Clinical Endocrinology News

Patients taking isotretinoin can use telemedicine to meet with their prescribing physicians instead of in-person visits, and female patients can use at-home pregnancy tests to comply with the requirements of the iPLEDGE program during the COVID-19 pandemic, according to an update program posted on the iPLEDGE website.

Obencem/Thinkstock

The program’s other requirements – the prescription window and two forms of birth control – remain unchanged.

The change follows recent guidance from the Department of Health & Human Services and the Food and Drug Administration regarding accommodations for medical care and drugs subject to Risk Evaluation and Mitigation Strategies (REMS) in the midst of a public health emergency that requires most people to remain in their homes except for essential services.

Allowing females to take at-home pregnancy tests and communicate the results to physician according to their preference is “a game changer for the middle of a pandemic, obviously,” Neil Goldberg, MD, a dermatologist in Westchester County, New York, said in an interview. “These are patients who don’t need to spend time outside just to get pregnancy tests done. It makes it a lot easier.”

Dr. Goldberg is frustrated, however, that the accommodations have not been more widely publicized; he discovered the change incidentally when speaking to an iPLEDGE program representative to request a waiver for a patient who had taken her pregnancy test too early. The program had denied a similar request for a 15-year-old patient of his the previous week, despite the patient being abstinent and having been in shelter-in-place for several weeks.

“The size of your notice [on the website] should be proportionate to how important it is,” Dr. Goldberg said, and the small red box on the site is easy to miss. By contrast, asking anyone to leave their homes to go to a lab for a pregnancy test in the midst of a global pandemic so they can continue their medication would be putting patients at risk, he added.

The iPLEDGE program is designed in part to ensure unplanned pregnancies do not occur in females while taking the teratogenic acne drug. But the rules are onerous and difficult even during normal times, pointed out Hilary Baldwin, MD, medical director of the Acne Treatment and Research Center in New York City and past president of the American Acne and Rosacea Society.

Male patients taking isotretinoin must visit their physician every month to get a new no-refills prescription, but females must get a pregnancy test at a Clinical Laboratory Improvement Amendments–certified lab, which must then provide physical results to the prescribing physician. The doctor enters the negative pregnancy test and the two forms of birth control the patient is taking in the iPLEDGE program site.

Then the patient must take an online test at home to acknowledge they understand what it means to not get pregnant and enter the two forms of birth control they are using – which must match what the doctor enters – before the pharmacy can dispense the drug. The entire process must occur within 7 days or else the patient has to wait 19 days before starting the process over.

“We run a very tight schedule for girls. And every month, we would worry that something would interfere, a snow storm or something else, and that they wouldn’t be able to complete their objectives within the 7-day period,” Dr Baldwin said in an interview. “It was always difficult, and now with us not being able to see the patient and the patient not wanting to go to the lab, this became completely impossible.”

Until this change, some patients may not have been able to get their prescription for severe nodulocystic acne, which can cause physical and psychological scarring, and “postponing treatment increases the likelihood of scarring,” Dr. Baldwin pointed out.

Patients taking isotretinoin can use telemedicine to meet with their prescribing physicians instead of in-person visits, and female patients can use at-home pregnancy tests to comply with the requirements of the iPLEDGE program during the COVID-19 pandemic, according to an update program posted on the iPLEDGE website.

Obencem/Thinkstock

The program’s other requirements – the prescription window and two forms of birth control – remain unchanged.

The change follows recent guidance from the Department of Health & Human Services and the Food and Drug Administration regarding accommodations for medical care and drugs subject to Risk Evaluation and Mitigation Strategies (REMS) in the midst of a public health emergency that requires most people to remain in their homes except for essential services.

Allowing females to take at-home pregnancy tests and communicate the results to physician according to their preference is “a game changer for the middle of a pandemic, obviously,” Neil Goldberg, MD, a dermatologist in Westchester County, New York, said in an interview. “These are patients who don’t need to spend time outside just to get pregnancy tests done. It makes it a lot easier.”

Dr. Goldberg is frustrated, however, that the accommodations have not been more widely publicized; he discovered the change incidentally when speaking to an iPLEDGE program representative to request a waiver for a patient who had taken her pregnancy test too early. The program had denied a similar request for a 15-year-old patient of his the previous week, despite the patient being abstinent and having been in shelter-in-place for several weeks.

“The size of your notice [on the website] should be proportionate to how important it is,” Dr. Goldberg said, and the small red box on the site is easy to miss. By contrast, asking anyone to leave their homes to go to a lab for a pregnancy test in the midst of a global pandemic so they can continue their medication would be putting patients at risk, he added.

The iPLEDGE program is designed in part to ensure unplanned pregnancies do not occur in females while taking the teratogenic acne drug. But the rules are onerous and difficult even during normal times, pointed out Hilary Baldwin, MD, medical director of the Acne Treatment and Research Center in New York City and past president of the American Acne and Rosacea Society.

Male patients taking isotretinoin must visit their physician every month to get a new no-refills prescription, but females must get a pregnancy test at a Clinical Laboratory Improvement Amendments–certified lab, which must then provide physical results to the prescribing physician. The doctor enters the negative pregnancy test and the two forms of birth control the patient is taking in the iPLEDGE program site.

Then the patient must take an online test at home to acknowledge they understand what it means to not get pregnant and enter the two forms of birth control they are using – which must match what the doctor enters – before the pharmacy can dispense the drug. The entire process must occur within 7 days or else the patient has to wait 19 days before starting the process over.

“We run a very tight schedule for girls. And every month, we would worry that something would interfere, a snow storm or something else, and that they wouldn’t be able to complete their objectives within the 7-day period,” Dr Baldwin said in an interview. “It was always difficult, and now with us not being able to see the patient and the patient not wanting to go to the lab, this became completely impossible.”

Until this change, some patients may not have been able to get their prescription for severe nodulocystic acne, which can cause physical and psychological scarring, and “postponing treatment increases the likelihood of scarring,” Dr. Baldwin pointed out.

Patients taking isotretinoin can use telemedicine to meet with their prescribing physicians instead of in-person visits, and female patients can use at-home pregnancy tests to comply with the requirements of the iPLEDGE program during the COVID-19 pandemic, according to an update program posted on the iPLEDGE website.

Obencem/Thinkstock

The program’s other requirements – the prescription window and two forms of birth control – remain unchanged.

The change follows recent guidance from the Department of Health & Human Services and the Food and Drug Administration regarding accommodations for medical care and drugs subject to Risk Evaluation and Mitigation Strategies (REMS) in the midst of a public health emergency that requires most people to remain in their homes except for essential services.

Allowing females to take at-home pregnancy tests and communicate the results to physician according to their preference is “a game changer for the middle of a pandemic, obviously,” Neil Goldberg, MD, a dermatologist in Westchester County, New York, said in an interview. “These are patients who don’t need to spend time outside just to get pregnancy tests done. It makes it a lot easier.”

Dr. Goldberg is frustrated, however, that the accommodations have not been more widely publicized; he discovered the change incidentally when speaking to an iPLEDGE program representative to request a waiver for a patient who had taken her pregnancy test too early. The program had denied a similar request for a 15-year-old patient of his the previous week, despite the patient being abstinent and having been in shelter-in-place for several weeks.

“The size of your notice [on the website] should be proportionate to how important it is,” Dr. Goldberg said, and the small red box on the site is easy to miss. By contrast, asking anyone to leave their homes to go to a lab for a pregnancy test in the midst of a global pandemic so they can continue their medication would be putting patients at risk, he added.

The iPLEDGE program is designed in part to ensure unplanned pregnancies do not occur in females while taking the teratogenic acne drug. But the rules are onerous and difficult even during normal times, pointed out Hilary Baldwin, MD, medical director of the Acne Treatment and Research Center in New York City and past president of the American Acne and Rosacea Society.

Male patients taking isotretinoin must visit their physician every month to get a new no-refills prescription, but females must get a pregnancy test at a Clinical Laboratory Improvement Amendments–certified lab, which must then provide physical results to the prescribing physician. The doctor enters the negative pregnancy test and the two forms of birth control the patient is taking in the iPLEDGE program site.

Then the patient must take an online test at home to acknowledge they understand what it means to not get pregnant and enter the two forms of birth control they are using – which must match what the doctor enters – before the pharmacy can dispense the drug. The entire process must occur within 7 days or else the patient has to wait 19 days before starting the process over.

“We run a very tight schedule for girls. And every month, we would worry that something would interfere, a snow storm or something else, and that they wouldn’t be able to complete their objectives within the 7-day period,” Dr Baldwin said in an interview. “It was always difficult, and now with us not being able to see the patient and the patient not wanting to go to the lab, this became completely impossible.”

Until this change, some patients may not have been able to get their prescription for severe nodulocystic acne, which can cause physical and psychological scarring, and “postponing treatment increases the likelihood of scarring,” Dr. Baldwin pointed out.

Characteristics of patients with chronic lymphocytic leukemia can mask COVID-19 infection, creating a risk for patients, practitioners, and the community, according to a case study published in the Lancet Haematology.

Courtesy NIAID-RML

A 39-year-old man with a history of non-Hodgkin lymphoma and chronic lymphocytic leukemia (CLL) presented at a clinic in Wenzhou, China, with symptoms of fever, sore throat, productive cough, and dyspnea, according to the authors. COVID-19 infection was not initially suspected, as his whole blood cell and lymphocyte counts were high, the CLL masked a potential infection, and the patient claimed he had no suspect recent travel history.

However, a CT chest scan showed bilateral ground-glass opacities and a small amount of fluid in the patient’s left pleural cavity, leading the attending physician to suspect COVID-19. Testing was ordered and the real-time reverse-transcription polymerase chain reaction assay result was positive. The patient was immediately transferred to the isolation ward for management and confirmed COVID-19 infection.

Subsequently, the patient admitted travel to the COVID-19 epicenter in Wuhan province, although it was 25 days prior, indicating a longer period of incubation than generally believed, according to the authors. The patient survived treatment and was eventually discharged.

“Clinical and biochemical data of COVID-19 might be partly masked by coexisting chronic lymphocytic leukemia; better diagnostic strategies (i.e., superior CT differential techniques such as radiomics) could be used for diagnosis,” the researchers concluded, speculating that the apparently longer-than-normal COVID-19 incubation period might be the result of the patient’s compromised immune system.

The authors reported that they had no conflicts of interest.

mlesney@mdedge.com

SOURCE: Jin X-H et al. Lancet Haematol. 2020;7(4):E351-2.

Characteristics of patients with chronic lymphocytic leukemia can mask COVID-19 infection, creating a risk for patients, practitioners, and the community, according to a case study published in the Lancet Haematology.

Courtesy NIAID-RML

A 39-year-old man with a history of non-Hodgkin lymphoma and chronic lymphocytic leukemia (CLL) presented at a clinic in Wenzhou, China, with symptoms of fever, sore throat, productive cough, and dyspnea, according to the authors. COVID-19 infection was not initially suspected, as his whole blood cell and lymphocyte counts were high, the CLL masked a potential infection, and the patient claimed he had no suspect recent travel history.

However, a CT chest scan showed bilateral ground-glass opacities and a small amount of fluid in the patient’s left pleural cavity, leading the attending physician to suspect COVID-19. Testing was ordered and the real-time reverse-transcription polymerase chain reaction assay result was positive. The patient was immediately transferred to the isolation ward for management and confirmed COVID-19 infection.

Subsequently, the patient admitted travel to the COVID-19 epicenter in Wuhan province, although it was 25 days prior, indicating a longer period of incubation than generally believed, according to the authors. The patient survived treatment and was eventually discharged.

“Clinical and biochemical data of COVID-19 might be partly masked by coexisting chronic lymphocytic leukemia; better diagnostic strategies (i.e., superior CT differential techniques such as radiomics) could be used for diagnosis,” the researchers concluded, speculating that the apparently longer-than-normal COVID-19 incubation period might be the result of the patient’s compromised immune system.

The authors reported that they had no conflicts of interest.

mlesney@mdedge.com

SOURCE: Jin X-H et al. Lancet Haematol. 2020;7(4):E351-2.

Characteristics of patients with chronic lymphocytic leukemia can mask COVID-19 infection, creating a risk for patients, practitioners, and the community, according to a case study published in the Lancet Haematology.

Courtesy NIAID-RML

A 39-year-old man with a history of non-Hodgkin lymphoma and chronic lymphocytic leukemia (CLL) presented at a clinic in Wenzhou, China, with symptoms of fever, sore throat, productive cough, and dyspnea, according to the authors. COVID-19 infection was not initially suspected, as his whole blood cell and lymphocyte counts were high, the CLL masked a potential infection, and the patient claimed he had no suspect recent travel history.

However, a CT chest scan showed bilateral ground-glass opacities and a small amount of fluid in the patient’s left pleural cavity, leading the attending physician to suspect COVID-19. Testing was ordered and the real-time reverse-transcription polymerase chain reaction assay result was positive. The patient was immediately transferred to the isolation ward for management and confirmed COVID-19 infection.

Subsequently, the patient admitted travel to the COVID-19 epicenter in Wuhan province, although it was 25 days prior, indicating a longer period of incubation than generally believed, according to the authors. The patient survived treatment and was eventually discharged.

“Clinical and biochemical data of COVID-19 might be partly masked by coexisting chronic lymphocytic leukemia; better diagnostic strategies (i.e., superior CT differential techniques such as radiomics) could be used for diagnosis,” the researchers concluded, speculating that the apparently longer-than-normal COVID-19 incubation period might be the result of the patient’s compromised immune system.

The authors reported that they had no conflicts of interest.

mlesney@mdedge.com

SOURCE: Jin X-H et al. Lancet Haematol. 2020;7(4):E351-2.

Skin manifestations were observed in about one-fifth of a group of patients with COVID-19 in the Alessandro Manzoni Hospital in Lecco, in northern Italy.

