Pediatric News

Combination treatment with the poly ADP-ribose polymerase inhibitor, olaparib, and the novel ataxia telangiectasia–mutated Rad3-related (ATR) inhibitor, ceralasertib, was well tolerated and showed some promise in pediatric patients with tumors with DNA replication stress or DNA repair deficiencies, in a new study.

The small phase 1 trial also identified some molecular signatures in responders that may inform future clinical trials.

The results, presented at the annual meeting of the American Association of Cancer Research, came from a single arm of the European Proof-of-Concept Therapeutic Stratification Trial of Molecular Anomalies in Relapsed or Refractory Tumors (ESMART) trial. This trial matches pediatric, adolescent, and young adult cancer patients with treatment regimens based on the molecular profile of their tumors.

In over 220 children to date, the trial has investigated 15 different treatment regimens, most of which are combination therapies.

In adults, poly ADP-ribose polymerase (PARP) inhibitors have been shown to be effective in tumors with deficiencies in homologous repair, which is a DNA repair mechanism, with notable successes in patients carrying the BRCA1 and BRCA2 mutations. But BRCA1 and BRCA2 mutations are rare in pediatric cancer, and there is a belief that there may be primary resistance to PARP inhibitors in pediatric tumors, according to Susanne Gatz, MD, PhD, who presented the research at the meeting.

Previous research identified alterations in pediatric tumors that are candidates for patient selection. “These tumors have alterations which could potentially cause this resistance effect [against PARP inhibitors] and [also cause] sensitivity to ataxia telangiectasia–mutated Rad3-related inhibitors. This is how this arm [of the ESMART trial] was born,” said Dr. Gatz.

The phase 1 portion of the study included 18 pediatric and young adult patients with relapsed or treatment-refractory tumors. There were eight sarcomas, five central nervous system tumors, four neuroblastomas, and one carcinoma. Each had mutations thought to lead to HR deficiency or replication stress. The study included three dose levels of twice-daily oral olaparib that was given continuously, and ceralasertib, which was given day 1-14 of each 28-day cycle.

Patients underwent a median of 3.5 cycles of treatment. There were dose-limiting adverse events of thrombocytopenia and neutropenia in five patients, two of which occurred at the dose that was recommended for phase 2.

There were some positive clinical signs, including one partial response in a pineoblastoma patient who received treatment for 11 cycles. A neuroblastoma patient had stable disease until cycle 9 of treatment, and then converted to a partial response and is currently in cycle 12. Two other patients remain in treatment at cycle 8 and one is in treatment at cycle 15. None of the patients who experienced clinical benefit had BRCA mutations.

An important goal of the study was to understand molecular signature that might predict response to the drug combination. Although no firm conclusions could be drawn, there were some interesting patterns. In particular, five of the six worst responders had TP53 mutations. “It is striking ... so we need to learn what TP53 in this setting means if it’s mutated, and if it could be a resistance factor,” said Dr. Gatz, an associate clinical professor in pediatric oncology at the Institute of Cancer and Genomic Sciences of the University of Birmingham, during her talk.

Although the study is too small and included too many tumor types to identify tumor-based patterns of response, it did provide some hints as to biomarkers that could inform future studies, according to Julia Glade Bender, MD, who served as a discussant following the presentation and is a pediatric oncologist at Memorial Sloan Kettering Cancer Center, New York.

“The pediatric frequency of the common DNA damage repair biomarkers that have been [identified in] the adult literature – that is to say, BRCA1 and 2 and [ataxia-telangiectasia mutation] – are exceedingly rare in pediatrics,” said Dr. Bender during the session while serving as a discussant. She highlighted the following findings: Loss of the 11q region on chromosome 11 is common among the patients and that region contains three genes involved in the DNA damage response, along with a gene involved in homologous recombination, telomere maintenance, and double strand break repair.

She added that 11q deletion is also found in up to 40% of neuroblastomas, and is associated with poor prognosis, and the patients have multiple segmental chromosomal abnormalities. “That begs the question [of] whether chromosomal instability is another biomarker for pediatric cancer,” said Dr. Bender.

“The research highlights the complexity of pediatric cancers, whose distinct biology could make them more vulnerable to ATR [kinase], [checkpoint kinase 1], and WEE1 pathway inhibition with a PARP inhibitor used to induce replication stress and be the sensitizer. The biomarker profiles are going to be complex, context-dependent, and likely to reflect a constellation of findings that would be signatures or algorithms, rather than single gene alterations. The post hoc iterative analysis of responders and nonresponders is going to be absolutely critical to understanding those biomarkers and the role of DNA damage response inhibitors in pediatrics. Given the rarity of these diagnoses, and then the molecular subclasses, I think collaboration across ages and geography is absolutely critical, and I really congratulate the ESMART consortium for doing just that in Europe,” said Dr. Bender.

The study is limited by its small sample size and the fact that it was not randomized.

The study received funding from French Institut National de Cancer, Imagine for Margo, Fondation ARC, AstraZeneca France, AstraZeneca Global R&D, AstraZeneca UK, Cancer Research UK, Fondation Gustave Roussy, and Little Princess Trust/Children’s Cancer and Leukaemia Group. Dr. Gatz has no relevant financial disclosures. Dr. Bender has done paid consulting for Jazz Pharmaceuticals and has done unpaid work for Bristol-Myers Squibb, Eisai, Springworks Therapeutics, Merck Sharp & Dohme, and Pfizer. She has received research support from Eli Lilly, Loxo-oncology, Eisai, Cellectar, Bayer, Amgen, and Jazz Pharmaceuticals.

From American Association for Cancer Research (AACR) Annual Meeting 2023: Abstract CT019. Presented Tuesday, April 18.

Combination treatment with the poly ADP-ribose polymerase inhibitor, olaparib, and the novel ataxia telangiectasia–mutated Rad3-related (ATR) inhibitor, ceralasertib, was well tolerated and showed some promise in pediatric patients with tumors with DNA replication stress or DNA repair deficiencies, in a new study.

The small phase 1 trial also identified some molecular signatures in responders that may inform future clinical trials.

The results, presented at the annual meeting of the American Association of Cancer Research, came from a single arm of the European Proof-of-Concept Therapeutic Stratification Trial of Molecular Anomalies in Relapsed or Refractory Tumors (ESMART) trial. This trial matches pediatric, adolescent, and young adult cancer patients with treatment regimens based on the molecular profile of their tumors.

In over 220 children to date, the trial has investigated 15 different treatment regimens, most of which are combination therapies.

In adults, poly ADP-ribose polymerase (PARP) inhibitors have been shown to be effective in tumors with deficiencies in homologous repair, which is a DNA repair mechanism, with notable successes in patients carrying the BRCA1 and BRCA2 mutations. But BRCA1 and BRCA2 mutations are rare in pediatric cancer, and there is a belief that there may be primary resistance to PARP inhibitors in pediatric tumors, according to Susanne Gatz, MD, PhD, who presented the research at the meeting.

Previous research identified alterations in pediatric tumors that are candidates for patient selection. “These tumors have alterations which could potentially cause this resistance effect [against PARP inhibitors] and [also cause] sensitivity to ataxia telangiectasia–mutated Rad3-related inhibitors. This is how this arm [of the ESMART trial] was born,” said Dr. Gatz.

The phase 1 portion of the study included 18 pediatric and young adult patients with relapsed or treatment-refractory tumors. There were eight sarcomas, five central nervous system tumors, four neuroblastomas, and one carcinoma. Each had mutations thought to lead to HR deficiency or replication stress. The study included three dose levels of twice-daily oral olaparib that was given continuously, and ceralasertib, which was given day 1-14 of each 28-day cycle.

Patients underwent a median of 3.5 cycles of treatment. There were dose-limiting adverse events of thrombocytopenia and neutropenia in five patients, two of which occurred at the dose that was recommended for phase 2.

There were some positive clinical signs, including one partial response in a pineoblastoma patient who received treatment for 11 cycles. A neuroblastoma patient had stable disease until cycle 9 of treatment, and then converted to a partial response and is currently in cycle 12. Two other patients remain in treatment at cycle 8 and one is in treatment at cycle 15. None of the patients who experienced clinical benefit had BRCA mutations.

An important goal of the study was to understand molecular signature that might predict response to the drug combination. Although no firm conclusions could be drawn, there were some interesting patterns. In particular, five of the six worst responders had TP53 mutations. “It is striking ... so we need to learn what TP53 in this setting means if it’s mutated, and if it could be a resistance factor,” said Dr. Gatz, an associate clinical professor in pediatric oncology at the Institute of Cancer and Genomic Sciences of the University of Birmingham, during her talk.

Although the study is too small and included too many tumor types to identify tumor-based patterns of response, it did provide some hints as to biomarkers that could inform future studies, according to Julia Glade Bender, MD, who served as a discussant following the presentation and is a pediatric oncologist at Memorial Sloan Kettering Cancer Center, New York.

“The pediatric frequency of the common DNA damage repair biomarkers that have been [identified in] the adult literature – that is to say, BRCA1 and 2 and [ataxia-telangiectasia mutation] – are exceedingly rare in pediatrics,” said Dr. Bender during the session while serving as a discussant. She highlighted the following findings: Loss of the 11q region on chromosome 11 is common among the patients and that region contains three genes involved in the DNA damage response, along with a gene involved in homologous recombination, telomere maintenance, and double strand break repair.

She added that 11q deletion is also found in up to 40% of neuroblastomas, and is associated with poor prognosis, and the patients have multiple segmental chromosomal abnormalities. “That begs the question [of] whether chromosomal instability is another biomarker for pediatric cancer,” said Dr. Bender.

“The research highlights the complexity of pediatric cancers, whose distinct biology could make them more vulnerable to ATR [kinase], [checkpoint kinase 1], and WEE1 pathway inhibition with a PARP inhibitor used to induce replication stress and be the sensitizer. The biomarker profiles are going to be complex, context-dependent, and likely to reflect a constellation of findings that would be signatures or algorithms, rather than single gene alterations. The post hoc iterative analysis of responders and nonresponders is going to be absolutely critical to understanding those biomarkers and the role of DNA damage response inhibitors in pediatrics. Given the rarity of these diagnoses, and then the molecular subclasses, I think collaboration across ages and geography is absolutely critical, and I really congratulate the ESMART consortium for doing just that in Europe,” said Dr. Bender.

The study is limited by its small sample size and the fact that it was not randomized.

The study received funding from French Institut National de Cancer, Imagine for Margo, Fondation ARC, AstraZeneca France, AstraZeneca Global R&D, AstraZeneca UK, Cancer Research UK, Fondation Gustave Roussy, and Little Princess Trust/Children’s Cancer and Leukaemia Group. Dr. Gatz has no relevant financial disclosures. Dr. Bender has done paid consulting for Jazz Pharmaceuticals and has done unpaid work for Bristol-Myers Squibb, Eisai, Springworks Therapeutics, Merck Sharp & Dohme, and Pfizer. She has received research support from Eli Lilly, Loxo-oncology, Eisai, Cellectar, Bayer, Amgen, and Jazz Pharmaceuticals.

From American Association for Cancer Research (AACR) Annual Meeting 2023: Abstract CT019. Presented Tuesday, April 18.

Combination treatment with the poly ADP-ribose polymerase inhibitor, olaparib, and the novel ataxia telangiectasia–mutated Rad3-related (ATR) inhibitor, ceralasertib, was well tolerated and showed some promise in pediatric patients with tumors with DNA replication stress or DNA repair deficiencies, in a new study.

The small phase 1 trial also identified some molecular signatures in responders that may inform future clinical trials.

The results, presented at the annual meeting of the American Association of Cancer Research, came from a single arm of the European Proof-of-Concept Therapeutic Stratification Trial of Molecular Anomalies in Relapsed or Refractory Tumors (ESMART) trial. This trial matches pediatric, adolescent, and young adult cancer patients with treatment regimens based on the molecular profile of their tumors.

In over 220 children to date, the trial has investigated 15 different treatment regimens, most of which are combination therapies.

In adults, poly ADP-ribose polymerase (PARP) inhibitors have been shown to be effective in tumors with deficiencies in homologous repair, which is a DNA repair mechanism, with notable successes in patients carrying the BRCA1 and BRCA2 mutations. But BRCA1 and BRCA2 mutations are rare in pediatric cancer, and there is a belief that there may be primary resistance to PARP inhibitors in pediatric tumors, according to Susanne Gatz, MD, PhD, who presented the research at the meeting.

Previous research identified alterations in pediatric tumors that are candidates for patient selection. “These tumors have alterations which could potentially cause this resistance effect [against PARP inhibitors] and [also cause] sensitivity to ataxia telangiectasia–mutated Rad3-related inhibitors. This is how this arm [of the ESMART trial] was born,” said Dr. Gatz.

The phase 1 portion of the study included 18 pediatric and young adult patients with relapsed or treatment-refractory tumors. There were eight sarcomas, five central nervous system tumors, four neuroblastomas, and one carcinoma. Each had mutations thought to lead to HR deficiency or replication stress. The study included three dose levels of twice-daily oral olaparib that was given continuously, and ceralasertib, which was given day 1-14 of each 28-day cycle.

Patients underwent a median of 3.5 cycles of treatment. There were dose-limiting adverse events of thrombocytopenia and neutropenia in five patients, two of which occurred at the dose that was recommended for phase 2.

There were some positive clinical signs, including one partial response in a pineoblastoma patient who received treatment for 11 cycles. A neuroblastoma patient had stable disease until cycle 9 of treatment, and then converted to a partial response and is currently in cycle 12. Two other patients remain in treatment at cycle 8 and one is in treatment at cycle 15. None of the patients who experienced clinical benefit had BRCA mutations.

An important goal of the study was to understand molecular signature that might predict response to the drug combination. Although no firm conclusions could be drawn, there were some interesting patterns. In particular, five of the six worst responders had TP53 mutations. “It is striking ... so we need to learn what TP53 in this setting means if it’s mutated, and if it could be a resistance factor,” said Dr. Gatz, an associate clinical professor in pediatric oncology at the Institute of Cancer and Genomic Sciences of the University of Birmingham, during her talk.

Although the study is too small and included too many tumor types to identify tumor-based patterns of response, it did provide some hints as to biomarkers that could inform future studies, according to Julia Glade Bender, MD, who served as a discussant following the presentation and is a pediatric oncologist at Memorial Sloan Kettering Cancer Center, New York.

“The pediatric frequency of the common DNA damage repair biomarkers that have been [identified in] the adult literature – that is to say, BRCA1 and 2 and [ataxia-telangiectasia mutation] – are exceedingly rare in pediatrics,” said Dr. Bender during the session while serving as a discussant. She highlighted the following findings: Loss of the 11q region on chromosome 11 is common among the patients and that region contains three genes involved in the DNA damage response, along with a gene involved in homologous recombination, telomere maintenance, and double strand break repair.

She added that 11q deletion is also found in up to 40% of neuroblastomas, and is associated with poor prognosis, and the patients have multiple segmental chromosomal abnormalities. “That begs the question [of] whether chromosomal instability is another biomarker for pediatric cancer,” said Dr. Bender.

