In the fall of 2019, the University of Pennsylvania in Philadelphia started a pilot program of home-based chemotherapy for two treatment regimens (one via infusion and one via injection). Six months later, the Cancer Care at Home program had treated 40 patients.

The uptake within the university’s large regional health system was acceptable but not rapid, admitted Amy Laughlin, MD, a hematology-oncology fellow involved with the program.

Then COVID-19 arrived, along with related travel restrictions.

Suddenly, in a 5-week period (March to April 7), 175 patients had been treated – a 300% increase from the first half year. Program staff jumped from 12 to 80 employees. The list of chemotherapies delivered went from two to seven, with more coming.

“We’re not the pilot anymore – we’re the standard of care,” Laughlin told Medscape Medical News.

“The impact [on patients] is amazing,” she said. “As long as you are selecting the right patients and right therapy, it is feasible and even preferable for a lot of patients.”

For example, patients with hormone-positive breast cancer who receive leuprolide (to shut down the ovaries and suppress estrogen production) ordinarily would have to visit a Penn facility for an injection every month, potentially for years. Now, a nurse can meet patients at home (or before the COVID-19 pandemic, even at their place of work) and administer the injection, saving the patient travel time and associated costs.

This home-based chemotherapy service does not appear to be offered elsewhere in the United States, and a major oncology organization – the Community Oncology Alliance – is opposed to the practice because of patient safety concerns.

The service is not offered at a sample of cancer centers queried by Medscape Medical News, including the Dana-Farber Cancer Institute in Boston, the Moffitt Cancer Center in Tampa, the Huntsman Cancer Institute in Salt Lake City, Utah, and Moores Cancer Center, the University of California, San Diego.

Opposition because of safety concerns

On April 9, the Community Oncology Alliance (COA) issued a statement saying it “fundamentally opposes home infusion of chemotherapy, cancer immunotherapy, and cancer treatment supportive drugs because of serious patient safety concerns.”

The COA warned that “many of the side effects caused by cancer treatment can have a rapid, unpredictable onset that places patients in incredible jeopardy and can even be life-threatening.”

In contrast, in a recent communication related to COVID-19, the National Comprehensive Cancer Network tacitly endorsed the concept, stating that a number of chemotherapies may potentially be administered at home, but it did not include guidelines for doing so.

The American Society of Clinical Oncology said that chemotherapy at home is “an issue [we] are monitoring closely,” according to a spokesperson.

What’s involved

Criteria for home-based chemotherapy at Penn include use of anticancer therapies that a patient has previously tolerated and low toxicity (that can be readily managed in the home setting). In addition, patients must be capable of following a med chart.

The chemotherapy is reconstituted at a Penn facility in a Philadelphia suburb. A courier then delivers the drug to the patient’s home, where it is administered by an oncology-trained nurse. Drugs must be stable for at least a few hours to qualify for the program.

The Penn program started with two regimens: EPOCH (etoposide, vincristine, doxorubicin, cyclophosphamide, and prednisone) for lymphoma, and leuprolide acetate injections for either breast or prostate cancer.

The two treatments are polar opposites in terms of complexity, common usage, and time required, which was intended, said Laughlin.

Time to deliver the chemo varies from a matter of minutes with leuprolide to more than 2 hours for rituximab, a lymphoma drug that may be added to EPOCH.

The current list of at-home chemo agents in the Penn program also includes bortezomib, lanreotide, zoledronic acid, and denosumab. Soon to come are rituximab and pembrolizumab for lung cancer and head and neck cancer.

Already practiced in some European countries

Home-based chemotherapy dates from at least the 1980s in the medical literature and is practiced in some European countries.

A 2018 randomized study of adjuvant treatment with capecitabine and oxaliplatin for stage II/III colon cancer in Denmark, where home-based care has been practiced for the past 2 years and is growing in use, concluded that “it might be a valuable alternative to treatment at an outpatient clinic.”

However, in the study, there was no difference in quality of life between the home and outpatient settings, which is somewhat surprising, inasmuch as a major appeal to receiving chemotherapy at home is that it is less disruptive compared to receiving it in a hospital or clinic, which requires travel.

Also, chemo at home “may be resource intensive” and have a “lower throughput of patients due to transportation time,” cautioned the Danish investigators, who were from Herlev and Gentofte Hospital.

A 2015 review called home chemo “a safe and patient‐centered alternative to hospital‐ and outpatient‐based service.” Jenna Evans, PhD, McMaster University, Toronto, Canada, and lead author of that review, says there are two major barriers to infusion chemotherapy in homes.

One is inadequate resources in the community, such as oncology-trained nurses to deliver treatment, and the other is perceptions of safety and quality, including among healthcare providers.

COVID-19 might prompt more chemo at home, said Evans, a health policy expert, in an email to Medscape Medical News. “It is not unusual for change of this type and scale to require a seismic event to become more mainstream,” she argued.

Reimbursement for home-based chemo is usually the same as for chemo in a free-standing infusion suite, says Cassandra Redmond, PharmD, MBA, director of pharmacy, Penn Home Infusion Therapy.

Private insurers and Medicare cover a subset of infused medications at home, but coverage is limited. “The opportunity now is to expand these initiatives ... to include other cancer therapies,” she said about coverage.
 

This article first appeared on Medscape.com.

In the fall of 2019, the University of Pennsylvania in Philadelphia started a pilot program of home-based chemotherapy for two treatment regimens (one via infusion and one via injection). Six months later, the Cancer Care at Home program had treated 40 patients.

The uptake within the university’s large regional health system was acceptable but not rapid, admitted Amy Laughlin, MD, a hematology-oncology fellow involved with the program.

Then COVID-19 arrived, along with related travel restrictions.

Suddenly, in a 5-week period (March to April 7), 175 patients had been treated – a 300% increase from the first half year. Program staff jumped from 12 to 80 employees. The list of chemotherapies delivered went from two to seven, with more coming.

“We’re not the pilot anymore – we’re the standard of care,” Laughlin told Medscape Medical News.

“The impact [on patients] is amazing,” she said. “As long as you are selecting the right patients and right therapy, it is feasible and even preferable for a lot of patients.”

For example, patients with hormone-positive breast cancer who receive leuprolide (to shut down the ovaries and suppress estrogen production) ordinarily would have to visit a Penn facility for an injection every month, potentially for years. Now, a nurse can meet patients at home (or before the COVID-19 pandemic, even at their place of work) and administer the injection, saving the patient travel time and associated costs.

This home-based chemotherapy service does not appear to be offered elsewhere in the United States, and a major oncology organization – the Community Oncology Alliance – is opposed to the practice because of patient safety concerns.

The service is not offered at a sample of cancer centers queried by Medscape Medical News, including the Dana-Farber Cancer Institute in Boston, the Moffitt Cancer Center in Tampa, the Huntsman Cancer Institute in Salt Lake City, Utah, and Moores Cancer Center, the University of California, San Diego.

Opposition because of safety concerns

On April 9, the Community Oncology Alliance (COA) issued a statement saying it “fundamentally opposes home infusion of chemotherapy, cancer immunotherapy, and cancer treatment supportive drugs because of serious patient safety concerns.”

The COA warned that “many of the side effects caused by cancer treatment can have a rapid, unpredictable onset that places patients in incredible jeopardy and can even be life-threatening.”

In contrast, in a recent communication related to COVID-19, the National Comprehensive Cancer Network tacitly endorsed the concept, stating that a number of chemotherapies may potentially be administered at home, but it did not include guidelines for doing so.

The American Society of Clinical Oncology said that chemotherapy at home is “an issue [we] are monitoring closely,” according to a spokesperson.

What’s involved

Criteria for home-based chemotherapy at Penn include use of anticancer therapies that a patient has previously tolerated and low toxicity (that can be readily managed in the home setting). In addition, patients must be capable of following a med chart.

The chemotherapy is reconstituted at a Penn facility in a Philadelphia suburb. A courier then delivers the drug to the patient’s home, where it is administered by an oncology-trained nurse. Drugs must be stable for at least a few hours to qualify for the program.

The Penn program started with two regimens: EPOCH (etoposide, vincristine, doxorubicin, cyclophosphamide, and prednisone) for lymphoma, and leuprolide acetate injections for either breast or prostate cancer.

The two treatments are polar opposites in terms of complexity, common usage, and time required, which was intended, said Laughlin.

Time to deliver the chemo varies from a matter of minutes with leuprolide to more than 2 hours for rituximab, a lymphoma drug that may be added to EPOCH.

The current list of at-home chemo agents in the Penn program also includes bortezomib, lanreotide, zoledronic acid, and denosumab. Soon to come are rituximab and pembrolizumab for lung cancer and head and neck cancer.

Already practiced in some European countries

Home-based chemotherapy dates from at least the 1980s in the medical literature and is practiced in some European countries.

A 2018 randomized study of adjuvant treatment with capecitabine and oxaliplatin for stage II/III colon cancer in Denmark, where home-based care has been practiced for the past 2 years and is growing in use, concluded that “it might be a valuable alternative to treatment at an outpatient clinic.”

However, in the study, there was no difference in quality of life between the home and outpatient settings, which is somewhat surprising, inasmuch as a major appeal to receiving chemotherapy at home is that it is less disruptive compared to receiving it in a hospital or clinic, which requires travel.

Also, chemo at home “may be resource intensive” and have a “lower throughput of patients due to transportation time,” cautioned the Danish investigators, who were from Herlev and Gentofte Hospital.

A 2015 review called home chemo “a safe and patient‐centered alternative to hospital‐ and outpatient‐based service.” Jenna Evans, PhD, McMaster University, Toronto, Canada, and lead author of that review, says there are two major barriers to infusion chemotherapy in homes.

One is inadequate resources in the community, such as oncology-trained nurses to deliver treatment, and the other is perceptions of safety and quality, including among healthcare providers.

COVID-19 might prompt more chemo at home, said Evans, a health policy expert, in an email to Medscape Medical News. “It is not unusual for change of this type and scale to require a seismic event to become more mainstream,” she argued.

Reimbursement for home-based chemo is usually the same as for chemo in a free-standing infusion suite, says Cassandra Redmond, PharmD, MBA, director of pharmacy, Penn Home Infusion Therapy.

Private insurers and Medicare cover a subset of infused medications at home, but coverage is limited. “The opportunity now is to expand these initiatives ... to include other cancer therapies,” she said about coverage.
 

This article first appeared on Medscape.com.

In the fall of 2019, the University of Pennsylvania in Philadelphia started a pilot program of home-based chemotherapy for two treatment regimens (one via infusion and one via injection). Six months later, the Cancer Care at Home program had treated 40 patients.

The uptake within the university’s large regional health system was acceptable but not rapid, admitted Amy Laughlin, MD, a hematology-oncology fellow involved with the program.

Then COVID-19 arrived, along with related travel restrictions.

Suddenly, in a 5-week period (March to April 7), 175 patients had been treated – a 300% increase from the first half year. Program staff jumped from 12 to 80 employees. The list of chemotherapies delivered went from two to seven, with more coming.

“We’re not the pilot anymore – we’re the standard of care,” Laughlin told Medscape Medical News.

“The impact [on patients] is amazing,” she said. “As long as you are selecting the right patients and right therapy, it is feasible and even preferable for a lot of patients.”

For example, patients with hormone-positive breast cancer who receive leuprolide (to shut down the ovaries and suppress estrogen production) ordinarily would have to visit a Penn facility for an injection every month, potentially for years. Now, a nurse can meet patients at home (or before the COVID-19 pandemic, even at their place of work) and administer the injection, saving the patient travel time and associated costs.

This home-based chemotherapy service does not appear to be offered elsewhere in the United States, and a major oncology organization – the Community Oncology Alliance – is opposed to the practice because of patient safety concerns.

The service is not offered at a sample of cancer centers queried by Medscape Medical News, including the Dana-Farber Cancer Institute in Boston, the Moffitt Cancer Center in Tampa, the Huntsman Cancer Institute in Salt Lake City, Utah, and Moores Cancer Center, the University of California, San Diego.

Opposition because of safety concerns

On April 9, the Community Oncology Alliance (COA) issued a statement saying it “fundamentally opposes home infusion of chemotherapy, cancer immunotherapy, and cancer treatment supportive drugs because of serious patient safety concerns.”

The COA warned that “many of the side effects caused by cancer treatment can have a rapid, unpredictable onset that places patients in incredible jeopardy and can even be life-threatening.”

In contrast, in a recent communication related to COVID-19, the National Comprehensive Cancer Network tacitly endorsed the concept, stating that a number of chemotherapies may potentially be administered at home, but it did not include guidelines for doing so.

The American Society of Clinical Oncology said that chemotherapy at home is “an issue [we] are monitoring closely,” according to a spokesperson.

What’s involved

Criteria for home-based chemotherapy at Penn include use of anticancer therapies that a patient has previously tolerated and low toxicity (that can be readily managed in the home setting). In addition, patients must be capable of following a med chart.

The chemotherapy is reconstituted at a Penn facility in a Philadelphia suburb. A courier then delivers the drug to the patient’s home, where it is administered by an oncology-trained nurse. Drugs must be stable for at least a few hours to qualify for the program.

The Penn program started with two regimens: EPOCH (etoposide, vincristine, doxorubicin, cyclophosphamide, and prednisone) for lymphoma, and leuprolide acetate injections for either breast or prostate cancer.

The two treatments are polar opposites in terms of complexity, common usage, and time required, which was intended, said Laughlin.

Time to deliver the chemo varies from a matter of minutes with leuprolide to more than 2 hours for rituximab, a lymphoma drug that may be added to EPOCH.

The current list of at-home chemo agents in the Penn program also includes bortezomib, lanreotide, zoledronic acid, and denosumab. Soon to come are rituximab and pembrolizumab for lung cancer and head and neck cancer.

Already practiced in some European countries

Home-based chemotherapy dates from at least the 1980s in the medical literature and is practiced in some European countries.

A 2018 randomized study of adjuvant treatment with capecitabine and oxaliplatin for stage II/III colon cancer in Denmark, where home-based care has been practiced for the past 2 years and is growing in use, concluded that “it might be a valuable alternative to treatment at an outpatient clinic.”

However, in the study, there was no difference in quality of life between the home and outpatient settings, which is somewhat surprising, inasmuch as a major appeal to receiving chemotherapy at home is that it is less disruptive compared to receiving it in a hospital or clinic, which requires travel.

Also, chemo at home “may be resource intensive” and have a “lower throughput of patients due to transportation time,” cautioned the Danish investigators, who were from Herlev and Gentofte Hospital.

A 2015 review called home chemo “a safe and patient‐centered alternative to hospital‐ and outpatient‐based service.” Jenna Evans, PhD, McMaster University, Toronto, Canada, and lead author of that review, says there are two major barriers to infusion chemotherapy in homes.

One is inadequate resources in the community, such as oncology-trained nurses to deliver treatment, and the other is perceptions of safety and quality, including among healthcare providers.

COVID-19 might prompt more chemo at home, said Evans, a health policy expert, in an email to Medscape Medical News. “It is not unusual for change of this type and scale to require a seismic event to become more mainstream,” she argued.

Reimbursement for home-based chemo is usually the same as for chemo in a free-standing infusion suite, says Cassandra Redmond, PharmD, MBA, director of pharmacy, Penn Home Infusion Therapy.

Private insurers and Medicare cover a subset of infused medications at home, but coverage is limited. “The opportunity now is to expand these initiatives ... to include other cancer therapies,” she said about coverage.
 

This article first appeared on Medscape.com.

Physicians should consider liver cancer screening for all patients with nonalcoholic fatty liver disease (NAFLD) and cirrhosis, according to a new clinical practice update from the American Gastroenterological Association.

Screening “should be offered for patients with cirrhosis of varying etiologies when the risk of hepatocellular carcinoma is approximately at least 1.5% per year, as has been noted with NAFLD cirrhosis,” wrote Rohit Loomba, MD, of the University of California, San Diego, and associates. Although patients with noncirrhotic NAFLD also can develop hepatocellular carcinoma, “[a]t this point, we believe that [the benefit of screening] is restricted to patients with compensated cirrhosis or those with decompensated cirrhosis listed for liver transplantation,” they wrote in Gastroenterology.

Liver cancer in NAFLD often goes undetected until it is advanced enough that patients are not candidates for curative therapy. Current guidelines provide limited recommendations on which patients with NAFLD to monitor for hepatocellular carcinoma, how best to do so, and how often. To fill this gap, Dr. Loomba and associates reviewed and cited 79 published papers and developed eight suggestions for clinical practice.

Patients with NAFLD and stage 0-2 fibrosis are at “extremely low” risk for hepatocellular carcinoma and should not be routinely screened, the practice update stated. Advanced fibrosis is a clear risk factor but can be challenging to detect in NAFLD – imaging is often insensitive, and screening biopsy tends to be infeasible. Hence, the experts suggest considering liver cancer screening if patients with NAFLD show evidence of advanced fibrosis or cirrhosis on at least two noninvasive tests of distinct modalities (that is, the two tests should not both be point-of-care, specialized blood tests or noninvasive imaging). To improve specificity, the recommended cut-point thresholds for cirrhosis are 16.1 kPa for vibration-controlled transient elastography and 5 kPa for magnetic resonance elastography.

Screening ultrasound accurately detects hepatocellular carcinoma in patients with cirrhosis who have a good acoustic window. However, ultrasound quality is operator dependent, and it can be difficult even for experienced users to detect mass lesions in overweight or obese patients. Thus, it is important always to document parenchymal heterogeneity, beam attenuation, and whether the entire liver was visualized. If ultrasound quality is inadequate, patients should be screened every 6 months with CT or MRI, with or without alpha-fetoprotein, according to the practice update.

The authors advised clinicians to counsel all patients with NAFLD and cirrhosis to avoid alcohol and tobacco. “Irrespective of NAFLD, the bulk of epidemiological data support alcohol drinking as a major risk for hepatocellular carcinoma,” they note. Likewise, pooled studies indicate that current smokers are at about 50%-85% greater risk of liver cancer than never smokers. The experts add that “[al]though specific data do not exist, we believe that e-cigarettes may turn out to be equally harmful and patients be counseled to abstain from those as well.”

They also recommended optimally managing dyslipidemia and diabetes among patients with NAFLD who are at risk for hepatocellular carcinoma. Statins are safe for patients with NAFLD and dyslipidemia and may lower hepatocellular carcinoma risk, although more research is needed, according to the experts. For now, they support “the notion that the benefits of statin therapy among patients with dyslipidemia and NAFLD significantly outweigh the risk and should be utilized routinely.” Type 2 diabetes mellitus clearly heightens the risk of hepatocellular carcinoma, which metformin appears to reduce among patients with NAFLD, cirrhosis, and type 2 diabetes. Glucagonlike peptide–1 receptor agonists and some thiazolidinediones also appear to attenuate liver steatosis, inflammation, degeneration, and fibrosis, but it remains unclear if these effects ultimately lower cancer risk.

