Journal of Clinical Outcomes Management

A Spanish-speaking patient navigator dramatically increased the percentage of Hispanics undergoing colorectal screening with colonoscopies in Providence, R.I.

Screening colonoscopies are a well-established approach to reducing colorectal cancer mortality by identifying and removing polyps. However, Hispanics in the United States lag behind the general population in completion rates for screening colonoscopies.

“Starting colorectal cancer colonoscopy screening at age 45 saves lives. But this life-saving procedure is underutilized by certain populations, not only because of limited access to care but because of cultural, language, and educational barriers that exist,” Abdul Saied Calvino, MD, MPH, program director of the Complex General Surgical Oncology Fellowship at Roger Williams Medical Center, Providence, R.I., told this news organization.

Tailored patient navigation is effective but has not been widely adopted. The new study is one of the first to look at the ‘real-life’ impact of these types of programs in the Hispanic population, Dr. Calvino and his colleagues reported in the journal Cancer.

Colorectal cancer is the second leading cause of cancer-related death in the United States overall and the third-most diagnosed cancer site, according to the American Cancer Society. Among Hispanics, colorectal cancer is the second leading cause of cancer mortality and the second-most diagnosed site of malignancy.

Dr. Calvino and his colleagues sought to learn if a culturally tailored patient navigation program could improve rates of screening colonoscopies among Hispanic residents in Providence.

The hospital hired a dedicated Spanish-speaking navigator/coordinator and enrolled 698 men and women into the program.

The navigator sent introductory letters in Spanish to study participants, made phone calls to educate patients about the importance of cancer screening, and called again to ensure that all potential barriers to colonoscopy were overcome, Dr. Calvino said. Colonoscopy completion, cancellations, and no-shows were recorded. Participants were followed for 28 months.

The program proved highly successful, according to the researchers. At the end of the study period, 85% of patients – exceeding the national goal of 80% set by the National Colorectal Cancer Roundtable – had completed testing, with no differences between men and women; the cancellation rate was 9% and only 6% of patients failed to show up for endoscopy.*  

Among the group that underwent colonoscopy, 254 (43%) had polyps removed and eight (1.3%) required colectomy, the researchers reported. Five patients (0.8%) were diagnosed with malignancy.

Dr. Calvino attributed the 15% combined rate of no-shows and cancellations to the cost of the procedure (copayment, out-of-pocket expense, and loss of wages) and the inability to follow-up with those patients. He added that 90% of those who completed the procedure said that without the patient navigation program they would not have completed the screening colonoscopies.

Aimee Afable, PhD, MPH, an expert on health disparities and immigrant health at Downstate Health Science University, New York, called the new study small but “important.”

Dr. Afable said strong evidence supports the ability of patient navigation programs to improve the reach and impact of screening programs aimed at the underserved. However, hospitals typically do not adequately fund such initiatives. (Dr. Calvino said the program at Roger Williams started with a grant from the OLDCO Foundation and is now supported by his institution.)

“In 2022, post-COVID, it is common to see health care support staff leaving institutions, hospitals because they’re not being paid well, and they are overburdened,” Dr. Afable told this news organization. “Patient navigation is not, unfortunately, a routine part of health care in the U.S. despite its central role in ensuring continuity of care.”

Funding for the study was provided by a grant from the OLDCO Foundation. Coauthor John C. Hardaway, MD, PhD, reports being a cancer liaison physician for the American College of Surgeons. The other authors have disclosed no relevant financial relationships. Dr. Afable has no disclosures. 

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

*Correction, 2/9/22: An earlier version of this article misidentified the group that set the national screening goal.

This article was updated 2/18/22.

A Spanish-speaking patient navigator dramatically increased the percentage of Hispanics undergoing colorectal screening with colonoscopies in Providence, R.I.

Screening colonoscopies are a well-established approach to reducing colorectal cancer mortality by identifying and removing polyps. However, Hispanics in the United States lag behind the general population in completion rates for screening colonoscopies.

“Starting colorectal cancer colonoscopy screening at age 45 saves lives. But this life-saving procedure is underutilized by certain populations, not only because of limited access to care but because of cultural, language, and educational barriers that exist,” Abdul Saied Calvino, MD, MPH, program director of the Complex General Surgical Oncology Fellowship at Roger Williams Medical Center, Providence, R.I., told this news organization.

Tailored patient navigation is effective but has not been widely adopted. The new study is one of the first to look at the ‘real-life’ impact of these types of programs in the Hispanic population, Dr. Calvino and his colleagues reported in the journal Cancer.

Colorectal cancer is the second leading cause of cancer-related death in the United States overall and the third-most diagnosed cancer site, according to the American Cancer Society. Among Hispanics, colorectal cancer is the second leading cause of cancer mortality and the second-most diagnosed site of malignancy.

Dr. Calvino and his colleagues sought to learn if a culturally tailored patient navigation program could improve rates of screening colonoscopies among Hispanic residents in Providence.

The hospital hired a dedicated Spanish-speaking navigator/coordinator and enrolled 698 men and women into the program.

The navigator sent introductory letters in Spanish to study participants, made phone calls to educate patients about the importance of cancer screening, and called again to ensure that all potential barriers to colonoscopy were overcome, Dr. Calvino said. Colonoscopy completion, cancellations, and no-shows were recorded. Participants were followed for 28 months.

The program proved highly successful, according to the researchers. At the end of the study period, 85% of patients – exceeding the national goal of 80% set by the National Colorectal Cancer Roundtable – had completed testing, with no differences between men and women; the cancellation rate was 9% and only 6% of patients failed to show up for endoscopy.*  

Among the group that underwent colonoscopy, 254 (43%) had polyps removed and eight (1.3%) required colectomy, the researchers reported. Five patients (0.8%) were diagnosed with malignancy.

Dr. Calvino attributed the 15% combined rate of no-shows and cancellations to the cost of the procedure (copayment, out-of-pocket expense, and loss of wages) and the inability to follow-up with those patients. He added that 90% of those who completed the procedure said that without the patient navigation program they would not have completed the screening colonoscopies.

Aimee Afable, PhD, MPH, an expert on health disparities and immigrant health at Downstate Health Science University, New York, called the new study small but “important.”

Dr. Afable said strong evidence supports the ability of patient navigation programs to improve the reach and impact of screening programs aimed at the underserved. However, hospitals typically do not adequately fund such initiatives. (Dr. Calvino said the program at Roger Williams started with a grant from the OLDCO Foundation and is now supported by his institution.)

“In 2022, post-COVID, it is common to see health care support staff leaving institutions, hospitals because they’re not being paid well, and they are overburdened,” Dr. Afable told this news organization. “Patient navigation is not, unfortunately, a routine part of health care in the U.S. despite its central role in ensuring continuity of care.”

Funding for the study was provided by a grant from the OLDCO Foundation. Coauthor John C. Hardaway, MD, PhD, reports being a cancer liaison physician for the American College of Surgeons. The other authors have disclosed no relevant financial relationships. Dr. Afable has no disclosures. 

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

*Correction, 2/9/22: An earlier version of this article misidentified the group that set the national screening goal.

This article was updated 2/18/22.

A Spanish-speaking patient navigator dramatically increased the percentage of Hispanics undergoing colorectal screening with colonoscopies in Providence, R.I.

Screening colonoscopies are a well-established approach to reducing colorectal cancer mortality by identifying and removing polyps. However, Hispanics in the United States lag behind the general population in completion rates for screening colonoscopies.

“Starting colorectal cancer colonoscopy screening at age 45 saves lives. But this life-saving procedure is underutilized by certain populations, not only because of limited access to care but because of cultural, language, and educational barriers that exist,” Abdul Saied Calvino, MD, MPH, program director of the Complex General Surgical Oncology Fellowship at Roger Williams Medical Center, Providence, R.I., told this news organization.

Tailored patient navigation is effective but has not been widely adopted. The new study is one of the first to look at the ‘real-life’ impact of these types of programs in the Hispanic population, Dr. Calvino and his colleagues reported in the journal Cancer.

Colorectal cancer is the second leading cause of cancer-related death in the United States overall and the third-most diagnosed cancer site, according to the American Cancer Society. Among Hispanics, colorectal cancer is the second leading cause of cancer mortality and the second-most diagnosed site of malignancy.

Dr. Calvino and his colleagues sought to learn if a culturally tailored patient navigation program could improve rates of screening colonoscopies among Hispanic residents in Providence.

The hospital hired a dedicated Spanish-speaking navigator/coordinator and enrolled 698 men and women into the program.

The navigator sent introductory letters in Spanish to study participants, made phone calls to educate patients about the importance of cancer screening, and called again to ensure that all potential barriers to colonoscopy were overcome, Dr. Calvino said. Colonoscopy completion, cancellations, and no-shows were recorded. Participants were followed for 28 months.

The program proved highly successful, according to the researchers. At the end of the study period, 85% of patients – exceeding the national goal of 80% set by the National Colorectal Cancer Roundtable – had completed testing, with no differences between men and women; the cancellation rate was 9% and only 6% of patients failed to show up for endoscopy.*  

Among the group that underwent colonoscopy, 254 (43%) had polyps removed and eight (1.3%) required colectomy, the researchers reported. Five patients (0.8%) were diagnosed with malignancy.

Dr. Calvino attributed the 15% combined rate of no-shows and cancellations to the cost of the procedure (copayment, out-of-pocket expense, and loss of wages) and the inability to follow-up with those patients. He added that 90% of those who completed the procedure said that without the patient navigation program they would not have completed the screening colonoscopies.

Aimee Afable, PhD, MPH, an expert on health disparities and immigrant health at Downstate Health Science University, New York, called the new study small but “important.”

Dr. Afable said strong evidence supports the ability of patient navigation programs to improve the reach and impact of screening programs aimed at the underserved. However, hospitals typically do not adequately fund such initiatives. (Dr. Calvino said the program at Roger Williams started with a grant from the OLDCO Foundation and is now supported by his institution.)

“In 2022, post-COVID, it is common to see health care support staff leaving institutions, hospitals because they’re not being paid well, and they are overburdened,” Dr. Afable told this news organization. “Patient navigation is not, unfortunately, a routine part of health care in the U.S. despite its central role in ensuring continuity of care.”

Funding for the study was provided by a grant from the OLDCO Foundation. Coauthor John C. Hardaway, MD, PhD, reports being a cancer liaison physician for the American College of Surgeons. The other authors have disclosed no relevant financial relationships. Dr. Afable has no disclosures. 

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

*Correction, 2/9/22: An earlier version of this article misidentified the group that set the national screening goal.

This article was updated 2/18/22.

Researchers have found a simple, low-cost way to get more adults to complete a fecal immunochemical test (FIT) to screen for colorectal cancer (CRC).

In a randomized controlled trial, patients who received an electronic “primer” message through their patient portal before the test kit arrived in their mailbox were more apt to complete and return the test than peers who didn’t get the electronic message.

ChrisChrisW/iStock/Getty Images

Heads-up message boosts compliance

CRC screening rates in the United States remain well below the national benchmark of 80%, and COVID-19 hasn’t helped. As a result, multiple medical and professional societies have emphasized the use of a mailed FIT outreach program.

As part of the outreach program, researchers at UCLA Health developed an electronic primer message within the electronic patient portal to alert patients due for CRC screening that they would be receiving a FIT kit in the mail.

They tested the impact of the primer messages in a randomized controlled trial involving 2,339 adults (mean age, 59 years, 57.5% women). Out of these, 1,157 received the standard mailed FIT kit (control group) and 1,182 received the standard mailed FIT kit plus a primer message sent through their personal patient portal.

Adding the primer message significantly increased the FIT completion rate at 6 months by 5.5%, with rates of 37.6% in the intervention group versus 32.1% in the control group.

After adjusting for patient demographics, the primer (versus no primer) led to significantly increased odds of completing CRC screening (adjusted odds ratio: 1.29; 95% confidence interval, 1.08-1.53; P = .004).

The primer message also shortened the time to FIT screening by 3 days (35 days with the primer vs. 38 days without).

Dr. Goshgarian and Dr. Croymans believe the priming messages worked well in their patient population because at the beginning of the intervention they identified a potential lack of awareness of the incoming FIT kit mailer as a barrier to uptake.

“We believe patients were receiving the kits with minimal advanced warning and discarding it as a mistake or hesitant to complete it because they did not understand the value to them,” they told this news organization.

“Therefore, a priming message helped to bridge that gap and allowed patients to be aware of the incoming FIT kits, know why it was important to do the FIT kit, and ultimately led to increasing our FIT kit return rates and thus CRC screening,” they said.

The researchers caution that their findings may be more relevant to patient populations who are more engaged in their health or who are more technologically savvy. In the UCLA Health system, roughly 84% of patients have an activated patient portal.
 

‘Good enhancement’ for health care systems

Reached for comment, Aasma Shaukat, MD, MPH, professor of medicine, NYU Langone Health, and first author of the American College of Gastroenterology (ACG) 2021 CRC screening guidelines, said the results are “interesting but not entirely surprising.”

“There’s literature supporting that a letter or notification prior to the FIT being mailed improves its uptake. Here, the authors applied it to their health care system in a quality improvement study and demonstrated it works,” Dr. Shaukat said.

“This is a good enhancement for health care systems where most of their patients are using or accessing their health chart portal,” added Dr. Shaukat.

“Caveats are that the generalizability is not known. It requires EHR [electronic health record] support tools and patients with access to a computer and enrolled and able to access their electronic chart, likely those with high literacy and English speaking.”

Funding for the study was provided by the UCLA Health Department of Medicine. Dr. Goshgarian, Dr. Croymans, and Dr. Shaukat have disclosed no relevant financial relationships.

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

Researchers have found a simple, low-cost way to get more adults to complete a fecal immunochemical test (FIT) to screen for colorectal cancer (CRC).

In a randomized controlled trial, patients who received an electronic “primer” message through their patient portal before the test kit arrived in their mailbox were more apt to complete and return the test than peers who didn’t get the electronic message.

ChrisChrisW/iStock/Getty Images

Heads-up message boosts compliance

CRC screening rates in the United States remain well below the national benchmark of 80%, and COVID-19 hasn’t helped. As a result, multiple medical and professional societies have emphasized the use of a mailed FIT outreach program.

As part of the outreach program, researchers at UCLA Health developed an electronic primer message within the electronic patient portal to alert patients due for CRC screening that they would be receiving a FIT kit in the mail.

They tested the impact of the primer messages in a randomized controlled trial involving 2,339 adults (mean age, 59 years, 57.5% women). Out of these, 1,157 received the standard mailed FIT kit (control group) and 1,182 received the standard mailed FIT kit plus a primer message sent through their personal patient portal.

Adding the primer message significantly increased the FIT completion rate at 6 months by 5.5%, with rates of 37.6% in the intervention group versus 32.1% in the control group.

After adjusting for patient demographics, the primer (versus no primer) led to significantly increased odds of completing CRC screening (adjusted odds ratio: 1.29; 95% confidence interval, 1.08-1.53; P = .004).

The primer message also shortened the time to FIT screening by 3 days (35 days with the primer vs. 38 days without).

