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Marijuana allergies on the rise
“Cannabis sativa is a weed and it causes reactions just like any other pollen allergy,” said William Silvers, MD, from the University of Colorado School of Medicine in Aurora.
Silvers’ clinic began to see people with allergic reactions to the plant after the increase in direct exposure that accompanied the legalization of recreational marijuana in Colorado. For people with allergic tendencies, first- and second-hand exposure to C. sativa will increase “classic responses,” such as allergic rhinitis, sneezing, wheezing, itching, and asthma, he told Medscape Medical News.
Smoking the weed, direct exposure to the plant, contact with others who have touched plants, and breathing air in a grow operation “can all cause reactions,” he said. “And the more exposure they had, the greater the reaction, especially those who have allergic tendency,” he said.
The type of exposure to C. sativa is also a factor. Smoking the plant can induce typical allergic responses, the ingestion of hemp seed has been known to induce anaphylaxis, and “working with the plant can lead to dermatitis or contact urticaria,” he explained.
Edibles made with C. sativa have led to overdoses because dosing is difficult to determine. “It takes an hour or so to have an effect, so you don›t have as much control as inhaling it,” Silvers explained.
Stoned Fruit, Stoned Patient
A 2018 case report describes a 24-year-old daily marijuana smoker who experienced anaphylaxis after ingesting hemp seed. He had a history of allergies to stoned fruits, nuts, crustaceans, and aeroallergens. It was his first known exposure to hemp seed.
The patient developed urticaria on his arms after contact with C. sativa leaves and flowers, but had no reaction when smoking marijuana. This case indicates how important mode of exposure is.
“There are only a few cases of anaphylaxis known from ingestion of hemp seed,” Silvers said, “but the ‘stoned fruit, stoned patients’ cross-reactivity looks to be a real thing.”
People allergic to ragweed and sage are more likely than others to have a reaction to cantaloupe and other fruits in the melon family, he explained. There is a common antigen in the C. sativa pollen and in certain foods with cross-reacting proteins, such as tomato, peach, and hazelnut. “We see a pollen and food cross-reactivity via nonspecific lipid transfer proteins.”
A 2017 review of C. sativa allergy points out that few reports of IgE-dependent allergic reactions have been published because of the illegal status of cannabis. However, it is becoming more prevalent as a potential allergen. For example, in Nebraska, C. sativa pollen accounts for 36% of the total pollen count.
People with IgE-mediated cannabis allergy can have a sensitization to the nonspecific lipid transfer protein of C. sativa, Can s 3, which might explain the secondary plant-derived food allergies seen in European patients with a cannabis allergy, according to the review. Can s 3 cross-reacts with various plant homologues.
“This is the sort of information that allergists need to have,” Silvers said.
Stigma Limits Discussion
The fact that federal law prohibits cannabis use in the United States has made research difficult.
A strain distributed by the University of Mississippi can be used for research, “but its potency is very low, at 5% or 7%,” Silvers explained. At medical marijuana dispensaries, the potency of the flower can be as high as 25%, and in other forms, the THC content can be above 80%.
The legal status makes cannabis allergy difficult to diagnose and impossible to treat. Immunotherapy is out of the question. “With federal illegality, we need to stay out of trouble in that regard,” said Silvers, adding that, currently, avoidance is advised.
But research is emerging from Canada, where medicinal and recreational marijuana use is legal.
Stigma around cannabis is still high. “Nobody wants to be seen as a ‘pot doctor’,” said Silvers. But after it became legal in Colorado in 2015, he was asked to give a talk and decided to speak up.
“I have never written a medical prescription for marijuana,” he said, explaining that he is involved with the Center for Bioethics and Humanities at the University of Colorado. “I try to take a societal as well as a medical perspective, looking at the value and concerns for abuse and misuse.”
“As it becomes more available, more legalized, patients are having more reactions,” he said. “Allergists need to get in the game.”
Attitudes need to change. Physicians and allergists need to understand what’s happening in the population “and be open-minded about it so they know what to do,” he added.
Patients Don’t Want to Be Told to Stop
Users of medical marijuana can become dependent, said Ellen Burnham, MD, also from the University of Colorado.
“Patients want a blessing from care providers that it’s okay to use,” she told Medscape Medical News. “We’re in a state where people are really interested in holistic approaches to health, and cannabis is a natural product, but it may exacerbate allergies.”
Some components of cannabis might have bronchodilator properties but there are so many unknowns at this time. “I don’t think allergists should be recommending or condoning cannabis as part of a patient’s therapy,” she said. “It’s not okay for everybody.”
As business flourishes for operators in the cannabis industry and for the legal profession, Burnham said she worries that there isn’t enough protection for workers. “Do workers exposed to plant material on a daily basis have adequate workplace protection,” such as masks and gowns? “There’s a downstream effect that impacts people that nobody has really thought about,” she pointed out.
If the cannabis industry becomes driven by money, with a lobby like the tobacco industry, there will be no way to keep people who are vulnerable from using cannabis.
Is an occasional joint, much like an occasional glass of wine, okay? “We don’t know,” said Burnham. “We just don’t have enough information about it.”
Research is needed to develop medicinal strains of cannabidiol, cannabigerol, and cannabinol, which offer “medicinal and anti-inflammatory relief without the psychologic affects,” Silvers added.
This article first appeared on Medscape.com.
“Cannabis sativa is a weed and it causes reactions just like any other pollen allergy,” said William Silvers, MD, from the University of Colorado School of Medicine in Aurora.
Silvers’ clinic began to see people with allergic reactions to the plant after the increase in direct exposure that accompanied the legalization of recreational marijuana in Colorado. For people with allergic tendencies, first- and second-hand exposure to C. sativa will increase “classic responses,” such as allergic rhinitis, sneezing, wheezing, itching, and asthma, he told Medscape Medical News.
Smoking the weed, direct exposure to the plant, contact with others who have touched plants, and breathing air in a grow operation “can all cause reactions,” he said. “And the more exposure they had, the greater the reaction, especially those who have allergic tendency,” he said.
The type of exposure to C. sativa is also a factor. Smoking the plant can induce typical allergic responses, the ingestion of hemp seed has been known to induce anaphylaxis, and “working with the plant can lead to dermatitis or contact urticaria,” he explained.
Edibles made with C. sativa have led to overdoses because dosing is difficult to determine. “It takes an hour or so to have an effect, so you don›t have as much control as inhaling it,” Silvers explained.
Stoned Fruit, Stoned Patient
A 2018 case report describes a 24-year-old daily marijuana smoker who experienced anaphylaxis after ingesting hemp seed. He had a history of allergies to stoned fruits, nuts, crustaceans, and aeroallergens. It was his first known exposure to hemp seed.
The patient developed urticaria on his arms after contact with C. sativa leaves and flowers, but had no reaction when smoking marijuana. This case indicates how important mode of exposure is.
“There are only a few cases of anaphylaxis known from ingestion of hemp seed,” Silvers said, “but the ‘stoned fruit, stoned patients’ cross-reactivity looks to be a real thing.”
People allergic to ragweed and sage are more likely than others to have a reaction to cantaloupe and other fruits in the melon family, he explained. There is a common antigen in the C. sativa pollen and in certain foods with cross-reacting proteins, such as tomato, peach, and hazelnut. “We see a pollen and food cross-reactivity via nonspecific lipid transfer proteins.”
A 2017 review of C. sativa allergy points out that few reports of IgE-dependent allergic reactions have been published because of the illegal status of cannabis. However, it is becoming more prevalent as a potential allergen. For example, in Nebraska, C. sativa pollen accounts for 36% of the total pollen count.
People with IgE-mediated cannabis allergy can have a sensitization to the nonspecific lipid transfer protein of C. sativa, Can s 3, which might explain the secondary plant-derived food allergies seen in European patients with a cannabis allergy, according to the review. Can s 3 cross-reacts with various plant homologues.
“This is the sort of information that allergists need to have,” Silvers said.
Stigma Limits Discussion
The fact that federal law prohibits cannabis use in the United States has made research difficult.
A strain distributed by the University of Mississippi can be used for research, “but its potency is very low, at 5% or 7%,” Silvers explained. At medical marijuana dispensaries, the potency of the flower can be as high as 25%, and in other forms, the THC content can be above 80%.
The legal status makes cannabis allergy difficult to diagnose and impossible to treat. Immunotherapy is out of the question. “With federal illegality, we need to stay out of trouble in that regard,” said Silvers, adding that, currently, avoidance is advised.
But research is emerging from Canada, where medicinal and recreational marijuana use is legal.
Stigma around cannabis is still high. “Nobody wants to be seen as a ‘pot doctor’,” said Silvers. But after it became legal in Colorado in 2015, he was asked to give a talk and decided to speak up.
“I have never written a medical prescription for marijuana,” he said, explaining that he is involved with the Center for Bioethics and Humanities at the University of Colorado. “I try to take a societal as well as a medical perspective, looking at the value and concerns for abuse and misuse.”
“As it becomes more available, more legalized, patients are having more reactions,” he said. “Allergists need to get in the game.”
Attitudes need to change. Physicians and allergists need to understand what’s happening in the population “and be open-minded about it so they know what to do,” he added.
Patients Don’t Want to Be Told to Stop
Users of medical marijuana can become dependent, said Ellen Burnham, MD, also from the University of Colorado.
“Patients want a blessing from care providers that it’s okay to use,” she told Medscape Medical News. “We’re in a state where people are really interested in holistic approaches to health, and cannabis is a natural product, but it may exacerbate allergies.”
Some components of cannabis might have bronchodilator properties but there are so many unknowns at this time. “I don’t think allergists should be recommending or condoning cannabis as part of a patient’s therapy,” she said. “It’s not okay for everybody.”
As business flourishes for operators in the cannabis industry and for the legal profession, Burnham said she worries that there isn’t enough protection for workers. “Do workers exposed to plant material on a daily basis have adequate workplace protection,” such as masks and gowns? “There’s a downstream effect that impacts people that nobody has really thought about,” she pointed out.
If the cannabis industry becomes driven by money, with a lobby like the tobacco industry, there will be no way to keep people who are vulnerable from using cannabis.
Is an occasional joint, much like an occasional glass of wine, okay? “We don’t know,” said Burnham. “We just don’t have enough information about it.”
Research is needed to develop medicinal strains of cannabidiol, cannabigerol, and cannabinol, which offer “medicinal and anti-inflammatory relief without the psychologic affects,” Silvers added.
This article first appeared on Medscape.com.
“Cannabis sativa is a weed and it causes reactions just like any other pollen allergy,” said William Silvers, MD, from the University of Colorado School of Medicine in Aurora.
Silvers’ clinic began to see people with allergic reactions to the plant after the increase in direct exposure that accompanied the legalization of recreational marijuana in Colorado. For people with allergic tendencies, first- and second-hand exposure to C. sativa will increase “classic responses,” such as allergic rhinitis, sneezing, wheezing, itching, and asthma, he told Medscape Medical News.
Smoking the weed, direct exposure to the plant, contact with others who have touched plants, and breathing air in a grow operation “can all cause reactions,” he said. “And the more exposure they had, the greater the reaction, especially those who have allergic tendency,” he said.
The type of exposure to C. sativa is also a factor. Smoking the plant can induce typical allergic responses, the ingestion of hemp seed has been known to induce anaphylaxis, and “working with the plant can lead to dermatitis or contact urticaria,” he explained.
Edibles made with C. sativa have led to overdoses because dosing is difficult to determine. “It takes an hour or so to have an effect, so you don›t have as much control as inhaling it,” Silvers explained.
Stoned Fruit, Stoned Patient
A 2018 case report describes a 24-year-old daily marijuana smoker who experienced anaphylaxis after ingesting hemp seed. He had a history of allergies to stoned fruits, nuts, crustaceans, and aeroallergens. It was his first known exposure to hemp seed.
The patient developed urticaria on his arms after contact with C. sativa leaves and flowers, but had no reaction when smoking marijuana. This case indicates how important mode of exposure is.
“There are only a few cases of anaphylaxis known from ingestion of hemp seed,” Silvers said, “but the ‘stoned fruit, stoned patients’ cross-reactivity looks to be a real thing.”
People allergic to ragweed and sage are more likely than others to have a reaction to cantaloupe and other fruits in the melon family, he explained. There is a common antigen in the C. sativa pollen and in certain foods with cross-reacting proteins, such as tomato, peach, and hazelnut. “We see a pollen and food cross-reactivity via nonspecific lipid transfer proteins.”
A 2017 review of C. sativa allergy points out that few reports of IgE-dependent allergic reactions have been published because of the illegal status of cannabis. However, it is becoming more prevalent as a potential allergen. For example, in Nebraska, C. sativa pollen accounts for 36% of the total pollen count.
People with IgE-mediated cannabis allergy can have a sensitization to the nonspecific lipid transfer protein of C. sativa, Can s 3, which might explain the secondary plant-derived food allergies seen in European patients with a cannabis allergy, according to the review. Can s 3 cross-reacts with various plant homologues.
“This is the sort of information that allergists need to have,” Silvers said.
Stigma Limits Discussion
The fact that federal law prohibits cannabis use in the United States has made research difficult.
A strain distributed by the University of Mississippi can be used for research, “but its potency is very low, at 5% or 7%,” Silvers explained. At medical marijuana dispensaries, the potency of the flower can be as high as 25%, and in other forms, the THC content can be above 80%.
The legal status makes cannabis allergy difficult to diagnose and impossible to treat. Immunotherapy is out of the question. “With federal illegality, we need to stay out of trouble in that regard,” said Silvers, adding that, currently, avoidance is advised.
But research is emerging from Canada, where medicinal and recreational marijuana use is legal.
Stigma around cannabis is still high. “Nobody wants to be seen as a ‘pot doctor’,” said Silvers. But after it became legal in Colorado in 2015, he was asked to give a talk and decided to speak up.
“I have never written a medical prescription for marijuana,” he said, explaining that he is involved with the Center for Bioethics and Humanities at the University of Colorado. “I try to take a societal as well as a medical perspective, looking at the value and concerns for abuse and misuse.”
“As it becomes more available, more legalized, patients are having more reactions,” he said. “Allergists need to get in the game.”
Attitudes need to change. Physicians and allergists need to understand what’s happening in the population “and be open-minded about it so they know what to do,” he added.
Patients Don’t Want to Be Told to Stop
Users of medical marijuana can become dependent, said Ellen Burnham, MD, also from the University of Colorado.
“Patients want a blessing from care providers that it’s okay to use,” she told Medscape Medical News. “We’re in a state where people are really interested in holistic approaches to health, and cannabis is a natural product, but it may exacerbate allergies.”
Some components of cannabis might have bronchodilator properties but there are so many unknowns at this time. “I don’t think allergists should be recommending or condoning cannabis as part of a patient’s therapy,” she said. “It’s not okay for everybody.”
As business flourishes for operators in the cannabis industry and for the legal profession, Burnham said she worries that there isn’t enough protection for workers. “Do workers exposed to plant material on a daily basis have adequate workplace protection,” such as masks and gowns? “There’s a downstream effect that impacts people that nobody has really thought about,” she pointed out.
If the cannabis industry becomes driven by money, with a lobby like the tobacco industry, there will be no way to keep people who are vulnerable from using cannabis.
Is an occasional joint, much like an occasional glass of wine, okay? “We don’t know,” said Burnham. “We just don’t have enough information about it.”
Research is needed to develop medicinal strains of cannabidiol, cannabigerol, and cannabinol, which offer “medicinal and anti-inflammatory relief without the psychologic affects,” Silvers added.
This article first appeared on Medscape.com.
The role of medication in autism spectrum disorder
Efforts toward early identification and treatment are an important facet of the public health work in autism spectrum disorder (ASD).
The prevalence of ASD is rising. With the most recent estimate from the Centers from Disease Control and Prevention of 1 in 59* children aged 8 years,1 it is important for pediatric health care providers to have an understanding of current recommendations for treatment so they can counsel and guide affected families. ASD is a heterogeneous condition, so this article seeks to touch on broad principles, recognizing that clinicians must take into account the full clinical picture of each individual and family.
It is important to acknowledge that while there is no cure for ASD, there are treatment modalities that have an evidence base for addressing specific areas that may be impaired in children with autism. While it is beyond the scope of this article to review all of the potential areas of intervention in children with ASD, it is important to be keep in mind a few important principles.
1. The best evidenced treatment for addressing challenging and problematic behavior as well as improving a host of outcomes in children with ASD is itself behavioral in nature. These treatments are based on the principles of applied behavioral analysis,2 an educational and therapeutic approach which involves looking at antecedents and consequences of behaviors. This approach also looks to shape, motivate, and reinforce functional behaviors while discouraging harmful and disruptive ones.
