Women with epilepsy are more than twice as likely as those without the disorder to report physical, sexual, or emotional abuse during pregnancy, new research shows.

Study investigator Naveed Chaudhry, MD, a recent epilepsy fellow and assistant professor of neurology, University of Colorado School of Medicine, described the finding as “alarming” and called for more support for this patient population.

Investigators found that women with epilepsy are also more likely to report other stressors, including divorce, illness, lost pay, and partner discord, while expecting.

“As epilepsy physicians, it’s important that we ask the right questions and dive a little bit deeper with these patients, even if it’s uncomfortable and not something we’re used to,” said Dr. Chaudhry.

The findings were presented at the annual meeting of the American Epilepsy Society.
 

Cause for concern

Women with epilepsy may be under stress for a variety of social and economic reasons. In some women, stress can trigger seizures, and during pregnancy, this can lead to complications such as preterm labor and low birth weight.

For the study, researchers tapped into the Center for Disease Control and Prevention Pregnancy Risk Assessment and Monitoring System (PRAMS). This database includes information from surveys asking women across the U.S. about their pregnancy and postpartum period.

Thirteen states collected data on stresses in women with and without epilepsy. Respondents were asked about 14 economic and other worries in the year prior to their baby’s birth, including the pregnancy period.

The analysis included 64,951 women, 1,140 of whom had epilepsy, who were included in surveys from 2012-2020. There were no significant demographic differences between those with and those without the disorder.

After adjusting for maternal age, race, ethnicity, marital status, education, and socioeconomic status, the study found that women with epilepsy experienced an average of 2.41 of the stressors compared with 1.72 for women without epilepsy.

Women with epilepsy were more likely to have experienced family illness, divorce, homelessness, partner job loss, reduced work or pay, increased arguments, having a partner in jail, drug use, and the death of someone close to them.

The results showed that unmarried and younger women as well as those with lower incomes were particularly prone to experience stress during pregnancy.

It’s not clear why women with epilepsy report more stressors. “Looking at the literature, no one has really looked at the exact reason for this, but we postulate it could be a lack of supports and support systems,” said Dr. Chaudhry.

Women were asked about physical, sexual, and emotional abuse. Results showed that substantially more women with epilepsy than those without the disorder reported such abuse during pregnancy – 10.6% versus 4.1%. The adjusted odds ratio for women with epilepsy reporting abuse was 2.78 (95% CI, 2.07-3.74).

“That raises our concern and needs to be looked at in more detail,” said Dr. Chaudhry.

It is unclear whether some women might have had psychogenic non-epileptic seizures (PNES), which are linked to a higher rate of abuse, said Dr. Chaudhry. “But the prevalence of PNES in the general population is quite low, so we don’t think it’s contributing to a large extent to this finding.”

The findings highlight the importance of addressing stress in women with epilepsy during pregnancy, he said. “We need to have good support services and we need to counsel women to optimize good outcomes.”

This applies to all women of childbearing age. “We suspect abuse and stressors are going to be going on throughout that period,” said Dr. Chaudhry. “It’s important to ask about it and have appropriate support staff and social work and people available to help when an issue is identified.”
 

Stress a common seizure trigger

Commenting on the research, Kimford Meador, MD, professor, Department of Neurology and Neurological Sciences, Stanford University School of Medicine, noted the study was well conducted and had a large sample size.

The findings are important, as stress is a common trigger for seizures in people with epilepsy and is associated with mood and anxiety, which can affect quality of life, said Dr. Meador.

Results of his analysis from the Maternal Outcomes and Neurodevelopmental Effects of Antiepileptic Drugs (MONEAD) study, also presented at this year’s AES meeting, showed that women with epilepsy had more depressive symptoms during the postpartum period and more anxiety symptoms during pregnancy and postpartum in comparison with those without epilepsy.

Dr. Meador’s group also recently conducted a study that was published in JAMA Neurology, showing that in women with epilepsy during the postpartum period, anxiety is associated with lower cognitive ability in their children at age 2 years.

“All these findings highlight the importance of assessing and managing stress, anxiety, and mood in women with epilepsy,” said Dr. Meador. “Interventions could impact seizures and quality of life in pregnant women with epilepsy and long-term outcomes in their children.”

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

Women with epilepsy are more than twice as likely as those without the disorder to report physical, sexual, or emotional abuse during pregnancy, new research shows.

Study investigator Naveed Chaudhry, MD, a recent epilepsy fellow and assistant professor of neurology, University of Colorado School of Medicine, described the finding as “alarming” and called for more support for this patient population.

Investigators found that women with epilepsy are also more likely to report other stressors, including divorce, illness, lost pay, and partner discord, while expecting.

“As epilepsy physicians, it’s important that we ask the right questions and dive a little bit deeper with these patients, even if it’s uncomfortable and not something we’re used to,” said Dr. Chaudhry.

The findings were presented at the annual meeting of the American Epilepsy Society.
 

Cause for concern

Women with epilepsy may be under stress for a variety of social and economic reasons. In some women, stress can trigger seizures, and during pregnancy, this can lead to complications such as preterm labor and low birth weight.

For the study, researchers tapped into the Center for Disease Control and Prevention Pregnancy Risk Assessment and Monitoring System (PRAMS). This database includes information from surveys asking women across the U.S. about their pregnancy and postpartum period.

Thirteen states collected data on stresses in women with and without epilepsy. Respondents were asked about 14 economic and other worries in the year prior to their baby’s birth, including the pregnancy period.

The analysis included 64,951 women, 1,140 of whom had epilepsy, who were included in surveys from 2012-2020. There were no significant demographic differences between those with and those without the disorder.

After adjusting for maternal age, race, ethnicity, marital status, education, and socioeconomic status, the study found that women with epilepsy experienced an average of 2.41 of the stressors compared with 1.72 for women without epilepsy.

Women with epilepsy were more likely to have experienced family illness, divorce, homelessness, partner job loss, reduced work or pay, increased arguments, having a partner in jail, drug use, and the death of someone close to them.

The results showed that unmarried and younger women as well as those with lower incomes were particularly prone to experience stress during pregnancy.

It’s not clear why women with epilepsy report more stressors. “Looking at the literature, no one has really looked at the exact reason for this, but we postulate it could be a lack of supports and support systems,” said Dr. Chaudhry.

Women were asked about physical, sexual, and emotional abuse. Results showed that substantially more women with epilepsy than those without the disorder reported such abuse during pregnancy – 10.6% versus 4.1%. The adjusted odds ratio for women with epilepsy reporting abuse was 2.78 (95% CI, 2.07-3.74).

“That raises our concern and needs to be looked at in more detail,” said Dr. Chaudhry.

It is unclear whether some women might have had psychogenic non-epileptic seizures (PNES), which are linked to a higher rate of abuse, said Dr. Chaudhry. “But the prevalence of PNES in the general population is quite low, so we don’t think it’s contributing to a large extent to this finding.”

The findings highlight the importance of addressing stress in women with epilepsy during pregnancy, he said. “We need to have good support services and we need to counsel women to optimize good outcomes.”

This applies to all women of childbearing age. “We suspect abuse and stressors are going to be going on throughout that period,” said Dr. Chaudhry. “It’s important to ask about it and have appropriate support staff and social work and people available to help when an issue is identified.”
 

Stress a common seizure trigger

Commenting on the research, Kimford Meador, MD, professor, Department of Neurology and Neurological Sciences, Stanford University School of Medicine, noted the study was well conducted and had a large sample size.

The findings are important, as stress is a common trigger for seizures in people with epilepsy and is associated with mood and anxiety, which can affect quality of life, said Dr. Meador.

Results of his analysis from the Maternal Outcomes and Neurodevelopmental Effects of Antiepileptic Drugs (MONEAD) study, also presented at this year’s AES meeting, showed that women with epilepsy had more depressive symptoms during the postpartum period and more anxiety symptoms during pregnancy and postpartum in comparison with those without epilepsy.

Dr. Meador’s group also recently conducted a study that was published in JAMA Neurology, showing that in women with epilepsy during the postpartum period, anxiety is associated with lower cognitive ability in their children at age 2 years.

“All these findings highlight the importance of assessing and managing stress, anxiety, and mood in women with epilepsy,” said Dr. Meador. “Interventions could impact seizures and quality of life in pregnant women with epilepsy and long-term outcomes in their children.”

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

Women with epilepsy are more than twice as likely as those without the disorder to report physical, sexual, or emotional abuse during pregnancy, new research shows.

Study investigator Naveed Chaudhry, MD, a recent epilepsy fellow and assistant professor of neurology, University of Colorado School of Medicine, described the finding as “alarming” and called for more support for this patient population.

Investigators found that women with epilepsy are also more likely to report other stressors, including divorce, illness, lost pay, and partner discord, while expecting.

“As epilepsy physicians, it’s important that we ask the right questions and dive a little bit deeper with these patients, even if it’s uncomfortable and not something we’re used to,” said Dr. Chaudhry.

The findings were presented at the annual meeting of the American Epilepsy Society.
 

Cause for concern

Women with epilepsy may be under stress for a variety of social and economic reasons. In some women, stress can trigger seizures, and during pregnancy, this can lead to complications such as preterm labor and low birth weight.

For the study, researchers tapped into the Center for Disease Control and Prevention Pregnancy Risk Assessment and Monitoring System (PRAMS). This database includes information from surveys asking women across the U.S. about their pregnancy and postpartum period.

Thirteen states collected data on stresses in women with and without epilepsy. Respondents were asked about 14 economic and other worries in the year prior to their baby’s birth, including the pregnancy period.

The analysis included 64,951 women, 1,140 of whom had epilepsy, who were included in surveys from 2012-2020. There were no significant demographic differences between those with and those without the disorder.

After adjusting for maternal age, race, ethnicity, marital status, education, and socioeconomic status, the study found that women with epilepsy experienced an average of 2.41 of the stressors compared with 1.72 for women without epilepsy.

Women with epilepsy were more likely to have experienced family illness, divorce, homelessness, partner job loss, reduced work or pay, increased arguments, having a partner in jail, drug use, and the death of someone close to them.

The results showed that unmarried and younger women as well as those with lower incomes were particularly prone to experience stress during pregnancy.

It’s not clear why women with epilepsy report more stressors. “Looking at the literature, no one has really looked at the exact reason for this, but we postulate it could be a lack of supports and support systems,” said Dr. Chaudhry.

Women were asked about physical, sexual, and emotional abuse. Results showed that substantially more women with epilepsy than those without the disorder reported such abuse during pregnancy – 10.6% versus 4.1%. The adjusted odds ratio for women with epilepsy reporting abuse was 2.78 (95% CI, 2.07-3.74).

“That raises our concern and needs to be looked at in more detail,” said Dr. Chaudhry.

It is unclear whether some women might have had psychogenic non-epileptic seizures (PNES), which are linked to a higher rate of abuse, said Dr. Chaudhry. “But the prevalence of PNES in the general population is quite low, so we don’t think it’s contributing to a large extent to this finding.”

The findings highlight the importance of addressing stress in women with epilepsy during pregnancy, he said. “We need to have good support services and we need to counsel women to optimize good outcomes.”

This applies to all women of childbearing age. “We suspect abuse and stressors are going to be going on throughout that period,” said Dr. Chaudhry. “It’s important to ask about it and have appropriate support staff and social work and people available to help when an issue is identified.”
 

Stress a common seizure trigger

Commenting on the research, Kimford Meador, MD, professor, Department of Neurology and Neurological Sciences, Stanford University School of Medicine, noted the study was well conducted and had a large sample size.

The findings are important, as stress is a common trigger for seizures in people with epilepsy and is associated with mood and anxiety, which can affect quality of life, said Dr. Meador.

Results of his analysis from the Maternal Outcomes and Neurodevelopmental Effects of Antiepileptic Drugs (MONEAD) study, also presented at this year’s AES meeting, showed that women with epilepsy had more depressive symptoms during the postpartum period and more anxiety symptoms during pregnancy and postpartum in comparison with those without epilepsy.

Dr. Meador’s group also recently conducted a study that was published in JAMA Neurology, showing that in women with epilepsy during the postpartum period, anxiety is associated with lower cognitive ability in their children at age 2 years.

“All these findings highlight the importance of assessing and managing stress, anxiety, and mood in women with epilepsy,” said Dr. Meador. “Interventions could impact seizures and quality of life in pregnant women with epilepsy and long-term outcomes in their children.”

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

In addition to high rates of anxiety and mood disorders, epilepsy is associated with several comorbidities, including headache, hypertension, and back pain, new research shows. Investigators also found racial and ethnic disparities in comorbidity prevalence.

“Our study identified that people with epilepsy have complex health care needs that extend well beyond their epilepsy,” said co-investigator Wyatt P. Bensken, a PhD candidate in the Department of Population and Quantitative Health Sciences at Case Western Reserve University, Cleveland.

The findings were presented at the annual meeting of the American Epilepsy Society.
 

A vulnerable population

Researchers identified individuals with epilepsy using Medicaid claims from 2010 to 2014. Mr. Bensken noted that the approximately one-third of patients with epilepsy covered by Medicaid represent “the most vulnerable” population with the disorder because they may not be working and often have other disabilities.

Based on an algorithm that puts diagnostic codes into clinically meaningful categories, the investigators focused on 190 conditions.

“A strength of the study was that we were able to cast such a broad net” to capture conditions, Mr. Bensken said.

Anxiety and mood disorders were originally in separate categories but were grouped together “after recognizing that those who had one pretty much had the other,” he added.

The researchers used a machine learning technique known as association rule mining (ARM) to uncover frequently occurring conditions and combinations of conditions. This same statistical technique is used by companies such as Amazon to determine future purchases based on articles people have bought.

Among 81,963 patients with epilepsy, the most common conditions were anxiety and mood disorders (46.5%). These were followed by hypertension (36.9%), back problems (35.2%), developmental disorders (31.6%), and headache including migraine (29.5%). Urinary tract infections (UTIs) were experienced by 22.8% of the sample.

The rate of anxiety and mood disorders was not unexpected, “but I was surprised to see hypertension so high on the list,” said Mr. Bensken. He noted there is also increasing evidence pointing to a cardiovascular-epilepsy connection.
 

What should neurologists do?

The study also highlights the relatively high rate of back problems, which are not usually considered a comorbidity in patients with epilepsy, Mr. Bensken said. “Back problems likely greatly impact a patient’s quality of life, and seeing them so high on the list makes me wonder if neurologists or epileptologists or primary care doctors are even asking about back pain and how that might impact the ability to function day to day,” he added.

How do these rates compare with the general population? From other studies, the estimated prevalence for anxiety and mood disorders is 20%-30%, compared with almost 50% of the current sample, said Mr. Bensken.

In addition, the rate of hypertension in the study’s epilepsy population was about 7% higher than the general population, and the rate of UTIs was about 12% higher, he reported.

When examining combinations of conditions, anxiety and mood disorders continued to have an “outsized” prevalence, appearing in nearly every combination, the investigators noted.

Almost a quarter (24.7%) of participants had back problems plus anxiety and a mood disorder, and about 15% had headaches and back problems as well as anxiety and a mood disorder.

“That’s a non-negligible amount of the population that have not just one or two things going on but three and four,” said Mr. Bensken.

These new results underscore how complex these patients can be and the need to integrate medical care among different specialties, he noted.

“We don’t believe it’s the neurologist’s job to also manage the hypertension, but being aware of how prevalent hypertension may be and working with the primary care doctor, or at least checking in with the patient and asking if they’re managing their hypertension, is a real priority,” he said.

Researchers also used the ARM system to identify racial disparities, “which have been largely understudied in the epilepsy context,” said Mr. Bensken.

American Indians and Alaskan Natives had a substantially higher prevalence of developmental disabilities, while Black participants had a higher prevalence of hypertension.

One of the study’s themes was that disparities were not uniform, Mr. Bensken noted. “It wasn’t that in every condition the prevalence was lowest for White individuals and highest for everybody else,” he said.

These results point to the need for a larger study to examine the cultural context of these subgroups and such things as structural racism that might drive disparities, he added.

When researchers examined combinations of comorbidities in individuals in the top quartile of hospitalizations and emergency department visits, they found high users had a much higher disease burden, with 75.8% having anxiety or a mood disorder.

The study highlights that patients with epilepsy on Medicaid are “a high priority population,” said Mr. Bensken.
 

