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Visualization tool aids migraine management
The tool is still in the prototype stage, but it could eventually synthesize patient responses to an integrated questionnaire and produce a chart illustrating where the patient stands with respect to a range of modifiable risk factors, including depression, medication overuse, insomnia, and body mass index, among others.
A few such tools exist for other conditions, such as stroke and risk of developing chronic diseases. Existing migraine visualization models focus only on individual risk factors, but they are capable of much more. “Visualization tools can effectively communicate a huge amount of clinical information,” said lead author Ami Cuneo, MD, who is a headache fellow at the University of Washington, Seattle, in an interview. Dr. Cuneo presented a poster describing the concept at the virtual annual meeting of the American Headache Society.
A picture is worth a thousand words
Dr. Cuneo’s background is well suited to the effort: Before entering medicine, she was a documentary producer. “I have a lot of interest in the patient story and history,” she added. She also believes that the tool could improve patient-provider relationships. In rushed sessions, patients may not feel heard. Patients gain a therapeutic benefit from the belief that their provider is listening to them and listening to their story. Visualization tools could promote that if the provider can quickly identify key elements of the patient’s condition. “A lot of headache patients can have a complex picture,” said Dr. Cuneo.
Physicians must see patients in short appointment periods, making it difficult to communicate all of the risk factors and behavioral characteristics that can contribute to risk of progression. “If you have a patient and you’re able to look at a visualization tool quickly and say: ‘Okay, my patient really is having insomnia and sleep issues,’ you can focus the session talking about sleep, cognitive-behavioral therapy for insomnia, and all the things we can help patients with,” said Dr. Cuneo.
The prototype visualization tool uses a color-coded wheel divided into pie slices, each representing a clinical characteristic or modifiable risk factor. In the proposed tool presented in the poster, these included depression, anxiety, functional disability, insomnia, nausea, headache frequency, medication overuse, optimization of abortive medication use, nontherapeutic diet, limited exercise, and body mass index range. The circle also contains colored concentric circles, ranging from red to green, and a small filled circle represents the patient’s status in each category as ranked using the integrated questionnaire. A line connects the circles in each pie, revealing the patient’s overall status.
The visual cue allows both the physician and patient to quickly assess these factors and see them in relationship to one another. Verbally communicating each factor is time consuming and harder for the patient to take in, according to Dr. Cuneo. “The provider can just look at it and see the areas to focus questions on to try to improve care. So it’s a way I’m hopeful that we can help target visits and improve patient-provider communication without extending visit time.”
A key challenge for the project will be choosing and consolidating scales so that the patient isn’t burdened with too many questions in advance of the appointment. The team will draw from existing scales and then create their own and validate it. “The questions will have to be vetted with patients through focus groups, and then the software platform [will have to be developed] so that patients can complete the survey online. Then we have to test it to see if providers and patients feel this is something that’s helpful in the clinical practice,” said Dr. Cuneo.
Will it change behavior?
If successful, the tool would be a welcome addition, according to Andrew Charles, MD, who was asked to comment on the work. “Epidemiological studies have identified these risk factors, but we haven’t had a way of operationalizing a strategy to reduce them systematically, so having some sort of tool that visualizes not just one but multiple risk factors is something I think could be helpful to address those factors more aggressively. The real question would be, if you put it in the hands of practitioners and patients, will they really be able to easily implement it and will it change behavior,” said Dr. Charles, who is a professor of neurology and director of the Goldberg Migraine Program at the University of California, Los Angeles.
The study received no funding. Dr. Cuneo and Dr. Charles have no relevant financial disclosures.
SOURCE; Cuneo A et al. AHS 2020, Abstract 273715.
The tool is still in the prototype stage, but it could eventually synthesize patient responses to an integrated questionnaire and produce a chart illustrating where the patient stands with respect to a range of modifiable risk factors, including depression, medication overuse, insomnia, and body mass index, among others.
A few such tools exist for other conditions, such as stroke and risk of developing chronic diseases. Existing migraine visualization models focus only on individual risk factors, but they are capable of much more. “Visualization tools can effectively communicate a huge amount of clinical information,” said lead author Ami Cuneo, MD, who is a headache fellow at the University of Washington, Seattle, in an interview. Dr. Cuneo presented a poster describing the concept at the virtual annual meeting of the American Headache Society.
A picture is worth a thousand words
Dr. Cuneo’s background is well suited to the effort: Before entering medicine, she was a documentary producer. “I have a lot of interest in the patient story and history,” she added. She also believes that the tool could improve patient-provider relationships. In rushed sessions, patients may not feel heard. Patients gain a therapeutic benefit from the belief that their provider is listening to them and listening to their story. Visualization tools could promote that if the provider can quickly identify key elements of the patient’s condition. “A lot of headache patients can have a complex picture,” said Dr. Cuneo.
Physicians must see patients in short appointment periods, making it difficult to communicate all of the risk factors and behavioral characteristics that can contribute to risk of progression. “If you have a patient and you’re able to look at a visualization tool quickly and say: ‘Okay, my patient really is having insomnia and sleep issues,’ you can focus the session talking about sleep, cognitive-behavioral therapy for insomnia, and all the things we can help patients with,” said Dr. Cuneo.
The prototype visualization tool uses a color-coded wheel divided into pie slices, each representing a clinical characteristic or modifiable risk factor. In the proposed tool presented in the poster, these included depression, anxiety, functional disability, insomnia, nausea, headache frequency, medication overuse, optimization of abortive medication use, nontherapeutic diet, limited exercise, and body mass index range. The circle also contains colored concentric circles, ranging from red to green, and a small filled circle represents the patient’s status in each category as ranked using the integrated questionnaire. A line connects the circles in each pie, revealing the patient’s overall status.
The visual cue allows both the physician and patient to quickly assess these factors and see them in relationship to one another. Verbally communicating each factor is time consuming and harder for the patient to take in, according to Dr. Cuneo. “The provider can just look at it and see the areas to focus questions on to try to improve care. So it’s a way I’m hopeful that we can help target visits and improve patient-provider communication without extending visit time.”
A key challenge for the project will be choosing and consolidating scales so that the patient isn’t burdened with too many questions in advance of the appointment. The team will draw from existing scales and then create their own and validate it. “The questions will have to be vetted with patients through focus groups, and then the software platform [will have to be developed] so that patients can complete the survey online. Then we have to test it to see if providers and patients feel this is something that’s helpful in the clinical practice,” said Dr. Cuneo.
Will it change behavior?
If successful, the tool would be a welcome addition, according to Andrew Charles, MD, who was asked to comment on the work. “Epidemiological studies have identified these risk factors, but we haven’t had a way of operationalizing a strategy to reduce them systematically, so having some sort of tool that visualizes not just one but multiple risk factors is something I think could be helpful to address those factors more aggressively. The real question would be, if you put it in the hands of practitioners and patients, will they really be able to easily implement it and will it change behavior,” said Dr. Charles, who is a professor of neurology and director of the Goldberg Migraine Program at the University of California, Los Angeles.
The study received no funding. Dr. Cuneo and Dr. Charles have no relevant financial disclosures.
SOURCE; Cuneo A et al. AHS 2020, Abstract 273715.
The tool is still in the prototype stage, but it could eventually synthesize patient responses to an integrated questionnaire and produce a chart illustrating where the patient stands with respect to a range of modifiable risk factors, including depression, medication overuse, insomnia, and body mass index, among others.
A few such tools exist for other conditions, such as stroke and risk of developing chronic diseases. Existing migraine visualization models focus only on individual risk factors, but they are capable of much more. “Visualization tools can effectively communicate a huge amount of clinical information,” said lead author Ami Cuneo, MD, who is a headache fellow at the University of Washington, Seattle, in an interview. Dr. Cuneo presented a poster describing the concept at the virtual annual meeting of the American Headache Society.
A picture is worth a thousand words
Dr. Cuneo’s background is well suited to the effort: Before entering medicine, she was a documentary producer. “I have a lot of interest in the patient story and history,” she added. She also believes that the tool could improve patient-provider relationships. In rushed sessions, patients may not feel heard. Patients gain a therapeutic benefit from the belief that their provider is listening to them and listening to their story. Visualization tools could promote that if the provider can quickly identify key elements of the patient’s condition. “A lot of headache patients can have a complex picture,” said Dr. Cuneo.
Physicians must see patients in short appointment periods, making it difficult to communicate all of the risk factors and behavioral characteristics that can contribute to risk of progression. “If you have a patient and you’re able to look at a visualization tool quickly and say: ‘Okay, my patient really is having insomnia and sleep issues,’ you can focus the session talking about sleep, cognitive-behavioral therapy for insomnia, and all the things we can help patients with,” said Dr. Cuneo.
The prototype visualization tool uses a color-coded wheel divided into pie slices, each representing a clinical characteristic or modifiable risk factor. In the proposed tool presented in the poster, these included depression, anxiety, functional disability, insomnia, nausea, headache frequency, medication overuse, optimization of abortive medication use, nontherapeutic diet, limited exercise, and body mass index range. The circle also contains colored concentric circles, ranging from red to green, and a small filled circle represents the patient’s status in each category as ranked using the integrated questionnaire. A line connects the circles in each pie, revealing the patient’s overall status.
The visual cue allows both the physician and patient to quickly assess these factors and see them in relationship to one another. Verbally communicating each factor is time consuming and harder for the patient to take in, according to Dr. Cuneo. “The provider can just look at it and see the areas to focus questions on to try to improve care. So it’s a way I’m hopeful that we can help target visits and improve patient-provider communication without extending visit time.”
A key challenge for the project will be choosing and consolidating scales so that the patient isn’t burdened with too many questions in advance of the appointment. The team will draw from existing scales and then create their own and validate it. “The questions will have to be vetted with patients through focus groups, and then the software platform [will have to be developed] so that patients can complete the survey online. Then we have to test it to see if providers and patients feel this is something that’s helpful in the clinical practice,” said Dr. Cuneo.
Will it change behavior?
If successful, the tool would be a welcome addition, according to Andrew Charles, MD, who was asked to comment on the work. “Epidemiological studies have identified these risk factors, but we haven’t had a way of operationalizing a strategy to reduce them systematically, so having some sort of tool that visualizes not just one but multiple risk factors is something I think could be helpful to address those factors more aggressively. The real question would be, if you put it in the hands of practitioners and patients, will they really be able to easily implement it and will it change behavior,” said Dr. Charles, who is a professor of neurology and director of the Goldberg Migraine Program at the University of California, Los Angeles.
The study received no funding. Dr. Cuneo and Dr. Charles have no relevant financial disclosures.
SOURCE; Cuneo A et al. AHS 2020, Abstract 273715.
FROM AHS 2020
Manage the pandemic with a multidisciplinary coalition
Implement a 6-P framework
The ongoing COVID-19 pandemic, arguably the biggest public health and economic catastrophe of modern times, elevated multiple deficiencies in public health infrastructures across the world, such as a slow or delayed response to suppress and mitigate the virus, an inadequately prepared and protected health care and public health workforce, and decentralized, siloed efforts.1 COVID-19 further highlighted the vulnerabilities of the health care, public health, and economic sectors.2,3 Irrespective of how robust health care systems may have been initially, rapidly spreading and deadly infectious diseases like COVID-19 can quickly derail the system, bringing the workforce and the patients they serve to a breaking point.
Hospital systems in the United States are not only at the crux of the current pandemic but are also well positioned to lead the response to the pandemic. Hospital administrators oversee nearly 33% of national health expenditure that amounts to the hospital-based care in the United States. Additionally, they may have an impact on nearly 30% of the expenditure that is related to physicians, prescriptions, and other facilities.4
The two primary goals underlying our proposed framework to target COVID-19 are based on the World Health Organization recommendations and lessons learned from countries such as South Korea that have successfully implemented these recommendations.5
1. Flatten the curve. According to the WHO and the Centers for Disease Control and Prevention, flattening the curve means that we must do everything that will help us to slow down the rate of infection, so the number of cases do not exceed the capacity of health systems.
2. Establish a standardized, interdisciplinary approach to flattening the curve. Pandemics can have major adverse consequences beyond health outcomes (e.g., economy) that can impact adherence to advisories and introduce multiple unintended consequences (e.g., deferred chronic care, unemployment). Managing the current pandemic and thoughtful consideration of and action regarding its ripple effects is heavily dependent on a standardized, interdisciplinary approach that is monitored, implemented, and evaluated well.
To achieve these two goals, we recommend establishing an interdisciplinary coalition representing multiple sectors. Our 6-P framework described below is intended to guide hospital administrators, to build the coalition, and to achieve these goals.
Structure of the pandemic coalition
A successful coalition invites a collaborative partnership involving senior members of respective disciplines, who would provide valuable, complementary perspectives in the coalition. We recommend hospital administrators take a lead in the formation of such a coalition. While we present the stakeholders and their roles below based on their intended influence and impact on the overall outcome of COVID-19, the basic guiding principles behind our 6-P framework remain true for any large-scale population health intervention.
Although several models for staging the transmission of COVID-19 are available, we adopted a four-stage model followed by the Indian Council for Medical Research.6 Irrespective of the origin of the infection, we believe that the four-stage model can cultivate situational awareness that can help guide the strategic design and systematic implementation of interventions.
Our 6-P framework integrates the four-stage model of COVID-19 transmission to identify action items for each stakeholder group and appropriate strategies selected based on the stages targeted.
1. Policy makers: Policy makers at all levels are critical in establishing policies, orders, and advisories, as well as dedicating resources and infrastructure, to enhance adherence to recommendations and guidelines at the community and population levels.7 They can assist hospitals in workforce expansion across county/state/discipline lines (e.g., accelerate the licensing and credentialing process, authorize graduate medical trainees, nurse practitioners, and other allied health professionals). Policy revisions for data sharing, privacy, communication, liability, and telehealth expansion.82. Providers: The health of the health care workforce itself is at risk because of their frontline services. Their buy-in will be crucial in both the formulation and implementation of evidence- and practice-based guidelines.9 Rapid adoption of telehealth for care continuum, policy revisions for elective procedures, visitor restriction, surge, resurge planning, capacity expansion, effective population health management, and working with employee unions, professional staff organizations are few, but very important action items that need to be implemented.
3. Public health authorities: Representation of public health authorities will be crucial in standardizing data collection, management, and reporting; providing up-to-date guidelines and advisories; developing, implementing, and evaluating short- and long-term public health interventions; and preparing and helping communities throughout the course of the pandemic. They also play a key role in identifying and reducing barriers related to the expansion of testing and contact tracing efforts.
4. Payers: In the United States, the Centers for Medicare & Medicaid Services oversees primary federally funded programs and serves as a point of reference for the American health care system. Having representation from all payer sources is crucial for achieving uniformity and standardization of the care process during the pandemic, with particular priority given to individuals and families who may have recently lost their health insurance because of job loss from COVID-19–related business furloughs, layoffs, and closures. Customer outreach initiatives, revision of patients’ out of pocket responsibilities, rapid claim settlement and denial management services, expansion of telehealth, elimination of prior authorization barriers, rapid credentialing of providers, data sharing, and assisting hospital systems in chronic disease management are examples of time-sensitive initiatives that are vital for population health management.
5. Partners: Establishing partnerships with pharma, health IT, labs, device industries, and other ancillary services is important to facilitate rapid innovation, production, and supply of essential medical devices and resources. These partners directly influence the outcomes of the pandemic and long-term health of the society through expansion of testing capability, contact tracing, leveraging technology for expanding access to COVID-19 and non–COVID-19 care, home monitoring of cases, innovation of treatment and prevention, and data sharing. Partners should consider options such as flexible medication delivery, electronic prescription services, and use of drones in supply chain to deliver test kits, test samples, medication, and blood products.
6. People/patients: Lastly and perhaps most critically, the trust, buy-in, and needs of the overall population are needed to enhance adherence to guidelines and recommendations. Many millions more than those who test positive for COVID-19 have and will continue to experience the crippling adverse economic, social, physical, and mental health effects of stay-at-home advisories, business and school closures, and physical distancing orders. Members of each community need to be heard in voicing their concerns and priorities and providing input on public health interventions to enhance acceptance and adherence (e.g., wear mask/face coverings in public, engage in physical distancing, etc.). Special attention should be given to managing chronic or existing medical problems and seek care when needed (e.g., avoid delaying of medical care).
An interdisciplinary and multipronged approach is necessary to address a complex, widespread, disruptive, and deadly pandemic such as COVID-19. The suggested activities put forth in our table are by no means exhaustive, nor do we expect all coalitions to be able to carry them all out. Our intention is that the 6-P framework encourages cross-sector collaboration to facilitate the design, implementation, evaluation, and scalability of preventive and intervention efforts based on the menu of items we have provided. Each coalition may determine which strategies they are able to prioritize and when within the context of specific national, regional, and local advisories, resulting in a tailored approach for each community or region that is thus better positioned for success.
Dr. Lingisetty is a hospitalist and physician executive at Baptist Health System, Little Rock, Ark. He is cofounder/president of SHM’s Arkansas chapter. Dr. Wang is assistant professor in the department of community health sciences at Boston University and adjunct assistant professor of health policy and management at the Harvard School of Public Health. Dr. Palabindala is the medical director, utilization management and physician advisory services, at the University of Mississippi Medical Center, Jackson. He is an associate professor of medicine and academic hospitalist at the University of Mississippi.
References
1. Powles J, Comim F. Public health infrastructure and knowledge, in Smith R et al. “Global Public Goods for Health.” Oxford: Oxford University Press, 2003.
2. Lombardi P, Petroni G. Virus outbreak pushes Italy’s health care system to the brink. Wall Street Journal. 2020 Mar 12. https://www.wsj.com/articles/virus-outbreak-pushes-italys-healthcare-system-to-the-brink-11583968769
3. Davies, R. How coronavirus is affecting the global economy. The Guardian. 2020 Feb 5. https://www.theguardian.com/world/2020/feb/05/coronavirus-global-economy
4. National Center for Health Statistics. FastStats. 2017. https://www.cdc.gov/nchs/fastats/health-expenditures.htm.
5. World Health Organization. Country & Technical Guidance–Coronavirus disease (COVID-19). https://www.who.int/emergencies/diseases/novel-coronavirus-2019/technical-guidance
6. Indian Council of Medical Research. Stages of transmission of COVID-19. https://main.icmr.nic.in/content/covid-19
7. Centers for Disease Control and Prevention. Coronavirus disease 2019 (COVID-19) – Prevention & treatment. 2020 Apr 24. https://www.cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/prevention.html
8. Ostriker R. Cutbacks for some doctors and nurses as they battle on the front line. Boston Globe. 2020 Mar 27. https://www.bostonglobe.com/2020/03/27/metro/coronavirus-rages-doctors-hit-with-cuts-compensation/
9. Centers for Medicare & Medicaid Services. News alert. 2020 Mar 26. https://www.cms.gov/newsroom/press-releases/cms-news-alert-march-26-2020
Implement a 6-P framework
Implement a 6-P framework
The ongoing COVID-19 pandemic, arguably the biggest public health and economic catastrophe of modern times, elevated multiple deficiencies in public health infrastructures across the world, such as a slow or delayed response to suppress and mitigate the virus, an inadequately prepared and protected health care and public health workforce, and decentralized, siloed efforts.1 COVID-19 further highlighted the vulnerabilities of the health care, public health, and economic sectors.2,3 Irrespective of how robust health care systems may have been initially, rapidly spreading and deadly infectious diseases like COVID-19 can quickly derail the system, bringing the workforce and the patients they serve to a breaking point.