It is unclear if obesity directly contributes to hepatocellular carcinoma among patients with NAFLD, but obesity is an “important risk factor” for NAFLD itself, and “weight-loss interventions are strongly recommended to improve NAFLD-related outcomes,” the experts wrote. Pending further studies on whether weight loss reduces liver cancer risk in patients with NAFLD, they called for lifestyle modifications, pharmacotherapy, or bariatric surgery or bariatric endoscopy procedures to optimally manage obesity in patients with NAFLD who are at risk for liver cancer.

The authors disclosed funding from the National Institute of Environmental Health Sciences, the National Center for Advancing Translational Sciences, the National Institute of Diabetes and Digestive and Kidney Diseases, the Cancer Prevention & Research Institute of Texas, and the Center for Gastrointestinal Development, Infection and Injury. Dr. Loomba disclosed ties to Intercept Pharmaceuticals, Bird Rock Bio, Celgene, Enanta Pharmaceuticals, and a number of other companies. Two coauthors disclosed ties to Allergan, AbbVie, Conatus Pharmaceuticals, Genfit, Gilead, and Intercept. The remaining coauthor reported having no conflicts of interest.

SOURCE: Loomba R et al. Gastroenterology. 2020 Jan 29. doi: 10.1053/j.gastro.2019.12.053.

Physicians should consider liver cancer screening for all patients with nonalcoholic fatty liver disease (NAFLD) and cirrhosis, according to a new clinical practice update from the American Gastroenterological Association.

Screening “should be offered for patients with cirrhosis of varying etiologies when the risk of hepatocellular carcinoma is approximately at least 1.5% per year, as has been noted with NAFLD cirrhosis,” wrote Rohit Loomba, MD, of the University of California, San Diego, and associates. Although patients with noncirrhotic NAFLD also can develop hepatocellular carcinoma, “[a]t this point, we believe that [the benefit of screening] is restricted to patients with compensated cirrhosis or those with decompensated cirrhosis listed for liver transplantation,” they wrote in Gastroenterology.

Liver cancer in NAFLD often goes undetected until it is advanced enough that patients are not candidates for curative therapy. Current guidelines provide limited recommendations on which patients with NAFLD to monitor for hepatocellular carcinoma, how best to do so, and how often. To fill this gap, Dr. Loomba and associates reviewed and cited 79 published papers and developed eight suggestions for clinical practice.

Patients with NAFLD and stage 0-2 fibrosis are at “extremely low” risk for hepatocellular carcinoma and should not be routinely screened, the practice update stated. Advanced fibrosis is a clear risk factor but can be challenging to detect in NAFLD – imaging is often insensitive, and screening biopsy tends to be infeasible. Hence, the experts suggest considering liver cancer screening if patients with NAFLD show evidence of advanced fibrosis or cirrhosis on at least two noninvasive tests of distinct modalities (that is, the two tests should not both be point-of-care, specialized blood tests or noninvasive imaging). To improve specificity, the recommended cut-point thresholds for cirrhosis are 16.1 kPa for vibration-controlled transient elastography and 5 kPa for magnetic resonance elastography.

Screening ultrasound accurately detects hepatocellular carcinoma in patients with cirrhosis who have a good acoustic window. However, ultrasound quality is operator dependent, and it can be difficult even for experienced users to detect mass lesions in overweight or obese patients. Thus, it is important always to document parenchymal heterogeneity, beam attenuation, and whether the entire liver was visualized. If ultrasound quality is inadequate, patients should be screened every 6 months with CT or MRI, with or without alpha-fetoprotein, according to the practice update.

The authors advised clinicians to counsel all patients with NAFLD and cirrhosis to avoid alcohol and tobacco. “Irrespective of NAFLD, the bulk of epidemiological data support alcohol drinking as a major risk for hepatocellular carcinoma,” they note. Likewise, pooled studies indicate that current smokers are at about 50%-85% greater risk of liver cancer than never smokers. The experts add that “[al]though specific data do not exist, we believe that e-cigarettes may turn out to be equally harmful and patients be counseled to abstain from those as well.”

They also recommended optimally managing dyslipidemia and diabetes among patients with NAFLD who are at risk for hepatocellular carcinoma. Statins are safe for patients with NAFLD and dyslipidemia and may lower hepatocellular carcinoma risk, although more research is needed, according to the experts. For now, they support “the notion that the benefits of statin therapy among patients with dyslipidemia and NAFLD significantly outweigh the risk and should be utilized routinely.” Type 2 diabetes mellitus clearly heightens the risk of hepatocellular carcinoma, which metformin appears to reduce among patients with NAFLD, cirrhosis, and type 2 diabetes. Glucagonlike peptide–1 receptor agonists and some thiazolidinediones also appear to attenuate liver steatosis, inflammation, degeneration, and fibrosis, but it remains unclear if these effects ultimately lower cancer risk.

It is unclear if obesity directly contributes to hepatocellular carcinoma among patients with NAFLD, but obesity is an “important risk factor” for NAFLD itself, and “weight-loss interventions are strongly recommended to improve NAFLD-related outcomes,” the experts wrote. Pending further studies on whether weight loss reduces liver cancer risk in patients with NAFLD, they called for lifestyle modifications, pharmacotherapy, or bariatric surgery or bariatric endoscopy procedures to optimally manage obesity in patients with NAFLD who are at risk for liver cancer.

The authors disclosed funding from the National Institute of Environmental Health Sciences, the National Center for Advancing Translational Sciences, the National Institute of Diabetes and Digestive and Kidney Diseases, the Cancer Prevention & Research Institute of Texas, and the Center for Gastrointestinal Development, Infection and Injury. Dr. Loomba disclosed ties to Intercept Pharmaceuticals, Bird Rock Bio, Celgene, Enanta Pharmaceuticals, and a number of other companies. Two coauthors disclosed ties to Allergan, AbbVie, Conatus Pharmaceuticals, Genfit, Gilead, and Intercept. The remaining coauthor reported having no conflicts of interest.

SOURCE: Loomba R et al. Gastroenterology. 2020 Jan 29. doi: 10.1053/j.gastro.2019.12.053.

Physicians should consider liver cancer screening for all patients with nonalcoholic fatty liver disease (NAFLD) and cirrhosis, according to a new clinical practice update from the American Gastroenterological Association.

Screening “should be offered for patients with cirrhosis of varying etiologies when the risk of hepatocellular carcinoma is approximately at least 1.5% per year, as has been noted with NAFLD cirrhosis,” wrote Rohit Loomba, MD, of the University of California, San Diego, and associates. Although patients with noncirrhotic NAFLD also can develop hepatocellular carcinoma, “[a]t this point, we believe that [the benefit of screening] is restricted to patients with compensated cirrhosis or those with decompensated cirrhosis listed for liver transplantation,” they wrote in Gastroenterology.

Liver cancer in NAFLD often goes undetected until it is advanced enough that patients are not candidates for curative therapy. Current guidelines provide limited recommendations on which patients with NAFLD to monitor for hepatocellular carcinoma, how best to do so, and how often. To fill this gap, Dr. Loomba and associates reviewed and cited 79 published papers and developed eight suggestions for clinical practice.

Patients with NAFLD and stage 0-2 fibrosis are at “extremely low” risk for hepatocellular carcinoma and should not be routinely screened, the practice update stated. Advanced fibrosis is a clear risk factor but can be challenging to detect in NAFLD – imaging is often insensitive, and screening biopsy tends to be infeasible. Hence, the experts suggest considering liver cancer screening if patients with NAFLD show evidence of advanced fibrosis or cirrhosis on at least two noninvasive tests of distinct modalities (that is, the two tests should not both be point-of-care, specialized blood tests or noninvasive imaging). To improve specificity, the recommended cut-point thresholds for cirrhosis are 16.1 kPa for vibration-controlled transient elastography and 5 kPa for magnetic resonance elastography.

Screening ultrasound accurately detects hepatocellular carcinoma in patients with cirrhosis who have a good acoustic window. However, ultrasound quality is operator dependent, and it can be difficult even for experienced users to detect mass lesions in overweight or obese patients. Thus, it is important always to document parenchymal heterogeneity, beam attenuation, and whether the entire liver was visualized. If ultrasound quality is inadequate, patients should be screened every 6 months with CT or MRI, with or without alpha-fetoprotein, according to the practice update.

The authors advised clinicians to counsel all patients with NAFLD and cirrhosis to avoid alcohol and tobacco. “Irrespective of NAFLD, the bulk of epidemiological data support alcohol drinking as a major risk for hepatocellular carcinoma,” they note. Likewise, pooled studies indicate that current smokers are at about 50%-85% greater risk of liver cancer than never smokers. The experts add that “[al]though specific data do not exist, we believe that e-cigarettes may turn out to be equally harmful and patients be counseled to abstain from those as well.”

They also recommended optimally managing dyslipidemia and diabetes among patients with NAFLD who are at risk for hepatocellular carcinoma. Statins are safe for patients with NAFLD and dyslipidemia and may lower hepatocellular carcinoma risk, although more research is needed, according to the experts. For now, they support “the notion that the benefits of statin therapy among patients with dyslipidemia and NAFLD significantly outweigh the risk and should be utilized routinely.” Type 2 diabetes mellitus clearly heightens the risk of hepatocellular carcinoma, which metformin appears to reduce among patients with NAFLD, cirrhosis, and type 2 diabetes. Glucagonlike peptide–1 receptor agonists and some thiazolidinediones also appear to attenuate liver steatosis, inflammation, degeneration, and fibrosis, but it remains unclear if these effects ultimately lower cancer risk.

It is unclear if obesity directly contributes to hepatocellular carcinoma among patients with NAFLD, but obesity is an “important risk factor” for NAFLD itself, and “weight-loss interventions are strongly recommended to improve NAFLD-related outcomes,” the experts wrote. Pending further studies on whether weight loss reduces liver cancer risk in patients with NAFLD, they called for lifestyle modifications, pharmacotherapy, or bariatric surgery or bariatric endoscopy procedures to optimally manage obesity in patients with NAFLD who are at risk for liver cancer.

The authors disclosed funding from the National Institute of Environmental Health Sciences, the National Center for Advancing Translational Sciences, the National Institute of Diabetes and Digestive and Kidney Diseases, the Cancer Prevention & Research Institute of Texas, and the Center for Gastrointestinal Development, Infection and Injury. Dr. Loomba disclosed ties to Intercept Pharmaceuticals, Bird Rock Bio, Celgene, Enanta Pharmaceuticals, and a number of other companies. Two coauthors disclosed ties to Allergan, AbbVie, Conatus Pharmaceuticals, Genfit, Gilead, and Intercept. The remaining coauthor reported having no conflicts of interest.

SOURCE: Loomba R et al. Gastroenterology. 2020 Jan 29. doi: 10.1053/j.gastro.2019.12.053.

A few weeks ago, I saw more than 60 responses to a post on Nextdoor.com entitled, “Toilet paper strategies?”

Asking for help is a great coping mechanism when one is struggling to find a strategy, even if it’s for toilet paper. What other kinds of coping strategies can help us through this historic and unprecedented time?

The late Stephen R. Covey, PhD, wrote about the coping strategies of highly effective people in his book, “The 7 Habits of Highly Effective People.”¹ For, no matter how smart, perfect, or careful you may be, life will never be trouble free. When trouble comes, it’s important to have coping strategies that help you navigate through choppy waters. Whether you are a practitioner trying to help your patients or someone who wants to maximize their personal resilience during a worldwide pandemic, here are my conceptualizations of the seven top strategies highly effective people use when facing challenges.
 

Strategy #1: Begin with the end in mind

In 2007, this strategy helped me not only survive but thrive when I battled for my right to practice as a holistic psychiatrist against the Maryland Board of Physicians.² From the first moment when I read the letter from the board, to the last when I read the administrative law judge’s dismissal, I turned to this strategy to help me cope with unrelenting stress.

I imagined myself remembering being the kind of person I wanted to be, wrote that script for myself, and created those memories for my future self. I wanted to remember myself as being brave, calm, strong, and grounded, so I behaved each day as if I were all of those things.

As Dr. Covey wrote, “ ‘Begin with the end in mind’ is based on the principle that all things are created twice. There’s a mental or first creation, and a physical or second creation to all things.” Imagine who you would like to remember yourself being a year or two down the road. Do you want to remember yourself showing good judgment and being positive and compassionate during this pandemic? Then, follow the script you’ve created in your mind and be that person now, knowing that you are forming memories for your future self. Your future self will look back at who you are right now with appreciation and satisfaction. Of course, this is a habit that you can apply to your entire life.
 

Strategy #2: Be proactive

Between the event and the outcome is you. You are the interpreter and transformer of the event, with the freedom to apply your will and intention on the event. Whether it is living through a pandemic or dealing with misplaced keys, every day you are revealing your nature through how you deal with life. To be proactive is different from being reactive. Within each of us there is a will, the drive, to rise above our difficult environments.

Dr. Covey wrote, “the ability to subordinate an impulse to a value is the essence of the proactive person.” A woman shared with me that she created an Excel spreadsheet with some of the things she plans to do with her free time while she stays in her NYC apartment. She doesn’t want to slip into a passive state and waste her time. That’s being proactive.
 

Strategy #3: Set proper priorities

Or, as Dr. Covey would say, “Put first things first.” During a pandemic, when the world seems to be precariously tilting at an angle, it’s easy to cling to outdated standards, expectations, and behavioral patterns. Doing so heightens our sense of regret, fear, and scarcity. If you are value-centered, you can adapt to rapid changes and shift your expectations to reflect the current reality more easily. Valuing gratitude will empower you to deal with financial loss differently because you can still remain grateful despite uncontrollable losses. We can choose “to have or to be” as psychoanalyst, Erich Fromm, PhD, would say.³ If your happiness is measured by how much money you have, then it would make sense that, when the amount shrinks, so does your happiness. However, if your happiness is a side effect of who you are, you will remain a mountain before the winds and tides of circumstance.

Strategy #4: Create a win/win mentality

This state of mind is built on character. Dr. Covey separates character into three categories: integrity, maturity, and abundance mentality. A lack of character resulted in the hoarding of toilet paper in many communities and the cry for help from Nextdoor.com. I noticed that, in the 60+ responses that included advice about using bidets, old towels, and even leaves, no one offered to share a bag of toilet paper. That’s because people experienced the fear of scarcity, in turn, causing the scarcity they feared.

During a pandemic, a highly effective person or company thinks beyond themselves to create a win/win scenario. At a grocery store in my neighborhood, a man stands at its entrance with a bottle of disinfectant spray in one hand for the shoppers and a sign on the sidewalk with guidelines for purchasing products to avoid hoarding. He tells you where the wipes are for the carts as you enter the store. People line up 6 feet apart, waiting to enter, to limit the number of shoppers inside the store, facilitating proper physical distancing. Instead of maximizing profits at the expense of everyone’s health and safety, the process is a win/win for everyone, from shoppers to employees.
 

Strategy #5: Develop empathy and understanding

Seeking to first understand and then be understood is one of the most powerful tools of effective people. In my holistic practice, every patient comes in with their own unique needs that evolve and transform over time. I must remain open, or I fail to deliver appropriately.

Learning to listen and then to clearly communicate ideas is essential to effective health care. During this time, it is critical that health care providers and political leaders first listen/understand and then communicate clearly to serve everyone in the best way possible.

In our brains, the frontal lobes (the adult in the room) manages our amygdala (the child in the room) when we get enough sleep, meditate, spend time in nature, exercise, and eat healthy food.⁴ Stress can interfere with the frontal lobe’s ability to maintain empathy, inhibit unhealthy impulses, and delay gratification. During the pandemic, we can help to shift from the stress response, or “fight-or-flight” response, driven by the sympathetic nervous system to a “rest-and-digest” response driven by the parasympathetic system through coherent breathing, taking slow, deep, relaxed breaths (6 seconds on inhalation and 6 seconds on exhalation). The vagus nerve connected to our diaphragm will help the heart return to a healthy rhythm.⁵

Strategy #6: Synergize and integrate

All of life is interdependent, each part no more or less important than any other. Is oxygen more important than hydrogen? Is H₂O different from the oxygen and hydrogen atoms that make it?

During a pandemic, it’s important for us to appreciate each other’s contributions and work synergistically for the good of the whole. Our survival depends on valuing each other and our planet. This perspective informs the practice of physical distancing and staying home to minimize the spread of the virus and its impact on the health care system, regardless of whether an individual belongs in the high-risk group or not.

Many high-achieving people train in extremely competitive settings in which survival depends on individual performance rather than mutual cooperation. This training process encourages a disregard for others. Good leaders, however, understand that cooperation and mutual respect are essential to personal well-being.
 

Strategy #7: Practice self-care

There are five aspects of our lives that depend on our self-care: spiritual, mental, emotional, physical, and social. Unfortunately, many kind-hearted people are kinder to others than to themselves. There is really only one person who can truly take care of you properly, and that is yourself. In Seattle, where many suffered early in the pandemic, holistic psychiatrist David Kopacz, MD, is reminding people to nurture themselves in his post, “Nurture Yourself During the Pandemic: Try New Recipes!”⁶ Indeed, that is what many must do since eating out is not an option now. If you find yourself stuck at home with more time on your hands, take the opportunity to care for yourself. Ask yourself what you really need during this time, and make the effort to provide it to yourself.

After the pandemic is over, will you have grown from the experiences and become a better person from it? Despite our current circumstances, we can continue to grow as individuals and as a community, armed with strategies that can benefit all of us.

References

1. Covey SR. The 7 Habits of Highly Effective People. New York: Simon & Schuster; 1989.

2. Lee AW. Townsend Letter. 2009 Jun;311:22-3.

3. Fromm E. To Have or To Be? New York: Continuum International Publishing; 2005.

4. Rushlau K. Integrative Healthcare Symposium. 2020 Feb 21.

5. Gerbarg PL. Mind Body Practices for Post-Traumatic Stress Disorder. Presentation at Integrative Medicine for Mental Health Conference. 2016 Sep.

6. Kopacz D. Nurture Yourself During the Pandemic: Try New Recipes! Being Fully Human. 2020 Mar 22.

Dr. Lee specializes in integrative and holistic psychiatry and has a private practice in Gaithersburg, Md. She has no disclosures.




 

A few weeks ago, I saw more than 60 responses to a post on Nextdoor.com entitled, “Toilet paper strategies?”

