MDedge Neurology

Pharma rep admits to health care fraud, money laundering, and more

Paul Camarda, a pharmaceutical sales representative, admitted to conspiring to defraud New Jersey County health benefits programs and conspiring to engage in money laundering and obstruct justice. Mr. Camarda pleaded guilty in federal court to one count of conspiracy to commit healthcare fraud and one count of conspiracy to obstruct justice and engage in money laundering.

Mr. Camarda, 39, of Holmdel, N. J., created a side business called Dynasty Capital LLC to independently market medical products and services for other companies, including compounded prescription medications for specialty pharmacies, according to the U.S. Department of Justice.

Mr. Camarda learned that certain local government employees had insurance coverage for these compounded medications and discovered that certain compounded medications were reimbursed up to thousands of dollars for a 1-month supply. Mr. Camarda recruited individuals with insurance coverage to fraudulently obtain medically unnecessary compounded medications.

He marketed compounded medications for several pharmacies. As part of his arrangements with the compounding pharmacies and his conspirators, Mr. Camarda was paid a percentage of the insurance payments received for prescriptions arranged by him and those working for him.

Mr. Camarda received more than $2.2 million in payments for the prescriptions he and those working with him arranged. Mr. Camarda and his recruits caused more than $3.4 million in fraudulent claims to be submitted to the pharmacy benefits administrator for compounded medications.

He is due to be sentenced in November and faces up to 15 years in prison plus $500,000 in fines.
 

Home health care and hospice agency owner defrauds Medicare for $31 million

Akop Atoyan, 48, of Glendale, Calif., pleaded guilty to one count of conspiracy to commit healthcare fraud and one count of conspiracy to pay and receive healthcare kickbacks.

According to the U.S. Department of Justice, Mr. Atoyan and his wife, Liana Karapetyan, owned and controlled home healthcare and hospice agencies in the greater Sacramento area: ANG Health Care Inc, Excel Home Healthcare Inc, and Excel Hospice Inc. Mr. Atoyan and Ms. Karapetyan certified to Medicare that their agencies would not pay kickbacks in exchange for Medicare beneficiary referrals.

Officials claim Mr. Atoyan and Ms. Karapetyan paid and directed others to pay kickbacks to multiple individuals for beneficiary referrals, including employees of healthcare facilities, as well as employees’ spouses. In total, Mr. Atoyan, Ms. Karapetyan, and others caused the agencies to submit over 8,000 claims to Medicare for the cost of home healthcare and hospice services. Medicare was billed about $31 million.

As part of his guilty plea, Mr. Atoyan agreed to pay about $2.5 million in restitution to the U.S. Department of Health and Human Services. He also agreed to forfeit that amount to the United States.
 

Medical clinic owner sentenced to jail for Medicaid fraud

Larry Lance Crawford, 49, of Las Vegas, was sentenced in a Medicaid fraud case involving the failure to maintain adequate records to substantiate claims submitted to Nevada Medicaid.

The Nevada Attorney General’s Office announced that Mr. Crawford was given 364 days in jail and was ordered to pay $50,000.00 in restitution.

The Medicaid Fraud Control Unit received information that Mr. Crawford, the owner of Dynamic Future, was using his business to submit false claims for services that were never provided to Medicaid recipients. The investigation revealed that Mr. Crawford failed to maintain records to support the services that were allegedly provided.

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

Pharma rep admits to health care fraud, money laundering, and more

Paul Camarda, a pharmaceutical sales representative, admitted to conspiring to defraud New Jersey County health benefits programs and conspiring to engage in money laundering and obstruct justice. Mr. Camarda pleaded guilty in federal court to one count of conspiracy to commit healthcare fraud and one count of conspiracy to obstruct justice and engage in money laundering.

Mr. Camarda, 39, of Holmdel, N. J., created a side business called Dynasty Capital LLC to independently market medical products and services for other companies, including compounded prescription medications for specialty pharmacies, according to the U.S. Department of Justice.

Mr. Camarda learned that certain local government employees had insurance coverage for these compounded medications and discovered that certain compounded medications were reimbursed up to thousands of dollars for a 1-month supply. Mr. Camarda recruited individuals with insurance coverage to fraudulently obtain medically unnecessary compounded medications.

He marketed compounded medications for several pharmacies. As part of his arrangements with the compounding pharmacies and his conspirators, Mr. Camarda was paid a percentage of the insurance payments received for prescriptions arranged by him and those working for him.

Mr. Camarda received more than $2.2 million in payments for the prescriptions he and those working with him arranged. Mr. Camarda and his recruits caused more than $3.4 million in fraudulent claims to be submitted to the pharmacy benefits administrator for compounded medications.

He is due to be sentenced in November and faces up to 15 years in prison plus $500,000 in fines.
 

Home health care and hospice agency owner defrauds Medicare for $31 million

Akop Atoyan, 48, of Glendale, Calif., pleaded guilty to one count of conspiracy to commit healthcare fraud and one count of conspiracy to pay and receive healthcare kickbacks.

According to the U.S. Department of Justice, Mr. Atoyan and his wife, Liana Karapetyan, owned and controlled home healthcare and hospice agencies in the greater Sacramento area: ANG Health Care Inc, Excel Home Healthcare Inc, and Excel Hospice Inc. Mr. Atoyan and Ms. Karapetyan certified to Medicare that their agencies would not pay kickbacks in exchange for Medicare beneficiary referrals.

Officials claim Mr. Atoyan and Ms. Karapetyan paid and directed others to pay kickbacks to multiple individuals for beneficiary referrals, including employees of healthcare facilities, as well as employees’ spouses. In total, Mr. Atoyan, Ms. Karapetyan, and others caused the agencies to submit over 8,000 claims to Medicare for the cost of home healthcare and hospice services. Medicare was billed about $31 million.

As part of his guilty plea, Mr. Atoyan agreed to pay about $2.5 million in restitution to the U.S. Department of Health and Human Services. He also agreed to forfeit that amount to the United States.
 

Medical clinic owner sentenced to jail for Medicaid fraud

Larry Lance Crawford, 49, of Las Vegas, was sentenced in a Medicaid fraud case involving the failure to maintain adequate records to substantiate claims submitted to Nevada Medicaid.

The Nevada Attorney General’s Office announced that Mr. Crawford was given 364 days in jail and was ordered to pay $50,000.00 in restitution.

The Medicaid Fraud Control Unit received information that Mr. Crawford, the owner of Dynamic Future, was using his business to submit false claims for services that were never provided to Medicaid recipients. The investigation revealed that Mr. Crawford failed to maintain records to support the services that were allegedly provided.

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

Pharma rep admits to health care fraud, money laundering, and more

Paul Camarda, a pharmaceutical sales representative, admitted to conspiring to defraud New Jersey County health benefits programs and conspiring to engage in money laundering and obstruct justice. Mr. Camarda pleaded guilty in federal court to one count of conspiracy to commit healthcare fraud and one count of conspiracy to obstruct justice and engage in money laundering.

Mr. Camarda, 39, of Holmdel, N. J., created a side business called Dynasty Capital LLC to independently market medical products and services for other companies, including compounded prescription medications for specialty pharmacies, according to the U.S. Department of Justice.

Mr. Camarda learned that certain local government employees had insurance coverage for these compounded medications and discovered that certain compounded medications were reimbursed up to thousands of dollars for a 1-month supply. Mr. Camarda recruited individuals with insurance coverage to fraudulently obtain medically unnecessary compounded medications.

He marketed compounded medications for several pharmacies. As part of his arrangements with the compounding pharmacies and his conspirators, Mr. Camarda was paid a percentage of the insurance payments received for prescriptions arranged by him and those working for him.

Mr. Camarda received more than $2.2 million in payments for the prescriptions he and those working with him arranged. Mr. Camarda and his recruits caused more than $3.4 million in fraudulent claims to be submitted to the pharmacy benefits administrator for compounded medications.

He is due to be sentenced in November and faces up to 15 years in prison plus $500,000 in fines.
 

Home health care and hospice agency owner defrauds Medicare for $31 million

Akop Atoyan, 48, of Glendale, Calif., pleaded guilty to one count of conspiracy to commit healthcare fraud and one count of conspiracy to pay and receive healthcare kickbacks.

According to the U.S. Department of Justice, Mr. Atoyan and his wife, Liana Karapetyan, owned and controlled home healthcare and hospice agencies in the greater Sacramento area: ANG Health Care Inc, Excel Home Healthcare Inc, and Excel Hospice Inc. Mr. Atoyan and Ms. Karapetyan certified to Medicare that their agencies would not pay kickbacks in exchange for Medicare beneficiary referrals.

Officials claim Mr. Atoyan and Ms. Karapetyan paid and directed others to pay kickbacks to multiple individuals for beneficiary referrals, including employees of healthcare facilities, as well as employees’ spouses. In total, Mr. Atoyan, Ms. Karapetyan, and others caused the agencies to submit over 8,000 claims to Medicare for the cost of home healthcare and hospice services. Medicare was billed about $31 million.

As part of his guilty plea, Mr. Atoyan agreed to pay about $2.5 million in restitution to the U.S. Department of Health and Human Services. He also agreed to forfeit that amount to the United States.
 

Medical clinic owner sentenced to jail for Medicaid fraud

Larry Lance Crawford, 49, of Las Vegas, was sentenced in a Medicaid fraud case involving the failure to maintain adequate records to substantiate claims submitted to Nevada Medicaid.

The Nevada Attorney General’s Office announced that Mr. Crawford was given 364 days in jail and was ordered to pay $50,000.00 in restitution.

The Medicaid Fraud Control Unit received information that Mr. Crawford, the owner of Dynamic Future, was using his business to submit false claims for services that were never provided to Medicaid recipients. The investigation revealed that Mr. Crawford failed to maintain records to support the services that were allegedly provided.

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

Dr Joseph Berger of the Perelman School of Medicine in Philadelphia discusses abstracts from ECTRIMS 2021 focusing on the use of disease-modifying therapies (DMTs) in patients with relapsing-remitting multiple sclerosis.

Dr Berger discusses ULTIMATE I and ULTIMATE II results, in which ublituximab — a novel monoclonal antibody — improved annualized relapse rates, Multiple Sclerosis Functional Composite scores, and percentages of patients with no evidence of disease activity compared to teriflunomide.

Dr Berger also highlights a study that examined the association between serum neurofilament light (NfL) levels and disease progression in patients on natalizumab. Although NfL levels were significantly reduced after initiation of therapy, no differences were evident between progressors and nonprogressors.

Next, he examines 3-year data from the CASTING study, which assessed ocrelizumab in patients who had a suboptimal response to one or two previous DMTs. Follow-up analysis showed that patients who received ocrelizumab had consistently low disease activity throughout the study period; mean Expanded Disability Status Scale (EDSS) scores, annualized relapse rates, and no evidence of disease activity were also stable.

Dr Berger concludes with a comparative analysis of patients who started on or switched to dimethyl fumarate or teriflunomide. Dimethyl fumarate showed more favorable outcomes in time to relapse, time to EDSS worsening, and sensitivity analysis.

--

Joseph R. Berger, MD, Professor; Associate Chief, Department of Neurology, Multiple Sclerosis Division, University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania

Joseph R. Berger, MD, has disclosed the following relevant financial relationships:

Received research grant from: Biogen; Roche/Genentech

Received income in an amount equal to or greater than $250 from: Amgen; Biogen; Bristol-Myers Squibb; Celgene; Genzyme; Excision Bio; Dr. Reddy; Serono; Morphic; Novartis; Inhibikase; Morphic; Encycle; Merck; Mapi

Dr Joseph Berger of the Perelman School of Medicine in Philadelphia discusses abstracts from ECTRIMS 2021 focusing on the use of disease-modifying therapies (DMTs) in patients with relapsing-remitting multiple sclerosis.

Dr Berger discusses ULTIMATE I and ULTIMATE II results, in which ublituximab — a novel monoclonal antibody — improved annualized relapse rates, Multiple Sclerosis Functional Composite scores, and percentages of patients with no evidence of disease activity compared to teriflunomide.

Dr Berger also highlights a study that examined the association between serum neurofilament light (NfL) levels and disease progression in patients on natalizumab. Although NfL levels were significantly reduced after initiation of therapy, no differences were evident between progressors and nonprogressors.

Next, he examines 3-year data from the CASTING study, which assessed ocrelizumab in patients who had a suboptimal response to one or two previous DMTs. Follow-up analysis showed that patients who received ocrelizumab had consistently low disease activity throughout the study period; mean Expanded Disability Status Scale (EDSS) scores, annualized relapse rates, and no evidence of disease activity were also stable.

Dr Berger concludes with a comparative analysis of patients who started on or switched to dimethyl fumarate or teriflunomide. Dimethyl fumarate showed more favorable outcomes in time to relapse, time to EDSS worsening, and sensitivity analysis.

--

Joseph R. Berger, MD, Professor; Associate Chief, Department of Neurology, Multiple Sclerosis Division, University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania

Joseph R. Berger, MD, has disclosed the following relevant financial relationships:

Received research grant from: Biogen; Roche/Genentech

Received income in an amount equal to or greater than $250 from: Amgen; Biogen; Bristol-Myers Squibb; Celgene; Genzyme; Excision Bio; Dr. Reddy; Serono; Morphic; Novartis; Inhibikase; Morphic; Encycle; Merck; Mapi

Dr Joseph Berger of the Perelman School of Medicine in Philadelphia discusses abstracts from ECTRIMS 2021 focusing on the use of disease-modifying therapies (DMTs) in patients with relapsing-remitting multiple sclerosis.

Dr Berger discusses ULTIMATE I and ULTIMATE II results, in which ublituximab — a novel monoclonal antibody — improved annualized relapse rates, Multiple Sclerosis Functional Composite scores, and percentages of patients with no evidence of disease activity compared to teriflunomide.

Dr Berger also highlights a study that examined the association between serum neurofilament light (NfL) levels and disease progression in patients on natalizumab. Although NfL levels were significantly reduced after initiation of therapy, no differences were evident between progressors and nonprogressors.

Next, he examines 3-year data from the CASTING study, which assessed ocrelizumab in patients who had a suboptimal response to one or two previous DMTs. Follow-up analysis showed that patients who received ocrelizumab had consistently low disease activity throughout the study period; mean Expanded Disability Status Scale (EDSS) scores, annualized relapse rates, and no evidence of disease activity were also stable.

Dr Berger concludes with a comparative analysis of patients who started on or switched to dimethyl fumarate or teriflunomide. Dimethyl fumarate showed more favorable outcomes in time to relapse, time to EDSS worsening, and sensitivity analysis.

--

Joseph R. Berger, MD, Professor; Associate Chief, Department of Neurology, Multiple Sclerosis Division, University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania

Joseph R. Berger, MD, has disclosed the following relevant financial relationships:

Received research grant from: Biogen; Roche/Genentech

Received income in an amount equal to or greater than $250 from: Amgen; Biogen; Bristol-Myers Squibb; Celgene; Genzyme; Excision Bio; Dr. Reddy; Serono; Morphic; Novartis; Inhibikase; Morphic; Encycle; Merck; Mapi

Over the past two decades, there has been a significant increase in the number of adults in the United States with small fiber neuropathy (SFN), but in many cases, no cause can be determined. The exact reason for the increase in isolated SFN “remains unclear,” said Christopher J. Klein, MD, of the Mayo Clinic in Rochester, Minn. However, “we noted during the study period the population has had increased BMI, which appears to be a risk factor for this disorder, with many (50%) developing either glucose impairment or frank diabetes during the study period even if not present at first small fiber neuropathy presentation, also with associated higher triglyceride levels,” he explained.

The study was published online October 27 in Neurology.
 

Significant upward trend

Investigators reviewed the records of all 94 adults diagnosed with pure SFN (no large fiber involvement) between 1998 and 2017 in Olmsted and adjacent counties in Minnesota – and compared them with 282 adults of similar age and gender who did not have neuropathy.

The incidence of SFN over the entire study period was 1.3 per 100,000 per year and the prevalence was 13.3 per 100,000.

There was a “significant upward trend” in SFN incidence over the study period that could not be attributed to the availability of intraepidermal nerve fiber density testing, the authors reported.

The median age of onset of SFN was 54 years and two-thirds were women (67%).

Diabetes, obesity, and hypertriglyceridemia were significantly more common in patients with SFN compared with matched controls. These metabolic risk factors are also associated with peripheral neuropathy regardless of fiber type.

Autonomic symptoms were common and generally mild, affecting 85% of patients with SFN, and included male erectile dysfunction, constipation, light-headedness and palpitations, urinary symptoms, diarrhea, dry eyes and mouth, sweat abnormalities, and gastroparesis.

Insomnia and use of opioid pain medication were more common in those with SFN than matched controls.

More than one-third (36%) of patients with SFN developed large fiber neuropathy an average of 5.3 years after developing SFN.

During an average follow-up of 6.1 years, adults with SFN were significantly more likely to suffer myocardial infarction (46% vs. 27%; odds ratio, 2.0; 95% CI, 1.8-4.9), congestive heart failure (27% vs. 12%; OR, 2.6; 95% CI, 1.4-4.8), peripheral vascular disease (22% vs. 6%; OR, 4.0; 95% CI, 1.9-8.1), stroke (24% vs. 10%; OR, 2.8; 95% CI, 1.5-5.3), diabetes (51% vs. 22%; OR, 4.6; 95% CI, 2.8-7.6) and rheumatologic disease (30% vs. 7%; OR, 5.3; 95% CI, 2.8-10.4).

For 70% of patients, no cause for SFN could be determined. Diabetes (15%) was the most common cause identified. Other less common causes included Sjögren syndrome, lupus, amyloidosis, and Fabry disease.

“It is important to quantitatively diagnose patients with SFN as many non-neurological musculoskeletal causes can mimic the disorder,” said Dr. Klein.

“If rates of progression are rapid, sinister causes such as out-of-control diabetes, hereditary [transthyretin] TTR amyloidosis, and Fabry disease can be responsible. For other patients, rates of progression are slow and generally do not lead to significant neurologic impairments,” he added.

“However,” he said, “internal medicine follow-up is important for all as this disorder associates with development with higher risk of cardiovascular disease, including commonly heart attacks.”

Of note, although mean age at death was not significantly different in patients with SFN than controls (70 vs. 73 years), there was a significantly higher number of deaths in patients with SFN (n = 18; 19%) than in matched controls (n = 35; 12%) from the time of symptom onset, the researchers reported.
 

Important research

This “important” study sheds light on the comorbidities and longitudinal consequences of SFN, wrote Brian Callaghan, MD, with the University of Michigan, Ann Arbor, and J. Robinson Singleton, MD, with the University of Utah, Salt Lake City, in an accompanying editorial in Neurology.

The study demonstrates clearly that SFN has “metabolic risk factors similar to those seen for sensory predominant peripheral neuropathies affecting a broader range of fiber types. As a result, therapies that address metabolic risk factors are likely to help prevent or treat both conditions,” they wrote.

Dr. Callaghan and Dr. Singleton added that a key strength of the study is the detailed follow-up that examines SFN progression over time. “The authors found that patients with SFN do not report high disability and that progression tends to be slow. Therefore, patients with SFN can be counseled that progression and disability are likely to be modest in most cases. However, when patients do progress quickly, uncommon etiologies should be sought,” the editorialists wrote.

The study was supported by the Mayo Clinic Foundation, Mayo Clinic Center for Individualized Medicine, and Mayo Clinic Center of MS and Autoimmune Neurology. Dr. Klein has received teaching honorarium from Ackea pharmaceuticals for lectures on hereditary transthyretin amyloidosis and Fabry disease, consulted for Pfizer regarding tafamidis (all compensation for consulting activities is paid directly to Mayo Clinic), and participated in the clinical trials for inotersen and patisiran but received no personal compensation for his participation. Dr. Callaghan consults for DynaMed, performs medical legal consultations, including consultations for the Vaccine Injury Compensation Program, and receives research support from the American Academy of Neurology. Dr. Singleton has consulted for Regenacy.

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

Over the past two decades, there has been a significant increase in the number of adults in the United States with small fiber neuropathy (SFN), but in many cases, no cause can be determined. The exact reason for the increase in isolated SFN “remains unclear,” said Christopher J. Klein, MD, of the Mayo Clinic in Rochester, Minn. However, “we noted during the study period the population has had increased BMI, which appears to be a risk factor for this disorder, with many (50%) developing either glucose impairment or frank diabetes during the study period even if not present at first small fiber neuropathy presentation, also with associated higher triglyceride levels,” he explained.

The study was published online October 27 in Neurology.
 

Significant upward trend

Investigators reviewed the records of all 94 adults diagnosed with pure SFN (no large fiber involvement) between 1998 and 2017 in Olmsted and adjacent counties in Minnesota – and compared them with 282 adults of similar age and gender who did not have neuropathy.

The incidence of SFN over the entire study period was 1.3 per 100,000 per year and the prevalence was 13.3 per 100,000.

There was a “significant upward trend” in SFN incidence over the study period that could not be attributed to the availability of intraepidermal nerve fiber density testing, the authors reported.

The median age of onset of SFN was 54 years and two-thirds were women (67%).

Diabetes, obesity, and hypertriglyceridemia were significantly more common in patients with SFN compared with matched controls. These metabolic risk factors are also associated with peripheral neuropathy regardless of fiber type.

Autonomic symptoms were common and generally mild, affecting 85% of patients with SFN, and included male erectile dysfunction, constipation, light-headedness and palpitations, urinary symptoms, diarrhea, dry eyes and mouth, sweat abnormalities, and gastroparesis.

Insomnia and use of opioid pain medication were more common in those with SFN than matched controls.

More than one-third (36%) of patients with SFN developed large fiber neuropathy an average of 5.3 years after developing SFN.