Hospital systems in the United States are not only at the crux of the current pandemic but are also well positioned to lead the response to the pandemic. Hospital administrators oversee nearly 33% of national health expenditure that amounts to the hospital-based care in the United States. Additionally, they may have an impact on nearly 30% of the expenditure that is related to physicians, prescriptions, and other facilities.4
The two primary goals underlying our proposed framework to target COVID-19 are based on the World Health Organization recommendations and lessons learned from countries such as South Korea that have successfully implemented these recommendations.5
1. Flatten the curve. According to the WHO and the Centers for Disease Control and Prevention, flattening the curve means that we must do everything that will help us to slow down the rate of infection, so the number of cases do not exceed the capacity of health systems.
2. Establish a standardized, interdisciplinary approach to flattening the curve. Pandemics can have major adverse consequences beyond health outcomes (e.g., economy) that can impact adherence to advisories and introduce multiple unintended consequences (e.g., deferred chronic care, unemployment). Managing the current pandemic and thoughtful consideration of and action regarding its ripple effects is heavily dependent on a standardized, interdisciplinary approach that is monitored, implemented, and evaluated well.
To achieve these two goals, we recommend establishing an interdisciplinary coalition representing multiple sectors. Our 6-P framework described below is intended to guide hospital administrators, to build the coalition, and to achieve these goals.
Structure of the pandemic coalition
A successful coalition invites a collaborative partnership involving senior members of respective disciplines, who would provide valuable, complementary perspectives in the coalition. We recommend hospital administrators take a lead in the formation of such a coalition. While we present the stakeholders and their roles below based on their intended influence and impact on the overall outcome of COVID-19, the basic guiding principles behind our 6-P framework remain true for any large-scale population health intervention.
Although several models for staging the transmission of COVID-19 are available, we adopted a four-stage model followed by the Indian Council for Medical Research.6 Irrespective of the origin of the infection, we believe that the four-stage model can cultivate situational awareness that can help guide the strategic design and systematic implementation of interventions.
Our 6-P framework integrates the four-stage model of COVID-19 transmission to identify action items for each stakeholder group and appropriate strategies selected based on the stages targeted.
1. Policy makers: Policy makers at all levels are critical in establishing policies, orders, and advisories, as well as dedicating resources and infrastructure, to enhance adherence to recommendations and guidelines at the community and population levels.7 They can assist hospitals in workforce expansion across county/state/discipline lines (e.g., accelerate the licensing and credentialing process, authorize graduate medical trainees, nurse practitioners, and other allied health professionals). Policy revisions for data sharing, privacy, communication, liability, and telehealth expansion.82. Providers: The health of the health care workforce itself is at risk because of their frontline services. Their buy-in will be crucial in both the formulation and implementation of evidence- and practice-based guidelines.9 Rapid adoption of telehealth for care continuum, policy revisions for elective procedures, visitor restriction, surge, resurge planning, capacity expansion, effective population health management, and working with employee unions, professional staff organizations are few, but very important action items that need to be implemented.
3. Public health authorities: Representation of public health authorities will be crucial in standardizing data collection, management, and reporting; providing up-to-date guidelines and advisories; developing, implementing, and evaluating short- and long-term public health interventions; and preparing and helping communities throughout the course of the pandemic. They also play a key role in identifying and reducing barriers related to the expansion of testing and contact tracing efforts.
4. Payers: In the United States, the Centers for Medicare & Medicaid Services oversees primary federally funded programs and serves as a point of reference for the American health care system. Having representation from all payer sources is crucial for achieving uniformity and standardization of the care process during the pandemic, with particular priority given to individuals and families who may have recently lost their health insurance because of job loss from COVID-19–related business furloughs, layoffs, and closures. Customer outreach initiatives, revision of patients’ out of pocket responsibilities, rapid claim settlement and denial management services, expansion of telehealth, elimination of prior authorization barriers, rapid credentialing of providers, data sharing, and assisting hospital systems in chronic disease management are examples of time-sensitive initiatives that are vital for population health management.
5. Partners: Establishing partnerships with pharma, health IT, labs, device industries, and other ancillary services is important to facilitate rapid innovation, production, and supply of essential medical devices and resources. These partners directly influence the outcomes of the pandemic and long-term health of the society through expansion of testing capability, contact tracing, leveraging technology for expanding access to COVID-19 and non–COVID-19 care, home monitoring of cases, innovation of treatment and prevention, and data sharing. Partners should consider options such as flexible medication delivery, electronic prescription services, and use of drones in supply chain to deliver test kits, test samples, medication, and blood products.
6. People/patients: Lastly and perhaps most critically, the trust, buy-in, and needs of the overall population are needed to enhance adherence to guidelines and recommendations. Many millions more than those who test positive for COVID-19 have and will continue to experience the crippling adverse economic, social, physical, and mental health effects of stay-at-home advisories, business and school closures, and physical distancing orders. Members of each community need to be heard in voicing their concerns and priorities and providing input on public health interventions to enhance acceptance and adherence (e.g., wear mask/face coverings in public, engage in physical distancing, etc.). Special attention should be given to managing chronic or existing medical problems and seek care when needed (e.g., avoid delaying of medical care).
An interdisciplinary and multipronged approach is necessary to address a complex, widespread, disruptive, and deadly pandemic such as COVID-19. The suggested activities put forth in our table are by no means exhaustive, nor do we expect all coalitions to be able to carry them all out. Our intention is that the 6-P framework encourages cross-sector collaboration to facilitate the design, implementation, evaluation, and scalability of preventive and intervention efforts based on the menu of items we have provided. Each coalition may determine which strategies they are able to prioritize and when within the context of specific national, regional, and local advisories, resulting in a tailored approach for each community or region that is thus better positioned for success.
Dr. Lingisetty is a hospitalist and physician executive at Baptist Health System, Little Rock, Ark. He is cofounder/president of SHM’s Arkansas chapter. Dr. Wang is assistant professor in the department of community health sciences at Boston University and adjunct assistant professor of health policy and management at the Harvard School of Public Health. Dr. Palabindala is the medical director, utilization management and physician advisory services, at the University of Mississippi Medical Center, Jackson. He is an associate professor of medicine and academic hospitalist at the University of Mississippi.
References
1. Powles J, Comim F. Public health infrastructure and knowledge, in Smith R et al. “Global Public Goods for Health.” Oxford: Oxford University Press, 2003.
2. Lombardi P, Petroni G. Virus outbreak pushes Italy’s health care system to the brink. Wall Street Journal. 2020 Mar 12. https://www.wsj.com/articles/virus-outbreak-pushes-italys-healthcare-system-to-the-brink-11583968769
3. Davies, R. How coronavirus is affecting the global economy. The Guardian. 2020 Feb 5. https://www.theguardian.com/world/2020/feb/05/coronavirus-global-economy
4. National Center for Health Statistics. FastStats. 2017. https://www.cdc.gov/nchs/fastats/health-expenditures.htm.
5. World Health Organization. Country & Technical Guidance–Coronavirus disease (COVID-19). https://www.who.int/emergencies/diseases/novel-coronavirus-2019/technical-guidance
6. Indian Council of Medical Research. Stages of transmission of COVID-19. https://main.icmr.nic.in/content/covid-19
7. Centers for Disease Control and Prevention. Coronavirus disease 2019 (COVID-19) – Prevention & treatment. 2020 Apr 24. https://www.cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/prevention.html
8. Ostriker R. Cutbacks for some doctors and nurses as they battle on the front line. Boston Globe. 2020 Mar 27. https://www.bostonglobe.com/2020/03/27/metro/coronavirus-rages-doctors-hit-with-cuts-compensation/
9. Centers for Medicare & Medicaid Services. News alert. 2020 Mar 26. https://www.cms.gov/newsroom/press-releases/cms-news-alert-march-26-2020
The ongoing COVID-19 pandemic, arguably the biggest public health and economic catastrophe of modern times, elevated multiple deficiencies in public health infrastructures across the world, such as a slow or delayed response to suppress and mitigate the virus, an inadequately prepared and protected health care and public health workforce, and decentralized, siloed efforts.1 COVID-19 further highlighted the vulnerabilities of the health care, public health, and economic sectors.2,3 Irrespective of how robust health care systems may have been initially, rapidly spreading and deadly infectious diseases like COVID-19 can quickly derail the system, bringing the workforce and the patients they serve to a breaking point.
Hospital systems in the United States are not only at the crux of the current pandemic but are also well positioned to lead the response to the pandemic. Hospital administrators oversee nearly 33% of national health expenditure that amounts to the hospital-based care in the United States. Additionally, they may have an impact on nearly 30% of the expenditure that is related to physicians, prescriptions, and other facilities.4
The two primary goals underlying our proposed framework to target COVID-19 are based on the World Health Organization recommendations and lessons learned from countries such as South Korea that have successfully implemented these recommendations.5
1. Flatten the curve. According to the WHO and the Centers for Disease Control and Prevention, flattening the curve means that we must do everything that will help us to slow down the rate of infection, so the number of cases do not exceed the capacity of health systems.
2. Establish a standardized, interdisciplinary approach to flattening the curve. Pandemics can have major adverse consequences beyond health outcomes (e.g., economy) that can impact adherence to advisories and introduce multiple unintended consequences (e.g., deferred chronic care, unemployment). Managing the current pandemic and thoughtful consideration of and action regarding its ripple effects is heavily dependent on a standardized, interdisciplinary approach that is monitored, implemented, and evaluated well.
To achieve these two goals, we recommend establishing an interdisciplinary coalition representing multiple sectors. Our 6-P framework described below is intended to guide hospital administrators, to build the coalition, and to achieve these goals.
Structure of the pandemic coalition
A successful coalition invites a collaborative partnership involving senior members of respective disciplines, who would provide valuable, complementary perspectives in the coalition. We recommend hospital administrators take a lead in the formation of such a coalition. While we present the stakeholders and their roles below based on their intended influence and impact on the overall outcome of COVID-19, the basic guiding principles behind our 6-P framework remain true for any large-scale population health intervention.
Although several models for staging the transmission of COVID-19 are available, we adopted a four-stage model followed by the Indian Council for Medical Research.6 Irrespective of the origin of the infection, we believe that the four-stage model can cultivate situational awareness that can help guide the strategic design and systematic implementation of interventions.
Our 6-P framework integrates the four-stage model of COVID-19 transmission to identify action items for each stakeholder group and appropriate strategies selected based on the stages targeted.
1. Policy makers: Policy makers at all levels are critical in establishing policies, orders, and advisories, as well as dedicating resources and infrastructure, to enhance adherence to recommendations and guidelines at the community and population levels.7 They can assist hospitals in workforce expansion across county/state/discipline lines (e.g., accelerate the licensing and credentialing process, authorize graduate medical trainees, nurse practitioners, and other allied health professionals). Policy revisions for data sharing, privacy, communication, liability, and telehealth expansion.82. Providers: The health of the health care workforce itself is at risk because of their frontline services. Their buy-in will be crucial in both the formulation and implementation of evidence- and practice-based guidelines.9 Rapid adoption of telehealth for care continuum, policy revisions for elective procedures, visitor restriction, surge, resurge planning, capacity expansion, effective population health management, and working with employee unions, professional staff organizations are few, but very important action items that need to be implemented.
3. Public health authorities: Representation of public health authorities will be crucial in standardizing data collection, management, and reporting; providing up-to-date guidelines and advisories; developing, implementing, and evaluating short- and long-term public health interventions; and preparing and helping communities throughout the course of the pandemic. They also play a key role in identifying and reducing barriers related to the expansion of testing and contact tracing efforts.
4. Payers: In the United States, the Centers for Medicare & Medicaid Services oversees primary federally funded programs and serves as a point of reference for the American health care system. Having representation from all payer sources is crucial for achieving uniformity and standardization of the care process during the pandemic, with particular priority given to individuals and families who may have recently lost their health insurance because of job loss from COVID-19–related business furloughs, layoffs, and closures. Customer outreach initiatives, revision of patients’ out of pocket responsibilities, rapid claim settlement and denial management services, expansion of telehealth, elimination of prior authorization barriers, rapid credentialing of providers, data sharing, and assisting hospital systems in chronic disease management are examples of time-sensitive initiatives that are vital for population health management.
5. Partners: Establishing partnerships with pharma, health IT, labs, device industries, and other ancillary services is important to facilitate rapid innovation, production, and supply of essential medical devices and resources. These partners directly influence the outcomes of the pandemic and long-term health of the society through expansion of testing capability, contact tracing, leveraging technology for expanding access to COVID-19 and non–COVID-19 care, home monitoring of cases, innovation of treatment and prevention, and data sharing. Partners should consider options such as flexible medication delivery, electronic prescription services, and use of drones in supply chain to deliver test kits, test samples, medication, and blood products.
6. People/patients: Lastly and perhaps most critically, the trust, buy-in, and needs of the overall population are needed to enhance adherence to guidelines and recommendations. Many millions more than those who test positive for COVID-19 have and will continue to experience the crippling adverse economic, social, physical, and mental health effects of stay-at-home advisories, business and school closures, and physical distancing orders. Members of each community need to be heard in voicing their concerns and priorities and providing input on public health interventions to enhance acceptance and adherence (e.g., wear mask/face coverings in public, engage in physical distancing, etc.). Special attention should be given to managing chronic or existing medical problems and seek care when needed (e.g., avoid delaying of medical care).
An interdisciplinary and multipronged approach is necessary to address a complex, widespread, disruptive, and deadly pandemic such as COVID-19. The suggested activities put forth in our table are by no means exhaustive, nor do we expect all coalitions to be able to carry them all out. Our intention is that the 6-P framework encourages cross-sector collaboration to facilitate the design, implementation, evaluation, and scalability of preventive and intervention efforts based on the menu of items we have provided. Each coalition may determine which strategies they are able to prioritize and when within the context of specific national, regional, and local advisories, resulting in a tailored approach for each community or region that is thus better positioned for success.
Dr. Lingisetty is a hospitalist and physician executive at Baptist Health System, Little Rock, Ark. He is cofounder/president of SHM’s Arkansas chapter. Dr. Wang is assistant professor in the department of community health sciences at Boston University and adjunct assistant professor of health policy and management at the Harvard School of Public Health. Dr. Palabindala is the medical director, utilization management and physician advisory services, at the University of Mississippi Medical Center, Jackson. He is an associate professor of medicine and academic hospitalist at the University of Mississippi.
References
1. Powles J, Comim F. Public health infrastructure and knowledge, in Smith R et al. “Global Public Goods for Health.” Oxford: Oxford University Press, 2003.
2. Lombardi P, Petroni G. Virus outbreak pushes Italy’s health care system to the brink. Wall Street Journal. 2020 Mar 12. https://www.wsj.com/articles/virus-outbreak-pushes-italys-healthcare-system-to-the-brink-11583968769
3. Davies, R. How coronavirus is affecting the global economy. The Guardian. 2020 Feb 5. https://www.theguardian.com/world/2020/feb/05/coronavirus-global-economy
4. National Center for Health Statistics. FastStats. 2017. https://www.cdc.gov/nchs/fastats/health-expenditures.htm.
5. World Health Organization. Country & Technical Guidance–Coronavirus disease (COVID-19). https://www.who.int/emergencies/diseases/novel-coronavirus-2019/technical-guidance
6. Indian Council of Medical Research. Stages of transmission of COVID-19. https://main.icmr.nic.in/content/covid-19
7. Centers for Disease Control and Prevention. Coronavirus disease 2019 (COVID-19) – Prevention & treatment. 2020 Apr 24. https://www.cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/prevention.html
8. Ostriker R. Cutbacks for some doctors and nurses as they battle on the front line. Boston Globe. 2020 Mar 27. https://www.bostonglobe.com/2020/03/27/metro/coronavirus-rages-doctors-hit-with-cuts-compensation/
9. Centers for Medicare & Medicaid Services. News alert. 2020 Mar 26. https://www.cms.gov/newsroom/press-releases/cms-news-alert-march-26-2020
Subclinical hypothyroidism appears common in women with miscarriage
according to a prospective observational study published in the Journal of Clinical Endocrinology & Metabolism.
Whether asymptomatic patients should be screened for mild subclinical hypothyroidism (SCH) or thyroid peroxidase antibodies (TPOAb) remains an open question, however. “In the absence of evidence of benefit with LT4 [levothyroxine] treatment and possible suggestion of harm ... we pose the question of whether screening should be performed at all in asymptomatic individuals,” wrote Rima K. Dhillon-Smith, MBChB, PhD, of the University of Birmingham (England), and colleagues. “Large randomized trials are needed to establish if preconception LT4 treatment of mild SCH with or without TPOAb positivity is beneficial. If treatment is found to be beneficial, this study presents the prevalence of thyroid disorders that can be expected.”
Subclinical hypothyroidism may represent an early stage of thyroid dysfunction. The condition has been associated with subfertility, miscarriage, preterm birth, preeclampsia, and perinatal mortality. Thyroid peroxidase antibodies also have been associated with adverse pregnancy outcomes, and their presence increases the risk of subclinical and overt thyroid disease in pregnancy. “There is international agreement on the treatment of overt thyroid disease,” the researchers wrote. “However, the treatment strategies for SCH or TPOAb preconception and antenatally are debated.”
The Thyroid Antibodies and Levothyroxine (TABLET) trial, to which the present study was linked, “found no improvement in live birth or any secondary pregnancy or neonatal outcomes in euthyroid women with TPOAb taking 50 mcg of LT4, compared with placebo.”
To examine various thyroid-stimulating hormone (TSH) cutoff levels for diagnosing subclinical thyroid disease in preconception asymptomatic women with a history of miscarriage or subfertility, Dr. Dhillon-Smith and colleagues conducted a prospective, observational cohort study at 49 hospitals in the United Kingdom. The study included more than 19,200 patients between November 2011 and January 2016. Participants were aged 16-41 years, had a history of miscarriage or subfertility, and were actively trying to get pregnant.
Using accepted reference ranges, the investigators identified undiagnosed overt hypothyroidism in 0.2%, overt hyperthyroidism in 0.3%, severe SCH (TSH greater than 10 mIU/L) in 0.2%, and SCH (TSH greater than 4.5 mIU/L) in 2.4%. “Lowering the upper limit of TSH to 2.5 mIU/L, as is the recommendation by international societies for ‘high-risk’ women,” such as those with recurrent pregnancy loss or those undergoing assisted reproductive technology, “would class 16%-20% of women as subclinically hypothyroid,” the authors reported.