2. Because communication often is impaired in children with ASD, providers always should investigate for possible medical causes of pain or discomfort that might explain sudden behavior change, as well as environmental changes that could be involved.
3. – because children with ASD often are particularly sensitive to medication side effects.
Irritability/aggression/extreme mood lability
There are only two medications with Food and Drug Administration labeling for an autism specific condition, and those are aripiprazole and risperidone, two second-generation antipsychotic agents approved for irritability associated with ASD on the basis of randomized controlled trials (RCTs) demonstrating their efficacy.3,4 Included under the umbrella of irritability are aggression, deliberate self-injurious behavior, extreme temper tantrums, and quick and extreme mood changes. For aripiprazole the approved ages are 6-17 years; a dosing range of 2-15 mg/day is recommended. For risperidone, the approved age range is 5-17 years; the recommended dosing range is 0.25-4 mg/day. Prior to starting either of these medications, a cardiac history should be obtained, and baseline laboratory values, particularly lipid levels and hemoglobin A1c (HbA1c) are recommended. All second-generation antipsychotics carry the risk of tardive dyskinesia (a movement disorder), as well as risk of weight gain and metabolic effects. Baseline weight prior to medication initiation with routine follow-up measurement is encouraged. In light of the burden of potential side effects, these medications tend to be reserved by clinicians for circumstances where there is a significant impact on functioning. Both medications are available in liquid form for children with difficulty swallowing pills.
ADHD
There are positive RCTs of methylphenidate in co-occurring ASD and ADHD,5 making it the preferred first line agent for treatment. Amphetamine salt based stimulant preparations do not have any RCTs in co-occurring ASD, but theoretically should be similarly effective. Again, the principle of starting low and going slow is applicable. Second line are the alpha 2 adrenergic agonists guanfacine and clonidine, both of whose long-acting formulations are approved for treatment of ADHD in children and adolescents without ASD, as well as atomoxetine, a selective norepinephrine reuptake inhibitor approved for ADHD. Guanfacine and atomoxetine have the stronger evidence base in the co-occurring condition. None of the second-line medications come in liquid preparation, although the immediate-release forms of guanfacine and clonidine both can be crushed and are used in clinical practice when the extended-release forms are not practicable.
Anxiety disorders and depression
Repetitive behaviors and insistence on sameness are broad headings that can be thought of as similar to obsessive compulsive disorder in children without ASD. However, controlled studies of SSRIs and clomipramine (a tricyclic antidepressant) have not shown a clear benefit in these behaviors in children with autism. There are no RCTs looking specifically at treatment of anxiety disorders in children with ASD, but expert consensus is that pharmacologic treatment is similar to that of children without ASD, with the SSRIs fluoxetine and sertraline the first-line agents due to the robust evidence for these two medications in treatment of anxiety disorders in children.6 Especially for kids with higher functioning ASD, cognitive behavioral therapy (CBT) should be considered and has some evidence for the co-occurring condition. Similarly, there are no RCTs for co-occurring depression in ASD, and clinical practice is to treat it as you would depression in the non-ASD population. Be aware that the studies of SSRIs in children with ASD reported higher than typical rates of behavioral activation on these medications, and again the principle of starting low and going slow is emphasized. Fluoxetine and sertraline both come in liquid form.
Insomnia
Insomnia is a common occurrence in children with ASD, and studies suggest melatonin can be effective, with immediate release clonidine a consideration with some limited evidence, if melatonin is not successful.
Finally I would be remiss in not mentioning that there is preliminary evidence from review7 and meta-analysis8 articles to suggest that regular exercise for individuals with ASD has a positive effect on multiple symptom domains, suggesting that this is an important additional treatment recommendation for children and families.
In conclusion, identification and treatment of ASD and co-occurring syndromes is often challenging, and while specialty referral often will be necessary, it is hoped that this overview provides a helpful frame of reference for primary care providers who encounter these conditions in clinical practice.
For further reading on this important subject, I recommend the American Academy of Child and Adolescent Psychiatry Practice Parameter for the Assessment and Treatment of Children and Adolescents with ASD and the Parents Medication Guide for Autism Spectrum Disorders.
Dr. Hoffnung is a pediatric psychiatrist at the University of Vermont Children’s Hospital and an assistant professor of psychiatry at the Robert Larner, M.D. College of Medicine at the University of Vermont, both in Burlington. He has no relevant financial disclosures. Email him at pdnews@mdedge.com.
References
1. MMWR Surveill Summ 2018;67(No. SS-6):1–23*
2. National Standards Project, Phase 2. National Autism Center 2015.
3. N Engl J Med. 2002 Aug 1;347(5):314-21.
4. J Am Acad Child Adolesc Psychiatry. 2009 Nov;48(11):1110-9.
5. Arch Gen Psychiatry. 2005 Nov;62(11):1266-74.
6. Pediatrics. 2016 Feb;137(Supplement 2):S115-S123.
7. Research in Autism Spectrum Disorders. 2010 Dec;4(4):565-76.
8. Research in Autism Spectrum Disorders. 2012;6(1):46-57.
*This article was updated 4/2/2020.
Efforts toward early identification and treatment are an important facet of the public health work in autism spectrum disorder (ASD).
The prevalence of ASD is rising. With the most recent estimate from the Centers from Disease Control and Prevention of 1 in 59* children aged 8 years,1 it is important for pediatric health care providers to have an understanding of current recommendations for treatment so they can counsel and guide affected families. ASD is a heterogeneous condition, so this article seeks to touch on broad principles, recognizing that clinicians must take into account the full clinical picture of each individual and family.
It is important to acknowledge that while there is no cure for ASD, there are treatment modalities that have an evidence base for addressing specific areas that may be impaired in children with autism. While it is beyond the scope of this article to review all of the potential areas of intervention in children with ASD, it is important to be keep in mind a few important principles.
1. The best evidenced treatment for addressing challenging and problematic behavior as well as improving a host of outcomes in children with ASD is itself behavioral in nature. These treatments are based on the principles of applied behavioral analysis,2 an educational and therapeutic approach which involves looking at antecedents and consequences of behaviors. This approach also looks to shape, motivate, and reinforce functional behaviors while discouraging harmful and disruptive ones.
2. Because communication often is impaired in children with ASD, providers always should investigate for possible medical causes of pain or discomfort that might explain sudden behavior change, as well as environmental changes that could be involved.
3. – because children with ASD often are particularly sensitive to medication side effects.
Irritability/aggression/extreme mood lability
There are only two medications with Food and Drug Administration labeling for an autism specific condition, and those are aripiprazole and risperidone, two second-generation antipsychotic agents approved for irritability associated with ASD on the basis of randomized controlled trials (RCTs) demonstrating their efficacy.3,4 Included under the umbrella of irritability are aggression, deliberate self-injurious behavior, extreme temper tantrums, and quick and extreme mood changes. For aripiprazole the approved ages are 6-17 years; a dosing range of 2-15 mg/day is recommended. For risperidone, the approved age range is 5-17 years; the recommended dosing range is 0.25-4 mg/day. Prior to starting either of these medications, a cardiac history should be obtained, and baseline laboratory values, particularly lipid levels and hemoglobin A1c (HbA1c) are recommended. All second-generation antipsychotics carry the risk of tardive dyskinesia (a movement disorder), as well as risk of weight gain and metabolic effects. Baseline weight prior to medication initiation with routine follow-up measurement is encouraged. In light of the burden of potential side effects, these medications tend to be reserved by clinicians for circumstances where there is a significant impact on functioning. Both medications are available in liquid form for children with difficulty swallowing pills.
ADHD
There are positive RCTs of methylphenidate in co-occurring ASD and ADHD,5 making it the preferred first line agent for treatment. Amphetamine salt based stimulant preparations do not have any RCTs in co-occurring ASD, but theoretically should be similarly effective. Again, the principle of starting low and going slow is applicable. Second line are the alpha 2 adrenergic agonists guanfacine and clonidine, both of whose long-acting formulations are approved for treatment of ADHD in children and adolescents without ASD, as well as atomoxetine, a selective norepinephrine reuptake inhibitor approved for ADHD. Guanfacine and atomoxetine have the stronger evidence base in the co-occurring condition. None of the second-line medications come in liquid preparation, although the immediate-release forms of guanfacine and clonidine both can be crushed and are used in clinical practice when the extended-release forms are not practicable.
Anxiety disorders and depression
Repetitive behaviors and insistence on sameness are broad headings that can be thought of as similar to obsessive compulsive disorder in children without ASD. However, controlled studies of SSRIs and clomipramine (a tricyclic antidepressant) have not shown a clear benefit in these behaviors in children with autism. There are no RCTs looking specifically at treatment of anxiety disorders in children with ASD, but expert consensus is that pharmacologic treatment is similar to that of children without ASD, with the SSRIs fluoxetine and sertraline the first-line agents due to the robust evidence for these two medications in treatment of anxiety disorders in children.6 Especially for kids with higher functioning ASD, cognitive behavioral therapy (CBT) should be considered and has some evidence for the co-occurring condition. Similarly, there are no RCTs for co-occurring depression in ASD, and clinical practice is to treat it as you would depression in the non-ASD population. Be aware that the studies of SSRIs in children with ASD reported higher than typical rates of behavioral activation on these medications, and again the principle of starting low and going slow is emphasized. Fluoxetine and sertraline both come in liquid form.
Insomnia
Insomnia is a common occurrence in children with ASD, and studies suggest melatonin can be effective, with immediate release clonidine a consideration with some limited evidence, if melatonin is not successful.
Finally I would be remiss in not mentioning that there is preliminary evidence from review7 and meta-analysis8 articles to suggest that regular exercise for individuals with ASD has a positive effect on multiple symptom domains, suggesting that this is an important additional treatment recommendation for children and families.
In conclusion, identification and treatment of ASD and co-occurring syndromes is often challenging, and while specialty referral often will be necessary, it is hoped that this overview provides a helpful frame of reference for primary care providers who encounter these conditions in clinical practice.
For further reading on this important subject, I recommend the American Academy of Child and Adolescent Psychiatry Practice Parameter for the Assessment and Treatment of Children and Adolescents with ASD and the Parents Medication Guide for Autism Spectrum Disorders.
Dr. Hoffnung is a pediatric psychiatrist at the University of Vermont Children’s Hospital and an assistant professor of psychiatry at the Robert Larner, M.D. College of Medicine at the University of Vermont, both in Burlington. He has no relevant financial disclosures. Email him at pdnews@mdedge.com.
References
1. MMWR Surveill Summ 2018;67(No. SS-6):1–23*
2. National Standards Project, Phase 2. National Autism Center 2015.
3. N Engl J Med. 2002 Aug 1;347(5):314-21.
4. J Am Acad Child Adolesc Psychiatry. 2009 Nov;48(11):1110-9.
5. Arch Gen Psychiatry. 2005 Nov;62(11):1266-74.
6. Pediatrics. 2016 Feb;137(Supplement 2):S115-S123.
7. Research in Autism Spectrum Disorders. 2010 Dec;4(4):565-76.
8. Research in Autism Spectrum Disorders. 2012;6(1):46-57.
*This article was updated 4/2/2020.
Efforts toward early identification and treatment are an important facet of the public health work in autism spectrum disorder (ASD).
The prevalence of ASD is rising. With the most recent estimate from the Centers from Disease Control and Prevention of 1 in 59* children aged 8 years,1 it is important for pediatric health care providers to have an understanding of current recommendations for treatment so they can counsel and guide affected families. ASD is a heterogeneous condition, so this article seeks to touch on broad principles, recognizing that clinicians must take into account the full clinical picture of each individual and family.
It is important to acknowledge that while there is no cure for ASD, there are treatment modalities that have an evidence base for addressing specific areas that may be impaired in children with autism. While it is beyond the scope of this article to review all of the potential areas of intervention in children with ASD, it is important to be keep in mind a few important principles.
1. The best evidenced treatment for addressing challenging and problematic behavior as well as improving a host of outcomes in children with ASD is itself behavioral in nature. These treatments are based on the principles of applied behavioral analysis,2 an educational and therapeutic approach which involves looking at antecedents and consequences of behaviors. This approach also looks to shape, motivate, and reinforce functional behaviors while discouraging harmful and disruptive ones.
2. Because communication often is impaired in children with ASD, providers always should investigate for possible medical causes of pain or discomfort that might explain sudden behavior change, as well as environmental changes that could be involved.
3. – because children with ASD often are particularly sensitive to medication side effects.
Irritability/aggression/extreme mood lability
There are only two medications with Food and Drug Administration labeling for an autism specific condition, and those are aripiprazole and risperidone, two second-generation antipsychotic agents approved for irritability associated with ASD on the basis of randomized controlled trials (RCTs) demonstrating their efficacy.3,4 Included under the umbrella of irritability are aggression, deliberate self-injurious behavior, extreme temper tantrums, and quick and extreme mood changes. For aripiprazole the approved ages are 6-17 years; a dosing range of 2-15 mg/day is recommended. For risperidone, the approved age range is 5-17 years; the recommended dosing range is 0.25-4 mg/day. Prior to starting either of these medications, a cardiac history should be obtained, and baseline laboratory values, particularly lipid levels and hemoglobin A1c (HbA1c) are recommended. All second-generation antipsychotics carry the risk of tardive dyskinesia (a movement disorder), as well as risk of weight gain and metabolic effects. Baseline weight prior to medication initiation with routine follow-up measurement is encouraged. In light of the burden of potential side effects, these medications tend to be reserved by clinicians for circumstances where there is a significant impact on functioning. Both medications are available in liquid form for children with difficulty swallowing pills.
ADHD
There are positive RCTs of methylphenidate in co-occurring ASD and ADHD,5 making it the preferred first line agent for treatment. Amphetamine salt based stimulant preparations do not have any RCTs in co-occurring ASD, but theoretically should be similarly effective. Again, the principle of starting low and going slow is applicable. Second line are the alpha 2 adrenergic agonists guanfacine and clonidine, both of whose long-acting formulations are approved for treatment of ADHD in children and adolescents without ASD, as well as atomoxetine, a selective norepinephrine reuptake inhibitor approved for ADHD. Guanfacine and atomoxetine have the stronger evidence base in the co-occurring condition. None of the second-line medications come in liquid preparation, although the immediate-release forms of guanfacine and clonidine both can be crushed and are used in clinical practice when the extended-release forms are not practicable.
Anxiety disorders and depression
Repetitive behaviors and insistence on sameness are broad headings that can be thought of as similar to obsessive compulsive disorder in children without ASD. However, controlled studies of SSRIs and clomipramine (a tricyclic antidepressant) have not shown a clear benefit in these behaviors in children with autism. There are no RCTs looking specifically at treatment of anxiety disorders in children with ASD, but expert consensus is that pharmacologic treatment is similar to that of children without ASD, with the SSRIs fluoxetine and sertraline the first-line agents due to the robust evidence for these two medications in treatment of anxiety disorders in children.6 Especially for kids with higher functioning ASD, cognitive behavioral therapy (CBT) should be considered and has some evidence for the co-occurring condition. Similarly, there are no RCTs for co-occurring depression in ASD, and clinical practice is to treat it as you would depression in the non-ASD population. Be aware that the studies of SSRIs in children with ASD reported higher than typical rates of behavioral activation on these medications, and again the principle of starting low and going slow is emphasized. Fluoxetine and sertraline both come in liquid form.
Insomnia
Insomnia is a common occurrence in children with ASD, and studies suggest melatonin can be effective, with immediate release clonidine a consideration with some limited evidence, if melatonin is not successful.
Finally I would be remiss in not mentioning that there is preliminary evidence from review7 and meta-analysis8 articles to suggest that regular exercise for individuals with ASD has a positive effect on multiple symptom domains, suggesting that this is an important additional treatment recommendation for children and families.
In conclusion, identification and treatment of ASD and co-occurring syndromes is often challenging, and while specialty referral often will be necessary, it is hoped that this overview provides a helpful frame of reference for primary care providers who encounter these conditions in clinical practice.
For further reading on this important subject, I recommend the American Academy of Child and Adolescent Psychiatry Practice Parameter for the Assessment and Treatment of Children and Adolescents with ASD and the Parents Medication Guide for Autism Spectrum Disorders.
Dr. Hoffnung is a pediatric psychiatrist at the University of Vermont Children’s Hospital and an assistant professor of psychiatry at the Robert Larner, M.D. College of Medicine at the University of Vermont, both in Burlington. He has no relevant financial disclosures. Email him at pdnews@mdedge.com.