During an average follow-up of 6.1 years, adults with SFN were significantly more likely to suffer myocardial infarction (46% vs. 27%; odds ratio, 2.0; 95% CI, 1.8-4.9), congestive heart failure (27% vs. 12%; OR, 2.6; 95% CI, 1.4-4.8), peripheral vascular disease (22% vs. 6%; OR, 4.0; 95% CI, 1.9-8.1), stroke (24% vs. 10%; OR, 2.8; 95% CI, 1.5-5.3), diabetes (51% vs. 22%; OR, 4.6; 95% CI, 2.8-7.6) and rheumatologic disease (30% vs. 7%; OR, 5.3; 95% CI, 2.8-10.4).

For 70% of patients, no cause for SFN could be determined. Diabetes (15%) was the most common cause identified. Other less common causes included Sjögren syndrome, lupus, amyloidosis, and Fabry disease.

“It is important to quantitatively diagnose patients with SFN as many non-neurological musculoskeletal causes can mimic the disorder,” said Dr. Klein.

“If rates of progression are rapid, sinister causes such as out-of-control diabetes, hereditary [transthyretin] TTR amyloidosis, and Fabry disease can be responsible. For other patients, rates of progression are slow and generally do not lead to significant neurologic impairments,” he added.

“However,” he said, “internal medicine follow-up is important for all as this disorder associates with development with higher risk of cardiovascular disease, including commonly heart attacks.”

Of note, although mean age at death was not significantly different in patients with SFN than controls (70 vs. 73 years), there was a significantly higher number of deaths in patients with SFN (n = 18; 19%) than in matched controls (n = 35; 12%) from the time of symptom onset, the researchers reported.
 

Important research

This “important” study sheds light on the comorbidities and longitudinal consequences of SFN, wrote Brian Callaghan, MD, with the University of Michigan, Ann Arbor, and J. Robinson Singleton, MD, with the University of Utah, Salt Lake City, in an accompanying editorial in Neurology.

The study demonstrates clearly that SFN has “metabolic risk factors similar to those seen for sensory predominant peripheral neuropathies affecting a broader range of fiber types. As a result, therapies that address metabolic risk factors are likely to help prevent or treat both conditions,” they wrote.

Dr. Callaghan and Dr. Singleton added that a key strength of the study is the detailed follow-up that examines SFN progression over time. “The authors found that patients with SFN do not report high disability and that progression tends to be slow. Therefore, patients with SFN can be counseled that progression and disability are likely to be modest in most cases. However, when patients do progress quickly, uncommon etiologies should be sought,” the editorialists wrote.

The study was supported by the Mayo Clinic Foundation, Mayo Clinic Center for Individualized Medicine, and Mayo Clinic Center of MS and Autoimmune Neurology. Dr. Klein has received teaching honorarium from Ackea pharmaceuticals for lectures on hereditary transthyretin amyloidosis and Fabry disease, consulted for Pfizer regarding tafamidis (all compensation for consulting activities is paid directly to Mayo Clinic), and participated in the clinical trials for inotersen and patisiran but received no personal compensation for his participation. Dr. Callaghan consults for DynaMed, performs medical legal consultations, including consultations for the Vaccine Injury Compensation Program, and receives research support from the American Academy of Neurology. Dr. Singleton has consulted for Regenacy.

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

Over the past two decades, there has been a significant increase in the number of adults in the United States with small fiber neuropathy (SFN), but in many cases, no cause can be determined. The exact reason for the increase in isolated SFN “remains unclear,” said Christopher J. Klein, MD, of the Mayo Clinic in Rochester, Minn. However, “we noted during the study period the population has had increased BMI, which appears to be a risk factor for this disorder, with many (50%) developing either glucose impairment or frank diabetes during the study period even if not present at first small fiber neuropathy presentation, also with associated higher triglyceride levels,” he explained.

The study was published online October 27 in Neurology.
 

Significant upward trend

Investigators reviewed the records of all 94 adults diagnosed with pure SFN (no large fiber involvement) between 1998 and 2017 in Olmsted and adjacent counties in Minnesota – and compared them with 282 adults of similar age and gender who did not have neuropathy.

The incidence of SFN over the entire study period was 1.3 per 100,000 per year and the prevalence was 13.3 per 100,000.

There was a “significant upward trend” in SFN incidence over the study period that could not be attributed to the availability of intraepidermal nerve fiber density testing, the authors reported.

The median age of onset of SFN was 54 years and two-thirds were women (67%).

Diabetes, obesity, and hypertriglyceridemia were significantly more common in patients with SFN compared with matched controls. These metabolic risk factors are also associated with peripheral neuropathy regardless of fiber type.

Autonomic symptoms were common and generally mild, affecting 85% of patients with SFN, and included male erectile dysfunction, constipation, light-headedness and palpitations, urinary symptoms, diarrhea, dry eyes and mouth, sweat abnormalities, and gastroparesis.

Insomnia and use of opioid pain medication were more common in those with SFN than matched controls.

More than one-third (36%) of patients with SFN developed large fiber neuropathy an average of 5.3 years after developing SFN.

During an average follow-up of 6.1 years, adults with SFN were significantly more likely to suffer myocardial infarction (46% vs. 27%; odds ratio, 2.0; 95% CI, 1.8-4.9), congestive heart failure (27% vs. 12%; OR, 2.6; 95% CI, 1.4-4.8), peripheral vascular disease (22% vs. 6%; OR, 4.0; 95% CI, 1.9-8.1), stroke (24% vs. 10%; OR, 2.8; 95% CI, 1.5-5.3), diabetes (51% vs. 22%; OR, 4.6; 95% CI, 2.8-7.6) and rheumatologic disease (30% vs. 7%; OR, 5.3; 95% CI, 2.8-10.4).

For 70% of patients, no cause for SFN could be determined. Diabetes (15%) was the most common cause identified. Other less common causes included Sjögren syndrome, lupus, amyloidosis, and Fabry disease.

“It is important to quantitatively diagnose patients with SFN as many non-neurological musculoskeletal causes can mimic the disorder,” said Dr. Klein.

“If rates of progression are rapid, sinister causes such as out-of-control diabetes, hereditary [transthyretin] TTR amyloidosis, and Fabry disease can be responsible. For other patients, rates of progression are slow and generally do not lead to significant neurologic impairments,” he added.

“However,” he said, “internal medicine follow-up is important for all as this disorder associates with development with higher risk of cardiovascular disease, including commonly heart attacks.”

Of note, although mean age at death was not significantly different in patients with SFN than controls (70 vs. 73 years), there was a significantly higher number of deaths in patients with SFN (n = 18; 19%) than in matched controls (n = 35; 12%) from the time of symptom onset, the researchers reported.
 

Important research

This “important” study sheds light on the comorbidities and longitudinal consequences of SFN, wrote Brian Callaghan, MD, with the University of Michigan, Ann Arbor, and J. Robinson Singleton, MD, with the University of Utah, Salt Lake City, in an accompanying editorial in Neurology.

The study demonstrates clearly that SFN has “metabolic risk factors similar to those seen for sensory predominant peripheral neuropathies affecting a broader range of fiber types. As a result, therapies that address metabolic risk factors are likely to help prevent or treat both conditions,” they wrote.

Dr. Callaghan and Dr. Singleton added that a key strength of the study is the detailed follow-up that examines SFN progression over time. “The authors found that patients with SFN do not report high disability and that progression tends to be slow. Therefore, patients with SFN can be counseled that progression and disability are likely to be modest in most cases. However, when patients do progress quickly, uncommon etiologies should be sought,” the editorialists wrote.

The study was supported by the Mayo Clinic Foundation, Mayo Clinic Center for Individualized Medicine, and Mayo Clinic Center of MS and Autoimmune Neurology. Dr. Klein has received teaching honorarium from Ackea pharmaceuticals for lectures on hereditary transthyretin amyloidosis and Fabry disease, consulted for Pfizer regarding tafamidis (all compensation for consulting activities is paid directly to Mayo Clinic), and participated in the clinical trials for inotersen and patisiran but received no personal compensation for his participation. Dr. Callaghan consults for DynaMed, performs medical legal consultations, including consultations for the Vaccine Injury Compensation Program, and receives research support from the American Academy of Neurology. Dr. Singleton has consulted for Regenacy.

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

Alopecia areata (AA) has been linked to a significantly increased risk for dementia, new research shows.

After controlling for an array of potential confounders, investigators found a threefold higher risk of developing any form of dementia and a fourfold higher risk of developing Alzheimer’s disease (AD) in those with AA versus the controls.

“AA shares a similar inflammatory signature with dementia and has great psychological impacts that lead to poor social engagement,” lead author Cheng-Yuan Li, MD, MSc, of the department of dermatology, Taipei (Taiwan) Veterans General Hospital.

“Poor social engagement and shared inflammatory cytokines might both be important links between AA and dementia,” said Dr. Li, who is also affiliated with the School of Medicine and the Institute of Brain Science at National Yang Ming Chiao Tung University, Taipei.

The study was published online Oct. 26, 2021, in the Journal of Clinical Psychiatry (doi: 10.4088/JCP.21m13931).
 

Significant psychological impact

Patients with AA often experience anxiety and depression, possibly caused by the negative emotional and psychological impact of the hair loss and partial or even complete baldness associated with the disease, the authors noted.

However, AA is also associated with an array of other atopic and autoimmune diseases, including psoriasis and systemic lupus erythematosus (SLE).

Epidemiologic research has suggested a link between dementia and autoimmune diseases such as psoriasis and SLE, with some evidence suggesting that autoimmune and inflammatory mechanisms may “play a role” in the development of AD.

Dementia in general and AD in particular, “have been shown to include an inflammatory component” that may share some of the same mediators seen in AA (eg, IL-1 beta, IL-6, and tumor necrosis factor–alpha).

Moreover, “the great negative psychosocial impact of AA might result in poor social engagement, a typical risk factor for dementia,” said Dr. Li. The investigators sought to investigate whether patients with AA actually do have a higher dementia risk than individuals without AA.

The researchers used data from the Taiwan National Health Insurance Research Database, comparing 2,534 patients with AA against 25,340 controls matched for age, sex, residence, income, dementia-related comorbidities, systemic steroid use, and annual outpatient visits. Participants were enrolled between 1998 and 2011 and followed to the end of 2013.

The mean age of the cohort was 53.9 years, and a little over half (57.6%) were female. The most common comorbidity was hypertension (32.3%), followed by dyslipidemia (27%) and diabetes (15.4%).
 

Dual intervention

After adjusting for potential confounders, those with AA were more likely to develop dementia, AD, and unspecified dementia, compared with controls. They also had a numerically higher risk for vascular dementia, compared with controls, but it was not statistically significant.

When participants were stratified by age, investigators found a significant association between AA and higher risk for any dementia as well as unspecified dementia in individuals of all ages and an increased risk for AD in patients with dementia age at onset of 65 years and older.

The mean age of dementia diagnosis was considerably younger in patients with AA versus controls (73.4 vs. 78.9 years, P = .002). The risk for any dementia and unspecified dementia was higher in patients of both sexes, but the risk for AD was higher only in male patients.

Sensitivity analyses that excluded the first year or first 3 years of observation yielded similar and consistent findings.

“Intervention targeting poor social engagement and inflammatory cytokines may be beneficial to AA-associated dementia,” said Dr. Li.

“Physicians should be more aware of this possible association, help reduce disease discrimination among the public, and encourage more social engagement for AA patients,” he said.

“Further studies are needed to elucidate the underlying pathophysiology between AA and dementia risk,” he added.
 

No cause and effect

Commenting on the study, Heather M. Snyder, PhD, vice president of medical and scientific affairs, Alzheimer’s Association, said, “We continue to learn about and better understand factors that may increase or decrease a person’s risk of dementia.”

“While we know the immune system plays a role in Alzheimer’s and other dementia, we are still investigating links between, and impact of, autoimmune diseases – like alopecia areata, rheumatoid arthritis, and others – on our overall health and our brains, [which] may eventually give us important information on risk reduction strategies as well,” said Dr. Snyder, who was not involved in the research.

She cautioned that although the study did show a correlation between AA and dementia risk, this does not equate to a demonstration of cause and effect.

At present, “the message for clinicians is that when a patient comes to your office with complaints about their memory, they should, No. 1, be taken seriously; and, No. 2, receive a thorough evaluation that takes into account the many factors that may lead to cognitive decline,” Dr. Snyder said.

The study was supported by a grant from Taipei Veterans General Hospital and the Ministry of Science and Technology, Taiwan. Dr. Li, coauthors, and Dr. Snyder disclosed no relevant financial relationships.

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

Alopecia areata (AA) has been linked to a significantly increased risk for dementia, new research shows.

After controlling for an array of potential confounders, investigators found a threefold higher risk of developing any form of dementia and a fourfold higher risk of developing Alzheimer’s disease (AD) in those with AA versus the controls.

“AA shares a similar inflammatory signature with dementia and has great psychological impacts that lead to poor social engagement,” lead author Cheng-Yuan Li, MD, MSc, of the department of dermatology, Taipei (Taiwan) Veterans General Hospital.

“Poor social engagement and shared inflammatory cytokines might both be important links between AA and dementia,” said Dr. Li, who is also affiliated with the School of Medicine and the Institute of Brain Science at National Yang Ming Chiao Tung University, Taipei.

The study was published online Oct. 26, 2021, in the Journal of Clinical Psychiatry (doi: 10.4088/JCP.21m13931).
 

Significant psychological impact

Patients with AA often experience anxiety and depression, possibly caused by the negative emotional and psychological impact of the hair loss and partial or even complete baldness associated with the disease, the authors noted.

However, AA is also associated with an array of other atopic and autoimmune diseases, including psoriasis and systemic lupus erythematosus (SLE).

Epidemiologic research has suggested a link between dementia and autoimmune diseases such as psoriasis and SLE, with some evidence suggesting that autoimmune and inflammatory mechanisms may “play a role” in the development of AD.

Dementia in general and AD in particular, “have been shown to include an inflammatory component” that may share some of the same mediators seen in AA (eg, IL-1 beta, IL-6, and tumor necrosis factor–alpha).

Moreover, “the great negative psychosocial impact of AA might result in poor social engagement, a typical risk factor for dementia,” said Dr. Li. The investigators sought to investigate whether patients with AA actually do have a higher dementia risk than individuals without AA.

The researchers used data from the Taiwan National Health Insurance Research Database, comparing 2,534 patients with AA against 25,340 controls matched for age, sex, residence, income, dementia-related comorbidities, systemic steroid use, and annual outpatient visits. Participants were enrolled between 1998 and 2011 and followed to the end of 2013.

The mean age of the cohort was 53.9 years, and a little over half (57.6%) were female. The most common comorbidity was hypertension (32.3%), followed by dyslipidemia (27%) and diabetes (15.4%).
 

Dual intervention

After adjusting for potential confounders, those with AA were more likely to develop dementia, AD, and unspecified dementia, compared with controls. They also had a numerically higher risk for vascular dementia, compared with controls, but it was not statistically significant.

When participants were stratified by age, investigators found a significant association between AA and higher risk for any dementia as well as unspecified dementia in individuals of all ages and an increased risk for AD in patients with dementia age at onset of 65 years and older.

The mean age of dementia diagnosis was considerably younger in patients with AA versus controls (73.4 vs. 78.9 years, P = .002). The risk for any dementia and unspecified dementia was higher in patients of both sexes, but the risk for AD was higher only in male patients.

Sensitivity analyses that excluded the first year or first 3 years of observation yielded similar and consistent findings.

“Intervention targeting poor social engagement and inflammatory cytokines may be beneficial to AA-associated dementia,” said Dr. Li.

“Physicians should be more aware of this possible association, help reduce disease discrimination among the public, and encourage more social engagement for AA patients,” he said.

“Further studies are needed to elucidate the underlying pathophysiology between AA and dementia risk,” he added.
 

No cause and effect

Commenting on the study, Heather M. Snyder, PhD, vice president of medical and scientific affairs, Alzheimer’s Association, said, “We continue to learn about and better understand factors that may increase or decrease a person’s risk of dementia.”

“While we know the immune system plays a role in Alzheimer’s and other dementia, we are still investigating links between, and impact of, autoimmune diseases – like alopecia areata, rheumatoid arthritis, and others – on our overall health and our brains, [which] may eventually give us important information on risk reduction strategies as well,” said Dr. Snyder, who was not involved in the research.

She cautioned that although the study did show a correlation between AA and dementia risk, this does not equate to a demonstration of cause and effect.

At present, “the message for clinicians is that when a patient comes to your office with complaints about their memory, they should, No. 1, be taken seriously; and, No. 2, receive a thorough evaluation that takes into account the many factors that may lead to cognitive decline,” Dr. Snyder said.

The study was supported by a grant from Taipei Veterans General Hospital and the Ministry of Science and Technology, Taiwan. Dr. Li, coauthors, and Dr. Snyder disclosed no relevant financial relationships.

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

Alopecia areata (AA) has been linked to a significantly increased risk for dementia, new research shows.

After controlling for an array of potential confounders, investigators found a threefold higher risk of developing any form of dementia and a fourfold higher risk of developing Alzheimer’s disease (AD) in those with AA versus the controls.

“AA shares a similar inflammatory signature with dementia and has great psychological impacts that lead to poor social engagement,” lead author Cheng-Yuan Li, MD, MSc, of the department of dermatology, Taipei (Taiwan) Veterans General Hospital.

“Poor social engagement and shared inflammatory cytokines might both be important links between AA and dementia,” said Dr. Li, who is also affiliated with the School of Medicine and the Institute of Brain Science at National Yang Ming Chiao Tung University, Taipei.

The study was published online Oct. 26, 2021, in the Journal of Clinical Psychiatry (doi: 10.4088/JCP.21m13931).
 

Significant psychological impact

Patients with AA often experience anxiety and depression, possibly caused by the negative emotional and psychological impact of the hair loss and partial or even complete baldness associated with the disease, the authors noted.

However, AA is also associated with an array of other atopic and autoimmune diseases, including psoriasis and systemic lupus erythematosus (SLE).

Epidemiologic research has suggested a link between dementia and autoimmune diseases such as psoriasis and SLE, with some evidence suggesting that autoimmune and inflammatory mechanisms may “play a role” in the development of AD.

Dementia in general and AD in particular, “have been shown to include an inflammatory component” that may share some of the same mediators seen in AA (eg, IL-1 beta, IL-6, and tumor necrosis factor–alpha).

Moreover, “the great negative psychosocial impact of AA might result in poor social engagement, a typical risk factor for dementia,” said Dr. Li. The investigators sought to investigate whether patients with AA actually do have a higher dementia risk than individuals without AA.

The researchers used data from the Taiwan National Health Insurance Research Database, comparing 2,534 patients with AA against 25,340 controls matched for age, sex, residence, income, dementia-related comorbidities, systemic steroid use, and annual outpatient visits. Participants were enrolled between 1998 and 2011 and followed to the end of 2013.

The mean age of the cohort was 53.9 years, and a little over half (57.6%) were female. The most common comorbidity was hypertension (32.3%), followed by dyslipidemia (27%) and diabetes (15.4%).
 

Dual intervention

After adjusting for potential confounders, those with AA were more likely to develop dementia, AD, and unspecified dementia, compared with controls. They also had a numerically higher risk for vascular dementia, compared with controls, but it was not statistically significant.

When participants were stratified by age, investigators found a significant association between AA and higher risk for any dementia as well as unspecified dementia in individuals of all ages and an increased risk for AD in patients with dementia age at onset of 65 years and older.

The mean age of dementia diagnosis was considerably younger in patients with AA versus controls (73.4 vs. 78.9 years, P = .002). The risk for any dementia and unspecified dementia was higher in patients of both sexes, but the risk for AD was higher only in male patients.

Sensitivity analyses that excluded the first year or first 3 years of observation yielded similar and consistent findings.

“Intervention targeting poor social engagement and inflammatory cytokines may be beneficial to AA-associated dementia,” said Dr. Li.

“Physicians should be more aware of this possible association, help reduce disease discrimination among the public, and encourage more social engagement for AA patients,” he said.

“Further studies are needed to elucidate the underlying pathophysiology between AA and dementia risk,” he added.
 

No cause and effect

Commenting on the study, Heather M. Snyder, PhD, vice president of medical and scientific affairs, Alzheimer’s Association, said, “We continue to learn about and better understand factors that may increase or decrease a person’s risk of dementia.”

“While we know the immune system plays a role in Alzheimer’s and other dementia, we are still investigating links between, and impact of, autoimmune diseases – like alopecia areata, rheumatoid arthritis, and others – on our overall health and our brains, [which] may eventually give us important information on risk reduction strategies as well,” said Dr. Snyder, who was not involved in the research.

She cautioned that although the study did show a correlation between AA and dementia risk, this does not equate to a demonstration of cause and effect.

At present, “the message for clinicians is that when a patient comes to your office with complaints about their memory, they should, No. 1, be taken seriously; and, No. 2, receive a thorough evaluation that takes into account the many factors that may lead to cognitive decline,” Dr. Snyder said.

The study was supported by a grant from Taipei Veterans General Hospital and the Ministry of Science and Technology, Taiwan. Dr. Li, coauthors, and Dr. Snyder disclosed no relevant financial relationships.

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

The authors of a study purportedly showing that ivermectin could treat patients with SARS-CoV-2 have retracted their paper after acknowledging that their data were garbled.

The paper, “Effects of a Single Dose of Ivermectin on Viral and Clinical Outcomes in Asymptomatic SARS-CoV-2 Infected Subjects: A Pilot Clinical Trial in Lebanon,” appeared in the journal Viruses in May. According to the abstract: “A randomized controlled trial was conducted in 100 asymptomatic Lebanese subjects that have tested positive for SARS-CoV2. Fifty patients received standard preventive treatment, mainly supplements, and the experimental group received a single dose (according to body weight) of ivermectin, in addition to the same supplements the control group received.”