“The research highlights the complexity of pediatric cancers, whose distinct biology could make them more vulnerable to ATR [kinase], [checkpoint kinase 1], and WEE1 pathway inhibition with a PARP inhibitor used to induce replication stress and be the sensitizer. The biomarker profiles are going to be complex, context-dependent, and likely to reflect a constellation of findings that would be signatures or algorithms, rather than single gene alterations. The post hoc iterative analysis of responders and nonresponders is going to be absolutely critical to understanding those biomarkers and the role of DNA damage response inhibitors in pediatrics. Given the rarity of these diagnoses, and then the molecular subclasses, I think collaboration across ages and geography is absolutely critical, and I really congratulate the ESMART consortium for doing just that in Europe,” said Dr. Bender.

The study is limited by its small sample size and the fact that it was not randomized.

The study received funding from French Institut National de Cancer, Imagine for Margo, Fondation ARC, AstraZeneca France, AstraZeneca Global R&D, AstraZeneca UK, Cancer Research UK, Fondation Gustave Roussy, and Little Princess Trust/Children’s Cancer and Leukaemia Group. Dr. Gatz has no relevant financial disclosures. Dr. Bender has done paid consulting for Jazz Pharmaceuticals and has done unpaid work for Bristol-Myers Squibb, Eisai, Springworks Therapeutics, Merck Sharp & Dohme, and Pfizer. She has received research support from Eli Lilly, Loxo-oncology, Eisai, Cellectar, Bayer, Amgen, and Jazz Pharmaceuticals.

From American Association for Cancer Research (AACR) Annual Meeting 2023: Abstract CT019. Presented Tuesday, April 18.

When most families hear the word rabies, they envision a dog foaming at the mouth and think about receiving multiple painful, often intra-abdominal injections. However, the epidemiology of rabies has changed in the United States. Postexposure prophylaxis (PEP) may not always be indicated and for certain persons preexposure prophylaxis (PrEP) is available and recommended.

Rabies is a Lyssavirus that is transmitted through saliva most often from the bite or scratch of an infected animal. Sometimes it’s via direct contact with mucous membranes. Although rare, cases have been described in which an undiagnosed donor passed the virus via transplant to recipients and four cases of aerosolized transmission were documented in two spelunkers and two laboratory technicians working with the virus. Worldwide it’s estimated that rabies causes 59,000 deaths annually.

CDC

Most cases (98%) are secondary to canine rabies. Prior to 1960, dogs were the major reservoir in the United States; however, after introduction of leash laws and animal vaccination in 1947, there was a drastic decline in cases caused by the canine rabies virus variant (CRVV). By 2004, CRVV was eliminated in the United States.

However, the proportion of strains associated with wildlife including raccoons, skunks, foxes, bats, coyotes, and mongoose now account for most of the cases in humans. Wildlife rabies is found in all states except Hawaii. Between 1960 and 2018, 89 cases were acquired in the United States and 62 (70%) were from bat exposure. Dog bites acquired during international travel were the cause of 36 cases.

Once signs and symptoms of disease develop there is no treatment. Regardless of the species variant, rabies virus infection is fatal in over 99% of cases. However, disease can be prevented with prompt initiation of PEP, which includes administration of rabies immune globulin (RIG) and rabies vaccine. Let’s look at a few different scenarios.

1. A delivery person is bitten by your neighbor’s dog while making a delivery. He was told to get rabies vaccine. What should we advise?

Canine rabies has been eliminated in the United States. However, unvaccinated canines can acquire rabies from wildlife. In this situation, you can determine the immunization status of the dog. Contact your local/state health department to assist with enforcement and management. Bites by cats and ferrets should be managed similarly.

Healthy dog:

1. Observe for 10 days.

2. PEP is not indicated unless the animal develops signs/symptoms of rabies. Then euthanize and begin PEP.

Dog appears rabid or suspected to be rabid:

1. Begin PEP.

2. Animal should be euthanized. If immunofluorescent test is negative discontinue PEP.

Dog unavailable:

Contact local/state health department. They are more familiar with rabies surveillance data.

2. Patient relocating to Malaysia for 3-4 years. Rabies PrEP was recommended but the family wants your opinion before receiving the vaccine. What would you advise?

Canine rabies is felt to be the primary cause of rabies outside of the United States. Canines are not routinely vaccinated in many foreign destinations, and the availability of RIG and rabies vaccine is not guaranteed in developing countries. As noted above, dog bites during international travel accounted for 28% of U.S. cases between 1960 and 2018.

In May 2022 recommendations for a modified two-dose PrEP schedule was published that identifies five risk groups and includes specific timing for checking rabies titers. The third rabies dose can now be administered up until year 3 (Morb Mortal Wkly Rep. 2022 May 6;71[18]:619-27). For individuals relocating to countries where CRVV is present, I prefer the traditional three-dose PrEP schedule administered between 21 and 28 days. However, we now have options. If exposure occurs any time after completion of a three-dose PrEP series or within 3 years after completion of a two-dose PrEP series, RIG would not be required. All patients would receive two doses of rabies vaccine (days 0, 3). If exposure occurs after 3 years in a person who received two doses of PrEP who did not have documentation of a protective rabies titer (> 5 IU/mL), treatment will include RIG plus four doses of vaccine (days 0, 3, 7, 14).

For this relocating patient, supporting PrEP would be strongly recommended.

3. A mother tells you she sees bats flying around her home at night and a few have even gotten into the home. This morning she saw one in her child’s room. He was still sleeping. Is there anything she needs to do?

Bats have become the predominant source of rabies in the United States. In addition to the cases noted above, three fatal cases occurred between Sept. 28 and Nov. 10, 2021, after bat exposures in August 2021 (MMWR Morb Mortal Wkly Rep. 2022 Jan 7;71:31-2). All had recognized contact with a bat 3-7 weeks prior to onset of symptoms and died 2-3 weeks after symptom onset. One declined PEP and the other two did not realize the risk for rabies from their exposure or did not notice a scratch or bite. Bites from bats may be small and unnoticed. Exposure to a bat in a closed room while sleeping is considered an exposure. Hawaii is the only state not reporting rabid bats.

PEP is recommended for her child. She should identify potential areas bats may enter the home and seal them in addition to removal of any bat roosts.

4. A parent realizes a house guest has been feeding raccoons in the backyard. What’s your response?

While bat rabies is the predominant variant associated with disease in the United States, as illustrated in Figure 1, other species of wildlife including raccoons are a major source of rabies. The geographic spread of the raccoon variant of rabies has been limited by oral vaccination via bait. In the situation noted here, the raccoons have returned because food was being offered thus increasing the families chance of a potential rabies exposure. Wildlife including skunks, raccoons, coyotes, foxes, and mongooses are always considered rabid until proven negative by laboratory testing.

CDC

You recommend to stop feeding wildlife and never to approach them. Have them contact the local rabies control unit and/or state wildlife services to assist with removal of the raccoons. Depending on the locale, pest control may be required at the owners expense. Inform the family to seek PEP if anyone is bitten or scratched by the raccoons.

As per the Centers for Disease Control and Prevention, about 55,000 residents receive PEP annually with health-associated expenditures including diagnostics, prevention, and control estimated between $245 and $510 million annually. Rabies is one of the most fatal diseases that can be prevented by avoiding contact with wild animals, maintenance of high immunization rates in pets, and keeping people informed of potential sources including bats. One can’t determine if an animal has rabies by looking at it. Rabies remains an urgent disease that we have to remember to address with our patients and their families. For additional information go to www.CDC.gov/rabies.

Dr. Word is a pediatric infectious disease specialist and director of the Houston Travel Medicine Clinic. She has no relevant financial disclosures.

When most families hear the word rabies, they envision a dog foaming at the mouth and think about receiving multiple painful, often intra-abdominal injections. However, the epidemiology of rabies has changed in the United States. Postexposure prophylaxis (PEP) may not always be indicated and for certain persons preexposure prophylaxis (PrEP) is available and recommended.

Rabies is a Lyssavirus that is transmitted through saliva most often from the bite or scratch of an infected animal. Sometimes it’s via direct contact with mucous membranes. Although rare, cases have been described in which an undiagnosed donor passed the virus via transplant to recipients and four cases of aerosolized transmission were documented in two spelunkers and two laboratory technicians working with the virus. Worldwide it’s estimated that rabies causes 59,000 deaths annually.

CDC

Most cases (98%) are secondary to canine rabies. Prior to 1960, dogs were the major reservoir in the United States; however, after introduction of leash laws and animal vaccination in 1947, there was a drastic decline in cases caused by the canine rabies virus variant (CRVV). By 2004, CRVV was eliminated in the United States.

However, the proportion of strains associated with wildlife including raccoons, skunks, foxes, bats, coyotes, and mongoose now account for most of the cases in humans. Wildlife rabies is found in all states except Hawaii. Between 1960 and 2018, 89 cases were acquired in the United States and 62 (70%) were from bat exposure. Dog bites acquired during international travel were the cause of 36 cases.

Once signs and symptoms of disease develop there is no treatment. Regardless of the species variant, rabies virus infection is fatal in over 99% of cases. However, disease can be prevented with prompt initiation of PEP, which includes administration of rabies immune globulin (RIG) and rabies vaccine. Let’s look at a few different scenarios.

1. A delivery person is bitten by your neighbor’s dog while making a delivery. He was told to get rabies vaccine. What should we advise?

Canine rabies has been eliminated in the United States. However, unvaccinated canines can acquire rabies from wildlife. In this situation, you can determine the immunization status of the dog. Contact your local/state health department to assist with enforcement and management. Bites by cats and ferrets should be managed similarly.

Healthy dog:

1. Observe for 10 days.

2. PEP is not indicated unless the animal develops signs/symptoms of rabies. Then euthanize and begin PEP.

Dog appears rabid or suspected to be rabid:

1. Begin PEP.

2. Animal should be euthanized. If immunofluorescent test is negative discontinue PEP.

Dog unavailable:

Contact local/state health department. They are more familiar with rabies surveillance data.

2. Patient relocating to Malaysia for 3-4 years. Rabies PrEP was recommended but the family wants your opinion before receiving the vaccine. What would you advise?

Canine rabies is felt to be the primary cause of rabies outside of the United States. Canines are not routinely vaccinated in many foreign destinations, and the availability of RIG and rabies vaccine is not guaranteed in developing countries. As noted above, dog bites during international travel accounted for 28% of U.S. cases between 1960 and 2018.

In May 2022 recommendations for a modified two-dose PrEP schedule was published that identifies five risk groups and includes specific timing for checking rabies titers. The third rabies dose can now be administered up until year 3 (Morb Mortal Wkly Rep. 2022 May 6;71[18]:619-27). For individuals relocating to countries where CRVV is present, I prefer the traditional three-dose PrEP schedule administered between 21 and 28 days. However, we now have options. If exposure occurs any time after completion of a three-dose PrEP series or within 3 years after completion of a two-dose PrEP series, RIG would not be required. All patients would receive two doses of rabies vaccine (days 0, 3). If exposure occurs after 3 years in a person who received two doses of PrEP who did not have documentation of a protective rabies titer (> 5 IU/mL), treatment will include RIG plus four doses of vaccine (days 0, 3, 7, 14).

For this relocating patient, supporting PrEP would be strongly recommended.

3. A mother tells you she sees bats flying around her home at night and a few have even gotten into the home. This morning she saw one in her child’s room. He was still sleeping. Is there anything she needs to do?

Bats have become the predominant source of rabies in the United States. In addition to the cases noted above, three fatal cases occurred between Sept. 28 and Nov. 10, 2021, after bat exposures in August 2021 (MMWR Morb Mortal Wkly Rep. 2022 Jan 7;71:31-2). All had recognized contact with a bat 3-7 weeks prior to onset of symptoms and died 2-3 weeks after symptom onset. One declined PEP and the other two did not realize the risk for rabies from their exposure or did not notice a scratch or bite. Bites from bats may be small and unnoticed. Exposure to a bat in a closed room while sleeping is considered an exposure. Hawaii is the only state not reporting rabid bats.

PEP is recommended for her child. She should identify potential areas bats may enter the home and seal them in addition to removal of any bat roosts.

4. A parent realizes a house guest has been feeding raccoons in the backyard. What’s your response?

While bat rabies is the predominant variant associated with disease in the United States, as illustrated in Figure 1, other species of wildlife including raccoons are a major source of rabies. The geographic spread of the raccoon variant of rabies has been limited by oral vaccination via bait. In the situation noted here, the raccoons have returned because food was being offered thus increasing the families chance of a potential rabies exposure. Wildlife including skunks, raccoons, coyotes, foxes, and mongooses are always considered rabid until proven negative by laboratory testing.

CDC

You recommend to stop feeding wildlife and never to approach them. Have them contact the local rabies control unit and/or state wildlife services to assist with removal of the raccoons. Depending on the locale, pest control may be required at the owners expense. Inform the family to seek PEP if anyone is bitten or scratched by the raccoons.

As per the Centers for Disease Control and Prevention, about 55,000 residents receive PEP annually with health-associated expenditures including diagnostics, prevention, and control estimated between $245 and $510 million annually. Rabies is one of the most fatal diseases that can be prevented by avoiding contact with wild animals, maintenance of high immunization rates in pets, and keeping people informed of potential sources including bats. One can’t determine if an animal has rabies by looking at it. Rabies remains an urgent disease that we have to remember to address with our patients and their families. For additional information go to www.CDC.gov/rabies.

Dr. Word is a pediatric infectious disease specialist and director of the Houston Travel Medicine Clinic. She has no relevant financial disclosures.

When most families hear the word rabies, they envision a dog foaming at the mouth and think about receiving multiple painful, often intra-abdominal injections. However, the epidemiology of rabies has changed in the United States. Postexposure prophylaxis (PEP) may not always be indicated and for certain persons preexposure prophylaxis (PrEP) is available and recommended.

Rabies is a Lyssavirus that is transmitted through saliva most often from the bite or scratch of an infected animal. Sometimes it’s via direct contact with mucous membranes. Although rare, cases have been described in which an undiagnosed donor passed the virus via transplant to recipients and four cases of aerosolized transmission were documented in two spelunkers and two laboratory technicians working with the virus. Worldwide it’s estimated that rabies causes 59,000 deaths annually.

CDC

Most cases (98%) are secondary to canine rabies. Prior to 1960, dogs were the major reservoir in the United States; however, after introduction of leash laws and animal vaccination in 1947, there was a drastic decline in cases caused by the canine rabies virus variant (CRVV). By 2004, CRVV was eliminated in the United States.

However, the proportion of strains associated with wildlife including raccoons, skunks, foxes, bats, coyotes, and mongoose now account for most of the cases in humans. Wildlife rabies is found in all states except Hawaii. Between 1960 and 2018, 89 cases were acquired in the United States and 62 (70%) were from bat exposure. Dog bites acquired during international travel were the cause of 36 cases.

Once signs and symptoms of disease develop there is no treatment. Regardless of the species variant, rabies virus infection is fatal in over 99% of cases. However, disease can be prevented with prompt initiation of PEP, which includes administration of rabies immune globulin (RIG) and rabies vaccine. Let’s look at a few different scenarios.