References
1. MMWR Surveill Summ 2018;67(No. SS-6):1–23*
2. National Standards Project, Phase 2. National Autism Center 2015.
3. N Engl J Med. 2002 Aug 1;347(5):314-21.
4. J Am Acad Child Adolesc Psychiatry. 2009 Nov;48(11):1110-9.
5. Arch Gen Psychiatry. 2005 Nov;62(11):1266-74.
6. Pediatrics. 2016 Feb;137(Supplement 2):S115-S123.
7. Research in Autism Spectrum Disorders. 2010 Dec;4(4):565-76.
8. Research in Autism Spectrum Disorders. 2012;6(1):46-57.
*This article was updated 4/2/2020.
Teriflunomide increases the likelihood of achieving NEDA in relapsing-remitting MS
WEST PALM BEACH, FLA. – , according to an analysis presented at the meeting held by the Americas Committee for Treatment and Research in Multiple Sclerosis. Teriflunomide reduces the risks of relapse, relapse resulting in hospital admission, and relapse resulting in prolonged hospitalization, compared with placebo.
Teriflunomide modulates the immune system and is an approved treatment for relapsing-remitting MS and clinically isolated syndrome. The phase 3 TEMSO study provided evidence that established the treatment’s safety and efficacy. In that study, significantly more patients who received a 14-mg dose of teriflunomide achieved NEDA, compared with patients who received placebo. Researchers generally weight all components of NEDA (i.e., confirmed disability worsening [CDW], relapse, and unique active MRI lesions) equally, but this approach could limit the interpretation of how each endpoint contributes to the effectiveness of a disease-modifying therapy.
A new analysis of TEMSO data
Keith R. Edwards, MD, director of the MS Center of Northeastern New York in Latham and colleagues conducted a win ratio matched-pairs analysis of TEMSO data to evaluate the efficacy of teriflunomide in enabling patients to achieve NEDA. In this analysis, the components of NEDA were assessed in order of priority, rather than as factors of equal weight.
In TEMSO, patients with relapsing-remitting MS received placebo or 14 mg of teriflunomide for 108 weeks. Dr. Edwards and colleagues matched active and control patients according to baseline characteristics. They compared the occurrence of disease activity events between the members of each pair. If a patient receiving teriflunomide had an event later than a control did, or did not have the event at all, teriflunomide was considered to “win.” If neither patient in a pair had a given event, the researchers omitted the pair from their analysis. Dr. Edwards and colleagues counted wins and summarized them as ratios. They conducted a second win ratio analysis of all relapses and relapses resulting in deaths, life-threatening events, prolonged hospitalizations, and hospital admissions.
NEDA components were ranked and assessed in the following order of decreasing priority: CDW, relapse, unique active MRI lesions. In a sensitivity analysis, the investigators ranked and assessed these components in the reverse order.
Sensitivity analysis supported primary analysis
Dr. Edwards and colleagues included 363 participants who received placebo and 358 who received teriflunomide in their analysis. Baseline characteristics did not differ significantly between the two groups. The population’s mean age was approximately 38 years, and about 73% of participants were female. The population’s mean baseline Expanded Disability Status Scale score was 2.7. Overall, about 72% of participants completed the study.
The researchers created 321 risk-matched pairs of participants. The win ratio analysis indicated that patients who received teriflunomide were significantly more likely to achieve NEDA, compared with controls (win ratio, 1.33). When the investigators analyzed the data by prioritizing the NEDA components in the reverse order, they found similar results (win ratio, 1.41).
When Dr. Edwards and colleagues analyzed relapse severity, they found that no relapses resulting in death or life-threatening events occurred in the active or control groups. Compared with placebo, teriflunomide significantly reduced the risk of relapse, relapses resulting in hospital admissions, and relapses resulting in prolonged hospitalizations (win ratio, 1.37).
The TEMSO study was funded by Sanofi. Dr. Edwards received grant or research support from Biogen, Genentech, Genzyme, and Novartis. Several authors received funding from Sanofi.
SOURCE: Edwards KR et al. ACTRIMS 2020, Abstract P036.
WEST PALM BEACH, FLA. – , according to an analysis presented at the meeting held by the Americas Committee for Treatment and Research in Multiple Sclerosis. Teriflunomide reduces the risks of relapse, relapse resulting in hospital admission, and relapse resulting in prolonged hospitalization, compared with placebo.
Teriflunomide modulates the immune system and is an approved treatment for relapsing-remitting MS and clinically isolated syndrome. The phase 3 TEMSO study provided evidence that established the treatment’s safety and efficacy. In that study, significantly more patients who received a 14-mg dose of teriflunomide achieved NEDA, compared with patients who received placebo. Researchers generally weight all components of NEDA (i.e., confirmed disability worsening [CDW], relapse, and unique active MRI lesions) equally, but this approach could limit the interpretation of how each endpoint contributes to the effectiveness of a disease-modifying therapy.
A new analysis of TEMSO data
Keith R. Edwards, MD, director of the MS Center of Northeastern New York in Latham and colleagues conducted a win ratio matched-pairs analysis of TEMSO data to evaluate the efficacy of teriflunomide in enabling patients to achieve NEDA. In this analysis, the components of NEDA were assessed in order of priority, rather than as factors of equal weight.
In TEMSO, patients with relapsing-remitting MS received placebo or 14 mg of teriflunomide for 108 weeks. Dr. Edwards and colleagues matched active and control patients according to baseline characteristics. They compared the occurrence of disease activity events between the members of each pair. If a patient receiving teriflunomide had an event later than a control did, or did not have the event at all, teriflunomide was considered to “win.” If neither patient in a pair had a given event, the researchers omitted the pair from their analysis. Dr. Edwards and colleagues counted wins and summarized them as ratios. They conducted a second win ratio analysis of all relapses and relapses resulting in deaths, life-threatening events, prolonged hospitalizations, and hospital admissions.
NEDA components were ranked and assessed in the following order of decreasing priority: CDW, relapse, unique active MRI lesions. In a sensitivity analysis, the investigators ranked and assessed these components in the reverse order.
Sensitivity analysis supported primary analysis
Dr. Edwards and colleagues included 363 participants who received placebo and 358 who received teriflunomide in their analysis. Baseline characteristics did not differ significantly between the two groups. The population’s mean age was approximately 38 years, and about 73% of participants were female. The population’s mean baseline Expanded Disability Status Scale score was 2.7. Overall, about 72% of participants completed the study.
The researchers created 321 risk-matched pairs of participants. The win ratio analysis indicated that patients who received teriflunomide were significantly more likely to achieve NEDA, compared with controls (win ratio, 1.33). When the investigators analyzed the data by prioritizing the NEDA components in the reverse order, they found similar results (win ratio, 1.41).
When Dr. Edwards and colleagues analyzed relapse severity, they found that no relapses resulting in death or life-threatening events occurred in the active or control groups. Compared with placebo, teriflunomide significantly reduced the risk of relapse, relapses resulting in hospital admissions, and relapses resulting in prolonged hospitalizations (win ratio, 1.37).
The TEMSO study was funded by Sanofi. Dr. Edwards received grant or research support from Biogen, Genentech, Genzyme, and Novartis. Several authors received funding from Sanofi.
SOURCE: Edwards KR et al. ACTRIMS 2020, Abstract P036.
WEST PALM BEACH, FLA. – , according to an analysis presented at the meeting held by the Americas Committee for Treatment and Research in Multiple Sclerosis. Teriflunomide reduces the risks of relapse, relapse resulting in hospital admission, and relapse resulting in prolonged hospitalization, compared with placebo.
Teriflunomide modulates the immune system and is an approved treatment for relapsing-remitting MS and clinically isolated syndrome. The phase 3 TEMSO study provided evidence that established the treatment’s safety and efficacy. In that study, significantly more patients who received a 14-mg dose of teriflunomide achieved NEDA, compared with patients who received placebo. Researchers generally weight all components of NEDA (i.e., confirmed disability worsening [CDW], relapse, and unique active MRI lesions) equally, but this approach could limit the interpretation of how each endpoint contributes to the effectiveness of a disease-modifying therapy.
A new analysis of TEMSO data
Keith R. Edwards, MD, director of the MS Center of Northeastern New York in Latham and colleagues conducted a win ratio matched-pairs analysis of TEMSO data to evaluate the efficacy of teriflunomide in enabling patients to achieve NEDA. In this analysis, the components of NEDA were assessed in order of priority, rather than as factors of equal weight.
In TEMSO, patients with relapsing-remitting MS received placebo or 14 mg of teriflunomide for 108 weeks. Dr. Edwards and colleagues matched active and control patients according to baseline characteristics. They compared the occurrence of disease activity events between the members of each pair. If a patient receiving teriflunomide had an event later than a control did, or did not have the event at all, teriflunomide was considered to “win.” If neither patient in a pair had a given event, the researchers omitted the pair from their analysis. Dr. Edwards and colleagues counted wins and summarized them as ratios. They conducted a second win ratio analysis of all relapses and relapses resulting in deaths, life-threatening events, prolonged hospitalizations, and hospital admissions.
NEDA components were ranked and assessed in the following order of decreasing priority: CDW, relapse, unique active MRI lesions. In a sensitivity analysis, the investigators ranked and assessed these components in the reverse order.
Sensitivity analysis supported primary analysis
Dr. Edwards and colleagues included 363 participants who received placebo and 358 who received teriflunomide in their analysis. Baseline characteristics did not differ significantly between the two groups. The population’s mean age was approximately 38 years, and about 73% of participants were female. The population’s mean baseline Expanded Disability Status Scale score was 2.7. Overall, about 72% of participants completed the study.
The researchers created 321 risk-matched pairs of participants. The win ratio analysis indicated that patients who received teriflunomide were significantly more likely to achieve NEDA, compared with controls (win ratio, 1.33). When the investigators analyzed the data by prioritizing the NEDA components in the reverse order, they found similar results (win ratio, 1.41).
When Dr. Edwards and colleagues analyzed relapse severity, they found that no relapses resulting in death or life-threatening events occurred in the active or control groups. Compared with placebo, teriflunomide significantly reduced the risk of relapse, relapses resulting in hospital admissions, and relapses resulting in prolonged hospitalizations (win ratio, 1.37).
The TEMSO study was funded by Sanofi. Dr. Edwards received grant or research support from Biogen, Genentech, Genzyme, and Novartis. Several authors received funding from Sanofi.
SOURCE: Edwards KR et al. ACTRIMS 2020, Abstract P036.
REPORTING FROM ACTRIMS Forum 2020
FDA, FTC uniting to promote biosimilars
The Food and Drug Administration is collaborating with the Federal Trade Commission (FTC) to expand the biosimilars market.
The two agencies signed a joint statement on Feb. 3, 2020, outlining four sets of goals aimed at creating meaningful competition from biosimilars against their reference biologic products.
“Competition is key for helping American patients have access to affordable medicines,” FDA Commissioner Stephen Hahn, MD, said in a statement. “Strengthening efforts to curtail and discourage anticompetitive behavior is key for facilitating robust competition for patients in the biologics marketplace, including through biosimilars, bringing down the costs of these crucial products for patients.”
The statement highlighted four goals. First is that the agencies will coordinate to promote greater competition in the biologic market, including the development of materials to educate the market about biosimilars. The FDA and FTC also sponsored a public workshop on March 9 to discuss competition for biologics.
The second goal has the FDA and FTC working together “to deter behavior that impedes access to samples needed for the development of biologics, including biosimilars,” the joint statement notes.
Third, the agencies will crack down on “false or misleading communications about biologics, including biosimilars, within their respective authorities,” according to the joint statement.
“FDA and FTC, as authorized by their respective statutes, will work together to address false or misleading communications about biologics, including biosimilars,” the statement continues. “In particular, if a communication makes a false or misleading comparison between a reference product and a biosimilar in a manner that misrepresents the safety or efficacy of biosimilars, deceives consumers, or deters competition, FDA and FTC intend to take appropriate action within their respective authorities. FDA intends to take appropriate action to address such communications where those communications have the potential to impact public health.”
Finally, the FTC committed to review patent settlement agreements involving biologics, including biosimilars, for antitrust violations.
Separately, the FDA issued a draft guidance document for comment on manufacturers seeking licensure of biosimilar products that do not cover all the approved uses of the reference product, as well as how to add uses over time that were not part of the initial license of the biosimilar product. The draft guidance covers licensure of products, labeling of biosimilars with fewer indications than the reference product, supplemental applications for indications not on the initial biosimilar application but covered by the reference product, and the timing of applications.
The FDA notes in the draft guidance that this is needed to cover situations such as when some indications on the reference product are covered by exclusivity, although it does encourage a biosimilar manufacturer to seek licensure for all indications that the reference product does have.
The Food and Drug Administration is collaborating with the Federal Trade Commission (FTC) to expand the biosimilars market.
The two agencies signed a joint statement on Feb. 3, 2020, outlining four sets of goals aimed at creating meaningful competition from biosimilars against their reference biologic products.
“Competition is key for helping American patients have access to affordable medicines,” FDA Commissioner Stephen Hahn, MD, said in a statement. “Strengthening efforts to curtail and discourage anticompetitive behavior is key for facilitating robust competition for patients in the biologics marketplace, including through biosimilars, bringing down the costs of these crucial products for patients.”
The statement highlighted four goals. First is that the agencies will coordinate to promote greater competition in the biologic market, including the development of materials to educate the market about biosimilars. The FDA and FTC also sponsored a public workshop on March 9 to discuss competition for biologics.
The second goal has the FDA and FTC working together “to deter behavior that impedes access to samples needed for the development of biologics, including biosimilars,” the joint statement notes.
Third, the agencies will crack down on “false or misleading communications about biologics, including biosimilars, within their respective authorities,” according to the joint statement.
“FDA and FTC, as authorized by their respective statutes, will work together to address false or misleading communications about biologics, including biosimilars,” the statement continues. “In particular, if a communication makes a false or misleading comparison between a reference product and a biosimilar in a manner that misrepresents the safety or efficacy of biosimilars, deceives consumers, or deters competition, FDA and FTC intend to take appropriate action within their respective authorities. FDA intends to take appropriate action to address such communications where those communications have the potential to impact public health.”
Finally, the FTC committed to review patent settlement agreements involving biologics, including biosimilars, for antitrust violations.
Separately, the FDA issued a draft guidance document for comment on manufacturers seeking licensure of biosimilar products that do not cover all the approved uses of the reference product, as well as how to add uses over time that were not part of the initial license of the biosimilar product. The draft guidance covers licensure of products, labeling of biosimilars with fewer indications than the reference product, supplemental applications for indications not on the initial biosimilar application but covered by the reference product, and the timing of applications.
The FDA notes in the draft guidance that this is needed to cover situations such as when some indications on the reference product are covered by exclusivity, although it does encourage a biosimilar manufacturer to seek licensure for all indications that the reference product does have.
The Food and Drug Administration is collaborating with the Federal Trade Commission (FTC) to expand the biosimilars market.
The two agencies signed a joint statement on Feb. 3, 2020, outlining four sets of goals aimed at creating meaningful competition from biosimilars against their reference biologic products.
“Competition is key for helping American patients have access to affordable medicines,” FDA Commissioner Stephen Hahn, MD, said in a statement. “Strengthening efforts to curtail and discourage anticompetitive behavior is key for facilitating robust competition for patients in the biologics marketplace, including through biosimilars, bringing down the costs of these crucial products for patients.”
The statement highlighted four goals. First is that the agencies will coordinate to promote greater competition in the biologic market, including the development of materials to educate the market about biosimilars. The FDA and FTC also sponsored a public workshop on March 9 to discuss competition for biologics.
The second goal has the FDA and FTC working together “to deter behavior that impedes access to samples needed for the development of biologics, including biosimilars,” the joint statement notes.
Third, the agencies will crack down on “false or misleading communications about biologics, including biosimilars, within their respective authorities,” according to the joint statement.
“FDA and FTC, as authorized by their respective statutes, will work together to address false or misleading communications about biologics, including biosimilars,” the statement continues. “In particular, if a communication makes a false or misleading comparison between a reference product and a biosimilar in a manner that misrepresents the safety or efficacy of biosimilars, deceives consumers, or deters competition, FDA and FTC intend to take appropriate action within their respective authorities. FDA intends to take appropriate action to address such communications where those communications have the potential to impact public health.”
Finally, the FTC committed to review patent settlement agreements involving biologics, including biosimilars, for antitrust violations.
Separately, the FDA issued a draft guidance document for comment on manufacturers seeking licensure of biosimilar products that do not cover all the approved uses of the reference product, as well as how to add uses over time that were not part of the initial license of the biosimilar product. The draft guidance covers licensure of products, labeling of biosimilars with fewer indications than the reference product, supplemental applications for indications not on the initial biosimilar application but covered by the reference product, and the timing of applications.
The FDA notes in the draft guidance that this is needed to cover situations such as when some indications on the reference product are covered by exclusivity, although it does encourage a biosimilar manufacturer to seek licensure for all indications that the reference product does have.