‘Drift down hypothesis’

Commenting on the findings, Fred A. Lado, MD, PhD, director of epilepsy at Northwell Health Eastern and Central Regions, said the increased incidence of comorbidities in patients of low socioeconomic status was not surprising.

“The interesting data here is that we see an even higher incidence among people with epilepsy,” said Dr. Lado, who was not involved with the research.

The study shows how epilepsy exacerbates the effects of low socioeconomic status, he added.

“One of the determinants of socioeconomic status in this case may well be the fact they have seizures and have a limited ability to work and are often more dependent on state assistance and disability support,” Dr. Lado said.

He also referred to the “drift down hypothesis” of chronic disease. “If you have epilepsy and are born into a middle-class family, chances are you will be on disability and can’t work, so you probably have a lower socioeconomic status than your family did as you grew up.”

Dr. Lado noted how “extremely common” mood disorders are in this population and that certain pain syndromes “tracked with those mood disorders.”

“We know mood disorders are more prevalent in people with epilepsy, and now we see that pain-related problems – headache and back pain – are more prevalent in people with epilepsy,” he said.

The data showing “downstream effects of the mood disorders,” from epilepsy to mood disorders to pain disorders, was “very interesting,” Dr. Lado said.

The study was funded by the Centers for Disease Control and Prevention and the National Institute on Minority Health and Health Disparities of the National Institutes of Health. Mr. Bensken has reported receiving research support for this work from the NIH.

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

In addition to high rates of anxiety and mood disorders, epilepsy is associated with several comorbidities, including headache, hypertension, and back pain, new research shows. Investigators also found racial and ethnic disparities in comorbidity prevalence.

“Our study identified that people with epilepsy have complex health care needs that extend well beyond their epilepsy,” said co-investigator Wyatt P. Bensken, a PhD candidate in the Department of Population and Quantitative Health Sciences at Case Western Reserve University, Cleveland.

The findings were presented at the annual meeting of the American Epilepsy Society.
 

A vulnerable population

Researchers identified individuals with epilepsy using Medicaid claims from 2010 to 2014. Mr. Bensken noted that the approximately one-third of patients with epilepsy covered by Medicaid represent “the most vulnerable” population with the disorder because they may not be working and often have other disabilities.

Based on an algorithm that puts diagnostic codes into clinically meaningful categories, the investigators focused on 190 conditions.

“A strength of the study was that we were able to cast such a broad net” to capture conditions, Mr. Bensken said.

Anxiety and mood disorders were originally in separate categories but were grouped together “after recognizing that those who had one pretty much had the other,” he added.

The researchers used a machine learning technique known as association rule mining (ARM) to uncover frequently occurring conditions and combinations of conditions. This same statistical technique is used by companies such as Amazon to determine future purchases based on articles people have bought.

Among 81,963 patients with epilepsy, the most common conditions were anxiety and mood disorders (46.5%). These were followed by hypertension (36.9%), back problems (35.2%), developmental disorders (31.6%), and headache including migraine (29.5%). Urinary tract infections (UTIs) were experienced by 22.8% of the sample.

The rate of anxiety and mood disorders was not unexpected, “but I was surprised to see hypertension so high on the list,” said Mr. Bensken. He noted there is also increasing evidence pointing to a cardiovascular-epilepsy connection.
 

What should neurologists do?

The study also highlights the relatively high rate of back problems, which are not usually considered a comorbidity in patients with epilepsy, Mr. Bensken said. “Back problems likely greatly impact a patient’s quality of life, and seeing them so high on the list makes me wonder if neurologists or epileptologists or primary care doctors are even asking about back pain and how that might impact the ability to function day to day,” he added.

How do these rates compare with the general population? From other studies, the estimated prevalence for anxiety and mood disorders is 20%-30%, compared with almost 50% of the current sample, said Mr. Bensken.

In addition, the rate of hypertension in the study’s epilepsy population was about 7% higher than the general population, and the rate of UTIs was about 12% higher, he reported.

When examining combinations of conditions, anxiety and mood disorders continued to have an “outsized” prevalence, appearing in nearly every combination, the investigators noted.

Almost a quarter (24.7%) of participants had back problems plus anxiety and a mood disorder, and about 15% had headaches and back problems as well as anxiety and a mood disorder.

“That’s a non-negligible amount of the population that have not just one or two things going on but three and four,” said Mr. Bensken.

These new results underscore how complex these patients can be and the need to integrate medical care among different specialties, he noted.

“We don’t believe it’s the neurologist’s job to also manage the hypertension, but being aware of how prevalent hypertension may be and working with the primary care doctor, or at least checking in with the patient and asking if they’re managing their hypertension, is a real priority,” he said.

Researchers also used the ARM system to identify racial disparities, “which have been largely understudied in the epilepsy context,” said Mr. Bensken.

American Indians and Alaskan Natives had a substantially higher prevalence of developmental disabilities, while Black participants had a higher prevalence of hypertension.

One of the study’s themes was that disparities were not uniform, Mr. Bensken noted. “It wasn’t that in every condition the prevalence was lowest for White individuals and highest for everybody else,” he said.

These results point to the need for a larger study to examine the cultural context of these subgroups and such things as structural racism that might drive disparities, he added.

When researchers examined combinations of comorbidities in individuals in the top quartile of hospitalizations and emergency department visits, they found high users had a much higher disease burden, with 75.8% having anxiety or a mood disorder.

The study highlights that patients with epilepsy on Medicaid are “a high priority population,” said Mr. Bensken.
 

‘Drift down hypothesis’

Commenting on the findings, Fred A. Lado, MD, PhD, director of epilepsy at Northwell Health Eastern and Central Regions, said the increased incidence of comorbidities in patients of low socioeconomic status was not surprising.

“The interesting data here is that we see an even higher incidence among people with epilepsy,” said Dr. Lado, who was not involved with the research.

The study shows how epilepsy exacerbates the effects of low socioeconomic status, he added.

“One of the determinants of socioeconomic status in this case may well be the fact they have seizures and have a limited ability to work and are often more dependent on state assistance and disability support,” Dr. Lado said.

He also referred to the “drift down hypothesis” of chronic disease. “If you have epilepsy and are born into a middle-class family, chances are you will be on disability and can’t work, so you probably have a lower socioeconomic status than your family did as you grew up.”

Dr. Lado noted how “extremely common” mood disorders are in this population and that certain pain syndromes “tracked with those mood disorders.”

“We know mood disorders are more prevalent in people with epilepsy, and now we see that pain-related problems – headache and back pain – are more prevalent in people with epilepsy,” he said.

The data showing “downstream effects of the mood disorders,” from epilepsy to mood disorders to pain disorders, was “very interesting,” Dr. Lado said.

The study was funded by the Centers for Disease Control and Prevention and the National Institute on Minority Health and Health Disparities of the National Institutes of Health. Mr. Bensken has reported receiving research support for this work from the NIH.

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

In addition to high rates of anxiety and mood disorders, epilepsy is associated with several comorbidities, including headache, hypertension, and back pain, new research shows. Investigators also found racial and ethnic disparities in comorbidity prevalence.

“Our study identified that people with epilepsy have complex health care needs that extend well beyond their epilepsy,” said co-investigator Wyatt P. Bensken, a PhD candidate in the Department of Population and Quantitative Health Sciences at Case Western Reserve University, Cleveland.

The findings were presented at the annual meeting of the American Epilepsy Society.
 

A vulnerable population

Researchers identified individuals with epilepsy using Medicaid claims from 2010 to 2014. Mr. Bensken noted that the approximately one-third of patients with epilepsy covered by Medicaid represent “the most vulnerable” population with the disorder because they may not be working and often have other disabilities.

Based on an algorithm that puts diagnostic codes into clinically meaningful categories, the investigators focused on 190 conditions.

“A strength of the study was that we were able to cast such a broad net” to capture conditions, Mr. Bensken said.

Anxiety and mood disorders were originally in separate categories but were grouped together “after recognizing that those who had one pretty much had the other,” he added.

The researchers used a machine learning technique known as association rule mining (ARM) to uncover frequently occurring conditions and combinations of conditions. This same statistical technique is used by companies such as Amazon to determine future purchases based on articles people have bought.

Among 81,963 patients with epilepsy, the most common conditions were anxiety and mood disorders (46.5%). These were followed by hypertension (36.9%), back problems (35.2%), developmental disorders (31.6%), and headache including migraine (29.5%). Urinary tract infections (UTIs) were experienced by 22.8% of the sample.

The rate of anxiety and mood disorders was not unexpected, “but I was surprised to see hypertension so high on the list,” said Mr. Bensken. He noted there is also increasing evidence pointing to a cardiovascular-epilepsy connection.
 

What should neurologists do?

The study also highlights the relatively high rate of back problems, which are not usually considered a comorbidity in patients with epilepsy, Mr. Bensken said. “Back problems likely greatly impact a patient’s quality of life, and seeing them so high on the list makes me wonder if neurologists or epileptologists or primary care doctors are even asking about back pain and how that might impact the ability to function day to day,” he added.

How do these rates compare with the general population? From other studies, the estimated prevalence for anxiety and mood disorders is 20%-30%, compared with almost 50% of the current sample, said Mr. Bensken.

In addition, the rate of hypertension in the study’s epilepsy population was about 7% higher than the general population, and the rate of UTIs was about 12% higher, he reported.

When examining combinations of conditions, anxiety and mood disorders continued to have an “outsized” prevalence, appearing in nearly every combination, the investigators noted.

Almost a quarter (24.7%) of participants had back problems plus anxiety and a mood disorder, and about 15% had headaches and back problems as well as anxiety and a mood disorder.

“That’s a non-negligible amount of the population that have not just one or two things going on but three and four,” said Mr. Bensken.

These new results underscore how complex these patients can be and the need to integrate medical care among different specialties, he noted.

“We don’t believe it’s the neurologist’s job to also manage the hypertension, but being aware of how prevalent hypertension may be and working with the primary care doctor, or at least checking in with the patient and asking if they’re managing their hypertension, is a real priority,” he said.

Researchers also used the ARM system to identify racial disparities, “which have been largely understudied in the epilepsy context,” said Mr. Bensken.

American Indians and Alaskan Natives had a substantially higher prevalence of developmental disabilities, while Black participants had a higher prevalence of hypertension.

One of the study’s themes was that disparities were not uniform, Mr. Bensken noted. “It wasn’t that in every condition the prevalence was lowest for White individuals and highest for everybody else,” he said.

These results point to the need for a larger study to examine the cultural context of these subgroups and such things as structural racism that might drive disparities, he added.

When researchers examined combinations of comorbidities in individuals in the top quartile of hospitalizations and emergency department visits, they found high users had a much higher disease burden, with 75.8% having anxiety or a mood disorder.

The study highlights that patients with epilepsy on Medicaid are “a high priority population,” said Mr. Bensken.
 

‘Drift down hypothesis’

Commenting on the findings, Fred A. Lado, MD, PhD, director of epilepsy at Northwell Health Eastern and Central Regions, said the increased incidence of comorbidities in patients of low socioeconomic status was not surprising.

“The interesting data here is that we see an even higher incidence among people with epilepsy,” said Dr. Lado, who was not involved with the research.

The study shows how epilepsy exacerbates the effects of low socioeconomic status, he added.

“One of the determinants of socioeconomic status in this case may well be the fact they have seizures and have a limited ability to work and are often more dependent on state assistance and disability support,” Dr. Lado said.

He also referred to the “drift down hypothesis” of chronic disease. “If you have epilepsy and are born into a middle-class family, chances are you will be on disability and can’t work, so you probably have a lower socioeconomic status than your family did as you grew up.”

Dr. Lado noted how “extremely common” mood disorders are in this population and that certain pain syndromes “tracked with those mood disorders.”

“We know mood disorders are more prevalent in people with epilepsy, and now we see that pain-related problems – headache and back pain – are more prevalent in people with epilepsy,” he said.

The data showing “downstream effects of the mood disorders,” from epilepsy to mood disorders to pain disorders, was “very interesting,” Dr. Lado said.

The study was funded by the Centers for Disease Control and Prevention and the National Institute on Minority Health and Health Disparities of the National Institutes of Health. Mr. Bensken has reported receiving research support for this work from the NIH.

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

Everyone can remember a book from their childhood that helped transform them, reinvent them, or turned the world on its head. Characters such as Harry Potter, Franklin the Turtle, Matilda, the Very Hungry Caterpillar, Corduroy, and Nancy Drew, among others, continue to exist in the cultural zeitgeist because they remind us of our childhood and the experience of discovering something innovative and exciting for the first time.

For many young children, introductions to these timeless characters first come from an adult reading to them. Those interactions, starting with watching mouths form words, to exploring pictures, to eventually reading along, leave a lasting impression. “Adults remember being read to,” says pediatrician Perri Klass, MD. “It’s a very powerful thing.”

Dr. Klass serves as national medical director of Reach Out and Read, a nonprofit organization that champions the positive effects of reading and other language-rich activities with young children.

And what better partners to involve in this mission than pediatricians? Before a child reaches the age of 4, the U.S. Department of Health and Human Services recommends that a child visit the pediatrician at least seven times. The Bright Futures/American Academy of Pediatrics suggests as many as 13 pediatrician visits before the child reaches that same milestone. Regardless of the exact number, almost all children are encountering a pediatrician multiple times during the most crucial years of their brain development.

In 1989, physicians Barry Zuckerman, MD, and Robert Needleman, MD, at Boston City Hospital (now Boston Medical Center) realized that they could reach a large population of children and parents, especially those coming from disadvantaged backgrounds, in the pediatrics ward of offices and hospitals all over the country.        

The design of Reach Out and Read, the organization they founded, is to work with pediatricians in how they can best support parents in making reading to their children a part of their daily routine, advocating for the importance of books for children, and making sure that a child leaves the office with a book to take home.

Rather than just dumping books onto nervous or busy parents, the organization trains doctors on how to teach parents to read to their children: how to hold the books, how to make it as active as possible, how to point to the pictures and make them come to life, and how to make sure the child is grasping the language.

“You don’t just prop a baby up and read to them,” Dr. Klass told this news organization. “You have to make it interactive.”
 

Physician-driven success  

Now an international organization, Dr. Klass has watched the nonprofit grow tremendously since it began during her fellowship in Boston over three decades ago. The initiative has over 6,100 sites in all 50 states and is able to get books into the hands of 4.2 million children every single year through government aid, individual contributions, and in-kind donations. On average, the organization is able to give parents 6.4 million books annually. Half of the children served every year by the program come from low-income backgrounds.

Dr. Klass ascribed some of the organization’s longevity and success to “practical realism,” its “mission-driven” approach, and its creation by people in primary care who understood the constraints, the upkeep, and the scaling.

“Our organization isn’t looking to pile 10 more things on to the hands of pediatricians who are already very busy,” she said. “We understand that conversation is important with our care providers. We always hear that watching children happily interacting with literature is one of the most rewarding parts of their job. So, we’re saying to them, ‘I want to help you do what you enjoy most.’”

Both Dr. Klass, who is also a presidential appointee to the Advisory Board of the National Institute For Literacy, and Brian Gallagher, MPA, the CEO of Reach Out and Read, said one of the most rewarding parts of their attachment to the organization is working with dedicated physicians all over the country.

“We hear all the time that physicians say working with these tools [from Reach Out and Read] is the most joyful part of their day,” said Mr. Gallagher. “Children are hope for the future and books help them grow.”

Amy Shriver, MD, an Iowa pediatrician and medical director of the Reach Out and Read Iowa Board, admitted that at first she just thought of the organization as a book drive. As Dr. Shriver got closer to the organization, though, she realized how she could utilize the book as a surveillance tool.

“At 6 months through 2 years, I hand the book to the patient, and I can always tell which children are familiar with books by their responses,” she said. After learning about and implementing Reach Out and Read’s ‘model, observe, coach’ methodology, Dr. Shriver said she was wowed by how much it helped families who weren’t reading to their child understand not only how to read with their children but why it’s so important.”

Dr. Shriver said that her clinic has purchased more diverse books to meet the needs of its patient population and has partnered with local libraries and a science center to promote early brain development. The biggest change is that Dr. Shriver finds herself spending more time observing and talking about parent/child relationships since starting with Reach Out and Read.

Mr. Gallagher attributed the organization’s success to the massive amounts of research that back up the practices of the organization. “Our model isn’t just a nice thing to do,” Mr. Gallagher said. “Our practice has been proven to be effective, and that’s why pediatricians continue to work with us. We’ve heard experts say that when they’re advocating for children’s health, they say ‘vaccines, sleep, and Reach Out and Read.’”

