Hypersomnolence, or excessive daytime sleepiness, in older adults is a risk factor for developing several serious medical conditions, including hypertension, heart disease, cancer, and diabetes, new research suggests. A study of almost 11,000 participants shows those who reported excessive sleepiness were twice as likely as their nonsleepy counterparts to develop these conditions. Hypersomnolence was also linked to development of musculoskeletal and connective tissue conditions.

“Paying attention to sleepiness in older adults could help doctors predict and prevent future medical conditions,” study investigator Maurice M. Ohayon, MD, PhD, Stanford University, California, said in a news release.

The findings were released March 1 ahead of the study’s scheduled presentation at the annual meeting of the American Academy of Neurology. The AAN canceled the meeting and released abstracts and access to presenters for press coverage.
 

Early warning sign

Prior research has suggested an association between hypersomnolence and several psychiatric disorders, as well as cognitive decline and Alzheimer’s disease. However, its role in the development of other medical conditions is not as well studied.

The current investigation included 10,930 adults who were interviewed by phone on two separate occasions 3 years apart. At the second interview, 3,701 participants were at least 65 years old and 59% were women.

About 23% of the elderly participants reported hypersomnolence in the first interview and 24% reported it in the second interview. Of these individuals, 41% said during the first and second interviews that excessive daytime sleepiness was a chronic problem.

After adjusting for gender and obstructive sleep apnea status, participants who reported hypersomnolence in the first interview had more than a twofold greater risk of developing diabetes (relative risk [RR], 2.3; 95% CI, 1.5 - 3.4) or hypertension (RR, 2.3; 95% CI, 1.5 - 3.4) 3 years later than those who did not report this problem. They were also twice as likely to develop cancer (RR, 2.0; 95% CI, 1.1 - 3.8).

Of the 840 participants who reported hypersomnolence at the first interview, 52 (6.2%) developed diabetes compared with 74 (2.9%) who did not have excessive daytime sleepiness. Twenty (2.4%) individuals who reported hypersomnolence developed cancer compared with 21 (0.8%) who did not have it. Chronic hypersomnolence was associated with a greater than twofold increased risk of developing heart disease (RR, 2.5; 95% CI, 1.8 - 3.4).

Those who reported hypersomnolence at the second interview also were 50% more likely to have diseases of the musculoskeletal system and connective tissue, such as arthritis, tendinitis, and lupus, than their peers who did not have excessive daytime sleepiness.

The findings suggest that hypersomnolence in the elderly “can be an early sign of a developing medical condition,” the investigators wrote.

A limitation of the study is that it relied on participants’ memories rather than monitoring their sleep length and quality and daytime sleepiness in a sleep clinic, they noted.

Sleep as a vital sign?

Commenting on the findings, Harly Greenberg, MD, medical director at the Northwell Health Sleep Disorders Center, New York City, called the study “informative.”

However, because the findings were associations, “the study does not necessarily indicate that hypersomnolence itself is causal for these conditions. Rather excessive sleepiness may be a marker of sleep disorders that can cause sleepiness as well as contribute to the risk of these medical conditions,” said Dr. Greenberg, who was not involved with the research.

“The takeaway point from this study is that excessive sleepiness should not be ignored. Not only does it impair quality of life, daytime function, and vigilance and increase risk of sleepiness-related accidents, it may also be a marker for serious sleep disorders that can increase risk for medical disorders,” he said.

Also commenting on the study, Nathaniel Watson, MD, professor of neurology at the University of Washington (UW) and director of the UW Medicine Sleep Clinic, said it is “not surprising” that excessive daytime sleepiness might contribute to diabetes, hypertension, and other diseases.

“Sleep is something we spend a third of our lives doing. It impacts nearly every aspect of human physiology and we have a lot of basic science and epidemiologic research that shows when sleep is either inadequate or of poor quality or not timed correctly it can be associated with some of these untoward health outcomes,” said Watson, who is a past president of the American Academy of Sleep Medicine.

“This research just provides further evidence in support of the importance of sleep for overall health and well-being,” he added.

Asking patients about sleepiness, sleep, or sleep quality should be a “vital sign just like temperature, blood pressure, weight, and these other measures,” Dr. Watson said.

The study was supported by the Arrillaga Foundation. Drs. Ohayon, Greenberg, and Watson have reported no relevant financial relationships.

This article first appeared on Medscape.com.

Hypersomnolence, or excessive daytime sleepiness, in older adults is a risk factor for developing several serious medical conditions, including hypertension, heart disease, cancer, and diabetes, new research suggests. A study of almost 11,000 participants shows those who reported excessive sleepiness were twice as likely as their nonsleepy counterparts to develop these conditions. Hypersomnolence was also linked to development of musculoskeletal and connective tissue conditions.

“Paying attention to sleepiness in older adults could help doctors predict and prevent future medical conditions,” study investigator Maurice M. Ohayon, MD, PhD, Stanford University, California, said in a news release.

The findings were released March 1 ahead of the study’s scheduled presentation at the annual meeting of the American Academy of Neurology. The AAN canceled the meeting and released abstracts and access to presenters for press coverage.
 

Early warning sign

Prior research has suggested an association between hypersomnolence and several psychiatric disorders, as well as cognitive decline and Alzheimer’s disease. However, its role in the development of other medical conditions is not as well studied.

The current investigation included 10,930 adults who were interviewed by phone on two separate occasions 3 years apart. At the second interview, 3,701 participants were at least 65 years old and 59% were women.

About 23% of the elderly participants reported hypersomnolence in the first interview and 24% reported it in the second interview. Of these individuals, 41% said during the first and second interviews that excessive daytime sleepiness was a chronic problem.

After adjusting for gender and obstructive sleep apnea status, participants who reported hypersomnolence in the first interview had more than a twofold greater risk of developing diabetes (relative risk [RR], 2.3; 95% CI, 1.5 - 3.4) or hypertension (RR, 2.3; 95% CI, 1.5 - 3.4) 3 years later than those who did not report this problem. They were also twice as likely to develop cancer (RR, 2.0; 95% CI, 1.1 - 3.8).

Of the 840 participants who reported hypersomnolence at the first interview, 52 (6.2%) developed diabetes compared with 74 (2.9%) who did not have excessive daytime sleepiness. Twenty (2.4%) individuals who reported hypersomnolence developed cancer compared with 21 (0.8%) who did not have it. Chronic hypersomnolence was associated with a greater than twofold increased risk of developing heart disease (RR, 2.5; 95% CI, 1.8 - 3.4).

Those who reported hypersomnolence at the second interview also were 50% more likely to have diseases of the musculoskeletal system and connective tissue, such as arthritis, tendinitis, and lupus, than their peers who did not have excessive daytime sleepiness.

The findings suggest that hypersomnolence in the elderly “can be an early sign of a developing medical condition,” the investigators wrote.

A limitation of the study is that it relied on participants’ memories rather than monitoring their sleep length and quality and daytime sleepiness in a sleep clinic, they noted.

Sleep as a vital sign?

Commenting on the findings, Harly Greenberg, MD, medical director at the Northwell Health Sleep Disorders Center, New York City, called the study “informative.”

However, because the findings were associations, “the study does not necessarily indicate that hypersomnolence itself is causal for these conditions. Rather excessive sleepiness may be a marker of sleep disorders that can cause sleepiness as well as contribute to the risk of these medical conditions,” said Dr. Greenberg, who was not involved with the research.

“The takeaway point from this study is that excessive sleepiness should not be ignored. Not only does it impair quality of life, daytime function, and vigilance and increase risk of sleepiness-related accidents, it may also be a marker for serious sleep disorders that can increase risk for medical disorders,” he said.

Also commenting on the study, Nathaniel Watson, MD, professor of neurology at the University of Washington (UW) and director of the UW Medicine Sleep Clinic, said it is “not surprising” that excessive daytime sleepiness might contribute to diabetes, hypertension, and other diseases.

“Sleep is something we spend a third of our lives doing. It impacts nearly every aspect of human physiology and we have a lot of basic science and epidemiologic research that shows when sleep is either inadequate or of poor quality or not timed correctly it can be associated with some of these untoward health outcomes,” said Watson, who is a past president of the American Academy of Sleep Medicine.

“This research just provides further evidence in support of the importance of sleep for overall health and well-being,” he added.

Asking patients about sleepiness, sleep, or sleep quality should be a “vital sign just like temperature, blood pressure, weight, and these other measures,” Dr. Watson said.

The study was supported by the Arrillaga Foundation. Drs. Ohayon, Greenberg, and Watson have reported no relevant financial relationships.

This article first appeared on Medscape.com.

Hypersomnolence, or excessive daytime sleepiness, in older adults is a risk factor for developing several serious medical conditions, including hypertension, heart disease, cancer, and diabetes, new research suggests. A study of almost 11,000 participants shows those who reported excessive sleepiness were twice as likely as their nonsleepy counterparts to develop these conditions. Hypersomnolence was also linked to development of musculoskeletal and connective tissue conditions.

“Paying attention to sleepiness in older adults could help doctors predict and prevent future medical conditions,” study investigator Maurice M. Ohayon, MD, PhD, Stanford University, California, said in a news release.

The findings were released March 1 ahead of the study’s scheduled presentation at the annual meeting of the American Academy of Neurology. The AAN canceled the meeting and released abstracts and access to presenters for press coverage.
 

Early warning sign

Prior research has suggested an association between hypersomnolence and several psychiatric disorders, as well as cognitive decline and Alzheimer’s disease. However, its role in the development of other medical conditions is not as well studied.

The current investigation included 10,930 adults who were interviewed by phone on two separate occasions 3 years apart. At the second interview, 3,701 participants were at least 65 years old and 59% were women.

About 23% of the elderly participants reported hypersomnolence in the first interview and 24% reported it in the second interview. Of these individuals, 41% said during the first and second interviews that excessive daytime sleepiness was a chronic problem.

After adjusting for gender and obstructive sleep apnea status, participants who reported hypersomnolence in the first interview had more than a twofold greater risk of developing diabetes (relative risk [RR], 2.3; 95% CI, 1.5 - 3.4) or hypertension (RR, 2.3; 95% CI, 1.5 - 3.4) 3 years later than those who did not report this problem. They were also twice as likely to develop cancer (RR, 2.0; 95% CI, 1.1 - 3.8).

Of the 840 participants who reported hypersomnolence at the first interview, 52 (6.2%) developed diabetes compared with 74 (2.9%) who did not have excessive daytime sleepiness. Twenty (2.4%) individuals who reported hypersomnolence developed cancer compared with 21 (0.8%) who did not have it. Chronic hypersomnolence was associated with a greater than twofold increased risk of developing heart disease (RR, 2.5; 95% CI, 1.8 - 3.4).

Those who reported hypersomnolence at the second interview also were 50% more likely to have diseases of the musculoskeletal system and connective tissue, such as arthritis, tendinitis, and lupus, than their peers who did not have excessive daytime sleepiness.

The findings suggest that hypersomnolence in the elderly “can be an early sign of a developing medical condition,” the investigators wrote.

A limitation of the study is that it relied on participants’ memories rather than monitoring their sleep length and quality and daytime sleepiness in a sleep clinic, they noted.

Sleep as a vital sign?

Commenting on the findings, Harly Greenberg, MD, medical director at the Northwell Health Sleep Disorders Center, New York City, called the study “informative.”

However, because the findings were associations, “the study does not necessarily indicate that hypersomnolence itself is causal for these conditions. Rather excessive sleepiness may be a marker of sleep disorders that can cause sleepiness as well as contribute to the risk of these medical conditions,” said Dr. Greenberg, who was not involved with the research.

“The takeaway point from this study is that excessive sleepiness should not be ignored. Not only does it impair quality of life, daytime function, and vigilance and increase risk of sleepiness-related accidents, it may also be a marker for serious sleep disorders that can increase risk for medical disorders,” he said.

Also commenting on the study, Nathaniel Watson, MD, professor of neurology at the University of Washington (UW) and director of the UW Medicine Sleep Clinic, said it is “not surprising” that excessive daytime sleepiness might contribute to diabetes, hypertension, and other diseases.

“Sleep is something we spend a third of our lives doing. It impacts nearly every aspect of human physiology and we have a lot of basic science and epidemiologic research that shows when sleep is either inadequate or of poor quality or not timed correctly it can be associated with some of these untoward health outcomes,” said Watson, who is a past president of the American Academy of Sleep Medicine.

“This research just provides further evidence in support of the importance of sleep for overall health and well-being,” he added.

Asking patients about sleepiness, sleep, or sleep quality should be a “vital sign just like temperature, blood pressure, weight, and these other measures,” Dr. Watson said.

The study was supported by the Arrillaga Foundation. Drs. Ohayon, Greenberg, and Watson have reported no relevant financial relationships.

This article first appeared on Medscape.com.

As I transition out of the role of medical editor for The Hospitalist, and into the role of president of the Society of Hospital Medicine, it is a bittersweet but exciting transition.

In the relatively short time I have served as editor, so much has changed in our hospitalist community! In the last 4 years alone, we have increased:

• Membership from 14,000 to 20,000

• Chapters from 46 to 68

• Special Interest Groups from 8 to 22

• Subscribers to The Hospitalist from 15,000 to 30,000.

This is all a testimony to the engagement of our membership. SHM is clearly no ordinary specialty society; it is full of incredibly intelligent, invested, and talented members, who actively participate in the society for the betterment of their local teams and patients. It is such a privilege to lead this amazing team.

As for The Hospitalist, I would like to warmly welcome Weijen Chang, MD, FACP, SFHM, as the incoming editor. Weijen served as the pediatrics editor for many years and has been extensively involved on The Hospitalist’s editorial advisory board for even longer. He also has a broad track record of experience as a hospitalist in many settings; that combined with an inquisitive mind and curious spirit makes him the ideal editor for The Hospitalist. He brings energy and enthusiasm and will serve us very well.

While I will miss being intimately involved with The Hospitalist, I am very much looking forward to serving in the role of SHM president starting in April. During this pivotal year, SHM will transition from our one-and-only CEO, Larry Wellikson, MD, MHM, to our newly minted CEO Eric Howell, MD, MHM, who will officially transition in July 2020.

This is a very exciting time in the history of SHM, as we refocus on our mission, vision, values, and core activities. As a membership organization, our primary focus has been, and will always be, serving our member’s needs! As a “Big Tent” organization, we have always supported a broad and diverse set of members, ranging far beyond physician hospitalists, to trainees, medical students, nurse practitioners, physician assistants, practice administrators, and other hospital-based specialists. Being in such a dynamic industry, our diverse members needs are constantly and rapidly changing along with the dramatic transformations in the landscape, including profound shifts in care and reimbursement models that could change the very definition of a hospitalist.

While we continuously scour the landscape and anticipate our members’ needs, we will never lose sight of our core mission, which is to promote exceptional care for hospitalized patients. We will continue to do this by supporting all of our members with tools and materials to help them be the very best they can, for all of our patients. As a humble and servant leader, I am prepared to meet the demands and challenges of the year ahead, with energy and focus, and fulfill the needs of our members, so that together, we can make health care better for those we serve.

Thank you in advance for allowing me the great pleasure of serving this amazing and innovative organization!
 

Dr. Scheurer is chief quality officer and professor of medicine at the Medical University of South Carolina, Charleston. She is the outgoing medical editor of The Hospitalist, and president-elect of SHM.

As I transition out of the role of medical editor for The Hospitalist, and into the role of president of the Society of Hospital Medicine, it is a bittersweet but exciting transition.

In the relatively short time I have served as editor, so much has changed in our hospitalist community! In the last 4 years alone, we have increased:

• Membership from 14,000 to 20,000

• Chapters from 46 to 68

• Special Interest Groups from 8 to 22

• Subscribers to The Hospitalist from 15,000 to 30,000.

This is all a testimony to the engagement of our membership. SHM is clearly no ordinary specialty society; it is full of incredibly intelligent, invested, and talented members, who actively participate in the society for the betterment of their local teams and patients. It is such a privilege to lead this amazing team.

As for The Hospitalist, I would like to warmly welcome Weijen Chang, MD, FACP, SFHM, as the incoming editor. Weijen served as the pediatrics editor for many years and has been extensively involved on The Hospitalist’s editorial advisory board for even longer. He also has a broad track record of experience as a hospitalist in many settings; that combined with an inquisitive mind and curious spirit makes him the ideal editor for The Hospitalist. He brings energy and enthusiasm and will serve us very well.