COVID-19: Older patients with cancer especially vulnerable
For oncologists and other clinicians caring for patients with cancer, the COVID-19 pandemic represents a dynamic clinical challenge that is changing daily and that can feel overwhelming at times, say experts.
“Oncology clinicians are well versed in caring for immunosuppressed patients with cancer, of all ages,” Merry-Jennifer Markham, MD, interim chief of the Division of Hematology and Oncology at the University of Florida Health, Gainesville, told Medscape Medical News.
However, she emphasized that, during this COVID-19 outbreak, “we must be especially diligent about screening for symptoms and exposure, and we must recognize that our older patients with cancer may be especially vulnerable.”
Patients with cancer who are in active treatment are immunosuppressed and are more susceptible to infection and to complications from infection, Markham pointed out. “While we don’t yet have much data on how COVID-19 impacts patients with cancer, I have to suspect that patients undergoing active cancer treatment may be especially vulnerable to the more severe illness associated with COVID-19,” she said.
Indeed, a recent report from China that was published in the Lancet Oncology supports this. The authors suggest that patients with cancer are at higher risk for COVID-19 and have a worse prognosis if they become infected than do those without cancer.
Commonsense rules
Commonsense rules apply for all patients with cancer, regardless of age, said Markham. Measures include thorough handwashing, staying home when sick, and avoiding sick contacts.
Markham, who acts as an expert spokesperson for the American Society of Clinical Oncology, provides information on what patients with cancer need to know about COVID-19 at Cancer.net, the society’s website for patients with cancer.
“Unfortunately, this outbreak of COVID-19 is happening rapidly and in real time,” Markham noted. “The entire medical community is learning as we go, rather than having the luxury of years of evidence-based literature to guide us.”
Another expert agrees. “Unfortunately, there are not a lot of data on how COVID-19 affects cancer patients,” Cardinale Smith, MD, PhD, director of Quality for Cancer Services in the Mount Sinai Health System, New York City, said in an interview.
“We need to minimize the risk for patients and minimize our own exposure by treating this situation like we would a really bad flu season,” Smith told Medscape Medical News. “Some patients have had a bad outcome, but the vast majority do not. The best we can do is stay calm and focused.”
At Mount Sinai, for patients with cancer, routine, nonurgent appointments are being rescheduled for May, Smith said. Those in active treatment are screened by telephone 24 to 48 hours before arrival, after which they undergo a full risk assessment in an isolation room. Those with a respiratory infection are given a mask.
“Patients are very anxious and worried about COVID-19,” said Smith, who has young children and an elderly parent at home. “We don’t have all the answers, and this can heighten anxiety.”
To help allay fears, social workers are asking patients with cancer who express anxiety to discuss their concerns and provide information. A one-page handout on both flu and COVID-10 is available in the waiting room.
The Web portal MyChart gives patients access to updated information on COVID-19 precautions and provides links to the hospital website and to the US Centers for Disease Control and Prevention. Patients who are not feeling well can speak to someone or get answers if they have additional questions.
When counseling patients, Smith advises them to use “an abundance of caution” and to be creative in efforts to minimize risk. “My suggestion is to use FaceTime and Skype to connect and communicate with your community,” she said.
Some churches are conducting services via teleconferencing to minimize risk, and seniors’ centers that offer yoga and other classes are also beginning to provide services virtually, she pointed out.
Data from China
A report published February 14 in the Lancet Oncology appears to be the first analysis in the literature to focus on COVID-19 in patients with cancer.
“Patients with cancer are more susceptible to infection than individuals without cancer because of their systemic immunosuppressive state caused by the malignancy and anticancer treatments, such as chemotherapy or surgery,” write the authors, led by Wenhua Liang, MD, of Guangzhou Medical University. However, in correspondence published in the Lancet Oncology, other experts in China question some of Liang’s and colleagues’ findings.
The report by Liang and colleagues concerns a prospective cohort of 1590 patients with COVID-19.
There were 2007 laboratory-confirmed cases of COVID-19 among patients admitted to 575 hospitals throughout China as of January 31. Of those cases, 417 were excluded from the analysis because of insufficient information regarding disease history.
The team reports that of 18 patients with cancer and COVID-19, 39% were at significantly higher risk for “severe events.” By comparison, of 1572 patients with COVID-19 who did not have cancer, 8% were at significantly higher risk (P = .0003). These events included rapid clinical deterioration that required admission to intensive care; invasive ventilation; or death.
Patients with cancer experienced a much more rapid deterioration in clinical status than did those without cancer. The median time to severe events was 13 days, vs 43 days (hazard ratio [HR] adjusted for age, 3.56; P < .0001).
The analysis also shows that patients who underwent chemotherapy or surgery in the past month had a 75% risk of experiencing clinically severe events, compared with a 43% risk for those who had not received recent treatment.
After adjusting for other risk factors, including age and smoking history, older age was the only risk factor for severe events (odds ratio [OR], 1.43; 95% confidence interval [CI], 0.97 – 2.12; P = .072), the study authors say.
Patients with lung cancer did not have a higher probability of severe events compared with patients with other cancer types (20% vs 62%, respectively; P = .294).
Liang and colleagues conclude that these findings provide “a timely reminder to physicians that more intensive attention should be paid to patients with cancer, in case of rapid deterioration.”
The team also proposes three strategies for managing patients with cancer who are at risk for COVID-19 or any other severe infectious disease. They recommend that intentional postponement of adjuvant chemotherapy or elective surgery be considered for patients with stable cancer who live in areas where disease is endemic. Stronger “personal protection provisions” could also be made for patients with cancer or for cancer survivors. Lastly, for patients with cancer who have COVID-19, especially those who are older or who have comorbidities, more intensive surveillance or treatment should be considered.
However, in comments in the Lancet Oncology, other authors in China say these findings should be interpreted with caution.
One group suggests that the increased susceptibility to COVID-19 in patients with cancer could be the result of higher rates of smoking compared with patients who did not have cancer. “Overall, current evidence remains insufficient to explain a conclusive association between cancer and COVID-19,” say Huahao Shen, PhD, of Zhejiang University School of Medicine, Hangzhou, Zhejiang, and colleagues.
Another group suggests that the significantly higher median age of patients with cancer compared with noncancer patients (63 years vs 49 years) may have contributed to poor prognosis.
These authors, led by Li Zhang, MD, PhD, and Hanping Wang, MD, of Peking Union Medical College and the Chinese Academy of Medical Sciences, Beijing, emphasize that patients with cancer need online medical counseling and that critical cases need to be identified and treated.
“In endemic areas outside Wuhan, decisions on whether or not to postpone cancer treatment need to made on a patient-by-patient basis and according to the risk to the patient and the prevailing situation because delays could lead to tumor progression and ultimately poorer outcomes,” they write.
The study was funded by the China National Science Foundation and the Key Project of Guangzhou Scientific Research Project. Liang and coauthors, Shen and coauthors, Zhang, Wang, and Smith have disclosed no relevant financial relationships. Markham has relationships with Aduro Biotech, Lilly, Tesaro, Novartis, and VBL Therapeutics.
This article first appeared on Medscape.com.
For oncologists and other clinicians caring for patients with cancer, the COVID-19 pandemic represents a dynamic clinical challenge that is changing daily and that can feel overwhelming at times, say experts.
“Oncology clinicians are well versed in caring for immunosuppressed patients with cancer, of all ages,” Merry-Jennifer Markham, MD, interim chief of the Division of Hematology and Oncology at the University of Florida Health, Gainesville, told Medscape Medical News.
However, she emphasized that, during this COVID-19 outbreak, “we must be especially diligent about screening for symptoms and exposure, and we must recognize that our older patients with cancer may be especially vulnerable.”
Patients with cancer who are in active treatment are immunosuppressed and are more susceptible to infection and to complications from infection, Markham pointed out. “While we don’t yet have much data on how COVID-19 impacts patients with cancer, I have to suspect that patients undergoing active cancer treatment may be especially vulnerable to the more severe illness associated with COVID-19,” she said.
Indeed, a recent report from China that was published in the Lancet Oncology supports this. The authors suggest that patients with cancer are at higher risk for COVID-19 and have a worse prognosis if they become infected than do those without cancer.
Commonsense rules
Commonsense rules apply for all patients with cancer, regardless of age, said Markham. Measures include thorough handwashing, staying home when sick, and avoiding sick contacts.
Markham, who acts as an expert spokesperson for the American Society of Clinical Oncology, provides information on what patients with cancer need to know about COVID-19 at Cancer.net, the society’s website for patients with cancer.
“Unfortunately, this outbreak of COVID-19 is happening rapidly and in real time,” Markham noted. “The entire medical community is learning as we go, rather than having the luxury of years of evidence-based literature to guide us.”
Another expert agrees. “Unfortunately, there are not a lot of data on how COVID-19 affects cancer patients,” Cardinale Smith, MD, PhD, director of Quality for Cancer Services in the Mount Sinai Health System, New York City, said in an interview.
“We need to minimize the risk for patients and minimize our own exposure by treating this situation like we would a really bad flu season,” Smith told Medscape Medical News. “Some patients have had a bad outcome, but the vast majority do not. The best we can do is stay calm and focused.”
At Mount Sinai, for patients with cancer, routine, nonurgent appointments are being rescheduled for May, Smith said. Those in active treatment are screened by telephone 24 to 48 hours before arrival, after which they undergo a full risk assessment in an isolation room. Those with a respiratory infection are given a mask.
“Patients are very anxious and worried about COVID-19,” said Smith, who has young children and an elderly parent at home. “We don’t have all the answers, and this can heighten anxiety.”
To help allay fears, social workers are asking patients with cancer who express anxiety to discuss their concerns and provide information. A one-page handout on both flu and COVID-10 is available in the waiting room.
The Web portal MyChart gives patients access to updated information on COVID-19 precautions and provides links to the hospital website and to the US Centers for Disease Control and Prevention. Patients who are not feeling well can speak to someone or get answers if they have additional questions.
When counseling patients, Smith advises them to use “an abundance of caution” and to be creative in efforts to minimize risk. “My suggestion is to use FaceTime and Skype to connect and communicate with your community,” she said.
Some churches are conducting services via teleconferencing to minimize risk, and seniors’ centers that offer yoga and other classes are also beginning to provide services virtually, she pointed out.
Data from China
A report published February 14 in the Lancet Oncology appears to be the first analysis in the literature to focus on COVID-19 in patients with cancer.
“Patients with cancer are more susceptible to infection than individuals without cancer because of their systemic immunosuppressive state caused by the malignancy and anticancer treatments, such as chemotherapy or surgery,” write the authors, led by Wenhua Liang, MD, of Guangzhou Medical University. However, in correspondence published in the Lancet Oncology, other experts in China question some of Liang’s and colleagues’ findings.
The report by Liang and colleagues concerns a prospective cohort of 1590 patients with COVID-19.
There were 2007 laboratory-confirmed cases of COVID-19 among patients admitted to 575 hospitals throughout China as of January 31. Of those cases, 417 were excluded from the analysis because of insufficient information regarding disease history.
The team reports that of 18 patients with cancer and COVID-19, 39% were at significantly higher risk for “severe events.” By comparison, of 1572 patients with COVID-19 who did not have cancer, 8% were at significantly higher risk (P = .0003). These events included rapid clinical deterioration that required admission to intensive care; invasive ventilation; or death.
Patients with cancer experienced a much more rapid deterioration in clinical status than did those without cancer. The median time to severe events was 13 days, vs 43 days (hazard ratio [HR] adjusted for age, 3.56; P < .0001).
The analysis also shows that patients who underwent chemotherapy or surgery in the past month had a 75% risk of experiencing clinically severe events, compared with a 43% risk for those who had not received recent treatment.
After adjusting for other risk factors, including age and smoking history, older age was the only risk factor for severe events (odds ratio [OR], 1.43; 95% confidence interval [CI], 0.97 – 2.12; P = .072), the study authors say.
Patients with lung cancer did not have a higher probability of severe events compared with patients with other cancer types (20% vs 62%, respectively; P = .294).
Liang and colleagues conclude that these findings provide “a timely reminder to physicians that more intensive attention should be paid to patients with cancer, in case of rapid deterioration.”
The team also proposes three strategies for managing patients with cancer who are at risk for COVID-19 or any other severe infectious disease. They recommend that intentional postponement of adjuvant chemotherapy or elective surgery be considered for patients with stable cancer who live in areas where disease is endemic. Stronger “personal protection provisions” could also be made for patients with cancer or for cancer survivors. Lastly, for patients with cancer who have COVID-19, especially those who are older or who have comorbidities, more intensive surveillance or treatment should be considered.
However, in comments in the Lancet Oncology, other authors in China say these findings should be interpreted with caution.
One group suggests that the increased susceptibility to COVID-19 in patients with cancer could be the result of higher rates of smoking compared with patients who did not have cancer. “Overall, current evidence remains insufficient to explain a conclusive association between cancer and COVID-19,” say Huahao Shen, PhD, of Zhejiang University School of Medicine, Hangzhou, Zhejiang, and colleagues.
Another group suggests that the significantly higher median age of patients with cancer compared with noncancer patients (63 years vs 49 years) may have contributed to poor prognosis.
These authors, led by Li Zhang, MD, PhD, and Hanping Wang, MD, of Peking Union Medical College and the Chinese Academy of Medical Sciences, Beijing, emphasize that patients with cancer need online medical counseling and that critical cases need to be identified and treated.
“In endemic areas outside Wuhan, decisions on whether or not to postpone cancer treatment need to made on a patient-by-patient basis and according to the risk to the patient and the prevailing situation because delays could lead to tumor progression and ultimately poorer outcomes,” they write.
The study was funded by the China National Science Foundation and the Key Project of Guangzhou Scientific Research Project. Liang and coauthors, Shen and coauthors, Zhang, Wang, and Smith have disclosed no relevant financial relationships. Markham has relationships with Aduro Biotech, Lilly, Tesaro, Novartis, and VBL Therapeutics.
This article first appeared on Medscape.com.
For oncologists and other clinicians caring for patients with cancer, the COVID-19 pandemic represents a dynamic clinical challenge that is changing daily and that can feel overwhelming at times, say experts.
“Oncology clinicians are well versed in caring for immunosuppressed patients with cancer, of all ages,” Merry-Jennifer Markham, MD, interim chief of the Division of Hematology and Oncology at the University of Florida Health, Gainesville, told Medscape Medical News.
However, she emphasized that, during this COVID-19 outbreak, “we must be especially diligent about screening for symptoms and exposure, and we must recognize that our older patients with cancer may be especially vulnerable.”
Patients with cancer who are in active treatment are immunosuppressed and are more susceptible to infection and to complications from infection, Markham pointed out. “While we don’t yet have much data on how COVID-19 impacts patients with cancer, I have to suspect that patients undergoing active cancer treatment may be especially vulnerable to the more severe illness associated with COVID-19,” she said.
Indeed, a recent report from China that was published in the Lancet Oncology supports this. The authors suggest that patients with cancer are at higher risk for COVID-19 and have a worse prognosis if they become infected than do those without cancer.
Commonsense rules
Commonsense rules apply for all patients with cancer, regardless of age, said Markham. Measures include thorough handwashing, staying home when sick, and avoiding sick contacts.
Markham, who acts as an expert spokesperson for the American Society of Clinical Oncology, provides information on what patients with cancer need to know about COVID-19 at Cancer.net, the society’s website for patients with cancer.
“Unfortunately, this outbreak of COVID-19 is happening rapidly and in real time,” Markham noted. “The entire medical community is learning as we go, rather than having the luxury of years of evidence-based literature to guide us.”
Another expert agrees. “Unfortunately, there are not a lot of data on how COVID-19 affects cancer patients,” Cardinale Smith, MD, PhD, director of Quality for Cancer Services in the Mount Sinai Health System, New York City, said in an interview.
“We need to minimize the risk for patients and minimize our own exposure by treating this situation like we would a really bad flu season,” Smith told Medscape Medical News. “Some patients have had a bad outcome, but the vast majority do not. The best we can do is stay calm and focused.”
At Mount Sinai, for patients with cancer, routine, nonurgent appointments are being rescheduled for May, Smith said. Those in active treatment are screened by telephone 24 to 48 hours before arrival, after which they undergo a full risk assessment in an isolation room. Those with a respiratory infection are given a mask.
“Patients are very anxious and worried about COVID-19,” said Smith, who has young children and an elderly parent at home. “We don’t have all the answers, and this can heighten anxiety.”
To help allay fears, social workers are asking patients with cancer who express anxiety to discuss their concerns and provide information. A one-page handout on both flu and COVID-10 is available in the waiting room.
The Web portal MyChart gives patients access to updated information on COVID-19 precautions and provides links to the hospital website and to the US Centers for Disease Control and Prevention. Patients who are not feeling well can speak to someone or get answers if they have additional questions.
