The Food and Drug Administration has expanded the indications for canakinumab (Ilaris) to include all patients with active Still’s disease older than 2 years, adding adult-onset Still’s disease (AOSD) to a previous approval for juvenile-onset Still’s disease, also known as systemic juvenile idiopathic arthritis (sJIA), making it the first approved treatment for AOSD, according to an FDA announcement.

The approval comes under a Priority Review designation that used “comparable pharmacokinetic exposure and extrapolation of established efficacy of canakinumab in patients with sJIA, as well as the safety of canakinumab in patients with AOSD and other diseases,” the FDA said.

The results from a randomized, double-blind, placebo-controlled study of 36 patients with AOSD aged 22-70 years showed that the efficacy and safety data in AOSD were generally consistent with the results of a pooled analysis of sJIA patients, according to Novartis, which markets canakinumab.

AOSD and sJIA share certain similarities, such as fever, arthritis, rash, and elevated markers of inflammation, which has led to suspicion that they are part of a continuum rather than wholly distinct, according to the agency. In addition, the role of interleukin-1 is well established in both diseases and is blocked by canakinumab.

The most common side effects (occurring in greater than 10% of patients) in sJIA studies included infections, abdominal pain, and injection-site reactions. Serious infections (e.g., pneumonia, varicella, gastroenteritis, measles, sepsis, otitis media, sinusitis, adenovirus, lymph node abscess, pharyngitis) were observed in approximately 4%-5%, according to the full prescribing information.

Canakinumab is also approved for the periodic fever syndromes of cryopyrin-associated periodic syndromes in adults and children aged 4 years and older (including familial cold auto-inflammatory syndrome and Muckle-Wells syndrome), tumor necrosis factor receptor associated periodic syndrome in adult and pediatric patients, hyperimmunoglobulin D syndrome/mevalonate kinase deficiency in adult and pediatric patients, and familial Mediterranean fever in adult and pediatric patients.

cpalmer@mdedge.com

The Food and Drug Administration has expanded the indications for canakinumab (Ilaris) to include all patients with active Still’s disease older than 2 years, adding adult-onset Still’s disease (AOSD) to a previous approval for juvenile-onset Still’s disease, also known as systemic juvenile idiopathic arthritis (sJIA), making it the first approved treatment for AOSD, according to an FDA announcement.

The approval comes under a Priority Review designation that used “comparable pharmacokinetic exposure and extrapolation of established efficacy of canakinumab in patients with sJIA, as well as the safety of canakinumab in patients with AOSD and other diseases,” the FDA said.

The results from a randomized, double-blind, placebo-controlled study of 36 patients with AOSD aged 22-70 years showed that the efficacy and safety data in AOSD were generally consistent with the results of a pooled analysis of sJIA patients, according to Novartis, which markets canakinumab.

AOSD and sJIA share certain similarities, such as fever, arthritis, rash, and elevated markers of inflammation, which has led to suspicion that they are part of a continuum rather than wholly distinct, according to the agency. In addition, the role of interleukin-1 is well established in both diseases and is blocked by canakinumab.

The most common side effects (occurring in greater than 10% of patients) in sJIA studies included infections, abdominal pain, and injection-site reactions. Serious infections (e.g., pneumonia, varicella, gastroenteritis, measles, sepsis, otitis media, sinusitis, adenovirus, lymph node abscess, pharyngitis) were observed in approximately 4%-5%, according to the full prescribing information.

Canakinumab is also approved for the periodic fever syndromes of cryopyrin-associated periodic syndromes in adults and children aged 4 years and older (including familial cold auto-inflammatory syndrome and Muckle-Wells syndrome), tumor necrosis factor receptor associated periodic syndrome in adult and pediatric patients, hyperimmunoglobulin D syndrome/mevalonate kinase deficiency in adult and pediatric patients, and familial Mediterranean fever in adult and pediatric patients.

cpalmer@mdedge.com

The Food and Drug Administration has expanded the indications for canakinumab (Ilaris) to include all patients with active Still’s disease older than 2 years, adding adult-onset Still’s disease (AOSD) to a previous approval for juvenile-onset Still’s disease, also known as systemic juvenile idiopathic arthritis (sJIA), making it the first approved treatment for AOSD, according to an FDA announcement.

The approval comes under a Priority Review designation that used “comparable pharmacokinetic exposure and extrapolation of established efficacy of canakinumab in patients with sJIA, as well as the safety of canakinumab in patients with AOSD and other diseases,” the FDA said.

The results from a randomized, double-blind, placebo-controlled study of 36 patients with AOSD aged 22-70 years showed that the efficacy and safety data in AOSD were generally consistent with the results of a pooled analysis of sJIA patients, according to Novartis, which markets canakinumab.

AOSD and sJIA share certain similarities, such as fever, arthritis, rash, and elevated markers of inflammation, which has led to suspicion that they are part of a continuum rather than wholly distinct, according to the agency. In addition, the role of interleukin-1 is well established in both diseases and is blocked by canakinumab.

The most common side effects (occurring in greater than 10% of patients) in sJIA studies included infections, abdominal pain, and injection-site reactions. Serious infections (e.g., pneumonia, varicella, gastroenteritis, measles, sepsis, otitis media, sinusitis, adenovirus, lymph node abscess, pharyngitis) were observed in approximately 4%-5%, according to the full prescribing information.

Canakinumab is also approved for the periodic fever syndromes of cryopyrin-associated periodic syndromes in adults and children aged 4 years and older (including familial cold auto-inflammatory syndrome and Muckle-Wells syndrome), tumor necrosis factor receptor associated periodic syndrome in adult and pediatric patients, hyperimmunoglobulin D syndrome/mevalonate kinase deficiency in adult and pediatric patients, and familial Mediterranean fever in adult and pediatric patients.

cpalmer@mdedge.com

Over the last few weeks, several conflicting reports about the efficacy of SARS-CoV-2 treatments have emerged, including high-profile papers that were placed in the limelight and groundbreaking retractions that were issued by the Lancet and New England Journal of Medicine, involving the potential dangers of COVID therapy with findings derived from the Surgisphere database. Hydroxychloroquine has garnered considerable media attention and was touted earlier by President Trump for its therapeutic effects.¹ Naturally, there are political connotations associated with the agent, and it is unlikely that hydroxychloroquine will be supplanted in the near future as ongoing clinical trials have demonstrated mixed results amid the controversy.

As clinicians navigating unchartered territory within the hospital setting, we have to come to terms with these new challenges, tailoring treatment protocols accordingly with the best clinical practices in mind. Patients with preexisting mental health conditions and who are being treated for COVID-19 are particularly susceptible to clinical deterioration. Recent studies have indicated that psychiatric patients are more prone to feelings of isolation and/or estrangement as well as exacerbation of symptoms such as paranoia.² Even more concerning is the medication regimen, namely, the novel combination therapies that arise when agents such as hydroxychloroquine are used in tandem with certain antipsychotics or antidepressants. As clinicians, we must reassess the psychotropic medication regimen for people who are currently being treated for or recovering from COVID-19.
 

What’s at stake for COVID-19–positive mental health care patients?

Although the efficacy of hydroxychloroquine is currently being investigated,³ the antimalarial is usually prescribed in tandem with azithromycin for people with COVID-19. The National Institute of Allergy and Infectious Diseases has advised against that particular combination therapy because of ongoing concerns about toxicities.^3,4

In another study, azithromycin was effectively substituted with doxycycline to help minimize systemic effects for patients with cardiac and/or pulmonary issues^.5 Azithromycin is notorious in the literature for influencing the electrical activity of the heart with the potential for fatal arrhythmia and sudden cardiac death in individuals at risk for cardiovascular disease.^5,6,7 It should be noted that both of these commonly prescribed COVID-19 medications (for example, hydroxychloroquine and azithromycin) could lead to QT interval prolongation especially within the context of combination therapy. This is largely concerning for psychiatrists and various other mental health practitioners for the following reasons: (1) higher rates of metabolic syndrome and cardiovascular diseases among psychiatric patients⁸ and/or (2) effects of certain antipsychotics (for example, IV haloperidol, thioridazine, and ziprasidone) and antidepressants (for example, citalopram and escitalopram) on the QT interval.⁹

SARS-CoV-2 and clinical judgment: Evaluating patients at higher risk

Although COVID-19 medication guidelines are still being actively developed, hydroxychloroquine appears to be commonly prescribed by physicians. The medication is known myriad untoward effects, including potential behavioral dysfunction (for example, irritability, agitation, suicidal ideation)10 as well as the aforementioned issues concerning arrhythmia (for example, torsades de pointes). Health care professionals might not have much control over the choice of COVID-19 agents because of a lack of available resources or limited options, but they can exercise clinical judgment with respect to selecting the appropriate psychotropic medications.

Treatment recommendations

1. Establish a baseline EKG

A baseline 12-lead EKG is the standard of care for patients currently being screened for COVID-19. It is necessary to rule out the presence of an underlying cardiovascular disease or a rhythm irregularity. A prolonged QTc interval is generally regarded as being around greater than 450-470 msecs with variations attributable to gender;¹¹ numerous studies have affirmed that the risk of acquiring torsades de pointes is substantial when the QTc interval exceeds 500 msecs.¹²

2. Medical management and risk assessment

Commonly prescribed antipsychotics such as IV haloperidol and ziprasidone are known for exerting a negative effect on the interval and should readily be substituted with other agents in patients who are being treated for COVID-19; the combination of these antipsychotics alongside some COVID-19 medication regimens (for example, hydroxychloroquine/azithromycin) might prove to be fatal. The same logic applies to COVID-19 patients previously on antidepressant therapeutics such as citalopram and escitalopram.

3. Embrace an individually tailored approach to therapeutics

While American Psychiatric Association guidelines historically supported a cessation or reduction in the offending agent under normal circumstances,¹² our team is recommending that the psychotropics associated with QTc interval prolongation are discontinued altogether (or substituted with a low-risk agent) in the event that a patient presents with suspected COVID-19. However, after the patients tests negative with COVID-19, they may resume therapy as indicated under the discretion of the mental health practitioner.
 

References

1. Offard C. “Lancet, NEJM Retract Surgisphere Studies on COVID-19 Patients.” The Scientist Magazine. 2020 Jun 4.

2. Shigemura J et al. Psychiatry Clin Neurosci. 2020 Apr;74(4):281-2.

3. Keshtkar-Jahromi M and Bavari S. Am J Trop Med Hyg. 2020 May;102(5):932-3.

4. Palca J. “NIH panel recommends against drug combination promoted by Trump for COVID-19.” NPR. 2020 Apr 21.

5. Mongelli L. “Long Island doctor tries new twist on hydroxychloroquine for elderly COVID-19 patients.” New York Post. 2020 Apr 4.

6. Hancox JC et al. Ther Adv Infect Dis. 2013 Oct;(5):155-65.

7. Giudicessi JR and Ackerman MJ. Cleve Clin J Med. 2013 Sep;80(9):539-44.

8. Casey DE. Am J Med. 2005 Apr 1;118(Suppl 2):15S-22S.

9. Beach SR et al. Psychosomatics. 2013 Jan 1;54(1):1-3.

10. Bogaczewicz A and Sobów T. Psychiatria i Psychologia Kliniczna. 2017;17(2):111-4.

11. Chohan PS et al. Pak J Med Sci. 2015 Sep-Oct;31(5):1269-71.

12. Lieberman JA et al. APA guidance on the use of antipsychotic drugs and cardiac sudden death. NYS Office of Mental Health. 2012.
 

Dr. Faisal A. Islam is medical adviser for the International Maternal and Child Health Foundation, Montreal, and is based in New York. He also is a postdoctoral fellow, psychopharmacologist, and a board-certified medical affairs specialist. Dr. Faisal Islam disclosed no relevant financial relationships.

Dr. Mohammed Islam is affiliated with the department of psychiatry at the Interfaith Medical Center, New York. He disclosed no relevant financial relationships.

Dr. Choudhry is the chief scientific officer and head of the department of mental health and clinical research at the International Maternal and Child Health Foundation. He disclosed no relevant financial relationships.

Over the last few weeks, several conflicting reports about the efficacy of SARS-CoV-2 treatments have emerged, including high-profile papers that were placed in the limelight and groundbreaking retractions that were issued by the Lancet and New England Journal of Medicine, involving the potential dangers of COVID therapy with findings derived from the Surgisphere database. Hydroxychloroquine has garnered considerable media attention and was touted earlier by President Trump for its therapeutic effects.¹ Naturally, there are political connotations associated with the agent, and it is unlikely that hydroxychloroquine will be supplanted in the near future as ongoing clinical trials have demonstrated mixed results amid the controversy.

As clinicians navigating unchartered territory within the hospital setting, we have to come to terms with these new challenges, tailoring treatment protocols accordingly with the best clinical practices in mind. Patients with preexisting mental health conditions and who are being treated for COVID-19 are particularly susceptible to clinical deterioration. Recent studies have indicated that psychiatric patients are more prone to feelings of isolation and/or estrangement as well as exacerbation of symptoms such as paranoia.² Even more concerning is the medication regimen, namely, the novel combination therapies that arise when agents such as hydroxychloroquine are used in tandem with certain antipsychotics or antidepressants. As clinicians, we must reassess the psychotropic medication regimen for people who are currently being treated for or recovering from COVID-19.
 

What’s at stake for COVID-19–positive mental health care patients?

