Here are the stories our MDedge editors across specialties think you need to know about today:

Long road to recovery includes lung rehab

For seriously ill COVID-19 patients, there may a long recovery period even after leaving the intensive care unit. Eladio (“Lad”) Braganza, age 77, is one of those patients. For 28 days, he was on a ventilator in a Seattle ICU. Now – after a 46-day hospitalization for SARS-CoV-2 infection – he’s making progress in inpatient rehab. “The vast majority of COVID patients in the ICU have lung disease that is quite severe, much more severe than I have seen in my 20 years of doing this,” said critical care specialist Anna Nolan, MD, of the department of medicine at New York University. READ MORE.

Detox unit keeps running during COVID-19

Substance use disorder doesn’t take a break for a pandemic. In fact, the stressors from the current COVID-19 situation have increased substance use. In a commentary published on MDedge, Keji Fagbemi, MD, a hospitalist at the BronxCare Health System, shared how his hospital kept its inpatient detoxification unit running, despite the challenges presented by COVID-19. “At a time when many inpatient detoxification units within the city were temporarily closed due to fear of inpatient spread of the virus or to provide extra COVID beds in anticipation for the peak surge, we have been able to provide a needed service,” he wrote. “In fact, several other inpatient detoxification programs within the city have been able to refer their patients to our facility.” READ MORE.

Air pollution linked to MS risk

Air pollution may be another environmental risk factor for developing multiple sclerosis, suggests new research released as part of the Congress of the European Academy of Neurology (EAN) 2020. The findings, which are based on a large cohort study of nearly 550,000 individuals in Italy, appear to confirm the relationship between exposure to air pollutants and risk for MS that has been shown in prior studies. “Countermeasures that cut air pollution can be important for public health, not only to reduce deaths related to cardiac and pulmonary diseases but also the risk of chronic autoimmune diseases such as MS,” said Roberto Bergamaschi, MD, PhD, director of the Multiple Sclerosis Center, IRCCS Mondino Foundation, Pavia, Italy. READ MORE.
 

Trials produce conflicting results in Alzheimer’s disease

High-dose aducanumab, a human monoclonal antibody in development for the treatment of Alzheimer’s disease, significantly reduced clinical decline in people with early disease in one randomized, placebo-controlled phase 3 study. But there was no statistically significant change in outcomes in an identical study. “We believe that the difference between the results was largely due to patients’ greater exposure to the high dose of aducanumab,” said Samantha Budd Haeberlein, PhD, one of the study investigators and senior vice president and head of the neurodegeneration development unit at Biogen, which is developing the drug. READ MORE.

Pregnant patients have asymptomatic SARS-CoV-2 infection

The rate of asymptomatic SARS-CoV-2 infection was 16% among women with a planned delivery in a New York City health system during the first half of April, according to recent study results. “If universal testing of pregnant patients in a high prevalence area is not performed, health care workers will be inadvertently exposed to COVID-19, unless universal precautions with personal protective equipment are taken,” researchers wrote in Obstetrics & Gynecology. READ MORE.

For more on COVID-19, visit our Resource Center. All of our latest news is available on MDedge.com.

Here are the stories our MDedge editors across specialties think you need to know about today:

Long road to recovery includes lung rehab

For seriously ill COVID-19 patients, there may a long recovery period even after leaving the intensive care unit. Eladio (“Lad”) Braganza, age 77, is one of those patients. For 28 days, he was on a ventilator in a Seattle ICU. Now – after a 46-day hospitalization for SARS-CoV-2 infection – he’s making progress in inpatient rehab. “The vast majority of COVID patients in the ICU have lung disease that is quite severe, much more severe than I have seen in my 20 years of doing this,” said critical care specialist Anna Nolan, MD, of the department of medicine at New York University. READ MORE.

Detox unit keeps running during COVID-19

Substance use disorder doesn’t take a break for a pandemic. In fact, the stressors from the current COVID-19 situation have increased substance use. In a commentary published on MDedge, Keji Fagbemi, MD, a hospitalist at the BronxCare Health System, shared how his hospital kept its inpatient detoxification unit running, despite the challenges presented by COVID-19. “At a time when many inpatient detoxification units within the city were temporarily closed due to fear of inpatient spread of the virus or to provide extra COVID beds in anticipation for the peak surge, we have been able to provide a needed service,” he wrote. “In fact, several other inpatient detoxification programs within the city have been able to refer their patients to our facility.” READ MORE.

Air pollution linked to MS risk

Air pollution may be another environmental risk factor for developing multiple sclerosis, suggests new research released as part of the Congress of the European Academy of Neurology (EAN) 2020. The findings, which are based on a large cohort study of nearly 550,000 individuals in Italy, appear to confirm the relationship between exposure to air pollutants and risk for MS that has been shown in prior studies. “Countermeasures that cut air pollution can be important for public health, not only to reduce deaths related to cardiac and pulmonary diseases but also the risk of chronic autoimmune diseases such as MS,” said Roberto Bergamaschi, MD, PhD, director of the Multiple Sclerosis Center, IRCCS Mondino Foundation, Pavia, Italy. READ MORE.
 

Trials produce conflicting results in Alzheimer’s disease

High-dose aducanumab, a human monoclonal antibody in development for the treatment of Alzheimer’s disease, significantly reduced clinical decline in people with early disease in one randomized, placebo-controlled phase 3 study. But there was no statistically significant change in outcomes in an identical study. “We believe that the difference between the results was largely due to patients’ greater exposure to the high dose of aducanumab,” said Samantha Budd Haeberlein, PhD, one of the study investigators and senior vice president and head of the neurodegeneration development unit at Biogen, which is developing the drug. READ MORE.

Pregnant patients have asymptomatic SARS-CoV-2 infection

The rate of asymptomatic SARS-CoV-2 infection was 16% among women with a planned delivery in a New York City health system during the first half of April, according to recent study results. “If universal testing of pregnant patients in a high prevalence area is not performed, health care workers will be inadvertently exposed to COVID-19, unless universal precautions with personal protective equipment are taken,” researchers wrote in Obstetrics & Gynecology. READ MORE.

For more on COVID-19, visit our Resource Center. All of our latest news is available on MDedge.com.

Here are the stories our MDedge editors across specialties think you need to know about today:

Long road to recovery includes lung rehab

For seriously ill COVID-19 patients, there may a long recovery period even after leaving the intensive care unit. Eladio (“Lad”) Braganza, age 77, is one of those patients. For 28 days, he was on a ventilator in a Seattle ICU. Now – after a 46-day hospitalization for SARS-CoV-2 infection – he’s making progress in inpatient rehab. “The vast majority of COVID patients in the ICU have lung disease that is quite severe, much more severe than I have seen in my 20 years of doing this,” said critical care specialist Anna Nolan, MD, of the department of medicine at New York University. READ MORE.

Detox unit keeps running during COVID-19

Substance use disorder doesn’t take a break for a pandemic. In fact, the stressors from the current COVID-19 situation have increased substance use. In a commentary published on MDedge, Keji Fagbemi, MD, a hospitalist at the BronxCare Health System, shared how his hospital kept its inpatient detoxification unit running, despite the challenges presented by COVID-19. “At a time when many inpatient detoxification units within the city were temporarily closed due to fear of inpatient spread of the virus or to provide extra COVID beds in anticipation for the peak surge, we have been able to provide a needed service,” he wrote. “In fact, several other inpatient detoxification programs within the city have been able to refer their patients to our facility.” READ MORE.

Air pollution linked to MS risk

Air pollution may be another environmental risk factor for developing multiple sclerosis, suggests new research released as part of the Congress of the European Academy of Neurology (EAN) 2020. The findings, which are based on a large cohort study of nearly 550,000 individuals in Italy, appear to confirm the relationship between exposure to air pollutants and risk for MS that has been shown in prior studies. “Countermeasures that cut air pollution can be important for public health, not only to reduce deaths related to cardiac and pulmonary diseases but also the risk of chronic autoimmune diseases such as MS,” said Roberto Bergamaschi, MD, PhD, director of the Multiple Sclerosis Center, IRCCS Mondino Foundation, Pavia, Italy. READ MORE.
 

Trials produce conflicting results in Alzheimer’s disease

High-dose aducanumab, a human monoclonal antibody in development for the treatment of Alzheimer’s disease, significantly reduced clinical decline in people with early disease in one randomized, placebo-controlled phase 3 study. But there was no statistically significant change in outcomes in an identical study. “We believe that the difference between the results was largely due to patients’ greater exposure to the high dose of aducanumab,” said Samantha Budd Haeberlein, PhD, one of the study investigators and senior vice president and head of the neurodegeneration development unit at Biogen, which is developing the drug. READ MORE.

Pregnant patients have asymptomatic SARS-CoV-2 infection

The rate of asymptomatic SARS-CoV-2 infection was 16% among women with a planned delivery in a New York City health system during the first half of April, according to recent study results. “If universal testing of pregnant patients in a high prevalence area is not performed, health care workers will be inadvertently exposed to COVID-19, unless universal precautions with personal protective equipment are taken,” researchers wrote in Obstetrics & Gynecology. READ MORE.

For more on COVID-19, visit our Resource Center. All of our latest news is available on MDedge.com.

AGA just released GI Distance Learning, agau.gastro.org/diweb/catalog/q/GI-Distance-Learning, a new initiative providing AGA trainee members and medical residents a complementary set of curated education and career development resources available online. A part of AGA University, GI Distance Learning enables you to enhance your knowledge in a number of GI-related topics at your own pace from the comfort of home.

Through GI Distance Learning, you will have free access until Aug. 1 to the 800+ questions and answers included in the DDSEP^® 9 Question Bank. Assess your knowledge, identify gaps in learning, and stay current on the latest advances in GI and liver disease.

To access the Question Bank free of charge:

• Visit AGA University and sign in to your AGA account.
• Go to the DDSEP 9 Question Bank.
• Add the Question Bank to your Cart and Checkout.
• Type DDSEP9Distance in the Discount Code box.
• Apply the discount and submit your order.
• Use the My Courses link to access the Question Bank.

During the COVID-19 pandemic, many of us are struggling with the new normal and changes in our daily routines. Resiliency, emotional intelligence, and strategies for combatting burnout become increasingly important. The following on-demand resources from GI Distance Learning can help.

• Resilient Leadership
• Emotional Intelligence
• Strategies to Combat Burnout in GI and Maintaining Work/Life Balance

Continue to check back regularly at AGA University as we will continue to add resources to GI Distance Learning in the coming weeks.

ginews@gastro.org

AGA just released GI Distance Learning, agau.gastro.org/diweb/catalog/q/GI-Distance-Learning, a new initiative providing AGA trainee members and medical residents a complementary set of curated education and career development resources available online. A part of AGA University, GI Distance Learning enables you to enhance your knowledge in a number of GI-related topics at your own pace from the comfort of home.

Through GI Distance Learning, you will have free access until Aug. 1 to the 800+ questions and answers included in the DDSEP^® 9 Question Bank. Assess your knowledge, identify gaps in learning, and stay current on the latest advances in GI and liver disease.

To access the Question Bank free of charge:

• Visit AGA University and sign in to your AGA account.
• Go to the DDSEP 9 Question Bank.
• Add the Question Bank to your Cart and Checkout.
• Type DDSEP9Distance in the Discount Code box.
• Apply the discount and submit your order.
• Use the My Courses link to access the Question Bank.

During the COVID-19 pandemic, many of us are struggling with the new normal and changes in our daily routines. Resiliency, emotional intelligence, and strategies for combatting burnout become increasingly important. The following on-demand resources from GI Distance Learning can help.

• Resilient Leadership
• Emotional Intelligence
• Strategies to Combat Burnout in GI and Maintaining Work/Life Balance

Continue to check back regularly at AGA University as we will continue to add resources to GI Distance Learning in the coming weeks.

ginews@gastro.org

AGA just released GI Distance Learning, agau.gastro.org/diweb/catalog/q/GI-Distance-Learning, a new initiative providing AGA trainee members and medical residents a complementary set of curated education and career development resources available online. A part of AGA University, GI Distance Learning enables you to enhance your knowledge in a number of GI-related topics at your own pace from the comfort of home.

