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New EPOCH for adult patients with Burkitt lymphoma
Adult patients with Burkitt lymphoma can achieve equally sound survival outcomes with dose-adjusted chemotherapy versus high-intensity regimens, but can do so while avoiding the severe toxicities, U.S. study data shows.
Although Burkitt lymphoma is the most common B-cell non-Hodgkin lymphoma in children, it accounts for only 1% to 2% of adult lymphoma cases.
Highly dose-intensive chemotherapy regimens, developed for children and young adults, have rendered the disease curable. But older patients in particular, and patients with comorbidities such as HIV, can suffer severe adverse effects, as well as late sequelae like second malignancies.
Mark Roschewski, MD, from the lymphoid malignancies branch at the National Cancer Institute in Bethesda, Md., and colleagues therefore examined whether a dose-adjusted regimen would maintain outcomes while reducing toxicities.
Tailoring treatment with etoposide, doxorubicin, and vincristine with prednisone, cyclophosphamide, and rituximab (EPOCH-R) to whether patients had high- or low-risk disease, they achieved 4-year survival rates of higher than 85%.
The research, published by the Journal of Clinical Oncology, also showed that patients taking the regimen, which was well tolerated, had low rates of relapse in the central nervous system.
The team reports that their results with the dose-adjusted regimen “significantly improve on the complexity, cost, and toxicity profile of other regimens,” also highlighting that it is administered on an outpatient basis.
As the outcomes also “compare favorably” with those with high intensity regimens, they say the findings “support our treatment strategies to ameliorate toxicity while maintaining efficacy.”
Importantly, they suggest highly dose-intensive chemotherapy is unnecessary for cure, and carefully defined low-risk patients may be treated with limited chemotherapy.
Dr. Roschewski said in an interview that, in patients aged 40 years and older, dose-adjusted EPOCH-R is “probably the preferred choice,” despite its “weakness” in controlling the disease in patients with active CNS involvement.
However, the “real question” is what to use in younger patients, Dr. Roschewski said, as the “unknown” is whether the additional magnitude of a high-intensity regimen that “gets into the CNS” outweighs the risk of toxicities.
“What was important about our study,” he said, was that patients with CNS involvement “did the worst but it was equally split among patients that died of toxicity and patients that progressed.”
In other words, each choice increases one risk while decreasing another. “So I would have to have that discussion with the patient, and individual patient decisions are typically based on the details,” said Dr. Roschewski.
One issue, however, that could limit the adoption of dose-adjusted EPOCH-R is that, without a randomized study comparing it directly with a high-intensity regimen, clinicians may to stick to what they know.
Dr. Roschewski said that “this is particularly true of more experienced clinicians.”
“They’re less likely, I think, to adopt something else outside of a randomized study because our natural inclination with this disease has always been dose intensity is critical. ... This is a dogma, and to shift from that probably does require a higher level of evidence, at least for some practitioners,” he explained.
Further study details
Following a pilot study of dose-adjusted EPOCH-R in 30 adult patients in which the authors say the regimen showed “high efficacy,” they enrolled 113 patients with untreated Burkitt lymphoma at 22 centers between June 2010 and May 2017.
The patients were divided into low-risk and high-risk categories, with low-risk defined as stage 1 or 2 disease, normal lactate dehydrogenase levels, ECOG performance status ≤ 1, and no tumor mass ≥ 7 cm.
High-risk patients were given six cycles of dose-adjusted EPOCH-R (with rituximab on day 1 only) along with CNS prophylaxis or active therapy with intrathecal methotrexate.
In contrast, low-risk patients were given two cycles of dose-adjusted EPOCH-R, with rituximab on days 1 and 5, followed by positron emission tomography.
If that was negative, the patients had one additional treatment cycle and no CNS prophylaxis, but if it was positive, they were given four additional cycles, plus intrathecal methotrexate.
Of the 113 patients enrolled, 79% were male, median age was 49 years, and 62% were aged at least 40 years, including 26% aged at least 60 years.
The team determined that 13% of the patients were of low risk, 87% were high risk, and 11% had cerebrospinal fluid involvement. One-quarter (24.7%) were HIV positive, with a median CD4+ T-cell count of 268 cells/mm3.
The majority (87%) of low-risk patients received three treatment cycles, and 82% of high-risk patents were administered six treatment cycles.
Over a median follow-up of 58.7 months (4.9 years), the 4-year event-free survival (EFS) rate across the whole cohort was 84.5% and overall survival was 87%.
At the time of analysis, all low-risk patients were in remission; among high-risk patients, the 4-year EFS was 82.1% and overall survival was 84.9%.
The team reports that treatment was equally effective across age groups, and irrespective of HIV status and International Prognostic Index risk group.
Only 2% of high-risk patients with no pretreatment evidence of CNS involvement had relapses in the brain parenchyma. Just over half (55%) of patients with cerebrospinal fluid involvement at presentation experienced disease progression or died.
Five patients died of treatment-related toxicity. Grade 3/4 thrombocytopenia occurred during 17% of cycles, and febrile neutropenia was seen during 16%. Tumor lysis syndrome was rare, occurring in 5% of patients.
Next, the researchers are planning on focusing on CNS disease, looking at EPOCH-R as the backbone and adding intrathecal methotrexate and an additional targeted agent with known CNS penetration.
Dr. Roschewski said that is “a very attractive strategy and ... we will initiate enrollment in that study probably in the next couple of months here at the NCI,” he added, noting that it will be an early phase 1 study.
Another issue he identified that “doesn’t get spoken about quite as much but I do think is important is potentially working on supportive care guidelines for how we manage these patients.” Dr. Roschewski explained, “One of the things you see over and over in these Burkitt lymphoma studies is that some patients don’t make it through therapy because they’re so sick at the beginning, and they have certain risks.
“I think simply improving that type of care, independent of what regimen is used, can potentially improve the outcomes across patient groups.”
The study was funded by the National Cancer Institute, National Institutes of Health, AIDS Malignancy Consortium, and the Cancer Therapy Evaluation Program and Lymphoid Malignancies Branch. The authors have disclosed no relevant financial relationships.
A version of this article originally appeared on Medscape.com.
Adult patients with Burkitt lymphoma can achieve equally sound survival outcomes with dose-adjusted chemotherapy versus high-intensity regimens, but can do so while avoiding the severe toxicities, U.S. study data shows.
Although Burkitt lymphoma is the most common B-cell non-Hodgkin lymphoma in children, it accounts for only 1% to 2% of adult lymphoma cases.
Highly dose-intensive chemotherapy regimens, developed for children and young adults, have rendered the disease curable. But older patients in particular, and patients with comorbidities such as HIV, can suffer severe adverse effects, as well as late sequelae like second malignancies.
Mark Roschewski, MD, from the lymphoid malignancies branch at the National Cancer Institute in Bethesda, Md., and colleagues therefore examined whether a dose-adjusted regimen would maintain outcomes while reducing toxicities.
Tailoring treatment with etoposide, doxorubicin, and vincristine with prednisone, cyclophosphamide, and rituximab (EPOCH-R) to whether patients had high- or low-risk disease, they achieved 4-year survival rates of higher than 85%.
The research, published by the Journal of Clinical Oncology, also showed that patients taking the regimen, which was well tolerated, had low rates of relapse in the central nervous system.
The team reports that their results with the dose-adjusted regimen “significantly improve on the complexity, cost, and toxicity profile of other regimens,” also highlighting that it is administered on an outpatient basis.
As the outcomes also “compare favorably” with those with high intensity regimens, they say the findings “support our treatment strategies to ameliorate toxicity while maintaining efficacy.”
Importantly, they suggest highly dose-intensive chemotherapy is unnecessary for cure, and carefully defined low-risk patients may be treated with limited chemotherapy.
Dr. Roschewski said in an interview that, in patients aged 40 years and older, dose-adjusted EPOCH-R is “probably the preferred choice,” despite its “weakness” in controlling the disease in patients with active CNS involvement.
However, the “real question” is what to use in younger patients, Dr. Roschewski said, as the “unknown” is whether the additional magnitude of a high-intensity regimen that “gets into the CNS” outweighs the risk of toxicities.
“What was important about our study,” he said, was that patients with CNS involvement “did the worst but it was equally split among patients that died of toxicity and patients that progressed.”
In other words, each choice increases one risk while decreasing another. “So I would have to have that discussion with the patient, and individual patient decisions are typically based on the details,” said Dr. Roschewski.
One issue, however, that could limit the adoption of dose-adjusted EPOCH-R is that, without a randomized study comparing it directly with a high-intensity regimen, clinicians may to stick to what they know.
Dr. Roschewski said that “this is particularly true of more experienced clinicians.”
“They’re less likely, I think, to adopt something else outside of a randomized study because our natural inclination with this disease has always been dose intensity is critical. ... This is a dogma, and to shift from that probably does require a higher level of evidence, at least for some practitioners,” he explained.
Further study details
Following a pilot study of dose-adjusted EPOCH-R in 30 adult patients in which the authors say the regimen showed “high efficacy,” they enrolled 113 patients with untreated Burkitt lymphoma at 22 centers between June 2010 and May 2017.
The patients were divided into low-risk and high-risk categories, with low-risk defined as stage 1 or 2 disease, normal lactate dehydrogenase levels, ECOG performance status ≤ 1, and no tumor mass ≥ 7 cm.
High-risk patients were given six cycles of dose-adjusted EPOCH-R (with rituximab on day 1 only) along with CNS prophylaxis or active therapy with intrathecal methotrexate.
In contrast, low-risk patients were given two cycles of dose-adjusted EPOCH-R, with rituximab on days 1 and 5, followed by positron emission tomography.
If that was negative, the patients had one additional treatment cycle and no CNS prophylaxis, but if it was positive, they were given four additional cycles, plus intrathecal methotrexate.
Of the 113 patients enrolled, 79% were male, median age was 49 years, and 62% were aged at least 40 years, including 26% aged at least 60 years.
The team determined that 13% of the patients were of low risk, 87% were high risk, and 11% had cerebrospinal fluid involvement. One-quarter (24.7%) were HIV positive, with a median CD4+ T-cell count of 268 cells/mm3.
The majority (87%) of low-risk patients received three treatment cycles, and 82% of high-risk patents were administered six treatment cycles.
Over a median follow-up of 58.7 months (4.9 years), the 4-year event-free survival (EFS) rate across the whole cohort was 84.5% and overall survival was 87%.
At the time of analysis, all low-risk patients were in remission; among high-risk patients, the 4-year EFS was 82.1% and overall survival was 84.9%.
The team reports that treatment was equally effective across age groups, and irrespective of HIV status and International Prognostic Index risk group.
Only 2% of high-risk patients with no pretreatment evidence of CNS involvement had relapses in the brain parenchyma. Just over half (55%) of patients with cerebrospinal fluid involvement at presentation experienced disease progression or died.
Five patients died of treatment-related toxicity. Grade 3/4 thrombocytopenia occurred during 17% of cycles, and febrile neutropenia was seen during 16%. Tumor lysis syndrome was rare, occurring in 5% of patients.
Next, the researchers are planning on focusing on CNS disease, looking at EPOCH-R as the backbone and adding intrathecal methotrexate and an additional targeted agent with known CNS penetration.
Dr. Roschewski said that is “a very attractive strategy and ... we will initiate enrollment in that study probably in the next couple of months here at the NCI,” he added, noting that it will be an early phase 1 study.
Another issue he identified that “doesn’t get spoken about quite as much but I do think is important is potentially working on supportive care guidelines for how we manage these patients.” Dr. Roschewski explained, “One of the things you see over and over in these Burkitt lymphoma studies is that some patients don’t make it through therapy because they’re so sick at the beginning, and they have certain risks.
“I think simply improving that type of care, independent of what regimen is used, can potentially improve the outcomes across patient groups.”
The study was funded by the National Cancer Institute, National Institutes of Health, AIDS Malignancy Consortium, and the Cancer Therapy Evaluation Program and Lymphoid Malignancies Branch. The authors have disclosed no relevant financial relationships.
A version of this article originally appeared on Medscape.com.
Adult patients with Burkitt lymphoma can achieve equally sound survival outcomes with dose-adjusted chemotherapy versus high-intensity regimens, but can do so while avoiding the severe toxicities, U.S. study data shows.
Although Burkitt lymphoma is the most common B-cell non-Hodgkin lymphoma in children, it accounts for only 1% to 2% of adult lymphoma cases.
Highly dose-intensive chemotherapy regimens, developed for children and young adults, have rendered the disease curable. But older patients in particular, and patients with comorbidities such as HIV, can suffer severe adverse effects, as well as late sequelae like second malignancies.
Mark Roschewski, MD, from the lymphoid malignancies branch at the National Cancer Institute in Bethesda, Md., and colleagues therefore examined whether a dose-adjusted regimen would maintain outcomes while reducing toxicities.
Tailoring treatment with etoposide, doxorubicin, and vincristine with prednisone, cyclophosphamide, and rituximab (EPOCH-R) to whether patients had high- or low-risk disease, they achieved 4-year survival rates of higher than 85%.
The research, published by the Journal of Clinical Oncology, also showed that patients taking the regimen, which was well tolerated, had low rates of relapse in the central nervous system.
The team reports that their results with the dose-adjusted regimen “significantly improve on the complexity, cost, and toxicity profile of other regimens,” also highlighting that it is administered on an outpatient basis.
As the outcomes also “compare favorably” with those with high intensity regimens, they say the findings “support our treatment strategies to ameliorate toxicity while maintaining efficacy.”
Importantly, they suggest highly dose-intensive chemotherapy is unnecessary for cure, and carefully defined low-risk patients may be treated with limited chemotherapy.
Dr. Roschewski said in an interview that, in patients aged 40 years and older, dose-adjusted EPOCH-R is “probably the preferred choice,” despite its “weakness” in controlling the disease in patients with active CNS involvement.
However, the “real question” is what to use in younger patients, Dr. Roschewski said, as the “unknown” is whether the additional magnitude of a high-intensity regimen that “gets into the CNS” outweighs the risk of toxicities.
“What was important about our study,” he said, was that patients with CNS involvement “did the worst but it was equally split among patients that died of toxicity and patients that progressed.”
In other words, each choice increases one risk while decreasing another. “So I would have to have that discussion with the patient, and individual patient decisions are typically based on the details,” said Dr. Roschewski.
One issue, however, that could limit the adoption of dose-adjusted EPOCH-R is that, without a randomized study comparing it directly with a high-intensity regimen, clinicians may to stick to what they know.
Dr. Roschewski said that “this is particularly true of more experienced clinicians.”
“They’re less likely, I think, to adopt something else outside of a randomized study because our natural inclination with this disease has always been dose intensity is critical. ... This is a dogma, and to shift from that probably does require a higher level of evidence, at least for some practitioners,” he explained.
Further study details
Following a pilot study of dose-adjusted EPOCH-R in 30 adult patients in which the authors say the regimen showed “high efficacy,” they enrolled 113 patients with untreated Burkitt lymphoma at 22 centers between June 2010 and May 2017.
The patients were divided into low-risk and high-risk categories, with low-risk defined as stage 1 or 2 disease, normal lactate dehydrogenase levels, ECOG performance status ≤ 1, and no tumor mass ≥ 7 cm.
High-risk patients were given six cycles of dose-adjusted EPOCH-R (with rituximab on day 1 only) along with CNS prophylaxis or active therapy with intrathecal methotrexate.