Dr. Goshgarian and Dr. Croymans believe the priming messages worked well in their patient population because at the beginning of the intervention they identified a potential lack of awareness of the incoming FIT kit mailer as a barrier to uptake.

“We believe patients were receiving the kits with minimal advanced warning and discarding it as a mistake or hesitant to complete it because they did not understand the value to them,” they told this news organization.

“Therefore, a priming message helped to bridge that gap and allowed patients to be aware of the incoming FIT kits, know why it was important to do the FIT kit, and ultimately led to increasing our FIT kit return rates and thus CRC screening,” they said.

The researchers caution that their findings may be more relevant to patient populations who are more engaged in their health or who are more technologically savvy. In the UCLA Health system, roughly 84% of patients have an activated patient portal.
 

‘Good enhancement’ for health care systems

Reached for comment, Aasma Shaukat, MD, MPH, professor of medicine, NYU Langone Health, and first author of the American College of Gastroenterology (ACG) 2021 CRC screening guidelines, said the results are “interesting but not entirely surprising.”

“There’s literature supporting that a letter or notification prior to the FIT being mailed improves its uptake. Here, the authors applied it to their health care system in a quality improvement study and demonstrated it works,” Dr. Shaukat said.

“This is a good enhancement for health care systems where most of their patients are using or accessing their health chart portal,” added Dr. Shaukat.

“Caveats are that the generalizability is not known. It requires EHR [electronic health record] support tools and patients with access to a computer and enrolled and able to access their electronic chart, likely those with high literacy and English speaking.”

Funding for the study was provided by the UCLA Health Department of Medicine. Dr. Goshgarian, Dr. Croymans, and Dr. Shaukat have disclosed no relevant financial relationships.

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

Researchers have found a simple, low-cost way to get more adults to complete a fecal immunochemical test (FIT) to screen for colorectal cancer (CRC).

In a randomized controlled trial, patients who received an electronic “primer” message through their patient portal before the test kit arrived in their mailbox were more apt to complete and return the test than peers who didn’t get the electronic message.

ChrisChrisW/iStock/Getty Images

Heads-up message boosts compliance

CRC screening rates in the United States remain well below the national benchmark of 80%, and COVID-19 hasn’t helped. As a result, multiple medical and professional societies have emphasized the use of a mailed FIT outreach program.

As part of the outreach program, researchers at UCLA Health developed an electronic primer message within the electronic patient portal to alert patients due for CRC screening that they would be receiving a FIT kit in the mail.

They tested the impact of the primer messages in a randomized controlled trial involving 2,339 adults (mean age, 59 years, 57.5% women). Out of these, 1,157 received the standard mailed FIT kit (control group) and 1,182 received the standard mailed FIT kit plus a primer message sent through their personal patient portal.

Adding the primer message significantly increased the FIT completion rate at 6 months by 5.5%, with rates of 37.6% in the intervention group versus 32.1% in the control group.

After adjusting for patient demographics, the primer (versus no primer) led to significantly increased odds of completing CRC screening (adjusted odds ratio: 1.29; 95% confidence interval, 1.08-1.53; P = .004).

The primer message also shortened the time to FIT screening by 3 days (35 days with the primer vs. 38 days without).

Dr. Goshgarian and Dr. Croymans believe the priming messages worked well in their patient population because at the beginning of the intervention they identified a potential lack of awareness of the incoming FIT kit mailer as a barrier to uptake.

“We believe patients were receiving the kits with minimal advanced warning and discarding it as a mistake or hesitant to complete it because they did not understand the value to them,” they told this news organization.

“Therefore, a priming message helped to bridge that gap and allowed patients to be aware of the incoming FIT kits, know why it was important to do the FIT kit, and ultimately led to increasing our FIT kit return rates and thus CRC screening,” they said.

The researchers caution that their findings may be more relevant to patient populations who are more engaged in their health or who are more technologically savvy. In the UCLA Health system, roughly 84% of patients have an activated patient portal.
 

‘Good enhancement’ for health care systems

Reached for comment, Aasma Shaukat, MD, MPH, professor of medicine, NYU Langone Health, and first author of the American College of Gastroenterology (ACG) 2021 CRC screening guidelines, said the results are “interesting but not entirely surprising.”

“There’s literature supporting that a letter or notification prior to the FIT being mailed improves its uptake. Here, the authors applied it to their health care system in a quality improvement study and demonstrated it works,” Dr. Shaukat said.

“This is a good enhancement for health care systems where most of their patients are using or accessing their health chart portal,” added Dr. Shaukat.

“Caveats are that the generalizability is not known. It requires EHR [electronic health record] support tools and patients with access to a computer and enrolled and able to access their electronic chart, likely those with high literacy and English speaking.”

Funding for the study was provided by the UCLA Health Department of Medicine. Dr. Goshgarian, Dr. Croymans, and Dr. Shaukat have disclosed no relevant financial relationships.

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

The U.S. Department of Agriculture has announced new changes to school nutrition standards for the next 2 school years, which will reinstate health goals that were rolled back during the Trump administration.

The Biden administration is also tightening rules for fat and salt content in foods after restrictions were eased during the pandemic, according to the Washington Post.

“Nutritious school meals give America’s children the foundation for successful, healthy lives,” Tom Vilsack, the U.S. agriculture secretary, said in a statement on Feb. 4.

“We applaud schools’ heroic efforts throughout the challenges of this pandemic to continue serving kids the most nutritious meals possible,” he said. “The standards we’re putting in place of the next 2 school years will help schools transition to a future that builds on the tremendous strides they’ve made improving school meal nutrition over the past decade.”

For the 2022-2023 school year, schools and childcare providers will be required to offer low-fat or nonfat unflavored milks and limit the fat in sweet flavored milks. In addition, at least 80% of the grains served during school breakfasts and lunches each week must be considered rich in whole grains.

For the 2023-2024 school year, the weekly sodium limit for school lunches will be decreased by 10%.

The changes mark a shift from the Trump administration, which eased policies on whole grains, nonfat milk, and sodium, the newspaper reported. Then the pandemic forced additional changes as school districts scrambled to package meals for students. The USDA granted extra flexibility and eased some guidelines to ensure that children could be fed while schools were closed or focused on remote learning.

Now the USDA is updating the nutrition standards to “give schools clear expectations for gradual transition from current pandemic operations to more nutritious meals,” Stacy Dean, the USDA’s deputy undersecretary for food, nutrition, and consumer services, told reporters.

The Biden administration’s changes represent a shift back to Obama-era nutrition standards from 2012, according to the Post. But some nutrition advocates have said the new changes don’t address enough issues, such as added sugars. Fruit and vegetable requirements, for instance, will remain the same as the 2012 standards.

That said, some advocates have said the transition could be tough as schools move out of pandemic-era protocols. The School Nutrition Association, which represents school food service manufacturers and professionals, has urged Congress to provide additional support and waiver extensions for the next school year.

“School nutrition professionals are frantic just trying to get enough food on the tray for our students amid relentless supply chain disruptions and labor shortages,” Beth Wallace, the association’s president, told the Washington Post.

The shift will likely require a balancing act and slow transition. The USDA has been consulting with stakeholders for months to determine how to move toward stricter school nutrition standards while also acknowledging the pandemic, supply chain disruptions, and labor shortages.

“This approach is really going to help move forward the nutrition of the meals and allows the schools to continue to function effectively,” Geri Henchy, director of nutrition policy at the Food Research and Action Center, told the Post.

“Schools can’t make big changes at this point because of the supply chain and staffing,” she said. “They have a lot of waivers at this point that are helping them, and this balances the needs of all the different sectors.”

The USDA plans to issue a proposed rule in fall 2022 to update nutrition standards for the future, the department said in its announcement, which would be finalized for the 2024-2025 school year.

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

The U.S. Department of Agriculture has announced new changes to school nutrition standards for the next 2 school years, which will reinstate health goals that were rolled back during the Trump administration.

The Biden administration is also tightening rules for fat and salt content in foods after restrictions were eased during the pandemic, according to the Washington Post.

“Nutritious school meals give America’s children the foundation for successful, healthy lives,” Tom Vilsack, the U.S. agriculture secretary, said in a statement on Feb. 4.

“We applaud schools’ heroic efforts throughout the challenges of this pandemic to continue serving kids the most nutritious meals possible,” he said. “The standards we’re putting in place of the next 2 school years will help schools transition to a future that builds on the tremendous strides they’ve made improving school meal nutrition over the past decade.”

For the 2022-2023 school year, schools and childcare providers will be required to offer low-fat or nonfat unflavored milks and limit the fat in sweet flavored milks. In addition, at least 80% of the grains served during school breakfasts and lunches each week must be considered rich in whole grains.

For the 2023-2024 school year, the weekly sodium limit for school lunches will be decreased by 10%.

The changes mark a shift from the Trump administration, which eased policies on whole grains, nonfat milk, and sodium, the newspaper reported. Then the pandemic forced additional changes as school districts scrambled to package meals for students. The USDA granted extra flexibility and eased some guidelines to ensure that children could be fed while schools were closed or focused on remote learning.

Now the USDA is updating the nutrition standards to “give schools clear expectations for gradual transition from current pandemic operations to more nutritious meals,” Stacy Dean, the USDA’s deputy undersecretary for food, nutrition, and consumer services, told reporters.

The Biden administration’s changes represent a shift back to Obama-era nutrition standards from 2012, according to the Post. But some nutrition advocates have said the new changes don’t address enough issues, such as added sugars. Fruit and vegetable requirements, for instance, will remain the same as the 2012 standards.

That said, some advocates have said the transition could be tough as schools move out of pandemic-era protocols. The School Nutrition Association, which represents school food service manufacturers and professionals, has urged Congress to provide additional support and waiver extensions for the next school year.

“School nutrition professionals are frantic just trying to get enough food on the tray for our students amid relentless supply chain disruptions and labor shortages,” Beth Wallace, the association’s president, told the Washington Post.

The shift will likely require a balancing act and slow transition. The USDA has been consulting with stakeholders for months to determine how to move toward stricter school nutrition standards while also acknowledging the pandemic, supply chain disruptions, and labor shortages.

“This approach is really going to help move forward the nutrition of the meals and allows the schools to continue to function effectively,” Geri Henchy, director of nutrition policy at the Food Research and Action Center, told the Post.

“Schools can’t make big changes at this point because of the supply chain and staffing,” she said. “They have a lot of waivers at this point that are helping them, and this balances the needs of all the different sectors.”

The USDA plans to issue a proposed rule in fall 2022 to update nutrition standards for the future, the department said in its announcement, which would be finalized for the 2024-2025 school year.

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

The U.S. Department of Agriculture has announced new changes to school nutrition standards for the next 2 school years, which will reinstate health goals that were rolled back during the Trump administration.

The Biden administration is also tightening rules for fat and salt content in foods after restrictions were eased during the pandemic, according to the Washington Post.

“Nutritious school meals give America’s children the foundation for successful, healthy lives,” Tom Vilsack, the U.S. agriculture secretary, said in a statement on Feb. 4.

“We applaud schools’ heroic efforts throughout the challenges of this pandemic to continue serving kids the most nutritious meals possible,” he said. “The standards we’re putting in place of the next 2 school years will help schools transition to a future that builds on the tremendous strides they’ve made improving school meal nutrition over the past decade.”

For the 2022-2023 school year, schools and childcare providers will be required to offer low-fat or nonfat unflavored milks and limit the fat in sweet flavored milks. In addition, at least 80% of the grains served during school breakfasts and lunches each week must be considered rich in whole grains.

For the 2023-2024 school year, the weekly sodium limit for school lunches will be decreased by 10%.

The changes mark a shift from the Trump administration, which eased policies on whole grains, nonfat milk, and sodium, the newspaper reported. Then the pandemic forced additional changes as school districts scrambled to package meals for students. The USDA granted extra flexibility and eased some guidelines to ensure that children could be fed while schools were closed or focused on remote learning.

Now the USDA is updating the nutrition standards to “give schools clear expectations for gradual transition from current pandemic operations to more nutritious meals,” Stacy Dean, the USDA’s deputy undersecretary for food, nutrition, and consumer services, told reporters.

The Biden administration’s changes represent a shift back to Obama-era nutrition standards from 2012, according to the Post. But some nutrition advocates have said the new changes don’t address enough issues, such as added sugars. Fruit and vegetable requirements, for instance, will remain the same as the 2012 standards.

That said, some advocates have said the transition could be tough as schools move out of pandemic-era protocols. The School Nutrition Association, which represents school food service manufacturers and professionals, has urged Congress to provide additional support and waiver extensions for the next school year.

“School nutrition professionals are frantic just trying to get enough food on the tray for our students amid relentless supply chain disruptions and labor shortages,” Beth Wallace, the association’s president, told the Washington Post.

The shift will likely require a balancing act and slow transition. The USDA has been consulting with stakeholders for months to determine how to move toward stricter school nutrition standards while also acknowledging the pandemic, supply chain disruptions, and labor shortages.

“This approach is really going to help move forward the nutrition of the meals and allows the schools to continue to function effectively,” Geri Henchy, director of nutrition policy at the Food Research and Action Center, told the Post.

“Schools can’t make big changes at this point because of the supply chain and staffing,” she said. “They have a lot of waivers at this point that are helping them, and this balances the needs of all the different sectors.”

The USDA plans to issue a proposed rule in fall 2022 to update nutrition standards for the future, the department said in its announcement, which would be finalized for the 2024-2025 school year.

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

The indication of an Omicron decline has become a trend: New cases of COVID-19 in children were down for a second consecutive week in the United States, according to the American Academy of Pediatrics and the Children’s Hospital Association.

The total for the week of Jan. 28 to Feb. 3 was still “extremely high, over double the peak level of the Delta surge in 2021,” the AAP noted, but the nearly 632,000 cases reported were down by 22% from the previous week and by 45% from what appears to be the peak of the Omicron surge during the week of Jan. 14-20, the AAP/CHA data show.

To put the effect of the Delta and Omicron variants into some sort of perspective, the total number of COVID-19 cases among children passed 5 million at the beginning of September 2021, about a year and a half into the pandemic. In the last 5 months, the cumulative count has more than doubled and now stands at 12 million, the AAP and CHA said in their weekly COVID report.

Hospital admissions and emergency department visits followed the same downward trend over the last week. The rate of new hospitalizations fell to 0.81 per 100,000 children aged 0-17 years as of Feb. 2 (down from a peak of 1.25 per 100,000 on Jan. 15), and ED visits with diagnosed COVID-19 dropped to 1.8% (peak was 14.1%), 1.9% (peak was 14.3%), and 3.4% (peak was 14%) of all visits for children aged 16-17, 12-15, and 0-11 years, respectively, the Centers for Disease Control and Prevention reported.

The vaccination response

The surge of infections brought about by the Omicron variant, however, did not translate into increased vaccination, at least for the youngest eligible children. Vaccine initiation rose slightly among children aged 5-11 in early and mid-January but, by early February, new vaccinations had declined to their lowest point since approval in early November of 2021, the AAP said in its weekly COVID vaccination report.