When counseling patients, Smith advises them to use “an abundance of caution” and to be creative in efforts to minimize risk. “My suggestion is to use FaceTime and Skype to connect and communicate with your community,” she said.
Some churches are conducting services via teleconferencing to minimize risk, and seniors’ centers that offer yoga and other classes are also beginning to provide services virtually, she pointed out.
Data from China
A report published February 14 in the Lancet Oncology appears to be the first analysis in the literature to focus on COVID-19 in patients with cancer.
“Patients with cancer are more susceptible to infection than individuals without cancer because of their systemic immunosuppressive state caused by the malignancy and anticancer treatments, such as chemotherapy or surgery,” write the authors, led by Wenhua Liang, MD, of Guangzhou Medical University. However, in correspondence published in the Lancet Oncology, other experts in China question some of Liang’s and colleagues’ findings.
The report by Liang and colleagues concerns a prospective cohort of 1590 patients with COVID-19.
There were 2007 laboratory-confirmed cases of COVID-19 among patients admitted to 575 hospitals throughout China as of January 31. Of those cases, 417 were excluded from the analysis because of insufficient information regarding disease history.
The team reports that of 18 patients with cancer and COVID-19, 39% were at significantly higher risk for “severe events.” By comparison, of 1572 patients with COVID-19 who did not have cancer, 8% were at significantly higher risk (P = .0003). These events included rapid clinical deterioration that required admission to intensive care; invasive ventilation; or death.
Patients with cancer experienced a much more rapid deterioration in clinical status than did those without cancer. The median time to severe events was 13 days, vs 43 days (hazard ratio [HR] adjusted for age, 3.56; P < .0001).
The analysis also shows that patients who underwent chemotherapy or surgery in the past month had a 75% risk of experiencing clinically severe events, compared with a 43% risk for those who had not received recent treatment.
After adjusting for other risk factors, including age and smoking history, older age was the only risk factor for severe events (odds ratio [OR], 1.43; 95% confidence interval [CI], 0.97 – 2.12; P = .072), the study authors say.
Patients with lung cancer did not have a higher probability of severe events compared with patients with other cancer types (20% vs 62%, respectively; P = .294).
Liang and colleagues conclude that these findings provide “a timely reminder to physicians that more intensive attention should be paid to patients with cancer, in case of rapid deterioration.”
The team also proposes three strategies for managing patients with cancer who are at risk for COVID-19 or any other severe infectious disease. They recommend that intentional postponement of adjuvant chemotherapy or elective surgery be considered for patients with stable cancer who live in areas where disease is endemic. Stronger “personal protection provisions” could also be made for patients with cancer or for cancer survivors. Lastly, for patients with cancer who have COVID-19, especially those who are older or who have comorbidities, more intensive surveillance or treatment should be considered.
However, in comments in the Lancet Oncology, other authors in China say these findings should be interpreted with caution.
One group suggests that the increased susceptibility to COVID-19 in patients with cancer could be the result of higher rates of smoking compared with patients who did not have cancer. “Overall, current evidence remains insufficient to explain a conclusive association between cancer and COVID-19,” say Huahao Shen, PhD, of Zhejiang University School of Medicine, Hangzhou, Zhejiang, and colleagues.
Another group suggests that the significantly higher median age of patients with cancer compared with noncancer patients (63 years vs 49 years) may have contributed to poor prognosis.
These authors, led by Li Zhang, MD, PhD, and Hanping Wang, MD, of Peking Union Medical College and the Chinese Academy of Medical Sciences, Beijing, emphasize that patients with cancer need online medical counseling and that critical cases need to be identified and treated.
“In endemic areas outside Wuhan, decisions on whether or not to postpone cancer treatment need to made on a patient-by-patient basis and according to the risk to the patient and the prevailing situation because delays could lead to tumor progression and ultimately poorer outcomes,” they write.
The study was funded by the China National Science Foundation and the Key Project of Guangzhou Scientific Research Project. Liang and coauthors, Shen and coauthors, Zhang, Wang, and Smith have disclosed no relevant financial relationships. Markham has relationships with Aduro Biotech, Lilly, Tesaro, Novartis, and VBL Therapeutics.
This article first appeared on Medscape.com.
A match made in medicine: Match Day 2020
Match Day is the celebration of the National Resident Matching Program® (NRMP®) results, which seals the fate not only of future medical professionals, but of the program placements dedicated to supporting the acceleration of their careers.
Daniel Ricotta, MD, FHM, an academic hospitalist at Beth Israel Deaconess Medical Center (BIDMC) in Boston, and an active SHM member since 2013, offers unique insight into the value of understanding both sides of this interview table.
As the associate program director of BIDMC’s Internal Medicine Residency Program and the director of Simulation Education at the Carl J. Shapiro Center for Education & Research, Dr. Ricotta is able to act on his passions for medical education and clinical care.
“I was attracted to the breadth of medicine and enjoyed learning everything,” Dr. Ricotta said. “I knew I wanted to do academic medicine and education, and I was able to get involved by working with students and residents early on in my career.”
A natural fit for his current roles, Dr. Ricotta has gained a unique perspective on the match process and how it has evolved since he began his residency nine years ago.
Preparing for Match Day includes an extensive checklist of life-altering to-dos that shape your career trajectory. Medical students must have noteworthy CV points, scholarly recommendations, stand-out interviews, and a thoughtful rank list – among many other things to consider throughout the course of the match. Dr. Ricotta said that while this application process has generally remained the same since his participation, he has noticed that the students themselves have changed.
“Students going into residency are more mature and further along professionally,” he explained. “I’ve seen more students go on to do something else for a while and have gained more experience. They’re taking time off for research or getting dual degrees.”
Additionally, according to Dr. Ricotta, students are applying to double the number of programs than in years past, and are even using technology to their benefit. Because interview slots are limited, some students set up “bot automation” to help lock in interviews.
Amidst what can feel like a free-for-all, Dr. Ricotta reminds his students that the match process is a two-sided relationship.
“I certainly didn’t realize how much work goes into recruitment when I was a student,” Dr. Ricotta admitted. “What students don’t think about is the amount of care that goes into trying to match students who share similar values, the mission, or are a good cultural fit.”
He went on to emphasize the importance of environmental compatibility.
“Go somewhere that you feel you will fit in. Where you will thrive,” he said. “Go somewhere that has a mission that resonates with your mission and think about your fellow applicants and potential mentorship. Could you see yourself being their classmate? Does this program have people there who can help you to achieve your goals?”
Keeping in mind questions like these, it is no surprise that because of hospital medicine’s scheduling flexibility and hands-on learning opportunities that more and more students are interested in exploring this specialty.
“What is amazing about hospital medicine is the ample opportunity for you to get involved earlier in your career and build from that,” he said. “There is more face time with patients, more training for medical students available, countless academic opportunities in research and scholarships, and even conferences.”
Because of the multiple career pathways available in hospital medicine, SHM aims to provide students and residents with professional tools and opportunities as early as possible to allow them to get a preview of what they can expect as a hospitalist – no matter which path they choose.
“SHM is about getting involved,” said Dr. Ricotta. “SHM encourages residents to become actively incorporated into the community through chapters, conferences, and other networking opportunities on both local and national levels. That’s really difficult to do as a resident.”
Whether you’re waiting on the NRMP® results this year or you are in the beginning stages of gathering your application materials, one thing is clear according to Dr. Ricotta, you’re not just an applicant number.
Are you a student interested in exploring a career in hospital medicine? SHM supports educational and professional needs at all stages of your career. When you join SHM during your residency training, you receive access to programs, resources, and opportunities that will enhance your skills and raise your professional profile. For more information about our Residents & Fellows membership opportunity, please visit: hospitalmedicine.org/residents.
Ms. Cowan is a marketing communications specialist at the Society of Hospital Medicine.
Match Day is the celebration of the National Resident Matching Program® (NRMP®) results, which seals the fate not only of future medical professionals, but of the program placements dedicated to supporting the acceleration of their careers.
Daniel Ricotta, MD, FHM, an academic hospitalist at Beth Israel Deaconess Medical Center (BIDMC) in Boston, and an active SHM member since 2013, offers unique insight into the value of understanding both sides of this interview table.
As the associate program director of BIDMC’s Internal Medicine Residency Program and the director of Simulation Education at the Carl J. Shapiro Center for Education & Research, Dr. Ricotta is able to act on his passions for medical education and clinical care.
“I was attracted to the breadth of medicine and enjoyed learning everything,” Dr. Ricotta said. “I knew I wanted to do academic medicine and education, and I was able to get involved by working with students and residents early on in my career.”
A natural fit for his current roles, Dr. Ricotta has gained a unique perspective on the match process and how it has evolved since he began his residency nine years ago.
Preparing for Match Day includes an extensive checklist of life-altering to-dos that shape your career trajectory. Medical students must have noteworthy CV points, scholarly recommendations, stand-out interviews, and a thoughtful rank list – among many other things to consider throughout the course of the match. Dr. Ricotta said that while this application process has generally remained the same since his participation, he has noticed that the students themselves have changed.
“Students going into residency are more mature and further along professionally,” he explained. “I’ve seen more students go on to do something else for a while and have gained more experience. They’re taking time off for research or getting dual degrees.”
Additionally, according to Dr. Ricotta, students are applying to double the number of programs than in years past, and are even using technology to their benefit. Because interview slots are limited, some students set up “bot automation” to help lock in interviews.
Amidst what can feel like a free-for-all, Dr. Ricotta reminds his students that the match process is a two-sided relationship.
“I certainly didn’t realize how much work goes into recruitment when I was a student,” Dr. Ricotta admitted. “What students don’t think about is the amount of care that goes into trying to match students who share similar values, the mission, or are a good cultural fit.”
He went on to emphasize the importance of environmental compatibility.
“Go somewhere that you feel you will fit in. Where you will thrive,” he said. “Go somewhere that has a mission that resonates with your mission and think about your fellow applicants and potential mentorship. Could you see yourself being their classmate? Does this program have people there who can help you to achieve your goals?”
Keeping in mind questions like these, it is no surprise that because of hospital medicine’s scheduling flexibility and hands-on learning opportunities that more and more students are interested in exploring this specialty.
“What is amazing about hospital medicine is the ample opportunity for you to get involved earlier in your career and build from that,” he said. “There is more face time with patients, more training for medical students available, countless academic opportunities in research and scholarships, and even conferences.”
Because of the multiple career pathways available in hospital medicine, SHM aims to provide students and residents with professional tools and opportunities as early as possible to allow them to get a preview of what they can expect as a hospitalist – no matter which path they choose.
“SHM is about getting involved,” said Dr. Ricotta. “SHM encourages residents to become actively incorporated into the community through chapters, conferences, and other networking opportunities on both local and national levels. That’s really difficult to do as a resident.”
Whether you’re waiting on the NRMP® results this year or you are in the beginning stages of gathering your application materials, one thing is clear according to Dr. Ricotta, you’re not just an applicant number.
Are you a student interested in exploring a career in hospital medicine? SHM supports educational and professional needs at all stages of your career. When you join SHM during your residency training, you receive access to programs, resources, and opportunities that will enhance your skills and raise your professional profile. For more information about our Residents & Fellows membership opportunity, please visit: hospitalmedicine.org/residents.
Ms. Cowan is a marketing communications specialist at the Society of Hospital Medicine.
Match Day is the celebration of the National Resident Matching Program® (NRMP®) results, which seals the fate not only of future medical professionals, but of the program placements dedicated to supporting the acceleration of their careers.
Daniel Ricotta, MD, FHM, an academic hospitalist at Beth Israel Deaconess Medical Center (BIDMC) in Boston, and an active SHM member since 2013, offers unique insight into the value of understanding both sides of this interview table.
As the associate program director of BIDMC’s Internal Medicine Residency Program and the director of Simulation Education at the Carl J. Shapiro Center for Education & Research, Dr. Ricotta is able to act on his passions for medical education and clinical care.
“I was attracted to the breadth of medicine and enjoyed learning everything,” Dr. Ricotta said. “I knew I wanted to do academic medicine and education, and I was able to get involved by working with students and residents early on in my career.”
A natural fit for his current roles, Dr. Ricotta has gained a unique perspective on the match process and how it has evolved since he began his residency nine years ago.
Preparing for Match Day includes an extensive checklist of life-altering to-dos that shape your career trajectory. Medical students must have noteworthy CV points, scholarly recommendations, stand-out interviews, and a thoughtful rank list – among many other things to consider throughout the course of the match. Dr. Ricotta said that while this application process has generally remained the same since his participation, he has noticed that the students themselves have changed.
“Students going into residency are more mature and further along professionally,” he explained. “I’ve seen more students go on to do something else for a while and have gained more experience. They’re taking time off for research or getting dual degrees.”
Additionally, according to Dr. Ricotta, students are applying to double the number of programs than in years past, and are even using technology to their benefit. Because interview slots are limited, some students set up “bot automation” to help lock in interviews.
Amidst what can feel like a free-for-all, Dr. Ricotta reminds his students that the match process is a two-sided relationship.
“I certainly didn’t realize how much work goes into recruitment when I was a student,” Dr. Ricotta admitted. “What students don’t think about is the amount of care that goes into trying to match students who share similar values, the mission, or are a good cultural fit.”
He went on to emphasize the importance of environmental compatibility.
“Go somewhere that you feel you will fit in. Where you will thrive,” he said. “Go somewhere that has a mission that resonates with your mission and think about your fellow applicants and potential mentorship. Could you see yourself being their classmate? Does this program have people there who can help you to achieve your goals?”
Keeping in mind questions like these, it is no surprise that because of hospital medicine’s scheduling flexibility and hands-on learning opportunities that more and more students are interested in exploring this specialty.
“What is amazing about hospital medicine is the ample opportunity for you to get involved earlier in your career and build from that,” he said. “There is more face time with patients, more training for medical students available, countless academic opportunities in research and scholarships, and even conferences.”
Because of the multiple career pathways available in hospital medicine, SHM aims to provide students and residents with professional tools and opportunities as early as possible to allow them to get a preview of what they can expect as a hospitalist – no matter which path they choose.
“SHM is about getting involved,” said Dr. Ricotta. “SHM encourages residents to become actively incorporated into the community through chapters, conferences, and other networking opportunities on both local and national levels. That’s really difficult to do as a resident.”
Whether you’re waiting on the NRMP® results this year or you are in the beginning stages of gathering your application materials, one thing is clear according to Dr. Ricotta, you’re not just an applicant number.
Are you a student interested in exploring a career in hospital medicine? SHM supports educational and professional needs at all stages of your career. When you join SHM during your residency training, you receive access to programs, resources, and opportunities that will enhance your skills and raise your professional profile. For more information about our Residents & Fellows membership opportunity, please visit: hospitalmedicine.org/residents.
Ms. Cowan is a marketing communications specialist at the Society of Hospital Medicine.
Program Helps Native Americans Get Back to the Roots of Good Health
Diabetes used to be rare among Native Americans. Before the 1950s, there were few accounts of lifestyle diseases like type 2 diabetes mellitus (T2DM), says Valarie Blue Bird Jernigan, a member of the Choctaw Nation and University of Oklahoma researcher who studies the impacts of food environments on Native American health: “They couldn’t really be found in Native American communities. The major problem was malnutrition.” In 1940, only 21 cases of T2DM were identified among the Akimel O’odham people living in the Sonoran Desert. By 2006, 38% of adults in that tribe had T2DM.
The rate of diagnosed T2DM among American Indian/Alaska Native (AI/AN) adults is now double that of white adults, and the incidence among children and young adults is > 10 times that of other groups.
“Focusing on biologic factors alone overlooks factors that propel development of chronic diseases,” say researchers from the University of New Mexico and the Centers for Disease Control and Prevention (CDC) Native Diabetes Wellness program. Poverty, historical trauma, and adverse childhood experiences all play a part in AI/AN health issues. But food insecurity—uncertain or limited access to enough food for a healthy life—also correlates with greater risk of T2DM. In 2016, nearly 30% of AI/AN households were food insecure, compared with 16% of non-AI/AN households. Rates of food insecurity among AI/AN children are about double the national rates. Compounding the problem, “food deserts” are still common in Indian Country.
Native Americans used to eat healthier, living off the land, hunting, and fishing. Then federal mandates affected the land and water resources of tribal nations, disrupting indigenous food systems and reducing access to traditional foods, the researchers say. In the 1970s, the federal government began buying up surplus foods to support prices for farmers, then providing them to Native communities. The food was needed—the problem was that it consisted largely of high-salt, high-fat, high-sugar canned foods. One consequence of the calorie-dense commodities-based diet was “commod bod,” a phrase coined in Native communities.