Results results results … and: “Ivermectin appears to be efficacious in providing clinical benefits in a randomized treatment of asymptomatic SARS-CoV-2-positive subjects, effectively resulting in fewer symptoms, lower viral load and reduced hospital admissions. However, larger-scale trials are warranted for this conclusion to be further cemented.”

However, in early October, the BBC reported — in a larger piece about the concerns about ivermectin-Covid-19 research — that the study “was found to have blocks of details of 11 patients that had been copied and pasted repeatedly – suggesting many of the trial’s apparent patients didn’t really exist.”

The study’s authors told the BBC that the ‘original set of data was rigged, sabotaged or mistakenly entered in the final file’ and that they have submitted a retraction to the scientific journal which published it.

That’s not quite what the retraction notice states: “The journal retracts the article, Effects of a Single Dose of Ivermectin on Viral and Clinical Outcomes in Asymptomatic SARS-CoV-2 Infected Subjects: A Pilot Clinical Trial in Lebanon [ 1 ], cited above. Following publication, the authors contacted the editorial office regarding an error between files used for the statistical analysis. Adhering to our complaints procedure, an investigation was conducted that confirmed the error reported by the authors.

This retraction was approved by the Editor in Chief of the journal. The authors agreed to this retraction.”

Ali Samaha, of Lebanese University in Beirut, and the lead author of the study, told us: “It was brought to our attention that we have used wrong file for our paper. We informed immediately the journal and we have run investigations. After revising the raw data we realised that a file that was used to train a research assistant was sent by mistake for analysis. Re-analysing the original data , the conclusions of the paper remained valid. For our transparency we asked for retraction.”

About that BBC report? Samaha said: “The BBC article was generated before the report of independent reviewers who confirmed an innocent mistake by using wrong file.”

Samaha added that he and his colleagues are now considering whether to resubmit the paper.

The article has been cited four times, according to Clarivate Analytics’ Web of Science — including in this meta-analysis published in June in the American Journal of Therapeutics , which concluded that: “Moderate-certainty evidence finds that large reductions in COVID-19 deaths are possible using ivermectin. Using ivermectin early in the clinical course may reduce numbers progressing to severe disease. The apparent safety and low cost suggest that ivermectin is likely to have a significant impact on the SARS-CoV-2 pandemic globally.”

That article was a social media darling, receiving more than 45,000 tweets and pickups in 90 news outlets, according to Altmetrics, which ranks it No. 7 among all papers published at that time.

A version of this article first appeared on Retraction Watch.

The authors of a study purportedly showing that ivermectin could treat patients with SARS-CoV-2 have retracted their paper after acknowledging that their data were garbled.

The paper, “Effects of a Single Dose of Ivermectin on Viral and Clinical Outcomes in Asymptomatic SARS-CoV-2 Infected Subjects: A Pilot Clinical Trial in Lebanon,” appeared in the journal Viruses in May. According to the abstract: “A randomized controlled trial was conducted in 100 asymptomatic Lebanese subjects that have tested positive for SARS-CoV2. Fifty patients received standard preventive treatment, mainly supplements, and the experimental group received a single dose (according to body weight) of ivermectin, in addition to the same supplements the control group received.”

Results results results … and: “Ivermectin appears to be efficacious in providing clinical benefits in a randomized treatment of asymptomatic SARS-CoV-2-positive subjects, effectively resulting in fewer symptoms, lower viral load and reduced hospital admissions. However, larger-scale trials are warranted for this conclusion to be further cemented.”

However, in early October, the BBC reported — in a larger piece about the concerns about ivermectin-Covid-19 research — that the study “was found to have blocks of details of 11 patients that had been copied and pasted repeatedly – suggesting many of the trial’s apparent patients didn’t really exist.”

The study’s authors told the BBC that the ‘original set of data was rigged, sabotaged or mistakenly entered in the final file’ and that they have submitted a retraction to the scientific journal which published it.

That’s not quite what the retraction notice states: “The journal retracts the article, Effects of a Single Dose of Ivermectin on Viral and Clinical Outcomes in Asymptomatic SARS-CoV-2 Infected Subjects: A Pilot Clinical Trial in Lebanon [ 1 ], cited above. Following publication, the authors contacted the editorial office regarding an error between files used for the statistical analysis. Adhering to our complaints procedure, an investigation was conducted that confirmed the error reported by the authors.

This retraction was approved by the Editor in Chief of the journal. The authors agreed to this retraction.”

Ali Samaha, of Lebanese University in Beirut, and the lead author of the study, told us: “It was brought to our attention that we have used wrong file for our paper. We informed immediately the journal and we have run investigations. After revising the raw data we realised that a file that was used to train a research assistant was sent by mistake for analysis. Re-analysing the original data , the conclusions of the paper remained valid. For our transparency we asked for retraction.”

About that BBC report? Samaha said: “The BBC article was generated before the report of independent reviewers who confirmed an innocent mistake by using wrong file.”

Samaha added that he and his colleagues are now considering whether to resubmit the paper.

The article has been cited four times, according to Clarivate Analytics’ Web of Science — including in this meta-analysis published in June in the American Journal of Therapeutics , which concluded that: “Moderate-certainty evidence finds that large reductions in COVID-19 deaths are possible using ivermectin. Using ivermectin early in the clinical course may reduce numbers progressing to severe disease. The apparent safety and low cost suggest that ivermectin is likely to have a significant impact on the SARS-CoV-2 pandemic globally.”

That article was a social media darling, receiving more than 45,000 tweets and pickups in 90 news outlets, according to Altmetrics, which ranks it No. 7 among all papers published at that time.

A version of this article first appeared on Retraction Watch.

The authors of a study purportedly showing that ivermectin could treat patients with SARS-CoV-2 have retracted their paper after acknowledging that their data were garbled.

The paper, “Effects of a Single Dose of Ivermectin on Viral and Clinical Outcomes in Asymptomatic SARS-CoV-2 Infected Subjects: A Pilot Clinical Trial in Lebanon,” appeared in the journal Viruses in May. According to the abstract: “A randomized controlled trial was conducted in 100 asymptomatic Lebanese subjects that have tested positive for SARS-CoV2. Fifty patients received standard preventive treatment, mainly supplements, and the experimental group received a single dose (according to body weight) of ivermectin, in addition to the same supplements the control group received.”

Results results results … and: “Ivermectin appears to be efficacious in providing clinical benefits in a randomized treatment of asymptomatic SARS-CoV-2-positive subjects, effectively resulting in fewer symptoms, lower viral load and reduced hospital admissions. However, larger-scale trials are warranted for this conclusion to be further cemented.”

However, in early October, the BBC reported — in a larger piece about the concerns about ivermectin-Covid-19 research — that the study “was found to have blocks of details of 11 patients that had been copied and pasted repeatedly – suggesting many of the trial’s apparent patients didn’t really exist.”

The study’s authors told the BBC that the ‘original set of data was rigged, sabotaged or mistakenly entered in the final file’ and that they have submitted a retraction to the scientific journal which published it.

That’s not quite what the retraction notice states: “The journal retracts the article, Effects of a Single Dose of Ivermectin on Viral and Clinical Outcomes in Asymptomatic SARS-CoV-2 Infected Subjects: A Pilot Clinical Trial in Lebanon [ 1 ], cited above. Following publication, the authors contacted the editorial office regarding an error between files used for the statistical analysis. Adhering to our complaints procedure, an investigation was conducted that confirmed the error reported by the authors.

This retraction was approved by the Editor in Chief of the journal. The authors agreed to this retraction.”

Ali Samaha, of Lebanese University in Beirut, and the lead author of the study, told us: “It was brought to our attention that we have used wrong file for our paper. We informed immediately the journal and we have run investigations. After revising the raw data we realised that a file that was used to train a research assistant was sent by mistake for analysis. Re-analysing the original data , the conclusions of the paper remained valid. For our transparency we asked for retraction.”

About that BBC report? Samaha said: “The BBC article was generated before the report of independent reviewers who confirmed an innocent mistake by using wrong file.”

Samaha added that he and his colleagues are now considering whether to resubmit the paper.

The article has been cited four times, according to Clarivate Analytics’ Web of Science — including in this meta-analysis published in June in the American Journal of Therapeutics , which concluded that: “Moderate-certainty evidence finds that large reductions in COVID-19 deaths are possible using ivermectin. Using ivermectin early in the clinical course may reduce numbers progressing to severe disease. The apparent safety and low cost suggest that ivermectin is likely to have a significant impact on the SARS-CoV-2 pandemic globally.”

That article was a social media darling, receiving more than 45,000 tweets and pickups in 90 news outlets, according to Altmetrics, which ranks it No. 7 among all papers published at that time.

A version of this article first appeared on Retraction Watch.

In early 2020, Justin Bullock, MD, MPH, did what few, if any, resident physicians have done: He published an honest account in the New England Journal of Medicine of a would-be suicide attempt during medical training.

In the article, Dr. Bullock matter-of-factly laid out how, in 2019, intern-year night shifts contributed to a depressive episode. For Dr. Bullock, who has a bipolar disorder, sleep dysregulation can be deadly. He had a plan for completing suicide, and this wouldn’t have been his first attempt. Thanks to his history and openness about his condition, Dr. Bullock had an experienced care team that helped him get to a psychiatric hospital before anything happened. While there for around 5 days, he wrote the bulk of the NEJM article.

The article took Dr. Bullock’s impact nationwide. In the medical world, where mental illness is a serious problem but still deeply stigmatized, Dr. Bullock’s unblinking honesty on the issue is still radical to many. On Twitter and in interviews, Dr. Bullock is an unapologetic advocate for accommodations for people in medicine with mental illness. “One of the things that inspired me to speak out early on is that I feel I stand in a place of so much privilege,” Dr. Bullock told this news organization. “I often feel this sense of ... ‘you have to speak up, Justin; no one else can.’ ”

Dr. Bullock’s activism is especially noteworthy, given that he is still establishing his career. In August, while an internal medicine resident at the University of California, San Francisco, he received a lifetime teaching award from UCSF because he had received three prior teaching awards; a recognition like this is considered rare someone so early in their career. Now in his final year of residency, he actively researches medical education, advocates for mental health support, and is working to become a leading voice on related issues.

“It seems to be working,” his older sister, Jacquis Mahoney, RN, said during a visit to the UCSF campus. Instead of any awkwardness, everyone is thrilled to learn that she is Justin’s sister. “There’s a lot of pride and excitement.”
 

Suicide attempts during medical training

Now 28, Dr. Bullock grew up in Detroit, with his mom and two older sisters. His father was incarcerated for much of Dr. Bullock’s childhood, in part because of his own bipolar disorder not being well controlled, Dr. Bullock said.

When he was younger, Dr. Bullock was the peacekeeper in the house between his two sisters, said Ms. Mahoney: “Justin was always very delicate and kind.”

He played soccer and ran track but also loved math and science. While outwardly accumulating an impressive resume, Dr. Bullock was internally struggling. In high school, he made what he now calls an “immature” attempt at suicide after coming out as gay to his family. While Dr. Bullock said he doesn’t necessarily dwell on the discrimination he has faced as a gay, Black man, his awareness of how others perceive and treat him because of his identity increases the background stress present in his daily life.

After high school, Dr. Bullock went to MIT in Boston, where he continued running and studied chemical-biological engineering. During college, Dr. Bullock thought he was going to have to withdraw from MIT because of his depression. Thankfully, he received counseling from student services and advice from a track coach who sat him down and talked about pragmatic solutions, like medication. “That was life-changing,” said Dr. Bullock.

When trying to decide between engineering and medicine, Dr. Bullock realized he preferred contemplating medical problems to engineering ones. So he applied to medical school. Dr. Bullock eventually ended up at UCSF, where he was selected to participate in the Program in Medical Education for the Urban Underserved, a 5-year track at the college for students committed to working with underserved communities.

By the time Dr. Bullock got to medical school, he was feeling good. In consultation with his psychiatrist, he thought it worthwhile to take a break from his medications. At that time, his diagnosis was major depressive disorder and he had only had one serious depressive episode, which didn’t necessarily indicate that he would need medication long-term, he said. 

Dr. Bullock loved everything about medical school. “One day when I was in my first year of med school, I called my mom and said: ‘It’s like science summer camp but every day!’” he recalled.

Despite his enthusiasm, though, he began feeling something troubling. Recognizing the symptoms of early depression, Dr. Bullock restarted his medication. But this time, the same SSRI only made things worse. He went from sleeping 8 hours to 90 minutes a night. He felt angry. One day, he went on a furious 22-mile run. Plus, within the first 6 months of moving to San Francisco, Dr. Bullock was stopped by the police three different times while riding his bike. He attributes this to his race, which has only further added to his stress. In September 2015, during his second year of medical school, Dr. Bullock attempted suicide again. This time, he was intubated in the ED and rushed to the ICU.

He was given a new diagnosis: bipolar disorder. He changed medications and lived for a time with Ms. Mahoney and his other sister, who moved from Chicago to California to be with him. “My family has helped me a lot,” he said.

Dr. Bullock was initially not sure whether he would be able to return to school after his attempted suicide. Overall, UCSF was extremely supportive, he said. That came as a relief. Medical school was a grounding force in his life, not a destabilizing one: “If I had been pushed out, it would have been really harmful to me.”

Then Dr. Bullock started residency. The sleep disruption that comes with the night shift – the resident rite of passage – triggered another episode. At first, Dr. Bullock was overly productive; his mind was active and alert after staying up all night. He worked on new research during the day instead of sleeping. 

Sleep disturbance is a hallmark symptom of bipolar disorder. “Justin should never be on a 24-hour call,” said Lisa Meeks, PhD, associate professor of psychiatry and family medicine at the University of Colorado at Denver, Aurora, and a leading scholar on disability advocacy for medical trainees. When he started residency, Dr. Bullock was open with his program director about his diagnosis and sought accommodations to go to therapy each week. But he didn’t try to get out of night shifts or 24-hour calls, despite his care team urging him to do so. “I have this sense of wanting to tough it out,” he said. He also felt guilty making his peers take on his share of those challenging shifts.

In December 2019, Dr. Bullock was voluntarily hospitalized for a few days and started writing the article that would later appear in NEJM. In January, a friend and UCSF medical student completed suicide. In March, the same month his NEJM article came out, Dr. Bullock attempted suicide again. This time, he quickly recognized that he was making a mistake and called an ambulance. “For me, as far as suicide attempts go, it’s the most positive one.”
 

Advocating for changes in medical training

Throughout his medical training, Dr. Bullock was always open about his struggles with his peers and with the administration. He shared his suicidal thoughts at a Mental Illness Among Us event during medical school. His story resonated with peers who were surprised that Dr. Bullock, who was thriving academically, could be struggling emotionally. 

During residency, he led small group discussions and gave lectures at the medical school, including a talk about his attempts to create institutional change at UCSF, such as his public fight against the college’s Fitness for Duty (FFD) assessment process. That discussion earned him an Outstanding Lecturer award. Because it was the third award he had received from the medical school, Dr. Bullock also automatically earned a lifetime teaching award. When he told his mom, a teacher herself, about the award, she joked: “Are you old enough for ‘lifetime’ anything?”

Dr. Bullock has also spoken out and actively fought against the processes within the medical community that prevent people from coming forward until it is too late. Physicians and trainees often fear that if they seek mental health treatment, they will have to disclose that treatment to a potential employer or licensing board and then be barred from practicing medicine. Because he has been open about his mental health for so long, Dr. Bullock feels that he is in a position to push back against these norms. For example, in June he coauthored another article, this time for the Journal of Hospital Medicine, describing the traumatizing FFD assessment that followed his March 2020 suicide attempt.

In that article, Dr. Bullock wrote how no mental health professional served on the UCSF Physician Well Being Committee – comprising physicians and lawyers who evaluate physician impairment or potential physician impairment – that evaluated him. Dr. Bullock was referred to an outside psychiatrist. He also describes how he was forced to release all of his psychiatric records and undergo extensive drug testing, despite having no history of substance abuse. To return to work, he had to sign a contract, agreeing to be monitored and to attend a specific kind of therapy.

While steps like these can, in the right circumstances, protect both the public and doctors-in-training in important ways, they can also “be very punitive and isolating for someone going through a mental health crisis,” said Dr. Meeks. There were also no Black physicians or lawyers on the committee evaluating Dr. Bullock. “That was really egregious, when you look back.” Dr. Meeks is a coauthor on Dr. Bullock’s JHM article and a mentor and previous student disability officer at UCSF. 

Dr. Bullock raised objections to UCSF administrators about how he felt that the committee was discriminating against him because of his mental illness despite assurances from the director of his program that there have never been any performance or professionalism concerns with him. He said the administrators told him he was the first person to question the FFD process. This isn’t surprising, given that all the power in such situations usually lies with the hospital and the administrators, whereas the resident or physician is worried about losing their job and their license, said Dr. Meeks.

Dr. Bullock contends that he’s in a unique position to speak out, considering his stellar academic and work records, openness about his mental illness before a crisis, access to quality mental health care, and extensive personal network among the UCSF administration. “I know that I hold power within my institution; I spoke out because I could,” Dr. Bullock said. In addition to writing an article about his experience, Dr. Bullock shared his story with a task force appointed by the medical staff president to review the Physician Well-Being Committee and the overall FFD process. Even before Dr. Bullock shared his story with the public, the task force had already been appointed as a result of the increased concern about physician mental health during the ongoing COVID-19 pandemic, Michelle Guy, MD, clinical professor of medicine at UCSF, told this news organization. 

Elizabeth Fernandez, a UCSF senior public information representative, declined to comment on Dr. Bullock’s specific experience as reported in the JHM. “As with every hospital accredited by the Joint Commission, UCSF Medical Center has a Physician Well Being Committee that provides resources for physicians who may need help with chemical dependency or mental illness,” Ms. Fernandez said.

“Our goal through this program is always, first, to provide the compassion and assistance our physicians need to address the issues they face and continue to pursue their careers. This program is entirely voluntary and is bound by federal and state laws and regulations to protect the confidentiality of its participants, while ensuring that – first and foremost – no one is harmed by the situation, including the participant.”
 

Overcoming stigma to change the system

All of the attention – from national media outlets such as Vox to struggling peers and others – is fulfilling, Dr. Bullock said. But it can also be overwhelming. “I have definitely been praised as ‘Black excellence,’ and that definitely has added to the pressure to keep going ... to keep pushing at times,” he said.

Ms. Mahoney added: “He’s willing to sacrifice himself in order to make a difference. He would be a sacrificial lamb” for the Black community, the gay community, or any minority community.

Despite these concerns and his past suicide attempts, colleagues feel that Dr. Bullock is in a strong place to make decisions. “I trust Justin to put the boundaries up when they are needed and to engage in a way that feels comfortable for him,” said Ms. Meeks. “He is someone who has incredible self-awareness.”

Dr. Bullock’s history isn’t just something he overcame: It’s something that makes him a better, more empathetic doctor, said Ms. Mahoney. He knows what it’s like to be hospitalized, to deal with the frustration of insurance, to navigate the complexity of the health care system as a patient, or to be facing a deep internal darkness. He “can genuinely hold that person’s hand and say: ‘I know what you’re going through and we’re going to work through this day by day,’ ” she said. “That is something he can bring that no other physician can bring.”

In his advocacy on Twitter, in lectures, and in conversations with UCSF administrators, Dr. Bullock is pushing for board licensing questions to be reformed so physicians are no longer penalized for seeking mental health treatment. He would also like residency programs to make it easier and less stigmatizing for trainees to receive accommodations for a disability or mental illness.

“They say one person can’t change a system,” said Dr. Meeks, “but I do think Justin is calling an awful lot of attention to the system and I do think there will be changes because of his advocacy.”

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

In early 2020, Justin Bullock, MD, MPH, did what few, if any, resident physicians have done: He published an honest account in the New England Journal of Medicine of a would-be suicide attempt during medical training.

In the article, Dr. Bullock matter-of-factly laid out how, in 2019, intern-year night shifts contributed to a depressive episode. For Dr. Bullock, who has a bipolar disorder, sleep dysregulation can be deadly. He had a plan for completing suicide, and this wouldn’t have been his first attempt. Thanks to his history and openness about his condition, Dr. Bullock had an experienced care team that helped him get to a psychiatric hospital before anything happened. While there for around 5 days, he wrote the bulk of the NEJM article.

The article took Dr. Bullock’s impact nationwide. In the medical world, where mental illness is a serious problem but still deeply stigmatized, Dr. Bullock’s unblinking honesty on the issue is still radical to many. On Twitter and in interviews, Dr. Bullock is an unapologetic advocate for accommodations for people in medicine with mental illness. “One of the things that inspired me to speak out early on is that I feel I stand in a place of so much privilege,” Dr. Bullock told this news organization. “I often feel this sense of ... ‘you have to speak up, Justin; no one else can.’ ”

Dr. Bullock’s activism is especially noteworthy, given that he is still establishing his career. In August, while an internal medicine resident at the University of California, San Francisco, he received a lifetime teaching award from UCSF because he had received three prior teaching awards; a recognition like this is considered rare someone so early in their career. Now in his final year of residency, he actively researches medical education, advocates for mental health support, and is working to become a leading voice on related issues.

“It seems to be working,” his older sister, Jacquis Mahoney, RN, said during a visit to the UCSF campus. Instead of any awkwardness, everyone is thrilled to learn that she is Justin’s sister. “There’s a lot of pride and excitement.”
 

Suicide attempts during medical training

Now 28, Dr. Bullock grew up in Detroit, with his mom and two older sisters. His father was incarcerated for much of Dr. Bullock’s childhood, in part because of his own bipolar disorder not being well controlled, Dr. Bullock said.

When he was younger, Dr. Bullock was the peacekeeper in the house between his two sisters, said Ms. Mahoney: “Justin was always very delicate and kind.”

