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Face mask type matters when sterilizing, study finds
according to researchers. The greatest reduction in filtration efficiency after sterilization occurred with surgical face masks.
With plasma vapor hydrogen peroxide (H2O2) sterilization, filtration efficiency of N95 and KN95 masks was maintained at more than 95%, but for surgical face masks, filtration efficiency was reduced to less than 95%. With chlorine dioxide (ClO2) sterilization, on the other hand, filtration efficiency was maintained at above 95% for N95 masks, but for KN95 and surgical face masks, filtration efficiency was reduced to less than 80%.
In a research letter published online June 15 in JAMA Network Open, researchers from the University of Oklahoma Health Sciences Center, Oklahoma City, report the results of a study of the two sterilization techniques on the pressure drop and filtration efficiency of N95, KN95, and surgical face masks.
“The H2O2 treatment showed a small effect on the overall filtration efficiency of the tested masks, but the ClO2 treatment showed marked reduction in the overall filtration efficiency of the KN95s and surgical face masks. All pressure drop changes were within the acceptable range,” the researchers write.
The study did not evaluate the effect of repeated sterilizations on face masks.
Five masks of each type were sterilized with either H2O2 or ClO2. Masks were then placed in a test chamber, and a salt aerosol was nebulized to assess both upstream and downstream filtration as well as pressure drop. The researchers used a mobility particle sizer to measure particle number concentration from 16.8 nm to 514 nm. An acceptable pressure drop was defined as a drop of less than 1.38 inches of water (35 mm) for inhalation.
Although pressure drop changes were within the acceptable range for all three mask types following sterilization with either method, H2O2 sterilization yielded the least reduction in filtration efficacy in all cases. After sterilization with H2O2, filtration efficiencies were 96.6%, 97.1%, and 91.6% for the N95s, KN95s, and the surgical face masks, respectively. In contrast, filtration efficiencies after ClO2 sterilization were 95.1%, 76.2%, and 77.9%, respectively.
The researchers note that, although overall filtration efficiency was maintained with ClO2 sterilization, there was a significant drop in efficiency with respect to particles of approximately 300 nm (0.3 microns) in size. For particles of that size, mean filtration efficiency decreased to 86.2% for N95s, 40.8% for KN95s, and 47.1% for surgical face masks.
The testing described in the report is “quite affordable at $350 per mask type, so it is hard to imagine any health care provider cannot set aside a small budget to conduct such an important test,” author Evan Floyd, PhD, told Medscape Medical News.
Given the high demand for effective face masks and the current risk for counterfeit products, Floyd suggested that individual facilities test all masks intended for use by healthcare workers before and after sterilization procedures.
“However, if for some reason testing is not an option, we would recommend sticking to established brands and suppliers, perhaps reach out to your state health department or a local representative of the strategic stockpile of PPE,” he noted.
The authors acknowledge that further studies using a larger sample size and a greater variety of masks, as well as studies to evaluate different sterilization techniques, are required. Further, “measuring the respirator’s filtration efficiency by aerosol size instead of only measuring the overall filtration efficiency” should also be considered. Such an approach would enable researchers to evaluate the degree to which masks protect against specific infectious agents.
This article first appeared on Medscape.com.
according to researchers. The greatest reduction in filtration efficiency after sterilization occurred with surgical face masks.
With plasma vapor hydrogen peroxide (H2O2) sterilization, filtration efficiency of N95 and KN95 masks was maintained at more than 95%, but for surgical face masks, filtration efficiency was reduced to less than 95%. With chlorine dioxide (ClO2) sterilization, on the other hand, filtration efficiency was maintained at above 95% for N95 masks, but for KN95 and surgical face masks, filtration efficiency was reduced to less than 80%.
In a research letter published online June 15 in JAMA Network Open, researchers from the University of Oklahoma Health Sciences Center, Oklahoma City, report the results of a study of the two sterilization techniques on the pressure drop and filtration efficiency of N95, KN95, and surgical face masks.
“The H2O2 treatment showed a small effect on the overall filtration efficiency of the tested masks, but the ClO2 treatment showed marked reduction in the overall filtration efficiency of the KN95s and surgical face masks. All pressure drop changes were within the acceptable range,” the researchers write.
The study did not evaluate the effect of repeated sterilizations on face masks.
Five masks of each type were sterilized with either H2O2 or ClO2. Masks were then placed in a test chamber, and a salt aerosol was nebulized to assess both upstream and downstream filtration as well as pressure drop. The researchers used a mobility particle sizer to measure particle number concentration from 16.8 nm to 514 nm. An acceptable pressure drop was defined as a drop of less than 1.38 inches of water (35 mm) for inhalation.
Although pressure drop changes were within the acceptable range for all three mask types following sterilization with either method, H2O2 sterilization yielded the least reduction in filtration efficacy in all cases. After sterilization with H2O2, filtration efficiencies were 96.6%, 97.1%, and 91.6% for the N95s, KN95s, and the surgical face masks, respectively. In contrast, filtration efficiencies after ClO2 sterilization were 95.1%, 76.2%, and 77.9%, respectively.
The researchers note that, although overall filtration efficiency was maintained with ClO2 sterilization, there was a significant drop in efficiency with respect to particles of approximately 300 nm (0.3 microns) in size. For particles of that size, mean filtration efficiency decreased to 86.2% for N95s, 40.8% for KN95s, and 47.1% for surgical face masks.
The testing described in the report is “quite affordable at $350 per mask type, so it is hard to imagine any health care provider cannot set aside a small budget to conduct such an important test,” author Evan Floyd, PhD, told Medscape Medical News.
Given the high demand for effective face masks and the current risk for counterfeit products, Floyd suggested that individual facilities test all masks intended for use by healthcare workers before and after sterilization procedures.
“However, if for some reason testing is not an option, we would recommend sticking to established brands and suppliers, perhaps reach out to your state health department or a local representative of the strategic stockpile of PPE,” he noted.
The authors acknowledge that further studies using a larger sample size and a greater variety of masks, as well as studies to evaluate different sterilization techniques, are required. Further, “measuring the respirator’s filtration efficiency by aerosol size instead of only measuring the overall filtration efficiency” should also be considered. Such an approach would enable researchers to evaluate the degree to which masks protect against specific infectious agents.
This article first appeared on Medscape.com.
according to researchers. The greatest reduction in filtration efficiency after sterilization occurred with surgical face masks.
With plasma vapor hydrogen peroxide (H2O2) sterilization, filtration efficiency of N95 and KN95 masks was maintained at more than 95%, but for surgical face masks, filtration efficiency was reduced to less than 95%. With chlorine dioxide (ClO2) sterilization, on the other hand, filtration efficiency was maintained at above 95% for N95 masks, but for KN95 and surgical face masks, filtration efficiency was reduced to less than 80%.
In a research letter published online June 15 in JAMA Network Open, researchers from the University of Oklahoma Health Sciences Center, Oklahoma City, report the results of a study of the two sterilization techniques on the pressure drop and filtration efficiency of N95, KN95, and surgical face masks.
“The H2O2 treatment showed a small effect on the overall filtration efficiency of the tested masks, but the ClO2 treatment showed marked reduction in the overall filtration efficiency of the KN95s and surgical face masks. All pressure drop changes were within the acceptable range,” the researchers write.
The study did not evaluate the effect of repeated sterilizations on face masks.
Five masks of each type were sterilized with either H2O2 or ClO2. Masks were then placed in a test chamber, and a salt aerosol was nebulized to assess both upstream and downstream filtration as well as pressure drop. The researchers used a mobility particle sizer to measure particle number concentration from 16.8 nm to 514 nm. An acceptable pressure drop was defined as a drop of less than 1.38 inches of water (35 mm) for inhalation.
Although pressure drop changes were within the acceptable range for all three mask types following sterilization with either method, H2O2 sterilization yielded the least reduction in filtration efficacy in all cases. After sterilization with H2O2, filtration efficiencies were 96.6%, 97.1%, and 91.6% for the N95s, KN95s, and the surgical face masks, respectively. In contrast, filtration efficiencies after ClO2 sterilization were 95.1%, 76.2%, and 77.9%, respectively.
The researchers note that, although overall filtration efficiency was maintained with ClO2 sterilization, there was a significant drop in efficiency with respect to particles of approximately 300 nm (0.3 microns) in size. For particles of that size, mean filtration efficiency decreased to 86.2% for N95s, 40.8% for KN95s, and 47.1% for surgical face masks.
The testing described in the report is “quite affordable at $350 per mask type, so it is hard to imagine any health care provider cannot set aside a small budget to conduct such an important test,” author Evan Floyd, PhD, told Medscape Medical News.
Given the high demand for effective face masks and the current risk for counterfeit products, Floyd suggested that individual facilities test all masks intended for use by healthcare workers before and after sterilization procedures.
“However, if for some reason testing is not an option, we would recommend sticking to established brands and suppliers, perhaps reach out to your state health department or a local representative of the strategic stockpile of PPE,” he noted.
The authors acknowledge that further studies using a larger sample size and a greater variety of masks, as well as studies to evaluate different sterilization techniques, are required. Further, “measuring the respirator’s filtration efficiency by aerosol size instead of only measuring the overall filtration efficiency” should also be considered. Such an approach would enable researchers to evaluate the degree to which masks protect against specific infectious agents.
This article first appeared on Medscape.com.
Ecchymotic patches
This patient’s circular ecchymotic patches were due to cupping. One of the clues that this was iatrogenic was the regular and repeated pattern on the skin.
Cupping is a centuries old treatment for pain relief (among other things) that involves applying glass globes or other hollow materials to the skin to create a vacuum. Traditionally, this vacuum is created by heating the air inside the vessel and then holding the vessel in place as the air cools. Practitioners may also use more modern instruments to induce the vacuum that are similar to those used to assist in vaginal deliveries. The mechanical devices leave these circular ecchymotic marks. The ecchymosis fades over time, and this procedure has been shown to significantly reduce myofascial neck and back pain in small trials.
It is important to recognize geometric patterns that are iatrogenic or due to abuse when evaluating skin findings. If skin findings do not follow dermatomal distributions, typical exanthem, or other classic patterns or presentations, there is the possibility that the pattern may be the result of neglect or abuse. On inspection, consider whether an odd pattern may have been caused from a belt buckle, striking instrument, furniture, medical equipment, or a hand strike.
This patient’s findings were consistent with his history of visiting a physical therapist for cupping. No treatment was required; the patient’s back pain from his car accident was improving, and the cupping marks were not troubling him.
Photo and text courtesy of Daniel Stulberg, MD, FAAFP, Department of Family and Community Medicine, University of New Mexico School of Medicine, Albuquerque.
Wang YT, Qi Y, Tang FY, et al. The effect of cupping therapy for low back pain: a meta-analysis based on existing randomized controlled trials. J Back Musculoskelet Rehabil. 2017;30:1187-1195.
This patient’s circular ecchymotic patches were due to cupping. One of the clues that this was iatrogenic was the regular and repeated pattern on the skin.
Cupping is a centuries old treatment for pain relief (among other things) that involves applying glass globes or other hollow materials to the skin to create a vacuum. Traditionally, this vacuum is created by heating the air inside the vessel and then holding the vessel in place as the air cools. Practitioners may also use more modern instruments to induce the vacuum that are similar to those used to assist in vaginal deliveries. The mechanical devices leave these circular ecchymotic marks. The ecchymosis fades over time, and this procedure has been shown to significantly reduce myofascial neck and back pain in small trials.
It is important to recognize geometric patterns that are iatrogenic or due to abuse when evaluating skin findings. If skin findings do not follow dermatomal distributions, typical exanthem, or other classic patterns or presentations, there is the possibility that the pattern may be the result of neglect or abuse. On inspection, consider whether an odd pattern may have been caused from a belt buckle, striking instrument, furniture, medical equipment, or a hand strike.
This patient’s findings were consistent with his history of visiting a physical therapist for cupping. No treatment was required; the patient’s back pain from his car accident was improving, and the cupping marks were not troubling him.
Photo and text courtesy of Daniel Stulberg, MD, FAAFP, Department of Family and Community Medicine, University of New Mexico School of Medicine, Albuquerque.
This patient’s circular ecchymotic patches were due to cupping. One of the clues that this was iatrogenic was the regular and repeated pattern on the skin.
Cupping is a centuries old treatment for pain relief (among other things) that involves applying glass globes or other hollow materials to the skin to create a vacuum. Traditionally, this vacuum is created by heating the air inside the vessel and then holding the vessel in place as the air cools. Practitioners may also use more modern instruments to induce the vacuum that are similar to those used to assist in vaginal deliveries. The mechanical devices leave these circular ecchymotic marks. The ecchymosis fades over time, and this procedure has been shown to significantly reduce myofascial neck and back pain in small trials.
It is important to recognize geometric patterns that are iatrogenic or due to abuse when evaluating skin findings. If skin findings do not follow dermatomal distributions, typical exanthem, or other classic patterns or presentations, there is the possibility that the pattern may be the result of neglect or abuse. On inspection, consider whether an odd pattern may have been caused from a belt buckle, striking instrument, furniture, medical equipment, or a hand strike.
This patient’s findings were consistent with his history of visiting a physical therapist for cupping. No treatment was required; the patient’s back pain from his car accident was improving, and the cupping marks were not troubling him.
Photo and text courtesy of Daniel Stulberg, MD, FAAFP, Department of Family and Community Medicine, University of New Mexico School of Medicine, Albuquerque.
Wang YT, Qi Y, Tang FY, et al. The effect of cupping therapy for low back pain: a meta-analysis based on existing randomized controlled trials. J Back Musculoskelet Rehabil. 2017;30:1187-1195.
Wang YT, Qi Y, Tang FY, et al. The effect of cupping therapy for low back pain: a meta-analysis based on existing randomized controlled trials. J Back Musculoskelet Rehabil. 2017;30:1187-1195.
