technology to bridge the gap between the access for the rich and poor, continue to expand telehealth, and reform payment programs to recognize social factors.

“The current finance system and the quality payment program are focused on downstream impacts of poor health,” Dr. Fox said.

Primary care needs to shed the expectation that it must show that it reduces costs in order to be valued, he continued. Care sometimes is necessary but doesn’t reduce cost. Also, cost reduction is often seen in the long run, but studied only in the short term, and therefore the evidence for cost reduction can be elusive.

What can internists do to help?

Dr. Candler said internal medicine physicians can do their part by collecting data on patients and staff and measuring outcomes to identify disparities. Additionally, they could run their practices with community and cultural needs in mind, she said.

“Some of that might mean hiring differently. Think about it – if you’re in a position to start building new practices, go where they need you,” Dr. Candler explained. “It might mean a little bit more of a commute for you. But your patients are already doing that with their untreated cataracts, so who’s safer on the roads?”

George Abraham, MD, MPH – president of ACP and professor of medicine at the University of Massachusetts , Boston, who did not present in the session – suggested physicians should be looking at their own practice style, location, and the way their practice runs, and see where there are opportunities to be more in touch.

“I’m sure we all have practices where we have a diverse patient population,” he said. What doctors can do is to specifically focus on their minority population and ask: ‘What do they experience that others don’t experience as my patient coming into my office?’ he said.

Dr. Abraham, who received his medical degree in India and is ACP’s first president who is an international medical graduate, pointed to ACP’s emphasis on diversifying the internal medicine workforce to reflect the communities.

Recent measures have included the creation of an ACP international medical graduate task force and establishing an antiharassment policy and reporting process.

“The conversation has started a lot more,” he said.

Dr. Candler reports financial relationships with Abbott, AbbVie, Johnson & Johnson, Merck, Medtronic, Pfizer, and other companies. She is also a member of the editorial advisory board of Internal Medicine News. Dr. Fox reports financial relationships with Obagi Cosmeceuticals. Dr. Liao reports financial relationships with Eli Lilly, Gilead, Johnson & Johnson, Novavax, and other companies. Dr. Abraham reports no relevant financial relationships.

LISBON – During the pandemic, critical and acute care hospitals with medium and high rates of antimicrobial resistance (AMR) showed significant increases in antibiotic prescriptions and longer durations of antibiotic treatment among all hospital admissions, and also in those patients who were bacterial culture negative, according to a large U.S.-based study.

The analysis across 271 U.S. hospitals also showed that AMR rates were significantly higher for pathogens during the pandemic period, compared with the prepandemic period in patients who were tested for SARS-CoV-2, and highest in SARS-CoV-2–positive patients.

More than a third of SARS-CoV-2–positive patients who were prescribed antibiotics were bacterial culture negative.

Findings of the study were presented by Vikas Gupta, PharmD, director of medical affairs at medical technology firm Becton Dickinson, at this year’s European Congress of Clinical Microbiology & Infectious Diseases. He conducted the study jointly with Karri Bauer, PharmD, from Merck Sharp & Dohme, Kenilworth, N.J., and colleagues.

“There are differences in AMR that go beyond COVID-positive admissions,” Dr. Gupta told this news organization. “There is opportunity for improvement especially with those hospitalized patients who had a negative culture result, or no culture collected.”

“We found a higher percentage of COVID-positive admissions that were prescribed antibacterial therapy even in those having [tested negative for bacteria] or no culture result,” said Dr. Gupta. “Our data also shows that the percentage of admissions with duration of antibacterial therapy over 3 days was significantly higher in COVID-positive but culture-negative/no culture patients, compared to other groups evaluated.”

Of all admissions prescribed antibiotics during the pandemic, 57.8% of SARS-CoV-2–positive patients were prescribed antibiotics whereas 88.1% of SARS-CoV-2–positive admissions were bacterial culture negative/no culture. Overall, prepandemic, 35% of admissions were prescribed antibiotics.

Duration of antibiotic therapy in the prepandemic era was an average of 3.5 days, compared with an average of 3.8 days overall in the pandemic and 5.7 days in patients who tested positive for SARS-CoV-2. Similarly, the percentage of patients who were bacterial culture negative or had no culture and received antibiotic therapy for more than 72 hours was 17.6% in the prepandemic era, compared with 19.2% overall in the pandemic era, and 41.1% in patients who tested positive for COVID-19.  

Dr. Gupta and Dr. Bauer wanted to look at all patients admitted to hospitals segmented by SARS-CoV-2 positive, negative, and not tested, to get a sense of how much antibiotic use there was and how long patients were on antibiotics. “We ultimately want to optimize and not overuse antibiotics and prescribe them for right period of time,” said Dr. Gupta.

“To date, there has been no conclusive evidence about the suggestion that the pandemic has led to increased AMR rates, so we aimed to evaluate the pandemic’s impact on AMR and antibiotic use across U.S. hospitals,” he explained.

The multicenter, retrospective cohort analysis made use of BD’s infection surveillance platform (BD HealthSight Infection Advisor with MedMined Insights) and was conducted across 271 U.S. critical access/acute care facilities, representing approximately 10%-13% of U.S. hospital admissions. It included all hospitalized patients with more than 1 day of in-patient admission. Patients were considered SARS-CoV-2 positive by polymerase chain reaction test or antigen test either 7 days or less prior to or within 14 days of admission.

Patients were categorized as hospitalized during the “prepandemic” period (July 1, 2019 through February 29, 2020) and the “pandemic” period (March 1, 2020 through Oct. 30, 2021) and were stratified based on their SARS-CoV-2 result. 

Investigators included all hospital admissions with an AMR event (first positive culture for select gram-negative or gram-positive pathogens that were reported as nonsusceptible across blood, urine, respiratory, intra-abdominal, skin/wound, and other sources).

The investigators calculated AMR rates at the patient-admission level and defined per 100 admissions. Also, they further evaluated AMR rates based on community onset (defined as culture collected ≤2 days from admission) or hospital onset (>2 days from admission). Finally, AMR rates were determined according to whether they related to prepandemic or pandemic periods. 

Hospitals were also categorized according to their AMR rates as low (<25%), medium (25%-75%), and high (>75%). 

Overall AMR rates were lower in the pandemic period, compared with the prepandemic period. However, reported Dr.Gupta, for hospital-onset pathogens specifically, AMR rates were significantly higher overall in the pandemic period and mostly driven by admissions tested for SARS-CoV-2 (whether positive or negative).

Hospitals with high AMR rates also tended to have more SARS-CoV-2 positive admissions (6.1% in high-AMR hospitals vs. 3% in low-AMR hospitals). The highest antibiotic-prescribing rates and highest duration of antibiotic use was also seen in those hospitals with highest AMR rates. 

Of the SARS-CoV-2 patients who were bacterial culture negative/no culture and were prescribed antibiotics, 36.5% were in hospitals with a high AMR rate. “Roughly one-third of patients without culture evidence of a bacterial infection were prescribed antibiotics in hospitals with a high AMR rate,” said Dr. Gupta.

The researchers wanted to tease out whether hospitals with high, moderate, or low AMR rates look different with respect to antibiotic-prescribing patterns. During the pandemic period, they found that hospitals with high and medium AMR rates experienced significant increases in antibiotic prescriptions and longer durations. Prepandemic, the overall hospital-onset AMR rate was 0.8 per 100 admissions, whereas during the pandemic this rose to 1.4 per 100 admissions in high-AMR hospitals and dropped to 0.4 in low-AMR hospitals.

SARS-CoV-2–positive admission rates were higher in facilities with medium (5.6%) and high AMR (6.1%) rates than those with low (3%) AMR rates. “We found that those with medium and high AMR rates were more likely to have COVID-positive admissions than facilities with low AMR rates,” Dr. Gupta said. “It appears as if COVID is contributing to AMR in the facilities.”

Asked for independent comment, Jason C. Gallagher, PharmD, BCPS, clinical professor at Temple University School of Pharmacy in Philadelphia, said in an interview, “It is not surprising that there was more antimicrobial resistance in patients with COVID than those without. Even though antibiotics do not work for COVID, they are often prescribed, and antibiotic use is a major risk factor for antimicrobial resistance. This is likely because clinicians are sometimes concerned about coinfections with bacteria (which are rare) and because hospitalized patients with severe COVID can acquire other infections as they are treated.”
 

Antibiotic stewardship programs

Antibiotic stewardship programs have been highly stressed during the pandemic, so the researchers hope their data support the need for better antibiotic stewardship practices during pandemic surges when control is more challenging.

Dr. Gupta explained that they were seeing interesting associations that can inform antimicrobial stewardship programs and teams. “We are not trying to imply causality,” he stressed.

It is a common practice for stewardship teams to evaluate the need for continuation of antibiotic therapy at 3 days, especially in patients who are culture negative or did not have a culture collected.

“Antibiotic time-out at 3 days is a recommended practice to evaluate for continuing antibiotic therapy based on the patient’s condition and culture results,” he said. “This is what made our study unique because we wanted to look at what percentage of admissions were prescribed antibiotics beyond 3 days and compare to the prepandemic period.”

Session moderator Evangelos J. Giamarellos-Bourboulis, MD, PhD, an assistant professor of internal medicine and infectious diseases, University of Athens, Greece, thanked Dr. Gupta for his “eloquent presentation” and sought to clarify whether the data “refer to antimicrobial use that was empirical or whether use was in hospitals with high AMR rates, or whether the approach was driven through microbiology?”

Dr. Gupta replied that this was why they evaluated the negative-culture and no-culture patients. “We wanted to get a measure of antibacterial use in this population too,” he said. “Definitely, there is empirical therapy as well as definitive therapy, but I think the negative and no-culture group provide a reference point where we see similar signals and trends to that of the overall population.”

An audience member also addressed a question to Dr. Gupta: “Did you look at the patient population, because in many cases, during COVID, these patients may have been more severe than in the prepandemic period?”

Dr. Gupta replied: “In our manuscript we’ve done an analysis where we adjusted for patient-level facility and regional-level factors. There are definitely differences in the patient populations but overall, these are pretty sick patients when we look at the level of severity overall.”

Dr. Gupta is an employee of and a shareholder in Becton Dickinson. Dr. Bauer is an employee of and a shareholder in Merck. Dr. Gallagher consults for many pharmaceutical companies including Merck.

Dr. Giamarellos-Bourboulis disclosed honoraria (paid to the University of Athens) from Abbott CH, Brahms Thermo Fisher GMBH Germany, GlaxoSmithKline, and Sobi; serving as a consultant for Abbott CH, Fab’nTech, InflaRx GmbH, UCB, Sobi, and Xbiotech; research grants (paid to the Hellenic Institute for the Study of Sepsis) from Abbott CH, BioMerieux France, Johnson & Johnson, MSD, Sobi, Thermo Fisher Brahms GmbH; and EU research funding: Horizon 2020 ITN European Sepsis Academy (granted to the University of Athens); Horizon 2020 ImmunoSep and RISinCOVID (granted to the Hellenic Institute for the Study of Sepsis); Horizon Health EPIC-CROWN-2 (granted to the Hellenic Institute for the Study of Sepsis).

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

LISBON – During the pandemic, critical and acute care hospitals with medium and high rates of antimicrobial resistance (AMR) showed significant increases in antibiotic prescriptions and longer durations of antibiotic treatment among all hospital admissions, and also in those patients who were bacterial culture negative, according to a large U.S.-based study.

The analysis across 271 U.S. hospitals also showed that AMR rates were significantly higher for pathogens during the pandemic period, compared with the prepandemic period in patients who were tested for SARS-CoV-2, and highest in SARS-CoV-2–positive patients.

More than a third of SARS-CoV-2–positive patients who were prescribed antibiotics were bacterial culture negative.

Findings of the study were presented by Vikas Gupta, PharmD, director of medical affairs at medical technology firm Becton Dickinson, at this year’s European Congress of Clinical Microbiology & Infectious Diseases. He conducted the study jointly with Karri Bauer, PharmD, from Merck Sharp & Dohme, Kenilworth, N.J., and colleagues.

“There are differences in AMR that go beyond COVID-positive admissions,” Dr. Gupta told this news organization. “There is opportunity for improvement especially with those hospitalized patients who had a negative culture result, or no culture collected.”

“We found a higher percentage of COVID-positive admissions that were prescribed antibacterial therapy even in those having [tested negative for bacteria] or no culture result,” said Dr. Gupta. “Our data also shows that the percentage of admissions with duration of antibacterial therapy over 3 days was significantly higher in COVID-positive but culture-negative/no culture patients, compared to other groups evaluated.”

Of all admissions prescribed antibiotics during the pandemic, 57.8% of SARS-CoV-2–positive patients were prescribed antibiotics whereas 88.1% of SARS-CoV-2–positive admissions were bacterial culture negative/no culture. Overall, prepandemic, 35% of admissions were prescribed antibiotics.

Duration of antibiotic therapy in the prepandemic era was an average of 3.5 days, compared with an average of 3.8 days overall in the pandemic and 5.7 days in patients who tested positive for SARS-CoV-2. Similarly, the percentage of patients who were bacterial culture negative or had no culture and received antibiotic therapy for more than 72 hours was 17.6% in the prepandemic era, compared with 19.2% overall in the pandemic era, and 41.1% in patients who tested positive for COVID-19.  

Dr. Gupta and Dr. Bauer wanted to look at all patients admitted to hospitals segmented by SARS-CoV-2 positive, negative, and not tested, to get a sense of how much antibiotic use there was and how long patients were on antibiotics. “We ultimately want to optimize and not overuse antibiotics and prescribe them for right period of time,” said Dr. Gupta.

“To date, there has been no conclusive evidence about the suggestion that the pandemic has led to increased AMR rates, so we aimed to evaluate the pandemic’s impact on AMR and antibiotic use across U.S. hospitals,” he explained.

The multicenter, retrospective cohort analysis made use of BD’s infection surveillance platform (BD HealthSight Infection Advisor with MedMined Insights) and was conducted across 271 U.S. critical access/acute care facilities, representing approximately 10%-13% of U.S. hospital admissions. It included all hospitalized patients with more than 1 day of in-patient admission. Patients were considered SARS-CoV-2 positive by polymerase chain reaction test or antigen test either 7 days or less prior to or within 14 days of admission.

Patients were categorized as hospitalized during the “prepandemic” period (July 1, 2019 through February 29, 2020) and the “pandemic” period (March 1, 2020 through Oct. 30, 2021) and were stratified based on their SARS-CoV-2 result. 

Investigators included all hospital admissions with an AMR event (first positive culture for select gram-negative or gram-positive pathogens that were reported as nonsusceptible across blood, urine, respiratory, intra-abdominal, skin/wound, and other sources).

The investigators calculated AMR rates at the patient-admission level and defined per 100 admissions. Also, they further evaluated AMR rates based on community onset (defined as culture collected ≤2 days from admission) or hospital onset (>2 days from admission). Finally, AMR rates were determined according to whether they related to prepandemic or pandemic periods. 

Hospitals were also categorized according to their AMR rates as low (<25%), medium (25%-75%), and high (>75%). 

Overall AMR rates were lower in the pandemic period, compared with the prepandemic period. However, reported Dr.Gupta, for hospital-onset pathogens specifically, AMR rates were significantly higher overall in the pandemic period and mostly driven by admissions tested for SARS-CoV-2 (whether positive or negative).

Hospitals with high AMR rates also tended to have more SARS-CoV-2 positive admissions (6.1% in high-AMR hospitals vs. 3% in low-AMR hospitals). The highest antibiotic-prescribing rates and highest duration of antibiotic use was also seen in those hospitals with highest AMR rates. 

