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Preventive treatment delays first seizure onset in tuberous sclerosis complex
according to research presented at the 2020 CNS-ICNA Conjoint Meeting, held virtually this year. This treatment strategy reduces the risk and severity of epilepsy, said the investigators.
As much as 90% of patients with TSC have epilepsy. Seizures generally start during infancy and are often resistant to medication. Clinicians are increasingly able to diagnose TSC prenatally, thus creating an opportunity for pursuing preventive strategies.
In the multicenter EPISTOP trial, Katarzyna Kotulska, MD, head of neurology and epileptology at Children’s Memorial Health Institute in Warsaw, and colleagues compared the efficacy and safety of preventive vigabatrin treatment with those of conventional vigabatrin treatment in infants with TSC. The researchers followed 94 infants with TSC and without a history of seizures with monthly video EEG. Conventional treatment was initiated after the first electrographic or clinical seizure, and preventive treatment was administered when epileptiform discharges were visible on EEG but before the first seizure.
Six sites randomly assigned patients to treatment in a equal groups in a randomized, controlled trial. At four other sites, treatment allocation was fixed in an open-label trial. All patients were followed until age 2 years. The study’s primary endpoint was the time to first clinical seizure.
A total of 53 patients participated in the randomized, controlled trial, and 41 participated in the open-label study; 79 patients completed the study. Of this group, 25 received preventive treatment, 25 received conventional treatment, and 22 patients had seizures before epileptiform activity was detected on EEG. Seven patients had neither seizures nor abnormal EEG.
The time to first clinical seizure was significantly longer in patients who received preventive treatment, compared with those who received conventional treatment. In the randomized, controlled trial, time to first seizure was 364 days in the preventive treatment group and 124 days in the conventional treatment group. In the open-label trial, time to first seizure was 426 days in the preventive treatment group and 106 days in the conventional treatment group.
A pooled analysis indicated that, at 24 months, preventive treatment significantly reduced the risk of clinical seizures (odds ratio, 0.21), drug-resistant epilepsy (OR, 0.23), and infantile spasms (OR, 0). The investigators did not record any adverse events related to preventive treatment.
The study was funded by the 7th Framework Program of the European Union. Dr. Kotulska did not report any disclosures.
SOURCE: Kotulska K et al. CNS-ICNA 2020, Abstract PL13.
according to research presented at the 2020 CNS-ICNA Conjoint Meeting, held virtually this year. This treatment strategy reduces the risk and severity of epilepsy, said the investigators.
As much as 90% of patients with TSC have epilepsy. Seizures generally start during infancy and are often resistant to medication. Clinicians are increasingly able to diagnose TSC prenatally, thus creating an opportunity for pursuing preventive strategies.
In the multicenter EPISTOP trial, Katarzyna Kotulska, MD, head of neurology and epileptology at Children’s Memorial Health Institute in Warsaw, and colleagues compared the efficacy and safety of preventive vigabatrin treatment with those of conventional vigabatrin treatment in infants with TSC. The researchers followed 94 infants with TSC and without a history of seizures with monthly video EEG. Conventional treatment was initiated after the first electrographic or clinical seizure, and preventive treatment was administered when epileptiform discharges were visible on EEG but before the first seizure.
Six sites randomly assigned patients to treatment in a equal groups in a randomized, controlled trial. At four other sites, treatment allocation was fixed in an open-label trial. All patients were followed until age 2 years. The study’s primary endpoint was the time to first clinical seizure.
A total of 53 patients participated in the randomized, controlled trial, and 41 participated in the open-label study; 79 patients completed the study. Of this group, 25 received preventive treatment, 25 received conventional treatment, and 22 patients had seizures before epileptiform activity was detected on EEG. Seven patients had neither seizures nor abnormal EEG.
The time to first clinical seizure was significantly longer in patients who received preventive treatment, compared with those who received conventional treatment. In the randomized, controlled trial, time to first seizure was 364 days in the preventive treatment group and 124 days in the conventional treatment group. In the open-label trial, time to first seizure was 426 days in the preventive treatment group and 106 days in the conventional treatment group.
A pooled analysis indicated that, at 24 months, preventive treatment significantly reduced the risk of clinical seizures (odds ratio, 0.21), drug-resistant epilepsy (OR, 0.23), and infantile spasms (OR, 0). The investigators did not record any adverse events related to preventive treatment.
The study was funded by the 7th Framework Program of the European Union. Dr. Kotulska did not report any disclosures.
SOURCE: Kotulska K et al. CNS-ICNA 2020, Abstract PL13.
according to research presented at the 2020 CNS-ICNA Conjoint Meeting, held virtually this year. This treatment strategy reduces the risk and severity of epilepsy, said the investigators.
As much as 90% of patients with TSC have epilepsy. Seizures generally start during infancy and are often resistant to medication. Clinicians are increasingly able to diagnose TSC prenatally, thus creating an opportunity for pursuing preventive strategies.
In the multicenter EPISTOP trial, Katarzyna Kotulska, MD, head of neurology and epileptology at Children’s Memorial Health Institute in Warsaw, and colleagues compared the efficacy and safety of preventive vigabatrin treatment with those of conventional vigabatrin treatment in infants with TSC. The researchers followed 94 infants with TSC and without a history of seizures with monthly video EEG. Conventional treatment was initiated after the first electrographic or clinical seizure, and preventive treatment was administered when epileptiform discharges were visible on EEG but before the first seizure.
Six sites randomly assigned patients to treatment in a equal groups in a randomized, controlled trial. At four other sites, treatment allocation was fixed in an open-label trial. All patients were followed until age 2 years. The study’s primary endpoint was the time to first clinical seizure.
A total of 53 patients participated in the randomized, controlled trial, and 41 participated in the open-label study; 79 patients completed the study. Of this group, 25 received preventive treatment, 25 received conventional treatment, and 22 patients had seizures before epileptiform activity was detected on EEG. Seven patients had neither seizures nor abnormal EEG.
The time to first clinical seizure was significantly longer in patients who received preventive treatment, compared with those who received conventional treatment. In the randomized, controlled trial, time to first seizure was 364 days in the preventive treatment group and 124 days in the conventional treatment group. In the open-label trial, time to first seizure was 426 days in the preventive treatment group and 106 days in the conventional treatment group.
A pooled analysis indicated that, at 24 months, preventive treatment significantly reduced the risk of clinical seizures (odds ratio, 0.21), drug-resistant epilepsy (OR, 0.23), and infantile spasms (OR, 0). The investigators did not record any adverse events related to preventive treatment.
The study was funded by the 7th Framework Program of the European Union. Dr. Kotulska did not report any disclosures.
SOURCE: Kotulska K et al. CNS-ICNA 2020, Abstract PL13.
FROM CNS-ICNA 2020
Comorbidity burden is greater among children with tics than children with stereotypies
, according to an analysis presented at the 2020 CNS-ICNA Conjoint Meeting, held virtually this year. The former also are younger at their first visit than are the latter. Compared with children with tics, children with stereotypies also have fewer comorbidities and receive fewer recommendations for interventions. This difference between groups may not merely reflect the younger age at presentation of children with stereotypies (e.g., at an age before a comorbidity is manifest). “At least in our population, it does seem to reflect an overall lower burden of comorbidities,” said Shannon Dean, MD, PhD, assistant professor of neurology at the Kennedy Krieger Institute of Johns Hopkins University in Baltimore.
Common pediatric movement disorders
Tics (i.e., short-lasting, sudden, repetitive movements) and stereotypies (i.e., rhythmic, fixed, deliberate, but purposeless movements) are common pediatric movement disorders with favorable prognoses. The disorders share several comorbidities, the most common of which are ADHD, anxiety, and obsessive-compulsive disorder (OCD). Dr. Dean and colleagues examined differences in comorbidity burden, resource use, and need for intervention between children with tics and those with stereotypies.
The investigators performed a retrospective chart review and identified 63 children diagnosed with stereotypies. They matched each of these children, by age when possible, with a child first diagnosed with a chronic or provisional tic disorder during the same year. All patients presented to the University of Rochester (N.Y.) Child Neurology Clinic between 2003 and 2016. Dr. Dean and colleagues excluded children with diagnoses for which stereotypies are considered a secondary feature (e.g., autism, intellectual disability, and blindness). They also excluded children who had tics and stereotypies.
The researchers examined the groups’ total number of visits, comorbidities, and recommended interventions. They also analyzed data from a follow-up survey that were available for 20 of the 63 patients with stereotypies. They tested continuous or discrete variables for normal distribution and used T tests or Mann–Whitney U as appropriate. To analyze categorical data, they used chi squared or Fisher’s exact test for groups smaller than five.
Differing rates of intervention
Children with stereotypies were younger at first visit (mean age, 5.6 years vs. 7.1 years) and at last visit (mean age, 6.5 years vs. 9.8 years) and had fewer total visits (1.8 vs. 4.5), compared with children with tics.
The three most common comorbidities in the population were more prevalent among patients with tics than among patients with stereotypies. The prevalence of ADHD was 27% among patients with stereotypies and 48% among patients with tics. The prevalence of OCD was 8% among children with stereotypies and 41% among children with tics. The prevalence of anxiety was 21% among children with stereotypies and 63% among children with tics. Children with stereotypies also had fewer neuropsychiatric comorbidities overall than did children with tics (0.7 per patient versus 1.9 per patient).
The clinicians had recommended at least one medication for tics in 22% of the children with tics. No medication is available for children with stereotypies. The clinicians recommended behavioral therapy for 13% of the children with tics, but for none of the children with stereotypies, “because none of them had functional impairment that would warrant intervention,” said Dr. Dean. The clinicians also made more recommendations for pharmaceutical and behavioral treatments for comorbidities in patients with tics than in patients with stereotypies.
When the investigators examined the follow-up survey data, they found that patients with stereotypies were older at last contact than patients with tics. Last contact was defined as the time of the survey for patients with stereotypies and the time of the last clinic visit for patients with tics. When Dr. Dean and colleagues examined the three most common comorbidities, however, they again found that the burden was greater among patients with tics (1.5 per patient) than among patients with stereotypies (0.8 per patient).
The study was funded by the T32 Experimental Therapeutics Training Grant from the University of Rochester, N.Y. Dr. Dean did not report any disclosures.
SOURCE: Dean S et al. CNS-ICNA 2020. Abstract PL52.
, according to an analysis presented at the 2020 CNS-ICNA Conjoint Meeting, held virtually this year. The former also are younger at their first visit than are the latter. Compared with children with tics, children with stereotypies also have fewer comorbidities and receive fewer recommendations for interventions. This difference between groups may not merely reflect the younger age at presentation of children with stereotypies (e.g., at an age before a comorbidity is manifest). “At least in our population, it does seem to reflect an overall lower burden of comorbidities,” said Shannon Dean, MD, PhD, assistant professor of neurology at the Kennedy Krieger Institute of Johns Hopkins University in Baltimore.
Common pediatric movement disorders
Tics (i.e., short-lasting, sudden, repetitive movements) and stereotypies (i.e., rhythmic, fixed, deliberate, but purposeless movements) are common pediatric movement disorders with favorable prognoses. The disorders share several comorbidities, the most common of which are ADHD, anxiety, and obsessive-compulsive disorder (OCD). Dr. Dean and colleagues examined differences in comorbidity burden, resource use, and need for intervention between children with tics and those with stereotypies.
The investigators performed a retrospective chart review and identified 63 children diagnosed with stereotypies. They matched each of these children, by age when possible, with a child first diagnosed with a chronic or provisional tic disorder during the same year. All patients presented to the University of Rochester (N.Y.) Child Neurology Clinic between 2003 and 2016. Dr. Dean and colleagues excluded children with diagnoses for which stereotypies are considered a secondary feature (e.g., autism, intellectual disability, and blindness). They also excluded children who had tics and stereotypies.
The researchers examined the groups’ total number of visits, comorbidities, and recommended interventions. They also analyzed data from a follow-up survey that were available for 20 of the 63 patients with stereotypies. They tested continuous or discrete variables for normal distribution and used T tests or Mann–Whitney U as appropriate. To analyze categorical data, they used chi squared or Fisher’s exact test for groups smaller than five.
Differing rates of intervention
Children with stereotypies were younger at first visit (mean age, 5.6 years vs. 7.1 years) and at last visit (mean age, 6.5 years vs. 9.8 years) and had fewer total visits (1.8 vs. 4.5), compared with children with tics.
The three most common comorbidities in the population were more prevalent among patients with tics than among patients with stereotypies. The prevalence of ADHD was 27% among patients with stereotypies and 48% among patients with tics. The prevalence of OCD was 8% among children with stereotypies and 41% among children with tics. The prevalence of anxiety was 21% among children with stereotypies and 63% among children with tics. Children with stereotypies also had fewer neuropsychiatric comorbidities overall than did children with tics (0.7 per patient versus 1.9 per patient).
The clinicians had recommended at least one medication for tics in 22% of the children with tics. No medication is available for children with stereotypies. The clinicians recommended behavioral therapy for 13% of the children with tics, but for none of the children with stereotypies, “because none of them had functional impairment that would warrant intervention,” said Dr. Dean. The clinicians also made more recommendations for pharmaceutical and behavioral treatments for comorbidities in patients with tics than in patients with stereotypies.
When the investigators examined the follow-up survey data, they found that patients with stereotypies were older at last contact than patients with tics. Last contact was defined as the time of the survey for patients with stereotypies and the time of the last clinic visit for patients with tics. When Dr. Dean and colleagues examined the three most common comorbidities, however, they again found that the burden was greater among patients with tics (1.5 per patient) than among patients with stereotypies (0.8 per patient).
The study was funded by the T32 Experimental Therapeutics Training Grant from the University of Rochester, N.Y. Dr. Dean did not report any disclosures.
SOURCE: Dean S et al. CNS-ICNA 2020. Abstract PL52.
, according to an analysis presented at the 2020 CNS-ICNA Conjoint Meeting, held virtually this year. The former also are younger at their first visit than are the latter. Compared with children with tics, children with stereotypies also have fewer comorbidities and receive fewer recommendations for interventions. This difference between groups may not merely reflect the younger age at presentation of children with stereotypies (e.g., at an age before a comorbidity is manifest). “At least in our population, it does seem to reflect an overall lower burden of comorbidities,” said Shannon Dean, MD, PhD, assistant professor of neurology at the Kennedy Krieger Institute of Johns Hopkins University in Baltimore.
Common pediatric movement disorders
Tics (i.e., short-lasting, sudden, repetitive movements) and stereotypies (i.e., rhythmic, fixed, deliberate, but purposeless movements) are common pediatric movement disorders with favorable prognoses. The disorders share several comorbidities, the most common of which are ADHD, anxiety, and obsessive-compulsive disorder (OCD). Dr. Dean and colleagues examined differences in comorbidity burden, resource use, and need for intervention between children with tics and those with stereotypies.