Coronavirus impact on medical education: Thoughts from two GI fellows’ perspectives
Introduction
We are living in an unprecedented time. During March 2020, in response to the COVID-19 (coronavirus disease 2019) outbreak, our institution removed all medical students from rotations with direct patient contact to prioritize their safety and well-being, following recommendations made by the Association of American Medical Colleges (AAMC).1 Similarly, we as gastroenterology fellows experienced an upheaval in our usual schedules and routines. Some of us were redeployed to other areas of the hospital, such as inpatient wards and emergency departments, to meet the needs of our patients and our health system. These changes were difficult, not only because we were practicing in different roles, but also because unknown situations commonly incite fear and anxiety.
Among the repercussions of the COVID-19 pandemic were the changes thrust upon medical students who suddenly found themselves without clinical exposure (both on core clerkships and electives) for the duration of the academic year.2 We too lost many of our educational and teaching opportunities as we adapted to our changing circumstances and new reality. Therefore, . We used the lessons we learned because of the changes in our own medical education to anticipate the best ways to provide learning opportunities for our students.
GI fellows’ experiences
The changes to our schedules and lack of in-person educational conferences seemingly happened overnight – the shock of being pulled from clinics, consults, and endoscopy left us feeling scared and lonely. We were quickly transitioned from knowing our roles and responsibilities as GI providers to taking over care for hospitalist patients as the “primary team,” working in the COVID emergency department (ED), and losing our clinic space. Redeployment to other clinical environments was anxiety-provoking. Self-doubt and fear were the most cited concerns as we asked ourselves: Do I remember enough general medicine to be an effective hospitalist? How do I place admission orders or perform a medication reconciliation on discharge? What can I expect in the COVID ED? Will I have to intubate someone? What about possible PPE shortages? Are my family members safe at home? Should I stay in a hotel? Do we have estimates on how long this will last?
Clinical schedules were reconfigured to consolidate the use of inpatient fellows and allow for reserves of fellows to be redeployed if needed. Schedules for the following 7 days were made just 48 hours prior to the start of each workweek. The anticipation and fear of the unknown were perhaps the hardest parts of the changes in our clinical learning environment. Little time was provided to make child care arrangements, coordinate with the schedules of significant others, or review topics and skills we might need in the next week that had gone unused for some time.
Our conference schedule was pared down considerably as fellows and attendings adjusted to their new responsibilities and a virtual platform for fellows’ education. While the transition to online lectures was seamless, the spirit of conference certainly changed. Impromptu questions and conversations that oftentimes arise organically during case conferences no longer occurred as virtual meetings do not offer the same space to foster these discussions as we awkwardly muted and unmuted ourselves. Participation in lectures seemed disjointed, which translated in some ways to less effective learning opportunities. Our involvement in endoscopy was also removed as only urgent cases were being performed and PPE conservation was of the utmost priority. This was especially concerning for third-year fellows on the cusp of graduation who would soon be independent practitioners without recent procedural practice. In general, the fellowship felt isolated and uncertain, which our program director addressed with weekly virtual COVID-19 “happy hour” updates.
GI fellows’ contribution
As our program encouraged us to come together during this time to support each other, we realized that while our clinical duties may look different during the COVID-19 crisis, our responsibility to learners was more important than ever. At many academic institutions, GI fellows are referred to as “the face of the division” owed in large part to our consistent presence on consult services and roles as teachers for medical students and residents who rotate with us. In an effort to assist the medical school’s charge to rapidly generate at-home curriculum for our students, we created an online curriculum for medical students to complete during the time they were previously scheduled to rotate with us on consults either as third- or fourth-year students.
We designed a series of interactive podcasts covering six topics that are commonly encountered issues on the GI consult service: upper GI bleeding, lower GI bleeding, biliary sepsis, acute pancreatitis, chronic diarrhea with a new diagnosis of inflammatory bowel disease, as well as cirrhosis and its associated complications.
Conclusion
The COVID-19 pandemic brought about significant change in the daily activities of GI fellows including new responsibilities and a great need for adaptation. We hope that the lessons the COVID-19 pandemic has taught us – to think of others and make our talents available to those who need them, to look for ways to adapt to challenges, to live in the present but focus on the future, and to spread creativity when able – will continue long after the curve has flattened.
References
1. Murphy B. American Medical Association website. https://www.ama-assn.org/residents-students/medical-school-life/online-learning-during-covid-19-tips-help-med-students. Apr 3, 2020.
2. Murphy B. American Medical Association website. https://www.ama-assn.org/delivering-care/public-health/covid-19-how-virus-impacting-medical-schools. Mar 20, 2020.
3. “H5P: Create, share and reuse interactive HTML5 content in your browser.” H5P website. https://h5p.org.
Dr. Bhavsar-Burke and Dr. Jansson-Knodell are GI fellows in the division of gastroenterology and hepatology, department of medicine, Indiana University, Indianapolis. The authors have no conflicts of interest.
Introduction
We are living in an unprecedented time. During March 2020, in response to the COVID-19 (coronavirus disease 2019) outbreak, our institution removed all medical students from rotations with direct patient contact to prioritize their safety and well-being, following recommendations made by the Association of American Medical Colleges (AAMC).1 Similarly, we as gastroenterology fellows experienced an upheaval in our usual schedules and routines. Some of us were redeployed to other areas of the hospital, such as inpatient wards and emergency departments, to meet the needs of our patients and our health system. These changes were difficult, not only because we were practicing in different roles, but also because unknown situations commonly incite fear and anxiety.
Among the repercussions of the COVID-19 pandemic were the changes thrust upon medical students who suddenly found themselves without clinical exposure (both on core clerkships and electives) for the duration of the academic year.2 We too lost many of our educational and teaching opportunities as we adapted to our changing circumstances and new reality. Therefore, . We used the lessons we learned because of the changes in our own medical education to anticipate the best ways to provide learning opportunities for our students.
GI fellows’ experiences
The changes to our schedules and lack of in-person educational conferences seemingly happened overnight – the shock of being pulled from clinics, consults, and endoscopy left us feeling scared and lonely. We were quickly transitioned from knowing our roles and responsibilities as GI providers to taking over care for hospitalist patients as the “primary team,” working in the COVID emergency department (ED), and losing our clinic space. Redeployment to other clinical environments was anxiety-provoking. Self-doubt and fear were the most cited concerns as we asked ourselves: Do I remember enough general medicine to be an effective hospitalist? How do I place admission orders or perform a medication reconciliation on discharge? What can I expect in the COVID ED? Will I have to intubate someone? What about possible PPE shortages? Are my family members safe at home? Should I stay in a hotel? Do we have estimates on how long this will last?
Clinical schedules were reconfigured to consolidate the use of inpatient fellows and allow for reserves of fellows to be redeployed if needed. Schedules for the following 7 days were made just 48 hours prior to the start of each workweek. The anticipation and fear of the unknown were perhaps the hardest parts of the changes in our clinical learning environment. Little time was provided to make child care arrangements, coordinate with the schedules of significant others, or review topics and skills we might need in the next week that had gone unused for some time.
Our conference schedule was pared down considerably as fellows and attendings adjusted to their new responsibilities and a virtual platform for fellows’ education. While the transition to online lectures was seamless, the spirit of conference certainly changed. Impromptu questions and conversations that oftentimes arise organically during case conferences no longer occurred as virtual meetings do not offer the same space to foster these discussions as we awkwardly muted and unmuted ourselves. Participation in lectures seemed disjointed, which translated in some ways to less effective learning opportunities. Our involvement in endoscopy was also removed as only urgent cases were being performed and PPE conservation was of the utmost priority. This was especially concerning for third-year fellows on the cusp of graduation who would soon be independent practitioners without recent procedural practice. In general, the fellowship felt isolated and uncertain, which our program director addressed with weekly virtual COVID-19 “happy hour” updates.
GI fellows’ contribution
As our program encouraged us to come together during this time to support each other, we realized that while our clinical duties may look different during the COVID-19 crisis, our responsibility to learners was more important than ever. At many academic institutions, GI fellows are referred to as “the face of the division” owed in large part to our consistent presence on consult services and roles as teachers for medical students and residents who rotate with us. In an effort to assist the medical school’s charge to rapidly generate at-home curriculum for our students, we created an online curriculum for medical students to complete during the time they were previously scheduled to rotate with us on consults either as third- or fourth-year students.
We designed a series of interactive podcasts covering six topics that are commonly encountered issues on the GI consult service: upper GI bleeding, lower GI bleeding, biliary sepsis, acute pancreatitis, chronic diarrhea with a new diagnosis of inflammatory bowel disease, as well as cirrhosis and its associated complications.
Conclusion
The COVID-19 pandemic brought about significant change in the daily activities of GI fellows including new responsibilities and a great need for adaptation. We hope that the lessons the COVID-19 pandemic has taught us – to think of others and make our talents available to those who need them, to look for ways to adapt to challenges, to live in the present but focus on the future, and to spread creativity when able – will continue long after the curve has flattened.
References
1. Murphy B. American Medical Association website. https://www.ama-assn.org/residents-students/medical-school-life/online-learning-during-covid-19-tips-help-med-students. Apr 3, 2020.
2. Murphy B. American Medical Association website. https://www.ama-assn.org/delivering-care/public-health/covid-19-how-virus-impacting-medical-schools. Mar 20, 2020.
3. “H5P: Create, share and reuse interactive HTML5 content in your browser.” H5P website. https://h5p.org.
Dr. Bhavsar-Burke and Dr. Jansson-Knodell are GI fellows in the division of gastroenterology and hepatology, department of medicine, Indiana University, Indianapolis. The authors have no conflicts of interest.
Introduction
We are living in an unprecedented time. During March 2020, in response to the COVID-19 (coronavirus disease 2019) outbreak, our institution removed all medical students from rotations with direct patient contact to prioritize their safety and well-being, following recommendations made by the Association of American Medical Colleges (AAMC).1 Similarly, we as gastroenterology fellows experienced an upheaval in our usual schedules and routines. Some of us were redeployed to other areas of the hospital, such as inpatient wards and emergency departments, to meet the needs of our patients and our health system. These changes were difficult, not only because we were practicing in different roles, but also because unknown situations commonly incite fear and anxiety.
Among the repercussions of the COVID-19 pandemic were the changes thrust upon medical students who suddenly found themselves without clinical exposure (both on core clerkships and electives) for the duration of the academic year.2 We too lost many of our educational and teaching opportunities as we adapted to our changing circumstances and new reality. Therefore, . We used the lessons we learned because of the changes in our own medical education to anticipate the best ways to provide learning opportunities for our students.
GI fellows’ experiences
The changes to our schedules and lack of in-person educational conferences seemingly happened overnight – the shock of being pulled from clinics, consults, and endoscopy left us feeling scared and lonely. We were quickly transitioned from knowing our roles and responsibilities as GI providers to taking over care for hospitalist patients as the “primary team,” working in the COVID emergency department (ED), and losing our clinic space. Redeployment to other clinical environments was anxiety-provoking. Self-doubt and fear were the most cited concerns as we asked ourselves: Do I remember enough general medicine to be an effective hospitalist? How do I place admission orders or perform a medication reconciliation on discharge? What can I expect in the COVID ED? Will I have to intubate someone? What about possible PPE shortages? Are my family members safe at home? Should I stay in a hotel? Do we have estimates on how long this will last?
Clinical schedules were reconfigured to consolidate the use of inpatient fellows and allow for reserves of fellows to be redeployed if needed. Schedules for the following 7 days were made just 48 hours prior to the start of each workweek. The anticipation and fear of the unknown were perhaps the hardest parts of the changes in our clinical learning environment. Little time was provided to make child care arrangements, coordinate with the schedules of significant others, or review topics and skills we might need in the next week that had gone unused for some time.
Our conference schedule was pared down considerably as fellows and attendings adjusted to their new responsibilities and a virtual platform for fellows’ education. While the transition to online lectures was seamless, the spirit of conference certainly changed. Impromptu questions and conversations that oftentimes arise organically during case conferences no longer occurred as virtual meetings do not offer the same space to foster these discussions as we awkwardly muted and unmuted ourselves. Participation in lectures seemed disjointed, which translated in some ways to less effective learning opportunities. Our involvement in endoscopy was also removed as only urgent cases were being performed and PPE conservation was of the utmost priority. This was especially concerning for third-year fellows on the cusp of graduation who would soon be independent practitioners without recent procedural practice. In general, the fellowship felt isolated and uncertain, which our program director addressed with weekly virtual COVID-19 “happy hour” updates.
GI fellows’ contribution
As our program encouraged us to come together during this time to support each other, we realized that while our clinical duties may look different during the COVID-19 crisis, our responsibility to learners was more important than ever. At many academic institutions, GI fellows are referred to as “the face of the division” owed in large part to our consistent presence on consult services and roles as teachers for medical students and residents who rotate with us. In an effort to assist the medical school’s charge to rapidly generate at-home curriculum for our students, we created an online curriculum for medical students to complete during the time they were previously scheduled to rotate with us on consults either as third- or fourth-year students.
We designed a series of interactive podcasts covering six topics that are commonly encountered issues on the GI consult service: upper GI bleeding, lower GI bleeding, biliary sepsis, acute pancreatitis, chronic diarrhea with a new diagnosis of inflammatory bowel disease, as well as cirrhosis and its associated complications.
Conclusion
The COVID-19 pandemic brought about significant change in the daily activities of GI fellows including new responsibilities and a great need for adaptation. We hope that the lessons the COVID-19 pandemic has taught us – to think of others and make our talents available to those who need them, to look for ways to adapt to challenges, to live in the present but focus on the future, and to spread creativity when able – will continue long after the curve has flattened.
References
1. Murphy B. American Medical Association website. https://www.ama-assn.org/residents-students/medical-school-life/online-learning-during-covid-19-tips-help-med-students. Apr 3, 2020.
2. Murphy B. American Medical Association website. https://www.ama-assn.org/delivering-care/public-health/covid-19-how-virus-impacting-medical-schools. Mar 20, 2020.
3. “H5P: Create, share and reuse interactive HTML5 content in your browser.” H5P website. https://h5p.org.
Dr. Bhavsar-Burke and Dr. Jansson-Knodell are GI fellows in the division of gastroenterology and hepatology, department of medicine, Indiana University, Indianapolis. The authors have no conflicts of interest.