Of the SARS-CoV-2 patients who were bacterial culture negative/no culture and were prescribed antibiotics, 36.5% were in hospitals with a high AMR rate. “Roughly one-third of patients without culture evidence of a bacterial infection were prescribed antibiotics in hospitals with a high AMR rate,” said Dr. Gupta.

The researchers wanted to tease out whether hospitals with high, moderate, or low AMR rates look different with respect to antibiotic-prescribing patterns. During the pandemic period, they found that hospitals with high and medium AMR rates experienced significant increases in antibiotic prescriptions and longer durations. Prepandemic, the overall hospital-onset AMR rate was 0.8 per 100 admissions, whereas during the pandemic this rose to 1.4 per 100 admissions in high-AMR hospitals and dropped to 0.4 in low-AMR hospitals.

SARS-CoV-2–positive admission rates were higher in facilities with medium (5.6%) and high AMR (6.1%) rates than those with low (3%) AMR rates. “We found that those with medium and high AMR rates were more likely to have COVID-positive admissions than facilities with low AMR rates,” Dr. Gupta said. “It appears as if COVID is contributing to AMR in the facilities.”

Asked for independent comment, Jason C. Gallagher, PharmD, BCPS, clinical professor at Temple University School of Pharmacy in Philadelphia, said in an interview, “It is not surprising that there was more antimicrobial resistance in patients with COVID than those without. Even though antibiotics do not work for COVID, they are often prescribed, and antibiotic use is a major risk factor for antimicrobial resistance. This is likely because clinicians are sometimes concerned about coinfections with bacteria (which are rare) and because hospitalized patients with severe COVID can acquire other infections as they are treated.”
 

Antibiotic stewardship programs

Antibiotic stewardship programs have been highly stressed during the pandemic, so the researchers hope their data support the need for better antibiotic stewardship practices during pandemic surges when control is more challenging.

Dr. Gupta explained that they were seeing interesting associations that can inform antimicrobial stewardship programs and teams. “We are not trying to imply causality,” he stressed.

It is a common practice for stewardship teams to evaluate the need for continuation of antibiotic therapy at 3 days, especially in patients who are culture negative or did not have a culture collected.

“Antibiotic time-out at 3 days is a recommended practice to evaluate for continuing antibiotic therapy based on the patient’s condition and culture results,” he said. “This is what made our study unique because we wanted to look at what percentage of admissions were prescribed antibiotics beyond 3 days and compare to the prepandemic period.”

Session moderator Evangelos J. Giamarellos-Bourboulis, MD, PhD, an assistant professor of internal medicine and infectious diseases, University of Athens, Greece, thanked Dr. Gupta for his “eloquent presentation” and sought to clarify whether the data “refer to antimicrobial use that was empirical or whether use was in hospitals with high AMR rates, or whether the approach was driven through microbiology?”

Dr. Gupta replied that this was why they evaluated the negative-culture and no-culture patients. “We wanted to get a measure of antibacterial use in this population too,” he said. “Definitely, there is empirical therapy as well as definitive therapy, but I think the negative and no-culture group provide a reference point where we see similar signals and trends to that of the overall population.”

An audience member also addressed a question to Dr. Gupta: “Did you look at the patient population, because in many cases, during COVID, these patients may have been more severe than in the prepandemic period?”

Dr. Gupta replied: “In our manuscript we’ve done an analysis where we adjusted for patient-level facility and regional-level factors. There are definitely differences in the patient populations but overall, these are pretty sick patients when we look at the level of severity overall.”

Dr. Gupta is an employee of and a shareholder in Becton Dickinson. Dr. Bauer is an employee of and a shareholder in Merck. Dr. Gallagher consults for many pharmaceutical companies including Merck.

Dr. Giamarellos-Bourboulis disclosed honoraria (paid to the University of Athens) from Abbott CH, Brahms Thermo Fisher GMBH Germany, GlaxoSmithKline, and Sobi; serving as a consultant for Abbott CH, Fab’nTech, InflaRx GmbH, UCB, Sobi, and Xbiotech; research grants (paid to the Hellenic Institute for the Study of Sepsis) from Abbott CH, BioMerieux France, Johnson & Johnson, MSD, Sobi, Thermo Fisher Brahms GmbH; and EU research funding: Horizon 2020 ITN European Sepsis Academy (granted to the University of Athens); Horizon 2020 ImmunoSep and RISinCOVID (granted to the Hellenic Institute for the Study of Sepsis); Horizon Health EPIC-CROWN-2 (granted to the Hellenic Institute for the Study of Sepsis).

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

LISBON – During the pandemic, critical and acute care hospitals with medium and high rates of antimicrobial resistance (AMR) showed significant increases in antibiotic prescriptions and longer durations of antibiotic treatment among all hospital admissions, and also in those patients who were bacterial culture negative, according to a large U.S.-based study.

The analysis across 271 U.S. hospitals also showed that AMR rates were significantly higher for pathogens during the pandemic period, compared with the prepandemic period in patients who were tested for SARS-CoV-2, and highest in SARS-CoV-2–positive patients.

More than a third of SARS-CoV-2–positive patients who were prescribed antibiotics were bacterial culture negative.

Findings of the study were presented by Vikas Gupta, PharmD, director of medical affairs at medical technology firm Becton Dickinson, at this year’s European Congress of Clinical Microbiology & Infectious Diseases. He conducted the study jointly with Karri Bauer, PharmD, from Merck Sharp & Dohme, Kenilworth, N.J., and colleagues.

“There are differences in AMR that go beyond COVID-positive admissions,” Dr. Gupta told this news organization. “There is opportunity for improvement especially with those hospitalized patients who had a negative culture result, or no culture collected.”

“We found a higher percentage of COVID-positive admissions that were prescribed antibacterial therapy even in those having [tested negative for bacteria] or no culture result,” said Dr. Gupta. “Our data also shows that the percentage of admissions with duration of antibacterial therapy over 3 days was significantly higher in COVID-positive but culture-negative/no culture patients, compared to other groups evaluated.”

Of all admissions prescribed antibiotics during the pandemic, 57.8% of SARS-CoV-2–positive patients were prescribed antibiotics whereas 88.1% of SARS-CoV-2–positive admissions were bacterial culture negative/no culture. Overall, prepandemic, 35% of admissions were prescribed antibiotics.

Duration of antibiotic therapy in the prepandemic era was an average of 3.5 days, compared with an average of 3.8 days overall in the pandemic and 5.7 days in patients who tested positive for SARS-CoV-2. Similarly, the percentage of patients who were bacterial culture negative or had no culture and received antibiotic therapy for more than 72 hours was 17.6% in the prepandemic era, compared with 19.2% overall in the pandemic era, and 41.1% in patients who tested positive for COVID-19.  

Dr. Gupta and Dr. Bauer wanted to look at all patients admitted to hospitals segmented by SARS-CoV-2 positive, negative, and not tested, to get a sense of how much antibiotic use there was and how long patients were on antibiotics. “We ultimately want to optimize and not overuse antibiotics and prescribe them for right period of time,” said Dr. Gupta.

“To date, there has been no conclusive evidence about the suggestion that the pandemic has led to increased AMR rates, so we aimed to evaluate the pandemic’s impact on AMR and antibiotic use across U.S. hospitals,” he explained.

The multicenter, retrospective cohort analysis made use of BD’s infection surveillance platform (BD HealthSight Infection Advisor with MedMined Insights) and was conducted across 271 U.S. critical access/acute care facilities, representing approximately 10%-13% of U.S. hospital admissions. It included all hospitalized patients with more than 1 day of in-patient admission. Patients were considered SARS-CoV-2 positive by polymerase chain reaction test or antigen test either 7 days or less prior to or within 14 days of admission.

Patients were categorized as hospitalized during the “prepandemic” period (July 1, 2019 through February 29, 2020) and the “pandemic” period (March 1, 2020 through Oct. 30, 2021) and were stratified based on their SARS-CoV-2 result. 

Investigators included all hospital admissions with an AMR event (first positive culture for select gram-negative or gram-positive pathogens that were reported as nonsusceptible across blood, urine, respiratory, intra-abdominal, skin/wound, and other sources).

The investigators calculated AMR rates at the patient-admission level and defined per 100 admissions. Also, they further evaluated AMR rates based on community onset (defined as culture collected ≤2 days from admission) or hospital onset (>2 days from admission). Finally, AMR rates were determined according to whether they related to prepandemic or pandemic periods. 

Hospitals were also categorized according to their AMR rates as low (<25%), medium (25%-75%), and high (>75%). 

Overall AMR rates were lower in the pandemic period, compared with the prepandemic period. However, reported Dr.Gupta, for hospital-onset pathogens specifically, AMR rates were significantly higher overall in the pandemic period and mostly driven by admissions tested for SARS-CoV-2 (whether positive or negative).

Hospitals with high AMR rates also tended to have more SARS-CoV-2 positive admissions (6.1% in high-AMR hospitals vs. 3% in low-AMR hospitals). The highest antibiotic-prescribing rates and highest duration of antibiotic use was also seen in those hospitals with highest AMR rates. 

Of the SARS-CoV-2 patients who were bacterial culture negative/no culture and were prescribed antibiotics, 36.5% were in hospitals with a high AMR rate. “Roughly one-third of patients without culture evidence of a bacterial infection were prescribed antibiotics in hospitals with a high AMR rate,” said Dr. Gupta.

The researchers wanted to tease out whether hospitals with high, moderate, or low AMR rates look different with respect to antibiotic-prescribing patterns. During the pandemic period, they found that hospitals with high and medium AMR rates experienced significant increases in antibiotic prescriptions and longer durations. Prepandemic, the overall hospital-onset AMR rate was 0.8 per 100 admissions, whereas during the pandemic this rose to 1.4 per 100 admissions in high-AMR hospitals and dropped to 0.4 in low-AMR hospitals.

SARS-CoV-2–positive admission rates were higher in facilities with medium (5.6%) and high AMR (6.1%) rates than those with low (3%) AMR rates. “We found that those with medium and high AMR rates were more likely to have COVID-positive admissions than facilities with low AMR rates,” Dr. Gupta said. “It appears as if COVID is contributing to AMR in the facilities.”

Asked for independent comment, Jason C. Gallagher, PharmD, BCPS, clinical professor at Temple University School of Pharmacy in Philadelphia, said in an interview, “It is not surprising that there was more antimicrobial resistance in patients with COVID than those without. Even though antibiotics do not work for COVID, they are often prescribed, and antibiotic use is a major risk factor for antimicrobial resistance. This is likely because clinicians are sometimes concerned about coinfections with bacteria (which are rare) and because hospitalized patients with severe COVID can acquire other infections as they are treated.”
 

Antibiotic stewardship programs

Antibiotic stewardship programs have been highly stressed during the pandemic, so the researchers hope their data support the need for better antibiotic stewardship practices during pandemic surges when control is more challenging.

Dr. Gupta explained that they were seeing interesting associations that can inform antimicrobial stewardship programs and teams. “We are not trying to imply causality,” he stressed.

It is a common practice for stewardship teams to evaluate the need for continuation of antibiotic therapy at 3 days, especially in patients who are culture negative or did not have a culture collected.

“Antibiotic time-out at 3 days is a recommended practice to evaluate for continuing antibiotic therapy based on the patient’s condition and culture results,” he said. “This is what made our study unique because we wanted to look at what percentage of admissions were prescribed antibiotics beyond 3 days and compare to the prepandemic period.”

Session moderator Evangelos J. Giamarellos-Bourboulis, MD, PhD, an assistant professor of internal medicine and infectious diseases, University of Athens, Greece, thanked Dr. Gupta for his “eloquent presentation” and sought to clarify whether the data “refer to antimicrobial use that was empirical or whether use was in hospitals with high AMR rates, or whether the approach was driven through microbiology?”

Dr. Gupta replied that this was why they evaluated the negative-culture and no-culture patients. “We wanted to get a measure of antibacterial use in this population too,” he said. “Definitely, there is empirical therapy as well as definitive therapy, but I think the negative and no-culture group provide a reference point where we see similar signals and trends to that of the overall population.”

An audience member also addressed a question to Dr. Gupta: “Did you look at the patient population, because in many cases, during COVID, these patients may have been more severe than in the prepandemic period?”

Dr. Gupta replied: “In our manuscript we’ve done an analysis where we adjusted for patient-level facility and regional-level factors. There are definitely differences in the patient populations but overall, these are pretty sick patients when we look at the level of severity overall.”

Dr. Gupta is an employee of and a shareholder in Becton Dickinson. Dr. Bauer is an employee of and a shareholder in Merck. Dr. Gallagher consults for many pharmaceutical companies including Merck.

Dr. Giamarellos-Bourboulis disclosed honoraria (paid to the University of Athens) from Abbott CH, Brahms Thermo Fisher GMBH Germany, GlaxoSmithKline, and Sobi; serving as a consultant for Abbott CH, Fab’nTech, InflaRx GmbH, UCB, Sobi, and Xbiotech; research grants (paid to the Hellenic Institute for the Study of Sepsis) from Abbott CH, BioMerieux France, Johnson & Johnson, MSD, Sobi, Thermo Fisher Brahms GmbH; and EU research funding: Horizon 2020 ITN European Sepsis Academy (granted to the University of Athens); Horizon 2020 ImmunoSep and RISinCOVID (granted to the Hellenic Institute for the Study of Sepsis); Horizon Health EPIC-CROWN-2 (granted to the Hellenic Institute for the Study of Sepsis).

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

Even mundane tasks such as making a meal can be exhausting for Louise Salant.

“I’m totally wiped out,” said the 71-year-old former private music instructor with asthma who lives in New York City and has been coping with debilitating symptoms of fatigue, shortness of breath, and gastrointestinal symptoms since recovering from a severe bout of COVID-19 2 years ago. “I just don’t have the energy.”

Ms. Salant is not alone. Many older people who contract COVID-19 experience prolonged symptoms of the disease. An analysis of Medicare Advantage claims data published in the BMJ found that about one-third of roughly 87,000 adults aged 65 in the database with a COVID-19 diagnosis sought care for persistent or new symptoms 21 or more days later.

That figure is about twice the rate of persistent COVID-19 related symptoms seen in a cohort of adults younger than age 65 with commercial insurance analyzed by the same group of researchers in a separate BMJ study. Compared with a 2020 comparator group of patients in this age cohort, these patients had a greater likelihood of respiratory failure, fatigue, hypertension, memory problems, kidney injury, mental health conditions, hypercoagulability, and cardiac rhythm disorders. When they compared post–COVID-19 symptoms to lasting symptoms of another serious viral disease – influenza – the researchers found that only respiratory failure, dementia, and post-viral fatigue were more common in the COVID-19 group.

“It became clear early in the pandemic that there is going to be a second pandemic related to all of the complications that we’ve seen related to COVID-19 infections,” said Ken Cohen, MD, executive director of translational research and national senior medical director for Optum Labs in Minnetonka, Minn., who coauthored the BMJ studies.

The results are among a growing body of evidence suggesting that older adults are at high risk of persistent post-COVID-19 symptoms.

Researchers in Rome, for example, found that 83% of 165 patients aged 65 or older who had been hospitalized for COVID-19 reported at least one lasting symptom – problems like fatigue, shortness of breath, joint pain, and coughing – in the months after hospitalization. One-third of those had two symptoms, and 46% had three or more.