The investigators performed a retrospective chart review and identified 63 children diagnosed with stereotypies. They matched each of these children, by age when possible, with a child first diagnosed with a chronic or provisional tic disorder during the same year. All patients presented to the University of Rochester (N.Y.) Child Neurology Clinic between 2003 and 2016. Dr. Dean and colleagues excluded children with diagnoses for which stereotypies are considered a secondary feature (e.g., autism, intellectual disability, and blindness). They also excluded children who had tics and stereotypies.
The researchers examined the groups’ total number of visits, comorbidities, and recommended interventions. They also analyzed data from a follow-up survey that were available for 20 of the 63 patients with stereotypies. They tested continuous or discrete variables for normal distribution and used T tests or Mann–Whitney U as appropriate. To analyze categorical data, they used chi squared or Fisher’s exact test for groups smaller than five.
Differing rates of intervention
Children with stereotypies were younger at first visit (mean age, 5.6 years vs. 7.1 years) and at last visit (mean age, 6.5 years vs. 9.8 years) and had fewer total visits (1.8 vs. 4.5), compared with children with tics.
The three most common comorbidities in the population were more prevalent among patients with tics than among patients with stereotypies. The prevalence of ADHD was 27% among patients with stereotypies and 48% among patients with tics. The prevalence of OCD was 8% among children with stereotypies and 41% among children with tics. The prevalence of anxiety was 21% among children with stereotypies and 63% among children with tics. Children with stereotypies also had fewer neuropsychiatric comorbidities overall than did children with tics (0.7 per patient versus 1.9 per patient).
The clinicians had recommended at least one medication for tics in 22% of the children with tics. No medication is available for children with stereotypies. The clinicians recommended behavioral therapy for 13% of the children with tics, but for none of the children with stereotypies, “because none of them had functional impairment that would warrant intervention,” said Dr. Dean. The clinicians also made more recommendations for pharmaceutical and behavioral treatments for comorbidities in patients with tics than in patients with stereotypies.
When the investigators examined the follow-up survey data, they found that patients with stereotypies were older at last contact than patients with tics. Last contact was defined as the time of the survey for patients with stereotypies and the time of the last clinic visit for patients with tics. When Dr. Dean and colleagues examined the three most common comorbidities, however, they again found that the burden was greater among patients with tics (1.5 per patient) than among patients with stereotypies (0.8 per patient).
The study was funded by the T32 Experimental Therapeutics Training Grant from the University of Rochester, N.Y. Dr. Dean did not report any disclosures.
SOURCE: Dean S et al. CNS-ICNA 2020. Abstract PL52.
FROM CNS-ICNA 2020
Outpatient visits rebound for most specialties to pre-COVID-19 levels
, according to new data.
Overall visits plunged by almost 60% at the low point in late March and did not start recovering until late June, when visits were still off by 10%. Visits began to rise again – by 2% over the March 1 baseline – around Labor Day.
As of Oct. 4, visits had returned to that March 1 baseline, which was slightly higher than in late February, according to data analyzed by Harvard University, the Commonwealth Fund, and the healthcare technology company Phreesia, which helps medical practices with patient registration, insurance verification, and payments, and has data on 50,000 providers in all 50 states.
The study was published online by the Commonwealth Fund.
In-person visits are still down 6% from the March 1 baseline. Telemedicine visits – which surged in mid-April to account for some 13%-14% of visits – have subsided to 6% of visits.
Many states reopened businesses and lifted travel restrictions in early September, benefiting medical practices in some areas. But clinicians in some regions are still facing rising COVID-19 cases, as well as “the challenges of keeping patients and clinicians safe while also maintaining revenue,” wrote the report authors.
Some specialties are still hard hit. For the week starting Oct. 4, visits to pulmonologists were off 20% from March 1. Otolaryngology visits were down 17%, and behavioral health visits were down 14%. Cardiology, allergy/immunology, neurology, gastroenterology, and endocrinology also saw drops of 5%-10% from March.
Patients were flocking to dermatologists, however. Visits were up 17% over baseline. Primary care also was popular, with a 13% increase over March 1.
At the height of the pandemic shutdown in late March, Medicare beneficiaries stayed away from doctors the most. Visits dipped 63%, compared with 56% for the commercially insured, and 52% for those on Medicaid. Now, Medicare visits are up 3% over baseline, while Medicaid visits are down 1% and commercially insured visits have risen 1% from March.
The over-65 age group did not have the steepest drop in visits when analyzed by age. Children aged 3-17 years saw the biggest decline at the height of the shutdown. Infants to 5-year-olds have still not returned to prepandemic visit levels. Those visits are off by 10%-18%. The 65-and-older group is up 4% from March.
Larger practices – with more than six clinicians – have seen the biggest rebound, after having had the largest dip in visits, from a decline of 53% in late March to a 14% rise over that baseline. Practices with fewer than five clinicians are still 6% down from the March baseline.
Wide variation in telemedicine use
The researchers reported a massive gap in the percentage of various specialties that are using telemedicine. At the top end are behavioral health specialists, where 41% of visits are by telemedicine.
The next-closest specialty is endocrinology, which has 14% of visits via telemedicine, on par with rheumatology, neurology, and gastroenterology. At the low end: ophthalmology, with zero virtual visits; otolaryngology (1%), orthopedics (1%), surgery (2%), and dermatology and ob.gyn., both at 3%.
Smaller practices – with fewer than five clinicians – never adopted telemedicine at the rate of the larger practices. During the mid-April peak, about 10% of the smaller practices were using telemedicine in adult primary care practices, compared with 19% of those primary care practices with more than six clinicians.
The gap persists. Currently, 9% of the larger practices are using telemedicine, compared with 4% of small practices.
One-third of all provider organizations analyzed never-adopted telemedicine. And while use continues, it is now mostly minimal. At the April peak, 35% of the practices with telemedicine reported heavy use – that is, in more than 20% of visits. In September, 9% said they had such heavy use.
A version of this article originally appeared on Medscape.com.
, according to new data.
Overall visits plunged by almost 60% at the low point in late March and did not start recovering until late June, when visits were still off by 10%. Visits began to rise again – by 2% over the March 1 baseline – around Labor Day.
As of Oct. 4, visits had returned to that March 1 baseline, which was slightly higher than in late February, according to data analyzed by Harvard University, the Commonwealth Fund, and the healthcare technology company Phreesia, which helps medical practices with patient registration, insurance verification, and payments, and has data on 50,000 providers in all 50 states.
The study was published online by the Commonwealth Fund.
In-person visits are still down 6% from the March 1 baseline. Telemedicine visits – which surged in mid-April to account for some 13%-14% of visits – have subsided to 6% of visits.
Many states reopened businesses and lifted travel restrictions in early September, benefiting medical practices in some areas. But clinicians in some regions are still facing rising COVID-19 cases, as well as “the challenges of keeping patients and clinicians safe while also maintaining revenue,” wrote the report authors.
Some specialties are still hard hit. For the week starting Oct. 4, visits to pulmonologists were off 20% from March 1. Otolaryngology visits were down 17%, and behavioral health visits were down 14%. Cardiology, allergy/immunology, neurology, gastroenterology, and endocrinology also saw drops of 5%-10% from March.
Patients were flocking to dermatologists, however. Visits were up 17% over baseline. Primary care also was popular, with a 13% increase over March 1.
At the height of the pandemic shutdown in late March, Medicare beneficiaries stayed away from doctors the most. Visits dipped 63%, compared with 56% for the commercially insured, and 52% for those on Medicaid. Now, Medicare visits are up 3% over baseline, while Medicaid visits are down 1% and commercially insured visits have risen 1% from March.
The over-65 age group did not have the steepest drop in visits when analyzed by age. Children aged 3-17 years saw the biggest decline at the height of the shutdown. Infants to 5-year-olds have still not returned to prepandemic visit levels. Those visits are off by 10%-18%. The 65-and-older group is up 4% from March.
Larger practices – with more than six clinicians – have seen the biggest rebound, after having had the largest dip in visits, from a decline of 53% in late March to a 14% rise over that baseline. Practices with fewer than five clinicians are still 6% down from the March baseline.
Wide variation in telemedicine use
The researchers reported a massive gap in the percentage of various specialties that are using telemedicine. At the top end are behavioral health specialists, where 41% of visits are by telemedicine.
The next-closest specialty is endocrinology, which has 14% of visits via telemedicine, on par with rheumatology, neurology, and gastroenterology. At the low end: ophthalmology, with zero virtual visits; otolaryngology (1%), orthopedics (1%), surgery (2%), and dermatology and ob.gyn., both at 3%.
Smaller practices – with fewer than five clinicians – never adopted telemedicine at the rate of the larger practices. During the mid-April peak, about 10% of the smaller practices were using telemedicine in adult primary care practices, compared with 19% of those primary care practices with more than six clinicians.
The gap persists. Currently, 9% of the larger practices are using telemedicine, compared with 4% of small practices.
One-third of all provider organizations analyzed never-adopted telemedicine. And while use continues, it is now mostly minimal. At the April peak, 35% of the practices with telemedicine reported heavy use – that is, in more than 20% of visits. In September, 9% said they had such heavy use.
A version of this article originally appeared on Medscape.com.
, according to new data.
Overall visits plunged by almost 60% at the low point in late March and did not start recovering until late June, when visits were still off by 10%. Visits began to rise again – by 2% over the March 1 baseline – around Labor Day.
As of Oct. 4, visits had returned to that March 1 baseline, which was slightly higher than in late February, according to data analyzed by Harvard University, the Commonwealth Fund, and the healthcare technology company Phreesia, which helps medical practices with patient registration, insurance verification, and payments, and has data on 50,000 providers in all 50 states.
The study was published online by the Commonwealth Fund.
In-person visits are still down 6% from the March 1 baseline. Telemedicine visits – which surged in mid-April to account for some 13%-14% of visits – have subsided to 6% of visits.
Many states reopened businesses and lifted travel restrictions in early September, benefiting medical practices in some areas. But clinicians in some regions are still facing rising COVID-19 cases, as well as “the challenges of keeping patients and clinicians safe while also maintaining revenue,” wrote the report authors.
Some specialties are still hard hit. For the week starting Oct. 4, visits to pulmonologists were off 20% from March 1. Otolaryngology visits were down 17%, and behavioral health visits were down 14%. Cardiology, allergy/immunology, neurology, gastroenterology, and endocrinology also saw drops of 5%-10% from March.
Patients were flocking to dermatologists, however. Visits were up 17% over baseline. Primary care also was popular, with a 13% increase over March 1.
At the height of the pandemic shutdown in late March, Medicare beneficiaries stayed away from doctors the most. Visits dipped 63%, compared with 56% for the commercially insured, and 52% for those on Medicaid. Now, Medicare visits are up 3% over baseline, while Medicaid visits are down 1% and commercially insured visits have risen 1% from March.
The over-65 age group did not have the steepest drop in visits when analyzed by age. Children aged 3-17 years saw the biggest decline at the height of the shutdown. Infants to 5-year-olds have still not returned to prepandemic visit levels. Those visits are off by 10%-18%. The 65-and-older group is up 4% from March.
Larger practices – with more than six clinicians – have seen the biggest rebound, after having had the largest dip in visits, from a decline of 53% in late March to a 14% rise over that baseline. Practices with fewer than five clinicians are still 6% down from the March baseline.
Wide variation in telemedicine use
The researchers reported a massive gap in the percentage of various specialties that are using telemedicine. At the top end are behavioral health specialists, where 41% of visits are by telemedicine.
The next-closest specialty is endocrinology, which has 14% of visits via telemedicine, on par with rheumatology, neurology, and gastroenterology. At the low end: ophthalmology, with zero virtual visits; otolaryngology (1%), orthopedics (1%), surgery (2%), and dermatology and ob.gyn., both at 3%.
Smaller practices – with fewer than five clinicians – never adopted telemedicine at the rate of the larger practices. During the mid-April peak, about 10% of the smaller practices were using telemedicine in adult primary care practices, compared with 19% of those primary care practices with more than six clinicians.
The gap persists. Currently, 9% of the larger practices are using telemedicine, compared with 4% of small practices.
One-third of all provider organizations analyzed never-adopted telemedicine. And while use continues, it is now mostly minimal. At the April peak, 35% of the practices with telemedicine reported heavy use – that is, in more than 20% of visits. In September, 9% said they had such heavy use.
A version of this article originally appeared on Medscape.com.
National three-digit suicide lifeline to take effect in 2022
Beginning in July 2022, Americans experiencing a mental health crisis will be able to dial 9-8-8 and be connected to the services and counselors at the National Suicide Prevention Lifeline.
The number was finalized when President Donald J. Trump signed the National Suicide Hotline Designation Act on Oct. 17. It completes what has been a multiyear effort by Republican and Democratic lawmakers to make it easier for individuals to reach out during mental health emergencies.
“When your house is on fire, you can get help by calling 9-1-1,” noted Rep. Seth Moulton (D-Mass.), a key sponsor of the legislation, in a statement. The new number “is a national step forward out of the shadows of stigma that prevent too many people from getting help and into a new era when mental health care is easy to get and normal to talk about,” said Rep. Moulton, a combat veteran who has openly discussed his struggles with PTSD.
The law requires the Department of Health & Human Services to develop a strategy to provide access to specialized services for high-risk populations such as LGBTQ youth, minorities, and people who live in rural areas.
“This law is a historic victory, as this is the first explicitly LGBTQ-inclusive bill to pass unanimously in history – and 9-8-8 will undoubtedly save countless lives,” said Sam Brinton, vice president of advocacy and government affairs for the Trevor Project, in a statement, also noting that “More than half of transgender and nonbinary youth having seriously considered it.”
Robert Gebbia, CEO of the American Foundation for Suicide Prevention, said in a statement: “This easy-to-remember number will increase public access to mental health and suicide prevention crisis resources, encourage help-seeking for individuals in need, and is a crucial entry point for establishing a continuum of crisis care.”
Mr. Gabbia called for more funding for local crisis centers to “respond to what we expect will be an increased call volume and provide effective crisis services to those in need when 9-8-8 is made available in July 2022.”
In 2017, then-Senator Orrin Hatch (R-Utah) and colleague Joe Donnelly (D-Ind.) pushed for a three-digit number for people having mental health crises. Their legislation passed in the Senate that fall and passed in the House in July 2018.
The bill directed the Federal Communications Commission to submit a report to Congress that would include a recommended number, a cost-benefit analysis comparing the three-digit code with the current hotline, and an assessment of how much it might cost service providers, states, local towns, and cities.
Mr. Trump signed that bill in 2018. The FCC unanimously approved the 9-8-8 number in July 2020.