In contrast, low-risk patients were given two cycles of dose-adjusted EPOCH-R, with rituximab on days 1 and 5, followed by positron emission tomography.
If that was negative, the patients had one additional treatment cycle and no CNS prophylaxis, but if it was positive, they were given four additional cycles, plus intrathecal methotrexate.
Of the 113 patients enrolled, 79% were male, median age was 49 years, and 62% were aged at least 40 years, including 26% aged at least 60 years.
The team determined that 13% of the patients were of low risk, 87% were high risk, and 11% had cerebrospinal fluid involvement. One-quarter (24.7%) were HIV positive, with a median CD4+ T-cell count of 268 cells/mm3.
The majority (87%) of low-risk patients received three treatment cycles, and 82% of high-risk patents were administered six treatment cycles.
Over a median follow-up of 58.7 months (4.9 years), the 4-year event-free survival (EFS) rate across the whole cohort was 84.5% and overall survival was 87%.
At the time of analysis, all low-risk patients were in remission; among high-risk patients, the 4-year EFS was 82.1% and overall survival was 84.9%.
The team reports that treatment was equally effective across age groups, and irrespective of HIV status and International Prognostic Index risk group.
Only 2% of high-risk patients with no pretreatment evidence of CNS involvement had relapses in the brain parenchyma. Just over half (55%) of patients with cerebrospinal fluid involvement at presentation experienced disease progression or died.
Five patients died of treatment-related toxicity. Grade 3/4 thrombocytopenia occurred during 17% of cycles, and febrile neutropenia was seen during 16%. Tumor lysis syndrome was rare, occurring in 5% of patients.
Next, the researchers are planning on focusing on CNS disease, looking at EPOCH-R as the backbone and adding intrathecal methotrexate and an additional targeted agent with known CNS penetration.
Dr. Roschewski said that is “a very attractive strategy and ... we will initiate enrollment in that study probably in the next couple of months here at the NCI,” he added, noting that it will be an early phase 1 study.
Another issue he identified that “doesn’t get spoken about quite as much but I do think is important is potentially working on supportive care guidelines for how we manage these patients.” Dr. Roschewski explained, “One of the things you see over and over in these Burkitt lymphoma studies is that some patients don’t make it through therapy because they’re so sick at the beginning, and they have certain risks.
“I think simply improving that type of care, independent of what regimen is used, can potentially improve the outcomes across patient groups.”
The study was funded by the National Cancer Institute, National Institutes of Health, AIDS Malignancy Consortium, and the Cancer Therapy Evaluation Program and Lymphoid Malignancies Branch. The authors have disclosed no relevant financial relationships.
A version of this article originally appeared on Medscape.com.
Your diet may be aging you
Recent studies have shown a correlation between many dietary elements and skin diseases including acne, rosacea, and perioral dermatitis. and there is now evidence that the aging process can also be slowed with a healthy diet. Previous studies have shown that intake of vegetables, fish, and foods high in vitamin C, carotenoids, olive oil, and linoleic acid are associated with decreased wrinkles.
In a Dutch population-based cohort study published in the Journal of the American Academy of Dermatology in 2019, Mekić et al. investigated the association between diet and facial wrinkles in an elderly population. Facial photographs were used to evaluate wrinkle severity and diet of the participants was assessed with the Food Frequency Questionnaire and adherence to the Dutch Healthy Diet Index (DHDI).
The DHDI is a measure of the ability to adhere to the Dutch Guidelines for a Healthy Diet. The guidelines recommend a daily intake in the diet of at least 200 g of vegetables daily; at least 200 g of fruit; 90 g of brown bread, wholemeal bread, or other whole-grain products; and at least 15 g of unsalted nuts. One serving of fish (preferably oily fish) per week and little to no dairy, alcohol, red meat, cooking fats, and sugar is also recommended.
The study revealed that better adherence to the DHDI was significantly associated with fewer wrinkles among women but not men. Women who ate more animal meat and fats and carbohydrates had more wrinkles than did those with a fruit-dominant diet.
Although other healthy behaviors such as exercise and alcohol are likely to play a role in confounding these data, UV exposure as a cause of wrinkling was accounted for, and in the study, increased outdoor exercise was associated with more wrinkles. Unhealthy food can induce oxidative stress, increased skin and gut inflammation, and glycation, which are some of the physiologic mechanisms suggested to increase wrinkle formation. In contrast, nutrients in fruits and vegetables stimulate collagen production and DNA repair and reduce oxidative stress on the skin.
Nutritional advice is largely rare in internal medicine, cardiology, and even endocrinology. We are developing better ways to assess and understand the way foods interact and cause inflammation of the gut and the body and skin. I highly recommend nutritional education be a part of our residency training programs and to make better guidelines on the prevention of skin disease and aging available for both practitioners and patients.
Dr. Wesley and Dr. Talakoub are cocontributors to this column. Dr. Wesley practices dermatology in Beverly Hills, Calif. Dr. Talakoub is in private practice in McLean, Va. This month’s column is by Dr. Talakoub. Write to them at dermnews@mdedge.com. They had no relevant disclosures.
References
Mekić S et al. J Am Acad Dermatol. 2019 May;80(5):1358-1363.e2.
Purba MB et al. J Am Coll Nutr. 2001;20(1):71‐80.
van Lee L et al. Nutr J. 2012 Jul 20;11:49.
Kromhout D et al. Eur J Clin Nutr. 2016 Aug;70(8):869‐78.
Recent studies have shown a correlation between many dietary elements and skin diseases including acne, rosacea, and perioral dermatitis. and there is now evidence that the aging process can also be slowed with a healthy diet. Previous studies have shown that intake of vegetables, fish, and foods high in vitamin C, carotenoids, olive oil, and linoleic acid are associated with decreased wrinkles.
In a Dutch population-based cohort study published in the Journal of the American Academy of Dermatology in 2019, Mekić et al. investigated the association between diet and facial wrinkles in an elderly population. Facial photographs were used to evaluate wrinkle severity and diet of the participants was assessed with the Food Frequency Questionnaire and adherence to the Dutch Healthy Diet Index (DHDI).
The DHDI is a measure of the ability to adhere to the Dutch Guidelines for a Healthy Diet. The guidelines recommend a daily intake in the diet of at least 200 g of vegetables daily; at least 200 g of fruit; 90 g of brown bread, wholemeal bread, or other whole-grain products; and at least 15 g of unsalted nuts. One serving of fish (preferably oily fish) per week and little to no dairy, alcohol, red meat, cooking fats, and sugar is also recommended.
The study revealed that better adherence to the DHDI was significantly associated with fewer wrinkles among women but not men. Women who ate more animal meat and fats and carbohydrates had more wrinkles than did those with a fruit-dominant diet.
Although other healthy behaviors such as exercise and alcohol are likely to play a role in confounding these data, UV exposure as a cause of wrinkling was accounted for, and in the study, increased outdoor exercise was associated with more wrinkles. Unhealthy food can induce oxidative stress, increased skin and gut inflammation, and glycation, which are some of the physiologic mechanisms suggested to increase wrinkle formation. In contrast, nutrients in fruits and vegetables stimulate collagen production and DNA repair and reduce oxidative stress on the skin.
Nutritional advice is largely rare in internal medicine, cardiology, and even endocrinology. We are developing better ways to assess and understand the way foods interact and cause inflammation of the gut and the body and skin. I highly recommend nutritional education be a part of our residency training programs and to make better guidelines on the prevention of skin disease and aging available for both practitioners and patients.
Dr. Wesley and Dr. Talakoub are cocontributors to this column. Dr. Wesley practices dermatology in Beverly Hills, Calif. Dr. Talakoub is in private practice in McLean, Va. This month’s column is by Dr. Talakoub. Write to them at dermnews@mdedge.com. They had no relevant disclosures.
References
Mekić S et al. J Am Acad Dermatol. 2019 May;80(5):1358-1363.e2.
Purba MB et al. J Am Coll Nutr. 2001;20(1):71‐80.
van Lee L et al. Nutr J. 2012 Jul 20;11:49.
Kromhout D et al. Eur J Clin Nutr. 2016 Aug;70(8):869‐78.
Recent studies have shown a correlation between many dietary elements and skin diseases including acne, rosacea, and perioral dermatitis. and there is now evidence that the aging process can also be slowed with a healthy diet. Previous studies have shown that intake of vegetables, fish, and foods high in vitamin C, carotenoids, olive oil, and linoleic acid are associated with decreased wrinkles.
In a Dutch population-based cohort study published in the Journal of the American Academy of Dermatology in 2019, Mekić et al. investigated the association between diet and facial wrinkles in an elderly population. Facial photographs were used to evaluate wrinkle severity and diet of the participants was assessed with the Food Frequency Questionnaire and adherence to the Dutch Healthy Diet Index (DHDI).
The DHDI is a measure of the ability to adhere to the Dutch Guidelines for a Healthy Diet. The guidelines recommend a daily intake in the diet of at least 200 g of vegetables daily; at least 200 g of fruit; 90 g of brown bread, wholemeal bread, or other whole-grain products; and at least 15 g of unsalted nuts. One serving of fish (preferably oily fish) per week and little to no dairy, alcohol, red meat, cooking fats, and sugar is also recommended.
The study revealed that better adherence to the DHDI was significantly associated with fewer wrinkles among women but not men. Women who ate more animal meat and fats and carbohydrates had more wrinkles than did those with a fruit-dominant diet.
Although other healthy behaviors such as exercise and alcohol are likely to play a role in confounding these data, UV exposure as a cause of wrinkling was accounted for, and in the study, increased outdoor exercise was associated with more wrinkles. Unhealthy food can induce oxidative stress, increased skin and gut inflammation, and glycation, which are some of the physiologic mechanisms suggested to increase wrinkle formation. In contrast, nutrients in fruits and vegetables stimulate collagen production and DNA repair and reduce oxidative stress on the skin.
Nutritional advice is largely rare in internal medicine, cardiology, and even endocrinology. We are developing better ways to assess and understand the way foods interact and cause inflammation of the gut and the body and skin. I highly recommend nutritional education be a part of our residency training programs and to make better guidelines on the prevention of skin disease and aging available for both practitioners and patients.
Dr. Wesley and Dr. Talakoub are cocontributors to this column. Dr. Wesley practices dermatology in Beverly Hills, Calif. Dr. Talakoub is in private practice in McLean, Va. This month’s column is by Dr. Talakoub. Write to them at dermnews@mdedge.com. They had no relevant disclosures.
References
Mekić S et al. J Am Acad Dermatol. 2019 May;80(5):1358-1363.e2.
Purba MB et al. J Am Coll Nutr. 2001;20(1):71‐80.
van Lee L et al. Nutr J. 2012 Jul 20;11:49.
Kromhout D et al. Eur J Clin Nutr. 2016 Aug;70(8):869‐78.
Dermatology News welcomes new advisory board member
at University Hospital Saint-Louis in Paris, in the inflammatory diseases outpatient clinic, where he treats patients with severe psoriasis and other inflammatory chronic skin diseases.
He is a member of several dermatology specialty organizations, including the Société Française de Dermatologie, the European Academy of Dermatology, as well as the American Academy of Dermatology. His research interests are in immunology and inflammatory diseases; he also has a passion for art and history.
at University Hospital Saint-Louis in Paris, in the inflammatory diseases outpatient clinic, where he treats patients with severe psoriasis and other inflammatory chronic skin diseases.
He is a member of several dermatology specialty organizations, including the Société Française de Dermatologie, the European Academy of Dermatology, as well as the American Academy of Dermatology. His research interests are in immunology and inflammatory diseases; he also has a passion for art and history.
at University Hospital Saint-Louis in Paris, in the inflammatory diseases outpatient clinic, where he treats patients with severe psoriasis and other inflammatory chronic skin diseases.
He is a member of several dermatology specialty organizations, including the Société Française de Dermatologie, the European Academy of Dermatology, as well as the American Academy of Dermatology. His research interests are in immunology and inflammatory diseases; he also has a passion for art and history.
Frequent hypoglycemic episodes raise cardiac event risk
Frequent hypoglycemic episodes were linked to a raised incidence of cardiovascular events in adults with type 2 diabetes in a recent retrospective study, suggesting certain hypoglycemia-associated diabetes drugs should be avoided, an investigator said.
Patients who had more than five hypoglycemic episodes per year had a 61% greater risk of cardiovascular (CV) events, compared with patients with less frequent episodes, according to results of the study.
Although there were fewer strokes among younger patients, the overall increase in cardiovascular event risk held up regardless of age group, according to investigator Aman Rajpal, MD, of Louis Stokes Veterans Affairs Medical Center and Case Western Reserve University, both in Cleveland.
On the basis of these and earlier studies tying hypoglycemia to CV risk, health care providers need to “pay close attention” to low blood sugar and personalize glycemic control targets for each patient based on risk of hypoglycemia, Dr. Rajpal said in a presentation of the study at the virtual annual scientific sessions of the American Diabetes Association.
“Also, this suggests that avoidance of drugs associated with increased risk of hypoglycemia – namely insulin, sulfonylureas, or others – is essential to avoid and minimize the risk of cardiovascular events in this patient population with type 2 diabetes,” said Dr. Rajpal. “Let us remember part of our Hippocratic oath: ‘Above all, do no harm.’ ”
Tailoring treatment to mitigate risk
Mark Schutta, MD, medical director of Penn Rodebaugh Diabetes Center in Philadelphia, said that results of this study suggest a need to carefully select medical therapy for each individual patient with diabetes in order to mitigate CV risk.
“It’s really about tailoring their drugs to their personal situation,” Dr. Schutta said in an interview.
Although newer diabetes drug classes are associated with low to no risk of hypoglycemia, Dr. Schutta said that there is still a place for drugs such as sulfonylureas in certain situations.
Among sulfonylureas, glyburide comes with a much higher incidence of hypoglycemia, compared with glipizide and glimepiride, according to Dr. Schutta. “I think there’s a role for both drugs, but you have to be very careful, and you have to get the data from your patients.”
Hypoglycemia frequency and outcomes
Speculation that hypoglycemia could be linked to adverse CV outcomes was sparked years ago by trials such as ADVANCE. Severe hypoglycemia in that study was associated with a 168% increased risk of death from a CV cause (N Engl J Med. 2010 Oct 7;363:1410-8).
At the time, ADVANCE investigators said they were unable to find evidence that multiple severe hypoglycemia episodes conferred a greater risk of CV events versus a single hypoglycemia episode, though they added that few patients had recurrent events.
“In other words, the association between the number of hypoglycemia events, and adverse CV outcomes is still unclear,” said Dr. Rajpal in his virtual ADA presentation.
Potential elevated risks with more than five episodes
To evaluate the association between frequent hypoglycemic episodes (i.e., more than five per year, compared with one to five episodes) and CV events, Dr. Rajpal and colleagues evaluated outcomes data for 4.9 million adults with type 2 diabetes found in a large commercial database including information on patients in 27 U.S. health care networks.
Database records indicated that about 182,000 patients, or nearly 4%, had episodes of hyperglycemia, which Dr. Rajpal said was presumed to mean a plasma glucose level of less than 70 mg/dL.
Characteristics of the patients with more than five hypoglycemic episodes were similar to those with one to five episodes, although they were more likely to be 65 years or older, and were “slightly more likely” to be on insulin, which could possibly precipitate more hypoglycemic episodes in that group, Dr. Rajpal said.