1. A delivery person is bitten by your neighbor’s dog while making a delivery. He was told to get rabies vaccine. What should we advise?

Canine rabies has been eliminated in the United States. However, unvaccinated canines can acquire rabies from wildlife. In this situation, you can determine the immunization status of the dog. Contact your local/state health department to assist with enforcement and management. Bites by cats and ferrets should be managed similarly.

Healthy dog:

1. Observe for 10 days.

2. PEP is not indicated unless the animal develops signs/symptoms of rabies. Then euthanize and begin PEP.

Dog appears rabid or suspected to be rabid:

1. Begin PEP.

2. Animal should be euthanized. If immunofluorescent test is negative discontinue PEP.

Dog unavailable:

Contact local/state health department. They are more familiar with rabies surveillance data.

2. Patient relocating to Malaysia for 3-4 years. Rabies PrEP was recommended but the family wants your opinion before receiving the vaccine. What would you advise?

Canine rabies is felt to be the primary cause of rabies outside of the United States. Canines are not routinely vaccinated in many foreign destinations, and the availability of RIG and rabies vaccine is not guaranteed in developing countries. As noted above, dog bites during international travel accounted for 28% of U.S. cases between 1960 and 2018.

In May 2022 recommendations for a modified two-dose PrEP schedule was published that identifies five risk groups and includes specific timing for checking rabies titers. The third rabies dose can now be administered up until year 3 (Morb Mortal Wkly Rep. 2022 May 6;71[18]:619-27). For individuals relocating to countries where CRVV is present, I prefer the traditional three-dose PrEP schedule administered between 21 and 28 days. However, we now have options. If exposure occurs any time after completion of a three-dose PrEP series or within 3 years after completion of a two-dose PrEP series, RIG would not be required. All patients would receive two doses of rabies vaccine (days 0, 3). If exposure occurs after 3 years in a person who received two doses of PrEP who did not have documentation of a protective rabies titer (> 5 IU/mL), treatment will include RIG plus four doses of vaccine (days 0, 3, 7, 14).

For this relocating patient, supporting PrEP would be strongly recommended.

3. A mother tells you she sees bats flying around her home at night and a few have even gotten into the home. This morning she saw one in her child’s room. He was still sleeping. Is there anything she needs to do?

Bats have become the predominant source of rabies in the United States. In addition to the cases noted above, three fatal cases occurred between Sept. 28 and Nov. 10, 2021, after bat exposures in August 2021 (MMWR Morb Mortal Wkly Rep. 2022 Jan 7;71:31-2). All had recognized contact with a bat 3-7 weeks prior to onset of symptoms and died 2-3 weeks after symptom onset. One declined PEP and the other two did not realize the risk for rabies from their exposure or did not notice a scratch or bite. Bites from bats may be small and unnoticed. Exposure to a bat in a closed room while sleeping is considered an exposure. Hawaii is the only state not reporting rabid bats.

PEP is recommended for her child. She should identify potential areas bats may enter the home and seal them in addition to removal of any bat roosts.

4. A parent realizes a house guest has been feeding raccoons in the backyard. What’s your response?

While bat rabies is the predominant variant associated with disease in the United States, as illustrated in Figure 1, other species of wildlife including raccoons are a major source of rabies. The geographic spread of the raccoon variant of rabies has been limited by oral vaccination via bait. In the situation noted here, the raccoons have returned because food was being offered thus increasing the families chance of a potential rabies exposure. Wildlife including skunks, raccoons, coyotes, foxes, and mongooses are always considered rabid until proven negative by laboratory testing.

CDC

You recommend to stop feeding wildlife and never to approach them. Have them contact the local rabies control unit and/or state wildlife services to assist with removal of the raccoons. Depending on the locale, pest control may be required at the owners expense. Inform the family to seek PEP if anyone is bitten or scratched by the raccoons.

As per the Centers for Disease Control and Prevention, about 55,000 residents receive PEP annually with health-associated expenditures including diagnostics, prevention, and control estimated between $245 and $510 million annually. Rabies is one of the most fatal diseases that can be prevented by avoiding contact with wild animals, maintenance of high immunization rates in pets, and keeping people informed of potential sources including bats. One can’t determine if an animal has rabies by looking at it. Rabies remains an urgent disease that we have to remember to address with our patients and their families. For additional information go to www.CDC.gov/rabies.

Dr. Word is a pediatric infectious disease specialist and director of the Houston Travel Medicine Clinic. She has no relevant financial disclosures.

The double whammy of pandemic burnout and the aging of baby boomer physicians has, indeed, the makings of some scary headlines. A recent survey by Elsevier Health predicts that up to 75% of health care workers will leave the profession by 2025. And a 2020 study conducted by the Association of American Medical Colleges (AAMC) projected a shortfall of up to 139,000 physicians by 2033.

“We’ve paid a lot of attention to physician retirement,” says Michael Dill, AAMC’s director of workforce studies. “It’s a significant concern in terms of whether we have an adequate supply of physicians in the U.S. to meet our nation’s medical care needs. Anyone who thinks otherwise is incorrect.”

To Mr. Dill, it’s the number of older physicians – in all specialties – ready to retire that should be the biggest concern for hospitals all across the country.

“The physician workforce as a whole is aging,” he said. “Close to a quarter of the physicians in the U.S. are 65 and over. So, you don’t need any extraordinary events driving retirement in order for retirement to be a real phenomenon of which we should all be concerned.”

And, although Mr. Dill said there aren’t any data to suggest that doctors in rural or urban areas are retiring faster than in the suburbs, that doesn’t mean retirement will have the same impact depending on where patients live.

“If you live in a rural area with one small practice in town and that physician retires, there goes the entirety of the physician supply,” he said. “In a major metro area, that’s not as big a deal.”
 

Why younger doctors are fast-tracking retirement

Fernando Mendoza, MD, 54, a pediatric emergency department physician in Miami, worries that physicians are getting so bogged down by paperwork that this may lead to even more doctors, at younger ages, leaving the profession.

“I love taking care of kids, but there’s going to be a cost to doing your work when you’re spending as much time as we need to spend on charts, pharmacy requests, and making sure all of the Medicare and Medicaid compliance issues are worked out.”

These stressors may compel some younger doctors to consider carving out a second career or fast-track younger physicians toward retirement.

“A medical degree carries a lot of weight, which helps when pivoting,” said Dr. Mendoza, who launched Scrivas, a Miami-based medical scribe agency, to help reduce the paperwork workload for physicians. “It might be that a doctor wants to get involved in the acquisition of medical equipment, or maybe they can focus on their investments. Either way, by leaving medicine, they’re not dealing with the hassle and churn-and-burn of seeing patients.”
 

What this means for patients

The time is now to stem the upcoming tide of retirement, said Mr. Dill. But the challenges remain daunting. For starters, the country needs more physicians trained now – but it will take years to replace those baby boomer doctors ready to hang up their white coats.

The medical profession also needs to find ways to support physicians who spend their days juggling an endless array of responsibilities, he said.

The AAMC study found that patients already feel the physician shortfall. Their public opinion research in 2019 said 35% of patients had trouble finding a physician over the past 2 or 3 years, up 10 percentage points since they asked the question in 2015.

Moreover, according to the report, the over-65 population is expected to grow by 45.1%, leaving a specialty care gap because older people generally have more complicated health cases that require specialists. In addition, physician burnout may lead more physicians under 65 to retire much earlier than expected.

Changes in how medicine is practiced, telemedicine care, and medical education – such as disruption of classes or clinical rotations, regulatory changes, and a lack of interest in certain specialties – could also be affected by a mass physician retirement.
 

What can we do about mass retirement?

The AAMC reports in “The Complexities of Physician Supply and Demand: Projections From 2019 to 2034” that federally funded GME support is in the works to train 15,000 physicians per year, with 3,000 new residency slots added per year over 5 years. The proposed model will add 3,750 new physicians each year beginning in 2026.

Other efforts include increasing use of APRNs and PAs, whose population is estimated to more than double by 2034, improve population health through preventive care, increase equity in health outcomes, and improve access and affordable care.

Removing licensing barriers for immigrant doctors can also help alleviate the shortage.

“We need to find better ways to leverage the entirety of the health care team so that not as much falls on physicians,” Mr. Dill said. “It’s also imperative that we focus on ways to support physician wellness and allow physicians to remain active in the field, but at a reduced rate.”

That’s precisely what Marie Brown, MD, director of practice redesign at the American Medical Association, is seeing nationwide. Cutting back their hours is not only trending, but it’s also helping doctors cope with burnout.

“We’re seeing physicians take a 20% or more cut in salary in order to decrease their burden,” she said. “They’ll spend 4 days on clinical time with patients so that on that fifth ‘day off,’ they’re doing the paperwork and documentation they need to do so they don’t compromise care on the other 4 days of the week.”

And this may only be a Band-Aid solution, she fears.

“If a physician is spending 3 hours a day doing unnecessary work that could be done by another team member, that’s contributing to burnout,” Dr. Brown said. “It’s no surprise that they’ll want to escape and retire if they’re in a financial situation to do so.”

“I advocate negotiating within your organization so you’re doing more of what you like, such as mentoring or running a residency, and less of what you don’t, while cutting back from full-time to something less than full-time while maintaining benefits,” said Joel Greenwald, MD, a certified financial planner in Minneapolis, who specializes in helping physicians manage their financial affairs.

“Falling into the ‘like less’ bucket are usually things like working weekends and taking calls,” he said.

“This benefits everyone on a large scale because those doctors who find things they enjoy are generally working to a later age but working less hard,” he said. “Remaining comfortably and happily gainfully employed for a longer period, even if you’re not working full-time, has a very powerful effect on your financial planning, and you’ll avoid the risk of running out of money.”
 

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

The double whammy of pandemic burnout and the aging of baby boomer physicians has, indeed, the makings of some scary headlines. A recent survey by Elsevier Health predicts that up to 75% of health care workers will leave the profession by 2025. And a 2020 study conducted by the Association of American Medical Colleges (AAMC) projected a shortfall of up to 139,000 physicians by 2033.

“We’ve paid a lot of attention to physician retirement,” says Michael Dill, AAMC’s director of workforce studies. “It’s a significant concern in terms of whether we have an adequate supply of physicians in the U.S. to meet our nation’s medical care needs. Anyone who thinks otherwise is incorrect.”

To Mr. Dill, it’s the number of older physicians – in all specialties – ready to retire that should be the biggest concern for hospitals all across the country.

“The physician workforce as a whole is aging,” he said. “Close to a quarter of the physicians in the U.S. are 65 and over. So, you don’t need any extraordinary events driving retirement in order for retirement to be a real phenomenon of which we should all be concerned.”

And, although Mr. Dill said there aren’t any data to suggest that doctors in rural or urban areas are retiring faster than in the suburbs, that doesn’t mean retirement will have the same impact depending on where patients live.

“If you live in a rural area with one small practice in town and that physician retires, there goes the entirety of the physician supply,” he said. “In a major metro area, that’s not as big a deal.”
 

Why younger doctors are fast-tracking retirement

Fernando Mendoza, MD, 54, a pediatric emergency department physician in Miami, worries that physicians are getting so bogged down by paperwork that this may lead to even more doctors, at younger ages, leaving the profession.

“I love taking care of kids, but there’s going to be a cost to doing your work when you’re spending as much time as we need to spend on charts, pharmacy requests, and making sure all of the Medicare and Medicaid compliance issues are worked out.”

These stressors may compel some younger doctors to consider carving out a second career or fast-track younger physicians toward retirement.

“A medical degree carries a lot of weight, which helps when pivoting,” said Dr. Mendoza, who launched Scrivas, a Miami-based medical scribe agency, to help reduce the paperwork workload for physicians. “It might be that a doctor wants to get involved in the acquisition of medical equipment, or maybe they can focus on their investments. Either way, by leaving medicine, they’re not dealing with the hassle and churn-and-burn of seeing patients.”
 

What this means for patients

The time is now to stem the upcoming tide of retirement, said Mr. Dill. But the challenges remain daunting. For starters, the country needs more physicians trained now – but it will take years to replace those baby boomer doctors ready to hang up their white coats.

The medical profession also needs to find ways to support physicians who spend their days juggling an endless array of responsibilities, he said.

The AAMC study found that patients already feel the physician shortfall. Their public opinion research in 2019 said 35% of patients had trouble finding a physician over the past 2 or 3 years, up 10 percentage points since they asked the question in 2015.

Moreover, according to the report, the over-65 population is expected to grow by 45.1%, leaving a specialty care gap because older people generally have more complicated health cases that require specialists. In addition, physician burnout may lead more physicians under 65 to retire much earlier than expected.

Changes in how medicine is practiced, telemedicine care, and medical education – such as disruption of classes or clinical rotations, regulatory changes, and a lack of interest in certain specialties – could also be affected by a mass physician retirement.
 

What can we do about mass retirement?

The AAMC reports in “The Complexities of Physician Supply and Demand: Projections From 2019 to 2034” that federally funded GME support is in the works to train 15,000 physicians per year, with 3,000 new residency slots added per year over 5 years. The proposed model will add 3,750 new physicians each year beginning in 2026.

Other efforts include increasing use of APRNs and PAs, whose population is estimated to more than double by 2034, improve population health through preventive care, increase equity in health outcomes, and improve access and affordable care.

Removing licensing barriers for immigrant doctors can also help alleviate the shortage.

“We need to find better ways to leverage the entirety of the health care team so that not as much falls on physicians,” Mr. Dill said. “It’s also imperative that we focus on ways to support physician wellness and allow physicians to remain active in the field, but at a reduced rate.”

That’s precisely what Marie Brown, MD, director of practice redesign at the American Medical Association, is seeing nationwide. Cutting back their hours is not only trending, but it’s also helping doctors cope with burnout.

“We’re seeing physicians take a 20% or more cut in salary in order to decrease their burden,” she said. “They’ll spend 4 days on clinical time with patients so that on that fifth ‘day off,’ they’re doing the paperwork and documentation they need to do so they don’t compromise care on the other 4 days of the week.”

And this may only be a Band-Aid solution, she fears.

“If a physician is spending 3 hours a day doing unnecessary work that could be done by another team member, that’s contributing to burnout,” Dr. Brown said. “It’s no surprise that they’ll want to escape and retire if they’re in a financial situation to do so.”

“I advocate negotiating within your organization so you’re doing more of what you like, such as mentoring or running a residency, and less of what you don’t, while cutting back from full-time to something less than full-time while maintaining benefits,” said Joel Greenwald, MD, a certified financial planner in Minneapolis, who specializes in helping physicians manage their financial affairs.

“Falling into the ‘like less’ bucket are usually things like working weekends and taking calls,” he said.

“This benefits everyone on a large scale because those doctors who find things they enjoy are generally working to a later age but working less hard,” he said. “Remaining comfortably and happily gainfully employed for a longer period, even if you’re not working full-time, has a very powerful effect on your financial planning, and you’ll avoid the risk of running out of money.”
 