The prevalence of TPOAb was 9.5%, and the presence of these antibodies “was the factor associated most significantly with any degree of thyroid dysfunction, after adjustment for confounders,” Dr. Dhillon-Smith and colleagues wrote. Multiple regression analyses found that the likelihood of subclinical hypothyroidism (TSH greater than 4.5 mIU/L) was increased for participants with a body mass index of 35 kg/m2 or greater (adjusted odds ratio, 1.71) and Asian ethnicity (aOR, 1.76).
The U.K. rates of thyroid dysfunction appear to be lower than rates in the United States, and it is unclear why higher body mass index and Asian ethnicity were independently associated with higher TSH concentrations, commented Mark P. Trolice, MD, director of Fertility CARE: The IVF Center in Winter Park, Fla., and professor of obstetrics and gynecology at the University of Central Florida, Orlando.
Women with a history of three or more miscarriages or subfertility were not more likely to be TPOAb positive, compared with women with one or two previous miscarriages, which “underscores the evidence that a recurrent pregnancy loss evaluation yields similar diagnostic findings at two versus three or more losses,” Dr. Trolice said.
According to the American Society for Reproductive Medicine, it is reasonable to test infertile women trying to conceive and to treat SCH with levothyroxine to maintain a TSH within the normal range. Women who have TSH greater than 2.5 mIU/L and/or are TPOAb positive can be considered for treatment with levothyroxine.
The Endocrine Society recommends levothyroxine treatment in women with SCH, especially if they are TPOAb positive.
An American Thyroid Association guideline recommends that subclinically hypothyroid women undergoing in vitro fertilization or intracytoplasmic sperm injection be treated with levothyroxine. A 2019 Cochrane Database review, however, found that low-quality evidence precludes clear conclusions.
“While thyroid autoimmunity has been associated with increased miscarriage, preterm births, and lower live birth rates, the confusion lies in which preconception women to test, when to obtain testing, and how to manage nonovert thyroid disease,” said Dr. Trolice, who is a member of the Ob.Gyn. News editorial advisory board.
The observational study was linked to the TABLET trial, which was funded by the National Institute for Health Research. The researchers had no relevant conflicts of interest.
SOURCE: Dhillon-Smith RK et al. J Clin Endocrinol Metab. 2020 Jun 17. doi: 10.1210/clinem/dgaa302.
according to a prospective observational study published in the Journal of Clinical Endocrinology & Metabolism.
Whether asymptomatic patients should be screened for mild subclinical hypothyroidism (SCH) or thyroid peroxidase antibodies (TPOAb) remains an open question, however. “In the absence of evidence of benefit with LT4 [levothyroxine] treatment and possible suggestion of harm ... we pose the question of whether screening should be performed at all in asymptomatic individuals,” wrote Rima K. Dhillon-Smith, MBChB, PhD, of the University of Birmingham (England), and colleagues. “Large randomized trials are needed to establish if preconception LT4 treatment of mild SCH with or without TPOAb positivity is beneficial. If treatment is found to be beneficial, this study presents the prevalence of thyroid disorders that can be expected.”
Subclinical hypothyroidism may represent an early stage of thyroid dysfunction. The condition has been associated with subfertility, miscarriage, preterm birth, preeclampsia, and perinatal mortality. Thyroid peroxidase antibodies also have been associated with adverse pregnancy outcomes, and their presence increases the risk of subclinical and overt thyroid disease in pregnancy. “There is international agreement on the treatment of overt thyroid disease,” the researchers wrote. “However, the treatment strategies for SCH or TPOAb preconception and antenatally are debated.”
The Thyroid Antibodies and Levothyroxine (TABLET) trial, to which the present study was linked, “found no improvement in live birth or any secondary pregnancy or neonatal outcomes in euthyroid women with TPOAb taking 50 mcg of LT4, compared with placebo.”
To examine various thyroid-stimulating hormone (TSH) cutoff levels for diagnosing subclinical thyroid disease in preconception asymptomatic women with a history of miscarriage or subfertility, Dr. Dhillon-Smith and colleagues conducted a prospective, observational cohort study at 49 hospitals in the United Kingdom. The study included more than 19,200 patients between November 2011 and January 2016. Participants were aged 16-41 years, had a history of miscarriage or subfertility, and were actively trying to get pregnant.
Using accepted reference ranges, the investigators identified undiagnosed overt hypothyroidism in 0.2%, overt hyperthyroidism in 0.3%, severe SCH (TSH greater than 10 mIU/L) in 0.2%, and SCH (TSH greater than 4.5 mIU/L) in 2.4%. “Lowering the upper limit of TSH to 2.5 mIU/L, as is the recommendation by international societies for ‘high-risk’ women,” such as those with recurrent pregnancy loss or those undergoing assisted reproductive technology, “would class 16%-20% of women as subclinically hypothyroid,” the authors reported.
The prevalence of TPOAb was 9.5%, and the presence of these antibodies “was the factor associated most significantly with any degree of thyroid dysfunction, after adjustment for confounders,” Dr. Dhillon-Smith and colleagues wrote. Multiple regression analyses found that the likelihood of subclinical hypothyroidism (TSH greater than 4.5 mIU/L) was increased for participants with a body mass index of 35 kg/m2 or greater (adjusted odds ratio, 1.71) and Asian ethnicity (aOR, 1.76).
The U.K. rates of thyroid dysfunction appear to be lower than rates in the United States, and it is unclear why higher body mass index and Asian ethnicity were independently associated with higher TSH concentrations, commented Mark P. Trolice, MD, director of Fertility CARE: The IVF Center in Winter Park, Fla., and professor of obstetrics and gynecology at the University of Central Florida, Orlando.
Women with a history of three or more miscarriages or subfertility were not more likely to be TPOAb positive, compared with women with one or two previous miscarriages, which “underscores the evidence that a recurrent pregnancy loss evaluation yields similar diagnostic findings at two versus three or more losses,” Dr. Trolice said.
According to the American Society for Reproductive Medicine, it is reasonable to test infertile women trying to conceive and to treat SCH with levothyroxine to maintain a TSH within the normal range. Women who have TSH greater than 2.5 mIU/L and/or are TPOAb positive can be considered for treatment with levothyroxine.
The Endocrine Society recommends levothyroxine treatment in women with SCH, especially if they are TPOAb positive.
An American Thyroid Association guideline recommends that subclinically hypothyroid women undergoing in vitro fertilization or intracytoplasmic sperm injection be treated with levothyroxine. A 2019 Cochrane Database review, however, found that low-quality evidence precludes clear conclusions.
“While thyroid autoimmunity has been associated with increased miscarriage, preterm births, and lower live birth rates, the confusion lies in which preconception women to test, when to obtain testing, and how to manage nonovert thyroid disease,” said Dr. Trolice, who is a member of the Ob.Gyn. News editorial advisory board.
The observational study was linked to the TABLET trial, which was funded by the National Institute for Health Research. The researchers had no relevant conflicts of interest.
SOURCE: Dhillon-Smith RK et al. J Clin Endocrinol Metab. 2020 Jun 17. doi: 10.1210/clinem/dgaa302.
according to a prospective observational study published in the Journal of Clinical Endocrinology & Metabolism.
Whether asymptomatic patients should be screened for mild subclinical hypothyroidism (SCH) or thyroid peroxidase antibodies (TPOAb) remains an open question, however. “In the absence of evidence of benefit with LT4 [levothyroxine] treatment and possible suggestion of harm ... we pose the question of whether screening should be performed at all in asymptomatic individuals,” wrote Rima K. Dhillon-Smith, MBChB, PhD, of the University of Birmingham (England), and colleagues. “Large randomized trials are needed to establish if preconception LT4 treatment of mild SCH with or without TPOAb positivity is beneficial. If treatment is found to be beneficial, this study presents the prevalence of thyroid disorders that can be expected.”
Subclinical hypothyroidism may represent an early stage of thyroid dysfunction. The condition has been associated with subfertility, miscarriage, preterm birth, preeclampsia, and perinatal mortality. Thyroid peroxidase antibodies also have been associated with adverse pregnancy outcomes, and their presence increases the risk of subclinical and overt thyroid disease in pregnancy. “There is international agreement on the treatment of overt thyroid disease,” the researchers wrote. “However, the treatment strategies for SCH or TPOAb preconception and antenatally are debated.”
The Thyroid Antibodies and Levothyroxine (TABLET) trial, to which the present study was linked, “found no improvement in live birth or any secondary pregnancy or neonatal outcomes in euthyroid women with TPOAb taking 50 mcg of LT4, compared with placebo.”
To examine various thyroid-stimulating hormone (TSH) cutoff levels for diagnosing subclinical thyroid disease in preconception asymptomatic women with a history of miscarriage or subfertility, Dr. Dhillon-Smith and colleagues conducted a prospective, observational cohort study at 49 hospitals in the United Kingdom. The study included more than 19,200 patients between November 2011 and January 2016. Participants were aged 16-41 years, had a history of miscarriage or subfertility, and were actively trying to get pregnant.
Using accepted reference ranges, the investigators identified undiagnosed overt hypothyroidism in 0.2%, overt hyperthyroidism in 0.3%, severe SCH (TSH greater than 10 mIU/L) in 0.2%, and SCH (TSH greater than 4.5 mIU/L) in 2.4%. “Lowering the upper limit of TSH to 2.5 mIU/L, as is the recommendation by international societies for ‘high-risk’ women,” such as those with recurrent pregnancy loss or those undergoing assisted reproductive technology, “would class 16%-20% of women as subclinically hypothyroid,” the authors reported.
The prevalence of TPOAb was 9.5%, and the presence of these antibodies “was the factor associated most significantly with any degree of thyroid dysfunction, after adjustment for confounders,” Dr. Dhillon-Smith and colleagues wrote. Multiple regression analyses found that the likelihood of subclinical hypothyroidism (TSH greater than 4.5 mIU/L) was increased for participants with a body mass index of 35 kg/m2 or greater (adjusted odds ratio, 1.71) and Asian ethnicity (aOR, 1.76).
The U.K. rates of thyroid dysfunction appear to be lower than rates in the United States, and it is unclear why higher body mass index and Asian ethnicity were independently associated with higher TSH concentrations, commented Mark P. Trolice, MD, director of Fertility CARE: The IVF Center in Winter Park, Fla., and professor of obstetrics and gynecology at the University of Central Florida, Orlando.
Women with a history of three or more miscarriages or subfertility were not more likely to be TPOAb positive, compared with women with one or two previous miscarriages, which “underscores the evidence that a recurrent pregnancy loss evaluation yields similar diagnostic findings at two versus three or more losses,” Dr. Trolice said.
According to the American Society for Reproductive Medicine, it is reasonable to test infertile women trying to conceive and to treat SCH with levothyroxine to maintain a TSH within the normal range. Women who have TSH greater than 2.5 mIU/L and/or are TPOAb positive can be considered for treatment with levothyroxine.
The Endocrine Society recommends levothyroxine treatment in women with SCH, especially if they are TPOAb positive.
An American Thyroid Association guideline recommends that subclinically hypothyroid women undergoing in vitro fertilization or intracytoplasmic sperm injection be treated with levothyroxine. A 2019 Cochrane Database review, however, found that low-quality evidence precludes clear conclusions.
“While thyroid autoimmunity has been associated with increased miscarriage, preterm births, and lower live birth rates, the confusion lies in which preconception women to test, when to obtain testing, and how to manage nonovert thyroid disease,” said Dr. Trolice, who is a member of the Ob.Gyn. News editorial advisory board.
The observational study was linked to the TABLET trial, which was funded by the National Institute for Health Research. The researchers had no relevant conflicts of interest.
SOURCE: Dhillon-Smith RK et al. J Clin Endocrinol Metab. 2020 Jun 17. doi: 10.1210/clinem/dgaa302.
FROM THE JOURNAL OF CLINICAL ENDOCRINOLOGY & METABOLISM
Intervention for AVM still too high risk: The latest from ARUBA
Enrollment into the trial, which compared medical management alone with medical management with interventional therapy (neurosurgery, embolization, or stereotactic radiotherapy, alone or in combination), was stopped prematurely in 2013 after 33 months of follow-up because of a much higher rate of death and stroke in the intervention group.
Reaffirming the benefit of no intervention
Now the investigators are reporting extended follow-up to 50 months. The results were very similar to those at 33 months.
The current 50-month follow-up results show that 15 of 110 patients in the medical group had died or had a stroke (3.39 per 100 patient-years) versus 41 of 116 (12.32 per 100 patient-years) in the intervention group. The results reaffirm the strong benefit of not undergoing intervention (hazard ratio, 0.31; 95% confidence interval, 0.17-0.56).
These latest results were published in the July issue of the Lancet Neurology.
“With an AVM, the natural reflex is to try and fix it, but our trial shows that the tools we have to do that seem to be more damaging than just living with the AVM. If we try to take it out, the stroke risk is three to five times higher than just leaving it alone,” coauthor Christian Stapf, MD, a professor at the University of Montreal, said in an interview.
Dr. Stapf explained that an AVM is a congenital abnormality in the linking of the arteries to the veins. “There are an excess number of arteries and veins. They usually sit there silently, but they can trigger seizures, as they can tickle the neurons in the vicinity.”
It is estimated that one to two AVMs are found spontaneously in every 100,000 persons every year, but this is dependent on the availability of MRI, and many go undetected, he noted. In MRI studies in healthy volunteers, the rate was about one AVM in every 2,000 individuals.
Challenging standard practice
With AVMs, rupture and intracerebral hemorrhage occur at a rate of about 1%-2% per year. Until the ARUBA results were published, the standard practice was to intervene to embolize or excise the malformation, Dr. Stapf said.
“The standard treatment was intervention. The experiment was not to do it. We were challenging standard practice, and the trial was not popular with interventionalists,” he said.
The initial study, which was published in 2014, received much criticism from the interventionalist community. Among the criticisms were that the selection criteria for enrollment limited its generalizability, fewer patients than expected in the intervention arm were referred for microvascular surgery, and the follow-up was too short to allow a meaningful comparison.
“The study received criticism, but this was mainly from interventionalists, who were having their income threatened,” Dr. Stapf said. “This was very unhappy news for them, especially in the U.S., with the fee-for-service system.”
But he says these longer-term results, together with additional analyses and data from other cohorts, reinforce their initial conclusions.
The current report also shows a benefit in functional outcome in the medical group. “After 5 years, patients are twice as likely to have a neurological handicap, defined as a score of 2 or higher on the modified Rankin scale in the intervention group,” he noted. “We also found that more patients in the intervention group had deficits not related to stroke, such as an increase in seizures.”
Results of subgroup analysis were consistent in all patient groups.
The “study was designed for 400 patients, but we only recruited about half that number. But even so, the effect of intervention on stroke is so strong there is no subgroup where it looks favorable,” Dr. Stapf said. “This result was not heterogeneous. The same effect is seen regardless of age, gender, presence of symptoms, size of AVM, location, anatomy, drainage. No matter how you look, there is no benefit for intervention.”
He also referred to a Scottish population-based cohort study that showed a similar risk reduction from not intervening. “This was an unselected population of every unruptured AVM patient in Scotland, which found a 65% relative reduction in death/stroke over 12 years. We found a 69% reduction. The Scottish study did not select any particular types of patients but showed the same result as us,” he noted. “It is hard to argue against these findings.”
Regarding the claim of selection bias, Dr. Stapf acknowledged that the study excluded patients who were judged to be in need of intervention and those judged to be at very low risk and who would not be considered for an intervention.
“But when we compared our cohort to two other unselected cohorts, they look very similar, apart from the fact that very large AVMs were not entered in our study, as they were considered too difficult to treat,” he said. “If there is a selection bias at all, it actually trends towards the intervention group, as we excluded those at the highest treatment risk, but we still showed more benefit of not intervening.”
He also says the microvascular surgery rates were consistent with real-world practice, with about 25% of patients undergoing such surgery. “This is similar to the Scottish population study. Our trial also showed a similar result in patients treated with the various different interventions – they all showed a much higher risk than not intervening,” he added.
He says practice has changed since the trial was first reported. “There are far fewer interventions now for unruptured AVMs. Most interventionalists have accepted the results now, although there are some who continue to find reasons to criticize the trial and carry on with the procedures.”
He says his advice to patients who have an unruptured AVM is to forget about it. “There doesn’t seem to be a trigger for rupture,” he said. “It doesn’t seem to be dependent on blood pressure or physical activity, and we can’t tell if it’s just about to go by looking at it. They are very different from an aneurysm in that regard.
“When I explain to patients that they are at an increased stroke risk and tell them about the results of the ARUBA study, they say they would prefer to get that stroke later in life than earlier. These patents can live for 30 or 40 years without a stroke.
“But, yes, there remains a major unmet need. We need to find a way to protect these patients. In future, we might find a better way of intervening, but at this point in time, the treatment we have is more dangerous than doing nothing,” he said.
Longer follow-up needed
In an editorial that accompanies the current study, Peter M. Rothwell, MD, of the University of Oxford, England, also dismisses much of the criticism of the ARUBA study. On the issue of external validity, he said: “I do not think that this is really any greater an issue for ARUBA than for most other similar trials.”
But Dr. Rothwell does believe that follow-up for longer than 5 years is needed. “To really understand the benefit/risk balance, we would need a 20- or 30-year follow-up. These patients are often in their 20s, 30s, or 40s, so we really need to know their cumulative risk over decades,” he said in an interview.
Noting that the study was funded by the National Institute of Neurological Disorders and Stroke (NINDS), Dr. Rothwell said funding should have been provided for much longer follow-up. “Patients who generously agreed to be randomly assigned in ARUBA and future similar patients have been let down by NINDS.
“We probably now won’t ever know the very–long-term impact, although the Scottish population study is following patients longer term,” he added.
“After this trial was first published, the guidelines recommended not to intervene. These latest results will not change that,” he said.
The ARUBA trial was funded internationally by the National Institutes of Health/NINDS. Dr. Stapf and Dr. Rothwell have disclosed no relevant financial relationships.
A version of this article originally appeared on Medscape.com.
Enrollment into the trial, which compared medical management alone with medical management with interventional therapy (neurosurgery, embolization, or stereotactic radiotherapy, alone or in combination), was stopped prematurely in 2013 after 33 months of follow-up because of a much higher rate of death and stroke in the intervention group.
Reaffirming the benefit of no intervention
Now the investigators are reporting extended follow-up to 50 months. The results were very similar to those at 33 months.
The current 50-month follow-up results show that 15 of 110 patients in the medical group had died or had a stroke (3.39 per 100 patient-years) versus 41 of 116 (12.32 per 100 patient-years) in the intervention group. The results reaffirm the strong benefit of not undergoing intervention (hazard ratio, 0.31; 95% confidence interval, 0.17-0.56).
These latest results were published in the July issue of the Lancet Neurology.
“With an AVM, the natural reflex is to try and fix it, but our trial shows that the tools we have to do that seem to be more damaging than just living with the AVM. If we try to take it out, the stroke risk is three to five times higher than just leaving it alone,” coauthor Christian Stapf, MD, a professor at the University of Montreal, said in an interview.