Nineteen independent studies have been done profiling the work of Reach Out and Read since its inception. The research has shown that exposure to the organization results in parents reading more often to their children, higher language scores, as well as an improvement in clinic culture and clinician well-being.

In 2014, the American Academy of Pediatrics quoted the research of Reach Out and Read in its policy statement “Literacy Promotion: An Essential Component of Primary Care Pediatric Practice,” which argued that pediatrics should advocate for literacy from birth. The abstract of the study suggests that practicing pediatricians “advise all parents that reading aloud with young children can enhance parent-child relationships and prepare young minds to learn language and early literacy skills ... provide developmentally appropriate books given at health supervision visits for all high-risk, low-income young children ... partnering with other child advocates to influence national messaging and policies that support and promote these key, early shared-reading experiences.”
 

Adapting to benefit children and parents

Reach Out and Read is not afraid to change with the times. When it began in 1989, there was no guidance for pediatricians on the importance of reading. Mr. Gallagher said that a common question Reach Out and Read received was, “Why not focus on physical health?” The organization was more interested in the shift in pediatric practice overtime. 

“We used to advocate starting off kids with books at 6 months old, but we always listen to the research,” Mr. Gallagher said. Now, the organization as well as the American Academy of Pediatrics advocate for beginning at birth. Other publications such as Green Child Magazine and Psychology Today speak of the importance of reading to babies still in the womb. The Proceedings of the National Academy of Sciences published an article in 2013 that suggests that third-trimester babies can not only pick up on language patterns but also can identify words first heard in the womb.

“We aren’t afraid to adjust our practice if it will be more effective and beneficial for children,” Mr. Gallagher said, “We follow the research and share the work that we are doing. It’s important to stay as up to date as possible.”

Although the focus is largely on the health of children, the impact on parents is crucial as well. Mr. Gallagher described the books at the center of the mission as “a vehicle for bonding” between parents and their children. “The relationship-building we see between families is truly quite magical,” he said.

“Parents will say it’s a respite in their day,” Dr. Klass said of the daily practice of reading aloud. She recalled a memory of talking to a mother with two rowdy young boys, who would sit down and read to them, immediately calming them down.

“When parents sit down to read to their children they don’t have to make anything up. It’s a script, it’s a prompt. You have this story, a picture to show. And kids get preferences,” she said. “When they pick a book that they want you to read, they get to exercise some control. It’s a satisfying routine for parents. It helps open up the world to your child. And when kids come over and hand a book to you for you to read together, it’s them saying, ‘I like the way you look, sound, and interact with me when we do this together.’”

A study from Ambulatory Pediatrics demonstrated that families working with Reach Out and Read were more likely to report reading aloud at bedtime, to read aloud three or more days per week, to mention reading aloud as a favorite parenting activity, and to own 10 or more children’s books. The American Journal of Diseases for Children, in a 1991 article co-authored by Needleman and Zuckerman, noted that the effects of Reach Out and Read were greater for those families who were receiving Aid to Families with Dependent Children. In 2015, the Pew Research Center unveiled a report, “Parenting in America” on raising a child in the modern age, the first generation in American history expected, on average, to make less than their parents.

The report stated that “a broad, demographically-based look at the landscape of American families reveals stark parenting divides linked less to philosophies or values and more to economic circumstances and changing family structure.”

As questions of access and privilege loom over the growing world of education, Reach Out and Read is trying to shorten the gap one book at a time. They are hoping, in time, that their model will be able to reach 90% of children in the United States and foster a relationship with reading and protecting children from toxic stress.

“Every time I look at a newborn, I think about the power of relationships,” said Dr. Shriver, the Iowa-based pediatrician. “I think about how much love passes between infants and their parents, and how shared reading is such a powerful way to show our children we love them. I know from my own experiences how good it feels to snuggle every night and read together. Those moments when the world falls away, and it’s just you, your child, and a book are magical.”

“I want every parent and child to have that experience and create those loving memories. I want all children to feel safe, secure, and loved. I want every child to have the opportunity to use books as a mirror to see themselves and as a window to see the world.”

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

Everyone can remember a book from their childhood that helped transform them, reinvent them, or turned the world on its head. Characters such as Harry Potter, Franklin the Turtle, Matilda, the Very Hungry Caterpillar, Corduroy, and Nancy Drew, among others, continue to exist in the cultural zeitgeist because they remind us of our childhood and the experience of discovering something innovative and exciting for the first time.

For many young children, introductions to these timeless characters first come from an adult reading to them. Those interactions, starting with watching mouths form words, to exploring pictures, to eventually reading along, leave a lasting impression. “Adults remember being read to,” says pediatrician Perri Klass, MD. “It’s a very powerful thing.”

Dr. Klass serves as national medical director of Reach Out and Read, a nonprofit organization that champions the positive effects of reading and other language-rich activities with young children.

And what better partners to involve in this mission than pediatricians? Before a child reaches the age of 4, the U.S. Department of Health and Human Services recommends that a child visit the pediatrician at least seven times. The Bright Futures/American Academy of Pediatrics suggests as many as 13 pediatrician visits before the child reaches that same milestone. Regardless of the exact number, almost all children are encountering a pediatrician multiple times during the most crucial years of their brain development.

In 1989, physicians Barry Zuckerman, MD, and Robert Needleman, MD, at Boston City Hospital (now Boston Medical Center) realized that they could reach a large population of children and parents, especially those coming from disadvantaged backgrounds, in the pediatrics ward of offices and hospitals all over the country.        

The design of Reach Out and Read, the organization they founded, is to work with pediatricians in how they can best support parents in making reading to their children a part of their daily routine, advocating for the importance of books for children, and making sure that a child leaves the office with a book to take home.

Rather than just dumping books onto nervous or busy parents, the organization trains doctors on how to teach parents to read to their children: how to hold the books, how to make it as active as possible, how to point to the pictures and make them come to life, and how to make sure the child is grasping the language.

“You don’t just prop a baby up and read to them,” Dr. Klass told this news organization. “You have to make it interactive.”
 

Physician-driven success  

Now an international organization, Dr. Klass has watched the nonprofit grow tremendously since it began during her fellowship in Boston over three decades ago. The initiative has over 6,100 sites in all 50 states and is able to get books into the hands of 4.2 million children every single year through government aid, individual contributions, and in-kind donations. On average, the organization is able to give parents 6.4 million books annually. Half of the children served every year by the program come from low-income backgrounds.

Dr. Klass ascribed some of the organization’s longevity and success to “practical realism,” its “mission-driven” approach, and its creation by people in primary care who understood the constraints, the upkeep, and the scaling.

“Our organization isn’t looking to pile 10 more things on to the hands of pediatricians who are already very busy,” she said. “We understand that conversation is important with our care providers. We always hear that watching children happily interacting with literature is one of the most rewarding parts of their job. So, we’re saying to them, ‘I want to help you do what you enjoy most.’”

Both Dr. Klass, who is also a presidential appointee to the Advisory Board of the National Institute For Literacy, and Brian Gallagher, MPA, the CEO of Reach Out and Read, said one of the most rewarding parts of their attachment to the organization is working with dedicated physicians all over the country.

“We hear all the time that physicians say working with these tools [from Reach Out and Read] is the most joyful part of their day,” said Mr. Gallagher. “Children are hope for the future and books help them grow.”

Amy Shriver, MD, an Iowa pediatrician and medical director of the Reach Out and Read Iowa Board, admitted that at first she just thought of the organization as a book drive. As Dr. Shriver got closer to the organization, though, she realized how she could utilize the book as a surveillance tool.

“At 6 months through 2 years, I hand the book to the patient, and I can always tell which children are familiar with books by their responses,” she said. After learning about and implementing Reach Out and Read’s ‘model, observe, coach’ methodology, Dr. Shriver said she was wowed by how much it helped families who weren’t reading to their child understand not only how to read with their children but why it’s so important.”

Dr. Shriver said that her clinic has purchased more diverse books to meet the needs of its patient population and has partnered with local libraries and a science center to promote early brain development. The biggest change is that Dr. Shriver finds herself spending more time observing and talking about parent/child relationships since starting with Reach Out and Read.

Mr. Gallagher attributed the organization’s success to the massive amounts of research that back up the practices of the organization. “Our model isn’t just a nice thing to do,” Mr. Gallagher said. “Our practice has been proven to be effective, and that’s why pediatricians continue to work with us. We’ve heard experts say that when they’re advocating for children’s health, they say ‘vaccines, sleep, and Reach Out and Read.’”

Nineteen independent studies have been done profiling the work of Reach Out and Read since its inception. The research has shown that exposure to the organization results in parents reading more often to their children, higher language scores, as well as an improvement in clinic culture and clinician well-being.

In 2014, the American Academy of Pediatrics quoted the research of Reach Out and Read in its policy statement “Literacy Promotion: An Essential Component of Primary Care Pediatric Practice,” which argued that pediatrics should advocate for literacy from birth. The abstract of the study suggests that practicing pediatricians “advise all parents that reading aloud with young children can enhance parent-child relationships and prepare young minds to learn language and early literacy skills ... provide developmentally appropriate books given at health supervision visits for all high-risk, low-income young children ... partnering with other child advocates to influence national messaging and policies that support and promote these key, early shared-reading experiences.”
 

Adapting to benefit children and parents

Reach Out and Read is not afraid to change with the times. When it began in 1989, there was no guidance for pediatricians on the importance of reading. Mr. Gallagher said that a common question Reach Out and Read received was, “Why not focus on physical health?” The organization was more interested in the shift in pediatric practice overtime. 

“We used to advocate starting off kids with books at 6 months old, but we always listen to the research,” Mr. Gallagher said. Now, the organization as well as the American Academy of Pediatrics advocate for beginning at birth. Other publications such as Green Child Magazine and Psychology Today speak of the importance of reading to babies still in the womb. The Proceedings of the National Academy of Sciences published an article in 2013 that suggests that third-trimester babies can not only pick up on language patterns but also can identify words first heard in the womb.

“We aren’t afraid to adjust our practice if it will be more effective and beneficial for children,” Mr. Gallagher said, “We follow the research and share the work that we are doing. It’s important to stay as up to date as possible.”

Although the focus is largely on the health of children, the impact on parents is crucial as well. Mr. Gallagher described the books at the center of the mission as “a vehicle for bonding” between parents and their children. “The relationship-building we see between families is truly quite magical,” he said.

“Parents will say it’s a respite in their day,” Dr. Klass said of the daily practice of reading aloud. She recalled a memory of talking to a mother with two rowdy young boys, who would sit down and read to them, immediately calming them down.

“When parents sit down to read to their children they don’t have to make anything up. It’s a script, it’s a prompt. You have this story, a picture to show. And kids get preferences,” she said. “When they pick a book that they want you to read, they get to exercise some control. It’s a satisfying routine for parents. It helps open up the world to your child. And when kids come over and hand a book to you for you to read together, it’s them saying, ‘I like the way you look, sound, and interact with me when we do this together.’”

A study from Ambulatory Pediatrics demonstrated that families working with Reach Out and Read were more likely to report reading aloud at bedtime, to read aloud three or more days per week, to mention reading aloud as a favorite parenting activity, and to own 10 or more children’s books. The American Journal of Diseases for Children, in a 1991 article co-authored by Needleman and Zuckerman, noted that the effects of Reach Out and Read were greater for those families who were receiving Aid to Families with Dependent Children. In 2015, the Pew Research Center unveiled a report, “Parenting in America” on raising a child in the modern age, the first generation in American history expected, on average, to make less than their parents.

The report stated that “a broad, demographically-based look at the landscape of American families reveals stark parenting divides linked less to philosophies or values and more to economic circumstances and changing family structure.”

As questions of access and privilege loom over the growing world of education, Reach Out and Read is trying to shorten the gap one book at a time. They are hoping, in time, that their model will be able to reach 90% of children in the United States and foster a relationship with reading and protecting children from toxic stress.

“Every time I look at a newborn, I think about the power of relationships,” said Dr. Shriver, the Iowa-based pediatrician. “I think about how much love passes between infants and their parents, and how shared reading is such a powerful way to show our children we love them. I know from my own experiences how good it feels to snuggle every night and read together. Those moments when the world falls away, and it’s just you, your child, and a book are magical.”

“I want every parent and child to have that experience and create those loving memories. I want all children to feel safe, secure, and loved. I want every child to have the opportunity to use books as a mirror to see themselves and as a window to see the world.”

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

Everyone can remember a book from their childhood that helped transform them, reinvent them, or turned the world on its head. Characters such as Harry Potter, Franklin the Turtle, Matilda, the Very Hungry Caterpillar, Corduroy, and Nancy Drew, among others, continue to exist in the cultural zeitgeist because they remind us of our childhood and the experience of discovering something innovative and exciting for the first time.

For many young children, introductions to these timeless characters first come from an adult reading to them. Those interactions, starting with watching mouths form words, to exploring pictures, to eventually reading along, leave a lasting impression. “Adults remember being read to,” says pediatrician Perri Klass, MD. “It’s a very powerful thing.”

Dr. Klass serves as national medical director of Reach Out and Read, a nonprofit organization that champions the positive effects of reading and other language-rich activities with young children.

And what better partners to involve in this mission than pediatricians? Before a child reaches the age of 4, the U.S. Department of Health and Human Services recommends that a child visit the pediatrician at least seven times. The Bright Futures/American Academy of Pediatrics suggests as many as 13 pediatrician visits before the child reaches that same milestone. Regardless of the exact number, almost all children are encountering a pediatrician multiple times during the most crucial years of their brain development.

In 1989, physicians Barry Zuckerman, MD, and Robert Needleman, MD, at Boston City Hospital (now Boston Medical Center) realized that they could reach a large population of children and parents, especially those coming from disadvantaged backgrounds, in the pediatrics ward of offices and hospitals all over the country.        

The design of Reach Out and Read, the organization they founded, is to work with pediatricians in how they can best support parents in making reading to their children a part of their daily routine, advocating for the importance of books for children, and making sure that a child leaves the office with a book to take home.

Rather than just dumping books onto nervous or busy parents, the organization trains doctors on how to teach parents to read to their children: how to hold the books, how to make it as active as possible, how to point to the pictures and make them come to life, and how to make sure the child is grasping the language.

“You don’t just prop a baby up and read to them,” Dr. Klass told this news organization. “You have to make it interactive.”
 

Physician-driven success  

Now an international organization, Dr. Klass has watched the nonprofit grow tremendously since it began during her fellowship in Boston over three decades ago. The initiative has over 6,100 sites in all 50 states and is able to get books into the hands of 4.2 million children every single year through government aid, individual contributions, and in-kind donations. On average, the organization is able to give parents 6.4 million books annually. Half of the children served every year by the program come from low-income backgrounds.

Dr. Klass ascribed some of the organization’s longevity and success to “practical realism,” its “mission-driven” approach, and its creation by people in primary care who understood the constraints, the upkeep, and the scaling.

“Our organization isn’t looking to pile 10 more things on to the hands of pediatricians who are already very busy,” she said. “We understand that conversation is important with our care providers. We always hear that watching children happily interacting with literature is one of the most rewarding parts of their job. So, we’re saying to them, ‘I want to help you do what you enjoy most.’”

Both Dr. Klass, who is also a presidential appointee to the Advisory Board of the National Institute For Literacy, and Brian Gallagher, MPA, the CEO of Reach Out and Read, said one of the most rewarding parts of their attachment to the organization is working with dedicated physicians all over the country.

“We hear all the time that physicians say working with these tools [from Reach Out and Read] is the most joyful part of their day,” said Mr. Gallagher. “Children are hope for the future and books help them grow.”

Amy Shriver, MD, an Iowa pediatrician and medical director of the Reach Out and Read Iowa Board, admitted that at first she just thought of the organization as a book drive. As Dr. Shriver got closer to the organization, though, she realized how she could utilize the book as a surveillance tool.

“At 6 months through 2 years, I hand the book to the patient, and I can always tell which children are familiar with books by their responses,” she said. After learning about and implementing Reach Out and Read’s ‘model, observe, coach’ methodology, Dr. Shriver said she was wowed by how much it helped families who weren’t reading to their child understand not only how to read with their children but why it’s so important.”

Dr. Shriver said that her clinic has purchased more diverse books to meet the needs of its patient population and has partnered with local libraries and a science center to promote early brain development. The biggest change is that Dr. Shriver finds herself spending more time observing and talking about parent/child relationships since starting with Reach Out and Read.