While I will miss being intimately involved with The Hospitalist, I am very much looking forward to serving in the role of SHM president starting in April. During this pivotal year, SHM will transition from our one-and-only CEO, Larry Wellikson, MD, MHM, to our newly minted CEO Eric Howell, MD, MHM, who will officially transition in July 2020.

This is a very exciting time in the history of SHM, as we refocus on our mission, vision, values, and core activities. As a membership organization, our primary focus has been, and will always be, serving our member’s needs! As a “Big Tent” organization, we have always supported a broad and diverse set of members, ranging far beyond physician hospitalists, to trainees, medical students, nurse practitioners, physician assistants, practice administrators, and other hospital-based specialists. Being in such a dynamic industry, our diverse members needs are constantly and rapidly changing along with the dramatic transformations in the landscape, including profound shifts in care and reimbursement models that could change the very definition of a hospitalist.

While we continuously scour the landscape and anticipate our members’ needs, we will never lose sight of our core mission, which is to promote exceptional care for hospitalized patients. We will continue to do this by supporting all of our members with tools and materials to help them be the very best they can, for all of our patients. As a humble and servant leader, I am prepared to meet the demands and challenges of the year ahead, with energy and focus, and fulfill the needs of our members, so that together, we can make health care better for those we serve.

Thank you in advance for allowing me the great pleasure of serving this amazing and innovative organization!
 

Dr. Scheurer is chief quality officer and professor of medicine at the Medical University of South Carolina, Charleston. She is the outgoing medical editor of The Hospitalist, and president-elect of SHM.

As I transition out of the role of medical editor for The Hospitalist, and into the role of president of the Society of Hospital Medicine, it is a bittersweet but exciting transition.

In the relatively short time I have served as editor, so much has changed in our hospitalist community! In the last 4 years alone, we have increased:

• Membership from 14,000 to 20,000

• Chapters from 46 to 68

• Special Interest Groups from 8 to 22

• Subscribers to The Hospitalist from 15,000 to 30,000.

This is all a testimony to the engagement of our membership. SHM is clearly no ordinary specialty society; it is full of incredibly intelligent, invested, and talented members, who actively participate in the society for the betterment of their local teams and patients. It is such a privilege to lead this amazing team.

As for The Hospitalist, I would like to warmly welcome Weijen Chang, MD, FACP, SFHM, as the incoming editor. Weijen served as the pediatrics editor for many years and has been extensively involved on The Hospitalist’s editorial advisory board for even longer. He also has a broad track record of experience as a hospitalist in many settings; that combined with an inquisitive mind and curious spirit makes him the ideal editor for The Hospitalist. He brings energy and enthusiasm and will serve us very well.

While I will miss being intimately involved with The Hospitalist, I am very much looking forward to serving in the role of SHM president starting in April. During this pivotal year, SHM will transition from our one-and-only CEO, Larry Wellikson, MD, MHM, to our newly minted CEO Eric Howell, MD, MHM, who will officially transition in July 2020.

This is a very exciting time in the history of SHM, as we refocus on our mission, vision, values, and core activities. As a membership organization, our primary focus has been, and will always be, serving our member’s needs! As a “Big Tent” organization, we have always supported a broad and diverse set of members, ranging far beyond physician hospitalists, to trainees, medical students, nurse practitioners, physician assistants, practice administrators, and other hospital-based specialists. Being in such a dynamic industry, our diverse members needs are constantly and rapidly changing along with the dramatic transformations in the landscape, including profound shifts in care and reimbursement models that could change the very definition of a hospitalist.

While we continuously scour the landscape and anticipate our members’ needs, we will never lose sight of our core mission, which is to promote exceptional care for hospitalized patients. We will continue to do this by supporting all of our members with tools and materials to help them be the very best they can, for all of our patients. As a humble and servant leader, I am prepared to meet the demands and challenges of the year ahead, with energy and focus, and fulfill the needs of our members, so that together, we can make health care better for those we serve.

Thank you in advance for allowing me the great pleasure of serving this amazing and innovative organization!
 

Dr. Scheurer is chief quality officer and professor of medicine at the Medical University of South Carolina, Charleston. She is the outgoing medical editor of The Hospitalist, and president-elect of SHM.

A healthier heart in young adulthood could mean fewer cognitive problems later in life, new research suggests. New findings from the Coronary Artery Risk Development in Young Adults (CARDIA) study show that individuals who had better cardiovascular health in their 20s scored higher on tests of thinking and memory 30 years later than their peers who had poorer cardiovascular health as young adults.

“We have learned that midlife vascular risk factors, rather than risk factors in older age, are particularly associated with cognition in older age,” study author Farzaneh Sorond, MD, PhD, Northwestern University Feinberg School of Medicine, Chicago, Illinois, told Medscape Medical News

“Our findings from the CARDIA study expand this knowledge and show that vascular health during young adulthood, rather than midlife, is also specifically associated with brain vascular health and cognitive function” in later life, Dr. Sorond said.

“These results indicate that people need to pay close attention to their health even in their early 20s,” she added in a statement.

The findings were released February 26 ahead of the study’s scheduled presentation at the annual meeting of the American Academy of Neurology. The AAN canceled the meeting and released abstracts and access to presenters for press coverage.
 

Early prevention key

The analysis examined data from 189 participants (45% women, 45% black) in the CARDIA study who were followed for 30 years. The mean age at baseline was 24 years.

Vascular risk factors were assessed eight times during the 30-year study period. A cardiovascular health score (range, 0 – 10) was calculated on the basis of smoking status, body mass index, blood pressure, total cholesterol level, and fasting glucose level.

At the final assessment, which was conducted 30 years after baseline, dynamic cerebral autoregulation was calculated as the transfer function phase of the spontaneous oscillations in blood pressure and flow velocity in the middle cerebral artery using transcranial Doppler ultrasound.

Good for the heart, good for the brain

Commenting on the findings, Rebecca Edelmayer, PhD, director of scientific engagement for the Alzheimer’s Association, said that the longitudinal study adds to the growing body of research showing that “what is good for the heart is also good for the brain.”

“This is still a relatively small study, and larger studies have been published that show similar results,” said Dr. Edelmayer, who was not involved with the research.

She noted that results of the large SPRINT-MIND trial, published last year in JAMA and reported by Medscape Medical News, “provided the strongest evidence to date about reducing risk of mild cognitive impairment through the management of high blood pressure.”

The Alzheimer’s Association has provided seed funding for SPRINT-MIND 2.0, a 2-year extension of the study to evaluate whether intensive blood pressure management reduces risk for all-cause dementia.

Support for the current study was provided by the National Institutes of Health, the National Heart, Lung, and Blood Institute, the University of Alabama at Birmingham, Northwestern University, the University of Minnesota, and the Kaiser Foundation Research Institute. Drs. Sorond and Edelmayer have reported no relevant financial relationships.

This article first appeared on Medscape.com.

A healthier heart in young adulthood could mean fewer cognitive problems later in life, new research suggests. New findings from the Coronary Artery Risk Development in Young Adults (CARDIA) study show that individuals who had better cardiovascular health in their 20s scored higher on tests of thinking and memory 30 years later than their peers who had poorer cardiovascular health as young adults.

“We have learned that midlife vascular risk factors, rather than risk factors in older age, are particularly associated with cognition in older age,” study author Farzaneh Sorond, MD, PhD, Northwestern University Feinberg School of Medicine, Chicago, Illinois, told Medscape Medical News

“Our findings from the CARDIA study expand this knowledge and show that vascular health during young adulthood, rather than midlife, is also specifically associated with brain vascular health and cognitive function” in later life, Dr. Sorond said.

“These results indicate that people need to pay close attention to their health even in their early 20s,” she added in a statement.

The findings were released February 26 ahead of the study’s scheduled presentation at the annual meeting of the American Academy of Neurology. The AAN canceled the meeting and released abstracts and access to presenters for press coverage.
 

Early prevention key

The analysis examined data from 189 participants (45% women, 45% black) in the CARDIA study who were followed for 30 years. The mean age at baseline was 24 years.

Vascular risk factors were assessed eight times during the 30-year study period. A cardiovascular health score (range, 0 – 10) was calculated on the basis of smoking status, body mass index, blood pressure, total cholesterol level, and fasting glucose level.

At the final assessment, which was conducted 30 years after baseline, dynamic cerebral autoregulation was calculated as the transfer function phase of the spontaneous oscillations in blood pressure and flow velocity in the middle cerebral artery using transcranial Doppler ultrasound.

Good for the heart, good for the brain

Commenting on the findings, Rebecca Edelmayer, PhD, director of scientific engagement for the Alzheimer’s Association, said that the longitudinal study adds to the growing body of research showing that “what is good for the heart is also good for the brain.”

“This is still a relatively small study, and larger studies have been published that show similar results,” said Dr. Edelmayer, who was not involved with the research.

She noted that results of the large SPRINT-MIND trial, published last year in JAMA and reported by Medscape Medical News, “provided the strongest evidence to date about reducing risk of mild cognitive impairment through the management of high blood pressure.”

The Alzheimer’s Association has provided seed funding for SPRINT-MIND 2.0, a 2-year extension of the study to evaluate whether intensive blood pressure management reduces risk for all-cause dementia.

Support for the current study was provided by the National Institutes of Health, the National Heart, Lung, and Blood Institute, the University of Alabama at Birmingham, Northwestern University, the University of Minnesota, and the Kaiser Foundation Research Institute. Drs. Sorond and Edelmayer have reported no relevant financial relationships.

This article first appeared on Medscape.com.

A healthier heart in young adulthood could mean fewer cognitive problems later in life, new research suggests. New findings from the Coronary Artery Risk Development in Young Adults (CARDIA) study show that individuals who had better cardiovascular health in their 20s scored higher on tests of thinking and memory 30 years later than their peers who had poorer cardiovascular health as young adults.

“We have learned that midlife vascular risk factors, rather than risk factors in older age, are particularly associated with cognition in older age,” study author Farzaneh Sorond, MD, PhD, Northwestern University Feinberg School of Medicine, Chicago, Illinois, told Medscape Medical News

“Our findings from the CARDIA study expand this knowledge and show that vascular health during young adulthood, rather than midlife, is also specifically associated with brain vascular health and cognitive function” in later life, Dr. Sorond said.

“These results indicate that people need to pay close attention to their health even in their early 20s,” she added in a statement.

The findings were released February 26 ahead of the study’s scheduled presentation at the annual meeting of the American Academy of Neurology. The AAN canceled the meeting and released abstracts and access to presenters for press coverage.
 

Early prevention key

The analysis examined data from 189 participants (45% women, 45% black) in the CARDIA study who were followed for 30 years. The mean age at baseline was 24 years.

Vascular risk factors were assessed eight times during the 30-year study period. A cardiovascular health score (range, 0 – 10) was calculated on the basis of smoking status, body mass index, blood pressure, total cholesterol level, and fasting glucose level.

At the final assessment, which was conducted 30 years after baseline, dynamic cerebral autoregulation was calculated as the transfer function phase of the spontaneous oscillations in blood pressure and flow velocity in the middle cerebral artery using transcranial Doppler ultrasound.

Good for the heart, good for the brain

Commenting on the findings, Rebecca Edelmayer, PhD, director of scientific engagement for the Alzheimer’s Association, said that the longitudinal study adds to the growing body of research showing that “what is good for the heart is also good for the brain.”

“This is still a relatively small study, and larger studies have been published that show similar results,” said Dr. Edelmayer, who was not involved with the research.

She noted that results of the large SPRINT-MIND trial, published last year in JAMA and reported by Medscape Medical News, “provided the strongest evidence to date about reducing risk of mild cognitive impairment through the management of high blood pressure.”

The Alzheimer’s Association has provided seed funding for SPRINT-MIND 2.0, a 2-year extension of the study to evaluate whether intensive blood pressure management reduces risk for all-cause dementia.

Support for the current study was provided by the National Institutes of Health, the National Heart, Lung, and Blood Institute, the University of Alabama at Birmingham, Northwestern University, the University of Minnesota, and the Kaiser Foundation Research Institute. Drs. Sorond and Edelmayer have reported no relevant financial relationships.

This article first appeared on Medscape.com.

In early March, 35 residents in the Life Care Center in Kirkland, Washington, died due to complications associated with COVID-19. And that facility thus became the first example of how extremely vulnerable nursing home residents are to COVID-19. Since then, around the US, thousands of nursing home residents have died from complications of the virus. US Department of Veterans Affairs (VA) nursing homes, while rated high in VA health inspection reports, have not been exempt.

As of April 21, the VA had confirmed > 5,500 coronavirus cases in 50 states, the District of Columbia, and Puerto Rico. More than 350 veterans have died of COVID-19, according to VA data. The VA calculates its rates by health care system or VA medical center and does not provide separate data for the community living centers (CLCs).

The VA initiated an isolation strategy on March 10 that suspended most new admissions and barred outsiders from all of its 134 nursing homes. The only exception to the rule was when a patient was expected to die soon. The VA has taken other precautions as well, including extra screening and directing patients to use telehealth where possible.

State-run long-term care facilities for veterans have been hard hit across the country. At the Soldiers’ Home in Holyoke, Massachusetts, which is run by the state of Massachusetts, 5 of 11 veterans who died recently tested positive for COVID-19. At the 4 state-run nursing homes in Alabama, as of April 14, 45 people were confirmed positive and 2 residents had died. The largest outbreak was in the Bill Nichols State Veterans Home in Alexander City. Alabama State Rep. Ed Oliver and Commissioner Kent Davis, of the Alabama Department of Veterans Affairs (ADVA), are looking into how the outbreak started and whether it could have been prevented. “We have reports of lack of hand sanitizers, and those are the things we’re looking at right now,” Rep. Oliver said. The ADVA says residents who test positive are isolated for treatment, and infected employees are prohibited from entering the homes.

States have deployed National Guard troops to facilities following large scale outbreaks and multiple deaths. Pennsylvania deployed 30 National Guard troops to its Southeastern Veterans Center facility in Spring City after at least 10 veterans had died and at least 19 health care workers had tested positive for the virus. The facility is 1 of 6 extended-care facilities run by the Pennsylvania Department of Military and Veterans Affairs. In New Jersey, 40 National Guard troops, 25 New Jersey Department of Health nurses, and 90 VA nurses were deployed to 2 of its veterans facilities amid worsening outbreaks. At the Paramus facility, 155 residents had tested positive and 39 had died, and at the home in Edison, 86 veterans had tested positive and 25 died; 6 more died at a third state facility.

However, reporting remains inconsistent across many states and facilities. Only on April 19 did the Centers for Medicare and Medicaid Services (CMS) order nursing home facilities to inform residents and families about COVID-19 cases inside. This followed similar orders in New Jersey, New York, California, Washington, and other states.

“Nursing homes have been ground zero for COVID-19,” said CMS Administrator Seema Verma in a written statement. “Nursing home reporting to the [Centers for Disease Control and Prevention] is a critical component of the go-forward national COVID-19 surveillance system and to efforts to reopen America.”

In early March, 35 residents in the Life Care Center in Kirkland, Washington, died due to complications associated with COVID-19. And that facility thus became the first example of how extremely vulnerable nursing home residents are to COVID-19. Since then, around the US, thousands of nursing home residents have died from complications of the virus. US Department of Veterans Affairs (VA) nursing homes, while rated high in VA health inspection reports, have not been exempt.

As of April 21, the VA had confirmed > 5,500 coronavirus cases in 50 states, the District of Columbia, and Puerto Rico. More than 350 veterans have died of COVID-19, according to VA data. The VA calculates its rates by health care system or VA medical center and does not provide separate data for the community living centers (CLCs).

The VA initiated an isolation strategy on March 10 that suspended most new admissions and barred outsiders from all of its 134 nursing homes. The only exception to the rule was when a patient was expected to die soon. The VA has taken other precautions as well, including extra screening and directing patients to use telehealth where possible.

State-run long-term care facilities for veterans have been hard hit across the country. At the Soldiers’ Home in Holyoke, Massachusetts, which is run by the state of Massachusetts, 5 of 11 veterans who died recently tested positive for COVID-19. At the 4 state-run nursing homes in Alabama, as of April 14, 45 people were confirmed positive and 2 residents had died. The largest outbreak was in the Bill Nichols State Veterans Home in Alexander City. Alabama State Rep. Ed Oliver and Commissioner Kent Davis, of the Alabama Department of Veterans Affairs (ADVA), are looking into how the outbreak started and whether it could have been prevented. “We have reports of lack of hand sanitizers, and those are the things we’re looking at right now,” Rep. Oliver said. The ADVA says residents who test positive are isolated for treatment, and infected employees are prohibited from entering the homes.