Daily Recap 6/17
Here are the stories our MDedge editors across specialties think you need to know about today:
Comorbidities increase COVID-19 deaths by factor of 12
COVID-19 patients with an underlying condition are 6 times as likely to be hospitalized and 12 times as likely to die, compared with those who have no such condition, according to the CDC.
The most frequently reported underlying conditions were cardiovascular disease (32%), diabetes (30%), chronic lung disease (18%), and renal disease (7.6%), and there were no significant differences between males and females.
The pandemic “continues to affect all populations and result in severe outcomes including death,” noted the CDC, emphasizing “the continued need for community mitigation strategies, especially for vulnerable populations, to slow COVID-19 transmission.” Read more.
Preventive services coalition recommends routine anxiety screening for women
Women and girls aged 13 years and older with no current diagnosis of anxiety should be screened routinely for anxiety, according to a new recommendation from the Women’s Preventive Services Initiative.
The lifetime prevalence of anxiety disorders in women in the United States is 40%, approximately twice that of men, and anxiety can be a manifestation of underlying issues including posttraumatic stress, sexual harassment, and assault.
“The WPSI based its rationale for anxiety screening on several considerations,” the researchers noted. “Anxiety disorders are the most prevalent mental health disorders in women, and the problems created by untreated anxiety can impair function in all areas of a woman’s life.” Read more.
High-fat, high-sugar diet may promote adult acne
A diet higher in fat, sugar, and milk was associated with having acne in a cross-sectional study of approximately 24,000 adults in France.
Although acne patients may believe that eating certain foods exacerbates acne, data on the effects of nutrition on acne, including associations between acne and a high-glycemic diet, are limited and have produced conflicting results, noted investigators.
“The results of our study appear to support the hypothesis that the Western diet (rich in animal products and fatty and sugary foods) is associated with the presence of acne in adulthood,” the researchers concluded.
Population study supports migraine-dementia link
Preliminary results from a population-based cohort study support previous reports that migraine is a midlife risk factor for dementia later in life, but further determined that migraine with aura and frequent hospital contacts significantly increased dementia risk after age 60 years, according to results from a Danish registry presented at the virtual annual meeting of the American Headache Society.
The preliminary findings revealed that the median age at diagnosis was 49 years and about 70% of the migraine population were women. “There was a 50% higher dementia rate in individuals who had any migraine diagnosis,” Dr. Islamoska said.
“To the best of our knowledge, no previous national register–based studies have investigated the risk of dementia among individuals who suffer from migraine with aura,” Dr. Sabrina Islamoska said.
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:
Comorbidities increase COVID-19 deaths by factor of 12
COVID-19 patients with an underlying condition are 6 times as likely to be hospitalized and 12 times as likely to die, compared with those who have no such condition, according to the CDC.
The most frequently reported underlying conditions were cardiovascular disease (32%), diabetes (30%), chronic lung disease (18%), and renal disease (7.6%), and there were no significant differences between males and females.
The pandemic “continues to affect all populations and result in severe outcomes including death,” noted the CDC, emphasizing “the continued need for community mitigation strategies, especially for vulnerable populations, to slow COVID-19 transmission.” Read more.
Preventive services coalition recommends routine anxiety screening for women
Women and girls aged 13 years and older with no current diagnosis of anxiety should be screened routinely for anxiety, according to a new recommendation from the Women’s Preventive Services Initiative.
The lifetime prevalence of anxiety disorders in women in the United States is 40%, approximately twice that of men, and anxiety can be a manifestation of underlying issues including posttraumatic stress, sexual harassment, and assault.
“The WPSI based its rationale for anxiety screening on several considerations,” the researchers noted. “Anxiety disorders are the most prevalent mental health disorders in women, and the problems created by untreated anxiety can impair function in all areas of a woman’s life.” Read more.
High-fat, high-sugar diet may promote adult acne
A diet higher in fat, sugar, and milk was associated with having acne in a cross-sectional study of approximately 24,000 adults in France.
Although acne patients may believe that eating certain foods exacerbates acne, data on the effects of nutrition on acne, including associations between acne and a high-glycemic diet, are limited and have produced conflicting results, noted investigators.
“The results of our study appear to support the hypothesis that the Western diet (rich in animal products and fatty and sugary foods) is associated with the presence of acne in adulthood,” the researchers concluded.
Population study supports migraine-dementia link
Preliminary results from a population-based cohort study support previous reports that migraine is a midlife risk factor for dementia later in life, but further determined that migraine with aura and frequent hospital contacts significantly increased dementia risk after age 60 years, according to results from a Danish registry presented at the virtual annual meeting of the American Headache Society.
The preliminary findings revealed that the median age at diagnosis was 49 years and about 70% of the migraine population were women. “There was a 50% higher dementia rate in individuals who had any migraine diagnosis,” Dr. Islamoska said.
“To the best of our knowledge, no previous national register–based studies have investigated the risk of dementia among individuals who suffer from migraine with aura,” Dr. Sabrina Islamoska said.
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:
Comorbidities increase COVID-19 deaths by factor of 12
COVID-19 patients with an underlying condition are 6 times as likely to be hospitalized and 12 times as likely to die, compared with those who have no such condition, according to the CDC.
The most frequently reported underlying conditions were cardiovascular disease (32%), diabetes (30%), chronic lung disease (18%), and renal disease (7.6%), and there were no significant differences between males and females.
The pandemic “continues to affect all populations and result in severe outcomes including death,” noted the CDC, emphasizing “the continued need for community mitigation strategies, especially for vulnerable populations, to slow COVID-19 transmission.” Read more.
Preventive services coalition recommends routine anxiety screening for women
Women and girls aged 13 years and older with no current diagnosis of anxiety should be screened routinely for anxiety, according to a new recommendation from the Women’s Preventive Services Initiative.
The lifetime prevalence of anxiety disorders in women in the United States is 40%, approximately twice that of men, and anxiety can be a manifestation of underlying issues including posttraumatic stress, sexual harassment, and assault.
“The WPSI based its rationale for anxiety screening on several considerations,” the researchers noted. “Anxiety disorders are the most prevalent mental health disorders in women, and the problems created by untreated anxiety can impair function in all areas of a woman’s life.” Read more.
High-fat, high-sugar diet may promote adult acne
A diet higher in fat, sugar, and milk was associated with having acne in a cross-sectional study of approximately 24,000 adults in France.
Although acne patients may believe that eating certain foods exacerbates acne, data on the effects of nutrition on acne, including associations between acne and a high-glycemic diet, are limited and have produced conflicting results, noted investigators.
“The results of our study appear to support the hypothesis that the Western diet (rich in animal products and fatty and sugary foods) is associated with the presence of acne in adulthood,” the researchers concluded.
Population study supports migraine-dementia link
Preliminary results from a population-based cohort study support previous reports that migraine is a midlife risk factor for dementia later in life, but further determined that migraine with aura and frequent hospital contacts significantly increased dementia risk after age 60 years, according to results from a Danish registry presented at the virtual annual meeting of the American Headache Society.
The preliminary findings revealed that the median age at diagnosis was 49 years and about 70% of the migraine population were women. “There was a 50% higher dementia rate in individuals who had any migraine diagnosis,” Dr. Islamoska said.
“To the best of our knowledge, no previous national register–based studies have investigated the risk of dementia among individuals who suffer from migraine with aura,” Dr. Sabrina Islamoska said.
For more on COVID-19, visit our Resource Center. All of our latest news is available on MDedge.com.
Getting unstuck: Helping patients with behavior change
Kyle is a 14-year-old cisgender male who just moved to your town. At his first well-check, his single father brings him in reluctantly, stating, “We’ve never liked doctors.” Kyle has a history of asthma and obesity that have been relatively unchanged over time. He is an average student, an avid gamer, and seems somewhat shy. Privately he admits to occasional cannabis use. His father has no concerns, lamenting, “He’s always been pretty healthy for a fat kid.” Next patient?
Of course there is a lot to work with here. You might be concerned with Kyle’s asthma; his weight, sedentary nature, and body image; the criticism from his father and concerns about self-esteem; the possibility of anxiety in relation to his shyness; and the health effects of his cannabis use. In the end, recommendations for behavior change seem likely. These might take the form of tips on exercise, nutrition, substance use, study habits, parenting, social activities, or mental health support; the literature on behavior change would suggest that any success will be predicated on trust. How can we learn from someone we do not trust?1
To build trust is no easy task, and yet is perhaps the foundation on which the entire clinical relationship rests. Guidance from decades of evidence supporting the use of motivational interviewing2 suggests that the process of building rapport can be neatly summed up in an acronym as PACE. This represents Partnership, Acceptance, Compassion, and Evocation. Almost too clichéd to repeat, the most powerful change agent is the person making the change. In the setting of pediatric health care, we sometimes lean on caregivers to initiate or promote change because they are an intimate part of the patient’s microsystem, and thus moving one gear (the parents) inevitably shifts something in connected gears (the children).
So Partnership is centered on the patient, but inclusive of any important person in the patient’s sphere. In a family-based approach, this might show up as leveraging Kyle’s father’s motivation for behavior change by having the father start an exercise routine. This role models behavior change, shifts the home environment around the behavior, and builds empathy in the parent for the inherent challenges of change processes.
Acceptance can be distilled into knowing that the patient and family are doing the best they can. This does not preclude the possibility of change, but it seats this possibility in an attitude of assumed adequacy. There is nothing wrong with the patient, nothing to be fixed, just the possibility for change.
Similarly, Compassion takes a nonjudgmental viewpoint. With the stance of “this could happen to anybody,” the patient can feel responsible without feeling blamed. Noting the patient’s suffering without blame allows the clinician to be motivated not just to empathize, but to help.
And from this basis of compassionate partnership, the work of Evocation begins. What is happening in the patient’s life and relationships? What are their own goals and values? Where are the discrepancies between what the patient wants and what the patient does? For teenagers, this often brings into conflict developmentally appropriate wishes for autonomy – wanting to drive or get a car or stay out later or have more privacy – with developmentally typical challenges regarding responsibility.3 For example:
Clinician: “You want to use the car, and your parents want you to pay for the gas, but you’re out of money from buying weed. I see how you’re stuck.”
Teen: “Yeah, they really need to give me more allowance. It’s not like we’re living in the 1990s anymore!”
Clinician: “So you could ask for more allowance to get more money for gas. Any other ideas?”
Teen: “I could give up smoking pot and just be miserable all the time.”
Clinician: “Yeah, that sounds too difficult right now; if anything it sounds like you’d like to smoke more pot if you had more money.”
Teen: “Nah, I’m not that hooked on it. ... I could probably smoke a bit less each week and save some gas money.”
The PACE acronym also serves as a reminder of the patience required to grow connection where none has previously existed – pace yourself. Here are some skills-based tips to foster the spirit of motivational interviewing to help balance patience with the time frame of a pediatric check-in. The OARS skills represent the fundamental building blocks of motivational interviewing in practice. Taking the case of Kyle as an example, an Open-Ended Question makes space for the child or parent to express their views with less interviewer bias. Reflections expand this space by underscoring and, in the case of complex Reflections, adding some nuance to what the patient has to say.
Clinician: “How do you feel about your body?”
Teen: “Well, I’m fat. Nobody really wants to be fat. It sucks. But what can I do?”
Clinician: “You feel fat and kind of hopeless.”
Teen: “Yeah, I know you’re going to tell me to go on a diet and start exercising. Doesn’t work. My dad says I was born fat; I guess I’m going to stay that way.”
Clinician: “Sounds like you and your dad can get down on you for your weight. That must feel terrible.”
Teen: “Ah, it’s not that bad. I’m kind of used to it. Fat kid at home, fat kid at school.”
Affirmations are statements focusing on positive actions or attributes of the patient. They tend to build rapport by demonstrating that the clinician sees the strengths of the patient, not just the problems.
Clinician: “I’m pretty impressed that you’re able to show up here and talk about this. It can’t be easy when it sounds like your family and friends have put you down so much that you’re even putting yourself down about your body.”
Teen: “I didn’t really want to come, but then I thought, maybe this new doctor will have some new ideas. I actually want to do something about it, I just don’t know if anything will help. Plus my dad said if I showed up, we could go to McDonald’s afterward.”
Summaries are multipurpose. They demonstrate that you have been listening closely, which builds rapport. They provide a chance to put information together so that both clinician and patient can reflect on the sum of the data and notice what may be missing. And they provide a pause to consider where to go next.
Clinician: “So if I’m getting it right, you’ve been worried about your weight for a long time now. Your dad and your friends give you a hard time about it, which makes you feel down and hopeless, but somehow you stay brave and keep trying to figure it out. You feel ready to do something, you just don’t know what, and you were hoping maybe coming here could give you a place to work on your health. Does that sound about right?”
Teen: “I think that’s pretty much it. Plus the McDonald’s.”
Clinician: “Right, that’s important too – we have to consider your motivation! I wonder if we could talk about this more at our next visit – would that be alright?”
Offices with additional resources might be able to offer some of those as well, if timing seems appropriate; for example, referral to a wellness coach or social worker or nutritionist could be helpful int his case. With the spirit of PACE and the skills of OARS, you can be well on your way to fostering behavior changes that could last a lifetime! Check out the resources from the American Academy of Pediatrics with video and narrative demonstrations of motivational interviewing in pediatrics.
Dr. Rosenfeld is assistant professor in the departments of psychiatry and pediatrics at the University of Vermont Medical Center and the university’s Robert Larner College of Medicine, Burlington. He reported no relevant disclosures. Email him at [email protected].
References
1. Miller WR, Rollnick S. “Engagement and disengagement,” in “Motivational interviewing: Helping people change,” 3rd ed. (New York: Guilford, 2013).
2. Miller WR, Rollnick S. “The spirit of motivational interviewing,” in “Motivational interviewing: Helping people change,” 3rd ed. (New York: Guilford, 2013).
3. Naar S, Suarez M. “Adolescence and emerging adulthood: A brief review of development,” in “Motivational interviewing with adolescents and young adults” (New York: Guilford, 2011).