Asking for help is a great coping mechanism when one is struggling to find a strategy, even if it’s for toilet paper. What other kinds of coping strategies can help us through this historic and unprecedented time?

The late Stephen R. Covey, PhD, wrote about the coping strategies of highly effective people in his book, “The 7 Habits of Highly Effective People.”¹ For, no matter how smart, perfect, or careful you may be, life will never be trouble free. When trouble comes, it’s important to have coping strategies that help you navigate through choppy waters. Whether you are a practitioner trying to help your patients or someone who wants to maximize their personal resilience during a worldwide pandemic, here are my conceptualizations of the seven top strategies highly effective people use when facing challenges.
 

Strategy #1: Begin with the end in mind

In 2007, this strategy helped me not only survive but thrive when I battled for my right to practice as a holistic psychiatrist against the Maryland Board of Physicians.² From the first moment when I read the letter from the board, to the last when I read the administrative law judge’s dismissal, I turned to this strategy to help me cope with unrelenting stress.

I imagined myself remembering being the kind of person I wanted to be, wrote that script for myself, and created those memories for my future self. I wanted to remember myself as being brave, calm, strong, and grounded, so I behaved each day as if I were all of those things.

As Dr. Covey wrote, “ ‘Begin with the end in mind’ is based on the principle that all things are created twice. There’s a mental or first creation, and a physical or second creation to all things.” Imagine who you would like to remember yourself being a year or two down the road. Do you want to remember yourself showing good judgment and being positive and compassionate during this pandemic? Then, follow the script you’ve created in your mind and be that person now, knowing that you are forming memories for your future self. Your future self will look back at who you are right now with appreciation and satisfaction. Of course, this is a habit that you can apply to your entire life.
 

Strategy #2: Be proactive

Between the event and the outcome is you. You are the interpreter and transformer of the event, with the freedom to apply your will and intention on the event. Whether it is living through a pandemic or dealing with misplaced keys, every day you are revealing your nature through how you deal with life. To be proactive is different from being reactive. Within each of us there is a will, the drive, to rise above our difficult environments.

Dr. Covey wrote, “the ability to subordinate an impulse to a value is the essence of the proactive person.” A woman shared with me that she created an Excel spreadsheet with some of the things she plans to do with her free time while she stays in her NYC apartment. She doesn’t want to slip into a passive state and waste her time. That’s being proactive.
 

Strategy #3: Set proper priorities

Or, as Dr. Covey would say, “Put first things first.” During a pandemic, when the world seems to be precariously tilting at an angle, it’s easy to cling to outdated standards, expectations, and behavioral patterns. Doing so heightens our sense of regret, fear, and scarcity. If you are value-centered, you can adapt to rapid changes and shift your expectations to reflect the current reality more easily. Valuing gratitude will empower you to deal with financial loss differently because you can still remain grateful despite uncontrollable losses. We can choose “to have or to be” as psychoanalyst, Erich Fromm, PhD, would say.³ If your happiness is measured by how much money you have, then it would make sense that, when the amount shrinks, so does your happiness. However, if your happiness is a side effect of who you are, you will remain a mountain before the winds and tides of circumstance.

Strategy #4: Create a win/win mentality

This state of mind is built on character. Dr. Covey separates character into three categories: integrity, maturity, and abundance mentality. A lack of character resulted in the hoarding of toilet paper in many communities and the cry for help from Nextdoor.com. I noticed that, in the 60+ responses that included advice about using bidets, old towels, and even leaves, no one offered to share a bag of toilet paper. That’s because people experienced the fear of scarcity, in turn, causing the scarcity they feared.

During a pandemic, a highly effective person or company thinks beyond themselves to create a win/win scenario. At a grocery store in my neighborhood, a man stands at its entrance with a bottle of disinfectant spray in one hand for the shoppers and a sign on the sidewalk with guidelines for purchasing products to avoid hoarding. He tells you where the wipes are for the carts as you enter the store. People line up 6 feet apart, waiting to enter, to limit the number of shoppers inside the store, facilitating proper physical distancing. Instead of maximizing profits at the expense of everyone’s health and safety, the process is a win/win for everyone, from shoppers to employees.
 

Strategy #5: Develop empathy and understanding

Seeking to first understand and then be understood is one of the most powerful tools of effective people. In my holistic practice, every patient comes in with their own unique needs that evolve and transform over time. I must remain open, or I fail to deliver appropriately.

Learning to listen and then to clearly communicate ideas is essential to effective health care. During this time, it is critical that health care providers and political leaders first listen/understand and then communicate clearly to serve everyone in the best way possible.

In our brains, the frontal lobes (the adult in the room) manages our amygdala (the child in the room) when we get enough sleep, meditate, spend time in nature, exercise, and eat healthy food.⁴ Stress can interfere with the frontal lobe’s ability to maintain empathy, inhibit unhealthy impulses, and delay gratification. During the pandemic, we can help to shift from the stress response, or “fight-or-flight” response, driven by the sympathetic nervous system to a “rest-and-digest” response driven by the parasympathetic system through coherent breathing, taking slow, deep, relaxed breaths (6 seconds on inhalation and 6 seconds on exhalation). The vagus nerve connected to our diaphragm will help the heart return to a healthy rhythm.⁵

Strategy #6: Synergize and integrate

All of life is interdependent, each part no more or less important than any other. Is oxygen more important than hydrogen? Is H₂O different from the oxygen and hydrogen atoms that make it?

During a pandemic, it’s important for us to appreciate each other’s contributions and work synergistically for the good of the whole. Our survival depends on valuing each other and our planet. This perspective informs the practice of physical distancing and staying home to minimize the spread of the virus and its impact on the health care system, regardless of whether an individual belongs in the high-risk group or not.

Many high-achieving people train in extremely competitive settings in which survival depends on individual performance rather than mutual cooperation. This training process encourages a disregard for others. Good leaders, however, understand that cooperation and mutual respect are essential to personal well-being.
 

Strategy #7: Practice self-care

There are five aspects of our lives that depend on our self-care: spiritual, mental, emotional, physical, and social. Unfortunately, many kind-hearted people are kinder to others than to themselves. There is really only one person who can truly take care of you properly, and that is yourself. In Seattle, where many suffered early in the pandemic, holistic psychiatrist David Kopacz, MD, is reminding people to nurture themselves in his post, “Nurture Yourself During the Pandemic: Try New Recipes!”⁶ Indeed, that is what many must do since eating out is not an option now. If you find yourself stuck at home with more time on your hands, take the opportunity to care for yourself. Ask yourself what you really need during this time, and make the effort to provide it to yourself.

After the pandemic is over, will you have grown from the experiences and become a better person from it? Despite our current circumstances, we can continue to grow as individuals and as a community, armed with strategies that can benefit all of us.

References

1. Covey SR. The 7 Habits of Highly Effective People. New York: Simon & Schuster; 1989.

2. Lee AW. Townsend Letter. 2009 Jun;311:22-3.

3. Fromm E. To Have or To Be? New York: Continuum International Publishing; 2005.

4. Rushlau K. Integrative Healthcare Symposium. 2020 Feb 21.

5. Gerbarg PL. Mind Body Practices for Post-Traumatic Stress Disorder. Presentation at Integrative Medicine for Mental Health Conference. 2016 Sep.

6. Kopacz D. Nurture Yourself During the Pandemic: Try New Recipes! Being Fully Human. 2020 Mar 22.

Dr. Lee specializes in integrative and holistic psychiatry and has a private practice in Gaithersburg, Md. She has no disclosures.




 

A few weeks ago, I saw more than 60 responses to a post on Nextdoor.com entitled, “Toilet paper strategies?”

Asking for help is a great coping mechanism when one is struggling to find a strategy, even if it’s for toilet paper. What other kinds of coping strategies can help us through this historic and unprecedented time?

The late Stephen R. Covey, PhD, wrote about the coping strategies of highly effective people in his book, “The 7 Habits of Highly Effective People.”¹ For, no matter how smart, perfect, or careful you may be, life will never be trouble free. When trouble comes, it’s important to have coping strategies that help you navigate through choppy waters. Whether you are a practitioner trying to help your patients or someone who wants to maximize their personal resilience during a worldwide pandemic, here are my conceptualizations of the seven top strategies highly effective people use when facing challenges.
 

Strategy #1: Begin with the end in mind

In 2007, this strategy helped me not only survive but thrive when I battled for my right to practice as a holistic psychiatrist against the Maryland Board of Physicians.² From the first moment when I read the letter from the board, to the last when I read the administrative law judge’s dismissal, I turned to this strategy to help me cope with unrelenting stress.

I imagined myself remembering being the kind of person I wanted to be, wrote that script for myself, and created those memories for my future self. I wanted to remember myself as being brave, calm, strong, and grounded, so I behaved each day as if I were all of those things.

As Dr. Covey wrote, “ ‘Begin with the end in mind’ is based on the principle that all things are created twice. There’s a mental or first creation, and a physical or second creation to all things.” Imagine who you would like to remember yourself being a year or two down the road. Do you want to remember yourself showing good judgment and being positive and compassionate during this pandemic? Then, follow the script you’ve created in your mind and be that person now, knowing that you are forming memories for your future self. Your future self will look back at who you are right now with appreciation and satisfaction. Of course, this is a habit that you can apply to your entire life.
 

Strategy #2: Be proactive

Between the event and the outcome is you. You are the interpreter and transformer of the event, with the freedom to apply your will and intention on the event. Whether it is living through a pandemic or dealing with misplaced keys, every day you are revealing your nature through how you deal with life. To be proactive is different from being reactive. Within each of us there is a will, the drive, to rise above our difficult environments.

Dr. Covey wrote, “the ability to subordinate an impulse to a value is the essence of the proactive person.” A woman shared with me that she created an Excel spreadsheet with some of the things she plans to do with her free time while she stays in her NYC apartment. She doesn’t want to slip into a passive state and waste her time. That’s being proactive.
 

Strategy #3: Set proper priorities

Or, as Dr. Covey would say, “Put first things first.” During a pandemic, when the world seems to be precariously tilting at an angle, it’s easy to cling to outdated standards, expectations, and behavioral patterns. Doing so heightens our sense of regret, fear, and scarcity. If you are value-centered, you can adapt to rapid changes and shift your expectations to reflect the current reality more easily. Valuing gratitude will empower you to deal with financial loss differently because you can still remain grateful despite uncontrollable losses. We can choose “to have or to be” as psychoanalyst, Erich Fromm, PhD, would say.³ If your happiness is measured by how much money you have, then it would make sense that, when the amount shrinks, so does your happiness. However, if your happiness is a side effect of who you are, you will remain a mountain before the winds and tides of circumstance.

Strategy #4: Create a win/win mentality

This state of mind is built on character. Dr. Covey separates character into three categories: integrity, maturity, and abundance mentality. A lack of character resulted in the hoarding of toilet paper in many communities and the cry for help from Nextdoor.com. I noticed that, in the 60+ responses that included advice about using bidets, old towels, and even leaves, no one offered to share a bag of toilet paper. That’s because people experienced the fear of scarcity, in turn, causing the scarcity they feared.

During a pandemic, a highly effective person or company thinks beyond themselves to create a win/win scenario. At a grocery store in my neighborhood, a man stands at its entrance with a bottle of disinfectant spray in one hand for the shoppers and a sign on the sidewalk with guidelines for purchasing products to avoid hoarding. He tells you where the wipes are for the carts as you enter the store. People line up 6 feet apart, waiting to enter, to limit the number of shoppers inside the store, facilitating proper physical distancing. Instead of maximizing profits at the expense of everyone’s health and safety, the process is a win/win for everyone, from shoppers to employees.
 

Strategy #5: Develop empathy and understanding

Seeking to first understand and then be understood is one of the most powerful tools of effective people. In my holistic practice, every patient comes in with their own unique needs that evolve and transform over time. I must remain open, or I fail to deliver appropriately.

Learning to listen and then to clearly communicate ideas is essential to effective health care. During this time, it is critical that health care providers and political leaders first listen/understand and then communicate clearly to serve everyone in the best way possible.

In our brains, the frontal lobes (the adult in the room) manages our amygdala (the child in the room) when we get enough sleep, meditate, spend time in nature, exercise, and eat healthy food.⁴ Stress can interfere with the frontal lobe’s ability to maintain empathy, inhibit unhealthy impulses, and delay gratification. During the pandemic, we can help to shift from the stress response, or “fight-or-flight” response, driven by the sympathetic nervous system to a “rest-and-digest” response driven by the parasympathetic system through coherent breathing, taking slow, deep, relaxed breaths (6 seconds on inhalation and 6 seconds on exhalation). The vagus nerve connected to our diaphragm will help the heart return to a healthy rhythm.⁵

Strategy #6: Synergize and integrate

All of life is interdependent, each part no more or less important than any other. Is oxygen more important than hydrogen? Is H₂O different from the oxygen and hydrogen atoms that make it?

During a pandemic, it’s important for us to appreciate each other’s contributions and work synergistically for the good of the whole. Our survival depends on valuing each other and our planet. This perspective informs the practice of physical distancing and staying home to minimize the spread of the virus and its impact on the health care system, regardless of whether an individual belongs in the high-risk group or not.

Many high-achieving people train in extremely competitive settings in which survival depends on individual performance rather than mutual cooperation. This training process encourages a disregard for others. Good leaders, however, understand that cooperation and mutual respect are essential to personal well-being.
 

Strategy #7: Practice self-care

There are five aspects of our lives that depend on our self-care: spiritual, mental, emotional, physical, and social. Unfortunately, many kind-hearted people are kinder to others than to themselves. There is really only one person who can truly take care of you properly, and that is yourself. In Seattle, where many suffered early in the pandemic, holistic psychiatrist David Kopacz, MD, is reminding people to nurture themselves in his post, “Nurture Yourself During the Pandemic: Try New Recipes!”⁶ Indeed, that is what many must do since eating out is not an option now. If you find yourself stuck at home with more time on your hands, take the opportunity to care for yourself. Ask yourself what you really need during this time, and make the effort to provide it to yourself.

After the pandemic is over, will you have grown from the experiences and become a better person from it? Despite our current circumstances, we can continue to grow as individuals and as a community, armed with strategies that can benefit all of us.

References

1. Covey SR. The 7 Habits of Highly Effective People. New York: Simon & Schuster; 1989.

2. Lee AW. Townsend Letter. 2009 Jun;311:22-3.

3. Fromm E. To Have or To Be? New York: Continuum International Publishing; 2005.

4. Rushlau K. Integrative Healthcare Symposium. 2020 Feb 21.

5. Gerbarg PL. Mind Body Practices for Post-Traumatic Stress Disorder. Presentation at Integrative Medicine for Mental Health Conference. 2016 Sep.

6. Kopacz D. Nurture Yourself During the Pandemic: Try New Recipes! Being Fully Human. 2020 Mar 22.

Dr. Lee specializes in integrative and holistic psychiatry and has a private practice in Gaithersburg, Md. She has no disclosures.




 

While often compared with the Spanish influenza contagion of 1918, the current COVID-19 pandemic is arguably unprecedented in scale and scope, global reach, and the rate at which it has spread across the world.
 

Unprecedented times

The United States now has the greatest burden of COVID-19 disease worldwide.¹ Although Boston has thus far been spared the full force of the disease’s impact, it is likely only a matter of time before it reaches here. To prepare for the imminent surge, we at Tufts Medical Center defined 4 short-term strategic imperatives to help guide our COVID-19 preparedness. Having a single unified strategy across our organization has helped to maintain focus and consistency in the messaging amidst all of the uncertainty. Our focus areas are outlined below.
 

1 Flatten the curve

This term refers to the use of “social distancing” and community isolation measures to keep the number of disease cases at a manageable level. COVID-19 is spread almost exclusively through contact with contaminated respiratory droplets. While several categories of risk have been described, the US Centers for Disease Control and Prevention (CDC) defines disease “exposure” as face-to-face contact within 6 feet of an infected individual for more than 15 minutes without wearing a mask.² Intervening at all 3 of these touchpoints effectively reduces transmission. Interventions include limiting in-person meetings, increasing the space between individuals (both providers and patients), and routinely using personal protective equipment (PPE).

Another effective strategy is to divide frontline providers into smaller units or teams to limit cross-contamination: the inpatient team versus the outpatient team, the day team versus the night team, the “on” team versus the “off” team. If the infection lays one team low, other providers can step in until they recover and return to work.

Visitor policies should be developed and strictly implemented. Many institutions do allow one support person in labor and delivery (L&D) regardless of the patient’s COVID-19 status, although that person should not be symptomatic or COVID-19 positive. Whether to test all patients and support persons for COVID-19 on arrival at L&D remains controversial.³ At a minimum, these individuals should be screened for symptoms. Although it was a major focus of initial preventative efforts, taking a travel and exposure history is no longer informative as the virus is now endemic and community spread is common.

Initial preventative efforts focused also on high-risk patients, but routine use of PPE for all encounters clearly is more effective because of the high rate of asymptomatic shedding. The virus can survive suspended in the air for up to 2 hours following an aerosol-generating procedure (AGP) and on surfaces for several hours or even days. Practices such as regular handwashing, cleaning of exposed work surfaces, and avoiding face touching should by now be part of our everyday routine.

Institutions throughout the United States have established inpatient COVID-19 units—so-called “dirty” units—with mixed success. As the pandemic spreads and the number of patients with asymptomatic shedding increases, it is harder to determine who is and who is not infected. Cross-contamination has rendered this approach largely ineffective. Whether this will change with the introduction of rapid point-of-care testing remains to be seen.

Continue to: 2 Preserve PPE...

2 Preserve PPE

PPE use is effective in reducing transmission. This includes tier 1 PPE with or without enhanced droplet precaution (surgical mask, eye protection, gloves, yellow gown) and tier 2 PPE (tier 1 plus N95 respirators or powered air-purifying respirators [PAPR]). Given the acute PPE shortage in many parts of the country, appropriate use of PPE is critical to maintain an adequate supply. For example, tier 2 PPE is required only in the setting of an AGP. This includes intubation and, in our determination, the second stage of labor for COVID-19–positive patients and patients under investigation (PUIs); we do not employ tier 2 PPE for all patients in the second stage of labor, although some hospitals endorse this practice.

Creative solutions to the impending PPE shortage abound, such as the use of 3D printers to make face shields and novel techniques to sterilize and reuse N95 respirators.

3 Create capacity

In the absence of effective treatment for COVID-19 and with a vaccine still many months away, supportive care is critical. The pulmonary sequelae with cytokine storm and acute hypoxemia can come on quickly, require urgent mechanical ventilatory support, and take several weeks to resolve.