Mr. Gallagher attributed the organization’s success to the massive amounts of research that back up the practices of the organization. “Our model isn’t just a nice thing to do,” Mr. Gallagher said. “Our practice has been proven to be effective, and that’s why pediatricians continue to work with us. We’ve heard experts say that when they’re advocating for children’s health, they say ‘vaccines, sleep, and Reach Out and Read.’”

Nineteen independent studies have been done profiling the work of Reach Out and Read since its inception. The research has shown that exposure to the organization results in parents reading more often to their children, higher language scores, as well as an improvement in clinic culture and clinician well-being.

In 2014, the American Academy of Pediatrics quoted the research of Reach Out and Read in its policy statement “Literacy Promotion: An Essential Component of Primary Care Pediatric Practice,” which argued that pediatrics should advocate for literacy from birth. The abstract of the study suggests that practicing pediatricians “advise all parents that reading aloud with young children can enhance parent-child relationships and prepare young minds to learn language and early literacy skills ... provide developmentally appropriate books given at health supervision visits for all high-risk, low-income young children ... partnering with other child advocates to influence national messaging and policies that support and promote these key, early shared-reading experiences.”
 

Adapting to benefit children and parents

Reach Out and Read is not afraid to change with the times. When it began in 1989, there was no guidance for pediatricians on the importance of reading. Mr. Gallagher said that a common question Reach Out and Read received was, “Why not focus on physical health?” The organization was more interested in the shift in pediatric practice overtime. 

“We used to advocate starting off kids with books at 6 months old, but we always listen to the research,” Mr. Gallagher said. Now, the organization as well as the American Academy of Pediatrics advocate for beginning at birth. Other publications such as Green Child Magazine and Psychology Today speak of the importance of reading to babies still in the womb. The Proceedings of the National Academy of Sciences published an article in 2013 that suggests that third-trimester babies can not only pick up on language patterns but also can identify words first heard in the womb.

“We aren’t afraid to adjust our practice if it will be more effective and beneficial for children,” Mr. Gallagher said, “We follow the research and share the work that we are doing. It’s important to stay as up to date as possible.”

Although the focus is largely on the health of children, the impact on parents is crucial as well. Mr. Gallagher described the books at the center of the mission as “a vehicle for bonding” between parents and their children. “The relationship-building we see between families is truly quite magical,” he said.

“Parents will say it’s a respite in their day,” Dr. Klass said of the daily practice of reading aloud. She recalled a memory of talking to a mother with two rowdy young boys, who would sit down and read to them, immediately calming them down.

“When parents sit down to read to their children they don’t have to make anything up. It’s a script, it’s a prompt. You have this story, a picture to show. And kids get preferences,” she said. “When they pick a book that they want you to read, they get to exercise some control. It’s a satisfying routine for parents. It helps open up the world to your child. And when kids come over and hand a book to you for you to read together, it’s them saying, ‘I like the way you look, sound, and interact with me when we do this together.’”

A study from Ambulatory Pediatrics demonstrated that families working with Reach Out and Read were more likely to report reading aloud at bedtime, to read aloud three or more days per week, to mention reading aloud as a favorite parenting activity, and to own 10 or more children’s books. The American Journal of Diseases for Children, in a 1991 article co-authored by Needleman and Zuckerman, noted that the effects of Reach Out and Read were greater for those families who were receiving Aid to Families with Dependent Children. In 2015, the Pew Research Center unveiled a report, “Parenting in America” on raising a child in the modern age, the first generation in American history expected, on average, to make less than their parents.

The report stated that “a broad, demographically-based look at the landscape of American families reveals stark parenting divides linked less to philosophies or values and more to economic circumstances and changing family structure.”

As questions of access and privilege loom over the growing world of education, Reach Out and Read is trying to shorten the gap one book at a time. They are hoping, in time, that their model will be able to reach 90% of children in the United States and foster a relationship with reading and protecting children from toxic stress.

“Every time I look at a newborn, I think about the power of relationships,” said Dr. Shriver, the Iowa-based pediatrician. “I think about how much love passes between infants and their parents, and how shared reading is such a powerful way to show our children we love them. I know from my own experiences how good it feels to snuggle every night and read together. Those moments when the world falls away, and it’s just you, your child, and a book are magical.”

“I want every parent and child to have that experience and create those loving memories. I want all children to feel safe, secure, and loved. I want every child to have the opportunity to use books as a mirror to see themselves and as a window to see the world.”

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

“I might have to close my office,” a colleague wrote me recently. “I can’t find reliable medical assistants; no one good applies. Sad, but oh, well.”

A paucity of good employees is just one of many reasons given by physicians who have decided to close up shop. (See my recent column, “Finding Employees During a Pandemic”).

At this point, you should also begin thinking about disposition of your patients’ records. You can’t just shred them, much as you might be tempted. Your attorney and malpractice carrier will guide you in how long they must be retained; 7-10 years is typical in many states, but it could be longer in yours. Unless you are selling part or all of your practice to another physician, you will have to designate someone else to be the legal custodian of the records and obtain a written custodial agreement from that person or organization.

Once that is arranged, you can notify your patients. Send them a letter or e-mail (or both) informing them of the date that you intend to close the practice. Let them know where their records will be kept, who to contact for a copy, and that their written consent will be required to obtain it. Some states also require that a notice be placed in the local newspaper or online, including the date of closure and how to request records.

This is also the time to inform all your third-party payers, including Medicare and Medicaid if applicable, any hospitals where you have privileges, and referring physicians. Notify any business concerns not notified already, such as utilities and other ancillary services. Your state medical board and the Drug Enforcement Agency will need to know as well. Contact a liquidator or used equipment dealer to arrange for disposal of any office equipment that has resale value. It is also a good time to decide how you will handle patient collections that trickle in after closing, and where mail should be forwarded.

As the closing date approaches, determine how to properly dispose of any medications you have on-hand. Your state may have requirements for disposal of controlled substances, and possibly for noncontrolled pharmaceuticals as well. Check your state’s controlled substances reporting system and other applicable regulators. Once the office is closed, don’t forget to shred any blank prescription pads and dissolve your corporation, if you have one.

Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. He is the author of numerous articles and textbook chapters, and is a longtime monthly columnist for Dermatology News. Write to him at [email protected].

“I might have to close my office,” a colleague wrote me recently. “I can’t find reliable medical assistants; no one good applies. Sad, but oh, well.”

A paucity of good employees is just one of many reasons given by physicians who have decided to close up shop. (See my recent column, “Finding Employees During a Pandemic”).

At this point, you should also begin thinking about disposition of your patients’ records. You can’t just shred them, much as you might be tempted. Your attorney and malpractice carrier will guide you in how long they must be retained; 7-10 years is typical in many states, but it could be longer in yours. Unless you are selling part or all of your practice to another physician, you will have to designate someone else to be the legal custodian of the records and obtain a written custodial agreement from that person or organization.

Once that is arranged, you can notify your patients. Send them a letter or e-mail (or both) informing them of the date that you intend to close the practice. Let them know where their records will be kept, who to contact for a copy, and that their written consent will be required to obtain it. Some states also require that a notice be placed in the local newspaper or online, including the date of closure and how to request records.

This is also the time to inform all your third-party payers, including Medicare and Medicaid if applicable, any hospitals where you have privileges, and referring physicians. Notify any business concerns not notified already, such as utilities and other ancillary services. Your state medical board and the Drug Enforcement Agency will need to know as well. Contact a liquidator or used equipment dealer to arrange for disposal of any office equipment that has resale value. It is also a good time to decide how you will handle patient collections that trickle in after closing, and where mail should be forwarded.

As the closing date approaches, determine how to properly dispose of any medications you have on-hand. Your state may have requirements for disposal of controlled substances, and possibly for noncontrolled pharmaceuticals as well. Check your state’s controlled substances reporting system and other applicable regulators. Once the office is closed, don’t forget to shred any blank prescription pads and dissolve your corporation, if you have one.

Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. He is the author of numerous articles and textbook chapters, and is a longtime monthly columnist for Dermatology News. Write to him at [email protected].

“I might have to close my office,” a colleague wrote me recently. “I can’t find reliable medical assistants; no one good applies. Sad, but oh, well.”

A paucity of good employees is just one of many reasons given by physicians who have decided to close up shop. (See my recent column, “Finding Employees During a Pandemic”).

At this point, you should also begin thinking about disposition of your patients’ records. You can’t just shred them, much as you might be tempted. Your attorney and malpractice carrier will guide you in how long they must be retained; 7-10 years is typical in many states, but it could be longer in yours. Unless you are selling part or all of your practice to another physician, you will have to designate someone else to be the legal custodian of the records and obtain a written custodial agreement from that person or organization.

Once that is arranged, you can notify your patients. Send them a letter or e-mail (or both) informing them of the date that you intend to close the practice. Let them know where their records will be kept, who to contact for a copy, and that their written consent will be required to obtain it. Some states also require that a notice be placed in the local newspaper or online, including the date of closure and how to request records.

This is also the time to inform all your third-party payers, including Medicare and Medicaid if applicable, any hospitals where you have privileges, and referring physicians. Notify any business concerns not notified already, such as utilities and other ancillary services. Your state medical board and the Drug Enforcement Agency will need to know as well. Contact a liquidator or used equipment dealer to arrange for disposal of any office equipment that has resale value. It is also a good time to decide how you will handle patient collections that trickle in after closing, and where mail should be forwarded.

As the closing date approaches, determine how to properly dispose of any medications you have on-hand. Your state may have requirements for disposal of controlled substances, and possibly for noncontrolled pharmaceuticals as well. Check your state’s controlled substances reporting system and other applicable regulators. Once the office is closed, don’t forget to shred any blank prescription pads and dissolve your corporation, if you have one.

Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. He is the author of numerous articles and textbook chapters, and is a longtime monthly columnist for Dermatology News. Write to him at [email protected].

A nose for the tooth

Have you ever had a stuffy nose that just wouldn’t go away? Those irritating head colds have nothing on the stuffy nose a man in New York recently had to go through. A stuffy nose to top all stuffy noses. One stuffy nose to rule them all, as it were.

John Oliver/Pixabay

This man went to a Mount Sinai clinic with difficulty breathing through his right nostril, a problem that had been going on for years. Let us repeat that: A stuffy nose that lasted for years. The exam revealed a white mass jutting through the back of the septum and a CT scan confirmed the diagnosis. Perhaps you’ve already guessed, since the headline does give things away. Yes, this man had a tooth growing into his nose.

The problem was a half-inch-long ectopic tooth. Ectopic teeth are rare, occurring in less than 1% of people, but an ectopic tooth growing backward into the nasal cavity? Well, that’s so uncommon that this man got a case report in the New England Journal of Medicine.

This story does have a happy ending. Not all ectopic teeth need to be treated, but this one really did have to go. The offending tooth was surgically removed and, at a 3-month follow-up, the stuffy nose issue was completely resolved. So our friend gets the best of both worlds: His issue gets cured and he gets a case report in a major medical publication. If that’s not living the dream, we don’t know what is, and that’s the tooth.
 

Lettuce recommend you a sleep aid

Lettuce is great for many things. The star in a salad? Of course. The fresh element in a BLT? Yep. A sleep aid? According to a TikTok hack with almost 5 million views, the pinch hitter in a sandwich is switching leagues to be used like a tea for faster sleep. But, does it really work? Researchers say yes and no, according to a recent report at Tyla.com.

PxHere

Studies conducted in 2013 and 2017 pointed toward a compound called lactucin, which is found in the plant’s n-butanol fraction. In the 2013 study, mice that received n-butanol fraction fell asleep faster and stayed asleep longer. In 2017, researchers found that lettuce made mice sleep longer and helped protect against cell inflammation and damage.

OK, so it works on mice. But what about humans? In the TikTok video, user Shapla Hoque pours hot water on a few lettuce leaves in a mug with a peppermint tea bag (for flavor). After 10 minutes, when the leaves are soaked and soggy, she removes them and drinks the lettuce tea. By the end of the video she’s visibly drowsy and ready to crash. Does this hold water?

Here’s the no. Dr. Charlotte Norton of the Slimming Clinic told Tyla.com that yeah, there are some properties in lettuce that will help you fall asleep, such as lactucarium, which is prominent in romaine. But you would need a massive amount of lettuce to get any effect. The TikTok video, she said, is an example of the placebo effect.
 

Brains get a rise out of Viagra

A lot of medications are used off label. Antidepressants for COVID have taken the cake recently, but here’s a new one: Viagra for Alzheimer’s disease.

©roberthyrons/thinkstockphotos.com

Omicron is not a social-distancing robot

COVID, safe to say, has not been your typical, run-of-the-mill pandemic. People have protested social distancing. People have protested lockdowns. People have protested mask mandates. People have protested vaccine mandates. People have protested people protesting vaccine mandates.

neo tam/Pixabay

Someone used a fake arm to get a COVID vaccine card. People have tried to reverse their COVID vaccinations. People had COVID contamination parties.

The common denominator? People. Humans. Maybe what we need is a nonhuman intervention. To fight COVID, we need a hero. A robotic hero.

And where can we find such a hero? The University of Maryland, of course, where computer scientists and engineers are working on an autonomous mobile robot to enforce indoor social-distancing rules.

Their robot can detect lapses in social distancing using cameras, both thermal and visual, along with a LiDAR (Light Detection and Ranging) sensor. It then sorts the offenders into various groups depending on whether they are standing still or moving and predicts their future movement using a state-of-the-art hybrid collision avoidance method known as Frozone, Adarsh Jagan Sathyamoorthy and associates explained in PLOS One.

“Once it reaches the breach, the robot encourages people to move apart via text that appears on a mounted display,” ScienceDaily said.

Maybe you were expecting a Terminator-type robot coming to enforce social distancing requirements rather than a simple text message. Let’s just hope that all COVID guidelines are followed, including social distancing, so the pandemic will finally end and won’t “be back.”

A nose for the tooth

Have you ever had a stuffy nose that just wouldn’t go away? Those irritating head colds have nothing on the stuffy nose a man in New York recently had to go through. A stuffy nose to top all stuffy noses. One stuffy nose to rule them all, as it were.

John Oliver/Pixabay

This man went to a Mount Sinai clinic with difficulty breathing through his right nostril, a problem that had been going on for years. Let us repeat that: A stuffy nose that lasted for years. The exam revealed a white mass jutting through the back of the septum and a CT scan confirmed the diagnosis. Perhaps you’ve already guessed, since the headline does give things away. Yes, this man had a tooth growing into his nose.

The problem was a half-inch-long ectopic tooth. Ectopic teeth are rare, occurring in less than 1% of people, but an ectopic tooth growing backward into the nasal cavity? Well, that’s so uncommon that this man got a case report in the New England Journal of Medicine.

This story does have a happy ending. Not all ectopic teeth need to be treated, but this one really did have to go. The offending tooth was surgically removed and, at a 3-month follow-up, the stuffy nose issue was completely resolved. So our friend gets the best of both worlds: His issue gets cured and he gets a case report in a major medical publication. If that’s not living the dream, we don’t know what is, and that’s the tooth.
 

Lettuce recommend you a sleep aid

Lettuce is great for many things. The star in a salad? Of course. The fresh element in a BLT? Yep. A sleep aid? According to a TikTok hack with almost 5 million views, the pinch hitter in a sandwich is switching leagues to be used like a tea for faster sleep. But, does it really work? Researchers say yes and no, according to a recent report at Tyla.com.

PxHere

Studies conducted in 2013 and 2017 pointed toward a compound called lactucin, which is found in the plant’s n-butanol fraction. In the 2013 study, mice that received n-butanol fraction fell asleep faster and stayed asleep longer. In 2017, researchers found that lettuce made mice sleep longer and helped protect against cell inflammation and damage.

OK, so it works on mice. But what about humans? In the TikTok video, user Shapla Hoque pours hot water on a few lettuce leaves in a mug with a peppermint tea bag (for flavor). After 10 minutes, when the leaves are soaked and soggy, she removes them and drinks the lettuce tea. By the end of the video she’s visibly drowsy and ready to crash. Does this hold water?

Here’s the no. Dr. Charlotte Norton of the Slimming Clinic told Tyla.com that yeah, there are some properties in lettuce that will help you fall asleep, such as lactucarium, which is prominent in romaine. But you would need a massive amount of lettuce to get any effect. The TikTok video, she said, is an example of the placebo effect.
 