Kyle is a 14-year-old cisgender male who just moved to your town. At his first well-check, his single father brings him in reluctantly, stating, “We’ve never liked doctors.” Kyle has a history of asthma and obesity that have been relatively unchanged over time. He is an average student, an avid gamer, and seems somewhat shy. Privately he admits to occasional cannabis use. His father has no concerns, lamenting, “He’s always been pretty healthy for a fat kid.” Next patient?
Of course there is a lot to work with here. You might be concerned with Kyle’s asthma; his weight, sedentary nature, and body image; the criticism from his father and concerns about self-esteem; the possibility of anxiety in relation to his shyness; and the health effects of his cannabis use. In the end, recommendations for behavior change seem likely. These might take the form of tips on exercise, nutrition, substance use, study habits, parenting, social activities, or mental health support; the literature on behavior change would suggest that any success will be predicated on trust. How can we learn from someone we do not trust?1
To build trust is no easy task, and yet is perhaps the foundation on which the entire clinical relationship rests. Guidance from decades of evidence supporting the use of motivational interviewing2 suggests that the process of building rapport can be neatly summed up in an acronym as PACE. This represents Partnership, Acceptance, Compassion, and Evocation. Almost too clichéd to repeat, the most powerful change agent is the person making the change. In the setting of pediatric health care, we sometimes lean on caregivers to initiate or promote change because they are an intimate part of the patient’s microsystem, and thus moving one gear (the parents) inevitably shifts something in connected gears (the children).
So Partnership is centered on the patient, but inclusive of any important person in the patient’s sphere. In a family-based approach, this might show up as leveraging Kyle’s father’s motivation for behavior change by having the father start an exercise routine. This role models behavior change, shifts the home environment around the behavior, and builds empathy in the parent for the inherent challenges of change processes.
Acceptance can be distilled into knowing that the patient and family are doing the best they can. This does not preclude the possibility of change, but it seats this possibility in an attitude of assumed adequacy. There is nothing wrong with the patient, nothing to be fixed, just the possibility for change.
Similarly, Compassion takes a nonjudgmental viewpoint. With the stance of “this could happen to anybody,” the patient can feel responsible without feeling blamed. Noting the patient’s suffering without blame allows the clinician to be motivated not just to empathize, but to help.
And from this basis of compassionate partnership, the work of Evocation begins. What is happening in the patient’s life and relationships? What are their own goals and values? Where are the discrepancies between what the patient wants and what the patient does? For teenagers, this often brings into conflict developmentally appropriate wishes for autonomy – wanting to drive or get a car or stay out later or have more privacy – with developmentally typical challenges regarding responsibility.3 For example:
Clinician: “You want to use the car, and your parents want you to pay for the gas, but you’re out of money from buying weed. I see how you’re stuck.”
Teen: “Yeah, they really need to give me more allowance. It’s not like we’re living in the 1990s anymore!”
Clinician: “So you could ask for more allowance to get more money for gas. Any other ideas?”
Teen: “I could give up smoking pot and just be miserable all the time.”
Clinician: “Yeah, that sounds too difficult right now; if anything it sounds like you’d like to smoke more pot if you had more money.”
Teen: “Nah, I’m not that hooked on it. ... I could probably smoke a bit less each week and save some gas money.”
The PACE acronym also serves as a reminder of the patience required to grow connection where none has previously existed – pace yourself. Here are some skills-based tips to foster the spirit of motivational interviewing to help balance patience with the time frame of a pediatric check-in. The OARS skills represent the fundamental building blocks of motivational interviewing in practice. Taking the case of Kyle as an example, an Open-Ended Question makes space for the child or parent to express their views with less interviewer bias. Reflections expand this space by underscoring and, in the case of complex Reflections, adding some nuance to what the patient has to say.
Clinician: “How do you feel about your body?”
Teen: “Well, I’m fat. Nobody really wants to be fat. It sucks. But what can I do?”
Clinician: “You feel fat and kind of hopeless.”
Teen: “Yeah, I know you’re going to tell me to go on a diet and start exercising. Doesn’t work. My dad says I was born fat; I guess I’m going to stay that way.”
Clinician: “Sounds like you and your dad can get down on you for your weight. That must feel terrible.”
Teen: “Ah, it’s not that bad. I’m kind of used to it. Fat kid at home, fat kid at school.”
Affirmations are statements focusing on positive actions or attributes of the patient. They tend to build rapport by demonstrating that the clinician sees the strengths of the patient, not just the problems.
Clinician: “I’m pretty impressed that you’re able to show up here and talk about this. It can’t be easy when it sounds like your family and friends have put you down so much that you’re even putting yourself down about your body.”
Teen: “I didn’t really want to come, but then I thought, maybe this new doctor will have some new ideas. I actually want to do something about it, I just don’t know if anything will help. Plus my dad said if I showed up, we could go to McDonald’s afterward.”
Summaries are multipurpose. They demonstrate that you have been listening closely, which builds rapport. They provide a chance to put information together so that both clinician and patient can reflect on the sum of the data and notice what may be missing. And they provide a pause to consider where to go next.
Clinician: “So if I’m getting it right, you’ve been worried about your weight for a long time now. Your dad and your friends give you a hard time about it, which makes you feel down and hopeless, but somehow you stay brave and keep trying to figure it out. You feel ready to do something, you just don’t know what, and you were hoping maybe coming here could give you a place to work on your health. Does that sound about right?”
Teen: “I think that’s pretty much it. Plus the McDonald’s.”
Clinician: “Right, that’s important too – we have to consider your motivation! I wonder if we could talk about this more at our next visit – would that be alright?”
Offices with additional resources might be able to offer some of those as well, if timing seems appropriate; for example, referral to a wellness coach or social worker or nutritionist could be helpful int his case. With the spirit of PACE and the skills of OARS, you can be well on your way to fostering behavior changes that could last a lifetime! Check out the resources from the American Academy of Pediatrics with video and narrative demonstrations of motivational interviewing in pediatrics.
Dr. Rosenfeld is assistant professor in the departments of psychiatry and pediatrics at the University of Vermont Medical Center and the university’s Robert Larner College of Medicine, Burlington. He reported no relevant disclosures. Email him at [email protected].
References
1. Miller WR, Rollnick S. “Engagement and disengagement,” in “Motivational interviewing: Helping people change,” 3rd ed. (New York: Guilford, 2013).
2. Miller WR, Rollnick S. “The spirit of motivational interviewing,” in “Motivational interviewing: Helping people change,” 3rd ed. (New York: Guilford, 2013).
3. Naar S, Suarez M. “Adolescence and emerging adulthood: A brief review of development,” in “Motivational interviewing with adolescents and young adults” (New York: Guilford, 2011).
Kyle is a 14-year-old cisgender male who just moved to your town. At his first well-check, his single father brings him in reluctantly, stating, “We’ve never liked doctors.” Kyle has a history of asthma and obesity that have been relatively unchanged over time. He is an average student, an avid gamer, and seems somewhat shy. Privately he admits to occasional cannabis use. His father has no concerns, lamenting, “He’s always been pretty healthy for a fat kid.” Next patient?
Of course there is a lot to work with here. You might be concerned with Kyle’s asthma; his weight, sedentary nature, and body image; the criticism from his father and concerns about self-esteem; the possibility of anxiety in relation to his shyness; and the health effects of his cannabis use. In the end, recommendations for behavior change seem likely. These might take the form of tips on exercise, nutrition, substance use, study habits, parenting, social activities, or mental health support; the literature on behavior change would suggest that any success will be predicated on trust. How can we learn from someone we do not trust?1
To build trust is no easy task, and yet is perhaps the foundation on which the entire clinical relationship rests. Guidance from decades of evidence supporting the use of motivational interviewing2 suggests that the process of building rapport can be neatly summed up in an acronym as PACE. This represents Partnership, Acceptance, Compassion, and Evocation. Almost too clichéd to repeat, the most powerful change agent is the person making the change. In the setting of pediatric health care, we sometimes lean on caregivers to initiate or promote change because they are an intimate part of the patient’s microsystem, and thus moving one gear (the parents) inevitably shifts something in connected gears (the children).
So Partnership is centered on the patient, but inclusive of any important person in the patient’s sphere. In a family-based approach, this might show up as leveraging Kyle’s father’s motivation for behavior change by having the father start an exercise routine. This role models behavior change, shifts the home environment around the behavior, and builds empathy in the parent for the inherent challenges of change processes.
Acceptance can be distilled into knowing that the patient and family are doing the best they can. This does not preclude the possibility of change, but it seats this possibility in an attitude of assumed adequacy. There is nothing wrong with the patient, nothing to be fixed, just the possibility for change.
Similarly, Compassion takes a nonjudgmental viewpoint. With the stance of “this could happen to anybody,” the patient can feel responsible without feeling blamed. Noting the patient’s suffering without blame allows the clinician to be motivated not just to empathize, but to help.
And from this basis of compassionate partnership, the work of Evocation begins. What is happening in the patient’s life and relationships? What are their own goals and values? Where are the discrepancies between what the patient wants and what the patient does? For teenagers, this often brings into conflict developmentally appropriate wishes for autonomy – wanting to drive or get a car or stay out later or have more privacy – with developmentally typical challenges regarding responsibility.3 For example:
Clinician: “You want to use the car, and your parents want you to pay for the gas, but you’re out of money from buying weed. I see how you’re stuck.”
Teen: “Yeah, they really need to give me more allowance. It’s not like we’re living in the 1990s anymore!”
Clinician: “So you could ask for more allowance to get more money for gas. Any other ideas?”
Teen: “I could give up smoking pot and just be miserable all the time.”
Clinician: “Yeah, that sounds too difficult right now; if anything it sounds like you’d like to smoke more pot if you had more money.”
Teen: “Nah, I’m not that hooked on it. ... I could probably smoke a bit less each week and save some gas money.”
The PACE acronym also serves as a reminder of the patience required to grow connection where none has previously existed – pace yourself. Here are some skills-based tips to foster the spirit of motivational interviewing to help balance patience with the time frame of a pediatric check-in. The OARS skills represent the fundamental building blocks of motivational interviewing in practice. Taking the case of Kyle as an example, an Open-Ended Question makes space for the child or parent to express their views with less interviewer bias. Reflections expand this space by underscoring and, in the case of complex Reflections, adding some nuance to what the patient has to say.
Clinician: “How do you feel about your body?”
Teen: “Well, I’m fat. Nobody really wants to be fat. It sucks. But what can I do?”
Clinician: “You feel fat and kind of hopeless.”
Teen: “Yeah, I know you’re going to tell me to go on a diet and start exercising. Doesn’t work. My dad says I was born fat; I guess I’m going to stay that way.”
Clinician: “Sounds like you and your dad can get down on you for your weight. That must feel terrible.”
Teen: “Ah, it’s not that bad. I’m kind of used to it. Fat kid at home, fat kid at school.”
Affirmations are statements focusing on positive actions or attributes of the patient. They tend to build rapport by demonstrating that the clinician sees the strengths of the patient, not just the problems.
Clinician: “I’m pretty impressed that you’re able to show up here and talk about this. It can’t be easy when it sounds like your family and friends have put you down so much that you’re even putting yourself down about your body.”
Teen: “I didn’t really want to come, but then I thought, maybe this new doctor will have some new ideas. I actually want to do something about it, I just don’t know if anything will help. Plus my dad said if I showed up, we could go to McDonald’s afterward.”
Summaries are multipurpose. They demonstrate that you have been listening closely, which builds rapport. They provide a chance to put information together so that both clinician and patient can reflect on the sum of the data and notice what may be missing. And they provide a pause to consider where to go next.
Clinician: “So if I’m getting it right, you’ve been worried about your weight for a long time now. Your dad and your friends give you a hard time about it, which makes you feel down and hopeless, but somehow you stay brave and keep trying to figure it out. You feel ready to do something, you just don’t know what, and you were hoping maybe coming here could give you a place to work on your health. Does that sound about right?”
Teen: “I think that’s pretty much it. Plus the McDonald’s.”
Clinician: “Right, that’s important too – we have to consider your motivation! I wonder if we could talk about this more at our next visit – would that be alright?”
Offices with additional resources might be able to offer some of those as well, if timing seems appropriate; for example, referral to a wellness coach or social worker or nutritionist could be helpful int his case. With the spirit of PACE and the skills of OARS, you can be well on your way to fostering behavior changes that could last a lifetime! Check out the resources from the American Academy of Pediatrics with video and narrative demonstrations of motivational interviewing in pediatrics.
Dr. Rosenfeld is assistant professor in the departments of psychiatry and pediatrics at the University of Vermont Medical Center and the university’s Robert Larner College of Medicine, Burlington. He reported no relevant disclosures. Email him at [email protected].
References
1. Miller WR, Rollnick S. “Engagement and disengagement,” in “Motivational interviewing: Helping people change,” 3rd ed. (New York: Guilford, 2013).
2. Miller WR, Rollnick S. “The spirit of motivational interviewing,” in “Motivational interviewing: Helping people change,” 3rd ed. (New York: Guilford, 2013).
3. Naar S, Suarez M. “Adolescence and emerging adulthood: A brief review of development,” in “Motivational interviewing with adolescents and young adults” (New York: Guilford, 2011).
New EPOCH for adult patients with Burkitt lymphoma
Adult patients with Burkitt lymphoma can achieve equally sound survival outcomes with dose-adjusted chemotherapy versus high-intensity regimens, but can do so while avoiding the severe toxicities, U.S. study data shows.
Although Burkitt lymphoma is the most common B-cell non-Hodgkin lymphoma in children, it accounts for only 1% to 2% of adult lymphoma cases.
Highly dose-intensive chemotherapy regimens, developed for children and young adults, have rendered the disease curable. But older patients in particular, and patients with comorbidities such as HIV, can suffer severe adverse effects, as well as late sequelae like second malignancies.
Mark Roschewski, MD, from the lymphoid malignancies branch at the National Cancer Institute in Bethesda, Md., and colleagues therefore examined whether a dose-adjusted regimen would maintain outcomes while reducing toxicities.
Tailoring treatment with etoposide, doxorubicin, and vincristine with prednisone, cyclophosphamide, and rituximab (EPOCH-R) to whether patients had high- or low-risk disease, they achieved 4-year survival rates of higher than 85%.