As a result, the 5- to 11-year-olds are well behind the pace set by those aged 12-15 for the first 3 months of their vaccination experience. Through the first 13 weeks after the COVID vaccine was approved for children aged 12-15 in early May, 44.5% had received at least one dose and 32.3% were fully vaccinated. Among children aged 5-11, the corresponding figures through 13 weeks were 31% and 22.5%, according to CDC data.

The vaccination reaction to Omicron was somewhat more robust for children aged 12-17, compared with the younger group, but initiations dropped at the same time that new cases began to decline. In terms of total volume, the response among 12- to 17-year-olds was much smaller than that seen in July and August of 2021 as the Delta surge was hitting the United States, the AAP vaccination report shows.

All those vaccinations add up to this: Over 16.8 million children aged 12-17 and almost 9 million aged 5-11 had received at least one dose of vaccine as of Feb. 7, which works out to 66.6% of the older group and 31.2% of the younger cohort. Almost 14.3 million (56.4%) of those aged 12-17 are fully vaccinated, as are 6.6 million (22.9%) of the 5- to 11-year-olds, the CDC said on its COVID Data Tracker.

The indication of an Omicron decline has become a trend: New cases of COVID-19 in children were down for a second consecutive week in the United States, according to the American Academy of Pediatrics and the Children’s Hospital Association.

The total for the week of Jan. 28 to Feb. 3 was still “extremely high, over double the peak level of the Delta surge in 2021,” the AAP noted, but the nearly 632,000 cases reported were down by 22% from the previous week and by 45% from what appears to be the peak of the Omicron surge during the week of Jan. 14-20, the AAP/CHA data show.

To put the effect of the Delta and Omicron variants into some sort of perspective, the total number of COVID-19 cases among children passed 5 million at the beginning of September 2021, about a year and a half into the pandemic. In the last 5 months, the cumulative count has more than doubled and now stands at 12 million, the AAP and CHA said in their weekly COVID report.

Hospital admissions and emergency department visits followed the same downward trend over the last week. The rate of new hospitalizations fell to 0.81 per 100,000 children aged 0-17 years as of Feb. 2 (down from a peak of 1.25 per 100,000 on Jan. 15), and ED visits with diagnosed COVID-19 dropped to 1.8% (peak was 14.1%), 1.9% (peak was 14.3%), and 3.4% (peak was 14%) of all visits for children aged 16-17, 12-15, and 0-11 years, respectively, the Centers for Disease Control and Prevention reported.

The vaccination response

The surge of infections brought about by the Omicron variant, however, did not translate into increased vaccination, at least for the youngest eligible children. Vaccine initiation rose slightly among children aged 5-11 in early and mid-January but, by early February, new vaccinations had declined to their lowest point since approval in early November of 2021, the AAP said in its weekly COVID vaccination report.

As a result, the 5- to 11-year-olds are well behind the pace set by those aged 12-15 for the first 3 months of their vaccination experience. Through the first 13 weeks after the COVID vaccine was approved for children aged 12-15 in early May, 44.5% had received at least one dose and 32.3% were fully vaccinated. Among children aged 5-11, the corresponding figures through 13 weeks were 31% and 22.5%, according to CDC data.

The vaccination reaction to Omicron was somewhat more robust for children aged 12-17, compared with the younger group, but initiations dropped at the same time that new cases began to decline. In terms of total volume, the response among 12- to 17-year-olds was much smaller than that seen in July and August of 2021 as the Delta surge was hitting the United States, the AAP vaccination report shows.

All those vaccinations add up to this: Over 16.8 million children aged 12-17 and almost 9 million aged 5-11 had received at least one dose of vaccine as of Feb. 7, which works out to 66.6% of the older group and 31.2% of the younger cohort. Almost 14.3 million (56.4%) of those aged 12-17 are fully vaccinated, as are 6.6 million (22.9%) of the 5- to 11-year-olds, the CDC said on its COVID Data Tracker.

The indication of an Omicron decline has become a trend: New cases of COVID-19 in children were down for a second consecutive week in the United States, according to the American Academy of Pediatrics and the Children’s Hospital Association.

The total for the week of Jan. 28 to Feb. 3 was still “extremely high, over double the peak level of the Delta surge in 2021,” the AAP noted, but the nearly 632,000 cases reported were down by 22% from the previous week and by 45% from what appears to be the peak of the Omicron surge during the week of Jan. 14-20, the AAP/CHA data show.

To put the effect of the Delta and Omicron variants into some sort of perspective, the total number of COVID-19 cases among children passed 5 million at the beginning of September 2021, about a year and a half into the pandemic. In the last 5 months, the cumulative count has more than doubled and now stands at 12 million, the AAP and CHA said in their weekly COVID report.

Hospital admissions and emergency department visits followed the same downward trend over the last week. The rate of new hospitalizations fell to 0.81 per 100,000 children aged 0-17 years as of Feb. 2 (down from a peak of 1.25 per 100,000 on Jan. 15), and ED visits with diagnosed COVID-19 dropped to 1.8% (peak was 14.1%), 1.9% (peak was 14.3%), and 3.4% (peak was 14%) of all visits for children aged 16-17, 12-15, and 0-11 years, respectively, the Centers for Disease Control and Prevention reported.

The vaccination response

The surge of infections brought about by the Omicron variant, however, did not translate into increased vaccination, at least for the youngest eligible children. Vaccine initiation rose slightly among children aged 5-11 in early and mid-January but, by early February, new vaccinations had declined to their lowest point since approval in early November of 2021, the AAP said in its weekly COVID vaccination report.

As a result, the 5- to 11-year-olds are well behind the pace set by those aged 12-15 for the first 3 months of their vaccination experience. Through the first 13 weeks after the COVID vaccine was approved for children aged 12-15 in early May, 44.5% had received at least one dose and 32.3% were fully vaccinated. Among children aged 5-11, the corresponding figures through 13 weeks were 31% and 22.5%, according to CDC data.

The vaccination reaction to Omicron was somewhat more robust for children aged 12-17, compared with the younger group, but initiations dropped at the same time that new cases began to decline. In terms of total volume, the response among 12- to 17-year-olds was much smaller than that seen in July and August of 2021 as the Delta surge was hitting the United States, the AAP vaccination report shows.

All those vaccinations add up to this: Over 16.8 million children aged 12-17 and almost 9 million aged 5-11 had received at least one dose of vaccine as of Feb. 7, which works out to 66.6% of the older group and 31.2% of the younger cohort. Almost 14.3 million (56.4%) of those aged 12-17 are fully vaccinated, as are 6.6 million (22.9%) of the 5- to 11-year-olds, the CDC said on its COVID Data Tracker.

Eating dinner close to bedtime when endogenous melatonin levels are high is associated with decreased insulin secretion and decreased glucose tolerance, which increase the risk of type 2 diabetes.

And people who are carriers of the G allele of the MTNR1B gene have greater impairment in glucose tolerance after eating a late dinner.

“In natural late eaters [in Spain], we simulated early and late dinner timing by administering a glucose drink and compared effects on blood sugar control over 2 hours,” said senior author Richa Saxena, PhD, a principal investigator at the Center for Genomic Medicine at Massachusetts General Hospital, Boston.  

The study also compared outcomes in carriers and noncarriers of the G allele variant of the melatonin receptor gene, Dr. Saxena pointed out in a press release from the hospital.

“We found that late eating disturbed blood sugar control in the whole group,” added lead author Marta Garaulet, PhD.

“This impaired glucose control was predominantly seen in genetic risk variant carriers, representing about half of the cohort,” said Dr. Garaulet, professor of physiology and nutrition, University of Murcia (Spain).

The study results “may be important in the effort toward prevention of type 2 diabetes,” according to co–senior author Frank A.J.L. Scheer, PhD.

“Our findings are applicable to about a third of the population in the industrialized world who consume food close to bedtime, as well as other populations who eat at night, including shift workers, or those experiencing jet lag or night-eating disorders, as well as those who routinely use melatonin supplements close to food intake,” said Dr. Scheer, director of the medical chronobiology program at Brigham and Women’s Hospital, Boston.

The results suggest people should not eat within 2 hours of bedtime, said the researchers.

“Notably, our study does not include patients with diabetes, so additional studies are needed to examine the impact of food timing and its link with melatonin and receptor variation in patients with diabetes,” Dr. Scheer said.

The findings, from the MTNR1B SNP*Food Timing Interaction on Glucose Control (ONTIME-MT) randomized crossover study, were recently published in Diabetes Care.

Melatonin plays a key role in glucose metabolism

Melatonin, a hormone primarily released at night that helps control the sleep-wake cycle, typically rises around 2 hours before bedtime, the researchers explained.

The discovery of MTNR1B as a type 2 diabetes–associated gene “suggests that, beyond sleep and circadian regulation, melatonin plays a key role in glucose metabolism,” they noted. However, whether melatonin improves or impairs glucose control is controversial, and the effect of MTNR1B genotypes on glucose control is not clear.

“We decided to test if late eating that usually occurs with elevated melatonin levels results in disturbed blood sugar control,” Dr. Saxena explained.

To investigate this, researchers enrolled 845 adults in Spain who were 18-70 years old and did not have diabetes. Participants were a mean age of 38 years and 71% were women. They had a mean body mass index of 25.7 kg/m2 and 18% had obesity.

On average, they typically ate dinner at 21:38 (9:38 p.m.) and went to bed at 24:32 (12:32 a.m.).

DNA analysis from participants’ blood samples determined that 50% had the CC genotype of the MTNR1B gene, 40% had the CG genotype, and 10% had the GG genotype.

Each participant underwent two oral glucose tolerance tests. They fasted for 8 hours and then had a 2-hour 75-g oral glucose tolerance test either 1 hour before bedtime (simulating a late dinner) or 4 hours before bedtime (simulating an early dinner). Then they repeated the test at the opposite dinner time on another night.

The average serum melatonin values were 3.5-fold higher after the late dinner than after the early dinner, resulting in 6.7% lower insulin area under the curve and 8.3% higher glucose AUC.

Genotype differences in glucose tolerance were attributed to reductions in beta-cell function.

“Our results confirm that late eating acutely impairs glucose tolerance through a defect in insulin secretion,” the researchers reiterated.

ONTIME-MT was funded by the National Institutes of Health; the Spanish Government of Investigation, Development, and Innovation; and the Seneca Foundation. The researchers reported no relevant financial disclosures.

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

Eating dinner close to bedtime when endogenous melatonin levels are high is associated with decreased insulin secretion and decreased glucose tolerance, which increase the risk of type 2 diabetes.

And people who are carriers of the G allele of the MTNR1B gene have greater impairment in glucose tolerance after eating a late dinner.

“In natural late eaters [in Spain], we simulated early and late dinner timing by administering a glucose drink and compared effects on blood sugar control over 2 hours,” said senior author Richa Saxena, PhD, a principal investigator at the Center for Genomic Medicine at Massachusetts General Hospital, Boston.  

The study also compared outcomes in carriers and noncarriers of the G allele variant of the melatonin receptor gene, Dr. Saxena pointed out in a press release from the hospital.

“We found that late eating disturbed blood sugar control in the whole group,” added lead author Marta Garaulet, PhD.

“This impaired glucose control was predominantly seen in genetic risk variant carriers, representing about half of the cohort,” said Dr. Garaulet, professor of physiology and nutrition, University of Murcia (Spain).

The study results “may be important in the effort toward prevention of type 2 diabetes,” according to co–senior author Frank A.J.L. Scheer, PhD.

“Our findings are applicable to about a third of the population in the industrialized world who consume food close to bedtime, as well as other populations who eat at night, including shift workers, or those experiencing jet lag or night-eating disorders, as well as those who routinely use melatonin supplements close to food intake,” said Dr. Scheer, director of the medical chronobiology program at Brigham and Women’s Hospital, Boston.

The results suggest people should not eat within 2 hours of bedtime, said the researchers.

“Notably, our study does not include patients with diabetes, so additional studies are needed to examine the impact of food timing and its link with melatonin and receptor variation in patients with diabetes,” Dr. Scheer said.

The findings, from the MTNR1B SNP*Food Timing Interaction on Glucose Control (ONTIME-MT) randomized crossover study, were recently published in Diabetes Care.

Melatonin plays a key role in glucose metabolism

Melatonin, a hormone primarily released at night that helps control the sleep-wake cycle, typically rises around 2 hours before bedtime, the researchers explained.

The discovery of MTNR1B as a type 2 diabetes–associated gene “suggests that, beyond sleep and circadian regulation, melatonin plays a key role in glucose metabolism,” they noted. However, whether melatonin improves or impairs glucose control is controversial, and the effect of MTNR1B genotypes on glucose control is not clear.

“We decided to test if late eating that usually occurs with elevated melatonin levels results in disturbed blood sugar control,” Dr. Saxena explained.

To investigate this, researchers enrolled 845 adults in Spain who were 18-70 years old and did not have diabetes. Participants were a mean age of 38 years and 71% were women. They had a mean body mass index of 25.7 kg/m2 and 18% had obesity.

On average, they typically ate dinner at 21:38 (9:38 p.m.) and went to bed at 24:32 (12:32 a.m.).

DNA analysis from participants’ blood samples determined that 50% had the CC genotype of the MTNR1B gene, 40% had the CG genotype, and 10% had the GG genotype.

Each participant underwent two oral glucose tolerance tests. They fasted for 8 hours and then had a 2-hour 75-g oral glucose tolerance test either 1 hour before bedtime (simulating a late dinner) or 4 hours before bedtime (simulating an early dinner). Then they repeated the test at the opposite dinner time on another night.

The average serum melatonin values were 3.5-fold higher after the late dinner than after the early dinner, resulting in 6.7% lower insulin area under the curve and 8.3% higher glucose AUC.

Genotype differences in glucose tolerance were attributed to reductions in beta-cell function.

“Our results confirm that late eating acutely impairs glucose tolerance through a defect in insulin secretion,” the researchers reiterated.

ONTIME-MT was funded by the National Institutes of Health; the Spanish Government of Investigation, Development, and Innovation; and the Seneca Foundation. The researchers reported no relevant financial disclosures.

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

Eating dinner close to bedtime when endogenous melatonin levels are high is associated with decreased insulin secretion and decreased glucose tolerance, which increase the risk of type 2 diabetes.

And people who are carriers of the G allele of the MTNR1B gene have greater impairment in glucose tolerance after eating a late dinner.

“In natural late eaters [in Spain], we simulated early and late dinner timing by administering a glucose drink and compared effects on blood sugar control over 2 hours,” said senior author Richa Saxena, PhD, a principal investigator at the Center for Genomic Medicine at Massachusetts General Hospital, Boston.  

The study also compared outcomes in carriers and noncarriers of the G allele variant of the melatonin receptor gene, Dr. Saxena pointed out in a press release from the hospital.

“We found that late eating disturbed blood sugar control in the whole group,” added lead author Marta Garaulet, PhD.

“This impaired glucose control was predominantly seen in genetic risk variant carriers, representing about half of the cohort,” said Dr. Garaulet, professor of physiology and nutrition, University of Murcia (Spain).

