Nonpharmaceutical interventions, such as masking, staying home, limiting travel, and social distancing, have been doing more than reducing the risk for COVID-19. They’re also having an impact on infection rates and the timing of seasonal surges of other common respiratory diseases, according to an article published July 23 in Morbidity and Mortality Weekly Report.

Typically, respiratory pathogens such as respiratory syncytial virus (RSV), common cold coronaviruses, parainfluenza viruses, and respiratory adenoviruses increase in the fall and remain high throughout winter, following the same basic patterns as influenza. Although the historically low rates of influenza remained low into spring 2021, that’s not the case for several other common respiratory viruses.

“Clinicians should be aware of increases in some respiratory virus activity and remain vigilant for off-season increases,” wrote Sonja J. Olsen, PhD, and her colleagues at the Centers for Disease Control and Prevention. She told this news organization that clinicians should use multipathogen testing to help guide treatment.

The authors also underscore the importance of fall influenza vaccination campaigns for anyone aged 6 months or older.

Timothy Brewer, MD, MPH, a professor of medicine in the Division of Infectious Diseases at the University of California, Los Angeles (UCLA), and of epidemiology at the UCLA Fielding School of Public Health, agreed that it’s important for health care professionals to consider off-season illnesses in their patients.

“Practitioners should be aware that if they see a sick child in the summer, outside of what normally might be influenza season, but they look like they have influenza, consider potentially influenza and test for it, because it might be possible that we may have disrupted that natural pattern,” Dr. Brewer told this news organization. Dr. Brewer, who was not involved in the CDC research, said it’s also “critically important” to encourage influenza vaccination as the season approaches.

The CDC researchers used the U.S. World Health Organization Collaborating Laboratories System and the CDC’s National Respiratory and Enteric Virus Surveillance System to analyze virologic data from Oct. 3, 2020, to May 22, 2021, for influenza and Jan. 4, 2020, to May 22, 2021, for other respiratory viruses. The authors compared virus circulation during these periods to circulation during the same dates from four previous years.

Data to calculate influenza and RSV hospitalization rates came from the Influenza Hospitalization Surveillance Network and RSV Hospitalization Surveillance Network.

The authors report that flu activity dropped dramatically in March 2020 to its lowest levels since 1997, the earliest season for which data are available. Only 0.2% of more than 1 million specimens tested positive for influenza; the rate of hospitalizations for lab-confirmed flu was 0.8 per 100,000 people. Flu levels remained low through the summer, fall, and on to May 2021.

A potential drawback to this low activity, however, is a more prevalent and severe upcoming flu season, the authors write. The repeated exposure to flu viruses every year often “does not lead to illness, but it does serve to boost our immune response to influenza viruses,” Dr. Olsen said in an interview. “The absence of influenza viruses in the community over the last year means that we are not getting these regular boosts to our immune system. When we finally get exposed, our body may mount a weak response, and this could mean we develop a more clinically severe illness.”

Children are most susceptible to that phenomenon because they haven’t had a lifetime of exposure to flu viruses, Dr. Olsen said.

“An immunologically naive child may be more likely to develop a severe illness than someone who has lived through several influenza seasons,” she said. “This is why it is especially important for everyone 6 months and older to get vaccinated against influenza this season.”

Rhinovirus and enterovirus infections rebounded fairly quickly after their decline in March 2020 and started increasing in May 2020 until they reached “near prepandemic seasonal levels,” the authors write.

RSV infections dropped from 15.3% of weekly positive results in January 2020 to 1.4% by April and then stayed below 1% through the end of 2020. In past years, weekly positive results climbed to 3% in October and peaked at 12.5% to 16.7% in late December. Instead, RSV weekly positive results began increasing in April 2021, rising from 1.1% to 2.8% in May.

The “unusually timed” late spring increase in RSV “is probably associated with various nonpharmaceutical measures that have been in place but are now relaxing,” Dr. Olsen stated.

The RSV hospitalization rate was 0.3 per 100,000 people from October 2020 to April 2021, compared to 27.1 and 33.4 per 100,000 people in the previous 2 years. Of all RSV hospitalizations in the past year, 76.5% occurred in April-May 2021.

Rates of illness caused by the four common human coronaviruses (OC43, NL63, 229E, and HKU1) dropped from 7.5% of weekly positive results in January 2020 to 1.3% in April 2020 and stayed below 1% through February 2021. Then they climbed to 6.6% by May 2021. Infection rates of parainfluenza viruses types 1-4 similarly dropped from 2.6% in January 2020 to 1% in March 2020 and stayed below 1% until April 2021. Since then, rates of the common coronaviruses increased to 6.6% and parainfluenza viruses to 10.9% in May 2021.

Normally, parainfluenza viruses peak in October-November and May-June, so “the current increase could represent a return to prepandemic seasonality,” the authors write.

Human pneumoviruses’ weekly positive results initially increased from 4.2% in January 2020 to 7% in March and then fell to 1.9% the second week of April and remained below 1% through May 2021. In typical years, these viruses peak from 6.2% to 7.7% in March-April. Respiratory adenovirus activity similarly dropped to historically low levels in April 2021 and then began increasing to reach 3% by May 2021, the usual level for that month.

“The different circulation patterns observed across respiratory viruses probably also reflect differences in the virus transmission routes and how effective various nonpharmaceutical measures are at stopping transmission,” Dr. Olsen said in an interview. “As pandemic mitigation measures continue to be adjusted, we expect to see more changes in the circulation of these viruses, including a return to prepandemic circulation, as seen for rhinoviruses and enteroviruses.”

Rhinovirus and enterovirus rates dropped from 14.9% in March 2020 to 3.2% in May – lower than typical – and then climbed to a peak in October 2020. The peak (21.7% weekly positive results) was, however, still lower than the usual median of 32.8%. After dropping to 9.9% in January 2021, it then rose 19.1% in May, potentially reflecting “the usual spring peak that has occurred in previous years,” the authors write.

The authors note that it’s not yet clear how the COVID-19 pandemic and related mitigation measures will continue to affect respiratory virus circulation.

The authors hypothesize that the reasons for a seeming return to seasonal activity of respiratory adenoviruses, rhinoviruses, and enteroviruses could involve “different transmission mechanisms, the role of asymptomatic transmission, and prolonged survival of these nonenveloped viruses on surfaces, all of which might make these viruses less susceptible to nonpharmaceutical interventions.”

Dr. Brewer, of UCLA, agreed.

All the viruses basically “flatline except for adenoviruses and enteroviruses, and they behave a little differently in terms of how they spread,” he said. “Enteroviruses are much more likely to be fecal-oral spread than the other viruses [in the study].”

The delayed circulation of parainfluenza and human coronaviruses may have resulted from suspension of in-person classes through late winter 2020, they write, but that doesn’t explain the relative absence of pneumovirus activity, which usually affects the same young pediatric populations as RSV.

Dr. Brewer said California is seeing a surge of RSV right now, as are many states, especially throughout in the South. He’s not surprised by RSV’s deferred season, because those most affected – children younger than 2 years – are less likely to wear masks now and were “not going to daycare, not being out in public” in 2020. “As people are doing more activities, that’s probably why RSV has been starting to go up since April,” he said.

Despite the fact that, unlike many East Asian cultures, the United States has not traditionally been a mask-wearing culture, Dr. Brewer wouldn’t be surprised if more Americans begin wearing masks during flu season. “Hopefully another thing that will come out of this is better hand hygiene, with people just getting used to washing their hands more, particularly after they come home from being out,” he added.

Dr. Brewer similarly emphasized the importance of flu vaccination for the upcoming season, especially for younger children who may have poorer natural immunity to influenza, owing to its low circulation rates in 2020-2021.

The study was funded by the CDC. Dr. Brewer and Dr. Olsen have disclosed no relevant financial relationships.

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

Nonpharmaceutical interventions, such as masking, staying home, limiting travel, and social distancing, have been doing more than reducing the risk for COVID-19. They’re also having an impact on infection rates and the timing of seasonal surges of other common respiratory diseases, according to an article published July 23 in Morbidity and Mortality Weekly Report.

Typically, respiratory pathogens such as respiratory syncytial virus (RSV), common cold coronaviruses, parainfluenza viruses, and respiratory adenoviruses increase in the fall and remain high throughout winter, following the same basic patterns as influenza. Although the historically low rates of influenza remained low into spring 2021, that’s not the case for several other common respiratory viruses.

“Clinicians should be aware of increases in some respiratory virus activity and remain vigilant for off-season increases,” wrote Sonja J. Olsen, PhD, and her colleagues at the Centers for Disease Control and Prevention. She told this news organization that clinicians should use multipathogen testing to help guide treatment.

The authors also underscore the importance of fall influenza vaccination campaigns for anyone aged 6 months or older.

Timothy Brewer, MD, MPH, a professor of medicine in the Division of Infectious Diseases at the University of California, Los Angeles (UCLA), and of epidemiology at the UCLA Fielding School of Public Health, agreed that it’s important for health care professionals to consider off-season illnesses in their patients.

“Practitioners should be aware that if they see a sick child in the summer, outside of what normally might be influenza season, but they look like they have influenza, consider potentially influenza and test for it, because it might be possible that we may have disrupted that natural pattern,” Dr. Brewer told this news organization. Dr. Brewer, who was not involved in the CDC research, said it’s also “critically important” to encourage influenza vaccination as the season approaches.

The CDC researchers used the U.S. World Health Organization Collaborating Laboratories System and the CDC’s National Respiratory and Enteric Virus Surveillance System to analyze virologic data from Oct. 3, 2020, to May 22, 2021, for influenza and Jan. 4, 2020, to May 22, 2021, for other respiratory viruses. The authors compared virus circulation during these periods to circulation during the same dates from four previous years.

Data to calculate influenza and RSV hospitalization rates came from the Influenza Hospitalization Surveillance Network and RSV Hospitalization Surveillance Network.

The authors report that flu activity dropped dramatically in March 2020 to its lowest levels since 1997, the earliest season for which data are available. Only 0.2% of more than 1 million specimens tested positive for influenza; the rate of hospitalizations for lab-confirmed flu was 0.8 per 100,000 people. Flu levels remained low through the summer, fall, and on to May 2021.

A potential drawback to this low activity, however, is a more prevalent and severe upcoming flu season, the authors write. The repeated exposure to flu viruses every year often “does not lead to illness, but it does serve to boost our immune response to influenza viruses,” Dr. Olsen said in an interview. “The absence of influenza viruses in the community over the last year means that we are not getting these regular boosts to our immune system. When we finally get exposed, our body may mount a weak response, and this could mean we develop a more clinically severe illness.”

Children are most susceptible to that phenomenon because they haven’t had a lifetime of exposure to flu viruses, Dr. Olsen said.

“An immunologically naive child may be more likely to develop a severe illness than someone who has lived through several influenza seasons,” she said. “This is why it is especially important for everyone 6 months and older to get vaccinated against influenza this season.”

Rhinovirus and enterovirus infections rebounded fairly quickly after their decline in March 2020 and started increasing in May 2020 until they reached “near prepandemic seasonal levels,” the authors write.

RSV infections dropped from 15.3% of weekly positive results in January 2020 to 1.4% by April and then stayed below 1% through the end of 2020. In past years, weekly positive results climbed to 3% in October and peaked at 12.5% to 16.7% in late December. Instead, RSV weekly positive results began increasing in April 2021, rising from 1.1% to 2.8% in May.

The “unusually timed” late spring increase in RSV “is probably associated with various nonpharmaceutical measures that have been in place but are now relaxing,” Dr. Olsen stated.

The RSV hospitalization rate was 0.3 per 100,000 people from October 2020 to April 2021, compared to 27.1 and 33.4 per 100,000 people in the previous 2 years. Of all RSV hospitalizations in the past year, 76.5% occurred in April-May 2021.

Rates of illness caused by the four common human coronaviruses (OC43, NL63, 229E, and HKU1) dropped from 7.5% of weekly positive results in January 2020 to 1.3% in April 2020 and stayed below 1% through February 2021. Then they climbed to 6.6% by May 2021. Infection rates of parainfluenza viruses types 1-4 similarly dropped from 2.6% in January 2020 to 1% in March 2020 and stayed below 1% until April 2021. Since then, rates of the common coronaviruses increased to 6.6% and parainfluenza viruses to 10.9% in May 2021.

Normally, parainfluenza viruses peak in October-November and May-June, so “the current increase could represent a return to prepandemic seasonality,” the authors write.

Human pneumoviruses’ weekly positive results initially increased from 4.2% in January 2020 to 7% in March and then fell to 1.9% the second week of April and remained below 1% through May 2021. In typical years, these viruses peak from 6.2% to 7.7% in March-April. Respiratory adenovirus activity similarly dropped to historically low levels in April 2021 and then began increasing to reach 3% by May 2021, the usual level for that month.

“The different circulation patterns observed across respiratory viruses probably also reflect differences in the virus transmission routes and how effective various nonpharmaceutical measures are at stopping transmission,” Dr. Olsen said in an interview. “As pandemic mitigation measures continue to be adjusted, we expect to see more changes in the circulation of these viruses, including a return to prepandemic circulation, as seen for rhinoviruses and enteroviruses.”

Rhinovirus and enterovirus rates dropped from 14.9% in March 2020 to 3.2% in May – lower than typical – and then climbed to a peak in October 2020. The peak (21.7% weekly positive results) was, however, still lower than the usual median of 32.8%. After dropping to 9.9% in January 2021, it then rose 19.1% in May, potentially reflecting “the usual spring peak that has occurred in previous years,” the authors write.

The authors note that it’s not yet clear how the COVID-19 pandemic and related mitigation measures will continue to affect respiratory virus circulation.

The authors hypothesize that the reasons for a seeming return to seasonal activity of respiratory adenoviruses, rhinoviruses, and enteroviruses could involve “different transmission mechanisms, the role of asymptomatic transmission, and prolonged survival of these nonenveloped viruses on surfaces, all of which might make these viruses less susceptible to nonpharmaceutical interventions.”

Dr. Brewer, of UCLA, agreed.

All the viruses basically “flatline except for adenoviruses and enteroviruses, and they behave a little differently in terms of how they spread,” he said. “Enteroviruses are much more likely to be fecal-oral spread than the other viruses [in the study].”

The delayed circulation of parainfluenza and human coronaviruses may have resulted from suspension of in-person classes through late winter 2020, they write, but that doesn’t explain the relative absence of pneumovirus activity, which usually affects the same young pediatric populations as RSV.

Dr. Brewer said California is seeing a surge of RSV right now, as are many states, especially throughout in the South. He’s not surprised by RSV’s deferred season, because those most affected – children younger than 2 years – are less likely to wear masks now and were “not going to daycare, not being out in public” in 2020. “As people are doing more activities, that’s probably why RSV has been starting to go up since April,” he said.

Despite the fact that, unlike many East Asian cultures, the United States has not traditionally been a mask-wearing culture, Dr. Brewer wouldn’t be surprised if more Americans begin wearing masks during flu season. “Hopefully another thing that will come out of this is better hand hygiene, with people just getting used to washing their hands more, particularly after they come home from being out,” he added.

Dr. Brewer similarly emphasized the importance of flu vaccination for the upcoming season, especially for younger children who may have poorer natural immunity to influenza, owing to its low circulation rates in 2020-2021.

The study was funded by the CDC. Dr. Brewer and Dr. Olsen have disclosed no relevant financial relationships.

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

Nonpharmaceutical interventions, such as masking, staying home, limiting travel, and social distancing, have been doing more than reducing the risk for COVID-19. They’re also having an impact on infection rates and the timing of seasonal surges of other common respiratory diseases, according to an article published July 23 in Morbidity and Mortality Weekly Report.

Typically, respiratory pathogens such as respiratory syncytial virus (RSV), common cold coronaviruses, parainfluenza viruses, and respiratory adenoviruses increase in the fall and remain high throughout winter, following the same basic patterns as influenza. Although the historically low rates of influenza remained low into spring 2021, that’s not the case for several other common respiratory viruses.

“Clinicians should be aware of increases in some respiratory virus activity and remain vigilant for off-season increases,” wrote Sonja J. Olsen, PhD, and her colleagues at the Centers for Disease Control and Prevention. She told this news organization that clinicians should use multipathogen testing to help guide treatment.

The authors also underscore the importance of fall influenza vaccination campaigns for anyone aged 6 months or older.

Timothy Brewer, MD, MPH, a professor of medicine in the Division of Infectious Diseases at the University of California, Los Angeles (UCLA), and of epidemiology at the UCLA Fielding School of Public Health, agreed that it’s important for health care professionals to consider off-season illnesses in their patients.

“Practitioners should be aware that if they see a sick child in the summer, outside of what normally might be influenza season, but they look like they have influenza, consider potentially influenza and test for it, because it might be possible that we may have disrupted that natural pattern,” Dr. Brewer told this news organization. Dr. Brewer, who was not involved in the CDC research, said it’s also “critically important” to encourage influenza vaccination as the season approaches.

The CDC researchers used the U.S. World Health Organization Collaborating Laboratories System and the CDC’s National Respiratory and Enteric Virus Surveillance System to analyze virologic data from Oct. 3, 2020, to May 22, 2021, for influenza and Jan. 4, 2020, to May 22, 2021, for other respiratory viruses. The authors compared virus circulation during these periods to circulation during the same dates from four previous years.

Data to calculate influenza and RSV hospitalization rates came from the Influenza Hospitalization Surveillance Network and RSV Hospitalization Surveillance Network.

The authors report that flu activity dropped dramatically in March 2020 to its lowest levels since 1997, the earliest season for which data are available. Only 0.2% of more than 1 million specimens tested positive for influenza; the rate of hospitalizations for lab-confirmed flu was 0.8 per 100,000 people. Flu levels remained low through the summer, fall, and on to May 2021.

A potential drawback to this low activity, however, is a more prevalent and severe upcoming flu season, the authors write. The repeated exposure to flu viruses every year often “does not lead to illness, but it does serve to boost our immune response to influenza viruses,” Dr. Olsen said in an interview. “The absence of influenza viruses in the community over the last year means that we are not getting these regular boosts to our immune system. When we finally get exposed, our body may mount a weak response, and this could mean we develop a more clinically severe illness.”

Children are most susceptible to that phenomenon because they haven’t had a lifetime of exposure to flu viruses, Dr. Olsen said.

“An immunologically naive child may be more likely to develop a severe illness than someone who has lived through several influenza seasons,” she said. “This is why it is especially important for everyone 6 months and older to get vaccinated against influenza this season.”

Rhinovirus and enterovirus infections rebounded fairly quickly after their decline in March 2020 and started increasing in May 2020 until they reached “near prepandemic seasonal levels,” the authors write.

RSV infections dropped from 15.3% of weekly positive results in January 2020 to 1.4% by April and then stayed below 1% through the end of 2020. In past years, weekly positive results climbed to 3% in October and peaked at 12.5% to 16.7% in late December. Instead, RSV weekly positive results began increasing in April 2021, rising from 1.1% to 2.8% in May.

The “unusually timed” late spring increase in RSV “is probably associated with various nonpharmaceutical measures that have been in place but are now relaxing,” Dr. Olsen stated.

The RSV hospitalization rate was 0.3 per 100,000 people from October 2020 to April 2021, compared to 27.1 and 33.4 per 100,000 people in the previous 2 years. Of all RSV hospitalizations in the past year, 76.5% occurred in April-May 2021.

Rates of illness caused by the four common human coronaviruses (OC43, NL63, 229E, and HKU1) dropped from 7.5% of weekly positive results in January 2020 to 1.3% in April 2020 and stayed below 1% through February 2021. Then they climbed to 6.6% by May 2021. Infection rates of parainfluenza viruses types 1-4 similarly dropped from 2.6% in January 2020 to 1% in March 2020 and stayed below 1% until April 2021. Since then, rates of the common coronaviruses increased to 6.6% and parainfluenza viruses to 10.9% in May 2021.

Normally, parainfluenza viruses peak in October-November and May-June, so “the current increase could represent a return to prepandemic seasonality,” the authors write.

Human pneumoviruses’ weekly positive results initially increased from 4.2% in January 2020 to 7% in March and then fell to 1.9% the second week of April and remained below 1% through May 2021. In typical years, these viruses peak from 6.2% to 7.7% in March-April. Respiratory adenovirus activity similarly dropped to historically low levels in April 2021 and then began increasing to reach 3% by May 2021, the usual level for that month.

“The different circulation patterns observed across respiratory viruses probably also reflect differences in the virus transmission routes and how effective various nonpharmaceutical measures are at stopping transmission,” Dr. Olsen said in an interview. “As pandemic mitigation measures continue to be adjusted, we expect to see more changes in the circulation of these viruses, including a return to prepandemic circulation, as seen for rhinoviruses and enteroviruses.”

Rhinovirus and enterovirus rates dropped from 14.9% in March 2020 to 3.2% in May – lower than typical – and then climbed to a peak in October 2020. The peak (21.7% weekly positive results) was, however, still lower than the usual median of 32.8%. After dropping to 9.9% in January 2021, it then rose 19.1% in May, potentially reflecting “the usual spring peak that has occurred in previous years,” the authors write.

The authors note that it’s not yet clear how the COVID-19 pandemic and related mitigation measures will continue to affect respiratory virus circulation.

The authors hypothesize that the reasons for a seeming return to seasonal activity of respiratory adenoviruses, rhinoviruses, and enteroviruses could involve “different transmission mechanisms, the role of asymptomatic transmission, and prolonged survival of these nonenveloped viruses on surfaces, all of which might make these viruses less susceptible to nonpharmaceutical interventions.”

Dr. Brewer, of UCLA, agreed.

