On April 13, the Centers for Disease Control and Prevention and the Food and Drug Administration issued a joint statement recommending a pause in Johnson & Johnson vaccine administration, pending review of six reported U.S. cases of a rare and severe type of blood clot occurring after receiving the Johnson & Johnson vaccine. To date, more than 6.8 million doses of that vaccine have been given in the United States, so at this point the rate of detected cases of this problem is less than one in a million.

The six cases occurred in women aged 18-48 years, and symptoms occurred 6-13 days after vaccination. In these cases, cerebral venous sinus thrombosis was seen in addition to thrombocytopenia.

Physicians may receive calls from concerned patients who have received a COVID vaccine. However, more than 95% of the vaccine administrations in the United States to date have been the Pfizer and Moderna messenger RNA vaccines. No association between these vaccines and blood clots has been detected. Also, these six cases occurred within 2 weeks of Johnson & Johnson vaccination, so even among those receiving the Johnson & Johnson vaccine, those who are more than 3 weeks out from their vaccination have no need for concern regarding this rare complication.

Physicians should counsel those who have received the Johnson & Johnson vaccine less than 3 weeks ago to watch for easy bruising, gum bleeding, nose bleeds, leg or arm pain or swelling, severe headache or abdominal pain, shortness of breath, or chest pain. If they notice one or more of those symptoms, they should seek medical attention.

The Centers for Disease Control and Prevention will convene a meeting of the Advisory Committee on Immunization Practices on April 14 to review the six U.S. cases of the Johnson & Johnson vaccine and determine their significance.

Several cases of unusual thromboses and thrombocytopenia have been detected after the Oxford AstraZeneca vaccine, which uses the same adenovirus vector technology as the Johnson & Johnson vaccine, but which is not authorized for use in the United States. The Oxford AstraZeneca vaccine uses a recombinant deficient chimpanzee adenovirus to deliver the message to cells to produce antibody against the SARS-CoV-2 spike protein. The Johnson & Johnson vaccine uses a recombinant deficient human adenovirus to deliver this same message.  

Two recent reports in the New England Journal of Medicine have reported on thrombosis and thrombocytopenia after the Oxford AstraZeneca vaccine in Europe. Both of these reports identified high levels of IgG antibodies to platelet factor 4–polyanion complexes, similar to the mechanism of heparin-induced thrombocytopenia. The term vaccine-induced immune thrombocytopenia was proposed for this phenomenon. Treatment of this condition involves administration of intravenous immunoglobulin and nonheparin anticoagulants. Recent updates from the World Health Organization report that 169 cases of cerebral venous sinus thrombosis and 53 of splanchnic venous thrombosis occurred after 34 million doses of the Oxford AstraZeneca vaccine was administered in the European Union and United Kingdom.

While this pause in Johnson & Johnson vaccination is disappointing news amid increased cases in parts of the country, the Johnson & Johnson vaccines make up less than 5% of the U.S. vaccine doses administered to date. According to the CDC, more than 122 million Americans have received at least one dose and more than 75 million are fully vaccinated.

Dr. Patterson has received an honorarium from Pfizer for an antifungal symposium and is a subinvestigator for the Novavax vaccine. Her spouse served as a consultant for SCYNEXIS, as a speaker for Gilead Sciences and Basilea, and has received a research grant from the National Institutes of Health for the ACTT remdesivir trial.

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

On April 13, the Centers for Disease Control and Prevention and the Food and Drug Administration issued a joint statement recommending a pause in Johnson & Johnson vaccine administration, pending review of six reported U.S. cases of a rare and severe type of blood clot occurring after receiving the Johnson & Johnson vaccine. To date, more than 6.8 million doses of that vaccine have been given in the United States, so at this point the rate of detected cases of this problem is less than one in a million.

The six cases occurred in women aged 18-48 years, and symptoms occurred 6-13 days after vaccination. In these cases, cerebral venous sinus thrombosis was seen in addition to thrombocytopenia.

Physicians may receive calls from concerned patients who have received a COVID vaccine. However, more than 95% of the vaccine administrations in the United States to date have been the Pfizer and Moderna messenger RNA vaccines. No association between these vaccines and blood clots has been detected. Also, these six cases occurred within 2 weeks of Johnson & Johnson vaccination, so even among those receiving the Johnson & Johnson vaccine, those who are more than 3 weeks out from their vaccination have no need for concern regarding this rare complication.

Physicians should counsel those who have received the Johnson & Johnson vaccine less than 3 weeks ago to watch for easy bruising, gum bleeding, nose bleeds, leg or arm pain or swelling, severe headache or abdominal pain, shortness of breath, or chest pain. If they notice one or more of those symptoms, they should seek medical attention.

The Centers for Disease Control and Prevention will convene a meeting of the Advisory Committee on Immunization Practices on April 14 to review the six U.S. cases of the Johnson & Johnson vaccine and determine their significance.

Several cases of unusual thromboses and thrombocytopenia have been detected after the Oxford AstraZeneca vaccine, which uses the same adenovirus vector technology as the Johnson & Johnson vaccine, but which is not authorized for use in the United States. The Oxford AstraZeneca vaccine uses a recombinant deficient chimpanzee adenovirus to deliver the message to cells to produce antibody against the SARS-CoV-2 spike protein. The Johnson & Johnson vaccine uses a recombinant deficient human adenovirus to deliver this same message.  

Two recent reports in the New England Journal of Medicine have reported on thrombosis and thrombocytopenia after the Oxford AstraZeneca vaccine in Europe. Both of these reports identified high levels of IgG antibodies to platelet factor 4–polyanion complexes, similar to the mechanism of heparin-induced thrombocytopenia. The term vaccine-induced immune thrombocytopenia was proposed for this phenomenon. Treatment of this condition involves administration of intravenous immunoglobulin and nonheparin anticoagulants. Recent updates from the World Health Organization report that 169 cases of cerebral venous sinus thrombosis and 53 of splanchnic venous thrombosis occurred after 34 million doses of the Oxford AstraZeneca vaccine was administered in the European Union and United Kingdom.

While this pause in Johnson & Johnson vaccination is disappointing news amid increased cases in parts of the country, the Johnson & Johnson vaccines make up less than 5% of the U.S. vaccine doses administered to date. According to the CDC, more than 122 million Americans have received at least one dose and more than 75 million are fully vaccinated.

Dr. Patterson has received an honorarium from Pfizer for an antifungal symposium and is a subinvestigator for the Novavax vaccine. Her spouse served as a consultant for SCYNEXIS, as a speaker for Gilead Sciences and Basilea, and has received a research grant from the National Institutes of Health for the ACTT remdesivir trial.

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

On April 13, the Centers for Disease Control and Prevention and the Food and Drug Administration issued a joint statement recommending a pause in Johnson & Johnson vaccine administration, pending review of six reported U.S. cases of a rare and severe type of blood clot occurring after receiving the Johnson & Johnson vaccine. To date, more than 6.8 million doses of that vaccine have been given in the United States, so at this point the rate of detected cases of this problem is less than one in a million.

The six cases occurred in women aged 18-48 years, and symptoms occurred 6-13 days after vaccination. In these cases, cerebral venous sinus thrombosis was seen in addition to thrombocytopenia.

Physicians may receive calls from concerned patients who have received a COVID vaccine. However, more than 95% of the vaccine administrations in the United States to date have been the Pfizer and Moderna messenger RNA vaccines. No association between these vaccines and blood clots has been detected. Also, these six cases occurred within 2 weeks of Johnson & Johnson vaccination, so even among those receiving the Johnson & Johnson vaccine, those who are more than 3 weeks out from their vaccination have no need for concern regarding this rare complication.

Physicians should counsel those who have received the Johnson & Johnson vaccine less than 3 weeks ago to watch for easy bruising, gum bleeding, nose bleeds, leg or arm pain or swelling, severe headache or abdominal pain, shortness of breath, or chest pain. If they notice one or more of those symptoms, they should seek medical attention.

The Centers for Disease Control and Prevention will convene a meeting of the Advisory Committee on Immunization Practices on April 14 to review the six U.S. cases of the Johnson & Johnson vaccine and determine their significance.

Several cases of unusual thromboses and thrombocytopenia have been detected after the Oxford AstraZeneca vaccine, which uses the same adenovirus vector technology as the Johnson & Johnson vaccine, but which is not authorized for use in the United States. The Oxford AstraZeneca vaccine uses a recombinant deficient chimpanzee adenovirus to deliver the message to cells to produce antibody against the SARS-CoV-2 spike protein. The Johnson & Johnson vaccine uses a recombinant deficient human adenovirus to deliver this same message.  

Two recent reports in the New England Journal of Medicine have reported on thrombosis and thrombocytopenia after the Oxford AstraZeneca vaccine in Europe. Both of these reports identified high levels of IgG antibodies to platelet factor 4–polyanion complexes, similar to the mechanism of heparin-induced thrombocytopenia. The term vaccine-induced immune thrombocytopenia was proposed for this phenomenon. Treatment of this condition involves administration of intravenous immunoglobulin and nonheparin anticoagulants. Recent updates from the World Health Organization report that 169 cases of cerebral venous sinus thrombosis and 53 of splanchnic venous thrombosis occurred after 34 million doses of the Oxford AstraZeneca vaccine was administered in the European Union and United Kingdom.

While this pause in Johnson & Johnson vaccination is disappointing news amid increased cases in parts of the country, the Johnson & Johnson vaccines make up less than 5% of the U.S. vaccine doses administered to date. According to the CDC, more than 122 million Americans have received at least one dose and more than 75 million are fully vaccinated.

Dr. Patterson has received an honorarium from Pfizer for an antifungal symposium and is a subinvestigator for the Novavax vaccine. Her spouse served as a consultant for SCYNEXIS, as a speaker for Gilead Sciences and Basilea, and has received a research grant from the National Institutes of Health for the ACTT remdesivir trial.

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

COVID vaccines do not work well for patients with hematologic malignancies, new data suggest.

A small study involving 67 such patients shows that nearly half did not produce antibodies and were therefore still at risk of contracting COVID-19, even though they had all received both doses of one of the new mRNA COVID vaccines (Moderna or Pfizer).

“[This] is in stark contrast with the results of phase 1 mRNA vaccine immunogenicity trials, in which robust antibody responses were seen in essentially 100% of participants,” said the authors, led by Mounzer Agha, MD, director of the Mario Lemieux Center for Blood Cancers at the University of Pittsburgh Medical Center’s Hillman Cancer Center.

“Clinicians caring for patients with hematological malignancies and other immunocompromising conditions should be aware of the possibility of COVID-19 vaccine failure,” they emphasized.

“It’s critically important for these patients to be aware of their continued risk [for SARS-CoV-2 infection] and to seek prompt medical attention if they have COVID-19 symptoms, even after vaccination,” Dr. Agha said in a statement.

The study was published online on April 9 as preprint in medRxiv and has not yet undergone peer review.


 

Antibody responses

The authors analyzed responses in a group of 67 patients who had a hematologic malignancy, including chronic lymphocytic leukemia (CLL), lymphoma, and multiple myeloma. Approximately 45% of the patients were receiving therapy for their cancer at the time of vaccination; the rest were under observation.

All patients received two doses of an mRNA COVID vaccine and so were considered to be fully vaccinated.

Antibody responses for these fully vaccinated patients were then analyzed. The median duration between receipt of the second dose of the vaccine and the antibody test was 23 days.

“In total ... 46.3% ... had a negative antibody result after vaccination and were therefore considered to be vaccine nonresponders,” the authors reported.

The worst responses occurred in patients with CLL, of whom only 23% produced measurable antibodies to either vaccine, although approximately 70% of these patients were not receiving any form of cancer therapy at the time of vaccination.

Older patients were more likely not to have a response to either vaccine compared with younger patients, the investigators added.

In contrast, gender, immunoglobulin G levels, the number of days between the second dose and the measurement of antibodies, and status of cancer therapy did not differ among patients who had a response to the vaccines and those who did not.

“Our findings underscore the importance of adherence to nonpharmaceutical interventions to prevent COVID-19 in hematological malignancy patients,” the authors wrote. This is particularly important, given the fact that among patients with hematologic malignancies who become infected with SARS-CoV-2, the mortality rate is in excess of 30%.

Moreover, among such patients, viral shedding may be prolonged, often lasting several months. As such, “these patients should be advised to wear masks and observe social distancing regardless of vaccination status,” the investigators advised.

As of March 2021, guidance from the Centers for Disease Control and Prevention has allowed gatherings of unmasked people who have been vaccinated and of those at low risk for COVID-19 who have not yet been vaccinated. “As we see more national guidance allowing for unmasked gatherings among vaccinated people, clinicians should counsel their immunocompromised patients about the possibility that COVID-19 vaccines may not fully protect them against SARS-CoV-2,” coauthor Ghady Haidar, MD, assistant professor of medicine at the University of Pittsburgh, said in a statement.

“Our results show that the odds of the vaccine producing an antibody response in people with hematologic malignancies are the equivalent of a coin flip,” he said.

The authors have disclosed no relevant financial relationships.
 

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

COVID vaccines do not work well for patients with hematologic malignancies, new data suggest.

A small study involving 67 such patients shows that nearly half did not produce antibodies and were therefore still at risk of contracting COVID-19, even though they had all received both doses of one of the new mRNA COVID vaccines (Moderna or Pfizer).

“[This] is in stark contrast with the results of phase 1 mRNA vaccine immunogenicity trials, in which robust antibody responses were seen in essentially 100% of participants,” said the authors, led by Mounzer Agha, MD, director of the Mario Lemieux Center for Blood Cancers at the University of Pittsburgh Medical Center’s Hillman Cancer Center.

“Clinicians caring for patients with hematological malignancies and other immunocompromising conditions should be aware of the possibility of COVID-19 vaccine failure,” they emphasized.

“It’s critically important for these patients to be aware of their continued risk [for SARS-CoV-2 infection] and to seek prompt medical attention if they have COVID-19 symptoms, even after vaccination,” Dr. Agha said in a statement.

The study was published online on April 9 as preprint in medRxiv and has not yet undergone peer review.


 

Antibody responses

The authors analyzed responses in a group of 67 patients who had a hematologic malignancy, including chronic lymphocytic leukemia (CLL), lymphoma, and multiple myeloma. Approximately 45% of the patients were receiving therapy for their cancer at the time of vaccination; the rest were under observation.

All patients received two doses of an mRNA COVID vaccine and so were considered to be fully vaccinated.

Antibody responses for these fully vaccinated patients were then analyzed. The median duration between receipt of the second dose of the vaccine and the antibody test was 23 days.

“In total ... 46.3% ... had a negative antibody result after vaccination and were therefore considered to be vaccine nonresponders,” the authors reported.

The worst responses occurred in patients with CLL, of whom only 23% produced measurable antibodies to either vaccine, although approximately 70% of these patients were not receiving any form of cancer therapy at the time of vaccination.

Older patients were more likely not to have a response to either vaccine compared with younger patients, the investigators added.

In contrast, gender, immunoglobulin G levels, the number of days between the second dose and the measurement of antibodies, and status of cancer therapy did not differ among patients who had a response to the vaccines and those who did not.

“Our findings underscore the importance of adherence to nonpharmaceutical interventions to prevent COVID-19 in hematological malignancy patients,” the authors wrote. This is particularly important, given the fact that among patients with hematologic malignancies who become infected with SARS-CoV-2, the mortality rate is in excess of 30%.

Moreover, among such patients, viral shedding may be prolonged, often lasting several months. As such, “these patients should be advised to wear masks and observe social distancing regardless of vaccination status,” the investigators advised.

As of March 2021, guidance from the Centers for Disease Control and Prevention has allowed gatherings of unmasked people who have been vaccinated and of those at low risk for COVID-19 who have not yet been vaccinated. “As we see more national guidance allowing for unmasked gatherings among vaccinated people, clinicians should counsel their immunocompromised patients about the possibility that COVID-19 vaccines may not fully protect them against SARS-CoV-2,” coauthor Ghady Haidar, MD, assistant professor of medicine at the University of Pittsburgh, said in a statement.

“Our results show that the odds of the vaccine producing an antibody response in people with hematologic malignancies are the equivalent of a coin flip,” he said.

The authors have disclosed no relevant financial relationships.
 

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

COVID vaccines do not work well for patients with hematologic malignancies, new data suggest.

A small study involving 67 such patients shows that nearly half did not produce antibodies and were therefore still at risk of contracting COVID-19, even though they had all received both doses of one of the new mRNA COVID vaccines (Moderna or Pfizer).

“[This] is in stark contrast with the results of phase 1 mRNA vaccine immunogenicity trials, in which robust antibody responses were seen in essentially 100% of participants,” said the authors, led by Mounzer Agha, MD, director of the Mario Lemieux Center for Blood Cancers at the University of Pittsburgh Medical Center’s Hillman Cancer Center.

“Clinicians caring for patients with hematological malignancies and other immunocompromising conditions should be aware of the possibility of COVID-19 vaccine failure,” they emphasized.

“It’s critically important for these patients to be aware of their continued risk [for SARS-CoV-2 infection] and to seek prompt medical attention if they have COVID-19 symptoms, even after vaccination,” Dr. Agha said in a statement.

The study was published online on April 9 as preprint in medRxiv and has not yet undergone peer review.


 

Antibody responses

The authors analyzed responses in a group of 67 patients who had a hematologic malignancy, including chronic lymphocytic leukemia (CLL), lymphoma, and multiple myeloma. Approximately 45% of the patients were receiving therapy for their cancer at the time of vaccination; the rest were under observation.

All patients received two doses of an mRNA COVID vaccine and so were considered to be fully vaccinated.

Antibody responses for these fully vaccinated patients were then analyzed. The median duration between receipt of the second dose of the vaccine and the antibody test was 23 days.

“In total ... 46.3% ... had a negative antibody result after vaccination and were therefore considered to be vaccine nonresponders,” the authors reported.

The worst responses occurred in patients with CLL, of whom only 23% produced measurable antibodies to either vaccine, although approximately 70% of these patients were not receiving any form of cancer therapy at the time of vaccination.

Older patients were more likely not to have a response to either vaccine compared with younger patients, the investigators added.

In contrast, gender, immunoglobulin G levels, the number of days between the second dose and the measurement of antibodies, and status of cancer therapy did not differ among patients who had a response to the vaccines and those who did not.

“Our findings underscore the importance of adherence to nonpharmaceutical interventions to prevent COVID-19 in hematological malignancy patients,” the authors wrote. This is particularly important, given the fact that among patients with hematologic malignancies who become infected with SARS-CoV-2, the mortality rate is in excess of 30%.

Moreover, among such patients, viral shedding may be prolonged, often lasting several months. As such, “these patients should be advised to wear masks and observe social distancing regardless of vaccination status,” the investigators advised.

As of March 2021, guidance from the Centers for Disease Control and Prevention has allowed gatherings of unmasked people who have been vaccinated and of those at low risk for COVID-19 who have not yet been vaccinated. “As we see more national guidance allowing for unmasked gatherings among vaccinated people, clinicians should counsel their immunocompromised patients about the possibility that COVID-19 vaccines may not fully protect them against SARS-CoV-2,” coauthor Ghady Haidar, MD, assistant professor of medicine at the University of Pittsburgh, said in a statement.

“Our results show that the odds of the vaccine producing an antibody response in people with hematologic malignancies are the equivalent of a coin flip,” he said.