Until the new number is active in July 2022, those in crisis should continue to call the National Suicide Lifeline at 1-800-273-TALK (8255).
A version of this article originally appeared on Medscape.com.
Beginning in July 2022, Americans experiencing a mental health crisis will be able to dial 9-8-8 and be connected to the services and counselors at the National Suicide Prevention Lifeline.
The number was finalized when President Donald J. Trump signed the National Suicide Hotline Designation Act on Oct. 17. It completes what has been a multiyear effort by Republican and Democratic lawmakers to make it easier for individuals to reach out during mental health emergencies.
“When your house is on fire, you can get help by calling 9-1-1,” noted Rep. Seth Moulton (D-Mass.), a key sponsor of the legislation, in a statement. The new number “is a national step forward out of the shadows of stigma that prevent too many people from getting help and into a new era when mental health care is easy to get and normal to talk about,” said Rep. Moulton, a combat veteran who has openly discussed his struggles with PTSD.
The law requires the Department of Health & Human Services to develop a strategy to provide access to specialized services for high-risk populations such as LGBTQ youth, minorities, and people who live in rural areas.
“This law is a historic victory, as this is the first explicitly LGBTQ-inclusive bill to pass unanimously in history – and 9-8-8 will undoubtedly save countless lives,” said Sam Brinton, vice president of advocacy and government affairs for the Trevor Project, in a statement, also noting that “More than half of transgender and nonbinary youth having seriously considered it.”
Robert Gebbia, CEO of the American Foundation for Suicide Prevention, said in a statement: “This easy-to-remember number will increase public access to mental health and suicide prevention crisis resources, encourage help-seeking for individuals in need, and is a crucial entry point for establishing a continuum of crisis care.”
Mr. Gabbia called for more funding for local crisis centers to “respond to what we expect will be an increased call volume and provide effective crisis services to those in need when 9-8-8 is made available in July 2022.”
In 2017, then-Senator Orrin Hatch (R-Utah) and colleague Joe Donnelly (D-Ind.) pushed for a three-digit number for people having mental health crises. Their legislation passed in the Senate that fall and passed in the House in July 2018.
The bill directed the Federal Communications Commission to submit a report to Congress that would include a recommended number, a cost-benefit analysis comparing the three-digit code with the current hotline, and an assessment of how much it might cost service providers, states, local towns, and cities.
Mr. Trump signed that bill in 2018. The FCC unanimously approved the 9-8-8 number in July 2020.
Until the new number is active in July 2022, those in crisis should continue to call the National Suicide Lifeline at 1-800-273-TALK (8255).
A version of this article originally appeared on Medscape.com.
Beginning in July 2022, Americans experiencing a mental health crisis will be able to dial 9-8-8 and be connected to the services and counselors at the National Suicide Prevention Lifeline.
The number was finalized when President Donald J. Trump signed the National Suicide Hotline Designation Act on Oct. 17. It completes what has been a multiyear effort by Republican and Democratic lawmakers to make it easier for individuals to reach out during mental health emergencies.
“When your house is on fire, you can get help by calling 9-1-1,” noted Rep. Seth Moulton (D-Mass.), a key sponsor of the legislation, in a statement. The new number “is a national step forward out of the shadows of stigma that prevent too many people from getting help and into a new era when mental health care is easy to get and normal to talk about,” said Rep. Moulton, a combat veteran who has openly discussed his struggles with PTSD.
The law requires the Department of Health & Human Services to develop a strategy to provide access to specialized services for high-risk populations such as LGBTQ youth, minorities, and people who live in rural areas.
“This law is a historic victory, as this is the first explicitly LGBTQ-inclusive bill to pass unanimously in history – and 9-8-8 will undoubtedly save countless lives,” said Sam Brinton, vice president of advocacy and government affairs for the Trevor Project, in a statement, also noting that “More than half of transgender and nonbinary youth having seriously considered it.”
Robert Gebbia, CEO of the American Foundation for Suicide Prevention, said in a statement: “This easy-to-remember number will increase public access to mental health and suicide prevention crisis resources, encourage help-seeking for individuals in need, and is a crucial entry point for establishing a continuum of crisis care.”
Mr. Gabbia called for more funding for local crisis centers to “respond to what we expect will be an increased call volume and provide effective crisis services to those in need when 9-8-8 is made available in July 2022.”
In 2017, then-Senator Orrin Hatch (R-Utah) and colleague Joe Donnelly (D-Ind.) pushed for a three-digit number for people having mental health crises. Their legislation passed in the Senate that fall and passed in the House in July 2018.
The bill directed the Federal Communications Commission to submit a report to Congress that would include a recommended number, a cost-benefit analysis comparing the three-digit code with the current hotline, and an assessment of how much it might cost service providers, states, local towns, and cities.
Mr. Trump signed that bill in 2018. The FCC unanimously approved the 9-8-8 number in July 2020.
Until the new number is active in July 2022, those in crisis should continue to call the National Suicide Lifeline at 1-800-273-TALK (8255).
A version of this article originally appeared on Medscape.com.
Teen vaping in the time of COVID-19
It’s an electronic cigarette maker’s dream, but a public health nightmare: The confluence of social isolation and anxiety resulting from the COVID-19 pandemic has the potential to make recent progress against e-cigarette use among teens go up in smoke.
“Stress and worsening mental health issues are well-known predisposing factors for smoking, both in quantity and frequency and in relapse,” said Mary Cataletto, MD, FCCP, clinical professor of pediatrics at New York University Winthrop Hospital, Mineola, during a webinar on e-cigarettes and vaping with asthma in the time of COVID-19, hosted by the Allergy & Asthma Network.
Prior to the pandemic, public health experts appeared to be making inroads into curbing e-cigarette use, according to results of the 2020 National Youth Tobacco Survey, a cross-sectional school-based survey of students from grades 6 to 12.
“In 2020, approximately 1 in 5 high school students and 1 in 20 middle school students currently used e-cigarettes. By comparison, in 2019, 27.5% of high school students (4.11 million) and 10.5% of middle school students (1.24 million) reported current e-cigarette use,” wrote Brian A. King, PhD, MPH, and colleagues, in an article reporting those results.
“We definitely believe that there was a real decline that occurred up until March. Those data from the National Youth Tobacco Survey were collected prior to youth leaving school settings and prior to the implementation of social distancing and other measures,” said Dr. King, deputy director for research translation in the Office on Smoking and Health within the National Center for Chronic Disease Prevention and Health Promotion at the Centers for Disease Control and Prevention.
“That said, the jury’s still out on what’s going to happen with youth use during the coming year, particularly during the COVID-19 pandemic” he said in an interview.
Flavor of the moment
Even though the data through March 2020 showed a distinct decline in e-cigarette use, Dr. King and colleagues found that 3.6 million U.S. adolescents still currently used e-cigarettes in 2020; among current users, more than 80% reported using flavored e-cigarettes.
Dr. Cataletto said in an interview that the 2020 National Youth Tobacco Survey continues to report widespread use of flavored e-cigarettes among young smokers despite Food and Drug Administration admonitions to manufacturers and retailers to remove unauthorized e-cigarettes from the market.
On Jan. 2, 2020, the FDA reported a finalized enforcement policy directed against “unauthorized flavored cartridge-based e-cigarettes that appeal to children, including fruit and mint.”
But as Dr. King and other investigators also mentioned in a separate analysis of e-cigarette unit sales, that enforcement policy applies only to prefilled cartridge e-cigarette products, such as those made by JUUL, and that while sales of mint- or fruit-flavored products of this type declined from September 2014 to May 2020, there was an increase in the sale of disposable e-cigarettes with flavors other than menthol or tobacco.
Dr. Cataletto pointed out that this vaping trend has coincided with the COVID-19 pandemic, noting that, on March 13, 2020, just 2 days after the World Health Organization declared that spread of COVID-19 was officially a pandemic, 16 states closed schools, leaving millions of middle school– and high school–age children at loose ends. She said: “This raised a number of concerns. Would students who used e-cigarettes be at increased risk of COVID-19? Would e-cigarette use increase again due to the social isolation and anxiety as predicted for tobacco smokers? How would access and availability impact e-cigarette use?
“It’s possible that use may go down, because youth may have less access to their typical social sources or other manners in which they obtain the product.” Dr. King said. “Alternatively, youth may have more disposable time on their hands and may be open to other sources of access to these products, and so use could increase.”
There is evidence to suggest that the latter scenario may be true, according to investigators who surveyed more than 1,000 Canadian adolescents about alcohol use, binge drinking, cannabis use, and vaping in the 3 weeks directly before and after social distancing measures took effect.
The investigators found that the frequency of both alcohol and cannabis use increased during social isolation, and that, although about half of respondents reported solitary substance use, 32% reported using substances with peers via technology, and 24% reported using substances face to face, despite social distancing mandates, reported Tara M. Dumas, PhD, from Huron University College, London, Ont.
“These authors suggest that teens who feared loss of friendships during quarantine might be more willing to engage in risky behaviors such as face to face substance use to maintain social status, while solitary substance use was related to both COVID19 fears and depressive symptomatology,” Dr. Cataletto said.
E-cigarettes and COVID-19
A recent survey of 4,351 adolescents and young adults in the United States showed that a COVID-19 diagnosis was five times more likely among those who had ever used e-cigarettes, seven times more likely among conventional cigarette and e-cigarette uses, and nearly seven times more likely among those who had used both within the past 30 days .
Perhaps not surprisingly, adolescents and young adults with asthma who also vape may be at especially high risk for COVID-19, but the exact effect may be hard to pin down with current levels of evidence.
“Prior to the pandemic we did see both new-onset asthma and asthma exacerbations in teens who reported either vaping or dual use with tobacco products,” Dr. Cataletto said. “However, numbers were small, were confounded by the bias of subspecialty practice, and the onset of the pandemic, which affected not only face-to-face visits but the opportunity to perform pulmonary function testing for a number of months.”
Dr. King noted: “There is an emerging body of science that does indicate that there could be some respiratory risks related to e-cigarette use, particularly among certain populations. ... That said, there’s no conclusive link between e-cigarette use and specific disease outcomes, which typically requires a robust body of different science conducted in multiple settings.”
He said that e-cigarette vapors contain ultrafine particles and heavy metals that can be inhaled deeply into the lungs, both of which have previously been associated with respiratory risk, including complications from asthma.
An ounce of prevention
“When it comes to cessation, we do know that about 50% of youth who are using tobacco products including e-cigarettes, want to quit, and about the same proportion make an effort to quit, so there’s certainly a will there, but we don’t clearly have an evidence-based way,” Dr. King said.
Combinations of behavioral interventions including face-to-face consultations and digital or telephone support can be helpful, Dr. Cataletto said, but both she and Dr. King agree that prevention is the most effective method of reducing e-cigarette use among teens and young adults, including peer support and education efforts.
Asked how she gets her patients to report honestly about their habits, Dr. Cataletto acknowledged that “this is a challenge for many kids. Some are unaware that many of the commercially available e-cigarette products contain nicotine and they are not ‘just vaping flavoring.’ Ongoing education is important, and it is happening in schools, in pediatrician’s offices, at home and in the community.”
Dr. Cataletto and Dr. King reported no relevant conflicts of interest. Dr. Cataletto serves on the editorial advisory board for Chest Physician.
It’s an electronic cigarette maker’s dream, but a public health nightmare: The confluence of social isolation and anxiety resulting from the COVID-19 pandemic has the potential to make recent progress against e-cigarette use among teens go up in smoke.
“Stress and worsening mental health issues are well-known predisposing factors for smoking, both in quantity and frequency and in relapse,” said Mary Cataletto, MD, FCCP, clinical professor of pediatrics at New York University Winthrop Hospital, Mineola, during a webinar on e-cigarettes and vaping with asthma in the time of COVID-19, hosted by the Allergy & Asthma Network.
Prior to the pandemic, public health experts appeared to be making inroads into curbing e-cigarette use, according to results of the 2020 National Youth Tobacco Survey, a cross-sectional school-based survey of students from grades 6 to 12.
“In 2020, approximately 1 in 5 high school students and 1 in 20 middle school students currently used e-cigarettes. By comparison, in 2019, 27.5% of high school students (4.11 million) and 10.5% of middle school students (1.24 million) reported current e-cigarette use,” wrote Brian A. King, PhD, MPH, and colleagues, in an article reporting those results.
“We definitely believe that there was a real decline that occurred up until March. Those data from the National Youth Tobacco Survey were collected prior to youth leaving school settings and prior to the implementation of social distancing and other measures,” said Dr. King, deputy director for research translation in the Office on Smoking and Health within the National Center for Chronic Disease Prevention and Health Promotion at the Centers for Disease Control and Prevention.
“That said, the jury’s still out on what’s going to happen with youth use during the coming year, particularly during the COVID-19 pandemic” he said in an interview.
Flavor of the moment
Even though the data through March 2020 showed a distinct decline in e-cigarette use, Dr. King and colleagues found that 3.6 million U.S. adolescents still currently used e-cigarettes in 2020; among current users, more than 80% reported using flavored e-cigarettes.
Dr. Cataletto said in an interview that the 2020 National Youth Tobacco Survey continues to report widespread use of flavored e-cigarettes among young smokers despite Food and Drug Administration admonitions to manufacturers and retailers to remove unauthorized e-cigarettes from the market.
On Jan. 2, 2020, the FDA reported a finalized enforcement policy directed against “unauthorized flavored cartridge-based e-cigarettes that appeal to children, including fruit and mint.”
But as Dr. King and other investigators also mentioned in a separate analysis of e-cigarette unit sales, that enforcement policy applies only to prefilled cartridge e-cigarette products, such as those made by JUUL, and that while sales of mint- or fruit-flavored products of this type declined from September 2014 to May 2020, there was an increase in the sale of disposable e-cigarettes with flavors other than menthol or tobacco.
Dr. Cataletto pointed out that this vaping trend has coincided with the COVID-19 pandemic, noting that, on March 13, 2020, just 2 days after the World Health Organization declared that spread of COVID-19 was officially a pandemic, 16 states closed schools, leaving millions of middle school– and high school–age children at loose ends. She said: “This raised a number of concerns. Would students who used e-cigarettes be at increased risk of COVID-19? Would e-cigarette use increase again due to the social isolation and anxiety as predicted for tobacco smokers? How would access and availability impact e-cigarette use?
“It’s possible that use may go down, because youth may have less access to their typical social sources or other manners in which they obtain the product.” Dr. King said. “Alternatively, youth may have more disposable time on their hands and may be open to other sources of access to these products, and so use could increase.”
There is evidence to suggest that the latter scenario may be true, according to investigators who surveyed more than 1,000 Canadian adolescents about alcohol use, binge drinking, cannabis use, and vaping in the 3 weeks directly before and after social distancing measures took effect.