All the viruses basically “flatline except for adenoviruses and enteroviruses, and they behave a little differently in terms of how they spread,” he said. “Enteroviruses are much more likely to be fecal-oral spread than the other viruses [in the study].”

The delayed circulation of parainfluenza and human coronaviruses may have resulted from suspension of in-person classes through late winter 2020, they write, but that doesn’t explain the relative absence of pneumovirus activity, which usually affects the same young pediatric populations as RSV.

Dr. Brewer said California is seeing a surge of RSV right now, as are many states, especially throughout in the South. He’s not surprised by RSV’s deferred season, because those most affected – children younger than 2 years – are less likely to wear masks now and were “not going to daycare, not being out in public” in 2020. “As people are doing more activities, that’s probably why RSV has been starting to go up since April,” he said.

Despite the fact that, unlike many East Asian cultures, the United States has not traditionally been a mask-wearing culture, Dr. Brewer wouldn’t be surprised if more Americans begin wearing masks during flu season. “Hopefully another thing that will come out of this is better hand hygiene, with people just getting used to washing their hands more, particularly after they come home from being out,” he added.

Dr. Brewer similarly emphasized the importance of flu vaccination for the upcoming season, especially for younger children who may have poorer natural immunity to influenza, owing to its low circulation rates in 2020-2021.

The study was funded by the CDC. Dr. Brewer and Dr. Olsen have disclosed no relevant financial relationships.

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

Less than one in five women physicians are practicing in the top five high-paying specialties. Women compose only 6% of orthopedic surgeons, 8% of interventional cardiologists, 10% of urologists, 17% of plastic surgeons, and 18% of otolaryngologists, according to the 2020 Association of American Medical Colleges Physician Specialty Data Report.

Plastic surgeons earn an average of $526,000 annually, which is the highest-paying specialty. Otolaryngologists earn an average of $417,000 annually, and urologists earn $427,000, according to the Medscape Physician Compensation Report 2021: The Recovery Begins.

Yet, far more women are practicing in specialties that pay less. Women are the majority in pediatrics (64%), ob.gyn. (59%), internal medicine (53%), and endocrinology (51%), the AAMC data show. The exception is dermatology, which pays well and in which 51% are women. The annual average pay is $394,000.

Why are so many women avoiding the top-paying specialties?

Several physician researchers and leaders in the top-paying specialties point to four main factors: Women are attracted to specialties that have more women in faculty and leadership positions, women prioritize work-life balance over pay, women residents may be deterred from the high-paying specialties because of gender discrimination and sexual harassment, and the longer training periods for surgical specialties may be a deterrent for women who want to have children.
 

Lack of women leaders

The specialties with the most women tend to have the highest proportion of women in leadership positions. For example, obstetrics and gynecology had the highest proportion of women department chairs (24.1%) and vice chairs (38.8). Pediatrics had the highest proportion of women division directors (31.5%) and residency program directors (64.6%), a study shows.

Surgical specialties, on the other hand, may have a harder time attracting female residents, possibly because of a lack of women in leadership positions. A recent study that examined gender differences in attitudes toward surgery training found that women would be more likely to go into surgery if there were more surgical faculty and residents of their same gender.

An analysis of orthopedic residency programs shows that more trainees were drawn to programs that had more female faculty members, including associate professors and women in leadership positions.

Terri Malcolm, MD, a board-certified ob.gyn. and CEO/founder of Master Physician Leaders, said women need to consider whether they want to be a trailblazer in a specialty that has fewer women. “What support systems are in place to accommodate your goals, whether it’s career advancement, having a family, or mentorship? Where can you show up as your whole self and be supported in that?”

Being the only woman in a residency program can be a challenge, said Dr. Malcolm. If the residents and attendings are predominantly men, for example, they may not think about creating a call schedule that takes into account maternity leave or the fact that women tend to be caretakers for their children and parents.

The study of gender differences toward surgery training shows that 75% of women, in comparison with 46% of men, would be more willing to enter surgery if maternity leave and childcare were made available to female residents and attending physicians.
 

Women want work-life balance

Although both men and women want families, women still shoulder more family and childcare responsibilities. That may explain why women physicians ranked work-life balance first and compensation second in the Medscape Women Physicians 2020 Report: The Issues They Care About.

“My physician colleagues have been and are supportive of intellectual abilities, but I feel they don’t fully understand the uneven distribution of childcare issues on women,” a woman dermatologist commented.

Women may want to work fewer hours or have a more flexible schedule to take care of children. “I can count on one hand the number of women who have a part-time job in orthopedics. It’s very rare, and working part time absolutely is a barrier for someone who wants to be a surgeon,” said Julie Samora, MD, PhD, a researcher and pediatric hand surgeon at Nationwide Children’s Hospital, in Columbus, Ohio. She is also a spokesperson for the American Association of Orthopedic Surgeons.

Preeti Malani, MD, a professor of medicine who specializes in infectious diseases at the University of Michigan, chose to work full-time in academia while raising two children with her husband. In a decade, she rose through the ranks to full professor. “I took the advice of a woman who wanted to recruit me to have a full-time position with maximum flexibility rather than work part time, often for more hours and less pay. I also have tried to build my career so I was not doing all clinical work.”

Her husband is a surgeon at the University of Michigan. His schedule was not flexible, and he was unable to take on family responsibilities, said Dr. Malani. “I knew someone had to be able to grab the kids from daycare or pick them up at school if they were sick.” She also took work home and worked weekends.

Young women physicians in particular are thinking about combining parenting with work – in the Medscape report, that issue ranked third among the issues women care about. Seeing other women doctors navigate that in their particular specialty can have a positive impact.

“When I chose adolescent medicine, I remember working with a doctor in this field who talked about how much she enjoyed raising her kids even as teenagers and how much she was enjoying them as young adults. She seemed so balanced and happy in her family, and it gave me a nice feeling about the field,” said Nancy Dodson, MD, MPH, a pediatrician specializing in adolescent medicine at Pediatrics on Hudson in New York.

Rachel Zhuk, MD, a reproductive psychiatrist in New York, took a break after medical school to spend time with her newborn son. She met a woman who was also a young parent and a psychiatrist. “We were both figuring out parenting together – it was like looking into my future.” That friendship and her desire to have more time with patients influenced her decision to pursue psychiatry instead of internal medicine.
 

Discrimination and harassment influence specialty choice

Women doctors in the top-paying surgical and other specialties have reported experiencing more discrimination and harassment than men.

Of 927 orthopedic surgeons who responded to an AAOS survey, 66% said they experienced gender discrimination, bullying, sexual harassment, or harassment in the health care workplace. More than twice as many women (81%) experienced these behaviors as men (35%).

“This study shows that women in orthopedic surgery disproportionately experience these negative behaviors, and only a handful of institutions in the United States provide any type of training to prevent them,” said Dr. Samora, the lead author of the AAOS report.

Radiology is another male-dominated field – women represent 26% of all radiologists, the 2020 AAMC specialty report shows. A systematic review shows that 40% of women radiologists experienced gender discrimination at work, compared with 1% of men, and that 47% of women experienced sexual harassment.

Female trainees in surgery have also reported disproportionate rates of discrimination and harassment. Female general surgical residents have experienced more gender discrimination than male residents (65.1% vs. 10.0%) and more sexual harassment than male residents (19.9% vs. 3.9), a national survey indicates.

When medical students are exposed to these behaviors through personal experience, witnessing, or hearing about them, it can affect which specialty they choose. A survey of fourth-year medical students shows that far more women than men reported that exposure to gender discrimination and sexual harassment influenced their specialty choices (45.3% vs. 16.4%) and residency rankings (25.3% vs. 10.9%). Women who chose general surgery were the most likely to experience gender discrimination and sexual harassment during residency selection; women who chose psychiatry were the least likely to experience such behaviors, the report shows.

“If young trainees witness such behaviors in a specific field, they would naturally migrate toward a different specialty,” said Dr. Samora.

Trainees can also be put off by residency directors asking them inappropriate questions. Of nearly 500 female orthopedic surgeons surveyed, 62% reported that they were asked inappropriate questions during their residency interviews. “Inappropriate questions and comments directed toward women during residency interviews are clearly not conducive to women entering the field,” the authors stated. They found that little changed during the study period from 1971 to 2015.

The most frequent inappropriate questions concerned whether the prospective residents would be getting pregnant or raising children during residency and their marital status. One female orthopedic surgeon reported: “I was asked if I have children and was told that it would be too difficult to complete an orthopedic residency with children.”

The interviewers also made frequent comments about the inferiority of women to men. For example, “I was told by one program interviewer that ‘I don’t have a bias about women in medicine, I have a bias about women in orthopedic surgery,’ ” another female orthopedic surgeon commented.
 

Longer training

Residency training for the top-paying surgical specialties, including orthopedic surgery, plastic surgery, and otolaryngology, lasts 5-6 years. This compares with 3-4 years for the lower-paying specialties, such as pediatrics, internal medicine, and ob.gyn., according to data from the American Medical Association.

Women doctors are in their prime childbearing years during residency. Women who want to start a family will consider whether they want to get pregnant during residency or wait until they finish their training, said Dr. Malcolm.

The vast majority (84%) of 190 female orthopedic surgery trainees who responded to a survey indicated that they did not have children or were pregnant during residency. Nearly half (48%) reported that they had postponed having children because they were in training.

“The longer training is definitely a concerning issue for women of childbearing age. Many professional women are waiting to have children, for multiple reasons, but one major fear is the stigma due to taking time off from work obligations. There is a risk of irritating your peers because they may have to take on more work and cover more calls for you during your absence,” said Dr. Samora.

That fear is not unfounded. At least half of the 190 female orthopedic residents reported that they encountered bias against becoming pregnant during training from both coresidents (60%) and attendings (50%), according to the study.

Another recent survey suggests that pregnant surgical residents face several barriers during their training, including a lack of salary for extended family leave, resentment from fellow residents who need to cover for them during maternity leave, and a lack of formal lactation policies.

A few policy changes by national board organizations, including those in the surgical specialties, may make life a little easier for female trainees to have children, suggested Dr. Samora.

Residents and fellows are now allowed a minimum of 6 weeks away for medical leave or caregiving once during training, without having to use vacation or sick leave and without having to extend their training, the American Board of Medical Specialties has announced.

In addition, the American Board of Orthopaedic Surgery and the American Board of Surgery have enacted policies that allow lactating women to take a break to pump during their board exams.

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

Less than one in five women physicians are practicing in the top five high-paying specialties. Women compose only 6% of orthopedic surgeons, 8% of interventional cardiologists, 10% of urologists, 17% of plastic surgeons, and 18% of otolaryngologists, according to the 2020 Association of American Medical Colleges Physician Specialty Data Report.

Plastic surgeons earn an average of $526,000 annually, which is the highest-paying specialty. Otolaryngologists earn an average of $417,000 annually, and urologists earn $427,000, according to the Medscape Physician Compensation Report 2021: The Recovery Begins.

Yet, far more women are practicing in specialties that pay less. Women are the majority in pediatrics (64%), ob.gyn. (59%), internal medicine (53%), and endocrinology (51%), the AAMC data show. The exception is dermatology, which pays well and in which 51% are women. The annual average pay is $394,000.

Why are so many women avoiding the top-paying specialties?

Several physician researchers and leaders in the top-paying specialties point to four main factors: Women are attracted to specialties that have more women in faculty and leadership positions, women prioritize work-life balance over pay, women residents may be deterred from the high-paying specialties because of gender discrimination and sexual harassment, and the longer training periods for surgical specialties may be a deterrent for women who want to have children.
 

Lack of women leaders

The specialties with the most women tend to have the highest proportion of women in leadership positions. For example, obstetrics and gynecology had the highest proportion of women department chairs (24.1%) and vice chairs (38.8). Pediatrics had the highest proportion of women division directors (31.5%) and residency program directors (64.6%), a study shows.

Surgical specialties, on the other hand, may have a harder time attracting female residents, possibly because of a lack of women in leadership positions. A recent study that examined gender differences in attitudes toward surgery training found that women would be more likely to go into surgery if there were more surgical faculty and residents of their same gender.

An analysis of orthopedic residency programs shows that more trainees were drawn to programs that had more female faculty members, including associate professors and women in leadership positions.

Terri Malcolm, MD, a board-certified ob.gyn. and CEO/founder of Master Physician Leaders, said women need to consider whether they want to be a trailblazer in a specialty that has fewer women. “What support systems are in place to accommodate your goals, whether it’s career advancement, having a family, or mentorship? Where can you show up as your whole self and be supported in that?”

Being the only woman in a residency program can be a challenge, said Dr. Malcolm. If the residents and attendings are predominantly men, for example, they may not think about creating a call schedule that takes into account maternity leave or the fact that women tend to be caretakers for their children and parents.

The study of gender differences toward surgery training shows that 75% of women, in comparison with 46% of men, would be more willing to enter surgery if maternity leave and childcare were made available to female residents and attending physicians.
 

Women want work-life balance

Although both men and women want families, women still shoulder more family and childcare responsibilities. That may explain why women physicians ranked work-life balance first and compensation second in the Medscape Women Physicians 2020 Report: The Issues They Care About.

“My physician colleagues have been and are supportive of intellectual abilities, but I feel they don’t fully understand the uneven distribution of childcare issues on women,” a woman dermatologist commented.

Women may want to work fewer hours or have a more flexible schedule to take care of children. “I can count on one hand the number of women who have a part-time job in orthopedics. It’s very rare, and working part time absolutely is a barrier for someone who wants to be a surgeon,” said Julie Samora, MD, PhD, a researcher and pediatric hand surgeon at Nationwide Children’s Hospital, in Columbus, Ohio. She is also a spokesperson for the American Association of Orthopedic Surgeons.

Preeti Malani, MD, a professor of medicine who specializes in infectious diseases at the University of Michigan, chose to work full-time in academia while raising two children with her husband. In a decade, she rose through the ranks to full professor. “I took the advice of a woman who wanted to recruit me to have a full-time position with maximum flexibility rather than work part time, often for more hours and less pay. I also have tried to build my career so I was not doing all clinical work.”

Her husband is a surgeon at the University of Michigan. His schedule was not flexible, and he was unable to take on family responsibilities, said Dr. Malani. “I knew someone had to be able to grab the kids from daycare or pick them up at school if they were sick.” She also took work home and worked weekends.

Young women physicians in particular are thinking about combining parenting with work – in the Medscape report, that issue ranked third among the issues women care about. Seeing other women doctors navigate that in their particular specialty can have a positive impact.

“When I chose adolescent medicine, I remember working with a doctor in this field who talked about how much she enjoyed raising her kids even as teenagers and how much she was enjoying them as young adults. She seemed so balanced and happy in her family, and it gave me a nice feeling about the field,” said Nancy Dodson, MD, MPH, a pediatrician specializing in adolescent medicine at Pediatrics on Hudson in New York.

Rachel Zhuk, MD, a reproductive psychiatrist in New York, took a break after medical school to spend time with her newborn son. She met a woman who was also a young parent and a psychiatrist. “We were both figuring out parenting together – it was like looking into my future.” That friendship and her desire to have more time with patients influenced her decision to pursue psychiatry instead of internal medicine.
 

Discrimination and harassment influence specialty choice

Women doctors in the top-paying surgical and other specialties have reported experiencing more discrimination and harassment than men.

Of 927 orthopedic surgeons who responded to an AAOS survey, 66% said they experienced gender discrimination, bullying, sexual harassment, or harassment in the health care workplace. More than twice as many women (81%) experienced these behaviors as men (35%).

“This study shows that women in orthopedic surgery disproportionately experience these negative behaviors, and only a handful of institutions in the United States provide any type of training to prevent them,” said Dr. Samora, the lead author of the AAOS report.

Radiology is another male-dominated field – women represent 26% of all radiologists, the 2020 AAMC specialty report shows. A systematic review shows that 40% of women radiologists experienced gender discrimination at work, compared with 1% of men, and that 47% of women experienced sexual harassment.

Female trainees in surgery have also reported disproportionate rates of discrimination and harassment. Female general surgical residents have experienced more gender discrimination than male residents (65.1% vs. 10.0%) and more sexual harassment than male residents (19.9% vs. 3.9), a national survey indicates.

When medical students are exposed to these behaviors through personal experience, witnessing, or hearing about them, it can affect which specialty they choose. A survey of fourth-year medical students shows that far more women than men reported that exposure to gender discrimination and sexual harassment influenced their specialty choices (45.3% vs. 16.4%) and residency rankings (25.3% vs. 10.9%). Women who chose general surgery were the most likely to experience gender discrimination and sexual harassment during residency selection; women who chose psychiatry were the least likely to experience such behaviors, the report shows.

“If young trainees witness such behaviors in a specific field, they would naturally migrate toward a different specialty,” said Dr. Samora.

Trainees can also be put off by residency directors asking them inappropriate questions. Of nearly 500 female orthopedic surgeons surveyed, 62% reported that they were asked inappropriate questions during their residency interviews. “Inappropriate questions and comments directed toward women during residency interviews are clearly not conducive to women entering the field,” the authors stated. They found that little changed during the study period from 1971 to 2015.

The most frequent inappropriate questions concerned whether the prospective residents would be getting pregnant or raising children during residency and their marital status. One female orthopedic surgeon reported: “I was asked if I have children and was told that it would be too difficult to complete an orthopedic residency with children.”

The interviewers also made frequent comments about the inferiority of women to men. For example, “I was told by one program interviewer that ‘I don’t have a bias about women in medicine, I have a bias about women in orthopedic surgery,’ ” another female orthopedic surgeon commented.
 

Longer training

Residency training for the top-paying surgical specialties, including orthopedic surgery, plastic surgery, and otolaryngology, lasts 5-6 years. This compares with 3-4 years for the lower-paying specialties, such as pediatrics, internal medicine, and ob.gyn., according to data from the American Medical Association.

Women doctors are in their prime childbearing years during residency. Women who want to start a family will consider whether they want to get pregnant during residency or wait until they finish their training, said Dr. Malcolm.

The vast majority (84%) of 190 female orthopedic surgery trainees who responded to a survey indicated that they did not have children or were pregnant during residency. Nearly half (48%) reported that they had postponed having children because they were in training.

“The longer training is definitely a concerning issue for women of childbearing age. Many professional women are waiting to have children, for multiple reasons, but one major fear is the stigma due to taking time off from work obligations. There is a risk of irritating your peers because they may have to take on more work and cover more calls for you during your absence,” said Dr. Samora.

That fear is not unfounded. At least half of the 190 female orthopedic residents reported that they encountered bias against becoming pregnant during training from both coresidents (60%) and attendings (50%), according to the study.

Another recent survey suggests that pregnant surgical residents face several barriers during their training, including a lack of salary for extended family leave, resentment from fellow residents who need to cover for them during maternity leave, and a lack of formal lactation policies.

A few policy changes by national board organizations, including those in the surgical specialties, may make life a little easier for female trainees to have children, suggested Dr. Samora.

Residents and fellows are now allowed a minimum of 6 weeks away for medical leave or caregiving once during training, without having to use vacation or sick leave and without having to extend their training, the American Board of Medical Specialties has announced.

In addition, the American Board of Orthopaedic Surgery and the American Board of Surgery have enacted policies that allow lactating women to take a break to pump during their board exams.

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

Less than one in five women physicians are practicing in the top five high-paying specialties. Women compose only 6% of orthopedic surgeons, 8% of interventional cardiologists, 10% of urologists, 17% of plastic surgeons, and 18% of otolaryngologists, according to the 2020 Association of American Medical Colleges Physician Specialty Data Report.

Plastic surgeons earn an average of $526,000 annually, which is the highest-paying specialty. Otolaryngologists earn an average of $417,000 annually, and urologists earn $427,000, according to the Medscape Physician Compensation Report 2021: The Recovery Begins.

Yet, far more women are practicing in specialties that pay less. Women are the majority in pediatrics (64%), ob.gyn. (59%), internal medicine (53%), and endocrinology (51%), the AAMC data show. The exception is dermatology, which pays well and in which 51% are women. The annual average pay is $394,000.

Why are so many women avoiding the top-paying specialties?

Several physician researchers and leaders in the top-paying specialties point to four main factors: Women are attracted to specialties that have more women in faculty and leadership positions, women prioritize work-life balance over pay, women residents may be deterred from the high-paying specialties because of gender discrimination and sexual harassment, and the longer training periods for surgical specialties may be a deterrent for women who want to have children.
 

Lack of women leaders

The specialties with the most women tend to have the highest proportion of women in leadership positions. For example, obstetrics and gynecology had the highest proportion of women department chairs (24.1%) and vice chairs (38.8). Pediatrics had the highest proportion of women division directors (31.5%) and residency program directors (64.6%), a study shows.

Surgical specialties, on the other hand, may have a harder time attracting female residents, possibly because of a lack of women in leadership positions. A recent study that examined gender differences in attitudes toward surgery training found that women would be more likely to go into surgery if there were more surgical faculty and residents of their same gender.

An analysis of orthopedic residency programs shows that more trainees were drawn to programs that had more female faculty members, including associate professors and women in leadership positions.

Terri Malcolm, MD, a board-certified ob.gyn. and CEO/founder of Master Physician Leaders, said women need to consider whether they want to be a trailblazer in a specialty that has fewer women. “What support systems are in place to accommodate your goals, whether it’s career advancement, having a family, or mentorship? Where can you show up as your whole self and be supported in that?”

Being the only woman in a residency program can be a challenge, said Dr. Malcolm. If the residents and attendings are predominantly men, for example, they may not think about creating a call schedule that takes into account maternity leave or the fact that women tend to be caretakers for their children and parents.