He played soccer and ran track but also loved math and science. While outwardly accumulating an impressive resume, Dr. Bullock was internally struggling. In high school, he made what he now calls an “immature” attempt at suicide after coming out as gay to his family. While Dr. Bullock said he doesn’t necessarily dwell on the discrimination he has faced as a gay, Black man, his awareness of how others perceive and treat him because of his identity increases the background stress present in his daily life.

After high school, Dr. Bullock went to MIT in Boston, where he continued running and studied chemical-biological engineering. During college, Dr. Bullock thought he was going to have to withdraw from MIT because of his depression. Thankfully, he received counseling from student services and advice from a track coach who sat him down and talked about pragmatic solutions, like medication. “That was life-changing,” said Dr. Bullock.

When trying to decide between engineering and medicine, Dr. Bullock realized he preferred contemplating medical problems to engineering ones. So he applied to medical school. Dr. Bullock eventually ended up at UCSF, where he was selected to participate in the Program in Medical Education for the Urban Underserved, a 5-year track at the college for students committed to working with underserved communities.

By the time Dr. Bullock got to medical school, he was feeling good. In consultation with his psychiatrist, he thought it worthwhile to take a break from his medications. At that time, his diagnosis was major depressive disorder and he had only had one serious depressive episode, which didn’t necessarily indicate that he would need medication long-term, he said. 

Dr. Bullock loved everything about medical school. “One day when I was in my first year of med school, I called my mom and said: ‘It’s like science summer camp but every day!’” he recalled.

Despite his enthusiasm, though, he began feeling something troubling. Recognizing the symptoms of early depression, Dr. Bullock restarted his medication. But this time, the same SSRI only made things worse. He went from sleeping 8 hours to 90 minutes a night. He felt angry. One day, he went on a furious 22-mile run. Plus, within the first 6 months of moving to San Francisco, Dr. Bullock was stopped by the police three different times while riding his bike. He attributes this to his race, which has only further added to his stress. In September 2015, during his second year of medical school, Dr. Bullock attempted suicide again. This time, he was intubated in the ED and rushed to the ICU.

He was given a new diagnosis: bipolar disorder. He changed medications and lived for a time with Ms. Mahoney and his other sister, who moved from Chicago to California to be with him. “My family has helped me a lot,” he said.

Dr. Bullock was initially not sure whether he would be able to return to school after his attempted suicide. Overall, UCSF was extremely supportive, he said. That came as a relief. Medical school was a grounding force in his life, not a destabilizing one: “If I had been pushed out, it would have been really harmful to me.”

Then Dr. Bullock started residency. The sleep disruption that comes with the night shift – the resident rite of passage – triggered another episode. At first, Dr. Bullock was overly productive; his mind was active and alert after staying up all night. He worked on new research during the day instead of sleeping. 

Sleep disturbance is a hallmark symptom of bipolar disorder. “Justin should never be on a 24-hour call,” said Lisa Meeks, PhD, associate professor of psychiatry and family medicine at the University of Colorado at Denver, Aurora, and a leading scholar on disability advocacy for medical trainees. When he started residency, Dr. Bullock was open with his program director about his diagnosis and sought accommodations to go to therapy each week. But he didn’t try to get out of night shifts or 24-hour calls, despite his care team urging him to do so. “I have this sense of wanting to tough it out,” he said. He also felt guilty making his peers take on his share of those challenging shifts.

In December 2019, Dr. Bullock was voluntarily hospitalized for a few days and started writing the article that would later appear in NEJM. In January, a friend and UCSF medical student completed suicide. In March, the same month his NEJM article came out, Dr. Bullock attempted suicide again. This time, he quickly recognized that he was making a mistake and called an ambulance. “For me, as far as suicide attempts go, it’s the most positive one.”
 

Advocating for changes in medical training

Throughout his medical training, Dr. Bullock was always open about his struggles with his peers and with the administration. He shared his suicidal thoughts at a Mental Illness Among Us event during medical school. His story resonated with peers who were surprised that Dr. Bullock, who was thriving academically, could be struggling emotionally. 

During residency, he led small group discussions and gave lectures at the medical school, including a talk about his attempts to create institutional change at UCSF, such as his public fight against the college’s Fitness for Duty (FFD) assessment process. That discussion earned him an Outstanding Lecturer award. Because it was the third award he had received from the medical school, Dr. Bullock also automatically earned a lifetime teaching award. When he told his mom, a teacher herself, about the award, she joked: “Are you old enough for ‘lifetime’ anything?”

Dr. Bullock has also spoken out and actively fought against the processes within the medical community that prevent people from coming forward until it is too late. Physicians and trainees often fear that if they seek mental health treatment, they will have to disclose that treatment to a potential employer or licensing board and then be barred from practicing medicine. Because he has been open about his mental health for so long, Dr. Bullock feels that he is in a position to push back against these norms. For example, in June he coauthored another article, this time for the Journal of Hospital Medicine, describing the traumatizing FFD assessment that followed his March 2020 suicide attempt.

In that article, Dr. Bullock wrote how no mental health professional served on the UCSF Physician Well Being Committee – comprising physicians and lawyers who evaluate physician impairment or potential physician impairment – that evaluated him. Dr. Bullock was referred to an outside psychiatrist. He also describes how he was forced to release all of his psychiatric records and undergo extensive drug testing, despite having no history of substance abuse. To return to work, he had to sign a contract, agreeing to be monitored and to attend a specific kind of therapy.

While steps like these can, in the right circumstances, protect both the public and doctors-in-training in important ways, they can also “be very punitive and isolating for someone going through a mental health crisis,” said Dr. Meeks. There were also no Black physicians or lawyers on the committee evaluating Dr. Bullock. “That was really egregious, when you look back.” Dr. Meeks is a coauthor on Dr. Bullock’s JHM article and a mentor and previous student disability officer at UCSF. 

Dr. Bullock raised objections to UCSF administrators about how he felt that the committee was discriminating against him because of his mental illness despite assurances from the director of his program that there have never been any performance or professionalism concerns with him. He said the administrators told him he was the first person to question the FFD process. This isn’t surprising, given that all the power in such situations usually lies with the hospital and the administrators, whereas the resident or physician is worried about losing their job and their license, said Dr. Meeks.

Dr. Bullock contends that he’s in a unique position to speak out, considering his stellar academic and work records, openness about his mental illness before a crisis, access to quality mental health care, and extensive personal network among the UCSF administration. “I know that I hold power within my institution; I spoke out because I could,” Dr. Bullock said. In addition to writing an article about his experience, Dr. Bullock shared his story with a task force appointed by the medical staff president to review the Physician Well-Being Committee and the overall FFD process. Even before Dr. Bullock shared his story with the public, the task force had already been appointed as a result of the increased concern about physician mental health during the ongoing COVID-19 pandemic, Michelle Guy, MD, clinical professor of medicine at UCSF, told this news organization. 

Elizabeth Fernandez, a UCSF senior public information representative, declined to comment on Dr. Bullock’s specific experience as reported in the JHM. “As with every hospital accredited by the Joint Commission, UCSF Medical Center has a Physician Well Being Committee that provides resources for physicians who may need help with chemical dependency or mental illness,” Ms. Fernandez said.

“Our goal through this program is always, first, to provide the compassion and assistance our physicians need to address the issues they face and continue to pursue their careers. This program is entirely voluntary and is bound by federal and state laws and regulations to protect the confidentiality of its participants, while ensuring that – first and foremost – no one is harmed by the situation, including the participant.”
 

Overcoming stigma to change the system

All of the attention – from national media outlets such as Vox to struggling peers and others – is fulfilling, Dr. Bullock said. But it can also be overwhelming. “I have definitely been praised as ‘Black excellence,’ and that definitely has added to the pressure to keep going ... to keep pushing at times,” he said.

Ms. Mahoney added: “He’s willing to sacrifice himself in order to make a difference. He would be a sacrificial lamb” for the Black community, the gay community, or any minority community.

Despite these concerns and his past suicide attempts, colleagues feel that Dr. Bullock is in a strong place to make decisions. “I trust Justin to put the boundaries up when they are needed and to engage in a way that feels comfortable for him,” said Ms. Meeks. “He is someone who has incredible self-awareness.”

Dr. Bullock’s history isn’t just something he overcame: It’s something that makes him a better, more empathetic doctor, said Ms. Mahoney. He knows what it’s like to be hospitalized, to deal with the frustration of insurance, to navigate the complexity of the health care system as a patient, or to be facing a deep internal darkness. He “can genuinely hold that person’s hand and say: ‘I know what you’re going through and we’re going to work through this day by day,’ ” she said. “That is something he can bring that no other physician can bring.”

In his advocacy on Twitter, in lectures, and in conversations with UCSF administrators, Dr. Bullock is pushing for board licensing questions to be reformed so physicians are no longer penalized for seeking mental health treatment. He would also like residency programs to make it easier and less stigmatizing for trainees to receive accommodations for a disability or mental illness.

“They say one person can’t change a system,” said Dr. Meeks, “but I do think Justin is calling an awful lot of attention to the system and I do think there will be changes because of his advocacy.”

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

In early 2020, Justin Bullock, MD, MPH, did what few, if any, resident physicians have done: He published an honest account in the New England Journal of Medicine of a would-be suicide attempt during medical training.

In the article, Dr. Bullock matter-of-factly laid out how, in 2019, intern-year night shifts contributed to a depressive episode. For Dr. Bullock, who has a bipolar disorder, sleep dysregulation can be deadly. He had a plan for completing suicide, and this wouldn’t have been his first attempt. Thanks to his history and openness about his condition, Dr. Bullock had an experienced care team that helped him get to a psychiatric hospital before anything happened. While there for around 5 days, he wrote the bulk of the NEJM article.

The article took Dr. Bullock’s impact nationwide. In the medical world, where mental illness is a serious problem but still deeply stigmatized, Dr. Bullock’s unblinking honesty on the issue is still radical to many. On Twitter and in interviews, Dr. Bullock is an unapologetic advocate for accommodations for people in medicine with mental illness. “One of the things that inspired me to speak out early on is that I feel I stand in a place of so much privilege,” Dr. Bullock told this news organization. “I often feel this sense of ... ‘you have to speak up, Justin; no one else can.’ ”

Dr. Bullock’s activism is especially noteworthy, given that he is still establishing his career. In August, while an internal medicine resident at the University of California, San Francisco, he received a lifetime teaching award from UCSF because he had received three prior teaching awards; a recognition like this is considered rare someone so early in their career. Now in his final year of residency, he actively researches medical education, advocates for mental health support, and is working to become a leading voice on related issues.

“It seems to be working,” his older sister, Jacquis Mahoney, RN, said during a visit to the UCSF campus. Instead of any awkwardness, everyone is thrilled to learn that she is Justin’s sister. “There’s a lot of pride and excitement.”
 

Suicide attempts during medical training

Now 28, Dr. Bullock grew up in Detroit, with his mom and two older sisters. His father was incarcerated for much of Dr. Bullock’s childhood, in part because of his own bipolar disorder not being well controlled, Dr. Bullock said.

When he was younger, Dr. Bullock was the peacekeeper in the house between his two sisters, said Ms. Mahoney: “Justin was always very delicate and kind.”

He played soccer and ran track but also loved math and science. While outwardly accumulating an impressive resume, Dr. Bullock was internally struggling. In high school, he made what he now calls an “immature” attempt at suicide after coming out as gay to his family. While Dr. Bullock said he doesn’t necessarily dwell on the discrimination he has faced as a gay, Black man, his awareness of how others perceive and treat him because of his identity increases the background stress present in his daily life.

After high school, Dr. Bullock went to MIT in Boston, where he continued running and studied chemical-biological engineering. During college, Dr. Bullock thought he was going to have to withdraw from MIT because of his depression. Thankfully, he received counseling from student services and advice from a track coach who sat him down and talked about pragmatic solutions, like medication. “That was life-changing,” said Dr. Bullock.

When trying to decide between engineering and medicine, Dr. Bullock realized he preferred contemplating medical problems to engineering ones. So he applied to medical school. Dr. Bullock eventually ended up at UCSF, where he was selected to participate in the Program in Medical Education for the Urban Underserved, a 5-year track at the college for students committed to working with underserved communities.

By the time Dr. Bullock got to medical school, he was feeling good. In consultation with his psychiatrist, he thought it worthwhile to take a break from his medications. At that time, his diagnosis was major depressive disorder and he had only had one serious depressive episode, which didn’t necessarily indicate that he would need medication long-term, he said. 

Dr. Bullock loved everything about medical school. “One day when I was in my first year of med school, I called my mom and said: ‘It’s like science summer camp but every day!’” he recalled.

Despite his enthusiasm, though, he began feeling something troubling. Recognizing the symptoms of early depression, Dr. Bullock restarted his medication. But this time, the same SSRI only made things worse. He went from sleeping 8 hours to 90 minutes a night. He felt angry. One day, he went on a furious 22-mile run. Plus, within the first 6 months of moving to San Francisco, Dr. Bullock was stopped by the police three different times while riding his bike. He attributes this to his race, which has only further added to his stress. In September 2015, during his second year of medical school, Dr. Bullock attempted suicide again. This time, he was intubated in the ED and rushed to the ICU.

He was given a new diagnosis: bipolar disorder. He changed medications and lived for a time with Ms. Mahoney and his other sister, who moved from Chicago to California to be with him. “My family has helped me a lot,” he said.

Dr. Bullock was initially not sure whether he would be able to return to school after his attempted suicide. Overall, UCSF was extremely supportive, he said. That came as a relief. Medical school was a grounding force in his life, not a destabilizing one: “If I had been pushed out, it would have been really harmful to me.”

Then Dr. Bullock started residency. The sleep disruption that comes with the night shift – the resident rite of passage – triggered another episode. At first, Dr. Bullock was overly productive; his mind was active and alert after staying up all night. He worked on new research during the day instead of sleeping. 

Sleep disturbance is a hallmark symptom of bipolar disorder. “Justin should never be on a 24-hour call,” said Lisa Meeks, PhD, associate professor of psychiatry and family medicine at the University of Colorado at Denver, Aurora, and a leading scholar on disability advocacy for medical trainees. When he started residency, Dr. Bullock was open with his program director about his diagnosis and sought accommodations to go to therapy each week. But he didn’t try to get out of night shifts or 24-hour calls, despite his care team urging him to do so. “I have this sense of wanting to tough it out,” he said. He also felt guilty making his peers take on his share of those challenging shifts.

In December 2019, Dr. Bullock was voluntarily hospitalized for a few days and started writing the article that would later appear in NEJM. In January, a friend and UCSF medical student completed suicide. In March, the same month his NEJM article came out, Dr. Bullock attempted suicide again. This time, he quickly recognized that he was making a mistake and called an ambulance. “For me, as far as suicide attempts go, it’s the most positive one.”
 

Advocating for changes in medical training

Throughout his medical training, Dr. Bullock was always open about his struggles with his peers and with the administration. He shared his suicidal thoughts at a Mental Illness Among Us event during medical school. His story resonated with peers who were surprised that Dr. Bullock, who was thriving academically, could be struggling emotionally. 

During residency, he led small group discussions and gave lectures at the medical school, including a talk about his attempts to create institutional change at UCSF, such as his public fight against the college’s Fitness for Duty (FFD) assessment process. That discussion earned him an Outstanding Lecturer award. Because it was the third award he had received from the medical school, Dr. Bullock also automatically earned a lifetime teaching award. When he told his mom, a teacher herself, about the award, she joked: “Are you old enough for ‘lifetime’ anything?”

Dr. Bullock has also spoken out and actively fought against the processes within the medical community that prevent people from coming forward until it is too late. Physicians and trainees often fear that if they seek mental health treatment, they will have to disclose that treatment to a potential employer or licensing board and then be barred from practicing medicine. Because he has been open about his mental health for so long, Dr. Bullock feels that he is in a position to push back against these norms. For example, in June he coauthored another article, this time for the Journal of Hospital Medicine, describing the traumatizing FFD assessment that followed his March 2020 suicide attempt.

In that article, Dr. Bullock wrote how no mental health professional served on the UCSF Physician Well Being Committee – comprising physicians and lawyers who evaluate physician impairment or potential physician impairment – that evaluated him. Dr. Bullock was referred to an outside psychiatrist. He also describes how he was forced to release all of his psychiatric records and undergo extensive drug testing, despite having no history of substance abuse. To return to work, he had to sign a contract, agreeing to be monitored and to attend a specific kind of therapy.

While steps like these can, in the right circumstances, protect both the public and doctors-in-training in important ways, they can also “be very punitive and isolating for someone going through a mental health crisis,” said Dr. Meeks. There were also no Black physicians or lawyers on the committee evaluating Dr. Bullock. “That was really egregious, when you look back.” Dr. Meeks is a coauthor on Dr. Bullock’s JHM article and a mentor and previous student disability officer at UCSF. 

Dr. Bullock raised objections to UCSF administrators about how he felt that the committee was discriminating against him because of his mental illness despite assurances from the director of his program that there have never been any performance or professionalism concerns with him. He said the administrators told him he was the first person to question the FFD process. This isn’t surprising, given that all the power in such situations usually lies with the hospital and the administrators, whereas the resident or physician is worried about losing their job and their license, said Dr. Meeks.

Dr. Bullock contends that he’s in a unique position to speak out, considering his stellar academic and work records, openness about his mental illness before a crisis, access to quality mental health care, and extensive personal network among the UCSF administration. “I know that I hold power within my institution; I spoke out because I could,” Dr. Bullock said. In addition to writing an article about his experience, Dr. Bullock shared his story with a task force appointed by the medical staff president to review the Physician Well-Being Committee and the overall FFD process. Even before Dr. Bullock shared his story with the public, the task force had already been appointed as a result of the increased concern about physician mental health during the ongoing COVID-19 pandemic, Michelle Guy, MD, clinical professor of medicine at UCSF, told this news organization. 

Elizabeth Fernandez, a UCSF senior public information representative, declined to comment on Dr. Bullock’s specific experience as reported in the JHM. “As with every hospital accredited by the Joint Commission, UCSF Medical Center has a Physician Well Being Committee that provides resources for physicians who may need help with chemical dependency or mental illness,” Ms. Fernandez said.

“Our goal through this program is always, first, to provide the compassion and assistance our physicians need to address the issues they face and continue to pursue their careers. This program is entirely voluntary and is bound by federal and state laws and regulations to protect the confidentiality of its participants, while ensuring that – first and foremost – no one is harmed by the situation, including the participant.”
 

Overcoming stigma to change the system

All of the attention – from national media outlets such as Vox to struggling peers and others – is fulfilling, Dr. Bullock said. But it can also be overwhelming. “I have definitely been praised as ‘Black excellence,’ and that definitely has added to the pressure to keep going ... to keep pushing at times,” he said.

Ms. Mahoney added: “He’s willing to sacrifice himself in order to make a difference. He would be a sacrificial lamb” for the Black community, the gay community, or any minority community.

Despite these concerns and his past suicide attempts, colleagues feel that Dr. Bullock is in a strong place to make decisions. “I trust Justin to put the boundaries up when they are needed and to engage in a way that feels comfortable for him,” said Ms. Meeks. “He is someone who has incredible self-awareness.”

Dr. Bullock’s history isn’t just something he overcame: It’s something that makes him a better, more empathetic doctor, said Ms. Mahoney. He knows what it’s like to be hospitalized, to deal with the frustration of insurance, to navigate the complexity of the health care system as a patient, or to be facing a deep internal darkness. He “can genuinely hold that person’s hand and say: ‘I know what you’re going through and we’re going to work through this day by day,’ ” she said. “That is something he can bring that no other physician can bring.”

In his advocacy on Twitter, in lectures, and in conversations with UCSF administrators, Dr. Bullock is pushing for board licensing questions to be reformed so physicians are no longer penalized for seeking mental health treatment. He would also like residency programs to make it easier and less stigmatizing for trainees to receive accommodations for a disability or mental illness.

“They say one person can’t change a system,” said Dr. Meeks, “but I do think Justin is calling an awful lot of attention to the system and I do think there will be changes because of his advocacy.”

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

Susan Haney, MD, a board-certified emergency physician in Coos Bay, Ore., was 2 years into her career when she had her first manic episode, likely a side effect of the steroid prednisone, which she had been prescribed for an asthma flare-up. Her boss at Bay Area Hospital told her that if she wanted to return to work, she would need to have written clearance from the medical board.

In retrospect, Dr. Haney says, “I don’t think they had any idea of what they would set in motion.”

Dr. Haney says the Oregon Medical Board posted her name and the nondisciplinary action on their website and in their newsletter. Her local newspaper read it and ran a story about her. “They effectively announced my mental illness to the general public despite my objections,” she says.

During the next decade, she had two more manic episodes, and more board investigations and actions followed. Despite being cleared for work each time, Dr. Haney says the board actions decimated her career in emergency medicine and her income, which is about half of what she would have earned by now. She is frustrated, sad, and angry about what happened but considers herself lucky to be practicing medicine in urgent care.
 

Being investigated is scary

After her first manic episode in 2006, Dr. Haney contacted the board’s medical director, a retired general surgeon, who told her the only way the board would authorize her return to work was if she agreed to open a board investigation.

She gave them the green light because she thought she had nothing to fear – she was cooperating fully and wasn’t impaired. Now Dr. Haney says she was naive. “The board is not your friend,” she says.

Dr. Haney was also anxious to return to work. She worked in a seven-person emergency department, and two colleagues were on maternity leave or medical leave.

“My colleagues kept calling asking me when I was going to return to work, and I kept saying, ‘I don’t know because the board won’t tell me,’ “ she says.

She was also feeling a lot of financial pressure. She was 2 years out of residency, owed $100,000 in student loans, and had just bought a house.

“I was really scared – I didn’t know how long this would last or if they would let me return to work. Early on, I even got a fitness for duty evaluation from the state’s consulting psychiatrist, who cleared me for work, and the board still wouldn’t let me return. They told me I had to go through their bureaucracy and a board meeting, which didn’t make sense to me.”