Courtesy of Dr. Randy Jacobs

Dermatologists there were pulled from their usual duty to help with the pandemic and looked at what was going on with the skin in 148 COVID-19 inpatients. They excluded 60 who had started new drugs within 15 days to rule out acute drug reactions, then reported what they saw (J Eur Acad Dermatol Venereol. 2020 Mar 26. doi: 10.1111/jdv.16387).

Of the 88 COVID-19 patients, 20.5% developed skin manifestations. Eight of the 18 (44%) had skin eruptions at symptom onset, and the rest after hospitalization. Fourteen (78%) had red rashes, three had widespread urticaria, and one had chickenpox-like vesicles. The most commonly affected area was the trunk. Itching was mild or absent, and lesions usually healed up in a few days. Most importantly, skin manifestations did not correlate with disease severity.

These skin manifestations “are similar to cutaneous involvement occurring during common viral infections,” said the author of the report, Sebastiano Recalcati, MD, a dermatologist at Alessandro Manzoni Hospital.

COVID-19 skin manifestations can cloud the diagnosis, according to the authors of another report from Thailand, where the first case of COVID-19 outside of China was reported.

They described a case of a COVID-19 infection in a Bangkok hospital that masqueraded as dengue fever. A person there presented with only a skin rash, petechiae, and a low platelet count, and was diagnosed with Dengue because that’s exactly what it looked like, the authors wrote (J Am Acad Dermatol. 2020 Mar 22. pii: S0190-9622[20]30454-0. doi: 10.1016/j.jaad.2020.03.036).

The correct diagnosis, COVID-19, was made at a tertiary care center after the patient was admitted with respiratory problems.

“There is a possibility that a COVID-19 patient might initially present with a skin rash that can be misdiagnosed as another common disease. ... The practitioner should recognize the possibility that the patient might have only a skin rash” at first, said the lead author of that report, Beuy Joob, PhD, of the Sanitation1 Medical Academic Center, Bangkok, and a coauthor.

There are similar reports in the United States, too. “Many have wondered if COVID-19 presents with any particular skin changes. The answer is yes,” said Randy Jacobs, MD, an assistant clinical professor of dermatology at the University of California, Riverside, who also has a private practice in southern California.

“COVID-19 can feature signs of small blood vessel occlusion. These can be petechiae or tiny bruises, and transient livedoid eruptions,” he said in an interview.

Dr. Jacobs had a 67-year-old patient who presented with a low fever, nasal congestion, postnasal drip, and a wet cough but no shortness of breath. It looked like a common cold. But a week later, the man had a nonpruritic blanching livedoid vascular eruption on his right anterior thigh, and blood in his urine, and he felt weak. The vascular eruption and bloody urine resolved in 24 hours, but the COVID-19 test came back positive and his cough became dry and hacking, and the weakness persisted. He’s in a hospital now and on oxygen, but not ventilated so far.

“Another dermatologist friend of mine also reported a similar transient COVID-19 unilateral livedoid eruption,” Dr. Jacobs said.

It suggests vaso-occlusion. Whether it’s neurogenic, microthrombotic, or immune complex mediated is unknown, but it’s “a skin finding that can help clinicians as they work up their patients with COVID-19 symptoms,” he noted.

Dr. Jacobs and the authors of the studies had no disclosures.

aotto@mdedge.com

Skin manifestations were observed in about one-fifth of a group of patients with COVID-19 in the Alessandro Manzoni Hospital in Lecco, in northern Italy.

Courtesy of Dr. Randy Jacobs

Dermatologists there were pulled from their usual duty to help with the pandemic and looked at what was going on with the skin in 148 COVID-19 inpatients. They excluded 60 who had started new drugs within 15 days to rule out acute drug reactions, then reported what they saw (J Eur Acad Dermatol Venereol. 2020 Mar 26. doi: 10.1111/jdv.16387).

Of the 88 COVID-19 patients, 20.5% developed skin manifestations. Eight of the 18 (44%) had skin eruptions at symptom onset, and the rest after hospitalization. Fourteen (78%) had red rashes, three had widespread urticaria, and one had chickenpox-like vesicles. The most commonly affected area was the trunk. Itching was mild or absent, and lesions usually healed up in a few days. Most importantly, skin manifestations did not correlate with disease severity.

These skin manifestations “are similar to cutaneous involvement occurring during common viral infections,” said the author of the report, Sebastiano Recalcati, MD, a dermatologist at Alessandro Manzoni Hospital.

COVID-19 skin manifestations can cloud the diagnosis, according to the authors of another report from Thailand, where the first case of COVID-19 outside of China was reported.

They described a case of a COVID-19 infection in a Bangkok hospital that masqueraded as dengue fever. A person there presented with only a skin rash, petechiae, and a low platelet count, and was diagnosed with Dengue because that’s exactly what it looked like, the authors wrote (J Am Acad Dermatol. 2020 Mar 22. pii: S0190-9622[20]30454-0. doi: 10.1016/j.jaad.2020.03.036).

The correct diagnosis, COVID-19, was made at a tertiary care center after the patient was admitted with respiratory problems.

“There is a possibility that a COVID-19 patient might initially present with a skin rash that can be misdiagnosed as another common disease. ... The practitioner should recognize the possibility that the patient might have only a skin rash” at first, said the lead author of that report, Beuy Joob, PhD, of the Sanitation1 Medical Academic Center, Bangkok, and a coauthor.

There are similar reports in the United States, too. “Many have wondered if COVID-19 presents with any particular skin changes. The answer is yes,” said Randy Jacobs, MD, an assistant clinical professor of dermatology at the University of California, Riverside, who also has a private practice in southern California.

“COVID-19 can feature signs of small blood vessel occlusion. These can be petechiae or tiny bruises, and transient livedoid eruptions,” he said in an interview.

Dr. Jacobs had a 67-year-old patient who presented with a low fever, nasal congestion, postnasal drip, and a wet cough but no shortness of breath. It looked like a common cold. But a week later, the man had a nonpruritic blanching livedoid vascular eruption on his right anterior thigh, and blood in his urine, and he felt weak. The vascular eruption and bloody urine resolved in 24 hours, but the COVID-19 test came back positive and his cough became dry and hacking, and the weakness persisted. He’s in a hospital now and on oxygen, but not ventilated so far.

“Another dermatologist friend of mine also reported a similar transient COVID-19 unilateral livedoid eruption,” Dr. Jacobs said.

It suggests vaso-occlusion. Whether it’s neurogenic, microthrombotic, or immune complex mediated is unknown, but it’s “a skin finding that can help clinicians as they work up their patients with COVID-19 symptoms,” he noted.

Dr. Jacobs and the authors of the studies had no disclosures.

aotto@mdedge.com

Skin manifestations were observed in about one-fifth of a group of patients with COVID-19 in the Alessandro Manzoni Hospital in Lecco, in northern Italy.

Courtesy of Dr. Randy Jacobs

Dermatologists there were pulled from their usual duty to help with the pandemic and looked at what was going on with the skin in 148 COVID-19 inpatients. They excluded 60 who had started new drugs within 15 days to rule out acute drug reactions, then reported what they saw (J Eur Acad Dermatol Venereol. 2020 Mar 26. doi: 10.1111/jdv.16387).

Of the 88 COVID-19 patients, 20.5% developed skin manifestations. Eight of the 18 (44%) had skin eruptions at symptom onset, and the rest after hospitalization. Fourteen (78%) had red rashes, three had widespread urticaria, and one had chickenpox-like vesicles. The most commonly affected area was the trunk. Itching was mild or absent, and lesions usually healed up in a few days. Most importantly, skin manifestations did not correlate with disease severity.

These skin manifestations “are similar to cutaneous involvement occurring during common viral infections,” said the author of the report, Sebastiano Recalcati, MD, a dermatologist at Alessandro Manzoni Hospital.

COVID-19 skin manifestations can cloud the diagnosis, according to the authors of another report from Thailand, where the first case of COVID-19 outside of China was reported.

They described a case of a COVID-19 infection in a Bangkok hospital that masqueraded as dengue fever. A person there presented with only a skin rash, petechiae, and a low platelet count, and was diagnosed with Dengue because that’s exactly what it looked like, the authors wrote (J Am Acad Dermatol. 2020 Mar 22. pii: S0190-9622[20]30454-0. doi: 10.1016/j.jaad.2020.03.036).

The correct diagnosis, COVID-19, was made at a tertiary care center after the patient was admitted with respiratory problems.

“There is a possibility that a COVID-19 patient might initially present with a skin rash that can be misdiagnosed as another common disease. ... The practitioner should recognize the possibility that the patient might have only a skin rash” at first, said the lead author of that report, Beuy Joob, PhD, of the Sanitation1 Medical Academic Center, Bangkok, and a coauthor.

There are similar reports in the United States, too. “Many have wondered if COVID-19 presents with any particular skin changes. The answer is yes,” said Randy Jacobs, MD, an assistant clinical professor of dermatology at the University of California, Riverside, who also has a private practice in southern California.

“COVID-19 can feature signs of small blood vessel occlusion. These can be petechiae or tiny bruises, and transient livedoid eruptions,” he said in an interview.

Dr. Jacobs had a 67-year-old patient who presented with a low fever, nasal congestion, postnasal drip, and a wet cough but no shortness of breath. It looked like a common cold. But a week later, the man had a nonpruritic blanching livedoid vascular eruption on his right anterior thigh, and blood in his urine, and he felt weak. The vascular eruption and bloody urine resolved in 24 hours, but the COVID-19 test came back positive and his cough became dry and hacking, and the weakness persisted. He’s in a hospital now and on oxygen, but not ventilated so far.

“Another dermatologist friend of mine also reported a similar transient COVID-19 unilateral livedoid eruption,” Dr. Jacobs said.

It suggests vaso-occlusion. Whether it’s neurogenic, microthrombotic, or immune complex mediated is unknown, but it’s “a skin finding that can help clinicians as they work up their patients with COVID-19 symptoms,” he noted.

Dr. Jacobs and the authors of the studies had no disclosures.

aotto@mdedge.com

Frontline COVID-19 healthcare workers across North America are dealing with unprecedented stress, but mental health therapists in both Canada and the US are doing their part to ensure the psychological well-being of their colleagues on the frontlines of the pandemic.

Over the past few weeks, thousands of licensed psychologists, psychotherapists, and social workers have signed up to offer free therapy sessions to healthcare professionals who find themselves psychologically overwhelmed by the pandemic’s economic, social, and financial fallout.

In Canada, the movement was started by Toronto psychotherapist Karen Dougherty, MA, who saw a social media post from someone in New York asking mental health workers to volunteer their time.

Inspired by this, Dougherty reached out to some of her close colleagues with a social media post of her own. A few days later, 450 people had signed up to volunteer and Ontario COVID-19 Therapists was born.

The sessions are provided by licensed Canadian psychotherapists and are free of charge to healthcare workers providing frontline COVID-19 care. After signing up online, users can choose from one of three therapists who will provide up to five free phone sessions.

In New York state, a similar initiative — which is not limited to healthcare workers — has gained incredible momentum. On March 21, Gov. Andrew Cuomo announced the creation of a statewide hotline [844-863-9314] to provide free mental health services to individuals sheltering at home who may be experiencing stress and anxiety as a result of COVID-19.

The governor called on mental-health professionals to volunteer their time and provide telephone and/or telehealth counseling. The New York State Psychiatric Association quickly got on board and encouraged its members to participate.

Just four days later, more than 6,000 mental health workers had volunteered their services, making New York the first state to address the mental health consequences of the pandemic in this way.

Self-care is vital for healthcare workers during the COVID-19 pandemic, particularly as stress mounts and workdays become longer and grimmer. Dougherty recommended that frontline workers manage overwhelming thoughts by limiting their intake of information about the virus.

Self-Care a “Selfless Act”

Clinicians need to balance the need to stay informed with the potential for information overload, which can contribute to anxiety, she said.

She also recommended that individuals continue to connect with loved ones while practicing social distancing. Equally important is talking to someone about the struggles people may be facing at work.

For Amin Azzam MD, MA, the benefits of these initiatives are obvious.

“There is always value in providing additional mental health services and tending to psychological well-being,” Azzam, adjunct professor of psychiatry, University of California, San Francisco and UC Berkeley, told Medscape Medical News.

“If there ever were a time when we can use all the emotional support possible, then it would be during a global pandemic,” added Azzam, who is also director of Open Learning Initiatives at Osmosis, a nonprofit health education company.

Azzam urged healthcare professionals to avail themselves of such resources as often as necessary.

“Taking care of ourselves is not a selfish act. When the oxygen masks come down on airplanes we are always instructed to put our own masks on first before helping those in need. It’s a sign of strength, not weakness, to seek emotional support,” he said.

However, it isn’t always easy. The longstanding stigma associated with seeking help for mental health issues has not stopped for COVID-19. Even workers who are in close daily contact with people infected with the virus are finding they’re not immune to the stigma associated with seeking mental health treatment, Azzam added.

“Nevertheless, the burden these frontline workers are facing is real…and often crushing. Some Ontario doctors have reported pretraumatic stress disorder, which they attribute to having watched the virus wreak havoc in other countries, and knowing that similar difficulties are headed their way,” he said.

A Growing Movement

Doris Grinspun, PhD, MSN, the CEO of Registered Nurses’ Association of Ontario (RNAO), said the province’s nurses are under intense pressure at work, then fear infecting family members once they come home. Some are even staying at hotels to ensure they don’t infect others, as reported by CBC News.

However, she added, most recognize the important role that psychotherapy can play, especially since many frontline healthcare workers find it difficult to speak with their families about the issues they face at work, for fear of adding stress to their family life as well.