States have deployed National Guard troops to facilities following large scale outbreaks and multiple deaths. Pennsylvania deployed 30 National Guard troops to its Southeastern Veterans Center facility in Spring City after at least 10 veterans had died and at least 19 health care workers had tested positive for the virus. The facility is 1 of 6 extended-care facilities run by the Pennsylvania Department of Military and Veterans Affairs. In New Jersey, 40 National Guard troops, 25 New Jersey Department of Health nurses, and 90 VA nurses were deployed to 2 of its veterans facilities amid worsening outbreaks. At the Paramus facility, 155 residents had tested positive and 39 had died, and at the home in Edison, 86 veterans had tested positive and 25 died; 6 more died at a third state facility.

However, reporting remains inconsistent across many states and facilities. Only on April 19 did the Centers for Medicare and Medicaid Services (CMS) order nursing home facilities to inform residents and families about COVID-19 cases inside. This followed similar orders in New Jersey, New York, California, Washington, and other states.

“Nursing homes have been ground zero for COVID-19,” said CMS Administrator Seema Verma in a written statement. “Nursing home reporting to the [Centers for Disease Control and Prevention] is a critical component of the go-forward national COVID-19 surveillance system and to efforts to reopen America.”

In early March, 35 residents in the Life Care Center in Kirkland, Washington, died due to complications associated with COVID-19. And that facility thus became the first example of how extremely vulnerable nursing home residents are to COVID-19. Since then, around the US, thousands of nursing home residents have died from complications of the virus. US Department of Veterans Affairs (VA) nursing homes, while rated high in VA health inspection reports, have not been exempt.

As of April 21, the VA had confirmed > 5,500 coronavirus cases in 50 states, the District of Columbia, and Puerto Rico. More than 350 veterans have died of COVID-19, according to VA data. The VA calculates its rates by health care system or VA medical center and does not provide separate data for the community living centers (CLCs).

The VA initiated an isolation strategy on March 10 that suspended most new admissions and barred outsiders from all of its 134 nursing homes. The only exception to the rule was when a patient was expected to die soon. The VA has taken other precautions as well, including extra screening and directing patients to use telehealth where possible.

State-run long-term care facilities for veterans have been hard hit across the country. At the Soldiers’ Home in Holyoke, Massachusetts, which is run by the state of Massachusetts, 5 of 11 veterans who died recently tested positive for COVID-19. At the 4 state-run nursing homes in Alabama, as of April 14, 45 people were confirmed positive and 2 residents had died. The largest outbreak was in the Bill Nichols State Veterans Home in Alexander City. Alabama State Rep. Ed Oliver and Commissioner Kent Davis, of the Alabama Department of Veterans Affairs (ADVA), are looking into how the outbreak started and whether it could have been prevented. “We have reports of lack of hand sanitizers, and those are the things we’re looking at right now,” Rep. Oliver said. The ADVA says residents who test positive are isolated for treatment, and infected employees are prohibited from entering the homes.

States have deployed National Guard troops to facilities following large scale outbreaks and multiple deaths. Pennsylvania deployed 30 National Guard troops to its Southeastern Veterans Center facility in Spring City after at least 10 veterans had died and at least 19 health care workers had tested positive for the virus. The facility is 1 of 6 extended-care facilities run by the Pennsylvania Department of Military and Veterans Affairs. In New Jersey, 40 National Guard troops, 25 New Jersey Department of Health nurses, and 90 VA nurses were deployed to 2 of its veterans facilities amid worsening outbreaks. At the Paramus facility, 155 residents had tested positive and 39 had died, and at the home in Edison, 86 veterans had tested positive and 25 died; 6 more died at a third state facility.

However, reporting remains inconsistent across many states and facilities. Only on April 19 did the Centers for Medicare and Medicaid Services (CMS) order nursing home facilities to inform residents and families about COVID-19 cases inside. This followed similar orders in New Jersey, New York, California, Washington, and other states.

“Nursing homes have been ground zero for COVID-19,” said CMS Administrator Seema Verma in a written statement. “Nursing home reporting to the [Centers for Disease Control and Prevention] is a critical component of the go-forward national COVID-19 surveillance system and to efforts to reopen America.”

International Laboratories has initiated a voluntary recall to the consumer level in the United States of a single lot of the antiplatelet clopidogrel because it is mislabeled and may contain simvastatin, a cholesterol-lowering drug, instead of clopidogrel.

The recalled product ― lot number 117099A of clopidogrel tablets (USP 75 mg) packaged in bottles of 30 tablets ― may contain clopidogrel 75 mg tablets or it could contain simvastatin tablets (USP 10 mg), according to a company announcement posted on the US Food and Drug Administration (FDA) website.

“Missed doses of clopidogrel increases the risk of heart attack and stroke which can be life threatening. Additionally, unintentional consumption of simvastatin could include the common side effects associated with its use and may cause fetal harm when administered to a pregnant woman,” the company cautions.

To date, the company has not received any reports of harm arising from the problem that prompted the recall.

The recalled product was distributed nationwide and was delivered to distribution centers in Arkansas, Georgia, Indiana, California, and Maryland and to retail stores in all US states.

International Laboratories is notifying distributors and customers by letter and is arranging for the return of all recalled products.

For questions regarding this recall, contact Inmar by phone 855-258-7280 (weekdays between 9:00 AM and 5:00 PM EST) or by email at [email protected].

Adverse reactions or quality problems experienced with the use of this product should be reported to the FDA’s MedWatch adverse event reporting program.
 

This article first appeared on Medscape.com.

International Laboratories has initiated a voluntary recall to the consumer level in the United States of a single lot of the antiplatelet clopidogrel because it is mislabeled and may contain simvastatin, a cholesterol-lowering drug, instead of clopidogrel.

The recalled product ― lot number 117099A of clopidogrel tablets (USP 75 mg) packaged in bottles of 30 tablets ― may contain clopidogrel 75 mg tablets or it could contain simvastatin tablets (USP 10 mg), according to a company announcement posted on the US Food and Drug Administration (FDA) website.

“Missed doses of clopidogrel increases the risk of heart attack and stroke which can be life threatening. Additionally, unintentional consumption of simvastatin could include the common side effects associated with its use and may cause fetal harm when administered to a pregnant woman,” the company cautions.

To date, the company has not received any reports of harm arising from the problem that prompted the recall.

The recalled product was distributed nationwide and was delivered to distribution centers in Arkansas, Georgia, Indiana, California, and Maryland and to retail stores in all US states.

International Laboratories is notifying distributors and customers by letter and is arranging for the return of all recalled products.

For questions regarding this recall, contact Inmar by phone 855-258-7280 (weekdays between 9:00 AM and 5:00 PM EST) or by email at [email protected].

Adverse reactions or quality problems experienced with the use of this product should be reported to the FDA’s MedWatch adverse event reporting program.
 

This article first appeared on Medscape.com.

International Laboratories has initiated a voluntary recall to the consumer level in the United States of a single lot of the antiplatelet clopidogrel because it is mislabeled and may contain simvastatin, a cholesterol-lowering drug, instead of clopidogrel.

The recalled product ― lot number 117099A of clopidogrel tablets (USP 75 mg) packaged in bottles of 30 tablets ― may contain clopidogrel 75 mg tablets or it could contain simvastatin tablets (USP 10 mg), according to a company announcement posted on the US Food and Drug Administration (FDA) website.

“Missed doses of clopidogrel increases the risk of heart attack and stroke which can be life threatening. Additionally, unintentional consumption of simvastatin could include the common side effects associated with its use and may cause fetal harm when administered to a pregnant woman,” the company cautions.

To date, the company has not received any reports of harm arising from the problem that prompted the recall.

The recalled product was distributed nationwide and was delivered to distribution centers in Arkansas, Georgia, Indiana, California, and Maryland and to retail stores in all US states.

International Laboratories is notifying distributors and customers by letter and is arranging for the return of all recalled products.

For questions regarding this recall, contact Inmar by phone 855-258-7280 (weekdays between 9:00 AM and 5:00 PM EST) or by email at [email protected].

Adverse reactions or quality problems experienced with the use of this product should be reported to the FDA’s MedWatch adverse event reporting program.
 

This article first appeared on Medscape.com.

Novel gene variants associated with the development of tau deposits in the brain, a key biological feature of Alzheimer’s disease, have been identified. Investigator Vijay Ramanan, MD, PhD, behavioral neurology fellow, Mayo Clinic, Rochester, Minnesota, noted that this is the first genome-wide study of tau positron-emission tomography (PET) and that it identifies variations in DNA profiles associated with tau load in the brain.

“These early results represent an important step to better understanding why some individuals have a greater susceptibility to tau accumulation while others are more resistant,” Dr. Ramanan told Medscape Medical News.

“As we learn more about that process, the longer-term hope would be to use that information to better predict who may become symptomatic from the disease and to develop targets for treatment based on those individualized profiles,” he added.

The findings were released March 9 ahead of the study’s scheduled presentation at the annual meeting of the American Academy of Neurology. The AAN canceled the meeting and released abstracts and access to presenters for press coverage.

Genome-wide associations

The researchers assessed genetic profile and regional tau-PET data for 754 participants (mean age, 72.4 years; 54.6% men; 87% cognitively unimpaired) in the Mayo Clinic Study of Aging.

They found that individuals with novel genetic variants on chromosomes 1 and 5 had a higher amount of tau in their brains, compared with their counterparts who had more typical gene sequences in those regions.

The genetic variants were found in 2% to 3% of the group, and those individuals had about 10% higher tau levels than patients who did not have the variants.

Specifically, investigators identified genome-wide significant associations with higher tau for rs76752255 in protein phosphatase 2 regulatory subunit B (PPP2R2B), an enzyme of the PPP2R2B gene on chromosome 5, and for rs115862481 in an intergenic region on chromosome 1. Each minor allele had a stronger association in amyloid-positive than in amyloid-negative individuals.

In addition, three single-nucleotide polymorphisms (SNPs) within microtubule-associated protein tau (MAPT) genes displayed nominal associations to tau burden. These included rs3785883, which previously was found to be associated with higher levels of cerebrospinal fluid tau in an independent cohort.

However, no associations with tau burden were identified for the SNPs defining apolipoprotein E (APOE) e4 or for genotyped SNPs previously associated with Alzheimer’s disease in large case-control studies.

“The fact that these variants are new, coupled with the lack of strong signal for tau in APOE, reinforces the concept that Alzheimer’s disease is complex and that across patients, different sets of genes may be involved in entering into the Alzheimer’s disease pathway versus modifying its course or symptomatic expression,” Dr. Ramanan said.

“Lots of exciting work is ongoing to try to disentangle those issues, and this study is a valuable step on that path,” he added.

Dr. Ramanan said there is a great need for a better understanding of the factors that influence tau deposition, particularly since the burden and location of tau buildup in the brain are closely related to cognitive symptoms of Alzheimer’s disease.

He noted that the approach of “imaging genetics”—using brain scans that capture disease biomarkers and connecting those with data on the genome to improve knowledge about risk and treatment targeting—has been growing. However, only recently has it become possible to apply that framework to tau.

Dr, Ramanan emphasized that replication studies and functional characterization of these novel genetic findings are needed.

“Distant” clinical implications

Commenting on the study, Howard Fillit, MD, founding executive director and chief science officer of the Alzheimer’s Drug Discovery Foundation, said that there is currently “a fair amount of this kind of work going on” in assessing polygenetic risk in Alzheimer’s disease. This includes examining APOE as well as “a whole bunch of other genes” associated with the disease.

“Far and away, the APOE genetic association with Alzheimer’s disease risk is the most powerful one. In and of themselves, none of these other risk genes cause Alzheimer’s disease, they only contribute to risk,” Dr. Fillit noted.

“This study found some new genes that were associated with susceptibility to tau deposition, but at the end of the day, they are just associations. They don’t prove causality,” he added.

“It’s interesting, but really hard to know what to conclude from it; and the clinical implications, I think, are rather distant,” Dr. Fillit concluded.

The study was supported by the National Institutes of Health; the Gerald and Henrietta Rauenhorst Foundation; the Alexander Family Alzheimer’s Disease Research Professorship of Mayo Clinic; the Mayo Foundation for Medical Education and Research; a Liston Award; the Elsie and Marvin Dekelboum Family Foundation; the Schuler Foundation; and Avid Radiopharmaceuticals, which supplied the imaging agent used by researchers to detect tau in the brain. Ramanan and Fillit have reported no relevant financial relationships.

This article first appeared on Medscape.com.

Novel gene variants associated with the development of tau deposits in the brain, a key biological feature of Alzheimer’s disease, have been identified. Investigator Vijay Ramanan, MD, PhD, behavioral neurology fellow, Mayo Clinic, Rochester, Minnesota, noted that this is the first genome-wide study of tau positron-emission tomography (PET) and that it identifies variations in DNA profiles associated with tau load in the brain.

“These early results represent an important step to better understanding why some individuals have a greater susceptibility to tau accumulation while others are more resistant,” Dr. Ramanan told Medscape Medical News.

“As we learn more about that process, the longer-term hope would be to use that information to better predict who may become symptomatic from the disease and to develop targets for treatment based on those individualized profiles,” he added.

The findings were released March 9 ahead of the study’s scheduled presentation at the annual meeting of the American Academy of Neurology. The AAN canceled the meeting and released abstracts and access to presenters for press coverage.

Genome-wide associations

The researchers assessed genetic profile and regional tau-PET data for 754 participants (mean age, 72.4 years; 54.6% men; 87% cognitively unimpaired) in the Mayo Clinic Study of Aging.

They found that individuals with novel genetic variants on chromosomes 1 and 5 had a higher amount of tau in their brains, compared with their counterparts who had more typical gene sequences in those regions.

The genetic variants were found in 2% to 3% of the group, and those individuals had about 10% higher tau levels than patients who did not have the variants.

Specifically, investigators identified genome-wide significant associations with higher tau for rs76752255 in protein phosphatase 2 regulatory subunit B (PPP2R2B), an enzyme of the PPP2R2B gene on chromosome 5, and for rs115862481 in an intergenic region on chromosome 1. Each minor allele had a stronger association in amyloid-positive than in amyloid-negative individuals.

In addition, three single-nucleotide polymorphisms (SNPs) within microtubule-associated protein tau (MAPT) genes displayed nominal associations to tau burden. These included rs3785883, which previously was found to be associated with higher levels of cerebrospinal fluid tau in an independent cohort.

However, no associations with tau burden were identified for the SNPs defining apolipoprotein E (APOE) e4 or for genotyped SNPs previously associated with Alzheimer’s disease in large case-control studies.

“The fact that these variants are new, coupled with the lack of strong signal for tau in APOE, reinforces the concept that Alzheimer’s disease is complex and that across patients, different sets of genes may be involved in entering into the Alzheimer’s disease pathway versus modifying its course or symptomatic expression,” Dr. Ramanan said.

“Lots of exciting work is ongoing to try to disentangle those issues, and this study is a valuable step on that path,” he added.

Dr. Ramanan said there is a great need for a better understanding of the factors that influence tau deposition, particularly since the burden and location of tau buildup in the brain are closely related to cognitive symptoms of Alzheimer’s disease.

He noted that the approach of “imaging genetics”—using brain scans that capture disease biomarkers and connecting those with data on the genome to improve knowledge about risk and treatment targeting—has been growing. However, only recently has it become possible to apply that framework to tau.

Dr, Ramanan emphasized that replication studies and functional characterization of these novel genetic findings are needed.

“Distant” clinical implications

Commenting on the study, Howard Fillit, MD, founding executive director and chief science officer of the Alzheimer’s Drug Discovery Foundation, said that there is currently “a fair amount of this kind of work going on” in assessing polygenetic risk in Alzheimer’s disease. This includes examining APOE as well as “a whole bunch of other genes” associated with the disease.

“Far and away, the APOE genetic association with Alzheimer’s disease risk is the most powerful one. In and of themselves, none of these other risk genes cause Alzheimer’s disease, they only contribute to risk,” Dr. Fillit noted.

“This study found some new genes that were associated with susceptibility to tau deposition, but at the end of the day, they are just associations. They don’t prove causality,” he added.

“It’s interesting, but really hard to know what to conclude from it; and the clinical implications, I think, are rather distant,” Dr. Fillit concluded.

The study was supported by the National Institutes of Health; the Gerald and Henrietta Rauenhorst Foundation; the Alexander Family Alzheimer’s Disease Research Professorship of Mayo Clinic; the Mayo Foundation for Medical Education and Research; a Liston Award; the Elsie and Marvin Dekelboum Family Foundation; the Schuler Foundation; and Avid Radiopharmaceuticals, which supplied the imaging agent used by researchers to detect tau in the brain. Ramanan and Fillit have reported no relevant financial relationships.