Recently some traditional foods, like hand-harvested wild rice, grass-fed bison, and wild-caught Pacific salmon, have been added to the food assistance programs; the US Department of Agriculture cites high rates of participant satisfaction. About one-third of 103 tribal organizations also now have “grocery-store–like models” where aid recipients can select their own foods, including fresh fruits and vegetables.
However, in February, the Trump administration released a proposal to overhaul the Supplemental Nutrition Assistance Program, replacing half the benefits people receive with boxed, nonperishable foods. According to recent research, Jernigan says, 60% of Native Americans who receive food assistance through the Supplemental Nutrition Assistance Program rely on the program as their primary source of food.
It became clear that one way to help AI/AN communities reclaim their health was to bring back the old ways. The Indian Health Service (IHS) Tribal Leaders Diabetes Committee has supported programs in which AI/AN communities integrate their own cultures and history, to encourage healthier lifestyles. The concept of a “food sovereignty movement” evolved into programs like the Traditional Foods Project (TFP).
The TFP has provided “modest” funding to AI/AN communities to design their own interventions promoting access to traditional foods, physical activity, and social support. The project began in 2008 with 11 tribes and tribal organizations, and expanded to 17 in 2009.
Recently, the CDC researchers reported on how the TFP was doing, evaluating data the tribal partners collected between 2008 and 2014 in 3 domains: traditional foods, physical activity, and social support. Each partner used various strategies aimed at behavior changes, with unique solutions in each group. Some of their initiatives covered > 1 domain: gardening, for instance, involved physical activity, social support, and traditional foods.
From 82% to 94% of the partners (numbers varied as more communities joined the TFP) reported gardening during summer months; 59% to 82% also gardened during the winter. Many started community gardens, but school gardens had the most participants. In 1 year, 6 communities had school gardens involving 3,017 people. Most of the partners also began focusing on sustainability, using heirloom seeds, for instance. One coordinator took a course to become a Master Composter, balancing traditional ecological knowledge and Western science, leading to “large yields of harvested produce.”
Healthy food outlets increased, reported by 11 of 16 communities in T10, up from 2 of 11 in the first test period. Moreover, by T10, nearly two-thirds of the partners reported that healthy food selections were available at 1 or more venues, including worksites, supermarkets, vending machines, and restaurants.
Most partners reported health education activities for each period, involving nearly 11,000 participants. Storytelling was an important teaching activity, the researchers say. Head Start organizations added physical activities, gardening, and a health education curriculum.
The partners measured changes such as weight loss, improved physical activity, and healthy food choices in 69 of 156 data points recorded during the 10 periods. In most periods, almost half of the partners measured participant change in 1 or more domains. As many as 7,500 participants took part in organized physical activities for 1 partner during 1 period. Involvement in activities peaked in the middle years but leveled off at a median of about 65%.
The researchers also gathered observations from the partners. The program’s impact was visible not only community-wide, but among individuals. One young man who had struggled with substance abuse said he “found himself through connection with the earth” in the community garden. Another participant said, “Food is good medicine.”
A thread in every discussion, the researchers say, was: “Traditional foods have become a way to talk about health.” The way to reclaim health, the partners came to believe, was to reconnect with the land, water, traditional foodways, and “all that they mean.”
Diabetes used to be rare among Native Americans. Before the 1950s, there were few accounts of lifestyle diseases like type 2 diabetes mellitus (T2DM), says Valarie Blue Bird Jernigan, a member of the Choctaw Nation and University of Oklahoma researcher who studies the impacts of food environments on Native American health: “They couldn’t really be found in Native American communities. The major problem was malnutrition.” In 1940, only 21 cases of T2DM were identified among the Akimel O’odham people living in the Sonoran Desert. By 2006, 38% of adults in that tribe had T2DM.
The rate of diagnosed T2DM among American Indian/Alaska Native (AI/AN) adults is now double that of white adults, and the incidence among children and young adults is > 10 times that of other groups.
“Focusing on biologic factors alone overlooks factors that propel development of chronic diseases,” say researchers from the University of New Mexico and the Centers for Disease Control and Prevention (CDC) Native Diabetes Wellness program. Poverty, historical trauma, and adverse childhood experiences all play a part in AI/AN health issues. But food insecurity—uncertain or limited access to enough food for a healthy life—also correlates with greater risk of T2DM. In 2016, nearly 30% of AI/AN households were food insecure, compared with 16% of non-AI/AN households. Rates of food insecurity among AI/AN children are about double the national rates. Compounding the problem, “food deserts” are still common in Indian Country.
Native Americans used to eat healthier, living off the land, hunting, and fishing. Then federal mandates affected the land and water resources of tribal nations, disrupting indigenous food systems and reducing access to traditional foods, the researchers say. In the 1970s, the federal government began buying up surplus foods to support prices for farmers, then providing them to Native communities. The food was needed—the problem was that it consisted largely of high-salt, high-fat, high-sugar canned foods. One consequence of the calorie-dense commodities-based diet was “commod bod,” a phrase coined in Native communities.
Recently some traditional foods, like hand-harvested wild rice, grass-fed bison, and wild-caught Pacific salmon, have been added to the food assistance programs; the US Department of Agriculture cites high rates of participant satisfaction. About one-third of 103 tribal organizations also now have “grocery-store–like models” where aid recipients can select their own foods, including fresh fruits and vegetables.
However, in February, the Trump administration released a proposal to overhaul the Supplemental Nutrition Assistance Program, replacing half the benefits people receive with boxed, nonperishable foods. According to recent research, Jernigan says, 60% of Native Americans who receive food assistance through the Supplemental Nutrition Assistance Program rely on the program as their primary source of food.
It became clear that one way to help AI/AN communities reclaim their health was to bring back the old ways. The Indian Health Service (IHS) Tribal Leaders Diabetes Committee has supported programs in which AI/AN communities integrate their own cultures and history, to encourage healthier lifestyles. The concept of a “food sovereignty movement” evolved into programs like the Traditional Foods Project (TFP).
The TFP has provided “modest” funding to AI/AN communities to design their own interventions promoting access to traditional foods, physical activity, and social support. The project began in 2008 with 11 tribes and tribal organizations, and expanded to 17 in 2009.
Recently, the CDC researchers reported on how the TFP was doing, evaluating data the tribal partners collected between 2008 and 2014 in 3 domains: traditional foods, physical activity, and social support. Each partner used various strategies aimed at behavior changes, with unique solutions in each group. Some of their initiatives covered > 1 domain: gardening, for instance, involved physical activity, social support, and traditional foods.
From 82% to 94% of the partners (numbers varied as more communities joined the TFP) reported gardening during summer months; 59% to 82% also gardened during the winter. Many started community gardens, but school gardens had the most participants. In 1 year, 6 communities had school gardens involving 3,017 people. Most of the partners also began focusing on sustainability, using heirloom seeds, for instance. One coordinator took a course to become a Master Composter, balancing traditional ecological knowledge and Western science, leading to “large yields of harvested produce.”
Healthy food outlets increased, reported by 11 of 16 communities in T10, up from 2 of 11 in the first test period. Moreover, by T10, nearly two-thirds of the partners reported that healthy food selections were available at 1 or more venues, including worksites, supermarkets, vending machines, and restaurants.
Most partners reported health education activities for each period, involving nearly 11,000 participants. Storytelling was an important teaching activity, the researchers say. Head Start organizations added physical activities, gardening, and a health education curriculum.
The partners measured changes such as weight loss, improved physical activity, and healthy food choices in 69 of 156 data points recorded during the 10 periods. In most periods, almost half of the partners measured participant change in 1 or more domains. As many as 7,500 participants took part in organized physical activities for 1 partner during 1 period. Involvement in activities peaked in the middle years but leveled off at a median of about 65%.
The researchers also gathered observations from the partners. The program’s impact was visible not only community-wide, but among individuals. One young man who had struggled with substance abuse said he “found himself through connection with the earth” in the community garden. Another participant said, “Food is good medicine.”
A thread in every discussion, the researchers say, was: “Traditional foods have become a way to talk about health.” The way to reclaim health, the partners came to believe, was to reconnect with the land, water, traditional foodways, and “all that they mean.”
Diabetes used to be rare among Native Americans. Before the 1950s, there were few accounts of lifestyle diseases like type 2 diabetes mellitus (T2DM), says Valarie Blue Bird Jernigan, a member of the Choctaw Nation and University of Oklahoma researcher who studies the impacts of food environments on Native American health: “They couldn’t really be found in Native American communities. The major problem was malnutrition.” In 1940, only 21 cases of T2DM were identified among the Akimel O’odham people living in the Sonoran Desert. By 2006, 38% of adults in that tribe had T2DM.
The rate of diagnosed T2DM among American Indian/Alaska Native (AI/AN) adults is now double that of white adults, and the incidence among children and young adults is > 10 times that of other groups.
“Focusing on biologic factors alone overlooks factors that propel development of chronic diseases,” say researchers from the University of New Mexico and the Centers for Disease Control and Prevention (CDC) Native Diabetes Wellness program. Poverty, historical trauma, and adverse childhood experiences all play a part in AI/AN health issues. But food insecurity—uncertain or limited access to enough food for a healthy life—also correlates with greater risk of T2DM. In 2016, nearly 30% of AI/AN households were food insecure, compared with 16% of non-AI/AN households. Rates of food insecurity among AI/AN children are about double the national rates. Compounding the problem, “food deserts” are still common in Indian Country.
Native Americans used to eat healthier, living off the land, hunting, and fishing. Then federal mandates affected the land and water resources of tribal nations, disrupting indigenous food systems and reducing access to traditional foods, the researchers say. In the 1970s, the federal government began buying up surplus foods to support prices for farmers, then providing them to Native communities. The food was needed—the problem was that it consisted largely of high-salt, high-fat, high-sugar canned foods. One consequence of the calorie-dense commodities-based diet was “commod bod,” a phrase coined in Native communities.
Recently some traditional foods, like hand-harvested wild rice, grass-fed bison, and wild-caught Pacific salmon, have been added to the food assistance programs; the US Department of Agriculture cites high rates of participant satisfaction. About one-third of 103 tribal organizations also now have “grocery-store–like models” where aid recipients can select their own foods, including fresh fruits and vegetables.
However, in February, the Trump administration released a proposal to overhaul the Supplemental Nutrition Assistance Program, replacing half the benefits people receive with boxed, nonperishable foods. According to recent research, Jernigan says, 60% of Native Americans who receive food assistance through the Supplemental Nutrition Assistance Program rely on the program as their primary source of food.
It became clear that one way to help AI/AN communities reclaim their health was to bring back the old ways. The Indian Health Service (IHS) Tribal Leaders Diabetes Committee has supported programs in which AI/AN communities integrate their own cultures and history, to encourage healthier lifestyles. The concept of a “food sovereignty movement” evolved into programs like the Traditional Foods Project (TFP).
The TFP has provided “modest” funding to AI/AN communities to design their own interventions promoting access to traditional foods, physical activity, and social support. The project began in 2008 with 11 tribes and tribal organizations, and expanded to 17 in 2009.
Recently, the CDC researchers reported on how the TFP was doing, evaluating data the tribal partners collected between 2008 and 2014 in 3 domains: traditional foods, physical activity, and social support. Each partner used various strategies aimed at behavior changes, with unique solutions in each group. Some of their initiatives covered > 1 domain: gardening, for instance, involved physical activity, social support, and traditional foods.
From 82% to 94% of the partners (numbers varied as more communities joined the TFP) reported gardening during summer months; 59% to 82% also gardened during the winter. Many started community gardens, but school gardens had the most participants. In 1 year, 6 communities had school gardens involving 3,017 people. Most of the partners also began focusing on sustainability, using heirloom seeds, for instance. One coordinator took a course to become a Master Composter, balancing traditional ecological knowledge and Western science, leading to “large yields of harvested produce.”
Healthy food outlets increased, reported by 11 of 16 communities in T10, up from 2 of 11 in the first test period. Moreover, by T10, nearly two-thirds of the partners reported that healthy food selections were available at 1 or more venues, including worksites, supermarkets, vending machines, and restaurants.
Most partners reported health education activities for each period, involving nearly 11,000 participants. Storytelling was an important teaching activity, the researchers say. Head Start organizations added physical activities, gardening, and a health education curriculum.
The partners measured changes such as weight loss, improved physical activity, and healthy food choices in 69 of 156 data points recorded during the 10 periods. In most periods, almost half of the partners measured participant change in 1 or more domains. As many as 7,500 participants took part in organized physical activities for 1 partner during 1 period. Involvement in activities peaked in the middle years but leveled off at a median of about 65%.
The researchers also gathered observations from the partners. The program’s impact was visible not only community-wide, but among individuals. One young man who had struggled with substance abuse said he “found himself through connection with the earth” in the community garden. Another participant said, “Food is good medicine.”
A thread in every discussion, the researchers say, was: “Traditional foods have become a way to talk about health.” The way to reclaim health, the partners came to believe, was to reconnect with the land, water, traditional foodways, and “all that they mean.”
Red meat intake linked to increased risk of fatal CHD in men
PHOENIX – Consumption of red meat, particularly the processed form, is linked to a higher risk of developing coronary heart disease in men, results from a large prospective analysis demonstrated.
“The findings of this study are in line with randomized trials showing that the consumption of red meat, as compared with plant-based protein sources, increases LDL cholesterol levels, and with previous studies on red meat and risk of coronary heart disease,” lead study author Laila Al-Shaar, MPH, PhD, said in an interview in advance of the Epidemiology and Prevention/Lifestyle and Cardiometabolic Health meeting.
According to Dr. Al-Shaar, a postdoctoral research fellow in the department of nutrition at the T.H. Chan School of Public Health at Harvard University, Boston, most of the existing studies on red meat and heart disease have examined the impact of increasing consumption of red meat while decreasing consumption of all other foods. For the current study, she and her colleagues used a substitution analysis approach to understand how replacing red meat (total, processed, or unprocessed) with another protein-rich food was associated with the risk of heart disease. “This would potentially provide more specific guidance for healthier alternatives for those planning to cut down their red meat intake,” she said.
She and her colleagues prospectively followed 43,259 men in the Health Professionals Follow-up Study (1986-2012) who had no known history of cancer or cardiovascular disease. Diet was assessed by a standardized and validated food frequency questionnaire that was updated every 4 years. Dr. Al-Shaar and her colleagues used multivariate Cox models to estimate hazard ratios and 95% confidence intervals of CHD risk across categories of red meat consumption. They performed substitution analyses by comparing coefficients in models including alternative foods as continuous variables.
Over roughly 933,000 person-years of follow-up, the researchers documented 4,148 incident CHD cases. Of these, 1,680 were fatal. After multivariate adjustment for dietary and nondietary risk factors, both total and processed red meat intake were associated with a modestly higher risk of CHD (hazard ratio for a one serving/day increment, 1.08; 95% confidence interval, 1.01-1.14 for total red meat; and HR, 1.13; 95% CI, 1.03-1.22 for processed red meat). Substitutions of one serving per day of other foods (including nuts, legumes, soy, whole grains, and low- and high-fat dairy) for one serving per day of total red meat were associated with a 10%-47% lower CHD risk.
Stronger inverse associations were observed between some of these substitutions for red meat and risk of fatal CHD. Substituting nuts lowered the risk of fatal heart disease by 17%, while replacing red meat with whole grains was linked to a 48% reduction in that outcome. Those associations were more pronounced when replacing processed red meat.
“Processed meats and meats in general have been thought to be potentially not favorable in terms of cardiovascular disease and cardiovascular disease risk,” Robert H. Eckel, MD, professor emeritus of medicine at the University of Colorado Anschutz Medical Campus, Aurora, said in an interview. “Now we have increasing data that not only is there a negative cardiovascular disease impact of animal protein, but we see this on all-cause mortality, including cancer.”
Dr. Al-Shaar said that the findings “support current recommendations to limit consumption of red meat and suggest that high-quality plant-based proteins such as nuts, legumes, and soy are good alternatives for individuals planning to have better food choices and healthier eating patterns.”
She acknowledged certain limitations of the study, including its observational design and the fact that it was limited to non-Hispanic white health professionals, “thus limiting the generalizability of its findings to the whole population.”
Dr. Eckel, who is a past president of the American Heart Association, underscored the importance of one’s overall diet in mitigating the risk of developing coronary heart disease. “It’s not simply substituting animal protein with plant protein,” he said. “Fruits and vegetables and whole grains, lean protein from fish – a Mediterranean-style diet – is what the AHA recommends.”
Dr. Al-Shaar reported having no financial disclosures. The study was supported by a T32 training grant from the National Institutes of Health and by other grants from the NIH. The meeting was sponsored by the AHA.
SOURCE: Al-Shaar L et al. Epi/Lifestyle 2020, Abstract P512.
PHOENIX – Consumption of red meat, particularly the processed form, is linked to a higher risk of developing coronary heart disease in men, results from a large prospective analysis demonstrated.