Through GI Distance Learning, you will have free access until Aug. 1 to the 800+ questions and answers included in the DDSEP^® 9 Question Bank. Assess your knowledge, identify gaps in learning, and stay current on the latest advances in GI and liver disease.

To access the Question Bank free of charge:

• Visit AGA University and sign in to your AGA account.
• Go to the DDSEP 9 Question Bank.
• Add the Question Bank to your Cart and Checkout.
• Type DDSEP9Distance in the Discount Code box.
• Apply the discount and submit your order.
• Use the My Courses link to access the Question Bank.

During the COVID-19 pandemic, many of us are struggling with the new normal and changes in our daily routines. Resiliency, emotional intelligence, and strategies for combatting burnout become increasingly important. The following on-demand resources from GI Distance Learning can help.

• Resilient Leadership
• Emotional Intelligence
• Strategies to Combat Burnout in GI and Maintaining Work/Life Balance

Continue to check back regularly at AGA University as we will continue to add resources to GI Distance Learning in the coming weeks.

ginews@gastro.org

Patients with relapsing multiple sclerosis (MS) who switch from treatment with the highly effective disease-modifying therapy natalizumab to a moderate-efficacy DMT show an increased risk of disability accumulation and disease activity over 2 years compared with switching to another highly effective DMT, new research shows.

“Owing to the vast number of available DMTs, not only understanding DMT performance but answering the question of what can come next if a patient needs to discontinue treatment due to safety or breakthrough disease is important,” said lead author Carrie M. Hersh, DO, of the Lou Ruvo Center for Brain Health, Cleveland Clinic, Las Vegas.

The study shows that, “patients transitioning from natalizumab to another high-efficacy therapy have better inflammatory and disability outcomes compared with those who de-escalate their therapy to a moderate-efficacy DMT,” she said.

Natalizumab (Tysabri) offers significant benefits in the treatment of relapsing forms of MS, however, its long-term use is associated with safety concerns, notably an increased risk of progressive multifocal leukoencephalopathy (PML). Although the risk can be reduced with a switch to a different DMT, the transition can have risks of its own, including a rebound of disease activity that could prove to be worse than the pre-natalizumab treatment period, and there is a lack of consensus on the safest avenues for switching to another DMT following discontinuation of natalizumab.

In research presented at the virtual meeting of the Consortium of Multiple Sclerosis Centers, Dr. Hersh and colleagues explored the issue in a real-world population of 556 patients discontinuing natalizumab at two MS centers. Of these, 270 switched to a moderate DMT (dimethyl fumarate, n = 130; or fingolimod, n = 140) and 130 switched to a highly effective DMT (ocrelizumab, n = 106; rituximab, n = 17; or alemtuzumab, n = 7).

Reasons for switching included a PML risk for 54.9%, breakthrough disease for 15.3%, and adverse effects for 17.3%.

At 24-month follow-up after the switch and after adjustment for propensity score matching, no differences were seen between the moderate and highly effective DMT groups in terms of the annualized relapse rate (ARR; P = 0.33) or the time to first relapse (P = 0.09).

However, significantly higher proportions of patients switching to moderate DMTs showed new T2 lesions (odds ratio, 2.15; P = .01), as well as new gadolinium-enhancing lesions (OR, 1.99; P = .02), and a 20% worsening of the timed 25-foot walk test (T25FW; OR, 1.83; P = .04) and 9-hole peg test (9-HPT; OR, 1.81; P = .04)

Those switching to moderate DMTs also had significantly lower rates of absence of disease activity over the 24 months (OR, 0.41, P = .004), and they had a higher risk of earlier time-to-first gadolinium-enhancing lesion (hazard ratio, 6.67, P = .002), compared with those switching to a high-efficacy DMT.

Other factors that have previously been shown to be associated with rebounds that are worse than pre-natalizumab treatment include washout periods that are longer than 3 months.

The authors noted that there were no significant differences between the groups in terms of mean washout duration, which were relatively short (moderate DMT, 1.4 months; highly effective treatment, 1.8 months; P = .34), In addition, there were no significant differences between the groups in terms of the average duration of natalizumab treatment.

Dr. Hersh speculated that the lack of ARR differences may reflect that the measure is not as objective as the more specific determinants of performance. “One could consider the comparable ARR as a little surprising, but relapse evaluation in a retrospective manner is limited,” she explained.

“Historically, radiographic markers of new inflammation via brain magnetic resonance imaging (MRI) and neuroperformance measures (T25FW and 9-HPT) are more objective compared to assessing clinical relapses, especially in a retrospective cohort where relapses cannot be validated by a central agency or the principal investigator. Therefore, one can surmise that patients transitioning from natalizumab to another high-efficacy DMT fare better than de-escalating treatment to a moderate-efficacy DMT.”

Dr. Hersh and team plan a larger, multicenter study to investigate the short- and long-term effects of post-natalizumab DMT sequencing to help validate the current findings.

Commenting on the research, Stephen Kamin, MD, professor, vice chair and chief of service, department of neurology, New Jersey Medical School, Newark, said the results are consistent with natalizumab’s general profile.

“In general, natalizumab has been used in patients with highly active disease, so I would expect fewer patients with no evidence of disease activity when switched to a moderately active drug rather than a highly active one,” he said in an interview.

Caveats of the findings include the trial’s observational nature, meaning potential confounding factors of baseline characteristics among patients who switched regimens are not known, noted Dr. Kamin, who was not involved with the study.

“Also, the patients were switched to a variety of drugs and even within a class there may be differences in outcome,” he explained.

Dr. Hersh reported consulting or research relationships with Biogen, Genentech, EMD Serono, Genzyme, Novartis, and PCORI. Dr. Kamin has received research support from Biogen, Novartis, and the Consortium of Multiple Sclerosis Centers.

This article first appeared on Medscape.com.

Patients with relapsing multiple sclerosis (MS) who switch from treatment with the highly effective disease-modifying therapy natalizumab to a moderate-efficacy DMT show an increased risk of disability accumulation and disease activity over 2 years compared with switching to another highly effective DMT, new research shows.

“Owing to the vast number of available DMTs, not only understanding DMT performance but answering the question of what can come next if a patient needs to discontinue treatment due to safety or breakthrough disease is important,” said lead author Carrie M. Hersh, DO, of the Lou Ruvo Center for Brain Health, Cleveland Clinic, Las Vegas.

The study shows that, “patients transitioning from natalizumab to another high-efficacy therapy have better inflammatory and disability outcomes compared with those who de-escalate their therapy to a moderate-efficacy DMT,” she said.

Natalizumab (Tysabri) offers significant benefits in the treatment of relapsing forms of MS, however, its long-term use is associated with safety concerns, notably an increased risk of progressive multifocal leukoencephalopathy (PML). Although the risk can be reduced with a switch to a different DMT, the transition can have risks of its own, including a rebound of disease activity that could prove to be worse than the pre-natalizumab treatment period, and there is a lack of consensus on the safest avenues for switching to another DMT following discontinuation of natalizumab.

In research presented at the virtual meeting of the Consortium of Multiple Sclerosis Centers, Dr. Hersh and colleagues explored the issue in a real-world population of 556 patients discontinuing natalizumab at two MS centers. Of these, 270 switched to a moderate DMT (dimethyl fumarate, n = 130; or fingolimod, n = 140) and 130 switched to a highly effective DMT (ocrelizumab, n = 106; rituximab, n = 17; or alemtuzumab, n = 7).

Reasons for switching included a PML risk for 54.9%, breakthrough disease for 15.3%, and adverse effects for 17.3%.

At 24-month follow-up after the switch and after adjustment for propensity score matching, no differences were seen between the moderate and highly effective DMT groups in terms of the annualized relapse rate (ARR; P = 0.33) or the time to first relapse (P = 0.09).

However, significantly higher proportions of patients switching to moderate DMTs showed new T2 lesions (odds ratio, 2.15; P = .01), as well as new gadolinium-enhancing lesions (OR, 1.99; P = .02), and a 20% worsening of the timed 25-foot walk test (T25FW; OR, 1.83; P = .04) and 9-hole peg test (9-HPT; OR, 1.81; P = .04)

Those switching to moderate DMTs also had significantly lower rates of absence of disease activity over the 24 months (OR, 0.41, P = .004), and they had a higher risk of earlier time-to-first gadolinium-enhancing lesion (hazard ratio, 6.67, P = .002), compared with those switching to a high-efficacy DMT.

Other factors that have previously been shown to be associated with rebounds that are worse than pre-natalizumab treatment include washout periods that are longer than 3 months.

The authors noted that there were no significant differences between the groups in terms of mean washout duration, which were relatively short (moderate DMT, 1.4 months; highly effective treatment, 1.8 months; P = .34), In addition, there were no significant differences between the groups in terms of the average duration of natalizumab treatment.

Dr. Hersh speculated that the lack of ARR differences may reflect that the measure is not as objective as the more specific determinants of performance. “One could consider the comparable ARR as a little surprising, but relapse evaluation in a retrospective manner is limited,” she explained.

“Historically, radiographic markers of new inflammation via brain magnetic resonance imaging (MRI) and neuroperformance measures (T25FW and 9-HPT) are more objective compared to assessing clinical relapses, especially in a retrospective cohort where relapses cannot be validated by a central agency or the principal investigator. Therefore, one can surmise that patients transitioning from natalizumab to another high-efficacy DMT fare better than de-escalating treatment to a moderate-efficacy DMT.”

Dr. Hersh and team plan a larger, multicenter study to investigate the short- and long-term effects of post-natalizumab DMT sequencing to help validate the current findings.

Commenting on the research, Stephen Kamin, MD, professor, vice chair and chief of service, department of neurology, New Jersey Medical School, Newark, said the results are consistent with natalizumab’s general profile.

“In general, natalizumab has been used in patients with highly active disease, so I would expect fewer patients with no evidence of disease activity when switched to a moderately active drug rather than a highly active one,” he said in an interview.

Caveats of the findings include the trial’s observational nature, meaning potential confounding factors of baseline characteristics among patients who switched regimens are not known, noted Dr. Kamin, who was not involved with the study.

“Also, the patients were switched to a variety of drugs and even within a class there may be differences in outcome,” he explained.

Dr. Hersh reported consulting or research relationships with Biogen, Genentech, EMD Serono, Genzyme, Novartis, and PCORI. Dr. Kamin has received research support from Biogen, Novartis, and the Consortium of Multiple Sclerosis Centers.

This article first appeared on Medscape.com.

Patients with relapsing multiple sclerosis (MS) who switch from treatment with the highly effective disease-modifying therapy natalizumab to a moderate-efficacy DMT show an increased risk of disability accumulation and disease activity over 2 years compared with switching to another highly effective DMT, new research shows.

“Owing to the vast number of available DMTs, not only understanding DMT performance but answering the question of what can come next if a patient needs to discontinue treatment due to safety or breakthrough disease is important,” said lead author Carrie M. Hersh, DO, of the Lou Ruvo Center for Brain Health, Cleveland Clinic, Las Vegas.

The study shows that, “patients transitioning from natalizumab to another high-efficacy therapy have better inflammatory and disability outcomes compared with those who de-escalate their therapy to a moderate-efficacy DMT,” she said.

Natalizumab (Tysabri) offers significant benefits in the treatment of relapsing forms of MS, however, its long-term use is associated with safety concerns, notably an increased risk of progressive multifocal leukoencephalopathy (PML). Although the risk can be reduced with a switch to a different DMT, the transition can have risks of its own, including a rebound of disease activity that could prove to be worse than the pre-natalizumab treatment period, and there is a lack of consensus on the safest avenues for switching to another DMT following discontinuation of natalizumab.