This article first appeared on Medscape.com.

Novel gene variants associated with the development of tau deposits in the brain, a key biological feature of Alzheimer’s disease, have been identified. Investigator Vijay Ramanan, MD, PhD, behavioral neurology fellow, Mayo Clinic, Rochester, Minnesota, noted that this is the first genome-wide study of tau positron-emission tomography (PET) and that it identifies variations in DNA profiles associated with tau load in the brain.

“These early results represent an important step to better understanding why some individuals have a greater susceptibility to tau accumulation while others are more resistant,” Dr. Ramanan told Medscape Medical News.

“As we learn more about that process, the longer-term hope would be to use that information to better predict who may become symptomatic from the disease and to develop targets for treatment based on those individualized profiles,” he added.

The findings were released March 9 ahead of the study’s scheduled presentation at the annual meeting of the American Academy of Neurology. The AAN canceled the meeting and released abstracts and access to presenters for press coverage.

Genome-wide associations

The researchers assessed genetic profile and regional tau-PET data for 754 participants (mean age, 72.4 years; 54.6% men; 87% cognitively unimpaired) in the Mayo Clinic Study of Aging.

They found that individuals with novel genetic variants on chromosomes 1 and 5 had a higher amount of tau in their brains, compared with their counterparts who had more typical gene sequences in those regions.

The genetic variants were found in 2% to 3% of the group, and those individuals had about 10% higher tau levels than patients who did not have the variants.

Specifically, investigators identified genome-wide significant associations with higher tau for rs76752255 in protein phosphatase 2 regulatory subunit B (PPP2R2B), an enzyme of the PPP2R2B gene on chromosome 5, and for rs115862481 in an intergenic region on chromosome 1. Each minor allele had a stronger association in amyloid-positive than in amyloid-negative individuals.

In addition, three single-nucleotide polymorphisms (SNPs) within microtubule-associated protein tau (MAPT) genes displayed nominal associations to tau burden. These included rs3785883, which previously was found to be associated with higher levels of cerebrospinal fluid tau in an independent cohort.

However, no associations with tau burden were identified for the SNPs defining apolipoprotein E (APOE) e4 or for genotyped SNPs previously associated with Alzheimer’s disease in large case-control studies.

“The fact that these variants are new, coupled with the lack of strong signal for tau in APOE, reinforces the concept that Alzheimer’s disease is complex and that across patients, different sets of genes may be involved in entering into the Alzheimer’s disease pathway versus modifying its course or symptomatic expression,” Dr. Ramanan said.

“Lots of exciting work is ongoing to try to disentangle those issues, and this study is a valuable step on that path,” he added.

Dr. Ramanan said there is a great need for a better understanding of the factors that influence tau deposition, particularly since the burden and location of tau buildup in the brain are closely related to cognitive symptoms of Alzheimer’s disease.

He noted that the approach of “imaging genetics”—using brain scans that capture disease biomarkers and connecting those with data on the genome to improve knowledge about risk and treatment targeting—has been growing. However, only recently has it become possible to apply that framework to tau.

Dr, Ramanan emphasized that replication studies and functional characterization of these novel genetic findings are needed.

“Distant” clinical implications

Commenting on the study, Howard Fillit, MD, founding executive director and chief science officer of the Alzheimer’s Drug Discovery Foundation, said that there is currently “a fair amount of this kind of work going on” in assessing polygenetic risk in Alzheimer’s disease. This includes examining APOE as well as “a whole bunch of other genes” associated with the disease.

“Far and away, the APOE genetic association with Alzheimer’s disease risk is the most powerful one. In and of themselves, none of these other risk genes cause Alzheimer’s disease, they only contribute to risk,” Dr. Fillit noted.

“This study found some new genes that were associated with susceptibility to tau deposition, but at the end of the day, they are just associations. They don’t prove causality,” he added.

“It’s interesting, but really hard to know what to conclude from it; and the clinical implications, I think, are rather distant,” Dr. Fillit concluded.

The study was supported by the National Institutes of Health; the Gerald and Henrietta Rauenhorst Foundation; the Alexander Family Alzheimer’s Disease Research Professorship of Mayo Clinic; the Mayo Foundation for Medical Education and Research; a Liston Award; the Elsie and Marvin Dekelboum Family Foundation; the Schuler Foundation; and Avid Radiopharmaceuticals, which supplied the imaging agent used by researchers to detect tau in the brain. Ramanan and Fillit have reported no relevant financial relationships.

This article first appeared on Medscape.com.

“To journey for the sake of saving our own lives is little by little to cease to live in any sense that really matters, even to ourselves, because it is only by journeying for the world’s sake—even when the world bores and sickens and scares you half to death—that little by little we start to come alive.”

—Frederick Buechner

On February 29, 2020, I find out by text from my intern when the first patient at our hospital in Seattle tests positive for COVID-19. He learns of it from his fellow intern who is caring for the patient. The news quickly spreads through the hospital like the virus itself, going from person to person while official communication channels remain initially silent. The news comes on the heels of a friend’s text that her daughter’s high school is closing for disinfection after a classmate also tested positive for COVID-19. I know the cataclysmic significance of these two events: Public health efforts to contain the SARS-CoV-2 coronavirus have failed, and there is ongoing community spread of the infection in Washington state. I text my intern back with the emoji of The Scream by Edvard Munch.

Could I be asymptomatically infected with the coronavirus? I work in close quarters with my colleagues who cared for the COVID-19–positive patient before he was placed in infection precautions. Social distancing has yet to enter our lexicon and our lives. In our crowded office, shared surfaces abound. Suddenly, every hard surface seems suspect—chairs, phones, dictaphone handsets, code pagers, printers, keypads, and door handles. All can be vectors of viral transmission. Normally insouciant about cleanliness, my coworkers and I start swabbing down every surface with disinfectant wipes. I ponder my likelihood of infection and decide it is possible but not probable.

In the next few days, I have a trip to Sedona, Arizona, planned with my extended family. Originally conceived as a celebration for my mom’s 80th birthday, we repurposed it as a time to grieve together after she unexpectedly passed away. I debate back and forth whether to go on the trip. If there is a chance I am infected with the coronavirus, it feels irresponsible to board an airplane with hundreds of other people. Yet the trip carries such high value for me. My family holds out hope I can get tested for the coronavirus, but I know just how limited testing capability is. It cuts me to the heart, but I cancel my flight. The deciding factor is that my sister has an autoimmune disease and is immunosuppressed. I don’t want to jeopardize her health. The world has truly gone topsy-turvy when the greatest thoughtfulness you can show to someone you love is to stay the hell away from her.

After my work stretch, I hunker down at home to monitor myself. I have a mild sore throat but convince myself it is psychosomatic. My plausible deniability of illness dies when I develop a cough and fatigue. Based on my symptoms, it is impossible to tell if I have the coronavirus or a common cold. I place myself on home quarantine. I don’t pursue coronavirus testing because there are hospitalized patients who need it much more than I do. I diligently monitor my temperature twice daily and it remains normal. My sore throat and fatigue go away, but my cough and some mild shortness of breath persists. I attribute it to my asthma, but the possibility of COVID-19 always lurks in the back of my mind. COVID-19 patients often don’t worsen until their second week of infection. Ordinarily, I would start using my steroid inhaler, but I hold off since steroids are thought to prolong viral replication. 

When I tire of staying in the house, I go outside to work in the yard. I get on a low ladder to pull down the English ivy climbing up and smothering a tree. The ivy strand I’m tugging on suddenly breaks and I fall hard onto my back. Like a slap in the face, the accident shocks me into a new state of mental clarity. As a hospitalist, I’m a precious resource to my community right now. I can’t knock myself out of commission for dumb reasons. I ban myself from climbing any more ladders. 

As my time in quarantine draws to a close, I put my legal and financial affairs in order and pack a just-in-case backpack. The emergency room doctor hospitalized at a nearby hospital with severe COVID-19 is about my age. I am still coughing so I check in with the head of Infection Control to see if I need to be tested before returning to work. He tells me no. As I start working, I realize that coughing is the new leprosy. Even though I wear a mask, I get tense looks from others who carefully keep their distance from me. I tell everyone I have cough variant asthma, but what they all want to know is if I have been tested for the coronavirus. I haven’t been.

When my hospital sets up a new dedicated Employee Health screening phone line, I call right away. The nurse tells me I don’t meet criteria for coronavirus testing even though I am working on the COVID-19 rule-out unit with patients who have tested positive. While I agree with her from a medical standpoint, I don’t from a social or psychological perspective. This is a particularly unpropitious time in history to be a Chinese American doctor who can’t stop coughing. A negative test will reassure my patients and coworkers I am not a risk to them. A positive test, which is a possibility because of known prolonged viral shedding of the coronavirus, will reassure me I’m likely on my way to developing serologic immunity. I don’t get a test. When I tell my colleague, he suggests I resort to lying, but I won’t do it. As I’ve watched how power, wealth, and privilege play out in access to testing, I refuse to manipulate the system. But my experience is pointed commentary on the abysmal failure of testing in the United States when a frontline symptomatic doctor taking care of COVID-19 patients in one of the epicenters of the pandemic can’t get a coronavirus test. During a meeting, the head of Infection Control bluntly states he hopes we know that all of us are going to get the coronavirus at some point, but hopefully it won’t take us out of commission all at once. I feel better hearing him acknowledge that because it confirms my own sense of reality. 

While the ongoing pandemic definitely increases stress and anxiety levels in the hospital, there also continues to be caring and kindness. As I don my personal protective equipment (PPE), a nurse notices an exposed gap in the back of my gown and fixes it for me. He has my back, literally and figuratively. Our unit clerk, hearing my persistent cough, braves the 6-foot danger zone to hand me cough drops. Another nurse asks when the last time was I drank anything, and I give her a blank look because I can’t remember. I’m trying to minimize my use of masks, so I have kept my current one on all day. The front of the mask may be contaminated, but as long as I don’t touch that surface, it is still protecting me. She hands me a cup of water and I consider the benefit of staying hydrated versus using up another mask. Having previously landed in the emergency room with a kidney stone from not properly hydrating, I take off the mask, throw it away, wash my hands, and drink the water. But in my mind, I’m acutely aware of our shrinking supply of PPE. 

On our time off work, my coworkers and I reach out to everyone we know to ask for mask donations. One friend tells me her husband is fashioning a mask for her from their furnace filter. She considers it the most romantic thing he’s ever done for her. The two of us agree that if we run out of PPE, we will go on caring for our patients anyway. We are doctors and caring for others is not only what we do, but an intrinsic part of who we are. Our journey amid the coronavirus pandemic may at times scare us half to death, but in caring for others “little by little we start to come alive.”

“To journey for the sake of saving our own lives is little by little to cease to live in any sense that really matters, even to ourselves, because it is only by journeying for the world’s sake—even when the world bores and sickens and scares you half to death—that little by little we start to come alive.”

—Frederick Buechner

On February 29, 2020, I find out by text from my intern when the first patient at our hospital in Seattle tests positive for COVID-19. He learns of it from his fellow intern who is caring for the patient. The news quickly spreads through the hospital like the virus itself, going from person to person while official communication channels remain initially silent. The news comes on the heels of a friend’s text that her daughter’s high school is closing for disinfection after a classmate also tested positive for COVID-19. I know the cataclysmic significance of these two events: Public health efforts to contain the SARS-CoV-2 coronavirus have failed, and there is ongoing community spread of the infection in Washington state. I text my intern back with the emoji of The Scream by Edvard Munch.

Could I be asymptomatically infected with the coronavirus? I work in close quarters with my colleagues who cared for the COVID-19–positive patient before he was placed in infection precautions. Social distancing has yet to enter our lexicon and our lives. In our crowded office, shared surfaces abound. Suddenly, every hard surface seems suspect—chairs, phones, dictaphone handsets, code pagers, printers, keypads, and door handles. All can be vectors of viral transmission. Normally insouciant about cleanliness, my coworkers and I start swabbing down every surface with disinfectant wipes. I ponder my likelihood of infection and decide it is possible but not probable.

In the next few days, I have a trip to Sedona, Arizona, planned with my extended family. Originally conceived as a celebration for my mom’s 80th birthday, we repurposed it as a time to grieve together after she unexpectedly passed away. I debate back and forth whether to go on the trip. If there is a chance I am infected with the coronavirus, it feels irresponsible to board an airplane with hundreds of other people. Yet the trip carries such high value for me. My family holds out hope I can get tested for the coronavirus, but I know just how limited testing capability is. It cuts me to the heart, but I cancel my flight. The deciding factor is that my sister has an autoimmune disease and is immunosuppressed. I don’t want to jeopardize her health. The world has truly gone topsy-turvy when the greatest thoughtfulness you can show to someone you love is to stay the hell away from her.

After my work stretch, I hunker down at home to monitor myself. I have a mild sore throat but convince myself it is psychosomatic. My plausible deniability of illness dies when I develop a cough and fatigue. Based on my symptoms, it is impossible to tell if I have the coronavirus or a common cold. I place myself on home quarantine. I don’t pursue coronavirus testing because there are hospitalized patients who need it much more than I do. I diligently monitor my temperature twice daily and it remains normal. My sore throat and fatigue go away, but my cough and some mild shortness of breath persists. I attribute it to my asthma, but the possibility of COVID-19 always lurks in the back of my mind. COVID-19 patients often don’t worsen until their second week of infection. Ordinarily, I would start using my steroid inhaler, but I hold off since steroids are thought to prolong viral replication. 

When I tire of staying in the house, I go outside to work in the yard. I get on a low ladder to pull down the English ivy climbing up and smothering a tree. The ivy strand I’m tugging on suddenly breaks and I fall hard onto my back. Like a slap in the face, the accident shocks me into a new state of mental clarity. As a hospitalist, I’m a precious resource to my community right now. I can’t knock myself out of commission for dumb reasons. I ban myself from climbing any more ladders. 

As my time in quarantine draws to a close, I put my legal and financial affairs in order and pack a just-in-case backpack. The emergency room doctor hospitalized at a nearby hospital with severe COVID-19 is about my age. I am still coughing so I check in with the head of Infection Control to see if I need to be tested before returning to work. He tells me no. As I start working, I realize that coughing is the new leprosy. Even though I wear a mask, I get tense looks from others who carefully keep their distance from me. I tell everyone I have cough variant asthma, but what they all want to know is if I have been tested for the coronavirus. I haven’t been.

When my hospital sets up a new dedicated Employee Health screening phone line, I call right away. The nurse tells me I don’t meet criteria for coronavirus testing even though I am working on the COVID-19 rule-out unit with patients who have tested positive. While I agree with her from a medical standpoint, I don’t from a social or psychological perspective. This is a particularly unpropitious time in history to be a Chinese American doctor who can’t stop coughing. A negative test will reassure my patients and coworkers I am not a risk to them. A positive test, which is a possibility because of known prolonged viral shedding of the coronavirus, will reassure me I’m likely on my way to developing serologic immunity. I don’t get a test. When I tell my colleague, he suggests I resort to lying, but I won’t do it. As I’ve watched how power, wealth, and privilege play out in access to testing, I refuse to manipulate the system. But my experience is pointed commentary on the abysmal failure of testing in the United States when a frontline symptomatic doctor taking care of COVID-19 patients in one of the epicenters of the pandemic can’t get a coronavirus test. During a meeting, the head of Infection Control bluntly states he hopes we know that all of us are going to get the coronavirus at some point, but hopefully it won’t take us out of commission all at once. I feel better hearing him acknowledge that because it confirms my own sense of reality. 

While the ongoing pandemic definitely increases stress and anxiety levels in the hospital, there also continues to be caring and kindness. As I don my personal protective equipment (PPE), a nurse notices an exposed gap in the back of my gown and fixes it for me. He has my back, literally and figuratively. Our unit clerk, hearing my persistent cough, braves the 6-foot danger zone to hand me cough drops. Another nurse asks when the last time was I drank anything, and I give her a blank look because I can’t remember. I’m trying to minimize my use of masks, so I have kept my current one on all day. The front of the mask may be contaminated, but as long as I don’t touch that surface, it is still protecting me. She hands me a cup of water and I consider the benefit of staying hydrated versus using up another mask. Having previously landed in the emergency room with a kidney stone from not properly hydrating, I take off the mask, throw it away, wash my hands, and drink the water. But in my mind, I’m acutely aware of our shrinking supply of PPE. 