The authors have disclosed no relevant financial relationships.
 

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

I suspect that very few of you chose to go into pediatrics as part of a get-rich-quick scheme. But, like me, you may have assumed that by going into medicine you would always have a job buffered from the erratic winds of the economy, an assumption that it turns out did not take into account the risk of a global pandemic.

I also bet that if you chose to subspecialize it was not because you felt you might make more money. I and most of the lay public have always naively assumed that specialists generally make more money because … well, because they spent more time training. You, on the other hand, may have discovered belatedly that becoming a pediatric subspecialist isn’t as lucrative as you thought it might be.

It turns out that, when subjected to some standard money-crunching exercises, the lifetime earning potential of most pediatric subspecialists falls significantly behind that of general pediatricians. In a paper published in the April 2021 issue of Pediatrics, investigators from the departments of neurology and pediatric neurology at Johns Hopkins University have reported that, with the exception of three hospital-based, procedure-oriented specialties (cardiology, critical care, and neonatology) the earning time lost during training is usually not recouped over the course of a subspecialist’s career. This observation may be explained in many cases by the fact that the income generated by most subspecialists is similar to and not greater than that of general pediatricians. Even when the income of a subspecialist is greater, it is generally not enough to allow for catch up for the earning power lost during training. The researchers observed this effect both in academic and nonacademic settings.

It is possible that, as the results of this study become more widely distributed, more pediatricians in training will begin to think a bit more about the bottom line when they are considering fellowship training. I suspect that drift is already underway, and if it continues, we will find more subspecialties experiencing shortages. And the importance of this lack of subspecialists on both a local and national level is not something to ignore.

The authors discuss several possible solutions. One option might be to shorten the subspecialty training period. Obviously, this would raise some concerns about quality. Another might be for the government to begin a program in which student loans were selectively forgiven based on a physician’s decision to pursue a subspecialty that is experiencing a shortage.

Another option might be to subsidize the income of some subspecialists. Although this might have a similar effect as loan forgiveness, as a physician with a longstanding pride in being a generalist I would hate to see subspecialists guaranteed a higher income merely because of the narrower mix of patients they have chosen to see. I have always felt that the challenge faced by a primary care generalist who must be prepared to deal with the breadth of complaints that present themselves at the door is at least as great and in many cases greater than that of a specialist whose patients to a large extent have been presorted.

Another solution that comes to mind is that, instead of shortening fellowship programs, one could restructure basic pediatric training programs to allow physicians who have already chosen to become subspecialists to enter a fellowship program after 2 years of house officer training. Restructuring of this magnitude would not be as simple as lopping off the last year of house officer training. It would require tailoring each physician’s shortened prefellowship learning experience to maximize his or her exposure to clinical situations that will be most relevant to the anticipated subspecialty they have chosen. A plan like this also assumes that a significant number of recent medical school graduates will be ready to make choices during their internship that will channel them into careers that will span decades.

Becoming a generalist was an easy decision for me. Any of the subspecialties I was considering would have meant I would have had to live and work in or near a high-density population. I am and always have been a small town kind of guy.
 

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at [email protected].

I suspect that very few of you chose to go into pediatrics as part of a get-rich-quick scheme. But, like me, you may have assumed that by going into medicine you would always have a job buffered from the erratic winds of the economy, an assumption that it turns out did not take into account the risk of a global pandemic.

I also bet that if you chose to subspecialize it was not because you felt you might make more money. I and most of the lay public have always naively assumed that specialists generally make more money because … well, because they spent more time training. You, on the other hand, may have discovered belatedly that becoming a pediatric subspecialist isn’t as lucrative as you thought it might be.

It turns out that, when subjected to some standard money-crunching exercises, the lifetime earning potential of most pediatric subspecialists falls significantly behind that of general pediatricians. In a paper published in the April 2021 issue of Pediatrics, investigators from the departments of neurology and pediatric neurology at Johns Hopkins University have reported that, with the exception of three hospital-based, procedure-oriented specialties (cardiology, critical care, and neonatology) the earning time lost during training is usually not recouped over the course of a subspecialist’s career. This observation may be explained in many cases by the fact that the income generated by most subspecialists is similar to and not greater than that of general pediatricians. Even when the income of a subspecialist is greater, it is generally not enough to allow for catch up for the earning power lost during training. The researchers observed this effect both in academic and nonacademic settings.

It is possible that, as the results of this study become more widely distributed, more pediatricians in training will begin to think a bit more about the bottom line when they are considering fellowship training. I suspect that drift is already underway, and if it continues, we will find more subspecialties experiencing shortages. And the importance of this lack of subspecialists on both a local and national level is not something to ignore.

The authors discuss several possible solutions. One option might be to shorten the subspecialty training period. Obviously, this would raise some concerns about quality. Another might be for the government to begin a program in which student loans were selectively forgiven based on a physician’s decision to pursue a subspecialty that is experiencing a shortage.

Another option might be to subsidize the income of some subspecialists. Although this might have a similar effect as loan forgiveness, as a physician with a longstanding pride in being a generalist I would hate to see subspecialists guaranteed a higher income merely because of the narrower mix of patients they have chosen to see. I have always felt that the challenge faced by a primary care generalist who must be prepared to deal with the breadth of complaints that present themselves at the door is at least as great and in many cases greater than that of a specialist whose patients to a large extent have been presorted.

Another solution that comes to mind is that, instead of shortening fellowship programs, one could restructure basic pediatric training programs to allow physicians who have already chosen to become subspecialists to enter a fellowship program after 2 years of house officer training. Restructuring of this magnitude would not be as simple as lopping off the last year of house officer training. It would require tailoring each physician’s shortened prefellowship learning experience to maximize his or her exposure to clinical situations that will be most relevant to the anticipated subspecialty they have chosen. A plan like this also assumes that a significant number of recent medical school graduates will be ready to make choices during their internship that will channel them into careers that will span decades.

Becoming a generalist was an easy decision for me. Any of the subspecialties I was considering would have meant I would have had to live and work in or near a high-density population. I am and always have been a small town kind of guy.
 

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at [email protected].

I suspect that very few of you chose to go into pediatrics as part of a get-rich-quick scheme. But, like me, you may have assumed that by going into medicine you would always have a job buffered from the erratic winds of the economy, an assumption that it turns out did not take into account the risk of a global pandemic.

I also bet that if you chose to subspecialize it was not because you felt you might make more money. I and most of the lay public have always naively assumed that specialists generally make more money because … well, because they spent more time training. You, on the other hand, may have discovered belatedly that becoming a pediatric subspecialist isn’t as lucrative as you thought it might be.

It turns out that, when subjected to some standard money-crunching exercises, the lifetime earning potential of most pediatric subspecialists falls significantly behind that of general pediatricians. In a paper published in the April 2021 issue of Pediatrics, investigators from the departments of neurology and pediatric neurology at Johns Hopkins University have reported that, with the exception of three hospital-based, procedure-oriented specialties (cardiology, critical care, and neonatology) the earning time lost during training is usually not recouped over the course of a subspecialist’s career. This observation may be explained in many cases by the fact that the income generated by most subspecialists is similar to and not greater than that of general pediatricians. Even when the income of a subspecialist is greater, it is generally not enough to allow for catch up for the earning power lost during training. The researchers observed this effect both in academic and nonacademic settings.

It is possible that, as the results of this study become more widely distributed, more pediatricians in training will begin to think a bit more about the bottom line when they are considering fellowship training. I suspect that drift is already underway, and if it continues, we will find more subspecialties experiencing shortages. And the importance of this lack of subspecialists on both a local and national level is not something to ignore.

The authors discuss several possible solutions. One option might be to shorten the subspecialty training period. Obviously, this would raise some concerns about quality. Another might be for the government to begin a program in which student loans were selectively forgiven based on a physician’s decision to pursue a subspecialty that is experiencing a shortage.

Another option might be to subsidize the income of some subspecialists. Although this might have a similar effect as loan forgiveness, as a physician with a longstanding pride in being a generalist I would hate to see subspecialists guaranteed a higher income merely because of the narrower mix of patients they have chosen to see. I have always felt that the challenge faced by a primary care generalist who must be prepared to deal with the breadth of complaints that present themselves at the door is at least as great and in many cases greater than that of a specialist whose patients to a large extent have been presorted.

Another solution that comes to mind is that, instead of shortening fellowship programs, one could restructure basic pediatric training programs to allow physicians who have already chosen to become subspecialists to enter a fellowship program after 2 years of house officer training. Restructuring of this magnitude would not be as simple as lopping off the last year of house officer training. It would require tailoring each physician’s shortened prefellowship learning experience to maximize his or her exposure to clinical situations that will be most relevant to the anticipated subspecialty they have chosen. A plan like this also assumes that a significant number of recent medical school graduates will be ready to make choices during their internship that will channel them into careers that will span decades.

Becoming a generalist was an easy decision for me. Any of the subspecialties I was considering would have meant I would have had to live and work in or near a high-density population. I am and always have been a small town kind of guy.
 

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at [email protected].

Two recent articles in the medical literature provide new information on mucocutaneous manifestations of COVID-19 in children, which may help guide dermatologists in making accurate diagnoses and stratifying children at risk for serious, systemic illness due to the virus.

In a single-center descriptive study carried out over a 9-month period, researchers in Madrid found that of 50 hospitalized children infected with COVID-19, 21 (42%) had mucocutaneous symptoms, most commonly exanthem, followed by conjunctival hyperemia without secretion and red cracked lips or strawberry tongue. In addition, 18 (36%) fulfilled criteria for Multisystem Inflammatory Syndrome in Children (MIS-C).

“Based on findings in adult patients, the skin manifestations of COVID-19 have been classified under five categories: acral pseudo-chilblain, vesicular eruptions, urticarial lesions, maculopapular eruptions, and livedo or necrosis,” David Andina-Martinez, MD, of Hospital Infantil Universitario Niño Jesús, Madrid, and colleagues wrote in the study, which was published online on April 2 in the Journal of the American Academy of Dermatology.

“Chilblain lesions in healthy children and adolescents have received much attention; these lesions resolve without complications after a few weeks,” they added. “Besides, other cutaneous manifestations of COVID-19 in children have been the matter of case reports or small case series. Nevertheless, the mucocutaneous manifestations in hospitalized children infected with SARS-CoV-2 and their implications on the clinical course have not yet been extensively described.”

In an effort to describe the mucocutaneous manifestations in children hospitalized for COVID-19, the researchers evaluated 50 children up to 18 years of age who were admitted between March 1 and Nov. 30, 2020, to Hospital Infantil Universitario Niño Jesús, which was designated as a pediatric reference center during the peak of the pandemic. The main reasons for admission were respiratory illness (40%) and MIS-C (40%).

Of the 50 patients, 44 (88%) had a positive RT-PCR for SARS-CoV-2 and 6 (12%) met clinical suspicion criteria and had a negative RT-PCR with a positive IgG serology. In 34 patients (68%), a close contact with a suspected or confirmed case of COVID-19 was referred, while the source of the infection remained unknown in the remaining 16 patients (32%).

The researchers reported that 21 patients (42%) had mucocutaneous symptoms, most commonly maculopapular exanthem (86%), conjunctival hyperemia (81%), and red cracked lips or strawberry tongue (43%). In addition, 18 of the 21 patients (86%) fulfilled criteria for MIS-C.

“A tricky thing about MIS-C is that it often manifests 4-5 weeks after a child had COVID-19,” said Christine Ko, MD, professor of dermatology and pathology at Yale University, New Haven, Conn., who was asked to comment on the study. “MIS-C is associated with characteristic bright red lips and a red tongue that might resemble a strawberry. Such oral findings should prompt rapid evaluation for other signs and symptoms. There can be redness of the eyes or other more nonspecific skin findings (large or small areas of redness on the trunk or limbs, sometimes with surface change), but more importantly, fever, a rapid heartbeat, diarrhea, or breathing issues. The risk with MIS-C is a rapid decline in a child’s health, with admission to an intensive care unit.”

Dr. Andina-Martinez and his colleagues also contrast the skin findings of MIS-C, which are not generally on the hands or feet, with the so-called “COVID toe” or finger phenomenon, which has also been associated with SARS-CoV-2, particularly in children. “Only one of the patients in this series had skin involvement of a finger, and it only appeared after recovery from MIS-C,” Dr. Ko noted. “Distinguishing COVID toes from MIS-C is important, as COVID toes has a very good outcome, while MIS-C can have severe consequences, including protracted heart disease.”

In other findings, patients who presented with mucocutaneous signs tended to be older than those without skin signs and they presented at the emergency department with poor general status and extreme tachycardia. They also had higher C-reactive protein and D-dimer levels and lower lymphocyte counts and faced a more than a 10-fold increased risk of being admitted to the PICU, compared with patients who did not have skin signs (OR, 10.24; P = .003).

In a separate study published online on April 7 in JAMA Dermatology, Zachary E. Holcomb, MD, of the combined dermatology residency program at Massachusetts General Hospital, Boston, and colleagues presented what is believed to be the first case report of reactive infectious mucocutaneous eruption (RIME) triggered by SARS-CoV-2. RIME is the preferred term for pediatric patients who present with mucositis and rash (often a scant or even absent skin eruption) triggered by various infectious agents.

The patient, a 17-year-old male, presented to the emergency department with 3 days of mouth pain and nonpainful penile erosions. “One week prior, he experienced transient anosmia and ageusia that had since spontaneously resolved,” the researchers wrote. “At that time, he was tested for SARS-CoV-2 infection via nasopharyngeal polymerase chain reaction (PCR), the results of which were positive.”

At presentation, the patient had no fever, his vital signs were normal, and the physical exam revealed shallow erosions of the vermilion lips and hard palate, circumferential erythematous erosions of the periurethral glans penis, and five small vesicles on the trunk and upper extremities. Serum analysis revealed a normal white blood cell count with mild absolute lymphopenia, slightly elevated creatinine level, normal liver function, slightly elevated C-reactive protein level, and normal ferritin level.

Dr. Holcomb and colleagues made a diagnosis of SARS-CoV-2–associated RIME based on microbiological results, which revealed positive repeated SARS-CoV-2 nasopharyngeal PCR and negative nasopharyngeal PCR testing for Mycoplasma pneumoniae, adenovirus, Chlamydophila pneumoniae, human metapneumovirus, influenza A/B, parainfluenza 1 to 4, rhinovirus, and respiratory syncytial virus. In addition, titers of Mycoplasma pneumoniae IgM levels were negative, but Mycoplasma pneumoniae IgG levels were elevated.

The lesions resolved with 60 mg of oral prednisone taken daily for 4 days. A recurrence of oral mucositis 3 months later responded to 80 mg oral prednisone taken daily for 6 days.

“It’s not surprising that SARS-CoV-2 is yet another trigger for RIME,” said Anna Yasmine Kirkorian, MD, chief of the division of dermatology at Children’s National Hospital, Washington, who was asked to comment about the case report.

“The take-home message is for clinicians to be aware of this association and distinguish these patients from those with MIS-C, because patients with MIS-C require monitoring and urgent systemic treatment. RIME and MIS-C may potentially be distinguished clinically based on the nature of the mucositis (hemorrhagic and erosive in RIME, dry, cracked lips with ‘strawberry tongue’ in MIS-C) but more importantly patients with RIME lack laboratory evidence of severe systemic inflammation,” such as ESR, CRP, or ferritin, she said.

“A final interesting point in this article was the recurrence of mucositis in this patient, which could mean that recurrent mucositis/recurrent RIME might be yet another manifestation of ‘long-COVID’ (now called post-Acute Sequelae of SARS-CoV-2 infection) in some patients,” Dr. Kirkorian added. She noted that the American Academy of Dermatology–International League of Dermatologic Societies COVID-19 Dermatology Registry and articles like these “provide invaluable ‘hot off the presses’ information for clinicians who are facing the protean manifestations of a novel viral epidemic.”

The researchers reported having no financial disclosures.
 

[email protected]

Two recent articles in the medical literature provide new information on mucocutaneous manifestations of COVID-19 in children, which may help guide dermatologists in making accurate diagnoses and stratifying children at risk for serious, systemic illness due to the virus.

In a single-center descriptive study carried out over a 9-month period, researchers in Madrid found that of 50 hospitalized children infected with COVID-19, 21 (42%) had mucocutaneous symptoms, most commonly exanthem, followed by conjunctival hyperemia without secretion and red cracked lips or strawberry tongue. In addition, 18 (36%) fulfilled criteria for Multisystem Inflammatory Syndrome in Children (MIS-C).

“Based on findings in adult patients, the skin manifestations of COVID-19 have been classified under five categories: acral pseudo-chilblain, vesicular eruptions, urticarial lesions, maculopapular eruptions, and livedo or necrosis,” David Andina-Martinez, MD, of Hospital Infantil Universitario Niño Jesús, Madrid, and colleagues wrote in the study, which was published online on April 2 in the Journal of the American Academy of Dermatology.

“Chilblain lesions in healthy children and adolescents have received much attention; these lesions resolve without complications after a few weeks,” they added. “Besides, other cutaneous manifestations of COVID-19 in children have been the matter of case reports or small case series. Nevertheless, the mucocutaneous manifestations in hospitalized children infected with SARS-CoV-2 and their implications on the clinical course have not yet been extensively described.”

In an effort to describe the mucocutaneous manifestations in children hospitalized for COVID-19, the researchers evaluated 50 children up to 18 years of age who were admitted between March 1 and Nov. 30, 2020, to Hospital Infantil Universitario Niño Jesús, which was designated as a pediatric reference center during the peak of the pandemic. The main reasons for admission were respiratory illness (40%) and MIS-C (40%).

Of the 50 patients, 44 (88%) had a positive RT-PCR for SARS-CoV-2 and 6 (12%) met clinical suspicion criteria and had a negative RT-PCR with a positive IgG serology. In 34 patients (68%), a close contact with a suspected or confirmed case of COVID-19 was referred, while the source of the infection remained unknown in the remaining 16 patients (32%).

The researchers reported that 21 patients (42%) had mucocutaneous symptoms, most commonly maculopapular exanthem (86%), conjunctival hyperemia (81%), and red cracked lips or strawberry tongue (43%). In addition, 18 of the 21 patients (86%) fulfilled criteria for MIS-C.

“A tricky thing about MIS-C is that it often manifests 4-5 weeks after a child had COVID-19,” said Christine Ko, MD, professor of dermatology and pathology at Yale University, New Haven, Conn., who was asked to comment on the study. “MIS-C is associated with characteristic bright red lips and a red tongue that might resemble a strawberry. Such oral findings should prompt rapid evaluation for other signs and symptoms. There can be redness of the eyes or other more nonspecific skin findings (large or small areas of redness on the trunk or limbs, sometimes with surface change), but more importantly, fever, a rapid heartbeat, diarrhea, or breathing issues. The risk with MIS-C is a rapid decline in a child’s health, with admission to an intensive care unit.”

Dr. Andina-Martinez and his colleagues also contrast the skin findings of MIS-C, which are not generally on the hands or feet, with the so-called “COVID toe” or finger phenomenon, which has also been associated with SARS-CoV-2, particularly in children. “Only one of the patients in this series had skin involvement of a finger, and it only appeared after recovery from MIS-C,” Dr. Ko noted. “Distinguishing COVID toes from MIS-C is important, as COVID toes has a very good outcome, while MIS-C can have severe consequences, including protracted heart disease.”