Dr. Stapf explained that an AVM is a congenital abnormality in the linking of the arteries to the veins. “There are an excess number of arteries and veins. They usually sit there silently, but they can trigger seizures, as they can tickle the neurons in the vicinity.”
It is estimated that one to two AVMs are found spontaneously in every 100,000 persons every year, but this is dependent on the availability of MRI, and many go undetected, he noted. In MRI studies in healthy volunteers, the rate was about one AVM in every 2,000 individuals.
Challenging standard practice
With AVMs, rupture and intracerebral hemorrhage occur at a rate of about 1%-2% per year. Until the ARUBA results were published, the standard practice was to intervene to embolize or excise the malformation, Dr. Stapf said.
“The standard treatment was intervention. The experiment was not to do it. We were challenging standard practice, and the trial was not popular with interventionalists,” he said.
The initial study, which was published in 2014, received much criticism from the interventionalist community. Among the criticisms were that the selection criteria for enrollment limited its generalizability, fewer patients than expected in the intervention arm were referred for microvascular surgery, and the follow-up was too short to allow a meaningful comparison.
“The study received criticism, but this was mainly from interventionalists, who were having their income threatened,” Dr. Stapf said. “This was very unhappy news for them, especially in the U.S., with the fee-for-service system.”
But he says these longer-term results, together with additional analyses and data from other cohorts, reinforce their initial conclusions.
The current report also shows a benefit in functional outcome in the medical group. “After 5 years, patients are twice as likely to have a neurological handicap, defined as a score of 2 or higher on the modified Rankin scale in the intervention group,” he noted. “We also found that more patients in the intervention group had deficits not related to stroke, such as an increase in seizures.”
Results of subgroup analysis were consistent in all patient groups.
The “study was designed for 400 patients, but we only recruited about half that number. But even so, the effect of intervention on stroke is so strong there is no subgroup where it looks favorable,” Dr. Stapf said. “This result was not heterogeneous. The same effect is seen regardless of age, gender, presence of symptoms, size of AVM, location, anatomy, drainage. No matter how you look, there is no benefit for intervention.”
He also referred to a Scottish population-based cohort study that showed a similar risk reduction from not intervening. “This was an unselected population of every unruptured AVM patient in Scotland, which found a 65% relative reduction in death/stroke over 12 years. We found a 69% reduction. The Scottish study did not select any particular types of patients but showed the same result as us,” he noted. “It is hard to argue against these findings.”
Regarding the claim of selection bias, Dr. Stapf acknowledged that the study excluded patients who were judged to be in need of intervention and those judged to be at very low risk and who would not be considered for an intervention.
“But when we compared our cohort to two other unselected cohorts, they look very similar, apart from the fact that very large AVMs were not entered in our study, as they were considered too difficult to treat,” he said. “If there is a selection bias at all, it actually trends towards the intervention group, as we excluded those at the highest treatment risk, but we still showed more benefit of not intervening.”
He also says the microvascular surgery rates were consistent with real-world practice, with about 25% of patients undergoing such surgery. “This is similar to the Scottish population study. Our trial also showed a similar result in patients treated with the various different interventions – they all showed a much higher risk than not intervening,” he added.
He says practice has changed since the trial was first reported. “There are far fewer interventions now for unruptured AVMs. Most interventionalists have accepted the results now, although there are some who continue to find reasons to criticize the trial and carry on with the procedures.”
He says his advice to patients who have an unruptured AVM is to forget about it. “There doesn’t seem to be a trigger for rupture,” he said. “It doesn’t seem to be dependent on blood pressure or physical activity, and we can’t tell if it’s just about to go by looking at it. They are very different from an aneurysm in that regard.
“When I explain to patients that they are at an increased stroke risk and tell them about the results of the ARUBA study, they say they would prefer to get that stroke later in life than earlier. These patents can live for 30 or 40 years without a stroke.
“But, yes, there remains a major unmet need. We need to find a way to protect these patients. In future, we might find a better way of intervening, but at this point in time, the treatment we have is more dangerous than doing nothing,” he said.
Longer follow-up needed
In an editorial that accompanies the current study, Peter M. Rothwell, MD, of the University of Oxford, England, also dismisses much of the criticism of the ARUBA study. On the issue of external validity, he said: “I do not think that this is really any greater an issue for ARUBA than for most other similar trials.”
But Dr. Rothwell does believe that follow-up for longer than 5 years is needed. “To really understand the benefit/risk balance, we would need a 20- or 30-year follow-up. These patients are often in their 20s, 30s, or 40s, so we really need to know their cumulative risk over decades,” he said in an interview.
Noting that the study was funded by the National Institute of Neurological Disorders and Stroke (NINDS), Dr. Rothwell said funding should have been provided for much longer follow-up. “Patients who generously agreed to be randomly assigned in ARUBA and future similar patients have been let down by NINDS.
“We probably now won’t ever know the very–long-term impact, although the Scottish population study is following patients longer term,” he added.
“After this trial was first published, the guidelines recommended not to intervene. These latest results will not change that,” he said.
The ARUBA trial was funded internationally by the National Institutes of Health/NINDS. Dr. Stapf and Dr. Rothwell have disclosed no relevant financial relationships.
A version of this article originally appeared on Medscape.com.
Enrollment into the trial, which compared medical management alone with medical management with interventional therapy (neurosurgery, embolization, or stereotactic radiotherapy, alone or in combination), was stopped prematurely in 2013 after 33 months of follow-up because of a much higher rate of death and stroke in the intervention group.
Reaffirming the benefit of no intervention
Now the investigators are reporting extended follow-up to 50 months. The results were very similar to those at 33 months.
The current 50-month follow-up results show that 15 of 110 patients in the medical group had died or had a stroke (3.39 per 100 patient-years) versus 41 of 116 (12.32 per 100 patient-years) in the intervention group. The results reaffirm the strong benefit of not undergoing intervention (hazard ratio, 0.31; 95% confidence interval, 0.17-0.56).
These latest results were published in the July issue of the Lancet Neurology.
“With an AVM, the natural reflex is to try and fix it, but our trial shows that the tools we have to do that seem to be more damaging than just living with the AVM. If we try to take it out, the stroke risk is three to five times higher than just leaving it alone,” coauthor Christian Stapf, MD, a professor at the University of Montreal, said in an interview.
Dr. Stapf explained that an AVM is a congenital abnormality in the linking of the arteries to the veins. “There are an excess number of arteries and veins. They usually sit there silently, but they can trigger seizures, as they can tickle the neurons in the vicinity.”
It is estimated that one to two AVMs are found spontaneously in every 100,000 persons every year, but this is dependent on the availability of MRI, and many go undetected, he noted. In MRI studies in healthy volunteers, the rate was about one AVM in every 2,000 individuals.
Challenging standard practice
With AVMs, rupture and intracerebral hemorrhage occur at a rate of about 1%-2% per year. Until the ARUBA results were published, the standard practice was to intervene to embolize or excise the malformation, Dr. Stapf said.
“The standard treatment was intervention. The experiment was not to do it. We were challenging standard practice, and the trial was not popular with interventionalists,” he said.
The initial study, which was published in 2014, received much criticism from the interventionalist community. Among the criticisms were that the selection criteria for enrollment limited its generalizability, fewer patients than expected in the intervention arm were referred for microvascular surgery, and the follow-up was too short to allow a meaningful comparison.
“The study received criticism, but this was mainly from interventionalists, who were having their income threatened,” Dr. Stapf said. “This was very unhappy news for them, especially in the U.S., with the fee-for-service system.”
But he says these longer-term results, together with additional analyses and data from other cohorts, reinforce their initial conclusions.
The current report also shows a benefit in functional outcome in the medical group. “After 5 years, patients are twice as likely to have a neurological handicap, defined as a score of 2 or higher on the modified Rankin scale in the intervention group,” he noted. “We also found that more patients in the intervention group had deficits not related to stroke, such as an increase in seizures.”
Results of subgroup analysis were consistent in all patient groups.
The “study was designed for 400 patients, but we only recruited about half that number. But even so, the effect of intervention on stroke is so strong there is no subgroup where it looks favorable,” Dr. Stapf said. “This result was not heterogeneous. The same effect is seen regardless of age, gender, presence of symptoms, size of AVM, location, anatomy, drainage. No matter how you look, there is no benefit for intervention.”
He also referred to a Scottish population-based cohort study that showed a similar risk reduction from not intervening. “This was an unselected population of every unruptured AVM patient in Scotland, which found a 65% relative reduction in death/stroke over 12 years. We found a 69% reduction. The Scottish study did not select any particular types of patients but showed the same result as us,” he noted. “It is hard to argue against these findings.”
Regarding the claim of selection bias, Dr. Stapf acknowledged that the study excluded patients who were judged to be in need of intervention and those judged to be at very low risk and who would not be considered for an intervention.
“But when we compared our cohort to two other unselected cohorts, they look very similar, apart from the fact that very large AVMs were not entered in our study, as they were considered too difficult to treat,” he said. “If there is a selection bias at all, it actually trends towards the intervention group, as we excluded those at the highest treatment risk, but we still showed more benefit of not intervening.”
He also says the microvascular surgery rates were consistent with real-world practice, with about 25% of patients undergoing such surgery. “This is similar to the Scottish population study. Our trial also showed a similar result in patients treated with the various different interventions – they all showed a much higher risk than not intervening,” he added.
He says practice has changed since the trial was first reported. “There are far fewer interventions now for unruptured AVMs. Most interventionalists have accepted the results now, although there are some who continue to find reasons to criticize the trial and carry on with the procedures.”
He says his advice to patients who have an unruptured AVM is to forget about it. “There doesn’t seem to be a trigger for rupture,” he said. “It doesn’t seem to be dependent on blood pressure or physical activity, and we can’t tell if it’s just about to go by looking at it. They are very different from an aneurysm in that regard.
“When I explain to patients that they are at an increased stroke risk and tell them about the results of the ARUBA study, they say they would prefer to get that stroke later in life than earlier. These patents can live for 30 or 40 years without a stroke.
“But, yes, there remains a major unmet need. We need to find a way to protect these patients. In future, we might find a better way of intervening, but at this point in time, the treatment we have is more dangerous than doing nothing,” he said.
Longer follow-up needed
In an editorial that accompanies the current study, Peter M. Rothwell, MD, of the University of Oxford, England, also dismisses much of the criticism of the ARUBA study. On the issue of external validity, he said: “I do not think that this is really any greater an issue for ARUBA than for most other similar trials.”
But Dr. Rothwell does believe that follow-up for longer than 5 years is needed. “To really understand the benefit/risk balance, we would need a 20- or 30-year follow-up. These patients are often in their 20s, 30s, or 40s, so we really need to know their cumulative risk over decades,” he said in an interview.
Noting that the study was funded by the National Institute of Neurological Disorders and Stroke (NINDS), Dr. Rothwell said funding should have been provided for much longer follow-up. “Patients who generously agreed to be randomly assigned in ARUBA and future similar patients have been let down by NINDS.
“We probably now won’t ever know the very–long-term impact, although the Scottish population study is following patients longer term,” he added.
“After this trial was first published, the guidelines recommended not to intervene. These latest results will not change that,” he said.
The ARUBA trial was funded internationally by the National Institutes of Health/NINDS. Dr. Stapf and Dr. Rothwell have disclosed no relevant financial relationships.
A version of this article originally appeared on Medscape.com.
FROM LANCET NEUROLOGY
The CGRP Receptor: What Neurologists Need to Know
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Two pandemics
This column is adapted from Dr. Eleryan’s speech at the George Washington University dermatology residency program’s virtual graduation ceremony on June 12.
I’ve been reflecting on my entire residency and the last 2 weeks have stood out the most. I have to admit that I’ve been angry, and so are numerous others who look like me. However, after conversations with a few important people in my life, I’ve realized that people care and are open to listening and changing if I give them the opportunity to see through my lens. I don’t want my legacy to be one of anger, but to be one of change, one of activism, one of heroism, and one of taking a stand in the midst of adversity.
So thank you to everyone who has played a part in my residency and is here to celebrate as I transition to the next step in my career.
But I must pause for a moment to say “I can’t breathe.” I can’t breathe because while I sit here in a place of honor for my accomplishments, I can’t forget that I’m standing in the gap for all of the black men and women who will never have the opportunity to experience a moment like this.
I can’t breathe because George Floyd, Breonna Taylor, Ahmaud Arbery, Tony McDade, Trayvon Martin, Philando Castile, Sandra Bland, Eric Garner, Tamir Rice, Mike Brown, Emmett Till, and so many others will never get to experience a celebratory occasion such as this because of their senseless executions as a likely result of racial bias.
As a black person in “the land of the free,” I have to live with the fact that my life may be taken for simply taking a stroll through a park, jogging through a neighborhood, driving down the street, walking back home from the store, or even sitting in my own home!
As a black physician, I must contend with the very notion that my privilege as a physician does not shield me from discrimination and bias. I recognize that my race walks into the room before I ever do. I know that many of my patients will question my abilities or my title – thinking I am the receptionist, food services worker, or even part of the janitorial staff – simply because of the color of my skin. And what’s even more disturbing is that some of my colleagues will confuse me with another black woman whom I look nothing like or challenge my intelligence and abilities and how I got my position.
All of this boils down to racism – pure and simple. Black people in this country don’t have the privilege of ignoring this truth. We know that this world is not colorblind; neither is anyone in it. We know that this is entrenched racism that for generations has created racial disparities in health care, education, housing, employment, and law enforcement. We weren’t born into a fragile or vulnerable state, yet we were born into a system of dis-enfranchisement, dis-investment, dis-crimination, dis-advantage, and dis-respect.
As physicians, we must recognize and acknowledge the lived experiences that walk through the door with our black patients. And we must understand that black patients walk around with the effects of trauma and toxic stress from just being black in America. That trauma and stress show up in very real ways that contribute to black people experiencing the brunt of chronic diseases and poorer health outcomes. There is no better example than the current COVID-19 pandemic. We are in the midst of a global pandemic from a virus that does not discriminate based on race, but black people are almost three times as likely to be hospitalized as are white people with COVID-19 . And why is that? Because of the “comorbidity” of racism that black people in this country live with. It is not a mere coincidence that the black population is overrepresented in essential jobs and black people are more likely to work in health care than are white people – all positions that increase the risk of infection and death from the virus. So, if we call COVID-19 a pandemic, racism most certainly has been a pandemic that this country has refused to acknowledge, treat, and vaccinate for centuries. We cannot ignore that both have tragically affected black people.
So as Pastor Reginald Sharpe Jr. in Chicago recently said, we’re dealing with two pandemics: One has no vaccination and one has no explanation; one can physiologically take your breath away because it affects the respiratory system, while the second can also take your breath away. Just ask Eric Garner and George Floyd.
As physicians, we must recognize that the mechanisms that tragically resulted in the deaths of George Floyd, Breonna Taylor, Ahmaud Arbery, and so many other black men and women are the same mechanisms that are harming and killing black people in our health care system. It’s not acceptable for institutions that built themselves on black and brown bodies to offer condolences, but to continue to do nothing about the racism that still runs rampant within. It’s not acceptable to do nothing. It’s important to note: Racist systems do not perpetuate themselves – the individuals operating within them do.
Martin Luther King Jr. once said, “He who passively accepts evil is as much involved in it as he who helps to perpetuate it. He who accepts evil without protesting against it is really cooperating with it.” Being well-intentioned, good-hearted, sad, or disheartened is not enough. We won’t be able to tear down the systems and institutions that have been a breeding ground for racism until outrage is met by action, not just from black people and people of color, but also by the white majority.
As physicians it’s time for us to look at how our health care institution – an institution instrumental in the victimization of black people – is affecting the health and well-being of our black patients. (For example, increased maternal mortality among black women.)
Are they being seen and heard? Are they receiving culturally relevant and sensitive care? Are their needs and concerns receiving the same amount of time and attention as other patients? It’s time to understand that, for many black patients, the health care system is another place of injustice that has not proved itself to be trustworthy or inclusive of black culture.
As physicians, we must affirm that the lives and health of black and brown people matter to us, that we see the racism they experience, and that we will use our platform as physicians to eliminate racism not just in the hospitals but in the world our patients live in.
So while I didn’t choose the body that I was born into, I fully embrace it and the challenges that come with it. I’m not here to make people feel comfortable, I’m here to continue the work of my ancestors, accomplish the dreams that they fought and lost their lives for, and most importantly, I’m here to continue the fight against the systems that work to prevent other marginalized persons from getting to where I am and even further.
The author James Baldwin once wrote, “Not everything that is faced can be changed, but nothing can be changed until it is faced.” So, I urge you to be loudly antiracist in every space that you hold. I urge you to educate yourselves about racism and white supremacy and privilege and how it permeates our health care system. I urge you to stand beside black people rather than in front of them. Use your privilege to amplify underheard voices and to challenge the biases of your peers, friends, and family members. Use your platform as physicians to advocate for a more just and equitable health care system.
So let me repeat ... we as physicians have the responsibility to eliminate racial bias in the practice of medicine and recognize racism as a threat to the health and well-being of black people and other people of color.
How do we do this? We are beyond lengthy dialogue and “Black History Month” talks. Now is the time for action. Taking action includes the following:
1. Medical academic institutions committing to having a diverse and inclusive faculty. We know it is critical and vital to the recruitment, success, and matriculation of medical students and residents of color to see faculty, particularly senior level faculty in their specialty, who look like them and can serve as mentors. Every year, these institutions need to set a goal that they will take additional steps to have at least one-third of their faculty be black and another third persons of color. In addition, senior faculty positions – those setting curricula, selecting incoming students and residents – must include at least one-third from underrepresented backgrounds (black, Hispanic, Native American/Indigenous).
2. Hospital administration has to resemble the communities in which the hospital serves. Unfortunately, all too often, we know this is not the case, and as a result, decisions that affect the care of black and brown people are often to their detriment because they perpetuate the racism within the existing system. In order to dismantle racism in the hospital system, hospital administrations must consist of diverse individuals. Therefore, hospitals need to commit to hiring and promoting black and brown staff to ensure one-third of its senior leaderships consists of individuals from underrepresented backgrounds.
3. Improving the pipeline that matriculates black and brown students into medical school and residency programs. Lack of access to mentors within the medical field, lack of funding for travel to/from interviews, and lack of knowledge of the overall application process are a few barriers faced by students of color seeking to enter into the medical field. In addition to current scholarship opportunities, medical schools need to allocate funds to connect underrepresented minority students with a range of lived experiences (not just those from impoverished backgrounds but also those from middle class backgrounds who face difficulty gaining acceptance into medical school and residency programs), such as connecting them with mentors by opening opportunities for them to shadow professionals at a conference, travel to residency interviews with most, if not all, expenses covered up front, and have access to local programs that expose them to physicians in several specialties.
These are just a few examples of the active steps we can take to dismantle racism and reconcile the effects of it in the medical field. So if I may borrow from other movements, “Time’s Up” for silence regarding the existence of racism and white supremacy, and now it’s time to truly show that “We are all in this together.”
It is not just my duty but yours also – to ensure that we never have to hear another black man, woman, or child say “I can’t breathe” at the hands of injustice.