“None of us are superhuman and immune to stress. When healthcare workers are facing workplace challenges never before seen in their lifetimes, they need opportunities to decompress to maintain their own health and well-being. This will help them pace themselves for the marathon — not sprint — to continue doing the important work of helping others,” said Azzam.

Given the attention it has garnered in such a short time, Azzam is hopeful that the free therapy movement will spread.

In Canada, mental health professionals in other provinces have already reached out to Dougherty, lending credence to the notion of a pan-Canadian network of therapists offering free services to healthcare workers during the outbreak.

In the US, other local initiatives are already underway.

“The one that I’m personally aware of is at my home institution at the University of California, San Francisco,” Azzam said. “We have a Care for the Caregiver program that is being greatly expanded at this time. As part of that initiative, the institution’s psychiatry department has solicited licensed mental health care providers to volunteer their time to provide those additional services.”

Azzam has also worked with colleagues developing a series of mental health tools that Osmosis has made available free of charge.

These include a central site with educational material about COVID-19, a video about supporting educators’ mental health during high-stress periods; a video about managing students’ mental health during public health emergencies; a summary of recommended resources for psychological health in distressing times; and a YouTube Live event he held regarding tips for maximizing psychological health during stressful times.

This article first appeared on Medscape.com.

Frontline COVID-19 healthcare workers across North America are dealing with unprecedented stress, but mental health therapists in both Canada and the US are doing their part to ensure the psychological well-being of their colleagues on the frontlines of the pandemic.

Over the past few weeks, thousands of licensed psychologists, psychotherapists, and social workers have signed up to offer free therapy sessions to healthcare professionals who find themselves psychologically overwhelmed by the pandemic’s economic, social, and financial fallout.

In Canada, the movement was started by Toronto psychotherapist Karen Dougherty, MA, who saw a social media post from someone in New York asking mental health workers to volunteer their time.

Inspired by this, Dougherty reached out to some of her close colleagues with a social media post of her own. A few days later, 450 people had signed up to volunteer and Ontario COVID-19 Therapists was born.

The sessions are provided by licensed Canadian psychotherapists and are free of charge to healthcare workers providing frontline COVID-19 care. After signing up online, users can choose from one of three therapists who will provide up to five free phone sessions.

In New York state, a similar initiative — which is not limited to healthcare workers — has gained incredible momentum. On March 21, Gov. Andrew Cuomo announced the creation of a statewide hotline [844-863-9314] to provide free mental health services to individuals sheltering at home who may be experiencing stress and anxiety as a result of COVID-19.

The governor called on mental-health professionals to volunteer their time and provide telephone and/or telehealth counseling. The New York State Psychiatric Association quickly got on board and encouraged its members to participate.

Just four days later, more than 6,000 mental health workers had volunteered their services, making New York the first state to address the mental health consequences of the pandemic in this way.

Self-care is vital for healthcare workers during the COVID-19 pandemic, particularly as stress mounts and workdays become longer and grimmer. Dougherty recommended that frontline workers manage overwhelming thoughts by limiting their intake of information about the virus.

Self-Care a “Selfless Act”

Clinicians need to balance the need to stay informed with the potential for information overload, which can contribute to anxiety, she said.

She also recommended that individuals continue to connect with loved ones while practicing social distancing. Equally important is talking to someone about the struggles people may be facing at work.

For Amin Azzam MD, MA, the benefits of these initiatives are obvious.

“There is always value in providing additional mental health services and tending to psychological well-being,” Azzam, adjunct professor of psychiatry, University of California, San Francisco and UC Berkeley, told Medscape Medical News.

“If there ever were a time when we can use all the emotional support possible, then it would be during a global pandemic,” added Azzam, who is also director of Open Learning Initiatives at Osmosis, a nonprofit health education company.

Azzam urged healthcare professionals to avail themselves of such resources as often as necessary.

“Taking care of ourselves is not a selfish act. When the oxygen masks come down on airplanes we are always instructed to put our own masks on first before helping those in need. It’s a sign of strength, not weakness, to seek emotional support,” he said.

However, it isn’t always easy. The longstanding stigma associated with seeking help for mental health issues has not stopped for COVID-19. Even workers who are in close daily contact with people infected with the virus are finding they’re not immune to the stigma associated with seeking mental health treatment, Azzam added.

“Nevertheless, the burden these frontline workers are facing is real…and often crushing. Some Ontario doctors have reported pretraumatic stress disorder, which they attribute to having watched the virus wreak havoc in other countries, and knowing that similar difficulties are headed their way,” he said.

A Growing Movement

Doris Grinspun, PhD, MSN, the CEO of Registered Nurses’ Association of Ontario (RNAO), said the province’s nurses are under intense pressure at work, then fear infecting family members once they come home. Some are even staying at hotels to ensure they don’t infect others, as reported by CBC News.

However, she added, most recognize the important role that psychotherapy can play, especially since many frontline healthcare workers find it difficult to speak with their families about the issues they face at work, for fear of adding stress to their family life as well.

“None of us are superhuman and immune to stress. When healthcare workers are facing workplace challenges never before seen in their lifetimes, they need opportunities to decompress to maintain their own health and well-being. This will help them pace themselves for the marathon — not sprint — to continue doing the important work of helping others,” said Azzam.

Given the attention it has garnered in such a short time, Azzam is hopeful that the free therapy movement will spread.

In Canada, mental health professionals in other provinces have already reached out to Dougherty, lending credence to the notion of a pan-Canadian network of therapists offering free services to healthcare workers during the outbreak.

In the US, other local initiatives are already underway.

“The one that I’m personally aware of is at my home institution at the University of California, San Francisco,” Azzam said. “We have a Care for the Caregiver program that is being greatly expanded at this time. As part of that initiative, the institution’s psychiatry department has solicited licensed mental health care providers to volunteer their time to provide those additional services.”

Azzam has also worked with colleagues developing a series of mental health tools that Osmosis has made available free of charge.

These include a central site with educational material about COVID-19, a video about supporting educators’ mental health during high-stress periods; a video about managing students’ mental health during public health emergencies; a summary of recommended resources for psychological health in distressing times; and a YouTube Live event he held regarding tips for maximizing psychological health during stressful times.

This article first appeared on Medscape.com.

Frontline COVID-19 healthcare workers across North America are dealing with unprecedented stress, but mental health therapists in both Canada and the US are doing their part to ensure the psychological well-being of their colleagues on the frontlines of the pandemic.

Over the past few weeks, thousands of licensed psychologists, psychotherapists, and social workers have signed up to offer free therapy sessions to healthcare professionals who find themselves psychologically overwhelmed by the pandemic’s economic, social, and financial fallout.

In Canada, the movement was started by Toronto psychotherapist Karen Dougherty, MA, who saw a social media post from someone in New York asking mental health workers to volunteer their time.

Inspired by this, Dougherty reached out to some of her close colleagues with a social media post of her own. A few days later, 450 people had signed up to volunteer and Ontario COVID-19 Therapists was born.

The sessions are provided by licensed Canadian psychotherapists and are free of charge to healthcare workers providing frontline COVID-19 care. After signing up online, users can choose from one of three therapists who will provide up to five free phone sessions.

In New York state, a similar initiative — which is not limited to healthcare workers — has gained incredible momentum. On March 21, Gov. Andrew Cuomo announced the creation of a statewide hotline [844-863-9314] to provide free mental health services to individuals sheltering at home who may be experiencing stress and anxiety as a result of COVID-19.

The governor called on mental-health professionals to volunteer their time and provide telephone and/or telehealth counseling. The New York State Psychiatric Association quickly got on board and encouraged its members to participate.

Just four days later, more than 6,000 mental health workers had volunteered their services, making New York the first state to address the mental health consequences of the pandemic in this way.

Self-care is vital for healthcare workers during the COVID-19 pandemic, particularly as stress mounts and workdays become longer and grimmer. Dougherty recommended that frontline workers manage overwhelming thoughts by limiting their intake of information about the virus.

Self-Care a “Selfless Act”

Clinicians need to balance the need to stay informed with the potential for information overload, which can contribute to anxiety, she said.

She also recommended that individuals continue to connect with loved ones while practicing social distancing. Equally important is talking to someone about the struggles people may be facing at work.

For Amin Azzam MD, MA, the benefits of these initiatives are obvious.

“There is always value in providing additional mental health services and tending to psychological well-being,” Azzam, adjunct professor of psychiatry, University of California, San Francisco and UC Berkeley, told Medscape Medical News.

“If there ever were a time when we can use all the emotional support possible, then it would be during a global pandemic,” added Azzam, who is also director of Open Learning Initiatives at Osmosis, a nonprofit health education company.

Azzam urged healthcare professionals to avail themselves of such resources as often as necessary.

“Taking care of ourselves is not a selfish act. When the oxygen masks come down on airplanes we are always instructed to put our own masks on first before helping those in need. It’s a sign of strength, not weakness, to seek emotional support,” he said.

However, it isn’t always easy. The longstanding stigma associated with seeking help for mental health issues has not stopped for COVID-19. Even workers who are in close daily contact with people infected with the virus are finding they’re not immune to the stigma associated with seeking mental health treatment, Azzam added.

“Nevertheless, the burden these frontline workers are facing is real…and often crushing. Some Ontario doctors have reported pretraumatic stress disorder, which they attribute to having watched the virus wreak havoc in other countries, and knowing that similar difficulties are headed their way,” he said.

A Growing Movement

Doris Grinspun, PhD, MSN, the CEO of Registered Nurses’ Association of Ontario (RNAO), said the province’s nurses are under intense pressure at work, then fear infecting family members once they come home. Some are even staying at hotels to ensure they don’t infect others, as reported by CBC News.

However, she added, most recognize the important role that psychotherapy can play, especially since many frontline healthcare workers find it difficult to speak with their families about the issues they face at work, for fear of adding stress to their family life as well.

“None of us are superhuman and immune to stress. When healthcare workers are facing workplace challenges never before seen in their lifetimes, they need opportunities to decompress to maintain their own health and well-being. This will help them pace themselves for the marathon — not sprint — to continue doing the important work of helping others,” said Azzam.

Given the attention it has garnered in such a short time, Azzam is hopeful that the free therapy movement will spread.

In Canada, mental health professionals in other provinces have already reached out to Dougherty, lending credence to the notion of a pan-Canadian network of therapists offering free services to healthcare workers during the outbreak.

In the US, other local initiatives are already underway.

“The one that I’m personally aware of is at my home institution at the University of California, San Francisco,” Azzam said. “We have a Care for the Caregiver program that is being greatly expanded at this time. As part of that initiative, the institution’s psychiatry department has solicited licensed mental health care providers to volunteer their time to provide those additional services.”

Azzam has also worked with colleagues developing a series of mental health tools that Osmosis has made available free of charge.

These include a central site with educational material about COVID-19, a video about supporting educators’ mental health during high-stress periods; a video about managing students’ mental health during public health emergencies; a summary of recommended resources for psychological health in distressing times; and a YouTube Live event he held regarding tips for maximizing psychological health during stressful times.

This article first appeared on Medscape.com.

Asymptomatic transmission is the most likely explanation for 6.4% of the locally acquired COVID-19 infections in Singapore, based on clinical and epidemiologic data for all cases reported in the country by March 16.

As of that date, there had been 243 cases of COVID-19, of which 157 were locally acquired. Among those 157 were 10 cases (6.4%) that involved probable presymptomatic transmission, Wycliffe E. Wei, MPH, and associates said April 1 in the Morbidity and Mortality Weekly Report.

They defined presymptomatic transmission “as the transmission of SARS-CoV-2 from an infected person (source patient) to a secondary patient before the source patient developed symptoms, as ascertained by exposure and symptom onset dates, with no evidence that the secondary patient had been exposed to anyone else with COVID-19.”

Investigation of all 243 cases in Singapore identified seven clusters, each involving two to five patients, as sources of presymptomatic transmission. In four of the clusters, the “exposure occurred 1-3 days before the source patient developed symptoms,” said Mr. Wei of the Singapore Ministry of Health and associates.

These findings, along with evidence from Chinese studies – one of which reported presymptomatic transmission in 12.6% of cases – support “the likelihood that viral shedding can occur in the absence of symptoms and before symptom onset,” they said.

rfranki@mdedge.com

SOURCE: Wei WE et al. MMWR. 2020 Apr 1;69(ePub):1-5. doi: 10.15585/mmwr.mm6914e1.

Asymptomatic transmission is the most likely explanation for 6.4% of the locally acquired COVID-19 infections in Singapore, based on clinical and epidemiologic data for all cases reported in the country by March 16.

As of that date, there had been 243 cases of COVID-19, of which 157 were locally acquired. Among those 157 were 10 cases (6.4%) that involved probable presymptomatic transmission, Wycliffe E. Wei, MPH, and associates said April 1 in the Morbidity and Mortality Weekly Report.

They defined presymptomatic transmission “as the transmission of SARS-CoV-2 from an infected person (source patient) to a secondary patient before the source patient developed symptoms, as ascertained by exposure and symptom onset dates, with no evidence that the secondary patient had been exposed to anyone else with COVID-19.”

Investigation of all 243 cases in Singapore identified seven clusters, each involving two to five patients, as sources of presymptomatic transmission. In four of the clusters, the “exposure occurred 1-3 days before the source patient developed symptoms,” said Mr. Wei of the Singapore Ministry of Health and associates.

These findings, along with evidence from Chinese studies – one of which reported presymptomatic transmission in 12.6% of cases – support “the likelihood that viral shedding can occur in the absence of symptoms and before symptom onset,” they said.

rfranki@mdedge.com

SOURCE: Wei WE et al. MMWR. 2020 Apr 1;69(ePub):1-5. doi: 10.15585/mmwr.mm6914e1.

Asymptomatic transmission is the most likely explanation for 6.4% of the locally acquired COVID-19 infections in Singapore, based on clinical and epidemiologic data for all cases reported in the country by March 16.