In other findings, patients who presented with mucocutaneous signs tended to be older than those without skin signs and they presented at the emergency department with poor general status and extreme tachycardia. They also had higher C-reactive protein and D-dimer levels and lower lymphocyte counts and faced a more than a 10-fold increased risk of being admitted to the PICU, compared with patients who did not have skin signs (OR, 10.24; P = .003).

In a separate study published online on April 7 in JAMA Dermatology, Zachary E. Holcomb, MD, of the combined dermatology residency program at Massachusetts General Hospital, Boston, and colleagues presented what is believed to be the first case report of reactive infectious mucocutaneous eruption (RIME) triggered by SARS-CoV-2. RIME is the preferred term for pediatric patients who present with mucositis and rash (often a scant or even absent skin eruption) triggered by various infectious agents.

The patient, a 17-year-old male, presented to the emergency department with 3 days of mouth pain and nonpainful penile erosions. “One week prior, he experienced transient anosmia and ageusia that had since spontaneously resolved,” the researchers wrote. “At that time, he was tested for SARS-CoV-2 infection via nasopharyngeal polymerase chain reaction (PCR), the results of which were positive.”

At presentation, the patient had no fever, his vital signs were normal, and the physical exam revealed shallow erosions of the vermilion lips and hard palate, circumferential erythematous erosions of the periurethral glans penis, and five small vesicles on the trunk and upper extremities. Serum analysis revealed a normal white blood cell count with mild absolute lymphopenia, slightly elevated creatinine level, normal liver function, slightly elevated C-reactive protein level, and normal ferritin level.

Dr. Holcomb and colleagues made a diagnosis of SARS-CoV-2–associated RIME based on microbiological results, which revealed positive repeated SARS-CoV-2 nasopharyngeal PCR and negative nasopharyngeal PCR testing for Mycoplasma pneumoniae, adenovirus, Chlamydophila pneumoniae, human metapneumovirus, influenza A/B, parainfluenza 1 to 4, rhinovirus, and respiratory syncytial virus. In addition, titers of Mycoplasma pneumoniae IgM levels were negative, but Mycoplasma pneumoniae IgG levels were elevated.

The lesions resolved with 60 mg of oral prednisone taken daily for 4 days. A recurrence of oral mucositis 3 months later responded to 80 mg oral prednisone taken daily for 6 days.

“It’s not surprising that SARS-CoV-2 is yet another trigger for RIME,” said Anna Yasmine Kirkorian, MD, chief of the division of dermatology at Children’s National Hospital, Washington, who was asked to comment about the case report.

“The take-home message is for clinicians to be aware of this association and distinguish these patients from those with MIS-C, because patients with MIS-C require monitoring and urgent systemic treatment. RIME and MIS-C may potentially be distinguished clinically based on the nature of the mucositis (hemorrhagic and erosive in RIME, dry, cracked lips with ‘strawberry tongue’ in MIS-C) but more importantly patients with RIME lack laboratory evidence of severe systemic inflammation,” such as ESR, CRP, or ferritin, she said.

“A final interesting point in this article was the recurrence of mucositis in this patient, which could mean that recurrent mucositis/recurrent RIME might be yet another manifestation of ‘long-COVID’ (now called post-Acute Sequelae of SARS-CoV-2 infection) in some patients,” Dr. Kirkorian added. She noted that the American Academy of Dermatology–International League of Dermatologic Societies COVID-19 Dermatology Registry and articles like these “provide invaluable ‘hot off the presses’ information for clinicians who are facing the protean manifestations of a novel viral epidemic.”

The researchers reported having no financial disclosures.
 

[email protected]

Two recent articles in the medical literature provide new information on mucocutaneous manifestations of COVID-19 in children, which may help guide dermatologists in making accurate diagnoses and stratifying children at risk for serious, systemic illness due to the virus.

In a single-center descriptive study carried out over a 9-month period, researchers in Madrid found that of 50 hospitalized children infected with COVID-19, 21 (42%) had mucocutaneous symptoms, most commonly exanthem, followed by conjunctival hyperemia without secretion and red cracked lips or strawberry tongue. In addition, 18 (36%) fulfilled criteria for Multisystem Inflammatory Syndrome in Children (MIS-C).

“Based on findings in adult patients, the skin manifestations of COVID-19 have been classified under five categories: acral pseudo-chilblain, vesicular eruptions, urticarial lesions, maculopapular eruptions, and livedo or necrosis,” David Andina-Martinez, MD, of Hospital Infantil Universitario Niño Jesús, Madrid, and colleagues wrote in the study, which was published online on April 2 in the Journal of the American Academy of Dermatology.

“Chilblain lesions in healthy children and adolescents have received much attention; these lesions resolve without complications after a few weeks,” they added. “Besides, other cutaneous manifestations of COVID-19 in children have been the matter of case reports or small case series. Nevertheless, the mucocutaneous manifestations in hospitalized children infected with SARS-CoV-2 and their implications on the clinical course have not yet been extensively described.”

In an effort to describe the mucocutaneous manifestations in children hospitalized for COVID-19, the researchers evaluated 50 children up to 18 years of age who were admitted between March 1 and Nov. 30, 2020, to Hospital Infantil Universitario Niño Jesús, which was designated as a pediatric reference center during the peak of the pandemic. The main reasons for admission were respiratory illness (40%) and MIS-C (40%).

Of the 50 patients, 44 (88%) had a positive RT-PCR for SARS-CoV-2 and 6 (12%) met clinical suspicion criteria and had a negative RT-PCR with a positive IgG serology. In 34 patients (68%), a close contact with a suspected or confirmed case of COVID-19 was referred, while the source of the infection remained unknown in the remaining 16 patients (32%).

The researchers reported that 21 patients (42%) had mucocutaneous symptoms, most commonly maculopapular exanthem (86%), conjunctival hyperemia (81%), and red cracked lips or strawberry tongue (43%). In addition, 18 of the 21 patients (86%) fulfilled criteria for MIS-C.

“A tricky thing about MIS-C is that it often manifests 4-5 weeks after a child had COVID-19,” said Christine Ko, MD, professor of dermatology and pathology at Yale University, New Haven, Conn., who was asked to comment on the study. “MIS-C is associated with characteristic bright red lips and a red tongue that might resemble a strawberry. Such oral findings should prompt rapid evaluation for other signs and symptoms. There can be redness of the eyes or other more nonspecific skin findings (large or small areas of redness on the trunk or limbs, sometimes with surface change), but more importantly, fever, a rapid heartbeat, diarrhea, or breathing issues. The risk with MIS-C is a rapid decline in a child’s health, with admission to an intensive care unit.”

Dr. Andina-Martinez and his colleagues also contrast the skin findings of MIS-C, which are not generally on the hands or feet, with the so-called “COVID toe” or finger phenomenon, which has also been associated with SARS-CoV-2, particularly in children. “Only one of the patients in this series had skin involvement of a finger, and it only appeared after recovery from MIS-C,” Dr. Ko noted. “Distinguishing COVID toes from MIS-C is important, as COVID toes has a very good outcome, while MIS-C can have severe consequences, including protracted heart disease.”

In other findings, patients who presented with mucocutaneous signs tended to be older than those without skin signs and they presented at the emergency department with poor general status and extreme tachycardia. They also had higher C-reactive protein and D-dimer levels and lower lymphocyte counts and faced a more than a 10-fold increased risk of being admitted to the PICU, compared with patients who did not have skin signs (OR, 10.24; P = .003).

In a separate study published online on April 7 in JAMA Dermatology, Zachary E. Holcomb, MD, of the combined dermatology residency program at Massachusetts General Hospital, Boston, and colleagues presented what is believed to be the first case report of reactive infectious mucocutaneous eruption (RIME) triggered by SARS-CoV-2. RIME is the preferred term for pediatric patients who present with mucositis and rash (often a scant or even absent skin eruption) triggered by various infectious agents.

The patient, a 17-year-old male, presented to the emergency department with 3 days of mouth pain and nonpainful penile erosions. “One week prior, he experienced transient anosmia and ageusia that had since spontaneously resolved,” the researchers wrote. “At that time, he was tested for SARS-CoV-2 infection via nasopharyngeal polymerase chain reaction (PCR), the results of which were positive.”

At presentation, the patient had no fever, his vital signs were normal, and the physical exam revealed shallow erosions of the vermilion lips and hard palate, circumferential erythematous erosions of the periurethral glans penis, and five small vesicles on the trunk and upper extremities. Serum analysis revealed a normal white blood cell count with mild absolute lymphopenia, slightly elevated creatinine level, normal liver function, slightly elevated C-reactive protein level, and normal ferritin level.

Dr. Holcomb and colleagues made a diagnosis of SARS-CoV-2–associated RIME based on microbiological results, which revealed positive repeated SARS-CoV-2 nasopharyngeal PCR and negative nasopharyngeal PCR testing for Mycoplasma pneumoniae, adenovirus, Chlamydophila pneumoniae, human metapneumovirus, influenza A/B, parainfluenza 1 to 4, rhinovirus, and respiratory syncytial virus. In addition, titers of Mycoplasma pneumoniae IgM levels were negative, but Mycoplasma pneumoniae IgG levels were elevated.

The lesions resolved with 60 mg of oral prednisone taken daily for 4 days. A recurrence of oral mucositis 3 months later responded to 80 mg oral prednisone taken daily for 6 days.

“It’s not surprising that SARS-CoV-2 is yet another trigger for RIME,” said Anna Yasmine Kirkorian, MD, chief of the division of dermatology at Children’s National Hospital, Washington, who was asked to comment about the case report.

“The take-home message is for clinicians to be aware of this association and distinguish these patients from those with MIS-C, because patients with MIS-C require monitoring and urgent systemic treatment. RIME and MIS-C may potentially be distinguished clinically based on the nature of the mucositis (hemorrhagic and erosive in RIME, dry, cracked lips with ‘strawberry tongue’ in MIS-C) but more importantly patients with RIME lack laboratory evidence of severe systemic inflammation,” such as ESR, CRP, or ferritin, she said.

“A final interesting point in this article was the recurrence of mucositis in this patient, which could mean that recurrent mucositis/recurrent RIME might be yet another manifestation of ‘long-COVID’ (now called post-Acute Sequelae of SARS-CoV-2 infection) in some patients,” Dr. Kirkorian added. She noted that the American Academy of Dermatology–International League of Dermatologic Societies COVID-19 Dermatology Registry and articles like these “provide invaluable ‘hot off the presses’ information for clinicians who are facing the protean manifestations of a novel viral epidemic.”

The researchers reported having no financial disclosures.
 

[email protected]

A personalized genomic cancer vaccine proved feasible to manufacture and was well tolerated in a phase 1 trial, according to researchers.

The vaccine, PGV-001, was given to 13 patients with solid tumors or multiple myeloma who had a high risk of recurrence after surgery or autologous stem cell transplant.

At last follow-up, four patients were still alive without evidence of disease and had not received subsequent therapy, four were alive and receiving therapy, three had died, and two were lost to follow-up.

Thomas Marron, MD, PhD , of Mount Sinai in New York presented these results in a poster at the American Association for Cancer Research Annual Meeting 2021: Week 1 ( Abstract LB048 ). Data in the abstract differ from the data presented.

“While cancer immunotherapy has revolutionized the treatment of cancer, we know that the majority of patients fail to achieve significant clinical response,” Dr. Marron said during his presentation. “One reason for this may be due to lack of preexisting primed T-cell response needed for PD-1 blockade to have a significant effect. To address this, personalized neoantigen vaccines may help prime an improved immune response against tumor cells.”

With this in mind, Dr. Marron and colleagues developed PGV-001, a vaccine consisting of patient-specific synthetic neoantigen peptides given to patients in the adjuvant setting.
 

Creating a personalized vaccine

The researchers synthesized PGV-001 for 15 patients with advanced malignancies. The patients first underwent tumor and germline DNA sequencing as well as HLA typing. Bulk RNA sequencing was performed on patients’ tumors as well.

Then, the researchers used a computational pipeline called OpenVax to identify candidate neoantigens. This pipeline, developed at Mount Sinai, identified and prioritized candidate neoantigens using predicted MHC class I binding affinity and neoantigen abundance.

OpenVax identified an average of 71.5 neoantigens per patient (range, 7-193). The goal was to synthesize a maximum of 10 peptides per patient, but two patients did not have an adequate number of neoantigens.
 

Vaccine administration

The peptides were administered over the course of 27 weeks along with poly-ICLC and a tetanus helper peptide. Before receiving their vaccine doses, patients with solid tumors had undergone curative-intent surgery, and those with multiple myeloma had undergone autologous stem cell transplant.

“Most experimental personalized cancer vaccines are administered in the metastatic setting, but prior research indicates that immunotherapies tend to be more effective in patients who have less cancer spread,” principal investigator Nina Bhardwaj, MD, PhD , of Mount Sinai, explained in a press release .

“We have, therefore, developed a neoantigen vaccine that is administered after standard-of-care adjuvant therapy, such as surgery in solid tumors and bone marrow transplant in multiple myeloma, when patients have minimal, typically microscopic, residual disease.”
 

Feasibility, safety, and immunogenicity

PGV-001 was synthesized for 15 patients and administered to 13 of them. Six of the 13 patients had head and neck squamous cell carcinoma, three had multiple myeloma, two had non–small cell lung cancer, one had breast cancer, and one had urothelial carcinoma.

Eleven patients received all 10 intended doses, and two patients received at least 8 doses.

“The vaccine was well tolerated, with only half of patients experiencing mild, grade 1 adverse events,” Dr. Marron said.

Transient injection site reactions occurred in four patients, and grade 1 fever was reported in one patient.

Immune monitoring is ongoing, but an initial analysis in one patient showed “robust responses” in CD4 and CD8 T cells by intracellular cytokine staining for interferon-gamma, tumor necrosis factor–alpha, and interleukin-2 after in vitro expansion in the presence of vaccine antigens, according to the researchers.

Dr. Marron noted that robust T-cell reactivity was seen at the completion of all 10 doses but was not seen after the 6th dose, and this supports the need for a prolonged dosing schedule.
 

Survival and subsequent therapy

At a mean follow-up of 880 days, four patients had no evidence of disease and had not received subsequent therapy. This includes one patient with stage IIIA non–small cell lung cancer, one with stage IVA HER-2 positive breast cancer, one with stage II urothelial carcinoma, and one with multiple myeloma.

Four patients were alive and receiving subsequent lines of therapy. Two of these patients had significant responses to anti–PD-1 therapy.

Three patients have died, two of whom had documented recurrence of their malignancy. The last two patients were lost to follow-up without documented recurrence.

“Our results demonstrate that the OpenVax pipeline is a viable approach to generate a safe, personalized cancer vaccine, which could potentially be used to treat a range of tumor types,” Dr. Bhardwaj said.

Trials combining neoantigens identified with the OpenVax platform are ongoing in patients with urothelial carcinoma and glioblastoma multiforme, Dr. Marron said.

The current study ( NCT02721043 ) is sponsored by Dr. Bhardwaj. Dr. Marron and Dr. Bhardwaj reported having no disclosures. Their colleagues disclosed relationships with Bristol Myers Squibb, Sema4, and Related Sciences.

A personalized genomic cancer vaccine proved feasible to manufacture and was well tolerated in a phase 1 trial, according to researchers.

The vaccine, PGV-001, was given to 13 patients with solid tumors or multiple myeloma who had a high risk of recurrence after surgery or autologous stem cell transplant.

At last follow-up, four patients were still alive without evidence of disease and had not received subsequent therapy, four were alive and receiving therapy, three had died, and two were lost to follow-up.

Thomas Marron, MD, PhD , of Mount Sinai in New York presented these results in a poster at the American Association for Cancer Research Annual Meeting 2021: Week 1 ( Abstract LB048 ). Data in the abstract differ from the data presented.

“While cancer immunotherapy has revolutionized the treatment of cancer, we know that the majority of patients fail to achieve significant clinical response,” Dr. Marron said during his presentation. “One reason for this may be due to lack of preexisting primed T-cell response needed for PD-1 blockade to have a significant effect. To address this, personalized neoantigen vaccines may help prime an improved immune response against tumor cells.”

With this in mind, Dr. Marron and colleagues developed PGV-001, a vaccine consisting of patient-specific synthetic neoantigen peptides given to patients in the adjuvant setting.
 

Creating a personalized vaccine

The researchers synthesized PGV-001 for 15 patients with advanced malignancies. The patients first underwent tumor and germline DNA sequencing as well as HLA typing. Bulk RNA sequencing was performed on patients’ tumors as well.

Then, the researchers used a computational pipeline called OpenVax to identify candidate neoantigens. This pipeline, developed at Mount Sinai, identified and prioritized candidate neoantigens using predicted MHC class I binding affinity and neoantigen abundance.

OpenVax identified an average of 71.5 neoantigens per patient (range, 7-193). The goal was to synthesize a maximum of 10 peptides per patient, but two patients did not have an adequate number of neoantigens.
 

Vaccine administration

The peptides were administered over the course of 27 weeks along with poly-ICLC and a tetanus helper peptide. Before receiving their vaccine doses, patients with solid tumors had undergone curative-intent surgery, and those with multiple myeloma had undergone autologous stem cell transplant.

“Most experimental personalized cancer vaccines are administered in the metastatic setting, but prior research indicates that immunotherapies tend to be more effective in patients who have less cancer spread,” principal investigator Nina Bhardwaj, MD, PhD , of Mount Sinai, explained in a press release .

“We have, therefore, developed a neoantigen vaccine that is administered after standard-of-care adjuvant therapy, such as surgery in solid tumors and bone marrow transplant in multiple myeloma, when patients have minimal, typically microscopic, residual disease.”
 

Feasibility, safety, and immunogenicity

PGV-001 was synthesized for 15 patients and administered to 13 of them. Six of the 13 patients had head and neck squamous cell carcinoma, three had multiple myeloma, two had non–small cell lung cancer, one had breast cancer, and one had urothelial carcinoma.

Eleven patients received all 10 intended doses, and two patients received at least 8 doses.

“The vaccine was well tolerated, with only half of patients experiencing mild, grade 1 adverse events,” Dr. Marron said.

Transient injection site reactions occurred in four patients, and grade 1 fever was reported in one patient.

Immune monitoring is ongoing, but an initial analysis in one patient showed “robust responses” in CD4 and CD8 T cells by intracellular cytokine staining for interferon-gamma, tumor necrosis factor–alpha, and interleukin-2 after in vitro expansion in the presence of vaccine antigens, according to the researchers.

Dr. Marron noted that robust T-cell reactivity was seen at the completion of all 10 doses but was not seen after the 6th dose, and this supports the need for a prolonged dosing schedule.
 

Survival and subsequent therapy

At a mean follow-up of 880 days, four patients had no evidence of disease and had not received subsequent therapy. This includes one patient with stage IIIA non–small cell lung cancer, one with stage IVA HER-2 positive breast cancer, one with stage II urothelial carcinoma, and one with multiple myeloma.

Four patients were alive and receiving subsequent lines of therapy. Two of these patients had significant responses to anti–PD-1 therapy.

Three patients have died, two of whom had documented recurrence of their malignancy. The last two patients were lost to follow-up without documented recurrence.