Key findings
In the main analysis, Dr. Rajpal said, risk of CV events was significantly increased in those with more than five hypoglycemic episodes, compared with those with one to five episodes, with an odds ratio of 1.61 (95% confidence interval, 1.56-1.66). The incidence of cardiovascular events was 33.1% in those with more than five episodes and 23.5% in those with one to five episodes, according to the data presented.
Risks were also significantly increased specifically for cardiac arrhythmias, cerebrovascular accidents, and MI, Dr. Rajpal said, with ORs of 1.65 (95% CI, 1.9-1.71), 1.38 (95% CI, 1.22-1.56), and 1.43 (95% CI, 1.36-1.50), respectively.
Because individuals in the group with more than five hypoglycemic episodes were more likely to be elderly, Dr. Rajpal said that he and coinvestigators decided to perform an age-specific stratified analysis.
Although cerebral vascular incidence was low in younger patients, risk of CV events overall was nevertheless significantly elevated for those aged 65 years or older, 45-64 years, and 18-44 years, with ORs of 1.69 (95% CI, 1.61-1.7), 1.58 (95% CI, 1.48-1.69), and 1.62 (95% CI, 1.33-1.97).
“The results were still valid in stratified analysis based on different age groups,” Dr. Rajpal said.
Dr. Rajpal and coauthors reported that he had no conflicts of interest related to the research.
SOURCE: Rajpal A et al. ADA 2020, Abstract 161-OR.
Frequent hypoglycemic episodes were linked to a raised incidence of cardiovascular events in adults with type 2 diabetes in a recent retrospective study, suggesting certain hypoglycemia-associated diabetes drugs should be avoided, an investigator said.
Patients who had more than five hypoglycemic episodes per year had a 61% greater risk of cardiovascular (CV) events, compared with patients with less frequent episodes, according to results of the study.
Although there were fewer strokes among younger patients, the overall increase in cardiovascular event risk held up regardless of age group, according to investigator Aman Rajpal, MD, of Louis Stokes Veterans Affairs Medical Center and Case Western Reserve University, both in Cleveland.
On the basis of these and earlier studies tying hypoglycemia to CV risk, health care providers need to “pay close attention” to low blood sugar and personalize glycemic control targets for each patient based on risk of hypoglycemia, Dr. Rajpal said in a presentation of the study at the virtual annual scientific sessions of the American Diabetes Association.
“Also, this suggests that avoidance of drugs associated with increased risk of hypoglycemia – namely insulin, sulfonylureas, or others – is essential to avoid and minimize the risk of cardiovascular events in this patient population with type 2 diabetes,” said Dr. Rajpal. “Let us remember part of our Hippocratic oath: ‘Above all, do no harm.’ ”
Tailoring treatment to mitigate risk
Mark Schutta, MD, medical director of Penn Rodebaugh Diabetes Center in Philadelphia, said that results of this study suggest a need to carefully select medical therapy for each individual patient with diabetes in order to mitigate CV risk.
“It’s really about tailoring their drugs to their personal situation,” Dr. Schutta said in an interview.
Although newer diabetes drug classes are associated with low to no risk of hypoglycemia, Dr. Schutta said that there is still a place for drugs such as sulfonylureas in certain situations.
Among sulfonylureas, glyburide comes with a much higher incidence of hypoglycemia, compared with glipizide and glimepiride, according to Dr. Schutta. “I think there’s a role for both drugs, but you have to be very careful, and you have to get the data from your patients.”
Hypoglycemia frequency and outcomes
Speculation that hypoglycemia could be linked to adverse CV outcomes was sparked years ago by trials such as ADVANCE. Severe hypoglycemia in that study was associated with a 168% increased risk of death from a CV cause (N Engl J Med. 2010 Oct 7;363:1410-8).
At the time, ADVANCE investigators said they were unable to find evidence that multiple severe hypoglycemia episodes conferred a greater risk of CV events versus a single hypoglycemia episode, though they added that few patients had recurrent events.
“In other words, the association between the number of hypoglycemia events, and adverse CV outcomes is still unclear,” said Dr. Rajpal in his virtual ADA presentation.
Potential elevated risks with more than five episodes
To evaluate the association between frequent hypoglycemic episodes (i.e., more than five per year, compared with one to five episodes) and CV events, Dr. Rajpal and colleagues evaluated outcomes data for 4.9 million adults with type 2 diabetes found in a large commercial database including information on patients in 27 U.S. health care networks.
Database records indicated that about 182,000 patients, or nearly 4%, had episodes of hyperglycemia, which Dr. Rajpal said was presumed to mean a plasma glucose level of less than 70 mg/dL.
Characteristics of the patients with more than five hypoglycemic episodes were similar to those with one to five episodes, although they were more likely to be 65 years or older, and were “slightly more likely” to be on insulin, which could possibly precipitate more hypoglycemic episodes in that group, Dr. Rajpal said.
Key findings
In the main analysis, Dr. Rajpal said, risk of CV events was significantly increased in those with more than five hypoglycemic episodes, compared with those with one to five episodes, with an odds ratio of 1.61 (95% confidence interval, 1.56-1.66). The incidence of cardiovascular events was 33.1% in those with more than five episodes and 23.5% in those with one to five episodes, according to the data presented.
Risks were also significantly increased specifically for cardiac arrhythmias, cerebrovascular accidents, and MI, Dr. Rajpal said, with ORs of 1.65 (95% CI, 1.9-1.71), 1.38 (95% CI, 1.22-1.56), and 1.43 (95% CI, 1.36-1.50), respectively.
Because individuals in the group with more than five hypoglycemic episodes were more likely to be elderly, Dr. Rajpal said that he and coinvestigators decided to perform an age-specific stratified analysis.
Although cerebral vascular incidence was low in younger patients, risk of CV events overall was nevertheless significantly elevated for those aged 65 years or older, 45-64 years, and 18-44 years, with ORs of 1.69 (95% CI, 1.61-1.7), 1.58 (95% CI, 1.48-1.69), and 1.62 (95% CI, 1.33-1.97).
“The results were still valid in stratified analysis based on different age groups,” Dr. Rajpal said.
Dr. Rajpal and coauthors reported that he had no conflicts of interest related to the research.
SOURCE: Rajpal A et al. ADA 2020, Abstract 161-OR.
Frequent hypoglycemic episodes were linked to a raised incidence of cardiovascular events in adults with type 2 diabetes in a recent retrospective study, suggesting certain hypoglycemia-associated diabetes drugs should be avoided, an investigator said.
Patients who had more than five hypoglycemic episodes per year had a 61% greater risk of cardiovascular (CV) events, compared with patients with less frequent episodes, according to results of the study.
Although there were fewer strokes among younger patients, the overall increase in cardiovascular event risk held up regardless of age group, according to investigator Aman Rajpal, MD, of Louis Stokes Veterans Affairs Medical Center and Case Western Reserve University, both in Cleveland.
On the basis of these and earlier studies tying hypoglycemia to CV risk, health care providers need to “pay close attention” to low blood sugar and personalize glycemic control targets for each patient based on risk of hypoglycemia, Dr. Rajpal said in a presentation of the study at the virtual annual scientific sessions of the American Diabetes Association.
“Also, this suggests that avoidance of drugs associated with increased risk of hypoglycemia – namely insulin, sulfonylureas, or others – is essential to avoid and minimize the risk of cardiovascular events in this patient population with type 2 diabetes,” said Dr. Rajpal. “Let us remember part of our Hippocratic oath: ‘Above all, do no harm.’ ”
Tailoring treatment to mitigate risk
Mark Schutta, MD, medical director of Penn Rodebaugh Diabetes Center in Philadelphia, said that results of this study suggest a need to carefully select medical therapy for each individual patient with diabetes in order to mitigate CV risk.
“It’s really about tailoring their drugs to their personal situation,” Dr. Schutta said in an interview.
Although newer diabetes drug classes are associated with low to no risk of hypoglycemia, Dr. Schutta said that there is still a place for drugs such as sulfonylureas in certain situations.
Among sulfonylureas, glyburide comes with a much higher incidence of hypoglycemia, compared with glipizide and glimepiride, according to Dr. Schutta. “I think there’s a role for both drugs, but you have to be very careful, and you have to get the data from your patients.”
Hypoglycemia frequency and outcomes
Speculation that hypoglycemia could be linked to adverse CV outcomes was sparked years ago by trials such as ADVANCE. Severe hypoglycemia in that study was associated with a 168% increased risk of death from a CV cause (N Engl J Med. 2010 Oct 7;363:1410-8).
At the time, ADVANCE investigators said they were unable to find evidence that multiple severe hypoglycemia episodes conferred a greater risk of CV events versus a single hypoglycemia episode, though they added that few patients had recurrent events.
“In other words, the association between the number of hypoglycemia events, and adverse CV outcomes is still unclear,” said Dr. Rajpal in his virtual ADA presentation.
Potential elevated risks with more than five episodes
To evaluate the association between frequent hypoglycemic episodes (i.e., more than five per year, compared with one to five episodes) and CV events, Dr. Rajpal and colleagues evaluated outcomes data for 4.9 million adults with type 2 diabetes found in a large commercial database including information on patients in 27 U.S. health care networks.
Database records indicated that about 182,000 patients, or nearly 4%, had episodes of hyperglycemia, which Dr. Rajpal said was presumed to mean a plasma glucose level of less than 70 mg/dL.
Characteristics of the patients with more than five hypoglycemic episodes were similar to those with one to five episodes, although they were more likely to be 65 years or older, and were “slightly more likely” to be on insulin, which could possibly precipitate more hypoglycemic episodes in that group, Dr. Rajpal said.
Key findings
In the main analysis, Dr. Rajpal said, risk of CV events was significantly increased in those with more than five hypoglycemic episodes, compared with those with one to five episodes, with an odds ratio of 1.61 (95% confidence interval, 1.56-1.66). The incidence of cardiovascular events was 33.1% in those with more than five episodes and 23.5% in those with one to five episodes, according to the data presented.
Risks were also significantly increased specifically for cardiac arrhythmias, cerebrovascular accidents, and MI, Dr. Rajpal said, with ORs of 1.65 (95% CI, 1.9-1.71), 1.38 (95% CI, 1.22-1.56), and 1.43 (95% CI, 1.36-1.50), respectively.
Because individuals in the group with more than five hypoglycemic episodes were more likely to be elderly, Dr. Rajpal said that he and coinvestigators decided to perform an age-specific stratified analysis.
Although cerebral vascular incidence was low in younger patients, risk of CV events overall was nevertheless significantly elevated for those aged 65 years or older, 45-64 years, and 18-44 years, with ORs of 1.69 (95% CI, 1.61-1.7), 1.58 (95% CI, 1.48-1.69), and 1.62 (95% CI, 1.33-1.97).
“The results were still valid in stratified analysis based on different age groups,” Dr. Rajpal said.
Dr. Rajpal and coauthors reported that he had no conflicts of interest related to the research.
SOURCE: Rajpal A et al. ADA 2020, Abstract 161-OR.
FROM ADA 2020
Choosing a career in health equity and health care policy
Dr. Anyane-Yeboa is a Commonwealth Fund Fellow in Minority Health Policy at Harvard University and a recent graduate of the Harvard T.H. Chan School of Public Health. She previously completed her gastroenterology fellowship at the University of Chicago. She will be an academic gastroenterologist at Massachusetts General Hospital starting in the fall of 2020.
How did your career pathway lead you to a career in health equity and policy?
I have been passionate about issues related to health equity, workforce diversity, and care of vulnerable populations since the early years of my career. For instance, as undergraduates my friends and I received a grant to start a program to provide mentorship for endangered youth in Boston. During my residency and chief residency, I advocated for increased resident diversity and created programs for underrepresented minority medical students to increase minority representation in medicine. During my gastroenterology fellowship, I remained passionate about the care of minority and underserved populations. During my second year of fellowship, I looked for advanced training opportunities where I could learn the skills to tackle health disparities in minority communities, and almost serendipitously came across the Commonwealth Fund Fellowship in Minority Health Policy. When I decided to apply for the fellowship, I knew that this would be a nontraditional path for most gastroenterology fellows, but the right path for me.
About the Commonwealth Fund Fellowship 
The purpose of the Commonwealth Fund Fellowship in Minority Health Policy at Harvard University is to train the next generation of leaders in health care. The program is based at Harvard Medical School and supported by the Commonwealth Fund whose mission is to “provide affordable quality health care for all.” To date, the fellowship has trained more than 130 physicians who are advancing health care across the nation as leaders in public health, academic medicine, and health policy.
The fellowship is a year-long, full-time, degree-granting program. Fellows are eligible for a master’s in public health with a concentration in health management or health policy from the Harvard T.H. Chan School of Public Health or a master’s in public administration from the Harvard Kennedy School.
The fellowship program and experiences have been transformative for me. The structure of the program consists of visits to the Massachusetts Department of Public Health, the Boston Public Health Commission, and the Commonwealth Fund, as well as lectures, seminars, and journal club sessions with national leaders in public health, health policy, and health care delivery reform. Additional opportunities include one-on-one shadowing experiences with leaders in hospital administration at academic institutions in Boston and private meetings with leaders and staff at several government agencies in Washington, including the Centers for Medicaid & Medicare Services, the Office of Minority Health, the Food and Drug Administration, the Health Resources & Services Administration, and the National Institutes of Health.
The program has given me an opportunity to meet and learn from physicians who have chosen a variety of different career paths. Through the program I have had exposure to physicians in academic medicine, health care administration, health policy, and public service as well as those who have chosen a combination of clinical practice with any of the above. This experience has opened my eyes to the different possibilities for physician careers and has encouraged me to be open if new opportunities should arise.
As part of the fellowship, we also have regular meetings with Joan Reede, MD, MPH, who is the director of the fellowship and has been with the program since its inception; she is also the Dean of Diversity and Inclusion at Harvard Medical School. Dr. Reede is an incredibly wise, insightful, and caring mentor, but also a powerhouse in issues surrounding workforce diversity, mentorship, policy, care of underserved communities, and being an advocate for change. To have access to such a powerful individual who has dedicated her career to the mentorship of individuals like myself, who cares deeply about the impact of our careers, and who genuinely values each fellow almost as her own child is a unique gift that is hard to describe in words.
The Commonwealth Fund Fellowship also provides a large network of mentors and advisers. My direct mentor for the program is Monica Bharel, MD, MPH, who is a former Commonwealth Fund fellow and the current Commissioner of the Massachusetts Department of Public Health. However, I also have a wealth of other mentors and advisers in the alumni fellows, including Darrell Gray II, MD, MPH, a former fellow and gastroenterologist at the Ohio State University College of Medicine, as well as the other faculty associated with the program. I never imagined that I would have access to leaders in so many different sectors of health care and policy who are genuinely and passionately rooting for my success. In addition, my cofellows and I have created a uniquely special bond, and they will likely continue as my close network of peer advisers as I move forward throughout my career.
After the fellowship
I have no doubt that the Commonwealth Fund Fellowship will alter the trajectory of my career. It has already affected my career path in ways that I could not have anticipated years ago. The knowledge that I have gained in health care policy, innovation, and equity, as well as the networks that I have access to as a fellow, will be invaluable as I move forward. In terms of next steps, I will be working as an academic gastroenterologist; I will continue to lead initiatives, perform research, and participate in projects to elevate the voices of underserved communities and work toward health equity in gastroenterology. I am particularly passionate about ending disparities in colorectal cancer in minority communities and increasing awareness around minorities with inflammatory bowel disease.