The investigators found that the frequency of both alcohol and cannabis use increased during social isolation, and that, although about half of respondents reported solitary substance use, 32% reported using substances with peers via technology, and 24% reported using substances face to face, despite social distancing mandates, reported Tara M. Dumas, PhD, from Huron University College, London, Ont.
“These authors suggest that teens who feared loss of friendships during quarantine might be more willing to engage in risky behaviors such as face to face substance use to maintain social status, while solitary substance use was related to both COVID19 fears and depressive symptomatology,” Dr. Cataletto said.
E-cigarettes and COVID-19
A recent survey of 4,351 adolescents and young adults in the United States showed that a COVID-19 diagnosis was five times more likely among those who had ever used e-cigarettes, seven times more likely among conventional cigarette and e-cigarette uses, and nearly seven times more likely among those who had used both within the past 30 days .
Perhaps not surprisingly, adolescents and young adults with asthma who also vape may be at especially high risk for COVID-19, but the exact effect may be hard to pin down with current levels of evidence.
“Prior to the pandemic we did see both new-onset asthma and asthma exacerbations in teens who reported either vaping or dual use with tobacco products,” Dr. Cataletto said. “However, numbers were small, were confounded by the bias of subspecialty practice, and the onset of the pandemic, which affected not only face-to-face visits but the opportunity to perform pulmonary function testing for a number of months.”
Dr. King noted: “There is an emerging body of science that does indicate that there could be some respiratory risks related to e-cigarette use, particularly among certain populations. ... That said, there’s no conclusive link between e-cigarette use and specific disease outcomes, which typically requires a robust body of different science conducted in multiple settings.”
He said that e-cigarette vapors contain ultrafine particles and heavy metals that can be inhaled deeply into the lungs, both of which have previously been associated with respiratory risk, including complications from asthma.
An ounce of prevention
“When it comes to cessation, we do know that about 50% of youth who are using tobacco products including e-cigarettes, want to quit, and about the same proportion make an effort to quit, so there’s certainly a will there, but we don’t clearly have an evidence-based way,” Dr. King said.
Combinations of behavioral interventions including face-to-face consultations and digital or telephone support can be helpful, Dr. Cataletto said, but both she and Dr. King agree that prevention is the most effective method of reducing e-cigarette use among teens and young adults, including peer support and education efforts.
Asked how she gets her patients to report honestly about their habits, Dr. Cataletto acknowledged that “this is a challenge for many kids. Some are unaware that many of the commercially available e-cigarette products contain nicotine and they are not ‘just vaping flavoring.’ Ongoing education is important, and it is happening in schools, in pediatrician’s offices, at home and in the community.”
Dr. Cataletto and Dr. King reported no relevant conflicts of interest. Dr. Cataletto serves on the editorial advisory board for Chest Physician.
It’s an electronic cigarette maker’s dream, but a public health nightmare: The confluence of social isolation and anxiety resulting from the COVID-19 pandemic has the potential to make recent progress against e-cigarette use among teens go up in smoke.
“Stress and worsening mental health issues are well-known predisposing factors for smoking, both in quantity and frequency and in relapse,” said Mary Cataletto, MD, FCCP, clinical professor of pediatrics at New York University Winthrop Hospital, Mineola, during a webinar on e-cigarettes and vaping with asthma in the time of COVID-19, hosted by the Allergy & Asthma Network.
Prior to the pandemic, public health experts appeared to be making inroads into curbing e-cigarette use, according to results of the 2020 National Youth Tobacco Survey, a cross-sectional school-based survey of students from grades 6 to 12.
“In 2020, approximately 1 in 5 high school students and 1 in 20 middle school students currently used e-cigarettes. By comparison, in 2019, 27.5% of high school students (4.11 million) and 10.5% of middle school students (1.24 million) reported current e-cigarette use,” wrote Brian A. King, PhD, MPH, and colleagues, in an article reporting those results.
“We definitely believe that there was a real decline that occurred up until March. Those data from the National Youth Tobacco Survey were collected prior to youth leaving school settings and prior to the implementation of social distancing and other measures,” said Dr. King, deputy director for research translation in the Office on Smoking and Health within the National Center for Chronic Disease Prevention and Health Promotion at the Centers for Disease Control and Prevention.
“That said, the jury’s still out on what’s going to happen with youth use during the coming year, particularly during the COVID-19 pandemic” he said in an interview.
Flavor of the moment
Even though the data through March 2020 showed a distinct decline in e-cigarette use, Dr. King and colleagues found that 3.6 million U.S. adolescents still currently used e-cigarettes in 2020; among current users, more than 80% reported using flavored e-cigarettes.
Dr. Cataletto said in an interview that the 2020 National Youth Tobacco Survey continues to report widespread use of flavored e-cigarettes among young smokers despite Food and Drug Administration admonitions to manufacturers and retailers to remove unauthorized e-cigarettes from the market.
On Jan. 2, 2020, the FDA reported a finalized enforcement policy directed against “unauthorized flavored cartridge-based e-cigarettes that appeal to children, including fruit and mint.”
But as Dr. King and other investigators also mentioned in a separate analysis of e-cigarette unit sales, that enforcement policy applies only to prefilled cartridge e-cigarette products, such as those made by JUUL, and that while sales of mint- or fruit-flavored products of this type declined from September 2014 to May 2020, there was an increase in the sale of disposable e-cigarettes with flavors other than menthol or tobacco.
Dr. Cataletto pointed out that this vaping trend has coincided with the COVID-19 pandemic, noting that, on March 13, 2020, just 2 days after the World Health Organization declared that spread of COVID-19 was officially a pandemic, 16 states closed schools, leaving millions of middle school– and high school–age children at loose ends. She said: “This raised a number of concerns. Would students who used e-cigarettes be at increased risk of COVID-19? Would e-cigarette use increase again due to the social isolation and anxiety as predicted for tobacco smokers? How would access and availability impact e-cigarette use?
“It’s possible that use may go down, because youth may have less access to their typical social sources or other manners in which they obtain the product.” Dr. King said. “Alternatively, youth may have more disposable time on their hands and may be open to other sources of access to these products, and so use could increase.”
There is evidence to suggest that the latter scenario may be true, according to investigators who surveyed more than 1,000 Canadian adolescents about alcohol use, binge drinking, cannabis use, and vaping in the 3 weeks directly before and after social distancing measures took effect.
The investigators found that the frequency of both alcohol and cannabis use increased during social isolation, and that, although about half of respondents reported solitary substance use, 32% reported using substances with peers via technology, and 24% reported using substances face to face, despite social distancing mandates, reported Tara M. Dumas, PhD, from Huron University College, London, Ont.
“These authors suggest that teens who feared loss of friendships during quarantine might be more willing to engage in risky behaviors such as face to face substance use to maintain social status, while solitary substance use was related to both COVID19 fears and depressive symptomatology,” Dr. Cataletto said.
E-cigarettes and COVID-19
A recent survey of 4,351 adolescents and young adults in the United States showed that a COVID-19 diagnosis was five times more likely among those who had ever used e-cigarettes, seven times more likely among conventional cigarette and e-cigarette uses, and nearly seven times more likely among those who had used both within the past 30 days .
Perhaps not surprisingly, adolescents and young adults with asthma who also vape may be at especially high risk for COVID-19, but the exact effect may be hard to pin down with current levels of evidence.
“Prior to the pandemic we did see both new-onset asthma and asthma exacerbations in teens who reported either vaping or dual use with tobacco products,” Dr. Cataletto said. “However, numbers were small, were confounded by the bias of subspecialty practice, and the onset of the pandemic, which affected not only face-to-face visits but the opportunity to perform pulmonary function testing for a number of months.”
Dr. King noted: “There is an emerging body of science that does indicate that there could be some respiratory risks related to e-cigarette use, particularly among certain populations. ... That said, there’s no conclusive link between e-cigarette use and specific disease outcomes, which typically requires a robust body of different science conducted in multiple settings.”
He said that e-cigarette vapors contain ultrafine particles and heavy metals that can be inhaled deeply into the lungs, both of which have previously been associated with respiratory risk, including complications from asthma.
An ounce of prevention
“When it comes to cessation, we do know that about 50% of youth who are using tobacco products including e-cigarettes, want to quit, and about the same proportion make an effort to quit, so there’s certainly a will there, but we don’t clearly have an evidence-based way,” Dr. King said.
Combinations of behavioral interventions including face-to-face consultations and digital or telephone support can be helpful, Dr. Cataletto said, but both she and Dr. King agree that prevention is the most effective method of reducing e-cigarette use among teens and young adults, including peer support and education efforts.
Asked how she gets her patients to report honestly about their habits, Dr. Cataletto acknowledged that “this is a challenge for many kids. Some are unaware that many of the commercially available e-cigarette products contain nicotine and they are not ‘just vaping flavoring.’ Ongoing education is important, and it is happening in schools, in pediatrician’s offices, at home and in the community.”
Dr. Cataletto and Dr. King reported no relevant conflicts of interest. Dr. Cataletto serves on the editorial advisory board for Chest Physician.
EMA panel backs peanut allergy desensitizing powder Palforzia
The product is intended for desensitizing children and adolescents to peanut allergy.
Palforzia will be available as an oral powder in capsules (0.5, 1, 10, 20, and 100 mg) and as oral powder in sachet (300 mg). The active substance is defatted powder of Arachis hypogaea.
Through use of the product, children with a peanut allergy receive controlled exposure to precise, increasing amounts of peanut protein, mixed with soft food, every day. Over time, this may help to decrease their sensitivity to small amounts of peanuts.
According to the press release from the EMA, Palforzia can mitigate accidental exposure to small amounts of peanut protein. “[A] single dose of a least 1 gram of peanut protein would cause no more than mild allergy symptoms,” the EMA said.
The treatment is indicated for patients aged 4 to 17 years who have received a confirmed diagnosis of peanut allergy. Treatment may be continued for patients aged 18 years or older, according to the press release.
It should be administered under the supervision of a healthcare provider qualified in the diagnosis and treatment of allergic diseases and should be used in conjunction with a peanut-avoidant diet, the EMA notes.
The most common side effects that have been reported are abdominal pain, throat irritation, itch, nausea, vomiting, urticaria, and upper abdominal discomfort.
The next step in the approval process is to obtain market authorization from the European Commission. Detailed recommendations for use will be described in the summary of product characteristics, which will be published in the European public assessment report and will be made available throughout Europe.
“We are encouraged by the CHMP opinion, which recommends Palforzia as the first and only treatment option in the European Union for patients with peanut allergy and their families,” Andrew Oxtoby, president and chief executive officer of Aimmune Therapeutics, said in a statement. “Today’s decision underscores the strong and compelling data from our Palforzia clinical trials and follows the US FDA approval of Palforzia earlier this year. We look forward to the European Commission’s final decision for the marketing approval of Palforzia, which we expect later this year.”
The FDA said in granting its approval that patients, parents, or caregivers must be counseled on the need for always-available injectable epinephrine, the need for continued peanut avoidance, and on how to recognize signs of anaphylaxis.
This article originally appeared on Medscape.com.
The product is intended for desensitizing children and adolescents to peanut allergy.
Palforzia will be available as an oral powder in capsules (0.5, 1, 10, 20, and 100 mg) and as oral powder in sachet (300 mg). The active substance is defatted powder of Arachis hypogaea.
Through use of the product, children with a peanut allergy receive controlled exposure to precise, increasing amounts of peanut protein, mixed with soft food, every day. Over time, this may help to decrease their sensitivity to small amounts of peanuts.
According to the press release from the EMA, Palforzia can mitigate accidental exposure to small amounts of peanut protein. “[A] single dose of a least 1 gram of peanut protein would cause no more than mild allergy symptoms,” the EMA said.
The treatment is indicated for patients aged 4 to 17 years who have received a confirmed diagnosis of peanut allergy. Treatment may be continued for patients aged 18 years or older, according to the press release.
It should be administered under the supervision of a healthcare provider qualified in the diagnosis and treatment of allergic diseases and should be used in conjunction with a peanut-avoidant diet, the EMA notes.
The most common side effects that have been reported are abdominal pain, throat irritation, itch, nausea, vomiting, urticaria, and upper abdominal discomfort.
The next step in the approval process is to obtain market authorization from the European Commission. Detailed recommendations for use will be described in the summary of product characteristics, which will be published in the European public assessment report and will be made available throughout Europe.
“We are encouraged by the CHMP opinion, which recommends Palforzia as the first and only treatment option in the European Union for patients with peanut allergy and their families,” Andrew Oxtoby, president and chief executive officer of Aimmune Therapeutics, said in a statement. “Today’s decision underscores the strong and compelling data from our Palforzia clinical trials and follows the US FDA approval of Palforzia earlier this year. We look forward to the European Commission’s final decision for the marketing approval of Palforzia, which we expect later this year.”
The FDA said in granting its approval that patients, parents, or caregivers must be counseled on the need for always-available injectable epinephrine, the need for continued peanut avoidance, and on how to recognize signs of anaphylaxis.
This article originally appeared on Medscape.com.
The product is intended for desensitizing children and adolescents to peanut allergy.
Palforzia will be available as an oral powder in capsules (0.5, 1, 10, 20, and 100 mg) and as oral powder in sachet (300 mg). The active substance is defatted powder of Arachis hypogaea.
Through use of the product, children with a peanut allergy receive controlled exposure to precise, increasing amounts of peanut protein, mixed with soft food, every day. Over time, this may help to decrease their sensitivity to small amounts of peanuts.
According to the press release from the EMA, Palforzia can mitigate accidental exposure to small amounts of peanut protein. “[A] single dose of a least 1 gram of peanut protein would cause no more than mild allergy symptoms,” the EMA said.
The treatment is indicated for patients aged 4 to 17 years who have received a confirmed diagnosis of peanut allergy. Treatment may be continued for patients aged 18 years or older, according to the press release.
It should be administered under the supervision of a healthcare provider qualified in the diagnosis and treatment of allergic diseases and should be used in conjunction with a peanut-avoidant diet, the EMA notes.
The most common side effects that have been reported are abdominal pain, throat irritation, itch, nausea, vomiting, urticaria, and upper abdominal discomfort.
The next step in the approval process is to obtain market authorization from the European Commission. Detailed recommendations for use will be described in the summary of product characteristics, which will be published in the European public assessment report and will be made available throughout Europe.
“We are encouraged by the CHMP opinion, which recommends Palforzia as the first and only treatment option in the European Union for patients with peanut allergy and their families,” Andrew Oxtoby, president and chief executive officer of Aimmune Therapeutics, said in a statement. “Today’s decision underscores the strong and compelling data from our Palforzia clinical trials and follows the US FDA approval of Palforzia earlier this year. We look forward to the European Commission’s final decision for the marketing approval of Palforzia, which we expect later this year.”