In research presented at the virtual meeting of the Consortium of Multiple Sclerosis Centers, Dr. Hersh and colleagues explored the issue in a real-world population of 556 patients discontinuing natalizumab at two MS centers. Of these, 270 switched to a moderate DMT (dimethyl fumarate, n = 130; or fingolimod, n = 140) and 130 switched to a highly effective DMT (ocrelizumab, n = 106; rituximab, n = 17; or alemtuzumab, n = 7).

Reasons for switching included a PML risk for 54.9%, breakthrough disease for 15.3%, and adverse effects for 17.3%.

At 24-month follow-up after the switch and after adjustment for propensity score matching, no differences were seen between the moderate and highly effective DMT groups in terms of the annualized relapse rate (ARR; P = 0.33) or the time to first relapse (P = 0.09).

However, significantly higher proportions of patients switching to moderate DMTs showed new T2 lesions (odds ratio, 2.15; P = .01), as well as new gadolinium-enhancing lesions (OR, 1.99; P = .02), and a 20% worsening of the timed 25-foot walk test (T25FW; OR, 1.83; P = .04) and 9-hole peg test (9-HPT; OR, 1.81; P = .04)

Those switching to moderate DMTs also had significantly lower rates of absence of disease activity over the 24 months (OR, 0.41, P = .004), and they had a higher risk of earlier time-to-first gadolinium-enhancing lesion (hazard ratio, 6.67, P = .002), compared with those switching to a high-efficacy DMT.

Other factors that have previously been shown to be associated with rebounds that are worse than pre-natalizumab treatment include washout periods that are longer than 3 months.

The authors noted that there were no significant differences between the groups in terms of mean washout duration, which were relatively short (moderate DMT, 1.4 months; highly effective treatment, 1.8 months; P = .34), In addition, there were no significant differences between the groups in terms of the average duration of natalizumab treatment.

Dr. Hersh speculated that the lack of ARR differences may reflect that the measure is not as objective as the more specific determinants of performance. “One could consider the comparable ARR as a little surprising, but relapse evaluation in a retrospective manner is limited,” she explained.

“Historically, radiographic markers of new inflammation via brain magnetic resonance imaging (MRI) and neuroperformance measures (T25FW and 9-HPT) are more objective compared to assessing clinical relapses, especially in a retrospective cohort where relapses cannot be validated by a central agency or the principal investigator. Therefore, one can surmise that patients transitioning from natalizumab to another high-efficacy DMT fare better than de-escalating treatment to a moderate-efficacy DMT.”

Dr. Hersh and team plan a larger, multicenter study to investigate the short- and long-term effects of post-natalizumab DMT sequencing to help validate the current findings.

Commenting on the research, Stephen Kamin, MD, professor, vice chair and chief of service, department of neurology, New Jersey Medical School, Newark, said the results are consistent with natalizumab’s general profile.

“In general, natalizumab has been used in patients with highly active disease, so I would expect fewer patients with no evidence of disease activity when switched to a moderately active drug rather than a highly active one,” he said in an interview.

Caveats of the findings include the trial’s observational nature, meaning potential confounding factors of baseline characteristics among patients who switched regimens are not known, noted Dr. Kamin, who was not involved with the study.

“Also, the patients were switched to a variety of drugs and even within a class there may be differences in outcome,” he explained.

Dr. Hersh reported consulting or research relationships with Biogen, Genentech, EMD Serono, Genzyme, Novartis, and PCORI. Dr. Kamin has received research support from Biogen, Novartis, and the Consortium of Multiple Sclerosis Centers.

This article first appeared on Medscape.com.

Air pollution may be another environmental risk factor for developing multiple sclerosis (MS), new research suggests. A large cohort study of almost 550,000 individuals living in Italy showed that participants living in areas with high levels of pollutants had a significantly greater risk of developing MS than those who lived in areas with low levels of pollutants.

The findings further confirm a relationship between exposure to air pollutants and risk for MS that has been shown in previous research, said Roberto Bergamaschi, MD, PhD, director of the Multiple Sclerosis Center, IRCCS Mondino Foundation, Pavia, Italy.

“Countermeasures that cut air pollution can be important for public health, not only to reduce deaths related to cardiac and pulmonary diseases but also the risk of chronic autoimmune diseases such as MS,” Dr. Bergamaschi said.

The findings were presented at the Congress of the European Academy of Neurology (EAN) 2020, which transitioned to a virtual/online meeting because of the COVID-19 pandemic.
 

Toxic pollutants

Several environmental factors may trigger an abnormal immune response that manifests in MS. The most studied of these are low vitamin D level, cigarette smoking, and an unhealthy diet, Dr. Bergamaschi said. However, “other environmental factors deserve to be studied—pollution included,” he added.

Among the most toxic air pollutants are particulate matter (PM), which is a mixture of fine solid and liquid particles suspended in the earth’s atmosphere. PM may range from 2.5 microns (PM_2.5) to 10 microns (PM₁₀) in diameter.

The main sources of such pollutants are household and commercial heating (53%) and industrial activities (17%), followed by road vehicle and non–road vehicle use, agriculture, and electricity production.

The World Health Organization estimates that more than 3.2 million individuals worldwide die prematurely every year because of lung cancer, cardiovascular disease, and other diseases related to air pollutants, said Dr. Bergamaschi.

Epidemiologic research has uncovered a relationship between air pollution and MS. A large American study published in 2008 in Science of the Total Environment showed a significant association between MS prevalence and PM₁₀ levels (P < 0.001). Other studies have shown an increase in the number of clinical relapses of MS that were linked to air pollution.

The current investigators assessed the association between PM_2.5 levels and MS prevalence in the northern province of Pavia, which has a population of 547,251 individuals in 188 municipalities.
 

Peculiar features

Pavia is situated in a flat territory that encompasses the highly industrialized regions of Piedmont, Lombardy, Emilia-Romagna, and Veneto. It has a high level of anthropogenic emissions, or environmental pollutants, originating from human activity, Dr. Bergamaschi reported. The region also has “peculiar” geographical features that “favor the accumulation of pollutants,” such as the natural barrier of the Alps in the north and low wind speed, he said.

The researchers identified 927 individuals with MS (315 male and 612 female) in the province. The overall MS prevalence rate was 169.4 per 100,000 population (95% confidence interval [CI], 158.8 – 180.6), which is 10-fold higher than 50 years ago, Dr. Bergamaschi said. In addition, this MS prevalence is higher than that in the United States, which is about 150 per 100,000 population.

Using sophisticated Bayesian disease mapping, the investigators looked for clusters of MS. They also gathered emission data for PM_2.5 from 2010 to 2017 from the European Monitoring and Evaluation Programme database. They then divided the region on the basis of average winter concentrations of PM_2.5.

Three distinct lateral areas of air pollution were identified. The more northern region, which includes the large urban center of Milan, had the highest level of air pollution. Concentrations decreased the further south the investigators looked.

After adjusting for age, urbanization (population density), and deprivation index, results showed that living in areas with high levels of pollutants was associated with increased MS risk. When controlling for PM_2.5 pollution, participants in urban areas had an increased risk for MS compared with rural dwellers (relative risk [RR], 1.16; 95% CI, 1.04 – 1.30; P = 0.003)

Dr. Bergamaschi said it is unclear whether this risk is higher for certain types of MS. “To my knowledge, no study has analyzed possible relationships between MS phenotypes and air pollution,” he noted.
 

Vitamin D’s role?

Several mechanisms might help explain the relationship between air pollution and MS risk, he added. These include oxidative stress, which results in cell damage, inflammation, and proinflammatory cytokine release. Vitamin D also likely plays some role, Dr. Bergamaschi said. Upon penetrating the lower strata of the earth’s atmosphere, ultraviolet B radiation is absorbed and scattered by suspended pollutants.

Several studies have highlighted the correlation between living in a polluted area and vitamin D hypovitaminosis; “so air pollution can contribute to increasing the risk of MS by reducing vitamin D synthesis,” he said.

Recent research has also shown that air pollution is associated with a higher risk for other autoimmune disorders, including systemic lupus erythematosus, rheumatoid arthritis, and type 1 diabetes mellitus.

However, pollution alone is only part of the picture. MS prevalence in highly populated and polluted countries such as China and India is low, with no more than 30 to 40 cases per 100,000 population, Dr. Bergamaschi noted. “This discrepancy is explained by different genetic backgrounds. While Caucasians are particularly susceptible to MS, Asians are not,” he said.

Study limitations cited included a possible bias because the analysis did not include other possible contributing risk factors, particularly other pollutants, Dr. Bergamaschi said.

Commenting on the research, Lily Jung Henson, MD, chief of neurology at Piedmont Healthcare in Stockbridge, Georgia, said the findings provide “a fascinating glimpse” into possible causative factors for MS and warrant further investigation.

“This research also suggests other opportunities to look at, such as progression of the degree of air pollution and the incidence of MS over time,” said Dr. Henson, who was not involved with the study.

Drs. Bergamaschi and Dr. Henson have reported no relevant financial relationships.

This article first appeared on Medscape.com.

Air pollution may be another environmental risk factor for developing multiple sclerosis (MS), new research suggests. A large cohort study of almost 550,000 individuals living in Italy showed that participants living in areas with high levels of pollutants had a significantly greater risk of developing MS than those who lived in areas with low levels of pollutants.

The findings further confirm a relationship between exposure to air pollutants and risk for MS that has been shown in previous research, said Roberto Bergamaschi, MD, PhD, director of the Multiple Sclerosis Center, IRCCS Mondino Foundation, Pavia, Italy.

“Countermeasures that cut air pollution can be important for public health, not only to reduce deaths related to cardiac and pulmonary diseases but also the risk of chronic autoimmune diseases such as MS,” Dr. Bergamaschi said.

The findings were presented at the Congress of the European Academy of Neurology (EAN) 2020, which transitioned to a virtual/online meeting because of the COVID-19 pandemic.
 

Toxic pollutants

Several environmental factors may trigger an abnormal immune response that manifests in MS. The most studied of these are low vitamin D level, cigarette smoking, and an unhealthy diet, Dr. Bergamaschi said. However, “other environmental factors deserve to be studied—pollution included,” he added.

Among the most toxic air pollutants are particulate matter (PM), which is a mixture of fine solid and liquid particles suspended in the earth’s atmosphere. PM may range from 2.5 microns (PM_2.5) to 10 microns (PM₁₀) in diameter.

The main sources of such pollutants are household and commercial heating (53%) and industrial activities (17%), followed by road vehicle and non–road vehicle use, agriculture, and electricity production.

The World Health Organization estimates that more than 3.2 million individuals worldwide die prematurely every year because of lung cancer, cardiovascular disease, and other diseases related to air pollutants, said Dr. Bergamaschi.

Epidemiologic research has uncovered a relationship between air pollution and MS. A large American study published in 2008 in Science of the Total Environment showed a significant association between MS prevalence and PM₁₀ levels (P < 0.001). Other studies have shown an increase in the number of clinical relapses of MS that were linked to air pollution.

The current investigators assessed the association between PM_2.5 levels and MS prevalence in the northern province of Pavia, which has a population of 547,251 individuals in 188 municipalities.
 

Peculiar features

Pavia is situated in a flat territory that encompasses the highly industrialized regions of Piedmont, Lombardy, Emilia-Romagna, and Veneto. It has a high level of anthropogenic emissions, or environmental pollutants, originating from human activity, Dr. Bergamaschi reported. The region also has “peculiar” geographical features that “favor the accumulation of pollutants,” such as the natural barrier of the Alps in the north and low wind speed, he said.

The researchers identified 927 individuals with MS (315 male and 612 female) in the province. The overall MS prevalence rate was 169.4 per 100,000 population (95% confidence interval [CI], 158.8 – 180.6), which is 10-fold higher than 50 years ago, Dr. Bergamaschi said. In addition, this MS prevalence is higher than that in the United States, which is about 150 per 100,000 population.

Using sophisticated Bayesian disease mapping, the investigators looked for clusters of MS. They also gathered emission data for PM_2.5 from 2010 to 2017 from the European Monitoring and Evaluation Programme database. They then divided the region on the basis of average winter concentrations of PM_2.5.