Our ability to create inpatient capacity to accommodate ill patients, monitor them closely, and intubate early will likely be the most critical driver of the case fatality rate. This requires deferring outpatient visits (or doing them via telemedicine), expanding intensive care unit capabilities (especially ventilator beds), and canceling elective surgeries. What constitutes “elective surgery” is not always clear. Our institution, for example, regards abortion services as essential and not elective, but this is not the case throughout the United States.

Creating capacity also refers to staffing. Where necessary, providers should be retrained and redeployed. This may require emergency credentialing of providers in areas outside their usual clinical practice and permission may be needed from the Accreditation Council for Graduate Medical Education to engage trainees outside their usual duty hours.
 

4 Support and protect your workforce

Everyone is anxious, and people convey their anxiety in different ways. I have found it helpful to acknowledge those feelings and provide a forum for staff to express and share their anxieties. That said, hospitals are not a democracy. While staff members should be encouraged to ask questions and voice their opinions, everyone is expected to follow protocol regarding patient care.

Celebrating small successes and finding creative ways to alleviate the stress and inject humor can help. Most institutions are using electronic conferencing platforms (such as Zoom or Microsoft Teams) to stay in touch and to continue education initiatives through interactive didactic sessions, grand rounds, morbidity and mortality conferences, and e-journal clubs. These are also a great platform for social events, such as w(h)ine and book clubs and virtual karaoke.

Since many ObGyn providers are women, the closure of day-care centers and schools is particularly challenging. Share best practices among your staff on how to address this problem, such as alternating on-call shifts or matching providers needing day care with ‘furloughed’ college students who are looking to keep busy and make a little money.

Continue to: Avoid overcommunicating...

Avoid overcommunicating

Clear, concise, and timely communication is key. This can be challenging given the rapidly evolving science of COVID-19 and the daily barrage of information from both reliable and unreliable sources. Setting up regular online meetings with your faculty 2 or 3 times per week can keep people informed, promote engagement, and boost morale.

If an urgent e-mail announcement is needed, keep the message focused. Highlight only updated information and changes to existing policies and guidelines. And consider adding a brief anecdote to illustrate the staff’s creativity and resilience: a “best catch” story, for example, or a staff member who started a “commit to sit” program (spending time in the room with patients who want company but are not able to have their family in attendance).
 

Look to the future

COVID-19 will pass. Herd immunity will inevitably develop. The question is how quickly and at what cost. Children delivered today are being born into a society already profoundly altered by COVID-19. Some have started to call them Generation C.

Exactly what life will look like at the back end of this pandemic depends on how effectively we leverage this crisis. There are numerous opportunities to change the way we think about health care and educate the next generation of providers. These include increasing the use of telehealth and remote education, redesigning our traditional prenatal care paradigms, and reinforcing the importance of preventive medicine. This is an opportunity to put the “health” back into “health care.”

Look after yourself

Amid all the chaos and uncertainty, do not forget to take care of yourself and your family. Be calm, be kind, and be flexible. Stay safe.

While often compared with the Spanish influenza contagion of 1918, the current COVID-19 pandemic is arguably unprecedented in scale and scope, global reach, and the rate at which it has spread across the world.
 

Unprecedented times

The United States now has the greatest burden of COVID-19 disease worldwide.¹ Although Boston has thus far been spared the full force of the disease’s impact, it is likely only a matter of time before it reaches here. To prepare for the imminent surge, we at Tufts Medical Center defined 4 short-term strategic imperatives to help guide our COVID-19 preparedness. Having a single unified strategy across our organization has helped to maintain focus and consistency in the messaging amidst all of the uncertainty. Our focus areas are outlined below.
 

1 Flatten the curve

This term refers to the use of “social distancing” and community isolation measures to keep the number of disease cases at a manageable level. COVID-19 is spread almost exclusively through contact with contaminated respiratory droplets. While several categories of risk have been described, the US Centers for Disease Control and Prevention (CDC) defines disease “exposure” as face-to-face contact within 6 feet of an infected individual for more than 15 minutes without wearing a mask.² Intervening at all 3 of these touchpoints effectively reduces transmission. Interventions include limiting in-person meetings, increasing the space between individuals (both providers and patients), and routinely using personal protective equipment (PPE).

Another effective strategy is to divide frontline providers into smaller units or teams to limit cross-contamination: the inpatient team versus the outpatient team, the day team versus the night team, the “on” team versus the “off” team. If the infection lays one team low, other providers can step in until they recover and return to work.

Visitor policies should be developed and strictly implemented. Many institutions do allow one support person in labor and delivery (L&D) regardless of the patient’s COVID-19 status, although that person should not be symptomatic or COVID-19 positive. Whether to test all patients and support persons for COVID-19 on arrival at L&D remains controversial.³ At a minimum, these individuals should be screened for symptoms. Although it was a major focus of initial preventative efforts, taking a travel and exposure history is no longer informative as the virus is now endemic and community spread is common.

Initial preventative efforts focused also on high-risk patients, but routine use of PPE for all encounters clearly is more effective because of the high rate of asymptomatic shedding. The virus can survive suspended in the air for up to 2 hours following an aerosol-generating procedure (AGP) and on surfaces for several hours or even days. Practices such as regular handwashing, cleaning of exposed work surfaces, and avoiding face touching should by now be part of our everyday routine.

Institutions throughout the United States have established inpatient COVID-19 units—so-called “dirty” units—with mixed success. As the pandemic spreads and the number of patients with asymptomatic shedding increases, it is harder to determine who is and who is not infected. Cross-contamination has rendered this approach largely ineffective. Whether this will change with the introduction of rapid point-of-care testing remains to be seen.

Continue to: 2 Preserve PPE...

2 Preserve PPE

PPE use is effective in reducing transmission. This includes tier 1 PPE with or without enhanced droplet precaution (surgical mask, eye protection, gloves, yellow gown) and tier 2 PPE (tier 1 plus N95 respirators or powered air-purifying respirators [PAPR]). Given the acute PPE shortage in many parts of the country, appropriate use of PPE is critical to maintain an adequate supply. For example, tier 2 PPE is required only in the setting of an AGP. This includes intubation and, in our determination, the second stage of labor for COVID-19–positive patients and patients under investigation (PUIs); we do not employ tier 2 PPE for all patients in the second stage of labor, although some hospitals endorse this practice.

Creative solutions to the impending PPE shortage abound, such as the use of 3D printers to make face shields and novel techniques to sterilize and reuse N95 respirators.

3 Create capacity

In the absence of effective treatment for COVID-19 and with a vaccine still many months away, supportive care is critical. The pulmonary sequelae with cytokine storm and acute hypoxemia can come on quickly, require urgent mechanical ventilatory support, and take several weeks to resolve.

Our ability to create inpatient capacity to accommodate ill patients, monitor them closely, and intubate early will likely be the most critical driver of the case fatality rate. This requires deferring outpatient visits (or doing them via telemedicine), expanding intensive care unit capabilities (especially ventilator beds), and canceling elective surgeries. What constitutes “elective surgery” is not always clear. Our institution, for example, regards abortion services as essential and not elective, but this is not the case throughout the United States.

Creating capacity also refers to staffing. Where necessary, providers should be retrained and redeployed. This may require emergency credentialing of providers in areas outside their usual clinical practice and permission may be needed from the Accreditation Council for Graduate Medical Education to engage trainees outside their usual duty hours.
 

4 Support and protect your workforce

Everyone is anxious, and people convey their anxiety in different ways. I have found it helpful to acknowledge those feelings and provide a forum for staff to express and share their anxieties. That said, hospitals are not a democracy. While staff members should be encouraged to ask questions and voice their opinions, everyone is expected to follow protocol regarding patient care.

Celebrating small successes and finding creative ways to alleviate the stress and inject humor can help. Most institutions are using electronic conferencing platforms (such as Zoom or Microsoft Teams) to stay in touch and to continue education initiatives through interactive didactic sessions, grand rounds, morbidity and mortality conferences, and e-journal clubs. These are also a great platform for social events, such as w(h)ine and book clubs and virtual karaoke.

Since many ObGyn providers are women, the closure of day-care centers and schools is particularly challenging. Share best practices among your staff on how to address this problem, such as alternating on-call shifts or matching providers needing day care with ‘furloughed’ college students who are looking to keep busy and make a little money.

Continue to: Avoid overcommunicating...

Avoid overcommunicating

Clear, concise, and timely communication is key. This can be challenging given the rapidly evolving science of COVID-19 and the daily barrage of information from both reliable and unreliable sources. Setting up regular online meetings with your faculty 2 or 3 times per week can keep people informed, promote engagement, and boost morale.

If an urgent e-mail announcement is needed, keep the message focused. Highlight only updated information and changes to existing policies and guidelines. And consider adding a brief anecdote to illustrate the staff’s creativity and resilience: a “best catch” story, for example, or a staff member who started a “commit to sit” program (spending time in the room with patients who want company but are not able to have their family in attendance).
 

Look to the future

COVID-19 will pass. Herd immunity will inevitably develop. The question is how quickly and at what cost. Children delivered today are being born into a society already profoundly altered by COVID-19. Some have started to call them Generation C.

Exactly what life will look like at the back end of this pandemic depends on how effectively we leverage this crisis. There are numerous opportunities to change the way we think about health care and educate the next generation of providers. These include increasing the use of telehealth and remote education, redesigning our traditional prenatal care paradigms, and reinforcing the importance of preventive medicine. This is an opportunity to put the “health” back into “health care.”

Look after yourself

Amid all the chaos and uncertainty, do not forget to take care of yourself and your family. Be calm, be kind, and be flexible. Stay safe.

While often compared with the Spanish influenza contagion of 1918, the current COVID-19 pandemic is arguably unprecedented in scale and scope, global reach, and the rate at which it has spread across the world.
 

Unprecedented times

The United States now has the greatest burden of COVID-19 disease worldwide.¹ Although Boston has thus far been spared the full force of the disease’s impact, it is likely only a matter of time before it reaches here. To prepare for the imminent surge, we at Tufts Medical Center defined 4 short-term strategic imperatives to help guide our COVID-19 preparedness. Having a single unified strategy across our organization has helped to maintain focus and consistency in the messaging amidst all of the uncertainty. Our focus areas are outlined below.
 

1 Flatten the curve

This term refers to the use of “social distancing” and community isolation measures to keep the number of disease cases at a manageable level. COVID-19 is spread almost exclusively through contact with contaminated respiratory droplets. While several categories of risk have been described, the US Centers for Disease Control and Prevention (CDC) defines disease “exposure” as face-to-face contact within 6 feet of an infected individual for more than 15 minutes without wearing a mask.² Intervening at all 3 of these touchpoints effectively reduces transmission. Interventions include limiting in-person meetings, increasing the space between individuals (both providers and patients), and routinely using personal protective equipment (PPE).

Another effective strategy is to divide frontline providers into smaller units or teams to limit cross-contamination: the inpatient team versus the outpatient team, the day team versus the night team, the “on” team versus the “off” team. If the infection lays one team low, other providers can step in until they recover and return to work.

Visitor policies should be developed and strictly implemented. Many institutions do allow one support person in labor and delivery (L&D) regardless of the patient’s COVID-19 status, although that person should not be symptomatic or COVID-19 positive. Whether to test all patients and support persons for COVID-19 on arrival at L&D remains controversial.³ At a minimum, these individuals should be screened for symptoms. Although it was a major focus of initial preventative efforts, taking a travel and exposure history is no longer informative as the virus is now endemic and community spread is common.

Initial preventative efforts focused also on high-risk patients, but routine use of PPE for all encounters clearly is more effective because of the high rate of asymptomatic shedding. The virus can survive suspended in the air for up to 2 hours following an aerosol-generating procedure (AGP) and on surfaces for several hours or even days. Practices such as regular handwashing, cleaning of exposed work surfaces, and avoiding face touching should by now be part of our everyday routine.

Institutions throughout the United States have established inpatient COVID-19 units—so-called “dirty” units—with mixed success. As the pandemic spreads and the number of patients with asymptomatic shedding increases, it is harder to determine who is and who is not infected. Cross-contamination has rendered this approach largely ineffective. Whether this will change with the introduction of rapid point-of-care testing remains to be seen.

Continue to: 2 Preserve PPE...

2 Preserve PPE

PPE use is effective in reducing transmission. This includes tier 1 PPE with or without enhanced droplet precaution (surgical mask, eye protection, gloves, yellow gown) and tier 2 PPE (tier 1 plus N95 respirators or powered air-purifying respirators [PAPR]). Given the acute PPE shortage in many parts of the country, appropriate use of PPE is critical to maintain an adequate supply. For example, tier 2 PPE is required only in the setting of an AGP. This includes intubation and, in our determination, the second stage of labor for COVID-19–positive patients and patients under investigation (PUIs); we do not employ tier 2 PPE for all patients in the second stage of labor, although some hospitals endorse this practice.

Creative solutions to the impending PPE shortage abound, such as the use of 3D printers to make face shields and novel techniques to sterilize and reuse N95 respirators.

3 Create capacity

In the absence of effective treatment for COVID-19 and with a vaccine still many months away, supportive care is critical. The pulmonary sequelae with cytokine storm and acute hypoxemia can come on quickly, require urgent mechanical ventilatory support, and take several weeks to resolve.

Our ability to create inpatient capacity to accommodate ill patients, monitor them closely, and intubate early will likely be the most critical driver of the case fatality rate. This requires deferring outpatient visits (or doing them via telemedicine), expanding intensive care unit capabilities (especially ventilator beds), and canceling elective surgeries. What constitutes “elective surgery” is not always clear. Our institution, for example, regards abortion services as essential and not elective, but this is not the case throughout the United States.

Creating capacity also refers to staffing. Where necessary, providers should be retrained and redeployed. This may require emergency credentialing of providers in areas outside their usual clinical practice and permission may be needed from the Accreditation Council for Graduate Medical Education to engage trainees outside their usual duty hours.
 

4 Support and protect your workforce

Everyone is anxious, and people convey their anxiety in different ways. I have found it helpful to acknowledge those feelings and provide a forum for staff to express and share their anxieties. That said, hospitals are not a democracy. While staff members should be encouraged to ask questions and voice their opinions, everyone is expected to follow protocol regarding patient care.

Celebrating small successes and finding creative ways to alleviate the stress and inject humor can help. Most institutions are using electronic conferencing platforms (such as Zoom or Microsoft Teams) to stay in touch and to continue education initiatives through interactive didactic sessions, grand rounds, morbidity and mortality conferences, and e-journal clubs. These are also a great platform for social events, such as w(h)ine and book clubs and virtual karaoke.

Since many ObGyn providers are women, the closure of day-care centers and schools is particularly challenging. Share best practices among your staff on how to address this problem, such as alternating on-call shifts or matching providers needing day care with ‘furloughed’ college students who are looking to keep busy and make a little money.

Continue to: Avoid overcommunicating...

Avoid overcommunicating

Clear, concise, and timely communication is key. This can be challenging given the rapidly evolving science of COVID-19 and the daily barrage of information from both reliable and unreliable sources. Setting up regular online meetings with your faculty 2 or 3 times per week can keep people informed, promote engagement, and boost morale.

If an urgent e-mail announcement is needed, keep the message focused. Highlight only updated information and changes to existing policies and guidelines. And consider adding a brief anecdote to illustrate the staff’s creativity and resilience: a “best catch” story, for example, or a staff member who started a “commit to sit” program (spending time in the room with patients who want company but are not able to have their family in attendance).
 

Look to the future

COVID-19 will pass. Herd immunity will inevitably develop. The question is how quickly and at what cost. Children delivered today are being born into a society already profoundly altered by COVID-19. Some have started to call them Generation C.

Exactly what life will look like at the back end of this pandemic depends on how effectively we leverage this crisis. There are numerous opportunities to change the way we think about health care and educate the next generation of providers. These include increasing the use of telehealth and remote education, redesigning our traditional prenatal care paradigms, and reinforcing the importance of preventive medicine. This is an opportunity to put the “health” back into “health care.”

Look after yourself

Amid all the chaos and uncertainty, do not forget to take care of yourself and your family. Be calm, be kind, and be flexible. Stay safe.

The American Lung Association has launched a $25 million initiative to end COVID-19 and defend against future respiratory virus pandemics.

The goals of the COVID-19 Action Initiative will be to expand the ALA’s respiratory research program, improve public health measures, and create an advanced network to prevent future respiratory virus pandemics. In cooperation with the public and private sectors, the initiative will promote research collaboration and develop new vaccines, diagnostic tests, and therapies. The initiative will take advantage of the ALA’s current research network and will also fund respiratory virus research. It also will fund education and advocacy to support public health measures against current and future respiratory viruses.

The COVID-19 Action Initiative will fund respiratory virus research through three main activities. It will expand COVID-19 research within the current clinical trials of the Airways Clinical Research Center (ACRC) Network. Second, it will fund coronavirus awards and grants for preventive research, vaccines, antivirals, and efforts to promote preparedness for future outbreaks. Third, it will provide ACRC pilot grants to evaluate the effect of COVID-19 on patients with chronic lung disease.

“More than 36 million people in the U.S. suffer from lung disease, which places them at higher risk for experiencing complications of COVID-19, making it even more critical that we urgently work on reducing its impact,” said Harold Wimmer, president and CEO of the ALA, in a press release.

The ALA has $8 million available and earmarked for the initiative. The association plans to raise additional funds during the next 3 years by reaching out to corporate partners, public health entities, and individuals. “With the help of our staff and volunteers, and with the support and donations of generous Americans, we can stand together and face the challenges to lung health of today and tomorrow,” said Mr. Wimmer in a press briefing.
 

egreb@mdedge.com

The American Lung Association has launched a $25 million initiative to end COVID-19 and defend against future respiratory virus pandemics.

The goals of the COVID-19 Action Initiative will be to expand the ALA’s respiratory research program, improve public health measures, and create an advanced network to prevent future respiratory virus pandemics. In cooperation with the public and private sectors, the initiative will promote research collaboration and develop new vaccines, diagnostic tests, and therapies. The initiative will take advantage of the ALA’s current research network and will also fund respiratory virus research. It also will fund education and advocacy to support public health measures against current and future respiratory viruses.

The COVID-19 Action Initiative will fund respiratory virus research through three main activities. It will expand COVID-19 research within the current clinical trials of the Airways Clinical Research Center (ACRC) Network. Second, it will fund coronavirus awards and grants for preventive research, vaccines, antivirals, and efforts to promote preparedness for future outbreaks. Third, it will provide ACRC pilot grants to evaluate the effect of COVID-19 on patients with chronic lung disease.