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

The double whammy of pandemic burnout and the aging of baby boomer physicians has, indeed, the makings of some scary headlines. A recent survey by Elsevier Health predicts that up to 75% of health care workers will leave the profession by 2025. And a 2020 study conducted by the Association of American Medical Colleges (AAMC) projected a shortfall of up to 139,000 physicians by 2033.

“We’ve paid a lot of attention to physician retirement,” says Michael Dill, AAMC’s director of workforce studies. “It’s a significant concern in terms of whether we have an adequate supply of physicians in the U.S. to meet our nation’s medical care needs. Anyone who thinks otherwise is incorrect.”

To Mr. Dill, it’s the number of older physicians – in all specialties – ready to retire that should be the biggest concern for hospitals all across the country.

“The physician workforce as a whole is aging,” he said. “Close to a quarter of the physicians in the U.S. are 65 and over. So, you don’t need any extraordinary events driving retirement in order for retirement to be a real phenomenon of which we should all be concerned.”

And, although Mr. Dill said there aren’t any data to suggest that doctors in rural or urban areas are retiring faster than in the suburbs, that doesn’t mean retirement will have the same impact depending on where patients live.

“If you live in a rural area with one small practice in town and that physician retires, there goes the entirety of the physician supply,” he said. “In a major metro area, that’s not as big a deal.”
 

Why younger doctors are fast-tracking retirement

Fernando Mendoza, MD, 54, a pediatric emergency department physician in Miami, worries that physicians are getting so bogged down by paperwork that this may lead to even more doctors, at younger ages, leaving the profession.

“I love taking care of kids, but there’s going to be a cost to doing your work when you’re spending as much time as we need to spend on charts, pharmacy requests, and making sure all of the Medicare and Medicaid compliance issues are worked out.”

These stressors may compel some younger doctors to consider carving out a second career or fast-track younger physicians toward retirement.

“A medical degree carries a lot of weight, which helps when pivoting,” said Dr. Mendoza, who launched Scrivas, a Miami-based medical scribe agency, to help reduce the paperwork workload for physicians. “It might be that a doctor wants to get involved in the acquisition of medical equipment, or maybe they can focus on their investments. Either way, by leaving medicine, they’re not dealing with the hassle and churn-and-burn of seeing patients.”
 

What this means for patients

The time is now to stem the upcoming tide of retirement, said Mr. Dill. But the challenges remain daunting. For starters, the country needs more physicians trained now – but it will take years to replace those baby boomer doctors ready to hang up their white coats.

The medical profession also needs to find ways to support physicians who spend their days juggling an endless array of responsibilities, he said.

The AAMC study found that patients already feel the physician shortfall. Their public opinion research in 2019 said 35% of patients had trouble finding a physician over the past 2 or 3 years, up 10 percentage points since they asked the question in 2015.

Moreover, according to the report, the over-65 population is expected to grow by 45.1%, leaving a specialty care gap because older people generally have more complicated health cases that require specialists. In addition, physician burnout may lead more physicians under 65 to retire much earlier than expected.

Changes in how medicine is practiced, telemedicine care, and medical education – such as disruption of classes or clinical rotations, regulatory changes, and a lack of interest in certain specialties – could also be affected by a mass physician retirement.
 

What can we do about mass retirement?

The AAMC reports in “The Complexities of Physician Supply and Demand: Projections From 2019 to 2034” that federally funded GME support is in the works to train 15,000 physicians per year, with 3,000 new residency slots added per year over 5 years. The proposed model will add 3,750 new physicians each year beginning in 2026.

Other efforts include increasing use of APRNs and PAs, whose population is estimated to more than double by 2034, improve population health through preventive care, increase equity in health outcomes, and improve access and affordable care.

Removing licensing barriers for immigrant doctors can also help alleviate the shortage.

“We need to find better ways to leverage the entirety of the health care team so that not as much falls on physicians,” Mr. Dill said. “It’s also imperative that we focus on ways to support physician wellness and allow physicians to remain active in the field, but at a reduced rate.”

That’s precisely what Marie Brown, MD, director of practice redesign at the American Medical Association, is seeing nationwide. Cutting back their hours is not only trending, but it’s also helping doctors cope with burnout.

“We’re seeing physicians take a 20% or more cut in salary in order to decrease their burden,” she said. “They’ll spend 4 days on clinical time with patients so that on that fifth ‘day off,’ they’re doing the paperwork and documentation they need to do so they don’t compromise care on the other 4 days of the week.”

And this may only be a Band-Aid solution, she fears.

“If a physician is spending 3 hours a day doing unnecessary work that could be done by another team member, that’s contributing to burnout,” Dr. Brown said. “It’s no surprise that they’ll want to escape and retire if they’re in a financial situation to do so.”

“I advocate negotiating within your organization so you’re doing more of what you like, such as mentoring or running a residency, and less of what you don’t, while cutting back from full-time to something less than full-time while maintaining benefits,” said Joel Greenwald, MD, a certified financial planner in Minneapolis, who specializes in helping physicians manage their financial affairs.

“Falling into the ‘like less’ bucket are usually things like working weekends and taking calls,” he said.

“This benefits everyone on a large scale because those doctors who find things they enjoy are generally working to a later age but working less hard,” he said. “Remaining comfortably and happily gainfully employed for a longer period, even if you’re not working full-time, has a very powerful effect on your financial planning, and you’ll avoid the risk of running out of money.”
 

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

Physician compensation continued to rise in 2022 after suffering a dip in 2020, according to the Medscape Physician Compensation Report 2023: Your Income Versus Your Peers’. In addition, gender-based pay disparity among primary care physicians shrank, and the number of physicians who declined to take new Medicare patients rose.
 

The annual report is based on a survey of more than 10,000 physicians in over 29 specialties who answered questions about their income, workload, challenges, and level of satisfaction.

Average compensation across specialties rose to $352,000 – up nearly 17% from the 2018 average of $299,000. Fallout from the COVID-19 public health emergency continued to affect both physician compensation and job satisfaction, including Medicare reimbursements and staffing shortages due to burnout or retirement.

“Many physicians reevaluated what drove them to be a physician,” says Marc Adam, a recruiter at MASC Medical, a Florida physician recruiting firm.

Adam cites telehealth as an example. “An overwhelming majority of physicians prefer telehealth because of the convenience, but some really did not want to do it long term. They miss the patient interaction.”

The report also revealed that the gender-based pay gap in primary physicians fell, with men earning 19% more – down from 25% more in recent years. Among specialists, the gender gap was 27% on average, down from 31% last year. One reason may be an increase in compensation transparency, which Mr. Adam says should be the norm.

Income increases will likely continue, owing in large part to the growing disparity between physician supply and demand.

The projected physician shortage is expected to grow to 124,000 by 2034, according to the American Association of Medical Colleges. Federal lawmakers are considering passing the Resident Physician Shortage Reduction Act of 2023, which would add 14,000 Medicare-funded residency positions to help alleviate shortages.
 

Patient needs, Medicare rules continue to shift

Specialties with the biggest increases in compensation include oncology, anesthesiology, gastroenterology, radiology, critical care, and urology. Many procedure-related specialties saw more volume post pandemic.

Some respondents identified Medicare cuts and low reimbursement rates as a factor in tamping down compensation hikes. The number of physicians who expect to continue to take new Medicare patients is 65%, down from 71% 5 years ago.

For example, Medicare reimbursements for telehealth are expected to scale down in May, when the COVID-19 Public Health Emergency, which expanded telehealth services for Medicare patients, winds down.

“Telehealth will still exist,” says Mr. Adam, “but certain requirements will shape it going forward.”

Medicare isn’t viewed negatively across the board, however. Florida is among the top-earning states for physicians – along with Indiana, Connecticut, and Missouri. One reason is Florida’s unique health care environment, explains Mr. Adam, whose Florida-based firm places physicians nationwide.

“Florida is very progressive in terms of health care. For one thing, we have a large aging population and a large Medicare population.” Several growing organizations that focus on quality-based care are based in Florida, including ChenMed and Cano Health. Add to that the fact that owners of Florida’s health care organizations don’t have to be physicians, he explains, and the stage is set for experimentation.

“Being able to segment tasks frees up physicians to be more focused on medicine and provide better care while other people focus on the business and innovation.”

If Florida’s high compensation ranking continues, it may help employers there fulfill a growing need. The state is among those expected to experience the largest physician shortages in 2030, along with California, Texas, Arizona, and Georgia.
 

Side gigs up, satisfaction (slightly) down

In general, physicians aren’t fazed by these challenges. Many reported taking side gigs, some for additional income. Even so, 73% say they would still choose medicine, and more than 90% of physicians in 10 specialties would choose their specialty again. Still, burnout and stressors have led some to stop practicing altogether.

More and more organizations are hiring “travel physicians,” Mr. Adam says, and more physicians are choosing to take contract work (“locum tenens”) and practice in many different regions. Contract physicians typically help meet patient demand or provide coverage during the hiring process as well as while staff are on vacation or maternity leave.

Says Mr. Adam, “There’s no security, but there’s higher income and more flexibility.”

According to CHG Healthcare, locum tenens staffing is rising – approximately 7% of U.S. physicians (around 50,000) filled assignments in 2022, up 88% from 2015. In 2022, 56% of locum tenens employers reported a reduction in staff burnout, up from 30% in 2020.

The report indicates that more than half of physicians are satisfied with their income, down slightly from 55% 5 years ago (prepandemic). Physicians in some of the lower-paying specialties are among those most satisfied with their income. It’s not very surprising to Mr. Adam: “Higher earners generally suffer the most from burnout.

“They’re overworked, they have the largest number of patients, and they’re performing in high-stress situations doing challenging procedures on a daily basis – and they probably have worse work-life balance.” These physicians know going in that they need to be paid more to deal with such burdens. “That’s the feedback I get when I speak to high earners,” says Mr. Adam.

“The experienced ones are very clear about their [compensation] expectations.”

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

Physician compensation continued to rise in 2022 after suffering a dip in 2020, according to the Medscape Physician Compensation Report 2023: Your Income Versus Your Peers’. In addition, gender-based pay disparity among primary care physicians shrank, and the number of physicians who declined to take new Medicare patients rose.
 

The annual report is based on a survey of more than 10,000 physicians in over 29 specialties who answered questions about their income, workload, challenges, and level of satisfaction.

Average compensation across specialties rose to $352,000 – up nearly 17% from the 2018 average of $299,000. Fallout from the COVID-19 public health emergency continued to affect both physician compensation and job satisfaction, including Medicare reimbursements and staffing shortages due to burnout or retirement.

“Many physicians reevaluated what drove them to be a physician,” says Marc Adam, a recruiter at MASC Medical, a Florida physician recruiting firm.

Adam cites telehealth as an example. “An overwhelming majority of physicians prefer telehealth because of the convenience, but some really did not want to do it long term. They miss the patient interaction.”

The report also revealed that the gender-based pay gap in primary physicians fell, with men earning 19% more – down from 25% more in recent years. Among specialists, the gender gap was 27% on average, down from 31% last year. One reason may be an increase in compensation transparency, which Mr. Adam says should be the norm.

Income increases will likely continue, owing in large part to the growing disparity between physician supply and demand.

The projected physician shortage is expected to grow to 124,000 by 2034, according to the American Association of Medical Colleges. Federal lawmakers are considering passing the Resident Physician Shortage Reduction Act of 2023, which would add 14,000 Medicare-funded residency positions to help alleviate shortages.
 

Patient needs, Medicare rules continue to shift

Specialties with the biggest increases in compensation include oncology, anesthesiology, gastroenterology, radiology, critical care, and urology. Many procedure-related specialties saw more volume post pandemic.

Some respondents identified Medicare cuts and low reimbursement rates as a factor in tamping down compensation hikes. The number of physicians who expect to continue to take new Medicare patients is 65%, down from 71% 5 years ago.

For example, Medicare reimbursements for telehealth are expected to scale down in May, when the COVID-19 Public Health Emergency, which expanded telehealth services for Medicare patients, winds down.

“Telehealth will still exist,” says Mr. Adam, “but certain requirements will shape it going forward.”

Medicare isn’t viewed negatively across the board, however. Florida is among the top-earning states for physicians – along with Indiana, Connecticut, and Missouri. One reason is Florida’s unique health care environment, explains Mr. Adam, whose Florida-based firm places physicians nationwide.

“Florida is very progressive in terms of health care. For one thing, we have a large aging population and a large Medicare population.” Several growing organizations that focus on quality-based care are based in Florida, including ChenMed and Cano Health. Add to that the fact that owners of Florida’s health care organizations don’t have to be physicians, he explains, and the stage is set for experimentation.

“Being able to segment tasks frees up physicians to be more focused on medicine and provide better care while other people focus on the business and innovation.”

If Florida’s high compensation ranking continues, it may help employers there fulfill a growing need. The state is among those expected to experience the largest physician shortages in 2030, along with California, Texas, Arizona, and Georgia.
 

Side gigs up, satisfaction (slightly) down

In general, physicians aren’t fazed by these challenges. Many reported taking side gigs, some for additional income. Even so, 73% say they would still choose medicine, and more than 90% of physicians in 10 specialties would choose their specialty again. Still, burnout and stressors have led some to stop practicing altogether.

More and more organizations are hiring “travel physicians,” Mr. Adam says, and more physicians are choosing to take contract work (“locum tenens”) and practice in many different regions. Contract physicians typically help meet patient demand or provide coverage during the hiring process as well as while staff are on vacation or maternity leave.

Says Mr. Adam, “There’s no security, but there’s higher income and more flexibility.”

According to CHG Healthcare, locum tenens staffing is rising – approximately 7% of U.S. physicians (around 50,000) filled assignments in 2022, up 88% from 2015. In 2022, 56% of locum tenens employers reported a reduction in staff burnout, up from 30% in 2020.

The report indicates that more than half of physicians are satisfied with their income, down slightly from 55% 5 years ago (prepandemic). Physicians in some of the lower-paying specialties are among those most satisfied with their income. It’s not very surprising to Mr. Adam: “Higher earners generally suffer the most from burnout.

“They’re overworked, they have the largest number of patients, and they’re performing in high-stress situations doing challenging procedures on a daily basis – and they probably have worse work-life balance.” These physicians know going in that they need to be paid more to deal with such burdens. “That’s the feedback I get when I speak to high earners,” says Mr. Adam.

“The experienced ones are very clear about their [compensation] expectations.”

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

Physician compensation continued to rise in 2022 after suffering a dip in 2020, according to the Medscape Physician Compensation Report 2023: Your Income Versus Your Peers’. In addition, gender-based pay disparity among primary care physicians shrank, and the number of physicians who declined to take new Medicare patients rose.
 

The annual report is based on a survey of more than 10,000 physicians in over 29 specialties who answered questions about their income, workload, challenges, and level of satisfaction.

Average compensation across specialties rose to $352,000 – up nearly 17% from the 2018 average of $299,000. Fallout from the COVID-19 public health emergency continued to affect both physician compensation and job satisfaction, including Medicare reimbursements and staffing shortages due to burnout or retirement.