“Our results demonstrate that the OpenVax pipeline is a viable approach to generate a safe, personalized cancer vaccine, which could potentially be used to treat a range of tumor types,” Dr. Bhardwaj said.

Trials combining neoantigens identified with the OpenVax platform are ongoing in patients with urothelial carcinoma and glioblastoma multiforme, Dr. Marron said.

The current study ( NCT02721043 ) is sponsored by Dr. Bhardwaj. Dr. Marron and Dr. Bhardwaj reported having no disclosures. Their colleagues disclosed relationships with Bristol Myers Squibb, Sema4, and Related Sciences.

A personalized genomic cancer vaccine proved feasible to manufacture and was well tolerated in a phase 1 trial, according to researchers.

The vaccine, PGV-001, was given to 13 patients with solid tumors or multiple myeloma who had a high risk of recurrence after surgery or autologous stem cell transplant.

At last follow-up, four patients were still alive without evidence of disease and had not received subsequent therapy, four were alive and receiving therapy, three had died, and two were lost to follow-up.

Thomas Marron, MD, PhD , of Mount Sinai in New York presented these results in a poster at the American Association for Cancer Research Annual Meeting 2021: Week 1 ( Abstract LB048 ). Data in the abstract differ from the data presented.

“While cancer immunotherapy has revolutionized the treatment of cancer, we know that the majority of patients fail to achieve significant clinical response,” Dr. Marron said during his presentation. “One reason for this may be due to lack of preexisting primed T-cell response needed for PD-1 blockade to have a significant effect. To address this, personalized neoantigen vaccines may help prime an improved immune response against tumor cells.”

With this in mind, Dr. Marron and colleagues developed PGV-001, a vaccine consisting of patient-specific synthetic neoantigen peptides given to patients in the adjuvant setting.
 

Creating a personalized vaccine

The researchers synthesized PGV-001 for 15 patients with advanced malignancies. The patients first underwent tumor and germline DNA sequencing as well as HLA typing. Bulk RNA sequencing was performed on patients’ tumors as well.

Then, the researchers used a computational pipeline called OpenVax to identify candidate neoantigens. This pipeline, developed at Mount Sinai, identified and prioritized candidate neoantigens using predicted MHC class I binding affinity and neoantigen abundance.

OpenVax identified an average of 71.5 neoantigens per patient (range, 7-193). The goal was to synthesize a maximum of 10 peptides per patient, but two patients did not have an adequate number of neoantigens.
 

Vaccine administration

The peptides were administered over the course of 27 weeks along with poly-ICLC and a tetanus helper peptide. Before receiving their vaccine doses, patients with solid tumors had undergone curative-intent surgery, and those with multiple myeloma had undergone autologous stem cell transplant.

“Most experimental personalized cancer vaccines are administered in the metastatic setting, but prior research indicates that immunotherapies tend to be more effective in patients who have less cancer spread,” principal investigator Nina Bhardwaj, MD, PhD , of Mount Sinai, explained in a press release .

“We have, therefore, developed a neoantigen vaccine that is administered after standard-of-care adjuvant therapy, such as surgery in solid tumors and bone marrow transplant in multiple myeloma, when patients have minimal, typically microscopic, residual disease.”
 

Feasibility, safety, and immunogenicity

PGV-001 was synthesized for 15 patients and administered to 13 of them. Six of the 13 patients had head and neck squamous cell carcinoma, three had multiple myeloma, two had non–small cell lung cancer, one had breast cancer, and one had urothelial carcinoma.

Eleven patients received all 10 intended doses, and two patients received at least 8 doses.

“The vaccine was well tolerated, with only half of patients experiencing mild, grade 1 adverse events,” Dr. Marron said.

Transient injection site reactions occurred in four patients, and grade 1 fever was reported in one patient.

Immune monitoring is ongoing, but an initial analysis in one patient showed “robust responses” in CD4 and CD8 T cells by intracellular cytokine staining for interferon-gamma, tumor necrosis factor–alpha, and interleukin-2 after in vitro expansion in the presence of vaccine antigens, according to the researchers.

Dr. Marron noted that robust T-cell reactivity was seen at the completion of all 10 doses but was not seen after the 6th dose, and this supports the need for a prolonged dosing schedule.
 

Survival and subsequent therapy

At a mean follow-up of 880 days, four patients had no evidence of disease and had not received subsequent therapy. This includes one patient with stage IIIA non–small cell lung cancer, one with stage IVA HER-2 positive breast cancer, one with stage II urothelial carcinoma, and one with multiple myeloma.

Four patients were alive and receiving subsequent lines of therapy. Two of these patients had significant responses to anti–PD-1 therapy.

Three patients have died, two of whom had documented recurrence of their malignancy. The last two patients were lost to follow-up without documented recurrence.

“Our results demonstrate that the OpenVax pipeline is a viable approach to generate a safe, personalized cancer vaccine, which could potentially be used to treat a range of tumor types,” Dr. Bhardwaj said.

Trials combining neoantigens identified with the OpenVax platform are ongoing in patients with urothelial carcinoma and glioblastoma multiforme, Dr. Marron said.

The current study ( NCT02721043 ) is sponsored by Dr. Bhardwaj. Dr. Marron and Dr. Bhardwaj reported having no disclosures. Their colleagues disclosed relationships with Bristol Myers Squibb, Sema4, and Related Sciences.

The next 20 years will see a big shift in cancer type rankings, researchers predict.

At the moment, the most common cancers in the United States are breast, lung, prostate, colorectal, and melanoma.

By 2040, melanoma will have become the second most common cancer type, while prostate cancer will drop in incidence all the way to 14, the study authors predicted. Breast cancer will remain the top cancer to be diagnosed, lung cancer will drop from second to third, and colorectal cancer will remain at fourth.

These predicted rankings of cancer types by their total number of annual cases were published online April 7, 2021, in JAMA Network Open.

The authors also rank cancer type by mortality. Currently, most cancer deaths are caused by lung cancer, followed by colorectal, pancreatic, and breast. By 2040, the most notable change in cancer deaths is that liver and intrahepatic bile duct cancer, currently at sixth, will jump up to third.

Two decades from now, the ranking in terms of cancer deaths will be lung, pancreatic, liver and intrahepatic bile duct, and colorectal.

“Our findings reflect the shifting dynamics of cancer screening and treatment,” lead author Lola Rahib, PhD, a pancreatic cancer scientist at Cancer Commons, the advocacy nonprofit, commented in a press statement.

The new analysis used population-growth projections (based on 2010 U.S. Census data) and current population-based cancer incidence and death rates (from Surveillance, Epidemiology, and End Results 2014-2016) to calculate the changes in incidences and deaths to the year 2040.

The projected, estimated numbers are not ironclad, the researchers acknowledged.

“Our projections assume that the observed rates and trends [from recent years] don’t change over time,” Dr. Rahib said in an interview, but she pointed out that change may indeed happen.

“Any long-term projections should be considered with a grain of salt,” said Kim Miller, MPH, a surveillance research scientist at the American Cancer Society, who was approached for comment.

Dr. Miller explained that “cancer trends can sometimes rapidly change within a few years.” Projections just 2-4 years ahead are “extremely difficult” and those 20 years ahead are even more so, she added in an interview.

“We’re encouraged to see the projected decreases in deaths from lung, colorectal, and breast cancer in the coming years,” said coauthor Lynn Matrisian, PhD, MBA, chief science officer at the Pancreatic Cancer Action Network. “It’s time to shift focus to some of the less commonly diagnosed cancers with the lowest survival rates, like pancreatic and liver cancer.”
 

Difference in opinion on prostate cancer

The huge fall in the incidence of prostate cancer that the authors predict will come about as a result of changes in prostate-specific antigen (PSA)–screening recommendations over the last 15 years, they suggested.

“The most recent change in 2018 recommends that men aged 55-69 can make their own decisions regarding screening, but previous changes recommended against PSA screening,” said Dr. Rahib.

“These changes in screening guidelines have influenced the number of diagnoses of prostate cancer in recent years and will continue to do so to 2040,” Dr. Rahib commented.

Dr. Miller casts doubt on this prediction.

Using data through 2017, “we have seen that the patterns in prostate cancer incidence are already shifting from the steep declines we saw in the early 2010s,” she said. “I would use caution when interpreting the overall trends for prostate, because this cancer in particular is dramatically affected by changes in recommendations for screening with the PSA test.”

Screening has also influenced colorectal cancer incidence, the authors pointed out, saying that the uptake of colorectal cancer screening is associated with a decrease in the number of colorectal cancers and deaths out to 2040, as a result of effectiveness of screening.

For breast cancer, the authors highlighted the fact that, although the number of breast cancers will continue to increase, the number of breast cancer deaths will decrease. That ongoing trend is most likely attributable to increased screening and advancements in treatment.

The study was supported by the National Institutes of Health, National Cancer Institute, the Cancer Prevention and Research Institute of Texas, Cancer Commons and the Pancreatic Cancer Action Network. The study authors and Dr. Miller disclosed no relevant financial relationships.

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

The next 20 years will see a big shift in cancer type rankings, researchers predict.

At the moment, the most common cancers in the United States are breast, lung, prostate, colorectal, and melanoma.

By 2040, melanoma will have become the second most common cancer type, while prostate cancer will drop in incidence all the way to 14, the study authors predicted. Breast cancer will remain the top cancer to be diagnosed, lung cancer will drop from second to third, and colorectal cancer will remain at fourth.

These predicted rankings of cancer types by their total number of annual cases were published online April 7, 2021, in JAMA Network Open.

The authors also rank cancer type by mortality. Currently, most cancer deaths are caused by lung cancer, followed by colorectal, pancreatic, and breast. By 2040, the most notable change in cancer deaths is that liver and intrahepatic bile duct cancer, currently at sixth, will jump up to third.

Two decades from now, the ranking in terms of cancer deaths will be lung, pancreatic, liver and intrahepatic bile duct, and colorectal.

“Our findings reflect the shifting dynamics of cancer screening and treatment,” lead author Lola Rahib, PhD, a pancreatic cancer scientist at Cancer Commons, the advocacy nonprofit, commented in a press statement.

The new analysis used population-growth projections (based on 2010 U.S. Census data) and current population-based cancer incidence and death rates (from Surveillance, Epidemiology, and End Results 2014-2016) to calculate the changes in incidences and deaths to the year 2040.

The projected, estimated numbers are not ironclad, the researchers acknowledged.

“Our projections assume that the observed rates and trends [from recent years] don’t change over time,” Dr. Rahib said in an interview, but she pointed out that change may indeed happen.

“Any long-term projections should be considered with a grain of salt,” said Kim Miller, MPH, a surveillance research scientist at the American Cancer Society, who was approached for comment.

Dr. Miller explained that “cancer trends can sometimes rapidly change within a few years.” Projections just 2-4 years ahead are “extremely difficult” and those 20 years ahead are even more so, she added in an interview.

“We’re encouraged to see the projected decreases in deaths from lung, colorectal, and breast cancer in the coming years,” said coauthor Lynn Matrisian, PhD, MBA, chief science officer at the Pancreatic Cancer Action Network. “It’s time to shift focus to some of the less commonly diagnosed cancers with the lowest survival rates, like pancreatic and liver cancer.”
 

Difference in opinion on prostate cancer

The huge fall in the incidence of prostate cancer that the authors predict will come about as a result of changes in prostate-specific antigen (PSA)–screening recommendations over the last 15 years, they suggested.

“The most recent change in 2018 recommends that men aged 55-69 can make their own decisions regarding screening, but previous changes recommended against PSA screening,” said Dr. Rahib.

“These changes in screening guidelines have influenced the number of diagnoses of prostate cancer in recent years and will continue to do so to 2040,” Dr. Rahib commented.

Dr. Miller casts doubt on this prediction.

Using data through 2017, “we have seen that the patterns in prostate cancer incidence are already shifting from the steep declines we saw in the early 2010s,” she said. “I would use caution when interpreting the overall trends for prostate, because this cancer in particular is dramatically affected by changes in recommendations for screening with the PSA test.”

Screening has also influenced colorectal cancer incidence, the authors pointed out, saying that the uptake of colorectal cancer screening is associated with a decrease in the number of colorectal cancers and deaths out to 2040, as a result of effectiveness of screening.

For breast cancer, the authors highlighted the fact that, although the number of breast cancers will continue to increase, the number of breast cancer deaths will decrease. That ongoing trend is most likely attributable to increased screening and advancements in treatment.

The study was supported by the National Institutes of Health, National Cancer Institute, the Cancer Prevention and Research Institute of Texas, Cancer Commons and the Pancreatic Cancer Action Network. The study authors and Dr. Miller disclosed no relevant financial relationships.

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

The next 20 years will see a big shift in cancer type rankings, researchers predict.

At the moment, the most common cancers in the United States are breast, lung, prostate, colorectal, and melanoma.

By 2040, melanoma will have become the second most common cancer type, while prostate cancer will drop in incidence all the way to 14, the study authors predicted. Breast cancer will remain the top cancer to be diagnosed, lung cancer will drop from second to third, and colorectal cancer will remain at fourth.

These predicted rankings of cancer types by their total number of annual cases were published online April 7, 2021, in JAMA Network Open.

The authors also rank cancer type by mortality. Currently, most cancer deaths are caused by lung cancer, followed by colorectal, pancreatic, and breast. By 2040, the most notable change in cancer deaths is that liver and intrahepatic bile duct cancer, currently at sixth, will jump up to third.

Two decades from now, the ranking in terms of cancer deaths will be lung, pancreatic, liver and intrahepatic bile duct, and colorectal.

“Our findings reflect the shifting dynamics of cancer screening and treatment,” lead author Lola Rahib, PhD, a pancreatic cancer scientist at Cancer Commons, the advocacy nonprofit, commented in a press statement.

The new analysis used population-growth projections (based on 2010 U.S. Census data) and current population-based cancer incidence and death rates (from Surveillance, Epidemiology, and End Results 2014-2016) to calculate the changes in incidences and deaths to the year 2040.

The projected, estimated numbers are not ironclad, the researchers acknowledged.

“Our projections assume that the observed rates and trends [from recent years] don’t change over time,” Dr. Rahib said in an interview, but she pointed out that change may indeed happen.

“Any long-term projections should be considered with a grain of salt,” said Kim Miller, MPH, a surveillance research scientist at the American Cancer Society, who was approached for comment.

Dr. Miller explained that “cancer trends can sometimes rapidly change within a few years.” Projections just 2-4 years ahead are “extremely difficult” and those 20 years ahead are even more so, she added in an interview.

“We’re encouraged to see the projected decreases in deaths from lung, colorectal, and breast cancer in the coming years,” said coauthor Lynn Matrisian, PhD, MBA, chief science officer at the Pancreatic Cancer Action Network. “It’s time to shift focus to some of the less commonly diagnosed cancers with the lowest survival rates, like pancreatic and liver cancer.”
 

Difference in opinion on prostate cancer

The huge fall in the incidence of prostate cancer that the authors predict will come about as a result of changes in prostate-specific antigen (PSA)–screening recommendations over the last 15 years, they suggested.

“The most recent change in 2018 recommends that men aged 55-69 can make their own decisions regarding screening, but previous changes recommended against PSA screening,” said Dr. Rahib.

“These changes in screening guidelines have influenced the number of diagnoses of prostate cancer in recent years and will continue to do so to 2040,” Dr. Rahib commented.

Dr. Miller casts doubt on this prediction.

Using data through 2017, “we have seen that the patterns in prostate cancer incidence are already shifting from the steep declines we saw in the early 2010s,” she said. “I would use caution when interpreting the overall trends for prostate, because this cancer in particular is dramatically affected by changes in recommendations for screening with the PSA test.”

Screening has also influenced colorectal cancer incidence, the authors pointed out, saying that the uptake of colorectal cancer screening is associated with a decrease in the number of colorectal cancers and deaths out to 2040, as a result of effectiveness of screening.

For breast cancer, the authors highlighted the fact that, although the number of breast cancers will continue to increase, the number of breast cancer deaths will decrease. That ongoing trend is most likely attributable to increased screening and advancements in treatment.

The study was supported by the National Institutes of Health, National Cancer Institute, the Cancer Prevention and Research Institute of Texas, Cancer Commons and the Pancreatic Cancer Action Network. The study authors and Dr. Miller disclosed no relevant financial relationships.

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

The World Psychiatric Association (WPA) has released new global telemedicine guidelines.

Prompted by the worldwide explosion of interest in telepsychiatry driven by the COVID-19 pandemic, the guidelines emphasize the need for international collaboration in psychiatry.

“Global teamwork is the light at the end of the tunnel” of the current crisis, lead author Davor Mucic, MD, The Little Prince Treatment Center, Copenhagen, told meeting attendees.

“Now is the time to build a user-friendly digital health care system that can better meet the inevitable future challenges,” Dr. Mucic said. “The hope is that WPA’s global guidelines for telepsychiatry can help us to move forward.”

The guidelines, which also address concerns over data security and device intercompatibility, were presented at the virtual European Psychiatric Association (EPA) 2021 Congress.
 

Breaking down barriers

Although telepsychiatry has been around since 1959, only with the rapid technologic advances of the past decade has it become available to the majority of psychiatric patients, Dr. Mucic noted.

“Unfortunately, regulatory constraints, in combination with clinicians’ concerns, kept telepsychiatry from being widely adopted and implemented prior to the current COVID-19 pandemic,” he added.

Concerns have been with regard to data safety, reimbursement for consultations, quality of care, lack of technical experience, and difficulties in changing routines.

For many clinicians, the pandemic was the “first time they used telepsychiatry, and very few have received training in how to do it,” Dr. Mucic said.

He pointed out that guidelines are available in the United States, Canada, Australia, and India, including the 2018 Best Practices in Videoconferencing-Based Telemental Health, released by the American Psychiatric Association and the American Telemedicine Association.

Dr. Mucic noted that because these documents are relevant and useful, clinicians may wonder, “Why do we need another set of guidelines?”

He explained that the current WPA guidelines outline universal recommendations that apply “regardless of local or regional regulations.” Therefore, they can be used just as easily in low- and middle-income countries as in countries where telepsychiatry is already established.
 

A new paradigm

Similar to other guidelines, the WPA’s guidelines discuss legal and regulatory requirements, informed consent, billing and reimbursement, patient selection, clinician training, the clinical setting, and more.

However, what makes the new document “so new and special” is that it opens the door to “some new and previously undiscussed aspects of telepsychiatry ... that are capable of changing the whole delivery of mental health care,” Dr. Mucic said.

The first of these new aspects is in regard to cross-cultural telepsychiatry. The goal is to eliminate the need for interpreters or competency in a different language for patients who do not speak the host country’s language by connecting them remotely with a bilingual health care professional who shares their cultural or ethnic background.

This “ethnic matching” model may lead to a “more precise and detailed symptomatology,” the authors note. They add that minimizing the risk for misinterpretation and misunderstanding can enable better diagnosis and treatment.

The second area highlighted by Dr. Mucic is in regard to international telepsychiatry; the technology could be used to obtain a second opinion from colleagues who share the relevant cultural and linguistic background.

“Further, international expertise may be brought via [telepsychiatry] to local health workers as a part of education, supervision, and scientific collaboration,” he said.

“The hope is the guidelines will pave the way for improved international collaboration, not only by clinicians but also by policymakers.”
 

A blended future?

