CHICAGO – Both physicians and patients like the idea of having health care delivered virtually, and telehealth will likely continue to be prominent in the U.S. medical landscape, according to the medical director for digital health and telemedicine at Johns Hopkins Medicine, Baltimore.

This physician, Brian Hasselfeld, MD, said his university’s health system did 50-80 telemedicine visits a month before COVID, during a presentation at the annual meeting of the American College of Physicians. This soared to close to 100,000 a month in the pandemic, and now the health system does close to 40,000 a month, he continued.

“Life is definitely different in how we engage with our patients on a day-to-day basis,” said Dr. Hasselfeld, who oversees the telehealth for six hospitals and 50 ambulatory-care locations in Maryland and three other states.

Attitudes gauged in Johns Hopkins surveys suggest that a lot of medical care will continue to be provided by telemedicine. Nine out of 10 patients said they would likely recommend telemedicine to friends and family, and 88% said it would be either moderately, very, or extremely important to have video visit options in the future, he said.

A survey of the Hopkins system’s 3,600 physicians, which generated about 1,300 responses, found that physicians would like to have a considerable chunk of time set aside for telemedicine visits – the median response was 30%.
 

Virtual care is in ‘early-adopter phase’

But Dr. Hasselfeld said virtual care is still in the “early-adopter phase.” While many physicians said they would like more than half of their time devoted to telehealth, a larger proportion was more likely to say they wanted very little time devoted to it, Dr. Hasselfeld said. Among those wanting to do it are some who want to do all of their visits virtually, he said.

Those who are eager to do it will be those guiding the change, Dr. Hasselfeld said.

“As we move forward – and thinking about how to optimize virtual-care options for your patients – it’s not going to be a forced issue,” he said.

Providing better access to certain patient groups continues to be a challenge. A dashboard developed at Hopkins to identify groups who are at a technological disadvantage and don’t have ready access to telemedicine found that those living in low-income zip codes, African-Americans, and those on Medicaid and Medicare tend to have higher percentages of “audio-only” visits, mainly because of lack of connectivity allowing video visits, Dr. Hasselfeld said.

The lower share of video visits in the inner city suggests that access to telemedicine isn’t just a problem in remote rural areas, as the conventional wisdom has gone, he said.

“It doesn’t matter how many towers we have in downtown Baltimore, or how much fiber we have in the ground,” he said. “If you can’t have a data plan to access that high-speed Internet, or have a home with high-speed Internet, it doesn’t matter.”

Hopkins has developed a tool to assess how likely it is that someone will have trouble connecting for a telemedicine visit – if they’ve previously had an audio-only visit, for instance – and try to get in touch with those patients shortly before a visit so that it runs smoothly, Dr. Hasselfeld said.

The explosion of telemedicine has led to the rise of companies providing care through apps on phones and tablets, he said.

“This is real care being provided to our patients through nontraditional routes, and this is a new force, one our patients see out in the marketplace,” he said. “We have to acknowledge and wrestle with the fact that convenience is a new part of what it means to [provide] access [to] care for patients.”

Heather Hirsch, MD, an internist with Brigham and Women’s Hospital in Boston, said in an interview after the session that telemedicine is poised to improve care.

“I think the good is definitely going to outweigh the bad so long as the infrastructure and the legislation will allow it,” said Dr. Hirsch, who does about half of her visits in person and half through telemedicine, which she performs while at the office. “It does allow for a lot of flexibility for both patients and providers.”

But health care at academic medical centers, she said, needs to adjust to the times.

“We need [academic medicine] for so many reasons,” she said, “but the reality is that it moves very slowly, and the old infrastructure and the slowness to catch up with technology is the worry.”

Dr. Hasselfeld reported financial relationships with Humana and TRUE-See Systems.

CHICAGO – Both physicians and patients like the idea of having health care delivered virtually, and telehealth will likely continue to be prominent in the U.S. medical landscape, according to the medical director for digital health and telemedicine at Johns Hopkins Medicine, Baltimore.

This physician, Brian Hasselfeld, MD, said his university’s health system did 50-80 telemedicine visits a month before COVID, during a presentation at the annual meeting of the American College of Physicians. This soared to close to 100,000 a month in the pandemic, and now the health system does close to 40,000 a month, he continued.

“Life is definitely different in how we engage with our patients on a day-to-day basis,” said Dr. Hasselfeld, who oversees the telehealth for six hospitals and 50 ambulatory-care locations in Maryland and three other states.

Attitudes gauged in Johns Hopkins surveys suggest that a lot of medical care will continue to be provided by telemedicine. Nine out of 10 patients said they would likely recommend telemedicine to friends and family, and 88% said it would be either moderately, very, or extremely important to have video visit options in the future, he said.

A survey of the Hopkins system’s 3,600 physicians, which generated about 1,300 responses, found that physicians would like to have a considerable chunk of time set aside for telemedicine visits – the median response was 30%.
 

Virtual care is in ‘early-adopter phase’

But Dr. Hasselfeld said virtual care is still in the “early-adopter phase.” While many physicians said they would like more than half of their time devoted to telehealth, a larger proportion was more likely to say they wanted very little time devoted to it, Dr. Hasselfeld said. Among those wanting to do it are some who want to do all of their visits virtually, he said.

Those who are eager to do it will be those guiding the change, Dr. Hasselfeld said.

“As we move forward – and thinking about how to optimize virtual-care options for your patients – it’s not going to be a forced issue,” he said.

Providing better access to certain patient groups continues to be a challenge. A dashboard developed at Hopkins to identify groups who are at a technological disadvantage and don’t have ready access to telemedicine found that those living in low-income zip codes, African-Americans, and those on Medicaid and Medicare tend to have higher percentages of “audio-only” visits, mainly because of lack of connectivity allowing video visits, Dr. Hasselfeld said.

The lower share of video visits in the inner city suggests that access to telemedicine isn’t just a problem in remote rural areas, as the conventional wisdom has gone, he said.

“It doesn’t matter how many towers we have in downtown Baltimore, or how much fiber we have in the ground,” he said. “If you can’t have a data plan to access that high-speed Internet, or have a home with high-speed Internet, it doesn’t matter.”

Hopkins has developed a tool to assess how likely it is that someone will have trouble connecting for a telemedicine visit – if they’ve previously had an audio-only visit, for instance – and try to get in touch with those patients shortly before a visit so that it runs smoothly, Dr. Hasselfeld said.

The explosion of telemedicine has led to the rise of companies providing care through apps on phones and tablets, he said.

“This is real care being provided to our patients through nontraditional routes, and this is a new force, one our patients see out in the marketplace,” he said. “We have to acknowledge and wrestle with the fact that convenience is a new part of what it means to [provide] access [to] care for patients.”

Heather Hirsch, MD, an internist with Brigham and Women’s Hospital in Boston, said in an interview after the session that telemedicine is poised to improve care.

“I think the good is definitely going to outweigh the bad so long as the infrastructure and the legislation will allow it,” said Dr. Hirsch, who does about half of her visits in person and half through telemedicine, which she performs while at the office. “It does allow for a lot of flexibility for both patients and providers.”

But health care at academic medical centers, she said, needs to adjust to the times.

“We need [academic medicine] for so many reasons,” she said, “but the reality is that it moves very slowly, and the old infrastructure and the slowness to catch up with technology is the worry.”

Dr. Hasselfeld reported financial relationships with Humana and TRUE-See Systems.

CHICAGO – Both physicians and patients like the idea of having health care delivered virtually, and telehealth will likely continue to be prominent in the U.S. medical landscape, according to the medical director for digital health and telemedicine at Johns Hopkins Medicine, Baltimore.

This physician, Brian Hasselfeld, MD, said his university’s health system did 50-80 telemedicine visits a month before COVID, during a presentation at the annual meeting of the American College of Physicians. This soared to close to 100,000 a month in the pandemic, and now the health system does close to 40,000 a month, he continued.

“Life is definitely different in how we engage with our patients on a day-to-day basis,” said Dr. Hasselfeld, who oversees the telehealth for six hospitals and 50 ambulatory-care locations in Maryland and three other states.

Attitudes gauged in Johns Hopkins surveys suggest that a lot of medical care will continue to be provided by telemedicine. Nine out of 10 patients said they would likely recommend telemedicine to friends and family, and 88% said it would be either moderately, very, or extremely important to have video visit options in the future, he said.

A survey of the Hopkins system’s 3,600 physicians, which generated about 1,300 responses, found that physicians would like to have a considerable chunk of time set aside for telemedicine visits – the median response was 30%.
 

Virtual care is in ‘early-adopter phase’

But Dr. Hasselfeld said virtual care is still in the “early-adopter phase.” While many physicians said they would like more than half of their time devoted to telehealth, a larger proportion was more likely to say they wanted very little time devoted to it, Dr. Hasselfeld said. Among those wanting to do it are some who want to do all of their visits virtually, he said.

Those who are eager to do it will be those guiding the change, Dr. Hasselfeld said.

“As we move forward – and thinking about how to optimize virtual-care options for your patients – it’s not going to be a forced issue,” he said.

Providing better access to certain patient groups continues to be a challenge. A dashboard developed at Hopkins to identify groups who are at a technological disadvantage and don’t have ready access to telemedicine found that those living in low-income zip codes, African-Americans, and those on Medicaid and Medicare tend to have higher percentages of “audio-only” visits, mainly because of lack of connectivity allowing video visits, Dr. Hasselfeld said.

The lower share of video visits in the inner city suggests that access to telemedicine isn’t just a problem in remote rural areas, as the conventional wisdom has gone, he said.

“It doesn’t matter how many towers we have in downtown Baltimore, or how much fiber we have in the ground,” he said. “If you can’t have a data plan to access that high-speed Internet, or have a home with high-speed Internet, it doesn’t matter.”

Hopkins has developed a tool to assess how likely it is that someone will have trouble connecting for a telemedicine visit – if they’ve previously had an audio-only visit, for instance – and try to get in touch with those patients shortly before a visit so that it runs smoothly, Dr. Hasselfeld said.

The explosion of telemedicine has led to the rise of companies providing care through apps on phones and tablets, he said.

“This is real care being provided to our patients through nontraditional routes, and this is a new force, one our patients see out in the marketplace,” he said. “We have to acknowledge and wrestle with the fact that convenience is a new part of what it means to [provide] access [to] care for patients.”

Heather Hirsch, MD, an internist with Brigham and Women’s Hospital in Boston, said in an interview after the session that telemedicine is poised to improve care.

“I think the good is definitely going to outweigh the bad so long as the infrastructure and the legislation will allow it,” said Dr. Hirsch, who does about half of her visits in person and half through telemedicine, which she performs while at the office. “It does allow for a lot of flexibility for both patients and providers.”

But health care at academic medical centers, she said, needs to adjust to the times.

“We need [academic medicine] for so many reasons,” she said, “but the reality is that it moves very slowly, and the old infrastructure and the slowness to catch up with technology is the worry.”

Dr. Hasselfeld reported financial relationships with Humana and TRUE-See Systems.

Just in time for Memorial Day outings, a new report on sunscreens is out.

The news isn’t all sunny. About 75% of more than 1,850 sunscreen products evaluated offer inferior sun protection or have worrisome ingredients, according to the Environmental Working Group, a nonprofit research and advocacy group that just issued its 16th annual Guide to Sunscreens.

In response, dermatologists, including the president of the American Academy of Dermatology, say that although some concerns have been raised about the safety of some sunscreen ingredients, sunscreens themselves remain an important tool in the fight against skin cancer. According to the Skin Cancer Foundation, 1 in 5 Americans will get skin cancer by age 70. Melanoma, the most deadly, has a 5-year survival rate of 99% if caught early.
 

2022 report

Overall, the Environmental Working Group found that about 1 in 4 sunscreens, or about 500 products, met their standards for providing adequate sun protection and avoiding ingredients linked to known health harms. Products meant for babies and children did slightly better, with about 1 in 3 meeting the standards. The group evaluated mineral sunscreens, also called physical sunscreens, and non-mineral sunscreens, also called chemical sunscreens. Mineral sunscreens contain zinc oxide or titanium dioxide and sit on the skin to deflect the sun’s rays. Chemical sunscreens, with ingredients such as oxybenzone or avobenzone, are partially absorbed into the skin.

Among the group’s concerns:

• The use of oxybenzone in the non-mineral sunscreens. About 30% of the non-mineral sunscreens have it, says Carla Burns, senior director for cosmetic science for the Environmental Working Group. Oxybenzone is a potential hormone disrupter and a skin sensitizer that may harm children and adults, she says. Some progress has been made, as the group found oxybenzone in 66% of the non-mineral sunscreens it reviewed in 2019. (The FDA is seeking more information on oxybenzone and many other sunscreen ingredients.)
• Contamination of sunscreens with benzene, which has been linked to leukemia and other blood disorders, according to the National Cancer Institute. But industry experts stress that that chemical is found in trace amounts in personal care products and does not pose a safety concern. “Benzene is a chemical that is ubiquitous in the environment and not an intentionally added ingredient in personal care products. People worldwide are exposed daily to benzene from indoor and outdoor sources, including air, drinking water, and food and beverages,” the Personal Care Products Council, an industry group, said in a statement.
• Protection from ultraviolet A (UVA) rays is often inadequate, according to research published last year by the Environmental Working Group.

Products on the ‘best’ list

The Environmental Working Group found that 282 recreational sunscreens met its criteria. Among them:

• Coral Safe Sunscreen Lotion, SPF 30
• Neutrogena Sheer Zinc Mineral Sunscreen Lotion, SPF 30
• Mad Hippie Facial Sunscreen Lotion, SPF 30+

The group chose 86 non-mineral sunscreens as better options, including:

• Alba Botanica Hawaiian Sunscreen Lotion, Aloe Vera, SPF 30
• Banana Boat Sport Ultra Sunscreen Stick, SPF 50+
• Black Girl Sunscreen Melanin Boosting Moisturizing Sunscreen Lotion, SPF 30

And 70 sunscreens made the kids’ best list, including:

• True Baby Everyday Play Sunscreen Lotion, SPF 30+
• Sun Biologic Kids’ Sunscreen Stick, SPF 30+
• Kiss My Face Organic Kids’ Defense Sunscreen Lotion, SPF 30

Industry response, FDA actions

In a statement, Alexandra Kowcz, chief scientist at the Personal Care Products Council, pointed out that “as part of a daily safe-sun regimen, sunscreen products help prevent sunburn and reduce skin cancer risk. It is unfortunate that as Americans spend more time outdoors, the Environmental Working Group’s (EWG) 2022 Guide to Sunscreens resorts to fear-mongering with misleading information that could keep consumers from using sunscreens altogether.”

The FDA has asked for more information about certain ingredients to further evaluate products, she says, and industry is working with the agency. The FDA says it is attempting to improve the quality, safety and effectiveness of over-the-counter sunscreen products. In September, 2021, the FDA issued a proposal for regulating OTC sunscreen products, as required under the CARES (Coronavirus Aid, Relief and Economic Security) Act. The effective date for the final order can’t be earlier than September 2022, the CARES Act says.
 

Dermatologists weigh in

“Every time something like this gets published, my patients come in hysterical,” says Michele Green, MD, a New York City dermatologist who reviewed the report for WebMD. She acknowledges that more research is needed on some sunscreen ingredients. “We really do not know the long-term consequence of oxybenzone,” she says.

Her advice: If her patients have melasma (a skin condition with brown patches on the face), she advises them to use both a chemical and a mineral sunscreen. “I don’t tell my patients in general not to use the chemical [sunscreens].”

For children, she says, the mineral sunscreens may be preferred. On her own children, who are teens, she uses the mineral sunscreens, due to possible concern about hormone disruption.

In a statement, Mark D. Kaufmann, MD, president of the American Academy of Dermatology, says that “sunscreen is an important part of a comprehensive sun protection strategy.”

Besides a broad-spectrum, water-resistant sunscreen with an SPF of 30 or higher for exposed skin, the academy recommends seeking shade and wearing sun-protective clothing to reduce skin cancer risk.

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

Just in time for Memorial Day outings, a new report on sunscreens is out.

The news isn’t all sunny. About 75% of more than 1,850 sunscreen products evaluated offer inferior sun protection or have worrisome ingredients, according to the Environmental Working Group, a nonprofit research and advocacy group that just issued its 16th annual Guide to Sunscreens.

In response, dermatologists, including the president of the American Academy of Dermatology, say that although some concerns have been raised about the safety of some sunscreen ingredients, sunscreens themselves remain an important tool in the fight against skin cancer. According to the Skin Cancer Foundation, 1 in 5 Americans will get skin cancer by age 70. Melanoma, the most deadly, has a 5-year survival rate of 99% if caught early.
 