“Many physicians reevaluated what drove them to be a physician,” says Marc Adam, a recruiter at MASC Medical, a Florida physician recruiting firm.

Adam cites telehealth as an example. “An overwhelming majority of physicians prefer telehealth because of the convenience, but some really did not want to do it long term. They miss the patient interaction.”

The report also revealed that the gender-based pay gap in primary physicians fell, with men earning 19% more – down from 25% more in recent years. Among specialists, the gender gap was 27% on average, down from 31% last year. One reason may be an increase in compensation transparency, which Mr. Adam says should be the norm.

Income increases will likely continue, owing in large part to the growing disparity between physician supply and demand.

The projected physician shortage is expected to grow to 124,000 by 2034, according to the American Association of Medical Colleges. Federal lawmakers are considering passing the Resident Physician Shortage Reduction Act of 2023, which would add 14,000 Medicare-funded residency positions to help alleviate shortages.
 

Patient needs, Medicare rules continue to shift

Specialties with the biggest increases in compensation include oncology, anesthesiology, gastroenterology, radiology, critical care, and urology. Many procedure-related specialties saw more volume post pandemic.

Some respondents identified Medicare cuts and low reimbursement rates as a factor in tamping down compensation hikes. The number of physicians who expect to continue to take new Medicare patients is 65%, down from 71% 5 years ago.

For example, Medicare reimbursements for telehealth are expected to scale down in May, when the COVID-19 Public Health Emergency, which expanded telehealth services for Medicare patients, winds down.

“Telehealth will still exist,” says Mr. Adam, “but certain requirements will shape it going forward.”

Medicare isn’t viewed negatively across the board, however. Florida is among the top-earning states for physicians – along with Indiana, Connecticut, and Missouri. One reason is Florida’s unique health care environment, explains Mr. Adam, whose Florida-based firm places physicians nationwide.

“Florida is very progressive in terms of health care. For one thing, we have a large aging population and a large Medicare population.” Several growing organizations that focus on quality-based care are based in Florida, including ChenMed and Cano Health. Add to that the fact that owners of Florida’s health care organizations don’t have to be physicians, he explains, and the stage is set for experimentation.

“Being able to segment tasks frees up physicians to be more focused on medicine and provide better care while other people focus on the business and innovation.”

If Florida’s high compensation ranking continues, it may help employers there fulfill a growing need. The state is among those expected to experience the largest physician shortages in 2030, along with California, Texas, Arizona, and Georgia.
 

Side gigs up, satisfaction (slightly) down

In general, physicians aren’t fazed by these challenges. Many reported taking side gigs, some for additional income. Even so, 73% say they would still choose medicine, and more than 90% of physicians in 10 specialties would choose their specialty again. Still, burnout and stressors have led some to stop practicing altogether.

More and more organizations are hiring “travel physicians,” Mr. Adam says, and more physicians are choosing to take contract work (“locum tenens”) and practice in many different regions. Contract physicians typically help meet patient demand or provide coverage during the hiring process as well as while staff are on vacation or maternity leave.

Says Mr. Adam, “There’s no security, but there’s higher income and more flexibility.”

According to CHG Healthcare, locum tenens staffing is rising – approximately 7% of U.S. physicians (around 50,000) filled assignments in 2022, up 88% from 2015. In 2022, 56% of locum tenens employers reported a reduction in staff burnout, up from 30% in 2020.

The report indicates that more than half of physicians are satisfied with their income, down slightly from 55% 5 years ago (prepandemic). Physicians in some of the lower-paying specialties are among those most satisfied with their income. It’s not very surprising to Mr. Adam: “Higher earners generally suffer the most from burnout.

“They’re overworked, they have the largest number of patients, and they’re performing in high-stress situations doing challenging procedures on a daily basis – and they probably have worse work-life balance.” These physicians know going in that they need to be paid more to deal with such burdens. “That’s the feedback I get when I speak to high earners,” says Mr. Adam.

“The experienced ones are very clear about their [compensation] expectations.”

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

More than one in three children and nearly three in five adults take dietary supplements in the United States, a new report shows.

The new figures continue a 15-year trend of small, steady increases in how many people in the United States use the products that can deliver essential nutrients, but their usage includes a risk of getting more nutrients than recommended. In 2007, 48% of adults took supplements, and that figure has reached nearly 59% in this latest count.

The new report looked at whether people took a multivitamin, as well as other more specific supplements. Among children and adolescents aged 19 and under, 23.5% took a multivitamin, while 31.5% of adults reported taking one. The most common specialized supplement that people took was vitamin D.

The report, released by the CDC’s National Center for Health Statistics, compiled survey data from 2017 through 2020 in which 15,548 people reported their household’s usage of dietary supplements. Dietary supplements include vitamins, minerals, herbs, or other botanicals that are taken by mouth in pill, capsule, tablet, or liquid form. The researchers said the vitamin and supplement market is large and growing, totaling $55.7 billion in sales in 2020.

More than one-third of adults (36%) reported taking more than one supplement, and one in four people aged 60 and older said they took four or more.

The data showed demographic trends in who uses dietary supplements. Women and girls were more likely to take supplements than men and boys, although there were similar usage levels for both genders among 1- to 2-year-olds. People with higher education or income levels were more likely to use supplements. Asian people and White people were more likely to take supplements, compared with Hispanic people and Black people.

The authors wrote that monitoring trends in supplement use is important because the products “contribute substantially to nutrient intake as well as increase the risk of excessive intake of certain micronutrients.”

A version of this article originally appeared on WebMD.com.

More than one in three children and nearly three in five adults take dietary supplements in the United States, a new report shows.

The new figures continue a 15-year trend of small, steady increases in how many people in the United States use the products that can deliver essential nutrients, but their usage includes a risk of getting more nutrients than recommended. In 2007, 48% of adults took supplements, and that figure has reached nearly 59% in this latest count.

The new report looked at whether people took a multivitamin, as well as other more specific supplements. Among children and adolescents aged 19 and under, 23.5% took a multivitamin, while 31.5% of adults reported taking one. The most common specialized supplement that people took was vitamin D.

The report, released by the CDC’s National Center for Health Statistics, compiled survey data from 2017 through 2020 in which 15,548 people reported their household’s usage of dietary supplements. Dietary supplements include vitamins, minerals, herbs, or other botanicals that are taken by mouth in pill, capsule, tablet, or liquid form. The researchers said the vitamin and supplement market is large and growing, totaling $55.7 billion in sales in 2020.

More than one-third of adults (36%) reported taking more than one supplement, and one in four people aged 60 and older said they took four or more.

The data showed demographic trends in who uses dietary supplements. Women and girls were more likely to take supplements than men and boys, although there were similar usage levels for both genders among 1- to 2-year-olds. People with higher education or income levels were more likely to use supplements. Asian people and White people were more likely to take supplements, compared with Hispanic people and Black people.

The authors wrote that monitoring trends in supplement use is important because the products “contribute substantially to nutrient intake as well as increase the risk of excessive intake of certain micronutrients.”

A version of this article originally appeared on WebMD.com.

More than one in three children and nearly three in five adults take dietary supplements in the United States, a new report shows.

The new figures continue a 15-year trend of small, steady increases in how many people in the United States use the products that can deliver essential nutrients, but their usage includes a risk of getting more nutrients than recommended. In 2007, 48% of adults took supplements, and that figure has reached nearly 59% in this latest count.

The new report looked at whether people took a multivitamin, as well as other more specific supplements. Among children and adolescents aged 19 and under, 23.5% took a multivitamin, while 31.5% of adults reported taking one. The most common specialized supplement that people took was vitamin D.

The report, released by the CDC’s National Center for Health Statistics, compiled survey data from 2017 through 2020 in which 15,548 people reported their household’s usage of dietary supplements. Dietary supplements include vitamins, minerals, herbs, or other botanicals that are taken by mouth in pill, capsule, tablet, or liquid form. The researchers said the vitamin and supplement market is large and growing, totaling $55.7 billion in sales in 2020.

More than one-third of adults (36%) reported taking more than one supplement, and one in four people aged 60 and older said they took four or more.

The data showed demographic trends in who uses dietary supplements. Women and girls were more likely to take supplements than men and boys, although there were similar usage levels for both genders among 1- to 2-year-olds. People with higher education or income levels were more likely to use supplements. Asian people and White people were more likely to take supplements, compared with Hispanic people and Black people.

The authors wrote that monitoring trends in supplement use is important because the products “contribute substantially to nutrient intake as well as increase the risk of excessive intake of certain micronutrients.”

A version of this article originally appeared on WebMD.com.

The bacterial, fungal, and atypical mycobacterial cultures from the lesions performed at the emergency department were all negative.

Pediatric dermatology was consulted and a punch biopsy of one of the lesions was done. Histopathologic examination showed a mixed perifollicular infiltrate of predominantly eosinophils with some neutrophils and associated microabscesses. Periodic acid Schiff and Fite stains failed to reveal any organisms. CD1 immunostain was negative. Fresh tissue cultures for bacteria, fungi, and atypical mycobacteria were negative.

Given the clinical presentation of chronic recurrent sterile pustules on an infant with associated eosinophilia and the reported histopathologic findings, the patient was diagnosed with eosinophilic pustular folliculitis of infancy (EPFI).

Dr. Catalina Matiz

EPFI is a rare and idiopathic cutaneous disorder present in children. About 70% of the cases reported occur in the first 6 month of life and rarely present past 3 years of age. EPF encompasses a group of conditions including the classic adult form, or Ofuji disease. EPF is seen in immunosuppressed patients, mainly HIV positive, and EPF is also seen in infants and children.

In EPFI, males are most commonly affected. The condition presents, as it did in our patient, with recurrent crops of sterile papules and pustules mainly on the scalp, but they can occur in other parts of the body. The lesions go away within a few weeks to months without leaving any scars but it can take months to years to resolve. Histopathologic analysis of the lesions show an eosinophilic infiltrate which can be follicular, perifollicular, or periadnexal with associated flame figures in about 26% of cases.

Aggressive treatment is usually not needed as lesions are self-limited. Lesions can be treated with topical corticosteroids and oral antihistamine medications like cetirizine if symptomatic.

If the lesions start to present during the neonatal period, one may consider in the differential diagnosis, neonatal rashes like transient neonatal pustular melanosis and erythema toxicum neonatorum. Both of these neonatal conditions tend to resolve in the first month of life, compared with EPFI where lesions can come and go for months to years. EPFI lesions can be described as pustules and inflammatory papules, as well as furuncles and vesicles. All of the lesions may be seen in one patient at one time, which will not be typical for transient neonatal pustular melanosis or erythema toxicum. Eosinophils can be seen in erythema toxicum but folliculitis is not present. The inflammatory infiltrate seen in transient neonatal pustular melanosis is polymorphonuclear, not eosinophilic.

Early in the presentation, infectious conditions like staphylococcal or streptococcal folliculitis, cellulitis and furunculosis, tinea capitis, atypical mycobacterial infections, herpes simplex, and parasitic infections like scabies should be considered. In young infants, empiric antibiotic treatment may be started until cultures are finalized. If there is a family history of pruritic papules and pustules, scabies should be considered. A scabies prep can be done to rule out this entity.

Langerhans cell histiocytosis can also present with pustules and papules in early infancy and also has a predilection for the scalp. When this condition is in question, a skin biopsy should be performed which shows a CD1 positive histiocytic infiltrate.

In conclusion, EPFI is a benign rare condition that can present in infants as recurrent pustules and papules, mainly on the scalp, which are self-limited and if symptomatic can be treated with topical corticosteroids and antihistamines.
 

References

Alonso-Castro L et al. Dermatol Online J. 2012 Oct 15;18(10):6.

Frølunde AS et al. Clin Case Rep. 2021 May 11;9(5):e04167.

Hernández-Martín Á et al. J Am Acad Dermatol. 2013 Jan;68(1):150-5.

The bacterial, fungal, and atypical mycobacterial cultures from the lesions performed at the emergency department were all negative.

Pediatric dermatology was consulted and a punch biopsy of one of the lesions was done. Histopathologic examination showed a mixed perifollicular infiltrate of predominantly eosinophils with some neutrophils and associated microabscesses. Periodic acid Schiff and Fite stains failed to reveal any organisms. CD1 immunostain was negative. Fresh tissue cultures for bacteria, fungi, and atypical mycobacteria were negative.

Given the clinical presentation of chronic recurrent sterile pustules on an infant with associated eosinophilia and the reported histopathologic findings, the patient was diagnosed with eosinophilic pustular folliculitis of infancy (EPFI).

Dr. Catalina Matiz

EPFI is a rare and idiopathic cutaneous disorder present in children. About 70% of the cases reported occur in the first 6 month of life and rarely present past 3 years of age. EPF encompasses a group of conditions including the classic adult form, or Ofuji disease. EPF is seen in immunosuppressed patients, mainly HIV positive, and EPF is also seen in infants and children.

In EPFI, males are most commonly affected. The condition presents, as it did in our patient, with recurrent crops of sterile papules and pustules mainly on the scalp, but they can occur in other parts of the body. The lesions go away within a few weeks to months without leaving any scars but it can take months to years to resolve. Histopathologic analysis of the lesions show an eosinophilic infiltrate which can be follicular, perifollicular, or periadnexal with associated flame figures in about 26% of cases.

Aggressive treatment is usually not needed as lesions are self-limited. Lesions can be treated with topical corticosteroids and oral antihistamine medications like cetirizine if symptomatic.

If the lesions start to present during the neonatal period, one may consider in the differential diagnosis, neonatal rashes like transient neonatal pustular melanosis and erythema toxicum neonatorum. Both of these neonatal conditions tend to resolve in the first month of life, compared with EPFI where lesions can come and go for months to years. EPFI lesions can be described as pustules and inflammatory papules, as well as furuncles and vesicles. All of the lesions may be seen in one patient at one time, which will not be typical for transient neonatal pustular melanosis or erythema toxicum. Eosinophils can be seen in erythema toxicum but folliculitis is not present. The inflammatory infiltrate seen in transient neonatal pustular melanosis is polymorphonuclear, not eosinophilic.

Early in the presentation, infectious conditions like staphylococcal or streptococcal folliculitis, cellulitis and furunculosis, tinea capitis, atypical mycobacterial infections, herpes simplex, and parasitic infections like scabies should be considered. In young infants, empiric antibiotic treatment may be started until cultures are finalized. If there is a family history of pruritic papules and pustules, scabies should be considered. A scabies prep can be done to rule out this entity.

Langerhans cell histiocytosis can also present with pustules and papules in early infancy and also has a predilection for the scalp. When this condition is in question, a skin biopsy should be performed which shows a CD1 positive histiocytic infiltrate.

In conclusion, EPFI is a benign rare condition that can present in infants as recurrent pustules and papules, mainly on the scalp, which are self-limited and if symptomatic can be treated with topical corticosteroids and antihistamines.
 

References

Alonso-Castro L et al. Dermatol Online J. 2012 Oct 15;18(10):6.

Frølunde AS et al. Clin Case Rep. 2021 May 11;9(5):e04167.