A similar study in Norway found that two-thirds of patients aged 60 or older reported reduced health-related quality of life during follow-up visits 6 months after hospitalization for COVID-19. The most-reported impairments among those patients were the inability to perform the tasks of daily life, reduced mobility, and increased pain and discomfort.
 

Cognitive concerns

Mounting evidence indicates that COVID-19 may contribute to chronic cognitive impairment in older adults. A multisite U.S. study found that 28% of 817 adults presenting to emergency departments with COVID-19 had delirium and poorer outcomes. A Chinese case-control study that enrolled 1,438 individuals hospitalized in Wuhan for COVID-19, along with 438 of their uninfected spouses, found that 12% of COVID-19 survivors experienced cognitive impairment a year after discharge. Matteo Tosato, MD, PhD, head of the outpatient clinic for patients with long COVID symptoms at Gemelli Hospital in Rome, called those findings “very concerning.”

Jin Ho Han, MD, associate professor of emergency medicine at Vanderbilt University, Nashville, Tenn., said cognitive impairment is common after an acute illness, particularly in frail or vulnerable patients.

“Hospitalization and the acute illness itself accelerate cognitive decline,” said Dr. Han, and previous evidence links delirium with worsening cognition. He and his colleagues are studying the potential role of delirium in longer-term cognitive decline in older patients after COVID-19.

Dr. Han emphasized the importance of preventing COVID-19-related delirium through vaccines and other strategies to reduce exposure of older patients to the virus. “Once you have cognitive decline, there are no interventions to reverse it,” he said.
 

Alarm bells for long-term care

Experts expressed concern that the situation might be even worse for people living in long-term care facilities. Many already need assistance with tasks of daily living and could be particularly vulnerable to lasting effects of COVID-19, said Karl Steinberg, MD, president of the Society for Post-Acute and Long-Term Care Medicine. He estimated that roughly half of his patients who have had COVID-19, regardless of the severity of their symptoms, have endured some degree of functional decline.

“It’s common for long-term care facility residents to experience functional and cognitive decline, even after seemingly minor things, like a cold or a trip to the hospital,” Dr. Steinberg, who has been a medical director of long-term care facilities in San Diego County for more than 2 decades, told this news organization. “It makes it a little harder to determine whether the declines we’ve been seeing post COVID in these residents are attributable to post COVID versus just an accelerated step in their overall expected decline.”

The pandemic may have contributed to worse outcomes for people in long-term care facilities in several ways: the disease itself, its effects on health care delivery, and necessary preventive measures to protect long-term care residents from exposure to the virus.

“During the many months where family visits were prohibited, we saw people – whether they had COVID-19 or not – suffer major clinical, functional, cognitive declines or severe psychological symptoms,” Dr. Steinberg said.

He emphasized the importance of preventive measures such as vaccines and boosters in patients in long-term care facilities. He said the benefit of preventing lasting symptoms is often a strong motivator for family caregivers of people with dementia to get them vaccinated or boosted.

“It’s clear that vaccination and booster reduce the incidence of post-COVID symptoms,” he said. Almost all studies have been in younger cohorts, but he expects the benefits would also apply to older patients.
 

Easing symptoms and offering support

As with long COVID generally, many questions remain about the causes of lasting symptoms of COVID-19 in older patients, and how best to treat them. Dr. Tosato, who led the study of long-COVID patients in Rome, is focusing on inflammation as a critical factor in the condition. He and colleagues across Europe hope to answer some of them by launching a multicenter study of lasting COVID-19 symptoms. 

In the meantime, Dr. Steinberg and Dr. Tosato said they are doing their best to evaluate and treat patients empirically.

“We pull from our armamentarium to treat system-specific symptoms,” Dr. Steinberg said. “We want to improve the quality of life and help each day be the best it can.”

Physicians in long-term care facilities might use medications such as antidepressants or nonpharmacologic approaches for patients experiencing depression symptoms. Families are also crucial in helping patients by bringing in home-cooked meals and encouraging loved ones who may be experiencing loss of taste or smell to eat, Dr. Steinberg said.

“We’ve seen with the return of families and loved ones visiting to some extent has alleviated some people’s symptoms, especially psychological ones,” he said.

Dr. Tosato said he and his colleagues start with an individualized, multidisciplinary assessment to determine what types of care may help. He noted that physicians might recommend medications or rehabilitative therapies depending on the patient’s needs.

“A personalized approach is key,” Dr. Tosato said. His study also found that the proportion of older patients experiencing symptoms declined over time – a glimmer of hope that many will recover. 

Dr. Cohen emphasized the need for a multimodal rehabilitation, an evidence-based approach used to care for patients who survived hospitalization with severe COVID-19 – a group that has substantially higher rates of persistent symptoms. This approach includes cognitive rehabilitation, physical therapy, occupational therapy, and a graded exercise program.

Dr. Han and colleagues are studying potential therapies such as cognitive rehabilitation in adults who’ve experienced delirium. But until evidence-based treatments are available, they stress the role of support for patients with cognitive decline and their families.   

“A lot of the work we do is teach patients and their families to compensate for newly acquired cognitive deficits from any illness, including COVID-19,” Dr. Han said.

Ms. Salant said she has experienced some improvement in her energy since her pulmonologist recommended a new inhaler based on her symptoms. Her sense of smell and taste, lost to the infection, returned after she received her first dose of a vaccine against COVID-19. She takes comfort in participating in Survivor Corps, a group of more than 170,000 COVID-19 survivors and their families who advocate for more scientific research on the disease.

She also expressed gratitude for the support she receives from her primary care physician, who she said has taken the time to learn more about the symptoms of long COVID, listens to her, and respects what she has to say.

“I have hope that I will keep getting better by baby steps,” Ms. Salant said. 

Dr. Tosato, Dr. Steinberg, and Dr. Han have disclosed no relevant financial relationships.

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

Even mundane tasks such as making a meal can be exhausting for Louise Salant.

“I’m totally wiped out,” said the 71-year-old former private music instructor with asthma who lives in New York City and has been coping with debilitating symptoms of fatigue, shortness of breath, and gastrointestinal symptoms since recovering from a severe bout of COVID-19 2 years ago. “I just don’t have the energy.”

Ms. Salant is not alone. Many older people who contract COVID-19 experience prolonged symptoms of the disease. An analysis of Medicare Advantage claims data published in the BMJ found that about one-third of roughly 87,000 adults aged 65 in the database with a COVID-19 diagnosis sought care for persistent or new symptoms 21 or more days later.

That figure is about twice the rate of persistent COVID-19 related symptoms seen in a cohort of adults younger than age 65 with commercial insurance analyzed by the same group of researchers in a separate BMJ study. Compared with a 2020 comparator group of patients in this age cohort, these patients had a greater likelihood of respiratory failure, fatigue, hypertension, memory problems, kidney injury, mental health conditions, hypercoagulability, and cardiac rhythm disorders. When they compared post–COVID-19 symptoms to lasting symptoms of another serious viral disease – influenza – the researchers found that only respiratory failure, dementia, and post-viral fatigue were more common in the COVID-19 group.

“It became clear early in the pandemic that there is going to be a second pandemic related to all of the complications that we’ve seen related to COVID-19 infections,” said Ken Cohen, MD, executive director of translational research and national senior medical director for Optum Labs in Minnetonka, Minn., who coauthored the BMJ studies.

The results are among a growing body of evidence suggesting that older adults are at high risk of persistent post-COVID-19 symptoms.

Researchers in Rome, for example, found that 83% of 165 patients aged 65 or older who had been hospitalized for COVID-19 reported at least one lasting symptom – problems like fatigue, shortness of breath, joint pain, and coughing – in the months after hospitalization. One-third of those had two symptoms, and 46% had three or more.

A similar study in Norway found that two-thirds of patients aged 60 or older reported reduced health-related quality of life during follow-up visits 6 months after hospitalization for COVID-19. The most-reported impairments among those patients were the inability to perform the tasks of daily life, reduced mobility, and increased pain and discomfort.
 

Cognitive concerns

Mounting evidence indicates that COVID-19 may contribute to chronic cognitive impairment in older adults. A multisite U.S. study found that 28% of 817 adults presenting to emergency departments with COVID-19 had delirium and poorer outcomes. A Chinese case-control study that enrolled 1,438 individuals hospitalized in Wuhan for COVID-19, along with 438 of their uninfected spouses, found that 12% of COVID-19 survivors experienced cognitive impairment a year after discharge. Matteo Tosato, MD, PhD, head of the outpatient clinic for patients with long COVID symptoms at Gemelli Hospital in Rome, called those findings “very concerning.”

Jin Ho Han, MD, associate professor of emergency medicine at Vanderbilt University, Nashville, Tenn., said cognitive impairment is common after an acute illness, particularly in frail or vulnerable patients.

“Hospitalization and the acute illness itself accelerate cognitive decline,” said Dr. Han, and previous evidence links delirium with worsening cognition. He and his colleagues are studying the potential role of delirium in longer-term cognitive decline in older patients after COVID-19.

Dr. Han emphasized the importance of preventing COVID-19-related delirium through vaccines and other strategies to reduce exposure of older patients to the virus. “Once you have cognitive decline, there are no interventions to reverse it,” he said.
 

Alarm bells for long-term care

Experts expressed concern that the situation might be even worse for people living in long-term care facilities. Many already need assistance with tasks of daily living and could be particularly vulnerable to lasting effects of COVID-19, said Karl Steinberg, MD, president of the Society for Post-Acute and Long-Term Care Medicine. He estimated that roughly half of his patients who have had COVID-19, regardless of the severity of their symptoms, have endured some degree of functional decline.

“It’s common for long-term care facility residents to experience functional and cognitive decline, even after seemingly minor things, like a cold or a trip to the hospital,” Dr. Steinberg, who has been a medical director of long-term care facilities in San Diego County for more than 2 decades, told this news organization. “It makes it a little harder to determine whether the declines we’ve been seeing post COVID in these residents are attributable to post COVID versus just an accelerated step in their overall expected decline.”

The pandemic may have contributed to worse outcomes for people in long-term care facilities in several ways: the disease itself, its effects on health care delivery, and necessary preventive measures to protect long-term care residents from exposure to the virus.

“During the many months where family visits were prohibited, we saw people – whether they had COVID-19 or not – suffer major clinical, functional, cognitive declines or severe psychological symptoms,” Dr. Steinberg said.

He emphasized the importance of preventive measures such as vaccines and boosters in patients in long-term care facilities. He said the benefit of preventing lasting symptoms is often a strong motivator for family caregivers of people with dementia to get them vaccinated or boosted.

“It’s clear that vaccination and booster reduce the incidence of post-COVID symptoms,” he said. Almost all studies have been in younger cohorts, but he expects the benefits would also apply to older patients.
 

Easing symptoms and offering support

As with long COVID generally, many questions remain about the causes of lasting symptoms of COVID-19 in older patients, and how best to treat them. Dr. Tosato, who led the study of long-COVID patients in Rome, is focusing on inflammation as a critical factor in the condition. He and colleagues across Europe hope to answer some of them by launching a multicenter study of lasting COVID-19 symptoms. 

In the meantime, Dr. Steinberg and Dr. Tosato said they are doing their best to evaluate and treat patients empirically.

“We pull from our armamentarium to treat system-specific symptoms,” Dr. Steinberg said. “We want to improve the quality of life and help each day be the best it can.”

Physicians in long-term care facilities might use medications such as antidepressants or nonpharmacologic approaches for patients experiencing depression symptoms. Families are also crucial in helping patients by bringing in home-cooked meals and encouraging loved ones who may be experiencing loss of taste or smell to eat, Dr. Steinberg said.

“We’ve seen with the return of families and loved ones visiting to some extent has alleviated some people’s symptoms, especially psychological ones,” he said.

Dr. Tosato said he and his colleagues start with an individualized, multidisciplinary assessment to determine what types of care may help. He noted that physicians might recommend medications or rehabilitative therapies depending on the patient’s needs.

“A personalized approach is key,” Dr. Tosato said. His study also found that the proportion of older patients experiencing symptoms declined over time – a glimmer of hope that many will recover. 

Dr. Cohen emphasized the need for a multimodal rehabilitation, an evidence-based approach used to care for patients who survived hospitalization with severe COVID-19 – a group that has substantially higher rates of persistent symptoms. This approach includes cognitive rehabilitation, physical therapy, occupational therapy, and a graded exercise program.

Dr. Han and colleagues are studying potential therapies such as cognitive rehabilitation in adults who’ve experienced delirium. But until evidence-based treatments are available, they stress the role of support for patients with cognitive decline and their families.   

“A lot of the work we do is teach patients and their families to compensate for newly acquired cognitive deficits from any illness, including COVID-19,” Dr. Han said.

Ms. Salant said she has experienced some improvement in her energy since her pulmonologist recommended a new inhaler based on her symptoms. Her sense of smell and taste, lost to the infection, returned after she received her first dose of a vaccine against COVID-19. She takes comfort in participating in Survivor Corps, a group of more than 170,000 COVID-19 survivors and their families who advocate for more scientific research on the disease.

She also expressed gratitude for the support she receives from her primary care physician, who she said has taken the time to learn more about the symptoms of long COVID, listens to her, and respects what she has to say.

“I have hope that I will keep getting better by baby steps,” Ms. Salant said. 

Dr. Tosato, Dr. Steinberg, and Dr. Han have disclosed no relevant financial relationships.

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

Even mundane tasks such as making a meal can be exhausting for Louise Salant.

“I’m totally wiped out,” said the 71-year-old former private music instructor with asthma who lives in New York City and has been coping with debilitating symptoms of fatigue, shortness of breath, and gastrointestinal symptoms since recovering from a severe bout of COVID-19 2 years ago. “I just don’t have the energy.”

Ms. Salant is not alone. Many older people who contract COVID-19 experience prolonged symptoms of the disease. An analysis of Medicare Advantage claims data published in the BMJ found that about one-third of roughly 87,000 adults aged 65 in the database with a COVID-19 diagnosis sought care for persistent or new symptoms 21 or more days later.

That figure is about twice the rate of persistent COVID-19 related symptoms seen in a cohort of adults younger than age 65 with commercial insurance analyzed by the same group of researchers in a separate BMJ study. Compared with a 2020 comparator group of patients in this age cohort, these patients had a greater likelihood of respiratory failure, fatigue, hypertension, memory problems, kidney injury, mental health conditions, hypercoagulability, and cardiac rhythm disorders. When they compared post–COVID-19 symptoms to lasting symptoms of another serious viral disease – influenza – the researchers found that only respiratory failure, dementia, and post-viral fatigue were more common in the COVID-19 group.

“It became clear early in the pandemic that there is going to be a second pandemic related to all of the complications that we’ve seen related to COVID-19 infections,” said Ken Cohen, MD, executive director of translational research and national senior medical director for Optum Labs in Minnetonka, Minn., who coauthored the BMJ studies.

The results are among a growing body of evidence suggesting that older adults are at high risk of persistent post-COVID-19 symptoms.

Researchers in Rome, for example, found that 83% of 165 patients aged 65 or older who had been hospitalized for COVID-19 reported at least one lasting symptom – problems like fatigue, shortness of breath, joint pain, and coughing – in the months after hospitalization. One-third of those had two symptoms, and 46% had three or more.

A similar study in Norway found that two-thirds of patients aged 60 or older reported reduced health-related quality of life during follow-up visits 6 months after hospitalization for COVID-19. The most-reported impairments among those patients were the inability to perform the tasks of daily life, reduced mobility, and increased pain and discomfort.
 