As of that date, there had been 243 cases of COVID-19, of which 157 were locally acquired. Among those 157 were 10 cases (6.4%) that involved probable presymptomatic transmission, Wycliffe E. Wei, MPH, and associates said April 1 in the Morbidity and Mortality Weekly Report.

They defined presymptomatic transmission “as the transmission of SARS-CoV-2 from an infected person (source patient) to a secondary patient before the source patient developed symptoms, as ascertained by exposure and symptom onset dates, with no evidence that the secondary patient had been exposed to anyone else with COVID-19.”

Investigation of all 243 cases in Singapore identified seven clusters, each involving two to five patients, as sources of presymptomatic transmission. In four of the clusters, the “exposure occurred 1-3 days before the source patient developed symptoms,” said Mr. Wei of the Singapore Ministry of Health and associates.

These findings, along with evidence from Chinese studies – one of which reported presymptomatic transmission in 12.6% of cases – support “the likelihood that viral shedding can occur in the absence of symptoms and before symptom onset,” they said.

rfranki@mdedge.com

SOURCE: Wei WE et al. MMWR. 2020 Apr 1;69(ePub):1-5. doi: 10.15585/mmwr.mm6914e1.

There are several steps cancer centers can take in response to the COVID-19 pandemic, according to the medical director of a cancer care alliance in the first U.S. epicenter of the coronavirus outbreak.

Jennie R. Crews, MD, the medical director of the Seattle Cancer Care Alliance (SCCA), discussed the SCCA experience and offered advice for other cancer centers in a webinar hosted by the Association of Community Cancer Centers.

Dr. Crews highlighted the SCCA’s use of algorithms to predict which patients can be managed via telehealth and which require face-to-face visits, human resource issues that arose at SCCA, screening and testing procedures, and the importance of communication with patients, caregivers, and staff.
 

Communication

Dr. Crews stressed the value of clear, regular, and internally consistent staff communication in a variety of formats. SCCA sends daily email blasts to their personnel regarding policies and procedures, which are archived on the SCCA intranet site.

SCCA also holds weekly town hall meetings at which leaders respond to staff questions regarding practical matters they have encountered and future plans. Providers’ up-to-the-minute familiarity with policies and procedures enables all team members to uniformly and clearly communicate to patients and caregivers.

Dr. Crews emphasized the value of consistency and “over-communication” in projecting confidence and preparedness to patients and caregivers during an unsettling time. SCCA has developed fact sheets, posted current information on the SCCA website, and provided education during doorway screenings.
 

Screening and testing

All SCCA staff members are screened daily at the practice entrance so they have personal experience with the process utilized for patients. Because symptoms associated with coronavirus infection may overlap with cancer treatment–related complaints, SCCA clinicians have expanded the typical coronavirus screening questionnaire for patients on cancer treatment.

Patients with ambiguous symptoms are masked, taken to a physically separate area of the SCCA clinics, and screened further by an advanced practice provider. The patients are then triaged to either the clinic for treatment or to the emergency department for further triage and care.

Although testing processes and procedures have been modified, Dr. Crews advised codifying those policies and procedures, including notification of results and follow-up for both patients and staff. Dr. Crews also stressed the importance of clearly articulated return-to-work policies for staff who have potential exposure and/or positive test results.

At the University of Washington’s virology laboratory, they have a test turnaround time of less than 12 hours.
 

Planning ahead

Dr. Crews highlighted the importance of community-based surge planning, utilizing predictive models to assess inpatient capacity requirements and potential repurposing of providers.

The SCCA is prepared to close selected community sites and shift personnel to other locations if personnel needs cannot be met because of illness or quarantine. Contingency plans include specialized pharmacy services for patients requiring chemotherapy.

The SCCA has not yet experienced shortages of personal protective equipment (PPE). However, Dr. Crews said staff require detailed education regarding the use of PPE in order to safeguard the supply while providing maximal staff protection.
 

Helping the helpers

During the pandemic, SCCA has dealt with a variety of challenging human resource issues, including:

• Extending sick time beyond what was previously “stored” in staff members’ earned time off.
• Childcare during an extended hiatus in school and daycare schedules.
• Programs to maintain and/or restore employee wellness (including staff-centered support services, spiritual care, mindfulness exercises, and town halls).

Dr. Crews also discussed recruitment of community resources to provide meals for staff from local restaurants with restricted hours and transportation resources for staff and patients, as visitors are restricted (currently one per patient).
 

Managing care

Dr. Crews noted that the University of Washington had a foundational structure for a telehealth program prior to the pandemic. Their telehealth committee enabled SCCA to scale up the service quickly with their academic partners, including training modules for and certification of providers, outfitting off-site personnel with dedicated lines and hardware, and provision of personal Zoom accounts.

SCCA also devised algorithms for determining when face-to-face visits, remote management, or deferred visits are appropriate in various scenarios. The algorithms were developed by disease-specialized teams.

As a general rule, routine chemotherapy and radiation are administered on schedule. On-treatment and follow-up office visits are conducted via telehealth if possible. In some cases, initiation of chemotherapy and radiation has been delayed, and screening services have been suspended.

In response to questions about palliative care during the pandemic, Dr. Crews said SCCA has encouraged their patients to complete, review, or update their advance directives. The SCCA has not had the need to resuscitate a coronavirus-infected outpatient but has instituted policies for utilizing full PPE on any patient requiring resuscitation.

In her closing remarks, Dr. Crews stressed that the response to COVID-19 in Washington state has required an intense collaboration among colleagues, the community, and government leaders, as the actions required extended far beyond medical decision makers alone.
 

Dr. Lyss was a community-based medical oncologist and clinical researcher for more than 35 years before his recent retirement. His clinical and research interests were focused on breast and lung cancers as well as expanding clinical trial access to medically underserved populations. He is based in St. Louis. He has no conflicts of interest.

There are several steps cancer centers can take in response to the COVID-19 pandemic, according to the medical director of a cancer care alliance in the first U.S. epicenter of the coronavirus outbreak.

Jennie R. Crews, MD, the medical director of the Seattle Cancer Care Alliance (SCCA), discussed the SCCA experience and offered advice for other cancer centers in a webinar hosted by the Association of Community Cancer Centers.

Dr. Crews highlighted the SCCA’s use of algorithms to predict which patients can be managed via telehealth and which require face-to-face visits, human resource issues that arose at SCCA, screening and testing procedures, and the importance of communication with patients, caregivers, and staff.
 

Communication

Dr. Crews stressed the value of clear, regular, and internally consistent staff communication in a variety of formats. SCCA sends daily email blasts to their personnel regarding policies and procedures, which are archived on the SCCA intranet site.

SCCA also holds weekly town hall meetings at which leaders respond to staff questions regarding practical matters they have encountered and future plans. Providers’ up-to-the-minute familiarity with policies and procedures enables all team members to uniformly and clearly communicate to patients and caregivers.

Dr. Crews emphasized the value of consistency and “over-communication” in projecting confidence and preparedness to patients and caregivers during an unsettling time. SCCA has developed fact sheets, posted current information on the SCCA website, and provided education during doorway screenings.
 

Screening and testing

All SCCA staff members are screened daily at the practice entrance so they have personal experience with the process utilized for patients. Because symptoms associated with coronavirus infection may overlap with cancer treatment–related complaints, SCCA clinicians have expanded the typical coronavirus screening questionnaire for patients on cancer treatment.

Patients with ambiguous symptoms are masked, taken to a physically separate area of the SCCA clinics, and screened further by an advanced practice provider. The patients are then triaged to either the clinic for treatment or to the emergency department for further triage and care.

Although testing processes and procedures have been modified, Dr. Crews advised codifying those policies and procedures, including notification of results and follow-up for both patients and staff. Dr. Crews also stressed the importance of clearly articulated return-to-work policies for staff who have potential exposure and/or positive test results.

At the University of Washington’s virology laboratory, they have a test turnaround time of less than 12 hours.
 

Planning ahead

Dr. Crews highlighted the importance of community-based surge planning, utilizing predictive models to assess inpatient capacity requirements and potential repurposing of providers.

The SCCA is prepared to close selected community sites and shift personnel to other locations if personnel needs cannot be met because of illness or quarantine. Contingency plans include specialized pharmacy services for patients requiring chemotherapy.

The SCCA has not yet experienced shortages of personal protective equipment (PPE). However, Dr. Crews said staff require detailed education regarding the use of PPE in order to safeguard the supply while providing maximal staff protection.
 

Helping the helpers

During the pandemic, SCCA has dealt with a variety of challenging human resource issues, including:

• Extending sick time beyond what was previously “stored” in staff members’ earned time off.
• Childcare during an extended hiatus in school and daycare schedules.
• Programs to maintain and/or restore employee wellness (including staff-centered support services, spiritual care, mindfulness exercises, and town halls).

Dr. Crews also discussed recruitment of community resources to provide meals for staff from local restaurants with restricted hours and transportation resources for staff and patients, as visitors are restricted (currently one per patient).
 

Managing care

Dr. Crews noted that the University of Washington had a foundational structure for a telehealth program prior to the pandemic. Their telehealth committee enabled SCCA to scale up the service quickly with their academic partners, including training modules for and certification of providers, outfitting off-site personnel with dedicated lines and hardware, and provision of personal Zoom accounts.

SCCA also devised algorithms for determining when face-to-face visits, remote management, or deferred visits are appropriate in various scenarios. The algorithms were developed by disease-specialized teams.

As a general rule, routine chemotherapy and radiation are administered on schedule. On-treatment and follow-up office visits are conducted via telehealth if possible. In some cases, initiation of chemotherapy and radiation has been delayed, and screening services have been suspended.

In response to questions about palliative care during the pandemic, Dr. Crews said SCCA has encouraged their patients to complete, review, or update their advance directives. The SCCA has not had the need to resuscitate a coronavirus-infected outpatient but has instituted policies for utilizing full PPE on any patient requiring resuscitation.

In her closing remarks, Dr. Crews stressed that the response to COVID-19 in Washington state has required an intense collaboration among colleagues, the community, and government leaders, as the actions required extended far beyond medical decision makers alone.
 

Dr. Lyss was a community-based medical oncologist and clinical researcher for more than 35 years before his recent retirement. His clinical and research interests were focused on breast and lung cancers as well as expanding clinical trial access to medically underserved populations. He is based in St. Louis. He has no conflicts of interest.

There are several steps cancer centers can take in response to the COVID-19 pandemic, according to the medical director of a cancer care alliance in the first U.S. epicenter of the coronavirus outbreak.

Jennie R. Crews, MD, the medical director of the Seattle Cancer Care Alliance (SCCA), discussed the SCCA experience and offered advice for other cancer centers in a webinar hosted by the Association of Community Cancer Centers.

Dr. Crews highlighted the SCCA’s use of algorithms to predict which patients can be managed via telehealth and which require face-to-face visits, human resource issues that arose at SCCA, screening and testing procedures, and the importance of communication with patients, caregivers, and staff.
 

Communication

Dr. Crews stressed the value of clear, regular, and internally consistent staff communication in a variety of formats. SCCA sends daily email blasts to their personnel regarding policies and procedures, which are archived on the SCCA intranet site.

SCCA also holds weekly town hall meetings at which leaders respond to staff questions regarding practical matters they have encountered and future plans. Providers’ up-to-the-minute familiarity with policies and procedures enables all team members to uniformly and clearly communicate to patients and caregivers.

Dr. Crews emphasized the value of consistency and “over-communication” in projecting confidence and preparedness to patients and caregivers during an unsettling time. SCCA has developed fact sheets, posted current information on the SCCA website, and provided education during doorway screenings.
 

Screening and testing

All SCCA staff members are screened daily at the practice entrance so they have personal experience with the process utilized for patients. Because symptoms associated with coronavirus infection may overlap with cancer treatment–related complaints, SCCA clinicians have expanded the typical coronavirus screening questionnaire for patients on cancer treatment.

Patients with ambiguous symptoms are masked, taken to a physically separate area of the SCCA clinics, and screened further by an advanced practice provider. The patients are then triaged to either the clinic for treatment or to the emergency department for further triage and care.

Although testing processes and procedures have been modified, Dr. Crews advised codifying those policies and procedures, including notification of results and follow-up for both patients and staff. Dr. Crews also stressed the importance of clearly articulated return-to-work policies for staff who have potential exposure and/or positive test results.

At the University of Washington’s virology laboratory, they have a test turnaround time of less than 12 hours.
 

Planning ahead

Dr. Crews highlighted the importance of community-based surge planning, utilizing predictive models to assess inpatient capacity requirements and potential repurposing of providers.

The SCCA is prepared to close selected community sites and shift personnel to other locations if personnel needs cannot be met because of illness or quarantine. Contingency plans include specialized pharmacy services for patients requiring chemotherapy.

The SCCA has not yet experienced shortages of personal protective equipment (PPE). However, Dr. Crews said staff require detailed education regarding the use of PPE in order to safeguard the supply while providing maximal staff protection.
 

Helping the helpers

During the pandemic, SCCA has dealt with a variety of challenging human resource issues, including:

• Extending sick time beyond what was previously “stored” in staff members’ earned time off.
• Childcare during an extended hiatus in school and daycare schedules.
• Programs to maintain and/or restore employee wellness (including staff-centered support services, spiritual care, mindfulness exercises, and town halls).

Dr. Crews also discussed recruitment of community resources to provide meals for staff from local restaurants with restricted hours and transportation resources for staff and patients, as visitors are restricted (currently one per patient).
 

Managing care

Dr. Crews noted that the University of Washington had a foundational structure for a telehealth program prior to the pandemic. Their telehealth committee enabled SCCA to scale up the service quickly with their academic partners, including training modules for and certification of providers, outfitting off-site personnel with dedicated lines and hardware, and provision of personal Zoom accounts.