Hernández-Martín Á et al. J Am Acad Dermatol. 2013 Jan;68(1):150-5.

The bacterial, fungal, and atypical mycobacterial cultures from the lesions performed at the emergency department were all negative.

Pediatric dermatology was consulted and a punch biopsy of one of the lesions was done. Histopathologic examination showed a mixed perifollicular infiltrate of predominantly eosinophils with some neutrophils and associated microabscesses. Periodic acid Schiff and Fite stains failed to reveal any organisms. CD1 immunostain was negative. Fresh tissue cultures for bacteria, fungi, and atypical mycobacteria were negative.

Given the clinical presentation of chronic recurrent sterile pustules on an infant with associated eosinophilia and the reported histopathologic findings, the patient was diagnosed with eosinophilic pustular folliculitis of infancy (EPFI).

Dr. Catalina Matiz

EPFI is a rare and idiopathic cutaneous disorder present in children. About 70% of the cases reported occur in the first 6 month of life and rarely present past 3 years of age. EPF encompasses a group of conditions including the classic adult form, or Ofuji disease. EPF is seen in immunosuppressed patients, mainly HIV positive, and EPF is also seen in infants and children.

In EPFI, males are most commonly affected. The condition presents, as it did in our patient, with recurrent crops of sterile papules and pustules mainly on the scalp, but they can occur in other parts of the body. The lesions go away within a few weeks to months without leaving any scars but it can take months to years to resolve. Histopathologic analysis of the lesions show an eosinophilic infiltrate which can be follicular, perifollicular, or periadnexal with associated flame figures in about 26% of cases.

Aggressive treatment is usually not needed as lesions are self-limited. Lesions can be treated with topical corticosteroids and oral antihistamine medications like cetirizine if symptomatic.

If the lesions start to present during the neonatal period, one may consider in the differential diagnosis, neonatal rashes like transient neonatal pustular melanosis and erythema toxicum neonatorum. Both of these neonatal conditions tend to resolve in the first month of life, compared with EPFI where lesions can come and go for months to years. EPFI lesions can be described as pustules and inflammatory papules, as well as furuncles and vesicles. All of the lesions may be seen in one patient at one time, which will not be typical for transient neonatal pustular melanosis or erythema toxicum. Eosinophils can be seen in erythema toxicum but folliculitis is not present. The inflammatory infiltrate seen in transient neonatal pustular melanosis is polymorphonuclear, not eosinophilic.

Early in the presentation, infectious conditions like staphylococcal or streptococcal folliculitis, cellulitis and furunculosis, tinea capitis, atypical mycobacterial infections, herpes simplex, and parasitic infections like scabies should be considered. In young infants, empiric antibiotic treatment may be started until cultures are finalized. If there is a family history of pruritic papules and pustules, scabies should be considered. A scabies prep can be done to rule out this entity.

Langerhans cell histiocytosis can also present with pustules and papules in early infancy and also has a predilection for the scalp. When this condition is in question, a skin biopsy should be performed which shows a CD1 positive histiocytic infiltrate.

In conclusion, EPFI is a benign rare condition that can present in infants as recurrent pustules and papules, mainly on the scalp, which are self-limited and if symptomatic can be treated with topical corticosteroids and antihistamines.
 

References

Alonso-Castro L et al. Dermatol Online J. 2012 Oct 15;18(10):6.

Frølunde AS et al. Clin Case Rep. 2021 May 11;9(5):e04167.

Hernández-Martín Á et al. J Am Acad Dermatol. 2013 Jan;68(1):150-5.

In an update to its 2016 recommendations for skin cancer screening, the U.S. Preventive Services Task Force (USPSTF) has once again determined that there is not enough evidence to recommend for or against screening with a visual skin exam in adolescents and adults without symptoms.

This final recommendation applies to the general public and is not meant for those at higher risk, such as people with a family history of skin cancer or who have any signs or symptoms, such as irregular moles.

“The new recommendations are consistent with those from 2016, and we are unable to balance benefits and harms,” said Task Force member Katrina Donahue, MD, MPH, professor and vice chair of research in the department of family medicine at the University of North Carolina, Chapel Hill. “Unfortunately, there is not enough evidence to recommend for or against screening, and health care professionals should use their judgment when deciding whether or not to screen.”

Dr. Donahue told this news organization that this is a call for more research: “Our recommendations are for patients who present to primary care without symptoms, and after a careful assessment of benefit and harms, we didn’t have evidence to push us towards screening as a benefit. We did look at data from two large screening programs, but they were from Europe and not representative of the U.S. population. They also did not show a benefit for reducing melanoma-related mortality.”

The USPSTF final recommendation statement and corresponding evidence summary have been published online in JAMA, as well as on the USPSTF website.

Skin cancer is the most commonly diagnosed cancer in the United States, but there are different types that vary in their incidence and severity. Basal and squamous cell carcinomas are the most common types of skin cancer, but they infrequently lead to death or substantial morbidity, notes the USPTSF. Melanomas represent about 1% of skin cancer and cause the most skin cancer deaths. An estimated 8,000 individuals in the United States will die of melanoma in 2023.

There are racial differences in melanoma incidence; it is about 30 times more common in White versus Black persons, but disease in persons with darker skin color tends to be diagnosed at a later stage. These disparities may be due to differences in risk factors, access to care, and clinical presentation.

In an accompanying editorial, Maryam M. Asgari, MD, MPH, of the department of dermatology, Massachusetts General Hospital, Boston, and Lori A. Crane, PhD, MPH, of the Colorado School of Public Health, University of Colorado, Aurora, point out that people with darker skin phenotypes also tend to be affected by skin cancers that are not associated with UV radiation, such as acral melanoma, which arises on the palms and soles, and skin cancers that arise in areas of chronic inflammation, such as wounds.

Review of evidence

The USPSTF commissioned a systematic review to evaluate the benefits and harms of screening for skin cancer in asymptomatic adolescents and adults, including evidence for both keratinocyte carcinoma (basal cell carcinoma and squamous cell carcinoma) and cutaneous melanoma.

Foundational evidence showed that the sensitivity of visual skin examination by a clinician to detect melanoma ranged from 40% to 70% and specificity ranged from 86% to 98%. Evidence that evaluated the diagnostic accuracy of visual skin examination to detect keratinocyte carcinoma was limited and inconsistent. There were no new studies reporting on diagnostic accuracy for an asymptomatic screening population.

The USPSTF also reviewed 20 studies in 29 articles (n = 6,053,411). This included three nonrandomized studies evaluating two skin cancer screening programs in Germany, but results were inconsistent. In addition, the ecological and nonrandomized design of the studies limited the conclusions that could be drawn and the applicability to a U.S. population was difficult to assess because of differences in population diversity and health care delivery in the United States.

Other nonrandomized studies that looked at various outcomes, such as harms and stage at diagnosis and melanoma or all-cause mortality, also did not provide sufficient evidence to support screening.
 

Research is needed

In a second accompanying editorial published in JAMA Dermatology, Adewole S. Adamson, MD, MPP, of the division of dermatology and dermatologic surgery at the University of Texas, Austin, pointed out that unlike other cancer screening programs, such as those for breast, colon, and prostate cancer, skin cancer screening programs are somewhat less organized.

The other programs focus on defined groups of the population, generally with easily identifiable characteristics such as age, sex, and family history, and importantly, there are always defined ages for initiation and halting of screening and intervals for screening frequency. None of these basic screening parameters have been widely adopted among dermatologists in the United States, he wrote. “One important reason why skin cancer screening has remained inconsistent is that it is not covered by Medicare or by many commercial insurance companies,” Dr. Adamson told this news organization. “The test, in this case the skin exam, is often performed as part of a routine dermatology visit.”

Dermatologists should take the lead on this, he said. “Dermatologists should push for a high quality prospective clinical trial of skin cancer screening, preferably in a high-risk population.”

Dr. Donahue agrees that research is needed, as noted in the recommendation. For example, studies are needed demonstrating consistent data of the effects of screening on morbidity and mortality or early detection of skin cancer, and clearer descriptions of skin color and inclusion of a full spectrum of skin colors in study participants. Clinical research is also needed on outcomes in participants that reflect the diversity of the U.S. population.

“I hope funding agencies will be interested in this area of study,” she said. “We put out the whole systematic review and point out the gaps. We need consistent evidence in detecting cancer early and reducing complications from skin cancer.”

The U.S. Congress mandates that the Agency for Healthcare Research and Quality support the operations of the USPSTF.

None of the USPSTF authors report any disclosures. Dr. Asgari reported receiving royalties from UpToDate. Dr. Crane did not make any disclosures. Dr. Adamson reported serving as an expert reviewer for the U.S. Preventive Services Task Force skin cancer screening report, as well as support from the Robert Wood Johnson Foundation, the Dermatology Foundation Public Health Career Development Award, the National Institutes of Health, the American Cancer Society, and Meredith’s Mission for Melanoma.

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

In an update to its 2016 recommendations for skin cancer screening, the U.S. Preventive Services Task Force (USPSTF) has once again determined that there is not enough evidence to recommend for or against screening with a visual skin exam in adolescents and adults without symptoms.

This final recommendation applies to the general public and is not meant for those at higher risk, such as people with a family history of skin cancer or who have any signs or symptoms, such as irregular moles.

“The new recommendations are consistent with those from 2016, and we are unable to balance benefits and harms,” said Task Force member Katrina Donahue, MD, MPH, professor and vice chair of research in the department of family medicine at the University of North Carolina, Chapel Hill. “Unfortunately, there is not enough evidence to recommend for or against screening, and health care professionals should use their judgment when deciding whether or not to screen.”

Dr. Donahue told this news organization that this is a call for more research: “Our recommendations are for patients who present to primary care without symptoms, and after a careful assessment of benefit and harms, we didn’t have evidence to push us towards screening as a benefit. We did look at data from two large screening programs, but they were from Europe and not representative of the U.S. population. They also did not show a benefit for reducing melanoma-related mortality.”

The USPSTF final recommendation statement and corresponding evidence summary have been published online in JAMA, as well as on the USPSTF website.

Skin cancer is the most commonly diagnosed cancer in the United States, but there are different types that vary in their incidence and severity. Basal and squamous cell carcinomas are the most common types of skin cancer, but they infrequently lead to death or substantial morbidity, notes the USPTSF. Melanomas represent about 1% of skin cancer and cause the most skin cancer deaths. An estimated 8,000 individuals in the United States will die of melanoma in 2023.

There are racial differences in melanoma incidence; it is about 30 times more common in White versus Black persons, but disease in persons with darker skin color tends to be diagnosed at a later stage. These disparities may be due to differences in risk factors, access to care, and clinical presentation.

In an accompanying editorial, Maryam M. Asgari, MD, MPH, of the department of dermatology, Massachusetts General Hospital, Boston, and Lori A. Crane, PhD, MPH, of the Colorado School of Public Health, University of Colorado, Aurora, point out that people with darker skin phenotypes also tend to be affected by skin cancers that are not associated with UV radiation, such as acral melanoma, which arises on the palms and soles, and skin cancers that arise in areas of chronic inflammation, such as wounds.

Review of evidence

The USPSTF commissioned a systematic review to evaluate the benefits and harms of screening for skin cancer in asymptomatic adolescents and adults, including evidence for both keratinocyte carcinoma (basal cell carcinoma and squamous cell carcinoma) and cutaneous melanoma.

Foundational evidence showed that the sensitivity of visual skin examination by a clinician to detect melanoma ranged from 40% to 70% and specificity ranged from 86% to 98%. Evidence that evaluated the diagnostic accuracy of visual skin examination to detect keratinocyte carcinoma was limited and inconsistent. There were no new studies reporting on diagnostic accuracy for an asymptomatic screening population.

The USPSTF also reviewed 20 studies in 29 articles (n = 6,053,411). This included three nonrandomized studies evaluating two skin cancer screening programs in Germany, but results were inconsistent. In addition, the ecological and nonrandomized design of the studies limited the conclusions that could be drawn and the applicability to a U.S. population was difficult to assess because of differences in population diversity and health care delivery in the United States.

Other nonrandomized studies that looked at various outcomes, such as harms and stage at diagnosis and melanoma or all-cause mortality, also did not provide sufficient evidence to support screening.
 

Research is needed

In a second accompanying editorial published in JAMA Dermatology, Adewole S. Adamson, MD, MPP, of the division of dermatology and dermatologic surgery at the University of Texas, Austin, pointed out that unlike other cancer screening programs, such as those for breast, colon, and prostate cancer, skin cancer screening programs are somewhat less organized.

The other programs focus on defined groups of the population, generally with easily identifiable characteristics such as age, sex, and family history, and importantly, there are always defined ages for initiation and halting of screening and intervals for screening frequency. None of these basic screening parameters have been widely adopted among dermatologists in the United States, he wrote. “One important reason why skin cancer screening has remained inconsistent is that it is not covered by Medicare or by many commercial insurance companies,” Dr. Adamson told this news organization. “The test, in this case the skin exam, is often performed as part of a routine dermatology visit.”

Dermatologists should take the lead on this, he said. “Dermatologists should push for a high quality prospective clinical trial of skin cancer screening, preferably in a high-risk population.”

Dr. Donahue agrees that research is needed, as noted in the recommendation. For example, studies are needed demonstrating consistent data of the effects of screening on morbidity and mortality or early detection of skin cancer, and clearer descriptions of skin color and inclusion of a full spectrum of skin colors in study participants. Clinical research is also needed on outcomes in participants that reflect the diversity of the U.S. population.

“I hope funding agencies will be interested in this area of study,” she said. “We put out the whole systematic review and point out the gaps. We need consistent evidence in detecting cancer early and reducing complications from skin cancer.”

The U.S. Congress mandates that the Agency for Healthcare Research and Quality support the operations of the USPSTF.

None of the USPSTF authors report any disclosures. Dr. Asgari reported receiving royalties from UpToDate. Dr. Crane did not make any disclosures. Dr. Adamson reported serving as an expert reviewer for the U.S. Preventive Services Task Force skin cancer screening report, as well as support from the Robert Wood Johnson Foundation, the Dermatology Foundation Public Health Career Development Award, the National Institutes of Health, the American Cancer Society, and Meredith’s Mission for Melanoma.

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

In an update to its 2016 recommendations for skin cancer screening, the U.S. Preventive Services Task Force (USPSTF) has once again determined that there is not enough evidence to recommend for or against screening with a visual skin exam in adolescents and adults without symptoms.

This final recommendation applies to the general public and is not meant for those at higher risk, such as people with a family history of skin cancer or who have any signs or symptoms, such as irregular moles.

“The new recommendations are consistent with those from 2016, and we are unable to balance benefits and harms,” said Task Force member Katrina Donahue, MD, MPH, professor and vice chair of research in the department of family medicine at the University of North Carolina, Chapel Hill. “Unfortunately, there is not enough evidence to recommend for or against screening, and health care professionals should use their judgment when deciding whether or not to screen.”

Dr. Donahue told this news organization that this is a call for more research: “Our recommendations are for patients who present to primary care without symptoms, and after a careful assessment of benefit and harms, we didn’t have evidence to push us towards screening as a benefit. We did look at data from two large screening programs, but they were from Europe and not representative of the U.S. population. They also did not show a benefit for reducing melanoma-related mortality.”