Cognitive concerns

Mounting evidence indicates that COVID-19 may contribute to chronic cognitive impairment in older adults. A multisite U.S. study found that 28% of 817 adults presenting to emergency departments with COVID-19 had delirium and poorer outcomes. A Chinese case-control study that enrolled 1,438 individuals hospitalized in Wuhan for COVID-19, along with 438 of their uninfected spouses, found that 12% of COVID-19 survivors experienced cognitive impairment a year after discharge. Matteo Tosato, MD, PhD, head of the outpatient clinic for patients with long COVID symptoms at Gemelli Hospital in Rome, called those findings “very concerning.”

Jin Ho Han, MD, associate professor of emergency medicine at Vanderbilt University, Nashville, Tenn., said cognitive impairment is common after an acute illness, particularly in frail or vulnerable patients.

“Hospitalization and the acute illness itself accelerate cognitive decline,” said Dr. Han, and previous evidence links delirium with worsening cognition. He and his colleagues are studying the potential role of delirium in longer-term cognitive decline in older patients after COVID-19.

Dr. Han emphasized the importance of preventing COVID-19-related delirium through vaccines and other strategies to reduce exposure of older patients to the virus. “Once you have cognitive decline, there are no interventions to reverse it,” he said.
 

Alarm bells for long-term care

Experts expressed concern that the situation might be even worse for people living in long-term care facilities. Many already need assistance with tasks of daily living and could be particularly vulnerable to lasting effects of COVID-19, said Karl Steinberg, MD, president of the Society for Post-Acute and Long-Term Care Medicine. He estimated that roughly half of his patients who have had COVID-19, regardless of the severity of their symptoms, have endured some degree of functional decline.

“It’s common for long-term care facility residents to experience functional and cognitive decline, even after seemingly minor things, like a cold or a trip to the hospital,” Dr. Steinberg, who has been a medical director of long-term care facilities in San Diego County for more than 2 decades, told this news organization. “It makes it a little harder to determine whether the declines we’ve been seeing post COVID in these residents are attributable to post COVID versus just an accelerated step in their overall expected decline.”

The pandemic may have contributed to worse outcomes for people in long-term care facilities in several ways: the disease itself, its effects on health care delivery, and necessary preventive measures to protect long-term care residents from exposure to the virus.

“During the many months where family visits were prohibited, we saw people – whether they had COVID-19 or not – suffer major clinical, functional, cognitive declines or severe psychological symptoms,” Dr. Steinberg said.

He emphasized the importance of preventive measures such as vaccines and boosters in patients in long-term care facilities. He said the benefit of preventing lasting symptoms is often a strong motivator for family caregivers of people with dementia to get them vaccinated or boosted.

“It’s clear that vaccination and booster reduce the incidence of post-COVID symptoms,” he said. Almost all studies have been in younger cohorts, but he expects the benefits would also apply to older patients.
 

Easing symptoms and offering support

As with long COVID generally, many questions remain about the causes of lasting symptoms of COVID-19 in older patients, and how best to treat them. Dr. Tosato, who led the study of long-COVID patients in Rome, is focusing on inflammation as a critical factor in the condition. He and colleagues across Europe hope to answer some of them by launching a multicenter study of lasting COVID-19 symptoms. 

In the meantime, Dr. Steinberg and Dr. Tosato said they are doing their best to evaluate and treat patients empirically.

“We pull from our armamentarium to treat system-specific symptoms,” Dr. Steinberg said. “We want to improve the quality of life and help each day be the best it can.”

Physicians in long-term care facilities might use medications such as antidepressants or nonpharmacologic approaches for patients experiencing depression symptoms. Families are also crucial in helping patients by bringing in home-cooked meals and encouraging loved ones who may be experiencing loss of taste or smell to eat, Dr. Steinberg said.

“We’ve seen with the return of families and loved ones visiting to some extent has alleviated some people’s symptoms, especially psychological ones,” he said.

Dr. Tosato said he and his colleagues start with an individualized, multidisciplinary assessment to determine what types of care may help. He noted that physicians might recommend medications or rehabilitative therapies depending on the patient’s needs.

“A personalized approach is key,” Dr. Tosato said. His study also found that the proportion of older patients experiencing symptoms declined over time – a glimmer of hope that many will recover. 

Dr. Cohen emphasized the need for a multimodal rehabilitation, an evidence-based approach used to care for patients who survived hospitalization with severe COVID-19 – a group that has substantially higher rates of persistent symptoms. This approach includes cognitive rehabilitation, physical therapy, occupational therapy, and a graded exercise program.

Dr. Han and colleagues are studying potential therapies such as cognitive rehabilitation in adults who’ve experienced delirium. But until evidence-based treatments are available, they stress the role of support for patients with cognitive decline and their families.   

“A lot of the work we do is teach patients and their families to compensate for newly acquired cognitive deficits from any illness, including COVID-19,” Dr. Han said.

Ms. Salant said she has experienced some improvement in her energy since her pulmonologist recommended a new inhaler based on her symptoms. Her sense of smell and taste, lost to the infection, returned after she received her first dose of a vaccine against COVID-19. She takes comfort in participating in Survivor Corps, a group of more than 170,000 COVID-19 survivors and their families who advocate for more scientific research on the disease.

She also expressed gratitude for the support she receives from her primary care physician, who she said has taken the time to learn more about the symptoms of long COVID, listens to her, and respects what she has to say.

“I have hope that I will keep getting better by baby steps,” Ms. Salant said. 

Dr. Tosato, Dr. Steinberg, and Dr. Han have disclosed no relevant financial relationships.

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

The National Comprehensive Cancer Network (NCCN) has recommended a fifth COVID-19 mRNA shot for people who are immunocompromised, including many with cancer or a history of cancer.

A fifth shot of an mRNA vaccine represents a second booster, the group explained, because the primary mRNA immunization series for immunocompromised individuals involves three doses of either the Pfizer or Moderna vaccine.

The update, issued today, comes from the NCCN’s Advisory Committee on COVID-19 Vaccination and Pre-exposure Prophylaxis, which released its first vaccine guidelines for patients with cancer in January 2021. The NCCN has issued numerous updates since then as information about the virus and vaccines has evolved. 

“We know a lot more about COVID-19 and the vaccines now, and we can use that knowledge to minimize the confusion and enhance the protection we can offer to our immunocompromised patients,” said advisory committee co-leader Lindsey Baden, MD, an infectious diseases specialist at the Dana-Farber Cancer Institute, Boston.

The latest iteration of the NCCN’s COVID guidelines includes an update for patients who initially received Johnson & Johnson’s single-shot vaccine, including a recommendation that patients receive an mRNA vaccine for both the first and second booster.

The group also updated dosing recommendations for pre-exposure prevention with tixagevimab plus cilgavimab (Evusheld, AstraZeneca), suggesting 300 mg of each monoclonal antibody instead of 150 mg, based on in vitro activity against Omicron variants.

The group noted that the Moderna and Pfizer shots can be used interchangeably for boosters.

“The NCCN Committee considers both homologous and heterologous boosters to be appropriate options,” the experts wrote.

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

The National Comprehensive Cancer Network (NCCN) has recommended a fifth COVID-19 mRNA shot for people who are immunocompromised, including many with cancer or a history of cancer.

A fifth shot of an mRNA vaccine represents a second booster, the group explained, because the primary mRNA immunization series for immunocompromised individuals involves three doses of either the Pfizer or Moderna vaccine.

The update, issued today, comes from the NCCN’s Advisory Committee on COVID-19 Vaccination and Pre-exposure Prophylaxis, which released its first vaccine guidelines for patients with cancer in January 2021. The NCCN has issued numerous updates since then as information about the virus and vaccines has evolved. 

“We know a lot more about COVID-19 and the vaccines now, and we can use that knowledge to minimize the confusion and enhance the protection we can offer to our immunocompromised patients,” said advisory committee co-leader Lindsey Baden, MD, an infectious diseases specialist at the Dana-Farber Cancer Institute, Boston.

The latest iteration of the NCCN’s COVID guidelines includes an update for patients who initially received Johnson & Johnson’s single-shot vaccine, including a recommendation that patients receive an mRNA vaccine for both the first and second booster.

The group also updated dosing recommendations for pre-exposure prevention with tixagevimab plus cilgavimab (Evusheld, AstraZeneca), suggesting 300 mg of each monoclonal antibody instead of 150 mg, based on in vitro activity against Omicron variants.

The group noted that the Moderna and Pfizer shots can be used interchangeably for boosters.

“The NCCN Committee considers both homologous and heterologous boosters to be appropriate options,” the experts wrote.

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

The National Comprehensive Cancer Network (NCCN) has recommended a fifth COVID-19 mRNA shot for people who are immunocompromised, including many with cancer or a history of cancer.

A fifth shot of an mRNA vaccine represents a second booster, the group explained, because the primary mRNA immunization series for immunocompromised individuals involves three doses of either the Pfizer or Moderna vaccine.

The update, issued today, comes from the NCCN’s Advisory Committee on COVID-19 Vaccination and Pre-exposure Prophylaxis, which released its first vaccine guidelines for patients with cancer in January 2021. The NCCN has issued numerous updates since then as information about the virus and vaccines has evolved. 

“We know a lot more about COVID-19 and the vaccines now, and we can use that knowledge to minimize the confusion and enhance the protection we can offer to our immunocompromised patients,” said advisory committee co-leader Lindsey Baden, MD, an infectious diseases specialist at the Dana-Farber Cancer Institute, Boston.

The latest iteration of the NCCN’s COVID guidelines includes an update for patients who initially received Johnson & Johnson’s single-shot vaccine, including a recommendation that patients receive an mRNA vaccine for both the first and second booster.

The group also updated dosing recommendations for pre-exposure prevention with tixagevimab plus cilgavimab (Evusheld, AstraZeneca), suggesting 300 mg of each monoclonal antibody instead of 150 mg, based on in vitro activity against Omicron variants.

The group noted that the Moderna and Pfizer shots can be used interchangeably for boosters.

“The NCCN Committee considers both homologous and heterologous boosters to be appropriate options,” the experts wrote.

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

Psychiatrists practice a field of medicine that relies on one’s clinical perspective to interpret observable behaviors originating from the brains of others. In this manner, psychiatry and photography are similar. And digital technology has changed them both.

In photography, there are many technical aspects for one to master when framing and capturing a shot. The length of exposure. The amount of light needed. The speed of the film, which is its sensitivity to light. The aperture that controls how much light falls on the film. The movement of the subject across the film during the exposure. Despite the fact that physical film has mostly yielded to electronic sensors over the past couple decades, these basic aspects of photography remain.

But perspective is the critical ingredient. This is what brings the greatest impact to photography. The composition, or the subject of the photograph and how its elements – foreground, background, shapes, patterns, texture, shadow, motion, leading lines, and focal points – are arranged. The most powerful way to improve the composition – more powerful than fancy camera bells and whistles – is to move. One step to the left or right, one step forward or back. Stand on your toes, or crouch to your knees. Pivot this way or that. A simple change in perspective dramatically changes the nature and the energy of the captured image.

While the field of medicine has similarly been impacted by the onset of digital technology, physicians’ perspectives about their work remain the key factor in the nature and the energy of what we do.

In fact, many physicians are changing what they actually do for a living. Pivoting their clinical perspectives. And applying those perspectives to other areas. The latest catalyst fueling these career pivots, these changes in perspectives, has been the incredible global impact of the tiny little coronavirus known as SARS-CoV-2. The COVID-19 pandemic that began two years ago has disrupted the entire planet. The virus has caused us all to change our perspective, to see our world differently, and our place in it.

The virus has exposed defects in our health care delivery system. And physicians have necessarily reacted, injecting changes in what they do and how they do it. Many of these changes rely on digital technology, building upon the groundwork laid over the past couple of decades to convert our paper processes into electronic processes, and our manual work flows into digital work flows. This groundwork is no small thing, as it relies on conventions and standards, such as DICOM, LOINC, AES, CDA, UMLS, FHIR, ICD, NDC, USCDI, and SNOMED-CT. Establishing, maintaining, and evolving health care standards requires organized groups of people to come together to share their diverse perspectives. This is but one of many places where physicians are using their unique clinical perspective to share what they see with others.

This column will focus on these professional pivots that physicians make when they take a step to the left or right to change their perspective and share their viewpoints in different settings with diverse groups of people. Some of these pivots are small, while others are career changing. But the theme that knits them together is about taking what one has learned while helping others achieve better health, and using that perspective to make a difference.

Dr. Daviss is chief medical officer for Optum Maryland and immediate past president of the Maryland-DC Society of Addiction Medicine, and former medical director and senior medical advisor at SAMHSA. He is coauthor of the 2011 book, Shrink Rap: Three Psychiatrists Explain Their Work. Psychiatrists and other physicians may share their own experience with pivots they have made with Dr. Daviss via email ([email protected]) or Twitter (@HITshrink). The opinions expressed are solely those of the author and do not necessarily reflect those of his employer or organizations with which he is associated.

Psychiatrists practice a field of medicine that relies on one’s clinical perspective to interpret observable behaviors originating from the brains of others. In this manner, psychiatry and photography are similar. And digital technology has changed them both.

In photography, there are many technical aspects for one to master when framing and capturing a shot. The length of exposure. The amount of light needed. The speed of the film, which is its sensitivity to light. The aperture that controls how much light falls on the film. The movement of the subject across the film during the exposure. Despite the fact that physical film has mostly yielded to electronic sensors over the past couple decades, these basic aspects of photography remain.

But perspective is the critical ingredient. This is what brings the greatest impact to photography. The composition, or the subject of the photograph and how its elements – foreground, background, shapes, patterns, texture, shadow, motion, leading lines, and focal points – are arranged. The most powerful way to improve the composition – more powerful than fancy camera bells and whistles – is to move. One step to the left or right, one step forward or back. Stand on your toes, or crouch to your knees. Pivot this way or that. A simple change in perspective dramatically changes the nature and the energy of the captured image.

While the field of medicine has similarly been impacted by the onset of digital technology, physicians’ perspectives about their work remain the key factor in the nature and the energy of what we do.

In fact, many physicians are changing what they actually do for a living. Pivoting their clinical perspectives. And applying those perspectives to other areas. The latest catalyst fueling these career pivots, these changes in perspectives, has been the incredible global impact of the tiny little coronavirus known as SARS-CoV-2. The COVID-19 pandemic that began two years ago has disrupted the entire planet. The virus has caused us all to change our perspective, to see our world differently, and our place in it.

The virus has exposed defects in our health care delivery system. And physicians have necessarily reacted, injecting changes in what they do and how they do it. Many of these changes rely on digital technology, building upon the groundwork laid over the past couple of decades to convert our paper processes into electronic processes, and our manual work flows into digital work flows. This groundwork is no small thing, as it relies on conventions and standards, such as DICOM, LOINC, AES, CDA, UMLS, FHIR, ICD, NDC, USCDI, and SNOMED-CT. Establishing, maintaining, and evolving health care standards requires organized groups of people to come together to share their diverse perspectives. This is but one of many places where physicians are using their unique clinical perspective to share what they see with others.

This column will focus on these professional pivots that physicians make when they take a step to the left or right to change their perspective and share their viewpoints in different settings with diverse groups of people. Some of these pivots are small, while others are career changing. But the theme that knits them together is about taking what one has learned while helping others achieve better health, and using that perspective to make a difference.

Dr. Daviss is chief medical officer for Optum Maryland and immediate past president of the Maryland-DC Society of Addiction Medicine, and former medical director and senior medical advisor at SAMHSA. He is coauthor of the 2011 book, Shrink Rap: Three Psychiatrists Explain Their Work. Psychiatrists and other physicians may share their own experience with pivots they have made with Dr. Daviss via email ([email protected]) or Twitter (@HITshrink). The opinions expressed are solely those of the author and do not necessarily reflect those of his employer or organizations with which he is associated.