SCCA also devised algorithms for determining when face-to-face visits, remote management, or deferred visits are appropriate in various scenarios. The algorithms were developed by disease-specialized teams.

As a general rule, routine chemotherapy and radiation are administered on schedule. On-treatment and follow-up office visits are conducted via telehealth if possible. In some cases, initiation of chemotherapy and radiation has been delayed, and screening services have been suspended.

In response to questions about palliative care during the pandemic, Dr. Crews said SCCA has encouraged their patients to complete, review, or update their advance directives. The SCCA has not had the need to resuscitate a coronavirus-infected outpatient but has instituted policies for utilizing full PPE on any patient requiring resuscitation.

In her closing remarks, Dr. Crews stressed that the response to COVID-19 in Washington state has required an intense collaboration among colleagues, the community, and government leaders, as the actions required extended far beyond medical decision makers alone.
 

Dr. Lyss was a community-based medical oncologist and clinical researcher for more than 35 years before his recent retirement. His clinical and research interests were focused on breast and lung cancers as well as expanding clinical trial access to medically underserved populations. He is based in St. Louis. He has no conflicts of interest.

On the evening of March 24, I got the email. When the bolded letters “We ask for your help” flashed across my screen, I knew exactly what was being asked of me: to graduate early and join the fight against COVID-19.

It would be a lie to say that my immediate reaction was to volunteer.

For the 120 fourth-year medical students in my class at NYU Grossman School of Medicine, the arrival of that email was always more a question of when than if. Similar moves had already been made in Italy as well as the United Kingdom, where the surge in patients with COVID-19 has devastated hospitals and left healthcare workers dead or drained. The New York hospitals where I’ve trained, places I have grown to love over the past 4 years, are now experiencing similar horrors. Residents and attending doctors – mentors and teachers – are burned out and exhausted. They need help.

Like most medical students, I chose to pursue medicine out of a desire to help. On both my medical school and residency applications, I spoke about my resolve to bear witness to and provide support to those suffering. Yet, being recruited to the front lines of a global pandemic felt deeply unsettling. Is this how I want to finally enter the world of medicine? The scope of what is actually being asked of me was immense.

Given the onslaught of bad news coming in on every device I had cozied up to during my social distancing, how could I want to do this? I’ve seen the death toll climb in Italy, with dozens of doctors dead. I’ve seen the photos of faces marred by masks worn for 12-16 hours at a time. I’ve been repeatedly reminded that we are just behind Italy. Things are certainly going to get worse.

It sounds selfish and petty, but I feel like COVID-19 has already robbed me of so much. Yet that was my first thought when I received the email. The end of fourth year in medical school is supposed to be a joyous, celebratory time. We have worked years for this moment. So many of us have fought burnout to reach this time, a brief moment of rest between being a medical student and becoming a full-fledged physician.

I matched into residency just 4 days before being asked to join the front lines of the pandemic. I found out my match results without the usual fanfare, sitting on a bench in Madison Square Park, FaceTiming my dad and safely social-distanced from my mom. They both cried tears of joy. Like so many people around the world right now, I couldn’t even embrace my parents. Would they want me to volunteer?

I reached out to my classmates. I thought that some of them would certainly share my worries. I thought they also had to be carrying this uncomfortable kind of grief, a heavy and acidic feeling of dreams collapsing into a moral duty. I received a unanimous reply: “We are needed. It’s our time to step up.” No matter how many “what ifs” I voiced, they wouldn’t crack or waver. Still, even if they never admitted it to me, I wondered whether they privately shared some of my concerns and fears.

Everyone knows information is shared instantly in our Twitter-centric world, but I was still shocked and unprepared for how quickly I was at the center of a major news story. Within an hour of that email, I was contacted by an old acquaintance from elementary school, now a journalist. He had found me through Facebook and asked, “Will you be one of the NYU students graduating early? Would love to get a comment.” Another friend texted me a photo of the leaked email, quipping, “Are you going to save us from the pandemic, Dr. Gabe?!” “It’s not a small decision!” I snapped back.

I went through something like the seven stages of grief in rapid succession. I found that with each excuse I made why I shouldn’t volunteer, I somehow became increasingly more anxious. To my surprise, when I decided I would join 50 of my peers at NYU, graduate early, and volunteer, my mind settled. The more I thought about it, the more I was overtaken by the selfless beauty of the profession I’m entering. This is what it means to be a doctor. I recalled a key part of the Hippocratic Oath: “I will remember that I remain a member of society, with special obligations to all my fellow human beings, those sound of mind and body as well as the infirm.”

I am going to fulfill my special obligations.

The fear is still there. I’m scared of COVID. I’m scared to infect others. I’m scared of winding up paralyzed and intubated. But I have also realized that all we have is each other. Healthcare workers supporting healthcare workers. New Yorkers supporting New Yorkers. Citizens of the world supporting citizens of the world. This is my time to be there for others, unwaveringly.

Logistical details continue to roll in, although they feel trivial in relation to the decision I have already made. The paperwork tells me that I will be onboarded to NYU’s internal medicine residency program. I will be compensated and protected under a similar contract to what current NYU residents sign. I have been promised that I will remain insured until I start my official residency program in July. My student loans won’t begin accruing interest until my normally planned graduation date. I am told that I will have personal protective equipment in line with the Centers for Disease Control and Prevention recommendations.

Questions still linger. Is it safe for me and my newly minted physician peers to continue living with our spouses, children, and friends? How long will I need to quarantine after my contract ends? Will there be a virtual graduation ceremony for my parents and loved ones to enjoy? In these challenging times, each day gives me a little more clarity about what exactly I am signing up for, but there are still so many uncertainties.

Am I naive to say that I do feel prepared? Or at least as prepared as anyone can be. With respect to my training, I have completed the requirements to graduate, which is why I am being permitted to graduate early in the first place. Our faculty points to our professionalism as the most promising indicator of our preparedness. They are heartened that we have embraced this truest test: our duty to others.

There is an eerie calm to New York City that contradicts what is shown on the news. With stores closed and streets quiet, it almost feels like Christmas morning here. Yet, inside the hospital, a fire rages. All the metaphors being used right now speak about violence, devastation, and immeasurable human suffering. “A war is being fought.” Or so I have heard. I guess I am about to find out.

Gabriel Redel-Traub is a fourth-year medical student at NYU Grossman School of Medicine. He will be starting residency in internal medicine at Columbia Presbyterian this summer. He is the former editor-in-chief of Dartmouth College’s Mouth Magazine, an editor of NYU’s LitMed Database, and has published most recently in the Hasting’s Center Magazine. Gabriel Redel-Traub has disclosed no relevant financial relationships.

This article first appeared on Medscape.com.

On the evening of March 24, I got the email. When the bolded letters “We ask for your help” flashed across my screen, I knew exactly what was being asked of me: to graduate early and join the fight against COVID-19.

It would be a lie to say that my immediate reaction was to volunteer.

For the 120 fourth-year medical students in my class at NYU Grossman School of Medicine, the arrival of that email was always more a question of when than if. Similar moves had already been made in Italy as well as the United Kingdom, where the surge in patients with COVID-19 has devastated hospitals and left healthcare workers dead or drained. The New York hospitals where I’ve trained, places I have grown to love over the past 4 years, are now experiencing similar horrors. Residents and attending doctors – mentors and teachers – are burned out and exhausted. They need help.

Like most medical students, I chose to pursue medicine out of a desire to help. On both my medical school and residency applications, I spoke about my resolve to bear witness to and provide support to those suffering. Yet, being recruited to the front lines of a global pandemic felt deeply unsettling. Is this how I want to finally enter the world of medicine? The scope of what is actually being asked of me was immense.

Given the onslaught of bad news coming in on every device I had cozied up to during my social distancing, how could I want to do this? I’ve seen the death toll climb in Italy, with dozens of doctors dead. I’ve seen the photos of faces marred by masks worn for 12-16 hours at a time. I’ve been repeatedly reminded that we are just behind Italy. Things are certainly going to get worse.

It sounds selfish and petty, but I feel like COVID-19 has already robbed me of so much. Yet that was my first thought when I received the email. The end of fourth year in medical school is supposed to be a joyous, celebratory time. We have worked years for this moment. So many of us have fought burnout to reach this time, a brief moment of rest between being a medical student and becoming a full-fledged physician.

I matched into residency just 4 days before being asked to join the front lines of the pandemic. I found out my match results without the usual fanfare, sitting on a bench in Madison Square Park, FaceTiming my dad and safely social-distanced from my mom. They both cried tears of joy. Like so many people around the world right now, I couldn’t even embrace my parents. Would they want me to volunteer?

I reached out to my classmates. I thought that some of them would certainly share my worries. I thought they also had to be carrying this uncomfortable kind of grief, a heavy and acidic feeling of dreams collapsing into a moral duty. I received a unanimous reply: “We are needed. It’s our time to step up.” No matter how many “what ifs” I voiced, they wouldn’t crack or waver. Still, even if they never admitted it to me, I wondered whether they privately shared some of my concerns and fears.

Everyone knows information is shared instantly in our Twitter-centric world, but I was still shocked and unprepared for how quickly I was at the center of a major news story. Within an hour of that email, I was contacted by an old acquaintance from elementary school, now a journalist. He had found me through Facebook and asked, “Will you be one of the NYU students graduating early? Would love to get a comment.” Another friend texted me a photo of the leaked email, quipping, “Are you going to save us from the pandemic, Dr. Gabe?!” “It’s not a small decision!” I snapped back.

I went through something like the seven stages of grief in rapid succession. I found that with each excuse I made why I shouldn’t volunteer, I somehow became increasingly more anxious. To my surprise, when I decided I would join 50 of my peers at NYU, graduate early, and volunteer, my mind settled. The more I thought about it, the more I was overtaken by the selfless beauty of the profession I’m entering. This is what it means to be a doctor. I recalled a key part of the Hippocratic Oath: “I will remember that I remain a member of society, with special obligations to all my fellow human beings, those sound of mind and body as well as the infirm.”

I am going to fulfill my special obligations.

The fear is still there. I’m scared of COVID. I’m scared to infect others. I’m scared of winding up paralyzed and intubated. But I have also realized that all we have is each other. Healthcare workers supporting healthcare workers. New Yorkers supporting New Yorkers. Citizens of the world supporting citizens of the world. This is my time to be there for others, unwaveringly.

Logistical details continue to roll in, although they feel trivial in relation to the decision I have already made. The paperwork tells me that I will be onboarded to NYU’s internal medicine residency program. I will be compensated and protected under a similar contract to what current NYU residents sign. I have been promised that I will remain insured until I start my official residency program in July. My student loans won’t begin accruing interest until my normally planned graduation date. I am told that I will have personal protective equipment in line with the Centers for Disease Control and Prevention recommendations.

Questions still linger. Is it safe for me and my newly minted physician peers to continue living with our spouses, children, and friends? How long will I need to quarantine after my contract ends? Will there be a virtual graduation ceremony for my parents and loved ones to enjoy? In these challenging times, each day gives me a little more clarity about what exactly I am signing up for, but there are still so many uncertainties.

Am I naive to say that I do feel prepared? Or at least as prepared as anyone can be. With respect to my training, I have completed the requirements to graduate, which is why I am being permitted to graduate early in the first place. Our faculty points to our professionalism as the most promising indicator of our preparedness. They are heartened that we have embraced this truest test: our duty to others.

There is an eerie calm to New York City that contradicts what is shown on the news. With stores closed and streets quiet, it almost feels like Christmas morning here. Yet, inside the hospital, a fire rages. All the metaphors being used right now speak about violence, devastation, and immeasurable human suffering. “A war is being fought.” Or so I have heard. I guess I am about to find out.

Gabriel Redel-Traub is a fourth-year medical student at NYU Grossman School of Medicine. He will be starting residency in internal medicine at Columbia Presbyterian this summer. He is the former editor-in-chief of Dartmouth College’s Mouth Magazine, an editor of NYU’s LitMed Database, and has published most recently in the Hasting’s Center Magazine. Gabriel Redel-Traub has disclosed no relevant financial relationships.

This article first appeared on Medscape.com.

On the evening of March 24, I got the email. When the bolded letters “We ask for your help” flashed across my screen, I knew exactly what was being asked of me: to graduate early and join the fight against COVID-19.

It would be a lie to say that my immediate reaction was to volunteer.

For the 120 fourth-year medical students in my class at NYU Grossman School of Medicine, the arrival of that email was always more a question of when than if. Similar moves had already been made in Italy as well as the United Kingdom, where the surge in patients with COVID-19 has devastated hospitals and left healthcare workers dead or drained. The New York hospitals where I’ve trained, places I have grown to love over the past 4 years, are now experiencing similar horrors. Residents and attending doctors – mentors and teachers – are burned out and exhausted. They need help.

Like most medical students, I chose to pursue medicine out of a desire to help. On both my medical school and residency applications, I spoke about my resolve to bear witness to and provide support to those suffering. Yet, being recruited to the front lines of a global pandemic felt deeply unsettling. Is this how I want to finally enter the world of medicine? The scope of what is actually being asked of me was immense.

Given the onslaught of bad news coming in on every device I had cozied up to during my social distancing, how could I want to do this? I’ve seen the death toll climb in Italy, with dozens of doctors dead. I’ve seen the photos of faces marred by masks worn for 12-16 hours at a time. I’ve been repeatedly reminded that we are just behind Italy. Things are certainly going to get worse.

It sounds selfish and petty, but I feel like COVID-19 has already robbed me of so much. Yet that was my first thought when I received the email. The end of fourth year in medical school is supposed to be a joyous, celebratory time. We have worked years for this moment. So many of us have fought burnout to reach this time, a brief moment of rest between being a medical student and becoming a full-fledged physician.