The FDA said in granting its approval that patients, parents, or caregivers must be counseled on the need for always-available injectable epinephrine, the need for continued peanut avoidance, and on how to recognize signs of anaphylaxis.
This article originally appeared on Medscape.com.
Are oncologists ready to confront a second wave of COVID-19?
Canceled appointments, postponed surgeries, and delayed cancer diagnoses – all are a recipe for exhaustion for oncologists around the world, struggling to reach and treat their patients during the pandemic. Physicians and their teams felt the pain as COVID-19 took its initial march around the globe.
“We saw the distress of people with cancer who could no longer get to anyone on the phone. Their medical visit was usually canceled. Their radiotherapy session was postponed or modified, and chemotherapy postponed,” says Axel Kahn, MD, chairman of the board of directors of La Ligue Nationale Contre le Cancer (National League Against Cancer). “In the vast majority of cases, cancer treatment can be postponed or readjusted, without affecting the patient’s chances of survival, but there has been a lot of anxiety because the patients do not know that.”
The stay-at-home factor was one that played out across many months during the first wave.
“I believe that the ‘stay-home’ message that we transmitted was rigorously followed by patients who should have come to the emergency room much earlier and who, therefore, were admitted with a much more deteriorated general condition than in non-COVID-19 times,” says Benjamín Domingo Arrué, MD, from the department of medical oncology at Hospital Universitari i Politècnic La Fe in Valencia, Spain.
And in Brazil, some of the impact from the initial hit of COVID-19 on oncology is only now being felt, according to Laura Testa, MD, head of breast medical oncology, Instituto do Câncer do Estado de São Paulo.
“We are starting to see a lot of cancer cases that didn’t show up at the beginning of the pandemic, but now they are arriving to us already in advanced stages,” she said. “These patients need hospital care. If the situation worsens and goes back to what we saw at the peak of the curve, I fear the public system won’t be able to treat properly the oncology patients that need hospital care and the patients with cancer who also have COVID-19.”
But even as health care worker fatigue and concerns linger, oncologists say that what they have learned in the last 6 months has helped them prepare as COVID-19 cases increase and a second global wave kicks up.
Lessons from the first wave
In the United States, COVID-19 hit different regions at different times and to different degrees. One of the areas hit first was Seattle.
“We jumped on top of this, we were evidence based, we put things in place very, very quickly,” said Julie Gralow, MD, professor at the University of Washington and the Fred Hutchinson Cancer Research Center, both in Seattle.
“We did a really good job keeping COVID out of our cancer centers,” Dr. Gralow said. “We learned how to be super safe, and to keep symptomatic people out of the building, and to limit the extra people they could bring with them. It’s all about the number of contacts you have.”
The story was different, though, for oncologists in several other countries, and sometimes it varied immensely within each nation.
“We treated fewer patients with cancer during the first wave,” says Dirk Arnold, MD, medical director of the Asklepios Tumor Center Hamburg (Germany), in an interview. “In part, this was because staff were quarantined and because we had a completely different infrastructure in all of the hospitals. But also fewer patients with cancer came to the clinic at all. A lot of resources were directed toward COVID-19.”
In Spain, telemedicine helped keep up with visits, but other areas felt the effect of COVID-19 patient loads.
“At least in the oncology department of our center, we have practically maintained 100% of visits, mostly by telephone,” says Dr. Arrué, “but the reality is that our country has not yet been prepared for telemedicine.”
Laura Mezquita, MD, of the department of medical oncology at Hospital Clinic de Barcelona, describes a more dramatic situation: “We have seen how some of our patients, especially with metastatic disease, have been dismissed for intensive care and life-support treatments, as well as specific treatments against COVID-19 (tocilizumab, remdesivir, etc.) due to the general health collapse of the former wave,” she said. She adds that specific oncologic populations, such as those with thoracic tumors, have been more affected.
Distress among oncologists
Many oncologists are still feeling stressed and fatigued after the first wave, just as a second string of outbreaks is on its way.
A survey presented at last month’s ESMO 2020 Congress found that, in July-August, moral distress was reported by one-third of the oncologists who responded, and more than half reported a feeling of exhaustion.
“The tiredness and team exhaustion is noticeable,” said Dr. Arnold. “We recently had a task force discussion about what will happen when we have a second wave and how the department and our services will adapt. It was clear that those who were at the very front in the first wave had only a limited desire to do that again in the second wave.”
Another concern: COVID-19’s effect on staffing levels.
“We have a population of young caregivers who are affected by the COVID-19 disease with an absenteeism rate that is quite unprecedented,” said Sophie Beaupère, general delegate of Unicancer since January.
She said that, in general, the absenteeism rate in the cancer centers averages 5%-6%, depending on the year. But that rate is now skyrocketing.
Stop-start cycle for surgery
As caregivers quarantined around the world, more than 10% of patients with cancer had treatment canceled or delayed during the first wave of the pandemic, according to another survey from ESMO, involving 109 oncologists from 18 countries.
Difficulties were reported for surgeries by 34% of the centers, but also difficulties with delivering chemotherapy (22% of centers), radiotherapy (13.7%), and therapy with checkpoint inhibitors (9.1%), monoclonal antibodies (9%), and oral targeted therapy (3.7%).
Stopping surgery is a real concern in France, noted Dr. Kahn, the National League Against Cancer chair. He says that in regions that were badly hit by COVID-19, “it was not possible to have access to the operating room for people who absolutely needed surgery; for example, patients with lung cancer that was still operable. Most of the recovery rooms were mobilized for resuscitation.”
There may be some solutions, suggested Thierry Breton, director general of the National Institute of Cancer in France. “We are getting prepared, with the health ministry, for a possible increase in hospital tension, which would lead to a situation where we would have to reschedule operations. Nationally, regionally, and locally, we are seeing how we can resume and prioritize surgeries that have not been done.”
Delays in cancer diagnosis
While COVID-19 affected treatment, many oncologists say the major impact of the first wave was a delay in diagnosing cancer. Some of this was a result of the suspension of cancer screening programs, but there was also fear among the general public about visiting clinics and hospitals during a pandemic.
“We didn’t do so well with cancer during the first wave here in the U.K.,” said Karol Sikora, PhD, MBBChir, professor of cancer medicine and founding dean at the University of Buckingham Medical School, London. “Cancer diagnostic pathways virtually stalled partly because patients didn’t seek help, but getting scans and biopsies was also very difficult. Even patients referred urgently under the ‘2-weeks-wait’ rule were turned down.”
In France, “the delay in diagnosis is indisputable,” said Dr. Kahn. “About 50% of the cancer diagnoses one would expect during this period were missed.”
“I am worried that there remains a major traffic jam that has not been caught up with, and, in the meantime, the health crisis is worsening,” he added.
In Seattle, Dr. Gralow said the first COVID-19 wave had little impact on treatment for breast cancer, but it was in screening for breast cancer “where things really got messed up.”
“Even though we’ve been fully ramped up again,” she said, concerns remain. To ensure that screening mammography is maintained, “we have spaced out the visits to keep our waiting rooms less populated, with a longer time between using the machine so we can clean it. To do this, we have extended operating hours and are now opening on Saturday.
“So we’re actually at 100% of our capacity, but I’m really nervous, though, that a lot of people put off their screening mammogram and aren’t going to come in and get it.
“Not only did people get the message to stay home and not do nonessential things, but I think a lot of people lost their health insurance when they lost their jobs,” she said, and without health insurance, they are not covered for cancer screening.
Looking ahead, with a plan
Many oncologists agree that access to care can and must be improved – and there were some positive moves.
“Some regimens changed during the first months of the pandemic, and I don’t see them going back to the way they were anytime soon,” said Dr. Testa. “The changes/adaptations that were made to minimize the chance of SARS-CoV-2 infection are still in place and will go on for a while. In this context, telemedicine helped a lot. The pandemic forced the stakeholders to step up and put it in place in March. And now it’s here to stay.”
The experience gained in the last several months has driven preparation for the next wave.
“We are not going to see the disorganization that we saw during the first wave,” said Florence Joly, MD, PhD, head of medical oncology at the Centre François Baclesse in Caen, France. “The difference between now and earlier this year is that COVID diagnostic tests are available. That was one of the problems in the first wave. We had no way to diagnose.”
On the East Coast of the United States, medical oncologist Charu Aggarwal, MD, MPH, is also optimistic: “I think we’re at a place where we can manage.”
“I believe if there was going to be a new wave of COVID-19 cases we would be: better psychologically prepared and better organized,” said Dr. Aggarwal, assistant professor of medicine in the hematology-oncology division at the University of Pennsylvania, Philadelphia. “We already have experience with all of the tools, we have telemedicine available, we have screening protocols available, we have testing, we are already universally masking, everyone’s hand-washing, so I do think that means we would be okay.”
Dr. Arnold agreed that “we are much better prepared than for the first wave, but … we have immense tasks in the area of patient management, the digitization of patient care, the clear allocation of resources when there is a second or third wave. In many areas of preparation, I believe, unfortunately, we are not as well positioned as we had actually hoped.”
The first wave of COVID hit cancer services in the United Kingdom particularly hard: One modeling study suggested that delays in cancer referrals will lead to thousands of additional deaths and tens of thousands of life-years lost.
“Cancer services are working at near normal levels now, but they are still fragile and could be severely compromised again if the NHS [National Health Service] gets flooded by COVID patients,” said Dr. Sikora.
The second wave may be different. “Although the number of infections has increased, the hospitalizations have only risen a little. Let’s see what happens,” he said in an interview. Since then, however, infections have continued to rise, and there has been an increase in hospitalizations. New social distancing measures in the United Kingdom were put into place on Oct. 12, with the aim of protecting the NHS from overload.
Dr. Arrué describes it this way: “The reality is that the ‘second wave’ has left behind the initial grief and shock that both patients and health professionals experienced when faced with something that, until now, we had only seen in the movies.” The second wave has led to new restrictions – including a partial lockdown since the beginning of October.
Dr. Aggarwal says her department recently had a conference with Anthony Fauci, MD, director of the National Institute of Allergy and Infectious Diseases, about the impact of COVID-19 on oncology.
“I asked him what advice he’d give oncologists, and he said to go back to as much screening as you were doing previously as quickly as possible. That’s what must be relayed to our oncologists in the community – and also to primary care physicians – because they are often the ones who are ordering and championing the screening efforts.”
This article was originated by Aude Lecrubier, Medscape French edition, and developed by Zosia Chustecka, Medscape Oncology. With additional reporting by Kate Johnson, freelance medical journalist, Claudia Gottschling for Medscape Germany, Leoleli Schwartz for Medscape em português, Tim Locke for Medscape United Kingdom, and Carla Nieto Martínez, freelance medical journalist for Medscape Spanish edition.
This article first appeared on Medscape.com.
Canceled appointments, postponed surgeries, and delayed cancer diagnoses – all are a recipe for exhaustion for oncologists around the world, struggling to reach and treat their patients during the pandemic. Physicians and their teams felt the pain as COVID-19 took its initial march around the globe.
“We saw the distress of people with cancer who could no longer get to anyone on the phone. Their medical visit was usually canceled. Their radiotherapy session was postponed or modified, and chemotherapy postponed,” says Axel Kahn, MD, chairman of the board of directors of La Ligue Nationale Contre le Cancer (National League Against Cancer). “In the vast majority of cases, cancer treatment can be postponed or readjusted, without affecting the patient’s chances of survival, but there has been a lot of anxiety because the patients do not know that.”
The stay-at-home factor was one that played out across many months during the first wave.
“I believe that the ‘stay-home’ message that we transmitted was rigorously followed by patients who should have come to the emergency room much earlier and who, therefore, were admitted with a much more deteriorated general condition than in non-COVID-19 times,” says Benjamín Domingo Arrué, MD, from the department of medical oncology at Hospital Universitari i Politècnic La Fe in Valencia, Spain.
And in Brazil, some of the impact from the initial hit of COVID-19 on oncology is only now being felt, according to Laura Testa, MD, head of breast medical oncology, Instituto do Câncer do Estado de São Paulo.
“We are starting to see a lot of cancer cases that didn’t show up at the beginning of the pandemic, but now they are arriving to us already in advanced stages,” she said. “These patients need hospital care. If the situation worsens and goes back to what we saw at the peak of the curve, I fear the public system won’t be able to treat properly the oncology patients that need hospital care and the patients with cancer who also have COVID-19.”
But even as health care worker fatigue and concerns linger, oncologists say that what they have learned in the last 6 months has helped them prepare as COVID-19 cases increase and a second global wave kicks up.
Lessons from the first wave
In the United States, COVID-19 hit different regions at different times and to different degrees. One of the areas hit first was Seattle.
“We jumped on top of this, we were evidence based, we put things in place very, very quickly,” said Julie Gralow, MD, professor at the University of Washington and the Fred Hutchinson Cancer Research Center, both in Seattle.
“We did a really good job keeping COVID out of our cancer centers,” Dr. Gralow said. “We learned how to be super safe, and to keep symptomatic people out of the building, and to limit the extra people they could bring with them. It’s all about the number of contacts you have.”
The story was different, though, for oncologists in several other countries, and sometimes it varied immensely within each nation.
“We treated fewer patients with cancer during the first wave,” says Dirk Arnold, MD, medical director of the Asklepios Tumor Center Hamburg (Germany), in an interview. “In part, this was because staff were quarantined and because we had a completely different infrastructure in all of the hospitals. But also fewer patients with cancer came to the clinic at all. A lot of resources were directed toward COVID-19.”
In Spain, telemedicine helped keep up with visits, but other areas felt the effect of COVID-19 patient loads.
“At least in the oncology department of our center, we have practically maintained 100% of visits, mostly by telephone,” says Dr. Arrué, “but the reality is that our country has not yet been prepared for telemedicine.”
Laura Mezquita, MD, of the department of medical oncology at Hospital Clinic de Barcelona, describes a more dramatic situation: “We have seen how some of our patients, especially with metastatic disease, have been dismissed for intensive care and life-support treatments, as well as specific treatments against COVID-19 (tocilizumab, remdesivir, etc.) due to the general health collapse of the former wave,” she said. She adds that specific oncologic populations, such as those with thoracic tumors, have been more affected.
Distress among oncologists
Many oncologists are still feeling stressed and fatigued after the first wave, just as a second string of outbreaks is on its way.
A survey presented at last month’s ESMO 2020 Congress found that, in July-August, moral distress was reported by one-third of the oncologists who responded, and more than half reported a feeling of exhaustion.