Psychiatrists practice a field of medicine that relies on one’s clinical perspective to interpret observable behaviors originating from the brains of others. In this manner, psychiatry and photography are similar. And digital technology has changed them both.

In photography, there are many technical aspects for one to master when framing and capturing a shot. The length of exposure. The amount of light needed. The speed of the film, which is its sensitivity to light. The aperture that controls how much light falls on the film. The movement of the subject across the film during the exposure. Despite the fact that physical film has mostly yielded to electronic sensors over the past couple decades, these basic aspects of photography remain.

But perspective is the critical ingredient. This is what brings the greatest impact to photography. The composition, or the subject of the photograph and how its elements – foreground, background, shapes, patterns, texture, shadow, motion, leading lines, and focal points – are arranged. The most powerful way to improve the composition – more powerful than fancy camera bells and whistles – is to move. One step to the left or right, one step forward or back. Stand on your toes, or crouch to your knees. Pivot this way or that. A simple change in perspective dramatically changes the nature and the energy of the captured image.

While the field of medicine has similarly been impacted by the onset of digital technology, physicians’ perspectives about their work remain the key factor in the nature and the energy of what we do.

In fact, many physicians are changing what they actually do for a living. Pivoting their clinical perspectives. And applying those perspectives to other areas. The latest catalyst fueling these career pivots, these changes in perspectives, has been the incredible global impact of the tiny little coronavirus known as SARS-CoV-2. The COVID-19 pandemic that began two years ago has disrupted the entire planet. The virus has caused us all to change our perspective, to see our world differently, and our place in it.

The virus has exposed defects in our health care delivery system. And physicians have necessarily reacted, injecting changes in what they do and how they do it. Many of these changes rely on digital technology, building upon the groundwork laid over the past couple of decades to convert our paper processes into electronic processes, and our manual work flows into digital work flows. This groundwork is no small thing, as it relies on conventions and standards, such as DICOM, LOINC, AES, CDA, UMLS, FHIR, ICD, NDC, USCDI, and SNOMED-CT. Establishing, maintaining, and evolving health care standards requires organized groups of people to come together to share their diverse perspectives. This is but one of many places where physicians are using their unique clinical perspective to share what they see with others.

This column will focus on these professional pivots that physicians make when they take a step to the left or right to change their perspective and share their viewpoints in different settings with diverse groups of people. Some of these pivots are small, while others are career changing. But the theme that knits them together is about taking what one has learned while helping others achieve better health, and using that perspective to make a difference.

Dr. Daviss is chief medical officer for Optum Maryland and immediate past president of the Maryland-DC Society of Addiction Medicine, and former medical director and senior medical advisor at SAMHSA. He is coauthor of the 2011 book, Shrink Rap: Three Psychiatrists Explain Their Work. Psychiatrists and other physicians may share their own experience with pivots they have made with Dr. Daviss via email ([email protected]) or Twitter (@HITshrink). The opinions expressed are solely those of the author and do not necessarily reflect those of his employer or organizations with which he is associated.

On April 12, 2022, the U.S. Preventive Services Task Force released the draft of a recommendation statement titled Screening for Anxiety in Children and Adolescents. Based on their observation that 7.8% of children and adolescents have a current anxiety disorder and their analysis of the magnitude of the net benefit, the Task Force plans on recommending that children ages 8-18 years be screened for the condition. However, the group could not find evidence to support screening for children 7 years and younger.

Over more than 4 decades of general pediatric practice, it became obvious to me that anxiety was driving a high percentage of my office visits. Most often in young children it was parental anxiety that was prompting the phone call or office visit. In older childhood and adolescence it was patient anxiety that began to play a larger role.

Over the last 2 decades the level of anxiety in all age groups has seemed to increase. How large a role the events of Sept. 11, 2001, and other terrorist attacks were playing in this phenomenon is unclear to me. However, I suspect they were significant. More recently the pandemic and the failure of both political parties to forge a working arrangement have fueled even more anxiety in many demographic segments. It may be safe to say that everyone is anxious to one degree or another.

Broad-based anxiety in the general population and the incidence of anxiety disorders severe enough to disrupt a child’s life are certainly two different kettles of fish. However, the factors that have raised the level of anxiety across all age groups certainly hasn’t made things any easier for the child who has inherited or developed an anxiety disorder.

Glancing at the 600-page evidence synthesis that accompanies the task force’s report it is clear that they have taken their challenge seriously. However, I wonder whether looking at the 7-and-under age group with a different lens might have resulted in the inclusion of younger children in their recommendation.

I understand that to support their recommendations the U.S. Preventive Services Task Forces must rely on data from peer-reviewed studies that have looked at quantifiable outcomes. However, I suspect the task force would agree that its recommendations shouldn’t prevent the rest of us from using our own observations and intuition when deciding whether to selectively screen our younger patients for anxiety disorders.

Although it may not generate a measurable data point, providing the parents of a 5-year-old whose troubling behavior is in part the result of an anxiety disorder is invaluable. Do we need to screen all 5-year-olds? The task force says probably not given the current state of our knowledge and I agree. But, the fact that almost 8% of the pediatric population carries the diagnosis and my anecdotal observations suggest that as pediatricians we should be learning more about anxiety disorders and their wide variety of presentations. Then we should selectively screen more of our patients. In fact, I suspect we might help our patients and ourselves by questioning more parents about their own mental health histories even before we have any inkling that their child has a problem. While the degree to which anxiety disorders are inheritable and the exact mechanism is far from clear, I think this history might be a valuable piece of information to learn as early as the prenatal get-acquainted visit. A simple question to a new or expecting parent about what worries them most about becoming a parent would be a good opener. Your reassurance that you expect parents to be worried and welcome hearing about their concerns should be a step in building a strong foundation for a family-provider relationship.

Anxiety happens and unfortunately so do anxiety disorders. We need to be doing a better job of acknowledging and responding to these two realities.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at [email protected].

*This column was updated on 5/4/2022.

On April 12, 2022, the U.S. Preventive Services Task Force released the draft of a recommendation statement titled Screening for Anxiety in Children and Adolescents. Based on their observation that 7.8% of children and adolescents have a current anxiety disorder and their analysis of the magnitude of the net benefit, the Task Force plans on recommending that children ages 8-18 years be screened for the condition. However, the group could not find evidence to support screening for children 7 years and younger.

Over more than 4 decades of general pediatric practice, it became obvious to me that anxiety was driving a high percentage of my office visits. Most often in young children it was parental anxiety that was prompting the phone call or office visit. In older childhood and adolescence it was patient anxiety that began to play a larger role.

Over the last 2 decades the level of anxiety in all age groups has seemed to increase. How large a role the events of Sept. 11, 2001, and other terrorist attacks were playing in this phenomenon is unclear to me. However, I suspect they were significant. More recently the pandemic and the failure of both political parties to forge a working arrangement have fueled even more anxiety in many demographic segments. It may be safe to say that everyone is anxious to one degree or another.

Broad-based anxiety in the general population and the incidence of anxiety disorders severe enough to disrupt a child’s life are certainly two different kettles of fish. However, the factors that have raised the level of anxiety across all age groups certainly hasn’t made things any easier for the child who has inherited or developed an anxiety disorder.

Glancing at the 600-page evidence synthesis that accompanies the task force’s report it is clear that they have taken their challenge seriously. However, I wonder whether looking at the 7-and-under age group with a different lens might have resulted in the inclusion of younger children in their recommendation.

I understand that to support their recommendations the U.S. Preventive Services Task Forces must rely on data from peer-reviewed studies that have looked at quantifiable outcomes. However, I suspect the task force would agree that its recommendations shouldn’t prevent the rest of us from using our own observations and intuition when deciding whether to selectively screen our younger patients for anxiety disorders.

Although it may not generate a measurable data point, providing the parents of a 5-year-old whose troubling behavior is in part the result of an anxiety disorder is invaluable. Do we need to screen all 5-year-olds? The task force says probably not given the current state of our knowledge and I agree. But, the fact that almost 8% of the pediatric population carries the diagnosis and my anecdotal observations suggest that as pediatricians we should be learning more about anxiety disorders and their wide variety of presentations. Then we should selectively screen more of our patients. In fact, I suspect we might help our patients and ourselves by questioning more parents about their own mental health histories even before we have any inkling that their child has a problem. While the degree to which anxiety disorders are inheritable and the exact mechanism is far from clear, I think this history might be a valuable piece of information to learn as early as the prenatal get-acquainted visit. A simple question to a new or expecting parent about what worries them most about becoming a parent would be a good opener. Your reassurance that you expect parents to be worried and welcome hearing about their concerns should be a step in building a strong foundation for a family-provider relationship.

Anxiety happens and unfortunately so do anxiety disorders. We need to be doing a better job of acknowledging and responding to these two realities.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at [email protected].

*This column was updated on 5/4/2022.

On April 12, 2022, the U.S. Preventive Services Task Force released the draft of a recommendation statement titled Screening for Anxiety in Children and Adolescents. Based on their observation that 7.8% of children and adolescents have a current anxiety disorder and their analysis of the magnitude of the net benefit, the Task Force plans on recommending that children ages 8-18 years be screened for the condition. However, the group could not find evidence to support screening for children 7 years and younger.

Over more than 4 decades of general pediatric practice, it became obvious to me that anxiety was driving a high percentage of my office visits. Most often in young children it was parental anxiety that was prompting the phone call or office visit. In older childhood and adolescence it was patient anxiety that began to play a larger role.

Over the last 2 decades the level of anxiety in all age groups has seemed to increase. How large a role the events of Sept. 11, 2001, and other terrorist attacks were playing in this phenomenon is unclear to me. However, I suspect they were significant. More recently the pandemic and the failure of both political parties to forge a working arrangement have fueled even more anxiety in many demographic segments. It may be safe to say that everyone is anxious to one degree or another.

Broad-based anxiety in the general population and the incidence of anxiety disorders severe enough to disrupt a child’s life are certainly two different kettles of fish. However, the factors that have raised the level of anxiety across all age groups certainly hasn’t made things any easier for the child who has inherited or developed an anxiety disorder.

Glancing at the 600-page evidence synthesis that accompanies the task force’s report it is clear that they have taken their challenge seriously. However, I wonder whether looking at the 7-and-under age group with a different lens might have resulted in the inclusion of younger children in their recommendation.

I understand that to support their recommendations the U.S. Preventive Services Task Forces must rely on data from peer-reviewed studies that have looked at quantifiable outcomes. However, I suspect the task force would agree that its recommendations shouldn’t prevent the rest of us from using our own observations and intuition when deciding whether to selectively screen our younger patients for anxiety disorders.

Although it may not generate a measurable data point, providing the parents of a 5-year-old whose troubling behavior is in part the result of an anxiety disorder is invaluable. Do we need to screen all 5-year-olds? The task force says probably not given the current state of our knowledge and I agree. But, the fact that almost 8% of the pediatric population carries the diagnosis and my anecdotal observations suggest that as pediatricians we should be learning more about anxiety disorders and their wide variety of presentations. Then we should selectively screen more of our patients. In fact, I suspect we might help our patients and ourselves by questioning more parents about their own mental health histories even before we have any inkling that their child has a problem. While the degree to which anxiety disorders are inheritable and the exact mechanism is far from clear, I think this history might be a valuable piece of information to learn as early as the prenatal get-acquainted visit. A simple question to a new or expecting parent about what worries them most about becoming a parent would be a good opener. Your reassurance that you expect parents to be worried and welcome hearing about their concerns should be a step in building a strong foundation for a family-provider relationship.

Anxiety happens and unfortunately so do anxiety disorders. We need to be doing a better job of acknowledging and responding to these two realities.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at [email protected].

*This column was updated on 5/4/2022.

Researchers are increasingly turning their attention to virtual reality (VR) for the treatment of psychiatric disorders in older adults.

Recent studies have highlighted the usefulness of VR in treating depression and loneliness in older patients who may be socially isolated because of their age, comorbidities, or the COVID-19 pandemic.

“The unique capability of virtual reality to create an immersive and engaging setting is an exciting opportunity for geriatric psychiatry,” Harmehr Sekhon, PhD, postdoctoral research fellow, Lady Davis Institute/Jewish General Hospital, McGill University, Montreal, and McLean Hospital, Harvard Medical School, Boston, told this news organization.

Because VR can be personalized and tailored for each patient, it represents “a cutting-edge technology” for novel applications, Dr. Sekhon said.

One novel approach involves using VR to administer a mindfulness intervention in older adults. Dr. Sekhon shared information on her own mindfulness study and on other developments in VR and telemedicine at the American Association for Geriatric Psychiatry annual meeting.
 

Potential bridging tool

As the population ages, the prevalence of mental health disorders increases. Telemedicine has proved to be a potential “bridge” to address the health care needs of older adults, Dr. Sekhon noted.

She cited her systematic review of telemedicine for older adults with dementia during COVID-19. Results showed that telemedicine was a “beneficial approach” to assisting these individuals and that it increased accessibility, said Dr. Sekhon.

In addition, a survey published last year showed that 87% of Americans in general want to continue using telehealth services after the pandemic. Most respondents agreed that telehealth had made it easier to get the care they needed. They also reported having received the same level of care via telehealth as with in-person care.

A growing body of research shows that VR has “positive influences on mood and well-being, cognition, pain management, [and] treatment of phobias in younger adults,” Dr. Sekhon said. She added that there is evidence that VR is feasible for older adults, with applications in cognitive disorders.

She cited a recent systematic review of 55 studies that assessed the impact of different types of VR on mental health in older adults. The results showed that VR could be helpful in screening for cognitive impairment – and it was comparable to some paper-based assessment. It was also useful as a training tool for those with cognitive impairment.

Examples of VR interventions that can be used to treat cognitive impairment include “virtual cities, kitchens, supermarkets,” Dr. Sekhon noted.

The technology is increasingly being used as a tool to deliver psychotherapy, in which patient engagement is “a key determinant” of outcomes, she added. “Virtual reality is a cutting-edge, engaging, and immersive technique to administer psychotherapy,” she said.

Such VR approaches are proving successful in older patients. Dr. Sekhon highlighted the case of an 85-year-old woman who engaged in ten sessions of psychodynamic psychotherapy that targeted persistent dysthymia and negativistic mood. The case was part of a proof-of-concept study published in the May issue of the American Journal of Geriatric Psychiatry.

Dr. Sekhon noted the intervention was well tolerated and was associated with minimal side effects.
 

VR-based meditation

Dr. Sekhon and her colleagues are now conducting a randomized controlled trial of VR meditation in older adults. VR-based meditation has been shown to increase relaxation and to decrease anxiety, sadness, and anger in younger adults. However, it has not been studied in the geriatric population.

The pilot study is assessing the feasibility and tolerability of VR meditation for older adults and its effects on stress, anxiety, depression, sleep, and quality of life. The study involves 30 adults aged 60 years and older.

Participants receive either 15-minute VR mindfulness meditation sessions twice a week for 4 weeks or are on a control wait list. The meditation sessions are user friendly and focus on breath meditation and body scans, Dr. Sekhon reported.

Because participants are older and balance is a concern, safety steps are incorporated into the sessions. “We ensure they’re doing this in a seated position, in a chair with arm rests, so that they’re very stable and there’s no risk of falls,” said Dr. Sekhon.