I plan to work with health centers, city- and state-level organizations, and community partners to raise awareness around issues of equity in gastroenterology and develop interventions to create change. I will also work with local legislators and community-based organizations to advocate for policies that remove barriers to screening both locally and nationally. Further down the line, I am open to exploring careers in the public sector or health care administration if that is where my career takes me. The exposure that I had to these fields as part of the fellowship has shown me that it is possible to be a practicing gastroenterologist and simultaneously work in the public sector, health policy, or health care administration. If you are interested in applying to the Commonwealth Fund Fellowship in Minority Health Policy at Harvard University, please feel free to contact me at adjoa.anyaneyeboa@gmail.com. More information about the program and how to apply can be found at https://cff.hms.harvard.edu/.
Dr. Anyane-Yeboa is a Commonwealth Fund Fellow in Minority Health Policy at Harvard University and a recent graduate of the Harvard T.H. Chan School of Public Health. She previously completed her gastroenterology fellowship at the University of Chicago. She will be an academic gastroenterologist at Massachusetts General Hospital starting in the fall of 2020.
How did your career pathway lead you to a career in health equity and policy?
I have been passionate about issues related to health equity, workforce diversity, and care of vulnerable populations since the early years of my career. For instance, as undergraduates my friends and I received a grant to start a program to provide mentorship for endangered youth in Boston. During my residency and chief residency, I advocated for increased resident diversity and created programs for underrepresented minority medical students to increase minority representation in medicine. During my gastroenterology fellowship, I remained passionate about the care of minority and underserved populations. During my second year of fellowship, I looked for advanced training opportunities where I could learn the skills to tackle health disparities in minority communities, and almost serendipitously came across the Commonwealth Fund Fellowship in Minority Health Policy. When I decided to apply for the fellowship, I knew that this would be a nontraditional path for most gastroenterology fellows, but the right path for me.
About the Commonwealth Fund Fellowship
The purpose of the Commonwealth Fund Fellowship in Minority Health Policy at Harvard University is to train the next generation of leaders in health care. The program is based at Harvard Medical School and supported by the Commonwealth Fund whose mission is to “provide affordable quality health care for all.” To date, the fellowship has trained more than 130 physicians who are advancing health care across the nation as leaders in public health, academic medicine, and health policy.
The fellowship is a year-long, full-time, degree-granting program. Fellows are eligible for a master’s in public health with a concentration in health management or health policy from the Harvard T.H. Chan School of Public Health or a master’s in public administration from the Harvard Kennedy School.
The fellowship program and experiences have been transformative for me. The structure of the program consists of visits to the Massachusetts Department of Public Health, the Boston Public Health Commission, and the Commonwealth Fund, as well as lectures, seminars, and journal club sessions with national leaders in public health, health policy, and health care delivery reform. Additional opportunities include one-on-one shadowing experiences with leaders in hospital administration at academic institutions in Boston and private meetings with leaders and staff at several government agencies in Washington, including the Centers for Medicaid & Medicare Services, the Office of Minority Health, the Food and Drug Administration, the Health Resources & Services Administration, and the National Institutes of Health.
The program has given me an opportunity to meet and learn from physicians who have chosen a variety of different career paths. Through the program I have had exposure to physicians in academic medicine, health care administration, health policy, and public service as well as those who have chosen a combination of clinical practice with any of the above. This experience has opened my eyes to the different possibilities for physician careers and has encouraged me to be open if new opportunities should arise.
As part of the fellowship, we also have regular meetings with Joan Reede, MD, MPH, who is the director of the fellowship and has been with the program since its inception; she is also the Dean of Diversity and Inclusion at Harvard Medical School. Dr. Reede is an incredibly wise, insightful, and caring mentor, but also a powerhouse in issues surrounding workforce diversity, mentorship, policy, care of underserved communities, and being an advocate for change. To have access to such a powerful individual who has dedicated her career to the mentorship of individuals like myself, who cares deeply about the impact of our careers, and who genuinely values each fellow almost as her own child is a unique gift that is hard to describe in words.
The Commonwealth Fund Fellowship also provides a large network of mentors and advisers. My direct mentor for the program is Monica Bharel, MD, MPH, who is a former Commonwealth Fund fellow and the current Commissioner of the Massachusetts Department of Public Health. However, I also have a wealth of other mentors and advisers in the alumni fellows, including Darrell Gray II, MD, MPH, a former fellow and gastroenterologist at the Ohio State University College of Medicine, as well as the other faculty associated with the program. I never imagined that I would have access to leaders in so many different sectors of health care and policy who are genuinely and passionately rooting for my success. In addition, my cofellows and I have created a uniquely special bond, and they will likely continue as my close network of peer advisers as I move forward throughout my career.
After the fellowship
I have no doubt that the Commonwealth Fund Fellowship will alter the trajectory of my career. It has already affected my career path in ways that I could not have anticipated years ago. The knowledge that I have gained in health care policy, innovation, and equity, as well as the networks that I have access to as a fellow, will be invaluable as I move forward. In terms of next steps, I will be working as an academic gastroenterologist; I will continue to lead initiatives, perform research, and participate in projects to elevate the voices of underserved communities and work toward health equity in gastroenterology. I am particularly passionate about ending disparities in colorectal cancer in minority communities and increasing awareness around minorities with inflammatory bowel disease.
I plan to work with health centers, city- and state-level organizations, and community partners to raise awareness around issues of equity in gastroenterology and develop interventions to create change. I will also work with local legislators and community-based organizations to advocate for policies that remove barriers to screening both locally and nationally. Further down the line, I am open to exploring careers in the public sector or health care administration if that is where my career takes me. The exposure that I had to these fields as part of the fellowship has shown me that it is possible to be a practicing gastroenterologist and simultaneously work in the public sector, health policy, or health care administration. If you are interested in applying to the Commonwealth Fund Fellowship in Minority Health Policy at Harvard University, please feel free to contact me at adjoa.anyaneyeboa@gmail.com. More information about the program and how to apply can be found at https://cff.hms.harvard.edu/.
Dr. Anyane-Yeboa is a Commonwealth Fund Fellow in Minority Health Policy at Harvard University and a recent graduate of the Harvard T.H. Chan School of Public Health. She previously completed her gastroenterology fellowship at the University of Chicago. She will be an academic gastroenterologist at Massachusetts General Hospital starting in the fall of 2020.
How did your career pathway lead you to a career in health equity and policy?
I have been passionate about issues related to health equity, workforce diversity, and care of vulnerable populations since the early years of my career. For instance, as undergraduates my friends and I received a grant to start a program to provide mentorship for endangered youth in Boston. During my residency and chief residency, I advocated for increased resident diversity and created programs for underrepresented minority medical students to increase minority representation in medicine. During my gastroenterology fellowship, I remained passionate about the care of minority and underserved populations. During my second year of fellowship, I looked for advanced training opportunities where I could learn the skills to tackle health disparities in minority communities, and almost serendipitously came across the Commonwealth Fund Fellowship in Minority Health Policy. When I decided to apply for the fellowship, I knew that this would be a nontraditional path for most gastroenterology fellows, but the right path for me.
About the Commonwealth Fund Fellowship
The purpose of the Commonwealth Fund Fellowship in Minority Health Policy at Harvard University is to train the next generation of leaders in health care. The program is based at Harvard Medical School and supported by the Commonwealth Fund whose mission is to “provide affordable quality health care for all.” To date, the fellowship has trained more than 130 physicians who are advancing health care across the nation as leaders in public health, academic medicine, and health policy.
The fellowship is a year-long, full-time, degree-granting program. Fellows are eligible for a master’s in public health with a concentration in health management or health policy from the Harvard T.H. Chan School of Public Health or a master’s in public administration from the Harvard Kennedy School.
The fellowship program and experiences have been transformative for me. The structure of the program consists of visits to the Massachusetts Department of Public Health, the Boston Public Health Commission, and the Commonwealth Fund, as well as lectures, seminars, and journal club sessions with national leaders in public health, health policy, and health care delivery reform. Additional opportunities include one-on-one shadowing experiences with leaders in hospital administration at academic institutions in Boston and private meetings with leaders and staff at several government agencies in Washington, including the Centers for Medicaid & Medicare Services, the Office of Minority Health, the Food and Drug Administration, the Health Resources & Services Administration, and the National Institutes of Health.
The program has given me an opportunity to meet and learn from physicians who have chosen a variety of different career paths. Through the program I have had exposure to physicians in academic medicine, health care administration, health policy, and public service as well as those who have chosen a combination of clinical practice with any of the above. This experience has opened my eyes to the different possibilities for physician careers and has encouraged me to be open if new opportunities should arise.
As part of the fellowship, we also have regular meetings with Joan Reede, MD, MPH, who is the director of the fellowship and has been with the program since its inception; she is also the Dean of Diversity and Inclusion at Harvard Medical School. Dr. Reede is an incredibly wise, insightful, and caring mentor, but also a powerhouse in issues surrounding workforce diversity, mentorship, policy, care of underserved communities, and being an advocate for change. To have access to such a powerful individual who has dedicated her career to the mentorship of individuals like myself, who cares deeply about the impact of our careers, and who genuinely values each fellow almost as her own child is a unique gift that is hard to describe in words.
The Commonwealth Fund Fellowship also provides a large network of mentors and advisers. My direct mentor for the program is Monica Bharel, MD, MPH, who is a former Commonwealth Fund fellow and the current Commissioner of the Massachusetts Department of Public Health. However, I also have a wealth of other mentors and advisers in the alumni fellows, including Darrell Gray II, MD, MPH, a former fellow and gastroenterologist at the Ohio State University College of Medicine, as well as the other faculty associated with the program. I never imagined that I would have access to leaders in so many different sectors of health care and policy who are genuinely and passionately rooting for my success. In addition, my cofellows and I have created a uniquely special bond, and they will likely continue as my close network of peer advisers as I move forward throughout my career.
After the fellowship
I have no doubt that the Commonwealth Fund Fellowship will alter the trajectory of my career. It has already affected my career path in ways that I could not have anticipated years ago. The knowledge that I have gained in health care policy, innovation, and equity, as well as the networks that I have access to as a fellow, will be invaluable as I move forward. In terms of next steps, I will be working as an academic gastroenterologist; I will continue to lead initiatives, perform research, and participate in projects to elevate the voices of underserved communities and work toward health equity in gastroenterology. I am particularly passionate about ending disparities in colorectal cancer in minority communities and increasing awareness around minorities with inflammatory bowel disease.
I plan to work with health centers, city- and state-level organizations, and community partners to raise awareness around issues of equity in gastroenterology and develop interventions to create change. I will also work with local legislators and community-based organizations to advocate for policies that remove barriers to screening both locally and nationally. Further down the line, I am open to exploring careers in the public sector or health care administration if that is where my career takes me. The exposure that I had to these fields as part of the fellowship has shown me that it is possible to be a practicing gastroenterologist and simultaneously work in the public sector, health policy, or health care administration. If you are interested in applying to the Commonwealth Fund Fellowship in Minority Health Policy at Harvard University, please feel free to contact me at adjoa.anyaneyeboa@gmail.com. More information about the program and how to apply can be found at https://cff.hms.harvard.edu/.
Vulvar melanoma is increasing in older women
Maia K. Erickson reported in a poster at the virtual annual meeting of the American Academy of Dermatology.
These are often aggressive malignancies. The 5-year survival following diagnosis of vulvar melanoma in women aged 60 years or older was 39.7%, compared with 61.9% in younger women, according to Ms. Erickson, a visiting research fellow in the department of dermatology at Northwestern University, Chicago.
She presented a population-based study of epidemiologic trends in vulvar melanoma based upon analysis of the National Cancer Institute’s Surveillance, Epidemiology and End Results database. Vulvar melanoma was rare during the study years 2000-2016, with an overall incidence rate of 0.1 cases per 100,000 women. That worked out to 746 analyzable cases. Of note, the incidence rate ratio was 680% higher in older women (age 60 and older).
One reason for the markedly worse 5-year survival in older women was that the predominant histologic subtype of vulvar melanoma in that population was nodular melanoma, accounting for 48% of the cases where a histologic subtype was specified. In contrast, the less-aggressive superficial spreading melanoma subtype prevailed in patients aged under 60 years, accounting for 63% of cases.
About 93% of vulvar melanomas occurred in whites; 63% were local and 8.7% were metastatic.
Ms. Erickson noted that the vulva is the most common site for gynecologic tract melanomas, accounting for 70% of them. And while the female genitalia make up only 1%-2% of body surface area, that’s the anatomic site of up to 7% of all melanomas in women.
She reported having no financial conflicts regarding her study.
Maia K. Erickson reported in a poster at the virtual annual meeting of the American Academy of Dermatology.
These are often aggressive malignancies. The 5-year survival following diagnosis of vulvar melanoma in women aged 60 years or older was 39.7%, compared with 61.9% in younger women, according to Ms. Erickson, a visiting research fellow in the department of dermatology at Northwestern University, Chicago.
She presented a population-based study of epidemiologic trends in vulvar melanoma based upon analysis of the National Cancer Institute’s Surveillance, Epidemiology and End Results database. Vulvar melanoma was rare during the study years 2000-2016, with an overall incidence rate of 0.1 cases per 100,000 women. That worked out to 746 analyzable cases. Of note, the incidence rate ratio was 680% higher in older women (age 60 and older).
One reason for the markedly worse 5-year survival in older women was that the predominant histologic subtype of vulvar melanoma in that population was nodular melanoma, accounting for 48% of the cases where a histologic subtype was specified. In contrast, the less-aggressive superficial spreading melanoma subtype prevailed in patients aged under 60 years, accounting for 63% of cases.
About 93% of vulvar melanomas occurred in whites; 63% were local and 8.7% were metastatic.
Ms. Erickson noted that the vulva is the most common site for gynecologic tract melanomas, accounting for 70% of them. And while the female genitalia make up only 1%-2% of body surface area, that’s the anatomic site of up to 7% of all melanomas in women.
She reported having no financial conflicts regarding her study.
Maia K. Erickson reported in a poster at the virtual annual meeting of the American Academy of Dermatology.
These are often aggressive malignancies. The 5-year survival following diagnosis of vulvar melanoma in women aged 60 years or older was 39.7%, compared with 61.9% in younger women, according to Ms. Erickson, a visiting research fellow in the department of dermatology at Northwestern University, Chicago.
She presented a population-based study of epidemiologic trends in vulvar melanoma based upon analysis of the National Cancer Institute’s Surveillance, Epidemiology and End Results database. Vulvar melanoma was rare during the study years 2000-2016, with an overall incidence rate of 0.1 cases per 100,000 women. That worked out to 746 analyzable cases. Of note, the incidence rate ratio was 680% higher in older women (age 60 and older).
One reason for the markedly worse 5-year survival in older women was that the predominant histologic subtype of vulvar melanoma in that population was nodular melanoma, accounting for 48% of the cases where a histologic subtype was specified. In contrast, the less-aggressive superficial spreading melanoma subtype prevailed in patients aged under 60 years, accounting for 63% of cases.
About 93% of vulvar melanomas occurred in whites; 63% were local and 8.7% were metastatic.
Ms. Erickson noted that the vulva is the most common site for gynecologic tract melanomas, accounting for 70% of them. And while the female genitalia make up only 1%-2% of body surface area, that’s the anatomic site of up to 7% of all melanomas in women.
She reported having no financial conflicts regarding her study.