“More than 36 million people in the U.S. suffer from lung disease, which places them at higher risk for experiencing complications of COVID-19, making it even more critical that we urgently work on reducing its impact,” said Harold Wimmer, president and CEO of the ALA, in a press release.

The ALA has $8 million available and earmarked for the initiative. The association plans to raise additional funds during the next 3 years by reaching out to corporate partners, public health entities, and individuals. “With the help of our staff and volunteers, and with the support and donations of generous Americans, we can stand together and face the challenges to lung health of today and tomorrow,” said Mr. Wimmer in a press briefing.
 

egreb@mdedge.com

The American Lung Association has launched a $25 million initiative to end COVID-19 and defend against future respiratory virus pandemics.

The goals of the COVID-19 Action Initiative will be to expand the ALA’s respiratory research program, improve public health measures, and create an advanced network to prevent future respiratory virus pandemics. In cooperation with the public and private sectors, the initiative will promote research collaboration and develop new vaccines, diagnostic tests, and therapies. The initiative will take advantage of the ALA’s current research network and will also fund respiratory virus research. It also will fund education and advocacy to support public health measures against current and future respiratory viruses.

The COVID-19 Action Initiative will fund respiratory virus research through three main activities. It will expand COVID-19 research within the current clinical trials of the Airways Clinical Research Center (ACRC) Network. Second, it will fund coronavirus awards and grants for preventive research, vaccines, antivirals, and efforts to promote preparedness for future outbreaks. Third, it will provide ACRC pilot grants to evaluate the effect of COVID-19 on patients with chronic lung disease.

“More than 36 million people in the U.S. suffer from lung disease, which places them at higher risk for experiencing complications of COVID-19, making it even more critical that we urgently work on reducing its impact,” said Harold Wimmer, president and CEO of the ALA, in a press release.

The ALA has $8 million available and earmarked for the initiative. The association plans to raise additional funds during the next 3 years by reaching out to corporate partners, public health entities, and individuals. “With the help of our staff and volunteers, and with the support and donations of generous Americans, we can stand together and face the challenges to lung health of today and tomorrow,” said Mr. Wimmer in a press briefing.
 

egreb@mdedge.com

In the latest issue of the Morbidity and Mortality Weekly Report, the Centers for Disease Control and Prevention recommended hepatitis C virus screening for all adults and all pregnant women – during each of their pregnancies – in areas where prevalence of the infection is 0.1% or greater.

That’s essentially the entire United States; there’s no state with a statewide adult prevalence below 0.1%, and “few settings are known to exist” otherwise, the CDC noted (MMWR Recomm Rep. 2020 Apr 10;69(2):1-17).

The agency encouraged providers to consult state or local health departments or the CDC directly to determine local HCV prevalence. “As a general guide ... approximately 59% of anti-HCV positive persons are HCV RNA positive,” indicating active infection, the agency noted.

The advice was an expansion from the CDC’s last universal screening recommendation in 2012, which was limited to people born from 1945 to 1965; the incidence of acute infections has climbed since then and is highest now among younger people, so the guideline needed to be revisited, explained authors led by Sarah Schillie, MD, of the CDC’s Division of Viral Hepatitis, Atlanta.

The U.S. Preventive Services Task Force also recently recommended universal adult screening after previously limiting it to baby boomers.

As for pregnancy, the CDC’s past advice was to screen pregnant women with known risk factors, but that needed to be revisited as well. For one thing, the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America have since recommended testing all pregnant women.

But also, the CDC said, it’s an opportune time for screening because “many women only have access to health care during pregnancy and the immediate postpartum period,” when treatment, if needed, can be started. Plus, HCV status is important for management decisions, such as using amniocentesis in positive women instead of chorionic villus sampling.

The rest of CDC’s 2012 recommendations stand, including screening all people with risk factors and repeating screening while they persist. Also, “any person who requests hepatitis C testing should receive it, regardless of disclosure of risk,” because people might be reluctant to report things like IV drug use, the authors said.

Screening in the guidelines means an HCV antibody test, followed by a nucleic acid test to check for active infection. The CDC encouraged automatic reflex testing, meaning immediately checking antibody positive samples for HCV RNA. RNA in the blood indicates active, replicating virus.

The new recommendations penciled out in modeling, with an incremental cost-effectiveness ratio (ICER) for universal adult screening of approximately $36,000 per quality-adjusted life year (QALY) gained, and an ICER of approximately $15,000 per QALY gained for pregnancy screening, where HCV prevalence is 0.1%; the 0.1% cost/benefit cutpoint was one of the reasons it was chosen as the prevalence threshold. An ICER under $50,000 is the conservative benchmark for cost-effectiveness, the authors noted.

There was no external funding, and the authors had no disclosures.

aotto@mdedge.com

SOURCE: Schillie S et al. MMWR Recomm Rep. 2020 Apr 10;69[2]:1-17).

In the latest issue of the Morbidity and Mortality Weekly Report, the Centers for Disease Control and Prevention recommended hepatitis C virus screening for all adults and all pregnant women – during each of their pregnancies – in areas where prevalence of the infection is 0.1% or greater.

That’s essentially the entire United States; there’s no state with a statewide adult prevalence below 0.1%, and “few settings are known to exist” otherwise, the CDC noted (MMWR Recomm Rep. 2020 Apr 10;69(2):1-17).

The agency encouraged providers to consult state or local health departments or the CDC directly to determine local HCV prevalence. “As a general guide ... approximately 59% of anti-HCV positive persons are HCV RNA positive,” indicating active infection, the agency noted.

The advice was an expansion from the CDC’s last universal screening recommendation in 2012, which was limited to people born from 1945 to 1965; the incidence of acute infections has climbed since then and is highest now among younger people, so the guideline needed to be revisited, explained authors led by Sarah Schillie, MD, of the CDC’s Division of Viral Hepatitis, Atlanta.

The U.S. Preventive Services Task Force also recently recommended universal adult screening after previously limiting it to baby boomers.

As for pregnancy, the CDC’s past advice was to screen pregnant women with known risk factors, but that needed to be revisited as well. For one thing, the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America have since recommended testing all pregnant women.

But also, the CDC said, it’s an opportune time for screening because “many women only have access to health care during pregnancy and the immediate postpartum period,” when treatment, if needed, can be started. Plus, HCV status is important for management decisions, such as using amniocentesis in positive women instead of chorionic villus sampling.

The rest of CDC’s 2012 recommendations stand, including screening all people with risk factors and repeating screening while they persist. Also, “any person who requests hepatitis C testing should receive it, regardless of disclosure of risk,” because people might be reluctant to report things like IV drug use, the authors said.

Screening in the guidelines means an HCV antibody test, followed by a nucleic acid test to check for active infection. The CDC encouraged automatic reflex testing, meaning immediately checking antibody positive samples for HCV RNA. RNA in the blood indicates active, replicating virus.

The new recommendations penciled out in modeling, with an incremental cost-effectiveness ratio (ICER) for universal adult screening of approximately $36,000 per quality-adjusted life year (QALY) gained, and an ICER of approximately $15,000 per QALY gained for pregnancy screening, where HCV prevalence is 0.1%; the 0.1% cost/benefit cutpoint was one of the reasons it was chosen as the prevalence threshold. An ICER under $50,000 is the conservative benchmark for cost-effectiveness, the authors noted.

There was no external funding, and the authors had no disclosures.

aotto@mdedge.com

SOURCE: Schillie S et al. MMWR Recomm Rep. 2020 Apr 10;69[2]:1-17).

In the latest issue of the Morbidity and Mortality Weekly Report, the Centers for Disease Control and Prevention recommended hepatitis C virus screening for all adults and all pregnant women – during each of their pregnancies – in areas where prevalence of the infection is 0.1% or greater.

That’s essentially the entire United States; there’s no state with a statewide adult prevalence below 0.1%, and “few settings are known to exist” otherwise, the CDC noted (MMWR Recomm Rep. 2020 Apr 10;69(2):1-17).

The agency encouraged providers to consult state or local health departments or the CDC directly to determine local HCV prevalence. “As a general guide ... approximately 59% of anti-HCV positive persons are HCV RNA positive,” indicating active infection, the agency noted.

The advice was an expansion from the CDC’s last universal screening recommendation in 2012, which was limited to people born from 1945 to 1965; the incidence of acute infections has climbed since then and is highest now among younger people, so the guideline needed to be revisited, explained authors led by Sarah Schillie, MD, of the CDC’s Division of Viral Hepatitis, Atlanta.

The U.S. Preventive Services Task Force also recently recommended universal adult screening after previously limiting it to baby boomers.

As for pregnancy, the CDC’s past advice was to screen pregnant women with known risk factors, but that needed to be revisited as well. For one thing, the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America have since recommended testing all pregnant women.

But also, the CDC said, it’s an opportune time for screening because “many women only have access to health care during pregnancy and the immediate postpartum period,” when treatment, if needed, can be started. Plus, HCV status is important for management decisions, such as using amniocentesis in positive women instead of chorionic villus sampling.

The rest of CDC’s 2012 recommendations stand, including screening all people with risk factors and repeating screening while they persist. Also, “any person who requests hepatitis C testing should receive it, regardless of disclosure of risk,” because people might be reluctant to report things like IV drug use, the authors said.

Screening in the guidelines means an HCV antibody test, followed by a nucleic acid test to check for active infection. The CDC encouraged automatic reflex testing, meaning immediately checking antibody positive samples for HCV RNA. RNA in the blood indicates active, replicating virus.

The new recommendations penciled out in modeling, with an incremental cost-effectiveness ratio (ICER) for universal adult screening of approximately $36,000 per quality-adjusted life year (QALY) gained, and an ICER of approximately $15,000 per QALY gained for pregnancy screening, where HCV prevalence is 0.1%; the 0.1% cost/benefit cutpoint was one of the reasons it was chosen as the prevalence threshold. An ICER under $50,000 is the conservative benchmark for cost-effectiveness, the authors noted.

There was no external funding, and the authors had no disclosures.

aotto@mdedge.com

SOURCE: Schillie S et al. MMWR Recomm Rep. 2020 Apr 10;69[2]:1-17).

The hospitalization rate for COVID-19 is 4.6 per 100,000 population, and almost 90% of hospitalized patients have some type of underlying condition, according to the Centers for Disease Control and Prevention.

Data collected by the newly created COVID-19–Associated Hospitalization Surveillance Network (COVID-NET) put the exact prevalence of underlying conditions at 89.3% for patients hospitalized during March 1-30, 2020, Shikha Garg, MD, of the CDC’s COVID-NET team and associates wrote in the MMWR.

The hospitalization rate, based on COVID-NET data for March 1-28, increased with patient age. Those aged 65 years and older were admitted at a rate of 13.8 per 100,000, with 50- to 64-year-olds next at 7.4 per 100,000 and 18- to 49-year-olds at 2.5, they wrote.

The patients aged 65 years and older also were the most likely to have one or more underlying conditions, at 94.4%, compared with 86.4% of those aged 50-64 years and 85.4% of individuals who were aged 18-44 years, the investigators reported.

Hypertension was the most common comorbidity among the oldest patients, with a prevalence of 72.6%, followed by cardiovascular disease at 50.8% and obesity at 41%. In the two younger groups, obesity was the condition most often seen in COVID-19 patients, with prevalences of 49% in 50- to 64-year-olds and 59% in those aged 18-49, Dr. Garg and associates wrote.

“These findings underscore the importance of preventive measures (e.g., social distancing, respiratory hygiene, and wearing face coverings in public settings where social distancing measures are difficult to maintain) to protect older adults and persons with underlying medical conditions,” the investigators wrote.

COVID-NET surveillance includes laboratory-confirmed hospitalizations in 99 counties in 14 states: California, Colorado, Connecticut, Georgia, Iowa, Maryland, Michigan, Minnesota, New Mexico, New York, Ohio, Oregon, Tennessee, and Utah. Those counties represent about 10% of the U.S. population.

rfranki@mdedge.com

SOURCE: Garg S et al. MMWR. 2020 Apr 8;69(early release):1-7.

The hospitalization rate for COVID-19 is 4.6 per 100,000 population, and almost 90% of hospitalized patients have some type of underlying condition, according to the Centers for Disease Control and Prevention.

Data collected by the newly created COVID-19–Associated Hospitalization Surveillance Network (COVID-NET) put the exact prevalence of underlying conditions at 89.3% for patients hospitalized during March 1-30, 2020, Shikha Garg, MD, of the CDC’s COVID-NET team and associates wrote in the MMWR.

The hospitalization rate, based on COVID-NET data for March 1-28, increased with patient age. Those aged 65 years and older were admitted at a rate of 13.8 per 100,000, with 50- to 64-year-olds next at 7.4 per 100,000 and 18- to 49-year-olds at 2.5, they wrote.

The patients aged 65 years and older also were the most likely to have one or more underlying conditions, at 94.4%, compared with 86.4% of those aged 50-64 years and 85.4% of individuals who were aged 18-44 years, the investigators reported.

Hypertension was the most common comorbidity among the oldest patients, with a prevalence of 72.6%, followed by cardiovascular disease at 50.8% and obesity at 41%. In the two younger groups, obesity was the condition most often seen in COVID-19 patients, with prevalences of 49% in 50- to 64-year-olds and 59% in those aged 18-49, Dr. Garg and associates wrote.

“These findings underscore the importance of preventive measures (e.g., social distancing, respiratory hygiene, and wearing face coverings in public settings where social distancing measures are difficult to maintain) to protect older adults and persons with underlying medical conditions,” the investigators wrote.

COVID-NET surveillance includes laboratory-confirmed hospitalizations in 99 counties in 14 states: California, Colorado, Connecticut, Georgia, Iowa, Maryland, Michigan, Minnesota, New Mexico, New York, Ohio, Oregon, Tennessee, and Utah. Those counties represent about 10% of the U.S. population.

rfranki@mdedge.com

SOURCE: Garg S et al. MMWR. 2020 Apr 8;69(early release):1-7.

The hospitalization rate for COVID-19 is 4.6 per 100,000 population, and almost 90% of hospitalized patients have some type of underlying condition, according to the Centers for Disease Control and Prevention.

Data collected by the newly created COVID-19–Associated Hospitalization Surveillance Network (COVID-NET) put the exact prevalence of underlying conditions at 89.3% for patients hospitalized during March 1-30, 2020, Shikha Garg, MD, of the CDC’s COVID-NET team and associates wrote in the MMWR.

The hospitalization rate, based on COVID-NET data for March 1-28, increased with patient age. Those aged 65 years and older were admitted at a rate of 13.8 per 100,000, with 50- to 64-year-olds next at 7.4 per 100,000 and 18- to 49-year-olds at 2.5, they wrote.

The patients aged 65 years and older also were the most likely to have one or more underlying conditions, at 94.4%, compared with 86.4% of those aged 50-64 years and 85.4% of individuals who were aged 18-44 years, the investigators reported.

Hypertension was the most common comorbidity among the oldest patients, with a prevalence of 72.6%, followed by cardiovascular disease at 50.8% and obesity at 41%. In the two younger groups, obesity was the condition most often seen in COVID-19 patients, with prevalences of 49% in 50- to 64-year-olds and 59% in those aged 18-49, Dr. Garg and associates wrote.

“These findings underscore the importance of preventive measures (e.g., social distancing, respiratory hygiene, and wearing face coverings in public settings where social distancing measures are difficult to maintain) to protect older adults and persons with underlying medical conditions,” the investigators wrote.

COVID-NET surveillance includes laboratory-confirmed hospitalizations in 99 counties in 14 states: California, Colorado, Connecticut, Georgia, Iowa, Maryland, Michigan, Minnesota, New Mexico, New York, Ohio, Oregon, Tennessee, and Utah. Those counties represent about 10% of the U.S. population.

rfranki@mdedge.com

SOURCE: Garg S et al. MMWR. 2020 Apr 8;69(early release):1-7.

On June 26, 2019, American Academic Health System and Philadelphia Academic Health System announced that Hahnemann University Hospital, a 496-bed tertiary care center in North Philadelphia in operation for over 170 years, would close that September.

The emergency department closed 52 days after the announcement, leaving little time for physicians and staff to coordinate care for patients and secure new employment. The announcement was also made right at the beginning of the new academic year, which meant residents and fellows were forced to find new training programs. In total, 2,500 workers at Hahnemann, including more than 570 hospitalists and physicians training as residents and fellows, were displaced as the hospital closed – the largest such closing in U.S. history.

For most of its existence, Hahnemann was a teaching hospital. While trainees were all eventually placed in new programs thanks to efforts from the Accreditation Council for Graduate Medical Education (ACGME), some of the permanent staff at Hahnemann weren’t so lucky. A month after the announcement, Drexel University’s president told university employees that 40% of the staff who worked at Hahnemann would be cut as a result of the closing. Drexel, also based in Philadelphia, had long had an academic affiliation agreement for training Drexel’s medical school students as a primary academic partner. Overall, Drexel’s entire clinical staff at Hahnemann was let go, and Tower Health Medical Group is expected to hire about 60% of the former Hahnemann staff.

Kevin D’Mello, MD, FACP, FHM, a hospitalist and assistant professor of medicine at Drexel University, said residents during Hahnemann’s closure were essentially teaching themselves how to swim. “There were just no laws, no rules,” he said.

The vast majority of programs accepting applications from residents at Hahnemann were sympathetic and accommodating, he said, but a few programs applied “pressure tactics” to some of the residents offered a transfer position, despite graduate medical education rules in place to prevent such a situation from happening. “The resident says: ‘Oh, well, I’m waiting to hear from this other program,’ ” said Dr. D’Mello. “They’d say: ‘Okay, well, we’re giving you a position now. You have 12 hours to answer.’ ”

Decision makers at the hospital also were not very forthcoming with information to residents, fellows and program directors, according to a recent paper written by Thomas J. Nasca, MD, current president and CEO of ACGME, and colleagues in the journal Academic Medicine (Nasca T et al. Acad Med. 2019 Dec 17. doi: 10.1097/ACM.0000000000003133). When Dr. Nasca and colleagues went to investigate the situation at Hahnemann firsthand, “the team found that residents, fellows, and program directors alike considered their voices to have been ignored in decision making and deemed themselves ‘out of the loop’ of important information that would affect their career transitions.”

While the hospital closed in September 2019, the effects are still being felt. In Pennsylvania, the Medical Care Availability and Reduction of Error Act requires that hospitals and providers have malpractice insurance, including tail insurance for when a doctor’s insurance policy expires. American Academic announced it would not be paying tail insurance for claims made while physicians were at Hahnemann. This meant residents, fellows and physicians who worked at Hahnemann during the closure would be on the hook for paying their own malpractice insurance.