Although the efficacy of hydroxychloroquine is currently being investigated,³ the antimalarial is usually prescribed in tandem with azithromycin for people with COVID-19. The National Institute of Allergy and Infectious Diseases has advised against that particular combination therapy because of ongoing concerns about toxicities.^3,4

In another study, azithromycin was effectively substituted with doxycycline to help minimize systemic effects for patients with cardiac and/or pulmonary issues^.5 Azithromycin is notorious in the literature for influencing the electrical activity of the heart with the potential for fatal arrhythmia and sudden cardiac death in individuals at risk for cardiovascular disease.^5,6,7 It should be noted that both of these commonly prescribed COVID-19 medications (for example, hydroxychloroquine and azithromycin) could lead to QT interval prolongation especially within the context of combination therapy. This is largely concerning for psychiatrists and various other mental health practitioners for the following reasons: (1) higher rates of metabolic syndrome and cardiovascular diseases among psychiatric patients⁸ and/or (2) effects of certain antipsychotics (for example, IV haloperidol, thioridazine, and ziprasidone) and antidepressants (for example, citalopram and escitalopram) on the QT interval.⁹

SARS-CoV-2 and clinical judgment: Evaluating patients at higher risk

Although COVID-19 medication guidelines are still being actively developed, hydroxychloroquine appears to be commonly prescribed by physicians. The medication is known myriad untoward effects, including potential behavioral dysfunction (for example, irritability, agitation, suicidal ideation)10 as well as the aforementioned issues concerning arrhythmia (for example, torsades de pointes). Health care professionals might not have much control over the choice of COVID-19 agents because of a lack of available resources or limited options, but they can exercise clinical judgment with respect to selecting the appropriate psychotropic medications.

Treatment recommendations

1. Establish a baseline EKG

A baseline 12-lead EKG is the standard of care for patients currently being screened for COVID-19. It is necessary to rule out the presence of an underlying cardiovascular disease or a rhythm irregularity. A prolonged QTc interval is generally regarded as being around greater than 450-470 msecs with variations attributable to gender;¹¹ numerous studies have affirmed that the risk of acquiring torsades de pointes is substantial when the QTc interval exceeds 500 msecs.¹²

2. Medical management and risk assessment

Commonly prescribed antipsychotics such as IV haloperidol and ziprasidone are known for exerting a negative effect on the interval and should readily be substituted with other agents in patients who are being treated for COVID-19; the combination of these antipsychotics alongside some COVID-19 medication regimens (for example, hydroxychloroquine/azithromycin) might prove to be fatal. The same logic applies to COVID-19 patients previously on antidepressant therapeutics such as citalopram and escitalopram.

3. Embrace an individually tailored approach to therapeutics

While American Psychiatric Association guidelines historically supported a cessation or reduction in the offending agent under normal circumstances,¹² our team is recommending that the psychotropics associated with QTc interval prolongation are discontinued altogether (or substituted with a low-risk agent) in the event that a patient presents with suspected COVID-19. However, after the patients tests negative with COVID-19, they may resume therapy as indicated under the discretion of the mental health practitioner.
 

References

1. Offard C. “Lancet, NEJM Retract Surgisphere Studies on COVID-19 Patients.” The Scientist Magazine. 2020 Jun 4.

2. Shigemura J et al. Psychiatry Clin Neurosci. 2020 Apr;74(4):281-2.

3. Keshtkar-Jahromi M and Bavari S. Am J Trop Med Hyg. 2020 May;102(5):932-3.

4. Palca J. “NIH panel recommends against drug combination promoted by Trump for COVID-19.” NPR. 2020 Apr 21.

5. Mongelli L. “Long Island doctor tries new twist on hydroxychloroquine for elderly COVID-19 patients.” New York Post. 2020 Apr 4.

6. Hancox JC et al. Ther Adv Infect Dis. 2013 Oct;(5):155-65.

7. Giudicessi JR and Ackerman MJ. Cleve Clin J Med. 2013 Sep;80(9):539-44.

8. Casey DE. Am J Med. 2005 Apr 1;118(Suppl 2):15S-22S.

9. Beach SR et al. Psychosomatics. 2013 Jan 1;54(1):1-3.

10. Bogaczewicz A and Sobów T. Psychiatria i Psychologia Kliniczna. 2017;17(2):111-4.

11. Chohan PS et al. Pak J Med Sci. 2015 Sep-Oct;31(5):1269-71.

12. Lieberman JA et al. APA guidance on the use of antipsychotic drugs and cardiac sudden death. NYS Office of Mental Health. 2012.
 

Dr. Faisal A. Islam is medical adviser for the International Maternal and Child Health Foundation, Montreal, and is based in New York. He also is a postdoctoral fellow, psychopharmacologist, and a board-certified medical affairs specialist. Dr. Faisal Islam disclosed no relevant financial relationships.

Dr. Mohammed Islam is affiliated with the department of psychiatry at the Interfaith Medical Center, New York. He disclosed no relevant financial relationships.

Dr. Choudhry is the chief scientific officer and head of the department of mental health and clinical research at the International Maternal and Child Health Foundation. He disclosed no relevant financial relationships.

Over the last few weeks, several conflicting reports about the efficacy of SARS-CoV-2 treatments have emerged, including high-profile papers that were placed in the limelight and groundbreaking retractions that were issued by the Lancet and New England Journal of Medicine, involving the potential dangers of COVID therapy with findings derived from the Surgisphere database. Hydroxychloroquine has garnered considerable media attention and was touted earlier by President Trump for its therapeutic effects.¹ Naturally, there are political connotations associated with the agent, and it is unlikely that hydroxychloroquine will be supplanted in the near future as ongoing clinical trials have demonstrated mixed results amid the controversy.

As clinicians navigating unchartered territory within the hospital setting, we have to come to terms with these new challenges, tailoring treatment protocols accordingly with the best clinical practices in mind. Patients with preexisting mental health conditions and who are being treated for COVID-19 are particularly susceptible to clinical deterioration. Recent studies have indicated that psychiatric patients are more prone to feelings of isolation and/or estrangement as well as exacerbation of symptoms such as paranoia.² Even more concerning is the medication regimen, namely, the novel combination therapies that arise when agents such as hydroxychloroquine are used in tandem with certain antipsychotics or antidepressants. As clinicians, we must reassess the psychotropic medication regimen for people who are currently being treated for or recovering from COVID-19.
 

What’s at stake for COVID-19–positive mental health care patients?

Although the efficacy of hydroxychloroquine is currently being investigated,³ the antimalarial is usually prescribed in tandem with azithromycin for people with COVID-19. The National Institute of Allergy and Infectious Diseases has advised against that particular combination therapy because of ongoing concerns about toxicities.^3,4

In another study, azithromycin was effectively substituted with doxycycline to help minimize systemic effects for patients with cardiac and/or pulmonary issues^.5 Azithromycin is notorious in the literature for influencing the electrical activity of the heart with the potential for fatal arrhythmia and sudden cardiac death in individuals at risk for cardiovascular disease.^5,6,7 It should be noted that both of these commonly prescribed COVID-19 medications (for example, hydroxychloroquine and azithromycin) could lead to QT interval prolongation especially within the context of combination therapy. This is largely concerning for psychiatrists and various other mental health practitioners for the following reasons: (1) higher rates of metabolic syndrome and cardiovascular diseases among psychiatric patients⁸ and/or (2) effects of certain antipsychotics (for example, IV haloperidol, thioridazine, and ziprasidone) and antidepressants (for example, citalopram and escitalopram) on the QT interval.⁹

SARS-CoV-2 and clinical judgment: Evaluating patients at higher risk

Although COVID-19 medication guidelines are still being actively developed, hydroxychloroquine appears to be commonly prescribed by physicians. The medication is known myriad untoward effects, including potential behavioral dysfunction (for example, irritability, agitation, suicidal ideation)10 as well as the aforementioned issues concerning arrhythmia (for example, torsades de pointes). Health care professionals might not have much control over the choice of COVID-19 agents because of a lack of available resources or limited options, but they can exercise clinical judgment with respect to selecting the appropriate psychotropic medications.

Treatment recommendations

1. Establish a baseline EKG

A baseline 12-lead EKG is the standard of care for patients currently being screened for COVID-19. It is necessary to rule out the presence of an underlying cardiovascular disease or a rhythm irregularity. A prolonged QTc interval is generally regarded as being around greater than 450-470 msecs with variations attributable to gender;¹¹ numerous studies have affirmed that the risk of acquiring torsades de pointes is substantial when the QTc interval exceeds 500 msecs.¹²

2. Medical management and risk assessment

Commonly prescribed antipsychotics such as IV haloperidol and ziprasidone are known for exerting a negative effect on the interval and should readily be substituted with other agents in patients who are being treated for COVID-19; the combination of these antipsychotics alongside some COVID-19 medication regimens (for example, hydroxychloroquine/azithromycin) might prove to be fatal. The same logic applies to COVID-19 patients previously on antidepressant therapeutics such as citalopram and escitalopram.

3. Embrace an individually tailored approach to therapeutics

While American Psychiatric Association guidelines historically supported a cessation or reduction in the offending agent under normal circumstances,¹² our team is recommending that the psychotropics associated with QTc interval prolongation are discontinued altogether (or substituted with a low-risk agent) in the event that a patient presents with suspected COVID-19. However, after the patients tests negative with COVID-19, they may resume therapy as indicated under the discretion of the mental health practitioner.
 

References

1. Offard C. “Lancet, NEJM Retract Surgisphere Studies on COVID-19 Patients.” The Scientist Magazine. 2020 Jun 4.

2. Shigemura J et al. Psychiatry Clin Neurosci. 2020 Apr;74(4):281-2.

3. Keshtkar-Jahromi M and Bavari S. Am J Trop Med Hyg. 2020 May;102(5):932-3.

4. Palca J. “NIH panel recommends against drug combination promoted by Trump for COVID-19.” NPR. 2020 Apr 21.

5. Mongelli L. “Long Island doctor tries new twist on hydroxychloroquine for elderly COVID-19 patients.” New York Post. 2020 Apr 4.

6. Hancox JC et al. Ther Adv Infect Dis. 2013 Oct;(5):155-65.

7. Giudicessi JR and Ackerman MJ. Cleve Clin J Med. 2013 Sep;80(9):539-44.

8. Casey DE. Am J Med. 2005 Apr 1;118(Suppl 2):15S-22S.

9. Beach SR et al. Psychosomatics. 2013 Jan 1;54(1):1-3.

10. Bogaczewicz A and Sobów T. Psychiatria i Psychologia Kliniczna. 2017;17(2):111-4.

11. Chohan PS et al. Pak J Med Sci. 2015 Sep-Oct;31(5):1269-71.

12. Lieberman JA et al. APA guidance on the use of antipsychotic drugs and cardiac sudden death. NYS Office of Mental Health. 2012.
 

Dr. Faisal A. Islam is medical adviser for the International Maternal and Child Health Foundation, Montreal, and is based in New York. He also is a postdoctoral fellow, psychopharmacologist, and a board-certified medical affairs specialist. Dr. Faisal Islam disclosed no relevant financial relationships.

Dr. Mohammed Islam is affiliated with the department of psychiatry at the Interfaith Medical Center, New York. He disclosed no relevant financial relationships.

Dr. Choudhry is the chief scientific officer and head of the department of mental health and clinical research at the International Maternal and Child Health Foundation. He disclosed no relevant financial relationships.

When sterilizing face masks, the type of face mask and the method of sterilization have a bearing on subsequent filtration efficiency, according to researchers. The greatest reduction in filtration efficiency after sterilization occurred with surgical face masks.

With plasma vapor hydrogen peroxide (H₂O₂) sterilization, filtration efficiency of N95 and KN95 masks was maintained at more than 95%, but for surgical face masks, filtration efficiency was reduced to less than 95%. With chlorine dioxide (ClO₂) sterilization, on the other hand, filtration efficiency was maintained at above 95% for N95 masks, but for KN95 and surgical face masks, filtration efficiency was reduced to less than 80%.

In a research letter published online June 15 in JAMA Network Open, researchers from the University of Oklahoma Health Sciences Center, Oklahoma City, report the results of a study of the two sterilization techniques on the pressure drop and filtration efficiency of N95, KN95, and surgical face masks.

“The H₂O₂ treatment showed a small effect on the overall filtration efficiency of the tested masks, but the ClO₂ treatment showed marked reduction in the overall filtration efficiency of the KN95s and surgical face masks. All pressure drop changes were within the acceptable range,” the researchers write.

The study did not evaluate the effect of repeated sterilizations on face masks.

Five masks of each type were sterilized with either H₂O₂ or ClO₂. Masks were then placed in a test chamber, and a salt aerosol was nebulized to assess both upstream and downstream filtration as well as pressure drop. The researchers used a mobility particle sizer to measure particle number concentration from 16.8 nm to 514 nm. An acceptable pressure drop was defined as a drop of less than 1.38 inches of water (35 mm) for inhalation.

Although pressure drop changes were within the acceptable range for all three mask types following sterilization with either method, H₂O₂ sterilization yielded the least reduction in filtration efficacy in all cases. After sterilization with H₂O₂, filtration efficiencies were 96.6%, 97.1%, and 91.6% for the N95s, KN95s, and the surgical face masks, respectively. In contrast, filtration efficiencies after ClO₂ sterilization were 95.1%, 76.2%, and 77.9%, respectively.

The researchers note that, although overall filtration efficiency was maintained with ClO₂ sterilization, there was a significant drop in efficiency with respect to particles of approximately 300 nm (0.3 microns) in size. For particles of that size, mean filtration efficiency decreased to 86.2% for N95s, 40.8% for KN95s, and 47.1% for surgical face masks.

The testing described in the report is “quite affordable at $350 per mask type, so it is hard to imagine any health care provider cannot set aside a small budget to conduct such an important test,” author Evan Floyd, PhD, told Medscape Medical News.