Dr. Eleryan (@skinclusionMD) is a social justice activist and was co-chief resident in dermatology (2019-2020) at George Washington University, Washington, DC, and is an Alpha Omega Alpha inductee (2020). She will be a micrographic surgery and dermatologic oncology fellow at the University of California, Los Angeles, in July 2020.
This column is adapted from Dr. Eleryan’s speech at the George Washington University dermatology residency program’s virtual graduation ceremony on June 12.
I’ve been reflecting on my entire residency and the last 2 weeks have stood out the most. I have to admit that I’ve been angry, and so are numerous others who look like me. However, after conversations with a few important people in my life, I’ve realized that people care and are open to listening and changing if I give them the opportunity to see through my lens. I don’t want my legacy to be one of anger, but to be one of change, one of activism, one of heroism, and one of taking a stand in the midst of adversity.
So thank you to everyone who has played a part in my residency and is here to celebrate as I transition to the next step in my career.
But I must pause for a moment to say “I can’t breathe.” I can’t breathe because while I sit here in a place of honor for my accomplishments, I can’t forget that I’m standing in the gap for all of the black men and women who will never have the opportunity to experience a moment like this.
I can’t breathe because George Floyd, Breonna Taylor, Ahmaud Arbery, Tony McDade, Trayvon Martin, Philando Castile, Sandra Bland, Eric Garner, Tamir Rice, Mike Brown, Emmett Till, and so many others will never get to experience a celebratory occasion such as this because of their senseless executions as a likely result of racial bias.
As a black person in “the land of the free,” I have to live with the fact that my life may be taken for simply taking a stroll through a park, jogging through a neighborhood, driving down the street, walking back home from the store, or even sitting in my own home!
As a black physician, I must contend with the very notion that my privilege as a physician does not shield me from discrimination and bias. I recognize that my race walks into the room before I ever do. I know that many of my patients will question my abilities or my title – thinking I am the receptionist, food services worker, or even part of the janitorial staff – simply because of the color of my skin. And what’s even more disturbing is that some of my colleagues will confuse me with another black woman whom I look nothing like or challenge my intelligence and abilities and how I got my position.
All of this boils down to racism – pure and simple. Black people in this country don’t have the privilege of ignoring this truth. We know that this world is not colorblind; neither is anyone in it. We know that this is entrenched racism that for generations has created racial disparities in health care, education, housing, employment, and law enforcement. We weren’t born into a fragile or vulnerable state, yet we were born into a system of dis-enfranchisement, dis-investment, dis-crimination, dis-advantage, and dis-respect.
As physicians, we must recognize and acknowledge the lived experiences that walk through the door with our black patients. And we must understand that black patients walk around with the effects of trauma and toxic stress from just being black in America. That trauma and stress show up in very real ways that contribute to black people experiencing the brunt of chronic diseases and poorer health outcomes. There is no better example than the current COVID-19 pandemic. We are in the midst of a global pandemic from a virus that does not discriminate based on race, but black people are almost three times as likely to be hospitalized as are white people with COVID-19 . And why is that? Because of the “comorbidity” of racism that black people in this country live with. It is not a mere coincidence that the black population is overrepresented in essential jobs and black people are more likely to work in health care than are white people – all positions that increase the risk of infection and death from the virus. So, if we call COVID-19 a pandemic, racism most certainly has been a pandemic that this country has refused to acknowledge, treat, and vaccinate for centuries. We cannot ignore that both have tragically affected black people.
So as Pastor Reginald Sharpe Jr. in Chicago recently said, we’re dealing with two pandemics: One has no vaccination and one has no explanation; one can physiologically take your breath away because it affects the respiratory system, while the second can also take your breath away. Just ask Eric Garner and George Floyd.
As physicians, we must recognize that the mechanisms that tragically resulted in the deaths of George Floyd, Breonna Taylor, Ahmaud Arbery, and so many other black men and women are the same mechanisms that are harming and killing black people in our health care system. It’s not acceptable for institutions that built themselves on black and brown bodies to offer condolences, but to continue to do nothing about the racism that still runs rampant within. It’s not acceptable to do nothing. It’s important to note: Racist systems do not perpetuate themselves – the individuals operating within them do.
Martin Luther King Jr. once said, “He who passively accepts evil is as much involved in it as he who helps to perpetuate it. He who accepts evil without protesting against it is really cooperating with it.” Being well-intentioned, good-hearted, sad, or disheartened is not enough. We won’t be able to tear down the systems and institutions that have been a breeding ground for racism until outrage is met by action, not just from black people and people of color, but also by the white majority.
As physicians it’s time for us to look at how our health care institution – an institution instrumental in the victimization of black people – is affecting the health and well-being of our black patients. (For example, increased maternal mortality among black women.)
Are they being seen and heard? Are they receiving culturally relevant and sensitive care? Are their needs and concerns receiving the same amount of time and attention as other patients? It’s time to understand that, for many black patients, the health care system is another place of injustice that has not proved itself to be trustworthy or inclusive of black culture.
As physicians, we must affirm that the lives and health of black and brown people matter to us, that we see the racism they experience, and that we will use our platform as physicians to eliminate racism not just in the hospitals but in the world our patients live in.
So while I didn’t choose the body that I was born into, I fully embrace it and the challenges that come with it. I’m not here to make people feel comfortable, I’m here to continue the work of my ancestors, accomplish the dreams that they fought and lost their lives for, and most importantly, I’m here to continue the fight against the systems that work to prevent other marginalized persons from getting to where I am and even further.
The author James Baldwin once wrote, “Not everything that is faced can be changed, but nothing can be changed until it is faced.” So, I urge you to be loudly antiracist in every space that you hold. I urge you to educate yourselves about racism and white supremacy and privilege and how it permeates our health care system. I urge you to stand beside black people rather than in front of them. Use your privilege to amplify underheard voices and to challenge the biases of your peers, friends, and family members. Use your platform as physicians to advocate for a more just and equitable health care system.
So let me repeat ... we as physicians have the responsibility to eliminate racial bias in the practice of medicine and recognize racism as a threat to the health and well-being of black people and other people of color.
How do we do this? We are beyond lengthy dialogue and “Black History Month” talks. Now is the time for action. Taking action includes the following:
1. Medical academic institutions committing to having a diverse and inclusive faculty. We know it is critical and vital to the recruitment, success, and matriculation of medical students and residents of color to see faculty, particularly senior level faculty in their specialty, who look like them and can serve as mentors. Every year, these institutions need to set a goal that they will take additional steps to have at least one-third of their faculty be black and another third persons of color. In addition, senior faculty positions – those setting curricula, selecting incoming students and residents – must include at least one-third from underrepresented backgrounds (black, Hispanic, Native American/Indigenous).
2. Hospital administration has to resemble the communities in which the hospital serves. Unfortunately, all too often, we know this is not the case, and as a result, decisions that affect the care of black and brown people are often to their detriment because they perpetuate the racism within the existing system. In order to dismantle racism in the hospital system, hospital administrations must consist of diverse individuals. Therefore, hospitals need to commit to hiring and promoting black and brown staff to ensure one-third of its senior leaderships consists of individuals from underrepresented backgrounds.
3. Improving the pipeline that matriculates black and brown students into medical school and residency programs. Lack of access to mentors within the medical field, lack of funding for travel to/from interviews, and lack of knowledge of the overall application process are a few barriers faced by students of color seeking to enter into the medical field. In addition to current scholarship opportunities, medical schools need to allocate funds to connect underrepresented minority students with a range of lived experiences (not just those from impoverished backgrounds but also those from middle class backgrounds who face difficulty gaining acceptance into medical school and residency programs), such as connecting them with mentors by opening opportunities for them to shadow professionals at a conference, travel to residency interviews with most, if not all, expenses covered up front, and have access to local programs that expose them to physicians in several specialties.
These are just a few examples of the active steps we can take to dismantle racism and reconcile the effects of it in the medical field. So if I may borrow from other movements, “Time’s Up” for silence regarding the existence of racism and white supremacy, and now it’s time to truly show that “We are all in this together.”
It is not just my duty but yours also – to ensure that we never have to hear another black man, woman, or child say “I can’t breathe” at the hands of injustice.
Dr. Eleryan (@skinclusionMD) is a social justice activist and was co-chief resident in dermatology (2019-2020) at George Washington University, Washington, DC, and is an Alpha Omega Alpha inductee (2020). She will be a micrographic surgery and dermatologic oncology fellow at the University of California, Los Angeles, in July 2020.
This column is adapted from Dr. Eleryan’s speech at the George Washington University dermatology residency program’s virtual graduation ceremony on June 12.
I’ve been reflecting on my entire residency and the last 2 weeks have stood out the most. I have to admit that I’ve been angry, and so are numerous others who look like me. However, after conversations with a few important people in my life, I’ve realized that people care and are open to listening and changing if I give them the opportunity to see through my lens. I don’t want my legacy to be one of anger, but to be one of change, one of activism, one of heroism, and one of taking a stand in the midst of adversity.
So thank you to everyone who has played a part in my residency and is here to celebrate as I transition to the next step in my career.
But I must pause for a moment to say “I can’t breathe.” I can’t breathe because while I sit here in a place of honor for my accomplishments, I can’t forget that I’m standing in the gap for all of the black men and women who will never have the opportunity to experience a moment like this.
I can’t breathe because George Floyd, Breonna Taylor, Ahmaud Arbery, Tony McDade, Trayvon Martin, Philando Castile, Sandra Bland, Eric Garner, Tamir Rice, Mike Brown, Emmett Till, and so many others will never get to experience a celebratory occasion such as this because of their senseless executions as a likely result of racial bias.
As a black person in “the land of the free,” I have to live with the fact that my life may be taken for simply taking a stroll through a park, jogging through a neighborhood, driving down the street, walking back home from the store, or even sitting in my own home!
As a black physician, I must contend with the very notion that my privilege as a physician does not shield me from discrimination and bias. I recognize that my race walks into the room before I ever do. I know that many of my patients will question my abilities or my title – thinking I am the receptionist, food services worker, or even part of the janitorial staff – simply because of the color of my skin. And what’s even more disturbing is that some of my colleagues will confuse me with another black woman whom I look nothing like or challenge my intelligence and abilities and how I got my position.
All of this boils down to racism – pure and simple. Black people in this country don’t have the privilege of ignoring this truth. We know that this world is not colorblind; neither is anyone in it. We know that this is entrenched racism that for generations has created racial disparities in health care, education, housing, employment, and law enforcement. We weren’t born into a fragile or vulnerable state, yet we were born into a system of dis-enfranchisement, dis-investment, dis-crimination, dis-advantage, and dis-respect.
As physicians, we must recognize and acknowledge the lived experiences that walk through the door with our black patients. And we must understand that black patients walk around with the effects of trauma and toxic stress from just being black in America. That trauma and stress show up in very real ways that contribute to black people experiencing the brunt of chronic diseases and poorer health outcomes. There is no better example than the current COVID-19 pandemic. We are in the midst of a global pandemic from a virus that does not discriminate based on race, but black people are almost three times as likely to be hospitalized as are white people with COVID-19 . And why is that? Because of the “comorbidity” of racism that black people in this country live with. It is not a mere coincidence that the black population is overrepresented in essential jobs and black people are more likely to work in health care than are white people – all positions that increase the risk of infection and death from the virus. So, if we call COVID-19 a pandemic, racism most certainly has been a pandemic that this country has refused to acknowledge, treat, and vaccinate for centuries. We cannot ignore that both have tragically affected black people.
So as Pastor Reginald Sharpe Jr. in Chicago recently said, we’re dealing with two pandemics: One has no vaccination and one has no explanation; one can physiologically take your breath away because it affects the respiratory system, while the second can also take your breath away. Just ask Eric Garner and George Floyd.
As physicians, we must recognize that the mechanisms that tragically resulted in the deaths of George Floyd, Breonna Taylor, Ahmaud Arbery, and so many other black men and women are the same mechanisms that are harming and killing black people in our health care system. It’s not acceptable for institutions that built themselves on black and brown bodies to offer condolences, but to continue to do nothing about the racism that still runs rampant within. It’s not acceptable to do nothing. It’s important to note: Racist systems do not perpetuate themselves – the individuals operating within them do.
Martin Luther King Jr. once said, “He who passively accepts evil is as much involved in it as he who helps to perpetuate it. He who accepts evil without protesting against it is really cooperating with it.” Being well-intentioned, good-hearted, sad, or disheartened is not enough. We won’t be able to tear down the systems and institutions that have been a breeding ground for racism until outrage is met by action, not just from black people and people of color, but also by the white majority.
As physicians it’s time for us to look at how our health care institution – an institution instrumental in the victimization of black people – is affecting the health and well-being of our black patients. (For example, increased maternal mortality among black women.)
Are they being seen and heard? Are they receiving culturally relevant and sensitive care? Are their needs and concerns receiving the same amount of time and attention as other patients? It’s time to understand that, for many black patients, the health care system is another place of injustice that has not proved itself to be trustworthy or inclusive of black culture.
As physicians, we must affirm that the lives and health of black and brown people matter to us, that we see the racism they experience, and that we will use our platform as physicians to eliminate racism not just in the hospitals but in the world our patients live in.
So while I didn’t choose the body that I was born into, I fully embrace it and the challenges that come with it. I’m not here to make people feel comfortable, I’m here to continue the work of my ancestors, accomplish the dreams that they fought and lost their lives for, and most importantly, I’m here to continue the fight against the systems that work to prevent other marginalized persons from getting to where I am and even further.
The author James Baldwin once wrote, “Not everything that is faced can be changed, but nothing can be changed until it is faced.” So, I urge you to be loudly antiracist in every space that you hold. I urge you to educate yourselves about racism and white supremacy and privilege and how it permeates our health care system. I urge you to stand beside black people rather than in front of them. Use your privilege to amplify underheard voices and to challenge the biases of your peers, friends, and family members. Use your platform as physicians to advocate for a more just and equitable health care system.
So let me repeat ... we as physicians have the responsibility to eliminate racial bias in the practice of medicine and recognize racism as a threat to the health and well-being of black people and other people of color.
How do we do this? We are beyond lengthy dialogue and “Black History Month” talks. Now is the time for action. Taking action includes the following:
1. Medical academic institutions committing to having a diverse and inclusive faculty. We know it is critical and vital to the recruitment, success, and matriculation of medical students and residents of color to see faculty, particularly senior level faculty in their specialty, who look like them and can serve as mentors. Every year, these institutions need to set a goal that they will take additional steps to have at least one-third of their faculty be black and another third persons of color. In addition, senior faculty positions – those setting curricula, selecting incoming students and residents – must include at least one-third from underrepresented backgrounds (black, Hispanic, Native American/Indigenous).
2. Hospital administration has to resemble the communities in which the hospital serves. Unfortunately, all too often, we know this is not the case, and as a result, decisions that affect the care of black and brown people are often to their detriment because they perpetuate the racism within the existing system. In order to dismantle racism in the hospital system, hospital administrations must consist of diverse individuals. Therefore, hospitals need to commit to hiring and promoting black and brown staff to ensure one-third of its senior leaderships consists of individuals from underrepresented backgrounds.
3. Improving the pipeline that matriculates black and brown students into medical school and residency programs. Lack of access to mentors within the medical field, lack of funding for travel to/from interviews, and lack of knowledge of the overall application process are a few barriers faced by students of color seeking to enter into the medical field. In addition to current scholarship opportunities, medical schools need to allocate funds to connect underrepresented minority students with a range of lived experiences (not just those from impoverished backgrounds but also those from middle class backgrounds who face difficulty gaining acceptance into medical school and residency programs), such as connecting them with mentors by opening opportunities for them to shadow professionals at a conference, travel to residency interviews with most, if not all, expenses covered up front, and have access to local programs that expose them to physicians in several specialties.
These are just a few examples of the active steps we can take to dismantle racism and reconcile the effects of it in the medical field. So if I may borrow from other movements, “Time’s Up” for silence regarding the existence of racism and white supremacy, and now it’s time to truly show that “We are all in this together.”
It is not just my duty but yours also – to ensure that we never have to hear another black man, woman, or child say “I can’t breathe” at the hands of injustice.
Dr. Eleryan (@skinclusionMD) is a social justice activist and was co-chief resident in dermatology (2019-2020) at George Washington University, Washington, DC, and is an Alpha Omega Alpha inductee (2020). She will be a micrographic surgery and dermatologic oncology fellow at the University of California, Los Angeles, in July 2020.
Skin patterns of COVID-19 vary widely
according to Christine Ko, MD.
“Things are very fluid,” Dr. Ko, professor of dermatology and pathology at Yale University, New Haven, Conn., said during the virtual annual meeting of the American Academy of Dermatology. “New studies are coming out daily. Due to the need for rapid dissemination, a lot of the studies are case reports, but there are some nice case series. Another caveat for the literature is that a lot of these cases were not necessarily confirmed with testing for SARS-CoV-2, but some were.”
Dr. Ko framed her remarks largely on a case collection survey of images and clinical data from 375 patients in Spain with suspected or confirmed COVID-19 that was published online April 29, 2020, in the British Journal of Dermatology (doi: 10.1111/bjd.19163). Cutaneous manifestations included early vesicular eruptions mainly on the trunk or limbs (9%), maculopapular (47%) to urticarial lesions (19%) mainly on the trunk, and acral areas of erythema sometimes with vesicles or erosion (perniosis-like) (19%) that seemed to be a later manifestation of COVID-19. Retiform purpura or necrosis (6%) was most concerning in terms of skin disease, with an associated with a mortality of 10%.
On histology, the early vesicular eruptions are typically marked by dyskeratotic keratinocytes, Dr. Ko said, while urticarial lesions are characterized by a mixed dermal infiltrate; maculopapular lesions were a broad category. “There are some case reports that show spongiotic dermatitis or parakeratosis with a lymphocytic infiltrate,” she said. “A caveat to keep in mind is that, although these patients may definitely have COVID-19 and be confirmed to have it by testing, hypersensitivity reactions may be due to the multiple medications they’re on.”
Patients can develop a spectrum of lesions that are suggestive of vascular damage or occlusion, Dr. Ko continued. Livedoid lesions may remain static and not eventuate into necrosis or purpura but will self-resolve. Purpuric lesions and acral gangrene have been described, and these lesions correspond to vascular occlusion on biopsy.
A later manifestation are the so-called “COVID toes” with a superficial and deep lymphocytic infiltrate, as published June 1, 2020, in JAAD Case Reports: (doi: 10.1016/j.jdcr.2020.04.011).
“There are patients in the literature that have slightly different pathology, with lymphocytic inflammation as well as occlusion of vessels,” Dr. Ko said. A paper published June 20, 2020, in the British Journal of Dermatology used immunohistochemical staining against the SARS-CoV-2 spike protein, and biopsies of “COVID toes” had positive staining of endothelial cells, supporting the notion that “COVID toes” are a direct manifestation of viral infection (doi: 10.1111/bjd.19327).