The study of gender differences toward surgery training shows that 75% of women, in comparison with 46% of men, would be more willing to enter surgery if maternity leave and childcare were made available to female residents and attending physicians.
 

Women want work-life balance

Although both men and women want families, women still shoulder more family and childcare responsibilities. That may explain why women physicians ranked work-life balance first and compensation second in the Medscape Women Physicians 2020 Report: The Issues They Care About.

“My physician colleagues have been and are supportive of intellectual abilities, but I feel they don’t fully understand the uneven distribution of childcare issues on women,” a woman dermatologist commented.

Women may want to work fewer hours or have a more flexible schedule to take care of children. “I can count on one hand the number of women who have a part-time job in orthopedics. It’s very rare, and working part time absolutely is a barrier for someone who wants to be a surgeon,” said Julie Samora, MD, PhD, a researcher and pediatric hand surgeon at Nationwide Children’s Hospital, in Columbus, Ohio. She is also a spokesperson for the American Association of Orthopedic Surgeons.

Preeti Malani, MD, a professor of medicine who specializes in infectious diseases at the University of Michigan, chose to work full-time in academia while raising two children with her husband. In a decade, she rose through the ranks to full professor. “I took the advice of a woman who wanted to recruit me to have a full-time position with maximum flexibility rather than work part time, often for more hours and less pay. I also have tried to build my career so I was not doing all clinical work.”

Her husband is a surgeon at the University of Michigan. His schedule was not flexible, and he was unable to take on family responsibilities, said Dr. Malani. “I knew someone had to be able to grab the kids from daycare or pick them up at school if they were sick.” She also took work home and worked weekends.

Young women physicians in particular are thinking about combining parenting with work – in the Medscape report, that issue ranked third among the issues women care about. Seeing other women doctors navigate that in their particular specialty can have a positive impact.

“When I chose adolescent medicine, I remember working with a doctor in this field who talked about how much she enjoyed raising her kids even as teenagers and how much she was enjoying them as young adults. She seemed so balanced and happy in her family, and it gave me a nice feeling about the field,” said Nancy Dodson, MD, MPH, a pediatrician specializing in adolescent medicine at Pediatrics on Hudson in New York.

Rachel Zhuk, MD, a reproductive psychiatrist in New York, took a break after medical school to spend time with her newborn son. She met a woman who was also a young parent and a psychiatrist. “We were both figuring out parenting together – it was like looking into my future.” That friendship and her desire to have more time with patients influenced her decision to pursue psychiatry instead of internal medicine.
 

Discrimination and harassment influence specialty choice

Women doctors in the top-paying surgical and other specialties have reported experiencing more discrimination and harassment than men.

Of 927 orthopedic surgeons who responded to an AAOS survey, 66% said they experienced gender discrimination, bullying, sexual harassment, or harassment in the health care workplace. More than twice as many women (81%) experienced these behaviors as men (35%).

“This study shows that women in orthopedic surgery disproportionately experience these negative behaviors, and only a handful of institutions in the United States provide any type of training to prevent them,” said Dr. Samora, the lead author of the AAOS report.

Radiology is another male-dominated field – women represent 26% of all radiologists, the 2020 AAMC specialty report shows. A systematic review shows that 40% of women radiologists experienced gender discrimination at work, compared with 1% of men, and that 47% of women experienced sexual harassment.

Female trainees in surgery have also reported disproportionate rates of discrimination and harassment. Female general surgical residents have experienced more gender discrimination than male residents (65.1% vs. 10.0%) and more sexual harassment than male residents (19.9% vs. 3.9), a national survey indicates.

When medical students are exposed to these behaviors through personal experience, witnessing, or hearing about them, it can affect which specialty they choose. A survey of fourth-year medical students shows that far more women than men reported that exposure to gender discrimination and sexual harassment influenced their specialty choices (45.3% vs. 16.4%) and residency rankings (25.3% vs. 10.9%). Women who chose general surgery were the most likely to experience gender discrimination and sexual harassment during residency selection; women who chose psychiatry were the least likely to experience such behaviors, the report shows.

“If young trainees witness such behaviors in a specific field, they would naturally migrate toward a different specialty,” said Dr. Samora.

Trainees can also be put off by residency directors asking them inappropriate questions. Of nearly 500 female orthopedic surgeons surveyed, 62% reported that they were asked inappropriate questions during their residency interviews. “Inappropriate questions and comments directed toward women during residency interviews are clearly not conducive to women entering the field,” the authors stated. They found that little changed during the study period from 1971 to 2015.

The most frequent inappropriate questions concerned whether the prospective residents would be getting pregnant or raising children during residency and their marital status. One female orthopedic surgeon reported: “I was asked if I have children and was told that it would be too difficult to complete an orthopedic residency with children.”

The interviewers also made frequent comments about the inferiority of women to men. For example, “I was told by one program interviewer that ‘I don’t have a bias about women in medicine, I have a bias about women in orthopedic surgery,’ ” another female orthopedic surgeon commented.
 

Longer training

Residency training for the top-paying surgical specialties, including orthopedic surgery, plastic surgery, and otolaryngology, lasts 5-6 years. This compares with 3-4 years for the lower-paying specialties, such as pediatrics, internal medicine, and ob.gyn., according to data from the American Medical Association.

Women doctors are in their prime childbearing years during residency. Women who want to start a family will consider whether they want to get pregnant during residency or wait until they finish their training, said Dr. Malcolm.

The vast majority (84%) of 190 female orthopedic surgery trainees who responded to a survey indicated that they did not have children or were pregnant during residency. Nearly half (48%) reported that they had postponed having children because they were in training.

“The longer training is definitely a concerning issue for women of childbearing age. Many professional women are waiting to have children, for multiple reasons, but one major fear is the stigma due to taking time off from work obligations. There is a risk of irritating your peers because they may have to take on more work and cover more calls for you during your absence,” said Dr. Samora.

That fear is not unfounded. At least half of the 190 female orthopedic residents reported that they encountered bias against becoming pregnant during training from both coresidents (60%) and attendings (50%), according to the study.

Another recent survey suggests that pregnant surgical residents face several barriers during their training, including a lack of salary for extended family leave, resentment from fellow residents who need to cover for them during maternity leave, and a lack of formal lactation policies.

A few policy changes by national board organizations, including those in the surgical specialties, may make life a little easier for female trainees to have children, suggested Dr. Samora.

Residents and fellows are now allowed a minimum of 6 weeks away for medical leave or caregiving once during training, without having to use vacation or sick leave and without having to extend their training, the American Board of Medical Specialties has announced.

In addition, the American Board of Orthopaedic Surgery and the American Board of Surgery have enacted policies that allow lactating women to take a break to pump during their board exams.

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

The Diagnosis: Levamisole-Induced Vasculopathy

Biopsy of one of the bullous retiform purpura on the leg (Figure 1) revealed a combined leukocytoclastic vasculitis and thrombotic vasculopathy (quiz images). Periodic acid-Schiff and Gram stains, with adequate controls, were negative for pathogenic fungal and bacterial organisms. Although this reaction pattern has an extensive differential, in this clinical setting with associated cocaine-positive urine toxicologic analysis, perinuclear antineutrophil cytoplasmic antibodies (p-ANCA), and leukopenia, the histopathologic findings were consistent with levamisole-induced vasculopathy (LIV).^1,2 Although not specific, leukocytoclastic vasculitis and thrombotic vasculopathy have been reported as the classic histopathologic findings of LIV. In addition, interstitial and perivascular neovascularization have been reported as a potential histopathologic finding associated with this entity but was not seen in our case.³  

Levamisole is an anthelminthic agent used to adulterate cocaine, a practice first noted in 2003 with increasing incidence.¹ Both levamisole and cocaine stimulate the sympathetic nervous system by increasing dopamine in the euphoric areas of the brain.^1,3 By combining the 2 substances, preparation costs are reduced and stimulant effects are enhanced. It is estimated that 69% to 80% of cocaine in the United States is contaminated with levamisole.^2,4,5 The constellation of findings seen in patients abusing levamisole-contaminated cocaine include agranulocytosis; p-ANCA; and a tender, vasculitic, retiform purpura presentation. The most common sites for the purpura include the cheeks and ears. The purpura can progress to bullous lesions, as seen in our patient, followed by necrosis.^4,6 Recurrent use of levamisole-contaminated cocaine is associated with recurrent agranulocytosis and classic skin findings, which is suggestive of a causal relationship.⁶  

Serologic testing for levamisole exposure presents a challenge. The half-life of levamisole is relatively short (estimated at 5.6 hours) and is found in urine samples approximately 3% of the time.^1,3,6 The volatile diagnostic characteristics of levamisole make concrete laboratory confirmation difficult. Although a skin biopsy can be helpful to rule out other causes of vasculitislike presentations, it is not specific for LIV. Therefore, clinical suspicion for LIV should remain high in patients who present with the cutaneous findings described as well as agranulocytosis, positive p-ANCA, and a history of cocaine use with a skin biopsy showing leukocytoclastic vasculitis and thrombotic vasculopathy.  

The differential diagnosis for LIV with retiform bullous lesions includes several other vasculitides and vesiculobullous diseases. Eosinophilic granulomatosis with polyangiitis (EGPA) is a multisystem vasculitis that is characterized by eosinophilia, asthma, and rhinosinusitis. Eosinophilic granulomatosis with polyangiitis primarily affects small and medium arteries in the skin and respiratory tract and occurs in 3 stages: prodromal, eosinophilic, and vasculitic. These stages are characterized by mild asthma or rhinitis, eosinophilia with multiorgan infiltration, and vasculitis with extravascular granulomatosis, respectively. Diagnosis often is clinical based on these findings and laboratory evaluation. Eosinophilic granulomatosis with polyangiitis presents with positive p-ANCA in 40% to 60% of patients.⁷ The vasculitis stage of EGPA presents with cutaneous findings in 60% of cases, including palpable purpura, infiltrated papules and plaques, urticaria, necrotizing lesions, and rarely vesicles and bullae.⁸ Classic histopathologic features include leukocytoclastic or eosinophilic vasculitis, an eosinophilic infiltrate, granuloma formation, and eosinophilic granule deposition onto collagen fibrils (otherwise known as flame figures)(Figure 2). Biopsy of these lesions with the aforementioned findings, in constellation with the described systemic signs and symptoms, can aid in diagnosis of EGPA.  

Polyarteritis nodosa (PAN) is a vasculitis that can be either multisystem or limited to one organ. Classic PAN affects the small- to medium-sized vessels. When there is multisystem involvement, it most often affects the skin, gastrointestinal tract, and kidneys. It presents with subcutaneous or dermal nodules, necrotic lesions, livedo reticularis, hypertension, abdominal pain, and an acute abdomen.⁹ When PAN is in its limited form, it most commonly occurs in the skin. The cutaneous manifestations of skin-limited PAN are identical to classic PAN, most commonly occurring on the legs and arms and less often on the trunk, head, and neck.¹⁰ To aid in diagnosis, biopsies of cutaneous lesions are beneficial. Dermatopathologic examination of PAN reveals fibrinoid necrosis of small and medium vessels with a perivascular mononuclear inflammatory infiltrate (Figure 3). Cutaneous PAN rarely progresses to multisystem classic PAN and carries a more favorable prognosis.  

Microvascular occlusion syndromes can result in clinical presentations that resemble LIV. Idiopathic thrombocytopenic purpura is a hematologic autoimmune condition resulting in destruction of platelets and subsequent thrombocytopenia. Idiopathic thrombocytopenic purpura can be either primary or secondary to infections, drugs, malignancy, or other autoimmune conditions. Clinically, it presents as mucosal or cutaneous bleeding, epistaxis, hematochezia, or hematuria and can result in substantial hemorrhage. On the skin, it can appear as petechiae and ecchymoses in dependent areas and rarely hemorrhagic bullae of the skin and mucous membranes in cases of severe thrombocytopenia.^11,12 Biopsies of these lesions will show notable extravasation of red blood cells with incipient hemorrhagic bullae formation (Figure 4). Recognition of hemorrhagic bullae as a presentation of idiopathic thrombocytopenic purpura is critical to identifying severe underlying disease.  

Beyond other vasculitides and microvascular occlusion syndromes, vessel-invasive microorganisms can result in similar histopathologic and clinical presentations to LIV. Ecthyma gangrenosum (EG) is a septic vasculitis, often caused by Pseudomonas aeruginosa, usually affecting immunocompromised patients. Ecthyma gangrenosum presents with vesiculobullous lesions with erythematous violaceous borders that develop into hemorrhagic bullae with necrotic centers.¹³ Biopsy of EG will show vascular occlusion and basophilic granular material within or around vessels, suggestive of bacterial sepsis (Figure 5). The detection of an infectious agent on histopathology allows one to easily distinguish between EG and LIV.  

The Diagnosis: Levamisole-Induced Vasculopathy

Biopsy of one of the bullous retiform purpura on the leg (Figure 1) revealed a combined leukocytoclastic vasculitis and thrombotic vasculopathy (quiz images). Periodic acid-Schiff and Gram stains, with adequate controls, were negative for pathogenic fungal and bacterial organisms. Although this reaction pattern has an extensive differential, in this clinical setting with associated cocaine-positive urine toxicologic analysis, perinuclear antineutrophil cytoplasmic antibodies (p-ANCA), and leukopenia, the histopathologic findings were consistent with levamisole-induced vasculopathy (LIV).^1,2 Although not specific, leukocytoclastic vasculitis and thrombotic vasculopathy have been reported as the classic histopathologic findings of LIV. In addition, interstitial and perivascular neovascularization have been reported as a potential histopathologic finding associated with this entity but was not seen in our case.³  

Levamisole is an anthelminthic agent used to adulterate cocaine, a practice first noted in 2003 with increasing incidence.¹ Both levamisole and cocaine stimulate the sympathetic nervous system by increasing dopamine in the euphoric areas of the brain.^1,3 By combining the 2 substances, preparation costs are reduced and stimulant effects are enhanced. It is estimated that 69% to 80% of cocaine in the United States is contaminated with levamisole.^2,4,5 The constellation of findings seen in patients abusing levamisole-contaminated cocaine include agranulocytosis; p-ANCA; and a tender, vasculitic, retiform purpura presentation. The most common sites for the purpura include the cheeks and ears. The purpura can progress to bullous lesions, as seen in our patient, followed by necrosis.^4,6 Recurrent use of levamisole-contaminated cocaine is associated with recurrent agranulocytosis and classic skin findings, which is suggestive of a causal relationship.⁶  

Serologic testing for levamisole exposure presents a challenge. The half-life of levamisole is relatively short (estimated at 5.6 hours) and is found in urine samples approximately 3% of the time.^1,3,6 The volatile diagnostic characteristics of levamisole make concrete laboratory confirmation difficult. Although a skin biopsy can be helpful to rule out other causes of vasculitislike presentations, it is not specific for LIV. Therefore, clinical suspicion for LIV should remain high in patients who present with the cutaneous findings described as well as agranulocytosis, positive p-ANCA, and a history of cocaine use with a skin biopsy showing leukocytoclastic vasculitis and thrombotic vasculopathy.  

The differential diagnosis for LIV with retiform bullous lesions includes several other vasculitides and vesiculobullous diseases. Eosinophilic granulomatosis with polyangiitis (EGPA) is a multisystem vasculitis that is characterized by eosinophilia, asthma, and rhinosinusitis. Eosinophilic granulomatosis with polyangiitis primarily affects small and medium arteries in the skin and respiratory tract and occurs in 3 stages: prodromal, eosinophilic, and vasculitic. These stages are characterized by mild asthma or rhinitis, eosinophilia with multiorgan infiltration, and vasculitis with extravascular granulomatosis, respectively. Diagnosis often is clinical based on these findings and laboratory evaluation. Eosinophilic granulomatosis with polyangiitis presents with positive p-ANCA in 40% to 60% of patients.⁷ The vasculitis stage of EGPA presents with cutaneous findings in 60% of cases, including palpable purpura, infiltrated papules and plaques, urticaria, necrotizing lesions, and rarely vesicles and bullae.⁸ Classic histopathologic features include leukocytoclastic or eosinophilic vasculitis, an eosinophilic infiltrate, granuloma formation, and eosinophilic granule deposition onto collagen fibrils (otherwise known as flame figures)(Figure 2). Biopsy of these lesions with the aforementioned findings, in constellation with the described systemic signs and symptoms, can aid in diagnosis of EGPA.  

Polyarteritis nodosa (PAN) is a vasculitis that can be either multisystem or limited to one organ. Classic PAN affects the small- to medium-sized vessels. When there is multisystem involvement, it most often affects the skin, gastrointestinal tract, and kidneys. It presents with subcutaneous or dermal nodules, necrotic lesions, livedo reticularis, hypertension, abdominal pain, and an acute abdomen.⁹ When PAN is in its limited form, it most commonly occurs in the skin. The cutaneous manifestations of skin-limited PAN are identical to classic PAN, most commonly occurring on the legs and arms and less often on the trunk, head, and neck.¹⁰ To aid in diagnosis, biopsies of cutaneous lesions are beneficial. Dermatopathologic examination of PAN reveals fibrinoid necrosis of small and medium vessels with a perivascular mononuclear inflammatory infiltrate (Figure 3). Cutaneous PAN rarely progresses to multisystem classic PAN and carries a more favorable prognosis.  

Microvascular occlusion syndromes can result in clinical presentations that resemble LIV. Idiopathic thrombocytopenic purpura is a hematologic autoimmune condition resulting in destruction of platelets and subsequent thrombocytopenia. Idiopathic thrombocytopenic purpura can be either primary or secondary to infections, drugs, malignancy, or other autoimmune conditions. Clinically, it presents as mucosal or cutaneous bleeding, epistaxis, hematochezia, or hematuria and can result in substantial hemorrhage. On the skin, it can appear as petechiae and ecchymoses in dependent areas and rarely hemorrhagic bullae of the skin and mucous membranes in cases of severe thrombocytopenia.^11,12 Biopsies of these lesions will show notable extravasation of red blood cells with incipient hemorrhagic bullae formation (Figure 4). Recognition of hemorrhagic bullae as a presentation of idiopathic thrombocytopenic purpura is critical to identifying severe underlying disease.  

Beyond other vasculitides and microvascular occlusion syndromes, vessel-invasive microorganisms can result in similar histopathologic and clinical presentations to LIV. Ecthyma gangrenosum (EG) is a septic vasculitis, often caused by Pseudomonas aeruginosa, usually affecting immunocompromised patients. Ecthyma gangrenosum presents with vesiculobullous lesions with erythematous violaceous borders that develop into hemorrhagic bullae with necrotic centers.¹³ Biopsy of EG will show vascular occlusion and basophilic granular material within or around vessels, suggestive of bacterial sepsis (Figure 5). The detection of an infectious agent on histopathology allows one to easily distinguish between EG and LIV.  

The Diagnosis: Levamisole-Induced Vasculopathy

Biopsy of one of the bullous retiform purpura on the leg (Figure 1) revealed a combined leukocytoclastic vasculitis and thrombotic vasculopathy (quiz images). Periodic acid-Schiff and Gram stains, with adequate controls, were negative for pathogenic fungal and bacterial organisms. Although this reaction pattern has an extensive differential, in this clinical setting with associated cocaine-positive urine toxicologic analysis, perinuclear antineutrophil cytoplasmic antibodies (p-ANCA), and leukopenia, the histopathologic findings were consistent with levamisole-induced vasculopathy (LIV).^1,2 Although not specific, leukocytoclastic vasculitis and thrombotic vasculopathy have been reported as the classic histopathologic findings of LIV. In addition, interstitial and perivascular neovascularization have been reported as a potential histopathologic finding associated with this entity but was not seen in our case.³  

Levamisole is an anthelminthic agent used to adulterate cocaine, a practice first noted in 2003 with increasing incidence.¹ Both levamisole and cocaine stimulate the sympathetic nervous system by increasing dopamine in the euphoric areas of the brain.^1,3 By combining the 2 substances, preparation costs are reduced and stimulant effects are enhanced. It is estimated that 69% to 80% of cocaine in the United States is contaminated with levamisole.^2,4,5 The constellation of findings seen in patients abusing levamisole-contaminated cocaine include agranulocytosis; p-ANCA; and a tender, vasculitic, retiform purpura presentation. The most common sites for the purpura include the cheeks and ears. The purpura can progress to bullous lesions, as seen in our patient, followed by necrosis.^4,6 Recurrent use of levamisole-contaminated cocaine is associated with recurrent agranulocytosis and classic skin findings, which is suggestive of a causal relationship.⁶  

Serologic testing for levamisole exposure presents a challenge. The half-life of levamisole is relatively short (estimated at 5.6 hours) and is found in urine samples approximately 3% of the time.^1,3,6 The volatile diagnostic characteristics of levamisole make concrete laboratory confirmation difficult. Although a skin biopsy can be helpful to rule out other causes of vasculitislike presentations, it is not specific for LIV. Therefore, clinical suspicion for LIV should remain high in patients who present with the cutaneous findings described as well as agranulocytosis, positive p-ANCA, and a history of cocaine use with a skin biopsy showing leukocytoclastic vasculitis and thrombotic vasculopathy.  