Three distinct lateral areas of air pollution were identified. The more northern region, which includes the large urban center of Milan, had the highest level of air pollution. Concentrations decreased the further south the investigators looked.

After adjusting for age, urbanization (population density), and deprivation index, results showed that living in areas with high levels of pollutants was associated with increased MS risk. When controlling for PM_2.5 pollution, participants in urban areas had an increased risk for MS compared with rural dwellers (relative risk [RR], 1.16; 95% CI, 1.04 – 1.30; P = 0.003)

Dr. Bergamaschi said it is unclear whether this risk is higher for certain types of MS. “To my knowledge, no study has analyzed possible relationships between MS phenotypes and air pollution,” he noted.
 

Vitamin D’s role?

Several mechanisms might help explain the relationship between air pollution and MS risk, he added. These include oxidative stress, which results in cell damage, inflammation, and proinflammatory cytokine release. Vitamin D also likely plays some role, Dr. Bergamaschi said. Upon penetrating the lower strata of the earth’s atmosphere, ultraviolet B radiation is absorbed and scattered by suspended pollutants.

Several studies have highlighted the correlation between living in a polluted area and vitamin D hypovitaminosis; “so air pollution can contribute to increasing the risk of MS by reducing vitamin D synthesis,” he said.

Recent research has also shown that air pollution is associated with a higher risk for other autoimmune disorders, including systemic lupus erythematosus, rheumatoid arthritis, and type 1 diabetes mellitus.

However, pollution alone is only part of the picture. MS prevalence in highly populated and polluted countries such as China and India is low, with no more than 30 to 40 cases per 100,000 population, Dr. Bergamaschi noted. “This discrepancy is explained by different genetic backgrounds. While Caucasians are particularly susceptible to MS, Asians are not,” he said.

Study limitations cited included a possible bias because the analysis did not include other possible contributing risk factors, particularly other pollutants, Dr. Bergamaschi said.

Commenting on the research, Lily Jung Henson, MD, chief of neurology at Piedmont Healthcare in Stockbridge, Georgia, said the findings provide “a fascinating glimpse” into possible causative factors for MS and warrant further investigation.

“This research also suggests other opportunities to look at, such as progression of the degree of air pollution and the incidence of MS over time,” said Dr. Henson, who was not involved with the study.

Drs. Bergamaschi and Dr. Henson have reported no relevant financial relationships.

This article first appeared on Medscape.com.

Air pollution may be another environmental risk factor for developing multiple sclerosis (MS), new research suggests. A large cohort study of almost 550,000 individuals living in Italy showed that participants living in areas with high levels of pollutants had a significantly greater risk of developing MS than those who lived in areas with low levels of pollutants.

The findings further confirm a relationship between exposure to air pollutants and risk for MS that has been shown in previous research, said Roberto Bergamaschi, MD, PhD, director of the Multiple Sclerosis Center, IRCCS Mondino Foundation, Pavia, Italy.

“Countermeasures that cut air pollution can be important for public health, not only to reduce deaths related to cardiac and pulmonary diseases but also the risk of chronic autoimmune diseases such as MS,” Dr. Bergamaschi said.

The findings were presented at the Congress of the European Academy of Neurology (EAN) 2020, which transitioned to a virtual/online meeting because of the COVID-19 pandemic.
 

Toxic pollutants

Several environmental factors may trigger an abnormal immune response that manifests in MS. The most studied of these are low vitamin D level, cigarette smoking, and an unhealthy diet, Dr. Bergamaschi said. However, “other environmental factors deserve to be studied—pollution included,” he added.

Among the most toxic air pollutants are particulate matter (PM), which is a mixture of fine solid and liquid particles suspended in the earth’s atmosphere. PM may range from 2.5 microns (PM_2.5) to 10 microns (PM₁₀) in diameter.

The main sources of such pollutants are household and commercial heating (53%) and industrial activities (17%), followed by road vehicle and non–road vehicle use, agriculture, and electricity production.

The World Health Organization estimates that more than 3.2 million individuals worldwide die prematurely every year because of lung cancer, cardiovascular disease, and other diseases related to air pollutants, said Dr. Bergamaschi.

Epidemiologic research has uncovered a relationship between air pollution and MS. A large American study published in 2008 in Science of the Total Environment showed a significant association between MS prevalence and PM₁₀ levels (P < 0.001). Other studies have shown an increase in the number of clinical relapses of MS that were linked to air pollution.

The current investigators assessed the association between PM_2.5 levels and MS prevalence in the northern province of Pavia, which has a population of 547,251 individuals in 188 municipalities.
 

Peculiar features

Pavia is situated in a flat territory that encompasses the highly industrialized regions of Piedmont, Lombardy, Emilia-Romagna, and Veneto. It has a high level of anthropogenic emissions, or environmental pollutants, originating from human activity, Dr. Bergamaschi reported. The region also has “peculiar” geographical features that “favor the accumulation of pollutants,” such as the natural barrier of the Alps in the north and low wind speed, he said.

The researchers identified 927 individuals with MS (315 male and 612 female) in the province. The overall MS prevalence rate was 169.4 per 100,000 population (95% confidence interval [CI], 158.8 – 180.6), which is 10-fold higher than 50 years ago, Dr. Bergamaschi said. In addition, this MS prevalence is higher than that in the United States, which is about 150 per 100,000 population.

Using sophisticated Bayesian disease mapping, the investigators looked for clusters of MS. They also gathered emission data for PM_2.5 from 2010 to 2017 from the European Monitoring and Evaluation Programme database. They then divided the region on the basis of average winter concentrations of PM_2.5.

Three distinct lateral areas of air pollution were identified. The more northern region, which includes the large urban center of Milan, had the highest level of air pollution. Concentrations decreased the further south the investigators looked.

After adjusting for age, urbanization (population density), and deprivation index, results showed that living in areas with high levels of pollutants was associated with increased MS risk. When controlling for PM_2.5 pollution, participants in urban areas had an increased risk for MS compared with rural dwellers (relative risk [RR], 1.16; 95% CI, 1.04 – 1.30; P = 0.003)

Dr. Bergamaschi said it is unclear whether this risk is higher for certain types of MS. “To my knowledge, no study has analyzed possible relationships between MS phenotypes and air pollution,” he noted.
 

Vitamin D’s role?

Several mechanisms might help explain the relationship between air pollution and MS risk, he added. These include oxidative stress, which results in cell damage, inflammation, and proinflammatory cytokine release. Vitamin D also likely plays some role, Dr. Bergamaschi said. Upon penetrating the lower strata of the earth’s atmosphere, ultraviolet B radiation is absorbed and scattered by suspended pollutants.

Several studies have highlighted the correlation between living in a polluted area and vitamin D hypovitaminosis; “so air pollution can contribute to increasing the risk of MS by reducing vitamin D synthesis,” he said.

Recent research has also shown that air pollution is associated with a higher risk for other autoimmune disorders, including systemic lupus erythematosus, rheumatoid arthritis, and type 1 diabetes mellitus.

However, pollution alone is only part of the picture. MS prevalence in highly populated and polluted countries such as China and India is low, with no more than 30 to 40 cases per 100,000 population, Dr. Bergamaschi noted. “This discrepancy is explained by different genetic backgrounds. While Caucasians are particularly susceptible to MS, Asians are not,” he said.

Study limitations cited included a possible bias because the analysis did not include other possible contributing risk factors, particularly other pollutants, Dr. Bergamaschi said.

Commenting on the research, Lily Jung Henson, MD, chief of neurology at Piedmont Healthcare in Stockbridge, Georgia, said the findings provide “a fascinating glimpse” into possible causative factors for MS and warrant further investigation.

“This research also suggests other opportunities to look at, such as progression of the degree of air pollution and the incidence of MS over time,” said Dr. Henson, who was not involved with the study.

Drs. Bergamaschi and Dr. Henson have reported no relevant financial relationships.

This article first appeared on Medscape.com.

During the deadliest wildfire in California’s history in 2018, dermatology clinics 175 miles away at the University of California, San Francisco, experienced an increase in the number of pediatric and adult visits for pruritus and atopic dermatitis associated with air pollution created from the wildfire, according to research presented at the annual meeting of the Society for Investigative Dermatology, held virtually.

In patients with and without atopic dermatitis (AD), “acute exposure to poor air quality associated with a wildfire event can increase the number of visits for itch,” Raj Fadadu, a medical student at the University of California, San Francisco, said in his presentation.

Not many studies have examined this potential association, but includes those that have found significant positive associations between exposure to air pollution and pruritus, the development of AD, and exacerbation of AD (J Allergy Clin Immunol. 2014 Nov;134[5]:993-9). Another study found outpatient visits for patients with eczema and dermatitis in Beijing increased as the level of particulate matter, nitrogen dioxide, and sulfur dioxide concentrations increased (Environ Sci Process Impacts. 2019 Jan 23;21[1]:163-73).

Mr. Faduda and colleagues set out to determine whether the number of appointments for and severity of skin disease increased as a result of the 2018 Camp Fire, which started in Paradise, Calif., using measures of air pollution and clinic visits in years where California did not experience a wildfire event as controls. Using the National Oceanic and Atmospheric Administration Hazard Mapping System for fire and smoke, the researchers graphed smoke plume density scores and particulate matter (PM_2.5) concentrations in the area. They then calculated the number of UCSF dermatology clinic visits for AD/eczema, and measured severity of skin disease with appointments for itch symptoms, and the number of prescribed medications during that time using ICD-10 codes.

The Camp Fire rapidly spread over a period of 17 days, between Nov. 8 and 25, 2018, during which time, PM_2.5 particulate matter concentrations increased 10-fold, while the NOAA smoke plume density score sharply increased. More pediatric and adult patients also seemed to be visiting clinics during this time, compared with several weeks before and several weeks after the fire, prompting a more expanded analysis of this signal, Mr. Fadadu said.

He and his coinvestigators compared data between October 2015 and February 2016 – a period of time where there were no wildfires in California – with data in 2018, when the Camp Fire occurred. They collected data on 3,448 adults and 699 children across 3 years with a total of 5,539 adult appointments for AD, 924 pediatric appointments for AD, 1,319 adult itch appointments, and 294 pediatric itch appointments. Cumulative and exposure lags were used to measure the effect of the wildfire in a Poisson regression analysis.

They found that, during the wildfire, pediatric AD weekly clinic visits were 1.75 times higher (95% confidence interval, 1.21-2.50) and pediatric itch visits were 2.10 times higher (95% CI, 1.44-3.00), compared with weeks where there was no fire. During the wildfire, pediatric AD clinic visits increased by 8% (rate ratio, 1.08; 95% CI, 1.04-1.12) per 10 mcg/m³ increase in PM_2.5 concentration.

In adults, clinic visits for AD were 1.28 times higher (95% CI, 1.08-1.51) during the wildfire, compared with nonfire weeks. While there was a positive association between pollution exposure and adult AD, “this effect is less than what we observed” for pediatric AD visits, said Mr. Fadadu. Air pollution was positively associated with the development of itch symptoms in adults and more prescriptions for AD medications, but the results were not statistically significant.

“This may be explained by the fact that 80% of pediatric itch patients carried an AD diagnosis, while in contrast, only half of the adult itch patients also have a diagnosis of AD,” he said.

While there are several possible limitations of the research, including assessment of air pollution exposure, Mr. Fadadu said, “these results can inform how dermatologists counsel patients during future episodes of poor air quality, as well as expand comprehension of the broader health effects of climate change that can significantly impact quality of life.”

This study was funded by the UCSF Summer Explore Fellowship, Marguerite Schoeneman Award, and Joint Medical Program Thesis Grant.

During the deadliest wildfire in California’s history in 2018, dermatology clinics 175 miles away at the University of California, San Francisco, experienced an increase in the number of pediatric and adult visits for pruritus and atopic dermatitis associated with air pollution created from the wildfire, according to research presented at the annual meeting of the Society for Investigative Dermatology, held virtually.

In patients with and without atopic dermatitis (AD), “acute exposure to poor air quality associated with a wildfire event can increase the number of visits for itch,” Raj Fadadu, a medical student at the University of California, San Francisco, said in his presentation.