The study results “may be important in the effort toward prevention of type 2 diabetes,” according to co–senior author Frank A.J.L. Scheer, PhD.

“Our findings are applicable to about a third of the population in the industrialized world who consume food close to bedtime, as well as other populations who eat at night, including shift workers, or those experiencing jet lag or night-eating disorders, as well as those who routinely use melatonin supplements close to food intake,” said Dr. Scheer, director of the medical chronobiology program at Brigham and Women’s Hospital, Boston.

The results suggest people should not eat within 2 hours of bedtime, said the researchers.

“Notably, our study does not include patients with diabetes, so additional studies are needed to examine the impact of food timing and its link with melatonin and receptor variation in patients with diabetes,” Dr. Scheer said.

The findings, from the MTNR1B SNP*Food Timing Interaction on Glucose Control (ONTIME-MT) randomized crossover study, were recently published in Diabetes Care.

Melatonin plays a key role in glucose metabolism

Melatonin, a hormone primarily released at night that helps control the sleep-wake cycle, typically rises around 2 hours before bedtime, the researchers explained.

The discovery of MTNR1B as a type 2 diabetes–associated gene “suggests that, beyond sleep and circadian regulation, melatonin plays a key role in glucose metabolism,” they noted. However, whether melatonin improves or impairs glucose control is controversial, and the effect of MTNR1B genotypes on glucose control is not clear.

“We decided to test if late eating that usually occurs with elevated melatonin levels results in disturbed blood sugar control,” Dr. Saxena explained.

To investigate this, researchers enrolled 845 adults in Spain who were 18-70 years old and did not have diabetes. Participants were a mean age of 38 years and 71% were women. They had a mean body mass index of 25.7 kg/m2 and 18% had obesity.

On average, they typically ate dinner at 21:38 (9:38 p.m.) and went to bed at 24:32 (12:32 a.m.).

DNA analysis from participants’ blood samples determined that 50% had the CC genotype of the MTNR1B gene, 40% had the CG genotype, and 10% had the GG genotype.

Each participant underwent two oral glucose tolerance tests. They fasted for 8 hours and then had a 2-hour 75-g oral glucose tolerance test either 1 hour before bedtime (simulating a late dinner) or 4 hours before bedtime (simulating an early dinner). Then they repeated the test at the opposite dinner time on another night.

The average serum melatonin values were 3.5-fold higher after the late dinner than after the early dinner, resulting in 6.7% lower insulin area under the curve and 8.3% higher glucose AUC.

Genotype differences in glucose tolerance were attributed to reductions in beta-cell function.

“Our results confirm that late eating acutely impairs glucose tolerance through a defect in insulin secretion,” the researchers reiterated.

ONTIME-MT was funded by the National Institutes of Health; the Spanish Government of Investigation, Development, and Innovation; and the Seneca Foundation. The researchers reported no relevant financial disclosures.

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

Imagine this: As a young girl, you decide you want to become a doctor when you grow up. You spend countless hours studying, researching, and volunteering to eventually make it into medical school. Four years later, you graduate top of your class and match into your first-choice residency program. You are so proud of yourself!

During your last year of residency, a pandemic takes the entire world by storm. You persevere through your last 14 months of residency that included additional time in the ICU, not seeing your colleagues, and interviewing for your new job all from your own living room. After all of this, you finally get to start doing what you have been waiting to do for the past decade: train with the brilliant minds in hematology and oncology.

All of a sudden, your female mentors and pillars of the oncology world start disappearing around you due to early retirement, new career opportunities, or deciding to leave clinical medicine all together. You start to question: If these incredible women have decided that the sacrifice this career requires is too much, then (1) How will I survive? and (2) Did I make a huge mistake in my career decision? Spoiler alert: This girl is me.

The World Health Organization defines burnout as a “syndrome conceptualized as resulting from chronic workplace stress that has not been successfully managed. It is characterized by energy depletion or exhaustion, increased mental distance from one’s job, and reduced professional efficacy.”

We know that 33% of oncologists are feeling burned out right now, according to the Medscape National Physician Burnout & Suicide Report 2021. Of the 51% of female physicians that are burned out, work-life balance has been identified as the biggest workplace concern to them. Research has shown that hours per week devoted to direct patient care is the dominant predictor of burnout for practicing oncologists. But in academic oncology, that is followed by grant deadlines, manuscript rejections, and the constant reminders that you are a new face in oncology, a specialty that was previously male-dominated.

In less than a year, we have had several key female oncologists leave our cancer center. While some made the decision to retire early, two of them chose to pivot their careers and leave clinical medicine to assist with drug development and clinical trials. Although this is extremely important work for cancer care, I was shocked to hear that these amazing and successful clinicians were choosing to remove all direct patient care from their practice, when for many of them, patient care was what motivated them to pursue medicine in the first place. They were loved by their patients, respected as researchers, and well known as educators within the division.

One shared that she no longer felt like she could be a good mother, wife, or daughter with what was currently being demanded of her to have a successful academic career. In hearing this news, I was saddened to have to say goodbye to a mentor of mine and immediately started second-guessing my career choice. I felt that my goal of having an impactful career and prosperous home life was not only unattainable but potentially unrealistic.

While we know that female physicians already experience a greater degree of burnout, the pandemic has only added fuel to the fire. This is especially true in cancer care. It has been estimated that new cancer diagnosis have decreased by as much as 23% since the beginning of the pandemic. This delay in diagnosis will lead to patients presenting with more advanced disease, busier clinic schedules, and worsened clinical outcomes for years to come. With no end in sight, I worry what this will mean for women currently in oncology, in addition to those in training or deciding if they should pursue this as a career.

Extrapolating evidence from prior epidemics, physicians are at increased risk for burnout due to immediate and long-term effects from this pandemic. We need to act now to not only continue addressing previously existing individual and organizational causes of burnout but also develop strategies to provide support for the COVID-19–specific impacts on oncologists’ well-being. An editorial published by the American Society of Clinical Oncology provides helpful suggestions on how to do this.

A recent cross-sectional survey found that 22% of academic female oncologists were likely or very likely to pursue a career outside of academia in the next 5 years. Losing these women would be detrimental to the field. This would mean a significant number of patients losing their long-term oncologists with whom they have years of care, trainees losing their professional and research mentors to guide and help mold them into successful independent practitioners and researchers, and arguably most important, little girls losing role models to show them that regardless of their gender, they can become an oncologist.Dr. Poterala is a current hematology and oncology fellow at the University of Wisconsin Carbone Cancer Center, Madison. She disclosed no relevant conflicts of interest.

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

Imagine this: As a young girl, you decide you want to become a doctor when you grow up. You spend countless hours studying, researching, and volunteering to eventually make it into medical school. Four years later, you graduate top of your class and match into your first-choice residency program. You are so proud of yourself!

During your last year of residency, a pandemic takes the entire world by storm. You persevere through your last 14 months of residency that included additional time in the ICU, not seeing your colleagues, and interviewing for your new job all from your own living room. After all of this, you finally get to start doing what you have been waiting to do for the past decade: train with the brilliant minds in hematology and oncology.

All of a sudden, your female mentors and pillars of the oncology world start disappearing around you due to early retirement, new career opportunities, or deciding to leave clinical medicine all together. You start to question: If these incredible women have decided that the sacrifice this career requires is too much, then (1) How will I survive? and (2) Did I make a huge mistake in my career decision? Spoiler alert: This girl is me.

The World Health Organization defines burnout as a “syndrome conceptualized as resulting from chronic workplace stress that has not been successfully managed. It is characterized by energy depletion or exhaustion, increased mental distance from one’s job, and reduced professional efficacy.”

We know that 33% of oncologists are feeling burned out right now, according to the Medscape National Physician Burnout & Suicide Report 2021. Of the 51% of female physicians that are burned out, work-life balance has been identified as the biggest workplace concern to them. Research has shown that hours per week devoted to direct patient care is the dominant predictor of burnout for practicing oncologists. But in academic oncology, that is followed by grant deadlines, manuscript rejections, and the constant reminders that you are a new face in oncology, a specialty that was previously male-dominated.

In less than a year, we have had several key female oncologists leave our cancer center. While some made the decision to retire early, two of them chose to pivot their careers and leave clinical medicine to assist with drug development and clinical trials. Although this is extremely important work for cancer care, I was shocked to hear that these amazing and successful clinicians were choosing to remove all direct patient care from their practice, when for many of them, patient care was what motivated them to pursue medicine in the first place. They were loved by their patients, respected as researchers, and well known as educators within the division.

One shared that she no longer felt like she could be a good mother, wife, or daughter with what was currently being demanded of her to have a successful academic career. In hearing this news, I was saddened to have to say goodbye to a mentor of mine and immediately started second-guessing my career choice. I felt that my goal of having an impactful career and prosperous home life was not only unattainable but potentially unrealistic.

While we know that female physicians already experience a greater degree of burnout, the pandemic has only added fuel to the fire. This is especially true in cancer care. It has been estimated that new cancer diagnosis have decreased by as much as 23% since the beginning of the pandemic. This delay in diagnosis will lead to patients presenting with more advanced disease, busier clinic schedules, and worsened clinical outcomes for years to come. With no end in sight, I worry what this will mean for women currently in oncology, in addition to those in training or deciding if they should pursue this as a career.

Extrapolating evidence from prior epidemics, physicians are at increased risk for burnout due to immediate and long-term effects from this pandemic. We need to act now to not only continue addressing previously existing individual and organizational causes of burnout but also develop strategies to provide support for the COVID-19–specific impacts on oncologists’ well-being. An editorial published by the American Society of Clinical Oncology provides helpful suggestions on how to do this.

A recent cross-sectional survey found that 22% of academic female oncologists were likely or very likely to pursue a career outside of academia in the next 5 years. Losing these women would be detrimental to the field. This would mean a significant number of patients losing their long-term oncologists with whom they have years of care, trainees losing their professional and research mentors to guide and help mold them into successful independent practitioners and researchers, and arguably most important, little girls losing role models to show them that regardless of their gender, they can become an oncologist.Dr. Poterala is a current hematology and oncology fellow at the University of Wisconsin Carbone Cancer Center, Madison. She disclosed no relevant conflicts of interest.

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

Imagine this: As a young girl, you decide you want to become a doctor when you grow up. You spend countless hours studying, researching, and volunteering to eventually make it into medical school. Four years later, you graduate top of your class and match into your first-choice residency program. You are so proud of yourself!

During your last year of residency, a pandemic takes the entire world by storm. You persevere through your last 14 months of residency that included additional time in the ICU, not seeing your colleagues, and interviewing for your new job all from your own living room. After all of this, you finally get to start doing what you have been waiting to do for the past decade: train with the brilliant minds in hematology and oncology.

All of a sudden, your female mentors and pillars of the oncology world start disappearing around you due to early retirement, new career opportunities, or deciding to leave clinical medicine all together. You start to question: If these incredible women have decided that the sacrifice this career requires is too much, then (1) How will I survive? and (2) Did I make a huge mistake in my career decision? Spoiler alert: This girl is me.

The World Health Organization defines burnout as a “syndrome conceptualized as resulting from chronic workplace stress that has not been successfully managed. It is characterized by energy depletion or exhaustion, increased mental distance from one’s job, and reduced professional efficacy.”

We know that 33% of oncologists are feeling burned out right now, according to the Medscape National Physician Burnout & Suicide Report 2021. Of the 51% of female physicians that are burned out, work-life balance has been identified as the biggest workplace concern to them. Research has shown that hours per week devoted to direct patient care is the dominant predictor of burnout for practicing oncologists. But in academic oncology, that is followed by grant deadlines, manuscript rejections, and the constant reminders that you are a new face in oncology, a specialty that was previously male-dominated.

In less than a year, we have had several key female oncologists leave our cancer center. While some made the decision to retire early, two of them chose to pivot their careers and leave clinical medicine to assist with drug development and clinical trials. Although this is extremely important work for cancer care, I was shocked to hear that these amazing and successful clinicians were choosing to remove all direct patient care from their practice, when for many of them, patient care was what motivated them to pursue medicine in the first place. They were loved by their patients, respected as researchers, and well known as educators within the division.

One shared that she no longer felt like she could be a good mother, wife, or daughter with what was currently being demanded of her to have a successful academic career. In hearing this news, I was saddened to have to say goodbye to a mentor of mine and immediately started second-guessing my career choice. I felt that my goal of having an impactful career and prosperous home life was not only unattainable but potentially unrealistic.

While we know that female physicians already experience a greater degree of burnout, the pandemic has only added fuel to the fire. This is especially true in cancer care. It has been estimated that new cancer diagnosis have decreased by as much as 23% since the beginning of the pandemic. This delay in diagnosis will lead to patients presenting with more advanced disease, busier clinic schedules, and worsened clinical outcomes for years to come. With no end in sight, I worry what this will mean for women currently in oncology, in addition to those in training or deciding if they should pursue this as a career.

Extrapolating evidence from prior epidemics, physicians are at increased risk for burnout due to immediate and long-term effects from this pandemic. We need to act now to not only continue addressing previously existing individual and organizational causes of burnout but also develop strategies to provide support for the COVID-19–specific impacts on oncologists’ well-being. An editorial published by the American Society of Clinical Oncology provides helpful suggestions on how to do this.

A recent cross-sectional survey found that 22% of academic female oncologists were likely or very likely to pursue a career outside of academia in the next 5 years. Losing these women would be detrimental to the field. This would mean a significant number of patients losing their long-term oncologists with whom they have years of care, trainees losing their professional and research mentors to guide and help mold them into successful independent practitioners and researchers, and arguably most important, little girls losing role models to show them that regardless of their gender, they can become an oncologist.Dr. Poterala is a current hematology and oncology fellow at the University of Wisconsin Carbone Cancer Center, Madison. She disclosed no relevant conflicts of interest.

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

Long COVID continues to be a moving target – continuously evolving and still surprising doctors and patients who have sometimes incapacitating long-term symptoms.

Little about the disorder seems predictable at this point. People can have long COVID after asymptomatic, mild, or severe COVID-19, for example. And when a person gets long COVID – also known as long-haul COVID – symptoms can vary widely.

To address all the uncertainty, the New York State Department of Health gathered experts in primary care, pediatrics, physical medicine, rehabilitation, and pulmonology to answer some pressing questions.

New York in 2020 was the first epicenter of the pandemic in the United States, making it also the center of the long COVID epidemic, says Emily Lutterloh, MD, director of the Division of Epidemiology at the New York State Department of Health.
 

What do you do when you’re seeing a patient with long COVID for the first time?

The first exam varies because there are so many different ways long COVID presents itself, says Benjamin Abramoff, MD, a physical medicine and rehabilitation specialist at Penn Medicine in Philadelphia.

I’ve now been seriously ill with #LongCovid for 11 months. I was never hospitalized. I didn’t even have a “mild” covid case. Instead, I developed Long Covid from an asymptomatic infection.

I’m far from unique. Up to 1/5 of asymptomatic patients go on to have long-term symptoms.