FROM AAD 2020
FDA approves Cosentyx for treatment of active nr-axSpA
The Food and Drug Administration has approved secukinumab (Cosentyx) for the treatment of active nonradiographic axial spondyloarthritis (nr-axSpA), according to an announcement from the drug’s manufacturer, Novartis.
FDA approval was based on results of the 2-year PREVENT trial, a randomized, double-blind, placebo-controlled, phase 3 study in 555 adults with active nr-axSpA who received a loading dose of 150 mg secukinumab subcutaneously weekly for 4 weeks, then maintenance dosing with 150 mg secukinumab monthly; 150 mg secukinumab monthly with no loading dose; or placebo. Patients were included if they were aged at least 18 years with 6 months or more of inflammatory back pain, had objective signs of inflammation (sacroiliitis on MRI and/or C-reactive protein at 5.0 mg/dL or higher), had active disease and spinal pain according to the Bath Ankylosing Spondylitis Disease Activity Index, had total back pain with a visual analog scale of 40 mm or greater, and had not received a tumor necrosis factor (TNF) inhibitor or had an inadequate response to no more than one TNF inhibitor. A total of 501 patients had not previously taken a biologic medication.
A significantly greater proportion of biologic-naive patients taking secukinumab in both active treatment arm met the trial’s primary endpoint of at least a 40% improvement in the Assessment of Spondyloarthritis International Society response criteria versus placebo after 52 weeks. Both loading and nonloading arms saw significant improvements in Ankylosing Spondylitis Quality of Life scores, compared with those in the placebo group.
The safety profile of secukinumab in PREVENT was shown to be consistent with previous clinical trials, with no new safety signals detected.
Secukinumab, a fully human monoclonal antibody that directly inhibits interleukin-17A, also received European Medicines Agency approval for the treatment of nr-axSpA in April 2020. It is already approved by the FDA for the treatment of moderate to severe plaque psoriasis, psoriatic arthritis, and ankylosing spondylitis.
The Food and Drug Administration has approved secukinumab (Cosentyx) for the treatment of active nonradiographic axial spondyloarthritis (nr-axSpA), according to an announcement from the drug’s manufacturer, Novartis.
FDA approval was based on results of the 2-year PREVENT trial, a randomized, double-blind, placebo-controlled, phase 3 study in 555 adults with active nr-axSpA who received a loading dose of 150 mg secukinumab subcutaneously weekly for 4 weeks, then maintenance dosing with 150 mg secukinumab monthly; 150 mg secukinumab monthly with no loading dose; or placebo. Patients were included if they were aged at least 18 years with 6 months or more of inflammatory back pain, had objective signs of inflammation (sacroiliitis on MRI and/or C-reactive protein at 5.0 mg/dL or higher), had active disease and spinal pain according to the Bath Ankylosing Spondylitis Disease Activity Index, had total back pain with a visual analog scale of 40 mm or greater, and had not received a tumor necrosis factor (TNF) inhibitor or had an inadequate response to no more than one TNF inhibitor. A total of 501 patients had not previously taken a biologic medication.
A significantly greater proportion of biologic-naive patients taking secukinumab in both active treatment arm met the trial’s primary endpoint of at least a 40% improvement in the Assessment of Spondyloarthritis International Society response criteria versus placebo after 52 weeks. Both loading and nonloading arms saw significant improvements in Ankylosing Spondylitis Quality of Life scores, compared with those in the placebo group.
The safety profile of secukinumab in PREVENT was shown to be consistent with previous clinical trials, with no new safety signals detected.
Secukinumab, a fully human monoclonal antibody that directly inhibits interleukin-17A, also received European Medicines Agency approval for the treatment of nr-axSpA in April 2020. It is already approved by the FDA for the treatment of moderate to severe plaque psoriasis, psoriatic arthritis, and ankylosing spondylitis.
The Food and Drug Administration has approved secukinumab (Cosentyx) for the treatment of active nonradiographic axial spondyloarthritis (nr-axSpA), according to an announcement from the drug’s manufacturer, Novartis.
FDA approval was based on results of the 2-year PREVENT trial, a randomized, double-blind, placebo-controlled, phase 3 study in 555 adults with active nr-axSpA who received a loading dose of 150 mg secukinumab subcutaneously weekly for 4 weeks, then maintenance dosing with 150 mg secukinumab monthly; 150 mg secukinumab monthly with no loading dose; or placebo. Patients were included if they were aged at least 18 years with 6 months or more of inflammatory back pain, had objective signs of inflammation (sacroiliitis on MRI and/or C-reactive protein at 5.0 mg/dL or higher), had active disease and spinal pain according to the Bath Ankylosing Spondylitis Disease Activity Index, had total back pain with a visual analog scale of 40 mm or greater, and had not received a tumor necrosis factor (TNF) inhibitor or had an inadequate response to no more than one TNF inhibitor. A total of 501 patients had not previously taken a biologic medication.
A significantly greater proportion of biologic-naive patients taking secukinumab in both active treatment arm met the trial’s primary endpoint of at least a 40% improvement in the Assessment of Spondyloarthritis International Society response criteria versus placebo after 52 weeks. Both loading and nonloading arms saw significant improvements in Ankylosing Spondylitis Quality of Life scores, compared with those in the placebo group.
The safety profile of secukinumab in PREVENT was shown to be consistent with previous clinical trials, with no new safety signals detected.
Secukinumab, a fully human monoclonal antibody that directly inhibits interleukin-17A, also received European Medicines Agency approval for the treatment of nr-axSpA in April 2020. It is already approved by the FDA for the treatment of moderate to severe plaque psoriasis, psoriatic arthritis, and ankylosing spondylitis.
Hospitalist well-being during the pandemic
Navigating COVID-19 requires self-care
The global COVID-19 pandemic has escalated everyone’s stress levels, especially clinicians caring for hospitalized patients. New pressures have added to everyday stress, new studies have revised prior patient care recommendations, and the world generally seems upside down. What can a busy hospitalist do to maintain a modicum of sanity in all the craziness?
The stressors facing hospitalists
Uncertainty
Of all the burdens COVID-19 has unleashed, the biggest may be uncertainty. Not only is there unease about the virus itself, there also is legitimate concern about the future of medicine, said Elizabeth Harry, MD, SFHM, a hospitalist and senior director of clinical affairs at the University of Colorado Hospital in Aurora.
“What does it look like after an event like this, particularly in areas like academic medicine and teaching our next generation and getting funding for research? And how do we continue to produce physicians that can provide excellent care?” she asked.
There is also uncertainty in the best way to care for patients, said Eileen Barrett, MD, MPH, SFHM, a hospitalist at the University of New Mexico, Albuquerque.
“There are some models that are emerging to predict who will have a worse outcome, but they’re still not great models, so we have uncertainty for a given patient.” And, she noted, as the science continues to evolve, there exists a constant worry that “you might have inadvertently caused someone harm.”
The financial implications of the pandemic are creating uncertainty too. “When you fund a health care system with elective procedures and you can’t do those, and instead have to shift to the most essential services, a lot of places are seeing a massive deficit, which is going to affect staff morale and some physician offices are going to close,” said Elisabeth Poorman, MD, MPH, a primary care and internal medicine physician and chair of the King County Medical Society Physician Wellness Committee in Seattle.
Fear
When the pandemic began in the United States, “fear of the unknown was perhaps the scariest part, particularly as it pertained to personal protective equipment,” said Mark Rudolph, MD, SFHM, chief experience officer and vice president of patient experience and physician development at Sound Physicians in Tacoma, Wash. “For most clinicians, this is the first time that they are themselves in harm’s way while they do their jobs. And worse, they risk bringing the virus home to their families. That is the concern I hear most.”
Anxiety
Worrying about being able to provide excellent patient care is a big stressor, especially since this is the heart and soul of why most hospitalists have gone into their line of work.
“Part of providing excellent care to your patients is providing excellent supportive care to their families,” Dr. Harry said. “There’s some dissonance there in not being able to allow the family to come visit, but wanting to keep them safe, and it feels really hard to support your patients and support their families in the best way. It can feel like you’re just watching and waiting to see what will happen, and that we don’t have a lot of agency over which direction things take.”
There is concern for health care team members as well, Dr. Harry added. “Physicians care a lot about their teams and how they’re doing. I think there’s a sense of esprit de corps among folks and worry for each other there.”
Guilt
Although you may be at the hospital all day, you may feel guilty when you are not providing direct patient care. Or maybe you or someone on your team has an immunodeficiency and can’t be on the front line. Perhaps one of your team members contracted COVID-19 and you did not. Whatever the case, guilt is another emotion that is rampant among hospitalists right now, Dr. Barrett said.
Burnout
Unfortunately, burnout is a potential reality in times of high stress. “Burnout is dynamic,” said Dr. Poorman. “It’s a process by which your emotional and cognitive reserves are exhausted. The people with the highest burnout are the ones who are still trying to provide the standard of care, or above the standard of care in dysfunctional systems.”
Dr. Harry noted that burnout presents in different ways for different people, but Dr. Rudolph added that it’s crucial for hospitalist team members to watch for signs of burnout so they can intervene and/or get help for their colleagues.
Warning signs in yourself or others that burnout could be on the horizon include:
- Fatigue/exhaustion – Whether emotional or physical (or both), this can become a problem if it “just doesn’t seem to go away despite rest and time away from work,” said Dr. Rudolph.
- Behavioral changes – Any behavior that’s out of the ordinary may be a red flag, like lashing out at someone at work.
- Overwork – Working too much can be caused by an inability to let go of patient care, Dr. Barrett said.
- Not working enough – This may include avoiding tasks and having difficulty meeting deadlines.
- Maladaptive coping behaviors – Excessive consumption of alcohol or drugs is a common coping mechanism. “Even excessive consumption of news is something that people are using to numb out a little bit,” said Dr. Harry.
- Depersonalization – “This is where you start to look at patients, colleagues, or administrators as ‘them’ and you can’t connect as deeply,” Dr. Harry said. “Part of that’s protective and a normal thing to do during a big trauma like this, but it’s also incredibly distancing. Any language that people start using that feels like ‘us’ or ‘them’ is a warning sign.”
- Disengagement – Many people disengage from their work, but Dr. Poorman said physicians tend to disengage from other parts of their lives, such as exercise and family interaction.
Protecting yourself while supporting others
Like the illustration of putting the oxygen mask on yourself first so you can help others, it’s important to protect your own mental and physical health as you support your fellow physicians. Here’s what the experts suggest.
Focus on basic needs
“When you’re in the midst of a trauma, which we are, you don’t want to open all of that up and go to the depths of your thoughts about the grief of all of it because it can actually make the trauma worse,” said Dr. Harry. “There’s a lot of literature that debriefing is really helpful after the event, but if you do it during the event, it can be really dangerous.”
Instead, she said, the goal should be focusing on your basic needs and what you need to do to get through each day, like keeping you and your family in good health. “What is your purpose? Staying connected to why you do this and staying focused on the present is really important,” Dr. Harry noted.
Do your best to get a good night’s sleep, exercise as much as you can, talk to others, and see a mental health provider if your anxiety is too high, advises Dr. Barrett. “Even avoiding blue light from phones and screens within 2 hours of bedtime, parking further away from the hospital and walking, and taking the stairs are things that add up in a big way.”
Keep up your normal routine
“Right now, it’s really critical for clinicians to keep up components of their routine that feel ‘normal,’ ” Dr. Rudolph said. “Whether it’s exercise, playing board games with their kids, or spending time on a hobby, it’s critical to allow yourself these comfortable, predictable, and rewarding detours.”
Set limits
People under stress tend to find unhealthy ways to cope. Instead, try being intentional about what you are consuming by putting limits on things like your news, alcohol consumption, and the number of hours you work, said Dr. Harry.
Implement a culture of wellness
Dr. Barrett believes in creating the work culture we want to be in, one that ensures people have psychological safety, allows them to ask for help, encourages them to disconnect completely from work, and makes them feel valued and listened to. She likes the example of “the pause,” which is called by a team member right after a patient expires.
“It’s a 30-second moment of silence where we reflect on the patient, their loved ones, and every member of the health care team who helped support and treat them,” said Dr. Barrett. “At the conclusion, you say: ‘Thank you. Is there anything you need to be able to go back to the care of other patients?’ Because it’s unnatural to have this terrible thing that happened and then just act like nothing happened.”
Target resources
Be proactive and know where to find resources before you need them, advised Dr. Harry. “Most institutions have free mental health resources, either through their employee assistance programs or HR, plus there’s lots of national organizations that are offering free resources to health care providers.”
Focus on what you can control
Separating what is under your control from what is not is a struggle for everyone, Dr. Poorman said, but it’s helpful to think about the ways you can have an impact and what you’re able to control.
“There was a woman who was diagnosed with early-onset Parkinson’s that I heard giving an interview at the beginning of this pandemic,” she said. “It was the most helpful advice I got, which was: ‘Think of the next good thing you can do.’ You can’t fix everything, so what’s the next good thing you can do?”
Maintain connectivity
Make sure you are utilizing your support circle and staying connected. “That sense of connection is incredibly protective on multiple fronts for depression, for burnout, for suicide ideation, etc.,” Dr. Harry said.
“It doesn’t matter if it’s your teammates at work, your family at home, your best friend from medical school – whomever you can debrief with, vent with, and just share your thoughts and feelings with, these outlets are critical for all of us to process our emotions and diffuse stress and anxiety,” said Dr. Rudolph.
Dr. Poorman is concerned that there could be a spike in physician suicides caused by increased stress, so she also encourages talking openly about what is going on and about getting help when it’s necessary. “Many of us are afraid to seek care because we can actually have our ability to practice medicine questioned, but now is not the time for heroes. Now is the time for people who are willing to recognize their own strengths and limitations to take care of one another.”
Be compassionate toward others
Keep in mind that everyone is stressed out and offer empathy and compassion. “I think everybody’s struggling to try to figure this out and the more that we can give each other the benefit of the doubt and a little grace, the more protective that is,” said Dr. Harry.
Listening is meaningful too. “Recognizing opportunities to validate and acknowledge the feelings that are being shared with you by your colleagues is critical,” Dr. Rudolph said. “We all need to know that we’re not alone, that our thoughts and feelings are okay, and when we share a difficult story, the value of someone saying something as simple as, ‘wow, that sounds like it was really hard,’ is immense.”
Be compassionate toward yourself
Try to give yourself a break and be as compassionate with yourself as you would with others. It’s okay that you’re not getting in shape, publishing prolifically, or redesigning your house right now.
“There’s a lot of data linking lack of self-compassion to burnout,” said Dr. Harry. She says there are courses on self-compassion available that help you work on being kinder to yourself.
Get a “battle buddy”
The American Medical Association has a free “buddy system” program called PeerRx to help physicians cope during the pandemic. Dr. Rudolph said that now is a great time to use this military-developed intervention in which each team member checks in with a chosen partner at agreed-upon intervals.
For example, “You can tell that person: ‘If I don’t call my family for a week that’s a red flag for me.’ And then you hold each other accountable to those things,” Dr. Harry said.
The buddy system is another way to harness that sense of connection that is so vital to our health and well-being.
“The simple act of showing that you care … can make all the difference when you’re doing this kind of work that is both challenging and dangerous,” said Dr. Rudolph.