Dr. Haney consented to give the board’s investigative staff access to her medical records because she feared that if she challenged them, they would suspend or revoke her license immediately.

After investigating her for 4 months, the board cleared Dr. Haney to return to work at Bay Area Hospital. She agreed to the board’s “corrective action” terms: She would continue to receive psychiatric care, maintain a physician-patient relationship with a primary care physician, and enroll in the Health Physicians Program (HPP) for substance abuse monitoring.

Dr. Haney suspects that the board investigation damaged her reputation at work. “Before this, my work evaluations were consistently excellent. Afterwards, they were all adequate. I don’t think that was a coincidence.”
 

Worst time of her life

Five years later, after taking prednisone for another asthma flare-up, Dr. Haney had a more severe manic episode and was hospitalized.

The consulting psychiatrist who evaluated her reported her case to the medical board, stating she had bipolar disorder, was mentally incompetent, and shouldn’t be practicing medicine. The board opened a second investigation of her in 2012, which lasted 4 months.

Dr. Haney had quit her job at Bay Area Hospital in 2011 because she was pregnant and was planning to take a year off to care for the baby at home.

“That was the worst time of my life. I lost the baby at 4 months, I wasn’t working, and now I was under investigation by the board again,” she says.

The board issued an “interim stipulated order” that required that she be monitored regularly for mental illness and substance abuse by the Health Professionals Services Program (HPSP) for 2 years. “The board accused me of abusing prednisone, which I wasn’t. I was using it as prescribed and medically indicated,” she said.

The board order was reported to the National Practitioner Databank and is now permanently in her record. Although the board cleared her to work, she could not find a permanent job in a hospital emergency department.

“The repeated ‘nondisciplinary’ public board orders have had the same net impact on my career as if I had been disciplined for killing or harming my patients. For all intents and purposes, people treat it as a disciplinary action for the rest of your career,” she said.

To keep afloat financially, she found locum tenens work in local emergency departments until 2019.
 

Mental health toll

Dr. Haney feels that the stress of repeated board investigations has affected her mental health. “Both times this happened, it made my mental health worse, made the mania worse, and subsequent depression worse.”

Particularly distressing to her was the fact that the administrative staff who investigated her were attorneys and persons in law enforcement, rather than medical professionals with mental health training.

“I was required to disclose intimate personal details of my psychological and psychiatric history to anybody at the board who requested them. These investigators were asking me about my childhood history. That was traumatic and none of their business!”

Dr. Haney had quietly managed episodes of major depression since she was in her early 20s with the help of a psychiatrist. Her third episode of mania, which occurred in 2014, triggered a more severe depression, which she says deepened when she learned that the HPSP had notified the board about her manic symptoms and that she would not be released from the 2-year monitoring contract. When the board notified her 2 weeks later that they were opening another investigation, Dr. Haney says she had an emotional crisis, attempted suicide, and was briefly hospitalized. Several weeks later, she decided to take a mood stabilizer, which she continues to take.

The board’s 2015 corrective action agreement required Dr. Haney to practice medicine only in settings that the board’s medical director preapproved and to obtain a preapproved monitoring health care provider who would send quarterly reports to the medical director. Dr. Haney says the “nondisciplinary” action agreement was also reported to the National Practitioner Data Bank.

She also agreed to ongoing monitoring by the HPSP for mental illness and substance abuse, which involved random drug testing. When she didn’t call in one day in 2019 and missed a scheduled test, the board opened another investigation on her that lasted 7 months until July 2020. Dr. Haney said this was despite three subsequent negative tests.

Dr. Haney believes that the “open investigation” doomed a job offer from a hospital emergency department in the Virgin Islands. “I had passed all the required credentialing and explained previous board orders. They pulled the rug from under me 1 week before I was supposed to move there,” says Dr. Haney.

Her license was inactivated again because she hadn’t practiced medicine for a year, which she says was a new board policy. Although Dr. Haney says the medical director reactivated her license after talking with her, “By the time I was able to apply emergency medicine jobs, no one was interested in me anymore.”
 

Financial toll

Dr. Haney started her medical career when she was 42 as a second career. She says the board investigations and actions have resulted in a significant loss of work and income. “I have only worked 14 of the past 17 years as a doctor. I live cheaply because I never know how much longer my career will last,” says Dr. Haney.

The ordeal has devastated her finances. She has shelled out at least $200,000 in legal fees – she hired an attorney in 2007 and filed a lawsuit against the board in Oregon district court alleging that members had violated several of her rights. The district judge sided with the state medical board, and it was upheld on appeal in 2012, referring to state laws that gave the board absolute immunity from civil lawsuits. “I had no legal recourse to contest their decisions, no matter how injurious or unjust,” says Dr. Haney.

She has also shelled out at least $100,000 to be evaluated and monitored by the health physician program (now HPSP) for several years. Physicians who agree to be monitored by these health programs have to pay their fees. The board finally agreed last July to end her HPSP participation.

Dr. Haney also filed a complaint in 2007 with the federal Department of Health & Human Services Office for Civil Rights, alleging that the board violated her civil rights under the Americans with Disabilities Act. She says that her lawsuit and the OCR investigation of the board enabled her to withdraw from the HPP in good standing in 2008..
 

What would she have done differently?

She regrets not hiring an attorney earlier because “most likely the board action would not have been made public. It snowballed after that -- any mistake I made in my career was viewed in the lens of potential impairment.”

She also regrets telling her employer about the nature of her illness and reporting it to the board. A psychiatrist she saw later shared advice he gives to other patients who want to remain anonymous: get help but go out of town, use a false name, and pay cash.

“I wish I had that advice when all this started. That was the best way to protect my career,” says Dr. Haney.
 

Protecting the public?

The Oregon Medical Board declined to comment on Dr. Haney’s experience because investigations are confidential, but the executive director, Nicole Krishnaswami, JD, answered questions in an email about how the current board operates.

She says the board has 11 medical professionals and employs a medical director and expert consultants in specialty-specific fields. MDs with mental health training are involved in investigating/reviewing cases involving doctors with mental illnesses.

“State medical boards have a responsibility to protect and inform the public. State laws further require state agencies to provide access and transparency regarding the board’s official actions. If the board receives a complaint that a licensee is impaired and thus unable to safely practice, the board has a responsibility to investigate and ensure the licensee is practicing medicine safely,” Ms. Krishnaswami said.

The HPSP is the monitoring program established by state law to provide oversight in order to ensure that licensees are not practicing while impaired. HPSP is separate from the board and the board adopted a statement outlining its perspective on the program in support of doctors with substance abuse and mental health disorder.

The board also founded the Oregon Wellness Program, which provides free, confidential counseling to all Oregon-licensed physicians and physician assistants.
 

Stigma continues

Dr. Haney feels there is huge stigma associated with mental illness in the medical profession. “If I had cancer twice, I wouldn’t have been put in this position and would be at the peak of my career,” she says.

Nearly half of the 862 emergency medicine physicians surveyed last October said they were reluctant to seek mental health treatment. The reasons included fear of professional repercussions and stigma in the workplace. Several physicians said they were concerned about potentially having to report the treatment on medical license applications in the future, according to a survey by the American College of Emergency Physicians.

In addition, 26% of the more than 12,000 physicians who responded to a Medscape survey last year said they didn’t want to risk disclosure (20%) or that they distrusted mental health professionals (6%).
 

Another physician fights back

Steven Miles, MD, an award-winning professor emeritus of medicine and bioethics at the Center for Bioethics at the University of Minnesota, in Minneapolis, understands their reluctance. In 1996, he disclosed on his license renewal application that he had recently been diagnosed with a mainly depressive type of bipolar disorder and was in treatment. He had already told his employer, who was supportive.

That set off a 14-month investigation of him by the Minnesota Board of Medical Practice. Dr. Miles and his psychiatrist refused to release his confidential records to a panel of physicians, most of whom had no expertise in mental health care. He also filed a federal claim that the board’s requests violated the ADA, and he won the case.

“Had the board given me evidence of impaired ability to practice with ordinary skill and safety, I would have cooperated. Instead, they proposed a course of action, which would have degraded the privacy of my relationship with my psychiatrist and arguably increased the barrier to getting proper care and the risk of impairment,” he said.

The board kept renewing his license, and Dr. Miles continued to work full time. “I was empowered and protected by my stature in the field at the time my mental illness was diagnosed. Early-career physicians do not yet have that protection and should be very careful of disclosing, given the still widespread stigma of mental illnesses,” he said.
 

His advocacy led to changes

Dr. Miles went public to mobilize support for his ADA claim. He wrote editorials that were published in JAMA and Minnesota Medicine that refer to the American Psychiatric Association’s 1984 position paper, which says that the mandatory disclosure of the physician’s confidential medical record is without merit. Dr. Miles adds that major newspapers ran stories based on his editorials.

The board backed down after Dr. Miles won his ADA case, and it met with him. “I said this is not good stewardship of the medical profession; you are injuring doctors by keeping them from psychiatric care, which is out of line with the medical view of the treatability of depression and that needs to change,” he says.

Dr. Miles says he won a victory because his practice continued. “I also won a victory in the way the board was handling these questions, which was an opening salvo in a process that continues to this day.”

The original form asked whether he had ever been diagnosed with or treated for manic depression, schizophrenia, compulsive gambling, or other psychiatric conditions.

The revised form asks, “Do you have a physical or mental condition that would affect your ability, with or without reasonable accommodation, to provide appropriate care to patients and otherwise perform the essential functions of a practitioner in your area of practice without posing a health or safety risk to your patients? If yes, what accommodations would help you provide appropriate care to patients and perform other essential functions?”

Dr. Miles says that the final wording wasn’t ideal and that it was confusing to physicians. He says this prompted additional changes in wording by the board. Starting in January, applicants will be asked, “Do you currently have any condition that is not being appropriately treated that is likely to impair or adversely affect your ability to practice medicine with reasonable skill and safety in a competent, ethical, and professional manner?” the medical board’s executive director, Ruth M. Martinez, said in an email.

When asked whether the board still investigates physicians who reveal mental illnesses on licensing applications, Ms. Martinez responded, “All disclosures are evaluated to assure that the practitioner is qualified and safe to practice.”

This article was updated 11/4/21.

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

Susan Haney, MD, a board-certified emergency physician in Coos Bay, Ore., was 2 years into her career when she had her first manic episode, likely a side effect of the steroid prednisone, which she had been prescribed for an asthma flare-up. Her boss at Bay Area Hospital told her that if she wanted to return to work, she would need to have written clearance from the medical board.

In retrospect, Dr. Haney says, “I don’t think they had any idea of what they would set in motion.”

Dr. Haney says the Oregon Medical Board posted her name and the nondisciplinary action on their website and in their newsletter. Her local newspaper read it and ran a story about her. “They effectively announced my mental illness to the general public despite my objections,” she says.

During the next decade, she had two more manic episodes, and more board investigations and actions followed. Despite being cleared for work each time, Dr. Haney says the board actions decimated her career in emergency medicine and her income, which is about half of what she would have earned by now. She is frustrated, sad, and angry about what happened but considers herself lucky to be practicing medicine in urgent care.
 

Being investigated is scary

After her first manic episode in 2006, Dr. Haney contacted the board’s medical director, a retired general surgeon, who told her the only way the board would authorize her return to work was if she agreed to open a board investigation.

She gave them the green light because she thought she had nothing to fear – she was cooperating fully and wasn’t impaired. Now Dr. Haney says she was naive. “The board is not your friend,” she says.

Dr. Haney was also anxious to return to work. She worked in a seven-person emergency department, and two colleagues were on maternity leave or medical leave.

“My colleagues kept calling asking me when I was going to return to work, and I kept saying, ‘I don’t know because the board won’t tell me,’ “ she says.

She was also feeling a lot of financial pressure. She was 2 years out of residency, owed $100,000 in student loans, and had just bought a house.

“I was really scared – I didn’t know how long this would last or if they would let me return to work. Early on, I even got a fitness for duty evaluation from the state’s consulting psychiatrist, who cleared me for work, and the board still wouldn’t let me return. They told me I had to go through their bureaucracy and a board meeting, which didn’t make sense to me.”

Dr. Haney consented to give the board’s investigative staff access to her medical records because she feared that if she challenged them, they would suspend or revoke her license immediately.

After investigating her for 4 months, the board cleared Dr. Haney to return to work at Bay Area Hospital. She agreed to the board’s “corrective action” terms: She would continue to receive psychiatric care, maintain a physician-patient relationship with a primary care physician, and enroll in the Health Physicians Program (HPP) for substance abuse monitoring.

Dr. Haney suspects that the board investigation damaged her reputation at work. “Before this, my work evaluations were consistently excellent. Afterwards, they were all adequate. I don’t think that was a coincidence.”
 

Worst time of her life

Five years later, after taking prednisone for another asthma flare-up, Dr. Haney had a more severe manic episode and was hospitalized.

The consulting psychiatrist who evaluated her reported her case to the medical board, stating she had bipolar disorder, was mentally incompetent, and shouldn’t be practicing medicine. The board opened a second investigation of her in 2012, which lasted 4 months.

Dr. Haney had quit her job at Bay Area Hospital in 2011 because she was pregnant and was planning to take a year off to care for the baby at home.

“That was the worst time of my life. I lost the baby at 4 months, I wasn’t working, and now I was under investigation by the board again,” she says.

The board issued an “interim stipulated order” that required that she be monitored regularly for mental illness and substance abuse by the Health Professionals Services Program (HPSP) for 2 years. “The board accused me of abusing prednisone, which I wasn’t. I was using it as prescribed and medically indicated,” she said.

The board order was reported to the National Practitioner Databank and is now permanently in her record. Although the board cleared her to work, she could not find a permanent job in a hospital emergency department.

“The repeated ‘nondisciplinary’ public board orders have had the same net impact on my career as if I had been disciplined for killing or harming my patients. For all intents and purposes, people treat it as a disciplinary action for the rest of your career,” she said.

To keep afloat financially, she found locum tenens work in local emergency departments until 2019.
 

Mental health toll

Dr. Haney feels that the stress of repeated board investigations has affected her mental health. “Both times this happened, it made my mental health worse, made the mania worse, and subsequent depression worse.”

Particularly distressing to her was the fact that the administrative staff who investigated her were attorneys and persons in law enforcement, rather than medical professionals with mental health training.

“I was required to disclose intimate personal details of my psychological and psychiatric history to anybody at the board who requested them. These investigators were asking me about my childhood history. That was traumatic and none of their business!”

Dr. Haney had quietly managed episodes of major depression since she was in her early 20s with the help of a psychiatrist. Her third episode of mania, which occurred in 2014, triggered a more severe depression, which she says deepened when she learned that the HPSP had notified the board about her manic symptoms and that she would not be released from the 2-year monitoring contract. When the board notified her 2 weeks later that they were opening another investigation, Dr. Haney says she had an emotional crisis, attempted suicide, and was briefly hospitalized. Several weeks later, she decided to take a mood stabilizer, which she continues to take.

The board’s 2015 corrective action agreement required Dr. Haney to practice medicine only in settings that the board’s medical director preapproved and to obtain a preapproved monitoring health care provider who would send quarterly reports to the medical director. Dr. Haney says the “nondisciplinary” action agreement was also reported to the National Practitioner Data Bank.

She also agreed to ongoing monitoring by the HPSP for mental illness and substance abuse, which involved random drug testing. When she didn’t call in one day in 2019 and missed a scheduled test, the board opened another investigation on her that lasted 7 months until July 2020. Dr. Haney said this was despite three subsequent negative tests.

Dr. Haney believes that the “open investigation” doomed a job offer from a hospital emergency department in the Virgin Islands. “I had passed all the required credentialing and explained previous board orders. They pulled the rug from under me 1 week before I was supposed to move there,” says Dr. Haney.

Her license was inactivated again because she hadn’t practiced medicine for a year, which she says was a new board policy. Although Dr. Haney says the medical director reactivated her license after talking with her, “By the time I was able to apply emergency medicine jobs, no one was interested in me anymore.”
 

Financial toll

Dr. Haney started her medical career when she was 42 as a second career. She says the board investigations and actions have resulted in a significant loss of work and income. “I have only worked 14 of the past 17 years as a doctor. I live cheaply because I never know how much longer my career will last,” says Dr. Haney.

The ordeal has devastated her finances. She has shelled out at least $200,000 in legal fees – she hired an attorney in 2007 and filed a lawsuit against the board in Oregon district court alleging that members had violated several of her rights. The district judge sided with the state medical board, and it was upheld on appeal in 2012, referring to state laws that gave the board absolute immunity from civil lawsuits. “I had no legal recourse to contest their decisions, no matter how injurious or unjust,” says Dr. Haney.

She has also shelled out at least $100,000 to be evaluated and monitored by the health physician program (now HPSP) for several years. Physicians who agree to be monitored by these health programs have to pay their fees. The board finally agreed last July to end her HPSP participation.

Dr. Haney also filed a complaint in 2007 with the federal Department of Health & Human Services Office for Civil Rights, alleging that the board violated her civil rights under the Americans with Disabilities Act. She says that her lawsuit and the OCR investigation of the board enabled her to withdraw from the HPP in good standing in 2008..
 

What would she have done differently?

She regrets not hiring an attorney earlier because “most likely the board action would not have been made public. It snowballed after that -- any mistake I made in my career was viewed in the lens of potential impairment.”

She also regrets telling her employer about the nature of her illness and reporting it to the board. A psychiatrist she saw later shared advice he gives to other patients who want to remain anonymous: get help but go out of town, use a false name, and pay cash.

“I wish I had that advice when all this started. That was the best way to protect my career,” says Dr. Haney.
 

Protecting the public?

The Oregon Medical Board declined to comment on Dr. Haney’s experience because investigations are confidential, but the executive director, Nicole Krishnaswami, JD, answered questions in an email about how the current board operates.

She says the board has 11 medical professionals and employs a medical director and expert consultants in specialty-specific fields. MDs with mental health training are involved in investigating/reviewing cases involving doctors with mental illnesses.

“State medical boards have a responsibility to protect and inform the public. State laws further require state agencies to provide access and transparency regarding the board’s official actions. If the board receives a complaint that a licensee is impaired and thus unable to safely practice, the board has a responsibility to investigate and ensure the licensee is practicing medicine safely,” Ms. Krishnaswami said.

The HPSP is the monitoring program established by state law to provide oversight in order to ensure that licensees are not practicing while impaired. HPSP is separate from the board and the board adopted a statement outlining its perspective on the program in support of doctors with substance abuse and mental health disorder.

The board also founded the Oregon Wellness Program, which provides free, confidential counseling to all Oregon-licensed physicians and physician assistants.
 

Stigma continues

Dr. Haney feels there is huge stigma associated with mental illness in the medical profession. “If I had cancer twice, I wouldn’t have been put in this position and would be at the peak of my career,” she says.

Nearly half of the 862 emergency medicine physicians surveyed last October said they were reluctant to seek mental health treatment. The reasons included fear of professional repercussions and stigma in the workplace. Several physicians said they were concerned about potentially having to report the treatment on medical license applications in the future, according to a survey by the American College of Emergency Physicians.

In addition, 26% of the more than 12,000 physicians who responded to a Medscape survey last year said they didn’t want to risk disclosure (20%) or that they distrusted mental health professionals (6%).
 

Another physician fights back

Steven Miles, MD, an award-winning professor emeritus of medicine and bioethics at the Center for Bioethics at the University of Minnesota, in Minneapolis, understands their reluctance. In 1996, he disclosed on his license renewal application that he had recently been diagnosed with a mainly depressive type of bipolar disorder and was in treatment. He had already told his employer, who was supportive.

That set off a 14-month investigation of him by the Minnesota Board of Medical Practice. Dr. Miles and his psychiatrist refused to release his confidential records to a panel of physicians, most of whom had no expertise in mental health care. He also filed a federal claim that the board’s requests violated the ADA, and he won the case.

“Had the board given me evidence of impaired ability to practice with ordinary skill and safety, I would have cooperated. Instead, they proposed a course of action, which would have degraded the privacy of my relationship with my psychiatrist and arguably increased the barrier to getting proper care and the risk of impairment,” he said.

The board kept renewing his license, and Dr. Miles continued to work full time. “I was empowered and protected by my stature in the field at the time my mental illness was diagnosed. Early-career physicians do not yet have that protection and should be very careful of disclosing, given the still widespread stigma of mental illnesses,” he said.
 

His advocacy led to changes

Dr. Miles went public to mobilize support for his ADA claim. He wrote editorials that were published in JAMA and Minnesota Medicine that refer to the American Psychiatric Association’s 1984 position paper, which says that the mandatory disclosure of the physician’s confidential medical record is without merit. Dr. Miles adds that major newspapers ran stories based on his editorials.

The board backed down after Dr. Miles won his ADA case, and it met with him. “I said this is not good stewardship of the medical profession; you are injuring doctors by keeping them from psychiatric care, which is out of line with the medical view of the treatability of depression and that needs to change,” he says.

Dr. Miles says he won a victory because his practice continued. “I also won a victory in the way the board was handling these questions, which was an opening salvo in a process that continues to this day.”

The original form asked whether he had ever been diagnosed with or treated for manic depression, schizophrenia, compulsive gambling, or other psychiatric conditions.

The revised form asks, “Do you have a physical or mental condition that would affect your ability, with or without reasonable accommodation, to provide appropriate care to patients and otherwise perform the essential functions of a practitioner in your area of practice without posing a health or safety risk to your patients? If yes, what accommodations would help you provide appropriate care to patients and perform other essential functions?”