2022 report

Overall, the Environmental Working Group found that about 1 in 4 sunscreens, or about 500 products, met their standards for providing adequate sun protection and avoiding ingredients linked to known health harms. Products meant for babies and children did slightly better, with about 1 in 3 meeting the standards. The group evaluated mineral sunscreens, also called physical sunscreens, and non-mineral sunscreens, also called chemical sunscreens. Mineral sunscreens contain zinc oxide or titanium dioxide and sit on the skin to deflect the sun’s rays. Chemical sunscreens, with ingredients such as oxybenzone or avobenzone, are partially absorbed into the skin.

Among the group’s concerns:

• The use of oxybenzone in the non-mineral sunscreens. About 30% of the non-mineral sunscreens have it, says Carla Burns, senior director for cosmetic science for the Environmental Working Group. Oxybenzone is a potential hormone disrupter and a skin sensitizer that may harm children and adults, she says. Some progress has been made, as the group found oxybenzone in 66% of the non-mineral sunscreens it reviewed in 2019. (The FDA is seeking more information on oxybenzone and many other sunscreen ingredients.)
• Contamination of sunscreens with benzene, which has been linked to leukemia and other blood disorders, according to the National Cancer Institute. But industry experts stress that that chemical is found in trace amounts in personal care products and does not pose a safety concern. “Benzene is a chemical that is ubiquitous in the environment and not an intentionally added ingredient in personal care products. People worldwide are exposed daily to benzene from indoor and outdoor sources, including air, drinking water, and food and beverages,” the Personal Care Products Council, an industry group, said in a statement.
• Protection from ultraviolet A (UVA) rays is often inadequate, according to research published last year by the Environmental Working Group.

Products on the ‘best’ list

The Environmental Working Group found that 282 recreational sunscreens met its criteria. Among them:

• Coral Safe Sunscreen Lotion, SPF 30
• Neutrogena Sheer Zinc Mineral Sunscreen Lotion, SPF 30
• Mad Hippie Facial Sunscreen Lotion, SPF 30+

The group chose 86 non-mineral sunscreens as better options, including:

• Alba Botanica Hawaiian Sunscreen Lotion, Aloe Vera, SPF 30
• Banana Boat Sport Ultra Sunscreen Stick, SPF 50+
• Black Girl Sunscreen Melanin Boosting Moisturizing Sunscreen Lotion, SPF 30

And 70 sunscreens made the kids’ best list, including:

• True Baby Everyday Play Sunscreen Lotion, SPF 30+
• Sun Biologic Kids’ Sunscreen Stick, SPF 30+
• Kiss My Face Organic Kids’ Defense Sunscreen Lotion, SPF 30

Industry response, FDA actions

In a statement, Alexandra Kowcz, chief scientist at the Personal Care Products Council, pointed out that “as part of a daily safe-sun regimen, sunscreen products help prevent sunburn and reduce skin cancer risk. It is unfortunate that as Americans spend more time outdoors, the Environmental Working Group’s (EWG) 2022 Guide to Sunscreens resorts to fear-mongering with misleading information that could keep consumers from using sunscreens altogether.”

The FDA has asked for more information about certain ingredients to further evaluate products, she says, and industry is working with the agency. The FDA says it is attempting to improve the quality, safety and effectiveness of over-the-counter sunscreen products. In September, 2021, the FDA issued a proposal for regulating OTC sunscreen products, as required under the CARES (Coronavirus Aid, Relief and Economic Security) Act. The effective date for the final order can’t be earlier than September 2022, the CARES Act says.
 

Dermatologists weigh in

“Every time something like this gets published, my patients come in hysterical,” says Michele Green, MD, a New York City dermatologist who reviewed the report for WebMD. She acknowledges that more research is needed on some sunscreen ingredients. “We really do not know the long-term consequence of oxybenzone,” she says.

Her advice: If her patients have melasma (a skin condition with brown patches on the face), she advises them to use both a chemical and a mineral sunscreen. “I don’t tell my patients in general not to use the chemical [sunscreens].”

For children, she says, the mineral sunscreens may be preferred. On her own children, who are teens, she uses the mineral sunscreens, due to possible concern about hormone disruption.

In a statement, Mark D. Kaufmann, MD, president of the American Academy of Dermatology, says that “sunscreen is an important part of a comprehensive sun protection strategy.”

Besides a broad-spectrum, water-resistant sunscreen with an SPF of 30 or higher for exposed skin, the academy recommends seeking shade and wearing sun-protective clothing to reduce skin cancer risk.

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

Just in time for Memorial Day outings, a new report on sunscreens is out.

The news isn’t all sunny. About 75% of more than 1,850 sunscreen products evaluated offer inferior sun protection or have worrisome ingredients, according to the Environmental Working Group, a nonprofit research and advocacy group that just issued its 16th annual Guide to Sunscreens.

In response, dermatologists, including the president of the American Academy of Dermatology, say that although some concerns have been raised about the safety of some sunscreen ingredients, sunscreens themselves remain an important tool in the fight against skin cancer. According to the Skin Cancer Foundation, 1 in 5 Americans will get skin cancer by age 70. Melanoma, the most deadly, has a 5-year survival rate of 99% if caught early.
 

2022 report

Overall, the Environmental Working Group found that about 1 in 4 sunscreens, or about 500 products, met their standards for providing adequate sun protection and avoiding ingredients linked to known health harms. Products meant for babies and children did slightly better, with about 1 in 3 meeting the standards. The group evaluated mineral sunscreens, also called physical sunscreens, and non-mineral sunscreens, also called chemical sunscreens. Mineral sunscreens contain zinc oxide or titanium dioxide and sit on the skin to deflect the sun’s rays. Chemical sunscreens, with ingredients such as oxybenzone or avobenzone, are partially absorbed into the skin.

Among the group’s concerns:

• The use of oxybenzone in the non-mineral sunscreens. About 30% of the non-mineral sunscreens have it, says Carla Burns, senior director for cosmetic science for the Environmental Working Group. Oxybenzone is a potential hormone disrupter and a skin sensitizer that may harm children and adults, she says. Some progress has been made, as the group found oxybenzone in 66% of the non-mineral sunscreens it reviewed in 2019. (The FDA is seeking more information on oxybenzone and many other sunscreen ingredients.)
• Contamination of sunscreens with benzene, which has been linked to leukemia and other blood disorders, according to the National Cancer Institute. But industry experts stress that that chemical is found in trace amounts in personal care products and does not pose a safety concern. “Benzene is a chemical that is ubiquitous in the environment and not an intentionally added ingredient in personal care products. People worldwide are exposed daily to benzene from indoor and outdoor sources, including air, drinking water, and food and beverages,” the Personal Care Products Council, an industry group, said in a statement.
• Protection from ultraviolet A (UVA) rays is often inadequate, according to research published last year by the Environmental Working Group.

Products on the ‘best’ list

The Environmental Working Group found that 282 recreational sunscreens met its criteria. Among them:

• Coral Safe Sunscreen Lotion, SPF 30
• Neutrogena Sheer Zinc Mineral Sunscreen Lotion, SPF 30
• Mad Hippie Facial Sunscreen Lotion, SPF 30+

The group chose 86 non-mineral sunscreens as better options, including:

• Alba Botanica Hawaiian Sunscreen Lotion, Aloe Vera, SPF 30
• Banana Boat Sport Ultra Sunscreen Stick, SPF 50+
• Black Girl Sunscreen Melanin Boosting Moisturizing Sunscreen Lotion, SPF 30

And 70 sunscreens made the kids’ best list, including:

• True Baby Everyday Play Sunscreen Lotion, SPF 30+
• Sun Biologic Kids’ Sunscreen Stick, SPF 30+
• Kiss My Face Organic Kids’ Defense Sunscreen Lotion, SPF 30

Industry response, FDA actions

In a statement, Alexandra Kowcz, chief scientist at the Personal Care Products Council, pointed out that “as part of a daily safe-sun regimen, sunscreen products help prevent sunburn and reduce skin cancer risk. It is unfortunate that as Americans spend more time outdoors, the Environmental Working Group’s (EWG) 2022 Guide to Sunscreens resorts to fear-mongering with misleading information that could keep consumers from using sunscreens altogether.”

The FDA has asked for more information about certain ingredients to further evaluate products, she says, and industry is working with the agency. The FDA says it is attempting to improve the quality, safety and effectiveness of over-the-counter sunscreen products. In September, 2021, the FDA issued a proposal for regulating OTC sunscreen products, as required under the CARES (Coronavirus Aid, Relief and Economic Security) Act. The effective date for the final order can’t be earlier than September 2022, the CARES Act says.
 

Dermatologists weigh in

“Every time something like this gets published, my patients come in hysterical,” says Michele Green, MD, a New York City dermatologist who reviewed the report for WebMD. She acknowledges that more research is needed on some sunscreen ingredients. “We really do not know the long-term consequence of oxybenzone,” she says.

Her advice: If her patients have melasma (a skin condition with brown patches on the face), she advises them to use both a chemical and a mineral sunscreen. “I don’t tell my patients in general not to use the chemical [sunscreens].”

For children, she says, the mineral sunscreens may be preferred. On her own children, who are teens, she uses the mineral sunscreens, due to possible concern about hormone disruption.

In a statement, Mark D. Kaufmann, MD, president of the American Academy of Dermatology, says that “sunscreen is an important part of a comprehensive sun protection strategy.”

Besides a broad-spectrum, water-resistant sunscreen with an SPF of 30 or higher for exposed skin, the academy recommends seeking shade and wearing sun-protective clothing to reduce skin cancer risk.

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

Counting calories, joining a gym, and taking part in exercise programs are popular methods used by people in the United Kingdom who want to shed some pounds, but they seem to be fairly ineffective strategies, according to an investigation.

A survey of adults with obesity from six countries in western Europe found that most who set out to reduce a meaningful amount of weight failed in their attempt.

The preliminary results, presented in two posters at the European Congress on Obesity, underlined the need for better support and solutions for weight management, the authors suggested.

Marc Evans, MB, BCh, a consultant physician in diabetes and endocrinology, from University Hospital, Cardiff, Wales, who led the analysis, said that, “while obesity’s impact on health is well known, our finding that a sizable proportion of adults with obesity appear at elevated risk of hospitalization or surgery due to multiple underlying illnesses, undoubtedly adds a sense of urgency to tackling Europe’s growing obesity epidemic.”

The study, which also involved analytics consultancy firm Lane Clark & Peacock, conducted a cross-sectional survey of 1,850 adults. Of those 500 were from the UK, and the remainder from France, Germany, Italy, Spain, and Sweden.

All participants had a body mass index of 30 kg/m², or higher. More specifically, 56.3%; were classified as obesity class I, 26.8% obesity class II, and 16.9% obesity class III.
 

Obesity-related conditions

In total, 25.7% of participants reported no obesity-related health conditions, 28.4% had one condition, 19.6% had two, and 26.3% had three or more. The most common comorbidities were hypertension, dyslipidemia, and type 2 diabetes.

Overall, 78.6% of respondents reported having tried to lose weight in the previous year. Asked in a questionnaire about how they had tried to achieve this, the responses indicated that the most common strategies were:

• Calorie-controlled/restricted diet (71.9%)
• Exercise program course (21.9%)
• Pharmaceutical treatment/medication (12.3%)
• Joined a gym (12%)
• Digital health app (9.7%)

Among other participants, 8.1% said they had used alternative treatments, 7.6% a weight loss service, and 2.1% cognitive-behavioral therapy.

Analysis of the survey results showed that 78% of the individuals who attempted to lose weight did not achieve a clinically meaningful loss of 5% or more of their body weight, while some actually weighed more afterward.

Exercise and restricted diet

Notably, while exercise and calorie-controlled or restricted diets were among the most popular weight-loss methods in U.K. participants, they were amongst the least successful strategies. For instance, while 26.5% of adults who controlled their diet said they had lost weight, 17.1% reported their weight had increased. For those who took part in an exercise program, 33.3% said they lost weight, but 15.5% said they gained weight.

Signing up for gym membership also scored poorly, with 27% shedding weight, compared with 32.4% who put weight on.

“Our survey results indicate that, while the majority of adults with obesity are actively trying to reduce their weight, using a variety of strategies, most are unsuccessful,” said Dr. Evans.

Further studies were needed to assess whether people who lose weight succeed in maintaining their weight loss, the authors said.

The conference posters have yet to be published in a journal but were peer reviewed by the ECO selection committee.

The studies were sponsored by Novo Nordisk, a researcher into and manufacturer of diabetes and obesity medications, and employer of several of the coauthors.

A version of this article first appeared on Medscape UK/Univadis.

Counting calories, joining a gym, and taking part in exercise programs are popular methods used by people in the United Kingdom who want to shed some pounds, but they seem to be fairly ineffective strategies, according to an investigation.

A survey of adults with obesity from six countries in western Europe found that most who set out to reduce a meaningful amount of weight failed in their attempt.

The preliminary results, presented in two posters at the European Congress on Obesity, underlined the need for better support and solutions for weight management, the authors suggested.

Marc Evans, MB, BCh, a consultant physician in diabetes and endocrinology, from University Hospital, Cardiff, Wales, who led the analysis, said that, “while obesity’s impact on health is well known, our finding that a sizable proportion of adults with obesity appear at elevated risk of hospitalization or surgery due to multiple underlying illnesses, undoubtedly adds a sense of urgency to tackling Europe’s growing obesity epidemic.”

The study, which also involved analytics consultancy firm Lane Clark & Peacock, conducted a cross-sectional survey of 1,850 adults. Of those 500 were from the UK, and the remainder from France, Germany, Italy, Spain, and Sweden.

All participants had a body mass index of 30 kg/m², or higher. More specifically, 56.3%; were classified as obesity class I, 26.8% obesity class II, and 16.9% obesity class III.
 

Obesity-related conditions

In total, 25.7% of participants reported no obesity-related health conditions, 28.4% had one condition, 19.6% had two, and 26.3% had three or more. The most common comorbidities were hypertension, dyslipidemia, and type 2 diabetes.

Overall, 78.6% of respondents reported having tried to lose weight in the previous year. Asked in a questionnaire about how they had tried to achieve this, the responses indicated that the most common strategies were:

• Calorie-controlled/restricted diet (71.9%)
• Exercise program course (21.9%)
• Pharmaceutical treatment/medication (12.3%)
• Joined a gym (12%)
• Digital health app (9.7%)

Among other participants, 8.1% said they had used alternative treatments, 7.6% a weight loss service, and 2.1% cognitive-behavioral therapy.

Analysis of the survey results showed that 78% of the individuals who attempted to lose weight did not achieve a clinically meaningful loss of 5% or more of their body weight, while some actually weighed more afterward.

Exercise and restricted diet

Notably, while exercise and calorie-controlled or restricted diets were among the most popular weight-loss methods in U.K. participants, they were amongst the least successful strategies. For instance, while 26.5% of adults who controlled their diet said they had lost weight, 17.1% reported their weight had increased. For those who took part in an exercise program, 33.3% said they lost weight, but 15.5% said they gained weight.

Signing up for gym membership also scored poorly, with 27% shedding weight, compared with 32.4% who put weight on.

“Our survey results indicate that, while the majority of adults with obesity are actively trying to reduce their weight, using a variety of strategies, most are unsuccessful,” said Dr. Evans.

Further studies were needed to assess whether people who lose weight succeed in maintaining their weight loss, the authors said.

The conference posters have yet to be published in a journal but were peer reviewed by the ECO selection committee.

The studies were sponsored by Novo Nordisk, a researcher into and manufacturer of diabetes and obesity medications, and employer of several of the coauthors.

A version of this article first appeared on Medscape UK/Univadis.

Counting calories, joining a gym, and taking part in exercise programs are popular methods used by people in the United Kingdom who want to shed some pounds, but they seem to be fairly ineffective strategies, according to an investigation.

A survey of adults with obesity from six countries in western Europe found that most who set out to reduce a meaningful amount of weight failed in their attempt.

The preliminary results, presented in two posters at the European Congress on Obesity, underlined the need for better support and solutions for weight management, the authors suggested.

Marc Evans, MB, BCh, a consultant physician in diabetes and endocrinology, from University Hospital, Cardiff, Wales, who led the analysis, said that, “while obesity’s impact on health is well known, our finding that a sizable proportion of adults with obesity appear at elevated risk of hospitalization or surgery due to multiple underlying illnesses, undoubtedly adds a sense of urgency to tackling Europe’s growing obesity epidemic.”