Given the high demand for effective face masks and the current risk for counterfeit products, Floyd suggested that individual facilities test all masks intended for use by healthcare workers before and after sterilization procedures.

“However, if for some reason testing is not an option, we would recommend sticking to established brands and suppliers, perhaps reach out to your state health department or a local representative of the strategic stockpile of PPE,” he noted.

The authors acknowledge that further studies using a larger sample size and a greater variety of masks, as well as studies to evaluate different sterilization techniques, are required. Further, “measuring the respirator’s filtration efficiency by aerosol size instead of only measuring the overall filtration efficiency” should also be considered. Such an approach would enable researchers to evaluate the degree to which masks protect against specific infectious agents.

This article first appeared on Medscape.com.

When sterilizing face masks, the type of face mask and the method of sterilization have a bearing on subsequent filtration efficiency, according to researchers. The greatest reduction in filtration efficiency after sterilization occurred with surgical face masks.

With plasma vapor hydrogen peroxide (H₂O₂) sterilization, filtration efficiency of N95 and KN95 masks was maintained at more than 95%, but for surgical face masks, filtration efficiency was reduced to less than 95%. With chlorine dioxide (ClO₂) sterilization, on the other hand, filtration efficiency was maintained at above 95% for N95 masks, but for KN95 and surgical face masks, filtration efficiency was reduced to less than 80%.

In a research letter published online June 15 in JAMA Network Open, researchers from the University of Oklahoma Health Sciences Center, Oklahoma City, report the results of a study of the two sterilization techniques on the pressure drop and filtration efficiency of N95, KN95, and surgical face masks.

“The H₂O₂ treatment showed a small effect on the overall filtration efficiency of the tested masks, but the ClO₂ treatment showed marked reduction in the overall filtration efficiency of the KN95s and surgical face masks. All pressure drop changes were within the acceptable range,” the researchers write.

The study did not evaluate the effect of repeated sterilizations on face masks.

Five masks of each type were sterilized with either H₂O₂ or ClO₂. Masks were then placed in a test chamber, and a salt aerosol was nebulized to assess both upstream and downstream filtration as well as pressure drop. The researchers used a mobility particle sizer to measure particle number concentration from 16.8 nm to 514 nm. An acceptable pressure drop was defined as a drop of less than 1.38 inches of water (35 mm) for inhalation.

Although pressure drop changes were within the acceptable range for all three mask types following sterilization with either method, H₂O₂ sterilization yielded the least reduction in filtration efficacy in all cases. After sterilization with H₂O₂, filtration efficiencies were 96.6%, 97.1%, and 91.6% for the N95s, KN95s, and the surgical face masks, respectively. In contrast, filtration efficiencies after ClO₂ sterilization were 95.1%, 76.2%, and 77.9%, respectively.

The researchers note that, although overall filtration efficiency was maintained with ClO₂ sterilization, there was a significant drop in efficiency with respect to particles of approximately 300 nm (0.3 microns) in size. For particles of that size, mean filtration efficiency decreased to 86.2% for N95s, 40.8% for KN95s, and 47.1% for surgical face masks.

The testing described in the report is “quite affordable at $350 per mask type, so it is hard to imagine any health care provider cannot set aside a small budget to conduct such an important test,” author Evan Floyd, PhD, told Medscape Medical News.

Given the high demand for effective face masks and the current risk for counterfeit products, Floyd suggested that individual facilities test all masks intended for use by healthcare workers before and after sterilization procedures.

“However, if for some reason testing is not an option, we would recommend sticking to established brands and suppliers, perhaps reach out to your state health department or a local representative of the strategic stockpile of PPE,” he noted.

The authors acknowledge that further studies using a larger sample size and a greater variety of masks, as well as studies to evaluate different sterilization techniques, are required. Further, “measuring the respirator’s filtration efficiency by aerosol size instead of only measuring the overall filtration efficiency” should also be considered. Such an approach would enable researchers to evaluate the degree to which masks protect against specific infectious agents.

This article first appeared on Medscape.com.

When sterilizing face masks, the type of face mask and the method of sterilization have a bearing on subsequent filtration efficiency, according to researchers. The greatest reduction in filtration efficiency after sterilization occurred with surgical face masks.

With plasma vapor hydrogen peroxide (H₂O₂) sterilization, filtration efficiency of N95 and KN95 masks was maintained at more than 95%, but for surgical face masks, filtration efficiency was reduced to less than 95%. With chlorine dioxide (ClO₂) sterilization, on the other hand, filtration efficiency was maintained at above 95% for N95 masks, but for KN95 and surgical face masks, filtration efficiency was reduced to less than 80%.

In a research letter published online June 15 in JAMA Network Open, researchers from the University of Oklahoma Health Sciences Center, Oklahoma City, report the results of a study of the two sterilization techniques on the pressure drop and filtration efficiency of N95, KN95, and surgical face masks.

“The H₂O₂ treatment showed a small effect on the overall filtration efficiency of the tested masks, but the ClO₂ treatment showed marked reduction in the overall filtration efficiency of the KN95s and surgical face masks. All pressure drop changes were within the acceptable range,” the researchers write.

The study did not evaluate the effect of repeated sterilizations on face masks.

Five masks of each type were sterilized with either H₂O₂ or ClO₂. Masks were then placed in a test chamber, and a salt aerosol was nebulized to assess both upstream and downstream filtration as well as pressure drop. The researchers used a mobility particle sizer to measure particle number concentration from 16.8 nm to 514 nm. An acceptable pressure drop was defined as a drop of less than 1.38 inches of water (35 mm) for inhalation.

Although pressure drop changes were within the acceptable range for all three mask types following sterilization with either method, H₂O₂ sterilization yielded the least reduction in filtration efficacy in all cases. After sterilization with H₂O₂, filtration efficiencies were 96.6%, 97.1%, and 91.6% for the N95s, KN95s, and the surgical face masks, respectively. In contrast, filtration efficiencies after ClO₂ sterilization were 95.1%, 76.2%, and 77.9%, respectively.

The researchers note that, although overall filtration efficiency was maintained with ClO₂ sterilization, there was a significant drop in efficiency with respect to particles of approximately 300 nm (0.3 microns) in size. For particles of that size, mean filtration efficiency decreased to 86.2% for N95s, 40.8% for KN95s, and 47.1% for surgical face masks.

The testing described in the report is “quite affordable at $350 per mask type, so it is hard to imagine any health care provider cannot set aside a small budget to conduct such an important test,” author Evan Floyd, PhD, told Medscape Medical News.

Given the high demand for effective face masks and the current risk for counterfeit products, Floyd suggested that individual facilities test all masks intended for use by healthcare workers before and after sterilization procedures.

“However, if for some reason testing is not an option, we would recommend sticking to established brands and suppliers, perhaps reach out to your state health department or a local representative of the strategic stockpile of PPE,” he noted.

The authors acknowledge that further studies using a larger sample size and a greater variety of masks, as well as studies to evaluate different sterilization techniques, are required. Further, “measuring the respirator’s filtration efficiency by aerosol size instead of only measuring the overall filtration efficiency” should also be considered. Such an approach would enable researchers to evaluate the degree to which masks protect against specific infectious agents.

This article first appeared on Medscape.com.

This patient’s circular ecchymotic patches were due to cupping. One of the clues that this was iatrogenic was the regular and repeated pattern on the skin.

Cupping is a centuries old treatment for pain relief (among other things) that involves applying glass globes or other hollow materials to the skin to create a vacuum. Traditionally, this vacuum is created by heating the air inside the vessel and then holding the vessel in place as the air cools. Practitioners may also use more modern instruments to induce the vacuum that are similar to those used to assist in vaginal deliveries. The mechanical devices leave these circular ecchymotic marks. The ecchymosis fades over time, and this procedure has been shown to significantly reduce myofascial neck and back pain in small trials.

It is important to recognize geometric patterns that are iatrogenic or due to abuse when evaluating skin findings. If skin findings do not follow dermatomal distributions, typical exanthem, or other classic patterns or presentations, there is the possibility that the pattern may be the result of neglect or abuse. On inspection, consider whether an odd pattern may have been caused from a belt buckle, striking instrument, furniture, medical equipment, or a hand strike.

This patient’s findings were consistent with his history of visiting a physical therapist for cupping. No treatment was required; the patient’s back pain from his car accident was improving, and the cupping marks were not troubling him.

‌

Photo and text courtesy of Daniel Stulberg, MD, FAAFP, Department of Family and Community Medicine, University of New Mexico School of Medicine, Albuquerque.

This patient’s circular ecchymotic patches were due to cupping. One of the clues that this was iatrogenic was the regular and repeated pattern on the skin.

Cupping is a centuries old treatment for pain relief (among other things) that involves applying glass globes or other hollow materials to the skin to create a vacuum. Traditionally, this vacuum is created by heating the air inside the vessel and then holding the vessel in place as the air cools. Practitioners may also use more modern instruments to induce the vacuum that are similar to those used to assist in vaginal deliveries. The mechanical devices leave these circular ecchymotic marks. The ecchymosis fades over time, and this procedure has been shown to significantly reduce myofascial neck and back pain in small trials.

It is important to recognize geometric patterns that are iatrogenic or due to abuse when evaluating skin findings. If skin findings do not follow dermatomal distributions, typical exanthem, or other classic patterns or presentations, there is the possibility that the pattern may be the result of neglect or abuse. On inspection, consider whether an odd pattern may have been caused from a belt buckle, striking instrument, furniture, medical equipment, or a hand strike.

This patient’s findings were consistent with his history of visiting a physical therapist for cupping. No treatment was required; the patient’s back pain from his car accident was improving, and the cupping marks were not troubling him.

‌

Photo and text courtesy of Daniel Stulberg, MD, FAAFP, Department of Family and Community Medicine, University of New Mexico School of Medicine, Albuquerque.

This patient’s circular ecchymotic patches were due to cupping. One of the clues that this was iatrogenic was the regular and repeated pattern on the skin.

Cupping is a centuries old treatment for pain relief (among other things) that involves applying glass globes or other hollow materials to the skin to create a vacuum. Traditionally, this vacuum is created by heating the air inside the vessel and then holding the vessel in place as the air cools. Practitioners may also use more modern instruments to induce the vacuum that are similar to those used to assist in vaginal deliveries. The mechanical devices leave these circular ecchymotic marks. The ecchymosis fades over time, and this procedure has been shown to significantly reduce myofascial neck and back pain in small trials.

It is important to recognize geometric patterns that are iatrogenic or due to abuse when evaluating skin findings. If skin findings do not follow dermatomal distributions, typical exanthem, or other classic patterns or presentations, there is the possibility that the pattern may be the result of neglect or abuse. On inspection, consider whether an odd pattern may have been caused from a belt buckle, striking instrument, furniture, medical equipment, or a hand strike.

This patient’s findings were consistent with his history of visiting a physical therapist for cupping. No treatment was required; the patient’s back pain from his car accident was improving, and the cupping marks were not troubling him.

‌

Photo and text courtesy of Daniel Stulberg, MD, FAAFP, Department of Family and Community Medicine, University of New Mexico School of Medicine, Albuquerque.

Introduction

We are living in an unprecedented time. During March 2020, in response to the COVID-19 (coronavirus disease 2019) outbreak, our institution removed all medical students from rotations with direct patient contact to prioritize their safety and well-being, following recommendations made by the Association of American Medical Colleges (AAMC).¹ Similarly, we as gastroenterology fellows experienced an upheaval in our usual schedules and routines. Some of us were redeployed to other areas of the hospital, such as inpatient wards and emergency departments, to meet the needs of our patients and our health system. These changes were difficult, not only because we were practicing in different roles, but also because unknown situations commonly incite fear and anxiety.

Among the repercussions of the COVID-19 pandemic were the changes thrust upon medical students who suddenly found themselves without clinical exposure (both on core clerkships and electives) for the duration of the academic year.² We too lost many of our educational and teaching opportunities as we adapted to our changing circumstances and new reality. Therefore, we endeavored to create an interactive, online GI curriculum for our students to complete during their time away from clinical medicine to promote at-home learning for our students and build bridges within our educational community during a tumultuous time. We used the lessons we learned because of the changes in our own medical education to anticipate the best ways to provide learning opportunities for our students.
 

GI fellows’ experiences

The changes to our schedules and lack of in-person educational conferences seemingly happened overnight – the shock of being pulled from clinics, consults, and endoscopy left us feeling scared and lonely. We were quickly transitioned from knowing our roles and responsibilities as GI providers to taking over care for hospitalist patients as the “primary team,” working in the COVID emergency department (ED), and losing our clinic space. Redeployment to other clinical environments was anxiety-provoking. Self-doubt and fear were the most cited concerns as we asked ourselves: Do I remember enough general medicine to be an effective hospitalist? How do I place admission orders or perform a medication reconciliation on discharge? What can I expect in the COVID ED? Will I have to intubate someone? What about possible PPE shortages? Are my family members safe at home? Should I stay in a hotel? Do we have estimates on how long this will last?

Clinical schedules were reconfigured to consolidate the use of inpatient fellows and allow for reserves of fellows to be redeployed if needed. Schedules for the following 7 days were made just 48 hours prior to the start of each workweek. The anticipation and fear of the unknown were perhaps the hardest parts of the changes in our clinical learning environment. Little time was provided to make child care arrangements, coordinate with the schedules of significant others, or review topics and skills we might need in the next week that had gone unused for some time.