“There’s a lot that we still don’t know, and some patterns are going to be outliers,” Dr. Ko concluded. “[As for] determining which skin manifestations are directly from coronavirus infection within the skin, more study is needed and likely time will tell.” She reported having no financial disclosures relevant to her talk.
according to Christine Ko, MD.
“Things are very fluid,” Dr. Ko, professor of dermatology and pathology at Yale University, New Haven, Conn., said during the virtual annual meeting of the American Academy of Dermatology. “New studies are coming out daily. Due to the need for rapid dissemination, a lot of the studies are case reports, but there are some nice case series. Another caveat for the literature is that a lot of these cases were not necessarily confirmed with testing for SARS-CoV-2, but some were.”
Dr. Ko framed her remarks largely on a case collection survey of images and clinical data from 375 patients in Spain with suspected or confirmed COVID-19 that was published online April 29, 2020, in the British Journal of Dermatology (doi: 10.1111/bjd.19163). Cutaneous manifestations included early vesicular eruptions mainly on the trunk or limbs (9%), maculopapular (47%) to urticarial lesions (19%) mainly on the trunk, and acral areas of erythema sometimes with vesicles or erosion (perniosis-like) (19%) that seemed to be a later manifestation of COVID-19. Retiform purpura or necrosis (6%) was most concerning in terms of skin disease, with an associated with a mortality of 10%.
On histology, the early vesicular eruptions are typically marked by dyskeratotic keratinocytes, Dr. Ko said, while urticarial lesions are characterized by a mixed dermal infiltrate; maculopapular lesions were a broad category. “There are some case reports that show spongiotic dermatitis or parakeratosis with a lymphocytic infiltrate,” she said. “A caveat to keep in mind is that, although these patients may definitely have COVID-19 and be confirmed to have it by testing, hypersensitivity reactions may be due to the multiple medications they’re on.”
Patients can develop a spectrum of lesions that are suggestive of vascular damage or occlusion, Dr. Ko continued. Livedoid lesions may remain static and not eventuate into necrosis or purpura but will self-resolve. Purpuric lesions and acral gangrene have been described, and these lesions correspond to vascular occlusion on biopsy.
A later manifestation are the so-called “COVID toes” with a superficial and deep lymphocytic infiltrate, as published June 1, 2020, in JAAD Case Reports: (doi: 10.1016/j.jdcr.2020.04.011).
“There are patients in the literature that have slightly different pathology, with lymphocytic inflammation as well as occlusion of vessels,” Dr. Ko said. A paper published June 20, 2020, in the British Journal of Dermatology used immunohistochemical staining against the SARS-CoV-2 spike protein, and biopsies of “COVID toes” had positive staining of endothelial cells, supporting the notion that “COVID toes” are a direct manifestation of viral infection (doi: 10.1111/bjd.19327).
“There’s a lot that we still don’t know, and some patterns are going to be outliers,” Dr. Ko concluded. “[As for] determining which skin manifestations are directly from coronavirus infection within the skin, more study is needed and likely time will tell.” She reported having no financial disclosures relevant to her talk.
according to Christine Ko, MD.
“Things are very fluid,” Dr. Ko, professor of dermatology and pathology at Yale University, New Haven, Conn., said during the virtual annual meeting of the American Academy of Dermatology. “New studies are coming out daily. Due to the need for rapid dissemination, a lot of the studies are case reports, but there are some nice case series. Another caveat for the literature is that a lot of these cases were not necessarily confirmed with testing for SARS-CoV-2, but some were.”
Dr. Ko framed her remarks largely on a case collection survey of images and clinical data from 375 patients in Spain with suspected or confirmed COVID-19 that was published online April 29, 2020, in the British Journal of Dermatology (doi: 10.1111/bjd.19163). Cutaneous manifestations included early vesicular eruptions mainly on the trunk or limbs (9%), maculopapular (47%) to urticarial lesions (19%) mainly on the trunk, and acral areas of erythema sometimes with vesicles or erosion (perniosis-like) (19%) that seemed to be a later manifestation of COVID-19. Retiform purpura or necrosis (6%) was most concerning in terms of skin disease, with an associated with a mortality of 10%.
On histology, the early vesicular eruptions are typically marked by dyskeratotic keratinocytes, Dr. Ko said, while urticarial lesions are characterized by a mixed dermal infiltrate; maculopapular lesions were a broad category. “There are some case reports that show spongiotic dermatitis or parakeratosis with a lymphocytic infiltrate,” she said. “A caveat to keep in mind is that, although these patients may definitely have COVID-19 and be confirmed to have it by testing, hypersensitivity reactions may be due to the multiple medications they’re on.”
Patients can develop a spectrum of lesions that are suggestive of vascular damage or occlusion, Dr. Ko continued. Livedoid lesions may remain static and not eventuate into necrosis or purpura but will self-resolve. Purpuric lesions and acral gangrene have been described, and these lesions correspond to vascular occlusion on biopsy.
A later manifestation are the so-called “COVID toes” with a superficial and deep lymphocytic infiltrate, as published June 1, 2020, in JAAD Case Reports: (doi: 10.1016/j.jdcr.2020.04.011).
“There are patients in the literature that have slightly different pathology, with lymphocytic inflammation as well as occlusion of vessels,” Dr. Ko said. A paper published June 20, 2020, in the British Journal of Dermatology used immunohistochemical staining against the SARS-CoV-2 spike protein, and biopsies of “COVID toes” had positive staining of endothelial cells, supporting the notion that “COVID toes” are a direct manifestation of viral infection (doi: 10.1111/bjd.19327).
“There’s a lot that we still don’t know, and some patterns are going to be outliers,” Dr. Ko concluded. “[As for] determining which skin manifestations are directly from coronavirus infection within the skin, more study is needed and likely time will tell.” She reported having no financial disclosures relevant to her talk.
FROM AAD 20
Novel rapid acoustic pulse device shows promise for treating cellulite
After a single treatment, it provided a roughly 1.16 point reduction in the five-point Cellulite Severity Scale at 12 weeks, which corresponds to a roughly 32.5% reduction in cellulite.
“In cellulite, we know that the septa within the fat – those fibrous bands that pull down the skin and tether – lead to the traditional look of cellulite dimples and ridges,” lead study author Elizabeth Tanzi, MD, said during a late-breaking abstract session at the virtual annual meeting of the American Academy of Dermatology. A rapid acoustic pulse (RAP) device being developed by Soliton emits rapid acoustic pulses and shock waves at 50 Hz that are transmitted through the skin. The pulses “rupture and shear the fibrotic septa, which causes release of the septa and smoothing of the skin dimples,” explained Dr. Tanzi, director of Capital Laser & Skin Care in Chevy Chase, Md.
She added that the repetition rate of the RAP device makes it stand out from other technologies currently on the market for cellulite treatment. “The repetition rate and very short rise times provide microscopic mechanical destruction to the targeted cellular level structures and the vacuoles,” Dr. Tanzi said. “The high peak pressure and fast repetition rate exploit the viscoelastic nature of the tissue. It’s the rapid rate at which the energy is being delivered, as well as the very short times that energy is being delivered, that makes the technology an entirely different device-tissue interaction.”
The physical effects observed occur in the extracellular matrix and in the destruction of fibrous septa. “That’s the acoustic subcision,” she continued. “But also, there’s no cavitation and there are nonthermal physical effects. There is some investigational research going into what biologic effects those shock waves have on the rest of the tissue, looking into neocollagenesis, potential angiogenesis, potential lymphangiogenesis, as well as inflammation inhibition.”
In a prospective pivotal clinical trial conducted at four sites, Dr. Tanzi and her colleagues evaluated the safety and effectiveness of the RAP device in 62 female patients who were treated with a single, rapid acoustic pulse treatment comprised of 1-2 minutes on each identified dimple or large ridge of cellulite. This amounted to a 19- to 33-minute treatment session for each patient. No anesthesia was required, and photographs were taken on all sites with QuantifiCare medical imaging software.
“It’s completely noninvasive and it’s truly an incisionless treatment,” Dr. Tanzi said of the procedure. “The skin’s never punctured. There’s physician oversight, but it is highly delegatable, and there is no recovery time for the patient.”
Following treatment, adverse effects and tolerability were reported, and safety and efficacy were assessed at 12 weeks. Efficacy was determined by photographic assessment by three blinded independent physicians who used a validated, simplified version of the Cellulite Severity Scale (CSS), a 0-5 scale based on the number of cellulite depressions, as well as the average depth of those depressions.
The mean age of patients was 43 years, 92% were white, and their mean body mass index was 24.5 kg/m2. The average time of treatment was 28 minutes. Based on the CSS scores, the researchers found that 87% of the study subjects had some improvement of their cellulite after a single RAP treatment. “If you break the data down further, half of patients had at least a 30% reduction of their CSS, and almost one-quarter had a 50% improvement of their CSS,” Dr. Tanzi said. “Overall, we saw a reduction of a 1.16 level on that six-point scale, which translates roughly into 32.5% reduction of the look of their cellulite from the baseline score.”
In addition, 84% of the time, the blinded assessors were able to correctly identify pre- and posttreatment unlabeled photos that they were presented at the 3-month mark. Those same blinded assessors graded about 86% of the treated cellulite areas as appearing either improved, much improved, or very much improved on the Global Aesthetic Improvement Scale (GAIS).
“We found a very favorable side-effect profile, although 95% of patients had some redness to their skin,” Dr. Tanzi added. “They had some erythema and folliculitis, but it was transient and very mild. In addition, 98% of patients said that the procedure was tolerable.”
As for pain, on a 0-10 scale, with 10 being the worst, subjects rated their pain level at 2.4 during the treatment and 0.3 immediately afterward. On subject satisfaction surveys, 92% of the patient said that they “agree” or “strongly agree” that their cellulite appeared improved.
“Patients with moderate cellulite seem to respond [to this treatment], too,” Dr. Tanzi said. “I don’t think there’s a ceiling or a floor to which we have to pigeonhole patients into potentially treating with this device. I think the key is [targeting] cellulite and not necessarily skin laxity.”
She emphasized that much remains to be known about the RAP device for treating cellulite. “What happens if we do multiple treatments to the tissue?” she asked. “Also, we need to further investigate what’s happening in the tissue, because not only does it seem like we’re getting a cleaving of the fibrous septa, but what is happening to the fibroblasts? What’s really happening in the tissue on a molecular level when those rapid acoustic pulses are going through the skin? There’s a lot of unanswered questions, but this is exciting technology.”
According to a news release from Soliton, the company is further reviewing and analyzing these results for inclusion in a marketing application to the Food and Drug Administration.
Soliton sponsored the trial. Dr. Tanzi disclosed that she is either a consultant for or is a member of the scientific advisory board for Allergan/Coolsculpting, Beiersdorf, Cutera, Merz/Ulthera, Pulse Biosciences, Sciton, Soliton, Solta, and Syneron/Candela.
After a single treatment, it provided a roughly 1.16 point reduction in the five-point Cellulite Severity Scale at 12 weeks, which corresponds to a roughly 32.5% reduction in cellulite.
“In cellulite, we know that the septa within the fat – those fibrous bands that pull down the skin and tether – lead to the traditional look of cellulite dimples and ridges,” lead study author Elizabeth Tanzi, MD, said during a late-breaking abstract session at the virtual annual meeting of the American Academy of Dermatology. A rapid acoustic pulse (RAP) device being developed by Soliton emits rapid acoustic pulses and shock waves at 50 Hz that are transmitted through the skin. The pulses “rupture and shear the fibrotic septa, which causes release of the septa and smoothing of the skin dimples,” explained Dr. Tanzi, director of Capital Laser & Skin Care in Chevy Chase, Md.
She added that the repetition rate of the RAP device makes it stand out from other technologies currently on the market for cellulite treatment. “The repetition rate and very short rise times provide microscopic mechanical destruction to the targeted cellular level structures and the vacuoles,” Dr. Tanzi said. “The high peak pressure and fast repetition rate exploit the viscoelastic nature of the tissue. It’s the rapid rate at which the energy is being delivered, as well as the very short times that energy is being delivered, that makes the technology an entirely different device-tissue interaction.”
The physical effects observed occur in the extracellular matrix and in the destruction of fibrous septa. “That’s the acoustic subcision,” she continued. “But also, there’s no cavitation and there are nonthermal physical effects. There is some investigational research going into what biologic effects those shock waves have on the rest of the tissue, looking into neocollagenesis, potential angiogenesis, potential lymphangiogenesis, as well as inflammation inhibition.”
In a prospective pivotal clinical trial conducted at four sites, Dr. Tanzi and her colleagues evaluated the safety and effectiveness of the RAP device in 62 female patients who were treated with a single, rapid acoustic pulse treatment comprised of 1-2 minutes on each identified dimple or large ridge of cellulite. This amounted to a 19- to 33-minute treatment session for each patient. No anesthesia was required, and photographs were taken on all sites with QuantifiCare medical imaging software.
“It’s completely noninvasive and it’s truly an incisionless treatment,” Dr. Tanzi said of the procedure. “The skin’s never punctured. There’s physician oversight, but it is highly delegatable, and there is no recovery time for the patient.”
Following treatment, adverse effects and tolerability were reported, and safety and efficacy were assessed at 12 weeks. Efficacy was determined by photographic assessment by three blinded independent physicians who used a validated, simplified version of the Cellulite Severity Scale (CSS), a 0-5 scale based on the number of cellulite depressions, as well as the average depth of those depressions.
The mean age of patients was 43 years, 92% were white, and their mean body mass index was 24.5 kg/m2. The average time of treatment was 28 minutes. Based on the CSS scores, the researchers found that 87% of the study subjects had some improvement of their cellulite after a single RAP treatment. “If you break the data down further, half of patients had at least a 30% reduction of their CSS, and almost one-quarter had a 50% improvement of their CSS,” Dr. Tanzi said. “Overall, we saw a reduction of a 1.16 level on that six-point scale, which translates roughly into 32.5% reduction of the look of their cellulite from the baseline score.”
In addition, 84% of the time, the blinded assessors were able to correctly identify pre- and posttreatment unlabeled photos that they were presented at the 3-month mark. Those same blinded assessors graded about 86% of the treated cellulite areas as appearing either improved, much improved, or very much improved on the Global Aesthetic Improvement Scale (GAIS).
“We found a very favorable side-effect profile, although 95% of patients had some redness to their skin,” Dr. Tanzi added. “They had some erythema and folliculitis, but it was transient and very mild. In addition, 98% of patients said that the procedure was tolerable.”
As for pain, on a 0-10 scale, with 10 being the worst, subjects rated their pain level at 2.4 during the treatment and 0.3 immediately afterward. On subject satisfaction surveys, 92% of the patient said that they “agree” or “strongly agree” that their cellulite appeared improved.
“Patients with moderate cellulite seem to respond [to this treatment], too,” Dr. Tanzi said. “I don’t think there’s a ceiling or a floor to which we have to pigeonhole patients into potentially treating with this device. I think the key is [targeting] cellulite and not necessarily skin laxity.”
She emphasized that much remains to be known about the RAP device for treating cellulite. “What happens if we do multiple treatments to the tissue?” she asked. “Also, we need to further investigate what’s happening in the tissue, because not only does it seem like we’re getting a cleaving of the fibrous septa, but what is happening to the fibroblasts? What’s really happening in the tissue on a molecular level when those rapid acoustic pulses are going through the skin? There’s a lot of unanswered questions, but this is exciting technology.”
According to a news release from Soliton, the company is further reviewing and analyzing these results for inclusion in a marketing application to the Food and Drug Administration.
Soliton sponsored the trial. Dr. Tanzi disclosed that she is either a consultant for or is a member of the scientific advisory board for Allergan/Coolsculpting, Beiersdorf, Cutera, Merz/Ulthera, Pulse Biosciences, Sciton, Soliton, Solta, and Syneron/Candela.
After a single treatment, it provided a roughly 1.16 point reduction in the five-point Cellulite Severity Scale at 12 weeks, which corresponds to a roughly 32.5% reduction in cellulite.
“In cellulite, we know that the septa within the fat – those fibrous bands that pull down the skin and tether – lead to the traditional look of cellulite dimples and ridges,” lead study author Elizabeth Tanzi, MD, said during a late-breaking abstract session at the virtual annual meeting of the American Academy of Dermatology. A rapid acoustic pulse (RAP) device being developed by Soliton emits rapid acoustic pulses and shock waves at 50 Hz that are transmitted through the skin. The pulses “rupture and shear the fibrotic septa, which causes release of the septa and smoothing of the skin dimples,” explained Dr. Tanzi, director of Capital Laser & Skin Care in Chevy Chase, Md.
She added that the repetition rate of the RAP device makes it stand out from other technologies currently on the market for cellulite treatment. “The repetition rate and very short rise times provide microscopic mechanical destruction to the targeted cellular level structures and the vacuoles,” Dr. Tanzi said. “The high peak pressure and fast repetition rate exploit the viscoelastic nature of the tissue. It’s the rapid rate at which the energy is being delivered, as well as the very short times that energy is being delivered, that makes the technology an entirely different device-tissue interaction.”
The physical effects observed occur in the extracellular matrix and in the destruction of fibrous septa. “That’s the acoustic subcision,” she continued. “But also, there’s no cavitation and there are nonthermal physical effects. There is some investigational research going into what biologic effects those shock waves have on the rest of the tissue, looking into neocollagenesis, potential angiogenesis, potential lymphangiogenesis, as well as inflammation inhibition.”
In a prospective pivotal clinical trial conducted at four sites, Dr. Tanzi and her colleagues evaluated the safety and effectiveness of the RAP device in 62 female patients who were treated with a single, rapid acoustic pulse treatment comprised of 1-2 minutes on each identified dimple or large ridge of cellulite. This amounted to a 19- to 33-minute treatment session for each patient. No anesthesia was required, and photographs were taken on all sites with QuantifiCare medical imaging software.
“It’s completely noninvasive and it’s truly an incisionless treatment,” Dr. Tanzi said of the procedure. “The skin’s never punctured. There’s physician oversight, but it is highly delegatable, and there is no recovery time for the patient.”
Following treatment, adverse effects and tolerability were reported, and safety and efficacy were assessed at 12 weeks. Efficacy was determined by photographic assessment by three blinded independent physicians who used a validated, simplified version of the Cellulite Severity Scale (CSS), a 0-5 scale based on the number of cellulite depressions, as well as the average depth of those depressions.
The mean age of patients was 43 years, 92% were white, and their mean body mass index was 24.5 kg/m2. The average time of treatment was 28 minutes. Based on the CSS scores, the researchers found that 87% of the study subjects had some improvement of their cellulite after a single RAP treatment. “If you break the data down further, half of patients had at least a 30% reduction of their CSS, and almost one-quarter had a 50% improvement of their CSS,” Dr. Tanzi said. “Overall, we saw a reduction of a 1.16 level on that six-point scale, which translates roughly into 32.5% reduction of the look of their cellulite from the baseline score.”
In addition, 84% of the time, the blinded assessors were able to correctly identify pre- and posttreatment unlabeled photos that they were presented at the 3-month mark. Those same blinded assessors graded about 86% of the treated cellulite areas as appearing either improved, much improved, or very much improved on the Global Aesthetic Improvement Scale (GAIS).