The study, which also involved analytics consultancy firm Lane Clark & Peacock, conducted a cross-sectional survey of 1,850 adults. Of those 500 were from the UK, and the remainder from France, Germany, Italy, Spain, and Sweden.

All participants had a body mass index of 30 kg/m², or higher. More specifically, 56.3%; were classified as obesity class I, 26.8% obesity class II, and 16.9% obesity class III.
 

Obesity-related conditions

In total, 25.7% of participants reported no obesity-related health conditions, 28.4% had one condition, 19.6% had two, and 26.3% had three or more. The most common comorbidities were hypertension, dyslipidemia, and type 2 diabetes.

Overall, 78.6% of respondents reported having tried to lose weight in the previous year. Asked in a questionnaire about how they had tried to achieve this, the responses indicated that the most common strategies were:

• Calorie-controlled/restricted diet (71.9%)
• Exercise program course (21.9%)
• Pharmaceutical treatment/medication (12.3%)
• Joined a gym (12%)
• Digital health app (9.7%)

Among other participants, 8.1% said they had used alternative treatments, 7.6% a weight loss service, and 2.1% cognitive-behavioral therapy.

Analysis of the survey results showed that 78% of the individuals who attempted to lose weight did not achieve a clinically meaningful loss of 5% or more of their body weight, while some actually weighed more afterward.

Exercise and restricted diet

Notably, while exercise and calorie-controlled or restricted diets were among the most popular weight-loss methods in U.K. participants, they were amongst the least successful strategies. For instance, while 26.5% of adults who controlled their diet said they had lost weight, 17.1% reported their weight had increased. For those who took part in an exercise program, 33.3% said they lost weight, but 15.5% said they gained weight.

Signing up for gym membership also scored poorly, with 27% shedding weight, compared with 32.4% who put weight on.

“Our survey results indicate that, while the majority of adults with obesity are actively trying to reduce their weight, using a variety of strategies, most are unsuccessful,” said Dr. Evans.

Further studies were needed to assess whether people who lose weight succeed in maintaining their weight loss, the authors said.

The conference posters have yet to be published in a journal but were peer reviewed by the ECO selection committee.

The studies were sponsored by Novo Nordisk, a researcher into and manufacturer of diabetes and obesity medications, and employer of several of the coauthors.

A version of this article first appeared on Medscape UK/Univadis.

A fertility procedure that mixes genetic material from three people to prevent couples from having children with certain debilitating and potentially fatal inherited disorders is now legal in two countries: the United Kingdom and Australia.

Australia’s senate passed a bill on March 30 amending pre-existing laws to allow the procedure in certain circumstances.

The goal of this procedure is to prevent genetic disorders caused by defective mitochondria, the power plants inside our cells that provide energy for normal growth and development. When mitochondria don’t produce any energy at all, the resulting genetic disorders are quickly fatal. When mitochondria make only a little energy, children can have severe illnesses and disabilities.

“The outcomes from this problem are really severe, and it’s highly likely that the baby will be very sick or die,” says Arthur Caplan, PhD, head of the division of medical ethics at the New York University Grossman School of Medicine.

Mitochondria have a little bit of DNA, and children inherit them from their mother. To avoid children inheriting this damaged genetic material, mitochondrial donation, also known as three-parent in vitro fertilization (IVF), takes the nucleus, which contains most of the DNA that makes us who we are, from an egg of the mother and puts it into a donated egg from a woman with healthy mitochondria.

The egg is then fertilized with sperm through IVF, and the resulting embryo has genetic material from two women and one man.

One ethical conundrum about mitochondrial donation is that any child conceived this way would inherit modified DNA and pass that along to their own children.

“I think it’s likely that we are going to go down this road to repair disease,” Dr. Caplan says. “I don’t think all genetic engineering of embryos is wrong, but we have to draw the line between enhancement versus treating disease.”

For couples who want a child that shares at least some of their own DNA, there are other ways to have a child without damaged mitochondria. One option would be genetic screening of their embryos to find healthy embryos without this defect, which would work for some women who have relatively few mitochondrial mutations. Another alternative is using a donor egg from a woman with healthy mitochondria.

Mitochondrial donation may appeal to couples who want their children to have a genetic connection to both parents, Dr. Caplan says. But prospective parents also need to be aware that this procedure is relatively new and, unlike egg donation, doesn’t have a long track record of success.

“It looks promising, but we don’t have the full safety picture yet, and we’re not going to start to get it for another decade or so,” Dr. Caplan cautions. “I do think it’s worth offering as one option, but you also have to get people to think about how important it is to have a biological child together and make sure that they understand that even if we try this technique, we don’t know the long-term outcomes for children yet.”

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

A fertility procedure that mixes genetic material from three people to prevent couples from having children with certain debilitating and potentially fatal inherited disorders is now legal in two countries: the United Kingdom and Australia.

Australia’s senate passed a bill on March 30 amending pre-existing laws to allow the procedure in certain circumstances.

The goal of this procedure is to prevent genetic disorders caused by defective mitochondria, the power plants inside our cells that provide energy for normal growth and development. When mitochondria don’t produce any energy at all, the resulting genetic disorders are quickly fatal. When mitochondria make only a little energy, children can have severe illnesses and disabilities.

“The outcomes from this problem are really severe, and it’s highly likely that the baby will be very sick or die,” says Arthur Caplan, PhD, head of the division of medical ethics at the New York University Grossman School of Medicine.

Mitochondria have a little bit of DNA, and children inherit them from their mother. To avoid children inheriting this damaged genetic material, mitochondrial donation, also known as three-parent in vitro fertilization (IVF), takes the nucleus, which contains most of the DNA that makes us who we are, from an egg of the mother and puts it into a donated egg from a woman with healthy mitochondria.

The egg is then fertilized with sperm through IVF, and the resulting embryo has genetic material from two women and one man.

One ethical conundrum about mitochondrial donation is that any child conceived this way would inherit modified DNA and pass that along to their own children.

“I think it’s likely that we are going to go down this road to repair disease,” Dr. Caplan says. “I don’t think all genetic engineering of embryos is wrong, but we have to draw the line between enhancement versus treating disease.”

For couples who want a child that shares at least some of their own DNA, there are other ways to have a child without damaged mitochondria. One option would be genetic screening of their embryos to find healthy embryos without this defect, which would work for some women who have relatively few mitochondrial mutations. Another alternative is using a donor egg from a woman with healthy mitochondria.

Mitochondrial donation may appeal to couples who want their children to have a genetic connection to both parents, Dr. Caplan says. But prospective parents also need to be aware that this procedure is relatively new and, unlike egg donation, doesn’t have a long track record of success.

“It looks promising, but we don’t have the full safety picture yet, and we’re not going to start to get it for another decade or so,” Dr. Caplan cautions. “I do think it’s worth offering as one option, but you also have to get people to think about how important it is to have a biological child together and make sure that they understand that even if we try this technique, we don’t know the long-term outcomes for children yet.”

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

A fertility procedure that mixes genetic material from three people to prevent couples from having children with certain debilitating and potentially fatal inherited disorders is now legal in two countries: the United Kingdom and Australia.

Australia’s senate passed a bill on March 30 amending pre-existing laws to allow the procedure in certain circumstances.

The goal of this procedure is to prevent genetic disorders caused by defective mitochondria, the power plants inside our cells that provide energy for normal growth and development. When mitochondria don’t produce any energy at all, the resulting genetic disorders are quickly fatal. When mitochondria make only a little energy, children can have severe illnesses and disabilities.

“The outcomes from this problem are really severe, and it’s highly likely that the baby will be very sick or die,” says Arthur Caplan, PhD, head of the division of medical ethics at the New York University Grossman School of Medicine.

Mitochondria have a little bit of DNA, and children inherit them from their mother. To avoid children inheriting this damaged genetic material, mitochondrial donation, also known as three-parent in vitro fertilization (IVF), takes the nucleus, which contains most of the DNA that makes us who we are, from an egg of the mother and puts it into a donated egg from a woman with healthy mitochondria.

The egg is then fertilized with sperm through IVF, and the resulting embryo has genetic material from two women and one man.

One ethical conundrum about mitochondrial donation is that any child conceived this way would inherit modified DNA and pass that along to their own children.

“I think it’s likely that we are going to go down this road to repair disease,” Dr. Caplan says. “I don’t think all genetic engineering of embryos is wrong, but we have to draw the line between enhancement versus treating disease.”

For couples who want a child that shares at least some of their own DNA, there are other ways to have a child without damaged mitochondria. One option would be genetic screening of their embryos to find healthy embryos without this defect, which would work for some women who have relatively few mitochondrial mutations. Another alternative is using a donor egg from a woman with healthy mitochondria.

Mitochondrial donation may appeal to couples who want their children to have a genetic connection to both parents, Dr. Caplan says. But prospective parents also need to be aware that this procedure is relatively new and, unlike egg donation, doesn’t have a long track record of success.

“It looks promising, but we don’t have the full safety picture yet, and we’re not going to start to get it for another decade or so,” Dr. Caplan cautions. “I do think it’s worth offering as one option, but you also have to get people to think about how important it is to have a biological child together and make sure that they understand that even if we try this technique, we don’t know the long-term outcomes for children yet.”

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

Heart failure (HF) is one of the leading causes of hospitalizations and the most expensive Medicare diagnosis. Its prevalence continues to rise with a projected increase of 46% from 2012 to 2030 resulting in > 8 million people aged ≥ 18 years with HF in the United States. Despite improvements in therapy, mortality remains unacceptably high with a 50% mortality rate within 5 years. Early detection strategies are needed to identify patients at risk of developing HF to delay the disease course and improve survival.^1,2

Emerging data indicates that natriuretic peptide biomarker-based screening using B-type natriuretic peptide (BNP) or N-terminal pro-B-type natriuretic peptide (NT-proBNP) and early intervention for patients at risk of HF could prevent development of left ventricular dysfunction or new-onset HF.^3-5 The 2013 St. Vincent’s Screening to Prevent Heart Failure (STOP-HF) trial is the largest study to date to evaluate BNP as a screening tool for patients at risk for HF.⁴ Patients at risk of HF who did not have established left ventricular systolic dysfunction or symptomatic HF were assigned randomly to usual primary care or BNP screening. Patients with BNP levels ≥ 50 pg/mL underwent echocardiogram and were referred to a cardiovascular specialty service for management. The cardiovascular specialty clinic included a team of registered nurses, nurse practitioners, pharmacists, dieticians, palliative care specialists, and cardiologists. Individuals in the intervention group showed increased renin-angiotensin system (RAS) inhibitor use at follow-up (control, 49.6%; intervention, 59.6%; P = .01). All patients received coaching by a nurse who emphasized individual risk, importance of medication adherence, and healthy lifestyle behaviors. After a mean follow-up of 4.2 years, 59 of 677 participants (8.7%) in the control group and 37 of 697 (5.3%) in the intervention group (odds ratio [OR], 0.55; 95% CI, 0.37 to 0.82; P = .003) met the primary end point of left ventricular dysfunction with or without HF. BNP-based screening in conjunction with collaborative care reduced rates of left ventricular dysfunction and HF.

In the 2013 PONTIAC trial, patients with type 2 diabetes mellitus (T2DM) without cardiac disease but with NT-proBNP levels > 125 pg/mL were randomized to usual diabetes care or intensified care at a cardiac outpatient clinic for initiation and increase of RAS inhibitors and β blockers.⁵ After 2 years, patients randomized to the intensified care group showed a 65% risk reduction of the primary endpoint of hospitalization or death from cardiac disease (P = .04).

Based on this evidence, the 2017 focused update of the American College of Cardiology (ACC)/American Heart Association (AHA)/Heart Failure Society of America (HFSA) guideline for managing HF added a IIa recommendation for natriuretic peptide biomarker screening in those at risk of developing HF.⁶ The guideline recommends biomarker screening in conjunction with team-based care, including a cardiovascular specialist, and guideline-directed management and therapy to prevent development of left ventricular dysfunction or new-onset HF.

Although ordering a natriuretic peptide biomarker laboratory test is straightforward, the variability of team-based care across institutions and health systems makes it difficult to standardize screening and interventions for patients at risk for HF. We developed and piloted a process using clinical pharmacists in primary care for natriuretic peptide biomarker screening and risk factor reduction within the established patient aligned care team (PACT) framework at a US Department of Veterans Affairs (VA) medical center. In this paper, we describe our implementation process including descriptive preliminary outcomes.

Methods

The PACT team-based approach in primary care clinics is similar to the patient-centered medical home framework. A PACT includes the veteran patient and an interdisciplinary team of health professionals composed of their primary care practitioner (PCP), registered nurse care manager, clinical pharmacist, and other clinical and administrative staff. The PACT clinical pharmacist has prescriptive authority within a scope of practice to provide postdiagnostic chronic disease state management including management of T2DM, hypertension, HF, chronic obstructive pulmonary disease, anticoagulation, tobacco cessation, and atherosclerotic cardiovascular disease (ASCVD) risk reduction. Clinical pharmacists can prescribe and adjust medications and order laboratory tests.

Our institution, Clement J. Zablocki VA Medical Center (CJZVAMC) in Milwaukee, Wisconsin, has a specialty HF clinic that primarily manages ACC/AHA Stage C HF patients. The HF clinic uses a team-based approach to collaborate and coordinate care for the veteran. The HF team is comprised of cardiology specialists, registered nurses, clinical pharmacists, dietitians, and administrative staff. Two PACT clinical pharmacists also staff the HF clinic at CJZVAMC and work collaboratively to initiate, adjust, and optimize veterans’ HF medication regimens.

Two primary care PACT panels were selected for this project. Before implementation, a pharmacy resident and 3 PACT clinical pharmacists (2 of whom also staff the HF clinic) met with a HF cardiology specialist and 2 PACT PCPs to finalize the team-based process and workflow. PCPs were presented with the evidence-based background, purpose, and project design, which included patient identification, NT-proBNP laboratory test ordering, medication adjustment schedules, and protocol for ordering echocardiograms (Figure). Templated notes were created to allow for consistent documentation in patients’ electronic health record. A telephone script also was written for the initial telephone call to patients to explain in patient-friendly terms the implications of an elevated NT-proBNP level, the echocardiogram procedure, and recommendations for risk reduction.

Patient Selection

Patients aged ≥ 18 years with hypertension, taking antihypertensive medication for ≥ 1 month, or diagnosed with T2DM for ≥ 6 months were included. Using the parameters provided in the STOP-HF trial, patients with evidence or history of left ventricular dysfunction, defined as a left ventricular ejection fraction (EF) < 50% or an E/e’ ratio > 15 in the setting of normal EF, or symptomatic HF were excluded. Patients with a diagnosis causing life expectancy < 1 year were excluded, which was determined based on review of the patient’s chart or discussion with the PCP.

A clinical pharmacist screened patients with an upcoming PCP appointment between September 2019 and January 2020 for eligibility. For patients who met criteria, the clinical pharmacist ordered a NT-proBNP laboratory test to their already scheduled tests and entered a templated note into the patient’s chart to alert the PCP of the test. NT-proBNP was used rather than BNP because it was the natriuretic peptide laboratory test available at CJZVAMC during this time. Patients with NT-proBNP < 125 pg/mL received usual care from their PCPs. Patients with NT-proBNP ≥ 125 pg/mL received a follow-up phone call from a clinical pharmacist to discuss the laboratory test result with recommendations for initiation or increase of RAS inhibitors and an echocardiogram. If the patient agreed to an echocardiogram, the PCP was notified to order the test. For patients aged > 80 years with elevated NT-proBNP, risk vs benefit and patient-specific goals of care were discussed with the PCP. For patients whose echocardiograms revealed left ventricular dysfunction, initiation or adjustment of β blockers was considered. During RAS inhibitor increase, the clinical pharmacists provided a review of the patient’s risk factors and optimized management of hypertension, T2DM, ASCVD risk reduction, oral nonsteroidal anti-inflammatory drug (NSAID) reduction, and tobacco cessation.

Outcome Measures

Outcome measures included the percentage of patients who met inclusion/exclusion criteria and had an elevated NT-proBNP level, percent change in RAS inhibitor prescriptions and optimized dosing after intervention, frequency of left ventricular dysfunction visualized with echocardiograms, and quantification of pharmacist interventions in disease state management. Descriptive statistics were used to analyze demographic data, RAS inhibitors prescriptions before and after intervention, echocardiogram results, pharmacist recommendations, and acceptance rates of disease state management.