Brains get a rise out of Viagra

A lot of medications are used off label. Antidepressants for COVID have taken the cake recently, but here’s a new one: Viagra for Alzheimer’s disease.

©roberthyrons/thinkstockphotos.com

Omicron is not a social-distancing robot

COVID, safe to say, has not been your typical, run-of-the-mill pandemic. People have protested social distancing. People have protested lockdowns. People have protested mask mandates. People have protested vaccine mandates. People have protested people protesting vaccine mandates.

neo tam/Pixabay

Someone used a fake arm to get a COVID vaccine card. People have tried to reverse their COVID vaccinations. People had COVID contamination parties.

The common denominator? People. Humans. Maybe what we need is a nonhuman intervention. To fight COVID, we need a hero. A robotic hero.

And where can we find such a hero? The University of Maryland, of course, where computer scientists and engineers are working on an autonomous mobile robot to enforce indoor social-distancing rules.

Their robot can detect lapses in social distancing using cameras, both thermal and visual, along with a LiDAR (Light Detection and Ranging) sensor. It then sorts the offenders into various groups depending on whether they are standing still or moving and predicts their future movement using a state-of-the-art hybrid collision avoidance method known as Frozone, Adarsh Jagan Sathyamoorthy and associates explained in PLOS One.

“Once it reaches the breach, the robot encourages people to move apart via text that appears on a mounted display,” ScienceDaily said.

Maybe you were expecting a Terminator-type robot coming to enforce social distancing requirements rather than a simple text message. Let’s just hope that all COVID guidelines are followed, including social distancing, so the pandemic will finally end and won’t “be back.”

A nose for the tooth

Have you ever had a stuffy nose that just wouldn’t go away? Those irritating head colds have nothing on the stuffy nose a man in New York recently had to go through. A stuffy nose to top all stuffy noses. One stuffy nose to rule them all, as it were.

John Oliver/Pixabay

This man went to a Mount Sinai clinic with difficulty breathing through his right nostril, a problem that had been going on for years. Let us repeat that: A stuffy nose that lasted for years. The exam revealed a white mass jutting through the back of the septum and a CT scan confirmed the diagnosis. Perhaps you’ve already guessed, since the headline does give things away. Yes, this man had a tooth growing into his nose.

The problem was a half-inch-long ectopic tooth. Ectopic teeth are rare, occurring in less than 1% of people, but an ectopic tooth growing backward into the nasal cavity? Well, that’s so uncommon that this man got a case report in the New England Journal of Medicine.

This story does have a happy ending. Not all ectopic teeth need to be treated, but this one really did have to go. The offending tooth was surgically removed and, at a 3-month follow-up, the stuffy nose issue was completely resolved. So our friend gets the best of both worlds: His issue gets cured and he gets a case report in a major medical publication. If that’s not living the dream, we don’t know what is, and that’s the tooth.
 

Lettuce recommend you a sleep aid

Lettuce is great for many things. The star in a salad? Of course. The fresh element in a BLT? Yep. A sleep aid? According to a TikTok hack with almost 5 million views, the pinch hitter in a sandwich is switching leagues to be used like a tea for faster sleep. But, does it really work? Researchers say yes and no, according to a recent report at Tyla.com.

PxHere

Studies conducted in 2013 and 2017 pointed toward a compound called lactucin, which is found in the plant’s n-butanol fraction. In the 2013 study, mice that received n-butanol fraction fell asleep faster and stayed asleep longer. In 2017, researchers found that lettuce made mice sleep longer and helped protect against cell inflammation and damage.

OK, so it works on mice. But what about humans? In the TikTok video, user Shapla Hoque pours hot water on a few lettuce leaves in a mug with a peppermint tea bag (for flavor). After 10 minutes, when the leaves are soaked and soggy, she removes them and drinks the lettuce tea. By the end of the video she’s visibly drowsy and ready to crash. Does this hold water?

Here’s the no. Dr. Charlotte Norton of the Slimming Clinic told Tyla.com that yeah, there are some properties in lettuce that will help you fall asleep, such as lactucarium, which is prominent in romaine. But you would need a massive amount of lettuce to get any effect. The TikTok video, she said, is an example of the placebo effect.
 

Brains get a rise out of Viagra

A lot of medications are used off label. Antidepressants for COVID have taken the cake recently, but here’s a new one: Viagra for Alzheimer’s disease.

©roberthyrons/thinkstockphotos.com

Omicron is not a social-distancing robot

COVID, safe to say, has not been your typical, run-of-the-mill pandemic. People have protested social distancing. People have protested lockdowns. People have protested mask mandates. People have protested vaccine mandates. People have protested people protesting vaccine mandates.

neo tam/Pixabay

Someone used a fake arm to get a COVID vaccine card. People have tried to reverse their COVID vaccinations. People had COVID contamination parties.

The common denominator? People. Humans. Maybe what we need is a nonhuman intervention. To fight COVID, we need a hero. A robotic hero.

And where can we find such a hero? The University of Maryland, of course, where computer scientists and engineers are working on an autonomous mobile robot to enforce indoor social-distancing rules.

Their robot can detect lapses in social distancing using cameras, both thermal and visual, along with a LiDAR (Light Detection and Ranging) sensor. It then sorts the offenders into various groups depending on whether they are standing still or moving and predicts their future movement using a state-of-the-art hybrid collision avoidance method known as Frozone, Adarsh Jagan Sathyamoorthy and associates explained in PLOS One.

“Once it reaches the breach, the robot encourages people to move apart via text that appears on a mounted display,” ScienceDaily said.

Maybe you were expecting a Terminator-type robot coming to enforce social distancing requirements rather than a simple text message. Let’s just hope that all COVID guidelines are followed, including social distancing, so the pandemic will finally end and won’t “be back.”

A raft of new studies that looked at the ability of Omicron to evade an array of currently available vaccines suggest a substantial loss of protection against the highly mutated variant.

Medscape Illustration/Dreamstime

The new studies, from teams of researchers in Germany, South Africa, Sweden, and the drug company Pfizer, showed 25 to 40-fold drops in the ability of antibodies created by two doses of the Pfizer-BioNTech vaccine to neutralize the virus.  

But there seemed to be a bright spot in the studies too. The virus didn’t completely escape the immunity from the vaccines, and giving a third, booster dose appeared to restore antibodies to a level that’s been associated with protection against variants in the past.

“One of the silver linings of this pandemic so far is that mRNA vaccines manufactured based on the ancestral SARS-CoV-2 continue to work in the laboratory and, importantly, in real life against variant strains,” said Hana El Sahly, MD, professor of molecular virology and microbiology at Baylor College of Medicine in Houston. “The strains so far vary by their degree of being neutralized by the antibodies from these vaccines, but they are being neutralized nonetheless.” 

Dr. El Sahly points out that the Beta variant was associated with a 10-fold drop in antibodies, but two doses of the vaccines still protected against it.

President Biden hailed the study results as good news.

“That Pfizer lab report came back saying that the expectation is that the existing vaccines protect against Omicron. But if you get the booster, you’re really in good shape. And so that’s very encouraging,” he said in a press briefing Dec. 8.
 

More research needed

Other scientists, however, stressed that these studies are from lab tests, and don’t necessarily reflect what will happen with Omicron in the real world. They cautioned about a worldwide push for boosters with so many countries still struggling to give first doses of vaccines.

Soumya Swaminathan, MD, chief scientist for the World Health Organization, stressed in a press briefing Dec. 8 that the results from the four studies varied widely, showing dips in neutralizing activity with Omicron that ranged from 5-fold to 40-fold.

The types of lab tests that were run were different, too, and involved small numbers of blood samples from patients.

She stressed that immunity depends not just on neutralizing antibodies, which act as a first line of defense when a virus invades, but also on B cells and T cells, and so far, tests show that these crucial components — which are important for preventing severe disease and death — had been less impacted than antibodies.

“So, I think it’s premature to conclude that this reduction in neutralizing activity would result in a significant reduction in vaccine effectiveness,” she said.

Whether or not these first-generation vaccines will be enough to stop Omicron, though, remains to be seen. A study of the Pfizer, Moderna, and AstraZeneca vaccines, led by German physician Sandra Ciesek, MD, who directs the Institute of Medical Virology at the University of Frankfurt, shows a booster didn’t appear to hold up well over time.

Dr. Ciesek and her team exposed Omicron viruses to the antibodies of volunteers who had been boosted with the Pfizer vaccine 3 months prior.  

She also compared the results to what happened to those same 3-month antibody levels against Delta variant viruses. She found only a 25% neutralization of Omicron compared with a 95% neutralization of Delta. That represented about a 37-fold reduction in the ability of the antibodies to neutralize Omicron vs Delta.

“The data confirm that developing a vaccine adapted for Omicron makes sense,” she tweeted as part of a long thread she posted on her results.
 

Retool the vaccines?

Both Pfizer and Moderna are retooling their vaccines to better match them to the changes in the Omicron variant. In a press release, Pfizer said it could start deliveries of that updated vaccine by March, pending U.S. Food and Drug Administration authorization.

“What the booster really does in neutralizing Omicron right now, they don’t know, they have no idea,” said Peter Palese, PhD, chair of the department of microbiology at the Mount Sinai School of Medicine in New York City.

Dr. Palese said he was definitely concerned about a possible Omicron wave.

“There are four major sites on the spike protein targeted by antibodies from the vaccines, and all four sites have mutations,” he said. “All these important antigenic sites are changed.

“If Omicron becomes the new Delta, and the old vaccines really aren’t good enough, then we have to make new Omicron vaccines. Then we have to revaccinate everybody twice,” he said, and the costs could be staggering. “I am worried.”

Tedros Adhanom Ghebreyesus, PhD, director general of the WHO, urged countries to move quickly.

“Don’t wait. Act now,” he said, even before all the science is in hand. “All of us, every government, every individual should use all the tools we have right now,” to drive down transmission, increase testing and surveillance, and share scientific findings.

“We can prevent Omicron [from] becoming a global crisis right now,” he said.

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

A raft of new studies that looked at the ability of Omicron to evade an array of currently available vaccines suggest a substantial loss of protection against the highly mutated variant.

Medscape Illustration/Dreamstime

The new studies, from teams of researchers in Germany, South Africa, Sweden, and the drug company Pfizer, showed 25 to 40-fold drops in the ability of antibodies created by two doses of the Pfizer-BioNTech vaccine to neutralize the virus.  

But there seemed to be a bright spot in the studies too. The virus didn’t completely escape the immunity from the vaccines, and giving a third, booster dose appeared to restore antibodies to a level that’s been associated with protection against variants in the past.

“One of the silver linings of this pandemic so far is that mRNA vaccines manufactured based on the ancestral SARS-CoV-2 continue to work in the laboratory and, importantly, in real life against variant strains,” said Hana El Sahly, MD, professor of molecular virology and microbiology at Baylor College of Medicine in Houston. “The strains so far vary by their degree of being neutralized by the antibodies from these vaccines, but they are being neutralized nonetheless.” 

Dr. El Sahly points out that the Beta variant was associated with a 10-fold drop in antibodies, but two doses of the vaccines still protected against it.

President Biden hailed the study results as good news.

“That Pfizer lab report came back saying that the expectation is that the existing vaccines protect against Omicron. But if you get the booster, you’re really in good shape. And so that’s very encouraging,” he said in a press briefing Dec. 8.
 

More research needed

Other scientists, however, stressed that these studies are from lab tests, and don’t necessarily reflect what will happen with Omicron in the real world. They cautioned about a worldwide push for boosters with so many countries still struggling to give first doses of vaccines.

Soumya Swaminathan, MD, chief scientist for the World Health Organization, stressed in a press briefing Dec. 8 that the results from the four studies varied widely, showing dips in neutralizing activity with Omicron that ranged from 5-fold to 40-fold.

The types of lab tests that were run were different, too, and involved small numbers of blood samples from patients.

She stressed that immunity depends not just on neutralizing antibodies, which act as a first line of defense when a virus invades, but also on B cells and T cells, and so far, tests show that these crucial components — which are important for preventing severe disease and death — had been less impacted than antibodies.

“So, I think it’s premature to conclude that this reduction in neutralizing activity would result in a significant reduction in vaccine effectiveness,” she said.

Whether or not these first-generation vaccines will be enough to stop Omicron, though, remains to be seen. A study of the Pfizer, Moderna, and AstraZeneca vaccines, led by German physician Sandra Ciesek, MD, who directs the Institute of Medical Virology at the University of Frankfurt, shows a booster didn’t appear to hold up well over time.

Dr. Ciesek and her team exposed Omicron viruses to the antibodies of volunteers who had been boosted with the Pfizer vaccine 3 months prior.  

She also compared the results to what happened to those same 3-month antibody levels against Delta variant viruses. She found only a 25% neutralization of Omicron compared with a 95% neutralization of Delta. That represented about a 37-fold reduction in the ability of the antibodies to neutralize Omicron vs Delta.

“The data confirm that developing a vaccine adapted for Omicron makes sense,” she tweeted as part of a long thread she posted on her results.
 

Retool the vaccines?

Both Pfizer and Moderna are retooling their vaccines to better match them to the changes in the Omicron variant. In a press release, Pfizer said it could start deliveries of that updated vaccine by March, pending U.S. Food and Drug Administration authorization.

“What the booster really does in neutralizing Omicron right now, they don’t know, they have no idea,” said Peter Palese, PhD, chair of the department of microbiology at the Mount Sinai School of Medicine in New York City.

Dr. Palese said he was definitely concerned about a possible Omicron wave.

“There are four major sites on the spike protein targeted by antibodies from the vaccines, and all four sites have mutations,” he said. “All these important antigenic sites are changed.

“If Omicron becomes the new Delta, and the old vaccines really aren’t good enough, then we have to make new Omicron vaccines. Then we have to revaccinate everybody twice,” he said, and the costs could be staggering. “I am worried.”

Tedros Adhanom Ghebreyesus, PhD, director general of the WHO, urged countries to move quickly.

“Don’t wait. Act now,” he said, even before all the science is in hand. “All of us, every government, every individual should use all the tools we have right now,” to drive down transmission, increase testing and surveillance, and share scientific findings.

“We can prevent Omicron [from] becoming a global crisis right now,” he said.

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

A raft of new studies that looked at the ability of Omicron to evade an array of currently available vaccines suggest a substantial loss of protection against the highly mutated variant.

Medscape Illustration/Dreamstime

The new studies, from teams of researchers in Germany, South Africa, Sweden, and the drug company Pfizer, showed 25 to 40-fold drops in the ability of antibodies created by two doses of the Pfizer-BioNTech vaccine to neutralize the virus.  

But there seemed to be a bright spot in the studies too. The virus didn’t completely escape the immunity from the vaccines, and giving a third, booster dose appeared to restore antibodies to a level that’s been associated with protection against variants in the past.

“One of the silver linings of this pandemic so far is that mRNA vaccines manufactured based on the ancestral SARS-CoV-2 continue to work in the laboratory and, importantly, in real life against variant strains,” said Hana El Sahly, MD, professor of molecular virology and microbiology at Baylor College of Medicine in Houston. “The strains so far vary by their degree of being neutralized by the antibodies from these vaccines, but they are being neutralized nonetheless.” 

Dr. El Sahly points out that the Beta variant was associated with a 10-fold drop in antibodies, but two doses of the vaccines still protected against it.

President Biden hailed the study results as good news.

“That Pfizer lab report came back saying that the expectation is that the existing vaccines protect against Omicron. But if you get the booster, you’re really in good shape. And so that’s very encouraging,” he said in a press briefing Dec. 8.
 

More research needed

Other scientists, however, stressed that these studies are from lab tests, and don’t necessarily reflect what will happen with Omicron in the real world. They cautioned about a worldwide push for boosters with so many countries still struggling to give first doses of vaccines.

Soumya Swaminathan, MD, chief scientist for the World Health Organization, stressed in a press briefing Dec. 8 that the results from the four studies varied widely, showing dips in neutralizing activity with Omicron that ranged from 5-fold to 40-fold.

The types of lab tests that were run were different, too, and involved small numbers of blood samples from patients.

She stressed that immunity depends not just on neutralizing antibodies, which act as a first line of defense when a virus invades, but also on B cells and T cells, and so far, tests show that these crucial components — which are important for preventing severe disease and death — had been less impacted than antibodies.