“On one hand, the risk is very low for the house staff. Lawsuits that come up later for house staff are generally dropped at some point,” said William W. Pinsky, MD, FAAP, FACC, president and CEO of the Educational Commission for Foreign Medical Graduates (ECFMG). “But who wants to take that risk going forward? It’s an issue that’s still not resolved.”

The American Medical Association, Association of American Medical Colleges (AAMC), the Philadelphia County Medical Society, and other medical societies have collectively put pressure on Hahnemann’s owners to pay for tail coverage. Beyond a Feb. 10, 2020 deadline, former Hahnemann physicians were still expected to cover their own tail insurance.

To further complicate matters, American Academic attempted to auction more than 570 residency slots at Hahnemann. The slots were sold to a consortium of six health systems in the area – Thomas Jefferson University Hospitals, Einstein Healthcare Network, Temple University Health System, Main Line Health, Cooper University Health Care, and Christiana Care Health System – for $55 million. The Centers for Medicare & Medicaid Services opposed the sale, arguing that the slots are a contract that hospitals enter into with CMS, rather than an asset to be sold. An appeal is currently pending.

The case is being watched by former physicians at Hahnemann. “American Academic said, ‘If we don’t get this $55 million, we’re not going to be able to cover this tail insurance.’ They’re kind of linking the two things,” said Dr. D’Mello. “To me, it’s almost like putting pressure to allow the sale to happen.”
 

Urban hospital closures disrupt health system balance

When an urban hospital like Hahnemann University Hospital closes, there is a major disruption to patient care. Patients need to relocate to other nearby centers, and they may not always be able to follow their physician to the next health center.

If patients have comorbidities, are being tracked across multiple care points, or change physicians during a hospital closure, details can be missed and care can become more complicated for physicians who end up seeing the patient at a new center. For example, a patient receiving obstetrics care at a hospital that closes will have to reschedule their delivery at another health center, noted Dr. Pinsky.

“Where patients get lost is when there’s not a physician or an individual can keep track of all that, coordinate, and help to be sure that the patient follows through,” he said.

Patients at a closing hospital need to go somewhere else for care, and patient volume naturally increases at other nearby centers, potentially causing problems for systems without the resources to handle the spike in traffic.

“I’m a service director of quality improvement and patient safety for Drexel internal medicine. I know that those sort of jumps and volumes are what increases medical errors and potentially could create some adverse outcomes,” said Dr. D’Mello. “That’s something I’m particularly worried about.”

Physicians are also reconciling their own personal situations during a hospital closure, attempting to figure out their next step while at the same time helping patients figure out theirs. In the case of international medical graduates on J-1 or H1-B visas, who are dependent on hospital positions and training programs to remain in the United States, the situation can be even more dire.

During Hahnemann’s closure, Dr. Pinsky said that the ECFMG, which represents 11,000 individuals with J-1 visas across the country, reached out to the 55 individuals on J-1 visas at the hospital and offered them assistance, including working with the Department of State to ensure they aren’t in jeopardy of deportation before they secure another training program position.

The ECFMG, AMA, AAMC, and ACGME also offered funding to help J-1 visa holders who needed to relocate outside Philadelphia. “Many of them spent a lot of their money or all their money just coming over here,” said Dr. Pinsky. “This was a way to help defray some immediate costs that they might have.”

Education and research, of which hospitalists and residents play a large role, are likewise affected during a hospital closure, Dr. Pinsky said. “Education and research in the hospital is an important contributor to the community, health care and medical education nationally overall. When it’s not considered, there can be a significant asset that is lost in the process, which is hard to ever regain.

“The hospitalists have an integral role in medical education. In most hospitals where there is graduate medical education, particularly in internal medicine or pediatrics, and where there is a hospitalist program, it’s the hospitalists that do the majority of the in-hospital or inpatient training and education,” he added.
 

Rural hospital closures affect access to care

Since 2005, 163 rural hospitals have closed in the United States. When rural hospitals close, the situation for hospitalists and other physicians is different. In communities where a larger health system owns a hospital, such as when Vidant Health closed Pungo District Hospital in Belhaven, N.C., in 2014 before reopening a nonemergency clinic in the area in 2016, health care services for the community may have limited interruption.

However, if there isn’t a nearby system to join, many doctors will end up leaving the area. More than half of rural hospitals that close end up not providing any kind of supplementary health care service, according to the NC Rural Health Research Program.

“A lot of the hospitals that have closed have not been owned by a system,” said George H. Pink, PhD, deputy director of the NC Rural Health Research Program at the University of North Carolina at Chapel Hill. “They’ve been independent, freestanding, and that perhaps is one of the reasons why they’re closing, is because they haven’t been able to find a system that would buy them out and inject capital into the community.”

This can also have an effect on the number of health care providers in the area, Dr. Pink said. “Their ability to refer patients and treat patients locally may be affected. That’s why, in many towns where hospitals have closed, we see a drop in the number of providers, particularly primary care doctors who actually live in the community.”

Politicians and federal entities have proposed a number of solutions to help protect rural hospitals from closure. Sen. Charles Grassley (R-Iowa), Sen. Amy Klobuchar (D-Minn.), and Sen. Cory Gardener (R-Colo.) have sponsored bills in the Senate, while Rep. Sam Graves (R-Mo.) has introduced legislation in the House. The Medicare Payment Advisory Commission has proposed two models of rural hospital care, and there are additional models proposed by the Kansas Hospital Association. A pilot program in Pennsylvania, the Pennsylvania Rural Health Model, is testing how a global budget by CMS for all inpatient and hospital-based outcomes might help rural hospitals.

“What we haven’t had a lot of action on is actually testing these models out and seeing whether they will work, and in what kinds of communities they will work,” Dr. Pink said.
 

Hospitalists as community advocates

Dr. D’Mello, who wrote an article for the Journal of Hospital Medicine on Hahnemann’s ownership by a private equity firm (doi: 10.12788/jhm.3378), said that the inherent nature of a for-profit entity trying to make a hospital profitable is a bad sign for a hospital and not necessarily what is in the best interest for an academic institution or for doctors who train there.

“I don’t know if I could blame the private equity firm completely, but in retrospect, the private equity firms stepping in was like the death knell of the hospital,” he said of Hahnemann’s closure.

“I think what the community needs to know – what the health care community, patient community, the hospitalist community need to know – is that there’s got to be more attention paid to these types of issues during mergers and acquisitions to prevent this from happening,” Dr. Pinsky said.

One larger issue was Hahnemann’s position as a safety net hospital, which partly played into American Academic’s lack of success in making the hospital as profitable as they wanted it to be, Dr. D’Mello noted. Hahnemann’s patient population consisted mostly of minority patients on Medicare, Medicaid, and charity care insurance, while recent studies have shown that hospitals are more likely to succeed when they have a larger proportion of patients with private insurance.

“Studies show that, to [make more] money from private insurance, you really have to have this huge footprint, because then you’ve got a better ability to negotiate with these private insurance companies,” Dr. D’Mello said. “Whether that’s actually good for health care is a different issue.”

Despite their own situations, it is not unusual for hospitalists and hospital physicians to step up during a hospital closure and advocate for their patients on behalf of the community, Dr. Pink said.

“When hospitals are in financial difficulty and there’s the risk of closure, typically, the medical staff are among the first to step up and warn the community: ‘We’re at risk of losing our service. We need some help,’ ” he said. “Generally speaking, the local physicians have been at the forefront of helping to keep access to hospital care available in some of these small communities – unfortunately, not always successfully.”

Dr. D’Mello, Dr. Pinsky, and Dr. Pink report no relevant conflicts of interest.

On June 26, 2019, American Academic Health System and Philadelphia Academic Health System announced that Hahnemann University Hospital, a 496-bed tertiary care center in North Philadelphia in operation for over 170 years, would close that September.

The emergency department closed 52 days after the announcement, leaving little time for physicians and staff to coordinate care for patients and secure new employment. The announcement was also made right at the beginning of the new academic year, which meant residents and fellows were forced to find new training programs. In total, 2,500 workers at Hahnemann, including more than 570 hospitalists and physicians training as residents and fellows, were displaced as the hospital closed – the largest such closing in U.S. history.

For most of its existence, Hahnemann was a teaching hospital. While trainees were all eventually placed in new programs thanks to efforts from the Accreditation Council for Graduate Medical Education (ACGME), some of the permanent staff at Hahnemann weren’t so lucky. A month after the announcement, Drexel University’s president told university employees that 40% of the staff who worked at Hahnemann would be cut as a result of the closing. Drexel, also based in Philadelphia, had long had an academic affiliation agreement for training Drexel’s medical school students as a primary academic partner. Overall, Drexel’s entire clinical staff at Hahnemann was let go, and Tower Health Medical Group is expected to hire about 60% of the former Hahnemann staff.

Kevin D’Mello, MD, FACP, FHM, a hospitalist and assistant professor of medicine at Drexel University, said residents during Hahnemann’s closure were essentially teaching themselves how to swim. “There were just no laws, no rules,” he said.

The vast majority of programs accepting applications from residents at Hahnemann were sympathetic and accommodating, he said, but a few programs applied “pressure tactics” to some of the residents offered a transfer position, despite graduate medical education rules in place to prevent such a situation from happening. “The resident says: ‘Oh, well, I’m waiting to hear from this other program,’ ” said Dr. D’Mello. “They’d say: ‘Okay, well, we’re giving you a position now. You have 12 hours to answer.’ ”

Decision makers at the hospital also were not very forthcoming with information to residents, fellows and program directors, according to a recent paper written by Thomas J. Nasca, MD, current president and CEO of ACGME, and colleagues in the journal Academic Medicine (Nasca T et al. Acad Med. 2019 Dec 17. doi: 10.1097/ACM.0000000000003133). When Dr. Nasca and colleagues went to investigate the situation at Hahnemann firsthand, “the team found that residents, fellows, and program directors alike considered their voices to have been ignored in decision making and deemed themselves ‘out of the loop’ of important information that would affect their career transitions.”

While the hospital closed in September 2019, the effects are still being felt. In Pennsylvania, the Medical Care Availability and Reduction of Error Act requires that hospitals and providers have malpractice insurance, including tail insurance for when a doctor’s insurance policy expires. American Academic announced it would not be paying tail insurance for claims made while physicians were at Hahnemann. This meant residents, fellows and physicians who worked at Hahnemann during the closure would be on the hook for paying their own malpractice insurance.

“On one hand, the risk is very low for the house staff. Lawsuits that come up later for house staff are generally dropped at some point,” said William W. Pinsky, MD, FAAP, FACC, president and CEO of the Educational Commission for Foreign Medical Graduates (ECFMG). “But who wants to take that risk going forward? It’s an issue that’s still not resolved.”

The American Medical Association, Association of American Medical Colleges (AAMC), the Philadelphia County Medical Society, and other medical societies have collectively put pressure on Hahnemann’s owners to pay for tail coverage. Beyond a Feb. 10, 2020 deadline, former Hahnemann physicians were still expected to cover their own tail insurance.

To further complicate matters, American Academic attempted to auction more than 570 residency slots at Hahnemann. The slots were sold to a consortium of six health systems in the area – Thomas Jefferson University Hospitals, Einstein Healthcare Network, Temple University Health System, Main Line Health, Cooper University Health Care, and Christiana Care Health System – for $55 million. The Centers for Medicare & Medicaid Services opposed the sale, arguing that the slots are a contract that hospitals enter into with CMS, rather than an asset to be sold. An appeal is currently pending.

The case is being watched by former physicians at Hahnemann. “American Academic said, ‘If we don’t get this $55 million, we’re not going to be able to cover this tail insurance.’ They’re kind of linking the two things,” said Dr. D’Mello. “To me, it’s almost like putting pressure to allow the sale to happen.”
 

Urban hospital closures disrupt health system balance

When an urban hospital like Hahnemann University Hospital closes, there is a major disruption to patient care. Patients need to relocate to other nearby centers, and they may not always be able to follow their physician to the next health center.

If patients have comorbidities, are being tracked across multiple care points, or change physicians during a hospital closure, details can be missed and care can become more complicated for physicians who end up seeing the patient at a new center. For example, a patient receiving obstetrics care at a hospital that closes will have to reschedule their delivery at another health center, noted Dr. Pinsky.

“Where patients get lost is when there’s not a physician or an individual can keep track of all that, coordinate, and help to be sure that the patient follows through,” he said.

Patients at a closing hospital need to go somewhere else for care, and patient volume naturally increases at other nearby centers, potentially causing problems for systems without the resources to handle the spike in traffic.

“I’m a service director of quality improvement and patient safety for Drexel internal medicine. I know that those sort of jumps and volumes are what increases medical errors and potentially could create some adverse outcomes,” said Dr. D’Mello. “That’s something I’m particularly worried about.”

Physicians are also reconciling their own personal situations during a hospital closure, attempting to figure out their next step while at the same time helping patients figure out theirs. In the case of international medical graduates on J-1 or H1-B visas, who are dependent on hospital positions and training programs to remain in the United States, the situation can be even more dire.

During Hahnemann’s closure, Dr. Pinsky said that the ECFMG, which represents 11,000 individuals with J-1 visas across the country, reached out to the 55 individuals on J-1 visas at the hospital and offered them assistance, including working with the Department of State to ensure they aren’t in jeopardy of deportation before they secure another training program position.

The ECFMG, AMA, AAMC, and ACGME also offered funding to help J-1 visa holders who needed to relocate outside Philadelphia. “Many of them spent a lot of their money or all their money just coming over here,” said Dr. Pinsky. “This was a way to help defray some immediate costs that they might have.”

Education and research, of which hospitalists and residents play a large role, are likewise affected during a hospital closure, Dr. Pinsky said. “Education and research in the hospital is an important contributor to the community, health care and medical education nationally overall. When it’s not considered, there can be a significant asset that is lost in the process, which is hard to ever regain.

“The hospitalists have an integral role in medical education. In most hospitals where there is graduate medical education, particularly in internal medicine or pediatrics, and where there is a hospitalist program, it’s the hospitalists that do the majority of the in-hospital or inpatient training and education,” he added.
 

Rural hospital closures affect access to care

Since 2005, 163 rural hospitals have closed in the United States. When rural hospitals close, the situation for hospitalists and other physicians is different. In communities where a larger health system owns a hospital, such as when Vidant Health closed Pungo District Hospital in Belhaven, N.C., in 2014 before reopening a nonemergency clinic in the area in 2016, health care services for the community may have limited interruption.

However, if there isn’t a nearby system to join, many doctors will end up leaving the area. More than half of rural hospitals that close end up not providing any kind of supplementary health care service, according to the NC Rural Health Research Program.

“A lot of the hospitals that have closed have not been owned by a system,” said George H. Pink, PhD, deputy director of the NC Rural Health Research Program at the University of North Carolina at Chapel Hill. “They’ve been independent, freestanding, and that perhaps is one of the reasons why they’re closing, is because they haven’t been able to find a system that would buy them out and inject capital into the community.”

This can also have an effect on the number of health care providers in the area, Dr. Pink said. “Their ability to refer patients and treat patients locally may be affected. That’s why, in many towns where hospitals have closed, we see a drop in the number of providers, particularly primary care doctors who actually live in the community.”

Politicians and federal entities have proposed a number of solutions to help protect rural hospitals from closure. Sen. Charles Grassley (R-Iowa), Sen. Amy Klobuchar (D-Minn.), and Sen. Cory Gardener (R-Colo.) have sponsored bills in the Senate, while Rep. Sam Graves (R-Mo.) has introduced legislation in the House. The Medicare Payment Advisory Commission has proposed two models of rural hospital care, and there are additional models proposed by the Kansas Hospital Association. A pilot program in Pennsylvania, the Pennsylvania Rural Health Model, is testing how a global budget by CMS for all inpatient and hospital-based outcomes might help rural hospitals.

“What we haven’t had a lot of action on is actually testing these models out and seeing whether they will work, and in what kinds of communities they will work,” Dr. Pink said.
 

Hospitalists as community advocates

Dr. D’Mello, who wrote an article for the Journal of Hospital Medicine on Hahnemann’s ownership by a private equity firm (doi: 10.12788/jhm.3378), said that the inherent nature of a for-profit entity trying to make a hospital profitable is a bad sign for a hospital and not necessarily what is in the best interest for an academic institution or for doctors who train there.

“I don’t know if I could blame the private equity firm completely, but in retrospect, the private equity firms stepping in was like the death knell of the hospital,” he said of Hahnemann’s closure.

“I think what the community needs to know – what the health care community, patient community, the hospitalist community need to know – is that there’s got to be more attention paid to these types of issues during mergers and acquisitions to prevent this from happening,” Dr. Pinsky said.

One larger issue was Hahnemann’s position as a safety net hospital, which partly played into American Academic’s lack of success in making the hospital as profitable as they wanted it to be, Dr. D’Mello noted. Hahnemann’s patient population consisted mostly of minority patients on Medicare, Medicaid, and charity care insurance, while recent studies have shown that hospitals are more likely to succeed when they have a larger proportion of patients with private insurance.

“Studies show that, to [make more] money from private insurance, you really have to have this huge footprint, because then you’ve got a better ability to negotiate with these private insurance companies,” Dr. D’Mello said. “Whether that’s actually good for health care is a different issue.”

Despite their own situations, it is not unusual for hospitalists and hospital physicians to step up during a hospital closure and advocate for their patients on behalf of the community, Dr. Pink said.

“When hospitals are in financial difficulty and there’s the risk of closure, typically, the medical staff are among the first to step up and warn the community: ‘We’re at risk of losing our service. We need some help,’ ” he said. “Generally speaking, the local physicians have been at the forefront of helping to keep access to hospital care available in some of these small communities – unfortunately, not always successfully.”

Dr. D’Mello, Dr. Pinsky, and Dr. Pink report no relevant conflicts of interest.

On June 26, 2019, American Academic Health System and Philadelphia Academic Health System announced that Hahnemann University Hospital, a 496-bed tertiary care center in North Philadelphia in operation for over 170 years, would close that September.

The emergency department closed 52 days after the announcement, leaving little time for physicians and staff to coordinate care for patients and secure new employment. The announcement was also made right at the beginning of the new academic year, which meant residents and fellows were forced to find new training programs. In total, 2,500 workers at Hahnemann, including more than 570 hospitalists and physicians training as residents and fellows, were displaced as the hospital closed – the largest such closing in U.S. history.

For most of its existence, Hahnemann was a teaching hospital. While trainees were all eventually placed in new programs thanks to efforts from the Accreditation Council for Graduate Medical Education (ACGME), some of the permanent staff at Hahnemann weren’t so lucky. A month after the announcement, Drexel University’s president told university employees that 40% of the staff who worked at Hahnemann would be cut as a result of the closing. Drexel, also based in Philadelphia, had long had an academic affiliation agreement for training Drexel’s medical school students as a primary academic partner. Overall, Drexel’s entire clinical staff at Hahnemann was let go, and Tower Health Medical Group is expected to hire about 60% of the former Hahnemann staff.