The research, published by the Journal of Clinical Oncology, also showed that patients taking the regimen, which was well tolerated, had low rates of relapse in the central nervous system.
The team reports that their results with the dose-adjusted regimen “significantly improve on the complexity, cost, and toxicity profile of other regimens,” also highlighting that it is administered on an outpatient basis.
As the outcomes also “compare favorably” with those with high intensity regimens, they say the findings “support our treatment strategies to ameliorate toxicity while maintaining efficacy.”
Importantly, they suggest highly dose-intensive chemotherapy is unnecessary for cure, and carefully defined low-risk patients may be treated with limited chemotherapy.
Dr. Roschewski said in an interview that, in patients aged 40 years and older, dose-adjusted EPOCH-R is “probably the preferred choice,” despite its “weakness” in controlling the disease in patients with active CNS involvement.
However, the “real question” is what to use in younger patients, Dr. Roschewski said, as the “unknown” is whether the additional magnitude of a high-intensity regimen that “gets into the CNS” outweighs the risk of toxicities.
“What was important about our study,” he said, was that patients with CNS involvement “did the worst but it was equally split among patients that died of toxicity and patients that progressed.”
In other words, each choice increases one risk while decreasing another. “So I would have to have that discussion with the patient, and individual patient decisions are typically based on the details,” said Dr. Roschewski.
One issue, however, that could limit the adoption of dose-adjusted EPOCH-R is that, without a randomized study comparing it directly with a high-intensity regimen, clinicians may to stick to what they know.
Dr. Roschewski said that “this is particularly true of more experienced clinicians.”
“They’re less likely, I think, to adopt something else outside of a randomized study because our natural inclination with this disease has always been dose intensity is critical. ... This is a dogma, and to shift from that probably does require a higher level of evidence, at least for some practitioners,” he explained.
Further study details
Following a pilot study of dose-adjusted EPOCH-R in 30 adult patients in which the authors say the regimen showed “high efficacy,” they enrolled 113 patients with untreated Burkitt lymphoma at 22 centers between June 2010 and May 2017.
The patients were divided into low-risk and high-risk categories, with low-risk defined as stage 1 or 2 disease, normal lactate dehydrogenase levels, ECOG performance status ≤ 1, and no tumor mass ≥ 7 cm.
High-risk patients were given six cycles of dose-adjusted EPOCH-R (with rituximab on day 1 only) along with CNS prophylaxis or active therapy with intrathecal methotrexate.
In contrast, low-risk patients were given two cycles of dose-adjusted EPOCH-R, with rituximab on days 1 and 5, followed by positron emission tomography.
If that was negative, the patients had one additional treatment cycle and no CNS prophylaxis, but if it was positive, they were given four additional cycles, plus intrathecal methotrexate.
Of the 113 patients enrolled, 79% were male, median age was 49 years, and 62% were aged at least 40 years, including 26% aged at least 60 years.
The team determined that 13% of the patients were of low risk, 87% were high risk, and 11% had cerebrospinal fluid involvement. One-quarter (24.7%) were HIV positive, with a median CD4+ T-cell count of 268 cells/mm3.
The majority (87%) of low-risk patients received three treatment cycles, and 82% of high-risk patents were administered six treatment cycles.
Over a median follow-up of 58.7 months (4.9 years), the 4-year event-free survival (EFS) rate across the whole cohort was 84.5% and overall survival was 87%.
At the time of analysis, all low-risk patients were in remission; among high-risk patients, the 4-year EFS was 82.1% and overall survival was 84.9%.
The team reports that treatment was equally effective across age groups, and irrespective of HIV status and International Prognostic Index risk group.
Only 2% of high-risk patients with no pretreatment evidence of CNS involvement had relapses in the brain parenchyma. Just over half (55%) of patients with cerebrospinal fluid involvement at presentation experienced disease progression or died.
Five patients died of treatment-related toxicity. Grade 3/4 thrombocytopenia occurred during 17% of cycles, and febrile neutropenia was seen during 16%. Tumor lysis syndrome was rare, occurring in 5% of patients.
Next, the researchers are planning on focusing on CNS disease, looking at EPOCH-R as the backbone and adding intrathecal methotrexate and an additional targeted agent with known CNS penetration.
Dr. Roschewski said that is “a very attractive strategy and ... we will initiate enrollment in that study probably in the next couple of months here at the NCI,” he added, noting that it will be an early phase 1 study.
Another issue he identified that “doesn’t get spoken about quite as much but I do think is important is potentially working on supportive care guidelines for how we manage these patients.” Dr. Roschewski explained, “One of the things you see over and over in these Burkitt lymphoma studies is that some patients don’t make it through therapy because they’re so sick at the beginning, and they have certain risks.
“I think simply improving that type of care, independent of what regimen is used, can potentially improve the outcomes across patient groups.”
The study was funded by the National Cancer Institute, National Institutes of Health, AIDS Malignancy Consortium, and the Cancer Therapy Evaluation Program and Lymphoid Malignancies Branch. The authors have disclosed no relevant financial relationships.
A version of this article originally appeared on Medscape.com.
Adult patients with Burkitt lymphoma can achieve equally sound survival outcomes with dose-adjusted chemotherapy versus high-intensity regimens, but can do so while avoiding the severe toxicities, U.S. study data shows.
Although Burkitt lymphoma is the most common B-cell non-Hodgkin lymphoma in children, it accounts for only 1% to 2% of adult lymphoma cases.
Highly dose-intensive chemotherapy regimens, developed for children and young adults, have rendered the disease curable. But older patients in particular, and patients with comorbidities such as HIV, can suffer severe adverse effects, as well as late sequelae like second malignancies.
Mark Roschewski, MD, from the lymphoid malignancies branch at the National Cancer Institute in Bethesda, Md., and colleagues therefore examined whether a dose-adjusted regimen would maintain outcomes while reducing toxicities.
Tailoring treatment with etoposide, doxorubicin, and vincristine with prednisone, cyclophosphamide, and rituximab (EPOCH-R) to whether patients had high- or low-risk disease, they achieved 4-year survival rates of higher than 85%.
The research, published by the Journal of Clinical Oncology, also showed that patients taking the regimen, which was well tolerated, had low rates of relapse in the central nervous system.
The team reports that their results with the dose-adjusted regimen “significantly improve on the complexity, cost, and toxicity profile of other regimens,” also highlighting that it is administered on an outpatient basis.
As the outcomes also “compare favorably” with those with high intensity regimens, they say the findings “support our treatment strategies to ameliorate toxicity while maintaining efficacy.”
Importantly, they suggest highly dose-intensive chemotherapy is unnecessary for cure, and carefully defined low-risk patients may be treated with limited chemotherapy.
Dr. Roschewski said in an interview that, in patients aged 40 years and older, dose-adjusted EPOCH-R is “probably the preferred choice,” despite its “weakness” in controlling the disease in patients with active CNS involvement.
However, the “real question” is what to use in younger patients, Dr. Roschewski said, as the “unknown” is whether the additional magnitude of a high-intensity regimen that “gets into the CNS” outweighs the risk of toxicities.
“What was important about our study,” he said, was that patients with CNS involvement “did the worst but it was equally split among patients that died of toxicity and patients that progressed.”
In other words, each choice increases one risk while decreasing another. “So I would have to have that discussion with the patient, and individual patient decisions are typically based on the details,” said Dr. Roschewski.
One issue, however, that could limit the adoption of dose-adjusted EPOCH-R is that, without a randomized study comparing it directly with a high-intensity regimen, clinicians may to stick to what they know.
Dr. Roschewski said that “this is particularly true of more experienced clinicians.”
“They’re less likely, I think, to adopt something else outside of a randomized study because our natural inclination with this disease has always been dose intensity is critical. ... This is a dogma, and to shift from that probably does require a higher level of evidence, at least for some practitioners,” he explained.
Further study details
Following a pilot study of dose-adjusted EPOCH-R in 30 adult patients in which the authors say the regimen showed “high efficacy,” they enrolled 113 patients with untreated Burkitt lymphoma at 22 centers between June 2010 and May 2017.
The patients were divided into low-risk and high-risk categories, with low-risk defined as stage 1 or 2 disease, normal lactate dehydrogenase levels, ECOG performance status ≤ 1, and no tumor mass ≥ 7 cm.
High-risk patients were given six cycles of dose-adjusted EPOCH-R (with rituximab on day 1 only) along with CNS prophylaxis or active therapy with intrathecal methotrexate.
In contrast, low-risk patients were given two cycles of dose-adjusted EPOCH-R, with rituximab on days 1 and 5, followed by positron emission tomography.
If that was negative, the patients had one additional treatment cycle and no CNS prophylaxis, but if it was positive, they were given four additional cycles, plus intrathecal methotrexate.
Of the 113 patients enrolled, 79% were male, median age was 49 years, and 62% were aged at least 40 years, including 26% aged at least 60 years.
The team determined that 13% of the patients were of low risk, 87% were high risk, and 11% had cerebrospinal fluid involvement. One-quarter (24.7%) were HIV positive, with a median CD4+ T-cell count of 268 cells/mm3.
The majority (87%) of low-risk patients received three treatment cycles, and 82% of high-risk patents were administered six treatment cycles.
Over a median follow-up of 58.7 months (4.9 years), the 4-year event-free survival (EFS) rate across the whole cohort was 84.5% and overall survival was 87%.
At the time of analysis, all low-risk patients were in remission; among high-risk patients, the 4-year EFS was 82.1% and overall survival was 84.9%.
The team reports that treatment was equally effective across age groups, and irrespective of HIV status and International Prognostic Index risk group.
Only 2% of high-risk patients with no pretreatment evidence of CNS involvement had relapses in the brain parenchyma. Just over half (55%) of patients with cerebrospinal fluid involvement at presentation experienced disease progression or died.
Five patients died of treatment-related toxicity. Grade 3/4 thrombocytopenia occurred during 17% of cycles, and febrile neutropenia was seen during 16%. Tumor lysis syndrome was rare, occurring in 5% of patients.
Next, the researchers are planning on focusing on CNS disease, looking at EPOCH-R as the backbone and adding intrathecal methotrexate and an additional targeted agent with known CNS penetration.
Dr. Roschewski said that is “a very attractive strategy and ... we will initiate enrollment in that study probably in the next couple of months here at the NCI,” he added, noting that it will be an early phase 1 study.
Another issue he identified that “doesn’t get spoken about quite as much but I do think is important is potentially working on supportive care guidelines for how we manage these patients.” Dr. Roschewski explained, “One of the things you see over and over in these Burkitt lymphoma studies is that some patients don’t make it through therapy because they’re so sick at the beginning, and they have certain risks.
“I think simply improving that type of care, independent of what regimen is used, can potentially improve the outcomes across patient groups.”
The study was funded by the National Cancer Institute, National Institutes of Health, AIDS Malignancy Consortium, and the Cancer Therapy Evaluation Program and Lymphoid Malignancies Branch. The authors have disclosed no relevant financial relationships.
A version of this article originally appeared on Medscape.com.
Adult patients with Burkitt lymphoma can achieve equally sound survival outcomes with dose-adjusted chemotherapy versus high-intensity regimens, but can do so while avoiding the severe toxicities, U.S. study data shows.
Although Burkitt lymphoma is the most common B-cell non-Hodgkin lymphoma in children, it accounts for only 1% to 2% of adult lymphoma cases.
Highly dose-intensive chemotherapy regimens, developed for children and young adults, have rendered the disease curable. But older patients in particular, and patients with comorbidities such as HIV, can suffer severe adverse effects, as well as late sequelae like second malignancies.
Mark Roschewski, MD, from the lymphoid malignancies branch at the National Cancer Institute in Bethesda, Md., and colleagues therefore examined whether a dose-adjusted regimen would maintain outcomes while reducing toxicities.
Tailoring treatment with etoposide, doxorubicin, and vincristine with prednisone, cyclophosphamide, and rituximab (EPOCH-R) to whether patients had high- or low-risk disease, they achieved 4-year survival rates of higher than 85%.
The research, published by the Journal of Clinical Oncology, also showed that patients taking the regimen, which was well tolerated, had low rates of relapse in the central nervous system.
The team reports that their results with the dose-adjusted regimen “significantly improve on the complexity, cost, and toxicity profile of other regimens,” also highlighting that it is administered on an outpatient basis.
As the outcomes also “compare favorably” with those with high intensity regimens, they say the findings “support our treatment strategies to ameliorate toxicity while maintaining efficacy.”
Importantly, they suggest highly dose-intensive chemotherapy is unnecessary for cure, and carefully defined low-risk patients may be treated with limited chemotherapy.
Dr. Roschewski said in an interview that, in patients aged 40 years and older, dose-adjusted EPOCH-R is “probably the preferred choice,” despite its “weakness” in controlling the disease in patients with active CNS involvement.
However, the “real question” is what to use in younger patients, Dr. Roschewski said, as the “unknown” is whether the additional magnitude of a high-intensity regimen that “gets into the CNS” outweighs the risk of toxicities.
“What was important about our study,” he said, was that patients with CNS involvement “did the worst but it was equally split among patients that died of toxicity and patients that progressed.”
In other words, each choice increases one risk while decreasing another. “So I would have to have that discussion with the patient, and individual patient decisions are typically based on the details,” said Dr. Roschewski.
One issue, however, that could limit the adoption of dose-adjusted EPOCH-R is that, without a randomized study comparing it directly with a high-intensity regimen, clinicians may to stick to what they know.
Dr. Roschewski said that “this is particularly true of more experienced clinicians.”
“They’re less likely, I think, to adopt something else outside of a randomized study because our natural inclination with this disease has always been dose intensity is critical. ... This is a dogma, and to shift from that probably does require a higher level of evidence, at least for some practitioners,” he explained.
Further study details
Following a pilot study of dose-adjusted EPOCH-R in 30 adult patients in which the authors say the regimen showed “high efficacy,” they enrolled 113 patients with untreated Burkitt lymphoma at 22 centers between June 2010 and May 2017.