On our time off work, my coworkers and I reach out to everyone we know to ask for mask donations. One friend tells me her husband is fashioning a mask for her from their furnace filter. She considers it the most romantic thing he’s ever done for her. The two of us agree that if we run out of PPE, we will go on caring for our patients anyway. We are doctors and caring for others is not only what we do, but an intrinsic part of who we are. Our journey amid the coronavirus pandemic may at times scare us half to death, but in caring for others “little by little we start to come alive.”

“To journey for the sake of saving our own lives is little by little to cease to live in any sense that really matters, even to ourselves, because it is only by journeying for the world’s sake—even when the world bores and sickens and scares you half to death—that little by little we start to come alive.”

—Frederick Buechner

On February 29, 2020, I find out by text from my intern when the first patient at our hospital in Seattle tests positive for COVID-19. He learns of it from his fellow intern who is caring for the patient. The news quickly spreads through the hospital like the virus itself, going from person to person while official communication channels remain initially silent. The news comes on the heels of a friend’s text that her daughter’s high school is closing for disinfection after a classmate also tested positive for COVID-19. I know the cataclysmic significance of these two events: Public health efforts to contain the SARS-CoV-2 coronavirus have failed, and there is ongoing community spread of the infection in Washington state. I text my intern back with the emoji of The Scream by Edvard Munch.

Could I be asymptomatically infected with the coronavirus? I work in close quarters with my colleagues who cared for the COVID-19–positive patient before he was placed in infection precautions. Social distancing has yet to enter our lexicon and our lives. In our crowded office, shared surfaces abound. Suddenly, every hard surface seems suspect—chairs, phones, dictaphone handsets, code pagers, printers, keypads, and door handles. All can be vectors of viral transmission. Normally insouciant about cleanliness, my coworkers and I start swabbing down every surface with disinfectant wipes. I ponder my likelihood of infection and decide it is possible but not probable.

In the next few days, I have a trip to Sedona, Arizona, planned with my extended family. Originally conceived as a celebration for my mom’s 80th birthday, we repurposed it as a time to grieve together after she unexpectedly passed away. I debate back and forth whether to go on the trip. If there is a chance I am infected with the coronavirus, it feels irresponsible to board an airplane with hundreds of other people. Yet the trip carries such high value for me. My family holds out hope I can get tested for the coronavirus, but I know just how limited testing capability is. It cuts me to the heart, but I cancel my flight. The deciding factor is that my sister has an autoimmune disease and is immunosuppressed. I don’t want to jeopardize her health. The world has truly gone topsy-turvy when the greatest thoughtfulness you can show to someone you love is to stay the hell away from her.

After my work stretch, I hunker down at home to monitor myself. I have a mild sore throat but convince myself it is psychosomatic. My plausible deniability of illness dies when I develop a cough and fatigue. Based on my symptoms, it is impossible to tell if I have the coronavirus or a common cold. I place myself on home quarantine. I don’t pursue coronavirus testing because there are hospitalized patients who need it much more than I do. I diligently monitor my temperature twice daily and it remains normal. My sore throat and fatigue go away, but my cough and some mild shortness of breath persists. I attribute it to my asthma, but the possibility of COVID-19 always lurks in the back of my mind. COVID-19 patients often don’t worsen until their second week of infection. Ordinarily, I would start using my steroid inhaler, but I hold off since steroids are thought to prolong viral replication. 

When I tire of staying in the house, I go outside to work in the yard. I get on a low ladder to pull down the English ivy climbing up and smothering a tree. The ivy strand I’m tugging on suddenly breaks and I fall hard onto my back. Like a slap in the face, the accident shocks me into a new state of mental clarity. As a hospitalist, I’m a precious resource to my community right now. I can’t knock myself out of commission for dumb reasons. I ban myself from climbing any more ladders. 

As my time in quarantine draws to a close, I put my legal and financial affairs in order and pack a just-in-case backpack. The emergency room doctor hospitalized at a nearby hospital with severe COVID-19 is about my age. I am still coughing so I check in with the head of Infection Control to see if I need to be tested before returning to work. He tells me no. As I start working, I realize that coughing is the new leprosy. Even though I wear a mask, I get tense looks from others who carefully keep their distance from me. I tell everyone I have cough variant asthma, but what they all want to know is if I have been tested for the coronavirus. I haven’t been.

When my hospital sets up a new dedicated Employee Health screening phone line, I call right away. The nurse tells me I don’t meet criteria for coronavirus testing even though I am working on the COVID-19 rule-out unit with patients who have tested positive. While I agree with her from a medical standpoint, I don’t from a social or psychological perspective. This is a particularly unpropitious time in history to be a Chinese American doctor who can’t stop coughing. A negative test will reassure my patients and coworkers I am not a risk to them. A positive test, which is a possibility because of known prolonged viral shedding of the coronavirus, will reassure me I’m likely on my way to developing serologic immunity. I don’t get a test. When I tell my colleague, he suggests I resort to lying, but I won’t do it. As I’ve watched how power, wealth, and privilege play out in access to testing, I refuse to manipulate the system. But my experience is pointed commentary on the abysmal failure of testing in the United States when a frontline symptomatic doctor taking care of COVID-19 patients in one of the epicenters of the pandemic can’t get a coronavirus test. During a meeting, the head of Infection Control bluntly states he hopes we know that all of us are going to get the coronavirus at some point, but hopefully it won’t take us out of commission all at once. I feel better hearing him acknowledge that because it confirms my own sense of reality. 

While the ongoing pandemic definitely increases stress and anxiety levels in the hospital, there also continues to be caring and kindness. As I don my personal protective equipment (PPE), a nurse notices an exposed gap in the back of my gown and fixes it for me. He has my back, literally and figuratively. Our unit clerk, hearing my persistent cough, braves the 6-foot danger zone to hand me cough drops. Another nurse asks when the last time was I drank anything, and I give her a blank look because I can’t remember. I’m trying to minimize my use of masks, so I have kept my current one on all day. The front of the mask may be contaminated, but as long as I don’t touch that surface, it is still protecting me. She hands me a cup of water and I consider the benefit of staying hydrated versus using up another mask. Having previously landed in the emergency room with a kidney stone from not properly hydrating, I take off the mask, throw it away, wash my hands, and drink the water. But in my mind, I’m acutely aware of our shrinking supply of PPE. 

On our time off work, my coworkers and I reach out to everyone we know to ask for mask donations. One friend tells me her husband is fashioning a mask for her from their furnace filter. She considers it the most romantic thing he’s ever done for her. The two of us agree that if we run out of PPE, we will go on caring for our patients anyway. We are doctors and caring for others is not only what we do, but an intrinsic part of who we are. Our journey amid the coronavirus pandemic may at times scare us half to death, but in caring for others “little by little we start to come alive.”

For Luanne Freer, MD, an expert in high-altitude pulmonary edema (HAPE) and founder and director of Everest ER, a nonprofit seasonal clinic at the Mt. Everest base camp in Nepal (elevation, 17,600 ft), a sudden flurry of messages and questions she received about a possible COVID-19/HAPE link was startling.

Courtesy Rowie Ververis

“That’s why it kind of poked me in the eye,” she said, referencing her extensive experience treating HAPE, which she described as a pressure-related phenomenon. “My goodness, they are so completely different.”

Dr. Freer, an emergency physician, reached out to several pulmonary intensivists with experience treating both HAPE and COVID-19 to gauge their reactions, and within 36 hours, they had drafted their response. In the commentary, published in High Altitude Medicine & Biology, the clinicians note that the comparison between HAPE and COVID-19 is potentially risky.

“As a group of physicians who have in some cases cared for patients with COVID-19 and in all cases cared for patients with HAPE and studied its pathophysiology and management, we feel it important to correct this misconception, as continued amplification of this message could have adverse effects on management of these patients,” they wrote.

The suggestion that COVID-19 lung injury sometimes looks more like HAPE than like acute respiratory distress syndrome (ARDS) appeared in a journal review article in late March and was put forth by medical professionals on social media where it gained traction in recent weeks and was amplified in multiple media outlets, including this one.

“With COVID, we don’t understand everything that’s going on, but we know for sure it’s an inflammatory process – not a pressure-related problem,” Dr. Freer said. “I thought ... this could be so dangerous to load the medicines that we use when we’re treating HAPE onto patients with COVID-19.”

The pathophysiological mechanisms in HAPE are different than those in other respiratory syndromes, including those associated with COVID-19, said Andrew M. Luks, MD, of the UW Medicine, Seattle, and the first author on the commentary.

“HAPE is a noncardiogenic form of pulmonary edema, as are ARDS due to bacteria or viral pneumonia, re-expansion pulmonary edema, immersion pulmonary edema, negative pressure pulmonary edema, and neurogenic pulmonary edema,” Dr. Luks, Dr. Freer, and colleagues wrote in the commentary, explaining that all of these entities cause varying degrees of hypoxemia and diffuse bilateral opacities on chest imaging. “Importantly, in all of these cases, edema accumulates in the interstitial and alveolar spaces of the lung as a result of imbalance in Starling forces.”

A difference between these entities, however, is “the mechanism by which that imbalance develops,” they noted.

The excessive and uneven hypoxic pulmonary vasoconstriction that leads to a marked increase in pulmonary artery pressure, subsequent lung overperfusion, increased pulmonary capillary hydrostatic pressure, and leakage of fluid from the vascular space into the alveolar space as seen in HAPE, is a “fundamentally different phenomenon than what is seen in COVID-19-related ARDS, which involves viral-mediated inflammatory responses as the primary pathophysiological mechanism,” they added.

The authors described several other differences between the conditions, ultimately noting that “understanding the distinction between the pathophysiological mechanisms of these entities is critical for patient management.”

In HAPE, supplemental oxygen alone may be sufficient; in COVID-19, it may improve hypoxemia but won’t resolve the underlying inflammation or injury, they explained, adding that “only good supportive care including mechanical ventilation, quite often for long periods of time, allows some patients to survive until their disease resolves.”

Further, HAPE can be prevented or treated with pulmonary vasodilators such a nifedipine or sildenafil, which decrease pulmonary artery pressure and, as a result lower pulmonary capillary hydrostatic pressure, they said.

Use of such medications for COVID-19 might decrease pulmonary artery pressure and improve right ventricular function in COVID-19, but “by releasing hypoxic pulmonary vasoconstriction and increasing perfusion to nonventilated regions of the lung, they could also worsen ventilation-perfusion mismatch” and thereby worsen hypoxemia, they explained, adding that the treatments can also cause or worsen hypotension.

Efforts to share observations and experience are important in medicine, but sometimes, as in this circumstance, “they get out there, spread around – like a brushfire almost – and get [unwarranted] face validity,” Dr. Luks said, noting that in response to information circulating about COVID-19 and HAPE, he has already heard medical professionals floating the idea of treating COVID-19 with treatments used for HAPE.

It’s true that some COVID-19 lung injury cases are behaving differently than typical ARDS, he said, adding that presentation can vary.

“But trying to equate HAPE and COVID-19 is just wrong,” he said. “HAPE and COVID-19 may share several features ...but those are features that are shared by a lot of different forms of respiratory failure.”

In a recent video interview, WebMD’s chief medical officer John Whyte, MD, spoke with a New York City physician trained in critical care and emergency medicine, Cameron Kyle-Sidell, MD, who raised the need to consider different respiratory protocols for COVID-19, noting that standard protocols were falling short in many cases.

“What we’re seeing ... is something unusual, it’s something that we are not used to,” Dr. Kyle-Sidell of Maimonides Medical Center said in that interview, stressing that the presentation differed from that seen in typical ARDS. “The patterns I was seeing did not make sense.”

Like others, he noted that COVID-19 patients were presenting with illness that clinically looked more like HAPE, but that the pathophysiology is not necessary similar to HAPE.

At around the same time, Luciano Gattinoni, MD, of the Medical University of Göttingen in Germany and colleagues, published a letter to the editor in the American Journal of Respiratory and Critical Care Medicine stressing that the ARDS presentation in COVID-19 patients is atypical and requires a patient physiology–driven treatment approach, rather than a standard protocol–driven approach. Dr. Gattinoni and colleagues suggested that instead of high positive end-expiratory pressure (PEEP), physicians should consider the lowest possible PEEP and gentle ventilation.

Dr. Luks agreed that “some patients with COVID-19 do not have the same physiologic derangements that we see in a lot of other people with ARDS.”

“[Dr. Gattinoni] is making the point that we need to treat these people differently ... and I think that’s a valid point, and honestly, that’s a point that applied even before COVID-19,” he said. “Most of the things that we see in clinical practice – there’s a lot of heterogeneity between patients, and you have to be prepared to tailor your therapy in light of the differences that you’re picking up from your observations at the bedside and other data that you’re getting on the patient.”

The main concern Dr. Luks and his coauthors wanted to convey, they said, is making sure that the anecdotal experiences and observations of clinicians struggling to find answers don’t spiral out of control without proper vetting, thereby leading to patient harm.

“In this challenging time, we must identify the best means to care for these critically ill patients. That approach should be grounded in sound pulmonary physiology, clinical experience and, when available, evidence from clinical studies,” they concluded.

Dr. Luks and Dr. Freer reported having no financial disclosures.

[email protected]

For Luanne Freer, MD, an expert in high-altitude pulmonary edema (HAPE) and founder and director of Everest ER, a nonprofit seasonal clinic at the Mt. Everest base camp in Nepal (elevation, 17,600 ft), a sudden flurry of messages and questions she received about a possible COVID-19/HAPE link was startling.

Courtesy Rowie Ververis

“That’s why it kind of poked me in the eye,” she said, referencing her extensive experience treating HAPE, which she described as a pressure-related phenomenon. “My goodness, they are so completely different.”

Dr. Freer, an emergency physician, reached out to several pulmonary intensivists with experience treating both HAPE and COVID-19 to gauge their reactions, and within 36 hours, they had drafted their response. In the commentary, published in High Altitude Medicine & Biology, the clinicians note that the comparison between HAPE and COVID-19 is potentially risky.

“As a group of physicians who have in some cases cared for patients with COVID-19 and in all cases cared for patients with HAPE and studied its pathophysiology and management, we feel it important to correct this misconception, as continued amplification of this message could have adverse effects on management of these patients,” they wrote.

The suggestion that COVID-19 lung injury sometimes looks more like HAPE than like acute respiratory distress syndrome (ARDS) appeared in a journal review article in late March and was put forth by medical professionals on social media where it gained traction in recent weeks and was amplified in multiple media outlets, including this one.

“With COVID, we don’t understand everything that’s going on, but we know for sure it’s an inflammatory process – not a pressure-related problem,” Dr. Freer said. “I thought ... this could be so dangerous to load the medicines that we use when we’re treating HAPE onto patients with COVID-19.”

The pathophysiological mechanisms in HAPE are different than those in other respiratory syndromes, including those associated with COVID-19, said Andrew M. Luks, MD, of the UW Medicine, Seattle, and the first author on the commentary.

“HAPE is a noncardiogenic form of pulmonary edema, as are ARDS due to bacteria or viral pneumonia, re-expansion pulmonary edema, immersion pulmonary edema, negative pressure pulmonary edema, and neurogenic pulmonary edema,” Dr. Luks, Dr. Freer, and colleagues wrote in the commentary, explaining that all of these entities cause varying degrees of hypoxemia and diffuse bilateral opacities on chest imaging. “Importantly, in all of these cases, edema accumulates in the interstitial and alveolar spaces of the lung as a result of imbalance in Starling forces.”

A difference between these entities, however, is “the mechanism by which that imbalance develops,” they noted.

The excessive and uneven hypoxic pulmonary vasoconstriction that leads to a marked increase in pulmonary artery pressure, subsequent lung overperfusion, increased pulmonary capillary hydrostatic pressure, and leakage of fluid from the vascular space into the alveolar space as seen in HAPE, is a “fundamentally different phenomenon than what is seen in COVID-19-related ARDS, which involves viral-mediated inflammatory responses as the primary pathophysiological mechanism,” they added.

The authors described several other differences between the conditions, ultimately noting that “understanding the distinction between the pathophysiological mechanisms of these entities is critical for patient management.”

In HAPE, supplemental oxygen alone may be sufficient; in COVID-19, it may improve hypoxemia but won’t resolve the underlying inflammation or injury, they explained, adding that “only good supportive care including mechanical ventilation, quite often for long periods of time, allows some patients to survive until their disease resolves.”

Further, HAPE can be prevented or treated with pulmonary vasodilators such a nifedipine or sildenafil, which decrease pulmonary artery pressure and, as a result lower pulmonary capillary hydrostatic pressure, they said.