Results

Between September 2019 and January 2020, 570 patients from 2 PACT teams were screened. Of the 570 patients, 246 met inclusion criteria with upcoming appointments. Of these, 24 were excluded, 10 for EF < 50%, 13 for E/e’ > 15 in setting of normal EF, and 1 for hypertension diagnosis without an antihypertensive regimen or elevated blood pressure. The remaining 222 patients had an NT-proBNP level ordered and drawn and 73 (32.9%) patients had an NT-proBNP ≥ 125 pg/mL. Baseline characteristics are described in Table 1.

Data was collected through March 2020 (due to COVID-19) found that among the 73 patients with elevated NT-proBNP: 14 had an echocardiogram within the past year without evidence of left ventricular dysfunction; 39 had echocardiograms ordered; and 19 had echocardiograms completed by March 2020. Among the 19 echocardiograms, 16 (84%) showed no evidence of left ventricular dysfunction, 2 (11%) revealed mildly reduced EF (40% to 50%), and 1 (5%) revealed a reduced EF (< 40%). These patients were identified early in the disease course before symptom onset and received intervention with RAS inhibitors and disease state management.

Patients prescribed RAS inhibitors increased from 44 to 50. The number of patients who were able to have their RAS inhibitor dosage adjusted increased from 28 to 31. For the 3 patients with mildly reduced or reduced EF, management with β blockers was based on RAS inhibitor adjustment toleration. One patient with mildly reduced EF was switched from metoprolol tartrate to metoprolol succinate.

Discussion

We included patients diagnosed with T2DM and hypertension for several reasons. Most patients (62%) studied in the STOP-HF trial were diagnosed with hypertension. Also, T2DM represented the patient population enrolled in the PONTIAC trial. Guidance from the European Society of Cardiology recommends use of natriuretic peptides in high-risk populations, such as patients with DM and hypertension, to help target initiation of preventive measures.⁷ Lastly, T2DM and hypertension patients were easily identified using population management software available at the VA.

The percentage of patients in this project with risk factors for HF and an elevated NT-proBNP were similar to the elevated levels described in the STOP-HF trial. In our project, 32.9% of patients had elevated NT-proBNP levels, similar to the 41.6% of patients in STOP-HF. Among the completed echocardiograms, 16% revealed mildly reduced or reduced EF. These patients were identified early in the disease course before symptom onset and received intervention with RAS inhibitors and disease state management.

In addition to early identification of reduced EF, this project allowed a targeted approach to identifying patients for risk factor reduction. Between the 2 PACT teams, 246 patients with T2DM and/or hypertension were seen from September 2019 to January 2020. By using natriuretic peptide screening, the clinical pharmacists were able to prioritize and focus risk factor management on patients at higher risk. Pharmacists were then able to intervene for all risk factors assessed: hypertension, T2DM, ASCVD risk reduction, NSAID use reduction, and tobacco cessation.

During the implementation period, VA criteria of use of the angiotensin receptor-neprilysin inhibitor, sacubitril/valsartan, was restricted to VA cardiology. For patients with reduced EF, it was up to the PCP’s discretion to consult cardiology for further follow-up. In November 2020, the VA removed the restriction to cardiology and PCPs were able to order sacubitril/valsartan. Although not included in the Figure at the time of project implementation, the clinical pharmacist could now transition a patient with reduced EF from a RAS inhibitor to sacubitril/valsartan and adjust to target dosages.

Limitations

Participants were identified initially through a computer-generated list of patients with hypertension or T2DM without a HF diagnosis documented in their problem list. This problem list is manually updated by PCPs. Although we reviewed records for exclusion criteria, eligible patients might have been excluded. The use and interpretation of an NT-proBNP level is not specific to cardiac disease. Elevations can be seen with increased age, kidney dysfunction, and pulmonary disease. Additionally, an NT-proBNP level might be falsely low in patients who are overweight or obese. Because of the relatively short period of time, we could not analyze associations with HF diagnosis or progression, hospitalizations due to HF, or mortality. Regarding external validity, because of the pre-established interdisciplinary clinic settings and VA pharmacists’ scope of practice with prescriptive authority, implementing this project might have been better received by PCPs and allowed for higher acceptance rates of pharmacist interventions at the VA compared with a community setting.

Conclusions

The ACC/AHA/HFSA guidelines recommended use of natriuretic peptide biomarker screening in conjunction with team-based care for those at risk of developing HF. We describe our process for implementing team-based care using clinical pharmacists in primary care. Our process provides a targeted approach to identifying patients for risk factor reduction through comprehensive medication management and could be replicated by other primary care clinics using a patient-centered medical home model.

Acknowledgments

We would like to acknowledge Dr. Sara Hariman, Dr. Payal Sanghani, and Dr. Cecilia Scholcoff for their support and collaboration with the project.

Heart failure (HF) is one of the leading causes of hospitalizations and the most expensive Medicare diagnosis. Its prevalence continues to rise with a projected increase of 46% from 2012 to 2030 resulting in > 8 million people aged ≥ 18 years with HF in the United States. Despite improvements in therapy, mortality remains unacceptably high with a 50% mortality rate within 5 years. Early detection strategies are needed to identify patients at risk of developing HF to delay the disease course and improve survival.^1,2

Emerging data indicates that natriuretic peptide biomarker-based screening using B-type natriuretic peptide (BNP) or N-terminal pro-B-type natriuretic peptide (NT-proBNP) and early intervention for patients at risk of HF could prevent development of left ventricular dysfunction or new-onset HF.^3-5 The 2013 St. Vincent’s Screening to Prevent Heart Failure (STOP-HF) trial is the largest study to date to evaluate BNP as a screening tool for patients at risk for HF.⁴ Patients at risk of HF who did not have established left ventricular systolic dysfunction or symptomatic HF were assigned randomly to usual primary care or BNP screening. Patients with BNP levels ≥ 50 pg/mL underwent echocardiogram and were referred to a cardiovascular specialty service for management. The cardiovascular specialty clinic included a team of registered nurses, nurse practitioners, pharmacists, dieticians, palliative care specialists, and cardiologists. Individuals in the intervention group showed increased renin-angiotensin system (RAS) inhibitor use at follow-up (control, 49.6%; intervention, 59.6%; P = .01). All patients received coaching by a nurse who emphasized individual risk, importance of medication adherence, and healthy lifestyle behaviors. After a mean follow-up of 4.2 years, 59 of 677 participants (8.7%) in the control group and 37 of 697 (5.3%) in the intervention group (odds ratio [OR], 0.55; 95% CI, 0.37 to 0.82; P = .003) met the primary end point of left ventricular dysfunction with or without HF. BNP-based screening in conjunction with collaborative care reduced rates of left ventricular dysfunction and HF.

In the 2013 PONTIAC trial, patients with type 2 diabetes mellitus (T2DM) without cardiac disease but with NT-proBNP levels > 125 pg/mL were randomized to usual diabetes care or intensified care at a cardiac outpatient clinic for initiation and increase of RAS inhibitors and β blockers.⁵ After 2 years, patients randomized to the intensified care group showed a 65% risk reduction of the primary endpoint of hospitalization or death from cardiac disease (P = .04).

Based on this evidence, the 2017 focused update of the American College of Cardiology (ACC)/American Heart Association (AHA)/Heart Failure Society of America (HFSA) guideline for managing HF added a IIa recommendation for natriuretic peptide biomarker screening in those at risk of developing HF.⁶ The guideline recommends biomarker screening in conjunction with team-based care, including a cardiovascular specialist, and guideline-directed management and therapy to prevent development of left ventricular dysfunction or new-onset HF.

Although ordering a natriuretic peptide biomarker laboratory test is straightforward, the variability of team-based care across institutions and health systems makes it difficult to standardize screening and interventions for patients at risk for HF. We developed and piloted a process using clinical pharmacists in primary care for natriuretic peptide biomarker screening and risk factor reduction within the established patient aligned care team (PACT) framework at a US Department of Veterans Affairs (VA) medical center. In this paper, we describe our implementation process including descriptive preliminary outcomes.

Methods

The PACT team-based approach in primary care clinics is similar to the patient-centered medical home framework. A PACT includes the veteran patient and an interdisciplinary team of health professionals composed of their primary care practitioner (PCP), registered nurse care manager, clinical pharmacist, and other clinical and administrative staff. The PACT clinical pharmacist has prescriptive authority within a scope of practice to provide postdiagnostic chronic disease state management including management of T2DM, hypertension, HF, chronic obstructive pulmonary disease, anticoagulation, tobacco cessation, and atherosclerotic cardiovascular disease (ASCVD) risk reduction. Clinical pharmacists can prescribe and adjust medications and order laboratory tests.

Our institution, Clement J. Zablocki VA Medical Center (CJZVAMC) in Milwaukee, Wisconsin, has a specialty HF clinic that primarily manages ACC/AHA Stage C HF patients. The HF clinic uses a team-based approach to collaborate and coordinate care for the veteran. The HF team is comprised of cardiology specialists, registered nurses, clinical pharmacists, dietitians, and administrative staff. Two PACT clinical pharmacists also staff the HF clinic at CJZVAMC and work collaboratively to initiate, adjust, and optimize veterans’ HF medication regimens.

Two primary care PACT panels were selected for this project. Before implementation, a pharmacy resident and 3 PACT clinical pharmacists (2 of whom also staff the HF clinic) met with a HF cardiology specialist and 2 PACT PCPs to finalize the team-based process and workflow. PCPs were presented with the evidence-based background, purpose, and project design, which included patient identification, NT-proBNP laboratory test ordering, medication adjustment schedules, and protocol for ordering echocardiograms (Figure). Templated notes were created to allow for consistent documentation in patients’ electronic health record. A telephone script also was written for the initial telephone call to patients to explain in patient-friendly terms the implications of an elevated NT-proBNP level, the echocardiogram procedure, and recommendations for risk reduction.

Patient Selection

Patients aged ≥ 18 years with hypertension, taking antihypertensive medication for ≥ 1 month, or diagnosed with T2DM for ≥ 6 months were included. Using the parameters provided in the STOP-HF trial, patients with evidence or history of left ventricular dysfunction, defined as a left ventricular ejection fraction (EF) < 50% or an E/e’ ratio > 15 in the setting of normal EF, or symptomatic HF were excluded. Patients with a diagnosis causing life expectancy < 1 year were excluded, which was determined based on review of the patient’s chart or discussion with the PCP.

A clinical pharmacist screened patients with an upcoming PCP appointment between September 2019 and January 2020 for eligibility. For patients who met criteria, the clinical pharmacist ordered a NT-proBNP laboratory test to their already scheduled tests and entered a templated note into the patient’s chart to alert the PCP of the test. NT-proBNP was used rather than BNP because it was the natriuretic peptide laboratory test available at CJZVAMC during this time. Patients with NT-proBNP < 125 pg/mL received usual care from their PCPs. Patients with NT-proBNP ≥ 125 pg/mL received a follow-up phone call from a clinical pharmacist to discuss the laboratory test result with recommendations for initiation or increase of RAS inhibitors and an echocardiogram. If the patient agreed to an echocardiogram, the PCP was notified to order the test. For patients aged > 80 years with elevated NT-proBNP, risk vs benefit and patient-specific goals of care were discussed with the PCP. For patients whose echocardiograms revealed left ventricular dysfunction, initiation or adjustment of β blockers was considered. During RAS inhibitor increase, the clinical pharmacists provided a review of the patient’s risk factors and optimized management of hypertension, T2DM, ASCVD risk reduction, oral nonsteroidal anti-inflammatory drug (NSAID) reduction, and tobacco cessation.

Outcome Measures

Outcome measures included the percentage of patients who met inclusion/exclusion criteria and had an elevated NT-proBNP level, percent change in RAS inhibitor prescriptions and optimized dosing after intervention, frequency of left ventricular dysfunction visualized with echocardiograms, and quantification of pharmacist interventions in disease state management. Descriptive statistics were used to analyze demographic data, RAS inhibitors prescriptions before and after intervention, echocardiogram results, pharmacist recommendations, and acceptance rates of disease state management.

Results

Between September 2019 and January 2020, 570 patients from 2 PACT teams were screened. Of the 570 patients, 246 met inclusion criteria with upcoming appointments. Of these, 24 were excluded, 10 for EF < 50%, 13 for E/e’ > 15 in setting of normal EF, and 1 for hypertension diagnosis without an antihypertensive regimen or elevated blood pressure. The remaining 222 patients had an NT-proBNP level ordered and drawn and 73 (32.9%) patients had an NT-proBNP ≥ 125 pg/mL. Baseline characteristics are described in Table 1.

Data was collected through March 2020 (due to COVID-19) found that among the 73 patients with elevated NT-proBNP: 14 had an echocardiogram within the past year without evidence of left ventricular dysfunction; 39 had echocardiograms ordered; and 19 had echocardiograms completed by March 2020. Among the 19 echocardiograms, 16 (84%) showed no evidence of left ventricular dysfunction, 2 (11%) revealed mildly reduced EF (40% to 50%), and 1 (5%) revealed a reduced EF (< 40%). These patients were identified early in the disease course before symptom onset and received intervention with RAS inhibitors and disease state management.

Patients prescribed RAS inhibitors increased from 44 to 50. The number of patients who were able to have their RAS inhibitor dosage adjusted increased from 28 to 31. For the 3 patients with mildly reduced or reduced EF, management with β blockers was based on RAS inhibitor adjustment toleration. One patient with mildly reduced EF was switched from metoprolol tartrate to metoprolol succinate.

Discussion

We included patients diagnosed with T2DM and hypertension for several reasons. Most patients (62%) studied in the STOP-HF trial were diagnosed with hypertension. Also, T2DM represented the patient population enrolled in the PONTIAC trial. Guidance from the European Society of Cardiology recommends use of natriuretic peptides in high-risk populations, such as patients with DM and hypertension, to help target initiation of preventive measures.⁷ Lastly, T2DM and hypertension patients were easily identified using population management software available at the VA.

The percentage of patients in this project with risk factors for HF and an elevated NT-proBNP were similar to the elevated levels described in the STOP-HF trial. In our project, 32.9% of patients had elevated NT-proBNP levels, similar to the 41.6% of patients in STOP-HF. Among the completed echocardiograms, 16% revealed mildly reduced or reduced EF. These patients were identified early in the disease course before symptom onset and received intervention with RAS inhibitors and disease state management.

In addition to early identification of reduced EF, this project allowed a targeted approach to identifying patients for risk factor reduction. Between the 2 PACT teams, 246 patients with T2DM and/or hypertension were seen from September 2019 to January 2020. By using natriuretic peptide screening, the clinical pharmacists were able to prioritize and focus risk factor management on patients at higher risk. Pharmacists were then able to intervene for all risk factors assessed: hypertension, T2DM, ASCVD risk reduction, NSAID use reduction, and tobacco cessation.

During the implementation period, VA criteria of use of the angiotensin receptor-neprilysin inhibitor, sacubitril/valsartan, was restricted to VA cardiology. For patients with reduced EF, it was up to the PCP’s discretion to consult cardiology for further follow-up. In November 2020, the VA removed the restriction to cardiology and PCPs were able to order sacubitril/valsartan. Although not included in the Figure at the time of project implementation, the clinical pharmacist could now transition a patient with reduced EF from a RAS inhibitor to sacubitril/valsartan and adjust to target dosages.

Limitations

Participants were identified initially through a computer-generated list of patients with hypertension or T2DM without a HF diagnosis documented in their problem list. This problem list is manually updated by PCPs. Although we reviewed records for exclusion criteria, eligible patients might have been excluded. The use and interpretation of an NT-proBNP level is not specific to cardiac disease. Elevations can be seen with increased age, kidney dysfunction, and pulmonary disease. Additionally, an NT-proBNP level might be falsely low in patients who are overweight or obese. Because of the relatively short period of time, we could not analyze associations with HF diagnosis or progression, hospitalizations due to HF, or mortality. Regarding external validity, because of the pre-established interdisciplinary clinic settings and VA pharmacists’ scope of practice with prescriptive authority, implementing this project might have been better received by PCPs and allowed for higher acceptance rates of pharmacist interventions at the VA compared with a community setting.

Conclusions

The ACC/AHA/HFSA guidelines recommended use of natriuretic peptide biomarker screening in conjunction with team-based care for those at risk of developing HF. We describe our process for implementing team-based care using clinical pharmacists in primary care. Our process provides a targeted approach to identifying patients for risk factor reduction through comprehensive medication management and could be replicated by other primary care clinics using a patient-centered medical home model.