Another concern with VR is motion sickness, she noted. “It’s pretty minimal, but the best way we found so far is giving older adults time to adapt and feel comfortable with the VR,” she said. From the first session, participants learn how to put on the device and are checked to make sure they are comfortable with the process. To help them get used to everything, video and audio are not included during the first session.

Dr. Sekhon noted that results from the study are expected later this year.

In addition to mindfulness, researchers are using VR to deliver other established interventions, such as exposure therapy – and are implementing these approaches in varied environments, including long-term and palliative care settings.

VR-related technology is constantly improving and is becoming easier to use and more affordable, said Dr. Sekhon. She noted that the simplest devices that rely on smartphones cost as little as $15.

Although VR in older adults is promising, there are barriers to its adoption and use in research, she noted. For example, older adults may have cognitive, visual, or hearing impairments. They may have limited digital literacy, and/or they may not have access to the required technology.

These barriers can be overcome through workarounds, including providing instructional videos and digital literacy assistance via Zoom and working with community partners to facilitate study recruitment of older patients, Dr. Sekhon said.

Dr. Sekhon’s research is funded by the Canadian Institutes of Health Research and the Fonds de recherche du Quebec Sante.

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

Researchers are increasingly turning their attention to virtual reality (VR) for the treatment of psychiatric disorders in older adults.

Recent studies have highlighted the usefulness of VR in treating depression and loneliness in older patients who may be socially isolated because of their age, comorbidities, or the COVID-19 pandemic.

“The unique capability of virtual reality to create an immersive and engaging setting is an exciting opportunity for geriatric psychiatry,” Harmehr Sekhon, PhD, postdoctoral research fellow, Lady Davis Institute/Jewish General Hospital, McGill University, Montreal, and McLean Hospital, Harvard Medical School, Boston, told this news organization.

Because VR can be personalized and tailored for each patient, it represents “a cutting-edge technology” for novel applications, Dr. Sekhon said.

One novel approach involves using VR to administer a mindfulness intervention in older adults. Dr. Sekhon shared information on her own mindfulness study and on other developments in VR and telemedicine at the American Association for Geriatric Psychiatry annual meeting.
 

Potential bridging tool

As the population ages, the prevalence of mental health disorders increases. Telemedicine has proved to be a potential “bridge” to address the health care needs of older adults, Dr. Sekhon noted.

She cited her systematic review of telemedicine for older adults with dementia during COVID-19. Results showed that telemedicine was a “beneficial approach” to assisting these individuals and that it increased accessibility, said Dr. Sekhon.

In addition, a survey published last year showed that 87% of Americans in general want to continue using telehealth services after the pandemic. Most respondents agreed that telehealth had made it easier to get the care they needed. They also reported having received the same level of care via telehealth as with in-person care.

A growing body of research shows that VR has “positive influences on mood and well-being, cognition, pain management, [and] treatment of phobias in younger adults,” Dr. Sekhon said. She added that there is evidence that VR is feasible for older adults, with applications in cognitive disorders.

She cited a recent systematic review of 55 studies that assessed the impact of different types of VR on mental health in older adults. The results showed that VR could be helpful in screening for cognitive impairment – and it was comparable to some paper-based assessment. It was also useful as a training tool for those with cognitive impairment.

Examples of VR interventions that can be used to treat cognitive impairment include “virtual cities, kitchens, supermarkets,” Dr. Sekhon noted.

The technology is increasingly being used as a tool to deliver psychotherapy, in which patient engagement is “a key determinant” of outcomes, she added. “Virtual reality is a cutting-edge, engaging, and immersive technique to administer psychotherapy,” she said.

Such VR approaches are proving successful in older patients. Dr. Sekhon highlighted the case of an 85-year-old woman who engaged in ten sessions of psychodynamic psychotherapy that targeted persistent dysthymia and negativistic mood. The case was part of a proof-of-concept study published in the May issue of the American Journal of Geriatric Psychiatry.

Dr. Sekhon noted the intervention was well tolerated and was associated with minimal side effects.
 

VR-based meditation

Dr. Sekhon and her colleagues are now conducting a randomized controlled trial of VR meditation in older adults. VR-based meditation has been shown to increase relaxation and to decrease anxiety, sadness, and anger in younger adults. However, it has not been studied in the geriatric population.

The pilot study is assessing the feasibility and tolerability of VR meditation for older adults and its effects on stress, anxiety, depression, sleep, and quality of life. The study involves 30 adults aged 60 years and older.

Participants receive either 15-minute VR mindfulness meditation sessions twice a week for 4 weeks or are on a control wait list. The meditation sessions are user friendly and focus on breath meditation and body scans, Dr. Sekhon reported.

Because participants are older and balance is a concern, safety steps are incorporated into the sessions. “We ensure they’re doing this in a seated position, in a chair with arm rests, so that they’re very stable and there’s no risk of falls,” said Dr. Sekhon.

Another concern with VR is motion sickness, she noted. “It’s pretty minimal, but the best way we found so far is giving older adults time to adapt and feel comfortable with the VR,” she said. From the first session, participants learn how to put on the device and are checked to make sure they are comfortable with the process. To help them get used to everything, video and audio are not included during the first session.

Dr. Sekhon noted that results from the study are expected later this year.

In addition to mindfulness, researchers are using VR to deliver other established interventions, such as exposure therapy – and are implementing these approaches in varied environments, including long-term and palliative care settings.

VR-related technology is constantly improving and is becoming easier to use and more affordable, said Dr. Sekhon. She noted that the simplest devices that rely on smartphones cost as little as $15.

Although VR in older adults is promising, there are barriers to its adoption and use in research, she noted. For example, older adults may have cognitive, visual, or hearing impairments. They may have limited digital literacy, and/or they may not have access to the required technology.

These barriers can be overcome through workarounds, including providing instructional videos and digital literacy assistance via Zoom and working with community partners to facilitate study recruitment of older patients, Dr. Sekhon said.

Dr. Sekhon’s research is funded by the Canadian Institutes of Health Research and the Fonds de recherche du Quebec Sante.

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

Researchers are increasingly turning their attention to virtual reality (VR) for the treatment of psychiatric disorders in older adults.

Recent studies have highlighted the usefulness of VR in treating depression and loneliness in older patients who may be socially isolated because of their age, comorbidities, or the COVID-19 pandemic.

“The unique capability of virtual reality to create an immersive and engaging setting is an exciting opportunity for geriatric psychiatry,” Harmehr Sekhon, PhD, postdoctoral research fellow, Lady Davis Institute/Jewish General Hospital, McGill University, Montreal, and McLean Hospital, Harvard Medical School, Boston, told this news organization.

Because VR can be personalized and tailored for each patient, it represents “a cutting-edge technology” for novel applications, Dr. Sekhon said.

One novel approach involves using VR to administer a mindfulness intervention in older adults. Dr. Sekhon shared information on her own mindfulness study and on other developments in VR and telemedicine at the American Association for Geriatric Psychiatry annual meeting.
 

Potential bridging tool

As the population ages, the prevalence of mental health disorders increases. Telemedicine has proved to be a potential “bridge” to address the health care needs of older adults, Dr. Sekhon noted.

She cited her systematic review of telemedicine for older adults with dementia during COVID-19. Results showed that telemedicine was a “beneficial approach” to assisting these individuals and that it increased accessibility, said Dr. Sekhon.

In addition, a survey published last year showed that 87% of Americans in general want to continue using telehealth services after the pandemic. Most respondents agreed that telehealth had made it easier to get the care they needed. They also reported having received the same level of care via telehealth as with in-person care.

A growing body of research shows that VR has “positive influences on mood and well-being, cognition, pain management, [and] treatment of phobias in younger adults,” Dr. Sekhon said. She added that there is evidence that VR is feasible for older adults, with applications in cognitive disorders.

She cited a recent systematic review of 55 studies that assessed the impact of different types of VR on mental health in older adults. The results showed that VR could be helpful in screening for cognitive impairment – and it was comparable to some paper-based assessment. It was also useful as a training tool for those with cognitive impairment.

Examples of VR interventions that can be used to treat cognitive impairment include “virtual cities, kitchens, supermarkets,” Dr. Sekhon noted.

The technology is increasingly being used as a tool to deliver psychotherapy, in which patient engagement is “a key determinant” of outcomes, she added. “Virtual reality is a cutting-edge, engaging, and immersive technique to administer psychotherapy,” she said.

Such VR approaches are proving successful in older patients. Dr. Sekhon highlighted the case of an 85-year-old woman who engaged in ten sessions of psychodynamic psychotherapy that targeted persistent dysthymia and negativistic mood. The case was part of a proof-of-concept study published in the May issue of the American Journal of Geriatric Psychiatry.

Dr. Sekhon noted the intervention was well tolerated and was associated with minimal side effects.
 

VR-based meditation

Dr. Sekhon and her colleagues are now conducting a randomized controlled trial of VR meditation in older adults. VR-based meditation has been shown to increase relaxation and to decrease anxiety, sadness, and anger in younger adults. However, it has not been studied in the geriatric population.

The pilot study is assessing the feasibility and tolerability of VR meditation for older adults and its effects on stress, anxiety, depression, sleep, and quality of life. The study involves 30 adults aged 60 years and older.

Participants receive either 15-minute VR mindfulness meditation sessions twice a week for 4 weeks or are on a control wait list. The meditation sessions are user friendly and focus on breath meditation and body scans, Dr. Sekhon reported.

Because participants are older and balance is a concern, safety steps are incorporated into the sessions. “We ensure they’re doing this in a seated position, in a chair with arm rests, so that they’re very stable and there’s no risk of falls,” said Dr. Sekhon.

Another concern with VR is motion sickness, she noted. “It’s pretty minimal, but the best way we found so far is giving older adults time to adapt and feel comfortable with the VR,” she said. From the first session, participants learn how to put on the device and are checked to make sure they are comfortable with the process. To help them get used to everything, video and audio are not included during the first session.

Dr. Sekhon noted that results from the study are expected later this year.

In addition to mindfulness, researchers are using VR to deliver other established interventions, such as exposure therapy – and are implementing these approaches in varied environments, including long-term and palliative care settings.

VR-related technology is constantly improving and is becoming easier to use and more affordable, said Dr. Sekhon. She noted that the simplest devices that rely on smartphones cost as little as $15.

Although VR in older adults is promising, there are barriers to its adoption and use in research, she noted. For example, older adults may have cognitive, visual, or hearing impairments. They may have limited digital literacy, and/or they may not have access to the required technology.

These barriers can be overcome through workarounds, including providing instructional videos and digital literacy assistance via Zoom and working with community partners to facilitate study recruitment of older patients, Dr. Sekhon said.

Dr. Sekhon’s research is funded by the Canadian Institutes of Health Research and the Fonds de recherche du Quebec Sante.

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

This video transcript has been edited for clarity.

Andrew N. Wilner, MD: Welcome to Medscape. I’m Dr Andrew Wilner, reporting from the American Epilepsy Society meeting.

Today, I have the pleasure of speaking with Dr. Chethan Rao, a child and adolescent neurology resident from the Mayo Clinic in Jacksonville, Fla. Dr. Rao has a particular interest in pediatric epilepsy. Welcome, Dr. Rao.

Chethan Rao, DO: Thank you, Dr. Wilner. It’s a pleasure to be here, and thanks for taking the time to highlight our work.

Dr. Wilner: You had a very interesting paper at the meeting that I wanted to talk about, focused on infantile spasms and smartphone video. Before we dive into the paper, tell us: What are infantile spasms, and why is it important to diagnose them early?

Dr. Rao: Infantile spasms, also known as epileptic spasms, are 1- to 2-second seizures, and they typically consist of sudden stiffening of the body with brief bending forward or backward of the arms, legs, and head. They usually happen around age 3-8 months, and they typically occur in clusters, most often after awakening from sleep.

The incidence is about 1 in 2,000-3,000 children. Many kids with spasms go on to develop seizures that are very difficult to treat, like Lennox-Gastaut epilepsy, and many go on to have developmental delays as well.

Dr. Wilner: Are these subtle? In other words, could a parent have a child like that and not really recognize that this is something abnormal? Or are they so dramatic that parents say: “We’re going to the emergency room?”

Dr. Rao: One of the problems that we encounter often is that in this age group of infants, they have benign sleep myoclonus; they have Sandifer syndrome related to reflux. Those can be very difficult mimics of spasms. They’re not the most clear-cut, but they look usually different enough from normal baby movements that they get parents to seek medical attention.

Dr. Wilner: You mentioned that the infantile spasms really are a type of epilepsy and symptomatic, usually, of some underlying neurologic condition. Why is it so important to diagnose them early?

Dr. Rao: Great question. Many studies have looked at developmental outcomes based on when spasms were diagnosed and treated, and all of them have replicated time over time that the earlier you get to treatment for the spasms, the better the outcomes are for seizure control and for development.

For this reason, infantile spasm is considered a neurologic urgency in our world. Like I said, accurate diagnosis is often complicated by these potential mimics. Prompt EEG is one of the most important things for confirmation of diagnosis.

Dr. Wilner: But to get that EEG, it has to get all the way to the neurologist, right? It’s not something they’re going to do in the ER. I saw a statistic: There are millions, if not billions, of smartphones out there. Where does the smartphone come in?

Dr. Rao: Absolutely. One of the things that we have on our side these days is that almost everyone has a smartphone at their disposal. One of the recent polls in 2021 showed that more than 95% of adults of childbearing age have smartphones with video access. As some other studies have shown in the adult world, we all really have an epilepsy monitoring unit minus the EEG in our own pockets.

It’s definitely a useful tool, as that first screening video can be used in adjunct to history and physical. There have been many of studies on the adult epilepsy side showing the predictive value of smartphone video for differentiating things like epileptic seizures and nonepileptic spells. What we wanted to do is use smartphone video to pin the diagnosis early of infantile spasms and get it treated as quickly as possible.

Dr. Wilner: I’m a fan. Every now and then, I do have a patient who brings in a video of some spell. I’m an adult neurologist. The patient had a spell, and you ask them – of course they don’t remember – and you ask the witness, who usually is not a trained observer. There have been one or two occasions where I thought: “Well, I don’t know if that was really a seizure.” Then they show me the video and it’s like, “Wow, that is definitely a convulsion.” A picture definitely can be worth a thousand words.

You studied this systematically for your poster. Tell me about what you did.

Dr. Rao: Since the poster, we’ve actually expanded the study, so I’ll give you the updated version. We looked at 101 infants retrospectively at two large children’s health care centers: Nemours Children’s, associated with Mayo Clinic in Jacksonville, Fla., and Texas Children’s Hospital in Houston. We narrowed it down to 80 patients whom we included. Of these, 43 had smartphone video capture when they first presented and 37 had no video when they first presented.

We found a 17-day difference by median in the time to diagnosis and treatment. In other words, the video group was diagnosed and treated 17 days by median, compared with the no-video group. Although 17 days may not sound like a big number, in this context it can make a huge difference. That’s been shown by one of these key studies in our field called the UK Infantile Spasms Study. The 2-week difference made about a 10-point difference on the developmental scale that they use – so pretty significant.

Dr. Wilner: Let me think about this for a minute. Was that because the parents brought the child in with their video and the doctor said, “Hey, that’s infantile spasms. Here’s your shot of ACTH [or whatever they’re using these days].” Or was it because the parents who were attentive enough to use video brought their kids in sooner?

Or was this the time from when they brought the child in to treatment? Is that the time you looked at? So it wasn’t just that these were more attentive parents and more likely to use the video – you’re looking at the time from presentation with or without video until treatment, is that right?