The differential diagnosis for LIV with retiform bullous lesions includes several other vasculitides and vesiculobullous diseases. Eosinophilic granulomatosis with polyangiitis (EGPA) is a multisystem vasculitis that is characterized by eosinophilia, asthma, and rhinosinusitis. Eosinophilic granulomatosis with polyangiitis primarily affects small and medium arteries in the skin and respiratory tract and occurs in 3 stages: prodromal, eosinophilic, and vasculitic. These stages are characterized by mild asthma or rhinitis, eosinophilia with multiorgan infiltration, and vasculitis with extravascular granulomatosis, respectively. Diagnosis often is clinical based on these findings and laboratory evaluation. Eosinophilic granulomatosis with polyangiitis presents with positive p-ANCA in 40% to 60% of patients.⁷ The vasculitis stage of EGPA presents with cutaneous findings in 60% of cases, including palpable purpura, infiltrated papules and plaques, urticaria, necrotizing lesions, and rarely vesicles and bullae.⁸ Classic histopathologic features include leukocytoclastic or eosinophilic vasculitis, an eosinophilic infiltrate, granuloma formation, and eosinophilic granule deposition onto collagen fibrils (otherwise known as flame figures)(Figure 2). Biopsy of these lesions with the aforementioned findings, in constellation with the described systemic signs and symptoms, can aid in diagnosis of EGPA.  

Polyarteritis nodosa (PAN) is a vasculitis that can be either multisystem or limited to one organ. Classic PAN affects the small- to medium-sized vessels. When there is multisystem involvement, it most often affects the skin, gastrointestinal tract, and kidneys. It presents with subcutaneous or dermal nodules, necrotic lesions, livedo reticularis, hypertension, abdominal pain, and an acute abdomen.⁹ When PAN is in its limited form, it most commonly occurs in the skin. The cutaneous manifestations of skin-limited PAN are identical to classic PAN, most commonly occurring on the legs and arms and less often on the trunk, head, and neck.¹⁰ To aid in diagnosis, biopsies of cutaneous lesions are beneficial. Dermatopathologic examination of PAN reveals fibrinoid necrosis of small and medium vessels with a perivascular mononuclear inflammatory infiltrate (Figure 3). Cutaneous PAN rarely progresses to multisystem classic PAN and carries a more favorable prognosis.  

Microvascular occlusion syndromes can result in clinical presentations that resemble LIV. Idiopathic thrombocytopenic purpura is a hematologic autoimmune condition resulting in destruction of platelets and subsequent thrombocytopenia. Idiopathic thrombocytopenic purpura can be either primary or secondary to infections, drugs, malignancy, or other autoimmune conditions. Clinically, it presents as mucosal or cutaneous bleeding, epistaxis, hematochezia, or hematuria and can result in substantial hemorrhage. On the skin, it can appear as petechiae and ecchymoses in dependent areas and rarely hemorrhagic bullae of the skin and mucous membranes in cases of severe thrombocytopenia.^11,12 Biopsies of these lesions will show notable extravasation of red blood cells with incipient hemorrhagic bullae formation (Figure 4). Recognition of hemorrhagic bullae as a presentation of idiopathic thrombocytopenic purpura is critical to identifying severe underlying disease.  

Beyond other vasculitides and microvascular occlusion syndromes, vessel-invasive microorganisms can result in similar histopathologic and clinical presentations to LIV. Ecthyma gangrenosum (EG) is a septic vasculitis, often caused by Pseudomonas aeruginosa, usually affecting immunocompromised patients. Ecthyma gangrenosum presents with vesiculobullous lesions with erythematous violaceous borders that develop into hemorrhagic bullae with necrotic centers.¹³ Biopsy of EG will show vascular occlusion and basophilic granular material within or around vessels, suggestive of bacterial sepsis (Figure 5). The detection of an infectious agent on histopathology allows one to easily distinguish between EG and LIV.  

Adolescents can develop mild myocarditis as a rare complication after COVID-19 vaccination, as has been reported in adults, an early case series from Boston confirms.

The adolescents who developed heart inflammation after vaccination typically had a benign course, with symptoms resolving without treatment, although one patient had persistent borderline low left ventricular (LV) function, report Audrey Dionne, MD, and colleagues at Boston Children’s Hospital.

“Despite the risks of myocarditis associated with vaccination, the benefits of vaccination likely outweigh risks in children and adolescents,” they say.

They estimate that for males 12-29 years of age COVID-19 vaccination prevents 11,000 COVID-19 cases, 560 hospitalizations, 138 intensive care unit admissions, and six deaths, compared with 39-47 expected myocarditis cases.

The case series was published online Aug. 10 in JAMA Cardiology.

Long-term risks unknown 

Dr. Dionne and colleagues reviewed the results of comprehensive cardiac imaging in 14 boys and 1 girl, 12-18 years of age (median, 15 years), who were hospitalized with myocarditis after receiving the Pfizer-BioNTech messenger RNA COVID-19 vaccine.

Symptoms started 1-6 days after vaccine administration (most after the second dose) and included chest pain in all 15 patients, fever in 10 (67%), myalgia in eight (53%), and headache in six (40%).

On admission, all patients had elevated troponin levels (median, 0.25 ng/mL; range, 0.08-3.15 ng/mL). Troponin levels peaked 0.1-2.3 days after admission.

Echocardiography revealed decreased LV ejection fraction (EF) in three patients (20%) and abnormal global longitudinal or circumferential strain in five patients (33%). No patient had a pericardial effusion.

Cardiac MRI findings were consistent with myocarditis in 13 patients (87%), including late gadolinium enhancement in 12 (80%), regional hyperintensity on T2-weighted imaging in two (13%), elevated extracellular volume fraction in three (20%), and elevated LV global native T1 in two (20%).

The patients remained in the hospital for 1-5 days (median, 2 days) and were discharged. No patient required admission to the intensive care unit.

In follow-up assessments performed 1-13 days after hospital discharge, symptoms of myocarditis had resolved in 11 patients (73%).

One patient (7%) had persistent borderline low LV systolic function on echocardiogram (LVEF, 54%).

Troponin levels remained mildly elevated in three patients (20%). One patient (7%) had nonsustained ventricular tachycardia on ambulatory monitor.

The authors say longitudinal studies of patients with myocarditis after COVID-19 vaccine “will be important to better understand long-term risks.”

In a statement from the UK nonprofit Science Media Centre, Peter Openshaw, FMedSci, Imperial College London, says: “The problem with case series of this type is the lack of comparison groups. How many cases of myocarditis might be seen in normal children, or those given other vaccines (including those that are not for COVID), or in teenagers infected with SARS-CoV-2?”

“As the authors note, myocarditis does happen after other vaccines. The estimated rate (62.8 cases per million) makes this a rare event,” Dr. Openshaw says.

“My view that teenagers should be considered for vaccination is not changed by this new publication,” he adds.

This study was funded by the McCance Foundation. The authors have declared no relevant conflicts of interest. Dr. Openshaw has served on scientific advisory boards for Janssen/J&J, Oxford Immunotech, GSK, Nestle, and Pfizer in relation to immunity to viruses (fees paid to Imperial College London).

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

Adolescents can develop mild myocarditis as a rare complication after COVID-19 vaccination, as has been reported in adults, an early case series from Boston confirms.

The adolescents who developed heart inflammation after vaccination typically had a benign course, with symptoms resolving without treatment, although one patient had persistent borderline low left ventricular (LV) function, report Audrey Dionne, MD, and colleagues at Boston Children’s Hospital.

“Despite the risks of myocarditis associated with vaccination, the benefits of vaccination likely outweigh risks in children and adolescents,” they say.

They estimate that for males 12-29 years of age COVID-19 vaccination prevents 11,000 COVID-19 cases, 560 hospitalizations, 138 intensive care unit admissions, and six deaths, compared with 39-47 expected myocarditis cases.

The case series was published online Aug. 10 in JAMA Cardiology.

Long-term risks unknown 

Dr. Dionne and colleagues reviewed the results of comprehensive cardiac imaging in 14 boys and 1 girl, 12-18 years of age (median, 15 years), who were hospitalized with myocarditis after receiving the Pfizer-BioNTech messenger RNA COVID-19 vaccine.

Symptoms started 1-6 days after vaccine administration (most after the second dose) and included chest pain in all 15 patients, fever in 10 (67%), myalgia in eight (53%), and headache in six (40%).

On admission, all patients had elevated troponin levels (median, 0.25 ng/mL; range, 0.08-3.15 ng/mL). Troponin levels peaked 0.1-2.3 days after admission.

Echocardiography revealed decreased LV ejection fraction (EF) in three patients (20%) and abnormal global longitudinal or circumferential strain in five patients (33%). No patient had a pericardial effusion.

Cardiac MRI findings were consistent with myocarditis in 13 patients (87%), including late gadolinium enhancement in 12 (80%), regional hyperintensity on T2-weighted imaging in two (13%), elevated extracellular volume fraction in three (20%), and elevated LV global native T1 in two (20%).

The patients remained in the hospital for 1-5 days (median, 2 days) and were discharged. No patient required admission to the intensive care unit.

In follow-up assessments performed 1-13 days after hospital discharge, symptoms of myocarditis had resolved in 11 patients (73%).

One patient (7%) had persistent borderline low LV systolic function on echocardiogram (LVEF, 54%).

Troponin levels remained mildly elevated in three patients (20%). One patient (7%) had nonsustained ventricular tachycardia on ambulatory monitor.

The authors say longitudinal studies of patients with myocarditis after COVID-19 vaccine “will be important to better understand long-term risks.”

In a statement from the UK nonprofit Science Media Centre, Peter Openshaw, FMedSci, Imperial College London, says: “The problem with case series of this type is the lack of comparison groups. How many cases of myocarditis might be seen in normal children, or those given other vaccines (including those that are not for COVID), or in teenagers infected with SARS-CoV-2?”

“As the authors note, myocarditis does happen after other vaccines. The estimated rate (62.8 cases per million) makes this a rare event,” Dr. Openshaw says.

“My view that teenagers should be considered for vaccination is not changed by this new publication,” he adds.

This study was funded by the McCance Foundation. The authors have declared no relevant conflicts of interest. Dr. Openshaw has served on scientific advisory boards for Janssen/J&J, Oxford Immunotech, GSK, Nestle, and Pfizer in relation to immunity to viruses (fees paid to Imperial College London).

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

Adolescents can develop mild myocarditis as a rare complication after COVID-19 vaccination, as has been reported in adults, an early case series from Boston confirms.

The adolescents who developed heart inflammation after vaccination typically had a benign course, with symptoms resolving without treatment, although one patient had persistent borderline low left ventricular (LV) function, report Audrey Dionne, MD, and colleagues at Boston Children’s Hospital.

“Despite the risks of myocarditis associated with vaccination, the benefits of vaccination likely outweigh risks in children and adolescents,” they say.

They estimate that for males 12-29 years of age COVID-19 vaccination prevents 11,000 COVID-19 cases, 560 hospitalizations, 138 intensive care unit admissions, and six deaths, compared with 39-47 expected myocarditis cases.

The case series was published online Aug. 10 in JAMA Cardiology.

Long-term risks unknown 

Dr. Dionne and colleagues reviewed the results of comprehensive cardiac imaging in 14 boys and 1 girl, 12-18 years of age (median, 15 years), who were hospitalized with myocarditis after receiving the Pfizer-BioNTech messenger RNA COVID-19 vaccine.

Symptoms started 1-6 days after vaccine administration (most after the second dose) and included chest pain in all 15 patients, fever in 10 (67%), myalgia in eight (53%), and headache in six (40%).

On admission, all patients had elevated troponin levels (median, 0.25 ng/mL; range, 0.08-3.15 ng/mL). Troponin levels peaked 0.1-2.3 days after admission.

Echocardiography revealed decreased LV ejection fraction (EF) in three patients (20%) and abnormal global longitudinal or circumferential strain in five patients (33%). No patient had a pericardial effusion.

Cardiac MRI findings were consistent with myocarditis in 13 patients (87%), including late gadolinium enhancement in 12 (80%), regional hyperintensity on T2-weighted imaging in two (13%), elevated extracellular volume fraction in three (20%), and elevated LV global native T1 in two (20%).

The patients remained in the hospital for 1-5 days (median, 2 days) and were discharged. No patient required admission to the intensive care unit.

In follow-up assessments performed 1-13 days after hospital discharge, symptoms of myocarditis had resolved in 11 patients (73%).

One patient (7%) had persistent borderline low LV systolic function on echocardiogram (LVEF, 54%).

Troponin levels remained mildly elevated in three patients (20%). One patient (7%) had nonsustained ventricular tachycardia on ambulatory monitor.

The authors say longitudinal studies of patients with myocarditis after COVID-19 vaccine “will be important to better understand long-term risks.”

In a statement from the UK nonprofit Science Media Centre, Peter Openshaw, FMedSci, Imperial College London, says: “The problem with case series of this type is the lack of comparison groups. How many cases of myocarditis might be seen in normal children, or those given other vaccines (including those that are not for COVID), or in teenagers infected with SARS-CoV-2?”

“As the authors note, myocarditis does happen after other vaccines. The estimated rate (62.8 cases per million) makes this a rare event,” Dr. Openshaw says.

“My view that teenagers should be considered for vaccination is not changed by this new publication,” he adds.

This study was funded by the McCance Foundation. The authors have declared no relevant conflicts of interest. Dr. Openshaw has served on scientific advisory boards for Janssen/J&J, Oxford Immunotech, GSK, Nestle, and Pfizer in relation to immunity to viruses (fees paid to Imperial College London).

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

Real-world protection from COVID-19 vaccination is better than expected in transplant recipients, reducing the risk of symptomatic infection by almost 80% in those who have had both doses compared with unvaccinated controls, a new transplant registry analysis shows.

“Persons who have received an organ transplant are considered to be at increased risk for COVID-19 and for a severe outcome because their immune systems are necessarily suppressed to ensure their transplants are successful and lasting,” lead author Saima Aslam, MD, professor of medicine, University of California, San Diego, said in a statement.

Because numerous studies have demonstrated reduced antibody responses to SARS-CoV-2 in solid organ transplant recipients and variable effect on T-cell responses, there has been a need to study clinical effectiveness and breakthrough infections in those who are vaccinated, they explained.

“These findings offer strong evidence that getting vaccinated provides significant protection,” Dr. Aslam noted.

The investigators say that recent data from France, as well as other studies, show an increased rate of detectable antibodies following a third dose of the Pfizer-BioNTech COVID-19 vaccine in organ transplant recipients, “but based on our data it is unclear if a third dose is clinically warranted.”

The researchers stressed that almost half of the solid organ transplant recipients analyzed in the study had not been vaccinated at all, even by the beginning of 2021 when the United States was well into a third wave of COVID-19 infections.

So there is still a significant need, the authors said, to continue to improve outreach efforts to those in the transplant community and promote the benefits of being fully vaccinated.

The study was published online recently in Transplant Infectious Disease.
 

Transplant registry

The researchers analyzed clinical data from the UC San Diego transplant registry from Jan. 1 through June 2 of this year, with 2,151 solid organ transplant recipients identified. The patients had received a variety of solid organ transplants including kidney, liver, lung, and heart; the largest percentage received a donor kidney.

Among all patients, 912 were fully vaccinated and 1,239 were not (1,151 of those 1,239 received no vaccine at all and 88 had been partially vaccinated; these 1,239 served as the control group).

Fully vaccinated patients had received two shots of either the Pfizer-BioNTech COVID-19 or the Moderna vaccine, or a single dose of the Johnson & Johnson vaccine. The majority, at nearly 70%, had received the Moderna vaccine. The mean age of the cohort was 57 years and the median time since patients had undergone transplantation was almost 5 years (57.5 months).

During the 6-month study interval, 65 cases of COVID-19 were documented in the group overall. Only 4 cases occurred among fully vaccinated individuals whereas 61 cases occurred among the unvaccinated, including in 2 patients who had been partially vaccinated.

Among the four cases that occurred among the fully vaccinated, two were considered mild and were treated on an outpatient basis, and the other two were moderate, requiring hospitalization and treatment with remdesivir.

There were no COVID-19–related deaths among the 4 patients who experienced breakthrough infections, whereas 2 (3.3%) of 61 of control patients died of COVID-19–related causes.

The authors noted that the incidence rate for COVID-19 was 0.065 per 1,000-person days among the fully vaccinated compared with an incidence rate of 0.34 per 1,000-person days in the control group.
 

Booster doses for especially vulnerable transplant recipients?

“These findings are encouraging for a couple of reasons,” said coauthor Kristin Mekeel, MD, chief of transplant and hepatobiliary surgery at UCSD.

“First, they demonstrate real-world clinical effectiveness of COVID-19 vaccination in a vulnerable population,” she noted.

“Second, the effectiveness is better than expected,” she added, “given that studies have found that only about half of solid organ transplant recipients develop detectable antibodies after vaccination.”

Although calls for patients who are immunosuppressed to receive a third booster dose of a COVID-19 vaccine may not be necessary, “prioritizing at-risk subsets of transplant recipients based on immunological profiles and clinical characteristics for a third vaccine dose could be considered,” they said, adding it’s still vitally important for transplant patients to continue to mask and practice social distancing.

And it is especially important for transplant recipients to encourage household members to get vaccinated, too, especially given the current COVID-19 surge in San Diego.

The study was funded by the Cystic Fibrosis Foundation.

Dr. Aslam reports receiving grants from the Cystic Fibrosis Foundation as well as honoraria from Gilead and Merck. Study author  Susan J. Little, MD, received grant funding from Gilead Sciences. Dr. Mekeel has disclosed no relevant financial relationships.

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

Real-world protection from COVID-19 vaccination is better than expected in transplant recipients, reducing the risk of symptomatic infection by almost 80% in those who have had both doses compared with unvaccinated controls, a new transplant registry analysis shows.

“Persons who have received an organ transplant are considered to be at increased risk for COVID-19 and for a severe outcome because their immune systems are necessarily suppressed to ensure their transplants are successful and lasting,” lead author Saima Aslam, MD, professor of medicine, University of California, San Diego, said in a statement.

Because numerous studies have demonstrated reduced antibody responses to SARS-CoV-2 in solid organ transplant recipients and variable effect on T-cell responses, there has been a need to study clinical effectiveness and breakthrough infections in those who are vaccinated, they explained.

“These findings offer strong evidence that getting vaccinated provides significant protection,” Dr. Aslam noted.

The investigators say that recent data from France, as well as other studies, show an increased rate of detectable antibodies following a third dose of the Pfizer-BioNTech COVID-19 vaccine in organ transplant recipients, “but based on our data it is unclear if a third dose is clinically warranted.”

The researchers stressed that almost half of the solid organ transplant recipients analyzed in the study had not been vaccinated at all, even by the beginning of 2021 when the United States was well into a third wave of COVID-19 infections.

So there is still a significant need, the authors said, to continue to improve outreach efforts to those in the transplant community and promote the benefits of being fully vaccinated.

The study was published online recently in Transplant Infectious Disease.
 

Transplant registry

The researchers analyzed clinical data from the UC San Diego transplant registry from Jan. 1 through June 2 of this year, with 2,151 solid organ transplant recipients identified. The patients had received a variety of solid organ transplants including kidney, liver, lung, and heart; the largest percentage received a donor kidney.

Among all patients, 912 were fully vaccinated and 1,239 were not (1,151 of those 1,239 received no vaccine at all and 88 had been partially vaccinated; these 1,239 served as the control group).

Fully vaccinated patients had received two shots of either the Pfizer-BioNTech COVID-19 or the Moderna vaccine, or a single dose of the Johnson & Johnson vaccine. The majority, at nearly 70%, had received the Moderna vaccine. The mean age of the cohort was 57 years and the median time since patients had undergone transplantation was almost 5 years (57.5 months).

During the 6-month study interval, 65 cases of COVID-19 were documented in the group overall. Only 4 cases occurred among fully vaccinated individuals whereas 61 cases occurred among the unvaccinated, including in 2 patients who had been partially vaccinated.

Among the four cases that occurred among the fully vaccinated, two were considered mild and were treated on an outpatient basis, and the other two were moderate, requiring hospitalization and treatment with remdesivir.

There were no COVID-19–related deaths among the 4 patients who experienced breakthrough infections, whereas 2 (3.3%) of 61 of control patients died of COVID-19–related causes.

The authors noted that the incidence rate for COVID-19 was 0.065 per 1,000-person days among the fully vaccinated compared with an incidence rate of 0.34 per 1,000-person days in the control group.
 

Booster doses for especially vulnerable transplant recipients?

“These findings are encouraging for a couple of reasons,” said coauthor Kristin Mekeel, MD, chief of transplant and hepatobiliary surgery at UCSD.

“First, they demonstrate real-world clinical effectiveness of COVID-19 vaccination in a vulnerable population,” she noted.

“Second, the effectiveness is better than expected,” she added, “given that studies have found that only about half of solid organ transplant recipients develop detectable antibodies after vaccination.”

Although calls for patients who are immunosuppressed to receive a third booster dose of a COVID-19 vaccine may not be necessary, “prioritizing at-risk subsets of transplant recipients based on immunological profiles and clinical characteristics for a third vaccine dose could be considered,” they said, adding it’s still vitally important for transplant patients to continue to mask and practice social distancing.

And it is especially important for transplant recipients to encourage household members to get vaccinated, too, especially given the current COVID-19 surge in San Diego.

The study was funded by the Cystic Fibrosis Foundation.

Dr. Aslam reports receiving grants from the Cystic Fibrosis Foundation as well as honoraria from Gilead and Merck. Study author  Susan J. Little, MD, received grant funding from Gilead Sciences. Dr. Mekeel has disclosed no relevant financial relationships.

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

Real-world protection from COVID-19 vaccination is better than expected in transplant recipients, reducing the risk of symptomatic infection by almost 80% in those who have had both doses compared with unvaccinated controls, a new transplant registry analysis shows.

“Persons who have received an organ transplant are considered to be at increased risk for COVID-19 and for a severe outcome because their immune systems are necessarily suppressed to ensure their transplants are successful and lasting,” lead author Saima Aslam, MD, professor of medicine, University of California, San Diego, said in a statement.