Our conference schedule was pared down considerably as fellows and attendings adjusted to their new responsibilities and a virtual platform for fellows’ education. While the transition to online lectures was seamless, the spirit of conference certainly changed. Impromptu questions and conversations that oftentimes arise organically during case conferences no longer occurred as virtual meetings do not offer the same space to foster these discussions as we awkwardly muted and unmuted ourselves. Participation in lectures seemed disjointed, which translated in some ways to less effective learning opportunities. Our involvement in endoscopy was also removed as only urgent cases were being performed and PPE conservation was of the utmost priority. This was especially concerning for third-year fellows on the cusp of graduation who would soon be independent practitioners without recent procedural practice. In general, the fellowship felt isolated and uncertain, which our program director addressed with weekly virtual COVID-19 “happy hour” updates.
 

GI fellows’ contribution

As our program encouraged us to come together during this time to support each other, we realized that while our clinical duties may look different during the COVID-19 crisis, our responsibility to learners was more important than ever. At many academic institutions, GI fellows are referred to as “the face of the division” owed in large part to our consistent presence on consult services and roles as teachers for medical students and residents who rotate with us. In an effort to assist the medical school’s charge to rapidly generate at-home curriculum for our students, we created an online curriculum for medical students to complete during the time they were previously scheduled to rotate with us on consults either as third- or fourth-year students.

We designed a series of interactive podcasts covering six topics that are commonly encountered issues on the GI consult service: upper GI bleeding, lower GI bleeding, biliary sepsis, acute pancreatitis, chronic diarrhea with a new diagnosis of inflammatory bowel disease, as well as cirrhosis and its associated complications.

Conclusion

The COVID-19 pandemic brought about significant change in the daily activities of GI fellows including new responsibilities and a great need for adaptation. We hope that the lessons the COVID-19 pandemic has taught us – to think of others and make our talents available to those who need them, to look for ways to adapt to challenges, to live in the present but focus on the future, and to spread creativity when able – will continue long after the curve has flattened.

References

1. Murphy B. American Medical Association website. https://www.ama-assn.org/residents-students/medical-school-life/online-learning-during-covid-19-tips-help-med-students. Apr 3, 2020.

2. Murphy B. American Medical Association website. https://www.ama-assn.org/delivering-care/public-health/covid-19-how-virus-impacting-medical-schools. Mar 20, 2020.

3. “H5P: Create, share and reuse interactive HTML5 content in your browser.” H5P website. https://h5p.org.
 

Dr. Bhavsar-Burke and Dr. Jansson-Knodell are GI fellows in the division of gastroenterology and hepatology, department of medicine, Indiana University, Indianapolis. The authors have no conflicts of interest.

Introduction

We are living in an unprecedented time. During March 2020, in response to the COVID-19 (coronavirus disease 2019) outbreak, our institution removed all medical students from rotations with direct patient contact to prioritize their safety and well-being, following recommendations made by the Association of American Medical Colleges (AAMC).¹ Similarly, we as gastroenterology fellows experienced an upheaval in our usual schedules and routines. Some of us were redeployed to other areas of the hospital, such as inpatient wards and emergency departments, to meet the needs of our patients and our health system. These changes were difficult, not only because we were practicing in different roles, but also because unknown situations commonly incite fear and anxiety.

Among the repercussions of the COVID-19 pandemic were the changes thrust upon medical students who suddenly found themselves without clinical exposure (both on core clerkships and electives) for the duration of the academic year.² We too lost many of our educational and teaching opportunities as we adapted to our changing circumstances and new reality. Therefore, we endeavored to create an interactive, online GI curriculum for our students to complete during their time away from clinical medicine to promote at-home learning for our students and build bridges within our educational community during a tumultuous time. We used the lessons we learned because of the changes in our own medical education to anticipate the best ways to provide learning opportunities for our students.
 

GI fellows’ experiences

The changes to our schedules and lack of in-person educational conferences seemingly happened overnight – the shock of being pulled from clinics, consults, and endoscopy left us feeling scared and lonely. We were quickly transitioned from knowing our roles and responsibilities as GI providers to taking over care for hospitalist patients as the “primary team,” working in the COVID emergency department (ED), and losing our clinic space. Redeployment to other clinical environments was anxiety-provoking. Self-doubt and fear were the most cited concerns as we asked ourselves: Do I remember enough general medicine to be an effective hospitalist? How do I place admission orders or perform a medication reconciliation on discharge? What can I expect in the COVID ED? Will I have to intubate someone? What about possible PPE shortages? Are my family members safe at home? Should I stay in a hotel? Do we have estimates on how long this will last?

Clinical schedules were reconfigured to consolidate the use of inpatient fellows and allow for reserves of fellows to be redeployed if needed. Schedules for the following 7 days were made just 48 hours prior to the start of each workweek. The anticipation and fear of the unknown were perhaps the hardest parts of the changes in our clinical learning environment. Little time was provided to make child care arrangements, coordinate with the schedules of significant others, or review topics and skills we might need in the next week that had gone unused for some time.

Our conference schedule was pared down considerably as fellows and attendings adjusted to their new responsibilities and a virtual platform for fellows’ education. While the transition to online lectures was seamless, the spirit of conference certainly changed. Impromptu questions and conversations that oftentimes arise organically during case conferences no longer occurred as virtual meetings do not offer the same space to foster these discussions as we awkwardly muted and unmuted ourselves. Participation in lectures seemed disjointed, which translated in some ways to less effective learning opportunities. Our involvement in endoscopy was also removed as only urgent cases were being performed and PPE conservation was of the utmost priority. This was especially concerning for third-year fellows on the cusp of graduation who would soon be independent practitioners without recent procedural practice. In general, the fellowship felt isolated and uncertain, which our program director addressed with weekly virtual COVID-19 “happy hour” updates.
 

GI fellows’ contribution

As our program encouraged us to come together during this time to support each other, we realized that while our clinical duties may look different during the COVID-19 crisis, our responsibility to learners was more important than ever. At many academic institutions, GI fellows are referred to as “the face of the division” owed in large part to our consistent presence on consult services and roles as teachers for medical students and residents who rotate with us. In an effort to assist the medical school’s charge to rapidly generate at-home curriculum for our students, we created an online curriculum for medical students to complete during the time they were previously scheduled to rotate with us on consults either as third- or fourth-year students.

We designed a series of interactive podcasts covering six topics that are commonly encountered issues on the GI consult service: upper GI bleeding, lower GI bleeding, biliary sepsis, acute pancreatitis, chronic diarrhea with a new diagnosis of inflammatory bowel disease, as well as cirrhosis and its associated complications.

Conclusion

The COVID-19 pandemic brought about significant change in the daily activities of GI fellows including new responsibilities and a great need for adaptation. We hope that the lessons the COVID-19 pandemic has taught us – to think of others and make our talents available to those who need them, to look for ways to adapt to challenges, to live in the present but focus on the future, and to spread creativity when able – will continue long after the curve has flattened.

References

1. Murphy B. American Medical Association website. https://www.ama-assn.org/residents-students/medical-school-life/online-learning-during-covid-19-tips-help-med-students. Apr 3, 2020.

2. Murphy B. American Medical Association website. https://www.ama-assn.org/delivering-care/public-health/covid-19-how-virus-impacting-medical-schools. Mar 20, 2020.

3. “H5P: Create, share and reuse interactive HTML5 content in your browser.” H5P website. https://h5p.org.
 

Dr. Bhavsar-Burke and Dr. Jansson-Knodell are GI fellows in the division of gastroenterology and hepatology, department of medicine, Indiana University, Indianapolis. The authors have no conflicts of interest.

Introduction

We are living in an unprecedented time. During March 2020, in response to the COVID-19 (coronavirus disease 2019) outbreak, our institution removed all medical students from rotations with direct patient contact to prioritize their safety and well-being, following recommendations made by the Association of American Medical Colleges (AAMC).¹ Similarly, we as gastroenterology fellows experienced an upheaval in our usual schedules and routines. Some of us were redeployed to other areas of the hospital, such as inpatient wards and emergency departments, to meet the needs of our patients and our health system. These changes were difficult, not only because we were practicing in different roles, but also because unknown situations commonly incite fear and anxiety.

Among the repercussions of the COVID-19 pandemic were the changes thrust upon medical students who suddenly found themselves without clinical exposure (both on core clerkships and electives) for the duration of the academic year.² We too lost many of our educational and teaching opportunities as we adapted to our changing circumstances and new reality. Therefore, we endeavored to create an interactive, online GI curriculum for our students to complete during their time away from clinical medicine to promote at-home learning for our students and build bridges within our educational community during a tumultuous time. We used the lessons we learned because of the changes in our own medical education to anticipate the best ways to provide learning opportunities for our students.
 

GI fellows’ experiences

The changes to our schedules and lack of in-person educational conferences seemingly happened overnight – the shock of being pulled from clinics, consults, and endoscopy left us feeling scared and lonely. We were quickly transitioned from knowing our roles and responsibilities as GI providers to taking over care for hospitalist patients as the “primary team,” working in the COVID emergency department (ED), and losing our clinic space. Redeployment to other clinical environments was anxiety-provoking. Self-doubt and fear were the most cited concerns as we asked ourselves: Do I remember enough general medicine to be an effective hospitalist? How do I place admission orders or perform a medication reconciliation on discharge? What can I expect in the COVID ED? Will I have to intubate someone? What about possible PPE shortages? Are my family members safe at home? Should I stay in a hotel? Do we have estimates on how long this will last?

Clinical schedules were reconfigured to consolidate the use of inpatient fellows and allow for reserves of fellows to be redeployed if needed. Schedules for the following 7 days were made just 48 hours prior to the start of each workweek. The anticipation and fear of the unknown were perhaps the hardest parts of the changes in our clinical learning environment. Little time was provided to make child care arrangements, coordinate with the schedules of significant others, or review topics and skills we might need in the next week that had gone unused for some time.

Our conference schedule was pared down considerably as fellows and attendings adjusted to their new responsibilities and a virtual platform for fellows’ education. While the transition to online lectures was seamless, the spirit of conference certainly changed. Impromptu questions and conversations that oftentimes arise organically during case conferences no longer occurred as virtual meetings do not offer the same space to foster these discussions as we awkwardly muted and unmuted ourselves. Participation in lectures seemed disjointed, which translated in some ways to less effective learning opportunities. Our involvement in endoscopy was also removed as only urgent cases were being performed and PPE conservation was of the utmost priority. This was especially concerning for third-year fellows on the cusp of graduation who would soon be independent practitioners without recent procedural practice. In general, the fellowship felt isolated and uncertain, which our program director addressed with weekly virtual COVID-19 “happy hour” updates.
 

GI fellows’ contribution

As our program encouraged us to come together during this time to support each other, we realized that while our clinical duties may look different during the COVID-19 crisis, our responsibility to learners was more important than ever. At many academic institutions, GI fellows are referred to as “the face of the division” owed in large part to our consistent presence on consult services and roles as teachers for medical students and residents who rotate with us. In an effort to assist the medical school’s charge to rapidly generate at-home curriculum for our students, we created an online curriculum for medical students to complete during the time they were previously scheduled to rotate with us on consults either as third- or fourth-year students.

We designed a series of interactive podcasts covering six topics that are commonly encountered issues on the GI consult service: upper GI bleeding, lower GI bleeding, biliary sepsis, acute pancreatitis, chronic diarrhea with a new diagnosis of inflammatory bowel disease, as well as cirrhosis and its associated complications.

Conclusion

The COVID-19 pandemic brought about significant change in the daily activities of GI fellows including new responsibilities and a great need for adaptation. We hope that the lessons the COVID-19 pandemic has taught us – to think of others and make our talents available to those who need them, to look for ways to adapt to challenges, to live in the present but focus on the future, and to spread creativity when able – will continue long after the curve has flattened.

References

1. Murphy B. American Medical Association website. https://www.ama-assn.org/residents-students/medical-school-life/online-learning-during-covid-19-tips-help-med-students. Apr 3, 2020.

2. Murphy B. American Medical Association website. https://www.ama-assn.org/delivering-care/public-health/covid-19-how-virus-impacting-medical-schools. Mar 20, 2020.

3. “H5P: Create, share and reuse interactive HTML5 content in your browser.” H5P website. https://h5p.org.
 

Dr. Bhavsar-Burke and Dr. Jansson-Knodell are GI fellows in the division of gastroenterology and hepatology, department of medicine, Indiana University, Indianapolis. The authors have no conflicts of interest.

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

Comorbidities increase COVID-19 deaths by factor of 12

COVID-19 patients with an underlying condition are 6 times as likely to be hospitalized and 12 times as likely to die, compared with those who have no such condition, according to the CDC.

The most frequently reported underlying conditions were cardiovascular disease (32%), diabetes (30%), chronic lung disease (18%), and renal disease (7.6%), and there were no significant differences between males and females.

The pandemic “continues to affect all populations and result in severe outcomes including death,” noted the CDC, emphasizing “the continued need for community mitigation strategies, especially for vulnerable populations, to slow COVID-19 transmission.” Read more.

Preventive services coalition recommends routine anxiety screening for women

Women and girls aged 13 years and older with no current diagnosis of anxiety should be screened routinely for anxiety, according to a new recommendation from the Women’s Preventive Services Initiative.

The lifetime prevalence of anxiety disorders in women in the United States is 40%, approximately twice that of men, and anxiety can be a manifestation of underlying issues including posttraumatic stress, sexual harassment, and assault.

“The WPSI based its rationale for anxiety screening on several considerations,” the researchers noted. “Anxiety disorders are the most prevalent mental health disorders in women, and the problems created by untreated anxiety can impair function in all areas of a woman’s life.” Read more.

High-fat, high-sugar diet may promote adult acne

A diet higher in fat, sugar, and milk was associated with having acne in a cross-sectional study of approximately 24,000 adults in France.