“So, I think it’s premature to conclude that this reduction in neutralizing activity would result in a significant reduction in vaccine effectiveness,” she said.

Whether or not these first-generation vaccines will be enough to stop Omicron, though, remains to be seen. A study of the Pfizer, Moderna, and AstraZeneca vaccines, led by German physician Sandra Ciesek, MD, who directs the Institute of Medical Virology at the University of Frankfurt, shows a booster didn’t appear to hold up well over time.

Dr. Ciesek and her team exposed Omicron viruses to the antibodies of volunteers who had been boosted with the Pfizer vaccine 3 months prior.  

She also compared the results to what happened to those same 3-month antibody levels against Delta variant viruses. She found only a 25% neutralization of Omicron compared with a 95% neutralization of Delta. That represented about a 37-fold reduction in the ability of the antibodies to neutralize Omicron vs Delta.

“The data confirm that developing a vaccine adapted for Omicron makes sense,” she tweeted as part of a long thread she posted on her results.
 

Retool the vaccines?

Both Pfizer and Moderna are retooling their vaccines to better match them to the changes in the Omicron variant. In a press release, Pfizer said it could start deliveries of that updated vaccine by March, pending U.S. Food and Drug Administration authorization.

“What the booster really does in neutralizing Omicron right now, they don’t know, they have no idea,” said Peter Palese, PhD, chair of the department of microbiology at the Mount Sinai School of Medicine in New York City.

Dr. Palese said he was definitely concerned about a possible Omicron wave.

“There are four major sites on the spike protein targeted by antibodies from the vaccines, and all four sites have mutations,” he said. “All these important antigenic sites are changed.

“If Omicron becomes the new Delta, and the old vaccines really aren’t good enough, then we have to make new Omicron vaccines. Then we have to revaccinate everybody twice,” he said, and the costs could be staggering. “I am worried.”

Tedros Adhanom Ghebreyesus, PhD, director general of the WHO, urged countries to move quickly.

“Don’t wait. Act now,” he said, even before all the science is in hand. “All of us, every government, every individual should use all the tools we have right now,” to drive down transmission, increase testing and surveillance, and share scientific findings.

“We can prevent Omicron [from] becoming a global crisis right now,” he said.

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

The photo distribution and annular quality of this patient’s rash, combined with his positive autoimmune work-up, led to a diagnosis of subacute cutaneous lupus erythematosus (SCLE), a nonscarring subtype of cutaneous lupus erythematosus.

SCLE is a chronic and relapsing condition that may manifest as either a papulosquamous or annular eruption.¹ It most commonly affects areas of sun exposure such as the shoulders, upper back, and extensor surfaces of the arms. This disorder typically affects young or middle-aged women between the ages of 30 and 40 years.

The differential diagnosis of this eruption includes dermatomyositis, polymorphous light eruption, psoriasis, tinea corporis, and other photodermatoses. The etiology of SCLE is multifactorial and may include a genetic susceptibility in combination with environmental triggers that provoke an autoimmune response to sunlight.¹ There is strong evidence linking drug-induced SCLE with proton pump inhibitors, anticonvulsants, beta-blockers, terbinafine, and immune modulators.²

As many as 70% of patients with SCLE have positive anti-Ro/SSA autoantibodies, and this is most often associated with Sjogren syndrome.¹ Interestingly, SCLE patients often exhibit symptoms that overlap with Sjogren syndrome. Systemic involvement is rare in SCLE, and if present, these symptoms are usually limited to arthritis and myalgia.

Treatment of SCLE includes photo-protective behaviors, topical corticosteroids/calcineurin inhibitors, and systemic therapies such as hydroxychloroquine (first-line), methotrexate, and mycophenolate mofetil (second-line).²

Our patient was started on hydroxychloroquine 200 mg orally bid, with complete resolution of the lesions at his 2 month–follow-up appointment. This case emphasizes the importance of distinguishing SCLE from other subtypes of lupus erythematosus as the prognostic course and treatment varies between these conditions.

‌

Photos courtesy of Kriti Mishra, MD. Text courtesy of Jaimie Lin, BS, Kriti Mishra, MD, Department of Dermatology, and Daniel Stulberg, MD, FAAFP, Department of Family and Community Medicine, University of New Mexico School of Medicine, Albuquerque.

The photo distribution and annular quality of this patient’s rash, combined with his positive autoimmune work-up, led to a diagnosis of subacute cutaneous lupus erythematosus (SCLE), a nonscarring subtype of cutaneous lupus erythematosus.

SCLE is a chronic and relapsing condition that may manifest as either a papulosquamous or annular eruption.¹ It most commonly affects areas of sun exposure such as the shoulders, upper back, and extensor surfaces of the arms. This disorder typically affects young or middle-aged women between the ages of 30 and 40 years.

The differential diagnosis of this eruption includes dermatomyositis, polymorphous light eruption, psoriasis, tinea corporis, and other photodermatoses. The etiology of SCLE is multifactorial and may include a genetic susceptibility in combination with environmental triggers that provoke an autoimmune response to sunlight.¹ There is strong evidence linking drug-induced SCLE with proton pump inhibitors, anticonvulsants, beta-blockers, terbinafine, and immune modulators.²

As many as 70% of patients with SCLE have positive anti-Ro/SSA autoantibodies, and this is most often associated with Sjogren syndrome.¹ Interestingly, SCLE patients often exhibit symptoms that overlap with Sjogren syndrome. Systemic involvement is rare in SCLE, and if present, these symptoms are usually limited to arthritis and myalgia.

Treatment of SCLE includes photo-protective behaviors, topical corticosteroids/calcineurin inhibitors, and systemic therapies such as hydroxychloroquine (first-line), methotrexate, and mycophenolate mofetil (second-line).²

Our patient was started on hydroxychloroquine 200 mg orally bid, with complete resolution of the lesions at his 2 month–follow-up appointment. This case emphasizes the importance of distinguishing SCLE from other subtypes of lupus erythematosus as the prognostic course and treatment varies between these conditions.

‌

Photos courtesy of Kriti Mishra, MD. Text courtesy of Jaimie Lin, BS, Kriti Mishra, MD, Department of Dermatology, and Daniel Stulberg, MD, FAAFP, Department of Family and Community Medicine, University of New Mexico School of Medicine, Albuquerque.

The photo distribution and annular quality of this patient’s rash, combined with his positive autoimmune work-up, led to a diagnosis of subacute cutaneous lupus erythematosus (SCLE), a nonscarring subtype of cutaneous lupus erythematosus.

SCLE is a chronic and relapsing condition that may manifest as either a papulosquamous or annular eruption.¹ It most commonly affects areas of sun exposure such as the shoulders, upper back, and extensor surfaces of the arms. This disorder typically affects young or middle-aged women between the ages of 30 and 40 years.

The differential diagnosis of this eruption includes dermatomyositis, polymorphous light eruption, psoriasis, tinea corporis, and other photodermatoses. The etiology of SCLE is multifactorial and may include a genetic susceptibility in combination with environmental triggers that provoke an autoimmune response to sunlight.¹ There is strong evidence linking drug-induced SCLE with proton pump inhibitors, anticonvulsants, beta-blockers, terbinafine, and immune modulators.²

As many as 70% of patients with SCLE have positive anti-Ro/SSA autoantibodies, and this is most often associated with Sjogren syndrome.¹ Interestingly, SCLE patients often exhibit symptoms that overlap with Sjogren syndrome. Systemic involvement is rare in SCLE, and if present, these symptoms are usually limited to arthritis and myalgia.

Treatment of SCLE includes photo-protective behaviors, topical corticosteroids/calcineurin inhibitors, and systemic therapies such as hydroxychloroquine (first-line), methotrexate, and mycophenolate mofetil (second-line).²

Our patient was started on hydroxychloroquine 200 mg orally bid, with complete resolution of the lesions at his 2 month–follow-up appointment. This case emphasizes the importance of distinguishing SCLE from other subtypes of lupus erythematosus as the prognostic course and treatment varies between these conditions.

‌

Photos courtesy of Kriti Mishra, MD. Text courtesy of Jaimie Lin, BS, Kriti Mishra, MD, Department of Dermatology, and Daniel Stulberg, MD, FAAFP, Department of Family and Community Medicine, University of New Mexico School of Medicine, Albuquerque.

A 42-year-old woman presented to our dermatology center with white scars on both of her ankles. She first noticed the lesions 2 years prior; they were initially erythematous and painful, even when she was at rest. Her past medical history included 3 spontaneous term miscarriages. She denied any prolonged standing or trauma.

On examination, atrophic porcelain-white stellate scars were visible with surrounding hyperpigmentation on the medial aspect of both ankles (FIGURE 1A & 1B). There were no tender erythematous nodules, livedo reticularis, varicosities, or pedal edema present. The dorsalis pedis pulse was well felt and capillary refill time was less than 2 seconds; sensation was intact.

WHAT IS YOUR DIAGNOSIS?
HOW WOULD YOU TREAT THIS PATIENT?

Atrophie blanche is a morphologic feature described as porcelain-white stellate scars with surrounding telangiectasia and hyperpigmentation. The lesions are typically found over the peri-malleolar region and are sequelae of healed erythematous and painful ulcers. The lesions arise from upper dermal, small vessel, thrombotic vasculopathy leading to ischemic rest pain; if left untreated, atrophic white scars eventually develop.

A sign of venous insufficiency or thrombotic vasculopathy

Atrophie blanche may develop following healing of an ulcer due to venous insufficiency or small vessel thrombotic vasculopathy.¹ The incidence of thrombotic vasculopathy is 1:100,000 with a female predominance, and up to 50% of cases are associated with procoagulant conditions.² Thrombotic vasculopathy can be due to an inherited or acquired thrombophilia.¹

Atrophie blanche is an important clue to acquired thrombophilia.

Causes of hereditary thrombophilia include Factor V Leiden/prothrombin mutations, anti-thrombin III/protein C/protein S deficiencies, dysfibrinogenemia, and hyperhomocysteinemia.

Acquired thrombophilia arises from underlying prothrombotic states associated with the Virchow triad: hypercoagulability, blood flow stasis, and endothelial injury. The use of oral contraceptives or hormone replacement therapy, presence of malignancy, and antiphospholipid syndrome (APS) are causes of acquired thrombophilia.²

Obtaining a careful history is crucial

Thorough history-taking and physical examination are required to determine the underlying cause of atrophie blanche.

Continue to: Chronic venous insufficiency

Chronic venous insufficiency is more likely in patients with a history of prolonged standing, obesity, or previous injury/surgery to leg veins. Physical examination would reveal hyperpigmentation, telangiectasia, varicose veins, pedal edema, and venous ulcers.³

Inherited thrombophilia may be at work in patients with a family history of arterial and venous thrombosis (eg, stroke, acute coronary syndrome, or deep vein thromboses).

Acquired thrombophilia should be suspected if there is a history of recurrent miscarriages or malignancy.⁴ Given our patient’s history of miscarriages, we ordered further lab work and found that she had elevated anticardiolipin levels (> 40 U/mL) fulfilling the revised Sapporo criteria⁵ for APS.

Thrombophilia or chronic venous insufficiency? In a patient with a history suggestive of thrombophilia, further work-up should be done before attributing atrophie blanche to healed venous ulcers from chronic venous insufficiency. A skin lesion biopsy could reveal classic changes of thrombotic vasculopathy subjacent to the ulcer, including intraluminal thrombosis, endothelial proliferation, and subintimal hyaline degeneration, as opposed to dermal changes consistent with venous stasis, such as increased siderophages, hemosiderin deposition, erythrocyte extravasation, dermal fibrosis, and adipocytic damage.

Differential diagnosis includes atrophic scarring

The differential diagnosis for hypopigmented atrophic macules and plaques over the lower limbs include atrophic scarring from previous trauma, guttate morphea, extra-genital lichen sclerosus, and tuberculoid leprosy.

Continue to: Atrophic scarring

Atrophic scarring occurs only after trauma.

Guttate morphea lesions are sclerotic and may be depressed.

Extra-genital lichen sclerosus is characterized by polygonal, shiny, ivory-white sclerotic lesions with or without follicular plugging.

Tuberculoid leprosy involves loss of nociception, hypotrichosis, and palpable thickened regional nerves (eg, great auricular, sural, or ulnar nerve).

Treatment requires long-term anticoagulation

Our patient had APS and the mainstay of treatment is long-term systemic anticoagulation along with attentive wound care.⁶ Warfarin is preferred over a direct oral anticoagulant as it is more effective in the prevention of recurrent thrombosis in patients with APS.⁷

Our patient was started on warfarin. Since APS may occur as a primary condition or in the setting of a systemic disease, such as systemic lupus erythematosus, she was referred to a rheumatologist. 

A 42-year-old woman presented to our dermatology center with white scars on both of her ankles. She first noticed the lesions 2 years prior; they were initially erythematous and painful, even when she was at rest. Her past medical history included 3 spontaneous term miscarriages. She denied any prolonged standing or trauma.

On examination, atrophic porcelain-white stellate scars were visible with surrounding hyperpigmentation on the medial aspect of both ankles (FIGURE 1A & 1B). There were no tender erythematous nodules, livedo reticularis, varicosities, or pedal edema present. The dorsalis pedis pulse was well felt and capillary refill time was less than 2 seconds; sensation was intact.

WHAT IS YOUR DIAGNOSIS?
HOW WOULD YOU TREAT THIS PATIENT?

Atrophie blanche is a morphologic feature described as porcelain-white stellate scars with surrounding telangiectasia and hyperpigmentation. The lesions are typically found over the peri-malleolar region and are sequelae of healed erythematous and painful ulcers. The lesions arise from upper dermal, small vessel, thrombotic vasculopathy leading to ischemic rest pain; if left untreated, atrophic white scars eventually develop.

A sign of venous insufficiency or thrombotic vasculopathy

Atrophie blanche may develop following healing of an ulcer due to venous insufficiency or small vessel thrombotic vasculopathy.¹ The incidence of thrombotic vasculopathy is 1:100,000 with a female predominance, and up to 50% of cases are associated with procoagulant conditions.² Thrombotic vasculopathy can be due to an inherited or acquired thrombophilia.¹

Atrophie blanche is an important clue to acquired thrombophilia.

Causes of hereditary thrombophilia include Factor V Leiden/prothrombin mutations, anti-thrombin III/protein C/protein S deficiencies, dysfibrinogenemia, and hyperhomocysteinemia.

Acquired thrombophilia arises from underlying prothrombotic states associated with the Virchow triad: hypercoagulability, blood flow stasis, and endothelial injury. The use of oral contraceptives or hormone replacement therapy, presence of malignancy, and antiphospholipid syndrome (APS) are causes of acquired thrombophilia.²

Obtaining a careful history is crucial

Thorough history-taking and physical examination are required to determine the underlying cause of atrophie blanche.

Continue to: Chronic venous insufficiency

Chronic venous insufficiency is more likely in patients with a history of prolonged standing, obesity, or previous injury/surgery to leg veins. Physical examination would reveal hyperpigmentation, telangiectasia, varicose veins, pedal edema, and venous ulcers.³

Inherited thrombophilia may be at work in patients with a family history of arterial and venous thrombosis (eg, stroke, acute coronary syndrome, or deep vein thromboses).

Acquired thrombophilia should be suspected if there is a history of recurrent miscarriages or malignancy.⁴ Given our patient’s history of miscarriages, we ordered further lab work and found that she had elevated anticardiolipin levels (> 40 U/mL) fulfilling the revised Sapporo criteria⁵ for APS.

Thrombophilia or chronic venous insufficiency? In a patient with a history suggestive of thrombophilia, further work-up should be done before attributing atrophie blanche to healed venous ulcers from chronic venous insufficiency. A skin lesion biopsy could reveal classic changes of thrombotic vasculopathy subjacent to the ulcer, including intraluminal thrombosis, endothelial proliferation, and subintimal hyaline degeneration, as opposed to dermal changes consistent with venous stasis, such as increased siderophages, hemosiderin deposition, erythrocyte extravasation, dermal fibrosis, and adipocytic damage.

Differential diagnosis includes atrophic scarring

The differential diagnosis for hypopigmented atrophic macules and plaques over the lower limbs include atrophic scarring from previous trauma, guttate morphea, extra-genital lichen sclerosus, and tuberculoid leprosy.

Continue to: Atrophic scarring

Atrophic scarring occurs only after trauma.

Guttate morphea lesions are sclerotic and may be depressed.