— Ravi Veriah Jacques (@RaviHVJ) February 3, 2022

Assessing their previous and current care also helps to direct their ongoing management, says Zijian Chen, MD, medical director of the Center for Post-COVID Care at Mount Sinai Health System in New York.
 

Can vaccination help people with long COVID?

Anything that we can do to help prevent people from being critically ill or being hospitalized with COVID-19 is helpful to prevent long COVID, says Dr. Abramoff, who is also director of the long COVID clinic at the University of Pennsylvania, Philadelphia.

“So that’s something I always discuss with patients. In some research, sometimes patients do feel better after the vaccine,” he says.
 

What kind of therapies do you find helpful for your patients?

Rehabilitation is a key part of recovery from long COVID, Dr. Abramoff says. “It is very important to make this very patient-specific.”

“We have patients that are working. They’re already going to the gym in some cases but don’t feel like they have the same endurance,” he says. “And then we have patients who are so crippled by their fatigue that they can’t get out of bed.”
 

1/ What is #LongCOVID?!

A disabling malady from ongoing inflammation, autoimmunity, & potential viral reservoirs (GI, brain?)

NEW DATA: The Lungs “light up” on special MRI Scans 3 to 9 months later in patients never hospitalized for COVID.https://t.co/I2kyZ4cK5F pic.twitter.com/dL1P67L2DK

— WesElyMD (@WesElyMD) February 2, 2022

An exercise program can help people who have long COVID.

“There’s a big role for therapy services in the recovery of these patients,” says John Baratta, MD, of the department of physical medicine and rehabilitation at the University of North Carolina at Chapel Hill.

But the limited number of long COVID clinics can mean some people are unable to get to therapists trained on the needs of patients with lingering COVID symptoms. Educating community physical and occupational therapists is one solution.
 

How long does it take for people with long COVID to recover and get back to 100% if they can?

Specific numbers aren’t really available, Dr. Baratta says.

“But I can tell you the general trend that I see is that a lot of patients have a gradual improvement of symptoms. The slow but steady improvement with time may be the body’s natural healing process, a result of medical interventions, or both.”

It can help to reassure people with long COVID that they will not be discharged from care until they feel they’ve maximized their health, says Sharagim Kemp, DO, medical director of the COVID Recovery Program for Nuvance Health, a health system in New York and Connecticut.

It’s essential to set realistic recovery expectations and tell patients that not everyone will return to 100% of their pre-COVID functioning, she says.

“Once we are able to help them reset their expectations, there’s almost an accelerated recovery because they are not putting that pressure on themselves anymore,” Dr. Kemp says.
 

What are the most common symptoms you’re seeing in long COVID?

It’s helpful to think of long COVID as a very broad umbrella term, Dr. Abramoff says.

Echoing what many others have observed, fatigue, cognitive dysfunction or “brain fog,“ and shortness of breath or troubled breathing appear to be the most common symptoms, he says.

Some reported vague symptoms, Dr. Kemp says.

People may go to the doctor “not even realizing that they had COVID. That’s one of the important points here – to have a high index of suspicion for patients who come in with multiple symptoms,” she says.

For this reason, patients can report symptoms that don’t necessarily fit into any specialty, says Sarah J. Ryan, MD, an internal medicine doctor at Columbia University Irving Medical Center in New York. People say they are “just not themselves” or they are tired after their COVID-19 recovery.
 

Is there a connection between severe COVID cases and severe long COVID?

“It’s not like that at all. I would say that more than 80% of the patients that we see had mild to moderate illness and they were not hospitalized,” Dr. Baratta says.

Long COVID is a bit different in children and teenagers, says Ixsy Ramirez, MD, a pediatric pulmonologist at University of Michigan Health, Ann Arbor. Most patients in the long COVID clinic at the University of Michigan were previously healthy, and not children with asthma or other lung conditions as one might expect. In fact, many are student athletes, or were before they had long COVID.

In this population, shortness of breath is most common, followed by chest pain and fatigue. Unfortunately, the symptoms are so serious for many kids that their performance is limited, even if they can return to competitive play.
 

Are there defined criteria you use to diagnose long COVID? How do you give someone a diagnosis?

That’s an ever-evolving question, Dr. Kemp says. The generally accepted definition centers on persistent or new symptoms 4 weeks or more after the original COVID-19 illness, but there are exceptions.

Researchers are working on lab tests to help confirm the diagnosis. But without a definitive blood biomarker, getting to the diagnosis requires “some thorough detective work,” Dr. Ryan says.
 

Do you bring in mental health providers to help with treatment?

“We focus on mental health quite a bit actually,” says, Dr. Chen, cofounder of his institution’s COVID recovery clinic. Mount Sinai offers one-on-one and group mental health services, for example.

“Personally, I’ve seen patients that I did not expect to have such severe mental health changes” with long COVID.
 

One of the most powerful accounts and testimonies I have seen on what most #LongCovid patients experience when interacting with their doctors.

“I did not fit in a box, so they chose not to see me, even worse they made me feel like it was my fault for not fitting in their box” pic.twitter.com/7GQLBucuO5

— charlos (@loscharlos) February 3, 2022

Examples include severe depression, cases of acute psychosis, hallucinations, and other problems “that are really unexpected after a viral illness.”

Stony Brook University Hospital in New York has a long COVID clinic staffed by multiple primary care doctors who do exams and refer patients to services. A bonus of offering psychological services to all post-COVID patients is doctors get a more complete picture of each person and a better understanding of what they are going through, says Abigail Chua, MD, a pulmonologist at Stony Brook.

Some empathy is essential, Dr. Baratta says. “It’s important to recognize that a lot of these patients present with a sense of grief or loss for their prior life.”
 

What does the future hold?

A simple test to diagnose long COVID, combined with an effective treatment that helps people feel better within a week, would be ideal, Dr. Abramoff says.

“That would be lovely. But you know, we’re just not at that point.”

And it would be helpful to start identifying subtypes of long COVID so diagnosis and treatment can be more targeted, Dr. Abramoff says. Otherwise, “It’s going to be a very challenging approach to try to treat all of our patients with long COVID symptoms the same way.”

Good clinical trials likewise are needed to address all the subtleties of long COVID.

A number of long COVID centers are collaborating on research to find out more, Dr. Chen says. Actions include setting up a bank of tissue samples from people with long COVID so researchers can continue to figure out the condition.

One goal, Dr. Chen says, would be the ability to treat long COVID rather than just its symptoms.

Long COVID emphasizes the need to prevent people from getting COVID in the first place, Dr. Ramirez says. This will continue to be important, particularly when some people dismiss the seriousness of COVID, comparing it to a cold if they get it. That attitude discounts the large number of people who unfortunately go on to develop long-term, often debilitating, symptoms.

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

Long COVID continues to be a moving target – continuously evolving and still surprising doctors and patients who have sometimes incapacitating long-term symptoms.

Little about the disorder seems predictable at this point. People can have long COVID after asymptomatic, mild, or severe COVID-19, for example. And when a person gets long COVID – also known as long-haul COVID – symptoms can vary widely.

To address all the uncertainty, the New York State Department of Health gathered experts in primary care, pediatrics, physical medicine, rehabilitation, and pulmonology to answer some pressing questions.

New York in 2020 was the first epicenter of the pandemic in the United States, making it also the center of the long COVID epidemic, says Emily Lutterloh, MD, director of the Division of Epidemiology at the New York State Department of Health.
 

What do you do when you’re seeing a patient with long COVID for the first time?

The first exam varies because there are so many different ways long COVID presents itself, says Benjamin Abramoff, MD, a physical medicine and rehabilitation specialist at Penn Medicine in Philadelphia.

I’ve now been seriously ill with #LongCovid for 11 months. I was never hospitalized. I didn’t even have a “mild” covid case. Instead, I developed Long Covid from an asymptomatic infection.

I’m far from unique. Up to 1/5 of asymptomatic patients go on to have long-term symptoms.

— Ravi Veriah Jacques (@RaviHVJ) February 3, 2022

Assessing their previous and current care also helps to direct their ongoing management, says Zijian Chen, MD, medical director of the Center for Post-COVID Care at Mount Sinai Health System in New York.
 

Can vaccination help people with long COVID?

Anything that we can do to help prevent people from being critically ill or being hospitalized with COVID-19 is helpful to prevent long COVID, says Dr. Abramoff, who is also director of the long COVID clinic at the University of Pennsylvania, Philadelphia.

“So that’s something I always discuss with patients. In some research, sometimes patients do feel better after the vaccine,” he says.
 

What kind of therapies do you find helpful for your patients?

Rehabilitation is a key part of recovery from long COVID, Dr. Abramoff says. “It is very important to make this very patient-specific.”

“We have patients that are working. They’re already going to the gym in some cases but don’t feel like they have the same endurance,” he says. “And then we have patients who are so crippled by their fatigue that they can’t get out of bed.”
 

1/ What is #LongCOVID?!

A disabling malady from ongoing inflammation, autoimmunity, & potential viral reservoirs (GI, brain?)

NEW DATA: The Lungs “light up” on special MRI Scans 3 to 9 months later in patients never hospitalized for COVID.https://t.co/I2kyZ4cK5F pic.twitter.com/dL1P67L2DK

— WesElyMD (@WesElyMD) February 2, 2022

An exercise program can help people who have long COVID.

“There’s a big role for therapy services in the recovery of these patients,” says John Baratta, MD, of the department of physical medicine and rehabilitation at the University of North Carolina at Chapel Hill.

But the limited number of long COVID clinics can mean some people are unable to get to therapists trained on the needs of patients with lingering COVID symptoms. Educating community physical and occupational therapists is one solution.
 

How long does it take for people with long COVID to recover and get back to 100% if they can?

Specific numbers aren’t really available, Dr. Baratta says.

“But I can tell you the general trend that I see is that a lot of patients have a gradual improvement of symptoms. The slow but steady improvement with time may be the body’s natural healing process, a result of medical interventions, or both.”

It can help to reassure people with long COVID that they will not be discharged from care until they feel they’ve maximized their health, says Sharagim Kemp, DO, medical director of the COVID Recovery Program for Nuvance Health, a health system in New York and Connecticut.

It’s essential to set realistic recovery expectations and tell patients that not everyone will return to 100% of their pre-COVID functioning, she says.

“Once we are able to help them reset their expectations, there’s almost an accelerated recovery because they are not putting that pressure on themselves anymore,” Dr. Kemp says.
 

What are the most common symptoms you’re seeing in long COVID?

It’s helpful to think of long COVID as a very broad umbrella term, Dr. Abramoff says.

Echoing what many others have observed, fatigue, cognitive dysfunction or “brain fog,“ and shortness of breath or troubled breathing appear to be the most common symptoms, he says.

Some reported vague symptoms, Dr. Kemp says.

People may go to the doctor “not even realizing that they had COVID. That’s one of the important points here – to have a high index of suspicion for patients who come in with multiple symptoms,” she says.

For this reason, patients can report symptoms that don’t necessarily fit into any specialty, says Sarah J. Ryan, MD, an internal medicine doctor at Columbia University Irving Medical Center in New York. People say they are “just not themselves” or they are tired after their COVID-19 recovery.
 

Is there a connection between severe COVID cases and severe long COVID?

“It’s not like that at all. I would say that more than 80% of the patients that we see had mild to moderate illness and they were not hospitalized,” Dr. Baratta says.

Long COVID is a bit different in children and teenagers, says Ixsy Ramirez, MD, a pediatric pulmonologist at University of Michigan Health, Ann Arbor. Most patients in the long COVID clinic at the University of Michigan were previously healthy, and not children with asthma or other lung conditions as one might expect. In fact, many are student athletes, or were before they had long COVID.

In this population, shortness of breath is most common, followed by chest pain and fatigue. Unfortunately, the symptoms are so serious for many kids that their performance is limited, even if they can return to competitive play.
 

Are there defined criteria you use to diagnose long COVID? How do you give someone a diagnosis?

That’s an ever-evolving question, Dr. Kemp says. The generally accepted definition centers on persistent or new symptoms 4 weeks or more after the original COVID-19 illness, but there are exceptions.

Researchers are working on lab tests to help confirm the diagnosis. But without a definitive blood biomarker, getting to the diagnosis requires “some thorough detective work,” Dr. Ryan says.
 

Do you bring in mental health providers to help with treatment?

“We focus on mental health quite a bit actually,” says, Dr. Chen, cofounder of his institution’s COVID recovery clinic. Mount Sinai offers one-on-one and group mental health services, for example.

“Personally, I’ve seen patients that I did not expect to have such severe mental health changes” with long COVID.
 

One of the most powerful accounts and testimonies I have seen on what most #LongCovid patients experience when interacting with their doctors.

“I did not fit in a box, so they chose not to see me, even worse they made me feel like it was my fault for not fitting in their box” pic.twitter.com/7GQLBucuO5

— charlos (@loscharlos) February 3, 2022

Examples include severe depression, cases of acute psychosis, hallucinations, and other problems “that are really unexpected after a viral illness.”

Stony Brook University Hospital in New York has a long COVID clinic staffed by multiple primary care doctors who do exams and refer patients to services. A bonus of offering psychological services to all post-COVID patients is doctors get a more complete picture of each person and a better understanding of what they are going through, says Abigail Chua, MD, a pulmonologist at Stony Brook.

Some empathy is essential, Dr. Baratta says. “It’s important to recognize that a lot of these patients present with a sense of grief or loss for their prior life.”
 

What does the future hold?

A simple test to diagnose long COVID, combined with an effective treatment that helps people feel better within a week, would be ideal, Dr. Abramoff says.

“That would be lovely. But you know, we’re just not at that point.”

And it would be helpful to start identifying subtypes of long COVID so diagnosis and treatment can be more targeted, Dr. Abramoff says. Otherwise, “It’s going to be a very challenging approach to try to treat all of our patients with long COVID symptoms the same way.”

Good clinical trials likewise are needed to address all the subtleties of long COVID.

A number of long COVID centers are collaborating on research to find out more, Dr. Chen says. Actions include setting up a bank of tissue samples from people with long COVID so researchers can continue to figure out the condition.

One goal, Dr. Chen says, would be the ability to treat long COVID rather than just its symptoms.

Long COVID emphasizes the need to prevent people from getting COVID in the first place, Dr. Ramirez says. This will continue to be important, particularly when some people dismiss the seriousness of COVID, comparing it to a cold if they get it. That attitude discounts the large number of people who unfortunately go on to develop long-term, often debilitating, symptoms.

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

Long COVID continues to be a moving target – continuously evolving and still surprising doctors and patients who have sometimes incapacitating long-term symptoms.

Little about the disorder seems predictable at this point. People can have long COVID after asymptomatic, mild, or severe COVID-19, for example. And when a person gets long COVID – also known as long-haul COVID – symptoms can vary widely.

To address all the uncertainty, the New York State Department of Health gathered experts in primary care, pediatrics, physical medicine, rehabilitation, and pulmonology to answer some pressing questions.

New York in 2020 was the first epicenter of the pandemic in the United States, making it also the center of the long COVID epidemic, says Emily Lutterloh, MD, director of the Division of Epidemiology at the New York State Department of Health.
 