Although acne patients may believe that eating certain foods exacerbates acne, data on the effects of nutrition on acne, including associations between acne and a high-glycemic diet, are limited and have produced conflicting results, noted investigators.

“The results of our study appear to support the hypothesis that the Western diet (rich in animal products and fatty and sugary foods) is associated with the presence of acne in adulthood,” the researchers concluded.
 

Population study supports migraine-dementia link

Preliminary results from a population-based cohort study support previous reports that migraine is a midlife risk factor for dementia later in life, but further determined that migraine with aura and frequent hospital contacts significantly increased dementia risk after age 60 years, according to results from a Danish registry presented at the virtual annual meeting of the American Headache Society.

The preliminary findings revealed that the median age at diagnosis was 49 years and about 70% of the migraine population were women. “There was a 50% higher dementia rate in individuals who had any migraine diagnosis,” Dr. Islamoska said.

“To the best of our knowledge, no previous national register–based studies have investigated the risk of dementia among individuals who suffer from migraine with aura,” Dr. Sabrina Islamoska said.

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

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

Comorbidities increase COVID-19 deaths by factor of 12

COVID-19 patients with an underlying condition are 6 times as likely to be hospitalized and 12 times as likely to die, compared with those who have no such condition, according to the CDC.

The most frequently reported underlying conditions were cardiovascular disease (32%), diabetes (30%), chronic lung disease (18%), and renal disease (7.6%), and there were no significant differences between males and females.

The pandemic “continues to affect all populations and result in severe outcomes including death,” noted the CDC, emphasizing “the continued need for community mitigation strategies, especially for vulnerable populations, to slow COVID-19 transmission.” Read more.

Preventive services coalition recommends routine anxiety screening for women

Women and girls aged 13 years and older with no current diagnosis of anxiety should be screened routinely for anxiety, according to a new recommendation from the Women’s Preventive Services Initiative.

The lifetime prevalence of anxiety disorders in women in the United States is 40%, approximately twice that of men, and anxiety can be a manifestation of underlying issues including posttraumatic stress, sexual harassment, and assault.

“The WPSI based its rationale for anxiety screening on several considerations,” the researchers noted. “Anxiety disorders are the most prevalent mental health disorders in women, and the problems created by untreated anxiety can impair function in all areas of a woman’s life.” Read more.

High-fat, high-sugar diet may promote adult acne

A diet higher in fat, sugar, and milk was associated with having acne in a cross-sectional study of approximately 24,000 adults in France.

Although acne patients may believe that eating certain foods exacerbates acne, data on the effects of nutrition on acne, including associations between acne and a high-glycemic diet, are limited and have produced conflicting results, noted investigators.

“The results of our study appear to support the hypothesis that the Western diet (rich in animal products and fatty and sugary foods) is associated with the presence of acne in adulthood,” the researchers concluded.
 

Population study supports migraine-dementia link

Preliminary results from a population-based cohort study support previous reports that migraine is a midlife risk factor for dementia later in life, but further determined that migraine with aura and frequent hospital contacts significantly increased dementia risk after age 60 years, according to results from a Danish registry presented at the virtual annual meeting of the American Headache Society.

The preliminary findings revealed that the median age at diagnosis was 49 years and about 70% of the migraine population were women. “There was a 50% higher dementia rate in individuals who had any migraine diagnosis,” Dr. Islamoska said.

“To the best of our knowledge, no previous national register–based studies have investigated the risk of dementia among individuals who suffer from migraine with aura,” Dr. Sabrina Islamoska said.

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

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

Comorbidities increase COVID-19 deaths by factor of 12

COVID-19 patients with an underlying condition are 6 times as likely to be hospitalized and 12 times as likely to die, compared with those who have no such condition, according to the CDC.

The most frequently reported underlying conditions were cardiovascular disease (32%), diabetes (30%), chronic lung disease (18%), and renal disease (7.6%), and there were no significant differences between males and females.

The pandemic “continues to affect all populations and result in severe outcomes including death,” noted the CDC, emphasizing “the continued need for community mitigation strategies, especially for vulnerable populations, to slow COVID-19 transmission.” Read more.

Preventive services coalition recommends routine anxiety screening for women

Women and girls aged 13 years and older with no current diagnosis of anxiety should be screened routinely for anxiety, according to a new recommendation from the Women’s Preventive Services Initiative.

The lifetime prevalence of anxiety disorders in women in the United States is 40%, approximately twice that of men, and anxiety can be a manifestation of underlying issues including posttraumatic stress, sexual harassment, and assault.

“The WPSI based its rationale for anxiety screening on several considerations,” the researchers noted. “Anxiety disorders are the most prevalent mental health disorders in women, and the problems created by untreated anxiety can impair function in all areas of a woman’s life.” Read more.

High-fat, high-sugar diet may promote adult acne

A diet higher in fat, sugar, and milk was associated with having acne in a cross-sectional study of approximately 24,000 adults in France.

Although acne patients may believe that eating certain foods exacerbates acne, data on the effects of nutrition on acne, including associations between acne and a high-glycemic diet, are limited and have produced conflicting results, noted investigators.

“The results of our study appear to support the hypothesis that the Western diet (rich in animal products and fatty and sugary foods) is associated with the presence of acne in adulthood,” the researchers concluded.
 

Population study supports migraine-dementia link

Preliminary results from a population-based cohort study support previous reports that migraine is a midlife risk factor for dementia later in life, but further determined that migraine with aura and frequent hospital contacts significantly increased dementia risk after age 60 years, according to results from a Danish registry presented at the virtual annual meeting of the American Headache Society.

The preliminary findings revealed that the median age at diagnosis was 49 years and about 70% of the migraine population were women. “There was a 50% higher dementia rate in individuals who had any migraine diagnosis,” Dr. Islamoska said.

“To the best of our knowledge, no previous national register–based studies have investigated the risk of dementia among individuals who suffer from migraine with aura,” Dr. Sabrina Islamoska said.

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

Kyle is a 14-year-old cisgender male who just moved to your town. At his first well-check, his single father brings him in reluctantly, stating, “We’ve never liked doctors.” Kyle has a history of asthma and obesity that have been relatively unchanged over time. He is an average student, an avid gamer, and seems somewhat shy. Privately he admits to occasional cannabis use. His father has no concerns, lamenting, “He’s always been pretty healthy for a fat kid.” Next patient?

SDI Productions/E+

Of course there is a lot to work with here. You might be concerned with Kyle’s asthma; his weight, sedentary nature, and body image; the criticism from his father and concerns about self-esteem; the possibility of anxiety in relation to his shyness; and the health effects of his cannabis use. In the end, recommendations for behavior change seem likely. These might take the form of tips on exercise, nutrition, substance use, study habits, parenting, social activities, or mental health support; the literature on behavior change would suggest that any success will be predicated on trust. How can we learn from someone we do not trust?¹

To build trust is no easy task, and yet is perhaps the foundation on which the entire clinical relationship rests. Guidance from decades of evidence supporting the use of motivational interviewing² suggests that the process of building rapport can be neatly summed up in an acronym as PACE. This represents Partnership, Acceptance, Compassion, and Evocation. Almost too clichéd to repeat, the most powerful change agent is the person making the change. In the setting of pediatric health care, we sometimes lean on caregivers to initiate or promote change because they are an intimate part of the patient’s microsystem, and thus moving one gear (the parents) inevitably shifts something in connected gears (the children).

So Partnership is centered on the patient, but inclusive of any important person in the patient’s sphere. In a family-based approach, this might show up as leveraging Kyle’s father’s motivation for behavior change by having the father start an exercise routine. This role models behavior change, shifts the home environment around the behavior, and builds empathy in the parent for the inherent challenges of change processes.

Acceptance can be distilled into knowing that the patient and family are doing the best they can. This does not preclude the possibility of change, but it seats this possibility in an attitude of assumed adequacy. There is nothing wrong with the patient, nothing to be fixed, just the possibility for change.

Similarly, Compassion takes a nonjudgmental viewpoint. With the stance of “this could happen to anybody,” the patient can feel responsible without feeling blamed. Noting the patient’s suffering without blame allows the clinician to be motivated not just to empathize, but to help.

And from this basis of compassionate partnership, the work of Evocation begins. What is happening in the patient’s life and relationships? What are their own goals and values? Where are the discrepancies between what the patient wants and what the patient does? For teenagers, this often brings into conflict developmentally appropriate wishes for autonomy – wanting to drive or get a car or stay out later or have more privacy – with developmentally typical challenges regarding responsibility.³ For example:

Clinician: “You want to use the car, and your parents want you to pay for the gas, but you’re out of money from buying weed. I see how you’re stuck.”

Teen: “Yeah, they really need to give me more allowance. It’s not like we’re living in the 1990s anymore!”

Clinician: “So you could ask for more allowance to get more money for gas. Any other ideas?”

Teen: “I could give up smoking pot and just be miserable all the time.”

Clinician: “Yeah, that sounds too difficult right now; if anything it sounds like you’d like to smoke more pot if you had more money.”

Teen: “Nah, I’m not that hooked on it. ... I could probably smoke a bit less each week and save some gas money.”

The PACE acronym also serves as a reminder of the patience required to grow connection where none has previously existed – pace yourself. Here are some skills-based tips to foster the spirit of motivational interviewing to help balance patience with the time frame of a pediatric check-in. The OARS skills represent the fundamental building blocks of motivational interviewing in practice. Taking the case of Kyle as an example, an Open-Ended Question makes space for the child or parent to express their views with less interviewer bias. Reflections expand this space by underscoring and, in the case of complex Reflections, adding some nuance to what the patient has to say.

Clinician: “How do you feel about your body?”

Teen: “Well, I’m fat. Nobody really wants to be fat. It sucks. But what can I do?”

Clinician: “You feel fat and kind of hopeless.”

Teen: “Yeah, I know you’re going to tell me to go on a diet and start exercising. Doesn’t work. My dad says I was born fat; I guess I’m going to stay that way.”

Clinician: “Sounds like you and your dad can get down on you for your weight. That must feel terrible.”

Teen: “Ah, it’s not that bad. I’m kind of used to it. Fat kid at home, fat kid at school.”

Affirmations are statements focusing on positive actions or attributes of the patient. They tend to build rapport by demonstrating that the clinician sees the strengths of the patient, not just the problems.

Clinician: “I’m pretty impressed that you’re able to show up here and talk about this. It can’t be easy when it sounds like your family and friends have put you down so much that you’re even putting yourself down about your body.”

Teen: “I didn’t really want to come, but then I thought, maybe this new doctor will have some new ideas. I actually want to do something about it, I just don’t know if anything will help. Plus my dad said if I showed up, we could go to McDonald’s afterward.”

Summaries are multipurpose. They demonstrate that you have been listening closely, which builds rapport. They provide a chance to put information together so that both clinician and patient can reflect on the sum of the data and notice what may be missing. And they provide a pause to consider where to go next.

Clinician: “So if I’m getting it right, you’ve been worried about your weight for a long time now. Your dad and your friends give you a hard time about it, which makes you feel down and hopeless, but somehow you stay brave and keep trying to figure it out. You feel ready to do something, you just don’t know what, and you were hoping maybe coming here could give you a place to work on your health. Does that sound about right?”

Teen: “I think that’s pretty much it. Plus the McDonald’s.”

Clinician: “Right, that’s important too – we have to consider your motivation! I wonder if we could talk about this more at our next visit – would that be alright?”

Offices with additional resources might be able to offer some of those as well, if timing seems appropriate; for example, referral to a wellness coach or social worker or nutritionist could be helpful int his case. The name of the game is small goals, building motivation a little more each visit, and maintaining the supportive connection. With the spirit of PACE and the skills of OARS, you can be well on your way to fostering behavior changes that could last a lifetime! Check out the resources from the American Academy of Pediatrics with video and narrative demonstrations of motivational interviewing in pediatrics.
 

Dr. Rosenfeld is assistant professor in the departments of psychiatry and pediatrics at the University of Vermont Medical Center and the university’s Robert Larner College of Medicine, Burlington. He reported no relevant disclosures. Email him at pdnews@mdedge.com.

References

1. Miller WR, Rollnick S. “Engagement and disengagement,” in “Motivational interviewing: Helping people change,” 3rd ed. (New York: Guilford, 2013).

2. Miller WR, Rollnick S. “The spirit of motivational interviewing,” in “Motivational interviewing: Helping people change,” 3rd ed. (New York: Guilford, 2013).

3. Naar S, Suarez M. “Adolescence and emerging adulthood: A brief review of development,” in “Motivational interviewing with adolescents and young adults” (New York: Guilford, 2011).

Kyle is a 14-year-old cisgender male who just moved to your town. At his first well-check, his single father brings him in reluctantly, stating, “We’ve never liked doctors.” Kyle has a history of asthma and obesity that have been relatively unchanged over time. He is an average student, an avid gamer, and seems somewhat shy. Privately he admits to occasional cannabis use. His father has no concerns, lamenting, “He’s always been pretty healthy for a fat kid.” Next patient?

SDI Productions/E+

Of course there is a lot to work with here. You might be concerned with Kyle’s asthma; his weight, sedentary nature, and body image; the criticism from his father and concerns about self-esteem; the possibility of anxiety in relation to his shyness; and the health effects of his cannabis use. In the end, recommendations for behavior change seem likely. These might take the form of tips on exercise, nutrition, substance use, study habits, parenting, social activities, or mental health support; the literature on behavior change would suggest that any success will be predicated on trust. How can we learn from someone we do not trust?¹

To build trust is no easy task, and yet is perhaps the foundation on which the entire clinical relationship rests. Guidance from decades of evidence supporting the use of motivational interviewing² suggests that the process of building rapport can be neatly summed up in an acronym as PACE. This represents Partnership, Acceptance, Compassion, and Evocation. Almost too clichéd to repeat, the most powerful change agent is the person making the change. In the setting of pediatric health care, we sometimes lean on caregivers to initiate or promote change because they are an intimate part of the patient’s microsystem, and thus moving one gear (the parents) inevitably shifts something in connected gears (the children).