Dr. Rao: We looked to the time from the start of the spasms, as reported by the parents, to the time of diagnosis and then the start of spasms to the time of treatment. What you asked was a fantastic question. We wanted to know who these parents are who are taking videos versus the ones that are not.

We looked at the race/ethnicity data and socioeconomic status data. There were no significant differences between the video and nonvideo group. That would not explain the difference in our results here.

Dr. Wilner: Do you have plans to follow these approximately 40 children 5 years from now and see who’s riding a bicycle and who’s still stuck in the stroller? Is there going to be a difference?

Dr. Rao: Because time to diagnosis and time to treatment were our primary outcomes, long-term follow-up may not really help as much in this study. We did have a couple of other ideas for future studies. One that we wanted to look at was kids who have risk factors for developing spasms, such as trisomy 21, tuberous sclerosis, and congenital cortical malformations; those kids are at a much higher risk for developing spasms around 3-8 months of life.

In giving targeted counseling to those families about how they can use smartphone video to minimize the time to diagnosis and treatment, we think we may be able to learn more and maybe do that prospectively.

The other interesting idea is using artificial intelligence technology for spasm detection in some of these smartphone videos. They’re already using it for different seizure types. It could be an efficient first pass when we get a whole bunch of smartphone videos to determine which ones we need to pursue further steps – to see whether we need to get long-term EEG monitoring or not.

Dr. Wilner: As an epileptologist, I was going to say that we have smartphone EKG. All we need now is smartphone EEG, and then you’ll have all the information you need on day one. It may be a ways away.

As a bottom line, would it be fair to say that parents should not hesitate to take a video of any suspiciously abnormal behavior and bring it to their family doctor or pediatric neurologist?

Dr. Rao: Yes. I was happy to see the Tuberous Sclerosis Alliance put out a promotional video that had some steps for when parents see things that are suspicious for spasms, and they do recommend using smartphone video and promptly showing it to their doctors. I think the difference that we hope to provide in this study is that we can now quantify the effect of having that smartphone video when they first present.

My takeaway from this study that I would like to show is encouraging the use of smartphone video as an adjunct tool and for providers to ask for the videos, but also for these pediatric centers to develop an infrastructure – either a secure, monitored email address like we have at our center or a patient portal – where parents can submit video concerning for spasms.

Dr. Wilner: Save the trip to the doctor. Get that video out there first.

Dr. Rao: Especially in the pandemic world, right?

Dr. Wilner: Yes. I understand that you are a neurology resident. To wrap up, what’s the next step for you?

Dr. Rao: I’m finishing up my child neurology residency this year, and I’m moving out to Stanford for pediatric epilepsy fellowship. We’re preparing this project we’re talking about for submission soon, and we’re working on another project, which is a systematic review of genetic testing and the presurgical workup for pediatric drug-resistant focal epilepsy.

Dr. Wilner: Excellent. That’s pretty exciting. Good luck to you. I want to thank you very much for telling us about your research.

Dr. Rao: It was a pleasure speaking with you, and I look forward to the next time.

Dr. Wilner: I’m Dr Andrew Wilner, reporting for Medscape. Thanks for watching.

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

This video transcript has been edited for clarity.

Andrew N. Wilner, MD: Welcome to Medscape. I’m Dr Andrew Wilner, reporting from the American Epilepsy Society meeting.

Today, I have the pleasure of speaking with Dr. Chethan Rao, a child and adolescent neurology resident from the Mayo Clinic in Jacksonville, Fla. Dr. Rao has a particular interest in pediatric epilepsy. Welcome, Dr. Rao.

Chethan Rao, DO: Thank you, Dr. Wilner. It’s a pleasure to be here, and thanks for taking the time to highlight our work.

Dr. Wilner: You had a very interesting paper at the meeting that I wanted to talk about, focused on infantile spasms and smartphone video. Before we dive into the paper, tell us: What are infantile spasms, and why is it important to diagnose them early?

Dr. Rao: Infantile spasms, also known as epileptic spasms, are 1- to 2-second seizures, and they typically consist of sudden stiffening of the body with brief bending forward or backward of the arms, legs, and head. They usually happen around age 3-8 months, and they typically occur in clusters, most often after awakening from sleep.

The incidence is about 1 in 2,000-3,000 children. Many kids with spasms go on to develop seizures that are very difficult to treat, like Lennox-Gastaut epilepsy, and many go on to have developmental delays as well.

Dr. Wilner: Are these subtle? In other words, could a parent have a child like that and not really recognize that this is something abnormal? Or are they so dramatic that parents say: “We’re going to the emergency room?”

Dr. Rao: One of the problems that we encounter often is that in this age group of infants, they have benign sleep myoclonus; they have Sandifer syndrome related to reflux. Those can be very difficult mimics of spasms. They’re not the most clear-cut, but they look usually different enough from normal baby movements that they get parents to seek medical attention.

Dr. Wilner: You mentioned that the infantile spasms really are a type of epilepsy and symptomatic, usually, of some underlying neurologic condition. Why is it so important to diagnose them early?

Dr. Rao: Great question. Many studies have looked at developmental outcomes based on when spasms were diagnosed and treated, and all of them have replicated time over time that the earlier you get to treatment for the spasms, the better the outcomes are for seizure control and for development.

For this reason, infantile spasm is considered a neurologic urgency in our world. Like I said, accurate diagnosis is often complicated by these potential mimics. Prompt EEG is one of the most important things for confirmation of diagnosis.

Dr. Wilner: But to get that EEG, it has to get all the way to the neurologist, right? It’s not something they’re going to do in the ER. I saw a statistic: There are millions, if not billions, of smartphones out there. Where does the smartphone come in?

Dr. Rao: Absolutely. One of the things that we have on our side these days is that almost everyone has a smartphone at their disposal. One of the recent polls in 2021 showed that more than 95% of adults of childbearing age have smartphones with video access. As some other studies have shown in the adult world, we all really have an epilepsy monitoring unit minus the EEG in our own pockets.

It’s definitely a useful tool, as that first screening video can be used in adjunct to history and physical. There have been many of studies on the adult epilepsy side showing the predictive value of smartphone video for differentiating things like epileptic seizures and nonepileptic spells. What we wanted to do is use smartphone video to pin the diagnosis early of infantile spasms and get it treated as quickly as possible.

Dr. Wilner: I’m a fan. Every now and then, I do have a patient who brings in a video of some spell. I’m an adult neurologist. The patient had a spell, and you ask them – of course they don’t remember – and you ask the witness, who usually is not a trained observer. There have been one or two occasions where I thought: “Well, I don’t know if that was really a seizure.” Then they show me the video and it’s like, “Wow, that is definitely a convulsion.” A picture definitely can be worth a thousand words.

You studied this systematically for your poster. Tell me about what you did.

Dr. Rao: Since the poster, we’ve actually expanded the study, so I’ll give you the updated version. We looked at 101 infants retrospectively at two large children’s health care centers: Nemours Children’s, associated with Mayo Clinic in Jacksonville, Fla., and Texas Children’s Hospital in Houston. We narrowed it down to 80 patients whom we included. Of these, 43 had smartphone video capture when they first presented and 37 had no video when they first presented.

We found a 17-day difference by median in the time to diagnosis and treatment. In other words, the video group was diagnosed and treated 17 days by median, compared with the no-video group. Although 17 days may not sound like a big number, in this context it can make a huge difference. That’s been shown by one of these key studies in our field called the UK Infantile Spasms Study. The 2-week difference made about a 10-point difference on the developmental scale that they use – so pretty significant.

Dr. Wilner: Let me think about this for a minute. Was that because the parents brought the child in with their video and the doctor said, “Hey, that’s infantile spasms. Here’s your shot of ACTH [or whatever they’re using these days].” Or was it because the parents who were attentive enough to use video brought their kids in sooner?

Or was this the time from when they brought the child in to treatment? Is that the time you looked at? So it wasn’t just that these were more attentive parents and more likely to use the video – you’re looking at the time from presentation with or without video until treatment, is that right?

Dr. Rao: We looked to the time from the start of the spasms, as reported by the parents, to the time of diagnosis and then the start of spasms to the time of treatment. What you asked was a fantastic question. We wanted to know who these parents are who are taking videos versus the ones that are not.

We looked at the race/ethnicity data and socioeconomic status data. There were no significant differences between the video and nonvideo group. That would not explain the difference in our results here.

Dr. Wilner: Do you have plans to follow these approximately 40 children 5 years from now and see who’s riding a bicycle and who’s still stuck in the stroller? Is there going to be a difference?

Dr. Rao: Because time to diagnosis and time to treatment were our primary outcomes, long-term follow-up may not really help as much in this study. We did have a couple of other ideas for future studies. One that we wanted to look at was kids who have risk factors for developing spasms, such as trisomy 21, tuberous sclerosis, and congenital cortical malformations; those kids are at a much higher risk for developing spasms around 3-8 months of life.

In giving targeted counseling to those families about how they can use smartphone video to minimize the time to diagnosis and treatment, we think we may be able to learn more and maybe do that prospectively.

The other interesting idea is using artificial intelligence technology for spasm detection in some of these smartphone videos. They’re already using it for different seizure types. It could be an efficient first pass when we get a whole bunch of smartphone videos to determine which ones we need to pursue further steps – to see whether we need to get long-term EEG monitoring or not.

Dr. Wilner: As an epileptologist, I was going to say that we have smartphone EKG. All we need now is smartphone EEG, and then you’ll have all the information you need on day one. It may be a ways away.

As a bottom line, would it be fair to say that parents should not hesitate to take a video of any suspiciously abnormal behavior and bring it to their family doctor or pediatric neurologist?

Dr. Rao: Yes. I was happy to see the Tuberous Sclerosis Alliance put out a promotional video that had some steps for when parents see things that are suspicious for spasms, and they do recommend using smartphone video and promptly showing it to their doctors. I think the difference that we hope to provide in this study is that we can now quantify the effect of having that smartphone video when they first present.

My takeaway from this study that I would like to show is encouraging the use of smartphone video as an adjunct tool and for providers to ask for the videos, but also for these pediatric centers to develop an infrastructure – either a secure, monitored email address like we have at our center or a patient portal – where parents can submit video concerning for spasms.

Dr. Wilner: Save the trip to the doctor. Get that video out there first.

Dr. Rao: Especially in the pandemic world, right?

Dr. Wilner: Yes. I understand that you are a neurology resident. To wrap up, what’s the next step for you?

Dr. Rao: I’m finishing up my child neurology residency this year, and I’m moving out to Stanford for pediatric epilepsy fellowship. We’re preparing this project we’re talking about for submission soon, and we’re working on another project, which is a systematic review of genetic testing and the presurgical workup for pediatric drug-resistant focal epilepsy.

Dr. Wilner: Excellent. That’s pretty exciting. Good luck to you. I want to thank you very much for telling us about your research.

Dr. Rao: It was a pleasure speaking with you, and I look forward to the next time.

Dr. Wilner: I’m Dr Andrew Wilner, reporting for Medscape. Thanks for watching.

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

This video transcript has been edited for clarity.

Andrew N. Wilner, MD: Welcome to Medscape. I’m Dr Andrew Wilner, reporting from the American Epilepsy Society meeting.

Today, I have the pleasure of speaking with Dr. Chethan Rao, a child and adolescent neurology resident from the Mayo Clinic in Jacksonville, Fla. Dr. Rao has a particular interest in pediatric epilepsy. Welcome, Dr. Rao.

Chethan Rao, DO: Thank you, Dr. Wilner. It’s a pleasure to be here, and thanks for taking the time to highlight our work.

Dr. Wilner: You had a very interesting paper at the meeting that I wanted to talk about, focused on infantile spasms and smartphone video. Before we dive into the paper, tell us: What are infantile spasms, and why is it important to diagnose them early?

Dr. Rao: Infantile spasms, also known as epileptic spasms, are 1- to 2-second seizures, and they typically consist of sudden stiffening of the body with brief bending forward or backward of the arms, legs, and head. They usually happen around age 3-8 months, and they typically occur in clusters, most often after awakening from sleep.

The incidence is about 1 in 2,000-3,000 children. Many kids with spasms go on to develop seizures that are very difficult to treat, like Lennox-Gastaut epilepsy, and many go on to have developmental delays as well.

Dr. Wilner: Are these subtle? In other words, could a parent have a child like that and not really recognize that this is something abnormal? Or are they so dramatic that parents say: “We’re going to the emergency room?”

Dr. Rao: One of the problems that we encounter often is that in this age group of infants, they have benign sleep myoclonus; they have Sandifer syndrome related to reflux. Those can be very difficult mimics of spasms. They’re not the most clear-cut, but they look usually different enough from normal baby movements that they get parents to seek medical attention.

Dr. Wilner: You mentioned that the infantile spasms really are a type of epilepsy and symptomatic, usually, of some underlying neurologic condition. Why is it so important to diagnose them early?

Dr. Rao: Great question. Many studies have looked at developmental outcomes based on when spasms were diagnosed and treated, and all of them have replicated time over time that the earlier you get to treatment for the spasms, the better the outcomes are for seizure control and for development.

For this reason, infantile spasm is considered a neurologic urgency in our world. Like I said, accurate diagnosis is often complicated by these potential mimics. Prompt EEG is one of the most important things for confirmation of diagnosis.

Dr. Wilner: But to get that EEG, it has to get all the way to the neurologist, right? It’s not something they’re going to do in the ER. I saw a statistic: There are millions, if not billions, of smartphones out there. Where does the smartphone come in?

Dr. Rao: Absolutely. One of the things that we have on our side these days is that almost everyone has a smartphone at their disposal. One of the recent polls in 2021 showed that more than 95% of adults of childbearing age have smartphones with video access. As some other studies have shown in the adult world, we all really have an epilepsy monitoring unit minus the EEG in our own pockets.

It’s definitely a useful tool, as that first screening video can be used in adjunct to history and physical. There have been many of studies on the adult epilepsy side showing the predictive value of smartphone video for differentiating things like epileptic seizures and nonepileptic spells. What we wanted to do is use smartphone video to pin the diagnosis early of infantile spasms and get it treated as quickly as possible.

Dr. Wilner: I’m a fan. Every now and then, I do have a patient who brings in a video of some spell. I’m an adult neurologist. The patient had a spell, and you ask them – of course they don’t remember – and you ask the witness, who usually is not a trained observer. There have been one or two occasions where I thought: “Well, I don’t know if that was really a seizure.” Then they show me the video and it’s like, “Wow, that is definitely a convulsion.” A picture definitely can be worth a thousand words.

You studied this systematically for your poster. Tell me about what you did.

Dr. Rao: Since the poster, we’ve actually expanded the study, so I’ll give you the updated version. We looked at 101 infants retrospectively at two large children’s health care centers: Nemours Children’s, associated with Mayo Clinic in Jacksonville, Fla., and Texas Children’s Hospital in Houston. We narrowed it down to 80 patients whom we included. Of these, 43 had smartphone video capture when they first presented and 37 had no video when they first presented.

We found a 17-day difference by median in the time to diagnosis and treatment. In other words, the video group was diagnosed and treated 17 days by median, compared with the no-video group. Although 17 days may not sound like a big number, in this context it can make a huge difference. That’s been shown by one of these key studies in our field called the UK Infantile Spasms Study. The 2-week difference made about a 10-point difference on the developmental scale that they use – so pretty significant.

Dr. Wilner: Let me think about this for a minute. Was that because the parents brought the child in with their video and the doctor said, “Hey, that’s infantile spasms. Here’s your shot of ACTH [or whatever they’re using these days].” Or was it because the parents who were attentive enough to use video brought their kids in sooner?