The USPSTF final recommendation statement and corresponding evidence summary have been published online in JAMA, as well as on the USPSTF website.

Skin cancer is the most commonly diagnosed cancer in the United States, but there are different types that vary in their incidence and severity. Basal and squamous cell carcinomas are the most common types of skin cancer, but they infrequently lead to death or substantial morbidity, notes the USPTSF. Melanomas represent about 1% of skin cancer and cause the most skin cancer deaths. An estimated 8,000 individuals in the United States will die of melanoma in 2023.

There are racial differences in melanoma incidence; it is about 30 times more common in White versus Black persons, but disease in persons with darker skin color tends to be diagnosed at a later stage. These disparities may be due to differences in risk factors, access to care, and clinical presentation.

In an accompanying editorial, Maryam M. Asgari, MD, MPH, of the department of dermatology, Massachusetts General Hospital, Boston, and Lori A. Crane, PhD, MPH, of the Colorado School of Public Health, University of Colorado, Aurora, point out that people with darker skin phenotypes also tend to be affected by skin cancers that are not associated with UV radiation, such as acral melanoma, which arises on the palms and soles, and skin cancers that arise in areas of chronic inflammation, such as wounds.

Review of evidence

The USPSTF commissioned a systematic review to evaluate the benefits and harms of screening for skin cancer in asymptomatic adolescents and adults, including evidence for both keratinocyte carcinoma (basal cell carcinoma and squamous cell carcinoma) and cutaneous melanoma.

Foundational evidence showed that the sensitivity of visual skin examination by a clinician to detect melanoma ranged from 40% to 70% and specificity ranged from 86% to 98%. Evidence that evaluated the diagnostic accuracy of visual skin examination to detect keratinocyte carcinoma was limited and inconsistent. There were no new studies reporting on diagnostic accuracy for an asymptomatic screening population.

The USPSTF also reviewed 20 studies in 29 articles (n = 6,053,411). This included three nonrandomized studies evaluating two skin cancer screening programs in Germany, but results were inconsistent. In addition, the ecological and nonrandomized design of the studies limited the conclusions that could be drawn and the applicability to a U.S. population was difficult to assess because of differences in population diversity and health care delivery in the United States.

Other nonrandomized studies that looked at various outcomes, such as harms and stage at diagnosis and melanoma or all-cause mortality, also did not provide sufficient evidence to support screening.
 

Research is needed

In a second accompanying editorial published in JAMA Dermatology, Adewole S. Adamson, MD, MPP, of the division of dermatology and dermatologic surgery at the University of Texas, Austin, pointed out that unlike other cancer screening programs, such as those for breast, colon, and prostate cancer, skin cancer screening programs are somewhat less organized.

The other programs focus on defined groups of the population, generally with easily identifiable characteristics such as age, sex, and family history, and importantly, there are always defined ages for initiation and halting of screening and intervals for screening frequency. None of these basic screening parameters have been widely adopted among dermatologists in the United States, he wrote. “One important reason why skin cancer screening has remained inconsistent is that it is not covered by Medicare or by many commercial insurance companies,” Dr. Adamson told this news organization. “The test, in this case the skin exam, is often performed as part of a routine dermatology visit.”

Dermatologists should take the lead on this, he said. “Dermatologists should push for a high quality prospective clinical trial of skin cancer screening, preferably in a high-risk population.”

Dr. Donahue agrees that research is needed, as noted in the recommendation. For example, studies are needed demonstrating consistent data of the effects of screening on morbidity and mortality or early detection of skin cancer, and clearer descriptions of skin color and inclusion of a full spectrum of skin colors in study participants. Clinical research is also needed on outcomes in participants that reflect the diversity of the U.S. population.

“I hope funding agencies will be interested in this area of study,” she said. “We put out the whole systematic review and point out the gaps. We need consistent evidence in detecting cancer early and reducing complications from skin cancer.”

The U.S. Congress mandates that the Agency for Healthcare Research and Quality support the operations of the USPSTF.

None of the USPSTF authors report any disclosures. Dr. Asgari reported receiving royalties from UpToDate. Dr. Crane did not make any disclosures. Dr. Adamson reported serving as an expert reviewer for the U.S. Preventive Services Task Force skin cancer screening report, as well as support from the Robert Wood Johnson Foundation, the Dermatology Foundation Public Health Career Development Award, the National Institutes of Health, the American Cancer Society, and Meredith’s Mission for Melanoma.

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

Rates of perinatal HIV have dropped so much that the disease is effectively eliminated in the United States, with less than 1 baby for every 100,000 live births having the virus, a new study released by researchers at the Centers for Disease Control and Prevention finds.

The report marks significant progress on the U.S. government’s goal to eradicate perinatal HIV, an immune-weakening and potentially deadly virus that is passed from mother to baby during pregnancy. Just 32 children in the country were diagnosed in 2019, compared with twice as many in 2010, according to the CDC.

Mothers who are HIV positive can prevent transmission of the infection by receiving antiretroviral therapy, according to Monica Gandhi, MD, MPH, a professor of medicine at University of California, San Francisco’s division of HIV, infectious disease and global medicine.

Dr. Gandhi said she could recall only one case of perinatal HIV in the San Francisco area over the last decade.

“This country has been really aggressive about counseling women who are pregnant and getting mothers in care,” Dr. Gandhi said.

The treatment method was discovered more than 30 years ago. Prior to the therapy and ensuing awareness campaigns to prevent transmission, mothers with HIV would typically pass the virus to their child in utero, during delivery, or while breastfeeding.

“There should be zero children born with HIV, given that we’ve had these drugs for so long,” Dr. Ghandi said. 
 

Disparities persist

But challenges remain in some communities, where babies born to Black mothers are disproportionately affected by the disease, the new study found. “Racial and ethnic differences in perinatal HIV diagnoses persisted through the 10-year period,” the report’s authors concluded. “The highest rates of perinatal HIV diagnoses were seen among infants born to Black women.”

Although rates of perinatal HIV declined for babies born to Black mothers over the decade-long study, the diagnosis rate was above the goal of elimination at 3.1 for every 100,000 live births, according to the data.

Meanwhile, transmission rates hovered around 1%-2% for Latinx and Hispanic women and mothers who identified as “other races,” including Native American.

Despite the availability of medication, expectant mothers may face several hurdles to getting the daily treatment they need to prevent transmission to their fetus, according to Jennifer Jao, MD, MPH, a physician of infectious diseases at Lurie Children’s Hospital of Chicago.

They might have trouble securing health insurance or finding transportation to doctor’s appointments, or face other problems like lacking secure housing or food – all factors that prevent them from prioritizing the care.

“All of those things play into the mix,” Dr. Jao said. “We see over and over again that closing the gap means you’ve got to reach the women who are pregnant and who don’t have resources.”
 

Progress in ‘danger’

Experts said they’re not sure what the impact of the COVID-19 pandemic, accompanied by a recent uptick in sexually transmitted diseases, will be on rates of perinatal HIV. Some women were unable to access prenatal health care during the pandemic because they couldn’t access public transportation or childcare, the U.S. Government Accountability Office said in 2022.

Globally, a decline in rates of HIV and AIDS rates has slowed, prompting the World Health Organization to warn last year that progress on the disease is in danger. Researchers only included HIV rates in the United States through 2019, so the data are outdated, Dr. Gandhi noted.

“All of this put together means we don’t know where we are with perinatal transmission over the last 3 years,” she said.

In an accompanying editorial, coauthors Nahida Chakhtoura, MD, MsGH, and Bill Kapogiannis, MD, both with the National Institutes of Health, urge health care professionals to take an active role in eliminating these racial and ethnic disparities in an effort to – as the title of their editorial proclaims – achieve a “road to zero perinatal HIV transmission” in the United States.

“The more proactive we are in identifying and promptly addressing systematic deficiencies that exacerbate health inequities in cutting-edge research innovations and optimal clinical service provision,” they write, “the less reactive we will need to be when new transmissible infections appear at our doorstep.”

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

Rates of perinatal HIV have dropped so much that the disease is effectively eliminated in the United States, with less than 1 baby for every 100,000 live births having the virus, a new study released by researchers at the Centers for Disease Control and Prevention finds.

The report marks significant progress on the U.S. government’s goal to eradicate perinatal HIV, an immune-weakening and potentially deadly virus that is passed from mother to baby during pregnancy. Just 32 children in the country were diagnosed in 2019, compared with twice as many in 2010, according to the CDC.

Mothers who are HIV positive can prevent transmission of the infection by receiving antiretroviral therapy, according to Monica Gandhi, MD, MPH, a professor of medicine at University of California, San Francisco’s division of HIV, infectious disease and global medicine.

Dr. Gandhi said she could recall only one case of perinatal HIV in the San Francisco area over the last decade.

“This country has been really aggressive about counseling women who are pregnant and getting mothers in care,” Dr. Gandhi said.

The treatment method was discovered more than 30 years ago. Prior to the therapy and ensuing awareness campaigns to prevent transmission, mothers with HIV would typically pass the virus to their child in utero, during delivery, or while breastfeeding.

“There should be zero children born with HIV, given that we’ve had these drugs for so long,” Dr. Ghandi said. 
 

Disparities persist

But challenges remain in some communities, where babies born to Black mothers are disproportionately affected by the disease, the new study found. “Racial and ethnic differences in perinatal HIV diagnoses persisted through the 10-year period,” the report’s authors concluded. “The highest rates of perinatal HIV diagnoses were seen among infants born to Black women.”

Although rates of perinatal HIV declined for babies born to Black mothers over the decade-long study, the diagnosis rate was above the goal of elimination at 3.1 for every 100,000 live births, according to the data.

Meanwhile, transmission rates hovered around 1%-2% for Latinx and Hispanic women and mothers who identified as “other races,” including Native American.

Despite the availability of medication, expectant mothers may face several hurdles to getting the daily treatment they need to prevent transmission to their fetus, according to Jennifer Jao, MD, MPH, a physician of infectious diseases at Lurie Children’s Hospital of Chicago.

They might have trouble securing health insurance or finding transportation to doctor’s appointments, or face other problems like lacking secure housing or food – all factors that prevent them from prioritizing the care.

“All of those things play into the mix,” Dr. Jao said. “We see over and over again that closing the gap means you’ve got to reach the women who are pregnant and who don’t have resources.”
 

Progress in ‘danger’

Experts said they’re not sure what the impact of the COVID-19 pandemic, accompanied by a recent uptick in sexually transmitted diseases, will be on rates of perinatal HIV. Some women were unable to access prenatal health care during the pandemic because they couldn’t access public transportation or childcare, the U.S. Government Accountability Office said in 2022.

Globally, a decline in rates of HIV and AIDS rates has slowed, prompting the World Health Organization to warn last year that progress on the disease is in danger. Researchers only included HIV rates in the United States through 2019, so the data are outdated, Dr. Gandhi noted.

“All of this put together means we don’t know where we are with perinatal transmission over the last 3 years,” she said.

In an accompanying editorial, coauthors Nahida Chakhtoura, MD, MsGH, and Bill Kapogiannis, MD, both with the National Institutes of Health, urge health care professionals to take an active role in eliminating these racial and ethnic disparities in an effort to – as the title of their editorial proclaims – achieve a “road to zero perinatal HIV transmission” in the United States.

“The more proactive we are in identifying and promptly addressing systematic deficiencies that exacerbate health inequities in cutting-edge research innovations and optimal clinical service provision,” they write, “the less reactive we will need to be when new transmissible infections appear at our doorstep.”

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

Rates of perinatal HIV have dropped so much that the disease is effectively eliminated in the United States, with less than 1 baby for every 100,000 live births having the virus, a new study released by researchers at the Centers for Disease Control and Prevention finds.

The report marks significant progress on the U.S. government’s goal to eradicate perinatal HIV, an immune-weakening and potentially deadly virus that is passed from mother to baby during pregnancy. Just 32 children in the country were diagnosed in 2019, compared with twice as many in 2010, according to the CDC.

Mothers who are HIV positive can prevent transmission of the infection by receiving antiretroviral therapy, according to Monica Gandhi, MD, MPH, a professor of medicine at University of California, San Francisco’s division of HIV, infectious disease and global medicine.

Dr. Gandhi said she could recall only one case of perinatal HIV in the San Francisco area over the last decade.

“This country has been really aggressive about counseling women who are pregnant and getting mothers in care,” Dr. Gandhi said.

The treatment method was discovered more than 30 years ago. Prior to the therapy and ensuing awareness campaigns to prevent transmission, mothers with HIV would typically pass the virus to their child in utero, during delivery, or while breastfeeding.

“There should be zero children born with HIV, given that we’ve had these drugs for so long,” Dr. Ghandi said. 
 

Disparities persist

But challenges remain in some communities, where babies born to Black mothers are disproportionately affected by the disease, the new study found. “Racial and ethnic differences in perinatal HIV diagnoses persisted through the 10-year period,” the report’s authors concluded. “The highest rates of perinatal HIV diagnoses were seen among infants born to Black women.”

Although rates of perinatal HIV declined for babies born to Black mothers over the decade-long study, the diagnosis rate was above the goal of elimination at 3.1 for every 100,000 live births, according to the data.

Meanwhile, transmission rates hovered around 1%-2% for Latinx and Hispanic women and mothers who identified as “other races,” including Native American.

Despite the availability of medication, expectant mothers may face several hurdles to getting the daily treatment they need to prevent transmission to their fetus, according to Jennifer Jao, MD, MPH, a physician of infectious diseases at Lurie Children’s Hospital of Chicago.

They might have trouble securing health insurance or finding transportation to doctor’s appointments, or face other problems like lacking secure housing or food – all factors that prevent them from prioritizing the care.

“All of those things play into the mix,” Dr. Jao said. “We see over and over again that closing the gap means you’ve got to reach the women who are pregnant and who don’t have resources.”
 

Progress in ‘danger’

Experts said they’re not sure what the impact of the COVID-19 pandemic, accompanied by a recent uptick in sexually transmitted diseases, will be on rates of perinatal HIV. Some women were unable to access prenatal health care during the pandemic because they couldn’t access public transportation or childcare, the U.S. Government Accountability Office said in 2022.

Globally, a decline in rates of HIV and AIDS rates has slowed, prompting the World Health Organization to warn last year that progress on the disease is in danger. Researchers only included HIV rates in the United States through 2019, so the data are outdated, Dr. Gandhi noted.

“All of this put together means we don’t know where we are with perinatal transmission over the last 3 years,” she said.

In an accompanying editorial, coauthors Nahida Chakhtoura, MD, MsGH, and Bill Kapogiannis, MD, both with the National Institutes of Health, urge health care professionals to take an active role in eliminating these racial and ethnic disparities in an effort to – as the title of their editorial proclaims – achieve a “road to zero perinatal HIV transmission” in the United States.

“The more proactive we are in identifying and promptly addressing systematic deficiencies that exacerbate health inequities in cutting-edge research innovations and optimal clinical service provision,” they write, “the less reactive we will need to be when new transmissible infections appear at our doorstep.”