Use of such medications for COVID-19 might decrease pulmonary artery pressure and improve right ventricular function in COVID-19, but “by releasing hypoxic pulmonary vasoconstriction and increasing perfusion to nonventilated regions of the lung, they could also worsen ventilation-perfusion mismatch” and thereby worsen hypoxemia, they explained, adding that the treatments can also cause or worsen hypotension.

Efforts to share observations and experience are important in medicine, but sometimes, as in this circumstance, “they get out there, spread around – like a brushfire almost – and get [unwarranted] face validity,” Dr. Luks said, noting that in response to information circulating about COVID-19 and HAPE, he has already heard medical professionals floating the idea of treating COVID-19 with treatments used for HAPE.

It’s true that some COVID-19 lung injury cases are behaving differently than typical ARDS, he said, adding that presentation can vary.

“But trying to equate HAPE and COVID-19 is just wrong,” he said. “HAPE and COVID-19 may share several features ...but those are features that are shared by a lot of different forms of respiratory failure.”

In a recent video interview, WebMD’s chief medical officer John Whyte, MD, spoke with a New York City physician trained in critical care and emergency medicine, Cameron Kyle-Sidell, MD, who raised the need to consider different respiratory protocols for COVID-19, noting that standard protocols were falling short in many cases.

“What we’re seeing ... is something unusual, it’s something that we are not used to,” Dr. Kyle-Sidell of Maimonides Medical Center said in that interview, stressing that the presentation differed from that seen in typical ARDS. “The patterns I was seeing did not make sense.”

Like others, he noted that COVID-19 patients were presenting with illness that clinically looked more like HAPE, but that the pathophysiology is not necessary similar to HAPE.

At around the same time, Luciano Gattinoni, MD, of the Medical University of Göttingen in Germany and colleagues, published a letter to the editor in the American Journal of Respiratory and Critical Care Medicine stressing that the ARDS presentation in COVID-19 patients is atypical and requires a patient physiology–driven treatment approach, rather than a standard protocol–driven approach. Dr. Gattinoni and colleagues suggested that instead of high positive end-expiratory pressure (PEEP), physicians should consider the lowest possible PEEP and gentle ventilation.

Dr. Luks agreed that “some patients with COVID-19 do not have the same physiologic derangements that we see in a lot of other people with ARDS.”

“[Dr. Gattinoni] is making the point that we need to treat these people differently ... and I think that’s a valid point, and honestly, that’s a point that applied even before COVID-19,” he said. “Most of the things that we see in clinical practice – there’s a lot of heterogeneity between patients, and you have to be prepared to tailor your therapy in light of the differences that you’re picking up from your observations at the bedside and other data that you’re getting on the patient.”

The main concern Dr. Luks and his coauthors wanted to convey, they said, is making sure that the anecdotal experiences and observations of clinicians struggling to find answers don’t spiral out of control without proper vetting, thereby leading to patient harm.

“In this challenging time, we must identify the best means to care for these critically ill patients. That approach should be grounded in sound pulmonary physiology, clinical experience and, when available, evidence from clinical studies,” they concluded.

Dr. Luks and Dr. Freer reported having no financial disclosures.

[email protected]

For Luanne Freer, MD, an expert in high-altitude pulmonary edema (HAPE) and founder and director of Everest ER, a nonprofit seasonal clinic at the Mt. Everest base camp in Nepal (elevation, 17,600 ft), a sudden flurry of messages and questions she received about a possible COVID-19/HAPE link was startling.

Courtesy Rowie Ververis

“That’s why it kind of poked me in the eye,” she said, referencing her extensive experience treating HAPE, which she described as a pressure-related phenomenon. “My goodness, they are so completely different.”

Dr. Freer, an emergency physician, reached out to several pulmonary intensivists with experience treating both HAPE and COVID-19 to gauge their reactions, and within 36 hours, they had drafted their response. In the commentary, published in High Altitude Medicine & Biology, the clinicians note that the comparison between HAPE and COVID-19 is potentially risky.

“As a group of physicians who have in some cases cared for patients with COVID-19 and in all cases cared for patients with HAPE and studied its pathophysiology and management, we feel it important to correct this misconception, as continued amplification of this message could have adverse effects on management of these patients,” they wrote.

The suggestion that COVID-19 lung injury sometimes looks more like HAPE than like acute respiratory distress syndrome (ARDS) appeared in a journal review article in late March and was put forth by medical professionals on social media where it gained traction in recent weeks and was amplified in multiple media outlets, including this one.

“With COVID, we don’t understand everything that’s going on, but we know for sure it’s an inflammatory process – not a pressure-related problem,” Dr. Freer said. “I thought ... this could be so dangerous to load the medicines that we use when we’re treating HAPE onto patients with COVID-19.”

The pathophysiological mechanisms in HAPE are different than those in other respiratory syndromes, including those associated with COVID-19, said Andrew M. Luks, MD, of the UW Medicine, Seattle, and the first author on the commentary.

“HAPE is a noncardiogenic form of pulmonary edema, as are ARDS due to bacteria or viral pneumonia, re-expansion pulmonary edema, immersion pulmonary edema, negative pressure pulmonary edema, and neurogenic pulmonary edema,” Dr. Luks, Dr. Freer, and colleagues wrote in the commentary, explaining that all of these entities cause varying degrees of hypoxemia and diffuse bilateral opacities on chest imaging. “Importantly, in all of these cases, edema accumulates in the interstitial and alveolar spaces of the lung as a result of imbalance in Starling forces.”

A difference between these entities, however, is “the mechanism by which that imbalance develops,” they noted.

The excessive and uneven hypoxic pulmonary vasoconstriction that leads to a marked increase in pulmonary artery pressure, subsequent lung overperfusion, increased pulmonary capillary hydrostatic pressure, and leakage of fluid from the vascular space into the alveolar space as seen in HAPE, is a “fundamentally different phenomenon than what is seen in COVID-19-related ARDS, which involves viral-mediated inflammatory responses as the primary pathophysiological mechanism,” they added.

The authors described several other differences between the conditions, ultimately noting that “understanding the distinction between the pathophysiological mechanisms of these entities is critical for patient management.”

In HAPE, supplemental oxygen alone may be sufficient; in COVID-19, it may improve hypoxemia but won’t resolve the underlying inflammation or injury, they explained, adding that “only good supportive care including mechanical ventilation, quite often for long periods of time, allows some patients to survive until their disease resolves.”

Further, HAPE can be prevented or treated with pulmonary vasodilators such a nifedipine or sildenafil, which decrease pulmonary artery pressure and, as a result lower pulmonary capillary hydrostatic pressure, they said.

Use of such medications for COVID-19 might decrease pulmonary artery pressure and improve right ventricular function in COVID-19, but “by releasing hypoxic pulmonary vasoconstriction and increasing perfusion to nonventilated regions of the lung, they could also worsen ventilation-perfusion mismatch” and thereby worsen hypoxemia, they explained, adding that the treatments can also cause or worsen hypotension.

Efforts to share observations and experience are important in medicine, but sometimes, as in this circumstance, “they get out there, spread around – like a brushfire almost – and get [unwarranted] face validity,” Dr. Luks said, noting that in response to information circulating about COVID-19 and HAPE, he has already heard medical professionals floating the idea of treating COVID-19 with treatments used for HAPE.

It’s true that some COVID-19 lung injury cases are behaving differently than typical ARDS, he said, adding that presentation can vary.

“But trying to equate HAPE and COVID-19 is just wrong,” he said. “HAPE and COVID-19 may share several features ...but those are features that are shared by a lot of different forms of respiratory failure.”

In a recent video interview, WebMD’s chief medical officer John Whyte, MD, spoke with a New York City physician trained in critical care and emergency medicine, Cameron Kyle-Sidell, MD, who raised the need to consider different respiratory protocols for COVID-19, noting that standard protocols were falling short in many cases.

“What we’re seeing ... is something unusual, it’s something that we are not used to,” Dr. Kyle-Sidell of Maimonides Medical Center said in that interview, stressing that the presentation differed from that seen in typical ARDS. “The patterns I was seeing did not make sense.”

Like others, he noted that COVID-19 patients were presenting with illness that clinically looked more like HAPE, but that the pathophysiology is not necessary similar to HAPE.

At around the same time, Luciano Gattinoni, MD, of the Medical University of Göttingen in Germany and colleagues, published a letter to the editor in the American Journal of Respiratory and Critical Care Medicine stressing that the ARDS presentation in COVID-19 patients is atypical and requires a patient physiology–driven treatment approach, rather than a standard protocol–driven approach. Dr. Gattinoni and colleagues suggested that instead of high positive end-expiratory pressure (PEEP), physicians should consider the lowest possible PEEP and gentle ventilation.

Dr. Luks agreed that “some patients with COVID-19 do not have the same physiologic derangements that we see in a lot of other people with ARDS.”

“[Dr. Gattinoni] is making the point that we need to treat these people differently ... and I think that’s a valid point, and honestly, that’s a point that applied even before COVID-19,” he said. “Most of the things that we see in clinical practice – there’s a lot of heterogeneity between patients, and you have to be prepared to tailor your therapy in light of the differences that you’re picking up from your observations at the bedside and other data that you’re getting on the patient.”

The main concern Dr. Luks and his coauthors wanted to convey, they said, is making sure that the anecdotal experiences and observations of clinicians struggling to find answers don’t spiral out of control without proper vetting, thereby leading to patient harm.

“In this challenging time, we must identify the best means to care for these critically ill patients. That approach should be grounded in sound pulmonary physiology, clinical experience and, when available, evidence from clinical studies,” they concluded.

Dr. Luks and Dr. Freer reported having no financial disclosures.

[email protected]

The American Society of Echocardiography (ASE) has issued a statement on protecting patients and echocardiography service providers during the COVID-19 pandemic.

Given the risk for cardiovascular complications associated with COVID-19, echocardiographic services will likely be needed for patients with suspected or confirmed COVID-19, meaning echo providers will be exposed to SARS-CoV-2, write the statement authors, led by James N. Kirkpatrick, MD, director of the echocardiography laboratory at University of Washington Medical Center in Seattle.

The statement was published online April 6 in the Journal of the American College of Cardiology.

The authors say the statement is intended to help guide the practice of echocardiography in this “challenging time.” It was developed with input from a variety of echocardiography providers and institutions who have experience with the COVID-19, or have been “actively and thoughtfully preparing for it.”

Who, When, Where, and How

The statement covers triaging and decision pathways for handling requests for echocardiography, as well as indications and recommended procedures, in cases of suspected or confirmed COVID-19.

Among the recommendations:

• Only perform transthoracic echocardiograms (TTE), stress echocardiograms, and transesophageal echocardiograms (TEE) if they are expected to provide clinical benefit. Appropriate-use criteria represent the first decision point as to whether an echocardiographic test should be performed.
• Determine which studies are “elective” and reschedule them, performing all others. Identify “nonelective” (urgent/emergent) indications and defer all others.
• Determine the clinical benefit of echocardiography for symptomatic patients whose SARS-CoV-2 status is unknown.
• Cautiously consider the benefit of a TEE examination weighed against the risk for exposure of healthcare personnel to aerosolization in a patient with suspected or confirmed COVID-19.
• Postpone or cancel TEEs if an alternative imaging modality can provide the necessary information.
• Note that treadmill or bicycle stress echo tests in patients with COVID-19 may lead to exposure because of deep breathing and/or coughing during exercise. These tests should generally be deferred or converted to a pharmacologic stress echo.
   

   

The ASE statement also provides advice on safe imaging protocol and adequate personal protection measures.

“In addition to limiting the number of echocardiography practitioners involved in scanning, consideration should be given to limiting the exposure of staff who may be particularly susceptible to severe complications of COVID-19,” the ASE advises.

Staff who are older than 60 years, who have chronic conditions, are immunocompromised or are pregnant may wish to avoid contact with patients suspected or confirmed to have COVID-19.

It’s also important to realize the risk for transmission in reading rooms. “Keyboards, monitors, mice, chairs, phones, desktops, and door knobs should be frequently cleaned, and ventilation provided wherever possible,” the ASE advises. When the echo lab reading room is located in a high-traffic area, remote review of images or via webinar might be advisable, they suggest.

Summing up, Kirkland and colleagues say providing echocardiographic service “remains crucial in this difficult time of the SARS-CoV-2 outbreak. Working together, we can continue to provide high-quality care while minimizing risk to ourselves, our patients, and the public at large. Carefully considering ‘Whom to Image’, ‘Where to Image’ and ‘How to Image’ has the potential to reduce the risks of transmission.”

The authors note that the statements and recommendations are primarily based on expert opinion rather than on scientifically verified data and are subject to change as the COVID-19 outbreak continues to evolve and new data emerges.
 

This article first appeared on Medscape.com.

The American Society of Echocardiography (ASE) has issued a statement on protecting patients and echocardiography service providers during the COVID-19 pandemic.

Given the risk for cardiovascular complications associated with COVID-19, echocardiographic services will likely be needed for patients with suspected or confirmed COVID-19, meaning echo providers will be exposed to SARS-CoV-2, write the statement authors, led by James N. Kirkpatrick, MD, director of the echocardiography laboratory at University of Washington Medical Center in Seattle.

The statement was published online April 6 in the Journal of the American College of Cardiology.

The authors say the statement is intended to help guide the practice of echocardiography in this “challenging time.” It was developed with input from a variety of echocardiography providers and institutions who have experience with the COVID-19, or have been “actively and thoughtfully preparing for it.”

Who, When, Where, and How

The statement covers triaging and decision pathways for handling requests for echocardiography, as well as indications and recommended procedures, in cases of suspected or confirmed COVID-19.

Among the recommendations:

• Only perform transthoracic echocardiograms (TTE), stress echocardiograms, and transesophageal echocardiograms (TEE) if they are expected to provide clinical benefit. Appropriate-use criteria represent the first decision point as to whether an echocardiographic test should be performed.
• Determine which studies are “elective” and reschedule them, performing all others. Identify “nonelective” (urgent/emergent) indications and defer all others.
• Determine the clinical benefit of echocardiography for symptomatic patients whose SARS-CoV-2 status is unknown.
• Cautiously consider the benefit of a TEE examination weighed against the risk for exposure of healthcare personnel to aerosolization in a patient with suspected or confirmed COVID-19.
• Postpone or cancel TEEs if an alternative imaging modality can provide the necessary information.
• Note that treadmill or bicycle stress echo tests in patients with COVID-19 may lead to exposure because of deep breathing and/or coughing during exercise. These tests should generally be deferred or converted to a pharmacologic stress echo.
   

   

The ASE statement also provides advice on safe imaging protocol and adequate personal protection measures.

“In addition to limiting the number of echocardiography practitioners involved in scanning, consideration should be given to limiting the exposure of staff who may be particularly susceptible to severe complications of COVID-19,” the ASE advises.

Staff who are older than 60 years, who have chronic conditions, are immunocompromised or are pregnant may wish to avoid contact with patients suspected or confirmed to have COVID-19.

It’s also important to realize the risk for transmission in reading rooms. “Keyboards, monitors, mice, chairs, phones, desktops, and door knobs should be frequently cleaned, and ventilation provided wherever possible,” the ASE advises. When the echo lab reading room is located in a high-traffic area, remote review of images or via webinar might be advisable, they suggest.

Summing up, Kirkland and colleagues say providing echocardiographic service “remains crucial in this difficult time of the SARS-CoV-2 outbreak. Working together, we can continue to provide high-quality care while minimizing risk to ourselves, our patients, and the public at large. Carefully considering ‘Whom to Image’, ‘Where to Image’ and ‘How to Image’ has the potential to reduce the risks of transmission.”

The authors note that the statements and recommendations are primarily based on expert opinion rather than on scientifically verified data and are subject to change as the COVID-19 outbreak continues to evolve and new data emerges.
 

This article first appeared on Medscape.com.

The American Society of Echocardiography (ASE) has issued a statement on protecting patients and echocardiography service providers during the COVID-19 pandemic.

Given the risk for cardiovascular complications associated with COVID-19, echocardiographic services will likely be needed for patients with suspected or confirmed COVID-19, meaning echo providers will be exposed to SARS-CoV-2, write the statement authors, led by James N. Kirkpatrick, MD, director of the echocardiography laboratory at University of Washington Medical Center in Seattle.

The statement was published online April 6 in the Journal of the American College of Cardiology.