Not many studies have examined this potential association, but includes those that have found significant positive associations between exposure to air pollution and pruritus, the development of AD, and exacerbation of AD (J Allergy Clin Immunol. 2014 Nov;134[5]:993-9). Another study found outpatient visits for patients with eczema and dermatitis in Beijing increased as the level of particulate matter, nitrogen dioxide, and sulfur dioxide concentrations increased (Environ Sci Process Impacts. 2019 Jan 23;21[1]:163-73).

Mr. Faduda and colleagues set out to determine whether the number of appointments for and severity of skin disease increased as a result of the 2018 Camp Fire, which started in Paradise, Calif., using measures of air pollution and clinic visits in years where California did not experience a wildfire event as controls. Using the National Oceanic and Atmospheric Administration Hazard Mapping System for fire and smoke, the researchers graphed smoke plume density scores and particulate matter (PM_2.5) concentrations in the area. They then calculated the number of UCSF dermatology clinic visits for AD/eczema, and measured severity of skin disease with appointments for itch symptoms, and the number of prescribed medications during that time using ICD-10 codes.

The Camp Fire rapidly spread over a period of 17 days, between Nov. 8 and 25, 2018, during which time, PM_2.5 particulate matter concentrations increased 10-fold, while the NOAA smoke plume density score sharply increased. More pediatric and adult patients also seemed to be visiting clinics during this time, compared with several weeks before and several weeks after the fire, prompting a more expanded analysis of this signal, Mr. Fadadu said.

He and his coinvestigators compared data between October 2015 and February 2016 – a period of time where there were no wildfires in California – with data in 2018, when the Camp Fire occurred. They collected data on 3,448 adults and 699 children across 3 years with a total of 5,539 adult appointments for AD, 924 pediatric appointments for AD, 1,319 adult itch appointments, and 294 pediatric itch appointments. Cumulative and exposure lags were used to measure the effect of the wildfire in a Poisson regression analysis.

They found that, during the wildfire, pediatric AD weekly clinic visits were 1.75 times higher (95% confidence interval, 1.21-2.50) and pediatric itch visits were 2.10 times higher (95% CI, 1.44-3.00), compared with weeks where there was no fire. During the wildfire, pediatric AD clinic visits increased by 8% (rate ratio, 1.08; 95% CI, 1.04-1.12) per 10 mcg/m³ increase in PM_2.5 concentration.

In adults, clinic visits for AD were 1.28 times higher (95% CI, 1.08-1.51) during the wildfire, compared with nonfire weeks. While there was a positive association between pollution exposure and adult AD, “this effect is less than what we observed” for pediatric AD visits, said Mr. Fadadu. Air pollution was positively associated with the development of itch symptoms in adults and more prescriptions for AD medications, but the results were not statistically significant.

“This may be explained by the fact that 80% of pediatric itch patients carried an AD diagnosis, while in contrast, only half of the adult itch patients also have a diagnosis of AD,” he said.

While there are several possible limitations of the research, including assessment of air pollution exposure, Mr. Fadadu said, “these results can inform how dermatologists counsel patients during future episodes of poor air quality, as well as expand comprehension of the broader health effects of climate change that can significantly impact quality of life.”

This study was funded by the UCSF Summer Explore Fellowship, Marguerite Schoeneman Award, and Joint Medical Program Thesis Grant.

During the deadliest wildfire in California’s history in 2018, dermatology clinics 175 miles away at the University of California, San Francisco, experienced an increase in the number of pediatric and adult visits for pruritus and atopic dermatitis associated with air pollution created from the wildfire, according to research presented at the annual meeting of the Society for Investigative Dermatology, held virtually.

In patients with and without atopic dermatitis (AD), “acute exposure to poor air quality associated with a wildfire event can increase the number of visits for itch,” Raj Fadadu, a medical student at the University of California, San Francisco, said in his presentation.

Not many studies have examined this potential association, but includes those that have found significant positive associations between exposure to air pollution and pruritus, the development of AD, and exacerbation of AD (J Allergy Clin Immunol. 2014 Nov;134[5]:993-9). Another study found outpatient visits for patients with eczema and dermatitis in Beijing increased as the level of particulate matter, nitrogen dioxide, and sulfur dioxide concentrations increased (Environ Sci Process Impacts. 2019 Jan 23;21[1]:163-73).

Mr. Faduda and colleagues set out to determine whether the number of appointments for and severity of skin disease increased as a result of the 2018 Camp Fire, which started in Paradise, Calif., using measures of air pollution and clinic visits in years where California did not experience a wildfire event as controls. Using the National Oceanic and Atmospheric Administration Hazard Mapping System for fire and smoke, the researchers graphed smoke plume density scores and particulate matter (PM_2.5) concentrations in the area. They then calculated the number of UCSF dermatology clinic visits for AD/eczema, and measured severity of skin disease with appointments for itch symptoms, and the number of prescribed medications during that time using ICD-10 codes.

The Camp Fire rapidly spread over a period of 17 days, between Nov. 8 and 25, 2018, during which time, PM_2.5 particulate matter concentrations increased 10-fold, while the NOAA smoke plume density score sharply increased. More pediatric and adult patients also seemed to be visiting clinics during this time, compared with several weeks before and several weeks after the fire, prompting a more expanded analysis of this signal, Mr. Fadadu said.

He and his coinvestigators compared data between October 2015 and February 2016 – a period of time where there were no wildfires in California – with data in 2018, when the Camp Fire occurred. They collected data on 3,448 adults and 699 children across 3 years with a total of 5,539 adult appointments for AD, 924 pediatric appointments for AD, 1,319 adult itch appointments, and 294 pediatric itch appointments. Cumulative and exposure lags were used to measure the effect of the wildfire in a Poisson regression analysis.

They found that, during the wildfire, pediatric AD weekly clinic visits were 1.75 times higher (95% confidence interval, 1.21-2.50) and pediatric itch visits were 2.10 times higher (95% CI, 1.44-3.00), compared with weeks where there was no fire. During the wildfire, pediatric AD clinic visits increased by 8% (rate ratio, 1.08; 95% CI, 1.04-1.12) per 10 mcg/m³ increase in PM_2.5 concentration.

In adults, clinic visits for AD were 1.28 times higher (95% CI, 1.08-1.51) during the wildfire, compared with nonfire weeks. While there was a positive association between pollution exposure and adult AD, “this effect is less than what we observed” for pediatric AD visits, said Mr. Fadadu. Air pollution was positively associated with the development of itch symptoms in adults and more prescriptions for AD medications, but the results were not statistically significant.

“This may be explained by the fact that 80% of pediatric itch patients carried an AD diagnosis, while in contrast, only half of the adult itch patients also have a diagnosis of AD,” he said.

While there are several possible limitations of the research, including assessment of air pollution exposure, Mr. Fadadu said, “these results can inform how dermatologists counsel patients during future episodes of poor air quality, as well as expand comprehension of the broader health effects of climate change that can significantly impact quality of life.”

This study was funded by the UCSF Summer Explore Fellowship, Marguerite Schoeneman Award, and Joint Medical Program Thesis Grant.

Nonpharmacologic recommendations for ankylosing spondylitis aren’t often followed by rheumatologists in the Boston-based Partners Healthcare system, and probably elsewhere, according to a review presented at the virtual annual meeting of the Spondyloarthritis Research and Treatment Network (SPARTAN).

The American College of Rheumatology, Spondylitis Association of America, and SPARTAN released joint guidelines for ankylosing spondylitis (AS) and nonradiographic axial spondyloarthritis in 2016. Nonpharmacologic recommendations for AS included regular disease activity monitoring using a validated measure and C-reactive protein or erythrocyte sedimentation rate; physical therapy (PT) or home back exercises; and screening for osteoporosis with dual x-ray absorptiometry (DXA) scanning.

However, “the extent to which these recommendations are followed in clinical practice is unknown,” said lead investigator Akash Patel, of the Brigham and Women’s Hospital Division of Rheumatology, Immunology, and Allergy, in Boston.

To find out, the team reviewed electronic records for 304 AS patients who had 564 rheumatology clinic visits with Brigham and Women’s and other Partners Healthcare physicians from July 1, 2016, to June 30, 2019.

Records documented DXA scans in less than 20% of visits. PT was documented in only 9% of visits, and home back exercise in just 7%. Inflammatory marker measurement was documented in about half of visits, and disease activity was measured in only 17%.

Comparing the first year of the study – right after the recommendations came out – to the third year, the team found just an 8% increase in disease activity documentation, and about a 3% increase in documentation of PT and back exercises.

In short, the recommendations “were performed at low frequencies in this study population,” Mr. Patel said at the meeting, which was held online this year because of the COVID-19 pandemic.

It’s unclear what’s going on. Perhaps some physicians disagree with the 2016 advice – the regular monitoring of disease activity, after all, was a conditional recommendation based on low-quality evidence. Other times, physicians might not have had enough time to talk about exercise or draw blood for AS biomarkers. Maybe they didn’t bring up PT when they knew their patients couldn’t afford the out-of-pocket cost.

Whatever the case, future iterations of the guidelines should include advice on how to implement them. “We believe that including some sort of strategy for rheumatologists may help increase compliance,” Mr. Patel said.

A member of the online viewing audience suggested that the problem may be widespread in rheumatology. "I think if we did this at my institution,” for example, “it would also look abysmal. I think we all just suck at this,” the attendee said.*

Mr. Patel and his team presented the results to Brigham and Women’s rheumatologists in February 2020, but it’s too early to tell if it made a difference.

It was a typical AS cohort. Almost three-quarters of the subjects were men; the average age was 50 years old; and the diagnosis was made by imaging. The majority of patients were HLA-B27 positive, and over one-third had a history of uveitis.

The study’s funding source and disclosures – if any – weren’t reported.

*Correction, 6/3/2020: A previous version of this story misattributed this quote.

aotto@mdedge.com

SOURCE: Patel A et al. SPARTAN 2020 abstract session May 15.

Nonpharmacologic recommendations for ankylosing spondylitis aren’t often followed by rheumatologists in the Boston-based Partners Healthcare system, and probably elsewhere, according to a review presented at the virtual annual meeting of the Spondyloarthritis Research and Treatment Network (SPARTAN).

The American College of Rheumatology, Spondylitis Association of America, and SPARTAN released joint guidelines for ankylosing spondylitis (AS) and nonradiographic axial spondyloarthritis in 2016. Nonpharmacologic recommendations for AS included regular disease activity monitoring using a validated measure and C-reactive protein or erythrocyte sedimentation rate; physical therapy (PT) or home back exercises; and screening for osteoporosis with dual x-ray absorptiometry (DXA) scanning.

However, “the extent to which these recommendations are followed in clinical practice is unknown,” said lead investigator Akash Patel, of the Brigham and Women’s Hospital Division of Rheumatology, Immunology, and Allergy, in Boston.

To find out, the team reviewed electronic records for 304 AS patients who had 564 rheumatology clinic visits with Brigham and Women’s and other Partners Healthcare physicians from July 1, 2016, to June 30, 2019.

Records documented DXA scans in less than 20% of visits. PT was documented in only 9% of visits, and home back exercise in just 7%. Inflammatory marker measurement was documented in about half of visits, and disease activity was measured in only 17%.

Comparing the first year of the study – right after the recommendations came out – to the third year, the team found just an 8% increase in disease activity documentation, and about a 3% increase in documentation of PT and back exercises.

In short, the recommendations “were performed at low frequencies in this study population,” Mr. Patel said at the meeting, which was held online this year because of the COVID-19 pandemic.

It’s unclear what’s going on. Perhaps some physicians disagree with the 2016 advice – the regular monitoring of disease activity, after all, was a conditional recommendation based on low-quality evidence. Other times, physicians might not have had enough time to talk about exercise or draw blood for AS biomarkers. Maybe they didn’t bring up PT when they knew their patients couldn’t afford the out-of-pocket cost.