So Partnership is centered on the patient, but inclusive of any important person in the patient’s sphere. In a family-based approach, this might show up as leveraging Kyle’s father’s motivation for behavior change by having the father start an exercise routine. This role models behavior change, shifts the home environment around the behavior, and builds empathy in the parent for the inherent challenges of change processes.

Acceptance can be distilled into knowing that the patient and family are doing the best they can. This does not preclude the possibility of change, but it seats this possibility in an attitude of assumed adequacy. There is nothing wrong with the patient, nothing to be fixed, just the possibility for change.

Similarly, Compassion takes a nonjudgmental viewpoint. With the stance of “this could happen to anybody,” the patient can feel responsible without feeling blamed. Noting the patient’s suffering without blame allows the clinician to be motivated not just to empathize, but to help.

And from this basis of compassionate partnership, the work of Evocation begins. What is happening in the patient’s life and relationships? What are their own goals and values? Where are the discrepancies between what the patient wants and what the patient does? For teenagers, this often brings into conflict developmentally appropriate wishes for autonomy – wanting to drive or get a car or stay out later or have more privacy – with developmentally typical challenges regarding responsibility.³ For example:

Clinician: “You want to use the car, and your parents want you to pay for the gas, but you’re out of money from buying weed. I see how you’re stuck.”

Teen: “Yeah, they really need to give me more allowance. It’s not like we’re living in the 1990s anymore!”

Clinician: “So you could ask for more allowance to get more money for gas. Any other ideas?”

Teen: “I could give up smoking pot and just be miserable all the time.”

Clinician: “Yeah, that sounds too difficult right now; if anything it sounds like you’d like to smoke more pot if you had more money.”

Teen: “Nah, I’m not that hooked on it. ... I could probably smoke a bit less each week and save some gas money.”

The PACE acronym also serves as a reminder of the patience required to grow connection where none has previously existed – pace yourself. Here are some skills-based tips to foster the spirit of motivational interviewing to help balance patience with the time frame of a pediatric check-in. The OARS skills represent the fundamental building blocks of motivational interviewing in practice. Taking the case of Kyle as an example, an Open-Ended Question makes space for the child or parent to express their views with less interviewer bias. Reflections expand this space by underscoring and, in the case of complex Reflections, adding some nuance to what the patient has to say.

Clinician: “How do you feel about your body?”

Teen: “Well, I’m fat. Nobody really wants to be fat. It sucks. But what can I do?”

Clinician: “You feel fat and kind of hopeless.”

Teen: “Yeah, I know you’re going to tell me to go on a diet and start exercising. Doesn’t work. My dad says I was born fat; I guess I’m going to stay that way.”

Clinician: “Sounds like you and your dad can get down on you for your weight. That must feel terrible.”

Teen: “Ah, it’s not that bad. I’m kind of used to it. Fat kid at home, fat kid at school.”

Affirmations are statements focusing on positive actions or attributes of the patient. They tend to build rapport by demonstrating that the clinician sees the strengths of the patient, not just the problems.

Clinician: “I’m pretty impressed that you’re able to show up here and talk about this. It can’t be easy when it sounds like your family and friends have put you down so much that you’re even putting yourself down about your body.”

Teen: “I didn’t really want to come, but then I thought, maybe this new doctor will have some new ideas. I actually want to do something about it, I just don’t know if anything will help. Plus my dad said if I showed up, we could go to McDonald’s afterward.”

Summaries are multipurpose. They demonstrate that you have been listening closely, which builds rapport. They provide a chance to put information together so that both clinician and patient can reflect on the sum of the data and notice what may be missing. And they provide a pause to consider where to go next.

Clinician: “So if I’m getting it right, you’ve been worried about your weight for a long time now. Your dad and your friends give you a hard time about it, which makes you feel down and hopeless, but somehow you stay brave and keep trying to figure it out. You feel ready to do something, you just don’t know what, and you were hoping maybe coming here could give you a place to work on your health. Does that sound about right?”

Teen: “I think that’s pretty much it. Plus the McDonald’s.”

Clinician: “Right, that’s important too – we have to consider your motivation! I wonder if we could talk about this more at our next visit – would that be alright?”

Offices with additional resources might be able to offer some of those as well, if timing seems appropriate; for example, referral to a wellness coach or social worker or nutritionist could be helpful int his case. The name of the game is small goals, building motivation a little more each visit, and maintaining the supportive connection. With the spirit of PACE and the skills of OARS, you can be well on your way to fostering behavior changes that could last a lifetime! Check out the resources from the American Academy of Pediatrics with video and narrative demonstrations of motivational interviewing in pediatrics.
 

Dr. Rosenfeld is assistant professor in the departments of psychiatry and pediatrics at the University of Vermont Medical Center and the university’s Robert Larner College of Medicine, Burlington. He reported no relevant disclosures. Email him at pdnews@mdedge.com.

References

1. Miller WR, Rollnick S. “Engagement and disengagement,” in “Motivational interviewing: Helping people change,” 3rd ed. (New York: Guilford, 2013).

2. Miller WR, Rollnick S. “The spirit of motivational interviewing,” in “Motivational interviewing: Helping people change,” 3rd ed. (New York: Guilford, 2013).

3. Naar S, Suarez M. “Adolescence and emerging adulthood: A brief review of development,” in “Motivational interviewing with adolescents and young adults” (New York: Guilford, 2011).

Kyle is a 14-year-old cisgender male who just moved to your town. At his first well-check, his single father brings him in reluctantly, stating, “We’ve never liked doctors.” Kyle has a history of asthma and obesity that have been relatively unchanged over time. He is an average student, an avid gamer, and seems somewhat shy. Privately he admits to occasional cannabis use. His father has no concerns, lamenting, “He’s always been pretty healthy for a fat kid.” Next patient?

SDI Productions/E+

Of course there is a lot to work with here. You might be concerned with Kyle’s asthma; his weight, sedentary nature, and body image; the criticism from his father and concerns about self-esteem; the possibility of anxiety in relation to his shyness; and the health effects of his cannabis use. In the end, recommendations for behavior change seem likely. These might take the form of tips on exercise, nutrition, substance use, study habits, parenting, social activities, or mental health support; the literature on behavior change would suggest that any success will be predicated on trust. How can we learn from someone we do not trust?¹

To build trust is no easy task, and yet is perhaps the foundation on which the entire clinical relationship rests. Guidance from decades of evidence supporting the use of motivational interviewing² suggests that the process of building rapport can be neatly summed up in an acronym as PACE. This represents Partnership, Acceptance, Compassion, and Evocation. Almost too clichéd to repeat, the most powerful change agent is the person making the change. In the setting of pediatric health care, we sometimes lean on caregivers to initiate or promote change because they are an intimate part of the patient’s microsystem, and thus moving one gear (the parents) inevitably shifts something in connected gears (the children).

So Partnership is centered on the patient, but inclusive of any important person in the patient’s sphere. In a family-based approach, this might show up as leveraging Kyle’s father’s motivation for behavior change by having the father start an exercise routine. This role models behavior change, shifts the home environment around the behavior, and builds empathy in the parent for the inherent challenges of change processes.

Acceptance can be distilled into knowing that the patient and family are doing the best they can. This does not preclude the possibility of change, but it seats this possibility in an attitude of assumed adequacy. There is nothing wrong with the patient, nothing to be fixed, just the possibility for change.

Similarly, Compassion takes a nonjudgmental viewpoint. With the stance of “this could happen to anybody,” the patient can feel responsible without feeling blamed. Noting the patient’s suffering without blame allows the clinician to be motivated not just to empathize, but to help.

And from this basis of compassionate partnership, the work of Evocation begins. What is happening in the patient’s life and relationships? What are their own goals and values? Where are the discrepancies between what the patient wants and what the patient does? For teenagers, this often brings into conflict developmentally appropriate wishes for autonomy – wanting to drive or get a car or stay out later or have more privacy – with developmentally typical challenges regarding responsibility.³ For example:

Clinician: “You want to use the car, and your parents want you to pay for the gas, but you’re out of money from buying weed. I see how you’re stuck.”

Teen: “Yeah, they really need to give me more allowance. It’s not like we’re living in the 1990s anymore!”

Clinician: “So you could ask for more allowance to get more money for gas. Any other ideas?”

Teen: “I could give up smoking pot and just be miserable all the time.”

Clinician: “Yeah, that sounds too difficult right now; if anything it sounds like you’d like to smoke more pot if you had more money.”

Teen: “Nah, I’m not that hooked on it. ... I could probably smoke a bit less each week and save some gas money.”

The PACE acronym also serves as a reminder of the patience required to grow connection where none has previously existed – pace yourself. Here are some skills-based tips to foster the spirit of motivational interviewing to help balance patience with the time frame of a pediatric check-in. The OARS skills represent the fundamental building blocks of motivational interviewing in practice. Taking the case of Kyle as an example, an Open-Ended Question makes space for the child or parent to express their views with less interviewer bias. Reflections expand this space by underscoring and, in the case of complex Reflections, adding some nuance to what the patient has to say.

Clinician: “How do you feel about your body?”

Teen: “Well, I’m fat. Nobody really wants to be fat. It sucks. But what can I do?”

Clinician: “You feel fat and kind of hopeless.”

Teen: “Yeah, I know you’re going to tell me to go on a diet and start exercising. Doesn’t work. My dad says I was born fat; I guess I’m going to stay that way.”

Clinician: “Sounds like you and your dad can get down on you for your weight. That must feel terrible.”

Teen: “Ah, it’s not that bad. I’m kind of used to it. Fat kid at home, fat kid at school.”

Affirmations are statements focusing on positive actions or attributes of the patient. They tend to build rapport by demonstrating that the clinician sees the strengths of the patient, not just the problems.

Clinician: “I’m pretty impressed that you’re able to show up here and talk about this. It can’t be easy when it sounds like your family and friends have put you down so much that you’re even putting yourself down about your body.”

Teen: “I didn’t really want to come, but then I thought, maybe this new doctor will have some new ideas. I actually want to do something about it, I just don’t know if anything will help. Plus my dad said if I showed up, we could go to McDonald’s afterward.”

Summaries are multipurpose. They demonstrate that you have been listening closely, which builds rapport. They provide a chance to put information together so that both clinician and patient can reflect on the sum of the data and notice what may be missing. And they provide a pause to consider where to go next.

Clinician: “So if I’m getting it right, you’ve been worried about your weight for a long time now. Your dad and your friends give you a hard time about it, which makes you feel down and hopeless, but somehow you stay brave and keep trying to figure it out. You feel ready to do something, you just don’t know what, and you were hoping maybe coming here could give you a place to work on your health. Does that sound about right?”

Teen: “I think that’s pretty much it. Plus the McDonald’s.”

Clinician: “Right, that’s important too – we have to consider your motivation! I wonder if we could talk about this more at our next visit – would that be alright?”

Offices with additional resources might be able to offer some of those as well, if timing seems appropriate; for example, referral to a wellness coach or social worker or nutritionist could be helpful int his case. The name of the game is small goals, building motivation a little more each visit, and maintaining the supportive connection. With the spirit of PACE and the skills of OARS, you can be well on your way to fostering behavior changes that could last a lifetime! Check out the resources from the American Academy of Pediatrics with video and narrative demonstrations of motivational interviewing in pediatrics.
 

Dr. Rosenfeld is assistant professor in the departments of psychiatry and pediatrics at the University of Vermont Medical Center and the university’s Robert Larner College of Medicine, Burlington. He reported no relevant disclosures. Email him at pdnews@mdedge.com.

References

1. Miller WR, Rollnick S. “Engagement and disengagement,” in “Motivational interviewing: Helping people change,” 3rd ed. (New York: Guilford, 2013).

2. Miller WR, Rollnick S. “The spirit of motivational interviewing,” in “Motivational interviewing: Helping people change,” 3rd ed. (New York: Guilford, 2013).

3. Naar S, Suarez M. “Adolescence and emerging adulthood: A brief review of development,” in “Motivational interviewing with adolescents and young adults” (New York: Guilford, 2011).

Adult patients with Burkitt lymphoma can achieve equally sound survival outcomes with dose-adjusted chemotherapy versus high-intensity regimens, but can do so while avoiding the severe toxicities, U.S. study data shows.

Courtesy Wikimedia Commons/Ed Uthman, MD/Creative Commons License

Although Burkitt lymphoma is the most common B-cell non-Hodgkin lymphoma in children, it accounts for only 1% to 2% of adult lymphoma cases.

Highly dose-intensive chemotherapy regimens, developed for children and young adults, have rendered the disease curable. But older patients in particular, and patients with comorbidities such as HIV, can suffer severe adverse effects, as well as late sequelae like second malignancies.

Mark Roschewski, MD, from the lymphoid malignancies branch at the National Cancer Institute in Bethesda, Md., and colleagues therefore examined whether a dose-adjusted regimen would maintain outcomes while reducing toxicities.

Tailoring treatment with etoposide, doxorubicin, and vincristine with prednisone, cyclophosphamide, and rituximab (EPOCH-R) to whether patients had high- or low-risk disease, they achieved 4-year survival rates of higher than 85%.

The research, published by the Journal of Clinical Oncology, also showed that patients taking the regimen, which was well tolerated, had low rates of relapse in the central nervous system.