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

Pediatricians increasingly are stepping in to prescribe drugs for anxiety and depression independently, easing the burden on subspecialists amid the child and adolescent mental health crisis, but a review of electronic health records highlights areas for improvement in delivering the care.

The findings were published online in Pediatrics.

The researchers, led by Talia R. Lester, MD, with the division of developmental behavioral pediatrics in the quantitative science unit at Stanford (Calif.) University, identified 1,685 patients aged 6-18 years who had at least one visit with a diagnosis of anxiety and/or depression in a large primary care network in northern California and who were prescribed an SSRI by a network primary care pediatrician (PCP). The team randomly chose 110 patients and reviewed charts from the visit when the SSRI was first prescribed (medication visit); the immediately previous visit; and immediately subsequent visit.
 

Encouraging signs

The chart reviews showed some encouraging signs. For example, when pediatricians prescribe an SSRI, 82% are appropriately documenting rationales for starting the medication at the medication visit. However, they are not monitoring medication side effects systematically, according to the report. Of 69 patients with a visit after the medication visit, fewer than half (48%) had documentation of monitoring for side effects.

Three areas for improvement

The researchers identified three main shortfall areas and suggested improvements.

PCPs often referred patients for unspecified therapy at the medication visit; however, they rarely prescribed evidence-based therapies such as cognitive-behavioral therapy (CBT) (4% of patients). The authors suggested embedding a summary of evidence-based treatment into order sets.

Secondly, PCPs are not often using screening tools. The data show only 26% of patients had a documented depression- or anxiety-specific screening tool result at the medication visit. The authors recommend making the screening tools accessible through the EHR to increase use.

The researchers also found many patients didn’t have a follow-up visit after SSRI medication was prescribed. Even when they did, the range was so wide between the medication visit and the follow-up (7-365 days) that it’s clear pediatricians are taking inconsistent approaches to scheduling follow-up.
 

Half are seeing only their primary care pediatrician

About half of children and adolescents prescribed an SSRI by a pediatrician for mental health reasons were seeing only their primary care pediatrician, the data showed.

Eric M. Butter, PhD, chief of psychology at Nationwide Children’s Hospital and Ohio State University, Columbus, pointed out in an accompanying editorial that some of the news in pediatricians’ expanded role is particularly encouraging.

Pediatricians, he noted, are making medication decisions consistent with decisions a subspecialist would make.

Of cases in which a subspecialist became involved after a pediatrician initiated medication, subspecialists changed the medication for only two patients, which “is encouraging because it validates pediatricians’ decisions,” Dr. Butter said.

It’s important for pediatricians to understand key evidence-based programs that can work in combination with medications to achieve better results, Dr. Butter said. For example, CBT can help with depression “and break the cycle of avoidance that worsens symptoms of anxiety.”

He highlighted Interpersonal Therapy for Adolescents, a 12-session treatment that “can also address depression by improving patients’ personal relationships.”

“No primary care pediatrician will have the training or time to implement the many treatments that are available,” Dr. Butter wrote. “However, pediatricians can work to understand the key features of the evidence-based treatments referenced by Lester et al.”
 

Most concerning statistics

Dr. Butter said the most concerning shortcoming in the pediatricians’ health care delivery was lack of referral for evidence-based psychological treatments and low rates for referral to access supports from schools through programs such as the education 504 plan and Individualized Education Plans.

Dr. Lester’s team found that pediatricians recommended that patients receive support from such programs in only 8% of cases.

“The children’s mental health crisis requires all child-serving health care providers to do more. Improved care for anxiety and depression in pediatric primary care is needed and does not have to be overly burdensome to pediatricians,” Dr. Butter wrote.

The authors and Dr. Butter declared no relevant financial relationships.

Pediatricians increasingly are stepping in to prescribe drugs for anxiety and depression independently, easing the burden on subspecialists amid the child and adolescent mental health crisis, but a review of electronic health records highlights areas for improvement in delivering the care.

The findings were published online in Pediatrics.

The researchers, led by Talia R. Lester, MD, with the division of developmental behavioral pediatrics in the quantitative science unit at Stanford (Calif.) University, identified 1,685 patients aged 6-18 years who had at least one visit with a diagnosis of anxiety and/or depression in a large primary care network in northern California and who were prescribed an SSRI by a network primary care pediatrician (PCP). The team randomly chose 110 patients and reviewed charts from the visit when the SSRI was first prescribed (medication visit); the immediately previous visit; and immediately subsequent visit.
 

Encouraging signs

The chart reviews showed some encouraging signs. For example, when pediatricians prescribe an SSRI, 82% are appropriately documenting rationales for starting the medication at the medication visit. However, they are not monitoring medication side effects systematically, according to the report. Of 69 patients with a visit after the medication visit, fewer than half (48%) had documentation of monitoring for side effects.

Three areas for improvement

The researchers identified three main shortfall areas and suggested improvements.

PCPs often referred patients for unspecified therapy at the medication visit; however, they rarely prescribed evidence-based therapies such as cognitive-behavioral therapy (CBT) (4% of patients). The authors suggested embedding a summary of evidence-based treatment into order sets.

Secondly, PCPs are not often using screening tools. The data show only 26% of patients had a documented depression- or anxiety-specific screening tool result at the medication visit. The authors recommend making the screening tools accessible through the EHR to increase use.

The researchers also found many patients didn’t have a follow-up visit after SSRI medication was prescribed. Even when they did, the range was so wide between the medication visit and the follow-up (7-365 days) that it’s clear pediatricians are taking inconsistent approaches to scheduling follow-up.
 

Half are seeing only their primary care pediatrician

About half of children and adolescents prescribed an SSRI by a pediatrician for mental health reasons were seeing only their primary care pediatrician, the data showed.

Eric M. Butter, PhD, chief of psychology at Nationwide Children’s Hospital and Ohio State University, Columbus, pointed out in an accompanying editorial that some of the news in pediatricians’ expanded role is particularly encouraging.

Pediatricians, he noted, are making medication decisions consistent with decisions a subspecialist would make.

Of cases in which a subspecialist became involved after a pediatrician initiated medication, subspecialists changed the medication for only two patients, which “is encouraging because it validates pediatricians’ decisions,” Dr. Butter said.

It’s important for pediatricians to understand key evidence-based programs that can work in combination with medications to achieve better results, Dr. Butter said. For example, CBT can help with depression “and break the cycle of avoidance that worsens symptoms of anxiety.”

He highlighted Interpersonal Therapy for Adolescents, a 12-session treatment that “can also address depression by improving patients’ personal relationships.”

“No primary care pediatrician will have the training or time to implement the many treatments that are available,” Dr. Butter wrote. “However, pediatricians can work to understand the key features of the evidence-based treatments referenced by Lester et al.”
 

Most concerning statistics

Dr. Butter said the most concerning shortcoming in the pediatricians’ health care delivery was lack of referral for evidence-based psychological treatments and low rates for referral to access supports from schools through programs such as the education 504 plan and Individualized Education Plans.

Dr. Lester’s team found that pediatricians recommended that patients receive support from such programs in only 8% of cases.

“The children’s mental health crisis requires all child-serving health care providers to do more. Improved care for anxiety and depression in pediatric primary care is needed and does not have to be overly burdensome to pediatricians,” Dr. Butter wrote.

The authors and Dr. Butter declared no relevant financial relationships.

Pediatricians increasingly are stepping in to prescribe drugs for anxiety and depression independently, easing the burden on subspecialists amid the child and adolescent mental health crisis, but a review of electronic health records highlights areas for improvement in delivering the care.

The findings were published online in Pediatrics.

The researchers, led by Talia R. Lester, MD, with the division of developmental behavioral pediatrics in the quantitative science unit at Stanford (Calif.) University, identified 1,685 patients aged 6-18 years who had at least one visit with a diagnosis of anxiety and/or depression in a large primary care network in northern California and who were prescribed an SSRI by a network primary care pediatrician (PCP). The team randomly chose 110 patients and reviewed charts from the visit when the SSRI was first prescribed (medication visit); the immediately previous visit; and immediately subsequent visit.
 

Encouraging signs

The chart reviews showed some encouraging signs. For example, when pediatricians prescribe an SSRI, 82% are appropriately documenting rationales for starting the medication at the medication visit. However, they are not monitoring medication side effects systematically, according to the report. Of 69 patients with a visit after the medication visit, fewer than half (48%) had documentation of monitoring for side effects.

Three areas for improvement

The researchers identified three main shortfall areas and suggested improvements.

PCPs often referred patients for unspecified therapy at the medication visit; however, they rarely prescribed evidence-based therapies such as cognitive-behavioral therapy (CBT) (4% of patients). The authors suggested embedding a summary of evidence-based treatment into order sets.

Secondly, PCPs are not often using screening tools. The data show only 26% of patients had a documented depression- or anxiety-specific screening tool result at the medication visit. The authors recommend making the screening tools accessible through the EHR to increase use.

The researchers also found many patients didn’t have a follow-up visit after SSRI medication was prescribed. Even when they did, the range was so wide between the medication visit and the follow-up (7-365 days) that it’s clear pediatricians are taking inconsistent approaches to scheduling follow-up.
 

Half are seeing only their primary care pediatrician

About half of children and adolescents prescribed an SSRI by a pediatrician for mental health reasons were seeing only their primary care pediatrician, the data showed.

Eric M. Butter, PhD, chief of psychology at Nationwide Children’s Hospital and Ohio State University, Columbus, pointed out in an accompanying editorial that some of the news in pediatricians’ expanded role is particularly encouraging.

Pediatricians, he noted, are making medication decisions consistent with decisions a subspecialist would make.

Of cases in which a subspecialist became involved after a pediatrician initiated medication, subspecialists changed the medication for only two patients, which “is encouraging because it validates pediatricians’ decisions,” Dr. Butter said.

It’s important for pediatricians to understand key evidence-based programs that can work in combination with medications to achieve better results, Dr. Butter said. For example, CBT can help with depression “and break the cycle of avoidance that worsens symptoms of anxiety.”

He highlighted Interpersonal Therapy for Adolescents, a 12-session treatment that “can also address depression by improving patients’ personal relationships.”

“No primary care pediatrician will have the training or time to implement the many treatments that are available,” Dr. Butter wrote. “However, pediatricians can work to understand the key features of the evidence-based treatments referenced by Lester et al.”
 

Most concerning statistics

Dr. Butter said the most concerning shortcoming in the pediatricians’ health care delivery was lack of referral for evidence-based psychological treatments and low rates for referral to access supports from schools through programs such as the education 504 plan and Individualized Education Plans.

Dr. Lester’s team found that pediatricians recommended that patients receive support from such programs in only 8% of cases.

“The children’s mental health crisis requires all child-serving health care providers to do more. Improved care for anxiety and depression in pediatric primary care is needed and does not have to be overly burdensome to pediatricians,” Dr. Butter wrote.

The authors and Dr. Butter declared no relevant financial relationships.

The new COVID-19 strain known as “Arcturus” has increased in the United States so much that it has been added to the Centers for Disease and Control’s watch list.

Officially labeled XBB.1.16, Arcturus is a subvariant of Omicron that was first seen in India and has been on the World Health Organization’s watchlist since the end of March. The CDC’s most recent update now lists Arcturus as causing 7% of U.S. coronavirus cases, landing it in second place behind its long-predominant Omicron cousin XBB.1.5, which causes 78% of cases.

Arcturus is more transmissible but not more dangerous than recent chart-topping strains, experts say.

“It is causing increasing case counts in certain parts of the world, including India. We’re not seeing high rates of XBB.1.16 yet in the United States, but it may become more prominent in coming weeks,” Mayo Clinic viral disease expert Matthew Binnicker, PhD, told The Seattle Times.

Arcturus has been causing a new symptom in children, Indian medical providers have reported.

“One new feature of cases caused by this variant is that it seems to be causing conjunctivitis, or red and itchy eyes, in young patients,” Dr. Binnicker said. “This is not something that we’ve seen with prior strains of the virus.”

More than 11,000 people in the United States remained hospitalized with COVID at the end of last week, and 1,327 people died of the virus last week, CDC data show. To date, 6.9 million people worldwide have died from COVID, the WHO says. Of those deaths, more than 1.1 million occurred in the U.S.

A version of this article originally appeared on WebMD.com.

The new COVID-19 strain known as “Arcturus” has increased in the United States so much that it has been added to the Centers for Disease and Control’s watch list.

Officially labeled XBB.1.16, Arcturus is a subvariant of Omicron that was first seen in India and has been on the World Health Organization’s watchlist since the end of March. The CDC’s most recent update now lists Arcturus as causing 7% of U.S. coronavirus cases, landing it in second place behind its long-predominant Omicron cousin XBB.1.5, which causes 78% of cases.

Arcturus is more transmissible but not more dangerous than recent chart-topping strains, experts say.

“It is causing increasing case counts in certain parts of the world, including India. We’re not seeing high rates of XBB.1.16 yet in the United States, but it may become more prominent in coming weeks,” Mayo Clinic viral disease expert Matthew Binnicker, PhD, told The Seattle Times.

Arcturus has been causing a new symptom in children, Indian medical providers have reported.

“One new feature of cases caused by this variant is that it seems to be causing conjunctivitis, or red and itchy eyes, in young patients,” Dr. Binnicker said. “This is not something that we’ve seen with prior strains of the virus.”

More than 11,000 people in the United States remained hospitalized with COVID at the end of last week, and 1,327 people died of the virus last week, CDC data show. To date, 6.9 million people worldwide have died from COVID, the WHO says. Of those deaths, more than 1.1 million occurred in the U.S.

A version of this article originally appeared on WebMD.com.

The new COVID-19 strain known as “Arcturus” has increased in the United States so much that it has been added to the Centers for Disease and Control’s watch list.

Officially labeled XBB.1.16, Arcturus is a subvariant of Omicron that was first seen in India and has been on the World Health Organization’s watchlist since the end of March. The CDC’s most recent update now lists Arcturus as causing 7% of U.S. coronavirus cases, landing it in second place behind its long-predominant Omicron cousin XBB.1.5, which causes 78% of cases.

Arcturus is more transmissible but not more dangerous than recent chart-topping strains, experts say.

“It is causing increasing case counts in certain parts of the world, including India. We’re not seeing high rates of XBB.1.16 yet in the United States, but it may become more prominent in coming weeks,” Mayo Clinic viral disease expert Matthew Binnicker, PhD, told The Seattle Times.

Arcturus has been causing a new symptom in children, Indian medical providers have reported.

“One new feature of cases caused by this variant is that it seems to be causing conjunctivitis, or red and itchy eyes, in young patients,” Dr. Binnicker said. “This is not something that we’ve seen with prior strains of the virus.”

More than 11,000 people in the United States remained hospitalized with COVID at the end of last week, and 1,327 people died of the virus last week, CDC data show. To date, 6.9 million people worldwide have died from COVID, the WHO says. Of those deaths, more than 1.1 million occurred in the U.S.

A version of this article originally appeared on WebMD.com.