I matched into residency just 4 days before being asked to join the front lines of the pandemic. I found out my match results without the usual fanfare, sitting on a bench in Madison Square Park, FaceTiming my dad and safely social-distanced from my mom. They both cried tears of joy. Like so many people around the world right now, I couldn’t even embrace my parents. Would they want me to volunteer?

I reached out to my classmates. I thought that some of them would certainly share my worries. I thought they also had to be carrying this uncomfortable kind of grief, a heavy and acidic feeling of dreams collapsing into a moral duty. I received a unanimous reply: “We are needed. It’s our time to step up.” No matter how many “what ifs” I voiced, they wouldn’t crack or waver. Still, even if they never admitted it to me, I wondered whether they privately shared some of my concerns and fears.

Everyone knows information is shared instantly in our Twitter-centric world, but I was still shocked and unprepared for how quickly I was at the center of a major news story. Within an hour of that email, I was contacted by an old acquaintance from elementary school, now a journalist. He had found me through Facebook and asked, “Will you be one of the NYU students graduating early? Would love to get a comment.” Another friend texted me a photo of the leaked email, quipping, “Are you going to save us from the pandemic, Dr. Gabe?!” “It’s not a small decision!” I snapped back.

I went through something like the seven stages of grief in rapid succession. I found that with each excuse I made why I shouldn’t volunteer, I somehow became increasingly more anxious. To my surprise, when I decided I would join 50 of my peers at NYU, graduate early, and volunteer, my mind settled. The more I thought about it, the more I was overtaken by the selfless beauty of the profession I’m entering. This is what it means to be a doctor. I recalled a key part of the Hippocratic Oath: “I will remember that I remain a member of society, with special obligations to all my fellow human beings, those sound of mind and body as well as the infirm.”

I am going to fulfill my special obligations.

The fear is still there. I’m scared of COVID. I’m scared to infect others. I’m scared of winding up paralyzed and intubated. But I have also realized that all we have is each other. Healthcare workers supporting healthcare workers. New Yorkers supporting New Yorkers. Citizens of the world supporting citizens of the world. This is my time to be there for others, unwaveringly.

Logistical details continue to roll in, although they feel trivial in relation to the decision I have already made. The paperwork tells me that I will be onboarded to NYU’s internal medicine residency program. I will be compensated and protected under a similar contract to what current NYU residents sign. I have been promised that I will remain insured until I start my official residency program in July. My student loans won’t begin accruing interest until my normally planned graduation date. I am told that I will have personal protective equipment in line with the Centers for Disease Control and Prevention recommendations.

Questions still linger. Is it safe for me and my newly minted physician peers to continue living with our spouses, children, and friends? How long will I need to quarantine after my contract ends? Will there be a virtual graduation ceremony for my parents and loved ones to enjoy? In these challenging times, each day gives me a little more clarity about what exactly I am signing up for, but there are still so many uncertainties.

Am I naive to say that I do feel prepared? Or at least as prepared as anyone can be. With respect to my training, I have completed the requirements to graduate, which is why I am being permitted to graduate early in the first place. Our faculty points to our professionalism as the most promising indicator of our preparedness. They are heartened that we have embraced this truest test: our duty to others.

There is an eerie calm to New York City that contradicts what is shown on the news. With stores closed and streets quiet, it almost feels like Christmas morning here. Yet, inside the hospital, a fire rages. All the metaphors being used right now speak about violence, devastation, and immeasurable human suffering. “A war is being fought.” Or so I have heard. I guess I am about to find out.

Gabriel Redel-Traub is a fourth-year medical student at NYU Grossman School of Medicine. He will be starting residency in internal medicine at Columbia Presbyterian this summer. He is the former editor-in-chief of Dartmouth College’s Mouth Magazine, an editor of NYU’s LitMed Database, and has published most recently in the Hasting’s Center Magazine. Gabriel Redel-Traub has disclosed no relevant financial relationships.

This article first appeared on Medscape.com.

Nearly one in five individuals with cancer who are treated with immune checkpoint inhibitors develop thyroid dysfunction, new research suggests.

Sebastian Kaulitzki/Fotolia

Immune checkpoint inhibitors have revolutionized the treatment of many different types of cancers, but can also trigger a variety of immune-related adverse effects. As these drugs become more widely used, rates of these events appear to be more common in the real-world compared with clinical trial settings.

In their new study, Zoe Quandt, MD, of the University of California, San Francisco (UCSF), and colleagues specifically looked at thyroid dysfunction in their own institution’s EHR data and found more than double the rate of hypothyroidism and more than triple the rate of hyperthyroidism, compared with rates in published trials.

Moreover, in contrast to previous studies that have found differences in thyroid dysfunction by checkpoint inhibitor type, Dr. Quandt and colleagues instead found significant differences by cancer type.

Dr. Quandt presented the findings during a virtual press briefing held March 31originally scheduled for ENDO 2020.

“Thyroid dysfunction following checkpoint inhibitor therapy appears to be much more common than was previously reported in clinical trials, and this is one of the first studies to show differences by cancer type rather than by checkpoint inhibitor type,” Dr. Quandt said during the presentation.

However, she also cautioned that there’s “a lot more research to be done to validate case definitions and validate these findings.”

Asked to comment, endocrinologist David C. Lieb, MD, associate professor of medicine at Eastern Virginia Medical School in Norfolk, said in an interview, “These drugs are becoming so much more commonly used, so it’s not surprising that we’re seeing more endocrine complications, especially thyroid disease.”

“Endocrinologists need to work closely with oncologists to make sure patients are being screened and followed appropriately.”

‘A much higher percentage than we were expecting’

Dr. Quandt’s study included 1,146 individuals treated with checkpoint inhibitors at UCSF during 2012-2018 who did not have thyroid cancer or preexisting thyroid dysfunction.

Pembrolizumab (Keytruda) was the most common treatment (45%), followed by nivolumab (Opdivo) (20%). Less than 10% of patients received atezolizumab (Tecentriq), durvalumab (Imfizi), ipilimumab (Yervoy) monotherapy, combined ipilimumab/nivolumab, or other combinations of checkpoint inhibitors.

A total of 19.1% developed thyroid disease, with 13.4% having hypothyroidism and 9.5% hyperthyroidism. These figures far exceed those found in a recent meta-analysis of 38 randomized clinical trials of checkpoint inhibitors that included 7551 patients.

“Using this approach, we found a much higher percentage of patients who developed thyroid dysfunction than we were expecting,” Dr. Quandt said.

In both cases, the two categories – hypothyroidism and hyperthyroidism – aren’t mutually exclusive as hypothyroidism can arise de novo or subsequent to hyperthyroidism.

Dr Lieb commented, “It would be interesting to see what the causes of hyperthyroidism are – thyroiditis or Graves disease.”

Dr. Quandt mentioned a possible reason for the large difference between clinical trial and real-world data.

“Once we’re actually using these drugs outside of clinical trials, some of the restrictions about using them in people with other autoimmune diseases have been lifted, so my guess is that as we give them to a broader population we’re seeing more of these [adverse effects],” she suggested.

Also, “In the initial trials, people weren’t quite as aware of the possibilities of these side effects, so now we’re doing many more labs. Patients get thyroid function tests with every infusion, so I think we’re probably catching more patients who develop disease.”
 

Differences by cancer type, not checkpoint inhibitor type

And in a new twist, Dr. Quandt found that, in contrast to the differences seen by checkpoint inhibitor type in randomized trials, “surprisingly, we found that this difference did not reach statistical significance.”

“Instead, we saw that cancer type was associated with development of thyroid dysfunction, even after taking checkpoint inhibitor type into account.”

The percentages of patients who developed thyroid dysfunction ranged from 9.7% of those with glioblastoma to 40.0% of those with renal cell carcinoma.

The reason for this is not clear, said Dr. Quandt in an interview.

One possibility relates to other treatments patients with cancer also receive. In renal cell carcinoma, for example, patients also are treated with tyrosine kinase inhibitors, which can also cause thyroid dysfunction, so they may be more susceptible. Or there may be shared antigens activating the immune system.

“That’s definitely one of the questions we’re looking at,” she said.

Dr. Quandt and Dr. Lieb have reported no relevant financial relationships.

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

Nearly one in five individuals with cancer who are treated with immune checkpoint inhibitors develop thyroid dysfunction, new research suggests.

Sebastian Kaulitzki/Fotolia

Immune checkpoint inhibitors have revolutionized the treatment of many different types of cancers, but can also trigger a variety of immune-related adverse effects. As these drugs become more widely used, rates of these events appear to be more common in the real-world compared with clinical trial settings.

In their new study, Zoe Quandt, MD, of the University of California, San Francisco (UCSF), and colleagues specifically looked at thyroid dysfunction in their own institution’s EHR data and found more than double the rate of hypothyroidism and more than triple the rate of hyperthyroidism, compared with rates in published trials.

Moreover, in contrast to previous studies that have found differences in thyroid dysfunction by checkpoint inhibitor type, Dr. Quandt and colleagues instead found significant differences by cancer type.

Dr. Quandt presented the findings during a virtual press briefing held March 31originally scheduled for ENDO 2020.

“Thyroid dysfunction following checkpoint inhibitor therapy appears to be much more common than was previously reported in clinical trials, and this is one of the first studies to show differences by cancer type rather than by checkpoint inhibitor type,” Dr. Quandt said during the presentation.

However, she also cautioned that there’s “a lot more research to be done to validate case definitions and validate these findings.”

Asked to comment, endocrinologist David C. Lieb, MD, associate professor of medicine at Eastern Virginia Medical School in Norfolk, said in an interview, “These drugs are becoming so much more commonly used, so it’s not surprising that we’re seeing more endocrine complications, especially thyroid disease.”

“Endocrinologists need to work closely with oncologists to make sure patients are being screened and followed appropriately.”

‘A much higher percentage than we were expecting’

Dr. Quandt’s study included 1,146 individuals treated with checkpoint inhibitors at UCSF during 2012-2018 who did not have thyroid cancer or preexisting thyroid dysfunction.

Pembrolizumab (Keytruda) was the most common treatment (45%), followed by nivolumab (Opdivo) (20%). Less than 10% of patients received atezolizumab (Tecentriq), durvalumab (Imfizi), ipilimumab (Yervoy) monotherapy, combined ipilimumab/nivolumab, or other combinations of checkpoint inhibitors.

A total of 19.1% developed thyroid disease, with 13.4% having hypothyroidism and 9.5% hyperthyroidism. These figures far exceed those found in a recent meta-analysis of 38 randomized clinical trials of checkpoint inhibitors that included 7551 patients.

“Using this approach, we found a much higher percentage of patients who developed thyroid dysfunction than we were expecting,” Dr. Quandt said.

In both cases, the two categories – hypothyroidism and hyperthyroidism – aren’t mutually exclusive as hypothyroidism can arise de novo or subsequent to hyperthyroidism.

Dr Lieb commented, “It would be interesting to see what the causes of hyperthyroidism are – thyroiditis or Graves disease.”

Dr. Quandt mentioned a possible reason for the large difference between clinical trial and real-world data.

“Once we’re actually using these drugs outside of clinical trials, some of the restrictions about using them in people with other autoimmune diseases have been lifted, so my guess is that as we give them to a broader population we’re seeing more of these [adverse effects],” she suggested.

Also, “In the initial trials, people weren’t quite as aware of the possibilities of these side effects, so now we’re doing many more labs. Patients get thyroid function tests with every infusion, so I think we’re probably catching more patients who develop disease.”
 

Differences by cancer type, not checkpoint inhibitor type

And in a new twist, Dr. Quandt found that, in contrast to the differences seen by checkpoint inhibitor type in randomized trials, “surprisingly, we found that this difference did not reach statistical significance.”

“Instead, we saw that cancer type was associated with development of thyroid dysfunction, even after taking checkpoint inhibitor type into account.”

The percentages of patients who developed thyroid dysfunction ranged from 9.7% of those with glioblastoma to 40.0% of those with renal cell carcinoma.

The reason for this is not clear, said Dr. Quandt in an interview.

One possibility relates to other treatments patients with cancer also receive. In renal cell carcinoma, for example, patients also are treated with tyrosine kinase inhibitors, which can also cause thyroid dysfunction, so they may be more susceptible. Or there may be shared antigens activating the immune system.

“That’s definitely one of the questions we’re looking at,” she said.

Dr. Quandt and Dr. Lieb have reported no relevant financial relationships.

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

Nearly one in five individuals with cancer who are treated with immune checkpoint inhibitors develop thyroid dysfunction, new research suggests.

Sebastian Kaulitzki/Fotolia

Immune checkpoint inhibitors have revolutionized the treatment of many different types of cancers, but can also trigger a variety of immune-related adverse effects. As these drugs become more widely used, rates of these events appear to be more common in the real-world compared with clinical trial settings.

In their new study, Zoe Quandt, MD, of the University of California, San Francisco (UCSF), and colleagues specifically looked at thyroid dysfunction in their own institution’s EHR data and found more than double the rate of hypothyroidism and more than triple the rate of hyperthyroidism, compared with rates in published trials.

Moreover, in contrast to previous studies that have found differences in thyroid dysfunction by checkpoint inhibitor type, Dr. Quandt and colleagues instead found significant differences by cancer type.

Dr. Quandt presented the findings during a virtual press briefing held March 31originally scheduled for ENDO 2020.

“Thyroid dysfunction following checkpoint inhibitor therapy appears to be much more common than was previously reported in clinical trials, and this is one of the first studies to show differences by cancer type rather than by checkpoint inhibitor type,” Dr. Quandt said during the presentation.

However, she also cautioned that there’s “a lot more research to be done to validate case definitions and validate these findings.”

Asked to comment, endocrinologist David C. Lieb, MD, associate professor of medicine at Eastern Virginia Medical School in Norfolk, said in an interview, “These drugs are becoming so much more commonly used, so it’s not surprising that we’re seeing more endocrine complications, especially thyroid disease.”