Also at EPA 2021, two experts debated whether the COVID-19 pandemic represented a turning point for e-health in psychiatry.

Taking the pro stance, Heleen Riper, PhD, professor of eMental-Health at the Vrije Universiteit Amsterdam, argued that the future is likely to blend face-to-face interaction with video conferencing.

She believes that to maintain current progress, the focus should be on treatment personalization, engagement, and improvement, rather than cost-effectiveness.

Hans-Jürgen Möller, MD, professor emeritus, department of psychiatry, Ludwig-Maximilians-University, Munich, argued against the idea that e-health represented a turning point in psychiatry. He noted that a survey of German psychotherapists indicated that there have been a number of drawbacks to video sessions during the pandemic.

Cautious optimism

Session chair Judit Simon, MD, DPhil, professor of health economics, Medical University of Vienna, asked the debaters whether video interventions will continue to replace in-person interventions once the pandemic is over or whether things will return to “where we were prepandemic.”

Dr. Riper said she did not believe that clinicians will return completely to in-patient practice. However, she emphasized the need for training and the development of new skills to improve the therapeutic relationship with patients.

Although Dr. Riper believes there is still a need for in-person doctor/patient interactions, “we will never get back to the pre-COVID phase, both in terms of diagnostics and treatment,” she said.

Dr. Möller added that although he has “some reservations” regarding the adoption of technologies by older patients and the lack of long-term data on telepsychiatry, he partially shares Dr. Riper’s optimism.

He suggested that there is an opportunity in psychiatry to use video conferencing for multidisciplinary team meetings similar to those seen in oncology.

This would allow discussion of patient diagnosis and treatment and would enable experts in mental health to help clinicians in other specialties. For example, it could help a general practitioner differentiate between depression and a depressive phase of schizophrenia, Dr. Riper said.

The presenters have disclosed no relevant financial relationships.

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

The World Psychiatric Association (WPA) has released new global telemedicine guidelines.

Prompted by the worldwide explosion of interest in telepsychiatry driven by the COVID-19 pandemic, the guidelines emphasize the need for international collaboration in psychiatry.

“Global teamwork is the light at the end of the tunnel” of the current crisis, lead author Davor Mucic, MD, The Little Prince Treatment Center, Copenhagen, told meeting attendees.

“Now is the time to build a user-friendly digital health care system that can better meet the inevitable future challenges,” Dr. Mucic said. “The hope is that WPA’s global guidelines for telepsychiatry can help us to move forward.”

The guidelines, which also address concerns over data security and device intercompatibility, were presented at the virtual European Psychiatric Association (EPA) 2021 Congress.
 

Breaking down barriers

Although telepsychiatry has been around since 1959, only with the rapid technologic advances of the past decade has it become available to the majority of psychiatric patients, Dr. Mucic noted.

“Unfortunately, regulatory constraints, in combination with clinicians’ concerns, kept telepsychiatry from being widely adopted and implemented prior to the current COVID-19 pandemic,” he added.

Concerns have been with regard to data safety, reimbursement for consultations, quality of care, lack of technical experience, and difficulties in changing routines.

For many clinicians, the pandemic was the “first time they used telepsychiatry, and very few have received training in how to do it,” Dr. Mucic said.

He pointed out that guidelines are available in the United States, Canada, Australia, and India, including the 2018 Best Practices in Videoconferencing-Based Telemental Health, released by the American Psychiatric Association and the American Telemedicine Association.

Dr. Mucic noted that because these documents are relevant and useful, clinicians may wonder, “Why do we need another set of guidelines?”

He explained that the current WPA guidelines outline universal recommendations that apply “regardless of local or regional regulations.” Therefore, they can be used just as easily in low- and middle-income countries as in countries where telepsychiatry is already established.
 

A new paradigm

Similar to other guidelines, the WPA’s guidelines discuss legal and regulatory requirements, informed consent, billing and reimbursement, patient selection, clinician training, the clinical setting, and more.

However, what makes the new document “so new and special” is that it opens the door to “some new and previously undiscussed aspects of telepsychiatry ... that are capable of changing the whole delivery of mental health care,” Dr. Mucic said.

The first of these new aspects is in regard to cross-cultural telepsychiatry. The goal is to eliminate the need for interpreters or competency in a different language for patients who do not speak the host country’s language by connecting them remotely with a bilingual health care professional who shares their cultural or ethnic background.

This “ethnic matching” model may lead to a “more precise and detailed symptomatology,” the authors note. They add that minimizing the risk for misinterpretation and misunderstanding can enable better diagnosis and treatment.

The second area highlighted by Dr. Mucic is in regard to international telepsychiatry; the technology could be used to obtain a second opinion from colleagues who share the relevant cultural and linguistic background.

“Further, international expertise may be brought via [telepsychiatry] to local health workers as a part of education, supervision, and scientific collaboration,” he said.

“The hope is the guidelines will pave the way for improved international collaboration, not only by clinicians but also by policymakers.”
 

A blended future?

Also at EPA 2021, two experts debated whether the COVID-19 pandemic represented a turning point for e-health in psychiatry.

Taking the pro stance, Heleen Riper, PhD, professor of eMental-Health at the Vrije Universiteit Amsterdam, argued that the future is likely to blend face-to-face interaction with video conferencing.

She believes that to maintain current progress, the focus should be on treatment personalization, engagement, and improvement, rather than cost-effectiveness.

Hans-Jürgen Möller, MD, professor emeritus, department of psychiatry, Ludwig-Maximilians-University, Munich, argued against the idea that e-health represented a turning point in psychiatry. He noted that a survey of German psychotherapists indicated that there have been a number of drawbacks to video sessions during the pandemic.

Cautious optimism

Session chair Judit Simon, MD, DPhil, professor of health economics, Medical University of Vienna, asked the debaters whether video interventions will continue to replace in-person interventions once the pandemic is over or whether things will return to “where we were prepandemic.”

Dr. Riper said she did not believe that clinicians will return completely to in-patient practice. However, she emphasized the need for training and the development of new skills to improve the therapeutic relationship with patients.

Although Dr. Riper believes there is still a need for in-person doctor/patient interactions, “we will never get back to the pre-COVID phase, both in terms of diagnostics and treatment,” she said.

Dr. Möller added that although he has “some reservations” regarding the adoption of technologies by older patients and the lack of long-term data on telepsychiatry, he partially shares Dr. Riper’s optimism.

He suggested that there is an opportunity in psychiatry to use video conferencing for multidisciplinary team meetings similar to those seen in oncology.

This would allow discussion of patient diagnosis and treatment and would enable experts in mental health to help clinicians in other specialties. For example, it could help a general practitioner differentiate between depression and a depressive phase of schizophrenia, Dr. Riper said.

The presenters have disclosed no relevant financial relationships.

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

The World Psychiatric Association (WPA) has released new global telemedicine guidelines.

Prompted by the worldwide explosion of interest in telepsychiatry driven by the COVID-19 pandemic, the guidelines emphasize the need for international collaboration in psychiatry.

“Global teamwork is the light at the end of the tunnel” of the current crisis, lead author Davor Mucic, MD, The Little Prince Treatment Center, Copenhagen, told meeting attendees.

“Now is the time to build a user-friendly digital health care system that can better meet the inevitable future challenges,” Dr. Mucic said. “The hope is that WPA’s global guidelines for telepsychiatry can help us to move forward.”

The guidelines, which also address concerns over data security and device intercompatibility, were presented at the virtual European Psychiatric Association (EPA) 2021 Congress.
 

Breaking down barriers

Although telepsychiatry has been around since 1959, only with the rapid technologic advances of the past decade has it become available to the majority of psychiatric patients, Dr. Mucic noted.

“Unfortunately, regulatory constraints, in combination with clinicians’ concerns, kept telepsychiatry from being widely adopted and implemented prior to the current COVID-19 pandemic,” he added.

Concerns have been with regard to data safety, reimbursement for consultations, quality of care, lack of technical experience, and difficulties in changing routines.

For many clinicians, the pandemic was the “first time they used telepsychiatry, and very few have received training in how to do it,” Dr. Mucic said.

He pointed out that guidelines are available in the United States, Canada, Australia, and India, including the 2018 Best Practices in Videoconferencing-Based Telemental Health, released by the American Psychiatric Association and the American Telemedicine Association.

Dr. Mucic noted that because these documents are relevant and useful, clinicians may wonder, “Why do we need another set of guidelines?”

He explained that the current WPA guidelines outline universal recommendations that apply “regardless of local or regional regulations.” Therefore, they can be used just as easily in low- and middle-income countries as in countries where telepsychiatry is already established.
 

A new paradigm

Similar to other guidelines, the WPA’s guidelines discuss legal and regulatory requirements, informed consent, billing and reimbursement, patient selection, clinician training, the clinical setting, and more.

However, what makes the new document “so new and special” is that it opens the door to “some new and previously undiscussed aspects of telepsychiatry ... that are capable of changing the whole delivery of mental health care,” Dr. Mucic said.

The first of these new aspects is in regard to cross-cultural telepsychiatry. The goal is to eliminate the need for interpreters or competency in a different language for patients who do not speak the host country’s language by connecting them remotely with a bilingual health care professional who shares their cultural or ethnic background.

This “ethnic matching” model may lead to a “more precise and detailed symptomatology,” the authors note. They add that minimizing the risk for misinterpretation and misunderstanding can enable better diagnosis and treatment.

The second area highlighted by Dr. Mucic is in regard to international telepsychiatry; the technology could be used to obtain a second opinion from colleagues who share the relevant cultural and linguistic background.

“Further, international expertise may be brought via [telepsychiatry] to local health workers as a part of education, supervision, and scientific collaboration,” he said.

“The hope is the guidelines will pave the way for improved international collaboration, not only by clinicians but also by policymakers.”
 

A blended future?

Also at EPA 2021, two experts debated whether the COVID-19 pandemic represented a turning point for e-health in psychiatry.

Taking the pro stance, Heleen Riper, PhD, professor of eMental-Health at the Vrije Universiteit Amsterdam, argued that the future is likely to blend face-to-face interaction with video conferencing.

She believes that to maintain current progress, the focus should be on treatment personalization, engagement, and improvement, rather than cost-effectiveness.

Hans-Jürgen Möller, MD, professor emeritus, department of psychiatry, Ludwig-Maximilians-University, Munich, argued against the idea that e-health represented a turning point in psychiatry. He noted that a survey of German psychotherapists indicated that there have been a number of drawbacks to video sessions during the pandemic.

Cautious optimism

Session chair Judit Simon, MD, DPhil, professor of health economics, Medical University of Vienna, asked the debaters whether video interventions will continue to replace in-person interventions once the pandemic is over or whether things will return to “where we were prepandemic.”

Dr. Riper said she did not believe that clinicians will return completely to in-patient practice. However, she emphasized the need for training and the development of new skills to improve the therapeutic relationship with patients.

Although Dr. Riper believes there is still a need for in-person doctor/patient interactions, “we will never get back to the pre-COVID phase, both in terms of diagnostics and treatment,” she said.

Dr. Möller added that although he has “some reservations” regarding the adoption of technologies by older patients and the lack of long-term data on telepsychiatry, he partially shares Dr. Riper’s optimism.

He suggested that there is an opportunity in psychiatry to use video conferencing for multidisciplinary team meetings similar to those seen in oncology.

This would allow discussion of patient diagnosis and treatment and would enable experts in mental health to help clinicians in other specialties. For example, it could help a general practitioner differentiate between depression and a depressive phase of schizophrenia, Dr. Riper said.

The presenters have disclosed no relevant financial relationships.

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

The Food and Drug Administration has responded to congressional criticism and launched a multiyear plan to reduce the amount of heavy metals such as mercury and arsenic found in baby food.

Catherine Delahaye/DigitalVision/Getty Images

Called “Closer to Zero,” the FDA plan calls for continued scientific investigation, establishes acceptable levels of heavy metals, sets up a way to monitor manufacturers’ compliance, and sets “action levels.”

“Although the FDA’s testing shows that children are not at an immediate health risk from exposure to toxic elements at the levels found in foods, we are starting the plan’s work immediately, with both short- and long-term goals for achieving continued improvements in reducing levels of toxic elements in these foods over time,” the FDA said.

However, Closer to Zero will only make recommendations on heavy metal levels.

“Although action levels are not binding, we have seen that, over the years, our guidance on action levels and other actions have contributed to significant reductions of toxic elements in food,” an FDA spokeswoman wrote in a statement, according to the Washington Post.

A congressional panel said in February 2021 that major brands of commercial baby food routinely have high levels of toxic heavy metals. The House Oversight Committee said this leaves babies at risk for serious developmental and neurologic problems.

The committee sharply criticized the FDA for not taking action.

“Despite the well-known risks of harm to babies from toxic heavy metals, FDA has not taken adequate steps to decrease their presence in baby foods,” the committee said. “FDA has not issued thresholds for the vast majority of toxic heavy metals in baby foods and does not require warning labels on any baby food products.”

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

The Food and Drug Administration has responded to congressional criticism and launched a multiyear plan to reduce the amount of heavy metals such as mercury and arsenic found in baby food.

Catherine Delahaye/DigitalVision/Getty Images

Called “Closer to Zero,” the FDA plan calls for continued scientific investigation, establishes acceptable levels of heavy metals, sets up a way to monitor manufacturers’ compliance, and sets “action levels.”

“Although the FDA’s testing shows that children are not at an immediate health risk from exposure to toxic elements at the levels found in foods, we are starting the plan’s work immediately, with both short- and long-term goals for achieving continued improvements in reducing levels of toxic elements in these foods over time,” the FDA said.

However, Closer to Zero will only make recommendations on heavy metal levels.

“Although action levels are not binding, we have seen that, over the years, our guidance on action levels and other actions have contributed to significant reductions of toxic elements in food,” an FDA spokeswoman wrote in a statement, according to the Washington Post.

A congressional panel said in February 2021 that major brands of commercial baby food routinely have high levels of toxic heavy metals. The House Oversight Committee said this leaves babies at risk for serious developmental and neurologic problems.

The committee sharply criticized the FDA for not taking action.

“Despite the well-known risks of harm to babies from toxic heavy metals, FDA has not taken adequate steps to decrease their presence in baby foods,” the committee said. “FDA has not issued thresholds for the vast majority of toxic heavy metals in baby foods and does not require warning labels on any baby food products.”

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

The Food and Drug Administration has responded to congressional criticism and launched a multiyear plan to reduce the amount of heavy metals such as mercury and arsenic found in baby food.

Catherine Delahaye/DigitalVision/Getty Images

Called “Closer to Zero,” the FDA plan calls for continued scientific investigation, establishes acceptable levels of heavy metals, sets up a way to monitor manufacturers’ compliance, and sets “action levels.”

“Although the FDA’s testing shows that children are not at an immediate health risk from exposure to toxic elements at the levels found in foods, we are starting the plan’s work immediately, with both short- and long-term goals for achieving continued improvements in reducing levels of toxic elements in these foods over time,” the FDA said.

However, Closer to Zero will only make recommendations on heavy metal levels.

“Although action levels are not binding, we have seen that, over the years, our guidance on action levels and other actions have contributed to significant reductions of toxic elements in food,” an FDA spokeswoman wrote in a statement, according to the Washington Post.

A congressional panel said in February 2021 that major brands of commercial baby food routinely have high levels of toxic heavy metals. The House Oversight Committee said this leaves babies at risk for serious developmental and neurologic problems.

The committee sharply criticized the FDA for not taking action.

“Despite the well-known risks of harm to babies from toxic heavy metals, FDA has not taken adequate steps to decrease their presence in baby foods,” the committee said. “FDA has not issued thresholds for the vast majority of toxic heavy metals in baby foods and does not require warning labels on any baby food products.”

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

Marine algae are relatively common raw sources for cosmeceutical products.¹ The photoprotective compounds identified among marine algae range from mycosporinelike amino acids, sulfated polysaccharides, and carotenoids to polyphenols, all of which are noted for absorbing UV and conferring antioxidant, matrix metalloproteinase–suppressing, anti-aging, and immunomodulatory effects.² Such biologic activities understandably account for the interest in harnessing their potential in the skin care realm. Indeed, marine ingredients have been steadily flowing into the market for skin care, and research has proliferated – so much so, in fact, that I’ll take two columns to cover some of the most recent research on various marine species and some of the indications or potential uses for these products in skin care.

ph2212/Getty Images

Key activities and potential uses

Kim and associates note that carbohydrates are the primary components of marine algae, with copious amounts delivering a moisturizing and thickening effect when incorporated into cosmetic products. They add that marine carbohydrates are also known to impart antioxidant, antimelanogenic, and anti-aging activities.³

In 2017, Colantonio and Rivers reviewed the evidence supporting the use of seaweed, among other plants, for dermatologic purposes. The researchers considered four plants and algae (seaweed, witch hazel, bearberry, and mayapple) used in traditional First Nations approaches to skin disease. They found that seaweed shows promise for clinical use in treating acne and wrinkles and could deliver healthy benefits when included in biofunctional textiles.⁴

Atopic dermatitis

Found in the seaweed Fucus vesiculosus, fucoidan is known to impart anti-inflammatory, antioxidant, and antitumor activity.⁵ In a 2019 BALB/c mouse study, Tian and associates showed that fucoidan, which is rich in polysaccharides, significantly improved ear swelling and skin lesions and reduced inflammatory cell infiltration. Given the resolution of the 2,4-dinitrofluorobenzene–induced atopic dermatitis symptoms, the investigators suggested that fucoidan may have potential as an anti-AD agent.⁵

Also that year, Gil and associates studied the effects of Seaweed fulvescens, a chlorophyll-rich green alga (also called Maesaengi) known to have antioxidant properties, in a mouse model of Dermatophagoides farinae body-induced AD and in tumor necrosis factor–alpha and interferon-gamma–stimulated HaCaT keratinocytes. They observed that 200-mg/mouse treatment hindered AD symptom development, compared with controls, with enhanced dorsal skin lesions, diminished thickness and infiltration of inflammation, and decreased proinflammatory cytokines. In addition, the investigators reported the dose-dependent inhibition of proinflammatory cytokine synthesis in HaCaT keratinocytes. They concluded that Seaweed fulvescens shows promise as a therapeutic option for AD treatment.⁶

Alopecia

In 2017, Kang and associates studied the impact and mechanism of Undariopsis peterseniana, an edible brown alga, and determined that the extract promotes hair growth by activating the Wnt/beta-catenin and ERK pathways. Specifically, they found that U. peterseniana significantly enhanced hair-fiber length ex vivo and in vivo. They also concluded that the brown alga has potential to treat alopecia as it accelerated anagen initiation.⁷

Skin protection potential of Ishige okamurae

In 2015, Piao and associates demonstrated that diphlorethohydroxycarmalol (DPHC), a phlorotannin isolated from Ishige okamurae, protected human keratinocytes from UVB-induced matrix metalloproteinase (MMP) expression by inactivating ERK and JNK. MMPs are known to contribute to photoaging and tumor promotion.⁸

Early in 2020, Wang and associates demonstrated that DPHC, isolated from the marine brown alga I. okamurae, exerted protective effects against UVB-induced photodamage in vitro in human dermal fibroblasts and in vivo in zebrafish by suppressing collagenase and elastase production and the expression of matrix metalloproteinases. In vivo, the brown alga extract lowered cell death by decreasing lipid peroxidation and inflammatory response. The investigators concluded that DPHC warrants consideration as an ingredient in cosmeceutical formulations intended to protect against the effects of UVB radiation.⁹

The same team also reported on their study of the protective effects of DPHC against skin damage in human dermal fibroblasts caused by particulate matter. They found that DPHC dose-dependently exerted significant decreases in intracellular synthesis of reactive oxygen species. The seaweed product also stimulated collagen production and suppressed collagenase activity, as well as matrix metalloproteinases. The researchers concluded that DPHC may be an effective skin-protective ingredient against particulate matter for use in cosmeceutical products.¹⁰

Skin protection mouse studies using various marine species

The last 3 years alone have featured several studies in mice that may have significant implications in accelerating our understanding of how to harness the bioactive properties of multiple marine species.