“The findings of this study are in line with randomized trials showing that the consumption of red meat, as compared with plant-based protein sources, increases LDL cholesterol levels, and with previous studies on red meat and risk of coronary heart disease,” lead study author Laila Al-Shaar, MPH, PhD, said in an interview in advance of the Epidemiology and Prevention/Lifestyle and Cardiometabolic Health meeting.
According to Dr. Al-Shaar, a postdoctoral research fellow in the department of nutrition at the T.H. Chan School of Public Health at Harvard University, Boston, most of the existing studies on red meat and heart disease have examined the impact of increasing consumption of red meat while decreasing consumption of all other foods. For the current study, she and her colleagues used a substitution analysis approach to understand how replacing red meat (total, processed, or unprocessed) with another protein-rich food was associated with the risk of heart disease. “This would potentially provide more specific guidance for healthier alternatives for those planning to cut down their red meat intake,” she said.
She and her colleagues prospectively followed 43,259 men in the Health Professionals Follow-up Study (1986-2012) who had no known history of cancer or cardiovascular disease. Diet was assessed by a standardized and validated food frequency questionnaire that was updated every 4 years. Dr. Al-Shaar and her colleagues used multivariate Cox models to estimate hazard ratios and 95% confidence intervals of CHD risk across categories of red meat consumption. They performed substitution analyses by comparing coefficients in models including alternative foods as continuous variables.
Over roughly 933,000 person-years of follow-up, the researchers documented 4,148 incident CHD cases. Of these, 1,680 were fatal. After multivariate adjustment for dietary and nondietary risk factors, both total and processed red meat intake were associated with a modestly higher risk of CHD (hazard ratio for a one serving/day increment, 1.08; 95% confidence interval, 1.01-1.14 for total red meat; and HR, 1.13; 95% CI, 1.03-1.22 for processed red meat). Substitutions of one serving per day of other foods (including nuts, legumes, soy, whole grains, and low- and high-fat dairy) for one serving per day of total red meat were associated with a 10%-47% lower CHD risk.
Stronger inverse associations were observed between some of these substitutions for red meat and risk of fatal CHD. Substituting nuts lowered the risk of fatal heart disease by 17%, while replacing red meat with whole grains was linked to a 48% reduction in that outcome. Those associations were more pronounced when replacing processed red meat.
“Processed meats and meats in general have been thought to be potentially not favorable in terms of cardiovascular disease and cardiovascular disease risk,” Robert H. Eckel, MD, professor emeritus of medicine at the University of Colorado Anschutz Medical Campus, Aurora, said in an interview. “Now we have increasing data that not only is there a negative cardiovascular disease impact of animal protein, but we see this on all-cause mortality, including cancer.”
Dr. Al-Shaar said that the findings “support current recommendations to limit consumption of red meat and suggest that high-quality plant-based proteins such as nuts, legumes, and soy are good alternatives for individuals planning to have better food choices and healthier eating patterns.”
She acknowledged certain limitations of the study, including its observational design and the fact that it was limited to non-Hispanic white health professionals, “thus limiting the generalizability of its findings to the whole population.”
Dr. Eckel, who is a past president of the American Heart Association, underscored the importance of one’s overall diet in mitigating the risk of developing coronary heart disease. “It’s not simply substituting animal protein with plant protein,” he said. “Fruits and vegetables and whole grains, lean protein from fish – a Mediterranean-style diet – is what the AHA recommends.”
Dr. Al-Shaar reported having no financial disclosures. The study was supported by a T32 training grant from the National Institutes of Health and by other grants from the NIH. The meeting was sponsored by the AHA.
SOURCE: Al-Shaar L et al. Epi/Lifestyle 2020, Abstract P512.
PHOENIX – Consumption of red meat, particularly the processed form, is linked to a higher risk of developing coronary heart disease in men, results from a large prospective analysis demonstrated.
“The findings of this study are in line with randomized trials showing that the consumption of red meat, as compared with plant-based protein sources, increases LDL cholesterol levels, and with previous studies on red meat and risk of coronary heart disease,” lead study author Laila Al-Shaar, MPH, PhD, said in an interview in advance of the Epidemiology and Prevention/Lifestyle and Cardiometabolic Health meeting.
According to Dr. Al-Shaar, a postdoctoral research fellow in the department of nutrition at the T.H. Chan School of Public Health at Harvard University, Boston, most of the existing studies on red meat and heart disease have examined the impact of increasing consumption of red meat while decreasing consumption of all other foods. For the current study, she and her colleagues used a substitution analysis approach to understand how replacing red meat (total, processed, or unprocessed) with another protein-rich food was associated with the risk of heart disease. “This would potentially provide more specific guidance for healthier alternatives for those planning to cut down their red meat intake,” she said.
She and her colleagues prospectively followed 43,259 men in the Health Professionals Follow-up Study (1986-2012) who had no known history of cancer or cardiovascular disease. Diet was assessed by a standardized and validated food frequency questionnaire that was updated every 4 years. Dr. Al-Shaar and her colleagues used multivariate Cox models to estimate hazard ratios and 95% confidence intervals of CHD risk across categories of red meat consumption. They performed substitution analyses by comparing coefficients in models including alternative foods as continuous variables.
Over roughly 933,000 person-years of follow-up, the researchers documented 4,148 incident CHD cases. Of these, 1,680 were fatal. After multivariate adjustment for dietary and nondietary risk factors, both total and processed red meat intake were associated with a modestly higher risk of CHD (hazard ratio for a one serving/day increment, 1.08; 95% confidence interval, 1.01-1.14 for total red meat; and HR, 1.13; 95% CI, 1.03-1.22 for processed red meat). Substitutions of one serving per day of other foods (including nuts, legumes, soy, whole grains, and low- and high-fat dairy) for one serving per day of total red meat were associated with a 10%-47% lower CHD risk.
Stronger inverse associations were observed between some of these substitutions for red meat and risk of fatal CHD. Substituting nuts lowered the risk of fatal heart disease by 17%, while replacing red meat with whole grains was linked to a 48% reduction in that outcome. Those associations were more pronounced when replacing processed red meat.
“Processed meats and meats in general have been thought to be potentially not favorable in terms of cardiovascular disease and cardiovascular disease risk,” Robert H. Eckel, MD, professor emeritus of medicine at the University of Colorado Anschutz Medical Campus, Aurora, said in an interview. “Now we have increasing data that not only is there a negative cardiovascular disease impact of animal protein, but we see this on all-cause mortality, including cancer.”
Dr. Al-Shaar said that the findings “support current recommendations to limit consumption of red meat and suggest that high-quality plant-based proteins such as nuts, legumes, and soy are good alternatives for individuals planning to have better food choices and healthier eating patterns.”
She acknowledged certain limitations of the study, including its observational design and the fact that it was limited to non-Hispanic white health professionals, “thus limiting the generalizability of its findings to the whole population.”
Dr. Eckel, who is a past president of the American Heart Association, underscored the importance of one’s overall diet in mitigating the risk of developing coronary heart disease. “It’s not simply substituting animal protein with plant protein,” he said. “Fruits and vegetables and whole grains, lean protein from fish – a Mediterranean-style diet – is what the AHA recommends.”
Dr. Al-Shaar reported having no financial disclosures. The study was supported by a T32 training grant from the National Institutes of Health and by other grants from the NIH. The meeting was sponsored by the AHA.
SOURCE: Al-Shaar L et al. Epi/Lifestyle 2020, Abstract P512.
REPORTING FROM EPI/LIFESTYLE 2020
Fracture risk for MM patients remains higher despite improvements in treatments, survival
Bone lesions are one of the primary symptoms in multiple myeloma (MM), and approximately 80% of patients experience a pathological fracture at initial presentation or during the course of the disease, according to the authors of a study published online in Bone.
The authors performed a study to determine if improved treatment strategies and supportive care over time, including the use of bisphosphonates, reduced the overall fracture risk in MM patients.
Their retrospective case-control study included 1,334 patients with MM in Denmark from the Danish National Health Service, of which 881 sustained a fracture between 1996 and 2011. MM patients were matched to patients from the database without MM.
The researchers found that the risk of any fracture was significantly higher in MM patients, compared with patients without MM at all three time periods examined, and remained high over time: adjusted odds ratio (95% confidence interval) 1996-2000: 1.7 (1.3–2.3); 2001-2006: 1.3 (1.1-1.6); 2007-2011: 1.7 (1.4-2.2)). The risk of vertebral fractures was particularly higher in MM patients and also remained high over time: ORadj (95% CI) 1996-2000: 3.5 (1.4–8.6); 2001-2006: 4.0 (1.9-8.2); 2007-2011: 3.0 (1.6-5.7).
In addition, they found that the risk of any fracture was equally high in men and women MM patients, and in patients aged ≤ 65 or > 65 years.
“New treatment strategies, even if they have a positive impact on overall survival, offer no guarantee for a corresponding reduction in bone lesions,” the authors concluded.
The majority of authors reported having no disclosures. One author reported grants and personal fees from three pharmaceutical companies, outside the submitted work.
SOURCE: Oortgiesen BE et al. Bone. 2020 doi.org/10.1016/j.bone.2020.115299.
Bone lesions are one of the primary symptoms in multiple myeloma (MM), and approximately 80% of patients experience a pathological fracture at initial presentation or during the course of the disease, according to the authors of a study published online in Bone.
The authors performed a study to determine if improved treatment strategies and supportive care over time, including the use of bisphosphonates, reduced the overall fracture risk in MM patients.
Their retrospective case-control study included 1,334 patients with MM in Denmark from the Danish National Health Service, of which 881 sustained a fracture between 1996 and 2011. MM patients were matched to patients from the database without MM.
The researchers found that the risk of any fracture was significantly higher in MM patients, compared with patients without MM at all three time periods examined, and remained high over time: adjusted odds ratio (95% confidence interval) 1996-2000: 1.7 (1.3–2.3); 2001-2006: 1.3 (1.1-1.6); 2007-2011: 1.7 (1.4-2.2)). The risk of vertebral fractures was particularly higher in MM patients and also remained high over time: ORadj (95% CI) 1996-2000: 3.5 (1.4–8.6); 2001-2006: 4.0 (1.9-8.2); 2007-2011: 3.0 (1.6-5.7).
In addition, they found that the risk of any fracture was equally high in men and women MM patients, and in patients aged ≤ 65 or > 65 years.
“New treatment strategies, even if they have a positive impact on overall survival, offer no guarantee for a corresponding reduction in bone lesions,” the authors concluded.
The majority of authors reported having no disclosures. One author reported grants and personal fees from three pharmaceutical companies, outside the submitted work.
SOURCE: Oortgiesen BE et al. Bone. 2020 doi.org/10.1016/j.bone.2020.115299.
Bone lesions are one of the primary symptoms in multiple myeloma (MM), and approximately 80% of patients experience a pathological fracture at initial presentation or during the course of the disease, according to the authors of a study published online in Bone.
The authors performed a study to determine if improved treatment strategies and supportive care over time, including the use of bisphosphonates, reduced the overall fracture risk in MM patients.
Their retrospective case-control study included 1,334 patients with MM in Denmark from the Danish National Health Service, of which 881 sustained a fracture between 1996 and 2011. MM patients were matched to patients from the database without MM.
The researchers found that the risk of any fracture was significantly higher in MM patients, compared with patients without MM at all three time periods examined, and remained high over time: adjusted odds ratio (95% confidence interval) 1996-2000: 1.7 (1.3–2.3); 2001-2006: 1.3 (1.1-1.6); 2007-2011: 1.7 (1.4-2.2)). The risk of vertebral fractures was particularly higher in MM patients and also remained high over time: ORadj (95% CI) 1996-2000: 3.5 (1.4–8.6); 2001-2006: 4.0 (1.9-8.2); 2007-2011: 3.0 (1.6-5.7).
In addition, they found that the risk of any fracture was equally high in men and women MM patients, and in patients aged ≤ 65 or > 65 years.
“New treatment strategies, even if they have a positive impact on overall survival, offer no guarantee for a corresponding reduction in bone lesions,” the authors concluded.
The majority of authors reported having no disclosures. One author reported grants and personal fees from three pharmaceutical companies, outside the submitted work.
SOURCE: Oortgiesen BE et al. Bone. 2020 doi.org/10.1016/j.bone.2020.115299.
FROM BONE
Health professionals fight against COVID-19 myths and misinformation
Misinformation about the COVID-19 travels faster than the virus and complicates the job of doctors who are treating those infected and responding to concerns of their other patients.
An array of myths springing up around this disease can be found on the Internet. The main themes appear to be false narratives about the origin of the virus, the size of the outbreak in the United States and in other countries, the availability of cures and treatments, and ways to prevent infection. Widespread misinformation hampers public health efforts to control the disease outbreak, confuses the public, and requires medical professionals to spend time refuting myths and re-educating patients.
A group of infectious disease experts became so alarmed by the misinformation trend they published a statement in The Lancet decrying the spread of false statements being circulated by some media outlets. “The rapid, open, and transparent sharing of data on this outbreak is now being threatened by rumours and misinformation ... Conspiracy theories do nothing but create fear, rumours, and prejudice that jeopardise our global collaboration in the fight against this virus,” wrote Charles H. Calisher, PhD, of Colorado State University, Fort Collins, and colleagues.
What can physicians do to counter misinformation?
Pulmonologist and critical care physician Cedric “Jamie” Rutland, MD, who practices in Riverside, Calif., sees misinformation about the novel coronavirus every day at home and on the job. His patients worry that everyone who gets infected will die or end up in the ICU. His neighbors ask him to pilfer surgical masks to protect them from the false notion that Chinese people in their community posed some kind of COVID-19 risk.
As he pondered how to counter myths with facts, Dr. Rutland turned to an unusual resource: His 7-year-old daughter Amelia. He explained to her how COVID-19 works and found that she could easily understand the basics. Now, Dr. Rutland draws upon the lessons from chats with his daughter as he explains COVID-19 to his patient audience on his YouTube channel “Medicine Deconstructed.” Simplicity, but not too much simplicity, is key, he said. Dr. Rutland uses a visual aid – a rough drawing of a virus – and shows how inflammation and antibodies enter the picture after infection. “I just teach them that if you’re a healthy person, this is how the body works, and this is what the immune system will do,” he said. “For the most part, you can calm people down when you make time for education.”
What are best practices? In a series of interviews, specialists emphasized the importance of fact-finding, wide-ranging communication, and – perhaps most difficult of all – humility.
Dr. Rutland emphasizes thoughtful communication based on facts and humility when communicating to patients about this potential health risk. “A lot of people finish medical school and think, ‘Everyone should trust me because I’m the pulmonologist or the GI doc.’ That’s not how it works. You still have to earn people’s trust,” he said.
Make sure all staff get reliable information
Hospitals are scrambling to keep staff safe with up-to-date directives and debunk false narratives about the virus. Keeping all hospital staff informed with verified and authoritative facts about the coronavirus is a key objective of the Massachusetts General Hospital’s Center for Disaster Medicine. The Center’s coronavirus educational materials are distributed to all staffers from physicians to janitors. “These provide information that they need to understand the risks and keep themselves safe,” said Eileen Searle, PhD, the Biothreats Clinical Operations program manager in the CDM.
According to Dr. Searle, the hospital keeps a continually updated COVID-19 Frequently Asked Questions document in its internal computer system. All employees can access it, she said, and it’s updated to include questions as they come up.
Even valets and front-desk volunteers are encouraged to read the FAQ, she said, since “they’re the first people that family and patients are interacting with.” The document “gives them reassurance about delivering messages,” she said.
Use patience with your patients
Dr. Rutland urges colleagues to take the time to listen to patients and educate them. “Reduce the gap between you and them,” said Dr. Rutland, who treats patients in Orange and Riverside counties. “Take off your white coat, sit down, and talk to the person about their concerns.”
Boston cardiologist Haider Warraich, MD, of Brigham and Women’s Hospital, Boston, said it’s important to “put medical information into a greater human context.” For example, he has told patients that he’s still taking his daughter to school despite COVID-19 risks. “I take the information I provide and apply it to my own life,” he said.
The Washington State Department of Health offers this advice to physicians to counter false information and stigma: “Stay updated and informed on COVID-19 to avoid miscommunication or inaccurate information. Talk openly about the harm of stigma. View people directly impacted by stigma as people first. Be conscious of your language. Acknowledge access and language barriers.”
Speak out on social media – but don’t fight
Should medical professionals speak out about COVID-19 misinformation via social media? It’s an individual decision, Dr. Warraich said, “but my sense is that it’s never been more important for physicians to be part of the fray and help quell the epidemic of misinformation that almost always follows any type of medial calamity.”