Because numerous studies have demonstrated reduced antibody responses to SARS-CoV-2 in solid organ transplant recipients and variable effect on T-cell responses, there has been a need to study clinical effectiveness and breakthrough infections in those who are vaccinated, they explained.

“These findings offer strong evidence that getting vaccinated provides significant protection,” Dr. Aslam noted.

The investigators say that recent data from France, as well as other studies, show an increased rate of detectable antibodies following a third dose of the Pfizer-BioNTech COVID-19 vaccine in organ transplant recipients, “but based on our data it is unclear if a third dose is clinically warranted.”

The researchers stressed that almost half of the solid organ transplant recipients analyzed in the study had not been vaccinated at all, even by the beginning of 2021 when the United States was well into a third wave of COVID-19 infections.

So there is still a significant need, the authors said, to continue to improve outreach efforts to those in the transplant community and promote the benefits of being fully vaccinated.

The study was published online recently in Transplant Infectious Disease.
 

Transplant registry

The researchers analyzed clinical data from the UC San Diego transplant registry from Jan. 1 through June 2 of this year, with 2,151 solid organ transplant recipients identified. The patients had received a variety of solid organ transplants including kidney, liver, lung, and heart; the largest percentage received a donor kidney.

Among all patients, 912 were fully vaccinated and 1,239 were not (1,151 of those 1,239 received no vaccine at all and 88 had been partially vaccinated; these 1,239 served as the control group).

Fully vaccinated patients had received two shots of either the Pfizer-BioNTech COVID-19 or the Moderna vaccine, or a single dose of the Johnson & Johnson vaccine. The majority, at nearly 70%, had received the Moderna vaccine. The mean age of the cohort was 57 years and the median time since patients had undergone transplantation was almost 5 years (57.5 months).

During the 6-month study interval, 65 cases of COVID-19 were documented in the group overall. Only 4 cases occurred among fully vaccinated individuals whereas 61 cases occurred among the unvaccinated, including in 2 patients who had been partially vaccinated.

Among the four cases that occurred among the fully vaccinated, two were considered mild and were treated on an outpatient basis, and the other two were moderate, requiring hospitalization and treatment with remdesivir.

There were no COVID-19–related deaths among the 4 patients who experienced breakthrough infections, whereas 2 (3.3%) of 61 of control patients died of COVID-19–related causes.

The authors noted that the incidence rate for COVID-19 was 0.065 per 1,000-person days among the fully vaccinated compared with an incidence rate of 0.34 per 1,000-person days in the control group.
 

Booster doses for especially vulnerable transplant recipients?

“These findings are encouraging for a couple of reasons,” said coauthor Kristin Mekeel, MD, chief of transplant and hepatobiliary surgery at UCSD.

“First, they demonstrate real-world clinical effectiveness of COVID-19 vaccination in a vulnerable population,” she noted.

“Second, the effectiveness is better than expected,” she added, “given that studies have found that only about half of solid organ transplant recipients develop detectable antibodies after vaccination.”

Although calls for patients who are immunosuppressed to receive a third booster dose of a COVID-19 vaccine may not be necessary, “prioritizing at-risk subsets of transplant recipients based on immunological profiles and clinical characteristics for a third vaccine dose could be considered,” they said, adding it’s still vitally important for transplant patients to continue to mask and practice social distancing.

And it is especially important for transplant recipients to encourage household members to get vaccinated, too, especially given the current COVID-19 surge in San Diego.

The study was funded by the Cystic Fibrosis Foundation.

Dr. Aslam reports receiving grants from the Cystic Fibrosis Foundation as well as honoraria from Gilead and Merck. Study author  Susan J. Little, MD, received grant funding from Gilead Sciences. Dr. Mekeel has disclosed no relevant financial relationships.

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

Our emotional health and that of our patients has taken a terrible beating at the hands of the COVID-19 pandemic. Suicides, substance abuse, levels of depression, and anxiety have risen dramatically. It is tempting to believe that it is the unfortunate events alone we hear about and experience that are causing us to feel the way we do. However, James Gross, PhD, professor of psychology and director of the Stanford (Calif.) University psychophysiology laboratory said: “It is actually the thoughts that we have about the situation that are leading us to feel negative emotions or fail to feel positive emotions.” (YouTube video – https://www.youtube.com/watch?v=Ay4_L1RfkIs).

With this premise as a jumping off point, a large group of psychophysiologists at a variety of centers around the world began a study of more than 20,000 subjects in more than 87 countries and regions. Half of the subjects were exposed to a brief (about 5 min) emotional regulation strategy called “reappraisal.” All the subjects were then shown images of the COVID-19 crisis culled from news sources and were then surveyed about their emotions. The researchers discovered that those subjects exposed to the reappraisal intervention demonstrated significantly increased positive responses and significantly decreased negative responses compared to the two control groups.

Reappraisal is an intervention that encourages individuals to think differently about their current situation in hopes of improving their emotional responses. The researchers tested two different types of reappraisal: “Reconstruing,” which aims to change the way the situation is represented mentally – for example, viewing it as controllable – and “repurposing,” in which the subject is encouraged to focus on the potentially positive outcomes of the situation. In other words, reappraisal basically tries to instill a glass-half-full, silver-lining mindset. The investigators report that both reappraisal strategies were equally effective at influencing the subjects’ responses.

The authors claimed that their findings suggest that reappraisal interventions might be of value for health care and other essential workers who have demonstrated a vulnerability to emotion upheaval during the pandemic. The authors also envisioned opportunities for political and business leaders to implement national and global reappraisal–based initiatives to generate resilience on a national and even global scale.

I will admit that, although I am usually skeptical of studies aimed at quantifying emotions, I found this study interesting. After watching a half hour of television news or reading the online edition of the New York Times I think we could all use a pep talk from someone who might be able to help us look on the bright side of things. However, I doubt that a single 5-minute reappraisal intervention is going to have much lasting benefit in the face of the shear magnitude of bad news we are fed every day. Catastrophic news sells newspapers and it is unlikely that dynamic is ever going to change.

I guess we could try mandating that every half hour of network news be followed by a 5-minute session of reconstruing or repurposing. That is, if we could find someone who could consistently put a positive spin on the news of the day. Even if we could locate that one-in-a-million individual with an absolutely unshakably sunny disposition and a knack for finding silver linings, I suspect after a few weeks he or she would be labeled the arch Pollyanna and be drummed off the air.

That is not to say that we should write off the findings of this international study as a statistical quirk. It may be, but clearly these last 2 years have taken a toll on our emotions and even those of us who are congenital optimists need a pep talk from time to time. Although my forte is denial, I think I already know how to reconstrue and repurpose, but I’m ready to listen to anyone who can help me learn to do it better.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at pdnews@mdedge.com.

Our emotional health and that of our patients has taken a terrible beating at the hands of the COVID-19 pandemic. Suicides, substance abuse, levels of depression, and anxiety have risen dramatically. It is tempting to believe that it is the unfortunate events alone we hear about and experience that are causing us to feel the way we do. However, James Gross, PhD, professor of psychology and director of the Stanford (Calif.) University psychophysiology laboratory said: “It is actually the thoughts that we have about the situation that are leading us to feel negative emotions or fail to feel positive emotions.” (YouTube video – https://www.youtube.com/watch?v=Ay4_L1RfkIs).

With this premise as a jumping off point, a large group of psychophysiologists at a variety of centers around the world began a study of more than 20,000 subjects in more than 87 countries and regions. Half of the subjects were exposed to a brief (about 5 min) emotional regulation strategy called “reappraisal.” All the subjects were then shown images of the COVID-19 crisis culled from news sources and were then surveyed about their emotions. The researchers discovered that those subjects exposed to the reappraisal intervention demonstrated significantly increased positive responses and significantly decreased negative responses compared to the two control groups.

Reappraisal is an intervention that encourages individuals to think differently about their current situation in hopes of improving their emotional responses. The researchers tested two different types of reappraisal: “Reconstruing,” which aims to change the way the situation is represented mentally – for example, viewing it as controllable – and “repurposing,” in which the subject is encouraged to focus on the potentially positive outcomes of the situation. In other words, reappraisal basically tries to instill a glass-half-full, silver-lining mindset. The investigators report that both reappraisal strategies were equally effective at influencing the subjects’ responses.

The authors claimed that their findings suggest that reappraisal interventions might be of value for health care and other essential workers who have demonstrated a vulnerability to emotion upheaval during the pandemic. The authors also envisioned opportunities for political and business leaders to implement national and global reappraisal–based initiatives to generate resilience on a national and even global scale.

I will admit that, although I am usually skeptical of studies aimed at quantifying emotions, I found this study interesting. After watching a half hour of television news or reading the online edition of the New York Times I think we could all use a pep talk from someone who might be able to help us look on the bright side of things. However, I doubt that a single 5-minute reappraisal intervention is going to have much lasting benefit in the face of the shear magnitude of bad news we are fed every day. Catastrophic news sells newspapers and it is unlikely that dynamic is ever going to change.

I guess we could try mandating that every half hour of network news be followed by a 5-minute session of reconstruing or repurposing. That is, if we could find someone who could consistently put a positive spin on the news of the day. Even if we could locate that one-in-a-million individual with an absolutely unshakably sunny disposition and a knack for finding silver linings, I suspect after a few weeks he or she would be labeled the arch Pollyanna and be drummed off the air.

That is not to say that we should write off the findings of this international study as a statistical quirk. It may be, but clearly these last 2 years have taken a toll on our emotions and even those of us who are congenital optimists need a pep talk from time to time. Although my forte is denial, I think I already know how to reconstrue and repurpose, but I’m ready to listen to anyone who can help me learn to do it better.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at pdnews@mdedge.com.

Our emotional health and that of our patients has taken a terrible beating at the hands of the COVID-19 pandemic. Suicides, substance abuse, levels of depression, and anxiety have risen dramatically. It is tempting to believe that it is the unfortunate events alone we hear about and experience that are causing us to feel the way we do. However, James Gross, PhD, professor of psychology and director of the Stanford (Calif.) University psychophysiology laboratory said: “It is actually the thoughts that we have about the situation that are leading us to feel negative emotions or fail to feel positive emotions.” (YouTube video – https://www.youtube.com/watch?v=Ay4_L1RfkIs).

With this premise as a jumping off point, a large group of psychophysiologists at a variety of centers around the world began a study of more than 20,000 subjects in more than 87 countries and regions. Half of the subjects were exposed to a brief (about 5 min) emotional regulation strategy called “reappraisal.” All the subjects were then shown images of the COVID-19 crisis culled from news sources and were then surveyed about their emotions. The researchers discovered that those subjects exposed to the reappraisal intervention demonstrated significantly increased positive responses and significantly decreased negative responses compared to the two control groups.

Reappraisal is an intervention that encourages individuals to think differently about their current situation in hopes of improving their emotional responses. The researchers tested two different types of reappraisal: “Reconstruing,” which aims to change the way the situation is represented mentally – for example, viewing it as controllable – and “repurposing,” in which the subject is encouraged to focus on the potentially positive outcomes of the situation. In other words, reappraisal basically tries to instill a glass-half-full, silver-lining mindset. The investigators report that both reappraisal strategies were equally effective at influencing the subjects’ responses.

The authors claimed that their findings suggest that reappraisal interventions might be of value for health care and other essential workers who have demonstrated a vulnerability to emotion upheaval during the pandemic. The authors also envisioned opportunities for political and business leaders to implement national and global reappraisal–based initiatives to generate resilience on a national and even global scale.

I will admit that, although I am usually skeptical of studies aimed at quantifying emotions, I found this study interesting. After watching a half hour of television news or reading the online edition of the New York Times I think we could all use a pep talk from someone who might be able to help us look on the bright side of things. However, I doubt that a single 5-minute reappraisal intervention is going to have much lasting benefit in the face of the shear magnitude of bad news we are fed every day. Catastrophic news sells newspapers and it is unlikely that dynamic is ever going to change.

I guess we could try mandating that every half hour of network news be followed by a 5-minute session of reconstruing or repurposing. That is, if we could find someone who could consistently put a positive spin on the news of the day. Even if we could locate that one-in-a-million individual with an absolutely unshakably sunny disposition and a knack for finding silver linings, I suspect after a few weeks he or she would be labeled the arch Pollyanna and be drummed off the air.

That is not to say that we should write off the findings of this international study as a statistical quirk. It may be, but clearly these last 2 years have taken a toll on our emotions and even those of us who are congenital optimists need a pep talk from time to time. Although my forte is denial, I think I already know how to reconstrue and repurpose, but I’m ready to listen to anyone who can help me learn to do it better.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at pdnews@mdedge.com.

COVID-19 rates are surging again, and many Americans who’ve been vaccinated are turning their anger toward those who refuse to get the shot.

Outraged at vaccine-hesitant people, some are even calling for mandates requiring all Americans to get inoculated, arguing the holdouts are allowing the Delta coronavirus variant to gain traction and reverse the progress the United States was making against the virus.

“I am angry, I am resentful, and I think it’s a fair and appropriate response,” said Jonathan Hyman, a Berea, Ohio, attorney who blames the unvaccinated for the backslide in pandemic progress.

Mr. Hyman has been following the difficult guidelines health experts have been urging from the beginning. He has been masking up, avoiding large gatherings, postponing travel, and he signed up to receive the vaccine as soon as it was available.

“We have been responsible, I did everything I was supposed to do,” said Mr. Hyman, 48, who didn’t visit his parents for 18 months to keep them safe. “Yet here we are, 16, 17 months later, and it feels like we’re in the exact same place we were last summer, and it’s all because some people refuse to do the responsible things they were told to do.”

James Simmons, a retired South Florida high school finance teacher, is also angered by the vaccine holdouts, citing new spikes in COVID-19 infections, hospitalization rates, and deaths across the country – nearly all of which are among unvaccinated people.

“I can’t fathom the fact that people have seen over 600,000 Americans die from COVID, yet are resistant to a vaccine that provides direct protection for themselves and others,” said Mr. Simmons, 63, who received the shot early. “Their irresponsible decision is an affront to those of us who are vaccinated and still wear masks for the benefit of our society.”

Melissa Martin, an Atlanta resident who contracted a serious case of COVID-19 in September 2020, says it is “perplexing and frustrating” that so many Americans are refusing the vaccine. She believes the anger so many vaccinated people feel is tied to fear.

“I believe at the core of this anger is a fear of losing the ones we love,” said Ms. Martin, 55, who has been vaccinated, as has her fiancé, Shane McGeehin. “I was very angry last year after contracting COVID. The experience of having COVID was negative physically, emotionally, and socially.”

She recalled arguing with friends and relatives who downplayed how severe the virus was and who still refuse vaccination, despite seeing how COVID affected her.

“I am trying to understand why they feel the way they do,” she said, “but I would describe the emotions I have now towards those who do not get the vaccine as frustration, confusion, and disbelief.”

Leana Wen, MD, an emergency medicine doctor and public health policy professor at George Washington University, said such sentiments are common and justified.

“I understand that feeling of frustration and anger, because it is the unvaccinated who are setting back the progress that we’ve made [because of] the many sacrifices that many people have undergone,” said Dr. Wen, author of the newly published book “Lifelines: A Doctor’s Journey in the Fight for Public Health.”

“I think it is appropriate for the vaccinated to feel like they’re being punished right now,” she said. “We as a country had the opportunity to beat this virus – to return to prepandemic normal [life] and have our kids go back to school without worrying about coronavirus and our economy fully recovering. We came so close to achieving this, but we didn’t, and now COVID-19 is surging again. The vaccinated are having to pay the price for the choices that some have made to not end this pandemic.”
 

COVID rising, driving anger

The rising anger among vaccinated Americans comes as health officials are reporting huge spikes in new cases, hospitalizations, and deaths. Meanwhile, only about half of all Americans fully vaccinated, according to the Centers for Disease Control and Prevention.

Per Aug. 6 estimates from the CDC, the nation is averaging more than 100,000 new cases every day – the highest levels seen since February.

Southern states, with the lowest vaccination rates in the country, have been particularly hard-hit. Florida and Louisiana recently set 7-day records for new cases and hospitalizations, beating previous peaks last summer. Those two states, along with Mississippi, North Carolina, South Carolina, Tennessee, Kentucky, and Georgia, account for 41% of all new COVID-19 hospitalizations in the country, according to the CDC.

“It’s time to start blaming the unvaccinated folks, not the regular folks,” an angry Gov. Kay Ivey (R) of Alabama, told reporters. “It’s the unvaccinated folks that are letting us down.”

In response to the resurgence in cases, President Joe Biden has ordered new vaccine mandates for millions of federal workers.

California started requiring health care professionals to be vaccinated in August 2021, removing the option for unvaccinated employees to submit to regular testing.

New York City became the first in the country to require proof of vaccination for all workers and customers to enter restaurants, gyms, concert halls, movie theaters, and Broadway venues.

Nearly 60 major medical organizations, including the American Medical Association and the American Nurses Association, have called for mandatory vaccination of all health care workers.

Meanwhile, many businesses are requiring workers to be vaccinated before returning to offices and other workplaces. Colleges across the country are mandating the shots for students and staff. And some states and cities are also returning to mask mandates, including Hawaii; Louisiana; Washington, D.C.; San Francisco; and Los Angeles.

Experts say the 90 million unvaccinated Americans are most at risk from COVID and have helped the new Delta variant gain a foothold and spread, posing a risk of “breakthrough” cases even in vaccinated people.

Delta is more contagious and causes more severe disease than other known variants of the virus, according to the CDC. It is also more contagious than the viruses that cause Middle East respiratory syndrome, severe acute respiratory syndrome, Ebola, the common cold, flu, and smallpox
 

Calls for mandates grow

With Delta helping to drive new spikes in COVID cases, some vaccinated Americans argue that the federal government should be taking a harder line with holdouts. Others have even advocated withholding government stimulus checks or tax credits from vaccine refusers and cutting federal funding to states that don’t meet vaccine targets.

Eric Jaffe, a creative writer and producer from Florida who is vaccinated, said he would like to see government agencies and private businesses do more to put pressure on unvaccinated Americans to get the shot.

“In the interest of public safety, I believe the government and private businesses need to [make] life difficult for the unvaccinated,” said Mr. Jaffe, 29, whose parents both contracted the virus but recovered. “They should not be allowed to dine at restaurants, ride public transportation, attend concerts, or broadly be in spaces with large concentrations of people without passing a COVID test at the door.

“They’ll stand in long lines and be inconvenienced at every turn, while vaccinated people get to fly through security, TSA PreCheck-style. The holdouts at [this] point are beyond convincing. The vaccinated should be able to return to a level of normalcy, and the unvaccinated should face restrictions. Any other dynamic puts the stress on citizens who did the right thing.”

Elif Akcali, 49, who teaches engineering at the University of Florida, Gainesville, worries that the rights of people who refuse the vaccine are being put ahead of those of vaccinated people. She’s also concerned for people who face greater COVID risks, including health care workers and children too young to be inoculated.

“Each infection is an opportunity for the virus to evolve into a stronger version in itself,” said Ms. Akcali, who felt such a sense of relief when she received her vaccination that she teared up. “Each hospitalization is an unnecessary burden to health care workers and the system. Each death brings heartbreak to someone in their circle.”

Ed Berliner, an Emmy Award–winning broadcast journalist and Florida-based media specialist, blames social media for spreading misinformation that has taken root with unvaccinated Americans.

“When America rallied together to combat polio, there were two things we didn’t have. One was a lack of the sewer-dwelling, troll-infested social media, which has become the main source of news for the less intelligent and arrogant,” said Mr. Berliner, CEO of Entourage Media and host of The Man in the Arena, a talk show. “Second, children were dying across the country, and that made people sit up and take notice.”

Mr. Berliner, who knows two people who’ve died from COVID and who received the vaccine early, also believes too many political leaders are still fueling falsehoods that are giving unvaccinated Americans a license to refuse the shot.

“We are also here because governments and officials spend too little time being brutally honest, choosing instead to dance around issues with soft words,” he said. “The first words out of their mouths should have been: ‘What we are doing is trying to save lives. Help us save your life and that of everyone else.’ Would it have made a difference? We will never know.”

Shon Neyland, senior pastor at the Highland Christian Center church in Portland, Ore., said vaccine tensions have divided his congregation, with about half refusing the shot by his estimation. But he said it’s important to understand why some are making that choice, rather than rage at them and hammer home the benefits of the shot.

Many vaccine holdouts don’t trust the government or medical establishment or have bought into political arguments against the shot, he says. Some conservative evangelicals are also swayed by spiritual beliefs that COVID-19 is a sign of “biblical end-times prophesies” and the vaccine is “the mark of the beast.”

But he has tried to counter those beliefs and biases, arguing they are false and unfounded, urging members of his church to get the vaccine, and partnering with local health officials to run clinics to deliver it.

“I gently try to show them that the vaccine is for our own good and, in fact, is a blessing from God, and it’s up to us to accept the blessing [so] we can get back to somewhat of normalcy,” said Mr. Neyland, author of “The Courage to Stand: A New America.”

“I also believe that to get a vaccine this quick, this was nothing short of a miracle to turn the tide so quickly. Now, for us to resist, it would cause us to continue to suffer and lose lives. And you can’t turn away from the lives that have already been lost.”

Mr. Hyman fears we may not have seen the worst of the pandemic and that the Delta variant won’t be the last or most virulent mutation to emerge.

“The number of unvaccinated people is allowing this virus to continue circulating in the community,” he noted. “And while I have a tremendous amount of confidence that the vaccine protects me now from Delta, I have less confidence that it’s going to protect me from whatever [variant] comes next.