In 2018, Wiraguna and associates studied the protective effects of 0.2% and 0.4% Caulerpa sp. (a genus of seaweed native to the Indo-Pacific region) extract gels on photoaging in the UVB-irradiated skin of Wistar mice, finding that topical applications of both concentrations of the seaweed extract protected mouse skin from UVB-induced photoaging, with treated mice revealed to have higher collagen expression and preserved collagen structure and decreased MMP-1 levels, compared with vehicle controls.¹¹

The next year, Prasedya and associates showed that the brown macroalgae Sargassum cristafolium exerted photoprotective activity against UVA in mice. Mice pretreated with the seaweed before exposure displayed intact collagen formation and no increases in epidermal thickness, compared with controls.¹²

At the same time, Santos and associates demonstrated that mice fed a diet supplemented with the red seaweed Porphyra umbilicalis experienced significant decreases in the incidence of human papillomavirus type 16–induced premalignant dysplastic skin lesions.¹³

Also that year, Zhen and associates evaluated the protective effects of eckol, a phlorotannin isolated from brown seaweed, on human HaCaT keratinocytes against PM2.5-induced cell damage. They showed that eckol (30 mcm) reduced reactive oxygen species production and protected cells from apoptosis by hampering the MAPK signaling pathway.¹⁴Earlier that year, Kim and associates studied the viability of the microalga Nannochloropsis oceanica, considered most often as a possible biofuel, for potential photoprotective activity against UVB-irradiated human dermal fibroblasts. They determined that pigment extracts (violaxanthin was identified as the main pigment) were not cytotoxic to the fibroblasts and that treatment with the pigment extract upregulated collagen expression and significantly inhibited UVB-induced damage. Further study revealed that violaxanthin significantly mitigated UVB-induced G1 phase arrest, senescence-associated beta-galactosidase activation, and p16 and p21 up-regulation, among other functions, suggesting its consideration, according to the authors, as a possible antiphotoaging agent.¹⁵

Finally, early in 2020, Bellan and associates evaluated the antitumor characteristics of the sulfated heterorhamnan derived from the green seaweed Gayralia brasiliensis as seen on the biological activities in the B16-F10 murine melanoma cell line. The polysaccharidic fraction was found to be effective in reducing melanoma cell migration and invasion capacity.¹⁶

Conclusion

Marine ingredients have been ripe for exploration, extraction, and usage in the cosmetic realm for several years. Evidence suggests widespread potential across several species for dermatologic purposes. Indeed, data indicate that some species appear to be suited for treating AD, alopecia, and wrinkles and may possibly render effective photoprotection. More research is necessary, of course, to ascertain the extent to which such ingredients can adequately address cutaneous health and how truly effective the marine ingredients are in currently marketed products.

Dr. Baumann is a private practice dermatologist, researcher, author, and entrepreneur who practices in Miami. She founded the Cosmetic Dermatology Center at the University of Miami in 1997. Dr. Baumann has written two textbooks and a New York Times Best Sellers book for consumers. Dr. Baumann has received funding for advisory boards and/or clinical research trials from Allergan, Galderma, Revance, Evolus, and Burt’s Bees. She is the CEO of Skin Type Solutions, a company that independently tests skin care products and makes recommendations to physicians on which skin care technologies are best. Write to her at [email protected].

References

1. Fabrowska J et al. Acta Pol Pharm. 2017 Mar;74(2):633-41.

2. Pangestuti R et al. Mar Drugs. 2018 Oct 23;16(11):399.

3. Kim JH et al. Mar Drugs. 2018 Nov 21;16(11):459.

4. Colantonio S & Rivers JK. J Cutan Med Surg. Jul/Aug 2017;21(4):299-307.

5. Tian T et al. Int Immunopharmacol. 2019 Oct;75:105823.

6. Gil TY et al. Mediators Inflamm. 2019 Mar 17;2019:3760934.

7. Kang JI et al. Mar Drugs. 2017 May 5;15(5):130.

8. Piao MJ et al. Biomol Ther (Seoul). 2015 Nov;23(6):557-63.

9. Wang L et al. Food Chem Toxicol. 2020 Feb;136:110963.

10. Wang L et al. Molecules. 2020 Feb 26;25(5):1055.

11. Wiraguna AAGP et al. Dermatol Reports. 2018 Oct 1;10(2):7597.

12. Prasedya ES et al. Biomedicines. 2019 Sep 27;7(4):77.

13. Santos S et al. Mar Drugs. 2019 Oct 29;17(11):615.

14. Zhen AX et al. Mar Drugs. 2019 Jul 27;17(8):444.

15. Kim HM et al. Photochem Photobiol. 2019 Mar;95(2):595-604.

16. Bellan DL et al. Mar Biotechnol. 2020 Apr;22(2):194-206.

Marine algae are relatively common raw sources for cosmeceutical products.¹ The photoprotective compounds identified among marine algae range from mycosporinelike amino acids, sulfated polysaccharides, and carotenoids to polyphenols, all of which are noted for absorbing UV and conferring antioxidant, matrix metalloproteinase–suppressing, anti-aging, and immunomodulatory effects.² Such biologic activities understandably account for the interest in harnessing their potential in the skin care realm. Indeed, marine ingredients have been steadily flowing into the market for skin care, and research has proliferated – so much so, in fact, that I’ll take two columns to cover some of the most recent research on various marine species and some of the indications or potential uses for these products in skin care.

ph2212/Getty Images

Key activities and potential uses

Kim and associates note that carbohydrates are the primary components of marine algae, with copious amounts delivering a moisturizing and thickening effect when incorporated into cosmetic products. They add that marine carbohydrates are also known to impart antioxidant, antimelanogenic, and anti-aging activities.³

In 2017, Colantonio and Rivers reviewed the evidence supporting the use of seaweed, among other plants, for dermatologic purposes. The researchers considered four plants and algae (seaweed, witch hazel, bearberry, and mayapple) used in traditional First Nations approaches to skin disease. They found that seaweed shows promise for clinical use in treating acne and wrinkles and could deliver healthy benefits when included in biofunctional textiles.⁴

Atopic dermatitis

Found in the seaweed Fucus vesiculosus, fucoidan is known to impart anti-inflammatory, antioxidant, and antitumor activity.⁵ In a 2019 BALB/c mouse study, Tian and associates showed that fucoidan, which is rich in polysaccharides, significantly improved ear swelling and skin lesions and reduced inflammatory cell infiltration. Given the resolution of the 2,4-dinitrofluorobenzene–induced atopic dermatitis symptoms, the investigators suggested that fucoidan may have potential as an anti-AD agent.⁵

Also that year, Gil and associates studied the effects of Seaweed fulvescens, a chlorophyll-rich green alga (also called Maesaengi) known to have antioxidant properties, in a mouse model of Dermatophagoides farinae body-induced AD and in tumor necrosis factor–alpha and interferon-gamma–stimulated HaCaT keratinocytes. They observed that 200-mg/mouse treatment hindered AD symptom development, compared with controls, with enhanced dorsal skin lesions, diminished thickness and infiltration of inflammation, and decreased proinflammatory cytokines. In addition, the investigators reported the dose-dependent inhibition of proinflammatory cytokine synthesis in HaCaT keratinocytes. They concluded that Seaweed fulvescens shows promise as a therapeutic option for AD treatment.⁶

Alopecia

In 2017, Kang and associates studied the impact and mechanism of Undariopsis peterseniana, an edible brown alga, and determined that the extract promotes hair growth by activating the Wnt/beta-catenin and ERK pathways. Specifically, they found that U. peterseniana significantly enhanced hair-fiber length ex vivo and in vivo. They also concluded that the brown alga has potential to treat alopecia as it accelerated anagen initiation.⁷

Skin protection potential of Ishige okamurae

In 2015, Piao and associates demonstrated that diphlorethohydroxycarmalol (DPHC), a phlorotannin isolated from Ishige okamurae, protected human keratinocytes from UVB-induced matrix metalloproteinase (MMP) expression by inactivating ERK and JNK. MMPs are known to contribute to photoaging and tumor promotion.⁸

Early in 2020, Wang and associates demonstrated that DPHC, isolated from the marine brown alga I. okamurae, exerted protective effects against UVB-induced photodamage in vitro in human dermal fibroblasts and in vivo in zebrafish by suppressing collagenase and elastase production and the expression of matrix metalloproteinases. In vivo, the brown alga extract lowered cell death by decreasing lipid peroxidation and inflammatory response. The investigators concluded that DPHC warrants consideration as an ingredient in cosmeceutical formulations intended to protect against the effects of UVB radiation.⁹

The same team also reported on their study of the protective effects of DPHC against skin damage in human dermal fibroblasts caused by particulate matter. They found that DPHC dose-dependently exerted significant decreases in intracellular synthesis of reactive oxygen species. The seaweed product also stimulated collagen production and suppressed collagenase activity, as well as matrix metalloproteinases. The researchers concluded that DPHC may be an effective skin-protective ingredient against particulate matter for use in cosmeceutical products.¹⁰

Skin protection mouse studies using various marine species

The last 3 years alone have featured several studies in mice that may have significant implications in accelerating our understanding of how to harness the bioactive properties of multiple marine species.

In 2018, Wiraguna and associates studied the protective effects of 0.2% and 0.4% Caulerpa sp. (a genus of seaweed native to the Indo-Pacific region) extract gels on photoaging in the UVB-irradiated skin of Wistar mice, finding that topical applications of both concentrations of the seaweed extract protected mouse skin from UVB-induced photoaging, with treated mice revealed to have higher collagen expression and preserved collagen structure and decreased MMP-1 levels, compared with vehicle controls.¹¹

The next year, Prasedya and associates showed that the brown macroalgae Sargassum cristafolium exerted photoprotective activity against UVA in mice. Mice pretreated with the seaweed before exposure displayed intact collagen formation and no increases in epidermal thickness, compared with controls.¹²

At the same time, Santos and associates demonstrated that mice fed a diet supplemented with the red seaweed Porphyra umbilicalis experienced significant decreases in the incidence of human papillomavirus type 16–induced premalignant dysplastic skin lesions.¹³

Also that year, Zhen and associates evaluated the protective effects of eckol, a phlorotannin isolated from brown seaweed, on human HaCaT keratinocytes against PM2.5-induced cell damage. They showed that eckol (30 mcm) reduced reactive oxygen species production and protected cells from apoptosis by hampering the MAPK signaling pathway.¹⁴Earlier that year, Kim and associates studied the viability of the microalga Nannochloropsis oceanica, considered most often as a possible biofuel, for potential photoprotective activity against UVB-irradiated human dermal fibroblasts. They determined that pigment extracts (violaxanthin was identified as the main pigment) were not cytotoxic to the fibroblasts and that treatment with the pigment extract upregulated collagen expression and significantly inhibited UVB-induced damage. Further study revealed that violaxanthin significantly mitigated UVB-induced G1 phase arrest, senescence-associated beta-galactosidase activation, and p16 and p21 up-regulation, among other functions, suggesting its consideration, according to the authors, as a possible antiphotoaging agent.¹⁵

Finally, early in 2020, Bellan and associates evaluated the antitumor characteristics of the sulfated heterorhamnan derived from the green seaweed Gayralia brasiliensis as seen on the biological activities in the B16-F10 murine melanoma cell line. The polysaccharidic fraction was found to be effective in reducing melanoma cell migration and invasion capacity.¹⁶

Conclusion

Marine ingredients have been ripe for exploration, extraction, and usage in the cosmetic realm for several years. Evidence suggests widespread potential across several species for dermatologic purposes. Indeed, data indicate that some species appear to be suited for treating AD, alopecia, and wrinkles and may possibly render effective photoprotection. More research is necessary, of course, to ascertain the extent to which such ingredients can adequately address cutaneous health and how truly effective the marine ingredients are in currently marketed products.

Dr. Baumann is a private practice dermatologist, researcher, author, and entrepreneur who practices in Miami. She founded the Cosmetic Dermatology Center at the University of Miami in 1997. Dr. Baumann has written two textbooks and a New York Times Best Sellers book for consumers. Dr. Baumann has received funding for advisory boards and/or clinical research trials from Allergan, Galderma, Revance, Evolus, and Burt’s Bees. She is the CEO of Skin Type Solutions, a company that independently tests skin care products and makes recommendations to physicians on which skin care technologies are best. Write to her at [email protected].

References

1. Fabrowska J et al. Acta Pol Pharm. 2017 Mar;74(2):633-41.

2. Pangestuti R et al. Mar Drugs. 2018 Oct 23;16(11):399.

3. Kim JH et al. Mar Drugs. 2018 Nov 21;16(11):459.

4. Colantonio S & Rivers JK. J Cutan Med Surg. Jul/Aug 2017;21(4):299-307.

5. Tian T et al. Int Immunopharmacol. 2019 Oct;75:105823.

6. Gil TY et al. Mediators Inflamm. 2019 Mar 17;2019:3760934.

7. Kang JI et al. Mar Drugs. 2017 May 5;15(5):130.

8. Piao MJ et al. Biomol Ther (Seoul). 2015 Nov;23(6):557-63.

9. Wang L et al. Food Chem Toxicol. 2020 Feb;136:110963.

10. Wang L et al. Molecules. 2020 Feb 26;25(5):1055.

11. Wiraguna AAGP et al. Dermatol Reports. 2018 Oct 1;10(2):7597.

12. Prasedya ES et al. Biomedicines. 2019 Sep 27;7(4):77.

13. Santos S et al. Mar Drugs. 2019 Oct 29;17(11):615.

14. Zhen AX et al. Mar Drugs. 2019 Jul 27;17(8):444.

15. Kim HM et al. Photochem Photobiol. 2019 Mar;95(2):595-604.

16. Bellan DL et al. Mar Biotechnol. 2020 Apr;22(2):194-206.

Marine algae are relatively common raw sources for cosmeceutical products.¹ The photoprotective compounds identified among marine algae range from mycosporinelike amino acids, sulfated polysaccharides, and carotenoids to polyphenols, all of which are noted for absorbing UV and conferring antioxidant, matrix metalloproteinase–suppressing, anti-aging, and immunomodulatory effects.² Such biologic activities understandably account for the interest in harnessing their potential in the skin care realm. Indeed, marine ingredients have been steadily flowing into the market for skin care, and research has proliferated – so much so, in fact, that I’ll take two columns to cover some of the most recent research on various marine species and some of the indications or potential uses for these products in skin care.

ph2212/Getty Images

Key activities and potential uses

Kim and associates note that carbohydrates are the primary components of marine algae, with copious amounts delivering a moisturizing and thickening effect when incorporated into cosmetic products. They add that marine carbohydrates are also known to impart antioxidant, antimelanogenic, and anti-aging activities.³

In 2017, Colantonio and Rivers reviewed the evidence supporting the use of seaweed, among other plants, for dermatologic purposes. The researchers considered four plants and algae (seaweed, witch hazel, bearberry, and mayapple) used in traditional First Nations approaches to skin disease. They found that seaweed shows promise for clinical use in treating acne and wrinkles and could deliver healthy benefits when included in biofunctional textiles.⁴

Atopic dermatitis

Found in the seaweed Fucus vesiculosus, fucoidan is known to impart anti-inflammatory, antioxidant, and antitumor activity.⁵ In a 2019 BALB/c mouse study, Tian and associates showed that fucoidan, which is rich in polysaccharides, significantly improved ear swelling and skin lesions and reduced inflammatory cell infiltration. Given the resolution of the 2,4-dinitrofluorobenzene–induced atopic dermatitis symptoms, the investigators suggested that fucoidan may have potential as an anti-AD agent.⁵

Also that year, Gil and associates studied the effects of Seaweed fulvescens, a chlorophyll-rich green alga (also called Maesaengi) known to have antioxidant properties, in a mouse model of Dermatophagoides farinae body-induced AD and in tumor necrosis factor–alpha and interferon-gamma–stimulated HaCaT keratinocytes. They observed that 200-mg/mouse treatment hindered AD symptom development, compared with controls, with enhanced dorsal skin lesions, diminished thickness and infiltration of inflammation, and decreased proinflammatory cytokines. In addition, the investigators reported the dose-dependent inhibition of proinflammatory cytokine synthesis in HaCaT keratinocytes. They concluded that Seaweed fulvescens shows promise as a therapeutic option for AD treatment.⁶

Alopecia

In 2017, Kang and associates studied the impact and mechanism of Undariopsis peterseniana, an edible brown alga, and determined that the extract promotes hair growth by activating the Wnt/beta-catenin and ERK pathways. Specifically, they found that U. peterseniana significantly enhanced hair-fiber length ex vivo and in vivo. They also concluded that the brown alga has potential to treat alopecia as it accelerated anagen initiation.⁷

Skin protection potential of Ishige okamurae

In 2015, Piao and associates demonstrated that diphlorethohydroxycarmalol (DPHC), a phlorotannin isolated from Ishige okamurae, protected human keratinocytes from UVB-induced matrix metalloproteinase (MMP) expression by inactivating ERK and JNK. MMPs are known to contribute to photoaging and tumor promotion.⁸

Early in 2020, Wang and associates demonstrated that DPHC, isolated from the marine brown alga I. okamurae, exerted protective effects against UVB-induced photodamage in vitro in human dermal fibroblasts and in vivo in zebrafish by suppressing collagenase and elastase production and the expression of matrix metalloproteinases. In vivo, the brown alga extract lowered cell death by decreasing lipid peroxidation and inflammatory response. The investigators concluded that DPHC warrants consideration as an ingredient in cosmeceutical formulations intended to protect against the effects of UVB radiation.⁹

The same team also reported on their study of the protective effects of DPHC against skin damage in human dermal fibroblasts caused by particulate matter. They found that DPHC dose-dependently exerted significant decreases in intracellular synthesis of reactive oxygen species. The seaweed product also stimulated collagen production and suppressed collagenase activity, as well as matrix metalloproteinases. The researchers concluded that DPHC may be an effective skin-protective ingredient against particulate matter for use in cosmeceutical products.¹⁰

Skin protection mouse studies using various marine species

The last 3 years alone have featured several studies in mice that may have significant implications in accelerating our understanding of how to harness the bioactive properties of multiple marine species.