The authors say the statement is intended to help guide the practice of echocardiography in this “challenging time.” It was developed with input from a variety of echocardiography providers and institutions who have experience with the COVID-19, or have been “actively and thoughtfully preparing for it.”

Who, When, Where, and How

The statement covers triaging and decision pathways for handling requests for echocardiography, as well as indications and recommended procedures, in cases of suspected or confirmed COVID-19.

Among the recommendations:

• Only perform transthoracic echocardiograms (TTE), stress echocardiograms, and transesophageal echocardiograms (TEE) if they are expected to provide clinical benefit. Appropriate-use criteria represent the first decision point as to whether an echocardiographic test should be performed.
• Determine which studies are “elective” and reschedule them, performing all others. Identify “nonelective” (urgent/emergent) indications and defer all others.
• Determine the clinical benefit of echocardiography for symptomatic patients whose SARS-CoV-2 status is unknown.
• Cautiously consider the benefit of a TEE examination weighed against the risk for exposure of healthcare personnel to aerosolization in a patient with suspected or confirmed COVID-19.
• Postpone or cancel TEEs if an alternative imaging modality can provide the necessary information.
• Note that treadmill or bicycle stress echo tests in patients with COVID-19 may lead to exposure because of deep breathing and/or coughing during exercise. These tests should generally be deferred or converted to a pharmacologic stress echo.
   

   

The ASE statement also provides advice on safe imaging protocol and adequate personal protection measures.

“In addition to limiting the number of echocardiography practitioners involved in scanning, consideration should be given to limiting the exposure of staff who may be particularly susceptible to severe complications of COVID-19,” the ASE advises.

Staff who are older than 60 years, who have chronic conditions, are immunocompromised or are pregnant may wish to avoid contact with patients suspected or confirmed to have COVID-19.

It’s also important to realize the risk for transmission in reading rooms. “Keyboards, monitors, mice, chairs, phones, desktops, and door knobs should be frequently cleaned, and ventilation provided wherever possible,” the ASE advises. When the echo lab reading room is located in a high-traffic area, remote review of images or via webinar might be advisable, they suggest.

Summing up, Kirkland and colleagues say providing echocardiographic service “remains crucial in this difficult time of the SARS-CoV-2 outbreak. Working together, we can continue to provide high-quality care while minimizing risk to ourselves, our patients, and the public at large. Carefully considering ‘Whom to Image’, ‘Where to Image’ and ‘How to Image’ has the potential to reduce the risks of transmission.”

The authors note that the statements and recommendations are primarily based on expert opinion rather than on scientifically verified data and are subject to change as the COVID-19 outbreak continues to evolve and new data emerges.
 

This article first appeared on Medscape.com.

Family physician Frank Maselli, MD, saw approximately 30 patients a day in his office in the Bronx before COVID-19. But New York City has become a hot spot for the virus that has claimed the lives of the lives of more than 40,000 people nationwide.

Now Maselli and the other 10 physicians in the practice each treat only eight or nine patients a day via telemedicine. He spends most of his time on the phone answering patients’ questions about COVID-19 symptoms and potential exposure. Although he tries to bill for telemedicine and phone calls, he says many commercial payers reject the claims because their processing systems aren’t updated to reflect new coverage policies. He has enough cash in reserve to cover two payrolls, but he knows he needs a backup plan if patient volumes continue to decrease indefinitely.

“Our doctors will take a pay cut before we let people go,” says Maselli. “So far we’re OK because we’re getting paid for things we did two months ago before all of this happened.”

Ninety-seven percent of medical practices have experienced a negative financial impact directly or indirectly related to the COVID-19 pandemic, according to new data from the Medical Group Management Association (MGMA). On average, practices report a 60% decrease in patient volume and a 55% decrease in revenue since the beginning of the public health emergency.
 

Four options for financial assistance

However, there are ways to offset revenue loss and remain financially viable during the economic uncertainty of the COVID-19 pandemic. Options include the US Small Business Administration’s (SBA) Paycheck Protection Program; the SBA’s Emergency Economic Injury Disaster Loan (EIDL); Medicare’s advanced payment program; and an SBA Coronavirus Economic Stabilization Act (CESA) loan. These are in addition to several other strategies aimed at reducing costs and improving revenue.

1. Maselli, for example, applied for the Paycheck Protection Program, a short-term loan that helps small businesses (i.e., for physician offices, those with an annual revenue of under $12 million) keep staff employed during the COVID-19 crisis. The loan covers a variety of costs, including payroll, rent, utilities, mortgage interest, and interest on any other debt obligations incurred before February 15 of this year.

“We have no idea if this is coming and when, but it would be a big help,” he adds.

(As of press time, the Paycheck Protection Program had stopped accepting applications, having reached the limit of its $349 billion budget. Congress must now agree on legislation to add additional funding to assist small businesses.)

Practices can take out a loan of up to 2.5 times the average monthly payroll (excluding payroll for those making more than $100,000 annually) with a cap of $10 million. For example, if the average monthly payroll is $10,000 – and no employees earn more than $100,000 annually – the maximum loan amount is $25,000.

Practices approved for this loan can expect to receive the funds from their SBA-approved lender within 10 calendar days of the date of loan approval. Although it’s technically a loan, the good news is that it doesn’t need to be repaid if the practice complies with all of the loan requirements – particularly these two: The practice uses at least 75% of the loan specifically for payroll, and the practice keeps employees on the payroll (or rehire, when necessary) for 8 weeks after the loan origination date.

Forgiveness is reduced if full-time headcount declines, or if salaries and wages decrease. If a practice does need to repay all or a portion of the loan, it must do so within 2 years at an interest rate of 1%, and payments are deferred for 6 months.

Andrew D. McDonald, FACHE, practice leader of health care consulting at LBMC Healthcare, says it behooves practices to apply for this loan because it’s essentially free money during a time when revenue may be at an all-time low. “While the devil is in the details, on the surface, the paycheck protection funds appear to be a no-brainer. However, each practice will need to confirm with their lender that it’s a solid decision.”

One challenge with this loan is that some banks weren’t necessarily ready to accept applications on April 3, and many continue to lag behind in processing these applications.

2. A second option is the SBA’s EIDL, a low-interest, long-term loan (capped at 3.75% for small businesses) that practices with 500 or fewer employees can use to pay fixed debts, payrolls, accounts payable, and other bills that could have been paid had the disaster not occurred. Borrowers can ask for up to $2 million, and the maximum term of this loan is 30 years, though the overall process for obtaining these loans will depend on the lender.

Practices have until December 16 to apply for this loan. They can also apply for an expedited disbursement (i.e., an Economic Injury Disaster Advance) of up to $10,000 that’s paid within 3 days of the request.

3. A third option is Medicare’s COVID-19 advanced payment program. Under this program, eligible physicians are those who:

• Billed Medicare for claims within 180 days prior to the date of the request
• Are financially solvent (i.e., aren’t in bankruptcy)
• Are free from any active medical review or program integrity investigations
• Are in good standing with Medicare (i.e., don’t have an outstanding delinquent Medicare overpayment)

If physicians meet this criteria, they can ask their Medicare Administrative Contractor (MAC) to provide an advanced payment of up to 100% of the Medicare payment amount based on a 3-month lookback period.

Once requested, MACs will issue payment within 7 calendar days from the date of the request. Repayment will occur in the form of automatic recoupments beginning 120 days after the advanced payment is received. Medicare has already approved more than 21,000 requests totaling more than $51 billion. CMS has provided a fact sheet to learn more about how to request an accelerated payment.

“The key is that you need to repay this, so you want to set a reasonable goal,” says Sarah Hostetter, senior consultant at Advisory Board, a health care research & data consulting firm. She says practices should consider what they’ll realistically be able to repay within 120 days.

4. A fourth option – specifically for mid-size practices – is a CESA loan, the details of which have yet to be announced, that will enable practices to access funds with an annualized rate no greater than 2% and with no principal or interest due for at least 6 months. The CARES Act, signed into law 3 weeks ago, provides $454 billion for this program.
 

Selecting the right option for your practice

Which singular option – or combination of options – is best for your practice? McDonald says to ask these questions:

• How well are patient volumes holding up?
• How well are physicians pivoting to telehealth?
• What is the overall economic loss?
• What are the available liquid assets, and how long can the practice maintain its financial viability over the next couple of months and beyond?

Cheryl Mongillo, MBA, administrative director of two independent family practices in Delaware, applied for both the Paycheck Protection Program and Medicare advanced payments because she’s worried about being able to pay staff while also covering costs related to personal protective equipment, medical waste, and cleaning, all of which have tripled since the pandemic began. One of the practices includes one physician and four nurse practitioners. The other includes five physicians and three nurse practitioners. In total, both practices employ 35 additional staff.

“I want our staff to know how much we care about them. My hope is that after this is over, our business will pick back up pretty quickly,” she adds. “However, until I can get the business back, I needed something to keep us afloat.”

Others are being more cautious. Crystal Bruning, practice manager at an Ob/Gyn clinic in Orlando, Florida, says her practice applied for the Paycheck Protection Program but is waiting another month or so before deciding whether it will also take advantage of Medicare advanced payments.

The practice is still trying to assess the true financial impact of its 30% reduction in patient volume. Bruning says the advanced payments wouldn’t amount to much anyway because only 10% of the practice’s patients have Medicare.
 

Making tough financial decisions while awaiting assistance

Kansas-based family physician Jennifer Bacani McKenney, MD, says she hasn’t paid herself a salary in weeks because of the revenue loss her practice has incurred.

“I want to make sure we can pay [all 12] employees,” she says. “In my family, we have two incomes, and we’re pretty good at saving money. However, I know not every physician can afford to do this.”

Although McKenney’s practice has seen a 75% reduction in patient volume, staff continue to provide virtual visits – including Zoom-based nursing home visits – phone visits, and in-person visits for acute illnesses. They also provide curbside immunizations. Still, long-term revenue loss is a concern. “I have a threshold in mind based on what we have in reserves,” she says. “If we hit that point, we would need to talk about a loan or Medicare advanced payments.”

Arkansas-based family physician Lonnie S. Robinson, MD, says he immediately applied for the Paycheck Protection Program after it was announced. “We also made sure we had a line of credit with our local bank during the very first discussions about what the pandemic would mean for our revenue streams,” he says.

However, because he’s in a rural area of the state, he continues to struggle with telemedicine due to broadband and connectivity challenges. Cash flow is another challenge because a lot of insurance companies are waiving copayments.

“I didn’t realize the amount of money we collect immediately from the patient,” he says. “This was a substantial revenue stream, and it was immediate revenue – not revenue waiting on a claim to be paid.”

Illinois-based family physician Deborah L. Winiger, MD, says she also applied for the Paycheck Protection Program but in the meantime had to reduce staff hours by a third because her patient volume dropped by more than half. She will also encourage staff to pursue temporary positions at a local hospital if the federal funds don’t materialize.

Kelly Shackleton, practice manager at a New York-based internal medicine practice, says she laid off 7 of her 16 staff members (including lab technicians, licensed practical nurses, billers, a referral specialist, and a file clerk) due to a 70% decrease in patient volume.

“I didn’t lay them all off at once,” she says. “I kept them until things were all caught up in each department. I plan to get them all back when the time is right, but I want to be sure to keep the practice afloat so they have a place to return to.” If the Paycheck Protection Program for which she applied comes through, then she will rehire them. She also applied for Medicare advanced payments and increased the practice’s line of credit.
 

Bill properly – and for everything you are still doing

Accurate and complete coding is critical during this time of financial instability, says Maselli. “I keep telling doctors to bill for everything they do,” he says. This includes phone calls between patients and physicians or other qualified healthcare providers (CPT codes 99441-99443). Note that these are time-based codes, requiring a minimum of five minutes of medical discussion.

Remote physiologic monitoring (including monitoring a patient’s oxygen saturation levels using pulse oximetry), virtual check-ins, and online digital evaluation and management services are also covered by Medicare and some commercial payers.

Other good news is that the Centers for Medicare & Medicaid Services added more than 80 additional services that providers can furnish using telehealth, including new patient office visits, home visits, prolonged office visits, smoking and tobacco cessation counseling, annual depression and alcohol screenings, advanced care planning, and much more.

Mongillo, the family practice administrator in Delaware, agrees that physicians need to bill for as many services as possible. At one of the family medicine practices she manages, physicians perform wellness visits, when appropriate, if patients are already coming into the office for another ailment.

Also look for ways to cut costs. For example, Mongillo was able to renegotiate the practice’s telemedicine contract after she received several proposals from other vendors offering three months of complimentary service. Shackleton discontinued provider dictation services to save money.

Physicians need to take a hard look at what’s going on to help them sustain their business through times of uncertainty, says Advisory Board’s Hostetter. “Now is the time to evaluate options and figure out what’s right for your practice,” she adds.

This article first appeared on Medscape.com.

Family physician Frank Maselli, MD, saw approximately 30 patients a day in his office in the Bronx before COVID-19. But New York City has become a hot spot for the virus that has claimed the lives of the lives of more than 40,000 people nationwide.

Now Maselli and the other 10 physicians in the practice each treat only eight or nine patients a day via telemedicine. He spends most of his time on the phone answering patients’ questions about COVID-19 symptoms and potential exposure. Although he tries to bill for telemedicine and phone calls, he says many commercial payers reject the claims because their processing systems aren’t updated to reflect new coverage policies. He has enough cash in reserve to cover two payrolls, but he knows he needs a backup plan if patient volumes continue to decrease indefinitely.

“Our doctors will take a pay cut before we let people go,” says Maselli. “So far we’re OK because we’re getting paid for things we did two months ago before all of this happened.”

Ninety-seven percent of medical practices have experienced a negative financial impact directly or indirectly related to the COVID-19 pandemic, according to new data from the Medical Group Management Association (MGMA). On average, practices report a 60% decrease in patient volume and a 55% decrease in revenue since the beginning of the public health emergency.
 

Four options for financial assistance

However, there are ways to offset revenue loss and remain financially viable during the economic uncertainty of the COVID-19 pandemic. Options include the US Small Business Administration’s (SBA) Paycheck Protection Program; the SBA’s Emergency Economic Injury Disaster Loan (EIDL); Medicare’s advanced payment program; and an SBA Coronavirus Economic Stabilization Act (CESA) loan. These are in addition to several other strategies aimed at reducing costs and improving revenue.

1. Maselli, for example, applied for the Paycheck Protection Program, a short-term loan that helps small businesses (i.e., for physician offices, those with an annual revenue of under $12 million) keep staff employed during the COVID-19 crisis. The loan covers a variety of costs, including payroll, rent, utilities, mortgage interest, and interest on any other debt obligations incurred before February 15 of this year.

“We have no idea if this is coming and when, but it would be a big help,” he adds.

(As of press time, the Paycheck Protection Program had stopped accepting applications, having reached the limit of its $349 billion budget. Congress must now agree on legislation to add additional funding to assist small businesses.)

Practices can take out a loan of up to 2.5 times the average monthly payroll (excluding payroll for those making more than $100,000 annually) with a cap of $10 million. For example, if the average monthly payroll is $10,000 – and no employees earn more than $100,000 annually – the maximum loan amount is $25,000.

Practices approved for this loan can expect to receive the funds from their SBA-approved lender within 10 calendar days of the date of loan approval. Although it’s technically a loan, the good news is that it doesn’t need to be repaid if the practice complies with all of the loan requirements – particularly these two: The practice uses at least 75% of the loan specifically for payroll, and the practice keeps employees on the payroll (or rehire, when necessary) for 8 weeks after the loan origination date.

Forgiveness is reduced if full-time headcount declines, or if salaries and wages decrease. If a practice does need to repay all or a portion of the loan, it must do so within 2 years at an interest rate of 1%, and payments are deferred for 6 months.

Andrew D. McDonald, FACHE, practice leader of health care consulting at LBMC Healthcare, says it behooves practices to apply for this loan because it’s essentially free money during a time when revenue may be at an all-time low. “While the devil is in the details, on the surface, the paycheck protection funds appear to be a no-brainer. However, each practice will need to confirm with their lender that it’s a solid decision.”

One challenge with this loan is that some banks weren’t necessarily ready to accept applications on April 3, and many continue to lag behind in processing these applications.

2. A second option is the SBA’s EIDL, a low-interest, long-term loan (capped at 3.75% for small businesses) that practices with 500 or fewer employees can use to pay fixed debts, payrolls, accounts payable, and other bills that could have been paid had the disaster not occurred. Borrowers can ask for up to $2 million, and the maximum term of this loan is 30 years, though the overall process for obtaining these loans will depend on the lender.