What do you do when you’re seeing a patient with long COVID for the first time?

The first exam varies because there are so many different ways long COVID presents itself, says Benjamin Abramoff, MD, a physical medicine and rehabilitation specialist at Penn Medicine in Philadelphia.

I’ve now been seriously ill with #LongCovid for 11 months. I was never hospitalized. I didn’t even have a “mild” covid case. Instead, I developed Long Covid from an asymptomatic infection.

I’m far from unique. Up to 1/5 of asymptomatic patients go on to have long-term symptoms.

— Ravi Veriah Jacques (@RaviHVJ) February 3, 2022

Assessing their previous and current care also helps to direct their ongoing management, says Zijian Chen, MD, medical director of the Center for Post-COVID Care at Mount Sinai Health System in New York.
 

Can vaccination help people with long COVID?

Anything that we can do to help prevent people from being critically ill or being hospitalized with COVID-19 is helpful to prevent long COVID, says Dr. Abramoff, who is also director of the long COVID clinic at the University of Pennsylvania, Philadelphia.

“So that’s something I always discuss with patients. In some research, sometimes patients do feel better after the vaccine,” he says.
 

What kind of therapies do you find helpful for your patients?

Rehabilitation is a key part of recovery from long COVID, Dr. Abramoff says. “It is very important to make this very patient-specific.”

“We have patients that are working. They’re already going to the gym in some cases but don’t feel like they have the same endurance,” he says. “And then we have patients who are so crippled by their fatigue that they can’t get out of bed.”
 

1/ What is #LongCOVID?!

A disabling malady from ongoing inflammation, autoimmunity, & potential viral reservoirs (GI, brain?)

NEW DATA: The Lungs “light up” on special MRI Scans 3 to 9 months later in patients never hospitalized for COVID.https://t.co/I2kyZ4cK5F pic.twitter.com/dL1P67L2DK

— WesElyMD (@WesElyMD) February 2, 2022

An exercise program can help people who have long COVID.

“There’s a big role for therapy services in the recovery of these patients,” says John Baratta, MD, of the department of physical medicine and rehabilitation at the University of North Carolina at Chapel Hill.

But the limited number of long COVID clinics can mean some people are unable to get to therapists trained on the needs of patients with lingering COVID symptoms. Educating community physical and occupational therapists is one solution.
 

How long does it take for people with long COVID to recover and get back to 100% if they can?

Specific numbers aren’t really available, Dr. Baratta says.

“But I can tell you the general trend that I see is that a lot of patients have a gradual improvement of symptoms. The slow but steady improvement with time may be the body’s natural healing process, a result of medical interventions, or both.”

It can help to reassure people with long COVID that they will not be discharged from care until they feel they’ve maximized their health, says Sharagim Kemp, DO, medical director of the COVID Recovery Program for Nuvance Health, a health system in New York and Connecticut.

It’s essential to set realistic recovery expectations and tell patients that not everyone will return to 100% of their pre-COVID functioning, she says.

“Once we are able to help them reset their expectations, there’s almost an accelerated recovery because they are not putting that pressure on themselves anymore,” Dr. Kemp says.
 

What are the most common symptoms you’re seeing in long COVID?

It’s helpful to think of long COVID as a very broad umbrella term, Dr. Abramoff says.

Echoing what many others have observed, fatigue, cognitive dysfunction or “brain fog,“ and shortness of breath or troubled breathing appear to be the most common symptoms, he says.

Some reported vague symptoms, Dr. Kemp says.

People may go to the doctor “not even realizing that they had COVID. That’s one of the important points here – to have a high index of suspicion for patients who come in with multiple symptoms,” she says.

For this reason, patients can report symptoms that don’t necessarily fit into any specialty, says Sarah J. Ryan, MD, an internal medicine doctor at Columbia University Irving Medical Center in New York. People say they are “just not themselves” or they are tired after their COVID-19 recovery.
 

Is there a connection between severe COVID cases and severe long COVID?

“It’s not like that at all. I would say that more than 80% of the patients that we see had mild to moderate illness and they were not hospitalized,” Dr. Baratta says.

Long COVID is a bit different in children and teenagers, says Ixsy Ramirez, MD, a pediatric pulmonologist at University of Michigan Health, Ann Arbor. Most patients in the long COVID clinic at the University of Michigan were previously healthy, and not children with asthma or other lung conditions as one might expect. In fact, many are student athletes, or were before they had long COVID.

In this population, shortness of breath is most common, followed by chest pain and fatigue. Unfortunately, the symptoms are so serious for many kids that their performance is limited, even if they can return to competitive play.
 

Are there defined criteria you use to diagnose long COVID? How do you give someone a diagnosis?

That’s an ever-evolving question, Dr. Kemp says. The generally accepted definition centers on persistent or new symptoms 4 weeks or more after the original COVID-19 illness, but there are exceptions.

Researchers are working on lab tests to help confirm the diagnosis. But without a definitive blood biomarker, getting to the diagnosis requires “some thorough detective work,” Dr. Ryan says.
 

Do you bring in mental health providers to help with treatment?

“We focus on mental health quite a bit actually,” says, Dr. Chen, cofounder of his institution’s COVID recovery clinic. Mount Sinai offers one-on-one and group mental health services, for example.

“Personally, I’ve seen patients that I did not expect to have such severe mental health changes” with long COVID.
 

One of the most powerful accounts and testimonies I have seen on what most #LongCovid patients experience when interacting with their doctors.

“I did not fit in a box, so they chose not to see me, even worse they made me feel like it was my fault for not fitting in their box” pic.twitter.com/7GQLBucuO5

— charlos (@loscharlos) February 3, 2022

Examples include severe depression, cases of acute psychosis, hallucinations, and other problems “that are really unexpected after a viral illness.”

Stony Brook University Hospital in New York has a long COVID clinic staffed by multiple primary care doctors who do exams and refer patients to services. A bonus of offering psychological services to all post-COVID patients is doctors get a more complete picture of each person and a better understanding of what they are going through, says Abigail Chua, MD, a pulmonologist at Stony Brook.

Some empathy is essential, Dr. Baratta says. “It’s important to recognize that a lot of these patients present with a sense of grief or loss for their prior life.”
 

What does the future hold?

A simple test to diagnose long COVID, combined with an effective treatment that helps people feel better within a week, would be ideal, Dr. Abramoff says.

“That would be lovely. But you know, we’re just not at that point.”

And it would be helpful to start identifying subtypes of long COVID so diagnosis and treatment can be more targeted, Dr. Abramoff says. Otherwise, “It’s going to be a very challenging approach to try to treat all of our patients with long COVID symptoms the same way.”

Good clinical trials likewise are needed to address all the subtleties of long COVID.

A number of long COVID centers are collaborating on research to find out more, Dr. Chen says. Actions include setting up a bank of tissue samples from people with long COVID so researchers can continue to figure out the condition.

One goal, Dr. Chen says, would be the ability to treat long COVID rather than just its symptoms.

Long COVID emphasizes the need to prevent people from getting COVID in the first place, Dr. Ramirez says. This will continue to be important, particularly when some people dismiss the seriousness of COVID, comparing it to a cold if they get it. That attitude discounts the large number of people who unfortunately go on to develop long-term, often debilitating, symptoms.

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

Two illicit drugs are contributing to a sharp rise in fentanyl-related deaths, a new study from the Centers for Disease Control and Prevention shows.

Para-fluorofentanyl, a schedule I substance often found in heroin packets and counterfeit pills, is making a comeback on the illicit drug market, Jordan Trecki, PhD, and associates reported in the Centers for Disease Control and Prevention’s Morbidity and Mortality Weekly Report (2022 Jan 28;71[4]:153-5). U.S. medical examiner reports and national law enforcement seizure data point to a rise in encounters of this drug along with metonitazene, a benzimidazole-opioid, in combination with fentanyl.

On their own, para-fluorofentanyl and metonitazene can kill the user through respiratory depression. Combinations of these substances and other opioids, including fentanyl-related compounds or adulterants, “pose an even greater potential harm to the patient than previously observed,” reported Dr. Trecki, a pharmacologist affiliated with the Drug Enforcement Administration, and colleagues.

Opioids contribute to about 75% of all U.S. drug overdose deaths, which rose by 28.5% during 2020-2021, according to the National Center for Health Statistics. And fentanyl is replacing heroin as the primary drug of use, said addiction specialist Brian Fuehrlein, MD, PhD, in an interview.

“For patients with stimulant use disorder and even cannabis use disorder, fentanyl is becoming more and more common as an adulterant in those substances, often resulting in inadvertent use. Hence, fentanyl and fentanyl-like drugs and fentanyl analogues are becoming increasingly common and important,” said Dr. Fuehrlein, director of the psychiatric emergency room at the VA Connecticut Healthcare System. He was not involved with the MMWR study.
 

Tennessee data reflect national problem

Recent data from a medical examiner in Knoxville, Tenn., illustrate what might be happening nationwide with those two emerging substances.

Over the last 2 years, the Knox County Regional Forensic Center has identified para-fluorofentanyl in the toxicology results of drug overdose victims, and metonitazene – either on its own or in combination with fentanyl and para-fluorofentanyl. Fentanyl appeared in 562 or 73% of 770 unintentional drug overdose deaths from November 2020 to August 2021. Forty-eight of these cases involved para-fluorofentanyl, and 26 involved metonitazene.

“Although the percentage of law enforcement encounters with these substances in Tennessee decreased relative to the national total percentage within this time frame, the increase in encounters both within Tennessee and nationally reflect an increased distribution of para-fluorofentanyl and metonitazene throughout the United States,” the authors reported.
 

How to identify substances, manage overdoses

The authors encouraged physicians, labs, and medical examiners to be on the lookout for these two substances either in the emergency department or when identifying the cause of drug overdose deaths.

They also advised that stronger opioids, such as fentanyl, para-fluorofentanyl, metonitazene, or other benzimidazoles may warrant additional doses of the opioid-reversal drug naloxone.

While he hasn’t personally seen any of these drugs in his practice, “I would assume that these are on the rise due to inexpensive cost to manufacture and potency of effect,” said Dr. Fuehrlein, also an associate professor of psychiatry at Yale University, New Haven, Conn.

The need for additional naloxone to manage acute overdoses is a key takeaway of the MMWR paper, he added. Clinicians should also educate patients about harm reduction strategies to avoid overdose death when using potentially powerful and unknown drugs. “Things like start low and go slow, buy from the same supplier, do not use opioids with alcohol or benzos, have Narcan available, do not use alone, etc.”

Dr. Fuehrlein had no disclosures.

Two illicit drugs are contributing to a sharp rise in fentanyl-related deaths, a new study from the Centers for Disease Control and Prevention shows.

Para-fluorofentanyl, a schedule I substance often found in heroin packets and counterfeit pills, is making a comeback on the illicit drug market, Jordan Trecki, PhD, and associates reported in the Centers for Disease Control and Prevention’s Morbidity and Mortality Weekly Report (2022 Jan 28;71[4]:153-5). U.S. medical examiner reports and national law enforcement seizure data point to a rise in encounters of this drug along with metonitazene, a benzimidazole-opioid, in combination with fentanyl.

On their own, para-fluorofentanyl and metonitazene can kill the user through respiratory depression. Combinations of these substances and other opioids, including fentanyl-related compounds or adulterants, “pose an even greater potential harm to the patient than previously observed,” reported Dr. Trecki, a pharmacologist affiliated with the Drug Enforcement Administration, and colleagues.

Opioids contribute to about 75% of all U.S. drug overdose deaths, which rose by 28.5% during 2020-2021, according to the National Center for Health Statistics. And fentanyl is replacing heroin as the primary drug of use, said addiction specialist Brian Fuehrlein, MD, PhD, in an interview.

“For patients with stimulant use disorder and even cannabis use disorder, fentanyl is becoming more and more common as an adulterant in those substances, often resulting in inadvertent use. Hence, fentanyl and fentanyl-like drugs and fentanyl analogues are becoming increasingly common and important,” said Dr. Fuehrlein, director of the psychiatric emergency room at the VA Connecticut Healthcare System. He was not involved with the MMWR study.
 

Tennessee data reflect national problem

Recent data from a medical examiner in Knoxville, Tenn., illustrate what might be happening nationwide with those two emerging substances.

Over the last 2 years, the Knox County Regional Forensic Center has identified para-fluorofentanyl in the toxicology results of drug overdose victims, and metonitazene – either on its own or in combination with fentanyl and para-fluorofentanyl. Fentanyl appeared in 562 or 73% of 770 unintentional drug overdose deaths from November 2020 to August 2021. Forty-eight of these cases involved para-fluorofentanyl, and 26 involved metonitazene.

“Although the percentage of law enforcement encounters with these substances in Tennessee decreased relative to the national total percentage within this time frame, the increase in encounters both within Tennessee and nationally reflect an increased distribution of para-fluorofentanyl and metonitazene throughout the United States,” the authors reported.
 

How to identify substances, manage overdoses

The authors encouraged physicians, labs, and medical examiners to be on the lookout for these two substances either in the emergency department or when identifying the cause of drug overdose deaths.

They also advised that stronger opioids, such as fentanyl, para-fluorofentanyl, metonitazene, or other benzimidazoles may warrant additional doses of the opioid-reversal drug naloxone.

While he hasn’t personally seen any of these drugs in his practice, “I would assume that these are on the rise due to inexpensive cost to manufacture and potency of effect,” said Dr. Fuehrlein, also an associate professor of psychiatry at Yale University, New Haven, Conn.

The need for additional naloxone to manage acute overdoses is a key takeaway of the MMWR paper, he added. Clinicians should also educate patients about harm reduction strategies to avoid overdose death when using potentially powerful and unknown drugs. “Things like start low and go slow, buy from the same supplier, do not use opioids with alcohol or benzos, have Narcan available, do not use alone, etc.”

Dr. Fuehrlein had no disclosures.

Two illicit drugs are contributing to a sharp rise in fentanyl-related deaths, a new study from the Centers for Disease Control and Prevention shows.

Para-fluorofentanyl, a schedule I substance often found in heroin packets and counterfeit pills, is making a comeback on the illicit drug market, Jordan Trecki, PhD, and associates reported in the Centers for Disease Control and Prevention’s Morbidity and Mortality Weekly Report (2022 Jan 28;71[4]:153-5). U.S. medical examiner reports and national law enforcement seizure data point to a rise in encounters of this drug along with metonitazene, a benzimidazole-opioid, in combination with fentanyl.

On their own, para-fluorofentanyl and metonitazene can kill the user through respiratory depression. Combinations of these substances and other opioids, including fentanyl-related compounds or adulterants, “pose an even greater potential harm to the patient than previously observed,” reported Dr. Trecki, a pharmacologist affiliated with the Drug Enforcement Administration, and colleagues.

Opioids contribute to about 75% of all U.S. drug overdose deaths, which rose by 28.5% during 2020-2021, according to the National Center for Health Statistics. And fentanyl is replacing heroin as the primary drug of use, said addiction specialist Brian Fuehrlein, MD, PhD, in an interview.