“We found a very favorable side-effect profile, although 95% of patients had some redness to their skin,” Dr. Tanzi added. “They had some erythema and folliculitis, but it was transient and very mild. In addition, 98% of patients said that the procedure was tolerable.”
As for pain, on a 0-10 scale, with 10 being the worst, subjects rated their pain level at 2.4 during the treatment and 0.3 immediately afterward. On subject satisfaction surveys, 92% of the patient said that they “agree” or “strongly agree” that their cellulite appeared improved.
“Patients with moderate cellulite seem to respond [to this treatment], too,” Dr. Tanzi said. “I don’t think there’s a ceiling or a floor to which we have to pigeonhole patients into potentially treating with this device. I think the key is [targeting] cellulite and not necessarily skin laxity.”
She emphasized that much remains to be known about the RAP device for treating cellulite. “What happens if we do multiple treatments to the tissue?” she asked. “Also, we need to further investigate what’s happening in the tissue, because not only does it seem like we’re getting a cleaving of the fibrous septa, but what is happening to the fibroblasts? What’s really happening in the tissue on a molecular level when those rapid acoustic pulses are going through the skin? There’s a lot of unanswered questions, but this is exciting technology.”
According to a news release from Soliton, the company is further reviewing and analyzing these results for inclusion in a marketing application to the Food and Drug Administration.
Soliton sponsored the trial. Dr. Tanzi disclosed that she is either a consultant for or is a member of the scientific advisory board for Allergan/Coolsculpting, Beiersdorf, Cutera, Merz/Ulthera, Pulse Biosciences, Sciton, Soliton, Solta, and Syneron/Candela.
FROM AAD 20
Daily Recap: Transgender patients turn to DIY treatments; ACIP plans priority vaccine groups
Here are the stories our MDedge editors across specialties think you need to know about today:
Ignored by doctors, transgender patients turn to DIY treatments
Without access to quality medical care, trans people around the world are seeking hormones from friends or through illegal online markets, even when the cost exceeds what it would through insurance. Although rare, others are resorting to self-surgery by cutting off their own penis and testicles or breasts.
Even with a doctor’s oversight, the health risks of transgender hormone therapy remain unclear, but without formal medical care, the do-it-yourself transition may be downright dangerous. To minimize these risks, some experts suggest health care reforms such as making it easier for primary care physicians to assess trans patients and prescribe hormones or creating specialized clinics where doctors prescribe hormones on demand.
Treating gender dysphoria should be just like treating a patient for any other condition. “It wouldn't be acceptable for someone to come into a primary care provider’s office with diabetes” and for the doctor to say “‘I can't actually treat you. Please leave,’” Zil Goldstein, associate medical director for transgender and gender non-binary health at the Callen-Lorde Community Health Center in New York City. Primary care providers need to see transgender care, she adds, “as a regular part of their practice.” Read more.
ACIP plans priority groups in advance of COVID-19 vaccine
Early plans for prioritizing vaccination when a COVID-19 vaccine becomes available include placing critical health care workers in the first tier, according to Sarah Mbaeyi, MD, MPH, of the CDC’s National Center for Immunization and Respiratory Diseases.
A COVID-19 vaccine work group is developing strategies and identifying priority groups for vaccination to help inform discussions about the use of COVID-19 vaccines, Dr. Mbaeyi said at a virtual meeting of the CDC’s Advisory Committee on Immunization Practices.
Based on current information, the work group has proposed that vaccine priority be given to health care personnel, essential workers, adults aged 65 years and older, long-term care facility residents, and persons with high-risk medical conditions.
Among these groups “a subset of critical health care and other workers should receive initial doses,” Dr. Mbaeyi said. Read more.
‘Nietzsche was wrong’: Past stressors do not create psychological resilience.
The famous quote from the German philosopher Friedrich Nietzsche, “That which does not kill us makes us stronger,” may not be true after all – at least when it comes to mental health.
Results of a new study show that individuals who have a history of a stressful life events are more likely to develop PTSD and/or major depressive disorder (MDD) following a major natural disaster than their counterparts who do not have such a history.
The investigation of more than a thousand Chilean residents – all of whom experienced one of the most powerful earthquakes in the country’s history – showed that the odds of developing postdisaster PTSD or MDD increased according to the number of predisaster stressors participants had experienced.
“At the clinical level, these findings help the clinician know which patients are more likely to need more intensive services,” said Stephen L. Buka, PhD. “And the more trauma and hardship they’ve experienced, the more attention they need and the less likely they’re going to be able to cope and manage on their own.” Read more.
High-impact training can build bone in older women
Older adults, particularly postmenopausal women, are often advised to pursue low-impact, low-intensity exercise as a way to preserve joint health, but that approach might actually contribute to a decline in bone mineral density, researchers report.
Concerns about falls and fracture risk have led many clinicians to advise against higher-impact activities, like jumping, but that is exactly the type of activity that improves bone density and physical function, said Belinda Beck, PhD, professor at the Griffith University School of Allied Health Sciences in Southport, Australia. But new findings show that high-intensity resistance and impact training was a safe and effective way to improve bone mass.
“Once women hit 60, they’re somehow regarded as frail, but that becomes a self-fulfilling prophecy when we take this kinder, gentler approach to exercise,” said Vanessa Yingling, PhD. Read more.
For more on COVID-19, visit our Resource Center. All of our latest news is available on MDedge.com.
Here are the stories our MDedge editors across specialties think you need to know about today:
Ignored by doctors, transgender patients turn to DIY treatments
Without access to quality medical care, trans people around the world are seeking hormones from friends or through illegal online markets, even when the cost exceeds what it would through insurance. Although rare, others are resorting to self-surgery by cutting off their own penis and testicles or breasts.
Even with a doctor’s oversight, the health risks of transgender hormone therapy remain unclear, but without formal medical care, the do-it-yourself transition may be downright dangerous. To minimize these risks, some experts suggest health care reforms such as making it easier for primary care physicians to assess trans patients and prescribe hormones or creating specialized clinics where doctors prescribe hormones on demand.
Treating gender dysphoria should be just like treating a patient for any other condition. “It wouldn't be acceptable for someone to come into a primary care provider’s office with diabetes” and for the doctor to say “‘I can't actually treat you. Please leave,’” Zil Goldstein, associate medical director for transgender and gender non-binary health at the Callen-Lorde Community Health Center in New York City. Primary care providers need to see transgender care, she adds, “as a regular part of their practice.” Read more.
ACIP plans priority groups in advance of COVID-19 vaccine
Early plans for prioritizing vaccination when a COVID-19 vaccine becomes available include placing critical health care workers in the first tier, according to Sarah Mbaeyi, MD, MPH, of the CDC’s National Center for Immunization and Respiratory Diseases.
A COVID-19 vaccine work group is developing strategies and identifying priority groups for vaccination to help inform discussions about the use of COVID-19 vaccines, Dr. Mbaeyi said at a virtual meeting of the CDC’s Advisory Committee on Immunization Practices.
Based on current information, the work group has proposed that vaccine priority be given to health care personnel, essential workers, adults aged 65 years and older, long-term care facility residents, and persons with high-risk medical conditions.
Among these groups “a subset of critical health care and other workers should receive initial doses,” Dr. Mbaeyi said. Read more.
‘Nietzsche was wrong’: Past stressors do not create psychological resilience.
The famous quote from the German philosopher Friedrich Nietzsche, “That which does not kill us makes us stronger,” may not be true after all – at least when it comes to mental health.
Results of a new study show that individuals who have a history of a stressful life events are more likely to develop PTSD and/or major depressive disorder (MDD) following a major natural disaster than their counterparts who do not have such a history.
The investigation of more than a thousand Chilean residents – all of whom experienced one of the most powerful earthquakes in the country’s history – showed that the odds of developing postdisaster PTSD or MDD increased according to the number of predisaster stressors participants had experienced.
“At the clinical level, these findings help the clinician know which patients are more likely to need more intensive services,” said Stephen L. Buka, PhD. “And the more trauma and hardship they’ve experienced, the more attention they need and the less likely they’re going to be able to cope and manage on their own.” Read more.
High-impact training can build bone in older women
Older adults, particularly postmenopausal women, are often advised to pursue low-impact, low-intensity exercise as a way to preserve joint health, but that approach might actually contribute to a decline in bone mineral density, researchers report.
Concerns about falls and fracture risk have led many clinicians to advise against higher-impact activities, like jumping, but that is exactly the type of activity that improves bone density and physical function, said Belinda Beck, PhD, professor at the Griffith University School of Allied Health Sciences in Southport, Australia. But new findings show that high-intensity resistance and impact training was a safe and effective way to improve bone mass.
“Once women hit 60, they’re somehow regarded as frail, but that becomes a self-fulfilling prophecy when we take this kinder, gentler approach to exercise,” said Vanessa Yingling, PhD. Read more.
For more on COVID-19, visit our Resource Center. All of our latest news is available on MDedge.com.
Here are the stories our MDedge editors across specialties think you need to know about today:
Ignored by doctors, transgender patients turn to DIY treatments
Without access to quality medical care, trans people around the world are seeking hormones from friends or through illegal online markets, even when the cost exceeds what it would through insurance. Although rare, others are resorting to self-surgery by cutting off their own penis and testicles or breasts.
Even with a doctor’s oversight, the health risks of transgender hormone therapy remain unclear, but without formal medical care, the do-it-yourself transition may be downright dangerous. To minimize these risks, some experts suggest health care reforms such as making it easier for primary care physicians to assess trans patients and prescribe hormones or creating specialized clinics where doctors prescribe hormones on demand.
Treating gender dysphoria should be just like treating a patient for any other condition. “It wouldn't be acceptable for someone to come into a primary care provider’s office with diabetes” and for the doctor to say “‘I can't actually treat you. Please leave,’” Zil Goldstein, associate medical director for transgender and gender non-binary health at the Callen-Lorde Community Health Center in New York City. Primary care providers need to see transgender care, she adds, “as a regular part of their practice.” Read more.
ACIP plans priority groups in advance of COVID-19 vaccine
Early plans for prioritizing vaccination when a COVID-19 vaccine becomes available include placing critical health care workers in the first tier, according to Sarah Mbaeyi, MD, MPH, of the CDC’s National Center for Immunization and Respiratory Diseases.
A COVID-19 vaccine work group is developing strategies and identifying priority groups for vaccination to help inform discussions about the use of COVID-19 vaccines, Dr. Mbaeyi said at a virtual meeting of the CDC’s Advisory Committee on Immunization Practices.
Based on current information, the work group has proposed that vaccine priority be given to health care personnel, essential workers, adults aged 65 years and older, long-term care facility residents, and persons with high-risk medical conditions.
Among these groups “a subset of critical health care and other workers should receive initial doses,” Dr. Mbaeyi said. Read more.
‘Nietzsche was wrong’: Past stressors do not create psychological resilience.
The famous quote from the German philosopher Friedrich Nietzsche, “That which does not kill us makes us stronger,” may not be true after all – at least when it comes to mental health.
Results of a new study show that individuals who have a history of a stressful life events are more likely to develop PTSD and/or major depressive disorder (MDD) following a major natural disaster than their counterparts who do not have such a history.
The investigation of more than a thousand Chilean residents – all of whom experienced one of the most powerful earthquakes in the country’s history – showed that the odds of developing postdisaster PTSD or MDD increased according to the number of predisaster stressors participants had experienced.
“At the clinical level, these findings help the clinician know which patients are more likely to need more intensive services,” said Stephen L. Buka, PhD. “And the more trauma and hardship they’ve experienced, the more attention they need and the less likely they’re going to be able to cope and manage on their own.” Read more.
High-impact training can build bone in older women
Older adults, particularly postmenopausal women, are often advised to pursue low-impact, low-intensity exercise as a way to preserve joint health, but that approach might actually contribute to a decline in bone mineral density, researchers report.
Concerns about falls and fracture risk have led many clinicians to advise against higher-impact activities, like jumping, but that is exactly the type of activity that improves bone density and physical function, said Belinda Beck, PhD, professor at the Griffith University School of Allied Health Sciences in Southport, Australia. But new findings show that high-intensity resistance and impact training was a safe and effective way to improve bone mass.
“Once women hit 60, they’re somehow regarded as frail, but that becomes a self-fulfilling prophecy when we take this kinder, gentler approach to exercise,” said Vanessa Yingling, PhD. Read more.
For more on COVID-19, visit our Resource Center. All of our latest news is available on MDedge.com.
Don't Let the Bedbugs Bite: An Unusual Presentation of Bedbug Infestation Resulting in Life-Threatening Anemia
To the Editor:
A 61-year-old man presented to the emergency department with a rash on the right leg, generalized pruritus, and chest pain. The patient described intermittent exertional pressure-like chest pain over the last few days but had no known prior cardiac history. He also noted worsening edema of the right leg with erythema. Three months prior he had been hospitalized for a similar presentation and was diagnosed with cellulitis of the right leg. The patient was treated with a course of trimethoprim-sulfamethoxazole and permethrin cream for presumed scabies and followed up with dermatology for the persistent generalized pruritic rash and cellulitis. At that time, he was diagnosed with stasis dermatitis with dermatitis neglecta and excoriations. He was educated on general hygiene and treated with triamcinolone, hydrophilic ointment, and pramoxine lotion for pruritus. He also was empirically treated again for scabies.
At the current presentation, preliminary investigation showed profound anemia with a hemoglobin level of 6.2 g/dL (baseline hemoglobin level 3 months prior, 13.1 g/dL). He was subsequently admitted to the general medicine ward for further investigation of severe symptomatic anemia. A medical history revealed moderate chronic obstructive pulmonary disease, hypertension, gastroesophageal reflux disease, xerosis, and fracture of the right ankle following open reduction internal fixation 6 years prior to admission. There was no history of blood loss, antiplatelet agents, or anticoagulants. He was on disability and lived in a single-room occupancy hotel. He did not report any high-risk sexual behaviors or abuse of alcohol or drugs. He actively smoked 1.5 packs of cigarettes per day for the last 30 years. He denied any allergies.
Physical examination revealed the patient was afebrile, nontoxic, disheveled, and in no acute distress. He had anicteric sclera and pale conjunctiva. The right leg appeared more erythematous and edematous compared to the left leg but without warmth or tenderness to palpation. He had innumerable 4- to 5-mm, erythematous, excoriated papules on the skin (Figure). His bed sheets were noted to have multiple rusty-black specks thought to be related to the crusted lesions. Physical examination was otherwise unremarkable.
Laboratory workup revealed severe iron-deficiency anemia without any evidence of hemolysis, marrow suppression, infection, or immune compromise (Table). He had a vitamin B12 deficiency (197 pg/mL [reference range, 239-931 pg/mL]), but we felt it was very unlikely to be responsible for his profound, sudden-onset microcytic anemia. Further evaluation for occult bleeding revealed an unremarkable upper endoscopy with push enteroscopy and colonoscopy. An alternate etiology of the anemia could not be identified.
Subsequently, he reported multiple pruritic bug bites sustained at the hotel room where he resided and continued to note pruritus while hospitalized. Pest control inspected the hospital room and identified bedbugs, Cimex lectularius, among his belongings. Upon further review, his clothes and walker were found to be completely infested with these organisms in different stages of development. Treatment included blood transfusions, iron supplementation, and environmental control of the infested living space both in the hospital and at his residence, with subsequent resolution of symptoms and anemia. Two weeks following discharge, the patient no longer reported pruritus, and his hemoglobin level had returned to baseline.
Over the last decade there has been an exponential resurgence in C lectularius infestations in developed countries attributed to increasing global travel, growing pesticide resistance, lack of public awareness, and inadequate pest control programs. This re-emergence has resulted in a public health problem. Although bedbugs are not known to transmit infectious diseases, severe infestation can result in notable dermatitis, iron-deficiency anemia from chronic blood loss, superinfection, allergic reactions including anaphylaxis in rare cases, and psychologic distress.
Iron-deficiency anemia caused by excessive bedbug biting in infants and children has been documented as early as the 1960s.1 Our knowledge of severe anemia due to bedbug infestation is limited to only 4 cases in the literature, according to a PubMed search of articles indexed for MEDLINE using the terms bedbugs anemia and cimex anemia.1-4 All cases reported bedbug infestations involving personal clothing, belongings, and/or living spaces. Patient concerns at presentation ranged from lethargy and fatigue with pruritic rash to chest pain and syncope with findings of severe microcytic or normocytic anemia (hemoglobin level, 5-8 g/dL). All cases were treated supportively with blood transfusion and iron supplementation, with hemoglobin recovery after several weeks. Environmental extermination also was required to prevent recurrence.1-4 Given that each bedbug blood meal is on average 7 mm3, one would have to incur a minimum of 143,000 bites to experience a blood loss of 1 L.3
The differential diagnosis for a patient with generalized pruritus should be broad and includes dermatologic conditions (eg, xerosis, atopic dermatitis, contact dermatitis, urticaria, dermatophytosis, lichen simplex chronicus, psoriasis, scabies, pediculosis corporis and pubis, other arthropod bites, bullous pemphigoid), systemic disorders (eg, renal disease, diabetes mellitus, thyroid disease, cholestasis, human immunodeficiency virus), malignancy, connective tissue disease, medication side effects, and psychogenic and neuropathic itch.
The diagnosis of C lectularius infestation is confirmed by finding the wingless, reddish brown, flat and ovular arthropod, with adult lengths of 4 to 7 mm, approximately the size of an apple seed.5-11 Bedbugs typically are active at night and feed for 3 to 10 minutes. After their feed or during the day, bedbugs will return to their nest in furniture, mattresses, beds, walls, and floors. Bedbug bites appear as small clusters or lines of pruritic erythematous papules with a central hemorrhagic puncta. Other cutaneous symptoms include isolated pruritus, papules, nodules, and bullous eruptions.7 Additional signs of bedbug infestation include black fecal stains in areas of inhabitation as well as actual bedbugs feeding during the day due to overcrowding.
Treatment of pruritic localized cutaneous reactions is supportive and includes antipruritic agents, topical steroids, topical anesthetics, antihistamines, or topical or systemic antibiotics for secondary infections.5-11 Systemic reactions, including anaphylaxis, are treated with epinephrine, antihistamines, and/or corticosteroids, while severe anemia is treated supportively with blood transfusions and iron supplementation.5-11 To prevent reoccurrence, environmental control in the form of nonchemical and chemical treatments is crucial in controlling bedbug infestations.5-11
This case highlights the relevance of a rare but notable morbidity associated with bedbug infestation and the adverse effects of bedbugs on public health. This patient's living situation in a single-room occupancy hotel, poor hygiene, and possible cognitive impairment from his multiple medical conditions may have increased his risk for extreme bedbug infestation. With a good history, physical examination, proper inspection of the patient's belongings, and provider awareness of this epidemic, the severity of this patient's anemia may have been circumvented on the prior hospital admission and follow-up office visit. Once such an infestation is confirmed, a multidisciplinary approach including social work assistance, health services, and pest control is needed to appropriately treat the patient and the environment. Methods in preventing and managing this growing public health problem include improving hygiene, avoiding secondhand goods, and increasing awareness in the identification and proper elimination of bedbugs.5-7
- Venkatachalam PS, Belavady B. Loss of haemoglobin iron due to excessive biting by bed bugs. a possible aetiological factor in the iron deficiency anaemia of infants and children. Trans R Soc Trop Med Hyg. 1962;56:218-221.