Acknowledgments

We would like to acknowledge Dr. Sara Hariman, Dr. Payal Sanghani, and Dr. Cecilia Scholcoff for their support and collaboration with the project.

Heart failure (HF) is one of the leading causes of hospitalizations and the most expensive Medicare diagnosis. Its prevalence continues to rise with a projected increase of 46% from 2012 to 2030 resulting in > 8 million people aged ≥ 18 years with HF in the United States. Despite improvements in therapy, mortality remains unacceptably high with a 50% mortality rate within 5 years. Early detection strategies are needed to identify patients at risk of developing HF to delay the disease course and improve survival.^1,2

Emerging data indicates that natriuretic peptide biomarker-based screening using B-type natriuretic peptide (BNP) or N-terminal pro-B-type natriuretic peptide (NT-proBNP) and early intervention for patients at risk of HF could prevent development of left ventricular dysfunction or new-onset HF.^3-5 The 2013 St. Vincent’s Screening to Prevent Heart Failure (STOP-HF) trial is the largest study to date to evaluate BNP as a screening tool for patients at risk for HF.⁴ Patients at risk of HF who did not have established left ventricular systolic dysfunction or symptomatic HF were assigned randomly to usual primary care or BNP screening. Patients with BNP levels ≥ 50 pg/mL underwent echocardiogram and were referred to a cardiovascular specialty service for management. The cardiovascular specialty clinic included a team of registered nurses, nurse practitioners, pharmacists, dieticians, palliative care specialists, and cardiologists. Individuals in the intervention group showed increased renin-angiotensin system (RAS) inhibitor use at follow-up (control, 49.6%; intervention, 59.6%; P = .01). All patients received coaching by a nurse who emphasized individual risk, importance of medication adherence, and healthy lifestyle behaviors. After a mean follow-up of 4.2 years, 59 of 677 participants (8.7%) in the control group and 37 of 697 (5.3%) in the intervention group (odds ratio [OR], 0.55; 95% CI, 0.37 to 0.82; P = .003) met the primary end point of left ventricular dysfunction with or without HF. BNP-based screening in conjunction with collaborative care reduced rates of left ventricular dysfunction and HF.

In the 2013 PONTIAC trial, patients with type 2 diabetes mellitus (T2DM) without cardiac disease but with NT-proBNP levels > 125 pg/mL were randomized to usual diabetes care or intensified care at a cardiac outpatient clinic for initiation and increase of RAS inhibitors and β blockers.⁵ After 2 years, patients randomized to the intensified care group showed a 65% risk reduction of the primary endpoint of hospitalization or death from cardiac disease (P = .04).

Based on this evidence, the 2017 focused update of the American College of Cardiology (ACC)/American Heart Association (AHA)/Heart Failure Society of America (HFSA) guideline for managing HF added a IIa recommendation for natriuretic peptide biomarker screening in those at risk of developing HF.⁶ The guideline recommends biomarker screening in conjunction with team-based care, including a cardiovascular specialist, and guideline-directed management and therapy to prevent development of left ventricular dysfunction or new-onset HF.

Although ordering a natriuretic peptide biomarker laboratory test is straightforward, the variability of team-based care across institutions and health systems makes it difficult to standardize screening and interventions for patients at risk for HF. We developed and piloted a process using clinical pharmacists in primary care for natriuretic peptide biomarker screening and risk factor reduction within the established patient aligned care team (PACT) framework at a US Department of Veterans Affairs (VA) medical center. In this paper, we describe our implementation process including descriptive preliminary outcomes.

Methods

The PACT team-based approach in primary care clinics is similar to the patient-centered medical home framework. A PACT includes the veteran patient and an interdisciplinary team of health professionals composed of their primary care practitioner (PCP), registered nurse care manager, clinical pharmacist, and other clinical and administrative staff. The PACT clinical pharmacist has prescriptive authority within a scope of practice to provide postdiagnostic chronic disease state management including management of T2DM, hypertension, HF, chronic obstructive pulmonary disease, anticoagulation, tobacco cessation, and atherosclerotic cardiovascular disease (ASCVD) risk reduction. Clinical pharmacists can prescribe and adjust medications and order laboratory tests.

Our institution, Clement J. Zablocki VA Medical Center (CJZVAMC) in Milwaukee, Wisconsin, has a specialty HF clinic that primarily manages ACC/AHA Stage C HF patients. The HF clinic uses a team-based approach to collaborate and coordinate care for the veteran. The HF team is comprised of cardiology specialists, registered nurses, clinical pharmacists, dietitians, and administrative staff. Two PACT clinical pharmacists also staff the HF clinic at CJZVAMC and work collaboratively to initiate, adjust, and optimize veterans’ HF medication regimens.

Two primary care PACT panels were selected for this project. Before implementation, a pharmacy resident and 3 PACT clinical pharmacists (2 of whom also staff the HF clinic) met with a HF cardiology specialist and 2 PACT PCPs to finalize the team-based process and workflow. PCPs were presented with the evidence-based background, purpose, and project design, which included patient identification, NT-proBNP laboratory test ordering, medication adjustment schedules, and protocol for ordering echocardiograms (Figure). Templated notes were created to allow for consistent documentation in patients’ electronic health record. A telephone script also was written for the initial telephone call to patients to explain in patient-friendly terms the implications of an elevated NT-proBNP level, the echocardiogram procedure, and recommendations for risk reduction.

Patient Selection

Patients aged ≥ 18 years with hypertension, taking antihypertensive medication for ≥ 1 month, or diagnosed with T2DM for ≥ 6 months were included. Using the parameters provided in the STOP-HF trial, patients with evidence or history of left ventricular dysfunction, defined as a left ventricular ejection fraction (EF) < 50% or an E/e’ ratio > 15 in the setting of normal EF, or symptomatic HF were excluded. Patients with a diagnosis causing life expectancy < 1 year were excluded, which was determined based on review of the patient’s chart or discussion with the PCP.

A clinical pharmacist screened patients with an upcoming PCP appointment between September 2019 and January 2020 for eligibility. For patients who met criteria, the clinical pharmacist ordered a NT-proBNP laboratory test to their already scheduled tests and entered a templated note into the patient’s chart to alert the PCP of the test. NT-proBNP was used rather than BNP because it was the natriuretic peptide laboratory test available at CJZVAMC during this time. Patients with NT-proBNP < 125 pg/mL received usual care from their PCPs. Patients with NT-proBNP ≥ 125 pg/mL received a follow-up phone call from a clinical pharmacist to discuss the laboratory test result with recommendations for initiation or increase of RAS inhibitors and an echocardiogram. If the patient agreed to an echocardiogram, the PCP was notified to order the test. For patients aged > 80 years with elevated NT-proBNP, risk vs benefit and patient-specific goals of care were discussed with the PCP. For patients whose echocardiograms revealed left ventricular dysfunction, initiation or adjustment of β blockers was considered. During RAS inhibitor increase, the clinical pharmacists provided a review of the patient’s risk factors and optimized management of hypertension, T2DM, ASCVD risk reduction, oral nonsteroidal anti-inflammatory drug (NSAID) reduction, and tobacco cessation.

Outcome Measures

Outcome measures included the percentage of patients who met inclusion/exclusion criteria and had an elevated NT-proBNP level, percent change in RAS inhibitor prescriptions and optimized dosing after intervention, frequency of left ventricular dysfunction visualized with echocardiograms, and quantification of pharmacist interventions in disease state management. Descriptive statistics were used to analyze demographic data, RAS inhibitors prescriptions before and after intervention, echocardiogram results, pharmacist recommendations, and acceptance rates of disease state management.

Results

Between September 2019 and January 2020, 570 patients from 2 PACT teams were screened. Of the 570 patients, 246 met inclusion criteria with upcoming appointments. Of these, 24 were excluded, 10 for EF < 50%, 13 for E/e’ > 15 in setting of normal EF, and 1 for hypertension diagnosis without an antihypertensive regimen or elevated blood pressure. The remaining 222 patients had an NT-proBNP level ordered and drawn and 73 (32.9%) patients had an NT-proBNP ≥ 125 pg/mL. Baseline characteristics are described in Table 1.

Data was collected through March 2020 (due to COVID-19) found that among the 73 patients with elevated NT-proBNP: 14 had an echocardiogram within the past year without evidence of left ventricular dysfunction; 39 had echocardiograms ordered; and 19 had echocardiograms completed by March 2020. Among the 19 echocardiograms, 16 (84%) showed no evidence of left ventricular dysfunction, 2 (11%) revealed mildly reduced EF (40% to 50%), and 1 (5%) revealed a reduced EF (< 40%). These patients were identified early in the disease course before symptom onset and received intervention with RAS inhibitors and disease state management.

Patients prescribed RAS inhibitors increased from 44 to 50. The number of patients who were able to have their RAS inhibitor dosage adjusted increased from 28 to 31. For the 3 patients with mildly reduced or reduced EF, management with β blockers was based on RAS inhibitor adjustment toleration. One patient with mildly reduced EF was switched from metoprolol tartrate to metoprolol succinate.

Discussion

We included patients diagnosed with T2DM and hypertension for several reasons. Most patients (62%) studied in the STOP-HF trial were diagnosed with hypertension. Also, T2DM represented the patient population enrolled in the PONTIAC trial. Guidance from the European Society of Cardiology recommends use of natriuretic peptides in high-risk populations, such as patients with DM and hypertension, to help target initiation of preventive measures.⁷ Lastly, T2DM and hypertension patients were easily identified using population management software available at the VA.

The percentage of patients in this project with risk factors for HF and an elevated NT-proBNP were similar to the elevated levels described in the STOP-HF trial. In our project, 32.9% of patients had elevated NT-proBNP levels, similar to the 41.6% of patients in STOP-HF. Among the completed echocardiograms, 16% revealed mildly reduced or reduced EF. These patients were identified early in the disease course before symptom onset and received intervention with RAS inhibitors and disease state management.

In addition to early identification of reduced EF, this project allowed a targeted approach to identifying patients for risk factor reduction. Between the 2 PACT teams, 246 patients with T2DM and/or hypertension were seen from September 2019 to January 2020. By using natriuretic peptide screening, the clinical pharmacists were able to prioritize and focus risk factor management on patients at higher risk. Pharmacists were then able to intervene for all risk factors assessed: hypertension, T2DM, ASCVD risk reduction, NSAID use reduction, and tobacco cessation.

During the implementation period, VA criteria of use of the angiotensin receptor-neprilysin inhibitor, sacubitril/valsartan, was restricted to VA cardiology. For patients with reduced EF, it was up to the PCP’s discretion to consult cardiology for further follow-up. In November 2020, the VA removed the restriction to cardiology and PCPs were able to order sacubitril/valsartan. Although not included in the Figure at the time of project implementation, the clinical pharmacist could now transition a patient with reduced EF from a RAS inhibitor to sacubitril/valsartan and adjust to target dosages.

Limitations

Participants were identified initially through a computer-generated list of patients with hypertension or T2DM without a HF diagnosis documented in their problem list. This problem list is manually updated by PCPs. Although we reviewed records for exclusion criteria, eligible patients might have been excluded. The use and interpretation of an NT-proBNP level is not specific to cardiac disease. Elevations can be seen with increased age, kidney dysfunction, and pulmonary disease. Additionally, an NT-proBNP level might be falsely low in patients who are overweight or obese. Because of the relatively short period of time, we could not analyze associations with HF diagnosis or progression, hospitalizations due to HF, or mortality. Regarding external validity, because of the pre-established interdisciplinary clinic settings and VA pharmacists’ scope of practice with prescriptive authority, implementing this project might have been better received by PCPs and allowed for higher acceptance rates of pharmacist interventions at the VA compared with a community setting.

Conclusions

The ACC/AHA/HFSA guidelines recommended use of natriuretic peptide biomarker screening in conjunction with team-based care for those at risk of developing HF. We describe our process for implementing team-based care using clinical pharmacists in primary care. Our process provides a targeted approach to identifying patients for risk factor reduction through comprehensive medication management and could be replicated by other primary care clinics using a patient-centered medical home model.

Acknowledgments

We would like to acknowledge Dr. Sara Hariman, Dr. Payal Sanghani, and Dr. Cecilia Scholcoff for their support and collaboration with the project.

 A new toolkit provides coping strategies for people who are anxious about climate change. These strategies include volunteering, building a community, discussing emotions with others, practicing mindfulness, and seeking therapy.

The toolkit, which was developed by nursing experts at the University of British Columbia in Vancouver, also offers reflection questions and a film with diverse voices for people to examine their values, emotions, and behaviors in relation to the environment.

“Many people have a hard time understanding the relationship between climate change and mental health and are experiencing high levels of stress about climate change,” Natania Abebe, MSN/MPH, RN, a registered nurse and graduate student at UBC who developed the toolkit, told this news organization.

“Youth, in particular, appear to have higher levels of consciousness regarding climate change because they’re the ones who are going to inherit the planet,” she said. “A big part of why they have mental health issues is that they feel trapped in sociopolitical structures that they didn’t agree to and didn’t necessarily create.”

The toolkit was published online on April 20.

Empowering agents for change

Ms. Abebe was inspired to create the toolkit after giving guest lectures on climate change and mental health as part of UBC’s Nursing 290 course. Her faculty advisor, Raluca Radu, MSN, a lecturer in the School of Nursing at UBC, developed the course in 2020 to teach students about the broad impacts of climate change on communities.

As the course has grown during the past 2 years, Ms. Abebe wanted to create a coping framework and engaging film for health educators to use with students, as well as for everyday people.

The toolkit includes contributions from three Canadian climate change experts, as well as six students from different backgrounds who have taken the course.

“I wanted to center the voices of youth and empower them to think they can be agents for change,” Ms. Abebe said. “I also wanted to highlight diverse voices and take a collaborative approach because climate change is such a big problem that we have to come together to address it.”

Ms. Abebe and Ms. Radu also noticed an increase in climate anxiety in recent years because of the pandemic, worldwide food and energy shortages, and extreme weather events that hit close to home, such as wildfires and floods in British Columbia.

“With the pandemic, people have been spending more time online and thinking about our world at large,” Ms. Abebe said. “At the same time that they’re thinking about it, climate change events are happening simultaneously – not in the future, but right now.”

Economic, social, and political shifts during the past 2 years have also prompted people to question standard practices and institutions, which has created an opportunity to discuss change, Ms. Radu told this news organization.

“It’s a pivotal time to question our values and highly consumerist society,” she said. “We’re at a point in time where, if we don’t take action, the planetary health will be in an irreversible state, and we won’t be able to turn back time and make changes.”

Our psyches and nature

The toolkit includes three main sections that feature video clips and reflective questions around eco-anxiety, eco-paralysis, and ecological grief.

In the first section, eco-anxiety is defined as a “chronic fear of environmental doom,” which could include anxiousness around the likelihood of a severe weather event because of ongoing news coverage and social media. The reflective questions prompt readers to discuss eco-anxiety in their life, work through their emotions, understand their beliefs and values, and determine how to use them to address climate change anxiety.

The second section defines eco-paralysis as the powerlessness that people may feel when they don’t believe they can do anything meaningful on an individual level to address climate change. Paralysis can look like apathy, complacency, or disengagement. The questions prompt readers to observe how paralysis may show up in their lives, explore the tension between individual versus collective responsibility, and consider ways to address their sense of helplessness about climate change.

In the third section, ecological grief centers around “experienced or anticipated ecological losses,” which could include the loss of species, ecosystems, and landscapes because of short- or long-term environmental change. The questions prompt readers to explore their feelings, beliefs, and values and feel empowered to address their ecological grief over climate change.

The toolkit also includes recommendations for books, journal articles, websites, podcasts, and meditations around mental health and climate change, as well as ways to get involved with others. For instance, health care practitioners can register with PaRx, a program in British Columbia that allows providers to prescribe time in nature to improve a client’s health. The program is being adopted across Canada, and people with a prescription can visit local and national parks, historic sites, and marine conservation areas for free.

“This is about recognizing that there is a connection between our psyches and nature, and by talking about it, we can name what we’re feeling,” Ms. Abebe said. “We can take action not only to handle our emotions, but also to live kinder and more sustainable lifestyles.”

Future work will need to focus on population-level approaches to climate change and mental health as well, including policy and financial support to address environmental changes directly.

“We need to start thinking beyond individualized approaches and focus on how to create supportive and resilient communities to respond to climate change,” Kiffer Card, PhD, executive director of the Mental Health and Climate Change Alliance and an assistant professor of health sciences at Simon Fraser University, Burnaby, B.C., told this news organization.