“So, I have a tremendous amount of concern for my own health and safety and welfare, and that of the people that I love. But I’m also concerned about what’s it going to do to businesses [and] the economy. Are we going to have more shutdowns if cases continue trending up? I’m very concerned as to what this could do [to] the country.”

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

COVID-19 rates are surging again, and many Americans who’ve been vaccinated are turning their anger toward those who refuse to get the shot.

Outraged at vaccine-hesitant people, some are even calling for mandates requiring all Americans to get inoculated, arguing the holdouts are allowing the Delta coronavirus variant to gain traction and reverse the progress the United States was making against the virus.

“I am angry, I am resentful, and I think it’s a fair and appropriate response,” said Jonathan Hyman, a Berea, Ohio, attorney who blames the unvaccinated for the backslide in pandemic progress.

Mr. Hyman has been following the difficult guidelines health experts have been urging from the beginning. He has been masking up, avoiding large gatherings, postponing travel, and he signed up to receive the vaccine as soon as it was available.

“We have been responsible, I did everything I was supposed to do,” said Mr. Hyman, 48, who didn’t visit his parents for 18 months to keep them safe. “Yet here we are, 16, 17 months later, and it feels like we’re in the exact same place we were last summer, and it’s all because some people refuse to do the responsible things they were told to do.”

James Simmons, a retired South Florida high school finance teacher, is also angered by the vaccine holdouts, citing new spikes in COVID-19 infections, hospitalization rates, and deaths across the country – nearly all of which are among unvaccinated people.

“I can’t fathom the fact that people have seen over 600,000 Americans die from COVID, yet are resistant to a vaccine that provides direct protection for themselves and others,” said Mr. Simmons, 63, who received the shot early. “Their irresponsible decision is an affront to those of us who are vaccinated and still wear masks for the benefit of our society.”

Melissa Martin, an Atlanta resident who contracted a serious case of COVID-19 in September 2020, says it is “perplexing and frustrating” that so many Americans are refusing the vaccine. She believes the anger so many vaccinated people feel is tied to fear.

“I believe at the core of this anger is a fear of losing the ones we love,” said Ms. Martin, 55, who has been vaccinated, as has her fiancé, Shane McGeehin. “I was very angry last year after contracting COVID. The experience of having COVID was negative physically, emotionally, and socially.”

She recalled arguing with friends and relatives who downplayed how severe the virus was and who still refuse vaccination, despite seeing how COVID affected her.

“I am trying to understand why they feel the way they do,” she said, “but I would describe the emotions I have now towards those who do not get the vaccine as frustration, confusion, and disbelief.”

Leana Wen, MD, an emergency medicine doctor and public health policy professor at George Washington University, said such sentiments are common and justified.

“I understand that feeling of frustration and anger, because it is the unvaccinated who are setting back the progress that we’ve made [because of] the many sacrifices that many people have undergone,” said Dr. Wen, author of the newly published book “Lifelines: A Doctor’s Journey in the Fight for Public Health.”

“I think it is appropriate for the vaccinated to feel like they’re being punished right now,” she said. “We as a country had the opportunity to beat this virus – to return to prepandemic normal [life] and have our kids go back to school without worrying about coronavirus and our economy fully recovering. We came so close to achieving this, but we didn’t, and now COVID-19 is surging again. The vaccinated are having to pay the price for the choices that some have made to not end this pandemic.”
 

COVID rising, driving anger

The rising anger among vaccinated Americans comes as health officials are reporting huge spikes in new cases, hospitalizations, and deaths. Meanwhile, only about half of all Americans fully vaccinated, according to the Centers for Disease Control and Prevention.

Per Aug. 6 estimates from the CDC, the nation is averaging more than 100,000 new cases every day – the highest levels seen since February.

Southern states, with the lowest vaccination rates in the country, have been particularly hard-hit. Florida and Louisiana recently set 7-day records for new cases and hospitalizations, beating previous peaks last summer. Those two states, along with Mississippi, North Carolina, South Carolina, Tennessee, Kentucky, and Georgia, account for 41% of all new COVID-19 hospitalizations in the country, according to the CDC.

“It’s time to start blaming the unvaccinated folks, not the regular folks,” an angry Gov. Kay Ivey (R) of Alabama, told reporters. “It’s the unvaccinated folks that are letting us down.”

In response to the resurgence in cases, President Joe Biden has ordered new vaccine mandates for millions of federal workers.

California started requiring health care professionals to be vaccinated in August 2021, removing the option for unvaccinated employees to submit to regular testing.

New York City became the first in the country to require proof of vaccination for all workers and customers to enter restaurants, gyms, concert halls, movie theaters, and Broadway venues.

Nearly 60 major medical organizations, including the American Medical Association and the American Nurses Association, have called for mandatory vaccination of all health care workers.

Meanwhile, many businesses are requiring workers to be vaccinated before returning to offices and other workplaces. Colleges across the country are mandating the shots for students and staff. And some states and cities are also returning to mask mandates, including Hawaii; Louisiana; Washington, D.C.; San Francisco; and Los Angeles.

Experts say the 90 million unvaccinated Americans are most at risk from COVID and have helped the new Delta variant gain a foothold and spread, posing a risk of “breakthrough” cases even in vaccinated people.

Delta is more contagious and causes more severe disease than other known variants of the virus, according to the CDC. It is also more contagious than the viruses that cause Middle East respiratory syndrome, severe acute respiratory syndrome, Ebola, the common cold, flu, and smallpox
 

Calls for mandates grow

With Delta helping to drive new spikes in COVID cases, some vaccinated Americans argue that the federal government should be taking a harder line with holdouts. Others have even advocated withholding government stimulus checks or tax credits from vaccine refusers and cutting federal funding to states that don’t meet vaccine targets.

Eric Jaffe, a creative writer and producer from Florida who is vaccinated, said he would like to see government agencies and private businesses do more to put pressure on unvaccinated Americans to get the shot.

“In the interest of public safety, I believe the government and private businesses need to [make] life difficult for the unvaccinated,” said Mr. Jaffe, 29, whose parents both contracted the virus but recovered. “They should not be allowed to dine at restaurants, ride public transportation, attend concerts, or broadly be in spaces with large concentrations of people without passing a COVID test at the door.

“They’ll stand in long lines and be inconvenienced at every turn, while vaccinated people get to fly through security, TSA PreCheck-style. The holdouts at [this] point are beyond convincing. The vaccinated should be able to return to a level of normalcy, and the unvaccinated should face restrictions. Any other dynamic puts the stress on citizens who did the right thing.”

Elif Akcali, 49, who teaches engineering at the University of Florida, Gainesville, worries that the rights of people who refuse the vaccine are being put ahead of those of vaccinated people. She’s also concerned for people who face greater COVID risks, including health care workers and children too young to be inoculated.

“Each infection is an opportunity for the virus to evolve into a stronger version in itself,” said Ms. Akcali, who felt such a sense of relief when she received her vaccination that she teared up. “Each hospitalization is an unnecessary burden to health care workers and the system. Each death brings heartbreak to someone in their circle.”

Ed Berliner, an Emmy Award–winning broadcast journalist and Florida-based media specialist, blames social media for spreading misinformation that has taken root with unvaccinated Americans.

“When America rallied together to combat polio, there were two things we didn’t have. One was a lack of the sewer-dwelling, troll-infested social media, which has become the main source of news for the less intelligent and arrogant,” said Mr. Berliner, CEO of Entourage Media and host of The Man in the Arena, a talk show. “Second, children were dying across the country, and that made people sit up and take notice.”

Mr. Berliner, who knows two people who’ve died from COVID and who received the vaccine early, also believes too many political leaders are still fueling falsehoods that are giving unvaccinated Americans a license to refuse the shot.

“We are also here because governments and officials spend too little time being brutally honest, choosing instead to dance around issues with soft words,” he said. “The first words out of their mouths should have been: ‘What we are doing is trying to save lives. Help us save your life and that of everyone else.’ Would it have made a difference? We will never know.”

Shon Neyland, senior pastor at the Highland Christian Center church in Portland, Ore., said vaccine tensions have divided his congregation, with about half refusing the shot by his estimation. But he said it’s important to understand why some are making that choice, rather than rage at them and hammer home the benefits of the shot.

Many vaccine holdouts don’t trust the government or medical establishment or have bought into political arguments against the shot, he says. Some conservative evangelicals are also swayed by spiritual beliefs that COVID-19 is a sign of “biblical end-times prophesies” and the vaccine is “the mark of the beast.”

But he has tried to counter those beliefs and biases, arguing they are false and unfounded, urging members of his church to get the vaccine, and partnering with local health officials to run clinics to deliver it.

“I gently try to show them that the vaccine is for our own good and, in fact, is a blessing from God, and it’s up to us to accept the blessing [so] we can get back to somewhat of normalcy,” said Mr. Neyland, author of “The Courage to Stand: A New America.”

“I also believe that to get a vaccine this quick, this was nothing short of a miracle to turn the tide so quickly. Now, for us to resist, it would cause us to continue to suffer and lose lives. And you can’t turn away from the lives that have already been lost.”

Mr. Hyman fears we may not have seen the worst of the pandemic and that the Delta variant won’t be the last or most virulent mutation to emerge.

“The number of unvaccinated people is allowing this virus to continue circulating in the community,” he noted. “And while I have a tremendous amount of confidence that the vaccine protects me now from Delta, I have less confidence that it’s going to protect me from whatever [variant] comes next.

“So, I have a tremendous amount of concern for my own health and safety and welfare, and that of the people that I love. But I’m also concerned about what’s it going to do to businesses [and] the economy. Are we going to have more shutdowns if cases continue trending up? I’m very concerned as to what this could do [to] the country.”

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

COVID-19 rates are surging again, and many Americans who’ve been vaccinated are turning their anger toward those who refuse to get the shot.

Outraged at vaccine-hesitant people, some are even calling for mandates requiring all Americans to get inoculated, arguing the holdouts are allowing the Delta coronavirus variant to gain traction and reverse the progress the United States was making against the virus.

“I am angry, I am resentful, and I think it’s a fair and appropriate response,” said Jonathan Hyman, a Berea, Ohio, attorney who blames the unvaccinated for the backslide in pandemic progress.

Mr. Hyman has been following the difficult guidelines health experts have been urging from the beginning. He has been masking up, avoiding large gatherings, postponing travel, and he signed up to receive the vaccine as soon as it was available.

“We have been responsible, I did everything I was supposed to do,” said Mr. Hyman, 48, who didn’t visit his parents for 18 months to keep them safe. “Yet here we are, 16, 17 months later, and it feels like we’re in the exact same place we were last summer, and it’s all because some people refuse to do the responsible things they were told to do.”

James Simmons, a retired South Florida high school finance teacher, is also angered by the vaccine holdouts, citing new spikes in COVID-19 infections, hospitalization rates, and deaths across the country – nearly all of which are among unvaccinated people.

“I can’t fathom the fact that people have seen over 600,000 Americans die from COVID, yet are resistant to a vaccine that provides direct protection for themselves and others,” said Mr. Simmons, 63, who received the shot early. “Their irresponsible decision is an affront to those of us who are vaccinated and still wear masks for the benefit of our society.”

Melissa Martin, an Atlanta resident who contracted a serious case of COVID-19 in September 2020, says it is “perplexing and frustrating” that so many Americans are refusing the vaccine. She believes the anger so many vaccinated people feel is tied to fear.

“I believe at the core of this anger is a fear of losing the ones we love,” said Ms. Martin, 55, who has been vaccinated, as has her fiancé, Shane McGeehin. “I was very angry last year after contracting COVID. The experience of having COVID was negative physically, emotionally, and socially.”

She recalled arguing with friends and relatives who downplayed how severe the virus was and who still refuse vaccination, despite seeing how COVID affected her.

“I am trying to understand why they feel the way they do,” she said, “but I would describe the emotions I have now towards those who do not get the vaccine as frustration, confusion, and disbelief.”

Leana Wen, MD, an emergency medicine doctor and public health policy professor at George Washington University, said such sentiments are common and justified.

“I understand that feeling of frustration and anger, because it is the unvaccinated who are setting back the progress that we’ve made [because of] the many sacrifices that many people have undergone,” said Dr. Wen, author of the newly published book “Lifelines: A Doctor’s Journey in the Fight for Public Health.”

“I think it is appropriate for the vaccinated to feel like they’re being punished right now,” she said. “We as a country had the opportunity to beat this virus – to return to prepandemic normal [life] and have our kids go back to school without worrying about coronavirus and our economy fully recovering. We came so close to achieving this, but we didn’t, and now COVID-19 is surging again. The vaccinated are having to pay the price for the choices that some have made to not end this pandemic.”
 

COVID rising, driving anger

The rising anger among vaccinated Americans comes as health officials are reporting huge spikes in new cases, hospitalizations, and deaths. Meanwhile, only about half of all Americans fully vaccinated, according to the Centers for Disease Control and Prevention.

Per Aug. 6 estimates from the CDC, the nation is averaging more than 100,000 new cases every day – the highest levels seen since February.

Southern states, with the lowest vaccination rates in the country, have been particularly hard-hit. Florida and Louisiana recently set 7-day records for new cases and hospitalizations, beating previous peaks last summer. Those two states, along with Mississippi, North Carolina, South Carolina, Tennessee, Kentucky, and Georgia, account for 41% of all new COVID-19 hospitalizations in the country, according to the CDC.

“It’s time to start blaming the unvaccinated folks, not the regular folks,” an angry Gov. Kay Ivey (R) of Alabama, told reporters. “It’s the unvaccinated folks that are letting us down.”

In response to the resurgence in cases, President Joe Biden has ordered new vaccine mandates for millions of federal workers.

California started requiring health care professionals to be vaccinated in August 2021, removing the option for unvaccinated employees to submit to regular testing.

New York City became the first in the country to require proof of vaccination for all workers and customers to enter restaurants, gyms, concert halls, movie theaters, and Broadway venues.

Nearly 60 major medical organizations, including the American Medical Association and the American Nurses Association, have called for mandatory vaccination of all health care workers.

Meanwhile, many businesses are requiring workers to be vaccinated before returning to offices and other workplaces. Colleges across the country are mandating the shots for students and staff. And some states and cities are also returning to mask mandates, including Hawaii; Louisiana; Washington, D.C.; San Francisco; and Los Angeles.

Experts say the 90 million unvaccinated Americans are most at risk from COVID and have helped the new Delta variant gain a foothold and spread, posing a risk of “breakthrough” cases even in vaccinated people.

Delta is more contagious and causes more severe disease than other known variants of the virus, according to the CDC. It is also more contagious than the viruses that cause Middle East respiratory syndrome, severe acute respiratory syndrome, Ebola, the common cold, flu, and smallpox
 

Calls for mandates grow

With Delta helping to drive new spikes in COVID cases, some vaccinated Americans argue that the federal government should be taking a harder line with holdouts. Others have even advocated withholding government stimulus checks or tax credits from vaccine refusers and cutting federal funding to states that don’t meet vaccine targets.

Eric Jaffe, a creative writer and producer from Florida who is vaccinated, said he would like to see government agencies and private businesses do more to put pressure on unvaccinated Americans to get the shot.

“In the interest of public safety, I believe the government and private businesses need to [make] life difficult for the unvaccinated,” said Mr. Jaffe, 29, whose parents both contracted the virus but recovered. “They should not be allowed to dine at restaurants, ride public transportation, attend concerts, or broadly be in spaces with large concentrations of people without passing a COVID test at the door.

“They’ll stand in long lines and be inconvenienced at every turn, while vaccinated people get to fly through security, TSA PreCheck-style. The holdouts at [this] point are beyond convincing. The vaccinated should be able to return to a level of normalcy, and the unvaccinated should face restrictions. Any other dynamic puts the stress on citizens who did the right thing.”

Elif Akcali, 49, who teaches engineering at the University of Florida, Gainesville, worries that the rights of people who refuse the vaccine are being put ahead of those of vaccinated people. She’s also concerned for people who face greater COVID risks, including health care workers and children too young to be inoculated.

“Each infection is an opportunity for the virus to evolve into a stronger version in itself,” said Ms. Akcali, who felt such a sense of relief when she received her vaccination that she teared up. “Each hospitalization is an unnecessary burden to health care workers and the system. Each death brings heartbreak to someone in their circle.”

Ed Berliner, an Emmy Award–winning broadcast journalist and Florida-based media specialist, blames social media for spreading misinformation that has taken root with unvaccinated Americans.

“When America rallied together to combat polio, there were two things we didn’t have. One was a lack of the sewer-dwelling, troll-infested social media, which has become the main source of news for the less intelligent and arrogant,” said Mr. Berliner, CEO of Entourage Media and host of The Man in the Arena, a talk show. “Second, children were dying across the country, and that made people sit up and take notice.”

Mr. Berliner, who knows two people who’ve died from COVID and who received the vaccine early, also believes too many political leaders are still fueling falsehoods that are giving unvaccinated Americans a license to refuse the shot.

“We are also here because governments and officials spend too little time being brutally honest, choosing instead to dance around issues with soft words,” he said. “The first words out of their mouths should have been: ‘What we are doing is trying to save lives. Help us save your life and that of everyone else.’ Would it have made a difference? We will never know.”

Shon Neyland, senior pastor at the Highland Christian Center church in Portland, Ore., said vaccine tensions have divided his congregation, with about half refusing the shot by his estimation. But he said it’s important to understand why some are making that choice, rather than rage at them and hammer home the benefits of the shot.

Many vaccine holdouts don’t trust the government or medical establishment or have bought into political arguments against the shot, he says. Some conservative evangelicals are also swayed by spiritual beliefs that COVID-19 is a sign of “biblical end-times prophesies” and the vaccine is “the mark of the beast.”

But he has tried to counter those beliefs and biases, arguing they are false and unfounded, urging members of his church to get the vaccine, and partnering with local health officials to run clinics to deliver it.

“I gently try to show them that the vaccine is for our own good and, in fact, is a blessing from God, and it’s up to us to accept the blessing [so] we can get back to somewhat of normalcy,” said Mr. Neyland, author of “The Courage to Stand: A New America.”

“I also believe that to get a vaccine this quick, this was nothing short of a miracle to turn the tide so quickly. Now, for us to resist, it would cause us to continue to suffer and lose lives. And you can’t turn away from the lives that have already been lost.”

Mr. Hyman fears we may not have seen the worst of the pandemic and that the Delta variant won’t be the last or most virulent mutation to emerge.

“The number of unvaccinated people is allowing this virus to continue circulating in the community,” he noted. “And while I have a tremendous amount of confidence that the vaccine protects me now from Delta, I have less confidence that it’s going to protect me from whatever [variant] comes next.

“So, I have a tremendous amount of concern for my own health and safety and welfare, and that of the people that I love. But I’m also concerned about what’s it going to do to businesses [and] the economy. Are we going to have more shutdowns if cases continue trending up? I’m very concerned as to what this could do [to] the country.”

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

Anaplasmosis prevalence in New York state nearly quadrupled statewide from 2010 to 2018, new research suggests, increasing by more than eightfold in the region surrounding Albany, the state capital. The proportion of ticks carrying Anaplasma phagocytophilum, the bacterium that causes the tick-borne disease, also increased during the study period. 

Although not as well-recognized as Lyme disease, anaplasmosis is one of the most common tickborne diseases in the United States. The bacterial disease is primarily transmitted to humans by the bites of blacklegged ticks infected with A. phagocytophilum, and often causes fever, headache, muscle aches, and chills. If treatment is delayed – or if a patient has underlying medical conditions – anaplasmosis can lead to difficulty breathing, bleeding problems, organ failure, and even death.

Since anaplasmosis become a nationally notifiable disease in 1999, cases have increased 16-fold in the United States, from 351 cases in 2000 to a high of 5,762 cases in 2017, according to data from the Centers for Disease Control and Prevention. Just eight states – Vermont, Maine, Rhode Island, Minnesota, Massachusetts, Wisconsin, New Hampshire, and New York – make up 90% of reported cases.

“While Lyme disease remains the most common tick-borne illness reported in New York state, anaplasmosis continues to account for a growing proportion of our tick-borne disease cases each year,” Melissa Prusinski, a research scientist at the New York State Department of Health and author of the study, told this news organization in an email. “It is critically important to investigate the environmental and epidemiological drivers facilitating this increase to better understand why and how risk for this serious illness is increasing.” The results were published in Emerging Infectious Diseases.

For the study, investigators analyzed human anaplasmosis cases reported to the New York State Department of Health from 2010-2018. They also included data from tick collection and pathogen testing in order to determine whether the prevalence of A. phagocytophilum in ticks increased along with cases. All New York State counties were included in the study, apart from the five boroughs of New York City: Manhattan, Brooklyn, the Bronx, Queens, and Staten Island.

There were 5,146 reported anaplasmosis cases in New York, with annual case numbers peaking at 1,112 in 2017. Researchers reported a dip in cases in 2018, a trend that was also seen nationally. Anaplasmosis incidence surged in the area surrounding Albany, increasing 8.4-fold from 4.3 cases per 100,000 people in 2010 to 36.3 cases per 100,000 persons in 2018.

Ms. Prusinski noted that the rapid increase in and around this inland hot spot is unlike the gradual spread of Lyme disease and other tick-borne illnesses like babesiosis, which spreads from coastal areas both northward and westward across New York. The research team also found that the incidence of ticks infected with A. phagocytophilum nearly doubled statewide and increased fourfold – from 2.9% to 12% – between 2010 and 2018 in the Albany area.