“The tiredness and team exhaustion is noticeable,” said Dr. Arnold. “We recently had a task force discussion about what will happen when we have a second wave and how the department and our services will adapt. It was clear that those who were at the very front in the first wave had only a limited desire to do that again in the second wave.”
Another concern: COVID-19’s effect on staffing levels.
“We have a population of young caregivers who are affected by the COVID-19 disease with an absenteeism rate that is quite unprecedented,” said Sophie Beaupère, general delegate of Unicancer since January.
She said that, in general, the absenteeism rate in the cancer centers averages 5%-6%, depending on the year. But that rate is now skyrocketing.
Stop-start cycle for surgery
As caregivers quarantined around the world, more than 10% of patients with cancer had treatment canceled or delayed during the first wave of the pandemic, according to another survey from ESMO, involving 109 oncologists from 18 countries.
Difficulties were reported for surgeries by 34% of the centers, but also difficulties with delivering chemotherapy (22% of centers), radiotherapy (13.7%), and therapy with checkpoint inhibitors (9.1%), monoclonal antibodies (9%), and oral targeted therapy (3.7%).
Stopping surgery is a real concern in France, noted Dr. Kahn, the National League Against Cancer chair. He says that in regions that were badly hit by COVID-19, “it was not possible to have access to the operating room for people who absolutely needed surgery; for example, patients with lung cancer that was still operable. Most of the recovery rooms were mobilized for resuscitation.”
There may be some solutions, suggested Thierry Breton, director general of the National Institute of Cancer in France. “We are getting prepared, with the health ministry, for a possible increase in hospital tension, which would lead to a situation where we would have to reschedule operations. Nationally, regionally, and locally, we are seeing how we can resume and prioritize surgeries that have not been done.”
Delays in cancer diagnosis
While COVID-19 affected treatment, many oncologists say the major impact of the first wave was a delay in diagnosing cancer. Some of this was a result of the suspension of cancer screening programs, but there was also fear among the general public about visiting clinics and hospitals during a pandemic.
“We didn’t do so well with cancer during the first wave here in the U.K.,” said Karol Sikora, PhD, MBBChir, professor of cancer medicine and founding dean at the University of Buckingham Medical School, London. “Cancer diagnostic pathways virtually stalled partly because patients didn’t seek help, but getting scans and biopsies was also very difficult. Even patients referred urgently under the ‘2-weeks-wait’ rule were turned down.”
In France, “the delay in diagnosis is indisputable,” said Dr. Kahn. “About 50% of the cancer diagnoses one would expect during this period were missed.”
“I am worried that there remains a major traffic jam that has not been caught up with, and, in the meantime, the health crisis is worsening,” he added.
In Seattle, Dr. Gralow said the first COVID-19 wave had little impact on treatment for breast cancer, but it was in screening for breast cancer “where things really got messed up.”
“Even though we’ve been fully ramped up again,” she said, concerns remain. To ensure that screening mammography is maintained, “we have spaced out the visits to keep our waiting rooms less populated, with a longer time between using the machine so we can clean it. To do this, we have extended operating hours and are now opening on Saturday.
“So we’re actually at 100% of our capacity, but I’m really nervous, though, that a lot of people put off their screening mammogram and aren’t going to come in and get it.
“Not only did people get the message to stay home and not do nonessential things, but I think a lot of people lost their health insurance when they lost their jobs,” she said, and without health insurance, they are not covered for cancer screening.
Looking ahead, with a plan
Many oncologists agree that access to care can and must be improved – and there were some positive moves.
“Some regimens changed during the first months of the pandemic, and I don’t see them going back to the way they were anytime soon,” said Dr. Testa. “The changes/adaptations that were made to minimize the chance of SARS-CoV-2 infection are still in place and will go on for a while. In this context, telemedicine helped a lot. The pandemic forced the stakeholders to step up and put it in place in March. And now it’s here to stay.”
The experience gained in the last several months has driven preparation for the next wave.
“We are not going to see the disorganization that we saw during the first wave,” said Florence Joly, MD, PhD, head of medical oncology at the Centre François Baclesse in Caen, France. “The difference between now and earlier this year is that COVID diagnostic tests are available. That was one of the problems in the first wave. We had no way to diagnose.”
On the East Coast of the United States, medical oncologist Charu Aggarwal, MD, MPH, is also optimistic: “I think we’re at a place where we can manage.”
“I believe if there was going to be a new wave of COVID-19 cases we would be: better psychologically prepared and better organized,” said Dr. Aggarwal, assistant professor of medicine in the hematology-oncology division at the University of Pennsylvania, Philadelphia. “We already have experience with all of the tools, we have telemedicine available, we have screening protocols available, we have testing, we are already universally masking, everyone’s hand-washing, so I do think that means we would be okay.”
Dr. Arnold agreed that “we are much better prepared than for the first wave, but … we have immense tasks in the area of patient management, the digitization of patient care, the clear allocation of resources when there is a second or third wave. In many areas of preparation, I believe, unfortunately, we are not as well positioned as we had actually hoped.”
The first wave of COVID hit cancer services in the United Kingdom particularly hard: One modeling study suggested that delays in cancer referrals will lead to thousands of additional deaths and tens of thousands of life-years lost.
“Cancer services are working at near normal levels now, but they are still fragile and could be severely compromised again if the NHS [National Health Service] gets flooded by COVID patients,” said Dr. Sikora.
The second wave may be different. “Although the number of infections has increased, the hospitalizations have only risen a little. Let’s see what happens,” he said in an interview. Since then, however, infections have continued to rise, and there has been an increase in hospitalizations. New social distancing measures in the United Kingdom were put into place on Oct. 12, with the aim of protecting the NHS from overload.
Dr. Arrué describes it this way: “The reality is that the ‘second wave’ has left behind the initial grief and shock that both patients and health professionals experienced when faced with something that, until now, we had only seen in the movies.” The second wave has led to new restrictions – including a partial lockdown since the beginning of October.
Dr. Aggarwal says her department recently had a conference with Anthony Fauci, MD, director of the National Institute of Allergy and Infectious Diseases, about the impact of COVID-19 on oncology.
“I asked him what advice he’d give oncologists, and he said to go back to as much screening as you were doing previously as quickly as possible. That’s what must be relayed to our oncologists in the community – and also to primary care physicians – because they are often the ones who are ordering and championing the screening efforts.”
This article was originated by Aude Lecrubier, Medscape French edition, and developed by Zosia Chustecka, Medscape Oncology. With additional reporting by Kate Johnson, freelance medical journalist, Claudia Gottschling for Medscape Germany, Leoleli Schwartz for Medscape em português, Tim Locke for Medscape United Kingdom, and Carla Nieto Martínez, freelance medical journalist for Medscape Spanish edition.
This article first appeared on Medscape.com.
Canceled appointments, postponed surgeries, and delayed cancer diagnoses – all are a recipe for exhaustion for oncologists around the world, struggling to reach and treat their patients during the pandemic. Physicians and their teams felt the pain as COVID-19 took its initial march around the globe.
“We saw the distress of people with cancer who could no longer get to anyone on the phone. Their medical visit was usually canceled. Their radiotherapy session was postponed or modified, and chemotherapy postponed,” says Axel Kahn, MD, chairman of the board of directors of La Ligue Nationale Contre le Cancer (National League Against Cancer). “In the vast majority of cases, cancer treatment can be postponed or readjusted, without affecting the patient’s chances of survival, but there has been a lot of anxiety because the patients do not know that.”
The stay-at-home factor was one that played out across many months during the first wave.
“I believe that the ‘stay-home’ message that we transmitted was rigorously followed by patients who should have come to the emergency room much earlier and who, therefore, were admitted with a much more deteriorated general condition than in non-COVID-19 times,” says Benjamín Domingo Arrué, MD, from the department of medical oncology at Hospital Universitari i Politècnic La Fe in Valencia, Spain.
And in Brazil, some of the impact from the initial hit of COVID-19 on oncology is only now being felt, according to Laura Testa, MD, head of breast medical oncology, Instituto do Câncer do Estado de São Paulo.
“We are starting to see a lot of cancer cases that didn’t show up at the beginning of the pandemic, but now they are arriving to us already in advanced stages,” she said. “These patients need hospital care. If the situation worsens and goes back to what we saw at the peak of the curve, I fear the public system won’t be able to treat properly the oncology patients that need hospital care and the patients with cancer who also have COVID-19.”
But even as health care worker fatigue and concerns linger, oncologists say that what they have learned in the last 6 months has helped them prepare as COVID-19 cases increase and a second global wave kicks up.
Lessons from the first wave
In the United States, COVID-19 hit different regions at different times and to different degrees. One of the areas hit first was Seattle.
“We jumped on top of this, we were evidence based, we put things in place very, very quickly,” said Julie Gralow, MD, professor at the University of Washington and the Fred Hutchinson Cancer Research Center, both in Seattle.
“We did a really good job keeping COVID out of our cancer centers,” Dr. Gralow said. “We learned how to be super safe, and to keep symptomatic people out of the building, and to limit the extra people they could bring with them. It’s all about the number of contacts you have.”
The story was different, though, for oncologists in several other countries, and sometimes it varied immensely within each nation.
“We treated fewer patients with cancer during the first wave,” says Dirk Arnold, MD, medical director of the Asklepios Tumor Center Hamburg (Germany), in an interview. “In part, this was because staff were quarantined and because we had a completely different infrastructure in all of the hospitals. But also fewer patients with cancer came to the clinic at all. A lot of resources were directed toward COVID-19.”
In Spain, telemedicine helped keep up with visits, but other areas felt the effect of COVID-19 patient loads.
“At least in the oncology department of our center, we have practically maintained 100% of visits, mostly by telephone,” says Dr. Arrué, “but the reality is that our country has not yet been prepared for telemedicine.”
Laura Mezquita, MD, of the department of medical oncology at Hospital Clinic de Barcelona, describes a more dramatic situation: “We have seen how some of our patients, especially with metastatic disease, have been dismissed for intensive care and life-support treatments, as well as specific treatments against COVID-19 (tocilizumab, remdesivir, etc.) due to the general health collapse of the former wave,” she said. She adds that specific oncologic populations, such as those with thoracic tumors, have been more affected.
Distress among oncologists
Many oncologists are still feeling stressed and fatigued after the first wave, just as a second string of outbreaks is on its way.
A survey presented at last month’s ESMO 2020 Congress found that, in July-August, moral distress was reported by one-third of the oncologists who responded, and more than half reported a feeling of exhaustion.
“The tiredness and team exhaustion is noticeable,” said Dr. Arnold. “We recently had a task force discussion about what will happen when we have a second wave and how the department and our services will adapt. It was clear that those who were at the very front in the first wave had only a limited desire to do that again in the second wave.”
Another concern: COVID-19’s effect on staffing levels.
“We have a population of young caregivers who are affected by the COVID-19 disease with an absenteeism rate that is quite unprecedented,” said Sophie Beaupère, general delegate of Unicancer since January.
She said that, in general, the absenteeism rate in the cancer centers averages 5%-6%, depending on the year. But that rate is now skyrocketing.
Stop-start cycle for surgery
As caregivers quarantined around the world, more than 10% of patients with cancer had treatment canceled or delayed during the first wave of the pandemic, according to another survey from ESMO, involving 109 oncologists from 18 countries.
Difficulties were reported for surgeries by 34% of the centers, but also difficulties with delivering chemotherapy (22% of centers), radiotherapy (13.7%), and therapy with checkpoint inhibitors (9.1%), monoclonal antibodies (9%), and oral targeted therapy (3.7%).
Stopping surgery is a real concern in France, noted Dr. Kahn, the National League Against Cancer chair. He says that in regions that were badly hit by COVID-19, “it was not possible to have access to the operating room for people who absolutely needed surgery; for example, patients with lung cancer that was still operable. Most of the recovery rooms were mobilized for resuscitation.”
There may be some solutions, suggested Thierry Breton, director general of the National Institute of Cancer in France. “We are getting prepared, with the health ministry, for a possible increase in hospital tension, which would lead to a situation where we would have to reschedule operations. Nationally, regionally, and locally, we are seeing how we can resume and prioritize surgeries that have not been done.”
Delays in cancer diagnosis
While COVID-19 affected treatment, many oncologists say the major impact of the first wave was a delay in diagnosing cancer. Some of this was a result of the suspension of cancer screening programs, but there was also fear among the general public about visiting clinics and hospitals during a pandemic.
“We didn’t do so well with cancer during the first wave here in the U.K.,” said Karol Sikora, PhD, MBBChir, professor of cancer medicine and founding dean at the University of Buckingham Medical School, London. “Cancer diagnostic pathways virtually stalled partly because patients didn’t seek help, but getting scans and biopsies was also very difficult. Even patients referred urgently under the ‘2-weeks-wait’ rule were turned down.”
In France, “the delay in diagnosis is indisputable,” said Dr. Kahn. “About 50% of the cancer diagnoses one would expect during this period were missed.”
“I am worried that there remains a major traffic jam that has not been caught up with, and, in the meantime, the health crisis is worsening,” he added.
In Seattle, Dr. Gralow said the first COVID-19 wave had little impact on treatment for breast cancer, but it was in screening for breast cancer “where things really got messed up.”
“Even though we’ve been fully ramped up again,” she said, concerns remain. To ensure that screening mammography is maintained, “we have spaced out the visits to keep our waiting rooms less populated, with a longer time between using the machine so we can clean it. To do this, we have extended operating hours and are now opening on Saturday.
“So we’re actually at 100% of our capacity, but I’m really nervous, though, that a lot of people put off their screening mammogram and aren’t going to come in and get it.
“Not only did people get the message to stay home and not do nonessential things, but I think a lot of people lost their health insurance when they lost their jobs,” she said, and without health insurance, they are not covered for cancer screening.
Looking ahead, with a plan
Many oncologists agree that access to care can and must be improved – and there were some positive moves.
“Some regimens changed during the first months of the pandemic, and I don’t see them going back to the way they were anytime soon,” said Dr. Testa. “The changes/adaptations that were made to minimize the chance of SARS-CoV-2 infection are still in place and will go on for a while. In this context, telemedicine helped a lot. The pandemic forced the stakeholders to step up and put it in place in March. And now it’s here to stay.”
The experience gained in the last several months has driven preparation for the next wave.
“We are not going to see the disorganization that we saw during the first wave,” said Florence Joly, MD, PhD, head of medical oncology at the Centre François Baclesse in Caen, France. “The difference between now and earlier this year is that COVID diagnostic tests are available. That was one of the problems in the first wave. We had no way to diagnose.”
On the East Coast of the United States, medical oncologist Charu Aggarwal, MD, MPH, is also optimistic: “I think we’re at a place where we can manage.”