“Endocrinologists need to work closely with oncologists to make sure patients are being screened and followed appropriately.”

‘A much higher percentage than we were expecting’

Dr. Quandt’s study included 1,146 individuals treated with checkpoint inhibitors at UCSF during 2012-2018 who did not have thyroid cancer or preexisting thyroid dysfunction.

Pembrolizumab (Keytruda) was the most common treatment (45%), followed by nivolumab (Opdivo) (20%). Less than 10% of patients received atezolizumab (Tecentriq), durvalumab (Imfizi), ipilimumab (Yervoy) monotherapy, combined ipilimumab/nivolumab, or other combinations of checkpoint inhibitors.

A total of 19.1% developed thyroid disease, with 13.4% having hypothyroidism and 9.5% hyperthyroidism. These figures far exceed those found in a recent meta-analysis of 38 randomized clinical trials of checkpoint inhibitors that included 7551 patients.

“Using this approach, we found a much higher percentage of patients who developed thyroid dysfunction than we were expecting,” Dr. Quandt said.

In both cases, the two categories – hypothyroidism and hyperthyroidism – aren’t mutually exclusive as hypothyroidism can arise de novo or subsequent to hyperthyroidism.

Dr Lieb commented, “It would be interesting to see what the causes of hyperthyroidism are – thyroiditis or Graves disease.”

Dr. Quandt mentioned a possible reason for the large difference between clinical trial and real-world data.

“Once we’re actually using these drugs outside of clinical trials, some of the restrictions about using them in people with other autoimmune diseases have been lifted, so my guess is that as we give them to a broader population we’re seeing more of these [adverse effects],” she suggested.

Also, “In the initial trials, people weren’t quite as aware of the possibilities of these side effects, so now we’re doing many more labs. Patients get thyroid function tests with every infusion, so I think we’re probably catching more patients who develop disease.”
 

Differences by cancer type, not checkpoint inhibitor type

And in a new twist, Dr. Quandt found that, in contrast to the differences seen by checkpoint inhibitor type in randomized trials, “surprisingly, we found that this difference did not reach statistical significance.”

“Instead, we saw that cancer type was associated with development of thyroid dysfunction, even after taking checkpoint inhibitor type into account.”

The percentages of patients who developed thyroid dysfunction ranged from 9.7% of those with glioblastoma to 40.0% of those with renal cell carcinoma.

The reason for this is not clear, said Dr. Quandt in an interview.

One possibility relates to other treatments patients with cancer also receive. In renal cell carcinoma, for example, patients also are treated with tyrosine kinase inhibitors, which can also cause thyroid dysfunction, so they may be more susceptible. Or there may be shared antigens activating the immune system.

“That’s definitely one of the questions we’re looking at,” she said.

Dr. Quandt and Dr. Lieb have reported no relevant financial relationships.

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

No staff members or patients were diagnosed with COVID-19 after “strict protective measures” for screening and managing patients were implemented at the National Cancer Center/Cancer Hospital, Chinese Academy of Sciences, in Beijing, according to a report published online April 1 in JAMA Oncology.

However, the time period for the analysis, which included nearly 3000 patients, was short — only about 3 weeks (February 12 to March 3). Also, Beijing is more than 1100 kilometers from Wuhan, the center of the Chinese outbreak of COVID-19.

The Beijing cancer hospital implemented a multipronged safety plan in February in order to “avoid COVID-19 related nosocomial cross-infection between patients and medical staff,” explain the authors, led by medical oncologist Zhijie Wang, MD.

Notably, “all of the measures taken in China are actively being implemented and used in major oncology centers in the United States,” Robert Carlson, MD, chief executive officer, National Comprehensive Cancer Network (NCCN), told Medscape Medical News.  

John Greene, MD, section chief, Infectious Disease and Tropical Medicine, Moffitt Cancer Center, Tampa, Florida, pointed out that the Chinese safety plan, which is full of “good measures,” is being largely used at his center. However, he observed that one tool — doing a temperature check at the hospital front door — is not well supported by most of the literature. “It gives good optics and looks like you are doing the most you possibly can, but scientifically it may not be as effective [as other screening measures],” he said.

The Chinese plan consists of four broad elements

First, the above-mentioned on-site temperature tests are performed at the entrances of the hospital, outpatient clinic, and wards. Contact and travel histories related to the Wuhan epidemic area are also established and recorded.

Second, an outpatient appointment scheduling system allows both online scheduling and on-site registration. Online consultation channels are open daily, featuring instruction on medication taking and cancer-related symptom management. These “substantially reduced the flow of people in the hospital,” write the authors. On-site patients must wear a mask and have their own disinfectant.

Third, for patients with cancer preparing to be admitted to hospital, symptoms associated with COVID-19, such as fever and cough, are recorded. Mandatory blood tests and CT scans of the lungs are performed. COVID-19 virus nucleic acid tests are performed for patients with suspected pneumonia on imaging.

Fourth, some anticancer drugs conventionally administered by infusion have been changed to oral administration, such as etoposide and vinorelbine. For adjuvant or maintenance chemotherapy, the infusion intervals were appropriately prolonged depending on patients’ conditions.

Eight out of 2,900 patients had imaging suspicious for infection

The Chinese authors report that a total of 2,944 patients with cancer were seen for clinic consultation and treatment in the wards (2795 outpatients and 149 inpatients).

Patients with cancer are believed to have a higher probability of severe illness and increased mortality compared with the healthy population once infected with COVID-19, point out the authors.

Under the new “strict screening strategy,” 27 patients showed radiologic manifestations of inflammatory changes or multiple-site exudative pneumonia in the lungs, including eight suspected of having COVID-19 infection. “Fortunately, negative results from nucleic acid testing ultimately excluded COVID-19 infection in all these patients,” the authors report.

However, two of these patients “presented with recovered pneumonia after symptomatic treatment.” Commenting on this finding, Moffitt’s Greene said that may mean these two patients were tested and found to be positive but were early in the infection and not yet shedding the virus, or they were infected after the initial negative result.

Greene said his center has implemented some measures not mentioned in the Chinese plan. For example, the Florida center no longer allows inpatient visitation. Also, one third of staff now work from home, resulting in less social interaction. Social distancing in meetings, the cafeteria, and hallways is being observed “aggressively,” and most meetings are now on Zoom, he said.

Moffitt has not been hard hit with COVID-19 and is at level one preparedness, the lowest rung. The center has performed 60 tests to date, with only one positive for the virus (< 2%), Greene told Medscape Medical News.

Currently, in the larger Tampa Bay community setting, about 12% of tests are positive.

The low percentage found among the Moffitt patients “tells you that a lot of cancer patients have fever and respiratory symptoms due to other viruses and, more importantly, other reasons, whether it’s their immunotherapy or chemotherapy or their cancer,” said Greene.

NCCN’s Carlson said the publication of the Chinese data was a good sign in terms of international science.

“This is a strong example of how the global oncology community rapidly shares information and experience whenever it makes a difference in patient care,” he commented.

The authors, as well as Carlson and Greene, have reported no relevant financial relationships.

This article first appeared on Medscape.com.

No staff members or patients were diagnosed with COVID-19 after “strict protective measures” for screening and managing patients were implemented at the National Cancer Center/Cancer Hospital, Chinese Academy of Sciences, in Beijing, according to a report published online April 1 in JAMA Oncology.

However, the time period for the analysis, which included nearly 3000 patients, was short — only about 3 weeks (February 12 to March 3). Also, Beijing is more than 1100 kilometers from Wuhan, the center of the Chinese outbreak of COVID-19.

The Beijing cancer hospital implemented a multipronged safety plan in February in order to “avoid COVID-19 related nosocomial cross-infection between patients and medical staff,” explain the authors, led by medical oncologist Zhijie Wang, MD.

Notably, “all of the measures taken in China are actively being implemented and used in major oncology centers in the United States,” Robert Carlson, MD, chief executive officer, National Comprehensive Cancer Network (NCCN), told Medscape Medical News.  

John Greene, MD, section chief, Infectious Disease and Tropical Medicine, Moffitt Cancer Center, Tampa, Florida, pointed out that the Chinese safety plan, which is full of “good measures,” is being largely used at his center. However, he observed that one tool — doing a temperature check at the hospital front door — is not well supported by most of the literature. “It gives good optics and looks like you are doing the most you possibly can, but scientifically it may not be as effective [as other screening measures],” he said.

The Chinese plan consists of four broad elements

First, the above-mentioned on-site temperature tests are performed at the entrances of the hospital, outpatient clinic, and wards. Contact and travel histories related to the Wuhan epidemic area are also established and recorded.

Second, an outpatient appointment scheduling system allows both online scheduling and on-site registration. Online consultation channels are open daily, featuring instruction on medication taking and cancer-related symptom management. These “substantially reduced the flow of people in the hospital,” write the authors. On-site patients must wear a mask and have their own disinfectant.

Third, for patients with cancer preparing to be admitted to hospital, symptoms associated with COVID-19, such as fever and cough, are recorded. Mandatory blood tests and CT scans of the lungs are performed. COVID-19 virus nucleic acid tests are performed for patients with suspected pneumonia on imaging.

Fourth, some anticancer drugs conventionally administered by infusion have been changed to oral administration, such as etoposide and vinorelbine. For adjuvant or maintenance chemotherapy, the infusion intervals were appropriately prolonged depending on patients’ conditions.

Eight out of 2,900 patients had imaging suspicious for infection

The Chinese authors report that a total of 2,944 patients with cancer were seen for clinic consultation and treatment in the wards (2795 outpatients and 149 inpatients).

Patients with cancer are believed to have a higher probability of severe illness and increased mortality compared with the healthy population once infected with COVID-19, point out the authors.

Under the new “strict screening strategy,” 27 patients showed radiologic manifestations of inflammatory changes or multiple-site exudative pneumonia in the lungs, including eight suspected of having COVID-19 infection. “Fortunately, negative results from nucleic acid testing ultimately excluded COVID-19 infection in all these patients,” the authors report.

However, two of these patients “presented with recovered pneumonia after symptomatic treatment.” Commenting on this finding, Moffitt’s Greene said that may mean these two patients were tested and found to be positive but were early in the infection and not yet shedding the virus, or they were infected after the initial negative result.

Greene said his center has implemented some measures not mentioned in the Chinese plan. For example, the Florida center no longer allows inpatient visitation. Also, one third of staff now work from home, resulting in less social interaction. Social distancing in meetings, the cafeteria, and hallways is being observed “aggressively,” and most meetings are now on Zoom, he said.

Moffitt has not been hard hit with COVID-19 and is at level one preparedness, the lowest rung. The center has performed 60 tests to date, with only one positive for the virus (< 2%), Greene told Medscape Medical News.

Currently, in the larger Tampa Bay community setting, about 12% of tests are positive.

The low percentage found among the Moffitt patients “tells you that a lot of cancer patients have fever and respiratory symptoms due to other viruses and, more importantly, other reasons, whether it’s their immunotherapy or chemotherapy or their cancer,” said Greene.

NCCN’s Carlson said the publication of the Chinese data was a good sign in terms of international science.

“This is a strong example of how the global oncology community rapidly shares information and experience whenever it makes a difference in patient care,” he commented.

The authors, as well as Carlson and Greene, have reported no relevant financial relationships.

This article first appeared on Medscape.com.

No staff members or patients were diagnosed with COVID-19 after “strict protective measures” for screening and managing patients were implemented at the National Cancer Center/Cancer Hospital, Chinese Academy of Sciences, in Beijing, according to a report published online April 1 in JAMA Oncology.

However, the time period for the analysis, which included nearly 3000 patients, was short — only about 3 weeks (February 12 to March 3). Also, Beijing is more than 1100 kilometers from Wuhan, the center of the Chinese outbreak of COVID-19.

The Beijing cancer hospital implemented a multipronged safety plan in February in order to “avoid COVID-19 related nosocomial cross-infection between patients and medical staff,” explain the authors, led by medical oncologist Zhijie Wang, MD.

Notably, “all of the measures taken in China are actively being implemented and used in major oncology centers in the United States,” Robert Carlson, MD, chief executive officer, National Comprehensive Cancer Network (NCCN), told Medscape Medical News.  

John Greene, MD, section chief, Infectious Disease and Tropical Medicine, Moffitt Cancer Center, Tampa, Florida, pointed out that the Chinese safety plan, which is full of “good measures,” is being largely used at his center. However, he observed that one tool — doing a temperature check at the hospital front door — is not well supported by most of the literature. “It gives good optics and looks like you are doing the most you possibly can, but scientifically it may not be as effective [as other screening measures],” he said.

The Chinese plan consists of four broad elements

First, the above-mentioned on-site temperature tests are performed at the entrances of the hospital, outpatient clinic, and wards. Contact and travel histories related to the Wuhan epidemic area are also established and recorded.

Second, an outpatient appointment scheduling system allows both online scheduling and on-site registration. Online consultation channels are open daily, featuring instruction on medication taking and cancer-related symptom management. These “substantially reduced the flow of people in the hospital,” write the authors. On-site patients must wear a mask and have their own disinfectant.

Third, for patients with cancer preparing to be admitted to hospital, symptoms associated with COVID-19, such as fever and cough, are recorded. Mandatory blood tests and CT scans of the lungs are performed. COVID-19 virus nucleic acid tests are performed for patients with suspected pneumonia on imaging.

Fourth, some anticancer drugs conventionally administered by infusion have been changed to oral administration, such as etoposide and vinorelbine. For adjuvant or maintenance chemotherapy, the infusion intervals were appropriately prolonged depending on patients’ conditions.

Eight out of 2,900 patients had imaging suspicious for infection

The Chinese authors report that a total of 2,944 patients with cancer were seen for clinic consultation and treatment in the wards (2795 outpatients and 149 inpatients).