The patients were divided into low-risk and high-risk categories, with low-risk defined as stage 1 or 2 disease, normal lactate dehydrogenase levels, ECOG performance status ≤ 1, and no tumor mass ≥ 7 cm.
High-risk patients were given six cycles of dose-adjusted EPOCH-R (with rituximab on day 1 only) along with CNS prophylaxis or active therapy with intrathecal methotrexate.
In contrast, low-risk patients were given two cycles of dose-adjusted EPOCH-R, with rituximab on days 1 and 5, followed by positron emission tomography.
If that was negative, the patients had one additional treatment cycle and no CNS prophylaxis, but if it was positive, they were given four additional cycles, plus intrathecal methotrexate.
Of the 113 patients enrolled, 79% were male, median age was 49 years, and 62% were aged at least 40 years, including 26% aged at least 60 years.
The team determined that 13% of the patients were of low risk, 87% were high risk, and 11% had cerebrospinal fluid involvement. One-quarter (24.7%) were HIV positive, with a median CD4+ T-cell count of 268 cells/mm3.
The majority (87%) of low-risk patients received three treatment cycles, and 82% of high-risk patents were administered six treatment cycles.
Over a median follow-up of 58.7 months (4.9 years), the 4-year event-free survival (EFS) rate across the whole cohort was 84.5% and overall survival was 87%.
At the time of analysis, all low-risk patients were in remission; among high-risk patients, the 4-year EFS was 82.1% and overall survival was 84.9%.
The team reports that treatment was equally effective across age groups, and irrespective of HIV status and International Prognostic Index risk group.
Only 2% of high-risk patients with no pretreatment evidence of CNS involvement had relapses in the brain parenchyma. Just over half (55%) of patients with cerebrospinal fluid involvement at presentation experienced disease progression or died.
Five patients died of treatment-related toxicity. Grade 3/4 thrombocytopenia occurred during 17% of cycles, and febrile neutropenia was seen during 16%. Tumor lysis syndrome was rare, occurring in 5% of patients.
Next, the researchers are planning on focusing on CNS disease, looking at EPOCH-R as the backbone and adding intrathecal methotrexate and an additional targeted agent with known CNS penetration.
Dr. Roschewski said that is “a very attractive strategy and ... we will initiate enrollment in that study probably in the next couple of months here at the NCI,” he added, noting that it will be an early phase 1 study.
Another issue he identified that “doesn’t get spoken about quite as much but I do think is important is potentially working on supportive care guidelines for how we manage these patients.” Dr. Roschewski explained, “One of the things you see over and over in these Burkitt lymphoma studies is that some patients don’t make it through therapy because they’re so sick at the beginning, and they have certain risks.
“I think simply improving that type of care, independent of what regimen is used, can potentially improve the outcomes across patient groups.”
The study was funded by the National Cancer Institute, National Institutes of Health, AIDS Malignancy Consortium, and the Cancer Therapy Evaluation Program and Lymphoid Malignancies Branch. The authors have disclosed no relevant financial relationships.
A version of this article originally appeared on Medscape.com.
Your diet may be aging you
Recent studies have shown a correlation between many dietary elements and skin diseases including acne, rosacea, and perioral dermatitis. and there is now evidence that the aging process can also be slowed with a healthy diet. Previous studies have shown that intake of vegetables, fish, and foods high in vitamin C, carotenoids, olive oil, and linoleic acid are associated with decreased wrinkles.
In a Dutch population-based cohort study published in the Journal of the American Academy of Dermatology in 2019, Mekić et al. investigated the association between diet and facial wrinkles in an elderly population. Facial photographs were used to evaluate wrinkle severity and diet of the participants was assessed with the Food Frequency Questionnaire and adherence to the Dutch Healthy Diet Index (DHDI).
The DHDI is a measure of the ability to adhere to the Dutch Guidelines for a Healthy Diet. The guidelines recommend a daily intake in the diet of at least 200 g of vegetables daily; at least 200 g of fruit; 90 g of brown bread, wholemeal bread, or other whole-grain products; and at least 15 g of unsalted nuts. One serving of fish (preferably oily fish) per week and little to no dairy, alcohol, red meat, cooking fats, and sugar is also recommended.
The study revealed that better adherence to the DHDI was significantly associated with fewer wrinkles among women but not men. Women who ate more animal meat and fats and carbohydrates had more wrinkles than did those with a fruit-dominant diet.
Although other healthy behaviors such as exercise and alcohol are likely to play a role in confounding these data, UV exposure as a cause of wrinkling was accounted for, and in the study, increased outdoor exercise was associated with more wrinkles. Unhealthy food can induce oxidative stress, increased skin and gut inflammation, and glycation, which are some of the physiologic mechanisms suggested to increase wrinkle formation. In contrast, nutrients in fruits and vegetables stimulate collagen production and DNA repair and reduce oxidative stress on the skin.
Nutritional advice is largely rare in internal medicine, cardiology, and even endocrinology. We are developing better ways to assess and understand the way foods interact and cause inflammation of the gut and the body and skin. I highly recommend nutritional education be a part of our residency training programs and to make better guidelines on the prevention of skin disease and aging available for both practitioners and patients.
Dr. Wesley and Dr. Talakoub are cocontributors to this column. Dr. Wesley practices dermatology in Beverly Hills, Calif. Dr. Talakoub is in private practice in McLean, Va. This month’s column is by Dr. Talakoub. Write to them at [email protected]. They had no relevant disclosures.
References
Mekić S et al. J Am Acad Dermatol. 2019 May;80(5):1358-1363.e2.
Purba MB et al. J Am Coll Nutr. 2001;20(1):71‐80.
van Lee L et al. Nutr J. 2012 Jul 20;11:49.
Kromhout D et al. Eur J Clin Nutr. 2016 Aug;70(8):869‐78.
Recent studies have shown a correlation between many dietary elements and skin diseases including acne, rosacea, and perioral dermatitis. and there is now evidence that the aging process can also be slowed with a healthy diet. Previous studies have shown that intake of vegetables, fish, and foods high in vitamin C, carotenoids, olive oil, and linoleic acid are associated with decreased wrinkles.
In a Dutch population-based cohort study published in the Journal of the American Academy of Dermatology in 2019, Mekić et al. investigated the association between diet and facial wrinkles in an elderly population. Facial photographs were used to evaluate wrinkle severity and diet of the participants was assessed with the Food Frequency Questionnaire and adherence to the Dutch Healthy Diet Index (DHDI).
The DHDI is a measure of the ability to adhere to the Dutch Guidelines for a Healthy Diet. The guidelines recommend a daily intake in the diet of at least 200 g of vegetables daily; at least 200 g of fruit; 90 g of brown bread, wholemeal bread, or other whole-grain products; and at least 15 g of unsalted nuts. One serving of fish (preferably oily fish) per week and little to no dairy, alcohol, red meat, cooking fats, and sugar is also recommended.
The study revealed that better adherence to the DHDI was significantly associated with fewer wrinkles among women but not men. Women who ate more animal meat and fats and carbohydrates had more wrinkles than did those with a fruit-dominant diet.
Although other healthy behaviors such as exercise and alcohol are likely to play a role in confounding these data, UV exposure as a cause of wrinkling was accounted for, and in the study, increased outdoor exercise was associated with more wrinkles. Unhealthy food can induce oxidative stress, increased skin and gut inflammation, and glycation, which are some of the physiologic mechanisms suggested to increase wrinkle formation. In contrast, nutrients in fruits and vegetables stimulate collagen production and DNA repair and reduce oxidative stress on the skin.
Nutritional advice is largely rare in internal medicine, cardiology, and even endocrinology. We are developing better ways to assess and understand the way foods interact and cause inflammation of the gut and the body and skin. I highly recommend nutritional education be a part of our residency training programs and to make better guidelines on the prevention of skin disease and aging available for both practitioners and patients.
Dr. Wesley and Dr. Talakoub are cocontributors to this column. Dr. Wesley practices dermatology in Beverly Hills, Calif. Dr. Talakoub is in private practice in McLean, Va. This month’s column is by Dr. Talakoub. Write to them at [email protected]. They had no relevant disclosures.
References
Mekić S et al. J Am Acad Dermatol. 2019 May;80(5):1358-1363.e2.
Purba MB et al. J Am Coll Nutr. 2001;20(1):71‐80.
van Lee L et al. Nutr J. 2012 Jul 20;11:49.
Kromhout D et al. Eur J Clin Nutr. 2016 Aug;70(8):869‐78.
Recent studies have shown a correlation between many dietary elements and skin diseases including acne, rosacea, and perioral dermatitis. and there is now evidence that the aging process can also be slowed with a healthy diet. Previous studies have shown that intake of vegetables, fish, and foods high in vitamin C, carotenoids, olive oil, and linoleic acid are associated with decreased wrinkles.
In a Dutch population-based cohort study published in the Journal of the American Academy of Dermatology in 2019, Mekić et al. investigated the association between diet and facial wrinkles in an elderly population. Facial photographs were used to evaluate wrinkle severity and diet of the participants was assessed with the Food Frequency Questionnaire and adherence to the Dutch Healthy Diet Index (DHDI).
The DHDI is a measure of the ability to adhere to the Dutch Guidelines for a Healthy Diet. The guidelines recommend a daily intake in the diet of at least 200 g of vegetables daily; at least 200 g of fruit; 90 g of brown bread, wholemeal bread, or other whole-grain products; and at least 15 g of unsalted nuts. One serving of fish (preferably oily fish) per week and little to no dairy, alcohol, red meat, cooking fats, and sugar is also recommended.
The study revealed that better adherence to the DHDI was significantly associated with fewer wrinkles among women but not men. Women who ate more animal meat and fats and carbohydrates had more wrinkles than did those with a fruit-dominant diet.
Although other healthy behaviors such as exercise and alcohol are likely to play a role in confounding these data, UV exposure as a cause of wrinkling was accounted for, and in the study, increased outdoor exercise was associated with more wrinkles. Unhealthy food can induce oxidative stress, increased skin and gut inflammation, and glycation, which are some of the physiologic mechanisms suggested to increase wrinkle formation. In contrast, nutrients in fruits and vegetables stimulate collagen production and DNA repair and reduce oxidative stress on the skin.
Nutritional advice is largely rare in internal medicine, cardiology, and even endocrinology. We are developing better ways to assess and understand the way foods interact and cause inflammation of the gut and the body and skin. I highly recommend nutritional education be a part of our residency training programs and to make better guidelines on the prevention of skin disease and aging available for both practitioners and patients.
Dr. Wesley and Dr. Talakoub are cocontributors to this column. Dr. Wesley practices dermatology in Beverly Hills, Calif. Dr. Talakoub is in private practice in McLean, Va. This month’s column is by Dr. Talakoub. Write to them at [email protected]. They had no relevant disclosures.
References
Mekić S et al. J Am Acad Dermatol. 2019 May;80(5):1358-1363.e2.
Purba MB et al. J Am Coll Nutr. 2001;20(1):71‐80.
van Lee L et al. Nutr J. 2012 Jul 20;11:49.
Kromhout D et al. Eur J Clin Nutr. 2016 Aug;70(8):869‐78.
Dermatology News welcomes new advisory board member
at University Hospital Saint-Louis in Paris, in the inflammatory diseases outpatient clinic, where he treats patients with severe psoriasis and other inflammatory chronic skin diseases.
He is a member of several dermatology specialty organizations, including the Société Française de Dermatologie, the European Academy of Dermatology, as well as the American Academy of Dermatology. His research interests are in immunology and inflammatory diseases; he also has a passion for art and history.
at University Hospital Saint-Louis in Paris, in the inflammatory diseases outpatient clinic, where he treats patients with severe psoriasis and other inflammatory chronic skin diseases.
He is a member of several dermatology specialty organizations, including the Société Française de Dermatologie, the European Academy of Dermatology, as well as the American Academy of Dermatology. His research interests are in immunology and inflammatory diseases; he also has a passion for art and history.
at University Hospital Saint-Louis in Paris, in the inflammatory diseases outpatient clinic, where he treats patients with severe psoriasis and other inflammatory chronic skin diseases.
He is a member of several dermatology specialty organizations, including the Société Française de Dermatologie, the European Academy of Dermatology, as well as the American Academy of Dermatology. His research interests are in immunology and inflammatory diseases; he also has a passion for art and history.
Frequent hypoglycemic episodes raise cardiac event risk
Frequent hypoglycemic episodes were linked to a raised incidence of cardiovascular events in adults with type 2 diabetes in a recent retrospective study, suggesting certain hypoglycemia-associated diabetes drugs should be avoided, an investigator said.
Patients who had more than five hypoglycemic episodes per year had a 61% greater risk of cardiovascular (CV) events, compared with patients with less frequent episodes, according to results of the study.
Although there were fewer strokes among younger patients, the overall increase in cardiovascular event risk held up regardless of age group, according to investigator Aman Rajpal, MD, of Louis Stokes Veterans Affairs Medical Center and Case Western Reserve University, both in Cleveland.
On the basis of these and earlier studies tying hypoglycemia to CV risk, health care providers need to “pay close attention” to low blood sugar and personalize glycemic control targets for each patient based on risk of hypoglycemia, Dr. Rajpal said in a presentation of the study at the virtual annual scientific sessions of the American Diabetes Association.
“Also, this suggests that avoidance of drugs associated with increased risk of hypoglycemia – namely insulin, sulfonylureas, or others – is essential to avoid and minimize the risk of cardiovascular events in this patient population with type 2 diabetes,” said Dr. Rajpal. “Let us remember part of our Hippocratic oath: ‘Above all, do no harm.’ ”
Tailoring treatment to mitigate risk
Mark Schutta, MD, medical director of Penn Rodebaugh Diabetes Center in Philadelphia, said that results of this study suggest a need to carefully select medical therapy for each individual patient with diabetes in order to mitigate CV risk.
“It’s really about tailoring their drugs to their personal situation,” Dr. Schutta said in an interview.
Although newer diabetes drug classes are associated with low to no risk of hypoglycemia, Dr. Schutta said that there is still a place for drugs such as sulfonylureas in certain situations.