Dr. Rutland, vice president and founding member of the Association for Healthcare Social Media, cautioned that effective communication via social media requires care. Avoid confrontation, he advised. “Don’t call people stupid or say things like, ‘I went to medical school and I’m smarter than you.’ ”
Instead, he said, “it’s important to just state the facts: These are the people who are dying, these are the people who are getting infected.”
And, he added, remember to push the most important message of all: Wash your hands!
Public health organizations fight the ‘infodemic’
In a trend that hearkens back to the days of snake oil cures for all maladies, advertisements for fake treatments are popping up on the Internet and on other media.
Facebook and Amazon have acted to remove these ads but these messages continue to flood social media such as Twitter, WhatsApp, and other sites. Discussion groups on platforms such as Reddit continue to pump out misinformation about COVID-19. Conspiracy theories that link the virus to espionage and bioweapons are making the rounds on the Internet and talk radio. Wrong information about the effectiveness of non-N95 face masks to protect wearers against infection is widespread, leading to shortages for medical personnel and price gouging. Pernicious rumors about the effectiveness of substances such a vinegar, silver, garlic, lemon juice, and even vodka to disinfect hands and surfaces abound on the Internet. An especially dangerous stream of misinformation stigmatizes ethnic groups and individuals as sources of the infection.
The World Health Organization identified early in the COVID-19 outbreak the global wave of misinformation about the virus and dubbed the problem the “infodemic.” The WHO “Q & A” page on COVID-19 is updated frequently and addresses myths and rumors currently circulating.
According to the WHO website, the agency has reached out to social media players such as Facebook, Twitter, Instagram, LinkedIn, Pinterest, TikTok, and Weibo, the microblogging site in China. WHO has worked with these sites to curb the “infodemic” of misinformation and has used these sites for public education outreach on COVID-19. “Myth busting” infographics posted on a WHO web page are also reposted on major social media sites.
The CDC has followed with its own “frequently asked questions” page to address questions and rumors. State health agencies have put up COVID-19 pages to address public concerns and offer advice on prevention. The Maryland Department of Health web page directly addresses dangerous misinformation: “Do not stigmatize people of any specific ethnicities or racial background. Viruses do not target people from specific populations, ethnicities or racial backgrounds. Stay informed and seek information from reliable, official sources. Be wary of myths, rumors and misinformation circulating online and elsewhere. Health information shared through social media is frequently inaccurate, unless coming from an official, reliable source such as the CDC, MDH or local health departments.”
The Washington State Department of Health has taken a more assertive stance on stigma. The COVID-19 web page recommends to the public: “Show compassion and support for individuals and communities more closely impacted. Avoid stigmatizing people who are in quarantine. They are making the right choice for their communities. Do not make assumptions about someone’s health status based on their ethnicity, race or national origin.”
Misinformation about the COVID-19 travels faster than the virus and complicates the job of doctors who are treating those infected and responding to concerns of their other patients.
An array of myths springing up around this disease can be found on the Internet. The main themes appear to be false narratives about the origin of the virus, the size of the outbreak in the United States and in other countries, the availability of cures and treatments, and ways to prevent infection. Widespread misinformation hampers public health efforts to control the disease outbreak, confuses the public, and requires medical professionals to spend time refuting myths and re-educating patients.
A group of infectious disease experts became so alarmed by the misinformation trend they published a statement in The Lancet decrying the spread of false statements being circulated by some media outlets. “The rapid, open, and transparent sharing of data on this outbreak is now being threatened by rumours and misinformation ... Conspiracy theories do nothing but create fear, rumours, and prejudice that jeopardise our global collaboration in the fight against this virus,” wrote Charles H. Calisher, PhD, of Colorado State University, Fort Collins, and colleagues.
What can physicians do to counter misinformation?
Pulmonologist and critical care physician Cedric “Jamie” Rutland, MD, who practices in Riverside, Calif., sees misinformation about the novel coronavirus every day at home and on the job. His patients worry that everyone who gets infected will die or end up in the ICU. His neighbors ask him to pilfer surgical masks to protect them from the false notion that Chinese people in their community posed some kind of COVID-19 risk.
As he pondered how to counter myths with facts, Dr. Rutland turned to an unusual resource: His 7-year-old daughter Amelia. He explained to her how COVID-19 works and found that she could easily understand the basics. Now, Dr. Rutland draws upon the lessons from chats with his daughter as he explains COVID-19 to his patient audience on his YouTube channel “Medicine Deconstructed.” Simplicity, but not too much simplicity, is key, he said. Dr. Rutland uses a visual aid – a rough drawing of a virus – and shows how inflammation and antibodies enter the picture after infection. “I just teach them that if you’re a healthy person, this is how the body works, and this is what the immune system will do,” he said. “For the most part, you can calm people down when you make time for education.”
What are best practices? In a series of interviews, specialists emphasized the importance of fact-finding, wide-ranging communication, and – perhaps most difficult of all – humility.
Dr. Rutland emphasizes thoughtful communication based on facts and humility when communicating to patients about this potential health risk. “A lot of people finish medical school and think, ‘Everyone should trust me because I’m the pulmonologist or the GI doc.’ That’s not how it works. You still have to earn people’s trust,” he said.
Make sure all staff get reliable information
Hospitals are scrambling to keep staff safe with up-to-date directives and debunk false narratives about the virus. Keeping all hospital staff informed with verified and authoritative facts about the coronavirus is a key objective of the Massachusetts General Hospital’s Center for Disaster Medicine. The Center’s coronavirus educational materials are distributed to all staffers from physicians to janitors. “These provide information that they need to understand the risks and keep themselves safe,” said Eileen Searle, PhD, the Biothreats Clinical Operations program manager in the CDM.
According to Dr. Searle, the hospital keeps a continually updated COVID-19 Frequently Asked Questions document in its internal computer system. All employees can access it, she said, and it’s updated to include questions as they come up.
Even valets and front-desk volunteers are encouraged to read the FAQ, she said, since “they’re the first people that family and patients are interacting with.” The document “gives them reassurance about delivering messages,” she said.
Use patience with your patients
Dr. Rutland urges colleagues to take the time to listen to patients and educate them. “Reduce the gap between you and them,” said Dr. Rutland, who treats patients in Orange and Riverside counties. “Take off your white coat, sit down, and talk to the person about their concerns.”
Boston cardiologist Haider Warraich, MD, of Brigham and Women’s Hospital, Boston, said it’s important to “put medical information into a greater human context.” For example, he has told patients that he’s still taking his daughter to school despite COVID-19 risks. “I take the information I provide and apply it to my own life,” he said.
The Washington State Department of Health offers this advice to physicians to counter false information and stigma: “Stay updated and informed on COVID-19 to avoid miscommunication or inaccurate information. Talk openly about the harm of stigma. View people directly impacted by stigma as people first. Be conscious of your language. Acknowledge access and language barriers.”
Speak out on social media – but don’t fight
Should medical professionals speak out about COVID-19 misinformation via social media? It’s an individual decision, Dr. Warraich said, “but my sense is that it’s never been more important for physicians to be part of the fray and help quell the epidemic of misinformation that almost always follows any type of medial calamity.”
Dr. Rutland, vice president and founding member of the Association for Healthcare Social Media, cautioned that effective communication via social media requires care. Avoid confrontation, he advised. “Don’t call people stupid or say things like, ‘I went to medical school and I’m smarter than you.’ ”
Instead, he said, “it’s important to just state the facts: These are the people who are dying, these are the people who are getting infected.”
And, he added, remember to push the most important message of all: Wash your hands!
Public health organizations fight the ‘infodemic’
In a trend that hearkens back to the days of snake oil cures for all maladies, advertisements for fake treatments are popping up on the Internet and on other media.
Facebook and Amazon have acted to remove these ads but these messages continue to flood social media such as Twitter, WhatsApp, and other sites. Discussion groups on platforms such as Reddit continue to pump out misinformation about COVID-19. Conspiracy theories that link the virus to espionage and bioweapons are making the rounds on the Internet and talk radio. Wrong information about the effectiveness of non-N95 face masks to protect wearers against infection is widespread, leading to shortages for medical personnel and price gouging. Pernicious rumors about the effectiveness of substances such a vinegar, silver, garlic, lemon juice, and even vodka to disinfect hands and surfaces abound on the Internet. An especially dangerous stream of misinformation stigmatizes ethnic groups and individuals as sources of the infection.
The World Health Organization identified early in the COVID-19 outbreak the global wave of misinformation about the virus and dubbed the problem the “infodemic.” The WHO “Q & A” page on COVID-19 is updated frequently and addresses myths and rumors currently circulating.
According to the WHO website, the agency has reached out to social media players such as Facebook, Twitter, Instagram, LinkedIn, Pinterest, TikTok, and Weibo, the microblogging site in China. WHO has worked with these sites to curb the “infodemic” of misinformation and has used these sites for public education outreach on COVID-19. “Myth busting” infographics posted on a WHO web page are also reposted on major social media sites.
The CDC has followed with its own “frequently asked questions” page to address questions and rumors. State health agencies have put up COVID-19 pages to address public concerns and offer advice on prevention. The Maryland Department of Health web page directly addresses dangerous misinformation: “Do not stigmatize people of any specific ethnicities or racial background. Viruses do not target people from specific populations, ethnicities or racial backgrounds. Stay informed and seek information from reliable, official sources. Be wary of myths, rumors and misinformation circulating online and elsewhere. Health information shared through social media is frequently inaccurate, unless coming from an official, reliable source such as the CDC, MDH or local health departments.”
The Washington State Department of Health has taken a more assertive stance on stigma. The COVID-19 web page recommends to the public: “Show compassion and support for individuals and communities more closely impacted. Avoid stigmatizing people who are in quarantine. They are making the right choice for their communities. Do not make assumptions about someone’s health status based on their ethnicity, race or national origin.”
Misinformation about the COVID-19 travels faster than the virus and complicates the job of doctors who are treating those infected and responding to concerns of their other patients.
An array of myths springing up around this disease can be found on the Internet. The main themes appear to be false narratives about the origin of the virus, the size of the outbreak in the United States and in other countries, the availability of cures and treatments, and ways to prevent infection. Widespread misinformation hampers public health efforts to control the disease outbreak, confuses the public, and requires medical professionals to spend time refuting myths and re-educating patients.
A group of infectious disease experts became so alarmed by the misinformation trend they published a statement in The Lancet decrying the spread of false statements being circulated by some media outlets. “The rapid, open, and transparent sharing of data on this outbreak is now being threatened by rumours and misinformation ... Conspiracy theories do nothing but create fear, rumours, and prejudice that jeopardise our global collaboration in the fight against this virus,” wrote Charles H. Calisher, PhD, of Colorado State University, Fort Collins, and colleagues.
What can physicians do to counter misinformation?
Pulmonologist and critical care physician Cedric “Jamie” Rutland, MD, who practices in Riverside, Calif., sees misinformation about the novel coronavirus every day at home and on the job. His patients worry that everyone who gets infected will die or end up in the ICU. His neighbors ask him to pilfer surgical masks to protect them from the false notion that Chinese people in their community posed some kind of COVID-19 risk.
As he pondered how to counter myths with facts, Dr. Rutland turned to an unusual resource: His 7-year-old daughter Amelia. He explained to her how COVID-19 works and found that she could easily understand the basics. Now, Dr. Rutland draws upon the lessons from chats with his daughter as he explains COVID-19 to his patient audience on his YouTube channel “Medicine Deconstructed.” Simplicity, but not too much simplicity, is key, he said. Dr. Rutland uses a visual aid – a rough drawing of a virus – and shows how inflammation and antibodies enter the picture after infection. “I just teach them that if you’re a healthy person, this is how the body works, and this is what the immune system will do,” he said. “For the most part, you can calm people down when you make time for education.”
What are best practices? In a series of interviews, specialists emphasized the importance of fact-finding, wide-ranging communication, and – perhaps most difficult of all – humility.
Dr. Rutland emphasizes thoughtful communication based on facts and humility when communicating to patients about this potential health risk. “A lot of people finish medical school and think, ‘Everyone should trust me because I’m the pulmonologist or the GI doc.’ That’s not how it works. You still have to earn people’s trust,” he said.
Make sure all staff get reliable information
Hospitals are scrambling to keep staff safe with up-to-date directives and debunk false narratives about the virus. Keeping all hospital staff informed with verified and authoritative facts about the coronavirus is a key objective of the Massachusetts General Hospital’s Center for Disaster Medicine. The Center’s coronavirus educational materials are distributed to all staffers from physicians to janitors. “These provide information that they need to understand the risks and keep themselves safe,” said Eileen Searle, PhD, the Biothreats Clinical Operations program manager in the CDM.
According to Dr. Searle, the hospital keeps a continually updated COVID-19 Frequently Asked Questions document in its internal computer system. All employees can access it, she said, and it’s updated to include questions as they come up.
Even valets and front-desk volunteers are encouraged to read the FAQ, she said, since “they’re the first people that family and patients are interacting with.” The document “gives them reassurance about delivering messages,” she said.
Use patience with your patients
Dr. Rutland urges colleagues to take the time to listen to patients and educate them. “Reduce the gap between you and them,” said Dr. Rutland, who treats patients in Orange and Riverside counties. “Take off your white coat, sit down, and talk to the person about their concerns.”
Boston cardiologist Haider Warraich, MD, of Brigham and Women’s Hospital, Boston, said it’s important to “put medical information into a greater human context.” For example, he has told patients that he’s still taking his daughter to school despite COVID-19 risks. “I take the information I provide and apply it to my own life,” he said.
The Washington State Department of Health offers this advice to physicians to counter false information and stigma: “Stay updated and informed on COVID-19 to avoid miscommunication or inaccurate information. Talk openly about the harm of stigma. View people directly impacted by stigma as people first. Be conscious of your language. Acknowledge access and language barriers.”
Speak out on social media – but don’t fight
Should medical professionals speak out about COVID-19 misinformation via social media? It’s an individual decision, Dr. Warraich said, “but my sense is that it’s never been more important for physicians to be part of the fray and help quell the epidemic of misinformation that almost always follows any type of medial calamity.”
Dr. Rutland, vice president and founding member of the Association for Healthcare Social Media, cautioned that effective communication via social media requires care. Avoid confrontation, he advised. “Don’t call people stupid or say things like, ‘I went to medical school and I’m smarter than you.’ ”
Instead, he said, “it’s important to just state the facts: These are the people who are dying, these are the people who are getting infected.”
And, he added, remember to push the most important message of all: Wash your hands!
Public health organizations fight the ‘infodemic’
In a trend that hearkens back to the days of snake oil cures for all maladies, advertisements for fake treatments are popping up on the Internet and on other media.
Facebook and Amazon have acted to remove these ads but these messages continue to flood social media such as Twitter, WhatsApp, and other sites. Discussion groups on platforms such as Reddit continue to pump out misinformation about COVID-19. Conspiracy theories that link the virus to espionage and bioweapons are making the rounds on the Internet and talk radio. Wrong information about the effectiveness of non-N95 face masks to protect wearers against infection is widespread, leading to shortages for medical personnel and price gouging. Pernicious rumors about the effectiveness of substances such a vinegar, silver, garlic, lemon juice, and even vodka to disinfect hands and surfaces abound on the Internet. An especially dangerous stream of misinformation stigmatizes ethnic groups and individuals as sources of the infection.
The World Health Organization identified early in the COVID-19 outbreak the global wave of misinformation about the virus and dubbed the problem the “infodemic.” The WHO “Q & A” page on COVID-19 is updated frequently and addresses myths and rumors currently circulating.
According to the WHO website, the agency has reached out to social media players such as Facebook, Twitter, Instagram, LinkedIn, Pinterest, TikTok, and Weibo, the microblogging site in China. WHO has worked with these sites to curb the “infodemic” of misinformation and has used these sites for public education outreach on COVID-19. “Myth busting” infographics posted on a WHO web page are also reposted on major social media sites.
The CDC has followed with its own “frequently asked questions” page to address questions and rumors. State health agencies have put up COVID-19 pages to address public concerns and offer advice on prevention. The Maryland Department of Health web page directly addresses dangerous misinformation: “Do not stigmatize people of any specific ethnicities or racial background. Viruses do not target people from specific populations, ethnicities or racial backgrounds. Stay informed and seek information from reliable, official sources. Be wary of myths, rumors and misinformation circulating online and elsewhere. Health information shared through social media is frequently inaccurate, unless coming from an official, reliable source such as the CDC, MDH or local health departments.”
The Washington State Department of Health has taken a more assertive stance on stigma. The COVID-19 web page recommends to the public: “Show compassion and support for individuals and communities more closely impacted. Avoid stigmatizing people who are in quarantine. They are making the right choice for their communities. Do not make assumptions about someone’s health status based on their ethnicity, race or national origin.”