“For patients with stimulant use disorder and even cannabis use disorder, fentanyl is becoming more and more common as an adulterant in those substances, often resulting in inadvertent use. Hence, fentanyl and fentanyl-like drugs and fentanyl analogues are becoming increasingly common and important,” said Dr. Fuehrlein, director of the psychiatric emergency room at the VA Connecticut Healthcare System. He was not involved with the MMWR study.
 

Tennessee data reflect national problem

Recent data from a medical examiner in Knoxville, Tenn., illustrate what might be happening nationwide with those two emerging substances.

Over the last 2 years, the Knox County Regional Forensic Center has identified para-fluorofentanyl in the toxicology results of drug overdose victims, and metonitazene – either on its own or in combination with fentanyl and para-fluorofentanyl. Fentanyl appeared in 562 or 73% of 770 unintentional drug overdose deaths from November 2020 to August 2021. Forty-eight of these cases involved para-fluorofentanyl, and 26 involved metonitazene.

“Although the percentage of law enforcement encounters with these substances in Tennessee decreased relative to the national total percentage within this time frame, the increase in encounters both within Tennessee and nationally reflect an increased distribution of para-fluorofentanyl and metonitazene throughout the United States,” the authors reported.
 

How to identify substances, manage overdoses

The authors encouraged physicians, labs, and medical examiners to be on the lookout for these two substances either in the emergency department or when identifying the cause of drug overdose deaths.

They also advised that stronger opioids, such as fentanyl, para-fluorofentanyl, metonitazene, or other benzimidazoles may warrant additional doses of the opioid-reversal drug naloxone.

While he hasn’t personally seen any of these drugs in his practice, “I would assume that these are on the rise due to inexpensive cost to manufacture and potency of effect,” said Dr. Fuehrlein, also an associate professor of psychiatry at Yale University, New Haven, Conn.

The need for additional naloxone to manage acute overdoses is a key takeaway of the MMWR paper, he added. Clinicians should also educate patients about harm reduction strategies to avoid overdose death when using potentially powerful and unknown drugs. “Things like start low and go slow, buy from the same supplier, do not use opioids with alcohol or benzos, have Narcan available, do not use alone, etc.”

Dr. Fuehrlein had no disclosures.

Patients undergoing bowel prep for colonoscopy had significantly greater decreases in potassium after prep with sodium phosphate, compared with those whose prep involved polyethylene glycol, based on data from a meta-analysis of more than 2,000 patients.

Electrolyte disturbances, though rare, represent a serious adverse event associated with bowel preparation, and the prevalence remains unclear, Atsushi Sakuraba, MD, of the University of Chicago said in an interview. Dr. Sakuraba, who was not involved in the study, said he was surprised by some of the study findings. “The incidence and degree of hypokalemia associated with sodium phosphate bowel preparation was greater than what I would have thought.”

Authors of the current analysis, led by Ankie Reumkens, MD, of Maastricht (the Netherlands) University Medical Center, noted in Digestive Endoscopy that the severity of adverse events is not directly related to the degree of electrolyte disturbance. “Electrolyte disturbances may vary from asymptomatic via mild and moderate symptoms (i.e., muscle weakness, constipation, nausea, and vomiting), to severe symptoms (i.e., paralysis, seizures, cardiac arrhythmias, coma, and death).” Although current guidelines do not include recommendations for electrolyte measurement, the European Society of Gastrointestinal Endoscopy recommends against routine use of sodium phosphate (NaP) despite a low level of evidence. Although polyethylene glycol (PEG) is the preferred choice for older patients and in patients with renal impairment, heart failure, and inflammatory bowel disease, the investigators noted that NaP and picosulfate with magnesium titrate (SPMC) have been associated with higher patient tolerance and compliance.

Bowel preparation solutions are available in high-volume versions that include high-volume PEG, while low-volume options include low-volume PEG, NaP, and SPMC; despite the variety of choices, bowel preparations of any type may cause electrolyte disturbances, and their extent, magnitude, and risk factors have not been well studied.

In their systemic review and meta-analysis, the researchers examined the pooled prevalence of electrolyte disturbances; the primary endpoint was the pooled prevalence of hypokalemia, hyponatremia, hyperphosphatemia, and hypocalcemia after bowel preparation, and the changes in mean potassium values. The review was based on 13 studies published between Jan. 1, 1995, and July 1, 2021, with a total of 2,386 patients.

Overall, hypokalemia occurred in 17.2 % of patients who underwent NaP for bowel preparation versus 4.8% of those who underwent PEG. Hyponatremia occurred in 0.9% of NaP patients versus3.3% of PEG patients; hyperphosphatemia occurred in 37.3% and 0.65% of NaP and PEG patients, respectively; and hypocalcemia occurred in 15.6% and 8.1% of NaP and PEG patients, respectively.

Pharmacokinetics may explain the increased disturbances in electrolyte balance with NaP, the researchers noted.

“PEG is iso-osmotic with plasma, causing no net absorption or excretion of water or ions,” they said, but “NaP is highly osmotic and therefore results in fluid shifts from the systemic compartment to the gastrointestinal tract.”

The study findings were limited by several factors including the potential underreporting of the prevalence of electrolyte disturbances, the exclusion of patients with renal insufficiency, heart failure, and bowel problems, and the incomplete data on bowel cleansing scores and adverse events, the researchers noted. More data on the prevalences of electrolyte disturbances after low-volume bowel preparations are needed to inform evidence-based recommendations, especially in light of the increased numbers of colonoscopies and increasing numbers of older patients and patients with comorbidities.

From a clinical practice perspective, Dr. Sakuraba agreed with the authors’ conclusion that the results support the recommendations of some current guidelines against the routine use of sodium phosphate for bowel preparation, even if the number of included studies was small.

The study received no outside funding. The researchers had no financial conflicts to disclose. Dr. Sakuraba had no financial conflicts to disclose.

Patients undergoing bowel prep for colonoscopy had significantly greater decreases in potassium after prep with sodium phosphate, compared with those whose prep involved polyethylene glycol, based on data from a meta-analysis of more than 2,000 patients.

Electrolyte disturbances, though rare, represent a serious adverse event associated with bowel preparation, and the prevalence remains unclear, Atsushi Sakuraba, MD, of the University of Chicago said in an interview. Dr. Sakuraba, who was not involved in the study, said he was surprised by some of the study findings. “The incidence and degree of hypokalemia associated with sodium phosphate bowel preparation was greater than what I would have thought.”

Authors of the current analysis, led by Ankie Reumkens, MD, of Maastricht (the Netherlands) University Medical Center, noted in Digestive Endoscopy that the severity of adverse events is not directly related to the degree of electrolyte disturbance. “Electrolyte disturbances may vary from asymptomatic via mild and moderate symptoms (i.e., muscle weakness, constipation, nausea, and vomiting), to severe symptoms (i.e., paralysis, seizures, cardiac arrhythmias, coma, and death).” Although current guidelines do not include recommendations for electrolyte measurement, the European Society of Gastrointestinal Endoscopy recommends against routine use of sodium phosphate (NaP) despite a low level of evidence. Although polyethylene glycol (PEG) is the preferred choice for older patients and in patients with renal impairment, heart failure, and inflammatory bowel disease, the investigators noted that NaP and picosulfate with magnesium titrate (SPMC) have been associated with higher patient tolerance and compliance.

Bowel preparation solutions are available in high-volume versions that include high-volume PEG, while low-volume options include low-volume PEG, NaP, and SPMC; despite the variety of choices, bowel preparations of any type may cause electrolyte disturbances, and their extent, magnitude, and risk factors have not been well studied.

In their systemic review and meta-analysis, the researchers examined the pooled prevalence of electrolyte disturbances; the primary endpoint was the pooled prevalence of hypokalemia, hyponatremia, hyperphosphatemia, and hypocalcemia after bowel preparation, and the changes in mean potassium values. The review was based on 13 studies published between Jan. 1, 1995, and July 1, 2021, with a total of 2,386 patients.

Overall, hypokalemia occurred in 17.2 % of patients who underwent NaP for bowel preparation versus 4.8% of those who underwent PEG. Hyponatremia occurred in 0.9% of NaP patients versus3.3% of PEG patients; hyperphosphatemia occurred in 37.3% and 0.65% of NaP and PEG patients, respectively; and hypocalcemia occurred in 15.6% and 8.1% of NaP and PEG patients, respectively.

Pharmacokinetics may explain the increased disturbances in electrolyte balance with NaP, the researchers noted.

“PEG is iso-osmotic with plasma, causing no net absorption or excretion of water or ions,” they said, but “NaP is highly osmotic and therefore results in fluid shifts from the systemic compartment to the gastrointestinal tract.”

The study findings were limited by several factors including the potential underreporting of the prevalence of electrolyte disturbances, the exclusion of patients with renal insufficiency, heart failure, and bowel problems, and the incomplete data on bowel cleansing scores and adverse events, the researchers noted. More data on the prevalences of electrolyte disturbances after low-volume bowel preparations are needed to inform evidence-based recommendations, especially in light of the increased numbers of colonoscopies and increasing numbers of older patients and patients with comorbidities.

From a clinical practice perspective, Dr. Sakuraba agreed with the authors’ conclusion that the results support the recommendations of some current guidelines against the routine use of sodium phosphate for bowel preparation, even if the number of included studies was small.

The study received no outside funding. The researchers had no financial conflicts to disclose. Dr. Sakuraba had no financial conflicts to disclose.

Patients undergoing bowel prep for colonoscopy had significantly greater decreases in potassium after prep with sodium phosphate, compared with those whose prep involved polyethylene glycol, based on data from a meta-analysis of more than 2,000 patients.

Electrolyte disturbances, though rare, represent a serious adverse event associated with bowel preparation, and the prevalence remains unclear, Atsushi Sakuraba, MD, of the University of Chicago said in an interview. Dr. Sakuraba, who was not involved in the study, said he was surprised by some of the study findings. “The incidence and degree of hypokalemia associated with sodium phosphate bowel preparation was greater than what I would have thought.”

Authors of the current analysis, led by Ankie Reumkens, MD, of Maastricht (the Netherlands) University Medical Center, noted in Digestive Endoscopy that the severity of adverse events is not directly related to the degree of electrolyte disturbance. “Electrolyte disturbances may vary from asymptomatic via mild and moderate symptoms (i.e., muscle weakness, constipation, nausea, and vomiting), to severe symptoms (i.e., paralysis, seizures, cardiac arrhythmias, coma, and death).” Although current guidelines do not include recommendations for electrolyte measurement, the European Society of Gastrointestinal Endoscopy recommends against routine use of sodium phosphate (NaP) despite a low level of evidence. Although polyethylene glycol (PEG) is the preferred choice for older patients and in patients with renal impairment, heart failure, and inflammatory bowel disease, the investigators noted that NaP and picosulfate with magnesium titrate (SPMC) have been associated with higher patient tolerance and compliance.

Bowel preparation solutions are available in high-volume versions that include high-volume PEG, while low-volume options include low-volume PEG, NaP, and SPMC; despite the variety of choices, bowel preparations of any type may cause electrolyte disturbances, and their extent, magnitude, and risk factors have not been well studied.

In their systemic review and meta-analysis, the researchers examined the pooled prevalence of electrolyte disturbances; the primary endpoint was the pooled prevalence of hypokalemia, hyponatremia, hyperphosphatemia, and hypocalcemia after bowel preparation, and the changes in mean potassium values. The review was based on 13 studies published between Jan. 1, 1995, and July 1, 2021, with a total of 2,386 patients.

Overall, hypokalemia occurred in 17.2 % of patients who underwent NaP for bowel preparation versus 4.8% of those who underwent PEG. Hyponatremia occurred in 0.9% of NaP patients versus3.3% of PEG patients; hyperphosphatemia occurred in 37.3% and 0.65% of NaP and PEG patients, respectively; and hypocalcemia occurred in 15.6% and 8.1% of NaP and PEG patients, respectively.

Pharmacokinetics may explain the increased disturbances in electrolyte balance with NaP, the researchers noted.

“PEG is iso-osmotic with plasma, causing no net absorption or excretion of water or ions,” they said, but “NaP is highly osmotic and therefore results in fluid shifts from the systemic compartment to the gastrointestinal tract.”

The study findings were limited by several factors including the potential underreporting of the prevalence of electrolyte disturbances, the exclusion of patients with renal insufficiency, heart failure, and bowel problems, and the incomplete data on bowel cleansing scores and adverse events, the researchers noted. More data on the prevalences of electrolyte disturbances after low-volume bowel preparations are needed to inform evidence-based recommendations, especially in light of the increased numbers of colonoscopies and increasing numbers of older patients and patients with comorbidities.

From a clinical practice perspective, Dr. Sakuraba agreed with the authors’ conclusion that the results support the recommendations of some current guidelines against the routine use of sodium phosphate for bowel preparation, even if the number of included studies was small.

The study received no outside funding. The researchers had no financial conflicts to disclose. Dr. Sakuraba had no financial conflicts to disclose.

A breakthrough neuromodulation system rapidly restores motor function in patients with a severe spinal cord injury (SCI), new research shows.

The study demonstrated that an epidural electrical stimulation (EES) system developed specifically for spinal cord injuries enabled three men with complete paralysis to stand, walk, cycle, swim, and move their torso within 1 day.

“Thanks to this technology, we have been able to target individuals with the most serious spinal cord injury, meaning those with clinically complete spinal cord injury, with no sensation and no movement in the legs,” Grégoire Courtine, PhD, professor of neuroscience and neurotechnology at the Swiss Federal Institute of Technology, University Hospital Lausanne (Switzerland), and the University of Lausanne, told reporters attending a press briefing.

The study was published online Feb. 7, 2022, in Nature Medicine.
 

More rapid, precise, effective

SCIs involve severed connections between the brain and extremities. To compensate for these lost connections, researchers have investigated stem cell therapy, brain-machine interfaces, and powered exoskeletons.

However, these approaches aren’t yet ready for prime time.

In the meantime, researchers discovered even patients with a “complete” injury may have low-functioning connections and started investigating epidural stimulators designed to treat chronic pain. Recent studies – including three published in 2018 – showed promise for these pain-related stimulators in patients with incomplete SCI.

But using such “repurposed” technology meant the electrode array was relatively narrow and short, “so we could not target all the regions of the spinal cord involving control of leg and trunk movements,” said Dr. Courtine. With the newer technology “we are much more precise, effective, and more rapid in delivering therapy.”

To develop this new approach, the researchers designed a paddle lead with an arrangement of electrodes that targets sacral, lumbar, and low-thoracic dorsal roots involved in leg and trunk movements. They also established a personalized computational framework that allows for optimal surgical placement of this paddle lead.

In addition, they developed software that renders the configuration of individualized activity–dependent stimulation programs rapid, simple, and predictable.

They tested these neurotechnologies in three men with complete sensorimotor paralysis as part of an ongoing clinical trial. The participants, aged 29, 32, and 41 years, suffered an SCI from a motor bike accident 3, 9, and 1 year before enrollment.

All three patients exhibited complete sensorimotor paralysis. They were unable to take any step, and muscles remained quiescent during these attempts.