Among sulfonylureas, glyburide comes with a much higher incidence of hypoglycemia, compared with glipizide and glimepiride, according to Dr. Schutta. “I think there’s a role for both drugs, but you have to be very careful, and you have to get the data from your patients.”
Hypoglycemia frequency and outcomes
Speculation that hypoglycemia could be linked to adverse CV outcomes was sparked years ago by trials such as ADVANCE. Severe hypoglycemia in that study was associated with a 168% increased risk of death from a CV cause (N Engl J Med. 2010 Oct 7;363:1410-8).
At the time, ADVANCE investigators said they were unable to find evidence that multiple severe hypoglycemia episodes conferred a greater risk of CV events versus a single hypoglycemia episode, though they added that few patients had recurrent events.
“In other words, the association between the number of hypoglycemia events, and adverse CV outcomes is still unclear,” said Dr. Rajpal in his virtual ADA presentation.
Potential elevated risks with more than five episodes
To evaluate the association between frequent hypoglycemic episodes (i.e., more than five per year, compared with one to five episodes) and CV events, Dr. Rajpal and colleagues evaluated outcomes data for 4.9 million adults with type 2 diabetes found in a large commercial database including information on patients in 27 U.S. health care networks.
Database records indicated that about 182,000 patients, or nearly 4%, had episodes of hyperglycemia, which Dr. Rajpal said was presumed to mean a plasma glucose level of less than 70 mg/dL.
Characteristics of the patients with more than five hypoglycemic episodes were similar to those with one to five episodes, although they were more likely to be 65 years or older, and were “slightly more likely” to be on insulin, which could possibly precipitate more hypoglycemic episodes in that group, Dr. Rajpal said.
Key findings
In the main analysis, Dr. Rajpal said, risk of CV events was significantly increased in those with more than five hypoglycemic episodes, compared with those with one to five episodes, with an odds ratio of 1.61 (95% confidence interval, 1.56-1.66). The incidence of cardiovascular events was 33.1% in those with more than five episodes and 23.5% in those with one to five episodes, according to the data presented.
Risks were also significantly increased specifically for cardiac arrhythmias, cerebrovascular accidents, and MI, Dr. Rajpal said, with ORs of 1.65 (95% CI, 1.9-1.71), 1.38 (95% CI, 1.22-1.56), and 1.43 (95% CI, 1.36-1.50), respectively.
Because individuals in the group with more than five hypoglycemic episodes were more likely to be elderly, Dr. Rajpal said that he and coinvestigators decided to perform an age-specific stratified analysis.
Although cerebral vascular incidence was low in younger patients, risk of CV events overall was nevertheless significantly elevated for those aged 65 years or older, 45-64 years, and 18-44 years, with ORs of 1.69 (95% CI, 1.61-1.7), 1.58 (95% CI, 1.48-1.69), and 1.62 (95% CI, 1.33-1.97).
“The results were still valid in stratified analysis based on different age groups,” Dr. Rajpal said.
Dr. Rajpal and coauthors reported that he had no conflicts of interest related to the research.
SOURCE: Rajpal A et al. ADA 2020, Abstract 161-OR.
Frequent hypoglycemic episodes were linked to a raised incidence of cardiovascular events in adults with type 2 diabetes in a recent retrospective study, suggesting certain hypoglycemia-associated diabetes drugs should be avoided, an investigator said.
Patients who had more than five hypoglycemic episodes per year had a 61% greater risk of cardiovascular (CV) events, compared with patients with less frequent episodes, according to results of the study.
Although there were fewer strokes among younger patients, the overall increase in cardiovascular event risk held up regardless of age group, according to investigator Aman Rajpal, MD, of Louis Stokes Veterans Affairs Medical Center and Case Western Reserve University, both in Cleveland.
On the basis of these and earlier studies tying hypoglycemia to CV risk, health care providers need to “pay close attention” to low blood sugar and personalize glycemic control targets for each patient based on risk of hypoglycemia, Dr. Rajpal said in a presentation of the study at the virtual annual scientific sessions of the American Diabetes Association.
“Also, this suggests that avoidance of drugs associated with increased risk of hypoglycemia – namely insulin, sulfonylureas, or others – is essential to avoid and minimize the risk of cardiovascular events in this patient population with type 2 diabetes,” said Dr. Rajpal. “Let us remember part of our Hippocratic oath: ‘Above all, do no harm.’ ”
Tailoring treatment to mitigate risk
Mark Schutta, MD, medical director of Penn Rodebaugh Diabetes Center in Philadelphia, said that results of this study suggest a need to carefully select medical therapy for each individual patient with diabetes in order to mitigate CV risk.
“It’s really about tailoring their drugs to their personal situation,” Dr. Schutta said in an interview.
Although newer diabetes drug classes are associated with low to no risk of hypoglycemia, Dr. Schutta said that there is still a place for drugs such as sulfonylureas in certain situations.
Among sulfonylureas, glyburide comes with a much higher incidence of hypoglycemia, compared with glipizide and glimepiride, according to Dr. Schutta. “I think there’s a role for both drugs, but you have to be very careful, and you have to get the data from your patients.”
Hypoglycemia frequency and outcomes
Speculation that hypoglycemia could be linked to adverse CV outcomes was sparked years ago by trials such as ADVANCE. Severe hypoglycemia in that study was associated with a 168% increased risk of death from a CV cause (N Engl J Med. 2010 Oct 7;363:1410-8).
At the time, ADVANCE investigators said they were unable to find evidence that multiple severe hypoglycemia episodes conferred a greater risk of CV events versus a single hypoglycemia episode, though they added that few patients had recurrent events.
“In other words, the association between the number of hypoglycemia events, and adverse CV outcomes is still unclear,” said Dr. Rajpal in his virtual ADA presentation.
Potential elevated risks with more than five episodes
To evaluate the association between frequent hypoglycemic episodes (i.e., more than five per year, compared with one to five episodes) and CV events, Dr. Rajpal and colleagues evaluated outcomes data for 4.9 million adults with type 2 diabetes found in a large commercial database including information on patients in 27 U.S. health care networks.
Database records indicated that about 182,000 patients, or nearly 4%, had episodes of hyperglycemia, which Dr. Rajpal said was presumed to mean a plasma glucose level of less than 70 mg/dL.
Characteristics of the patients with more than five hypoglycemic episodes were similar to those with one to five episodes, although they were more likely to be 65 years or older, and were “slightly more likely” to be on insulin, which could possibly precipitate more hypoglycemic episodes in that group, Dr. Rajpal said.
Key findings
In the main analysis, Dr. Rajpal said, risk of CV events was significantly increased in those with more than five hypoglycemic episodes, compared with those with one to five episodes, with an odds ratio of 1.61 (95% confidence interval, 1.56-1.66). The incidence of cardiovascular events was 33.1% in those with more than five episodes and 23.5% in those with one to five episodes, according to the data presented.
Risks were also significantly increased specifically for cardiac arrhythmias, cerebrovascular accidents, and MI, Dr. Rajpal said, with ORs of 1.65 (95% CI, 1.9-1.71), 1.38 (95% CI, 1.22-1.56), and 1.43 (95% CI, 1.36-1.50), respectively.
Because individuals in the group with more than five hypoglycemic episodes were more likely to be elderly, Dr. Rajpal said that he and coinvestigators decided to perform an age-specific stratified analysis.
Although cerebral vascular incidence was low in younger patients, risk of CV events overall was nevertheless significantly elevated for those aged 65 years or older, 45-64 years, and 18-44 years, with ORs of 1.69 (95% CI, 1.61-1.7), 1.58 (95% CI, 1.48-1.69), and 1.62 (95% CI, 1.33-1.97).
“The results were still valid in stratified analysis based on different age groups,” Dr. Rajpal said.
Dr. Rajpal and coauthors reported that he had no conflicts of interest related to the research.
SOURCE: Rajpal A et al. ADA 2020, Abstract 161-OR.
Frequent hypoglycemic episodes were linked to a raised incidence of cardiovascular events in adults with type 2 diabetes in a recent retrospective study, suggesting certain hypoglycemia-associated diabetes drugs should be avoided, an investigator said.
Patients who had more than five hypoglycemic episodes per year had a 61% greater risk of cardiovascular (CV) events, compared with patients with less frequent episodes, according to results of the study.
Although there were fewer strokes among younger patients, the overall increase in cardiovascular event risk held up regardless of age group, according to investigator Aman Rajpal, MD, of Louis Stokes Veterans Affairs Medical Center and Case Western Reserve University, both in Cleveland.
On the basis of these and earlier studies tying hypoglycemia to CV risk, health care providers need to “pay close attention” to low blood sugar and personalize glycemic control targets for each patient based on risk of hypoglycemia, Dr. Rajpal said in a presentation of the study at the virtual annual scientific sessions of the American Diabetes Association.
“Also, this suggests that avoidance of drugs associated with increased risk of hypoglycemia – namely insulin, sulfonylureas, or others – is essential to avoid and minimize the risk of cardiovascular events in this patient population with type 2 diabetes,” said Dr. Rajpal. “Let us remember part of our Hippocratic oath: ‘Above all, do no harm.’ ”
Tailoring treatment to mitigate risk
Mark Schutta, MD, medical director of Penn Rodebaugh Diabetes Center in Philadelphia, said that results of this study suggest a need to carefully select medical therapy for each individual patient with diabetes in order to mitigate CV risk.
“It’s really about tailoring their drugs to their personal situation,” Dr. Schutta said in an interview.
Although newer diabetes drug classes are associated with low to no risk of hypoglycemia, Dr. Schutta said that there is still a place for drugs such as sulfonylureas in certain situations.
Among sulfonylureas, glyburide comes with a much higher incidence of hypoglycemia, compared with glipizide and glimepiride, according to Dr. Schutta. “I think there’s a role for both drugs, but you have to be very careful, and you have to get the data from your patients.”
Hypoglycemia frequency and outcomes
Speculation that hypoglycemia could be linked to adverse CV outcomes was sparked years ago by trials such as ADVANCE. Severe hypoglycemia in that study was associated with a 168% increased risk of death from a CV cause (N Engl J Med. 2010 Oct 7;363:1410-8).
At the time, ADVANCE investigators said they were unable to find evidence that multiple severe hypoglycemia episodes conferred a greater risk of CV events versus a single hypoglycemia episode, though they added that few patients had recurrent events.
“In other words, the association between the number of hypoglycemia events, and adverse CV outcomes is still unclear,” said Dr. Rajpal in his virtual ADA presentation.
Potential elevated risks with more than five episodes
To evaluate the association between frequent hypoglycemic episodes (i.e., more than five per year, compared with one to five episodes) and CV events, Dr. Rajpal and colleagues evaluated outcomes data for 4.9 million adults with type 2 diabetes found in a large commercial database including information on patients in 27 U.S. health care networks.
Database records indicated that about 182,000 patients, or nearly 4%, had episodes of hyperglycemia, which Dr. Rajpal said was presumed to mean a plasma glucose level of less than 70 mg/dL.
Characteristics of the patients with more than five hypoglycemic episodes were similar to those with one to five episodes, although they were more likely to be 65 years or older, and were “slightly more likely” to be on insulin, which could possibly precipitate more hypoglycemic episodes in that group, Dr. Rajpal said.
Key findings
In the main analysis, Dr. Rajpal said, risk of CV events was significantly increased in those with more than five hypoglycemic episodes, compared with those with one to five episodes, with an odds ratio of 1.61 (95% confidence interval, 1.56-1.66). The incidence of cardiovascular events was 33.1% in those with more than five episodes and 23.5% in those with one to five episodes, according to the data presented.
Risks were also significantly increased specifically for cardiac arrhythmias, cerebrovascular accidents, and MI, Dr. Rajpal said, with ORs of 1.65 (95% CI, 1.9-1.71), 1.38 (95% CI, 1.22-1.56), and 1.43 (95% CI, 1.36-1.50), respectively.
Because individuals in the group with more than five hypoglycemic episodes were more likely to be elderly, Dr. Rajpal said that he and coinvestigators decided to perform an age-specific stratified analysis.
Although cerebral vascular incidence was low in younger patients, risk of CV events overall was nevertheless significantly elevated for those aged 65 years or older, 45-64 years, and 18-44 years, with ORs of 1.69 (95% CI, 1.61-1.7), 1.58 (95% CI, 1.48-1.69), and 1.62 (95% CI, 1.33-1.97).
“The results were still valid in stratified analysis based on different age groups,” Dr. Rajpal said.
Dr. Rajpal and coauthors reported that he had no conflicts of interest related to the research.
SOURCE: Rajpal A et al. ADA 2020, Abstract 161-OR.
FROM ADA 2020
Choosing a career in health equity and health care policy
Dr. Anyane-Yeboa is a Commonwealth Fund Fellow in Minority Health Policy at Harvard University and a recent graduate of the Harvard T.H. Chan School of Public Health. She previously completed her gastroenterology fellowship at the University of Chicago. She will be an academic gastroenterologist at Massachusetts General Hospital starting in the fall of 2020.
How did your career pathway lead you to a career in health equity and policy?
I have been passionate about issues related to health equity, workforce diversity, and care of vulnerable populations since the early years of my career. For instance, as undergraduates my friends and I received a grant to start a program to provide mentorship for endangered youth in Boston. During my residency and chief residency, I advocated for increased resident diversity and created programs for underrepresented minority medical students to increase minority representation in medicine. During my gastroenterology fellowship, I remained passionate about the care of minority and underserved populations. During my second year of fellowship, I looked for advanced training opportunities where I could learn the skills to tackle health disparities in minority communities, and almost serendipitously came across the Commonwealth Fund Fellowship in Minority Health Policy. When I decided to apply for the fellowship, I knew that this would be a nontraditional path for most gastroenterology fellows, but the right path for me.
About the Commonwealth Fund Fellowship 
The purpose of the Commonwealth Fund Fellowship in Minority Health Policy at Harvard University is to train the next generation of leaders in health care. The program is based at Harvard Medical School and supported by the Commonwealth Fund whose mission is to “provide affordable quality health care for all.” To date, the fellowship has trained more than 130 physicians who are advancing health care across the nation as leaders in public health, academic medicine, and health policy.