Or was this the time from when they brought the child in to treatment? Is that the time you looked at? So it wasn’t just that these were more attentive parents and more likely to use the video – you’re looking at the time from presentation with or without video until treatment, is that right?

Dr. Rao: We looked to the time from the start of the spasms, as reported by the parents, to the time of diagnosis and then the start of spasms to the time of treatment. What you asked was a fantastic question. We wanted to know who these parents are who are taking videos versus the ones that are not.

We looked at the race/ethnicity data and socioeconomic status data. There were no significant differences between the video and nonvideo group. That would not explain the difference in our results here.

Dr. Wilner: Do you have plans to follow these approximately 40 children 5 years from now and see who’s riding a bicycle and who’s still stuck in the stroller? Is there going to be a difference?

Dr. Rao: Because time to diagnosis and time to treatment were our primary outcomes, long-term follow-up may not really help as much in this study. We did have a couple of other ideas for future studies. One that we wanted to look at was kids who have risk factors for developing spasms, such as trisomy 21, tuberous sclerosis, and congenital cortical malformations; those kids are at a much higher risk for developing spasms around 3-8 months of life.

In giving targeted counseling to those families about how they can use smartphone video to minimize the time to diagnosis and treatment, we think we may be able to learn more and maybe do that prospectively.

The other interesting idea is using artificial intelligence technology for spasm detection in some of these smartphone videos. They’re already using it for different seizure types. It could be an efficient first pass when we get a whole bunch of smartphone videos to determine which ones we need to pursue further steps – to see whether we need to get long-term EEG monitoring or not.

Dr. Wilner: As an epileptologist, I was going to say that we have smartphone EKG. All we need now is smartphone EEG, and then you’ll have all the information you need on day one. It may be a ways away.

As a bottom line, would it be fair to say that parents should not hesitate to take a video of any suspiciously abnormal behavior and bring it to their family doctor or pediatric neurologist?

Dr. Rao: Yes. I was happy to see the Tuberous Sclerosis Alliance put out a promotional video that had some steps for when parents see things that are suspicious for spasms, and they do recommend using smartphone video and promptly showing it to their doctors. I think the difference that we hope to provide in this study is that we can now quantify the effect of having that smartphone video when they first present.

My takeaway from this study that I would like to show is encouraging the use of smartphone video as an adjunct tool and for providers to ask for the videos, but also for these pediatric centers to develop an infrastructure – either a secure, monitored email address like we have at our center or a patient portal – where parents can submit video concerning for spasms.

Dr. Wilner: Save the trip to the doctor. Get that video out there first.

Dr. Rao: Especially in the pandemic world, right?

Dr. Wilner: Yes. I understand that you are a neurology resident. To wrap up, what’s the next step for you?

Dr. Rao: I’m finishing up my child neurology residency this year, and I’m moving out to Stanford for pediatric epilepsy fellowship. We’re preparing this project we’re talking about for submission soon, and we’re working on another project, which is a systematic review of genetic testing and the presurgical workup for pediatric drug-resistant focal epilepsy.

Dr. Wilner: Excellent. That’s pretty exciting. Good luck to you. I want to thank you very much for telling us about your research.

Dr. Rao: It was a pleasure speaking with you, and I look forward to the next time.

Dr. Wilner: I’m Dr Andrew Wilner, reporting for Medscape. Thanks for watching.

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

Upper airway hypoglossal nerve stimulation is safe and effective in adolescents with Down syndrome and severe persistent obstructive sleep apnea (OSA) occurring after adenotonsillectomy and who couldn’t tolerate positive airway pressure, early research suggests.

In a phase I study, 42 adolescents received a surgically implanted device that moves the tongue forward during sleep. Results at 1-year follow-up showed 66% “responded well” to treatment and showed a drop in apnea-hypopnea index (AHI) of at least 50%.

“Parents came back to us and said not only is the sleep better but my child seems to be doing better during the day,” lead investigator Christopher Hartnick, MD, director of the Division of Pediatric Otolaryngology and the Pediatric Airway, Voice, and Swallowing Center at Massachusetts Eye and Ear, Boston, told this news organization.

The findings were published online  in JAMA Otolaryngology – Head and Neck Surgery.
 

Limited options

Upper airway simulation has been shown previously to be effective for adults with OSA, but up until now, the process has not been evaluated in children.

The device used in the current study “stimulates the hypoglossal nerve to protrude the tongue and open the airway on inspiration during sleep,” the investigators note.

“Hypoglossal nerve stimulation may be a particularly suitable therapy for patients with Down syndrome because it can augment neuromuscular airway tone and reduce anatomical obstruction at the base of the tongue, a common site of residual obstruction in children with Down syndrome,” they add.

“This study was born out of the frustration of not having an effective treatment option for children with Down syndrome who struggle with sleep apnea,” Dr. Hartnick said in a news release.

A total of 42 adolescents (67% male; mean age, 15 years) with Down syndrome and persistent severe OSA after adenotonsillectomy were implanted with the hypoglossal nerve stimulator. All were followed for 12 months.

The surgery was safe, with the most common adverse event being temporary tongue discomfort in five patients (12%). This typically resolved in weeks, the researchers note.
 

High response, adherence rates

Results showed response rates and adherence to therapy was high. The mean duration of nightly therapy was 9 hours, with 40 children (95.2%) using the device at least 4 hours every night.

The implant was also effective, with a mean decrease in AHI of 12.9 events per hour (95% confidence interval, –17.0 to –8.7 events per hour).

Nearly two-thirds of the children had at least a 50% reduction in their AHI, while roughly three-fourths had a 12-month follow-up AHI of less than 10 events per hour.

There were also significant improvements in polysomnographic and parent-reported quality of life outcomes 12 months after the implant, including improvement in sleep and daily functioning, behavior, and language.

“Sleep apnea remains one of the most common conditions that I grapple with working with patients with Down syndrome and their families,” co-investigator Brian Skotko, MD, Emma Campbell endowed chair on Down syndrome at Massachusetts General Hospital, Boston, said in the release.

“Until now, so many of our patients had run out of treatment options, and their health and well-being were declining. Now, with the hypoglossal nerve stimulator treatment, we may have an effective and safe way to treat apnea and maximize brain health for people with Down syndrome,” Dr. Skotko added.

Dr. Hartnick and Dr. Skotko have received a $4 million, 5-year grant from the National Institutes of Health to assess whether upper airway stimulation might help cognition in children with Down syndrome.
 

Landmark investigation

Co-authors of an invited commentary said they “applaud” the researchers for their “landmark” investigation, which demonstrated a response to upper airway stimulation in children with Down syndrome and OSA that is on par with what has been achieved in adults with OSA.

“They have established the safety of the procedure; however, future research is necessary to optimize the results of implant,” write Norman Friedman, MD, and Katherine Green, MD, both from the department of otolaryngology – head and neck surgery, University of Colorado School of Medicine, Aurora.

“Further assessment regarding patient selection and the systematic preoperative identification of potential barriers that might affect successful use of therapy will be beneficial to improve longitudinal outcomes and success in this population that is uniquely different from the adult cohorts that have received implants to date,” they add.

The study was funded by Inspire Medical Systems, which provided eight devices for the study but otherwise did not have a role in its design and conduct. The LuMind IDSC Down Syndrome Foundation also provided funding for the study. Dr. Hartnick and the editorialists have disclosed no relevant financial relationships. A complete list of disclosures for the other investigators is available in the original article.

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

Upper airway hypoglossal nerve stimulation is safe and effective in adolescents with Down syndrome and severe persistent obstructive sleep apnea (OSA) occurring after adenotonsillectomy and who couldn’t tolerate positive airway pressure, early research suggests.

In a phase I study, 42 adolescents received a surgically implanted device that moves the tongue forward during sleep. Results at 1-year follow-up showed 66% “responded well” to treatment and showed a drop in apnea-hypopnea index (AHI) of at least 50%.

“Parents came back to us and said not only is the sleep better but my child seems to be doing better during the day,” lead investigator Christopher Hartnick, MD, director of the Division of Pediatric Otolaryngology and the Pediatric Airway, Voice, and Swallowing Center at Massachusetts Eye and Ear, Boston, told this news organization.

The findings were published online  in JAMA Otolaryngology – Head and Neck Surgery.
 

Limited options

Upper airway simulation has been shown previously to be effective for adults with OSA, but up until now, the process has not been evaluated in children.

The device used in the current study “stimulates the hypoglossal nerve to protrude the tongue and open the airway on inspiration during sleep,” the investigators note.

“Hypoglossal nerve stimulation may be a particularly suitable therapy for patients with Down syndrome because it can augment neuromuscular airway tone and reduce anatomical obstruction at the base of the tongue, a common site of residual obstruction in children with Down syndrome,” they add.

“This study was born out of the frustration of not having an effective treatment option for children with Down syndrome who struggle with sleep apnea,” Dr. Hartnick said in a news release.

A total of 42 adolescents (67% male; mean age, 15 years) with Down syndrome and persistent severe OSA after adenotonsillectomy were implanted with the hypoglossal nerve stimulator. All were followed for 12 months.

The surgery was safe, with the most common adverse event being temporary tongue discomfort in five patients (12%). This typically resolved in weeks, the researchers note.
 

High response, adherence rates

Results showed response rates and adherence to therapy was high. The mean duration of nightly therapy was 9 hours, with 40 children (95.2%) using the device at least 4 hours every night.

The implant was also effective, with a mean decrease in AHI of 12.9 events per hour (95% confidence interval, –17.0 to –8.7 events per hour).

Nearly two-thirds of the children had at least a 50% reduction in their AHI, while roughly three-fourths had a 12-month follow-up AHI of less than 10 events per hour.

There were also significant improvements in polysomnographic and parent-reported quality of life outcomes 12 months after the implant, including improvement in sleep and daily functioning, behavior, and language.

“Sleep apnea remains one of the most common conditions that I grapple with working with patients with Down syndrome and their families,” co-investigator Brian Skotko, MD, Emma Campbell endowed chair on Down syndrome at Massachusetts General Hospital, Boston, said in the release.

“Until now, so many of our patients had run out of treatment options, and their health and well-being were declining. Now, with the hypoglossal nerve stimulator treatment, we may have an effective and safe way to treat apnea and maximize brain health for people with Down syndrome,” Dr. Skotko added.

Dr. Hartnick and Dr. Skotko have received a $4 million, 5-year grant from the National Institutes of Health to assess whether upper airway stimulation might help cognition in children with Down syndrome.
 

Landmark investigation

Co-authors of an invited commentary said they “applaud” the researchers for their “landmark” investigation, which demonstrated a response to upper airway stimulation in children with Down syndrome and OSA that is on par with what has been achieved in adults with OSA.

“They have established the safety of the procedure; however, future research is necessary to optimize the results of implant,” write Norman Friedman, MD, and Katherine Green, MD, both from the department of otolaryngology – head and neck surgery, University of Colorado School of Medicine, Aurora.

“Further assessment regarding patient selection and the systematic preoperative identification of potential barriers that might affect successful use of therapy will be beneficial to improve longitudinal outcomes and success in this population that is uniquely different from the adult cohorts that have received implants to date,” they add.

The study was funded by Inspire Medical Systems, which provided eight devices for the study but otherwise did not have a role in its design and conduct. The LuMind IDSC Down Syndrome Foundation also provided funding for the study. Dr. Hartnick and the editorialists have disclosed no relevant financial relationships. A complete list of disclosures for the other investigators is available in the original article.

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

Upper airway hypoglossal nerve stimulation is safe and effective in adolescents with Down syndrome and severe persistent obstructive sleep apnea (OSA) occurring after adenotonsillectomy and who couldn’t tolerate positive airway pressure, early research suggests.

In a phase I study, 42 adolescents received a surgically implanted device that moves the tongue forward during sleep. Results at 1-year follow-up showed 66% “responded well” to treatment and showed a drop in apnea-hypopnea index (AHI) of at least 50%.

“Parents came back to us and said not only is the sleep better but my child seems to be doing better during the day,” lead investigator Christopher Hartnick, MD, director of the Division of Pediatric Otolaryngology and the Pediatric Airway, Voice, and Swallowing Center at Massachusetts Eye and Ear, Boston, told this news organization.

The findings were published online  in JAMA Otolaryngology – Head and Neck Surgery.
 

Limited options

Upper airway simulation has been shown previously to be effective for adults with OSA, but up until now, the process has not been evaluated in children.

The device used in the current study “stimulates the hypoglossal nerve to protrude the tongue and open the airway on inspiration during sleep,” the investigators note.

“Hypoglossal nerve stimulation may be a particularly suitable therapy for patients with Down syndrome because it can augment neuromuscular airway tone and reduce anatomical obstruction at the base of the tongue, a common site of residual obstruction in children with Down syndrome,” they add.

“This study was born out of the frustration of not having an effective treatment option for children with Down syndrome who struggle with sleep apnea,” Dr. Hartnick said in a news release.

A total of 42 adolescents (67% male; mean age, 15 years) with Down syndrome and persistent severe OSA after adenotonsillectomy were implanted with the hypoglossal nerve stimulator. All were followed for 12 months.

The surgery was safe, with the most common adverse event being temporary tongue discomfort in five patients (12%). This typically resolved in weeks, the researchers note.
 

High response, adherence rates

Results showed response rates and adherence to therapy was high. The mean duration of nightly therapy was 9 hours, with 40 children (95.2%) using the device at least 4 hours every night.

The implant was also effective, with a mean decrease in AHI of 12.9 events per hour (95% confidence interval, –17.0 to –8.7 events per hour).

Nearly two-thirds of the children had at least a 50% reduction in their AHI, while roughly three-fourths had a 12-month follow-up AHI of less than 10 events per hour.

There were also significant improvements in polysomnographic and parent-reported quality of life outcomes 12 months after the implant, including improvement in sleep and daily functioning, behavior, and language.

“Sleep apnea remains one of the most common conditions that I grapple with working with patients with Down syndrome and their families,” co-investigator Brian Skotko, MD, Emma Campbell endowed chair on Down syndrome at Massachusetts General Hospital, Boston, said in the release.

“Until now, so many of our patients had run out of treatment options, and their health and well-being were declining. Now, with the hypoglossal nerve stimulator treatment, we may have an effective and safe way to treat apnea and maximize brain health for people with Down syndrome,” Dr. Skotko added.

Dr. Hartnick and Dr. Skotko have received a $4 million, 5-year grant from the National Institutes of Health to assess whether upper airway stimulation might help cognition in children with Down syndrome.
 

Landmark investigation

Co-authors of an invited commentary said they “applaud” the researchers for their “landmark” investigation, which demonstrated a response to upper airway stimulation in children with Down syndrome and OSA that is on par with what has been achieved in adults with OSA.

“They have established the safety of the procedure; however, future research is necessary to optimize the results of implant,” write Norman Friedman, MD, and Katherine Green, MD, both from the department of otolaryngology – head and neck surgery, University of Colorado School of Medicine, Aurora.

“Further assessment regarding patient selection and the systematic preoperative identification of potential barriers that might affect successful use of therapy will be beneficial to improve longitudinal outcomes and success in this population that is uniquely different from the adult cohorts that have received implants to date,” they add.

The study was funded by Inspire Medical Systems, which provided eight devices for the study but otherwise did not have a role in its design and conduct. The LuMind IDSC Down Syndrome Foundation also provided funding for the study. Dr. Hartnick and the editorialists have disclosed no relevant financial relationships. A complete list of disclosures for the other investigators is available in the original article.

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