A neurosurgeon implanted electrodes along the spinal cord of study subjects. Wires from these electrodes were connected to a neurostimulator implanted under the skin in the abdomen.

The men can select different activity-based programs from a tablet that sends signals to the implanted device.
 

Personalized approach

Within a single day of the surgery, the participants were able to stand, walk, cycle, swim, and control trunk movements.

“It was not perfect at the very beginning, but they could train very early on to have a more fluid gait,” said study investigator neurosurgeon Joceylyne Bloch, MD, associate professor, University of Lausanne and University Hospital Lausanne.

At this stage, not all paralyzed patients are eligible for the procedure. Dr. Bloch explained that at least 6 cm of healthy spinal cord under the lesion is needed to implant the electrodes.

“There’s a huge variability of spinal cord anatomy between individuals. That’s why it’s important to study each person individually and to have individual models in order to be precise.”

Researchers envision having “a library of electrode arrays,” added Dr. Courtine. With preoperative imaging of the individual’s spinal cord, “the neurosurgeon can select the more appropriate electrode array for that specific patient.”

Dr. Courtine noted recovery of sensation with the system differs from one individual to another. One study participant, Michel Roccati, now 30, told the briefing he feels a contraction in his muscle during the stimulation.

Currently, only individuals whose injury is more than a year old are included in the study to ensure patients have “a stable lesion” and reached “a plateau of recovery,” said Dr. Bloch. However, animal models show intervening earlier might boost the benefits.

A patient’s age can influence the outcome, as younger patients are likely in better condition and more motivated than older patients, said Dr. Bloch. However, she noted patients closing in on 50 years have responded well to the therapy.

Such stimulation systems may prove useful in treating conditions typically associated with SCI, such as hypertension and bladder control, and perhaps also in patients with Parkinson’s disease, said Dr. Courtine.

The researchers plan to conduct another study that will include a next-generation pulse generator with features that make the stimulation even more effective and user friendly. A voice recognition system could eventually be connected to the system.

“The next step is a minicomputer that you implant in the body that communicates in real time with an external iPhone,” said Dr. Courtine.

ONWARD Medical, which developed the technology, has received a breakthrough device designation from the Food and Drug Administration. The company is in discussions with the FDA to carry out a clinical trial of the device in the United States.
 

A ‘huge step forward’

Peter J. Grahn, PhD, assistant professor, department of physical medicine and rehabilitation and department of neurologic surgery, Mayo Clinic, Rochester, Minn., an author of one of the 2018 studies, said this technology “is a huge step forward” and “really pushes the field.”

Compared with the device used in his study that’s designed to treat neuropathic pain, this new system “is much more capable of dynamic stimulation,” said Dr. Grahn. “You can tailor the stimulation based on which area of the spinal cord you want to target during a specific function.”

There has been “a lot of hope and hype” recently around stem cells and biological molecules that were supposed to be “magic pills” to cure spinal cord dysfunction, said Dr. Grahn. “I don’t think this is one of those.”

However, he questioned the researchers’ use of the word “walking.”

“They say independent stepping or walking is restored on day 1, but the graphs show day 1 function is having over 60% of their body weight supported when they’re taking these steps,” he said.

In addition, the “big question” is how this technology can “be distilled down” into an approach “applicable across rehabilitation centers,” said Dr. Grahn.

The study was supported by numerous organizations, including ONWARD Medical. Dr. Courtine and Dr. Bloch hold various patents in relation with the present work. Dr. Courtine is a consultant with ONWARD Medical, and he and Dr. Bloch are shareholders of ONWARD Medical, a company with direct relationships with the presented work. Dr. Grahn reported no relevant financial relationships.

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

A breakthrough neuromodulation system rapidly restores motor function in patients with a severe spinal cord injury (SCI), new research shows.

The study demonstrated that an epidural electrical stimulation (EES) system developed specifically for spinal cord injuries enabled three men with complete paralysis to stand, walk, cycle, swim, and move their torso within 1 day.

“Thanks to this technology, we have been able to target individuals with the most serious spinal cord injury, meaning those with clinically complete spinal cord injury, with no sensation and no movement in the legs,” Grégoire Courtine, PhD, professor of neuroscience and neurotechnology at the Swiss Federal Institute of Technology, University Hospital Lausanne (Switzerland), and the University of Lausanne, told reporters attending a press briefing.

The study was published online Feb. 7, 2022, in Nature Medicine.
 

More rapid, precise, effective

SCIs involve severed connections between the brain and extremities. To compensate for these lost connections, researchers have investigated stem cell therapy, brain-machine interfaces, and powered exoskeletons.

However, these approaches aren’t yet ready for prime time.

In the meantime, researchers discovered even patients with a “complete” injury may have low-functioning connections and started investigating epidural stimulators designed to treat chronic pain. Recent studies – including three published in 2018 – showed promise for these pain-related stimulators in patients with incomplete SCI.

But using such “repurposed” technology meant the electrode array was relatively narrow and short, “so we could not target all the regions of the spinal cord involving control of leg and trunk movements,” said Dr. Courtine. With the newer technology “we are much more precise, effective, and more rapid in delivering therapy.”

To develop this new approach, the researchers designed a paddle lead with an arrangement of electrodes that targets sacral, lumbar, and low-thoracic dorsal roots involved in leg and trunk movements. They also established a personalized computational framework that allows for optimal surgical placement of this paddle lead.

In addition, they developed software that renders the configuration of individualized activity–dependent stimulation programs rapid, simple, and predictable.

They tested these neurotechnologies in three men with complete sensorimotor paralysis as part of an ongoing clinical trial. The participants, aged 29, 32, and 41 years, suffered an SCI from a motor bike accident 3, 9, and 1 year before enrollment.

All three patients exhibited complete sensorimotor paralysis. They were unable to take any step, and muscles remained quiescent during these attempts.

A neurosurgeon implanted electrodes along the spinal cord of study subjects. Wires from these electrodes were connected to a neurostimulator implanted under the skin in the abdomen.

The men can select different activity-based programs from a tablet that sends signals to the implanted device.
 

Personalized approach

Within a single day of the surgery, the participants were able to stand, walk, cycle, swim, and control trunk movements.

“It was not perfect at the very beginning, but they could train very early on to have a more fluid gait,” said study investigator neurosurgeon Joceylyne Bloch, MD, associate professor, University of Lausanne and University Hospital Lausanne.

At this stage, not all paralyzed patients are eligible for the procedure. Dr. Bloch explained that at least 6 cm of healthy spinal cord under the lesion is needed to implant the electrodes.

“There’s a huge variability of spinal cord anatomy between individuals. That’s why it’s important to study each person individually and to have individual models in order to be precise.”

Researchers envision having “a library of electrode arrays,” added Dr. Courtine. With preoperative imaging of the individual’s spinal cord, “the neurosurgeon can select the more appropriate electrode array for that specific patient.”

Dr. Courtine noted recovery of sensation with the system differs from one individual to another. One study participant, Michel Roccati, now 30, told the briefing he feels a contraction in his muscle during the stimulation.

Currently, only individuals whose injury is more than a year old are included in the study to ensure patients have “a stable lesion” and reached “a plateau of recovery,” said Dr. Bloch. However, animal models show intervening earlier might boost the benefits.

A patient’s age can influence the outcome, as younger patients are likely in better condition and more motivated than older patients, said Dr. Bloch. However, she noted patients closing in on 50 years have responded well to the therapy.

Such stimulation systems may prove useful in treating conditions typically associated with SCI, such as hypertension and bladder control, and perhaps also in patients with Parkinson’s disease, said Dr. Courtine.

The researchers plan to conduct another study that will include a next-generation pulse generator with features that make the stimulation even more effective and user friendly. A voice recognition system could eventually be connected to the system.

“The next step is a minicomputer that you implant in the body that communicates in real time with an external iPhone,” said Dr. Courtine.

ONWARD Medical, which developed the technology, has received a breakthrough device designation from the Food and Drug Administration. The company is in discussions with the FDA to carry out a clinical trial of the device in the United States.
 

A ‘huge step forward’

Peter J. Grahn, PhD, assistant professor, department of physical medicine and rehabilitation and department of neurologic surgery, Mayo Clinic, Rochester, Minn., an author of one of the 2018 studies, said this technology “is a huge step forward” and “really pushes the field.”

Compared with the device used in his study that’s designed to treat neuropathic pain, this new system “is much more capable of dynamic stimulation,” said Dr. Grahn. “You can tailor the stimulation based on which area of the spinal cord you want to target during a specific function.”

There has been “a lot of hope and hype” recently around stem cells and biological molecules that were supposed to be “magic pills” to cure spinal cord dysfunction, said Dr. Grahn. “I don’t think this is one of those.”

However, he questioned the researchers’ use of the word “walking.”

“They say independent stepping or walking is restored on day 1, but the graphs show day 1 function is having over 60% of their body weight supported when they’re taking these steps,” he said.

In addition, the “big question” is how this technology can “be distilled down” into an approach “applicable across rehabilitation centers,” said Dr. Grahn.

The study was supported by numerous organizations, including ONWARD Medical. Dr. Courtine and Dr. Bloch hold various patents in relation with the present work. Dr. Courtine is a consultant with ONWARD Medical, and he and Dr. Bloch are shareholders of ONWARD Medical, a company with direct relationships with the presented work. Dr. Grahn reported no relevant financial relationships.

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

A breakthrough neuromodulation system rapidly restores motor function in patients with a severe spinal cord injury (SCI), new research shows.

The study demonstrated that an epidural electrical stimulation (EES) system developed specifically for spinal cord injuries enabled three men with complete paralysis to stand, walk, cycle, swim, and move their torso within 1 day.

“Thanks to this technology, we have been able to target individuals with the most serious spinal cord injury, meaning those with clinically complete spinal cord injury, with no sensation and no movement in the legs,” Grégoire Courtine, PhD, professor of neuroscience and neurotechnology at the Swiss Federal Institute of Technology, University Hospital Lausanne (Switzerland), and the University of Lausanne, told reporters attending a press briefing.

The study was published online Feb. 7, 2022, in Nature Medicine.
 

More rapid, precise, effective

SCIs involve severed connections between the brain and extremities. To compensate for these lost connections, researchers have investigated stem cell therapy, brain-machine interfaces, and powered exoskeletons.

However, these approaches aren’t yet ready for prime time.

In the meantime, researchers discovered even patients with a “complete” injury may have low-functioning connections and started investigating epidural stimulators designed to treat chronic pain. Recent studies – including three published in 2018 – showed promise for these pain-related stimulators in patients with incomplete SCI.

But using such “repurposed” technology meant the electrode array was relatively narrow and short, “so we could not target all the regions of the spinal cord involving control of leg and trunk movements,” said Dr. Courtine. With the newer technology “we are much more precise, effective, and more rapid in delivering therapy.”

To develop this new approach, the researchers designed a paddle lead with an arrangement of electrodes that targets sacral, lumbar, and low-thoracic dorsal roots involved in leg and trunk movements. They also established a personalized computational framework that allows for optimal surgical placement of this paddle lead.

In addition, they developed software that renders the configuration of individualized activity–dependent stimulation programs rapid, simple, and predictable.

They tested these neurotechnologies in three men with complete sensorimotor paralysis as part of an ongoing clinical trial. The participants, aged 29, 32, and 41 years, suffered an SCI from a motor bike accident 3, 9, and 1 year before enrollment.

All three patients exhibited complete sensorimotor paralysis. They were unable to take any step, and muscles remained quiescent during these attempts.

A neurosurgeon implanted electrodes along the spinal cord of study subjects. Wires from these electrodes were connected to a neurostimulator implanted under the skin in the abdomen.

The men can select different activity-based programs from a tablet that sends signals to the implanted device.
 

Personalized approach

Within a single day of the surgery, the participants were able to stand, walk, cycle, swim, and control trunk movements.

“It was not perfect at the very beginning, but they could train very early on to have a more fluid gait,” said study investigator neurosurgeon Joceylyne Bloch, MD, associate professor, University of Lausanne and University Hospital Lausanne.

At this stage, not all paralyzed patients are eligible for the procedure. Dr. Bloch explained that at least 6 cm of healthy spinal cord under the lesion is needed to implant the electrodes.

“There’s a huge variability of spinal cord anatomy between individuals. That’s why it’s important to study each person individually and to have individual models in order to be precise.”

Researchers envision having “a library of electrode arrays,” added Dr. Courtine. With preoperative imaging of the individual’s spinal cord, “the neurosurgeon can select the more appropriate electrode array for that specific patient.”

Dr. Courtine noted recovery of sensation with the system differs from one individual to another. One study participant, Michel Roccati, now 30, told the briefing he feels a contraction in his muscle during the stimulation.

Currently, only individuals whose injury is more than a year old are included in the study to ensure patients have “a stable lesion” and reached “a plateau of recovery,” said Dr. Bloch. However, animal models show intervening earlier might boost the benefits.

A patient’s age can influence the outcome, as younger patients are likely in better condition and more motivated than older patients, said Dr. Bloch. However, she noted patients closing in on 50 years have responded well to the therapy.

Such stimulation systems may prove useful in treating conditions typically associated with SCI, such as hypertension and bladder control, and perhaps also in patients with Parkinson’s disease, said Dr. Courtine.

The researchers plan to conduct another study that will include a next-generation pulse generator with features that make the stimulation even more effective and user friendly. A voice recognition system could eventually be connected to the system.

“The next step is a minicomputer that you implant in the body that communicates in real time with an external iPhone,” said Dr. Courtine.

ONWARD Medical, which developed the technology, has received a breakthrough device designation from the Food and Drug Administration. The company is in discussions with the FDA to carry out a clinical trial of the device in the United States.
 

A ‘huge step forward’

Peter J. Grahn, PhD, assistant professor, department of physical medicine and rehabilitation and department of neurologic surgery, Mayo Clinic, Rochester, Minn., an author of one of the 2018 studies, said this technology “is a huge step forward” and “really pushes the field.”

Compared with the device used in his study that’s designed to treat neuropathic pain, this new system “is much more capable of dynamic stimulation,” said Dr. Grahn. “You can tailor the stimulation based on which area of the spinal cord you want to target during a specific function.”

There has been “a lot of hope and hype” recently around stem cells and biological molecules that were supposed to be “magic pills” to cure spinal cord dysfunction, said Dr. Grahn. “I don’t think this is one of those.”

However, he questioned the researchers’ use of the word “walking.”

“They say independent stepping or walking is restored on day 1, but the graphs show day 1 function is having over 60% of their body weight supported when they’re taking these steps,” he said.

In addition, the “big question” is how this technology can “be distilled down” into an approach “applicable across rehabilitation centers,” said Dr. Grahn.

The study was supported by numerous organizations, including ONWARD Medical. Dr. Courtine and Dr. Bloch hold various patents in relation with the present work. Dr. Courtine is a consultant with ONWARD Medical, and he and Dr. Bloch are shareholders of ONWARD Medical, a company with direct relationships with the presented work. Dr. Grahn reported no relevant financial relationships.

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