Extra-genital lichen sclerosus is characterized by polygonal, shiny, ivory-white sclerotic lesions with or without follicular plugging.

Tuberculoid leprosy involves loss of nociception, hypotrichosis, and palpable thickened regional nerves (eg, great auricular, sural, or ulnar nerve).

Treatment requires long-term anticoagulation

Our patient had APS and the mainstay of treatment is long-term systemic anticoagulation along with attentive wound care.⁶ Warfarin is preferred over a direct oral anticoagulant as it is more effective in the prevention of recurrent thrombosis in patients with APS.⁷

Our patient was started on warfarin. Since APS may occur as a primary condition or in the setting of a systemic disease, such as systemic lupus erythematosus, she was referred to a rheumatologist. 

A 42-year-old woman presented to our dermatology center with white scars on both of her ankles. She first noticed the lesions 2 years prior; they were initially erythematous and painful, even when she was at rest. Her past medical history included 3 spontaneous term miscarriages. She denied any prolonged standing or trauma.

On examination, atrophic porcelain-white stellate scars were visible with surrounding hyperpigmentation on the medial aspect of both ankles (FIGURE 1A & 1B). There were no tender erythematous nodules, livedo reticularis, varicosities, or pedal edema present. The dorsalis pedis pulse was well felt and capillary refill time was less than 2 seconds; sensation was intact.

WHAT IS YOUR DIAGNOSIS?
HOW WOULD YOU TREAT THIS PATIENT?

Atrophie blanche is a morphologic feature described as porcelain-white stellate scars with surrounding telangiectasia and hyperpigmentation. The lesions are typically found over the peri-malleolar region and are sequelae of healed erythematous and painful ulcers. The lesions arise from upper dermal, small vessel, thrombotic vasculopathy leading to ischemic rest pain; if left untreated, atrophic white scars eventually develop.

A sign of venous insufficiency or thrombotic vasculopathy

Atrophie blanche may develop following healing of an ulcer due to venous insufficiency or small vessel thrombotic vasculopathy.¹ The incidence of thrombotic vasculopathy is 1:100,000 with a female predominance, and up to 50% of cases are associated with procoagulant conditions.² Thrombotic vasculopathy can be due to an inherited or acquired thrombophilia.¹

Atrophie blanche is an important clue to acquired thrombophilia.

Causes of hereditary thrombophilia include Factor V Leiden/prothrombin mutations, anti-thrombin III/protein C/protein S deficiencies, dysfibrinogenemia, and hyperhomocysteinemia.

Acquired thrombophilia arises from underlying prothrombotic states associated with the Virchow triad: hypercoagulability, blood flow stasis, and endothelial injury. The use of oral contraceptives or hormone replacement therapy, presence of malignancy, and antiphospholipid syndrome (APS) are causes of acquired thrombophilia.²

Obtaining a careful history is crucial

Thorough history-taking and physical examination are required to determine the underlying cause of atrophie blanche.

Continue to: Chronic venous insufficiency

Chronic venous insufficiency is more likely in patients with a history of prolonged standing, obesity, or previous injury/surgery to leg veins. Physical examination would reveal hyperpigmentation, telangiectasia, varicose veins, pedal edema, and venous ulcers.³

Inherited thrombophilia may be at work in patients with a family history of arterial and venous thrombosis (eg, stroke, acute coronary syndrome, or deep vein thromboses).

Acquired thrombophilia should be suspected if there is a history of recurrent miscarriages or malignancy.⁴ Given our patient’s history of miscarriages, we ordered further lab work and found that she had elevated anticardiolipin levels (> 40 U/mL) fulfilling the revised Sapporo criteria⁵ for APS.

Thrombophilia or chronic venous insufficiency? In a patient with a history suggestive of thrombophilia, further work-up should be done before attributing atrophie blanche to healed venous ulcers from chronic venous insufficiency. A skin lesion biopsy could reveal classic changes of thrombotic vasculopathy subjacent to the ulcer, including intraluminal thrombosis, endothelial proliferation, and subintimal hyaline degeneration, as opposed to dermal changes consistent with venous stasis, such as increased siderophages, hemosiderin deposition, erythrocyte extravasation, dermal fibrosis, and adipocytic damage.

Differential diagnosis includes atrophic scarring

The differential diagnosis for hypopigmented atrophic macules and plaques over the lower limbs include atrophic scarring from previous trauma, guttate morphea, extra-genital lichen sclerosus, and tuberculoid leprosy.

Continue to: Atrophic scarring

Atrophic scarring occurs only after trauma.

Guttate morphea lesions are sclerotic and may be depressed.

Extra-genital lichen sclerosus is characterized by polygonal, shiny, ivory-white sclerotic lesions with or without follicular plugging.

Tuberculoid leprosy involves loss of nociception, hypotrichosis, and palpable thickened regional nerves (eg, great auricular, sural, or ulnar nerve).

Treatment requires long-term anticoagulation

Our patient had APS and the mainstay of treatment is long-term systemic anticoagulation along with attentive wound care.⁶ Warfarin is preferred over a direct oral anticoagulant as it is more effective in the prevention of recurrent thrombosis in patients with APS.⁷

Our patient was started on warfarin. Since APS may occur as a primary condition or in the setting of a systemic disease, such as systemic lupus erythematosus, she was referred to a rheumatologist. 

The recent Practice Alert by Dr. Campos-Outcalt, “How to proceed when it comes to vitamin D” (J Fam Pract. 2021;70:289-292) claimed that the value of vitamin D supplements for prevention is nil or still unknown.¹ Most of the references cited in support of this statement were centered on randomized controlled trials (RCTs) based on vitamin D dose rather than achieved 25-­hydroxyvitamin D [25(OH)D] concentration. Since the health effects of vitamin D supplementation are correlated with 25(OH)D concentration, the latter should be used to evaluate the results of vitamin D RCTs—a point I made in my 2018 article on the topic.²

For example, in the Vitamin D and Type 2 Diabetes (D2d) Study, in which participants in the treatment arm received 4000 IU/d vitamin D₃, there was no reduced rate of progression from prediabetes to diabetes. However, when 25(OH)D concentrations were analyzed for those in the vitamin D arm during the trial, the risk was found to be reduced by 25% (hazard ratio [HR] = 0.75; 95% CI, 0.68-0.82) per 10 ng/mL increase in 25(OH)D.³

There are significant benefits of vitamin D supplementation to achieve a 25(OH)D concentration of 30 to 60 ng/mL for important health outcomes.

Another trial, the Harvard-led VITamin D and OmegA-3 TriaL (VITAL), enrolled more than 25,000 participants, with the treatment arm receiving 2000 IU/d vitamin D₃.⁴ There were no significant reductions in incidence of either cancer or cardiovascular disease for the entire group. The mean baseline 25(OH)D concentration for those for whom values were provided was 31 ng/mL (32.2 ng/mL for White participants, 24.9 ng/mL for Black participants). However, there were ~25% reductions in cancer risk among Black participants (who had lower 25(OH)D concentrations than White participants) and those with a body mass index < 25. A posthoc analysis suggested a possible benefit related to the rate of total cancer deaths.

A recent article reported the results of long-term vitamin D supplementation among Veterans Health Administration patients who had an initial 25(OH)D concentration of < 20 ng/mL.⁵ For those who were treated with vitamin D and achieved a 25(OH)D concentration of > 30 ng/mL (compared to those who were untreated and had an average concentration of < 20 ng/mL), the risk of myocardial infarction was 27% lower (HR = 0.73; 95% CI, 0.55-0.96) and the risk of all-cause mortality was reduced by 39% (HR = 0.61; 95% CI, 0.56-0.67).

An analysis of SARS-CoV-2 positivity examined data for more than 190,000 patients in the United States who had serum 25(OH)D concentration measurements taken up to 1 year prior to their SARS-CoV-2 test. Positivity rates were 12.5% (95% CI, 12.2%-12.8%) for those with a 25(OH)D concentration < 20 ng/mL vs 5.9% (95% CI, 5.5%-6.4%) for those with a 25(OH)D concentration ≥55 ng/mL.⁶

Thus, there are significant benefits of vitamin D supplementation to achieve a 25(OH)D concentration of 30 to 60 ng/mL for important health outcomes.

Continue to: Author's Response

Author's response

I appreciate the letter from Dr. Grant in response to my previous Practice Alert, as it provides an opportunity to make some important points about assessment of scientific evidence and drawing conclusions based on sound methodology. There is an overabundance of scientific literature published, much of which is of questionable quality, meaning a “study” or 2 can be found to support any preconceived point of view.

In 2011, the Institute of Medicine (now the National Academy of Medicine) published a series of recommendations on how trustworthy recommendations and guidelines should be produced.^1,2 Key among the steps recommended is a full assessment of the totality of the literature on the subject by an independent, nonconflicted panel. This should be based on a systematic review that includes standard search methods to find all pertinent articles, an assessment of the quality of each study using standardized tools, and an overall assessment of the quality of the evidence. A high-quality systematic review meeting these standards was the basis for my review article on vitamin D.³

A “study” or 2 can be found to support any preconceived point of view.

To challenge the findings of the unproven benefits of vitamin D, Dr. Grant cited 4 studies to support the purported benefit of achieving a specific serum 25(OH)D level to prevent cardiovascular disease, diabetes, cancer, and COVID-19. After reading these studies, I would not consider any of them a “game changer.”

The first study was restricted to those with prediabetes, had limited follow-up (mean of 2.5 years), and found different results for those with the same 25(OH)D concentrations in the placebo and treatment groups.⁴ The second study was a large, well-conducted clinical trial that found no benefit of vitamin D supplementation in preventing cancer and cardiovascular disease.⁵ While Dr. Grant claims that benefits were found for some subgroups, I could locate only the statistics on cancer incidence in Black participants, and the confidence intervals showed no statistically significant benefit. It is always questionable to look at multiple outcomes in multiple subgroups without a prior hypothesis because of the likely occurrence of chance findings in so many comparisons. The third was a retrospective observational study with all the potential biases and challenges to validity that such studies present.⁶ A single study, especially 1 with observational methods, almost never conclusively settles a point.

The role of vitamin D in the prevention or treatment of COVID-19 is an aspect that was not covered in the systematic review by the US Preventive Services Task Force. The study on this issuecited by Dr. Grant was a large retrospective observational study that found an inverse relationship between serum 25(OH)D levels and SARS-CoV-2 positivity rates.⁷ This is 1 observational study with interesting results. However, I believe the conclusion of the National Institutes of Health is currently still the correct one: “There is insufficient evidence to recommend either for or against the use of vitamin D for the prevention or treatment of COVID-19.”⁸

With time and further research, Dr. Grant may eventually prove to be correct on specific points. However, when challenging a high-quality systematic review, one must assess the quality of the studies used while also placing them in context of the totality of the literature.

Doug Campos-Outcalt, MD, MPA
Phoenix, AZ

References

1. Institute of Medicine. Finding What Works in Health Care. The National Academy Press, 2011.

2. Institute of Medicine. Clinical Practice Guidelines We Can Trust. The National Academy Press, 2011.

3. Kahwati LC, LeBlanc E, Weber RP, et al. Screening for vitamin D deficiency in adults; updated evidence report and systematic review for the US Preventive Services Task Force. JAMA. 2021;325:1443-1463. doi: 10.1001/jama.2020.26498

4. Dawson-Hughes B, Staten MA, Knowler WC, et al. Intratrial exposure to vitamin D and new-onset diabetes among adults with prediabetes: a secondary analysis from the Vitamin D and Type 2 Diabetes (D2d) Study. Diabetes Care. 2020;43:2916-2922. doi: 10.2337/dc20-1765

5. Manson JE, Cook NR, Lee I-M, et al. Vitamin D supplements and prevention of cancer and cardiovascular disease. N Engl J Med. 2019;380:33-44. doi: 10.1056/NEJMoa1809944

6. Acharya P, Dalia T, Ranka S, et al. The effects of vitamin D supplementation and 25-hydroxyvitamin D levels on the risk of myocardial infarction and mortality. J Endocr Soc. 2021;5:bvab124. doi: 10.1210/jendso/bvab124

7. Kaufman HW, Niles JK, Kroll MH, et al. SARS-CoV-2 positivity rates associated with circulating 25-hydroxyvitamin D levels. PLoS One. 2020;15:e0239252. doi: 10.1371/journal.pone.0239252

8. National Institutes of Health. Vitamin D. COVID-19 treatment guidelines. Updated April 21, 2021. Accessed November 18, 2021. www.covid19treatmentguidelines.nih.gov/therapies/supplements/vitamin-d/

The recent Practice Alert by Dr. Campos-Outcalt, “How to proceed when it comes to vitamin D” (J Fam Pract. 2021;70:289-292) claimed that the value of vitamin D supplements for prevention is nil or still unknown.¹ Most of the references cited in support of this statement were centered on randomized controlled trials (RCTs) based on vitamin D dose rather than achieved 25-­hydroxyvitamin D [25(OH)D] concentration. Since the health effects of vitamin D supplementation are correlated with 25(OH)D concentration, the latter should be used to evaluate the results of vitamin D RCTs—a point I made in my 2018 article on the topic.²

For example, in the Vitamin D and Type 2 Diabetes (D2d) Study, in which participants in the treatment arm received 4000 IU/d vitamin D₃, there was no reduced rate of progression from prediabetes to diabetes. However, when 25(OH)D concentrations were analyzed for those in the vitamin D arm during the trial, the risk was found to be reduced by 25% (hazard ratio [HR] = 0.75; 95% CI, 0.68-0.82) per 10 ng/mL increase in 25(OH)D.³

There are significant benefits of vitamin D supplementation to achieve a 25(OH)D concentration of 30 to 60 ng/mL for important health outcomes.

Another trial, the Harvard-led VITamin D and OmegA-3 TriaL (VITAL), enrolled more than 25,000 participants, with the treatment arm receiving 2000 IU/d vitamin D₃.⁴ There were no significant reductions in incidence of either cancer or cardiovascular disease for the entire group. The mean baseline 25(OH)D concentration for those for whom values were provided was 31 ng/mL (32.2 ng/mL for White participants, 24.9 ng/mL for Black participants). However, there were ~25% reductions in cancer risk among Black participants (who had lower 25(OH)D concentrations than White participants) and those with a body mass index < 25. A posthoc analysis suggested a possible benefit related to the rate of total cancer deaths.

A recent article reported the results of long-term vitamin D supplementation among Veterans Health Administration patients who had an initial 25(OH)D concentration of < 20 ng/mL.⁵ For those who were treated with vitamin D and achieved a 25(OH)D concentration of > 30 ng/mL (compared to those who were untreated and had an average concentration of < 20 ng/mL), the risk of myocardial infarction was 27% lower (HR = 0.73; 95% CI, 0.55-0.96) and the risk of all-cause mortality was reduced by 39% (HR = 0.61; 95% CI, 0.56-0.67).

An analysis of SARS-CoV-2 positivity examined data for more than 190,000 patients in the United States who had serum 25(OH)D concentration measurements taken up to 1 year prior to their SARS-CoV-2 test. Positivity rates were 12.5% (95% CI, 12.2%-12.8%) for those with a 25(OH)D concentration < 20 ng/mL vs 5.9% (95% CI, 5.5%-6.4%) for those with a 25(OH)D concentration ≥55 ng/mL.⁶

Thus, there are significant benefits of vitamin D supplementation to achieve a 25(OH)D concentration of 30 to 60 ng/mL for important health outcomes.

Continue to: Author's Response

Author's response

I appreciate the letter from Dr. Grant in response to my previous Practice Alert, as it provides an opportunity to make some important points about assessment of scientific evidence and drawing conclusions based on sound methodology. There is an overabundance of scientific literature published, much of which is of questionable quality, meaning a “study” or 2 can be found to support any preconceived point of view.

In 2011, the Institute of Medicine (now the National Academy of Medicine) published a series of recommendations on how trustworthy recommendations and guidelines should be produced.^1,2 Key among the steps recommended is a full assessment of the totality of the literature on the subject by an independent, nonconflicted panel. This should be based on a systematic review that includes standard search methods to find all pertinent articles, an assessment of the quality of each study using standardized tools, and an overall assessment of the quality of the evidence. A high-quality systematic review meeting these standards was the basis for my review article on vitamin D.³

A “study” or 2 can be found to support any preconceived point of view.