Dr. Card, who wasn’t involved in developing the toolkit, has researched recent trends around climate change anxiety in Canada and fielded questions from health care practitioners and mental health professionals who are looking for ways to help their patients.

“Communities need to be ready to stand up and respond to acute emergency disasters, and government leaders need to take this seriously,” he said. “Those who are experiencing climate anxiety now are the canaries in the coal mine for the severe weather events and consequences to come.”

The toolkit was developed with funding from the Alma Mater Society of the University of British Columbia, Vancouver. Ms. Abebe, Ms. Radu, and Dr. Card reported no relevant disclosures.

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

 A new toolkit provides coping strategies for people who are anxious about climate change. These strategies include volunteering, building a community, discussing emotions with others, practicing mindfulness, and seeking therapy.

The toolkit, which was developed by nursing experts at the University of British Columbia in Vancouver, also offers reflection questions and a film with diverse voices for people to examine their values, emotions, and behaviors in relation to the environment.

“Many people have a hard time understanding the relationship between climate change and mental health and are experiencing high levels of stress about climate change,” Natania Abebe, MSN/MPH, RN, a registered nurse and graduate student at UBC who developed the toolkit, told this news organization.

“Youth, in particular, appear to have higher levels of consciousness regarding climate change because they’re the ones who are going to inherit the planet,” she said. “A big part of why they have mental health issues is that they feel trapped in sociopolitical structures that they didn’t agree to and didn’t necessarily create.”

The toolkit was published online on April 20.

Empowering agents for change

Ms. Abebe was inspired to create the toolkit after giving guest lectures on climate change and mental health as part of UBC’s Nursing 290 course. Her faculty advisor, Raluca Radu, MSN, a lecturer in the School of Nursing at UBC, developed the course in 2020 to teach students about the broad impacts of climate change on communities.

As the course has grown during the past 2 years, Ms. Abebe wanted to create a coping framework and engaging film for health educators to use with students, as well as for everyday people.

The toolkit includes contributions from three Canadian climate change experts, as well as six students from different backgrounds who have taken the course.

“I wanted to center the voices of youth and empower them to think they can be agents for change,” Ms. Abebe said. “I also wanted to highlight diverse voices and take a collaborative approach because climate change is such a big problem that we have to come together to address it.”

Ms. Abebe and Ms. Radu also noticed an increase in climate anxiety in recent years because of the pandemic, worldwide food and energy shortages, and extreme weather events that hit close to home, such as wildfires and floods in British Columbia.

“With the pandemic, people have been spending more time online and thinking about our world at large,” Ms. Abebe said. “At the same time that they’re thinking about it, climate change events are happening simultaneously – not in the future, but right now.”

Economic, social, and political shifts during the past 2 years have also prompted people to question standard practices and institutions, which has created an opportunity to discuss change, Ms. Radu told this news organization.

“It’s a pivotal time to question our values and highly consumerist society,” she said. “We’re at a point in time where, if we don’t take action, the planetary health will be in an irreversible state, and we won’t be able to turn back time and make changes.”

Our psyches and nature

The toolkit includes three main sections that feature video clips and reflective questions around eco-anxiety, eco-paralysis, and ecological grief.

In the first section, eco-anxiety is defined as a “chronic fear of environmental doom,” which could include anxiousness around the likelihood of a severe weather event because of ongoing news coverage and social media. The reflective questions prompt readers to discuss eco-anxiety in their life, work through their emotions, understand their beliefs and values, and determine how to use them to address climate change anxiety.

The second section defines eco-paralysis as the powerlessness that people may feel when they don’t believe they can do anything meaningful on an individual level to address climate change. Paralysis can look like apathy, complacency, or disengagement. The questions prompt readers to observe how paralysis may show up in their lives, explore the tension between individual versus collective responsibility, and consider ways to address their sense of helplessness about climate change.

In the third section, ecological grief centers around “experienced or anticipated ecological losses,” which could include the loss of species, ecosystems, and landscapes because of short- or long-term environmental change. The questions prompt readers to explore their feelings, beliefs, and values and feel empowered to address their ecological grief over climate change.

The toolkit also includes recommendations for books, journal articles, websites, podcasts, and meditations around mental health and climate change, as well as ways to get involved with others. For instance, health care practitioners can register with PaRx, a program in British Columbia that allows providers to prescribe time in nature to improve a client’s health. The program is being adopted across Canada, and people with a prescription can visit local and national parks, historic sites, and marine conservation areas for free.

“This is about recognizing that there is a connection between our psyches and nature, and by talking about it, we can name what we’re feeling,” Ms. Abebe said. “We can take action not only to handle our emotions, but also to live kinder and more sustainable lifestyles.”

Future work will need to focus on population-level approaches to climate change and mental health as well, including policy and financial support to address environmental changes directly.

“We need to start thinking beyond individualized approaches and focus on how to create supportive and resilient communities to respond to climate change,” Kiffer Card, PhD, executive director of the Mental Health and Climate Change Alliance and an assistant professor of health sciences at Simon Fraser University, Burnaby, B.C., told this news organization.

Dr. Card, who wasn’t involved in developing the toolkit, has researched recent trends around climate change anxiety in Canada and fielded questions from health care practitioners and mental health professionals who are looking for ways to help their patients.

“Communities need to be ready to stand up and respond to acute emergency disasters, and government leaders need to take this seriously,” he said. “Those who are experiencing climate anxiety now are the canaries in the coal mine for the severe weather events and consequences to come.”

The toolkit was developed with funding from the Alma Mater Society of the University of British Columbia, Vancouver. Ms. Abebe, Ms. Radu, and Dr. Card reported no relevant disclosures.

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

 A new toolkit provides coping strategies for people who are anxious about climate change. These strategies include volunteering, building a community, discussing emotions with others, practicing mindfulness, and seeking therapy.

The toolkit, which was developed by nursing experts at the University of British Columbia in Vancouver, also offers reflection questions and a film with diverse voices for people to examine their values, emotions, and behaviors in relation to the environment.

“Many people have a hard time understanding the relationship between climate change and mental health and are experiencing high levels of stress about climate change,” Natania Abebe, MSN/MPH, RN, a registered nurse and graduate student at UBC who developed the toolkit, told this news organization.

“Youth, in particular, appear to have higher levels of consciousness regarding climate change because they’re the ones who are going to inherit the planet,” she said. “A big part of why they have mental health issues is that they feel trapped in sociopolitical structures that they didn’t agree to and didn’t necessarily create.”

The toolkit was published online on April 20.

Empowering agents for change

Ms. Abebe was inspired to create the toolkit after giving guest lectures on climate change and mental health as part of UBC’s Nursing 290 course. Her faculty advisor, Raluca Radu, MSN, a lecturer in the School of Nursing at UBC, developed the course in 2020 to teach students about the broad impacts of climate change on communities.

As the course has grown during the past 2 years, Ms. Abebe wanted to create a coping framework and engaging film for health educators to use with students, as well as for everyday people.

The toolkit includes contributions from three Canadian climate change experts, as well as six students from different backgrounds who have taken the course.

“I wanted to center the voices of youth and empower them to think they can be agents for change,” Ms. Abebe said. “I also wanted to highlight diverse voices and take a collaborative approach because climate change is such a big problem that we have to come together to address it.”

Ms. Abebe and Ms. Radu also noticed an increase in climate anxiety in recent years because of the pandemic, worldwide food and energy shortages, and extreme weather events that hit close to home, such as wildfires and floods in British Columbia.

“With the pandemic, people have been spending more time online and thinking about our world at large,” Ms. Abebe said. “At the same time that they’re thinking about it, climate change events are happening simultaneously – not in the future, but right now.”

Economic, social, and political shifts during the past 2 years have also prompted people to question standard practices and institutions, which has created an opportunity to discuss change, Ms. Radu told this news organization.

“It’s a pivotal time to question our values and highly consumerist society,” she said. “We’re at a point in time where, if we don’t take action, the planetary health will be in an irreversible state, and we won’t be able to turn back time and make changes.”

Our psyches and nature

The toolkit includes three main sections that feature video clips and reflective questions around eco-anxiety, eco-paralysis, and ecological grief.

In the first section, eco-anxiety is defined as a “chronic fear of environmental doom,” which could include anxiousness around the likelihood of a severe weather event because of ongoing news coverage and social media. The reflective questions prompt readers to discuss eco-anxiety in their life, work through their emotions, understand their beliefs and values, and determine how to use them to address climate change anxiety.

The second section defines eco-paralysis as the powerlessness that people may feel when they don’t believe they can do anything meaningful on an individual level to address climate change. Paralysis can look like apathy, complacency, or disengagement. The questions prompt readers to observe how paralysis may show up in their lives, explore the tension between individual versus collective responsibility, and consider ways to address their sense of helplessness about climate change.

In the third section, ecological grief centers around “experienced or anticipated ecological losses,” which could include the loss of species, ecosystems, and landscapes because of short- or long-term environmental change. The questions prompt readers to explore their feelings, beliefs, and values and feel empowered to address their ecological grief over climate change.

The toolkit also includes recommendations for books, journal articles, websites, podcasts, and meditations around mental health and climate change, as well as ways to get involved with others. For instance, health care practitioners can register with PaRx, a program in British Columbia that allows providers to prescribe time in nature to improve a client’s health. The program is being adopted across Canada, and people with a prescription can visit local and national parks, historic sites, and marine conservation areas for free.

“This is about recognizing that there is a connection between our psyches and nature, and by talking about it, we can name what we’re feeling,” Ms. Abebe said. “We can take action not only to handle our emotions, but also to live kinder and more sustainable lifestyles.”

Future work will need to focus on population-level approaches to climate change and mental health as well, including policy and financial support to address environmental changes directly.

“We need to start thinking beyond individualized approaches and focus on how to create supportive and resilient communities to respond to climate change,” Kiffer Card, PhD, executive director of the Mental Health and Climate Change Alliance and an assistant professor of health sciences at Simon Fraser University, Burnaby, B.C., told this news organization.

Dr. Card, who wasn’t involved in developing the toolkit, has researched recent trends around climate change anxiety in Canada and fielded questions from health care practitioners and mental health professionals who are looking for ways to help their patients.

“Communities need to be ready to stand up and respond to acute emergency disasters, and government leaders need to take this seriously,” he said. “Those who are experiencing climate anxiety now are the canaries in the coal mine for the severe weather events and consequences to come.”

The toolkit was developed with funding from the Alma Mater Society of the University of British Columbia, Vancouver. Ms. Abebe, Ms. Radu, and Dr. Card reported no relevant disclosures.

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

The U.S. Food and Drug Administration has approved two vonoprazan-based treatments for Helicobacter pylori infection: Voquezna Triple Pak (vonoprazan, amoxicillin, clarithromycin) and Voquezna Dual Pak (vonoprazan, amoxicillin), both from Phathom Pharmaceuticals.

Vonoprazan is an oral potassium-competitive acid blocker and “the first innovative acid suppressant from a new drug class approved in the United States in over 30 years,” the company said in a news release announcing the approval.

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

The U.S. Food and Drug Administration has approved two vonoprazan-based treatments for Helicobacter pylori infection: Voquezna Triple Pak (vonoprazan, amoxicillin, clarithromycin) and Voquezna Dual Pak (vonoprazan, amoxicillin), both from Phathom Pharmaceuticals.

Vonoprazan is an oral potassium-competitive acid blocker and “the first innovative acid suppressant from a new drug class approved in the United States in over 30 years,” the company said in a news release announcing the approval.

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

The U.S. Food and Drug Administration has approved two vonoprazan-based treatments for Helicobacter pylori infection: Voquezna Triple Pak (vonoprazan, amoxicillin, clarithromycin) and Voquezna Dual Pak (vonoprazan, amoxicillin), both from Phathom Pharmaceuticals.

Vonoprazan is an oral potassium-competitive acid blocker and “the first innovative acid suppressant from a new drug class approved in the United States in over 30 years,” the company said in a news release announcing the approval.

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

Tuberculosis cases are increasing in Washington, which has put public health officials on “heightened alert,” according to a recent announcement from the Washington State Department of Health.

Widespread disruptions in health care and missed tuberculosis diagnoses during the COVID-19 pandemic have likely added to the increase – both locally and globally.

“It’s been 20 years since we saw a cluster of TB cases like this,” Tao Sheng Kwan-Gett, MD, the state’s chief science officer, said in the announcement.

“The pandemic has likely contributed to the rise in cases and the outbreak in at least one correctional facility,” he said. “Increased access to TB testing and treatment in the community is going to be key to getting TB under control.”

Case numbers appeared to fall in Washington during the first year of the pandemic, possibly because of less reporting and missed diagnoses. But in 2021, cases rose quickly. The state reported 199 cases, marking a 22% increase from 2020.

So far this year, 70 cases have been reported, including 17 new cases that all have connections with each other and several state prisons.

The state’s Department of Corrections, Department of Health, and the Centers for Disease Control and Prevention are working together on testing and decreasing spread, MaryAnn Curl, MD, the chief medical officer for the Department of Corrections, said in the statement.

Tuberculosis cases are increasing worldwide. For the first time in more than a decade, TB deaths increased to about 1.5 million, according to the World Health Organization’s 2021 Global Tuberculosis Report.

Across the U.S., the number of reported TB cases significantly declined at the beginning of the pandemic in 2020 but increased again in 2021, according to a recent CDC study.

The Kansas Department of Health also reported an outbreak of TB cases in March, according to USA Today.

At the beginning of the pandemic, some people with TB may have been diagnosed with COVID-19 because both are infectious diseases that attack the lungs and have similar symptoms, the Washington Health Department said.

Like COVID-19, tuberculosis can spread through the air when an infected person coughs or sneezes. But unlike COVID-19, TB typically requires that you have prolonged exposure to become infected.

Symptoms of tuberculosis can include chest pain and coughing, with or without blood, as well as fever, night sweats, weight loss, and fatigue.

Tuberculosis is preventable, treatable, and curable, the Washington Health Department said. Those who travel to countries where TB is more common face higher risks for exposure, as well as those who live or work in settings where TB may spread, such as homeless shelters, prisons, jails, and nursing homes.

People can develop inactive TB, also called latent TB, which doesn’t have any symptoms and isn’t contagious. If people with inactive TB don’t get quick diagnosis or treatment, the infection can become active TB and cause symptoms. State health officials estimated that about 200,000 people in Washington have inactive TB.

Tuberculosis treatment can take a minimum of 6 months, and if it’s not followed carefully, symptoms can become more severe, the Health Department said. Incomplete treatment can also contribute to the spread of antibiotic-resistant strains of tuberculosis.

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

Tuberculosis cases are increasing in Washington, which has put public health officials on “heightened alert,” according to a recent announcement from the Washington State Department of Health.

Widespread disruptions in health care and missed tuberculosis diagnoses during the COVID-19 pandemic have likely added to the increase – both locally and globally.

“It’s been 20 years since we saw a cluster of TB cases like this,” Tao Sheng Kwan-Gett, MD, the state’s chief science officer, said in the announcement.

“The pandemic has likely contributed to the rise in cases and the outbreak in at least one correctional facility,” he said. “Increased access to TB testing and treatment in the community is going to be key to getting TB under control.”

Case numbers appeared to fall in Washington during the first year of the pandemic, possibly because of less reporting and missed diagnoses. But in 2021, cases rose quickly. The state reported 199 cases, marking a 22% increase from 2020.

So far this year, 70 cases have been reported, including 17 new cases that all have connections with each other and several state prisons.

The state’s Department of Corrections, Department of Health, and the Centers for Disease Control and Prevention are working together on testing and decreasing spread, MaryAnn Curl, MD, the chief medical officer for the Department of Corrections, said in the statement.

Tuberculosis cases are increasing worldwide. For the first time in more than a decade, TB deaths increased to about 1.5 million, according to the World Health Organization’s 2021 Global Tuberculosis Report.

Across the U.S., the number of reported TB cases significantly declined at the beginning of the pandemic in 2020 but increased again in 2021, according to a recent CDC study.

The Kansas Department of Health also reported an outbreak of TB cases in March, according to USA Today.

At the beginning of the pandemic, some people with TB may have been diagnosed with COVID-19 because both are infectious diseases that attack the lungs and have similar symptoms, the Washington Health Department said.

Like COVID-19, tuberculosis can spread through the air when an infected person coughs or sneezes. But unlike COVID-19, TB typically requires that you have prolonged exposure to become infected.

Symptoms of tuberculosis can include chest pain and coughing, with or without blood, as well as fever, night sweats, weight loss, and fatigue.