Patients with cancer are believed to have a higher probability of severe illness and increased mortality compared with the healthy population once infected with COVID-19, point out the authors.

Under the new “strict screening strategy,” 27 patients showed radiologic manifestations of inflammatory changes or multiple-site exudative pneumonia in the lungs, including eight suspected of having COVID-19 infection. “Fortunately, negative results from nucleic acid testing ultimately excluded COVID-19 infection in all these patients,” the authors report.

However, two of these patients “presented with recovered pneumonia after symptomatic treatment.” Commenting on this finding, Moffitt’s Greene said that may mean these two patients were tested and found to be positive but were early in the infection and not yet shedding the virus, or they were infected after the initial negative result.

Greene said his center has implemented some measures not mentioned in the Chinese plan. For example, the Florida center no longer allows inpatient visitation. Also, one third of staff now work from home, resulting in less social interaction. Social distancing in meetings, the cafeteria, and hallways is being observed “aggressively,” and most meetings are now on Zoom, he said.

Moffitt has not been hard hit with COVID-19 and is at level one preparedness, the lowest rung. The center has performed 60 tests to date, with only one positive for the virus (< 2%), Greene told Medscape Medical News.

Currently, in the larger Tampa Bay community setting, about 12% of tests are positive.

The low percentage found among the Moffitt patients “tells you that a lot of cancer patients have fever and respiratory symptoms due to other viruses and, more importantly, other reasons, whether it’s their immunotherapy or chemotherapy or their cancer,” said Greene.

NCCN’s Carlson said the publication of the Chinese data was a good sign in terms of international science.

“This is a strong example of how the global oncology community rapidly shares information and experience whenever it makes a difference in patient care,” he commented.

The authors, as well as Carlson and Greene, have reported no relevant financial relationships.

This article first appeared on Medscape.com.

Loss of meibomian glands in the eye, which contribute to producing tears, appears to be associated with high rates of dry eye in individuals with diabetes and may serve as a biomarker for suboptimal glycemic control, new research suggests.

Gloria Wu, MD, an ophthalmologist at the University of California, San Francisco, presented the findings from a small study using infrared imaging of the eyelids in 120 patients with dry eye during a virtual press briefing held March 30, originally scheduled for the ENDO 2020 meeting.

The meibomian glands are the vertical striations that line the margins of the lower eyelids. They produce the lipid that combines with aqueous fluid from the lacrimal gland to create the tear film. Absence of meibomian glands can lead to dry eyes, eye pain, discomfort, and blurred vision.

Dry eye affects about 7% of the U.S. population, compared with 57% of people with type 1 diabetes and 70% with type 2 diabetes. Two proposed mechanisms for the phenomenon in diabetes are microischemia and inflammation, Dr. Wu said.

In her study, loss of meibomian glands was far more common among the 60 participants with dry eye and diabetes than among the 60 participants with dry eye but without diabetes, and the amount of gland loss was directly linked to A_1c level.

The findings suggest that loss of meibomian glands could serve as a diabetes biomarker, particularly in underserved areas where A_1c testing might not be readily available.

Dr. Wu noted many newer smartphones, including the Samsung Galaxy 10S and iPhone 10, Xs, and 11, have infrared cameras that could help characterize dry eye in patients with diabetes.

“In the future, we hope patients can use [smartphones] and flip their own eyelids and take a picture. We hope that in rural health clinics and community health centers we can use this device that people have ... When people complain of dry eye and they have diabetes we can consider [closer diabetes monitoring],” said Dr. Wu.

Asked to comment, endocrinologist David C. Lieb, MD, said in an interview: “It’s important for providers who care for people with diabetes to know that diabetes is associated with a high incidence of meibomian gland dysfunction leading to dry eye. That’s another reason people with diabetes need to make sure they see their eye care specialist on a regular basis.

“When I ask patients if they’ve seen their eye specialist I may add dry eye to my list of questions rather than just asking them when was the last time they went,” added Dr. Lieb, associate professor of medicine at Eastern Virginia Medical School in Norfolk.

“I may ask them if they have symptoms of dry eye, and if they do, it’s something they need to talk about with that individual.”
 

Gland disappearance correlated with glycemic control

Dr. Wu and colleagues retrospectively reviewed electronic health records for 120 patients diagnosed with dry eye: 60 patients with and 60 patients without type 2 diabetes.

Those with diabetes were a mean age of 65 years, and were split evenly between men and women. The controls were younger, averaging 54 years, and comprised 37 men and 23 women.

Researchers performed infrared imaging (820 nm) of the lid; percentage loss of meibomian glands was calculated for each eye, then averaged per patient.

They found that 51.5% of patients in the diabetes group had lost meibomian glands, compared with just 11.3% of controls, a highly significant difference (P = .0001).

When A_1c was also assessed, only 4 of 60 participants with A_1c ≤ 5.9% lost ≥ 25% of the glands, compared with 55 of 60 participants with A_1c ≥ 6.0%.

And specifically among those with diabetes, 35 of 37 with A_1c > 6.6% lost > 40% of the glands, compared with just 12 of 23 participants with A_1c < 6.5% (all P < .0001).

“In patients with dry eye and diabetes, loss of meibomian glands is associated with elevated A_1c ... [and] may suggest a need for ... further monitoring of the patient’s diabetic condition,” the researchers noted.

Asked whether the glands could re-grow with improved glycemic control, Dr. Wu said she has not looked at that in people with diabetes, but in some patients who receive intensive treatment for dry eye with artificial tears or cyclosporine, the glands do grow back after about 6 months.

Dr. Lieb said he found the smartphone diagnostic idea “fascinating, especially in an area where you might not be able to easily measure an A_1c. Most people have access to point-of-care A_1c testing but not everybody can make it to a doctor’s office.”

And, he added, “anything that’s noninvasive has some potential benefit.”

Dr. Wu and Dr. Lieb have reported no relevant financial relationships.
 

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

Loss of meibomian glands in the eye, which contribute to producing tears, appears to be associated with high rates of dry eye in individuals with diabetes and may serve as a biomarker for suboptimal glycemic control, new research suggests.

Gloria Wu, MD, an ophthalmologist at the University of California, San Francisco, presented the findings from a small study using infrared imaging of the eyelids in 120 patients with dry eye during a virtual press briefing held March 30, originally scheduled for the ENDO 2020 meeting.

The meibomian glands are the vertical striations that line the margins of the lower eyelids. They produce the lipid that combines with aqueous fluid from the lacrimal gland to create the tear film. Absence of meibomian glands can lead to dry eyes, eye pain, discomfort, and blurred vision.

Dry eye affects about 7% of the U.S. population, compared with 57% of people with type 1 diabetes and 70% with type 2 diabetes. Two proposed mechanisms for the phenomenon in diabetes are microischemia and inflammation, Dr. Wu said.

In her study, loss of meibomian glands was far more common among the 60 participants with dry eye and diabetes than among the 60 participants with dry eye but without diabetes, and the amount of gland loss was directly linked to A_1c level.

The findings suggest that loss of meibomian glands could serve as a diabetes biomarker, particularly in underserved areas where A_1c testing might not be readily available.

Dr. Wu noted many newer smartphones, including the Samsung Galaxy 10S and iPhone 10, Xs, and 11, have infrared cameras that could help characterize dry eye in patients with diabetes.

“In the future, we hope patients can use [smartphones] and flip their own eyelids and take a picture. We hope that in rural health clinics and community health centers we can use this device that people have ... When people complain of dry eye and they have diabetes we can consider [closer diabetes monitoring],” said Dr. Wu.

Asked to comment, endocrinologist David C. Lieb, MD, said in an interview: “It’s important for providers who care for people with diabetes to know that diabetes is associated with a high incidence of meibomian gland dysfunction leading to dry eye. That’s another reason people with diabetes need to make sure they see their eye care specialist on a regular basis.

“When I ask patients if they’ve seen their eye specialist I may add dry eye to my list of questions rather than just asking them when was the last time they went,” added Dr. Lieb, associate professor of medicine at Eastern Virginia Medical School in Norfolk.

“I may ask them if they have symptoms of dry eye, and if they do, it’s something they need to talk about with that individual.”
 

Gland disappearance correlated with glycemic control

Dr. Wu and colleagues retrospectively reviewed electronic health records for 120 patients diagnosed with dry eye: 60 patients with and 60 patients without type 2 diabetes.

Those with diabetes were a mean age of 65 years, and were split evenly between men and women. The controls were younger, averaging 54 years, and comprised 37 men and 23 women.

Researchers performed infrared imaging (820 nm) of the lid; percentage loss of meibomian glands was calculated for each eye, then averaged per patient.

They found that 51.5% of patients in the diabetes group had lost meibomian glands, compared with just 11.3% of controls, a highly significant difference (P = .0001).

When A_1c was also assessed, only 4 of 60 participants with A_1c ≤ 5.9% lost ≥ 25% of the glands, compared with 55 of 60 participants with A_1c ≥ 6.0%.

And specifically among those with diabetes, 35 of 37 with A_1c > 6.6% lost > 40% of the glands, compared with just 12 of 23 participants with A_1c < 6.5% (all P < .0001).

“In patients with dry eye and diabetes, loss of meibomian glands is associated with elevated A_1c ... [and] may suggest a need for ... further monitoring of the patient’s diabetic condition,” the researchers noted.

Asked whether the glands could re-grow with improved glycemic control, Dr. Wu said she has not looked at that in people with diabetes, but in some patients who receive intensive treatment for dry eye with artificial tears or cyclosporine, the glands do grow back after about 6 months.

Dr. Lieb said he found the smartphone diagnostic idea “fascinating, especially in an area where you might not be able to easily measure an A_1c. Most people have access to point-of-care A_1c testing but not everybody can make it to a doctor’s office.”

And, he added, “anything that’s noninvasive has some potential benefit.”

Dr. Wu and Dr. Lieb have reported no relevant financial relationships.
 

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

Loss of meibomian glands in the eye, which contribute to producing tears, appears to be associated with high rates of dry eye in individuals with diabetes and may serve as a biomarker for suboptimal glycemic control, new research suggests.

Gloria Wu, MD, an ophthalmologist at the University of California, San Francisco, presented the findings from a small study using infrared imaging of the eyelids in 120 patients with dry eye during a virtual press briefing held March 30, originally scheduled for the ENDO 2020 meeting.

The meibomian glands are the vertical striations that line the margins of the lower eyelids. They produce the lipid that combines with aqueous fluid from the lacrimal gland to create the tear film. Absence of meibomian glands can lead to dry eyes, eye pain, discomfort, and blurred vision.

Dry eye affects about 7% of the U.S. population, compared with 57% of people with type 1 diabetes and 70% with type 2 diabetes. Two proposed mechanisms for the phenomenon in diabetes are microischemia and inflammation, Dr. Wu said.

In her study, loss of meibomian glands was far more common among the 60 participants with dry eye and diabetes than among the 60 participants with dry eye but without diabetes, and the amount of gland loss was directly linked to A_1c level.

The findings suggest that loss of meibomian glands could serve as a diabetes biomarker, particularly in underserved areas where A_1c testing might not be readily available.

Dr. Wu noted many newer smartphones, including the Samsung Galaxy 10S and iPhone 10, Xs, and 11, have infrared cameras that could help characterize dry eye in patients with diabetes.

“In the future, we hope patients can use [smartphones] and flip their own eyelids and take a picture. We hope that in rural health clinics and community health centers we can use this device that people have ... When people complain of dry eye and they have diabetes we can consider [closer diabetes monitoring],” said Dr. Wu.

Asked to comment, endocrinologist David C. Lieb, MD, said in an interview: “It’s important for providers who care for people with diabetes to know that diabetes is associated with a high incidence of meibomian gland dysfunction leading to dry eye. That’s another reason people with diabetes need to make sure they see their eye care specialist on a regular basis.

“When I ask patients if they’ve seen their eye specialist I may add dry eye to my list of questions rather than just asking them when was the last time they went,” added Dr. Lieb, associate professor of medicine at Eastern Virginia Medical School in Norfolk.

“I may ask them if they have symptoms of dry eye, and if they do, it’s something they need to talk about with that individual.”
 

Gland disappearance correlated with glycemic control

Dr. Wu and colleagues retrospectively reviewed electronic health records for 120 patients diagnosed with dry eye: 60 patients with and 60 patients without type 2 diabetes.

Those with diabetes were a mean age of 65 years, and were split evenly between men and women. The controls were younger, averaging 54 years, and comprised 37 men and 23 women.

Researchers performed infrared imaging (820 nm) of the lid; percentage loss of meibomian glands was calculated for each eye, then averaged per patient.

They found that 51.5% of patients in the diabetes group had lost meibomian glands, compared with just 11.3% of controls, a highly significant difference (P = .0001).

When A_1c was also assessed, only 4 of 60 participants with A_1c ≤ 5.9% lost ≥ 25% of the glands, compared with 55 of 60 participants with A_1c ≥ 6.0%.

And specifically among those with diabetes, 35 of 37 with A_1c > 6.6% lost > 40% of the glands, compared with just 12 of 23 participants with A_1c < 6.5% (all P < .0001).

“In patients with dry eye and diabetes, loss of meibomian glands is associated with elevated A_1c ... [and] may suggest a need for ... further monitoring of the patient’s diabetic condition,” the researchers noted.

Asked whether the glands could re-grow with improved glycemic control, Dr. Wu said she has not looked at that in people with diabetes, but in some patients who receive intensive treatment for dry eye with artificial tears or cyclosporine, the glands do grow back after about 6 months.

Dr. Lieb said he found the smartphone diagnostic idea “fascinating, especially in an area where you might not be able to easily measure an A_1c. Most people have access to point-of-care A_1c testing but not everybody can make it to a doctor’s office.”

And, he added, “anything that’s noninvasive has some potential benefit.”

Dr. Wu and Dr. Lieb have reported no relevant financial relationships.
 

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