Navigating COVID-19 requires self-care
Navigating COVID-19 requires self-care
The global COVID-19 pandemic has escalated everyone’s stress levels, especially clinicians caring for hospitalized patients. New pressures have added to everyday stress, new studies have revised prior patient care recommendations, and the world generally seems upside down. What can a busy hospitalist do to maintain a modicum of sanity in all the craziness?
The stressors facing hospitalists
Uncertainty
Of all the burdens COVID-19 has unleashed, the biggest may be uncertainty. Not only is there unease about the virus itself, there also is legitimate concern about the future of medicine, said Elizabeth Harry, MD, SFHM, a hospitalist and senior director of clinical affairs at the University of Colorado Hospital in Aurora.
“What does it look like after an event like this, particularly in areas like academic medicine and teaching our next generation and getting funding for research? And how do we continue to produce physicians that can provide excellent care?” she asked.
There is also uncertainty in the best way to care for patients, said Eileen Barrett, MD, MPH, SFHM, a hospitalist at the University of New Mexico, Albuquerque.
“There are some models that are emerging to predict who will have a worse outcome, but they’re still not great models, so we have uncertainty for a given patient.” And, she noted, as the science continues to evolve, there exists a constant worry that “you might have inadvertently caused someone harm.”
The financial implications of the pandemic are creating uncertainty too. “When you fund a health care system with elective procedures and you can’t do those, and instead have to shift to the most essential services, a lot of places are seeing a massive deficit, which is going to affect staff morale and some physician offices are going to close,” said Elisabeth Poorman, MD, MPH, a primary care and internal medicine physician and chair of the King County Medical Society Physician Wellness Committee in Seattle.
Fear
When the pandemic began in the United States, “fear of the unknown was perhaps the scariest part, particularly as it pertained to personal protective equipment,” said Mark Rudolph, MD, SFHM, chief experience officer and vice president of patient experience and physician development at Sound Physicians in Tacoma, Wash. “For most clinicians, this is the first time that they are themselves in harm’s way while they do their jobs. And worse, they risk bringing the virus home to their families. That is the concern I hear most.”
Anxiety
Worrying about being able to provide excellent patient care is a big stressor, especially since this is the heart and soul of why most hospitalists have gone into their line of work.
“Part of providing excellent care to your patients is providing excellent supportive care to their families,” Dr. Harry said. “There’s some dissonance there in not being able to allow the family to come visit, but wanting to keep them safe, and it feels really hard to support your patients and support their families in the best way. It can feel like you’re just watching and waiting to see what will happen, and that we don’t have a lot of agency over which direction things take.”
There is concern for health care team members as well, Dr. Harry added. “Physicians care a lot about their teams and how they’re doing. I think there’s a sense of esprit de corps among folks and worry for each other there.”
Guilt
Although you may be at the hospital all day, you may feel guilty when you are not providing direct patient care. Or maybe you or someone on your team has an immunodeficiency and can’t be on the front line. Perhaps one of your team members contracted COVID-19 and you did not. Whatever the case, guilt is another emotion that is rampant among hospitalists right now, Dr. Barrett said.
Burnout
Unfortunately, burnout is a potential reality in times of high stress. “Burnout is dynamic,” said Dr. Poorman. “It’s a process by which your emotional and cognitive reserves are exhausted. The people with the highest burnout are the ones who are still trying to provide the standard of care, or above the standard of care in dysfunctional systems.”
Dr. Harry noted that burnout presents in different ways for different people, but Dr. Rudolph added that it’s crucial for hospitalist team members to watch for signs of burnout so they can intervene and/or get help for their colleagues.
Warning signs in yourself or others that burnout could be on the horizon include:
- Fatigue/exhaustion – Whether emotional or physical (or both), this can become a problem if it “just doesn’t seem to go away despite rest and time away from work,” said Dr. Rudolph.
- Behavioral changes – Any behavior that’s out of the ordinary may be a red flag, like lashing out at someone at work.
- Overwork – Working too much can be caused by an inability to let go of patient care, Dr. Barrett said.
- Not working enough – This may include avoiding tasks and having difficulty meeting deadlines.
- Maladaptive coping behaviors – Excessive consumption of alcohol or drugs is a common coping mechanism. “Even excessive consumption of news is something that people are using to numb out a little bit,” said Dr. Harry.
- Depersonalization – “This is where you start to look at patients, colleagues, or administrators as ‘them’ and you can’t connect as deeply,” Dr. Harry said. “Part of that’s protective and a normal thing to do during a big trauma like this, but it’s also incredibly distancing. Any language that people start using that feels like ‘us’ or ‘them’ is a warning sign.”
- Disengagement – Many people disengage from their work, but Dr. Poorman said physicians tend to disengage from other parts of their lives, such as exercise and family interaction.
Protecting yourself while supporting others
Like the illustration of putting the oxygen mask on yourself first so you can help others, it’s important to protect your own mental and physical health as you support your fellow physicians. Here’s what the experts suggest.
Focus on basic needs
“When you’re in the midst of a trauma, which we are, you don’t want to open all of that up and go to the depths of your thoughts about the grief of all of it because it can actually make the trauma worse,” said Dr. Harry. “There’s a lot of literature that debriefing is really helpful after the event, but if you do it during the event, it can be really dangerous.”
Instead, she said, the goal should be focusing on your basic needs and what you need to do to get through each day, like keeping you and your family in good health. “What is your purpose? Staying connected to why you do this and staying focused on the present is really important,” Dr. Harry noted.
Do your best to get a good night’s sleep, exercise as much as you can, talk to others, and see a mental health provider if your anxiety is too high, advises Dr. Barrett. “Even avoiding blue light from phones and screens within 2 hours of bedtime, parking further away from the hospital and walking, and taking the stairs are things that add up in a big way.”
Keep up your normal routine
“Right now, it’s really critical for clinicians to keep up components of their routine that feel ‘normal,’ ” Dr. Rudolph said. “Whether it’s exercise, playing board games with their kids, or spending time on a hobby, it’s critical to allow yourself these comfortable, predictable, and rewarding detours.”
Set limits
People under stress tend to find unhealthy ways to cope. Instead, try being intentional about what you are consuming by putting limits on things like your news, alcohol consumption, and the number of hours you work, said Dr. Harry.
Implement a culture of wellness
Dr. Barrett believes in creating the work culture we want to be in, one that ensures people have psychological safety, allows them to ask for help, encourages them to disconnect completely from work, and makes them feel valued and listened to. She likes the example of “the pause,” which is called by a team member right after a patient expires.
“It’s a 30-second moment of silence where we reflect on the patient, their loved ones, and every member of the health care team who helped support and treat them,” said Dr. Barrett. “At the conclusion, you say: ‘Thank you. Is there anything you need to be able to go back to the care of other patients?’ Because it’s unnatural to have this terrible thing that happened and then just act like nothing happened.”
Target resources
Be proactive and know where to find resources before you need them, advised Dr. Harry. “Most institutions have free mental health resources, either through their employee assistance programs or HR, plus there’s lots of national organizations that are offering free resources to health care providers.”
Focus on what you can control
Separating what is under your control from what is not is a struggle for everyone, Dr. Poorman said, but it’s helpful to think about the ways you can have an impact and what you’re able to control.
“There was a woman who was diagnosed with early-onset Parkinson’s that I heard giving an interview at the beginning of this pandemic,” she said. “It was the most helpful advice I got, which was: ‘Think of the next good thing you can do.’ You can’t fix everything, so what’s the next good thing you can do?”
Maintain connectivity
Make sure you are utilizing your support circle and staying connected. “That sense of connection is incredibly protective on multiple fronts for depression, for burnout, for suicide ideation, etc.,” Dr. Harry said.
“It doesn’t matter if it’s your teammates at work, your family at home, your best friend from medical school – whomever you can debrief with, vent with, and just share your thoughts and feelings with, these outlets are critical for all of us to process our emotions and diffuse stress and anxiety,” said Dr. Rudolph.
Dr. Poorman is concerned that there could be a spike in physician suicides caused by increased stress, so she also encourages talking openly about what is going on and about getting help when it’s necessary. “Many of us are afraid to seek care because we can actually have our ability to practice medicine questioned, but now is not the time for heroes. Now is the time for people who are willing to recognize their own strengths and limitations to take care of one another.”
Be compassionate toward others
Keep in mind that everyone is stressed out and offer empathy and compassion. “I think everybody’s struggling to try to figure this out and the more that we can give each other the benefit of the doubt and a little grace, the more protective that is,” said Dr. Harry.
Listening is meaningful too. “Recognizing opportunities to validate and acknowledge the feelings that are being shared with you by your colleagues is critical,” Dr. Rudolph said. “We all need to know that we’re not alone, that our thoughts and feelings are okay, and when we share a difficult story, the value of someone saying something as simple as, ‘wow, that sounds like it was really hard,’ is immense.”
Be compassionate toward yourself
Try to give yourself a break and be as compassionate with yourself as you would with others. It’s okay that you’re not getting in shape, publishing prolifically, or redesigning your house right now.
“There’s a lot of data linking lack of self-compassion to burnout,” said Dr. Harry. She says there are courses on self-compassion available that help you work on being kinder to yourself.
Get a “battle buddy”
The American Medical Association has a free “buddy system” program called PeerRx to help physicians cope during the pandemic. Dr. Rudolph said that now is a great time to use this military-developed intervention in which each team member checks in with a chosen partner at agreed-upon intervals.
For example, “You can tell that person: ‘If I don’t call my family for a week that’s a red flag for me.’ And then you hold each other accountable to those things,” Dr. Harry said.
The buddy system is another way to harness that sense of connection that is so vital to our health and well-being.
“The simple act of showing that you care … can make all the difference when you’re doing this kind of work that is both challenging and dangerous,” said Dr. Rudolph.
The global COVID-19 pandemic has escalated everyone’s stress levels, especially clinicians caring for hospitalized patients. New pressures have added to everyday stress, new studies have revised prior patient care recommendations, and the world generally seems upside down. What can a busy hospitalist do to maintain a modicum of sanity in all the craziness?
The stressors facing hospitalists
Uncertainty
Of all the burdens COVID-19 has unleashed, the biggest may be uncertainty. Not only is there unease about the virus itself, there also is legitimate concern about the future of medicine, said Elizabeth Harry, MD, SFHM, a hospitalist and senior director of clinical affairs at the University of Colorado Hospital in Aurora.
“What does it look like after an event like this, particularly in areas like academic medicine and teaching our next generation and getting funding for research? And how do we continue to produce physicians that can provide excellent care?” she asked.
There is also uncertainty in the best way to care for patients, said Eileen Barrett, MD, MPH, SFHM, a hospitalist at the University of New Mexico, Albuquerque.
“There are some models that are emerging to predict who will have a worse outcome, but they’re still not great models, so we have uncertainty for a given patient.” And, she noted, as the science continues to evolve, there exists a constant worry that “you might have inadvertently caused someone harm.”
The financial implications of the pandemic are creating uncertainty too. “When you fund a health care system with elective procedures and you can’t do those, and instead have to shift to the most essential services, a lot of places are seeing a massive deficit, which is going to affect staff morale and some physician offices are going to close,” said Elisabeth Poorman, MD, MPH, a primary care and internal medicine physician and chair of the King County Medical Society Physician Wellness Committee in Seattle.
Fear
When the pandemic began in the United States, “fear of the unknown was perhaps the scariest part, particularly as it pertained to personal protective equipment,” said Mark Rudolph, MD, SFHM, chief experience officer and vice president of patient experience and physician development at Sound Physicians in Tacoma, Wash. “For most clinicians, this is the first time that they are themselves in harm’s way while they do their jobs. And worse, they risk bringing the virus home to their families. That is the concern I hear most.”
Anxiety
Worrying about being able to provide excellent patient care is a big stressor, especially since this is the heart and soul of why most hospitalists have gone into their line of work.
“Part of providing excellent care to your patients is providing excellent supportive care to their families,” Dr. Harry said. “There’s some dissonance there in not being able to allow the family to come visit, but wanting to keep them safe, and it feels really hard to support your patients and support their families in the best way. It can feel like you’re just watching and waiting to see what will happen, and that we don’t have a lot of agency over which direction things take.”
There is concern for health care team members as well, Dr. Harry added. “Physicians care a lot about their teams and how they’re doing. I think there’s a sense of esprit de corps among folks and worry for each other there.”
Guilt
Although you may be at the hospital all day, you may feel guilty when you are not providing direct patient care. Or maybe you or someone on your team has an immunodeficiency and can’t be on the front line. Perhaps one of your team members contracted COVID-19 and you did not. Whatever the case, guilt is another emotion that is rampant among hospitalists right now, Dr. Barrett said.
Burnout
Unfortunately, burnout is a potential reality in times of high stress. “Burnout is dynamic,” said Dr. Poorman. “It’s a process by which your emotional and cognitive reserves are exhausted. The people with the highest burnout are the ones who are still trying to provide the standard of care, or above the standard of care in dysfunctional systems.”
Dr. Harry noted that burnout presents in different ways for different people, but Dr. Rudolph added that it’s crucial for hospitalist team members to watch for signs of burnout so they can intervene and/or get help for their colleagues.
Warning signs in yourself or others that burnout could be on the horizon include:
- Fatigue/exhaustion – Whether emotional or physical (or both), this can become a problem if it “just doesn’t seem to go away despite rest and time away from work,” said Dr. Rudolph.
- Behavioral changes – Any behavior that’s out of the ordinary may be a red flag, like lashing out at someone at work.
- Overwork – Working too much can be caused by an inability to let go of patient care, Dr. Barrett said.
- Not working enough – This may include avoiding tasks and having difficulty meeting deadlines.
- Maladaptive coping behaviors – Excessive consumption of alcohol or drugs is a common coping mechanism. “Even excessive consumption of news is something that people are using to numb out a little bit,” said Dr. Harry.
- Depersonalization – “This is where you start to look at patients, colleagues, or administrators as ‘them’ and you can’t connect as deeply,” Dr. Harry said. “Part of that’s protective and a normal thing to do during a big trauma like this, but it’s also incredibly distancing. Any language that people start using that feels like ‘us’ or ‘them’ is a warning sign.”
- Disengagement – Many people disengage from their work, but Dr. Poorman said physicians tend to disengage from other parts of their lives, such as exercise and family interaction.
Protecting yourself while supporting others
Like the illustration of putting the oxygen mask on yourself first so you can help others, it’s important to protect your own mental and physical health as you support your fellow physicians. Here’s what the experts suggest.
Focus on basic needs
“When you’re in the midst of a trauma, which we are, you don’t want to open all of that up and go to the depths of your thoughts about the grief of all of it because it can actually make the trauma worse,” said Dr. Harry. “There’s a lot of literature that debriefing is really helpful after the event, but if you do it during the event, it can be really dangerous.”
Instead, she said, the goal should be focusing on your basic needs and what you need to do to get through each day, like keeping you and your family in good health. “What is your purpose? Staying connected to why you do this and staying focused on the present is really important,” Dr. Harry noted.
Do your best to get a good night’s sleep, exercise as much as you can, talk to others, and see a mental health provider if your anxiety is too high, advises Dr. Barrett. “Even avoiding blue light from phones and screens within 2 hours of bedtime, parking further away from the hospital and walking, and taking the stairs are things that add up in a big way.”
Keep up your normal routine
“Right now, it’s really critical for clinicians to keep up components of their routine that feel ‘normal,’ ” Dr. Rudolph said. “Whether it’s exercise, playing board games with their kids, or spending time on a hobby, it’s critical to allow yourself these comfortable, predictable, and rewarding detours.”