Tuberculosis is preventable, treatable, and curable, the Washington Health Department said. Those who travel to countries where TB is more common face higher risks for exposure, as well as those who live or work in settings where TB may spread, such as homeless shelters, prisons, jails, and nursing homes.

People can develop inactive TB, also called latent TB, which doesn’t have any symptoms and isn’t contagious. If people with inactive TB don’t get quick diagnosis or treatment, the infection can become active TB and cause symptoms. State health officials estimated that about 200,000 people in Washington have inactive TB.

Tuberculosis treatment can take a minimum of 6 months, and if it’s not followed carefully, symptoms can become more severe, the Health Department said. Incomplete treatment can also contribute to the spread of antibiotic-resistant strains of tuberculosis.

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

Tuberculosis cases are increasing in Washington, which has put public health officials on “heightened alert,” according to a recent announcement from the Washington State Department of Health.

Widespread disruptions in health care and missed tuberculosis diagnoses during the COVID-19 pandemic have likely added to the increase – both locally and globally.

“It’s been 20 years since we saw a cluster of TB cases like this,” Tao Sheng Kwan-Gett, MD, the state’s chief science officer, said in the announcement.

“The pandemic has likely contributed to the rise in cases and the outbreak in at least one correctional facility,” he said. “Increased access to TB testing and treatment in the community is going to be key to getting TB under control.”

Case numbers appeared to fall in Washington during the first year of the pandemic, possibly because of less reporting and missed diagnoses. But in 2021, cases rose quickly. The state reported 199 cases, marking a 22% increase from 2020.

So far this year, 70 cases have been reported, including 17 new cases that all have connections with each other and several state prisons.

The state’s Department of Corrections, Department of Health, and the Centers for Disease Control and Prevention are working together on testing and decreasing spread, MaryAnn Curl, MD, the chief medical officer for the Department of Corrections, said in the statement.

Tuberculosis cases are increasing worldwide. For the first time in more than a decade, TB deaths increased to about 1.5 million, according to the World Health Organization’s 2021 Global Tuberculosis Report.

Across the U.S., the number of reported TB cases significantly declined at the beginning of the pandemic in 2020 but increased again in 2021, according to a recent CDC study.

The Kansas Department of Health also reported an outbreak of TB cases in March, according to USA Today.

At the beginning of the pandemic, some people with TB may have been diagnosed with COVID-19 because both are infectious diseases that attack the lungs and have similar symptoms, the Washington Health Department said.

Like COVID-19, tuberculosis can spread through the air when an infected person coughs or sneezes. But unlike COVID-19, TB typically requires that you have prolonged exposure to become infected.

Symptoms of tuberculosis can include chest pain and coughing, with or without blood, as well as fever, night sweats, weight loss, and fatigue.

Tuberculosis is preventable, treatable, and curable, the Washington Health Department said. Those who travel to countries where TB is more common face higher risks for exposure, as well as those who live or work in settings where TB may spread, such as homeless shelters, prisons, jails, and nursing homes.

People can develop inactive TB, also called latent TB, which doesn’t have any symptoms and isn’t contagious. If people with inactive TB don’t get quick diagnosis or treatment, the infection can become active TB and cause symptoms. State health officials estimated that about 200,000 people in Washington have inactive TB.

Tuberculosis treatment can take a minimum of 6 months, and if it’s not followed carefully, symptoms can become more severe, the Health Department said. Incomplete treatment can also contribute to the spread of antibiotic-resistant strains of tuberculosis.

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

Children who have greater acute appendicitis pain may be less likely to improve if they’re treated with antibiotics alone, according to a secondary analysis of a nonrandomized clinical trial.

“While approximately 35% of families chose nonoperative management, a high pain score between 7-10 on a 10-point scale nearly doubled in-hospital treatment failure,” Rebecca M. Rentea, MD, a pediatric surgeon and the director of the Comprehensive Colorectal Center at Children’s Mercy Kansas City, Mo., told this news organization in an email.

“Even if nonoperative management of pediatric appendicitis did not work – resulting in the need to remove the appendix in 34% of cases – families were happy with their decisions 1 year later,” added Dr. Rentea, who coauthored an invited commentary about the study.

Lead study author Peter C. Minneci, MD, MHSc, a pediatric surgeon at Nationwide Children’s Hospital, Columbus, Ohio, and colleagues analyzed a subgroup of patients from a larger study in 10 tertiary children’s hospitals in the Midwest Pediatric Surgery Consortium.

As they reported in JAMA Network Open, the larger prospective, nonrandomized clinical trial enrolled 1,068 children between 2015 and 2018. The children ranged in age from 7 to 17 years, and they had imaging-confirmed appendicitis with an appendix diameter of 1.1 cm or less, no abscess, no appendicolith, and no phlegmon. White blood cell count was between 5,000 and 18,000 cells/μL, and abdominal pain began less than 48 hours before they received antibiotic therapy.

Caregivers chose either surgery or nonoperative antibiotic management. Patients who were treated first with antibiotics alone and who did not undergo appendectomy within 1 year were considered to have successfully completed nonoperative treatment.

The secondary analysis included the 370 children enrolled in the nonoperative group. Of these, 229 were boys, and the median age was 12.3 years. In this subgroup, the researchers compared outcomes after nonoperative, antibiotic management vs. surgery.

At 1 year, treatment failure had occurred in 125 patients, with 53 having undergone appendectomy during their first hospitalization, and 72 having experienced delayed treatment failure after being discharged.

• Higher patient-reported pain at presentation was linked to higher risk for in-hospital treatment failure (relative risk, 2.1; 95% confidence interval, 1.0-4.4) but not for delayed treatment failure (RR, 1.3; 95% CI, 0.7-2.3) or overall treatment failure at 1 year (RR, 1.5; 95% CI, 1.0-2.2).
• Pain lasting longer than 24 hours was linked to lower risk for delayed treatment failure (RR, 0.3; 95% CI, 0.1-1.0) but not for in-hospital treatment failure (RR, 1.2; 95% CI, 0.5-2.7) or treatment failure at 1 year (RR, 0.7; 95% CI, 0.4-1.2).
• Satisfaction with the decision was higher with successful nonoperative management at 30 days (28.0 vs. 27.0; difference, 1.0; 95% CI, 0.01-2.0) and at 1 year (28.1 vs 27.0; difference, 1.1; 95% CI, 0.2-2.0).

The researchers found no increased risk for treatment failure based on age, sex, race, ethnicity, white blood cell count, primary language, insurance status, transfer status, presentation symptoms, or imaging results.

Antibiotics-only is a safe option for children

“This study suggests that pediatric patients with uncomplicated acute appendicitis should be offered treatment options, including nonoperative management,” the authors write. “Treatment with antibiotics alone is a safe and equitable option for children, with no increased risk of treatment failure based on sociodemographic or objective clinical characteristics at presentation.”

But, the authors advise: “Families need to be made aware that treatment failure is not uncommon, and they should be provided with anticipatory guidance on how to proceed should symptoms recur.”

The investigators acknowledged limitations to the study, including the nonrandomized design that may have introduced bias, the loss to follow-up, and the study population being U.S. Midwest children, who may differ from children elsewhere in the country.

Shawn D. St Peter, MD, a pediatric surgeon, medical chair, and a senior vice president at Children’s Mercy Kansas City told this news organization in an email that having a nonoperative alternative to surgical appendectomy is important.

“Antibiotics are the initial treatment for appendicitis and can be the definitive treatment,” he said.

“Surprisingly, no sociodemographic or clinical characteristics were associated with an increased risk of nonoperative appendicitis treatment failure,” added Dr. St Peter, who coauthored the commentary with Dr. Rentea.

Howard C. Jen, MD, a pediatric surgeon at University of California, Los Angeles, Mattel Children’s Hospital, was not surprised by the findings.

“Nonoperative management for acute noncomplicated appendicitis in children continues to be safe and effective in highly selected patients,” he said in an email. “This alternative to surgery should be offered routinely to patients with early acute appendicitis.” 

Dr. Jen, who was not involved with the current study, noted that it did not address the impact and costs to families of nonoperative management vs. surgery.

“For the most vulnerable children who had difficulties accessing medical care, what is the best treatment option? What factors are important to the families when making this decision?” he asked.

All study and editorial authors report no relevant financial relationships. The study was funded by the Patient-Centered Outcomes Research Institute and the National Center for Advancing Translational Sciences.

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

Children who have greater acute appendicitis pain may be less likely to improve if they’re treated with antibiotics alone, according to a secondary analysis of a nonrandomized clinical trial.

“While approximately 35% of families chose nonoperative management, a high pain score between 7-10 on a 10-point scale nearly doubled in-hospital treatment failure,” Rebecca M. Rentea, MD, a pediatric surgeon and the director of the Comprehensive Colorectal Center at Children’s Mercy Kansas City, Mo., told this news organization in an email.

“Even if nonoperative management of pediatric appendicitis did not work – resulting in the need to remove the appendix in 34% of cases – families were happy with their decisions 1 year later,” added Dr. Rentea, who coauthored an invited commentary about the study.

Lead study author Peter C. Minneci, MD, MHSc, a pediatric surgeon at Nationwide Children’s Hospital, Columbus, Ohio, and colleagues analyzed a subgroup of patients from a larger study in 10 tertiary children’s hospitals in the Midwest Pediatric Surgery Consortium.

As they reported in JAMA Network Open, the larger prospective, nonrandomized clinical trial enrolled 1,068 children between 2015 and 2018. The children ranged in age from 7 to 17 years, and they had imaging-confirmed appendicitis with an appendix diameter of 1.1 cm or less, no abscess, no appendicolith, and no phlegmon. White blood cell count was between 5,000 and 18,000 cells/μL, and abdominal pain began less than 48 hours before they received antibiotic therapy.

Caregivers chose either surgery or nonoperative antibiotic management. Patients who were treated first with antibiotics alone and who did not undergo appendectomy within 1 year were considered to have successfully completed nonoperative treatment.

The secondary analysis included the 370 children enrolled in the nonoperative group. Of these, 229 were boys, and the median age was 12.3 years. In this subgroup, the researchers compared outcomes after nonoperative, antibiotic management vs. surgery.

At 1 year, treatment failure had occurred in 125 patients, with 53 having undergone appendectomy during their first hospitalization, and 72 having experienced delayed treatment failure after being discharged.

• Higher patient-reported pain at presentation was linked to higher risk for in-hospital treatment failure (relative risk, 2.1; 95% confidence interval, 1.0-4.4) but not for delayed treatment failure (RR, 1.3; 95% CI, 0.7-2.3) or overall treatment failure at 1 year (RR, 1.5; 95% CI, 1.0-2.2).
• Pain lasting longer than 24 hours was linked to lower risk for delayed treatment failure (RR, 0.3; 95% CI, 0.1-1.0) but not for in-hospital treatment failure (RR, 1.2; 95% CI, 0.5-2.7) or treatment failure at 1 year (RR, 0.7; 95% CI, 0.4-1.2).
• Satisfaction with the decision was higher with successful nonoperative management at 30 days (28.0 vs. 27.0; difference, 1.0; 95% CI, 0.01-2.0) and at 1 year (28.1 vs 27.0; difference, 1.1; 95% CI, 0.2-2.0).

The researchers found no increased risk for treatment failure based on age, sex, race, ethnicity, white blood cell count, primary language, insurance status, transfer status, presentation symptoms, or imaging results.

Antibiotics-only is a safe option for children

“This study suggests that pediatric patients with uncomplicated acute appendicitis should be offered treatment options, including nonoperative management,” the authors write. “Treatment with antibiotics alone is a safe and equitable option for children, with no increased risk of treatment failure based on sociodemographic or objective clinical characteristics at presentation.”

But, the authors advise: “Families need to be made aware that treatment failure is not uncommon, and they should be provided with anticipatory guidance on how to proceed should symptoms recur.”

The investigators acknowledged limitations to the study, including the nonrandomized design that may have introduced bias, the loss to follow-up, and the study population being U.S. Midwest children, who may differ from children elsewhere in the country.

Shawn D. St Peter, MD, a pediatric surgeon, medical chair, and a senior vice president at Children’s Mercy Kansas City told this news organization in an email that having a nonoperative alternative to surgical appendectomy is important.

“Antibiotics are the initial treatment for appendicitis and can be the definitive treatment,” he said.

“Surprisingly, no sociodemographic or clinical characteristics were associated with an increased risk of nonoperative appendicitis treatment failure,” added Dr. St Peter, who coauthored the commentary with Dr. Rentea.

Howard C. Jen, MD, a pediatric surgeon at University of California, Los Angeles, Mattel Children’s Hospital, was not surprised by the findings.

“Nonoperative management for acute noncomplicated appendicitis in children continues to be safe and effective in highly selected patients,” he said in an email. “This alternative to surgery should be offered routinely to patients with early acute appendicitis.” 

Dr. Jen, who was not involved with the current study, noted that it did not address the impact and costs to families of nonoperative management vs. surgery.

“For the most vulnerable children who had difficulties accessing medical care, what is the best treatment option? What factors are important to the families when making this decision?” he asked.

All study and editorial authors report no relevant financial relationships. The study was funded by the Patient-Centered Outcomes Research Institute and the National Center for Advancing Translational Sciences.

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

Children who have greater acute appendicitis pain may be less likely to improve if they’re treated with antibiotics alone, according to a secondary analysis of a nonrandomized clinical trial.

“While approximately 35% of families chose nonoperative management, a high pain score between 7-10 on a 10-point scale nearly doubled in-hospital treatment failure,” Rebecca M. Rentea, MD, a pediatric surgeon and the director of the Comprehensive Colorectal Center at Children’s Mercy Kansas City, Mo., told this news organization in an email.

“Even if nonoperative management of pediatric appendicitis did not work – resulting in the need to remove the appendix in 34% of cases – families were happy with their decisions 1 year later,” added Dr. Rentea, who coauthored an invited commentary about the study.

Lead study author Peter C. Minneci, MD, MHSc, a pediatric surgeon at Nationwide Children’s Hospital, Columbus, Ohio, and colleagues analyzed a subgroup of patients from a larger study in 10 tertiary children’s hospitals in the Midwest Pediatric Surgery Consortium.

As they reported in JAMA Network Open, the larger prospective, nonrandomized clinical trial enrolled 1,068 children between 2015 and 2018. The children ranged in age from 7 to 17 years, and they had imaging-confirmed appendicitis with an appendix diameter of 1.1 cm or less, no abscess, no appendicolith, and no phlegmon. White blood cell count was between 5,000 and 18,000 cells/μL, and abdominal pain began less than 48 hours before they received antibiotic therapy.

Caregivers chose either surgery or nonoperative antibiotic management. Patients who were treated first with antibiotics alone and who did not undergo appendectomy within 1 year were considered to have successfully completed nonoperative treatment.

The secondary analysis included the 370 children enrolled in the nonoperative group. Of these, 229 were boys, and the median age was 12.3 years. In this subgroup, the researchers compared outcomes after nonoperative, antibiotic management vs. surgery.

At 1 year, treatment failure had occurred in 125 patients, with 53 having undergone appendectomy during their first hospitalization, and 72 having experienced delayed treatment failure after being discharged.

• Higher patient-reported pain at presentation was linked to higher risk for in-hospital treatment failure (relative risk, 2.1; 95% confidence interval, 1.0-4.4) but not for delayed treatment failure (RR, 1.3; 95% CI, 0.7-2.3) or overall treatment failure at 1 year (RR, 1.5; 95% CI, 1.0-2.2).
• Pain lasting longer than 24 hours was linked to lower risk for delayed treatment failure (RR, 0.3; 95% CI, 0.1-1.0) but not for in-hospital treatment failure (RR, 1.2; 95% CI, 0.5-2.7) or treatment failure at 1 year (RR, 0.7; 95% CI, 0.4-1.2).
• Satisfaction with the decision was higher with successful nonoperative management at 30 days (28.0 vs. 27.0; difference, 1.0; 95% CI, 0.01-2.0) and at 1 year (28.1 vs 27.0; difference, 1.1; 95% CI, 0.2-2.0).

The researchers found no increased risk for treatment failure based on age, sex, race, ethnicity, white blood cell count, primary language, insurance status, transfer status, presentation symptoms, or imaging results.

Antibiotics-only is a safe option for children

“This study suggests that pediatric patients with uncomplicated acute appendicitis should be offered treatment options, including nonoperative management,” the authors write. “Treatment with antibiotics alone is a safe and equitable option for children, with no increased risk of treatment failure based on sociodemographic or objective clinical characteristics at presentation.”