Whatever the case, future iterations of the guidelines should include advice on how to implement them. “We believe that including some sort of strategy for rheumatologists may help increase compliance,” Mr. Patel said.

A member of the online viewing audience suggested that the problem may be widespread in rheumatology. "I think if we did this at my institution,” for example, “it would also look abysmal. I think we all just suck at this,” the attendee said.*

Mr. Patel and his team presented the results to Brigham and Women’s rheumatologists in February 2020, but it’s too early to tell if it made a difference.

It was a typical AS cohort. Almost three-quarters of the subjects were men; the average age was 50 years old; and the diagnosis was made by imaging. The majority of patients were HLA-B27 positive, and over one-third had a history of uveitis.

The study’s funding source and disclosures – if any – weren’t reported.

*Correction, 6/3/2020: A previous version of this story misattributed this quote.

aotto@mdedge.com

SOURCE: Patel A et al. SPARTAN 2020 abstract session May 15.

Nonpharmacologic recommendations for ankylosing spondylitis aren’t often followed by rheumatologists in the Boston-based Partners Healthcare system, and probably elsewhere, according to a review presented at the virtual annual meeting of the Spondyloarthritis Research and Treatment Network (SPARTAN).

The American College of Rheumatology, Spondylitis Association of America, and SPARTAN released joint guidelines for ankylosing spondylitis (AS) and nonradiographic axial spondyloarthritis in 2016. Nonpharmacologic recommendations for AS included regular disease activity monitoring using a validated measure and C-reactive protein or erythrocyte sedimentation rate; physical therapy (PT) or home back exercises; and screening for osteoporosis with dual x-ray absorptiometry (DXA) scanning.

However, “the extent to which these recommendations are followed in clinical practice is unknown,” said lead investigator Akash Patel, of the Brigham and Women’s Hospital Division of Rheumatology, Immunology, and Allergy, in Boston.

To find out, the team reviewed electronic records for 304 AS patients who had 564 rheumatology clinic visits with Brigham and Women’s and other Partners Healthcare physicians from July 1, 2016, to June 30, 2019.

Records documented DXA scans in less than 20% of visits. PT was documented in only 9% of visits, and home back exercise in just 7%. Inflammatory marker measurement was documented in about half of visits, and disease activity was measured in only 17%.

Comparing the first year of the study – right after the recommendations came out – to the third year, the team found just an 8% increase in disease activity documentation, and about a 3% increase in documentation of PT and back exercises.

In short, the recommendations “were performed at low frequencies in this study population,” Mr. Patel said at the meeting, which was held online this year because of the COVID-19 pandemic.

It’s unclear what’s going on. Perhaps some physicians disagree with the 2016 advice – the regular monitoring of disease activity, after all, was a conditional recommendation based on low-quality evidence. Other times, physicians might not have had enough time to talk about exercise or draw blood for AS biomarkers. Maybe they didn’t bring up PT when they knew their patients couldn’t afford the out-of-pocket cost.

Whatever the case, future iterations of the guidelines should include advice on how to implement them. “We believe that including some sort of strategy for rheumatologists may help increase compliance,” Mr. Patel said.

A member of the online viewing audience suggested that the problem may be widespread in rheumatology. "I think if we did this at my institution,” for example, “it would also look abysmal. I think we all just suck at this,” the attendee said.*

Mr. Patel and his team presented the results to Brigham and Women’s rheumatologists in February 2020, but it’s too early to tell if it made a difference.

It was a typical AS cohort. Almost three-quarters of the subjects were men; the average age was 50 years old; and the diagnosis was made by imaging. The majority of patients were HLA-B27 positive, and over one-third had a history of uveitis.

The study’s funding source and disclosures – if any – weren’t reported.

*Correction, 6/3/2020: A previous version of this story misattributed this quote.

aotto@mdedge.com

SOURCE: Patel A et al. SPARTAN 2020 abstract session May 15.

Substance use disorder and its daily consequences take no breaks even during a pandemic. The stressors created by COVID-19, including deaths of loved ones and the disruptions to normal life from policies aimed at flattening the curve, seem to have increased substance use.

Courtesy Dr. Keji Fagbemi

I practice as a hospitalist with an internal medicine background and specialty in addiction medicine at BronxCare Health System’s inpatient detoxification unit, a 24/7, 20-bed medically-supervised unit in South Bronx in New York City. It is one of the comprehensive services provided by the BronxCare’s life recovery center and addiction services, which also includes an outpatient clinic, opioid treatment program, inpatient rehab, and a half-way house. Inpatient detoxification units like ours are designed to treat serious addictions and chemical dependency and prevent and treat life-threatening withdrawal symptoms and signs or complications. Our patients come from all over the city and its adjoining suburbs, including from emergency room referrals, referral clinics, courts and the justice system, walk-ins, and self-referrals.

At a time when many inpatient detoxification units within the city were temporarily closed due to fear of inpatient spread of the virus or to provide extra COVID beds in anticipation for the peak surge, we have been able to provide a needed service. In fact, several other inpatient detoxification programs within the city have been able to refer their patients to our facility.

Individuals with substance use disorder have historically been a vulnerable and underserved population and possess high risk for multiple health problems as well as preexisting conditions. Many have limited life options financially, educationally, and with housing, and encounter barriers to accessing primary health care services, including preventive services. The introduction of the COVID-19 pandemic into these patients’ precarious health situations only made things worse as many of the limited resources for patients with substance use disorder were diverted to battling the pandemic. Numerous inpatient and outpatient addiction services, for example, were temporarily shut down. This has led to an increase in domestic violence, and psychiatric decompensation, including psychosis, suicidal attempts, and worsening of medical comorbidities in these patients.

Our wake-up call came when the first case of COVID-19 was confirmed in New York in early March. Within a short period of time the state became the epicenter for COVID-19. With the projection of millions of cases being positive and the number of new cases doubling every third day at the onset in New York City, we knew we had a battle brewing and needed to radically transform our mode of operation fast.

Our first task was to ensure the safety of our patients and the dedicated health workers attending to them. Instead of shutting down we decided to focus on education, screening, mask usage, social distancing, and intensifying hygiene. We streamlined the patient point of entry through one screening site, while also brushing up on our history-taking to intently screen for COVID-19. This included not just focusing on travels from China, but from Europe and other parts of the world.

Yes, we did ask patients about cough, fever, shortness of breath or difficulty breathing, feeling fatigued, severe body ache, and possible contact with someone who is sick or has traveled overseas. But we were also attuned to the increased rate of community spread and the presentation of other symptoms, such as loss of taste and smell, early in the process. Hence we were able to triage patients with suspected cases to the appropriate sections of the hospital for further screening, testing, and evaluation, instead of having those patients admitted to the detox unit.

Courtesy Dr. Keji Fagbemi

Dr. Fagbemi is a hospitalist at BronxCare Health System, a not-for-profit health and teaching hospital system serving South and Central Bronx in New York. He has no conflicts of interest to disclose.

Substance use disorder and its daily consequences take no breaks even during a pandemic. The stressors created by COVID-19, including deaths of loved ones and the disruptions to normal life from policies aimed at flattening the curve, seem to have increased substance use.

Courtesy Dr. Keji Fagbemi

I practice as a hospitalist with an internal medicine background and specialty in addiction medicine at BronxCare Health System’s inpatient detoxification unit, a 24/7, 20-bed medically-supervised unit in South Bronx in New York City. It is one of the comprehensive services provided by the BronxCare’s life recovery center and addiction services, which also includes an outpatient clinic, opioid treatment program, inpatient rehab, and a half-way house. Inpatient detoxification units like ours are designed to treat serious addictions and chemical dependency and prevent and treat life-threatening withdrawal symptoms and signs or complications. Our patients come from all over the city and its adjoining suburbs, including from emergency room referrals, referral clinics, courts and the justice system, walk-ins, and self-referrals.

At a time when many inpatient detoxification units within the city were temporarily closed due to fear of inpatient spread of the virus or to provide extra COVID beds in anticipation for the peak surge, we have been able to provide a needed service. In fact, several other inpatient detoxification programs within the city have been able to refer their patients to our facility.

Individuals with substance use disorder have historically been a vulnerable and underserved population and possess high risk for multiple health problems as well as preexisting conditions. Many have limited life options financially, educationally, and with housing, and encounter barriers to accessing primary health care services, including preventive services. The introduction of the COVID-19 pandemic into these patients’ precarious health situations only made things worse as many of the limited resources for patients with substance use disorder were diverted to battling the pandemic. Numerous inpatient and outpatient addiction services, for example, were temporarily shut down. This has led to an increase in domestic violence, and psychiatric decompensation, including psychosis, suicidal attempts, and worsening of medical comorbidities in these patients.

Our wake-up call came when the first case of COVID-19 was confirmed in New York in early March. Within a short period of time the state became the epicenter for COVID-19. With the projection of millions of cases being positive and the number of new cases doubling every third day at the onset in New York City, we knew we had a battle brewing and needed to radically transform our mode of operation fast.

Our first task was to ensure the safety of our patients and the dedicated health workers attending to them. Instead of shutting down we decided to focus on education, screening, mask usage, social distancing, and intensifying hygiene. We streamlined the patient point of entry through one screening site, while also brushing up on our history-taking to intently screen for COVID-19. This included not just focusing on travels from China, but from Europe and other parts of the world.

Yes, we did ask patients about cough, fever, shortness of breath or difficulty breathing, feeling fatigued, severe body ache, and possible contact with someone who is sick or has traveled overseas. But we were also attuned to the increased rate of community spread and the presentation of other symptoms, such as loss of taste and smell, early in the process. Hence we were able to triage patients with suspected cases to the appropriate sections of the hospital for further screening, testing, and evaluation, instead of having those patients admitted to the detox unit.

Courtesy Dr. Keji Fagbemi

Dr. Fagbemi is a hospitalist at BronxCare Health System, a not-for-profit health and teaching hospital system serving South and Central Bronx in New York. He has no conflicts of interest to disclose.

Substance use disorder and its daily consequences take no breaks even during a pandemic. The stressors created by COVID-19, including deaths of loved ones and the disruptions to normal life from policies aimed at flattening the curve, seem to have increased substance use.

Courtesy Dr. Keji Fagbemi

I practice as a hospitalist with an internal medicine background and specialty in addiction medicine at BronxCare Health System’s inpatient detoxification unit, a 24/7, 20-bed medically-supervised unit in South Bronx in New York City. It is one of the comprehensive services provided by the BronxCare’s life recovery center and addiction services, which also includes an outpatient clinic, opioid treatment program, inpatient rehab, and a half-way house. Inpatient detoxification units like ours are designed to treat serious addictions and chemical dependency and prevent and treat life-threatening withdrawal symptoms and signs or complications. Our patients come from all over the city and its adjoining suburbs, including from emergency room referrals, referral clinics, courts and the justice system, walk-ins, and self-referrals.

At a time when many inpatient detoxification units within the city were temporarily closed due to fear of inpatient spread of the virus or to provide extra COVID beds in anticipation for the peak surge, we have been able to provide a needed service. In fact, several other inpatient detoxification programs within the city have been able to refer their patients to our facility.

Individuals with substance use disorder have historically been a vulnerable and underserved population and possess high risk for multiple health problems as well as preexisting conditions. Many have limited life options financially, educationally, and with housing, and encounter barriers to accessing primary health care services, including preventive services. The introduction of the COVID-19 pandemic into these patients’ precarious health situations only made things worse as many of the limited resources for patients with substance use disorder were diverted to battling the pandemic. Numerous inpatient and outpatient addiction services, for example, were temporarily shut down. This has led to an increase in domestic violence, and psychiatric decompensation, including psychosis, suicidal attempts, and worsening of medical comorbidities in these patients.

Our wake-up call came when the first case of COVID-19 was confirmed in New York in early March. Within a short period of time the state became the epicenter for COVID-19. With the projection of millions of cases being positive and the number of new cases doubling every third day at the onset in New York City, we knew we had a battle brewing and needed to radically transform our mode of operation fast.