Set limits
People under stress tend to find unhealthy ways to cope. Instead, try being intentional about what you are consuming by putting limits on things like your news, alcohol consumption, and the number of hours you work, said Dr. Harry.
Implement a culture of wellness
Dr. Barrett believes in creating the work culture we want to be in, one that ensures people have psychological safety, allows them to ask for help, encourages them to disconnect completely from work, and makes them feel valued and listened to. She likes the example of “the pause,” which is called by a team member right after a patient expires.
“It’s a 30-second moment of silence where we reflect on the patient, their loved ones, and every member of the health care team who helped support and treat them,” said Dr. Barrett. “At the conclusion, you say: ‘Thank you. Is there anything you need to be able to go back to the care of other patients?’ Because it’s unnatural to have this terrible thing that happened and then just act like nothing happened.”
Target resources
Be proactive and know where to find resources before you need them, advised Dr. Harry. “Most institutions have free mental health resources, either through their employee assistance programs or HR, plus there’s lots of national organizations that are offering free resources to health care providers.”
Focus on what you can control
Separating what is under your control from what is not is a struggle for everyone, Dr. Poorman said, but it’s helpful to think about the ways you can have an impact and what you’re able to control.
“There was a woman who was diagnosed with early-onset Parkinson’s that I heard giving an interview at the beginning of this pandemic,” she said. “It was the most helpful advice I got, which was: ‘Think of the next good thing you can do.’ You can’t fix everything, so what’s the next good thing you can do?”
Maintain connectivity
Make sure you are utilizing your support circle and staying connected. “That sense of connection is incredibly protective on multiple fronts for depression, for burnout, for suicide ideation, etc.,” Dr. Harry said.
“It doesn’t matter if it’s your teammates at work, your family at home, your best friend from medical school – whomever you can debrief with, vent with, and just share your thoughts and feelings with, these outlets are critical for all of us to process our emotions and diffuse stress and anxiety,” said Dr. Rudolph.
Dr. Poorman is concerned that there could be a spike in physician suicides caused by increased stress, so she also encourages talking openly about what is going on and about getting help when it’s necessary. “Many of us are afraid to seek care because we can actually have our ability to practice medicine questioned, but now is not the time for heroes. Now is the time for people who are willing to recognize their own strengths and limitations to take care of one another.”
Be compassionate toward others
Keep in mind that everyone is stressed out and offer empathy and compassion. “I think everybody’s struggling to try to figure this out and the more that we can give each other the benefit of the doubt and a little grace, the more protective that is,” said Dr. Harry.
Listening is meaningful too. “Recognizing opportunities to validate and acknowledge the feelings that are being shared with you by your colleagues is critical,” Dr. Rudolph said. “We all need to know that we’re not alone, that our thoughts and feelings are okay, and when we share a difficult story, the value of someone saying something as simple as, ‘wow, that sounds like it was really hard,’ is immense.”
Be compassionate toward yourself
Try to give yourself a break and be as compassionate with yourself as you would with others. It’s okay that you’re not getting in shape, publishing prolifically, or redesigning your house right now.
“There’s a lot of data linking lack of self-compassion to burnout,” said Dr. Harry. She says there are courses on self-compassion available that help you work on being kinder to yourself.
Get a “battle buddy”
The American Medical Association has a free “buddy system” program called PeerRx to help physicians cope during the pandemic. Dr. Rudolph said that now is a great time to use this military-developed intervention in which each team member checks in with a chosen partner at agreed-upon intervals.
For example, “You can tell that person: ‘If I don’t call my family for a week that’s a red flag for me.’ And then you hold each other accountable to those things,” Dr. Harry said.
The buddy system is another way to harness that sense of connection that is so vital to our health and well-being.
“The simple act of showing that you care … can make all the difference when you’re doing this kind of work that is both challenging and dangerous,” said Dr. Rudolph.
Study compares pulse vs. continuous therapy for dermatophyte toenail onychomycosis
There appear to be results from a systematic review and network meta-analysis showed.
“Previous meta-analyses of pulse and continuous therapies have generated ambiguous results,” study authors led by Aditya K. Gupta, MD, PhD, wrote in a poster abstract presented at the virtual annual meeting of the American Academy of Dermatology. “There are few head-to-head clinical studies and no meta-analyses comparing regimens of terbinafine to regimens of itraconazole.”
In what is believed to be the first study of its kind, Dr. Gupta, professor of dermatology at the University of Toronto, and colleagues used network meta-analysis to compare pulse and continuous systemic therapies for toenail onychomycosis. They used PubMed to search for randomized, controlled trials of oral antifungal treatments for the condition in patients aged 18 years and older that included data on mycologic cure, complete cure, adverse events, and dropout rates. Treatment effects were based on intention-to-treat cure rates, and the researchers excluded studies of ketoconazole and griseofulvin since they are no longer indicated for the condition.
For their network meta-analysis, Dr. Gupta and colleagues evaluated 22 studies from 20 publications that included 4,205 randomized patients. Data on complete cure were excluded because of a lack of studies. When the researchers compared all treatments to placebo, the likelihood of mycologic cure did not differ significantly between continuous and pulse regimens for terbinafine and itraconazole. Compared with placebo, the most successful treatments were continuous terbinafine 250 mg daily for 24 weeks (risk ratio of achieving mycologic cure, 11.0) and continuous terbinafine 250 mg daily for 16 weeks (RR, 8.90). The researchers also observed no significant differences in the likelihood of adverse events between any continuous and pulse regimens of terbinafine, itraconazole, and fluconazole.
“Although continuous terbinafine 250 mg for 24 weeks was significantly more likely to produce mycologic cure than continuous itraconazole 200 mg for 12 weeks and weekly fluconazole (150-450 mg), it is not significantly different from the other included treatments,” Dr. Gupta and colleagues wrote in the abstract. “Considering the fungal life cycle, pulse therapy should theoretically be as effective as, or more effective than, continuous therapies: the sudden high concentration of an antifungal drug eliminates hyphae, sparing already-present spores. During the ‘off’ portion, these spores may germinate and be eliminated during the next pulse. Continuous therapy spares the spores, allowing them to germinate once treatment ends.”
They went on to note that, in clinical practice, “neither continuous nor pulse therapy is necessarily better. It is possible that the drug concentration in the nail is maintained during the ‘off’ period of pulse therapy. In both therapies, it may be that residual spores that have not been eliminated by the end of therapy are left to germinate, possibly contributing to the recalcitrant nature of onychomycosis.”
The study was awarded fourth place in the AAD’s 2020 poster awards. Dr. Gupta disclosed that he is a clinical trials investigator for Moberg Pharma and Bausch Health Canada and a speaker for Bausch Health Canada.
SOURCE: Gupta A et al. AAD 20, Abstract 16014.
There appear to be results from a systematic review and network meta-analysis showed.
“Previous meta-analyses of pulse and continuous therapies have generated ambiguous results,” study authors led by Aditya K. Gupta, MD, PhD, wrote in a poster abstract presented at the virtual annual meeting of the American Academy of Dermatology. “There are few head-to-head clinical studies and no meta-analyses comparing regimens of terbinafine to regimens of itraconazole.”
In what is believed to be the first study of its kind, Dr. Gupta, professor of dermatology at the University of Toronto, and colleagues used network meta-analysis to compare pulse and continuous systemic therapies for toenail onychomycosis. They used PubMed to search for randomized, controlled trials of oral antifungal treatments for the condition in patients aged 18 years and older that included data on mycologic cure, complete cure, adverse events, and dropout rates. Treatment effects were based on intention-to-treat cure rates, and the researchers excluded studies of ketoconazole and griseofulvin since they are no longer indicated for the condition.
For their network meta-analysis, Dr. Gupta and colleagues evaluated 22 studies from 20 publications that included 4,205 randomized patients. Data on complete cure were excluded because of a lack of studies. When the researchers compared all treatments to placebo, the likelihood of mycologic cure did not differ significantly between continuous and pulse regimens for terbinafine and itraconazole. Compared with placebo, the most successful treatments were continuous terbinafine 250 mg daily for 24 weeks (risk ratio of achieving mycologic cure, 11.0) and continuous terbinafine 250 mg daily for 16 weeks (RR, 8.90). The researchers also observed no significant differences in the likelihood of adverse events between any continuous and pulse regimens of terbinafine, itraconazole, and fluconazole.
“Although continuous terbinafine 250 mg for 24 weeks was significantly more likely to produce mycologic cure than continuous itraconazole 200 mg for 12 weeks and weekly fluconazole (150-450 mg), it is not significantly different from the other included treatments,” Dr. Gupta and colleagues wrote in the abstract. “Considering the fungal life cycle, pulse therapy should theoretically be as effective as, or more effective than, continuous therapies: the sudden high concentration of an antifungal drug eliminates hyphae, sparing already-present spores. During the ‘off’ portion, these spores may germinate and be eliminated during the next pulse. Continuous therapy spares the spores, allowing them to germinate once treatment ends.”
They went on to note that, in clinical practice, “neither continuous nor pulse therapy is necessarily better. It is possible that the drug concentration in the nail is maintained during the ‘off’ period of pulse therapy. In both therapies, it may be that residual spores that have not been eliminated by the end of therapy are left to germinate, possibly contributing to the recalcitrant nature of onychomycosis.”
The study was awarded fourth place in the AAD’s 2020 poster awards. Dr. Gupta disclosed that he is a clinical trials investigator for Moberg Pharma and Bausch Health Canada and a speaker for Bausch Health Canada.
SOURCE: Gupta A et al. AAD 20, Abstract 16014.
There appear to be results from a systematic review and network meta-analysis showed.
“Previous meta-analyses of pulse and continuous therapies have generated ambiguous results,” study authors led by Aditya K. Gupta, MD, PhD, wrote in a poster abstract presented at the virtual annual meeting of the American Academy of Dermatology. “There are few head-to-head clinical studies and no meta-analyses comparing regimens of terbinafine to regimens of itraconazole.”
In what is believed to be the first study of its kind, Dr. Gupta, professor of dermatology at the University of Toronto, and colleagues used network meta-analysis to compare pulse and continuous systemic therapies for toenail onychomycosis. They used PubMed to search for randomized, controlled trials of oral antifungal treatments for the condition in patients aged 18 years and older that included data on mycologic cure, complete cure, adverse events, and dropout rates. Treatment effects were based on intention-to-treat cure rates, and the researchers excluded studies of ketoconazole and griseofulvin since they are no longer indicated for the condition.
For their network meta-analysis, Dr. Gupta and colleagues evaluated 22 studies from 20 publications that included 4,205 randomized patients. Data on complete cure were excluded because of a lack of studies. When the researchers compared all treatments to placebo, the likelihood of mycologic cure did not differ significantly between continuous and pulse regimens for terbinafine and itraconazole. Compared with placebo, the most successful treatments were continuous terbinafine 250 mg daily for 24 weeks (risk ratio of achieving mycologic cure, 11.0) and continuous terbinafine 250 mg daily for 16 weeks (RR, 8.90). The researchers also observed no significant differences in the likelihood of adverse events between any continuous and pulse regimens of terbinafine, itraconazole, and fluconazole.
“Although continuous terbinafine 250 mg for 24 weeks was significantly more likely to produce mycologic cure than continuous itraconazole 200 mg for 12 weeks and weekly fluconazole (150-450 mg), it is not significantly different from the other included treatments,” Dr. Gupta and colleagues wrote in the abstract. “Considering the fungal life cycle, pulse therapy should theoretically be as effective as, or more effective than, continuous therapies: the sudden high concentration of an antifungal drug eliminates hyphae, sparing already-present spores. During the ‘off’ portion, these spores may germinate and be eliminated during the next pulse. Continuous therapy spares the spores, allowing them to germinate once treatment ends.”
They went on to note that, in clinical practice, “neither continuous nor pulse therapy is necessarily better. It is possible that the drug concentration in the nail is maintained during the ‘off’ period of pulse therapy. In both therapies, it may be that residual spores that have not been eliminated by the end of therapy are left to germinate, possibly contributing to the recalcitrant nature of onychomycosis.”
The study was awarded fourth place in the AAD’s 2020 poster awards. Dr. Gupta disclosed that he is a clinical trials investigator for Moberg Pharma and Bausch Health Canada and a speaker for Bausch Health Canada.
SOURCE: Gupta A et al. AAD 20, Abstract 16014.
FROM AAD 20
Racism: Developmental perspective can inform tough conversations
Can we help our pediatric patients with the complicated problems of racism, especially if we are privileged (and even white) professionals? We may not have experienced discrimination, but we can still advise and address it. Racist discrimination, fear, trauma, or distress may produce or exacerbate conditions we are treating.
Three levels of racism impact children’s health and health care: “structural or institutional” policies that influence social determinants of health; “personally mediated” differential treatment based on assumptions about one’s abilities, motives, or intents; and the resulting “internalization” of stereotypes into one’s identity, undermining confidence, self-esteem, and mental health. We can help advocate about structural racism and ensure equity within our offices, but how best to counsel the families and children themselves?
Racism includes actions of “assigning value based on the social interpretation of how a person looks” (Ethn Dis. 2008;18[4]:496-504). “Social interpretations” develop from an early age. Newborns detect differences in appearance and may startle or cry seeing a parent’s drastic haircut or new hat. Parents generally know to use soothing words and tone, bring the difference into view gradually, smile and comfort the child, and explain the change; these are good skills for later, too. Infants notice skin color, which, unlike clothes, is a stable feature by which to recognize parents. Social interpretation of these differences is cued from the parents’ feelings and reactions. Adults naturally transmit biases from their own past unless they work to dampen them. If the parent was taught to regard “other” as negative or is generally fearful, the child mirrors this. Working to reduce racism thus requires parents (and professionals) to examine their prejudices to be able to convey positive or neutral reactions to people who are different. Parents need to show curiosity, positive affect, and comfort about people who are different, and do well to seek contact and friendships with people from other groups and include their children in these relationships. We can encourage this outreach plus ensure diversity and respectful interactions in our offices.
Children from age 3 years value fairness and are upset seeing others treated unfairly – easily understanding “not fair” or “mean.” If the person being hurt is like them in race, ethnicity, religion, gender, or sexual preference, they also fear for themselves, family, and friends. Balance is needed in discussing racism to avoid increasing fear or overpromising as risks are real and solutions difficult. Children look to adults for understanding and evidence of action to feel safer, rather than helpless. We should state that leaders are working on “making the rules more fair,” ensuring that people “won’t be allowed do it again,” and “teaching that everyone deserves respect.” Even better, parents and children can generate ideas about child actions, giving them some power as an antidote to anxiety. Age-related possibilities might include drawing a picture of people getting along, talking at show-and-tell, writing a note to officials, making a protest sign, posting thoughts on Facebook, or protesting.
With age, the culture increasingly influences a child’s attitudes. Children see lots of teasing and bullying based on differences from being overweight or wearing glasses, to skin color. It is helpful to interpret for children that bullies are insecure, or sometimes have been hurt, and they put other people down to feel better than someone else. Thinking about racist acts this way may reduce the desire for revenge and a cycle of aggression. Effective anti-bullying programs help children recognize bullying, see it as an emergency that requires their action, tell adults, and take action. This action could be surrounding the bully, standing tall, making eye contact, having a dismissive retort, or asking questions that require the bully to think, such as “What do you want to happen by doing this?” We can coach our patients and their parents on these principles as well as advising schools.