This increase in cases could be the result, at least in part, of more robust testing efforts over time, said Susan Elias, PhD, of the Vector-Borne Disease Laboratory at the Maine Medical Center Research Institute in Scarborough. She was not involved with the recently published study. “The more you look for something, the more you find,” she said. For example, she added, a 602% surge in anaplasmosis cases in Maine from 2013-2017 occurred alongside a 10-fold increase in use of tick-borne disease panels that test for multiple pathogens.

Ms. Prusinski agreed that increased testing at least partially explains the surge of cases in New York, but she did not have data on how many tick-borne disease panels were used to diagnose cases in the state.

Proliferation of A. phagocytophilum in tick populations could also partially explain this dramatic increase in cases. With the suburbanization of America, “we have basically laid out a buffet” for ticks, Dr. Elias said. Patches of forest and yards create edge habitats where ticks, and the small mammals they feed on, thrive. “Then, once you have a large expanding blacklegged tick population, it makes it easier for the pathogens and carriers to amplify,” she added.

While the study did not differentiate between a variant of A. phagocytophilum associated with small mammals that causes illness and another found in white-tailed deer that is nonpathogenic, Ms. Prusinski suspects that the infectious variant is likely more prevalent and is circulating in animals and ticks in and around Albany. Research is ongoing to see if this could help explain the spread of disease in this anaplasmosis hotspot.

“The unique geographic pattern of anaplasmosis spread in New York state and elsewhere leads to many further questions about the vector ecology and epidemiology of this emerging tick-borne illness,” Ms. Prusinski added. “Learning all we can about this dynamic disease system will help us better identify at-risk populations and may lead to novel ways to prevent anaplasmosis.”

Dr. Elias and Ms. Prusinski disclosed no relevant financial relationships.

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

Anaplasmosis prevalence in New York state nearly quadrupled statewide from 2010 to 2018, new research suggests, increasing by more than eightfold in the region surrounding Albany, the state capital. The proportion of ticks carrying Anaplasma phagocytophilum, the bacterium that causes the tick-borne disease, also increased during the study period. 

Although not as well-recognized as Lyme disease, anaplasmosis is one of the most common tickborne diseases in the United States. The bacterial disease is primarily transmitted to humans by the bites of blacklegged ticks infected with A. phagocytophilum, and often causes fever, headache, muscle aches, and chills. If treatment is delayed – or if a patient has underlying medical conditions – anaplasmosis can lead to difficulty breathing, bleeding problems, organ failure, and even death.

Since anaplasmosis become a nationally notifiable disease in 1999, cases have increased 16-fold in the United States, from 351 cases in 2000 to a high of 5,762 cases in 2017, according to data from the Centers for Disease Control and Prevention. Just eight states – Vermont, Maine, Rhode Island, Minnesota, Massachusetts, Wisconsin, New Hampshire, and New York – make up 90% of reported cases.

“While Lyme disease remains the most common tick-borne illness reported in New York state, anaplasmosis continues to account for a growing proportion of our tick-borne disease cases each year,” Melissa Prusinski, a research scientist at the New York State Department of Health and author of the study, told this news organization in an email. “It is critically important to investigate the environmental and epidemiological drivers facilitating this increase to better understand why and how risk for this serious illness is increasing.” The results were published in Emerging Infectious Diseases.

For the study, investigators analyzed human anaplasmosis cases reported to the New York State Department of Health from 2010-2018. They also included data from tick collection and pathogen testing in order to determine whether the prevalence of A. phagocytophilum in ticks increased along with cases. All New York State counties were included in the study, apart from the five boroughs of New York City: Manhattan, Brooklyn, the Bronx, Queens, and Staten Island.

There were 5,146 reported anaplasmosis cases in New York, with annual case numbers peaking at 1,112 in 2017. Researchers reported a dip in cases in 2018, a trend that was also seen nationally. Anaplasmosis incidence surged in the area surrounding Albany, increasing 8.4-fold from 4.3 cases per 100,000 people in 2010 to 36.3 cases per 100,000 persons in 2018.

Ms. Prusinski noted that the rapid increase in and around this inland hot spot is unlike the gradual spread of Lyme disease and other tick-borne illnesses like babesiosis, which spreads from coastal areas both northward and westward across New York. The research team also found that the incidence of ticks infected with A. phagocytophilum nearly doubled statewide and increased fourfold – from 2.9% to 12% – between 2010 and 2018 in the Albany area.

This increase in cases could be the result, at least in part, of more robust testing efforts over time, said Susan Elias, PhD, of the Vector-Borne Disease Laboratory at the Maine Medical Center Research Institute in Scarborough. She was not involved with the recently published study. “The more you look for something, the more you find,” she said. For example, she added, a 602% surge in anaplasmosis cases in Maine from 2013-2017 occurred alongside a 10-fold increase in use of tick-borne disease panels that test for multiple pathogens.

Ms. Prusinski agreed that increased testing at least partially explains the surge of cases in New York, but she did not have data on how many tick-borne disease panels were used to diagnose cases in the state.

Proliferation of A. phagocytophilum in tick populations could also partially explain this dramatic increase in cases. With the suburbanization of America, “we have basically laid out a buffet” for ticks, Dr. Elias said. Patches of forest and yards create edge habitats where ticks, and the small mammals they feed on, thrive. “Then, once you have a large expanding blacklegged tick population, it makes it easier for the pathogens and carriers to amplify,” she added.

While the study did not differentiate between a variant of A. phagocytophilum associated with small mammals that causes illness and another found in white-tailed deer that is nonpathogenic, Ms. Prusinski suspects that the infectious variant is likely more prevalent and is circulating in animals and ticks in and around Albany. Research is ongoing to see if this could help explain the spread of disease in this anaplasmosis hotspot.

“The unique geographic pattern of anaplasmosis spread in New York state and elsewhere leads to many further questions about the vector ecology and epidemiology of this emerging tick-borne illness,” Ms. Prusinski added. “Learning all we can about this dynamic disease system will help us better identify at-risk populations and may lead to novel ways to prevent anaplasmosis.”

Dr. Elias and Ms. Prusinski disclosed no relevant financial relationships.

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

Anaplasmosis prevalence in New York state nearly quadrupled statewide from 2010 to 2018, new research suggests, increasing by more than eightfold in the region surrounding Albany, the state capital. The proportion of ticks carrying Anaplasma phagocytophilum, the bacterium that causes the tick-borne disease, also increased during the study period. 

Although not as well-recognized as Lyme disease, anaplasmosis is one of the most common tickborne diseases in the United States. The bacterial disease is primarily transmitted to humans by the bites of blacklegged ticks infected with A. phagocytophilum, and often causes fever, headache, muscle aches, and chills. If treatment is delayed – or if a patient has underlying medical conditions – anaplasmosis can lead to difficulty breathing, bleeding problems, organ failure, and even death.

Since anaplasmosis become a nationally notifiable disease in 1999, cases have increased 16-fold in the United States, from 351 cases in 2000 to a high of 5,762 cases in 2017, according to data from the Centers for Disease Control and Prevention. Just eight states – Vermont, Maine, Rhode Island, Minnesota, Massachusetts, Wisconsin, New Hampshire, and New York – make up 90% of reported cases.

“While Lyme disease remains the most common tick-borne illness reported in New York state, anaplasmosis continues to account for a growing proportion of our tick-borne disease cases each year,” Melissa Prusinski, a research scientist at the New York State Department of Health and author of the study, told this news organization in an email. “It is critically important to investigate the environmental and epidemiological drivers facilitating this increase to better understand why and how risk for this serious illness is increasing.” The results were published in Emerging Infectious Diseases.

For the study, investigators analyzed human anaplasmosis cases reported to the New York State Department of Health from 2010-2018. They also included data from tick collection and pathogen testing in order to determine whether the prevalence of A. phagocytophilum in ticks increased along with cases. All New York State counties were included in the study, apart from the five boroughs of New York City: Manhattan, Brooklyn, the Bronx, Queens, and Staten Island.

There were 5,146 reported anaplasmosis cases in New York, with annual case numbers peaking at 1,112 in 2017. Researchers reported a dip in cases in 2018, a trend that was also seen nationally. Anaplasmosis incidence surged in the area surrounding Albany, increasing 8.4-fold from 4.3 cases per 100,000 people in 2010 to 36.3 cases per 100,000 persons in 2018.

Ms. Prusinski noted that the rapid increase in and around this inland hot spot is unlike the gradual spread of Lyme disease and other tick-borne illnesses like babesiosis, which spreads from coastal areas both northward and westward across New York. The research team also found that the incidence of ticks infected with A. phagocytophilum nearly doubled statewide and increased fourfold – from 2.9% to 12% – between 2010 and 2018 in the Albany area.

This increase in cases could be the result, at least in part, of more robust testing efforts over time, said Susan Elias, PhD, of the Vector-Borne Disease Laboratory at the Maine Medical Center Research Institute in Scarborough. She was not involved with the recently published study. “The more you look for something, the more you find,” she said. For example, she added, a 602% surge in anaplasmosis cases in Maine from 2013-2017 occurred alongside a 10-fold increase in use of tick-borne disease panels that test for multiple pathogens.

Ms. Prusinski agreed that increased testing at least partially explains the surge of cases in New York, but she did not have data on how many tick-borne disease panels were used to diagnose cases in the state.

Proliferation of A. phagocytophilum in tick populations could also partially explain this dramatic increase in cases. With the suburbanization of America, “we have basically laid out a buffet” for ticks, Dr. Elias said. Patches of forest and yards create edge habitats where ticks, and the small mammals they feed on, thrive. “Then, once you have a large expanding blacklegged tick population, it makes it easier for the pathogens and carriers to amplify,” she added.

While the study did not differentiate between a variant of A. phagocytophilum associated with small mammals that causes illness and another found in white-tailed deer that is nonpathogenic, Ms. Prusinski suspects that the infectious variant is likely more prevalent and is circulating in animals and ticks in and around Albany. Research is ongoing to see if this could help explain the spread of disease in this anaplasmosis hotspot.

“The unique geographic pattern of anaplasmosis spread in New York state and elsewhere leads to many further questions about the vector ecology and epidemiology of this emerging tick-borne illness,” Ms. Prusinski added. “Learning all we can about this dynamic disease system will help us better identify at-risk populations and may lead to novel ways to prevent anaplasmosis.”

Dr. Elias and Ms. Prusinski disclosed no relevant financial relationships.

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

Eating at least half a serving per day of foods rich in flavonoids – like strawberries, oranges, peppers, and apples – may help lower the risk of age-related cognitive decline, new research shows.

Among the different types of flavonoids, flavones (found in some spices and yellow or orange fruits and vegetables) and anthocyanins (found in blueberries, blackberries, and cherries) seem to have most protective effect, the researchers report.

“There is mounting evidence suggesting flavonoids are powerhouses when it comes to preventing your thinking skills from declining as you get older,” study investigator Walter Willett, MD, DrPH, Harvard University, Boston, said in a statement.

“Our results are exciting because they show that making simple changes to your diet could help prevent cognitive decline,” said Dr. Willett.

The study was published online July 28 in the journal Neurology.
 

Antioxidant punch

Flavonoids, naturally occurring phytochemicals found in plants, are strong antioxidants. Considering the likely role of oxidative stress in age-related cognitive decline, flavonoids have been proposed as a potentially important preventive.  

For the study, Dr. Willett and colleagues prospectively examined associations between long-term dietary flavonoids (flavonols, flavones, flavanones, flavan-3-ols, anthocyanins, polymeric flavonoids, and proanthocyanidins) and subjective cognitive decline in 49,493 women from the Nurses’ Health Study (1984-2006) and 27,842 men from the Health Professionals Follow-up Study (1986-2002).

Those in the highest quintile of flavonoid consumption consumed about 600 mg daily on average while those in the lowest quintile got only about 150 mg daily.

After adjusting for age, total energy intake, major nondietary factors, and specific dietary factors, a higher intake of total flavonoids was associated with lower likelihood of self-reported subjective cognitive decline during follow up.

Individuals in the highest quintile of daily consumption had about a 20% lower risk of subjective cognitive decline relative to peers in the lowest quintile (pooled multivariable-adjusted odds ratio: 0.81; 95% confidence interval, 0.76-0.89).

The strongest protective associations were found for flavones (OR, 0.62; 95% confidence interval, 0.57-0.68), flavanones (OR, 0.64; 95% CI, 0.58-0.68), and anthocyanins (OR, 0.76; 95% CI, 0.72-0.84) (P trend < .0001 for all groups).

“The people in our study who did the best over time ate an average of at least half a serving per day of foods like orange juice, oranges, peppers, celery, grapefruits, grapefruit juice, apples, and pears,” Dr. Willett said.

“While it is possible other phytochemicals are at work here, a colorful diet rich in flavonoids – and specifically flavones and anthocyanins – seems to be a good bet for promoting long-term brain health,” he added.

A limitation of the study is that participants reported on their diets and may not recall perfectly what they ate or how much.
 

Healthy diet best bet for brain health

Reached for comment, Christopher Weber, PhD, director of global science initiatives for the Alzheimer’s Association, said this study “adds to our understanding of which elements of a healthy diet may be important in reducing dementia risk; flavonols may be one of those elements.”

“However, at this point, people should not put too much stock in specific nutrients – including subsets of flavonols – for reducing dementia risk until more research is done. Rather, they should focus on eating an overall healthy diet,” he said.

“It would be wonderful if a particular food or supplement could delay or prevent Alzheimer’s disease, but we do not have scientific evidence to support such claims. Randomized controlled clinical trials are necessary to evaluate whether any food or supplement has a scientifically proven beneficial effect,” Dr. Weber added.

For now, the Alzheimer’s Association “encourages everyone to eat a healthy and balanced diet as a way to help reduce the risk of cognitive decline,” Dr. Weber said.

“With more than 6 million Americans living with Alzheimer’s disease and other dementia today, there is a pressing need to test the effectiveness of a healthy lifestyle regimen to reduce risk of cognitive decline in a large and diverse population,” he added.

The Alzheimer’s Association has launched a 2-year clinical trial, called the U.S. Study to Protect Brain Health Through Lifestyle Intervention to Reduce Risk (U.S. POINTER), to do just that.

“While we research that definitive lifestyle ‘recipe,’ there are things we can do today that may decrease our risk of cognitive decline as we age. Eating a heart-healthy diet, exercising regularly, and staying cognitively engaged are just a few,” Dr. Weber added.

Also weighing in, Taylor Wallace, PhD, adjunct professor, department of nutrition and food studies, George Mason University, Fairfax, Va., said the study results are not surprising.

“Scientific data on the ability of flavonoids to prevent age-related chronic diseases, including cognitive decline, has accumulated immensely over the last decade. This epidemiological study reinforces findings from smaller shorter-duration clinical trials and mechanistic studies,” said Dr. Wallace, who was not involved in the study.

“Flavonoids show great potential in reducing inflammation and oxidative stress in the body. They are also vasodilators that help improve blood flow, which is important for the cardiovascular and cerebrovascular systems,” he noted.

“Typically, foods rich in flavonoids are also nutrient-dense in vitamins, minerals, and dietary fiber (eg, fruits and vegetables). Anthocyanins in blueberries have long been known to prevent cognitive decline with age,” Dr. Wallace said.

Dr. Wallace was part of a 14-member panel of nutrition scientists who recently reviewed available evidence around fruit and vegetable intake and health.

“Our findings are consistent with this study in regard to cognitive decline and other disease states. Cruciferous vegetables, dark-green leafy vegetables, citrus fruits, and dark-colored berries seem to have superior effects on health promotion and disease prevention in general,” said Dr. Wallace.

This work was supported by grants from the National Institutes of Health. The authors have disclosed no relevant financial relationships. Dr. Weber has no relevant disclosures. Dr. Wallace is principal and chief executive officer of the Think Healthy Group; editor of the Journal of Dietary Supplements; and deputy editor-in-chief of the Journal of the American College of Nutrition.

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

Eating at least half a serving per day of foods rich in flavonoids – like strawberries, oranges, peppers, and apples – may help lower the risk of age-related cognitive decline, new research shows.

Among the different types of flavonoids, flavones (found in some spices and yellow or orange fruits and vegetables) and anthocyanins (found in blueberries, blackberries, and cherries) seem to have most protective effect, the researchers report.

“There is mounting evidence suggesting flavonoids are powerhouses when it comes to preventing your thinking skills from declining as you get older,” study investigator Walter Willett, MD, DrPH, Harvard University, Boston, said in a statement.

“Our results are exciting because they show that making simple changes to your diet could help prevent cognitive decline,” said Dr. Willett.

The study was published online July 28 in the journal Neurology.
 

Antioxidant punch

Flavonoids, naturally occurring phytochemicals found in plants, are strong antioxidants. Considering the likely role of oxidative stress in age-related cognitive decline, flavonoids have been proposed as a potentially important preventive.  

For the study, Dr. Willett and colleagues prospectively examined associations between long-term dietary flavonoids (flavonols, flavones, flavanones, flavan-3-ols, anthocyanins, polymeric flavonoids, and proanthocyanidins) and subjective cognitive decline in 49,493 women from the Nurses’ Health Study (1984-2006) and 27,842 men from the Health Professionals Follow-up Study (1986-2002).

Those in the highest quintile of flavonoid consumption consumed about 600 mg daily on average while those in the lowest quintile got only about 150 mg daily.

After adjusting for age, total energy intake, major nondietary factors, and specific dietary factors, a higher intake of total flavonoids was associated with lower likelihood of self-reported subjective cognitive decline during follow up.

Individuals in the highest quintile of daily consumption had about a 20% lower risk of subjective cognitive decline relative to peers in the lowest quintile (pooled multivariable-adjusted odds ratio: 0.81; 95% confidence interval, 0.76-0.89).

The strongest protective associations were found for flavones (OR, 0.62; 95% confidence interval, 0.57-0.68), flavanones (OR, 0.64; 95% CI, 0.58-0.68), and anthocyanins (OR, 0.76; 95% CI, 0.72-0.84) (P trend < .0001 for all groups).

“The people in our study who did the best over time ate an average of at least half a serving per day of foods like orange juice, oranges, peppers, celery, grapefruits, grapefruit juice, apples, and pears,” Dr. Willett said.

“While it is possible other phytochemicals are at work here, a colorful diet rich in flavonoids – and specifically flavones and anthocyanins – seems to be a good bet for promoting long-term brain health,” he added.

A limitation of the study is that participants reported on their diets and may not recall perfectly what they ate or how much.
 

Healthy diet best bet for brain health

Reached for comment, Christopher Weber, PhD, director of global science initiatives for the Alzheimer’s Association, said this study “adds to our understanding of which elements of a healthy diet may be important in reducing dementia risk; flavonols may be one of those elements.”

“However, at this point, people should not put too much stock in specific nutrients – including subsets of flavonols – for reducing dementia risk until more research is done. Rather, they should focus on eating an overall healthy diet,” he said.

“It would be wonderful if a particular food or supplement could delay or prevent Alzheimer’s disease, but we do not have scientific evidence to support such claims. Randomized controlled clinical trials are necessary to evaluate whether any food or supplement has a scientifically proven beneficial effect,” Dr. Weber added.

For now, the Alzheimer’s Association “encourages everyone to eat a healthy and balanced diet as a way to help reduce the risk of cognitive decline,” Dr. Weber said.

“With more than 6 million Americans living with Alzheimer’s disease and other dementia today, there is a pressing need to test the effectiveness of a healthy lifestyle regimen to reduce risk of cognitive decline in a large and diverse population,” he added.

The Alzheimer’s Association has launched a 2-year clinical trial, called the U.S. Study to Protect Brain Health Through Lifestyle Intervention to Reduce Risk (U.S. POINTER), to do just that.

“While we research that definitive lifestyle ‘recipe,’ there are things we can do today that may decrease our risk of cognitive decline as we age. Eating a heart-healthy diet, exercising regularly, and staying cognitively engaged are just a few,” Dr. Weber added.

Also weighing in, Taylor Wallace, PhD, adjunct professor, department of nutrition and food studies, George Mason University, Fairfax, Va., said the study results are not surprising.

“Scientific data on the ability of flavonoids to prevent age-related chronic diseases, including cognitive decline, has accumulated immensely over the last decade. This epidemiological study reinforces findings from smaller shorter-duration clinical trials and mechanistic studies,” said Dr. Wallace, who was not involved in the study.

“Flavonoids show great potential in reducing inflammation and oxidative stress in the body. They are also vasodilators that help improve blood flow, which is important for the cardiovascular and cerebrovascular systems,” he noted.

“Typically, foods rich in flavonoids are also nutrient-dense in vitamins, minerals, and dietary fiber (eg, fruits and vegetables). Anthocyanins in blueberries have long been known to prevent cognitive decline with age,” Dr. Wallace said.

Dr. Wallace was part of a 14-member panel of nutrition scientists who recently reviewed available evidence around fruit and vegetable intake and health.

“Our findings are consistent with this study in regard to cognitive decline and other disease states. Cruciferous vegetables, dark-green leafy vegetables, citrus fruits, and dark-colored berries seem to have superior effects on health promotion and disease prevention in general,” said Dr. Wallace.

This work was supported by grants from the National Institutes of Health. The authors have disclosed no relevant financial relationships. Dr. Weber has no relevant disclosures. Dr. Wallace is principal and chief executive officer of the Think Healthy Group; editor of the Journal of Dietary Supplements; and deputy editor-in-chief of the Journal of the American College of Nutrition.

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

Eating at least half a serving per day of foods rich in flavonoids – like strawberries, oranges, peppers, and apples – may help lower the risk of age-related cognitive decline, new research shows.

Among the different types of flavonoids, flavones (found in some spices and yellow or orange fruits and vegetables) and anthocyanins (found in blueberries, blackberries, and cherries) seem to have most protective effect, the researchers report.