“I believe if there was going to be a new wave of COVID-19 cases we would be: better psychologically prepared and better organized,” said Dr. Aggarwal, assistant professor of medicine in the hematology-oncology division at the University of Pennsylvania, Philadelphia. “We already have experience with all of the tools, we have telemedicine available, we have screening protocols available, we have testing, we are already universally masking, everyone’s hand-washing, so I do think that means we would be okay.”
Dr. Arnold agreed that “we are much better prepared than for the first wave, but … we have immense tasks in the area of patient management, the digitization of patient care, the clear allocation of resources when there is a second or third wave. In many areas of preparation, I believe, unfortunately, we are not as well positioned as we had actually hoped.”
The first wave of COVID hit cancer services in the United Kingdom particularly hard: One modeling study suggested that delays in cancer referrals will lead to thousands of additional deaths and tens of thousands of life-years lost.
“Cancer services are working at near normal levels now, but they are still fragile and could be severely compromised again if the NHS [National Health Service] gets flooded by COVID patients,” said Dr. Sikora.
The second wave may be different. “Although the number of infections has increased, the hospitalizations have only risen a little. Let’s see what happens,” he said in an interview. Since then, however, infections have continued to rise, and there has been an increase in hospitalizations. New social distancing measures in the United Kingdom were put into place on Oct. 12, with the aim of protecting the NHS from overload.
Dr. Arrué describes it this way: “The reality is that the ‘second wave’ has left behind the initial grief and shock that both patients and health professionals experienced when faced with something that, until now, we had only seen in the movies.” The second wave has led to new restrictions – including a partial lockdown since the beginning of October.
Dr. Aggarwal says her department recently had a conference with Anthony Fauci, MD, director of the National Institute of Allergy and Infectious Diseases, about the impact of COVID-19 on oncology.
“I asked him what advice he’d give oncologists, and he said to go back to as much screening as you were doing previously as quickly as possible. That’s what must be relayed to our oncologists in the community – and also to primary care physicians – because they are often the ones who are ordering and championing the screening efforts.”
This article was originated by Aude Lecrubier, Medscape French edition, and developed by Zosia Chustecka, Medscape Oncology. With additional reporting by Kate Johnson, freelance medical journalist, Claudia Gottschling for Medscape Germany, Leoleli Schwartz for Medscape em português, Tim Locke for Medscape United Kingdom, and Carla Nieto Martínez, freelance medical journalist for Medscape Spanish edition.
This article first appeared on Medscape.com.
SHM announces 2021 virtual annual conference: SHM Converge
The Society of Hospital Medicine has announced its virtual annual conference for 2021: SHM Converge. Formerly known as Hospital Medicine 2021, SHM Converge will take place virtually from May 3-7, 2021, and will offer a fully digital experience with the same education, professional development, and networking hospitalists have come to expect from SHM’s annual conference.
“This year, COVID-19 has challenged us to embrace change and to innovate to better serve our hospital medicine community,” said Danielle Scheurer, MD, MSCR, SFHM, president of SHM’s board of directors. “In that spirit, not only are we introducing an exciting new brand for the SHM annual conference, we are unveiling a reimagined experience for attendees, complete with sessions highlighting the latest research, best practices and innovations in the field.”
The SHM Converge schedule features 20 educational tracks, including the addition of four new tracks to support hospital medicine professionals in some of the most relevant topics affecting health care: diagnostic safety; diversity, equity, and inclusion; leadership; and wellness and resilience
Attendees will also have the option to follow many of the most popular tracks from previous SHM annual conferences, including Rapid Fire, Clinical Updates, and High-Value Care, among others. In many sessions, speakers will present the latest data and information available about COVID-19’s impact on the practice of hospital medicine. Precourses will be held on May 3.
SHM Converge will also offer additional professional development opportunities, including the Research, Innovations, and Clinical Vignettes scientific abstract competition and a speed mentoring session. Networking will be an integral component of SHM Converge. Attendees will be able to choose from more than 20 Special Interest forums, live Q&A sessions and networking events through the interactive conference platform.
“While SHM Converge may look a bit different than the SHM annual conference we are accustomed to, I am confident the content will be among the best we have ever offered, spanning a broad range of clinical topics and issues affecting hospitalists and their patients,” said Daniel Steinberg, MD, SFHM, course director for SHM Converge. “This virtual experience will unite hospitalists from around the globe and connect them with renowned faculty members and thought leaders in hospital medicine – as well as with their hospitalist colleagues they look forward to reconnecting with each year.”
Keynote speaker announcements are forthcoming.
Registration for SHM Converge opens in November 2020. Learn more at shmconverge.org.
Members of the media can obtain press passes beginning in November 2020 by contacting [email protected].
The Society of Hospital Medicine has announced its virtual annual conference for 2021: SHM Converge. Formerly known as Hospital Medicine 2021, SHM Converge will take place virtually from May 3-7, 2021, and will offer a fully digital experience with the same education, professional development, and networking hospitalists have come to expect from SHM’s annual conference.
“This year, COVID-19 has challenged us to embrace change and to innovate to better serve our hospital medicine community,” said Danielle Scheurer, MD, MSCR, SFHM, president of SHM’s board of directors. “In that spirit, not only are we introducing an exciting new brand for the SHM annual conference, we are unveiling a reimagined experience for attendees, complete with sessions highlighting the latest research, best practices and innovations in the field.”
The SHM Converge schedule features 20 educational tracks, including the addition of four new tracks to support hospital medicine professionals in some of the most relevant topics affecting health care: diagnostic safety; diversity, equity, and inclusion; leadership; and wellness and resilience
Attendees will also have the option to follow many of the most popular tracks from previous SHM annual conferences, including Rapid Fire, Clinical Updates, and High-Value Care, among others. In many sessions, speakers will present the latest data and information available about COVID-19’s impact on the practice of hospital medicine. Precourses will be held on May 3.
SHM Converge will also offer additional professional development opportunities, including the Research, Innovations, and Clinical Vignettes scientific abstract competition and a speed mentoring session. Networking will be an integral component of SHM Converge. Attendees will be able to choose from more than 20 Special Interest forums, live Q&A sessions and networking events through the interactive conference platform.
“While SHM Converge may look a bit different than the SHM annual conference we are accustomed to, I am confident the content will be among the best we have ever offered, spanning a broad range of clinical topics and issues affecting hospitalists and their patients,” said Daniel Steinberg, MD, SFHM, course director for SHM Converge. “This virtual experience will unite hospitalists from around the globe and connect them with renowned faculty members and thought leaders in hospital medicine – as well as with their hospitalist colleagues they look forward to reconnecting with each year.”
Keynote speaker announcements are forthcoming.
Registration for SHM Converge opens in November 2020. Learn more at shmconverge.org.
Members of the media can obtain press passes beginning in November 2020 by contacting [email protected].
The Society of Hospital Medicine has announced its virtual annual conference for 2021: SHM Converge. Formerly known as Hospital Medicine 2021, SHM Converge will take place virtually from May 3-7, 2021, and will offer a fully digital experience with the same education, professional development, and networking hospitalists have come to expect from SHM’s annual conference.
“This year, COVID-19 has challenged us to embrace change and to innovate to better serve our hospital medicine community,” said Danielle Scheurer, MD, MSCR, SFHM, president of SHM’s board of directors. “In that spirit, not only are we introducing an exciting new brand for the SHM annual conference, we are unveiling a reimagined experience for attendees, complete with sessions highlighting the latest research, best practices and innovations in the field.”
The SHM Converge schedule features 20 educational tracks, including the addition of four new tracks to support hospital medicine professionals in some of the most relevant topics affecting health care: diagnostic safety; diversity, equity, and inclusion; leadership; and wellness and resilience
Attendees will also have the option to follow many of the most popular tracks from previous SHM annual conferences, including Rapid Fire, Clinical Updates, and High-Value Care, among others. In many sessions, speakers will present the latest data and information available about COVID-19’s impact on the practice of hospital medicine. Precourses will be held on May 3.
SHM Converge will also offer additional professional development opportunities, including the Research, Innovations, and Clinical Vignettes scientific abstract competition and a speed mentoring session. Networking will be an integral component of SHM Converge. Attendees will be able to choose from more than 20 Special Interest forums, live Q&A sessions and networking events through the interactive conference platform.
“While SHM Converge may look a bit different than the SHM annual conference we are accustomed to, I am confident the content will be among the best we have ever offered, spanning a broad range of clinical topics and issues affecting hospitalists and their patients,” said Daniel Steinberg, MD, SFHM, course director for SHM Converge. “This virtual experience will unite hospitalists from around the globe and connect them with renowned faculty members and thought leaders in hospital medicine – as well as with their hospitalist colleagues they look forward to reconnecting with each year.”
Keynote speaker announcements are forthcoming.
Registration for SHM Converge opens in November 2020. Learn more at shmconverge.org.
Members of the media can obtain press passes beginning in November 2020 by contacting [email protected].
Survey: Acceptance of COVID-19 vaccine dips below 50%
Less than half of Americans now say that they would get a coronavirus vaccine if one became available, according to a survey conducted Oct. 8-10.
the lowest number since the weekly survey began at the end of February, digital media company Morning Consult reported.
Americans’ willingness to receive such a vaccine reached its high point, 72%, in early April but has been steadily dropping. “Overall willingness has hovered around 50% throughout September, fueled primarily by a sharp drop among Democrats since mid-August, around the time reports of White House interference at the Food and Drug Administration and other federal health agencies began to command more public attention,” Morning Consult noted.
Despite that drop, a majority of Democrats (55%) are still willing to get a COVID-19 vaccine, compared with 48% of Republicans and just 41% of independents. The willingness gap between the two parties was quite a bit wider in the previous poll, conducted Oct. 1-4: 60% of Democrats versus 48% for Republicans, the company said.
“Keeping with longstanding trends, the survey also shows women were less likely to say they’d seek a vaccine than men (42% to 55%), as were people with lower education levels and those who live in rural areas,” the news outlet added.
The latest poll results also show that 33% of respondents (43% of Republicans/25% of Democrats) are socializing in public places. The overall number was just 8% in mid-April but was up to 27% by mid-June. The proportion of all adults who believe in the effectiveness of face masks has been around 80% since April, but there is a significant gap between those who strongly approve of President Trump (66%) and those who strongly disapprove (95%), Morning Consult said.
Less than half of Americans now say that they would get a coronavirus vaccine if one became available, according to a survey conducted Oct. 8-10.
the lowest number since the weekly survey began at the end of February, digital media company Morning Consult reported.
Americans’ willingness to receive such a vaccine reached its high point, 72%, in early April but has been steadily dropping. “Overall willingness has hovered around 50% throughout September, fueled primarily by a sharp drop among Democrats since mid-August, around the time reports of White House interference at the Food and Drug Administration and other federal health agencies began to command more public attention,” Morning Consult noted.
Despite that drop, a majority of Democrats (55%) are still willing to get a COVID-19 vaccine, compared with 48% of Republicans and just 41% of independents. The willingness gap between the two parties was quite a bit wider in the previous poll, conducted Oct. 1-4: 60% of Democrats versus 48% for Republicans, the company said.
“Keeping with longstanding trends, the survey also shows women were less likely to say they’d seek a vaccine than men (42% to 55%), as were people with lower education levels and those who live in rural areas,” the news outlet added.
The latest poll results also show that 33% of respondents (43% of Republicans/25% of Democrats) are socializing in public places. The overall number was just 8% in mid-April but was up to 27% by mid-June. The proportion of all adults who believe in the effectiveness of face masks has been around 80% since April, but there is a significant gap between those who strongly approve of President Trump (66%) and those who strongly disapprove (95%), Morning Consult said.
Less than half of Americans now say that they would get a coronavirus vaccine if one became available, according to a survey conducted Oct. 8-10.
the lowest number since the weekly survey began at the end of February, digital media company Morning Consult reported.
Americans’ willingness to receive such a vaccine reached its high point, 72%, in early April but has been steadily dropping. “Overall willingness has hovered around 50% throughout September, fueled primarily by a sharp drop among Democrats since mid-August, around the time reports of White House interference at the Food and Drug Administration and other federal health agencies began to command more public attention,” Morning Consult noted.
Despite that drop, a majority of Democrats (55%) are still willing to get a COVID-19 vaccine, compared with 48% of Republicans and just 41% of independents. The willingness gap between the two parties was quite a bit wider in the previous poll, conducted Oct. 1-4: 60% of Democrats versus 48% for Republicans, the company said.
“Keeping with longstanding trends, the survey also shows women were less likely to say they’d seek a vaccine than men (42% to 55%), as were people with lower education levels and those who live in rural areas,” the news outlet added.
The latest poll results also show that 33% of respondents (43% of Republicans/25% of Democrats) are socializing in public places. The overall number was just 8% in mid-April but was up to 27% by mid-June. The proportion of all adults who believe in the effectiveness of face masks has been around 80% since April, but there is a significant gap between those who strongly approve of President Trump (66%) and those who strongly disapprove (95%), Morning Consult said.
When the only clinical choices are ‘lose-lose’
Among the many tolls inflicted on health care workers by COVID-19 is one that is not as easily measured as rates of death or disease, but is no less tangible: moral injury. This is the term by which we describe the psychological, social, and spiritual impact of high-stakes situations that lead to the betrayal or transgression of our own deeply held moral beliefs and values.
The current pandemic has provided innumerable such situations that can increase the risk for moral injury, whether we deal directly with patients infected by the coronavirus or not. Telling family members they cannot visit critically ill loved ones. Delaying code activities, even momentarily, to get fully protected with personal protective equipment. Seeing patients who have delayed their necessary or preventive care. Using video rather than touch to reassure people.
Knowing that we are following guidelines from the Centers for Disease Control and Prevention does not stop our feelings of guilt. The longer this pandemic goes on, the more likely it is that these situations will begin to take a toll on us.
For most of us, being exposed to moral injuries is new; they have historically been most associated with severe traumatic wartime experiences. Soldiers, philosophers, and writers have described the ethical dilemmas inherent in war for as long as recorded history. But the use of this term is a more recent development, which the Moral Injury Project at Syracuse (N.Y.) University describes as probably originating in the Vietnam War–era writings of veteran and peace activist Camillo “Mac” Bica and psychiatrist Jonathan Shay. Examples of wartime events that have been thought to lead to moral injury include: causing the harm or death of civilians, knowingly but without alternatives, or accidentally; failing to provide medical aid to an injured civilian or service member; and following orders that were illegal, immoral, and/or against the rules of engagement or the Geneva Conventions.
However, the occurrence of moral injuries in modern health care is increasingly being reported, primarily as an adverse effect of health care inefficiencies that can contribute to burnout. COVID-19 has now provided an array of additional stressors that can cause moral injuries among health care workers. A recent guidance document on moral injury published by the American Psychiatric Association noted that, in the context of a public health disaster, such as COVID-19, it is sometimes necessary to transition from ordinary standards of care to those more appropriate in a crisis, as in wartime. This forces us all to confront challenging questions for which there may be no clear answers, and to make “lose-lose” choices in which no one involved – patients, family, or clinicians – ends up feeling satisfied or even comfortable.