Children need to be told that those being put down or held down – especially those like them – have strengths; have made discoveries; have produced writings, art, and music; have shown military bravery, moral leadership, and resistance to discrimination, but it is not the time to show strength when confronted by a gun or police. We can use and arm parents with examples to discuss strengths and accomplishments to help buffer the child from internalization of racist stereotypes. Children need positive role models who look like them; parents can seek out diverse professionals in their children’s lives, such as dentists, doctors, teachers, clergy, mentors, or coaches. We, and parents, can ensure that dolls and books are available, and that the children’s shows, movies, and video games are watched together and include diverse people doing good or brave things. These exposures also are key to all children becoming anti-racist.
Parents can be advised to initiate discussion of racism because children, detecting adult discomfort, may avoid the topic. We can encourage families to give their point of view; otherwise children simply absorb those of peers or the press. Parents should tell their children, “I want you to be able to talk about it if someone is mean or treats you unfairly because of [the color of your skin, your religion, your sex, your disability, etc.]. You might feel helpless, or angry, which is natural. We need to talk about this so you can feel strong. Then we can plan on what we are going to do.” The “sandwich” method of “ask-give information-ask what they think” can encourage discussion and correct misperceptions.
Racist policies have succeeded partly by adult “bullies” dehumanizing the “other.” Most children can consider someone else’s point of view by 4½ years old, shaped with adult help. Parents can begin by telling babies, “That hurts, doesn’t it?” asking toddlers and older, “How would you feel if ... [someone called you a name just because of having red hair]?” or “How do you think she feels when ... [someone pushes her out of line because she wears certain clothes]?” in cases of grabbing, not sharing, hitting, bullying, etc. Older children and teens can analyze more abstract situations when asked, “What if you were the one who ... [got expelled for mumbling about the teacher]?” or “What if that were your sister?” or “How would the world be if everyone ... [got a chance to go to college]?” We can encourage parents to propose these mental exercises to build the child’s perspective-taking while conveying their opinions.
Experiences, including through media, may increase or decrease fear; the child needs to have a supportive person moderating the exposure, providing a positive interpretation, and protecting the child from overwhelm, if needed.
Experiences are insufficient for developing anti-racist attitudes; listening and talking are needed. The first step is to ask children about what they notice, think, and feel about situations reflecting racism, especially as they lack words for these complicated observations. There are television, Internet, and newspaper examples of both racism and anti-racism that can be fruitfully discussed. We can recommend watching or reading together, and asking questions such as, “Why do you think they are shouting [protesting]?” “How do you think the [victim, police] felt?” or “What do you think should be done about this?”
It is important to acknowledge the child’s confusion, fear, anxiety, sadness, or anger as normal and appropriate, not dismissing, too quickly reassuring, or changing the subject, even though it’s uncomfortable.
Physicians and nurse practitioners can make a difference by being aware of our privilege and biases, being open, modeling discussion, screening for impact, offering strategies, advocating with schools, and providing resources such as therapy or legal counsel, as for other social determinants of health.
Dr. Howard is assistant professor of pediatrics at Johns Hopkins University, Baltimore, and creator of CHADIS (https://www.site.chadis.com/). She had no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to MDedge News. E-mail her at pdnews@mdedge.com.
Can we help our pediatric patients with the complicated problems of racism, especially if we are privileged (and even white) professionals? We may not have experienced discrimination, but we can still advise and address it. Racist discrimination, fear, trauma, or distress may produce or exacerbate conditions we are treating.
Three levels of racism impact children’s health and health care: “structural or institutional” policies that influence social determinants of health; “personally mediated” differential treatment based on assumptions about one’s abilities, motives, or intents; and the resulting “internalization” of stereotypes into one’s identity, undermining confidence, self-esteem, and mental health. We can help advocate about structural racism and ensure equity within our offices, but how best to counsel the families and children themselves?
Racism includes actions of “assigning value based on the social interpretation of how a person looks” (Ethn Dis. 2008;18[4]:496-504). “Social interpretations” develop from an early age. Newborns detect differences in appearance and may startle or cry seeing a parent’s drastic haircut or new hat. Parents generally know to use soothing words and tone, bring the difference into view gradually, smile and comfort the child, and explain the change; these are good skills for later, too. Infants notice skin color, which, unlike clothes, is a stable feature by which to recognize parents. Social interpretation of these differences is cued from the parents’ feelings and reactions. Adults naturally transmit biases from their own past unless they work to dampen them. If the parent was taught to regard “other” as negative or is generally fearful, the child mirrors this. Working to reduce racism thus requires parents (and professionals) to examine their prejudices to be able to convey positive or neutral reactions to people who are different. Parents need to show curiosity, positive affect, and comfort about people who are different, and do well to seek contact and friendships with people from other groups and include their children in these relationships. We can encourage this outreach plus ensure diversity and respectful interactions in our offices.
Children from age 3 years value fairness and are upset seeing others treated unfairly – easily understanding “not fair” or “mean.” If the person being hurt is like them in race, ethnicity, religion, gender, or sexual preference, they also fear for themselves, family, and friends. Balance is needed in discussing racism to avoid increasing fear or overpromising as risks are real and solutions difficult. Children look to adults for understanding and evidence of action to feel safer, rather than helpless. We should state that leaders are working on “making the rules more fair,” ensuring that people “won’t be allowed do it again,” and “teaching that everyone deserves respect.” Even better, parents and children can generate ideas about child actions, giving them some power as an antidote to anxiety. Age-related possibilities might include drawing a picture of people getting along, talking at show-and-tell, writing a note to officials, making a protest sign, posting thoughts on Facebook, or protesting.
With age, the culture increasingly influences a child’s attitudes. Children see lots of teasing and bullying based on differences from being overweight or wearing glasses, to skin color. It is helpful to interpret for children that bullies are insecure, or sometimes have been hurt, and they put other people down to feel better than someone else. Thinking about racist acts this way may reduce the desire for revenge and a cycle of aggression. Effective anti-bullying programs help children recognize bullying, see it as an emergency that requires their action, tell adults, and take action. This action could be surrounding the bully, standing tall, making eye contact, having a dismissive retort, or asking questions that require the bully to think, such as “What do you want to happen by doing this?” We can coach our patients and their parents on these principles as well as advising schools.
Children need to be told that those being put down or held down – especially those like them – have strengths; have made discoveries; have produced writings, art, and music; have shown military bravery, moral leadership, and resistance to discrimination, but it is not the time to show strength when confronted by a gun or police. We can use and arm parents with examples to discuss strengths and accomplishments to help buffer the child from internalization of racist stereotypes. Children need positive role models who look like them; parents can seek out diverse professionals in their children’s lives, such as dentists, doctors, teachers, clergy, mentors, or coaches. We, and parents, can ensure that dolls and books are available, and that the children’s shows, movies, and video games are watched together and include diverse people doing good or brave things. These exposures also are key to all children becoming anti-racist.
Parents can be advised to initiate discussion of racism because children, detecting adult discomfort, may avoid the topic. We can encourage families to give their point of view; otherwise children simply absorb those of peers or the press. Parents should tell their children, “I want you to be able to talk about it if someone is mean or treats you unfairly because of [the color of your skin, your religion, your sex, your disability, etc.]. You might feel helpless, or angry, which is natural. We need to talk about this so you can feel strong. Then we can plan on what we are going to do.” The “sandwich” method of “ask-give information-ask what they think” can encourage discussion and correct misperceptions.
Racist policies have succeeded partly by adult “bullies” dehumanizing the “other.” Most children can consider someone else’s point of view by 4½ years old, shaped with adult help. Parents can begin by telling babies, “That hurts, doesn’t it?” asking toddlers and older, “How would you feel if ... [someone called you a name just because of having red hair]?” or “How do you think she feels when ... [someone pushes her out of line because she wears certain clothes]?” in cases of grabbing, not sharing, hitting, bullying, etc. Older children and teens can analyze more abstract situations when asked, “What if you were the one who ... [got expelled for mumbling about the teacher]?” or “What if that were your sister?” or “How would the world be if everyone ... [got a chance to go to college]?” We can encourage parents to propose these mental exercises to build the child’s perspective-taking while conveying their opinions.
Experiences, including through media, may increase or decrease fear; the child needs to have a supportive person moderating the exposure, providing a positive interpretation, and protecting the child from overwhelm, if needed.
Experiences are insufficient for developing anti-racist attitudes; listening and talking are needed. The first step is to ask children about what they notice, think, and feel about situations reflecting racism, especially as they lack words for these complicated observations. There are television, Internet, and newspaper examples of both racism and anti-racism that can be fruitfully discussed. We can recommend watching or reading together, and asking questions such as, “Why do you think they are shouting [protesting]?” “How do you think the [victim, police] felt?” or “What do you think should be done about this?”
It is important to acknowledge the child’s confusion, fear, anxiety, sadness, or anger as normal and appropriate, not dismissing, too quickly reassuring, or changing the subject, even though it’s uncomfortable.
Physicians and nurse practitioners can make a difference by being aware of our privilege and biases, being open, modeling discussion, screening for impact, offering strategies, advocating with schools, and providing resources such as therapy or legal counsel, as for other social determinants of health.
Dr. Howard is assistant professor of pediatrics at Johns Hopkins University, Baltimore, and creator of CHADIS (https://www.site.chadis.com/). She had no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to MDedge News. E-mail her at pdnews@mdedge.com.
Can we help our pediatric patients with the complicated problems of racism, especially if we are privileged (and even white) professionals? We may not have experienced discrimination, but we can still advise and address it. Racist discrimination, fear, trauma, or distress may produce or exacerbate conditions we are treating.
Three levels of racism impact children’s health and health care: “structural or institutional” policies that influence social determinants of health; “personally mediated” differential treatment based on assumptions about one’s abilities, motives, or intents; and the resulting “internalization” of stereotypes into one’s identity, undermining confidence, self-esteem, and mental health. We can help advocate about structural racism and ensure equity within our offices, but how best to counsel the families and children themselves?
Racism includes actions of “assigning value based on the social interpretation of how a person looks” (Ethn Dis. 2008;18[4]:496-504). “Social interpretations” develop from an early age. Newborns detect differences in appearance and may startle or cry seeing a parent’s drastic haircut or new hat. Parents generally know to use soothing words and tone, bring the difference into view gradually, smile and comfort the child, and explain the change; these are good skills for later, too. Infants notice skin color, which, unlike clothes, is a stable feature by which to recognize parents. Social interpretation of these differences is cued from the parents’ feelings and reactions. Adults naturally transmit biases from their own past unless they work to dampen them. If the parent was taught to regard “other” as negative or is generally fearful, the child mirrors this. Working to reduce racism thus requires parents (and professionals) to examine their prejudices to be able to convey positive or neutral reactions to people who are different. Parents need to show curiosity, positive affect, and comfort about people who are different, and do well to seek contact and friendships with people from other groups and include their children in these relationships. We can encourage this outreach plus ensure diversity and respectful interactions in our offices.
Children from age 3 years value fairness and are upset seeing others treated unfairly – easily understanding “not fair” or “mean.” If the person being hurt is like them in race, ethnicity, religion, gender, or sexual preference, they also fear for themselves, family, and friends. Balance is needed in discussing racism to avoid increasing fear or overpromising as risks are real and solutions difficult. Children look to adults for understanding and evidence of action to feel safer, rather than helpless. We should state that leaders are working on “making the rules more fair,” ensuring that people “won’t be allowed do it again,” and “teaching that everyone deserves respect.” Even better, parents and children can generate ideas about child actions, giving them some power as an antidote to anxiety. Age-related possibilities might include drawing a picture of people getting along, talking at show-and-tell, writing a note to officials, making a protest sign, posting thoughts on Facebook, or protesting.
With age, the culture increasingly influences a child’s attitudes. Children see lots of teasing and bullying based on differences from being overweight or wearing glasses, to skin color. It is helpful to interpret for children that bullies are insecure, or sometimes have been hurt, and they put other people down to feel better than someone else. Thinking about racist acts this way may reduce the desire for revenge and a cycle of aggression. Effective anti-bullying programs help children recognize bullying, see it as an emergency that requires their action, tell adults, and take action. This action could be surrounding the bully, standing tall, making eye contact, having a dismissive retort, or asking questions that require the bully to think, such as “What do you want to happen by doing this?” We can coach our patients and their parents on these principles as well as advising schools.
Children need to be told that those being put down or held down – especially those like them – have strengths; have made discoveries; have produced writings, art, and music; have shown military bravery, moral leadership, and resistance to discrimination, but it is not the time to show strength when confronted by a gun or police. We can use and arm parents with examples to discuss strengths and accomplishments to help buffer the child from internalization of racist stereotypes. Children need positive role models who look like them; parents can seek out diverse professionals in their children’s lives, such as dentists, doctors, teachers, clergy, mentors, or coaches. We, and parents, can ensure that dolls and books are available, and that the children’s shows, movies, and video games are watched together and include diverse people doing good or brave things. These exposures also are key to all children becoming anti-racist.
Parents can be advised to initiate discussion of racism because children, detecting adult discomfort, may avoid the topic. We can encourage families to give their point of view; otherwise children simply absorb those of peers or the press. Parents should tell their children, “I want you to be able to talk about it if someone is mean or treats you unfairly because of [the color of your skin, your religion, your sex, your disability, etc.]. You might feel helpless, or angry, which is natural. We need to talk about this so you can feel strong. Then we can plan on what we are going to do.” The “sandwich” method of “ask-give information-ask what they think” can encourage discussion and correct misperceptions.
Racist policies have succeeded partly by adult “bullies” dehumanizing the “other.” Most children can consider someone else’s point of view by 4½ years old, shaped with adult help. Parents can begin by telling babies, “That hurts, doesn’t it?” asking toddlers and older, “How would you feel if ... [someone called you a name just because of having red hair]?” or “How do you think she feels when ... [someone pushes her out of line because she wears certain clothes]?” in cases of grabbing, not sharing, hitting, bullying, etc. Older children and teens can analyze more abstract situations when asked, “What if you were the one who ... [got expelled for mumbling about the teacher]?” or “What if that were your sister?” or “How would the world be if everyone ... [got a chance to go to college]?” We can encourage parents to propose these mental exercises to build the child’s perspective-taking while conveying their opinions.
Experiences, including through media, may increase or decrease fear; the child needs to have a supportive person moderating the exposure, providing a positive interpretation, and protecting the child from overwhelm, if needed.
Experiences are insufficient for developing anti-racist attitudes; listening and talking are needed. The first step is to ask children about what they notice, think, and feel about situations reflecting racism, especially as they lack words for these complicated observations. There are television, Internet, and newspaper examples of both racism and anti-racism that can be fruitfully discussed. We can recommend watching or reading together, and asking questions such as, “Why do you think they are shouting [protesting]?” “How do you think the [victim, police] felt?” or “What do you think should be done about this?”
It is important to acknowledge the child’s confusion, fear, anxiety, sadness, or anger as normal and appropriate, not dismissing, too quickly reassuring, or changing the subject, even though it’s uncomfortable.
Physicians and nurse practitioners can make a difference by being aware of our privilege and biases, being open, modeling discussion, screening for impact, offering strategies, advocating with schools, and providing resources such as therapy or legal counsel, as for other social determinants of health.
Dr. Howard is assistant professor of pediatrics at Johns Hopkins University, Baltimore, and creator of CHADIS (https://www.site.chadis.com/). She had no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to MDedge News. E-mail her at pdnews@mdedge.com.