Kevin D’Mello, MD, FACP, FHM, a hospitalist and assistant professor of medicine at Drexel University, said residents during Hahnemann’s closure were essentially teaching themselves how to swim. “There were just no laws, no rules,” he said.

The vast majority of programs accepting applications from residents at Hahnemann were sympathetic and accommodating, he said, but a few programs applied “pressure tactics” to some of the residents offered a transfer position, despite graduate medical education rules in place to prevent such a situation from happening. “The resident says: ‘Oh, well, I’m waiting to hear from this other program,’ ” said Dr. D’Mello. “They’d say: ‘Okay, well, we’re giving you a position now. You have 12 hours to answer.’ ”

Decision makers at the hospital also were not very forthcoming with information to residents, fellows and program directors, according to a recent paper written by Thomas J. Nasca, MD, current president and CEO of ACGME, and colleagues in the journal Academic Medicine (Nasca T et al. Acad Med. 2019 Dec 17. doi: 10.1097/ACM.0000000000003133). When Dr. Nasca and colleagues went to investigate the situation at Hahnemann firsthand, “the team found that residents, fellows, and program directors alike considered their voices to have been ignored in decision making and deemed themselves ‘out of the loop’ of important information that would affect their career transitions.”

While the hospital closed in September 2019, the effects are still being felt. In Pennsylvania, the Medical Care Availability and Reduction of Error Act requires that hospitals and providers have malpractice insurance, including tail insurance for when a doctor’s insurance policy expires. American Academic announced it would not be paying tail insurance for claims made while physicians were at Hahnemann. This meant residents, fellows and physicians who worked at Hahnemann during the closure would be on the hook for paying their own malpractice insurance.

“On one hand, the risk is very low for the house staff. Lawsuits that come up later for house staff are generally dropped at some point,” said William W. Pinsky, MD, FAAP, FACC, president and CEO of the Educational Commission for Foreign Medical Graduates (ECFMG). “But who wants to take that risk going forward? It’s an issue that’s still not resolved.”

The American Medical Association, Association of American Medical Colleges (AAMC), the Philadelphia County Medical Society, and other medical societies have collectively put pressure on Hahnemann’s owners to pay for tail coverage. Beyond a Feb. 10, 2020 deadline, former Hahnemann physicians were still expected to cover their own tail insurance.

To further complicate matters, American Academic attempted to auction more than 570 residency slots at Hahnemann. The slots were sold to a consortium of six health systems in the area – Thomas Jefferson University Hospitals, Einstein Healthcare Network, Temple University Health System, Main Line Health, Cooper University Health Care, and Christiana Care Health System – for $55 million. The Centers for Medicare & Medicaid Services opposed the sale, arguing that the slots are a contract that hospitals enter into with CMS, rather than an asset to be sold. An appeal is currently pending.

The case is being watched by former physicians at Hahnemann. “American Academic said, ‘If we don’t get this $55 million, we’re not going to be able to cover this tail insurance.’ They’re kind of linking the two things,” said Dr. D’Mello. “To me, it’s almost like putting pressure to allow the sale to happen.”
 

Urban hospital closures disrupt health system balance

When an urban hospital like Hahnemann University Hospital closes, there is a major disruption to patient care. Patients need to relocate to other nearby centers, and they may not always be able to follow their physician to the next health center.

If patients have comorbidities, are being tracked across multiple care points, or change physicians during a hospital closure, details can be missed and care can become more complicated for physicians who end up seeing the patient at a new center. For example, a patient receiving obstetrics care at a hospital that closes will have to reschedule their delivery at another health center, noted Dr. Pinsky.

“Where patients get lost is when there’s not a physician or an individual can keep track of all that, coordinate, and help to be sure that the patient follows through,” he said.

Patients at a closing hospital need to go somewhere else for care, and patient volume naturally increases at other nearby centers, potentially causing problems for systems without the resources to handle the spike in traffic.

“I’m a service director of quality improvement and patient safety for Drexel internal medicine. I know that those sort of jumps and volumes are what increases medical errors and potentially could create some adverse outcomes,” said Dr. D’Mello. “That’s something I’m particularly worried about.”

Physicians are also reconciling their own personal situations during a hospital closure, attempting to figure out their next step while at the same time helping patients figure out theirs. In the case of international medical graduates on J-1 or H1-B visas, who are dependent on hospital positions and training programs to remain in the United States, the situation can be even more dire.

During Hahnemann’s closure, Dr. Pinsky said that the ECFMG, which represents 11,000 individuals with J-1 visas across the country, reached out to the 55 individuals on J-1 visas at the hospital and offered them assistance, including working with the Department of State to ensure they aren’t in jeopardy of deportation before they secure another training program position.

The ECFMG, AMA, AAMC, and ACGME also offered funding to help J-1 visa holders who needed to relocate outside Philadelphia. “Many of them spent a lot of their money or all their money just coming over here,” said Dr. Pinsky. “This was a way to help defray some immediate costs that they might have.”

Education and research, of which hospitalists and residents play a large role, are likewise affected during a hospital closure, Dr. Pinsky said. “Education and research in the hospital is an important contributor to the community, health care and medical education nationally overall. When it’s not considered, there can be a significant asset that is lost in the process, which is hard to ever regain.

“The hospitalists have an integral role in medical education. In most hospitals where there is graduate medical education, particularly in internal medicine or pediatrics, and where there is a hospitalist program, it’s the hospitalists that do the majority of the in-hospital or inpatient training and education,” he added.
 

Rural hospital closures affect access to care

Since 2005, 163 rural hospitals have closed in the United States. When rural hospitals close, the situation for hospitalists and other physicians is different. In communities where a larger health system owns a hospital, such as when Vidant Health closed Pungo District Hospital in Belhaven, N.C., in 2014 before reopening a nonemergency clinic in the area in 2016, health care services for the community may have limited interruption.

However, if there isn’t a nearby system to join, many doctors will end up leaving the area. More than half of rural hospitals that close end up not providing any kind of supplementary health care service, according to the NC Rural Health Research Program.

“A lot of the hospitals that have closed have not been owned by a system,” said George H. Pink, PhD, deputy director of the NC Rural Health Research Program at the University of North Carolina at Chapel Hill. “They’ve been independent, freestanding, and that perhaps is one of the reasons why they’re closing, is because they haven’t been able to find a system that would buy them out and inject capital into the community.”

This can also have an effect on the number of health care providers in the area, Dr. Pink said. “Their ability to refer patients and treat patients locally may be affected. That’s why, in many towns where hospitals have closed, we see a drop in the number of providers, particularly primary care doctors who actually live in the community.”

Politicians and federal entities have proposed a number of solutions to help protect rural hospitals from closure. Sen. Charles Grassley (R-Iowa), Sen. Amy Klobuchar (D-Minn.), and Sen. Cory Gardener (R-Colo.) have sponsored bills in the Senate, while Rep. Sam Graves (R-Mo.) has introduced legislation in the House. The Medicare Payment Advisory Commission has proposed two models of rural hospital care, and there are additional models proposed by the Kansas Hospital Association. A pilot program in Pennsylvania, the Pennsylvania Rural Health Model, is testing how a global budget by CMS for all inpatient and hospital-based outcomes might help rural hospitals.

“What we haven’t had a lot of action on is actually testing these models out and seeing whether they will work, and in what kinds of communities they will work,” Dr. Pink said.
 

Hospitalists as community advocates

Dr. D’Mello, who wrote an article for the Journal of Hospital Medicine on Hahnemann’s ownership by a private equity firm (doi: 10.12788/jhm.3378), said that the inherent nature of a for-profit entity trying to make a hospital profitable is a bad sign for a hospital and not necessarily what is in the best interest for an academic institution or for doctors who train there.

“I don’t know if I could blame the private equity firm completely, but in retrospect, the private equity firms stepping in was like the death knell of the hospital,” he said of Hahnemann’s closure.

“I think what the community needs to know – what the health care community, patient community, the hospitalist community need to know – is that there’s got to be more attention paid to these types of issues during mergers and acquisitions to prevent this from happening,” Dr. Pinsky said.

One larger issue was Hahnemann’s position as a safety net hospital, which partly played into American Academic’s lack of success in making the hospital as profitable as they wanted it to be, Dr. D’Mello noted. Hahnemann’s patient population consisted mostly of minority patients on Medicare, Medicaid, and charity care insurance, while recent studies have shown that hospitals are more likely to succeed when they have a larger proportion of patients with private insurance.

“Studies show that, to [make more] money from private insurance, you really have to have this huge footprint, because then you’ve got a better ability to negotiate with these private insurance companies,” Dr. D’Mello said. “Whether that’s actually good for health care is a different issue.”

Despite their own situations, it is not unusual for hospitalists and hospital physicians to step up during a hospital closure and advocate for their patients on behalf of the community, Dr. Pink said.

“When hospitals are in financial difficulty and there’s the risk of closure, typically, the medical staff are among the first to step up and warn the community: ‘We’re at risk of losing our service. We need some help,’ ” he said. “Generally speaking, the local physicians have been at the forefront of helping to keep access to hospital care available in some of these small communities – unfortunately, not always successfully.”

Dr. D’Mello, Dr. Pinsky, and Dr. Pink report no relevant conflicts of interest.

Participants who had higher levels of fitness when beginning a behavioral weight-loss intervention kept off more weight over the course of an 18-month study, compared with those with lower levels of fitness at baseline.

Those with higher baseline fitness also were able to achieve higher levels of moderate to vigorous physical activity at the 18-month mark, Adnin Zaman, MD, said during a virtual news conference held by the Endocrine Society. The study had been slated for presentation during ENDO 2020, the society's annual meeting, which was canceled because of the COVID-19 pandemic.

“Our study really comes from an observation that we often see significant variability in how much weight participants lose during a behavioral weight-loss intervention study, said Dr. Zaman, an endocrinology research fellow at the University of Colorado at Denver, Aurora.

She and her colleagues wanted to look at baseline cardiovascular fitness as an individual-specific factor that could affect how much weight people lost when participating in a behavioral intervention.

“Very little is known about how cardiovascular fitness affects [people’s] ability to lose weight [or] to adhere to high levels of physical activity, which is a very common recommendation during a program for both weight loss and weight-loss maintenance,” she added.

Dr. Zaman and colleagues conducted a secondary analysis of data from an 18-month trial of behavioral interventions for weight loss. The trial randomized 170 participants 1:1 to receive either concurrent exercise and a dietary behavior modification intervention or sequential dietary and exercise interventions.

The 85 participants in the concurrent intervention arm received 18 months of combined dietary modifications (calorie-restricted diet and group-based behavioral support) and exercise (supervised for the first 6 months of the study, unsupervised for the final 12). Those participating in the sequential intervention arm received a diet-only intervention during the first 6 months of the study, after which supervised exercise was added to the dietary intervention for 6 months, followed by a final 6 months of unsupervised exercise.

Participants in both study arms worked up to 300 minutes a week of moderate to vigorous physical activity in the supervised exercise phase.

For the secondary analysis, Dr. Zaman and colleagues looked only at the 60 participants who received concurrent diet and exercise interventions and who completed the full 18-month study. The mean age in that group was 40 years, mean baseline body mass index (BMI) was 34.6 kg/m², and 80% of participants in the group were women.

Cardiovascular fitness as measured by VO_2max was assessed at baseline using a graded exercise test. Participants were designated as having either “very poor” or “poor or better” cardiovascular fitness (20 and 40 participants, respectively).

Participants in the original trial were inactive at baseline and had a BMI range of 27-42 kg/m². Among the subset of participants studied by Dr. Zaman and colleagues, those who were in the poor or better fitness category actually weighed less at baseline and had a lower BMI, compared with those in the very poor group (33.7 vs. 36.2, respectively), she said. Mean VO_2max for those with very poor fitness was 22.5 mL/kg per minute, compared with 25.6 mL/kg per minute for those with poor or better fitness.

“Despite those differences, it is interesting to note that, during the supervised exercise portion of the study ... everyone lost pretty much the same amount of weight in the first 6 months,” said Dr. Zaman. At the 6-month mark, those with very poor fitness had lost 9.2 kg (20.3 pounds), and those with poor or better fitness had lost 9.1 kg (20.1 pounds). However, weight regain was less likely in those with poor or better fitness, and those participants had a net loss of weight from baseline of 8.2 kg (18.1 pounds), compared with 4.4 kg (9.7 pounds) for those with very poor fitness.

Those with poor or better fitness were able to sustain a 33-minute bout of moderate to vigorous physical activity at baseline, whereas those with very poor fitness could achieve only about half of that. The difference in achievable physical activity between the two groups persisted throughout the study, with a peak at the 6-month mark, at about 60 minutes for the more fit participants and 38 minutes for those in the poor fitness group. By the end of the study, the less-fit participants achieved about 24 minutes of activity, whereas those who were more fit could sustain about 42 minutes of moderate to vigorous physical activity.

Physical activity levels were measured with a validated, wrist-worn device during a 1-week period at baseline and again at study months 6, 12, and 18.

Dr. Zaman noted that baseline weight may have confounded fitness categorization, because VO_2max includes body weight in its calculations. A newer method of calculating cardiorespiratory fitness that scales VO_2max to body weight may help minimize this potential confounder.

The investigators reported no outside sources of funding and reported that they had no financial conflicts of interest.

The research will be published in a special supplemental issue of the Journal of the Endocrine Society. In addition to a series of news conferences on March 30-31, the society will host ENDO Online 2020 during June 8-22, which will present programming for clinicians and researchers.

SOURCE: Zaman A et al. ENDO 2020, Abstract 575.

This article was updated on 4/17/2020.

Participants who had higher levels of fitness when beginning a behavioral weight-loss intervention kept off more weight over the course of an 18-month study, compared with those with lower levels of fitness at baseline.

Those with higher baseline fitness also were able to achieve higher levels of moderate to vigorous physical activity at the 18-month mark, Adnin Zaman, MD, said during a virtual news conference held by the Endocrine Society. The study had been slated for presentation during ENDO 2020, the society's annual meeting, which was canceled because of the COVID-19 pandemic.

“Our study really comes from an observation that we often see significant variability in how much weight participants lose during a behavioral weight-loss intervention study, said Dr. Zaman, an endocrinology research fellow at the University of Colorado at Denver, Aurora.

She and her colleagues wanted to look at baseline cardiovascular fitness as an individual-specific factor that could affect how much weight people lost when participating in a behavioral intervention.

“Very little is known about how cardiovascular fitness affects [people’s] ability to lose weight [or] to adhere to high levels of physical activity, which is a very common recommendation during a program for both weight loss and weight-loss maintenance,” she added.

Dr. Zaman and colleagues conducted a secondary analysis of data from an 18-month trial of behavioral interventions for weight loss. The trial randomized 170 participants 1:1 to receive either concurrent exercise and a dietary behavior modification intervention or sequential dietary and exercise interventions.

The 85 participants in the concurrent intervention arm received 18 months of combined dietary modifications (calorie-restricted diet and group-based behavioral support) and exercise (supervised for the first 6 months of the study, unsupervised for the final 12). Those participating in the sequential intervention arm received a diet-only intervention during the first 6 months of the study, after which supervised exercise was added to the dietary intervention for 6 months, followed by a final 6 months of unsupervised exercise.

Participants in both study arms worked up to 300 minutes a week of moderate to vigorous physical activity in the supervised exercise phase.

For the secondary analysis, Dr. Zaman and colleagues looked only at the 60 participants who received concurrent diet and exercise interventions and who completed the full 18-month study. The mean age in that group was 40 years, mean baseline body mass index (BMI) was 34.6 kg/m², and 80% of participants in the group were women.

Cardiovascular fitness as measured by VO_2max was assessed at baseline using a graded exercise test. Participants were designated as having either “very poor” or “poor or better” cardiovascular fitness (20 and 40 participants, respectively).

Participants in the original trial were inactive at baseline and had a BMI range of 27-42 kg/m². Among the subset of participants studied by Dr. Zaman and colleagues, those who were in the poor or better fitness category actually weighed less at baseline and had a lower BMI, compared with those in the very poor group (33.7 vs. 36.2, respectively), she said. Mean VO_2max for those with very poor fitness was 22.5 mL/kg per minute, compared with 25.6 mL/kg per minute for those with poor or better fitness.

“Despite those differences, it is interesting to note that, during the supervised exercise portion of the study ... everyone lost pretty much the same amount of weight in the first 6 months,” said Dr. Zaman. At the 6-month mark, those with very poor fitness had lost 9.2 kg (20.3 pounds), and those with poor or better fitness had lost 9.1 kg (20.1 pounds). However, weight regain was less likely in those with poor or better fitness, and those participants had a net loss of weight from baseline of 8.2 kg (18.1 pounds), compared with 4.4 kg (9.7 pounds) for those with very poor fitness.

Those with poor or better fitness were able to sustain a 33-minute bout of moderate to vigorous physical activity at baseline, whereas those with very poor fitness could achieve only about half of that. The difference in achievable physical activity between the two groups persisted throughout the study, with a peak at the 6-month mark, at about 60 minutes for the more fit participants and 38 minutes for those in the poor fitness group. By the end of the study, the less-fit participants achieved about 24 minutes of activity, whereas those who were more fit could sustain about 42 minutes of moderate to vigorous physical activity.

Physical activity levels were measured with a validated, wrist-worn device during a 1-week period at baseline and again at study months 6, 12, and 18.

Dr. Zaman noted that baseline weight may have confounded fitness categorization, because VO_2max includes body weight in its calculations. A newer method of calculating cardiorespiratory fitness that scales VO_2max to body weight may help minimize this potential confounder.

The investigators reported no outside sources of funding and reported that they had no financial conflicts of interest.

The research will be published in a special supplemental issue of the Journal of the Endocrine Society. In addition to a series of news conferences on March 30-31, the society will host ENDO Online 2020 during June 8-22, which will present programming for clinicians and researchers.

SOURCE: Zaman A et al. ENDO 2020, Abstract 575.

This article was updated on 4/17/2020.

Participants who had higher levels of fitness when beginning a behavioral weight-loss intervention kept off more weight over the course of an 18-month study, compared with those with lower levels of fitness at baseline.

Those with higher baseline fitness also were able to achieve higher levels of moderate to vigorous physical activity at the 18-month mark, Adnin Zaman, MD, said during a virtual news conference held by the Endocrine Society. The study had been slated for presentation during ENDO 2020, the society's annual meeting, which was canceled because of the COVID-19 pandemic.