But, the authors advise: “Families need to be made aware that treatment failure is not uncommon, and they should be provided with anticipatory guidance on how to proceed should symptoms recur.”

The investigators acknowledged limitations to the study, including the nonrandomized design that may have introduced bias, the loss to follow-up, and the study population being U.S. Midwest children, who may differ from children elsewhere in the country.

Shawn D. St Peter, MD, a pediatric surgeon, medical chair, and a senior vice president at Children’s Mercy Kansas City told this news organization in an email that having a nonoperative alternative to surgical appendectomy is important.

“Antibiotics are the initial treatment for appendicitis and can be the definitive treatment,” he said.

“Surprisingly, no sociodemographic or clinical characteristics were associated with an increased risk of nonoperative appendicitis treatment failure,” added Dr. St Peter, who coauthored the commentary with Dr. Rentea.

Howard C. Jen, MD, a pediatric surgeon at University of California, Los Angeles, Mattel Children’s Hospital, was not surprised by the findings.

“Nonoperative management for acute noncomplicated appendicitis in children continues to be safe and effective in highly selected patients,” he said in an email. “This alternative to surgery should be offered routinely to patients with early acute appendicitis.” 

Dr. Jen, who was not involved with the current study, noted that it did not address the impact and costs to families of nonoperative management vs. surgery.

“For the most vulnerable children who had difficulties accessing medical care, what is the best treatment option? What factors are important to the families when making this decision?” he asked.

All study and editorial authors report no relevant financial relationships. The study was funded by the Patient-Centered Outcomes Research Institute and the National Center for Advancing Translational Sciences.

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

Version 11.0 of the 2021 revised European AIDS Clinical Society (EACS) Guidelines updates all aspects of HIV care and adds recommendations on COVID-19 and antiretroviral treatment (ART) in children and adolescents, the guidelines authors reported in HIV Medicine.

“Conducting a systematic and timely annual revision of all guidelines recommendations is an EACS cornerstone,” EACS Guidelines coordinator Lene Ryom, MD, PhD, DMSc, a researcher at the University of Copenhagen, said in an interview. “These revisions ensure that the EACS Guidelines remain clinically relevant, are updated with the latest scientific evidence, and that they cover all key aspects related to HIV management.”

Key revisions in this update include:
 

Antiretroviral therapy (ART)

• Six recommended treatment options for first-line regimens for ART-naive adults include triple-drug regimens consisting of tenofovir (either tenofovir disoproxil fumarate or tenofovir alafenamide) with either lamivudine or emtricitabine plus dolutegravir, raltegravir, bictegravir, or doravirine; abacavir/lamivudine plus dolutegravir; or dual therapy with emtricitabine plus dolutegravir. These drug combinations are recommended in single-tablet form if available.
• Alternatives consisting of triple-drug tenofovir-based regimens along with efavirenz, rilpivirine, or boosted darunavir, are advised when no recommended regimens are feasible.
• Bimonthly injections with long-acting cabotegravir plus rilpivirine are now advised as a switch option for people who are virologically suppressed.
• Pre-exposure prophylaxis on demand is advised for cisgender men, and PrEP may be continued during pregnancy and breastfeeding for people at risk of acquiring HIV.

Drug-drug interactions (DDIs) and other prescribing issues

• Four new DDI tables cover antituberculosis drugs, anxiolytics, hormone therapy, and COVID-19 therapies.

Comorbidities

• This update acknowledged the impact of the COVID-19 pandemic on routine health care, provides recommendations, and highlights the role of shared care and consultation for anxiety and other mental health disorders.
• Treatments involving diabetes, hypertension, cardiovascular disease, heart failure, chronic kidney disease, hypercholesterolemia, obesity, cancer, and sexual health have been updated, with new information about elderly and frail patients, women’s sexual health, and special considerations for transgender people.

Viral hepatitis coinfection

Immediate treatment of recently acquired hepatitis C is recommended for people living with HIV and ongoing risk behavior. Bulevirtide is added as a treatment option for hepatitis Delta virus.

Opportunistic infections and COVID-19

• The revision adds new guidance on management of HIV and COVID-19, covering epidemiology, risk factors for severe COVID-19, COVID-19 management, HIV care during a pandemic, HIV management during COVID-19 treatment, and management of long-term COVID-19 symptoms and prophylaxis.
• It includes guidance on management of tuberculosis meningitis, cryptococcosis, Pneumocystis jirovecii pneumonia, and drug-resistant tuberculosis.

Pediatric HIV infection treatments

• This new section, developed with the European pediatric research organization Penta, updates guidance for the use of preferred and alternative first-line drugs from birth to adolescence. Combinations include new child-friendly formulations of dolutegravir as early as 4 weeks of age and 3 kg (6.6 lb) of weight as well as an increased emphasis on dolutegravir as first-line preferred agent for all children except newborns. Abacavir is recommended for children younger than 3 months.
• ART regimens for children with infectious hepatitis or tuberculosis are also provided.

Laura Jane Waters, MD, a genitourinary consultant and HIV and hepatitis lead at Central and North West London National Health Service Mortimer Market Centre, and chair of the British HIV Association (BHIVA), shared her perspective on the revision. She was not involved with the EACS Guidelines revision.

“The addition of a section on COVID-19 in people with HIV, including management, drug interactions, and vaccination, is welcomed, as is the inclusion of key references and, for selected references, the key findings,” Dr. Waters said in an interview.

“Finally, for the first time, EACS covers pediatric HIV treatment by integrating with the Penta guidelines,” she added. “This is an important evolution, considering there are still cases of vertical HIV transmission in Europe, not to mention children living with HIV who have immigrated. Ensuring high and equitable standards of HIV treatment for young people is crucial.”

“This update to the always-pragmatic EACS guidelines further diverges from the United States Department of Health & Human Services guidelines,” Dr. Waters explained. “For 6 months, both guidelines preferred the same ... regimens for first-line therapy, but since DHSS removed raltegravir-based ART in June 2021 and EACS added doravirine-based regimens in October 2021, we’re back in the more familiar territory of EACS offering a broader range of preferred choices.”

Dr. Ryom noted that modern HIV care needs to consider managing coinfections, opportunistic diseases, comorbidities, aging, addictions, and mental health.

“Ensuring an integrated and personalized approach to HIV management is becoming increasingly important in an aging population living with HIV with the potential for complex needs,” she said.

The guidelines are available in several formats: as a free smartphone app, an interactive web version, and an online PDF.

Funding information was not provided. Dr. Ryom and several coauthors disclosed no relevant financial relationships. Most of the guideline coauthors declared financial relationships with pharmaceutical companies “outside the submitted work.” Dr. Waters provided no information on conflicts of interest.

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

Version 11.0 of the 2021 revised European AIDS Clinical Society (EACS) Guidelines updates all aspects of HIV care and adds recommendations on COVID-19 and antiretroviral treatment (ART) in children and adolescents, the guidelines authors reported in HIV Medicine.

“Conducting a systematic and timely annual revision of all guidelines recommendations is an EACS cornerstone,” EACS Guidelines coordinator Lene Ryom, MD, PhD, DMSc, a researcher at the University of Copenhagen, said in an interview. “These revisions ensure that the EACS Guidelines remain clinically relevant, are updated with the latest scientific evidence, and that they cover all key aspects related to HIV management.”

Key revisions in this update include:
 

Antiretroviral therapy (ART)

• Six recommended treatment options for first-line regimens for ART-naive adults include triple-drug regimens consisting of tenofovir (either tenofovir disoproxil fumarate or tenofovir alafenamide) with either lamivudine or emtricitabine plus dolutegravir, raltegravir, bictegravir, or doravirine; abacavir/lamivudine plus dolutegravir; or dual therapy with emtricitabine plus dolutegravir. These drug combinations are recommended in single-tablet form if available.
• Alternatives consisting of triple-drug tenofovir-based regimens along with efavirenz, rilpivirine, or boosted darunavir, are advised when no recommended regimens are feasible.
• Bimonthly injections with long-acting cabotegravir plus rilpivirine are now advised as a switch option for people who are virologically suppressed.
• Pre-exposure prophylaxis on demand is advised for cisgender men, and PrEP may be continued during pregnancy and breastfeeding for people at risk of acquiring HIV.

Drug-drug interactions (DDIs) and other prescribing issues

• Four new DDI tables cover antituberculosis drugs, anxiolytics, hormone therapy, and COVID-19 therapies.

Comorbidities

• This update acknowledged the impact of the COVID-19 pandemic on routine health care, provides recommendations, and highlights the role of shared care and consultation for anxiety and other mental health disorders.
• Treatments involving diabetes, hypertension, cardiovascular disease, heart failure, chronic kidney disease, hypercholesterolemia, obesity, cancer, and sexual health have been updated, with new information about elderly and frail patients, women’s sexual health, and special considerations for transgender people.

Viral hepatitis coinfection

Immediate treatment of recently acquired hepatitis C is recommended for people living with HIV and ongoing risk behavior. Bulevirtide is added as a treatment option for hepatitis Delta virus.

Opportunistic infections and COVID-19

• The revision adds new guidance on management of HIV and COVID-19, covering epidemiology, risk factors for severe COVID-19, COVID-19 management, HIV care during a pandemic, HIV management during COVID-19 treatment, and management of long-term COVID-19 symptoms and prophylaxis.
• It includes guidance on management of tuberculosis meningitis, cryptococcosis, Pneumocystis jirovecii pneumonia, and drug-resistant tuberculosis.

Pediatric HIV infection treatments

• This new section, developed with the European pediatric research organization Penta, updates guidance for the use of preferred and alternative first-line drugs from birth to adolescence. Combinations include new child-friendly formulations of dolutegravir as early as 4 weeks of age and 3 kg (6.6 lb) of weight as well as an increased emphasis on dolutegravir as first-line preferred agent for all children except newborns. Abacavir is recommended for children younger than 3 months.
• ART regimens for children with infectious hepatitis or tuberculosis are also provided.

Laura Jane Waters, MD, a genitourinary consultant and HIV and hepatitis lead at Central and North West London National Health Service Mortimer Market Centre, and chair of the British HIV Association (BHIVA), shared her perspective on the revision. She was not involved with the EACS Guidelines revision.

“The addition of a section on COVID-19 in people with HIV, including management, drug interactions, and vaccination, is welcomed, as is the inclusion of key references and, for selected references, the key findings,” Dr. Waters said in an interview.

“Finally, for the first time, EACS covers pediatric HIV treatment by integrating with the Penta guidelines,” she added. “This is an important evolution, considering there are still cases of vertical HIV transmission in Europe, not to mention children living with HIV who have immigrated. Ensuring high and equitable standards of HIV treatment for young people is crucial.”

“This update to the always-pragmatic EACS guidelines further diverges from the United States Department of Health & Human Services guidelines,” Dr. Waters explained. “For 6 months, both guidelines preferred the same ... regimens for first-line therapy, but since DHSS removed raltegravir-based ART in June 2021 and EACS added doravirine-based regimens in October 2021, we’re back in the more familiar territory of EACS offering a broader range of preferred choices.”

Dr. Ryom noted that modern HIV care needs to consider managing coinfections, opportunistic diseases, comorbidities, aging, addictions, and mental health.

“Ensuring an integrated and personalized approach to HIV management is becoming increasingly important in an aging population living with HIV with the potential for complex needs,” she said.

The guidelines are available in several formats: as a free smartphone app, an interactive web version, and an online PDF.

Funding information was not provided. Dr. Ryom and several coauthors disclosed no relevant financial relationships. Most of the guideline coauthors declared financial relationships with pharmaceutical companies “outside the submitted work.” Dr. Waters provided no information on conflicts of interest.

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

Version 11.0 of the 2021 revised European AIDS Clinical Society (EACS) Guidelines updates all aspects of HIV care and adds recommendations on COVID-19 and antiretroviral treatment (ART) in children and adolescents, the guidelines authors reported in HIV Medicine.

“Conducting a systematic and timely annual revision of all guidelines recommendations is an EACS cornerstone,” EACS Guidelines coordinator Lene Ryom, MD, PhD, DMSc, a researcher at the University of Copenhagen, said in an interview. “These revisions ensure that the EACS Guidelines remain clinically relevant, are updated with the latest scientific evidence, and that they cover all key aspects related to HIV management.”

Key revisions in this update include:
 

Antiretroviral therapy (ART)

• Six recommended treatment options for first-line regimens for ART-naive adults include triple-drug regimens consisting of tenofovir (either tenofovir disoproxil fumarate or tenofovir alafenamide) with either lamivudine or emtricitabine plus dolutegravir, raltegravir, bictegravir, or doravirine; abacavir/lamivudine plus dolutegravir; or dual therapy with emtricitabine plus dolutegravir. These drug combinations are recommended in single-tablet form if available.
• Alternatives consisting of triple-drug tenofovir-based regimens along with efavirenz, rilpivirine, or boosted darunavir, are advised when no recommended regimens are feasible.
• Bimonthly injections with long-acting cabotegravir plus rilpivirine are now advised as a switch option for people who are virologically suppressed.
• Pre-exposure prophylaxis on demand is advised for cisgender men, and PrEP may be continued during pregnancy and breastfeeding for people at risk of acquiring HIV.

Drug-drug interactions (DDIs) and other prescribing issues

• Four new DDI tables cover antituberculosis drugs, anxiolytics, hormone therapy, and COVID-19 therapies.

Comorbidities

• This update acknowledged the impact of the COVID-19 pandemic on routine health care, provides recommendations, and highlights the role of shared care and consultation for anxiety and other mental health disorders.
• Treatments involving diabetes, hypertension, cardiovascular disease, heart failure, chronic kidney disease, hypercholesterolemia, obesity, cancer, and sexual health have been updated, with new information about elderly and frail patients, women’s sexual health, and special considerations for transgender people.

Viral hepatitis coinfection

Immediate treatment of recently acquired hepatitis C is recommended for people living with HIV and ongoing risk behavior. Bulevirtide is added as a treatment option for hepatitis Delta virus.

Opportunistic infections and COVID-19

• The revision adds new guidance on management of HIV and COVID-19, covering epidemiology, risk factors for severe COVID-19, COVID-19 management, HIV care during a pandemic, HIV management during COVID-19 treatment, and management of long-term COVID-19 symptoms and prophylaxis.
• It includes guidance on management of tuberculosis meningitis, cryptococcosis, Pneumocystis jirovecii pneumonia, and drug-resistant tuberculosis.

Pediatric HIV infection treatments

• This new section, developed with the European pediatric research organization Penta, updates guidance for the use of preferred and alternative first-line drugs from birth to adolescence. Combinations include new child-friendly formulations of dolutegravir as early as 4 weeks of age and 3 kg (6.6 lb) of weight as well as an increased emphasis on dolutegravir as first-line preferred agent for all children except newborns. Abacavir is recommended for children younger than 3 months.
• ART regimens for children with infectious hepatitis or tuberculosis are also provided.

Laura Jane Waters, MD, a genitourinary consultant and HIV and hepatitis lead at Central and North West London National Health Service Mortimer Market Centre, and chair of the British HIV Association (BHIVA), shared her perspective on the revision. She was not involved with the EACS Guidelines revision.

“The addition of a section on COVID-19 in people with HIV, including management, drug interactions, and vaccination, is welcomed, as is the inclusion of key references and, for selected references, the key findings,” Dr. Waters said in an interview.

“Finally, for the first time, EACS covers pediatric HIV treatment by integrating with the Penta guidelines,” she added. “This is an important evolution, considering there are still cases of vertical HIV transmission in Europe, not to mention children living with HIV who have immigrated. Ensuring high and equitable standards of HIV treatment for young people is crucial.”

“This update to the always-pragmatic EACS guidelines further diverges from the United States Department of Health & Human Services guidelines,” Dr. Waters explained. “For 6 months, both guidelines preferred the same ... regimens for first-line therapy, but since DHSS removed raltegravir-based ART in June 2021 and EACS added doravirine-based regimens in October 2021, we’re back in the more familiar territory of EACS offering a broader range of preferred choices.”

Dr. Ryom noted that modern HIV care needs to consider managing coinfections, opportunistic diseases, comorbidities, aging, addictions, and mental health.

“Ensuring an integrated and personalized approach to HIV management is becoming increasingly important in an aging population living with HIV with the potential for complex needs,” she said.

The guidelines are available in several formats: as a free smartphone app, an interactive web version, and an online PDF.

Funding information was not provided. Dr. Ryom and several coauthors disclosed no relevant financial relationships. Most of the guideline coauthors declared financial relationships with pharmaceutical companies “outside the submitted work.” Dr. Waters provided no information on conflicts of interest.

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