Our lives have been altered significantly, and for many, completely turned upside down by enormous sacrifices and tragic losses. Globally, physicians account for over half of healthcare worker deaths. In the United States alone, over 900 health care workers have died of COVID-19.
Most of us have felt the symptoms of moral injury: frustration, anger, disgust, guilt. A recent report describes three levels of stressors in health care occurring during the pandemic, which are not dissimilar to those wartime events described previously.
- Severe moral stressors, such as the denial of treatment to a COVID-19 patient owing to lack of resources, the inability to provide optimal care to non–COVID-19 patients for many reasons, and concern about passing COVID to loved ones.
- Moderate moral stressors, such as preventing visitors, especially to dying patients, triaging patients for healthcare services with inadequate information, and trying to solve the tension between the need for self-preservation and the need to treat.
- Lower-level but common moral challenges, especially in the community – for example, seeing others not protecting the community by hoarding food, gathering for large parties, and not social distancing or wearing masks. Such stressors lead to frustration and contempt, especially from healthcare workers making personal sacrifices and who may be at risk for infection caused by these behaviors.
Every one of us is affected by these stressors. I certainly am.
What are the outcomes? We know that moral injuries are a risk factor for the development of mental health problems and burnout, and not surprisingly we are seeing that mental health problems, suicidality, and substance use disorders have increased markedly during COVID-19, as recently detailed by the CDC.
Common emotions that occur in response to moral injuries are: feelings of guilt, shame, anger, sadness, anxiety, and disgust; intrapersonal outcomes, including lowered self-esteem, high self-criticism, and beliefs about being bad, damaged, unworthy, failing, or weak; interpersonal outcomes, including loss of faith in people, avoidance of intimacy, and lack of trust in authority figures; and existential and spiritual outcomes, including loss of faith in previous religious beliefs and no longer believing in a just world.
Moral injuries tend to originate primarily from systems-based problems, as we have seen with the lack of concerted national approaches to the pandemic. On the positive side, solutions typically also involve systems-based changes, which in this case may mean changes in leadership styles nationally and locally, as well as changes in the culture of medicine and the way healthcare is practiced and managed in the modern era. We are starting to see some of those changes with the increased use of telemedicine and health technologies, as well as more of a focus on the well-being of health care workers, now deemed “essential.”
As individuals, we are not helpless. There are things we can do in our workplaces to create change. I suggest:
- Acknowledge that you, like me, are affected by these stressors. This is not a secret, and you should not be ashamed of your feelings.
- Talk with your colleagues, loved ones, and friends about how you and they are affected. You are not alone. Encourage others to share their thoughts, stories, and feelings.
- Put this topic on your meeting and departmental agendas and discuss these moral issues openly with your colleagues. Allow sufficient time to engage in open dialogue.
- Work out ways of assisting those who are in high-risk situations, especially for moderate to severe injuries. Be supportive toward those affected.
- Modify policies and change rosters and rotate staff between high- and low-stress roles. Protect and support at-risk colleagues.
- Think about difficult ethical decisions in advance so they can be made by groups, not individuals, and certainly not “on the fly.”
- Keep everyone in your workplace constantly informed, especially of impending staff or equipment shortages.
- Maintain your inherent self-care and resilience with rest, good nutrition, sleep, exercise, love, caring, socialization, and work-life balance.
- Be prepared to access the many professional support services available in our community if you are intensely distressed or if the above suggestions are not enough.
Remember, we are in this together and will find strength in each other. This too will pass.
This article first appeared on Medscape.com.
Among the many tolls inflicted on health care workers by COVID-19 is one that is not as easily measured as rates of death or disease, but is no less tangible: moral injury. This is the term by which we describe the psychological, social, and spiritual impact of high-stakes situations that lead to the betrayal or transgression of our own deeply held moral beliefs and values.
The current pandemic has provided innumerable such situations that can increase the risk for moral injury, whether we deal directly with patients infected by the coronavirus or not. Telling family members they cannot visit critically ill loved ones. Delaying code activities, even momentarily, to get fully protected with personal protective equipment. Seeing patients who have delayed their necessary or preventive care. Using video rather than touch to reassure people.
Knowing that we are following guidelines from the Centers for Disease Control and Prevention does not stop our feelings of guilt. The longer this pandemic goes on, the more likely it is that these situations will begin to take a toll on us.
For most of us, being exposed to moral injuries is new; they have historically been most associated with severe traumatic wartime experiences. Soldiers, philosophers, and writers have described the ethical dilemmas inherent in war for as long as recorded history. But the use of this term is a more recent development, which the Moral Injury Project at Syracuse (N.Y.) University describes as probably originating in the Vietnam War–era writings of veteran and peace activist Camillo “Mac” Bica and psychiatrist Jonathan Shay. Examples of wartime events that have been thought to lead to moral injury include: causing the harm or death of civilians, knowingly but without alternatives, or accidentally; failing to provide medical aid to an injured civilian or service member; and following orders that were illegal, immoral, and/or against the rules of engagement or the Geneva Conventions.
However, the occurrence of moral injuries in modern health care is increasingly being reported, primarily as an adverse effect of health care inefficiencies that can contribute to burnout. COVID-19 has now provided an array of additional stressors that can cause moral injuries among health care workers. A recent guidance document on moral injury published by the American Psychiatric Association noted that, in the context of a public health disaster, such as COVID-19, it is sometimes necessary to transition from ordinary standards of care to those more appropriate in a crisis, as in wartime. This forces us all to confront challenging questions for which there may be no clear answers, and to make “lose-lose” choices in which no one involved – patients, family, or clinicians – ends up feeling satisfied or even comfortable.
Our lives have been altered significantly, and for many, completely turned upside down by enormous sacrifices and tragic losses. Globally, physicians account for over half of healthcare worker deaths. In the United States alone, over 900 health care workers have died of COVID-19.
Most of us have felt the symptoms of moral injury: frustration, anger, disgust, guilt. A recent report describes three levels of stressors in health care occurring during the pandemic, which are not dissimilar to those wartime events described previously.
- Severe moral stressors, such as the denial of treatment to a COVID-19 patient owing to lack of resources, the inability to provide optimal care to non–COVID-19 patients for many reasons, and concern about passing COVID to loved ones.
- Moderate moral stressors, such as preventing visitors, especially to dying patients, triaging patients for healthcare services with inadequate information, and trying to solve the tension between the need for self-preservation and the need to treat.
- Lower-level but common moral challenges, especially in the community – for example, seeing others not protecting the community by hoarding food, gathering for large parties, and not social distancing or wearing masks. Such stressors lead to frustration and contempt, especially from healthcare workers making personal sacrifices and who may be at risk for infection caused by these behaviors.
Every one of us is affected by these stressors. I certainly am.
What are the outcomes? We know that moral injuries are a risk factor for the development of mental health problems and burnout, and not surprisingly we are seeing that mental health problems, suicidality, and substance use disorders have increased markedly during COVID-19, as recently detailed by the CDC.
Common emotions that occur in response to moral injuries are: feelings of guilt, shame, anger, sadness, anxiety, and disgust; intrapersonal outcomes, including lowered self-esteem, high self-criticism, and beliefs about being bad, damaged, unworthy, failing, or weak; interpersonal outcomes, including loss of faith in people, avoidance of intimacy, and lack of trust in authority figures; and existential and spiritual outcomes, including loss of faith in previous religious beliefs and no longer believing in a just world.
Moral injuries tend to originate primarily from systems-based problems, as we have seen with the lack of concerted national approaches to the pandemic. On the positive side, solutions typically also involve systems-based changes, which in this case may mean changes in leadership styles nationally and locally, as well as changes in the culture of medicine and the way healthcare is practiced and managed in the modern era. We are starting to see some of those changes with the increased use of telemedicine and health technologies, as well as more of a focus on the well-being of health care workers, now deemed “essential.”
As individuals, we are not helpless. There are things we can do in our workplaces to create change. I suggest:
- Acknowledge that you, like me, are affected by these stressors. This is not a secret, and you should not be ashamed of your feelings.
- Talk with your colleagues, loved ones, and friends about how you and they are affected. You are not alone. Encourage others to share their thoughts, stories, and feelings.
- Put this topic on your meeting and departmental agendas and discuss these moral issues openly with your colleagues. Allow sufficient time to engage in open dialogue.
- Work out ways of assisting those who are in high-risk situations, especially for moderate to severe injuries. Be supportive toward those affected.
- Modify policies and change rosters and rotate staff between high- and low-stress roles. Protect and support at-risk colleagues.
- Think about difficult ethical decisions in advance so they can be made by groups, not individuals, and certainly not “on the fly.”
- Keep everyone in your workplace constantly informed, especially of impending staff or equipment shortages.
- Maintain your inherent self-care and resilience with rest, good nutrition, sleep, exercise, love, caring, socialization, and work-life balance.
- Be prepared to access the many professional support services available in our community if you are intensely distressed or if the above suggestions are not enough.
Remember, we are in this together and will find strength in each other. This too will pass.
This article first appeared on Medscape.com.
Among the many tolls inflicted on health care workers by COVID-19 is one that is not as easily measured as rates of death or disease, but is no less tangible: moral injury. This is the term by which we describe the psychological, social, and spiritual impact of high-stakes situations that lead to the betrayal or transgression of our own deeply held moral beliefs and values.
The current pandemic has provided innumerable such situations that can increase the risk for moral injury, whether we deal directly with patients infected by the coronavirus or not. Telling family members they cannot visit critically ill loved ones. Delaying code activities, even momentarily, to get fully protected with personal protective equipment. Seeing patients who have delayed their necessary or preventive care. Using video rather than touch to reassure people.
Knowing that we are following guidelines from the Centers for Disease Control and Prevention does not stop our feelings of guilt. The longer this pandemic goes on, the more likely it is that these situations will begin to take a toll on us.
For most of us, being exposed to moral injuries is new; they have historically been most associated with severe traumatic wartime experiences. Soldiers, philosophers, and writers have described the ethical dilemmas inherent in war for as long as recorded history. But the use of this term is a more recent development, which the Moral Injury Project at Syracuse (N.Y.) University describes as probably originating in the Vietnam War–era writings of veteran and peace activist Camillo “Mac” Bica and psychiatrist Jonathan Shay. Examples of wartime events that have been thought to lead to moral injury include: causing the harm or death of civilians, knowingly but without alternatives, or accidentally; failing to provide medical aid to an injured civilian or service member; and following orders that were illegal, immoral, and/or against the rules of engagement or the Geneva Conventions.
However, the occurrence of moral injuries in modern health care is increasingly being reported, primarily as an adverse effect of health care inefficiencies that can contribute to burnout. COVID-19 has now provided an array of additional stressors that can cause moral injuries among health care workers. A recent guidance document on moral injury published by the American Psychiatric Association noted that, in the context of a public health disaster, such as COVID-19, it is sometimes necessary to transition from ordinary standards of care to those more appropriate in a crisis, as in wartime. This forces us all to confront challenging questions for which there may be no clear answers, and to make “lose-lose” choices in which no one involved – patients, family, or clinicians – ends up feeling satisfied or even comfortable.
Our lives have been altered significantly, and for many, completely turned upside down by enormous sacrifices and tragic losses. Globally, physicians account for over half of healthcare worker deaths. In the United States alone, over 900 health care workers have died of COVID-19.
Most of us have felt the symptoms of moral injury: frustration, anger, disgust, guilt. A recent report describes three levels of stressors in health care occurring during the pandemic, which are not dissimilar to those wartime events described previously.
- Severe moral stressors, such as the denial of treatment to a COVID-19 patient owing to lack of resources, the inability to provide optimal care to non–COVID-19 patients for many reasons, and concern about passing COVID to loved ones.
- Moderate moral stressors, such as preventing visitors, especially to dying patients, triaging patients for healthcare services with inadequate information, and trying to solve the tension between the need for self-preservation and the need to treat.
- Lower-level but common moral challenges, especially in the community – for example, seeing others not protecting the community by hoarding food, gathering for large parties, and not social distancing or wearing masks. Such stressors lead to frustration and contempt, especially from healthcare workers making personal sacrifices and who may be at risk for infection caused by these behaviors.
Every one of us is affected by these stressors. I certainly am.
What are the outcomes? We know that moral injuries are a risk factor for the development of mental health problems and burnout, and not surprisingly we are seeing that mental health problems, suicidality, and substance use disorders have increased markedly during COVID-19, as recently detailed by the CDC.
Common emotions that occur in response to moral injuries are: feelings of guilt, shame, anger, sadness, anxiety, and disgust; intrapersonal outcomes, including lowered self-esteem, high self-criticism, and beliefs about being bad, damaged, unworthy, failing, or weak; interpersonal outcomes, including loss of faith in people, avoidance of intimacy, and lack of trust in authority figures; and existential and spiritual outcomes, including loss of faith in previous religious beliefs and no longer believing in a just world.
Moral injuries tend to originate primarily from systems-based problems, as we have seen with the lack of concerted national approaches to the pandemic. On the positive side, solutions typically also involve systems-based changes, which in this case may mean changes in leadership styles nationally and locally, as well as changes in the culture of medicine and the way healthcare is practiced and managed in the modern era. We are starting to see some of those changes with the increased use of telemedicine and health technologies, as well as more of a focus on the well-being of health care workers, now deemed “essential.”
As individuals, we are not helpless. There are things we can do in our workplaces to create change. I suggest:
- Acknowledge that you, like me, are affected by these stressors. This is not a secret, and you should not be ashamed of your feelings.
- Talk with your colleagues, loved ones, and friends about how you and they are affected. You are not alone. Encourage others to share their thoughts, stories, and feelings.
- Put this topic on your meeting and departmental agendas and discuss these moral issues openly with your colleagues. Allow sufficient time to engage in open dialogue.
- Work out ways of assisting those who are in high-risk situations, especially for moderate to severe injuries. Be supportive toward those affected.
- Modify policies and change rosters and rotate staff between high- and low-stress roles. Protect and support at-risk colleagues.
- Think about difficult ethical decisions in advance so they can be made by groups, not individuals, and certainly not “on the fly.”
- Keep everyone in your workplace constantly informed, especially of impending staff or equipment shortages.
- Maintain your inherent self-care and resilience with rest, good nutrition, sleep, exercise, love, caring, socialization, and work-life balance.
- Be prepared to access the many professional support services available in our community if you are intensely distressed or if the above suggestions are not enough.
Remember, we are in this together and will find strength in each other. This too will pass.
This article first appeared on Medscape.com.