The fellowship is a year-long, full-time, degree-granting program. Fellows are eligible for a master’s in public health with a concentration in health management or health policy from the Harvard T.H. Chan School of Public Health or a master’s in public administration from the Harvard Kennedy School.
The fellowship program and experiences have been transformative for me. The structure of the program consists of visits to the Massachusetts Department of Public Health, the Boston Public Health Commission, and the Commonwealth Fund, as well as lectures, seminars, and journal club sessions with national leaders in public health, health policy, and health care delivery reform. Additional opportunities include one-on-one shadowing experiences with leaders in hospital administration at academic institutions in Boston and private meetings with leaders and staff at several government agencies in Washington, including the Centers for Medicaid & Medicare Services, the Office of Minority Health, the Food and Drug Administration, the Health Resources & Services Administration, and the National Institutes of Health.
The program has given me an opportunity to meet and learn from physicians who have chosen a variety of different career paths. Through the program I have had exposure to physicians in academic medicine, health care administration, health policy, and public service as well as those who have chosen a combination of clinical practice with any of the above. This experience has opened my eyes to the different possibilities for physician careers and has encouraged me to be open if new opportunities should arise.
As part of the fellowship, we also have regular meetings with Joan Reede, MD, MPH, who is the director of the fellowship and has been with the program since its inception; she is also the Dean of Diversity and Inclusion at Harvard Medical School. Dr. Reede is an incredibly wise, insightful, and caring mentor, but also a powerhouse in issues surrounding workforce diversity, mentorship, policy, care of underserved communities, and being an advocate for change. To have access to such a powerful individual who has dedicated her career to the mentorship of individuals like myself, who cares deeply about the impact of our careers, and who genuinely values each fellow almost as her own child is a unique gift that is hard to describe in words.
The Commonwealth Fund Fellowship also provides a large network of mentors and advisers. My direct mentor for the program is Monica Bharel, MD, MPH, who is a former Commonwealth Fund fellow and the current Commissioner of the Massachusetts Department of Public Health. However, I also have a wealth of other mentors and advisers in the alumni fellows, including Darrell Gray II, MD, MPH, a former fellow and gastroenterologist at the Ohio State University College of Medicine, as well as the other faculty associated with the program. I never imagined that I would have access to leaders in so many different sectors of health care and policy who are genuinely and passionately rooting for my success. In addition, my cofellows and I have created a uniquely special bond, and they will likely continue as my close network of peer advisers as I move forward throughout my career.
After the fellowship
I have no doubt that the Commonwealth Fund Fellowship will alter the trajectory of my career. It has already affected my career path in ways that I could not have anticipated years ago. The knowledge that I have gained in health care policy, innovation, and equity, as well as the networks that I have access to as a fellow, will be invaluable as I move forward. In terms of next steps, I will be working as an academic gastroenterologist; I will continue to lead initiatives, perform research, and participate in projects to elevate the voices of underserved communities and work toward health equity in gastroenterology. I am particularly passionate about ending disparities in colorectal cancer in minority communities and increasing awareness around minorities with inflammatory bowel disease.
I plan to work with health centers, city- and state-level organizations, and community partners to raise awareness around issues of equity in gastroenterology and develop interventions to create change. I will also work with local legislators and community-based organizations to advocate for policies that remove barriers to screening both locally and nationally. Further down the line, I am open to exploring careers in the public sector or health care administration if that is where my career takes me. The exposure that I had to these fields as part of the fellowship has shown me that it is possible to be a practicing gastroenterologist and simultaneously work in the public sector, health policy, or health care administration. If you are interested in applying to the Commonwealth Fund Fellowship in Minority Health Policy at Harvard University, please feel free to contact me at [email protected]. More information about the program and how to apply can be found at https://cff.hms.harvard.edu/.
Dr. Anyane-Yeboa is a Commonwealth Fund Fellow in Minority Health Policy at Harvard University and a recent graduate of the Harvard T.H. Chan School of Public Health. She previously completed her gastroenterology fellowship at the University of Chicago. She will be an academic gastroenterologist at Massachusetts General Hospital starting in the fall of 2020.
How did your career pathway lead you to a career in health equity and policy?
I have been passionate about issues related to health equity, workforce diversity, and care of vulnerable populations since the early years of my career. For instance, as undergraduates my friends and I received a grant to start a program to provide mentorship for endangered youth in Boston. During my residency and chief residency, I advocated for increased resident diversity and created programs for underrepresented minority medical students to increase minority representation in medicine. During my gastroenterology fellowship, I remained passionate about the care of minority and underserved populations. During my second year of fellowship, I looked for advanced training opportunities where I could learn the skills to tackle health disparities in minority communities, and almost serendipitously came across the Commonwealth Fund Fellowship in Minority Health Policy. When I decided to apply for the fellowship, I knew that this would be a nontraditional path for most gastroenterology fellows, but the right path for me.
About the Commonwealth Fund Fellowship
The purpose of the Commonwealth Fund Fellowship in Minority Health Policy at Harvard University is to train the next generation of leaders in health care. The program is based at Harvard Medical School and supported by the Commonwealth Fund whose mission is to “provide affordable quality health care for all.” To date, the fellowship has trained more than 130 physicians who are advancing health care across the nation as leaders in public health, academic medicine, and health policy.
The fellowship is a year-long, full-time, degree-granting program. Fellows are eligible for a master’s in public health with a concentration in health management or health policy from the Harvard T.H. Chan School of Public Health or a master’s in public administration from the Harvard Kennedy School.
The fellowship program and experiences have been transformative for me. The structure of the program consists of visits to the Massachusetts Department of Public Health, the Boston Public Health Commission, and the Commonwealth Fund, as well as lectures, seminars, and journal club sessions with national leaders in public health, health policy, and health care delivery reform. Additional opportunities include one-on-one shadowing experiences with leaders in hospital administration at academic institutions in Boston and private meetings with leaders and staff at several government agencies in Washington, including the Centers for Medicaid & Medicare Services, the Office of Minority Health, the Food and Drug Administration, the Health Resources & Services Administration, and the National Institutes of Health.
The program has given me an opportunity to meet and learn from physicians who have chosen a variety of different career paths. Through the program I have had exposure to physicians in academic medicine, health care administration, health policy, and public service as well as those who have chosen a combination of clinical practice with any of the above. This experience has opened my eyes to the different possibilities for physician careers and has encouraged me to be open if new opportunities should arise.
As part of the fellowship, we also have regular meetings with Joan Reede, MD, MPH, who is the director of the fellowship and has been with the program since its inception; she is also the Dean of Diversity and Inclusion at Harvard Medical School. Dr. Reede is an incredibly wise, insightful, and caring mentor, but also a powerhouse in issues surrounding workforce diversity, mentorship, policy, care of underserved communities, and being an advocate for change. To have access to such a powerful individual who has dedicated her career to the mentorship of individuals like myself, who cares deeply about the impact of our careers, and who genuinely values each fellow almost as her own child is a unique gift that is hard to describe in words.
The Commonwealth Fund Fellowship also provides a large network of mentors and advisers. My direct mentor for the program is Monica Bharel, MD, MPH, who is a former Commonwealth Fund fellow and the current Commissioner of the Massachusetts Department of Public Health. However, I also have a wealth of other mentors and advisers in the alumni fellows, including Darrell Gray II, MD, MPH, a former fellow and gastroenterologist at the Ohio State University College of Medicine, as well as the other faculty associated with the program. I never imagined that I would have access to leaders in so many different sectors of health care and policy who are genuinely and passionately rooting for my success. In addition, my cofellows and I have created a uniquely special bond, and they will likely continue as my close network of peer advisers as I move forward throughout my career.
After the fellowship
I have no doubt that the Commonwealth Fund Fellowship will alter the trajectory of my career. It has already affected my career path in ways that I could not have anticipated years ago. The knowledge that I have gained in health care policy, innovation, and equity, as well as the networks that I have access to as a fellow, will be invaluable as I move forward. In terms of next steps, I will be working as an academic gastroenterologist; I will continue to lead initiatives, perform research, and participate in projects to elevate the voices of underserved communities and work toward health equity in gastroenterology. I am particularly passionate about ending disparities in colorectal cancer in minority communities and increasing awareness around minorities with inflammatory bowel disease.
I plan to work with health centers, city- and state-level organizations, and community partners to raise awareness around issues of equity in gastroenterology and develop interventions to create change. I will also work with local legislators and community-based organizations to advocate for policies that remove barriers to screening both locally and nationally. Further down the line, I am open to exploring careers in the public sector or health care administration if that is where my career takes me. The exposure that I had to these fields as part of the fellowship has shown me that it is possible to be a practicing gastroenterologist and simultaneously work in the public sector, health policy, or health care administration. If you are interested in applying to the Commonwealth Fund Fellowship in Minority Health Policy at Harvard University, please feel free to contact me at [email protected]. More information about the program and how to apply can be found at https://cff.hms.harvard.edu/.
Dr. Anyane-Yeboa is a Commonwealth Fund Fellow in Minority Health Policy at Harvard University and a recent graduate of the Harvard T.H. Chan School of Public Health. She previously completed her gastroenterology fellowship at the University of Chicago. She will be an academic gastroenterologist at Massachusetts General Hospital starting in the fall of 2020.
How did your career pathway lead you to a career in health equity and policy?
I have been passionate about issues related to health equity, workforce diversity, and care of vulnerable populations since the early years of my career. For instance, as undergraduates my friends and I received a grant to start a program to provide mentorship for endangered youth in Boston. During my residency and chief residency, I advocated for increased resident diversity and created programs for underrepresented minority medical students to increase minority representation in medicine. During my gastroenterology fellowship, I remained passionate about the care of minority and underserved populations. During my second year of fellowship, I looked for advanced training opportunities where I could learn the skills to tackle health disparities in minority communities, and almost serendipitously came across the Commonwealth Fund Fellowship in Minority Health Policy. When I decided to apply for the fellowship, I knew that this would be a nontraditional path for most gastroenterology fellows, but the right path for me.
About the Commonwealth Fund Fellowship
The purpose of the Commonwealth Fund Fellowship in Minority Health Policy at Harvard University is to train the next generation of leaders in health care. The program is based at Harvard Medical School and supported by the Commonwealth Fund whose mission is to “provide affordable quality health care for all.” To date, the fellowship has trained more than 130 physicians who are advancing health care across the nation as leaders in public health, academic medicine, and health policy.
The fellowship is a year-long, full-time, degree-granting program. Fellows are eligible for a master’s in public health with a concentration in health management or health policy from the Harvard T.H. Chan School of Public Health or a master’s in public administration from the Harvard Kennedy School.
The fellowship program and experiences have been transformative for me. The structure of the program consists of visits to the Massachusetts Department of Public Health, the Boston Public Health Commission, and the Commonwealth Fund, as well as lectures, seminars, and journal club sessions with national leaders in public health, health policy, and health care delivery reform. Additional opportunities include one-on-one shadowing experiences with leaders in hospital administration at academic institutions in Boston and private meetings with leaders and staff at several government agencies in Washington, including the Centers for Medicaid & Medicare Services, the Office of Minority Health, the Food and Drug Administration, the Health Resources & Services Administration, and the National Institutes of Health.
The program has given me an opportunity to meet and learn from physicians who have chosen a variety of different career paths. Through the program I have had exposure to physicians in academic medicine, health care administration, health policy, and public service as well as those who have chosen a combination of clinical practice with any of the above. This experience has opened my eyes to the different possibilities for physician careers and has encouraged me to be open if new opportunities should arise.
As part of the fellowship, we also have regular meetings with Joan Reede, MD, MPH, who is the director of the fellowship and has been with the program since its inception; she is also the Dean of Diversity and Inclusion at Harvard Medical School. Dr. Reede is an incredibly wise, insightful, and caring mentor, but also a powerhouse in issues surrounding workforce diversity, mentorship, policy, care of underserved communities, and being an advocate for change. To have access to such a powerful individual who has dedicated her career to the mentorship of individuals like myself, who cares deeply about the impact of our careers, and who genuinely values each fellow almost as her own child is a unique gift that is hard to describe in words.
The Commonwealth Fund Fellowship also provides a large network of mentors and advisers. My direct mentor for the program is Monica Bharel, MD, MPH, who is a former Commonwealth Fund fellow and the current Commissioner of the Massachusetts Department of Public Health. However, I also have a wealth of other mentors and advisers in the alumni fellows, including Darrell Gray II, MD, MPH, a former fellow and gastroenterologist at the Ohio State University College of Medicine, as well as the other faculty associated with the program. I never imagined that I would have access to leaders in so many different sectors of health care and policy who are genuinely and passionately rooting for my success. In addition, my cofellows and I have created a uniquely special bond, and they will likely continue as my close network of peer advisers as I move forward throughout my career.
After the fellowship
I have no doubt that the Commonwealth Fund Fellowship will alter the trajectory of my career. It has already affected my career path in ways that I could not have anticipated years ago. The knowledge that I have gained in health care policy, innovation, and equity, as well as the networks that I have access to as a fellow, will be invaluable as I move forward. In terms of next steps, I will be working as an academic gastroenterologist; I will continue to lead initiatives, perform research, and participate in projects to elevate the voices of underserved communities and work toward health equity in gastroenterology. I am particularly passionate about ending disparities in colorectal cancer in minority communities and increasing awareness around minorities with inflammatory bowel disease.
I plan to work with health centers, city- and state-level organizations, and community partners to raise awareness around issues of equity in gastroenterology and develop interventions to create change. I will also work with local legislators and community-based organizations to advocate for policies that remove barriers to screening both locally and nationally. Further down the line, I am open to exploring careers in the public sector or health care administration if that is where my career takes me. The exposure that I had to these fields as part of the fellowship has shown me that it is possible to be a practicing gastroenterologist and simultaneously work in the public sector, health policy, or health care administration. If you are interested in applying to the Commonwealth Fund Fellowship in Minority Health Policy at Harvard University, please feel free to contact me at [email protected]. More information about the program and how to apply can be found at https://cff.hms.harvard.edu/.