To challenge the findings of the unproven benefits of vitamin D, Dr. Grant cited 4 studies to support the purported benefit of achieving a specific serum 25(OH)D level to prevent cardiovascular disease, diabetes, cancer, and COVID-19. After reading these studies, I would not consider any of them a “game changer.”

The first study was restricted to those with prediabetes, had limited follow-up (mean of 2.5 years), and found different results for those with the same 25(OH)D concentrations in the placebo and treatment groups.⁴ The second study was a large, well-conducted clinical trial that found no benefit of vitamin D supplementation in preventing cancer and cardiovascular disease.⁵ While Dr. Grant claims that benefits were found for some subgroups, I could locate only the statistics on cancer incidence in Black participants, and the confidence intervals showed no statistically significant benefit. It is always questionable to look at multiple outcomes in multiple subgroups without a prior hypothesis because of the likely occurrence of chance findings in so many comparisons. The third was a retrospective observational study with all the potential biases and challenges to validity that such studies present.⁶ A single study, especially 1 with observational methods, almost never conclusively settles a point.

The role of vitamin D in the prevention or treatment of COVID-19 is an aspect that was not covered in the systematic review by the US Preventive Services Task Force. The study on this issuecited by Dr. Grant was a large retrospective observational study that found an inverse relationship between serum 25(OH)D levels and SARS-CoV-2 positivity rates.⁷ This is 1 observational study with interesting results. However, I believe the conclusion of the National Institutes of Health is currently still the correct one: “There is insufficient evidence to recommend either for or against the use of vitamin D for the prevention or treatment of COVID-19.”⁸

With time and further research, Dr. Grant may eventually prove to be correct on specific points. However, when challenging a high-quality systematic review, one must assess the quality of the studies used while also placing them in context of the totality of the literature.

Doug Campos-Outcalt, MD, MPA
Phoenix, AZ

References

1. Institute of Medicine. Finding What Works in Health Care. The National Academy Press, 2011.

2. Institute of Medicine. Clinical Practice Guidelines We Can Trust. The National Academy Press, 2011.

3. Kahwati LC, LeBlanc E, Weber RP, et al. Screening for vitamin D deficiency in adults; updated evidence report and systematic review for the US Preventive Services Task Force. JAMA. 2021;325:1443-1463. doi: 10.1001/jama.2020.26498

4. Dawson-Hughes B, Staten MA, Knowler WC, et al. Intratrial exposure to vitamin D and new-onset diabetes among adults with prediabetes: a secondary analysis from the Vitamin D and Type 2 Diabetes (D2d) Study. Diabetes Care. 2020;43:2916-2922. doi: 10.2337/dc20-1765

5. Manson JE, Cook NR, Lee I-M, et al. Vitamin D supplements and prevention of cancer and cardiovascular disease. N Engl J Med. 2019;380:33-44. doi: 10.1056/NEJMoa1809944

6. Acharya P, Dalia T, Ranka S, et al. The effects of vitamin D supplementation and 25-hydroxyvitamin D levels on the risk of myocardial infarction and mortality. J Endocr Soc. 2021;5:bvab124. doi: 10.1210/jendso/bvab124

7. Kaufman HW, Niles JK, Kroll MH, et al. SARS-CoV-2 positivity rates associated with circulating 25-hydroxyvitamin D levels. PLoS One. 2020;15:e0239252. doi: 10.1371/journal.pone.0239252

8. National Institutes of Health. Vitamin D. COVID-19 treatment guidelines. Updated April 21, 2021. Accessed November 18, 2021. www.covid19treatmentguidelines.nih.gov/therapies/supplements/vitamin-d/

The recent Practice Alert by Dr. Campos-Outcalt, “How to proceed when it comes to vitamin D” (J Fam Pract. 2021;70:289-292) claimed that the value of vitamin D supplements for prevention is nil or still unknown.¹ Most of the references cited in support of this statement were centered on randomized controlled trials (RCTs) based on vitamin D dose rather than achieved 25-­hydroxyvitamin D [25(OH)D] concentration. Since the health effects of vitamin D supplementation are correlated with 25(OH)D concentration, the latter should be used to evaluate the results of vitamin D RCTs—a point I made in my 2018 article on the topic.²

For example, in the Vitamin D and Type 2 Diabetes (D2d) Study, in which participants in the treatment arm received 4000 IU/d vitamin D₃, there was no reduced rate of progression from prediabetes to diabetes. However, when 25(OH)D concentrations were analyzed for those in the vitamin D arm during the trial, the risk was found to be reduced by 25% (hazard ratio [HR] = 0.75; 95% CI, 0.68-0.82) per 10 ng/mL increase in 25(OH)D.³

There are significant benefits of vitamin D supplementation to achieve a 25(OH)D concentration of 30 to 60 ng/mL for important health outcomes.

Another trial, the Harvard-led VITamin D and OmegA-3 TriaL (VITAL), enrolled more than 25,000 participants, with the treatment arm receiving 2000 IU/d vitamin D₃.⁴ There were no significant reductions in incidence of either cancer or cardiovascular disease for the entire group. The mean baseline 25(OH)D concentration for those for whom values were provided was 31 ng/mL (32.2 ng/mL for White participants, 24.9 ng/mL for Black participants). However, there were ~25% reductions in cancer risk among Black participants (who had lower 25(OH)D concentrations than White participants) and those with a body mass index < 25. A posthoc analysis suggested a possible benefit related to the rate of total cancer deaths.

A recent article reported the results of long-term vitamin D supplementation among Veterans Health Administration patients who had an initial 25(OH)D concentration of < 20 ng/mL.⁵ For those who were treated with vitamin D and achieved a 25(OH)D concentration of > 30 ng/mL (compared to those who were untreated and had an average concentration of < 20 ng/mL), the risk of myocardial infarction was 27% lower (HR = 0.73; 95% CI, 0.55-0.96) and the risk of all-cause mortality was reduced by 39% (HR = 0.61; 95% CI, 0.56-0.67).

An analysis of SARS-CoV-2 positivity examined data for more than 190,000 patients in the United States who had serum 25(OH)D concentration measurements taken up to 1 year prior to their SARS-CoV-2 test. Positivity rates were 12.5% (95% CI, 12.2%-12.8%) for those with a 25(OH)D concentration < 20 ng/mL vs 5.9% (95% CI, 5.5%-6.4%) for those with a 25(OH)D concentration ≥55 ng/mL.⁶

Thus, there are significant benefits of vitamin D supplementation to achieve a 25(OH)D concentration of 30 to 60 ng/mL for important health outcomes.

Continue to: Author's Response

Author's response

I appreciate the letter from Dr. Grant in response to my previous Practice Alert, as it provides an opportunity to make some important points about assessment of scientific evidence and drawing conclusions based on sound methodology. There is an overabundance of scientific literature published, much of which is of questionable quality, meaning a “study” or 2 can be found to support any preconceived point of view.

In 2011, the Institute of Medicine (now the National Academy of Medicine) published a series of recommendations on how trustworthy recommendations and guidelines should be produced.^1,2 Key among the steps recommended is a full assessment of the totality of the literature on the subject by an independent, nonconflicted panel. This should be based on a systematic review that includes standard search methods to find all pertinent articles, an assessment of the quality of each study using standardized tools, and an overall assessment of the quality of the evidence. A high-quality systematic review meeting these standards was the basis for my review article on vitamin D.³

A “study” or 2 can be found to support any preconceived point of view.

To challenge the findings of the unproven benefits of vitamin D, Dr. Grant cited 4 studies to support the purported benefit of achieving a specific serum 25(OH)D level to prevent cardiovascular disease, diabetes, cancer, and COVID-19. After reading these studies, I would not consider any of them a “game changer.”

The first study was restricted to those with prediabetes, had limited follow-up (mean of 2.5 years), and found different results for those with the same 25(OH)D concentrations in the placebo and treatment groups.⁴ The second study was a large, well-conducted clinical trial that found no benefit of vitamin D supplementation in preventing cancer and cardiovascular disease.⁵ While Dr. Grant claims that benefits were found for some subgroups, I could locate only the statistics on cancer incidence in Black participants, and the confidence intervals showed no statistically significant benefit. It is always questionable to look at multiple outcomes in multiple subgroups without a prior hypothesis because of the likely occurrence of chance findings in so many comparisons. The third was a retrospective observational study with all the potential biases and challenges to validity that such studies present.⁶ A single study, especially 1 with observational methods, almost never conclusively settles a point.

The role of vitamin D in the prevention or treatment of COVID-19 is an aspect that was not covered in the systematic review by the US Preventive Services Task Force. The study on this issuecited by Dr. Grant was a large retrospective observational study that found an inverse relationship between serum 25(OH)D levels and SARS-CoV-2 positivity rates.⁷ This is 1 observational study with interesting results. However, I believe the conclusion of the National Institutes of Health is currently still the correct one: “There is insufficient evidence to recommend either for or against the use of vitamin D for the prevention or treatment of COVID-19.”⁸

With time and further research, Dr. Grant may eventually prove to be correct on specific points. However, when challenging a high-quality systematic review, one must assess the quality of the studies used while also placing them in context of the totality of the literature.

Doug Campos-Outcalt, MD, MPA
Phoenix, AZ

References

1. Institute of Medicine. Finding What Works in Health Care. The National Academy Press, 2011.

2. Institute of Medicine. Clinical Practice Guidelines We Can Trust. The National Academy Press, 2011.

3. Kahwati LC, LeBlanc E, Weber RP, et al. Screening for vitamin D deficiency in adults; updated evidence report and systematic review for the US Preventive Services Task Force. JAMA. 2021;325:1443-1463. doi: 10.1001/jama.2020.26498

4. Dawson-Hughes B, Staten MA, Knowler WC, et al. Intratrial exposure to vitamin D and new-onset diabetes among adults with prediabetes: a secondary analysis from the Vitamin D and Type 2 Diabetes (D2d) Study. Diabetes Care. 2020;43:2916-2922. doi: 10.2337/dc20-1765

5. Manson JE, Cook NR, Lee I-M, et al. Vitamin D supplements and prevention of cancer and cardiovascular disease. N Engl J Med. 2019;380:33-44. doi: 10.1056/NEJMoa1809944

6. Acharya P, Dalia T, Ranka S, et al. The effects of vitamin D supplementation and 25-hydroxyvitamin D levels on the risk of myocardial infarction and mortality. J Endocr Soc. 2021;5:bvab124. doi: 10.1210/jendso/bvab124

7. Kaufman HW, Niles JK, Kroll MH, et al. SARS-CoV-2 positivity rates associated with circulating 25-hydroxyvitamin D levels. PLoS One. 2020;15:e0239252. doi: 10.1371/journal.pone.0239252

8. National Institutes of Health. Vitamin D. COVID-19 treatment guidelines. Updated April 21, 2021. Accessed November 18, 2021. www.covid19treatmentguidelines.nih.gov/therapies/supplements/vitamin-d/

I have been wrong about the COVID-19 pandemic any number of times. During the early days of the pandemic, a colleague asked me if he should book his airline ticket to Chicago for our annual Essential Evidence conference. I told him to go ahead. The country shut down the next week.

In September of this year, I was ready to book my flight to Phoenix for a presentation at the Arizona Academy of Family Physicians annual meeting. I thought ­COVID-19 activity was winding down. I was wrong again. The conference was changed to virtual presentations.

And now, as I write this editorial late in November, I find myself wrong a third time. I figured the smoldering COVID-19 activity in Michigan, where I live, would wind down before Thanksgiving. But it is expanding wildly throughout the Midwest.

Wrong again, and again.

There is no question that everyone in the United States— and most likely, the entire world—will eventually get vaccinated against COVID-19 or get infected with it.

I figured most everyone would be vaccinated as soon as vaccines were available, given the dangerous nature of the virus and the benign nature of the vaccines. But here we are, more than 750,000 deaths later and, as a country, we still have not learned our lesson. I won’t get into the disinformation campaign against the existence of the pandemic and the effectiveness and safety of the vaccines; this disinformation campaign seems to be designed to kill as many Americans as possible.

The COVID-19 epidemic is personal for all of us. Not one of us has been immune to its effects. All of us have had a relative or friend die of COVID-19 infection. All of us have had to wear masks and be cautious about contacts with others. All of us have cancelled or restricted travel. My wife and I are debating whether or not we should gather for the holidays with our children and grandchildren in Michigan, despite the fact that all of us have been immunized. One of my sons has a mother-in-law with pulmonary fibrosis; he and his family will all be doing home testing for COVID-19 the day before visiting her.

When will this nightmare end? There is no question that everyone in the United States—and most likely, the entire world—will eventually get vaccinated against COVID-19 or get infected with it. We must continue urging everyone to make the smart, safe choice and get vaccinated.

There are still hundreds of thousands of lives to be saved.

I have been wrong about the COVID-19 pandemic any number of times. During the early days of the pandemic, a colleague asked me if he should book his airline ticket to Chicago for our annual Essential Evidence conference. I told him to go ahead. The country shut down the next week.

In September of this year, I was ready to book my flight to Phoenix for a presentation at the Arizona Academy of Family Physicians annual meeting. I thought ­COVID-19 activity was winding down. I was wrong again. The conference was changed to virtual presentations.

And now, as I write this editorial late in November, I find myself wrong a third time. I figured the smoldering COVID-19 activity in Michigan, where I live, would wind down before Thanksgiving. But it is expanding wildly throughout the Midwest.

Wrong again, and again.

There is no question that everyone in the United States— and most likely, the entire world—will eventually get vaccinated against COVID-19 or get infected with it.

I figured most everyone would be vaccinated as soon as vaccines were available, given the dangerous nature of the virus and the benign nature of the vaccines. But here we are, more than 750,000 deaths later and, as a country, we still have not learned our lesson. I won’t get into the disinformation campaign against the existence of the pandemic and the effectiveness and safety of the vaccines; this disinformation campaign seems to be designed to kill as many Americans as possible.

The COVID-19 epidemic is personal for all of us. Not one of us has been immune to its effects. All of us have had a relative or friend die of COVID-19 infection. All of us have had to wear masks and be cautious about contacts with others. All of us have cancelled or restricted travel. My wife and I are debating whether or not we should gather for the holidays with our children and grandchildren in Michigan, despite the fact that all of us have been immunized. One of my sons has a mother-in-law with pulmonary fibrosis; he and his family will all be doing home testing for COVID-19 the day before visiting her.

When will this nightmare end? There is no question that everyone in the United States—and most likely, the entire world—will eventually get vaccinated against COVID-19 or get infected with it. We must continue urging everyone to make the smart, safe choice and get vaccinated.

There are still hundreds of thousands of lives to be saved.

I have been wrong about the COVID-19 pandemic any number of times. During the early days of the pandemic, a colleague asked me if he should book his airline ticket to Chicago for our annual Essential Evidence conference. I told him to go ahead. The country shut down the next week.

In September of this year, I was ready to book my flight to Phoenix for a presentation at the Arizona Academy of Family Physicians annual meeting. I thought ­COVID-19 activity was winding down. I was wrong again. The conference was changed to virtual presentations.

And now, as I write this editorial late in November, I find myself wrong a third time. I figured the smoldering COVID-19 activity in Michigan, where I live, would wind down before Thanksgiving. But it is expanding wildly throughout the Midwest.

Wrong again, and again.

There is no question that everyone in the United States— and most likely, the entire world—will eventually get vaccinated against COVID-19 or get infected with it.

I figured most everyone would be vaccinated as soon as vaccines were available, given the dangerous nature of the virus and the benign nature of the vaccines. But here we are, more than 750,000 deaths later and, as a country, we still have not learned our lesson. I won’t get into the disinformation campaign against the existence of the pandemic and the effectiveness and safety of the vaccines; this disinformation campaign seems to be designed to kill as many Americans as possible.

The COVID-19 epidemic is personal for all of us. Not one of us has been immune to its effects. All of us have had a relative or friend die of COVID-19 infection. All of us have had to wear masks and be cautious about contacts with others. All of us have cancelled or restricted travel. My wife and I are debating whether or not we should gather for the holidays with our children and grandchildren in Michigan, despite the fact that all of us have been immunized. One of my sons has a mother-in-law with pulmonary fibrosis; he and his family will all be doing home testing for COVID-19 the day before visiting her.

When will this nightmare end? There is no question that everyone in the United States—and most likely, the entire world—will eventually get vaccinated against COVID-19 or get infected with it. We must continue urging everyone to make the smart, safe choice and get vaccinated.

There are still hundreds of thousands of lives to be saved.