Our first task was to ensure the safety of our patients and the dedicated health workers attending to them. Instead of shutting down we decided to focus on education, screening, mask usage, social distancing, and intensifying hygiene. We streamlined the patient point of entry through one screening site, while also brushing up on our history-taking to intently screen for COVID-19. This included not just focusing on travels from China, but from Europe and other parts of the world.

Yes, we did ask patients about cough, fever, shortness of breath or difficulty breathing, feeling fatigued, severe body ache, and possible contact with someone who is sick or has traveled overseas. But we were also attuned to the increased rate of community spread and the presentation of other symptoms, such as loss of taste and smell, early in the process. Hence we were able to triage patients with suspected cases to the appropriate sections of the hospital for further screening, testing, and evaluation, instead of having those patients admitted to the detox unit.

Courtesy Dr. Keji Fagbemi

Dr. Fagbemi is a hospitalist at BronxCare Health System, a not-for-profit health and teaching hospital system serving South and Central Bronx in New York. He has no conflicts of interest to disclose.

Since the beginning of the pandemic, AGA has objected to the Centers for Medicare & Medicaid Services’ (CMS) low reimbursement rate for evaluation and management (E/M) services provided by telephone. Today, CMS fixed the problem. Retroactive to March 1, 2020, CMS will pay E/M services provided by telephone at the same rate as in-person, office/outpatient E/M services.

Thanks to everyone who helped us push CMS to address this issue. AGA worked together in coalition with other specialties and Congress on resolving this problem from the start of the pandemic.

Here are more details:

• Medicare’s updated guidance to physicians states, “Medicare payment for the telephone evaluation and management visits (CPT codes 99441-99443) is equivalent to the Medicare payment for office/outpatient visits with established patients effective March 1, 2020.
• The CMS press release outlined the new rates for telephone E/M:
• CMS is also increasing payments for these telephone visits to match payments for similar office and outpatient visits. This would increase payments for these services from a range of about $14-$41 to about $46-$110. The payments are retroactive to March 1, 2020.

We are pleased CMS listened to our message and has addressed this issue. Join the discussion on the AGA Community.

ginews@gastro.org

Since the beginning of the pandemic, AGA has objected to the Centers for Medicare & Medicaid Services’ (CMS) low reimbursement rate for evaluation and management (E/M) services provided by telephone. Today, CMS fixed the problem. Retroactive to March 1, 2020, CMS will pay E/M services provided by telephone at the same rate as in-person, office/outpatient E/M services.

Thanks to everyone who helped us push CMS to address this issue. AGA worked together in coalition with other specialties and Congress on resolving this problem from the start of the pandemic.

Here are more details:

• Medicare’s updated guidance to physicians states, “Medicare payment for the telephone evaluation and management visits (CPT codes 99441-99443) is equivalent to the Medicare payment for office/outpatient visits with established patients effective March 1, 2020.
• The CMS press release outlined the new rates for telephone E/M:
• CMS is also increasing payments for these telephone visits to match payments for similar office and outpatient visits. This would increase payments for these services from a range of about $14-$41 to about $46-$110. The payments are retroactive to March 1, 2020.

We are pleased CMS listened to our message and has addressed this issue. Join the discussion on the AGA Community.

ginews@gastro.org

Since the beginning of the pandemic, AGA has objected to the Centers for Medicare & Medicaid Services’ (CMS) low reimbursement rate for evaluation and management (E/M) services provided by telephone. Today, CMS fixed the problem. Retroactive to March 1, 2020, CMS will pay E/M services provided by telephone at the same rate as in-person, office/outpatient E/M services.

Thanks to everyone who helped us push CMS to address this issue. AGA worked together in coalition with other specialties and Congress on resolving this problem from the start of the pandemic.

Here are more details:

• Medicare’s updated guidance to physicians states, “Medicare payment for the telephone evaluation and management visits (CPT codes 99441-99443) is equivalent to the Medicare payment for office/outpatient visits with established patients effective March 1, 2020.
• The CMS press release outlined the new rates for telephone E/M:
• CMS is also increasing payments for these telephone visits to match payments for similar office and outpatient visits. This would increase payments for these services from a range of about $14-$41 to about $46-$110. The payments are retroactive to March 1, 2020.

We are pleased CMS listened to our message and has addressed this issue. Join the discussion on the AGA Community.

ginews@gastro.org

AGA has published new expert recommendations in Gastroenterology: AGA Institute Rapid Review of the GI and Liver Manifestations of COVID-19, Meta-Analysis of International Data, and Recommendations for the Consultative Management of Patients with COVID-19.

Key guidance for gastroenterologists:

• GI symptoms are not as common in COVID-19 as previously estimated: The overall prevalence was 7.7% (95% CI 7.4 to 8.6%) for diarrhea, 7.8% (95% CI: 7.1 to 8.5%) for nausea/vomiting, and 3.6% (95% CI 3.0 to 4.3%) for abdominal pain. Notably, in outpatients, the pooled prevalence of diarrhea is lower (4.0%).
• However, COVID-19 can present atypically, with GI symptoms: COVID-19 can present with diarrhea as an initial symptom, with a pooled prevalence of 7.9% across 35 studies, encompassing 9,717 patients. Most often, diarrhea is accompanied by other upper respiratory infection symptoms. However, in some cases, diarrhea can precede other symptoms by a few days, and COVID-19 may present as isolated GI symptoms prior to the development of upper respiratory infection symptoms.
• Monitor patients with new diarrhea, nausea, or vomiting for other COVID-19 symptoms: Patients should inform gastroenterologists if they begin to experience new fever, cough, shortness of breath, or other upper respiratory infection symptoms after the onset of GI symptoms. If this occurs, testing for COVID-19 should be considered.
• Abnormalities in liver function tests should prompt thorough evaluation: Liver test abnormalities can be seen in COVID-19 (in approximately 15% of patients); however, available data support that these abnormalities are more commonly attributable to secondary effects from severe disease, rather than primary virus-mediated liver injury. Therefore, it is important to consider alternative etiologies, such as viral hepatitis, when new elevations in aminotransferases are observed.

For all seven evidence-based recommendations and a detailed discussion, review the full publication in Gastroenterology.
 

Authors: Shahnaz Sultan, Osama Altayar, Shazia M. Siddique, Perica Davitkov, Joseph D. Feuerstein, Joseph K. Lim, Yngve Falck-Ytter, Hashem B. El-Serag on behalf of the AGA.

ginews@gastro.org

AGA has published new expert recommendations in Gastroenterology: AGA Institute Rapid Review of the GI and Liver Manifestations of COVID-19, Meta-Analysis of International Data, and Recommendations for the Consultative Management of Patients with COVID-19.

Key guidance for gastroenterologists:

• GI symptoms are not as common in COVID-19 as previously estimated: The overall prevalence was 7.7% (95% CI 7.4 to 8.6%) for diarrhea, 7.8% (95% CI: 7.1 to 8.5%) for nausea/vomiting, and 3.6% (95% CI 3.0 to 4.3%) for abdominal pain. Notably, in outpatients, the pooled prevalence of diarrhea is lower (4.0%).
• However, COVID-19 can present atypically, with GI symptoms: COVID-19 can present with diarrhea as an initial symptom, with a pooled prevalence of 7.9% across 35 studies, encompassing 9,717 patients. Most often, diarrhea is accompanied by other upper respiratory infection symptoms. However, in some cases, diarrhea can precede other symptoms by a few days, and COVID-19 may present as isolated GI symptoms prior to the development of upper respiratory infection symptoms.
• Monitor patients with new diarrhea, nausea, or vomiting for other COVID-19 symptoms: Patients should inform gastroenterologists if they begin to experience new fever, cough, shortness of breath, or other upper respiratory infection symptoms after the onset of GI symptoms. If this occurs, testing for COVID-19 should be considered.
• Abnormalities in liver function tests should prompt thorough evaluation: Liver test abnormalities can be seen in COVID-19 (in approximately 15% of patients); however, available data support that these abnormalities are more commonly attributable to secondary effects from severe disease, rather than primary virus-mediated liver injury. Therefore, it is important to consider alternative etiologies, such as viral hepatitis, when new elevations in aminotransferases are observed.

For all seven evidence-based recommendations and a detailed discussion, review the full publication in Gastroenterology.
 

Authors: Shahnaz Sultan, Osama Altayar, Shazia M. Siddique, Perica Davitkov, Joseph D. Feuerstein, Joseph K. Lim, Yngve Falck-Ytter, Hashem B. El-Serag on behalf of the AGA.

ginews@gastro.org

AGA has published new expert recommendations in Gastroenterology: AGA Institute Rapid Review of the GI and Liver Manifestations of COVID-19, Meta-Analysis of International Data, and Recommendations for the Consultative Management of Patients with COVID-19.

Key guidance for gastroenterologists:

• GI symptoms are not as common in COVID-19 as previously estimated: The overall prevalence was 7.7% (95% CI 7.4 to 8.6%) for diarrhea, 7.8% (95% CI: 7.1 to 8.5%) for nausea/vomiting, and 3.6% (95% CI 3.0 to 4.3%) for abdominal pain. Notably, in outpatients, the pooled prevalence of diarrhea is lower (4.0%).
• However, COVID-19 can present atypically, with GI symptoms: COVID-19 can present with diarrhea as an initial symptom, with a pooled prevalence of 7.9% across 35 studies, encompassing 9,717 patients. Most often, diarrhea is accompanied by other upper respiratory infection symptoms. However, in some cases, diarrhea can precede other symptoms by a few days, and COVID-19 may present as isolated GI symptoms prior to the development of upper respiratory infection symptoms.
• Monitor patients with new diarrhea, nausea, or vomiting for other COVID-19 symptoms: Patients should inform gastroenterologists if they begin to experience new fever, cough, shortness of breath, or other upper respiratory infection symptoms after the onset of GI symptoms. If this occurs, testing for COVID-19 should be considered.
• Abnormalities in liver function tests should prompt thorough evaluation: Liver test abnormalities can be seen in COVID-19 (in approximately 15% of patients); however, available data support that these abnormalities are more commonly attributable to secondary effects from severe disease, rather than primary virus-mediated liver injury. Therefore, it is important to consider alternative etiologies, such as viral hepatitis, when new elevations in aminotransferases are observed.

For all seven evidence-based recommendations and a detailed discussion, review the full publication in Gastroenterology.
 

Authors: Shahnaz Sultan, Osama Altayar, Shazia M. Siddique, Perica Davitkov, Joseph D. Feuerstein, Joseph K. Lim, Yngve Falck-Ytter, Hashem B. El-Serag on behalf of the AGA.

ginews@gastro.org

Author's note: This is the first of a two-part series. In December 2018, Atlanta Gastroenterology Associates partnered with Frazier Healthcare Partners to form the practice management company United Digestive (UD). Since that time, colleagues across the country have evaluated their own private equity prospects and partnerships, as well as monitored the progress of our transition.

Our guiding principle is to provide a best-in-class operational infrastructure, so independent gastroenterologists can focus on delivering the highest quality patient care. Thus, in the first year, significant efforts and capital have been invested into United Digestive’s scalable platform to promote organic growth, as well as facilitate a smooth transition for other groups and physicians joining the team. So how are things going? Enjoy this two-part article where we reached out to several team members from all levels within the organization and asked them to share their personal experiences – both highlights and challenges – during UD’s first year. Here’s what they had to say.
 

During the COVID-19 crisis, how has UD management responded? How has the UD management services organization model affected partner level physician (PLP) compensation?