In 2018, Wiraguna and associates studied the protective effects of 0.2% and 0.4% Caulerpa sp. (a genus of seaweed native to the Indo-Pacific region) extract gels on photoaging in the UVB-irradiated skin of Wistar mice, finding that topical applications of both concentrations of the seaweed extract protected mouse skin from UVB-induced photoaging, with treated mice revealed to have higher collagen expression and preserved collagen structure and decreased MMP-1 levels, compared with vehicle controls.¹¹

The next year, Prasedya and associates showed that the brown macroalgae Sargassum cristafolium exerted photoprotective activity against UVA in mice. Mice pretreated with the seaweed before exposure displayed intact collagen formation and no increases in epidermal thickness, compared with controls.¹²

At the same time, Santos and associates demonstrated that mice fed a diet supplemented with the red seaweed Porphyra umbilicalis experienced significant decreases in the incidence of human papillomavirus type 16–induced premalignant dysplastic skin lesions.¹³

Also that year, Zhen and associates evaluated the protective effects of eckol, a phlorotannin isolated from brown seaweed, on human HaCaT keratinocytes against PM2.5-induced cell damage. They showed that eckol (30 mcm) reduced reactive oxygen species production and protected cells from apoptosis by hampering the MAPK signaling pathway.¹⁴Earlier that year, Kim and associates studied the viability of the microalga Nannochloropsis oceanica, considered most often as a possible biofuel, for potential photoprotective activity against UVB-irradiated human dermal fibroblasts. They determined that pigment extracts (violaxanthin was identified as the main pigment) were not cytotoxic to the fibroblasts and that treatment with the pigment extract upregulated collagen expression and significantly inhibited UVB-induced damage. Further study revealed that violaxanthin significantly mitigated UVB-induced G1 phase arrest, senescence-associated beta-galactosidase activation, and p16 and p21 up-regulation, among other functions, suggesting its consideration, according to the authors, as a possible antiphotoaging agent.¹⁵

Finally, early in 2020, Bellan and associates evaluated the antitumor characteristics of the sulfated heterorhamnan derived from the green seaweed Gayralia brasiliensis as seen on the biological activities in the B16-F10 murine melanoma cell line. The polysaccharidic fraction was found to be effective in reducing melanoma cell migration and invasion capacity.¹⁶

Conclusion

Marine ingredients have been ripe for exploration, extraction, and usage in the cosmetic realm for several years. Evidence suggests widespread potential across several species for dermatologic purposes. Indeed, data indicate that some species appear to be suited for treating AD, alopecia, and wrinkles and may possibly render effective photoprotection. More research is necessary, of course, to ascertain the extent to which such ingredients can adequately address cutaneous health and how truly effective the marine ingredients are in currently marketed products.

Dr. Baumann is a private practice dermatologist, researcher, author, and entrepreneur who practices in Miami. She founded the Cosmetic Dermatology Center at the University of Miami in 1997. Dr. Baumann has written two textbooks and a New York Times Best Sellers book for consumers. Dr. Baumann has received funding for advisory boards and/or clinical research trials from Allergan, Galderma, Revance, Evolus, and Burt’s Bees. She is the CEO of Skin Type Solutions, a company that independently tests skin care products and makes recommendations to physicians on which skin care technologies are best. Write to her at [email protected].

References

1. Fabrowska J et al. Acta Pol Pharm. 2017 Mar;74(2):633-41.

2. Pangestuti R et al. Mar Drugs. 2018 Oct 23;16(11):399.

3. Kim JH et al. Mar Drugs. 2018 Nov 21;16(11):459.

4. Colantonio S & Rivers JK. J Cutan Med Surg. Jul/Aug 2017;21(4):299-307.

5. Tian T et al. Int Immunopharmacol. 2019 Oct;75:105823.

6. Gil TY et al. Mediators Inflamm. 2019 Mar 17;2019:3760934.

7. Kang JI et al. Mar Drugs. 2017 May 5;15(5):130.

8. Piao MJ et al. Biomol Ther (Seoul). 2015 Nov;23(6):557-63.

9. Wang L et al. Food Chem Toxicol. 2020 Feb;136:110963.

10. Wang L et al. Molecules. 2020 Feb 26;25(5):1055.

11. Wiraguna AAGP et al. Dermatol Reports. 2018 Oct 1;10(2):7597.

12. Prasedya ES et al. Biomedicines. 2019 Sep 27;7(4):77.

13. Santos S et al. Mar Drugs. 2019 Oct 29;17(11):615.

14. Zhen AX et al. Mar Drugs. 2019 Jul 27;17(8):444.

15. Kim HM et al. Photochem Photobiol. 2019 Mar;95(2):595-604.

16. Bellan DL et al. Mar Biotechnol. 2020 Apr;22(2):194-206.

Hospitalists around the country are devoting large portions of their spare time to a wide range of advocacy efforts. From health policy to caring for the unhoused population to diversity and equity to advocating for fellow hospitalists, these physicians are passionate about their causes and determined to make a difference.

Championing the unhoused

Sarah Stella, MD, FHM, a hospitalist at Denver Health, was initially drawn there because of the population the hospital serves, which includes a high concentration of people experiencing homelessness. As she cared for her patients, Dr. Stella, who is also associate professor of hospital medicine at the University of Colorado, increasingly felt the desire to help prevent the negative downstream outcomes the hospital sees.

To understand the experiences of the unhoused outside the hospital, Dr. Stella started talking to her patients and people in community-based organizations that serve this population. “I learned a ton,” she said. “Homelessness feels like such an intractable, hopeless thing, but the more I talked to people, the more opportunities I saw to work toward something better.”

This led to a pilot grant to work with the Colorado Coalition for the Homeless to set up a community advisory panel. “My goal was to better understand their experiences and to develop a shared vision for how we collectively can do better,” said Dr. Stella. Eventually, she also received a grant from the University of Colorado, and multiple opportunities have sprung up ever since.

For the past several years, Dr. Stella has worked with Denver Health leadership to improve care for the homeless. “Right now, I’m working with a community team on developing an idea to provide peer support from people with a shared lived experience for people who are experiencing homelessness when they’re hospitalized. That’s really where my passion has been in working on the partnership,” she said.

Her advocacy role has been beneficial in her work as a hospitalist, particularly when COVID began. Dr. Stella again partnered with the Colorado Coalition for the Homeless to start a joint task force. “Everyone on our task force is motivated by this powerful desire to improve the health and lives of this community and that’s one of the silver linings in this pandemic for me,” said Dr. Stella.

Advocacy work has also increased Dr. Stella’s knowledge of what community support options are available for the unhoused. This allows her to educate her patients about their options and how to access them.

While she has colleagues who are able to compartmentalize their work, “I absolutely could not be a hospitalist without being an advocate,” Dr. Stella said. “For me, it has been a protective strategy in terms of burnout because I have to feel like I’m working to advocate for better policies and more appropriate resources to address the gaps that I’m seeing.”

Dr. Stella believes that physicians have a special credibility to advocate, tell stories, and use data to back their stories up. “We have to realize that we have this power, and we have it so we can empower others,” she said. “The people I’ve seen in my community who are working so hard to help people who are experiencing homelessness are the heroes. Understanding that and giving power to those people through our voice and our well-respected place in society drives me.”
 

Strengthening diversity, equity, and inclusion

In September 2020, Michael Bryant, MD, became the inaugural vice chair of Diversity, Equity, and Inclusion for the department of pediatrics at Children’s Hospital Los Angeles, where he is also the division head of pediatric hospital medicine. “I was motivated to apply for this position because I wanted to be an agent for change to eliminate the institutional racism, social injustice, and marginalization that continues to threaten the lives and well-beings of so many Americans,” Dr. Bryant said.

Between the pandemic, the economic decline it has created, and the divisive political landscape, people of color have been especially affected. “These are poignant examples of the ever-widening divide and disenfranchisement many Americans feel,” said Dr. Bryant. “Gandhi said, ‘Be the change that you want to see,’ and that is what I want to model.”

At work, advocacy for diversity, equality, and inclusion is an innate part of everything he does. From the new physicians he recruits to the candidates he considers for leadership positions, Dr. Bryant strives “to have a workforce that mirrors the diversity of the patients we humbly care for and serve.”

Advocacy is intrinsic to Dr. Bryant’s worldview, in his quest to understand and accept each individual’s uniqueness, his desire “to embrace cultural humility,” his recognition that “our differences enhance us instead of diminishing us,” and his willingness to engage in difficult conversations.

“Advocacy means that I acknowledge that intent does not equal impact and that I must accept that what I do and what I say may have unintended consequences,” he said. “When that happens, I must resist becoming defensive and instead be willing to listen and learn.”

Dr. Bryant is proud of his accomplishments and enjoys his advocacy work. In his workplace, there are few African Americans in leadership roles. This means that he is in high demand when it comes to making sure there’s representation during various processes such as hiring and vetting, a disparity known as the “minority tax.”

“I am thankful for the opportunities, but it does take a toll at times,” Dr. Bryant said, which is yet another reason why he is a proponent of increasing diversity and inclusion. “This allows us to build the resource pool as these needs arise and minimizes the toll of the ‘minority tax’ on any single person or small group of individuals.”

This summer, physicians from Dr. Bryant’s hospital participated in the national “White Coats for Black Lives” effort. He found it to be “an incredibly moving event” that hundreds of his colleagues participated in.

Dr. Bryant’s advice for hospitalists who want to get involved in advocacy efforts is to check out the movie “John Lewis: Good Trouble.” “He was a champion of human rights and fought for these rights until his death,” Dr. Bryant said. “He is a true American hero and a wonderful example.”
 

Bolstering health care change

Since his residency, Joshua Lenchus, DO, FACP, SFHM, has developed an ever-increasing interest in legislative advocacy, particularly health policy. Getting involved in this arena requires an understanding of civics and government that goes beyond just the basics. “My desire to affect change in my own profession really served as the catalyst to get involved,” said Dr. Lenchus, the regional chief medical officer at Broward Health Medical Center in Fort Lauderdale, Fla. “What better way to do that than by combining what we do on a daily basis in the practice of medicine with this new understanding of how laws are passed and promulgated?”

Dr. Lenchus has been involved with both state and national medical organizations and has served on public policy committees as a member and as a chair. “The charge of these committees is to monitor and navigate position statements and policies that will drive the entire organization,” he said. This means becoming knowledgeable enough about a topic to be able to talk about it eloquently and adding supporting personal or professional illustrations that reinforce the position to lawmakers.

He finds his advocacy efforts “incredibly rewarding” because they contribute to his endeavors “to help my colleagues practice medicine in a safe, efficient, and productive manner.” For instance, some of the organizations Dr. Lenchus was involved with helped make changes to the Affordable Care Act that ended up in its final version, as well as changes after it passed. “There are tangible things that advocacy enables us to do in our daily practice,” he said.

When something his organizations have advocated for does not pass, they know they need to try a different outlet. “You can’t win every fight,” he said. “Every time you go and comment on an issue, you have to understand that you’re there to do your best, and to the extent that the people you’re talking to are willing to listen to what you have to say, that’s where I think you can make the most impact.” When changes he has helped fight for do pass, “it really is amazing that you can tell your colleagues about your role in achieving meaningful change in the profession.”

Dr. Lenchus acknowledges that advocacy “can be all-consuming at times. We have to understand our limits.” That said, he thinks not engaging in advocacy could increase stress and potential burnout. “I think being involved in advocacy efforts really helps people conduct meaningful work and educates them about what it means not just to them, but to the rest of the medical profession and the patients that we serve,” he said.

For hospitalists who are interested in health policy advocacy, there are many ways to get involved, Dr. Lenchus said. You could join an organization (many organized medical societies have public policy committees), participate in advocacy activities, work on a political campaign, or even run for office yourself. “Ultimately, education and some level of involvement really will make the difference in who navigates our future as hospitalists,” he said.
 

Questioning co-management practices

Though he says he’s in the minority, Hardik Vora, MD, SFHM, medical director for hospital medicine at Riverside Regional Medical Center in Newport News, Va., believes that co-management is going to “make or break hospital medicine. It’s going to have a huge impact on our specialty.”

In the roughly 25-year history of hospital medicine, it has evolved from admitting and caring for patients of primary care physicians to patients of specialists and, more recently, surgical patients. “Now there are (hospital medicine) programs across the country that are pretty much admitting everything,” said Dr. Vora.

As a recruiter for the Riverside Health System for the past eight years, “I have not met a single resident who is trained to do what we’re doing in hospital medicine, because you’re admitting surgical patients all the time and you have primary attending responsibility,” Dr. Vora said. “I see that as a cause of a significant amount of stress because now you’re responsible for something that you don’t have adequate training for.”

In the co-management discussion, Dr. Vora notes that people often bring up the research that shows that the practice has improved surgeon satisfaction. “What bothers me is that…you need to add one more question – how does it affect your hospitalists? And I bet the answer to that question is ‘it has a terrible effect.’”

The expectations surrounding hospitalists these days is a big concern in terms of burnout, Dr. Vora said. “We talk a lot about the drivers of burnout, whether it’s schedule or COVID,” he said. The biggest issue when it comes to burnout, as he sees it, is not COVID; it’s when hospitalists are performing tasks that make them feel they aren’t adding value. “I think that’s a huge topic in hospital medicine right now.”

Dr. Vora believes there should be more discussion and awareness of the potential pitfalls. “Hospitalists should get involved in co-management where they are adding value and certainly not take up the attending responsibility where they’re not adding value and it’s out of the scope of their training and expertise,” he said. “Preventing scope creep and burnout from co-management are some of the key issues I’m really passionate about.”

Dr. Vora said it is important to set realistic goals and remember that it takes time to make change when it comes to advocacy. “You still have to operate within whatever environment is given to you and then you can make change from within,” he said.

His enthusiasm for co-management awareness has led to creating a co-management forum through SHM in his local Hampton Roads chapter. He was also a panelist for an SHM webinar in February 2021 in which the panelists debated co-management.

“I think we really need to look at this as a specialty. Are we going in the right direction?” Dr. Vora asked. “We need to come together as a specialty and make a decision, which is going to be hard because there are competing financial interests and various practice models.”
 

Improving patient care

Working as a hospitalist at University Medical Center, a safety net hospital in New Orleans, Celeste Newby, MD, PhD, sees plenty of patients who are underinsured or not insured at all. “A lot of my interest in health policy stems from that,” she said.

During her residency, which she finished in 2015, Louisiana became a Medicaid expansion state. This impressed upon Dr. Newby how much Medicaid improved the lives of patients who had previously been uninsured. “We saw procedures getting done that had been put on hold because of financial concerns or medicines that were now affordable that weren’t before,” she said. “It really did make a difference.”

When repeated attempts to repeal the Affordable Care Act began, “it was a call to do health policy work for me personally that just hadn’t come up in the past,” said Dr. Newby, who is also assistant professor of medicine at Tulane University in New Orleans. “I personally found that the best way to do (advocacy work) was to go through medical societies because there is a much stronger voice when you have more people saying the same thing,” she said.

Dr. Newby sits on the Council of Legislation for the Louisiana State Medical Society and participates in the Leadership and Health Policy (LEAHP) Program through the Society of General Internal Medicine.

The LEAHP Program has been instrumental in expanding Dr. Newby’s knowledge of how health policy is made and the mechanisms behind it. It has also taught her “how we can either advise, guide, leverage, or advocate for things that we think would be important for change and moving the country in the right direction in terms of health care.”

Another reason involvement in medical societies is helpful is because, as a busy clinician, it is impossible to keep up with everything. “Working with medical societies, you have people who are more directly involved in the legislature and can give you quicker notice about things that are coming up that are going to be important to you or your co-workers or your patients,” Dr. Newby said.

Dr. Newby feels her advocacy work is an outlet for stress and “a way to work at more of a macro level on problems that I see with my individual patients. It’s a nice compliment.” At the hospital, she can only help one person at a time, but with her advocacy efforts, there’s potential to make changes for many.

“Advocacy now is such a large umbrella that encompasses so many different projects at all kinds of levels,” Dr. Newby said. She suggests looking around your community to see where the needs lie. If you’re passionate about a certain topic or population, see what you can do to help advocate for change there.




 

Hospitalists around the country are devoting large portions of their spare time to a wide range of advocacy efforts. From health policy to caring for the unhoused population to diversity and equity to advocating for fellow hospitalists, these physicians are passionate about their causes and determined to make a difference.

Championing the unhoused

Sarah Stella, MD, FHM, a hospitalist at Denver Health, was initially drawn there because of the population the hospital serves, which includes a high concentration of people experiencing homelessness. As she cared for her patients, Dr. Stella, who is also associate professor of hospital medicine at the University of Colorado, increasingly felt the desire to help prevent the negative downstream outcomes the hospital sees.

To understand the experiences of the unhoused outside the hospital, Dr. Stella started talking to her patients and people in community-based organizations that serve this population. “I learned a ton,” she said. “Homelessness feels like such an intractable, hopeless thing, but the more I talked to people, the more opportunities I saw to work toward something better.”

This led to a pilot grant to work with the Colorado Coalition for the Homeless to set up a community advisory panel. “My goal was to better understand their experiences and to develop a shared vision for how we collectively can do better,” said Dr. Stella. Eventually, she also received a grant from the University of Colorado, and multiple opportunities have sprung up ever since.

For the past several years, Dr. Stella has worked with Denver Health leadership to improve care for the homeless. “Right now, I’m working with a community team on developing an idea to provide peer support from people with a shared lived experience for people who are experiencing homelessness when they’re hospitalized. That’s really where my passion has been in working on the partnership,” she said.

Her advocacy role has been beneficial in her work as a hospitalist, particularly when COVID began. Dr. Stella again partnered with the Colorado Coalition for the Homeless to start a joint task force. “Everyone on our task force is motivated by this powerful desire to improve the health and lives of this community and that’s one of the silver linings in this pandemic for me,” said Dr. Stella.

Advocacy work has also increased Dr. Stella’s knowledge of what community support options are available for the unhoused. This allows her to educate her patients about their options and how to access them.

While she has colleagues who are able to compartmentalize their work, “I absolutely could not be a hospitalist without being an advocate,” Dr. Stella said. “For me, it has been a protective strategy in terms of burnout because I have to feel like I’m working to advocate for better policies and more appropriate resources to address the gaps that I’m seeing.”

Dr. Stella believes that physicians have a special credibility to advocate, tell stories, and use data to back their stories up. “We have to realize that we have this power, and we have it so we can empower others,” she said. “The people I’ve seen in my community who are working so hard to help people who are experiencing homelessness are the heroes. Understanding that and giving power to those people through our voice and our well-respected place in society drives me.”
 

Strengthening diversity, equity, and inclusion

In September 2020, Michael Bryant, MD, became the inaugural vice chair of Diversity, Equity, and Inclusion for the department of pediatrics at Children’s Hospital Los Angeles, where he is also the division head of pediatric hospital medicine. “I was motivated to apply for this position because I wanted to be an agent for change to eliminate the institutional racism, social injustice, and marginalization that continues to threaten the lives and well-beings of so many Americans,” Dr. Bryant said.

Between the pandemic, the economic decline it has created, and the divisive political landscape, people of color have been especially affected. “These are poignant examples of the ever-widening divide and disenfranchisement many Americans feel,” said Dr. Bryant. “Gandhi said, ‘Be the change that you want to see,’ and that is what I want to model.”

At work, advocacy for diversity, equality, and inclusion is an innate part of everything he does. From the new physicians he recruits to the candidates he considers for leadership positions, Dr. Bryant strives “to have a workforce that mirrors the diversity of the patients we humbly care for and serve.”

Advocacy is intrinsic to Dr. Bryant’s worldview, in his quest to understand and accept each individual’s uniqueness, his desire “to embrace cultural humility,” his recognition that “our differences enhance us instead of diminishing us,” and his willingness to engage in difficult conversations.