The team reports that their results with the dose-adjusted regimen “significantly improve on the complexity, cost, and toxicity profile of other regimens,” also highlighting that it is administered on an outpatient basis.

As the outcomes also “compare favorably” with those with high intensity regimens, they say the findings “support our treatment strategies to ameliorate toxicity while maintaining efficacy.”

Importantly, they suggest highly dose-intensive chemotherapy is unnecessary for cure, and carefully defined low-risk patients may be treated with limited chemotherapy.

Dr. Roschewski said in an interview that, in patients aged 40 years and older, dose-adjusted EPOCH-R is “probably the preferred choice,” despite its “weakness” in controlling the disease in patients with active CNS involvement.

However, the “real question” is what to use in younger patients, Dr. Roschewski said, as the “unknown” is whether the additional magnitude of a high-intensity regimen that “gets into the CNS” outweighs the risk of toxicities.

“What was important about our study,” he said, was that patients with CNS involvement “did the worst but it was equally split among patients that died of toxicity and patients that progressed.”

In other words, each choice increases one risk while decreasing another. “So I would have to have that discussion with the patient, and individual patient decisions are typically based on the details,” said Dr. Roschewski.

One issue, however, that could limit the adoption of dose-adjusted EPOCH-R is that, without a randomized study comparing it directly with a high-intensity regimen, clinicians may to stick to what they know.

Dr. Roschewski said that “this is particularly true of more experienced clinicians.”

“They’re less likely, I think, to adopt something else outside of a randomized study because our natural inclination with this disease has always been dose intensity is critical. ... This is a dogma, and to shift from that probably does require a higher level of evidence, at least for some practitioners,” he explained.
 

Further study details

Following a pilot study of dose-adjusted EPOCH-R in 30 adult patients in which the authors say the regimen showed “high efficacy,” they enrolled 113 patients with untreated Burkitt lymphoma at 22 centers between June 2010 and May 2017.

The patients were divided into low-risk and high-risk categories, with low-risk defined as stage 1 or 2 disease, normal lactate dehydrogenase levels, ECOG performance status ≤ 1, and no tumor mass ≥ 7 cm.

High-risk patients were given six cycles of dose-adjusted EPOCH-R (with rituximab on day 1 only) along with CNS prophylaxis or active therapy with intrathecal methotrexate.

In contrast, low-risk patients were given two cycles of dose-adjusted EPOCH-R, with rituximab on days 1 and 5, followed by positron emission tomography.

If that was negative, the patients had one additional treatment cycle and no CNS prophylaxis, but if it was positive, they were given four additional cycles, plus intrathecal methotrexate.

Of the 113 patients enrolled, 79% were male, median age was 49 years, and 62% were aged at least 40 years, including 26% aged at least 60 years.

The team determined that 13% of the patients were of low risk, 87% were high risk, and 11% had cerebrospinal fluid involvement. One-quarter (24.7%) were HIV positive, with a median CD4+ T-cell count of 268 cells/mm³.

The majority (87%) of low-risk patients received three treatment cycles, and 82% of high-risk patents were administered six treatment cycles.

Over a median follow-up of 58.7 months (4.9 years), the 4-year event-free survival (EFS) rate across the whole cohort was 84.5% and overall survival was 87%.

At the time of analysis, all low-risk patients were in remission; among high-risk patients, the 4-year EFS was 82.1% and overall survival was 84.9%.

The team reports that treatment was equally effective across age groups, and irrespective of HIV status and International Prognostic Index risk group.

Only 2% of high-risk patients with no pretreatment evidence of CNS involvement had relapses in the brain parenchyma. Just over half (55%) of patients with cerebrospinal fluid involvement at presentation experienced disease progression or died.

Five patients died of treatment-related toxicity. Grade 3/4 thrombocytopenia occurred during 17% of cycles, and febrile neutropenia was seen during 16%. Tumor lysis syndrome was rare, occurring in 5% of patients.

Next, the researchers are planning on focusing on CNS disease, looking at EPOCH-R as the backbone and adding intrathecal methotrexate and an additional targeted agent with known CNS penetration.

Dr. Roschewski said that is “a very attractive strategy and ... we will initiate enrollment in that study probably in the next couple of months here at the NCI,” he added, noting that it will be an early phase 1 study.

Another issue he identified that “doesn’t get spoken about quite as much but I do think is important is potentially working on supportive care guidelines for how we manage these patients.” Dr. Roschewski explained, “One of the things you see over and over in these Burkitt lymphoma studies is that some patients don’t make it through therapy because they’re so sick at the beginning, and they have certain risks.

“I think simply improving that type of care, independent of what regimen is used, can potentially improve the outcomes across patient groups.”

The study was funded by the National Cancer Institute, National Institutes of Health, AIDS Malignancy Consortium, and the Cancer Therapy Evaluation Program and Lymphoid Malignancies Branch. The authors have disclosed no relevant financial relationships.

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

Adult patients with Burkitt lymphoma can achieve equally sound survival outcomes with dose-adjusted chemotherapy versus high-intensity regimens, but can do so while avoiding the severe toxicities, U.S. study data shows.

Courtesy Wikimedia Commons/Ed Uthman, MD/Creative Commons License

Although Burkitt lymphoma is the most common B-cell non-Hodgkin lymphoma in children, it accounts for only 1% to 2% of adult lymphoma cases.

Highly dose-intensive chemotherapy regimens, developed for children and young adults, have rendered the disease curable. But older patients in particular, and patients with comorbidities such as HIV, can suffer severe adverse effects, as well as late sequelae like second malignancies.

Mark Roschewski, MD, from the lymphoid malignancies branch at the National Cancer Institute in Bethesda, Md., and colleagues therefore examined whether a dose-adjusted regimen would maintain outcomes while reducing toxicities.

Tailoring treatment with etoposide, doxorubicin, and vincristine with prednisone, cyclophosphamide, and rituximab (EPOCH-R) to whether patients had high- or low-risk disease, they achieved 4-year survival rates of higher than 85%.

The research, published by the Journal of Clinical Oncology, also showed that patients taking the regimen, which was well tolerated, had low rates of relapse in the central nervous system.

The team reports that their results with the dose-adjusted regimen “significantly improve on the complexity, cost, and toxicity profile of other regimens,” also highlighting that it is administered on an outpatient basis.

As the outcomes also “compare favorably” with those with high intensity regimens, they say the findings “support our treatment strategies to ameliorate toxicity while maintaining efficacy.”

Importantly, they suggest highly dose-intensive chemotherapy is unnecessary for cure, and carefully defined low-risk patients may be treated with limited chemotherapy.

Dr. Roschewski said in an interview that, in patients aged 40 years and older, dose-adjusted EPOCH-R is “probably the preferred choice,” despite its “weakness” in controlling the disease in patients with active CNS involvement.

However, the “real question” is what to use in younger patients, Dr. Roschewski said, as the “unknown” is whether the additional magnitude of a high-intensity regimen that “gets into the CNS” outweighs the risk of toxicities.

“What was important about our study,” he said, was that patients with CNS involvement “did the worst but it was equally split among patients that died of toxicity and patients that progressed.”

In other words, each choice increases one risk while decreasing another. “So I would have to have that discussion with the patient, and individual patient decisions are typically based on the details,” said Dr. Roschewski.

One issue, however, that could limit the adoption of dose-adjusted EPOCH-R is that, without a randomized study comparing it directly with a high-intensity regimen, clinicians may to stick to what they know.

Dr. Roschewski said that “this is particularly true of more experienced clinicians.”

“They’re less likely, I think, to adopt something else outside of a randomized study because our natural inclination with this disease has always been dose intensity is critical. ... This is a dogma, and to shift from that probably does require a higher level of evidence, at least for some practitioners,” he explained.
 

Further study details

Following a pilot study of dose-adjusted EPOCH-R in 30 adult patients in which the authors say the regimen showed “high efficacy,” they enrolled 113 patients with untreated Burkitt lymphoma at 22 centers between June 2010 and May 2017.

The patients were divided into low-risk and high-risk categories, with low-risk defined as stage 1 or 2 disease, normal lactate dehydrogenase levels, ECOG performance status ≤ 1, and no tumor mass ≥ 7 cm.

High-risk patients were given six cycles of dose-adjusted EPOCH-R (with rituximab on day 1 only) along with CNS prophylaxis or active therapy with intrathecal methotrexate.

In contrast, low-risk patients were given two cycles of dose-adjusted EPOCH-R, with rituximab on days 1 and 5, followed by positron emission tomography.

If that was negative, the patients had one additional treatment cycle and no CNS prophylaxis, but if it was positive, they were given four additional cycles, plus intrathecal methotrexate.

Of the 113 patients enrolled, 79% were male, median age was 49 years, and 62% were aged at least 40 years, including 26% aged at least 60 years.

The team determined that 13% of the patients were of low risk, 87% were high risk, and 11% had cerebrospinal fluid involvement. One-quarter (24.7%) were HIV positive, with a median CD4+ T-cell count of 268 cells/mm³.

The majority (87%) of low-risk patients received three treatment cycles, and 82% of high-risk patents were administered six treatment cycles.

Over a median follow-up of 58.7 months (4.9 years), the 4-year event-free survival (EFS) rate across the whole cohort was 84.5% and overall survival was 87%.

At the time of analysis, all low-risk patients were in remission; among high-risk patients, the 4-year EFS was 82.1% and overall survival was 84.9%.

The team reports that treatment was equally effective across age groups, and irrespective of HIV status and International Prognostic Index risk group.

Only 2% of high-risk patients with no pretreatment evidence of CNS involvement had relapses in the brain parenchyma. Just over half (55%) of patients with cerebrospinal fluid involvement at presentation experienced disease progression or died.

Five patients died of treatment-related toxicity. Grade 3/4 thrombocytopenia occurred during 17% of cycles, and febrile neutropenia was seen during 16%. Tumor lysis syndrome was rare, occurring in 5% of patients.

Next, the researchers are planning on focusing on CNS disease, looking at EPOCH-R as the backbone and adding intrathecal methotrexate and an additional targeted agent with known CNS penetration.

Dr. Roschewski said that is “a very attractive strategy and ... we will initiate enrollment in that study probably in the next couple of months here at the NCI,” he added, noting that it will be an early phase 1 study.

Another issue he identified that “doesn’t get spoken about quite as much but I do think is important is potentially working on supportive care guidelines for how we manage these patients.” Dr. Roschewski explained, “One of the things you see over and over in these Burkitt lymphoma studies is that some patients don’t make it through therapy because they’re so sick at the beginning, and they have certain risks.

“I think simply improving that type of care, independent of what regimen is used, can potentially improve the outcomes across patient groups.”

The study was funded by the National Cancer Institute, National Institutes of Health, AIDS Malignancy Consortium, and the Cancer Therapy Evaluation Program and Lymphoid Malignancies Branch. The authors have disclosed no relevant financial relationships.

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

Adult patients with Burkitt lymphoma can achieve equally sound survival outcomes with dose-adjusted chemotherapy versus high-intensity regimens, but can do so while avoiding the severe toxicities, U.S. study data shows.

Courtesy Wikimedia Commons/Ed Uthman, MD/Creative Commons License

Although Burkitt lymphoma is the most common B-cell non-Hodgkin lymphoma in children, it accounts for only 1% to 2% of adult lymphoma cases.

Highly dose-intensive chemotherapy regimens, developed for children and young adults, have rendered the disease curable. But older patients in particular, and patients with comorbidities such as HIV, can suffer severe adverse effects, as well as late sequelae like second malignancies.

Mark Roschewski, MD, from the lymphoid malignancies branch at the National Cancer Institute in Bethesda, Md., and colleagues therefore examined whether a dose-adjusted regimen would maintain outcomes while reducing toxicities.

Tailoring treatment with etoposide, doxorubicin, and vincristine with prednisone, cyclophosphamide, and rituximab (EPOCH-R) to whether patients had high- or low-risk disease, they achieved 4-year survival rates of higher than 85%.

The research, published by the Journal of Clinical Oncology, also showed that patients taking the regimen, which was well tolerated, had low rates of relapse in the central nervous system.

The team reports that their results with the dose-adjusted regimen “significantly improve on the complexity, cost, and toxicity profile of other regimens,” also highlighting that it is administered on an outpatient basis.

As the outcomes also “compare favorably” with those with high intensity regimens, they say the findings “support our treatment strategies to ameliorate toxicity while maintaining efficacy.”

Importantly, they suggest highly dose-intensive chemotherapy is unnecessary for cure, and carefully defined low-risk patients may be treated with limited chemotherapy.

Dr. Roschewski said in an interview that, in patients aged 40 years and older, dose-adjusted EPOCH-R is “probably the preferred choice,” despite its “weakness” in controlling the disease in patients with active CNS involvement.

However, the “real question” is what to use in younger patients, Dr. Roschewski said, as the “unknown” is whether the additional magnitude of a high-intensity regimen that “gets into the CNS” outweighs the risk of toxicities.

“What was important about our study,” he said, was that patients with CNS involvement “did the worst but it was equally split among patients that died of toxicity and patients that progressed.”

In other words, each choice increases one risk while decreasing another. “So I would have to have that discussion with the patient, and individual patient decisions are typically based on the details,” said Dr. Roschewski.

One issue, however, that could limit the adoption of dose-adjusted EPOCH-R is that, without a randomized study comparing it directly with a high-intensity regimen, clinicians may to stick to what they know.

Dr. Roschewski said that “this is particularly true of more experienced clinicians.”

“They’re less likely, I think, to adopt something else outside of a randomized study because our natural inclination with this disease has always been dose intensity is critical. ... This is a dogma, and to shift from that probably does require a higher level of evidence, at least for some practitioners,” he explained.
 