Dr. Marc Rosenberg, UD Physician Executive Committee member:

• “Immediately, the entire leadership team recognized the threat of COVID to our community, patients, staff, and business. A multidisciplinary task force including clinical and business leaders utilized our PE partner’s vast resources, local hospital expertise, national societal recommendations and colleagues’ experiences from around the country to focus on protocols and procedures to protect our patients and staff. A few of the team’s timely decisions included: closing the majority of our patient fronting services, transitioning to telehealth, hiring an infection control consultant, allowing physical distancing of our staff with off sight work, instituting symptomatic pathways, donating personal protective gear to local hospitals, covering all benefits as well as provided resources to obtain government benefits to furloughed team members, developing a provider wellness program, and encouraging hospital coverage considerations for high risk providers. I also know the team is focusing on how we re-open at the appropriate time with necessary safety considerations, like investigating testing options and ensuring appropriate PPE is in place. The collaboration between clinical and business leadership has been tremendous through this evolving and challenging period. As for UD physician partner compensation, our model is uniquely organized such that the MSO covers all overhead expenses with partners contributing a fixed percentage of a partner’s collections, while others typically share overhead expenses. During uncertain times, like the COVID-19 crisis, it is reassuring to partners to know that they are not responsible for the cost of infrastructure (i.e. leases, capital equipment, EHR system, consultants, etc.) and staffing, including current and new associates.”

With formation of United Digestive as an MSO, has your day-to-day work life changed or your clinical decision-making been impacted?

Dr. Aja McCutchen, UD Physician Executive Committee Member:

• “With the formation of UD, my daily work life has changed very little; however, with their focus on improving “back-office” functions, my schedule is now fully optimized by reducing gaps from cancellations with same-day/next-day scheduling. In addition, the patient experience has been enhanced with decreased wait times, easier appointment scheduling, and quicker access to support staff. The procurement of business intelligence tools, and, more importantly, the implementation of dashboards, has provided much needed visibility across the organization allowing managerial decisions to be driven by accurate data.

From a clinical decision-making standpoint, Atlanta Gastroenterology was already armed with strong clinical teams and committees. We have been able to build upon our pre-existing committees and optimize their ability to steward best practices and develop clinical pathways. This, in turn, translates to consistency across the organization in the delivery of evidence-based, comprehensive GI care.”
 

Kimberly Orleck, PA-C, Advanced Practice Provider (APP) Supervisor:

• “The formation of UD has not affected my clinical decision-making abilities. In fact, this new platform is dedicated to empowering and establishing APPs as independent clinicians with appropriate physician oversight. As a result, I have welcomed more administrative responsibilities and have become more involved in business meetings and decision making. We have worked together to better utilize APPs using data to match supply with demand.”

Physician compensation improvement is typically a key concern for physicians who work with private equity MSOs. How has United Digestive performed for its partner-level physicians in year one?

Dr. Marc Rosenberg:

• “The MSO has helped to improve physician income – slowly at first and now on a steeper trajectory. We have been ahead of expected income improvement based on models we reviewed when evaluating the formations of an MSO in potential partnership with Frazier Healthcare Partners. United Digestive’s EBIDTA, of which each partner-level physician owns a significant percentage through shares from rollover proceeds, has grown impressively in one year. This has been achieved mostly through significant organic growth and to a lesser degree through mergers and acquisitions. UD has helped to enhance the bottom line through increased reimbursements from payor negotiated contracts, new revenue-generating service lines, and operational efficiencies.”

Dr. Patel and Dr. Sonnenshine are with Atlanta Gastroenterology Associates in Atlanta, which is part of United Digestive. They have no conflicts.

*This story was updated on 6/1/2020.

Author's note: This is the first of a two-part series. In December 2018, Atlanta Gastroenterology Associates partnered with Frazier Healthcare Partners to form the practice management company United Digestive (UD). Since that time, colleagues across the country have evaluated their own private equity prospects and partnerships, as well as monitored the progress of our transition.

Our guiding principle is to provide a best-in-class operational infrastructure, so independent gastroenterologists can focus on delivering the highest quality patient care. Thus, in the first year, significant efforts and capital have been invested into United Digestive’s scalable platform to promote organic growth, as well as facilitate a smooth transition for other groups and physicians joining the team. So how are things going? Enjoy this two-part article where we reached out to several team members from all levels within the organization and asked them to share their personal experiences – both highlights and challenges – during UD’s first year. Here’s what they had to say.
 

During the COVID-19 crisis, how has UD management responded? How has the UD management services organization model affected partner level physician (PLP) compensation?

Dr. Marc Rosenberg, UD Physician Executive Committee member:

• “Immediately, the entire leadership team recognized the threat of COVID to our community, patients, staff, and business. A multidisciplinary task force including clinical and business leaders utilized our PE partner’s vast resources, local hospital expertise, national societal recommendations and colleagues’ experiences from around the country to focus on protocols and procedures to protect our patients and staff. A few of the team’s timely decisions included: closing the majority of our patient fronting services, transitioning to telehealth, hiring an infection control consultant, allowing physical distancing of our staff with off sight work, instituting symptomatic pathways, donating personal protective gear to local hospitals, covering all benefits as well as provided resources to obtain government benefits to furloughed team members, developing a provider wellness program, and encouraging hospital coverage considerations for high risk providers. I also know the team is focusing on how we re-open at the appropriate time with necessary safety considerations, like investigating testing options and ensuring appropriate PPE is in place. The collaboration between clinical and business leadership has been tremendous through this evolving and challenging period. As for UD physician partner compensation, our model is uniquely organized such that the MSO covers all overhead expenses with partners contributing a fixed percentage of a partner’s collections, while others typically share overhead expenses. During uncertain times, like the COVID-19 crisis, it is reassuring to partners to know that they are not responsible for the cost of infrastructure (i.e. leases, capital equipment, EHR system, consultants, etc.) and staffing, including current and new associates.”

With formation of United Digestive as an MSO, has your day-to-day work life changed or your clinical decision-making been impacted?

Dr. Aja McCutchen, UD Physician Executive Committee Member:

• “With the formation of UD, my daily work life has changed very little; however, with their focus on improving “back-office” functions, my schedule is now fully optimized by reducing gaps from cancellations with same-day/next-day scheduling. In addition, the patient experience has been enhanced with decreased wait times, easier appointment scheduling, and quicker access to support staff. The procurement of business intelligence tools, and, more importantly, the implementation of dashboards, has provided much needed visibility across the organization allowing managerial decisions to be driven by accurate data.

From a clinical decision-making standpoint, Atlanta Gastroenterology was already armed with strong clinical teams and committees. We have been able to build upon our pre-existing committees and optimize their ability to steward best practices and develop clinical pathways. This, in turn, translates to consistency across the organization in the delivery of evidence-based, comprehensive GI care.”
 

Kimberly Orleck, PA-C, Advanced Practice Provider (APP) Supervisor:

• “The formation of UD has not affected my clinical decision-making abilities. In fact, this new platform is dedicated to empowering and establishing APPs as independent clinicians with appropriate physician oversight. As a result, I have welcomed more administrative responsibilities and have become more involved in business meetings and decision making. We have worked together to better utilize APPs using data to match supply with demand.”

Physician compensation improvement is typically a key concern for physicians who work with private equity MSOs. How has United Digestive performed for its partner-level physicians in year one?

Dr. Marc Rosenberg:

• “The MSO has helped to improve physician income – slowly at first and now on a steeper trajectory. We have been ahead of expected income improvement based on models we reviewed when evaluating the formations of an MSO in potential partnership with Frazier Healthcare Partners. United Digestive’s EBIDTA, of which each partner-level physician owns a significant percentage through shares from rollover proceeds, has grown impressively in one year. This has been achieved mostly through significant organic growth and to a lesser degree through mergers and acquisitions. UD has helped to enhance the bottom line through increased reimbursements from payor negotiated contracts, new revenue-generating service lines, and operational efficiencies.”

Dr. Patel and Dr. Sonnenshine are with Atlanta Gastroenterology Associates in Atlanta, which is part of United Digestive. They have no conflicts.

*This story was updated on 6/1/2020.

Author's note: This is the first of a two-part series. In December 2018, Atlanta Gastroenterology Associates partnered with Frazier Healthcare Partners to form the practice management company United Digestive (UD). Since that time, colleagues across the country have evaluated their own private equity prospects and partnerships, as well as monitored the progress of our transition.

Our guiding principle is to provide a best-in-class operational infrastructure, so independent gastroenterologists can focus on delivering the highest quality patient care. Thus, in the first year, significant efforts and capital have been invested into United Digestive’s scalable platform to promote organic growth, as well as facilitate a smooth transition for other groups and physicians joining the team. So how are things going? Enjoy this two-part article where we reached out to several team members from all levels within the organization and asked them to share their personal experiences – both highlights and challenges – during UD’s first year. Here’s what they had to say.
 

During the COVID-19 crisis, how has UD management responded? How has the UD management services organization model affected partner level physician (PLP) compensation?

Dr. Marc Rosenberg, UD Physician Executive Committee member:

• “Immediately, the entire leadership team recognized the threat of COVID to our community, patients, staff, and business. A multidisciplinary task force including clinical and business leaders utilized our PE partner’s vast resources, local hospital expertise, national societal recommendations and colleagues’ experiences from around the country to focus on protocols and procedures to protect our patients and staff. A few of the team’s timely decisions included: closing the majority of our patient fronting services, transitioning to telehealth, hiring an infection control consultant, allowing physical distancing of our staff with off sight work, instituting symptomatic pathways, donating personal protective gear to local hospitals, covering all benefits as well as provided resources to obtain government benefits to furloughed team members, developing a provider wellness program, and encouraging hospital coverage considerations for high risk providers. I also know the team is focusing on how we re-open at the appropriate time with necessary safety considerations, like investigating testing options and ensuring appropriate PPE is in place. The collaboration between clinical and business leadership has been tremendous through this evolving and challenging period. As for UD physician partner compensation, our model is uniquely organized such that the MSO covers all overhead expenses with partners contributing a fixed percentage of a partner’s collections, while others typically share overhead expenses. During uncertain times, like the COVID-19 crisis, it is reassuring to partners to know that they are not responsible for the cost of infrastructure (i.e. leases, capital equipment, EHR system, consultants, etc.) and staffing, including current and new associates.”

With formation of United Digestive as an MSO, has your day-to-day work life changed or your clinical decision-making been impacted?

Dr. Aja McCutchen, UD Physician Executive Committee Member:

• “With the formation of UD, my daily work life has changed very little; however, with their focus on improving “back-office” functions, my schedule is now fully optimized by reducing gaps from cancellations with same-day/next-day scheduling. In addition, the patient experience has been enhanced with decreased wait times, easier appointment scheduling, and quicker access to support staff. The procurement of business intelligence tools, and, more importantly, the implementation of dashboards, has provided much needed visibility across the organization allowing managerial decisions to be driven by accurate data.

From a clinical decision-making standpoint, Atlanta Gastroenterology was already armed with strong clinical teams and committees. We have been able to build upon our pre-existing committees and optimize their ability to steward best practices and develop clinical pathways. This, in turn, translates to consistency across the organization in the delivery of evidence-based, comprehensive GI care.”
 

Kimberly Orleck, PA-C, Advanced Practice Provider (APP) Supervisor:

• “The formation of UD has not affected my clinical decision-making abilities. In fact, this new platform is dedicated to empowering and establishing APPs as independent clinicians with appropriate physician oversight. As a result, I have welcomed more administrative responsibilities and have become more involved in business meetings and decision making. We have worked together to better utilize APPs using data to match supply with demand.”

Physician compensation improvement is typically a key concern for physicians who work with private equity MSOs. How has United Digestive performed for its partner-level physicians in year one?

Dr. Marc Rosenberg:

• “The MSO has helped to improve physician income – slowly at first and now on a steeper trajectory. We have been ahead of expected income improvement based on models we reviewed when evaluating the formations of an MSO in potential partnership with Frazier Healthcare Partners. United Digestive’s EBIDTA, of which each partner-level physician owns a significant percentage through shares from rollover proceeds, has grown impressively in one year. This has been achieved mostly through significant organic growth and to a lesser degree through mergers and acquisitions. UD has helped to enhance the bottom line through increased reimbursements from payor negotiated contracts, new revenue-generating service lines, and operational efficiencies.”

Dr. Patel and Dr. Sonnenshine are with Atlanta Gastroenterology Associates in Atlanta, which is part of United Digestive. They have no conflicts.

*This story was updated on 6/1/2020.