Dr. Miles says that the final wording wasn’t ideal and that it was confusing to physicians. He says this prompted additional changes in wording by the board. Starting in January, applicants will be asked, “Do you currently have any condition that is not being appropriately treated that is likely to impair or adversely affect your ability to practice medicine with reasonable skill and safety in a competent, ethical, and professional manner?” the medical board’s executive director, Ruth M. Martinez, said in an email.

When asked whether the board still investigates physicians who reveal mental illnesses on licensing applications, Ms. Martinez responded, “All disclosures are evaluated to assure that the practitioner is qualified and safe to practice.”

This article was updated 11/4/21.

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

Susan Haney, MD, a board-certified emergency physician in Coos Bay, Ore., was 2 years into her career when she had her first manic episode, likely a side effect of the steroid prednisone, which she had been prescribed for an asthma flare-up. Her boss at Bay Area Hospital told her that if she wanted to return to work, she would need to have written clearance from the medical board.

In retrospect, Dr. Haney says, “I don’t think they had any idea of what they would set in motion.”

Dr. Haney says the Oregon Medical Board posted her name and the nondisciplinary action on their website and in their newsletter. Her local newspaper read it and ran a story about her. “They effectively announced my mental illness to the general public despite my objections,” she says.

During the next decade, she had two more manic episodes, and more board investigations and actions followed. Despite being cleared for work each time, Dr. Haney says the board actions decimated her career in emergency medicine and her income, which is about half of what she would have earned by now. She is frustrated, sad, and angry about what happened but considers herself lucky to be practicing medicine in urgent care.
 

Being investigated is scary

After her first manic episode in 2006, Dr. Haney contacted the board’s medical director, a retired general surgeon, who told her the only way the board would authorize her return to work was if she agreed to open a board investigation.

She gave them the green light because she thought she had nothing to fear – she was cooperating fully and wasn’t impaired. Now Dr. Haney says she was naive. “The board is not your friend,” she says.

Dr. Haney was also anxious to return to work. She worked in a seven-person emergency department, and two colleagues were on maternity leave or medical leave.

“My colleagues kept calling asking me when I was going to return to work, and I kept saying, ‘I don’t know because the board won’t tell me,’ “ she says.

She was also feeling a lot of financial pressure. She was 2 years out of residency, owed $100,000 in student loans, and had just bought a house.

“I was really scared – I didn’t know how long this would last or if they would let me return to work. Early on, I even got a fitness for duty evaluation from the state’s consulting psychiatrist, who cleared me for work, and the board still wouldn’t let me return. They told me I had to go through their bureaucracy and a board meeting, which didn’t make sense to me.”

Dr. Haney consented to give the board’s investigative staff access to her medical records because she feared that if she challenged them, they would suspend or revoke her license immediately.

After investigating her for 4 months, the board cleared Dr. Haney to return to work at Bay Area Hospital. She agreed to the board’s “corrective action” terms: She would continue to receive psychiatric care, maintain a physician-patient relationship with a primary care physician, and enroll in the Health Physicians Program (HPP) for substance abuse monitoring.

Dr. Haney suspects that the board investigation damaged her reputation at work. “Before this, my work evaluations were consistently excellent. Afterwards, they were all adequate. I don’t think that was a coincidence.”
 

Worst time of her life

Five years later, after taking prednisone for another asthma flare-up, Dr. Haney had a more severe manic episode and was hospitalized.

The consulting psychiatrist who evaluated her reported her case to the medical board, stating she had bipolar disorder, was mentally incompetent, and shouldn’t be practicing medicine. The board opened a second investigation of her in 2012, which lasted 4 months.

Dr. Haney had quit her job at Bay Area Hospital in 2011 because she was pregnant and was planning to take a year off to care for the baby at home.

“That was the worst time of my life. I lost the baby at 4 months, I wasn’t working, and now I was under investigation by the board again,” she says.

The board issued an “interim stipulated order” that required that she be monitored regularly for mental illness and substance abuse by the Health Professionals Services Program (HPSP) for 2 years. “The board accused me of abusing prednisone, which I wasn’t. I was using it as prescribed and medically indicated,” she said.

The board order was reported to the National Practitioner Databank and is now permanently in her record. Although the board cleared her to work, she could not find a permanent job in a hospital emergency department.

“The repeated ‘nondisciplinary’ public board orders have had the same net impact on my career as if I had been disciplined for killing or harming my patients. For all intents and purposes, people treat it as a disciplinary action for the rest of your career,” she said.

To keep afloat financially, she found locum tenens work in local emergency departments until 2019.
 

Mental health toll

Dr. Haney feels that the stress of repeated board investigations has affected her mental health. “Both times this happened, it made my mental health worse, made the mania worse, and subsequent depression worse.”

Particularly distressing to her was the fact that the administrative staff who investigated her were attorneys and persons in law enforcement, rather than medical professionals with mental health training.

“I was required to disclose intimate personal details of my psychological and psychiatric history to anybody at the board who requested them. These investigators were asking me about my childhood history. That was traumatic and none of their business!”

Dr. Haney had quietly managed episodes of major depression since she was in her early 20s with the help of a psychiatrist. Her third episode of mania, which occurred in 2014, triggered a more severe depression, which she says deepened when she learned that the HPSP had notified the board about her manic symptoms and that she would not be released from the 2-year monitoring contract. When the board notified her 2 weeks later that they were opening another investigation, Dr. Haney says she had an emotional crisis, attempted suicide, and was briefly hospitalized. Several weeks later, she decided to take a mood stabilizer, which she continues to take.

The board’s 2015 corrective action agreement required Dr. Haney to practice medicine only in settings that the board’s medical director preapproved and to obtain a preapproved monitoring health care provider who would send quarterly reports to the medical director. Dr. Haney says the “nondisciplinary” action agreement was also reported to the National Practitioner Data Bank.

She also agreed to ongoing monitoring by the HPSP for mental illness and substance abuse, which involved random drug testing. When she didn’t call in one day in 2019 and missed a scheduled test, the board opened another investigation on her that lasted 7 months until July 2020. Dr. Haney said this was despite three subsequent negative tests.

Dr. Haney believes that the “open investigation” doomed a job offer from a hospital emergency department in the Virgin Islands. “I had passed all the required credentialing and explained previous board orders. They pulled the rug from under me 1 week before I was supposed to move there,” says Dr. Haney.

Her license was inactivated again because she hadn’t practiced medicine for a year, which she says was a new board policy. Although Dr. Haney says the medical director reactivated her license after talking with her, “By the time I was able to apply emergency medicine jobs, no one was interested in me anymore.”
 

Financial toll

Dr. Haney started her medical career when she was 42 as a second career. She says the board investigations and actions have resulted in a significant loss of work and income. “I have only worked 14 of the past 17 years as a doctor. I live cheaply because I never know how much longer my career will last,” says Dr. Haney.

The ordeal has devastated her finances. She has shelled out at least $200,000 in legal fees – she hired an attorney in 2007 and filed a lawsuit against the board in Oregon district court alleging that members had violated several of her rights. The district judge sided with the state medical board, and it was upheld on appeal in 2012, referring to state laws that gave the board absolute immunity from civil lawsuits. “I had no legal recourse to contest their decisions, no matter how injurious or unjust,” says Dr. Haney.

She has also shelled out at least $100,000 to be evaluated and monitored by the health physician program (now HPSP) for several years. Physicians who agree to be monitored by these health programs have to pay their fees. The board finally agreed last July to end her HPSP participation.

Dr. Haney also filed a complaint in 2007 with the federal Department of Health & Human Services Office for Civil Rights, alleging that the board violated her civil rights under the Americans with Disabilities Act. She says that her lawsuit and the OCR investigation of the board enabled her to withdraw from the HPP in good standing in 2008..
 

What would she have done differently?

She regrets not hiring an attorney earlier because “most likely the board action would not have been made public. It snowballed after that -- any mistake I made in my career was viewed in the lens of potential impairment.”

She also regrets telling her employer about the nature of her illness and reporting it to the board. A psychiatrist she saw later shared advice he gives to other patients who want to remain anonymous: get help but go out of town, use a false name, and pay cash.

“I wish I had that advice when all this started. That was the best way to protect my career,” says Dr. Haney.
 

Protecting the public?

The Oregon Medical Board declined to comment on Dr. Haney’s experience because investigations are confidential, but the executive director, Nicole Krishnaswami, JD, answered questions in an email about how the current board operates.

She says the board has 11 medical professionals and employs a medical director and expert consultants in specialty-specific fields. MDs with mental health training are involved in investigating/reviewing cases involving doctors with mental illnesses.

“State medical boards have a responsibility to protect and inform the public. State laws further require state agencies to provide access and transparency regarding the board’s official actions. If the board receives a complaint that a licensee is impaired and thus unable to safely practice, the board has a responsibility to investigate and ensure the licensee is practicing medicine safely,” Ms. Krishnaswami said.

The HPSP is the monitoring program established by state law to provide oversight in order to ensure that licensees are not practicing while impaired. HPSP is separate from the board and the board adopted a statement outlining its perspective on the program in support of doctors with substance abuse and mental health disorder.

The board also founded the Oregon Wellness Program, which provides free, confidential counseling to all Oregon-licensed physicians and physician assistants.
 

Stigma continues

Dr. Haney feels there is huge stigma associated with mental illness in the medical profession. “If I had cancer twice, I wouldn’t have been put in this position and would be at the peak of my career,” she says.

Nearly half of the 862 emergency medicine physicians surveyed last October said they were reluctant to seek mental health treatment. The reasons included fear of professional repercussions and stigma in the workplace. Several physicians said they were concerned about potentially having to report the treatment on medical license applications in the future, according to a survey by the American College of Emergency Physicians.

In addition, 26% of the more than 12,000 physicians who responded to a Medscape survey last year said they didn’t want to risk disclosure (20%) or that they distrusted mental health professionals (6%).
 

Another physician fights back

Steven Miles, MD, an award-winning professor emeritus of medicine and bioethics at the Center for Bioethics at the University of Minnesota, in Minneapolis, understands their reluctance. In 1996, he disclosed on his license renewal application that he had recently been diagnosed with a mainly depressive type of bipolar disorder and was in treatment. He had already told his employer, who was supportive.

That set off a 14-month investigation of him by the Minnesota Board of Medical Practice. Dr. Miles and his psychiatrist refused to release his confidential records to a panel of physicians, most of whom had no expertise in mental health care. He also filed a federal claim that the board’s requests violated the ADA, and he won the case.

“Had the board given me evidence of impaired ability to practice with ordinary skill and safety, I would have cooperated. Instead, they proposed a course of action, which would have degraded the privacy of my relationship with my psychiatrist and arguably increased the barrier to getting proper care and the risk of impairment,” he said.

The board kept renewing his license, and Dr. Miles continued to work full time. “I was empowered and protected by my stature in the field at the time my mental illness was diagnosed. Early-career physicians do not yet have that protection and should be very careful of disclosing, given the still widespread stigma of mental illnesses,” he said.
 

His advocacy led to changes

Dr. Miles went public to mobilize support for his ADA claim. He wrote editorials that were published in JAMA and Minnesota Medicine that refer to the American Psychiatric Association’s 1984 position paper, which says that the mandatory disclosure of the physician’s confidential medical record is without merit. Dr. Miles adds that major newspapers ran stories based on his editorials.

The board backed down after Dr. Miles won his ADA case, and it met with him. “I said this is not good stewardship of the medical profession; you are injuring doctors by keeping them from psychiatric care, which is out of line with the medical view of the treatability of depression and that needs to change,” he says.

Dr. Miles says he won a victory because his practice continued. “I also won a victory in the way the board was handling these questions, which was an opening salvo in a process that continues to this day.”

The original form asked whether he had ever been diagnosed with or treated for manic depression, schizophrenia, compulsive gambling, or other psychiatric conditions.

The revised form asks, “Do you have a physical or mental condition that would affect your ability, with or without reasonable accommodation, to provide appropriate care to patients and otherwise perform the essential functions of a practitioner in your area of practice without posing a health or safety risk to your patients? If yes, what accommodations would help you provide appropriate care to patients and perform other essential functions?”

Dr. Miles says that the final wording wasn’t ideal and that it was confusing to physicians. He says this prompted additional changes in wording by the board. Starting in January, applicants will be asked, “Do you currently have any condition that is not being appropriately treated that is likely to impair or adversely affect your ability to practice medicine with reasonable skill and safety in a competent, ethical, and professional manner?” the medical board’s executive director, Ruth M. Martinez, said in an email.

When asked whether the board still investigates physicians who reveal mental illnesses on licensing applications, Ms. Martinez responded, “All disclosures are evaluated to assure that the practitioner is qualified and safe to practice.”

This article was updated 11/4/21.

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

No, Mr. Bond, I expect you to die

Movie watching usually requires a certain suspension of disbelief, and it’s safe to say James Bond movies require this more than most. Between the impossible gadgets and ludicrous doomsday plans, very few have ever stopped to consider the health risks of the James Bond universe.

Tumisu/Pixabay

Now, however, Bond, James Bond, has met his most formidable opponent: Wouter Graumans, a graduate student in epidemiology from the Netherlands. During a foray to Burkina Faso to study infectious diseases, Mr. Graumans came down with a case of food poisoning, which led him to wonder how 007 is able to trot across this big world of ours without contracting so much as a sinus infection.

Because Mr. Graumans is a man of science and conviction, mere speculation wasn’t enough. He and a group of coauthors wrote an entire paper on the health risks of the James Bond universe.

Doing so required watching over 3,000 minutes of numerous movies and analyzing Bond’s 86 total trips to 46 different countries based on current Centers for Disease Control and Prevention advice for travel to those countries. Time which, the authors state in the abstract, “could easily have been spent on more pressing societal issues or forms of relaxation that are more acceptable in academic circles.”

Naturally, Mr. Bond’s line of work entails exposure to unpleasant things, such as poison, dehydration, heatstroke, and dangerous wildlife (everything from ticks to crocodiles), though oddly enough he never succumbs to any of it. He’s also curiously immune to hangovers, despite rarely drinking anything nonalcoholic. There are also less obvious risks: For one, 007 rarely washes his hands. During one movie, he handles raw chicken to lure away a pack of crocodiles but fails to wash his hands afterward, leaving him at risk for multiple food-borne illnesses.

Of course, we must address the elephant in the bedroom: Mr. Bond’s numerous, er, encounters with women. One would imagine the biggest risk to those women would be from the various STDs that likely course through Bond’s body, but of the 27% who died shortly after … encountering … him, all involved violence, with disease playing no obvious role. Who knows, maybe he’s clean? Stranger things have happened.

The timing of this article may seem a bit suspicious. Was it a PR stunt by the studio? Rest assured, the authors addressed this, noting that they received no funding for the study, and that, “given the futility of its academic value, this is deemed entirely appropriate by all authors.” We love when a punchline writes itself.
 

How to see Atlanta on $688.35 a day

The world is always changing, so we have to change with it. This week, LOTME becomes a travel guide, and our first stop is the Big A, the Big Peach, Dogwood City, Empire City of the South, Wakanda.

There’s lots to do in Atlanta: Celebrate a World Series win, visit the College Football Hall of Fame or the World of Coca Cola, or take the Stranger Things/Upside Down film locations tour. Serious adventurers, however, get out of the city and go to Emory Decatur Hospital in – you guessed it – Decatur (unofficial motto: “Everything is Greater in Decatur”).

©Getty Images

Find the emergency room and ask for Taylor Davis, who will be your personal guide. She’ll show you how to check in at the desk, sit in the waiting room for 7 hours, and then leave without seeing any medical personnel or receiving any sort of attention whatsoever. All the things she did when she went there in July for a head injury.

Ms. Davis told Fox5 Atlanta: “I didn’t get my vitals taken, nobody called my name. I wasn’t seen at all.”

But wait! There’s more! By booking your trip through LOTMEgo* and using the code “Decatur,” you’ll get the Taylor Davis special, which includes a bill/cover charge for $688.35 from the hospital. An Emory Healthcare patient financial services employee told Ms. Davis that “you get charged before you are seen. Not for being seen.”

If all this has you ready to hop in your car (really?), then check out LOTMEgo* on Twittbook and InstaTok. You’ll also find trick-or-treating tips and discounts on haunted hospital tours.

*Does not actually exist

Breaking down the hot flash

Do you ever wonder why we scramble for cold things when we’re feeling nauseous? Whether it’s the cool air that needs to hit your face in the car or a cold, damp towel on the back of your neck, scientists think it could possibly be an evolutionary mechanism at the cellular level.

Piqsels

Motion sickness it’s actually a battle of body temperature, according to an article from LiveScience. Capillaries in the skin dilate, allowing for more blood flow near the skin’s surface and causing core temperature to fall. Once body temperature drops, the hypothalamus, which regulates temperature, tries to do its job by raising body temperature. Thus the hot flash!

The cold compress and cool air help fight the battle by counteracting the hypothalamus, but why the drop in body temperature to begin with?

There are a few theories. Dr. Robert Glatter, an emergency physician at Lenox Hill Hospital in New York, told LiveScience that the lack of oxygen needed in body tissue to survive at lower temperatures could be making it difficult to get oxygen to the body when a person is ill, and is “more likely an adaptive response influenced by poorly understood mechanisms at the cellular level.”

Another theory is that the nausea and body temperature shift is the body’s natural response to help people vomit.

Then there’s the theory of “defensive hypothermia,” which suggests that cold sweats are a possible mechanism to conserve energy so the body can fight off an intruder, which was supported by a 2014 study and a 2016 review.

It’s another one of the body’s many survival tricks.
 

Teachers were right: Pupils can do the math

Teachers liked to preach that we wouldn’t have calculators with us all the time, but that wound up not being true. Our phones have calculators at the press of a button. But maybe even calculators aren’t always needed because our pupils do more math than you think.

pxfuel

The pupil light reflex – constrict in light and dilate in darkness – is well known, but recent work shows that pupil size is also regulated by cognitive and perceptual factors. By presenting subjects with images of various numbers of dots and measuring pupil size, the investigators were able to show “that numerical information is intrinsically related to perception,” lead author Dr. Elisa Castaldi of Florence University noted in a written statement.

The researchers found that pupils are responsible for important survival techniques. Coauthor David Burr of the University of Sydney and the University of Florence gave an evolutionary perspective: “When we look around, we spontaneously perceive the form, size, movement and colour of a scene. Equally spontaneously, we perceive the number of items before us. This ability, shared with most other animals, is an evolutionary fundamental: It reveals immediately important quantities, such as how many apples there are on the tree, or how many enemies are attacking.”

Useful information, indeed, but our pupils seem to be more interested in the quantity of beers in the refrigerator.

No, Mr. Bond, I expect you to die

Movie watching usually requires a certain suspension of disbelief, and it’s safe to say James Bond movies require this more than most. Between the impossible gadgets and ludicrous doomsday plans, very few have ever stopped to consider the health risks of the James Bond universe.

Tumisu/Pixabay

Now, however, Bond, James Bond, has met his most formidable opponent: Wouter Graumans, a graduate student in epidemiology from the Netherlands. During a foray to Burkina Faso to study infectious diseases, Mr. Graumans came down with a case of food poisoning, which led him to wonder how 007 is able to trot across this big world of ours without contracting so much as a sinus infection.

Because Mr. Graumans is a man of science and conviction, mere speculation wasn’t enough. He and a group of coauthors wrote an entire paper on the health risks of the James Bond universe.

Doing so required watching over 3,000 minutes of numerous movies and analyzing Bond’s 86 total trips to 46 different countries based on current Centers for Disease Control and Prevention advice for travel to those countries. Time which, the authors state in the abstract, “could easily have been spent on more pressing societal issues or forms of relaxation that are more acceptable in academic circles.”

Naturally, Mr. Bond’s line of work entails exposure to unpleasant things, such as poison, dehydration, heatstroke, and dangerous wildlife (everything from ticks to crocodiles), though oddly enough he never succumbs to any of it. He’s also curiously immune to hangovers, despite rarely drinking anything nonalcoholic. There are also less obvious risks: For one, 007 rarely washes his hands. During one movie, he handles raw chicken to lure away a pack of crocodiles but fails to wash his hands afterward, leaving him at risk for multiple food-borne illnesses.

Of course, we must address the elephant in the bedroom: Mr. Bond’s numerous, er, encounters with women. One would imagine the biggest risk to those women would be from the various STDs that likely course through Bond’s body, but of the 27% who died shortly after … encountering … him, all involved violence, with disease playing no obvious role. Who knows, maybe he’s clean? Stranger things have happened.

The timing of this article may seem a bit suspicious. Was it a PR stunt by the studio? Rest assured, the authors addressed this, noting that they received no funding for the study, and that, “given the futility of its academic value, this is deemed entirely appropriate by all authors.” We love when a punchline writes itself.
 

How to see Atlanta on $688.35 a day

The world is always changing, so we have to change with it. This week, LOTME becomes a travel guide, and our first stop is the Big A, the Big Peach, Dogwood City, Empire City of the South, Wakanda.

There’s lots to do in Atlanta: Celebrate a World Series win, visit the College Football Hall of Fame or the World of Coca Cola, or take the Stranger Things/Upside Down film locations tour. Serious adventurers, however, get out of the city and go to Emory Decatur Hospital in – you guessed it – Decatur (unofficial motto: “Everything is Greater in Decatur”).

©Getty Images

Find the emergency room and ask for Taylor Davis, who will be your personal guide. She’ll show you how to check in at the desk, sit in the waiting room for 7 hours, and then leave without seeing any medical personnel or receiving any sort of attention whatsoever. All the things she did when she went there in July for a head injury.

Ms. Davis told Fox5 Atlanta: “I didn’t get my vitals taken, nobody called my name. I wasn’t seen at all.”

But wait! There’s more! By booking your trip through LOTMEgo* and using the code “Decatur,” you’ll get the Taylor Davis special, which includes a bill/cover charge for $688.35 from the hospital. An Emory Healthcare patient financial services employee told Ms. Davis that “you get charged before you are seen. Not for being seen.”