Further study details

Following a pilot study of dose-adjusted EPOCH-R in 30 adult patients in which the authors say the regimen showed “high efficacy,” they enrolled 113 patients with untreated Burkitt lymphoma at 22 centers between June 2010 and May 2017.

The patients were divided into low-risk and high-risk categories, with low-risk defined as stage 1 or 2 disease, normal lactate dehydrogenase levels, ECOG performance status ≤ 1, and no tumor mass ≥ 7 cm.

High-risk patients were given six cycles of dose-adjusted EPOCH-R (with rituximab on day 1 only) along with CNS prophylaxis or active therapy with intrathecal methotrexate.

In contrast, low-risk patients were given two cycles of dose-adjusted EPOCH-R, with rituximab on days 1 and 5, followed by positron emission tomography.

If that was negative, the patients had one additional treatment cycle and no CNS prophylaxis, but if it was positive, they were given four additional cycles, plus intrathecal methotrexate.

Of the 113 patients enrolled, 79% were male, median age was 49 years, and 62% were aged at least 40 years, including 26% aged at least 60 years.

The team determined that 13% of the patients were of low risk, 87% were high risk, and 11% had cerebrospinal fluid involvement. One-quarter (24.7%) were HIV positive, with a median CD4+ T-cell count of 268 cells/mm³.

The majority (87%) of low-risk patients received three treatment cycles, and 82% of high-risk patents were administered six treatment cycles.

Over a median follow-up of 58.7 months (4.9 years), the 4-year event-free survival (EFS) rate across the whole cohort was 84.5% and overall survival was 87%.

At the time of analysis, all low-risk patients were in remission; among high-risk patients, the 4-year EFS was 82.1% and overall survival was 84.9%.

The team reports that treatment was equally effective across age groups, and irrespective of HIV status and International Prognostic Index risk group.

Only 2% of high-risk patients with no pretreatment evidence of CNS involvement had relapses in the brain parenchyma. Just over half (55%) of patients with cerebrospinal fluid involvement at presentation experienced disease progression or died.

Five patients died of treatment-related toxicity. Grade 3/4 thrombocytopenia occurred during 17% of cycles, and febrile neutropenia was seen during 16%. Tumor lysis syndrome was rare, occurring in 5% of patients.

Next, the researchers are planning on focusing on CNS disease, looking at EPOCH-R as the backbone and adding intrathecal methotrexate and an additional targeted agent with known CNS penetration.

Dr. Roschewski said that is “a very attractive strategy and ... we will initiate enrollment in that study probably in the next couple of months here at the NCI,” he added, noting that it will be an early phase 1 study.

Another issue he identified that “doesn’t get spoken about quite as much but I do think is important is potentially working on supportive care guidelines for how we manage these patients.” Dr. Roschewski explained, “One of the things you see over and over in these Burkitt lymphoma studies is that some patients don’t make it through therapy because they’re so sick at the beginning, and they have certain risks.

“I think simply improving that type of care, independent of what regimen is used, can potentially improve the outcomes across patient groups.”

The study was funded by the National Cancer Institute, National Institutes of Health, AIDS Malignancy Consortium, and the Cancer Therapy Evaluation Program and Lymphoid Malignancies Branch. The authors have disclosed no relevant financial relationships.

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

Recent studies have shown a correlation between many dietary elements and skin diseases including acne, rosacea, and perioral dermatitis. In my practice, nutritional counseling is as important as skincare counseling. I have found that inflammatory skin conditions can be improved to some extent with dietary modifications, and there is now evidence that the aging process can also be slowed with a healthy diet. Previous studies have shown that intake of vegetables, fish, and foods high in vitamin C, carotenoids, olive oil, and linoleic acid are associated with decreased wrinkles.

Lisovskaya/iStock/Getty Images

In a Dutch population-based cohort study published in the Journal of the American Academy of Dermatology in 2019, Mekić et al. investigated the association between diet and facial wrinkles in an elderly population. Facial photographs were used to evaluate wrinkle severity and diet of the participants was assessed with the Food Frequency Questionnaire and adherence to the Dutch Healthy Diet Index (DHDI).

The DHDI is a measure of the ability to adhere to the Dutch Guidelines for a Healthy Diet. The guidelines recommend a daily intake in the diet of at least 200 g of vegetables daily; at least 200 g of fruit; 90 g of brown bread, wholemeal bread, or other whole-grain products; and at least 15 g of unsalted nuts. One serving of fish (preferably oily fish) per week and little to no dairy, alcohol, red meat, cooking fats, and sugar is also recommended.

The study revealed that better adherence to the DHDI was significantly associated with fewer wrinkles among women but not men. Women who ate more animal meat and fats and carbohydrates had more wrinkles than did those with a fruit-dominant diet.

Although other healthy behaviors such as exercise and alcohol are likely to play a role in confounding these data, UV exposure as a cause of wrinkling was accounted for, and in the study, increased outdoor exercise was associated with more wrinkles. Unhealthy food can induce oxidative stress, increased skin and gut inflammation, and glycation, which are some of the physiologic mechanisms suggested to increase wrinkle formation. In contrast, nutrients in fruits and vegetables stimulate collagen production and DNA repair and reduce oxidative stress on the skin.

Nutritional advice is largely rare in internal medicine, cardiology, and even endocrinology. We are developing better ways to assess and understand the way foods interact and cause inflammation of the gut and the body and skin. I highly recommend nutritional education be a part of our residency training programs and to make better guidelines on the prevention of skin disease and aging available for both practitioners and patients.


Dr. Wesley and Dr. Talakoub are cocontributors to this column. Dr. Wesley practices dermatology in Beverly Hills, Calif. Dr. Talakoub is in private practice in McLean, Va. This month’s column is by Dr. Talakoub. Write to them at dermnews@mdedge.com. They had no relevant disclosures.


References

Mekić S et al. J Am Acad Dermatol. 2019 May;80(5):1358-1363.e2.

Purba MB et al. J Am Coll Nutr. 2001;20(1):71‐80.

van Lee L et al. Nutr J. 2012 Jul 20;11:49.

Kromhout D et al. Eur J Clin Nutr. 2016 Aug;70(8):869‐78.


 

Recent studies have shown a correlation between many dietary elements and skin diseases including acne, rosacea, and perioral dermatitis. In my practice, nutritional counseling is as important as skincare counseling. I have found that inflammatory skin conditions can be improved to some extent with dietary modifications, and there is now evidence that the aging process can also be slowed with a healthy diet. Previous studies have shown that intake of vegetables, fish, and foods high in vitamin C, carotenoids, olive oil, and linoleic acid are associated with decreased wrinkles.

Lisovskaya/iStock/Getty Images

In a Dutch population-based cohort study published in the Journal of the American Academy of Dermatology in 2019, Mekić et al. investigated the association between diet and facial wrinkles in an elderly population. Facial photographs were used to evaluate wrinkle severity and diet of the participants was assessed with the Food Frequency Questionnaire and adherence to the Dutch Healthy Diet Index (DHDI).

The DHDI is a measure of the ability to adhere to the Dutch Guidelines for a Healthy Diet. The guidelines recommend a daily intake in the diet of at least 200 g of vegetables daily; at least 200 g of fruit; 90 g of brown bread, wholemeal bread, or other whole-grain products; and at least 15 g of unsalted nuts. One serving of fish (preferably oily fish) per week and little to no dairy, alcohol, red meat, cooking fats, and sugar is also recommended.

The study revealed that better adherence to the DHDI was significantly associated with fewer wrinkles among women but not men. Women who ate more animal meat and fats and carbohydrates had more wrinkles than did those with a fruit-dominant diet.

Although other healthy behaviors such as exercise and alcohol are likely to play a role in confounding these data, UV exposure as a cause of wrinkling was accounted for, and in the study, increased outdoor exercise was associated with more wrinkles. Unhealthy food can induce oxidative stress, increased skin and gut inflammation, and glycation, which are some of the physiologic mechanisms suggested to increase wrinkle formation. In contrast, nutrients in fruits and vegetables stimulate collagen production and DNA repair and reduce oxidative stress on the skin.

Nutritional advice is largely rare in internal medicine, cardiology, and even endocrinology. We are developing better ways to assess and understand the way foods interact and cause inflammation of the gut and the body and skin. I highly recommend nutritional education be a part of our residency training programs and to make better guidelines on the prevention of skin disease and aging available for both practitioners and patients.


Dr. Wesley and Dr. Talakoub are cocontributors to this column. Dr. Wesley practices dermatology in Beverly Hills, Calif. Dr. Talakoub is in private practice in McLean, Va. This month’s column is by Dr. Talakoub. Write to them at dermnews@mdedge.com. They had no relevant disclosures.


References

Mekić S et al. J Am Acad Dermatol. 2019 May;80(5):1358-1363.e2.

Purba MB et al. J Am Coll Nutr. 2001;20(1):71‐80.

van Lee L et al. Nutr J. 2012 Jul 20;11:49.

Kromhout D et al. Eur J Clin Nutr. 2016 Aug;70(8):869‐78.


 

Recent studies have shown a correlation between many dietary elements and skin diseases including acne, rosacea, and perioral dermatitis. In my practice, nutritional counseling is as important as skincare counseling. I have found that inflammatory skin conditions can be improved to some extent with dietary modifications, and there is now evidence that the aging process can also be slowed with a healthy diet. Previous studies have shown that intake of vegetables, fish, and foods high in vitamin C, carotenoids, olive oil, and linoleic acid are associated with decreased wrinkles.

Lisovskaya/iStock/Getty Images

In a Dutch population-based cohort study published in the Journal of the American Academy of Dermatology in 2019, Mekić et al. investigated the association between diet and facial wrinkles in an elderly population. Facial photographs were used to evaluate wrinkle severity and diet of the participants was assessed with the Food Frequency Questionnaire and adherence to the Dutch Healthy Diet Index (DHDI).

The DHDI is a measure of the ability to adhere to the Dutch Guidelines for a Healthy Diet. The guidelines recommend a daily intake in the diet of at least 200 g of vegetables daily; at least 200 g of fruit; 90 g of brown bread, wholemeal bread, or other whole-grain products; and at least 15 g of unsalted nuts. One serving of fish (preferably oily fish) per week and little to no dairy, alcohol, red meat, cooking fats, and sugar is also recommended.

The study revealed that better adherence to the DHDI was significantly associated with fewer wrinkles among women but not men. Women who ate more animal meat and fats and carbohydrates had more wrinkles than did those with a fruit-dominant diet.

Although other healthy behaviors such as exercise and alcohol are likely to play a role in confounding these data, UV exposure as a cause of wrinkling was accounted for, and in the study, increased outdoor exercise was associated with more wrinkles. Unhealthy food can induce oxidative stress, increased skin and gut inflammation, and glycation, which are some of the physiologic mechanisms suggested to increase wrinkle formation. In contrast, nutrients in fruits and vegetables stimulate collagen production and DNA repair and reduce oxidative stress on the skin.

Nutritional advice is largely rare in internal medicine, cardiology, and even endocrinology. We are developing better ways to assess and understand the way foods interact and cause inflammation of the gut and the body and skin. I highly recommend nutritional education be a part of our residency training programs and to make better guidelines on the prevention of skin disease and aging available for both practitioners and patients.


Dr. Wesley and Dr. Talakoub are cocontributors to this column. Dr. Wesley practices dermatology in Beverly Hills, Calif. Dr. Talakoub is in private practice in McLean, Va. This month’s column is by Dr. Talakoub. Write to them at dermnews@mdedge.com. They had no relevant disclosures.


References

Mekić S et al. J Am Acad Dermatol. 2019 May;80(5):1358-1363.e2.

Purba MB et al. J Am Coll Nutr. 2001;20(1):71‐80.

van Lee L et al. Nutr J. 2012 Jul 20;11:49.

Kromhout D et al. Eur J Clin Nutr. 2016 Aug;70(8):869‐78.


 

Dermatology News welcomes Marius-Anton (Toni) Ionescu, MD, PhD, to its editorial advisory board. Dr. Ionescu is a specialist in dermatology and venereology in the department of dermatology at University Hospital Saint-Louis in Paris, in the inflammatory diseases outpatient clinic, where he treats patients with severe psoriasis and other inflammatory chronic skin diseases.

He is a member of several dermatology specialty organizations, including the Société Française de Dermatologie, the European Academy of Dermatology, as well as the American Academy of Dermatology. His research interests are in immunology and inflammatory diseases; he also has a passion for art and history.

Dermatology News welcomes Marius-Anton (Toni) Ionescu, MD, PhD, to its editorial advisory board. Dr. Ionescu is a specialist in dermatology and venereology in the department of dermatology at University Hospital Saint-Louis in Paris, in the inflammatory diseases outpatient clinic, where he treats patients with severe psoriasis and other inflammatory chronic skin diseases.

He is a member of several dermatology specialty organizations, including the Société Française de Dermatologie, the European Academy of Dermatology, as well as the American Academy of Dermatology. His research interests are in immunology and inflammatory diseases; he also has a passion for art and history.

Dermatology News welcomes Marius-Anton (Toni) Ionescu, MD, PhD, to its editorial advisory board. Dr. Ionescu is a specialist in dermatology and venereology in the department of dermatology at University Hospital Saint-Louis in Paris, in the inflammatory diseases outpatient clinic, where he treats patients with severe psoriasis and other inflammatory chronic skin diseases.

He is a member of several dermatology specialty organizations, including the Société Française de Dermatologie, the European Academy of Dermatology, as well as the American Academy of Dermatology. His research interests are in immunology and inflammatory diseases; he also has a passion for art and history.