“Our study really comes from an observation that we often see significant variability in how much weight participants lose during a behavioral weight-loss intervention study, said Dr. Zaman, an endocrinology research fellow at the University of Colorado at Denver, Aurora.

She and her colleagues wanted to look at baseline cardiovascular fitness as an individual-specific factor that could affect how much weight people lost when participating in a behavioral intervention.

“Very little is known about how cardiovascular fitness affects [people’s] ability to lose weight [or] to adhere to high levels of physical activity, which is a very common recommendation during a program for both weight loss and weight-loss maintenance,” she added.

Dr. Zaman and colleagues conducted a secondary analysis of data from an 18-month trial of behavioral interventions for weight loss. The trial randomized 170 participants 1:1 to receive either concurrent exercise and a dietary behavior modification intervention or sequential dietary and exercise interventions.

The 85 participants in the concurrent intervention arm received 18 months of combined dietary modifications (calorie-restricted diet and group-based behavioral support) and exercise (supervised for the first 6 months of the study, unsupervised for the final 12). Those participating in the sequential intervention arm received a diet-only intervention during the first 6 months of the study, after which supervised exercise was added to the dietary intervention for 6 months, followed by a final 6 months of unsupervised exercise.

Participants in both study arms worked up to 300 minutes a week of moderate to vigorous physical activity in the supervised exercise phase.

For the secondary analysis, Dr. Zaman and colleagues looked only at the 60 participants who received concurrent diet and exercise interventions and who completed the full 18-month study. The mean age in that group was 40 years, mean baseline body mass index (BMI) was 34.6 kg/m², and 80% of participants in the group were women.

Cardiovascular fitness as measured by VO_2max was assessed at baseline using a graded exercise test. Participants were designated as having either “very poor” or “poor or better” cardiovascular fitness (20 and 40 participants, respectively).

Participants in the original trial were inactive at baseline and had a BMI range of 27-42 kg/m². Among the subset of participants studied by Dr. Zaman and colleagues, those who were in the poor or better fitness category actually weighed less at baseline and had a lower BMI, compared with those in the very poor group (33.7 vs. 36.2, respectively), she said. Mean VO_2max for those with very poor fitness was 22.5 mL/kg per minute, compared with 25.6 mL/kg per minute for those with poor or better fitness.

“Despite those differences, it is interesting to note that, during the supervised exercise portion of the study ... everyone lost pretty much the same amount of weight in the first 6 months,” said Dr. Zaman. At the 6-month mark, those with very poor fitness had lost 9.2 kg (20.3 pounds), and those with poor or better fitness had lost 9.1 kg (20.1 pounds). However, weight regain was less likely in those with poor or better fitness, and those participants had a net loss of weight from baseline of 8.2 kg (18.1 pounds), compared with 4.4 kg (9.7 pounds) for those with very poor fitness.

Those with poor or better fitness were able to sustain a 33-minute bout of moderate to vigorous physical activity at baseline, whereas those with very poor fitness could achieve only about half of that. The difference in achievable physical activity between the two groups persisted throughout the study, with a peak at the 6-month mark, at about 60 minutes for the more fit participants and 38 minutes for those in the poor fitness group. By the end of the study, the less-fit participants achieved about 24 minutes of activity, whereas those who were more fit could sustain about 42 minutes of moderate to vigorous physical activity.

Physical activity levels were measured with a validated, wrist-worn device during a 1-week period at baseline and again at study months 6, 12, and 18.

Dr. Zaman noted that baseline weight may have confounded fitness categorization, because VO_2max includes body weight in its calculations. A newer method of calculating cardiorespiratory fitness that scales VO_2max to body weight may help minimize this potential confounder.

The investigators reported no outside sources of funding and reported that they had no financial conflicts of interest.

The research will be published in a special supplemental issue of the Journal of the Endocrine Society. In addition to a series of news conferences on March 30-31, the society will host ENDO Online 2020 during June 8-22, which will present programming for clinicians and researchers.

SOURCE: Zaman A et al. ENDO 2020, Abstract 575.

This article was updated on 4/17/2020.

In utero exposure to bisphenol-A (BPA) analogs led to hypertension in female rats, findings in a new study have shown.

Researchers tested exposures to BPA, as well as bisphenol-S (BPS) and bisphenol-F (BPF), which have been introduced in recent years as BPA alternatives and are now increasingly detectable in human and animal tissues. BPS and BPF are often found in products labeled as “BPA free.”

BPS and BPF have similar physiochemical properties to BPA, and there is concern over their effects.

But their physiological impact is not yet clear, according to Puliyur MohanKumar, DVM, PhD, of the University of Georgia Regenerative Bioscience Center, Athens. “We are exposed to BPA and related compounds on a regular basis, and the important thing is that BPA and related compounds easily cross the placental barrier,” Dr. MohanKumar said during a virtual news conference held by the Endocrine Society. The study had been slated for presentation during ENDO 2020, the society's annual meeting, which was canceled because of the COVID-19 pandemic.

Dr. MohanKumar and colleagues exposed pregnant rats to BPA, BPS, or BPF. When the offspring reached adulthood, the researchers implanted them with radiotelemetry devices to track systolic and diastolic blood pressure, which they measured every 10 minutes over a 24-hour period. This was repeated once a week for 11 weeks.

“The female offspring had elevated systolic as well as diastolic blood pressure, and this was an increase of about 8 mm [Hg] higher than the control animals. That was pretty significant. Keeping these animals at such a prehypertensive state for such a long period of time is going to [lead to] lots of cardiovascular issues later on,” said Dr. MohanKumar.

Robert Sargis, MD, PhD, professor of endocrinology, diabetes, and metabolism at the University of Illinois at Chicago, noted that, although animal studies don’t necessarily translate to similar outcomes in humans, the results are cause for concern.

“What’s particularly interesting, is that there is whole area of essential hypertension, where people develop hypertension and we don’t really know why. We just treat it,” he said in an interview. “But thinking about biological origins [of hypertension] is potentially interesting for a couple of reasons. These bisphenol compounds are really common. Most Americans are exposed to bisphenol A, and it’s been associated with other adverse metabolic effects, including alterations to body weight and glucose homeostasis.

“[These findings] feed into a whole series of studies that have begun to look at the BPA replacements and the fact that they may be, at best, as bad as BPA, and at worst, possibly slightly worse, depending on which outcomes you’re looking at,” Dr. Sargis added.

In the study, seven pregnant rats were orally exposed to saline, four pregnant rats to 5 mcg/kg BPA, four to 5 mcg/kg BPS, and five to 1 mcg/kg BPF during days 6-21 of pregnancy. The lower dose of BPF was used because a dose of 5 mcg/kg proved too toxic. When the offspring reached adulthood, the researchers implanted radiotelemetry devices in the offspring’s femoral artery.

Mean daytime systolic BP was highest in the BPA group (133.3 mg Hg; P < .05), followed by BPS (132.5 mm Hg; P < .05) and BPF (129.2 mm Hg; nonsignificant), compared with 125.2 mm Hg in controls. Nighttime systolic BP was again highest in the BPA group (134.2 mm Hg; P < .01), followed by BPS (133.2 mm Hg; P < .05) and BPF (129.6 mm Hg; nonsignificant), compared with 125.1 mm Hg in controls.

During the day, diastolic BP was highest in the BPS group (91.3 mm Hg; P < .01), followed by BPA (88.8 mm Hg; nonsignificant) and BPF (88.6 mm Hg; nonsignificant), compared with 84.1 mm Hg in controls. At night, diastolic BP was highest in the BPS group (89.7 mm Hg; P < .01), followed by BPA (89.6 mm Hg; P < .01) and BPF (88.6 mm Hg; P < .01), compared with 83.3 mm Hg in controls.

During the day, mean arterial pressure was highest in the BPA group (110.5 mm Hg; P < .01), followed by BPS (108.9 mm Hg; P < .01) and BPF (105.2 mm Hg; nonsignificant), compared with 102.6 mm Hg in controls. At night, mean arterial pressure was highest in BPS (108.6 mm Hg; P < .05), followed by BPA (107.5 mm Hg; nonsignificant) and BPF (105.7 mm Hg; nonsignificant), compared with 101.8 mm Hg in controls.

“These results indicate that prenatal exposure to low levels of BPA analogs has a profound effect on hypertension” in the offspring of pregnant rats exposed to bisphenols, Dr. MohanKumar and colleagues wrote in the abstract.

He noted during his presentation that he and his colleagues plan to repeat the study in male offspring to determine if there are sex differences.

Dr. MohanKumar and colleagues reported having no relevant financial disclosures. Dr. Sargis also reported no conflicts of interest.

The research will be published in a special supplemental issue of the Journal of the Endocrine Society. In addition to a series of news conferences on March 30-31, the society will host ENDO Online 2020 during June 8-22, which will present programming for clinicians and researchers.

SOURCE: MohanKumar P et al. ENDO 2020, Abstract 719.

This article was updated on 4/17/2020.

In utero exposure to bisphenol-A (BPA) analogs led to hypertension in female rats, findings in a new study have shown.

Researchers tested exposures to BPA, as well as bisphenol-S (BPS) and bisphenol-F (BPF), which have been introduced in recent years as BPA alternatives and are now increasingly detectable in human and animal tissues. BPS and BPF are often found in products labeled as “BPA free.”

BPS and BPF have similar physiochemical properties to BPA, and there is concern over their effects.

But their physiological impact is not yet clear, according to Puliyur MohanKumar, DVM, PhD, of the University of Georgia Regenerative Bioscience Center, Athens. “We are exposed to BPA and related compounds on a regular basis, and the important thing is that BPA and related compounds easily cross the placental barrier,” Dr. MohanKumar said during a virtual news conference held by the Endocrine Society. The study had been slated for presentation during ENDO 2020, the society's annual meeting, which was canceled because of the COVID-19 pandemic.

Dr. MohanKumar and colleagues exposed pregnant rats to BPA, BPS, or BPF. When the offspring reached adulthood, the researchers implanted them with radiotelemetry devices to track systolic and diastolic blood pressure, which they measured every 10 minutes over a 24-hour period. This was repeated once a week for 11 weeks.

“The female offspring had elevated systolic as well as diastolic blood pressure, and this was an increase of about 8 mm [Hg] higher than the control animals. That was pretty significant. Keeping these animals at such a prehypertensive state for such a long period of time is going to [lead to] lots of cardiovascular issues later on,” said Dr. MohanKumar.

Robert Sargis, MD, PhD, professor of endocrinology, diabetes, and metabolism at the University of Illinois at Chicago, noted that, although animal studies don’t necessarily translate to similar outcomes in humans, the results are cause for concern.

“What’s particularly interesting, is that there is whole area of essential hypertension, where people develop hypertension and we don’t really know why. We just treat it,” he said in an interview. “But thinking about biological origins [of hypertension] is potentially interesting for a couple of reasons. These bisphenol compounds are really common. Most Americans are exposed to bisphenol A, and it’s been associated with other adverse metabolic effects, including alterations to body weight and glucose homeostasis.

“[These findings] feed into a whole series of studies that have begun to look at the BPA replacements and the fact that they may be, at best, as bad as BPA, and at worst, possibly slightly worse, depending on which outcomes you’re looking at,” Dr. Sargis added.

In the study, seven pregnant rats were orally exposed to saline, four pregnant rats to 5 mcg/kg BPA, four to 5 mcg/kg BPS, and five to 1 mcg/kg BPF during days 6-21 of pregnancy. The lower dose of BPF was used because a dose of 5 mcg/kg proved too toxic. When the offspring reached adulthood, the researchers implanted radiotelemetry devices in the offspring’s femoral artery.

Mean daytime systolic BP was highest in the BPA group (133.3 mg Hg; P < .05), followed by BPS (132.5 mm Hg; P < .05) and BPF (129.2 mm Hg; nonsignificant), compared with 125.2 mm Hg in controls. Nighttime systolic BP was again highest in the BPA group (134.2 mm Hg; P < .01), followed by BPS (133.2 mm Hg; P < .05) and BPF (129.6 mm Hg; nonsignificant), compared with 125.1 mm Hg in controls.

During the day, diastolic BP was highest in the BPS group (91.3 mm Hg; P < .01), followed by BPA (88.8 mm Hg; nonsignificant) and BPF (88.6 mm Hg; nonsignificant), compared with 84.1 mm Hg in controls. At night, diastolic BP was highest in the BPS group (89.7 mm Hg; P < .01), followed by BPA (89.6 mm Hg; P < .01) and BPF (88.6 mm Hg; P < .01), compared with 83.3 mm Hg in controls.

During the day, mean arterial pressure was highest in the BPA group (110.5 mm Hg; P < .01), followed by BPS (108.9 mm Hg; P < .01) and BPF (105.2 mm Hg; nonsignificant), compared with 102.6 mm Hg in controls. At night, mean arterial pressure was highest in BPS (108.6 mm Hg; P < .05), followed by BPA (107.5 mm Hg; nonsignificant) and BPF (105.7 mm Hg; nonsignificant), compared with 101.8 mm Hg in controls.

“These results indicate that prenatal exposure to low levels of BPA analogs has a profound effect on hypertension” in the offspring of pregnant rats exposed to bisphenols, Dr. MohanKumar and colleagues wrote in the abstract.

He noted during his presentation that he and his colleagues plan to repeat the study in male offspring to determine if there are sex differences.

Dr. MohanKumar and colleagues reported having no relevant financial disclosures. Dr. Sargis also reported no conflicts of interest.

The research will be published in a special supplemental issue of the Journal of the Endocrine Society. In addition to a series of news conferences on March 30-31, the society will host ENDO Online 2020 during June 8-22, which will present programming for clinicians and researchers.

SOURCE: MohanKumar P et al. ENDO 2020, Abstract 719.

This article was updated on 4/17/2020.

In utero exposure to bisphenol-A (BPA) analogs led to hypertension in female rats, findings in a new study have shown.

Researchers tested exposures to BPA, as well as bisphenol-S (BPS) and bisphenol-F (BPF), which have been introduced in recent years as BPA alternatives and are now increasingly detectable in human and animal tissues. BPS and BPF are often found in products labeled as “BPA free.”

BPS and BPF have similar physiochemical properties to BPA, and there is concern over their effects.

But their physiological impact is not yet clear, according to Puliyur MohanKumar, DVM, PhD, of the University of Georgia Regenerative Bioscience Center, Athens. “We are exposed to BPA and related compounds on a regular basis, and the important thing is that BPA and related compounds easily cross the placental barrier,” Dr. MohanKumar said during a virtual news conference held by the Endocrine Society. The study had been slated for presentation during ENDO 2020, the society's annual meeting, which was canceled because of the COVID-19 pandemic.

Dr. MohanKumar and colleagues exposed pregnant rats to BPA, BPS, or BPF. When the offspring reached adulthood, the researchers implanted them with radiotelemetry devices to track systolic and diastolic blood pressure, which they measured every 10 minutes over a 24-hour period. This was repeated once a week for 11 weeks.

“The female offspring had elevated systolic as well as diastolic blood pressure, and this was an increase of about 8 mm [Hg] higher than the control animals. That was pretty significant. Keeping these animals at such a prehypertensive state for such a long period of time is going to [lead to] lots of cardiovascular issues later on,” said Dr. MohanKumar.

Robert Sargis, MD, PhD, professor of endocrinology, diabetes, and metabolism at the University of Illinois at Chicago, noted that, although animal studies don’t necessarily translate to similar outcomes in humans, the results are cause for concern.

“What’s particularly interesting, is that there is whole area of essential hypertension, where people develop hypertension and we don’t really know why. We just treat it,” he said in an interview. “But thinking about biological origins [of hypertension] is potentially interesting for a couple of reasons. These bisphenol compounds are really common. Most Americans are exposed to bisphenol A, and it’s been associated with other adverse metabolic effects, including alterations to body weight and glucose homeostasis.

“[These findings] feed into a whole series of studies that have begun to look at the BPA replacements and the fact that they may be, at best, as bad as BPA, and at worst, possibly slightly worse, depending on which outcomes you’re looking at,” Dr. Sargis added.

In the study, seven pregnant rats were orally exposed to saline, four pregnant rats to 5 mcg/kg BPA, four to 5 mcg/kg BPS, and five to 1 mcg/kg BPF during days 6-21 of pregnancy. The lower dose of BPF was used because a dose of 5 mcg/kg proved too toxic. When the offspring reached adulthood, the researchers implanted radiotelemetry devices in the offspring’s femoral artery.

Mean daytime systolic BP was highest in the BPA group (133.3 mg Hg; P < .05), followed by BPS (132.5 mm Hg; P < .05) and BPF (129.2 mm Hg; nonsignificant), compared with 125.2 mm Hg in controls. Nighttime systolic BP was again highest in the BPA group (134.2 mm Hg; P < .01), followed by BPS (133.2 mm Hg; P < .05) and BPF (129.6 mm Hg; nonsignificant), compared with 125.1 mm Hg in controls.

During the day, diastolic BP was highest in the BPS group (91.3 mm Hg; P < .01), followed by BPA (88.8 mm Hg; nonsignificant) and BPF (88.6 mm Hg; nonsignificant), compared with 84.1 mm Hg in controls. At night, diastolic BP was highest in the BPS group (89.7 mm Hg; P < .01), followed by BPA (89.6 mm Hg; P < .01) and BPF (88.6 mm Hg; P < .01), compared with 83.3 mm Hg in controls.

During the day, mean arterial pressure was highest in the BPA group (110.5 mm Hg; P < .01), followed by BPS (108.9 mm Hg; P < .01) and BPF (105.2 mm Hg; nonsignificant), compared with 102.6 mm Hg in controls. At night, mean arterial pressure was highest in BPS (108.6 mm Hg; P < .05), followed by BPA (107.5 mm Hg; nonsignificant) and BPF (105.7 mm Hg; nonsignificant), compared with 101.8 mm Hg in controls.

“These results indicate that prenatal exposure to low levels of BPA analogs has a profound effect on hypertension” in the offspring of pregnant rats exposed to bisphenols, Dr. MohanKumar and colleagues wrote in the abstract.

He noted during his presentation that he and his colleagues plan to repeat the study in male offspring to determine if there are sex differences.

Dr. MohanKumar and colleagues reported having no relevant financial disclosures. Dr. Sargis also reported no conflicts of interest.

The research will be published in a special supplemental issue of the Journal of the Endocrine Society. In addition to a series of news conferences on March 30-31, the society will host ENDO Online 2020 during June 8-22, which will present programming for clinicians and researchers.

SOURCE: MohanKumar P et al. ENDO 2020, Abstract 719.

This article was updated on 4/17/2020.