If all this has you ready to hop in your car (really?), then check out LOTMEgo* on Twittbook and InstaTok. You’ll also find trick-or-treating tips and discounts on haunted hospital tours.

*Does not actually exist

Breaking down the hot flash

Do you ever wonder why we scramble for cold things when we’re feeling nauseous? Whether it’s the cool air that needs to hit your face in the car or a cold, damp towel on the back of your neck, scientists think it could possibly be an evolutionary mechanism at the cellular level.

Piqsels

Motion sickness it’s actually a battle of body temperature, according to an article from LiveScience. Capillaries in the skin dilate, allowing for more blood flow near the skin’s surface and causing core temperature to fall. Once body temperature drops, the hypothalamus, which regulates temperature, tries to do its job by raising body temperature. Thus the hot flash!

The cold compress and cool air help fight the battle by counteracting the hypothalamus, but why the drop in body temperature to begin with?

There are a few theories. Dr. Robert Glatter, an emergency physician at Lenox Hill Hospital in New York, told LiveScience that the lack of oxygen needed in body tissue to survive at lower temperatures could be making it difficult to get oxygen to the body when a person is ill, and is “more likely an adaptive response influenced by poorly understood mechanisms at the cellular level.”

Another theory is that the nausea and body temperature shift is the body’s natural response to help people vomit.

Then there’s the theory of “defensive hypothermia,” which suggests that cold sweats are a possible mechanism to conserve energy so the body can fight off an intruder, which was supported by a 2014 study and a 2016 review.

It’s another one of the body’s many survival tricks.
 

Teachers were right: Pupils can do the math

Teachers liked to preach that we wouldn’t have calculators with us all the time, but that wound up not being true. Our phones have calculators at the press of a button. But maybe even calculators aren’t always needed because our pupils do more math than you think.

pxfuel

The pupil light reflex – constrict in light and dilate in darkness – is well known, but recent work shows that pupil size is also regulated by cognitive and perceptual factors. By presenting subjects with images of various numbers of dots and measuring pupil size, the investigators were able to show “that numerical information is intrinsically related to perception,” lead author Dr. Elisa Castaldi of Florence University noted in a written statement.

The researchers found that pupils are responsible for important survival techniques. Coauthor David Burr of the University of Sydney and the University of Florence gave an evolutionary perspective: “When we look around, we spontaneously perceive the form, size, movement and colour of a scene. Equally spontaneously, we perceive the number of items before us. This ability, shared with most other animals, is an evolutionary fundamental: It reveals immediately important quantities, such as how many apples there are on the tree, or how many enemies are attacking.”

Useful information, indeed, but our pupils seem to be more interested in the quantity of beers in the refrigerator.

No, Mr. Bond, I expect you to die

Movie watching usually requires a certain suspension of disbelief, and it’s safe to say James Bond movies require this more than most. Between the impossible gadgets and ludicrous doomsday plans, very few have ever stopped to consider the health risks of the James Bond universe.

Tumisu/Pixabay

Now, however, Bond, James Bond, has met his most formidable opponent: Wouter Graumans, a graduate student in epidemiology from the Netherlands. During a foray to Burkina Faso to study infectious diseases, Mr. Graumans came down with a case of food poisoning, which led him to wonder how 007 is able to trot across this big world of ours without contracting so much as a sinus infection.

Because Mr. Graumans is a man of science and conviction, mere speculation wasn’t enough. He and a group of coauthors wrote an entire paper on the health risks of the James Bond universe.

Doing so required watching over 3,000 minutes of numerous movies and analyzing Bond’s 86 total trips to 46 different countries based on current Centers for Disease Control and Prevention advice for travel to those countries. Time which, the authors state in the abstract, “could easily have been spent on more pressing societal issues or forms of relaxation that are more acceptable in academic circles.”

Naturally, Mr. Bond’s line of work entails exposure to unpleasant things, such as poison, dehydration, heatstroke, and dangerous wildlife (everything from ticks to crocodiles), though oddly enough he never succumbs to any of it. He’s also curiously immune to hangovers, despite rarely drinking anything nonalcoholic. There are also less obvious risks: For one, 007 rarely washes his hands. During one movie, he handles raw chicken to lure away a pack of crocodiles but fails to wash his hands afterward, leaving him at risk for multiple food-borne illnesses.

Of course, we must address the elephant in the bedroom: Mr. Bond’s numerous, er, encounters with women. One would imagine the biggest risk to those women would be from the various STDs that likely course through Bond’s body, but of the 27% who died shortly after … encountering … him, all involved violence, with disease playing no obvious role. Who knows, maybe he’s clean? Stranger things have happened.

The timing of this article may seem a bit suspicious. Was it a PR stunt by the studio? Rest assured, the authors addressed this, noting that they received no funding for the study, and that, “given the futility of its academic value, this is deemed entirely appropriate by all authors.” We love when a punchline writes itself.
 

How to see Atlanta on $688.35 a day

The world is always changing, so we have to change with it. This week, LOTME becomes a travel guide, and our first stop is the Big A, the Big Peach, Dogwood City, Empire City of the South, Wakanda.

There’s lots to do in Atlanta: Celebrate a World Series win, visit the College Football Hall of Fame or the World of Coca Cola, or take the Stranger Things/Upside Down film locations tour. Serious adventurers, however, get out of the city and go to Emory Decatur Hospital in – you guessed it – Decatur (unofficial motto: “Everything is Greater in Decatur”).

©Getty Images

Find the emergency room and ask for Taylor Davis, who will be your personal guide. She’ll show you how to check in at the desk, sit in the waiting room for 7 hours, and then leave without seeing any medical personnel or receiving any sort of attention whatsoever. All the things she did when she went there in July for a head injury.

Ms. Davis told Fox5 Atlanta: “I didn’t get my vitals taken, nobody called my name. I wasn’t seen at all.”

But wait! There’s more! By booking your trip through LOTMEgo* and using the code “Decatur,” you’ll get the Taylor Davis special, which includes a bill/cover charge for $688.35 from the hospital. An Emory Healthcare patient financial services employee told Ms. Davis that “you get charged before you are seen. Not for being seen.”

If all this has you ready to hop in your car (really?), then check out LOTMEgo* on Twittbook and InstaTok. You’ll also find trick-or-treating tips and discounts on haunted hospital tours.

*Does not actually exist

Breaking down the hot flash

Do you ever wonder why we scramble for cold things when we’re feeling nauseous? Whether it’s the cool air that needs to hit your face in the car or a cold, damp towel on the back of your neck, scientists think it could possibly be an evolutionary mechanism at the cellular level.

Piqsels

Motion sickness it’s actually a battle of body temperature, according to an article from LiveScience. Capillaries in the skin dilate, allowing for more blood flow near the skin’s surface and causing core temperature to fall. Once body temperature drops, the hypothalamus, which regulates temperature, tries to do its job by raising body temperature. Thus the hot flash!

The cold compress and cool air help fight the battle by counteracting the hypothalamus, but why the drop in body temperature to begin with?

There are a few theories. Dr. Robert Glatter, an emergency physician at Lenox Hill Hospital in New York, told LiveScience that the lack of oxygen needed in body tissue to survive at lower temperatures could be making it difficult to get oxygen to the body when a person is ill, and is “more likely an adaptive response influenced by poorly understood mechanisms at the cellular level.”

Another theory is that the nausea and body temperature shift is the body’s natural response to help people vomit.

Then there’s the theory of “defensive hypothermia,” which suggests that cold sweats are a possible mechanism to conserve energy so the body can fight off an intruder, which was supported by a 2014 study and a 2016 review.

It’s another one of the body’s many survival tricks.
 

Teachers were right: Pupils can do the math

Teachers liked to preach that we wouldn’t have calculators with us all the time, but that wound up not being true. Our phones have calculators at the press of a button. But maybe even calculators aren’t always needed because our pupils do more math than you think.

pxfuel

The pupil light reflex – constrict in light and dilate in darkness – is well known, but recent work shows that pupil size is also regulated by cognitive and perceptual factors. By presenting subjects with images of various numbers of dots and measuring pupil size, the investigators were able to show “that numerical information is intrinsically related to perception,” lead author Dr. Elisa Castaldi of Florence University noted in a written statement.

The researchers found that pupils are responsible for important survival techniques. Coauthor David Burr of the University of Sydney and the University of Florence gave an evolutionary perspective: “When we look around, we spontaneously perceive the form, size, movement and colour of a scene. Equally spontaneously, we perceive the number of items before us. This ability, shared with most other animals, is an evolutionary fundamental: It reveals immediately important quantities, such as how many apples there are on the tree, or how many enemies are attacking.”

Useful information, indeed, but our pupils seem to be more interested in the quantity of beers in the refrigerator.

Use of cannabis is common in patients with multiple sclerosis (MS), especially for the treatment of MS-related spasticity, new research suggests. Findings from a survey conducted through a large registry in 2020 showed that 31% of patients with MS reported trying cannabis to treat their symptoms – and 20% reported regular use.

Spasticity was reported by 80% as the reason why they used cannabis, while pain was cited as the reason by 69% and sleep problems/insomnia was cited by 61%.

Investigators noted that the new data reflect the latest patterns of use amid sweeping changes in recreational and medical marijuana laws.

“Interest in the use of cannabis for managing MS symptoms continues to increase as more data become available and access becomes easier,” co-investigator Amber Salter, PhD, associate professor, UT Southwestern Medical Center, Dallas, told attendees at the 2021 Annual Meeting of the Consortium of Multiple Sclerosis Centers (CMSC).
 

Administration routes vary

The survey was conducted through the longitudinal North American Research Committee on Multiple Sclerosis (NARCOMS) Registry, a voluntary, self-report registry for patients with MS. Of 6,934 registry participants invited to participate, 3,249 (47%) responded. The majority of responders were women (79%) and the mean age was 61 years. About 63% were being treated with disease-modifying therapies.

Overall, 31% of respondents reported having used cannabis to treat their MS symptoms. In addition, 20% reported regular current cannabis use, with an average use of 20 days in the past month. As many as 40% of the current users reported using cannabis daily.

“In general we saw some small differences in current users, who tended to include more males; have higher spasticity, pain, and sleep symptoms; and [were] more likely to be unemployed and younger,” Dr. Salter said.

The most common forms of cannabis administration were smoking (33%) and eating (20%). In addition, 12% reported vaporizing cannabis with a highly concentrated material, 11% administered cannabis sublingually, and 11% reported swallowing it.

Further, 8% reported vaporizing cannabis as a dried flower, 5% used it topically, and 1% reported drinking it.

Of note, the definition of “cannabis/marijuana” in the study excluded hemp cannabidiol (CBD) or products marketed as CBD only.
 

Consistent use

The most common reason for use by far was spasticity (80%). This was followed by for pain (69%) and sleep/insomnia problems (61%). Among users, 37% reported doing so to treat all three of those problems.

Regarding other symptoms, 36% used cannabis for anxiety, 24% for depression, 18% for overactive bladder, 17% for nausea or gastrointestinal problems, 16% for migraine or headaches, 14% for tremors, and 6% for other purposes.

The vast majority (95%) reported cannabis to be very or somewhat helpful for their symptoms.

Among the 69% of respondents who reported not using cannabis for their MS symptoms, the most commonly cited reasons were a lack of evidence on efficacy (40%) or safety (27%), concerns of legality (25%), lack of insurance coverage (22%), prohibitive cost (18%), and adverse side effects.

Surprisingly, the dramatic shift in the legalization of cannabis use in many states does not appear to be reflected in changes in cannabis use for MS, Dr. Salter said.

“We conducted an anonymous NARCOMS survey a couple of years prior to this survey, and our results are generally consistent. There’s been a small increase in the use and an acceptance or willingness to consider cannabis, but it’s relatively consistent,” she said.

“Despite the changes in access, the landscape hasn’t really changed very much in terms of evidence of the effects on MS symptoms, so that could be why,” Dr. Salter added.

Most patients appear to feel comfortable discussing their cannabis use with their physician, with 75% reporting doing so. However, the most common primary source of medical guidance for treating MS with cannabis was “nobody/self”; for 20%, the source for medical guidance was a dispensary professional.

As many as 62% of respondents reported obtaining their cannabis products from dispensaries, while other sources included family/friend (18%) or an acquaintance (13%). About 31% reported their most preferred type of cannabis to be equal parts THC and cannabidiol, while 30% preferred high THC/low cannabidiol (30%).
 

Mirrors clinical practice findings

Commenting on the study, Laura T. Safar, MD, vice chair of Psychiatry at Lahey Hospital and Medical Center and assistant professor of psychiatry at Harvard Medical School, Boston, said the findings generally fall in line with cannabis use among patients with MS in her practice.

“This is [consistent] with my general experience: A high percentage of my patients with MS are using cannabis with the goal of addressing their MS symptoms that way,” said Dr. Safar, who was not involved with the research.

One notable recent change in patients’ inquiries about cannabis is their apparent confidence in the information they’re getting, she noted. This is a sign of the ever-expanding sources of information – but from sources who may or may not have an understanding of effects in MS, she added.

“What seems new is a certain level of specificity in the information patients state – regardless of its accuracy. There is more technical information widely available about cannabis online and in the dispensaries,” said Dr. Safar.

“A lot of that information may not have been tested scientifically, but it is presented with an aura of truth,” she said.

While misconceptions about cannabis use in MS may not be new, “the conviction with which they are stated and believed seems stronger,” even though they have been validated by questionably expert sources, Dr. Safar noted.

She pointed out that psychiatric effects are among her patients’ notable concerns of cannabis use in MS.

“Cannabis use, especially daily use in moderate to large amounts, can have negative cognitive side effects,” she said. “In addition, it can have other psychiatric side effects: worsening of mood and anxiety, apathy, and anhedonia, a lack of pleasure or enjoyment, and a flattening of the emotional experience.”
 

Countering misinformation

Dr. Safar said she works to counter misinformation and provide more reliable, evidence-based recommendations.

“I educate my patients about what we know from scientific trials about the potential benefits, including possible help with pain, excluding central pain, and with spasticity,” she said. Dr. Safar added that she also discusses possible risks, such as worsening of cognition, mood, and anxiety.

On the basis of an individual’s presentation, and working in collaboration with their neurologist as appropriate, Dr. Safar said she discusses the following issues with the patient:

• Does cannabis make sense for the symptoms being presented?
• Has the patient received benefit so far?
• Are there side effects they may be experiencing?
• Would it be appropriate to lower the cannabis dose/frequency of its use?
• If a patient is using cannabis with an objective that is not backed up by the literature, such as depression, are they open to information about other treatment options?

The study was sponsored by GW Research. Dr. Salter has conducted research for GW Pharmaceuticals companies. Dr. Safar has disclosed no relevant financial relationships.

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

Use of cannabis is common in patients with multiple sclerosis (MS), especially for the treatment of MS-related spasticity, new research suggests. Findings from a survey conducted through a large registry in 2020 showed that 31% of patients with MS reported trying cannabis to treat their symptoms – and 20% reported regular use.

Spasticity was reported by 80% as the reason why they used cannabis, while pain was cited as the reason by 69% and sleep problems/insomnia was cited by 61%.

Investigators noted that the new data reflect the latest patterns of use amid sweeping changes in recreational and medical marijuana laws.

“Interest in the use of cannabis for managing MS symptoms continues to increase as more data become available and access becomes easier,” co-investigator Amber Salter, PhD, associate professor, UT Southwestern Medical Center, Dallas, told attendees at the 2021 Annual Meeting of the Consortium of Multiple Sclerosis Centers (CMSC).
 

Administration routes vary

The survey was conducted through the longitudinal North American Research Committee on Multiple Sclerosis (NARCOMS) Registry, a voluntary, self-report registry for patients with MS. Of 6,934 registry participants invited to participate, 3,249 (47%) responded. The majority of responders were women (79%) and the mean age was 61 years. About 63% were being treated with disease-modifying therapies.

Overall, 31% of respondents reported having used cannabis to treat their MS symptoms. In addition, 20% reported regular current cannabis use, with an average use of 20 days in the past month. As many as 40% of the current users reported using cannabis daily.

“In general we saw some small differences in current users, who tended to include more males; have higher spasticity, pain, and sleep symptoms; and [were] more likely to be unemployed and younger,” Dr. Salter said.

The most common forms of cannabis administration were smoking (33%) and eating (20%). In addition, 12% reported vaporizing cannabis with a highly concentrated material, 11% administered cannabis sublingually, and 11% reported swallowing it.

Further, 8% reported vaporizing cannabis as a dried flower, 5% used it topically, and 1% reported drinking it.

Of note, the definition of “cannabis/marijuana” in the study excluded hemp cannabidiol (CBD) or products marketed as CBD only.
 

Consistent use

The most common reason for use by far was spasticity (80%). This was followed by for pain (69%) and sleep/insomnia problems (61%). Among users, 37% reported doing so to treat all three of those problems.

Regarding other symptoms, 36% used cannabis for anxiety, 24% for depression, 18% for overactive bladder, 17% for nausea or gastrointestinal problems, 16% for migraine or headaches, 14% for tremors, and 6% for other purposes.

The vast majority (95%) reported cannabis to be very or somewhat helpful for their symptoms.

Among the 69% of respondents who reported not using cannabis for their MS symptoms, the most commonly cited reasons were a lack of evidence on efficacy (40%) or safety (27%), concerns of legality (25%), lack of insurance coverage (22%), prohibitive cost (18%), and adverse side effects.

Surprisingly, the dramatic shift in the legalization of cannabis use in many states does not appear to be reflected in changes in cannabis use for MS, Dr. Salter said.

“We conducted an anonymous NARCOMS survey a couple of years prior to this survey, and our results are generally consistent. There’s been a small increase in the use and an acceptance or willingness to consider cannabis, but it’s relatively consistent,” she said.

“Despite the changes in access, the landscape hasn’t really changed very much in terms of evidence of the effects on MS symptoms, so that could be why,” Dr. Salter added.

Most patients appear to feel comfortable discussing their cannabis use with their physician, with 75% reporting doing so. However, the most common primary source of medical guidance for treating MS with cannabis was “nobody/self”; for 20%, the source for medical guidance was a dispensary professional.

As many as 62% of respondents reported obtaining their cannabis products from dispensaries, while other sources included family/friend (18%) or an acquaintance (13%). About 31% reported their most preferred type of cannabis to be equal parts THC and cannabidiol, while 30% preferred high THC/low cannabidiol (30%).
 

Mirrors clinical practice findings

Commenting on the study, Laura T. Safar, MD, vice chair of Psychiatry at Lahey Hospital and Medical Center and assistant professor of psychiatry at Harvard Medical School, Boston, said the findings generally fall in line with cannabis use among patients with MS in her practice.

“This is [consistent] with my general experience: A high percentage of my patients with MS are using cannabis with the goal of addressing their MS symptoms that way,” said Dr. Safar, who was not involved with the research.

One notable recent change in patients’ inquiries about cannabis is their apparent confidence in the information they’re getting, she noted. This is a sign of the ever-expanding sources of information – but from sources who may or may not have an understanding of effects in MS, she added.

“What seems new is a certain level of specificity in the information patients state – regardless of its accuracy. There is more technical information widely available about cannabis online and in the dispensaries,” said Dr. Safar.

“A lot of that information may not have been tested scientifically, but it is presented with an aura of truth,” she said.

While misconceptions about cannabis use in MS may not be new, “the conviction with which they are stated and believed seems stronger,” even though they have been validated by questionably expert sources, Dr. Safar noted.

She pointed out that psychiatric effects are among her patients’ notable concerns of cannabis use in MS.

“Cannabis use, especially daily use in moderate to large amounts, can have negative cognitive side effects,” she said. “In addition, it can have other psychiatric side effects: worsening of mood and anxiety, apathy, and anhedonia, a lack of pleasure or enjoyment, and a flattening of the emotional experience.”
 

Countering misinformation

Dr. Safar said she works to counter misinformation and provide more reliable, evidence-based recommendations.

“I educate my patients about what we know from scientific trials about the potential benefits, including possible help with pain, excluding central pain, and with spasticity,” she said. Dr. Safar added that she also discusses possible risks, such as worsening of cognition, mood, and anxiety.

On the basis of an individual’s presentation, and working in collaboration with their neurologist as appropriate, Dr. Safar said she discusses the following issues with the patient:

• Does cannabis make sense for the symptoms being presented?
• Has the patient received benefit so far?
• Are there side effects they may be experiencing?
• Would it be appropriate to lower the cannabis dose/frequency of its use?
• If a patient is using cannabis with an objective that is not backed up by the literature, such as depression, are they open to information about other treatment options?

The study was sponsored by GW Research. Dr. Salter has conducted research for GW Pharmaceuticals companies. Dr. Safar has disclosed no relevant financial relationships.

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

Use of cannabis is common in patients with multiple sclerosis (MS), especially for the treatment of MS-related spasticity, new research suggests. Findings from a survey conducted through a large registry in 2020 showed that 31% of patients with MS reported trying cannabis to treat their symptoms – and 20% reported regular use.

Spasticity was reported by 80% as the reason why they used cannabis, while pain was cited as the reason by 69% and sleep problems/insomnia was cited by 61%.

Investigators noted that the new data reflect the latest patterns of use amid sweeping changes in recreational and medical marijuana laws.

“Interest in the use of cannabis for managing MS symptoms continues to increase as more data become available and access becomes easier,” co-investigator Amber Salter, PhD, associate professor, UT Southwestern Medical Center, Dallas, told attendees at the 2021 Annual Meeting of the Consortium of Multiple Sclerosis Centers (CMSC).
 

Administration routes vary

The survey was conducted through the longitudinal North American Research Committee on Multiple Sclerosis (NARCOMS) Registry, a voluntary, self-report registry for patients with MS. Of 6,934 registry participants invited to participate, 3,249 (47%) responded. The majority of responders were women (79%) and the mean age was 61 years. About 63% were being treated with disease-modifying therapies.