Practices have until December 16 to apply for this loan. They can also apply for an expedited disbursement (i.e., an Economic Injury Disaster Advance) of up to $10,000 that’s paid within 3 days of the request.

3. A third option is Medicare’s COVID-19 advanced payment program. Under this program, eligible physicians are those who:

• Billed Medicare for claims within 180 days prior to the date of the request
• Are financially solvent (i.e., aren’t in bankruptcy)
• Are free from any active medical review or program integrity investigations
• Are in good standing with Medicare (i.e., don’t have an outstanding delinquent Medicare overpayment)

If physicians meet this criteria, they can ask their Medicare Administrative Contractor (MAC) to provide an advanced payment of up to 100% of the Medicare payment amount based on a 3-month lookback period.

Once requested, MACs will issue payment within 7 calendar days from the date of the request. Repayment will occur in the form of automatic recoupments beginning 120 days after the advanced payment is received. Medicare has already approved more than 21,000 requests totaling more than $51 billion. CMS has provided a fact sheet to learn more about how to request an accelerated payment.

“The key is that you need to repay this, so you want to set a reasonable goal,” says Sarah Hostetter, senior consultant at Advisory Board, a health care research & data consulting firm. She says practices should consider what they’ll realistically be able to repay within 120 days.

4. A fourth option – specifically for mid-size practices – is a CESA loan, the details of which have yet to be announced, that will enable practices to access funds with an annualized rate no greater than 2% and with no principal or interest due for at least 6 months. The CARES Act, signed into law 3 weeks ago, provides $454 billion for this program.
 

Selecting the right option for your practice

Which singular option – or combination of options – is best for your practice? McDonald says to ask these questions:

• How well are patient volumes holding up?
• How well are physicians pivoting to telehealth?
• What is the overall economic loss?
• What are the available liquid assets, and how long can the practice maintain its financial viability over the next couple of months and beyond?

Cheryl Mongillo, MBA, administrative director of two independent family practices in Delaware, applied for both the Paycheck Protection Program and Medicare advanced payments because she’s worried about being able to pay staff while also covering costs related to personal protective equipment, medical waste, and cleaning, all of which have tripled since the pandemic began. One of the practices includes one physician and four nurse practitioners. The other includes five physicians and three nurse practitioners. In total, both practices employ 35 additional staff.

“I want our staff to know how much we care about them. My hope is that after this is over, our business will pick back up pretty quickly,” she adds. “However, until I can get the business back, I needed something to keep us afloat.”

Others are being more cautious. Crystal Bruning, practice manager at an Ob/Gyn clinic in Orlando, Florida, says her practice applied for the Paycheck Protection Program but is waiting another month or so before deciding whether it will also take advantage of Medicare advanced payments.

The practice is still trying to assess the true financial impact of its 30% reduction in patient volume. Bruning says the advanced payments wouldn’t amount to much anyway because only 10% of the practice’s patients have Medicare.
 

Making tough financial decisions while awaiting assistance

Kansas-based family physician Jennifer Bacani McKenney, MD, says she hasn’t paid herself a salary in weeks because of the revenue loss her practice has incurred.

“I want to make sure we can pay [all 12] employees,” she says. “In my family, we have two incomes, and we’re pretty good at saving money. However, I know not every physician can afford to do this.”

Although McKenney’s practice has seen a 75% reduction in patient volume, staff continue to provide virtual visits – including Zoom-based nursing home visits – phone visits, and in-person visits for acute illnesses. They also provide curbside immunizations. Still, long-term revenue loss is a concern. “I have a threshold in mind based on what we have in reserves,” she says. “If we hit that point, we would need to talk about a loan or Medicare advanced payments.”

Arkansas-based family physician Lonnie S. Robinson, MD, says he immediately applied for the Paycheck Protection Program after it was announced. “We also made sure we had a line of credit with our local bank during the very first discussions about what the pandemic would mean for our revenue streams,” he says.

However, because he’s in a rural area of the state, he continues to struggle with telemedicine due to broadband and connectivity challenges. Cash flow is another challenge because a lot of insurance companies are waiving copayments.

“I didn’t realize the amount of money we collect immediately from the patient,” he says. “This was a substantial revenue stream, and it was immediate revenue – not revenue waiting on a claim to be paid.”

Illinois-based family physician Deborah L. Winiger, MD, says she also applied for the Paycheck Protection Program but in the meantime had to reduce staff hours by a third because her patient volume dropped by more than half. She will also encourage staff to pursue temporary positions at a local hospital if the federal funds don’t materialize.

Kelly Shackleton, practice manager at a New York-based internal medicine practice, says she laid off 7 of her 16 staff members (including lab technicians, licensed practical nurses, billers, a referral specialist, and a file clerk) due to a 70% decrease in patient volume.

“I didn’t lay them all off at once,” she says. “I kept them until things were all caught up in each department. I plan to get them all back when the time is right, but I want to be sure to keep the practice afloat so they have a place to return to.” If the Paycheck Protection Program for which she applied comes through, then she will rehire them. She also applied for Medicare advanced payments and increased the practice’s line of credit.
 

Bill properly – and for everything you are still doing

Accurate and complete coding is critical during this time of financial instability, says Maselli. “I keep telling doctors to bill for everything they do,” he says. This includes phone calls between patients and physicians or other qualified healthcare providers (CPT codes 99441-99443). Note that these are time-based codes, requiring a minimum of five minutes of medical discussion.

Remote physiologic monitoring (including monitoring a patient’s oxygen saturation levels using pulse oximetry), virtual check-ins, and online digital evaluation and management services are also covered by Medicare and some commercial payers.

Other good news is that the Centers for Medicare & Medicaid Services added more than 80 additional services that providers can furnish using telehealth, including new patient office visits, home visits, prolonged office visits, smoking and tobacco cessation counseling, annual depression and alcohol screenings, advanced care planning, and much more.

Mongillo, the family practice administrator in Delaware, agrees that physicians need to bill for as many services as possible. At one of the family medicine practices she manages, physicians perform wellness visits, when appropriate, if patients are already coming into the office for another ailment.

Also look for ways to cut costs. For example, Mongillo was able to renegotiate the practice’s telemedicine contract after she received several proposals from other vendors offering three months of complimentary service. Shackleton discontinued provider dictation services to save money.

Physicians need to take a hard look at what’s going on to help them sustain their business through times of uncertainty, says Advisory Board’s Hostetter. “Now is the time to evaluate options and figure out what’s right for your practice,” she adds.

This article first appeared on Medscape.com.

Family physician Frank Maselli, MD, saw approximately 30 patients a day in his office in the Bronx before COVID-19. But New York City has become a hot spot for the virus that has claimed the lives of the lives of more than 40,000 people nationwide.

Now Maselli and the other 10 physicians in the practice each treat only eight or nine patients a day via telemedicine. He spends most of his time on the phone answering patients’ questions about COVID-19 symptoms and potential exposure. Although he tries to bill for telemedicine and phone calls, he says many commercial payers reject the claims because their processing systems aren’t updated to reflect new coverage policies. He has enough cash in reserve to cover two payrolls, but he knows he needs a backup plan if patient volumes continue to decrease indefinitely.

“Our doctors will take a pay cut before we let people go,” says Maselli. “So far we’re OK because we’re getting paid for things we did two months ago before all of this happened.”

Ninety-seven percent of medical practices have experienced a negative financial impact directly or indirectly related to the COVID-19 pandemic, according to new data from the Medical Group Management Association (MGMA). On average, practices report a 60% decrease in patient volume and a 55% decrease in revenue since the beginning of the public health emergency.
 

Four options for financial assistance

However, there are ways to offset revenue loss and remain financially viable during the economic uncertainty of the COVID-19 pandemic. Options include the US Small Business Administration’s (SBA) Paycheck Protection Program; the SBA’s Emergency Economic Injury Disaster Loan (EIDL); Medicare’s advanced payment program; and an SBA Coronavirus Economic Stabilization Act (CESA) loan. These are in addition to several other strategies aimed at reducing costs and improving revenue.

1. Maselli, for example, applied for the Paycheck Protection Program, a short-term loan that helps small businesses (i.e., for physician offices, those with an annual revenue of under $12 million) keep staff employed during the COVID-19 crisis. The loan covers a variety of costs, including payroll, rent, utilities, mortgage interest, and interest on any other debt obligations incurred before February 15 of this year.

“We have no idea if this is coming and when, but it would be a big help,” he adds.

(As of press time, the Paycheck Protection Program had stopped accepting applications, having reached the limit of its $349 billion budget. Congress must now agree on legislation to add additional funding to assist small businesses.)

Practices can take out a loan of up to 2.5 times the average monthly payroll (excluding payroll for those making more than $100,000 annually) with a cap of $10 million. For example, if the average monthly payroll is $10,000 – and no employees earn more than $100,000 annually – the maximum loan amount is $25,000.

Practices approved for this loan can expect to receive the funds from their SBA-approved lender within 10 calendar days of the date of loan approval. Although it’s technically a loan, the good news is that it doesn’t need to be repaid if the practice complies with all of the loan requirements – particularly these two: The practice uses at least 75% of the loan specifically for payroll, and the practice keeps employees on the payroll (or rehire, when necessary) for 8 weeks after the loan origination date.

Forgiveness is reduced if full-time headcount declines, or if salaries and wages decrease. If a practice does need to repay all or a portion of the loan, it must do so within 2 years at an interest rate of 1%, and payments are deferred for 6 months.

Andrew D. McDonald, FACHE, practice leader of health care consulting at LBMC Healthcare, says it behooves practices to apply for this loan because it’s essentially free money during a time when revenue may be at an all-time low. “While the devil is in the details, on the surface, the paycheck protection funds appear to be a no-brainer. However, each practice will need to confirm with their lender that it’s a solid decision.”

One challenge with this loan is that some banks weren’t necessarily ready to accept applications on April 3, and many continue to lag behind in processing these applications.

2. A second option is the SBA’s EIDL, a low-interest, long-term loan (capped at 3.75% for small businesses) that practices with 500 or fewer employees can use to pay fixed debts, payrolls, accounts payable, and other bills that could have been paid had the disaster not occurred. Borrowers can ask for up to $2 million, and the maximum term of this loan is 30 years, though the overall process for obtaining these loans will depend on the lender.

Practices have until December 16 to apply for this loan. They can also apply for an expedited disbursement (i.e., an Economic Injury Disaster Advance) of up to $10,000 that’s paid within 3 days of the request.

3. A third option is Medicare’s COVID-19 advanced payment program. Under this program, eligible physicians are those who:

• Billed Medicare for claims within 180 days prior to the date of the request
• Are financially solvent (i.e., aren’t in bankruptcy)
• Are free from any active medical review or program integrity investigations
• Are in good standing with Medicare (i.e., don’t have an outstanding delinquent Medicare overpayment)

If physicians meet this criteria, they can ask their Medicare Administrative Contractor (MAC) to provide an advanced payment of up to 100% of the Medicare payment amount based on a 3-month lookback period.

Once requested, MACs will issue payment within 7 calendar days from the date of the request. Repayment will occur in the form of automatic recoupments beginning 120 days after the advanced payment is received. Medicare has already approved more than 21,000 requests totaling more than $51 billion. CMS has provided a fact sheet to learn more about how to request an accelerated payment.

“The key is that you need to repay this, so you want to set a reasonable goal,” says Sarah Hostetter, senior consultant at Advisory Board, a health care research & data consulting firm. She says practices should consider what they’ll realistically be able to repay within 120 days.

4. A fourth option – specifically for mid-size practices – is a CESA loan, the details of which have yet to be announced, that will enable practices to access funds with an annualized rate no greater than 2% and with no principal or interest due for at least 6 months. The CARES Act, signed into law 3 weeks ago, provides $454 billion for this program.
 

Selecting the right option for your practice

Which singular option – or combination of options – is best for your practice? McDonald says to ask these questions:

• How well are patient volumes holding up?
• How well are physicians pivoting to telehealth?
• What is the overall economic loss?
• What are the available liquid assets, and how long can the practice maintain its financial viability over the next couple of months and beyond?

Cheryl Mongillo, MBA, administrative director of two independent family practices in Delaware, applied for both the Paycheck Protection Program and Medicare advanced payments because she’s worried about being able to pay staff while also covering costs related to personal protective equipment, medical waste, and cleaning, all of which have tripled since the pandemic began. One of the practices includes one physician and four nurse practitioners. The other includes five physicians and three nurse practitioners. In total, both practices employ 35 additional staff.

“I want our staff to know how much we care about them. My hope is that after this is over, our business will pick back up pretty quickly,” she adds. “However, until I can get the business back, I needed something to keep us afloat.”

Others are being more cautious. Crystal Bruning, practice manager at an Ob/Gyn clinic in Orlando, Florida, says her practice applied for the Paycheck Protection Program but is waiting another month or so before deciding whether it will also take advantage of Medicare advanced payments.

The practice is still trying to assess the true financial impact of its 30% reduction in patient volume. Bruning says the advanced payments wouldn’t amount to much anyway because only 10% of the practice’s patients have Medicare.
 

Making tough financial decisions while awaiting assistance

Kansas-based family physician Jennifer Bacani McKenney, MD, says she hasn’t paid herself a salary in weeks because of the revenue loss her practice has incurred.

“I want to make sure we can pay [all 12] employees,” she says. “In my family, we have two incomes, and we’re pretty good at saving money. However, I know not every physician can afford to do this.”

Although McKenney’s practice has seen a 75% reduction in patient volume, staff continue to provide virtual visits – including Zoom-based nursing home visits – phone visits, and in-person visits for acute illnesses. They also provide curbside immunizations. Still, long-term revenue loss is a concern. “I have a threshold in mind based on what we have in reserves,” she says. “If we hit that point, we would need to talk about a loan or Medicare advanced payments.”

Arkansas-based family physician Lonnie S. Robinson, MD, says he immediately applied for the Paycheck Protection Program after it was announced. “We also made sure we had a line of credit with our local bank during the very first discussions about what the pandemic would mean for our revenue streams,” he says.

However, because he’s in a rural area of the state, he continues to struggle with telemedicine due to broadband and connectivity challenges. Cash flow is another challenge because a lot of insurance companies are waiving copayments.

“I didn’t realize the amount of money we collect immediately from the patient,” he says. “This was a substantial revenue stream, and it was immediate revenue – not revenue waiting on a claim to be paid.”

Illinois-based family physician Deborah L. Winiger, MD, says she also applied for the Paycheck Protection Program but in the meantime had to reduce staff hours by a third because her patient volume dropped by more than half. She will also encourage staff to pursue temporary positions at a local hospital if the federal funds don’t materialize.

Kelly Shackleton, practice manager at a New York-based internal medicine practice, says she laid off 7 of her 16 staff members (including lab technicians, licensed practical nurses, billers, a referral specialist, and a file clerk) due to a 70% decrease in patient volume.

“I didn’t lay them all off at once,” she says. “I kept them until things were all caught up in each department. I plan to get them all back when the time is right, but I want to be sure to keep the practice afloat so they have a place to return to.” If the Paycheck Protection Program for which she applied comes through, then she will rehire them. She also applied for Medicare advanced payments and increased the practice’s line of credit.
 

Bill properly – and for everything you are still doing

Accurate and complete coding is critical during this time of financial instability, says Maselli. “I keep telling doctors to bill for everything they do,” he says. This includes phone calls between patients and physicians or other qualified healthcare providers (CPT codes 99441-99443). Note that these are time-based codes, requiring a minimum of five minutes of medical discussion.

Remote physiologic monitoring (including monitoring a patient’s oxygen saturation levels using pulse oximetry), virtual check-ins, and online digital evaluation and management services are also covered by Medicare and some commercial payers.

Other good news is that the Centers for Medicare & Medicaid Services added more than 80 additional services that providers can furnish using telehealth, including new patient office visits, home visits, prolonged office visits, smoking and tobacco cessation counseling, annual depression and alcohol screenings, advanced care planning, and much more.

Mongillo, the family practice administrator in Delaware, agrees that physicians need to bill for as many services as possible. At one of the family medicine practices she manages, physicians perform wellness visits, when appropriate, if patients are already coming into the office for another ailment.

Also look for ways to cut costs. For example, Mongillo was able to renegotiate the practice’s telemedicine contract after she received several proposals from other vendors offering three months of complimentary service. Shackleton discontinued provider dictation services to save money.

Physicians need to take a hard look at what’s going on to help them sustain their business through times of uncertainty, says Advisory Board’s Hostetter. “Now is the time to evaluate options and figure out what’s right for your practice,” she adds.

This article first appeared on Medscape.com.