“There is mounting evidence suggesting flavonoids are powerhouses when it comes to preventing your thinking skills from declining as you get older,” study investigator Walter Willett, MD, DrPH, Harvard University, Boston, said in a statement.

“Our results are exciting because they show that making simple changes to your diet could help prevent cognitive decline,” said Dr. Willett.

The study was published online July 28 in the journal Neurology.
 

Antioxidant punch

Flavonoids, naturally occurring phytochemicals found in plants, are strong antioxidants. Considering the likely role of oxidative stress in age-related cognitive decline, flavonoids have been proposed as a potentially important preventive.  

For the study, Dr. Willett and colleagues prospectively examined associations between long-term dietary flavonoids (flavonols, flavones, flavanones, flavan-3-ols, anthocyanins, polymeric flavonoids, and proanthocyanidins) and subjective cognitive decline in 49,493 women from the Nurses’ Health Study (1984-2006) and 27,842 men from the Health Professionals Follow-up Study (1986-2002).

Those in the highest quintile of flavonoid consumption consumed about 600 mg daily on average while those in the lowest quintile got only about 150 mg daily.

After adjusting for age, total energy intake, major nondietary factors, and specific dietary factors, a higher intake of total flavonoids was associated with lower likelihood of self-reported subjective cognitive decline during follow up.

Individuals in the highest quintile of daily consumption had about a 20% lower risk of subjective cognitive decline relative to peers in the lowest quintile (pooled multivariable-adjusted odds ratio: 0.81; 95% confidence interval, 0.76-0.89).

The strongest protective associations were found for flavones (OR, 0.62; 95% confidence interval, 0.57-0.68), flavanones (OR, 0.64; 95% CI, 0.58-0.68), and anthocyanins (OR, 0.76; 95% CI, 0.72-0.84) (P trend < .0001 for all groups).

“The people in our study who did the best over time ate an average of at least half a serving per day of foods like orange juice, oranges, peppers, celery, grapefruits, grapefruit juice, apples, and pears,” Dr. Willett said.

“While it is possible other phytochemicals are at work here, a colorful diet rich in flavonoids – and specifically flavones and anthocyanins – seems to be a good bet for promoting long-term brain health,” he added.

A limitation of the study is that participants reported on their diets and may not recall perfectly what they ate or how much.
 

Healthy diet best bet for brain health

Reached for comment, Christopher Weber, PhD, director of global science initiatives for the Alzheimer’s Association, said this study “adds to our understanding of which elements of a healthy diet may be important in reducing dementia risk; flavonols may be one of those elements.”

“However, at this point, people should not put too much stock in specific nutrients – including subsets of flavonols – for reducing dementia risk until more research is done. Rather, they should focus on eating an overall healthy diet,” he said.

“It would be wonderful if a particular food or supplement could delay or prevent Alzheimer’s disease, but we do not have scientific evidence to support such claims. Randomized controlled clinical trials are necessary to evaluate whether any food or supplement has a scientifically proven beneficial effect,” Dr. Weber added.

For now, the Alzheimer’s Association “encourages everyone to eat a healthy and balanced diet as a way to help reduce the risk of cognitive decline,” Dr. Weber said.

“With more than 6 million Americans living with Alzheimer’s disease and other dementia today, there is a pressing need to test the effectiveness of a healthy lifestyle regimen to reduce risk of cognitive decline in a large and diverse population,” he added.

The Alzheimer’s Association has launched a 2-year clinical trial, called the U.S. Study to Protect Brain Health Through Lifestyle Intervention to Reduce Risk (U.S. POINTER), to do just that.

“While we research that definitive lifestyle ‘recipe,’ there are things we can do today that may decrease our risk of cognitive decline as we age. Eating a heart-healthy diet, exercising regularly, and staying cognitively engaged are just a few,” Dr. Weber added.

Also weighing in, Taylor Wallace, PhD, adjunct professor, department of nutrition and food studies, George Mason University, Fairfax, Va., said the study results are not surprising.

“Scientific data on the ability of flavonoids to prevent age-related chronic diseases, including cognitive decline, has accumulated immensely over the last decade. This epidemiological study reinforces findings from smaller shorter-duration clinical trials and mechanistic studies,” said Dr. Wallace, who was not involved in the study.

“Flavonoids show great potential in reducing inflammation and oxidative stress in the body. They are also vasodilators that help improve blood flow, which is important for the cardiovascular and cerebrovascular systems,” he noted.

“Typically, foods rich in flavonoids are also nutrient-dense in vitamins, minerals, and dietary fiber (eg, fruits and vegetables). Anthocyanins in blueberries have long been known to prevent cognitive decline with age,” Dr. Wallace said.

Dr. Wallace was part of a 14-member panel of nutrition scientists who recently reviewed available evidence around fruit and vegetable intake and health.

“Our findings are consistent with this study in regard to cognitive decline and other disease states. Cruciferous vegetables, dark-green leafy vegetables, citrus fruits, and dark-colored berries seem to have superior effects on health promotion and disease prevention in general,” said Dr. Wallace.

This work was supported by grants from the National Institutes of Health. The authors have disclosed no relevant financial relationships. Dr. Weber has no relevant disclosures. Dr. Wallace is principal and chief executive officer of the Think Healthy Group; editor of the Journal of Dietary Supplements; and deputy editor-in-chief of the Journal of the American College of Nutrition.

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

With the need to adapt to the given challenges associated with COVID-19, artificial intelligence (AI) serves as a potential tool in providing access to medical-based diagnosis in a novel way. Artificial intelligence is defined as intelligence harnessed by machines that have the ability to perform what is called cognitive thinking and to mimic the problem-solving abilities of the human mind. Virtual AI in dermatology entails neural network–based guidance that includes developing algorithms to detect skin pathology through photographs.¹ To use AI in dermatology, recognition of visual patterns must be established to give diagnoses. These neural networks have been used to classify skin diseases, including cancer, actinic keratosis, and warts.²

AI for Skin Cancer

The use of AI to classify melanoma and nonmelanoma skin cancer has been studied extensively, including the following 2 research projects.

Convolutional Neural Network
In 2017, Stanford University published a study in which a deep-learning algorithm known as a convolutional neural network was used to classify skin lesions.³ The network was trained using a dataset of 129,450 clinical images of 2032 diseases. Its performance was compared to that of 21 board-certified dermatologists on biopsy-proven clinical images with 2 classifications of cases: (1) keratinocyte carcinoma as opposed to benign seborrheic keratosis and (2) malignant melanoma as opposed to benign nevi—the first representing the most common skin cancers, and the second, the deadliest skin cancers. The study showed that the machine could accurately identify and classify skin cancers compared to the work of board-certified dermatologists. The study did not include demographic information, which limits its external validity.³

Dermoscopic Image Classification
A 2019 study by Brinker and colleagues⁴ showed the superiority of automated dermoscopic melanoma image classifications compared to the work of board-certified dermatologists. For the study, 804 biopsy-proven images of melanoma and nevi (1:1 ratio) were randomly presented to dermatologists for their evaluation and recommended treatment (yielding 19,296 recommendations). The dermatologists classified the lesions with a sensitivity of 67.2% and specificity of 62.2%; the trained convolutional neural network attained both higher sensitivity (82.3%) and higher specificity (77.9%).⁴

Smartphone Diagnosis of Melanoma

An application of AI has been to use smartphone apps for the diagnosis of melanoma. The most utilized and novel algorithm-based smartphone app that assesses skin lesions for malignancy characteristics is SkinVision. With a simple download from Apple’s App Store, this technology allows a person to check their skin spots by taking a photograph and receiving algorithmic risk-assessment feedback. This inexpensive software ($51.78 a year) also allows a patient’s physician to assess the photograph and then validate their assessment by comparing it with the algorithmic analysis that the program provides.⁵

A review of SkinVision conducted by Thissen and colleagues⁶ found that, in a hypothetical population of 1000 adults of whom 3% actually had melanoma, 4 of those 30 people would not have been flagged as at “high risk” by SkinVision. There also was a high false-positive rate with the app, with more than 200 people flagged as at high risk. The analysis pegged SkinVision as having a sensitivity of 88% and specificity of 79%.⁶

In summary, systematic review of diagnostic accuracy has shown that, although there is accuracy in AI analyses, it should be used only as a guide for health care advice due to variability in algorithm performance.⁷

Utility of AI in Telehealth

Artificial intelligence algorithms could be created to ensure telehealth image accuracy, stratify risk, and track patient progress. With teledermatology visits on the rise during the COVID-19 pandemic, AI algorithms could ensure that photographs of appropriate quality are taken. Also, patients could be organized by risk factors with such algorithms, allowing physicians to save time on triage and stratification. Algorithms also could be used to track a telehealth patient’s treatment and progress.⁸

Furthermore, there is a need for an algorithm that has the ability to detect, quantify, and monitor changes in dermatologic conditions using images that patients have uploaded. This capability will lead to creation of a standardized quantification scale that will allow physicians to virtually track the progression of visible skin pathologies.

Hazards of Racial Bias in AI

Artificial intelligence is limited by racial disparity bias seen in computerized medicine. For years, the majority of dermatology research, especially in skin cancer, has been conducted on fairer-skinned populations. This bias has existed at the expense of darker-skinned patients, whose skin conditions and symptoms present differently,⁹ and reflects directly in available data sets that can be used to develop AI algorithms. Because these data are inadequate to the task, AI might misdiagnose skin cancer in people of color or miss an existing condition entirely.¹⁰ Consequently, the higher rate of skin cancer mortality that is reported in people of color is likely to persist with the rise of AI in dermatology.¹¹ A more representative database of imaged skin lesions needs to be utilized to create a diversely representative and applicable data set for AI algorithms.¹²

Benefits of Conversational Agents

Another method by which AI could be incorporated into dermatology is through what is known as a conversational agent (CA)—AI software that engages in a dialogue with users by interpreting their voice and replying to them through text, image, or voice.¹³ Conversational agents facilitate remote patient management, allow clinicians to focus on other functions, and aid in data collection.¹⁴ A 2014 study showed that patients were significantly more likely to disclose history and emotions when informed they were interacting with a CA than with a human clinician (P=.007).¹⁵ Such benefits could be invaluable in dermatology, where emotions and patient perceptions of skin conditions play into the treatment process.

However, some evidence showed that CAs cannot respond to patients’ statements in all circumstances.¹⁶ It also is unclear how well CAs recognize nuanced statements that might signal potential harm. This fits into the greater theme of a major problem with AI: the lack of a reliable response in all circumstances.¹³

Final Thoughts

The practical implementations of AI in dermatology are still being explored. Given the uncertainty surrounding the COVID-19 pandemic and the future of patient care, AI might serve as an important asset in assisting with the diagnosis and treatment of dermatologic conditions, physician productivity, and patient monitoring.

With the need to adapt to the given challenges associated with COVID-19, artificial intelligence (AI) serves as a potential tool in providing access to medical-based diagnosis in a novel way. Artificial intelligence is defined as intelligence harnessed by machines that have the ability to perform what is called cognitive thinking and to mimic the problem-solving abilities of the human mind. Virtual AI in dermatology entails neural network–based guidance that includes developing algorithms to detect skin pathology through photographs.¹ To use AI in dermatology, recognition of visual patterns must be established to give diagnoses. These neural networks have been used to classify skin diseases, including cancer, actinic keratosis, and warts.²

AI for Skin Cancer

The use of AI to classify melanoma and nonmelanoma skin cancer has been studied extensively, including the following 2 research projects.

Convolutional Neural Network
In 2017, Stanford University published a study in which a deep-learning algorithm known as a convolutional neural network was used to classify skin lesions.³ The network was trained using a dataset of 129,450 clinical images of 2032 diseases. Its performance was compared to that of 21 board-certified dermatologists on biopsy-proven clinical images with 2 classifications of cases: (1) keratinocyte carcinoma as opposed to benign seborrheic keratosis and (2) malignant melanoma as opposed to benign nevi—the first representing the most common skin cancers, and the second, the deadliest skin cancers. The study showed that the machine could accurately identify and classify skin cancers compared to the work of board-certified dermatologists. The study did not include demographic information, which limits its external validity.³

Dermoscopic Image Classification
A 2019 study by Brinker and colleagues⁴ showed the superiority of automated dermoscopic melanoma image classifications compared to the work of board-certified dermatologists. For the study, 804 biopsy-proven images of melanoma and nevi (1:1 ratio) were randomly presented to dermatologists for their evaluation and recommended treatment (yielding 19,296 recommendations). The dermatologists classified the lesions with a sensitivity of 67.2% and specificity of 62.2%; the trained convolutional neural network attained both higher sensitivity (82.3%) and higher specificity (77.9%).⁴

Smartphone Diagnosis of Melanoma

An application of AI has been to use smartphone apps for the diagnosis of melanoma. The most utilized and novel algorithm-based smartphone app that assesses skin lesions for malignancy characteristics is SkinVision. With a simple download from Apple’s App Store, this technology allows a person to check their skin spots by taking a photograph and receiving algorithmic risk-assessment feedback. This inexpensive software ($51.78 a year) also allows a patient’s physician to assess the photograph and then validate their assessment by comparing it with the algorithmic analysis that the program provides.⁵

A review of SkinVision conducted by Thissen and colleagues⁶ found that, in a hypothetical population of 1000 adults of whom 3% actually had melanoma, 4 of those 30 people would not have been flagged as at “high risk” by SkinVision. There also was a high false-positive rate with the app, with more than 200 people flagged as at high risk. The analysis pegged SkinVision as having a sensitivity of 88% and specificity of 79%.⁶

In summary, systematic review of diagnostic accuracy has shown that, although there is accuracy in AI analyses, it should be used only as a guide for health care advice due to variability in algorithm performance.⁷

Utility of AI in Telehealth

Artificial intelligence algorithms could be created to ensure telehealth image accuracy, stratify risk, and track patient progress. With teledermatology visits on the rise during the COVID-19 pandemic, AI algorithms could ensure that photographs of appropriate quality are taken. Also, patients could be organized by risk factors with such algorithms, allowing physicians to save time on triage and stratification. Algorithms also could be used to track a telehealth patient’s treatment and progress.⁸

Furthermore, there is a need for an algorithm that has the ability to detect, quantify, and monitor changes in dermatologic conditions using images that patients have uploaded. This capability will lead to creation of a standardized quantification scale that will allow physicians to virtually track the progression of visible skin pathologies.

Hazards of Racial Bias in AI

Artificial intelligence is limited by racial disparity bias seen in computerized medicine. For years, the majority of dermatology research, especially in skin cancer, has been conducted on fairer-skinned populations. This bias has existed at the expense of darker-skinned patients, whose skin conditions and symptoms present differently,⁹ and reflects directly in available data sets that can be used to develop AI algorithms. Because these data are inadequate to the task, AI might misdiagnose skin cancer in people of color or miss an existing condition entirely.¹⁰ Consequently, the higher rate of skin cancer mortality that is reported in people of color is likely to persist with the rise of AI in dermatology.¹¹ A more representative database of imaged skin lesions needs to be utilized to create a diversely representative and applicable data set for AI algorithms.¹²

Benefits of Conversational Agents

Another method by which AI could be incorporated into dermatology is through what is known as a conversational agent (CA)—AI software that engages in a dialogue with users by interpreting their voice and replying to them through text, image, or voice.¹³ Conversational agents facilitate remote patient management, allow clinicians to focus on other functions, and aid in data collection.¹⁴ A 2014 study showed that patients were significantly more likely to disclose history and emotions when informed they were interacting with a CA than with a human clinician (P=.007).¹⁵ Such benefits could be invaluable in dermatology, where emotions and patient perceptions of skin conditions play into the treatment process.

However, some evidence showed that CAs cannot respond to patients’ statements in all circumstances.¹⁶ It also is unclear how well CAs recognize nuanced statements that might signal potential harm. This fits into the greater theme of a major problem with AI: the lack of a reliable response in all circumstances.¹³

Final Thoughts

The practical implementations of AI in dermatology are still being explored. Given the uncertainty surrounding the COVID-19 pandemic and the future of patient care, AI might serve as an important asset in assisting with the diagnosis and treatment of dermatologic conditions, physician productivity, and patient monitoring.

With the need to adapt to the given challenges associated with COVID-19, artificial intelligence (AI) serves as a potential tool in providing access to medical-based diagnosis in a novel way. Artificial intelligence is defined as intelligence harnessed by machines that have the ability to perform what is called cognitive thinking and to mimic the problem-solving abilities of the human mind. Virtual AI in dermatology entails neural network–based guidance that includes developing algorithms to detect skin pathology through photographs.¹ To use AI in dermatology, recognition of visual patterns must be established to give diagnoses. These neural networks have been used to classify skin diseases, including cancer, actinic keratosis, and warts.²

AI for Skin Cancer

The use of AI to classify melanoma and nonmelanoma skin cancer has been studied extensively, including the following 2 research projects.

Convolutional Neural Network
In 2017, Stanford University published a study in which a deep-learning algorithm known as a convolutional neural network was used to classify skin lesions.³ The network was trained using a dataset of 129,450 clinical images of 2032 diseases. Its performance was compared to that of 21 board-certified dermatologists on biopsy-proven clinical images with 2 classifications of cases: (1) keratinocyte carcinoma as opposed to benign seborrheic keratosis and (2) malignant melanoma as opposed to benign nevi—the first representing the most common skin cancers, and the second, the deadliest skin cancers. The study showed that the machine could accurately identify and classify skin cancers compared to the work of board-certified dermatologists. The study did not include demographic information, which limits its external validity.³

Dermoscopic Image Classification
A 2019 study by Brinker and colleagues⁴ showed the superiority of automated dermoscopic melanoma image classifications compared to the work of board-certified dermatologists. For the study, 804 biopsy-proven images of melanoma and nevi (1:1 ratio) were randomly presented to dermatologists for their evaluation and recommended treatment (yielding 19,296 recommendations). The dermatologists classified the lesions with a sensitivity of 67.2% and specificity of 62.2%; the trained convolutional neural network attained both higher sensitivity (82.3%) and higher specificity (77.9%).⁴

Smartphone Diagnosis of Melanoma

An application of AI has been to use smartphone apps for the diagnosis of melanoma. The most utilized and novel algorithm-based smartphone app that assesses skin lesions for malignancy characteristics is SkinVision. With a simple download from Apple’s App Store, this technology allows a person to check their skin spots by taking a photograph and receiving algorithmic risk-assessment feedback. This inexpensive software ($51.78 a year) also allows a patient’s physician to assess the photograph and then validate their assessment by comparing it with the algorithmic analysis that the program provides.⁵

A review of SkinVision conducted by Thissen and colleagues⁶ found that, in a hypothetical population of 1000 adults of whom 3% actually had melanoma, 4 of those 30 people would not have been flagged as at “high risk” by SkinVision. There also was a high false-positive rate with the app, with more than 200 people flagged as at high risk. The analysis pegged SkinVision as having a sensitivity of 88% and specificity of 79%.⁶

In summary, systematic review of diagnostic accuracy has shown that, although there is accuracy in AI analyses, it should be used only as a guide for health care advice due to variability in algorithm performance.⁷

Utility of AI in Telehealth

Artificial intelligence algorithms could be created to ensure telehealth image accuracy, stratify risk, and track patient progress. With teledermatology visits on the rise during the COVID-19 pandemic, AI algorithms could ensure that photographs of appropriate quality are taken. Also, patients could be organized by risk factors with such algorithms, allowing physicians to save time on triage and stratification. Algorithms also could be used to track a telehealth patient’s treatment and progress.⁸

Furthermore, there is a need for an algorithm that has the ability to detect, quantify, and monitor changes in dermatologic conditions using images that patients have uploaded. This capability will lead to creation of a standardized quantification scale that will allow physicians to virtually track the progression of visible skin pathologies.

Hazards of Racial Bias in AI

Artificial intelligence is limited by racial disparity bias seen in computerized medicine. For years, the majority of dermatology research, especially in skin cancer, has been conducted on fairer-skinned populations. This bias has existed at the expense of darker-skinned patients, whose skin conditions and symptoms present differently,⁹ and reflects directly in available data sets that can be used to develop AI algorithms. Because these data are inadequate to the task, AI might misdiagnose skin cancer in people of color or miss an existing condition entirely.¹⁰ Consequently, the higher rate of skin cancer mortality that is reported in people of color is likely to persist with the rise of AI in dermatology.¹¹ A more representative database of imaged skin lesions needs to be utilized to create a diversely representative and applicable data set for AI algorithms.¹²

Benefits of Conversational Agents

Another method by which AI could be incorporated into dermatology is through what is known as a conversational agent (CA)—AI software that engages in a dialogue with users by interpreting their voice and replying to them through text, image, or voice.¹³ Conversational agents facilitate remote patient management, allow clinicians to focus on other functions, and aid in data collection.¹⁴ A 2014 study showed that patients were significantly more likely to disclose history and emotions when informed they were interacting with a CA than with a human clinician (P=.007).¹⁵ Such benefits could be invaluable in dermatology, where emotions and patient perceptions of skin conditions play into the treatment process.

However, some evidence showed that CAs cannot respond to patients’ statements in all circumstances.¹⁶ It also is unclear how well CAs recognize nuanced statements that might signal potential harm. This fits into the greater theme of a major problem with AI: the lack of a reliable response in all circumstances.¹³

Final Thoughts

The practical implementations of AI in dermatology are still being explored. Given the uncertainty surrounding the COVID-19 pandemic and the future of patient care, AI might serve as an important asset in assisting with the diagnosis and treatment of dermatologic conditions, physician productivity, and patient monitoring.