Overall, 31% of respondents reported having used cannabis to treat their MS symptoms. In addition, 20% reported regular current cannabis use, with an average use of 20 days in the past month. As many as 40% of the current users reported using cannabis daily.

“In general we saw some small differences in current users, who tended to include more males; have higher spasticity, pain, and sleep symptoms; and [were] more likely to be unemployed and younger,” Dr. Salter said.

The most common forms of cannabis administration were smoking (33%) and eating (20%). In addition, 12% reported vaporizing cannabis with a highly concentrated material, 11% administered cannabis sublingually, and 11% reported swallowing it.

Further, 8% reported vaporizing cannabis as a dried flower, 5% used it topically, and 1% reported drinking it.

Of note, the definition of “cannabis/marijuana” in the study excluded hemp cannabidiol (CBD) or products marketed as CBD only.
 

Consistent use

The most common reason for use by far was spasticity (80%). This was followed by for pain (69%) and sleep/insomnia problems (61%). Among users, 37% reported doing so to treat all three of those problems.

Regarding other symptoms, 36% used cannabis for anxiety, 24% for depression, 18% for overactive bladder, 17% for nausea or gastrointestinal problems, 16% for migraine or headaches, 14% for tremors, and 6% for other purposes.

The vast majority (95%) reported cannabis to be very or somewhat helpful for their symptoms.

Among the 69% of respondents who reported not using cannabis for their MS symptoms, the most commonly cited reasons were a lack of evidence on efficacy (40%) or safety (27%), concerns of legality (25%), lack of insurance coverage (22%), prohibitive cost (18%), and adverse side effects.

Surprisingly, the dramatic shift in the legalization of cannabis use in many states does not appear to be reflected in changes in cannabis use for MS, Dr. Salter said.

“We conducted an anonymous NARCOMS survey a couple of years prior to this survey, and our results are generally consistent. There’s been a small increase in the use and an acceptance or willingness to consider cannabis, but it’s relatively consistent,” she said.

“Despite the changes in access, the landscape hasn’t really changed very much in terms of evidence of the effects on MS symptoms, so that could be why,” Dr. Salter added.

Most patients appear to feel comfortable discussing their cannabis use with their physician, with 75% reporting doing so. However, the most common primary source of medical guidance for treating MS with cannabis was “nobody/self”; for 20%, the source for medical guidance was a dispensary professional.

As many as 62% of respondents reported obtaining their cannabis products from dispensaries, while other sources included family/friend (18%) or an acquaintance (13%). About 31% reported their most preferred type of cannabis to be equal parts THC and cannabidiol, while 30% preferred high THC/low cannabidiol (30%).
 

Mirrors clinical practice findings

Commenting on the study, Laura T. Safar, MD, vice chair of Psychiatry at Lahey Hospital and Medical Center and assistant professor of psychiatry at Harvard Medical School, Boston, said the findings generally fall in line with cannabis use among patients with MS in her practice.

“This is [consistent] with my general experience: A high percentage of my patients with MS are using cannabis with the goal of addressing their MS symptoms that way,” said Dr. Safar, who was not involved with the research.

One notable recent change in patients’ inquiries about cannabis is their apparent confidence in the information they’re getting, she noted. This is a sign of the ever-expanding sources of information – but from sources who may or may not have an understanding of effects in MS, she added.

“What seems new is a certain level of specificity in the information patients state – regardless of its accuracy. There is more technical information widely available about cannabis online and in the dispensaries,” said Dr. Safar.

“A lot of that information may not have been tested scientifically, but it is presented with an aura of truth,” she said.

While misconceptions about cannabis use in MS may not be new, “the conviction with which they are stated and believed seems stronger,” even though they have been validated by questionably expert sources, Dr. Safar noted.

She pointed out that psychiatric effects are among her patients’ notable concerns of cannabis use in MS.

“Cannabis use, especially daily use in moderate to large amounts, can have negative cognitive side effects,” she said. “In addition, it can have other psychiatric side effects: worsening of mood and anxiety, apathy, and anhedonia, a lack of pleasure or enjoyment, and a flattening of the emotional experience.”
 

Countering misinformation

Dr. Safar said she works to counter misinformation and provide more reliable, evidence-based recommendations.

“I educate my patients about what we know from scientific trials about the potential benefits, including possible help with pain, excluding central pain, and with spasticity,” she said. Dr. Safar added that she also discusses possible risks, such as worsening of cognition, mood, and anxiety.

On the basis of an individual’s presentation, and working in collaboration with their neurologist as appropriate, Dr. Safar said she discusses the following issues with the patient:

• Does cannabis make sense for the symptoms being presented?
• Has the patient received benefit so far?
• Are there side effects they may be experiencing?
• Would it be appropriate to lower the cannabis dose/frequency of its use?
• If a patient is using cannabis with an objective that is not backed up by the literature, such as depression, are they open to information about other treatment options?

The study was sponsored by GW Research. Dr. Salter has conducted research for GW Pharmaceuticals companies. Dr. Safar has disclosed no relevant financial relationships.

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

Centers for Disease Control and Prevention (CDC) Director Rochelle Walensky, MD, has endorsed a two-dose regimen of Pfizer’s lower-dose mRNA vaccine for children ages 5 through 11 years-old – meaning the shots are now available for immediate use.

The Nov. 2 decision came mere hours after experts that advise the CDC on vaccinations strongly recommended the vaccine for this age group.

“Together, with science leading the charge, we have taken another important step forward in our nation’s fight against the virus that causes COVID-19. We know millions of parents are eager to get their children vaccinated and with this decision, we now have recommended that about 28 million children receive a COVID-19 vaccine. As a mom, I encourage parents with questions to talk to their pediatrician, school nurse, or local pharmacist to learn more about the vaccine and the importance of getting their children vaccinated,” Dr. Walensky said in a prepared statement.

President Joe Biden applauded Dr. Walensky’s endorsement: “Today, we have reached a turning point in our battle against COVID-19: authorization of a safe, effective vaccine for children age 5 to 11. It will allow parents to end months of anxious worrying about their kids, and reduce the extent to which children spread the virus to others. It is a major step forward for our nation in our fight to defeat the virus,” he said in a statement.

The 14 members of the Advisory Committee on Immunization Practices (ACIP) voted unanimously earlier in the day to recommend the vaccine for kids.

“I feel like I have a responsibility to make this vaccine available to children and their parents,” said committee member Beth Bell, MD, MPH, a clinical professor at the University of Washington in Seattle. Bell noted that all evidence the committee had reviewed pointed to a vaccine that was safe and effective for younger children.

“If I had a grandchild, I would certainly get that grandchild vaccinated as soon as possible,” she said.

Their recommendations follow the U.S. Food and Drug Administration’s emergency authorization of Pfizer-BioNTech’s vaccine for this same age group last week.

“I’m voting for this because I think it could have a huge positive impact on [kids’] health and their social and emotional wellbeing,” said Grace Lee, MD, a professor of pediatrics at Stanford University School of Medicine, who chairs the CDC’s ACIP.

She noted that, though masks are available to reduce the risk for kids, they aren’t perfect and transmission still occurs.

“Vaccines are really the only consistent and reliable way to provide that protection,” Lee said.

The vaccine for children is two doses given 3 weeks apart. Each dose is 10 micrograms, which is one-third of the dose used in adults and teens.

To avoid confusion, the smaller dose for kids will come in bottles with orange labels and orange tops. The vaccine for adults is packaged in purple.

The CDC also addressed the question of kids who are close to age 12 when they get their first dose.

In general, pediatricians allow for a 4-day grace period around birthdays to determine which dose is needed. That will be the same with the COVID-19 vaccine.

For kids who are 11 when they start the series, they should get another 10-microgram dose after they turn 12 a few weeks later.

COVID-19 cases in this age group have climbed sharply over the summer and into the fall as schools have fully reopened, sometimes without the benefit of masks.

In the first week of October, roughly 10% of all COVID-19 cases recorded in the United States were among children ages 5 through 11. Since the start of pandemic, about 1.9 million children in this age group have been infected, though that’s almost certainly an undercount. More than 8,300 have been hospitalized, and 94 children have died.

Children of color have been disproportionately impacted. More than two-thirds of hospitalized children have been black or Hispanic.

Weighing benefits and risks

In clinical trials that included more than 4,600 children, the most common adverse events were pain and swelling at the injection site. They could also have side effects like fevers, fatigue, headache, chills, and sometimes swollen lymph nodes.

These kinds of side effects appear to be less common in children ages 5 to 11 than they have been in teens and adults, and they were temporary.

No cases of myocarditis or pericarditis were seen in the studies, but myocarditis is a very rare side effect, and the studies were too small to pick up these cases.

Still, doctors say they’re watching for it. In general, the greatest risk for myocarditis after vaccination has been seen in younger males between the ages of 12 and 30.

Even without COVID-19 or vaccines in the mix, doctors expect to see as many as two cases of myocarditis for every million people over the course of a week. The risk for myocarditis jumps up to about 11 cases for every million doses of mRNA vaccine given to men ages 25 to 30. It’s between 37 and 69 cases per million doses in boys between the ages of 12 and 24.

Still, experts say the possibility of this rare risk shouldn’t deter parents from vaccinating younger children.

Here’s why: The risk for myocarditis is higher after COVID-19 infection than after vaccination. Younger children have a lower risk for myocarditis than teens and young adults, suggesting that this side effect may be less frequent in this age group, although that remains to be seen.

Additionally, the smaller dose authorized for children is expected to minimize the risk for myocarditis even further.

The CDC says parents should call their doctor if a child develops pain in their chest, has trouble breathing, or feels like they have a beating or fluttering heart after vaccination.

What about benefits?

Models looking at the impact of vaccines in this age group predict that, nationally, cases would drop by about 8% if children are vaccinated.

The models also suggested that vaccination of kids this age would slow — but not stop — the emergence of new variants.

For every million doses, the CDC’s modeling predicts that more than 56,000 COVID-19 infections would be prevented in this age group, along with dozens of hospitalizations, and post-COVID conditions like multisystem inflammatory syndrome in children.

CDC experts estimate that just 10 kids would need to be vaccinated over 6 months to prevent a single case of COVID-19.

The CDC pointed out that vaccinating kids may help slow transmission of the virus and would give parents and other caregivers greater confidence in participating in school and extracurricular activities.

CDC experts said they would use a variety of systems, including hospital networks, the open Vaccines and Adverse Events Reporting System (VAERS) database, the cell-phone based V-SAFE app, and insurance claims databases to keep an eye out for any rare adverse events related to the vaccines in children.

This article, a version of which first appeared on Medscape.com, was updated on Nov. 3, 2021.

Centers for Disease Control and Prevention (CDC) Director Rochelle Walensky, MD, has endorsed a two-dose regimen of Pfizer’s lower-dose mRNA vaccine for children ages 5 through 11 years-old – meaning the shots are now available for immediate use.

The Nov. 2 decision came mere hours after experts that advise the CDC on vaccinations strongly recommended the vaccine for this age group.

“Together, with science leading the charge, we have taken another important step forward in our nation’s fight against the virus that causes COVID-19. We know millions of parents are eager to get their children vaccinated and with this decision, we now have recommended that about 28 million children receive a COVID-19 vaccine. As a mom, I encourage parents with questions to talk to their pediatrician, school nurse, or local pharmacist to learn more about the vaccine and the importance of getting their children vaccinated,” Dr. Walensky said in a prepared statement.

President Joe Biden applauded Dr. Walensky’s endorsement: “Today, we have reached a turning point in our battle against COVID-19: authorization of a safe, effective vaccine for children age 5 to 11. It will allow parents to end months of anxious worrying about their kids, and reduce the extent to which children spread the virus to others. It is a major step forward for our nation in our fight to defeat the virus,” he said in a statement.

The 14 members of the Advisory Committee on Immunization Practices (ACIP) voted unanimously earlier in the day to recommend the vaccine for kids.

“I feel like I have a responsibility to make this vaccine available to children and their parents,” said committee member Beth Bell, MD, MPH, a clinical professor at the University of Washington in Seattle. Bell noted that all evidence the committee had reviewed pointed to a vaccine that was safe and effective for younger children.

“If I had a grandchild, I would certainly get that grandchild vaccinated as soon as possible,” she said.

Their recommendations follow the U.S. Food and Drug Administration’s emergency authorization of Pfizer-BioNTech’s vaccine for this same age group last week.

“I’m voting for this because I think it could have a huge positive impact on [kids’] health and their social and emotional wellbeing,” said Grace Lee, MD, a professor of pediatrics at Stanford University School of Medicine, who chairs the CDC’s ACIP.

She noted that, though masks are available to reduce the risk for kids, they aren’t perfect and transmission still occurs.

“Vaccines are really the only consistent and reliable way to provide that protection,” Lee said.

The vaccine for children is two doses given 3 weeks apart. Each dose is 10 micrograms, which is one-third of the dose used in adults and teens.

To avoid confusion, the smaller dose for kids will come in bottles with orange labels and orange tops. The vaccine for adults is packaged in purple.

The CDC also addressed the question of kids who are close to age 12 when they get their first dose.

In general, pediatricians allow for a 4-day grace period around birthdays to determine which dose is needed. That will be the same with the COVID-19 vaccine.

For kids who are 11 when they start the series, they should get another 10-microgram dose after they turn 12 a few weeks later.

COVID-19 cases in this age group have climbed sharply over the summer and into the fall as schools have fully reopened, sometimes without the benefit of masks.

In the first week of October, roughly 10% of all COVID-19 cases recorded in the United States were among children ages 5 through 11. Since the start of pandemic, about 1.9 million children in this age group have been infected, though that’s almost certainly an undercount. More than 8,300 have been hospitalized, and 94 children have died.

Children of color have been disproportionately impacted. More than two-thirds of hospitalized children have been black or Hispanic.

Weighing benefits and risks

In clinical trials that included more than 4,600 children, the most common adverse events were pain and swelling at the injection site. They could also have side effects like fevers, fatigue, headache, chills, and sometimes swollen lymph nodes.

These kinds of side effects appear to be less common in children ages 5 to 11 than they have been in teens and adults, and they were temporary.

No cases of myocarditis or pericarditis were seen in the studies, but myocarditis is a very rare side effect, and the studies were too small to pick up these cases.

Still, doctors say they’re watching for it. In general, the greatest risk for myocarditis after vaccination has been seen in younger males between the ages of 12 and 30.

Even without COVID-19 or vaccines in the mix, doctors expect to see as many as two cases of myocarditis for every million people over the course of a week. The risk for myocarditis jumps up to about 11 cases for every million doses of mRNA vaccine given to men ages 25 to 30. It’s between 37 and 69 cases per million doses in boys between the ages of 12 and 24.

Still, experts say the possibility of this rare risk shouldn’t deter parents from vaccinating younger children.

Here’s why: The risk for myocarditis is higher after COVID-19 infection than after vaccination. Younger children have a lower risk for myocarditis than teens and young adults, suggesting that this side effect may be less frequent in this age group, although that remains to be seen.

Additionally, the smaller dose authorized for children is expected to minimize the risk for myocarditis even further.

The CDC says parents should call their doctor if a child develops pain in their chest, has trouble breathing, or feels like they have a beating or fluttering heart after vaccination.

What about benefits?

Models looking at the impact of vaccines in this age group predict that, nationally, cases would drop by about 8% if children are vaccinated.

The models also suggested that vaccination of kids this age would slow — but not stop — the emergence of new variants.

For every million doses, the CDC’s modeling predicts that more than 56,000 COVID-19 infections would be prevented in this age group, along with dozens of hospitalizations, and post-COVID conditions like multisystem inflammatory syndrome in children.

CDC experts estimate that just 10 kids would need to be vaccinated over 6 months to prevent a single case of COVID-19.

The CDC pointed out that vaccinating kids may help slow transmission of the virus and would give parents and other caregivers greater confidence in participating in school and extracurricular activities.

CDC experts said they would use a variety of systems, including hospital networks, the open Vaccines and Adverse Events Reporting System (VAERS) database, the cell-phone based V-SAFE app, and insurance claims databases to keep an eye out for any rare adverse events related to the vaccines in children.

This article, a version of which first appeared on Medscape.com, was updated on Nov. 3, 2021.

Centers for Disease Control and Prevention (CDC) Director Rochelle Walensky, MD, has endorsed a two-dose regimen of Pfizer’s lower-dose mRNA vaccine for children ages 5 through 11 years-old – meaning the shots are now available for immediate use.

The Nov. 2 decision came mere hours after experts that advise the CDC on vaccinations strongly recommended the vaccine for this age group.

“Together, with science leading the charge, we have taken another important step forward in our nation’s fight against the virus that causes COVID-19. We know millions of parents are eager to get their children vaccinated and with this decision, we now have recommended that about 28 million children receive a COVID-19 vaccine. As a mom, I encourage parents with questions to talk to their pediatrician, school nurse, or local pharmacist to learn more about the vaccine and the importance of getting their children vaccinated,” Dr. Walensky said in a prepared statement.

President Joe Biden applauded Dr. Walensky’s endorsement: “Today, we have reached a turning point in our battle against COVID-19: authorization of a safe, effective vaccine for children age 5 to 11. It will allow parents to end months of anxious worrying about their kids, and reduce the extent to which children spread the virus to others. It is a major step forward for our nation in our fight to defeat the virus,” he said in a statement.

The 14 members of the Advisory Committee on Immunization Practices (ACIP) voted unanimously earlier in the day to recommend the vaccine for kids.

“I feel like I have a responsibility to make this vaccine available to children and their parents,” said committee member Beth Bell, MD, MPH, a clinical professor at the University of Washington in Seattle. Bell noted that all evidence the committee had reviewed pointed to a vaccine that was safe and effective for younger children.

“If I had a grandchild, I would certainly get that grandchild vaccinated as soon as possible,” she said.

Their recommendations follow the U.S. Food and Drug Administration’s emergency authorization of Pfizer-BioNTech’s vaccine for this same age group last week.

“I’m voting for this because I think it could have a huge positive impact on [kids’] health and their social and emotional wellbeing,” said Grace Lee, MD, a professor of pediatrics at Stanford University School of Medicine, who chairs the CDC’s ACIP.

She noted that, though masks are available to reduce the risk for kids, they aren’t perfect and transmission still occurs.

“Vaccines are really the only consistent and reliable way to provide that protection,” Lee said.

The vaccine for children is two doses given 3 weeks apart. Each dose is 10 micrograms, which is one-third of the dose used in adults and teens.

To avoid confusion, the smaller dose for kids will come in bottles with orange labels and orange tops. The vaccine for adults is packaged in purple.

The CDC also addressed the question of kids who are close to age 12 when they get their first dose.

In general, pediatricians allow for a 4-day grace period around birthdays to determine which dose is needed. That will be the same with the COVID-19 vaccine.

For kids who are 11 when they start the series, they should get another 10-microgram dose after they turn 12 a few weeks later.

COVID-19 cases in this age group have climbed sharply over the summer and into the fall as schools have fully reopened, sometimes without the benefit of masks.

In the first week of October, roughly 10% of all COVID-19 cases recorded in the United States were among children ages 5 through 11. Since the start of pandemic, about 1.9 million children in this age group have been infected, though that’s almost certainly an undercount. More than 8,300 have been hospitalized, and 94 children have died.

Children of color have been disproportionately impacted. More than two-thirds of hospitalized children have been black or Hispanic.

Weighing benefits and risks

In clinical trials that included more than 4,600 children, the most common adverse events were pain and swelling at the injection site. They could also have side effects like fevers, fatigue, headache, chills, and sometimes swollen lymph nodes.

These kinds of side effects appear to be less common in children ages 5 to 11 than they have been in teens and adults, and they were temporary.

No cases of myocarditis or pericarditis were seen in the studies, but myocarditis is a very rare side effect, and the studies were too small to pick up these cases.

Still, doctors say they’re watching for it. In general, the greatest risk for myocarditis after vaccination has been seen in younger males between the ages of 12 and 30.

Even without COVID-19 or vaccines in the mix, doctors expect to see as many as two cases of myocarditis for every million people over the course of a week. The risk for myocarditis jumps up to about 11 cases for every million doses of mRNA vaccine given to men ages 25 to 30. It’s between 37 and 69 cases per million doses in boys between the ages of 12 and 24.

Still, experts say the possibility of this rare risk shouldn’t deter parents from vaccinating younger children.

Here’s why: The risk for myocarditis is higher after COVID-19 infection than after vaccination. Younger children have a lower risk for myocarditis than teens and young adults, suggesting that this side effect may be less frequent in this age group, although that remains to be seen.

Additionally, the smaller dose authorized for children is expected to minimize the risk for myocarditis even further.

The CDC says parents should call their doctor if a child develops pain in their chest, has trouble breathing, or feels like they have a beating or fluttering heart after vaccination.

What about benefits?

Models looking at the impact of vaccines in this age group predict that, nationally, cases would drop by about 8% if children are vaccinated.

The models also suggested that vaccination of kids this age would slow — but not stop — the emergence of new variants.

For every million doses, the CDC’s modeling predicts that more than 56,000 COVID-19 infections would be prevented in this age group, along with dozens of hospitalizations, and post-COVID conditions like multisystem inflammatory syndrome in children.

CDC experts estimate that just 10 kids would need to be vaccinated over 6 months to prevent a single case of COVID-19.

The CDC pointed out that vaccinating kids may help slow transmission of the virus and would give parents and other caregivers greater confidence in participating in school and extracurricular activities.

CDC experts said they would use a variety of systems, including hospital networks, the open Vaccines and Adverse Events Reporting System (VAERS) database, the cell-phone based V-SAFE app, and insurance claims databases to keep an eye out for any rare adverse events related to the vaccines in children.

This article, a version of which first appeared on Medscape.com, was updated on Nov. 3, 2021.