- Pritchard MJ, Hwang SW. Severe anemia from bedbugs. CMAJ. 2009;181:287-288.
- Paulke-Korinek M, Széll M, Laferl H, et al. Bed bugs can cause severe anaemia in adults. Parasitol Res. 2012;110:2577-2579.
- Sabou M, Imperiale DG, Andrés E, et al. Bed bugs reproductive life cycle in the clothes of a patient suffering from Alzheimer's disease results in iron deficiency anemia. Parasite. 2013;20:16.
- Studdiford JS, Conniff KM, Trayes KP, et al. Bedbug infestation. Am Fam Physician. 2012;86:653-658.
- Goddard J, deShazo R. Bed bugs (Cimex lectularis) and clinical consequences of their bites. JAMA. 2009;301:1358-1366.
- Bernardeschi C, Le Cleach L, Delaunay P, et al. Bed bug infestation. BMJ. 2013;346:f138.
- Silvia Munoz-Price L, Safdar N, Beier JC, et al. Bed bugs inhealthcare settings. Infect Control Hosp Epidemiol. 2012;33:1137-1142.
- Huntington MK. When bed bugs bite. J Fam Pract. 2012;61:384-388.
- Delaunay P, Blanc V, Del Giudice P, et al. Bedbugs and infectious diseases. Clin Infect Dis. 2011;52:200-212.
- Doggett SL, Dwyer DE, Penas PF, et al. Bed bugs: clinical relevance and control options. Clin Microbiol Rev. 2012;25:164-192.
To the Editor:
A 61-year-old man presented to the emergency department with a rash on the right leg, generalized pruritus, and chest pain. The patient described intermittent exertional pressure-like chest pain over the last few days but had no known prior cardiac history. He also noted worsening edema of the right leg with erythema. Three months prior he had been hospitalized for a similar presentation and was diagnosed with cellulitis of the right leg. The patient was treated with a course of trimethoprim-sulfamethoxazole and permethrin cream for presumed scabies and followed up with dermatology for the persistent generalized pruritic rash and cellulitis. At that time, he was diagnosed with stasis dermatitis with dermatitis neglecta and excoriations. He was educated on general hygiene and treated with triamcinolone, hydrophilic ointment, and pramoxine lotion for pruritus. He also was empirically treated again for scabies.
At the current presentation, preliminary investigation showed profound anemia with a hemoglobin level of 6.2 g/dL (baseline hemoglobin level 3 months prior, 13.1 g/dL). He was subsequently admitted to the general medicine ward for further investigation of severe symptomatic anemia. A medical history revealed moderate chronic obstructive pulmonary disease, hypertension, gastroesophageal reflux disease, xerosis, and fracture of the right ankle following open reduction internal fixation 6 years prior to admission. There was no history of blood loss, antiplatelet agents, or anticoagulants. He was on disability and lived in a single-room occupancy hotel. He did not report any high-risk sexual behaviors or abuse of alcohol or drugs. He actively smoked 1.5 packs of cigarettes per day for the last 30 years. He denied any allergies.
Physical examination revealed the patient was afebrile, nontoxic, disheveled, and in no acute distress. He had anicteric sclera and pale conjunctiva. The right leg appeared more erythematous and edematous compared to the left leg but without warmth or tenderness to palpation. He had innumerable 4- to 5-mm, erythematous, excoriated papules on the skin (Figure). His bed sheets were noted to have multiple rusty-black specks thought to be related to the crusted lesions. Physical examination was otherwise unremarkable.
Laboratory workup revealed severe iron-deficiency anemia without any evidence of hemolysis, marrow suppression, infection, or immune compromise (Table). He had a vitamin B12 deficiency (197 pg/mL [reference range, 239-931 pg/mL]), but we felt it was very unlikely to be responsible for his profound, sudden-onset microcytic anemia. Further evaluation for occult bleeding revealed an unremarkable upper endoscopy with push enteroscopy and colonoscopy. An alternate etiology of the anemia could not be identified.
Subsequently, he reported multiple pruritic bug bites sustained at the hotel room where he resided and continued to note pruritus while hospitalized. Pest control inspected the hospital room and identified bedbugs, Cimex lectularius, among his belongings. Upon further review, his clothes and walker were found to be completely infested with these organisms in different stages of development. Treatment included blood transfusions, iron supplementation, and environmental control of the infested living space both in the hospital and at his residence, with subsequent resolution of symptoms and anemia. Two weeks following discharge, the patient no longer reported pruritus, and his hemoglobin level had returned to baseline.
Over the last decade there has been an exponential resurgence in C lectularius infestations in developed countries attributed to increasing global travel, growing pesticide resistance, lack of public awareness, and inadequate pest control programs. This re-emergence has resulted in a public health problem. Although bedbugs are not known to transmit infectious diseases, severe infestation can result in notable dermatitis, iron-deficiency anemia from chronic blood loss, superinfection, allergic reactions including anaphylaxis in rare cases, and psychologic distress.
Iron-deficiency anemia caused by excessive bedbug biting in infants and children has been documented as early as the 1960s.1 Our knowledge of severe anemia due to bedbug infestation is limited to only 4 cases in the literature, according to a PubMed search of articles indexed for MEDLINE using the terms bedbugs anemia and cimex anemia.1-4 All cases reported bedbug infestations involving personal clothing, belongings, and/or living spaces. Patient concerns at presentation ranged from lethargy and fatigue with pruritic rash to chest pain and syncope with findings of severe microcytic or normocytic anemia (hemoglobin level, 5-8 g/dL). All cases were treated supportively with blood transfusion and iron supplementation, with hemoglobin recovery after several weeks. Environmental extermination also was required to prevent recurrence.1-4 Given that each bedbug blood meal is on average 7 mm3, one would have to incur a minimum of 143,000 bites to experience a blood loss of 1 L.3
The differential diagnosis for a patient with generalized pruritus should be broad and includes dermatologic conditions (eg, xerosis, atopic dermatitis, contact dermatitis, urticaria, dermatophytosis, lichen simplex chronicus, psoriasis, scabies, pediculosis corporis and pubis, other arthropod bites, bullous pemphigoid), systemic disorders (eg, renal disease, diabetes mellitus, thyroid disease, cholestasis, human immunodeficiency virus), malignancy, connective tissue disease, medication side effects, and psychogenic and neuropathic itch.
The diagnosis of C lectularius infestation is confirmed by finding the wingless, reddish brown, flat and ovular arthropod, with adult lengths of 4 to 7 mm, approximately the size of an apple seed.5-11 Bedbugs typically are active at night and feed for 3 to 10 minutes. After their feed or during the day, bedbugs will return to their nest in furniture, mattresses, beds, walls, and floors. Bedbug bites appear as small clusters or lines of pruritic erythematous papules with a central hemorrhagic puncta. Other cutaneous symptoms include isolated pruritus, papules, nodules, and bullous eruptions.7 Additional signs of bedbug infestation include black fecal stains in areas of inhabitation as well as actual bedbugs feeding during the day due to overcrowding.
Treatment of pruritic localized cutaneous reactions is supportive and includes antipruritic agents, topical steroids, topical anesthetics, antihistamines, or topical or systemic antibiotics for secondary infections.5-11 Systemic reactions, including anaphylaxis, are treated with epinephrine, antihistamines, and/or corticosteroids, while severe anemia is treated supportively with blood transfusions and iron supplementation.5-11 To prevent reoccurrence, environmental control in the form of nonchemical and chemical treatments is crucial in controlling bedbug infestations.5-11
This case highlights the relevance of a rare but notable morbidity associated with bedbug infestation and the adverse effects of bedbugs on public health. This patient's living situation in a single-room occupancy hotel, poor hygiene, and possible cognitive impairment from his multiple medical conditions may have increased his risk for extreme bedbug infestation. With a good history, physical examination, proper inspection of the patient's belongings, and provider awareness of this epidemic, the severity of this patient's anemia may have been circumvented on the prior hospital admission and follow-up office visit. Once such an infestation is confirmed, a multidisciplinary approach including social work assistance, health services, and pest control is needed to appropriately treat the patient and the environment. Methods in preventing and managing this growing public health problem include improving hygiene, avoiding secondhand goods, and increasing awareness in the identification and proper elimination of bedbugs.5-7
To the Editor:
A 61-year-old man presented to the emergency department with a rash on the right leg, generalized pruritus, and chest pain. The patient described intermittent exertional pressure-like chest pain over the last few days but had no known prior cardiac history. He also noted worsening edema of the right leg with erythema. Three months prior he had been hospitalized for a similar presentation and was diagnosed with cellulitis of the right leg. The patient was treated with a course of trimethoprim-sulfamethoxazole and permethrin cream for presumed scabies and followed up with dermatology for the persistent generalized pruritic rash and cellulitis. At that time, he was diagnosed with stasis dermatitis with dermatitis neglecta and excoriations. He was educated on general hygiene and treated with triamcinolone, hydrophilic ointment, and pramoxine lotion for pruritus. He also was empirically treated again for scabies.
At the current presentation, preliminary investigation showed profound anemia with a hemoglobin level of 6.2 g/dL (baseline hemoglobin level 3 months prior, 13.1 g/dL). He was subsequently admitted to the general medicine ward for further investigation of severe symptomatic anemia. A medical history revealed moderate chronic obstructive pulmonary disease, hypertension, gastroesophageal reflux disease, xerosis, and fracture of the right ankle following open reduction internal fixation 6 years prior to admission. There was no history of blood loss, antiplatelet agents, or anticoagulants. He was on disability and lived in a single-room occupancy hotel. He did not report any high-risk sexual behaviors or abuse of alcohol or drugs. He actively smoked 1.5 packs of cigarettes per day for the last 30 years. He denied any allergies.
Physical examination revealed the patient was afebrile, nontoxic, disheveled, and in no acute distress. He had anicteric sclera and pale conjunctiva. The right leg appeared more erythematous and edematous compared to the left leg but without warmth or tenderness to palpation. He had innumerable 4- to 5-mm, erythematous, excoriated papules on the skin (Figure). His bed sheets were noted to have multiple rusty-black specks thought to be related to the crusted lesions. Physical examination was otherwise unremarkable.
Laboratory workup revealed severe iron-deficiency anemia without any evidence of hemolysis, marrow suppression, infection, or immune compromise (Table). He had a vitamin B12 deficiency (197 pg/mL [reference range, 239-931 pg/mL]), but we felt it was very unlikely to be responsible for his profound, sudden-onset microcytic anemia. Further evaluation for occult bleeding revealed an unremarkable upper endoscopy with push enteroscopy and colonoscopy. An alternate etiology of the anemia could not be identified.
Subsequently, he reported multiple pruritic bug bites sustained at the hotel room where he resided and continued to note pruritus while hospitalized. Pest control inspected the hospital room and identified bedbugs, Cimex lectularius, among his belongings. Upon further review, his clothes and walker were found to be completely infested with these organisms in different stages of development. Treatment included blood transfusions, iron supplementation, and environmental control of the infested living space both in the hospital and at his residence, with subsequent resolution of symptoms and anemia. Two weeks following discharge, the patient no longer reported pruritus, and his hemoglobin level had returned to baseline.
Over the last decade there has been an exponential resurgence in C lectularius infestations in developed countries attributed to increasing global travel, growing pesticide resistance, lack of public awareness, and inadequate pest control programs. This re-emergence has resulted in a public health problem. Although bedbugs are not known to transmit infectious diseases, severe infestation can result in notable dermatitis, iron-deficiency anemia from chronic blood loss, superinfection, allergic reactions including anaphylaxis in rare cases, and psychologic distress.
Iron-deficiency anemia caused by excessive bedbug biting in infants and children has been documented as early as the 1960s.1 Our knowledge of severe anemia due to bedbug infestation is limited to only 4 cases in the literature, according to a PubMed search of articles indexed for MEDLINE using the terms bedbugs anemia and cimex anemia.1-4 All cases reported bedbug infestations involving personal clothing, belongings, and/or living spaces. Patient concerns at presentation ranged from lethargy and fatigue with pruritic rash to chest pain and syncope with findings of severe microcytic or normocytic anemia (hemoglobin level, 5-8 g/dL). All cases were treated supportively with blood transfusion and iron supplementation, with hemoglobin recovery after several weeks. Environmental extermination also was required to prevent recurrence.1-4 Given that each bedbug blood meal is on average 7 mm3, one would have to incur a minimum of 143,000 bites to experience a blood loss of 1 L.3
The differential diagnosis for a patient with generalized pruritus should be broad and includes dermatologic conditions (eg, xerosis, atopic dermatitis, contact dermatitis, urticaria, dermatophytosis, lichen simplex chronicus, psoriasis, scabies, pediculosis corporis and pubis, other arthropod bites, bullous pemphigoid), systemic disorders (eg, renal disease, diabetes mellitus, thyroid disease, cholestasis, human immunodeficiency virus), malignancy, connective tissue disease, medication side effects, and psychogenic and neuropathic itch.
The diagnosis of C lectularius infestation is confirmed by finding the wingless, reddish brown, flat and ovular arthropod, with adult lengths of 4 to 7 mm, approximately the size of an apple seed.5-11 Bedbugs typically are active at night and feed for 3 to 10 minutes. After their feed or during the day, bedbugs will return to their nest in furniture, mattresses, beds, walls, and floors. Bedbug bites appear as small clusters or lines of pruritic erythematous papules with a central hemorrhagic puncta. Other cutaneous symptoms include isolated pruritus, papules, nodules, and bullous eruptions.7 Additional signs of bedbug infestation include black fecal stains in areas of inhabitation as well as actual bedbugs feeding during the day due to overcrowding.
Treatment of pruritic localized cutaneous reactions is supportive and includes antipruritic agents, topical steroids, topical anesthetics, antihistamines, or topical or systemic antibiotics for secondary infections.5-11 Systemic reactions, including anaphylaxis, are treated with epinephrine, antihistamines, and/or corticosteroids, while severe anemia is treated supportively with blood transfusions and iron supplementation.5-11 To prevent reoccurrence, environmental control in the form of nonchemical and chemical treatments is crucial in controlling bedbug infestations.5-11
This case highlights the relevance of a rare but notable morbidity associated with bedbug infestation and the adverse effects of bedbugs on public health. This patient's living situation in a single-room occupancy hotel, poor hygiene, and possible cognitive impairment from his multiple medical conditions may have increased his risk for extreme bedbug infestation. With a good history, physical examination, proper inspection of the patient's belongings, and provider awareness of this epidemic, the severity of this patient's anemia may have been circumvented on the prior hospital admission and follow-up office visit. Once such an infestation is confirmed, a multidisciplinary approach including social work assistance, health services, and pest control is needed to appropriately treat the patient and the environment. Methods in preventing and managing this growing public health problem include improving hygiene, avoiding secondhand goods, and increasing awareness in the identification and proper elimination of bedbugs.5-7
- Venkatachalam PS, Belavady B. Loss of haemoglobin iron due to excessive biting by bed bugs. a possible aetiological factor in the iron deficiency anaemia of infants and children. Trans R Soc Trop Med Hyg. 1962;56:218-221.
- Pritchard MJ, Hwang SW. Severe anemia from bedbugs. CMAJ. 2009;181:287-288.
- Paulke-Korinek M, Széll M, Laferl H, et al. Bed bugs can cause severe anaemia in adults. Parasitol Res. 2012;110:2577-2579.
- Sabou M, Imperiale DG, Andrés E, et al. Bed bugs reproductive life cycle in the clothes of a patient suffering from Alzheimer's disease results in iron deficiency anemia. Parasite. 2013;20:16.
- Studdiford JS, Conniff KM, Trayes KP, et al. Bedbug infestation. Am Fam Physician. 2012;86:653-658.
- Goddard J, deShazo R. Bed bugs (Cimex lectularis) and clinical consequences of their bites. JAMA. 2009;301:1358-1366.
- Bernardeschi C, Le Cleach L, Delaunay P, et al. Bed bug infestation. BMJ. 2013;346:f138.
- Silvia Munoz-Price L, Safdar N, Beier JC, et al. Bed bugs inhealthcare settings. Infect Control Hosp Epidemiol. 2012;33:1137-1142.
- Huntington MK. When bed bugs bite. J Fam Pract. 2012;61:384-388.
- Delaunay P, Blanc V, Del Giudice P, et al. Bedbugs and infectious diseases. Clin Infect Dis. 2011;52:200-212.
- Doggett SL, Dwyer DE, Penas PF, et al. Bed bugs: clinical relevance and control options. Clin Microbiol Rev. 2012;25:164-192.
- Venkatachalam PS, Belavady B. Loss of haemoglobin iron due to excessive biting by bed bugs. a possible aetiological factor in the iron deficiency anaemia of infants and children. Trans R Soc Trop Med Hyg. 1962;56:218-221.
- Pritchard MJ, Hwang SW. Severe anemia from bedbugs. CMAJ. 2009;181:287-288.
- Paulke-Korinek M, Széll M, Laferl H, et al. Bed bugs can cause severe anaemia in adults. Parasitol Res. 2012;110:2577-2579.
- Sabou M, Imperiale DG, Andrés E, et al. Bed bugs reproductive life cycle in the clothes of a patient suffering from Alzheimer's disease results in iron deficiency anemia. Parasite. 2013;20:16.
- Studdiford JS, Conniff KM, Trayes KP, et al. Bedbug infestation. Am Fam Physician. 2012;86:653-658.
- Goddard J, deShazo R. Bed bugs (Cimex lectularis) and clinical consequences of their bites. JAMA. 2009;301:1358-1366.
- Bernardeschi C, Le Cleach L, Delaunay P, et al. Bed bug infestation. BMJ. 2013;346:f138.
- Silvia Munoz-Price L, Safdar N, Beier JC, et al. Bed bugs inhealthcare settings. Infect Control Hosp Epidemiol. 2012;33:1137-1142.
- Huntington MK. When bed bugs bite. J Fam Pract. 2012;61:384-388.
- Delaunay P, Blanc V, Del Giudice P, et al. Bedbugs and infectious diseases. Clin Infect Dis. 2011;52:200-212.
- Doggett SL, Dwyer DE, Penas PF, et al. Bed bugs: clinical relevance and control options. Clin Microbiol Rev. 2012;25:164-192.
Practice Points
- There has been a resurgence in bedbug (Cimex lectularius) infestations in developed countries.
- Although rare, anemia due to bedbug infestation should be considered in patients presenting with anemia and a widespread pruritic papular eruption.
- A thorough history and physical examination are essential to prevent a delay in diagnosis and avoid a costly and unnecessary workup.
- Successful treatment requires a multidisciplinary approach, which includes medical management, social services, and pest control.