“Advocacy means that I acknowledge that intent does not equal impact and that I must accept that what I do and what I say may have unintended consequences,” he said. “When that happens, I must resist becoming defensive and instead be willing to listen and learn.”

Dr. Bryant is proud of his accomplishments and enjoys his advocacy work. In his workplace, there are few African Americans in leadership roles. This means that he is in high demand when it comes to making sure there’s representation during various processes such as hiring and vetting, a disparity known as the “minority tax.”

“I am thankful for the opportunities, but it does take a toll at times,” Dr. Bryant said, which is yet another reason why he is a proponent of increasing diversity and inclusion. “This allows us to build the resource pool as these needs arise and minimizes the toll of the ‘minority tax’ on any single person or small group of individuals.”

This summer, physicians from Dr. Bryant’s hospital participated in the national “White Coats for Black Lives” effort. He found it to be “an incredibly moving event” that hundreds of his colleagues participated in.

Dr. Bryant’s advice for hospitalists who want to get involved in advocacy efforts is to check out the movie “John Lewis: Good Trouble.” “He was a champion of human rights and fought for these rights until his death,” Dr. Bryant said. “He is a true American hero and a wonderful example.”
 

Bolstering health care change

Since his residency, Joshua Lenchus, DO, FACP, SFHM, has developed an ever-increasing interest in legislative advocacy, particularly health policy. Getting involved in this arena requires an understanding of civics and government that goes beyond just the basics. “My desire to affect change in my own profession really served as the catalyst to get involved,” said Dr. Lenchus, the regional chief medical officer at Broward Health Medical Center in Fort Lauderdale, Fla. “What better way to do that than by combining what we do on a daily basis in the practice of medicine with this new understanding of how laws are passed and promulgated?”

Dr. Lenchus has been involved with both state and national medical organizations and has served on public policy committees as a member and as a chair. “The charge of these committees is to monitor and navigate position statements and policies that will drive the entire organization,” he said. This means becoming knowledgeable enough about a topic to be able to talk about it eloquently and adding supporting personal or professional illustrations that reinforce the position to lawmakers.

He finds his advocacy efforts “incredibly rewarding” because they contribute to his endeavors “to help my colleagues practice medicine in a safe, efficient, and productive manner.” For instance, some of the organizations Dr. Lenchus was involved with helped make changes to the Affordable Care Act that ended up in its final version, as well as changes after it passed. “There are tangible things that advocacy enables us to do in our daily practice,” he said.

When something his organizations have advocated for does not pass, they know they need to try a different outlet. “You can’t win every fight,” he said. “Every time you go and comment on an issue, you have to understand that you’re there to do your best, and to the extent that the people you’re talking to are willing to listen to what you have to say, that’s where I think you can make the most impact.” When changes he has helped fight for do pass, “it really is amazing that you can tell your colleagues about your role in achieving meaningful change in the profession.”

Dr. Lenchus acknowledges that advocacy “can be all-consuming at times. We have to understand our limits.” That said, he thinks not engaging in advocacy could increase stress and potential burnout. “I think being involved in advocacy efforts really helps people conduct meaningful work and educates them about what it means not just to them, but to the rest of the medical profession and the patients that we serve,” he said.

For hospitalists who are interested in health policy advocacy, there are many ways to get involved, Dr. Lenchus said. You could join an organization (many organized medical societies have public policy committees), participate in advocacy activities, work on a political campaign, or even run for office yourself. “Ultimately, education and some level of involvement really will make the difference in who navigates our future as hospitalists,” he said.
 

Questioning co-management practices

Though he says he’s in the minority, Hardik Vora, MD, SFHM, medical director for hospital medicine at Riverside Regional Medical Center in Newport News, Va., believes that co-management is going to “make or break hospital medicine. It’s going to have a huge impact on our specialty.”

In the roughly 25-year history of hospital medicine, it has evolved from admitting and caring for patients of primary care physicians to patients of specialists and, more recently, surgical patients. “Now there are (hospital medicine) programs across the country that are pretty much admitting everything,” said Dr. Vora.

As a recruiter for the Riverside Health System for the past eight years, “I have not met a single resident who is trained to do what we’re doing in hospital medicine, because you’re admitting surgical patients all the time and you have primary attending responsibility,” Dr. Vora said. “I see that as a cause of a significant amount of stress because now you’re responsible for something that you don’t have adequate training for.”

In the co-management discussion, Dr. Vora notes that people often bring up the research that shows that the practice has improved surgeon satisfaction. “What bothers me is that…you need to add one more question – how does it affect your hospitalists? And I bet the answer to that question is ‘it has a terrible effect.’”

The expectations surrounding hospitalists these days is a big concern in terms of burnout, Dr. Vora said. “We talk a lot about the drivers of burnout, whether it’s schedule or COVID,” he said. The biggest issue when it comes to burnout, as he sees it, is not COVID; it’s when hospitalists are performing tasks that make them feel they aren’t adding value. “I think that’s a huge topic in hospital medicine right now.”

Dr. Vora believes there should be more discussion and awareness of the potential pitfalls. “Hospitalists should get involved in co-management where they are adding value and certainly not take up the attending responsibility where they’re not adding value and it’s out of the scope of their training and expertise,” he said. “Preventing scope creep and burnout from co-management are some of the key issues I’m really passionate about.”

Dr. Vora said it is important to set realistic goals and remember that it takes time to make change when it comes to advocacy. “You still have to operate within whatever environment is given to you and then you can make change from within,” he said.

His enthusiasm for co-management awareness has led to creating a co-management forum through SHM in his local Hampton Roads chapter. He was also a panelist for an SHM webinar in February 2021 in which the panelists debated co-management.

“I think we really need to look at this as a specialty. Are we going in the right direction?” Dr. Vora asked. “We need to come together as a specialty and make a decision, which is going to be hard because there are competing financial interests and various practice models.”
 

Improving patient care

Working as a hospitalist at University Medical Center, a safety net hospital in New Orleans, Celeste Newby, MD, PhD, sees plenty of patients who are underinsured or not insured at all. “A lot of my interest in health policy stems from that,” she said.

During her residency, which she finished in 2015, Louisiana became a Medicaid expansion state. This impressed upon Dr. Newby how much Medicaid improved the lives of patients who had previously been uninsured. “We saw procedures getting done that had been put on hold because of financial concerns or medicines that were now affordable that weren’t before,” she said. “It really did make a difference.”

When repeated attempts to repeal the Affordable Care Act began, “it was a call to do health policy work for me personally that just hadn’t come up in the past,” said Dr. Newby, who is also assistant professor of medicine at Tulane University in New Orleans. “I personally found that the best way to do (advocacy work) was to go through medical societies because there is a much stronger voice when you have more people saying the same thing,” she said.

Dr. Newby sits on the Council of Legislation for the Louisiana State Medical Society and participates in the Leadership and Health Policy (LEAHP) Program through the Society of General Internal Medicine.

The LEAHP Program has been instrumental in expanding Dr. Newby’s knowledge of how health policy is made and the mechanisms behind it. It has also taught her “how we can either advise, guide, leverage, or advocate for things that we think would be important for change and moving the country in the right direction in terms of health care.”

Another reason involvement in medical societies is helpful is because, as a busy clinician, it is impossible to keep up with everything. “Working with medical societies, you have people who are more directly involved in the legislature and can give you quicker notice about things that are coming up that are going to be important to you or your co-workers or your patients,” Dr. Newby said.

Dr. Newby feels her advocacy work is an outlet for stress and “a way to work at more of a macro level on problems that I see with my individual patients. It’s a nice compliment.” At the hospital, she can only help one person at a time, but with her advocacy efforts, there’s potential to make changes for many.

“Advocacy now is such a large umbrella that encompasses so many different projects at all kinds of levels,” Dr. Newby said. She suggests looking around your community to see where the needs lie. If you’re passionate about a certain topic or population, see what you can do to help advocate for change there.




 

Hospitalists around the country are devoting large portions of their spare time to a wide range of advocacy efforts. From health policy to caring for the unhoused population to diversity and equity to advocating for fellow hospitalists, these physicians are passionate about their causes and determined to make a difference.

Championing the unhoused

Sarah Stella, MD, FHM, a hospitalist at Denver Health, was initially drawn there because of the population the hospital serves, which includes a high concentration of people experiencing homelessness. As she cared for her patients, Dr. Stella, who is also associate professor of hospital medicine at the University of Colorado, increasingly felt the desire to help prevent the negative downstream outcomes the hospital sees.

To understand the experiences of the unhoused outside the hospital, Dr. Stella started talking to her patients and people in community-based organizations that serve this population. “I learned a ton,” she said. “Homelessness feels like such an intractable, hopeless thing, but the more I talked to people, the more opportunities I saw to work toward something better.”

This led to a pilot grant to work with the Colorado Coalition for the Homeless to set up a community advisory panel. “My goal was to better understand their experiences and to develop a shared vision for how we collectively can do better,” said Dr. Stella. Eventually, she also received a grant from the University of Colorado, and multiple opportunities have sprung up ever since.

For the past several years, Dr. Stella has worked with Denver Health leadership to improve care for the homeless. “Right now, I’m working with a community team on developing an idea to provide peer support from people with a shared lived experience for people who are experiencing homelessness when they’re hospitalized. That’s really where my passion has been in working on the partnership,” she said.

Her advocacy role has been beneficial in her work as a hospitalist, particularly when COVID began. Dr. Stella again partnered with the Colorado Coalition for the Homeless to start a joint task force. “Everyone on our task force is motivated by this powerful desire to improve the health and lives of this community and that’s one of the silver linings in this pandemic for me,” said Dr. Stella.

Advocacy work has also increased Dr. Stella’s knowledge of what community support options are available for the unhoused. This allows her to educate her patients about their options and how to access them.

While she has colleagues who are able to compartmentalize their work, “I absolutely could not be a hospitalist without being an advocate,” Dr. Stella said. “For me, it has been a protective strategy in terms of burnout because I have to feel like I’m working to advocate for better policies and more appropriate resources to address the gaps that I’m seeing.”

Dr. Stella believes that physicians have a special credibility to advocate, tell stories, and use data to back their stories up. “We have to realize that we have this power, and we have it so we can empower others,” she said. “The people I’ve seen in my community who are working so hard to help people who are experiencing homelessness are the heroes. Understanding that and giving power to those people through our voice and our well-respected place in society drives me.”
 

Strengthening diversity, equity, and inclusion

In September 2020, Michael Bryant, MD, became the inaugural vice chair of Diversity, Equity, and Inclusion for the department of pediatrics at Children’s Hospital Los Angeles, where he is also the division head of pediatric hospital medicine. “I was motivated to apply for this position because I wanted to be an agent for change to eliminate the institutional racism, social injustice, and marginalization that continues to threaten the lives and well-beings of so many Americans,” Dr. Bryant said.

Between the pandemic, the economic decline it has created, and the divisive political landscape, people of color have been especially affected. “These are poignant examples of the ever-widening divide and disenfranchisement many Americans feel,” said Dr. Bryant. “Gandhi said, ‘Be the change that you want to see,’ and that is what I want to model.”

At work, advocacy for diversity, equality, and inclusion is an innate part of everything he does. From the new physicians he recruits to the candidates he considers for leadership positions, Dr. Bryant strives “to have a workforce that mirrors the diversity of the patients we humbly care for and serve.”

Advocacy is intrinsic to Dr. Bryant’s worldview, in his quest to understand and accept each individual’s uniqueness, his desire “to embrace cultural humility,” his recognition that “our differences enhance us instead of diminishing us,” and his willingness to engage in difficult conversations.

“Advocacy means that I acknowledge that intent does not equal impact and that I must accept that what I do and what I say may have unintended consequences,” he said. “When that happens, I must resist becoming defensive and instead be willing to listen and learn.”

Dr. Bryant is proud of his accomplishments and enjoys his advocacy work. In his workplace, there are few African Americans in leadership roles. This means that he is in high demand when it comes to making sure there’s representation during various processes such as hiring and vetting, a disparity known as the “minority tax.”

“I am thankful for the opportunities, but it does take a toll at times,” Dr. Bryant said, which is yet another reason why he is a proponent of increasing diversity and inclusion. “This allows us to build the resource pool as these needs arise and minimizes the toll of the ‘minority tax’ on any single person or small group of individuals.”

This summer, physicians from Dr. Bryant’s hospital participated in the national “White Coats for Black Lives” effort. He found it to be “an incredibly moving event” that hundreds of his colleagues participated in.

Dr. Bryant’s advice for hospitalists who want to get involved in advocacy efforts is to check out the movie “John Lewis: Good Trouble.” “He was a champion of human rights and fought for these rights until his death,” Dr. Bryant said. “He is a true American hero and a wonderful example.”
 

Bolstering health care change

Since his residency, Joshua Lenchus, DO, FACP, SFHM, has developed an ever-increasing interest in legislative advocacy, particularly health policy. Getting involved in this arena requires an understanding of civics and government that goes beyond just the basics. “My desire to affect change in my own profession really served as the catalyst to get involved,” said Dr. Lenchus, the regional chief medical officer at Broward Health Medical Center in Fort Lauderdale, Fla. “What better way to do that than by combining what we do on a daily basis in the practice of medicine with this new understanding of how laws are passed and promulgated?”

Dr. Lenchus has been involved with both state and national medical organizations and has served on public policy committees as a member and as a chair. “The charge of these committees is to monitor and navigate position statements and policies that will drive the entire organization,” he said. This means becoming knowledgeable enough about a topic to be able to talk about it eloquently and adding supporting personal or professional illustrations that reinforce the position to lawmakers.

He finds his advocacy efforts “incredibly rewarding” because they contribute to his endeavors “to help my colleagues practice medicine in a safe, efficient, and productive manner.” For instance, some of the organizations Dr. Lenchus was involved with helped make changes to the Affordable Care Act that ended up in its final version, as well as changes after it passed. “There are tangible things that advocacy enables us to do in our daily practice,” he said.

When something his organizations have advocated for does not pass, they know they need to try a different outlet. “You can’t win every fight,” he said. “Every time you go and comment on an issue, you have to understand that you’re there to do your best, and to the extent that the people you’re talking to are willing to listen to what you have to say, that’s where I think you can make the most impact.” When changes he has helped fight for do pass, “it really is amazing that you can tell your colleagues about your role in achieving meaningful change in the profession.”

Dr. Lenchus acknowledges that advocacy “can be all-consuming at times. We have to understand our limits.” That said, he thinks not engaging in advocacy could increase stress and potential burnout. “I think being involved in advocacy efforts really helps people conduct meaningful work and educates them about what it means not just to them, but to the rest of the medical profession and the patients that we serve,” he said.

For hospitalists who are interested in health policy advocacy, there are many ways to get involved, Dr. Lenchus said. You could join an organization (many organized medical societies have public policy committees), participate in advocacy activities, work on a political campaign, or even run for office yourself. “Ultimately, education and some level of involvement really will make the difference in who navigates our future as hospitalists,” he said.
 

Questioning co-management practices

Though he says he’s in the minority, Hardik Vora, MD, SFHM, medical director for hospital medicine at Riverside Regional Medical Center in Newport News, Va., believes that co-management is going to “make or break hospital medicine. It’s going to have a huge impact on our specialty.”

In the roughly 25-year history of hospital medicine, it has evolved from admitting and caring for patients of primary care physicians to patients of specialists and, more recently, surgical patients. “Now there are (hospital medicine) programs across the country that are pretty much admitting everything,” said Dr. Vora.

As a recruiter for the Riverside Health System for the past eight years, “I have not met a single resident who is trained to do what we’re doing in hospital medicine, because you’re admitting surgical patients all the time and you have primary attending responsibility,” Dr. Vora said. “I see that as a cause of a significant amount of stress because now you’re responsible for something that you don’t have adequate training for.”

In the co-management discussion, Dr. Vora notes that people often bring up the research that shows that the practice has improved surgeon satisfaction. “What bothers me is that…you need to add one more question – how does it affect your hospitalists? And I bet the answer to that question is ‘it has a terrible effect.’”

The expectations surrounding hospitalists these days is a big concern in terms of burnout, Dr. Vora said. “We talk a lot about the drivers of burnout, whether it’s schedule or COVID,” he said. The biggest issue when it comes to burnout, as he sees it, is not COVID; it’s when hospitalists are performing tasks that make them feel they aren’t adding value. “I think that’s a huge topic in hospital medicine right now.”

Dr. Vora believes there should be more discussion and awareness of the potential pitfalls. “Hospitalists should get involved in co-management where they are adding value and certainly not take up the attending responsibility where they’re not adding value and it’s out of the scope of their training and expertise,” he said. “Preventing scope creep and burnout from co-management are some of the key issues I’m really passionate about.”

Dr. Vora said it is important to set realistic goals and remember that it takes time to make change when it comes to advocacy. “You still have to operate within whatever environment is given to you and then you can make change from within,” he said.

His enthusiasm for co-management awareness has led to creating a co-management forum through SHM in his local Hampton Roads chapter. He was also a panelist for an SHM webinar in February 2021 in which the panelists debated co-management.

“I think we really need to look at this as a specialty. Are we going in the right direction?” Dr. Vora asked. “We need to come together as a specialty and make a decision, which is going to be hard because there are competing financial interests and various practice models.”
 

Improving patient care

Working as a hospitalist at University Medical Center, a safety net hospital in New Orleans, Celeste Newby, MD, PhD, sees plenty of patients who are underinsured or not insured at all. “A lot of my interest in health policy stems from that,” she said.

During her residency, which she finished in 2015, Louisiana became a Medicaid expansion state. This impressed upon Dr. Newby how much Medicaid improved the lives of patients who had previously been uninsured. “We saw procedures getting done that had been put on hold because of financial concerns or medicines that were now affordable that weren’t before,” she said. “It really did make a difference.”

When repeated attempts to repeal the Affordable Care Act began, “it was a call to do health policy work for me personally that just hadn’t come up in the past,” said Dr. Newby, who is also assistant professor of medicine at Tulane University in New Orleans. “I personally found that the best way to do (advocacy work) was to go through medical societies because there is a much stronger voice when you have more people saying the same thing,” she said.

Dr. Newby sits on the Council of Legislation for the Louisiana State Medical Society and participates in the Leadership and Health Policy (LEAHP) Program through the Society of General Internal Medicine.

The LEAHP Program has been instrumental in expanding Dr. Newby’s knowledge of how health policy is made and the mechanisms behind it. It has also taught her “how we can either advise, guide, leverage, or advocate for things that we think would be important for change and moving the country in the right direction in terms of health care.”

Another reason involvement in medical societies is helpful is because, as a busy clinician, it is impossible to keep up with everything. “Working with medical societies, you have people who are more directly involved in the legislature and can give you quicker notice about things that are coming up that are going to be important to you or your co-workers or your patients,” Dr. Newby said.

Dr. Newby feels her advocacy work is an outlet for stress and “a way to work at more of a macro level on problems that I see with my individual patients. It’s a nice compliment.” At the hospital, she can only help one person at a time, but with her advocacy efforts, there’s potential to make changes for many.

“Advocacy now is such a large umbrella that encompasses so many different projects at all kinds of levels,” Dr. Newby said. She suggests looking around your community to see where the needs lie. If you’re passionate about a certain topic or population, see what you can do to help advocate for change there.